WU NURS 402 Actual Exam Study and Rev ision Questions and Answer s A+ Graded with Rationales Walden University. A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? SATA (ATI MN p.70) A) Fetal distress B) Preterm labor C) Vaginal bleeding D) Cervical dilation greater than 6cm E) Severe gestational hypertension Verified Answer -A) C) D) A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include in the teaching? (ATI MN p.70) A) Use a condom with sexual intercourse B) Avoid bubble bath solution when taking a tub bath C) Wipe from the back to front when performing perineal hygiene D) Keep a daily record of fetal kick counts Verified A nswer -D) A client calls a providers office and reports having contractions for 2 hr that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the fo llowing manifestations is the client experiencing? (ATI MN p.79) A) Braxton hicks contractions B) Rupture of the membranes C) Fetal descent D) True contractions Verified Answer -D) A nurse is caring for a client having contractions every 8 min that are 30 to 40 seconds in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station with a FHR around 140/min. Which of the following stages and phases of labor is this client experiencing? (ATI MN p.79) A) First stage, latent phase B) First stage, active phase C) First stage, transition phase D) Second stage of labor Verified Answer -A) In stage 1. latent phase, the cervix dilates from 0 to 3 cm, and contraction duration ranges from 30 to 45 seconds A nurse is caring for a client who is at 40 weeks of gestation and reports having a large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first? (ATI MN p.79) A) Examine the amniotic fluid for meconium B) Check the FHR C) Dry the client and make them comfortable D) Apply a tocotransducer Verified Answer -B) The greatest risk to the client and fetus is umbilical cord prolapse, leading to fetal distress following rupture of membranes. The first action to take is to check the FHR for clinical findings of distress. A nurse is completing an admission assessment for a client who is at 39 weeks of gestation and reports fluid leaking from the vagina for two days. Which of the following conditions is the client at risk for developing? (ATI MN p.79) A) Cord prolapse B) Infection C) Postpartum hemorrhage D) Hydramnios Verified Answer -B) A nurse is caring for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits and states, "I've had enough, I can't do this anymore." Which of the following stages of labor is the client experiencing? (A TI MN p.79) A) Second stage B) Fourth stage C) Transition phase D) Latent phase Verified Answer -C) The transition phase of labor occurs when the client becomes irritable, feels rectal pressure similar to the need to have a bowel movement, and can become nauseous with emesis. A nurse is caring for a client who is in active labor. The cervix is dilated to 5cm, and the membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes an FHR of 115 to 125/min with occasional increases up to 150 to 155 /min that last for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. This client is exhibiting manifestations of which of the following? SATA (ATI MN p.93) A) Moderate variability B) FHR accelerations C) FHR decelerations D) Normal baseline FHR E) Fetal tachycardia Verified Answer -A) B) D)
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