Nursing Elites

1. A pregnant client is learning about Kegel exercises in the third trimester. Which statement signifies understanding of the teaching?

• A. These exercises facilitate preventing constipation.
• B. These exercises aid pelvic muscle stretching during birth.
• C. They assist in decreasing backaches.
• D. They can prevent additional stretch marks.

Correct answer: B

Rationale: Kegel exercises are beneficial during pregnancy to help strengthen pelvic muscles, which is crucial for childbirth. Pelvic muscle stretching during birth is a key aspect of labor, making choice B the correct statement indicating understanding of the teaching. Choices A, C, and D are incorrect because Kegel exercises primarily focus on strengthening pelvic floor muscles to support the uterus, bladder, and bowel, aiding in labor and delivery. They are not directly related to preventing constipation, decreasing backaches, or preventing stretch marks.

2. When a client states, 'My water just broke,' what is the nurse's priority intervention?

• A. Perform Nitrazine testing.
• B. Assess the fluid.
• C. Check cervical dilation.
• D. Begin FHR monitoring.

Correct answer: D

Rationale: The correct answer is D: Begin FHR monitoring. The priority intervention when a client's water breaks is to assess the fetal well-being due to the risk of umbilical cord prolapse. Monitoring the fetal heart rate (FHR) will help the nurse ensure the fetus's well-being. Performing Nitrazine testing (choice A) or assessing the fluid (choice B) may provide information about the rupture of membranes but does not directly address fetal well-being. Checking cervical dilation (choice C) is important but not the priority when the client's water has broken.

3. A client who is at 42 weeks gestation and in labor asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make?

• A. Your baby will have excess baby fat.
• B. Your baby will have flat areola without breast buds.
• C. Your baby's heels will easily move to his ears.
• D. Your baby's skin will have a leathery appearance.

Correct answer: D

Rationale: The correct answer is D: 'Your baby's skin will have a leathery appearance.' Postmature infants, born after 42 weeks of gestation, may have a leathery appearance of the skin due to prolonged exposure to amniotic fluid. This occurs as the protective vernix caseosa is shed, and the skin loses its protective covering, leading to a wrinkled and dry appearance. Choices A, B, and C are incorrect. Excess baby fat is not a typical characteristic of postmature infants. Flat areola without breast buds and the ability of the baby's heels to easily move to his ears are not associated with postmaturity.

4. During an assessment of a newborn following a vacuum-assisted delivery, which of the following findings should the healthcare provider be informed about?

• A. Poor sucking
• B. Blue discoloration of the hands and feet
• C. Soft, edematous area on the scalp
• D. Facial edema

Correct answer: A

Rationale: Poor sucking in a newborn following a vacuum-assisted delivery could indicate potential issues with feeding or neurological function, which need to be promptly addressed by the healthcare provider to ensure the well-being of the infant. It is essential for the healthcare provider to be informed about poor sucking to facilitate further evaluation and intervention. Choices B, C, and D are not typically associated with vacuum-assisted delivery and do not pose immediate concerns that require urgent attention.

5. A newborn was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect to observe?

• A. Bruising over the buttocks
• B. Hard nodules on the roof of the mouth
• C. Petechiae over the head
• D. Bilateral periauricular papillomas

Correct answer: C

Rationale: When a newborn experiences a tight nuchal cord during delivery, it can lead to petechiae, which are small red or purple spots on the skin caused by bleeding under the skin. These petechiae may appear over the head, face, and neck due to the pressure of the cord. It is essential for the nurse to recognize this as a possible consequence and monitor the newborn for any signs of complications. Bruising over the buttocks (Choice A) is not typically associated with a tight nuchal cord. Hard nodules on the roof of the mouth (Choice B) are more indicative of Epstein pearls or Bohn's nodules, which are considered normal findings in newborns. Bilateral periauricular papillomas (Choice D) are not related to a tight nuchal cord but are seen in congenital syphilis.

Similar Questions