NUR 195_MCN RLE

P1W1 POST TEST RATIONALIZATION

1.A client centered goal is a specific and measurable behavior or response that reflects a client’s:
A. Desire for specific health care interventions
B. Highest possible level of wellness and independence in function.
C. Physician’s goal for the specific client
D. Response when compared to another client with a like problem.

2. When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report
the following:
A. Length of time the current treatment has been in place.
B. The spouse’s reaction to the client’s dressing change.
C. Client’s concern about the current treatment.
D. Physician’s reluctance to change the current treatment plan.
This gives the consulting nurse facts that will influence a new plan. (b, c, and d. These are all subjective and
emotional issues/conclusions about the current treatment plan and may cause a bias in the decision of a new
treatment plan by the nurse consultant.)

3. The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary
nurse is obligated to:
A. Implement the specialist’s recommendations.
B. Report the recommendations to the primary physician.
C. Clarify the suggestions with the client and family members.
D. Discuss and review advised strategies with CNS
The primary nurse requested the consultation, it is important that they communicate and discuss
recommendations. The primary nurse can then accept or reject the CNS recommendations.

4. A pregnant patient needs consultation with a specialist due to her condition aside from her OB-GYNE.
Collaborative interventions are therapies that require:
A. Physician and nurse interventions.
B. Nurse and client interventions.
C. Client and Physician intervention.
D. Multiple health care professionals.

5. The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis,
which of the following would indicate the need for further action and analysis?
A. A client’s family attending a diabetic teaching session.
B. Canceling physical therapy sessions on the weekend.
C. Normal VS and absence of wound infection in a post-op client.
D. A client demonstrating accurate medication administration following teaching.

6. A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first
considers:
A. Notifying the physician.
B. Calling the wound care nurse
C. Changing the wound care treatment.
D. Consulting with another nurse
Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound
management. Professional and competent nurses recognize limitations and seek appropriate consultation.
7. The following statements appear on a nursing care plan for a client after a mastectomy: Incision site
approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These
statements are examples of:
A. Nursing interventions
B. Short-term goals
C. Long-term goals
D. Expected outcomes.

8. After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered
goal:
A. Encourage client to implement guided imagery when pain begins.
B. Determine effect of pain intensity on client function.
C. Administer analgesic 30 minutes before physical therapy treatment.
D. Pain intensity reported as a 3 or less during hospital stay.
This is measurable and objective.

9.To initiate an intervention the nurse must be competent in three areas, which include:
A. Knowledge, function, and specific skills
B. Experience, advanced education, and skills.
C. Skills, finances, and leadership.
D. Leadership, autonomy, and skills.

10. The nursing care plan is:

A. A written guideline for implementation and evaluation.
B. A documentation of client care.
C. A projection of potential alterations in client behaviors
D. A tool to set goals and project outcomes.

11. As goals, outcomes, and interventions are developed, the nurse must:
A. Be in charge of all care and planning for the client.
B. Be aware of and committed to accepted standards of practice from nursing and other disciples.
C. Not change the plan of care for the client.
D. Be in control of all interventions for the client.

12. Planning is a category of nursing behaviors in which:

A. The nurse determines the health care needed for the client.
B. The Physician determines the plan of care for the client.
C. Client-centered goals and expected outcomes are established.
D. The client determines the care needed.

13.The following statement appears on the nursing care plan for an immunosuppressed client: The client will
remain free from infection throughout hospitalization. This statement is an example of a (an):
A. Nursing diagnosis
B. Short-term goal
C. Long-term goal
D. Expected outcome

14. The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the
clients, which client would the RN need to develop a care plan first?
A. A client who is ambulatory.
B. A client, who has a fever, is diaphoretic and restless.
C. A client scheduled for OT at 1300.
D. A client who just had an appendectomy and has just received pain medication.
This client's needs are a priority.

15. Which of the following nursing interventions are written correctly?

A. Apply continuous passive motion machine during day.
B. Perform neurovascular checks.
C. Elevate head of bed 30 degrees before meals.
D. Change dressing once a shift.
It is specific in what to do and when.

16. Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a:
A. Plan is developed for nursing care.
B. Physical assessment begins
C. List of priorities is determined.
D. Review of the assessment is conducted with other team members.

17. Which of the following statements about the nursing process is most accurate?
A. The nursing process is a four-step procedure for identifying and resolving patient problems.
B. Beginning in Florence Nightingale’s days, nursing students learned and practiced the nursing process.
C. Use of the nursing process is optional for nurses, since there are many ways to accomplish the work of
nursing.
D. The state board examinations for professional nursing practice now use the nursing process rather than
medical specialties as an organizing concept.
Option A: The nursing process is a five-step process.
Option B: The term nursing process was first used by Hall in 1955.
Option C: Nursing process is not optional since standards demand the use of it.

18. Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has
multiple problems or alterations. Priorities are determined by the client’s:
A. Physician
B. Non Emergent, non-life threatening needs
C. Future well-being.
D. Urgency of problems

19. The nurse writes an expected outcome statement in measurable terms. An example is:
A. Client will have less pain.
B. Client will be pain free.
C. Client will report pain acuity less than 4 on a scale of 0-10.
D. Client will take pain medication every 4 hours around the clock.

20. Well formulated, client-centered goals should:

A. Meet immediate client needs.
B. Include preventative health care.
C. Include rehabilitation needs.
D. All of the above.

21. When establishing realistic goals, the nurse:

A. Bases the goals on the nurse’s personal knowledge.
B. Knows the resources of the health care facility, family, and the client.
C. Must have a client who is physically and emotionally stable.
D. Must have the client’s cooperation.

22. For clients to participate in goal setting, they should be:

A. Alert and have some degree of independence.
 B. Ambulatory and mobile.
C. Able to speak and write.
D. Able to read and write.

23. The planning step of the nursing process includes which of the following activities?
A. Assessing and diagnosing
B. Evaluating goal achievement.
C. Performing nursing actions and documenting them.
D. Setting goals and selecting interventions.

24. When completing a client assessment and determining nursing diagnoses, the nurse may make an error. A
diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error
is if the nurse:
A. Formulates a diagnosis too closely resembling a medical diagnosis
B. Distinguishes the nursing focus instead of other health care disciplines
C. Validates the assessment information in the data base
D. Uses the North American Nursing Diagnosis Association (NANDA) list of diagnoses as a source
A nursing diagnosis should identify the client’s response, not the medical diagnosis. Because the medical diagnosis
requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis.

25. After completion of the client assessment, the nurse uses nursing diagnoses because they
A. Assist the nurse to distinguish medical from nursing problems
B. Identify the domain and focus of nursing
C. Are required for accreditation purposes
D. Make all client problems become more quickly and easily resolved
After completing the client assessment, the nurse develops nursing diagnoses based on the data obtained. Nursing
diagnoses distinguish the nurse’s role from that of the physician, and help nurses to focus on the role of nursing in
client care.

26. The nurse recognizes that which one of the following statements is true with regard to the formulation of
nursing diagnoses?
A. The diagnosis must remain constant during the client’s hospitalization.
B. The diagnosis should include the problem and the related contributing conditions.
C. The diagnosis should identify a “cause and effect” relation.
D. The etiology of the diagnosis must be within the scope of the health care team’s practice.
This is a true statement. Related factors are causative or other contributing factors that have influence the client’s
actual or potential response to the health problem and can be changed by nursing interventions.

27. It is the ratio between the number of live-born births in the year and the average total population of that year.
A. Birth rate
B. Fertility rate
C. Fetal death rate
D. Neonatal death rate

28. When the number of deaths per 1000 live births occurring at birth or in the first 12 months of life is tackled, it
means:
A. Perinatal death rate
B. Maternal mortality rate
C. Infant mortality rate
D. Childhood mortality rate:

29. What does it mean when we discuss Perinatal death rate?

 A. the number of deaths of fetuses weighing more than 500 g and within the first 28 days of life per 1000
live births
B. the Number of deaths per 1000 population in children, 1 to 14 years of age.
C. Number of deaths per 1000 live births occurring at birth or in the first 28 days of life.
D. Number of pregnancies per 1000 women of childbearing age.

30. The __________________ of a country is an index of its general health because it measures the quality of
pregnancy care, nutrition, and sanitation as well as infant health.
A. Perinatal death rate
B. Maternal mortality rate
C. Infant mortality rate
D. Childhood mortality rate:

31.. What is the best time for a pregnant woman to attend an antenatal care clinic for the First time?
A. A.Within the First 12 weeks.
B. B.Within the First 10 weeks.
C. C.Within the First 11 weeks.
D. D.Within the First 9 weeks.

RATIONALE: pregnant women should

book for antenatal care within the First 12
weeks. The duration of pregnancy can then
be confirmed with reasonable accuracy on
physical examination, medical problems canbe diagnosed early, and screening tests can be done as soon as
possible.

32. .When should this patient return for her next antenatal visit?
A. 28 Weeks.
B. 26 weeks
C. 27 weeks
D. 25 weeks

33. A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular
contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding,
which nursing action is appropriate?
A. Contact the primary health care provider
B. Instruct the client to maintain bed rest for the remainder of the pregnancy
C. Inform the client that these contractions are common and may occur throughout the pregnancy
D. Call the maternity unit and inform them that the client will be admitted in a preterm labor condition
Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy.
Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, there is
no reason to notify the primary health care provider. This client is not in preterm labor and, therefore, does not
need to be placed on bed rest or be admitted to the hospital to be monitored.

34. Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that
she is in labor and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her
first?
A. “Do you have any chronic illness?”
B. “Do you have any allergies?”
C. “What is your expected due date?”
D. “Who will be with you during labor?”
When obtaining the history of a patient who may be in labor, the nurse’s highest priority is to determine her
current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and
the potential for labor complications. Later, the nurse should ask about chronic illness, allergies, and support
persons.

35.A client who is 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the client’s preparation
for parenting, the nurse might ask which question?
A. “Are you planning to have epidural anesthesia?”
B. “Have you begun prenatal classes?”
C. “What changes have you made at home to get ready for the baby?”
D. “Can you tell me about the meals you typically eat each day?”
During the third trimester, the pregnant client typically perceives the fetus as a separate being. To verify that this
has occurred, the nurse should ask whether she has made appropriate changes at home such as obtaining infant
supplies and equipment.

36. 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 clots. What is the primary nursing diagnosis for this patient?
A. Knowledge deficit
B. Fluid volume deficit
C. Anticipatory grieving
D. Pain
If bleeding and clots are excessive, this patient may become hypovolemic. Pad count should be instituted. Blood
volume expands during pregnancy, and a considerable portion of the weight of a pregnant woman is retained
water.

37.You are measuring the fundal height of a patient who is 20 weeks pregnant. Where do you expect to locate the
fundus of the uterus?
A. Umbilicus
B. Symphysis pubis
C. Xiphoid process
D. None of the above
At 20 weeks gestation, the fundus can be palpable at the level of the umbilicus.

38. When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider
attending childbirth preparation classes. When is the best time for the couple to attend these classes?
A. At 16 weeks of gestation.
B. At 20 weeks of gestation.
C. At 24 weeks of gestation.
D. At 30 weeks of gestation.
Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the
pregnancy when they are beginning to anticipate the onset of labor and the birth of their child. At 30 weeks, is
closest to the time when parents would be ready for such classes.

39. Part of the prenatal care to an expecting mother is breastfeeding. Which statement made by the client indicates
that the mother understands the limitations of breastfeeding her newborn?
A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period."
B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear
my breast milk."
C. "I can start smoking cigarettes while breastfeeding because it will not affect my breast milk."
D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between
breastfeedings."
Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will
suppress ovulation and menses, but is not completely effective as a birth control method.
40.. A patient has undergone an amniocentesis for evaluation of fetal well-being. Which intervention would be
included in the nurse’s plan of care after the procedure? Select all that apply.
I. Perform ultrasound to determine fetal positioning.
II. Observe the patient for possible uterine contractions.
III. Administer RhoGAM to the patient if she is Rh-negative.
IV. Perform a mini catheterization to obtain a urine specimen to assess for bleeding.

A. I&II B. II & III C. III & IV D. I & IV

Ultrasound is used prior to the procedure as a visualization aid to assist with insertion of the transabdominal
needle. RhoGAM is a prescription medicine that is used to prevent Rh immunization, a condition in which an
individual with Rh-negative blood develops antibodies after exposure to Rh-positive blood. RhoGAM is
administered by intramuscular (IM) injection. RhoGAM is purified from human plasma containing anti-Rh (anti-D).

41. The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse
measures the fundal height in centimeters and notes that the fundal height is 30cm. How should the nurse
interpret this finding?
A. The client is measuring large for gestational age
B. The client is measuring small for gestational age
C. The client is measuring normal for gestational age
D. More evidence is needed to determine size for gestational age
During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the
fetus's age in weeks +2 cm. Therefore, if the client is at 28 weeks' gestation, a fundal height of 30 cm would indicate
that the client is measuring normal for gestational age. At 16 weeks, the fundus can be located halfway between
the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is
at the xiphoid process.

42. The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement
by the client indicates a need for further instruction?
A. "I will record the number of movements or kicks."
B. "I need to lie flat on my back to perform the procedure."
C. "If I count fewer than 10 kicks in a 2 hour period, I should count the kicks again over the next 2 hours."
D. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to
count the kicks."
The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to
perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The
client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements.
The client records the number of movements felt during a specified time period. The client needs to notify the
primary health care provider if she feels fewer than 10 kicks over two consecutive 2 hour intervals or as instructed
by the PHCP.

43.. A nonstress test is performed on a client who is pregnant, and the results of the test indicate non-reactive
findings. The primary health care provider prescribes a contraction stress test, and the results are documented as
negative. How should the nurse document this finding?
A. A normal test result
B. An abnormal test result
C. A high risk for fetal demise
D. The need for a cesarean section
Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A
negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was
stressed by 3 contractions of at least 40 seconds' duration in a 10 minute period. Options 2, 3, and 4 are incorrect
interpretations.
44. The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction
should the nurse provide?
A. Strict bed rest is required after the procedure
B. Hospitalization is necessary for 24 hours after the procedure
C. An informed consent needs to be signed before the procedure
D. A fever is expected after the procedure because of the trauma to the abdomen
Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure.
After the procedure, the client is instructed to rest, but may resume light activity after the cramping subsides. The
client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding,
leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping.
Amniocentesis is an outpatient procedure and may be done in the obstetrician's office or in a special prenatal
testing unit. Hospitalization is not necessary after the procedure.

45. A nurse providing care for the antepartum woman should understand that the contraction stress test (CST):
A. Sometimes uses vibroacoustic stimulation.
B. Is an invasive test; however, contractions are stimulated.
C. Is considered to have a negative result if no late decelerations are observed with the contractions.
D. Is more effective than nonstress test (NST) if the membranes have already been ruptured.
No late decelerations indicate a positive CST result.

46. The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout
the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition
to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis?
A. Doppler blood flow analysis
B. Contraction stress test (CST)
C. Amniocentesis
D. Daily fetal movement counts
Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the
placenta. It is a helpful tool in the management of high-risk pregnancy due to intrauterine growth restriction
(IUGR), diabetes mellitus, multiple fetuses, or preterm labor.

47. During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done to identify fetal
abnormalities. Between 18 and 40 weeks gestation, which procedure is used to detect fetal anomalies?
A. Amniocentesis
B. Chorionic villi sampling
C. Fetoscopy
D. Ultrasound
Ultrasound is used between 18 and 40 weeks’ gestation to identify normal fetal growth and detect fetal anomalies
and other problems.

48. A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her
BPP score is 8. What does this score indicate?
A. The fetus should be delivered within 24 hours.
B. The client should repeat the test in 24 hours.
C. The fetus isn’t in distress at this time.
D. The client should repeat the test in 1 week.
The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal
tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives
2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that
the fetus has a low risk of oxygen deprivation and isn’t in distress. A fetus with a score of 6 or lower is at risk for
asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if
the score isn’t within normal limits.
49. A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct
understanding of the test?
A. "I will need to have a full bladder for the test to be done accurately."
B. "I should have my husband drive me home after the test because I may be nauseated."
C. "This test will help to determine whether the baby has Down syndrome or a neural tube defect."
D. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the
well-being of the baby."
The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by
monitoring fetal heart rate in conjunction with fetal activity and movements.

50. The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using
Nagele’s rule, the nurse determines her EDD to be which of the following?
A. September 27
B. October 21
C. November 7
D. December 27
To calculate the EDD by Nagele’s rule, add 7 days to the first day of the last menstrual period and count back 3
months, changing the year appropriately.
NUR 195_MCN RLE
P1W2 POST TEST RATIONALIZATION

1.During a prenatal visit at 38 weeks, a nurse assesses the fetal heart rate. The nurse determines that the fetal
heart rate is normal if which of the following is noted?
A. 80 BPM
B. 100 BPM
C. 150 BPM
D. 180 BPM
The fetal heart rate depends on gestational age and ranges from 160-170 BPM in the first trimester but slows with
fetal growth to 120-160 BPM near or at term. At or near term, if the fetal heart rate is less than 120 or more than
160 BPM with the uterus at rest, the fetus may be in distress.

2. A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is
appropriate to suggest to her at this time?
A Biophysical profile
B Amniocentesis
C Maternal serum alpha-fetoprotein (MSAFP)
D Transvaginal ultrasound
A biophysical profile is a method of biophysical assessment of fetal well-being in the third trimester. An
amniocentesis is performed after the fourteenth week of pregnancy. A MSAFP test is performed from week 15 to
week 22 of the gestation (weeks 16 to 18 are ideal). An ultrasound is the method of biophysical assessment of the
infant that is performed at this gestational age. Transvaginal ultrasound is especially useful for obese women whose
thick abdominal layers cannot be penetrated adequately with the abdominal approach.

3. A woman who is at 36 weeks of gestation is having a nonstress test. Which statement by the woman would
indicate a correct understanding of the test?
A. "I will need to have a full bladder for the test to be done accurately."
B. "I should have my husband drive me home after the test because I may be nauseous."
C. "This test will help to determine if the baby has Down syndrome or a neural tube defect."
D. None of the above
An ultrasound is the test that requires a full bladder.
An amniocentesis would be the test that a pregnant woman should be driven home afterward.

4. A nurse is performing an assessment of a primipara who is being evaluated in a clinic during her second trimester
of pregnancy. Which of the following indicates an abnormal physical finding necessitating further testing?
A. Consistent increase in fundal height
B. Fetal heart rate of 180 BPM
C. Braxton Hicks contractions
D. Quickening
The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160-170 BPM in the
first trimester and slows with fetal growth, near and at term, the fetal heart rate ranges from 120-160 BPM. The
other options are expected.

5. A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician
has documented the presence of a Goodell’s sign. The nurse determines this sign indicates:
A. A softening of the cervix.
B. A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus.
C. The presence of hCG in the urine.
D. The presence of fetal movement.
In the early weeks of pregnancy, the cervix becomes softer as a result of increased vascularity and hyperplasia,
which causes the Goodell’s sign.

6. A nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in
reducing breast tenderness. The nurse tells the client to:
A. Avoid wearing a bra.
B. Wash the nipples and areola area daily with soap and massage the breasts with lotion.
C. Wear tight-fitting blouses or dresses to provide support.
D. Wash the breasts with warm water and keep them dry.
The pregnant woman should be instructed to wash the breasts with warm water and keep them dry. Breasts can
become sore in early pregnancy for several reasons, but one of the primary causes is changing hormone levels
(such as estrogen, progesterone, and prolactin).

7. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been
experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding
management of care. Which statement, if made by the client, indicates a need for further education?
A. “I will maintain strict bedrest throughout the remainder of the pregnancy.”
B. “I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of
bleeding.”
C. “I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the
pad.”
D. “I will watch for the evidence of the passage of tissue.”
Strict bed rest throughout the remainder of pregnancy is not required. Bedrest and other activity restrictions have
not been found to be efficacious in the prevention of a threatened abortion progressing to spontaneous abortion
and have been shown to increase the risk of other complications including deep vein thrombosis and/or pulmonary
embolism and therefore should not be recommended

8. A nurse providing care for the antepartum woman should understand that the contraction stress test (CST):
L. sometimes uses vibroacoustic stimulation.
M. is an invasive test; however, contractions are stimulated.
N. is considered negative if no late decelerations are observed with the contractions.
O. is more effective than nonstress test (NST) if the membranes have already been ruptured.
Vibroacoustic stimulation is sometimes used with NST. CST is invasive if stimulation is by IV oxytocin but not if by
nipple stimulation. No late decelerations indicate a positive CST. CST is contraindicated if the membranes have
ruptured.
Vibroacoustic stimulation is sometimes used with NST. CST is invasive if stimulation is by IV oxytocin but not if by
nipple stimulation. No late decelerations indicate a positive CST. CST is contraindicated if the membranes have
ruptured.

9. The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout
the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition
to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis?
P. Doppler blood flow analysis
Q. Contraction stress test (CST)
R. Amniocentesis
S. Daily fetal movement counts
Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the
placenta. It is a helpful tool in the management of high-risk pregnancies because of intrauterine growth restriction
(IUGR), diabetes mellitus, multiple fetuses, or preterm labor. Because of the potential risk of inducing labor and
causing fetal distress, a CST is not performed on a woman whose fetus is preterm. Indications for an amniocentesis
include diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, and the
diagnosis of fetal hemolytic disease, not IUGR. Fetal kick count monitoring is performed to monitor the fetus in
pregnancies complicated by conditions that may affect fetal oxygenation. Although this may be a useful tool at
some point later in this woman's pregnancy, it is not used to diagnose IUGR.

10. A nonstress test (NST) is ordered on a pregnant women at 37 weeks gestation. What are the most appropriate
teaching points to include when explaining the procedure to the patient? (Select all that apply)
KK. After 20 minutes, a nonreactive reading indicates the test is complete.
LL. Vibroacoustic stimulation may be used during the test.
MM. Drinking orange juice before the test is appropriate.
NN. A needle biopsy may be needed to stimulate contractions.
OO. Two sensors are placed on the abdomen to measure contractions and fetal heart tones.
A nonreactive test requires further evaluation. The testing period is often extended, usually for an additional 20
minutes, with the expectation that the fetal sleep state will change and the test will become reactive. During this
time vibroacoustic stimulation (see later discussion) may be used to stimulate fetal activity. Vibroacoustic
stimulation is often used to stimulate fetal activity if the initial NST result is nonreactive and thus hopefully
shortens the time required to complete the test. Care providers sometimes suggest that the woman drink orange
juice or be given glucose to increase her blood sugar level and thereby stimulate fetal movements. Although this
practice is common, there is no evidence that it increases fetal activity. A needle biopsy is not part of a NST. The
FHR is recorded with a Doppler transducer, and a tocodynamometer is applied to detect uterine contractions or
fetal movements. The tracing is observed for signs of fetal activity and a concurrent acceleration of FHR.

11. Patient B has a problem which requires continuous additional care and has multiple pregnancy. With this data,
the patient is considered at what risk?
A. Low risk
B. Average risk
C. Intermediate risk
D. High risk
.High risk- has a problem which requires continuous additional care such as heart valve disease or a patient with a
multiple pregnancy.

12. All except one are factors that might contribute to a high-risk pregnancy include:
A. First time mothers
B. Pregnancy history
C. Advanced maternal age
D. Pregnancy complications
A history of pregnancy-related hypertension disorders increases the risk of having this diagnosis during the next
pregnancy. Pregnancy risks are higher for mothers older than age 35. Various complications that develop during
pregnancy can pose risks.

13. What does it mean when a pregnant woman is considered to be in an intermediate pregnancy?
A. Patients have a problem which requires continuous additional care such as heart valve disease or a patient
with a multiple pregnancy.
B. Patient has no maternal or fetal risk factors present. These patients can receive primary care from a
midwife
C. Patient has a problem which requires additional care such as grande multipara .
D. All of the above

14. When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband attend
childbirth preparation classes. When is the best time for the couple to participate in these classes?
A. At 16 weeks of gestation
B. At 20 weeks of gestation
C. At 24 weeks of gestation
D. At 30 weeks of gestation
Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the
pregnancy, when they anticipate the onset of labor and the birth of their child. (D) is closest to the time when
parents would be ready for such classes. (A, B, and C) are not the best times during pregnancy for the couple to
attend childbirth education classes. At these times, they will have other teaching needs. Early pregnancy classes
often include nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal development,
maternal and fetal risk factors, and evolving roles of the mother and her significant others.

15. A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health
nurse has taught her how to take her blood pressure and gave her parameters to judge a significant increase in
blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse
provide?
A. Lie on your left side and call 911 for emergency assistance.
B. Take an antacid and call back if the pain has not subsided.
C. Take your blood pressure now and if it is seriously elevated, go to the hospital.
D. See your health care provider to obtain a prescription for a histamine blocking agent.
Checking the blood pressure for an elevation (C) is the best instruction to give at this time. A blood pressure
exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure
(eclampsia), a life-threatening complication of gestational hypertension. Additional data are needed to confirm an
emergency situation as described in (A). (B and D) ignore the threat to client safety posed by a significant increase
in blood pressure.

16. Which finding(s) is (are) of most concern to the nurse when caring for a woman in the first trimester of
pregnancy?
1. Cramping with bright red spotting
2. Extreme tenderness of the breast
3. Lack of the tenderness of the breast
4. Increased amounts of discharge
5. Increased right-side flank pain
A. 1,3,5 B. 1,2,3 C. 3,4,5 D. 2,3,4
(1 and 3) are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client’s menstrual
cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that
a miscarriage is imminent. (5) could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time
before rupture. (2 and 4) are normal signs during the first trimester of pregnancy.

17. In developing a teaching plan for expectant parents, the nurse decides to include information about when the
parents can expect the infant’s fontanels to close. Which statement is accurate regarding the timing of an infant’s
fontanels’ closure should be included in this teaching plan?
A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week.
B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week.
C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month.
D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.
In the normal infant, the anterior fontanel closes at 12 to 18 months of age, and the posterior fontanel closes by
the end of the second month (D). These growth and development milestones are frequently included in questions
on the licensure examination. (A, B, and C) are incorrect.

18. A pregnant client is concerned about a blow to the abdomen if she continues to play basketball during her
pregnancy. The nurse’s response is based upon her knowledge of which of the following facts concerning amniotic
fluid?
A. The total amount of amniotic fluid during pregnancy is 300 mL.
B. Amniotic fluid functions as a cushion to protect against mechanical injury.
C. The fetus does not contribute to the production of amniotic fluid.
D. Amniotic fluid is slightly acidic.
19.A client at 28 weeks gestation is admitted to the labor and birth unit. Which test would most likely be used to
assess the client’s comprehensive fetal status?
A. Ultrasound for physical structure
B. Nonstress test (NST)
C. Biophysical profile (BPP)
D. Amniocentesis
Biophysical profile is a comprehensive test that would be used to assess the client’s fetal status at 28 weeks
gestation. Ultrasound for physical structure is limited to identifying the growth and development of the fetus, and
does not assess for other parameters of fetal well-being. Women with a high-risk factor will probably begin having
NSTs at 30-32 weeks gestation and at frequent intervals for the remainder of the pregnancy. Amniocentesis late in
pregnancy is used to test for lung maturity, not overall fetal status in labor, and when performed earlier, it is used to
test for specific disorders.

20. A pregnant client asks why ultrasound is used so frequently during pregnancy. The nurse’s response is based on
her knowledge that the advantages of ultrasound include which of the following? Select all that apply.
A. “It is non-invasive and painless.”
B. “It can be used to estimate gestational age.”
C. “Results are immediate.”
D. “The ultrasound is the only test to determine gender.”
The ability to accurately establish fetal age by ultrasound is lost in the third trimester because fetal growth is not as
uniform as in the first two trimesters; however, ultrasound can be used to approximate gestational age within 1-3
weeks accuracy during the third trimester. A comprehensive ultrasound is used to detect anatomical defects, not
gestational age. Ultrasound is not used to determine gender.

21. A nurse is teaching a group of student nurses about amniotic fluid. Which of the following statements by the
student nurse reflects an understanding of the fetus’s contribution to the quality of amniotic fluid? Select all that
apply.
A. “The fetus contributes to the volume of amniotic fluid by excreting urine.”
B. “Approximately 400 mL of amniotic fluid flows out of the fetal lungs each day.”
C. “The fetus swallows about 600 mL of the fluid in 24 hours.”
D. “A fetus can move freely and develop normally, even if there is no amniotic fluid.”
“The fetus contributes to the volume of amniotic fluid by excreting urine.” Approximately 400 mL of amniotic fluid
flows out of the fetal lungs each day. The fetus swallows about 600 mL of the fluid in 24 hours. An average volume
of amniotic fluid is necessary for good fetal movement. Regular movement is necessary for good musculoskeletal
development.

22. A nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why
the fertilized ovum stays in the Fallopian tube for 3 days, the nurse responds that the reason for this is that it:
A. Promotes the fertilized ovum’s chances of survival.
B. Promotes the fertilized ovum’s exposure to estrogen & progesterone.
C. Promotes the fertilized ovum’s normal implantation in the top portion of the uterus.
D. Promotes the fertilized ovum’s exposure to LH and FSH.
Fertilized egg stays in the fallopian tube for about 72-96 hours, or 3-4 days. However, during the first 24 hours of
fertilization, mitosis occurs, and the cell keeps on dividing as it makes its way to the uterus for implantation.

23. The nurse is taking an initial history of a prenatal client. Which of the following, if detected by the nurse
practitioner, would indicate a positive, or diagnostic sign of pregnancy?
A. Positive pregnancy test
B. Goodell’s sign
C. Uterine enlargement and amenorrhea
D. Fetal heartbeat with a Doppler at 11 weeks gestation
The positive signs of pregnancy are completely objective, cannot be confused with a pathologic state, and offer
conclusive proof of pregnancy. The fetal heartbeat can be detected with an electronic Doppler device as early as
weeks 10-12 of pregnancy. Pregnancy tests detect the presence of hCG in the maternal blood or urine. These are
not considered a positive sign of pregnancy because other conditions can cause elevated hCG levels. Physical
changes, like Godell’s sign and uterine enlargement, can also have other causes and do not confirm pregnancy. The
subjective changes of pregnancy, like amenorrhea, are the symptoms the woman experiences and reports. Because
other conditions can cause them, they cannot be considered proof of pregnancy.

24. Which of the following patients would be at high risk of developing preeclampsia? Select all that apply.
A. A patient who is pregnant with her 3rd child
B. A patient who is married
C. A patient who is 40 yrs old
D. A patient who is overweight
E. A patient who is pregnant with twinsk
Pre-eclampsia is a state that develops during pregnancy in which a mother has high blood pressure and starts
losing protein into the urine.Certain risks that increase such as a first-time pregnancy, advanced maternal age,
overweight or obesity in the mother, and pregnancy with multiple babies.

25. A woman at 35 weeks of gestation has had an amniocentesis. The results reveal that surface-active
phospholipids are present in the amniotic fluid. The nurse is aware that this finding indicates:
A. the fetus is at risk for Down syndrome.
B. the woman is at high risk for developing preterm labor.
C. lung maturity.
D. meconium is present in the amniotic fluid.
The presence of surface-active phospholipids is not an indication of Down syndrome. This result reveals the fetal
lungs are mature and in no way indicate risk for preterm labor. The detection of the presence of pulmonary
surfactants, surface-active phospholipids, in amniotic fluid has been used to determine fetal lung maturity or the
ability of the lungs to function after birth. This occurs at approximately 35 weeks of gestation. Meconium should
not be present in the amniotic fluid.

26. A pregnant patient has a systolic blood pressure that exceeds 160 mm Hg. Which action should the nurse take
for this patient?
A. Administer magnesium sulfate intravenously.
B. Obtain a prescription for antihypertensive medications.
C. Restrict intravenous and oral fluids to 125 mL/hr.
D. Monitor fetal heart rate (FHR) and uterine contractions (UCs).
Systolic blood pressure exceeding 160 mm Hg indicates severe hypertension in the patient. The nurse should alert
the health care provider and obtain a prescription for antihypertensive medications, such as nifedipine (Adalat) and
labetalol hydrochloride (Normodyne). Magnesium sulfate would be administered if the patient was experiencing
eclamptic seizures. Oral and intravenous fluids are restricted when the patient is at risk for pulmonary edema.
Monitoring FHR and UCs is a priority when the patient experiences a trauma so that any complications can be
addressed immediately.

27. A patient reports excessive vomiting in the first trimester of the pregnancy, which has resulted in nutritional
deficiency and weight loss. The urinalysis report of the patient indicates ketonuria. Which disorder does the patient
have?
A. Preeclampsia
B. Hyperthyroid disorder
C. Gestational hypertension
D. Hyperemesis gravidarum
Hyperemesis gravidarum is characterized by excessive vomiting during pregnancy, which causes nutritional
deficiency and weight loss. The presence of ketonuria is another indication of this disorder. Preeclampsia refers to
hypertension and proteinuria in patients after 20 weeks of gestation. Hyperthyroid disorder may be one of the
causes of hyperemesis gravidarum. Gestationaconditionension also develops after 20 weeks of pregnancy.
28. After being rehydrated in the emergency department, a 24-year-old primipara in her 18th week of pregnancy is
at home and is to rest at home for the next two days and take in small but frequent fluids and food as possible.
Discharge teaching at the hospital by the nurse has been effective if the patient makes which statement?
A. “I’m going to eat five to six small servings per day, which contain such foods and fluids as tea, crackers, or a
few bites of baked potato.”
B. “A strip of bacon and a fried egg will taste good as long as I eat them slowly.”
C. “As long as I eat small amounts and allow enough time for digestion, I can eat almost anything, like barbequed
chicken or spaghetti.”
D. “I’m going to stay only on clear fluids for the next 24 hours and then add dairy products like eggs and milk.”
Once the vomiting has stopped, feedings are started in small amounts at frequent intervals. In the beginning,
limited amounts of oral fluids and bland foods such as crackers, toast, or baked chicken are offered. Clear fluids
alone do not contain enough calories and contain no protein. Most women are able to take nourishment by mouth
after several days of treatment. They should be encouraged to eat small, frequent meals and foods that sound
appealing (e.g., nongreasy, dry, sweet, and salty foods).

29.A pregnant woman presents to the emergency department complaining of persistent nausea and vomiting. She
was diagnosed with hyperemesis gravidarum. The nurse should include which information when teaching about
diet for hyperemesis? Select all that apply.
A. Eat three larger meals a day.
B. Eat a high-protein snack at bedtime.
C. Ice cream may stay down better than other foods.
D. Avoid ginger tea or sweet drinks.
E. Eat what sounds good to you even if your meals are not well-balanced.
The diet for hyperemesis includes: (1) Avoid an empty stomach. Eat frequently, at least every 2 to 3 hours. Separate
liquids from solids and alternate every 2 to 3 hours. (2) Eat a high-protein snack at bedtime. (3) Eat dry, bland,
low-fat, and high-protein foods. Cold foods may be better tolerated than those served at a warm temperature. (4)
In general, eat what sounds good to you rather than trying to balance your meals. (5) Follow the salty and sweet
approach; even so-called junk foods are okay. (6) Eat protein after sweets. (7) Dairy products may stay down more
easily than other foods. (8) If you vomit even when your stomach is empty, try sucking on a Popsicle. (9) Try ginger
tea. Peel and finely dice a knuckle-sized piece of ginger and place it in a mug of boiling water. Steep for 5 to 8
minutes and add brown sugar to taste. (10) Try warm ginger ale (with sugar, not artificial sweetener) or water with
a slice of lemon. (11) Drink liquids from a cup with a lid.

30. Which of the following are functions of dressings? (select all that apply)
A. promote hemostasis
B. keep wound bed dry
C. wound debridement
D. prevent contamination
E. increase circulation
We don't want to keep the wound bed dry and dressings don't increase circulation

31. Which of the following patients would be expected to benefit from a moist to dry dressing (mechanical
debridement)? (select all that apply)
A. 24 year old with an open infected wound from a spider bite
B. 7 year old with an abrasion on bilateral knees
C. 50 year old with a post operative knee replacement incision
D. 30 year old who had a large cyst removed and now has some necrotic tissue present in the crater type wound

32. Which of the following devices should be used to ensure the appropriate amount of irrigation pressure during
wound irrigation?
A. 10 mL syringe with a 19 gauge needle
B. 35 mL syringe with a 19 gauge needle
C. steady flow of fluid from a height of 12 inches above the wound
D. steady but gentle squirt of irrigant through a catheter irrigation system

33. The nurse is caring for a patient who had knee replacement surgery 5 days go. The patient's knee appears red
and warm to the touch and patient is requesting increased pain medication. What complication should the nurse
be concerned about?
A. nothing, this is expected post operatively
B. patient is becoming dependent on pain medication
C. post operative wound dehiscence
D. post operative wound infection

34. When educating a patient about wound healing the nurse should include what in the teaching?
A. inadequate nutrition delays wound healing and increases risk of infection.
B. chronic wounds heal better in a dry, open environment so leave them open to air.
C. fat tissue heals more rapidly because there is less vascularization.
D. long term steroid use diminishes the inflammatory response and speeds up wound healing

35. The first step in donning sterile gloves, after choosing the correct size is:
A. Wash hand with soap and water using good hand-washing technique
B. Use the folded cuffs in the wrapper to open the sides fully
C. Open the wrapper fully, touching only the outer 1inch edge of the paper
D. Fold the first flap of the outer wrapper away from you

36. Sterile gloves must be worn for each of these procedures except:
A. Urinary Catheterization
B. Tracheostomy dressing change
C. Postpartum perineal care
D. Central line dressing change
Perineal care does not require a sterile field, or sterile gloves. The nurse should wear clean non-sterile gloves to
provide personal care to a patient due to the risk of contamination with body fluids.

37. To doff (remove) used sterile gloves the nurse should:

A. Pull both off from the inside edge, the nurse will wash their hands afterwards, so touching the gloves is
not a concern.
B. Wash the gloved hands with soap and water before removing the gloves to remove blood or body fluids.
C. Use clean tongs from the procedure tray to take them off so that the hands are not contaminated
D. Pull off the first glove by grasping slightly back from the wrist, turning it inside out, and wading the dirty
glove into the still gloved hand.
The first glove is removed by pinching near the wrist on the outside of the glove, wading the now "inside out" glove
into the still gloved hand. The second glove is removed by slipping a finger inside the wrist and turning the glove
inside out, keeping the first glove contained in the second, so that the nurses bare finger does not touch the
outside of the contaminated glove.

38. The outer boarder of the paper wrapper that holds the sterile gloves:
A. Is the preferred place to rest your sterile instruments so that can be picked up easily.
B. Is sterile, because it was inside the package with the gloves
C. Should extend over the edge of the table so the nurse won't touch the table by accident
D. Is not sterile 1 inch all the way around
The 1 inch boarder of the sterile wrapper is considered contaminated - and can be touched before gloving to center
the wrapper on the table, but should not be touched after the sterile gloves are donned.

39. While wearing sterile gloves, the nurse must keep the hands above their own waist at all times.
A. True
B. False
The nurse must consider anything below waist level contaminated, and should not allow the gloved hands to go
below the waist level until ready to remove the sterile field.

40. Which of the following would require the nurse put on a new pair of sterile gloves?
A. Picking up unused gauze from the central line dressing tray and dropping it on the table
B. Grasping the patients gown to move it out of the way
C. Tucking a drape under the patients hips using the inside of the drape cuff
D. Arranging the sterile supplies on the center of the sterile field
Touching the patient gown, bed-rails, or other non-sterile items will require the nurse to put on a new pair of sterile
gloves. Dropping gauze off the sterile field make the gauze unsterile, but does not contaminate the gloves as long
as the nurse does not pick it back up, keeping the gloved hands "inside" the drape cuff allows placement of the
drape without contaminating the gloves, same as organizing the sterile supplies inside the sterile field.
BSN 2_ P1 WEEK 3 POST TEST
NUR 195_MCN RLE
____________________________________________________________________________________
__________________________________________
GENERAL INSTRUCTIONS:
Shade only those that apply to each question on your answer sheet.
Read the question carefully and choose the best answer.
STRICTLY NO ERASURES.

1.Which is the most effective nursing action for controlling the spread of infection? CHAP 31. 2

A. Thorough hand hygiene

B. Wearing gloves and masks when providing direct client
care
C. Implementing appropriate isolation precautions
D. Administering broad-spectrum prophylactic antibiotics

RATIONALE: Rationale: Since the hands are frequently in contact with clients and equipment, they are
the most obvious source of transmission.

2.In caring for a client on contact precautions for a draining infected foot ulcer, which action should the
nurse perform? CHAP 31.3

A. Wear a mask during dressing changes.

B. Provide disposable meal trays and silverware.
C. Follow standard precautions in all interactions with the client.
D. Use surgical aseptic technique for all direct contact with
the client.

RATIONALE: Standard precautions include all aspects ofcontact precautions with the exception of placing
the client in a private room. A mask is indicated when working over a sterile wound
rather than an infected one (option A). Disposable food trays are not necessary for clients with infected
wounds unlikely to contaminate the client’s hands (option B). Sterile technique (surgical asepsis) is
not indicated for all contact with the client (option
D). The nurse would utilize clean technique when dressing the wound to prevent
introduction of additional microbes

3 When caring for a single client during one shift, it is

appropriate for the nurse to reuse only which of the
following personal protective equipment? 31.4

A. Goggles
B. Gown
C. Surgical mask
D. Clean gloves

RATIONALE : Unless overly contaminated by material that has splashed in the nurse’s face and cannot
be effectively rinsed off, goggles may be worn repeatedly (option A). Since gowns are at high
risk for contamination, they should be used only once and then discarded or washed (option B). Surgical
masks (option C) and gloves
(option D) are never washed or reused.

4.While applying sterile gloves (open method), the cuff of the first glove rolls under itself about 1/4 inch.
What is the best action for the nurse to take? 31.5

A. Remove the glove and start over with a new pair.

B. Wait until the second glove is in place and then unroll the cuff with the other sterile hand.
C. Ask a colleague to assist by unrolling the cuff.
D. Leave the cuff rolled under

RATIONALE :

5. After teaching a client and family strategies to prevent infection prevention, which statement by the
client would indicate effective learning has occurred? 31.8

A. “We will use antimicrobial soap and hot water to wash our hands at least three times per day.”
B. “We must wash or peel all raw fruits and vegetables before eating.”
C. “A wound or sore is not infected unless we see it
draining pus.”
D. “We should not share toothbrushes but it is OK to share towels and washcloths.”

6. Which of the numbered areas is considered sterile on a person in the operating room?

A.1
B. 3
C.2
D.4
7.. The nurse determines that a field remains sterile if which of the following conditions exist? 31.10

A. Tips of wet forceps are held upward when held in ungloved hands.
B. The field was set up 1 hour before the procedure.
C. Sterile items are 2 inches from the edge of the field.
D. The nurse reaches over the field rather than around the
Edges.

8.What is the best reason for a nurse to select a prepackaged sterile kit for a sterile
procedure?
a. Sterile pre packaged kits do not have expiration dates.
b. The wrapper of the sterile kit can be used as a sterile field.
c. Adding supplies to the sterile field takes less time than using a prepackaged kit.
d. The prepackaged sterile kit will take up less space on the bedside table.

RATIONALE: The container is designed to provide a readily accessible sterile field.

9. Which action is the most important step the nurse can take to keep the field sterile when using an
overbed table as the work surface for a sterile field?

A. Position the table out of the patient's reach.

B. Assess the table for stability.
C. Position the height of the table to be above waist level.
D. Assemble ahead of time any supplies and equipment not included in the kit.

RATIONALE: To remain sterile, the field must be above the level of the waist. Anything below
waist level is considered contaminated.

10.While opening a prepackaged sterile kit, a package of sterile 4 × 4s falls to the floor. What will the
nurse ask ancillary staff to do to ensure the integrity of the sterile field?

A. "I will have to set up another sterile field; please take these items away."
B. "Please go to the clean utility room and get me a package of sterile 4 × 4s."
C. "Please watch that nothing contaminates this sterile field while I go and get a replacement
item."
D. "Please explain to the patient the importance of remaining still during this procedure so no
other items will be contaminated."

11.When adding a sterile liquid to a sterile field, which action will contaminate the field?

a. Extending your arm over the sterile field to pour the liquid into the receptacle
b. Holding the bottle with the label facing the palm
c. Adding a liquid with a usable period that expires in 2 days
d. Placing the receptacle 1 inch (about 2.5 cm) from the edge of the sterile field

12.When opening a sterile pack, which action compromises the sterility of the contents?

A. Keeping the contents of the pack away from the table edge
B. Holding or moving the object below the waist
C. Opening the pack just before the procedure
D. Allowing movement around the sterile field that does not touch near the sterile field

RATIONALE: The area below the waist is more likely out of direct vision and can become
contaminated easier by contact with a nonsterile surface.

13. When performing a sterile procedure at the bedside, the Nursing Assistant can help by
assisting the nurse to ______________ the patient.

A. Mechanics
B. Position
C. Application
D. Intervention

RATIONALE: The Nurse Attendant can be most effective by helping the patient assume and
maintain the position that the nurse needs to perform the procedure.

14.A nurse is supervising a nursing student setting up for a sterile dressing change. Which
action by the nursing student would require intervention from the nurse?
A. The first flap of the sterile package is opened away from the student’s body.
B. The glove for the dominant hand is pulled on first.
C. When pouring a solution on to the sterile field, the label of the solution bottle is facing the floor.
D. The bottle of solution is kept above the student’s waist.

RATIONALE: The label of the bottle should be facing the student’s palm so it does not become
distorted or ruined if fluid runs down the bottle.

15.In setting up a sterile field, which of the listed actions would require intervention?
A. The bottle of solution is poured with the label facing up.
B. The sterile drape is allowed to unfold above the waist.
C. The first flap of the sterile package is opened toward the nurse.
D. The glove for the dominant hand is pulled on first.
RATIONALE: Opening the first flap toward the nurse would require the nurse to reach over the
sterile field to completely open the pack. The flap should open away from the nurse.

16. When teaching a female client how to catheterize

herself, how far into the urethra should the nurse instruct the client to insert the catheter?
A. 1″ (2.5 cm)
B. 2″ (5 cm)
C. 3″ (7.5 cm)
D. 4″ (10 cm)
RATIONALE: female urethra is approximately 1½″ (4 cm) long, but the catheter must be inserted
somewhat farther to ensure that the tip of the catheter is fully within the bladder

17. When preparing the client for catheterization, how should the nurse position the client?
A. Lithotomy position
B. Recumbent
C. Knee-chest position
D. Prone
RATIONALE: To access the urinary meatus and provide comfort for the client during the catheterization
procedure, it is best that the client lies on her back with the knees bent and spread apart

18. When the nurse mistakenly inserts the catheter into the client’s vagina rather than the urinary meatus,
which action is best to take next?
A. Wipe the catheter tip with an alcohol swab.
B. clean the tip with povidone-iodine solution (Betadine)
C. discard the catheter and use another sterile one.
D. Withdraw the catheter and insert it in the urethra
RATIONALE: a urinary catheter should remain sterile and the vagina is essentially unsterile.
Consequently the catheter is no longer sterile and must be replaced before proceeding further

19. Which of the following demonstrate that further teaching is required to prevent an infection related to
being catheterized? (Select all that apply.)
A. An elderly female carries her urinary drainage bag like a purse under her arm as she ambulates.
B. A patient drinks an entire pitcher of water over the period of one day.
C. As a patient is being transferred in a wheelchair, he places the drainage bag in his lap.
D. The NAP places a patient's drainage bag on a lowered side rail or on the floor.
E. A female patient keeps her catheter secured to her thigh with tape.
RATIONALE: the catheter bag should always below the patient bladder but not touching the floor

20. The nursing instructor is reviewing the renal system and urinary catheterization with her students.
Which statement, if made by a nursing student, indicates that further instruction is needed?
A. "The urinary tract is considered to be sterile."
B. "The nurse may use clean technique to insert an indwelling catheter."
C. "The urge to void is felt when the bladder contains 150 to 200 mL in an adult."
D. "The minimum average hourly urine output is 30 mL."
RATIONALE: Catheterization is always performed under sterile technique

21. What is included in the preparation for an assessment of the female genitalia?

a. Having the patient empty the bladder.

b. Explaining the exam thoroughly if it is the patient’s first exam.
c. Laying the head of the table flat
d. Both A and B.

RATIONALE: D having the patient empty her bladder and explaining the exam thoroughly are both part of
preparation for assessment of the female genitalia. The female patient is instructed to empty the bladder
before the assessment of the female genitalia. If this is the patient’s first exam, the exam is explained
thoroughly. A model or illustration is used to show the patient what will happen and what will be looked
for.

22. When should gloves be changed?

a. After touching the genital skin.

b. After completing the internal vaginal exam.
c. After completing the rectal exam
 d. All of the above.

RATIONALE: D gloves are considered contaminated as soon as you touch the genital skin, internal
vaginal area, or rectum.

23. Which description is consistent with normal vaginal secretion?

a. Clear, thick, and with a fishy odor.

b. Clear or cloudy, and odorless or with a slight odor.
c. Yellow, thin, and with a strong odor.
d. Green, thick, and with a foul odor.

RATIONALE: B vaginal secretions that are clear or cloudy, and odorless or with a slight odor are a
normal finding. Vaginal secretions that are thick with a fishy odor are not a normal finding and are a sign
of vaginitis. Vaginal secretions that are yellow with a strong odor are not a normal finding and are a sign
of vaginitis. Vaginal secretions that are green, thick and with a foul odor are not a normal finding and are a
sign of vaginitis.

24. The following are true regarding vaginal examination, EXCEPT?

a. Inspection of the cervix and vaginal walls.

b. Palpation of the vagina and vaginal cervix by digital examination.
c. Bimanual examination of the pelvic organs.
d. Rectal examination.

RATIONALE: D the procedure consists of introducing the index finger in the vagina and the middle finger
in the rectum. This examination may help to determine whether the lesion is in the bowel or between the
rectum and vagina.

25. Screening for endometrial cancer consists of reinforcing the need to report?

a. Bloody stools
b. Painful bowel movements
c. Unexpected vaginal bleeding or spotting.
d. Green or yellow vaginal

RATIONALE: C unexpected vaginal bleeding or spotting can be a sign of endometrial cancer; bloody
stools are not a sign of endometrial cancer; this can be a sign of colon cancer. Painful bowel movements
are not a sign of endometrial cancer.

26. Which of the following interventions of the nurse is considered priority in dealing with sexuality
problems and issues of the client?

a. Identifying the personal life experiences and feelings towards the client.
b. Becoming sensitive to the client’s feelings
c. Focusing on the client’s emotional contents
d. Portraying concern and sympathy with the client.

RATIONALE: A Identifying the personal life experiences and feelings towards the client is considered a
priority in dealing with sexuality problems and issues of the client.

27. The Papanicolaou test can detect the following, EXCEPT:

a. Pre-cancerous cell changes

b. The presence of HPV
 c. The presence of genital warts
d. The presence of cancer

RATIONALE: C genital warts can be seen by a physical examination of any areas where suspected warts
may be occurring.

28. When the results of a Pap smear are reported as class 5, the nurse recognizes that the common
interpretation is:

a. Malignant
b. Normal
c. Probably normal
d. Suspicious

RATIONALE: A a class 5 pap smear, according to the bethesa classification, indicates squamous cell.

29. When scheduling an annual pelvic examination and Pap smear test, the client asks if she should
abstain from intercourse before the test. Which is the nurse’s best response?

a. “yes avoid having intercourse for 24 hours before the test”

b. “yes avoid having intercourse for 2 hours before the test”
c. “no, intercourse does not interfere with this test”
d. “No intercourse can actually enhance the test result”

RATIONALE: A the woman should not douche, use vaginal medication or deodorants, or have sexual
intercourse for at least 24 hours before the test. Such activities may prevent the accurate evaluation of
smears, cultures, and cytologic data.

30. The nurse is counseling a mother who wants her teenage daughter to have a Pap smear and pelvic
examination. Which statement by the nurse is most accurate?

a. “if your daughter is over 18, she needs a pelvic examination and Pap smear”
b. “A teenager does not need this examination unless she is sexually active”.
c. “teach her to have her first examination by the age of 21 at the latest”.
d. “it is not needed unless you are worried about sexually transmitted disease.

RATIONALE: C. a woman needs to have her first pelvic examination with Pap smear by the age of 21, or
within 3 years of becoming sexually active, the other statements are not accurate.

31. The client in the gynecology clinic asks the nurse “What are the risk factors for developing cancer of
the cervix?”. Which statement is the nurse’s best response?

a. “The earlier age of sexual activity and the more partner, the greater the risk”
b. “Eating fast food high in fact and taking birth control pills are risk factors”
c. “A chlamydia infection can cause cancer of the cervix”
d. “Having early pap smears will protect you from developing cancer”

RATIONALE: A risk factor for cancer of the cervix include sexually activity before the age of 20 years;
multiple sexual partner; early childbearing; exposure to HPV; HIV infection; smoking; and nutritional
deficits of folates, beta carotene and vitamin C.

32.What type of lochia will the nurse assess initially after delivery?
 a. Serosa
b. Rubra
c. Alba
d. Vaginalis

RATIONALE: B the initial vaginal discharge after delivery is called lochia rubra. It is red and moderately
heavy. Lochia rubra lasts for up to 3 days postpartum.

33. A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the
nurse would include what information about lochia?

a. Lochia should disappear 2 to 4 weeks postpartum.

b. It is normal for the lochia to have a slightly foul odor.
c. A change in lochia from pink to bright red should be reported.
d. A decrease in flow will be noticed with ambulation and activity.

RATIONALE: C a return to bright red lochia rubra may indicate a late postpartum hemorrhage and must
be reported.

34. During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following
signs/symptoms should the nurse expect to see?

a. diaphoresis
b. lochia alba
c. cracked nipples
d. None of the above

RATIONALE: The normal progression of lochial change is as follows: lochia rubra, days 1 to 3; lochia
serosa, days 3 to 10; and lochia alba, days 10 until discharge stops. There is some variation in the exact
timing of the lochial change, but it is important for the client to know that the lochia should not revert
backwards. In other words, if a client whose lochia is alba again begins to have bright red discharge, she
should notify her health care practitioner.

35. The nurse is examining a 2-day postpartum client whose fundus is 2 cm below the umbilicus and
whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in
the nursing record?

A. Abnormal involution, lochia rubra heavy.

B. Abnormal involution, lochia serosa scant.
C. Normal involution, lochia rubra moderate.
D. Normal involution, lochia serosa heavy.

RATIONALE: Lochia rubra is bright red, lochia serosa is pinkish to brownish, and lochia alba is whitish.
The nurse would expect the fundus to descend below the umbilicus approximately 1 cm per postpartum
day. In other words, 1 day postpartum, the fundus is usually felt 1 cm below the umbilicus; 2 days
postpartum, it is usually felt 2 cm below the umbilicus, and so on

36. Ahealth care provider has ordered an indwelling catheter to be inserted to bedside
drainage. Which of the following is NOT an expected indication for Foley
catheterization?

A. Preoperative status
B. To determine urinary retention.
C. To obtain accurate urinary output in a critically ill patient.
 D. To allow a pressure ulcer on the coccyx to heal in a patient with urinary
incontinence

37. A nurse inserting an indwelling Foley catheter in a female patient advances the
catheter and obtains clear yellow urine. What is the next action the nurse should take?

A. Inflate the balloon with the prefilled syringe of sterile water in the balloon port.
B. Pull gently back on the catheter approximately 1 inch or until resistance is met.
C. Advance the catheter another 1 to 2 inches and inflate the balloon.
D. Ask the patient to bear down as if to void.

38. The nurse has inserted a catheter 7.5 cm (3 inches) in a female patient and obtains
no urine return even though her bladder is distended. What action should the nurse take
at this time?

a. Remove the catheter and have another nurse attempt to catheterize the patient.
b. Leave the catheter in vagina as a landmark and insert another sterile catheter.
c. Remove the catheter and reinsert into the urethra. The nurse may straighten the
urethra by inserting one finger of sterile gloved hand inside the vagina and
applying gentle pressure upward.
d. Inflate the balloon and reassess in 1 hour for urine return in the bedside
drainage bag.

39. As part of catheter insertion assessment, where should the nurse palpate?

a. At the costovertebral angle

b. Above the symphysis pubis
c. Starting at the right iliac crest and moving upward along the midclavicular line
d. Midway between the xyphoid process and symphysis pubis

40. These are the types of lochia. except

a. Rubra
b. Serosa
c. Alba
d. Denara
BSN 2_ P1 WEEK 4 POST TEST
NUR 195_MCN RLE
__________________________________________________
GENERAL INSTRUCTIONS:
Shade only those that apply to each question on your answer sheet.
Read the question carefully and choose the best answer.
STRICTLY NO ERASURES.

1. A woman has just arrived at the labor and delivery suite. In order to report the client’s status to
her primary health care practitioner, which of the following assessments should the nurse
perform? Select all that apply.
a. fetal heart rate
b. contraction pattern
c. contraction stress test
d. vital signs
e. biophysical profile
RATIONALE: The nurse should assess the fetal heart before reporting the client’s status to the health
care provider. The nurse should assess the contraction pattern before reporting the client’s status. The
nurse should assess the woman’s vital signs before reporting her status.

2. Which of the following represents the correct order of the stages of labor?
A. Latent phase; active phase; transitional phase; second stage
B. Acceleration phase; active phase; second stage; deceleration phase
C. First stage, latent phase, active phase, phase of linear slope
D. Latency, active labor, second stage, transitional phase
RATIONALE: A, Latent phase; active phase; transitional phase; second stage is the correct order for the
first
stage of labor up to second stage

3. Which of the following is not a characteristic of the latent phase of labor?

A. It may normally last more than 16 h in a nullipara
B. Considerable fetal descent usually occurs
C. It may be lengthened by analgesic use
D. It is a period of considerable cervical ripening
RATIONALE: B, Early labor is referred to as the latent phase. This is the least difficult phase of labor but
often
lasts the longest. Some women are in early labor for several days, while others remain in this phase for
only a few hours.

4. A fetal head that is floating above the inlet during early labor:
A. Is always associated with a deflexed attitude
B. Is associated with an increased risk of Cesarean delivery
C Signifies a malposition
D Only occurs in cases of android pelvic architecture
RATIONALE: B, If the labor progresses and the presenting part is still floating then the patient can deliver
for a cesarean.

5. A nullipara has a normal first stage. At full cervical dilation, the head is at station 0 and the
position is left occiput transverse. Two hours later the station is between + 2 and + 3. She has
had no anesthesia. Which of the following is correct?
A. There is a deep transverse arrest
B. Descent is normal and no intervention is necessary
C. The use of forceps or a vacuum extractor is necessary if delivery does not occur within 30 min
D. Descent is protracted
RATIONALE: B, If the labor progresses and the presenting part is descending then the patient can deliver
through a normal spontaneous delivery.

6. During the latent phase of labor:

A. The fetal head normally rotates internally
B. The cervix dilates at ≤ 5 cm/h
C. Uterine contractions occur irregularly
D. All of the above
RATIONALE: B, Early labor is referred to as the latent phase. This is the least difficult phase of labor but
often lasts the longest. Some women are in early labor for several days, while others remain in this phase
for only a few hours.

7. During most of the active phase:

A. Fetal descent occurs
B. Uterine contractility diminishes
C. Cervical dilation occurs linearly
D. The cervix remains very posterior
RATIONALE: C, While the cervix dilates from 6 to 8 centimeters (called the Active Phase), contractions
get stronger and are about 3 minutes apart, lasting about 45 seconds. Patient may have a backache and
increased bleeding from the vagina (called the "bloody show"). If the amniotic membrane ruptures the
contractions may get much stronger.

8. Which of the following is generally true of multiparas?

A. Labor is longer than in nulliparas
B. Labor begins with the fetal head at a higher station than in nulliparas
C. Prolonged latent phase is diagnosed after 20 h of labor
D. Labor begins with a less mature cervix than in nulliparas
RATIONALE: B, Labor begins with the fetal head at a higher station than in nulliparas

9. In recording the findings in the partograph, we should start by labeling the record with pertinent
patient identifying information.
A. TRUE
B. FALSE

10. Start when woman is in ACTIVE LABOR (4 cm or more) and is contracting adequately (3-4
contractions in 15 minutes)
A. TRUE
B. FALSE

11. Status of membranes, write ___ if intact

A. B
B. C
C. I
D. M
RATIONALE: C, the answer is I if we talk about the membrane if it is intact.

12. If ruptured, note color of amniotic fluid, write ___ if meconium stained.
A. M
B. I
C. C
D. B
RATIONALE: A, the answer is M if we talk about the membrane is meconium stained.

13. If she remains in latent phase for next 8 hours (labor is prolonged)
A. record only other findings (BP, FHT etc).
B. transfer her to hospital
C. Note the color of the amniotic fluid.
D. let her drink.
RATIONALE: B, the mother needs to be transfer to the hospital to monitor her labor and also to give
necessary intervention based on her needs.

14. To perform internal examination _______________, or more often if necessary, and plot findings
each time.
A. every 4 hours
B. every 5 hours
C. every 2 hours
D. every 3 hours

15. To progress of labor is ___________ if plotting stays on or to the left of the alert line (green part).
A. abnormal
B. normal
C. needs follow up care
D. needs to be reported from the physician.
RATIONALE: B, when plotting in partograph it is normal when it reaches to the green row.

16. If plotting passes alert line the nurse should:

A. Reassess woman and consider referral if facilities are not available to deal with obstetric
emergencies, unless delivery is imminent
B. do nothing
C. let the mother rest.
D. record the findings.
RATIONALE: A, as a nurse you must assess the mother and consider any referral facilities or any
obstetric emergencies.

17. The cervical dilatation taken at 8:00 A.M. in a G1P0 patient was 6 cm. A repeat I.E. done at 10
A.M. showed that cervical dilation was 7 cm. The correct interpretation of this result is:
A The duration of labor is normal
B Labor is progressing as expected
C The latent phase of Stage 1 is prolonged
D The active phase of Stage 1 is protracted
RATIONALE: D, The active phase of Stage I starts from 4cm cervical dilatation and is expected that the
uterus will dilate by 1cm every hour. Since the time lapsed is already 2 hours, the dilatation is expected to
be already 8 cm. Hence, the active phase is protracted.

18. To monitor the frequency of the uterine contraction during labor, the right technique is to time the
contraction
A From the end of one contraction to the beginning of the next contraction
B From the deceleration of one contraction to the acme of the next contraction
C From the beginning of one contraction to the beginning of the next contraction
D From the beginning of one contraction to the end of the same contraction
RATIONALE: C, Frequency of the uterine contraction is defined as from the beginning of one contraction
to the beginning of another contraction.

19. When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk
woman, G1 P0000? Select all that apply.
A. After vaginal exams
B. before administration of analgesics
C. periodically at the end of a contraction
D. every ten minutes
E. before ambulating
RATIONALE: Except for invasive procedures, assessment of the fetal heart pattern is the only way to
evaluate the well-being of a fetus during labor. The fetal heart pattern should, therefore, be assessed
whenever there is a potential for injury to the baby or to the umbilical cord. At each of the times noted in
the scenario—vaginal exam, analgesic administration, contraction, and ambulation— either the cord could
be compressed or the baby could be compromised.

20. The nurse is assessing the fetal station during a vaginal examination. Which of the following
structures should the nurse palpate?
A. Sacral promontory
B. ischial spines
C. cervix
D. symphysis pubis
RATIONALE: . Station is determined by creating an imaginary line between the ischial spines. The
descent of the presenting part of the fetus is then compared with the level of that “line.”

21. A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms
would indicate that the woman is progressing into the second stage of labor? Select all that apply.
A. Bulging perineum.
B. Increased bloody show.
C. Spontaneous rupture of the membranes.
D. Uncontrollable urge to push.
E. Inability to breathe through contractions.
RATIONALE: The three phases of the first stage of labor—latent, active, and transition— are related to
changes in cervical dilation and maternal behaviors. The three stages of labor are defined by specific
labor progressions—cervical change to full dilation (stage 1), full dilation to birth of the baby (stage 2),
birth of the baby to birth of the placenta (stage 3).

22. During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and
are 1 cm above the ischial spines. Which of the following is consistent with this assessment?
A. LOA -1 station.
B. LSP -1 station.
C. LMP +1 station.
D. LSA +1 station.
RATIONALE: When the presenting part of the fetus is at zero (0) station, the part is at the same level as
an imaginary line between the mother’s ischial spines. When the presenting part is above the spines, the
station is negative (). When the presenting part has moved past the spines, the station is defined as
positive (). Since the question states that the nurse palpated the buttocks above the spines, the station is
negative. This effectively eliminates the two answer options that include a positive station.

23. The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions
by the nurse is appropriate?
A. Inform the mother that the rate is normal.
B. Reassess in 5 minutes to verify the results.
C. Immediately report the rate to the health care practitioner.
D. Place the client on her left side and apply oxygen by face mask.
RATIONALE: The normal fetal heart rate is 110 to 160 bpm. A rate of 152, therefore, is within normal
limits. No further action is needed at this time.

24. The nurse documents in a laboring woman’s chart that the fetal heart is being “assessed via
intermittent auscultation.” To be consistent with this statement, the nurse, using a Doppler electrode,
should assess the fetal heart at which of the following times?
A. After every contraction.
B. For 10 minutes every half hour.
C. Periodically during the peak of contractions.
D. For 1 minute immediately after contractions.
RATIONALE: Although most babies are monitored via electronic fetal monitoring in labor, there is a great
deal of evidence to show that intermittent auscultation is as effective a method of monitoring the fetal
heart. It is essential, however, that the fetal heart be monitored immediately after contractions for 1 full
minute in order to identify the presence of any late or variable decelerations

25. While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing
shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What
should the nurse do?
A. Provide caring labor support.
B. Administer oxygen via face mask.
C. Change the client’s position.
D. Speed up the client’s intravenous.
RATIONALE: The baseline fetal heart variability is the most important fetal heart assessment that the
nurse makes. If the baby’s heart rate shows average variability, the nurse can assume that the baby is not
hypoxic or acidotic. In addition, the normal heart rate of 142 is reassuring.

26. While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal
heart decelerations present. Which of the following assessments must the nurse make at this time?
A. The relationship between the decelerations and the labor contractions.
B. The maternal blood pressure.
C. The gestational age of the fetus.
D. The placement of the fetal heart electrode in relation to the fetal position.
RATIONALE: Decelerations are defined by their relationship to the contraction pattern. It is essential that
the nurse determine which of the three types of decelerations is present. Early decelerations mirror
contractions, late decelerations develop at the peak of contractions and return to baseline well after
contractions are over, and variable decelerations can occur at anytime and are unrelated to contractions.

27. True or False: A normal fetal heart rate is between 100-120 bpm.
A. True
B. False
C. Maybe
D. None of the above
RATIONALE: The answer is FALSE. A normal fetal heart rate is between 120-160 bpm.

28.On the fetal heart monitor you see early decelerations. What is the cause of this finding?
A. The baby’s head is pressing against the pelvis or soft tissue
B. It is due to uteroplacental insufficiency.
C. It is caused by cord compression.
D. It is caused by a prolapsed uterus.
RATIONALE: The baby’s head is pressing against the pelvis or soft tissue

29. Which of the following statements describe a variable deceleration?

A. Variable decelerations are uniform
B. On the fetal tracing, the heart rate will mirror the mother’s contraction and represent
uteroplacental insufficiency.
C. On the fetal tracing, the heart rate will increase after the mother’s contraction and return to
baseline after the contraction ends
D. On the fetal tracing, the heart rate will go up and down and present when the cord is being
compressed.
RATIONALE: On the fetal tracing, the heart rate will go up and down and present when the cord is being
compressed.

30. True or False: Variable Deceleration may appear at random and may be unrelated to the mother’s
contractions.
A. True
B. False
 C. Maybe
D. None of the above

31. A woman is in active labor and is being monitored electronically. She has just received
Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on
the internal monitor tracing?
A. Variable decelerations.
B. Late decelerations.
C. Decreased variability.
D. Transient accelerations.
RATIONALE: The analgesics used in labor are opiates. The CNS-depressant effect of the opiates is
therapeutic for the mother who is in pain, but the baby is also affected by the medication, often exhibiting
decreased variability.

32. The nurse is assessing an internal fetal heart monitor tracing of an unmedicated,
full-term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret
as normal?
A. Variable baseline of 140 with V-shaped decelerations to 120 unrelated to contractions.
B. Variable baseline of 140 with decelerations to 100 that mirror each of the contractions.
C. Flat baseline of 140 with decelerations to 120 that return to baseline after the end of the
contractions.
D. Flat baseline of 140 with no obvious decelerations or accelerations.
RATIONALE:Even though there are decelerations in choice 2, the decelerations are expected because
the woman is currently in the transition phase of the first stage of labor

33. A woman is in the second stage of labor with a strong urge to push. Which of the following actions by
the nurse is appropriate at this time?
A. Assess the fetal heart rate between contractions every 60 minutes.
B. Encourage the woman to grunt during contractions.
C. Assess the pulse and respirations of the mother every 5 minutes.
D. Position the woman on her back with her knees on her chest.
RATIONALE: During second stage labor, the woman should push on an open glottis to prevent the
vasovagal response. Research has shown that when women push without being coached, they do not
hold their breaths to bear down, but instead grunt during the second stage.

34. A nurse is coaching a woman who is in the second stage of labor. Which of the following should the
nurse encourage the woman to do?
A. Hold her breath for twenty seconds during every contraction.
B. Blow out forcefully during every contraction.
C. Push between contractions until the fetal head is visible.
D. Take a slow cleansing breath before bearing down.
RATIONALE: : It is essential that the test taker read each question and the possible answer options
carefully. If the test taker were to read response “3” quickly, he or she might mistakenly choose it as the
correct response. Because the woman is being encouraged to push between contractions, however, the
answer is incorrect.

35. What is the cause of variable deceleration?

a. head compression
b. cord compression
c. placental insufficiency
d. none of the above

36. What is the cause of Early Deceleration?

a. head compression
 b. cord compression
c. placental insufficiency
d. none of the above

37. What is the cause of accelerations?

a. head compression
b. cord compression
c. That's normal, may need oxygen
d. placental insufficiency

38. What is the cause of late deceleration?

a. head compression
b. cord compression
c. That's normal, may need oxygen
d. placental insufficiency

39. which of the following nursing interventions for cord compression:

a. Change position
b. Discontinue oxytocin
c. Increase IV fluids
d. Position change

40. Nursing interventions for Late decelerations:

a. Administer O2
b. Amnioinfusion
c. Change position
d. None
NUR 195_MCN RLE
P1W5 POST TEST RATIONALIZATION

1.C The success of the rhythm method of birth control is dependent on the client’s menses being regular.
It is not dependent on the age of the client. Frequency of intercourse. or range of the client’s
temperature; therefore. Answers A. B. and D are incorrect.

2. C This question is the most important for the nurse to ask. The nurse is trying to learn whether or not
the client is having intercourse with more than one partner and/or whether the client has intercourse
with men or women or both.

3. C It is important for couples to be aware of potential side effects in order for them to make an
informed decision regarding the use of contraceptives. Even if a method is less reliable, it still carries
with it side effects that require informed consent. A written consent is required if the contraceptive
choice involves a surgical procedure. Some contraceptive procedures are invasive; however, do not
require hospitalization for insertion.

4. B As ovulation approaches, cervical mucus is abundant and clear, resembling raw egg white. Ovulation
generally occurs 14 days (plus or minus 2 days) before the beginning of menses. During the luteal phase
of the cycle, which occurs after ovulation, the cervical mucus is thick and sticky, making it difficult for
sperm to pass. Changes in the cervical mucus are related to the influences of estrogen and progesterone.
Cervical mucus is always present.

5. A. At ovulation body temperature drops, then rises sharply and remains elevated for several days.

6. C. Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature
increase of 0.7 degrees F to 0.8 degrees F and clear, thin cervical mucus. A return to the preovulatory
body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early
in the cycle is not significant. Breast tenderness and mittelschmerz are not reliable indicators of
ovulation.

7. B The correct use of barrier methods helps protect against the transmission of STDs compared with
other methods of contraception. The use of oral contraceptives has no effect on the transmission of
STDs. The effectiveness of oral contraceptives is increased related to the prevention of pregnancy
compared with other methods with the exception of abstinence. The method of sexual activity does not
affect the transmission of STDs.
8. D When the client is taking oral contraceptives and begins antibiotics, another method of birth
control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately
5–10 pounds of weight gain is not unusual, so reporting weight gain to the physician is incorrect. If the
client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the
pill. If the client misses one or more pills, two pills should be taken per day for 1 week is incorrect. If she
misses two, she should take two; if she misses more than two, she should take the missed pills but use
another method of birth control for the remainder of the cycle.

9. A. the typical failure rate of condom is approximately 12-14%. Adding a spermicide can decrease this
potential failure rate because it offers additional protection against pregnancy. Natural skin condoms do
not offer the same protection against sexually transmitted diseases caused by viruses as latex condoms
do.

10. B. The foreskin should be pulled back before applying the condom

11. B. The best method of birth control for the client with diabetes is the diaphragm. A permanent
intrauterine device can cause a continuing inflammatory response in diabetics that should be avoided.
oral contraceptives tend to elevate blood glucose levels. and contraceptive sponges are not good at
preventing pregnancy.

12. C. The client needs further instruction when she says that cervical caps fit better than the diaphragm.
Many women are unable to use cervical caps because their cervix is too short for the cap to fit the cervix
properly. A cervical cap may remain in place for up to 48 hours after intercourse, whereas it is
recommended that a diaphragm be left in place for only 24 hours. The cervical cap is associated with
cervical irritation.

13. A. Oral contraceptive pills typically contain a combination of estrogen and progestin hormones.

14. B. A woman should feel for the string periodically, especially after her period, to confirm the
presence of the IUD.

15. D. Intrauterine devices produce a spermicidal intrauterine environment. A copper IUD (ParaGard
T380A) inflames the endometrium, damaging or killing sperm and preventing fertilization and/or
implantation; a Mirena IUD (LNG-IUS) releases levonorgestrel, damaging sperm and causing the
endometrium to atrophy, thus preventing fertilization and/implantation. A diaphragm blocks the cervical
os. The IUD does not act by blocking the openings to the fallopian tubes.Preventing sperm from reaching
the vagina is the function of a condom.

16. D. After IUD insertion there may be excessive menstrual flow for several cycles. Because the IUD is a
foreign body, there is an increase in the blood supply, a result of the inflammatory process. There is no
documentation of a tubal pregnancy. Rupture of the uterus may occur on insertion but is uncommon.
Expulsion of the device may occur, but it is not classified as a side effect.
17. B. Because sperm are distal to the severed vas deferens, sperm will be in the ejaculate for about a
month. A sperm count after that period of time should be performed to confirm the absence of sperm.
Intercourse does not have to be delayed, but an alternate method of contraception should be used.
Erections and sexual pleasure are not affected by a vasectomy.

18. D. A vasectomy takes about 20 minutes and is performed on an outpatient basis under local
anesthesia.

19. B. the nurse should teach the patient that cervical mucus is thin and watery at ovulation. Subjective
sensation of warmth, breast tenderness, and emotional liability are not safe and reliable indicators.

20. A. The nurse should teach the patient that tubal ligation is a minor surgical procedure in which he
fallopian tubes are occluded by cautery, crushed, clamped, or blocked, thereby preventing passage of
both sperm and ova.

21.C. Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will
decrease the progression of labor. Answers A. B. and D are incorrect for the stem.

22. A. Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant.
The steps of the procedure for inserting an indwelling urinary catheter are as follows: The nurse should
gently insert the tip of the prefilled syringe into the urethra and instill the lubricant. Then the nurse
should ask the patient to bear down as though trying to void, as she slowly inserts the end of the
catheter into the meatus. She should continue to insert the catheter about 7 to 9 inches (17 to 22.5 cm)
or until urine flows. When urine appears, she should advance the catheter 1 to 2 inches (2.5 to 5 cm)
more. She should hold the catheter securely with her dominant hand while the urine flows. After urine
flows, she should stabilize the catheter's position in the urethra and use the other hand to pick up the
saline-filled syringe and inflate the catheter balloon.

23. A. True
ANSWER: True. Indwelling urinary catheters and drainage bags should not be changed at routine, fixed
intervals. Routine changing does not reduce the chance of developing an infection and increases the
opportunity for indwelling catheter contamination.

24.b. Ureters
Ureters drain urine from the kidneys into the bladder; if they become obstructed, peristaltic waves
attempt to push the obstruction
into the bladder. The kidney, bladder, and urethra do not produce peristaltic waves. Obstruction of both
bladder and urethra
typically does not occur.

25. c. Assess for bladder distention.

The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be
that the patient does not
have adequate intake, or it could be that the bladder sphincter is not functioning and the patient is
retaining water. Increasing fluids
is effective if the patient does not have adequate intake, or if dehydration occurs. Caffeine can work as a
diuretic but is not helpful if an underlying pathology is present. An order for diuretics can be obtained if
the patient was retaining water, but this should not be

26. A. True
ANSWER: True. It is good practice to disinfect the drainage bag sampling port before obtaining urine
samples. This will help reduce the possibility of contamination and the chance that the resident will
develop an infection.

27. A. Eliminate pressure at the penoscrotal angle.

The primary reason for taping an indwelling catheter to a male client is so the penis is held in a lateral
position to prevent pressure at the penoscrotal angle. Prolonged pressure at the penoscrotal angle can
cause a urethrocutaneous fistula.

28.B. False
Gloves should always be worn when handling an indwelling urinary catheter, accessing the drainage
system, emptying the drainage bag, and collecting a urine sample.

29.B. False
Gloves play a key role in preventing hand contamination, but glove use does not replace proper hand
hygiene. Hand hygiene should always be performed both before and after any contact with the resident,
handling an indwelling urinary catheter, accessing the drainage system, emptying the drainage bag, and
collecting a urine sample.

30.
C. Bladder D. Nephrons

31. Care for an indwelling urinary catheter should include which of the following interventions?
Insert the catheter using a clean technique.
Keep the drainage bag on the bed with the client.
Remove obvious encrustations from the external catheter surface by washing it gently with soap and
water.
Lay the drainage bag on the floor to allow for maximum drainage through gravity.
Vigorous cleaning of the meatus while the catheter's in place isn't recommended, but the area can be
gently washed with soap and water to remove obvious encrustations from the external catheter surface.
Insert the catheter using sterile technique. To avoid backflow of contaminated urine into the bladder and
increasing the chance of infection, don't raise the collection bag above the level of the client's bladder.
To prevent contamination of the closed system, never let the drainage bag touch the floor; hang it on the
bed in a dependent position.

32. When providing perineal care, we always

A) until peri area is red
B) wipe back to front
C) wipe front to back
D) using a back and forth motion

33. D) Wash hands and explain procedure

34.True
35.Washing a Patient's genital and anal area

36. The perineum____________.

A. is the cleaning and care of a patients genital and anal areas
B. The area between the external genitals and the anus
C. a tube inserted through the urethra and into the bladder
D. a catheter

37. What supplies are needed to successfully complete peri-care?

A. biohazard bag
B. Shampoo
C. gloves,Cotton balls
D. plastic bag, gloves, wipes, skin cleanser, barrier cream
E. ointment

38.For an uncircumcised male patient you need to first____________

A. pull back the foreskin
B. turn the penis to the side
C. push the foreskin forward
D. gently pat the area with a dry towel before washing

39. How many times can you use cotton ?

A. Twice
B. until you can't use it anymore
C. one cotton ball per wipe
D. six

40. The perineal care given to protect the patient from_____________

A. pain
B. urinary leakage and allows for drainage of the bladder
C. urinary tract infections
D. none of the above