Question

A client at 39 weeks gestation reports experiencing contractions. The nurse observes that the contractions are irregular, decrease in intensity with walking. and the client has no cervical dilation on examination. Based on these findings, what is the most appropriate nursing action?

Answer 1

Correct Answers:

Educate the client that these are false labor contractions and suggest rest and hydration to alleviate discomfort.

Rationale :

🤎 False labor contractions are typically irregular and do not progressively increase in frequency, duration, and intensity.

🤎 The client's contractions decrease in intensity with walking, which strongly supports false labor rather than true labor.

🤎 True labor contractions usually become progressively stronger, longer, and closer together despite changes in activity or position.

🤎 The absence of cervical dilation further indicates that the contractions are not producing progressive cervical change.

🤎 Rest, hydration, and position changes may decrease the discomfort associated with false labor contractions.

🤎 The client should be taught to monitor for regular intensifying contractions, rupture of membranes, vaginal bleeding, decreased fetal movement, or other indications for evaluation.

🤎 Education can help the client distinguish false labor from true labor and recognize when to return for assessment.

🤎 The findings therefore support reassurance, education, rest, and hydration rather than preparation for immediate delivery.

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Answer 2

Correct Answers:

Notify the healthcare provider immediately and prepare for potential emergency interventions for postpartum hemorrhage.

Rationale :

🖤 Soaking more than one perineal pad per hour represents excessive postpartum bleeding and requires immediate intervention.

🖤 Passage of large blood clots provides additional evidence of significant abnormal postpartum blood loss.

🖤 Dizziness and near-syncope suggest decreased circulating blood volume and possible developing hypovolemia.

🖤 Postpartum hemorrhage can progress rapidly to hypovolemic shock, organ hypoperfusion, and death if treatment is delayed.

🖤 The nurse should rapidly assess the client's fundus, bleeding, vital signs, level of consciousness, and overall hemodynamic status while initiating the emergency response.

🖤 The healthcare provider should be notified promptly, and the nurse should prepare for interventions such as uterine massage, uterotonic medications, IV fluid resuscitation, laboratory testing, and blood products as indicated.

🖤 Continuous reassessment is necessary because the client's condition can deteriorate rapidly with ongoing hemorrhage.

🖤 Immediate recognition and emergency management of suspected postpartum hemorrhage take priority over routine postpartum comfort measures.

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Answer 3

Correct Answers:

Prepare for possible surgical birth
Notify the provider
Discontinue oxytocin

Rationale :

Prepare for possible surgical birth

⏩ A Category III fetal heart rate pattern is abnormal and indicates a significant risk for fetal acidemia when the pattern persists.

⏩ Recurrent late decelerations indicate that fetal oxygenation may be compromised during uterine contractions.

⏩ Minimal variability combined with recurrent late decelerations and fetal bradycardia is especially concerning for impaired fetal oxygenation.

⏩ A fetal heart rate of 100 beats/min represents bradycardia when sustained and adds to the concerning fetal assessment.

⏩ Immediate intrauterine resuscitative measures should be initiated while the fetal response is continuously evaluated.

⏩ Failure of the fetal heart rate pattern to improve can require expedited birth to prevent progressive fetal hypoxia and acidemia.

⏩ The nurse should therefore anticipate and prepare for an emergency operative birth if corrective measures do not rapidly resolve the abnormal pattern.

⏩ Preparing for possible surgical birth prevents unnecessary delay if immediate delivery becomes necessary.

Notify the provider

⏩ A Category III fetal heart rate tracing requires immediate evaluation and corrective interventions.

⏩ The healthcare provider should be promptly notified because persistent abnormalities may require expedited delivery.

⏩ Communication should include the fetal baseline rate, variability, deceleration pattern, uterine activity, and interventions already performed.

⏩ Recurrent late decelerations suggest impaired uteroplacental oxygen exchange during contractions.

⏩ The combination of late decelerations, minimal variability, and fetal bradycardia indicates significant fetal compromise.

⏩ Prompt provider involvement allows rapid decisions regarding additional interventions and the potential need for operative birth.

⏩ Continuous fetal monitoring should continue while corrective measures and preparations are underway.

⏩ Immediate provider notification is therefore an essential response to this Category III pattern.

Discontinue oxytocin

⏩ Oxytocin stimulates uterine contractions and can increase contraction frequency and intensity.

⏩ Excessive uterine activity can reduce uteroplacental blood flow and compromise fetal oxygenation.

⏩ Recurrent late decelerations indicate that the fetus may not be tolerating the current uterine contraction pattern.

⏩ Discontinuing oxytocin decreases uterine stimulation and can provide more time for placental reperfusion between contractions.

⏩ Oxytocin should be stopped promptly when a concerning fetal heart rate pattern develops during an induction or augmentation.

⏩ Additional corrective measures commonly include maternal repositioning and IV fluid administration as clinically indicated.

⏩ The fetal heart rate should be continuously reassessed for improvement after interventions are initiated.

⏩ Discontinuing oxytocin therefore directly removes a potentially reversible contributor to fetal compromise.

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Answer 4

Correct Answers:

Calculate the estimated date of birth (EDB) and obtain a complete health history to identify potential risks.

Rationale :

✅ Calculate the estimated date of birth (EDB) and obtain a complete health history to identify potential risks — Correct

✅ The first prenatal visit establishes essential baseline information needed to guide care throughout the pregnancy.

✅ Calculating the estimated date of birth (EDB) helps determine gestational age and guides the timing of prenatal assessments, screening, and fetal surveillance.

✅ A complete health history identifies maternal conditions, previous pregnancy complications, medication exposures, family history, and other factors that can influence pregnancy outcomes.

✅ The initial assessment should also evaluate obstetric, gynecologic, medical, surgical, psychosocial, nutritional, and family history.

✅ Early identification of risk factors allows appropriate referrals, diagnostic testing, education, and preventive interventions to begin promptly.

✅ Initial prenatal care also commonly includes a physical assessment and appropriate laboratory screening rather than delaying evaluation until later pregnancy.

✅ Accurate gestational dating is particularly valuable early in pregnancy because many screening and diagnostic procedures have specific gestational windows.

✅ Calculating the EDB and obtaining a comprehensive health history therefore provide the strongest foundation for promoting optimal pregnancy outcomes.

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Answer 5

Correct Answers:

Perform immediate uterine massage to stimulate contraction of the uterus

Rationale :

➡️ Uterine atony occurs when the uterus fails to contract effectively after delivery and is a major cause of postpartum hemorrhage.

➡️ A soft, boggy fundus with heavy lochia strongly indicates inadequate uterine contraction and excessive postpartum bleeding.

➡️ The nurse should immediately perform fundal massage to stimulate the uterine muscle to contract.

➡️ Effective uterine contraction compresses the open blood vessels at the placental implantation site, helping reduce blood loss.

➡️ The nurse should continue assessing the fundal tone, location, lochia, amount of bleeding, and maternal vital signs while interventions are performed.

➡️ Uterotonic medications such as oxytocin may also be administered as prescribed if uterine tone and bleeding do not adequately improve.

➡️ Continued heavy bleeding requires rapid escalation because postpartum hemorrhage can lead to hypovolemia and shock.

➡️ Immediate uterine massage therefore directly addresses the underlying cause of bleeding and is the priority action.

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Answer 6

Correct Answers:

"An Apgar score evaluates how the newborn is transitioning to extrauterine life."

Rationale :

↪️ The Apgar score provides a rapid assessment of the newborn's physiologic condition and adaptation after birth.

↪️ The assessment evaluates five components: Appearance, Pulse, Grimace, Activity, and Respiration.

↪️ Each component receives a score of 0, 1, or 2, producing a maximum total score of 10.

↪️ Apgar scoring is routinely performed at 1 minute and 5 minutes after birth, with additional assessments when clinically indicated.

↪️ The 1-minute score reflects how well the newborn initially tolerated the birth process and is adapting to extrauterine life.

↪️ The 5-minute score provides information about continued adaptation and response to any interventions that have been performed.

↪️ Apgar scores should not be used to delay necessary newborn resuscitation, because interventions are initiated according to the newborn's clinical condition.

↪️ The statement correctly recognizes the Apgar score as an assessment of the newborn's transition following birth.

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Answer 7

Correct Answers:

"Newborns begin to form their own antibodies between 2-3 months

Rationale :

*️⃣ Newborns enter extrauterine life with an immature immune system and initially depend heavily on passive maternal immunity.

*️⃣ Maternal IgG antibodies cross the placenta during pregnancy and provide the newborn with temporary protection against certain infections.

*️⃣ These maternally acquired antibodies gradually decline during the first several months after birth.

*️⃣ The infant's own immune system progressively develops its ability to produce immunoglobulins and specific antibody responses after birth.

*️⃣ The early months therefore represent a period when maternal antibody levels are decreasing while the infant's adaptive immune responses are still developing.

*️⃣ Breast milk provides secretory IgA and other immune factors that help protect mucosal surfaces, particularly in the gastrointestinal tract.

*️⃣ Immunizations also stimulate the infant's developing immune system to produce protective antigen-specific responses.

*️⃣ Among the choices provided, the statement describing development of the newborn's own antibody production during early infancy best reflects normal biologic adaptation.

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Answer 8

Correct Answers:

Ensure the scale is zeroed and lined with a clean, dry cloth before placing the newborn on it.

Rationale :

💠 The newborn scale should be zeroed before weighing to ensure an accurate measurement.

💠 A clean, dry cloth provides a hygienic surface and reduces direct contact between the newborn and a potentially cold scale.

💠 Newborns are particularly vulnerable to heat loss because of their relatively large body surface area compared with their body mass.

💠 Contact with a cold surface can produce conductive heat loss, causing body heat to transfer from the newborn to the cooler scale.

💠 The newborn should generally be weighed without clothing or a diaper when an accurate weight is required, while minimizing the duration of exposure.

💠 The nurse should remain directly beside the newborn throughout the procedure because an infant should never be left unattended on a scale.

💠 The newborn should be dried, weighed efficiently, and returned to a warm environment promptly to support thermal stability.

💠 Zeroing the scale and using a clean, dry barrier therefore promotes both measurement accuracy and newborn safety.

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Answer 9

Correct Answers:

37 weeks' gestation.

Rationale :

❇️ Routine prenatal screening for group B Streptococcus (GBS) is performed late in pregnancy because colonization can be transient or intermittent.

❇️ Current obstetric guidance generally recommends screening at 36 0/7 through 37 6/7 weeks of gestation for pregnant clients who meet criteria for routine screening.

❇️ A client at 37 weeks' gestation therefore falls within the recommended screening window.

❇️ Screening typically involves obtaining vaginal and rectal specimens for GBS culture.

❇️ Identifying maternal GBS colonization helps determine whether intrapartum antibiotic prophylaxis is indicated during labor.

❇️ Appropriate intrapartum prophylaxis substantially reduces the risk of early-onset neonatal GBS disease.

❇️ Screening too early can be less predictive of colonization at delivery because GBS colonization status may change during pregnancy.

❇️ Among the gestational ages provided, 37 weeks is therefore the appropriate time for routine GBS screening.

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Answer 10

Correct Answers:

contractions lasting up to 60 seconds
cervical dilation (dilatation) of 7 cm

Rationale :

Contractions lasting up to 60 seconds

⏭️ During the active phase of the first stage of labor, uterine contractions become progressively stronger, longer, and more regular.

⏭️ Contractions during active labor commonly last approximately 40–70 seconds, making a duration of up to 60 seconds consistent with this phase.

⏭️ Effective contractions promote progressive cervical dilation and effacement by applying pressure to the cervix.

⏭️ The contractions generally become more coordinated and intense as labor progresses.

⏭️ The client usually experiences increasing discomfort and requires greater concentration and coping strategies during contractions.

⏭️ Contraction duration should be assessed together with frequency, intensity, cervical dilation, and fetal response rather than interpreted independently.

⏭️ A contraction lasting approximately 60 seconds is consistent with the expected contraction pattern during active labor.

⏭️ This finding therefore supports that the client has progressed into the active phase of labor.

Cervical dilation of 7 cm

⏭️ Cervical dilation provides one of the most important objective indicators of progression through the first stage of labor.

⏭️ The active phase is generally characterized by more rapid and progressive cervical dilation as effective contractions continue.

⏭️ A cervix dilated to 7 cm clearly indicates that the client is in the active portion of the first stage rather than early labor.

⏭️ Progressive dilation results from coordinated uterine contractions combined with fetal pressure against the cervix.

⏩ Cervical examinations allow the healthcare team to assess the client's labor progress over time.

⏭️ Continued progression toward 10 cm dilation indicates movement toward the second stage of labor.

⏭️ The urge to push should generally be resisted until complete cervical dilation has occurred unless otherwise directed by the healthcare team.

⏭️ A cervical dilation of 7 cm therefore strongly supports the determination that the client is in active labor.

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Custom: NURS2221 Unit 2 Exam Fall 2026

No.

1 :
A client at 39 weeks gestation reports experiencing contractions. The nurse observes that the contractions are irregular, decrease in intensity with walking. and the client has no cervical dilation on examination. Based on these findings, what is the most appropriate nursing action?

2 :
A postpartum client reports soaking more than one perineal pad per hour, passing large blood clots, and experiencing dizziness and near-syncope episodes. What is the nurse's priority action?

4 :
A client comes to the clinic for their first prenatal visit at 9 weeks gestation. Which action should the nurse prioritize during this visit to promote optimal pregnancy outcomes?

5 :
A nurse is caring for a postpartum client who has uterine atony following vaginal delivery. The client's fundus is soft and boggy, and lochia is heavy. Which nursing action should be prioritized to manage this condition effectively?

6 :
A nurse is teaching a student nurse about Apgar scores in newborns. Which of the following statements by the student demonstrates that they understand the teaching?

7 :
A nurse is teaching a newly licensed nurse about biological adaptations of newborns. Which of the following statements by the newly hired nurse demonstrates understanding of the teaching?

8 :
A nurse is preparing to weigh a newborn in the neonatal unit. Which of the following steps should the nurse prioritize to ensure a safe and accurate weight measurement, considering the newborn's thermal regulation needs?

9 :
A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus (GBS) infection in the client who is at:

10 :
A nurse is providing care to a client in labor. The nurse determines that the client has moved into the active phase based on which assessment finding(s) (Select all that apply N 0/1)

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Custom: NURS2221 Unit 2 Exam Fall 2026

No.

1 : A client at 39 weeks gestation reports experiencing contractions. The nurse observes that the contractions are irregular, decrease in intensity with walking. and the client has no cervical dilation on examination. Based on these findings, what is the most appropriate nursing action?

2 : A postpartum client reports soaking more than one perineal pad per hour, passing large blood clots, and experiencing dizziness and near-syncope episodes. What is the nurse's priority action?

4 : A client comes to the clinic for their first prenatal visit at 9 weeks gestation. Which action should the nurse prioritize during this visit to promote optimal pregnancy outcomes?

5 : A nurse is caring for a postpartum client who has uterine atony following vaginal delivery. The client's fundus is soft and boggy, and lochia is heavy. Which nursing action should be prioritized to manage this condition effectively?

6 : A nurse is teaching a student nurse about Apgar scores in newborns. Which of the following statements by the student demonstrates that they understand the teaching?

7 : A nurse is teaching a newly licensed nurse about biological adaptations of newborns. Which of the following statements by the newly hired nurse demonstrates understanding of the teaching?

8 : A nurse is preparing to weigh a newborn in the neonatal unit. Which of the following steps should the nurse prioritize to ensure a safe and accurate weight measurement, considering the newborn's thermal regulation needs?

9 : A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus (GBS) infection in the client who is at:

10 : A nurse is providing care to a client in labor. The nurse determines that the client has moved into the active phase based on which assessment finding(s) (Select all that apply N 0/1)

1 :
A client at 39 weeks gestation reports experiencing contractions. The nurse observes that the contractions are irregular, decrease in intensity with walking. and the client has no cervical dilation on examination. Based on these findings, what is the most appropriate nursing action?

2 :
A postpartum client reports soaking more than one perineal pad per hour, passing large blood clots, and experiencing dizziness and near-syncope episodes. What is the nurse's priority action?

4 :
A client comes to the clinic for their first prenatal visit at 9 weeks gestation. Which action should the nurse prioritize during this visit to promote optimal pregnancy outcomes?

5 :
A nurse is caring for a postpartum client who has uterine atony following vaginal delivery. The client's fundus is soft and boggy, and lochia is heavy. Which nursing action should be prioritized to manage this condition effectively?

6 :
A nurse is teaching a student nurse about Apgar scores in newborns. Which of the following statements by the student demonstrates that they understand the teaching?

7 :
A nurse is teaching a newly licensed nurse about biological adaptations of newborns. Which of the following statements by the newly hired nurse demonstrates understanding of the teaching?

8 :
A nurse is preparing to weigh a newborn in the neonatal unit. Which of the following steps should the nurse prioritize to ensure a safe and accurate weight measurement, considering the newborn's thermal regulation needs?

9 :
A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus (GBS) infection in the client who is at:

10 :
A nurse is providing care to a client in labor. The nurse determines that the client has moved into the active phase based on which assessment finding(s) (Select all that apply N 0/1)