1. When assessing a laboring client, the nurse finds a prolapsed cord. The
nurse should:
A. Attempt to replace the cord
B. Place the client on her left
... [Show More] side
C. Elevate the client’s hips
D. Cover the cord with a dry, sterile gauze
Answer C: The client with a prolapsed cord should be treated by elevating
the hips and covering the cord with a moist, sterile saline gauze. The nurse
should use her fingers to push up on the presenting part until a Caesarean
section can be performed. Do not attempt to replace the cord, as stated in
answer A. Answer B is incorrect because turning the client to the left side
will not help take pressure off the cord. Answer D is incorrect because the
cord should be covered with a moist, sterile gauze, not dry gauze.
2. The nurse is caring for a 30-year-old male admitted with a stab wound.
While in the emergency room, a chest tube is inserted. Which of the
following explains the primary rationale for insertion of chest tubes?
A. The tube will allow for equalization of the lung expansion.
B. Chest tubes serve as a method of draining blood and serous fluid, and
assist in reinflating the lungs.
C. Chest tubes relieve pain associated with a collapsed lung.
D. Chest tubes assist with cardiac function by stabilizing lung expansion.
Answer B: Chest tubes work to reinflate the lung and drain serous fluid. The
tube does not equalize expansion of the lungs, so answer A is incorrect. Pain
is associated with collapse of the lung, and insertion of chest tubes is painful,
so answer C is incorrect. Answer D is true but is not the primary rationale for
performing chest tube insertion.
3. A client who delivered this morning tells the nurse that she plans to
breastfeed her baby. The nurse is aware that successful breastfeeding is most
dependent on the:
A. Mother’s educational level
B. Infant’s birth weight
C. Size of the mother’s breast
D. Mother’s desire to breastfeed
Answer D: Success with breastfeeding depends on many factors, but the
most dependable reason for success is desire and willingness to continue the
breastfeeding until the infant and mother have time to adapt. The educational
level, infant’s birth weight, and size of the mother’s breast have nothing to do
with success, so answers A, B, and C are incorrect.
4. The nurse is monitoring the progress of a client in labor. Which finding
should be reported to the physician immediately?
A. The presence of scant bloody discharge
B. Frequent urination
C. The presence of green-tinged amniotic fluid
D. Moderate uterine contractions [Show Less]