Nursing Elites

1. A client in labor requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort?

• A. Assisting the client into a squatting position
• B. Having the client lie in a supine position
• C. Applying fundal pressure during contractions
• D. Encouraging the client to void every 6 hours

Correct answer: A

Rationale: Assisting the client into a squatting position promotes comfort during labor. This position can help relieve pain by utilizing gravity, allowing the pelvic outlet to widen, and potentially facilitating the progress of labor. Lying in a supine position (Choice B) can hinder labor progression and increase discomfort. Applying fundal pressure (Choice C) can be inappropriate and may cause harm as it is not routinely recommended during labor. Encouraging the client to void every 6 hours (Choice D) is important for bladder management but does not directly address pain relief during labor.

2. Females with Turner syndrome:

• A. possess more thymine than cytosine.
• B. are taller than average.
• C. produce little estrogen.
• D. are more likely to give birth to twins.

Correct answer: C

Rationale: Turner syndrome is a chromosomal disorder in females characterized by short stature and underdeveloped ovaries, resulting in low estrogen production. This leads to symptoms such as delayed puberty and infertility. Choice A is incorrect because the chromosomal abnormality in Turner syndrome does not affect the thymine-cytosine ratio. Choice B is incorrect as females with Turner syndrome are typically shorter than average. Choice D is incorrect as Turner syndrome does not increase the likelihood of giving birth to twins.

3. What information should the nurse include when teaching a client at 41 weeks of gestation about a non-stress test?

• A. This test will confirm fetal lung maturity.
• B. This test will determine the adequacy of placental perfusion.
• C. This test will detect fetal infection.
• D. This test will predict maternal readiness for labor.

Correct answer: B

Rationale: The correct answer is B: 'This test will determine the adequacy of placental perfusion.' The non-stress test is used to assess fetal well-being by monitoring the fetal heart rate in response to its own movements. It helps determine if the fetus is receiving enough oxygen and nutrients through placental perfusion. Choice A is incorrect because confirming fetal lung maturity is typically determined through tests like amniocentesis, not the non-stress test. Choice C is incorrect because detecting fetal infection is not the primary purpose of a non-stress test. Choice D is incorrect because predicting maternal readiness for labor is not the purpose of the non-stress test; it focuses on fetal well-being.

4. A client at 38 weeks of gestation has a prescription for intravaginal misoprostol. Which of the following statements should the nurse make?

• A. “You will need to stay in a side-lying position for 30 minutes after each dose.”
• B. “You will receive an IV infusion of oxytocin 1 hour after your last dose.”
• C. “You will receive a magnesium supplement immediately following therapy.”
• D. “You will need to have a full bladder before the therapy begins.”

Correct answer: A

Rationale: The correct answer is A. Instructing the client to stay in a side-lying position after receiving misoprostol intravaginally is essential. This position helps keep the medication in place, allowing for better absorption. Choice B is incorrect because oxytocin administration is not typically indicated after misoprostol use. Choice C is incorrect as magnesium supplementation is not part of the standard protocol for misoprostol administration. Choice D is incorrect as having a full bladder is not necessary before initiating misoprostol therapy.

5. A client in the transition phase of labor reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take?

• A. Instruct the client to use effleurage.
• B. Apply counterpressure to the client's sacrum.
• C. Assist the client with patterned-paced breathing.
• D. Teach the client the technique of biofeedback.

Correct answer: B

Rationale: During the transition phase of labor, a client may experience intense back pain due to the pressure of the baby descending. Applying counterpressure to the client's sacrum can help alleviate this discomfort. Effleurage is a light stroking massage technique that may not provide adequate relief for intense back pain. Patterned-paced breathing is beneficial for managing contractions but may not directly address back pain. Biofeedback is a technique that helps individuals gain awareness and control of certain physiological functions, but it may not be the most appropriate intervention for acute labor pain.

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