ACTUAL EXAM COMPREHENSIVE
QUESTIONS AND VERIFIED ANSWERS
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The nurse is assessing a client who is having a non-stress test (NST) at
41-weeks gestation. The nurse determines that the client is not having
contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR
accelerations are occurring. What action should the nurse take? -
✔✔✔ Correct Answer > Ask the client if she has felt any fetal
movement.
A new mother is afraid to touch her baby's head for fear of hurting the
"large soft spot." Which explanation should the nurse give to this
anxious client? - ✔✔✔ Correct Answer > There's a strong, tough
membrane there to protect the baby so you need not be afraid to wash
or comb his/her hair.
A multigravida client at 41-weeks gestation presents in the labor and
delivery unit after a non-stress test indicated that the fetus is
experiencing some difficulties in utero. Which diagnostic test should
the nurse prepare the client for additional information about fetal
status? - ✔✔✔ Correct Answer > Biophysical profile (BPP)
,A 40-week gestation primigravida client is being induced with an
oxytocin (Pitocin) secondary infusion and complains of pain in her lower
back. Which intervention should the nurse implement? - ✔✔✔
Correct Answer > Apply firm pressure to sacral area
The nurse is preparing to give an enema to a laboring client. Which
client would require the most caution when carrying out this
procedure? - ✔✔✔ Correct Answer > A 40 week primigravida who is
at 6 cm cervical dilation and the presenting part is not engaged.
A client at 32-weeks gestation comes to the prenatal clinic with
complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which
question is most important for the nurse to ask this client? - ✔✔✔
Correct Answer > Do you have a history of rheumatic fever?
A client who had a miscarriage 6 months ago becomes pregnant. Which
instruction is most important for the nurse to provide this client? -
✔✔✔ Correct Answer > Take prescribed multivitamin and mineral
supplements
A 42-week gestational client is receiving an intravenous infusion of
oxytocin (Pitocin) to augment early labor. Which pattern of
contractions should alert the nurse to discontinue the oxytocin
infusion? - ✔✔✔ Correct Answer > Transition labor with contractions
every 2 minutes, lasting 90 seconds each.
, The nurse is assessing the umbilical cord of a newborn. Which finding
constitutes a normal finding? - ✔✔✔ Correct Answer > Three
vessels: two arteries and one vein
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 heart rate from the 180s to the 140s.
full term infant is admitted to the newborn nursery. After careful
assessment, the nurse suspects that the infant may have an esophageal
atresia. Which symptoms are this newborn likely to exhibit? - ✔✔✔
Correct Answer > Choking, coughing, and cyanosis.
After each feeding, a 3-day-old newborn is spitting up large amounts of
a non-dairy based Newborn formula. The pediatric healthcare provider
changes the neonate's formula to a soy protein isolate based infant
formula. What information should the nurse provide to the mother
about the newly prescribed formula? - ✔✔✔ Correct Answer > The
prescribed formula is well tolerated by lactose intolerant infants
A newborn, whose mother is HIV positive, is scheduled for follow-up
assessments. The nurse knows that the most likely presenting symptom
for a pediatric client with AIDS is - ✔✔✔ Correct Answer > a
persistent cold.