I85PREP
⌘ K
Cambodia Nursing Exit Exam study materials
Cambodia Nursing Exit Exam study resources

Cambodia Nursing Exit Exam practice questions

One question at a time. Build your Cambodia Nursing Exit Exam understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Medical-Surgical Nursing

A patient with acute decompensated heart failure is receiving furosemide 80 mg IV. Which assessment finding best indicates that the medication is having the intended therapeutic effect?

  1. Urine output increases with reduced jugular venous distension Correct answer.
  2. Heart rate falls from 118 to 96 beats per minute
  3. Serum creatinine decreases from 180 to 150 µmol/L
  4. Serum potassium rises from 3.2 to 3.9 mmol/L

Explanation

Loop diuretics such as furosemide relieve congestion in decompensated heart failure by promoting natriuresis, so the expected therapeutic sign is a brisk diuresis with falling filling pressures, seen clinically as reduced jugular venous distension and less dyspnea. A rising potassium would suggest the opposite of loop-diuretic effect, and heart rate or creatinine changes are not the primary marker of decongestion.

Question 2Medical-Surgical Nursing

A patient three days after abdominal surgery reports sudden dyspnea and pleuritic chest pain. Oxygen saturation is 88% on room air, respiratory rate 32/min, and the right calf is swollen and tender. Which action should the nurse take first?

  1. Apply warm compresses to the right calf and reassess in one hour
  2. Administer prescribed oral analgesia and document the finding
  3. Apply supplemental oxygen and notify the provider immediately Correct answer.
  4. Assist the patient to walk to improve venous return

Explanation

The presentation suggests postoperative pulmonary embolism from a deep vein thrombosis, which is a life-threatening emergency. The priority is oxygenation and urgent escalation for diagnostic evaluation and anticoagulation, so oxygen plus immediate provider notification is the correct first action.

Question 3Medical-Surgical Nursing

Which finding is most characteristic of hypovolemic shock in an adult?

  1. Widened pulse pressure with polyuria
  2. Tachycardia with narrowed pulse pressure and oliguria Correct answer.
  3. Warm flushed skin with bounding pulses
  4. Bradycardia with hypertension and flushed skin

Explanation

In hypovolemic shock, loss of circulating volume triggers compensatory sympathetic responses: tachycardia, peripheral vasoconstriction that narrows the pulse pressure, and renal hypoperfusion causing oliguria. Warm flushed skin with bounding pulses and bradycardia with hypertension are not features of volume loss.

Question 4Medical-Surgical Nursing

A patient with chronic kidney disease has a serum potassium of 6.8 mmol/L and peaked T waves on the ECG. Which prescribed intervention should the nurse administer first?

  1. IV calcium gluconate Correct answer.
  2. Subcutaneous insulin with oral glucose
  3. IV sodium bicarbonate infusion
  4. Oral sodium polystyrene sulfonate

Explanation

Hyperkalemia with ECG changes indicates cardiac membrane instability and risk of fatal arrhythmia. IV calcium stabilizes the myocardium within minutes and is the first-line emergency measure, while the other agents shift or remove potassium but do not protect the heart immediately.

Question 5Medical-Surgical Nursing

A patient is receiving a blood transfusion. Fifteen minutes into the infusion the patient reports chills, flank pain, and dark urine, and the temperature rises to 39°C. What should the nurse do first?

  1. Stop the transfusion and maintain IV access with normal saline Correct answer.
  2. Administer prescribed antipyretic and continue the transfusion
  3. Slow the transfusion rate and reassess vital signs in 30 minutes
  4. Obtain a urine sample and continue monitoring

Explanation

Fever, chills, flank pain, and hemoglobinuria during transfusion suggest an acute hemolytic reaction, which can be fatal. The immediate action is to stop the transfusion, keep the line patent with saline using new tubing, and notify the blood bank and provider.

Question 6Medical-Surgical Nursing

Which assessment finding should the nurse report immediately in a patient receiving IV heparin for deep vein thrombosis?

  1. New bruising at the venipuncture site
  2. Sudden severe headache with confusion Correct answer.
  3. Activated partial thromboplastin time of 60 seconds
  4. Platelet count of 210,000/µL

Explanation

A sudden severe headache with confusion may indicate intracranial hemorrhage, a serious complication of anticoagulation requiring urgent evaluation. Minor bruising and a therapeutic aPTT are expected findings, and a normal platelet count is reassuring.

Question 7Medical-Surgical Nursing

A patient with type 1 diabetes has a blood glucose of 28 mmol/L, deep rapid respirations, fruity breath, and dry mucous membranes. Which prescription should the nurse anticipate implementing first?

  1. Subcutaneous long-acting insulin
  2. Rapid IV infusion of 0.9% sodium chloride Correct answer.
  3. Oral rehydration with glucose-containing fluids
  4. IV potassium replacement before any fluids

Explanation

This presentation is diabetic ketoacidosis, in which profound dehydration and volume depletion are present. Isotonic saline resuscitation is the initial priority, followed by insulin and electrolyte replacement, because insulin given before volume resuscitation can worsen hypotension.

Question 8Medical-Surgical Nursing

A patient has a chest tube connected to a water-seal drainage system after a lobectomy. Which observation requires immediate nursing action?

  1. Continuous bubbling in the water-seal chamber Correct answer.
  2. Serosanguineous drainage of 50 mL in the first hour
  3. Tidaling of fluid in the water-seal chamber with respiration
  4. Drainage tubing looped loosely at the bedside

Explanation

Continuous bubbling in the water-seal chamber indicates an air leak in the system, which can lead to loss of negative pressure and pneumothorax. Tidaling with respiration is expected, moderate drainage is common early after surgery, and loose loops prevent dependent kinks.

Question 9Medical-Surgical Nursing

Which symptom is most typical of left-sided heart failure?

  1. Jugular venous distension at 45 degrees
  2. Hepatomegaly with right upper quadrant tenderness
  3. Orthopnea and paroxysmal nocturnal dyspnea Correct answer.
  4. Dependent pitting edema of the ankles

Explanation

Left-sided heart failure causes pulmonary congestion, producing dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Peripheral edema, hepatomegaly, and jugular venous distension reflect systemic venous congestion typical of right-sided failure.

Question 10Medical-Surgical Nursing

A patient with an acute exacerbation of asthma has audible wheezing and an oxygen saturation of 91%. Which intervention should the nurse implement first?

  1. Teach pursed-lip breathing
  2. Obtain a sputum culture
  3. Administer prescribed short-acting beta-2 agonist nebulization Correct answer.
  4. Administer prescribed IV corticosteroid

Explanation

Acute asthma with hypoxemia and wheezing is treated first with a short-acting beta-2 agonist to relieve bronchospasm rapidly. Corticosteroids reduce inflammation but have a slower onset, and cultures or breathing retraining do not address acute bronchospasm.

Question 11Medical-Surgical Nursing

A patient is admitted with a suspected stroke and reports sudden onset of symptoms 45 minutes ago. Which action is the priority?

  1. Administer aspirin immediately
  2. Place the patient in a supine position with head flat
  3. Give oral fluids to maintain hydration
  4. Determine the exact time of symptom onset and obtain urgent brain imaging Correct answer.

Explanation

Thrombolytic therapy for ischemic stroke depends on the time of onset and exclusion of hemorrhage by imaging, so establishing the exact onset time and obtaining urgent CT are the priority. Aspirin must be withheld until hemorrhage is excluded.

Question 12Medical-Surgical Nursing

Which finding is an early sign of increased intracranial pressure?

  1. Decreased level of consciousness Correct answer.
  2. Decerebrate posturing
  3. Fixed dilated pupils
  4. Absent corneal reflex

Explanation

A declining level of consciousness is often the earliest indicator of rising intracranial pressure. Fixed dilated pupils, decerebrate posturing, and absent corneal reflexes are later, more ominous signs of brainstem compromise.

Question 13Medical-Surgical Nursing

A patient with a spinal cord injury at T4 develops a pounding headache, profuse sweating above the injury, and a blood pressure of 190/110 mmHg. What should the nurse do first?

  1. Apply a cool compress to the forehead
  2. Administer prescribed antihypertensive medication
  3. Elevate the head of the bed and check for bladder distension Correct answer.
  4. Reassess blood pressure in 15 minutes

Explanation

These findings indicate autonomic dysreflexia, most often triggered by bladder or bowel distension. Immediate measures are to sit the patient upright to reduce blood pressure and identify and remove the trigger, such as a full bladder.

Question 14Medical-Surgical Nursing

A patient with severe acute pancreatitis reports worsening abdominal pain and has a serum calcium of 1.75 mmol/L. Which finding is most consistent with this complication?

  1. Increased bowel sounds
  2. Positive Chvostek sign Correct answer.
  3. Hyperactive deep tendon reflexes with hyporeflexia
  4. Polyuria with hypernatremia

Explanation

Hypocalcemia is a complication of severe pancreatitis, often from fat saponification, and manifests with neuromuscular irritability such as a positive Chvostek or Trousseau sign. Hyperreflexia rather than hyporeflexia would be expected, and bowel sounds typically decrease with pancreatitis.

Question 15Medical-Surgical Nursing

Which dietary instruction is appropriate for a patient with cirrhosis and esophageal varices?

  1. Increase intake of rough high-fiber foods
  2. Increase protein to 2 g/kg daily regardless of mental status
  3. Drink hot fluids with each meal
  4. Eat small frequent meals of soft, bland foods Correct answer.

Explanation

Soft, bland foods in small frequent meals reduce the risk of mechanical irritation and bleeding from varices. Rough high-fiber foods and hot fluids can traumatize varices, and very high protein is not automatically appropriate, especially with hepatic encephalopathy.

Question 16Medical-Surgical Nursing

A patient is one day after a total thyroidectomy and reports tingling around the mouth and fingers with muscle twitching. Which intervention should the nurse anticipate?

  1. Administer prescribed IV calcium gluconate Correct answer.
  2. Administer prescribed levothyroxine
  3. Encourage a high-iodine diet
  4. Place the patient in respiratory isolation

Explanation

Perioral and digital paresthesia with twitching after thyroidectomy suggests hypocalcemia from parathyroid disruption. Treatment is calcium replacement, initially IV if symptomatic, with close monitoring of calcium levels and airway status.

Question 17Medical-Surgical Nursing

A patient with a fractured femur has a sudden onset of confusion, petechiae on the chest, and dyspnea. Which condition should the nurse suspect?

  1. Deep vein thrombosis
  2. Fat embolism syndrome Correct answer.
  3. Pneumonia
  4. Compartment syndrome

Explanation

The triad of respiratory distress, neurological changes, and a petechial rash after long-bone fracture is classic for fat embolism syndrome. Compartment syndrome causes localized pain and neurovascular changes in the limb, while DVT and pneumonia do not typically produce petechiae.

Question 18Medical-Surgical Nursing

Which finding indicates that a patient's cast may be causing compartment syndrome?

  1. Warm dry skin distal to the cast
  2. Pain out of proportion that worsens with passive stretch Correct answer.
  3. Pain that is relieved by prescribed opioid
  4. Capillary refill of 2 seconds

Explanation

The earliest and most reliable sign of compartment syndrome is severe pain that is disproportionate to the injury and increases with passive stretching of the affected muscles. Opioid relief, warm skin, and normal capillary refill do not suggest compartment syndrome.

Question 19Medical-Surgical Nursing

A patient with chronic obstructive pulmonary disease has an oxygen saturation of 86% and is prescribed oxygen. Which approach is appropriate?

  1. Administer high-flow oxygen at 10 L/min by mask
  2. Titrate oxygen to a target saturation of about 88–92% Correct answer.
  3. Withhold oxygen to avoid suppressing the respiratory drive
  4. Administer oxygen only during meals

Explanation

In COPD with chronic hypercapnia, oxygen should be titrated to a target saturation of roughly 88–92% to correct hypoxemia while avoiding excessive hyperoxia that can worsen carbon dioxide retention. High-flow oxygen and withholding oxygen are both unsafe.

Question 20Medical-Surgical Nursing

Which manifestation should the nurse expect in a patient with syndrome of inappropriate antidiuretic hormone secretion?

  1. Hyperglycemia with osmotic diuresis
  2. Hypokalemia with metabolic alkalosis
  3. Concentrated urine with dilutional hyponatremia Correct answer.
  4. Hypernatremia with polyuria

Explanation

SIADH causes excessive water reabsorption, producing concentrated urine and dilutional hyponatremia with low serum osmolality. Hypernatremia with polyuria suggests diabetes insipidus, and the other options are unrelated patterns.

Question 21Medical-Surgical Nursing

A patient with an ileostomy has had high-volume liquid output for two days and now reports weakness and palpitations. Which electrolyte disturbance should the nurse anticipate?

  1. Hypokalemia Correct answer.
  2. Hypercalcemia
  3. Hyperkalemia
  4. Hypernatremia with fluid overload

Explanation

Large-volume ileostomy losses are rich in potassium and sodium, leading to hypokalemia, which can cause weakness and palpitations. Hyperkalemia, hypercalcemia, and fluid overload are not expected with ongoing gastrointestinal losses.

Question 22Medical-Surgical Nursing

A patient receiving chemotherapy has a neutrophil count of 0.4 × 10⁹/L and a temperature of 38.4°C. Which action is the priority?

  1. Obtain cultures and start prescribed broad-spectrum antibiotics promptly Correct answer.
  2. Place the patient in a negative-pressure room and await results
  3. Encourage fresh fruit and flowers to improve morale
  4. Give prescribed oral iron and reassess in 24 hours

Explanation

Febrile neutropenia is an oncologic emergency requiring cultures followed by prompt empiric broad-spectrum antibiotics, ideally within an hour. Iron does not treat neutropenic sepsis, and fresh fruit or flowers introduce pathogens.

Question 23Medical-Surgical Nursing

A patient has a stage 3 pressure injury over the sacrum. Which nursing intervention best supports healing?

  1. Massage the surrounding skin vigorously to stimulate circulation
  2. Keep the wound open to air and apply heat lamps
  3. Reposition every 4 hours and keep the area moist with saline-soaked gauze that is changed daily
  4. Reposition at regular intervals and use a pressure-redistributing surface Correct answer.

Explanation

Healing of a stage 3 pressure injury requires offloading pressure through regular repositioning and a pressure-redistributing surface, along with appropriate moist wound care. Massage over bony prominences, prolonged air exposure, and heat lamps cause further tissue damage.

Question 24Medical-Surgical Nursing

A patient is admitted with burns over 30% of the total body surface area. During the first 24 hours, which fluid management goal is correct?

  1. Replace losses guided by a formula such as Parkland and monitor urine output Correct answer.
  2. Maintain a urine output below 10 mL/hour
  3. Restrict fluids to prevent edema
  4. Give only colloids in the first 8 hours

Explanation

Burn shock from capillary leak requires large-volume crystalloid resuscitation, commonly calculated with the Parkland formula and titrated to a urine output of about 0.5 mL/kg/hour in adults. Fluid restriction, colloid-only regimens, and very low urine output targets are incorrect.

Question 25Medical-Surgical Nursing

A patient with a new colostomy is learning stoma care. Which statement indicates correct understanding?

  1. I will cut the skin barrier much larger than the stoma to allow swelling
  2. I should avoid emptying the pouch until it is completely full
  3. I will change the pouch every day regardless of leakage
  4. I should clean the skin around the stoma with mild soap and water and pat dry Correct answer.

Explanation

Peristomal skin should be cleaned gently with mild soap and water and dried thoroughly before applying a properly sized barrier. The barrier opening should be only slightly larger than the stoma, the pouch is emptied when about one-third to one-half full, and daily changes are unnecessary without leakage.

Question 26Medical-Surgical Nursing

A patient with an acute upper gastrointestinal bleed has a nasogastric tube in place. Which finding on the aspirate most strongly suggests an arterial source of bleeding?

  1. Bright red blood that continues to return after lavage Correct answer.
  2. Coffee-ground material that clears with saline lavage
  3. Dark clots that stop draining after 30 minutes
  4. Yellow-green fluid with a pH of 6

Explanation

Continued bright red return after lavage indicates active arterial bleeding that is not clotting, which is a medical emergency requiring urgent endoscopy and volume resuscitation. Coffee-ground or dark material reflects older, partially digested blood and is less suggestive of brisk arterial flow.

Question 27Medical-Surgical Nursing

A patient is admitted with diabetic ketoacidosis and has received 4 litres of 0.9% sodium chloride. Which assessment parameter is the most reliable indicator that fluid resuscitation is adequate?

  1. A fall in respiratory rate below 12 breaths per minute
  2. A rise in serum sodium to 150 mmol/L
  3. Absence of ketones on a urine dipstick
  4. Urine output of at least 0.5 mL/kg/hour Correct answer.

Explanation

Adequate urine output of at least 0.5 mL/kg/hour reflects restored renal perfusion and is a practical endpoint of fluid resuscitation in DKA. Serum sodium may rise with correction but is not itself a marker of adequate volume, and urine ketones lag behind clinical improvement.

Question 28Medical-Surgical Nursing

Which instruction should the nurse give a patient who is starting isoniazid therapy for active tuberculosis?

  1. Take the medication with a high-fat meal to improve absorption
  2. Expect orange discolouration of urine and tears
  3. Stop the drug once the cough resolves
  4. Avoid alcohol and report yellowing of the eyes or dark urine Correct answer.

Explanation

Isoniazid is hepatotoxic, so patients must avoid alcohol and report jaundice or dark urine promptly so the drug can be reviewed. Orange discolouration is characteristic of rifampicin, and treatment must be completed in full rather than stopped when symptoms improve.

Question 29Medical-Surgical Nursing

A patient with chronic kidney disease has a serum potassium of 6.9 mmol/L and peaked T waves on the ECG. Which prescribed intervention should the nurse administer first?

  1. Intravenous sodium bicarbonate infusion
  2. Intravenous calcium gluconate Correct answer.
  3. Subcutaneous insulin with oral glucose
  4. Oral sodium polystyrene sulfonate

Explanation

Intravenous calcium stabilises the myocardial membrane within minutes and is the first action for hyperkalaemia with ECG changes, because it prevents lethal arrhythmias while potassium is shifted and removed. Insulin-glucose, bicarbonate and binders lower potassium but act too slowly to protect the heart acutely.

Question 30Medical-Surgical Nursing

A patient with a permanent pacemaker is scheduled for magnetic resonance imaging. Which action should the nurse take first?

  1. Verify that the device is MRI-conditional and has been programmed appropriately Correct answer.
  2. Place a defibrillator pad on the chest during the scan
  3. Remove the pacemaker with a magnet before entering the scanner
  4. Cancel the scan permanently because pacemakers are never compatible

Explanation

Many modern pacemakers are MRI-conditional, but safe scanning requires confirming device and lead compatibility and reprogramming the device to an appropriate mode before the procedure. A magnet is used to change mode temporarily, not to remove the device, and blanket cancellation is outdated.

Question 31Medical-Surgical Nursing

A patient with rheumatoid arthritis has been taking methotrexate weekly. Which report requires the most urgent follow-up?

  1. New mouth ulcers with fever and chills Correct answer.
  2. Mild nausea on the day after the dose
  3. Joint stiffness that is worse in the morning
  4. A dry cough that occurs only at night

Explanation

Methotrexate suppresses bone marrow and mucosal tissue, so mouth ulcers with fever suggests myelosuppression with infection and possible mucositis, requiring urgent blood counts and drug review. Nausea and morning stiffness are expected features of therapy and disease, and an isolated nocturnal cough is less specific.

Question 32Medical-Surgical Nursing

A patient has a new ileal conduit after cystectomy. Which observation of the stoma should the nurse report to the surgeon?

  1. The stoma is edematous two days after surgery
  2. The stoma produces small amounts of blood-tinged urine initially
  3. The stoma is moist and rose-red
  4. The stoma is dusky and cool to touch Correct answer.

Explanation

A dusky, cool stoma indicates compromised blood supply and possible ischaemia, which must be reported immediately to preserve the conduit. Moist rose-red colour is healthy, mild oedema is expected early after surgery, and slight blood tingeing of urine is normal in the immediate postoperative period.

Question 33Medical-Surgical Nursing

A patient receiving a blood transfusion develops fever, flank pain and dark urine 20 minutes into the transfusion. Which action should the nurse take first?

  1. Obtain a urine sample before stopping the transfusion
  2. Slow the transfusion rate and reassess in 15 minutes
  3. Administer the prescribed antihistamine and continue the transfusion
  4. Stop the transfusion and maintain intravenous access with normal saline Correct answer.

Explanation

Fever, flank pain and haemoglobinuria suggest an acute haemolytic reaction, so the transfusion must be stopped immediately and patency maintained with saline while the reaction is reported. Slowing the infusion or giving antihistamines delays treatment of a potentially fatal reaction.

Question 34Medical-Surgical Nursing

Which finding in a patient with a new below-knee amputation suggests that a haematoma is forming under the stump dressing?

  1. The patient reports phantom limb sensations
  2. The stump is cool with a pale distal edge
  3. Serosanguineous drainage is visible on the outer dressing
  4. The dressing is saturated with blood and the stump feels firm and tense Correct answer.

Explanation

A saturated dressing together with a firm, tense stump indicates accumulating blood beneath the dressing, which can compromise healing and requires prompt inspection and pressure. Phantom sensation is expected, and a small amount of serosanguineous drainage is normal after amputation.

Question 35Medical-Surgical Nursing

A patient with myasthenia gravis reports increasing difficulty swallowing and a weaker voice in the late afternoon. Which action should the nurse take?

  1. Encourage the patient to eat a large meal to build strength
  2. Reassure the patient that afternoon fatigue is expected and requires no action
  3. Withhold all anticholinesterase medication until the next morning
  4. Assess respiratory status and notify the provider about possible myasthenic crisis Correct answer.

Explanation

Bulbar weakness that worsens through the day may signal myasthenic crisis with risk of aspiration and respiratory failure, so oxygenation, vital capacity and swallowing safety must be assessed and the provider notified. Withholding medication or encouraging a large meal would worsen weakness and aspiration risk.

Question 36Medical-Surgical Nursing

Which instruction should the nurse give a patient who is learning to use a metered-dose inhaler with a spacer for asthma?

  1. Actuate one puff, then breathe in slowly and deeply, and hold the breath Correct answer.
  2. Store the inhaler in the refrigerator between uses
  3. Inhale as quickly and forcefully as possible
  4. Actuate several puffs in a row before inhaling

Explanation

A single actuation followed by a slow, deep inhalation and a breath hold allows the drug to reach the lower airways, and the spacer reduces oropharyngeal deposition. Rapid forceful inhalation deposits drug in the upper airway, and inhalers should be stored at room temperature.

Question 37Medical-Surgical Nursing

A patient with a large pleural effusion is scheduled for thoracentesis. Which instruction should the nurse give immediately before the procedure?

  1. Remain still and avoid coughing during needle insertion Correct answer.
  2. Drink a large volume of water just before the procedure
  3. Take deep breaths continuously throughout the procedure
  4. Lie on the side of the effusion during the procedure

Explanation

Movement and coughing during needle insertion risk lung puncture and bleeding, so the patient must stay still and suppress cough until the needle is withdrawn. Deep breathing during insertion increases that risk, and the procedure is performed upright or seated.

Question 38Medical-Surgical Nursing

A patient with an acute exacerbation of ulcerative colitis has 12 bloody stools per day, a haemoglobin of 82 g/L and a heart rate of 118 beats per minute. Which priority nursing action is indicated?

  1. Administer a prescribed antidiarrhoeal agent to slow stool frequency
  2. Apply a heating pad to the abdomen for comfort
  3. Encourage a high-fibre diet to bulk the stool
  4. Assess for orthostatic hypotension and prepare for intravenous fluids Correct answer.

Explanation

Tachycardia with anaemia and frequent bloody stools suggests hypovolaemia from severe colitis, so haemodynamic assessment and volume replacement take priority. Antidiarrhoeals and high-fibre diets can precipitate toxic megacolon or worsen inflammation in acute severe disease.

Question 39Medical-Surgical Nursing

A patient has been prescribed enoxaparin after hip replacement surgery. Which technique should the nurse use when giving the injection?

  1. Inject into the deltoid muscle at a 90-degree angle
  2. Inject into the abdominal subcutaneous tissue without expelling the air bubble Correct answer.
  3. Massage the site firmly after injection to spread the drug
  4. Aspirate before injecting to check for blood return

Explanation

Low-molecular-weight heparin is given into abdominal subcutaneous fat, and the air bubble is retained to clear the needle of drug while the site is not massaged or aspirated. Massage increases bruising, aspiration is unnecessary, and intramuscular injection is inappropriate.

Question 40Medical-Surgical Nursing

A patient is two days after a femoropopliteal bypass graft. Which finding in the affected leg should the nurse report immediately?

  1. Absent pedal pulse with a cool, pale foot Correct answer.
  2. Mild incisional pain controlled by analgesia
  3. Serous drainage on the incision dressing
  4. Dependent rubor of the foot when the leg is lowered

Explanation

An absent pulse with a cool, pale foot suggests acute graft occlusion or thrombosis and threatens limb viability, requiring immediate surgical notification. Small serous drainage, controlled incisional pain and dependent rubor are expected after revascularisation surgery.

Question 41Maternal and Newborn Nursing (Antenatal, Intrapartum, Postpartum, Neonatal Care)

A woman at 38 weeks gestation reports a sudden gush of clear fluid from the vagina. On speculum examination, fluid is seen pooling in the posterior fornix. Which finding would most reliably confirm that the membranes have ruptured?

  1. Presence of lactobacilli on wet mount
  2. A vaginal pH of 4.5
  3. A negative ferning pattern on dried fluid
  4. A positive nitrazine test turning the paper blue Correct answer.

Explanation

Amniotic fluid is alkaline (pH about 7.0–7.5), so nitrazine paper turns blue when amniotic fluid is present, whereas normal vaginal secretions are acidic. This makes the nitrazine test a standard bedside confirmation of membrane rupture.

Question 42Maternal and Newborn Nursing (Antenatal, Intrapartum, Postpartum, Neonatal Care)

During the active phase of the first stage of labor, a primigravida's cervix is 6 cm dilated with contractions every 3 minutes. Which nursing action is the priority at this point?

  1. Restrict all oral intake and position her flat on her back
  2. Assess fetal heart rate and maternal vital signs at scheduled intervals Correct answer.
  3. Prepare for immediate delivery in the room
  4. Encourage the woman to push with each contraction

Explanation

In the active phase, ongoing monitoring of fetal heart rate and maternal vital signs detects signs of fetal compromise and maternal deterioration early. Pushing is not appropriate until full dilatation, and routine supine positioning is not recommended.

Question 43Maternal and Newborn Nursing (Antenatal, Intrapartum, Postpartum, Neonatal Care)

A woman is admitted in the second stage of labor with a fetal heart rate baseline of 140 beats per minute. Which finding on vaginal examination indicates that she is in the second stage?

  1. Cervix 8 cm dilated with 50% effacement
  2. Cervix 4 cm dilated with a floating presenting part
  3. Cervix fully dilated with the presenting part at +2 station Correct answer.
  4. Cervix 10 cm dilated with a station of −3

Explanation

The second stage begins at full dilatation (10 cm) and ends with delivery of the baby. Full dilatation with the presenting part descended to +2 station indicates active descent and the onset of expulsive effort.

Question 44Maternal and Newborn Nursing (Antenatal, Intrapartum, Postpartum, Neonatal Care)

Immediately after a spontaneous vaginal delivery, which action should the nurse take first to reduce the risk of postpartum hemorrhage?

  1. Apply ice packs to the perineum
  2. Massage the uterine fundus and administer a uterotonic as ordered Correct answer.
  3. Delay assessment until the placenta is delivered
  4. Assist the woman to breastfeed before assessing the uterus

Explanation

Uterine atony is the leading cause of postpartum hemorrhage, so assessing fundal tone and giving a prophylactic uterotonic such as oxytocin are the key early measures. Massaging a boggy fundus promotes contraction and helps control bleeding.

Question 45Maternal and Newborn Nursing (Antenatal, Intrapartum, Postpartum, Neonatal Care)

A newborn is born at term and placed skin-to-skin with the mother. Which assessment finding in the first minute of life would score 0 on the Apgar respiratory effort component?

  1. Good crying
  2. Slow, irregular breathing
  3. Apnea Correct answer.
  4. Weak cry

Explanation

The Apgar respiratory component scores 2 for a good cry, 1 for slow or irregular breathing, and 0 for apnea. Absence of respiratory effort is the most concerning finding and requires immediate stimulation and support.

Question 46Maternal and Newborn Nursing (Antenatal, Intrapartum, Postpartum, Neonatal Care)

A pregnant woman at 28 weeks gestation has a hemoglobin of 9 g/dL. Which instruction is most appropriate for her?

  1. Take iron supplements with a glass of milk to improve absorption
  2. Take iron supplements with vitamin C-rich juice between meals Correct answer.
  3. Defer treatment until after delivery
  4. Stop all iron supplements because anemia is normal in pregnancy

Explanation

Iron absorption is enhanced by vitamin C and reduced by calcium and tannins. Taking iron with citrus juice between meals maximizes absorption, which is important for treating iron-deficiency anemia in pregnancy.

Question 47Maternal and Newborn Nursing (Antenatal, Intrapartum, Postpartum, Neonatal Care)

A woman at 34 weeks gestation reports a sudden gush of bright red vaginal bleeding with a soft, non-tender uterus. Which action should the nurse take?

  1. Place the woman in a semi-Fowler position and give oral fluids
  2. Encourage the woman to ambulate to promote labor
  3. Perform a sterile vaginal examination to assess dilatation
  4. Withhold vaginal examination and notify the provider immediately Correct answer.

Explanation

Painless bright red bleeding in late pregnancy suggests placenta previa, and a digital vaginal examination can provoke catastrophic hemorrhage. The nurse should avoid vaginal examination, notify the provider, and prepare for ultrasound and monitoring.

Question 48Maternal and Newborn Nursing (Antenatal, Intrapartum, Postpartum, Neonatal Care)

A newborn at 2 hours of life has a respiratory rate of 80 breaths per minute with nasal flaring and grunting. Which interpretation is correct?

  1. The infant should be swaddled tightly and left to sleep
  2. These signs suggest respiratory distress and require prompt evaluation Correct answer.
  3. This is a normal finding in the first hours of life
  4. The infant should be fed to increase energy

Explanation

A respiratory rate above 60 per minute with flaring and grunting indicates respiratory distress, which may reflect transient tachypnea, respiratory distress syndrome, or infection. Prompt assessment and provider notification are required.

Question 49Maternal and Newborn Nursing (Antenatal, Intrapartum, Postpartum, Neonatal Care)

A woman at 39 weeks gestation has a blood pressure of 158/104 mmHg and 3+ proteinuria. Which finding would most increase the nurse's concern for severe preeclampsia?

  1. Fetal heart rate of 140 beats per minute
  2. Report of a persistent frontal headache Correct answer.
  3. Blood pressure 132/84 mmHg on recheck
  4. Mild ankle edema

Explanation

A persistent headache, especially frontal, is a warning sign of cerebral involvement in severe preeclampsia and may precede eclampsia. Severe-range blood pressure with proteinuria plus neurologic symptoms warrants urgent escalation of care.

Question 50Maternal and Newborn Nursing (Antenatal, Intrapartum, Postpartum, Neonatal Care)

A woman in active labor has a fetal heart rate pattern showing repetitive variable decelerations. Which nursing intervention should be performed first?

  1. Administer a bolus of oxytocin to strengthen contractions
  2. Reposition the mother to a left lateral or knee-chest position Correct answer.
  3. Increase the oxytocin infusion rate
  4. Perform a sterile vaginal examination and prepare for forceps

Explanation

Variable decelerations usually reflect umbilical cord compression, and changing maternal position relieves pressure on the cord and improves fetal oxygenation. This is the first-line intrauterine resuscitation measure before other interventions.