NURS 3334 Practice Questions Exam 5
A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? a. assist the client into the left-lateral position b. apply a fetal scalp electrode c. insert an IV catheter d. perform a vaginal exam
a. assist the client into the left-lateral position
The fetal heart rate baseline is 140 beats/min. When contractions being, the fetal heart rate drops suddenly to 120 and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? a. assist the client to change position b. apply oxygen to the client at 2 L per NC c. notify the operating room of the need for a cesarean birth d. determine the color of the leaking amniotic fluid
a. assist the client to change position these are variable decels
A nurse is caring for a client who is at 32 weeks gestation and experiencing preterm labor. Which of the following should the nurse administer? a. betamethasone b. misoprostol c. methylergonovine d. poractant alfa
a. betamethasone
A nurse is caring for a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations? a. blood-tinged sputum b. dizziness c. pallor d. somnolence
b. dizziness
A nurse is reviewing findings of a client's BPP. The nurse should expect which of the following variables to be included in the this test? SATA a. fetal weight b. fetal breathing movement c. fetal tone d. fetal position e. amniotic fluid volume
b. fetal breathing movement c. fetal tone e. amniotic fluid volume
A nurse is teaching a client about a non stress test. Which of the following statements by the client indicates understanding of the teaching? a. I know not to say anything after midnight b. I will have medication given to me to cause contractions c. I should press the button on the handheld marker when my baby moves d. I will have to stimulate my breast to cause contractions
c. I should press the button on the handheld marker when my baby moves
A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching? a. you will lay on your right side during the procedure b. you should not eat or drink anything for 24 hours prior to the procedure c. you should empty your bladder prior to the procedure d. the test is done to determine gestational age
c. you should empty your bladder prior to the procedure
A nurse is reviewing the electronic monitor tracing of a client who is in active labor. The nurse should know that a fetus receives more oxygen when which of the following appears on the tracing? a. peak of uterine contraction b. moderate variability c. FHR accelerations d. relaxation between uterine contractions
d. relaxation between uterine contractions
The nurse is preparing a client for an amniocentesis. Which statement would indicate that the client clearly understands the risk of the amniocentesis? a. I might go into labor early b. It could produce a congenital defect in my baby c. actually, there is not real risk to this procedure d. the test could stunt my baby's growth
a. I might go into labor early
A nurse is caring for a client who is pregnant and is to undergo a contraction stress test (CST). Which of the following findings are indications for this procedure? SATA a. decreased fetal movement b. intrauterine growth restriction (IUGR) c. post maturity d. placenta previa e. amniotic fluid emboli
a. decreased fetal movement b. intrauterine growth restriction (IUGR) c. post maturity
The laboring client fetal heart rate is 120 beats per minutes. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110 and is at 120 by the end of the contraction. What nursing action is best? a. document fetal heart rate b. apply oxygen via mask at 10 L c. prepare for imminent delivery d. assist the client into Fowler's position
a. document fetal heart rate (early decels associated with head compression) `
A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? SATA a. fetal distress b. preterm labor c. vaginal bleeding d. cervical dilation greater than 6 cm e. severe gestational hypertension
a. fetal distress c. vaginal bleeding d. cervical dilation greater than 6 cm
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? a. hands and knees b. lithotomy c. trendelenburg d. supine with a rolled towel under one hip
a. hands and knees
The laboring client is complaining of tingling and numbness in her fingers and toes, dizziness, and spots before her eyes. The nurse recognizes that these are clinical manifestations of which of the following? a. hyperventilation b. seizure auras c. imminent birth d. anxiety
a. hyperventilation what would you do? give her a paper bag
A nurse is providing care for a client who is in active labor. Her cervix is dilated to 5 cm, and her membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150 and 155/min that last for 25 seconds, and have beat to beat variability of 20 / min. There is no slowing of FHR from the baseline. The nurse should recognize that this client is exhibiting signs of which of the following? SATA a. moderate variability b. FHR accelerations c. FHR decelerations d. normal baseline FHR e. fetal tachycardia
a. moderate variability b. FHR accelerations d. normal baseline FHR
A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. The nurse should identify that which of the following are risk factors for the client? SATA a. obesity b. multifetal pregnancy c. maternal age greater than 40 d. migraine headache e. oligohydramnios
a. obesity b. multifetal pregnancy d. migraine headache
A nurse is caring for a client who is at 42 weeks of gestation and is admitted to the labor and delivery unit. During an ultrasound, it is noted that the fetus is large for gestational age. The nurse reviews the prescription from the provider to begin an amnioinfusion. Which of the following conditions should the nurse plan to prepare an amnioinfusion? SATA a. oligohydramnios b. hydramnios c. fetal cord compression d. hydration e. fetal immaturity
a. oligohydramnios c. fetal cord compression
A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? SATA a. respirations less than 12/min b. urinary output less than 30 mL/hr c. hyperreflexic deep-tendon reflexes d. decreased level of consciousness e. flushing and sweating
a. respirations less than 12/min b. urinary output less than 30 mL/hr d. decreased level of consciousness
A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? a. respiratory depression b. hypothermia c. hypoglycemia d. jaundice
a. respiratory depression
A nurse is caring for a client whose membranes have ruptured and is in active labor. The fetal monitor tracing reveals late decels. Which of the following actions should the nurse take first? a. turn the client onto her left side b. palpate the client's uterus c. administer oxygen to the client d. increase the client's IV fluids
a. turn the client onto her left side
A nurse is caring for a client who reports indications of preterm labor. Which of the following findings are risk factors of this condition? SATA a. urinary tract infection b. multifetal pregnancy c. oligohydramnios d. diabetes mellitus e. uterine abnormalities
a. urinary tract infection b. multifetal pregnancy d. diabetes mellitus e. uterine abnormalities
A nurse is caring for a client who is at 37 weeks gestation and is undergoing a NST. The FHR is 130 without accels for the past 10 min. Which of the following actions should the nurse take? a. use vibroacoustic stimulation on the client's abdomen for 3 seconds b. report the nonreactive test result to the provider immediately c. request a prescription for an internal fetal scalp electrode d. auscultate the FHR with a doppler transducer
a. use vibroacoustic stimulation on the client's abdomen for 3 seconds
The nurse is caring for a client who is in the active phase of labor. The nurse observes late decels in the FHR. Which of the following findings should the nurse identify as the cause of late decelerations? a. uteroplacental insufficiency b. fetal head compression c. fetal ventricular septal defect d. umbilical cord compression
a. uteroplacental insufficiency
A nurse receives report one a client who is in labor and is experiencing contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? a. contractions that last for 60 seconds each with a 4 min rest between contractions b. contractions that last for 60 seconds each with a 3 min rest between contractions c. a contraction that lasts 4 min followed by a period of relaxation d. contraction that lasts 45 seconds each with a 3 min rest between contractions
b. contractions that last for 60 seconds each with a 3 min rest between contractions
A nurse administers betamethasone to a client who is at 33 weeks of gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? a. hyperthermia b. decreased blood glucose c. rapid pulse rate d. irritability
b. decreased blood glucose
A nurse is caring for a client who is receiving oxytocin for induction of labor and has an IUPC places to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin? a. frequency of every 2 min b. duration of 90 to 120 seconds c. intensity of 60 to 90 mmHg d. resting tone of 15 mmHg
b. duration of 90 to 120 seconds
A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include in the teaching? SATA a. it is considered a noninvasive procedure b. it can detect abnormal fetal heart tones early c. it can determine the amount of amniotic fluid you have d. it allows for accurate readings with maternal movement e. it can measure uterine contraction intensity
b. it can detect abnormal fetal heart tones early d. it allows for accurate readings with maternal movement e. it can measure uterine contraction intensity
A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity? a. alpha-fetoprotein b. lecithin/sphingomyelin (L/S) ratio c. Kleihauer- Bete test d. Indirect Coombs test
b. lecithin/sphingomyelin (L/S) ratio
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? a. apply palms of both hands to sides of uterus b. palpate the fundus of the uterus c. grasp lower uterine segment between thumb and fingers d. stand facing client's feet with fingertips outlining cephalic prominence
b. palpate the fundus of the uterus
A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications? a. prolonged labor b. reduced fetal oxygen supply c. delayed cervical dilation d. increased maternal stress
b. reduced fetal oxygen supply
The nurse is aware of the different breathing techniques that are used during labor. Why are breathing techniques used during labor? SATA a. they are a form of anesthesia b. they are a source of relaxation c. they increase the ability to cope with contraction d. they are a source of distraction e. they increase a woman's pain threshold
b. they are a source of relaxation c. they increase the ability to cope with contraction d. they are a source of distraction e. they increase a woman's pain threshold
A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a manifestation of this condition? a. Hgb 12.2 g/dL b. urine ketones present c. alanine aminotransferase 20 IU/L d. serum glucose 114 mg/dL
b. urine ketones present
A nurse is teaching a client who is at 10 weeks gestation about an abdominal ultrasound in the first trimester. Which of the following information should the nurse include in the teaching? a. you will have a non stress test prior to the u/s b. you will need to have a full bladder during the u/s c. the u/s will determine the length of your cervix d. you will experience uterine cramping during the ultrasound
b. you will need to have a full bladder during the u/s
The client with an abnormal quadruple screen is scheduled for an ultrasound. Which statement indicates that the client understands the need for this additional antepartal fetal surveillance? a. after ultrasound, my partner and I will decide how to decorate the nursery b. during the ultrasound, we will see which one of us the baby looks like c. the ultrasound will show whether there are abnormalities with the baby's spine d. the blood test wasn't run correctly, now we need to have the sonogram
c. the ultrasound will show whether there are abnormalities with the baby's spine
A multigravida client is admitted to the labor area from the emergency department. At the time of admission, the fetal is crowning and the client yells "the baby is coming!" To help the client remain calm and cooperative during imminent birth, which response by the nurse is most appropriate? a. You're right, the baby is coming so just relax b. please do not push because you will tear your cervix c. your healthcare provider will be here as soon as possible d. I'll explain what is happening to guide you as we go along and I won't leave you
d. I'll explain what is happening to guide you as we go along and I won't leave you
A nurse in labor and delivery is providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? a. calcium gluconate b. indomethacin c. nifedipine d. betamethasone
d. betamethasone
A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? a. nifedipine b. pyridoxine c. ferrous sulfate d. calcium gluconate
d. calcium gluconate
A nurse is caring fo a client in active labor. When last examined 2 hours ago, the client's cervix was 3 cm dilated, 100% effaced and membranes intact and the fetus was at -2 station. The client suddenly states "my water broke." The monitor reveals a FHR of 80 to 85 / min and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? a. place the client in trendeleburg b. apply pressure to the presenting part with her fingers c. administer oxygen at 10 L/min via a face mask d. call for assistance
d. call for assistance
A nurse is caring for a client who is pregnant and undergoing a non stress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make? a. it is used to stimulate uterine contractions b. it will decrease the incidence of uterine contractions c. it lulls the fetus to sleep d. it awakens a sleeping fetus
d. it awakens a sleeping fetus
A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks gestation. Which of the following instructions should the nurse include in the teaching? a. use a condom with sexual intercourse b. avoid bubble bath solution when taking a tub bath c. wipe from back to front when performing perineal hygiene d. keep a daily record of fetal kick counts
d. keep a daily record of fetal kick counts
A nurse is caring for a client who is at 34 weeks gestation and has a prescription for terbulatine for preterm labor. Which statement by the client is the priority? a. my ankles are swollen at the end of the day b. I can feel the baby kicking my ribs and it is very uncomfortable c. I'm growing more and more worried every day d. my heart feels as if it is racing
d. my heart feels as if it is racing
A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take? a. administer oxygen via nasal cannula at 2L/min b. apply a warm blanket c. assist the client to a side-lying position d. place an oxygen mask over the client's nose and mouth
d. place an oxygen mask over the client's nose and mouth
A nurse is caring for a client who is admitted to the labor and delivery unit. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following complications should the nurse observe? a. precipitous labor b. premature rupture of membranes c. postmaturity syndrome d. prolapsed umbilical cord
d. prolapsed umbilical cord
