NUR 166 Concepts of Family-Centered Nursing for the
Practical Nurse Exam Review| Questions and Verified
Answers| 100% Correct-
A nurse is assisting with the care of a client who is in active labor, irritable, and reports
the urge to have a bowel movement. The client vomits and states "I've had enough. I
can't do this anymore." Which of the following stages of labor is the client experiencing?
A) Second stage
B) Fourth stage
C) Transition stage
D) Latent phase - C) Transition stage
Rationale: The transition phase of labor occurs when the client becomes irritable, feels
rectal pressure similar to thee need to have a bowel movement, and can become
nauseous with emesis.
A nurse is assisting with the care for a client who is at 40 weeks of gestation and
experiencing contractions every 3 to 5 min and becoming stronger. A vaginal exam by
the registered nurse reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1
station. The client asks for pain medication. Which of the following actions should the
nurse prepare to take? (SATA)
A) Encourage the use of patterned breathing techniques
B) Insert an indwelling urinary catheter
C) Administer opioid analgesic medication
D) Suggest application of cold
E) Provide ice chips - A) Encourage the use of patterned breathing techniques
C) Administer opioid analgesic medication
D) Suggest application of cold
A nurse is reinforcing teaching with a client who is in labor about an episiotomy. Which
of the following information should the nurse include?
A) An episiotomy is a perineal tear that is created while pushing during labor
B) A fourth degree episiotomy extends to the rectal area
C) An episiotomy is an incision that is made by the provider to facilitate the delivery of
the fetus
D) A mediolateral episiotomy is easier to repair than a median episiotomy - C) An
episiotomy is an incision that is made by the provider to facilitate the delivery of the
fetus
, A nurse is assisting with the care for a client who is at 42 weeks of gestation and is
having an ultrasound. For which of the following conditions should the nurse prepare for
an amniofusion? (SATA)
A) Oligohydramnios
B) Hydramnios
C) Fetal cord compression
D) Hydration
E) Fetal immaturity - A) Oligohydramnios
C) Fetal cord compression
A nurse is assisting with the care of a client in active labor. The nurse observes clear
fluid and a loop of pulsating umbilical cord outside the vagina. Which of the following
actions should the nurse perform first?
A) Place the client in Trendelenburg position
B) Apply finger pressure to the presenting part
C) Administer O2 at 10 L/min via a nonrebreather
D) Call for assistance - D) Call for assistance
Schedule for prenatal visits conception-28 weeks - every 4 weeks
Schedule for prenatal visits 29-36 weeks - every 2 weeks
Schedule for prenatal visits 37-birth - weekly
Nagele's Rule - LNMP, count back 3 months and add 7 days
Chadwick's sign - bluish or purplish discoloration of cervix, vagina and vulva caused by
increased vascular congestion
Hegar's sign - softening of the lower uterine segment
McDonald's sign - because of softening, body of the uterus can flex against the cervix
Braxton hicks contractions - irregular, painless uterine contractions that begin in second
trimester
What is Leopold's Maneuver? - A way to determine fetal position and presentation by
abdominal palpitations; presentation, position, confirm presentation, attitude
What is the best location to hear fetal heart rate? - Back
Pt enters the ER, is 39 weeks and her membranes have ruptured. It has been
determined that she is in false labor. Will she be admitted or sent home? - Because her
Practical Nurse Exam Review| Questions and Verified
Answers| 100% Correct-
A nurse is assisting with the care of a client who is in active labor, irritable, and reports
the urge to have a bowel movement. The client vomits and states "I've had enough. I
can't do this anymore." Which of the following stages of labor is the client experiencing?
A) Second stage
B) Fourth stage
C) Transition stage
D) Latent phase - C) Transition stage
Rationale: The transition phase of labor occurs when the client becomes irritable, feels
rectal pressure similar to thee need to have a bowel movement, and can become
nauseous with emesis.
A nurse is assisting with the care for a client who is at 40 weeks of gestation and
experiencing contractions every 3 to 5 min and becoming stronger. A vaginal exam by
the registered nurse reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1
station. The client asks for pain medication. Which of the following actions should the
nurse prepare to take? (SATA)
A) Encourage the use of patterned breathing techniques
B) Insert an indwelling urinary catheter
C) Administer opioid analgesic medication
D) Suggest application of cold
E) Provide ice chips - A) Encourage the use of patterned breathing techniques
C) Administer opioid analgesic medication
D) Suggest application of cold
A nurse is reinforcing teaching with a client who is in labor about an episiotomy. Which
of the following information should the nurse include?
A) An episiotomy is a perineal tear that is created while pushing during labor
B) A fourth degree episiotomy extends to the rectal area
C) An episiotomy is an incision that is made by the provider to facilitate the delivery of
the fetus
D) A mediolateral episiotomy is easier to repair than a median episiotomy - C) An
episiotomy is an incision that is made by the provider to facilitate the delivery of the
fetus
, A nurse is assisting with the care for a client who is at 42 weeks of gestation and is
having an ultrasound. For which of the following conditions should the nurse prepare for
an amniofusion? (SATA)
A) Oligohydramnios
B) Hydramnios
C) Fetal cord compression
D) Hydration
E) Fetal immaturity - A) Oligohydramnios
C) Fetal cord compression
A nurse is assisting with the care of a client in active labor. The nurse observes clear
fluid and a loop of pulsating umbilical cord outside the vagina. Which of the following
actions should the nurse perform first?
A) Place the client in Trendelenburg position
B) Apply finger pressure to the presenting part
C) Administer O2 at 10 L/min via a nonrebreather
D) Call for assistance - D) Call for assistance
Schedule for prenatal visits conception-28 weeks - every 4 weeks
Schedule for prenatal visits 29-36 weeks - every 2 weeks
Schedule for prenatal visits 37-birth - weekly
Nagele's Rule - LNMP, count back 3 months and add 7 days
Chadwick's sign - bluish or purplish discoloration of cervix, vagina and vulva caused by
increased vascular congestion
Hegar's sign - softening of the lower uterine segment
McDonald's sign - because of softening, body of the uterus can flex against the cervix
Braxton hicks contractions - irregular, painless uterine contractions that begin in second
trimester
What is Leopold's Maneuver? - A way to determine fetal position and presentation by
abdominal palpitations; presentation, position, confirm presentation, attitude
What is the best location to hear fetal heart rate? - Back
Pt enters the ER, is 39 weeks and her membranes have ruptured. It has been
determined that she is in false labor. Will she be admitted or sent home? - Because her
