Nursing Elites

1. The client at 10 weeks' gestation is palpated with the fundus at 3 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. What action should the nurse take?

• A. Collect a urine sample for urinalysis.
• B. Measure vital signs.
• C. Recommend bed rest.
• D. Obtain human chorionic gonadotropin levels.

Correct answer: D

Rationale: In a pregnant client with a fundal height greater than expected at 10 weeks and experiencing scant dark brown vaginal discharge, there is a concern for a molar pregnancy. Assessing human chorionic gonadotropin (hCG) levels is crucial in this situation to confirm or rule out this condition.

2. What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula?

• A. Body temperature.
• B. Level of pain.
• C. Time of first void.
• D. Number of vessels in the cord.

Correct answer: D

Rationale: The priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula is to check the number of vessels in the cord. This assessment is crucial to identify any potential anomalies related to the TE fistula, as abnormalities in the cord vessels may indicate associated congenital anomalies that need immediate attention.

3. During a newborn assessment, which symptom would indicate respiratory distress if present in a newborn?

• A. Flaring of the nares.
• B. Shallow and irregular respirations.
• C. Respiratory rate of 50 breaths per minute.
• D. Abdominal breathing with synchronous chest movement.

Correct answer: A

Rationale: Flaring of the nares is a classic sign of respiratory distress in newborns. It indicates that the newborn is working hard to breathe, and immediate attention should be given to assess and address the respiratory status of the infant.

4. A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother, who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which intervention is most important to implement?

• A. Provide a bottle of electrolyte solution.
• B. Infuse normal saline intravenously.
• C. Administer an antipyretic rectally.
• D. Apply an external cooling blanket.

Correct answer: B

Rationale: Infusing normal saline intravenously is crucial to treat dehydration caused by fever and diarrhea. In this scenario, the infant's weak cry with no tears indicates severe dehydration, necessitating rapid fluid replacement via intravenous normal saline to restore fluid balance and prevent complications.

5. What is the most important assessment for the healthcare provider to conduct before the administration of epidural anesthesia to a client at 40 weeks' gestation?

• A. Maternal blood pressure.
• B. Level of pain sensation.
• C. Station of presenting part.
• D. Variability of fetal heart rate.

Correct answer: A

Rationale: Assessing maternal blood pressure is crucial before administering epidural anesthesia because it can cause hypotension, affecting both the mother and the fetus. Hypotension can lead to decreased placental perfusion, potentially compromising the fetal oxygen supply. Monitoring and maintaining maternal blood pressure within a safe range are essential to ensure the well-being of both the mother and the fetus during the administration of epidural anesthesia. The other options, such as assessing the level of pain sensation, station of presenting part, and variability of fetal heart rate, are important in obstetric care but are not as critical as monitoring maternal blood pressure to prevent complications related to epidural anesthesia administration.

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