Nursing Elites

1. The _____ is the inner layer of the embryo from which the lungs and digestive system develop.

• A. neural tube
• B. mesoderm
• C. endoderm
• D. umbilical cord

Correct answer: C

Rationale: The endoderm is the correct answer. It is the innermost layer of the embryo that gives rise to organs such as the lungs, digestive system, liver, and pancreas. The neural tube (Choice A) forms the brain and spinal cord, not the lungs or digestive system. Mesoderm (Choice B) develops into structures like muscles, bones, and circulatory system, not the lungs or digestive system. The umbilical cord (Choice D) serves as a connection between the embryo and the placenta, providing nutrients and oxygen, but it is not the layer from which lungs and digestive system develop.

2. 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).

3. Why is a client with gestational diabetes being scheduled for an amniocentesis when the fetus has an estimated weight of eight pounds (3629 grams) at 36 weeks gestation? What information is the amniocentesis seeking to obtain?

• A. Presence of a neural tube defect.
• B. Chromosomal abnormalities.
• C. Gender of the fetus.
• D. Fetal lung maturity.

Correct answer: D

Rationale: An amniocentesis in this scenario is most likely being performed to assess fetal lung maturity. This is necessary when considering early delivery due to macrosomia (large fetal size), which is a common concern in gestational diabetes. Evaluating fetal lung maturity is crucial to determine if the fetus's lungs are developed enough to support breathing independently outside the womb. The presence of a neural tube defect and chromosomal abnormalities are not typically assessed through amniocentesis in this situation, and determining the gender of the fetus is not the primary purpose of the procedure here.

4. A nurse is planning to teach a group of clients who are breastfeeding after returning to work. Which of the following instructions should the nurse include in the teaching?

• A. “Thawed breast milk can be refrigerated for up to 24 hours.”
• B. “Breast milk can be stored in a deep freezer for 12 months.”
• C. “Breast milk can be stored at room temperature for up to 4 hours.”
• D. “Thawed breast milk that is unused cannot be refrozen.”

Correct answer: B

Rationale: The correct answer is B: “Breast milk can be stored in a deep freezer for 12 months.” This instruction is important for mothers returning to work to ensure a long-term storage option for breast milk. Choice A is incorrect because thawed breast milk should be used within 24 hours if stored in the refrigerator. Choice C is incorrect as breast milk can be kept at room temperature for only up to 4 hours. Choice D is incorrect as thawed breast milk that is unused should not be refrozen due to safety concerns.

5. A healthcare professional is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the healthcare professional include in the plan of care?

• A. Dress the newborn in lightweight clothing.
• B. Avoid using lotion or ointment on the newborn's skin.
• C. Keep the newborn supine throughout treatment.
• D. Measure the newborn's temperature every 8 hours.

Correct answer: B

Rationale: When a newborn is receiving phototherapy, it is important to avoid using lotions or ointments on their skin as these products can lead to skin irritation and burns under the phototherapy lights. Dressing the newborn in lightweight clothing helps ensure proper exposure to the phototherapy lights. Keeping the newborn supine during treatment helps maximize exposure to the light. However, the key consideration in this scenario is to prevent skin irritation and burns by avoiding lotions or ointments.

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