Exam 3 NCLEX Book Questions Flashcards
(89 cards)
1
Q
A client comes to the clinic requesting an ultrasound to confirm a pregnancy. Her last menstrual period was 15 days ago. The nurse’s best response would be to:
A
Inform her that an ultrasound cannot confirm a pregnancy this early.
2
Q
An 8-month-pregnant client comes to the clinic complaining that she has not felt the baby move for the past 48 hours. Other than checking the fetal heart tones, the nurse can also anticipate which fetal study?
A
Ultrasonography
3
Q
An ultrasound is ordered for a client who is 8½ months pregnant. It is important for the nurse to:
A
Place a wedge under one hip when placing her on the examination table
4
Q
A pregnant client has a 2-year history of uncontrolled hypertension. The nurse can anticipate that which fetal study to be ordered?
A
Doppler ultrasound blood flow assessment
5
Q
A client’s maternal serum alpha-fetoprotein (MSAFP) levels are elevated. The nurse can anticipate that the next test done will be:
A
Ultrasound
6
Q
A 36-year-old primigravida is in the clinic for her first prenatal appointment. The nurse can anticipate that the multiple-marker screening may be done on this client to screen for:
A
Trisomy disorders.
7
Q
The physician has ordered a chorionic villus sampling to be done on a client. The nurse knows to schedule the test to be done between which weeks of gestation?
A
10 and 12 weeks
8
Q
An amniocentesis is ordered for an 8-month-pregnant client. The nurse is aware that the most common reason for this test at this time is to test for:
A
Fetal lung maturity.
9
Q
An ultrasound is done prior to an amniocentesis to:
A
Locate fetal and placental position.
10
Q
After a percutaneous umbilical blood sampling (PUBS) on a client, the nurse notes a fetal heart rate of 100 beats/min. The nurse is aware that this indicates a:
A
Common complication and is usually brief.
11
Q
In preparing a pregnant client for a nonstress test, the nurse should:
A
Ask the client if she smokes and when she had her last cigarette.
12
Q
During a contraction stress test, the nurse notices late decelerations with three of the six contractions. These results are classified as:
A
Positive
13
Q
The client has a biophysical profile done. The nurse notes that the NST test was reactive, the fetal breathing movements were absent, there was one gross body movement in 30 minutes, the fetal tone showed fetal extremity extension and return to flexion, and one pocket of amniotic fluid measured 3 cm. The nurse anticipates that next action by the physician will be:
A
Further study because a score of 6 is not normal.
14
Q
Which conditions are associated with elevated levels of serum alpha-fetoprotein?
A
Open neural tube defects
Threatened abortion
Fetal Demise
15
Q
Immediately following an amniotomy to observe for complications, the nurse must assess the:
A
Fetal heart rate.
16
Q
A laboring woman just had an amniotomy performed to augment labor. The nurse is aware that the assessment times for which vital signs will be altered?
A
Maternal temperature
17
Q
When admitting a client for induction of labor, the nurse will question the procedure if which of the following is on the client’s prenatal record?
A
Placenta previa
18
Q
Induction is more successful if the Bishop score is greater than
A
8
19
Q
The fFN (fetal fibronectin) is present in the vaginal secretions about ____ prior to the onset of term labor.
A
2 weeks
20
Q
A woman is receiving oxytocin for labor induction. The nurse notices the woman is having contractions every 2 minutes lasting for 100 seconds. The fetal heart rate is 120 to 130 bpm, with moderate variability. The nurse’s next action should be to:
A
Turn off the oxytocin.
21
Q
The uterine resting tone should have at least ___ seconds between contractions.
A
30
22
Q
The postpartum woman who had a long labor induced by oxytocin is at higher risk for which complication?
A
Hemorrhage
23
Q
Prolonged use of oxytocin can produce ____
A
uterine atony
24
Q
While caring for a woman who is 10 cm dilated and is pushing, the nurse notices that the fetal heart rate has dropped to 85 bpm. The station is +3. The nurse can anticipate:
A
A low operative vaginal birth.
25
Which of the following measures will help prevent complications from an episiotomy?
Cold applications after birth
26
Misoprostol (Cytotec), 50 mcg, has been ordered for a woman to assist with the ripening of the cervix. The nurse’s action should be to:
Question the dosage amount.
27
Which of the following are used to assist with the cervical ripening process prior to induction of labor? (Select all that apply).
Prostaglandin
Misoprostol (Cytotec)
Laminaria tents
28
Which of the following would be an indication for a cesarean birth? (Select all that apply).
Cephalopelvic disproportion
Active genital herpes
Persistent nonreassuring FHR patters
29
A woman has just had a spontaneous abortion. She asks the nurse, “Why did this happen?” The nurse is aware that the most common cause of spontaneous abortion is:
Severe congenital abnormalities.
30
The first sign of threatened abortion is
vaginal bleeding
31
A woman has just been admitted to the maternity unit with a diagnosis of incomplete abortion. The physician has written the following orders:
(1) NPO
(2) Type and crossmatch for two units of blood.
(3) Start intravenous line and run Ringer’s lactate at 150 mL/hr.
(4) Administer Pitocin, 10 units intramuscular.
(5) Acetaminophen and codeine (Tylenol with Codeine #3), every 3 to 4 hours as needed for pain
(6) Bed rest with bathroom privileges
Which order to carry out first?
Start the IV and draw blood to send for the type and crossmatch.
32
A woman is admitted with a diagnosis of missed abortion. After taking her blood pressure, the nurse notices petechiae on the woman’s arm where the cuff was located. The nurse’s next action should be to:
Notify the HCP
33
A 20-week-pregnant client attending her first prenatal visit tells the nurse at the maternity clinic that she has had vaginal bleeding and excessive nausea and vomiting for the past 3 days. The nurse assesses her blood pressure at 142/95 mm Hg, pulse 86 bpm, respirations 16 breaths/min. When the nurse helps the client onto the examining table, the abdomen looks larger than normal for a 20-week pregnancy. The nurse is aware that these are signs of:
Hydatidiform mole.
34
Signs of a threatened abortion are noted in a woman at 8 weeks of gestation. Which of the following is an appropriate management approach for this type of abortion?
Prepare the woman for an ultrasound to determine the integrity of the gestational sac.
35
A 32-week-pregnant woman calls the prenatal clinic complaining of bleeding without pain or contractions. The nurse should:
Tell her to go to the hospital to be evaluated
36
A woman in labor has a long history of uncontrolled hypertension. The hypertension has continued throughout the pregnancy and labor. The nurse is aware that the woman is at high risk for which complication?
Abruptio placentae
37
During labor, a woman suddenly complains of increasing pain, and the electronic monitor shows no uterine activity. The abdomen is boardlike and tender and the fetal heart tones show late decelerations. The nurse should:
Notify the health care provider.
38
A woman is admitted to the maternity unit with preeclampsia. She is started on magnesium sulfate IV, a urinary catheter is inserted, and she is put on bed rest. The nurse understands it is important to monitor urinary output hourly. It is important that the client have an output of at least:
30 mL
39
A pregnant woman at 36 weeks of gestation is admitted to the high-risk pregnancy unit with hypertension. Assessment findings indicate severe preeclampsia. The nurse should:
Expect a maintenance dose of intravenous magnesium sulfate to be about
2 g/hr.
40
The __ assessment of edema indicates edema of the lower extremities, face, hands, and sacral area.
+3
41
During pregnancy a woman has an indirect Coombs test done. The nurse can teach her that this test will show:
Her previous exposure to Rh-positive blood.
42
Which of the following women are at higher risk for an ectopic pregnancy? (Select all that apply).
A. History of pelvic infection
B. Had a tubal ligation 1 year ago
C. History of hormonal implants for contraception 4 years ago
D. Conception was by assisted reproduction
E. Use of alcohol during the first 2 weeks of the pregnancy
F. History of intrauterine contraceptive device
G. Had five therapeutic abortions
A, B, D, F, G
43
A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client should know that:
Oral hypoglycemic agents are the preferred choice to control an elevated blood sugar leveL
44
A newly diagnosed pregnant woman has diabetes mellitus, type 2. When planning the prenatal care for this woman, the nurse identifies actions based on the knowledge that:
The danger of diabetic ketoacidosis is highest during the second and third trimesters.
45
Increased fetal surveillance should occur in the first trimester of a pregnant woman with preexisting diabetes mellitus to monitor for:
Congenital anomalies.
46
A 39-week-gestation gravida 1 is 6 cm dilated. Membranes are intact. The labor contractions have decreased in intensity, and she has not dilated in the past 2 hours. A diagnosis of hypotonic dysfunctional labor has been made. The nurse can anticipate which of the following actions?
Immediate cesarean section
Amniotomy
Narcotic administration
Having her walk around
Amniotomy
47
Fetal heart tones are located in the ___ quadrants when the fetus is in a breech presentation.
upper
48
A nulliparous woman in labor has been diagnosed with a prolonged latent phase of the first stage of labor. Which of the following is true regarding this dysfunctional labor pattern?
Diagnosis for this woman would have been made once the duration of the latent phase exceeded 14 hours.
Hypotonic contractions are typically associated with this labor pattern.
Management often involves therapeutic rest.
Cephalopelvic disproportion (CPD). with failure of the fetal head to stimulate the cervix. is often the underlying cause of this pattern.
Management often involves therapeutic rest.
49
A woman had premature rupture of the membranes at 37 weeks of gestation. She went into labor within 10 hours and delivered a 7 lb, 12 oz boy after a 12-hour labor. In planning care for the newborn, it is important to monitor him for:
Respiratory distress syndrome.
Transient tachypnea of the newborn. Incorrect
Infections.
Cardiac anomalies.
Infections
50
Research has found that bed rest as an intervention for preventing preterm labor can result in:
Maternal weight gain. Incorrect
Diarrhea.
Increased maternal plasma volume and cardiac.
Bone demineralization, with calcium loss.
Bone demineralization, with calcium loss.
51
A constant low backache is a common symptom of ____.
preterm labor
52
Fetal fibronectin is normally found in the vaginal secretions until about ___ weeks’ gestation and again at term.
20 weeks’ gestation
If it is found between those dates, it suggests early labor.
A negative report indicates that the woman is at low risk for labor at this time.
53
A woman is receiving magnesium sulfate intravenously to control preterm labor. She is at the maximum dose and the contractions have slowed to eight/ hr. The nurse is assessing the woman’s vital signs every hour. In addition to blood pressure, pulse, and respirations, what other assessments should be carried out hourly?
Lung sounds
Edema in lower extremities
Bowel sounds
Range of motion to the lower extremities
Lung sounds
54
Nifedipine is a vasodilator, so the woman may be prone to ____.
postural hypotension
55
A woman came in for a prenatal check up on March 15. She tells the nurse that her last normal menstrual period was June 2. The nurse is aware that she will be scheduled for:
Immediate birth.
Testing to determine fetal well-being.
Follow-up appointments every week until birth.
Ultrasound to determine fetal age.
Testing to determine fetal well-being.
56
A fetus that is in a ___ station is at high risk for a prolapsed cord when the membranes rupture.
high
57
Which type of uterine rupture may go undiagnosed during labor and the postpartum period?
Dehiscence
little/no bleeding, no S+S
58
A potentially fatal complication of pregnancy that occurs when the pulmonary artery is obstructed by a blood clot that was swept into circulation from a vein or by amniotic fluid is called a
pulmonary embolism
59
One of the earliest signs of hypovolemic shock is
tachycardia
60
Postpartum hemorrhage that occurs within the first 24 hours after childbirth is termed
early
61
Clinical signs and symptoms of pulmonary embolism may include which of the following
```
Dyspnea
Sudden sharp chest pain
Bradycardia
Syncope
Tachypnea
Hemoptysis
```
```
Dyspnea
Sudden sharp chest pain
Syncope
Tachypnea
Hemoptysis
```
62
A breastfeeding woman develops mastitis. She tells the nurse that she will just feed her baby formula instead of breastfeeding. The best nursing response is that:
- Emptying the breast is important to prevent an abscess.
- A tight breast binder or bra will help reduce engorgement.
- She should continue to drink extra fluids while weaning.
- Breastfeeding can continue when her temperature is normal.
Emptying the breast is important to prevent an abscess
63
The best position for a woman who has postpartum endometritis is:
Fowler’s
64
When assessing the lochia of a new mother for the last time before discharge, the nurse notes a foul smell from the vaginal discharge. The mother states that she noticed it for the first time a couple of hours ago. The nurse should assess for:
Fever
65
The uterus descends at the rate of about ___ cm/day. By ____ days, it is no longer palpable above the symphysis pubis. This is a normal finding.
1cm/day
10-14
66
Cervical lacerations occur frequently when the cervix ____
dilates rapidly during the first stage of labor.
67
An infant born at 35 weeks of gestation and weighs 4 lb, 3 oz would be classified as:
Preterm, low birth weight.
Preterm, very low birth weight, with intrauterine growth restriction.
Preterm, extremely low birth weight.
Full term, low birth weight.
Preterm, low birth weight.
68
Heat loss in a preterm infant is more significant than in a full-term infant. The nurse should assess for heat loss continually in a preterm infant. The first sign that the infant’s temperature is low may be:
Hyperglycemia.
Hypoglycemia.
Respiratory stability.
Increased flexion.
Hypoglycemia
69
A preterm infant is on intake and output. During the past 8 hours, the infant had used three diapers that weighed 5 g before putting them on and 6, 9, and 12 g on removal. In addition, the lab had drawn 3 mL of blood for testing. There was no emesis or stools. The output should be recorded as:
15 mL.
12 mL.
3 mL.
Unable to determine with information given.
15 mL
70
The nurse is taking care of a 30-week gestation preterm infant who is 3 days old. The infant is stable enough for a bath to remove the old blood and vernix, but has areas of cracking on the skin. During the bath, it is best for the nurse to use:
Plain warm water.
A soap especially formulated for an infant’s skin.
Warm sterile water.
Distilled water.
Warm sterile water.
71
A small-for-gestational age infant was born. During the initial assessment, a nurse notes that the infant’s body is in proportion and appears normally developed for the size. The nurse is aware that this infant’s problem probably occurred:
Early in the pregnancy.
In the middle of the pregnancy.
Late in the pregnancy.
During labor.
Early in the pregnancy.
72
During the initial assessment of a large-for-gestational age (LGA) infant, it is important that the nurse assess for complications that are common for this infant, such as:
Congenital defects.
Fractures of the clavicle.
Thinning of the skin.
Decreased subcutaneous fat
Fractures of the clavicle.
73
There are many complications that can occur with preterm infants. Select those listed that may be directly related to the use of high oxygen content during the acute phases of care. (Select all that apply).
Bronchopulmonary dysplasia
Periventricular-intraventricular hemorrhage Incorrect
Retinopathy of prematurity
Necrotizing enterocolitis
Bronchopulmonary dysplasia
| Retinopathy of prematurity
74
The infant who has the highest risk for asphyxia during labor and birth is the infant who is __________
post-term
75
At birth, a newborn has a respiratory rate of 75 breaths/min. In 1 minute, the newborn stops breathing. The first action by the nurse should be to:
Stimulate the newborn.
Initiate rescue breathing.
Administer oxygen.
Initiate cardiopulmonary resuscitation.
Stimulate the newborn.
76
Risk factors for transient tachypnea of the newborn include ___ AND ____
cesarean birth and mothers who are diabetic.
77
During the labor of a 43-week-gestation gravida 2, the nurse notes meconium staining of the amniotic fluid. After birth, the newborn was diagnosed with meconium aspiration syndrome. The nurse should monitor the newborn for respiratory distress and signs of:
Infection.
Skin breakdown.
Persistent pulmonary hypertension of the newborn.
Hyperbilirubinemia.
Persistent pulmonary hypertension of the newborn.
78
The nurse notes a yellow discoloration over the face of a 12-hour-old newborn. The nurse’s next actions should be based on prevention of:
Pathologic jaundice.
Renal damage.
Skin damage.
Neurotoxicity.
Neurotoxicity
79
Jaundice is considered pathologic when it appears in the ___hours after birth.
first 24
80
A newborn develops jaundice at 16 hours of age. The nurse notes that the Coombs test is positive. The nurse orders a total serum bilirubin test and the results are 10 mg/dL. The nurse’s next action should be to:
Monitor the respiratory rate every 30 minutes.
Prepare the newborn for phototherapy.
Initiate oxygen therapy.
Assess the bilirubin level in 1 hour.
Prepare the newborn for phototherapy.
81
A full-term newborn is placed in phototherapy to decrease serum bilirubin levels. A nursing diagnosis appropriate for this infant during phototherapy would be:
Risk for injury.
Risk for infection.
Risk for deficient fluid volume.
Ineffective breastfeeding.
Risk for deficient fluid volume.
82
A large-for-gestational age infant is born outside of the hospital. The infant is brought to the emergency department 5 hours after birth with tremors, diaphoresis, and respirations of 75 breaths/min. The nurse’s next action should be to assess the:
Temperature.
Cardiac status.
Bilirubin level.
Blood glucose level.
Blood glucose level.
83
An infant of a diabetic mother has a total serum calcium level of 5 mg/dL. There is an order for calcium to be given intravenously. Before administering the calcium, the nurse should assess the:
Respiratory rate. Incorrect
Thyroid gland for enlargement.
Infant with a cardiac monitor.
Blood pressure.
Infant with a cardiac monitor.
84
A newborn who is 12 hours old develops tremors. The nurse has assessed the blood glucose and calcium levels and they are both within normal limits. The next assessment by the nurse should be to assess for:
Hypothermia.
Prenatal drug exposure.
Lung sounds.
Cardiac defects.
Prenatal drug exposure.
85
A woman with gestational diabetes is at 36 weeks’ gestation. On the regular antepartal visit, the woman tells the nurse, “I am so excited. My blood sugars have gone down and I have been able to decrease the amount of insulin I need by about half.” The nurse should be aware that this is an indication of a:
Diabetic in good glycemic control.
Fetal problem that needs further investigation.
Placental problem that needs further investigation.
Maternal pancreas that is increasing its insulin production.
Placental problem that needs further investigation.
86
Which of the following is associated with preexisting diabetes in a pregnant woman, but not in a woman with gestational diabetes?
Neonatal hypocalcemia
Neonatal hypoglycemia
Congenital malformations
Macrosomia
Congenital malformations
87
Hypoglycemia should be treated at once to prevent damage to the brain. The woman should take ____.
15 g of carbohydrate, which is about ½ cup of fruit juice
88
the earliest sign of decompensation is most often:
Decreasing energy level.
89
Which pregnancy hormones are responsible for creating insulin resistance in maternal cells?
Estrogen
