NUR 158 Test #3: Comprehensive
Practice Exam Questions and Well
Detailed answers Plus Rationales||
GRADED A+|| LATEST UPDATE 2026
The nurse suspects a thrombus after assessing a client who has pain in her right
calf 2 days after a cesarean birth. Which is the nurse's immediate action?
A) Confine client to bed.
B) Apply warm soaks.
C) Perform leg exercises.
D) Massage the affected area.
A) Confine client to bed.
Rationale:
When a thrombus is suspected but before a definitive diagnosis is made, the client
should be confined to bed so that further complications may be avoided. Applying warm
soaks may cause vasodilation, which could allow a thrombus to dislodge and circulate
freely. If a thrombus is present, massage may dislodge it and lead to a pulmonary
embolism.
Morning sickness generally disappears by the end of which month?
A) Fifth month
B) Third month
C) Fourth month
D) Second month
B) Third month
Rationale:
Because of a decrease in chorionic gonadotropin, morning sickness seldom persists
beyond the first trimester. Morning sickness usually ends at the end of the third month,
not the second month, when the chorionic gonadotropin level falls. It is still present in
the second month because of the high level of chorionic gonadotropin but has usually
diminished by the fifth month.
Which descriptor would the nurse use when explaining to a client how to time the
frequency of contractions?
A) From the end of 1 contraction to the end of the next contraction
B) From the end of 1 contraction to the beginning of the next contraction
,C) From the beginning of 1 contraction to the end of the next contraction
D) From the beginning of 1 contraction to the beginning of the next contraction
D) From the beginning of 1 contraction to the beginning of the next contraction
Rationale:
The frequency of contractions is timed from the beginning of 1 contraction to the
beginning of the next; this is the definition of 1 contraction cycle. The beginning, not the
end, of a contraction is the starting point for timing the frequency of contractions. The
time between the end of 1 contraction and the beginning of the next contraction is the
interval between contractions. Timing from the beginning of 1 contraction to the end of
the next contraction is too long a time frame and will produce inaccurate information.
Which technique would the nurse suggest to a laboring woman's partner that
involves gently stroking the woman's abdomen in rhythm with her breathing
during a contraction?
A) Massage
B) Effleurage
C) Acupressure
D) Counterpressure
B) Effleurage
Rationale:
Effleurage is the gentle stroking of the abdomen in rhythm with her breathing during a
contraction. Massage is the application of therapeutic touch and pressure on the body.
Acupressure is the application of pressure along special acupressure points.
Counterpressure is the application of pressure to the sacrum during a contraction.
At which point during a human pregnancy does the embryo become a fetus?
A) During the 8th week of the pregnancy
B) At the end of the 2nd week of pregnancy
C) When the fertilized egg becomes implanted
D) When the products of conception are seen on the ultrasound
A) During the 8th week of the pregnancy
Rationale:
During the 8th week of pregnancy the organ systems and other structures are
developed to the extent that they take the human form; at this time the embryo becomes
a fetus and remains so until birth. At the end of the 2nd week of pregnancy, the
developing cells are called an embryo. At the time of implantation, the group of
developing cells is called a blastocyst. The embryo can be visualized on ultrasound
before it becomes a fetus.
When a client at 39 weeks' gestation arrives at the birthing suite she says, 'I've
been having contractions for 3 hours, and I think my water broke.' Which action
would the nurse take to confirm that the membranes have ruptured?
A) Take the client's oral temperature.
,B) Test the leaking fluid with nitrazine paper.
C) Obtain a clean-catch urine specimen.
D) Inspect the perineum for leaking fluid.
B) Test the leaking fluid with nitrazine paper.
Rationale
Nitrazine paper will turn dark blue if amniotic fluid is present; it remains the same color
in the presence of urine. Temperature assessment is not specific to ruptured
membranes at this time; vital signs are part of the initial assessment. Although this may
be done as part of the initial assessment, a urine test is unrelated to leakage of amniotic
fluid. Inspecting the perineum for leaking fluid will not confirm rupture of the
membranes.
A client who is at 20 weeks' gestation visits the prenatal clinic for the first time.
Assessment reveals temperature of 98.8°F (37.1°C), pulse of 80 beats per minute,
blood pressure of 128/80 mm Hg, weight of 142 lb (64.4 kg) (prepregnancy weight
was 132 lb [59.9 kg]), fetal heart rate (FHR) of 140 beats per minute, urine that is
negative for protein, and fasting blood glucose level of 92 mg/dL (5.2 mmol/L).
Which would the nurse do after making these assessments?
A) Report the findings because the client needs immediate intervention.
B) Document the results because they are expected at 20 weeks' gestation.
C) Record the findings in the medical record because they are not within the
norm but are not critical.
D) Prepare the client for an emergency admission because these findings may
represent jeopardy to the client and fetus.
B) Document the results because they are expected at 20 weeks' gestation.
Rationale
All data presented are expected for a client at 20 weeks' gestation and should be
documented. There is no need for immediate intervention or an emergency admission
because all findings are expected.
The first day of a client's last menstrual period was July 22. Which is the
estimated date of birth (EDB)?
A) May 7
B) April 29
C) April 22
D) March 6
B) April 29
Her EDB is April 29. Naegele's rule is an indirect, noninvasive method for estimating the
date of birth: EDB = last menstrual period + 9 months + 7 days or LMP - 3 months + 7
days, remember to adjust the year accordingly. May 7 is beyond the EDB. April 22 and
March 6 are both before the EDB.
A prenatal client's vaginal mucosa is noted to have a purplish discoloration.
Which sign would be documented in the client's clinical record?
, A) Hegar
B) Goodell
C) Chadwick
D) Braxton-Hicks
C) Chadwick
Rationale
A purplish coloration, called the Chadwick sign, results from the increased vascularity
and blood vessel engorgement of the vagina. The Hegar sign is softening of the lower
uterine segment. The Goodell sign is softening of the cervix. After the fourth month of
pregnancy, irregular, painless uterine contractions, called Braxton-Hicks contractions,
can be felt through the abdominal wall.
A nonstress test (NST) is scheduled for a client with mild preeclampsia. During an
NST, the client asks what it means when the fetal heart rate goes up every time
the fetus moves. Which is an appropriate response?
A) 'These accelerations are a sign of fetal well-being.'
B) 'These accelerations indicate fetal head compression.'
C) 'Umbilical cord compression is causing these accelerations.'
D) 'Uteroplacental insufficiency is causing these accelerations.'
A) 'These accelerations are a sign of fetal well-being.'
Rationale
The NST is performed before labor begins. Accelerations with movement and a
baseline variability of 5 to 15 beats/min indicate fetal well-being. This reactive NST is
considered positive. Early decelerations are associated with fetal head compression
during a contraction stress test (CST) or during labor. Variable decelerations are
associated with cord compression during a CST or during labor. Late decelerations
during a CST or during labor are associated with uteroplacental insufficiency.
Which statement by a breastfeeding mother indicates that the nurse's teaching
regarding stimulating the let-down reflex has been successful?
A) I will take a cool shower before each feeding.
B) I will drink a couple of quarts of fat-free milk a day.
C) I will wear a snug-fitting breast binder day and night.
D) I will apply warm packs and massage my breasts before each feeding.
D) I will apply warm packs and massage my breasts before each feeding.
Rationale
Applying warm packs and massaging the breasts before each feeding help dilate milk
ducts, promote emptying of the breasts, and stimulate further lactation. Taking a cool
shower before each feeding will contract the milk ducts and interfere with the let-down
reflex. Heavy consumption of milk products is not required to stimulate the production of
milk. Breast binders may inhibit lactation by fooling the body into thinking that milk
secretion is no longer needed.
Practice Exam Questions and Well
Detailed answers Plus Rationales||
GRADED A+|| LATEST UPDATE 2026
The nurse suspects a thrombus after assessing a client who has pain in her right
calf 2 days after a cesarean birth. Which is the nurse's immediate action?
A) Confine client to bed.
B) Apply warm soaks.
C) Perform leg exercises.
D) Massage the affected area.
A) Confine client to bed.
Rationale:
When a thrombus is suspected but before a definitive diagnosis is made, the client
should be confined to bed so that further complications may be avoided. Applying warm
soaks may cause vasodilation, which could allow a thrombus to dislodge and circulate
freely. If a thrombus is present, massage may dislodge it and lead to a pulmonary
embolism.
Morning sickness generally disappears by the end of which month?
A) Fifth month
B) Third month
C) Fourth month
D) Second month
B) Third month
Rationale:
Because of a decrease in chorionic gonadotropin, morning sickness seldom persists
beyond the first trimester. Morning sickness usually ends at the end of the third month,
not the second month, when the chorionic gonadotropin level falls. It is still present in
the second month because of the high level of chorionic gonadotropin but has usually
diminished by the fifth month.
Which descriptor would the nurse use when explaining to a client how to time the
frequency of contractions?
A) From the end of 1 contraction to the end of the next contraction
B) From the end of 1 contraction to the beginning of the next contraction
,C) From the beginning of 1 contraction to the end of the next contraction
D) From the beginning of 1 contraction to the beginning of the next contraction
D) From the beginning of 1 contraction to the beginning of the next contraction
Rationale:
The frequency of contractions is timed from the beginning of 1 contraction to the
beginning of the next; this is the definition of 1 contraction cycle. The beginning, not the
end, of a contraction is the starting point for timing the frequency of contractions. The
time between the end of 1 contraction and the beginning of the next contraction is the
interval between contractions. Timing from the beginning of 1 contraction to the end of
the next contraction is too long a time frame and will produce inaccurate information.
Which technique would the nurse suggest to a laboring woman's partner that
involves gently stroking the woman's abdomen in rhythm with her breathing
during a contraction?
A) Massage
B) Effleurage
C) Acupressure
D) Counterpressure
B) Effleurage
Rationale:
Effleurage is the gentle stroking of the abdomen in rhythm with her breathing during a
contraction. Massage is the application of therapeutic touch and pressure on the body.
Acupressure is the application of pressure along special acupressure points.
Counterpressure is the application of pressure to the sacrum during a contraction.
At which point during a human pregnancy does the embryo become a fetus?
A) During the 8th week of the pregnancy
B) At the end of the 2nd week of pregnancy
C) When the fertilized egg becomes implanted
D) When the products of conception are seen on the ultrasound
A) During the 8th week of the pregnancy
Rationale:
During the 8th week of pregnancy the organ systems and other structures are
developed to the extent that they take the human form; at this time the embryo becomes
a fetus and remains so until birth. At the end of the 2nd week of pregnancy, the
developing cells are called an embryo. At the time of implantation, the group of
developing cells is called a blastocyst. The embryo can be visualized on ultrasound
before it becomes a fetus.
When a client at 39 weeks' gestation arrives at the birthing suite she says, 'I've
been having contractions for 3 hours, and I think my water broke.' Which action
would the nurse take to confirm that the membranes have ruptured?
A) Take the client's oral temperature.
,B) Test the leaking fluid with nitrazine paper.
C) Obtain a clean-catch urine specimen.
D) Inspect the perineum for leaking fluid.
B) Test the leaking fluid with nitrazine paper.
Rationale
Nitrazine paper will turn dark blue if amniotic fluid is present; it remains the same color
in the presence of urine. Temperature assessment is not specific to ruptured
membranes at this time; vital signs are part of the initial assessment. Although this may
be done as part of the initial assessment, a urine test is unrelated to leakage of amniotic
fluid. Inspecting the perineum for leaking fluid will not confirm rupture of the
membranes.
A client who is at 20 weeks' gestation visits the prenatal clinic for the first time.
Assessment reveals temperature of 98.8°F (37.1°C), pulse of 80 beats per minute,
blood pressure of 128/80 mm Hg, weight of 142 lb (64.4 kg) (prepregnancy weight
was 132 lb [59.9 kg]), fetal heart rate (FHR) of 140 beats per minute, urine that is
negative for protein, and fasting blood glucose level of 92 mg/dL (5.2 mmol/L).
Which would the nurse do after making these assessments?
A) Report the findings because the client needs immediate intervention.
B) Document the results because they are expected at 20 weeks' gestation.
C) Record the findings in the medical record because they are not within the
norm but are not critical.
D) Prepare the client for an emergency admission because these findings may
represent jeopardy to the client and fetus.
B) Document the results because they are expected at 20 weeks' gestation.
Rationale
All data presented are expected for a client at 20 weeks' gestation and should be
documented. There is no need for immediate intervention or an emergency admission
because all findings are expected.
The first day of a client's last menstrual period was July 22. Which is the
estimated date of birth (EDB)?
A) May 7
B) April 29
C) April 22
D) March 6
B) April 29
Her EDB is April 29. Naegele's rule is an indirect, noninvasive method for estimating the
date of birth: EDB = last menstrual period + 9 months + 7 days or LMP - 3 months + 7
days, remember to adjust the year accordingly. May 7 is beyond the EDB. April 22 and
March 6 are both before the EDB.
A prenatal client's vaginal mucosa is noted to have a purplish discoloration.
Which sign would be documented in the client's clinical record?
, A) Hegar
B) Goodell
C) Chadwick
D) Braxton-Hicks
C) Chadwick
Rationale
A purplish coloration, called the Chadwick sign, results from the increased vascularity
and blood vessel engorgement of the vagina. The Hegar sign is softening of the lower
uterine segment. The Goodell sign is softening of the cervix. After the fourth month of
pregnancy, irregular, painless uterine contractions, called Braxton-Hicks contractions,
can be felt through the abdominal wall.
A nonstress test (NST) is scheduled for a client with mild preeclampsia. During an
NST, the client asks what it means when the fetal heart rate goes up every time
the fetus moves. Which is an appropriate response?
A) 'These accelerations are a sign of fetal well-being.'
B) 'These accelerations indicate fetal head compression.'
C) 'Umbilical cord compression is causing these accelerations.'
D) 'Uteroplacental insufficiency is causing these accelerations.'
A) 'These accelerations are a sign of fetal well-being.'
Rationale
The NST is performed before labor begins. Accelerations with movement and a
baseline variability of 5 to 15 beats/min indicate fetal well-being. This reactive NST is
considered positive. Early decelerations are associated with fetal head compression
during a contraction stress test (CST) or during labor. Variable decelerations are
associated with cord compression during a CST or during labor. Late decelerations
during a CST or during labor are associated with uteroplacental insufficiency.
Which statement by a breastfeeding mother indicates that the nurse's teaching
regarding stimulating the let-down reflex has been successful?
A) I will take a cool shower before each feeding.
B) I will drink a couple of quarts of fat-free milk a day.
C) I will wear a snug-fitting breast binder day and night.
D) I will apply warm packs and massage my breasts before each feeding.
D) I will apply warm packs and massage my breasts before each feeding.
Rationale
Applying warm packs and massaging the breasts before each feeding help dilate milk
ducts, promote emptying of the breasts, and stimulate further lactation. Taking a cool
shower before each feeding will contract the milk ducts and interfere with the let-down
reflex. Heavy consumption of milk products is not required to stimulate the production of
milk. Breast binders may inhibit lactation by fooling the body into thinking that milk
secretion is no longer needed.
