NURS 480 LABELS Questions and Answers- West Coast University, Los Angeles
NURS 480 LABELS Questions and Answers- West Coast University, Los Angeles
1.
... [Show More] During the last 6 wks of gestation, which of the following tests are not used to determine
fetal well being?
a. Maternal blood count
b. NST
c. Fetal movement/kick count
d. BPP
2. A nurse is assessing a premature infant. What would initially alert the nurse that the
infant is having respiratory distress?
a. Decreased pulse rate
b. Sporadic crying
c. Retractions
d. Jitteriness
3. The nurse would suspect preeclampsia if which of the following was found during
assessment? SATA
a. Ankle edema
b. elevated BUN and creatinine levels
c. generalized edema
d. Hypertension
e. Proteinuria
f. diminished reflexes
4. A baby was born four days ago at 37 weeks gestation. She is receiving phototherapy as
ordered by The Physician for physiologic jaundice. She has symptoms of temperature
instability, dry skin, poor feeding, lethargy, and irritability. What are the nurse's priority
nursing actions? SATA
a. Calculate 24-hour intake and output to check for dehydration
b. verify laboratory results to check for hypomagnesemia
c. feed the infant every 2 to 3 hours
d. verify laboratory results to check for hypoglycemia
e. monitor the baby's temperature to check for hypothermia
5. Which statement by a couple demonstrates understanding of the consequences of not
treating chlamydia? SATA
a. he could get an infection in the urethra
b. she could have severe vaginal itching
c. she could become pregnant
d. she could develop a worse infection of the uterus and tubes leading to PID
e. it could cause us to develop rashes
6. A client at 20 weeks of gestation tells the nurse at the prenatal clinic that she is
concerned that exercise might pose risks to the pregnancy. Which of the following is an
appropriate nursing response?
a. You should rest 30 minutes before each new activity
b. it's a good idea to increase your weight bearing exercise
c. moderate exercise can help improve your circulation
d. be careful about exercises that include stretching
7. A patient is sent to triage for fetal well-being evaluation after complaining of decreased
fetal movement. She overhears her physician give instructions to the perinatal nurse to
discharge the patient home if she achieves a category 1 fhr. Which means of fetal heart
rate tracing that includes all of the following except for?
a. Presence of accelerations
b. absence of decelerations
c. Baseline 110 to 160 BPM
d. minimal or absent variability
8. The nurse is caring for a newborn that was born to a narcotic addicted mother. At the
age of twenty-four hours, which expected assessment findings should the nurse consider
when planning care for this newborn. SATA
a. Jitteriness
b. Lethargy
c. exaggerated reflexes
d. decreased muscle tone
e. irritability
f. high-pitched cry
9. The following are expected assessment findings on post mature neonates except for
a. Absent creases
b. Dry, cracked, peeling skin
c. Lack of vernix
d. Long fingernails
10. A nurse is caring for a twenty-three-year-old G2 P2 patient immediately following a
vaginal delivery. Her assessment shows that the patient is experiencing profuse
bleeding. What is the most likely cause for the bleeding.
a. Uterine subinvolution
b. vaginal hematoma
c. uterine atony
d. vaginal laceration
11. 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 (SATA)
a. Wash the perineal area using a squeeze bottle of warm water after each voiding?
b. Preform hand hygiene before and after voiding
c. Blot perineal area dry, and avoid wiping after voiding
d. Apply ice packs to the perineal area several times a day
e. Clean the perineal are from front to back
12. Because a woman has a history of toxic shock syndrome she should be taught to avoid
which of the following forms of birth control
a. Cervical cap
b. contraceptive patch
c. male diaphragm
d. intrauterine device
13. A nurse is providing teaching to the mother of an infant born small for gestational age.
Which of the following should the nurse include as a cause of this condition?
a. Primipara
b. placental insufficiency
c. perinatal asphyxia
d. maternal obesity
14. As a newborn nurse strokes the lateral surface of the 2-hour old infants foot Sole
hyperextension and Fanning of the toes was observed this indicates
a. post maturity
b. Prematurity
c. neurological damage
d. normal infant reflex
15. A nurse is assessing a client for postpartum infection. Which of the following findings
should indicate to the nurse that the client requires further evaluation for endometritis
a. Hematuria
b. dark red lochia
c. Bradycardia
d. pelvic pain
16. In Leopold's maneuver step number three you palpated a hard round movable mass at
the suprapubic area the correct interpretation is that the mass palpated is
a. the mass palpated is the head so the presentation is cephalic
b. the buttocks because the presentation is breech
c. the mass palpated is the fetal small part
d. the mass palpated is the fetal back
17. The nurse is to tell a patient that her pap smear result was abnormal. Which statement
should the nurse include?
a. Colposcopy to further examine your cervix is the next step
b. the pap smear is used to diagnose cervical cancer
c. your cervix needs to be treated with cryotherapy
d. Loop electrosurgical excision procedure is needed
18. A 32 week G2 P1 is admitted to the antepartum unit for preterm Labor Management her
urinalysis result is normal and her amniotic membrane remain intact. Her current
medications include mag sulfate to grams per hour. Ampicillin to grams every 6 hours
and Betamethasone 12 mg IM every 24 hours total of two doses she asked the nurse
why she is given antibiotics what would the nurses best response be?
a. You are only 32 weeks and we don't have a GBS status the antibiotic would
serve as a prophylactic for your baby
b. we give antibiotics to all preterm patients it's better safe than sorry
c. you are only 32 weeks and we don't have a GPS status the antibiotics would
serve as a prophylactic for you
d. you were running a urinary tract infection which may have been the cause of
your preterm contractions
19. The nurse suspects that a client has developed a perineal hematoma. Which
assessment finding would the nurse have detected to leave to this conclusion?
a. Facial petechiae
b. large soft hemorrhoids
c. elevated temperature
d. tense tissues with severe pain
20. Gonorrhea in a teenage female can be asymptomatic and difficult to detect; therefore it
may go untreated. What complication is most likely to occur as a result of this?
a. Cervical cancer
b. proliferating endometriosis
c. ovarian cysts
d. obstructed fallopian tubes
21. Speculum examination is performed during Cynthia's first prenatal visit. The clinic nurse
notes a bluish purple coloration of the cervix this finding is a probable sign of pregnancy
termed
a. Linea nigra
b. Goodell sign
c. Chadwicks sign
d. striae gravidarum
22. The nurses working on the postpartum unit. Which patient should she assess first?
a. Pp1 precipitous delivery with a blood loss of 400 ml at delivery
b. po2 cesarean delivery with absent bowel sounds
c. pp3 delivery with a WBC of 12000
d. gp1 vaginal delivery who complains of burning on urination
23. The new grad nurse has been assigned to care for a patient schedule for an induction of
labor with oxytocin. As she reviews the effects of oxytocin, she recalls that one of the
risks of oxytocin infusion includes FHR changes related to:
a. Decreased placental perfusion
b. Maternal hypotonic contractions
c. Maternal hypotension
d. Oligohydramnios
24. During a prenatal examination, the woman reports having cats at home. The nurse
informs her that she should not be cleaning the litter box while she is pregnant. When
the woman questions the nurse as to why the nurses best response would be
a. cat feces are known to carry e-coli which can cause a severe infection in both
you and your baby
b. your cat could be carrying toxoplasmosis. This is a zoonotic parasite that can
affect you and have severe effects on your unborn child
c. you and your baby can be exposed to the HIV virus in your cat's feces
d. it's just gross you should make your husband clean the litter boxes
25. The triage nurse receives a call from a 28-week pregnant woman. She reported that she
was watching tv while lying down on the sofa when all of a sudden she felt dizzy and
lightheaded. Based on the nurse’s knowledge of physiological changes occurring with
pregnancy, what would be an appropriate question to ask the woman?
a. Did you go for a warm shower prior to lying down?
b. Did you take your iron pills today?
c. How much time did you spend walking out under the sun today?
d. Were you lying down flat on your back when you felt the symptoms of
hypotension?
26. Nurse assesses a newborn with asymmetric gluteal and thigh skinfold, a left leg longer
than the right, and a clicking sound of the right hip. What condition does this information
most indicate on this infant?
a. A fractured right leg
b. a fractured pelvis
c. congenital hip dysplasia
d. an underdeveloped femur
27. A mother and her two-day-old baby are preparing for discharge. Which situation would
require the baby's discharge to be cancelled?
a. The parents only on a car seat that faces the rear of the car
b. the baby's bilirubin is 16 mg per deciliter
c. the baby's blood sugar is 58 mg per deciliter
d. The baby has a rash on his face
28. An adult female patient is using the rhythm ( calendar basal body temperature) method
of family planning. The unsafe period for sexual intercourse is indicated by
a. breast tenderness and mittelschmerz
b. basal body temperature increase of 0.1 degrees to 0.2 degrees on the second or
third day of cycle
c. return to preovulatory basal body temperature
d. three consecutive days of elevated basal body temperature and thin clear
cervical mucus
29. An adult female patient is using the rhythm (calendar basal body temperature) method of
family planning. In this method, the unsafe period for sexual intercourse is indicated by
a. Breast tenderness and mittelschmerz
b. Basal body temp increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd day of
cycle
c. Return to pre-ovulatory basal body temp
d. 3 consecutive days of elevated basal body temp and clear, thin cervical mucus
30. The student nurse is making her morning rounds and assessments on her postpartum
patient she knows that one patient has petechiae and oozing from her IV site, and
immediately recognizes that this patient is at risk for developing
a. Thrombosis
b. postpartum hemorrhage
c. amniotic fluid embolism
d. disseminated intravascular coagulation
31. During the postpartum assessment the perinatal nurse notes that a patient who has just
experienced a forceps assisted birth now has a large quantity of bright red bleeding. Are
uterine fundus is firm. The nurses most appropriate action is to notify the physician and
describe a
a. need for further information for the woman / family about forceps
b. requirement for bladder assessment and catheterization
c. need for vaginal assessment and repair
d. requirement for an oxytocin infusion
32. Which of the following statements most accurately reflects the nurses responsibility in
cases of suspected intimate partner abuse?
a. We have a list of places where you can safely stay and be protected from your
abusive partner
b. I do not see any bruises or scrapes on your body so it seems like he did not hurt
you badly. I need evidence of his abusive acts in order for me to make proper
documentation of your complaints
c. don't worry I will call the police for you so you can report the abuse that your
boyfriend is doing to you
d. if you decide not to report your husband's abusive behavior there is nothing we
can do to help you. You may go back home and try to endure your misery
33. A client is admitted to the maternity ward who is 38 weeks gestation and experiencing
polyhydramnios. The nurse understand this diagnosis means that
a. There is the normal amount of amniotic fluid, thinner in volume
b. A leak is causing fluid to accumulate outside the amniotic sac
c. A less-than-normal amount of amniotic fluid is present
d. An excessive amount of amniotic fluid is present
34. For which client is the HCP most likely to order a cervical-vaginal fetal fibronectin test?
a. 32 week gestation with regular uterine contractions
b. 34 week gestation with gestational diabetes
c. 37 week multi fetal gestation
d. 28 week gestation with ROM
35. A 36 hours pp woman told the nurse that she has decided to breastfeed her baby
exclusively. 2 hours later, the nurse overhears the woman having a conversation over
the phone which sounds like a topic about diet and nutrition. Which among the
statements, if made by the woman, would require an intervention by the nurse?
a. I need to get back in shape very badly so I’m going to start watching the portions
of food that I put on my plate
b. Since I need to increase the amount of fluid that I take, I told my husband to buy
me a big jug water bottle that I can carry around with me whenever I leave the
house
c. I will wait until my baby can sit independently before I try to introduce solid food
d. I am so glad that there are portable breast pumps that I can use when I go back
to work
36. A client whose newborn is 3 weeks old comes to the clinic to report feeling “down,” and
sad, having no energy, and wanting to cry. The priority intervention is to
a. Ask the client why she is having these feelings
b. Notify the family that the client needs more support
c. Use a postpartum depression screening tool with the client
d. Request a prescription for an antidepressant medication
37. A nurse suspects that a pp client has mastitis. The following assessment provides what
data to support this assessment? SATA
a. Nipple soreness when the infant latches on
b. Late onset of nipple pain
c. Pink, flaking, pruritic skin of the affected nipple
d. Shooting pain in her nipple during breastfeeding
38. A premature infant never seems to sleep longer than an hour at a time. Each time a light
is turned on, an incubator closes, or people talk near her crib, she wakes up and cries
inconsolably until held. The correct nursing diagnosis is ineffective coping r/t:
a. Severe immaturity
b. Physiologic distress
c. Environmental stress
d. Interpersonal interactions
39. A nurse is teaching the parents of a newborn who has physiological jaundice regarding
the complications that can develop from worsening jaundice. Kernicterus is a specific
example that occurs when:
a. Bilirubin deposits are in the brain- causing encephalopathy
b. Bilirubin collects in the liver
c. Bilirubin deposits are concentrated in the cardiac muscles
d. The kidney excretes bilirubin
40. Four babies with the following conditions are being assessed by the nurse. Which of the
babies is at high risk for physiological jaundice?
a. Cephalohematoma
b. Mongolian spotting
c. Harlequin coloring
d. Caput succedaneum
41. After an abnormal 1-hr glucola test, the patient is instructed to return for a 3 hr GTT.
which of the test results would lead to a dx of GDM?
a. 93 (fasting), 175 (1 hr), 150 (2 hr), 135 (3 hr)
b. 92 (fasting), 185 (1 hr), 149 (2 hr), 138 (3 hr)
c. 99 (fasting), 186 (1 hr), 160 (2 hr), 140 (3 hr)
d. 90 (fasting), 170 (1 hr), 156 (2 hr), 138 (3 hr)
42. A nurse is caring for a pt who is 38 weeks pregnant in labor and has seropositive HIV.
Her plan of care would include everything except for
a. Leaving fetal membrane intact
b. Providing emotional support
c. Avoiding instrument - use during delivery
d. Attaching fetal scalp electrodes
43. A nurse is assessing a client who is 12 hr postpartum. Which of the following findings
should alert the nurse to the possibility of a postpartum complication?
a. Urinary output 3,000ml/12 hr
b. Fundus at umbilicus level
c. Pulse rate 110/min
d. Chills shortly after delivery
44. The labor and delivery nurse determines by vaginal examination that the pt is fully
dilated and the fetal presenting part is descending rapidly with the patient’s pushing
efforts. The most important nursing intervention at this time would be to
a. Provide information to the patient’s partner about the her stage of labor
b. Assist the patient with breathing to slow down her pushing
c. Leave the room to call the physician to come for the birth
d. Document the patient’s progress and coping abilities in labor
45. A 19 year old patient presents to OB triage in labor at term, having had no prenatal care.
After birth, her baby boy is found to be small for gestational age with small eyes, a thin
upper lip, and microcephalic. Based on these physical assessment findings, this patient
should be questioned regarding her use of which substance during pregnancy?
a. Heroin
b. Cocaine
c. Marijuana
d. Alcohol
46. A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse
notes late decels and interprets them as indicating which of the following?
a. Delivery of the fetus is imminent
b. Normal response to contractions
c. Potential for fetal distress
d. Labor is failing to progress
47. A newborn girl was delivered vaginally 2 hours ago at 38 weeks gestation and weighing
4.2 kg. The newborn appears to have a flushed complexion and is very tremulous. The
student nurse recognizes that the tremors are most likely the result of :
a. Hypoglycemia
b. Seizures
c. Hypocalcemia
d. Birth injury
48. The nurse suspects that a client has developed a perineal hematoma. What assessment
findings would the nurse have detected to lead to this conclusion?
a. Large, firm hemorrhoids
b. Tense tissues with severe pain
c. Facial petechiae
d. Elevated temperature
49. The nurse knows that an FHR monitor printout indicates a category III abnormal fetal
heart rate pattern when:
a. Baseline variability is minimal or absent with decelerations
b. Occasional periodic accels occur
c. Baseline variability is 6-25 bpm with decels
d. FHR mirrors the uterine contractions
50. A nurse is caring for a group of clients on an intrapartum unit. Which of the following
findings should the reported to the RN immediately?
a. A client who has a diagnosis of preeclampsia has 2+ patellar reflexes and 2+
proteinuria
b. A client who is 28 weeks of gestation and receiving terbutaline reports fine
tremors
c. A client who has a diagnosis of preeclampsia reports epigastric pain and
unresolved headache
d. A client who is 32 weeks of gestation and is experiencing irregular, frequent
contractions is tearful.
51. A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The
newborn’s mother asks about the swollen area on her son’s head. After palpation to
identify that the swelling crosses the suture line, which of the following is an appropriate
response by the nurse?
a. Mongolian spots can be found on the skin of many newborns
b. This is a cephalohematoma which can occur spontaneously
c. This is erythema toxicum which is a transient condition
d. A caput succedaneum occurs due to compression of blood vessels
52. A nurse is reinforcing expected gestational changes with 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 tell my doctor before using home remedies for nausea
b. I will use only nonprescription medications while pregnant
c. I should monitor my weight gain during the remaining months
d. I am going to reduce my stress level
53. A middle aged female client asks a nurse about hot flashes. How should the nurse
explain the primary cause of this condition?
a. Decreased estrogen levels
b. Increased FSH
c. Increased LH
d. Increased estrogen
54. The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The
nurse should tell the patient that she can expect to feel the fetus move at which time?
a. Between 10 and 12 weeks of gestation
b. Between 24 and 26 weeks of gestation
c. Between 16 and 20 weeks of gestation
d. Between 21 and 23 weeks of gestation
55. A patient is receiving an oxytocin drip for augmentation of labor. While reviewing the fetal
heart strip, the nurse notices decels in fetal heart rate with every contraction. The
decrease in fetal heart rate occurs at the onset of a contraction and drops gradually
reaching the nadir at the same time the contraction reaches its peak. Given this type of
fetal heart decel, the nurse is expected to
a. Turn the patient to the side
b. Continue fetal heart rate and contraction monitoring
c. Discontinue the oxytocin
d. Decrease the amount of oxytocin by half
56. A client postpartum 24 hours from a spontaneous vaginal delivery with rupture of
membranes for 42 hours. Which s/s would make the nurse suspect endometritis? SATA
a. Decreased urine output
b. Engorged breasts
c. Increased temperature
d. Clusters of hemorrhoids
e. Abdominal pain
f. Foul smelling lochia
57. The new grad nurse is receiving an orientation in the labor and delivery unit. On her first
patient admission, her preceptor observes her perform leopold’s maneuver. Which of the
following actions by the new grad nurse would prompt the nurse preceptor to intervene?
a. The new grad nurse puts her one hand on the fundus and one hand down at the
suprapubic area to determine the location of the cephalic prominence
b. The new grad first places her two hands and palpates the fundal area of the
uterus
c. With the use of her two hands, the new grad nurse palpates the lower abdomen
to determine the fetal part that lies over the pelvic inlet
d. She asks the pt to turn side to side as she palpates and determines the location
of the fetal back
58. The following are correct regarding endometriosis? SATA
a. the abnormal tissue bleeds into the surrounding tissue during the secretory
stage of the menstrual cycle
b. Endometriosis can cause sterility-infertility?
c. it can be treated with NSAIDs hormonal and surgery
d. the physical symptoms of endometriosis can affect the woman's Mental Health
e. increases pelvic pain and can affect sexual activity
59. On the first pp day, the nurse teaches the patient about breastfeeding. 3 hrs later, the
mother seems to remember very little of the teaching. The nurse understands this
memory lapse to be due to which condition?
a. The taking hold phase
b. Epidural anesthesia
c. Fatigue after delivery
d. The taking in phase
60. A nurse is assessing a client who is 6 hrs pp after delivering a full term healthy infant.
The client complains to the nurse of feelings of faintness and dizziness. Which nursing
action would be most appropriate?
a. Inform the nursery room nurse to avoid bring the newborn infant to the client until
the feelings of faintness and dizziness have subsided
b. Elevate the client’s legs
c. Determine the hgb and hct levels- anemia/hemorrhage?
d. Instruct the client to request help when getting out of bed
61. You are teaching a group of women ages 35-60 about osteoporosis and its prevention.
Which foods in the list would you recommend as a good source of calcium besides dairy
products?
a. Banana
b. Brown rice
c. Canned sardines
d. Sweet potato
62. A 48 year old woman asks the nurse how she could determine if she is in the
premenopausal stage. Based on the nurse’s knowledge about the stages of menopause,
which among the woman’s statements would best help the nurse answer her inquiry?
a. I cannot fall asleep at night unless I have my socks on
b. Lately I have been dying my hair more frequently bc the grey hairs grow too
quickly
c. I don’t recall getting my period last month, but I know I had one prior to that
month
d. Warm showers really relax me. In fact, I regularly soak in a warm jacuzzi after I
go to the gm
63. A nurse is caring for a client during an NST. The nurse observes 2 decels of 15x15 in the
fetal heart rate during a period of fetal movement. Each del lasts 20 seconds. This
indicates which of the following findings? What is this question?
a. A reactive test
b. A nonreactive test
c. A negative test
d. A positive test
64. A breastfeeding client, G10P6408, delivered 10 minutes ago. Which assessment is most
important for the nurse to perform at this time?
a. Breast
b. Pulse
c. Fundus
d. Bladder
65. A woman has delivered a macrosomic baby after prolonged labor. For which
complication should the nurse be carefully monitoring during the immediate postpartum
period?
a. Urinary tract infection
b. Endometritis
c. postpartum depression
d. uterine atony
66. You are caring for a 5-hour postpartum patient. When you take her oral temperature the
thermometer reads 99.8. Based on this result your next action is
a. recommended blood draw for WBC
b. administer antipyretic per physician order
c. obtain an order for an antibiotic
d. encourage the patient to increase fluid intake and continue monitoring
67. Assessing a newborn baby girl at 1 minute of life. She has a pink color, a pulse rate of
105, and an irregular cry. She grimaces in response to stimuli, and has limited muscle
movement. This patient has an apgar score of
a. 6
68. *******The registered nurse is teaching a client how to correctly use oral contraceptives.
The nurse should include which information in the teaching plan? (SATA)
a. Is taking antibiotics the woman needs an additional method of contraception
utilized through the remainder of that cycle
b. an additional method of contraception is not needed through the end of the cycle
of more than one pill is missed-no
c. skip five days between the end of one pill cycle and the beginning of the nextnot this
d. take the pills with calcium rich foods to promote absorption no
e. take one pill anytime of the day everyday-no i dont know
69. The NICU nurse is caring for a premature infant with necrotizing enterocolitis. Her
assessment finding would include
a. hypertension absence of apnea and Dusky skin color
b. abdominal distension temperature instability and grossly bloody stools
c. hypertonia tachycardia and metabolic alkalosis
d. scaphoid abdomen no residual with feedings and increased urinary output
70. When a woman is diagnosed with pp depression, what is one of the main concerns?
a. She may neglect her hygiene
b. She may lose interest in her husband
c. She may have outburst of anger
d. She may harm her infant
71. A 16 week gestation client is having an amniocentesis, for which of the following
indications is the test being done?
a. Evaluation of the amniotic fluid volume
b. Genetic evaluation
c. Assessment of fetal lung maturity
d. Assessment of intrauterine growth restriction
72. The plan of are for a newborn boy experiencing symptoms of drug withdrawal should
include
a. Administer chloral hydrate for sedation
b. Feeding every 4-6 hours to allow extra rest
c. Playing soft music during feeding
d. Swaddling the infant snuggly and holding tight
73. A nurse performs her shift assessment on a one day old infant. Upon inspection of the
head, the nurse notices the fontanelles to be hollow and depressed. The nurse suspects
the newborn is experiencing
a. Hypotension
b. Hypospadias
c. Hypoglycemia
d. dehydration
74. A postpartum nurse is providing instructions to the mother of an infant with
hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate
instructions to the mother
a. Feed infant less frequently
b. Stop the breast feedings and switch to bottle feeding permanently
c. Switch to bottle feeding for two weeks
d. Continue to breastfeed every 2-4
75. *****The nurse teaches the woman with premenstrual syndrome PMS about self-help
strategies to help diminish symptoms. For example the nurse may suggest
a. taking evening evening primrose oil during the menstrual period
b. Engaging and relaxation techniques and stress relief therapy such as massage
in yoga
c. decreasing physical activity approximately one week before expected menses
d. increasing the intake of water approximately 5 to 7 days before menstruation
76. Nurse is caring for a mother who delivered a stillborn infant and strongly encourages the
mother to hold the baby. What is the primary rationale for this intervention SATA
a. let the parents decide if they want an autopsy
b. give the mother a chance to say goodbye
c. Shortens the grieving period
d. Give the mother one chance to see the baby
e. help the mother except the finality of the death
77. The nurse has assessed 4 primigravida client in the prenatal clinic. Which women would
the nurse refer to the nurse midwife for further assessment?
a. 26 weeks gestation complaining of ankle edema and chloasma
b. 10 weeks gestation complaining of fatigue with N/V
c. 32 weeks gestation complaining of facial edema and epigastric pain
d. 37 weeks gestation complaining of bleeding gums and urinary frequency
78. The nurse is caring for a patient whose postpartum hemorrhage was recently resolved,
however, remains at risk for developing hemorrhagic shock. The nurse recognizes that
the most objective and least invasive assessment of adequate organ perfusion and
oxygenation is:
a. Adequate urinary output -kidney function but not oxygenation
b. Absence of cyanosis in the buccal mucosa
c. Diminished restlessness - yes but subjective
d. Cool, dry skin - would be warm, dry
79. A woman in labor is found to have meconium-stained amniotic fluid upon rupture of her
membranes. At delivery, which would the nurse anticipate to be the priority nursing intervention?
a. Deliver the neonate on its side with head up, to facilitate drainage of secretions
b. Suction the oropharynx when the head has delivered
c. Prepare for the immediate use of positive pressure to expand the lungs
d. Monitor the woman’s temperature
80. You are training a new-grad nurse in a postpartum unit. You assign her to care for G1P1
Chinese patient who delivered vaginally 12 hours ago. Which of the following nursing actions
made by the new grad nurse would require that you intervene?
a. She encourages the patient to hold and care for her infant more than the female relative
to improve her knowledge and skills in parenting
b. She agrees to warm up the soup the female relative brought for the patient
c. She instructs the housekeeper not to open room windows while cleaning
d. She encourages both the new parents to watch while she demonstrates to them how to
change infant diaper
81. A pregnant woman was admitted for induction of labor at 43 weeks gestation with sure
dates. A nonstress test in the obstetricians office revealed a non reactive NSt. Upon artificial
ROM, thick meconium-stained fluid was noted. The nurse caring for the infant after birth should
anticipate which of the following?
a. Golden yellow to green stained skin and nails, absence of scalp hair, and increased
amount of subcutaneous fat
b. Meconium aspiration, hypoglycemia, and dry cracked skin
c. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance
d. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome
82. A nurse is caring for a client who is primigravida, at term, and having contractions but it is
stating that she is not really sure if she is in labor or not. The nurse should recognize which of
the following is an indication of true labor?
a. Station of the presenting part
b. Changes in the cervix
c. Rupture of the membranes
d. Pattern of contractions
83. A client has just discovered her first newborn. The nurse anticipates hyperbilirubinemia due
to ABO incompatibility . Hyperbilirubinemia occurs with ABO incompatibility between client and
fetus because
a. The newborn develops a congenital defect shortly after birth that causes the destruction
of red blood cells
b. The clients blood does not contain the A & B factors, so she produces anti- A & B
antibodies that cross the placenta barrier and cause hemolysis of red blood cells in
newborns
c. The clients blood contains the A & B factors and the newborns does not, and antibodies
that destroy red blood cells are formed in the baby
d. The client has a history of previous jaundice caused by a blood transfusion, affecting the
fetus through the placenta
84. A nurse is conducting a class for a local women's group about recommendations for a pap
smear. One of the participants asks “at which age should a woman have her first pap smear?
The nurse responds by stating that a woman should have her first pap smear at which age?
a. 21
b. 40
c. 25
d. 18
85. You are teaching discharge instructions to a postpartum patient about circumcision care of
the infant. The following instructions are included in your teaching plan except?
a. Apply protective lubricant over the circumcision site after each diaper change
b. Report any signs of infection such as redness, swelling, foul odor, and drainage
c. Gently wash off the yellow crusty mucus that forms over the glans
86. A nursery nurse observes that a full-term AGA neonate has nasal congestion, hypertonia,
and tremors and is extremely irritable. Based on these observations, the nurse suspects which
of the following?
a. Neonatal withdrawal
b. Hypercalcemia
c. Hypoglycemic
d. Cold stressed
87. A client at 40 weeks gestation is about to undergo a biophysical profile The nurse should
explain that this profile focuses on which of the following parameters? SATA
a. Amniotic fluid volume
b. Nuchal translucency
c. Fetal Gender
d. Fetal motion
e. Fetal breathing
88. When teaching a group of postmenopausal women about hot flashes and night sweats, the
nurse would address which of the following as the primary cause?
a. Poor dietary intake
b. Changes in vaginal pH
c. Active lifestyle
d. Estrogen deficiency
89. Intimate Partner Abuse is an abusive relationship characterized by the abusers desire to
have
a. Power and control in the relationship
b. The victims sympathy
c. A sense of intimacy
d. Financial security
90. A woman gave birth vaginally to a 9-pound, 12 ounce girl yesterday. Her primary health care
provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener.
Which of the following information is most closely correlated with these orders?
a. The women has an episiotomy
b. The women had a vacuum-assisted birth
c. The women is gravida 2, para 2
d. The women received an epidural anesthesia
91. Which nursing consideration is a contraindication when contemplating administering
methergine to a 20 year old patient who has recently undergone normal spontaneous delivery
one hour ago? Patients current visits are BP 140/90, Respirations 22, Heart rate 100, Temp
99.5.
a. Patients heart rate of 110
b. Patients fundus is boggy
c. Patients BP is 140/90
d. Patients fundus is 1 cm above the umbilicus and deviated to the right
92. A woman comes to the crisis prevention center anxious and upset. She tells the volunteer
nurse who is working as a client advocate that she has been raped. The client says “I think it is
my fault this happened. I should never have worn that tight skirt” which response by the nurse
would be most appropriate?
a. You need to stop blaming yourself
b. You should not dwell on why it happened. Now you need to deal with the complications
that may occur because of the rape
c. Your reaction represents a myth. Women do not have to provoke the assailant to be
raped.
d. Even if you did provoke the assailant by wearing a tight skirt, he is responsible for his
behavior
93. Which of the following measures would the nurse like to include in the teaching plan for a
woman to reduce the risk of osteoporosis after menopause?
a. Eating high-fiber, high-calorie foods
b. Taking iron supplements daily
c. Restricting fluid to 1,000ml daily
d. Participating in regular weight-bearing exercise
94. Normal physiological changes that accompany menopause include?
a. Decreased levels of estrogen and progesterone
b. An increase in muscle mass
c. Less elastic skin with decreased melanin
d. Vaginal lengthening with an increased production of cervical mucus
95. Which of the following supports the diagnosis of pathologic jaundice?
a. Clinical jaundice evident within 24 hours of birth
b. Serum bilirubin levels greater than than 10mg/dl in full-term newborn
c. Serum bilirubin concentrations greater than 2mg/dl in cord blood
d. Serum Billirubin levels increasing more than 1mg/dl in 24 hours
96. During a health visit, a 23-year old patient shares with her health-care provider that she has
been experiencing a yellowish mucus vaginal discharge, pain during sexual intercourse, and
burning on urination. A culture of the cervical epithelial cells is obtained. Based on the patient
information, the culture is obtained to assist in the diagnosis of which of the following? SATA
a. Syphillis
b. Cervical cancer
c. Gonorrhea
d. Chlamydia
e. Gential Herpes
97. On day three of life, a newborn continues to require 100% oxygen by nasal cannula. The
parents ask if they can hold their infant during his next gavage feeding. Given that his newborn
is physiologically stable, what response would the nurse give?
a. You may only hold your baby's hand during the feeding
b. Parents are not allowed to hold their infants who are dependent on oxygen
c. Feedings cause more physiological stress, so the baby must be closely monitored.
Therefore, I don't think you should hold your baby
d. You may hold your baby during the feeding - absolutely
98. The postpartum client has developed thrombophlebitis in her right leg. Which finding
requires immediate intervention?
a. Becomes upset that she cant go home yet
b. Appears anxious, and describes pressure in her chest
c. Develops a temp of 101
d. Develops pain and swelling in her left lower leg
99. When caring for a 3 day old neonate who is receiving phototherapy to treat jaundice, the
nurse in charge would expect to do which of the following?
a. Turn the neonate every 6 hours
b. Check the vital signs every 2 to 4 hours - bc phototherapy can cause hyperthermia
c. Instruct parents to apply lotions to the skin to prevent dryness
d. Encourage the mother to discontinue breastfeeding
100. A nurse is caring for a preterm newborn. To help the newborn conserve energy, the nurse
should incorporate which of the following into the plan of care?
a. Cluster the newborns care activities
b. Change the newborns position every 2 hr
c. Place elbow restraints on newborn
d. Allow opportunities for newborn massage [Show Less]