Nursing Elites

1. A client at 42 weeks of gestation is having an ultrasound. For which of the following conditions should the nurse prepare for an amnioinfusion? (Select all that apply)

• A. Oligohydramnios
• B. Hydramnios
• C. Fetal cord compression
• D. Polyhydramnios

Correct answer: A

Rationale: In this scenario, the correct answer is "Oligohydramnios". Oligohydramnios, which refers to low amniotic fluid volume, may necessitate amnioinfusion to address the deficiency. Fetal cord compression is another indication for amnioinfusion as it can help alleviate pressure on the umbilical cord. Hydramnios or polyhydramnios, conversely, involve an excess of amniotic fluid and do not typically require amnioinfusion. Therefore, choices B, C, and D are incorrect in this context.

2. 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.

3. When caring for a client receiving nifedipine for prevention of preterm labor, the nurse should monitor the client for which of the following manifestations?

• A. Blood-tinged sputum
• B. Dizziness
• C. Pallor
• D. Somnolence

Correct answer: B

Rationale: Corrected Question: When caring for a client receiving nifedipine for prevention of preterm labor, the nurse should monitor the client for which of the following manifestations? Rationale: Nifedipine, a calcium channel blocker, causes vasodilation, potentially leading to a decrease in blood pressure and side effects such as dizziness. Monitoring for dizziness is essential to ensure the client's safety and well-being during treatment. Choices A, C, and D are incorrect as they are not typically associated with nifedipine use for preventing preterm labor. Blood-tinged sputum may indicate other conditions like pulmonary issues, pallor could suggest anemia or circulatory problems, and somnolence is not a common side effect of nifedipine.

4. What is the most appropriate statement for a nurse to make to a client who has recently experienced a perinatal death?

• A. It must be a comfort to know you have another child.
• B. I'm sad for you.
• C. There is usually something wrong with the baby.
• D. You will always have an angel in heaven.

Correct answer: B

Rationale: Option B, 'I'm sad for you,' is the most appropriate response for the nurse to make to the client who has experienced a perinatal death. This statement conveys empathy and compassion, acknowledging the client's grief and validating their emotions. It opens the door for the client to express their feelings and facilitates further communication and support from the nurse. Choices A, C, and D are not appropriate in this context. Choice A may come across as dismissive of the client's grief by redirecting the focus to another child. Choice C suggests blame or fault, which is not helpful or accurate in most cases of perinatal death. Choice D, while well-intentioned, may not be comforting to all clients and could impose a specific belief system on the client's experience.

5. A client is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown after childbirth. Which of the following conditions is associated with these manifestations?

• A. Postpartum fatigue
• B. Postpartum psychosis
• C. Letting-go phase
• D. Postpartum blues

Correct answer: D

Rationale: The correct answer is D, Postpartum blues. Postpartum blues, also known as baby blues, are common after childbirth and are characterized by symptoms like tearfulness, insomnia, lack of appetite, and a feeling of letdown. This condition is typically self-limiting and resolves without specific treatment. Postpartum fatigue (choice A) refers to extreme tiredness after childbirth but does not typically include symptoms like tearfulness and insomnia. Postpartum psychosis (choice B) is a severe condition that includes symptoms such as hallucinations and delusions, which are not present in the scenario. The letting-go phase (choice C) does not represent a specific postpartum condition related to the symptoms described.

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