Question: A nurse is providing care for a client in labor who is 38 weeks gestation. The nurse notices late decelerations in the fetal heart rate pattern. Which of the following actions should the nurse take first?
Answer Options:
A. Increase the IV fluid rate to 125 mL/hr.
B. Prepare the client for an emergency cesarean section.
C. Reposition the client to the left side.
D. Administer oxygen via face mask at 10 L/min.
Answer: C — Reposition the client to the left side.
Question: On a busy labor and delivery unit, four clients are undergoing induction with oxytocin. Which client requires immediate action by the bedside nurse?
Answer Options:
A. A patient with contractions every 10 minutes with a fetal heart rate of 150 bpm.
B. A patient with contractions every 1½ minutes with a fetal heart rate of 140 bpm.
C. A patient with contractions every 2–3 minutes with a fetal heart rate of 130 bpm, who is moaning and crying.
D. A patient with contractions every 6 minutes, who is leaking clear amniotic fluid with a fetal heart of 150 bpm.
Answer: B — A patient with contractions every 1½ minutes with a fetal heart rate of 140 bpm.
Question: A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client’s laboratory studies, the nurse will expect the results to indicate what findings?
Answer Options:
A. Hypokalemia, hyponatremia, elevated hematocrit
B. Hyperkalemia, hypernatremia, decreased hematocrit
C. Hypokalemia, hypernatremia, decreased hematocrit
D. Hyperkalemia, hyponatremia, elevated hematocrit
Answer: D — Hyperkalemia, hyponatremia, elevated hematocrit
Question: The nurse is assessing the fetal station during a vaginal examination. Which one of the following pelvic structures should the nurse palpate?
Answer Options:
A. Ischial spines
B. Pubic bone
C. Sacral promontory
D. Cervix
Answer: A — Ischial spines
Question: A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The FHR has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. What disposition would the nurse anticipate?
Answer Options:
A. Admitted for extended observation.
B. Discharged home with a sedative
C. Admitted and prepared for a cesarean birth
D. Discharged home to await the onset of true labor
Answer: D — Discharged home to await the onset of true labor
Question: A 40-year-old multiparous client is admitted to labor and delivery with ruptured membranes for 2 hours. She has a noticeable odor of alcohol and cigarettes. Which complication is she at increased risk for?
Answer Options:
A. Abruptio placentae
B. Placenta accreta
C. Placenta previa
D. Gestational diabetes
Answer: A — Abruptio placentae
Question: A pregnant woman was admitted for induction of labor at 42 weeks of gestation. A nonstress test (NST) revealed a nonreactive tracing. On artificial rupture of membranes, thick meconium-stained fluid was noted. What should the nurse caring for the infant after birth anticipate?
Answer Options:
A. Golden yellow to green-stained skin and nails, absence of scalp hair, and increased subcutaneous fat
B. Meconium aspiration, hypoglycemia, and dry, cracked skin
C. Hyperglycemia, hyperthermia, and alert, wide-eyed appearance
D. Excessive vernix caseosa, lethargy, and RDS
Answer: B — Meconium aspiration, hypoglycemia, and dry, cracked skin
Question: A multiparous client presents with contractions every 2 minutes lasting 60 seconds. She’s 100% effaced and 8 cm dilated. What stage of labor is this?
Answer Options:
A. Fourth stage
B. Transition phase
C. Second stage
D. Active phase
Answer: B — Transition phase
Question: On a busy labor and delivery unit, four clients are undergoing induction with oxytocin. Which client requires immediate action by the bedside nurse?
Answer Options:
A. A patient with contractions every 10 minutes with a fetal heart rate of 150 beats/min.
B. A patient with contractions every 1 ½ minutes with a fetal heart rate of 140 beats/min.
C. A patient with contractions every 2–3 minutes with a fetal heart rate of 130 beats/min, who is moaning and crying.
D. A patient with contractions every 6 minutes, who is leaking clear amniotic fluid with a fetal heart rate of 150 beats/min.
Answer: B — A patient with contractions every 1 ½ minutes with a fetal heart rate of 140 beats/min.
Question: When providing care for a client diagnosed with oligohydramnios, the nurse should remain vigilant for the development of which potential complication?
Answer Options:
A. Cardiovascular complications due to increased amniotic fluid.
B. Placenta abruption from uterine overdistention.
C. Variable decelerations of the fetal heart rate due to cord compression.
D. Preterm delivery caused by contractions from uterine pressure.
Answer: C — Variable decelerations of the fetal heart rate due to cord compression.
Question: Amniotic fluid embolism is a frequently fatal complication associated with childbirth. Which of the following factors is considered an increased risk for the occurrence of this event?
Answer Options:
A. Diabetic mother
B. IUGR infant
C. Cesarean Section
D. Primigravida
Answer: C — Cesarean Section
Question: The nurse is assisting with the preparation of a patient admitted for a planned cesarean birth. The patient has signed the consent form and discussed the elected regional anesthesia with the nurse anesthetist. Which is the most important action for the nurse related to anesthesia?
Answer Options:
A. Start an IV line and administer IV fluid as ordered.
B. Verify the patient has been nothing by mouth (NPO) for 6–8 hours.
C. Obtain a baseline fetal heart rate (FHR) monitor strip.
D. Administer preoperative medications per order.
Answer: B — Verify the patient has been nothing by mouth (NPO) for 6–8 hours.
Question: The nurse on a postpartum unit observes a patient who delivered 2 days ago. The nurse notices extreme agitation and depressed mood. The patient states, “I think that my baby is deformed inside and we have to fix him.” Which risk factor is most strongly related to possible postpartum psychosis (PPP)?
Answer Options:
A. Personal history of bipolar disorder
B. Separation from the baby’s father
C. Lack of sleep during the postpartum period.
D. Prolonged labor resulting in cesarean
Answer: A — Personal history of bipolar disorder
Question: A laboring client is about to receive epidural anesthesia. What nursing action helps prevent the most common complication?
Answer Options:
A. Place the client in a right lateral position
B. Rapidly infuse 500–1000 mL of IV fluids
C. Observe fetal heart rate variability
D. Teach the client appropriate breathing techniques
Answer: B — Rapidly infuse 500–1000 mL of IV fluids
Question: The nurse is caring for a 34-year-old woman who is G2P1001 at 39 weeks and 1 day. The patient is an observant Muslim and is in active labor. Which outcome would be the most effective form of applying culturally sensitive communication?
Answer Options:
A. Discussing labor and delivery options while respecting religious practices and preferences
B. Asking the patient to follow all hospital routines without exception
C. Making sure that the patient has Kosher meat for her postpartum meal.
D. Avoiding conversations about cultural or religious beliefs to prevent offense
Answer: A — Discussing labor and delivery options while respecting religious practices and preferences
Question: (Select All That Apply) A uterus assessment shows the fundus is soft and boggy, displaced to the left, and bleeding is noted. If uterine massage doesn’t help, what actions should the nurse implement?
Answer Options:
A. Place a call to the health-care provider (HCP)
B. Make the patient nothing by mouth (NPO) for surgery
C. Assist the patient to the bathroom to void
D. Assist the patient to lie in the left lateral position
E. Administer oxytocin as prescribed
Answer: A, C, E