NUR 4455 MOD 2 NCLEX QUIZ
1. The client is undergoing an amniocentesis at 16 weeks gestation
to detect the presence of biochemical or chromosomal
abnormalities. Which instructions should the nurse reinforce to
the client?
a. The bladder must be full during the exam
b. The bladder must be empty during the exam
c. She will be given RhoGAM because she is Rh positive
d. Do not eat or drink anything 4-6 hrs before exam
Answer: A
Rationale: before 20 weeks, the bladder must be kept full during the
exam to support the weigh of the uterus. After 20 weeks the bladder
should be emptied to minimize the chance of puncturing the placenta
or fetus. Rh immune globulin (RhoGAM) is admin to Rh neg women
because of the risk of contact with the fetal blood during the exam.
There are no fluid or food restrictions. Monitoring the fetal heart tone
and vs throughout and after the exam is an important intervention.
2. The client at 28 weeks gestation is Rh negative and Coombs
antibody negative. The nurse determines that the client
understands what the nurse has taught her about Rh sensitization
when the client makes which statement? (227)
a. I know I can never have another child
b. I am glad I won’t have to have these shots if I have
another child
c. I will have to have an injection once a month until the
baby is born
d. I will tell the nurse at the hospital that I had RhoGAM
during pregnancy
,Answer: D
Rationale: it is accepted practice to admin Rh immune globulin
(RhoGAM) to an Rh negative woman at 28 weeks with a second
injection within 72hrs of delivery. This prevents sensitization which
could jeopardize a future pregnancy. For subsequent pregnancies or
abortions, the injections must be repeated, because the immunity is
passive. Options a, b and c are inaccurate info
3. While assisting with the measurement of fundal height the client
at 36 weeks’ gestation states that she is feeling lightheaded.
Based on the nurse’s knowledge of pregnancy, the nurse
determines that this is most likely a result of which?
a. A full bladder
b. Emotional instability
c. Insufficient iron intake
d. Compression of the vena cava
Answer: D
Rationale: compression of the inferior vena cava and aorta by the
uterus may cause supine hypotension syndrome during pregnancy.
Having the woman turn onto her left side or elevate the r.butt during
fundal height measurement will prevent or correct the problem.
Options 1, 2 and 3 are not the cause of the problem.
4. A contraction stress test is schedule for the client. The women ask
the nurse about the test. Which response described the most
accurate description of the test?
a. Uterine contractions are stimulated by Leopolds maneuvers
b. An internal fetal monitor is attached, and you will walk on a
treadmill until contractions begin
, c. The uterus is stimulated to contract by either small amounts
of oxytocin or by nipple stimulation
d. Small amounts of oxytocin are administered during internal
fetal monitoring to stimulate uterine contractions
Answer: C
Rationale: A contraction stress test assesses placental oxygenation and
function and determines the fetus’ ability to tolerate labor, as well as
its well-being. The test is performed if the non stress test result is abx.
During the stress test, the fetus is exposed to the stressor of
contractions to assess the adequacy of placental perfusion under
simulated labor conditions. A 20-30 min baseline strip is monitored off
a external fetal monitor. The uterus is stimulated to contract with by
the admin of diluted dose of oxytocin or by having the mother use
nipple stim until three palpable contractions during of 40 sec duration.
Frequent maternal bp readings are performed; and the client is
monitored closely while increasing doses of oxytocin are given.
Leopolds maneuvers are performed to locate the position of the fetus.
5. The client at 38 weeks gestation is admitted to the birthing center
in early labor. The client is carrying twins and one of the fetuses is
in a breech presentation. The nurse assists with planning care for
the client and identifies which as least likely necessary for the care
of this client?
a. Measuring the fundal height
b. Attaching electronic fetal monitoring
c. Preparing the client for possible cesarean section
d. Gathering equipment for starting an intravenous line
Answer: A
, Rationale: option A is a low priority because the fundal height should be
measure at each antepartal clinic visit; it is not the priority care during
the intrapartum period. Options 2, 3 and 4 are all HIGH priorities. The
twins should be monitored by dual electronic fetal monitoring, and any
signs of distress should be reported. Many health care providers choose
to perform a cesarean birth if either twin is breech. The mother should
have an IV line in place in case fluid or blood replacement is required.
6. The perinatal client is admitted to the OB unit during exacerbation
of a heart condition. When planning for the nutritional
requirements of the client, the nurse should consult with the
dietitian to ensure which dietary measure?
a. A low-cal diet to ensure the absence of weight gain
b. A diet that is high in fluids and fiber to decrease constipation
c. A diet that is low I fluids and fiber to decrease blood volume
d. Unlimited sodium intake to increase the circulating blood
volume
Answer: B
Rationale: Constipation causes the client to use Valsalva’s maneuver.
This causes blood to rush to the heart and overload the cardiac system.
The absence of weight gain is not recommended during pregnancy.
Diets that are low in fluid and fiber cause a decrease in blood volume,
which in turn deprives the fetus of nutrients. Too much sodium could
cause an overload to the circulating blood volume and contribute to
cardiac condition.
7. The nurse caring for a client with abruptio placentae is monitoring
the client for signs of disseminated intravascular coagulopathy
(DIC). The nurse would suspect DIC if which is observed?
a. Rapid clotting times
b. Pain and swelling in calf
1. The client is undergoing an amniocentesis at 16 weeks gestation
to detect the presence of biochemical or chromosomal
abnormalities. Which instructions should the nurse reinforce to
the client?
a. The bladder must be full during the exam
b. The bladder must be empty during the exam
c. She will be given RhoGAM because she is Rh positive
d. Do not eat or drink anything 4-6 hrs before exam
Answer: A
Rationale: before 20 weeks, the bladder must be kept full during the
exam to support the weigh of the uterus. After 20 weeks the bladder
should be emptied to minimize the chance of puncturing the placenta
or fetus. Rh immune globulin (RhoGAM) is admin to Rh neg women
because of the risk of contact with the fetal blood during the exam.
There are no fluid or food restrictions. Monitoring the fetal heart tone
and vs throughout and after the exam is an important intervention.
2. The client at 28 weeks gestation is Rh negative and Coombs
antibody negative. The nurse determines that the client
understands what the nurse has taught her about Rh sensitization
when the client makes which statement? (227)
a. I know I can never have another child
b. I am glad I won’t have to have these shots if I have
another child
c. I will have to have an injection once a month until the
baby is born
d. I will tell the nurse at the hospital that I had RhoGAM
during pregnancy
,Answer: D
Rationale: it is accepted practice to admin Rh immune globulin
(RhoGAM) to an Rh negative woman at 28 weeks with a second
injection within 72hrs of delivery. This prevents sensitization which
could jeopardize a future pregnancy. For subsequent pregnancies or
abortions, the injections must be repeated, because the immunity is
passive. Options a, b and c are inaccurate info
3. While assisting with the measurement of fundal height the client
at 36 weeks’ gestation states that she is feeling lightheaded.
Based on the nurse’s knowledge of pregnancy, the nurse
determines that this is most likely a result of which?
a. A full bladder
b. Emotional instability
c. Insufficient iron intake
d. Compression of the vena cava
Answer: D
Rationale: compression of the inferior vena cava and aorta by the
uterus may cause supine hypotension syndrome during pregnancy.
Having the woman turn onto her left side or elevate the r.butt during
fundal height measurement will prevent or correct the problem.
Options 1, 2 and 3 are not the cause of the problem.
4. A contraction stress test is schedule for the client. The women ask
the nurse about the test. Which response described the most
accurate description of the test?
a. Uterine contractions are stimulated by Leopolds maneuvers
b. An internal fetal monitor is attached, and you will walk on a
treadmill until contractions begin
, c. The uterus is stimulated to contract by either small amounts
of oxytocin or by nipple stimulation
d. Small amounts of oxytocin are administered during internal
fetal monitoring to stimulate uterine contractions
Answer: C
Rationale: A contraction stress test assesses placental oxygenation and
function and determines the fetus’ ability to tolerate labor, as well as
its well-being. The test is performed if the non stress test result is abx.
During the stress test, the fetus is exposed to the stressor of
contractions to assess the adequacy of placental perfusion under
simulated labor conditions. A 20-30 min baseline strip is monitored off
a external fetal monitor. The uterus is stimulated to contract with by
the admin of diluted dose of oxytocin or by having the mother use
nipple stim until three palpable contractions during of 40 sec duration.
Frequent maternal bp readings are performed; and the client is
monitored closely while increasing doses of oxytocin are given.
Leopolds maneuvers are performed to locate the position of the fetus.
5. The client at 38 weeks gestation is admitted to the birthing center
in early labor. The client is carrying twins and one of the fetuses is
in a breech presentation. The nurse assists with planning care for
the client and identifies which as least likely necessary for the care
of this client?
a. Measuring the fundal height
b. Attaching electronic fetal monitoring
c. Preparing the client for possible cesarean section
d. Gathering equipment for starting an intravenous line
Answer: A
, Rationale: option A is a low priority because the fundal height should be
measure at each antepartal clinic visit; it is not the priority care during
the intrapartum period. Options 2, 3 and 4 are all HIGH priorities. The
twins should be monitored by dual electronic fetal monitoring, and any
signs of distress should be reported. Many health care providers choose
to perform a cesarean birth if either twin is breech. The mother should
have an IV line in place in case fluid or blood replacement is required.
6. The perinatal client is admitted to the OB unit during exacerbation
of a heart condition. When planning for the nutritional
requirements of the client, the nurse should consult with the
dietitian to ensure which dietary measure?
a. A low-cal diet to ensure the absence of weight gain
b. A diet that is high in fluids and fiber to decrease constipation
c. A diet that is low I fluids and fiber to decrease blood volume
d. Unlimited sodium intake to increase the circulating blood
volume
Answer: B
Rationale: Constipation causes the client to use Valsalva’s maneuver.
This causes blood to rush to the heart and overload the cardiac system.
The absence of weight gain is not recommended during pregnancy.
Diets that are low in fluid and fiber cause a decrease in blood volume,
which in turn deprives the fetus of nutrients. Too much sodium could
cause an overload to the circulating blood volume and contribute to
cardiac condition.
7. The nurse caring for a client with abruptio placentae is monitoring
the client for signs of disseminated intravascular coagulopathy
(DIC). The nurse would suspect DIC if which is observed?
a. Rapid clotting times
b. Pain and swelling in calf
