with Correct Answers
1. A couple, concerned because the woman has not been able to conceive, is
referred to a healthcare provider for a fertility workup and a
hysterosalpingography is scheduled. Which post procedure complaint
indicates that the fallopian tubes are patent? - ANSWER If the tubes are
patent (open), pain is referred to the shoulder (C) from a sub diaphragmatic
collection of peritoneal dye/gas.
2. A client who delivered an infant an hour ago tells the nurse that she feels wet
underneath her buttock. The nurse notes that both perineal pads are
completely saturated and the client is lying in a 6-inch diameter pool of
blood. Which action should the nurse implement next? - ANSWER Palpate
the firmness of the fundus.
3. One hour after giving birth to an 8-pound infant, a client's lochia rubra has
increased from small to large and her fundus is boggy despite massage. The
client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare
provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse
take immediately? - ANSWER Methergine is contraindicated for clients
with elevated blood pressure, so the nurse should contact the healthcare
provider and question the prescription (D).
4. A client at 32-weeks gestation comes to the prenatal clinic with complaints
of pedal edema, dyspnea, fatigue, and a moist cough. Which question is
most important for the nurse to ask this client? -
ANSWER
Do you have a history of rheumatic fever? Clients with a history of rheumatic
fever (D) may develop mitral valve prolapse, which increases the risk for
,cardiac decompensation due to the increased blood volume that occurs during
pregnancy, so obtaining information about this client's health history is a
priority.
5. A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to
augment labor. Which adverse effect should the nurse monitor for during the
infusion of Pitocin? - ANSWER Pitocin causes the uterine myofibril to
contract, so unless the infusion is closely monitored, the client is at risk for
hyperstimulation (B) which can lead to tetanic contractions, uterine rupture,
and fetal distress or demise.
6. After performing an Ortolani test, the nurse observes that a newborn has
asymmetric gluteal and thigh skinfolds and uneven knee levels. What does
the nurse infer from this assessment? The infant had:
A low birth weight.
A vertex presentation at birth.
Amniotic prolapse before birth.
A breech presentation at birth. - ANSWER A breech presentation at birth.
7. The nurse is taking care of a newborn. The nurse finds out that the infant
weighs 1800 g and the mother's HBsAg status is unknown. When should the
nurse administer the hepatitis B immune globulin (HGIB) vaccine to the
infant?
9 hours after the infant is born
,13 hours after the infant is born
14 hours after the infant is born
18 hours after the infant is born - ANSWER 9 hours after the infant is born
8. During the assessment of a postpartum patient, the nurse finds the patient
has endometritis. Which medication should be administered in the treatment
plan for this patient?
Clindamycin (Cleocin)
Misoprostol (Cytotec)
Ergonovine (Ergotrate)
Methylergonovine (Methergine) - ANSWER Clindamycin (Cleocin)
An examiner who discovers unequal movement or uneven gluteal skinfolds
during the Ortolani maneuver:
tells the parents that one leg may be longer than the other, but they will equal
out by the time the infant is walking.
alerts the physician that the infant has a dislocated hip.
, informs the parents and physician that molding has not taken place.
suggests that if the condition does not change, surgery to correct vision
problems might be needed. - ANSWER alerts the physician that the infant has
a dislocated hip.
Upon assessment, the nurse finds that the infant has a sunken abdomen, bowel
sounds heard in the chest, nasal flaring, and grunting. What clinical condition does
the nurse suspect the infant has based on these findings?
Epispadias
A ruptured viscus
A diaphragmatic hernia
Hirschsprung's disease - ANSWER A diaphragmatic hernia
The nurse observes increased bilirubin levels in the laboratory reports of a
newborn. Which complication does the nurse expect in the newborn if this
condition is poorly monitored?
Syndactyly
Kernicterus
Rectal fistula