nur 4455 mod 3 nclex quiz version 1 nur4455 mod 3 nclex quiz| latestrasmussen college 100 correct
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NUR 4455 MOD 3 NCLEX QUIZ
1. The nurse is assigned to care for a patient who is in early labor.
When collecting data from the patient, which should the nurse
check first?
a. Baseline fetal heart rate
b. Intensity of contractions
c. Maternal bp
d. Freq. of contractions
Answer. A
Rationale: the nurse should first determine the baseline fetal
heart rate this is the priority
2. Leopold’s maneuvers will be performed on a pregnant patient.
The patient asks the nurse about the procedure. Which
information should the nurse provide to the patient about
Leopold’s maneuvers?
A. The maneuvers measure the height of the maternal fundus
B. The maneuvers determine the “lie” and attitude of the fetus
C. The maneuvers are systematic method for palpating the
fetus through the maternal back
D. The maneuvers are a systematic method for palpating the
fetus through the maternal abdominal wall
Answer: D
Rationale: Leopold maneuvers comprise a systematic method for
palpating the fetus through the maternal abdominal wall
3. The nurse is caring for a patient who is in labor. The nurse
rechecks the clients blood pressure and notes that it has dropped.
, To decrease the incidence of supine hypotension, the nurse
should encourage the client to remain in which position?
a. Squatting
b. Side lying
c. Tailor sitting
d. Semi-fowlers
Answer: B
Rationale: Pressure from the enlarged uterus on the aorta and
vena cava when the woman is supine can result in hypotension. This
can be relieved by having the women lie on her side
4. After a precipitous delivery the nurse note the new mother is
passive and only touches her newborn briefly with her fingertips.
The nurse should do what to help the women process what has
happened
a. Encourage the mother to breastfeed soon after birth
b. Support the mother in her reaction to the newborn
c. Tell the mother that it is important to hold the baby
d. Document a complete account of the mothers reaction in
the birth record
Answer: B
Rationale: Women who have experienced precipitous labor and
delivery often describe feeling of disbelief that their labor has
progressed so rapidly. To assist the woman with understanding what
has happened, it is best to support the mother and her reaction to her
newborn.
5. A primigravida’s membrane rupture spontaneously. Which actions
should the nurse take first?
, a. Determine the fetal heart rate
b. Prepare for immediate delivery
c. Monitor contractions pattern
d. Note the amount color and odor of the amniotic fluid
Answer: A
Rationale: When the membranes rupture, the nurse immediately
assesses the fetal heart rate to detect changes associated with prolapse
or the compression of the umbilical cord. Monitoring the contraction
pattern and noting the amount, color, odor of the amniotic fluid may be
performed, but these would not be the first action.
6. After the client vaginally delivers a viable newborn, the nurse sees
the umbilical cord lengthen and observes a spurt of blood from
the vagina. The nurse recognizes these findings as signs of which
condition
a. Uterine atony
b. Placenta previa
c. Abruptio placentae
d. Placental separation
Answer: D
Rationale: As the placenta separates, it settles downward into the
lower uterine segment, the umbilical cord lengthens, and a sudden
trickle or spurt of blood appears.
7. The nurse is assigned to assist with caring for a client who has
been admitted to the labor unit. The client is 9cm dilated and is
experiencing precipitous labor. Which is the priority nursing
intervention?
a. Prepare for oxytocin infusion
b. Keep the patient in a side lying position
, c. Prepare the client for epidural anesthesia
d. Encourage the client to start pushing with the contractions
Answer: B
Rationale: Precipitous labor progresses quickly, with frequent
contractions and short periods of relaxation between them. This does
not allow for the maximal reperfusion of the placenta with oxygenated
blood. Priority care of this client includes the promotion of fetal oxygen.
8. The client is admitted to the labor suite complaining of painless
vaginal bleeding. The nurse assists with the examination of the
client, knowing that which routine labor procedure is
contraindicated?
a. Leopold’s maneuvers
b. A manual pelvic examination
c. Hemoglobin and hematocrit evaluation
d. External electronic fetal heart rate monitoring
Answer: B
Rationale: Painless vaginal bleeding is a sign of possible placenta
previa. Digital examination of the cervix is contraindicated because it
can cause maternal and fetal hemorrhage.
Reference:
Silvestri, L. A. (2016). Saunders comprehensive review for the NCLEX-PN
Examination (6th ed.). St. Louis, MO: Elsevier.
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