MaternitygEvolvegExam
1. Agnonstressgtestgisgperformed,gandgthegphysiciangdocumentsg“accelerationsglastingglessgthang15gsecon
dsgthroughoutgfetalgmovement.”gThegnurseginterpretsgthesegfindingsgas:
A. Normal
B. Reactive
C. NonreactivegCorrect
D. Inconclusive
Rationale:gAgreactivegnonstressgtestgisgagnormal,gorgnegative,gresultgandgindicatesgaghealthygfetus.gThegresultgrequiresgtw
ogorgmoregfetalgheartgrategaccelerationsgofgatgleastg15gbeats/minglastinggatgleastg15gsecondsgfromgthegbeginninggofgthega
ccelerationgtogthegend,gingassociationgwithgfetalgmovement,gduringgag20-minutegperiod.gAgnonreactivegtestgisgangabnormal
gtest,gshowinggnogaccelerationsgorgaccelerationsgofglessgthang15gbeats/mingorglastingglessgthang15gsecondsgduringgag40-g
minutegobservation.gAnginconclusivegresultgisgonegthatgcannotgbeginterpretedgbecausegofgthegpoorgqualitygofgthegfetalghear
tgrategrecording.
Test-TakinggStrategy:gUsegthegprocessgofgelimination.gEliminategagreactivegnonstressgtestgandgagnormalgnonstressgtestgfir
stgbecausegtheygaregcomparablegorgalike.gTogselectgfromgthegremaininggoptions,gnotegthegrelationshipgbetweeng“lessgtha
ng15gseconds”gingthegquestiongandg“nonreactive”gingthegcorrectgoption.gIfgyoughadgdifficultygansweringgthisgquestion,grevi
ewgtheginterpretationgofgnonstressgtestgresults.
2. Agnursegcaringgforgagclientginglaborgperformsgangassessment.gThegclientgisghavinggconsistentgcontractionsglessgth
ang2gminutesgapart.gThegfetalgheartgrateg(FHR)gisg170gbeats/min,gandgfetalgmonitoringgindicatesgagpatterngofgdecreased
gvariability.gInglightgofgthesegfindings,gthegappropriategnursinggactiongis:
A. ContactinggthegphysiciangCorrect
B. Documentinggthegfindings
C. Continuinggtogmonitorgthegclient
D. Reassuringgthegclientgandghergpartnergthatglaborgisgprogressinggnormally
Rationale:gSignsgofgpotentialgcomplicationsgofglaborgincludegcontractionsgconsistentlyglastingg90gsecondsgorglonger,gcontr
actionsgconsistentlygoccurringg2gminutesgorglessgapart,gfetalgbradycardia,gtachycardia,gpersistentlygdecreasedgvariability,g
organgirregulargFHR.gThegnormalgFHRgisg110gtog160gbeats/min.gTherefore,gbecausegthegfindinggisgabnormal,gthegphysician
gmustgbegcontacted.gContinuinggtogmonitorgthegclientgdelaysgnecessarygintervention.gReassuringgthegclientgthatglaborgisgp
rogressinggnormallygisgincorrect.gThegnursegwouldgdocumentgthegdata,gactionsgtaken,gandgthegclient’sgresponse,gbut,gofgt
hegoptionsgprovided,gcontactinggthegphysiciangisgthegmostgappropriate.
Test-TakinggStrategy:gUsegthegprocessgofgeliminationgandgfocusgongthegdatagingthegquestion.gEliminategthegoptionsgthatga
regcomparablegorgalikegandgindicategthatgthegdatagingthegquestiongaregnormalgfindings.gReviewgnormalgassessmentgfindin
gsgduringgtheglaborgprocessgifgyoughadgdifficultygwithgthisgquestion.
3. Agstillbornginfantgwasgdeliveredgagfewghoursgago.gAftergthegbirth,gthegfamilygremainsgtogether,gholdinggandgtouchi
nggthegbaby.gWhichgstatementgbygthegnursegisgappropriate?
A. “Igknowghowgyougfeel.”
B. “Thisgmustgbeghardgforgyou.”gCorrect
C. “Nowgyoughavegangangelgingheaven.”
, D. “You’regyoung.gYougcanghavegothergchildren.”
Rationale:gTherapeuticgcommunicationghelpsgthegmother,gfather,gandgothergfamilygmembersgexpressgtheirgfeelingsgandge
motions.g“Thisgmustgbeghardgforgyou”gisgagcaringgandgempatheticgresponse,gfocusedgongfeelingsgandgencouraginggcomm
unication.gThegothergoptionsgaregnontherapeuticgandgmaygdevaluegthegfamilygmembers'gfeelings.
Test-TakinggStrategy:gUsegyourgknowledgegofgtherapeuticgcommunicationgtechniques.gThegcorrectgoptiongisgthegonlygopti
ongthatgisgfocusedgongthegfamilygmembers’gfeelings.gReviewgtherapeuticgcommunicationgtechniquesgifgyoughadgdifficultyg
withgthisgquestion.
4. Agrubellagantibodygscreengisgperformedgingagpregnantgclient,gandgthegresultsgindicategthatgthegclientgisgnotgimmune
gtogrubella.gThegnursegtellsgthegclientgthat:
A. Agrubellagvaccinegmustgbegadministeredgimmediately
B. AgrubellagvaccinegmustgbegadministeredgaftergchildbirthgCorrect
C. Shegwillgnotgcontractgrubellagifgshegisgexposedgtogthegdisease
D. Shegdoesgnotgneedgtogbegconcernedgaboutgbeinggexposedgtogrubella
Rationale:gAgprenatalgrubellagantibodygscreengisgperformedgingeverygpregnantgwomangtogdeterminegwhethergshegisgimmu
negtogrubella,gwhichgcangcausegseriousgfetalganomalies.gIfgshegisgnotgimmune,grubellagvaccinegisgofferedgaftergchildbirthgto
gkeepghergfromgcontractinggrubellagduringgsubsequentgpregnancies.gThegvaccinegisgaglivegvirus,gandgdefectsgmightgoccurg
ingthegfetusgifgthegvaccinegweregadministeredgduringgpregnancygorgifgthegmothergweregtogbecomegpregnantgsoongaftergitg
wasgadministered.gAdministeringgagrubellagvaccinegimmediatelygplacesgthegfetusgatgrisk.gTellinggthegclientgthatgshegdoesg
notgneedgtogbegconcernedgaboutgbeinggexposedgtogrubellagisgincorrect,gbecausegthegpossibilitygofgexposure,gwhichgcouldg
begharmfulgtogthegfetus,gdoesgexist.
Test-TakinggStrategy:gUsegthegprocessgofgelimination.gEliminategfirstgthegoptionsgthatgaregcomparablegorgalikeg(i.e.,gthegc
lientgwillgnotgacquiregrubellagandgdoesgnotgneedgtogbegconcernedgaboutgexposure).gTogselectgfromgthegremaininggoptions,g
recallgthatgrubellagvaccinegisgaglivegvirus;gthisgwillgdirectgyougtogthegcorrectgoption.gReviewgrubellagvaccinegandgitsgimplica
tionsgduringgpregnancygifgyoughadgdifficultygwithgthisgquestion.
5. Agnursegcaringgforgagclientgingthegactivegstagegofglaborgassessesgthegfetalgstatusgandgnotesgaglategdecelerationg
ongthegmonitorgstrip.gInglightgofgthisgfinding,gwhichgnursinggactiongisgthegpriority?
A. Documentinggthegfinding
B. Preparinggforgimmediategbirth
C. AdministeringgoxygengbygwaygofgfacegmaskgCorrect
D. Increasinggthegrategofgthegoxytocing(Pitocin)ginfusion
Rationale:gLategdecelerationsgaregagresultgofguteroplacentalginsufficiencygstemminggfromgdecreasedgbloodgflowgandgoxyge
ngtransfergtogthegfetusgduringguterinegcontractions.gThisgcausesghypoxemia;gthereforegoxygengisgnecessary,gmakinggtheg
administrationgofgoxygengthegcorrectgchoice.gLategdecelerationsgaregconsideredgangominousgsigngbutgdognotgnecessarilygr
equiregimmediategbirthgofgthegbaby.gThegoxytocinginfusiongshouldgbegdiscontinuedgwhengaglategdecelerationgisgnoted.gTh
egoxytocingwouldgcausegfurtherghypoxemia,gbecausegthegmedicationgstimulatesgcontractions,gleadinggtogincreasedguterop
lacentalginsufficiency.gAlthoughgthegfindinggneedsgtogbegdocumented,gdocumentationgisgnotgthegprioritygactiongingthisgsitu
ation.
Test-TakinggStrategy:gNotegthegstrategicgwordg“priority”gingthegquestion.gUsegyourgknowledgegofgthegABCsg—gairway,
, breathing,gandgcirculationg—
gtoganswergthegquestion.gThisgwillgdirectgyougtogthegcorrectgoption,gthegonegthatgaddressesgoxygen.gReviewgcontentgonglat
egdecelerationsgifgyoughadgdifficultygwithgthisgquestion.
6. Agnursegprovidesginstructionsgregardinggpostpartumgexercisesgtogagclientgwhoghasgdeliveredgagnewborngvaginall
y.gThegnursegtellsgthegclientgthat:
A. Thegexercisesgshouldgbegdelayedgforg1gmonthgtogallowghealing
B. Performinggsuchgexercisesgingthegpostpartumgperiodgmaygresultgingstressgurinarygincontinence
C. AlternatinggcontractiongandgrelaxationgofgthegmusclesgofgthegperinealgareagshouldgbegpracticedgCorrect
D. Abdominalgexercisesgwillgbegstartedgwhilegthegclientgisgingtheghospitalgasgagmeansgofgevaluati
nggtolerance
Rationale:gPostpartumgexercisesgmaygbegstartedgsoongaftergbirth,galthoughgthegwomangshouldgbegencouragedgtogbegingwi
thgsimplegexercisesgandggraduallygprogressgtogmoregstrenuousgones.gAbdominalgexercisesgaregpostponedguntilgapproxima
telyg4gweeksgaftergagcesareangbirth.gKegelgexercisesg(alternatedgcontractiongandgrelaxationgofgthegmusclesgofgthegperinea
lgarea)garegextremelygimportantgingstrengtheninggthegmusclegtonegofgthegperinealgareagaftergvaginalgbirth.gKegelgexercise
sghelpgrestoregthegmusclegtonegthatgisgoftenglostgasgpelvicgtissuesgaregstretchedgandgtorngduringgpregnancygandgbirth.gWo
mengwhogmaintaingmusclegstrengthgmaygbenefitgyearsglater,gexperiencinggcontinuedgurinarygcontinence.
Test-TakinggStrategy:gUsegthegprocessgofgelimination.gNotegthegrelationshipgbetweengthegwordg“vaginally”gingthegquesti
ongandg“perinealgarea”gingthegcorrectgoption.gReviewgthegpurposegandgbenefitgofgKegelgexercisesgifgyoughadgdifficultygwit
hgthisgquestion.
7. Agclientgingthegfirstgtrimestergofgpregnancygarrivesgatgthegclinicgandgreportsgthatgsheghasgbeengexperiencinggvagi
nalgbleeding.gThreatenedgabortiongisgsuspected,gandgthegnursegprovidesginstructionsgtogthegclientgregardinggcare.gWhic
hgstatementgbygthegclientgindicatesgthegneedgforgfurtherginstruction?
A. “Igneedgtogstaygingbedgforgthegrestgofgmygpregnancy.”gCorrect
B. “Igneedgtogavoidghavinggsexguntilgthegbleedingghasgstopped.”
C. “Igneedgtogwatchgforgstuffgthatglooksglikegtissuegcominggfromgmygvagina.”
D. “IgneedgtogcountgthegnumbergofgperinealgpadsgthatgIgusegeachgdaygandgmakegagnotegofgthegamountga
ndgcolorgofgbloodgongeachgpad.”
Rationale:gStrictgbedgrestgthroughoutgthegremaindergofgthegpregnancygisgnotgrequired.gThegwomangisgadvisedgtogcurtailgs
exualgactivitiesguntilgbleedingghasgceasedgandgforg2gweeksgaftergtheglastgevidencegofgbleeding,gasgrecommendedgbygthegp
hysiciangorgnurse-midwife.gThegwomangisginstructedgtogcountgthegperinealgpadsgshegusesgeachgdaygandgtognotegthegqua
ntitygandgcolorgofgbloodgongeachgpad.gThegwomangshouldgalsogwatchgforgthegevidencegofgthegpassagegofgtissue.
Test-TakinggStrategy:gUsegthegprocessgofgelimination.gNotegthegstrategicgwordsg“needgforgfurtherginstruction”gingthegque
stion,gwhichgindicategagnegativegeventgquerygandgthegneedgtogselectgthegincorrectgclientgstatement.gNotinggthegwordsg“sta
ygingbedgforgthegrestgofgmygpregnancy”gwillgdirectgyougtogthisgoption.gReviewgtherapeuticgmanagementgforgthreatenedgabor
tiongifgyoughadgdifficultygwithgthisgquestion.
8. Agnursegisgassessinggthegrespiratorygrategofgagnewborn.gWhichgfindinggwouldgthegnursegdocumentgasgnormal?
A. 20gbreaths/min
B. 25gbreaths/min
, C. 50gbreaths/mingCorrect
D. 70gbreaths/min
Rationale:gThegnormalgrespiratorygrategforgagnewbornginfantgisg30gtog60gbreaths/min.gAllgofgthegothergoptionsgaregoutsidegt
hegnormalgrange.
Test-TakinggStrategy:gKnowledgegregardinggthegnormalgrespiratorygrategofgagnewborngisgrequiredgtoganswergthisgquestion.
Ifgyougaregunfamiliargwithgthegnormalgrangesgforgnewborngvitalgsigns,greviewgthisgcontent.
9. AgnursegnotesgthatgtheglaboratorygreportgofgagpregnantgclientgwithgsuspectedgHIVginfectiongindicatesgleukopeni
a,gthrombocytopenia,ganemia,gandgangincreasedgerythrocytegsedimentationgrate.gWhichglaboratorygtestgthatgwouldgfur
thergconfirmgthegpresencegofgHIVgdoesgthegnurseganticipategthatgthegphysiciangwillgprescribe?
A. Plateletgcount
B. Angiotensinglevel
C. Glomerulargfiltrationgrate
D. T-lymphocytegdeterminationgCorrect
Rationale:gHIVghasgagstronggaffinitygforgsurfacegmarkergproteinsgonglymphocytes.gThisgaffinitygofgHIVgforgT-lymphocytesgl
eadsgtogsignificantgcellgdestruction.gAngiotensingisgproducedgingthegkidneygandgplaysgagrolegingbloodgpressuregcontrol.gGlo
merulargfiltrationgrategisgangindicatorgofgkidneygfunction.gThegplateletgcountgisgimportantgandgmaygbegusedgasgangindicatorg
ofgthegeffectsgofgHIV,gbutgthegplateletgcountg(thrombocytopenia)ghasgalreadygbeengaddressedgingthegquestion.
Test-TakinggStrategy:gUsegthegprocessgofgelimination,gfocusinggongthegsubject,gthegpresencegofgHIV.gEliminategthegplatele
tgcount,gbecausegthisghasgalreadygbeengaddressedgingthegquestiong(thrombocytopenia).gNextgeliminategthegoptionsgthatga
regcomparablegorgalikegingthatgtheygaregrelatedgtogkidneygfunction.gIfgyoughadgdifficultygwithgthisgquestion,greviewgthegclin
icalgmanifestationsgandgpathologygofgHIVginfection.
10. Agnursegpalpatesgtheganteriorgfontanelgofgagneonategandgnotesgthatgitgfeelsgsof
t.gThisgnurseginterpretsgthisgassessmentgdatagas:
A. AgnormalgfindinggCorrect
B. Indicativegofgdehydration
C. Indicativegofgincreasedgintracranialgpressure
D. Indicativegofgdecreasedgintracranialgpressure
Rationale:gTheganteriorgfontanel,gwhichgisgdiamondgshaped,gisglocatedgongthegtopgofgtheghead.gItgmeasuresg1gtog4gcmgbu
tgvariesgbecausegofgmoldinggandgindividualgdifferences.gItgnormallygclosesgbyg12gtog18gmonthsgofgage.gItgmaygbegdescribe
dgasgsoft,gwhichgisgnormal,gorgfullgandgbulging,gwhichgmaygbegindicativegofgincreasedgintracranialgpressure.gConversely,ga
gdepressedgfontanelgcouldgmeangthatgthegneonategisgdehydrated.
Test-TakinggStrategy:gUsegthegprocessgofgelimination,gnotinggthegstrategicgwordsg“feelsgsoft”gingthegquestion.gRememb
ergthatgtheganteriorgfontanelgisgsoftgingthegneonate.gIfgyoughadgdifficultygansweringgthisgquestion,greviewgnormalgassess
mentgfindingsgingthegneonate.
11. Agnursegprovidesginformationgaboutgthegtreatmentgforghypoglycemiagtogagclientgwithggestationalgdiabetesgwhogwillg
begtakingginsulin.gThegnursegtellsgthegclientgthatgifgsignsgandgsymptomsgofghypoglycemiagoccur,gshegmustgimmediately:
1. Agnonstressgtestgisgperformed,gandgthegphysiciangdocumentsg“accelerationsglastingglessgthang15gsecon
dsgthroughoutgfetalgmovement.”gThegnurseginterpretsgthesegfindingsgas:
A. Normal
B. Reactive
C. NonreactivegCorrect
D. Inconclusive
Rationale:gAgreactivegnonstressgtestgisgagnormal,gorgnegative,gresultgandgindicatesgaghealthygfetus.gThegresultgrequiresgtw
ogorgmoregfetalgheartgrategaccelerationsgofgatgleastg15gbeats/minglastinggatgleastg15gsecondsgfromgthegbeginninggofgthega
ccelerationgtogthegend,gingassociationgwithgfetalgmovement,gduringgag20-minutegperiod.gAgnonreactivegtestgisgangabnormal
gtest,gshowinggnogaccelerationsgorgaccelerationsgofglessgthang15gbeats/mingorglastingglessgthang15gsecondsgduringgag40-g
minutegobservation.gAnginconclusivegresultgisgonegthatgcannotgbeginterpretedgbecausegofgthegpoorgqualitygofgthegfetalghear
tgrategrecording.
Test-TakinggStrategy:gUsegthegprocessgofgelimination.gEliminategagreactivegnonstressgtestgandgagnormalgnonstressgtestgfir
stgbecausegtheygaregcomparablegorgalike.gTogselectgfromgthegremaininggoptions,gnotegthegrelationshipgbetweeng“lessgtha
ng15gseconds”gingthegquestiongandg“nonreactive”gingthegcorrectgoption.gIfgyoughadgdifficultygansweringgthisgquestion,grevi
ewgtheginterpretationgofgnonstressgtestgresults.
2. Agnursegcaringgforgagclientginglaborgperformsgangassessment.gThegclientgisghavinggconsistentgcontractionsglessgth
ang2gminutesgapart.gThegfetalgheartgrateg(FHR)gisg170gbeats/min,gandgfetalgmonitoringgindicatesgagpatterngofgdecreased
gvariability.gInglightgofgthesegfindings,gthegappropriategnursinggactiongis:
A. ContactinggthegphysiciangCorrect
B. Documentinggthegfindings
C. Continuinggtogmonitorgthegclient
D. Reassuringgthegclientgandghergpartnergthatglaborgisgprogressinggnormally
Rationale:gSignsgofgpotentialgcomplicationsgofglaborgincludegcontractionsgconsistentlyglastingg90gsecondsgorglonger,gcontr
actionsgconsistentlygoccurringg2gminutesgorglessgapart,gfetalgbradycardia,gtachycardia,gpersistentlygdecreasedgvariability,g
organgirregulargFHR.gThegnormalgFHRgisg110gtog160gbeats/min.gTherefore,gbecausegthegfindinggisgabnormal,gthegphysician
gmustgbegcontacted.gContinuinggtogmonitorgthegclientgdelaysgnecessarygintervention.gReassuringgthegclientgthatglaborgisgp
rogressinggnormallygisgincorrect.gThegnursegwouldgdocumentgthegdata,gactionsgtaken,gandgthegclient’sgresponse,gbut,gofgt
hegoptionsgprovided,gcontactinggthegphysiciangisgthegmostgappropriate.
Test-TakinggStrategy:gUsegthegprocessgofgeliminationgandgfocusgongthegdatagingthegquestion.gEliminategthegoptionsgthatga
regcomparablegorgalikegandgindicategthatgthegdatagingthegquestiongaregnormalgfindings.gReviewgnormalgassessmentgfindin
gsgduringgtheglaborgprocessgifgyoughadgdifficultygwithgthisgquestion.
3. Agstillbornginfantgwasgdeliveredgagfewghoursgago.gAftergthegbirth,gthegfamilygremainsgtogether,gholdinggandgtouchi
nggthegbaby.gWhichgstatementgbygthegnursegisgappropriate?
A. “Igknowghowgyougfeel.”
B. “Thisgmustgbeghardgforgyou.”gCorrect
C. “Nowgyoughavegangangelgingheaven.”
, D. “You’regyoung.gYougcanghavegothergchildren.”
Rationale:gTherapeuticgcommunicationghelpsgthegmother,gfather,gandgothergfamilygmembersgexpressgtheirgfeelingsgandge
motions.g“Thisgmustgbeghardgforgyou”gisgagcaringgandgempatheticgresponse,gfocusedgongfeelingsgandgencouraginggcomm
unication.gThegothergoptionsgaregnontherapeuticgandgmaygdevaluegthegfamilygmembers'gfeelings.
Test-TakinggStrategy:gUsegyourgknowledgegofgtherapeuticgcommunicationgtechniques.gThegcorrectgoptiongisgthegonlygopti
ongthatgisgfocusedgongthegfamilygmembers’gfeelings.gReviewgtherapeuticgcommunicationgtechniquesgifgyoughadgdifficultyg
withgthisgquestion.
4. Agrubellagantibodygscreengisgperformedgingagpregnantgclient,gandgthegresultsgindicategthatgthegclientgisgnotgimmune
gtogrubella.gThegnursegtellsgthegclientgthat:
A. Agrubellagvaccinegmustgbegadministeredgimmediately
B. AgrubellagvaccinegmustgbegadministeredgaftergchildbirthgCorrect
C. Shegwillgnotgcontractgrubellagifgshegisgexposedgtogthegdisease
D. Shegdoesgnotgneedgtogbegconcernedgaboutgbeinggexposedgtogrubella
Rationale:gAgprenatalgrubellagantibodygscreengisgperformedgingeverygpregnantgwomangtogdeterminegwhethergshegisgimmu
negtogrubella,gwhichgcangcausegseriousgfetalganomalies.gIfgshegisgnotgimmune,grubellagvaccinegisgofferedgaftergchildbirthgto
gkeepghergfromgcontractinggrubellagduringgsubsequentgpregnancies.gThegvaccinegisgaglivegvirus,gandgdefectsgmightgoccurg
ingthegfetusgifgthegvaccinegweregadministeredgduringgpregnancygorgifgthegmothergweregtogbecomegpregnantgsoongaftergitg
wasgadministered.gAdministeringgagrubellagvaccinegimmediatelygplacesgthegfetusgatgrisk.gTellinggthegclientgthatgshegdoesg
notgneedgtogbegconcernedgaboutgbeinggexposedgtogrubellagisgincorrect,gbecausegthegpossibilitygofgexposure,gwhichgcouldg
begharmfulgtogthegfetus,gdoesgexist.
Test-TakinggStrategy:gUsegthegprocessgofgelimination.gEliminategfirstgthegoptionsgthatgaregcomparablegorgalikeg(i.e.,gthegc
lientgwillgnotgacquiregrubellagandgdoesgnotgneedgtogbegconcernedgaboutgexposure).gTogselectgfromgthegremaininggoptions,g
recallgthatgrubellagvaccinegisgaglivegvirus;gthisgwillgdirectgyougtogthegcorrectgoption.gReviewgrubellagvaccinegandgitsgimplica
tionsgduringgpregnancygifgyoughadgdifficultygwithgthisgquestion.
5. Agnursegcaringgforgagclientgingthegactivegstagegofglaborgassessesgthegfetalgstatusgandgnotesgaglategdecelerationg
ongthegmonitorgstrip.gInglightgofgthisgfinding,gwhichgnursinggactiongisgthegpriority?
A. Documentinggthegfinding
B. Preparinggforgimmediategbirth
C. AdministeringgoxygengbygwaygofgfacegmaskgCorrect
D. Increasinggthegrategofgthegoxytocing(Pitocin)ginfusion
Rationale:gLategdecelerationsgaregagresultgofguteroplacentalginsufficiencygstemminggfromgdecreasedgbloodgflowgandgoxyge
ngtransfergtogthegfetusgduringguterinegcontractions.gThisgcausesghypoxemia;gthereforegoxygengisgnecessary,gmakinggtheg
administrationgofgoxygengthegcorrectgchoice.gLategdecelerationsgaregconsideredgangominousgsigngbutgdognotgnecessarilygr
equiregimmediategbirthgofgthegbaby.gThegoxytocinginfusiongshouldgbegdiscontinuedgwhengaglategdecelerationgisgnoted.gTh
egoxytocingwouldgcausegfurtherghypoxemia,gbecausegthegmedicationgstimulatesgcontractions,gleadinggtogincreasedguterop
lacentalginsufficiency.gAlthoughgthegfindinggneedsgtogbegdocumented,gdocumentationgisgnotgthegprioritygactiongingthisgsitu
ation.
Test-TakinggStrategy:gNotegthegstrategicgwordg“priority”gingthegquestion.gUsegyourgknowledgegofgthegABCsg—gairway,
, breathing,gandgcirculationg—
gtoganswergthegquestion.gThisgwillgdirectgyougtogthegcorrectgoption,gthegonegthatgaddressesgoxygen.gReviewgcontentgonglat
egdecelerationsgifgyoughadgdifficultygwithgthisgquestion.
6. Agnursegprovidesginstructionsgregardinggpostpartumgexercisesgtogagclientgwhoghasgdeliveredgagnewborngvaginall
y.gThegnursegtellsgthegclientgthat:
A. Thegexercisesgshouldgbegdelayedgforg1gmonthgtogallowghealing
B. Performinggsuchgexercisesgingthegpostpartumgperiodgmaygresultgingstressgurinarygincontinence
C. AlternatinggcontractiongandgrelaxationgofgthegmusclesgofgthegperinealgareagshouldgbegpracticedgCorrect
D. Abdominalgexercisesgwillgbegstartedgwhilegthegclientgisgingtheghospitalgasgagmeansgofgevaluati
nggtolerance
Rationale:gPostpartumgexercisesgmaygbegstartedgsoongaftergbirth,galthoughgthegwomangshouldgbegencouragedgtogbegingwi
thgsimplegexercisesgandggraduallygprogressgtogmoregstrenuousgones.gAbdominalgexercisesgaregpostponedguntilgapproxima
telyg4gweeksgaftergagcesareangbirth.gKegelgexercisesg(alternatedgcontractiongandgrelaxationgofgthegmusclesgofgthegperinea
lgarea)garegextremelygimportantgingstrengtheninggthegmusclegtonegofgthegperinealgareagaftergvaginalgbirth.gKegelgexercise
sghelpgrestoregthegmusclegtonegthatgisgoftenglostgasgpelvicgtissuesgaregstretchedgandgtorngduringgpregnancygandgbirth.gWo
mengwhogmaintaingmusclegstrengthgmaygbenefitgyearsglater,gexperiencinggcontinuedgurinarygcontinence.
Test-TakinggStrategy:gUsegthegprocessgofgelimination.gNotegthegrelationshipgbetweengthegwordg“vaginally”gingthegquesti
ongandg“perinealgarea”gingthegcorrectgoption.gReviewgthegpurposegandgbenefitgofgKegelgexercisesgifgyoughadgdifficultygwit
hgthisgquestion.
7. Agclientgingthegfirstgtrimestergofgpregnancygarrivesgatgthegclinicgandgreportsgthatgsheghasgbeengexperiencinggvagi
nalgbleeding.gThreatenedgabortiongisgsuspected,gandgthegnursegprovidesginstructionsgtogthegclientgregardinggcare.gWhic
hgstatementgbygthegclientgindicatesgthegneedgforgfurtherginstruction?
A. “Igneedgtogstaygingbedgforgthegrestgofgmygpregnancy.”gCorrect
B. “Igneedgtogavoidghavinggsexguntilgthegbleedingghasgstopped.”
C. “Igneedgtogwatchgforgstuffgthatglooksglikegtissuegcominggfromgmygvagina.”
D. “IgneedgtogcountgthegnumbergofgperinealgpadsgthatgIgusegeachgdaygandgmakegagnotegofgthegamountga
ndgcolorgofgbloodgongeachgpad.”
Rationale:gStrictgbedgrestgthroughoutgthegremaindergofgthegpregnancygisgnotgrequired.gThegwomangisgadvisedgtogcurtailgs
exualgactivitiesguntilgbleedingghasgceasedgandgforg2gweeksgaftergtheglastgevidencegofgbleeding,gasgrecommendedgbygthegp
hysiciangorgnurse-midwife.gThegwomangisginstructedgtogcountgthegperinealgpadsgshegusesgeachgdaygandgtognotegthegqua
ntitygandgcolorgofgbloodgongeachgpad.gThegwomangshouldgalsogwatchgforgthegevidencegofgthegpassagegofgtissue.
Test-TakinggStrategy:gUsegthegprocessgofgelimination.gNotegthegstrategicgwordsg“needgforgfurtherginstruction”gingthegque
stion,gwhichgindicategagnegativegeventgquerygandgthegneedgtogselectgthegincorrectgclientgstatement.gNotinggthegwordsg“sta
ygingbedgforgthegrestgofgmygpregnancy”gwillgdirectgyougtogthisgoption.gReviewgtherapeuticgmanagementgforgthreatenedgabor
tiongifgyoughadgdifficultygwithgthisgquestion.
8. Agnursegisgassessinggthegrespiratorygrategofgagnewborn.gWhichgfindinggwouldgthegnursegdocumentgasgnormal?
A. 20gbreaths/min
B. 25gbreaths/min
, C. 50gbreaths/mingCorrect
D. 70gbreaths/min
Rationale:gThegnormalgrespiratorygrategforgagnewbornginfantgisg30gtog60gbreaths/min.gAllgofgthegothergoptionsgaregoutsidegt
hegnormalgrange.
Test-TakinggStrategy:gKnowledgegregardinggthegnormalgrespiratorygrategofgagnewborngisgrequiredgtoganswergthisgquestion.
Ifgyougaregunfamiliargwithgthegnormalgrangesgforgnewborngvitalgsigns,greviewgthisgcontent.
9. AgnursegnotesgthatgtheglaboratorygreportgofgagpregnantgclientgwithgsuspectedgHIVginfectiongindicatesgleukopeni
a,gthrombocytopenia,ganemia,gandgangincreasedgerythrocytegsedimentationgrate.gWhichglaboratorygtestgthatgwouldgfur
thergconfirmgthegpresencegofgHIVgdoesgthegnurseganticipategthatgthegphysiciangwillgprescribe?
A. Plateletgcount
B. Angiotensinglevel
C. Glomerulargfiltrationgrate
D. T-lymphocytegdeterminationgCorrect
Rationale:gHIVghasgagstronggaffinitygforgsurfacegmarkergproteinsgonglymphocytes.gThisgaffinitygofgHIVgforgT-lymphocytesgl
eadsgtogsignificantgcellgdestruction.gAngiotensingisgproducedgingthegkidneygandgplaysgagrolegingbloodgpressuregcontrol.gGlo
merulargfiltrationgrategisgangindicatorgofgkidneygfunction.gThegplateletgcountgisgimportantgandgmaygbegusedgasgangindicatorg
ofgthegeffectsgofgHIV,gbutgthegplateletgcountg(thrombocytopenia)ghasgalreadygbeengaddressedgingthegquestion.
Test-TakinggStrategy:gUsegthegprocessgofgelimination,gfocusinggongthegsubject,gthegpresencegofgHIV.gEliminategthegplatele
tgcount,gbecausegthisghasgalreadygbeengaddressedgingthegquestiong(thrombocytopenia).gNextgeliminategthegoptionsgthatga
regcomparablegorgalikegingthatgtheygaregrelatedgtogkidneygfunction.gIfgyoughadgdifficultygwithgthisgquestion,greviewgthegclin
icalgmanifestationsgandgpathologygofgHIVginfection.
10. Agnursegpalpatesgtheganteriorgfontanelgofgagneonategandgnotesgthatgitgfeelsgsof
t.gThisgnurseginterpretsgthisgassessmentgdatagas:
A. AgnormalgfindinggCorrect
B. Indicativegofgdehydration
C. Indicativegofgincreasedgintracranialgpressure
D. Indicativegofgdecreasedgintracranialgpressure
Rationale:gTheganteriorgfontanel,gwhichgisgdiamondgshaped,gisglocatedgongthegtopgofgtheghead.gItgmeasuresg1gtog4gcmgbu
tgvariesgbecausegofgmoldinggandgindividualgdifferences.gItgnormallygclosesgbyg12gtog18gmonthsgofgage.gItgmaygbegdescribe
dgasgsoft,gwhichgisgnormal,gorgfullgandgbulging,gwhichgmaygbegindicativegofgincreasedgintracranialgpressure.gConversely,ga
gdepressedgfontanelgcouldgmeangthatgthegneonategisgdehydrated.
Test-TakinggStrategy:gUsegthegprocessgofgelimination,gnotinggthegstrategicgwordsg“feelsgsoft”gingthegquestion.gRememb
ergthatgtheganteriorgfontanelgisgsoftgingthegneonate.gIfgyoughadgdifficultygansweringgthisgquestion,greviewgnormalgassess
mentgfindingsgingthegneonate.
11. Agnursegprovidesginformationgaboutgthegtreatmentgforghypoglycemiagtogagclientgwithggestationalgdiabetesgwhogwillg
begtakingginsulin.gThegnursegtellsgthegclientgthatgifgsignsgandgsymptomsgofghypoglycemiagoccur,gshegmustgimmediately:
