Nursing Elites

1. When discussing intermittent fetal heart monitoring with a newly licensed nurse, which statement should a nurse include?

• A. Count the fetal heart rate for 15 seconds to determine the baseline.
• B. Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor.
• C. Count the fetal heart rate after a contraction to determine baseline changes.
• D. Auscultate the fetal heart rate every 30 minutes during the second stage of labor.

Correct answer: C

Rationale: When discussing intermittent fetal heart monitoring, it is crucial to count the fetal heart rate after a contraction to determine baseline changes. This practice allows for the assessment of variations in the fetal heart rate pattern associated with uterine contractions. Monitoring the fetal heart rate after contractions provides valuable insights into fetal well-being and potential distress. Option A is incorrect because determining the baseline involves assessing the fetal heart rate over a more extended period. Option B is incorrect as auscultation every 5 minutes during the active phase of the first stage of labor is too frequent for intermittent monitoring. Option D is incorrect as auscultating the fetal heart rate every 30 minutes during the second stage of labor is too infrequent for proper monitoring of fetal well-being.

2. A healthcare provider in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the healthcare provider expect? (Select all that apply)

• A. Joint pain
• B. Malaise
• C. Rash
• D. Tender lymph nodes

Correct answer: D

Rationale: A TORCH infection can cause joint pain, malaise, rash, and tender lymph nodes. These findings are characteristic of TORCH infections and are important to recognize in pregnant individuals as they can have serious implications for both the mother and the fetus. While joint pain, malaise, and rash can be present in TORCH infections, tender lymph nodes are a common finding that the healthcare provider should expect. Tender lymph nodes are often associated with the inflammatory response to infection and can be palpated during a physical examination. Therefore, in this scenario, the healthcare provider should anticipate the presence of tender lymph nodes in a client with a TORCH infection, making option D the correct answer.

3. A client at 40 weeks of gestation is experiencing contractions every 3 to 5 minutes, becoming stronger. A vaginal exam by the registered nurse reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client requests pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply)

• A. Provide ice chips.
• B. Insert an indwelling urinary catheter.
• C. Administer opioid analgesic medication.
• D. Provide ice chips.

Correct answer: C

Rationale: During labor, effective pain management is crucial. The nurse should assist the client with patterned breathing techniques to help manage pain and administer opioid analgesic medication as ordered. Providing ice chips is a comfort measure but does not directly address pain relief. Inserting a urinary catheter is not typically indicated at this stage of labor unless there are specific medical indications, such as the need to closely monitor urine output. Therefore, the correct action for the nurse to prepare to take in this scenario is to administer opioid analgesic medication.

4. A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?

• A. Preterm newborns have a smaller body surface area than normal newborns.
• B. The added brown fat layer in a preterm newborn reduces his ability to generate heat.
• C. Preterm newborns lack adequate temperature control mechanisms.
• D. The heat in the incubator rapidly dries the sweat of preterm newborns.

Correct answer: C

Rationale: The correct answer is C because preterm newborns have immature temperature regulation mechanisms, making it difficult for them to maintain their body temperature. An incubator helps maintain a stable thermal environment. Choice A is incorrect as the body surface area is not the primary reason for needing an incubator. Choice B is incorrect because brown fat in preterm newborns actually helps generate heat. Choice D is incorrect as the purpose of the incubator is not to dry sweat but to regulate the newborn's temperature.

5. A client who is at 12 weeks of gestation is reviewing a new prescription of ferrous sulfate. Which of the following statements by the client indicates understanding of the teaching?

• A. I will take this pill with my breakfast.
• B. I will take this medication with a glass of milk.
• C. I plan to drink more orange juice while taking this pill.
• D. I plan to add more calcium-rich foods to my diet while taking this medication.

Correct answer: C

Rationale: The correct answer is C. Taking iron supplements with orange juice, which contains vitamin C, enhances the absorption of iron, making the treatment more effective. Choices A, B, and D are incorrect because taking ferrous sulfate with milk, calcium-rich foods, or breakfast may hinder iron absorption due to interactions with calcium or other substances that compete with iron absorption.

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