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1. A nurse is reviewing the medical record of a client who is at 33
weeks of gestation and has placenta previa and bleeding. Which of the
following prescriptions should the nurse clarify with the provider?
A. Insert a large-bore IV catheter
B. Perform a vaginal examination
C. Obtain a blood sample for laboratory testing
D. Perform continuous external fetal monitoring
CORRECT ANSWER: B
Rationale: In placenta previa, the placenta implants over the cervical os.
Vaginal examination can disrupt the placenta, cause severe
hemorrhage, and precipitate emergency delivery. The nurse should
clarify this prescription.
2. A nurse is caring for a client who is pregnant and is at the end of her
first trimester. The nurse should place the Doppler ultrasound
stethoscope in which of the following locations to begin assessing for
the fetal heart tones (FHT)?
,A. At the level of the umbilicus
B. In the left upper quadrant
C. Just above the symphysis pubis
D. In the right lower quadrant
CORRECT ANSWER: C
Rationale: At the end of the first trimester, the uterus is still low in the
pelvis. The Doppler should be placed just above the symphysis pubis to
auscultate fetal heart tones.
3. A nurse is teaching a client who is at 36 weeks of gestation and has
a prescription for a non-stress test. Which of the following statements
should the nurse include in the teaching?
A. "You will need to remain NPO for 8 hours before the test."
B. "You will be offered orange juice to drink during the test."
C. "You will need to lie flat on your back for the entire test."
D. "The test will take approximately 5 minutes to complete."
CORRECT ANSWER: B
Rationale: Orange juice or other glucose-containing fluids are offered
during a non-stress test to stimulate fetal movement, which typically
causes accelerations in the fetal heart rate—the desired response.
4. A nurse is reviewing the medical record of a newly admitted client
who is at 32 weeks of gestation. Which of the following conditions is
an indication for fetal assessment using electronic fetal monitoring?
,A. Urinary tract infection
B. Anemia
C. Oligohydramnios
D. Gestational diabetes
CORRECT ANSWER: C
Rationale: Oligohydramnios (decreased amniotic fluid) can indicate
placental insufficiency or fetal compromise, making continuous
electronic fetal monitoring essential to assess fetal well-being.
5. A nurse is caring for a newborn who is undergoing phototherapy to
treat hyperbilirubinemia. Which of the following actions should the
nurse take?
A. Discontinue therapy if the newborn develops a rash
B. Apply lotion to the newborn's skin to prevent dryness
C. Cover the newborn's eyes while under the phototherapy light
D. Position the newborn in a prone position
CORRECT ANSWER: C
Rationale: The newborn's eyes must be covered with protective shields
during phototherapy to prevent retinal damage from the intense light.
6. A nurse is caring for a client who has preeclampsia and is receiving a
continuous infusion of magnesium sulfate IV. Which of the following
actions should the nurse take?
A. Have calcium gluconate readily available
B. Place the client in a supine position
, C. Decrease the client's fluid intake
D. Administer potassium chloride IV
CORRECT ANSWER: A
Rationale: Calcium gluconate is the antidote for magnesium sulfate
toxicity. It must be readily available at the bedside to reverse respiratory
depression and cardiac arrest if toxicity occurs.
7. A nurse is providing discharge teaching to the parents of a newborn
about car seat safety. Which of the following instructions should the
nurse include?
A. Place padding behind the newborn's head for support
B. Place the retainer clip at the level of the newborn's armpits
C. Position the car seat in the front seat facing forward
D. Secure the harness straps loosely for comfort
CORRECT ANSWER: B
Rationale: The retainer clip should be positioned at the level of the
newborn's armpits to keep the harness straps securely over the
shoulders and prevent injury in a crash.
8. A school nurse is providing teaching to an adolescent about
levonorgestrel contraception. Which of the following information
should the nurse include in the teaching?
A. Take the medication within 72 hours following unprotected sexual
intercourse
B. Take the medication with a full meal to reduce nausea