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NLN ACE PN-RN study materials
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NLN ACE PN-RN practice questions

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Question 1Nursing Care of the Adult Client

A client admitted with an acute exacerbation of heart failure has a potassium level of 3.1 mEq/L. Which assessment finding should the nurse report immediately?

  1. A dry, nonproductive cough that began yesterday
  2. Frequent premature ventricular contractions on the monitor Correct answer.
  3. A positive Trousseau sign during blood pressure measurement
  4. Bilateral pitting edema of the lower extremities

Explanation

Hypokalemia lowers the threshold for myocardial irritability, so ectopy such as frequent PVCs can progress to ventricular tachycardia or fibrillation and warrants urgent reporting and potassium replacement. Edema and cough reflect the heart failure itself, and Trousseau sign is associated with hypocalcemia rather than low potassium.

Question 2Nursing Care of the Adult Client

The nurse is caring for a client receiving a continuous heparin infusion. Which laboratory result should the nurse monitor to evaluate therapeutic effect?

  1. Fibrinogen level
  2. Platelet count
  3. Activated partial thromboplastin time Correct answer.
  4. International normalized ratio

Explanation

Unfractionated heparin potentiates antithrombin and prolongs the activated partial thromboplastin time, which is the standard test used to titrate the infusion to a therapeutic range. The INR is used for warfarin, while platelets and fibrinogen screen for other problems such as heparin-induced thrombocytopenia.

Question 3Nursing Care of the Adult Client

A client with type 1 diabetes is found diaphoretic, tremulous, and confused. The client is awake and able to swallow. Which action should the nurse take first?

  1. Give 15 grams of a fast-acting oral carbohydrate Correct answer.
  2. Start an intravenous line and give 50% dextrose
  3. Administer the scheduled dose of subcutaneous insulin
  4. Recheck the blood glucose in one hour

Explanation

These signs indicate hypoglycemia, and the conscious client who can swallow should receive the rule of 15: about 15 grams of rapid-acting carbohydrate, followed by a glucose recheck in 15 minutes. Intravenous dextrose is reserved for clients who are unconscious or unable to swallow safely.

Question 4Nursing Care of the Adult Client

A client is admitted with a suspected small bowel obstruction. Which finding most supports this diagnosis?

  1. High-pitched, hyperactive bowel sounds with vomiting Correct answer.
  2. Left lower quadrant pain relieved by defecation
  3. Absent bowel sounds with a rigid, board-like abdomen
  4. Bright red blood per rectum with a drop in hemoglobin

Explanation

In early small bowel obstruction the bowel works hard against the blockage, producing hyperactive, high-pitched tinkling sounds with nausea and bilious vomiting. Absent sounds with rigidity suggests perforation or peritonitis, and the other options point to lower gastrointestinal bleeding or diverticular disease.

Question 5Nursing Care of the Adult Client

The nurse is caring for a client in the first 24 hours after an acute myocardial infarction. Which complication should the nurse monitor for most closely during this period?

  1. Pulmonary embolism from prolonged bed rest
  2. Pericarditis from myocardial inflammation
  3. Hyperkalemia related to tissue breakdown
  4. Ventricular dysrhythmias from myocardial irritability Correct answer.

Explanation

The first 24 hours after infarction carry the highest risk of sudden death from ventricular fibrillation, so continuous cardiac monitoring and prompt treatment of ectopy are priorities. Pericarditis typically appears days later, and immobility-related embolism is a later concern.

Question 6Nursing Care of the Adult Client

A client with chronic obstructive pulmonary disease has an oxygen saturation of 86% on room air and is short of breath. Which oxygen delivery approach is most appropriate?

  1. High-flow oxygen at 10 L/min by nonrebreather mask
  2. Titrated low-flow oxygen to keep saturation near 88% to 92% Correct answer.
  3. Oxygen only during sleep to prevent daytime dependence
  4. No supplemental oxygen because of carbon dioxide retention

Explanation

Clients with COPD who retain carbon dioxide are given carefully titrated oxygen targeting a saturation of about 88% to 92% to correct hypoxemia without worsening hypercapnia. Withholding oxygen entirely is unsafe, and uncontrolled high-flow oxygen risks carbon dioxide narcosis.

Question 7Nursing Care of the Adult Client

A client is receiving furosemide for fluid overload. Which laboratory value should the nurse review as the priority before giving the dose?

  1. Serum potassium Correct answer.
  2. Serum calcium
  3. Serum bilirubin
  4. Serum amylase

Explanation

Loop diuretics such as furosemide promote potassium excretion, and hypokalemia increases the risk of dysrhythmias, especially in clients also taking digoxin. Calcium, bilirubin, and amylase do not relate to the primary adverse effect of this drug.

Question 8Nursing Care of the Adult Client

A client with a new ileostomy reports that the pouch output has become watery and the stoma has changed from pink to a dusky blue color. What should the nurse do first?

  1. Notify the surgeon immediately of possible ischemia Correct answer.
  2. Apply a tight abdominal binder over the stoma
  3. Document the findings as a normal postoperative change
  4. Change the pouch and recheck the stoma in four hours

Explanation

A dusky or blue stoma suggests compromised blood flow and possible ischemia, which requires immediate notification of the surgeon to preserve the stoma. A healthy stoma should remain pink to red and moist, so this finding is never a normal variant.

Question 9Nursing Care of the Adult Client

The nurse is assessing a client with a suspected stroke whose symptoms began 90 minutes ago. Which action is the priority?

  1. Begin range-of-motion exercises of the affected side
  2. Lower the blood pressure aggressively
  3. Give aspirin 325 mg by mouth
  4. Obtain a stat noncontrast head CT scan Correct answer.

Explanation

Immediate head imaging is needed to distinguish ischemic stroke from hemorrhage, because thrombolytic therapy is time-limited and contraindicated in bleeding. Aspirin must wait until hemorrhage is excluded, and blood pressure is not lowered aggressively in acute ischemic stroke.

Question 10Nursing Care of the Adult Client

A client with a chest tube for a pneumothorax has continuous bubbling in the water-seal chamber. What should the nurse do first?

  1. Assess the insertion site and tubing for an air leak Correct answer.
  2. Clamp the chest tube near the insertion site
  3. Add sterile water to the water-seal chamber
  4. Milk the tubing to clear any obstruction

Explanation

Continuous bubbling in the water-seal chamber suggests an air leak in the system, so the nurse inspects the insertion site and connections to locate it. Clamping the tube is dangerous because it can cause tension pneumothorax, and routine milking of tubes is not recommended.

Question 11Nursing Care of the Adult Client

A client with a new below-the-knee amputation has a rigid compression dressing. Which finding should the nurse report immediately?

  1. A saturated spot of serosanguineous drainage on the dressing
  2. Phantom sensation described as the foot still being present
  3. Mild incisional pain relieved by prescribed analgesia
  4. Loss of the popliteal pulse and cool, pale skin above the dressing Correct answer.

Explanation

Absent pulses with cool, pale skin suggest arterial compromise from a constricting dressing or vascular occlusion and require immediate intervention to save tissue. Phantom sensation and mild incisional pain are expected, and a small drainage spot is common in the early postoperative period.

Question 12Nursing Care of the Adult Client

A client with acute pancreatitis is admitted with severe epigastric pain. Which nursing intervention is most appropriate?

  1. Position the client flat on the back after meals
  2. Apply firm pressure to the abdomen during assessment
  3. Encourage a high-fat diet to stimulate digestion
  4. Maintain nothing by mouth and provide pain control Correct answer.

Explanation

Pancreatic rest is achieved by keeping the client NPO, and analgesia plus intravenous fluids are central to early management. Fatty foods stimulate enzyme secretion and worsen pain, and deep palpation is avoided because the abdomen is tender.

Question 13Nursing Care of the Adult Client

The nurse is reviewing discharge teaching for a client starting warfarin therapy. Which statement indicates the client needs further teaching?

  1. I can take ibuprofen whenever I have a headache Correct answer.
  2. I will report any black stools or unusual bruising
  3. I will use an electric razor instead of a blade razor
  4. I will keep my appointments for blood tests to check my clotting time

Explanation

Nonsteroidal anti-inflammatory drugs such as ibuprofen increase bleeding risk and gastric irritation in clients taking warfarin, so acetaminophen is generally preferred for pain. INR monitoring, electric razor use, and reporting bleeding signs all reflect correct understanding.

Question 14Nursing Care of the Adult Client

A client with a spinal cord injury at T4 suddenly reports a pounding headache and has a blood pressure of 210/110 mm Hg with bradycardia. What should the nurse do first?

  1. Sit the client upright and check for bladder distention Correct answer.
  2. Place the client flat and give a prescribed sedative
  3. Administer a prescribed dose of oral antihypertensive
  4. Massage the client's legs to promote circulation

Explanation

These findings indicate autonomic dysreflexia, which is triggered by noxious stimuli such as a distended bladder or fecal impaction. The immediate action is to raise the head of the bed to lower blood pressure and remove the stimulus, then treat with antihypertensives if needed.

Question 15Nursing Care of the Adult Client

A client is receiving a blood transfusion. Fifteen minutes into the infusion the client reports chills, low back pain, and dark urine. What should the nurse do first?

  1. Flush the IV tubing to clear the blood from the line
  2. Slow the transfusion and reassess in 30 minutes
  3. Stop the transfusion and maintain IV access with normal saline Correct answer.
  4. Give the prescribed antipyretic and continue the transfusion

Explanation

Fever, chills, back pain, and hemoglobinuria suggest an acute hemolytic reaction, which requires stopping the transfusion immediately and keeping the line open with normal saline. The unit and tubing are then returned for analysis and the provider is notified.

Question 16Nursing Care of the Adult Client

A client with chronic kidney disease has a serum potassium of 6.8 mEq/L. Which finding is most consistent with this value?

  1. Increased urine output with dilute urine
  2. Prolonged QT interval on the electrocardiogram
  3. Peaked T waves on the electrocardiogram Correct answer.
  4. Hyperactive deep tendon reflexes

Explanation

Hyperkalemia produces tall, peaked T waves that can progress to a widened QRS and ventricular dysrhythmias, making cardiac monitoring essential. Prolonged QT and hyperreflexia are associated with hypocalcemia, and polyuria with dilute urine reflects impaired concentrating ability rather than high potassium.

Question 17Nursing Care of the Adult Client

The nurse is caring for a client with a new tracheostomy. Which intervention is most important for maintaining airway patency?

  1. Changing the tracheostomy ties only when soiled
  2. Suctioning the airway every hour on a fixed schedule
  3. Deflating the cuff every shift to prevent pressure
  4. Providing humidification and performing as-needed suctioning Correct answer.

Explanation

Humidification keeps secretions thin and movable, and suctioning is done when the client shows signs of need rather than on a fixed schedule to avoid mucosal trauma. Cuff deflation schedules and routine tie changes are not evidence-based priorities for patency.

Question 18Nursing Care of the Adult Client

A client is admitted with syndrome of inappropriate antidiuretic hormone secretion. Which nursing action is most appropriate?

  1. Place the client in a high-Fowler position to promote diuresis
  2. Administer intravenous normal saline at a rapid rate
  3. Encourage liberal fluid intake to dilute the urine
  4. Restrict fluids and monitor serum sodium Correct answer.

Explanation

In SIADH excessive antidiuretic hormone causes water retention and dilutional hyponatremia, so fluid restriction and serial sodium monitoring are central to care. Rapid saline administration can worsen the dilutional state, and increased fluid intake would deepen the hyponatremia.

Question 19Nursing Care of the Adult Client

A client with type 2 diabetes is admitted with a blood glucose of 720 mg/dL, deep rapid respirations, and fruity breath. Which finding should the nurse anticipate?

  1. Normal arterial blood gas values
  2. Metabolic acidosis with positive serum ketones Correct answer.
  3. Metabolic alkalosis with elevated bicarbonate
  4. Respiratory alkalosis with decreased respiratory rate

Explanation

Kussmaul respirations and fruity breath indicate ketoacidosis, in which ketone accumulation produces an anion gap metabolic acidosis with low bicarbonate. The rapid breathing is a compensatory attempt to blow off carbon dioxide, so respiratory rate is increased rather than decreased.

Question 20Nursing Care of the Adult Client

A client is one day postoperative after an open reduction and internal fixation of a femur fracture. Which finding should the nurse report immediately?

  1. Sudden shortness of breath with a drop in oxygen saturation Correct answer.
  2. Pain with movement that is relieved by prescribed opioids
  3. A temperature of 100.2 degrees Fahrenheit in the evening
  4. Serosanguineous drainage on the surgical dressing

Explanation

Sudden dyspnea and falling oxygen saturation after long bone fracture suggest fat embolism or pulmonary embolism and require urgent assessment and provider notification. Mild incisional drainage and a low-grade evening temperature are common postoperative findings.

Question 21Nursing Care of the Adult Client

The nurse is teaching a client with cirrhosis about managing ascites. Which instruction is most important?

  1. Drink extra fluids to flush out retained sodium
  2. Take over-the-counter ibuprofen for abdominal discomfort
  3. Follow a low-sodium diet and weigh yourself daily Correct answer.
  4. Increase protein intake to at least 200 grams daily

Explanation

Sodium restriction and daily weights help detect fluid accumulation early and guide diuretic therapy in cirrhosis with ascites. NSAIDs are avoided because of bleeding and renal risks, and excessive protein or fluid does not correct the underlying portal hypertension.

Question 22Nursing Care of the Adult Client

A client is receiving total parenteral nutrition through a central line. Which action should the nurse take when the bag is nearly empty?

  1. Switch to 5% dextrose in water until the next bag arrives
  2. Hang a new bag before the current one empties Correct answer.
  3. Stop the infusion abruptly and flush the line
  4. Increase the rate to finish the remaining solution

Explanation

Abrupt interruption of concentrated TPN can cause rebound hypoglycemia, so the next bag is hung before the current one empties. If TPN must be interrupted, dextrose 10% is typically used rather than abruptly stopping or speeding the infusion.

Question 23Nursing Care of the Adult Client

A client with a history of peptic ulcer disease reports sudden severe abdominal pain with a rigid, board-like abdomen. What should the nurse do first?

  1. Administer prescribed oral antacids
  2. Apply a heating pad to the abdomen
  3. Prepare the client for immediate surgical evaluation Correct answer.
  4. Encourage the client to drink milk to soothe the stomach

Explanation

Sudden severe pain with a rigid abdomen suggests a perforated ulcer with peritonitis, a surgical emergency requiring immediate evaluation. Oral intake, antacids, and heat are contraindicated because they delay treatment and may worsen the condition.

Question 24Nursing Care of the Adult Client

The nurse is caring for a client with a new colostomy. Which observation of the stoma requires further assessment?

  1. The stoma is pale and dry with a narrow lumen Correct answer.
  2. The stoma is pink to red and moist
  3. The stoma produces small amounts of bloody drainage initially
  4. The stoma is slightly edematous in the first days

Explanation

A healthy stoma is pink to red and moist; a pale, dry stoma with a narrowed lumen suggests poor blood supply or stenosis and needs evaluation. Mild edema and small amounts of bloody drainage are common in the early postoperative period.

Question 25Nursing Care of the Adult Client

A client with a pulmonary artery catheter has a pulmonary artery wedge pressure of 4 mm Hg. Which finding should the nurse anticipate?

  1. Crackles and jugular venous distention
  2. Hypotension and decreased urine output Correct answer.
  3. Hypertension and bounding pulses
  4. Pulmonary edema on chest radiograph

Explanation

A low pulmonary artery wedge pressure indicates reduced left ventricular filling, as in hypovolemia or dehydration, leading to hypotension and poor renal perfusion. Elevated wedge pressures with crackles, hypertension, and edema reflect volume overload rather than depletion.

Question 26Nursing Care of the Adult Client

A client is two days postoperative after abdominal surgery and reports sudden calf pain and swelling in the left leg. Which action should the nurse take first?

  1. Keep the leg elevated and apply warm compresses
  2. Massage the calf to promote venous return
  3. Notify the health care provider and anticipate anticoagulant therapy Correct answer.
  4. Encourage the client to ambulate immediately

Explanation

Unilateral calf pain and swelling after surgery suggest deep vein thrombosis, and the priority is to report the finding and anticipate anticoagulation and diagnostic ultrasound. Massaging the leg is contraindicated because it can dislodge a thrombus and cause pulmonary embolism. Ambulation is not started until the clot is evaluated and treatment is underway.

Question 27Nursing Care of the Adult Client

A client with heart failure has gained 2.5 kg (5.5 lb) in three days and reports increasing shortness of breath when lying flat. Which assessment finding should the nurse expect?

  1. Crackles at the lung bases Correct answer.
  2. Distended neck veins while upright
  3. Dry mucous membranes
  4. Flat neck veins when supine

Explanation

Rapid weight gain with orthopnea indicates fluid volume excess from heart failure, and dependent fluid in the lungs produces crackles at the bases. Neck vein distention is assessed with the head of the bed at 30 to 45 degrees, not with the client upright, because upright posture normally flattens the veins. Dry mucous membranes suggest dehydration rather than overload.

Question 28Nursing Care of the Adult Client

A client is admitted with an acute exacerbation of ulcerative colitis and has had 12 bloody stools in 24 hours. Which laboratory result should the nurse monitor most closely?

  1. Serum potassium Correct answer.
  2. Serum calcium
  3. Serum magnesium
  4. Serum sodium

Explanation

Profuse bloody diarrhea causes significant gastrointestinal loss of potassium, and hypokalemia can produce dysrhythmias and muscle weakness. Potassium is the electrolyte most directly depleted by large-volume diarrheal losses. Calcium, sodium, and magnesium are less acutely affected by short-term diarrheal losses.

Question 29Nursing Care of the Adult Client

A client with an acute exacerbation of asthma is using accessory muscles and has a peak expiratory flow at 40% of personal best. Which medication should the nurse anticipate administering first?

  1. Inhaled salmeterol
  2. Intravenous methylprednisolone
  3. Inhaled albuterol via nebulizer Correct answer.
  4. Oral prednisone

Explanation

A short-acting beta-2 agonist such as albuterol is the first-line rescue treatment for acute bronchospasm because it provides rapid bronchodilation. Corticosteroids reduce airway inflammation but take hours to act and do not relieve bronchospasm immediately. Salmeterol is a long-acting agent used for maintenance and is not appropriate for acute rescue.

Question 30Nursing Care of the Adult Client

A client is receiving a continuous heparin infusion for a pulmonary embolism. Which laboratory value should the nurse monitor to evaluate the effectiveness of therapy?

  1. Fibrinogen level
  2. International normalized ratio
  3. Platelet count
  4. Activated partial thromboplastin time Correct answer.

Explanation

Unfractionated heparin therapy is titrated to the activated partial thromboplastin time, which reflects the intrinsic clotting pathway that heparin affects. The international normalized ratio is used to monitor warfarin, not heparin. Platelet count is monitored to detect heparin-induced thrombocytopenia but does not measure anticoagulant effect.

Question 31Nursing Care of the Adult Client

A client with a new suprapubic catheter reports burning at the insertion site and has cloudy urine with a temperature of 38.6 C (101.5 F). Which action should the nurse take?

  1. Clamp the catheter for one hour
  2. Apply an antibiotic ointment to the site
  3. Notify the provider and obtain a urine specimen for culture Correct answer.
  4. Irrigate the catheter with sterile saline

Explanation

Fever, cloudy urine, and site burning in a client with an indwelling urinary catheter suggest a catheter-associated urinary tract infection, which requires a specimen for culture and provider notification. Routine irrigation is not indicated and can introduce organisms. Clamping the catheter promotes urine stasis and worsens infection risk.

Question 32Nursing Care of the Adult Client

A client is admitted with a suspected small bowel obstruction and has vomited repeatedly. Which finding should the nurse report immediately?

  1. Absent bowel sounds with abdominal distention Correct answer.
  2. Serum potassium of 3.0 mEq/L
  3. Complaint of mild nausea
  4. Nasogastric output of 200 mL in eight hours

Explanation

Absent bowel sounds with distention in a suspected obstruction may signal strangulation or perforation, which is a surgical emergency requiring immediate reporting. Hypokalemia from vomiting is expected and is corrected with replacement rather than being an emergency by itself. Moderate nasogastric output and mild nausea are anticipated findings.

Question 33Nursing Care of the Adult Client

A client with type 1 diabetes reports palpitations, tremors, and sweating and has a blood glucose of 58 mg/dL. The client is alert and able to swallow. Which action should the nurse take first?

  1. Start an intravenous infusion of 5% dextrose
  2. Give 15 g of a fast-acting carbohydrate Correct answer.
  3. Recheck the blood glucose in 30 minutes
  4. Administer subcutaneous regular insulin

Explanation

For an alert client with hypoglycemia, the first action is to give 15 g of a rapid-acting carbohydrate, then recheck the glucose in about 15 minutes. Insulin would lower glucose further and is contraindicated. Intravenous dextrose is reserved for clients who cannot swallow or are unconscious.

Question 34Nursing Care of the Adult Client

A client is one day postoperative after a hip replacement and has a Hemovac drain. Which action is correct when emptying the drain?

  1. Milk the tubing toward the insertion site
  2. Irrigate the drain with sterile saline
  3. Compress the device before replacing the cap to maintain suction Correct answer.
  4. Keep the drain above the level of the wound

Explanation

A Hemovac drain works by negative pressure, so the device must be compressed flat before the cap is replaced to reestablish suction. Milking the tubing toward the wound can force drainage back into the surgical site. The drain is kept below the wound, and routine irrigation is not performed.

Question 35Nursing Care of the Adult Client

A client with a new diagnosis of hypertension asks why lifestyle changes are needed when medication is available. Which response by the nurse is most accurate?

  1. Lifestyle changes allow many clients to reduce or avoid medication and lower cardiovascular risk Correct answer.
  2. Medication is only needed until lifestyle changes take effect
  3. Lifestyle changes cure hypertension permanently in most clients
  4. Lifestyle changes only help clients who are overweight

Explanation

Weight loss, sodium restriction, exercise, and alcohol moderation can lower blood pressure and reduce the medication burden while also lowering overall cardiovascular risk. Lifestyle changes rarely cure hypertension permanently, and medication is often continued long term. The benefits apply to clients of all body weights.

Question 36Nursing Care of the Adult Client

A client is admitted with an acute exacerbation of chronic pancreatitis and reports severe pain. Which intervention should the nurse implement?

  1. Encourage a low-fat diet to promote healing
  2. Place a heating pad on the abdomen
  3. Administer prescribed opioid analgesia and maintain nothing-by-mouth status Correct answer.
  4. Encourage frequent ambulation to relieve pain

Explanation

Acute pancreatitis is managed with bowel rest, intravenous fluids, and adequate analgesia, typically with opioids. Oral intake is withheld to reduce pancreatic stimulation. Heat and ambulation do not address the underlying inflammation and may worsen discomfort.

Question 37Nursing Care of the Adult Client

A client with atrial fibrillation is started on dabigatran. Which statement by the client indicates correct understanding of the medication?

  1. I will take this medication at the same times each day and report unusual bleeding Correct answer.
  2. I will take the capsule with a large glass of water and can open it if it is hard to swallow
  3. I should double the next dose if I miss one
  4. I will need monthly blood tests to check how thin my blood is

Explanation

Dabigatran is a direct thrombin inhibitor taken twice daily, and clients must report signs of bleeding such as bruising, black stools, or blood in the urine. It does not require routine coagulation monitoring like warfarin. Capsules must be swallowed whole and never opened, and missed doses are not doubled.

Question 38Nursing Care of the Adult Client

A client is receiving intravenous gentamicin. Which assessment finding should the nurse report to the provider before the next dose?

  1. Urine output of 50 mL per hour
  2. Trough level of 0.5 mcg/mL
  3. Peak level of 6 mcg/mL
  4. Trough level of 3 mcg/mL Correct answer.

Explanation

A gentamicin trough above 2 mcg/mL raises concern for nephrotoxicity and ototoxicity, so the dose should be held and the provider notified. Therapeutic trough levels are generally below 2 mcg/mL. A peak of 6 mcg/mL and a trough of 0.5 mcg/mL are within acceptable ranges, and normal urine output indicates adequate renal perfusion.

Question 39Nursing Care of the Adult Client

A client with an acute ischemic stroke is being evaluated for thrombolytic therapy. Which finding should the nurse report as an absolute contraindication?

  1. Blood glucose of 140 mg/dL
  2. Age of 72 years
  3. Blood pressure of 168/94 mm Hg
  4. History of a hemorrhagic stroke two years ago Correct answer.

Explanation

A prior hemorrhagic stroke is an absolute contraindication to thrombolytic therapy because of the high risk of intracranial hemorrhage. Blood pressure must be controlled below 185/110 mm Hg before treatment, but 168/94 mm Hg is acceptable. Age and a glucose of 140 mg/dL do not exclude a client from thrombolysis.

Question 40Nursing Care of the Adult Client

A client with a new permanent colostomy asks how to care for the stoma. Which instruction should the nurse include?

  1. Clean the stoma with mild soap and water and pat it dry Correct answer.
  2. Scrub the stoma with alcohol to prevent infection
  3. Apply lotion to the stoma to prevent dryness
  4. Cover the stoma with a gauze dressing instead of a pouch

Explanation

The stoma is cleaned gently with mild soap and water and patted dry before applying a new pouch; the surrounding skin is protected with a barrier. Alcohol is drying and irritating to stoma tissue. Lotions and occlusive gauze dressings interfere with pouch adhesion and are not used.

Question 41Maternal and Newborn Nursing

A client at 39 weeks' gestation is admitted in active labor with a cervix dilated 5 cm. The nurse documents contractions every 3 minutes, each lasting 60 seconds and palpated as strong. Which finding should the nurse report to the provider immediately?

  1. Fetal heart rate of 130 beats per minute with moderate variability
  2. Fetal heart rate pattern showing recurrent late decelerations Correct answer.
  3. Sudden gush of clear fluid from the vagina
  4. Contraction pattern of 3 minutes apart lasting 60 seconds

Explanation

Recurrent late decelerations reflect uteroplacental insufficiency and fetal hypoxemia, so they require immediate notification and intrauterine resuscitation. A normal contraction pattern, a baseline rate of 130 with moderate variability, and a clear fluid gush are expected findings.

Question 42Maternal and Newborn Nursing

A client in the second stage of labor feels a strong urge to push but the cervix is only 8 cm dilated. Which nursing action is most appropriate?

  1. Apply fundal pressure to shorten the second stage
  2. Ask the client to hold her breath for 10 seconds during contractions
  3. Instruct the client to bear down with each contraction
  4. Coach the client to use panting or blow-out breathing to avoid pushing Correct answer.

Explanation

Pushing against an incompletely dilated cervix can cause cervical edema and lacerations, so the urge is managed with panting or blow-out breathing until full dilation. Fundal pressure is unsafe, and prolonged breath holding is not recommended.

Question 43Maternal and Newborn Nursing

A client at 34 weeks' gestation is diagnosed with preterm premature rupture of membranes and has no signs of infection. Which intervention should the nurse anticipate?

  1. Immediate cesarean birth regardless of fetal status
  2. Routine pelvic examinations every 4 hours to assess dilation
  3. Induction of labor with oxytocin within 12 hours
  4. Administration of antenatal corticosteroids and antibiotics with continued monitoring Correct answer.

Explanation

Before 37 weeks with preterm premature rupture of membranes, expectant management with corticosteroids for fetal lung maturity and antibiotics to prolong latency is standard when infection is absent. Frequent digital exams increase infection risk and are avoided.

Question 44Maternal and Newborn Nursing

A client is receiving magnesium sulfate for preeclampsia with severe features. Which assessment finding indicates magnesium toxicity and requires immediate action?

  1. Report of flushing and warmth
  2. Respiratory rate of 11 breaths per minute with absent deep tendon reflexes Correct answer.
  3. Urine output of 60 mL per hour
  4. Blood pressure of 148/92 mm Hg

Explanation

Magnesium sulfate toxicity first appears as loss of deep tendon reflexes, followed by respiratory depression and then cardiac arrest. A respiratory rate of 11 with absent reflexes signals toxicity and requires stopping the infusion and notifying the provider.

Question 45Maternal and Newborn Nursing

A client at 32 weeks' gestation reports a sudden painless episode of bright red vaginal bleeding. Which nursing action is the priority?

  1. Reassure the client that painless bleeding is normal in late pregnancy
  2. Ambulate the client to evaluate whether bleeding increases
  3. Perform a sterile vaginal examination to determine dilation
  4. Place the client on bed rest and prepare for immediate assessment without a vaginal exam Correct answer.

Explanation

Painless bright red bleeding in late pregnancy suggests placenta previa, and a digital vaginal exam can provoke catastrophic hemorrhage. The nurse should avoid vaginal examination, monitor maternal and fetal status, and prepare for ultrasound.

Question 46Maternal and Newborn Nursing

A client at 36 weeks' gestation presents with a rigid, board-like abdomen, dark vaginal bleeding, and fetal heart rate in the 90s. Which condition should the nurse suspect?

  1. Placental abruption Correct answer.
  2. Placenta previa
  3. Uterine rupture
  4. Vasa previa

Explanation

Painful dark bleeding with a rigid uterus and fetal bradycardia is the classic presentation of placental abruption. Placenta previa causes painless bleeding, and vasa previa produces bleeding with membrane rupture.

Question 47Maternal and Newborn Nursing

A client at 40 weeks' gestation is admitted with a blood pressure of 162/110 mm Hg and a headache. Which medication should the nurse anticipate administering first for seizure prophylaxis?

  1. Betamethasone
  2. Hydralazine
  3. Oxytocin
  4. Magnesium sulfate Correct answer.

Explanation

Magnesium sulfate is the standard for preventing and treating eclamptic seizures in preeclampsia with severe features. Hydralazine lowers blood pressure but does not prevent seizures, and betamethasone is for fetal lung maturity.

Question 48Maternal and Newborn Nursing

A client in active labor is dilated 4 cm and requests epidural analgesia. Which action should the nurse take before the epidural is placed?

  1. Place the client in the lithotomy position
  2. Give an oral opioid for breakthrough pain
  3. Administer an intravenous fluid bolus as ordered Correct answer.
  4. Insert an indwelling urinary catheter

Explanation

An intravenous fluid bolus is given before epidural placement to offset the vasodilation and hypotension that follow sympathetic blockade. A urinary catheter is often placed after the epidural, and positioning is not a prerequisite.

Question 49Maternal and Newborn Nursing

A client at 30 weeks' gestation with a history of preterm birth is prescribed a cervical cerclage. Which statement by the client indicates correct understanding of the procedure?

  1. I should report any contractions or fluid leakage immediately Correct answer.
  2. The cerclage guarantees I will deliver at term
  3. I will need to remain on strict bed rest for the rest of the pregnancy
  4. The stitch will be removed when I go into labor or near term

Explanation

A cerclage reinforces a weak cervix but does not eliminate the risk of preterm labor or membrane rupture, so the client must report contractions or fluid loss promptly. The suture is typically removed at 36 to 37 weeks or with labor onset.

Question 50Maternal and Newborn Nursing

A client at 28 weeks' gestation reports a sudden decrease in fetal movement. Which action should the nurse take first?

  1. Tell the client to drink cold water and lie on her left side, then ignore the change
  2. Schedule a routine visit for the following week
  3. Instruct the client to perform a fetal movement count and contact the provider Correct answer.
  4. Reassure the client that fetal movement decreases as pregnancy advances

Explanation

Decreased fetal movement warrants prompt evaluation because it may signal fetal compromise. The nurse should have the client perform a kick count and notify the provider for further testing such as a nonstress test.