Nursing Elites

1. A client who is postpartum is receiving discharge teaching from a nurse. For which of the following clinical manifestations should the client be instructed to monitor and report to the provider?

• A. Persistent abdominal striae
• B. Temperature 37.8° C (100.2° F)
• C. Unilateral breast pain
• D. Brownish-red discharge on day 5

Correct answer: C

Rationale: Unilateral breast pain can be a sign of mastitis, an infection of the breast tissue, which requires prompt evaluation and treatment. The nurse should instruct the client to report this clinical manifestation to the provider to prevent complications and promote recovery.

2. A nurse is assisting the nurse manager with an educational session about ways to prevent TORCH infections during pregnancy with a group of newly licensed nurses. Which of the following statements by one of the session participants indicates understanding?

• A. Seeking an immunization against rubella early in pregnancy.
• B. Receiving prophylactic treatment for cytomegalovirus if detected during pregnancy.
• C. Clients should avoid crowded places during pregnancy.
• D. Clients should avoid consuming undercooked meat while pregnant.

Correct answer: D

Rationale: The correct answer is D. To prevent TORCH infections during pregnancy, it is essential for clients to avoid consuming undercooked meat, as it can be a potential source of toxoplasmosis. This infection, along with others in the TORCH group, can pose risks to the fetus, making it crucial for pregnant individuals to follow proper food safety practices. Choices A, B, and C are incorrect because seeking an immunization against rubella, receiving prophylactic treatment for cytomegalovirus, and avoiding crowded places are not directly related to preventing TORCH infections through food safety measures.

3. A client is to receive oxytocin to augment labor. Which finding contraindicates the initiation of the oxytocin infusion and should be reported to the provider?

• A. Late decelerations
• B. Moderate variability of the FHR
• C. Cessation of uterine dilation
• D. Prolonged active phase of labor

Correct answer: A

Rationale: Late decelerations are indicative of uteroplacental insufficiency, which can be exacerbated by oxytocin administration, potentially compromising fetal well-being. Therefore, detecting late decelerations should prompt immediate reporting to the provider to prevent harm to the fetus. Choices B, C, and D are not contraindications for initiating oxytocin infusion. Moderate variability of the FHR is a reassuring sign of fetal well-being, cessation of uterine dilation may indicate a pause in labor progress but does not contraindicate oxytocin, and prolonged active phase of labor may necessitate oxytocin administration to augment contractions and progress labor.

4. A client at 39 weeks of gestation in a prenatal clinic asks about signs preceding labor. Which of the following should the nurse identify as a sign that precedes labor?

• A. Decreased vaginal discharge
• B. A surge of energy
• C. Urinary retention
• D. Weight gain of 0.5 to 1.5 kg

Correct answer: B

Rationale: A surge of energy is a common sign that precedes labor. This burst of energy, often referred to as the 'nesting instinct,' is believed to occur as the body prepares for labor, prompting the individual to undertake tasks to prepare for the arrival of the baby. Decreased vaginal discharge is not a typical sign preceding labor. Urinary retention is not a sign that precedes labor and may indicate another issue. Weight gain of 0.5 to 1.5 kg is not a specific sign of impending labor.

5. A client at 11 weeks of gestation reports slight occasional vaginal bleeding over the past 2 weeks. After an examination, the provider informs the client that the fetus has died, and the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings?

• A. Incomplete miscarriage
• B. Missed miscarriage
• C. Inevitable miscarriage
• D. Complete miscarriage

Correct answer: B

Rationale: The correct answer is B: 'Missed miscarriage.' In a missed miscarriage, fetal and placental tissues are retained in the uterus after fetal demise, which matches the scenario described in the question. This situation often requires medical or surgical intervention to remove the remaining products of conception and prevent complications. 'Incomplete miscarriage' (Choice A) typically involves partial expulsion of products of conception, 'Inevitable miscarriage' (Choice C) indicates that miscarriage is in progress and cannot be stopped, and 'Complete miscarriage' (Choice D) signifies that all products of conception have been expelled from the uterus.

Similar Questions