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Situation:
Mrs. Tierra, G4P3 arrives at the hospital in active labor she has had
three children by cesarean section and was scheduled for a
repeat cesarean section.
49. The nurses primary concern for Mrs. Tierra would be:
a. Tetanic contractions
b. Precipitous labor
c. Uterine rupture
d. abruptio placenta
2. The physician notes state that the fetal position is ROA. The
nurse will listen for fetal heart tones in which quadrant of the
mothers abdomen?
a. upper right
b. lower right
c. upper left
d. lower left
3. Mrs. Buenavista inquires about signs of true labor. The nurse
tells her to call the doctor if the following occurs:
a. loss of the mucus plug
b. increased vaginal discharge
c. frequent regular contractions that
do not cease with walking
d. increased urinary frequency
4. Mrs. Buenavista complains of frequent indigestion. In order to
decrease this occurrence the nurse suggest that she:
a. use an antacid as needed
b. decrease intake of spicy foods
c. increase amount of fruit eaten
d. discontinue the use of sugar substitutes
5. Constipation is a common third trimester problem. Which of the
following is not part of the nursing instructions for Mrs.
Buenavista?
a. increase fluid intake
b. add banana to her diet
c. use enema as needed
d. exercise regularly each day
6. Mrs. Buenavista reports a weight gain of 1 pound a week during
her 8th month of pregnancy. Which of the following actions
should be taken?
a. None, since this is a normal weight increase
b. make an appointment with the nutritionist
c. suggest a weight loss program
d. check for proteinuria and hypertension
Situation:
Mrs. Lujan, age 28, arrives at the antepartal clinic for her initial
visit. She has missed two menstrual periods, her last period
was October 30. Her obstetric history reveals one elective
abortion 6 years ago and the birth of a son 4 years ago at the
39th week of gestation. Her present pregnancy has been
confirmed.
7. Based on the above history, the nurse should classify Mrs. Lujan
as:
a. Gravida 2 Para 1101
b. Gravida 2 Para 1011
c. Gravida 3 Para 0111
d. Gravida 3 Para 1011
8. Which assessment findings noted during the initial examination
would support the diagnosis of pregnancy?
a. ballottement
b. abdominal enlargement
c. bluish discoloration of the vaginal
mucosa
d. softening of the lower uterine
segment
9. Using Nageles rule, the nurse would calculate Mrs. Lujans
expected date of delivery as:
a. May 2
b. July 6
c. July 31
d. August 6
10. Mrs. Lujan, tells the nurse that her morning sickness is
lessening but she still feels nauseated in the afternoons.
Which nursing action would be most appropriate?
a. suggesting that she eat dry crackers before getting out of
bed
b. suggesting that she eat small frequent meals
c. instructing her to drink skim milk with her meals
d. determining her food preferences
11. Which physiologic change of pregnancy probably is causing
Mrs. Lujans nausea and vomiting?
a. high levels of human chorionic gonadotropin
b. increased gastric motility
c. reflux of acidic secretions into lower esophagus
d. altered stomach position
12. Mrs. Lujan drinks one quart of milk daily, which supplies her
with large amount of:
a. Vitamin B12 and Niacin
b. Folic acid and Thiamine
c. Riboflavin and Vitamin A
d. Vitamin C
13.
14. Mrs. Lujan tells the nurse that she has experienced intermittent
nosebleeds. Which normal physiologic change of pregnancy
is probably responsible?
a. elevated HCG level
b. hyperemia of the nasal mucous
membranes
c. vascular congestion of nasal
turbinates from tissue edema
d. elevated blood pressure
15. Mrs. Lujan experiences urinary frequency. This condition
which is common during the first trimester of pregnancy is
physiologically related to:
a. pressure on the bladder from the enlarging uterus
b. increased renal blood flow and glomerular filtration rate
c. excessive intake of coffee
d.
smooth muscle relaxation caused by an increase
production of progesterone
Situation:
Mrs. Lujan is now in her second trimester of pregnancy, continues
coming to the clinic for her monthly check-ups.
16. During the second trimester, the nurse would expect Mrs. Lujan
to:
a. feel ambivalent about her pregnancy
b. identify the fetus as a separate human being
c. anticipate labor and delivery
d. realistically prepare for childbirth
Situation:
Mrs. Carissa, G1P1 had a spontaneous vaginal delivery of an 8
pound infant.
59. Mrs. Carissa complains of episiotomy pain in the recovery
room following delivery. Edema is noted. The nurse should:
a. apply pressure pad
b. expose perineum to heat lamp
c. elevate the hips on the pillows
d. place an ice pack to the episiotomy
60. During a postpartum check, the nurse finds that Mrs. Carissas
uterus is displaced to her right side. This is most likely
indicative of:
a. uterine rupture
b. uterine atony
c. a distended bladder
d. hematoma formation
Situation:
Mrs. Futura, gravida 3 para 3003, is admitted to the postpartal unit
after an uncomplicated labor and vaginal delivery. She plans to
bottle-feed her neonate.
61. Mrs. Futura tells the nurse that she has urinated four (4) times
within the last hour but only voided a small amount each time.
The nurses initial action should be to:
a. catheterize Mrs. Futura to remove any retained urine
b. explain that this is normal during the first 24 hours after
delivery
c. begin measuring and recording Mrs. Futuras I and O
d. Palpate Mrs. Futuras fundus to assess uterine consistency
and location
62. Which assessment finding is most indicative of postpartal
infection?
a. elevated body temperature
b. increased pulse rate
c. white blood cell count of 25,000/meg.
d. foul-smelling lochia
63. Mrs. Futura asks the nurse when her menstrual period will
return. The nurse correctly states that non-breast feeding
patients typically resume menstruating in about:
a. 4-6 weeks
b. 8-12 weeks
c. 3-6 weeks
d. 4-8 weeks
64. The physician prescribes a rubella vaccination because Mrs.
Futuras rubella titer is negative. Which information should
the nurse emphasize to Mrs. Futura before administering the
vaccine?
a. she must avoid pregnancy for at least 3 months
b. the rubella vaccine has no adverse effects
c. she should avoid contact with her neonate for at least 24
hours after vaccination
d.
17. The physician diagnoses slight megaloblastic anemia from
folic acid deficiency. To help correct this anemia, Mrs. Lujan
should increase her intake of:
a. fish, cheese and eggs
b. green leafy vegetables
c. milk and milk products
d. citrus fruits
18. During the second trimester, Mrs. Lujan develops recurrent
ankle edema in the afternoon. Assessment reveals that her
blood pressure and urinalysis results are within normal limits.
The edema is probably related to:
a. pressure from the enlarging uterus
b. pregnancy induced hypertension
c. increased serum albumin levels
d. increased progesterone levels
19. Which nursing instruction would not be appropriate when
teaching Mrs. Lujan how to relieve her ankle edema?
a. Elevate her legs and feet for a short period several times
daily
b. Avoid tight clothing, tight socks and knee high stockings
c. Lie down on her left side when resting or sleeping
d. Restrict her fluid intake during the later afternoon
Situation:
Mrs. Lujan enters her third trimester of pregnancy.
20. Mrs. Lujan complains to the nurse that she is having frequent
leg cramps. The nurses initial action should be:
a. to assess Mrs. Lujans intake of dairy products
b. to assess for positive Homans sign
c. to determine how frequently Mrs. Lujan performs pelvic
rocking exercises
d. to assess Mrs. Lujans intake of foods from the bread and
cereal group
21. To prevent leg cramps from disturbing her sleep, Mrs. Lujan
should:
a. extend her legs and dorsiflex her foot before bedtime
b. elevate and support her legs on pillows while sleeping
c. massage her calves with lotion before bedtime
d. drink a warm glass of milk before bedtime
22. Mrs. Lujan also reports occasional lower back pain. Which
nursing measure would be most appropriate?
a. teaching her how to apply sacral pressure
b. encouraging her to take frequent long walks
c. teaching her pelvic rocking exercises
d. suggesting that she sit in straight-backed chairs
23. Mr. Lujan tells the nurse that his wife is insisting that he attend
Lamaze classes with her. One purpose of the breathing
techniques taught in Lamaze classes is to decrease the
discomfort of uterine contractions during labor by:
a. elevating the diaphragm during contractions
b. enhancing fetal descent through the pelvis
c. reducing the strength of the contractions
d. lowering the diaphragm during contractions
Situation:
Angelica, 26 year old mother of 5 year old twin sons, is making her
initial visit to the antepartal clinic. Her obstetric history reveals
the birth of a stillborn infant in the 38th week of gestation and
the birth of her twins in the 35th week of gestation. The
physician has confirmed her current pregnancy and estimated
her fetus to be at 16 weeks of gestation.
73.
a.
b.
c.
d.
33. Mrs. Dela Fuentes condition worsens and she is brought to the
labor and delivery area for magnesium sulfate therapy.
MgSo4 is administered primarily to:
a. increase the CNSs response to stimuli
b. decrease neuromuscular irritability
c. increase calcium resorption by the muscles
d. reduce peripheral vascular resistance and lower BP
34.
85. Two days after delivery, the nurse discovers that the neonate
weighs 3 oz (85 g) less than his birth weight. This weight
loss:
a. is normal during the first few days after delivery
b. is probably sign of dehydration
c. indicates the need to increase the neonates nutritional
intake
d. is probably a sign of neonatal infection
37. Once the seizure has passed, the nurses first action should be
to:
a. evaluate the fetal heart rate for signs of fetal hypoxia
b. catheterize the patient if a chateter is already in place
c. administer an anti-hypertensive agent to prevent CVA
d. turn the patient on her side to prevent aspiration in case
vomiting occur
Situation:
Mrs. Kassandra, a 32 year old gravida 6 para 2305 with a history of
chronic hypertension arrives at the labor and delivery area with
dark red vaginal bleeding, and severe abdominal pain. The
physician, Dr. Luis Ignacio diagnoses abruptio placenta.
b. cardiovascular
c. neuromuscular
d. renal
97.