Exam Review

A nurse is caring for a client that has a perineal laceration that requires repair after birth. Which of the following options should the nurse offer as the best option for the client?
A)
Epidural.
B)
Spinal block.
C)
Opioid antagonist.
D)
Pudendal nerve block.
A nurse is assisting in the care of a newborn who had delayed cord clamping for 2 minutes after birth. Which of the following findings should the nurse anticipate due to this practice?
A)
Temperature 36.6 C (98 F).
B)
Yellow sclera.
C)
Acrocyanosis.
D)
Heart rate of 156/min.
A nurse is assisting with monitoring a client who has been administered methylergonovine in the third stage of labor. Which of the following findings should indicate to the nurse the medication is effective?
A)
Heart rate increase from 80/min to 120/min.
B)
Blood pressure elevated to 140/90 mm Hg.
C)
Decrease in bleeding.
D)
Decrease in fundal tone.
A nurse is reviewing a client in labor's laboratory results and notices that the WBC count is 15,000/mm. Which of the following actions by the nurse is an appropriate response to this finding?
A)
Call the laboratory to verify the WBC count.
B)
Continue to monitor the client's temperature.
C)
Initiate isolation precautions.
D)
Anticipate a prescription for broad spectrum antibiotics.

Page 1 of 13

Exam Review

A nurse is assisting in the care of a client in labor who expresses concern and embarrassment over mild incontinence during the peak of a contraction. Which of the following nursing interventions should the nurse implement?
A)
Advise the client to limit fluid intake.
B)
Reinforce education on Kegel exercises.
C)
Use absorbent pads to manage incontinence.
D)
Request a prescription for insertion of an indwelling urinary catheter.
A nurse is assisting in the care of several clients who have asked to have a home birth. Which of the following clients should the nurse be concerned about having a home birth?
A)
A client that is 38 weeks of gestation.
B)
A client with a history of two vaginal births.
C)
A client with a fetus in the cephalic presentation.
D)
A client that lives an hour from the hospital.
A nurse on a labor and delivery unit is teaching a newly licensed nurse about operative vaginal birth. Which of the following statements by the newly licensed nurse indicates the teaching was effective?
A)
"If the client is experiencing a prolapsed cord in the early second stage, a vaginal birth should be expected.”.
B)
"If the client is experiencing nonreassuring fetal heart pattern late in the second stage of labor, an operative vaginal birth should be expected.”.
C)
"If the client is experiencing vaginal bleeding in the first stage of labor, an operative vaginal birth should be expected.”.
D)
"If the client is experiencing meconium staining during the second stage, an operative vaginal birth should be expected.”.
A nurse is reviewing the chart of a client who is in the first stage of labor. Which of the following interpretations should the nurse make from the results of the last vaginal examination stating, "6 cm/70
A)
The cervix is dilated to a diameter of 6 cm, the cervix is fully effaced, and the fetus is engaged in the client pelvis.
B)
The cervix is 70
C)
The cervix is dilated to a diameter of 6 cm, effaced 70
D)
The cervix is 6 cm dilated, 70

Page 2 of 13

Exam Review

A client on a 30-week gestation appointment would like to discuss non-pharmacological pain management options. The client has a history of anxiety and psychosis. Which of the following options would the nurse want to avoid offering the client?
A)
Hypnosis.
B)
Effleurage.
C)
Water therapy.
D)
Position changes.
A nurse is assisting in the care of a client at 36 weeks of gestation who is experiencing contractions. The client asks why a home birth would not be recommended. Which of the following findings, found in the client's medical record, should the nurse include as reasons for the recommendation of a hospital birth?
(SATA)
A)
This is the client's first pregnancy.
B)
The fetus is in a shoulder presentation.
C)
The client is at 36 weeks of gestation.
D)
The client has gestational hypertension.
E)
The client is 30 years old.
A client asks the nurse to explain why some newborns have elongated heads. Which of the following explanations should the nurse provide?
A)
Newborns who are born with elongated heads should be monitored frequently with head circumference assessments.
B)
The spaces between the fetal skull bones allow the fetal head to change shape as it passes through the client pelvis.
C)
Elongation of the fetal head during labor is common and usually resolves within a few months following birth.
D)
Elongation of the fetal head is an unexpected finding that rarely results in any brain damage.
A nurse is assisting with a prenatal class and a learner asks the nurse to explain what happens during a prolapsed umbilical cord. Which of the following statements should the nurse make?
A)
An occult cord prolapse occurs when the umbilical cord is hidden within the vagina.
B)
An occult prolapsed cord occurs when the umbilical cord is wrapped around the fetal neck.
C)
A compound prolapsed cord occurs when the cord is felt through the cervix inside the intact amniotic sac.
D)
An overt prolapsed cord occurs when the umbilical cord comes through the cervix ahead of the presenting part.

Page 3 of 13

Exam Review

A practical nurse has gathered data on a laboring client who prefers nonpharmacological methods for pain management. The client is experiencing anxiety, has an elevated blood pressure and has erratic, rapid respirations. Which of the following methods will the practical nurse reinforce that will most likely aid in decreasing blood pressure and respiratory rate?
A)
Acupressure.
B)
Effleurage.
C)
Bradley method.
D)
Lamaze method.
E)
Yoga.
A nurse is assisting with the removal of an epidural catheter for a client postpartum. Which of the following findings are important for the nurse to include as they are gathering and reviewing data? Select all that apply.
A)
Tip of the catheter.
B)
Bleeding at the site.
C)
Signs and symptoms of infection.
D)
Urinary output.
E)
Pain during removal.
A nurse is assisting the RN who is caring for a client at 36 weeks of gestation who reports vomiting and diarrhea for the past 48 hours. The client reports no amniotic fluid leakage, bleeding, or uterine contractions. The fetal heart rate baseline is 180/min. Which of the following factors should the nurse anticipate the RN identifying as most likely associated with the fetal heart rate pattern?
A)
Prematurity.
B)
Client dehydration.
C)
Fetal cardiac anomalies.
D)
Prolonged fetal activity.
A nurse is assisting in the care of a client in labor who states, "I am really afraid of giving birth," and begins crying. The client is currently in active labor and vaginal exam reveals 7 cm dilation, 80 Which of the following factors of labor should the nurse identify as needing addressed at this time?
A)
Passageway.
B)
Powers.
C)
Passenger.
D)
Psyche.

Page 4 of 13

Exam Review

A nurse on an obstetric triage unit is assisting in the care of a client at 28 weeks of gestation who reports "feeling contractions.”. Which of the following assessment findings should the nurse identify as most closely related to the pathophysiology of preterm labor?
A)
Fetal heart rate pattern is nonreassuring.
B)
Uterine contractions are present on the monitor strip.
C)
Amniotic membranes are intact.
D)
Cervix is effacing.
A practical nurse is gathering data from a client in the office who did not feel they were able to make decisions during their first labor and birth. Which of the following will be most influential on the client's pain management during labor?
A)
Support.
B)
Environment.
C)
Previous experiences.
D)
Culture.
A nursing student is giving a presentation to their class about uterine rupture. Which of the following points should the student include in the presentation to explain what happens during a uterine rupture?
A)
During uterine rupture, all three layers of uterine muscle are torn.
B)
During uterine rupture, the cervix stretches rapidly during dilation and experiences small tears.
C)
During uterine rupture the lower part of the uterus thins out.
D)
During uterine rupture, the fundus of the uterus thins out.
A nurse is assisting with the care of a client who has their newborn placed skin to skin immediately following birth with a temperature of 37° C (98.6° F). Which of the following interventions by the nurse would place the newborn at higher risk for hypothermia?
A)
Dry and stimulate newborn with a towel.
B)
Maintain the delivery room temperature at 20° C (68° F).
C)
Place a hat on the newborn's head.
D)
Place a blanket on top of maternal client and newborn.

Page 5 of 13

Exam Review

A nurse is reinforcing teaching to a student nurse about the anticipated care of a maternal client with ruptured membranes during the second stage of labor. Which of the following statements by the student indicates an understanding of the teaching?
A)
The client should feel the urge to push at -2 station.
B)
The client's temperature will need to be checked every hour when the membranes have ruptured.
C)
The client's cervix will need to be checked every 30 minutes.
D)
The client will progress one station every 2 hours.
A nurse is assisting in the care of a client who had an episiotomy during labor after the fetal heart had shown multiple decelerations. Which of the following explanations should the nurse provide to explain the reason for this procedure?
A)
An episiotomy will help prevent a cervical prolapse.
B)
An episiotomy can be done to speed up birth if the fetus is in distress.
C)
An episiotomy can be done to prevent a first-degree perineal tear.
D)
An episiotomy is recommended for all spontaneous vaginal births.
A nurse is collecting data from a fetal monitor strip and recognizes late decelerations. Which of the following actions should the nurse expect to be taken at this time?
A)
Reposition the client to a left lateral position.
B)
Document the findings in the electronic health record.
C)
Adjust the fetal monitor sensors.
D)
Insert a fetal scalp electrode.
A nurse is reinforcing education with a client on the potential complications of an epidural. Which of the following statements by the client requires follow up by the nurse?
A)
My newborn could experience respiratory depression.
B)
There is a risk for infection.
C)
Hematoma is a potential complication.
D)
It is possible I could have a severe headache.

Page 6 of 13