Nursing Elites

1. 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.

2. A nurse in a clinic receives a phone call from a client who would like information about pregnancy testing. Which of the following information should the nurse provide to the client?

• A. You should wait 4 weeks after conception to be tested for pregnancy.
• B. You should be off any medications for 24 hours prior to the pregnancy test.
• C. You should not eat or drink for at least 8 hours prior to the pregnancy test.
• D. You should use your first morning urination specimen for a home pregnancy test.

Correct answer: D

Rationale: For the most accurate results, a home pregnancy test should be done using the first morning urine, which contains the highest concentration of hCG.

3. 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.

4. During a teaching session with a client in labor, a nurse is explaining episiotomy. Which of the following information should the nurse include?

• A. An episiotomy is a perineal incision made by the provider to facilitate delivery of the fetus
• B. A fourth-degree episiotomy extends into the rectal area and is not recommended
• C. An episiotomy is an incision made by the provider to facilitate delivery of the fetus
• D. A mediolateral episiotomy is preferred over a median episiotomy for most deliveries

Correct answer: C

Rationale: The correct answer is C because an episiotomy is an intentional incision made by the healthcare provider to widen the vaginal opening during delivery. This procedure is performed to facilitate the birth of the baby and prevent uncontrolled tearing of the perineum. It is important for the nurse to educate the client on the purpose and implications of episiotomy to ensure informed decision-making and proper postpartum care. Choice A is incorrect because an episiotomy is not a perineal tear but a deliberate incision. Choice B is incorrect because a fourth-degree episiotomy extending into the rectal area is not a standard practice and can lead to complications. Choice D is incorrect because a mediolateral episiotomy is not universally considered easier to repair than a median episiotomy; the choice of incision type depends on the healthcare provider's preference and clinical situation.

5. After an amniotomy, what is the priority nursing action?

• A. Observe color and consistency of fluid
• B. Assess the fetal heart rate pattern
• C. Assess the client's temperature
• D. Evaluate the client for the presence of chills and increased uterine tenderness using palpation

Correct answer: B

Rationale: After an amniotomy, the priority nursing action is to assess the fetal heart rate pattern. This is crucial to monitor for any signs of fetal distress, as changes in the fetal heart rate could indicate potential complications related to the procedure. Observing the color and consistency of the fluid (Choice A) is important but not the priority over assessing fetal well-being. Assessing the client's temperature (Choice C) and evaluating the client for chills and increased uterine tenderness (Choice D) are not immediate priorities following an amniotomy.

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