NURS 351 EXAM 2 REVIEW PREPU
QUESTIONS AND ANSWERS WITH
RATIONALES GRADED A+
The nurse is assessing the external fetal monitor and notes the following: fetal
heart rate of 175 beats/min, decrease in variability, and late decelerations. Which
action should the nurse tale first? - ANSWER- Have the client change position.
Rationale
Fetal tachycardia, decreased variability, and late decelerations are possible
indications of cord compression. The first step is to ask the client to change
position to see if that will take the pressure off the cord. The health care
provider should be notified, especially if a change of position is ineffective.
The nurse should continue to monitor the pattern continuously until the
situation is changed and to evaluate the effectiveness of interventions. This
could be an ominous sign indicating the need for further interventions to
include cesarean birth.
A woman is lightly stroking her abdomen in rhythm with her breathing during
contractions. The nurse identifies this technique as: - ANSWER- effleurage
,Rationale. Effleurage is a light, stroking, superficial touch of the abdomen in
rhythm with breathing during contractions. Acupressure involves the
application of a finger or massage at a trigger point to reduce the pain
sensation. Patterned breathing involves controlled breathing techniques to
reduce pain through a stimulus-response conditioning. Therapeutic touch
involves light or firm touch to the energy field of the body using the hands to
redirect the energy fields that lead to pain.
The nurse tests the pH of fluid found on the vaginal exam and determines that the
woman's membranes have ruptured based on which result? - ANSWER- 6.5
rationale:
Amniotic fluid is alkaline, so the membranes are probably ruptured if the pH
ranges from 6.5 to 7.5.
A 16-year-old client has been in the active phase of labor for 14 hours. An
ultrasound reveals that the likely cause of delay in dilation (dilatation) is
cephalopelvic disproportion. Which intervention should the nurse most expect in
this case? - ANSWER- cesarean birth
Rationale. If the cause of the delay in dilation (dilatation) is fetal malposition
or cephalopelvic disproportion (CPD), cesarean birth may be necessary.
Oxytocin would be administered to augment labor only if CPD were ruled out.
Administration of morphine sulfate (an analgesic) and darkening room lights
and decreasing noise and stimulation are used in the management of a
prolonged latent phase caused by hypertonic contractions. These measures
would not help in the case of CPD
During the assessment of a laboring client, the nurse learns that the client has
cardiovascular disease (CVD). Which assessment would be priority for the
newborn? - ANSWER- respiratory function
, rationale:
The nurse should identify respiratory distress syndrome as a major risk that
can be faced by the offspring of a client with cardiovascular disease. While the
other assessments are important, they are not priority
A novice nurse asks to be assigned to the least complex antepartum client. Which
condition would necessitate the least complex care requirements? - ANSWER-
gestational hypertension
Rationale. Hypertensive disorders represent the most common complication
of pregnancy. Gestational hypertension is elevated blood pressure without
proteinuria, other signs of preeclampsia, or preexisting hypertension.
Placental abruption (abruptio placentae), a separation of the placenta from
the uterine wall; placenta previa (placenta covering the cervical os); and
preeclampsia are high-risk, potentially life-threatening conditions for the fetus
and mother during labor and birth.
A 24-year-old client presents in labor. The nurse notes there is an order to
administer Rho(D) immune globulin after the birth of her infant. When asked by
the client the reason for this injection, which reason should the nurse point out? -
ANSWER- prevent maternal D antibody formation.
Rationale. Because Rho(D) immune globulin contains passive antibodies, the
solution will prevent the woman from forming long-lasting antibodies which
may harm a future fetus. The administration of Rho(D) immune globulin does
not promote the formation of maternal D antibodies; it does not stimulate
maternal D immune antigens or prevent fetal Rh blood formation.
A nurse is providing care to a pregnant woman with preterm prelabor rupture of
membranes (PPROM). On admission, the client's baseline information was as
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