Southeastern College Maternity exam
Total Questions : 55
Showing 25 questions, Sign in for moreThe nurse encourages a female client with human papillomavirus (HPV) to receive continued follow-up care because she is at risk for:.
Explanation
Choice A rationale:
While HPV can cause fertility issues in some cases, it is not the primary risk associated with the virus.
Choice B rationale:
Dysmenorrhea, or painful periods, is not directly linked to HPV.
Choice C rationale:
Dyspareunia, or painful intercourse, is not a common symptom of HPV.
Choice D rationale:
Women with HPV are at a higher risk for cervical cancer. This is why regular follow-up care is crucial.
So, the correct answer is D, Cervical cancer.
A woman in labor received an opioid close to the time of birth.
Explanation
Choice A rationale:
Abdominal distention is not a common side effect of opioids in newborns.
Choice B rationale:
Respiratory depression is a known side effect of opioid use, and newborns are particularly susceptible.
Choice C rationale:
Hyperreflexia is not typically associated with opioid use.
Choice D rationale:
Urinary retention is not a common side effect of opioids in newborns.
A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction.
Explanation
Choice A rationale:
Notifying the primary care provider is important but not the immediate next step. The nurse has other immediate responsibilities to ensure the safety of the mother and baby.
Choice B rationale:
A vaginal exam could introduce bacteria into the uterus and is not the immediate next step after rupture of membranes.
Choice C rationale:
Changing the linen saver pad is not the immediate next step. While it might be necessary for the comfort of the mother, it does not address the potential risks associated with rupture of membranes.
Choice D rationale:
Checking the fetal heart rate is the correct next step. This ensures that the baby is not in distress following the rupture of membranes.
Your patient is receiving Heparin via a continuous IV infusion at a rate of 1600 units per hour.
The bag is labeled N/S 500 mLs and contains Heparin 40,000 units.
What rate should the IV pump be set at to deliver this ordered amount of Heparin? mLs/hr.
Explanation
Answer and explanation
Step 1 is to calculate the total units of Heparin in 1 mL of the solution. This is done by dividing the total units of Heparin in the bag (40,000 units) by the total volume of the bag (500 mL). So, 40,000 units ÷ 500 mL = 80 units/mL. Step 2 is to calculate the rate at which the IV pump should be set. This is done by dividing the ordered amount of Heparin per hour (1600 units) by the units of Heparin per mL (80 units/mL). So, 1600 units/hr ÷ 80 units/mL = 20 mL/hr.
So, the correct answer is 20 mL/hr.
The nurse is counseling a couple who suspect that they could bear a child with a genetic abnormality.
What would be most important for the nurse to do when working with this family?.
Explanation
Choice A rationale:
Informing the family of the need for information is important, but it is not the most important aspect when working with a family who suspects they could bear a child with a genetic abnormality.
Choice B rationale:
Presenting the information in a factual, nondirective manner is the most important aspect. This allows the family to make informed decisions based on accurate information without being influenced by the nurse’s personal beliefs or opinions.
Choice C rationale:
Maintaining the confidentiality of the information is a standard nursing practice and while it is important, it is not the most important aspect in this scenario.
Choice D rationale:
Gathering information for three generations can provide valuable insight into the family’s genetic history, but it is not the most important aspect in this scenario.
When teaching a group of postmenopausal women about hot flashes and night sweats, the nurse would address which primary cause?.
Explanation
Choice A rationale:
Estrogen deficiency is the primary cause of hot flashes and night sweats in postmenopausal women. As estrogen levels decrease, it affects the hypothalamus, which is responsible for regulating body temperature, leading to these symptoms.
Choice B rationale:
Changes in vaginal pH occur during menopause due to estrogen deficiency, but this is not the primary cause of hot flashes and night sweats.
Choice C rationale:
An active lifestyle can help manage symptoms of menopause, but it is not the primary cause of hot flashes and night sweats.
Choice D rationale:
Poor dietary intake can exacerbate symptoms of menopause, but it is not the primary cause of hot flashes and night sweats.
A nurse is preparing a class for pregnant women about labor and birth.
When describing the typical movements that the fetus goes through as it travels through the passageway, which movements would the nurse include? Select all that apply.
Explanation
Choice A rationale:
Internal rotation is a movement the fetus makes as it travels through the birth canal.
Choice B rationale:
Flexion is another movement that occurs as the fetus adjusts its position during labor.
Choice C rationale:
Pronation is not typically included in the description of fetal movements during labor and birth.
Choice D rationale:
Abduction is not a movement associated with the fetus’s journey through the birth canal.
Choice E rationale:
Descent is a key movement that occurs as the fetus moves down through the birth canal.
Which measure would the nurse include in the teaching plan for a woman to reduce the risk of osteoporosis after menopause?.
Explanation
Answer and explanation
Choice A rationale:
Participating in regular daily exercise, especially weight-bearing exercises, can help maintain bone density and reduce the risk of osteoporosis.
Choice B rationale:
Eating high-fiber, high-calorie foods does not directly contribute to reducing the risk of osteoporosis.
Choice C rationale:
Taking vitamin supplements, particularly Vitamin D and calcium, can help maintain bone health and reduce the risk of osteoporosis.
Choice D rationale:
Restricting fluid to 1,000 mL daily is not recommended for reducing the risk of osteoporosis.
A pregnant woman with diabetes at 10 weeks' gestation has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which possible fetal outcome?.
Explanation
Choice A rationale:
While placental abruption is a serious condition, it is not directly linked to high HbA1c levels in early pregnancy.
Choice B rationale:
Congenital anomalies are a significant concern for pregnancies with high HbA1c levels, as high blood sugar around the time of conception increases the risk of birth defects.
Choice C rationale:
Placenta previa is not directly associated with high HbA1c levels in early pregnancy.
Choice D rationale:
An incompetent cervix is not directly linked to high HbA1c levels in early pregnancy.
A woman in labor who received an opioid for pain relief develops respiratory depression.
The nurse would expect which agent to be administered?.
Explanation
Answer and explanation
Choice A rationale:
Butorphanol is an opioid agonist-antagonist. It would not be the first choice to treat opioid-induced respiratory depression because it can also cause respiratory depression.
Choice B rationale:
Promethazine is an antihistamine that has sedative effects and could potentially worsen respiratory depression.
Choice C rationale:
Fentanyl is a potent opioid and would likely exacerbate respiratory depression.
Choice D rationale:
Naloxone is an opioid antagonist used to reverse the effects of opioids such as respiratory depression.
A client is diagnosed with gestational hypertension and is receiving magnesium sulfate.
The nurse determines that the medication is at a therapeutic level based on which finding?.
Explanation
Choice A rationale:
A respiratory rate of 10 breaths/minute is low and could indicate magnesium toxicity.
Choice B rationale:
Difficulty in arousing could also indicate magnesium toxicity.
Choice C rationale:
Urinary output of 20 mL per hour is low and could indicate renal impairment.
Choice D rationale:
Deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug.
A nurse is assessing a woman in labor.
Which finding would the nurse identify as a cause for concern during a contraction?.
Explanation
Choice A rationale:
A slight increase in blood pressure during contractions is normal.
Choice B rationale:
A white blood cell count of 12,000 cells/mm is within the normal range.
Choice C rationale:
A respiratory rate of 10 breaths/minute is low and could indicate respiratory depression.
Choice D rationale:
A heart rate increase from 76 bpm to 90 bpm is within the normal range.
A client who is 4 months pregnant is at the prenatal clinic for her initial visit.
Her history reveals she has 7-year-old twins who were born at 34 weeks' gestation, a 2-year-old son born at 39 weeks' gestation, and a spontaneous abortion (miscarriage) 1 year ago at 6 weeks' gestation.
Using the GTPAL method, the nurse would document her obstetric history as:.
Explanation
Choice A rationale:
This choice indicates 3 pregnancies, 1 term, 2 preterm, 2 living children, and 3 abortions. However, the client has had 4 pregnancies (twins, a son, and a miscarriage), so this choice is incorrect.
Choice B rationale:
This choice indicates 3 pregnancies, 2 term, 1 preterm, no living children, and 3 abortions. The client has 3 living children (twins and a son), so this choice is incorrect.
Choice C rationale:
This choice indicates 4 pregnancies, 1 term, 1 preterm, 1 living child, and 3 abortions. The client has 3 living children (twins and a son), so this choice is incorrect.
Choice D rationale:
This choice indicates 4 pregnancies, 2 term, 1 preterm, 3 living children, and 1 abortion. This correctly reflects the client’s obstetric history.
A nurse is conducting an in-service program for a group of nurses working in the labor and birth suite of the facility.
After teaching the group about the factors affecting the labor process, the nurse determines that the teaching was successful when the group identifies which component as part of the true pelvis? Select all that apply.
Explanation
Choice A rationale:
The vagina is not part of the true pelvis. It is the canal that leads from the uterus to the exterior of the body.
Choice B rationale:
The pelvic inlet is the upper part of the lesser pelvis where the baby’s head engages during labor. It is part of the true pelvis.
Choice C rationale:
The pelvic outlet is the lower opening of the pelvis. It is part of the true pelvis.
Choice D rationale:
The mid pelvis is the part of the pelvis where the baby turns to get into the right position for birth. It is part of the true pelvis.
Choice E rationale:
The pelvic floor muscles support the pelvic organs and help in the process of childbirth. They are part of the true pelvis.
Choice F rationale:
The cervix is the lower part of the uterus that opens into the vagina. It is not part of the true pelvis. So, the correct answers are B, C, D, and E.
After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman's first:.
Explanation
Choice A rationale:
The first sign of breast development is not menarche. It is a part of puberty, but it is not the definition of menarche.
Choice B rationale:
A woman’s first sexual experience is not menarche. Menarche refers to a specific biological event.
Choice C rationale:
Menarche is defined as a woman’s first menstrual period. This is the correct definition.
Choice D rationale:
A full hormonal cycle is not menarche. While the hormonal cycle is related to menstruation, it is not the definition of menarche.
During a follow-up prenatal visit, a pregnant woman asks the nurse, "How long do you think I will be in labor?" Which response by the nurse would be most appropriate?.
Explanation
Choice A rationale:
This statement emphasizes the importance of health over time, which is true. However, it doesn’t directly answer the woman’s question about the duration of labor.
Choice B rationale:
The size of the baby can influence labor duration, but it’s not the only factor. Other factors like the woman’s health, age, and labor progression also matter.
Choice C rationale:
This response is supportive and honest. It acknowledges the unpredictability of labor while assuring the woman of continuous support.
Choice D rationale:
While it’s true that first-time mothers may have longer labors, predicting a specific duration like 10 hours isn’t accurate or helpful.
Your patient is ordered to receive 20 units Pitocin in D5%W 500 mLs at 12 milliunits/minute.
What flow rate will you set the IV pump to deliver? Numeric values only.
Explanation
Step 1 is to convert the order from milliunits/minute to units/hour. So, 12 milliunits/minute is equal to 0.72 units/hour. Step 2 is to calculate the total units in the IV bag, which is 20 units. Step 3 is to calculate the total volume of the IV bag, which is 500 mL. Step 4 is to calculate the flow rate. So, (0.72 units/hour ÷ 20 units) × 500 mL = 18 mL/hr. So, the correct flow rate to set on the IV pump is 18 mL/hr.
When assessing a woman at follow-up prenatal visits, the nurse would anticipate which procedure to be performed?.
Explanation
Choice A rationale:
Fundal height measurement is a common procedure during prenatal visits to monitor the baby’s growth.
Choice B rationale:
While ultrasounds are performed during pregnancy, they aren’t typically done at every prenatal visit.
Choice C rationale:
Urine cultures are important for detecting urinary tract infections, but they aren’t a routine part of every prenatal visit.
Choice D rationale:
Hemoglobin and hematocrit tests are done to check for anemia, but they aren’t typically performed at every visit.
A client is in active labor.
Checking the EFM tracing, the nurse notes variables that are abnormal.
What would be the nurse's first nursing intervention?
Explanation
Choice A rationale:
Checking for a compressed umbilical cord is important as it can cause fetal distress. However, it’s not the first step in response to abnormal EFM tracing.
Choice B rationale:
Preparing for an emergency cesarean birth might be necessary if the abnormality persists and indicates fetal distress. But it’s not the immediate first step.
Choice C rationale:
Documenting the finding is part of the nursing process, but immediate interventions to address the abnormality take precedence.
Choice D rationale:
Helping the woman change positions can relieve pressure on the umbilical cord, potentially resolving the abnormality. This is often the first intervention.
A client states "I think my water broke! I felt this gush of fluid between my legs.”. The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns:.
Explanation
Choice A rationale:
Olive green is not the color nitrazine paper turns when it comes into contact with amniotic fluid.
Choice B rationale:
Pink is not the color nitrazine paper turns when it comes into contact with amniotic fluid.
Choice C rationale:
Blue is the color nitrazine paper turns when it comes into contact with amniotic fluid, indicating likely membrane rupture.
Choice D rationale:
Yellow is not the color nitrazine paper turns when it comes into contact with amniotic fluid.
A young adult woman who is HIV-positive is receiving anti-retroviral therapy (ART) and is having difficulty with adherence.
To promote adherence, which area would be most important for the nurse to assess?.
Explanation
Choice A rationale:
Understanding the patient’s beliefs and education level can help tailor an adherence plan that the patient can understand and follow.
Choice B rationale:
Knowing the patient’s living arrangements can help identify potential barriers to adherence, such as lack of privacy.
Choice C rationale:
While important for overall health, these factors may not directly impact adherence to ART6.
Choice D rationale:
Financial constraints and lack of insurance can significantly impact a patient’s ability to access and adhere to ART6.
Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying.
Which response by the nurse would be most appropriate?.
Explanation
Choice A rationale:
Asking “Why are you crying?” may seem insensitive as it’s clear the client is upset due to the loss.
Choice B rationale:
Saying “A baby still wasn’t formed in your uterus.”. might be factually correct, but it can be hurtful as it dismisses the emotional attachment the client may have had.
Choice C rationale:
Offering a pill for pain might be practical, but it doesn’t address the emotional pain the client is likely experiencing.
Choice D rationale:
Saying “I’m sorry you lost your baby.”. acknowledges the client’s loss and offers sympathy, showing empathy and understanding.
A nurse palpates a woman's fundus to determine contraction intensity.
What would be most appropriate for the nurse to use for palpation?.
Explanation
Choice A rationale:
The back of the hand is sensitive to temperature, not pressure, making it less suitable for assessing contraction intensity.
Choice B rationale:
Finger tips are sensitive and can detect small changes, but they may not cover a large enough area to accurately assess contraction intensity.
Choice C rationale:
The palm of the hand covers a larger area and can better gauge the overall firmness of the uterus.
Choice D rationale:
Finger pads are sensitive to texture, not pressure, making them less suitable for this task.
When developing a teaching plan for a couple who are considering contraception options, the nurse would include which statement?.
Explanation
Choice A rationale:
The best contraceptive is indeed one that the couple will use correctly and consistently, as effectiveness largely depends on correct use.
Choice B rationale:
No contraceptive method is 100% effective, so this statement could give false assurance.
Choice C rationale:
While cost and convenience are important factors, they should not be the only considerations when choosing a contraceptive.
Choice D rationale:
Some effective contraceptives do require a prescription, so this statement could limit the couple’s options.
Touch and massage can be helpful during labor.
Which touch and massage methods are used in labor? Select all that apply.
No explanation
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