ACLS Exam Latest 2025 (100+ Questions and
VERIFIED Answers) LATEST SOLUTIONS.
The client is presenting with signs of placental abruption. Disseminated intravascular
coagulation is a complication of placental abruption, characterized by abnormal
bleeding. Invasive vaginal procedures can increase the abruption and bleeding. A client
at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is
most indicative of an impending convulsion? - CORRECT ANSWER>>3+ DTR and
hyperclonus
Immediately after birth a newborn is suctioned, dried, and placed under a radiant
warmer. The infant has spontaneous respirations and the nurse assesses an apical heart
rate of 80 bpm and respirations of 20 bpm. What action should the nurse perform
next? - CORRECT ANSWER>>Initiate positive pressure ventilation.
Infant's vital signs are not within the normal range, and oxygen deprivation leads to
cardiac depression in infants.
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her
childbearing history, the client indicate that she has delivered premature twins, one
full term baby, and has had no abortions. Which GTPAL should the nurse document in
this
client's record? - CORRECT ANSWER>>3-1-1-0-3
The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor.
Before initiating this prescription, it is most important for the nurse to assess the
client for which condition? - CORRECT ANSWER>>Gestational diabetes terbutaline
increases blood glucose levels.
,A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last
three weeks. Which assessment finding indicates to the nurse that the drug is effective?
- CORRECT ANSWER>>Changes in apical hear rate from the 180s to the 140s.
Epogen, given to prevent or treat anemia, stimulates erythropoietin production,
resulting
in an increase in RBCs, Since the body has not had to compensate for anemia with an
increased heart rate, changes in heart rate from high to normal is on indicator that
Epogen is effective.
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The
nurse explains to the client that her vaginal discharge will change from red to pink and
then to white. The client asks, "What if I start having red bleeding after it changes?"
What should the nurse instruct the client to do? - CORRECT ANSWER>>Reduce activity
level and notify the healthcare provider.
A pregnant client tells the nurse that the first day of her last menstrual period was
August 2, 2006. Based on Naegele's rule, what is the estimated date of delivery? -
CORRECT ANSWER>>May 9, 2007
LMC -3 month + 7 days + 1 year
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!"
The nurse preforms a vaginal examination that reveals the cervix is 3 cm dilated and
75% effaced. What additional information is most important for the nurse to obtain? -
CORRECT ANSWER>>Date of last normal menstrual period.
Evaluating the gestation of the pregnancy takes priority. If the fetus is preterm and the
FHR is reassuring, the HCP may attempt to prolong the pregnancy and administer
corticosteroids to mature the lungs of the fetus.
The nurse is preparing a client with a term pregnancy who is in active labor for an
amniotomy. What equipment should the nurse have available at the client's bedside? -
, CORRECT ANSWER>>A sterile glove
An amniotic hook
A Doppler
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is
recommended for which purpose? - CORRECT ANSWER>>Screen for neural tube defects
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment,
the nurse determines that both breast are swollen, warm, and tender upon palpation.
What action should the nurse take? - CORRECT ANSWER>>Apply cold compresses to
both for comfort.
During labor, the nurse determines that a full-term client is demonstrating late
decelerations. In which sequence should the nurse implement these nursing actions? -
CORRECT ANSWER>>Reposition the client.
Provide oxygen via face mask
Increase IV fluid
Call the healthcare provider
A vaginally delivered infant of an HIV positive mother is admitted to the newborn
nursery. What intervention should the nurse preform first? - CORRECT ANSWER>>Bathe
the infant with an antimicrobial soap.
A 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull
pain the in right lower quadrant of her abdomen. The nurse obtains a blood sample and
initiates an IV> Thirty minutes after admission, the client reports feeling sharp
abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart
rate of 120 bpm, and a blood pressure of 86/48. Which action should the nurse
implement first? - CORRECT ANSWER>>Increase the rate of IV fluids. demonstrating
symptoms of blood loss, probably the result of an ectopic pregnancy. Client teaching is
an important part of the maternity nurse's role. Which factor has the greatest influence
VERIFIED Answers) LATEST SOLUTIONS.
The client is presenting with signs of placental abruption. Disseminated intravascular
coagulation is a complication of placental abruption, characterized by abnormal
bleeding. Invasive vaginal procedures can increase the abruption and bleeding. A client
at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is
most indicative of an impending convulsion? - CORRECT ANSWER>>3+ DTR and
hyperclonus
Immediately after birth a newborn is suctioned, dried, and placed under a radiant
warmer. The infant has spontaneous respirations and the nurse assesses an apical heart
rate of 80 bpm and respirations of 20 bpm. What action should the nurse perform
next? - CORRECT ANSWER>>Initiate positive pressure ventilation.
Infant's vital signs are not within the normal range, and oxygen deprivation leads to
cardiac depression in infants.
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her
childbearing history, the client indicate that she has delivered premature twins, one
full term baby, and has had no abortions. Which GTPAL should the nurse document in
this
client's record? - CORRECT ANSWER>>3-1-1-0-3
The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor.
Before initiating this prescription, it is most important for the nurse to assess the
client for which condition? - CORRECT ANSWER>>Gestational diabetes terbutaline
increases blood glucose levels.
,A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last
three weeks. Which assessment finding indicates to the nurse that the drug is effective?
- CORRECT ANSWER>>Changes in apical hear rate from the 180s to the 140s.
Epogen, given to prevent or treat anemia, stimulates erythropoietin production,
resulting
in an increase in RBCs, Since the body has not had to compensate for anemia with an
increased heart rate, changes in heart rate from high to normal is on indicator that
Epogen is effective.
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The
nurse explains to the client that her vaginal discharge will change from red to pink and
then to white. The client asks, "What if I start having red bleeding after it changes?"
What should the nurse instruct the client to do? - CORRECT ANSWER>>Reduce activity
level and notify the healthcare provider.
A pregnant client tells the nurse that the first day of her last menstrual period was
August 2, 2006. Based on Naegele's rule, what is the estimated date of delivery? -
CORRECT ANSWER>>May 9, 2007
LMC -3 month + 7 days + 1 year
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!"
The nurse preforms a vaginal examination that reveals the cervix is 3 cm dilated and
75% effaced. What additional information is most important for the nurse to obtain? -
CORRECT ANSWER>>Date of last normal menstrual period.
Evaluating the gestation of the pregnancy takes priority. If the fetus is preterm and the
FHR is reassuring, the HCP may attempt to prolong the pregnancy and administer
corticosteroids to mature the lungs of the fetus.
The nurse is preparing a client with a term pregnancy who is in active labor for an
amniotomy. What equipment should the nurse have available at the client's bedside? -
, CORRECT ANSWER>>A sterile glove
An amniotic hook
A Doppler
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is
recommended for which purpose? - CORRECT ANSWER>>Screen for neural tube defects
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment,
the nurse determines that both breast are swollen, warm, and tender upon palpation.
What action should the nurse take? - CORRECT ANSWER>>Apply cold compresses to
both for comfort.
During labor, the nurse determines that a full-term client is demonstrating late
decelerations. In which sequence should the nurse implement these nursing actions? -
CORRECT ANSWER>>Reposition the client.
Provide oxygen via face mask
Increase IV fluid
Call the healthcare provider
A vaginally delivered infant of an HIV positive mother is admitted to the newborn
nursery. What intervention should the nurse preform first? - CORRECT ANSWER>>Bathe
the infant with an antimicrobial soap.
A 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull
pain the in right lower quadrant of her abdomen. The nurse obtains a blood sample and
initiates an IV> Thirty minutes after admission, the client reports feeling sharp
abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart
rate of 120 bpm, and a blood pressure of 86/48. Which action should the nurse
implement first? - CORRECT ANSWER>>Increase the rate of IV fluids. demonstrating
symptoms of blood loss, probably the result of an ectopic pregnancy. Client teaching is
an important part of the maternity nurse's role. Which factor has the greatest influence
