Question: A 28-year-old woman presents to the clinic with irregular menstrual cycles, hirsutism, and difficulty conceiving. Laboratory testing shows elevated LH and evidence of insulin resistance. The provider diagnoses PCOS. Which nursing intervention is most appropriate to include in the plan of care?
Answer Options:
A. Encourage weight management and lifestyle modifications to improve ovulation
B. Advise the client to avoid pregnancy due to increased obstetric risks
C. Inform the client that PCOS has no effect on fertility
D. Educate the client that pregnancy is unlikely without surgical intervention
Answer: A — Encourage weight management and lifestyle modifications to improve ovulation
Question: A nurse is providing care for a client whose pattern of laboratory testing reveals long-standing hypocalcemia. Which other laboratory result is most consistent with this finding?
Answer Options:
A. An increased calcitonin level
B. A decreased vitamin D level
C. An elevated parathyroid hormone level
D. An elevated potassium level
Answer: B — A decreased vitamin D level
Question: Scenario: A postpartum woman is receiving Pitocin (oxytocin) IV for uterine atony. The infusion is prepared as 20 units of Pitocin in 1,000 mL of Lactated Ringer’s solution. Orders: Administer 4 milliunits per minute. Directions: Calculate the IV flow rate in mL/hr needed to deliver the ordered dose.
Answer Options:
N/A (computation-based)
Answer: 12 mL/hr
Question: Which of the following is the appropriate nursing action before an external cephalic version (ECV)?
Answer Options:
A. Ensure consent was obtained and that an ultrasound machine will be available for use during the procedure.
B. Encourage the client to drink large amounts of fluids immediately before the procedure.
C. Have a consent signed for an epidural analgesia.
D. Assist the woman in assuming a supine position.
Answer: A — Ensure consent was obtained and that an ultrasound machine will be available for use during the procedure.
Question: The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client’s most recent laboratory reports, the nurse notes that the client’s magnesium levels are high. The nurse should prioritize assessment for what health problem?
Answer Options:
A. Cool, clammy skin
B. Diminished deep tendon reflexes
C. Tachycardia
D. Acute flank pain
Answer: B — Diminished deep tendon reflexes
Question: A nurse is assessing a client during the postpartum period and notes that the client’s uterus is boggy and displaced to the right. Which of the following is the priority nursing action?
Answer Options:
A. Administer oxytocin as prescribed.
B. Assess the client’s blood pressure and pulse rate.
C. Assist the client to the bathroom to void.
D. Massage the fundus to encourage uterine contraction.
Answer: C — Assist the client to the bathroom to void.
Question: A nurse is caring for a client with preterm labor who is receiving terbutaline (Brethine). Which of the following assessments should be included to monitor for potential side effects of this medication?
Answer Options:
A. Assess for edema
B. Assess for hypoglycemia
C. Assess deep tendon reflexes
D. Assess for tachycardia
Answer: D — Assess for tachycardia
Question: A 28-year-old woman presents to the clinic with irregular menstrual cycles, hirsutism, and difficulty conceiving. Laboratory testing shows elevated luteinizing hormone (LH) levels and evidence of insulin resistance. The provider diagnoses polycystic ovary syndrome (PCOS). Which nursing intervention is most appropriate to include in the plan of care?
Answer Options:
A. Encourage weight management and lifestyle modifications to improve ovulation
B. Advise the client to avoid pregnancy due to increased obstetric risks
C. Inform the client that PCOS has no effect on fertility
D. Educate the client that pregnancy is unlikely without surgical intervention
Answer: A — Encourage weight management and lifestyle modifications to improve ovulation
Question: The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate slowly drops to 120, and then returns to 140 by the end of the contraction, mirroring the contraction. Which nursing intervention is best?
Answer Options:
A. Assist the patient to change from Fowler’s to left lateral position.
B. Notify the operating room of the need for a cesarean birth.
C. Continue to monitor the FHR and encourage the patient to breathe through the contractions.
D. Apply oxygen to the patient at 2 liters per nasal cannula.
Answer: C — Continue to monitor the FHR and encourage the patient to breathe through the contractions.
Question: A 32-week pregnant client is diagnosed with polyhydramnios. Which of the following signs or complications should the nurse monitor for in this client when in labor?
Answer Options:
A. Post-term pregnancy
B. Intrauterine growth restriction (IUGR)
C. Oliguria and dehydration
D. Umbilical cord prolapse
Answer: D — Umbilical cord prolapse
Question: The nurse is caring for a client who is delivering her baby. When assisting the mother to push, the nurse sees the fetal head deliver and then retract back (Turtle Sign). The nurse is prepared for a shoulder dystocia and implements which of the following interventions?
Answer Options:
A. Apply fundal pressure while the provider attempts to deliver the shoulder
B. Call for assistance and lower the head of the bed, pull the client’s legs back (McRoberts), apply suprapubic pressure
C. Ask the mother to stop pushing while the provider tries maneuvers to deliver
D. Sit the client upright and encourage more pushing
Answer: B — Call for assistance and lower the head of the bed, pull the client’s legs back (McRoberts), apply suprapubic pressure
Question: The client presents to the labor and delivery unit stating that her water broke 2 hours ago. To confirm the client for leaking amniotic fluid, the nurse uses litmus paper which will turn which color to confirm amniotic fluid is present?
Answer Options:
A. Blue
B. Red
C. Yellow
D. Pink
Answer: A — Blue
Question: A 32-week gestation client thinks she is leaking amniotic fluid. Which test could confirm rupture of membranes?
Answer Options:
A. Biophysical profile
B. Amniocentesis
C. PUBS test
D. Fern test or Nitrazine paper
Answer: D — Fern test or Nitrazine paper
Question: A woman’s position is an important component of the labor progress. Which guidance is important for the nurse to provide to the laboring client?
Answer Options:
A. Frequent changes in position help relieve fatigue, increase the comfort of the laboring client, and help the fetus to descend.
B. The supine position, which is commonly used in the United States, increases blood flow.
C. In a sitting or squatting position, abdominal muscles of the laboring client will have to work harder.
D. The laboring client positioned on her hands and knees (“all fours” position) is hard on the woman’s back.
Answer: A — Frequent changes in position help relieve fatigue, increase the comfort of the laboring client, and help the fetus to descend.
Question: A client is receiving magnesium sulfate IV at 1 gram/hour after a loading dose. The client looks flushed and complains of feeling warm. What is the priority action of the nurse?
Answer Options:
A. Turn the client on her left side and increase IV fluids
B. Reassure the client that this is a normal response
C. Stop the drug and call the physician
D. Perform a vaginal exam to determine labor progress
Answer: B — Reassure the client that this is a normal response
Question: The nurse is performing Leopold’s maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first?
Answer Options:
A. Feel for the fetal back and limbs as the hands move laterally on the abdomen.
B. Feel for the fetal buttocks or head while palpating the abdomen.
C. Determine flexion by pressing downward toward the symphysis pubis.
D. Palpate for the presenting part in the area just above the symphysis pubis.
Answer: B — Feel for the fetal buttocks or head while palpating the abdomen.
Question: The nurse is performing a nutritional assessment on a client who has been diagnosed with cancer of the larynx. Which laboratory values would be assessed when determining the nutritional status of the client?
Answer Options:
A. Glucose level
B. White blood cell count
C. Protein level
D. Platelet count
E. Albumin level
Answer: A, C, E — Glucose level, Protein level, Albumin level