Nursing Elites

1. During a prenatal visit, for which of the following clients should the nurse auscultate the fetal heart rate?

• A. A client who has an ultrasound confirming a molar pregnancy
• B. A client who has a crown-rump length corresponding to 7 weeks gestation
• C. A client who has a positive urine pregnancy test 1 week after missed menses
• D. A client who has felt quickening for the first time

Correct answer: D

Rationale: The correct answer is D because feeling quickening typically occurs around 18-20 weeks of gestation, indicating fetal movement. This is an appropriate time to auscultate the fetal heart rate. Choice A is incorrect because a molar pregnancy is not a viable pregnancy, and auscultating the fetal heart rate in this case is not applicable. Choice B is incorrect because a crown-rump length of 7 weeks gestation is too early for fetal heart rate auscultation. Choice C is incorrect because a positive urine pregnancy test alone does not indicate the appropriate timing for fetal heart rate auscultation.

2. A 30-year-old primigravida delivers a nine-pound (4082 gram) infant vaginally after a 30-hour labor. What is the priority nursing action for this client?

• A. Assess the blood pressure for hypertension.
• B. Gently massage fundus every four hours.
• C. Observe for signs of uterine hemorrhage.
• D. Encourage direct contact with the infant.

Correct answer: C

Rationale: After a prolonged labor and delivery of a large infant, the client is at an increased risk for uterine atony and postpartum hemorrhage, making observation for signs of bleeding a priority. Assessing the blood pressure for hypertension (Choice A) is not the priority in this situation as the immediate concern is postpartum hemorrhage. Gently massaging the fundus every four hours (Choice B) is a routine postpartum care activity but is not the priority in this scenario. Encouraging direct contact with the infant (Choice D) is important for bonding but does not address the immediate risk of uterine hemorrhage after delivery.

3. Rubella, also called German measles, is a viral infection passed from the mother to the fetus that can cause birth defects such as deafness, intellectual disabilities, blindness, and heart disease in the embryo.

• A. Rubella
• B. Syphilis
• C. Cystic fibrosis
• D. Phenylketonuria

Correct answer: A

Rationale: Rubella, also known as German measles, is a viral infection that can lead to severe birth defects when contracted by a mother during pregnancy. Rubella is the correct answer because it is specifically associated with causing birth defects such as deafness, intellectual disabilities, blindness, and heart disease in the embryo. Syphilis (Choice B) can be passed from mother to fetus but does not cause the mentioned birth defects associated with Rubella. Cystic fibrosis (Choice C) and Phenylketonuria (Choice D) are genetic conditions and not infections transmitted from mother to fetus, making them incorrect choices in this context.

4. A nurse is caring for a newborn who is 6 hours old and has a bedside glucometer reading of 65 mg/dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?

• A. Obtain a blood sample for a serum glucose level
• B. Feed the newborn immediately
• C. Administer 50 mL of dextrose solution IV
• D. Reassess the blood glucose level prior to the next feeding

Correct answer: D

Rationale: A bedside glucometer reading of 65 mg/dL is within the normal range for a newborn. Reassessing the blood glucose level prior to the next feeding ensures ongoing monitoring without unnecessary intervention. Obtaining a blood sample for a serum glucose level (Choice A) is not necessary as the initial reading is normal. Feeding the newborn immediately (Choice B) may not be indicated and could lead to unnecessary interventions. Administering dextrose solution IV (Choice C) is not warranted as the glucose level is within the normal range and does not require immediate correction.

5. Do dizygotic (DZ) twins run in families?

• A. Yes
• B. No
• C. Rarely
• D. Never

Correct answer: A

Rationale: Yes, dizygotic (DZ) twins can run in families. This is due to genetic factors that influence hyperovulation, where a woman releases multiple eggs during her menstrual cycle. This genetic predisposition can be passed down through generations, increasing the likelihood of having dizygotic twins. Choices B, C, and D are incorrect because the statement that dizygotic twins run in families is true, as supported by scientific evidence. It is important to note that while the genetic predisposition for dizygotic twins can run in families, it does not guarantee that every generation will have twins, as other factors also play a role in twin pregnancies.

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