FORMAT - ALL BRAND NEW QUESTIONS & 100% CORRECT – GUARANTEED PASS!!
VERSION 1
1. 1. A client at 37 weeks gestation presents to labor and delivery with contrac-
tions every two minutes the nurse observes several shallow small vesicles
on her pubis labia and perineum.the nurse should recognize the clients is
prohibiting symptoms of which condition?
1. German measles
2. herpes simplex virus
3. syphilis
4. genital warts ANS 2. herpes simplex virus
2. A client who had her first baby three months ago and is breastfeeding
her infant tells the nurse that she is currently using the same diaphragm
1/5
,that she used before becoming pregnant. Which information should the nurse
provide this client? ANS Use alternative form of birth control until new diaphragm
can be obtained.
3. A 30- year-old primigravida delivers a 9-pound infant vaginally after a 30-
hour labor. What is the priority nursing action for this client? ANS Massage
the fundus Q 4 hours
4. At 0600 while admitting a woman for a scheduled repeat cesarean section
(CSection), the client tells the nurse that she drank a cup a coffee at 0400
because she wanted to avoid getting a headache. Which action should the
nurse take first? ANS Inform the anesthesia care provider
5. The nurse is caring for a postpartum client who is exhibiting symptoms of
a
spinal headache 24 hours following delivery of a normal newborn. Prior to the
anesthesiologist arrival on the unit, which action should the nurse perform?-
ANS Place procedure equipment at bedside
6. The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds,
14 ounces, has ahead circumference of 13 inches, and a chest circumference
of 10 inches. Based on these physical findings, assessment for which condi-
tion has the highest priority? ANS Hypoglycemia
7. the nurse is caring for a 35 week gestation infant delivered by cesarean
section 2 hours ago.the nurse observes the infants respiratory rate is 72
breaths minute with nasal flaring, grunting, and retractions. the nurse should
recognize these finding indicate which complication? ANS transient
tachypnea of the newborn
8. A primipara client at 42 weeks gestation is admitted for induction. within
one hour after initiating an oxytocin infusion, her cervix is 100% effaced and
6 cm dilated, contractions are occuring every 1 minute with a 75 second
duration. when nurse stops the oxytocin and starts oxygen. after 30 minutes
of uterine rest, the contractions are occuring every 5 minutes with 20 second
2/5
,duration. which intervention should the nurse implement? ANS Restart the
oxytocin per oxytocin protocol
9. A primigravida arrives at the observation unit of the maternity unit because
she thinks she is in labor. the nurse applies the external fetal heart monitor
and determines she is not in labor. What makes the nurse realize she is not in
labor? ANS Contractions stop when the client is walking
10. A primigravida client with gestational hypertension and bishop score of 3
is
scheduled for induction of labor. the nurse administers misoprostol at 0700
then observes regular contractions with cervical changes at 0900 which action
should the nurse take? ANS Administer oxytocin 4 hours later
11. A multigravida client in labor is receiving oxytocin Pitocin 4mu/minute
to help promote an effective contraction pattern. The available solution is
Lactated Ringers 1,000 ml with Pitocin 20 units. The nurse should program
the infusion pump to deliver how many ml/hr? ANS To calculate the infusion
rate in mL/hr, we need to determine how many milliliters contain the desired
dose of oxytocin (Pitocin).
1. Available concentration ANS 20 units of Pitocin in 1,000 mL of Lactated Ringer's.
2. Desired dose ANS 4 milliunits (mu) per
minute. Steps to Calculate ANS
Convert 4 mu/min to units per hour ANS
4 mu/min×60 minutes=240 mu/hr4 { mu/min} \times 60 minutes = 240
{ mu/hr}4 mu/min×60 minutes=240 mu/hr
Convert milliunits to units ANS
240 mu/hr=0.24 units/hr(since 1,000 mu=1 unit)240 mu/hr} = 0.24 { units/hr} {since
} 1,000 { mu} = 1 \unit})240 mu/hr=0.24 units/hr(since 1,000 mu=1 unit)
3 N/
N5
, Determine the mL/hr rate ANS We know that 20 units are in 1,000 mL. Therefore, 1
unit
= 1,000/20= 50 mL.
So, 0.24 units will be in ANS
0.24×50=12 mL/hr
The nurse should program the infusion pump to deliver 12 mL/hr.
12. The nurse is caring for a client whose fetus died in utero at 32 weeks
gestation. After the fetus is delivered vaginally, the nurse implements routine
demise protocol and identification procedures. What action is most important
for the nurse to take? ANS Encourage the mother to hold and spend time with her
baby
13. Following a minor vehicle collision, a client 36 weeks gestation is brought
to the emergency center. She is lying supine on a backboard , is awake , denies
any complaints. Her blood pressure is 80/50 mm Hg and heart rate is 130 beats
4 N/
N5