Nursing Elites

1. A client who is postpartum and has thrombophlebitis requires nursing interventions. Which of the following nursing interventions should the nurse recommend?

• A. Apply cold compresses to the affected extremity
• B. Massage the affected extremity
• C. Allow the client to ambulate
• D. Measure leg circumferences

Correct answer: D

Rationale: Measuring leg circumferences is crucial in monitoring for changes that may indicate worsening of thrombophlebitis, such as increased swelling or redness. This assessment helps in early detection of complications and timely intervention, reducing the risk of further health problems for the client. Applying cold compresses may worsen the condition by causing vasoconstriction. Massaging the affected extremity can dislodge a clot and lead to embolism. Allowing the client to ambulate may increase the risk of clot migration.

2. When should a provider order a maternal serum alpha-fetoprotein (MSAFP) screening for pregnant clients?

• A. A client who has mitral valve prolapse
• B. A client who has been exposed to AIDS
• C. All pregnant clients
• D. A client who has a history of preterm labor

Correct answer: C

Rationale: Maternal serum alpha-fetoprotein (MSAFP) screening is recommended for all pregnant clients to assess the risk of neural tube defects. It is a routine screening test used to detect increased levels of alpha-fetoprotein in maternal blood, which may indicate a higher risk for conditions such as neural tube defects in the developing fetus. Therefore, all pregnant clients, regardless of their medical history or risk factors, should undergo MSAFP screening as part of routine prenatal care. Choices A, B, and D are incorrect because the MSAFP screening is not specific to certain medical conditions or histories; it is a standard screening procedure for all pregnant individuals to evaluate neural tube defect risk in the fetus.

3. A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding?

• A. Hand the parent the newborn and suggest that they change the diaper.
• B. Ask the parent why they are so anxious and nervous.
• C. Tell the parent that they will grow accustomed to the newborn.
• D. Provide reinforcement about infant care when the parent is present.

Correct answer: D

Rationale: Providing reinforcement about infant care when the parent is present can help alleviate anxiety and promote positive parent-infant bonding. By offering guidance and support while the parent is interacting with the newborn, the nurse can help build the parent's confidence and strengthen the bond between the parent and the infant. Choice A is not ideal as it does not address the parent's anxiety and may increase stress levels. Choice B focuses on the parent's emotions without providing direct support for bonding. Choice C is dismissive and does not offer practical assistance in fostering bonding between the parent and the infant.

4. When assessing a newborn with respiratory distress syndrome who received synthetic surfactant, which parameter should the nurse monitor to evaluate the newborn's condition?

• A. Oxygen saturation
• B. Body temperature
• C. Serum bilirubin
• D. Heart rate

Correct answer: A

Rationale: In a newborn with respiratory distress syndrome who has received synthetic surfactant, monitoring oxygen saturation is crucial to evaluate the effectiveness of the treatment. Oxygen saturation levels provide valuable information about the newborn's respiratory status and the adequacy of gas exchange. Changes in oxygen saturation can indicate improvements or deterioration in the newborn's condition following the administration of synthetic surfactant. Monitoring oxygen saturation helps the nurse assess the newborn's response to treatment and make timely interventions if needed. Body temperature, serum bilirubin, and heart rate are important parameters to monitor in newborns for other conditions but are not specific indicators of the effectiveness of synthetic surfactant in treating respiratory distress syndrome.

5. A client is being educated by a healthcare provider about the changes she should expect when planning to become pregnant. Identify the correct sequence of maternal changes. A. Amenorrhea B.Lightening C. Goodell's sign D. Quickening

• A. A,B,C,D
• B. D,B,A,C
• C. A,D,B,C
• D. A,C,D,B

Correct answer: D

Rationale: The correct sequence of maternal changes during pregnancy is as follows: Amenorrhea (absence of menstrual periods), Goodell's sign (softening of the cervix), Quickening (first fetal movements felt by the mother), and Lightening (baby descending into the pelvis). These changes occur at different stages of pregnancy and are important indicators of fetal development and maternal adaptation. Choice A is correct as it is the initial change indicating possible pregnancy. Choices B, C, and D follow in the correct order of occurrence during pregnancy. Choices B, C, and D are incorrect as they do not follow the correct sequence of maternal changes.

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