Nursing Elites

1. The _____ is the inner layer of the embryo from which the lungs and digestive system develop.

• A. neural tube
• B. mesoderm
• C. endoderm
• D. umbilical cord

Correct answer: C

Rationale: The endoderm is the correct answer. It is the innermost layer of the embryo that gives rise to organs such as the lungs, digestive system, liver, and pancreas. The neural tube (Choice A) forms the brain and spinal cord, not the lungs or digestive system. Mesoderm (Choice B) develops into structures like muscles, bones, and circulatory system, not the lungs or digestive system. The umbilical cord (Choice D) serves as a connection between the embryo and the placenta, providing nutrients and oxygen, but it is not the layer from which lungs and digestive system develop.

2. 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.

3. A client is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?

• A. Increase the infusion rate every 30 to 60 minutes.
• B. Maintain the client in a supine position.
• C. Titrate the infusion rate by 4 milliunits/min.
• D. Limit IV intake to 4 L per 24 hours.

Correct answer: A

Rationale: The correct answer is to increase the infusion rate every 30 to 60 minutes. This approach allows for the careful monitoring and adjustment of oxytocin administration during labor induction. Choice B is incorrect because maintaining the client in a supine position can decrease blood flow to the placenta and compromise fetal oxygenation. Choice C is incorrect as titrating the infusion rate by 4 milliunits/min is not a standard practice for oxytocin administration. Choice D is incorrect as limiting IV intake to 4 L per 24 hours is not specifically related to the administration of oxytocin for labor induction.

4. _____ is a life-threatening disease, characterized by high blood pressure that may afflict women late in the second or early in the third trimester.

• A. Rubella
• B. Syphilis
• C. Preeclampsia
• D. Phenylketonuria

Correct answer: C

Rationale: Preeclampsia is a serious pregnancy complication characterized by high blood pressure that typically occurs in the second half of pregnancy. If left untreated, it can lead to severe complications for both the mother and the baby. Rubella (choice A) is a viral infection that can harm the developing fetus but is not directly related to high blood pressure in pregnancy. Syphilis (choice B) is a sexually transmitted infection that can affect pregnancy but does not specifically cause high blood pressure. Phenylketonuria (choice D) is a genetic disorder that affects metabolism and is not associated with high blood pressure in pregnancy.

5. A client who is at 24 weeks of gestation is receiving teaching about expected changes during pregnancy. Which of the following information should the nurse include?

• A. Your stomach will empty rapidly
• B. You should expect your uterus to double in size
• C. You should anticipate nasal stuffiness
• D. Your nipples will become lighter in color

Correct answer: C

Rationale: Nasal stuffiness is a common symptom during pregnancy due to increased blood flow and hormonal changes. This symptom is caused by the increased blood volume and hormonal changes that lead to swelling of the nasal passages. Choices A, B, and D are incorrect. Stomach emptying rate does not significantly change during pregnancy; the uterus does not double in size at 24 weeks but rather grows steadily, and nipples typically darken in color due to increased pigmentation.

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