MCN QUIZZES

PRELIMS:

1. Assessment is very important to determine if the couple are at risk to have a child with genetic.
What are the things to be noted or recorded by the nurse during assessment? Select all that apply.
 Age of the mother (<35 years old)
 Age of the father (>55 years old)
 Relationship of the couple by blood
 Ethnic background
 Prenatal history

2. One of the genetic disorders has a code of 46XY23q. what is this disorder?
 Down syndrome
 Cri-du-chat syndrome
 Fragile x syndrome
 Klinefelter syndrome

3. Trisomy 13 is also known as Patau syndrome. What are the characteristics of this disorder? Select
all that apply.
 Cleft lip and palate
 Small jaw
 Small eyes
 Most do not survive beyond early childhood
 Long face

4. The following characteristics are TRUE about Turner’s syndrome, EXCEPT. Select all that apply.
 It has a code of 45X0
 Common among males
 Low set hairline
 Small testes
 Webbed neck

5. This is a diagnostic test that is being done between 14 th-16th week of pregnancy. This is called
 Amniocentesis

6. This refers to the study of surface markings on the skin

 Dermatoglyphics

7. This is a disorder in which the child exhibit a rag doll appearance, with brushfield spots, large
tongue and with small mouth cavity. This is
 Trisomy 18
 Trisomy 13
 Trisomy 21
 Trisomy 28

8. A diagnostic procedure wherein a sample of peripheral venous blood or a scraping of cells from the
buccal membrane is taken.
 Karyotyping

9. What do we need to remember about klineflter syndrome? Select all that apply.
 It has a code of 46XXY
 Common among females
 With an extra X chromosome
 Nonfunctional ovaries
 Small testes
10. What is the normal genome?
 46XXY/ 46XY

11. This refers to actual gene composition.

 Genotype

1. A rheumatic heart disease is a beta hemolytic streptococcal infection which particularly involves the
 Atrium
 Ventricles
 Aorta
 Valves

2. When assessing a pregnant woman’s risk for complications, which of the following would lead the
nurse to suspect that the woman is considered high risk? Select all that apply.
 BMI between 18.5 and 30
 History of intimate partner abuse
 Previous pregnancy with twins
 Two previous miscarriages
 30 years of age

3. Angelique Abaga is 22 years old who developed deep vein thrombosis during her stay in the
hospital. On bed rest and is prescribed low molecular weight heparin subcutaneous. What education
will she need in relation to this?
 Her infant will be born with scattered petechiae on his trunk.
 Heparin can cause darkened or non flexible skin in newborns.
 Heparin does not cross the placenta and she does not affect the fetus
 Some infants will be born with allergic symptoms to heparin

4. During an assessment of Angela Parong, a perinatal client with a history of left-sided heart failure.
Nurse Acosta notes that Angela Parong is experiencing unusual episodes of non-productive cough on
minimal exertion. Nurse Acosta interprets that this finding may be the first initial indicator of which
important cardiac problem?
 Orthopnea
 Pulmonary edema
 Right sided heart failure
 Decreased blood volume

5. As oxygen saturation of Lailanie decreases, chemoreceptors stimulate the respiratory center to

 Increase heart rate
 Increase respiratory rate
 Decrease respiratory rate
 Increase systemic blood pressure

6. When planning care for pregnant woman with heart disease, the nurse should do which of the
following?
 Plan an exercise schedule to prevent thrombus formation during labor.
 Assess complaints of fatigue and note as desired to promote maximum fetal and maternal
nutrition.
 Instruct the client to eat as much food as desire to promote maximum fetal and maternal
nutrition.
 Discourage the mother from taking any medications during pregnancy since it will affect the
baby.

7. Almost all women are screened for gestational diabetes by a 50 gram glucose challenge test. For
this test, you would instruct a woman that
 She will have to fast for 12 hours prior to the test.
 The test takes up to 12 hours prior to the test
 She will need to collect a 24 hour urine following test
 If serum glucose is above 140mg/dl, more testing will be required.

8. A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational
diabetes. Which statement if made by the client indicates for further education?
 I need to stay on the diabetic diet
 I will perform glucose monitoring at home
 I need to avoid exercise because negative effects on insulin production.
 I need to be aware of the infections.

9. Which statement is INCORRECT regarding the oral glucose challenge test on mothers being
screened for gestational diabetes?
 This is usually done during the 24th-28th week of pregnancy
 After 50g oral glucose is ingested, venous sample is taken for glucose determination after 60
minutes
 If the serum glucose at 1 hour is 140 mg/dl, the woman is scheduled are above 120 mg/dl, a 3
hour fasting glucose
 If two or more blood samples collected for fasting glucose are above 120 mg/dl, a diagnosis of
diabetes is made

10. Marie is suffering from cardiovascular disease and therefore needs a team approach during
pregnancy. She should visit her obstetrician before conception so her health care team can be familiar
with her health state and evaluate her heart function. A pregnant client with cardiac classification III is

 A woman who has moderate to marked limitation of physical activity her less than ordinary
activities are enough for her to experience excessive fatigue, palpitations and dyspnea.

11. Patricia’s cousin develops diabetes during pregnancy. What are the possible complications? Select
all that apply.
 Hydramnios
 LGA
 Hyperbilirubinemia
 Difficult labor
 Congenital anomalies

12. Absence of lower extremities for the baby as a result of having of having diabetic mother. This
refers to

 Caudal regression syndrome

13. It is the accumulation of fluid in the peritoneal area

 Ascites

14. The mother has history of seizure and she’s pregnant. The following are effects EXCEPT;

 Cerebral palsy

15. This is atest that is being done on the 4th - 6th week of pregnancy detecting hyperglycemia

 Glycosylated hemoglobin

16. What are the signs and symptoms of left sided heart disease EXCEPT. Select all that apply
 Peripheral edema
 Jugular distention

17. If polyuria Is for excessive urination, what about for excessive thirst?
 Polydipsia

18. Oral hypoglycemic drugs are recommended for pregnant clients with diabetes.
 FALSE

19. Babies with diabetic mothers are hypoglycemic while still inside the uteru and hyperglycemic after
birth
 FALSE

20. The normal fasting blood glucose

 95

21. At 16 weeks gestation, no fetal heart rate was detected during assessment of a pregnant patient.
An ultrasound confirmed a hydratidiform molar pregnancy. Which of the action should the nurse tell,
the patient expect during her one year follow-up?
 Multiple serum chorionic gonadotrophin levels will be drawn

22. In taking care of patients with placenta previa, the health personnel should do the following.
EXCEPT.
 Internal examination

23. While observing Cara’s signs and symptoms, the nurse understands that abruption placenta is

 Premature separation of a normally implanted placenta.

24. The following are signs and symptoms of placenta previa. Select all that apply.
 Bright red vaginal bleeding
 Soft, relaxed nontender uterus

25. A client who’s 3 months pregnant with her first child reports that she has had increasing morning
sickness for the past month. Nursing assessment reveals a fundal height of 20 cm and no audible fetal
heart tones. The nurse should suspect which complication of pregnancy.
 Gestational trophoblastic disease

26. A pregnant client is diagnosed with partial placental previa. In explaining the diagnosis, the nurse
tells the client that the usual treatment for placenta previa is which of the following?
 Activity limited to bed rest

27. A woman, who is 22 weeks pregnant, has a routine ultrasound performed. The ultrasound shows
that the placenta is located at the edge of the cervical opening. As the nurse you know that which
statement is FALSE about this finding>
 The patient will need to have a c-section and cannot deliver vaginally.

28. Your patient who is 34 weeks pregnant is diagnosed with total placenta previa. The patient is A
positive. What nursing interventions below will you include in the patients care? Select all that apply.
 Monitoring vital signs
 Placing patient on side lying position
 Monitoring pad count’
 Monitoring CBC and clotting levels

29. Select all the signs and symptoms associated with placenta previa.
 Painless bright red bleeding
 Normal fetal heart rate
 Abnormal fetal position
30. A patient who is 25 weeks pregnant has a partial placenta previa. As the nurse, you’re educating
the patient about the condition and self care. Which statement by the patient requires you to re-
educate the patient?
 “I may start to experience dark red bleeding with pain.”

31. After an Rh (-) mother has delivered her Rh (+) baby, the mother is given Rhogam. This is done in
order to

 Prevent the mother from producing antibodies against the Rh (+) antigen that she may have
gotten when she delivered to her Rh (+) baby.

32. Because of a rapidly rising bilirubin level, exchange transfusion was performed on the newborn.
The nurse understands that the blood to be transfused to the newborn should be

 Type O, Rh negative

33. A nurse provides instructions to a malnourished client regarding iron supplementation during
pregnancy. Which statement when made by the client would indicate an understanding of the
instructions?

 The iron is best taken on full stomach.

34. Marina with sickle cell anemia has an increased risk for having a sickle cell crisis during pregnancy.
Aggressive management of a sickle cell crisis includes which of the following measures? Select all that
apply.

 Hospitalization
 Intravenous fluids
 Blood transfusion

35. Clients with megaloblastic anemia should be encouraged to do which of the following?

 Take the prescribed folic acid supplements

1. A 34-year-old female is currently 16 weeks pregnant. You’re collecting the patient’s health history.
She has the following health history: gravida 5, para 4, BMI 28, hypertension, depression, and family
history of type 2 diabetes. Select below all the risk factors in this scenario that increases the patient’s
risk for developing gestational diabetes.

 34 years old
 Gravida 5, para 4
 BMI 28
 Family history of type 2 diabetes

2. The best technique to determine if the client has ectopic pregnancy that is done initially is

 Ultrasound

3. There are three common classifications of anemia. What classification does not require the client to
have iron supplement?

 Sickle cell anemia

4. The student nurse was asked to enumerate the s/s of left sided heart failure. She’s correct if

 Pulmonary edema
 Weight gain
 Cough

5. This refers to the elevated amount of glucose

 Hyperglycemia

6. Rh (D) immune globulin is being given when? Select all that apply.
 28 weeks of gestation
 40 weeks gestation
 Within 72 hours after delivery

7. You’re providing an educational class for pregnant women about gestational diabetes. You discuss
the role of insulin in the body. Select all the correct statement about the role and function of insulin
 “insulin is a hormone secreted by the beta cells of the pancreas.”
 “insulin influences cells by causing them to uptake glucose from the blood.”

8. You’re teaching a pregnant mother with gestational diabetes about the signs and symptoms of
hyperglycemia. What are the signs and symptoms you will include in your education to the patient?
Select all that apply.

 Frequent hunger
 Polydipsia
 Frequent urination

9. When are most pregnant patients tested for gestational diabetes?

 24-28 weeks gestation

10. A 36 year old woman, who is 38 weeks pregnant, reports having dark red bleeding. The patient
experienced abruptio placentae with her last pregnancy at 29 weeks. What other signs and symptoms
can present with abruptio placentae? Select all that apply.

 Hard abdomen
 Tender uterus
 Fetal distress

11. Select all the signs and symptoms associated with placenta previa

 Painless bright red bleeding

 Normal fetal heart rate
 Abnormal fetal position

12. A patient who is 25 weeks pregnant has partial placenta previa. As the nurse, you’re educating the
patient about the condition and self-care. Which statement by

 “i may start to experience dark red bleeding with pain.”

13. The 36th week pregnant client went to the hospital for prenatal check-up. She was diagnosed
before to have placenta previa. Which of the following interventions should not be observed during
the check-up of the client?

 Monitor vital signs

 Checking cervical dilatation
 Monitoring the position of the baby via ultrasound
 Checking FHT via doppler

14. Which of the following statement is TRUE regarding abruptio placenta?

 It needs fibrinogen via IV

15. The student nurse is correct when she states that the type of bleeding for a client with placenta
previa is

 Bright red

16. What do you need to observe when the client has H-mole? Select all that apply.
 Persistent nausea and vomiting
 HCG level is between 1-2 million

17. Which statement is correct about gestational trophoblastic disease? Select all that apply.
 Mole is detected via ultrasound
 Risk for choriocarcinoma
 Risk to have preeclampsia

18. What are the signs and symptoms that may suggest ectopic pregnancy? Select all that apply.
 Shoulder pain
 Cervical motion tenderness
 Cullen’s sign

19. The drug of choice for unruptured ectopic pregnancy is

 Methotrexate

20. A client is said to be Rh sensitized if, select all that apply

 History of miscarriage
 Had ectopic pregnancy
 Had amniocentesis

MIDTERMS:

1. The cervical dilatation taken at 8:00 AM in a G1P0 patient was 6 cm. A repeat IE done at 10 AM
showed that cervical dilation was 7 cm. The correct interpretation of this result is

 Protracted active phase

2. A nurse monitoring the client who is in the active stage of labor. The client has been experiencing
contractions that are short, irregular and weak. The nurse documents that the client is experiencing
which type of labor dystocia?

 Hypotonic

3. After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not
strong enough to dilate the cervix. Which of the following would the nurse anticipate doing?

 Obtaining an order to begin IV oxytocin infusion

4. The client is in active labor. She is on oxytocin per IV infusion drip. Which of the following situations
would require that the infusion be stopped?

 Contractions occur at less than 2 minute intervals or at last for longer than 90 seconds.

5. When uterine rupture occurs, which of the following would be the priority?

 Limiting hypovolemic shock

6. Which of the following would be a sign that uterine rupture has occured?
 Sharp abdominal pain in between contractions

7. A woman develops a pathologic retraction ring during labor. On assessment, you would expect to
find its appearance as

 A line of indention over the lower abdomen

8. In terms of planning care, why is the development of a pathologic retraction ring important?

 It precedes surrounding rupture

9. If the labor period lasts only for 3 hours, the nurse should suspect that the following conditions may
occur. Select all that apply.

 Fetal anoxia
 Laceration of the cervix
 Laceration of perineum
 Cranial hematoma in the fetus

10. Which of the following best describes preterm labor?

 Labor that begins after 20 weeks gestation and before 37 weeks gestation

11. To prevent preterm labor from progressing, drugs are usually prescribed to halt labor. The drugs
commonly given are? Select all that apply.

 Magnesium sulfate
 Terbutaline

12. Mrs. Madrid has prolonged labor. What is the most common cause for arrest of descent during
the second stage of labor?

 Cephaloperlvic disproportion

13. A woman you care for during labor is having contractions 2 minutes apart but rarely over 50
mmHg in strength; the resting tone is high, 20-25 mmHg. She asks what she can do to make
contractions more effective. Your best response would be that

 She needs to rest because her contractions are hypertonic

14. A gravid 7, para 6 woman is in the hospital only 15 minutes when she begins to deliver
precipitously. The fetal head begins to deliver as you walk into the labor room. Your best action would
be to

 Place a gloved hand gently on the fetal head to guide delivery

15. The following are common causes of dysfunctional labor. Which of these can a nurse, on her
manage?

 Full bladder

16. The danger of a resting tone that is too high is that

 Lack of relaxation

17. Which of the following describes why hypertonic contractions tend to become very painful?
 The myometrium becomes sensitive from the lack of relaxation and anoxia of uterne cells

18. Formation of a pathologic contraction ring is a danger sign of labor. To assess for this, you would

 Palpate the lower segment of the uterus.

19. Which of the following indicates that Ritodrine is effective in a woman with preterm labor?

 Uterine contraction stops

20. Labor is said to be precipitous if select all that apply

 The total length of labor is under 3 hours

 Sudden cervical dilatation and effacement
 Sudden expulsion of the baby
 Sudden descent of the baby

1. If a fetus is determined to be in face presentation. What would be most important to observe in the
newborn after birth?

 Signs of dehydration

2. Shoulder dystocia is a birth problem that occurs when the fetal head is born but the shoulders are
to broad to enter and be born through the pelvic outlet. This happens during

 The second stage of labor

3. A student nurse is studying the different types of breech presentation. She came across an
illustration in which the hips of the fetus are flexed and the knees are flexed, the elbows are flexed,
the buttocks alone present to the cervix. She is correct if she identified this as

 Complete breech

4. Mc Robert’s maneuver may widen the pelvic outlet and help in letting the anterior shoulder be
delivered. This maneuver is described as

 Asking the woman to flex her thighs sharply on her abdomen

5. You assess that a fetus is in a breech presentation. Where would you auscultate for fetal heart
sounds?

 High in the abdomen

6. If the fetus is large, which means the baby is at risk for shoulder dystocia. Which finding in the
newborn would be most important to assess for the following shoulder dystocia in labor?

 Uncoordinated respirations

7. Situation: Mrs. Favour, gravida 2 para 0010, is admitted to the labor and delivery area. Initial
assessment reveals cervical dilatation of 4cm; cervical effacement, 100 % station 0, contractions
moderately intense and occurring every 5-6 minutes and lasting 45-60 seconds. Fetal heart tones are
loudest in the left upper quadrant. When performing Leopold’s maneuver, nurse Tina detects a hard,
round object at the level of the fundus. Assessment findings for Mrs. Favour indicate that the fetus

 Breech presentation
8. The arc of rotation of the fetal head in a posterior position is longer than in the anterior position.
The fetal head rotation against sacrum causes the intense pressure and pain in the lower back of the
woman. All of the following measures will alleviate the pain EXCEPT

 Maintaining a dorsal recumbent position

9. The nurse understands that the fetal head is in which of the following positions with a face
presentation?

 Completely extended

10. As a delivery room nurse, you would expect that the nurse will do which of the following
interventions to relieve the impacted fetal shoulders quickly?

 Suprapubic pressure

11. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate
would be most audible in which of the following areas?

 Above the maternal umbilicus and to the right of midline

12. Mc Robert’s maneuver may widen the pelvic outlet and help in letting the anterior shoulder be
delivered. This maneuver is described as

 Asking the woman to flex her thighs sharply on her abdomen

13. When the bag of water ruptures spontaneously, the nurse should inspect the vaginal for possible
cord prolapsed. If here is part of the cord that has prolapsed into the vaginal of the correct nursing
intervention is to

 Cover the prolapsed cord with strike gauze wet with sterile saline

14. Which of the following statements is true regarding asynclitism?

 Face and brow presentation are examples of this

15. If a fetus is in breech position, it can be turned to a cephalic position by external cephalic version
just before or during labor. An important assessment to make immediately following this would be

 Fetal heart rate

16. A laboring client has been dilated 9-10 cm for 2 hours. The fetal head ha remained at zero station
for 45 minutes despite adequate pushing efforts by the client. A sterile vaginal exam reveals a position
of occiput posterior. Which of the following actions by the nurse would be most appropriate?

 Assist the client to a hands and knees position

17. The client’s history reveals that a condition preventing the fetus to pass through maternal pelvis is
interpreted as

 Maternal disproportion

18. The student states the following for breech presentation. She needs further instruction if she
includes which of the following cause of breech presentation?

 Oligohydramnios allowing free fetal movement

19. Which of the following statements is true regarding asynclitism?

 Face and brow presentation are examples of this

20. The woman is in active labor. The presentation of the fetus left occiput posterior. Which of the
following measures should be included when caring for the client?

 Provide back massage

FINAL QUIZZES IN MCN LEC

QUIZ 1
1. A nurse in the nursery is caring for a neonate. On assessment the infant is exhibiting
grunting, tachypnea, nasal flaring and grunting. Respiratory distress syndrome is diagnosed
and the physician prescribes surfactant replacement therapy. The nurse would prepare to
administer this therapy by
- Instillation of the preparation into the lungs through an endotracheal tube.
2. Which of the following is the most important concept associated with the high-risk new-
born?
- Support the high risk newborn’s cardiopulmonary adaptation by maintaining adequate
airway.
3. A nurse is assessing a new-born who was born at 32 weeks gestation. Which of the
following would the nurse most likely find? Select all that apply
- Ruddy skin
- Abundant Lanugo
- Copious vernix caseosa
4. Small for gestational age newborns are at risk for difficulty of maintaining body
temperature due to
- They do not have as much fat stores as do other infants.
5. Hypothermia is common in newborn because of their inability to control heat. The
following would be an appropriate nursing intervention to prevent heat loss EXCEPT
- Place the crib beside the wall
6. Andrea has no spontaneous respirations at birth. Suppose her amniotic fluid is heavily
stained with meconium. Which would be your best action?
- Keep her warm until a laryngoscope can be passed.
7. Heat regulation is the most critical factor for a newborn's survival next to establishing
respiration. Which of the following characteristics of newborns predispose them to poor
heat regulation?
- Newborns cannot shiver yet.
8. Which of the following nursing diagnoses would be given priority in then care of a newborn
one hour of age?
- Ineffective thermoregulation
9. The reason nurse May keeps the neonate in a neutral thermal environment is that when a
newborn becomes too cool, the neonate requires
- More oxygen, and the newborn’s metabolic rate increases.
10. Heat regulation is the most critical factor for a newborn's survival next to establishing
respiration. Which of the following characteristics of newborns predispose them to poor
heat regulation?
- Newborns cannot shiver yet
11. An insulin dependent diabetic delivered a 10-pound male. When the baby is brought to the
nursery, the priority care is to
- Check the baby’s serum glucose level and administer glucose if <40mg/dl
12. Therese has just given birth at 42 weeks gestation. When the nurse assesses the neonate,
which physical finding is expected
- Desquamation of the epidermis
13. The physical finding you would expected to be seen in ljezie because of prematurity is
- Lack of sole creases on her feet.
 14. After therapeutic interventions, a newborn demonstrates adequate lung expansion. The
amount of pressure that would enable her to continue to reinflate the alveoli of her lungs
would be.
- 15-20 cm H2o
15. Which of the following manifestations in a six-month-old infant who was born prematurely
would lead a nurse to suspect that the infant has apnea?
- Episodes of breath-holding during periods of stress.

Quiz 2 finals

1. Baby Nicks has surfactant administered at birth. The purpose of surfactant is to

- Prevent alveoli from collapsing on expiration
2. When developing the initial plan of care for a neonate who was born at 41 weeks '
gestation was diagnosed with meconium aspiration syndrome (MAS), and requires
mechanical ventilation, which of the following should the nurse include
- Care of an umbilical arterial line
3. Which of the following are typical signs and symptoms of pneumonia? Select - all - that
-appl
- Coarse crackles
- Oxygen saturation 90%
- Elevated WBC
- Tachypnea
4. A nurse in the nursery caring for a neonate. On assessment the infant is exhibiting
grunting, tachypnea, nasal flaring and grunting Respiratory distress syndrome is diagnosed
and the physician prescribes surfactant replacement therapy. The nurse would prepare to
administer this therapy by
- Installation of the preparation into the lungs through an endotracheal tube
5. The GI system plays a major role in maintaining fluid, electrolyte, and acid - base balance.
The GI system often is involved with two severe acid base imbalances which is
- Metabolic acidosis and metabolic alkalosis
6. A two -month - old is showing signs and symptoms of heart failure. An echocardiogram is
ordered. The test shows the infant has a ventricular septal defect (VSD). Which statement
below best describes the blood flow in the heart due to this congenital heart defect?
- The blood in the heart is shunting from the left ventricle to the right ventricle, which is
increasing pulmonary blood flow.
7. While assessing a newborn's heart sounds you note a loud murmur at the left upper sternal
border. You report this to the physician who suspects the infant may have patent ductus
arteriosus. The physician asks you to obtain a pulse pressure. If patent ductus arteriosus is
present the pulse pressure would be
- wide
8. Atrial septal defects can lead to a decrease in lung blood flow.
- False (increase)
9. In Hypertonic Dehydration water is lost in a greater proportion than electrolytes and it
occurs when fluid intake decreases in conjunction with a fluid loss increase. It occurs in a
child with Select that apply
- Nausea (preventing fluid intake)
- Fever (increase fluid loss through perspiration)
- Profuse diarrhea- where there is a greater loss of fluid than salt
- Renal disease- associated with polyuria such as nephrosis with diuresis.
10. An echocardiogram shows that your patient has an atrial septal defect located at the
bottom of the septum near the tricuspid and mitral valves. As, the nurse you know this is
what type of atrial septal defect (ASD)?
- Ostium primum
11. Interpret the ABG's. pH=7.36; PaCO2=55; HCO3; =28
- Respiratory acidosis fully compensated
12. Overhydration is serious as dehydration because the ECF overload can lead to
cardiovascular overload and cardiac failure. All of the following are true about
overhydration except
- The excess fluid in these instances is usually intravascular and interstitial
13. All of the following are included in the Assessment in Metabolic alkalosis. Select all the
apply.
- The child will breathe slowly and shallowly
14. The level of bicarbonate (HCO3) in arterial blood is normally
- 22-26 mEq/L
15. MAS can be prevented by
- Tracheal suctioning once baby is delivered.
16. The family is caring for their youngest child Justin who is suffering from Tetralogy of fallot.
Which of the following are defects associated with this congenital heart condition?
- Ventricular septal defect, overriding aorta, pulmonic stenosis and right ventricular
hypertrophy.
17. Hypotonic Dehydration occurs when there is a disproportionately high loss of electrolytes
relative to fluid lost. The plasma concentration of sodium and chloride will be low. This
could result from all of the following except?
- Excessive intake of salt associated with great gain through intake
18. When diarrhea occurs, or when a child becomes diaphoretic because of fever, the fluid
output can be markedly decreased
- False (increase)
19. Select all the correct options that represent the pathophysiology of an asthma attack
- The mucosa lining experiences severe inflammation
- The goblet cells within the mucosa lining produce excessive amounts of mucous.
20. Metabolic acidosis may result from diarrhea When diarrhea occurs, a great deal of sodium
is lost with stool. This excessive loss of Na, in turn, causes the body to conserve Hions in an
attempt to keep the total number of positive and negative ions in serum balanced. As a
result, all of the following will occur except
- Arterial blood gas analysis will reveal a increased pH
21. Isotonic Dehydration is when a child's body loses more water than it absorbs (as with
diarrhea) or absorbs less fluid than it excretes (as with nausea and vomiting). As a result,
all of the following will occur. Select all that apply
- There will be a decrease in the volume of blood plasma
- The body compensates for this rapidly by shifting interstitial fluid into the blood vessels
22. You're caring for a 2-year-old patient who has a large atrial septal defect that needs repair.
This defect is causing complications. These complications are arising from an abnormal
shunting of blood throughout the heart. As the nurse, you know that a shunt is occurring in
the heart due to the defect.
- Left-right
23. Fluid shifts from the blood stream to interstitial and intracellular spaces (from areas of
great osmotic pressure to areas of lesser pressure).
- False (lesser to great)
24. You're working on a unit that provides specialized cardiac care to the pediatric population.
Which patient below would be the best candidate for Indomethacin from the treatment of
patent ductus arteriosus?
- A premature infant
25. What is the interpretation of the ABG if the pH = 7.60; PaCO2=33^ prime HCO3=16?
- Metabolic alkalosis, partially compensated
26. A nurse in the nursery is monitoring a preterm infant for respiratory distress syndrome.
Which assessment signs if noted in the newborn would alert the nurse to the possibility of
this syndrome
- Tachypnea and retractions
27. You're caring for a 2-day- old infant with a large patent ductus arteriosus. The mother of
the infant is anxious and asks you to explain her child's condition to her again. Which
statement below BEST describes this condition?
 - The vessel connecting the aorta and pulmonary artery has failed to close at birth, which
is leading to a left to right shunt of blood.

Quiz 3 finals
1. The nurse is caring for an infant following a cleft lip repair. What are the post-operative
Intervention to be observe Select all that apply.
- Maintain patent airway
- Cleanse the suture line
- Prevent the child from crying
- Place the infant in supine position
2. A nurse visits a child with Mono and provides care instructions to the parents Which
Instruction should the nurse give the parents?
- Notify HCP if child develops abdominal pain left shoulder pain.
3. While assessing a newborn with cleft lip, the nurse would be alert that which of the
following will most likely be compromised?
- Sucking ability
4. The nurse is reviewing the laboratory report of a client who underwent a bone marrow
biopsy. The finding that would most strongly support a diagnosis of acute leukemia is the
existence of a large number of immature
- leukocytes
5. For a child with infectious mononucleosis, why must abdominal palpation be performed
gently?
- The enlarged spleen can rupture
6. A child is diagnosed with Wilm's tumor. In planning teaching interventions, what key
points should the nurse emphasize for the parents
- Do not put pressure on the abdomen.
7. A 5-year-old is admitted to the hospital with complaints of leg pain and fever. On physical
examination, the child is pale and has bruising over various areas of the body. The
physician suspects that the child has ALL The informs the parent that the diagnosis will be
confirmed by which of the following?
- Bone marrow aspirate
8. Which of the following interventions should NOT be included in the care plan for a three
month old Infant who has just undergone cleft palate repair?
- Place the infant in supine position
9. A child is diagnosed with intussusceptions. The nurse performs an assessment on a child
knowing that which of the following is a characteristic of this disorder?
- Invagination of a section of the intestine into the distal bowel.
10. A parent tells a nurse "My three month old infant has passed several stools that resembled
clumpy red jelly ". The nurse should suspect that the infant has developed
- intussuspection
11. Willy is being assessed by Nurse Detdet for possible intussusception; which of the
following would be least likely to provide valuable information?
- Family history
12. The following are signs and symptoms of intussusceptions EXCEPT
- Slow rr
Dapat na answer ay: distended abdomen, dance’s sign, hematochezia (s&s of intussusceptions)
13. Parents are often unaware that their child is developing leukemia. What are the first signs
commonly seen a child with acute lymphocytic leukemia (ALL)?
- Fatigue and bruising
14. David age 15 months is recovering from surgery to remove Wilm's tumor. Which findings
best indicates that the child is free from pain?
- Increased interest in play
15. A child with leukemia is being discharged after beginning chemotherapy. What instructions
will the nurse include in the teaching plan for the parents of this child?
- Avoid fresh vegetables that are not cooked.
 16. When assessing a child with Wilm's tumor, the nurse should keep in mind that it is most
Important to avoid which of the following?
- Palpating the child’s abdomen
17. A nurse preparing to care for a child with a diagnosis of intussusceptions. The nurse
reviews the child's record and expects to note which symptom of this disorder
documented?
- Bright red blood and mucus in the stools
18. Baby RR is a 4 month old infant with a tentative diagnosis of intussusceptions. Which
procedure will likely be ordered for the infant?
- Barium enema
19. A child is diagnosed with Wilm's tumor. During assessment, the nurse in charge expects to
find
- An abdominal mass.
20. Which of the following is a priority nursing intervention for the infant with cleft lip?
- Monitoring for adequate nutritional intake
21. A nurse caring for a patient with acute lymphoblastic leukemia (ALL). Which of the
following is the most likely age range of the patient?
- 3-10 years old
22. Julius is scheduled for surgical repair of his cleft palate. A priority in the post -op plan of
care for Julius would include teaching the mother
- To use cup or wide bowl spoon for feeding
23. The mode of trandmission of infectious mononucleosis is select all that apply
- Kissing
- Sexual intercourse
- Saliva
- Direct contact (not sure)
24. Situation: Cathy, 3 months old had cleftlip on the left side of the mouth. She is scheduled
for surgical correction of the defect. All of the following nursing interventions are included
in the care plan for Cathy who has just undergone cleft lip repair. Which of the following
actions by the mother should NOT be allowed by the nurse?
- Position the infant in prone position.

MIDTERM EXAM
1. A nurse in labor room is monitoring a client with dysfunctional labor for signs of fetal or
maternal compromise. Which of the following assessment findings would alert the nurse to
a compromise?
- Persistent nonreassuring fetal heart tone.
2. The cervical dilatation taken at 8:00 AM in a G1P0 patient was 6cm. A repeat IE done at 10
AM showed that cervical dilation was 7 cm. The correct interpretation of this result is?
- The active phase stage is protracted.
3. A nurse is monitoring the client who is in the active stage of labor. The client has been
experiencing contractions that are short, irregular and weak. The nurse documents that
the client is experiencing which type of labor dystocia?
- Hypotonic
4. A multigravida at 38 weeks ' gestation is admitted with painless, bright red bleeding and
mild contractions every 7 to 10 minutes. Which of the following assessments should be
avoided?
- Cervical dilation
5. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the physician's order and would expect to note which
of the following prescribed treatments for this condition?
- Oxytocin infusion
6. After 4 hours of active labor, the nurse notes that the contractions point of a primigravida
client are not strong enough to dilate the cervix. Which of the following would the nurse
anticipate doing?
- Obtaining an order to begin IV Pitocin infusion.
7. Nurse Igube is aware that one of the following is the most serious adverse effect
associated with oxytocin (Pitocin) administration during labor.
- Water intoxication.
8. Mrs. Maine Corpuz is in active labor. She is on oxytocin per IV infusion drip. Which of the
following situations would require that the infusion be stopped?
- Contractions occur at less than 2 minutes interval or last longer than 90 seconds.
9. If contractions are hypertonic, the resting tone will be above average. A usual resting tone
is
- 15 mmhg
10. Nurse Soria is in labor room preparing to care for a client with hypertonic uterine
dysfunction. Nurse Soria told that the client that she's experiencing uncoordinated
contractions that are erratic in their frequency, duration and intensity. The priority nursing
intervention in caring for the client is to
- Provide pain relief measures.
11. Situation Mrs. Hernandez gravida 2 para 0010, is admitted to the labor and delivery area.
Initial assessment reveals cervical dilataion of 4 cm; cervical effacement, 100% station 0;
contractions, moderately intense and occurring every 5-6 minutes and lasting 45-60
seconds. Fetal heart tones are loudest in the left upper quadrant When performing
Leopold’s manoeuvre nurse Katerina detects a hard, round object at the level of the
fundus.

Assessment findings for Mrs. Fernandez indicate that the fetus is in a.

- Breech presentation
12. If a fetus is in a breech position, it can be turned to a cephalic position by external cephalic
version just before or during labor. An important assessment to make immediately
following this would be
- Fetal heart rate
13. You assess that a fetus is in a breech presentation Where wo you auscultate for fetal heart
sounds?
- High in the abdomen
14. Mr. Meyer, a student nurse is studying the different types of breech presentation, He came
across an illustration in which the hips of the fetus are flexed and the knees are flexed, the
elbows are flexed, the buttocks alone present to the cervix. He is correct if she identified
this as
- Footling breech
15. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal
heart rate would be most audible in which of the following areas?
- Above the maternal umbilicus and to the left midline.
16. Ms. Patacsil a student nurse states the following reasons for breech presentation. She is
CORRECT if she includes which of the following causes breech presentation? Select all that
apply.
- Multiple gestation
- Pendulous abdomen
- Any space occupying mass in the uterus.
17. Breech presentation is more hazardous to a fetus than a cephalic presentation because
there is a higher risk of the following complications. The student nurse needs further
instruction if she states which of the following as a complication.
- Brachial Fracture
18. The arc of rotation of the fetal head in a posterior position is longer than in the anterior
position. The fetal head rotation against the sacrum causes the intense pressure and pain
in the lower back of the woman. All of the following measures will alleviate the pain
EXCEPT
- Maintaining a dorsal recumbent position
19. If a fetus is determined to be in a face presentation, what would be most important to
observe for in the new born after birth?
- Signs of dehydration
20. The nurse understands that the fetal head is in which of the following positions with a chin
presentation?
- Completely extended
21. If the fetus is large which means the baby is at risk for shoulder dystocia. Which finding in
the new born would be most important to assess for following shoulder dystocia in labor?
- Uncoordinated breathing
22. The rarest presentation which occurs in multipara with a relaxed abdominal muscle is
- Brow presentation
23. Which of the following statements is true regarding asynclitism?
- face and brow presentation are examples of this
24. Shoulder dystocia is a birth problem that occurs when the fetal head is but the shoulders
are too broad to enter and be born through the pelvic outlet. This happens during
- Second stage of labor
25. A laboring client is admitted and assessment reveals that the fetus is in a footling breech
position. The nurse should be aware that EXCEPT
- The length of labor is shortened with the fetus in this position.
26. Mrs. Angela Parong, a laboring client has been dilated 9-10 cm for 2 hours. The fetal head
has remained at zero station for 45 minutes despite adequate pushing effects by the client.
A sterile vaginal exam reveals a position of occiput posterior. Which of the following
actions by the nurse would be most appropriate?
- Assist the client to a hands and knees position
27. The client's past history reveals that a condition preventing the fetus to pass through the
maternal pelvis is interpreted by the nurse as
- Cephalopelvic disproportion
28. a primigravida, the nurse would suspect cephalopelvic disproportion when
- the cervix remains unchanged for 3 hours with regular contractions and prior cervical
dilation.
29. A client has a midpelvic contracture from a previous pelvic injury due to motor vehicle
accident as a teenager. The nurse is aware that this could prevent a fetus from passing
through or around which structure during childbirth?
- Ischial spines
30. Mc Robert's maneuver may widen the pelvic outlet and help in letting the anterior
shoulder be delivered. This maneuver is described as
- Asking the woman to flex her thighs sharply on her abdomen.
31. A nurse has developed a plan of care for a client experiencing dystocia and includes several
nursing interventions in the plan of care. Which of the following interventions will be
included in the plan of care to a client experiencing dystocia? Select all that apply
- Monitor fetal heart rate
- Provide comfort measures
- Changing the client’s position frequently
- Keeping the significant others informed of the progress of labor
32. As a delivery room nurse, you would expect that the nurse midwife will do which of the
following interventions to relieve the impacted fetal shoulders (dystocia) quickly?
- Suprapubic pressure
33. The nurse establishes an IV. line, then connects Mrs. Hernandez to an electronic fetal
monitor. The fetal monitoring strip shows an FHR deceleration occurring about 30 seconds
after each contraction begins, the FHR returns to the baseline after the contraction is over.
This type of deceleration is caused by
- Uteroplacental insufficiency
34. if the has uteroplacental Insufficiency, the nurse's first action should be to
- position the client on her left side
35. Mr. Cawis is monitoring the fetal heart rate of a client who is in labor. He is correct if he
will report to his clinical instructor that fetal heart rate is said to be in distress if select all
that apply
- FHT is 160 bpm, weak and irregular
- FHT is less than 120 bpm or over 160 bpm
- FHT decreased during a contraction and persists even after the uterine contraction ends.
36. Situation: Mrs. Erin Magtanggol gravid 2 para 1001 comes to the labor and delivery area
and reports ruptured amniotic membranes and contractions that occur every 3 minutes
and last 50 to 60 seconds. The fetus is in left occiput anterior (LOA) position.
- Check the FHR
37. The woman is in active labor. The presentation of the fetus is left occiput posterior. Which
of the following measures should be included when caring for the client?
- Provide back massage
38. Late in the first stage of labor Mrs Estal receives a spinal block to relieve discomfort. A
short time later, her husband tells the nurse that his wife feels dizzy and is complaining of
numbness around her lips. What do the client's symptoms suggest?
- Anaesthesia overdose
39. Mrs. Ramos has prolonged labor. What is the most common cause for the arrest of descent
during the second stage of labor?
- Cephalopelvic disproportion
40. When giving narcotic analgesics to mother in labor, the special consideration to follow is
- Uterine contractions are strong and the baby will not be delivered yet within the next 3
hours.
41. A woman you care for during labor is having contractions 2 minutes apart but rarely over
5ommHg in strength; the resting tone is high, 20-25 mmHg. She asks what she can do to
make contractions more effective. Your best response would be that
- She needs to rest because her contractions are hypertonic
42. A gravid 7 para 6 woman is in the hospital only 15 minutes when she begins to deliver
precipitously. The fetal head begins to deliver as you walk into the labor room. Your best
action would be to
- place a glove hand gently on the fetal head to guide delivery.
43. When PROM occurs, which of the following provides evidence of the nurse's understanding
of the client's immediate needs?
- PROM removes the fetus most effective defense against infection
44. It is essential for a nurse to take which of the following actions immediately after artificial
rupture of membranes?
- Assess the fetal heart rate
45. When uterine rupture occurs, which of the following would be the priority?
- Limiting hypovolemic shock
46. A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse
would monitor the client closely for the risk of uterine rupture if which of the following
occurred?
- Forcep delivery
47. Which of the following would be a sign that uterine rupture has occurred?
- Sharp abdominal pain in between contractions
48. A nurse in labor room is performing a vaginal assessment on a pregnant client in labor. The
nurse notes the presence of umbilical cord protruding from the vagina. Which of the
following would be the initial nursing action?
- Place the client in Trendelenburg position
49. When the bag of waters ruptures spontaneously, the nurse should inspect the vaginal
introitus for possible cord prolapsed. If there is part of the cord that has prolapsed into the
vaginal opening, the correct nursing intervention is to
- Cover the prolapsed cord with sterile gauze wet in sterile NSS
50. A nurse is providing emergency measures to a client in labor who has been diagnosed with
a prolapsed cord. The mother becomes anxious and frightened and says to the nurse,
"Why are all of these people in here? Is my baby going to be alright? Which of the
following nursing diagnoses would be most appropriate for this client at this time?
- fear
51. Suppose a woman experiences a uterine inversion and the placenta is still attached. What
would be your best action?
- Increase the woman’s intravenous fluid to help restore blood loss.
52. Which of the following techniques during labor and delivery can lead to uterine inversion?
 - Strongly tugging on the umbilical cord to deliver the placenta and hasten placental
separation.
53. A woman develops a pathologic retraction ring during labor. On assessment, you would
expect to find its appearance as
- a line of indentation over the lower abdomen.
54. In terms of planning care, why is the development of a pathologic retraction ring
important?
- It precedes surrounding rupture
55. A nurse is monitoring a client who is experiencing a precipitous birth. The nurse is waiting
for the physician to arrive. When the infant's head crowns, the nurse would instruct the
client to
- breath rapidly (pant)
56. If the labor period lasts only for 3 hours, the nurse should suspect that the following
conditions may occur Select all that apply
- Fetal anoxia
- Laceration of the cervix
- Laceration of perineum
- Cranial hematoma in the fetus
57. After a precipitous delivery, a nurse notes that the new mother is passive and only touches
her new born infant briefly with her fingertips. The nurse would do which of the following
to help the woman process what has happened?
- Support the mother in her reaction the newborn infant
58. Which of the following best describes preterm labor?
- Labor that begins after 20 weeks gestation and before 37 weeks gestation.
59. To prevent preterm labor from progressing, drugs are usually prescribed to halt labor. The
drugs commonly given are. Select all that apply
- Magnesium sulfate
- Terbutaline
- ritodrine
60. A woman is one hour postpartum after vaginal delivery is experiencing heavy vaginal
bleeding. Which of the following actions would a nurse take first?
- Massage the uterine fundus
61. A nurse is monitoring a new mother in the postpartum period for signs of hemorrhage.
Which of the following signs, if noted in the mother, would be an early sign of excessive
blood loss?
- An increase in the PR from 88 bpm to 102 bpm
62. A nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm
but that bleeding is excessive. The initial nursing action would be which of the following?
- Notify the physician
63. Nurse Xianel assess a client for evidence of postpartum point hemorrhage during the third
stage of labor. Early signs of this postpartum complication include
- Increased pulse rate
- Increase respiratory rate
- Decrease BP
64. Upon assessment, the nurse got the following findings: 2 perineal pads highly saturated
with blood within 2 hours post-partum PR= 80 bpm. fundus soft and boundaries not well
defined. The appropriate nursing diagnosis is
- Hemorraghe secondary to uterine atony.
65. The nurse should anticipate that hemorrhage related to uterine atony may occur
postpartally if this condition was present during the delivery
- Excessive analgesia was given to the mother
66. A new mother received epidural anaesthesia during labor and had a forceps delivery after
pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20
points, her diastolic BP has dropped 10 points, and her pulse is 120bpm. The client is
anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying
the health care provider the nurse immediately plans to
- Prepare the client for surgery
67. After surgical evacuation and repair of a paravaginal hematoma, the mother is discharged
3 days postpartum. A nurse knows that the new mother needs further discharge
instructions when the new mother states
- “the only medications I will take are prenatal vitamins and stool softener
68. Cynthia has a perineal hematoma. A common cause of this is
- Bleeding from the placing of perineal episiotomy sutures
69. A nurse in a postpartum unit checks the temperature of a client who delivered a healthy
new born 4 hours ago. The mother's temperature is 100.8F. The nurse provides oral
hydration to the mother and encourages fluids. Four hours later the nurse rechecks the
temperature and notes that it is still the same. Which of the following is the most
appropriate intervention?
- Continue hydration and recheck the temperature after 4 hours.
70. Which temperature best signals postpartum infection?
- 101.2 F on the third postpartal day
71. A postpartum client has a nursing diagnosis of High Risk for infection. The goal formulated
is: " The client will not develop an infection during her hospital stay." Which of the
following assessment data would support the conclusion that the goal has been met?
- Absence of fever
72. Helen has a WBC of 25, mm3. For a postpartal woman, you would assess this as
- A normal count
73. A nurse is developing a plan of care for a post-partum client who was diagnosed with
superficial venous thrombosis. Which of the following interventions would be a
component of the plan of care?
- Elevation of the affected extremity
74. Situation: Aiko, a 37 years old multipara, is admitted with a tentative diagnosis of femoral
thrombophlebitis. The nurse assesses the patient with
- Leg pain
75. Which of the following best describes thrombophlebitis?
- Inflammation of the vascular endothelium with clot formation on the vessel wall.
76. While the postpartum client is receiving heparin for thrombophlebitis, which of the
following drugs would the nurse Mica expect to administer if the client develops
complications related to heparin therapy?
- Protamine sulfate
77. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours.
For which of the following would the nurse be alert?
- Endometritis
78. The physician confirms the diagnosis of femoral thrombophlebitis and orders 5,000 units
heparin subcutaneously every 12 hours. The physician has prescribed heparin for Mrs.
Cariaga to
- Prevent additional thrombus formation
79. Fe develops endometritis. What would be the best activity for her?
- Walking in her room listening to music
80. It is essential that a nurse take which of the following measures prior to discharging a
woman who is at risk for postpartum depression?
- Arrange a visit to the woman’s home within the next 48 hours
81. Which statement by Ms. Nabua is most suggestive of a woman developing postpartal
psychosis?
- My baby has the devil’s eyes.
82. The Manganti couple will undergo testing for subfertility. Subfertility is said to exist when
- a couple has been trying to conceive for 1 year
83. Cely and her husband have been trying for a year and a half to conceive a third child. What
is the average time span it takes a couple to conceive?
- Pregnancy usually occurs within 1 year of unprotected coitus.
84. Situation: Hero and Celine have been married for almost 18 months already. They came to
the clinic because they have been trying to get pregnant during the entire duration of their
marriage without success. When assessing the inadequacy of sperm for conception to
occur, which of the following is the most useful criterion?
 - Sperm count
85. Situation: Hero and Celine have been married for almost 18 months already. They came to
the clinic because they have been trying to get pregnant during the entire duration of their
marriage without success. Celine is instructed by the nurse to record signs and symptoms
of her ovulation. Which is NOT included?
- irritability
86. After thorough evaluation, the doctor confirmed that all findings are normal Celine asked
the nurse, "What does it mean to be diagnosed with primary infertility? " The nurse
appropriate reply is that
- The diagnosis means that she and her husband are normal but they just could not get
pregnant yet.
87. The physician schedules Celine for hysterosalpingogram (HSG). The nurse should explain to
her that this procedure will be performed
- 2-6 days after next menses
88. Hero asks you what is therapeutic insemination by donor entails. Which would be your
best answer?
- Donor sperm are introduced vaginally into the uterus or cervix.
89. Mr. Hero asks his nurse. "What can I do to make sure that the analysis of my semen sample
is as accurate as possible?" The nurse is incorrect if she includes which of the following as
health teaching.
- use lubricant when you collect the specimen.
90. Carol has been told she has blocked fallopian tubes. Which of the following options should
the nurse help her explore?
- In vitro fertilization
91. When discussing the benefits associated with childless living with a couple who is
subfertile, which of the following should the nurse include? Select all that apply
- Career growth,
- pursuit of hobbies,
- personal contributions to society,
- continuance of education
92. Which of the following would be most appropriate to include when teaching a man to
increase his sperm count?
- Wear clothing that does not restrict or over hear the scrotum
- Avoid frequent use of saunas
- Limit alcohol intake
- Increase frequency of coitus

93. The physician confirms the diagnosis of femoral thrombophlebitis and orders 5,000 units
heparin subcutaneously every 12 hours. The physician has prescribed heparin for Mrs.
Cariaga to
- Prevent additional thrombus formation
94. A nurse is caring for a client who has developed postpartum endometritis Based on the
nurse's knowledge of this condition, which symptoms would the nurse expect to see?
- Pelvic pain and fever
95. Suppose Marites has a retained placental fragment that is causing extensive postpartal
bleeding. What hormone test would you anticipate being ordered?
- Human chorionic gonadotropin hormone
96. A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which
of the following statements if made by the mother indicates a need for further education?
- “I need to stop breastfeeding until the condition resolves”
97. A nurse determines that a G3P3 client is beginning to go into shock and is hemorrhaging as
a result of a partial inversion of the uterus. The nurse pages the obstetrician STAT and calls
for assistance. The client asks in an apprehensive voice. "what is happening to me? I feel so
funny and I know I am bleeding. Am I dying? The nurse responds to the client, knowing
that the client is feeling
- Panic secondary to shock
98. The nurse is assessing a patient, who has many risk factors for the development of a DVT,
for signs and symptoms of a deep vein thrombosis. What signs and symptoms below would
possibly indicate a deep vein thrombosis is present? Select all that apply’
- Redness
- Pain
- Warm extremity
- Swelling
99. Which option below is considered a positive Homan's Sign for the assessment of a deep
vein thrombosis (DVT)?
- The patient reports pain when the foot is manually dorsiflexed.