Ricci Chapter 14 - Test Bank - 4th Edition
UPDATED ACTUAL Exam Questions and
CORRECT Answers
1. A woman in labor who received an opioid for pain relief develops respiratory depression. The
nurse would expect which agent to be administered?
A. butorphanol
B. fentanyl
C. naloxone
D. promethazine - CORRECT ANSWER - Answer: C
Rationale: Naloxone is an opioid antagonist used to reverse the effects of opioids such as
respiratory depression. Butorphanol and fentanyl are opioids and would cause further respiratory
depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of the
opioid.
2. A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a
contraction. What would the nurse do next?
A. Check the fetal heart rate.
B. Perform a vaginal exam.
C. Notify the primary care provider immediately.
D. Change the linen saver pad. - CORRECT ANSWER - Answer: A
Rationale: When membranes rupture, the priority focus is on assessing fetal heart rate first to
identify a deceleration, which might indicate cord compression secondary to cord prolapse. A
vaginal exam may be done later to evaluate for continued progression of labor. The primary care
provider should be notified, but this is not a priority at this time. Changing the linen saver pad
would be appropriate once the fetal status is determined and the primary care provider has been
notified.
, 3. A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the
presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding
as:
A. +2 station.
B. 0 station.
C. -2 station.
D. crowning. - CORRECT ANSWER - Answer: C
Rationale: The ischial spines serve as landmarks and are designated as zero status. If the
presenting part is palpated higher than the maternal ischial spines, a negative number is assigned.
Therefore, the nurse would document the finding as -2 station. If the presenting part is below the
ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head
at the vaginal opening.
4. A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse
tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns:
A. yellow.
B. olive green.
C. pink.
D. blue. - CORRECT ANSWER - Answer: D
Rationale: Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine swabs that remain
yellow to olive green suggests that the membranes are most likely intact.
5. A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse
prepares the client for this monitoring based on the understanding that which criterion must be
present?
A. intact membranes
B. cervical dilation of 2 cm or more
C. floating presenting fetal part
UPDATED ACTUAL Exam Questions and
CORRECT Answers
1. A woman in labor who received an opioid for pain relief develops respiratory depression. The
nurse would expect which agent to be administered?
A. butorphanol
B. fentanyl
C. naloxone
D. promethazine - CORRECT ANSWER - Answer: C
Rationale: Naloxone is an opioid antagonist used to reverse the effects of opioids such as
respiratory depression. Butorphanol and fentanyl are opioids and would cause further respiratory
depression. Promethazine is an ataractic used as an adjunct to potentiate the effectiveness of the
opioid.
2. A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a
contraction. What would the nurse do next?
A. Check the fetal heart rate.
B. Perform a vaginal exam.
C. Notify the primary care provider immediately.
D. Change the linen saver pad. - CORRECT ANSWER - Answer: A
Rationale: When membranes rupture, the priority focus is on assessing fetal heart rate first to
identify a deceleration, which might indicate cord compression secondary to cord prolapse. A
vaginal exam may be done later to evaluate for continued progression of labor. The primary care
provider should be notified, but this is not a priority at this time. Changing the linen saver pad
would be appropriate once the fetal status is determined and the primary care provider has been
notified.
, 3. A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the
presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding
as:
A. +2 station.
B. 0 station.
C. -2 station.
D. crowning. - CORRECT ANSWER - Answer: C
Rationale: The ischial spines serve as landmarks and are designated as zero status. If the
presenting part is palpated higher than the maternal ischial spines, a negative number is assigned.
Therefore, the nurse would document the finding as -2 station. If the presenting part is below the
ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head
at the vaginal opening.
4. A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse
tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns:
A. yellow.
B. olive green.
C. pink.
D. blue. - CORRECT ANSWER - Answer: D
Rationale: Amniotic fluid is alkaline and turns Nitrazine paper blue. Nitrazine swabs that remain
yellow to olive green suggests that the membranes are most likely intact.
5. A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse
prepares the client for this monitoring based on the understanding that which criterion must be
present?
A. intact membranes
B. cervical dilation of 2 cm or more
C. floating presenting fetal part
