98 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5361) 

A 26-year-old, gravida 3, para 0, term 0, preterm 0, abortion 2, living 0 in early labor is admitted to labor and delivery. She is not sure if her membranes have ruptured. She has had some leakage of fluid. How should the nurse begin the assessment? 

A. “Tell me about your other labor experiences.”

B. “How old are your other children?” 

C. “Did you bring an example of the fluid that was leaking with you?” 

D. “Describe your contractions to me.” 

Answer: D 

Explanation: This is the appropriate assessment in early labor. Because she is para 0 and abortion 2, the nurse knows that she has not carried a pregnancy at least 20 weeks. She has not had labor and has not given birth, so answers 1 and 2 are not appropriate. It is not reasonable to expect the woman to bring a sample of the fluid with her. 

Question 5362) 

A woman, 38 weeks pregnant, arrives in the labor and delivery suite and tells the nurse that she thinks her membranes have ruptured. The nurse uses phenaphthazine (Nitrazine) paper to test the leaking fluid. The nurse expects the Nitrazine paper to turn which color if amniotic fluid is present? 

A. Red 

B. Orange 

C. Blue 

D. Purple 

Answer: C Explanation: Amniotic fluid is alkaline and turns Nitrazine paper blue. Urine is acidic and turns Nitrazine paper red. 

Question 5363) 

A 29-year-old woman who is pregnant for the first time and is 40 weeks gestation is admitted to labor and delivery. She is 3-cm dilated, 80% effaced, and head at 0 station. She and her husband have been to prepared childbirth classes and are eager to give birth naturally. During her first contraction in the hospital, which lasts 30 seconds, the nurse observes the client using rapid pant-blow breathing. What is the most appropriate response for the nurse to make at this time? 

A. “Don’t pant. It’s too early in labor for panting.” 

B. “Continue using pant-blow breathing until the RN checks to see if you are fully dilated.” C. “Good. You are using your breathing from class. Keep it up.” 

D. “What kinds of breathing techniques did you learn in childbirth class?” 

Answer: D 

Explanation: panting is not appropriate breathing pattern at this time. Panting is important when the woman has the desire to push but she should not push. Further assessment is needed to help her alter her breathing to a more appropriate pace. If she continues panting at this time, she will be at risk for developing respiratory alkalosis and exhausting herself. Answer 1 is a true statement but is a putdown to the client. Answer 2 is not correct. Her contractions are not compatible with late first stage of labor (transition), when the pant-blow breathing pattern is appropriate. Answer 3 is not correct. She is using an inappropriate breathing technique. 

Question 5364) 

The physician is performing an amniotomy on a woman in labor. What is the most important nursing action during this procedure? A. Assist the physician B. Keep the mother informed C. Monitor fetal heart tones D. Encourage slow chest breathing Answer: C Explanation: Amniotomy can be stressful for the fetus. Assessing the fetal heart rate is the priority nursing measure during amniotomy. Keeping the mother informed is not as important as fetal safety. The procedure is painless, so breathing techniques are not necessary. 

Question 5365) 

who is having contractions every five to seven minutes that last 45 to 50 seconds. Her husband asks if this is transition because his wife is getting restless and irritable and feels pressure. What is the best response for the nurse to make? 

A. “Transition is still a long way off. Don’t you remember this from your classes?” 

B. “Her contractions are not typical of transition, but I’ll have the RN check her.” 

C. “The contractions are typical of transition. You are very observant 

D. “It’s impossible to tell where she is without doing an exam.” 

Answer: B 

Explanation: Contractions during transition usually occur every two to three minutes and last 60 to 90 seconds. Her contractions are not typical of transition, but the only way to be sure is to have the RN do a vaginal exam. Answer 1 ignores the symptoms and puts the client down. Answer 3 is incorrect information; her contractions are not typical of transition. Irritability and restlessness can be signs of transition. Answer 4 is not a useful response. It is not completely true, and it is certainly not a therapeutic response. 

Question 5366) 

A woman is in labor with her first baby. She has prepared for a natural childbirth. As labor progresses, she becomes increasingly irritable with her husband, complaining of lower back pain and fatigue. What is the most appropriate response for the nurse to make? 

A. Have the client turn on her side and give her a back rub. 

B. Ask the client if she would like the doctor to give her something for the discomfort 

C. Reassure the husband that irritability is normal now, and teach him to apply pressure to his wife’s lower back. 

D. Encourage the client to try and get some rest, and ask her husband if he would like to take a coffee break. 

Answer: C 

Explanation: Rubbing the lower back usually helps the husband deal with his feelings of helplessness and fosters the couple’s sense of mutual experience. Answer 1 is not appropriate because it is better for the mate to give the back rub if he is able and willing than for the nurse to do it. Answer 2 is not appropriate because she has said that she wants to have a natural childbirth. Answer 4 is not realistic. It is not realistic to encourage a woman in active labor to rest. Sending the husband away is not appropriate. 

Question 5367)

An epidural block is ordered for a woman in labor. Which nursing action is essential because the client has epidural anesthesia 

A. Monitoring the uterus for uterine tetany 

B. Giving oxytocin to counteract the effect of the epidural in slowing contractions 

C. Having the woman lie flat in bed to avoid postanesthesia headache 

D. Monitoring blood pressure for possible hypotension 

Answer: D 

Explanation: Hypotension is a frequent side effect of regional anesthesia. Maternal hypotension causes fetal bradycardia and hypoxia. Answer 1 is not correct because epidural anesthesia does not cause uterine tetany. Answer 2 is not correct. Even though contractions are sometimes slowed after administering an epidural, oxytocin is not routinely administered. Answer 3 is not correct. The woman who has had an epidural anesthesia will have her head elevated to prevent respiratory depression. Postanesthesia headache occurs after spinal or saddle block anesthesia, not after epidural anesthesia. 

Question 5368) 

The nurse is positioning a laboring woman who has not reached the transition phase. The nurse should avoid placing her in the supine position because the supine position has which effect? 

A. It increases gravitational forces and prolongs labor. 

B. It causes decreased perfusion of the placenta 

C. It may impede free movement of the symphysis pubis. 

D. It frequently leads to transient episodes of hypertension. 

Answer: B 

Explanation: Pressure of the uterus against major blood vessels reduces circulation, causing decreased perfusion of the placenta. Answer 1 is not correct; the supine position does not prolong labor. Answer 3 is not correct; the supine position does not impede free movement of the symphysis pubis. Answer 4 is not correct; the supine position does not cause transient episodes of hypertension in the laboring woman. 

Question 5369) 

A woman in labor is experiencing very strong contractions every two to three minutes, lasting 60 to 75 seconds. She complains of a severe backache and is irritable. The best interpretation of these data is that the woman is in which stage/phase of labor? 

A. Early first stage of labor 

B. Transition phase of labor 

C. Late second stage of labor 

D. Early third stage of labor 

Answer: B 

Explanation: Contractions during the transition phase typically occur every two to three minutes and last 60 to 90 seconds. The woman is often irritable and has a backache. Answer 1 is not correct. Early first stage labor contractions are usually several minutes apart, lasting only a few seconds. Backache and irritability are not common in early first stage labor. Answer 3 is not correct. Late second stage labor is the “pushing stage” just before delivery. Early third stage labor is after delivery of the baby, just before the placenta is expelled. Third stage labor is usually only a few minutes. 

Question 5370) 

A woman who is completely dilated is pushing with contractions. After 30 minutes of pushing, the baby is still at 0 station. What is the most appropriate nursing action at this time? 

A. Assess for a full bladder 

B. Prepare for a cesarean delivery 

C. Monitor fetal heart tones 

D. Turn the mother to her left side Answer: A Explanation: Lack of descent is often related to a full bladder. Answer 2 is not correct. Until a full bladder has been ruled out as a cause of failure to descend, cesarean delivery would not be considered. Answer 3 is not correct. Routine fetal assessment will of course be done. However, there are no specific data suggesting a fetal problem and no need for additional fetal monitoring. Answer 4 is not correct. Position is not the most likely cause for failure to descend. Turning the mother to the left side would be an appropriate intervention for a sudden drop in blood pressure resulting from vena caval syndrome.