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. Four clients at full term present to the labor and delivery unit at the same time. Which client should a nurse assess first?

• A. Multipara with contractions occurring every three minutes
• B. Multipara scheduled for non-stress test and biophysical profile
• C. Primipara with vaginal show and leaking membranes
• D. Primipara with burning on urination and urinary frequency

Correct answer: C

Rationale: A primipara with vaginal show and leaking membranes requires immediate assessment as she may be in active labor or at risk of infection. The vaginal show and leaking membranes suggest potential rupture of membranes and the start of labor. Assessing her first ensures prompt management and monitoring. The other options, while important, do not indicate immediate or emergent needs. Contractions every three minutes in a multipara can be managed with ongoing monitoring; non-stress tests and biophysical profiles can be scheduled and are not acute needs. Burning on urination and urinary frequency in a primipara may indicate a urinary tract infection, which is important but not as urgent as assessing for active labor or rupture of membranes.

3. During which of the following periods does the development of arms and legs occur in a pregnancy?

• A. Development of the lungs
• B. Development of the heart
• C. Development of arms and legs
• D. Development of the stomach

Correct answer: C

Rationale: The correct answer is C. The development of arms and legs occurs during the critical period of the fourth to eighth weeks of pregnancy. This timeframe is crucial for the formation of limbs and other key body parts. Choices A, B, and D are incorrect because the development of the lungs, heart, and stomach respectively occurs at different stages of fetal development and is not primarily associated with the fourth to eighth weeks of pregnancy.

4. A client at 38 weeks gestation is admitted to labor and delivery with a complaint of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears the noise of a baby. What should the nurse do first?

• A. Push the call light for help
• B. Inspect the client's perineum
• C. Notify a healthcare provider
• D. Turn on the infant warmer

Correct answer: B

Rationale: Inspecting the client's perineum immediately is necessary to assess if the baby is being delivered, which would require urgent action. Pushing the call light for help (Choice A) may delay the assessment and immediate action needed. Notifying a healthcare provider (Choice C) might cause further delays, as the situation requires urgent attention. Turning on the infant warmer (Choice D) is not the priority; ensuring safe delivery and assessment of the baby's condition come first.

5. A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What is the nurse’s highest priority in this situation?

• A. Prepare the woman for imminent birth.
• B. Notify the woman’s primary healthcare provider.
• C. Document the characteristics of the fluid.
• D. Assess the fetal heart rate (FHR) and pattern.

Correct answer: D

Rationale: The correct answer is to assess the fetal heart rate (FHR) and pattern (Choice D). When a multiparous woman's membranes rupture after 8 hours of labor, the nurse's priority is to assess the fetal well-being. Rupture of membranes can lead to potential complications such as umbilical cord prolapse. Monitoring the fetal heart rate and pattern immediately after the rupture of membranes is crucial to ensure the fetus is not in distress. This assessment helps in determining the need for immediate interventions to safeguard the fetus. Documenting the characteristics of the fluid (Choice C) may be necessary but is of lower priority compared to assessing fetal well-being. While preparing the woman for imminent birth (Choice A) is important, assessing the fetal heart rate takes precedence to ensure the fetus is not compromised. Notifying the woman's primary healthcare provider (Choice B) is also important but not the highest priority at this moment.

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