Nursing Elites

1. At 12 hours after the birth of a healthy infant, the mother complains of feeling constant vaginal pressure. The nurse determines the fundus is firm and at midline with moderate rubra lochia. Which action should the nurse take?

• A. Check the suprapubic area for distention
• B. Inform the client to take a warm sitz bath
• C. Inspect the client's perineal and rectal areas
• D. Apply a fresh pad and check in 1 hour

Correct answer: C

Rationale: In this situation, the mother's complaint of constant vaginal pressure along with a firm fundus and moderate rubra lochia indicates a potential perineal injury or hematoma. The correct action for the nurse to take is to inspect the client's perineal and rectal areas to assess for any signs of trauma or hematoma. Checking the suprapubic area for distention (Choice A) is not the priority here since the symptoms suggest a perineal issue. Advising a warm sitz bath (Choice B) may not address the underlying issue and could potentially worsen any existing trauma. Applying a fresh pad and checking in 1 hour (Choice D) does not address the need for immediate assessment of the perineal and rectal areas in response to the reported symptoms.

2. A client with hyperemesis gravidarum is being cared for by a nurse. Which of the following laboratory tests should the nurse anticipate?

• A. Urine Ketones
• B. Rapid plasma reagin
• C. Prothrombin time
• D. Urine culture

Correct answer: A

Rationale: Urine ketones should be anticipated as a laboratory test for a client with hyperemesis gravidarum because it helps assess the severity of dehydration and malnutrition, which are common complications of this condition. Choice B, rapid plasma reagin, is a test for syphilis and is not relevant to hyperemesis gravidarum. Choice C, prothrombin time, is a measure of blood clotting function and is not typically indicated for hyperemesis gravidarum. Choice D, urine culture, is used to identify bacteria in the urine and is not directly related to assessing dehydration and malnutrition in clients with hyperemesis gravidarum.

3. _____ is a life-threatening disease, characterized by high blood pressure that may afflict women late in the second or early in the third trimester.

• A. Rubella
• B. Syphilis
• C. Preeclampsia
• D. Phenylketonuria

Correct answer: C

Rationale: Preeclampsia is a serious pregnancy complication characterized by high blood pressure that typically occurs in the second half of pregnancy. If left untreated, it can lead to severe complications for both the mother and the baby. Rubella (choice A) is a viral infection that can harm the developing fetus but is not directly related to high blood pressure in pregnancy. Syphilis (choice B) is a sexually transmitted infection that can affect pregnancy but does not specifically cause high blood pressure. Phenylketonuria (choice D) is a genetic disorder that affects metabolism and is not associated with high blood pressure in pregnancy.

4. A client tells the nurse that she thinks she's pregnant. Which signs or symptoms provide the best indication that the client is pregnant?

• A. Morning sickness.
• B. Breast tenderness.
• C. Amenorrhea.
• D. Hegar's sign.

Correct answer: D

Rationale: Hegar's sign, which is a softening of the lower uterine segment, is considered a probable sign of pregnancy as it indicates changes in the cervix and uterus that occur during pregnancy. Amenorrhea, the absence of menstruation, is a common early sign of pregnancy but can also be due to other factors. Morning sickness, nausea and vomiting, can be a sign of early pregnancy but is not as specific as Hegar's sign. Breast tenderness is a common symptom in early pregnancy due to hormonal changes, but it is not as definitive as Hegar's sign in indicating pregnancy.

5. Which of the following statements is true of Down’s syndrome?

• A. Down’s syndrome is usually caused by an extra copy of chromosome 21 in an individual.
• B. The symptoms of Down’s syndrome are similar to those of sickle-cell anemia.
• C. Down’s syndrome is caused by a sexually transmitted infection (STI) during conception.
• D. The probability of having a child with Down’s syndrome increases with the age of the parents.

Correct answer: D

Rationale: The correct answer is D. The likelihood of having a child with Down’s syndrome increases as the age of the parents increases, particularly the mother's age. Choice A is incorrect because Down’s syndrome is caused by an extra copy of chromosome 21, not a defect in the sex chromosomes. Choice B is incorrect as the symptoms of Down’s syndrome and sickle-cell anemia are different. Choice C is also incorrect as Down’s syndrome is not caused by a sexually transmitted infection during conception.

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