NURS 505 Comprehensive Test 2 Review Questions and Correct Answers
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Course
NURS 505
Institution
NURS 505
A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?
A. Cut the umbilical cord
B. Apply perineal pressure to the emerging fetal head
C. Prevent the perineum from teari...
NURS 505 Comprehensive Test 2 Review
Questions and Correct Answers
A nurse is caring for a client who presents to a labor and delivery unit experiencing
rapidly progressing labor. Which of the following is the priority action for the nurse to
take?
A. Cut the umbilical cord
B. Apply perineal pressure to the emerging fetal head
C. Prevent the perineum from tearing
D. Promote delivery of the placenta ✅b
(using maslow's hierarchy of needs, the priority intervention is to prevent injury to the
fetus during the delivery by applying gentle perineal pressure to the emerging head.
This avoids rapid expulsion of the fetal head. A change in pressure within the fetal skull
due to a rapid delivery can cause neurologic damage (increased intracranial pressure
and dural/subdural tearing). Rapid birth can also cause maternal injury, such as vaginal
or perineal lacerations.)
A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of
labor. Which of the following assessment findings should the nurse report to the
provider first?
A. Expulsion of a blood-tinged mucous plug
B. Continuous contraction lasting 2 min
C. Pressure on the perineum causing the client to bear down
D. Expulsion of clear fluid from the vagina ✅b
(a uterus contracting for more than 90 seconds is a sign of tetany and could lead to
uterine rupture, which is the greatest risk to the client at this time. The nurse should
report this finding immediately.)
A nurse is caring for a client who is having a nonstress test performed. The fetal heart
rate (fhr) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of
the following actions should the nurse perform?
,A. Immediately report the situation to the client's provider and prepare the client for
induction of labor
B. Encourage the client to walk around without the monitoring unit for 10 min, then
resume monitoring
C. Offer the client a snack of orange juice and crackers
D. Turn the client onto her left side ✅c
(a nonstress test depends upon fetal movement, and this fetus is most likely asleep.
Most fetuses are more active after meals due to the increase in the mother's blood
sugar. Giving the mother a snack will promote fetal movement.)
A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and
reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning
and is not accompanied by contractions. The client is not in distress and she states that
she can "feel the baby moving." an ultrasound is scheduled stat. The nurse should
explain to the client that the purpose of the ultrasound is to determine which of the
following?
A. Fetal lung maturity
B. Location of the placenta
C. Viability of the fetus
D. The biparietal diameter ✅b
(painless, spontaneous vaginal bleeding might indicate that the client has placenta
previa. Placenta previa is a condition in which the placenta is implanted low in the
uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the
client begins to bleed. The ultrasound will show the location of the placenta and help to
determine what sort of delivery the client requires and how emergent it is.)
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The
nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse
should suspect that the fetus is in which of the following positions?
A. Cephalic
B. Transverse
C. Posterior
D. Frank breech ✅d
,(with a frank breech presentation, the fetal heart is generally above the level of the
client's umbilicus.)
(a - with a cephalic presentation, the fetal heart is generally below the level of the
client's umbilicus.)
(b-with a transverse presentation, the fetal heart is generally below the level of the
client's umbilicus.)
(c-with a posterior presentation, the fetal heart is generally below the level of the client's
umbilicus.)
A nurse is assessing a client who received magnesium sulfate to treat preterm labor.
Which of the following clinical findings should the nurse identify as an indication of
toxicity of magnesium sulfate therapy and report to the provider?
A. Respiratory depression
B. Facial flushing
C. Nausea
D. Drowsiness ✅a
(magnesium sulfate toxicity can cause life-threatening adverse effects, including
respiratory and cns depression. The nurse should report a respiratory rate slower than
12/min immediately to the provider and stop the infusion.)
A nurse is caring for several clients. The nurse should recognize that it is safe to
administer tocolytic therapy to which of the following clients?
A. A client who is experiencing fetal death at 32 weeks of gestation
B. A client who is experiencing preterm labor at 26 weeks of gestation
C. A client who is experiencing braxton-hicks contractions at 36 weeks of gestation
D. A client who has a post-term pregnancy at 42 weeks of gestation ✅b
(tocolytic medications, such as terbutaline, indomethacin, and nifedipine are used to
relax the uterus in preterm labor. A client who is in preterm labor at 26 weeks of
gestation is a candidate for tocolytic therapy.)
, A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client
asks the nurse, "will my baby be okay?" which of the following responses should the
nurse offer?
A. "you must be feeling scared and powerless"
B. "everyone worries about her baby when she's in labor"
C. "you pregnancy is advanced so your baby should be fine"
D. "we have a neonatal unit here that's equipped to handle emergencies" ✅a
(this response illustrates the therapeutic communication technique of restatement. The
nurse shows empathy for the client by recognizing that the client is concerned about the
safety of the fetus and is powerless to do anything about the situation. This open-ended
statement encourages further communication by the client.)
A nurse on the obstetric unit is caring for a client who experienced abruptio placentae.
The nurse observes petechia and bleeding around the iv access site. The nurse should
recognize that this client is at risk for which of the following complications?
A. Anaphylactoid syndrome of pregnancy
B. Disseminated intravascular coagulation
C. Preeclamsia
D. Peurperal infection ✅b
(clinical manifestations of disseminated intravascular coagulation (dic) include oozing
from intravenous access and venipuncture sites; petechiae, especially under the site of
the blood pressure cuff; spontaneous bleeding from the gums and nose; other signs of
bruising; and hematuria.)
(a-anaphylactoid syndrome of pregnancy, due to an amniotic fluid embolism, typically
occurs within 30 min after birth and is manifested by sudden, acute onset of hypoxia,
hypotension, cardiac arrest, and coagulopathy.)
(c-preeclampsia is typically seen in the antepartum period and is manifested by
elevated blood pressure, hyperactive reflexes, proteinuria, and edema.)
(d-puerperal or postpartum infection is identified by the presence of a fever of 380 c
(100.40 f) or higher on 2 consecutive days of the first 10 postpartum days and can
include endometritis, wound infections, urinary tract infections, and mastitis.)
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