EAQ NCLEX questions and Answers 100% Solved
What can be determined only by electronic fetal monitoring?
A. Variability
B. Tachycardia
C. Bradycardia
D. Fetal response to contractions Correct Ans-A
A. Variability cannot be determined by auscultation, because auscultation provides only an
average fetal heart rate as it fluctuates.
B. Tachycardia can be determined by electronic fetal monitoring and auscultation.
C. Bradycardia can be determined by electronic fetal monitoring and auscultation.
D. Fetal response to contractions is best determined by electronic fetal monitoring, but some
responses can be determined through auscultation.
Why should continuous electronic fetal monitoring be used when oxytocin is administered?
A. The woman may become hypotensive.
B. Uteroplacental exchange may be compromised.
C. Maternal fluid volume deficit may occur.
D. Fetal chemoreceptors are stimulated. Correct Ans-B
A. Oxytocin use does not have hypotension as a common side effect.
, EAQ NCLEX questions and Answers 100% Solved
B. The uterus may contract more firmly, and the resting tone may be increased with oxytocin
use. This reduces entrance of freshly oxygenated maternal blood into the intervillous spaces,
depleting fetal oxygen reserves.
C. Oxytocin may increase the maternal fluid volume. However, this is not the reason for fetal
monitoring.
D. Oxytocin does not stimulate the fetal chemoreceptors
The physician obtains a sample of fetal scalp blood to evaluate the pH. The results of the pH
were 7.35. The nurse knows the next action will be
A. Nothing—this is a normal pH
B. Preparing for delivery—the pH shows acidosis
C. Preparing for delivery—the pH shows alkalosis
D. Repeating the pH in 20 minutes, because it is borderline Correct Ans-A
Normal scalp pH of a fetus is 7.25-7.35
The nurse has just started a new shift and is reviewing the chart for her assigned patient. The
patient is 6 cm dilated, 100% effaced, -4 station with intact membranes. Ten minutes later, the
patient informs the nurse that her membranes have just ruptured. The nurse notices variable
decelerations on the monitor. The nurse's next action should be to
A. Assess for a prolapsed cord
B. Increase the intravenous fluids and start oxygen
, EAQ NCLEX questions and Answers 100% Solved
C. Notify the nurse-midwife
D. Nothing, this is normal immediately after membranes rupture Correct Ans-A
A
A. With a -4 station, the fetus is at high risk for a prolapsed cord when the membranes
rupture.
B. If the pattern had been caused by uteroplacental insufficiency, then increasing the
intravenous fluids and starting oxygen would be appropriate.
C. It is important to notify the primary care giver with this pattern; however, it is not the first
priority. The nurse should assess for a prolapsed cord and try to relieve the pressure.
D. This is not a normal pattern after membranes rupture. It is nonreassuring
The nurse in charge identifies a patient's responses to actual or potential health problems
during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating Correct Ans-Answer: B
Rationale- The nurse identifies human responses to actual or potential health problems
during the nursing diagnoses step of the nursing process. During the assessment step, the
nurse collects data. During the planning step, the nurse develops strategies to resolve or
decrease the patient's problem. During evaluation, the nurse determines the effectiveness of
the plan of care.
, EAQ NCLEX questions and Answers 100% Solved
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should
receive the highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion Correct Ans-Answer: D
Rationale: This answer takes highest priority because venous inflammation and clot
formation impede blood flow in a patient with deep-vein thrombosis.
Option A is incorrect because impaired gas exchange is related to decreased, not increased,
blood flow. Option B is inappropriate because no evidence suggests that this patient has a
fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion
A nurse is revising a client's care plan. During which step of the nursing process does such a
revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation Correct Ans-Answer: D
What can be determined only by electronic fetal monitoring?
A. Variability
B. Tachycardia
C. Bradycardia
D. Fetal response to contractions Correct Ans-A
A. Variability cannot be determined by auscultation, because auscultation provides only an
average fetal heart rate as it fluctuates.
B. Tachycardia can be determined by electronic fetal monitoring and auscultation.
C. Bradycardia can be determined by electronic fetal monitoring and auscultation.
D. Fetal response to contractions is best determined by electronic fetal monitoring, but some
responses can be determined through auscultation.
Why should continuous electronic fetal monitoring be used when oxytocin is administered?
A. The woman may become hypotensive.
B. Uteroplacental exchange may be compromised.
C. Maternal fluid volume deficit may occur.
D. Fetal chemoreceptors are stimulated. Correct Ans-B
A. Oxytocin use does not have hypotension as a common side effect.
, EAQ NCLEX questions and Answers 100% Solved
B. The uterus may contract more firmly, and the resting tone may be increased with oxytocin
use. This reduces entrance of freshly oxygenated maternal blood into the intervillous spaces,
depleting fetal oxygen reserves.
C. Oxytocin may increase the maternal fluid volume. However, this is not the reason for fetal
monitoring.
D. Oxytocin does not stimulate the fetal chemoreceptors
The physician obtains a sample of fetal scalp blood to evaluate the pH. The results of the pH
were 7.35. The nurse knows the next action will be
A. Nothing—this is a normal pH
B. Preparing for delivery—the pH shows acidosis
C. Preparing for delivery—the pH shows alkalosis
D. Repeating the pH in 20 minutes, because it is borderline Correct Ans-A
Normal scalp pH of a fetus is 7.25-7.35
The nurse has just started a new shift and is reviewing the chart for her assigned patient. The
patient is 6 cm dilated, 100% effaced, -4 station with intact membranes. Ten minutes later, the
patient informs the nurse that her membranes have just ruptured. The nurse notices variable
decelerations on the monitor. The nurse's next action should be to
A. Assess for a prolapsed cord
B. Increase the intravenous fluids and start oxygen
, EAQ NCLEX questions and Answers 100% Solved
C. Notify the nurse-midwife
D. Nothing, this is normal immediately after membranes rupture Correct Ans-A
A
A. With a -4 station, the fetus is at high risk for a prolapsed cord when the membranes
rupture.
B. If the pattern had been caused by uteroplacental insufficiency, then increasing the
intravenous fluids and starting oxygen would be appropriate.
C. It is important to notify the primary care giver with this pattern; however, it is not the first
priority. The nurse should assess for a prolapsed cord and try to relieve the pressure.
D. This is not a normal pattern after membranes rupture. It is nonreassuring
The nurse in charge identifies a patient's responses to actual or potential health problems
during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating Correct Ans-Answer: B
Rationale- The nurse identifies human responses to actual or potential health problems
during the nursing diagnoses step of the nursing process. During the assessment step, the
nurse collects data. During the planning step, the nurse develops strategies to resolve or
decrease the patient's problem. During evaluation, the nurse determines the effectiveness of
the plan of care.
, EAQ NCLEX questions and Answers 100% Solved
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should
receive the highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion Correct Ans-Answer: D
Rationale: This answer takes highest priority because venous inflammation and clot
formation impede blood flow in a patient with deep-vein thrombosis.
Option A is incorrect because impaired gas exchange is related to decreased, not increased,
blood flow. Option B is inappropriate because no evidence suggests that this patient has a
fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion
A nurse is revising a client's care plan. During which step of the nursing process does such a
revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation Correct Ans-Answer: D
