NSG 504 Questions and Correct
Answers- Exam 2
D. Encourage the mother to verbalize her disappointment. ✅The nurse is caring for a
woman who gave birth to a daughter yesterdaybut greatly desired a son. Today she
seems withdrawn, staying in bed and staring at a wall. What is the most appropriate
intervention?
A. Monitor this normal response after delivery.
B. Refer the client for a psychiatric consultation.
C. Tell the client she should be thankful her baby is healthy.
D. Encourage the mother to verbalize her disappointment.
D. Three voidings totaling 240cc in 12 hours. ✅A client is to be discharged 12 hours
after deliver. The nurse should delay the discharge and notify the physician if which of
the following is observed?
A. Moderate lochia rubra.
B. Fundus firm at umbilicus.
C. Pulse 62 beats per minute.
D. Three voidings totaling 240cc in 12 hours.
D. total duration of labor. ✅The primary difference between the labor of a nullipara and
that of a multipara is the:
A. amount of cervical dilation.
B. level of pain experienced.
C. sequence of labor mechanisms.
D. total duration of labor.
D. Uteroplacental exchange may be compromised. ✅Why is continuous electronic fetal
monitoring usually used when oxytocin is administered?
A. Fetal chemoreceptors are stimulated.
B. Maternal fluid volume deficit may occur.
C. The mother may become hypotensive.
D. Uteroplacental exchange may be compromised.
D. assess the mother's radial pulse. ✅When auscultating the fetal heart rate, the nurse
notes a rate of 86 and a soft sound. The appropriate nursing action is to:
A. chart this expectes fetal heart rate.
B. notify the physician of the abnormal fetal heart rate.
C. determine the woman's current labor status.
,D. assess the mother's radial pulse.
B. Have client void and reassess the fundus. ✅You are assessing a client's fundus and
find it firm, 2 cm above the umbilicus, and displaced to the right. What is the most
appropriate intervention?
A. Massage the fundus until firm.
B. Have client void and reassess the fundus.
C. Notify the physician.
D. Start a pad count.
A. give the woman oxygen by facemask. ✅The nurse notes a pattern of late
decelerations on the fetal monitor. The most appropriate first action is to:
A. give the woman oxygen by facemask.
B. continue observation of this reassuring pattern.
C. notify the physician or nurse-midwife.
D. place the woman in a Trendelenburg position.
B. an intrauterine pressure catheter. ✅The nurse-midwife is concerned that a woman's
uterine activity is too intense and that her obesity is preventing accurate assessment of
the actual intrauterine pressure. On the basis of this information, the nurse should
obtain:
A. a tocotransducer.
B. an intrauterine pressure catheter.
C. a scalp electrode.
D. a Doppler transducer.
B. Edema and discoloration of the labia and perineum ✅After a forceps-assisted birth,
the mother is observed to have continuous bright red lochia but a firm fundus. What
other data would indicate the presence of a potential vaginal wall hematoma?
A. Mild, intermittent perineal pain
B. Edema and discoloration of the labia and perineum
C. Lack of an episiotomy
D. Lack of pain in the perineal area
A. 2 station ✅To provide safe care for the woman, the nurse understands that which
condition is a contraindication for an amniotomy?
A. 2 station
B. Dilation less than 3 cm
C. Right occiput posterior position
D. Cephalic presentation
, A. Remind the woman to empty her bladder every 1 to 2 hours. ✅What is the primary
nursing measure to promote fetal descent?
A. Remind the woman to empty her bladder every 1 to 2 hours.
B. Assist fetal head rotation while doing a vaginal examination.
C. Have a woman push atleast three times with each contraction.
D. Promote intake of glucose-containing fluids during labor.
A. Walking decreases the risk of blood clots after surgery. ✅This is the first
postoperative day for a client who delivered by cesarean. The client asks the nurse why
she has to get up and walk when it hurts her incision so much. The nurse responds that:
A. Walking decreases the risk of blood clots after surgery.
B. Walking encourages deep breaths to blow off the anesthetic from surgery.
C. Early ambulation is important to stimulate milk production.
D. Walking will decrease the occurrence of afterpains.
B. a trickle of fluid from the vagina. ✅A woman at 40 weeks of gestation should be
instructed to go to a hospital or birth center for evaluation when she experiences:
A. irregular contractions for 1 hour.
B. a trickle of fluid from the vagina.
C. thick pink or dark red vaginal mucus.
D. fetal movement.
A. massage the fundus ✅If a woman's fundus is soft 30 minutes after birth, the nurse's
first response should be to:
A. massage the fundus
B. take the blood pressure
C. notify the physician or nurse-midwife
D. place the woman in Trendelenburg position
B. diminishes as the spiral arteries are compressed. ✅The maternity nurse
understands that as the uterus contracts during labor, maternal-fetal exchange of
oxygen and waste products:
A. continues except when placental functions are reduced.
B. diminishes as the spiral arteries are compressed.
C. is not significantly affected.
D. increases as blood pressure decreases.
A. Are temporary and will disappear. ✅Parents of a newborn with a forceps-assisted
vaginal birth ask about small reddened areas on the infant's cheeks. The nurse should
tell them that the areas:
Answers- Exam 2
D. Encourage the mother to verbalize her disappointment. ✅The nurse is caring for a
woman who gave birth to a daughter yesterdaybut greatly desired a son. Today she
seems withdrawn, staying in bed and staring at a wall. What is the most appropriate
intervention?
A. Monitor this normal response after delivery.
B. Refer the client for a psychiatric consultation.
C. Tell the client she should be thankful her baby is healthy.
D. Encourage the mother to verbalize her disappointment.
D. Three voidings totaling 240cc in 12 hours. ✅A client is to be discharged 12 hours
after deliver. The nurse should delay the discharge and notify the physician if which of
the following is observed?
A. Moderate lochia rubra.
B. Fundus firm at umbilicus.
C. Pulse 62 beats per minute.
D. Three voidings totaling 240cc in 12 hours.
D. total duration of labor. ✅The primary difference between the labor of a nullipara and
that of a multipara is the:
A. amount of cervical dilation.
B. level of pain experienced.
C. sequence of labor mechanisms.
D. total duration of labor.
D. Uteroplacental exchange may be compromised. ✅Why is continuous electronic fetal
monitoring usually used when oxytocin is administered?
A. Fetal chemoreceptors are stimulated.
B. Maternal fluid volume deficit may occur.
C. The mother may become hypotensive.
D. Uteroplacental exchange may be compromised.
D. assess the mother's radial pulse. ✅When auscultating the fetal heart rate, the nurse
notes a rate of 86 and a soft sound. The appropriate nursing action is to:
A. chart this expectes fetal heart rate.
B. notify the physician of the abnormal fetal heart rate.
C. determine the woman's current labor status.
,D. assess the mother's radial pulse.
B. Have client void and reassess the fundus. ✅You are assessing a client's fundus and
find it firm, 2 cm above the umbilicus, and displaced to the right. What is the most
appropriate intervention?
A. Massage the fundus until firm.
B. Have client void and reassess the fundus.
C. Notify the physician.
D. Start a pad count.
A. give the woman oxygen by facemask. ✅The nurse notes a pattern of late
decelerations on the fetal monitor. The most appropriate first action is to:
A. give the woman oxygen by facemask.
B. continue observation of this reassuring pattern.
C. notify the physician or nurse-midwife.
D. place the woman in a Trendelenburg position.
B. an intrauterine pressure catheter. ✅The nurse-midwife is concerned that a woman's
uterine activity is too intense and that her obesity is preventing accurate assessment of
the actual intrauterine pressure. On the basis of this information, the nurse should
obtain:
A. a tocotransducer.
B. an intrauterine pressure catheter.
C. a scalp electrode.
D. a Doppler transducer.
B. Edema and discoloration of the labia and perineum ✅After a forceps-assisted birth,
the mother is observed to have continuous bright red lochia but a firm fundus. What
other data would indicate the presence of a potential vaginal wall hematoma?
A. Mild, intermittent perineal pain
B. Edema and discoloration of the labia and perineum
C. Lack of an episiotomy
D. Lack of pain in the perineal area
A. 2 station ✅To provide safe care for the woman, the nurse understands that which
condition is a contraindication for an amniotomy?
A. 2 station
B. Dilation less than 3 cm
C. Right occiput posterior position
D. Cephalic presentation
, A. Remind the woman to empty her bladder every 1 to 2 hours. ✅What is the primary
nursing measure to promote fetal descent?
A. Remind the woman to empty her bladder every 1 to 2 hours.
B. Assist fetal head rotation while doing a vaginal examination.
C. Have a woman push atleast three times with each contraction.
D. Promote intake of glucose-containing fluids during labor.
A. Walking decreases the risk of blood clots after surgery. ✅This is the first
postoperative day for a client who delivered by cesarean. The client asks the nurse why
she has to get up and walk when it hurts her incision so much. The nurse responds that:
A. Walking decreases the risk of blood clots after surgery.
B. Walking encourages deep breaths to blow off the anesthetic from surgery.
C. Early ambulation is important to stimulate milk production.
D. Walking will decrease the occurrence of afterpains.
B. a trickle of fluid from the vagina. ✅A woman at 40 weeks of gestation should be
instructed to go to a hospital or birth center for evaluation when she experiences:
A. irregular contractions for 1 hour.
B. a trickle of fluid from the vagina.
C. thick pink or dark red vaginal mucus.
D. fetal movement.
A. massage the fundus ✅If a woman's fundus is soft 30 minutes after birth, the nurse's
first response should be to:
A. massage the fundus
B. take the blood pressure
C. notify the physician or nurse-midwife
D. place the woman in Trendelenburg position
B. diminishes as the spiral arteries are compressed. ✅The maternity nurse
understands that as the uterus contracts during labor, maternal-fetal exchange of
oxygen and waste products:
A. continues except when placental functions are reduced.
B. diminishes as the spiral arteries are compressed.
C. is not significantly affected.
D. increases as blood pressure decreases.
A. Are temporary and will disappear. ✅Parents of a newborn with a forceps-assisted
vaginal birth ask about small reddened areas on the infant's cheeks. The nurse should
tell them that the areas:
