Nursing Elites

1. What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy?

• A. Assessing FHR and maternal vital signs.
• B. Performing a venipuncture for hemoglobin and hematocrit levels.
• C. Placing clean disposable pads to collect any drainage.
• D. Monitoring uterine contractions.

Correct answer: A

Rationale: The highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to assess the fetal heart rate (FHR) and maternal vital signs. This assessment is crucial in determining the extent of blood loss and its impact on both the mother and the fetus. Ensuring the well-being of both the mother and the fetus is the top priority in this situation. While obtaining hemoglobin and hematocrit levels is important, it can be done after the initial assessment. Placing clean disposable pads is necessary for managing any drainage but does not take precedence over assessing vital signs. Monitoring uterine contractions is important but is not the highest priority when compared to assessing the FHR and maternal vital signs.

2. On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?

• A. Firm, larger, and very tender to the touch
• B. Slightly firm with an immediate let-down response
• C. Soft with no change from before delivery
• D. Filling and secreting colostrum

Correct answer: D

Rationale: On the first postpartum day, the nurse is most likely to find the breasts filling and secreting colostrum. Colostrum secretion is common as the body prepares for breastfeeding in the initial days after delivery. Choice A is incorrect as breasts are not typically very tender immediately postpartum. Choice B is incorrect as an immediate let-down response is more related to lactation rather than the first postpartum day. Choice C is incorrect as the breasts typically undergo changes, such as filling with colostrum, after delivery.

3. A newborn who was born post-term is being assessed by a nurse. Which of the following findings should the nurse expect?

• A. A Rh-negative mother who has an Rh-positive infant
• B. A Rh-positive mother who has an Rh-negative infant
• C. A Rh-positive mother who has an Rh-positive infant
• D. A Rh-negative mother who has an Rh-negative infant

Correct answer: A

Rationale: The correct answer is A: 'A Rh-negative mother who has an Rh-positive infant.' In cases where the newborn is born post-term, the mismatched Rh factor between the mother (Rh-negative) and the infant (Rh-positive) can lead to hemolytic disease of the newborn. This condition occurs when maternal antibodies attack fetal red blood cells, causing hemolysis. This can result in jaundice, anemia, and other serious complications for the infant. Choices B, C, and D are incorrect because they do not reflect the mismatched Rh factor scenario that poses a risk for hemolytic disease of the newborn.

4. A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats per minute and contractions are occurring irregularly every 10 to 15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time?

• A. Membranes are intact.
• B. 2+ pitting edema in lower extremities.
• C. Contractions decrease with walking.
• D. Cervical dilation is 1 centimeter.

Correct answer: C

Rationale: The correct answer is C. Contractions that decrease with walking are typically indicative of false labor, as true labor contractions tend to intensify with activity. Choices A, B, and D are incorrect. A) Intact membranes are a normal finding and do not confirm the absence of labor. B) 2+ pitting edema in lower extremities is a sign of fluid retention and not directly related to labor status. D) Cervical dilation of 1 centimeter indicates some cervical changes, but it alone does not confirm active labor.

5. Which synthetic hormone is used to prevent miscarriages and can cause masculinization of the fetus?

• A. Testosterone
• B. Estrogen
• C. Progestin
• D. Oxytocin

Correct answer: C

Rationale: Progestin is the synthetic hormone used to prevent miscarriages. While it is beneficial in maintaining pregnancy, in some cases, it can lead to masculinization of the fetus. Testosterone (Choice A) and estrogen (Choice B) are not typically used to prevent miscarriages and do not cause masculinization of the fetus in this context. Oxytocin (Choice D) is a hormone involved in labor and breastfeeding, but it is not used to prevent miscarriages nor does it cause masculinization of the fetus.

Similar Questions