Вы находитесь на странице: 1из 57

51. The nurse is monitoring the patient who is experiencing an ectopic pregnancy.

She notes that vaginal bleeding is scanty while the patient is showing signs of hypovolemic shock. She evaluates that:
a. Shock signs are misleading in this case b. Infection could cause signs of shock c. Level of pain is causing signs of shock d. Bleeding into the pelvic cavity is occurring

d. Bleeding into the pelvic cavity is occurring

52. In order to assess bleeding into the peritoneal cavity, the nurse looks for Cullens sign. This is:
a. cyanosis around the lips and tip of nose b. scant, dark reddish-brown vaginal bleeding c. frequent gush of bright red blood from vagina d. bluish tinge surrounding the umbilical area
d. bluish tinge surrounding the umbilical area

53. The nurse caring for a patient in pre-term labor may exhibit which of the following side effects when administered intravenous terbutaline sulfate (Brethine)? a. uterine hypertonia b. epistaxis c. tachycardia d. dysuria
c. tachycardia

54. A breast-feeding mother on her third postpartum day states that she is planning the lactational amenorrhea method (LAM) for contraception. The most appropriate nursing response would be to inform the mother that: a. this method can be used for one year b. this method is effective if she is fully breastfeeding and menses has not returned c. she can supplement with formula for the night feedings d. she should check her basal temperature to determine effectiveness of the method
d. she should check her basal temperature to determine effectiveness of the method

55. Which of the following actions would be the highest priority in the treatment of disseminated intravascular coagulation (DIC)? a. maintaining central blood volume b. correcting the coagulation deficit c. correcting the triggering cause d. maintaining strict intake and output
b. correcting the coagulation deficit

56. In primigravida, the nurse would suspect cephalopelvic disproportion when a. an unopened cervix fails to dilate after 20 hours of contractions b. the cervix remains unchanged for 3 hours with regular contractions and prior cervical dilatation c. the fetus descends in active labor at a rate of 1.0cm per hour d. the woman complains of an urge to push at 7cm dilatation
b. the cervix remains unchanged for 3 hours with regular contractions and prior cervical dilatation

57. A primigravida complains to the nurse about dyspnea, nausea, and bladder fullness. The nurse should be aware that these symptoms during pregnancy are usually the result of an increase in which of the following hormones? a. Estrogen b. Progesterone c. follicle stimulating hormone d. melanocyte stimulating hormone

b. Progesterone

58. The nurse should be aware that for a fetal non-stress test (NST) to be considered reactive, which of the following criteria should be met? a. Fetal heart rate baseline is above 110, with no decelerations during fetal movement b. Fetal heart rate baseline is above 110, with accelerations noted during fetal activity c. Fetal heart rate baseline is between 110-160, with two accelerations of 15 beats for 15 seconds in response to fetal activity for 10 mins d. Fetal heart baseline is between 110 and 160, with less than two accelerations during a 20-minute period c. Fetal heart rate baseline is between 110-160, with two accelerations of 15 beats for 15 seconds in response to fetal activity for 10 mins

59. A patient planning to become pregnant asks the prenatal nurse for dietary advice. To facilitate normal spinal cord formation in a developing fetus, the nurse should instruct the patient to include foods in her diet that contain a. Fiber b. Calcium c. folic acid d. protein

c. folic acid

60. A patient has begun prenatal care in the first trimester of pregnancy. The nurse should instruct the patient to return for the next visit in how many weeks? a. One b. Two c. Four d. Eight

c. Four

61. The nurse should carry out which of the following interventions first when caring for a patient experiencing variable decelerations during labor? a. Encourage the patient to breath deeply b. Administer oxygen, 21/min via face mask c. Reposition patient onto her left side d. Cleanse the perineum in preparation for delivery
c. Reposition patient onto her left side.

62. At 16 weeks gestation, no fetal heart rate was detected during assessment of a pregnant patient. An ultrasound confirmed a hydatidiform molar pregnancy. Which of the following actions should the nurse tell the patient to expect during her one-year follow-up? a. Multiple serum chorionic gonadotrophin levels will be drawn b. An intrauterine device will be used to decrease vaginal bleeding c. Pregnancy will be restricted for another year d. Oral contraceptives will not be prescribed because they will increase the risk for cancer a. Multiple serum chorionic gonadotrophin levels will be drawn

63. Because a woman who is confirmed to be at 30 weeks gestation has sudden painless bright red vaginal bleeding, a nurse would suspect the woman is experiencing: a. Abruption placentae b. An ectopic pregnancy c. Placenta previa d. A molar pregnancy

c. Placenta previa

64. A woman who is at 32 week gestation has had rupture membranes for 26 hours. A nurse would assess the woman for which of the following manifestation? a. Proteinuria b. Dependent edema c. Constipation d. Elevated temp

d. Elevated temp

65. A Rh-negative mother would need to receive Rho(D) immune globulin (RhoGam) within 72 hours after delivery if her newborn had which of the following blood test result a. RH negative, Coombs positive b. RH negative, Coombs negative c. RH positive, Coombs negative d. RH positive, Coombs positive
c. RH positive, Coombs negative

66. When planning care for a 14 year-old female who is pregnant, a nurse should recognize that the adolescent is at risk of: a. Glucose intolerance b. Fetal chromosomal abnormality c. Incompetent cervix d. Iron deficiency anemia
d. Iron deficiency anemia

67. At 36 weeks of pregnancy, a woman is to have a lecithin/sphinomyelin (L/S) ration performed. She should be instructed that the purpose of this test is to determine
a. The amount of fetal muscle mass b. Whether the fetal kidneys are mature enough to excrete createnine c. Fetal pulmonary maturity d. The functioning of the placental unit c. Fetal pulmonary maturity

68. A pregnant womans uterine fundus is palpated at the level of the umbilicus. The nurse would expect the woman to be how many weeks pregnant?
a. 12 b. 16
c. 20

c. 20 d. 24

69. Following an amniocentesis, the nurse should instruct a client to immediately report which of the following signs and symptoms a. Flu-like symptoms b. Inability to sleep c. A decrease in uterine contractions d. An increase in uterine contractions

d. An increase in uterine contractions

70. To help a woman recognize the best time for conceiving, a nurse would instruct the woman to monitor for which of the following manifestations of ovulation? a. drop in body temperature lasting for several days b. increase in amount of cervical mucus that is clear and stretches c. abnormal bloating that occurs suddenly d. breast tenderness accompanied by slight nipple discharge
b. increase in amount of cervical mucus that is clear and stretches

71. The client report frequent constipation. To help relieve constipation, the nurse should instruct the client to a. Use glycerin suppositories b. Drink a glass of hot water in the morning c. Avoid highly seasoned foods d. Administer enema
b. Drink a glass of hot water in the morning

72. The physician schedules the client for diagnostic ultrasound to assess fetal growth. After instructing the client about the ultrasound procedure, the nurse considers the teaching effective when the client makes the statement: a. The procedure requires the use of a needle which will be inserted into the uterus b. I cant have anything to eat or drink after midnight on the day of the procedure c. I may feel some pain and discomfort after the procedure d. I need to drink 32 to 40 ounces of fluid 1 hour before the procedure
d. I need to drink 32 to 40 ounces of fluid 1 hour before the procedure

73. Following spontaneous rupture of the mebranes, if the cord prolapses, the nurse should plan immediately a. Relieve pressure of the cord b. Expedite delivery c. Turn the client to a supine position d. Replace the cord into the vagina

a. Relieve pressure of the cord

74. A 31-year-old multigravida at 10 weeks gestation is receiving prenatal care in high risk clinic. She is insulin-dependent diabetic. The nurse discusses the importance of keeping blood glucose levels near normal throughout the pregnancy. The nurse explains to the client that as pregnancy progresses, her insulin needs will: a. increase b. decrease c. remain constant d. cannot be predicted a. increase

75. In planning care for the neonate of a diabetic mother, the nurse plans to treat potential hypoglycemia by preparing a a. 10% glucose intravenous infusion b. 25% glucose intravenous infusion c. A bottle of 24-caloric formula d. A balanced electrolyte infusion

a. 10% glucose intravenous infusion

76. When instructing the client about drinking alcoholic beverages during pregnancy, the nurse should include which of the following?
a. Limit drinking to beer and wine b. Abstain from drinking alcoholic beverages c. Drink no more than 1 ounce of liquor per day d. None of the above

b. Abstain from drinking alcoholic beverages

77. When the head of the infant has been delivered, which of the following nursing actions is not appropriate? a.Tell the mother to stop pushing b. Ask mother to do rapid shallow breathing c. Coach mother to continue bearing down d.Suction the mucus present in the infants airway

c. Coach mother to continue bearing down

78. After the birth of the baby, she observes for the signs of placental separation. Which of the following signs indicate that the placenta has separated?
1. gradual descent of the uterus further into the pelvis 2. protrusion of several more inches of umbilical cord 3. uterus becoming firm and rounded 4. a sudden gush or blood from the vagina 5. Mrs. A holds her abdomen

a. 1 and 2 b. 2, 3 and 4

c. 2, 3 and 5 d. all of them

b. 2, 3 and 4

79. When the placenta has been delivered, the first thing that the nurse should do: a. Inspect the placenta for the completeness of the cotyledon b. Palpate the uterus to see if it is contracted c. Administer oxytocin drug as ordered d. Estimate the blood loss to detect any bleeding

a. Inspect the placenta for the completeness of the cotyledon

80. The placenta was expelled by Schultzes mechanism. Which of the following describe the mechanism?
1. Placenta separates first from its center 2. the shiny surface presents at vaginal opening 3. Placenta separates first at its edges 4. The raw, red, irregular surface presents at the vaginal opening

a. 1 and 2 b. 1 and 4
a. 1 and 2

c. 2 and 3 d. 3 and 4

81. During the fourth stage of labor, if the nurse feels that mothers fundus is not well contracted and is shifted to the right she should realize that this is due mainly to: a. A solid mass c. a full bladder b. a clotted blood d. retained placental fragment
c. a full bladder

82. What nursing action must she take? a. Ignore the condition b. Notify the doctor so it would not worsen c. Massage fundus and/or express blood clots d.Encourage mother to void
d.Encourage mother to void

83. The nurse has encouraged mother to ambulate early after delivery which of the following seem to be the advantages gained from early ambulation?
1. Improve bowel and bladder functions 2. Mrs. C. would be able to regain her strength more readily 3. Minimizes the chance of hemorrhage 4. Eliminates incidence of thrombophlebitis

a. 1 & 2 c. 2, 3 & 4

b. 1, 3 & 4 d. 1, 2, 3 & 4

d. 1, 2, 3 & 4

84. The mother is in taking- in phase. Which of these behaviors would indicate this phase of restorative period? a. Requesting rooming- in immediately after delivery b. Asking to bathe her baby c. Experiencing transient feelings of depression d. Verbalizing the reaction to her labor and delivery

d. Verbalizing the reaction to her labor and delivery

85. What is the priority need of a tearful mother with post partum depression? a. Fluids and nutrients to combat dehydration foster feelings of general well-being. b. Chance to see and touch her baby c. Privacy and reassurance that crying is normal and therapeutic d. Talk with her husband
c. Privacy and reassurance that crying is normal and therapeutic

86. The mother complains of breast enlargement which prevents her baby from latching on her nipple. An appropriate nursing intervention which would be to; a. Teach her, breast massage or manual expression of milk. b. Use ice pack to breast immediately prior to feeding. c. Teach her shoulder circling exercises. d. Advise her to restrict her fluids.
a. Teach her, breast massage or manual expression of milk.

87. Most common cause of post partum hemorrhage is uterine atony. The first thing to do;
a. Administer an oxytocin drug b. Take a firm grasp of the fundus and massage it c. Empty bladder d. Check for hypotension

b. Take a firm grasp of the fundus and massage it

88. In response to the nurses question about how she feels, the client replies that she is tired, sore, and hungry. Begins to relate her birth experience. Based on the assessment data, the nurse determines that the client is in which phase of post partal psychological adaptation process. a. Acting out c. Taking hold b. Taking in d. Letting go

b. Taking in

89. The nurse caring for a client detects a firm fundus, yet on inspection of the perineum, there is constant trickle of blood. The nurse should assess the client for a. vaginal tears b.retained placental tissue c. uterine inversion d. uterine infection
a. vaginal tears

90. Which of the following situation a post partal woman would be most indicative of an abnormality? a. chilling shortly after delivery b. pulse rate of 60 the morning after delivery c. urinary output of 1,200 ml on second day post partum d. oral temperature of 38 C on the third day post partum
d. oral temperature of 38 C on the third day post partum

91. During the second day the post partum, the nurse examines the client, which of the following is a normal finding a. lochia serosa, fundus 4-5 cm below umbilicus b. lochia rubra, fundus 2-3 cm below umbilicus c. lochia alba, fundus 4-5 cm above the umbilicus d. lochia serosa, fundus 2-3 cm above the umbilicus
b. lochia rubra, fundus 2-3 cm below umbilicus

92. The most common position for the fetus at birth is the: a. right occiput anterior b. left occitput anterior c. right occiput posterior d. left occiput posterior
b. left occitput anterior

93. What is used to relieve perineal discomfort on the second postpartum day? a. application of ice bag b. application of heat c. administration of oxytocic d. administration of hormones

b. application of heat

94. There are several theories for the cause of labor onset. The theory that states the need for inhibition of uterine contractility throughout pregnancy is known as: a. oxytocin theory b. prostaglandin theory c. fetal endocrine control theory d. progesterone deprivation theory
d. progesterone deprivation theory

95. The nurse performed Leopolds maneuver in examining Ara. Abdominal palpation revealed a soft rounded mass in the fundus, irregular lumps or nodules on Aras right side and a hard prominence on Aras right side above the symphysis pubis. The most accurate assessment of fetal position would be: a. left occiput anterior b. left sacrum anterior c. right sacrum posterior d. right occiput posterior

a. left occiput anterior

96. The fetus is most likely to be damaged by the pregnant womans ingestion of drugs during a. first trimester c. third trimester b. second trimester d.entire trimester

a. first trimester

97. The nurse would suspect an ectopic pregnancy if the client complained of: a. lower abdominal cramping for a long period of time b. sharp lower right or left abdominal pain radiating to the shoulder c. leucorrhea and dysuria a few days after missed period d. an adherent painful ovarian mass

b. sharp lower right or left abdominal pain radiating to the shoulder

98. The pregnant woman complains of morning sickness. The nurse realizes that a predisposing factor which causes morning sickness during the first trimester or pregnancy is the adaptation to increased level of: a. estrogen c. leuteinizing hormone

b. progesterone

d. pituitary gland

a. estrogen

99. Which of the following statements by a client with hyperemesis indicates effective teaching about post discharge management plan? a. Im glad I wont ever have to be hospitalized again for this b. I need to eat small, frequent meals to maintain my weight c. I hope the doctor will give me medicine to stop this nausea d. Prenatal vitamins are making me sick. I need to quit taking them. b. I need to eat small, frequent meals to maintain my weight

100. The hormone that is secreted by the corpus luteum and prepares the endometrium for implantation is: a. estrogen c. progesterone b. luteinizing hormone d. prostaglandin

c. progesterone