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    Exam Review

    1. A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following?
      A)
      Lightening
      B)
      Chloasma
      C)
      Ballottement
      D)
      Quickening
    2. A nurse is providing education to a client who is in labor and has a prescription for a continuous IV infusion of oxytocin. Which of the information should the nurse include?
      A)
      I will remove the electronic fetal monitor once contractions are regular.
      B)
      You can push the button on the control device to administer more medication.
      C)
      Your contractions will become stronger and more frequent.
      D)
      This medication will help prevent nausea and vomiting.
    3. A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?
      A)
      Monitor weight
      B)
      Monitor blood glucose levels
      C)
      Monitor intake and output (I&O)
      D)
      Monitor axillary temperature
    4. A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?
      A)
      This could result in profound bleeding.
      B)
      There is an increased risk of introducing infection.
      C)
      There is an increased risk of rupture of the membranes.
      D)
      This could initiate preterm labor.
    Page 1 of 9

    Exam Review

    1. A nurse is assessing a fifteen-year-old adolescent who is being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?
      A)
      Coarse hair growth
      B)
      Tachycardia
      C)
      Warm, flushed extremities
      D)
      Muscle weakness
    2. Which of the following approaches would be most appropriate when working with parents of an infant admitted to the hospital with failure to thrive?
      A)
      Observe the parents’ feeding techniques but refrain from making any comments.
      B)
      Observe the parents’ feeding techniques and assist the parents in recognizing hunger cues.
      C)
      Feed the infant while they are hospitalized to give parents a break from feedings.
      D)
      Encourage the parents to rock their infant during and after each feeding.
    3. A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?
      A)
      Have the client ambulate.
      B)
      Massage the client’s posterior lower legs.
      C)
      Place pillows under the client’s knees when resting in bed.
      D)
      Apply warm, moist heat to the client’s lower extremities.
    4. A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action?
      A)
      Initiation of pushing
      B)
      Preparation for cesarean birth
      C)
      Examination to determine cervical status
      D)
      A magnesium sulfate infusion
    Page 2 of 9

    Exam Review

    1. An adolescent is being admitted to an inpatient facility for the treatment of bulimia nervosa. The nurse reviews the treatment plan with the adolescent. Which actions would the nurse teach the adolescent about the plan? (Select All that Apply.)
      (SATA)
      A)
      You will eat your meals in the dining room with others.
      B)
      We will weigh you twice a day.
      C)
      The staff will stay with you for a period of time after meals.
      D)
      The calorie amount in your diet will be reduced.
      E)
      You will be evaluated by the dietitian.
    2. A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
      A)
      Variable decelerations
      B)
      Early decelerations
      C)
      Late decelerations
      D)
      Accelerations
    3. A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?
      A)
      At least you know you have a healthy baby.
      B)
      It sounds like you are feeling sad that things didn’t go as planned.
      C)
      You can resume sexual relations sooner than if you had delivered vaginally.
      D)
      Maybe next time you can have a vaginal delivery.
    4. A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 0 station, and the client’s amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?
      A)
      Assist the client into a comfortable position.
      B)
      Help the client to the bathroom to void.
      C)
      Observe the perineum for signs of crowning.
      D)
      Have the client pant during the next contractions.
    Page 3 of 9

    Exam Review

    1. A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)
      A)
      Administer methylergonovine maleate if uterus is boggy.
      B)
      Massage a firm fundus.
      C)
      Observe the lochia during palpation of fundus.
      D)
      Document fundal height.
      E)
      Determine whether the fundus is midline.
    2. A nurse is teaching a client about positive signs of pregnancy. Which of the following findings should the nurse include?
      A)
      Fetal heart tones detected by ultrasound
      B)
      Breast tenderness
      C)
      Fatigue
      D)
      Positive urine pregnancy test
    3. A nurse is teaching a client who is postpartum and has been diagnosed with iron deficiency anemia. Which of the following dietary recommendations should the nurse include in the teaching plan?
      A)
      Fish and cottage cheese
      B)
      Milk and turkey slices
      C)
      Yogurt and mozzarella
      D)
      Spinach and red meat (generated to complete the 4 choices)
    4. A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client’s blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?
      A)
      Notify the provider.
      B)
      Elevate the client’s legs.
      C)
      Monitor vital signs every 5 min.
      D)
      Place the client in a lateral position.
    Page 4 of 9

    Exam Review

    1. A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first?
      A)
      Assess the bladder for distention.
      B)
      Prepare to administer a prescribed oxytocic preparation.
      C)
      Massage the client’s fundus.
      D)
      Assess the client’s blood pressure.
    2. An adolescent with a severe binge-eating disorder has been prescribed lisdexamfetamine. Which of the following is a side effect of this medication?
      A)
      Urinary retention
      B)
      Tachycardia
      C)
      Growth spurt
      D)
      Drowsiness
    3. A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
      A)
      Fetal head compression
      B)
      Uteroplacental insufficiency
      C)
      Maternal bradycardia
      D)
      Umbilical cord compression
    4. A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?
      A)
      Fundus firm, at the level of the umbilicus
      B)
      Fundus soft 2 cm above the umbilicus
      C)
      Fundus soft 1 cm to the right of the umbilicus
      D)
      Fundus present to the left of the umbilicus
    Page 5 of 9

    Exam Review

    1. A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?
      A)
      Encourage the client to perform Kegel exercises.
      B)
      Encourage the client to move to the left lateral position.
      C)
      Ask the client to rate her pain.
      D)
      Assist the client to the bathroom to void.
    2. A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?
      A)
      Threatened abortion
      B)
      Precipitous labor
      C)
      Placenta previa
      D)
      Abruptio placentae
    3. A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
      A)
      Place the client in knee-chest position.
      B)
      Cover the cord with a sterile, moist saline dressing.
      C)
      Insert a gloved hand into the vagina to relieve pressure on the cord.
      D)
      Prepare the client for an immediate birth.
    4. A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?
      A)
      Elevate the client’s legs.
      B)
      Administer oxygen using a nonrebreather mask.
      C)
      Increase the rate of maintenance IV infusion.
      D)
      Place the client in the lateral position.
    Page 6 of 9