NACE - Care of Childbearing Family NLN NACE Practice
Questions & Answers Latest Version
After a client received an epidural anesthesia, a nurse should make which of these assessments first?
· Determine whether the client has bladder distention
· Determine whether the client has sensory impairment in the legs
· Determine the frequency of the client's contractions
Determine the client’s blood pressure - ✔✔✔ - The nurse should determine the client's blood
pressure first. Since epidural anesthesia may cause the blood pressure to drop, it is important to
ensure there is adequate blood flow to the baby. The other options may be subsequent assessments
the nurse would make, but should not be the first assessment.
The client who is 16 weeks pregnant attends the antepartal clinic. She makes all of these comments
to a nurse. Which of these comments by this client requires FURTHER discussion by the nurse?
· I drink about 2.5 quarts of fluids every day
· I've gained about 7 pounds so far. I'll probably gain another 20 pounds by the time I deliver
· I had a problem with hemorrhoids with my other pregnancy, so now I eat a large serving of bran
every evening
· I'm being careful to eat mostly salt-free and to use no salt in my cooking - ✔✔✔ - The fourth
statement requires further discussion. Sodium requirements increase during pregnancy. However,
the sodium provided by the average diet is likely to be adequate for expectant mothers. Use of
additional salt is rarely warranted.
A nurse teaches pregnancy exercises to a group of pregnant women. The nurse should include an
explanation that pelvic rock will be helpful at any time in their lives should the women develop which
of these conditions?
· Hemorrhoids
· Intestinal flatus
· Lower back pain
,· Leg cramps - ✔✔✔ - Pelvic rock helps to relieve lower back pains. Pelvic rocking helps to relieve a
sore back by stretching the lower back muscles. Pelvic rocking also helps stimulate the digestive
system, realigns the uterus, and keeps the stomach muscles toned.
A client who is in active labor has a vaginal examination which reveals she is 5cm dilated and 100%
effaced at a -1 station. At the peak of a contraction, the amniotic fluid ruptures. Which of these actions
should a nurse take first?
· Records the findings and notify the provider
· Change the linen and make the client comfortable
· Check the perineal area and assess for crowning
· Assess the fetal heart rate and check for regularity - ✔✔✔ - After rupture of the membranes, there
is a danger of cord prolapse; therefore, the nurse should assess the fetal heart rate for regularity.
Variable decelerations can occur as a result of cord compression secondary to cord prolapse. There
is also a risk for infection after membrane rupture.
After teaching a class about relieving leg cramps during pregnancy, a nurse evaluates the
effectiveness of the instructions. Which of these comments, if made by the participants, would require
FURTHER instruction?
· When I get a leg cramps in the middle of the night, my husband presses on my knee and pushes my
foot toward my leg
· Sometimes when I'm sitting at my typewriter, I get a horrible leg cramp. First, I stand and bear
weight on my leg in the middle of the night
· I take a heating pad to bed with me so that I can use it if I get a leg cramp in the middle of the night
· When I get a leg cramp while sitting at my desk, I flex my knee and extend my foot - ✔✔✔ - The
fourth comment would require further education. With leg cramps, the leg should be straightened
and toes should be flexed toward the shin.
A client who is scheduled for a cesarean delivery has the following written preoperative orders.
Which should the nurse question?
· Nothing by mouth after midnight
· Atropine sulfate 0.4mg IM on call
· Indwelling urinary catheter to be inserted in the morning
, · Cleansing enema this evening - ✔✔✔ - The order for a cleansing enema in the evening should be
discussed with the physician. A cleansing enema is not usually done prior to a cesarean section.
A client who is G1P0 is receiving IV oxytocin injection for labor augmentation. Because of the effects
of Pitocin, a nurse should assess the client for which of these adverse effects of Pitocin?
· Bradypnea and diarrhea
· Insomnia and tachycardia
· Hypotension and diuresis
· Headache and water intoxication - ✔✔✔ - With doses of 20mU/min on above, oxytocin exerts an
antidiuretic effect decreases free water exchange in the kidney, and markedly decreases urine output.
Blood pressure initially may decrease, but after prolonged administration, the blood pressure
increases above the baseline. Oxytocin does not cause bradycardia, diarrhea, insomnia, or
tachycardia.
With doses of 20mU/min on above, oxytocin exerts an antidiuretic effect decreases free water
exchange in the kidney, and markedly decreases urine output. Blood pressure initially may decrease,
but after prolonged administration, the blood pressure increases above the baseline. Oxytocin does
not cause bradycardia, diarrhea, insomnia, or tachycardia. - ✔✔✔ - Breastfeeding accounts for up to
20-40% of mother-to-child HIV transmissions. Thus, HIV infected women are encouraged to formula
feed their infants.
When a client's cervix is 9cm dilated, the woman says to the nurse "I really want something for pain."
The client has an order for IM narcotic analgesic. Which of these statements is accurate about the
effect a narcotic analgesic may have if it is given at this time?
· The effect on the fetal CNS may cause neonatal respiratory distress
· The effect on smooth muscles may intervene with uterine contractility
· The hypotensive effect may cause fetal hypotension
· The bradycardic effect may increase the chance of placental insufficiency - ✔✔✔ - Narcotic
analgesics cause CNS depression. If narcotic analgesics are given to the client too close to the time of
delivery, the neonate will be delivered with respiratory depression.
A primagradiva who is at 40 weeks gestation is admitted to the labor and delivery unit in active labor.
To facilitate the progress of the client's labor, which nursing action should be included in her nursing
care?
Questions & Answers Latest Version
After a client received an epidural anesthesia, a nurse should make which of these assessments first?
· Determine whether the client has bladder distention
· Determine whether the client has sensory impairment in the legs
· Determine the frequency of the client's contractions
Determine the client’s blood pressure - ✔✔✔ - The nurse should determine the client's blood
pressure first. Since epidural anesthesia may cause the blood pressure to drop, it is important to
ensure there is adequate blood flow to the baby. The other options may be subsequent assessments
the nurse would make, but should not be the first assessment.
The client who is 16 weeks pregnant attends the antepartal clinic. She makes all of these comments
to a nurse. Which of these comments by this client requires FURTHER discussion by the nurse?
· I drink about 2.5 quarts of fluids every day
· I've gained about 7 pounds so far. I'll probably gain another 20 pounds by the time I deliver
· I had a problem with hemorrhoids with my other pregnancy, so now I eat a large serving of bran
every evening
· I'm being careful to eat mostly salt-free and to use no salt in my cooking - ✔✔✔ - The fourth
statement requires further discussion. Sodium requirements increase during pregnancy. However,
the sodium provided by the average diet is likely to be adequate for expectant mothers. Use of
additional salt is rarely warranted.
A nurse teaches pregnancy exercises to a group of pregnant women. The nurse should include an
explanation that pelvic rock will be helpful at any time in their lives should the women develop which
of these conditions?
· Hemorrhoids
· Intestinal flatus
· Lower back pain
,· Leg cramps - ✔✔✔ - Pelvic rock helps to relieve lower back pains. Pelvic rocking helps to relieve a
sore back by stretching the lower back muscles. Pelvic rocking also helps stimulate the digestive
system, realigns the uterus, and keeps the stomach muscles toned.
A client who is in active labor has a vaginal examination which reveals she is 5cm dilated and 100%
effaced at a -1 station. At the peak of a contraction, the amniotic fluid ruptures. Which of these actions
should a nurse take first?
· Records the findings and notify the provider
· Change the linen and make the client comfortable
· Check the perineal area and assess for crowning
· Assess the fetal heart rate and check for regularity - ✔✔✔ - After rupture of the membranes, there
is a danger of cord prolapse; therefore, the nurse should assess the fetal heart rate for regularity.
Variable decelerations can occur as a result of cord compression secondary to cord prolapse. There
is also a risk for infection after membrane rupture.
After teaching a class about relieving leg cramps during pregnancy, a nurse evaluates the
effectiveness of the instructions. Which of these comments, if made by the participants, would require
FURTHER instruction?
· When I get a leg cramps in the middle of the night, my husband presses on my knee and pushes my
foot toward my leg
· Sometimes when I'm sitting at my typewriter, I get a horrible leg cramp. First, I stand and bear
weight on my leg in the middle of the night
· I take a heating pad to bed with me so that I can use it if I get a leg cramp in the middle of the night
· When I get a leg cramp while sitting at my desk, I flex my knee and extend my foot - ✔✔✔ - The
fourth comment would require further education. With leg cramps, the leg should be straightened
and toes should be flexed toward the shin.
A client who is scheduled for a cesarean delivery has the following written preoperative orders.
Which should the nurse question?
· Nothing by mouth after midnight
· Atropine sulfate 0.4mg IM on call
· Indwelling urinary catheter to be inserted in the morning
, · Cleansing enema this evening - ✔✔✔ - The order for a cleansing enema in the evening should be
discussed with the physician. A cleansing enema is not usually done prior to a cesarean section.
A client who is G1P0 is receiving IV oxytocin injection for labor augmentation. Because of the effects
of Pitocin, a nurse should assess the client for which of these adverse effects of Pitocin?
· Bradypnea and diarrhea
· Insomnia and tachycardia
· Hypotension and diuresis
· Headache and water intoxication - ✔✔✔ - With doses of 20mU/min on above, oxytocin exerts an
antidiuretic effect decreases free water exchange in the kidney, and markedly decreases urine output.
Blood pressure initially may decrease, but after prolonged administration, the blood pressure
increases above the baseline. Oxytocin does not cause bradycardia, diarrhea, insomnia, or
tachycardia.
With doses of 20mU/min on above, oxytocin exerts an antidiuretic effect decreases free water
exchange in the kidney, and markedly decreases urine output. Blood pressure initially may decrease,
but after prolonged administration, the blood pressure increases above the baseline. Oxytocin does
not cause bradycardia, diarrhea, insomnia, or tachycardia. - ✔✔✔ - Breastfeeding accounts for up to
20-40% of mother-to-child HIV transmissions. Thus, HIV infected women are encouraged to formula
feed their infants.
When a client's cervix is 9cm dilated, the woman says to the nurse "I really want something for pain."
The client has an order for IM narcotic analgesic. Which of these statements is accurate about the
effect a narcotic analgesic may have if it is given at this time?
· The effect on the fetal CNS may cause neonatal respiratory distress
· The effect on smooth muscles may intervene with uterine contractility
· The hypotensive effect may cause fetal hypotension
· The bradycardic effect may increase the chance of placental insufficiency - ✔✔✔ - Narcotic
analgesics cause CNS depression. If narcotic analgesics are given to the client too close to the time of
delivery, the neonate will be delivered with respiratory depression.
A primagradiva who is at 40 weeks gestation is admitted to the labor and delivery unit in active labor.
To facilitate the progress of the client's labor, which nursing action should be included in her nursing
care?
