Exam 2 OB nclex questions

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• A G1P0 client calls the hospital and says to the nurse, "I

think I am having labor pains. When should I come to the hospital?" The nurse correctly replies that the client

should come in when her contractions are: a. 5-10 minutes

apart for 30 minutes. b. 10-15 minutes apart for 1 hour. c.6-8 minutes apart for 1 hour. d. 5 minutes apart for 1 hour.D

• A G1P0 client at 39 weeks' gestation arrives at the

birthing center with irregular contractions ranging from 10 to 30 minutes apart. Assessment reveals 1-2 cm cervical dilation, membranes intact, and a thick cervix. There are no complications. What treatment decision would the nurse expect at this time? a. The client will be admitted to the birthing center. b. The client will be started on hydration with IV fluids. c. The client will be sent home to ambulate. d. The client will be monitored with pelvic checks every hour.C

• A G3P0 client in active labor is admitted to the birthing

center. Which data set should the nurse interpret as being

within the normal range? (Hint: Provision of Care in the

First Stage) a. Temperature 99.4°F and blood pressure 130/80. b. Temperature 98.6°F and pulse 56. c.Temperature 98.4°F and blood pressure 142/90. d.Temperature 99.8°F and pulse 88.A

• There are four clients in the birthing center. Which

client should the nurse encourage to ambulate? a. G2P1 with ruptured membranes and 0 engagement. b. G4P3 with ruptured membranes and 9 cm dilation. c. G3P2 with intact membranes and 4 cm dilation. d. G5P4 with intact membranes and 8 cm dilation.C

• A laboring client in the birthing center has a hematocrit

of 49. The nurse should anticipate that this finding is

related to: a. Anemia. b. Dehydration. c. Infection. d.

Hemorrhage.B

• A Hmong client has just given birth to a 5-pound baby

girl. What culturally sensitive nursing action is appropriate at this time? a. Offer the mother a soft-boiled egg to eat.

• Comment on the daintiness of her baby girl. c. Assist

the mother in bathing the baby. d. Encourage the client to eat cold foods and drink cold fluids.A

• The nurse is caring for a client in the transitional stage

of labor. What objective physiologic data would indicate that the client is having pain? a. Muscle relaxation and decreased blood pressure. b. Dilated pupils and increased blood pressure. c. Constricted pupils and decreased blood pressure. d. Decreased respiration and decreased blood pressure.B

• The nurse is caring for four laboring clients at Stage 1 of

labor. Which client is demonstrating responses commonly seen during the latent phase? a. A client who is happy and talkative. b. A client who has just delivered a healthy newborn. c. A client with increased fatigue, restlessness, and anxiety. d. A client with increased irritability and feeling out of control.A

• A laboring client complains of numbness of nose,

fingers, and toes, and spots before her eyes. What should be the initial action by the nurse? a. Implement seizure precautions. b. Encourage slow, shallow breaths. c.Administer oxygen at 5 L per minute. d. Notify the physician or midwife.B

• A low-risk client's vaginal exam reveals that her cervix

is dilated to 8 cm with 75% effacement. How frequently should the nurse assess this client's blood pressure, pulse, and respirations? a. Every 5 minutes. b. Every 10 minutes.

• Every 15 minutes. d. Every 30 minutes.

D

• A client in the prenatal clinic complains of nausea and

vomiting. Which intervention should the nurse suggest? a.Eat dry crackers or toast before arising in the morning. b.Consume liquids with meals. c. Eat foods high in fiber. d.Brush teeth right after eating.A

• A second-trimester client in the prenatal clinic

complains of ankle edema. Which intervention should the nurse suggest? a. Elevate legs when sitting. b. Stretching exercises before bedtime. c. Practice plantar flexion when standing. d. Wear ankle socks daily.A

• A prenatal client at 10 weeks' gestation is complaining

of urinary frequency. Which self-care strategy should the nurse teach? a. Empty bladder every 4 hours. b. Decrease the amount of fluid intake. c. Empty the bladder when the urge is felt. d. Empty bladder every hour.C

• A prenatal client in the third trimester of pregnancy is

diagnosed with varicosities in the vulva and perineum.Which self-care strategy should the nurse teach? a.Change shoes several times throughout the day. b.Elevate legs and feet while sitting or lying down. c.Elevate legs level with hips while sitting or lying down. d.Use supportive hose in the afternoon and evening.C

• A pregnant client complains of severe heartburn. The

nurse suggests which of the following relief measures for heartburn? a. Avoid fried and highly spiced foods. b. Lie down for half an hour after eating. c. Take a teaspoon of sodium bicarbonate in water after meals. d. Eat three well-spaced meals each day.A

• The nurse is teaching a group of prenatal clients about

care of the breasts during pregnancy. Which self-care measure might be effective for women with inverted nipples? a. A bra with wide straps. b. A bra with tucks that allow expansion for breast tissue. c. Breast shields. d. A bra that supports the nipple between shoulder and elbow.C

• A client at 38 weeks' gestation tells the nurse, "I had

white liquid leaking out of my nipples while warm water was running over my breasts in the shower last night." The

nurse explains that: a. "You have a galactoma, and will

require a brain scan." b. "You will need to pump your breasts because your milk has come in early." c. "The liquid was colostrum, just removed with warm water." d. "I will need to culture the liquid because it might indicate mastitis." C

• A nurse is teaching a group of prenatal clients about

hazards in the workplace during pregnancy. The nurse correctly teaches that pregnant women who have jobs requiring long periods of standing have higher

incidences of: a. Preterm birth. b. Placenta previa. c.

Prolapsed cord. d. Abruptio placentae.A

• A nurse is teaching a group of prenatal clients about

the importance of exercise during pregnancy. Which client would be the best candidate to continue with her exercise regime? a. A client with placenta previa. b. A client with a diagnosis of diabetes. c. A client with a diagnosis of pre-eclampsia. d. A client with an incompetent cervix and cerclage.B

• The pregnant woman who is over the age of 35 years

has risks related to pregnancy outcome. Which statement about increased risk in this age group is true? a. Fetal death is significantly lower in women 35 years and older.

• Chronic health problems are less likely to occur in

women 35 years and older. c. Amniocentesis is recommended for all women 35 years and older. d. The cesarean section rate is decreased in women 35 years of age or older.C

• A newborn is born at 38 weeks' gestation weighing

2,250 grams. Which is the most appropriate nursing diagnosis? a. Risk for Altered Body Temperature. b.Ineffective Airway Clearance. c. Acute Pain. d. Altered

Nutrition: More than Body Requirements.

A

• What would be important abnormal information to

note upon the initial physical assessment of the newborn? a. A two-vessel cord. b. Loud, continued crying. c. The newborn required suctioning of the mouth and nares immediately after delivery. d. Apgars of 8 at 1 minute and 9 at 5 minutes, respectively.A

• To assist the nurse in providing comprehensive

maternal-newborn care, which of the following subjective data is pertinent to document? a. Available support system. b. Newborn screening results. c. Gestational examination results. d. Height/weight/body mass index.A

• Blood glucose evaluation is clinically indicated in

which of the following newborn scenarios? Select all that apply. a. A newborn who is large for gestational age. b. A newborn with increased temperature and increased heart rate. c. A newborn with jitteriness. d. A newborn who is inconsolable.A, C

• Before giving a newborn his first sponge bath, the

nurse must first do which of the following? a. Decrease room lighting. b. Check the temperature. c. Check capillary refill. d. Weigh the baby.C