Nursing Elites

1. A nurse is assessing a client who is in active labor. The client reports the urge to have a bowel movement and begins to bear down during contractions. Which of the following actions should the nurse take?

• A. Instruct the client to perform rapid, shallow breathing
• B. Prepare the client for an emergency cesarean birth
• C. Have the client perform pelvic tilts during contractions
• D. Apply counterpressure to the client's sacrum

Correct answer: A

Rationale: The correct answer is to instruct the client to perform rapid, shallow breathing. The urge to bear down during contractions indicates the second stage of labor, and pushing prematurely can lead to complications. Rapid, shallow breathing helps prevent pushing until the cervix is fully dilated. Choice B is incorrect because preparing for an emergency cesarean birth is not indicated based on the information provided. Choice C is incorrect as pelvic tilts are not appropriate when the client is already bearing down. Choice D is incorrect since applying counterpressure to the sacrum is not the priority when the client is showing signs of advancing labor.

2. A nurse is providing care for a client who is in active labor and receiving oxytocin. Which of the following findings should the nurse report to the provider?

• A. Contraction frequency of 2 minutes
• B. Contraction duration of 90 seconds
• C. Fetal heart rate of 150/min
• D. Urine output of 60 mL/hr

Correct answer: B

Rationale: A contraction duration of 90 seconds can indicate uterine tachysystole, which may lead to fetal hypoxia. Uterine tachysystole is defined as more than five contractions in 10 minutes, averaged over a 30-minute window. Contractions every 2 minutes (Choice A) may occur in active labor but need to be assessed in conjunction with other factors. A fetal heart rate of 150/min (Choice C) is within the normal range. Urine output of 60 mL/hr (Choice D) is also within the expected range for a client in labor.

3. A nurse is assessing a client who is at 28 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?

• A. 1+ proteinuria
• B. Blood pressure 144/92 mm Hg
• C. Respiratory rate 22/min
• D. Urine output 20 mL/hr

Correct answer: D

Rationale: The nurse should report a urine output of 20 mL/hr. This finding can indicate decreased renal perfusion and possible development of preeclampsia, which is a severe complication of gestational hypertension. Inadequate urine output can suggest compromised kidney function and impaired maternal and fetal well-being. Options A, B, and C are within normal limits for a client with gestational hypertension and may not require immediate reporting to the provider.

4. A nurse is assessing a newborn who was delivered 24 hours ago. Which of the following findings should the nurse report to the provider?

• A. Caput succedaneum
• B. Jaundice
• C. Acrocyanosis
• D. Overlapping cranial sutures

Correct answer: B

Rationale: Jaundice occurring within the first 24 hours of life is a sign of pathological jaundice and should be reported to the provider. Caput succedaneum, acrocyanosis, and overlapping cranial sutures are common findings in newborns and do not necessarily require immediate reporting unless they are severe or indicate other underlying issues.

5. A nurse is preparing to administer terbutaline to a client who is experiencing preterm labor. Which of the following statements by the client is an indication that the medication is effective?

• A. I feel like my contractions are getting stronger.
• B. I feel like my heart is racing.
• C. My baby is moving less than before.
• D. My contractions have stopped.

Correct answer: D

Rationale: Terbutaline is a tocolytic medication used to stop uterine contractions. The client stating that the contractions have stopped indicates that the medication is effective. Choices A, B, and C are incorrect because feeling stronger contractions, a racing heart, or decreased fetal movement are not signs of terbutaline effectiveness in managing preterm labor.

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