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OMSB Nurse Exam practice questions

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Question 1Medical-Surgical Nursing

A patient is 6 hours post-appendectomy and reports sudden sharp abdominal pain with a rigid abdomen and a heart rate of 124/min. Which complication should the nurse suspect first?

  1. Atelectasis
  2. Anastomotic leak with peritonitis Correct answer.
  3. Wound dehiscence
  4. Paralytic ileus

Explanation

Sudden sharp abdominal pain with a rigid, board-like abdomen and tachycardia after bowel surgery suggests an anastomotic leak causing chemical peritonitis, a surgical emergency requiring immediate notification of the surgeon. Paralytic ileus and atelectasis produce different findings, and wound dehiscence is visible at the incision.

Question 2Medical-Surgical Nursing

Which finding is most characteristic of hypovolemic shock in an adult medical-surgical patient?

  1. Jugular venous distension with crackles
  2. Warm flushed skin with bradycardia
  3. Narrowed pulse pressure with cool clammy extremities Correct answer.
  4. Bounding pulse with hypertension

Explanation

Hypovolemia reduces stroke volume, so the body compensates with vasoconstriction and tachycardia, producing a narrowed pulse pressure, cool clammy skin, and delayed capillary refill. Bounding pulses and JVD indicate fluid overload or cardiogenic causes instead.

Question 3Medical-Surgical Nursing

A patient with chronic kidney disease has a serum potassium of 6.9 mEq/L and peaked T waves on the ECG. Which action should the nurse take first?

  1. Encourage a high-fiber diet
  2. Administer oral sodium polystyrene sulfonate
  3. Obtain a repeat potassium level
  4. Administer intravenous calcium gluconate Correct answer.

Explanation

Peaked T waves with severe hyperkalemia indicate cardiac membrane instability, so intravenous calcium is given first to stabilize the myocardium while other measures shift or remove potassium. Potassium binders and dietary changes act too slowly to protect against arrhythmia.

Question 4Medical-Surgical Nursing

Which assessment finding should the nurse report immediately in a patient receiving a blood transfusion for 30 minutes?

  1. Heart rate decreasing from 92 to 84/min
  2. Mild itching at the venipuncture site
  3. Temperature rise of 1.8 degrees Celsius with chills and flank pain Correct answer.
  4. Complaint of feeling cold with mild fatigue

Explanation

Fever with chills and flank or back pain suggests an acute hemolytic transfusion reaction, which requires stopping the transfusion immediately, maintaining IV access with normal saline, and notifying the provider and blood bank. Isolated mild itching or feeling cold is far less concerning.

Question 5Medical-Surgical Nursing

A patient with type 1 diabetes has a blood glucose of 48 mg/dL and is drowsy but able to swallow. What should the nurse give first?

  1. Subcutaneous insulin
  2. A high-protein snack
  3. Intravenous 50% dextrose
  4. 15 grams of fast-acting oral carbohydrate Correct answer.

Explanation

For a conscious patient who can swallow, the first step in treating hypoglycemia is 15 grams of rapid-acting carbohydrate, followed by rechecking glucose in 15 minutes. Intravenous dextrose is reserved for patients who cannot swallow or are unconscious.

Question 6Medical-Surgical Nursing

Which instruction is most important for a patient starting warfarin therapy?

  1. Avoid all green leafy vegetables permanently
  2. Keep a consistent vitamin K intake and report bleeding or bruising Correct answer.
  3. Take aspirin for any minor pain
  4. Double the dose if a dose is missed

Explanation

Warfarin's effect is altered by vitamin K, so patients should keep intake consistent rather than eliminate greens, and they must report signs of bleeding. Missed doses are never doubled, and aspirin increases bleeding risk.

Question 7Medical-Surgical Nursing

A patient with an acute exacerbation of asthma has a respiratory rate of 32/min, speaks in single words, and has an oxygen saturation of 88% on room air. Which intervention has priority?

  1. Obtain a sputum culture
  2. Encourage oral fluids
  3. Administer prescribed short-acting beta-2 agonist nebulizer and supplemental oxygen Correct answer.
  4. Teach pursed-lip breathing

Explanation

Single-word speech, tachypnea, and hypoxemia indicate a severe asthma exacerbation, so immediate bronchodilator therapy and oxygen are the priority. Teaching and diagnostics follow once the airway and oxygenation are stabilized.

Question 8Medical-Surgical Nursing

Which position is most appropriate for a patient with acute decompensated heart failure who has orthopnea and bibasilar crackles?

  1. Supine with legs flat
  2. High Fowler's position Correct answer.
  3. Prone position
  4. Trendelenburg position

Explanation

High Fowler's position lowers venous return and reduces pulmonary congestion, improving ventilation in acute heart failure with orthopnea. Supine and Trendelenburg positions increase venous return and worsen dyspnea.

Question 9Medical-Surgical Nursing

A patient has a chest tube connected to a water-seal drainage system. Which observation requires immediate intervention?

  1. Fluid level fluctuating slightly at the suction control chamber
  2. Drainage of 50 mL of serosanguineous fluid in the first hour
  3. Tidaling of fluid in the water-seal chamber with respiration
  4. Continuous bubbling in the water-seal chamber Correct answer.

Explanation

Continuous bubbling in the water-seal chamber indicates an air leak in the system or pleural space, which must be assessed and corrected promptly. Intermittent tidaling with breathing and modest serosanguineous drainage are expected findings.

Question 10Medical-Surgical Nursing

A patient with a new ileostomy has liquid output of 1,800 mL in 24 hours. Which assessment is the priority?

  1. Signs of urinary retention
  2. Signs of dehydration and electrolyte loss Correct answer.
  3. Signs of constipation
  4. Signs of increased intracranial pressure

Explanation

High-output ileostomies cause large losses of water, sodium, and potassium, so assessing for dehydration, orthostasis, and electrolyte imbalance is the priority. Constipation is not possible from an ileostomy, and the other options are unrelated.

Question 11Medical-Surgical Nursing

Which laboratory value is most concerning for a patient receiving gentamicin intravenously?

  1. Sodium of 138 mEq/L
  2. Hemoglobin of 12 g/dL
  3. Platelet count of 250,000/mm3
  4. Rising serum creatinine Correct answer.

Explanation

Aminoglycosides such as gentamicin are nephrotoxic, so a rising creatinine signals acute kidney injury and warrants prompt reporting and possible dose adjustment. The other listed values are within normal limits.

Question 12Medical-Surgical Nursing

A patient with a spinal cord injury at T6 suddenly develops severe headache, hypertension, and profuse sweating with bradycardia. What should the nurse do first?

  1. Elevate the head of the bed and check for bladder distension Correct answer.
  2. Document the finding and reassess in one hour
  3. Administer a prescribed antipyretic
  4. Encourage the patient to ambulate

Explanation

These signs indicate autonomic dysreflexia, triggered by a noxious stimulus such as bladder distension. Immediate action is to sit the patient upright to reduce blood pressure and identify and remove the trigger.

Question 13Medical-Surgical Nursing

Which finding best indicates that a patient's nasogastric tube is correctly positioned in the stomach before initial use?

  1. Injection of 30 mL of air with a whoosh sound
  2. A pH of 5.5 from aspirated fluid Correct answer.
  3. Measurement of tube length at the nostril
  4. Presence of a cough during insertion

Explanation

Aspirate pH of 5.5 or lower supports gastric placement and is the recommended bedside verification method. The auscultatory whoosh method is unreliable, and tube length marking alone does not confirm placement.

Question 14Medical-Surgical Nursing

A patient in the emergency department has a suspected tension pneumothorax with tracheal deviation and hypotension. Which action should the nurse anticipate?

  1. Application of a heating pad
  2. Immediate needle decompression Correct answer.
  3. Administration of a diuretic
  4. Placement of a urinary catheter

Explanation

Tension pneumothorax is a life-threatening emergency treated with immediate needle decompression followed by chest tube placement. Diuretics, catheterization, and heat have no role in this condition.

Question 15Medical-Surgical Nursing

Which symptom should the nurse teach a patient to report as an early sign of an acute coronary syndrome?

  1. Pain relieved by leaning forward
  2. Burning pain after meals
  3. Sharp pain on deep inspiration only
  4. Chest pressure radiating to the jaw or arm Correct answer.

Explanation

Chest pressure or discomfort radiating to the jaw, neck, or arm is the classic presentation of myocardial ischemia. Pleuritic pain, positional pain relieved by leaning forward, and postprandial burning suggest other diagnoses.

Question 16Medical-Surgical Nursing

A patient with a below-knee amputation reports a sharp, burning sensation in the missing limb. Which response by the nurse is most appropriate?

  1. Ignore the complaint as expected
  2. Apply a tight tourniquet to the residual limb
  3. Tell the patient the pain is imaginary
  4. Explain that phantom limb pain is real and offer prescribed analgesia Correct answer.

Explanation

Phantom limb pain is a genuine neuropathic phenomenon, and patients benefit from validation plus prescribed analgesics, mirror therapy, or desensitization techniques. Dismissing the pain damages trust and leaves it untreated.

Question 17Medical-Surgical Nursing

A patient with a new colostomy is learning to change the pouch. Which instruction is correct?

  1. Clean the peristomal skin with mild soap and water and dry thoroughly Correct answer.
  2. Cut the wafer opening larger than the stoma
  3. Use alcohol to clean the stoma
  4. Apply the pouch over moist skin

Explanation

The peristomal skin should be cleaned gently and dried completely before applying the skin barrier so the pouch adheres and skin breakdown is prevented. Alcohol is drying and irritating, moisture prevents adhesion, and an oversized opening exposes skin to effluent.

Question 18Medical-Surgical Nursing

A patient is admitted with diabetic ketoacidosis. Which finding is most consistent with this condition?

  1. Blood glucose 480 mg/dL, pH 7.20, and deep rapid respirations Correct answer.
  2. Blood glucose 600 mg/dL with pH 7.40 and no ketones
  3. Blood glucose 90 mg/dL and pH 7.45
  4. Blood glucose 120 mg/dL with shallow slow respirations

Explanation

DKA is characterized by hyperglycemia, metabolic acidosis, and Kussmaul respirations as the body attempts to blow off carbon dioxide. A normal pH without ketones suggests hyperosmolar hyperglycemic state instead.

Question 19Medical-Surgical Nursing

Which assessment is most important for a patient receiving intravenous furosemide?

  1. Serum calcium and pupil size
  2. Deep tendon reflexes only
  3. Serum potassium and urine output Correct answer.
  4. Blood glucose before each dose

Explanation

Loop diuretics cause potassium loss and volume depletion, so monitoring potassium and urine output is essential to prevent hypokalemia and dehydration. Calcium, reflexes, and glucose are not the primary concerns with furosemide.

Question 20Medical-Surgical Nursing

A patient with a head injury has a Glasgow Coma Scale score that dropped from 14 to 10 over two hours. What should the nurse do?

  1. Give a prescribed sedative
  2. Reassess in four hours
  3. Notify the provider immediately and prepare for possible intervention Correct answer.
  4. Document as expected after head injury

Explanation

A declining Glasgow Coma Scale indicates worsening neurologic status, possibly from expanding intracranial hemorrhage or edema, and requires urgent provider notification and preparation for imaging or surgery. Sedation would further obscure assessment.

Question 21Medical-Surgical Nursing

Which precaution is essential when caring for a patient with a new tracheostomy during suctioning?

  1. Suction routinely every 30 minutes regardless of need
  2. Apply continuous suction while inserting the catheter
  3. Use the largest catheter available to improve removal
  4. Limit suction to 10 to 15 seconds and hyperoxygenate before and after Correct answer.

Explanation

Suctioning should be limited to 10 to 15 seconds with hyperoxygenation to prevent hypoxemia and mucosal trauma, and suction is applied only during withdrawal. Routine scheduled suctioning without indication causes unnecessary injury.

Question 22Medical-Surgical Nursing

A patient with cirrhosis has ascites and a serum albumin of 2.1 g/dL. Which nursing intervention is most appropriate?

  1. Restrict all fluids to zero
  2. Encourage vigorous exercise
  3. Monitor daily weight, abdominal girth, and strict intake and output Correct answer.
  4. Encourage a high-sodium diet

Explanation

Ascites management relies on tracking weight, abdominal girth, and fluid balance to evaluate diuretic response and detect rapid fluid shifts. Sodium restriction, not supplementation, is indicated, and vigorous exercise is not appropriate in decompensated cirrhosis.

Question 23Medical-Surgical Nursing

A patient is receiving intravenous vancomycin. Which assessment finding should be reported to the provider?

  1. Blood pressure of 118/76 mm Hg
  2. Temperature of 37.0 degrees Celsius
  3. Urine output of 40 mL/hour
  4. Flushing of the face and neck during infusion Correct answer.

Explanation

Flushing of the face and neck during vancomycin infusion suggests vancomycin infusion reaction, related to rapid infusion, and the rate should be slowed and the provider notified. The other values are normal.

Question 24Medical-Surgical Nursing

Which finding in a patient with a casted lower leg suggests compartment syndrome?

  1. Severe pain out of proportion to injury that worsens with passive stretch Correct answer.
  2. Itching under the cast
  3. Capillary refill of 2 seconds
  4. Mild swelling controlled by elevation

Explanation

Compartment syndrome presents with pain disproportionate to the injury, pain on passive stretch, paresthesia, pallor, and pulselessness late in the course. Mild swelling, itching, and normal capillary refill are not warning signs.

Question 25Medical-Surgical Nursing

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

  1. Target a saturation of 100%
  2. Withhold oxygen entirely
  3. Administer high-flow oxygen at 15 L/min by mask
  4. Titrate oxygen to a target saturation of 88% to 92% Correct answer.

Explanation

In COPD with chronic carbon dioxide retention, oxygen is titrated to 88% to 92% to correct hypoxemia while avoiding hyperoxia that can worsen carbon dioxide retention. Withholding oxygen is unsafe, and targeting 100% is excessive.

Question 26Medical-Surgical Nursing

A patient is admitted with a suspected peptic ulcer and reports sudden, severe epigastric pain that radiates to the back. On assessment, the abdomen is rigid and board-like, and bowel sounds are absent. Which complication should the nurse suspect first?

  1. Perforation of the ulcer Correct answer.
  2. Gastric outlet obstruction
  3. Acute pancreatitis
  4. Upper gastrointestinal bleeding

Explanation

Sudden severe epigastric pain radiating to the back with a rigid, board-like abdomen and absent bowel sounds indicates peritonitis from a perforated peptic ulcer. This is a surgical emergency requiring immediate notification of the provider and preparation for surgery or drainage.

Question 27Medical-Surgical Nursing

A patient with a new diagnosis of type 1 diabetes mellitus is being taught about sick-day management. Which instruction should the nurse include?

  1. Continue taking insulin even if you are unable to eat Correct answer.
  2. Increase your intake of simple sugars to prevent hypoglycemia
  3. Check your blood glucose only when you feel symptomatic
  4. Stop taking insulin if you are vomiting

Explanation

During illness, stress hormones increase blood glucose, so insulin must be continued even if the patient cannot eat to prevent diabetic ketoacidosis. The patient should check blood glucose more frequently and seek medical advice if vomiting persists.

Question 28Medical-Surgical Nursing

A patient is receiving a blood transfusion. Fifteen minutes into the transfusion, the patient reports chills, and the nurse notes a temperature of 38.5°C, tachycardia, and a drop in blood pressure. What is the nurse's first action?

  1. Slow the transfusion rate and administer acetaminophen
  2. Continue the transfusion and notify the blood bank
  3. Administer diphenhydramine and continue the transfusion
  4. Stop the transfusion and maintain intravenous access with normal saline Correct answer.

Explanation

These findings suggest an acute hemolytic transfusion reaction, which can be life-threatening. The nurse must stop the transfusion immediately, keep the IV line patent with normal saline, and notify the provider and blood bank while monitoring vital signs.

Question 29Medical-Surgical Nursing

A patient with chronic kidney disease has a serum potassium of 6.8 mEq/L. Which finding should the nurse report immediately?

  1. Muscle cramps
  2. Hypoactive bowel sounds
  3. Peaked T waves on the electrocardiogram Correct answer.
  4. Increased urine output

Explanation

Peaked T waves are an early electrocardiographic sign of hyperkalemia and can progress to lethal arrhythmias such as ventricular fibrillation. The nurse should report this immediately and anticipate treatment with calcium gluconate, insulin, and glucose.

Question 30Medical-Surgical Nursing

A patient with a new diagnosis of heart failure is prescribed furosemide. Which instruction should the nurse include in discharge teaching?

  1. Take the medication at bedtime to avoid daytime urination
  2. Increase your intake of potassium-rich foods without consulting your provider
  3. Limit fluid intake to 500 mL per day
  4. Weigh yourself daily and report a gain of more than 2 to 3 pounds in a day Correct answer.

Explanation

Daily weight monitoring is essential for detecting fluid retention early. A weight gain of 2 to 3 pounds in one day or 5 pounds in a week should be reported to the provider.

Question 31Medical-Surgical Nursing

A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which oxygen administration approach is most appropriate?

  1. Titrate oxygen to maintain a saturation of 88% to 92% Correct answer.
  2. Use a nonrebreather mask at 15 L/min continuously
  3. Withhold oxygen unless the patient is in respiratory distress
  4. Administer high-flow oxygen to maintain a saturation of 100%

Explanation

In COPD, the hypoxic drive may be blunted, and excessive oxygen can lead to hypercarbia and respiratory depression. Oxygen should be titrated to a target saturation of 88% to 92% to ensure adequate oxygenation while avoiding toxicity.

Question 32Medical-Surgical Nursing

A patient with a spinal cord injury at T6 develops a severe headache, hypertension, and bradycardia after a distended bladder is noted. Which action should the nurse take first?

  1. Catheterize the bladder to relieve the distension Correct answer.
  2. Administer a prescribed antihypertensive medication
  3. Notify the provider and wait for orders
  4. Place the patient in a supine position

Explanation

These findings indicate autonomic dysreflexia, a life-threatening emergency triggered by noxious stimuli such as bladder distension. The first action is to remove the stimulus, which in this case is relieving bladder distension by catheterization.

Question 33Medical-Surgical Nursing

A patient is scheduled for a colonoscopy. Which instruction should the nurse give during preprocedure teaching?

  1. You should stop taking all medications 1 week before the procedure
  2. You may eat a light breakfast on the morning of the procedure
  3. You will need to follow a clear liquid diet for 1 to 2 days before the procedure Correct answer.
  4. You will receive sedation, so you can drive yourself home afterward

Explanation

Bowel preparation for a colonoscopy includes a clear liquid diet for 1 to 2 days and a prescribed bowel cleansing regimen. This ensures adequate visualization of the colon.

Question 34Medical-Surgical Nursing

A patient is receiving total parenteral nutrition (TPN) through a central venous catheter. Which action is most important for the nurse to take?

  1. Increase the infusion rate if the patient reports hunger
  2. Monitor blood glucose levels every 6 hours Correct answer.
  3. Change the TPN tubing every 72 hours
  4. Flush the catheter with heparin every 4 hours

Explanation

TPN contains high concentrations of dextrose and can cause hyperglycemia. Blood glucose should be monitored regularly, typically every 6 hours, until the patient is stable.

Question 35Medical-Surgical Nursing

A patient is admitted with a diagnosis of acute pancreatitis. Which nursing intervention is the priority?

  1. Maintain NPO status and administer intravenous fluids as prescribed Correct answer.
  2. Administer prescribed oral analgesics
  3. Place the patient in a supine position for comfort
  4. Encourage a low-fat diet to promote healing

Explanation

Acute pancreatitis requires bowel rest to decrease pancreatic stimulation. The patient should remain NPO, and intravenous fluids are given to maintain hydration and electrolyte balance.

Question 36Medical-Surgical Nursing

A patient with a head injury has a Glasgow Coma Scale score of 13. Which nursing action is most important?

  1. Perform neurological assessments every 1 to 2 hours Correct answer.
  2. Encourage the patient to ambulate frequently
  3. Administer a sedative to prevent restlessness
  4. Restrict all visitors to prevent stimulation

Explanation

A Glasgow Coma Scale score of 13 indicates mild impairment, and frequent neurological assessments are essential to detect deterioration. Changes in level of consciousness are often the earliest sign of increased intracranial pressure.

Question 37Medical-Surgical Nursing

A patient is receiving intravenous gentamicin. Which laboratory value should the nurse monitor most closely?

  1. Platelet count
  2. Serum creatinine Correct answer.
  3. Serum potassium
  4. Hemoglobin

Explanation

Gentamicin is nephrotoxic and can cause acute kidney injury. Serum creatinine and blood urea nitrogen should be monitored to detect renal impairment early.

Question 38Medical-Surgical Nursing

A patient with a new ileostomy has liquid output of 1,500 mL in 24 hours. Which assessment is the priority?

  1. The color of the stoma
  2. The patient's dietary preferences
  3. The patient's ability to change the pouch
  4. Signs of dehydration and electrolyte imbalance Correct answer.

Explanation

High-output ileostomies can lead to significant fluid and electrolyte losses, particularly sodium and potassium. The nurse should monitor for dehydration, electrolyte imbalances, and signs of hypovolemia.

Question 39Medical-Surgical Nursing

A patient with a casted lower leg reports severe pain that is not relieved by prescribed analgesics. The nurse notes pallor and decreased sensation in the toes. Which action should the nurse take first?

  1. Apply ice packs to the cast
  2. Notify the provider immediately Correct answer.
  3. Elevate the leg above the level of the heart
  4. Administer an additional dose of analgesic

Explanation

These findings suggest compartment syndrome, a surgical emergency. The nurse must notify the provider immediately to prevent permanent nerve and muscle damage.

Question 40Medical-Surgical Nursing

A patient with cirrhosis and ascites is scheduled for a paracentesis. Which instruction should the nurse give before the procedure?

  1. Avoid eating or drinking for 12 hours before the procedure
  2. Empty your bladder before the procedure Correct answer.
  3. Lie flat on your back during the procedure
  4. Take your diuretic medication as usual

Explanation

An empty bladder reduces the risk of bladder puncture during paracentesis. The patient should be instructed to void immediately before the procedure.

Question 41Maternal and Child Health Nursing

A woman at 32 weeks' gestation reports a sudden gush of clear fluid from the vagina. On speculum examination, pooling of fluid is seen in the posterior fornix. Which finding best confirms that the membranes have ruptured?

  1. A closed, firm cervix on digital examination
  2. A fern-like crystallization pattern when the fluid dries on a glass slide Correct answer.
  3. Presence of white blood cells in the vaginal fluid
  4. A cervical pH of 4.5 on nitrazine paper

Explanation

Amniotic fluid contains salts and proteins that crystallize into a fern pattern when dried on a slide, which is a classic confirmatory test for ruptured membranes. Vaginal fluid is normally acidic, so nitrazine paper turns blue only when the alkaline amniotic fluid raises the pH, usually to about 7.0 or higher.

Question 42Maternal and Child Health Nursing

During the active phase of the first stage of labor, a nulliparous woman's cervix is assessed at 4 cm dilated. Which finding indicates that she has entered the active phase according to widely used criteria?

  1. Cervical dilatation of 4 cm with a station of minus 3
  2. Rupture of membranes before 4 cm dilatation
  3. Cervical dilatation of at least 6 cm with regular contractions Correct answer.
  4. Complete effacement with a station of zero

Explanation

Contemporary criteria define the active phase as beginning at about 6 cm dilatation in most women, when cervical change accelerates. Before that point, slow change is expected and should not automatically be labeled as labor arrest.

Question 43Maternal and Child Health Nursing

A newborn is delivered at 39 weeks and placed skin-to-skin. Which action should the nurse take first to support thermoregulation?

  1. Dry the infant thoroughly and cover the head with a dry cap Correct answer.
  2. Give a warm bath within the first 30 minutes
  3. Delay any covering until the first feeding is completed
  4. Place the infant under a radiant warmer set to maximum

Explanation

Evaporative heat loss is the largest source of neonatal heat loss immediately after birth, so drying the skin and covering the head is the priority. Skin-to-skin contact with the mother then provides conductive warmth while supporting breastfeeding and bonding.

Question 44Maternal and Child Health Nursing

A woman at 36 weeks' gestation has a blood pressure of 158/104 mmHg on two occasions four hours apart, with 3+ proteinuria. Which medication should the nurse anticipate to prevent seizures?

  1. Hydralazine by mouth
  2. Methylergonovine intramuscularly
  3. Oxytocin by continuous infusion
  4. Magnesium sulfate by intravenous infusion Correct answer.

Explanation

Magnesium sulfate is the standard anticonvulsant for seizure prophylaxis in preeclampsia with severe features. The nurse monitors for toxicity using deep tendon reflexes, respiratory rate, and urine output, with calcium gluconate available as the antidote.

Question 45Maternal and Child Health Nursing

A woman who is 10 weeks postpartum reports painful, red, warm areas on one breast and flu-like symptoms with a fever of 38.6 degrees Celsius. What is the priority nursing instruction?

  1. Pump and discard all milk for at least 14 days
  2. Apply cold packs and bind the breasts tightly
  3. Stop breastfeeding on both breasts until the fever resolves
  4. Continue breastfeeding or expressing milk and start prescribed antibiotics promptly Correct answer.

Explanation

Mastitis is usually caused by staphylococcal infection and is managed with continued milk removal and prompt antibiotic therapy. Emptying the breast prevents stasis and abscess formation, and the milk remains safe for the infant.

Question 46Maternal and Child Health Nursing

A term newborn at 6 hours of life has a respiratory rate of 80 breaths per minute with grunting and nasal flaring. Which action should the nurse take first?

  1. Position the infant and initiate continuous monitoring while notifying the provider Correct answer.
  2. Wait one hour and reassess without intervention
  3. Feed the infant to help settle the breathing
  4. Apply a tight abdominal binder

Explanation

Tachypnea above 60 breaths per minute with grunting and flaring suggests respiratory distress such as transient tachypnea of the newborn or respiratory distress syndrome. The nurse should support airway positioning, monitor oxygen saturation, and obtain urgent medical review rather than delay.

Question 47Maternal and Child Health Nursing

A client at 28 weeks' gestation has a hemoglobin of 9.8 g/dL and a ferritin of 8 ng/mL. Which recommendation is most appropriate?

  1. Restrict dietary protein to reduce iron demand
  2. Begin oral iron supplementation with vitamin C and recheck in four weeks Correct answer.
  3. Take calcium supplements with each meal
  4. Increase milk intake to four glasses daily

Explanation

Low ferritin confirms iron deficiency anemia, which is common in pregnancy due to expanded plasma volume and fetal demand. Oral iron taken with vitamin C improves absorption and should be followed by repeat hemoglobin testing.

Question 48Maternal and Child Health Nursing

A woman at 34 weeks' gestation reports decreased fetal movement. Which initial assessment should the nurse perform?

  1. Reassure her that fetal movement decreases normally at this gestation
  2. Instruct her to lie supine for one hour and count movements
  3. Schedule a routine visit in two weeks
  4. Auscultate the fetal heart rate and perform a nonstress test as ordered Correct answer.

Explanation

Reduced fetal movement warrants immediate evaluation of fetal wellbeing, typically with heart rate auscultation and a nonstress test or biophysical profile. Decreased movement can signal placental insufficiency or fetal compromise and should never be dismissed.

Question 49Maternal and Child Health Nursing

During the second stage of labor, the fetal heart rate drops to 90 beats per minute and remains low for three minutes. Which action should the nurse take first?

  1. Instruct the mother to push harder with each contraction
  2. Reposition the mother to the left side and notify the provider immediately Correct answer.
  3. Prepare for immediate forceps rotation
  4. Increase the oxytocin infusion rate

Explanation

A prolonged fetal bradycardia requires intrauterine resuscitation, beginning with maternal repositioning to relieve aortocaval compression and improve placental perfusion. The provider must be notified at once so further measures or expedited delivery can be arranged.

Question 50Maternal and Child Health Nursing

A woman at 38 weeks' gestation with a previous cesarean birth requests a trial of labor. Which factor most strongly supports vaginal birth after cesarean?

  1. Two previous cesarean births with a vertical incision
  2. A prior low transverse uterine incision and no other uterine scars Correct answer.
  3. A prior classical incision with a single-layer closure
  4. A history of uterine rupture in a prior pregnancy

Explanation

A low transverse incision carries the lowest risk of rupture during labor and is the standard criterion for a trial of labor after cesarean. Other factors that improve success include spontaneous labor and a prior vaginal birth.