Nursing Elites

1. A client is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 minutes apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The client is in which of the following phases of labor?

• A. Active
• B. Transition
• C. Latent
• D. Descent

Correct answer: B

Rationale: The client is in the transition phase of labor, characterized by cervical dilatation of 8 to 10 cm and contractions every 2 to 3 minutes, each lasting 45 to 90 seconds. In this phase, the cervix is nearly fully dilated, preparing the client for the pushing stage. The active phase of labor typically involves cervical dilatation from 4 to 7 cm, whereas the latent phase is the early phase of labor when the cervix dilates from 0 to 3 cm. Descent is not a phase of labor but rather refers to the movement of the fetus through the birth canal during the second stage of labor.

2. A newborn is small for gestational age (SGA). Which of the following findings is associated with this condition?

• A. Moist skin
• B. Protruding abdomen
• C. Gray umbilical cord
• D. Wide skull sutures

Correct answer: D

Rationale: Wide skull sutures are a common finding in newborns who are small for gestational age (SGA) due to reduced intrauterine growth. This occurs because the skull bones do not grow at the same rate as the brain, leading to wider sutures. Moist skin, a protruding abdomen, and a gray umbilical cord are not typically associated with being small for gestational age.

3. A client with hyperemesis gravidarum is receiving dietary teaching. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will eat foods that appeal to my taste instead of trying to balance my meals.
• B. I will avoid having a snack at bedtime.
• C. I will have 8 ounces of hot tea with each meal.
• D. I will pair my sweets with a starch instead of eating them alone.

Correct answer: A

Rationale: In hyperemesis gravidarum, where there is severe nausea and vomiting during pregnancy, it is essential for the client to eat foods that appeal to their taste to prevent further nausea. Balancing meals may not be a priority initially if the client is struggling to keep any food down. Choice B is unrelated to managing hyperemesis gravidarum. Choice C, having hot tea with each meal, may not necessarily address the issue of taste preferences. Choice D, pairing sweets with a starch, is not as relevant as choosing foods appealing to taste for managing hyperemesis gravidarum.

4. When assessing a newborn with respiratory distress syndrome who received synthetic surfactant, which parameter should the nurse monitor to evaluate the newborn's condition?

• A. Oxygen saturation
• B. Body temperature
• C. Serum bilirubin
• D. Heart rate

Correct answer: A

Rationale: In a newborn with respiratory distress syndrome who has received synthetic surfactant, monitoring oxygen saturation is crucial to evaluate the effectiveness of the treatment. Oxygen saturation levels provide valuable information about the newborn's respiratory status and the adequacy of gas exchange. Changes in oxygen saturation can indicate improvements or deterioration in the newborn's condition following the administration of synthetic surfactant. Monitoring oxygen saturation helps the nurse assess the newborn's response to treatment and make timely interventions if needed. Body temperature, serum bilirubin, and heart rate are important parameters to monitor in newborns for other conditions but are not specific indicators of the effectiveness of synthetic surfactant in treating respiratory distress syndrome.

5. While observing the electronic fetal heart rate monitor tracing for a client at 40 weeks of gestation in labor, a nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

• A. Early decelerations
• B. Accelerations
• C. Late decelerations
• D. Variable decelerations

Correct answer: D

Rationale: Variable decelerations can indicate umbilical cord compression, which is a concern that may arise due to the umbilical cord being compressed during labor. This compression can lead to reduced blood flow and oxygen delivery to the fetus, necessitating close monitoring and potentially interventions to alleviate the pressure on the cord. Early decelerations are typically benign and mirror the contractions, indicating fetal head compression. Accelerations are reassuring patterns that show a healthy response to fetal movement. Late decelerations are concerning as they suggest uteroplacental insufficiency, indicating potential oxygen deprivation to the fetus.

Similar Questions