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    Exam Review

    1. A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following?
      A)Lightening
      B)Chloasma
      C)Ballottement
      D)Quickening
    2. A nurse is providing education to a client who is in labor and has a prescription for a continuous IV infusion of oxytocin. Which of the information should the nurse include?
      A)I will remove the electronic fetal monitor once contractions are regular.
      B)You can push the button on the control device to administer more medication.
      C)Your contractions will become stronger and more frequent.
      D)This medication will help prevent nausea and vomiting.
    3. A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?
      A)Monitor weight
      B)Monitor blood glucose levels
      C)Monitor intake and output (I&O)
      D)Monitor axillary temperature
    4. A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?
      A)This could result in profound bleeding.
      B)There is an increased risk of introducing infection.
      C)There is an increased risk of rupture of the membranes.
      D)This could initiate preterm labor.
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    Exam Review

    1. A nurse is assessing a fifteen-year-old adolescent who is being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?
      A)Coarse hair growth
      B)Tachycardia
      C)Warm, flushed extremities
      D)Muscle weakness
    2. Which of the following approaches would be most appropriate when working with parents of an infant admitted to the hospital with failure to thrive?
      A)Observe the parents’ feeding techniques but refrain from making any comments.
      B)Observe the parents’ feeding techniques and assist the parents in recognizing hunger cues.
      C)Feed the infant while they are hospitalized to give parents a break from feedings.
      D)Encourage the parents to rock their infant during and after each feeding.
    3. A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?
      A)Have the client ambulate.
      B)Massage the client’s posterior lower legs.
      C)Place pillows under the client’s knees when resting in bed.
      D)Apply warm, moist heat to the client’s lower extremities.
    4. A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action?
      A)Initiation of pushing
      B)Preparation for cesarean birth
      C)Examination to determine cervical status
      D)A magnesium sulfate infusion
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    Exam Review

    1. A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
      A)Variable decelerations
      B)Early decelerations
      C)Late decelerations
      D)Accelerations
    2. Choice A reason: Variable decelerations are abrupt decreases in fetal heart rate that vary in duration, intensity, and timing relative to contractions. They are most commonly caused by umbilical cord compression, which reduces blood flow and oxygen delivery to the fetus. This pattern is a hallmark sign of cord problems and requires nursing interventions such as repositioning the mother, administering oxygen, or preparing for further interventions if persistent.
      A)Choice B reason: Early decelerations are gradual decreases in fetal heart rate that mirror uterine contractions. They are caused by fetal head compression and are considered benign, not associated with fetal distress or cord problems. They are expected during labor and do not indicate pathology.
      B)Choice C reason: Late decelerations occur after the peak of a contraction and are associated with uteroplacental insufficiency, not cord compression. They indicate impaired oxygen exchange between mother and fetus, often due to maternal hypotension, uterine hyperstimulation, or placental dysfunction. While serious, they are not linked to cord problems.
      C)Choice D reason: Accelerations are transient increases in fetal heart rate and are considered reassuring signs of fetal well-being. They indicate adequate oxygenation and intact neurologic response. Accelerations are not associated with cord compression or fetal compromise.
    3. A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 0 station, and the client’s amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?
      A)Assist the client into a comfortable position.
      B)Help the client to the bathroom to void.
      C)Observe the perineum for signs of crowning.
      D)Have the client pant during the next contractions.
    4. A nurse is teaching a client about positive signs of pregnancy. Which of the following findings should the nurse include?
      A)Fetal heart tones detected by ultrasound
      B)Breast tenderness
      C)Fatigue
      D)Positive urine pregnancy test
    Page 3 of 5

    Exam Review

    1. A nurse is teaching a client who is postpartum and has been diagnosed with iron deficiency anemia. Which of the following dietary recommendations should the nurse include in the teaching plan?
      A)Fish and cottage cheese
      B)Milk and turkey slices
      C)Yogurt and mozzarella
      D)Spinach and red meat (generated to complete the 4 choices)
    2. A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client’s blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?
      A)Notify the provider.
      B)Elevate the client’s legs.
      C)Monitor vital signs every 5 min.
      D)Place the client in a lateral position.
    3. A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first?
      A)Assess the bladder for distention.
      B)Prepare to administer a prescribed oxytocic preparation.
      C)Massage the client’s fundus.
      D)Assess the client’s blood pressure.
    4. An adolescent with a severe binge-eating disorder has been prescribed lisdexamfetamine. Which of the following is a side effect of this medication?
      A)Urinary retention
      B)Tachycardia
      C)Growth spurt
      D)Drowsiness
    Page 4 of 5

    Exam Review

    1. A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
      A)Fetal head compression
      B)Uteroplacental insufficiency
      C)Maternal bradycardia
      D)Umbilical cord compression
    2. A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?
      A)Fundus firm, at the level of the umbilicus
      B)Fundus soft 2 cm above the umbilicus
      C)Fundus soft 1 cm to the right of the umbilicus
      D)Fundus present to the left of the umbilicus
    3. A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?
      A)Encourage the client to perform Kegel exercises.
      B)Encourage the client to move to the left lateral position.
      C)Ask the client to rate her pain.
      D)Assist the client to the bathroom to void.
    4. A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?
      A)Threatened abortion
      B)Precipitous labor
      C)Placenta previa
      D)Abruptio placentae
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