NUR 404 Exam 4 Questions with Correct Answers Latest Update 2025 Graded A+
A multipara client in labor is having contractions which are 2 minutes apart but rarely over 50 mm Hg in
strength; the resting uterine tone is high, 20 to 25 mm Hg. The client asks what she can do to make
contractions more effective. The nurse's best response is:
A. rest between contractions.
B. request oxytocin to strengthen the contractions.
C. be patient as contractions will strengthen by themselves.
D. ambulate to make the contractions regular. - Answers A
The client's contractions are hypertonic because of the high resting tone. Hypertonic contractions occur
because the uterus is being overstimulated or erratically stimulated. Rest, not activity, is effective in
helping contractions become more productive. Oxytocin is contraindicated. There is no guarantee that
waiting will change the status of the contractions.
When a woman in labor has reached 8 cm dilation, the nurse notices the fetal heat rate suddenly slows.
On perineal inspection, the nurse observes the fetal cord has prolapsed. The nurse's first action would
be to:
A. turn her to her left side.
B. place her in a knee-chest position.
C. replace the cord with gentle pressure.
D. cover the exposed cord with a dry, sterile wrap. - Answers B
Keeping the pressure of the fetus off the cord improves fetal circulation. Placing the woman in a knee-
chest position accomplishes this. Replacing the cord could knot it; allowing it to dry would constrict cord
blood vessels.
A woman is going to have labor induced with oxytocin. Which statement reflects the induction
technique the nurse anticipates the primary care provider will prescribe?
,A. Administer oxytocin in a 20 cc bolus of saline.
B. Administer oxytocin in two divided intramuscular sites.
C. Administer oxytocin diluted in the main intravenous fluid.
D. Administer oxytocin diluted as a "piggyback" infusion. - Answers D
Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if
overstimulation of the uterus occurs.
After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's
best action would be to:
A. assess the rate of flow of the oxytocin infusion.
B. administer oral orange juice for added potassium.
C. assess her vaginally for full dilation (dilatation).
D. instruct her to breathe in and out rapidly. - Answers A
A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea.
Assessing and slowing the infusion rate will relieve symptoms.
A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head
begins to emerge as the nurse walks into the labor room. The nurse's best action would be to:
A. place a hand gently on the fetal head to guide birth.
B. ask her to push with the next contraction so birth is rapid.
C. assess blood pressure and pulse to detect placental bleeding.
D. attach a fetal monitor to determine fetal status. - Answers A
If a head is controlled as it emerges, trauma to internal vessels or to the maternal cervix is less apt to
occur.
,A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action
would be to:
A. administer oxygen by mask.
B. increase her intravenous fluid infusion rate.
C. put firm pressure on the fundus of her uterus.
D. tell the woman to take short, catchy breaths. - Answers A
An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to
compensate for the sudden blockage of blood flow through her lungs.
Which action would be most appropriate for the woman who experiences dysfunctional labor in the first
stage of labor?
A. Hold all explanations until after the birth to conserve the woman's energy.
B. Limit discussing things the woman asks questions about.
C. Provide ongoing communication about what is happening.
D. Tell her not to feel anxious or discouraged about what is happening. - Answers C
Dysfunctional labor at any point is frustrating to women. Maintaining open lines of communication at
least keeps the woman well informed about what is happening.
A pregnant client in labor is having contractions about 4 minutes apart but rarely higher than 20 mm Hg
in strength with resting tone ranging from 5 to 8 mm Hg. The client asks what can be done to make
contractions more effective. How will the nurse respond to the client?
A. "Get some rest, because the contractions are hypertonic."
B. "You may need oxytocin to strengthen contractions."
C. "Relax, because contractions of this kind will strengthen by themselves."
D. "Try sitting up a little more erect to make the contractions more regular." - Answers B
, The client is experiencing hypotonic contractions which are often helped with the administration of
oxytocin. Such contractions may or may not begin to strengthen on their own. Additionally, telling the
client to relax ignores the client's concerns. Resting would be appropriate for hypertonic contractions.
Sitting up will not help make the contractions more regular.
A pregnant client is prescribed to have labor induced with oxytocin. The nurse is preparing to administer
the medication. Which action is appropriate?
A. Prepare a syringe with a bolus dose of medication.
B. Give the initial dose as an intramuscular injection.
C. Use a port closest to the client for the oxytocin infusion.
D. Add the oxytocin to the prescribed Ringer's lactate main infusion. - Answers C
When administering oxytocin, the infusion should be "piggybacked" to a maintenance IV solution and
add the piggyback to the main infusion at the port closest to the client. If the oxytocin needs to be
discontinued quickly during the induction, and solution remains in the tubing to still infuse, and the main
IV line can still be maintained. Oxytocin is not administered as an intravenous bolus nor initial
intramuscular injection. Oxytocin is not diluted in the main intravenous fluid.
After an hour of oxytocin therapy, a client in labor experiences headaches and vomiting. What should
the nurse do?
A. Perform a pelvic examination to assess for full dilation.
B. Stop the infusion, then notify the health care provider.
C. Urge the client to breathe in and out quickly in succession.
D. Administer oxygen via nasal cannula. - Answers B
A side effect of oxytocin is that it can result in decreased urine flow, possibly leading to water
intoxication. This is first manifested by headache and vomiting. If these danger signs are observed in the
client during induction of labor, the nurse will stop the infusion immediately and then report it.
Assessing the vagina for dilation, rapid breathing, and administering supplemental oxygen willnot help
with water intoxication.
A multipara client in labor is having contractions which are 2 minutes apart but rarely over 50 mm Hg in
strength; the resting uterine tone is high, 20 to 25 mm Hg. The client asks what she can do to make
contractions more effective. The nurse's best response is:
A. rest between contractions.
B. request oxytocin to strengthen the contractions.
C. be patient as contractions will strengthen by themselves.
D. ambulate to make the contractions regular. - Answers A
The client's contractions are hypertonic because of the high resting tone. Hypertonic contractions occur
because the uterus is being overstimulated or erratically stimulated. Rest, not activity, is effective in
helping contractions become more productive. Oxytocin is contraindicated. There is no guarantee that
waiting will change the status of the contractions.
When a woman in labor has reached 8 cm dilation, the nurse notices the fetal heat rate suddenly slows.
On perineal inspection, the nurse observes the fetal cord has prolapsed. The nurse's first action would
be to:
A. turn her to her left side.
B. place her in a knee-chest position.
C. replace the cord with gentle pressure.
D. cover the exposed cord with a dry, sterile wrap. - Answers B
Keeping the pressure of the fetus off the cord improves fetal circulation. Placing the woman in a knee-
chest position accomplishes this. Replacing the cord could knot it; allowing it to dry would constrict cord
blood vessels.
A woman is going to have labor induced with oxytocin. Which statement reflects the induction
technique the nurse anticipates the primary care provider will prescribe?
,A. Administer oxytocin in a 20 cc bolus of saline.
B. Administer oxytocin in two divided intramuscular sites.
C. Administer oxytocin diluted in the main intravenous fluid.
D. Administer oxytocin diluted as a "piggyback" infusion. - Answers D
Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if
overstimulation of the uterus occurs.
After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's
best action would be to:
A. assess the rate of flow of the oxytocin infusion.
B. administer oral orange juice for added potassium.
C. assess her vaginally for full dilation (dilatation).
D. instruct her to breathe in and out rapidly. - Answers A
A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea.
Assessing and slowing the infusion rate will relieve symptoms.
A woman is in the hospital only 15 minutes when she begins to give birth precipitously. The fetal head
begins to emerge as the nurse walks into the labor room. The nurse's best action would be to:
A. place a hand gently on the fetal head to guide birth.
B. ask her to push with the next contraction so birth is rapid.
C. assess blood pressure and pulse to detect placental bleeding.
D. attach a fetal monitor to determine fetal status. - Answers A
If a head is controlled as it emerges, trauma to internal vessels or to the maternal cervix is less apt to
occur.
,A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action
would be to:
A. administer oxygen by mask.
B. increase her intravenous fluid infusion rate.
C. put firm pressure on the fundus of her uterus.
D. tell the woman to take short, catchy breaths. - Answers A
An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to
compensate for the sudden blockage of blood flow through her lungs.
Which action would be most appropriate for the woman who experiences dysfunctional labor in the first
stage of labor?
A. Hold all explanations until after the birth to conserve the woman's energy.
B. Limit discussing things the woman asks questions about.
C. Provide ongoing communication about what is happening.
D. Tell her not to feel anxious or discouraged about what is happening. - Answers C
Dysfunctional labor at any point is frustrating to women. Maintaining open lines of communication at
least keeps the woman well informed about what is happening.
A pregnant client in labor is having contractions about 4 minutes apart but rarely higher than 20 mm Hg
in strength with resting tone ranging from 5 to 8 mm Hg. The client asks what can be done to make
contractions more effective. How will the nurse respond to the client?
A. "Get some rest, because the contractions are hypertonic."
B. "You may need oxytocin to strengthen contractions."
C. "Relax, because contractions of this kind will strengthen by themselves."
D. "Try sitting up a little more erect to make the contractions more regular." - Answers B
, The client is experiencing hypotonic contractions which are often helped with the administration of
oxytocin. Such contractions may or may not begin to strengthen on their own. Additionally, telling the
client to relax ignores the client's concerns. Resting would be appropriate for hypertonic contractions.
Sitting up will not help make the contractions more regular.
A pregnant client is prescribed to have labor induced with oxytocin. The nurse is preparing to administer
the medication. Which action is appropriate?
A. Prepare a syringe with a bolus dose of medication.
B. Give the initial dose as an intramuscular injection.
C. Use a port closest to the client for the oxytocin infusion.
D. Add the oxytocin to the prescribed Ringer's lactate main infusion. - Answers C
When administering oxytocin, the infusion should be "piggybacked" to a maintenance IV solution and
add the piggyback to the main infusion at the port closest to the client. If the oxytocin needs to be
discontinued quickly during the induction, and solution remains in the tubing to still infuse, and the main
IV line can still be maintained. Oxytocin is not administered as an intravenous bolus nor initial
intramuscular injection. Oxytocin is not diluted in the main intravenous fluid.
After an hour of oxytocin therapy, a client in labor experiences headaches and vomiting. What should
the nurse do?
A. Perform a pelvic examination to assess for full dilation.
B. Stop the infusion, then notify the health care provider.
C. Urge the client to breathe in and out quickly in succession.
D. Administer oxygen via nasal cannula. - Answers B
A side effect of oxytocin is that it can result in decreased urine flow, possibly leading to water
intoxication. This is first manifested by headache and vomiting. If these danger signs are observed in the
client during induction of labor, the nurse will stop the infusion immediately and then report it.
Assessing the vagina for dilation, rapid breathing, and administering supplemental oxygen willnot help
with water intoxication.
