Exam Review

A nurse assesses a client's uterus during contractions and notes that it becomes firm with each contraction, lasting 45 seconds, and softens completely between contractions. Cervical change from 4 cm to 6 cm is noted. What does this indicate?
A)
False labor.
B)
Placental abruption.
C)
Uterine tachysystole.
D)
True labor.
A 39-week gravida 2 client arrives at the birthing unit stating, "I've been contracting every 5 minutes for the past hour, and they're getting stronger.”. She says walking made the contractions feel even more intense. Cervical exam: 3 cm dilated, 80
A)
The client is experiencing Braxton Hicks contractions.
B)
The client is in true labor.
C)
The client is in the latent phase of false labor.
D)
The client is experiencing false labor.
A 37-week primigravida tells the nurse, "I feel like my baby dropped. I can finally take a deep breath again, but now I have to go to the bathroom all the time.”. Which nursing response is most appropriate?
A)
"This is a normal sign that your body is getting ready for labor.”.
B)
"You may have a urinary tract infection.”.
C)
"You should go to the hospital right away.”.
D)
"You should avoid walking to prevent preterm labor.”. —
A labor and delivery nurse is caring for a 26-year-old G1P0 client who was admitted in active labor. The provider has ordered vaginal exams as indicated. In which of the following situations would the nurse appropriately perform a vaginal exam?
(SATA)
A)
Before administering analgesic or anesthetic medications.
B)
When the membranes rupture or an abnormal fetal heart rate pattern is observed.
C)
On admission to determine baseline cervical dilation and effacement.
D)
Every hour to check for progression of labor.
E)
The client is positive for Group B Streptococcus.

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Exam Review

A laboring woman experienced spontaneous rupture of membranes (SROM) 18 hours ago. Her temperature is now 100.8°F (38.2°C) and the amniotic fluid has a foul odor. What complication should the nurse suspect?
A)
Uterine atony.
B)
Placental abruption.
C)
Fetal acidosis.
D)
Chorioamnionitis.
When assessing a multiparous woman who has just given birth to an 8-pound boy 15 minutes ago, the nurse notes that the woman's fundus has become globular in shape. A gush of dark red blood comes from her vagina. What is the nurse's interpretation of these findings?
A)
A cervical tear occurred during the birth.
B)
The placenta has separated.
C)
Clots have formed in the upper uterine segment.
D)
The woman is beginning to hemorrhage.
A client 40 weeks in early labor tells the nurse she feels wet. The nurse observes spontaneous rupture of membranes with clear fluid. Which nursing action is priority?
A)
Assist client to the bathroom.
B)
Document uterine contraction pattern.
C)
Prepare the client for delivery.
D)
Evaluate fetal heart tracing.
Ten minutes after placental delivery, the nurse notes a soft, boggy uterus and steady trickle of bright red blood. What is the nurse's first action?
A)
Notify the provider immediately.
B)
Begin fundal massage.
C)
Prepare the client for surgery.
D)
Administer intravenous Pitocin.

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Exam Review

A 40 weeks gestation client delivered a baby girl 20 minutes ago. The nurse observes a gush of blood from the vagina and lengthening of the umbilical cord. The nurse prepares Pitocin IV to be administered after delivery of the placenta with the understanding that Pitocin is given:
A)
to promote progressive cervical change.
B)
to relieve pain.
C)
to facilitate rest and relaxation of the uterus.
D)
to stimulate uterine contractions and prevent hemorrhage.
A nurse is caring for a laboring client whose membranes ruptured spontaneously. Immediately afterward, the fetal heart rate drops to 70 beats per minute and does not recover after repositioning to her left side. The nurse notes variable decelerations on the fetal monitor. What is the nurse's immediate next step?
A)
Perform a sterile vaginal examination.
B)
Administer Magnesium Sulfate intravenously.
C)
Check the maternal vital signs.
D)
Increase the oxytocin infusion rate.
A nurse is caring for a client who is 1 hour postpartum and observes minimal lochia rubra with a dime-sized clot on the sanitary pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
A)
Document the findings and continue to monitor.
B)
Notify the provider.
C)
Increase the frequency of fundal massage.
D)
Encourage the client to empty her bladder.
A postpartum client who delivered 24 hours ago continues to complain of severe perineal pain after being medicated with pain medication. The client's vital signs are stable. The uterus is firm and midline. Which of the following assessments should the nurse perform?
A)
Reassess the fundus.
B)
Reassess need for Oxytocin.
C)
Assess client's temperature.
D)
Assess the perineum for hematomas.

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Exam Review

A nurse is assessing a client who is 2 days postpartum and is breastfeeding. The nurse notes that the fundus is two centimeters below the umbilicus, lochia rubra is scant, and the breasts are warm to touch. Which of the following interpretations of these findings should the nurse make?
A)
No interventions are indicated at this time.
B)
The client's breasts are engorged.
C)
The client is exhibiting early signs of mastitis.
D)
Subinvolution is observed.
The nurse is caring for a postpartum client who delivered 1 hour ago by Cesarean section. The client had a quantity blood loss of 350 milliliters during the delivery. One hour later, the client's bed is soaked with blood and the client's blood pressure is 140/90. What is the priority nursing action to take next?
A)
Increase the intravenous rate of lactated Ringer's solution.
B)
Assess the uterine fundus for firmness and location.
C)
Apply oxygen via nonrebreather mask at 10 liters per minute.
D)
Call the healthcare provider to report the findings.
A postpartum client delivered by Cesarean section 1 day ago. The mother's blood type is O negative and the newborn's blood type is B positive. Which of the interventions should the nurse perform?
A)
Administer RhoGAM within 72 hours.
B)
Keep client NPO.
C)
Document the blood types and take no action.
D)
Prepare a blood transfusion to be administered.
A postpartum client who is 2 days post-vaginal delivery reports cramping in her lower abdomen that worsens while she is breastfeeding. Which response by the nurse best explains this finding?
A)
"Breastfeeding causes the release of oxytocin, which contracts your uterus.”.
B)
"You should stop breastfeeding until the pain subsides.”.
C)
"The cramps mean your uterus isn't healing properly.”.
D)
"This may be a sign of uterine infection.”. —

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Exam Review

A postpartum woman chooses not to breastfeed and reports painful, swollen breasts two days after delivery. Which nursing intervention is most appropriate?
A)
Encourage frequent breast stimulation and milk expression.
B)
Apply warm compresses to increase milk flow.
C)
Manually express milk every 4 hours.
D)
Apply cold compresses and wear a supportive bra continuously.
A nurse is caring for a client who experienced a vaginal delivery 48 hours ago. When assessing the client's uterus, where should the nurse expect to palpate the uterine fundus at this time?
A)
To the right of the umbilicus.
B)
1 centimeter above the symphysis pubis.
C)
2 centimeters above the umbilicus.
D)
At the level of the umbilicus.
Four hours postpartum, the nurse notes the uterus is firm but displaced to the right. The client voided 150 mL one hour ago and feels pressure in her bladder. What should the nurse do first?
A)
Document and reassess in one hour.
B)
Administer intravenous pain medication.
C)
Massage the fundus.
D)
Encourage the client to void again.
A postpartum woman at day 8 reports that her vaginal discharge has turned yellow-white and has no foul odor. The client denies pain or any urinary discomfort. Which interpretation is correct?
A)
Retained products of conception.
B)
Early return of menstruation.
C)
Normal progression to lochia alba.
D)
Infection developing.

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Exam Review

The nurse teaches new parents about normal healing after circumcision. Which observation should the parents report to the provider?
A)
Slight swelling or redness around the site.
B)
No urine output within 12 hours after the procedure.
C)
Yellow crust or film forming over the glans.
D)
A few drops of blood on the diaper.
A newborn is lying naked on a cold mattress near a drafty window. Which two types of heat loss are occurring simultaneously?
A)
Radiation and convection.
B)
Conduction and evaporation.
C)
Radiation and conduction.
D)
Convection and evaporation.
The nurse is assessing an infant's heart rate who woke up crying for 5 minutes. The infant's heart rate is 170 beats per minute. When would it be appropriate for the nurse to reassess the infant's heart rate?
A)
During the next deep sleep cycle.
B)
After the infant is in a quiet alert state.
C)
Immediately.
D)
Two hours later.
A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains the purpose of Erythromycin is to:
A)
Erythromycin prevents potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes.
B)
Erythromycin ophthalmic ointment destroys an infectious exudate caused by Staphylococcus that could make the infant blind.
C)
This ointment prevents the infant's eyelids from sticking together and helps the infant see.
D)
This ophthalmic ointment prevents gonorrheal infection of the infant's eyes, potentially acquired from the birth canal.

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