NURS 306 Quiz 7 V1 | NURS 306 OB |
Actual Q&A with Rationale (NURS306 Quiz
7) | West Coast University
1. A nurse is caring for a client who is in the first stage of labor and is using patterned-paced
breathing. The client reports feeling lightheaded and her fingers are tingling. Which of the
following actions should the nurse take?
A. Administer oxygen via nasal cannula at 2 L/min
B. Place the client in a Trendelenburg position
C. Instruct the client to breathe into a paper bag
D. Check the client’s blood pressure
Answer: C
Rationale: The client is experiencing respiratory alkalosis due to hyperventilation, which
is common during patterned breathing. Breathing into a paper bag or cupped hands helps
the client re-breathe carbon dioxide to restore acid-base balance. This intervention directly
addresses the physiological cause of the tingling and lightheadedness.
2. A nurse is reviewing the laboratory results of a client who is at 34 weeks of gestation and
has preeclampsia. Which of the following results should the nurse report to the provider?
A. Platelets 70,000/mm3
B. Hemoglobin 12 g/dL
,C. Creatinine 0.8 mg/dL
D. BUN 15 mg/dL
Answer: A
Rationale: A platelet count of 70,000/mm3 is significantly below the normal range and
indicates thrombocytopenia, a feature of HELLP syndrome. Preeclampsia can progress to
systemic complications affecting liver enzymes and coagulation. The nurse must report this
finding immediately as it increases the risk of hemorrhage.
3. A nurse is assessing a client who is 2 hours postpartum and has a boggy uterus with heavy
lochia rubra. Which of the following medications should the nurse anticipate administering?
A. Magnesium sulfate
B. Oxytocin
C. Terbutaline
D. Betamethasone
Answer: B
Rationale: Oxytocin is a uterotonic medication used to increase uterine contractions and
prevent postpartum hemorrhage caused by uterine atony. A boggy uterus indicates that the
uterine muscles are not contracting sufficiently to compress the blood vessels at the
placental site. Administering oxytocin helps the uterus become firm and reduces excessive
bleeding.
,4. A nurse is performing a physical assessment of a newborn. Which of the following findings
should the nurse report to the provider?
A. Acrocyanosis
B. Chest wall retractions
C. Milia on the nose
D. Epstein pearls on the palate
Answer: B
Rationale: Chest wall retractions are a clinical sign of respiratory distress in a newborn
and require immediate evaluation. Acrocyanosis is a normal finding in the first 24 to 48
hours of life as the peripheral circulation adapts. Milia and Epstein pearls are benign
findings that do not require medical intervention.
5. A nurse is teaching a client who is at 30 weeks of gestation about a nonstress test (NST).
Which of the following statements by the client indicates an understanding of the teaching?
A. I will need to be NPO for 4 hours before the test
B. This test will determine if my baby’s lungs are mature
C. I should drink a glass of orange juice before the test to stimulate the baby
D. The test will take about 2 hours to complete
Answer: C
, Rationale: Drinking orange juice or consuming a snack provides glucose, which can
stimulate fetal movement during a nonstress test. An NST is considered reactive if there are
at least two accelerations of the fetal heart rate within a 20-minute period. This test
assesses fetal well-being by observing the fetal heart rate response to fetal movement.
6. A nurse is caring for a client who is at 32 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preterm labor. Which of the following is the priority nursing
assessment?
A. Temperature
B. Urine output
C. Deep tendon reflexes
D. Respiratory rate
Answer: D
Rationale: Respiratory depression is a critical sign of magnesium toxicity and takes
priority according to the ABC (Airway, Breathing, Circulation) framework. While
monitoring deep tendon reflexes and urine output is necessary, a respiratory rate below
12/min is the most immediate life-threatening complication. The nurse must have calcium
gluconate available as an antidote.
7. A nurse is caring for a client who is postpartum and has a prescription for a rubella vaccine.
Which of the following instructions should the nurse include?
A. You should stop breastfeeding for 24 hours after the injection
Actual Q&A with Rationale (NURS306 Quiz
7) | West Coast University
1. A nurse is caring for a client who is in the first stage of labor and is using patterned-paced
breathing. The client reports feeling lightheaded and her fingers are tingling. Which of the
following actions should the nurse take?
A. Administer oxygen via nasal cannula at 2 L/min
B. Place the client in a Trendelenburg position
C. Instruct the client to breathe into a paper bag
D. Check the client’s blood pressure
Answer: C
Rationale: The client is experiencing respiratory alkalosis due to hyperventilation, which
is common during patterned breathing. Breathing into a paper bag or cupped hands helps
the client re-breathe carbon dioxide to restore acid-base balance. This intervention directly
addresses the physiological cause of the tingling and lightheadedness.
2. A nurse is reviewing the laboratory results of a client who is at 34 weeks of gestation and
has preeclampsia. Which of the following results should the nurse report to the provider?
A. Platelets 70,000/mm3
B. Hemoglobin 12 g/dL
,C. Creatinine 0.8 mg/dL
D. BUN 15 mg/dL
Answer: A
Rationale: A platelet count of 70,000/mm3 is significantly below the normal range and
indicates thrombocytopenia, a feature of HELLP syndrome. Preeclampsia can progress to
systemic complications affecting liver enzymes and coagulation. The nurse must report this
finding immediately as it increases the risk of hemorrhage.
3. A nurse is assessing a client who is 2 hours postpartum and has a boggy uterus with heavy
lochia rubra. Which of the following medications should the nurse anticipate administering?
A. Magnesium sulfate
B. Oxytocin
C. Terbutaline
D. Betamethasone
Answer: B
Rationale: Oxytocin is a uterotonic medication used to increase uterine contractions and
prevent postpartum hemorrhage caused by uterine atony. A boggy uterus indicates that the
uterine muscles are not contracting sufficiently to compress the blood vessels at the
placental site. Administering oxytocin helps the uterus become firm and reduces excessive
bleeding.
,4. A nurse is performing a physical assessment of a newborn. Which of the following findings
should the nurse report to the provider?
A. Acrocyanosis
B. Chest wall retractions
C. Milia on the nose
D. Epstein pearls on the palate
Answer: B
Rationale: Chest wall retractions are a clinical sign of respiratory distress in a newborn
and require immediate evaluation. Acrocyanosis is a normal finding in the first 24 to 48
hours of life as the peripheral circulation adapts. Milia and Epstein pearls are benign
findings that do not require medical intervention.
5. A nurse is teaching a client who is at 30 weeks of gestation about a nonstress test (NST).
Which of the following statements by the client indicates an understanding of the teaching?
A. I will need to be NPO for 4 hours before the test
B. This test will determine if my baby’s lungs are mature
C. I should drink a glass of orange juice before the test to stimulate the baby
D. The test will take about 2 hours to complete
Answer: C
, Rationale: Drinking orange juice or consuming a snack provides glucose, which can
stimulate fetal movement during a nonstress test. An NST is considered reactive if there are
at least two accelerations of the fetal heart rate within a 20-minute period. This test
assesses fetal well-being by observing the fetal heart rate response to fetal movement.
6. A nurse is caring for a client who is at 32 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preterm labor. Which of the following is the priority nursing
assessment?
A. Temperature
B. Urine output
C. Deep tendon reflexes
D. Respiratory rate
Answer: D
Rationale: Respiratory depression is a critical sign of magnesium toxicity and takes
priority according to the ABC (Airway, Breathing, Circulation) framework. While
monitoring deep tendon reflexes and urine output is necessary, a respiratory rate below
12/min is the most immediate life-threatening complication. The nurse must have calcium
gluconate available as an antidote.
7. A nurse is caring for a client who is postpartum and has a prescription for a rubella vaccine.
Which of the following instructions should the nurse include?
A. You should stop breastfeeding for 24 hours after the injection
