RLE P2

1.When assessing a mother 12 hours following the delivery of a baby, where should the nurse
expect to palpate the fundus?

A.2 cm below the umbilicus

B. At the umbilicus
C. 1 cm below the umbilicus
D. Halfway between the umbilicus and the symphysis pubis

2. What is the name of the vaginal discharge that occurs immediately following delivery?
A. Lochia serosa
B.Lochia rubra
C. Lochia palatine
D. Lochia alba

3. What is the first secretion produced by the breast?

A. Prolactin
B. False milk
C. Colostrum
D. Whey

4. What should be included in a teaching plan regarding breast engorgement?

A. It typically occurs on the first postpartum day .
B.It is usually first observed in the axillary region
C. It occurs only in women who are not breastfeeding
D. It occurs near the nipple on the third postpartum day

5. When is breast engorgement most likely to occur?

A. When the infant's mouth surrounds the areola when feeding
B. When the breast tissue becomes congested
C. When the breast is emptied completely at each feeding
D. When the infant's mouth grasps the nipple firmly

6. Which statement would be a correct description of colostrum?

A. Slightly yellow and low in protein
B.Slightly yellow and provides antibodies
C. Creamy and high in fat and protein
D. Colorless and high in fat and carbohydrate

7. The new mother has decided not to breastfeed the baby. How should the nurse correctly
instruct the mother to suppress her milk supply?
A. Pump the breasts to remove milk
B. Apply warm, moist compresses
C. Restrict oral fluids
D. Apply a firm bra and ice pack.

8. During the immediate postpartum period, the mother has a temperature of 100.2° F, pulse 52,
respirations 18, BP 138/84. What should the nurse do?
A. Report the temperature as abnormal
B. Continue to monitor every 15 minutes
C. Report the pulse as abnormal
D. Nothing as the vital signs are normal

9. Within the first hour following a vaginal delivery, the nurse assesses the mother and finds the
fundus is firm and there is a trickle of bright red blood. What should be the nurse's reaction to
the assessment?
A.This is a normal occurrence.
B. This is abnormal and should be reported.
C. The patient should administered
D. The patient should be restricted to bed rest.

10. What is the appropriate way to assess the fundus of the postpartum patient?
A. Using the side of one hand moving down from the umbilicus
B.Using one hand over the lower segment of the uterus
C.Using one hand pushing upward from the lower uterus
D. Using one hand on the lower uterine segment while the other hand locates the fundus of the
uterus

11. The postpartum mother with a third degree laceration tells the nurse she is afraid to have a
bowel movement because of her painful episiotomy. What should the nurse do?
A. Offer a suppository or enema
B. Encourage ambulation
C.Offer stool softeners as prescribed
D. Offer pain medication before defecating

12. A new mother had spinal anesthesia during a cesarean delivery. She now has a desire to
void and can wiggle her toes. What should be the nurse's response when the mother asks to go
the bathroom?
A. Assess her blood pressure
B. Obtain a wheelchair
C. Palpate her bladder
D. Put slippers on her feet

13. A mother delivered her baby at midnight and it is now 9 AM. She wants to sleep and asks
the nurse to take care of the baby. What is this considered?
A. Fatigue from labor
B. Normal "taking in" response
C. Abnormal "taking in" response
D. Risk for altered maternal-infant bonding

14. Which of the following would be considered a normal assessment finding in a 1 day
postpartum patient?
A. Pinkish to brown lochia
B. Voiding frequently 50 mL to 75 mL of urine
C. Complaining of "after pains"
D. Fundus 1 cm above the umbilicus

15. A new Native American mother tells the nurse that when she goes home, her mother-in-law
will be caring for the baby while she rests. The nurse has concerns. What should the nurse do
A. Explain the importance of ambulating to recover
B.Explain the importance of maternal-infant bonding
C. Explore ways to blend this with safe health teaching
D. Encourage this cultural behavior

16. Before initially feeding an infant, what reflex should the nurse assess?
A. Moro reflex
B. Rooting reflex
C. Babinski reflex
D. Swallow reflex

17. Following delivery of the newborn, which nursing intervention should be carried out
immediately?
A. Weigh the infant
B. Warm the infant
C. Bathe the infant
D. Inoculate the infant

18. Where would acrocyanosis be assessed on a newborn?

A. Circumoral area
B. Brow
C. Feet
D. Mucous membrane

19. The nurse identifies that the newborn is jaundiced within the first 24 hours of birth, with
jaundice occurring over bony prominences of the face and the mucous membrane. What type of
jaundice does this represent?
A. Physiological
B. Pathologic
C. Normal
D. Transitory
20. What is the term for the cream cheese-like substance that protects the infant's skin from
amniotic fluid?
A. Lanugo
B. Meconium
C. Desquamation
D. Vernix caseosa

21. Which tests are performed to detect inborn errors of metabolism in the newborn?
A. Blood glucose
B. Phenylketonuria (PKU)
C. Blood urea nitrogen (BUN)
D. Prothrombin time (PT)

22. Which newborn assessment finding can suggest a chromosomal disorder?

A. Epstein pearls
B. Gynecomastia
C. Babinski reflex
D. Simian crease

23. Why is vitamin K given by injection to the newborn?

A. Most mothers have a vitamin K deficiency that develops during pregnancy.
B. Bacteria that synthesize vitamin K are not present in newborns.
C. Vitamin K prevents the synthesis of prothrombin.
D. The newborn does not store vitamin K.

24. What should be included when discussing the care of a circumcised infant after discharge
from the hospital?
A. Gently remove the yellow exudate from the foreskin.
B.Apply sterile petroleum gauze after each diaper change.
C. Wipe the circumcision with alcohol each day.
D. Avoid the use of cloth diapers until the foreskin has healed.

25. The nurse is caring for a newborn who was circumcised earlier in the day. What should be
included in the plan of care?
A. Administration of a topical anesthetic to the site
B. Application of ice to stop bleeding
C. Retraction of any remaining foreskin
D. Observation for bleeding for the first 12 hours

26. Which finding should the nurse suspect as abnormal in the newborn during the initial
assessment?
A. Eyes crossed at times
B. Persistent high-pitched cry
C. Arms and legs flexed
D. Slight bluish tinge of the extremities

27. What is characteristic of a normal breastfed infant's stool?

A. Green and loose
B. Dark green and sticky
C. Pale yellow and frequent
D. Light brown and pasty

28. The new mother calls the nurse to her room to show how her baby is "jerking around" when
she changes his position. The nurse understands that the baby is exhibiting which normal
reflex?
A. Traction reflex
C. Tonic neck reflex
B. Babinski reflex
D. Moro reflex

29. The nurse is giving a bath demonstration for a group of new mothers. What should be
included in the
démonstration?
A. Apply baby powder generously to keep baby dry.
B.Cleanse perineum from front to back.
C. Use scented soap to make baby smell good.
D. Partially submerge head in water when shampooing.

30. Which of the following measures could help prevent infant abduction?
A. Require staff members to wear appropriate identification badges
B. Respond immediately when an alarm sounds
C. Never leave infants unattended at any time
D. All of the above

31. The nurse is observing a new mother interact with her infant. Which observation would
indicate that bonding is occurring?
A. The mother is making eye contact with the infant.
B. The mother is cuddling with the infant and napping.
C. The mother states that her favorite thing to do with her baby is to breastfeed.
D. All of the above

32. A new mother asks for advice on how to quiet her fussy newborn. Which responses would
be appropriate to suggest to the mother? (Select all that apply.)
A.Prewarm the crib sheets with a hot water bottle
B. Swaddle the newborn tightly in a receiving blanket
C. Offer a pacifier or allow the infant to suckle at the breast
D. All of the above

33. On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs
of distress. The nurse should document as:
A.Cold stress.
B. Acrocyanosis.
C. Potential for respiratory distress.
D. Poor oxygenation

34. The AGPAR score is based on which 5 parameters?

A. Heart rate, respiratory effort, temperature, tone, and color
B. Heart rate, breaths per minute, irritability, reflexes, and color
C.Heart rate, muscle tone, reflex irritability, respiratory effort, and color
D. Heart rate, breaths per minute, irritability, tone, and color

35. Which vital sign is not routinely assessed in a term, healthy newborn with 9/9 AGPARs?
A. Pain
B. Pulse
C. Respirations
D. Temperature
E. Blood pressure

36. You record a newborn's Apgar score at birth. A normal 1-minute Apgar score is
A. 5 to 9.
B. 1 to 2.
C. 12 to 15.
D. 7 to 10

37. Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and
flaccid, she makes a face when she is stimulated, and her body and extremities are pink
A. 3
B. 4
C. 6
D. 5

38. The nurse is monitoring a client in active labor and notes that the client is having
contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate
between contractions is 100 beats per minute. Which nursing action is most appropriate?
A.Notify the PHCP
B. Continue monitoring the fetal heart rate
C. Encourage the client to continue pushing with each contraction
D. Instruct the client's coach to continue to encourage breathing techniques
39. The nurse is reviewing true and false labor signs with a multiparous cent. The nurse
determines that the client understands the signs of true labor if she makes which statement?
A. "I won't be in labor until my baby drops.
B. "My contractions will be felt in my abdominal area."
C."My contractions will not be as painful if I walk around."
D. "My contractions will increase in duration and intensity."

40. The nurse has been working with a laboring client and notes that she has been pushing
effectively for 1 hour. What is the client's primary physiological need at this time?
A. Ambulation
B. Rest between contractions
C. Change positions frequently
D. Consume oral food and fluids

41. The nurse is performing health assessment of the abdomen is the correct order to perform
the asseessment?
A.Auscultate, percuss, palpate, inspect
B. Palpate, percuss, auscultate, inspect
C Inspect, auscultate, palpate, percuss
D. Inspect, auscultate, percuss, palpate

42. The nurse is performing a health assessment and notes a yellow tinge to the sclera of the
eye. The nurse would document this as which of the following?
A. Cyanosis
B. Pallor
C. Jaundice
D. Erythema

43. While performing an assessment of the integumentary system, the nurse notes the client's
eyeballs are protruding and the upper eyelids are elevated. What term would the nurse use to
document this finding?
A. Erythema
B. Cyanosis
C. Normocephalic
D. Exophthalmos

44. The nurse is preparing for morning rounds. Which of the following may not be delegated to
the nursing assistant?
A.Skull and face assessment
B. Ambulate surgical clients
C. Vital signs
D. Fill water pitcher
45. The nurse is performing a lung assessment on a client with suspected pneumonia. Which of
the following assessments should the nurse report to the physician immediately?
A. Breath sounds equal bilaterally
B. Chest symmetrical
C. Asymmetric chest expansion
D. Bilateral symmetric vocal fremitus

46. While performing a health assessment, in which position should the nurse place the client
for inspection of the jugular veins?
A. 15-degree angle
B. 30- to 45-degree angle
C. 90-degree angle
D. 60-degree angle

47. The nurse is assessing peripheral pulses on a client with suspected peripheral vascular
disease. Which of the following should the nurse report to the physician immediately?
A.Thready pulses
B. Full pulsations
C. Pulses equal bilaterally
D. Pulses present bilaterally

48. The nurse is assessing a female's breasts. The nurse finds both breasts rounded, slightly
unequal in size, skin smooth and intact, and nipples without discharge. What is the nurse's next
action?
A. Document the findings in the nurse's notes as abnormal.
B. Document the findings in the nurse's notes as normal.
C. Notify the physician.
D. Notify the charge nurse

49. The nurse is preparing a client for an abdominal examination. Which of the following should
be performed before the examination?
A. Assess vital signs.
B. Ask client to urinate.
C. Ask client to drink 8 ounces of water.
D. Assess heart rate

50. The nurse is performing a musculoskeletal assessment on a client admitted with a possible
stroke. When testing for muscle grip strength, the nurse should ask the client to:
A.Grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out.
B. Flex each arm and then try to extend it against the nurse's attempt to keep the arm in flexion.
C. Shrug the shoulders against the resistance of the nurse's hands.
D. Hold an arm up and resist while the nurse tries to push it down.
51. Many Paner, Level 2 student is assigned to take the vital signs of a patient in Floor of SHH.
Which of the following statement by the student nurse shows understanding about temperature?
A. Body temperature never changes during a 24 hour period.
B. Body temperature is constantly high
C. The highest body temperature occurs between 1:00 and 4:00 AM
D. The highest body temperature occurs later in the day around 6:00 pm

52. Is considered as the safest and most non invasive method of temperature taking.
A.Axillary
B. Rectal
C. Oral
D. Temporal

53.Jomar, a 15-year-old patient was admitted and diagnosed with dengue fever. The student
took his vital signs and the temperature was elevated. She knows that the normal range of
temperature is which of these?
A. 37 C
B. 36 C
C. 36 C-37.5 C
D. 35 C--36 C

54. A 2 year old client came to OPD for consultation, due to on and off fever. What vital signs
must the nurse take first
A. Temperature
C. Respiratory rate
B. Pulse rate
D. Blood pressure

55. Physical assessment entails touching some body parts of the child, therefore anxiety is likely
expected. in order to prevent or minimize anxiety, which of the following is helpful?
A. Give her favorite food
B. Ask the favor from the mother to do the task when it needs touch
C.Let the child see and touch the equipment before you begin to use it.
D. Discontinue the examination if uncooperative

56. During the nursing rounds the patient verbalized that he feels hot. Which of the following
signifies febrile values of vital signs?
A. Temperature =37.8 C
B. Temperature =37.4 C
C. Respiratory rate =16 cpm
D. Respiratory rate = 21cpm
57. Jericho, a clinical instructor share to his students that intervention to perform if the patient is
febrile. Which of the following is NOT included in his teaching?
A. Encourage drinking adequate fluids
B. Perform tepid sponge bath
C. Elevate of head of bed
D. Give medications as ordered

58. Which of the following indicates a normal finding on auscultation of the lungs?
A. Tympany over the right upper lobe
B. Resonance over the left upper lobe
C. Hyperresonance over the left lower lobe
D. Dullness above the left 10th intercostal space

59. After auscultating the abdomen, the nurse should report which of the following to the primary
care provider?
A.Bruit over the aorta
B. Absence of bowel sounds for 60 seconds
C. Continuous bowel sounds over the ileocecal valve
D. A completely irregular pattern of bowel sounds

60. If unable to locate the client's popliteal pulse during a routine examination, the nurse should
perform which of the following next?
A.Check for a pedal pulse.
B. Check for a femoral pulse.
C. Take the client's blood pressure on that thigh.
D. Ask another nurse to try to locate the pulse

61. Which of the following is an expected finding during assessment of the older adult?
A. Facial hair becomes finer and softer.
B. Decreased peripheral, color, and night vision.
C. Increased sensitivity to odors.
D. Respiratory rate and rhythm are irregular at rest.

62. If the client reports loss of short-term memory, the nurse would assess this using which one
of the following?
A. Have the client repeat a series of three numbers, increasing to eight if possible.
B. Have the client describe his or her childhood illnesses.
c. Ask the client to describe how he or she arrived at this location.
D. Ask the client to count backwards from 100 subtracting seven each time.

63. The nurse will take the oral temperature of her client who had a rectal surgery, but the client
had just eaten and drank. Which of the following action should be done by the nurse?
A. Do not take the temperature at all.
B. Take the temperature rectally
C. Wait 15-30 minutes before taking an oral temperature
D. Take the temperature at 12 noon

64. A type of heat loss that occurs when heat is dissipated by air currents.
A. Convection
B. Radiation
C. Conduction
D. Evaporation

65. A process of heat loss which involves the transfer of heat from one surface to another Is.
A. Convection
B. Radiation
C. Conduction
D. Evaporation

66. The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The
client's contractions are moderate and occurring every 3 to 3 minutes, with a duration of 60
seconds. An internal fetal heart monitor is in place. The baseline fetal heart rate has been 120
to 122 bpm for the past hour. What is the priority nursing action?
A. Notify the HCP
B. Discontinue the infusion of oxytocin
C. Place oxygen on at 8 to 10 L/minute via face mask
D. Contact the client's primary support person(s) if not currently present

67. When assessing a woman in labor, the nurse is aware that the relationship of the fetal body
parts to one another is called fetal:
A. Lie
B. Position
C. Presentation
D. Attitude

68. To adequately care for a laboring woman, the nurse knows that which stage of labor varies
the most in length?
A. First
B. Fourth
C. Third
D. Second

69. When assessing the fetus using Leopold maneuvers, the nurse feels a round, hard, movable
fetal part just above the symphysis and a long, smooth surface in the mother's left side close to
midline. In the fundus, there is a prominence- when pushed the whole body seems to follow.
What is the likely position of the fetus?
A. RSA
B. ROA
C. LSP
D. LOA

70. How do you assess uterine contractions?

A. Asses duration from the beginning of the contraction to the peak of the same contraction,
frequency by measuring the time between the beginning of one contraction to the beginning of
the next contraction.
B. Assess frequency as the time between the end of one contraction and the beginning of the
next contraction, duration as the length of time from the beginning to the end of contractions,
and palpate the uterus for strength
C. Assess duration from beginning to end of each contraction. Assess the strength of the
contraction by the external fetal monitor reading. Measure frequency by measuring the
beginning of one contraction to another.
D. Assess duration from beginning to end of each contraction., frequency by measuring the time
between the beginnings of contractions, and palpate the funds of the uterus for strength.

71. John has fever of 38.5 degrees Celsius. It surges at around 40 degrees Celsius and go back
to 38. 5 degrees Celsius 6 times today in a typical pattern. What kind of fever does John have?
A. Intermittent
B. Remittent
C. Relapsing
D. Constant

72. Andrew's temperature 8 hours ago was normal, 36.5 degrees Celsius, 4 hours ago his fever
was 38.9 degrees Celsius. Right now, his temp is back to normal. Which of the following best
describe the fever Andrew is having?
A. Intermittent
B. Remittent
C. Relapsing
D. Constant

73. Two days ago, Mr. X had fever of 39.5 degrees Celsius. But yesterday, he had a normal
temperature of 36.5 degrees Celsius. Today, his temperature surge to 40 degrees Celsius. What
type of fever does Mr. X have?
A. Intermittent
B. Remittent
C. Relapsing
D. Constant

74. Which of the following statement is TRUE about pulse

A. Children have higher pulse rate than adults.
B. In lying position, pulse rate is higher
C. Fever does not affect pulse rate
D. Radial pulse is the most reliable for infants and small children
75. The following are correct actions when taking radial pulse Except.
A. Put the palms downward
b. Use the thumb to palpate the artery
C. Use 2 to 3 fingers to palpate the pulses
D. Assess the pulse rhythm, rate and amplitude.

76. You know that pulse rate is just easy to take because no devices are used for it, if peripheral
pulses are to be taken. Which pulse site the should not be palpated together in taking the pulse
fate?
A. Carotid
B. Radial
C. Popliteal
D. Brachial

77. During a nursing assessment an adult client is noted to have shallow respirations at a rate of
8 cycles per minute. His heart rate is 46 beats per minute. His vital signs would be described as;
A. Bradycardia and apnea
B. Tachycardia and apnea
C. Bradycardia and bradypnea
D. Tachycardia and bradypnea

78. The difference between the systolic and diastolic is termed as:
A. Apical pressure
B. Cardiac pressure
C. Pulse pressure
D. Pulse deficit

79. The nurse will perform physical assessment to a client. A systematic approach is followed
using the four techniques. He followed the head to toe approach, which is referred to as:
A. Cephalocaudal
B. Proximodistal
C. Mediolateral
D. External to internal

80. The factors that affect the process of labor and birth, known commonly as the five Ps,
include all EXCEPT:
A. Passageway.
B. Powers.
C. Passenger.
D. Pressure.

81. While evaluating an external monitor tracing of a woman in active labor, the nurse notes that
the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the
contraction, with the nadir of the decelerations occurring after the peak of the contraction. The
nurse's first priority is to:
A. Notify the care provider.
B. Assist with amnioinfusion
C. Change the woman's position
D. Insert a scalp electrode

82. What three measures should the nurse implement to provide intrauterine resuscitation?
Select the response that best indicates the priority of actions that should be taken.
A. Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask.
B. Perform a vaginal examination, reposition the mother, and provide oxygen via face mask.
C. Administer oxygen to the mother, increase IV fluid, and notify the care provider.
D. Call the provider, reposition the mother, and perform a vaginal examination

83. The nurse providing care for the laboring woman should understand that variable fetal heart
rate (FHR)
decelerations are caused by:
A. Umbilical cord compression.
B. Altered fetal cerebral blood flow
C. Fetal hypoxemia.
D. Uteroplacental insufficiency

84. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional
nursing measures should you take?
A. Call for help and Notify the care provider immediately
B. Start pitocin
C. Have her empty her bladder
D. Insert a Foley catheter

85. With regard to systemic analgesics administered during labor, nurses should be aware that:
A. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal
blood-brain barrier.
B. Effects on the fetus and newborn can include decreased alertness and delayed sucking.
C. Intramuscular administration (IM) is preferred over intravenous (IV) administration.
D. IV patient-controlled analgesia (PCA) results in increased use of an analgesic

86. Nursing care measures are commonly offered to women in labor. Which nursing measure
reflects application of the gate-control theory?
A. Massaging the woman's back
B. Changing the woman's position
C. Giving the prescribed medication
D. Encouraging the woman to rest between contractions
87. A woman in the active phase of the first stage of labor is using a shallow pattern of
breathing, which is about twice the normal adult breathing rate. She starts to complain about
feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should:
A. Notify the woman's physician.
B. Tell the woman to "calm down" and slow the pace of her breathing.
C. Administer oxygen via a mask or nasal cannula.
D. Help her breathe into a paper bag

88. When planning care for a laboring woman whose membranes have ruptured, the nurse
recognizes that the woman's risk for __ has increased.
A. Intrauterine infection
B. Hemorrhage
C. Precipitous labor
D. Supine hypotension

89. Ophthalmia neonatorum is contracted when a mother has which sexually transmitted
infection(s)?
A. Chlamydia
B. Gonorrhea
C. Trichomonas
D. Both A and B
E. Both B and C

90. Infants receive vitamin K within the first hour after delivery. What is the rationale for
administering the
A. Administered to give the infant better eye sight.
B. Is a routine vitamin needed by the infant.
C. Helps in formation of clotting factors, to prevent bleeding.
D. Used to help infant fight infections.

91. A purse tests a newborn's nervous functioning by stroking the sole of the baby's foot in an
inverted "J" curve from the heel upward. The baby responds by fanning his toes. Which reflex
has lust been demonstrated?
A. Extrusion
B. Moro
C. Babinski reflex
D. Rooting reflex

92. Ophthalmia neonatorum is contracted when a mother has which sexually transmitted
infection(s)?
A. Chlamydia
B. Gonorrhea
C. Trichomonas
D. Both A and B
E. Both B and C

93. Infants receive vitamin K within the first hour after delivery. What is the rationale for
administering the
A. Administered to give the infant better eye sight.
B. Is a routine vitamin needed by the infant.
C. Helps in formation of clotting factors, to prevent bleeding.
D. Used to help infant fight infections

94. A purse tests a newborn's nervous functioning by stroking the sole of the baby's foot in an
inverted "J" curve from the heel upward. The baby responds by fanning his toes. Which reflex
has lust been demonstrated?
A. Extrusion
B. Moro
C. Babinski reflex
D. Rooting reflex

95. All of the following are ways the nurse can encourage bonding between the parents and the
newborn EXCEPT
A. Asking the parents' permission to pick up the newborn
B. Encouraging parents to provide care while you are there to observe them
C. Telling the mother that the best way to bond with her baby is to breastfeed
D. Talking to the newborn in front of the parents

96. When evaluating neurologic maturity to determine gestational age, which of the following is
not part of the assessment?
A. Rooting
B. Popliteal angle
C. Square window
D. Posture

97. On an Apgar evaluation, reflex irritability is tested by which of the following?

A. Dorsiflexing a foot against pressure resistance
B. Raising the infant's head and letting it fall back
C. Tightly flexing the infant's trunk and then releasing it
D. Slapping the soles of the feet and observing the response

98. The nurse in the labor room is caring for a client in the active stage of the first phase of
labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor
strip. What is the most appropriate nursing action?
A. Administer oxygen via face mask
B. Place the mother in a supine position
C. Increase the rate of the oxytocin intravenous infusion
D. Document the findings and continue to monitor the fetal patterns
99. The nurse is performing an assessment of a client who is scheduled for a cesarean delivery
at 39 weeks of station. Which assessment finding indicates the need to contact the primary
health care provider?
A. Hemoglobin of 11 g/dL
B. Fetal heart rate of 180 beats per minute
C. Maternal pulse rate of 85 beats per minute
D. White blood cell count of 12,000

100. The nurse is caring for a 54-year-old unconscious female patient who has just been
admitted to the post-anesthesia care unit after abdominal hysterectomy. How should the nurse
position the patient?
A. Left lateral position with head supported on a pillow
B. Prone position with a pillow supporting the abdomen
c. Supine position with head of bed elevated 30 degrees
D. Semi-Fowler's position with the head turned to the right

101. The nurse is providing discharge teaching to a 51-year-old female patient who has had a
laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the
patient, indicates an understanding of the discharge instructions?
A. I will have someone stay with me for 24 hours in case I feel dizzy."
B. " should wait for the pain to be severe before taking the medication."
C. "Because I did not have general anesthesia, I will be able to drive home."
D. "It is expected after this surgery to have a temperature up to 102.40 F."

102. The nurse is working on a surgical floor and is preparing to receive a postoperative patient
from the post-anesthesia care unit (PACU. What should the nurse's initial action be upon the
patient's arrival?
A. Assess the patient's pain.
B. Assess the patient's vital signs.
C. Check the rate of the IV infusion.
D. Check the physician's postoperative orders

103. When assessing a patient's surgical dressing on the first postoperative day, the nurse
notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should
the nurse do first?
A. Recheck in 1 hour for increased drainage.
B. Notify the surgeon of a potential hemorrhage.
c. Assess the patient's blood pressure and heart rate.
D. Remove the dressing and assess the surgical incision.

104. In planning postoperative interventions to promote repositioning, ambulation, coughing,

and deep breathing, which action should the nurse recognize will best enable the patient to
achieve the desired outcomes?
A. Administering adequate analgesics to promote relief or control of pain
B. Asking the patient to demonstrate the postoperative exercises every 1 hour
C. Giving the patient positive feedback when the activities are performed correctly
D. Warning the patient about possible complications if the activities are not performed

105. The patient donated a kidney, and early ambulation is included in her plan of care. But the
patient refuses to get up and walk. What rationale should the nurse explain to the patient for
early ambulation?
A. "Early walking keeps your legs limber and strong."
B. "Early ambulation will help you be ready to go home."
C. "Early ambulation will help you get rid of your syncope and pain."
D. "Early walking is the best way to prevent postoperative complications."

106. The PACU nurse is receiving the client from the OR. Which intervention should the nurse
implement first?
A. Assess the client's breath sounds
B. Apply oxygen via nasal cannula
C. Take the client's BP
D. Monitor the pulse ox reading

107. Which assessment data indicate the post op client who had spinal anesthesia is suffering a
complication of the anesthesia?
A. Loss of sensation at the lumbar (L5) dermatome
B. Absence of the client's posterior tibial pulse
C. The client has a respiratory rate of 8
D. The blood pressure is within 20% of the client's baseline

108. The PACU nurse administers Narcan, an opioid antagonist, to a post op client. Which client
problem should the nurse include to the plan of care based on this medication?
A. Alteration in comfort
B. Risk for depressed respiratory pattern
C. Potential for infection
D. Fluid and electrolyte imbalance

109. The nurse and the unlicensed assistive personnel (UAP) are working on the surgical unit.
Which task can the nurse delegate to the UAP?
A. Take routine vital signs on clients
B. Check the Jackson Pratt insertion site
C. Hang the client's next IV bag
D. Ensure the client obtains pain relief

110. The charge nurse is making shift assignments. Which postoperative client should be
assigned to the most experienced nurse?
A. The 4 year old who had a tonsillectomy and is able to swallow fluids
B. The 74 year old with a repair of the left hip who is unable to ambulate
C. The 24 year old who had an uncomplicated appendectomy the previous day
D. The 80 year old client with small bowel obstruction and congestive heart failure

111. Which statement would be an expected outcome for the postoperative client who had
general anesthesia?
A. The client will be able to sit in the chair for 30 minutes
B. The client will have a pulse oximetry reading of 97% on room air
C. The client will have a urine output of 30 mL per hour
D. The client will be able to distinguish sharp from dull sensations

112. Which problem should the nurse identify as priority for client who is one day post op?
A. Potential for hemorrhaging
B. Potential for injury
C. Potential for fluid volume excess
D. Potential for infection

113. A full-term newborn was just born. Which nursing intervention is important for the nurse to
perform first?
A. Remove wet blankets.
B. Assess Apgar score
C. Insert eye prophylaxis’.
D. Elicit the Moro reflex

114. A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just
been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the
birth weight. Which of the following nursing actions is appropriate?
A. Do nothing because this is a normal weight loss.
B. Notify the neonatologist of the significant weight loss.
C. Advise the mother to bottle feed the baby at the next feed.
D. Assess the baby for hypoglycemia with a glucose monitor

115. A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the
following actions by the nurse is appropriate?
A. Place child in an isolette.
B. Administer oxygen.
C. Swaddle baby in a blanket.
D. Apply pulse oximeter.

116. The nurse is assessing a newborn on admission to the newborn nursery. Which of the
following findings should the nurse report to the neonatologist?
A. Intracostal retractions.
B. Caput succedaneum.
C. Epstein's pearls.
D. Harlequin sign

117. A neonate is in the active alert behavioral state. Which of the following would the nurse
expect to see?
A. Baby is showing signs of hunger and frustration.
B. Baby is starting to whimper and cry.
C. Baby is wide awake and attending to a picture.
D. Baby is asleep and breathing rhythmically.

118. The nurse is about to elicit the Moro reflex. Which of the following responses should the
nurse expect to see?
A. When the cheek of the baby is touched, the newborn turns toward the side that is touched.
B. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan
outward.
C. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and
the knees flex.
D. When the newborn is supine and the head is turned to one side, the arm on that same side
extends.

119. The mother notes that her baby has a "bulge" on the back of one side of the head. She
calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the
right parietal bone but does not cross the suture lines. The nurse explains to the mother that the
bulge results from which of the following?
A. Molding of the baby's skull so that the baby could fit through her pelvis.
B. Swelling of the tissues of the baby's head from the pressure of her pushing.
C. The position that the baby took in her pelvis during the last trimester of her pregnancy.
D. Small blood vessels that broke under the baby's scalp during birth.

120. A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following
needles could the nurse safely choose for the injection?
A. 5/8 inch, 18 gauge.
B. 5/8 inch, 25 gauge.
C. 1 inch, 18 gauge.
D. 1 inch, 25 gauge.