Nursing Elites

1. A parent of a newborn is being taught about crib safety. Which statement by the client indicates understanding of the teaching?

• A. I will place my baby on his stomach when he is sleeping.
• B. I should remove extra blankets from my baby's crib.
• C. I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps.
• D. I should place my baby's crib next to the heater to keep him warm during the winter.

Correct answer: B

Rationale: The correct answer is B. Removing extra blankets from the crib is essential to prevent suffocation and reduce the risk of sudden infant death syndrome (SIDS). Extra blankets can pose a suffocation hazard to the baby during sleep. It is recommended to keep the crib free from loose bedding, pillows, and other soft items to provide a safe sleep environment for the newborn. Choices A, C, and D are incorrect. Placing the baby on his stomach (Choice A) increases the risk of SIDS. Padding the mattress (Choice C) can also pose a suffocation risk, and placing the crib next to a heater (Choice D) can lead to overheating, which is associated with an increased risk of SIDS.

2. While assisting with the care of a client in active labor, a nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?

• A. Place the client in the Trendelenburg position
• B. Apply finger pressure to the presenting part
• C. Administer oxygen at 10 L/min via a non-rebreather
• D. Call for assistance

Correct answer: D

Rationale: In the scenario of umbilical cord prolapse during labor, the nurse should first call for assistance. Umbilical cord prolapse is a critical obstetric emergency that requires immediate attention and skilled assistance. Calling for help ensures that additional support is on the way to provide prompt intervention. Placing the client in the Trendelenburg position (Choice A) is no longer recommended as it may worsen the situation. Applying finger pressure to the presenting part (Choice B) can further compress the cord. Administering oxygen (Choice C) is important but should come after addressing the prolapsed cord.

3. A client who is at 6 weeks of gestation is being educated about common discomforts of pregnancy. Which of the following findings should the individual include? (Select all that apply)

• A. Breast tenderness
• B. Urinary frequency
• C. Epistaxis
• D. All of the above

Correct answer: D

Rationale: During early pregnancy, common discomforts include breast tenderness due to hormonal changes, urinary frequency caused by increased blood flow to the kidneys, and epistaxis (nosebleeds) due to increased blood volume and hormonal changes. Educating the client about these discomforts helps them understand what to expect during this stage. Choice D, 'All of the above,' is the correct answer because all the listed findings are common discomforts experienced during early pregnancy. Choices A, B, and C are individually correct as well, as breast tenderness, urinary frequency, and epistaxis are all common discomforts that pregnant individuals may encounter.

4. A woman at 38 weeks of gestation is admitted in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

• A. Recheck the client's temperature in 4 hours.
• B. Administer glucocorticoids intramuscularly.
• C. Assess the odor of the amniotic fluid.
• D. Prepare the client for emergency cesarean section.

Correct answer: C

Rationale: An elevated temperature in a woman with ruptured membranes may indicate infection. Assessing the odor of the amniotic fluid can help determine if chorioamnionitis (an infection of the amniotic fluid) is present. This assessment is crucial to guide further interventions and management of the client's condition. Options A, B, and D are incorrect. Rechecking the client's temperature in 4 hours does not address the immediate concern of potential infection. Administering glucocorticoids intramuscularly is not indicated based solely on an elevated temperature. Preparing the client for an emergency cesarean section is premature and not supported by the information provided.

5. During preterm labor, a client is scheduled for an amniocentesis. The nurse should review which of the following tests to assess fetal lung maturity?

• A. Alpha-fetoprotein (AFP)
• B. Lecithin/sphingomyelin (L/S) ratio
• C. Kleihauer-Betke test
• D. Indirect Coombs' test

Correct answer: B

Rationale: The Lecithin/sphingomyelin (L/S) ratio is a test used to evaluate fetal lung maturity. An L/S ratio greater than 2:1 indicates fetal lung maturity. This test helps in determining the risk of respiratory distress syndrome in the newborn. Alpha-fetoprotein (AFP) is used in screening for neural tube defects, not for assessing lung maturity. The Kleihauer-Betke test is used to detect fetal-maternal hemorrhage, not fetal lung maturity. The Indirect Coombs' test is used to identify the presence of antibodies in the mother's blood that could attack fetal red blood cells, not for assessing lung maturity.

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