401 - 500 Solved NCLEX Styled Practical MCQ Test Questions Bank

401. The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care?
A. A 10-year-old with lacerations of the face
B. A 15-year-old with sternal bruises
C. A 34-year-old with a fractured femur
D. A 50-year-old with dislocation of the elbow

402. Which roommate would be most suitable for a client newly diagnosed with myasthenia gravis?
A. A client with diabetes
B. A client with exacerbation of ulcerative colitis
C. A client with a venous stasis ulcer
D. A client with bronchitis

403. Which observation indicates that a student nurse needs further teaching in the proper way to assess central venous pressure?
A. The student places the client in a supine position to read the manometer.
B. The student places the zero reading of the manometer at the phlebostatic axis.
C. The student instructs the client to perform the Valsalva maneuver during the CVP reading.
D. The student records the CVP reading as the level noted at the top of the meniscus

404. The nurse working with another nurse and a patient care assistant. Which of the following clients should be assigned to the registered nurse?
A. A client two days post-appendectomy
B. A client one week post-thyroidectomy
C. A client three days post-splenectomy
D. A client two days post-thoracotomy

405. The physician has ordered Prostin E2 (dinoprostone) gel to induce labor. After inserting the gel, which action should the nurse take?
A. Raise the head of the bed
B. Apply nasal oxygen at 2L/min
C. Help the client to the bathroom
D. Elevate the client’s hips for 30 minutes

406. The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client:
A. To restrict her fat intake for one week before the test
B. To omit creams, powders, or deodorants before the exam
C. That mammography replaces the need for self-breast exams
D. That mammography requires a higher dose of radiation than x-rays

407. Which action by the novice nurse indicates a need for further teaching?
A. The nurse fails to wear gloves consistently when removing a dressing.
B. The nurse applies an oxygen saturation monitor to the ear lobe.
C. The nurse elevates the head of the bed to check the blood pressure.
D. The nurse places the arm in a dependent position to perform a fingerstick.

408. The physician has ordered the Schilling test for a patient with suspected pernicious anemia. What other vitamin level is often assessed at the same time as the B12 level?
A. Folic acid
B. Pyridoxine
C. Ascorbic acid
D. Thiamine

409. The nurse is assigned to care for a newborn with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin?
A. Offering the newborn water between formula feedings
B. Maintaining the newborn’s temperature at 98.6ºF
C. Minimizing tactile stimulation
D. Decreasing caloric intake

410. A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
A. A client with AIDS being treated with Foscavir (foscarnet)
B. A client with a fractured femur in a long leg cast
C. A client with a recent laryngectomy for laryngeal cancer
D. A client with diabetic ulcers to the left foot

411. The charge nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should:
A. Change the nursing assistant’s assignment
B. Explore the interaction with the nursing assistant
C. Discuss the matter with the client’s family
D. Initiate a group session with the nursing assistant

412. The nurse discovers a patient care assistant looking through the client’s belongings while the client is out of the room. Which action should be taken by the nurse?
A. Discuss the nursing assistant’s behavior with the family.
B. Report the incident to the charge nurse.
C. Monitor the situation and note whether any items are missing.
D. Ignore the situation until items are reported missing

413. Which client is best assigned to a newly licensed nurse?
A. A client receiving chemotherapy
B. A clientpostcoronary artery bypass graft
C. A client with a transurethral prostatectomy
D. A client with diverticulosis

414. A patient with acute lymphocytic leukemia is receiving intrathecal chemotherapy. Intrathecal chemotherapy is used to:
A. Increase the number circulating neutrophils
B. Prevent systemic effects common to most chemotherapeutic agents
C. Increase the number of mature white blood cells
D. Destroy leukemic cells hiding in the cerebrospinal fluid

415. The client is admitted after an abdominal cholecystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
A. The client is at risk for evisceration.
B. The client will require frequent dressing changes.
C. The straps provide support for drains that are inserted into the incision.
D. No sutures or clips are used to secure the incision.

416. Which order would the nurse anticipate for a client hospitalized with acute pancreatitis?
A. Vital signs once per shift
B. Insertion of a nasogastric tube
C. Patient controlled analgesia with Demerol (meperidine)
D. Low-fat diet as tolerated

417. The nurse is caring for a client with a diagnosis of cirrhosis who is experiencing pruritis. Which of the following is an appropriate nursing intervention?
A. Suggesting that the client take warm showers twice daily
B. Applying a lotion containing menthol or camphor to the skin after bathing
C. Applying powder to the client’s skin
D. Placing warm compresses on the affected areas

418. Which of the following would be most appropriate for the nurse to wear when providing direct care to a client with influenza?
A. Mask
B. Gown
C. Gloves
D. Goggles

419. A client is brought to the mental health clinic by her sister after the death of their father. Which statement made by the client’s sister suggests the client may have abnormal grieving?
A. “My sister still has episodes of crying, and it’s been three months since Daddy died.”
B. “My sister seems to have forgotten a lot of the bad things that Daddy did in his lifetime.”
C. “My sister has really had a hard time after Daddy’s funeral.”
D. “My sister doesn’t seem sad at all and acts like nothing has happened.”

420. The nurse is obtaining a history on an 80-year-old client. Which statement made by the client might indicate a potential for fluid and electrolyte imbalance?
A. “My skin is always so dry, especially in the winter.”
B. “I have to use laxatives two or three times a week.”
C. “I drink three or four glasses of ice tea during the day.”
D. “I sometimes have a problem with dribbling urine.”

421. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 mEq/L. What behavior changes would be most common for this client?
A. Anger
B. Mania
C. Depression
D. Psychosis

422. The nurse is assessing a client with symptoms of hyperphosphatemia. Which of the following is most likely related to the client’s symptoms?
A. Radiation to the neck
B. Recent orthopedic surgery
C. Minimal physical activity
D. Adherence to a vegan diet

423. The nurse is assessing the chart of a client scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
A. Call the physician and ask him or her to clarify the information with the client.
B. Explain the procedure and complications to the client.
C. Check in the physician’s progress notes to see if client understanding has been documented.
D. Talk with the client’s family to determine if they understand the procedure fully.

424. The nurse is preparing a client for surgery who requests to “go as he is.” Which item is most important for the nurse to remove before sending the client to surgery?
A. Hearing aid
B. Contact lenses
C. Wedding ring
D. Dentures

425. A client is two days post-operative bowel resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is appropriate?
A. Reinserting the protruding bowel and covering the site with sterile 4×4s
B. Covering the site with a sterile abdominal dressing
C. Covering the site with a sterile saline-soaked dressing
D. Applying an abdominal binder and manual pressure to the site

426. A client with cervical cancer is staged as Tis. A staging of Tis indicates that:
A. The cancer stage cannot be assessed.
B. The cancer is localized to the primary site.
C. The cancer shows increasing lymph node involvement.
D. The cancer is accompanied by distant metastasis.

427. A client with suspected renal cancer is to be scheduled for an intravenous pyelogram. Before the IVP, the nurse should:
A. Offer additional fluids
B. Ask the client to empty his bladder
C. Withhold the client’s medication for 8 hours before the IVP
D. Administer pain medication

428. A 25-year-old client arrives in the emergency room with a possible fracture of the right femur. The nurse should anticipate an order for:
A. Bryant’s traction
B. Ice to the entire extremity
C. Buck’s traction
D. An abduction pillow

429. The nurse is performing an assessment on a client with possible pernicious anemia. Which finding is specific to pernicious anemia?
A. A weight loss of 10 pounds in six months
B. Fatigue
C. Glossitis
D. Pallor

430. Which statement should be included in the teaching session of a client scheduled for a renal biopsy?
A. “You will be placed in a sitting position for the biopsy.”
B. “You may experience a feeling of pressure or discomfort during aspiration of the biopsy.”
C. “You will be asleep during the procedure.”
D. “You will not be able to drink fluids for 24 hours following the study.”

431. The nurse is caring for a client scheduled for repair of an abdominal aortic aneurysm. Which pre-op assessment is most important?
A. Level of anxiety
B. Exercise tolerance
C. Quality of peripheral pulses
D. Bowel sounds

432. The dysrhythmia most commonly seen during tracheal suctioning is:
A. Bradycardia
B. Tachycardia
C. Premature ventricular beats
D. Heart block

433. The nurse is performing discharge teaching for a client with an implanted defibrillator. What discharge instruction is essential?
A. “You cannot prepare food in a microwave.”
B. “You should avoid shoulder movement on the side of the defibrillator for six weeks.”
C. “You should use your cell phone on your right side.”
D. “You won’t be able to fly on a commercial airliner with an implanted defibrillator.”

434. Six hours after birth, the newborn is found to have swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
A. Cephalohematoma
B. Molding
C. Subdural hematoma
D. Caput succedaneum

435. A left-lower lobectomy is performed on a client with lung cancer. The nurse should expect postoperative care to include:
A. A closed chest drainage system
B. Bed rest for 48 hours
C. Positioning supine or right-side lying
D. Chest physiotherapy

436. The nurse is caring for a client with laryngeal cancer. Which finding is not associated with laryngeal cancer?
A. Halitosis
B. Dysphagia
C. H. pylori infection
D. Chronic hiccups

437. A mother asks why her newborn has lost weight since his birth one week ago. The best explanation of weight loss in the newborn is:
A. The newborn is dehydrated.
B. The newborn is hypoglycemic.
C. The newborn is not used to the formula.
D. The newborn loses weigh because of the passage of meconium stools and loss of fluid.

438. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client’s diet?
A. Roasted chicken
B. Noodles
C. Cooked broccoli
D. Custard

439. The physician has ordered Betoptic (betaxolol) ophthalmic suspension for a patient with open angle glaucoma. Which statement is true regarding the medication?
A. Optic suspensions of Betoptic have no systemic side effects.
B. Betoptic is safe for use by patients who have a history of congestive heart failure.
C. Betoptic decreases the effects of insulin.
D. Betoptic may cause dizziness or vertigo.

440. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?
A. Bran flakes
B. Peaches
C. Cucumber and tomato salad
D. Whole wheat bread

441. An 18-month-old is admitted with symptoms of intussusception. Which information is helpful in establishing the diagnosis?
A. When he last ate
B. The characteristic of vomitus
C. A description of his stools
D. The number of times voided in the last eight hours

442. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value indicates an adverse effect of the medication?
A. Uric acid of 5mg/dL
B. Hematocrit of 33%
C. WBC 2000 per cubic millimeter
D. Platelets 150,000 per cubic millimeter

443. A client is admitted with a Ewing’s sarcoma. Which symptom would be expected due to this tumor’s location?
A. Hemiplegia
B. Aphasia
C. Loss of balance
D. Bone pain

444. The mother asks the nurse when the “soft spot” on the top of her baby’s head will close. The nurse should tell the mother that the anterior fontanel usually closes by:
A. Three months
B. Six months
C. Twelve months
D. Eighteen months

445. The nurse is making initial rounds on a client with a C5 fracture stabilized by Crutchfield tongs. Which equipment should be kept at the bedside?
A. Forceps
B. Torque wrench
C. Wire cutters
D. Screwdriver

446. A client with osteoporosis has a new prescription for alendronate (Fosamax). Which instruction should be given to the client?
A. Rest in bed after taking the medication for at least 30 minutes.
B. Avoid rapid movements after taking the medication.
C. Take the medication with water only.
D. Allow at least one hour between taking the medicine and taking other medications.

447. The nurse is working in the emergency room when a client arrives with severe burns of the face and neck. Which action should receive priority?
A. Starting an IV of Ringer’s lactate
B. Assessing the airway and applying oxygen
C. Obtaining blood gases
D. Administering pain medication

448. A client is scheduled for surgery in the morning. Which of the following is the primary preoperative responsibility of the nurse?
A. Making sure the vital signs are recorded
B. Obtaining a signed permit for surgery
C. Explaining the surgical procedure
D. Answering questions about the surgery

449. A client’s lab values reveal Hgb 12.6, WBC 6500cu.mm, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000cu.mm. The nurse evaluates that the client is experiencing which of the following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukopenia

450. Which of the following is the best indication of resolution of a paralytic ileus?
A. Passage of stool
B. Eructation
C. Presence of bowel sounds
D. Decreasing abdominal girth

451. Which finding is expected in a client with a ruptured spleen?
A. Kehr’s sign
B. Chvostek’s sign
C. Kernig’s sign
D. Trendelenburg’s sign

452. The nurse is caring for a client with chronic hepatitis. Which is the best method to use for determining the degree of early ascites?
A. Inspection of the abdomen for enlargement
B. Bimanual palpation for hepatomegaly
C. Daily measurement of abdominal girth
D. Assessment for peritoneal fluid wave

453. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client’s most appropriate priority nursing diagnosis?
A. Alteration in cerebral tissue perfusion
B. Fluid volume deficit
C. Ineffective airway clearance
D. Alteration in sensory perception

454. Which of the following assessment findings raises concern for a child with sickle cell anemia?
A. He enjoys playing baseball with the school team.
B. He drinks several carbonated drinks per day.
C. He requires eight to ten hours sleep a night.
D. He occasionally uses ibuprofen to control minor pain.

455. The nurse on an oncology unit is caring for a client with neutropenia. During evening visitation, a visitor brings a potted plant to the room. What action should the nurse take?
A. Allow the client to keep the plant.
B. Place the plant by the window.
C. Water the plant for the client.
D. Ask the family to take the plant home.

456. The nurse is caring for a postoperative patient when suddenly the patient becomes less responsive and pale, with a BP of 70/40. The nurse’s initial action should be to:
A. Increase the rate of IV fluids
B. Lower the head of the bed
C. Notify the physician
D. Obtain a crash cart

457. Which of the following newborns is at greatest risk for iron deficiency anemia?
A. A newborn who is fed infant formula
B. A newborn delivered at 32 weeks gestation
C. A newborn who is one of a set of quadruplets
D. A newborn who is breastfed

458. A client being treated with Coumadin (sodium warfarin) has an INR of 8.0. Which intervention is appropriate based on the INR level?
A. Assessing for signs of bleeding
B. Administering intranasal DDAVP
C. Administering an injection of protamine sulfate
D. Limiting the intake of foods rich in vitamin K

459. Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease?
A. A granola bar
B. A bran muffin
C. Yogurt
D. Raisins

460. A client with preeclampsia is admitted with an order for intravenous magnesium sulfate. Which statement is true regarding the administration of magnesium sulfate?
A. A 4 gram loading dose is administered over 20–30 minutes via infusion pump.
B. Side effects include feeling cold and tremulous.
C. IV infusion rate is adjusted to maintain urine output of 20 to 30 mL per hour.
D. The brachial reflex is checked prior to initiation of medication

461. The nurse is caring for a 12-year-old who requires a blood transfusion for life-threatening injuries sustained in an automobile accident. The child’s mother refuses to sign the blood permit based on her religious beliefs. What nursing action is appropriate?
A. Administer the blood transfusion without a signed permit.
B. Encourage the mother to reconsider her decision.
C. Explain the consequences if he does not receive a transfusion.
D. Notify the physician of the mother’s refusal to sign the permit.

462. A client is admitted with partial thickness burns to the neck, face, and anterior trunk. The nurse would be most concerned about the client developing which of the following?
A. Hypovolemia
B. Laryngeal edema
C. Hypernatremia
D. Oliguria

463. The nurse is evaluating nutritional outcomes for an adolescent with anorexia nervosa. Which observation best indicates that the plan of care is effective?
A. The client selects a balanced diet from the menu.
B. The client is less interested in intense exercise.
C. The client reads magazine articles on food preparation.
D. The client has gained four pounds in the last week.

464. A client is admitted following the repair of a fractured tibia with cast application. Which nursing assessment should be reported to the physician?
A. Pain beneath the cast
B. Warm toes
C. Pedal pulses weak and rapid
D. Paresthesia of the toes

465. The client is having a cardiac catheterization. During the procedure, the client tells the nurse, “I’m feeling really hot.” What is the correct explanation for the client’s statement?
A. He is having an allergic reaction to the contrast media.
B. A feeling of warmth is normal when the contrast media is injected.
C. “The feeling of warmth” indicates that the clots in the coronary vessels are dissolving.
D. He has increased anxiety due to the invasive procedure.

466. A school nurse is explaining the dangers of anabolic steroid use to a group of high school athletes. Which organ is adversely affected by the use of anabolic steroids?
A. Kidney
B. Stomach
C. Pancreas
D. Liver

467. A client is having electroconvulsive therapy for treatment of severe depression. Which of the findings is expected during electroconvulsive therapy?
A. Loss of consciousness
B. Nausea and vomiting
C. Bradycardia
D. Tonic clonic seizure

468. Which information should be given to the patient undergoing radiation therapy for breast cancer?
A. Avoid exposing radiation areas to sunlight during treatment time and for a year after completion of therapy
B. Moisturize the radiation site with oil-based lotion to prevent blistering
C. Use bath oil when tub bathing to prevent drying and peeling
D. Report redness and soreness of the area to the physician

469. The physician has prescribed Vermox (mebendazole) for a child with pinworms. Which statement is true regarding the medication?
A. Medication is administered intramuscularly.
B. The entire family will need to take the medication.
C. Medication will be repeated in two months.
D. Intravenous antibiotic therapy will be ordered.

470. The registered nurse on a pediatric unit is making assignments for the day. Which patient should not be assigned to the nurse who is pregnant?
A. A child with cystic fibrosis who is receiving Nebcin (tobramycin)
B. An infant with respiratory syncytial virus receiving Virazole (ribavirin)
C. A child with Hirschsprung’s disease scheduled for barium enema
D. A child with Meckel’s diverticulum scheduled for radiographic scintigraphy

471. A patient of Greek descent has been prescribed Bactrim (sulfamethoxazole-trimethoprim) for treatment of a urinary tract infection. Before beginning the medication, the patient should be assessed for which of the following disorders?
A. G6PD deficiency
B. ß-thalassemia
C. Sickle cell anemia
D. Von Willebrand disease

472. The nurse is caring for an obstetrical patient admitted with HELLP syndrome. The nurse anticipates an order for which medication?
A. Yutopar (ritodrine)
B. Brethine (terbutaline)
C. Methergine (methylergonovine)
D. Pitocin (oxytocin)

473. Which assignment is not within the scope of practice of the registered nurse?
A. Performing a vaginal exam on a patient in labor
B. Removing a PICC line
C. Monitoring central venous pressure
D. Performing wound closure with sutures and clips

474. An obstetrical client arrives at the women’s hospital with abdominal cramping and gross bright red vaginal bleeding. Which action(s) should the nurse take?
A. Perform a vaginal exam
B. Check FHT and notify the physician
C. Request a stat hemoglobin and hematocrit
D. Perform Leopold’s maneuver to check for fetal position

475. The physician has ordered Brethine (terbutaline) for a patient with premature labor. The nurse is aware that the medication may cause:
A. Bradycardia
B. Hyperglycemia
C. Decreased muscle tone
D. Hot flashes

476. Which medication is used to treat iron toxicity?
A. Narcan (naloxone)
B. Digibind (digoxin immune Fab)
C. Desferal (deferoxamine)
D. Zinecard (dexrazoxane)

477. The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with:
A. Fraud
B. Malpractice
C. Negligence
D. Tort

478. The home health nurse is planning for the day’s visits. Which client should be seen first?
A. The client with renal insufficiency
B. The client with Alzheimer’s disease
C. The client with diabetes who has a decubitus ulcer
D. The client with multiple sclerosis who is being treated with IV cortisone

479. Which clients can be assigned to share a room in the emergency department during a disaster?
A. A client with schizophrenia having visual and auditory hallucinations and the client with ulcerative colitis
B. The client who is six months pregnant with abdominal pain and the client with facial lacerations and fractured arm
C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury
D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain

480. Before administering eye drops, the nurse should recognize that it is essential to consider which of the following?
A. The eye should be cleansed with warm water to remove any exudate before instilling the eye drops.
B. The patient will be more comfortable if allowed to instill his own eye drops.
C. Eye drops should be instilled with the patient looking down.
D. Eye drops should always be warmed before instilling in the patient’s eyes.

481. To decrease the risk of urinary tract infections, a female client should be taught to:
A. Drink citrus fruit juices
B. Avoid using tampons
C. Increase the intake of red meats
D. Clean the perineum from front to back

482. Which nursing intervention would you expect when working with a hospitalized toddler?
A. Ask the parent to leave the room when assessments are being performed
B. Explain that items from home should not be brought into the hospital
C. Tell the parents that they may stay with the toddler
D. Ask the toddler if he is ready to have his temperature checked

483. Which instruction should be given to a client who is fitted with a behind-the-ear hearing aid?
A. Remove the ear mold and clean with alcohol
B. Avoid exposing the hearing aid to extremes in temperature
C. Use a cotton-tipped applicator to clean debris from the hole in the middle of the hearing aid
D. Continue to use cosmetics and spray cologne as before

484. Which statement is true regarding the measurement of fetal heart tones?
A. The normal range for FHT is 100–180 beats per minute.
B. A Doppler ultrasound can detect FHT at 18 to 20 weeks gestation.
C. FHT can be detected at eight weeks gestation using vaginal ultrasound.
D. A TOCO monitor is an invasive means of measuring FHT.

485. The physician ordered Zyprexa (olanzapine) for a patient with schizophrenia. Before administering the medication, the nurse should:
A. Ask the patient to void and measure the amount
B. Check the apical pulse rate
C. Check the temperature
D. Offer additional fluids

486. The nurse is caring for a child with suspected epiglottitis. Which finding is not associated with epiglottitis?
A. Drooling
B. Brassy cough
C. Muffled phonation
D. Inspiratory stridor

487. Which of the following is an ocular change that may be found in the patient with hyperthyroidism?
A. Ptosis
B. Open angle glaucoma
C. Exophthalmos
D. Presbyopia

488. The nurse is providing dietary instructions to the mother of a fouryear-old diagnosed with celiac disease. Which food, if selected by the mother, would indicate her understanding of the dietary instructions?
A. Wheat toast
B. Spaghetti
C. Oatmeal
D. Rice

489. Which infant is exempt from the recommendations of the American Academy of Pediatrics “Back to Sleep” campaign against SIDS?
A. An infant with intussusception
B. An infant with pyloric stenosis
C. An infant with gastroesophageal reflux
D. An infant with a cleft palate

490. A gravida 2 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after an amniotomy?
A. Fetal heart tones of 160 beats per minute
B. A moderate amount of straw-colored clear vaginal fluid
C. A small amount of greenish vaginal fluid
D. A small segment of the umbilical cord protruding from the vagina

491. The vaginal exam of a laboring patient reveals that she is 3 cm dilated. Which of the following statements would the nurse expect the patient to make?
A. “I can’t decide what to name the baby.”
B. “It feels good to push with each contraction.”
C. “Don’t touch me. I’m trying to concentrate.”
D. “When can I get my epidural?”

492. The laboring client is having fetal heart rates of 100–110 beats per minute during contractions. The first action/actions the nurse should take is to:
A. Apply an internal fetal monitor
B. Turn the client on her left side and apply oxygen
C. Get the client up and walk her in the hall
D. Move the client to the delivery room

493. In evaluating the effectiveness of IV Pitocin (oxytocin) for a client with secondary dystocia, the nurse should expect:
A. A rapid delivery
B. Cervical effacement
C. Infrequent contractions
D. Progressive cervical dilation

494. Vaginal exam of a term gravida 2 para 1 reveals a breech presentation. The nurse should take which action at this time?
A. Prepare the client for a Caesarean section
B. Apply the fetal heart monitor
C. Place the client in the Trendelenburg position
D. Perform an ultrasound exam

495. The nurse is caring for a client admitted to labor and delivery. Which finding indicates fetal distress?
A. Contractions every three minutes
B. Absent variability
C. Fetal heart tone accelerations with movement
D. Fetal heart tone 120–130 beats per minute

496. The following are all nursing diagnoses appropriate for a gravida 4 para 3 in labor. Which one would be most appropriate for the client as she completes the latent phase of labor?
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

497. As the client reaches 8 cm dilation, the nurse notes a pattern on the fetal monitor that shows a drop in the fetal heart rate of 30 beats per minute beginning at the peak of the contraction and ending at the end of the contraction. The FHR baseline is 165–175 beats per minute with a variability of 0–2 beats per minute. What is the most likely explanation of this pattern?
A. The fetus is asleep.
B. The umbilical cord is compressed.
C. There is a vagal response.
D. There is uteroplacental insufficiency.

498. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
A. Notify the physician
B. Increase the rate of IV fluid
C. Reposition the client
D. Readjust the monitor

499. Which of the following is a characteristic of a reassuring fetal heart rate pattern?
A. A fetal heart rate of 180 beats per minute
B. A baseline variability of 35 beats per minute
C. A fetal heart rate of 90 at the baseline
D. Acceleration of FHR with fetal movements

500. The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is:
A. The bladder fills more rapidly because of the medication used for the epidural.
B. Her level of consciousness is altered.
C. The sensation of the bladder filling is diminished or lost.
D. To allow her to rest uninterrupted after delivery.