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 client who is pregnant and has phenylketonuria (PKU) is receiving teaching from a nurse. Which of the following foods should the nurse instruct the client to eliminate from her diet?

• A. Peanut butter
• B. Potatoes
• C. Apple juice
• D. Broccoli

Correct answer: A

Rationale: Individuals with phenylketonuria (PKU) have difficulty breaking down phenylalanine, an amino acid found in protein-rich foods like peanut butter. Therefore, clients with PKU should avoid foods high in phenylalanine, such as peanut butter, to prevent adverse effects on their health. Choices B, C, and D are not typically high in phenylalanine and do not pose the same risk to individuals with PKU as peanut butter.

3. During newborn gestational age assessment, which finding should be recorded as part of this assessment on the newborn?

• A. Acrocyanosis of hands and feet
• B. Anterior fontanel soft and level
• C. Plantar creases cover 2/3 of sole
• D. Vernix caseosa in inguinal creases

Correct answer: C

Rationale: Plantar creases covering 2/3 of the sole is an important physical characteristic used to assess gestational age in a newborn. This finding is significant because as gestational age advances, the plantar creases cover a larger portion of the sole. It is a valuable clue to the healthcare provider in determining the newborn's maturity level. Choices A, B, and D are incorrect as they do not specifically relate to gestational age assessment. Acrocyanosis and vernix caseosa are common findings in newborns but are not directly used for determining gestational age. The softness and level of the anterior fontanel can provide information about intracranial pressure but are not directly related to gestational age assessment.

4. 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.

5. A healthcare provider is instructing a client who is taking an oral contraceptive about manifestations to report. Which of the following manifestations should the healthcare provider include?

• A. Reduced menstrual flow
• B. Breast tenderness
• C. Shortness of breath
• D. Increased appetite

Correct answer: C

Rationale: Shortness of breath is a symptom that can indicate a serious side effect of oral contraceptives, such as a potential blood clot in the lungs. This condition requires immediate medical attention to prevent complications. Choices A, B, and D are not typically associated with serious side effects of oral contraceptives and are considered normal or common side effects that do not require urgent medical attention.

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