WorksheetsFINAL EXAM
Total questions: 50
Worksheet time: 1hrs 17mins
The nurse is explaining the stages of labor to a primigravida patient. Which of the following statements by the patient indicates understanding?
"The second stage of labor is when my cervix dilates from 4 to 7 centimeters."
"The third stage begins after my baby is born and ends when the placenta comes out."
"The first stage ends when my water breaks."
"The fourth stage is the active pushing stage."
A nurse is educating a childbirth class about the characteristics of the active phase of labor. Which statement is correct?
"Contractions may feel like mild cramps and occur every 15–30 minutes."
"The cervix will dilate from 0 to 5 cm during this phase."
"This phase usually lasts 4 to 7 hours and contractions grow more intense."
"Your baby will be delivered during this phase."
During the second stage of labor, which of the following nursing actions is the highest priority?
Encourage the support person to take a break
Monitor maternal vital signs every 30 minutes
Coach the mother on effective pushing techniques
Prepare oxytocin for placental delivery
A nurse is assessing a client in active labor. Which of the following is an expected physiologic change during this stage?
Decreased cardiac output
Decreased respiratory rate
Increased gastrointestinal motility
Increased blood pressure during contractions
A laboring client is hyperventilating during contractions and reports dizziness and tingling in her fingers. What is the nurse’s priority intervention?
Administer oxygen via non-rebreather mask
Notify the provider immediately
Encourage slow breathing into cupped hands or a paper bag
Offer an anti-anxiety medication
A pregnant woman at 28 weeks reports severe, sudden-onset abdominal pain and vaginal bleeding. Her abdomen is rigid and tender. What condition does the nurse suspect?
Placenta previa
UTI
Ectopic pregnancy
Placental abruption
A nurse is planning care for a 32-week pregnant client diagnosed with severe preeclampsia. Which intervention is the highest priority to reduce the risk of maternal and fetal mortality?
Monitor daily weight and record intake and output
Teach the client to report mild headaches and swelling
Maintain the client on bed rest in a left lateral position and initiate continuous fetal monitoring
Provide education on signs of preterm labor and breastfeeding preparation
A nurse is teaching a pregnant client recently diagnosed with gestational diabetes. Which of the following statements by the client indicates a need for further teaching?
"I will check my blood sugar before and after meals."
"I will begin a low-carb, high-protein diet and walk daily."
"My baby may be smaller than average because of this condition."
"If my blood sugar stays elevated, I may need insulin."
A pregnant patient needs an emergency cholecystectomy. What is the best explanation the nurse can give about timing of surgery during pregnancy?
“All surgeries are postponed until after delivery to protect the fetus.”
“Emergency surgeries are performed as needed, but the second trimester is generally the safest time.”
“Surgery is safest in the first trimester because the fetus is not fully developed.”
“Surgeries are more dangerous after 20 weeks due to complete placental formation.”
A nurse encourages position changes every 30–60 minutes during the first stage of labor. What is the primary benefit of frequent position changes?
They eliminate the need for pain medication
They keep the mom from falling asleep
They increase cervical edema
They improve maternal comfort and promote labor progression
Which of the following is an appropriate nursing action to prevent hypotension prior to the administration of spinal anesthesia for a cesarean delivery?
Administer an IV fluid bolus as ordered
Apply cold packs to the lower extremities
Restrict oral fluids prior to the procedure
Instruct the patient to bear down during administration
During a prenatal class, a nurse is teaching about epidural anesthesia. Which statement by the client indicates the need for further teaching?
“I understand that the epidural can help manage pain but may cause some numbness in my legs.”
“I will need to remain still during the insertion of the epidural needle to avoid complications.”
“I won’t be able to feel the contractions, but I’ll still be able to push when it’s time.”
“I will be able to walk and move around after receiving the epidural.”
A fetal monitor strip shows a baseline FHR of 100 bpm for 10 minutes with minimal variability. What condition is the nurse most concerned about?
Maternal anxiety
Normal fetal sleep cycle
Fetal hypoxia or acidosis
Maternal hyperglycemia
A nurse notes uniform, gradual fetal heart rate decelerations that mirror the contractions during the active phase of labor. What is the most appropriate nursing action?
Reposition the patient and administer oxygen
Document the finding as a normal response
Prepare for emergency delivery
Discontinue oxytocin immediately
The fetal heart monitor shows abrupt drops in heart rate that vary in timing with contractions. Which condition does the nurse suspect?
Uterine rupture
Cord compression
Maternal hypotension
Fetal head compression
A nurse is preparing to place an internal fetal scalp electrode (FSE). Which of the following conditions must be met?
The membranes must be ruptured, and the cervix dilated at least 1–2 cm
The patient must have an epidural in place
The fetus must be breech
The maternal blood pressure must be elevated
A nurse is assessing a 32-week pregnant client at a routine prenatal visit. The client reports a headache that has persisted for 2 days, blurred vision, and swelling in her hands and face. Her blood pressure is 152/96 mmHg. Which nursing action is the priority?
Recheck the blood pressure in 30 minutes
Instruct the client to reduce sodium intake and rest
Notify the healthcare provider immediately
Encourage the client to increase fluid intake to reduce swelling
The nurse is caring for four clients in labor. Which patient should be assessed first?
A patient with ruptured membranes and green-colored amniotic fluid
A patient who is 6 cm dilated with contractions every 5 minutes
A patient receiving oxytocin with contractions every 2 minutes lasting 45 seconds
A patient at 3 cm dilation ambulating in the hallway
A patient at 30 weeks’ gestation is receiving terbutaline for preterm labor. Which of the following assessment findings should prompt the nurse to withhold the next dose and notify the provider?
Maternal heart rate of 120 bpm
Uterine contractions every 15 minutes
Fetal heart rate of 140 bpm
Blood pressure of 110/70 mmHg
During delivery, the infant’s head delivers, but the shoulders do not emerge. What is the nurse’s priority action?
Apply fundal pressure
Flex the mother’s thighs onto her abdomen
Encourage pushing
Give terbutaline to relax the uterus
Which of the following patients is most at risk for developing placental abruption?
A 24-year-old in early labor with no prenatal complications
A 35-year-old with chronic hypertension and cocaine use
A 28-year-old with BMI 22 and normal fetal movement
A 19-year-old at 40 weeks with spontaneous labor
A nurse is assessing a postpartum client who delivered 2 hours ago. The uterus is boggy and located above the umbilicus, and the client has saturated a peripad in 15 minutes. What is the priority nursing action?
Document the findings and reassess in 30 minutes
Massage the fundus firmly and call for help
Administer pain medication
Encourage the patient to ambulate to stimulate uterine tone
A postpartum patient is tearful, fatigued, and reports feeling overwhelmed 5 days after delivery. She is eating and sleeping, but cries easily and feels anxious about caring for the baby. What is the most appropriate nursing response?
Refer the patient to a psychiatrist for evaluation
Explain that these symptoms are common and usually resolve within two weeks
Administer a PRN sedative and reassess in 24 hours
Notify the provider of suspected postpartum depression
Which statement should the nurse include in postpartum discharge instructions regarding uterine involution?
Your uterus should not be palpable by the 2nd postpartum day."
"It is normal for your uterus to feel firm above the umbilicus for several weeks."
"Your uterus should be firm and descend about 1 cm per day."
"Uterine cramping is abnormal and should be reported immediately."
A nurse is assessing the effectiveness of breastfeeding. Which finding indicates that the infant is feeding well?
Baby feeds for only 3 minutes on each breast
Baby has 6-7 wet diapers per day
Baby feeds 7 times a day
Mother reports intense pain during latching
Which hormone is primarily responsible for stimulating milk production in lactating women?
estrogen
oxytocin
progesterone
prolactin
A nurse notes that a 1-day-old term newborn has a cephalohematoma on the right parietal area. What is the most important nursing consideration related to this finding?
Monitor for facial asymmetry
Reassure the parents that it resolves within hours
Observe for signs of jaundice and hyperbilirubinemia
Apply warm compresses to reduce swelling
A nurse is planning care for a term newborn delivered via cesarean section. Which of the following interventions is most important during the first two hours of life?
Administer the first hepatitis B vaccine
Weigh the newborn and obtain measurements
Maintain thermoregulation and monitor for transient tachypnea
Bathe the newborn to remove vernix and reduce infection risk
A nurse is educating parents on newborn feeding cues. Which behavior is an early cue indicating readiness to feed?
Crying loudly
Sucking on fists and turning head side to side
Flailing arms and legs
Closing the eyes and appearing sleepy
A nurse is reviewing newborn discharge instructions with a parent. Which statement by the parent requires immediate follow-up?
“I’ll call the provider if the baby’s temperature goes above 100.4°F (38°C).”
“I plan to give the baby a sponge bath until the umbilical cord falls off.”
“I’ll use a rectal thermometer to check his temperature if i suspect a fever.”
“I’ll place him in a rear-facing car seat in the back seat.”
The provider prescribes ampicillin 100 mg/kg/day IV divided every 12 hours for a newborn who weighs 3.2 kg. How many milligrams per dose should the nurse prepare?
160mg
320mg
100mg
80mg
A nurse is caring for a newborn with respiratory distress syndrome (RDS). Which interventions should the nurse include in the plan of care? (Select all that apply.)
Administer surfactant via endotracheal tube as prescribed
Encourage early oral feedings to stimulate breathing
Monitor arterial blood gases and oxygen saturation
Cluster care to allow for uninterrupted rest periods
Place the infant supine with neck slightly extended
A 6-year-old child is admitted for surgery and expresses fear about the procedure. Which of the following is the most appropriate nursing response to address this child’s stressor?
“The surgery will help you get better, so you won’t need to worry about it.”
“Let’s play with some medical toys to understand the procedure better.”
“Don’t be afraid; the doctor will take care of everything while you sleep.”
“Surgery is a very serious matter, and we need to talk about what will happen.”
A nurse is assessing pain in a 3-year-old child who is recovering from surgery. Which of the following pain assessment tools is most appropriate for this child
Wong-Baker FACES Pain Rating Scale
Numerical Rating Scale (NRS)
FLACC Scale (Face, Legs, Activity, Cry, Consolability)
McGill Pain Questionnaire
A nurse is providing end-of-life care for a pediatric patient. The child is actively dying, and the family is present at the bedside. The nurse is preparing the family for the changes they may witness in the child’s appearance as death approaches. Which of the following statements by the nurse is most appropriate?
“You may notice your child’s breathing become irregular, and their skin may look pale or mottled.”
“Your child will likely not show any changes; they will simply fall asleep peacefully.”
“You can expect that your child will pass very quickly with no signs of distress.”
“You should try not to focus on your child’s appearance during this time.”
A nurse is providing care for a 2-year-old child with suspected acute epiglottitis. Which of the following interventions should the nurse avoid?
Using a tongue depressor to examine the throat
Keeping the child in an upright position to promote easier breathing
Administering oxygen to maintain oxygen saturation above 94%
Administering antibiotics and corticosteroids as prescribed
A nurse is caring for a child diagnosed with Wilms’ tumor. Which nursing intervention is the highest priority?
Encourage high-protein foods to support healing
Palpate the abdomen every shift to monitor mass size
Monitor intake and output to assess renal function
Avoid palpating the abdomen to prevent tumor rupture
A nurse is developing a discharge teaching plan for a school-aged child with acute lymphoblastic leukemia (ALL) who is receiving chemotherapy. Which of the following should be included in the plan?
"Attend school daily to maintain routine and immune strength."
"Avoid crowded places and sick individuals."
"Increase raw fruits and vegetables for increased fiber."
"Skip dental visits to reduce exposure to chemicals."
A 9-year-old child recently diagnosed with Hodgkin lymphoma tells the nurse, “I’m scared I’m going to die.” What is the most therapeutic response?
"Don’t worry, you’re going to be just fine."
"You shouldn’t think that way; many kids survive cancer."
"It’s okay to feel scared. Would you like to talk more about it?"
"You’ll feel better once treatment starts."
A newborn is diagnosed with atrioventricular septal defect (AVSD). The nurse knows this defect is commonly associated with which of the following conditions?
Down syndrome (trisomy 21)
Cystic fibrosis
Turner syndrome
Spina bifida
Which of the following maternal behaviors during pregnancy poses the greatest risk for the infant developing a congenital heart defect?
Occasional caffeine use
Daily alcohol consumption
Mild physical activity
Sleeping on the left side
A 5-year-old child is hospitalized with Kawasaki disease. Which medications should the nurse expect to administer as part of the treatment plan?
Acetaminophen and ampicillin
Prednisone and ibuprofen
Intravenous immunoglobulin and aspirin
Albuterol and loratadine
A child is admitted with rheumatic fever following an untreated strep throat infection. The nurse should closely monitor the child for signs of which serious complication?
Deep vein thrombosis
Carditis leading to permanent valve damage
Congenital heart defect
Gastrointestinal bleeding
The nurse is preparing discharge teaching for the parents of a child with nephrotic syndrome. Which statement by the parent shows understanding of the care plan?
"We will stop giving steroids once the swelling goes down."
"We’ll give the steroid only when there's blood in the urine."
"We will monitor daily weights and check for facial swelling."
"My child should drink as much water as possible during a relapse."
A 5-week-old infant is scheduled for surgery to correct pyloric stenosis. Which preoperative nursing action is most important?
Encourage breastfeeding before surgery
Correct fluid and electrolyte imbalances
Start oral rehydration therapy immediately
Position the infant on the left side after feeding
A 2-year-old child is brought to the emergency department with severe abdominal pain, vomiting, and bloody stools. The nurse suspects intussusception. Which of the following interventions should be priority in the management of this child?
Administer a broad-spectrum antibiotic
Prepare for an air or contrast enema
Start oral rehydration therapy immediately
Offer small, frequent feedings of clear liquids
A 1-month-old infant is diagnosed with clubfoot (talipes equinovarus). The nurse observes that the baby’s foot is turned inward and downward, with resistance to passive movement. Which of the following findings is consistent with the diagnosis of clubfoot?
Inability to passively move the foot into neutral position
Foot that is able to be repositioned into a neutral position without resistance
Mild inward rotation of the foot with no other issues
No noticeable deformity of the foot at all
A 6-year-old child is placed in skeletal traction following a femur fracture. The nurse is reviewing the child's care plan and preparing for daily assessments. Which of the following is the primary function of skeletal traction in this child, and which action should the nurse prioritize to promote comfort and prevent complications?
Function of traction: Immobilize the fracture and realign the bone; Action: Assess for signs of infection at the pin site and maintain proper alignment of the leg
Function of traction: Apply weight to reduce swelling; Action: Monitor the child’s body temperature and encourage deep breathing exercises to reduce anxiety
Function of traction: Provide stability and reduce muscle spasms; Action: Administer oral pain medication every 4 hours as ordered
Function of traction: Prevent dislocation of the hip joint; Action: Provide the child with a pillow to support the hips during rest
A nurse is caring for a child diagnosed with bacterial meningitis. The child is on precautionary isolation to prevent the spread of the infection. Which of the following actions is the most important in preventing the spread of infection?
Use a face mask and gown when caring for the child
Administer IV antibiotics promptly, as prescribed
Encourage the child to increase fluid intake to prevent dehydration
Limit visitors to prevent exposure to others
A 5-year-old child has sustained a moderate traumatic brain injury (TBI). The nurse is monitoring the child for potential complications. Which of the following would be the most concerning finding that requires immediate attention?
Fatigue and drowsiness
Unequal pupil reaction to light
Headache and dizziness
Decreased appetite
