Nursing Elites

1. During active labor, a nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?

• A. Maternal fever
• B. Fetal heart failure
• C. Maternal hypoglycemia
• D. Fetal head compression

Correct answer: A

Rationale: Maternal fever can lead to fetal tachycardia due to the transmission of maternal fever to the fetus. This can result in an increased fetal heart rate, making it the correct potential cause in this scenario. Fetal heart failure (choice B) would typically present with bradycardia rather than tachycardia, making it an incorrect choice. Maternal hypoglycemia (choice C) is more likely to cause fetal distress rather than tachycardia. Fetal head compression (choice D) may lead to decelerations in the fetal heart rate pattern, but not necessarily tachycardia.

2. A client who is postpartum received methylergonovine. Which of the following findings indicates that the medication was effective?

• A. Increase in blood pressure
• B. Fundus firm to palpation
• C. Increase in lochia
• D. Report of absent breast pain

Correct answer: B

Rationale: Methylergonovine is used to prevent or treat postpartum hemorrhage by contracting the uterus. A firm fundus indicates effective uterine contraction and less bleeding. Therefore, the correct answer is a firm fundus to palpation. The increase in blood pressure (Choice A) is not a typical finding associated with the effectiveness of methylergonovine. Increase in lochia (Choice C) may indicate excessive bleeding rather than the medication's effectiveness. Absence of breast pain (Choice D) is not directly related to the medication's effectiveness in treating postpartum hemorrhage.

3. A healthcare provider in a clinic is reinforcing teaching with a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency?

• A. Iron deficiency anemia
• B. Poor bone formation
• C. Macrosomic fetus
• D. Neural tube defects

Correct answer: D

Rationale: The correct answer is D: Neural tube defects. Folic acid deficiency during pregnancy can lead to neural tube defects in the fetus, affecting the brain, spine, or spinal cord development. Iron deficiency anemia (choice A) is not directly related to folic acid deficiency. Poor bone formation (choice B) is more associated with calcium and vitamin D deficiencies. Macrosomic fetus (choice C) refers to a baby with excessive birth weight and is not a typical outcome of folic acid deficiency in pregnancy. Therefore, it is crucial for individuals of childbearing age to take recommended folic acid supplements to prevent neural tube defects.

4. When monitoring uterine contractions in a client in the active phase of the first stage of labor, which finding should the nurse report to the provider?

• A. Contractions lasting longer than 90 seconds
• B. Contractions occurring every 3 to 5 minutes
• C. Contractions are strong in intensity
• D. Client reports feeling contractions in the lower back

Correct answer: A

Rationale: During the active phase of the first stage of labor, contractions lasting longer than 90 seconds can indicate uterine hyperstimulation, leading to decreased placental perfusion and fetal oxygenation. This finding should be reported to the provider for further evaluation and management. Choices B, C, and D are not the priority findings in this scenario. Contractions occurring every 3 to 5 minutes are within the normal range for the active phase of labor. Strong contractions and feeling contractions in the lower back are common experiences during labor and not necessarily concerning unless associated with other complications.

5. A client who is at 24 weeks of gestation and reports daily mild headaches is being cared for by a nurse. Which of the following instructions should the nurse include in the plan of care?

• A. Administer ibuprofen 400 mg twice daily.
• B. Recommend that the client perform conscious relaxation techniques daily.
• C. Give the client ginseng tea with each meal.
• D. Instruct the client to soak in a bath with a water temperature of 105°F for 15 minutes daily.

Correct answer: B

Rationale: Mild headaches during pregnancy can be common and are often related to stress and tension. Recommending conscious relaxation techniques daily can help to relieve tension, reduce stress, and alleviate headaches without the need for medication, which is safer during pregnancy. Choice A is incorrect as ibuprofen is not recommended during pregnancy due to potential risks to the fetus. Choice C is incorrect because ginseng tea is not recommended during pregnancy as it may have adverse effects. Choice D is incorrect as soaking in a hot bath with a water temperature of 105°F can raise the body temperature, which is not safe during pregnancy.

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