Exam 3 NCLEX Book Questions

Question 1

A client comes to the clinic requesting an ultrasound to confirm a pregnancy. Her last menstrual period was 15 days ago. The nurse’s best response would be to:

Answer 1

Inform her that an ultrasound cannot confirm a pregnancy this early.

Question 2

An 8-month-pregnant client comes to the clinic complaining that she has not felt the baby move for the past 48 hours. Other than checking the fetal heart tones, the nurse can also anticipate which fetal study?

Answer 2

Ultrasonography

Question 3

An ultrasound is ordered for a client who is 8½ months pregnant. It is important for the nurse to:

Answer 3

Place a wedge under one hip when placing her on the examination table

Question 4

A pregnant client has a 2-year history of uncontrolled hypertension. The nurse can anticipate that which fetal study to be ordered?

Answer 4

Doppler ultrasound blood flow assessment

Question 5

A client’s maternal serum alpha-fetoprotein (MSAFP) levels are elevated. The nurse can anticipate that the next test done will be:

Answer 5

Ultrasound

Question 6

A 36-year-old primigravida is in the clinic for her first prenatal appointment. The nurse can anticipate that the multiple-marker screening may be done on this client to screen for:

Answer 6

Trisomy disorders.

Question 7

The physician has ordered a chorionic villus sampling to be done on a client. The nurse knows to schedule the test to be done between which weeks of gestation?

Answer 7

10 and 12 weeks

Question 8

An amniocentesis is ordered for an 8-month-pregnant client. The nurse is aware that the most common reason for this test at this time is to test for:

Answer 8

Fetal lung maturity.

Question 9

An ultrasound is done prior to an amniocentesis to:

Answer 9

Locate fetal and placental position.

Question 10

After a percutaneous umbilical blood sampling (PUBS) on a client, the nurse notes a fetal heart rate of 100 beats/min. The nurse is aware that this indicates a:

Answer 10

Common complication and is usually brief.

Question 11

In preparing a pregnant client for a nonstress test, the nurse should:

Answer 11

Ask the client if she smokes and when she had her last cigarette.

Question 12

During a contraction stress test, the nurse notices late decelerations with three of the six contractions. These results are classified as:

Answer 12

Positive

Question 13

The client has a biophysical profile done. The nurse notes that the NST test was reactive, the fetal breathing movements were absent, there was one gross body movement in 30 minutes, the fetal tone showed fetal extremity extension and return to flexion, and one pocket of amniotic fluid measured 3 cm. The nurse anticipates that next action by the physician will be:

Answer 13

Further study because a score of 6 is not normal.

Question 14

Which conditions are associated with elevated levels of serum alpha-fetoprotein?

Answer 14

Open neural tube defects

Threatened abortion

Fetal Demise

Question 15

Immediately following an amniotomy to observe for complications, the nurse must assess the:

Answer 15

Fetal heart rate.

Question 16

A laboring woman just had an amniotomy performed to augment labor. The nurse is aware that the assessment times for which vital signs will be altered?

Answer 16

Maternal temperature

Question 17

When admitting a client for induction of labor, the nurse will question the procedure if which of the following is on the client’s prenatal record?

Answer 17

Placenta previa

Question 18

Induction is more successful if the Bishop score is greater than

Answer 18

8

Question 19

The fFN (fetal fibronectin) is present in the vaginal secretions about ____ prior to the onset of term labor.

Answer 19

2 weeks

Question 20

A woman is receiving oxytocin for labor induction. The nurse notices the woman is having contractions every 2 minutes lasting for 100 seconds. The fetal heart rate is 120 to 130 bpm, with moderate variability. The nurse’s next action should be to:

Answer 20

Turn off the oxytocin.

Question 21

The uterine resting tone should have at least ___ seconds between contractions.

Answer 21

30

Question 22

The postpartum woman who had a long labor induced by oxytocin is at higher risk for which complication?

Answer 22

Hemorrhage

Question 23

Prolonged use of oxytocin can produce ____

Answer 23

uterine atony

Question 24

While caring for a woman who is 10 cm dilated and is pushing, the nurse notices that the fetal heart rate has dropped to 85 bpm. The station is +3. The nurse can anticipate:

Answer 24

A low operative vaginal birth.

Question 25

Which of the following measures will help prevent complications from an episiotomy?

Answer 25

Cold applications after birth

Question 26

Misoprostol (Cytotec), 50 mcg, has been ordered for a woman to assist with the ripening of the cervix. The nurse’s action should be to:

Answer 26

Question the dosage amount.

Question 27

Which of the following are used to assist with the cervical ripening process prior to induction of labor? (Select all that apply).

Answer 27

Prostaglandin
Misoprostol (Cytotec)
Laminaria tents

Question 28

Which of the following would be an indication for a cesarean birth? (Select all that apply).

Answer 28

Cephalopelvic disproportion

Active genital herpes

Persistent nonreassuring FHR patters

Question 29

A woman has just had a spontaneous abortion. She asks the nurse, “Why did this happen?” The nurse is aware that the most common cause of spontaneous abortion is:

Answer 29

Severe congenital abnormalities.

Question 30

The first sign of threatened abortion is

Answer 30

vaginal bleeding

Question 31

A woman has just been admitted to the maternity unit with a diagnosis of incomplete abortion. The physician has written the following orders:

(1) NPO
(2) Type and crossmatch for two units of blood.
(3) Start intravenous line and run Ringer’s lactate at 150 mL/hr.
(4) Administer Pitocin, 10 units intramuscular.
(5) Acetaminophen and codeine (Tylenol with Codeine #3), every 3 to 4 hours as needed for pain
(6) Bed rest with bathroom privileges

Which order to carry out first?

Answer 31

Start the IV and draw blood to send for the type and crossmatch.

Question 32

A woman is admitted with a diagnosis of missed abortion. After taking her blood pressure, the nurse notices petechiae on the woman’s arm where the cuff was located. The nurse’s next action should be to:

Answer 32

Notify the HCP

Question 33

A 20-week-pregnant client attending her first prenatal visit tells the nurse at the maternity clinic that she has had vaginal bleeding and excessive nausea and vomiting for the past 3 days. The nurse assesses her blood pressure at 142/95 mm Hg, pulse 86 bpm, respirations 16 breaths/min. When the nurse helps the client onto the examining table, the abdomen looks larger than normal for a 20-week pregnancy. The nurse is aware that these are signs of:

Answer 33

Hydatidiform mole.

Question 34

Signs of a threatened abortion are noted in a woman at 8 weeks of gestation. Which of the following is an appropriate management approach for this type of abortion?

Answer 34

Prepare the woman for an ultrasound to determine the integrity of the gestational sac.

Question 35

A 32-week-pregnant woman calls the prenatal clinic complaining of bleeding without pain or contractions. The nurse should:

Answer 35

Tell her to go to the hospital to be evaluated

Question 36

A woman in labor has a long history of uncontrolled hypertension. The hypertension has continued throughout the pregnancy and labor. The nurse is aware that the woman is at high risk for which complication?

Answer 36

Abruptio placentae

Question 37

During labor, a woman suddenly complains of increasing pain, and the electronic monitor shows no uterine activity. The abdomen is boardlike and tender and the fetal heart tones show late decelerations. The nurse should:

Answer 37

Notify the health care provider.

Question 38

A woman is admitted to the maternity unit with preeclampsia. She is started on magnesium sulfate IV, a urinary catheter is inserted, and she is put on bed rest. The nurse understands it is important to monitor urinary output hourly. It is important that the client have an output of at least:

Answer 38

30 mL

Question 39

A pregnant woman at 36 weeks of gestation is admitted to the high-risk pregnancy unit with hypertension. Assessment findings indicate severe preeclampsia. The nurse should:

Answer 39

Expect a maintenance dose of intravenous magnesium sulfate to be about
2 g/hr.

Question 40

The __ assessment of edema indicates edema of the lower extremities, face, hands, and sacral area.

Answer 40

+3

Question 41

During pregnancy a woman has an indirect Coombs test done. The nurse can teach her that this test will show:

Answer 41

Her previous exposure to Rh-positive blood.

Question 42

Which of the following women are at higher risk for an ectopic pregnancy? (Select all that apply).
A. History of pelvic infection
B. Had a tubal ligation 1 year ago
C. History of hormonal implants for contraception 4 years ago
D. Conception was by assisted reproduction
E. Use of alcohol during the first 2 weeks of the pregnancy
F. History of intrauterine contraceptive device
G. Had five therapeutic abortions

Answer 42

A, B, D, F, G

Question 43

A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client should know that:

Answer 43

Oral hypoglycemic agents are the preferred choice to control an elevated blood sugar leveL

Question 44

A newly diagnosed pregnant woman has diabetes mellitus, type 2. When planning the prenatal care for this woman, the nurse identifies actions based on the knowledge that:

Answer 44

The danger of diabetic ketoacidosis is highest during the second and third trimesters.

Question 45

Increased fetal surveillance should occur in the first trimester of a pregnant woman with preexisting diabetes mellitus to monitor for:

Answer 45

Congenital anomalies.

Question 46

A 39-week-gestation gravida 1 is 6 cm dilated. Membranes are intact. The labor contractions have decreased in intensity, and she has not dilated in the past 2 hours. A diagnosis of hypotonic dysfunctional labor has been made. The nurse can anticipate which of the following actions?

Immediate cesarean section
Amniotomy
Narcotic administration
Having her walk around

Answer 46

Amniotomy

Question 47

Fetal heart tones are located in the ___ quadrants when the fetus is in a breech presentation.

Answer 47

upper

Question 48

A nulliparous woman in labor has been diagnosed with a prolonged latent phase of the first stage of labor. Which of the following is true regarding this dysfunctional labor pattern?

Diagnosis for this woman would have been made once the duration of the latent phase exceeded 14 hours.

Hypotonic contractions are typically associated with this labor pattern.

Management often involves therapeutic rest.

Cephalopelvic disproportion (CPD). with failure of the fetal head to stimulate the cervix. is often the underlying cause of this pattern.

Answer 48

Management often involves therapeutic rest.

Question 49

A woman had premature rupture of the membranes at 37 weeks of gestation. She went into labor within 10 hours and delivered a 7 lb, 12 oz boy after a 12-hour labor. In planning care for the newborn, it is important to monitor him for:

Respiratory distress syndrome.
Transient tachypnea of the newborn. Incorrect
Infections.
Cardiac anomalies.

Answer 49

Infections

Question 50

Research has found that bed rest as an intervention for preventing preterm labor can result in:

Maternal weight gain. Incorrect
Diarrhea.
Increased maternal plasma volume and cardiac.
Bone demineralization, with calcium loss.

Answer 50

Bone demineralization, with calcium loss.

Question 51

A constant low backache is a common symptom of ____.

Answer 51

preterm labor

Question 52

Fetal fibronectin is normally found in the vaginal secretions until about ___ weeks’ gestation and again at term.

Answer 52

20 weeks’ gestation

If it is found between those dates, it suggests early labor.

A negative report indicates that the woman is at low risk for labor at this time.

Question 53

A woman is receiving magnesium sulfate intravenously to control preterm labor. She is at the maximum dose and the contractions have slowed to eight/ hr. The nurse is assessing the woman’s vital signs every hour. In addition to blood pressure, pulse, and respirations, what other assessments should be carried out hourly?

Lung sounds
Edema in lower extremities
Bowel sounds
Range of motion to the lower extremities

Answer 53

Lung sounds

Question 54

Nifedipine is a vasodilator, so the woman may be prone to ____.

Answer 54

postural hypotension

Question 55

A woman came in for a prenatal check up on March 15. She tells the nurse that her last normal menstrual period was June 2. The nurse is aware that she will be scheduled for:

Immediate birth.
Testing to determine fetal well-being.
Follow-up appointments every week until birth.
Ultrasound to determine fetal age.

Answer 55

Testing to determine fetal well-being.

Question 56

A fetus that is in a ___ station is at high risk for a prolapsed cord when the membranes rupture.

Answer 56

high

Question 57

Which type of uterine rupture may go undiagnosed during labor and the postpartum period?

Answer 57

Dehiscence

little/no bleeding, no S+S

Question 58

A potentially fatal complication of pregnancy that occurs when the pulmonary artery is obstructed by a blood clot that was swept into circulation from a vein or by amniotic fluid is called a

Answer 58

pulmonary embolism

Question 59

One of the earliest signs of hypovolemic shock is

Answer 59

tachycardia

Question 60

Postpartum hemorrhage that occurs within the first 24 hours after childbirth is termed

Answer 60

early

Question 61

Clinical signs and symptoms of pulmonary embolism may include which of the following

Dyspnea
  Sudden sharp chest pain
  Bradycardia
  Syncope
  Tachypnea
  Hemoptysis

Answer 61

Dyspnea
Sudden sharp chest pain 
Syncope
Tachypnea
Hemoptysis

Question 62

A breastfeeding woman develops mastitis. She tells the nurse that she will just feed her baby formula instead of breastfeeding. The best nursing response is that:

• Emptying the breast is important to prevent an abscess.
• A tight breast binder or bra will help reduce engorgement.
• She should continue to drink extra fluids while weaning.
• Breastfeeding can continue when her temperature is normal.

Answer 62

Emptying the breast is important to prevent an abscess

Question 63

The best position for a woman who has postpartum endometritis is:

Answer 63

Fowler’s

Question 64

When assessing the lochia of a new mother for the last time before discharge, the nurse notes a foul smell from the vaginal discharge. The mother states that she noticed it for the first time a couple of hours ago. The nurse should assess for:

Answer 64

Fever

Question 65

The uterus descends at the rate of about ___ cm/day. By ____ days, it is no longer palpable above the symphysis pubis. This is a normal finding.

Answer 65

1cm/day

10-14

Question 66

Cervical lacerations occur frequently when the cervix ____

Answer 66

dilates rapidly during the first stage of labor.

Question 67

An infant born at 35 weeks of gestation and weighs 4 lb, 3 oz would be classified as:

Preterm, low birth weight.
Preterm, very low birth weight, with intrauterine growth restriction.
Preterm, extremely low birth weight.
Full term, low birth weight.

Answer 67

Preterm, low birth weight.

Question 68

Heat loss in a preterm infant is more significant than in a full-term infant. The nurse should assess for heat loss continually in a preterm infant. The first sign that the infant’s temperature is low may be:

Hyperglycemia.
Hypoglycemia.
Respiratory stability.
Increased flexion.

Answer 68

Hypoglycemia

Question 69

A preterm infant is on intake and output. During the past 8 hours, the infant had used three diapers that weighed 5 g before putting them on and 6, 9, and 12 g on removal. In addition, the lab had drawn 3 mL of blood for testing. There was no emesis or stools. The output should be recorded as:

15 mL.
12 mL.
3 mL.
Unable to determine with information given.

Answer 69

15 mL

Question 70

The nurse is taking care of a 30-week gestation preterm infant who is 3 days old. The infant is stable enough for a bath to remove the old blood and vernix, but has areas of cracking on the skin. During the bath, it is best for the nurse to use:

Plain warm water.
A soap especially formulated for an infant’s skin.
Warm sterile water.
Distilled water.

Answer 70

Warm sterile water.

Question 71

A small-for-gestational age infant was born. During the initial assessment, a nurse notes that the infant’s body is in proportion and appears normally developed for the size. The nurse is aware that this infant’s problem probably occurred:

Early in the pregnancy.
In the middle of the pregnancy.
Late in the pregnancy.
During labor.

Answer 71

Early in the pregnancy.

Question 72

During the initial assessment of a large-for-gestational age (LGA) infant, it is important that the nurse assess for complications that are common for this infant, such as:

Congenital defects.
Fractures of the clavicle.
Thinning of the skin.
Decreased subcutaneous fat

Answer 72

Fractures of the clavicle.

Question 73

There are many complications that can occur with preterm infants. Select those listed that may be directly related to the use of high oxygen content during the acute phases of care. (Select all that apply).

Bronchopulmonary dysplasia
Periventricular-intraventricular hemorrhage Incorrect
Retinopathy of prematurity
Necrotizing enterocolitis

Answer 73

Bronchopulmonary dysplasia

Retinopathy of prematurity

Question 74

The infant who has the highest risk for asphyxia during labor and birth is the infant who is __________

Answer 74

post-term

Question 75

At birth, a newborn has a respiratory rate of 75 breaths/min. In 1 minute, the newborn stops breathing. The first action by the nurse should be to:

Stimulate the newborn.
Initiate rescue breathing.
Administer oxygen.
Initiate cardiopulmonary resuscitation.

Answer 75

Stimulate the newborn.

Question 76

Risk factors for transient tachypnea of the newborn include ___ AND ____

Answer 76

cesarean birth and mothers who are diabetic.

Question 77

During the labor of a 43-week-gestation gravida 2, the nurse notes meconium staining of the amniotic fluid. After birth, the newborn was diagnosed with meconium aspiration syndrome. The nurse should monitor the newborn for respiratory distress and signs of:

Infection.
Skin breakdown.
Persistent pulmonary hypertension of the newborn.
Hyperbilirubinemia.

Answer 77

Persistent pulmonary hypertension of the newborn.

Question 78

The nurse notes a yellow discoloration over the face of a 12-hour-old newborn. The nurse’s next actions should be based on prevention of:

Pathologic jaundice.
Renal damage.
Skin damage.
Neurotoxicity.

Answer 78

Neurotoxicity

Question 79

Jaundice is considered pathologic when it appears in the ___hours after birth.

Answer 79

first 24

Question 80

A newborn develops jaundice at 16 hours of age. The nurse notes that the Coombs test is positive. The nurse orders a total serum bilirubin test and the results are 10 mg/dL. The nurse’s next action should be to:

Monitor the respiratory rate every 30 minutes.
Prepare the newborn for phototherapy.
Initiate oxygen therapy.
Assess the bilirubin level in 1 hour.

Answer 80

Prepare the newborn for phototherapy.

Question 81

A full-term newborn is placed in phototherapy to decrease serum bilirubin levels. A nursing diagnosis appropriate for this infant during phototherapy would be:

Risk for injury.
Risk for infection.
Risk for deficient fluid volume.
Ineffective breastfeeding.

Answer 81

Risk for deficient fluid volume.

Question 82

A large-for-gestational age infant is born outside of the hospital. The infant is brought to the emergency department 5 hours after birth with tremors, diaphoresis, and respirations of 75 breaths/min. The nurse’s next action should be to assess the:

Temperature.
Cardiac status.
Bilirubin level.
Blood glucose level.

Answer 82

Blood glucose level.

Question 83

An infant of a diabetic mother has a total serum calcium level of 5 mg/dL. There is an order for calcium to be given intravenously. Before administering the calcium, the nurse should assess the:

Respiratory rate. Incorrect
Thyroid gland for enlargement.
Infant with a cardiac monitor.
Blood pressure.

Answer 83

Infant with a cardiac monitor.

Question 84

A newborn who is 12 hours old develops tremors. The nurse has assessed the blood glucose and calcium levels and they are both within normal limits. The next assessment by the nurse should be to assess for:

Hypothermia.
Prenatal drug exposure.
Lung sounds.
Cardiac defects.

Answer 84

Prenatal drug exposure.

Question 85

A woman with gestational diabetes is at 36 weeks’ gestation. On the regular antepartal visit, the woman tells the nurse, “I am so excited. My blood sugars have gone down and I have been able to decrease the amount of insulin I need by about half.” The nurse should be aware that this is an indication of a:

Diabetic in good glycemic control.
Fetal problem that needs further investigation.
Placental problem that needs further investigation.
Maternal pancreas that is increasing its insulin production.

Answer 85

Placental problem that needs further investigation.

Question 86

Which of the following is associated with preexisting diabetes in a pregnant woman, but not in a woman with gestational diabetes?

Neonatal hypocalcemia
Neonatal hypoglycemia
Congenital malformations
Macrosomia

Answer 86

Congenital malformations

Question 87

Hypoglycemia should be treated at once to prevent damage to the brain. The woman should take ____.

Answer 87

15 g of carbohydrate, which is about ½ cup of fruit juice

Question 88

the earliest sign of decompensation is most often:

Answer 88

Decreasing energy level.

Question 89

Which pregnancy hormones are responsible for creating insulin resistance in maternal cells?

Answer 89

Estrogen