Nursing Elites

1. A healthcare provider is discussing the differences between true labor and false labor with a group of expectant parents. Which of the following characteristics should the healthcare provider include when discussing true labor?

• A. Contractions become stronger with walking.
• B. Discomfort can be relieved with a back massage.
• C. Contractions become irregular with a change in activity.
• D. Discomfort is felt above the umbilicus.

Correct answer: A

Rationale: During true labor, contractions typically become stronger and more regular with activity, such as walking. This is a key characteristic that helps differentiate true labor from false labor. In false labor, contractions often remain irregular and do not intensify with changes in activity. Choice B is incorrect because discomfort in true labor is not typically relieved with a back massage. Choice C is incorrect as contractions in true labor become stronger and more regular with activity rather than irregular. Choice D is incorrect because discomfort in true labor is usually felt in the lower abdomen and pelvis, not above the umbilicus.

2. A client who is breastfeeding and has mastitis is receiving teaching from the nurse. Which of the following responses should the nurse make?

• A. Limit the amount of time the infant nurses on each breast.
• B. Nurse the infant only on the unaffected breast until resolved.
• C. Completely empty each breast at each feeding or use a pump.
• D. Wear a tight-fitting bra until lactation has ceased.

Correct answer: C

Rationale: The correct response is to completely empty each breast at each feeding or use a pump to prevent milk stasis, which can exacerbate mastitis. By ensuring proper drainage of the affected breast, the client can help alleviate symptoms and promote healing. Choice A is incorrect because limiting feeding time can lead to inadequate drainage, potentially worsening the condition. Choice B is incorrect as it can cause engorgement in the unaffected breast, leading to further complications. Choice D is incorrect as wearing a tight-fitting bra can worsen symptoms by putting pressure on the affected breast, hindering proper drainage and exacerbating mastitis.

3. A newborn is small for gestational age (SGA). Which of the following findings is associated with this condition?

• A. Moist skin
• B. Protruding abdomen
• C. Gray umbilical cord
• D. Wide skull sutures

Correct answer: D

Rationale: Wide skull sutures are a common finding in newborns who are small for gestational age (SGA) due to reduced intrauterine growth. This occurs because the skull bones do not grow at the same rate as the brain, leading to wider sutures. Moist skin, a protruding abdomen, and a gray umbilical cord are not typically associated with being small for gestational age.

4. When educating a pregnant client about potential complications, which manifestation should the nurse emphasize reporting to the provider promptly?

• A. Vaginal bleeding
• B. Swelling of the ankles
• C. Heartburn after eating
• D. Lightheadedness when lying on back

Correct answer: A

Rationale: Vaginal bleeding during pregnancy is a concerning sign that could indicate serious complications like miscarriage or placental issues. Prompt reporting to the healthcare provider is crucial for timely evaluation and management to ensure the best outcomes for both the mother and the baby. Swelling of the ankles (choice B), heartburn after eating (choice C), and lightheadedness when lying on the back (choice D) are common discomforts during pregnancy but are not typically associated with serious complications that require immediate attention.

5. 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.

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