Nursing Elites

1. When does the fetus typically begin to turn and respond to external stimulation during pregnancy?

• A. During the second or third week
• B. After the first trimester
• C. Sometimes
• D. Never

Correct answer: B

Rationale: The correct answer is B. The fetus typically begins to respond to external stimulation much later in pregnancy, usually after the first trimester. During the second or third week of pregnancy, the fetus is still in the early stages of development and is not yet capable of turning or responding to external stimuli. Choices A, C, and D are incorrect because they do not accurately reflect the timeline of fetal development when it comes to responding to external stimulation.

2. A client is in the second stage of labor. Which of the following manifestations should the nurse expect?

• A. The client expels the placenta
• B. The client experiences gradual dilation of the cervix
• C. The client begins having regular contractions
• D. The client delivers the newborn

Correct answer: D

Rationale: During the second stage of labor, the cervix is fully dilated, and the client delivers the newborn. The expulsion of the placenta occurs during the third stage of labor, not the second stage. Regular contractions typically begin in the first stage of labor, not the second. Gradual dilation of the cervix occurs during the first stage of labor, specifically during the active phase.

3. A client who is 24 weeks gestation arrives at the clinic reporting swollen hands. On examination, the nurse notes the client has had a rapid weight gain over six weeks. Which action should the nurse implement next?

• A. Review the client's previous blood pressures in the chart.
• B. Obtain the client's blood pressure.
• C. Observe and time the client's contractions.
• D. Examine the client for pedal edema.

Correct answer: B

Rationale: Swollen hands and rapid weight gain could be signs of preeclampsia, so the next step is to check the client's blood pressure. Elevated blood pressure is a key indicator in assessing for preeclampsia in pregnancy. Reviewing the client's previous blood pressures may provide additional context but obtaining the current blood pressure is crucial for immediate assessment. Observing and timing contractions are not relevant in this scenario as the client is not presenting with signs of active labor. Examining for pedal edema is important in assessing for fluid retention, but obtaining the blood pressure takes precedence in this case due to the potential seriousness of preeclampsia.

4. Rubella, also called German measles, is a viral infection passed from the mother to the fetus that can cause birth defects such as deafness, intellectual disabilities, blindness, and heart disease in the embryo.

• A. Rubella
• B. Syphilis
• C. Cystic fibrosis
• D. Phenylketonuria

Correct answer: A

Rationale: Rubella, also known as German measles, is a viral infection that can lead to severe birth defects when contracted by a mother during pregnancy. Rubella is the correct answer because it is specifically associated with causing birth defects such as deafness, intellectual disabilities, blindness, and heart disease in the embryo. Syphilis (Choice B) can be passed from mother to fetus but does not cause the mentioned birth defects associated with Rubella. Cystic fibrosis (Choice C) and Phenylketonuria (Choice D) are genetic conditions and not infections transmitted from mother to fetus, making them incorrect choices in this context.

5. A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. The client shows the nurse her readings for the past few days. Which reading signals the nurse that the client may require an adjustment of insulin or carbohydrates?

• A. 75 mg/dl before lunch. This is low; better eat now.
• B. 115 mg/dl 1 hour after lunch. This is a little high; maybe eat a little less next time.
• C. 115 mg/dl 2 hours after lunch. This is too high; it is time for insulin.
• D. 50 mg/dl just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.

Correct answer: D

Rationale: 50 mg/dl after waking from a nap is too low. During hours of sleep, glucose levels should not be less than 60 mg/dl. Snacks before sleeping can be helpful. The premeal acceptable range is 60 to 99 mg/dl. The readings 1 hour after a meal should be less than 129 mg/dl. Two hours after eating, the readings should be less than 120 mg/dl.

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