NSG550 / NSG 550 EXAM 2 (LATEST 2024 / 2025 UPDATE): DIAGNOSTIC REASONING FOR NURSE PRAC, Exams of Nursing

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NSG550 / NSG 550 EXAM 2 (LATEST 2024 / 2025

UPDATE): DIAGNOSTIC REASONING FOR NURSE

PRACTITIONERS | QUESTIONS AND VERIFIED

ANSWERS | 100% CORRECT | GRADE A - WILKES

A nurse is performing a vaginal exam on a client in labor and finds the fetal presentation 1 cm above the ischial spines. How should the nurse document the fetal station? a) 0 b) - 1 c) + d) - 2 b) - 1 Upon examining a laboring client's cervix, the nurse notes the assessment as 7, 80, - 3. How does the nurse interpret this assessment? a) Cervix dilated 7 cm, 50% effaced, fetus 3 cm below the ischial spines. b) Cervix dilated 7 cm, 80% effaced, presenting 3 cm above the ischial spines. c) Cervix dilated 7 cm, 80% effaced, presenting part at the level of the ischial spines. d) Cervix dilated 5 cm, 80% effaced, presenting 3 cm above the ischial spines. b) Cervix dilated 7 cm, 80% effaced, presenting 3 cm above the ischial spines. The nurse recognizes that uterine activity during labor requires additional assessment and possible intervention when the nurse's assessment reveals which of the following? a) Contractions lasting 60 seconds, 5 minutes apart. b) Contractions lasting longer than 90 seconds with less than 30 seconds of resting. c) Contractions lasting 45 seconds, 5 times within a 10-minute period. d) Contractions lasting 70 seconds, 4 times within a 10-minute period. b) Contractions lasting longer than 90 seconds with less than 30 seconds of resting. A client comes to the prenatal clinic for fetal monitoring, and the nurse notes fetal tachycardia. Which of the following could be a possible cause? a) Maternal hypothermia b) Fetal bradycardia c) Maternal hyperthermia d) Fetal sleep cycle

c) Maternal hyperthermia A 28-year-old woman has now reached the second stage of labor. What is the optimal position for her at this point? a) Lying on her back with legs raised b) Standing c) Squatting d) Sitting in a reclined position c) Squatting The prenatal ultrasound reveals the sacrum of the fetus as the presenting part. How is the fetal position described? a) Vertex b) Transverse c) Breech d) Cephalic c) Breech A client in labor begins complaining of intense pain in her lower back. What non- pharmacological measure would provide the best relief? a) Breathing exercises b) Epidural anesthesia c) Counter-sacral pressure d) Changing positions frequently c) Counter-sacral pressure Which of the following signs indicates that the second stage of labor has begun? a) Contractions are 5 minutes apart. b) The cervix is fully dilated. c) The water breaks. d) Fetal descent into the pelvis. b) The cervix is fully dilated. What type of anesthesia is a spinal epidural classified as? a) Local b) General c) Regional d) Topical c) Regional Methotrexate is recommended as part of the treatment plan for which obstetric complication? a) Gestational diabetes b) Unruptured ectopic pregnancy c) Severe preeclampsia d) Placental abruption

b) Unruptured ectopic pregnancy A biophysical profile (BPP) cannot determine which of the following? a) Fetal tone b) Amniotic fluid volume c) Fetal weight d) Fetal breathing movements c) Fetal weight A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to: a) Stimulate fetal surfactant production. b) Reduce maternal and fetal tachycardia associated with ritodrine administration. c) Suppress uterine contractions. d) Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy. a) Stimulate fetal surfactant production During fetal anemia, what might the nurse hear on fetal heart monitoring? a) Tachycardia b) Bradycardia c) Regular rhythm d) Sinusoidal rhythm d) Sinusoidal rhythm What do primary powers during labor do? a) Promote maternal comfort and relaxation. b) Involve voluntary pushing during the second stage of labor. c) Involve dilation and effacement of the cervix. d) Control the maternal heart rate and blood pressure. c) Involve dilation and effacement of the cervix. The alpha-fetoprotein (AFP) test is primarily used to detect which of the following? a) Fetal liver function b) Maternal nutrition levels c) Fetal abnormalities, such as spina bifida d) Maternal-fetal blood type compatibility c) Fetal abnormalities, such as spina bifida Induction of labor is considered an acceptable obstetric procedure if it is in the best interest of delivering the fetus. Which of the following are specific conditions appropriate for labor induction? (Select all that apply.) a) Rupture of membranes at or near term

b) Convenience of the woman or her physician c) Chorioamnionitis d) Postterm pregnancy e) Fetal death a) Rupture of membranes at or near term c) Chorioamnionitis, d) Postterm pregnancy e) Fetal death Complications and risks associated with cesarean births include which of the following? (Select all that apply.) a) Placental abruption b) Wound dehiscence c) Hemorrhage d) Urinary tract infections e) Fetal injuries b) Wound dehiscence c) Hemorrhage d) Urinary tract infections e) Fetal injuries How should the umbilical cord be cared for and cleaned? (Select all that apply.) a) Clean cord with plain water around the base of the cord b) Keep diaper folded down to avoid covering the cord c) Apply alcohol to the base of the cord at every diaper change d) Notify healthcare provider (HCP) for odor, discharge, or redness a) Clean cord with plain water around the base of the cord b) Keep diaper folded down to avoid covering the cord d) Notify healthcare provider (HCP) for odor, discharge, or redness After a cesarean section, a mother should be taught to report which of the following symptoms as they could indicate infection or complications? a) Mild abdominal discomfort b) Temperature of 38°C (100.4°F) and abdominal pain c) Slight redness around the incision site d) Itching sensation around the incision area b) Temperature of 38°C (100.4°F) and abdominal pain If a laboring woman is 7 cm dilated, what breathing technique should she be encouraged to use? a) Shallow, rapid breathing b) Hold her breath for longer periods c) Use deep breathing and do not hold her breath d) Pant-like a dog

c) Use deep breathing and do not hold her breath The acronym HELLP, used in the context of obstetrics, stands for which of the following? a) Healthy Eating, Low Lipids, Pregnancy b) Hemolysis, Elevated Liver enzymes, Low Platelets c) High Estrogen, Low Lactation, Pre-eclampsia d) Hepatitis, Elevated Leukocytes, Pregnancy b) Hemolysis, Elevated Liver enzymes, Low Platelets What drug is likely the cause of early labor due to its effect on the placenta? a) Heroin b) Marijuana c) Cocaine d) Methamphetamines c) Cocaine True or False: A stress test is recommended for diagnosing placenta previa. False During labor, contractions lasting 40-90 seconds are considered: a) Normal b) Too high c) Too low a) Normal The medication terbutaline should be discontinued when the patient exhibits: a) High blood pressure b) Low respiration rate c) Increased heart rate d) Nausea b) Low respiration rate In the management of high blood pressure during pregnancy, what drug is commonly prescribed? a) Metoprolol b) Hydralazine c) Ibuprofen d) Acetaminophen b) Hydralazine Severe preeclampsia can escalate into which serious condition? a) Gestational diabetes b) Hyperemesis gravidarum c) Seizure (Eclampsia) d) HELLP syndrome c) Seizure (Eclampsia)

Before attempting to place a fetal heart rate monitor, which assessment technique should be performed first? a) Ultrasound b) Leopold's maneuvers c) Doppler auscultation d) Palpation of maternal abdomen b) Leopold's maneuvers Which medication should be taken with orange juice to enhance its absorption? a) Vitamin C b) Calcium carbonate c) Ferrous sulfate d) Vitamin D c) Ferrous sulfate In a woman with a platypelloid pelvis, the fetus is more likely to be in which position? a) Vertex b) Breech c) Transverse d) Posterior c) Transverse What is NOT included in a Biophysical Profile (BPP)? a) Nonstress test b) Fetal breathing movements c) Amniotic fluid volume d) Fetal weight d) Fetal weight A woman with a history of which condition is most at risk for uterine rupture? a) Gestational diabetes b) Pre-eclampsia c) Multiple gestations d) Previous cesarean sections d) Previous cesarean sections Which drug is contraindicated for patients with asthma due to the risk of exacerbating breathing difficulties? a) Oxytocin

b) Methylergonovine (Methergine) c) Carboprost tromethamine (Hemabate) d) Misoprostol c) Carboprost tromethamine (Hemabate) After a car accident, what is the priority nursing action for a pregnant woman? a) Assess for maternal injuries b) Administer pain medication c) Assess the fetus d) Check for contractions c) Assess the fetus Which test is used to assess fetal lung maturity? a) Lecithin/sphingomyelin (L/S) ratio b) Amniocentesis c) Alpha-fetoprotein d) Lamellar body count Lecithin/sphingomyelin (L/S) ratio In the first stage of pregnancy, what adjustment should a diabetic make to their insulin regimen? a) Increase insulin b) Decrease insulin c) No change d) Switch to an oral hypoglycemic agent b) Decrease insulin Which vitamin is recommended to prevent neural tube defects? a) Vitamin A b) Vitamin B c) Folic acid d) Vitamin D c) Folic acid Why should a sterile vaginal exam not be performed in the presence of active vaginal bleeding? a) Risk of introducing infection b) May increase bleeding c) Could exacerbate placental abruption d) Could exacerbate placenta previa

d) Could exacerbate placenta previa For a patient with asthma, which medication is considered a contraindication? a) Beta blockers b) Carboprost tromethamine (Hemabate) c) Corticosteroids d) None of the above; asthma medication should be used b) Carboprost tromethamine (Hemabate) Which medication is contraindicated for diabetic patients due to its potential to raise blood glucose levels? a) Insulin b) Metformin c) Betamethasone d) Glyburide c) Betamethasone The sudden gush of dark red blood during pregnancy is most indicative of: a) Placenta previa b) Placental abruption c) Vasa previa d) Uterine rupture b) Placental abruption A baby's heart rate in the 190s could indicate: a) Normal variability b) Fetal distress c) Prolapsed umbilical cord d) Maternal fever b) Fetal distress What indicates magnesium toxicity in a patient? a) Elevated blood pressure b) Respiration rate of 10 c) Urine output of 30 mL/hr d) Swelling of hands and feet b) Respiration rate of 10 In a primigravida being monitored for preeclampsia, which finding should concern the nurse?

a) Blood pressure increase to 138/86 mm Hg b) Weight gain of 0.5 kg during the past 2 weeks c) A dipstick value of 3+ for protein in her urine d) Pitting pedal edema at the end of the day c) A dipstick value of 3+ for protein in her urine An umbilical cord with only one vein and one artery (instead of the usual two arteries and one vein) could indicate which of the following issues in a neonate? a) Gastrointestinal anomalies b) Renal anomalies c) No associated health issues d) Respiratory issues b) Renal anomalies A boggy uterus that is displaced to the right of the umbilicus is most likely caused by: a) Uterine atony b) Full bladder c) Infection d) Remaining placental fragments b) Full bladder Upon noting meconium-stained amniotic fluid after the membranes have ruptured, the nurse's priority action should be to: a) Prepare for immediate delivery b) Assess fetal heart rate c) Administer oxygen to the mother d) Call the physician b) Assess fetal heart rate Which statement best describes an abnormal uterine activity pattern in labor? a) Contractions lasting less than 45 seconds b) Contractions occurring more than 5 minutes apart c) Contractions lasting approximately 2 minutes d) Contractions with a resting tone below 10 mm Hg c) Contractions lasting approximately 2 minutes A reassuring fetal monitor tracing would most likely include: a) Decelerations b) Variable heart rate

c) Accelerations d) Bradycardia c) Accelerations The mechanism of labor is influenced by: a) The mother's emotional state b) The administration of epidural anesthesia c) The forces determining descent, modified by the shape of the woman's pelvis and the size of the fetal head d) The time of day c) The forces determining descent, modified by the shape of the woman's pelvis and the size of the fetal head Effleurage performed by a nurse for a primigravida in labor is: a) Deep tissue massage b) Application of cold compresses c) Light stroking of the skin surface d) Application of pressure to specific points c) Light stroking of the skin surface After administering an epidural to a client in labor, the most important nursing intervention is to: a) Encourage the client to walk around b) Monitor blood pressure for hypotension c) Immediately start a tocolytic medication d) Increase the rate of intravenous fluids b) Monitor blood pressure for hypotension When administering pain medication to a laboring client via IV, it is important for the nurse to know that: a) The medication should be given as a rapid bolus b) Pain medication is contraindicated during labor c) The medication is given slowly in small increments between contractions d) Oral administration is preferred over IV c) The medication is given slowly in small increments between contractions Which cardinal movement allows the fetal head to be born by having the baby's neck extend as the head passes under the pubic symphysis? a) Flexion b) Descent

c) Internal rotation d) Extension d) Extension What is the leading cause of maternal mortality among the conditions listed? a) Gestational diabetes b) Gestational hypertension c) Postpartum hemorrhage d) Infection b) Gestational hypertension For which condition is amnioinfusion most appropriately administered? a) Polyhydramnios b) Oligohydramnios & fetal cord compression c) Gestational diabetes d) Fetal bradycardia b) Oligohydramnios & fetal cord compression Fetal monitor tracings showing accelerations are interpreted as: a) Non-reassuring b) Reassuring c) Indicative of fetal distress d) Inconclusive b) Reassuring Which description correctly categorizes the fetal heart rate patterns according to the standard categories? a) Category 1: Everything is good b) Category 2: Not everything is good, but not terrible c) Category 3: Terrible d) All of the above d) All of the above Which statement about the stages of labor is correct? a) The first stage begins with regular uterine contractions and ends with full dilation. b) The second stage starts with full dilation and ends with the birth of the baby. c) The third stage is from the birth of the baby to the delivery of the placenta. d) All of the above d) All of the above

What is NOT a likely cause of a fetal heart rate in the 190s? a) Maternal fever b) Fetal distress c) Prolapsed umbilical cord d) Normal fetal activity c) Prolapsed umbilical cord When performing the Leopold maneuver and feeling something round and moveable towards the symphysis pubis, how should the nurse document this finding? a) Fetal buttocks b) Fetal back c) Fetal head d) Fetal limbs c) Fetal head Smoking during pregnancy can result in which of the following? a) Increased fetal weight b) Restricted uterine growth c) Decreased risk of preterm labor d) Improved placental function b) Restricted uterine growth When a nurse observes pink blood on her glove after a sterile vaginal exam and is asked by the parents if everything is okay, what is the best response? a) "This is completely abnormal." b) "This is normal and is called 'bloody show'; it indicates the cervix is dilating." c) "We need to perform an emergency C-section." d) "This could indicate a serious problem." b) "This is normal and is called 'bloody show'; it indicates the cervix is dilating." In the third trimester, a woman reports she can breathe easier but needs to urinate more frequently. This is most likely due to: a) The onset of labor b) Fetal descent into the pelvis, known as lightening c) Urinary tract infection d) Increased fluid intake b) Fetal descent into the pelvis, known as lightening

Increasing the infusion rate of non-additive IV fluids can primarily increase fetal oxygenation by: a) Decreasing maternal blood pressure b) Expanding maternal blood volume c) Reducing fetal heart rate d) Increasing maternal oxygen intake b) Expanding maternal blood volume What does a contraction stress test with no decelerations indicate? a) Positive b) Negative c) Inconclusive d) Abnormal b) Negative A pregnant woman has been receiving magnesium sulfate for severe preeclampsia. Her respiratory rate has dropped to 10 breaths/min, and she has absent tendon reflexes. What should be the nurse's priority intervention? a) Continue monitoring the patient closely b) Increase the magnesium sulfate infusion rate c) Discontinue the magnesium sulfate infusion d) Administer a bolus of IV fluids c) Discontinue the magnesium sulfate infusion The nurse understands that the administration of opioids during labor can have which effect on the mother and fetus? a) Increased maternal blood pressure b) No significant effects c) Late or variable decelerations of the fetal heart rate d) Accelerated fetal heart rate c) Late or variable decelerations of the fetal heart rate Screening for gestational diabetes mellitus (GDM) is recommended during which weeks of pregnancy? a) 16-20 weeks b) 20-24 weeks c) 24-28 weeks d) 28-32 weeks c) 24-28 weeks

Med math 0. Med math 0. Med math 2 Med math 12 Med math 0. Med math 0. Med math 2 Med math 12 SATA 4: ALL EXCEPT METABOLIC PANEL At how many weeks can lightening or dropping occur in prima gravidas? a) 36 b) 38 c) 37 d) 35 c) 37 By what week should cerclage be placed, and until what week does it stay in? a) 16; 36 b) 14; 28 c) 15, 30 d) 18; 32 a) 16; 36 What is the resting tone range? a) 10 mmHg b) 15 mmHg c) 8 mmhHg d) 12 mmHg a) 10 mmHg A woman with preeclampsia has a seizure. The nurse's primary duty during the seizure is to a) insert an oral airway. b) suction the mouth to prevent aspiration. c) administer oxygen by mask. d) stay with the patient and call for help. d) stay with the patient and call for help. In planning care for women with preeclampsia, nurses should be aware that a) induction of labor is likely, as near term as possible. b) if at home, the woman should be confined to her bed, even with mild preeclampsia.

c) a special diet low in protein and salt should be initiated. d) vaginal birth is still an option, even in severe cases. a) induction of labor is likely, as near term as possible. A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be a. admitted and prepared for a cesarean birth. b. admitted for extended observation. c. discharged home with a sedative. d. discharged home to await the onset of true labor. d. discharged home to await the onset of true labor. Regarding cervical cerclage removal: What further teaching is necessary if it is planned to remove the cerclage at 28 weeks? A) No further teaching is needed; 28 weeks is the standard removal time. B) Teach that cerclage is typically removed later in pregnancy, unless specific complications arise. C) Inform that cerclage should not be removed at 28 weeks as it is too early and could lead to premature labor. D) Explain that removal timing is based on individual assessment and may vary from the 28-week guideline. C) Inform that cerclage should not be removed at 28 weeks as it is too early and could lead to premature labor. For a nurse caring for a woman with hyperemesis gravidarum: What indicates the need for further teaching if the patient states, "I will take antiemetics to prevent me from needing IV fluids"? A) No further teaching is required; this is an appropriate use of antiemetics. B) Teach that antiemetics alone may not be sufficient to prevent the need for IV fluids in severe cases of hyperemesis gravidarum. C) Inform that antiemetics should not be used without consulting a healthcare professional first. D) Explain that IV fluids are not related to the use of antiemetics and their use should be based on hydration status, not nausea control. B) Teach that antiemetics alone may not be sufficient to prevent the need for IV fluids in severe cases of hyperemesis gravidarum. What does it indicate when a fetal monitor shows decelerations that start at the beginning of a contraction and end at the end of the contraction? A) Head compression

B) Umbilical cord compression C) Uteroplacental insufficiency D) Fetal hypoxia A) Head compression