NURS 155 Exam 3 Success Questions

4. A woman has just arrived at the labor and delivery suite. In order to report the client's status to her primary health care practitioner, which of the following assessments should the nurse perform? Select all that apply. 1. Fetal heart rate. 2. Contraction pattern. 3. Contraction stress test. 4. Vital signs. 5. Biophysical profile.

. 1, 2, and 4 are correct. 1. The nurse should assess the fetal heart before reporting the client's status to the health care provider. 2. The nurse should assess the contraction pattern before reporting the client's status 4. The nurse should assess the woman's vital signs before reporting her status.

61. A woman is planning to become pregnant. Which of the following actions should she be counseled to take before stopping birth control? Select all that apply. 1. Take a daily multivitamin. 2. See a medical doctor. 3. Drink beer instead of vodka. 4. Stop all over-the-counter medications. 5. Stop smoking cigarettes.

. 1, 2, and 5 are correct. 1. It is very important that women, before attempting to become pregnant, begin taking daily multivitamin tablets. 2. Women who wish to become pregnant should first see a medical doctor for a complete check-up 5. Women who wish to become pregnant should be counseled to stop smoking.

88. The health care practitioner orders the following medication for a laboring client: Stadol 0.5 mg IV stat for pain. The drug is on hand in the following concentration: Stadol 2 mg/mL. How many mL of medication will the nurse administer? _____ mL

0.25 mL

66. A nurse is advising a pregnant woman about the danger signs of pregnancy. The nurse should teach the mother that she should notify the physician immediately if she experiences which of the following signs/symptoms? Select all that apply. 1. Convulsions. 2. Double vision. 3. Epigastric pain. 4. Persistent vomiting. 5. Polyuria.

1, 2, 3, and 4 are correct. 1. Convulsions are a danger sign of pregnancy. 2. Double vision is a danger sign of pregnancy. 3. Epigastric pain is a danger sign of pregnancy. 4. Persistent vomiting is a danger sign of pregnancy.

45. A nurse is working in the prenatal clinic. Which of the following findings seen in third-trimester pregnant women would the nurse consider to be within normal limits? Select all that apply. 1. Leg cramps. 2. Varicose veins. 3. Hemorrhoids. 4. Fainting spells. 5. Lordosis.

1, 2, 3, and 5 are correct. 1. Leg cramps are normal, although the client's diet should be assessed. 2. Varicose veins are normal, although client teaching may be needed. 3. Hemorrhoids are normal, although client teaching may be needed. 5. Lordosis, or change in the curvature of the spine, is normal, although patient teaching may be needed.

76. Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply. 1. Assess fetal heart rate. 2. Infuse 1000 cc of Ringer's lactate. 3. Place woman in Trendelenburg position. 4. Monitor blood pressure every 5 minutes for 15 minutes. 5. Have woman empty her bladder.

1, 2, and 5 are correct. 1. Before a woman is given regional anesthesia, the nurse should assess the fetal heart rate. 2. The nurse should infuse Ringer's lactate before the woman is given regional anesthesia 5. The nurse should ask the woman to empty her bladder.

33. A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the doula to perform? 1. Give the mother a back rub. 2. Assess the fetal heart rate. 3. Check the blood pressure. 4. Regulate the intravenous

1. An appropriate action by the doula is giving the woman a back massage.

82. A nurse is discussing diet with a pregnant woman. Which of the following foods should the nurse advise the client to avoid consuming during her pregnancy? 1. Bologna. 2. Cantaloupe. 3. Asparagus. 4. Popcorn.

1. Bologna should not be consumed during pregnancy unless it is thoroughly cooked.

87. A mother is experiencing nausea and vomiting every afternoon. The ingestion of which of the following spices has been shown to be a safe complementary therapy for this complaint? 1. Ginger. 2. Sage. 3. Cloves. 4. Nutmeg.

1. Ginger has been shown to be a safe antiemetic agent for pregnant women

5. Because nausea and vomiting are such common complaints of pregnant women, the nurse provides anticipatory guidance to a 6-week gestation client by telling her to do which of the following? 1. Avoid eating greasy foods. 2. Drink orange juice before rising. 3. Drink 2 glasses of water with each meal. 4. Eat 3 large meals plus a bedtime snack.

1. Greasy foods should be avoided

82. A nurse is caring for women from four different countries. Which of the women is most likely to request that her head be kept covered throughout her hospitalization? 1. Arabic woman. 2. Chinese woman. 3. Russian woman. 4. Greek woman.

1. Muslim women, who are often from Arabic countries, are expected to keep their heads covered at all times.

20. Which of the following findings in an 8-week gestation client, G2 P1001, should the nurse highlight for the nurse midwife? 1. Body mass index of 17. 2. Blood pressure of 100/60. 3. Hematocrit of 36%. 4. Hemoglobin of 13.2.

1. The BMI of 17 is of concern. This client is entering her pregnancy underweight.

35. Which of the following vital sign changes should the nurse highlight for a pregnant woman's obstetrician? 1. Prepregnancy blood pressure (BP) 100/60 and third trimester BP 140/90. 2. Prepregnancy respiratory rate (RR) 16 rpm and third trimester RR 22 rpm. 3. Prepregnancy heart rate (HR) 76 bpm and third trimester HR 88 bpm. 4. Prepregnancy temperature (T) 98.6ºF and third trimester T 99.2ºF.

1. The blood pressure should not elevate during pregnancy. This change should be reported to the health care practitioner.

90. A woman asks the nurse about the function of amniotic fluid. Which of the following statements by the woman indicates that additional teaching is needed? 1. The fluid provides fetal nutrition. 2. The fluid cushions the fetus from injury. 3. The fluid enables the fetus to grow. 4. The fluid provides a stable thermal environment

1. The umbilical cord, not the amniotic fluid, delivers nutrition to the developing fetus.

58. A gravid woman who recently emigrated from mainland China is being seen at her first prenatal visit. She was never vaccinated in her home country. An injection to prevent which of the following communicable diseases should be administered to the woman during her pregnancy? 1. Influenza. 2. Mumps. 3. Rubella. 4. Varicella

1. The woman should receive the influenza injection. The nasal spray, however, should not be administered to a pregnant woman.

69. The nurse is caring for a pregnant client who is a vegan. Which of the following foods should the nurse suggest the client consume as substitutes for restricted foods? 1. Tofu, legumes, broccoli. 2. Corn, yams, green beans. 3. Potatoes, parsnips, turnips. 4. Cheese, yogurt, fish.

1. Tofu, legumes, and broccoli are excellent substitutes for the restricted foods

44. A third-trimester client is being seen for routine prenatal care. Which of the following assessments will the nurse perform during the visit? Select all that apply. 1. Blood glucose. 2. Blood pressure. 3. Fetal heart rate. 4. Urine protein. 5. Pelvic ultrasound.

2, 3, and 4 are correct. 2. The blood pressure is assessed at each prenatal visit. 3. The fetal heart rate is assessed at each prenatal visit. Depending on the equipment available, it will be assessed mechanically via Doppler or manually via fetoscope. The fetal heart is audible via Doppler many weeks before it is audible via fetoscope. 4. Urine protein is performed at each prenatal visit

77. Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following? 1. Paresthesias in her feet and legs. 2. Drop in blood pressure. 3. Increase in central venous pressure. 4. Fetal heart accelerations.

2. Hypotension is a very common side effect of regional anesthesia.

81. Which of the following actions is appropriate for the nurse to perform when caring for a Chinese-speaking woman in active labor? 1. Apply heat to the woman's back. 2. Inquire regarding the woman's pain level. 3. Make sure that the woman's head is covered. 4. Accept the woman's loud verbalizations.

2. It is important to inquire about the pain level of all women in labor, but especially those from the Asian culture.

47. The nurse is interviewing a 38-week gestation Muslim woman. Which of the following questions would be inappropriate for the nurse to ask? 1. "Do you plan to breastfeed your baby?" 2. "What do you plan to name the baby?" 3. "Which pediatrician do you plan to use?" 4. "How do you feel about having an episiotomy?"

2. It is inappropriate to ask the Muslim client about the name for the baby

34. The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged

2. Once the cervix begins to dilate, a client is in true labor.

7. The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory. 2. Ischial spines. 3. Cervix. 4. Symphysis pubis.

2. Station is assessed by palpating the ischial spines

24. A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push.

2. The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor.

11. A 16-year-old, G1 P0000, is being seen at her 10-week gestation visit. She tells the nurse that she felt the baby move that morning. Which of the following responses by the nurse is appropriate? 1. "That is very exciting. The baby must be very healthy." 2. "Would you please describe what you felt for me?" 3. "That is impossible. The baby is not big enough yet." 4. "Would you please let me see if I can feel the baby?"

2. The nurse should query the young woman about what she felt.

33. Which of the following exercises should be taught to a pregnant woman who complains of backaches? 1. Kegeling. 2. Pelvic tilting. 3. Leg lifting. 4. Crunching

2. The pelvic tilt is an exercise that can reduce backache pain

19. A client, who is 7 cm dilated and 100% effaced, is breathing at a rate of 30 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers with some lightheadedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman onto her side. 4. Check the fetal heart rate.

2. This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations.

41. A client, in her third trimester, is concerned that she will not know the difference between labor contractions and normal aches and pains of pregnancy. How should the nurse respond? 1. "Don't worry. You'll know the difference when the contractions start." 2. "The contractions may feel just like a backache, but they will come and go." 3. "Contractions are a lot worse than your pregnancy aches and pains." 4. "I understand. You don't want to come to the hospital before you are in labor."

2. This is a true statement

25. The nurse midwife tells a client that the baby is growing and that ballottement was evident during the vaginal examination. How should the nurse explain what the nurse midwife means by ballottement? 1. The nurse midwife saw that the mucus plug was intact. 2. The nurse midwife felt the baby rebound after being pushed. 3. The nurse midwife palpated the fetal parts through the uterine wall. 4. The nurse midwife assessed that the baby is head down

2. This is the definition of ballottement

87. The physician writes the following order for a newly admitted client in labor: Begin a 1000 cc IV of D5 1/2 NS at 150 cc/hr. The IV tubing states that the drop factor is 10 gtt/cc. Calculate the drip rate. _______ gtt/min

25 gtt/min

58. A woman is in active labor and is being monitored electronically. She has just received Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? 1. Variable decelerations. 2. Late decelerations. 3. Decreased variability. 4. Transient accelerations.

3. Analgesics are CNS depressants. The variability of the fetal heart rate, therefore, will be decreased.

30. An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

3. It is essential to assess the fetal heart rate immediately after an amniotomy

83. The nurse is caring for an Orthodox Jewish woman in labor. It would be appropriate for the nurse to include which of the following in the plan of care? 1. Encourage the father to hold his partner's hand during labor. 2. Ask the woman if she would like to speak with her priest. 3. Provide the woman with a long-sleeved hospital gown. 4. Place an order for the woman's postpartum vegetarian diet.

3. Observant Jewish women are expected to have their elbows covered at all times. A long-sleeved gown, therefore, should be provided for them.

74. On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is 2 and the baseline fetal heart rate is 130 with no decelerations. Which of the following nursing actions is appropriate at this time? 1. Coach the woman to hold her breath while pushing 3 to 4 times with each contraction. 2. Administer oxygen via face mask at 8 to 10 liters per minute. 3. Delay pushing until the baby descends further and the mother has a strong urge to push. 4. Place the woman on her side and assess her oxygen saturation.

3. Once the woman has a strong urge to push, then she should be encouraged to push against an open glottis in order to birth the baby.

16. Which of the following responses is the primary rationale for providing general information as well as breathing and relaxation exercises in childbirth education classes? 1. Mothers who are doing breathing exercises during labor will refrain from yelling. 2. Breathing and relaxation exercises are less exhausting than crying and moaning. 3. Knowledge learned at childbirth education classes helps to break the feartension-pain cycle. 4. Childbirth education classes help to promote positive maternal-newborn bonding

3. Some of the techniques learned at childbirth education classes are meant to break the fear-tension-pain cycle.

64. A pregnant woman informs the nurse that her last normal menstrual period was on September 20, 2006. Using Nagele's rule, the nurse calculates the client's estimated date of delivery as: 1. May 30, 2007. 2. June 20, 2007. 3. June 27, 2007. 4. July 3, 2007.

3. The estimated date of delivery is June 27, 2007.

16. A client makes the following statement after finding out that her pregnancy test is positive, "This is not a good time. I am in college and the baby will be due during final exams!" Which of the following responses by the nurse would be most appropriate at this time? 1. "I'm absolutely positive that everything will turn out all right." 2. "I suggest that you e-mail your professors to set up an alternate plan." 3. "It sounds like you're feeling a little overwhelmed right now." 4. "You and the baby's father will find a way to get through the pregnancy."

3. This is the best comment. It acknowledges the concerns that the client is having.

29. A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Use a hydrotherapy tub

3. When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head.

2. A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status? 1. Leopold's maneuvers. 2. Fundal contractility. 3. Fetal heart assessment. 4. Vaginal examination.

4. A vaginal examination will provide the nurse with the best information about the status of labor.

61. A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? 1. Hold her breath for twenty seconds during every contraction. 2. Blow out forcefully during every contraction. 3. Push between contractions until the fetal head is visible. 4. Take a slow cleansing breath before bearing down

4. By taking a slow, cleansing breath before pushing, the woman is waiting until the contraction builds to its peak. Her pushes will be more effective at this point in the contraction.

28. A client is 15 weeks pregnant. She calls the obstetric office to request a medication for a headache. The nurse answers the telephone. Which of the following is the nurse's best response? 1. "Because the organ systems in the baby are developing right now, it is risky to take medicine." 2. "You can take any of the over-the-counter medications because they are all safe in pregnancy." 3. "The physician will prescribe a category "X" medication for you." 4. "You can take acetaminophen because it is a category "B" medicine."

4. Category "B" medications have been shown to be safe to take throughout pregnancy.

73. A client informs the nurse that she is "very constipated." Which of the following foods would be best for the nurse to recommend to the client? 1. Bananas. 2. Rice. 3. Yogurt. 4. Celery

4. Celery is an excellent food to reverse constipation.

18. The nurse takes the history of a client, G2 P1001, at her first prenatal visit. Which of the following statements would indicate that the client should be referred to a genetic counselor? 1. "My first child has cerebral palsy." 2. "My first child has hypertension." 3. "My first child has asthma." 4. "My first child has cystic fibrosis."

4. Cystic fibrosis is an autosomal recessive genetic disease so the client with a history of cystic fibrosis should be referred to a genetic counselor.

38. A 37-week gravid client states that she noticed a "white liquid" leaking from her breasts during a recent shower. Which of the following nursing responses is appropriate at this time? 1. Advise the woman that she may have a galactocele. 2. Encourage the woman to pump her breasts to stimulate an adequate milk supply. 3. Assess the liquid because a breast discharge is diagnostic of a mammary infection. 4. Reassure the mother that this is normal in the third trimester

4. It is normal for colostrum to be expressed late in pregnancy.

26. A multigravid client is 22 weeks pregnant. Which of the following symptoms would the nurse expect the client to exhibit? 1. Nausea. 2. Dyspnea. 3. Urinary frequency. 4. Leg cramping.

4. Leg cramping is often a complaint of clients in the second trimester.

40. The nurse is providing anticipatory guidance to a woman in her second trimester regarding signs/symptoms that she might experience in the coming weeks. Which of the following comments by the client indicates that further teaching is needed? 1. "During the third trimester I may experience frequent urination." 2. "During the third trimester I may experience heartburn." 3. "During the third trimester I may experience back pain." 4. "During the third trimester I may experience persistent headache."

4. Persistent headache should not be seen in pregnant women

4. A woman whose prenatal weight was 105 lb weighs 109 lb at her 12-week visit. Which of the following comments by the nurse is appropriate at this time? 1. "We expect you to gain 1 lb per week, so your weight is a little low at this time." 2. "Most women gain no weight during the first trimester, so I would suggest you eat fewer desserts for the next few weeks." 3. "You entered the pregnancy well underweight, so we should check your diet to make sure you are getting the nutrients you need." 4. "Your weight gain is exactly what we would expect it to be at this time."

4. The weight gain is within normal for the first trimester.

36. A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? 1. "The contractions are 5 to 20 minutes apart." 2. "I saw a pink discharge on the toilet tissue when I went to the bathroom." 3. "I have had cramping for the past 3 or 4 hours." 4. "The contractions are about a minute long and I am unable to talk through them."

4. This client is exhibiting clear signs of true labor. Not only are the contractions lasting a full minute but she is stating that they are so uncomfortable that she is unable to speak through them. She should be seen.

68. The partner of a gravida accompanies her to her prenatal appointment. The nurse notes that the father of the baby has gained weight since she last saw him. Which of the following comments is most appropriate for the nurse to make to the father? 1. "I see that you are gaining weight right along with your partner." 2. "You and your partner will be able to go on a diet together after the baby is born." 3. "I can see that you are a bad influence on your partner's eating habits." 4. "I am so glad to see that you are taking so much interest in your partner's pregnancy."

4. This is an appropriate comment to make at this time.

51. Which of the following pictures depicts a fetus in the frank breech position?

arms crossed, feet at head, head at the top.

1. An antenatal client is informing the nurse of her prenatal signs and symptoms. Which of the following findings would the nurse determine are presumptive signs of pregnancy? Select all that apply. 1. Amenorrhea. 2. Breast tenderness. 3. Quickening. 4. Frequent urination. 5. Uterine growth.

. 1, 2, 3, and 4 are correct. 1. Amenorrhea is a presumptive sign of pregnancy. 2. Breast tenderness is a presumptive sign of pregnancy. 3. Quickening is a presumptive sign of pregnancy. 4. Frequent urination is a presumptive sign of pregnancy

7. A gravida, G1 P0000, is having her first prenatal physical examination. Which of the following assessments should the nurse inform the client that she will have that day? 1. Pap smear. 2. Mammogram. 3. Glucose challenge test. 4. Biophysical profile.

. 1. The client will have a Pap smear done.