Physiologic Adaptation NCLEX Review Answers and Rationale

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1. Answer: C. The uterus is being over-stimulated with oxytocin. Remember, most sources recommend discontinuing Pitocin if contraction last longer than 75-90 seconds, are less than 2 minutes apart, have minimal or no resting tone, or if there is an ominous or non-reassuring FHR pattern.

2. Answer: A. Administering anesthesia depresses the central nervous system and causes all muscles, including the stomach muscles, to relax. This tends to produce a gastric reflux that may lead to aspiration. Antacids help to neutralize the hydrochloride acid in the stomach and reduce the chance of gastric reflux.

3. Answer: C. The absence of fetal accelerations and minimal long-term variability suggests the fetus is going into distress. Variability refers to the irregularity of the fetal heart rate resulting from the normal interplay of the sympathetic and parasympathetic nervous system. A fetal acceleration is a positive sign. It is present when the fetus’s heart rate increases 15 beats per minute and lasts 15 seconds. If there are no accelerations and the long term variability is minimal, the nurse should be concerned.

4. Answer: A. Tetracycline hydrochloride loses its therapeutic values of taken on a full stomach. Dietary minerals such as iron, magnesium, calcium, and aluminum salts can chemically join with tetracycline to form tiny solid particles of insoluble precipitate that prevent the drug from being absorbed properly. Therefore, taking the medication at least one hour before or two hours after a meal is usually recommended.

5. Answer: C. The chorion is the outermost layer of the fetal membranes, composed of trophoblast lined with mesoderm.

6. Answer: B. The toes should hyperextend and fan upward, not flex. If the toes flex, a neurological problem may be indicated. Flexing of the toes is called a positive Babinski reflex. The Babinski reflex is normal in an infant but abnormal after 12 to 18 months of age.

7. Answer: C. Assessing deep tendons reflexes is crucial for the client receiving magnesium sulfate. Reflexes should be assessed immediately before and after administration of magnesium sulfate and at least every hour thereafter. Remember: in cases of magnesium sulfate toxicity, the reflexes are the first thing to go. If magnesium sulfate is given when the reflexes are absent, respiratory failure will follow.

8. Answer: A. General anesthesia wears off abruptly and pain will return very quickly. If pain medications are given as early as possible, the client can obtain better relief from the pain than if waiting until the pain severe. Most clients will be returned to their rooms today with a patient controlled anesthesia pump (PCA). The nurse is responsible for teaching the client how to use the PCA correctly, monitoring and documenting its use, and assessing its effectiveness.

9. Answer: C. A retroverted uterus is one that is turned or tilted backward. A retroverted uterus may be congenital or may be caused from trauma to the round and uterosacral ligaments during childbirth. Most women who have a retroverted uterus are asymptomatic. Some may complain of low back pain, constipation, and dyspareunia. Usually a retroverted uterus is treated with a pessary, which is placed in the vagina to support the uterus.

10. Answer: B. The case scenario indicates the client is in circulatory failure from receiving too much fluid. The nurse doesn’t want the client to get more fluid but should also realize the client may need to receive emergency medication. When a client is in circulatory failure, it may be difficult to insert an intravenous line because of circulatory collapse of the major blood vessels. Therefore, the first thing the nurse should do is slow the intravenous rate to keep the veins open

11. Answer: C.  A flow of 500 ml is far too much blood loss. The average flow is 30-50 ml per cycle

12. Answer: D. Pitocin is the only oxytocin drug that may be safely administered to an antepartum woman.

13. Answer: A. The nurse needs to inform the client that menstruation will cease. In addition, since the ovaries will be removed, estrogen will no longer be produces. Therefore, estrogen replacement therapy may be necessary

14. Answer: A. Clients first need to be turned onto their backs or unaffected sides due to decreased circulation in the extremity from removal of lymph nodes and muscle tissue.

15. Answer: A. An epidural is effective if the client is able to push with contractions. The second stage of labor is also knows as the pushing stage. The cervix is 100% effaced and 10 cm dilated.

16. Answer: D. The best time to do a self-breast examination is immediately following a period because the breasts are less apt to be tender or swollen at this time.

17. Answer: B. Lying in the left side relieves pressure from being exerted on the inferior vena cava and provides better blood supply and oxygenation to the tissues and fetus.

18. Answer: D. Betamethasone is given to the woman in premature labor to rapidly mature the fetal lungs, but it has no effect on uterine activity.

19. Answer: D. This is very honest statement and yet is non-threatening to the client.

20. Answer: B. Progesterone, which is produced initially by the corpus luteum and then by the placenta, plays the greatest role in maintaining pregnancy. Progesterone maintains the endometrium and inhibits spontaneous absorption.

21. Answer: D. This respiratory rate is excessive and may be a sign of impending pulmonary edema. The nurse needs to auscultate lung sounds on this client.

22. Answer: A. This will help to relax the muscles in the lower back and relieve the pressure of the fetal head pressing against the mother’s spine during labor.

23. Answer: C. Clients who are given anesthesia before the active phase of labor will usually find the progress of their labor experience slows. The medication depresses the central nervous system and, therefore, it will take longer for the cervix to dilate and efface.

24. Answer: C. A level of 4-7 mg/dl is therapeutic and usually controls seizures activity without manifestations of toxicity.

25. Answer: B. Due to thromboplastin being released at the site of tissue destruction and decreased fibrinogen, partial thromboplastin time is prolonged.