Nursing Elites

1. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:

• A. Increase maternal fluids.
• B. Administer oxygen.
• C. Decrease maternal fluids.
• D. Turn the mother.

Correct answer: C

Rationale: When fetal heart monitoring indicates fetal distress, interventions are aimed at improving oxygenation to the fetus. Increasing maternal fluids helps improve placental perfusion and oxygen delivery to the fetus. Administering oxygen also aids in increasing oxygen supply to the fetus. Turning the mother can help relieve pressure on the vena cava, optimizing blood flow to the placenta. Therefore, decreasing maternal fluids would not be performed as it can further compromise placental perfusion and fetal oxygenation, making it the exception. Decreasing maternal fluids could potentially exacerbate fetal distress by reducing oxygen delivery and nutrient supply to the fetus, which is contrary to the goal of managing fetal distress.

2. Which fetal heart monitor pattern can indicate cord compression?

• A. variable decelerations
• B. early decelerations
• C. bradycardia
• D. tachycardia

Correct answer: A

Rationale: Variable decelerations can indicate cord compression as they are caused by umbilical cord compression or prolapse. This pattern shows an abrupt decrease in heart rate with an erratic shape, often resembling a V or W. Early decelerations (choice B) are typically caused by head compression during contractions and are considered benign. Bradycardia (choice C) is a consistent low heart rate below 110 bpm and is not specific to cord compression. Tachycardia (choice D) is an abnormally high heart rate above 160 bpm and is not associated with cord compression.

3. A neighbor telephones the nurse to tell her that her child has erythema infectiosum and asks for information. The nurse knows that another name for the disorder is:

• A. Kawasaki disease
• B. rheumatic disease
• C. lupus erythematosus
• D. fifth disease

Correct answer: D

Rationale: The correct answer is 'fifth disease.' Erythema infectiosum, also known as fifth disease, is a parvovirus flu-like illness that is self-limiting but contagious for two to three weeks. Choice A, Kawasaki disease, is a different condition that involves inflammation of the blood vessels, predominantly affecting children. Choices B and C, rheumatic disease and lupus erythematosus, are also different conditions unrelated to erythema infectiosum.

4. To remove hard contact lenses from an unresponsive client, what should the nurse do?

• A. Gently irrigate the eye with an irrigating solution from the inner canthus outward
• B. Grasp the lens with a gentle pinching motion
• C. Don sterile gloves before attempting the procedure
• D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens

Correct answer: D

Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.

5. Which hormone in the urine is specifically indicative of pregnancy?

• A. estrogen
• B. progesterone
• C. testosterone
• D. human chorionic gonadotropin

Correct answer: D

Rationale: Human chorionic gonadotropin is the hormone specifically indicative of pregnancy as it is produced by the placenta after implantation. It can be detected in urine and blood samples to confirm pregnancy. Estrogen and progesterone play crucial roles in the menstrual cycle and pregnancy but are not specific indicators of pregnancy on their own. Testosterone is a hormone primarily associated with male reproductive functions and is not directly related to pregnancy, making it an incorrect choice in this context.

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