Nursing Elites

1. A nurse is determining the fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take?

• A. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse.
• B. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.
• C. Ask the mother to lie still while both the FHR and the radial pulse rate are counted.
• D. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds.

Correct answer: B

Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother's radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother's abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic sound (blood flowing through the umbilical cord) and the uterine sound (blood flowing through the uterine vessels). The funic sound is synchronized with the FHR; the uterine sound is synchronized with the mother's pulse. Therefore, moving the fetoscope to a different area will help in accurately locating and counting the fetal heart rate. Choice A is incorrect because counting for 60 seconds without changing the position may not address the issue of accurately locating the FHR. Choice C is incorrect as it does not address the need to reposition the fetoscope to locate the fetal heart. Choice D is incorrect because counting the FHR and the radial pulse rate separately may not help in differentiating the two sounds.

2. What is the primary theory that explains a family's concept of health and illness?

• A. Health Belief Model
• B. Education-School-Completing Factor
• C. Family Health Expert Factor
• D. Disconnected Family Factor

Correct answer: A

Rationale: The correct answer is the Health Belief Model. This model explains a family's concept of health and illness by focusing on readiness factors, perceived susceptibility, and seriousness of health problems, and positive motivation for wellness. The Health Belief Model is widely used in healthcare to understand and predict health behaviors. Choices B, C, and D are incorrect as they do not specifically address how a family perceives health and illness. The Health Belief Model is the most appropriate choice as it is specifically designed to explain individual and family beliefs and behaviors related to health and illness.

3. After reviewing the child's immunization record, which scheduled vaccine should the nurse prepare to administer next?

• A. Hib
• B. IPV
• C. MMR
• D. DTaP

Correct answer: D

Rationale: The correct answer is DTaP. DTaP is administered at 2, 4, and 6 months of age; between 15 and 18 months of age; and between 4 and 6 years of age. Since the child has only received three doses of this vaccine, the next dose of DTaP should be administered. The other options are incorrect because Hib is administered at 2, 4, and 6 months of age and between 12 and 15 months; IPV is administered at 2, 4, and 6 months of age and between 4 and 6 years of age; MMR is administered between 12 and 15 months of age and again between 4 and 6 years of age.

4. When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is:

• A. "Fertility counseling should be sought when you have been unable to conceive after 1 year of unprotected intercourse."?
• B. "Fertility counseling should be sought when you have not been able to conceive after 6-9 months of unprotected intercourse."?
• C. "The average time it takes someone your age to conceive is 5.3 months, so if you haven't conceived by then, we can refer you."?
• D. "We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn't happen within a year."?

Correct answer: D

Rationale: The best response in this scenario is to offer immediate guidance while also indicating when fertility counseling should be sought. While Choice A is technically correct as guidelines recommend seeking fertility counseling after 1 year of unprotected intercourse, it lacks providing immediate guidance. Choice B suggests seeking counseling after 6-9 months, which is earlier than the standard recommendation of 1 year. Choice C mentions the average time to conceive for someone of the client's age without addressing the client's current concern. Therefore, Choice D is the most appropriate response as it offers immediate guidance along with a plan for referral if needed.

5. Which of the following is least appropriate when caring for a stable postpartum client?

• A. Assess the location and height of the fundus.
• B. Conduct a family assessment, including the mother's future plans for returning to work, if applicable.
• C. Monitor the client for bleeding.
• D. Provide perineal care.

Correct answer: D

Rationale: Providing perineal care is not the least appropriate when caring for a stable postpartum client. Perineal care is essential for maintaining hygiene and preventing infection after delivery. Assessing the location and height of the fundus helps in monitoring postpartum uterine involution, which is crucial for assessing the recovery progress. Conducting a family assessment, including the mother's future plans for returning to work, is important for understanding the support system available for the mother during the postpartum period. Monitoring the client for bleeding is critical to promptly identify and address any postpartum hemorrhage. Therefore, providing perineal care is the least appropriate option among the choices provided as it is a fundamental aspect of postpartum care.

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