401 - 500 Solved CBT Styled Practical MCQ Test Questions Bank

401. What should be included in your initial assessment of your patients respiratory status?
A. Review the patients notes and charts, to obtain the patients history.
B. Review the results of routine investigations.
C. Observe the patients breathing for ease and comfort, rate and pattern.
D. Perform a systematic examination and ask the relatives for the patient’s history.

402. What should be included in your initial assessment of your patient's respiratory status?
A. Observe the patient's breathing for ease and comfort, rate and pattern.
B. Review the results of routine investigations.
C. Review the patient's notes and charts, to obtain the patient's history.
D. Check for any drains.

403. Position to make breathing effective?
A. left lateral
B. Supine
C. Right Lateral
D. High sidelying

404. A client breathes shallowly and looks upward when listening to the nurse. Which sensory mode should the nurse plan to use with this client?
A. Touch
B. Auditory
C. Kinesthetic
D. Visual

405. While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?
A. Help client into the chair but more quickly
B. Document client’s vital signs taken just prior to moving the client
C. Help client back to bed immediately
D. Observe clients skin color and take another set of vital signs

406. A patient under developed shortness of breath while climbing stairs. U inform this to the doctor. This response is interpreted as:
A. Breaching of patients confidentiality
B. Essential, as it is the matter of patient’s health
C. All of the above
D. None of the above

407. Which of the following is NOT a cause of Type 1 (hypoxaemic) respiratory failure?
A. Asthma
B. Pulmonary oedema
C. Drug overdose
D. Granulomatous lung disease

408. Respiratory protective equipment include:
A. gloves
B. mask
C. apron
D. paper towels

409. What should be included in a prescription for oxygen therapy?
A. You don't need a prescription for oxygen unless in an emergency.
B. The date it should commence, the doctor's signature and bleep number.
C. The type of oxygen delivery system, inspired oxygen percentage and duration of the therapy.
D. You only need a prescription if the patient is going to have home oxygen.

410. Patient is in for oxygen therapy
A. A prescription is required including route, method and how long
B. No prescription is required unless he will use it at home.
C. Prescription not required for oxygen therapy
D. None of the above

411. Why is it essential to humidify oxygen used during respiratory therapy?
A. Oxygen is a very hot gas so if humidification isnt used, the oxygen will burn the respiratory tract and cause considerable pain for the patient when they breathe.
B. Oxygen is a dry gas which can cause evaporation of water from the respiratory tract and lead to thickened mucus in the airways, reduction of the movement of cilia and increased susceptibility to respiratory infection.
C. Humidification cleans the oxygen as it is administered to ensure it is free from any aerobic pathogens before it is inhaled by the patient.
D. None of the above

412. When using nasal cannulae, the maximum oxygen flow rate that should be used is 6 litres/min. Why?
A. Nasal cannulae are only capable of delivering an inspired oxygen concentration between 24% and 40%.
B. For any given flow rate, the inspired oxygen concentration will vary between breaths, as it depends upon the rate and depth of the patients breath and the inspiratory flow rate.
C. Higher rates can cause nasal mucosal drying and may lead to epistaxis.
D. If oxygen is administered at greater than 40% it should be humidified. You cannot humidify oxygen via nasal cannulae.

413. If a patient is prescribed nebulizers, what is the minimum flow rate in litres per minute required?
A. 2 - 4
B. 4 - 6
C. 6 – 8
D. 8–10

414. Which of the following oxygen masks is able to deliver between 60-90% of oxygen when delivered at a flow rate of 10 – 15L/min?
A. Simple semi rigid plastic masks (5 – 6L/min=21-60% O2)
B. Nasal cannulas (up to 6 L/min=28-44% O2)
C. Venture high flow mask (4 – 15L/min=40-50% O2)
D. Non-rebreathing masks (10 – 15L/min=60-90% O2)

415. Prior to sending a patient home on oxygen, healthcare providers must ensure the patient and family understand the dangers of smoking in an oxygen-rich environment. Why is this necessary?
A. It is especially dangerous to the patient's health to smoke while using oxygen
B. Oxygen is highly flammable and there is a risk of fire
C. Oxygen and cigarette smoke can combine to produce a poisonous mixture
D. Oxygen can lead to an increased consumption of cigarette

416. What do you need to consider when helping a patient with shortness of breath sit out in a chair?
A. They should not sit out on a chair; lying flat is the only position for someone with shortness of breath so that there are no negative effects of gravity putting pressure in lungs.
B. Sitting in a reclining position with legs elevated to reduce the use of postural muscle oxygen requirements, increasing lung volumes and optimizing perfusion for the best V/Q ratio. The patient should also be kept in an environment that is quiet so they don’t expend any unnecessary energy.
C. The patient needs to be able to sit in a forward leaning position supported by pillows. They may also need access to a nebulizer and humidified oxygen so they must be in a position where this is accessible without being a risk to others.
D. There are two possible positions, either sitting upright or side lying. Which is used and is determined by the age of the patient. It is also important to remember that they will always need a nebulizer and oxygen and the air temperature must be below20 degree Celsius.

417. What do you expect patients with COPD to manifest?
A. Inc Pco2, dec O2
B. Dec Pco2, inc o2
C. Inc pco2, inc o2
D. Dec pco2, dec o2

418. Which of the following indicates signs of severe Chronic Obstructive Pulmonary disease (COPD)?
A. high p02 and high pC02
B. Low p02 and low pC02
C. low p02 and high pC02
D. high p02 and low pC02

419. A COPD patient is in home care. When you visit the patient, he is dyspnoeic, anxious and frightened. He is already on 2 lit oxygen with nasal cannula.What will be your action
A. Call the emergency service.
B. Give Oramorph 5mg medications as prescribed.
C. Ask the patient to calm down.
D. Increase the flow of oxygen to 5L

420. A COPD patient is about to be discharged from the hospital. What is the best health teaching to provide this patient?
A. Increase fluid intake
B. Do not use home oxygen
C. Quit smoking
D. Nebulize as needed

421. As a nurse, what health teachings will you give to a COPD patient?
A. Encourage to stop smoking
B. Administer oxygen inhalation as prescribed
C. Enroll in a pulmonary rehabilitation programme
D. All of the Above

422. You are caring for a patient with a history of COAD who is requiring 70% humidified oxygen via a facemask. You are monitoring his response to therapy by observing his colour, degree of respiratory distress and respiratory rate. The patient's oxygen saturations have been between 95% and 98%. In addition, the doctor has been taking arterial blood gases. What is the reason for this?
A. Oximeters may be unreliable under certain circumstances, e.g. if tissue perfusion is poor, if the environment is cold and if the patient's nails are covered with nail polish.
B. Arterial blood gases should be sampled if the patient is receiving >60% oxygen.
C. Pulse oximeters provide excellent evidence of oxygenation, but they do not measure the adequacy of ventilation.
D. Arterial blood gases measure both oxygen and carbon dioxide levels and therefore give an indication of both ventilation and oxygenation

423. Joy, a COPD patient is to be discharged in the community. As her nurse, which of the following interventions will you encourage him to do to prevent progression of disease.
A. Oxygen therapy
B. Breathing exercise
C. Cessation of smoking
D. coughing exercise

424. You are caring for a 17 year old woman who has been admitted with acute exacerbation of asthma. Her peak flow readings are deteriorating and she is becoming wheezy. What would you do?
A. Sit her upright, listen to her chest and refer to the chest physiotherapist.
B. Suggest that the patient takes her Ventolin inhaler and continue to monitor the patient.
C. Undertake a full set of observations to include oxygen saturations and respiratory rate. Administer humidified oxygen, bronchodilators, corticosteroids and antimicrobial therapy as prescribed.
D. Reassure the patient: you know from reading her notes that stress and anxiety often trigger her asthma.

425. Lisa, a working mother of 3, has approached you during a recent attendance of her daughter in Accident and Emergency because of an acute asthma attack about smoking cessation. What is your most appropriate response to her?
A. Smoking cessation will help prevent further asthma attack
B. Referral can be made to the local NHS Stop smoking service
C. Discuss with her the NICE recommendations on smoking cessation
D. It is not common for people like her to stop smoking

426. Reason for dyspnoea in patients who diagnosed with Glomerulonephritis patients?
A. Albumin loss increase oncotic pressure causes water retention in cells
B. Albumin loss causes decrease in oncotic pressure causes water retention causing fluid retention I alveoli
C. Albumin loss has no effect on oncotic pressure
D. None of the above

427. Your patient has bronchitis and has difficulty in clearing his chest. What position would help to maximize the drainage of secretions?
A. Lying on his side with the area to be drained uppermost after the patient has had humidified air
B. Lying flat on his back while using a nebulizer
C. Sitting up leaning on pillows and inhaling humidified oxygen
D. Standing up in fresh air taking deep breaths

428. A client diagnosed of cancer visits the OPD and after consulting the doctor breaks down in the corridor and begins to cry. What would the nurses best action?
A. Ignore the client and let her cry in the hallway
B. Inform the client about the preparing to come forth next appointment for further discussion on the treatment planned
C. Take her to a room and try to understand her worries and do the needful and assist her with further information if required
D. Explain her about the list of cancer treatments to survive

429. When an oropharyngeal airway is inserted properly, what is the sign
A. Airway obstruction
B. Retching and vomiting
C. Bradycardia
D. Tachycardia

430. Which of the following is a potential complication of putting an oropharyngeal airway adjunct:
A. Retching, vomiting
B. Bradycardia
C. Obstruction
D. Nasal injury

431. What are the principles of gaining informed consent prior to a planned surgery?
A. Gaining permission for an imminent procedure by providing information in medical terms, ensuring a patient knows the potential risks and intended benefits.
B. Gaining permission from a patient who is competent to give it, by providing information, both verbally and with written material, relating to the planned procedure, for them to read on the day of planned surgery.
C. Gaining permission from a patient who is competent to give it, by informing them about the procedure and highlighting risks if the procedure is not carried out.
D. Gaining permission from a patient who is competent to give it, by providing information in understandable terms prior to surgery, allowing time for answering questions, and inviting voluntary participation.

432. When do you gain consent from a patient and consider it valid?
A. Only if a patient has the mental capacity to give consent
B. Only before a clinical procedure
C. None of the Above
D. None of the above

433. A patient is assessed as lacking capacity to give consent if they are unable to:
A. Understand information about the decision and remember that information
B. Use that information to make a decision
C. Communicate their decision by talking, using sign language or by any other means
D. All of the Above

434. The following must be considered in procuring a consent, except:
A. respect and support people’s rights to accept or decline treatment or care
B. withhold people’s rights to be fully involved in decisions about their care
C. be aware of the legislation regarding mental capacity
D. gain consent before treatment or care starts

435. What do you have to consider if you are obtaining a consent from the patient?
A. Understanding
B. Capacity
C. Intellect
D. Patient’s condition

436. An adult has been medicated for her surgery. The operating room (OR) nurse, when going through the client's chart, realizes that the consent form has not been signed. Which of the following is the best action for the nurse to take?
A. Assume it is emergency surgery & the consent is implied
B. Get the consent form & have the client sign it
C. Tell the physician that the consent form is not signed
D. Have a family member sign the consent form

437. A patient doesn’t sign the consent for mastectomy. But bystanders strongly feel that she needs surgery.
A. Allow family members to take decision on behalf of patient
B. Doc can proceed with surgery, since it is in line with the best interest and outcome
C. Respect patient’s decision. She has the right to accept or deny
D. None of the above

438. A client is brought to the emergency room by the emergency medical services after being hit by car. The name of the client is not known. The client has sustained a severe head injury, multiple fractures and is unconscious. An emergency craniotomy is required, regarding informed consent for the surgical procedure, which of the following is the best action?
A. Call the police to identify the client and locate the family
B. Obtain a court order for the surgical procedure
C. Ask the emergency medical services team to sign the informed consent
D. Transport the victim to the operating room for surgery

439. What does assessing for no refusal means?
A. That the person has not already refused treatment
B. That the person cannot or is unable to refuse treatment
C. That the person does not already have an advanced decision
D. The person is already detained/ being treated under the mental health act.

440. Barbara, a 75-year old patient from a nursing home was admitted on your ward because of fractured neck of femur after a trip. She will require an open-reduction and internal fixation (ORIF) procedure to correct the injury. Which of the following statements will help her understand the procedure?
A. You are going to have an ORIF done to correct your fracture.
B. Some metal screws and pins will be attached to your hip to help with the healing of your broken bone.
C. The operation will require a metal fixator implanted to your femur and adjacent bones to keep it secured
D. The ORIF procedure will be done under general anaesthesia by an orthopaedic surgeon

441. What is right in case of consent among children under 18?
A. Only children between 16-18 are competent to give it.
B. Parents are responsible to give consent with children
C. Children who are intellectually developed and understand matters can give consent
D. None of the above

442. Recommended preoperative fasting times are:
A. 2-4 hours
B. 6-12 hours
C. 12-14 hours
D. None of the above

443. A patient is being prepared for a surgery and was placed on NPO. What is the purpose of NPO?
A. Prevention of aspiration pneumonia
B. To facilitate induction of pre-op meds
C. For abdominal procedures
D. To decrease production of fluids

444. Which is the safest and most appropriate method to remove hair pre-operatively?
A. Shaving
B. Clipping
C. Chemical removal
D. Washing

445. Who should mark the skin with an indelible pen ahead of surgery?
A. The nurse should mark the skin in consultation with the patient
B. A senior nurse should be asked to mark the patient's skin
C. The surgeon should mark the skin
D. It is best not to mark the patient's skin for fear of distressing the patient.

446. A patient is scheduled to undergo an Elective Surgery. What is the least thing that should be done?
A. Assess/Obtain the patient’s understanding of, and consent to, the procedure, and a share in the decision-making process.
B. Ensure pre-operative fasting, the proposed pain relief method, and expected sequelae are carried out and discussed.
C. Discuss the risk of operation if it won’t push through.
D. The documentation of details of any discussion in the anaesthetic record.

447. Safe moving and handling of an anaesthetized patient is imperative to reduce harm to both the patient and staff. What is the minimum number of staff required to provide safe manual handling of a patient in theatre?
A. 3 (1 either side, 1 at head)
B. 5 (2 each side, 1 at head)
C. 4 (1 each side, 1 at head, 1 at feet)
D. 6 (2 each side, 1 at head, 1 at feet)

448. You are the nurse assigned in recovery room or post anaesthetic care unit. The main priority of care in such area is:
A. Keeping airway intact
B. keeping patient pain free
C. keeping neurological condition stable
D. keeping relatives informed of patient’s condition

449. As a registered nurse in a unit what would consider as a priority to a patient immediately post operatively?
A. pain relief
B. blood loss
C. airway patency
D. None of the above

450. Gurgling sound from airway in a postoperative client indicates what
A. Complete obstruction of lower airway
B. Partial obstruction of upper airway
C. Common sign of a post-operative patient
D. None of the above

451. Accurate postoperative observations are key to assessing a patient's deterioration or recovery. The Modified Early Warning Score (MEWS) is a scoring system that supports that aim. What is the primary purpose of MEWS?
A. Identifies patients at risk of deterioration.
B. Identifies potential respiratory distress.
C. improves communication between nursing staff and doctors.
D. Assesses the impact of pre-existing conditions on postoperative recovery

452. What serious condition is a possibility for patients positioned in the Lloyd Davies position during surgery?
A. Stroke
B. Cardiac arrest
C. Compartment syndrome
D. There are no drawbacks to the Lloyd Davies position

453. A patient has just returned from theatre following surgery on their left arm. They have a PCA infusion connected and from the admission, you remember that they have poor dexterity with their right hand. They are currently pain free.
A. Educate the patient's family to push the button when the patient asks for it. Encourage them to tell the nursing staff when they leave the ward so that staff can take over.
B. Routinely offer the patient a bolus and document this clearly.
C. Contact the pain team/anaesthetist to discuss the situation and suggest that the means of delivery are changed.
D. The patient has paracetamol q.d.s. written up, so this should be adequate pain relief

454. The night after an exploratory laparotomy, a patient who has a nasogastric tube attached to low suction reports nausea. A nurse should take which of the following actions first?
A. Administer the prescribed antiemetic to the patient.
B. Determine the patency of the patient's nasogastric tube.
C. Instruct the patient to take deep breaths.
D. Assess the patient for pain

455. You are looking after a postoperative patient and when carrying out their observations, you discover that they are tachycardic and anxious, with an increased respiratory rate. What could be happening? What would you do?
A. The patient is showing symptoms of hypovolaemic shock. Investigate source of fluid loss, administer fluid replacement and get medical support.
B. The patient is demonstrating symptoms of atelectasis. Administer a nebulizer, refer to physiotherapist for assessment.
C. The patient is demonstrating symptoms of uncontrolled pain. Administer prescribed analgesia, seek assistance from medical team.
D. The patient is demonstrating symptoms of hyperventilation. Offer reassurance, administer oxygen

456. Patient is post of repair of tibia and fibula possible signs of compartment syndrome include
A. Numbness and tingling
B. Cool dusky toes
C. Pain
D. All of the Above

457. Now the medical team encourages early ambulation in the post-operative period. which complication is least prevented by this?
A. Tissue wasting
B. Thrombophlebitis
C. Wound infection
D. Pneumonia

458. If a client is experiencing hypotension post operatively, the head is not tilted in which of the following surgeries
A. Chest surgery
B. Abdominal surgery
C. Gynaecological surgery
D. Lower limb surgery

459. You went back to see Mr Derby who is 1 day post-herniorraphy. As you approach him he complained of difficulty of breathing with respiration rate of 23 breaths per minute and oxygen saturation 92% in room air. What is your next action to help him?
A. give him oxygen
B. give him pain relief
C. give him antibiotics
D. give him nebulisers

460. Barbara was screaming in pain later in the day despite the PCA in-situ. You refer back to your nurse in charge for a stronger pain killer. She refused to call the doctor because her pain relief was reassessed earlier. What will you do next?
A. Continue to refer back to her until she calls the doctor
B. Encourage Barbara to continuously use the PCA
C. Give Barbara some sedatives to keep her calm
D. Wait until her pain stops

461. How soon after surgery is the patient expected to pass urine?
A. 1-2 hours
B. 2-4 hours
C. 4-6 hours
D. 6-8 hours

462. A patient has just returned to the unit from surgery. The nurse transferred him to his bed but did not put up the side rails. The patient fell and was injured. What kind of liability does the nurse have?
A. None
B. Negligence
C. Intentional tort
D. Assault and battery

463. Which of these is not a symptom of an ectopic pregnancy?
A. Pain
B. Bleeding
C. Vomiting
D. Diarrhoea

464. A young woman gets admitted with abdominal pain & vaginal bleeding. Nurse should consider an ectopic pregnancy. Which among the following is not a symptom of ectopic pregnancy?
A. Pain at the shoulder tip
B. Dysuria
C. Positive pregnancy test
D. None of the above

465. The signs and symptoms of ectopic pregnancy except:
A. Vaginal bleeding
B. Positive pregnancy test
C. Shoulder tip pain
D. Protein excretion exceeds 2 g/day

466. Which of the following is NOT a risk factor for ectopic pregnancy?
A. Alcohol abuse
B. Smoking
C. Tubal or pelvic surgery
D. previous ectopic pregnancy

467. What is not a sign of meconium aspiration
A. Floppy in appearance
B. Apnoea
C. Crying
D. None of the above

468. An 18 year old 26 week pregnant woman who uses illicit drugs frequently, the factors in risk for which one of the following:
A. Spina bifida
B. Meconium aspiration
C. Pneumonia
D. Teratogenicity

469. Common minor disorder in pregnancy?
A. abdominal pain
B. heart burn
C. headache
D. None of the above

470. An unmarried young female admitted with ectopic pregnancy with her friend to hospital with complaints of abdominal pain. Her friend assisted a procedure and became aware of her pregnancy and when the family arrives to hospital, she reveals the truth. The family reacts negatively. What could the nurse have done to protect the confidentiality of the patient information?
A. should tell the family that they don’t have any rights to know the patient information
B. That the friend was mistaken and the doctor will confirm the patient’s condition
C. should insist friend on confidentiality
D. should have asked another staff nurse to be a chaperone while assisting a procedure

471. Jenny was admitted to your ward with severe bleeding after 48 hours following her labour. What stage of post partum haemorrhage is she experiencing?
A. Primary
B. Secondary
C. Tertiary
D. Emergency

472. Postpartum haemorrhage: A patient gave birth via NSD. After 48 hours, patient came back due to bleeding, bleeding after birth is called post partum haemorrhage. What type?
A. primary postpartum haemorrhage
B. secondary postpartum haemorrhage
C. tertiary postpartum haemorrhage
D. lochia

473. A young mother who delivered 48hrs ago comes back to the emergency department with post partum haemorrhage. What type of PPH is it?
A. primary post-partum haemorrhage
B. secondary post-partum haemorrhage
C. tertiary post-partum haemorrhage.
D. None of the above

474. A new mother is admitted to the acute psychiatric unit with severe postpartum depression. She is tearful and states, "I don't know why this happened to me I was so excited for my baby to come, but now I don't know!" Which of the following responses by the nurse is MOST therapeutic?
A. Maybe you weren't ready for a child after all.
B. Having a new baby is stressful, and the tiredness and different hormone levels don't help. It happens to many new mothers and is very treatable.
C. What happened once you brought the baby home? Did you feel nervous?
D. Has your husband been helping you with the housework at all?

475. In a G.P clinic when you assessing a pregnant lady you observe some bruises on her hand. When you asked her about this she remains silent. What is your action?
A. Call her husband to know what is happening
B. Tell her that you are concerned of her welfare and you may need to share this information appropriately with the people who offer help
C. Do nothing as she does not want to speak anything
D. Call the police

476. A client is admitted to the labour and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labour?
A. Active
B. Latent
C. Transition
D. Early

477. After the physician performs an amniotomy, the nurse’s first action should be to assess the:
A. Degree of cervical dilation
B. Fetal heart tones
C. Client’s vital signs
D. Client’s level of discomfort

478. The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
A. Within 72 hours of delivery
B. Within one week of delivery
C. Within two weeks of delivery
D. Within one month of delivery

479. The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
A. Low birth weight
B. Large for gestational age
C. Preterm birth, but appropriate size for gestation
D. Growth retardation in weight and length

480. A client telephones the emergency room stating that she thinks that she is in labour. The nurse should tell the client that labour has probably begun when:
A. Her contractions are two minutes apart.
B. She has back pain and a bloody discharge.
C. She experiences abdominal pain and frequent urination.
D. Her contractions are five minutes apart.

481. A client is admitted to the labour and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:
A. Assess the fetal heart tones.
B. Check for cervical dilation.
C. Check for firmness of the uterus.
D. Obtain a detailed history

482. The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
A. Diabetes
B. HIV
C. Hypertension
D. Thyroid disease

483. The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
A. Hypoglycemic, small for gestational age
B. Hyperglycemic, large for gestational age
C. Hypoglycemic, large for gestational age
D. Hyperglycemic, small for gestational age

484. A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
A. Elevated human chorionic gonadatropin
B. The presence of fetal heart tones
C. Uterine enlargement
D. Breast enlargement and tenderness

485. The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?
A. Hamburger patty, green beans, French fries, and iced tea
B. Roast beef sandwich, potato chips, baked beans, and cola
C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea
D. Fish sandwich, gelatin with fruit, and coffee

486. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of a ruptured ectopic pregnancy?
A. Painless vaginal bleeding
B. Abdominal cramping
C. Throbbing pain in the upper quadrant
D. Sudden, stabbing pain in the lower quadrant

487. Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?
A. A fetal heart rate of 120–130bpm
B. A baseline variability of 6–10bpm
C. Accelerations in FHR with fetal movement
D. A recurrent rate of 90–100bpm at the end of the contractions

488. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
A. Notify her doctor.
B. Start an IV.
C. Reposition the client.
D. Readjust the monitor.

489. As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely Rationale of this pattern?
A. The baby is sleeping.
B. The umbilical cord is compressed.
C. There is head compression.
D. There is uteroplacental insufficiency.

490. The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labour. Which one would be most appropriate for the primagravida as she completes the early phase of labour?
A. Impaired gas exchange related to hyperventilation
B. Alteration in placental perfusion related to maternal position
C. Impaired physical mobility related to fetal-monitoring equipment
D. Potential fluid volume deficit related to decreased fluid intake

491. A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
A. The cervix is closed.
B. The membranes are still intact.
C. The fetal heart tones are within normal limits.
D. The contractions are intense enough for insertion of an internal monitor.

492. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
A. Anticipate the need for a Caesarean section.
B. Apply an internal fetal monitor.
C. Place the client in Genu Pectoral position.
D. Perform an ultrasound.

493. The obstetric client’s fetal heart rate is 80–90 during the contractions. The first action the nurse should take is:
A. Reposition the monitor.
B. Turn the client to her left side.
C. Ask the client to ambulate.
D. Prepare the client for delivery.

494. Which observation would the nurse expect to make after an amniotomy?
A. Dark yellow amniotic fluid
B. Clear amniotic fluid
C. Greenish amniotic fluid
D. Red amniotic fluid

495. The client with pre-eclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates the understanding of magnesium toxicity?
A. The nurse performs a vaginal exam every 30 minutes.
B. The nurse places a padded tongue blade at the bedside.
C. The nurse inserts a Foley catheter.
D. The nurse darkens the room.

496. Which selection would provide the most calcium for the client who is four months pregnant?
A. A granola bar
B. A bran muffin
C. A cup of yogurt
D. A glass of fruit juice

497. The nurse is monitoring a client with a history of stillborn infant. The nurse is aware that nonstress test can be ordered for the client to:
A. Determine lung maturity
B. Measure the fetal activity
C. Show the effect of contractions on fetal heart rate
D. Measure the well-being of the fetus

498. The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because:
A. New parents need time to learn how to hold the baby.
B. The umbilical cord needs time to separate.
C. Newborn skin is easily traumatized by washing.
D. The chance of chilling the baby outweighs the benefits of bathing.

499. When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:
A. Check the client for bladder distention.
B. Assess the blood pressure for hypotension.
C. Determine whether an oxytocic drug was given.
D. Check for the expulsion of small clots.

500. A client is admitted to the labour and delivery unit in active labour. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
A. Document the finding.
B. Report the finding to the doctor.
C. Prepare the client for a C-section.
D. Continue primary care as prescribed.