Nursing Elites

1. A healthcare provider is teaching a prenatal class about immunizations that newborns receive following birth. Which of the following immunizations should the provider include in the teaching?

• A. Hepatitis B
• B. Rotavirus
• C. Pneumococcal
• D. Varicella

Correct answer: A

Rationale: The correct answer is Hepatitis B. Newborns receive the Hepatitis B vaccine shortly after birth to provide protection against the virus. Rotavirus, Pneumococcal, and Varicella vaccines are typically administered at later stages of infancy or childhood, not immediately after birth. Rotavirus vaccine helps prevent severe diarrhea, Pneumococcal vaccine protects against infections like pneumonia and meningitis, and Varicella vaccine prevents chickenpox. However, these vaccines are not part of the routine immunizations given to newborns immediately after birth.

2. On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?

• A. Firm, larger, and very tender to the touch
• B. Slightly firm with an immediate let-down response
• C. Soft with no change from before delivery
• D. Filling and secreting colostrum

Correct answer: D

Rationale: On the first postpartum day, the nurse is most likely to find the breasts filling and secreting colostrum. Colostrum secretion is common as the body prepares for breastfeeding in the initial days after delivery. Choice A is incorrect as breasts are not typically very tender immediately postpartum. Choice B is incorrect as an immediate let-down response is more related to lactation rather than the first postpartum day. Choice C is incorrect as the breasts typically undergo changes, such as filling with colostrum, after delivery.

3. A newborn who was born post-term is being assessed by a nurse. Which of the following findings should the nurse expect?

• A. A Rh-negative mother who has an Rh-positive infant
• B. A Rh-positive mother who has an Rh-negative infant
• C. A Rh-positive mother who has an Rh-positive infant
• D. A Rh-negative mother who has an Rh-negative infant

Correct answer: A

Rationale: The correct answer is A: 'A Rh-negative mother who has an Rh-positive infant.' In cases where the newborn is born post-term, the mismatched Rh factor between the mother (Rh-negative) and the infant (Rh-positive) can lead to hemolytic disease of the newborn. This condition occurs when maternal antibodies attack fetal red blood cells, causing hemolysis. This can result in jaundice, anemia, and other serious complications for the infant. Choices B, C, and D are incorrect because they do not reflect the mismatched Rh factor scenario that poses a risk for hemolytic disease of the newborn.

4. The nurse has received a report regarding a client in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this assessment?

• A. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
• B. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
• C. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
• D. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.

Correct answer: B

Rationale: The correct interpretation of the assessment provided is that the cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines. In the given assessment, the measurements are ordered as dilation, effacement, and station. Choice A is incorrect as it wrongly places the presenting part below the ischial spines. Choice C is incorrect because it places the presenting part below the ischial spines. Choice D is also incorrect as it incorrectly states that the presenting part is below the ischial spines, even though it correctly mentions the dilation and effacement of the cervix.

5. A client in labor requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort?

• A. Assisting the client into a squatting position
• B. Having the client lie in a supine position
• C. Applying fundal pressure during contractions
• D. Encouraging the client to void every 6 hours

Correct answer: A

Rationale: Assisting the client into a squatting position promotes comfort during labor. This position can help relieve pain by utilizing gravity, allowing the pelvic outlet to widen, and potentially facilitating the progress of labor. Lying in a supine position (Choice B) can hinder labor progression and increase discomfort. Applying fundal pressure (Choice C) can be inappropriate and may cause harm as it is not routinely recommended during labor. Encouraging the client to void every 6 hours (Choice D) is important for bladder management but does not directly address pain relief during labor.

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