NURS 326 EXAM #2 QUESTIONS WITH VERIFIED
ACCURATE ANSWERS
A reactive non-stress test is a determined by the following criteria?
a. Three FHR accelerations lasting 15 minutes and 15 beats above baseline in a 30
minute period.
b. Three FHR accelerations of any duration in a 30 minute period.
c. Two FHR accelerations lasting 15 seconds and 15 beats above baseline in a 20
minute period.
d. Two FHR accelerations of any duration in a 20 minute period. - Answers -c. Two
FHR accelerations lasting 15 seconds and 15 beats above baseline in a 20 minute
period.
A client calls a provider's office and reports having contractions for 2 hrs that increased
w/ activity & did not decrease w/ rest. The client denies leaking of vaginal fluid but did
notice blood when wiping after voiding. Which of the following is the client experiencing?
a. Braxton Hicks contractions
b. Rupture of membranes
c. Fetal descent
d. True contractions - Answers -d. True contractions
A nurse is caring for a client having contractions every 8 min that are 30 to 40 seconds
in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at -2 station
with a FHR around 140/min. Which of the following phases of labor is the client
experiencing?
a. First stage, latent phase
b. First stage, active phase
c. First stage, transition phase
d. Second stage of labor - Answers -a. First stage, latent phase
A nurse is caring for a client who is 40 weeks gestation and reports a large gush of fluid
from the vagina while walking to the bathroom. Which of the following actions should the
nurse take first?
a. Examine the amniotic fluid for meconium
b. Check the FHR
c. Dry the client & make them comfortable
d. Apply a tocotransducer - Answers -b. Check the FHR
,A nurse is completing an admission assessment for a client who is 39 weeks of
gestation & reports fluid leaking from the vagina for 2 days. Which of the following
conditions is the client at risk for developing?
a. Cord prolapse
b. Infection
c. Postpartum hemorrhage
d. Hydramnios - Answers -b. Infection
A nurse is caring for a client who is in active labor, irritable, and reports the urge to have
a bowel movement. The client vomits & states, "I've had enough. I can't do this
anymore." Which of the following stages of labor is the client experiencing?
a. Second stage
b. Fourth stage
c. Transition stage
d. Latent phase - Answers -c. Transition stage
A nurse is caring for a client who is 40 weeks gestation and experiencing contractions
every 3 to 5 minutes and increasing. A vaginal exam reveals the client's cervix is 3 cm
dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the
following actions should the nurse take? Select all that apply.
a. Encourage use of patterned breathing
b. Insert urinary catheter
c. Administer opioid analgesics
d. Suggest application of cold
e. Provide ice chips - Answers -c and d
A nurse is caring for a client in a active labor. The cervix is dilated 5 cm & membranes
are intact. Based on external fetal monitoring, the FHR is 115 to 125/min with
occasional increased up to 150 - 155/min that lasts 25 seconds with moderate
variability. There is no slowing of the FHR from baseline. The client is exhibiting
manifestations of which of the following? Select all that apply.
a. Moderate variability
b. FHR accelerations
c. FHR decelerations
d. Normal baseline FHR
e. Fetal tachycardia - Answers -a, b, and d
A nurse is caring for a client who is in labor and observes late decelerations on the
electronic fetal monitor. Which of the following is the first action the nurse should take?
a. Assist the client into the left-lateral position
b. Apply a fetal scalp electrode
, c. Insert an IV catheter
d. Perform a vaginal exam - Answers -a. Assist the client into the left-lateral position
Rationale: The first action should be to increase circulation to the fetus
A nurse is caring for a client who is in the transition phase of labor and reports that they
need to have a bowel movement with the peak of contractions. Which of the following
actions should the nurse make?
a. Assist the client to the bathroom
b. Prepare for an impending delivery
c. Prepare to remove a fecal impaction
d. Encourage the client to take deep,, cleansing breaths - Answers -b. Prepare for an
impending delivery
A nurse is caring for a client in the third stage of labor. Which of the following findings
indicate placental separation? Select all that apply.
a. Lengthening of the umbilical cord
b. Swift gush of clear amniotic fluid
c. Softening of the lower uterine segment
d. Appearance of dark blood from the vagina
e. Fundus firm upon palpation - Answers -a, d, and e
A nurse is caring for a client who is 42 weeks of gestation and is in active labor. Which
of the following findings is the fetus at risk for developing?
a. Intrauterine growth restriction
b. Hyperglycemia
c. Meconium aspiration
d. Polyhydramnios - Answers -c. Meconium aspiration
A nurse is providing care for a client who has abruptio placentae. Which of the following
findings are risk factors for developing the condition? Select all that apply.
a. Fetal position
b. Blunt abdominal trauma
c. Cocaine use
d. Maternal age
e. Cigarette smoking - Answers -b, c, and e
A nurse is caring for a client who is experiencing a ruptured ectopic pregnancy. Which
of the following findings is expected with this condition?
a. No alteration in menses
b. Transvaginal ultrasound indicating a fetus in the uterus
ACCURATE ANSWERS
A reactive non-stress test is a determined by the following criteria?
a. Three FHR accelerations lasting 15 minutes and 15 beats above baseline in a 30
minute period.
b. Three FHR accelerations of any duration in a 30 minute period.
c. Two FHR accelerations lasting 15 seconds and 15 beats above baseline in a 20
minute period.
d. Two FHR accelerations of any duration in a 20 minute period. - Answers -c. Two
FHR accelerations lasting 15 seconds and 15 beats above baseline in a 20 minute
period.
A client calls a provider's office and reports having contractions for 2 hrs that increased
w/ activity & did not decrease w/ rest. The client denies leaking of vaginal fluid but did
notice blood when wiping after voiding. Which of the following is the client experiencing?
a. Braxton Hicks contractions
b. Rupture of membranes
c. Fetal descent
d. True contractions - Answers -d. True contractions
A nurse is caring for a client having contractions every 8 min that are 30 to 40 seconds
in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at -2 station
with a FHR around 140/min. Which of the following phases of labor is the client
experiencing?
a. First stage, latent phase
b. First stage, active phase
c. First stage, transition phase
d. Second stage of labor - Answers -a. First stage, latent phase
A nurse is caring for a client who is 40 weeks gestation and reports a large gush of fluid
from the vagina while walking to the bathroom. Which of the following actions should the
nurse take first?
a. Examine the amniotic fluid for meconium
b. Check the FHR
c. Dry the client & make them comfortable
d. Apply a tocotransducer - Answers -b. Check the FHR
,A nurse is completing an admission assessment for a client who is 39 weeks of
gestation & reports fluid leaking from the vagina for 2 days. Which of the following
conditions is the client at risk for developing?
a. Cord prolapse
b. Infection
c. Postpartum hemorrhage
d. Hydramnios - Answers -b. Infection
A nurse is caring for a client who is in active labor, irritable, and reports the urge to have
a bowel movement. The client vomits & states, "I've had enough. I can't do this
anymore." Which of the following stages of labor is the client experiencing?
a. Second stage
b. Fourth stage
c. Transition stage
d. Latent phase - Answers -c. Transition stage
A nurse is caring for a client who is 40 weeks gestation and experiencing contractions
every 3 to 5 minutes and increasing. A vaginal exam reveals the client's cervix is 3 cm
dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the
following actions should the nurse take? Select all that apply.
a. Encourage use of patterned breathing
b. Insert urinary catheter
c. Administer opioid analgesics
d. Suggest application of cold
e. Provide ice chips - Answers -c and d
A nurse is caring for a client in a active labor. The cervix is dilated 5 cm & membranes
are intact. Based on external fetal monitoring, the FHR is 115 to 125/min with
occasional increased up to 150 - 155/min that lasts 25 seconds with moderate
variability. There is no slowing of the FHR from baseline. The client is exhibiting
manifestations of which of the following? Select all that apply.
a. Moderate variability
b. FHR accelerations
c. FHR decelerations
d. Normal baseline FHR
e. Fetal tachycardia - Answers -a, b, and d
A nurse is caring for a client who is in labor and observes late decelerations on the
electronic fetal monitor. Which of the following is the first action the nurse should take?
a. Assist the client into the left-lateral position
b. Apply a fetal scalp electrode
, c. Insert an IV catheter
d. Perform a vaginal exam - Answers -a. Assist the client into the left-lateral position
Rationale: The first action should be to increase circulation to the fetus
A nurse is caring for a client who is in the transition phase of labor and reports that they
need to have a bowel movement with the peak of contractions. Which of the following
actions should the nurse make?
a. Assist the client to the bathroom
b. Prepare for an impending delivery
c. Prepare to remove a fecal impaction
d. Encourage the client to take deep,, cleansing breaths - Answers -b. Prepare for an
impending delivery
A nurse is caring for a client in the third stage of labor. Which of the following findings
indicate placental separation? Select all that apply.
a. Lengthening of the umbilical cord
b. Swift gush of clear amniotic fluid
c. Softening of the lower uterine segment
d. Appearance of dark blood from the vagina
e. Fundus firm upon palpation - Answers -a, d, and e
A nurse is caring for a client who is 42 weeks of gestation and is in active labor. Which
of the following findings is the fetus at risk for developing?
a. Intrauterine growth restriction
b. Hyperglycemia
c. Meconium aspiration
d. Polyhydramnios - Answers -c. Meconium aspiration
A nurse is providing care for a client who has abruptio placentae. Which of the following
findings are risk factors for developing the condition? Select all that apply.
a. Fetal position
b. Blunt abdominal trauma
c. Cocaine use
d. Maternal age
e. Cigarette smoking - Answers -b, c, and e
A nurse is caring for a client who is experiencing a ruptured ectopic pregnancy. Which
of the following findings is expected with this condition?
a. No alteration in menses
b. Transvaginal ultrasound indicating a fetus in the uterus
