NursGuru

    Exam Review

    1. The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?
      A)
      Encourage voiding
      B)
      Notify healthcare provider
      C)
      Inspect the perineal pad
      D)
      Monitor vital signs
    2. The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?
      A)
      Insert a Foley catheter with a urimeter to monitor hourly output
      B)
      Have calcium gluconate immediately available
      C)
      Provide a quiet environment with subdued lighting.
      D)
      Assess deep tendon reflexes (DTRS) every 4 hours.
    3. A woman at 36-weeks gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor Two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?
      A)
      Determine fetal position by performing Leopold maneuvers.
      B)
      Assess the fetal heart rate and client's contraction pattern
      C)
      Confirm Rh and Coombs status for Rho(D) immunoglobulin administration
      D)
      Perform sterile vaginal examination to determine dilatation
    4. The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
      A)
      Hemoglobin and hematocrit
      B)
      Abdominal contour and bowel sounds
      C)
      Heart rate and blood pressure
      D)
      Urinary output and IV fluid intake

    Exam Review

    1. The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?
      A)
      Flaring of the nares
      B)
      Shallow and irregular respirations
      C)
      Respiratory rate of 50 breaths per minute
      D)
      Abdominal breathing with synchronous chest movement
    2. Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
      A)
      Unilateral lower leg pain.
      B)
      Soft, spongy fundus
      C)
      Saturating two perineal pads per hour.
      D)
      Pulse rate of 56 beats/minute
    3. A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
      A)
      Inspect the client's face for edema
      B)
      Ascertain the frequency of headaches
      C)
      Evaluate for history of cluster headaches
      D)
      Observe and time client's contractions
    4. A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
      A)
      Prepare for a cesarean section
      B)
      Cover the lesion with a dressing
      C)
      Obtain blood cultures
      D)
      Administer penicillin.

    Exam Review

    1. A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?
      A)
      Discuss options for intrauterine surgical correction of congenital defects.
      B)
      Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated.
      C)
      Reassure the client that the AFP results are likely to be a false reading.
      D)
      Explain that a sonogram should be scheduled for definitive results
    2. The healthcare provider prescribes oxytocin 2 milliunits/minute to induce labor for a client at 41-weeks gestation. The nurse initiates an infusion of Ringer's Lactate solution 1000 mL with oxytocin 10 units. How many mL/hour should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number)
      Correct Answer:12 ml/hour
    3. The nurse is reviewing a woman's health care record during her first prenatal visit. The client has a history of chicken pox as a child and syphills as a teenager. Which action is most important for the nurse to take?
      A)
      Obtain blood and urine for prenatal screens
      B)
      Explain common complications of pregnancy
      C)
      Obtain baseline blood pressure and weight
      D)
      Schedule prenatal visits to occur monthly
    4. Which type of anesthesia, used with a client in labor, produces a loss of sensation only to the vagina and perineum?
      A)
      Epidural block
      B)
      Saddle block
      C)
      Paracervical block.
      D)
      Pudendal block

    Exam Review

    1. A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?
      A)
      Placenta accreta
      B)
      Hard, painful uterine afterpains.
      C)
      Postpartum psychosis.
      D)
      Disseminated intravascular coagulation
    2. What instruction is most important for the nurse to provide a client in the first trimester of pregnancy who is experiencing nausea?
      A)
      Avoid alcohol, caffeine, and smoking.
      B)
      Eliminate between meal snacks
      C)
      Practice relaxation techniques when the nausea first begins
      D)
      Increase intake of fluids to 3 quarts daily
    3. During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?
      A)
      Notify the healthcare provider of the complaint
      B)
      Recommend an over-the-counter yeast medication
      C)
      Inform her that this is a normal physiological change.
      D)
      Prepare the client for a sterile speculum exam
    4. A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)
      A)
      Place client in a negative pressure room
      B)
      Implement droplet precautions
      C)
      Encourage the mother to bottle-feed
      D)
      Give antiviral medication intravenously
      E)
      Use standard precautions

    Exam Review

    1. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing Which intervention should the nurse plan to include in this client's nursing care plan?
      A)
      Monitor blood pressure pulse, and respirations every 4 hour
      B)
      Keep an airway at the bedside
      C)
      Allow liberal family visitation
      D)
      Assess temperature every hour
    2. The nurse is caring for a postpartal client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?
      A)
      Cleanse the spinal injection site
      B)
      Apply an abdominal binder
      C)
      Insert an indwelling Foley catheter
      D)
      Place procedure equipment at bedside
    3. A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?
      A)
      Estimated amount of fluid.
      B)
      Color and consistency of fluid.
      C)
      Time the membranes ruptured
      D)
      Any odor noted when membranes ruptured
    4. The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?
      A)
      Bleeding tendencies
      B)
      Heat loss
      C)
      Hypoglycemia
      D)
      Fluid balance

    Exam Review

    1. A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following the procedure the client calls the nurse to report a temperature of 99.8° F (37.67°C). Which action should the nurse implement?
      A)
      Instruct the client to maintain bed rest for 24 hours.
      B)
      Encourage the client to increase her intake of oral fluids
      C)
      Schedule a visit with the healthcare provider today
      D)
      Verify the administered Rho(D) immune globulin's compatibility
    2. A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
      A)
      Schedule an appointment for the client with the diabetic nurse educator.
      B)
      Counsel her to increase her caloric intake
      C)
      Inform her that a decreased need for insulin occurs while breastfeeding
      D)
      Advise the client to breastfeed more frequently
    3. During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
      A)
      Use a fingertip to palpate the inguinal canal for a weakening or indentation
      B)
      Measure the size of the scrotal sac for length and width.
      C)
      Perform transillumination of the scrotal sac to visualize shadows of the testes
      D)
      Observe the urethral opening on the surface of the penis when the newborn voids
    4. After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?
      A)
      Strawberries
      B)
      Collard greens.
      C)
      Whole milk
      D)
      Yogurt