Saunders Comprehensive Review for the NCLEX-
PN® Examination
9th Edition
TEST BANK
1 — Antepartum: PROM at 34 Weeks
A 29-year-old G2P1 at 34 weeks gestation reports a
sudden gush of fluid. She is afebrile and fetal heart
rate is 140/min. What is the nurse’s best initial
action?
A. Obtain a sterile speculum exam and perform a
nitrazine test.
B. Perform a bedside nitrazine or ferning test and
assess fetal heart rate continuously. (Correct)
C. Encourage oral fluids and schedule outpatient
follow-up in 24 hours.
D. Begin oxytocin to augment labor.
Correct: B
Rationale (correct — B): Suspected rupture of
membranes requires rapid confirmation
,(nitrazine/ferning) and fetal monitoring to detect
immediate distress or labor onset. These bedside
actions are timely and minimally invasive, guiding
further management (antibiotics, steroids,
hospitalization).
Rationale (incorrect):
A — A sterile speculum exam may be performed but
increases infection risk and is not the fastest initial
step.
C — Outpatient observation is unsafe when
membranes have likely ruptured, due to infection
risk and potential preterm labor.
D — Starting oxytocin is inappropriate without
confirming labor status and assessing fetal/maternal
condition.
2 — Fetal Monitoring: Late Decelerations
During active labor with oxytocin infusion, the fetal
monitor shows recurrent late decelerations. Uterine
contractions are every 2–3 minutes, lasting 60–80
seconds. What is the nurse’s priority intervention?
,A. Increase oxytocin to shorten labor.
B. Reposition the client to left lateral, stop oxytocin,
administer oxygen, and give an IV bolus. (Correct)
C. Document and continue current regimen.
D. Encourage the mother to push with the next
contraction.
Correct: B
Rationale (correct — B): Late decelerations indicate
uteroplacental insufficiency and fetal hypoxia.
Priority interventions aim to improve uteroplacental
blood flow: stop uterotonics, reposition, give
oxygen, and restore maternal intravascular volume
(IV bolus).
Rationale (incorrect):
A — Increasing oxytocin worsens uterine
hyperstimulation and reduces fetal oxygenation.
C — Documentation only fails to address fetal
compromise.
D — Pushing is for second stage; doing so with fetal
compromise is inappropriate.
, 3 — Intrapartum: Variable Decels & Cord Prolapse
Risk (Select all that apply)
A client at 39 weeks with spontaneous rupture of
membranes starts having abrupt variable
decelerations on the monitor. Which actions should
the nurse take? (Select all that apply.)
A. Perform a sterile vaginal exam to check for cord
prolapse. (Correct)
B. Reposition client (Trendelenburg or knee-chest)
and call for immediate assistance. (Correct)
C. Increase oxytocin infusion to speed delivery.
D. Apply firm fundal pressure to accelerate descent.
Correct: A, B
Rationale (A — correct): Variable decelerations
suggest cord compression; an immediate sterile
vaginal exam can identify a prolapsed cord that
requires urgent action.
Rationale (B — correct): Positioning (knee-
chest/Trendelenburg) can relieve cord compression
and is an emergency measure while calling for help.
Rationale (C — incorrect): Increasing oxytocin may
PN® Examination
9th Edition
TEST BANK
1 — Antepartum: PROM at 34 Weeks
A 29-year-old G2P1 at 34 weeks gestation reports a
sudden gush of fluid. She is afebrile and fetal heart
rate is 140/min. What is the nurse’s best initial
action?
A. Obtain a sterile speculum exam and perform a
nitrazine test.
B. Perform a bedside nitrazine or ferning test and
assess fetal heart rate continuously. (Correct)
C. Encourage oral fluids and schedule outpatient
follow-up in 24 hours.
D. Begin oxytocin to augment labor.
Correct: B
Rationale (correct — B): Suspected rupture of
membranes requires rapid confirmation
,(nitrazine/ferning) and fetal monitoring to detect
immediate distress or labor onset. These bedside
actions are timely and minimally invasive, guiding
further management (antibiotics, steroids,
hospitalization).
Rationale (incorrect):
A — A sterile speculum exam may be performed but
increases infection risk and is not the fastest initial
step.
C — Outpatient observation is unsafe when
membranes have likely ruptured, due to infection
risk and potential preterm labor.
D — Starting oxytocin is inappropriate without
confirming labor status and assessing fetal/maternal
condition.
2 — Fetal Monitoring: Late Decelerations
During active labor with oxytocin infusion, the fetal
monitor shows recurrent late decelerations. Uterine
contractions are every 2–3 minutes, lasting 60–80
seconds. What is the nurse’s priority intervention?
,A. Increase oxytocin to shorten labor.
B. Reposition the client to left lateral, stop oxytocin,
administer oxygen, and give an IV bolus. (Correct)
C. Document and continue current regimen.
D. Encourage the mother to push with the next
contraction.
Correct: B
Rationale (correct — B): Late decelerations indicate
uteroplacental insufficiency and fetal hypoxia.
Priority interventions aim to improve uteroplacental
blood flow: stop uterotonics, reposition, give
oxygen, and restore maternal intravascular volume
(IV bolus).
Rationale (incorrect):
A — Increasing oxytocin worsens uterine
hyperstimulation and reduces fetal oxygenation.
C — Documentation only fails to address fetal
compromise.
D — Pushing is for second stage; doing so with fetal
compromise is inappropriate.
, 3 — Intrapartum: Variable Decels & Cord Prolapse
Risk (Select all that apply)
A client at 39 weeks with spontaneous rupture of
membranes starts having abrupt variable
decelerations on the monitor. Which actions should
the nurse take? (Select all that apply.)
A. Perform a sterile vaginal exam to check for cord
prolapse. (Correct)
B. Reposition client (Trendelenburg or knee-chest)
and call for immediate assistance. (Correct)
C. Increase oxytocin infusion to speed delivery.
D. Apply firm fundal pressure to accelerate descent.
Correct: A, B
Rationale (A — correct): Variable decelerations
suggest cord compression; an immediate sterile
vaginal exam can identify a prolapsed cord that
requires urgent action.
Rationale (B — correct): Positioning (knee-
chest/Trendelenburg) can relieve cord compression
and is an emergency measure while calling for help.
Rationale (C — incorrect): Increasing oxytocin may
