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NUR 114 Test 2 adaptive Questions and Correct
Answers | Latest Update
An epidural anesthetic is planned for the adolescent who is in labor.
What nursing interventions are essential before epidural anesthesia is
administered? Select all that apply.
1. Performing a baseline vaginal examination
2. Telling the adolescent what to expect with each procedure
© 2026 Assignment
3. Identifying risk factors that contraindicate epidural anesthesia
4. Having the parents sign a consent form for the epidural anesthesia
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Expert
5. Explaining the need to stay in one position while the epidural catheter
is in place Ans: 1. Performing a baseline vaginal examination
2. Telling the adolescent what to expect with each procedure
3. Identifying risk factors that contraindicate epidural anesthesia
A baseline vaginal examination is needed to determine the extent of
cervical dilation and effacement. Before any procedure is implemented,
the nurse should explain the procedure and answer any questions. Risk
factors that contraindicate epidural anesthesia include antepartum
hemorrhage, bleeding disorders, and allergy to the medication. None of
these conditions is indicated in the client's history. Although a signed
informed consent is legally required for this invasive procedure, the
adolescent, not the parents, should sign the consent; a pregnant woman
is considered an emancipated minor and is legally empowered to sign the
consent. The client should change position from side to side every hour
to promote distribution of the anesthetic and to maintain circulation to
the uterus and placenta.
Which physiologic alteration does the nurse expect in a client's
hematologic system during the second trimester of pregnancy?
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1. An increase in hematocrit
2. An increase in blood volume
3. A decrease in sedimentation rate
4. A decrease in white blood cells Ans: 2. An increase in blood volume
The blood volume increases by approximately 50% during pregnancy.
Peak blood volume occurs between 30 and 34 weeks' gestation. The
hematocrit decreases as a result of hemodilution. The sedimentation rate
© 2026 Assignment
increases because of a decrease in plasma proteins. White blood cells
count remains stable during the antepartum period.
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A laboring client who is positive for group B Streptococcus (GBS) is given
Expert
an initial dose of 2 g of ampicillin at 9 AM. According to established
guidelines for intrapartum management of this client, what should the
next dose be?
1. 2 g given at 10 AM
2. 1 g given at 11 AM
3. 2 g given at noon
4. 1 g given at 1 PM Ans: 4. 1 g given at 1 PM
The established guidelines for intrapartum antibiotic prophylaxis for a
client infected with GBS is an initial dose of 2 g followed by a 1-g dose
every 4 hours.
A client's membranes rupture during labor, and the amniotic fluid is
meconium stained. Which heart rate pattern indicates that the fetus's
status is nonreassuring?
1. Early decelerations with average variability
2. Changes in baseline variability from 5 to 10 beats/min
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3. Increases in fetal heart rate from 135 to 150 beats/min with fetal
activity
4. Variable decelerations that last 60 seconds, then return to baseline
tachycardia Ans: 4. Variable decelerations that last 60 seconds, then
return to baseline tachycardia
Variable decelerations indicate cord compression; they should return to
baseline. Tachycardia indicates fetal hypoxia, maternal fever, infection,
or some other factor that is stressing the fetus. Early decelerations and
© 2026 Assignment
changes in baseline variability are both expected, benign findings.
Increases in fetal heart rate with fetal movement are an expected finding.
A woman in labor with her third child is dilated to 7 cm, and the fetal
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Expert
head is at station +1. The client's membranes rupture. What is the nurse's
priority intervention?
1. Notify the practitioner.
2. Observe the vaginal opening for a prolapsed cord.
3. Reposition the client on a sterile towel on her left side.
4. Check the fetal heart rate while observing the color of the amniotic
fluid. Ans: 4. Check the fetal heart rate while observing the color of the
amniotic fluid.
Fetal well-being is the priority. The fetal heart rate will reflect the fetus's
response to the rupture of the membranes, and the color of the amniotic
fluid will reveal whether there is meconium staining. Notifying the
practitioner is necessary if the nurse's assessments reveal fetal
compromise. Although checking the vaginal opening for cord prolapse is
important, it is not the priority; the fetal head is engaged at station +1.
Although positioning the client on the left side promotes placental
perfusion, it is not the priority, and a sterile pad is not needed.
NUR 114 Test 2 adaptive Questions and Correct
Answers | Latest Update
An epidural anesthetic is planned for the adolescent who is in labor.
What nursing interventions are essential before epidural anesthesia is
administered? Select all that apply.
1. Performing a baseline vaginal examination
2. Telling the adolescent what to expect with each procedure
© 2026 Assignment
3. Identifying risk factors that contraindicate epidural anesthesia
4. Having the parents sign a consent form for the epidural anesthesia
Guru01 - Stuvia
Expert
5. Explaining the need to stay in one position while the epidural catheter
is in place Ans: 1. Performing a baseline vaginal examination
2. Telling the adolescent what to expect with each procedure
3. Identifying risk factors that contraindicate epidural anesthesia
A baseline vaginal examination is needed to determine the extent of
cervical dilation and effacement. Before any procedure is implemented,
the nurse should explain the procedure and answer any questions. Risk
factors that contraindicate epidural anesthesia include antepartum
hemorrhage, bleeding disorders, and allergy to the medication. None of
these conditions is indicated in the client's history. Although a signed
informed consent is legally required for this invasive procedure, the
adolescent, not the parents, should sign the consent; a pregnant woman
is considered an emancipated minor and is legally empowered to sign the
consent. The client should change position from side to side every hour
to promote distribution of the anesthetic and to maintain circulation to
the uterus and placenta.
Which physiologic alteration does the nurse expect in a client's
hematologic system during the second trimester of pregnancy?
, 2 for specific request mail
1. An increase in hematocrit
2. An increase in blood volume
3. A decrease in sedimentation rate
4. A decrease in white blood cells Ans: 2. An increase in blood volume
The blood volume increases by approximately 50% during pregnancy.
Peak blood volume occurs between 30 and 34 weeks' gestation. The
hematocrit decreases as a result of hemodilution. The sedimentation rate
© 2026 Assignment
increases because of a decrease in plasma proteins. White blood cells
count remains stable during the antepartum period.
Guru01 - Stuvia
A laboring client who is positive for group B Streptococcus (GBS) is given
Expert
an initial dose of 2 g of ampicillin at 9 AM. According to established
guidelines for intrapartum management of this client, what should the
next dose be?
1. 2 g given at 10 AM
2. 1 g given at 11 AM
3. 2 g given at noon
4. 1 g given at 1 PM Ans: 4. 1 g given at 1 PM
The established guidelines for intrapartum antibiotic prophylaxis for a
client infected with GBS is an initial dose of 2 g followed by a 1-g dose
every 4 hours.
A client's membranes rupture during labor, and the amniotic fluid is
meconium stained. Which heart rate pattern indicates that the fetus's
status is nonreassuring?
1. Early decelerations with average variability
2. Changes in baseline variability from 5 to 10 beats/min
, 3 for specific request mail
3. Increases in fetal heart rate from 135 to 150 beats/min with fetal
activity
4. Variable decelerations that last 60 seconds, then return to baseline
tachycardia Ans: 4. Variable decelerations that last 60 seconds, then
return to baseline tachycardia
Variable decelerations indicate cord compression; they should return to
baseline. Tachycardia indicates fetal hypoxia, maternal fever, infection,
or some other factor that is stressing the fetus. Early decelerations and
© 2026 Assignment
changes in baseline variability are both expected, benign findings.
Increases in fetal heart rate with fetal movement are an expected finding.
A woman in labor with her third child is dilated to 7 cm, and the fetal
Guru01 - Stuvia
Expert
head is at station +1. The client's membranes rupture. What is the nurse's
priority intervention?
1. Notify the practitioner.
2. Observe the vaginal opening for a prolapsed cord.
3. Reposition the client on a sterile towel on her left side.
4. Check the fetal heart rate while observing the color of the amniotic
fluid. Ans: 4. Check the fetal heart rate while observing the color of the
amniotic fluid.
Fetal well-being is the priority. The fetal heart rate will reflect the fetus's
response to the rupture of the membranes, and the color of the amniotic
fluid will reveal whether there is meconium staining. Notifying the
practitioner is necessary if the nurse's assessments reveal fetal
compromise. Although checking the vaginal opening for cord prolapse is
important, it is not the priority; the fetal head is engaged at station +1.
Although positioning the client on the left side promotes placental
perfusion, it is not the priority, and a sterile pad is not needed.
