Nursing Elites

1. During a weekly prenatal visit, a nurse is assessing a client at 38 weeks of gestation. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 136/88 mm Hg
• B. Report of insomnia
• C. Weight gain of 2.2 kg (4.8 lb)
• D. Report of Braxton-Hicks contractions

Correct answer: C

Rationale: A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range for a client at 38 weeks of gestation and could indicate complications such as preeclampsia or gestational hypertension. Rapid weight gain at this stage requires immediate attention and should be reported to the provider for further evaluation and management. Choices A, B, and D are not the priority findings to report to the provider at this stage of gestation. Blood pressure of 136/88 mm Hg is within normal limits in pregnancy, insomnia is common in the third trimester, and Braxton-Hicks contractions are expected in the third trimester as the body prepares for labor.

2. A client is learning how to check basal temperature to determine ovulation. When should the client check her temperature?

• A. On days 13 to 17 of her menstrual cycle
• B. Every morning before arising
• C. 1 hour following intercourse
• D. Before going to bed every night

Correct answer: B

Rationale: The basal body temperature should be taken every morning before arising as it provides the most accurate reading. This time ensures consistency and eliminates variations that may occur throughout the day due to activities or environmental factors. Choice A is incorrect because ovulation can vary among individuals, and checking temperature on specific days may not align with the actual ovulation day. Choice C is incorrect as there is no direct correlation between intercourse and basal body temperature. Choice D is incorrect because taking the temperature before going to bed does not provide a consistent baseline reading.

3. During a vaginal exam on a client in labor who reports severe pressure and pain in the lower back, a nurse notes that the fetal head is in a posterior position. Which of the following is the best nonpharmacological intervention for the nurse to perform to relieve the client's discomfort?

• A. Back rub
• B. Counter-pressure
• C. Playing music
• D. Foot massage

Correct answer: B

Rationale: In cases where the fetus is in a posterior position causing severe pressure and pain in the lower back during labor, applying counter-pressure is the most effective nonpharmacological intervention. Counter-pressure helps lift the fetal head off the spinal nerve, offering relief to the client. This technique is evidence-based and recommended to alleviate discomfort associated with a posterior fetal position. Choices A, C, and D are not as effective in this situation. While a back rub or playing music may provide some comfort, they do not directly address the issue caused by the fetal head's position. Similarly, a foot massage may offer relaxation but may not significantly relieve the specific discomfort arising from the posterior fetal position and the associated lower back pain.

4. A newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight should be classified as which of the following?

• A. Low birth weight
• B. Appropriate for gestational age
• C. Small for gestational age
• D. Large for gestational age

Correct answer: B

Rationale: The classification of a newborn as appropriate for gestational age is determined by considering the weight and gestational age. In this case, the newborn's weight falls within the normal range for the gestational age, indicating that the newborn is appropriately sized for the length of time spent in the womb. Choice A, 'Low birth weight,' is incorrect as the newborn's weight is within the normal range. Choice C, 'Small for gestational age,' is incorrect because the newborn's weight is not below the 10th percentile for gestational age. Choice D, 'Large for gestational age,' is incorrect as the newborn's weight is not above the 90th percentile, rather falling within the 60th percentile which is considered normal.

5. A patient on the labor and delivery unit is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?

• A. Decrease the rate of infusion of the maintenance IV solution.
• B. Discontinue the infusion of the IV oxytocin.
• C. Increase the rate of infusion of the IV oxytocin.
• D. Slow the client's breathing rate.

Correct answer: B

Rationale: The described pattern suggests late decelerations, indicating uteroplacental insufficiency. Discontinuing the oxytocin infusion helps reduce uterine contractions, improving placental blood flow and fetal oxygenation. This intervention is essential to prevent fetal compromise and potential harm during labor. Choice A is incorrect because decreasing the rate of the maintenance IV solution does not directly address the cause of the late decelerations. Choice C is incorrect because increasing the rate of IV oxytocin can worsen uterine contractions, exacerbating the fetal distress. Choice D is incorrect because slowing the client's breathing rate is not indicated in the management of late decelerations during labor.

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