Nursing Elites

1. A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action?

• A. Insert a gloved finger into the mother's vagina to feel for cord compression
• B. Position the mother so that her hips are elevated
• C. Notify the registered nurse
• D. Perform a vaginal examination on the mother

Correct answer: B

Rationale: When variable decelerations on the fetal heart rate monitor strip suggest cord compression, the immediate action the nurse should take is to reposition the mother to alleviate the compression. Elevating the mother's hips or changing her position can help shift the fetal presenting part and relieve pressure on the cord. This action aims to improve or resolve the variable decelerations. Contacting the registered nurse may be necessary, but it is not the immediate action required in this situation. Performing a vaginal examination is contraindicated due to the potential risk of further compromising blood flow through the umbilical cord. Inserting a gloved finger into the mother's vagina to feel for the cord is also not recommended as it poses a similar risk of exacerbating the situation.

2. A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of:

• A. climacteric
• B. menopause
• C. perimenopause
• D. postmenopause

Correct answer: C

Rationale: Perimenopause refers to a period during which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause typically lasts around five years. Climacteric is a term that describes the period when physiologic changes result in the cessation of a woman's reproductive ability and decreased sexual activity. This term applies to both genders. Menopause is the time when menstruation permanently stops. Postmenopause refers to the period after menopausal changes are complete. In this scenario, the woman's irregular menses indicate she is likely in the perimenopausal stage, experiencing hormonal fluctuations and changes.

3. A nurse preparing to assist with data collection of the abdomen asks the client to void and then assists the client into a supine position. Which primary finding does the nurse expect to note on percussing all four quadrants of the abdominal cavity?

• A. Dullness
• B. Tympany
• C. Borborygmus
• D. Hyperresonance

Correct answer: B

Rationale: The nurse expects to primarily note tympany when percussing the abdomen. Tympany should predominate because air in the intestines rises to the surface when the client is in a supine position. Dullness is usually heard over a distended bladder, adipose tissue, fluid, or a mass. Borborygmus, which refers to hyperperistalsis, is typically heard on auscultation, not percussion. Hyperresonance is present with gaseous distention, not the typical finding when percussing all four quadrants of the abdomen.

4. A nurse assisting with data collection plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal which disorder?

• A. Loss of hearing acuity
• B. A problem with balance
• C. A problem with distant hearing
• D. A problem discriminating high-pitched and low-pitched sounds

Correct answer: B

Rationale: The Romberg test is a balance assessment that evaluates cerebellar function. During the test, the client stands with feet together and eyes closed, aiming to maintain balance for about 20 seconds. This test helps identify issues related to balance and proprioception, not hearing acuity or sound discrimination. Choices C and D are incorrect as the Romberg test focuses on balance, not distant hearing or sound discrimination.

5. In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases?

• A. measles, polio, pertussis, hepatitis B
• B. diphtheria, pertussis, polio, tetanus
• C. rubella, polio, pertussis, hepatitis A
• D. measles, mumps, rubella, polio

Correct answer: B

Rationale: By 12 months of age, children should have received the DTaP (diphtheria, pertussis, and tetanus) vaccine along with the polio vaccine. The MMR (measles, mumps, and rubella) vaccine is not typically given until the child is 12-15 months old. Therefore, option B is correct as it includes vaccines that are usually administered by 12 months of age. Options A, C, and D are incorrect as they include vaccines that are typically given after 12 months of age.

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