Nursing Elites

1. A client who is at 6 weeks of gestation is being educated about common discomforts of pregnancy. Which of the following findings should the individual include? (Select all that apply)

• A. Breast tenderness
• B. Urinary frequency
• C. Epistaxis
• D. All of the above

Correct answer: D

Rationale: During early pregnancy, common discomforts include breast tenderness due to hormonal changes, urinary frequency caused by increased blood flow to the kidneys, and epistaxis (nosebleeds) due to increased blood volume and hormonal changes. Educating the client about these discomforts helps them understand what to expect during this stage. Choice D, 'All of the above,' is the correct answer because all the listed findings are common discomforts experienced during early pregnancy. Choices A, B, and C are individually correct as well, as breast tenderness, urinary frequency, and epistaxis are all common discomforts that pregnant individuals may encounter.

2. A caregiver is being taught about bottle feeding a newborn. Which of the following statements by the caregiver indicates a need for further instruction?

• A. I will keep the baby's head elevated while feeding.
• B. I will allow the baby to burp several times during each feeding.
• C. I will tilt the bottle to prevent air from entering as the baby sucks.
• D. My baby will have soft, formed yellow stools.

Correct answer: C

Rationale: Tilting the bottle to prevent air from entering as the baby sucks can lead to the baby swallowing air, causing discomfort and potential issues like colic or gas. The correct way to bottle-feed a newborn is by ensuring that the nipple is always filled with milk to avoid air intake, which can lead to problems. Keeping the baby's head elevated while feeding helps prevent choking, allowing the baby to burp several times during each feeding helps release swallowed air, and soft, formed yellow stools indicate a healthy digestion process in newborns.

3. A nurse is assisting the nurse manager with an educational session about ways to prevent TORCH infections during pregnancy with a group of newly licensed nurses. Which of the following statements by one of the session participants indicates understanding?

• A. Seeking an immunization against rubella early in pregnancy.
• B. Receiving prophylactic treatment for cytomegalovirus if detected during pregnancy.
• C. Clients should avoid crowded places during pregnancy.
• D. Clients should avoid consuming undercooked meat while pregnant.

Correct answer: D

Rationale: The correct answer is D. To prevent TORCH infections during pregnancy, it is essential for clients to avoid consuming undercooked meat, as it can be a potential source of toxoplasmosis. This infection, along with others in the TORCH group, can pose risks to the fetus, making it crucial for pregnant individuals to follow proper food safety practices. Choices A, B, and C are incorrect because seeking an immunization against rubella, receiving prophylactic treatment for cytomegalovirus, and avoiding crowded places are not directly related to preventing TORCH infections through food safety measures.

4. A client who is at 24 weeks of gestation and reports daily mild headaches is being cared for by a nurse. Which of the following instructions should the nurse include in the plan of care?

• A. Administer ibuprofen 400 mg twice daily.
• B. Recommend that the client perform conscious relaxation techniques daily.
• C. Give the client ginseng tea with each meal.
• D. Instruct the client to soak in a bath with a water temperature of 105°F for 15 minutes daily.

Correct answer: B

Rationale: Mild headaches during pregnancy can be common and are often related to stress and tension. Recommending conscious relaxation techniques daily can help to relieve tension, reduce stress, and alleviate headaches without the need for medication, which is safer during pregnancy. Choice A is incorrect as ibuprofen is not recommended during pregnancy due to potential risks to the fetus. Choice C is incorrect because ginseng tea is not recommended during pregnancy as it may have adverse effects. Choice D is incorrect as soaking in a hot bath with a water temperature of 105°F can raise the body temperature, which is not safe during pregnancy.

5. A client who is at 40 weeks gestation and in active labor has 6 cm of cervical dilation and 100% cervical effacement. The client's blood pressure reading is 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

• A. Prepare for a cesarean birth.
• B. Assist the client to an upright position.
• C. Prepare for an immediate vaginal delivery.
• D. Assist the client to turn onto her side.

Correct answer: D

Rationale: Turning the client onto her side is the appropriate nursing intervention in this scenario. This position can help improve blood pressure by enhancing venous return, which may aid in increasing perfusion to vital organs. It can also alleviate pressure on the inferior vena cava, promoting better circulation and supporting blood pressure stabilization during labor. Choices A, B, and C are incorrect. A cesarean birth is not indicated based on the information provided. Assisting the client to an upright position may worsen her blood pressure due to decreased venous return. Lastly, there is no indication for an immediate vaginal delivery solely based on the client's blood pressure reading.

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