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. Which statement by the client will assist the healthcare provider in determining whether she is in true labor as opposed to false labor?

• A. I passed some thick, pink mucus when I urinated this morning.
• B. My bag of waters just broke.
• C. The contractions in my uterus are getting stronger and closer together.
• D. My baby dropped, and I have to urinate more frequently now.

Correct answer: C

Rationale: The correct answer is C. Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Choice A indicates the passing of the mucus plug, which is a sign of early labor but not definitive for true labor. Choice B, the breaking of the bag of waters, is a sign of labor but does not confirm whether it is true or false labor. Choice D, the baby dropping and increased urination frequency, suggests lightening, a sign that labor may be approaching, but it does not confirm true labor.

3. Chromosomes contain thousands of segments called:

• A. nuclei.
• B. nodes.
• C. capillaries.
• D. genes.

Correct answer: D

Rationale: Chromosomes are structures composed of DNA and genes. Genes are the functional segments within chromosomes that encode specific traits and characteristics. The other choices ('nuclei,' 'nodes,' 'capillaries') do not accurately describe the segments found within chromosomes and are unrelated to their structure or function.

4. Which FHR finding is the most concerning to the nurse providing care to a laboring client?

• A. Accelerations with fetal movement.
• B. Early decelerations.
• C. Average FHR of 126 beats per minute.
• D. Late decelerations.

Correct answer: D

Rationale: Late decelerations are caused by uteroplacental insufficiency, resulting in fetal hypoxemia. They are considered ominous if persistent, indicating compromised oxygen supply to the fetus. Accelerations with fetal movement (Choice A) are reassuring signs of fetal well-being. Early decelerations (Choice B) are typically benign, associated with head compression during contractions. An average FHR of 126 beats per minute (Choice C) falls within the normal range for fetal heart rate and is not concerning. Therefore, the most concerning FHR finding in a laboring client is late decelerations (Choice D).

5. Which information regarding the care of antepartum women with cardiac conditions is most important for the nurse to understand?

• A. Stress on the heart is greatest in the first trimester and the last 2 weeks before labor.
• B. Women with class II cardiac disease should avoid heavy exertion and any activity that causes even minor symptoms.
• C. Women with class III cardiac disease should get 8 to 10 hours of sleep every day and limit housework, shopping, and exercise.
• D. Women with class I cardiac disease need bed rest through most of the pregnancy and face the possibility of hospitalization near term.

Correct answer: B

Rationale: Class II cardiac disease is symptomatic with ordinary activity. Women in this category need to avoid heavy exertion and limit regular activities as symptoms dictate. Stress is greatest between weeks 28 and 32 of gestation, when hemodynamic changes reach their maximum. Class III cardiac disease is symptomatic with less-than-ordinary activity. These women need bed rest most of the day and face the possibility of hospitalization near term. Class I cardiac disease is asymptomatic at normal levels of activity. These women can perform limited normal activities with discretion, although they still need a good amount of sleep.

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