NU 317 EXAM 2 WITH CORRECT
ANSWERS
A nurse on the labor and delivery unit is caring for a client following a
vaginal examination by the provider which is documented as: -1. Which of
the following interpretations of this finding should the nurse make?
A. The presenting part is 1 cm above the ischial spines.
B. The presenting part is 1 cm below the ischial spines.
C. The cervix is 1 cm dilated.
D. The cervix is effaced 1 cm. - ANSWER A. The presenting part is 1 cm above
the ischial spines
A woman is in the second stage of labor and has a spinal block in place for
pain management. The nurse obtains the woman's blood pressure and notes
that it is 20% lower than the baseline level. Which action should the nurse
take?
A. Encourage her to empty her bladder.
B. Decrease her intravenous (IV) rate to a keep vein-open rate.
C. Turn the woman to the left lateral position or place a pillow under her hip
D. No action is necessary since a decrease in the woman's blood pressure is
expected. - ANSWER C. Turn the woman to the left lateral position or place a
pillow under her hip
,When monitoring a woman in labor who has just received spinal analgesia,
the nurse should report which assessment findings to the health care
provider or charge nurse? (Select all that apply.)
A. Maternal blood pressure of 108/79
B. Maternal heart rate of 98
C. Respiratory rate of 14 breaths/min
D. Fetal heart rate of 100 beats/min
E. Minimal variability on a fetal heart monitor - ANSWER D. Fetal heart rate
of 100 beats/min
E. Minimal variability on a fetal heart monitor
The nurse would expect which maternal cardiovascular finding during labor?
A. Increased cardiac output
B. Decreased pulse rate
C. Decreased white blood cell count
D. Decreased blood pressure - ANSWER A. Increased cardiac output
After delivering a healthy baby boy with epidural anesthesia, a woman on the
postpartum unit complains of a severe headache. The nurse should anticipate
which actions in the patient's plan of care? (Select all that apply.)
, A. Keeping the head of bed elevated at all times
B. Administration of oral analgesics
C. Avoid caffeine
D. Assisting with a blood patch procedure
E. Frequent monitoring of vital signs - ANSWER B. Administration of oral
analgesics
D. Assisting with a blood patch procedure
E. Frequent monitoring of vital signs
Which test is performed to determine if membranes are ruptured?
A. Urine analysis
B. Fern test
C. Leopold maneuvers
D. Artificial rupture of membranes (AROM) - ANSWER B. Fern test
.Through vaginal examination the nurse determines that a woman is 4 cm
dilated, and the external fetal monitor shows uterine contractions every 3.5
to 4 minutes. The nurse would report this as:
A. first stage, latent phase.
B. first stage, active phase.
C. first stage, transition phase.
ANSWERS
A nurse on the labor and delivery unit is caring for a client following a
vaginal examination by the provider which is documented as: -1. Which of
the following interpretations of this finding should the nurse make?
A. The presenting part is 1 cm above the ischial spines.
B. The presenting part is 1 cm below the ischial spines.
C. The cervix is 1 cm dilated.
D. The cervix is effaced 1 cm. - ANSWER A. The presenting part is 1 cm above
the ischial spines
A woman is in the second stage of labor and has a spinal block in place for
pain management. The nurse obtains the woman's blood pressure and notes
that it is 20% lower than the baseline level. Which action should the nurse
take?
A. Encourage her to empty her bladder.
B. Decrease her intravenous (IV) rate to a keep vein-open rate.
C. Turn the woman to the left lateral position or place a pillow under her hip
D. No action is necessary since a decrease in the woman's blood pressure is
expected. - ANSWER C. Turn the woman to the left lateral position or place a
pillow under her hip
,When monitoring a woman in labor who has just received spinal analgesia,
the nurse should report which assessment findings to the health care
provider or charge nurse? (Select all that apply.)
A. Maternal blood pressure of 108/79
B. Maternal heart rate of 98
C. Respiratory rate of 14 breaths/min
D. Fetal heart rate of 100 beats/min
E. Minimal variability on a fetal heart monitor - ANSWER D. Fetal heart rate
of 100 beats/min
E. Minimal variability on a fetal heart monitor
The nurse would expect which maternal cardiovascular finding during labor?
A. Increased cardiac output
B. Decreased pulse rate
C. Decreased white blood cell count
D. Decreased blood pressure - ANSWER A. Increased cardiac output
After delivering a healthy baby boy with epidural anesthesia, a woman on the
postpartum unit complains of a severe headache. The nurse should anticipate
which actions in the patient's plan of care? (Select all that apply.)
, A. Keeping the head of bed elevated at all times
B. Administration of oral analgesics
C. Avoid caffeine
D. Assisting with a blood patch procedure
E. Frequent monitoring of vital signs - ANSWER B. Administration of oral
analgesics
D. Assisting with a blood patch procedure
E. Frequent monitoring of vital signs
Which test is performed to determine if membranes are ruptured?
A. Urine analysis
B. Fern test
C. Leopold maneuvers
D. Artificial rupture of membranes (AROM) - ANSWER B. Fern test
.Through vaginal examination the nurse determines that a woman is 4 cm
dilated, and the external fetal monitor shows uterine contractions every 3.5
to 4 minutes. The nurse would report this as:
A. first stage, latent phase.
B. first stage, active phase.
C. first stage, transition phase.
