Nursing Elites

1. When caring for a client in labor, which of the following infections can be treated during labor or immediately following birth? (Select all that apply)

• A. Gonorrhea
• B. Chlamydia
• C. HIV
• D. All of the Above

Correct answer: D

Rationale: Infections such as gonorrhea, chlamydia, and HIV can be treated during labor or immediately following birth to prevent transmission to the newborn. It is crucial to identify and treat these infections promptly to reduce the risk of vertical transmission to the infant. Therefore, all the given options are correct as they can be treated during labor or immediately following birth to prevent transmission to the newborn. Other choices are incorrect because only gonorrhea, chlamydia, and HIV can be effectively treated during labor or immediately after birth to prevent vertical transmission.

2. A pregnant client is learning about Kegel exercises in the third trimester. Which statement signifies understanding of the teaching?

• A. These exercises facilitate preventing constipation.
• B. These exercises aid pelvic muscle stretching during birth.
• C. They assist in decreasing backaches.
• D. They can prevent additional stretch marks.

Correct answer: B

Rationale: Kegel exercises are beneficial during pregnancy to help strengthen pelvic muscles, which is crucial for childbirth. Pelvic muscle stretching during birth is a key aspect of labor, making choice B the correct statement indicating understanding of the teaching. Choices A, C, and D are incorrect because Kegel exercises primarily focus on strengthening pelvic floor muscles to support the uterus, bladder, and bowel, aiding in labor and delivery. They are not directly related to preventing constipation, decreasing backaches, or preventing stretch marks.

3. A client in a prenatal clinic is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make?

• A. This is due to an increase in blood volume.
• B. This is due to pressure from the uterus on the diaphragm.
• C. This is due to the weight of the uterus on the vena cava.
• D. This is due to increased cardiac output.

Correct answer: C

Rationale: Maternal hypotension during pregnancy is often caused by the weight of the uterus pressing on the vena cava when the client is lying on her back, which reduces blood flow to the heart. This compression can lead to a decrease in blood pressure and subsequent symptoms of hypotension. Choice A is incorrect because an increase in blood volume typically leads to increased blood pressure rather than hypotension. Choice B is incorrect as pressure from the uterus on the diaphragm is not a common cause of maternal hypotension. Choice D is incorrect because increased cardiac output would not directly cause maternal hypotension.

4. A client in active labor is irritable, reports the urge to have a bowel movement, vomits, and states, 'I've had enough. I can't do this anymore.' Which of the following stages of labor is the client experiencing?

• A. Second stage
• B. Fourth stage
• C. Transition phase
• D. Latent phase

Correct answer: C

Rationale: The client in active labor displaying irritability, the urge to have a bowel movement, nausea, vomiting, and expressing frustration indicates that they are in the transition phase of labor. This phase typically occurs just before entering the second stage of labor, marked by intense contractions and cervical dilation from 8 to 10 centimeters. During this phase, the client may feel overwhelmed, exhausted, and may express a sense of losing control. It is a crucial phase indicating that the client is close to delivering the baby. Choice A, the second stage of labor, is characterized by complete cervical dilation and the birth of the baby, not the symptoms described in the scenario. Choice B, the fourth stage, is the period following the delivery of the placenta, not the phase before giving birth. Choice D, the latent phase, is the early phase of labor where contractions are mild and occur at irregular intervals, not the phase described in the scenario.

5. A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client?

• A. The client's room number
• B. The client's telephone number
• C. The client's birth date
• D. The client's medical record number

Correct answer: A

Rationale: The correct answer is A. Using the client's room number as a secondary identifier is not an appropriate method for client identification in healthcare settings. It can lead to confusion and potential errors, especially in a busy environment like a postpartum unit. Room numbers are not unique to individual patients and can change frequently. Instead, healthcare providers should use more reliable and specific identifiers like the client's name, medical record number, or date of birth to ensure accurate identification and safe administration of medications. Choices B, C, and D are more appropriate secondary identifiers for client identification as they are more specific and less prone to errors than room numbers.

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