NUR230 GALEN EXAM 3 (PEDS EXAM 1) STRUCTURED WITH
COMPLETE AND VERIFIED QUESTIONS AND RATIONALS
<ALREADY GRADED A+>|UPDATED VERSION|
A nurse is caring for a client who in the first trimester of a low-risk pregnancy. The client tells
the nurse that she and her partner would like to continue their sexual relationship, but she is
afraid it will cause a miscarriage. Which of the following responses should the nurse make?
A. "I will talk to your provider about a referral to a sex therapist."
B. "You can safely have intercourse as long as you don't feel discomfort."
C. "You should try alternative positions for sexual intercourse."
D. "You should abstain from intercourse until 6 weeks postpartum." - ANSWER✔ B. "You can
safely have intercourse as long as you don't feel discomfort."
The nurse should inform the client that sexual intercourse will not cause a miscarriage. However,
the client should report any discomfort experienced during intercourse to the provider so the
cause can be identified.
Incorrect Answers: A. Couples who have long-standing sexual problems that are intensified by
pregnancy are candidates for sex therapy. The nurse should be prepared to answer a client's
questions about sexual activity during pregnancy. C. The client is concerned about safety and has
not reported discomfort. Alternative positions are helpful for preventing maternal discomfort but
have no effect on the fetus or the pregnancy. D. Intercourse is safe as long as it is not
uncomfortable and the client has no history of premature cervical dilation, problems with the
placenta, or ruptured membranes in the current pregnancy.
QUESTION A nurse is assisting with the care of a client who is in labor and experienced a
spontaneous rupture of membranes. Which of the following findings requires intervention by the
charge nurse?
A. Intense contractions lasting less than 30 seconds
B. Rest periods between contractions lasting longer than 90 seconds
C. Fetal heart rate decreased by 15/min
,D. Maternal temperature of 37.8°C (100°F) after ruptured membranes - ANSWER✔ C. Fetal
heart rate decreased by 15/min
A fetal heart rate decrease of 15/min is known as VARIABLE DECELERATIONS and requires
intervention by the nurse due to cord compression. The cord can prolapse after the rupture of
membranes, compromising the fetus. The fetal heart rate and pattern should be monitored for
several minutes after the rupture of membranes to assess the wellbeing of the fetus.
Incorrect Answers: A. Contractions lasting less than 30 seconds are an expected finding.
Contractions lasting longer than 90 seconds can be a risk with or without membrane rupture. B.
Rest periods lasting longer than 90 seconds allow the fetus to recover. Rest periods lasting less
than 30 seconds can be a risk for the fetus because of the shortened recovery period. D. A
temperature of less than 37.8°C (100°F) would be an expected finding and not an indication of a
potential problem. However, a maternal temperature over 37.8°C (100°F) after membranes are
ruptured could indicate the potential for infection.
QUESTION A nurse is collecting data from a client who is at 37 weeks of gestation and is HIV
positive. Which of the following orders should the nurse clarify with the provider?
A. Intermittent auscultation
B. Biophysical profile
C. Non-stress test (NST)
D. Fetal scalp electrode - ANSWER✔ D. Fetal scalp electrode
The placement of a fetal scalp electrode is an invasive procedure that requires ruptured
membranes. The electrode is inserted into the fetal scalp, which will increase the fetus's exposure
to HIV and is contraindicated.
Incorrect Answers: A. Intermittent auscultation with a Doppler is a noninvasive and safe method
of fetal monitoring for a client who is HIV positive and poses no risk of transmitting HIV to the
fetus. B. A biophysical profile includes an ultrasound and external fetal monitoring. It is a
noninvasive method of evaluating fetal wellbeing and poses no risk for transmitting HIV to the
fetus. C. An NST includes the application of external fetal and uterine monitors. It is a
noninvasive and safe method of fetal monitoring for a client who is HIV positive and poses no
risk of transmitting HIV to the fetus.
, QUESTION A nurse is assisting with the care of a client who is attempting a trial of labor
(TOL) after several cesarean births. The client reports a sudden onset of constant abdominal
pain, and the nurse observes a prolonged deceleration on the fetal heart rate tracing. Which of the
following actions should the nurse take?
A. Assist the client to the bathroom to empty her bladder
B. Place the client in a knee-chest position
C. Plan to administer calcium gluconate
D. Prepare the client for an emergency cesarean delivery - ANSWER✔ D. Prepare the client for
an emergency cesarean delivery
A sudden onset of abdominal pain in a laboring client who previously delivered by cesarean
section, accompanied by a prolonged fetal deceleration, is a manifestation of a uterine rupture,
which requires an emergency cesarean delivery.
Incorrect Answers: A. It would not be appropriate to ambulate this client to the bathroom. B. A
knee-chest position is a nursing intervention for variable decelerations or a prolapsed cord, not a
uterine rupture. C. The administration of calcium gluconate is indicated for a client who has
magnesium toxicity, not a uterine rupture.
QUESTION A nurse is reinforcing teaching about oxytocin with a client who is in the third
trimester of pregnancy and has pre-eclampsia. Which of the following is a contraindication for
use of this medication?
A. Prolonged rupture of membranes at 38 weeks of gestation
B. Intrauterine growth restriction
C. Active genital herpes
D. Post-term pregnancy - ANSWER✔ C. 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.
Incorrect Answers: A. When the client is at or near term with prolonged rupture of membranes,
oxytocin induction is indicated. B. Intrauterine growth restriction is an indication for the use of
, oxytocin to induce labor. D. Induction of labor with oxytocin is suggested in post-term
pregnancies.
QUESTION A nurse is assisting with an amniotomy for a client who is in active labor. Which of
the following actions should the nurse take?
A. Assess the fetal heart rate before and after the procedure
B. Monitor the client's temperature every 4 hours after the procedure
C. Medicate the client for pain 30 minutes prior to the procedure
D. Perform cervical assessments every 2 hours after the procedure - ANSWER✔ A. Assess the
fetal heart rate before and after the procedure
The nurse should assess the fetal heart rate for the presence of variable decelerations or
bradycardia, which can occur after rupture of the membranes if the umbilical cord has prolapsed.
Incorrect Answers: B. The client's temperature should be assessed every 2 hours after rupture of
the membranes due to the increased risk of infection. C. An amniotomy procedure is not painful
because there are no nerve endings in the amniotic sac. D. The nurse should limit vaginal
examinations for cervical assessment after rupture of the membranes, as microorganisms from
the vagina can ascend to the uterus and cause an infection.
QUESTION A nurse is reinforcing teaching with a client who has active genital herpes simplex
virus, type 2. Which of the following statements by the nurse should be included in the teaching?
A. "You will have a cesarean birth prior to the onset of labor."
B. "Your baby will receive erythromycin eye ointment after birth to treat the infection."
C. "You should take oral metronidazole for 7 days prior to 37 weeks of gestation."
D. "You should schedule a cesarean birth after your water breaks." - ANSWER✔ A. "You will
have a cesarean birth prior to the onset of labor."
Whenever possible, a cesarean birth should be scheduled prior to the onset of labor or rupture of
membranes to reduce the risk of neonatal transmission of herpes.
COMPLETE AND VERIFIED QUESTIONS AND RATIONALS
<ALREADY GRADED A+>|UPDATED VERSION|
A nurse is caring for a client who in the first trimester of a low-risk pregnancy. The client tells
the nurse that she and her partner would like to continue their sexual relationship, but she is
afraid it will cause a miscarriage. Which of the following responses should the nurse make?
A. "I will talk to your provider about a referral to a sex therapist."
B. "You can safely have intercourse as long as you don't feel discomfort."
C. "You should try alternative positions for sexual intercourse."
D. "You should abstain from intercourse until 6 weeks postpartum." - ANSWER✔ B. "You can
safely have intercourse as long as you don't feel discomfort."
The nurse should inform the client that sexual intercourse will not cause a miscarriage. However,
the client should report any discomfort experienced during intercourse to the provider so the
cause can be identified.
Incorrect Answers: A. Couples who have long-standing sexual problems that are intensified by
pregnancy are candidates for sex therapy. The nurse should be prepared to answer a client's
questions about sexual activity during pregnancy. C. The client is concerned about safety and has
not reported discomfort. Alternative positions are helpful for preventing maternal discomfort but
have no effect on the fetus or the pregnancy. D. Intercourse is safe as long as it is not
uncomfortable and the client has no history of premature cervical dilation, problems with the
placenta, or ruptured membranes in the current pregnancy.
QUESTION A nurse is assisting with the care of a client who is in labor and experienced a
spontaneous rupture of membranes. Which of the following findings requires intervention by the
charge nurse?
A. Intense contractions lasting less than 30 seconds
B. Rest periods between contractions lasting longer than 90 seconds
C. Fetal heart rate decreased by 15/min
,D. Maternal temperature of 37.8°C (100°F) after ruptured membranes - ANSWER✔ C. Fetal
heart rate decreased by 15/min
A fetal heart rate decrease of 15/min is known as VARIABLE DECELERATIONS and requires
intervention by the nurse due to cord compression. The cord can prolapse after the rupture of
membranes, compromising the fetus. The fetal heart rate and pattern should be monitored for
several minutes after the rupture of membranes to assess the wellbeing of the fetus.
Incorrect Answers: A. Contractions lasting less than 30 seconds are an expected finding.
Contractions lasting longer than 90 seconds can be a risk with or without membrane rupture. B.
Rest periods lasting longer than 90 seconds allow the fetus to recover. Rest periods lasting less
than 30 seconds can be a risk for the fetus because of the shortened recovery period. D. A
temperature of less than 37.8°C (100°F) would be an expected finding and not an indication of a
potential problem. However, a maternal temperature over 37.8°C (100°F) after membranes are
ruptured could indicate the potential for infection.
QUESTION A nurse is collecting data from a client who is at 37 weeks of gestation and is HIV
positive. Which of the following orders should the nurse clarify with the provider?
A. Intermittent auscultation
B. Biophysical profile
C. Non-stress test (NST)
D. Fetal scalp electrode - ANSWER✔ D. Fetal scalp electrode
The placement of a fetal scalp electrode is an invasive procedure that requires ruptured
membranes. The electrode is inserted into the fetal scalp, which will increase the fetus's exposure
to HIV and is contraindicated.
Incorrect Answers: A. Intermittent auscultation with a Doppler is a noninvasive and safe method
of fetal monitoring for a client who is HIV positive and poses no risk of transmitting HIV to the
fetus. B. A biophysical profile includes an ultrasound and external fetal monitoring. It is a
noninvasive method of evaluating fetal wellbeing and poses no risk for transmitting HIV to the
fetus. C. An NST includes the application of external fetal and uterine monitors. It is a
noninvasive and safe method of fetal monitoring for a client who is HIV positive and poses no
risk of transmitting HIV to the fetus.
, QUESTION A nurse is assisting with the care of a client who is attempting a trial of labor
(TOL) after several cesarean births. The client reports a sudden onset of constant abdominal
pain, and the nurse observes a prolonged deceleration on the fetal heart rate tracing. Which of the
following actions should the nurse take?
A. Assist the client to the bathroom to empty her bladder
B. Place the client in a knee-chest position
C. Plan to administer calcium gluconate
D. Prepare the client for an emergency cesarean delivery - ANSWER✔ D. Prepare the client for
an emergency cesarean delivery
A sudden onset of abdominal pain in a laboring client who previously delivered by cesarean
section, accompanied by a prolonged fetal deceleration, is a manifestation of a uterine rupture,
which requires an emergency cesarean delivery.
Incorrect Answers: A. It would not be appropriate to ambulate this client to the bathroom. B. A
knee-chest position is a nursing intervention for variable decelerations or a prolapsed cord, not a
uterine rupture. C. The administration of calcium gluconate is indicated for a client who has
magnesium toxicity, not a uterine rupture.
QUESTION A nurse is reinforcing teaching about oxytocin with a client who is in the third
trimester of pregnancy and has pre-eclampsia. Which of the following is a contraindication for
use of this medication?
A. Prolonged rupture of membranes at 38 weeks of gestation
B. Intrauterine growth restriction
C. Active genital herpes
D. Post-term pregnancy - ANSWER✔ C. 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.
Incorrect Answers: A. When the client is at or near term with prolonged rupture of membranes,
oxytocin induction is indicated. B. Intrauterine growth restriction is an indication for the use of
, oxytocin to induce labor. D. Induction of labor with oxytocin is suggested in post-term
pregnancies.
QUESTION A nurse is assisting with an amniotomy for a client who is in active labor. Which of
the following actions should the nurse take?
A. Assess the fetal heart rate before and after the procedure
B. Monitor the client's temperature every 4 hours after the procedure
C. Medicate the client for pain 30 minutes prior to the procedure
D. Perform cervical assessments every 2 hours after the procedure - ANSWER✔ A. Assess the
fetal heart rate before and after the procedure
The nurse should assess the fetal heart rate for the presence of variable decelerations or
bradycardia, which can occur after rupture of the membranes if the umbilical cord has prolapsed.
Incorrect Answers: B. The client's temperature should be assessed every 2 hours after rupture of
the membranes due to the increased risk of infection. C. An amniotomy procedure is not painful
because there are no nerve endings in the amniotic sac. D. The nurse should limit vaginal
examinations for cervical assessment after rupture of the membranes, as microorganisms from
the vagina can ascend to the uterus and cause an infection.
QUESTION A nurse is reinforcing teaching with a client who has active genital herpes simplex
virus, type 2. Which of the following statements by the nurse should be included in the teaching?
A. "You will have a cesarean birth prior to the onset of labor."
B. "Your baby will receive erythromycin eye ointment after birth to treat the infection."
C. "You should take oral metronidazole for 7 days prior to 37 weeks of gestation."
D. "You should schedule a cesarean birth after your water breaks." - ANSWER✔ A. "You will
have a cesarean birth prior to the onset of labor."
Whenever possible, a cesarean birth should be scheduled prior to the onset of labor or rupture of
membranes to reduce the risk of neonatal transmission of herpes.
