NursGuru
    Login/Signup
    Review ModeExam ModePractice Mode

    Exam Review

    1. A nurse is caring for a client who is in active labor and notes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first?
      A)
      Apply a fetal scalp electrode.
      B)
      Increase the rate of the intravenous infusion.
      C)
      Administer oxygen at 10 L/min via a nonrebreather mask.
      D)
      Change the client's position.
    2. A nurse is caring for a newborn 1 hour following birth. The newborn has a history of a 39-week gestation, emergency cesarean birth for abruptio placentae and non-reassuring fetal heart rate, an Apgar score of 5 at 1 minute and 8 at 5 minutes, and required positive pressure ventilation for 1 minute followed by free-flow oxygen. Select the five findings the nurse should report to the provider.
      (SATA)
      A)
      Temperature
      B)
      Heart rate
      C)
      Serum glucose
      D)
      White blood cells
      E)
      Hematocrit
      F)
      Respiratory assessment
      G)
      Hemoglobin —
    3. A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?
      A)
      Flex her knee while resting.
      B)
      Massage the affected area.
      C)
      Elevate her leg.
      D)
      Apply cold compresses.
    4. A nurse is caring for a client who is 6 hours postpartum and asks the nurse to feed her newborn. Which of the following responses should the nurse provide?
      A)
      "I'll feed him today. Maybe tomorrow you can try it.”.
      B)
      "Oh, this isn't difficult.You'll be fine doing this.”.
      C)
      "You can learn to feed him; I wasn't comfortable the first time I fed a baby either.”.
      D)
      "Feeding an infant can feel a little intimidating at first, but I'll stay and help you.”. . .
    Page 1 of 8

    Exam Review

    1. A nurse is caring for a client who is 6 hours postpartum and asks the nurse to feed her newborn. Which of the following responses should the nurse provide?
      A)
      "I'll feed him today, maybe tomorrow you can try it.”.
      B)
      "Oh, this isn't difficult, you'll be fine doing this.”.
      C)
      "You can learn to feed him; I wasn't comfortable the first time I fed a baby either.”.
      D)
      "Feeding an infant can feel a little intimidating at first, but I'll stay and help you.”.
    2. A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect?
      A)
      Fetal heart rate 100/min.
      B)
      Weakened uterine contractions.
      C)
      Enhanced production of fetal lung surfactant.
      D)
      Maternal blood glucose 63 mg/dL.
    3. A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?
      A)
      The client reports weakness of the lower extremities.
      B)
      Blood pressure 80/56 mm Hg.
      C)
      Temperature 38.2°C (100.8°F).
      D)
      The client reports profuse itching.
    4. A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?
      A)
      Discontinue the medication infusion.
      B)
      Prepare for an emergency cesarean birth.
      C)
      Assess maternal blood glucose.
      D)
      Place the client in Trendelenburg position.
    Page 2 of 8

    Exam Review

    1. A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?
      A)
      1+ pitting sacral edema.
      B)
      3+ protein in the urine.
      C)
      Blood pressure 148/98 mm Hg.
      D)
      Deep tendon reflexes of +1. .
    2. A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?
      A)
      Keep four side rails up while the client is in bed.
      B)
      Check the cervix prior to analgesic administration.
      C)
      Monitor the fetal heart rate (FHR) every hour.
      D)
      Insert an indwelling urinary catheter.
    3. A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?
      A)
      Keep four side rails up while the client is in bed.
      B)
      Check the cervix prior to analgesic administration.
      C)
      Monitor the fetal heart rate (FHR) every hour.
      D)
      Insert an indwelling urinary catheter.
    4. A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?
      A)
      Cut the umbilical cord.
      B)
      Apply perineal pressure to the emerging fetal head.
      C)
      Prevent the perineum from tearing.
      D)
      Promote delivery of the placenta.
    Page 3 of 8

    Exam Review

    1. A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?
      A)
      "I will reduce my stress level.”.
      B)
      "I will tell my doctor before using home remedies for nausea.”.
      C)
      "I will monitor my weight gain during the remaining months.”.
      D)
      "I will use only nonprescription medications while pregnant.”. —
    2. A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?
      A)
      Saturated perineal pad in 30 min.
      B)
      Deep tendon reflexes 4+.
      C)
      Fundus at level of umbilicus.
      D)
      Approximated edges of episiotomy.
    3. A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?
      A)
      Rapid decline in human chorionic gonadotropin (hCG) levels
      B)
      Excessive uterine enlargement
      C)
      Irregular fetal heart rate
      D)
      Profuse, clear vaginal discharge
    4. A nurse is caring for a client during a routine prenatal visit. The client is a Gravida 2 Para 1 who is at 29 weeks of gestation. The client reports active fetal movements, the fundal height is 28 cm, and the FHR is 136/min. No edema is noted to the lower extremities. The client works as an elementary school teacher and states they are registered for a childbirth education class with their partner in a few weeks. Which of the following actions should the nurse take?
      A)
      Advise the client to increase their intake of leafy green vegetables.
      B)
      Discuss warning signs of preterm labor with the client.
      C)
      Schedule the client for a glucose tolerance test.
      D)
      Instruct the client on proper car seat installation.
    Page 4 of 8

    Exam Review

    1. A nurse in a clinic is teaching the mother of a 4-month-old infant who has been breastfed. The mother plans to switch her infant to an iron-fortified formula. Which of the following should be included in the teaching?
      A)
      Iron facilitates development of vision in infants.
      B)
      Iron stores in infants begin to deplete.
      C)
      Iron facilitates growth of bones in infants.
      D)
      Iron is poorly absorbed in infants.
    2. A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)
      A)
      Clean the perineal area from front to back.
      B)
      Blot the perineal area dry after cleansing.
      C)
      Perform hand hygiene before and after voiding.
      D)
      Apply ice packs to the perineal area several times daily.
      E)
      Wash the perineal area using a squeeze bottle of warm water after each voiding.
    3. A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable?
      A)
      An intrauterine device (IUD).
      B)
      An oral contraceptive.
      C)
      A male condom.
      D)
      A diaphragm with spermicide.
    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 1+ 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)
      Observe the perineum for signs of crowning.
      C)
      Have the client pant during the next contractions.
      D)
      Help the client to the bathroom to void.
    Page 5 of 8

    Exam Review

    1. 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)
      Prepare the client for an immediate birth.
      B)
      Place the client in knee-chest position.
      C)
      Insert a gloved hand into the vagina to relieve pressure on the cord.
      D)
      Cover the cord with a sterile, moist saline dressing.
    2. A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?
      A)
      A client who is at 14 weeks of gestation and reports nausea and vomiting.
      B)
      A client who is at 28 weeks of gestation and reports painless vaginal bleeding.
      C)
      A client who is at 38 weeks of gestation and reports a cough and fever.
      D)
      A client who has missed a period and reports vaginal spotting.
    3. A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D C) following a spontaneous miscarriage. Which of the following should be included in the teaching?
      A)
      Vaginal intercourse can be resumed after 2 weeks.
      B)
      Products of conception will be present in vaginal bleeding.
      C)
      Increased intake of zinc-rich foods is recommended.
      D)
      Aspirin may be taken for cramps.
    4. A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?
      A)
      Decreased urge to void.
      B)
      Increased urine output.
      C)
      Displaced fundus from the midline.
      D)
      Fundal height below the umbilicus.
    Page 6 of 8