Nursing Elites

1. In the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-month-old infant has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

• A. Provide blow-by oxygen
• B. Provide a capillary blood glucose test
• C. Draw arterial blood gases
• D. Apply a pulse oximeter to the foot

Correct answer: B

Rationale: Late preterm infants, such as those with a gestational age of 42 weeks, are at higher risk for hypoglycemia due to immature metabolic regulation. Monitoring capillary blood glucose is crucial to detect and manage hypoglycemia promptly. Providing blow-by oxygen (Choice A) is not indicated for an infant at risk for hypoglycemia. Drawing arterial blood gases (Choice C) is not the primary intervention for assessing hypoglycemia. Applying a pulse oximeter to the foot (Choice D) is not directly related to monitoring blood glucose levels in this context.

2. 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.

3. When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective?

• A. Dilation of the cervix.
• B. Descent of the fetus to –2 station.
• C. Rupture of the amniotic membranes.
• D. Increase in bloody show.

Correct answer: A

Rationale: During the first stage of labor, effective uterine contractions lead to cervical dilation. Dilation of the cervix is a key indicator that uterine contractions are progressing labor. Descent of the fetus to -2 station (Choice B) is related to the fetal position in the pelvis and not a direct indicator of uterine contraction effectiveness. Rupture of the amniotic membranes (Choice C) signifies the rupture of the fluid-filled sac surrounding the fetus and does not directly reflect uterine contraction effectiveness. An increase in bloody show (Choice D) can be a sign of impending labor, but it is not a direct indicator of uterine contraction effectiveness.

4. A healthcare provider is reviewing laboratory results for a client who is pregnant. The healthcare provider should expect which of the following laboratory values to increase?

• A. RBC count
• B. Bilirubin
• C. Fasting blood glucose
• D. BUN

Correct answer: A

Rationale: During pregnancy, the body increases the production of red blood cells (RBCs) to meet the increased oxygen demands. This physiological response is known as physiological anemia of pregnancy. Therefore, the RBC count is expected to increase during pregnancy. Bilirubin levels may remain relatively stable, fasting blood glucose levels might fluctuate due to gestational diabetes, and blood urea nitrogen (BUN) levels are not typically affected by pregnancy, making them less likely to increase in this scenario. The correct answer is A because an increase in RBC count is a normal physiological adaptation to pregnancy to support the increased oxygen needs of the mother and the growing fetus. Bilirubin, a product of red blood cell breakdown, is more related to liver function and not expected to increase during pregnancy. Fasting blood glucose levels may vary due to gestational diabetes, but it is not a consistent finding in all pregnant individuals. BUN levels are related to kidney function and are not typically impacted by pregnancy, making it an unlikely choice for an expected increase in laboratory values during pregnancy.

5. A perinatal nurse is caring for a woman in the immediate postpartum period. Assessment reveals that the client is experiencing profuse bleeding. What is the most likely cause of this bleeding?

• A. Uterine atony.
• B. Uterine inversion.
• C. Vaginal hematoma.
• D. Vaginal laceration.

Correct answer: A

Rationale: Uterine atony is significant hypotonia of the uterus and is the leading cause of postpartum hemorrhage. It results in the inability of the uterus to contract effectively after delivery, leading to excessive bleeding. Uterine inversion is a rare but serious complication that involves the turning inside out of the uterus, leading to hemorrhage, but it is not the most likely cause of profuse bleeding in this scenario. Vaginal hematoma may cause bleeding but is typically associated with pain as a primary symptom rather than profuse bleeding. Vaginal lacerations can cause bleeding, but in the presence of a firm, contracted uterine fundus, uterine atony is a more likely cause of ongoing profuse bleeding in the postpartum period.

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