Evolve Maternity – At Risk Actual Exam
Questions And Answers Verified 100% Correct
A nurse concludes that a positive contraction stress test (CST) result may be indicative
of potential fetal compromise. A CST result is considered positive when during
contractions the fetal heart rate shows: - ANSWER- Late decelerations
A client who has undergone a cesarean birth because of the presence of active genital
herpes is transferred to the postpartum unit. What type of isolation precautions does the
nurse plan to institute? - ANSWER- Contact
A primigravida is admitted with a ruptured fallopian tube resulting from a tubal
pregnancy and surgery is performed to remove the fallopian tube. What should
postoperative nursing care include? - ANSWER- Explaining that the client may still be
capable of becoming pregnant
The nurse is counseling a pregnant client with type 1 diabetes about medication
changes as pregnancy progresses. Which medication will be needed in increased
dosages during the second half of her pregnancy? - ANSWER- Insulin
After an incomplete abortion, a client tells a nurse that although her health care provider
explained what an incomplete abortion was, she did not understand. What is the best
response by the nurse? - ANSWER- "It's when the fetus is expelled but other parts of
the pregnancy remain in the uterus."
A client at term is admitted in active labor. She has tested positive for HIV. Which
intervention in the standard orders should the nurse question as a risk to the fetus? -
ANSWER- Internal fetal scalp electrode
A nurse is caring for a client who has had a spontaneous abortion. For what
complication should the nurse monitor this client? - ANSWER- Hemorrhage
While auscultating the lungs of a client admitted with severe preeclampsia, the nurse
identifies crackles. What inference does the nurse make when considering the presence
of crackles in the lungs? - ANSWER- Pulmonary edema has developed.
A client who is in the first trimester is being discharged after a week of hospitalization for
hyperemesis gravidarum. She is to be maintained at home with rehydration infusion
therapy. What is the priority nursing activity for the home health nurse? - ANSWER-
Monitoring the client for signs of electrolyte imbalances
,A client who had tocolytic therapy for preterm labor is being discharged. What
instructions should the nurse include in the teaching plan? - ANSWER- Limit daily
activities.
A nurse is caring for a client who is admitted to the birthing unit with a diagnosis of
abruptio placentae. For what complication associated with this problem should the
nurse monitor this client? - ANSWER- Hypovolemic shock
A client who had a cesarean birth is unable to void 3 hours after the removal of an
indwelling catheter. How can the nurse evaluate whether the client's bladder is
distended? - ANSWER- By palpating the client's suprapubic area gently
A client at 36 weeks' gestation arrives at the prenatal clinic for a routine examination.
The nurse determines that the client's blood pressure has increased from 102/60 to
134/88 mm Hg and becomes concerned she may be experiencing mild preeclampsia.
What other sign of mild preeclampsia does the nurse anticipate? - ANSWER-
Proteinuria of 1+
A client gives birth vaginally, with a midline episiotomy, to an infant who weighs 8 lb 13
oz (4000 g). An ice pack is applied to the perineum to ease the swelling and pain. The
client complains, "This pain in my vaginal and rectum is excruciating, and my vagina
feels so full and heavy." What does the nurse suspect as the cause of the pain? -
ANSWER- Vaginal hematoma
A client in labor, who is at term, is admitted to the birthing room. The fetus is in the left
occiput posterior position. The client's membranes rupture spontaneously. What
observation requires the nurse to notify the practitioner? - ANSWER- Greenish amniotic
fluid
A client is admitted in active labor at 39 weeks' gestation. During the initial examination
the nurse identifies multiple red blister-like lesions on the edges of the client's vaginal
orifice. Once the nurse has spoken to the practitioner and receive prescriptions, the
priority nursing action is: - ANSWER- Preparing for a cesarean birth
A client who has had a postpartum hemorrhage is to receive 1 unit of packed red blood
cells (RBCs). The nurse manager observes a staff nurse administering the packed
RBCs without wearing gloves. What does the nurse manager conclude? - ANSWER-
The nurse should have worn gloves for self-protection.
A nurse is caring for a client with placenta previa who is in labor. What action is most
important for the nurse to take? - ANSWER- Evaluating external blood loss by counting
pads
, A nurse is teaching a pregnant client with sickle cell anemia about the importance of
taking supplemental folic acid. Folic acid is important for this client because it: -
ANSWER- Compensates for a rapid turnover of red blood cells
After an unexpected emergency cesarean birth the client tells the nurse, "I failed natural
childbirth." Which postpartum phase of adjustment does this statement most closely
typify? - ANSWER- Taking-in
A nurse provides a list of foods for a breastfeeding client with phenylketonuria (PKU) to
avoid. Which nutrient is included on the list? - ANSWER- Amino acids
-PKU is an inborn error of metabolism involving an inability to metabolize phenylalanine,
an essential amino acid. Lactose, glucose, and fatty acids are all metabolized by people
with PKU.
A client with worsening preeclampsia is admitted to the high-risk unit, and the nurse
manager places her in a private room. A nonstimulating environment is important for a
client with increased cerebral irritability because it: - ANSWER- Decreases the
probability of generalized seizures
A 16-year-old primigravida at 36 weeks' gestation visits the prenatal clinic for a routine
examination. Her blood pressure is significantly increased, and there is 1+ proteinuria.
The client's blood pressure had been averaging 92/70 mm Hg during her previous
prenatal visits. What is the lowest blood pressure that should cause the nurse to
become concerned? - ANSWER- 122/86 mm Hg
-An increase of 30 mm Hg systolic and/or 15 mm Hg diastolic has been removed from
the official definition of preeclampsia. The new definition encourages practitioners to
consider the total situation in determining a diagnosis of preeclampsia.
A nurse is counseling a pregnant woman with type 1 diabetes. What is the most
important nursing consideration in the planning of care for this client? - ANSWER-
Requirement of intensive prenatal care
A multipara whose membranes have ruptured is admitted in early labor. Assessment
reveals a breech presentation, cervical dilation of 3 cm, and fetal station at -2. For what
complication should the nurse assess when caring for this client? - ANSWER- Prolapse
of the umbilical cord
A client in labor is admitted with a suspected breech presentation. For what occurrence
should the nurse be prepared? - ANSWER- Prolapsed cord
Questions And Answers Verified 100% Correct
A nurse concludes that a positive contraction stress test (CST) result may be indicative
of potential fetal compromise. A CST result is considered positive when during
contractions the fetal heart rate shows: - ANSWER- Late decelerations
A client who has undergone a cesarean birth because of the presence of active genital
herpes is transferred to the postpartum unit. What type of isolation precautions does the
nurse plan to institute? - ANSWER- Contact
A primigravida is admitted with a ruptured fallopian tube resulting from a tubal
pregnancy and surgery is performed to remove the fallopian tube. What should
postoperative nursing care include? - ANSWER- Explaining that the client may still be
capable of becoming pregnant
The nurse is counseling a pregnant client with type 1 diabetes about medication
changes as pregnancy progresses. Which medication will be needed in increased
dosages during the second half of her pregnancy? - ANSWER- Insulin
After an incomplete abortion, a client tells a nurse that although her health care provider
explained what an incomplete abortion was, she did not understand. What is the best
response by the nurse? - ANSWER- "It's when the fetus is expelled but other parts of
the pregnancy remain in the uterus."
A client at term is admitted in active labor. She has tested positive for HIV. Which
intervention in the standard orders should the nurse question as a risk to the fetus? -
ANSWER- Internal fetal scalp electrode
A nurse is caring for a client who has had a spontaneous abortion. For what
complication should the nurse monitor this client? - ANSWER- Hemorrhage
While auscultating the lungs of a client admitted with severe preeclampsia, the nurse
identifies crackles. What inference does the nurse make when considering the presence
of crackles in the lungs? - ANSWER- Pulmonary edema has developed.
A client who is in the first trimester is being discharged after a week of hospitalization for
hyperemesis gravidarum. She is to be maintained at home with rehydration infusion
therapy. What is the priority nursing activity for the home health nurse? - ANSWER-
Monitoring the client for signs of electrolyte imbalances
,A client who had tocolytic therapy for preterm labor is being discharged. What
instructions should the nurse include in the teaching plan? - ANSWER- Limit daily
activities.
A nurse is caring for a client who is admitted to the birthing unit with a diagnosis of
abruptio placentae. For what complication associated with this problem should the
nurse monitor this client? - ANSWER- Hypovolemic shock
A client who had a cesarean birth is unable to void 3 hours after the removal of an
indwelling catheter. How can the nurse evaluate whether the client's bladder is
distended? - ANSWER- By palpating the client's suprapubic area gently
A client at 36 weeks' gestation arrives at the prenatal clinic for a routine examination.
The nurse determines that the client's blood pressure has increased from 102/60 to
134/88 mm Hg and becomes concerned she may be experiencing mild preeclampsia.
What other sign of mild preeclampsia does the nurse anticipate? - ANSWER-
Proteinuria of 1+
A client gives birth vaginally, with a midline episiotomy, to an infant who weighs 8 lb 13
oz (4000 g). An ice pack is applied to the perineum to ease the swelling and pain. The
client complains, "This pain in my vaginal and rectum is excruciating, and my vagina
feels so full and heavy." What does the nurse suspect as the cause of the pain? -
ANSWER- Vaginal hematoma
A client in labor, who is at term, is admitted to the birthing room. The fetus is in the left
occiput posterior position. The client's membranes rupture spontaneously. What
observation requires the nurse to notify the practitioner? - ANSWER- Greenish amniotic
fluid
A client is admitted in active labor at 39 weeks' gestation. During the initial examination
the nurse identifies multiple red blister-like lesions on the edges of the client's vaginal
orifice. Once the nurse has spoken to the practitioner and receive prescriptions, the
priority nursing action is: - ANSWER- Preparing for a cesarean birth
A client who has had a postpartum hemorrhage is to receive 1 unit of packed red blood
cells (RBCs). The nurse manager observes a staff nurse administering the packed
RBCs without wearing gloves. What does the nurse manager conclude? - ANSWER-
The nurse should have worn gloves for self-protection.
A nurse is caring for a client with placenta previa who is in labor. What action is most
important for the nurse to take? - ANSWER- Evaluating external blood loss by counting
pads
, A nurse is teaching a pregnant client with sickle cell anemia about the importance of
taking supplemental folic acid. Folic acid is important for this client because it: -
ANSWER- Compensates for a rapid turnover of red blood cells
After an unexpected emergency cesarean birth the client tells the nurse, "I failed natural
childbirth." Which postpartum phase of adjustment does this statement most closely
typify? - ANSWER- Taking-in
A nurse provides a list of foods for a breastfeeding client with phenylketonuria (PKU) to
avoid. Which nutrient is included on the list? - ANSWER- Amino acids
-PKU is an inborn error of metabolism involving an inability to metabolize phenylalanine,
an essential amino acid. Lactose, glucose, and fatty acids are all metabolized by people
with PKU.
A client with worsening preeclampsia is admitted to the high-risk unit, and the nurse
manager places her in a private room. A nonstimulating environment is important for a
client with increased cerebral irritability because it: - ANSWER- Decreases the
probability of generalized seizures
A 16-year-old primigravida at 36 weeks' gestation visits the prenatal clinic for a routine
examination. Her blood pressure is significantly increased, and there is 1+ proteinuria.
The client's blood pressure had been averaging 92/70 mm Hg during her previous
prenatal visits. What is the lowest blood pressure that should cause the nurse to
become concerned? - ANSWER- 122/86 mm Hg
-An increase of 30 mm Hg systolic and/or 15 mm Hg diastolic has been removed from
the official definition of preeclampsia. The new definition encourages practitioners to
consider the total situation in determining a diagnosis of preeclampsia.
A nurse is counseling a pregnant woman with type 1 diabetes. What is the most
important nursing consideration in the planning of care for this client? - ANSWER-
Requirement of intensive prenatal care
A multipara whose membranes have ruptured is admitted in early labor. Assessment
reveals a breech presentation, cervical dilation of 3 cm, and fetal station at -2. For what
complication should the nurse assess when caring for this client? - ANSWER- Prolapse
of the umbilical cord
A client in labor is admitted with a suspected breech presentation. For what occurrence
should the nurse be prepared? - ANSWER- Prolapsed cord
