Question 5381)
A woman spontaneously delivers a baby girl who is immediately handed to the
nurse. Which action is of highest priority for the nurse?
A. Do an Apgar assessment
B. Check neonatal heart rate
C. Apply identification bracelets
D. Clear the nasopharynx.
Answer: D
Explanation: Always make sure the airway is clear first. Apgar scoring is not the licensed practical nurse’s
responsibility, and it is not the highest priority. Checking heart rate and applying identification bracelets are
secondary to clearing the airway.
Question 5382)
At one minute after birth, an infant is crying, has a heart rate of 140, has
acrocyanosis, resists the suction catheter, and keeps his arms extended and his legs flexed. What
is the Apgar score?
A. 4
B. 6
C. 8
D. 10
Answer: C
Explanation: He receives 2 points for respiratory effort because he is crying. He receives 2 points for his heartbeat
because it is over 100. He receives 1 point for acrocyanosis (blue extremities). He receives 2 points for reflexes
because he resists the suction catheters. He receives 1 point instead of 2 because his arms are extended instead of
flexed. He receives 8 points out of the maximum score of 10 points.
Question 5383)
The delivery room nurse is explaining Apgar scoring to new parents. Which
information pertaining to the purpose of a five-minute Apgar score should be included in the
explanation?
A. It evaluates the effectiveness of the labor and delivery.
B. It measures the adequacy of transition to extrauterine life.
C. It assesses the possibility of respiratory distress syndrome
D. It gives an estimate of the gestational age of the infant.
Answer: B
Explanation: The Apgar score assesses the infant on respiratory effort, heart rate, color, reflexes, and muscle tone.
These indicate his adaptation to extrauterine life. The purpose of the Apgar score is not to evaluate the
effectiveness of labor and delivery, assess respiratory distress syndrome, or give an estimate of gestational age of
the infant.
Question 5384)
The nurse is caring for a woman who has had a spinal anesthetic. Which of the
following would be most likely to occur after spinal anesthesia?
A. The client states that she is dizzy and lightheaded.
B. The temperature is 101°F.
C. The nurse observes the client shivering.
D. The client develops a red, itchy rash on her back and chest.
Answer: C
Explanation: Chills occurs frequently after administration of a regional anesthetic such as Carbocaine. A spinal
anesthetic does not usually cause the client to be dizzy and light-headed. Fever and rash are not likely to occur
after spinal anesthesia
Question 5385)
What action is essential for the nurse during the fourth stage of labor?
A. Firmly massage the fundus every 15 minutes.
B. Take the vital signs every 1 hour
C. Turn the client on her side during a lochia check.
D. Assist the client to the bathroom to void.
Answer: C
Explanation: Lochia can accumulate under the buttocks. It cannot be accurately observed in a supine position. The
nurse assesses the fundus every 15 minutes and massages it only when it is soft. Vital signs will be every 15
minutes, not every hour. The client will not get up to void this soon after delivery.
Question 5386)
Which of the following is the most important nursing assessment during the fourth
stage of labor?
A. Bonding behaviors
B. Distention of the bladder
C. Ability to relax
D. Knowledge of newborn behavior
Answer: B
Explanation: A distended bladder may interfere with involution of the uterus and cause excessive bleeding. The
nurse will observe for appropriate bonding behaviors and maternal relaxation and maternal knowledge of newborn
behavior, but the most important is assessment for bladder distention (because that could cause uterine relaxation
and hemorrhage).
Question 5387)
A woman who is 32 weeks gestation is admitted with contractions every four
minutes. Ritodrine is given for which of the following purposes?
A. To suppress uterine activity
B. To make her more comfortable
C. To enhance contractions
D. To increase fetal oxygenation
Answer: A
Explanation: This woman is in premature labor. Ritodrine is used to suppress uterine activity. Note that answers 1
and 3 are opposites. Usually when there are opposites, one of the opposites is the correct answer. It would not be
logical to enhance contractions in a woman who is not at term. Ritodrine is not an analgesic and does not increase
fetal oxygenation.
Question 5388)
The nursing care plan for a woman who has placenta abruptio should include
careful assessment for signs and symptoms of which of the following?
A. Jaundice
B. Hypovolemic shock
C. Impending convulsions
D. Hypertension
Answer: B
Explanation: Abruptio placenta causes hemorrhage, either apparent or concealed. The nurse must observe for
hypovolemic shock. Jaundice is not seen with placenta abruptio. Convulsions occur with eclampsia or pregnancyinduced hypertension. The client who is hemorrhaging will develop shock, not hypertension. Note the opposites;
shock is low blood pressure, and hypertension is high blood pressure. The answer is likely to be one of the
opposites.
Question 5389)
A woman had a normal deliver two hours ago has just arrived on the postpartum
floor. Vital signs are normal. When assessing her uterus, the nurse notes that it is boggy. What
should be the nurse’s initial intervention?
A. Massage the uterus
B. Report to the charge nurse
C. Contact the doctor stat
D. Continue to assess it frequently
Answer: A
Explanation: The initial response is to massage the uterus. Most of the time, massaging the uterus will cause it to
firm up immediately. If it does not respond to massage by becoming firm, then the practical nurse should report it
to the charge nurse or contact the physician. The nurse will continue to assess frequently after massaging the
fundus. Note that the question asked for the initial intervention.
Question 5390)
The nurse is caring for a woman who had a normal vaginal delivery two hours ago
and has just arrived on the postpartum floor. Two hours later, her uterus is displaced to the right.
What is the most likely explanation for this?
A. A fibroid tumor
B. A full bladder
C. An increase in interstitial fluid
D. Retained placental fragments
Answer: B
Explanation: A full bladder causes the uterus to be elevated above the umbilicus and displaced to the right. A
fibroid tumor, if present, would not cause a change in position of the uterus in a two-hour time period. Interstitial
fluid does not accumulate in the uterus and could not cause the uterine position change. Retained placental
fragments would cause an increase in vaginal bleeding or a boggy fundus but not displacement of the fundus.
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