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 healthcare provider in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the healthcare provider expect? (Select all that apply)

• A. Joint pain
• B. Malaise
• C. Rash
• D. Tender lymph nodes

Correct answer: D

Rationale: A TORCH infection can cause joint pain, malaise, rash, and tender lymph nodes. These findings are characteristic of TORCH infections and are important to recognize in pregnant individuals as they can have serious implications for both the mother and the fetus. While joint pain, malaise, and rash can be present in TORCH infections, tender lymph nodes are a common finding that the healthcare provider should expect. Tender lymph nodes are often associated with the inflammatory response to infection and can be palpated during a physical examination. Therefore, in this scenario, the healthcare provider should anticipate the presence of tender lymph nodes in a client with a TORCH infection, making option D the correct answer.

3. In a prenatal clinic, a client in the first trimester of pregnancy has a health record that includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply)

• A. Client has delivered one newborn at term
• B. Client has experienced no preterm labor
• C. Client has had two prior pregnancies
• D. ALL OF THE ABOVE - has one living child

Correct answer: D

Rationale: The client's health record data is interpreted as follows: G3 (gravida 3 - total number of pregnancies), T1 (term births - number of full-term deliveries), P0 (preterm births - number of preterm deliveries), A1 (abortions/miscarriages - total number of miscarriages or abortions), L1 (living children - total number of living children). Therefore, the client has had three pregnancies, one full-term delivery, no preterm labor, one miscarriage/abortion, and one living child. The correct interpretation is that the client has delivered one newborn at term, experienced no preterm labor, had two prior pregnancies, and has one living child. Therefore, choice D is correct. Choices A, B, and C are incorrect as they do not provide a comprehensive interpretation of all aspects of the client's health record data.

4. A client at 28 weeks of gestation received terbutaline. Which of the following findings should the nurse expect?

• A. Fetal heart rate 100/min
• B. Weakened uterine contractions
• C. Enhanced production of fetal lung surfactant
• D. Maternal blood glucose 63 mg/dL

Correct answer: B

Rationale: Terbutaline is a tocolytic medication that works by relaxing the uterine muscles, leading to weakened uterine contractions. This effect helps to prevent preterm labor. Therefore, the nurse should expect weakened uterine contractions in a client who has received terbutaline at 28 weeks of gestation. Choices A, C, and D are incorrect. Terbutaline administration would not directly affect the fetal heart rate, enhance fetal lung surfactant production, or cause maternal hypoglycemia.

5. During an assessment, a client at 26 weeks of gestation presents with which of the following clinical manifestations that should be reported to the provider?

• A. Leukorrhea
• B. Supine hypotension
• C. Periodic numbness of the fingers
• D. Decreased urine output

Correct answer: D

Rationale: During pregnancy, decreased urine output can be indicative of decreased renal perfusion and impaired fetal well-being. It can also be a sign of preeclampsia when associated with symptoms like increased blood pressure, proteinuria, and decreased fetal activity. Therefore, the nurse should promptly report this finding to the healthcare provider for further evaluation and management. Leukorrhea is a common finding in pregnancy and not typically concerning. Supine hypotension and periodic numbness of the fingers can be managed by changing positions or adjusting posture and are not as urgent as decreased urine output in this context.

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