103. The obstetric client’s fetal heart rate is 80–90 during the contrac-tions. The first action the nurse should take is:
❍ A. Reposition the monitor.
❍ B. Turn the client to her left side. ❍ C. Ask the client to ambulate.
❍ D. Prepare the client for delivery.
104. Arterial ulcers are best described as ulcers that:
❍ A. Are smooth in texture ❍ B. Have irregular borders ❍ C. Are cool to touch
❍ D. Are painful to touch
105. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
❍ A. Anticipate the need for a Caesarean section. ❍ B. Apply an internal fetal monitor.
❍ C. Place the client in Genu Pectoral position. ❍ D. Perform an ultrasound.
106. A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
❍ A. The cervix is closed.
❍ B. The membranes are still intact.
❍ C. The fetal heart tones are within normal limits.
❍ D. The contractions are intense enough for insertion of an internal monitor.
107. The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primagravida as she completes the early phase of labor?
❍ A. Impaired gas exchange related to hyperventilation
❍ B. Alteration in placental perfusion related to maternal position
❍ C. Impaired physical mobility related to fetal-monitoring equipment
❍ D. Potential fluid volume deficit related to decreased fluid intake
108. As the client reaches 6cm dilation, the nurse notes late decelera-tions on the fetal monitor. What is the most likely explanation of this pattern?
❍ A. The baby is sleeping.
❍ B. The umbilical cord is compressed. ❍ C. There is head compression.
❍ D. There is uteroplacental insufficiency.
109. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
❍ A. Notify her doctor. ❍ B. Start an IV.
❍ C. Reposition the client. ❍ D. Readjust the monitor.
110. Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?
❍ A. A fetal heart rate of 120–130bpm ❍ B. A baseline variability of 6–10bpm
❍ C. Accelerations in FHR with fetal movement
❍ D. A recurrent rate of 90–100bpm at the end of the con-tractions
111. The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
❍ A. The bladder fills more rapidly because of the medica-tion used for the epidural.
❍ B. Her level of consciousness is such that she is in a trancelike state.
❍ C. The sensation of the bladder filling is diminished or lost.
❍ D. She is embarrassed to ask for the bedpan that fre-quently.
112. A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:
❍ A. Estrogen levels are low
❍ B. Lutenizing hormone is high ❍ C. The endometrial lining is thin ❍ D. The progesterone level is low
113. A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:
❍ A. Age of the client
❍ B. Frequency of intercourse ❍ C. Regularity of the menses
❍ D. Range of the client’s temperature
114. A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?
❍ A. Intrauterine device ❍ B. Oral contraceptives ❍ C. Diaphragm
❍ D. Contraceptive sponge
115. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of a ruptured ectopic pregnancy?
❍ A. Painless vaginal bleeding ❍ B. Abdominal cramping
❍ C. Throbbing pain in the upper quadrant
❍ D. Sudden, stabbing pain in the lower quadrant
116. The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutri-tional needs of the pregnant client?
❍ A. Hamburger patty, green beans, French fries, and
iced tea
❍ B. Roast beef sandwich, potato chips, baked beans, and cola
❍ C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea
❍ D. Fish sandwich, gelatin with fruit, and coffee
117. The client with hyperemesis gravidarum is at risk for developing:
❍ A. Respiratory alkalosis without dehydration ❍ B. Metabolic acidosis with dehydration
❍ C. Respiratory acidosis without dehydration ❍ D. Metabolic alkalosis with dehydration
118. A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
❍ A. Elevated human chorionic gonadatropin ❍ B. The presence of fetal heart tones
❍ C. Uterine enlargement
❍ D. Breast enlargement and tenderness
119. The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
❍ A. Hypoglycemic, small for gestational age ❍ B. Hyperglycemic, large for gestational age ❍ C. Hypoglycemic, large for gestational age ❍ D. Hyperglycemic, small for gestational age
120. Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?
❍ A. Weight gain should be reported to the physician.
❍ B. An alternate method of birth control is needed when taking antibiotics.
❍ C. If the client misses one or more pills, two pills should be taken per day for one week.
❍ D. Changes in the menstrual flow should be reported to the physician.
121. The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
❍ A. Diabetes ❍ B. HIV
❍ C. Hypertension ❍ D. Thyroid disease
122. A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:
❍ A. Assess the fetal heart tones. ❍ B. Check for cervical dilation.
❍ C. Check for firmness of the uterus. ❍ D. Obtain a detailed history.
123. A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
❍ A. Her contractions are two minutes apart. ❍ B. She has back pain and a bloody discharge.
❍ C. She experiences abdominal pain and frequent urina-tion.
❍ D. Her contractions are five minutes apart.
124. The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is asso-ciated with babies born to mothers who smoked during pregnancy?
❍ A. Low birth weight
❍ B. Large for gestational age
❍ C. Preterm birth, but appropriate size for gestation ❍ D. Growth retardation in weight and length
125. The physician has ordered an injection of RhoGam for the post-partum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
❍ A. Within 72 hours of delivery ❍ B. Within one week of delivery ❍ C. Within two weeks of delivery ❍ D. Within one month of delivery
126. After the physician performs an amniotomy, the nurse’s first action should be to assess the:
❍ A. Degree of cervical dilation ❍ B. Fetal heart tones
❍ C. Client’s vital signs
❍ D. Client’s level of discomfort
127. A client is admitted to the labor and delivery unit. The nurse per-forms a vaginal exam and determines that the client’s cervix is 5cm dilated with 75% effacement. Based on the nurse’s assess-ment, the client is in which phase of labor?
❍ A. Active ❍ B. Latent
❍ C. Transition ❍ D. Early
128. A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:
❍ A. Teaching the mother to provide tactile stimulation ❍ B. Wrapping the newborn snugly in a blanket
❍ C. Placing the newborn in the infant seat
❍ D. Initiating an early infant-stimulation program
129. A client elects to have epidural anesthesia to relieve the discom-fort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
❍ A. Checking for cervical dilation
❍ B. Placing the client in a supine position ❍ C. Checking the client’s blood pressure ❍ D. Obtaining a fetal heart rate
130. The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to:
❍ A. Administer a prescribed antibiotic.
❍ B. Wash her hands for two minutes before care. ❍ C. Wear a mask when providing care.
❍ D. Ask the client to cover her mouth when she coughs.
131. The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
❍ A. Pain
❍ B. Disalignment ❍ C. Cool extremity
❍ D. Absence of pedal pulses
132. The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
❍ A. Lack of exercise
❍ B. Hormonal disturbances ❍ C. Lack of calcium
❍ D. Genetic predisposition
133. A two-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?
❍ A. The infant no longer complains of pain. ❍ B. The buttocks are 15° off the bed.
❍ C. The legs are suspended in the traction. ❍ D. The pins are secured within the pulley.
134. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
❍ A. Uses a Steinman pin
❍ B. Requires that both legs be secured ❍ C. Utilizes Kirschner wires
❍ D. Is used primarily to heal the fractured hips
135. The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
❍ A. Serum collection (Davol) drain ❍ B. Client’s pain
❍ C. Nutritional status ❍ D. Immobilizer
136. Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse’s teaching?
❍ A. “I must flush the tube with water after feedings and clamp the tube.”
❍ B. “I must check placement four times per day.”
❍ C. “I will report to the doctor any signs of indigestion.”
❍ D. “If my father is unable to swallow, I will discontinue the feeding and call the clinic.”
137. The nurse is assessing the client with a total knee replacement two hours post-operative. Which information requires notification of the doctor?
❍ A. Scant bleeding on the dressing ❍ B. Low-grade temperature
❍ C. Hemoglobin of 7gm
❍ D. The urinary output has been 120ml during the
last hour
138. The nurse is caring for the client with a five-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?
❍ A. The client has traveled out of the country in the last six months.
❍ B. The client’s parents are skilled stained-glass artists. ❍ C. The client lives in a house built in 1990.
❍ D. The client has several brothers and sisters.
139. A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replace-ment with activities of daily living?
❍ A. High-seat commode ❍ B. Recliner
❍ C. TENS unit
❍ D. Abduction pillow
140. An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
❍ A. Administer oxygen via nasal cannula. ❍ B. Have narcan (naloxane) available.
❍ C. Prepare to administer blood products. ❍ D. Prepare to do cardioresuscitation.
141. Which roommate would be most suitable for the six-year-old male with a fractured femur in Russell’s traction?
❍ A. 16-year-old female with scoliosis
❍ B. 12-year-old male with a fractured femur ❍ C. 10-year-old male with sarcoma
❍ D. 6-year-old male with osteomylitis
142. A client with osteoarthritis has a prescription for Celebrex (cele-coxib). Which instruction should be included in the discharge teaching?
❍ A. Take the medication with milk. ❍ B. Report chest pain.
❍ C. Remain upright after taking for 30 minutes. ❍ D. Allow six weeks for optimal effects.
143. A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse:
❍ A. Handles the cast with the fingertips ❍ B. Petals the cast
❍ C. Dries the cast with a hair dryer
❍ D. Allows 24 hours before bearing weight
144. The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?
❍ A. “It will be alright for your friends to autograph the cast.”
❍ B. “Because the cast is made of plaster, autographing can weaken the cast.”
❍ C. “If they don’t use chalk to autograph, it is okay.”
❍ D. “Autographing or writing on the cast in any form will harm the cast.”
145. The nurse is assigned to care for the client with a Steinman pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
❍ A. Assisting the LPN with opening sterile packages and peroxide
❍ B. Telling the LPN that clean gloves are allowed
❍ C. Telling the LPN that the registered nurse should per-form pin care
❍ D. Asking the LPN to clean the weights and pulleys with peroxide
146. A child with scoliosis has a spica cast applied. Which action spe-cific to the spica cast should be taken?
❍ A. Check the bowel sounds. ❍ B. Assess the blood pressure. ❍ C. Offer pain medication.
❍ D. Check for swelling.
147. The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
❍ A. Russell’s traction ❍ B. Buck’s traction ❍ C. Halo traction
❍ D. Crutchfield tong traction
148. A client with a total knee replacement has a CPM (continuous pas-sive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?
❍ A. “Use of the CPM will permit the client to ambulate during the therapy.”
❍ B. “The CPM machine controls should be positioned dis-tal to the site.”
❍ C. “If the client complains of pain during the therapy, I will turn off the machine and call the doctor.”
❍ D. “Use of the CPM machine will alleviate the need for physical therapy after the client is discharged.”
149. A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
❍ A. Palms rest lightly on the handles ❍ B. Elbows are flexed 0°
❍ C. Client walks to the front of the walker ❍ D. Client carries the walker
150. When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
❍ A. Attempt to replace the cord.
❍ B. Place the client on her left side. ❍ C. Elevate the client’s hips.
❍ D. Cover the cord with a dry, sterile gauze.
