Nursing Elites

1. A new parent is receiving discharge teaching about car seat safety from a nurse. Which statement by the parent indicates an understanding of the teaching?

• A. “I should position my baby’s car seat at a 45-degree angle in the car.”
• B. “I should place the car seat rear-facing until my baby is 12 months old.”
• C. “I should place the harness snugly in a slot above my baby’s shoulders.”
• D. “I should position the retainer clip at the top of my baby’s abdomen.”

Correct answer: A

Rationale: The correct answer is A. Positioning the car seat at a 45-degree angle is crucial to prevent the baby's head from falling forward, which can obstruct the airway. Choice B is incorrect because the recommendation is to keep the car seat rear-facing until the baby reaches the height or weight limit set by the car seat manufacturer, typically beyond 12 months. Choice C is incorrect as the harness should be snugly placed at or below the baby's shoulders, not above. Choice D is incorrect as the retainer clip should be positioned at armpit level to secure the harness straps properly.

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. A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats per minute and contractions are occurring irregularly every 10 to 15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time?

• A. Membranes are intact.
• B. 2+ pitting edema in lower extremities.
• C. Contractions decrease with walking.
• D. Cervical dilation is 1 centimeter.

Correct answer: C

Rationale: The correct answer is C. Contractions that decrease with walking are typically indicative of false labor, as true labor contractions tend to intensify with activity. Choices A, B, and D are incorrect. A) Intact membranes are a normal finding and do not confirm the absence of labor. B) 2+ pitting edema in lower extremities is a sign of fluid retention and not directly related to labor status. D) Cervical dilation of 1 centimeter indicates some cervical changes, but it alone does not confirm active labor.

4. What is the most critical action in caring for the newborn immediately after birth?

• A. Keeping the airway clear.
• B. Fostering parent-newborn attachment.
• C. Drying the newborn and wrapping the infant in a blanket.
• D. Administering eye drops and vitamin K.

Correct answer: A

Rationale: The most critical action in caring for the newborn immediately after birth is keeping the airway clear. This is essential to ensure that the newborn can breathe effectively and prevent any respiratory distress. Fostering parent-newborn attachment, although important, is not the most critical action immediately after birth. Drying the newborn and wrapping the infant in a blanket is important for temperature regulation but is not as critical as maintaining a clear airway. Administering eye drops and vitamin K is typically done later and is not the most critical action immediately after birth.

5. Which of the following pairs share 100% of their genes?

• A. Biovular twins
• B. Fraternal twins
• C. Dizygotic (DZ) twins
• D. Monozygotic (MZ) twins

Correct answer: D

Rationale: The correct answer is Monozygotic (MZ) twins. Monozygotic twins, also known as identical twins, share 100% of their genes because they originate from the same fertilized egg that splits into two. Fraternal twins (choice B), also known as dizygotic (DZ) twins (choice C), result from two separate fertilized eggs and share approximately 50% of their genes. Biovular twins (choice A) is not a term used in genetics and does not describe a type of twinning.

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