Nursing Elites

1. During the admission assessment of a newborn, which anatomical landmark should be used for measuring the newborn's chest circumference?

• A. Sternal notch
• B. Nipple line
• C. Xiphoid process
• D. Fifth intercostal space

Correct answer: B

Rationale: When measuring a newborn's chest circumference, the appropriate anatomical landmark to use is the nipple line. This point is consistent and allows for accurate and standardized measurements across all newborn assessments. The sternal notch is not typically used for chest circumference measurements in newborns. The xiphoid process is located at the lower end of the sternum and is not an appropriate landmark for chest circumference measurement. The fifth intercostal space is typically used for locating the point of maximal impulse (PMI) during cardiac assessments, not for measuring chest circumference.

2. While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?

• A. Place the client in the Trendelenburg position
• B. Apply finger pressure to the presenting part
• C. Administer oxygen at 10 L/min via a non-rebreather
• D. Call for assistance

Correct answer: D

Rationale: In the scenario of umbilical cord prolapse during labor, the nurse should first call for assistance. Umbilical cord prolapse is a critical obstetric emergency that requires immediate attention and skilled assistance. Calling for help ensures that additional support is on the way to provide prompt intervention. Placing the client in the Trendelenburg position (Choice A) is no longer recommended as it may worsen the situation. Applying finger pressure to the presenting part (Choice B) can further compress the cord. Administering oxygen (Choice C) is important but should come after addressing the prolapsed cord.

3. During an assessment, a client at 26 weeks of gestation presents with which of the following clinical manifestations that should be reported to the provider?

• A. Leukorrhea
• B. Supine hypotension
• C. Periodic numbness of the fingers
• D. Decreased urine output

Correct answer: D

Rationale: During pregnancy, decreased urine output can be indicative of decreased renal perfusion and impaired fetal well-being. It can also be a sign of preeclampsia when associated with symptoms like increased blood pressure, proteinuria, and decreased fetal activity. Therefore, the nurse should promptly report this finding to the healthcare provider for further evaluation and management. Leukorrhea is a common finding in pregnancy and not typically concerning. Supine hypotension and periodic numbness of the fingers can be managed by changing positions or adjusting posture and are not as urgent as decreased urine output in this context.

4. A client in a prenatal clinic is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make?

• A. This is due to an increase in blood volume.
• B. This is due to pressure from the uterus on the diaphragm.
• C. This is due to the weight of the uterus on the vena cava.
• D. This is due to increased cardiac output.

Correct answer: C

Rationale: Maternal hypotension during pregnancy is often caused by the weight of the uterus pressing on the vena cava when the client is lying on her back, which reduces blood flow to the heart. This compression can lead to a decrease in blood pressure and subsequent symptoms of hypotension. Choice A is incorrect because an increase in blood volume typically leads to increased blood pressure rather than hypotension. Choice B is incorrect as pressure from the uterus on the diaphragm is not a common cause of maternal hypotension. Choice D is incorrect because increased cardiac output would not directly cause maternal hypotension.

5. A client in active labor reports back pain while being examined by a nurse who finds her to be 8 cm dilated, 100% effaced, -2 station, and in the occiput posterior position. What action should the nurse take?

• A. Perform effleurage during contractions.
• B. Place the client in lithotomy position.
• C. Assist the client to the hands and knees position.
• D. Apply a scalp electrode to the fetus.

Correct answer: C

Rationale: The nurse should assist the client into the hands and knees position during contractions to help relieve her back pain and facilitate the rotation of the fetus from the posterior to an anterior occiput position. This position can aid in optimal fetal positioning for delivery. Choice A, performing effleurage, is a massage technique that may provide comfort but does not address the fetal position. Placing the client in lithotomy position (Choice B) may not be ideal for a client experiencing back pain due to the occiput posterior position. Applying a scalp electrode to the fetus (Choice D) is not indicated solely for addressing the client's back pain.

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