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 premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents?

• A. “Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide.”
• B. “The drug keeps your baby from requiring too much sedation.”
• C. “Surfactant is used to reduce episodes of periodic apnea.”
• D. “Your baby needs this medication to fight a possible respiratory tract infection.”

Correct answer: A

Rationale: Artificial surfactant can be administered as an adjunct to oxygen and ventilation therapy for premature infants with respiratory distress syndrome (RDS). It helps improve respiratory compliance by aiding in the exchange of oxygen and carbon dioxide until the infant can produce enough surfactant naturally. The correct explanation to the parents would be that surfactant therapy enhances the baby’s lung function by facilitating the exchange of oxygen and carbon dioxide. Choice B is incorrect because surfactant therapy does not affect sedation needs. Choice C is inaccurate as surfactant is not used to reduce episodes of periodic apnea. Choice D is incorrect as surfactant is not administered to fight respiratory tract infections; it specifically targets improving lung function in RDS.

3. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7-pound, 10-ounce (3220-gram) infant. Which information should the nurse provide to the client about these findings?

• A. The uterus should be firm to prevent an intrauterine infection.
• B. Both the lower uterine segment and the fundus must be massaged.
• C. A firm uterus prevents the endometrial lining from being sloughed.
• D. Clots may form inside a boggy uterus and need to be expelled.

Correct answer: D

Rationale: After childbirth, a boggy uterus indicates poor uterine tone, which can lead to the formation of clots. Massaging the fundus helps the uterus contract and expel clots, reducing the risk of postpartum hemorrhage. Choices A, B, and C are incorrect because the main concern with a boggy uterus is the risk of clot formation and postpartum hemorrhage, not solely preventing intrauterine infection, massaging the lower uterine segment, or preventing the endometrial lining from sloughing.

4. At 31 weeks gestation, a client with a fundal height measurement of 25 cm is scheduled for a series of ultrasounds to be performed every two weeks. Which explanation should the nurse provide?

• A. Assessment for congenital anomalies
• B. Recalculation of gestational age
• C. Evaluation of fetal growth
• D. Determination of fetal presentation

Correct answer: C

Rationale: The correct answer is C: 'Evaluation of fetal growth.' A fundal height measurement smaller than expected may indicate intrauterine growth restriction (IUGR), requiring serial ultrasounds to monitor fetal growth. Assessing for congenital anomalies (choice A) is usually done through detailed anatomy scans earlier in pregnancy. Recalculating gestational age (choice B) is typically unnecessary at this stage unless there are concerns about accuracy. Determining fetal presentation (choice D) is usually done closer to term to plan for the mode of delivery.

5. Which of the following is most likely to develop sickle cell anemia?

• A. European American
• B. Native American
• C. African American
• D. Asian American

Correct answer: C

Rationale: Sickle cell anemia is most commonly found in individuals of African American descent. This is because sickle cell trait provides some protection against malaria, and historically, regions where malaria is or was prevalent have higher rates of sickle cell anemia. Therefore, individuals with African ancestry are at a higher risk of developing sickle cell anemia compared to other populations. Choices A, B, and D are less likely to develop sickle cell anemia due to lower genetic prevalence in their respective populations.

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