Nursing Elites

1. A healthcare provider in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the healthcare provider expect? (Select all that apply)

• A. Joint pain
• B. Malaise
• C. Rash
• D. Tender lymph nodes

Correct answer: D

Rationale: A TORCH infection can cause joint pain, malaise, rash, and tender lymph nodes. These findings are characteristic of TORCH infections and are important to recognize in pregnant individuals as they can have serious implications for both the mother and the fetus. While joint pain, malaise, and rash can be present in TORCH infections, tender lymph nodes are a common finding that the healthcare provider should expect. Tender lymph nodes are often associated with the inflammatory response to infection and can be palpated during a physical examination. Therefore, in this scenario, the healthcare provider should anticipate the presence of tender lymph nodes in a client with a TORCH infection, making option D the correct answer.

2. A client who is at 8 weeks of gestation tells the nurse, 'I am not sure I am happy about being pregnant.' Which of the following responses should the nurse make?

• A. I will inform the provider that you are having these feelings.
• B. It is normal to have these feelings during the first few months of pregnancy.
• C. You should be happy that you are going to bring new life into the world.
• D. I am going to make an appointment with the counselor for you to discuss these thoughts.

Correct answer: B

Rationale: During the first few months of pregnancy, it is common for individuals to experience mixed feelings due to hormonal changes and the significant life adjustments that come with pregnancy. The nurse's response should acknowledge the client's feelings as normal and provide reassurance rather than dismissive or directive statements. By acknowledging the normalcy of these emotions, the nurse validates the client's experience and offers support during this critical time. Choices A, C, and D are less appropriate. Choice A focuses on informing the provider without addressing the client's emotions directly. Choice C disregards the client's current feelings and imposes a specific emotional response. Choice D jumps to scheduling a counseling appointment without first acknowledging the client's emotions or providing immediate support and validation.

3. When advising a woman considering pregnancy on nutritional needs to reduce the risk of giving birth to a newborn with a neural tube defect, what information should the nurse include?

• A. Limit alcohol consumption.
• B. Increase intake of iron-rich foods.
• C. Consume foods fortified with folic acid.
• D. Avoid foods containing aspartame.

Correct answer: C

Rationale: The correct answer is C: Consume foods fortified with folic acid. Folic acid plays a crucial role in preventing neural tube defects. It is advised to consume foods fortified with folic acid or take a supplement containing at least 400 micrograms of folic acid daily. This nutrient is essential for the developing fetus and can significantly reduce the risk of neural tube defects when taken before and during early pregnancy. Choices A, B, and D are incorrect. While limiting alcohol consumption is important during pregnancy, it is not directly related to reducing the risk of neural tube defects. Increasing intake of iron-rich foods is essential for preventing anemia but is not specifically linked to neural tube defects. Avoiding foods containing aspartame is generally recommended, but it is not directly related to reducing the risk of neural tube defects.

4. A client is being educated by a healthcare provider about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching?

• A. I should gain more than 15 to 20 pounds during my pregnancy.
• B. I will likely need to use alternative positions for sexual intercourse.
• C. I'm glad I had a breast reduction years ago so they will not enlarge with my pregnancy.
• D. I'm glad I have a light complexion and will not get any stretch marks.

Correct answer: B

Rationale: During pregnancy, weight gain is expected. The client's understanding is demonstrated by acknowledging the need for alternative sexual positions due to the physiological changes, such as weight gain and a growing abdomen. This statement reflects comprehension of the teaching provided by the healthcare provider.

5. A client who is 2 hours postpartum is in the taking-hold phase. Which intervention should the nurse plan to implement during this phase of postpartum behavioral adjustment?

• A. Discuss contraceptive options with the client and her partner.
• B. Repeat information to ensure client understanding.
• C. Listen to the client and her partner as they reflect upon the birth experience.
• D. Demonstrate to the client how to perform a newborn bath.

Correct answer: D

Rationale: During the taking-hold phase of postpartum behavioral adjustment, the new mother starts taking a stronger interest in her new role as a mother. This phase involves the mother focusing on the care of her newborn and acquiring parenting skills. Demonstrating how to perform a newborn bath is an appropriate intervention during this phase as it helps the mother actively engage in caring for her baby, which aligns with the developmental tasks of this phase. Choices A, B, and C are incorrect as they do not specifically address the mother's need to actively engage in caring for her newborn during the taking-hold phase. Discussing contraceptive options, repeating information, and listening to reflections on the birth experience are more relevant to other phases of postpartum adjustment.

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