NUR 221 - Final (k) Exam Questions with Correct Answers Verified by Experts| Latest Update
The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse
observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse
documents these observations as signs of which condition?
A. Hematoma
B. Uterine atony
C. Placenta previa
D. Placental separation Correct Answer: D
As the placenta separates, it settles downward into the lower uterine segment. The umbilical
cord lengthens, and a sudden trickle or spurt of blood appears. Options 1, 2, and 3 are incorrect
interpretations.
A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a
child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the
client?
A. "You should avoid all school-age children during pregnancy."
B. "There is no need to be concerned if you don't have a fever or rash within the next 2 days."
C. "You were wise to call. Your rubella titer indicates that you are immune and your baby is not
at risk."
D. "Be sure to tell the health care provider in 2 weeks as additional screening will be prescribed
during your second trimester." Correct Answer: C
Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and
has an incubation period of 14 to 21 days. The risks of maternal and subsequent fetal infection
during the second trimester include hearing loss and congenital anomalies; these risks decrease
after the first 12 weeks of pregnancy. Rubella titer determination is a standard antenatal test
for pregnant women during their initial screening and entry into the health care delivery
system. As noted in this client's chart, she is immune to rubella. The correct option is the only
option that helps clarify maternal concerns with accurate information.
,The nurse is developing a plan of care for a preterm newborn infant. The nurse develops
measures to provide skin care, knowing that the preterm newborn infant's skin appears in what
way?
A. Thin and gelatinous, with increased subcutaneous fat
B. Thin and gelatinous, with increased amounts of brown fat
C. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat
D. With fine downy hair on thin epidermal and dermal layers, with increased amount of brown
fat Correct Answer: C
The skin of a newborn infant plays a significant role in thermoregulation and as a barrier against
infection. The skin of a preterm newborn infant is immature in comparison with that of a term
newborn infant. The skin of a preterm newborn is thin and gelatinous, with decreased amounts
of subcutaneous fat, brown fat, and glycogen stores. In addition, preterm newborn infants lose
heat because of their large body surface area in relation to their weight and because their
posture is more relaxed, with less flexion. Therefore preterm newborn infants are less able to
generate heat, which places them at risk for increased heat loss and increased fluid
requirements.
The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The
nurse measures the fundal height in centimeters and expects which finding?
A. 22 cm
B. 30 cm
C. 36 cm
D.40 cm Correct Answer: B
During the second and third trimesters (weeks 18 to 30), fundal height in centimeters
approximately equals the fetus' age in weeks ± 2 cm. At 16 weeks, the fundus can be located
halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the
umbilicus. At 36 weeks, the fundus is at the xiphoid process.
,The nurse is collecting data from a client during the first prenatal visit. The client is anxious to
know the gender of the fetus and asks the nurse when she will be able to know. The nurse
should respond to the client knowing that the gender of the fetus is determined by which
weeks?
A. 6 to 8
B. 8 to 10
C. 13 to 16
D. 20 to 22 Correct Answer: C
By the end of the twelfth week of gestation, the fetal gender can be determined by the
appearance of the external genitalia on ultrasound; therefore the other options are incorrect.
The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first
prenatal visit. The nurse notes that the health care provider has documented that the woman
has a platypelloid pelvis. On the basis of this documentation, the nurse plans care, knowing that
this type of pelvis has which characteristic?
A. Is heart-shaped
B. Has a flat
C. Is oval-shaped
D. Is normal Correct Answer: B
A platypelloid pelvis has a flat shape. An anthropoid pelvis has an oval shape, and an android
pelvis is heart-shaped. A gynecoid pelvis is a normal female pelvis.
The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for
premature rupture of the membranes. Gestational age of the fetus is determined to be 37
weeks. Which prescription should the nurse question?
, A. Monitor fetal heart rate continuously.
B. Monitor maternal vital signs frequently.
C. Perform a vaginal examination every shift.
D. Administer ampicillin 1 g as an intravenous piggyback every 6 hours. Correct Answer: C
Vaginal examinations should not be done routinely on a client with premature rupture of the
membranes because of the risk of infection. The nurse would expect to monitor fetal heart
rate, monitor maternal vital signs, and administer an antibiotic.
A client who delivered an infant an hour ago tells the nurse the she feels wet underneath her
buttock. The nurse notes that the perineal pad is saturated and the client is lying in a 6-inch
diameter pool of blood. Which action should the nurse implement first?
A. Cleanse the perineum
B. Obtain a blood pressure
C. Palpate the firmness of the fundus
D. Inspect the perineum for lacerations Correct Answer: C
A firm uterus is needed to control bleeding from the placental site of attachment on the uterine
wall. The nurse should FIRST assess for firmness and massage the fundus as indicated.
A woman who thinks she could be pregnant calls her neighbor, who is a nurse, to ask when she
should use a home pregnancy test. Which response is appropriate?
A. "A home pregnancy test can be used right after your first missed period."
B. "These tests are most accurate after you missed your second period."
C "Home pregnancy tests often give false positives and should not be trusted."
The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse
observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse
documents these observations as signs of which condition?
A. Hematoma
B. Uterine atony
C. Placenta previa
D. Placental separation Correct Answer: D
As the placenta separates, it settles downward into the lower uterine segment. The umbilical
cord lengthens, and a sudden trickle or spurt of blood appears. Options 1, 2, and 3 are incorrect
interpretations.
A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a
child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the
client?
A. "You should avoid all school-age children during pregnancy."
B. "There is no need to be concerned if you don't have a fever or rash within the next 2 days."
C. "You were wise to call. Your rubella titer indicates that you are immune and your baby is not
at risk."
D. "Be sure to tell the health care provider in 2 weeks as additional screening will be prescribed
during your second trimester." Correct Answer: C
Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and
has an incubation period of 14 to 21 days. The risks of maternal and subsequent fetal infection
during the second trimester include hearing loss and congenital anomalies; these risks decrease
after the first 12 weeks of pregnancy. Rubella titer determination is a standard antenatal test
for pregnant women during their initial screening and entry into the health care delivery
system. As noted in this client's chart, she is immune to rubella. The correct option is the only
option that helps clarify maternal concerns with accurate information.
,The nurse is developing a plan of care for a preterm newborn infant. The nurse develops
measures to provide skin care, knowing that the preterm newborn infant's skin appears in what
way?
A. Thin and gelatinous, with increased subcutaneous fat
B. Thin and gelatinous, with increased amounts of brown fat
C. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat
D. With fine downy hair on thin epidermal and dermal layers, with increased amount of brown
fat Correct Answer: C
The skin of a newborn infant plays a significant role in thermoregulation and as a barrier against
infection. The skin of a preterm newborn infant is immature in comparison with that of a term
newborn infant. The skin of a preterm newborn is thin and gelatinous, with decreased amounts
of subcutaneous fat, brown fat, and glycogen stores. In addition, preterm newborn infants lose
heat because of their large body surface area in relation to their weight and because their
posture is more relaxed, with less flexion. Therefore preterm newborn infants are less able to
generate heat, which places them at risk for increased heat loss and increased fluid
requirements.
The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The
nurse measures the fundal height in centimeters and expects which finding?
A. 22 cm
B. 30 cm
C. 36 cm
D.40 cm Correct Answer: B
During the second and third trimesters (weeks 18 to 30), fundal height in centimeters
approximately equals the fetus' age in weeks ± 2 cm. At 16 weeks, the fundus can be located
halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the
umbilicus. At 36 weeks, the fundus is at the xiphoid process.
,The nurse is collecting data from a client during the first prenatal visit. The client is anxious to
know the gender of the fetus and asks the nurse when she will be able to know. The nurse
should respond to the client knowing that the gender of the fetus is determined by which
weeks?
A. 6 to 8
B. 8 to 10
C. 13 to 16
D. 20 to 22 Correct Answer: C
By the end of the twelfth week of gestation, the fetal gender can be determined by the
appearance of the external genitalia on ultrasound; therefore the other options are incorrect.
The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first
prenatal visit. The nurse notes that the health care provider has documented that the woman
has a platypelloid pelvis. On the basis of this documentation, the nurse plans care, knowing that
this type of pelvis has which characteristic?
A. Is heart-shaped
B. Has a flat
C. Is oval-shaped
D. Is normal Correct Answer: B
A platypelloid pelvis has a flat shape. An anthropoid pelvis has an oval shape, and an android
pelvis is heart-shaped. A gynecoid pelvis is a normal female pelvis.
The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for
premature rupture of the membranes. Gestational age of the fetus is determined to be 37
weeks. Which prescription should the nurse question?
, A. Monitor fetal heart rate continuously.
B. Monitor maternal vital signs frequently.
C. Perform a vaginal examination every shift.
D. Administer ampicillin 1 g as an intravenous piggyback every 6 hours. Correct Answer: C
Vaginal examinations should not be done routinely on a client with premature rupture of the
membranes because of the risk of infection. The nurse would expect to monitor fetal heart
rate, monitor maternal vital signs, and administer an antibiotic.
A client who delivered an infant an hour ago tells the nurse the she feels wet underneath her
buttock. The nurse notes that the perineal pad is saturated and the client is lying in a 6-inch
diameter pool of blood. Which action should the nurse implement first?
A. Cleanse the perineum
B. Obtain a blood pressure
C. Palpate the firmness of the fundus
D. Inspect the perineum for lacerations Correct Answer: C
A firm uterus is needed to control bleeding from the placental site of attachment on the uterine
wall. The nurse should FIRST assess for firmness and massage the fundus as indicated.
A woman who thinks she could be pregnant calls her neighbor, who is a nurse, to ask when she
should use a home pregnancy test. Which response is appropriate?
A. "A home pregnancy test can be used right after your first missed period."
B. "These tests are most accurate after you missed your second period."
C "Home pregnancy tests often give false positives and should not be trusted."
