Nursing Elites

1. Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?

• A. Risk for infection
• B. Pain
• C. Knowledge Deficit
• D. Anticipatory Grieving

Correct answer: D

Rationale: Anticipatory grieving is the priority nursing diagnosis for a client with an ectopic pregnancy. An ectopic pregnancy is a life-threatening condition that requires immediate medical intervention, often resulting in emotional distress and potential loss. Anticipatory grieving addresses the emotional needs of the client and their family in anticipation of a possible loss. While pain management and infection prevention are important aspects of care, addressing the emotional well-being and coping mechanisms should take precedence in this situation. Knowledge deficit may also be relevant, but emotional support is crucial in this critical scenario.

2. At 34-40 weeks of pregnancy, the breast changes include:

• A. Nipples become prominent and mobile.
• B. Colostrum can be expressed.
• C. Breasts become tender.
• D. Montgomery's tubercles are prominent.

Correct answer: D

Rationale: During the 34-40 weeks of pregnancy, Montgomery's tubercles become prominent. These are sebaceous glands on the areola, not the nipples. Choice A is incorrect as it describes the changes in nipples, not Montgomery's tubercles. Choice B is incorrect as colostrum production usually starts around the 16th week. Choice C is incorrect as breast tenderness is more common in early pregnancy due to hormonal changes.

3. At what point is a fetus considered viable?

• A. 26 weeks
• B. 28 weeks
• C. 37 weeks
• D. 12 weeks

Correct answer: C

Rationale: A fetus is considered viable after 37 weeks of gestation. At this stage, the fetus has a higher chance of surviving outside the womb with medical support. Choice A (26 weeks), Choice B (28 weeks), and Choice D (12 weeks) are incorrect because a fetus is not typically considered viable at those earlier gestational ages.

4. A client 12 weeks pregnant comes to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cm cervical dilation. The nurse would document these findings as which of the following?

• A. Threatened abortion
• B. Inevitable abortion
• C. Complete abortion
• D. Missed abortion

Correct answer: B

Rationale: The nurse would document these findings as an inevitable abortion. Inevitable abortion is characterized by cervical dilation with or without rupture of membranes and is associated with moderate to heavy vaginal bleeding. 'Threatened abortion' (choice A) refers to vaginal bleeding with a closed cervical os and no tissue passage. 'Complete abortion' (choice C) involves the passage of all products of conception. 'Missed abortion' (choice D) is the retention of a failed intrauterine pregnancy for an extended period without symptoms.

5. Which of the following are layers of endometrium in pregnancy EXCEPT?

• A. Decidua compacta
• B. Decidua spongiosum
• C. Decidua functionalis
• D. Decidua basalis

Correct answer: C

Rationale: During pregnancy, the layers of endometrium include decidua compacta, decidua spongiosum, and decidua basalis. Decidua functionalis is the layer that sheds during menstruation and regenerates each cycle, not a layer of the endometrium during pregnancy. Therefore, choice C is the correct answer. Decidua compacta is the layer closest to the conceptus, decidua spongiosum is the middle layer, and decidua basalis is the layer adjacent to the myometrium.

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