NUR 114 TEST 2 ADAPTIVE QUIZ | QUESTIONS
AND ANSWERS | 2026 UPDATE WITH
COMPLETE SOLUTION
An epidural anesthetic is planned for the adolescent who is in labor. What
nursing interventions are essential before epidural anesthesia is
administered? Select all that apply.
1. Performing a baseline vaginal examination
2. Telling the adolescent what to expect with each procedure
3. Identifying risk factors that contraindicate epidural anesthesia
4. Having the parents sign a consent form for the epidural anesthesia
5. Explaining the need to stay in one position while the epidural catheter is in
place - ANSWERS-1. Performing a baseline vaginal examination
2. Telling the adolescent what to expect with each procedure
3. Identifying risk factors that contraindicate epidural anesthesia
A baseline vaginal examination is needed to determine the extent of cervical
dilation and effacement. Before any procedure is implemented, the nurse
should explain the procedure and answer any questions. Risk factors that
contraindicate epidural anesthesia include antepartum hemorrhage, bleeding
disorders, and allergy to the medication. None of these conditions is
indicated in the client's history. Although a signed informed consent is legally
required for this invasive procedure, the adolescent, not the parents, should
sign the consent; a pregnant woman is considered an emancipated minor
and is legally empowered to sign the consent. The client should change
position from side to side every hour to promote distribution of the
anesthetic and to maintain circulation to the uterus and placenta.
Which physiologic alteration does the nurse expect in a client's hematologic
system during the second trimester of pregnancy?
,1. An increase in hematocrit
2. An increase in blood volume
3. A decrease in sedimentation rate
4. A decrease in white blood cells - ANSWERS-2. An increase in blood volume
The blood volume increases by approximately 50% during pregnancy. Peak
blood volume occurs between 30 and 34 weeks' gestation. The hematocrit
decreases as a result of hemodilution. The sedimentation rate increases
because of a decrease in plasma proteins. White blood cells count remains
stable during the antepartum period.
A laboring client who is positive for group B Streptococcus (GBS) is given an
initial dose of 2 g of ampicillin at 9 AM. According to established guidelines
for intrapartum management of this client, what should the next dose be?
1. 2 g given at 10 AM
2. 1 g given at 11 AM
3. 2 g given at noon
4. 1 g given at 1 PM - ANSWERS-4. 1 g given at 1 PM
The established guidelines for intrapartum antibiotic prophylaxis for a client
infected with GBS is an initial dose of 2 g followed by a 1-g dose every 4
hours.
A client's membranes rupture during labor, and the amniotic fluid is
meconium stained. Which heart rate pattern indicates that the fetus's status
is nonreassuring?
1. Early decelerations with average variability
2. Changes in baseline variability from 5 to 10 beats/min
3. Increases in fetal heart rate from 135 to 150 beats/min with fetal activity
, 4. Variable decelerations that last 60 seconds, then return to baseline
tachycardia - ANSWERS-4. Variable decelerations that last 60 seconds, then
return to baseline tachycardia
Variable decelerations indicate cord compression; they should return to
baseline. Tachycardia indicates fetal hypoxia, maternal fever, infection, or
some other factor that is stressing the fetus. Early decelerations and
changes in baseline variability are both expected, benign findings. Increases
in fetal heart rate with fetal movement are an expected finding.
A woman in labor with her third child is dilated to 7 cm, and the fetal head is
at station +1. The client's membranes rupture. What is the nurse's priority
intervention?
1. Notify the practitioner.
2. Observe the vaginal opening for a prolapsed cord.
3. Reposition the client on a sterile towel on her left side.
4. Check the fetal heart rate while observing the color of the amniotic fluid. -
ANSWERS-4. Check the fetal heart rate while observing the color of the
amniotic fluid.
Fetal well-being is the priority. The fetal heart rate will reflect the fetus's
response to the rupture of the membranes, and the color of the amniotic
fluid will reveal whether there is meconium staining. Notifying the
practitioner is necessary if the nurse's assessments reveal fetal compromise.
Although checking the vaginal opening for cord prolapse is important, it is
not the priority; the fetal head is engaged at station +1. Although positioning
the client on the left side promotes placental perfusion, it is not the priority,
and a sterile pad is not needed.
A woman who gave birth to a second child 3 weeks ago is depressed and
having difficulty caring for her children. At the end of the day both of the
children are dirty, wet, and crying. The woman tells her husband that she
"just can't take this anymore." The husband calls the women's health clinic
and asks what he should do. What is the best response by the nurse?
AND ANSWERS | 2026 UPDATE WITH
COMPLETE SOLUTION
An epidural anesthetic is planned for the adolescent who is in labor. What
nursing interventions are essential before epidural anesthesia is
administered? Select all that apply.
1. Performing a baseline vaginal examination
2. Telling the adolescent what to expect with each procedure
3. Identifying risk factors that contraindicate epidural anesthesia
4. Having the parents sign a consent form for the epidural anesthesia
5. Explaining the need to stay in one position while the epidural catheter is in
place - ANSWERS-1. Performing a baseline vaginal examination
2. Telling the adolescent what to expect with each procedure
3. Identifying risk factors that contraindicate epidural anesthesia
A baseline vaginal examination is needed to determine the extent of cervical
dilation and effacement. Before any procedure is implemented, the nurse
should explain the procedure and answer any questions. Risk factors that
contraindicate epidural anesthesia include antepartum hemorrhage, bleeding
disorders, and allergy to the medication. None of these conditions is
indicated in the client's history. Although a signed informed consent is legally
required for this invasive procedure, the adolescent, not the parents, should
sign the consent; a pregnant woman is considered an emancipated minor
and is legally empowered to sign the consent. The client should change
position from side to side every hour to promote distribution of the
anesthetic and to maintain circulation to the uterus and placenta.
Which physiologic alteration does the nurse expect in a client's hematologic
system during the second trimester of pregnancy?
,1. An increase in hematocrit
2. An increase in blood volume
3. A decrease in sedimentation rate
4. A decrease in white blood cells - ANSWERS-2. An increase in blood volume
The blood volume increases by approximately 50% during pregnancy. Peak
blood volume occurs between 30 and 34 weeks' gestation. The hematocrit
decreases as a result of hemodilution. The sedimentation rate increases
because of a decrease in plasma proteins. White blood cells count remains
stable during the antepartum period.
A laboring client who is positive for group B Streptococcus (GBS) is given an
initial dose of 2 g of ampicillin at 9 AM. According to established guidelines
for intrapartum management of this client, what should the next dose be?
1. 2 g given at 10 AM
2. 1 g given at 11 AM
3. 2 g given at noon
4. 1 g given at 1 PM - ANSWERS-4. 1 g given at 1 PM
The established guidelines for intrapartum antibiotic prophylaxis for a client
infected with GBS is an initial dose of 2 g followed by a 1-g dose every 4
hours.
A client's membranes rupture during labor, and the amniotic fluid is
meconium stained. Which heart rate pattern indicates that the fetus's status
is nonreassuring?
1. Early decelerations with average variability
2. Changes in baseline variability from 5 to 10 beats/min
3. Increases in fetal heart rate from 135 to 150 beats/min with fetal activity
, 4. Variable decelerations that last 60 seconds, then return to baseline
tachycardia - ANSWERS-4. Variable decelerations that last 60 seconds, then
return to baseline tachycardia
Variable decelerations indicate cord compression; they should return to
baseline. Tachycardia indicates fetal hypoxia, maternal fever, infection, or
some other factor that is stressing the fetus. Early decelerations and
changes in baseline variability are both expected, benign findings. Increases
in fetal heart rate with fetal movement are an expected finding.
A woman in labor with her third child is dilated to 7 cm, and the fetal head is
at station +1. The client's membranes rupture. What is the nurse's priority
intervention?
1. Notify the practitioner.
2. Observe the vaginal opening for a prolapsed cord.
3. Reposition the client on a sterile towel on her left side.
4. Check the fetal heart rate while observing the color of the amniotic fluid. -
ANSWERS-4. Check the fetal heart rate while observing the color of the
amniotic fluid.
Fetal well-being is the priority. The fetal heart rate will reflect the fetus's
response to the rupture of the membranes, and the color of the amniotic
fluid will reveal whether there is meconium staining. Notifying the
practitioner is necessary if the nurse's assessments reveal fetal compromise.
Although checking the vaginal opening for cord prolapse is important, it is
not the priority; the fetal head is engaged at station +1. Although positioning
the client on the left side promotes placental perfusion, it is not the priority,
and a sterile pad is not needed.
A woman who gave birth to a second child 3 weeks ago is depressed and
having difficulty caring for her children. At the end of the day both of the
children are dirty, wet, and crying. The woman tells her husband that she
"just can't take this anymore." The husband calls the women's health clinic
and asks what he should do. What is the best response by the nurse?
