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. When developing an educational program for adolescents about nutrition during the third trimester of pregnancy, which of the following statements should be included?

• A. Consume three to four servings of dairy each day.
• B. Increase daily caloric intake by 600 to 700 calories.
• C. Limit daily sodium intake to less than 1 gram.
• D. Increase protein intake to 40 to 50 grams per day.

Correct answer: A

Rationale: The correct statement to include when developing an educational program for adolescents about nutrition during the third trimester of pregnancy is to consume three to four servings of dairy each day. Adequate calcium intake is crucial for bone development during pregnancy and helps prevent complications related to inadequate calcium intake. Increasing daily caloric intake by 600 to 700 calories (Choice B) is not necessary during the third trimester; excessive caloric intake can lead to unnecessary weight gain. Limiting daily sodium intake to less than 1 gram (Choice C) is not suitable during pregnancy, as some sodium intake is necessary for maintaining fluid balance. Increasing protein intake to 40 to 50 grams per day (Choice D) is important during pregnancy, but the emphasis in this case should be on calcium from dairy sources for bone development.

3. A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, 'I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device.' The nurse should suspect which of the following?

• A. Missed abortion
• B. Ectopic pregnancy
• C. Severe preeclampsia
• D. Hydatidiform mole

Correct answer: B

Rationale: Ectopic pregnancy should be suspected in clients with abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding, especially if they have an intrauterine device (IUD). In this case, the client's symptoms are classic for ectopic pregnancy, where the fertilized egg implants outside the uterus, commonly in the fallopian tube. Missed abortion (choice A) refers to a nonviable embryo or fetus in the uterus, which is not consistent with the client's presentation. Severe preeclampsia (choice C) is characterized by hypertension and proteinuria, not the symptoms described. Hydatidiform mole (choice D) presents with vaginal bleeding but typically lacks abdominal pain and is not related to the presence of an IUD.

4. During an assessment of a client in labor who received epidural anesthesia, which finding should the nurse identify as a complication of the epidural block?

• A. Vomiting
• B. Tachycardia
• C. Respiratory depression
• D. Hypotension

Correct answer: D

Rationale: Hypotension is a common complication of epidural anesthesia due to the vasodilation effect of the medication. Epidural anesthesia can lead to vasodilation, causing a decrease in blood pressure. This hypotension may result in decreased perfusion to vital organs and compromise maternal and fetal well-being. Tachycardia is less likely as a complication of epidural anesthesia since it tends to have a vasodilatory effect. Respiratory depression is more commonly associated with other forms of anesthesia, such as general anesthesia, rather than epidural anesthesia. Vomiting is not typically a direct complication of epidural anesthesia and is more commonly seen with other factors such as pain or medications given during labor.

5. A client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

• A. Check the client's temperature.
• B. Observe for uterine contractions.
• C. Administer Rho(D) immune globulin.
• D. Monitor the fetal heart rate (FHR).

Correct answer: D

Rationale: After an amniocentesis, the priority nursing intervention is to monitor the fetal heart rate (FHR) as the greatest risk to the client and fetus is fetal death. This monitoring helps in early identification of any fetal distress or compromise, allowing prompt intervention to ensure fetal well-being. Checking the client's temperature (Choice A) is not the priority as monitoring the fetus is crucial for immediate assessment. Observing for uterine contractions (Choice B) is important but not the priority after an amniocentesis. Administering Rho(D) immune globulin (Choice C) is typically done to Rh-negative clients after procedures that may lead to fetal-maternal hemorrhage, not immediately after an amniocentesis.

Similar Questions