CRITICAL CARE EXAM QUESTIONS AND ANSWERS
A female client tells the nurse that her home pregnancy test is positive and her last menstrual
period (LMP) was February 14. The client wants to know the expected date of birth (EDB).
How should the nurse respond?
• September 17.
• December 17.
• November 21.
• October 21.
Using Nägele’s rule to calculate EDB, subtract 3 months and add 7 days to the first day of the
last normal menstrual period. The client's LMP is February 14, so less 3 months + 7 days is
November 21 (B) of the next year. (A, C, and D) are inaccurate.
Two hours after the vaginal delivery of a 7-pound, 3-ounce infant, a client's fundus is 3 cm
above the umbilicus, boggy, and located to the right of midline. Which action should the nurse
take first?
• Massage the uterine fundus.
• Palpate above the symphysis for the bladder.
• Inspect the perineum for excessive bleeding.
• Perform bi-manual massage.
Two hours after giving birth, the uterus should be firm, in the midline, and below the
umbilicus.
If the fundus is high, dextroverted and boggy, urinary retention is likely distending the
bladder,
so palpating for a full bladder above the symphysis (B) should be implemented first. (A, C,
and
,• are implemented after the client voids or the bladder is emptied by catheterization.
The clinic nurse identifies an elevation in the results of the triple marker screening test for a
client who is in the first trimester of pregnancy. Which action should the nurse prepare the
client for?
• Securing permission for pregnancy termination.
• Repeating the triple marker test.
• Counseling about possible fetal defects.
• Preparing for other diagnostic testing.
The triple marker screen measures maternal serum levels for alpha-fetoprotein (AFP), human
chorionic gonadotropin (HCG), and estriol, which screens for indications of possible fetal
defects. An elevated result may be a false indicator, so other tests are indicated (B). (A) is not
necessary or helpful. Elevated results warrant further testing with ultrasound or amniocentesis
before initiating (C or D).
Prenatal diagnostic testing is recommended for a couple expecting their first child who have a
family history of congenital disorders. The couple tells the nurse that they are opposed to
abortion for religious reasons. Which concept should the nurse consider when responding to
this couple?
• There is limited value in diagnostic testing if termination of pregnancy is not
an option.
• Many states legally require prenatal testing as a means of protecting the fetus.
• Diagnostic testing may indicate a fetal problem that could be treated prior to
delivery.
• Counseling about advantages and disadvantages of termination should be
helpful.
,Although the couple is opposed to abortion, prenatal testing may reveal a fetal disorder
that is
treatable in utero or immediately after birth with favorable results (C). (A) is not an due
to the
couple's stated opposition. Prenatal testing has value beyond termination (B) because it
provides
knowledge and time for the couple to prepare for various possibilities. Prenatal testing is
voluntary (D).
Which finding should the nurse identify as an early clinical manifestation of
neonatal encephalopathy related to hyperbilirubinemia?
• Increased or unstable temperature.
• Mental retardation.
• Lethargy or irritability
• Rigid extension of all extremities.
Hyperbilirubinemia causes severe brain damage, encephalopathy (kernicterus), that
results from
the deposition of unconjugated bilirubin in brain cells. Prodromal clinical manifestations
of
central nervous system involvement includes decreased activity, a loss of interest in
feeding, and
lethargy or irritability (C). Without treatment, progressive signs of neurologic damage
include
(A, B, and D).
Which approach should the nurse use when preparing a toddler for a procedure?
• Plan a teaching session to last about 20 minutes.
• Show equipment but prevent child from handling it.
• Avoid asking the child to make choices.
, • Demonstrate the procedure using a doll
Imitation is one of the most distinguishing characteristics of toddler play, so
demonstration of a
procedure on a doll (A) enables a non-threatening, dramatic experience that can help
prepare the
toddler for the actual procedure. The primary developmental task in toddlerhood is
acquiring a
sense of autonomy, so giving choices whenever possible to a toddler is recommended, not
(B).
Since the toddler's attention span is short, teaching sessions should be brief (C) and can be
repeated for reinforcement. Showing the equipment before its use helps relieve anxiety, but the
child should be allowed to handle some of the equipment (D) to prevent frustration and alleviate
fear.
Which action should the nurse implement when administering a prescription drug that should
be given on an empty stomach?
• Administer after an eight-hour fast.
• Provide the dose after the client has missed a meal.
• Give one hour before or two hours after a meal.
• Take with liquids, but no solid foods.
When administering a drug on an empty stomach, the drug should be given either one
hour
before a meal or two hours after a meal (B), which is the average transit time from the
stomach
to the duodenum after eating. An eight-hour fast is more time than is needed for the
stomach to
empty (C) and is not necessary. The last time any food or drink has been ingested is a
better
A female client tells the nurse that her home pregnancy test is positive and her last menstrual
period (LMP) was February 14. The client wants to know the expected date of birth (EDB).
How should the nurse respond?
• September 17.
• December 17.
• November 21.
• October 21.
Using Nägele’s rule to calculate EDB, subtract 3 months and add 7 days to the first day of the
last normal menstrual period. The client's LMP is February 14, so less 3 months + 7 days is
November 21 (B) of the next year. (A, C, and D) are inaccurate.
Two hours after the vaginal delivery of a 7-pound, 3-ounce infant, a client's fundus is 3 cm
above the umbilicus, boggy, and located to the right of midline. Which action should the nurse
take first?
• Massage the uterine fundus.
• Palpate above the symphysis for the bladder.
• Inspect the perineum for excessive bleeding.
• Perform bi-manual massage.
Two hours after giving birth, the uterus should be firm, in the midline, and below the
umbilicus.
If the fundus is high, dextroverted and boggy, urinary retention is likely distending the
bladder,
so palpating for a full bladder above the symphysis (B) should be implemented first. (A, C,
and
,• are implemented after the client voids or the bladder is emptied by catheterization.
The clinic nurse identifies an elevation in the results of the triple marker screening test for a
client who is in the first trimester of pregnancy. Which action should the nurse prepare the
client for?
• Securing permission for pregnancy termination.
• Repeating the triple marker test.
• Counseling about possible fetal defects.
• Preparing for other diagnostic testing.
The triple marker screen measures maternal serum levels for alpha-fetoprotein (AFP), human
chorionic gonadotropin (HCG), and estriol, which screens for indications of possible fetal
defects. An elevated result may be a false indicator, so other tests are indicated (B). (A) is not
necessary or helpful. Elevated results warrant further testing with ultrasound or amniocentesis
before initiating (C or D).
Prenatal diagnostic testing is recommended for a couple expecting their first child who have a
family history of congenital disorders. The couple tells the nurse that they are opposed to
abortion for religious reasons. Which concept should the nurse consider when responding to
this couple?
• There is limited value in diagnostic testing if termination of pregnancy is not
an option.
• Many states legally require prenatal testing as a means of protecting the fetus.
• Diagnostic testing may indicate a fetal problem that could be treated prior to
delivery.
• Counseling about advantages and disadvantages of termination should be
helpful.
,Although the couple is opposed to abortion, prenatal testing may reveal a fetal disorder
that is
treatable in utero or immediately after birth with favorable results (C). (A) is not an due
to the
couple's stated opposition. Prenatal testing has value beyond termination (B) because it
provides
knowledge and time for the couple to prepare for various possibilities. Prenatal testing is
voluntary (D).
Which finding should the nurse identify as an early clinical manifestation of
neonatal encephalopathy related to hyperbilirubinemia?
• Increased or unstable temperature.
• Mental retardation.
• Lethargy or irritability
• Rigid extension of all extremities.
Hyperbilirubinemia causes severe brain damage, encephalopathy (kernicterus), that
results from
the deposition of unconjugated bilirubin in brain cells. Prodromal clinical manifestations
of
central nervous system involvement includes decreased activity, a loss of interest in
feeding, and
lethargy or irritability (C). Without treatment, progressive signs of neurologic damage
include
(A, B, and D).
Which approach should the nurse use when preparing a toddler for a procedure?
• Plan a teaching session to last about 20 minutes.
• Show equipment but prevent child from handling it.
• Avoid asking the child to make choices.
, • Demonstrate the procedure using a doll
Imitation is one of the most distinguishing characteristics of toddler play, so
demonstration of a
procedure on a doll (A) enables a non-threatening, dramatic experience that can help
prepare the
toddler for the actual procedure. The primary developmental task in toddlerhood is
acquiring a
sense of autonomy, so giving choices whenever possible to a toddler is recommended, not
(B).
Since the toddler's attention span is short, teaching sessions should be brief (C) and can be
repeated for reinforcement. Showing the equipment before its use helps relieve anxiety, but the
child should be allowed to handle some of the equipment (D) to prevent frustration and alleviate
fear.
Which action should the nurse implement when administering a prescription drug that should
be given on an empty stomach?
• Administer after an eight-hour fast.
• Provide the dose after the client has missed a meal.
• Give one hour before or two hours after a meal.
• Take with liquids, but no solid foods.
When administering a drug on an empty stomach, the drug should be given either one
hour
before a meal or two hours after a meal (B), which is the average transit time from the
stomach
to the duodenum after eating. An eight-hour fast is more time than is needed for the
stomach to
empty (C) and is not necessary. The last time any food or drink has been ingested is a
better
