Nursing Elites

1. The client is 24 weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?

• A. Hemoglobin A1C.
• B. Postprandial blood glucose test.
• C. Oral glucose tolerance test.
• D. Fasting blood glucose.

Correct answer: C

Rationale: An abnormal oral glucose tolerance test result is indicative of gestational diabetes. This test is crucial in diagnosing gestational diabetes as it evaluates how well the body processes glucose after a sugary drink. Reporting abnormal results promptly allows for timely intervention and management to ensure the well-being of both the mother and the baby. The other options are not the primary tests used to diagnose gestational diabetes. Hemoglobin A1C is not recommended for diagnosing gestational diabetes as it reflects long-term glucose control. Postprandial blood glucose and fasting blood glucose tests are not as sensitive as the oral glucose tolerance test for diagnosing gestational diabetes.

2. An infant delivered vaginally by an HIV-positive mother is admitted to the newborn nursery. What intervention should the healthcare provider perform first?

• A. Bathe the infant with an antimicrobial soap.
• B. Measure the head and chest circumference.
• C. Obtain the infant's footprints.
• D. Administer vitamin K (AquaMEPHYTON).

Correct answer: A

Rationale: The initial intervention should be to bathe the infant with an antimicrobial soap to reduce the risk of HIV transmission from maternal fluids. This immediate action helps minimize potential exposure to the virus and promotes infection control practices in the care of infants born to HIV-positive mothers. Choice B, measuring head and chest circumference, is important for assessing growth and development but not the priority in this scenario. Choice C, obtaining footprints, is a routine procedure but not a priority over infection control measures. Choice D, administering vitamin K, is important for clotting factors but does not address the immediate risk of HIV transmission.

3. A primipara has delivered a stillborn fetus at 30 weeks gestation. To assist the parents in the grieving process, which intervention is most important for the nurse to implement?

• A. Provide an opportunity for the parents to hold their infant in privacy.
• B. Assist the couple in completing a request for autopsy.
• C. Encourage the couple to seek family counseling within the next few weeks.
• D. Explain the possible causes of fetal demise.

Correct answer: A

Rationale: Allowing the parents to hold their infant in privacy is crucial for facilitating the grieving process after the loss of a stillborn child. This intimate moment can help the parents create memories, bond with their baby, and start the healing process.

4. The client delivered hours ago and has a boggy uterus displaced above and to the right of the umbilicus. What action should the nurse take?

• A. Inspect the perineal pad.
• B. Encourage voiding.
• C. Monitor vital signs.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: A boggy uterus that is displaced above and to the right of the umbilicus may indicate a full bladder, which can impede uterine contraction and lead to hemorrhage. Encouraging the client to void helps relieve pressure on the uterus, promoting better contraction and preventing postpartum hemorrhage.

5. Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

• A. Unilateral lower leg pain.
• B. Saturating two perineal pads per hour.
• C. Pulse rate of 56 bpm.
• D. Soft, spongy fundus.

Correct answer: C

Rationale: A pulse rate of 56 bpm is a normal finding for a primigravida client who is 12 hours postpartum. Bradycardia (pulse rate 50-70 bpm) can be a normal postpartum occurrence due to increased stroke volume and decreased cardiac output after delivery. Unilateral lower leg pain and saturating two perineal pads per hour are not normal findings and require further assessment. A soft, spongy fundus could indicate uterine atony, which is abnormal postpartum.

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