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1.vAvnursevisvcaringvforvavclientvwhovisvatv36vweeksvofvgestationvandvwhovhasvavsuspectedvplacentavprevia.vWhichvofvthe
vfollowingvfindingsvsupportvthisvdiagnosis?
A. Painlessvredvvaginalvbleeding
Rationale:vPlacentavpreviavisvavconditionvofvpregnancyvwhenvthevplacentavimplantsvinvthevlowervpartvofvthevut
erus,vpartlyvorvcompletelyvobstructingvthevcervicalvosv(outletvtovthevvagina).vBrightvred,vpainlessvva
ginalvbleedingvoccursvinvthevsecondvandvthirdvtrimester.
B. Increasingvabdominalvpainvwithvavnonrelaxedvuterus
Rationale:vAbruptiovplacentavisvseparationvofvthevplacentavfromvthevsitevofvuterinevimplantationvbeforevdeliver
yvofvthevfetus.vWhenvthevplacentavseparatesvprematurely,vtherevisvinternalvbleeding,vwhichvisvpainf
ul,vandvthevuterusvisvnonrelaxedvorvbecomesvrigidvasvthevseparationvadvances.
C. Abdominalvpainvwithvscantvredvvaginalvbleeding
Rationale:vPlacentavpreviavinvolvesvminimalvtovseverevbrightvredvvaginalvbleedingvinvthevabsencevofvabdomi
nalvpain.
D. Intermittentvabdominalvpainvfollowingvpassagevofvbloodyvmucus
Rationale:vIntermittentvabdominalvpainvfollowingvpassagevofvbloodyvmucusvisvavdescriptionvofvnormalvlabor.v
Thevpassagevofvbloodyvmucusvrepresentsvthevlossvofvthevcervicalvmucousvplug,valsovreferredvto
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VERIFIEDvSOLUTIONS/A+vGRADEvASSURED
asvthev"bloodyvshow."
2.vAvnursevisvcaringvforvavclientvwhovisv1vhrvpostpartumvandvobservesvavlargevamountvofvlochiavrubravandvseveralvsmallvc
lotsvonvthevclient'svperinealvpad.vThevfundusvisvmidlinevandvfirmvatvthevumbilicus.vWhichvofvthevfollowingvactionsvshou
ldvthevnursevtake?
A. Documentvthevfindingsvandvcontinuevtovmonitorvthevclient.
Rationale:vThesevarevexpectedvfindings.vAtv1vhrvpostpartum,vlochiavrubravshouldvbevintermittentvandvassociat
edvwithvuterinevcontractions.vThevvolumevofvlochiavresemblesvthatvofvavheavyvmenstrualvperiod.vS
mallvclotsvarevcommon.vThevnursevshouldvdocumentvthevfindingsvandvcontinuevtovmonitorvthevcli
ent.
B. Notifyvthevclient‟sv provider.
Rationale:vThesevarevexpectedvfindings,vsovtherevisvnovneedvtovnotifyvthevprovider.
C. Increasevthevfrequencyvofvfundalvmassage.
Rationale:vThesevarevexpectedvfindingsvandvthevfundusvisvalreadyvfirm.vIncreasingvthevfrequencyvofvfundalv
massagevisvnotvindicatedvatvthisvtime.
D. Encouragevthevclientvtovemptyvhervbladder.
Rationale:vThesevarevexpectedvfindings,vandvthevfundusvisvfirmvatvthevmidline.vIfvthevfundusvwasvdeviated,vt
hisvwouldvbevanvindicationvofvavdistendedvbladdervandvthevclientvshouldvbevencouragedvtovvoidvt
ovpreventvuterinevatony.
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3.vAvnursevisvcaringvforvavnewbornvimmediatelyvfollowingvbirth.vAftervassuringvavpatentvairway,vwhatvisvthevpriorityvnursin
gvaction?
A. AdministervvitaminvK.
Rationale:vAdministrationvofvvitaminvKvisvimportant,vbutvitvcanvbevdelayedvuntilvthevnewbornvisvheldvbyvthevmo
thervandvisvbreastfed.vTherevisvanother,vmorevimportantvnursingvaction.
B. Dryvthevskin.
Rationale:vThevnewbornvshouldvbevthoroughlyvdried,vcoveredvwithvavwarmvblanket,vplacedvonvthevmother‟sva
bdomen,vandvavcapvappliedvtovthevnewborn‟svheadvtovpreventvcoldvstress.vThevnewbornvrespond
svtovthevcoolervenvironmentvbyvincreasingvhisvrespiratoryvrate,vwhichvcanvleadvtovrespiratoryvdistr
ess.vBasedvonvMaslow‟svhierarchyvofvneeds,vthisvisvthevmostvimportantvnursingvactionvaftervsecuri
ngvthevairway.
C. Administerveyevprophylaxis.
Rationale:vAdministrationvofveyevprophylaxisvshouldvoccurvwithinvthevfirstvhourvaftervbirth.vTherevisvanother,v
morevimportantvnursingvaction.
D. Placevanvidentificationvbracelet.
Rationale:vCorrectvidentificationvofvthevnewbornvisvimportant,vbutvitvcanvbevdelayed,vasvlongvasvitvisvcomplete
dvpriorvtovthevmothervandvnewbornvleavingvthevdeliveryvroom.vTherevisvanother,vmorevimportantv
nursingvaction.
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, (NGN)vATIvRNvMATERNALvNEWBORNvPROCTOREDvEXAMvTESTBANKACTUALvQUESTIONSvWITHv
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4. Avnursevinvavprenatalvclinicvisvcaringvforvavclientvwhovisvatv7vweeksvofvgestation.vThevclientvreportsvurinaryvfrequencyva
ndvasksvifvthisvwillvcontinuevuntilvdelivery.vWhichvofvthevfollowingvresponsesvshouldvthevnursevmake?
A. "It'svavminorvinconvenience,vwhichvyouvshouldvignore."
Rationale:vThisvisvavnontherapeuticvresponsevthatvdisregardsvthevclient‟svconcernvandvoffersvunwarrantedvrea
ssurance.
B. "Invmostvcasesvitvonlyvlastsvuntilvthev12thvweek,vbutvitvwillvcontinuevifvyouvhavevpoorvbladdervtone."
Rationale:vThevpresencevorvabsencevofvbladdervtonevhasvnovbearingvonvurinaryvfrequencyvduringvpregnancy
.
C. "Therevisvnovwayvtovpredictvhowvlongvitvwillvlastvinveachvindividualvclient."
Rationale:vThisvisvavnontherapeuticvresponsevthatvdoesvnotvprovidevappropriatevinformationvtovthevclient.
D. "Itvoccursvduringvthevfirstvtrimestervandvnearvthevendvofvthevpregnancy."
Rationale:vUrinaryvfrequencyvisvduevtovincreasedvbladdervsensitivityvduringvthevfirstvtrimestervandvrecursvnea
rvthevendvofvthevpregnancyvasvthevenlargingvuterusvplacesvpressurevonvthevbladder.
Avnursevisvcaringvforvavclientvduringvthevfirstvtrimestervofvpregnancy.vAftervreviewingvthevclient'svbloodvwork,vthevnurse
noticesvshevdoesvnotvhavevimmunityvtovrubella.vWhichvofvthevfollowingvtimesvshouldvthevnursevunderstandvisvrecommen
dedvforvrubellavimmunization?
E. Shortlyvaftervgivingvbirth
Rationale:vThevrubellavimmunizationvshouldvbevofferedvtovthevclientvfollowingvbirth,vpreferablyvpriorvtovdischar
gevfromvthevhospital.vThisvpreventsvthevclientvfromvcontractingvrubellavduringvthevcurrentvorvsubse
quentvpregnancies,vwhichvwouldvputvhervfetusvatvriskvforvrubellavsyndrome.
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1.vAvnursevisvcaringvforvavclientvwhovisvatv36vweeksvofvgestationvandvwhovhasvavsuspectedvplacentavprevia.vWhichvofvthe
vfollowingvfindingsvsupportvthisvdiagnosis?
A. Painlessvredvvaginalvbleeding
Rationale:vPlacentavpreviavisvavconditionvofvpregnancyvwhenvthevplacentavimplantsvinvthevlowervpartvofvthevut
erus,vpartlyvorvcompletelyvobstructingvthevcervicalvosv(outletvtovthevvagina).vBrightvred,vpainlessvva
ginalvbleedingvoccursvinvthevsecondvandvthirdvtrimester.
B. Increasingvabdominalvpainvwithvavnonrelaxedvuterus
Rationale:vAbruptiovplacentavisvseparationvofvthevplacentavfromvthevsitevofvuterinevimplantationvbeforevdeliver
yvofvthevfetus.vWhenvthevplacentavseparatesvprematurely,vtherevisvinternalvbleeding,vwhichvisvpainf
ul,vandvthevuterusvisvnonrelaxedvorvbecomesvrigidvasvthevseparationvadvances.
C. Abdominalvpainvwithvscantvredvvaginalvbleeding
Rationale:vPlacentavpreviavinvolvesvminimalvtovseverevbrightvredvvaginalvbleedingvinvthevabsencevofvabdomi
nalvpain.
D. Intermittentvabdominalvpainvfollowingvpassagevofvbloodyvmucus
Rationale:vIntermittentvabdominalvpainvfollowingvpassagevofvbloodyvmucusvisvavdescriptionvofvnormalvlabor.v
Thevpassagevofvbloodyvmucusvrepresentsvthevlossvofvthevcervicalvmucousvplug,valsovreferredvto
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, (NGN)vATIvRNvMATERNALvNEWBORNvPROCTOREDvEXAMvTESTBANKACTUALvQUESTIONSvWITHv
VERIFIEDvSOLUTIONS/A+vGRADEvASSURED
asvthev"bloodyvshow."
2.vAvnursevisvcaringvforvavclientvwhovisv1vhrvpostpartumvandvobservesvavlargevamountvofvlochiavrubravandvseveralvsmallvc
lotsvonvthevclient'svperinealvpad.vThevfundusvisvmidlinevandvfirmvatvthevumbilicus.vWhichvofvthevfollowingvactionsvshou
ldvthevnursevtake?
A. Documentvthevfindingsvandvcontinuevtovmonitorvthevclient.
Rationale:vThesevarevexpectedvfindings.vAtv1vhrvpostpartum,vlochiavrubravshouldvbevintermittentvandvassociat
edvwithvuterinevcontractions.vThevvolumevofvlochiavresemblesvthatvofvavheavyvmenstrualvperiod.vS
mallvclotsvarevcommon.vThevnursevshouldvdocumentvthevfindingsvandvcontinuevtovmonitorvthevcli
ent.
B. Notifyvthevclient‟sv provider.
Rationale:vThesevarevexpectedvfindings,vsovtherevisvnovneedvtovnotifyvthevprovider.
C. Increasevthevfrequencyvofvfundalvmassage.
Rationale:vThesevarevexpectedvfindingsvandvthevfundusvisvalreadyvfirm.vIncreasingvthevfrequencyvofvfundalv
massagevisvnotvindicatedvatvthisvtime.
D. Encouragevthevclientvtovemptyvhervbladder.
Rationale:vThesevarevexpectedvfindings,vandvthevfundusvisvfirmvatvthevmidline.vIfvthevfundusvwasvdeviated,vt
hisvwouldvbevanvindicationvofvavdistendedvbladdervandvthevclientvshouldvbevencouragedvtovvoidvt
ovpreventvuterinevatony.
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v v
3.vAvnursevisvcaringvforvavnewbornvimmediatelyvfollowingvbirth.vAftervassuringvavpatentvairway,vwhatvisvthevpriorityvnursin
gvaction?
A. AdministervvitaminvK.
Rationale:vAdministrationvofvvitaminvKvisvimportant,vbutvitvcanvbevdelayedvuntilvthevnewbornvisvheldvbyvthevmo
thervandvisvbreastfed.vTherevisvanother,vmorevimportantvnursingvaction.
B. Dryvthevskin.
Rationale:vThevnewbornvshouldvbevthoroughlyvdried,vcoveredvwithvavwarmvblanket,vplacedvonvthevmother‟sva
bdomen,vandvavcapvappliedvtovthevnewborn‟svheadvtovpreventvcoldvstress.vThevnewbornvrespond
svtovthevcoolervenvironmentvbyvincreasingvhisvrespiratoryvrate,vwhichvcanvleadvtovrespiratoryvdistr
ess.vBasedvonvMaslow‟svhierarchyvofvneeds,vthisvisvthevmostvimportantvnursingvactionvaftervsecuri
ngvthevairway.
C. Administerveyevprophylaxis.
Rationale:vAdministrationvofveyevprophylaxisvshouldvoccurvwithinvthevfirstvhourvaftervbirth.vTherevisvanother,v
morevimportantvnursingvaction.
D. Placevanvidentificationvbracelet.
Rationale:vCorrectvidentificationvofvthevnewbornvisvimportant,vbutvitvcanvbevdelayed,vasvlongvasvitvisvcomplete
dvpriorvtovthevmothervandvnewbornvleavingvthevdeliveryvroom.vTherevisvanother,vmorevimportantv
nursingvaction.
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, (NGN)vATIvRNvMATERNALvNEWBORNvPROCTOREDvEXAMvTESTBANKACTUALvQUESTIONSvWITHv
VERIFIEDvSOLUTIONS/A+vGRADEvASSURED
4. Avnursevinvavprenatalvclinicvisvcaringvforvavclientvwhovisvatv7vweeksvofvgestation.vThevclientvreportsvurinaryvfrequencyva
ndvasksvifvthisvwillvcontinuevuntilvdelivery.vWhichvofvthevfollowingvresponsesvshouldvthevnursevmake?
A. "It'svavminorvinconvenience,vwhichvyouvshouldvignore."
Rationale:vThisvisvavnontherapeuticvresponsevthatvdisregardsvthevclient‟svconcernvandvoffersvunwarrantedvrea
ssurance.
B. "Invmostvcasesvitvonlyvlastsvuntilvthev12thvweek,vbutvitvwillvcontinuevifvyouvhavevpoorvbladdervtone."
Rationale:vThevpresencevorvabsencevofvbladdervtonevhasvnovbearingvonvurinaryvfrequencyvduringvpregnancy
.
C. "Therevisvnovwayvtovpredictvhowvlongvitvwillvlastvinveachvindividualvclient."
Rationale:vThisvisvavnontherapeuticvresponsevthatvdoesvnotvprovidevappropriatevinformationvtovthevclient.
D. "Itvoccursvduringvthevfirstvtrimestervandvnearvthevendvofvthevpregnancy."
Rationale:vUrinaryvfrequencyvisvduevtovincreasedvbladdervsensitivityvduringvthevfirstvtrimestervandvrecursvnea
rvthevendvofvthevpregnancyvasvthevenlargingvuterusvplacesvpressurevonvthevbladder.
Avnursevisvcaringvforvavclientvduringvthevfirstvtrimestervofvpregnancy.vAftervreviewingvthevclient'svbloodvwork,vthevnurse
noticesvshevdoesvnotvhavevimmunityvtovrubella.vWhichvofvthevfollowingvtimesvshouldvthevnursevunderstandvisvrecommen
dedvforvrubellavimmunization?
E. Shortlyvaftervgivingvbirth
Rationale:vThevrubellavimmunizationvshouldvbevofferedvtovthevclientvfollowingvbirth,vpreferablyvpriorvtovdischar
gevfromvthevhospital.vThisvpreventsvthevclientvfromvcontractingvrubellavduringvthevcurrentvorvsubse
quentvpregnancies,vwhichvwouldvputvhervfetusvatvriskvforvrubellavsyndrome.
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