Detailed Answer Key

medical

1.A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of

the following findings support this diagnosis?

A. Painless red vaginal bleeding

Rationale:Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the

uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless

vaginal bleeding occurs in the second and third trimester.

B. Increasing abdominal pain with a nonrelaxed uterus

Rationale:Abruptio placenta is separation of the placenta from the site of uterine implantation before

delivery of the fetus. When the placenta separates prematurely, there is internal bleeding, which

is painful, and the uterus is nonrelaxed or becomes rigid as the separation advances.

C. Abdominal pain with scant red vaginal bleeding

Rationale:Placenta previa involves minimal to severe bright red vaginal bleeding in the absence of

abdominal pain.

D. Intermittent abdominal pain following passage of bloody mucus

Rationale:Intermittent abdominal pain following passage of bloody mucus is a description of normal labor.

The passage of bloody mucus represents the loss of the cervical mucous plug, also referred to

as the "bloody show."

2.A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small

clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions

should the nurse take?

A. Document the findings and continue to monitor the client.

Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and

associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual

period. Small clots are common. The nurse should document the findings and continue to

monitor the client.

B. Notify the client’s provider.

Rationale: These are expected findings, so there is no need to notify the provider.

C. Increase the frequency of fundal massage.

Rationale: These are expected findings and the fundus is already firm. Increasing the frequency of fundal

massage is not indicated at this time.

D. Encourage the client to empty her bladder.

Rationale: These are expected findings, and the fundus is firm at the midline. If the fundus was deviated,

this would be an indication of a distended bladder and the client should be encouraged to void to

prevent uterine atony.

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Detailed Answer Key

medical

3.A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority

nursing action?

A. Administer vitamin K.

Rationale:Administration of vitamin K is important, but it can be delayed until the newborn is held by the

mother and is breastfed. There is another, more important nursing action.

B. Dry the skin.

Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother’s

abdomen, and a cap applied to the newborn’s head to prevent cold stress. The newborn

responds to the cooler environment by increasing his respiratory rate, which can lead to

respiratory distress. Based on Maslow’s hierarchy of needs, this is the most important nursing

action after securing the airway.

C. Administer eye prophylaxis.

Rationale:Administration of eye prophylaxis should occur within the first hour after birth. There is another,

more important nursing action.

D. Place an identification bracelet.

Rationale: Correct identification of the newborn is important, but it can be delayed, as long as it is

completed prior to the mother and newborn leaving the delivery room. There is another, more

important nursing action.

4.A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency

and asks if this will continue until delivery. Which of the following responses should the nurse make?

A. "It's a minor inconvenience, which you should ignore."

Rationale: This is a nontherapeutic response that disregards the client’s concern and offers unwarranted

reassurance.

B. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone."

Rationale: The presence or absence of bladder tone has no bearing on urinary frequency during

pregnancy.

C. "There is no way to predict how long it will last in each individual client."

Rationale: This is a nontherapeutic response that does not provide appropriate information to the client.

D. "It occurs during the first trimester and near the end of the pregnancy."

Rationale: Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs

near the end of the pregnancy as the enlarging uterus places pressure on the bladder.

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Detailed Answer Key

medical

5.A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse

notices she does not have immunity to rubella. Which of the following times should the nurse understand is

recommended for rubella immunization?

A. Shortly after giving birth

Rationale: The rubella immunization should be offered to the client following birth, preferably prior to

discharge from the hospital. This prevents the client from contracting rubella during the current

or subsequent pregnancies, which would put her fetus at risk for rubella syndrome.

B. In the third trimester

Rationale:Because the rubella vaccine contains a live virus, immunizing the client at this point in

pregnancy would put her fetus at risk for developing rubella syndrome.

C. Immediately

Rationale:Because the rubella vaccine contains a live virus, immunizing the client during the first trimester

would put the fetus at risk for developing a severe manifestations of rubella syndrome.

D. During her next attempt to get pregnant

Rationale: Rubella immunization must be given at least 28 days prior to pregnancy to assure that the

developing fetus is not exposed to the virus and put at risk for rubella syndrome.

6.A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be

done first to care for the newborn?

A. Clear the respiratory tract.

Rationale: Clearing the airway of the infant is the first action the nurse should take immediately following

delivery.

B. Dry the infant off and cover the head.

Rationale: Drying the infant and covering the head should be done shortly after the delivery, but it is not the

first action the nurse should take.

C. Stimulate the infant to cry.

Rationale:Stimulating the infant to cry should be done shortly after the delivery, but it is not the first action

the nurse should take.

D. Cut the umbilical cord.

Rationale: Cutting the umbilical cord should be done shortly after the delivery, but it is not the first action

the nurse should take.

7.A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives.

The client states that she is nervous because she has never had a pelvic examination. Which of the following

responses should the nurse make?

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Detailed Answer Key

medical

A. "What part of the exam makes you most nervous?"

Rationale: This therapeutic response recognizes the client's feelings. It also uses the therapeutic technique

of clarification to encourage the client to tell the nurse more about her concerns.

B. "Don't worry, I will be with you during the exam."

Rationale: This closed-ended nontherapeutic response discounts the client's feelings and does not

encourage further discussion.

C. "All you need to do is relax."

Rationale: This closed-ended nontherapeutic response does not address the client's concerns and does

not encourage further discussion. It blocks communication by using a cliché and false

reassurance.

D. "A pelvic exam is required if you want birth control pills."

Rationale: This statement fails to address the client’s feelings that she shared with the nurse. It blocks

communication and does not encourage further discussion.

8.A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the

umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

A. Two veins and one artery

Rationale: This is not the correct combination of vessels.

B. One artery and one vein

Rationale: This is not the correct combination of vessels.

C. Two arteries and one vein

Rationale: The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two

arteries returned the blood to the placenta.

D. Two arteries and two veins

Rationale: This is not the correct combination of vessels.

9.A nurse is caring for a client who is considering several methods of contraception. Which of the following methods

of contraception should the nurse identify as being most reliable?

A. A male condom

Rationale: This method of contraception has 11 to 16 failures for every 100 users.

B. An intrauterine device (IUD)

Rationale:An IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most

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