Nursing Elites

1. A client is in the second stage of labor. Which of the following manifestations should the nurse expect?

• A. The client expels the placenta
• B. The client experiences gradual dilation of the cervix
• C. The client begins having regular contractions
• D. The client delivers the newborn

Correct answer: D

Rationale: During the second stage of labor, the cervix is fully dilated, and the client delivers the newborn. The expulsion of the placenta occurs during the third stage of labor, not the second stage. Regular contractions typically begin in the first stage of labor, not the second. Gradual dilation of the cervix occurs during the first stage of labor, specifically during the active phase.

2. What is the most critical action in caring for the newborn immediately after birth?

• A. Keeping the airway clear.
• B. Fostering parent-newborn attachment.
• C. Drying the newborn and wrapping the infant in a blanket.
• D. Administering eye drops and vitamin K.

Correct answer: A

Rationale: The most critical action in caring for the newborn immediately after birth is keeping the airway clear. This is essential to ensure that the newborn can breathe effectively and prevent any respiratory distress. Fostering parent-newborn attachment, although important, is not the most critical action immediately after birth. Drying the newborn and wrapping the infant in a blanket is important for temperature regulation but is not as critical as maintaining a clear airway. Administering eye drops and vitamin K is typically done later and is not the most critical action immediately after birth.

3. The nurse has received a report regarding a client in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this assessment?

• A. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
• B. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
• C. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
• D. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.

Correct answer: B

Rationale: The correct interpretation of the assessment provided is that the cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines. In the given assessment, the measurements are ordered as dilation, effacement, and station. Choice A is incorrect as it wrongly places the presenting part below the ischial spines. Choice C is incorrect because it places the presenting part below the ischial spines. Choice D is also incorrect as it incorrectly states that the presenting part is below the ischial spines, even though it correctly mentions the dilation and effacement of the cervix.

4. A client experiencing preterm labor is being taught about terbutaline by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “The medication could cause me to experience heart palpitations.”
• B. “This medication could cause me to experience blurred vision.”
• C. “This medication could cause me to experience ringing in my ears.”
• D. “This medication could cause me to experience frequent urination.”

Correct answer: A

Rationale: The correct answer is A. Terbutaline is a beta-adrenergic agonist used to stop preterm labor. One of its common side effects is heart palpitations due to its action on beta receptors in the heart. Choices B and C are incorrect because blurred vision and ringing in the ears are not common side effects of terbutaline. Choice D is irrelevant to the side effects of terbutaline.

5. A client has active genital herpes simplex virus type 2. Which of the following medications should the nurse plan to administer?

• A. Metronidazole
• B. Penicillin
• C. Acyclovir
• D. Gentamicin

Correct answer: C

Rationale: Acyclovir is the antiviral medication specifically used to treat herpes simplex virus infections, including genital herpes caused by herpes simplex virus type 2. Metronidazole (Choice A) is an antibiotic used for different types of infections, but not for viral infections like herpes. Penicillin (Choice B) is an antibiotic effective against bacterial infections, not viruses like herpes. Gentamicin (Choice D) is an antibiotic mainly used to treat bacterial infections, not viral infections like herpes.

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