BSN366 Exam 4 Actual Exam Style V3 |
BSN 366 HESI RN Exit | Nightingale
1. A nurse is caring for a client in labor who is receiving oxytocin. The nurse notes late
decelerations on the fetal monitor. What is the priority nursing action?
A. Reposition the client to the lateral position.
B. Increase the oxytocin infusion rate.
C. Document the findings as normal labor progress.
D. Prepare for an immediate vaginal delivery.
Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve oxygenation. Repositioning the mother to the lateral
position helps relieve pressure on the vena cava and increases blood flow to the placenta.
The nurse should also stop the oxytocin and notify the provider if the pattern persists.
2. A postpartum nurse is assessing a client 2 hours after delivery. The fundus is boggy and
displaced to the right. Which action should the nurse take first?
A. Massage the fundus until firm.
B. Assist the client to the bathroom to void.
C. Administer methylergonovine as ordered.
,D. Notify the healthcare provider immediately.
Answer: B
Rationale: A fundus that is displaced to the right and boggy usually indicates a distended
bladder, which prevents the uterus from contracting. Assisting the client to void is the
priority to allow the uterus to return to the midline and contract effectively. If the fundus
remains boggy after voiding, massage and medications would be the next steps.
3. Which clinical finding should the nurse report immediately for a newborn who is 12 hours
old?
A. Milia across the bridge of the nose.
B. Acrocyanosis in the hands and feet.
C. Passing of the first meconium stool.
D. Jaundice appearing on the face and chest.
Answer: D
Rationale: Jaundice appearing within the first 24 hours of life is considered pathological
and requires immediate investigation for hemolytic disease. In contrast, acrocyanosis is a
normal finding in the first 24-48 hours post-birth. Milia and meconium passage are also
standard developmental findings in a healthy newborn.
4. A nurse is teaching a parent of a child with cystic fibrosis. Which information about
nutrition is most important to include?
A. Restrict fluids to prevent pulmonary edema.
, B. Provide a low-protein, low-calorie diet.
C. Administer pancreatic enzymes with all meals and snacks.
D. Avoid the use of salt during the summer months.
Answer: C
Rationale: Children with cystic fibrosis have pancreatic insufficiency and require
supplemental enzymes to digest fats and proteins. These enzymes must be taken with
every meal and snack to ensure adequate nutrient absorption. A high-calorie, high-protein
diet is generally recommended to meet the increased metabolic demands of the disease.
5. A pregnant client at 34 weeks gestation reports a sudden onset of bright red, painless
vaginal bleeding. What condition should the nurse suspect?
A. Abruptio placentae
B. Rupture of the uterus
C. Placenta previa
D. Ectopic pregnancy
Answer: C
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding during
the third trimester as the cervix begins to dilate. Abruptio placentae, on the other hand,
typically presents with dark red bleeding and severe abdominal pain. It is critical to avoid
vaginal exams in patients with suspected placenta previa to prevent further hemorrhage.
BSN 366 HESI RN Exit | Nightingale
1. A nurse is caring for a client in labor who is receiving oxytocin. The nurse notes late
decelerations on the fetal monitor. What is the priority nursing action?
A. Reposition the client to the lateral position.
B. Increase the oxytocin infusion rate.
C. Document the findings as normal labor progress.
D. Prepare for an immediate vaginal delivery.
Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve oxygenation. Repositioning the mother to the lateral
position helps relieve pressure on the vena cava and increases blood flow to the placenta.
The nurse should also stop the oxytocin and notify the provider if the pattern persists.
2. A postpartum nurse is assessing a client 2 hours after delivery. The fundus is boggy and
displaced to the right. Which action should the nurse take first?
A. Massage the fundus until firm.
B. Assist the client to the bathroom to void.
C. Administer methylergonovine as ordered.
,D. Notify the healthcare provider immediately.
Answer: B
Rationale: A fundus that is displaced to the right and boggy usually indicates a distended
bladder, which prevents the uterus from contracting. Assisting the client to void is the
priority to allow the uterus to return to the midline and contract effectively. If the fundus
remains boggy after voiding, massage and medications would be the next steps.
3. Which clinical finding should the nurse report immediately for a newborn who is 12 hours
old?
A. Milia across the bridge of the nose.
B. Acrocyanosis in the hands and feet.
C. Passing of the first meconium stool.
D. Jaundice appearing on the face and chest.
Answer: D
Rationale: Jaundice appearing within the first 24 hours of life is considered pathological
and requires immediate investigation for hemolytic disease. In contrast, acrocyanosis is a
normal finding in the first 24-48 hours post-birth. Milia and meconium passage are also
standard developmental findings in a healthy newborn.
4. A nurse is teaching a parent of a child with cystic fibrosis. Which information about
nutrition is most important to include?
A. Restrict fluids to prevent pulmonary edema.
, B. Provide a low-protein, low-calorie diet.
C. Administer pancreatic enzymes with all meals and snacks.
D. Avoid the use of salt during the summer months.
Answer: C
Rationale: Children with cystic fibrosis have pancreatic insufficiency and require
supplemental enzymes to digest fats and proteins. These enzymes must be taken with
every meal and snack to ensure adequate nutrient absorption. A high-calorie, high-protein
diet is generally recommended to meet the increased metabolic demands of the disease.
5. A pregnant client at 34 weeks gestation reports a sudden onset of bright red, painless
vaginal bleeding. What condition should the nurse suspect?
A. Abruptio placentae
B. Rupture of the uterus
C. Placenta previa
D. Ectopic pregnancy
Answer: C
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding during
the third trimester as the cervix begins to dilate. Abruptio placentae, on the other hand,
typically presents with dark red bleeding and severe abdominal pain. It is critical to avoid
vaginal exams in patients with suspected placenta previa to prevent further hemorrhage.
