Exam Study Guide: High-Yield Questions, Rationales,
and Preparation Tip With 300 Questions
A nurse is caring for a client who is at 8 weeks of gestation with twins
and primigravida. The client states that even though she and her
husband planned this pregnancy, she is experiencing many
ambivalent feelings about it. Which of the following responses should
the nurse make?
"Have you told your husband about these feelings?"
"These feelings are quite normal at the beginning of pregnancy."
"Perhaps you should see a counselor to discuss these feelings."
"I am quite concerned about these feelings. Could you explain more?"
These feelings are quite normal at the beginning of pregnancy
This client needs reassurance that these feelings are normal and there is
no reason for concern.
A nurse is assessing a newborn who is 12 hours old and notes mild
jaundice of the face and trunk. Which of the following actions should
the nurse take?
Administer phytonadione IM.
Obtain a stat prescription for a bilirubin level.
Obtain a bagged urine specimen.
Perform a gestational age assessment.
Obtain a stat prescription for a bilirubin level
Jaundice in the first 24 hr of life is pathologic. The nurse should notify the
provider and obtain a stat prescription for a bilirubin level.
A nurse is teaching a client who has active genital herpes simplex
virus, type 2. Which of the following statements should the nurse
include in the teaching?
"You will have a cesarean birth prior to the onset of labor."
"Your baby will receive erythromycin eye ointment after birth to treat
,the infection."
"You should take oral metronidazole for 7 days prior to 37 weeks of
gestation."
"You should schedule a cesarean birth after your water breaks."
You will have a cesarean birth prior to the onset of labor
Whenever possible, the cesarean birth should be scheduled prior to the
onset of labor or rupture of membranes to reduce the risk of neonatal
transmission of herpes.
A nurse is caring for a client who has a prescription for naloxone.
Which of the following is the intended action of the medication in
relation to the central nervous system?
Accentuate effects of narcotics on the CNS
Depress activity of the CNS
Block effects of narcotics on the CNS
Stimulate activity of the CNS
Blocks effects of narcotics on the CNS
By blocking the effects of narcotics on the CNS, naloxone prevents CNS
and respiratory depression in the newborn following delivery.
A nurse in a prenatal clinic is caring for a client who is within the
recommended guidelines for weight. The client asks the nurse how
much weight is safe for her to gain during her pregnancy. Which of
the following responses should the nurse make?
"Your provider can discuss an appropriate amount of weight gain with
you."
"A weight gain of about 14 pounds each trimester is suggested."
"If you eat nutritious foods when you feel hungry, the amount of
weight gain is insignificant."
"A weight gain of about 25 to 35 pounds is good."
A weight gain of about 25-35 pounds is good
A weight gain of 25 to 35 lb is associated with good fetal outcome. A gain
of 4 lb in the first trimester and 12 lb each for the second and third trimester
is recommended.
A nurse is caring for a client who is in labor and has an epidural for
pain relief. Which of the following is a complication from the epidural
block?
Nausea and vomiting
Tachycardia
,Hypotension
Respiratory depression
Hypotension
Maternal hypotension is an adverse effect of epidural anesthesia. The
nurse should administer an IV fluid bolus prior to the placement of epidural
anesthesia in order to decrease the likelihood of this complication.
A nurse is providing discharge teaching to a client following the
removal of a hydatidiform mole. Which of the following statements
should the nurse include in the teaching?
"Do not become pregnant for at least 1 year."
"Seek genetic counseling for yourself and your partner prior to
getting pregnant again."
"You should have an hCG level drawn in 6 weeks."
"Have your blood pressure checked weekly for the next month."
Do not become pregnant for at least 1 year
Hydatidiform moles are uncontrolled growths in the uterus arising from
placental or fetal tissue in early pregnancy. There is an increased incidence
of choriocarcinoma associated with molar pregnancies. Pregnancy must be
avoided for 1 year so the client can be closely monitored for manifestations
of this condition.
A nurse is planning care for a client who is at 35 weeks of gestation.
Which of the following laboratory tests should the nurse obtain?
Rubella titer
Blood type
Group B streptococcus ß-hemolytic
1-hour glucose tolerance test
Group B streptococcus B-hemolytic
The nurse should obtain a vaginal/anal group B streptococcus ß-hemolytic
(GBS) culture at 35 to 37 weeks of gestation to screen for infection.
Prophylactic antibiotics should be given during labor to the client who is
positive for GBS.
A nurse is caring for a client who is at 34 weeks of gestation and has
a prescription for terbutaline for preterm labor. Which of the following
statements by the client is the priority?
"My ankles are swollen at the end of the day."
"I can feel the baby kicking my ribs, and it is very uncomfortable."
, "I'm growing more and more worried every day."
"My heart feels as if it is racing."
My heart feels as if it is racing
The primary action of terbutaline is to cause bronchodilation and relax
smooth muscles. However, an adverse effect is tachycardia. If the pulse is
greater than 130/min, the terbutaline needs to be held until the provider is
notified.
A nurse is planning care for a newborn who requires phototherapy for
hyperbilirubinemia. Which of the following actions should the nurse
include in the plan of care?
Swaddle the newborn in a receiving blanket during the treatment.
Maintain NPO status until the newborn's bilirubin is within the
expected reference range.
Ensure the newborn's eyes are closed before applying the eye shield.
Apply lotion to the newborn's skin twice per day.
Ensure the newborns eyes are closed before applying the eye shield
Overexposure to the lights during treatment can cause damage to the
newborn's corneas. Therefore, the nurse should gently close the newborn's
eyes prior to applying the eye shield.
A nurse administers betamethasone to a client who is at 33 weeks
gestation to stimulate fetal lung maturity. Which planning care for the
newborn, which of the following conditions should the nurse identify
as an adverse effect of this medication?
Hyperthermia
Decreased blood glucose
Rapid pulse rate
Irritability
Decreased blood glucose
Betamethasone causes hyperglycemia in the client, which predisposes the
newborn to hypoglycemia in the first hours after delivery. It is important to
assess the newborn's blood glucose level within the first hour following
birth and frequently thereafter until blood glucose levels are stable.
A nurse is caring for a client who is at 16 weeks of gestation and has
severe iron deficiency anemia. The provider prescribes an injection of
iron dextran IM. Which of the following methods should the nurse use
to administer the medication?
Use a 20-gauge needle, and administer the medication using the Z-