NURS 230 COMPREHENSIVE EXAM
QUESTIONS AND ANSWERS
LATEST UPDATE
1201.Anurse would lookforwhichoneofthe followingfindingsinthe prenatalclient
asmostindicativeof placentalabruption?
1. Severenauseaandvomiting
2. Painlessbleeding
3. Tendertorigidabdomen
4. Normal blood
pressureAnswer:3
Rationale:Signs of placental abruption include tender, rigid abdomen; pain,
cramp-like tosevere;darkredvaginalbleeding;andmaternalshockandfetal
distress.Theotheroptionsarenot findings in placentalabruption.
Test-Taking Strategy:To answer this question accurately, you must be familiar
with themanifestations of this clinical problem.Remember, a sign of placental
abruption includes
atender,rigidabdomen.Reviewthefindingsinplacentalabruptionifyouhaddifficultywi
ththisquestion.
LevelofCognitiveAbility:Comprehen
sionClient Needs:Physiological
Integrity
IntegratedProcess:NursingProcess/DataColle
ctionContentArea:Maternity/Antepartum
Reference:Leifer,G.(2005).Maternitynursing(9thed.).Philadelphia:W.B.Saunders,p.2
17.
1202.Anurseplanningcareforaclient withplacentalabruptionwouldplan to:
, NURS 230 COMPREHENSIVE EXAM
QUESTIONS AND ANSWERS
LATEST UPDATE
1. Preparetheclientforacesareanbirth
2. Administerfrequentenemasuntilclear
3. Preparetheclient forastresstest
4. Repositiontheclienttotheleftsi
deAnswer:1
Rationale:Early diagnosis of placental abruption is critical in managing it
effectively.Plansshould be instituted for continuous fetal monitoring, blood work
analysis, and either
animmediatecesareanbirthorvaginaldelivery.Theincorrectoptionsarenothelpfulinm
anagingthisproblem.
Test-Taking Strategy:Use the process of elimination.Begin to answer this question
byeliminating options 2 and 3 first, because they are the least likely to be helpful in
this situation.Choosecorrectlybetween theremaining
optionsknowingthatcesareanbirthwilldeliverthebabyquicklyandminimize
theriskofmaternalandfetal death.Reviewthe interventionsforthiscomplication if
youhaddifficultywith this question.
Level of Cognitive
Ability:ApplicationClient
Needs:PhysiologicalIntegrityIntegrated
Process:NursingProcess/PlanningConte
ntArea:Maternity/Intrapartum
Reference:Leifer,G.(2005).Maternitynursing(9thed.).Philadelphia:W.B.Saunders,p.2
18.
, NURS 230 COMPREHENSIVE EXAM
QUESTIONS AND ANSWERS
LATEST UPDATE
1203.Anurse overhearsthat aprenatal clientisat riskforplacental abruption.The
nursewouldexpectto find whichrisk factordocumentedintheclient’srecord?
1. Gestationaldiabetes
2. Hyperemesisgravidarum
3. Maternalhypertension
4. Oliguri
aAnswer:
3
Rationale:It is possible that placental abruption can result from maternal
hypertension thatcauses degenerative changes in the small arteries that supply
intervillous spaces.This results
inthrombosis,causingretroplacentalhematoma,andleadingtoplacentalseparation.Opt
ions1,2,and 4 arenotspecificriskfactors for placentalabruption.
Test-Taking Strategy:Use the process of elimination and the ABCs—airway,
breathing, andcirculation.Option 3 addresses circulatory status.Review the risk
factors associated withplacentalabruption if youhad difficultywith this question.
LevelofCognitiveAbility:Comprehen
sionClient Needs:Physiological
Integrity
IntegratedProcess:NursingProcess/DataColle
ctionContentArea:Maternity/Antepartum
Reference:Leifer,G.(2005).Maternitynursing(9thed.).Philadelphia:W.B.Saunders,p.2
17.
1204.A nurse is giving instructions to the mother of a preschool child who was
recentlydiagnosedwithpediculosiscapitis(headlice).Whichitemshouldbeincludedin
, NURS 230 COMPREHENSIVE EXAM
QUESTIONS AND ANSWERS
LATEST UPDATE
discussionstopreventareinfestation?
1. Machinewashallwashableclothing,towels,andbedlinens
andplaceinawarmdryerforatleast20 minutes
2. Shavethechild’shairifpediculocideandnit-removalcombsareineffective
3. Spraythe furniture andbedswithinsecticide
4. Sealnonwashableitemsin aplastic bagfor2to
3weeksinawarmplaceiftheycannotbevacuumedor drycleaned
Answer:4
Rationale: The adult louse can survive up to 48 hours away from a host, while nits
can hatch in 7to 10 days if they are shed into the environment. Thus, 2 weeks
represents a safe interval of
timethatpreventsreinfestationfromoccurring.Hotwaterandairareusedinthewasherand
dryer.
Shaving the hair is unnecessary with proper treatment and would have an adverse
psychologicaleffectontheclient.Insecticides
canendangerchildrenandanimalsandshouldnotbesprayedonfurnitureand beds.
Test-Taking Strategy:Use the process of elimination.Begin to answer this question
byeliminatingoption3,becauseinsecticidescanendangerchildrenandanimals.Eliminat
eoption2 next because shaving the head would risk psychological harm to the child
and is
unnecessary.Knowingthathotwaterandahotdryerarerecommended,notwarm(option1
),willdirectyouto option 4.If heat could damage clothing or linen, the items can be
sealed in a plastic bag for
2to3weeksinawarmplace.Reviewtheseteachingpointsifyouhaddifficultywiththisque
stion.Levelof CognitiveAbility:Application
QUESTIONS AND ANSWERS
LATEST UPDATE
1201.Anurse would lookforwhichoneofthe followingfindingsinthe prenatalclient
asmostindicativeof placentalabruption?
1. Severenauseaandvomiting
2. Painlessbleeding
3. Tendertorigidabdomen
4. Normal blood
pressureAnswer:3
Rationale:Signs of placental abruption include tender, rigid abdomen; pain,
cramp-like tosevere;darkredvaginalbleeding;andmaternalshockandfetal
distress.Theotheroptionsarenot findings in placentalabruption.
Test-Taking Strategy:To answer this question accurately, you must be familiar
with themanifestations of this clinical problem.Remember, a sign of placental
abruption includes
atender,rigidabdomen.Reviewthefindingsinplacentalabruptionifyouhaddifficultywi
ththisquestion.
LevelofCognitiveAbility:Comprehen
sionClient Needs:Physiological
Integrity
IntegratedProcess:NursingProcess/DataColle
ctionContentArea:Maternity/Antepartum
Reference:Leifer,G.(2005).Maternitynursing(9thed.).Philadelphia:W.B.Saunders,p.2
17.
1202.Anurseplanningcareforaclient withplacentalabruptionwouldplan to:
, NURS 230 COMPREHENSIVE EXAM
QUESTIONS AND ANSWERS
LATEST UPDATE
1. Preparetheclientforacesareanbirth
2. Administerfrequentenemasuntilclear
3. Preparetheclient forastresstest
4. Repositiontheclienttotheleftsi
deAnswer:1
Rationale:Early diagnosis of placental abruption is critical in managing it
effectively.Plansshould be instituted for continuous fetal monitoring, blood work
analysis, and either
animmediatecesareanbirthorvaginaldelivery.Theincorrectoptionsarenothelpfulinm
anagingthisproblem.
Test-Taking Strategy:Use the process of elimination.Begin to answer this question
byeliminating options 2 and 3 first, because they are the least likely to be helpful in
this situation.Choosecorrectlybetween theremaining
optionsknowingthatcesareanbirthwilldeliverthebabyquicklyandminimize
theriskofmaternalandfetal death.Reviewthe interventionsforthiscomplication if
youhaddifficultywith this question.
Level of Cognitive
Ability:ApplicationClient
Needs:PhysiologicalIntegrityIntegrated
Process:NursingProcess/PlanningConte
ntArea:Maternity/Intrapartum
Reference:Leifer,G.(2005).Maternitynursing(9thed.).Philadelphia:W.B.Saunders,p.2
18.
, NURS 230 COMPREHENSIVE EXAM
QUESTIONS AND ANSWERS
LATEST UPDATE
1203.Anurse overhearsthat aprenatal clientisat riskforplacental abruption.The
nursewouldexpectto find whichrisk factordocumentedintheclient’srecord?
1. Gestationaldiabetes
2. Hyperemesisgravidarum
3. Maternalhypertension
4. Oliguri
aAnswer:
3
Rationale:It is possible that placental abruption can result from maternal
hypertension thatcauses degenerative changes in the small arteries that supply
intervillous spaces.This results
inthrombosis,causingretroplacentalhematoma,andleadingtoplacentalseparation.Opt
ions1,2,and 4 arenotspecificriskfactors for placentalabruption.
Test-Taking Strategy:Use the process of elimination and the ABCs—airway,
breathing, andcirculation.Option 3 addresses circulatory status.Review the risk
factors associated withplacentalabruption if youhad difficultywith this question.
LevelofCognitiveAbility:Comprehen
sionClient Needs:Physiological
Integrity
IntegratedProcess:NursingProcess/DataColle
ctionContentArea:Maternity/Antepartum
Reference:Leifer,G.(2005).Maternitynursing(9thed.).Philadelphia:W.B.Saunders,p.2
17.
1204.A nurse is giving instructions to the mother of a preschool child who was
recentlydiagnosedwithpediculosiscapitis(headlice).Whichitemshouldbeincludedin
, NURS 230 COMPREHENSIVE EXAM
QUESTIONS AND ANSWERS
LATEST UPDATE
discussionstopreventareinfestation?
1. Machinewashallwashableclothing,towels,andbedlinens
andplaceinawarmdryerforatleast20 minutes
2. Shavethechild’shairifpediculocideandnit-removalcombsareineffective
3. Spraythe furniture andbedswithinsecticide
4. Sealnonwashableitemsin aplastic bagfor2to
3weeksinawarmplaceiftheycannotbevacuumedor drycleaned
Answer:4
Rationale: The adult louse can survive up to 48 hours away from a host, while nits
can hatch in 7to 10 days if they are shed into the environment. Thus, 2 weeks
represents a safe interval of
timethatpreventsreinfestationfromoccurring.Hotwaterandairareusedinthewasherand
dryer.
Shaving the hair is unnecessary with proper treatment and would have an adverse
psychologicaleffectontheclient.Insecticides
canendangerchildrenandanimalsandshouldnotbesprayedonfurnitureand beds.
Test-Taking Strategy:Use the process of elimination.Begin to answer this question
byeliminatingoption3,becauseinsecticidescanendangerchildrenandanimals.Eliminat
eoption2 next because shaving the head would risk psychological harm to the child
and is
unnecessary.Knowingthathotwaterandahotdryerarerecommended,notwarm(option1
),willdirectyouto option 4.If heat could damage clothing or linen, the items can be
sealed in a plastic bag for
2to3weeksinawarmplace.Reviewtheseteachingpointsifyouhaddifficultywiththisque
stion.Levelof CognitiveAbility:Application
