Nursing Elites

1. A nurse is teaching a client who is at 20 weeks of gestation about the glucose tolerance test. Which of the following instructions should the nurse include?

• A. You should eat a low-carbohydrate diet for 3 days before the test.
• B. You will need to fast for 12 hours before the test.
• C. You should expect the test to take about 1 hour.
• D. You will need to limit fluid intake to water before the test.

Correct answer: C

Rationale: The correct answer is C. During a glucose tolerance test, the client is required to drink a glucose solution, and blood samples are taken at specific intervals, typically over a period of 1 to 3 hours. In this case, the nurse should inform the client to expect the test to take about 1 hour. Choices A, B, and D are incorrect because there is no specific instruction to eat a low-carbohydrate diet for 3 days before the test, fast for 12 hours before the test, or limit fluid intake to water before the test in a standard glucose tolerance test.

2. A nurse is providing prenatal education to a client who is in the second trimester of pregnancy. Which of the following statements should the nurse include?

• A. You should expect to feel your baby move at 12 weeks.
• B. You will need to increase your calcium intake during pregnancy.
• C. You should avoid exercise during the second trimester.
• D. You will need to limit your intake of folic acid during pregnancy.

Correct answer: B

Rationale: The correct answer is B. Calcium intake is crucial during pregnancy to support fetal bone development. The nurse should educate the client to increase their calcium intake. Choice A is incorrect because fetal movements are usually felt around 18-25 weeks, not at 12 weeks. Choice C is incorrect as exercise is generally encouraged during pregnancy, including the second trimester, as long as it is not high-impact or risky. Choice D is incorrect as folic acid intake is essential during pregnancy to prevent neural tube defects, and pregnant individuals are usually advised to increase their folic acid intake.

3. A nurse is assessing a client who is in the first stage of labor and has an external fetal monitor in place. The nurse observes early decelerations in the fetal heart rate. Which of the following actions should the nurse take?

• A. Continue to monitor the fetal heart rate
• B. Reposition the client
• C. Administer oxygen via face mask
• D. Increase the rate of the IV fluids

Correct answer: A

Rationale: Early decelerations are a benign finding that typically indicate fetal head compression, a normal response to uterine contractions. They do not require intervention as they are not associated with fetal compromise. The appropriate action for the nurse in this scenario is to continue to monitor the fetal heart rate. Repositioning the client, administering oxygen, or increasing IV fluids are not indicated responses to early decelerations and could be unnecessary or potentially harmful.

4. A client who is postpartum reports abdominal cramping during breastfeeding. Which of the following actions should the nurse take?

• A. Administer ibuprofen
• B. Administer oxytocin
• C. Place a warm compress on the client's abdomen
• D. Assist the client to change positions

Correct answer: A

Rationale: Abdominal cramping during breastfeeding is common due to the release of oxytocin. Ibuprofen, an analgesic, is suitable for relieving discomfort. Administering oxytocin is unnecessary and may exacerbate the cramping. Placing a warm compress may not address the underlying cause of the cramping. Changing positions may provide temporary relief but does not address the cause of the cramping.

5. A nurse is providing discharge teaching to a client who is postpartum and has an episiotomy. Which of the following statements should the nurse include in the teaching?

• A. Avoid sitting for long periods of time.
• B. Apply a cold pack to the perineal area for the first 24 hours.
• C. Use a sitz bath once per week.
• D. Begin Kegel exercises after the first week.

Correct answer: B

Rationale: The correct statement to include in the teaching is to apply a cold pack to the perineal area for the first 24 hours. This helps reduce swelling and promote comfort, aiding in the healing process after an episiotomy. Option A is incorrect as it does not provide specific guidance on managing postpartum recovery. Option C is incorrect because using a sitz bath once per week may not be frequent enough for proper wound care. Option D is incorrect because beginning Kegel exercises immediately after delivery can put excessive strain on the perineal area, potentially hindering healing.

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