EXAM 2025 WITH VERIFIED QUESTIONS AND
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A nurse is caring for a client who is in labor. A vaginal examination reveals the
following information: 2cm, 50%, +1, right occiput anterior. Based on this
information, which of the following position should the nurse document in the
medical record?
A. Transverse
B. Breech
C. Vertex
D. Mentum - ANSWER-C. Vertex
ROA describes the relationship of the presenting part of the fetus to the client's
pelvis. In this case, the occipital bone is the presenting part and is located
anteriorly in the client's right side. Based on the presentation of the fetus, the
position is vertex.
A nurse is caring for a client who desires an intrauterine device (IUD) for
contraception. Which of the following findings is a contraindication for the use
of this device?
A. Hypertension
B. Menorrhagia
C. History of multiple gestations
D. History of thromboembolic disease - ANSWER-B. Menorrhagia
,An IUD is a small plastic or copper device placed inside the uterus that changes
the uterine environment to prevent pregnancy. An IUD is contraindicated for
women who have menorrhagia, severe dysmenorrhea, or history of ectopic
pregnancy.
A nurse is caring for a client who is at 39 weeks of gestation and is in active
labor. Which of the following actions should the nurse include in the plan of
care?
A. Keep four side rails up while the client is in bed.
B. Monitor fetal heart rate every hour.
C. Insert an indwelling urinary catheter.
D. Check the cervix prior to analgesic administration. - ANSWER-D. Check the
cervix prior to analgesic administration
Prior to administering an analgesic during active labor, the nurse must know
how many centimeters the cervix is dilated. If administered too close to the time
of delivery, the analgesic could cause respiratory depression in the newborn.
A nurse is caring for a newborn who was born to a client who has a narcotic use
disorder. Which of the following nursing actions should the nurse identify as a
contraindication for the care of the newborn?
A. Promoting maternal-newborn bonding
B. Tight swaddling of the newborn
C. Small frequent feedings
D. Frequent stimulation - ANSWER-D. Frequent stimulation
This newborn needs a quiet, calm environment with minimal stimulation to
promote rest and reduce stress. A stimulating environment can trigger
irritability and hyperactive behaviors.
,A nurse is caring for a client whose membranes have ruptured and is in active
labor. The fetal monitor tracing reveals late decelerations. Which of the
following actions should the nurse take first?
A. Turn the client onto her left side.
B. Palpate the client's uterus.
C. Administer oxygen to the client.
D. Increase the client's IV fluids. - ANSWER-A. Turn the client onto her left
side
Late decelerations indicate that the client is experiencing uteroplacental
insufficiency. The client might be experiencing pressure on the inferior vena
cava, which decreases the oxygen to the placenta and thus to the fetus. Turning
the client onto her left side will relieve the pressure and facilitate better blood
flow to the placenta, thereby increasing the fetal oxygen supply.
A nurse is planning care for a client who has a prescription for oxytocin. Which
of the following is a contraindication for the use of this medication?
A. Prolonged rupture of membranes at 38 weeks of gestation
B. Intrauterine growth restriction
C. Postterm pregnancy
D. Active genital herpes - ANSWER-D. Active genital herpes
The use of oxytocin is contraindicated for clients who have an active genital
herpes infection. The newborn can acquire the infection as they pass through the
birth canal. Therefore, a cesarean birth is recommended for clients who have an
active genital herpes infection.
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which
of the following clinical findings should the nurse expect?
A. Extended periods of sleep
B. Poor muscle tone
, C. Respiratory rate 50/min
D. Exaggerated reflexes - ANSWER-D. Exaggerated reflexes
A newborn who has neonatal abstinence syndrome usually exhibits clinical
findings of hyperactivity within the central nervous system (CNS). Exaggerated
reflexes are indicative of CNS irritability.
A nurse receives report on a client who is in labor and is experiencing
contractions 4 minutes apart. Which of the following patterns should the nurse
expect on the fetal monitoring tracing?
A. Contractions that last for 60 seconds each with a 4-min rest between
contractions
B. Contractions that last for 60 seconds each with a 3-min rest between
contractions
C. A contraction that lasts 4 min followed by a period of relaxation
D. Contractions that last 45 seconds each with a 3-min rest between
contractions - ANSWER-B. Contractions that last for 60 seconds each with a 3-
minute rest between contractions
A contraction interval is how often a uterine contraction occurs. The nurse will
measure the interval from the beginning of one contraction to the beginning of
the next contraction. A contraction lasting 60 seconds with a relaxation period
of 3 min is equivalent to contractions every 4 min.
A nurse is caring for a client who has clinical manifestations of an ectopic
pregnancy. Which of the following findings is a risk factor for an ectopic
pregnancy?
A. Anemia
B. Frequent urinary tract infections
C. Previous cesarean birth
D. Pelvic inflammatory disease (PID) - ANSWER-D. Pelvic inflammatory
disease (PID)