Nursing Elites

1. A client at 38 weeks of gestation with a diagnosis of preeclampsia has the following findings. Which of the following should the nurse identify as inconsistent with preeclampsia?

• A. 1+ pitting sacral edema
• B. 3+ protein in the urine
• C. Blood pressure 148/98 mm Hg
• D. Deep tendon reflexes of +1

Correct answer: D

Rationale: Deep tendon reflexes of +1 are inconsistent with preeclampsia. Preeclampsia typically presents with hyperreflexia, not diminished reflexes. Diminished reflexes may indicate other neurological conditions, thus making this finding inconsistent with preeclampsia. Choices A, B, and C are consistent with preeclampsia. Pitting sacral edema, protein in the urine, and elevated blood pressure are common findings in preeclampsia due to fluid retention, kidney involvement, and hypertension associated with the condition.

2. When checking for the Moro reflex in a newborn, what action should the nurse take?

• A. Hold the newborn vertically under arms and allow one foot to touch the table.
• B. Stimulate the pads of the newborn's hands with stroking or massage.
• C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot.
• D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.

Correct answer: D

Rationale: The correct action to check for the Moro reflex in a newborn is to hold the newborn in a semi-sitting position and then allow the newborn's head and trunk to fall backward. The Moro reflex is elicited by a sudden loss of support or a loud noise. The normal response involves symmetrical abduction and extension of the arms, followed by their return to the midline in an embracing motion. Choices A, B, and C do not describe the correct method for assessing the Moro reflex and are therefore incorrect.

3. A client who underwent an amniotomy is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

• A. Maintain the client in the lithotomy position.
• B. Perform vaginal examinations frequently.
• C. Remind the client to bear down with each contraction.
• D. Encourage the client to empty her bladder every 2 hours.

Correct answer: D

Rationale: Encouraging the client to empty her bladder every 2 hours is essential during labor to prevent bladder distention, which can hinder labor progress and cause discomfort. A distended bladder can also lead to potential complications such as uterine atony or increased risk of infection. Choice A is incorrect as maintaining the client in the lithotomy position is not necessary during the active phase of the first stage of labor and may not be comfortable for the client. Choice B is incorrect because performing vaginal examinations frequently can increase the risk of introducing infection and disrupt the natural progress of labor. Choice C is incorrect as bearing down with each contraction is typically reserved for the second stage of labor when the cervix is fully dilated, not during the active phase of the first stage.

4. A healthcare provider in a clinic is reinforcing teaching with a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency?

• A. Iron deficiency anemia
• B. Poor bone formation
• C. Macrosomic fetus
• D. Neural tube defects

Correct answer: D

Rationale: The correct answer is D: Neural tube defects. Folic acid deficiency during pregnancy can lead to neural tube defects in the fetus, affecting the brain, spine, or spinal cord development. Iron deficiency anemia (choice A) is not directly related to folic acid deficiency. Poor bone formation (choice B) is more associated with calcium and vitamin D deficiencies. Macrosomic fetus (choice C) refers to a baby with excessive birth weight and is not a typical outcome of folic acid deficiency in pregnancy. Therefore, it is crucial for individuals of childbearing age to take recommended folic acid supplements to prevent neural tube defects.

5. An adolescent is being taught about levonorgestrel contraception by a school nurse. What information should the nurse include in the teaching?

• A. You should take the medication within 72 hours following unprotected sexual intercourse.
• B. Do not take this medication if you are on an oral contraceptive.
• C. If you do not start your period within 5 days of taking this medication, you will need a pregnancy test.
• D. One dose of this medication will prevent pregnancy for 14 days after taking it.

Correct answer: A

Rationale: Levonorgestrel is an emergency contraceptive that works by inhibiting ovulation to prevent conception. It is most effective when taken as soon as possible within 72 hours following unprotected sexual intercourse. Therefore, the nurse should instruct the adolescent to take the medication promptly to maximize its effectiveness. Choice B is incorrect because levonorgestrel can be used even if the individual is on oral contraceptives. Choice C is incorrect as the efficacy of levonorgestrel is not determined by the onset of menstruation. Choice D is incorrect because levonorgestrel is a single-dose emergency contraceptive and does not provide protection for 14 days after ingestion.

Similar Questions