NURS 3610 TEST 1& 2 QUESTIONS & ANSWERS
A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of
labor. Which of the following assessment findings should the nurse report to the
provider first?
A. Expulsion of a blood-tinged mucous plug
B. Continuous contraction lasting 2 min
C. Pressure on the perineum causing the client to bear down
D. Expulsion of clear fluid from the vagina - Answers - B. Continuous contraction
lasting 2 min
i: A uterus contracting for more than 90 seconds is a sign of tetany and could lead to
uterine rupture, which is the greatest risk to the client at this time. The nurse should
report this finding immediately.
A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which
of the following statements by the nurse should be included in the teaching?
A. "You will need to increase your calcium intake during breastfeeding."
B. "Prenatal vitamins will meet your need for increased vitamin D during pregnancy."
C. "Vitamin E requirements decline during pregnancy due to the increase in body fat."
D. "You will need to double your intake of iron during pregnancy." - Answers - D. "You
will need to double your intake of iron during pregnancy."
i: During pregnancy, the need for iron increases to allow transfer of the appropriate
amounts to the fetus and to support expansion of the client's red blood cell volume.
A nurse is teaching about fetal development to a group of clients in the antenatal clinic.
Which of the following statements should the nurse include in the teaching?
A. "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of
pregnancy."
B. "The sex of the baby is determined by week 8 of pregnancy."
C. "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of
pregnancy."
D. "You will first feel your baby move in week 24 of pregnancy." - Answers - A. "The
baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy."
i: The fetal heartbeat is audible by Doppler stethoscope between 8 to 17 weeks of
gestation.
A nurse on the labor and delivery unit is caring for a client following a vaginal
examination by the provider which is documented as: -1. Which of the following
interpretations of this finding should the nurse make?
A. The presenting part is 1cm above the ischial spines.
B. The presenting art is 1cm below the ischial spines.
C. The cervix is 1cm dilated.
,D. The cervix is effaced 1cm. - Answers - A. The presenting part is 1cm above the
ischial spines.
i: Station is the relation of the presenting part to the ischial spines of the maternal pelvis
and is measured in centimeters above, below, or at the level of the spines. If the station
is minus 1, then the presenting part is 1cm above the ischial spines.
A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and
scheduled for an amniocentesis. The client asks why she is having an ultrasound prior
to the procedure. Which of the following is an appropriate response by the nurse?
A. "This will determine is there is more than one fetus."
B. "It is useful for estimating fetal age."
C. "It assists in identifying the location of the placenta and fetus."
D. "This is a screening tool for spina bifida." - Answers - C. "It assists in identifying the
location of the placenta and fetus."
i: Identifying the positions of the fetus, placenta, and amniotic fluid pockets immediately
prior to the amniocentesis increases the safety of this test by assisting with correct
placement of the needle.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse
determines that the contractions have a durtiong of 1min and a frequency of 3min. The
nurse obtains the following vitals: fetal heart rate 130/min, maternal heart rate 128/min,
and maternal blood pressure 92/54mmHg. Which of the following is the priority action
for the nurse to take?
A. Notify the provider of the findings.
B. Position the client with one hip elevated.
C. Ask the client if she needs pain medication.
D. Have the client void. - Answers - B. Position the client with one hip elevated.
i: Based on Maslow's hierarchy of needs, the client's need for an adequate blood
pressure to perfuse herself and her fetus is a physiological need that requires
immediate intervention. Supine hypotension is a frequent cause of low blood pressure in
clients who are pregnant. By turning the client on her side and retaking her blood
pressure, the nurse is attempting to correct the low blood pressure and reassess.
A nurse is caring for a group of clients on an intrapartum unit. Which of the following
findings should be reported to the provider immediately?
A. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent
contractions.
B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine
tremors.
C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar
reflexes.
,D. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved
headache. - Answers - D. A client who has a diagnosis of preeclampsia reports
epigastric pain and unresolved headache.
i: These findings indicate that the client's condition is worsening and are signs of severe
preeclampsia. They should be reported to the provider immediately. Other
manifestations of severe preeclampsia include: blood pressure of 160/100 mm Hg or
greater, proteinuria 3+ to 4+, oliguria, visual disturbances, such as blurred vision,
hyperreflexia with clonus, nausea, vomiting, epigastric pain, and right upper-quadrant
pain.
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The
client has 6cm of cervical dilation and 100% cervical effacement. The nurse obtains the
client's blood pressure reading as 82/52mmHg. Which of the following nursing
interventions should the nurse perform?
A. Prepare for a cesarean birth.
B. Assist the client to an upright position.
C. Prepare for an immediate vaginal delivery.
D. Assist the client to turn onto her side. - Answers - D. Assist the client to turn onto
her side.
i: Maternal hypotension results from the pressure of the enlarged uterus on the inferior
vena cava. Turning the client to her right side relieves this pressure and restores blood
pressure to the expected reference range.
A nurse is caring for a client who is having a nonstress test performed. The fetal heart
rate is 130 to 150/min, but there has been no fetal movement for 15min. Which of the
following actions should the nurse perform?
A. Immediately report the situation to the client's provider and prepare the client for
induction of labor.
B. Encourage the client to walk around without the monitoring unit for 10min, then
resume monitoring.
C. Offer the client a snack of orange juice and crackers.
D. Turn the client onto her left side. - Answers - C. Offer the client a snack of orange
juice and crackers.
i: A nonstress test depends upon fetal movement, and this fetus is most likely asleep.
Most fetuses are more active after meals due to the increase in the mother's blood
sugar. Giving the mother a snack will promote fetal movement.
A nurse is caring for a client during the first trimester of pregnancy. After reviewing the
client's blood work, the nurse notices she does not have immunity to rubella. Which of
the following times should the nurse understand is recommended for rubella
immunization?
A. Shortly after giving birth
B. In the third trimester
, C. Immediately
D. During her next attempt to get pregnant - Answers - A. Shortly after giving birth
i: The rubella immunization should be offered to the client following birth, preferably
prior to discharge from the hospital. This prevents the client from contracting rubella
during the current or subsequent pregnancies, which would put her fetus at risk for
rubella syndrome.
A nurse in a prenatal clinic is completing a skin assessment of a client who is in the
second trimester. Which of the following findings should the nurse expect? (SATA)
A. Eczema
B. Psoriasis
C. Linea nigra
D. Chloasma
E. Striae gravidarum - Answers - C, D, E
i: Linea nigra manifests as a line of pigmentation extending from the symphysis pubis to
the top of the fundus and is an expected finding during pregnancy. Chloasma, or the
mask of pregnancy, manifests as blotchy, brownish hyperpigmentation of the skin over
the forehead, nose, and cheeks and is an expected finding during pregnancy. Striae
gravidarum, or stretch marks, occur because of the separation of underlying connective
tissue on the breasts, thighs, and abdomen. They are an expected finding during
pregnancy.
A nurse is performing Leopold maneuvers on a client who is in labor and determines the
fetus is in an RSA position. Which of the following fetal presentations should the nurse
document in the client's medical record?
A. Vertex
B. Shoulder
C. Breech
D. Mentum - Answers - C. Breech
i: An RSA position indicates that the body part of the fetus that is closest to the cervix is
the sacrum. Therefore, the buttocks or feet are the presenting part, which is classified
as a breech presentation.
A nurse is caring for a client who is at 18 weeks gestation. The client tells the nurse that
she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret
this finding as which of the following?
A. Ballottement
B. Lightening
C. Quickening
D. Chloasma - Answers - C. Quickening
i: Clients describe quickening as a fluttering sensation, which can be felt as early as the
14th week of gestation. It reflects fetal movement.
A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of
labor. Which of the following assessment findings should the nurse report to the
provider first?
A. Expulsion of a blood-tinged mucous plug
B. Continuous contraction lasting 2 min
C. Pressure on the perineum causing the client to bear down
D. Expulsion of clear fluid from the vagina - Answers - B. Continuous contraction
lasting 2 min
i: A uterus contracting for more than 90 seconds is a sign of tetany and could lead to
uterine rupture, which is the greatest risk to the client at this time. The nurse should
report this finding immediately.
A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which
of the following statements by the nurse should be included in the teaching?
A. "You will need to increase your calcium intake during breastfeeding."
B. "Prenatal vitamins will meet your need for increased vitamin D during pregnancy."
C. "Vitamin E requirements decline during pregnancy due to the increase in body fat."
D. "You will need to double your intake of iron during pregnancy." - Answers - D. "You
will need to double your intake of iron during pregnancy."
i: During pregnancy, the need for iron increases to allow transfer of the appropriate
amounts to the fetus and to support expansion of the client's red blood cell volume.
A nurse is teaching about fetal development to a group of clients in the antenatal clinic.
Which of the following statements should the nurse include in the teaching?
A. "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of
pregnancy."
B. "The sex of the baby is determined by week 8 of pregnancy."
C. "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of
pregnancy."
D. "You will first feel your baby move in week 24 of pregnancy." - Answers - A. "The
baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy."
i: The fetal heartbeat is audible by Doppler stethoscope between 8 to 17 weeks of
gestation.
A nurse on the labor and delivery unit is caring for a client following a vaginal
examination by the provider which is documented as: -1. Which of the following
interpretations of this finding should the nurse make?
A. The presenting part is 1cm above the ischial spines.
B. The presenting art is 1cm below the ischial spines.
C. The cervix is 1cm dilated.
,D. The cervix is effaced 1cm. - Answers - A. The presenting part is 1cm above the
ischial spines.
i: Station is the relation of the presenting part to the ischial spines of the maternal pelvis
and is measured in centimeters above, below, or at the level of the spines. If the station
is minus 1, then the presenting part is 1cm above the ischial spines.
A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and
scheduled for an amniocentesis. The client asks why she is having an ultrasound prior
to the procedure. Which of the following is an appropriate response by the nurse?
A. "This will determine is there is more than one fetus."
B. "It is useful for estimating fetal age."
C. "It assists in identifying the location of the placenta and fetus."
D. "This is a screening tool for spina bifida." - Answers - C. "It assists in identifying the
location of the placenta and fetus."
i: Identifying the positions of the fetus, placenta, and amniotic fluid pockets immediately
prior to the amniocentesis increases the safety of this test by assisting with correct
placement of the needle.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse
determines that the contractions have a durtiong of 1min and a frequency of 3min. The
nurse obtains the following vitals: fetal heart rate 130/min, maternal heart rate 128/min,
and maternal blood pressure 92/54mmHg. Which of the following is the priority action
for the nurse to take?
A. Notify the provider of the findings.
B. Position the client with one hip elevated.
C. Ask the client if she needs pain medication.
D. Have the client void. - Answers - B. Position the client with one hip elevated.
i: Based on Maslow's hierarchy of needs, the client's need for an adequate blood
pressure to perfuse herself and her fetus is a physiological need that requires
immediate intervention. Supine hypotension is a frequent cause of low blood pressure in
clients who are pregnant. By turning the client on her side and retaking her blood
pressure, the nurse is attempting to correct the low blood pressure and reassess.
A nurse is caring for a group of clients on an intrapartum unit. Which of the following
findings should be reported to the provider immediately?
A. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent
contractions.
B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine
tremors.
C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar
reflexes.
,D. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved
headache. - Answers - D. A client who has a diagnosis of preeclampsia reports
epigastric pain and unresolved headache.
i: These findings indicate that the client's condition is worsening and are signs of severe
preeclampsia. They should be reported to the provider immediately. Other
manifestations of severe preeclampsia include: blood pressure of 160/100 mm Hg or
greater, proteinuria 3+ to 4+, oliguria, visual disturbances, such as blurred vision,
hyperreflexia with clonus, nausea, vomiting, epigastric pain, and right upper-quadrant
pain.
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The
client has 6cm of cervical dilation and 100% cervical effacement. The nurse obtains the
client's blood pressure reading as 82/52mmHg. Which of the following nursing
interventions should the nurse perform?
A. Prepare for a cesarean birth.
B. Assist the client to an upright position.
C. Prepare for an immediate vaginal delivery.
D. Assist the client to turn onto her side. - Answers - D. Assist the client to turn onto
her side.
i: Maternal hypotension results from the pressure of the enlarged uterus on the inferior
vena cava. Turning the client to her right side relieves this pressure and restores blood
pressure to the expected reference range.
A nurse is caring for a client who is having a nonstress test performed. The fetal heart
rate is 130 to 150/min, but there has been no fetal movement for 15min. Which of the
following actions should the nurse perform?
A. Immediately report the situation to the client's provider and prepare the client for
induction of labor.
B. Encourage the client to walk around without the monitoring unit for 10min, then
resume monitoring.
C. Offer the client a snack of orange juice and crackers.
D. Turn the client onto her left side. - Answers - C. Offer the client a snack of orange
juice and crackers.
i: A nonstress test depends upon fetal movement, and this fetus is most likely asleep.
Most fetuses are more active after meals due to the increase in the mother's blood
sugar. Giving the mother a snack will promote fetal movement.
A nurse is caring for a client during the first trimester of pregnancy. After reviewing the
client's blood work, the nurse notices she does not have immunity to rubella. Which of
the following times should the nurse understand is recommended for rubella
immunization?
A. Shortly after giving birth
B. In the third trimester
, C. Immediately
D. During her next attempt to get pregnant - Answers - A. Shortly after giving birth
i: The rubella immunization should be offered to the client following birth, preferably
prior to discharge from the hospital. This prevents the client from contracting rubella
during the current or subsequent pregnancies, which would put her fetus at risk for
rubella syndrome.
A nurse in a prenatal clinic is completing a skin assessment of a client who is in the
second trimester. Which of the following findings should the nurse expect? (SATA)
A. Eczema
B. Psoriasis
C. Linea nigra
D. Chloasma
E. Striae gravidarum - Answers - C, D, E
i: Linea nigra manifests as a line of pigmentation extending from the symphysis pubis to
the top of the fundus and is an expected finding during pregnancy. Chloasma, or the
mask of pregnancy, manifests as blotchy, brownish hyperpigmentation of the skin over
the forehead, nose, and cheeks and is an expected finding during pregnancy. Striae
gravidarum, or stretch marks, occur because of the separation of underlying connective
tissue on the breasts, thighs, and abdomen. They are an expected finding during
pregnancy.
A nurse is performing Leopold maneuvers on a client who is in labor and determines the
fetus is in an RSA position. Which of the following fetal presentations should the nurse
document in the client's medical record?
A. Vertex
B. Shoulder
C. Breech
D. Mentum - Answers - C. Breech
i: An RSA position indicates that the body part of the fetus that is closest to the cervix is
the sacrum. Therefore, the buttocks or feet are the presenting part, which is classified
as a breech presentation.
A nurse is caring for a client who is at 18 weeks gestation. The client tells the nurse that
she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret
this finding as which of the following?
A. Ballottement
B. Lightening
C. Quickening
D. Chloasma - Answers - C. Quickening
i: Clients describe quickening as a fluttering sensation, which can be felt as early as the
14th week of gestation. It reflects fetal movement.
