Practice Exams ALL ANSWERS 100% CORRECT FALL-2021/2022 ‘SOLVED’ LATEST GUARANTEED GRADE A+

1. A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? -Painless, bright red vaginal bleeding -A soft abdomen -Absence of abdominal pain -Uterine tenderness/pain Response Feedback: Placental abruption may be painful with dark red blood. The patient may experience a rigid, board-like abdomen. 2. As the client reaches 8 cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165- 175 bpm with variability of 0-2 bpm. What is the most likely explanation of this pattern? -There is a vagal response -The umbilical cord is compressed -The baby is asleep -There is uteroplacental insufficiency Response Feedback: Late decels are caused by placental insufficiencies. 3. The client has a FHR baseline of 145 bpm. You notice on the monitor that the fetus is having fetal heart rates of 90- 110 bpm after the contractions. The first action the nurse should take is: -Prepare the client for delivery -Reposition the monitor -Turn the client to her left side -Ask the client to ambulate Response Feedback: The patient is experiencing Late Decels, turn the patient, bolus of fluids, administer O2, and turn off pitocin. 4. The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by: -Palpating the maternal radial pulse while listening to the fetal heart rate -Placing the client on her left side -Noting if the heart rate is greater than 140 bpm -Performing Leopold's maneuver first to determine the location of the fetal heart Response Feedback: By performing the Leopold's maneuver, you can identify where the fetal back is in order to better listen to the fetal heart beat. 5. Which of the following is a characteristic of a reassuring fetal heart rate pattern? -Palpating the maternal radial pulse while listening to the fetal heart rate -Placing the client on her left side -Noting if the heart rate is greater than 140 bpm -Performing Leopold's maneuver first to determine the location of the fetal heart Response Feedback: Reassuring fetal heart rate pattern would include accelerations of FHR with fetal movements. FHR above 160 is considered tachycardia, baseline variability of 25 is considered Marked and not necessarily reassuring. Ominous periodic changes are never a good thing. 1. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? -Short-term Variability -Early Decelerations -Late Decelerations -Variable Decelerations Response Feedback: Variable Decelerations would be present if the fetus is experiencing cord compression = prolapsed cord. 2. A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: -Place the mother in the supine position. -Turn the patient on her left side. -Increase the rate of IV Pitocin -Document the findings and continue to monitor. Response Feedback: To increase uteroplacental perfusion, you would turn the patient onto her left side to avoid compression of the vena cava. You would NOT increase pitocin - turn it off, do not lay the patient supine, and this is a concerning pattern; so, yes document, but please provide an intervention. 3. A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the monitor, the initial nursing assessment is which of the following? -Determining the frequency of the contractions. -Assessing the baseline fetal heart rate. -Determining the intensity of the contractions. -Identifying the types of accelerations. Response Feedback: The first thing you will assess is the fetal baseline. After that is determined, you would look at variability, accels, decels, and contractions. 4. A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? -Changes in the shape of the uterus. -The umbilical cord shortens in length and changes in color. -Maternal complaints of severe uterine cramping. -A soft and boggy uterus. Response Feedback: The uterus will become firm and round with the delivery of the placenta. The cord will lengthen, not shorten; the uterus will be firm not soft and boggy; the patient will experience mild-moderate cramping - not severe. 5. A nurse is in the labor room and notes that the physician has documented that the fetus is -1 station. The nurse determines that the fetal presenting part is: -1 inch below the iliac crest -1 cm above the ischial spine -1 inch below the coccyx -1 fingerbreadth below the symphysis pubis Response Feedback: 1 cm above the ischial spine is how this would be measured and documented. 1. A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? -A fetal heart rate of 90 beats per minute -Three contractions occurring within a 10-minute period -Adequate resting tone of the uterus palpated between contractions -Increased urinary output 2. A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as a sign of: -Postpartum hemorrhage -Uterine atony -Placental separation -Hematoma 3. A client arrives at a birthing center in active labor. Her membranes are still intact and the nurse midwife prepares to perform an amniotomy. A nurse who is assisting the nurse midwife explains to the client that after this procedure she will most likely have: -Increased efficiency of contractions -The need for increased maternal blood pressure monitoring -Decreased number of contractions -Less pressure on her cervix 4. Childbirth involves four distinct stages. Which of these stages occurs after the cervix is dilated to 10 cm until the delivery of the baby? -1st stage -2nd stage -3rd stage -4th stage 5. In understanding the physiologic process of labor, which of the following is NOT one of the "five Ps?" -Powers -Presence -Passenger -Passageway Response Feedback: Passenger, Passageway, Power, Position of mother, Psychologic response 1. A newborn’s primary method of heat production is through nonshivering thermogenesis. This process oxidizes which of the following in response to cold exposure? -White fat -Muscles -Nerves -Brown fat Response Feedback: The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. The brown color is derived from the fat's rich supply of blood vessels and nerve endings. 2. The APGAR score is based on which 5 parameters? -Heart rate, breaths per minute, irritability, tone and color -Heart rate, muscle tone, reflex irritability, respiratory effort and color -Heart rate, respiratory effort, temperature, tone and color -Heart rate, breaths per minute, irritability, reflexes and color Response Feedback: A newborn can receive an APGAR score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluted by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet. 3. Ophthalmia neonatorum is contracted when a mother has which sexually transmitted infection(s)? -Chlamydia -Gonnorrhea -Trichomonas -Both A and B -Both B and C Response Feedback: Colonization of chlamydia and gonorrhea in the vaginal tract can lead to ophthalmia neonatorum in the newborn. 4. A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? -Insert eye prophylaxis -Assess the APGAR score -Elicit the Moro reflex -Remove wet blankets first Response Feedback: When newborns are wet they can become hypothermic from heat loss resulting from evaporation. They may then develop cold stress syndrome 5. A client has just given birth at 42 weeks gestation. When assessing the neonate, which physical finding is expected? -Desquamation of the epidermis -A sleepy, lethargic baby -Lanugo covering the body -Vernix caseosa covering the body Response Feedback: