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 at 37 weeks gestation presents to labor and delivery with contractions every two minutes. The nurse observes several shallow small vesicles on her pubis, labia, and perineum. The nurse should recognize the client is exhibiting symptoms of which condition?

• A. Genital Warts
• B. Syphilis
• C. Herpes Simplex Virus
• D. German Measles

Correct answer: C

Rationale: The correct answer is C: Herpes Simplex Virus (HSV). HSV can present with small vesicles on the genital area, and it is a concern during labor due to the risk of transmission to the newborn. Genital warts (Choice A) are caused by the human papillomavirus (HPV) and typically present as flesh-colored growths, not vesicles. Syphilis (Choice B) manifests as painless sores and can have systemic effects but does not typically present with vesicles. German measles (Choice D), also known as Rubella, is a viral illness characterized by a red rash, fever, and lymphadenopathy, not vesicles.

3. A newborn is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?

• A. Apply a thin layer of lotion to the newborn's skin every 8 hours.
• B. Give the newborn 1 oz of glucose water every 4 hours.
• C. Ensure the newborn's eyes are closed beneath the shield.
• D. Dress the newborn in a thin layer of clothing during therapy.

Correct answer: C

Rationale: During phototherapy using a lamp, it is crucial to protect the newborn's eyes from the light to prevent damage. Closing the newborn's eyes beneath the shield is essential for this purpose. Applying lotion to the skin (Choice A) is not recommended as it can intensify the effects of the phototherapy. Giving glucose water (Choice B) is unrelated to the phototherapy process and is not indicated. Dressing the newborn in clothing (Choice D) may hinder the effectiveness of the phototherapy by blocking the light exposure to the skin.

4. A client is experiencing preterm labor and has a prescription for 4 doses of dexamethasone 6 mg IM every 12 hours. The available concentration is dexamethasone 10 mg/mL. How many mL of dexamethasone should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use trailing zero.)

• A. 0.6 mL
• B. ---
• C. ---
• D. ---

Correct answer: A

Rationale: Calculation: (6 mg/dose) / (10 mg/mL) = 0.6 mL per dose. The correct answer is 0.6 mL. This calculation is obtained by dividing the dose needed (6 mg) by the concentration available (10 mg/mL). The resulting value is 0.6 mL per dose. Choices B, C, and D are not applicable as the correct answer has been calculated accurately.

5. At 12 hours after the birth of a healthy infant, the mother complains of feeling constant vaginal pressure. The nurse determines the fundus is firm and at midline with moderate rubra lochia. Which action should the nurse take?

• A. Check the suprapubic area for distention
• B. Inform the client to take a warm sitz bath
• C. Inspect the client's perineal and rectal areas
• D. Apply a fresh pad and check in 1 hour

Correct answer: C

Rationale: In this situation, the mother's complaint of constant vaginal pressure along with a firm fundus and moderate rubra lochia indicates a potential perineal injury or hematoma. The correct action for the nurse to take is to inspect the client's perineal and rectal areas to assess for any signs of trauma or hematoma. Checking the suprapubic area for distention (Choice A) is not the priority here since the symptoms suggest a perineal issue. Advising a warm sitz bath (Choice B) may not address the underlying issue and could potentially worsen any existing trauma. Applying a fresh pad and checking in 1 hour (Choice D) does not address the need for immediate assessment of the perineal and rectal areas in response to the reported symptoms.

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