Exam 2 Possible Questions
1. The nurse is assessing a 25-year-old primigravida who is 20 weeks pregnant. Which vital signs finding should
the nurse report immediately to the physician?
1. Pulse 88/min
2. Respirations 30/min
3. Blood pressure 134/82
4. Temperature 37.4°C (99.3°F)
A slight increase in pulse is an expected finding during pregnancy due to the increased oxygen consumption to
support fetal metabolism. Tachypnea is not a normal finding and requires medical care. The blood pressure is
within normal limits. A slightly elevated temperature is an expected finding during pregnancy due to the
increased oxygen consumption to support fetal metabolism.
The nurse is teaching a first-time mother on the danger signs to report to the health care provider. What
information should the nurse include in this teaching? (Select all that apply.)
A) Extreme thirst
B) Shaking chills
C) Aching muscles
D) Painful urination
E) Passage of blood clots
A patient has just delivered a baby. Her prelabor vital signs were T - 98.8 B/P-P-R 120/70, 80, 20. Which
combination of findings during the early postpartum period should be reported immediately?
A) Shaking chills with a fever of 100.3ºF
B) B/P-P-R 90/50, 120, 24
C) Bradycardia and excessive, soaking diaphoresis
D) Blood loss of 250 mL and WBC 25,000 cells/mL
A newborn was diagnosed with a congenital heart defect and will undergo surgery at a later time. The nurse is
teaching the parents about signs and symptoms that need to be reported. The nurse determines that the
parents have understood the instructions when they state that they will report which of the following? (Select
all that apply.)
A) Weight loss
B) Pale skin
C) Fever
D) Absence of edema
E) Increased respiratory rate
A patient with gestational hypertension is exhibiting all of the signs below. What should the nurse report
immediately?
a. Diarrhea
b. Urticaria
c. Blurred vision
d. Backache
Visual disturbances indicate worsening pregnancy-induced hypertension and must be reported promptly for
effective intervention to prevent preeclampsia and convulsion.
The nurse is conducting discharge teaching for a client going home after a cesarean birth. Which signs and
symptoms should the client be taught to report? (Select all that apply.)
, a. Mild incisional pain
b. Feeling of pelvic fullness
c. Lochia changing from red to pink in color
d. Frequency, urgency, or burning on urination
e. Redness or edema of the abdominal incision
The signs and symptoms to watch for after a cesarean birth are feelings of pelvic fullness, frequency, urgency
or burning on urination, and redness or edema of the abdominal incision. Mild incisional pain is expected and
the lochia should change from a bright red (rubra) to a pinkish color (serosa).
The nurse assesses a preterm infant in the NICU. What signs should be reported to the physician? (Select all
that apply.)
a. Paleness
b. Transparent skin
c. Superficial scalp veins
d. Vomiting
e. Bulging fontanelles
Paleness, vomiting, and bulging fontanelles can indicate complications in the preterm newborn. Transparent
skin and superficial scalp veins are expected findings.
2. The nurse is supervising care in the emergency department. Which situation requires immediate
intervention?
1. Bright red bleeding with clots at 32 weeks’ gestation; pulse = 110, blood pressure 90/50, respirations
= 20.
2. Dark red bleeding at 30 weeks’ gestation with normal vital signs; client reports the presence of fetal
movement.
3. Spotting of pinkish brown discharge at 6 weeks’ gestation and abdominal cramping; ultrasound
scheduled in 1 hour.
4. Moderate vaginal bleeding at 36 weeks’ gestation; client has an IV of lactated Ringer solution running
at 125 mL/hour.
1. Bleeding in the third trimester is usually associated with placenta previa or placental abruption. Blood loss
can be heavy and rapid. This client has a low blood pressure with an increased pulse rate, which indicates
hypovolemic shock, which can be fatal to the mother and therefore the baby. Both lives are at risk in this
situation. Since there is no information given that the client has an IV started, this client is the least stable, and
therefore the highest priority. 2. Occasional spotting can occur. The presence of normal vital signs and usual
fetal movements reduces this client’s risk of needing immediate intervention. 3. Bleeding in the first trimester
can be indicative of the beginning of spontaneous abortion or of an ectopic pregnancy. An ultrasound will
diagnose which situation is occurring and will determine care. Because this client is very early in the pregnancy
and only experiencing spotting, it is not appropriate to have an IV at this time. 4. Bleeding in the third trimester
is usually associated with placenta previa or placental abruption. Blood loss can be heavy and rapid, so having
an IV stabilizes the client’s vascular volume.
A nurse has admitted a woman pregnant in her third trimester with moderate vaginal bleeding and severe
abdominal pain. After assessing maternal vital signs, obtaining the fetal heart rate, and starting an IV line,
which action should the nurse do next?
A. Administer betamethasone (Celestone) just prior to delivery.
B. Discuss pros and cons of continuous fetal monitoring.
C. Facilitate laboratory work, including blood type and screen.
D. Obtain informed consent for emergent delivery.
1. The nurse is assessing a 25-year-old primigravida who is 20 weeks pregnant. Which vital signs finding should
the nurse report immediately to the physician?
1. Pulse 88/min
2. Respirations 30/min
3. Blood pressure 134/82
4. Temperature 37.4°C (99.3°F)
A slight increase in pulse is an expected finding during pregnancy due to the increased oxygen consumption to
support fetal metabolism. Tachypnea is not a normal finding and requires medical care. The blood pressure is
within normal limits. A slightly elevated temperature is an expected finding during pregnancy due to the
increased oxygen consumption to support fetal metabolism.
The nurse is teaching a first-time mother on the danger signs to report to the health care provider. What
information should the nurse include in this teaching? (Select all that apply.)
A) Extreme thirst
B) Shaking chills
C) Aching muscles
D) Painful urination
E) Passage of blood clots
A patient has just delivered a baby. Her prelabor vital signs were T - 98.8 B/P-P-R 120/70, 80, 20. Which
combination of findings during the early postpartum period should be reported immediately?
A) Shaking chills with a fever of 100.3ºF
B) B/P-P-R 90/50, 120, 24
C) Bradycardia and excessive, soaking diaphoresis
D) Blood loss of 250 mL and WBC 25,000 cells/mL
A newborn was diagnosed with a congenital heart defect and will undergo surgery at a later time. The nurse is
teaching the parents about signs and symptoms that need to be reported. The nurse determines that the
parents have understood the instructions when they state that they will report which of the following? (Select
all that apply.)
A) Weight loss
B) Pale skin
C) Fever
D) Absence of edema
E) Increased respiratory rate
A patient with gestational hypertension is exhibiting all of the signs below. What should the nurse report
immediately?
a. Diarrhea
b. Urticaria
c. Blurred vision
d. Backache
Visual disturbances indicate worsening pregnancy-induced hypertension and must be reported promptly for
effective intervention to prevent preeclampsia and convulsion.
The nurse is conducting discharge teaching for a client going home after a cesarean birth. Which signs and
symptoms should the client be taught to report? (Select all that apply.)
, a. Mild incisional pain
b. Feeling of pelvic fullness
c. Lochia changing from red to pink in color
d. Frequency, urgency, or burning on urination
e. Redness or edema of the abdominal incision
The signs and symptoms to watch for after a cesarean birth are feelings of pelvic fullness, frequency, urgency
or burning on urination, and redness or edema of the abdominal incision. Mild incisional pain is expected and
the lochia should change from a bright red (rubra) to a pinkish color (serosa).
The nurse assesses a preterm infant in the NICU. What signs should be reported to the physician? (Select all
that apply.)
a. Paleness
b. Transparent skin
c. Superficial scalp veins
d. Vomiting
e. Bulging fontanelles
Paleness, vomiting, and bulging fontanelles can indicate complications in the preterm newborn. Transparent
skin and superficial scalp veins are expected findings.
2. The nurse is supervising care in the emergency department. Which situation requires immediate
intervention?
1. Bright red bleeding with clots at 32 weeks’ gestation; pulse = 110, blood pressure 90/50, respirations
= 20.
2. Dark red bleeding at 30 weeks’ gestation with normal vital signs; client reports the presence of fetal
movement.
3. Spotting of pinkish brown discharge at 6 weeks’ gestation and abdominal cramping; ultrasound
scheduled in 1 hour.
4. Moderate vaginal bleeding at 36 weeks’ gestation; client has an IV of lactated Ringer solution running
at 125 mL/hour.
1. Bleeding in the third trimester is usually associated with placenta previa or placental abruption. Blood loss
can be heavy and rapid. This client has a low blood pressure with an increased pulse rate, which indicates
hypovolemic shock, which can be fatal to the mother and therefore the baby. Both lives are at risk in this
situation. Since there is no information given that the client has an IV started, this client is the least stable, and
therefore the highest priority. 2. Occasional spotting can occur. The presence of normal vital signs and usual
fetal movements reduces this client’s risk of needing immediate intervention. 3. Bleeding in the first trimester
can be indicative of the beginning of spontaneous abortion or of an ectopic pregnancy. An ultrasound will
diagnose which situation is occurring and will determine care. Because this client is very early in the pregnancy
and only experiencing spotting, it is not appropriate to have an IV at this time. 4. Bleeding in the third trimester
is usually associated with placenta previa or placental abruption. Blood loss can be heavy and rapid, so having
an IV stabilizes the client’s vascular volume.
A nurse has admitted a woman pregnant in her third trimester with moderate vaginal bleeding and severe
abdominal pain. After assessing maternal vital signs, obtaining the fetal heart rate, and starting an IV line,
which action should the nurse do next?
A. Administer betamethasone (Celestone) just prior to delivery.
B. Discuss pros and cons of continuous fetal monitoring.
C. Facilitate laboratory work, including blood type and screen.
D. Obtain informed consent for emergent delivery.
