In a prenatal clinic, a client in the first trimester of pregnancy has a health record that includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply)

Correct Answer: D

Rationale: The data G3 T1 P0 A1 L1 indicates Gravida (total pregnancies), Term births, Preterm births, Abortions, and Living children. By interpreting G3 as three total pregnancies, T1 as one term birth, and L1 as one living child, the nurse can deduce that the client has one living child. Choice A is incorrect as it only refers to term births, not living children. Choice B is incorrect as there is no mention of preterm labor specifically. Choice C is incorrect as it only refers to the total number of pregnancies, not the number of living children. Thus, the correct answer is D, as it accurately summarizes the information provided in the data.

Correct Answer: C

Rationale: The correct answer is C: Petechiae over the head. Tight nuchal cord during delivery can lead to compression of blood vessels in the neck, resulting in small, pinpoint hemorrhages known as petechiae on the baby's head. This occurs due to decreased blood flow and oxygen supply to the area. Bruising over the buttocks (Choice A) is more commonly associated with vacuum extraction or forceps delivery. Hard nodules on the roof of the mouth (Choice B) are likely palatal cysts that are unrelated to nuchal cord compression. Bilateral periauricular papillomas (Choice D) are benign skin lesions and not indicative of nuchal cord complications.

Correct Answer: D

Rationale: The correct answer is D, tender lymph nodes. TORCH infections are a group of infections that can be harmful to a developing fetus during pregnancy. Tender lymph nodes can be a common finding in TORCH infections due to the body's immune response to the infection. Joint pain (A), malaise (B), and rash (C) are not typically associated with TORCH infections. Joint pain and rash are more commonly seen in other types of infections, while malaise is a general feeling of discomfort or unease and is not a specific symptom of TORCH infections.

Correct Answer: C

Rationale: The correct answer is C: Perform the pelvic rock exercise every day. This exercise helps strengthen the muscles that support the back, reducing backache during pregnancy. It also improves flexibility and posture. A: Avoid any lifting - This is incorrect because avoiding all lifting is not practical or necessary during pregnancy. Some light lifting may be fine with proper form. B: Perform Kegel exercises twice a day - Kegel exercises focus on pelvic floor muscles, not specifically back muscles. While important during pregnancy, they do not directly address backache. D: Avoid standing for prolonged periods - This is a helpful tip to reduce backache, but it is not as effective as performing exercises that specifically target back muscles like the pelvic rock exercise.

Correct Answer: C

Rationale: The correct answer is C: Hydatidiform mole. At 4 months gestation, prune-colored discharge and larger than expected fundal height are concerning for this rare condition. Hydatidiform mole presents with symptoms like persistent nausea, vomiting, and abnormal vaginal bleeding. It is characterized by abnormal placental tissue growth and can lead to complications such as hyperthyroidism, preeclampsia, or even choriocarcinoma. Incorrect choices: A: Hyperemesis gravidarum typically presents with severe nausea, vomiting, and weight loss, which is not seen in this case. B: Threatened abortion usually presents with vaginal bleeding and cramping, not prune-colored discharge. D: Preterm labor presents with regular contractions and cervical changes, not prune-colored discharge or larger than expected fundal height.

Correct Answer: C

Rationale: The correct answer is C: "I plan to drink more orange juice while taking this pill." Orange juice is a good source of vitamin C, which helps with the absorption of iron from ferrous sulfate. Vitamin C enhances the body's ability to absorb iron, making it more effective. Taking the medication with orange juice will optimize iron absorption, which is crucial during pregnancy to prevent anemia. Choice A is incorrect because taking the pill with breakfast doesn't address the issue of enhancing iron absorption. Choice B is incorrect because taking ferrous sulfate with milk can decrease its absorption due to the calcium content in milk. Choice D is incorrect because adding more calcium-rich foods to the diet while taking ferrous sulfate can also hinder iron absorption.

Correct Answer: C

Rationale: The correct answer is C: Administer opioid analgesic medication. At 3 cm dilated, 80% effaced, and -1 station, the client is in active labor. Opioid analgesics can help manage pain without affecting labor progress. Ice chips (choices A and D) are not necessary for pain management at this stage. Inserting a urinary catheter (choice B) is not indicated unless there are specific medical reasons.

Correct Answer: B

Rationale: The correct answer is B: Lecithin/sphingomyelin (L/S) ratio. This test measures the ratio of two substances in the amniotic fluid and indicates fetal lung maturity. A high L/S ratio suggests mature lungs, reducing the risk of respiratory distress syndrome. Choice A (Alpha-fetoprotein) is a test for neural tube defects, not lung maturity. Choice C (Kleihauer-Betke test) is used to detect fetal-maternal hemorrhage, not lung maturity. Choice D (Indirect Coombs' test) is for detecting Rh incompatibility, not lung maturity.

Correct Answer: C

Rationale: The client is experiencing the transition phase of labor. This is characterized by intense contractions, irritability, urge to have a bowel movement, self-doubt, and feeling overwhelmed. These symptoms indicate the cervix is rapidly dilating from 8-10cm. The second stage is characterized by pushing and delivery of the baby, the fourth stage is the immediate postpartum period, and the latent phase is the early phase of labor with mild contractions. Therefore, the correct answer is C: Transition phase.