100 - Nursing Exams Questions & Answers - Svastham Exemplar

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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Question 5371) 

Which nursing action has the highest priority for a client in the second stage of labor? 

A. Help the mother push effectively 

B. Prepare the mother to breastfeed on the delivery table 

C. Check the fetal position 

D. Administer medication for pain 

Answer: A 

Explanation: The second stage of labor is the pushing stage. The nurse should help the mother push effectively. Answer 2 is not correct. The mother cannot breastfeed the infant until it is born. Breastfeeding on the delivery table might be an appropriate action in the third stage of labor. Answer 3 is not correct. Checking the fetal position is not the highest priority action during second stage labor. Answer 4 is not correct. Pain medication should not be administered in the second stage because it will cause a sleepy baby. 

Question 5372) 

A woman, gravida 5, para 4, is unable to get to the hospital because labor has progressed very rapidly. A nurse, who lives upstairs, comes down to assist her with the emergency home delivery. The nurse examines the woman and assesses that the perineum is bulging. What is the priority nursing measure at this time? 

A. Encourage the woman to push during the contraction 

B. Place a clean sheet under the perineal area 

C. Accurately time the contractions 

D. Contact the physician by phone for instructions 

Answer: B 

Explanation: The woman is a gravida 5, para 4, and the perineum is bulging. Delivery is imminent. Contamination will be minimized by catching the infant on a clean surface. Answer 1 is not correct. The woman will not need to be encouraged to push; she will be doing it on her own. Secondly, it will be more appropriate to have her pant so that the delivery can be controlled. Answer 3 is not correct. Delivery is imminent. There is no time or need to time the contractions. Answer 4 is not correct. Delivery is imminent. There is no time to contact the physician for instructions. The nurse should be able to handle this emergency delivery. 

Question 5373) 

During an emergency home delivery, the head is beginning to crown. What is the most appropriate action for the nurse to take at this time? 

A. Instruct the mother to push down vigorously. 

B. Press down on the fundus to expel the baby 

C. Apply gentle perineal pressure to prevent rapid expulsion of the head. 

D. Direct the mother to take prolonged deep breaths to improve fetal oxygenation. 

Answer: C 

Explanation: Applying gentle counter pressure to the perineum prevents too rapid expulsion of the head, which can lead to increased intracranial pressure in the infant and laceration in the mother. Answer 1 is not correct. The mother will be encouraged to pant so that the delivery can be controlled. Answer 2 is not correct. The nurse does not press down on the fundus to expel the baby. Answer 4 is not correct. There is no need to tell the mother to take prolonged deep breaths. Applying gentle perineal pressure is by far the most appropriate action for the nurse at this time. 

Question 5374) 

What is the most common complication associated with too rapid delivery in precipitate labor? 

A. Pitting edema of the baby’s scalp 

B. Dural or subdural tears in fetal brain tissue

C. Premature separation of the placenta 

D. Prolonged retention of the placenta 

Answer: B 

Explanation: The sudden change of pressure tends to tear away dural linings. The mother can also get perineal tears. Answer 1 is not correct. Edema of the scalp is not a complication with precipitate labor. Sometimes prolonged labor can cause caput succedaneum, where the baby has bleeding under the scalp. Answers 3 and 4 are not correct. Rapid delivery is not particularly associated with placental problems. 

Question 5375) 

The nurse has just completed emergency delivery of a term infant. What is the priority nursing concern at this time? 

A. Controlling hemorrhage in the mother 

B. Removing the afterbirth 

C. Keeping the infant warm 

D. Cutting the umbilical cord Answer: C Explanation: Newborns have immature temperature regulating mechanisms. The nurse should dry the infant and place the infant in a blanket or towel on the mother’s abdomen. Answer 1 is not correct. The first concern is clearing the infant’s airway and keeping the infant warm. The mother is not likely to hemorrhage at this time. Maternal hemorrhage would be more likely after delivery of the placenta. Answer 2 is not correct. The afterbirth or placenta should separate and deliver itself within 5 to 15 minutes after the baby is born. The nurse should care for the baby until this happens. Answer 4 is not correct. There is no hurry to cut the cord. The cord should never be cut with anything that is not sterile because the baby could develop a fatal infection. 

Question 5376) 

What should the nurse do to stimulate the separation of the placenta after home delivery of a baby? 

A. Ask the mother to push down vigorously 

B. Push the fundus down vigorously 

C. Encourage the baby to breastfeed 

D. Place gentle tension on the umbilical cord 

Answer: C 

Explanation: Breastfeeding stimulates uterine contractions, which will help the placenta to separate. Answer 1 is not correct. Having the mother push down vigorously will not stimulate the placenta to separate. Answer 2 is not correct. The nurse should not push down on the fundus. This is not necessary for the placenta to separate. Answer 4 is not correct. The nurse should never pull on the cord. This could cause inversion of the uterus. 

Question 5377) 

A woman delivered a baby in the car on the way to the hospital. In the emergency room, the physician examined the mother. What is the priority action for the nurse at this time? 

A. Gently tug on the cord and massage the uterus to see if the placenta is ready to be delivered

B. Clamp and cut the cord with sterile scissors 

C. Note and record the Apgar score 

D. Clear the mucus from the baby’s mouth and nose 

Answer: D 

Explanation: A clear airway for the infant is first priority. Answer 1 is not correct. Tugging on the cord before the placenta is expelled could cause inversion of the uterus. Answer 2 is not correct. The cord does not need to be cut immediately. Clearing the infant’s airway is a much higher priority. Answer 3 is not correct. The nurse may assess the infant and get an Apgar score. However, the airway is a much higher priority than the Apgar. 

Question 5378) 

A woman who is giving birth at home wonders if her baby will need drops in the eyes because she knows that neither she nor her husband has gonorrhea. The best answer for the nurse to give should include which of the following? 

A. It is desirable for the baby to receive the eye drops, but it is not essential. 

B. If you do not want your baby to have the eye drops, you must sign a waiver stating that you refuse them. 

C. The baby needs the drops but does not have to receive them for up to two hours after birth. 

D. The drops are needed to prevent the eye condition known as retrolental fibroplasia. 

Answer: C 

Explanation: Antibiotic eye drops have to be instilled into the neonate’s conjunctival sacs to prevent infection, not just from gonorrhea and chlamydia but also from pathogens in the birth canal such as pneumococcus and Streptococcus. It is safe to wait up to two hours to instill the drops. This allows time for maternal-child eye contact and interaction, which facilitates attachment. Answers 1 and 2 are not correct. There is a legal requirement to give the baby eye prophylaxis. Answer 4 is not correct. Retrolental fibroplasia results from too much oxygen concentration in immature retinal vessels during oxygen therapy for the compromised neonate. 

Question 5379) 

The nurse is caring for a laboring woman who has a history of rheumatic heart disease. How should the nurse position her during labor? 

A. Supine 

B. Semi-recumbent 

C. Side-lying 

D. Sitting 

Answer: B 

Explanation: Semi-recumbent or semi-Fowler’s position would be the most appropriate position to reduce the cardiac work load and ease breathing. The laboring woman who has a history of rheumatic heart disease is at risk for congestive heart failure. The supine and side-lying positions would increase the cardiac work load. Sitting upright is not the best choice. 

Question 5380) 

The nurse is caring for a laboring woman who has a history of rheumatic heart disease. Which instruction should the nurse give to her during the second stage of labor? 

A. Avoid prolonged bearing down. 

B. Breathe shallowly and rapidly 

C. Sit on the side of the bed 

D. Sleep between contractions. 

Answer: A 

Explanation: The woman with cardiac disease should not bear down excessively. She will likely be given an epidural anesthesia, and outlet forceps may be indicated to shorten the second stage of labor. Answer 2 is not correct. Breathing shallowly and rapidly will cause respiratory alkalosis. Answer 3 is not correct. Sitting on the side of the bed is not an appropriate action during second stage labor. Second stage labor is the expulsion stage. Answer 4 is not correct. Sometimes mothers do doze between contractions in second stage. However, answer 1 is the priority instruction that the nurse should give this mother.

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. 

97 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5351) 

A pregnant 16-year-old asks the nurse if she should have an abortion. How should the nurse respond initially?

A. “You should ask your parents for advice.” 

B. “Abortion is the deliberate killing of a human being.” 

C. “An abortion would let you finish growing up before you have children.” 

D. “What are your feelings about abortion?” 

Answer: D 

Explanation: The nurse should initially encourage the client to formulate and express her thoughts and concerns. The nurse should not try to impose her or his values on the client, as answers 2 and 3 do. Answer 1 tells the client what to do and is not appropriate for an initial response, although discussing the issue with her parents should be encouraged 

Question 5352) 

A 25-year-old woman is four months pregnant. She had rheumatic fever at age 15 and developed a systolic murmur. She reports exertional dyspnea. What instruction should the nurse give her? 

A. “Try to keep as active as possible, but eliminate any activity that you find tiring.” 

B. “Carry on all your usual activities, but learn to work at a slower pace.” 

C. “Avoid heavy housework, shopping, stair climbing, and all unnecessary physical effort.” D. “Get someone to do your housework, and stay in bed or in a wheelchair.” 

Answer: C 

Explanation: The client reports exertional dyspnea. The answer relates to avoiding exertion or things requiring extra effort. The data do not suggest that it is necessary at this point to stay in bed or in a wheelchair. Answers 1 and 2 do not relate to the data, which include exertional dyspnea. 

Question 5353) 

A pregnant woman comes for her sixth-month checkup and mentions to the nurse that she is gaining so much weight that even her shoes and rings are getting tight. What should the nurse plan to include in her care? 

A. Teaching about the food pyramid and the importance of a well-balanced diet 

B. Further assessment of her weight, blood pressure, and urine 

C. Encouraging the use of a comfortable walking shoe with a medium heel 

D. Reassurance that weight gain is normal as long as it does not exceed 25 lb 

Answer: B 

Explanation: Her symptoms suggest pregnancy-induced hypertension; particularly significant is the fact that her rings are getting tight. Upper body edema is highly suggestive of PIH. The nurse should record her weight and note how much weight has been gained in the last month. Monitoring blood pressure for elevation and checking urine for protein will help to determine if this woman has PIH. Dietary teaching as described in answer 1 is important, but the action relating to the data in the question is assessment for PIH. The advice in answer 3 regarding a comfortable walking shoe is also appropriate for a pregnant woman but does not relate to the data in this question. More important than total weight gain is the pattern of weight gain. A sudden increase in weight gain may indicate fluid retention accompanying PIH, even if the total is not yet above 25 lbs. 

Question 5354) 

A 23-year-old woman, pregnant for the first time, is 39 weeks gestation. She is admitted to the labor room with contractions every five minutes lasting 45 seconds. On vaginal exam, she is noted to be completely effaced and 5-cm dilated. Station is 0. She asks the nurse for pain medication. What is the best response for the nurse to make? 

A. “I’ll ask your doctor for medication.” 

B. “Can you hold out for a few more minutes? It’s too soon for you to have medication.” 

C. “Pain medication will hurt your baby. We would rather not give you any unless absolutely necessary.” 

D. “Can your husband help you with your breathing techniques?” 

Answer: A 

Explanation: Analgesia can usually be safely given after 5 cm of dilation and until one to two hours before delivery. Answer 2 is not appropriate because according to the data given, the mother is a good candidate for some type of analgesia. Answer 3 is not true. Pain medication too early may slow labor, and pain medication too late may depress the baby’s respirations and heartbeat. Pain medication given appropriately is often very helpful during labor. Answer 4 is not appropriate. It does not address the question that the client asked about pain medication. 

Question 5355) 

After several hours of active labor, a woman says to the nurse, “I have to push. I have to push.” What is the best initial response for the nurse to make? 

A. “Pull your knees up to your chest and hold on to them. Take a deep breath and push down as though you are having a bowel movement.” 

B. “Let me have the RN examine you before you start to push.” 

C. “That means the baby is coming. I’ll take you into the delivery room now.” 

D. “Women often feel that way during labor. Turn on your left side, and you will be more comfortable.” 

Answer: B 

Explanation: Before encouraging the mother to push, the nurse should determine that the mother has completed transition and is fully dilated. She should not push before she is fully dilated. Answer 1 is a good description of pushing. However, the woman should not push until she is fully dilated. Most women need to push for a while before the baby is born. Answer 4 is a true statement; however, it is not the best response for the nurse to make. 

Question 5356) 

A laboring woman is to be transferred to the delivery room. The nurse is positioning her on the table when she has a very strong contraction and starts to bear down. What should the nurse tell her to do? 

A. Pant 

B. Bear down strongly 

C. Put her legs up in the stirrups 

D. Ignore the contraction 

Answer: A 

Explanation: When it is not desirable for a woman to push, such as when moving from bed to table, she should be instructed to pant. It is not possible for a woman to pant and push at the same time. The mother will probably be unable to put her legs up in stirrups during a contraction. At this stage of labor, she will be unable to ignore contractions. 

Question 5357) 

A 32-year-old, gravida 2, para 1, term 1, preterm 0, abortion 0, living 1, is admitted to the labor room. Her previous delivery was a normal, spontaneous vaginal delivery without complications. She has been having contractions for four hours at home. The registered nurse examines her and determines that she is 4-cm dilated and 70% effaced. The fetus is in the breech position. She calls for the nurse saying, “My water just broke!” What should the practical nurse do initially? 

A. Notify the physician 

B. Do a vaginal exam. 

C. Check the fetal heart rate 

D. Prepare for delivery 

Answer: C 

Explanation: The practical nurse should initially check the fetal heart rate, and then the registered nurse (RN) should perform a vaginal exam. A breech fetus is at high risk for a prolapsed cord when the membranes rupture. Following assessment of the fetal heart rate, the RN will perform a vaginal exam. A woman with a breech presentation may need a cesarean delivery. After the initial assessments, the physician will be notified because this baby is in a breech position. The physician is not automatically notified when the membranes rupture. 

Question 5358) 

The fetus is in the breech position. Inspection of the amniotic fluid after the membranes rupture shows a greenish-black cast to the fluid. What is the best interpretation of this finding? 

A. The baby is in acute distress. 

B. The fluid is contaminated with feces from the mother 

C. The mother has diabetes mellitus. 

D. It may be normal since the baby is presenting breech 

Answer: D 

Explanation: Breech presentations frequently have amnioticstained fluid. Amniotic-stained fluid in a vertex presentation is a sign of fetal distress. Maternal diabetes does not cause amniotic-stained fluid unless the fetus happens to be in distress. 

Question 5359) 

A woman in labor does not continue to dilate. The physician decides to perform a cesarean section. A healthy 7-lb, 12-oz baby boy is delivered. What is the most essential nursing intervention in the immediate postpartum period? 

A. Check the uterine fundus for firmness. 

B. Assess the episiotomy for bleeding. 

C. Assist the woman with accepting the necessity of having had a cesarean section. 

D. Encourage fluid intake 

Answer: A 

Explanation: Checking the uterine fundus for hemorrhage is of highest priority. The placenta separates from the uterus in a woman who has had a cesarean delivery just as it does in a vaginal delivery. Both types of deliveries have a risk of postpartum hemorrhage. It is essential to keep the fundus firm for both types of deliveries. The woman who had a cesarean delivery has no episiotomy. Assisting with emotional adjustment will be a part of nursing care but is not the highest priority. Encouraging fluid intake is important but is not the highest priority. 

Question 5360) 

A woman, gravida 2, para 2, term 2, preterm 0, abortion 0, living 2, who has just had an unexpected cesarean delivery asks the nurse if having a cesarean means that she cannot have any more children. What is the best response for the nurse to give this mother? 

A. “Many women are able to have another child after having had a cesarean delivery.”

B. “Since you have two healthy children, it would be better not to attempt another delivery.” 

C. “Is it important for you to have more children?” 

D. “That is a question you will have to discuss with your physician.” 

Answer: A 

Explanation: A cesarean delivery is not in itself a contraindication for another pregnancy. Many women can have a vaginal delivery after a cesarean. The old rule of only two cesarean deliveries is no longer true. Remember that this client had one vaginal delivery and one cesarean. Answer 2 does not give accurate information. Answer 3 does not answer the question. Answer 4 contains some truth, but the nurse should be able to give general information to this mother. 

96 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5341) 

The nurse is caring for a woman who is 30 weeks gestation, has gained 17 pounds during the pregnancy, and has a blood pressure of 110/70. The woman states that she feels warmer than everyone around her. Which interpretation of these findings is most correct? 

A. All of these findings are normal. 

B. Her weight gain is excessive for this point in pregnancy. 

C. The blood pressure is abnormal 

D. She should be evaluated for a serious infection because pregnant women are usually cooler than other people. 

Answer: A 

Explanation: All of these findings are within normal limits. Weight gain during the first trimester is usually 3 to 5 lb. After that, the normal weight gain is around 12 oz (three-quarters of a pound) a week. Using these guidelines, her weight gain should be 16 to 18 lb. Her blood pressure is well within normal limits, even though we are not given a baseline. Pregnant women have a high metabolic rate and usually feel warmer than everyone else. 

Question 5342) 

What should the nurse do to assess for a positive sign of pregnancy? 

A. Perform a pregnancy test on the woman’s urine. 

B. Auscultate for fetal heart sounds 

C. Ask the woman when she had her last menstrual period 

D. Ask the woman if her breasts are tender. 

Answer: B 

Explanation: Fetal heart sounds, sonograms, and x-rays are positive signs of pregnancy. A positive pregnancy test is a probable sign of pregnancy. Amenorrhea and breast tenderness are presumptive signs of pregnancy. 

Question 5343) 

An oxytocin challenge test is ordered for a woman who is 42 weeks pregnant. What should the nurse plan for in the care of this client? 

A. Place her in the supine position during the test. 

B. Keep her NPO before the test 

C. Have her empty her bladder before the test. 

D. Prepare the client for the insertion of internal monitors. 

Answer: C 

Explanation: The mother should empty her bladder before oxytocin is given and contractions begin. It is not necessary to be supine; the head will be elevated. NPO is not essential. The monitor with an oxytocin challenge test is external, not internal 

Question 5344) 

Woman comes to Doctor office for her routine checkup. She is 34 weeks gestation. The nurse notes all of the following. Which would be of greatest concern to the nurse? 

A. Weight gain of 2 lb in two weeks 

B. Small amount of dependent edema 

C. Fetal heart rate of 155 bpm 

D. Blood pressure of 150/94 

Answer: D 

Explanation: A blood pressure of 150/94 is indicative of pregnancy-induced hypertension. Weight gain of a pound a week, slight dependent edema, and a fetal heartbeat of 155 are all normal. 

Question 5345) 

A pregnant woman is admitted to the hospital. Her initial admitting vital signs are blood pressure 160/94; pulse 88; respirations 24; and temperature 98°F. She complains of epigastric pain and headache. What should the nurse do initially? 

A. Insert an indwelling catheter. 

B. Give Maalox 30 cc now. 

C. Contact the doctor stat with findings 

D. Provide supportive care for impending convulsion. 

Answer: D 

Explanation: Epigastric pain and headache suggest that a seizure is imminent. Supportive care to protect the client from injury is essential. An indwelling catheter may be inserted but only after the nurse ensures that the client is safe should a seizure occur. The epigastric pain is most likely related to preeclampsia, not gastritis. The doctor should be notified, but the client should be made safe first. 

Question 5346) 

Magnesium sulfate is ordered for a client who is hospitalized for pregnancyinduced hypertension (PIH). What effects would the nurse expect to see as a result of this medication? 

A. CNS depression 

B. Decreased gastric acidity 

C. Onset of contractions 

D. Decrease in number of bowel movements 

Answer: A 

Explanation: Magnesium sulfate is a central nervous system depressant. It is given to prevent seizures. Magnesium hydroxide gel is an antacid. Oxytocin is given to initiate contractions. Magnesium sulfate may decrease contractions. Magnesium sulfate does not cause constipation. Some laxatives contain magnesium 

Question 5347) 

A client with PIH asks the nurse, “When will I get over this?” What is the best response for the nurse to make? 

A. “Your disease can be controlled with medication 

B. “After your baby is born.” 

C. “After delivery, you will need further testing.” 

D. “You could have this condition for years.” 

Answer: B 

Explanation: Preeclampsia is pregnancy-induced hypertension and disappears shortly after the birth of the baby 

Question 5348) 

A 40-year-old woman who is 28 weeks gestation comes to the emergency room with painless, bright red bleeding of 1.5 hours duration. What condition does the nurse suspect this client has? 

A. Abruptio placenta 

B. Placenta previa 

C. Hydatidiform mole 

D. Prolapsed cord 

Answer: B

Explanation: Placenta previa is characterized by painless bleeding in the third trimester. Abruptio is characterized by abdominal pain and a rigid abdomen with or without obvious bleeding. Shock develops rapidly in placenta abruptio. Hydatidiform mole is characterized by severe nausea and vomiting and the passage of grapelike vesicles. Prolapsed cord often occurs when the membranes rupture and is not characterized by bleeding. 

Question 5349) 

A woman who is 28 weeks gestation comes to the emergency room with painless, bright red bleeding of 1.5 hours in duration. Which of the following would the nurse expect during assessment of this woman? 

A. Alterations in fetal heart rate 

B. Board-like uterus 

C. Severe abdominal pain 

D. Elevated temperature 

Answer: A 

Explanation: The history suggests placenta previa. The baby may well develop fetal distress. A boardlike abdomen and severe pain are characteristic of abruptio placenta. Elevated temperature is not characteristic of placenta previa. 

Question 5350) 

A woman is admitted with suspected placenta previa. What test does the nurse expect will be done to confirm the diagnosis? 

A. Internal exam 

B. Nonstress test 

C. Oxytocin challenge test 

D. Ultrasound 

Answer: D 

Explanation: A sonogram will show the position of the placenta in the uterus. An internal exam will probably not be done because it can cause severe bleeding when there is a placenta previa. The nonstress test and the oxytocin challenge test are done to see how the fetus responds to contractions

95 - Nursing Exams Questions & Answers - Svastham Exemplar

Question 5331) 

The nurse is assessing a woman who thinks she may be pregnant. Which information from the client is most significant in confirming the diagnosis of pregnancy? 

A. . The client is experiencing nausea before bedtime and after meals. 

B. The client says she has gained six pounds and her slacks are tight. 

C. The client has noticed it is difficult to sleep on her “stomach” because her breasts are tender. 

D. The client has a history of regular menstrual periods since age 13, and she has missed her second period. 

Answer: D 

Explanation: Amenorrhea in an otherwise healthy woman of childbearing age is strongly suggestive of pregnancy. Nausea, weight gain, and tender breasts are all presumptive signs but are not as significant as amenorrhea. 

Question 5332) 

After her examination by the physician, the antepartal client tells the nurse that the doctor said she had positive Chadwick’s and Goodell’s signs. She asks the nurse what this means. What is the best response for the nurse to make? 

A. “Chadwick’s sign is a dark blue coloring of the vagina and cervix. Goodell’s sign is softening of the cervix of the uterus.” 

B. “These help to confirm pregnancy. They refer to color changes and changes in the uterus caused by increased hormones of pregnancy.” 

C. “Those are medical terms. You don’t need to be concerned about them.” 

D. “It refers to changes that occasionally happen in pregnancy but are unlikely to cause problems.” 

Answer: B 

Explanation: This answer is most appropriate to give the client. Answer 1 is a true statement but uses vocabulary that is inappropriate for the client. These changes are normal changes and occur in most pregnancies. Answer 3 is a real put-down to the client. Answer 4 is not correct. These are normal findings that help to confirm the diagnosis of pregnancy. 

Question 5333) 

An antepartal client asks when her baby is due. Her last menstrual period was August 28. Using Naegele’s rule, calculate the estimated date of delivery.

A. May 21 

B. May 28 

C. June 4 

D. June 28 

Answer: C 

Explanation: Add nine months or take away three months and then add seven days. August 28 minus three months is May 28. Adding seven days would make it May 35. Since there are only 31 days in May, the days are carried into June—making June 4 the expected delivery date. Answer 1 subtracts seven days instead of adding seven days. Answer 2 does not add seven days. Answer 4 subtracts only 2 months instead of 3 months and does not add seven days. 

Question 5334) 

In establishing a teaching plan for a client who is in the first trimester of pregnancy, the nurse identifies a long list of topics to discuss. Which is most appropriate for the first visit? 

A. Preparation for labor and delivery 

B. Asking the woman what questions and concerns she has about parenting 

C. Nutrition and activity during pregnancy 

D. Dealing with heartburn and abdominal discomfort 

Answer: C 

Explanation: Nutrition and activity are important concerns from the first trimester onward. Labor and delivery is a third trimester concern, and parenting is of most concern in either the third trimester or after delivery. Heartburn and abdominal discomfort do not usually occur until the third trimester. 

Question 5335) 

When a woman in early pregnancy is leaving the clinic, she blushes and asks the nurse if it is true that sex during pregnancy is bad for the baby, What is the best response from the Nurse to make? 

A. “The baby is protected by his sac. Sex is perfectly alright.” 

B. “It is unlikely to harm the baby. What you do with your personal life is your concern.” 

C. “In a normal pregnancy, intercourse will not harm the baby. However, many women experience a change in desire. How are you feeling?” 

D. “Intercourse during pregnancy is usually alright, but you need to ask the doctor if it is acceptable for you.” 

Answer: C 

Explanation: Intercourse is not harmful during a normal pregnancy. This response recognizes the changes in libido that may occur during pregnancy and allows for the expression of feelings. Answer 1 is factual information, but answer 3 allows the woman to express her feelings. The question says that “she blushes.” This may indicate that the woman has concerns about sex. Answer 2 gives factual information but does not allow the woman to express her concerns. Answer 4 again does not give the woman a chance to discuss this with the nurse. The nurse should be able to answer this question. 

Question 5336) 

The doctor told a pregnant woman to eat a well balanced diet and increase her iron intake. She says, “I hate liver. How can I increase my iron?” What is the best response for the nurse to make? 

A. “Although liver is a good source of iron, beets, poultry, and milk are also good sources.” B. “Many people dislike liver. Red meats, dark green vegetables, and dried fruits are also good sources of iron.” 

C. “You should eat liver as it is the best source of iron. There are lots of ways to disguise the taste.” 

D. “You can eat almost anything you like because your prenatal vitamins have all the vitamins and minerals needed for a healthy pregnancy.” 

Answer: B 

Explanation: This answer recognizes that a dislike of liver is common and suggests good sources of iron. Answer 1 includes information that is not correct; milk contains no iron. Answer 3 has some correct information; liver is high in iron. It is also high in cholesterol. There are many other sources of iron. It is not necessary to eat liver to get iron in the diet. At one time, eating liver regularly was thought to be the best way to get iron. Answers 3 vitamins do contain iron. However, they should not be considered a substitute for a proper diet 

Question 5337) 

A woman who is at about six weeks gestation asks if she can listen to the baby’s heartbeat today. What should be included in the nurse’s reply 

A. The heart is not beating at six weeks. 

B. The heart is formed and beating but is too weak to be heard with a stethoscope 

C. The heartbeat can be heard with an electronic fetoscope. 

D. The heart does not start beating until 20 weeks gestation. 

Answer: B 

Explanation: The heart chambers are formed and the heart is beating by four weeks gestation. However, it cannot be heard even with a fetoscope. Answer 1 is incorrect. The heart is beating by four weeks. Answer 3 is not correct. It cannot be heard at this time. Answer 4 is incorrect. The heart rate will be audible with a standard fetoscope by 20 weeks, but it has been beating since about four weeks. 

Question 5338) 

A woman who is in early pregnancy asks the nurse what to do about her “morning sickness.” What should the nurse include in the reply? 

A. Eating a heavy bedtime snack containing fat helps to keep nausea from developing in the morning. 

B. Eating dry crackers before getting out of bed may help. 

C. Drinking liquids before getting up in the morning helps relieve nausea 

D. The doctor can prescribe an antiemetic if she has had three or more vomiting episodes. 

Answer: B 

Explanation: Eating dry carbohydrates in the morning before rising often helps. The woman should avoid fatty foods and those with strong odors. Drinking liquids in the morning usually makes morning sickness worse, not better. Antiemetics are not prescribed because of the possible teratogenic effect on the developing embryo. 

Question 5339) 

A woman who is 38 weeks gestation tells the nurse that she sometimes gets dizzy when she lies down. Which information is it important for the nurse to give the client? 

A. This is a sign of a serious complication and should be reported to the physician whenever it occurs. 

B. Try to sleep in an upright position on your back to prevent the dizziness. 

C. Try lying on your left side rather than on your back. 

D. Sleeping on your back with several pillows should help. 

Answer: C 

Explanation: Dizziness when lying on the back suggests that she may have vena caval syndrome—pressure on the vena cava from the enlarged uterus and fetus that decreases venous return and causes the blood pressure to drop. Lying on the left side usually reduces pressure on the vena cava and prevents the drop in blood pressure and dizziness. Sleeping in an upright position on her back will cause vena caval syndrome. Sleeping on the back with several pillows is similar to answer 2, which was incorrect 

Question 5340) 

The nurse asks the newly pregnant woman if she has a cat for which of the following reasons? 

A. Cats may suffocate new babies and should not be in the home when a baby arrives 

B. Cat feces may cause toxoplasmosis, which can lead to blindness, brain defects, and stillbirth. 

C. If the mother gets scratched by a cat, the baby may develop heart defects. 

D. Cats are jealous of babies and may try to kill them during infancy. 

Answer: B 

Explanation: Cats may become infected with toxoplasmosis, which, if ingested by the mother, can cause toxoplasmosis and lead to neurologic lesions causing blindness, brain defects, and death. Parents should be alert for safety with any pet, but cats do not suffocate new babies or try to kill them. It is not being scratched by a cat that is the biggest danger during pregnancy; it is the possibility of developing toxoplasmosis from the feces. Raw meat can also carry toxoplasmosis. 

 

94 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5321)

A woman is to have a routine gynecological examination tomorrow. What instructions should the nurse give this client? 

A. “Bring a urine sample with you.” 

B. “Be sure to drink plenty of fluids in the morning before you come so that your bladder will be full.” 

C. “Be sure not to douche today or tomorrow.” 

D. “Don’t eat breakfast. You will be able to eat right after the exam.” 

Answer: C 

Explanation: There is no special preparation for a gynecological exam. The client should not douche, however. There is no need to bring a urine specimen. The client may be asked to give a specimen prior to the examination. Drinking plenty of fluids would be appropriate prior to a pelvic ultrasound examination. There is no need to fast before a gynecological exam. 

Question 5322) 

A 46-year-old woman visits her gynecologist because she has been spotting. She is to be evaluated for carcinoma of the cervix. If she has cancer of the cervix, she is most likely to report that vaginal spotting occurred at what time? 

A. On arising 

B. While sitting 

C. After intercourse 

D. On stair climbing 

Answer: C 

Explanation: Postcoital (after intercourse) spotting is often seen with cancer of the cervix. The other responses are not correct. 

Question 5323) 

The nurse is discussing breast self-examination with a group of women in a clinic. One woman asks, “When should I do this examination?” What is the best response for the nurse? 

A. “You should perform breast self-examination early in the morning for most accurate results.” 

B. “Breast self-examination should be done a few days after your period begins every month.” 

C. “Breast self-examination should be done by women after the age of 40 on the first of every month.” 

D. “Breast self-examination is best done just before you expect your menstrual period.” 

Answer: B 

Explanation: The best time to perform breast self-examination is a few days after the menstrual period begins because the breasts are least tender at this time. It should be done every month. Answer 1 is incorrect. It does not matter what time of day the exam is performed. Breast self-examination should be done monthly, starting right after puberty. The incidence of breast cancer does increase with age, but it can occur in teenagers. The breasts are most tender just before the period starts; this is the least desirable time to do a breast self-examination. 

Question 5324) 

The physician prescribes clomiphene (Clomid) for a woman who has been having difficulty getting pregnant. When discussing this drug with the woman, the nurse should know that which of the following is known to be a side effect of clomiphene? 

A. Infertility 

B. Multiple births 

C. Vaginal bleeding 

D. Painful intercourse 

Answer: B 

Explanation: One of the major side effects of fertility drugs, such as clomiphene, which increases ovulation, is multiple births. Clomiphene is used to treat infertility; it does not cause infertility. Clomiphene does not cause vaginal bleeding or painful intercourse. 

Question 5325) 

A young couple asks the nurse which method of contraception is the best and the one that they should use. Which response is most helpful to the couple? 

A. “The pill is the best because it is 100% effective with few side effects.” 

B. “The best method is the one that you both agree upon and will use consistently.”

C. “The condom is the best method because it prevents diseases as well as pregnancy.” 

D. “No method is completely effective; you should practice abstinence until you are ready to have children.” 

Answer: B 

Explanation: The best method for any couple is one they will use consistently. The only 100% effective method is abstinence, which is not a realistic choice for most couples. To be effective, contraception must be used consistently and correctly. Answer 1 is not correct. If the pill is not taken exactly as directed, pregnancies can and do occur. The pill has several side effects, including nausea, weight gain, and enlarged breasts. Answer 3 contains correct information in that the condom does help to prevent disease transmission. However, with a married couple, this is not likely to be an issue. Answer 4 is an unrealistic answer for a married couple and therefore is not very helpful. 

Question 5326) 

A woman is being treated for Trichomonas vaginalis with metronidazole (Flagyl). Which statement the woman makes indicates a need for further teaching? 

A. My husband is also taking medicines 

B. “I will take Flagyl with meals.” 

C. The doctor said I might get a metallic taste in my mouth while I am taking Flagyl.” 

D. “I will drink only one glass of wine per meal while I am taking Flagyl.” 

Answer: D 

Explanation: Alcohol taken with Flagyl causes an Antabuselike reaction, nausea, and vomiting. The client should drink no alcoholic beverages. The husband (partner) should also be treated, even if he has no symptoms, to prevent reinfection. Flagyl, unless it is extended release, should be taken with food to decrease gastrointestinal side effects. People commonly get a metallic taste when taking Flagyl. 

Question 5327) 

A client who is being treated for syphilis says to the nurse, “Why does the doctor want to know who I have had sex with?” What should the nurse include when responding to this question? 

A. It really is not any of the physician’s concern. 

B. The physician wants to help you make better decisions about your lifestyle. 

C. Reporting of sexual contacts is mandatory so that the contacts can receive testing and treatment. 

D. Studies need to be done on sexual activities to learn how to reduce the spread of the disease. 

Answer: C 

Explanation: Sexual contacts must be reported so that they can be contacted, tested, and treated to avoid the serious complications of untreated syphilis. Answer 1 is not correct. It is possible that there might be some truth to answer 2. However, the information regarding contacts is usually obtained in a nonjudgmental manner for the reasons described above. Answer 4 is not correct. 

Question 5328) 

During the early period following a right modified radical mastectomy, which nursing action would be appropriate to include in the client’s plan of care? 

A. Position the client in the right lateral position 

B. Encourage a high fluid intake 

C. Ambulate as soon as sensation and motion have returned 

D. Elevate the right arm on pillows

Answer: D 

Explanation: The arm on the affected side should be elevated on pillows to help prevent the development of lymphedema. The client should not be positioned on the affected side. Once the client is awake following anesthesia, the head of the bed will be elevated. The client may have liquids following surgery, but there is no particular need to encourage a high fluid intake. The client will begin to ambulate fairly quickly. However, the client will not have had an epidural anesthetic for a mastectomy, so the return of sensation and motion is not an issue. A mastectomy is too high for an epidural. Epidurals are not given for surgery above the waist. 

Question 5329) 

The nurse is caring for a client who has had a right modified radical mastectomy this morning. Which exercise should the nurse encourage the client to perform this evening? 

A. Hair combing exercises with the right arm 

B. Wall climbing exercises with the right arm 

C. Movement of the fingers and wrists of the right arm 

D. Exercises of the left arm only 

Answer: C 

Explanation: On the day of surgery, the client should be encouraged to move the fingers and wrists of the affected arm. Hair combing and wall climbing exercises will be performed later, not on the day of surgery. The client should be encouraged to exercise the fingers and wrists of the affected extremity on the day of surgery as well as exercising the unaffected arm. 

Question 5330) 

The client is being discharged following a left simple mastectomy. Which statement the client makes indicates an understanding of discharge teaching? 

A. “I won’t let anyone take blood pressures on my left arm.” 

B. “I understand that I should not have sexual relations for at least three months.” 

C. “I won’t move my arm any more than necessary.” 

D. “I will not lift my arm above my head for the next two weeks.” 

Answer: A 

Explanation: The client who has had a mastectomy should not have blood drawn or blood pressures taken on that arm. There is no reason why she should not have sexual relations for three months. As soon as she feels well enough, sexual relations can resume. She should use a position that does not put pressure on her left side. Answers 3 and 4 are incorrect. A woman who has had a mastectomy will need to perform arm exercises regularly. These will include lifting the arm above the head in exercises like hair combing and wall climbing. 

93 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5311) 

A 39-year-old woman is seen in the gynecology clinic and asks the nurse about menopause. What is the best explanation for the nurse to give her? 

A. “It usually occurs around the age of 40. You can expect severe hot flashes.” 

B. “It usually occurs after the age of 45 and frequently marks the end of a woman’s sex life.” 

C. “You can expect to have symptoms for about three years while your body adjusts to additional hormones.” 

D. “No more ovarian hormones are produced, so you will stop menstruating.” 

Answer: D 

Explanation: Menopause is the cessation of production of ovarian hormones. Amenorrhea will occur. Not all women have hot flashes. Menopause is not the end of a woman’s sex life. It is the end of her capacity to reproduce. Menopause occurs when a woman is in her 40s or 50s. 

Question 5312) 

A 42-year-old woman sees her physician because of painless spotting between periods that is worse after intercourse. A Pap smear is done. The results come back as stage III. The client asks the nurse what a stage III Pap smear means. The nurse’s response is based on the knowledge that a stage III Pap smear indicates that: 

A. only normal cells are present. 

B. atypical cells are present. 

C. cells suggestive but not diagnostic of malignancy are present 

D. many malignant cells are present. 

Answer: C 

Explanation: Stage III is characterized by cells suggestive but not diagnostic of malignancy. Stage I contains normal cells. Stage II contains atypical cells. Stage IV contains malignant cells. 

Question 5313) 

A woman is to have internal radiation as part of her treatment for cancer of the cervix. In teaching her about the preoperative preparation for this procedure, the nurse should include which information? 

A. A high-residue diet will be ordered. 

B. An indwelling catheter will be inserted

C. A nasogastric tube will be inserted. 

D. Several units of blood will be ready for transfusion if needed 

Answer: B 

Explanation: During the time the radium rods are in place, the client should move as little as possible to prevent dislodgment of the radium. She will have an indwelling catheter in place so her bladder will not become full and also to prevent damage to the bladder from the radiation. She will have an enema before the procedure and a lowresidue or clear liquid diet before surgery and while the rods are in place. There is no need for a nasogastric tube or blood transfusions. 

Question 5314) 

The nurse is caring for a woman after insertion of radium rods for treatment of cancer of the cervix. The nurse positions her in a supine position with legs extended for which reason? 

A. To keep the rods in the correct position 

B. To prevent the urinary bladder from becoming overdistended 

C. To reduce pressure on the pelvic and back areas 

D. To limit the amount of radiation exposure 

Answer: A 

Explanation: The client is kept flat to prevent the rods from becoming dislodged. She will have an indwelling catheter in place. Positioning does not reduce radiation exposure. 

Question 5315) 

The nurse is caring for a woman after the insertion of radium rods for treatment of cancer of the cervix. Which discomfort should the nurse anticipate that the client may have while the rods are in place? 

A. Headache 

B. Urinary retention 

C. Constipation 

D. Uterine cramps 

Answer: D 

Explanation: Uterine cramping occurs frequently. She will be on a clear liquid or low-residue diet so that she is not likely to be constipated. Prior to the procedure, she will have had a laxative bowel prep. She will have a catheter in place so she will not have urinary retention. 

Question 5316) 

The nurse is caring for a woman the day after the insertion of radium rods for treatment of cancer of the cervix. The woman calls the nurse and says, “There is something between my legs. It fell out of me.” What is the most appropriate initial action for the nurse to take? 

A. Call the radiation safety officer 

B. Put on rubber gloves and put the radiation rod in the bathroom until help arrives 

C. Using long forceps, place the radium needle in a lead-lined container 

D. Calmly reinsert the rod in the vagina 

Answer: C 

Explanation: There should always be long forceps and a lead-lined container readily available whenever a person has radium inserted. The nurse should pick up the rod with the long forceps and immediately place it in a leadlined container. The radiation safety officer should then be notified. Leaving the rod between the client’s legs exposes her and others to unnecessary radiation. Rubber gloves offer no protection from radiation. The nurse does not reinsert the radium 

Question 5317) 

A young woman comes to the clinic for contraceptive advice. She says she wants to take the pill. Vital signs are within normal limits. She tells the nurse she has been having intercourse for the past year without protection. What question is it most important for the nurse to ask her? 

A. How much exercise do you get each day? 

B. What do you usually eat each day? 

C. How many cigarettes do you smoke each day? 

D. Are you under stress? 

Answer: C 

Explanation: Cigarette smoking is a contraindication for the use of the pill. There is a higher incidence of thromboembolic problems when a person smokes. 

Question 5318) 

A young woman asks the nurse if oral contraceptives have any side effects. What is the best response for the nurse to make? 

A. “Nausea, fluid retention, and weight gain.” 

B. “Why do you ask? Look at the benefits.” 

C. “Are you concerned about something?” 

D. “Increased libido, decreased breast size, and diarrhea.” 

Answer: A 

Explanation: These are side effects of the pill. Answers 2 and 3 do not answer the question asked. Answer 4 is not correct. 

Question 5319) 

A client asks the nurse the difference between an intrauterine device (IUD) and a diaphragm. The nurse’s response should be based on which information? 

A. The diaphragm is inserted into the uterine cavity, and the IUD covers the cervix. 

B. The IUD is 97% effective, and the diaphragm is 50% effective. 

C. The IUD is placed into the uterine cavity by the doctor, and the diaphragm is placed into the vagina each time by the user. 

D. The IUD must be used with contraceptive jelly, and the diaphragm does not require contraceptive jelly. 

Answer: C 

Explanation: The IUD must be inserted into the uterus by the physician. The woman inserts the diaphragm before each act of intercourse. Both types are very effective when used as directed. The diaphragm requires contraceptive jelly; the IUD does not. 

Question 5320) 

A young woman tells the nurse that her boyfriend used a “rubber” once. What is the most important information about condoms for the nurse to provide the client? 

A. Always use Vaseline as a lubricant. 

B. Apply the condom to the penis right before ejaculation.

C. You do not need a medical prescription for condoms. 

D. The condom must be applied before any penilevaginal contact. 

Answer: D 

Explanation: Preejaculatory secretions may contain sperm. A condom must be applied before there is any penilevaginal contact. Vaseline should never be used as a lubricant. Lubricants should always be water soluble, such as KY jelly or Surgilube. Answer 3 is a true statement but not the most important information to give the client.