NCLEX: Maternal And Child Nursing Exam Practice Test
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A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert?
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Endometritis
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Endometriosis
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Salpingitis
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Pelvic thrombophlebitis
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Welcome to "NCLEX Questions For Maternal And Child Nursing Practice Test." Nursing is a tough study, but it's both rewarding for the hospitals that need them and rewarding for the people who eventually get to aid in one of the most beautiful, natural aspects of human life – pregnancy and childbirth. Do you know enough to be able to assist See morein maternal and child nursing? Well, this quiz is here to test your knowledge of the same. Let's see if you can answer these questions and score the highest marks.
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- 2.
A client at 36 weeks’ gestation is scheduled for a routine ultrasound prior to amniocentesis. After teaching the client about the purpose of the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction?
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The ultrasound will help to locate the placenta.
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The ultrasound identifies blood flow through the umbilical cord.
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The test will determine where to insert the needle.
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The ultrasound locates a pool of amniotic fluid.
Correct Answer
A. The ultrasound identifies blood flow through the umbilical cord.Explanation
The client's statement that the ultrasound identifies blood flow through the umbilical cord indicates a need for further instruction. Ultrasound does not typically assess blood flow through the umbilical cord. It is used to locate the placenta, determine the insertion site for amniocentesis, and locate a pool of amniotic fluid.Rate this question:
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- 3.
While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse Mica expect to administer if the client develops complications related to heparin therapy?
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Calcium gluconate
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Protamine sulfate
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Methylergonovine (Methergine)
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Nitrofurantoin (macrodantin)
Correct Answer
A. Protamine sulfateExplanation
Protamine sulfate is the antidote for heparin therapy. Heparin is an anticoagulant medication used to prevent blood clots. However, in some cases, it can cause excessive bleeding or other complications. Protamine sulfate works by neutralizing the effects of heparin, helping to reverse its anticoagulant effects and prevent further bleeding or complications. Therefore, if the postpartum client develops complications related to heparin therapy, the nurse would expect to administer protamine sulfate to counteract the effects of heparin.Rate this question:
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- 4.
When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following?
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Turn the neonate every 6 hours
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Encourage the mother to discontinue breast-feeding
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Notify the physician if the skin becomes bronze in color
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Check the vital signs every 2 to 4 hours
Correct Answer
A. Check the vital signs every 2 to 4 hoursExplanation
Checking the vital signs every 2 to 4 hours is important when caring for a neonate receiving phototherapy for jaundice. Phototherapy can cause dehydration and electrolyte imbalances, so monitoring vital signs regularly helps to assess the neonate's hydration status and overall well-being. Turning the neonate every 6 hours is not specific to phototherapy and is more related to preventing pressure ulcers. Encouraging the mother to discontinue breastfeeding is not necessary as breastfeeding is important for the neonate's nutrition and hydration. Notifying the physician if the skin becomes bronze in color may indicate a potential adverse reaction to phototherapy, but it is not the most immediate and essential action to take.Rate this question:
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- 5.
A primigravida in active labor is about 9 days post-term. The client desires bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective?
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Back
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Abdomen
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Fundus
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Perineum
Correct Answer
A. PerineumExplanation
The perineum is the correct location for relief after a bilateral pudendal block anesthesia. This type of anesthesia involves injecting a local anesthetic into the area around the pudendal nerve, which provides pain relief to the perineum during delivery. Therefore, if the client identifies the perineum as the area of relief, it indicates that the teaching was effective and the client understands the intended location of the anesthesia.Rate this question:
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- 6.
The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says:
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“Nausea and vomiting can be decreased if I eat a few crackers before arising”
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“If I start to leak colostrum, I should cleanse my nipples with soap and water”
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“If I have a vaginal discharge, I should wear nylon underwear”
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“Leg cramps can be alleviated if I put an ice pack on the area”
Correct Answer
A. “Nausea and vomiting can be decreased if I eat a few crackers before arising”Explanation
The client's statement that "Nausea and vomiting can be decreased if I eat a few crackers before arising" demonstrates understanding of self-care measures for common discomforts of pregnancy. Eating crackers before getting out of bed in the morning can help alleviate morning sickness by providing a bland, dry substance in the stomach. This can help absorb stomach acids and prevent nausea. This self-care measure is commonly recommended for pregnant women experiencing morning sickness.Rate this question:
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- 7.
Thirty hours after delivery, the nurse in charge plans discharges teaching for the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following?
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Taking in
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Letting go
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Taking hold
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Resolution
Correct Answer
A. Taking holdExplanation
Thirty hours after delivery, the nurse expects that the client would be in the phase of postpartum psychological adaptation known as "Taking hold." This phase occurs after the initial "Taking in" phase, where the client is focused on her own needs and is dependent on others for care. In the "Taking hold" phase, the client starts to take more initiative and becomes more interested in learning about and caring for her infant. This is an important time for the nurse to provide teaching on infant care. "Letting go" and "Resolution" are not the correct answers as they do not accurately describe this specific phase of postpartum adaptation.Rate this question:
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- 8.
A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following?
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Activity limited to bed rest
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Platelet infusion
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Immediate cesarean delivery
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Labor induction with oxytocin
Correct Answer
A. Activity limited to bed restExplanation
Partial placenta previa is a condition in which the placenta partially covers the cervix. The usual treatment for partial placenta previa is activity limited to bed rest. This is because bed rest helps to reduce the risk of bleeding and complications. By limiting activity, the client can minimize the pressure on the placenta and reduce the chances of further displacement or detachment. It is important for the client to avoid any strenuous activity or heavy lifting to prevent any harm to the placenta and the baby.Rate this question:
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- 9.
Nurse Julia plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan?
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Feeding the neonate a maximum of 5 minutes per side on the first day
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Wearing a supportive brassiere with nipple shields
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Breast-feeding the neonate at frequent intervals
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Decreasing fluid intake for the first 24 to 48 hours
Correct Answer
A. Breast-feeding the neonate at frequent intervalsExplanation
Breast-feeding the neonate at frequent intervals helps to prevent breast engorgement. Frequent feeding stimulates milk production and helps to maintain a steady milk supply, reducing the risk of engorgement. This also helps to ensure that the baby is getting enough milk and promotes bonding between the mother and baby. Wearing a supportive brassiere with nipple shields may provide comfort, but it does not directly prevent engorgement. Feeding the neonate for only 5 minutes per side on the first day may not be sufficient to establish a good milk supply. Decreasing fluid intake for the first 24 to 48 hours is not recommended as it can lead to dehydration and does not prevent engorgement.Rate this question:
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- 10.
When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes?
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Startle reflex
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Babinski reflex
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Grasping reflex
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Tonic neck reflex
Correct Answer
A. Startle reflexExplanation
When the nurse accidentally bumps the bassinet, the neonate's reaction of throwing out its arms, hands opened and crying is indicative of the startle reflex. The startle reflex is a normal reflex that occurs in response to a sudden, unexpected stimulus. This reflex is characterized by the baby's sudden extension and abduction of the arms, followed by bringing them back to the body and crying. It is an involuntary response that helps protect the baby from potential harm or danger.Rate this question:
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- 11.
A primigravida client at 25 weeks’ gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform:
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Tailor sitting
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Leg lifting
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Shoulder circling
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Squatting exercises
Correct Answer
A. Tailor sittingExplanation
Tailor sitting is a sitting position that involves sitting on the floor with the knees bent and the soles of the feet together. This position helps to open up the pelvis and relieve pressure on the lower back. It can also help to improve posture and strengthen the pelvic floor muscles. By suggesting tailor sitting, the nurse is recommending a position that can help alleviate the client's lower back pain and provide some relief after a long day at work.Rate this question:
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- 12.
Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?
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Notify the neonate’s pediatrician immediately
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Check the diaper and circumcision again in 30 minutes
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Secure the diaper tightly to apply pressure on the site
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Apply gently pressure to the site with a sterile gauze pad
Correct Answer
A. Apply gently pressure to the site with a sterile gauze padExplanation
After observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision, the nurse in charge would first apply gentle pressure to the site with a sterile gauze pad. This is the most appropriate action to control the bleeding and promote clot formation. It is important to address the bleeding promptly to prevent further complications. Notifying the pediatrician immediately may be necessary depending on the severity of the bleeding, but applying pressure should be the first step taken. Checking the diaper and circumcision again in 30 minutes or securing the diaper tightly to apply pressure on the site are not the most appropriate initial actions.Rate this question:
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- 13.
Which of the following would the nurse Sandra most likely expect to find when assessing a pregnant client with abruption placenta?
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Excessive vaginal bleeding
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Rigid, boardlike abdomen
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Titanic uterine contractions
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Premature rupture of membranes
Correct Answer
A. Rigid, boardlike abdomenExplanation
A pregnant client with abruption placenta is likely to have a rigid, boardlike abdomen. This is because abruption placenta is a condition where the placenta separates from the uterine wall prematurely, leading to internal bleeding. The accumulation of blood behind the placenta causes the uterus to become tense and rigid, resulting in a boardlike feeling when palpated by the nurse. This symptom is an important indicator of abruption placenta and requires immediate medical attention.Rate this question:
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- 14.
While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse’s most appropriate action?
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Note the fetal heart rate patterns
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Notify the physician immediately
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Administer oxygen at 6 liters by mask
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Have the client pant-blow during the contractions
Correct Answer
A. Notify the physician immediatelyExplanation
The nurse should notify the physician immediately because the client is in active labor with twins and the cervix is 5 cm dilated. Contractions occurring every 7 to 8 minutes in a 30-minute period may indicate a potential problem or complication that requires medical attention. It is important to involve the physician in order to ensure the safety and well-being of both the mother and the babies.Rate this question:
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- 15.
A client tells the nurse, “I think my baby likes to hear me talk to him.” When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response?
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High-pitched speech with tonal variations
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Low-pitched speech with a sameness of tone
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Cooing sounds rather than words
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Repeated stimulation with loud sounds
Correct Answer
A. High-pitched speech with tonal variationsExplanation
High-pitched speech with tonal variations is the best means to elicit the best response from neonates. Neonates are more responsive to high-pitched sounds and tonal variations because their auditory system is still developing. High-pitched speech with tonal variations can capture their attention and engage them in a more meaningful way. This type of speech can also help in promoting language development and bonding between the caregiver and the baby.Rate this question:
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- 16.
A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 stations. What phase of labor is she in?
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Active phase
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Latent phase
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Expulsive phase
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Transitional phase
Correct Answer
A. Transitional phaseExplanation
The transitional phase of labor is the phase between the active phase and the second stage of labor. During this phase, the cervix dilates from 8 to 10 cm and the baby moves further down the birth canal. The woman may experience strong contractions and intense pain. In this case, the woman's cervix is already at 8 cm and completely effaced, indicating that she is in the transitional phase of labor.Rate this question:
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- 17.
A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the nurse respond?
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“Yes, it produces no adverse effect.”
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“No, it can initiate premature uterine contractions.”
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“No, it can promote sodium retention.”
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“No, it can lead to increased absorption of fat-soluble vitamins.”
Correct Answer
A. “No, it can initiate premature uterine contractions.”Explanation
The nurse should respond "No, it can initiate premature uterine contractions." because castor oil is known to stimulate the bowels and can potentially cause uterine contractions, which may lead to premature labor. It is important for pregnant patients to avoid any substances or medications that can potentially harm the fetus or cause complications during pregnancy.Rate this question:
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- 18.
A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several cloths. What is the primary nursing diagnosis for this patient?
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Knowledge deficit
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Fluid volume deficit
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Anticipatory grieving
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Pain
Correct Answer
A. Fluid volume deficitExplanation
The primary nursing diagnosis for this patient is fluid volume deficit. The patient is experiencing vaginal bleeding and has passed several clots, indicating a potential loss of blood. This can lead to a decrease in circulating blood volume, resulting in fluid volume deficit. The abdominal cramping may also be a symptom of this deficit. The other options, knowledge deficit, anticipatory grieving, and pain, do not directly address the patient's physical condition and symptoms.Rate this question:
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- 19.
Immediately after delivery, the nurse-midwife assesses the neonate’s head for signs of molding. Which factors determine the type of molding?
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Fetal body flexion or extension
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Maternal age, body frame, and weight
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Maternal and paternal ethnic backgrounds
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Maternal parity and gravidity
Correct Answer
A. Fetal body flexion or extensionExplanation
The type of molding in a neonate's head is determined by fetal body flexion or extension. This means that the positioning of the baby's body during delivery, whether it is flexed or extended, can affect the shape of the head. Molding occurs as the baby's skull bones shift and overlap to fit through the birth canal. The amount of molding can vary depending on how the baby is positioned during delivery.Rate this question:
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- 20.
For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied?
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The membranes must rupture
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The fetus must be at 0 station
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The cervix must be dilated fully
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The patient must receive anesthesia
Correct Answer
A. The membranes must ruptureExplanation
Before applying an internal electronic fetal monitoring (EFM) device, the membranes must rupture. This is because the internal EFM is inserted through the cervix and into the uterus, and it needs direct contact with the amniotic fluid to accurately monitor the fetal heart rate. If the membranes have not ruptured, there is a risk of infection or injury to the fetus if the EFM is inserted. Therefore, it is necessary for the membranes to rupture before using an internal EFM.Rate this question:
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- 21.
A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in the early part of the first stage of labor. Her pain is likely to be most intense:
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Around the pelvic girdle
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Around the pelvic girdle and in the upper arms
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Around the pelvic girdle and at the perineum
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At the perineum
Correct Answer
A. Around the pelvic girdleExplanation
During the early part of the first stage of labor, the pain is likely to be most intense around the pelvic girdle. This is because the cervix is dilating and the baby's head is descending into the pelvis, causing pressure and stretching of the pelvic ligaments and muscles. The pain may radiate to the lower back and thighs as well. However, as the labor progresses, the pain may also be felt at the perineum, which is the area between the vagina and the anus, as the baby's head puts pressure on this area during the pushing stage.Rate this question:
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- 22.
A female adult patient is taking a progestin-only oral contraceptive or minipill. Progestin use may increase the patient’s risk for:
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Endometriosis
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Female hypogonadism
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Premenstrual syndrome
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Tubal or ectopic pregnancy
Correct Answer
A. Tubal or ectopic pregnancyExplanation
Progestin-only oral contraceptives, also known as minipills, are a type of birth control pill that contains only progestin hormone. These pills work by thickening the cervical mucus, which makes it difficult for sperm to reach the egg. However, they do not always prevent ovulation. In rare cases, if ovulation occurs while taking the minipill, there is a risk of fertilization happening outside the uterus, leading to a tubal or ectopic pregnancy. This is because the minipill does not provide the same level of protection against pregnancy as combined oral contraceptives, which contain both estrogen and progestin hormones.Rate this question:
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- 23.
A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms?
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Proteinuria, headaches, vaginal bleeding
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Headaches, double vision, vaginal bleeding
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Proteinuria, headaches, double vision
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Proteinuria, double vision, uterine contractions
Correct Answer
A. Proteinuria, headaches, double visionExplanation
A patient with pregnancy-induced hypertension may exhibit proteinuria, which is the presence of excessive protein in the urine. This is because high blood pressure can damage the blood vessels in the kidneys, leading to the leakage of protein into the urine. Headaches are also a common symptom of pregnancy-induced hypertension, as the high blood pressure can cause increased pressure in the brain. Double vision may occur due to the effects of high blood pressure on the blood vessels in the eyes.Rate this question:
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- 24.
Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient’s fluid intake and output closely during oxytocin administration?
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Oxytocin causes water intoxication
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Oxytocin causes excessive thirst
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Oxytocin is toxic to the kidneys
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Oxytocin has a diuretic effect
Correct Answer
A. Oxytocin causes water intoxicationExplanation
During oxytocin administration, the nurse must monitor the patient's fluid intake and output closely because oxytocin can cause water intoxication. Oxytocin has antidiuretic effects, which means it can cause the body to retain water. This can lead to an imbalance in fluid levels and electrolytes, potentially causing water intoxication. Monitoring the patient's fluid intake and output is important to ensure that they are not retaining too much fluid and to detect any signs of water intoxication, such as fluid overload or hyponatremia.Rate this question:
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- 25.
Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss?
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Low room humidity
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Cold weight scale
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Cools incubator walls
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Cool room temperature
Correct Answer
A. Cools incubator wallsExplanation
Cools incubator walls can be a common source of radiant heat loss for a neonate. Incubators are designed to maintain a warm and controlled environment for newborns, but if the walls of the incubator are cool, they can absorb and dissipate heat, leading to hypothermia in the neonate. It is important for the nurse to ensure that the incubator is functioning properly and that the walls are adequately insulated to prevent heat loss.Rate this question:
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- 26.
After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur?
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Decreased peristalsis
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Increase heart rate
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Dry mucous membranes
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Nausea and Vomiting
Correct Answer
A. Nausea and VomitingExplanation
Bethanechol is a cholinergic agonist that stimulates the parasympathetic nervous system. One of its common side effects is nausea and vomiting. This occurs because the drug increases gastrointestinal motility, leading to increased gastric emptying and potential irritation of the stomach lining. Therefore, it is expected for the nurse to monitor the patient for these adverse effects after administering bethanechol.Rate this question:
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- 27.
The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage?
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Active phase
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Complete phase
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Latent phase
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Transitional phase
Correct Answer
A. Transitional phaseExplanation
The transitional phase is the shortest but most difficult part of the first stage of labor. This phase occurs when the cervix is dilated from 8 to 10 centimeters and the contractions become stronger and closer together. The woman may experience intense pain and discomfort during this phase, as well as feelings of exhaustion and uncertainty. The transitional phase is often described as the most challenging part of labor because it marks the transition from early labor to active labor, and the woman may feel overwhelmed by the intensity of the contractions and the physical and emotional changes she is experiencing.Rate this question:
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- 28.
After 3 days of breastfeeding, a postpartum patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she:
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Apply warm compresses to her nipples just before feedings
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Lubricate her nipples with expressed milk before feeding
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Dry her nipples with a soft towel after feedings
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Apply soap directly to her nipples, and then rinse
Correct Answer
A. Lubricate her nipples with expressed milk before feedingExplanation
Lubricating the nipples with expressed milk before feeding can help to relieve nipple soreness. Breast milk has natural moisturizing properties and can help to soothe and protect the nipples during breastfeeding. Additionally, lubricating the nipples with breast milk can also help to prevent friction and irritation during feeding.Rate this question:
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- 29.
The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time?
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Between 10 and 12 weeks’ gestation
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Between 16 and 20 weeks’ gestation
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Between 21 and 23 weeks’ gestation
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Between 24 and 26 weeks’ gestation
Correct Answer
A. Between 16 and 20 weeks’ gestationExplanation
The correct answer is between 16 and 20 weeks' gestation. This is when the patient can expect to feel the fetus move, also known as quickening. At this stage of pregnancy, the fetus has developed enough to start making movements that can be felt by the mother. Before this time, the fetus is still too small and the movements are not strong enough to be noticeable. After 20 weeks, the movements become more pronounced and can be felt regularly.Rate this question:
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- 30.
Normal lochial findings in the first 24 hours post-delivery include:
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Bright red blood
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Large clots or tissue fragments
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A foul odor
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The complete absence of lochia
Correct Answer
A. Bright red bloodExplanation
In the first 24 hours post-delivery, it is normal to experience bright red blood as part of the lochial discharge. This is because the uterus is shedding the lining that built up during pregnancy. The presence of bright red blood indicates that the healing process is underway and the body is expelling the excess blood. It is important to note that large clots or tissue fragments, a foul odor, or the complete absence of lochia are not normal and may indicate a complication that requires medical attention.Rate this question:
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Jul 26, 2024Quiz Edited by
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Feb 16, 2011Quiz Created by
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