ATI RN MATERNITY PROCTORED EXAM WITH NGN 3-5 VERSIONS
ATI RN MATERNITY PROCTORED EXAM
ATI – Maternity
VERSION 3
1. A nurse is providing community education regarding risk factors for ovarian cancer. Identify
five (5) risk factors associated with the development of ovarian cancer. (Review the Med Surg
RM)
Answer:
1. Age greater than 40 years
2. Nulliparity or first pregnancy after 30 years of age
3. BRCA1 OR BRCA2 gene mutations
4. High fat diet
5. Endometriosis
2. The client enters the obstetrical clinic for birth control information on using a diaphragm.
What five (5) instructions would be provided by the nurse to explain use of the diaphragm?
Answer:
1. A client should be properly fitted with a diaphragm by a provider.
2. Replaced q 2 years and refitted for a 20% weight fluctuation, after abdominal surgery, and
after every pregnancy.
3. Requires proper insertion and removal. Prior to coitus, the diaphragm is inserted vaginally
over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome
around the rim. The diaphragm can be inserted up to 6 hours before intercourse and must Tay in
place 6 hours after intercourse but no more than 24 hours.
4. Spermicide must be reapplied with each act of coitus.
5. A client should empty her bladder prior to insertion of the diaphragm. Wash with mild soap
and water after each use.
3. What are risks/possible complications/contraindications for the use of intrauterine
contraceptive devices?
Answer:
1. Best used by women in monogamous relationships due to the risks of STIs.
2. Can cause irregular mistral bleeding
3. Risk of bacterial vaginosis, uterine perforation, or uterine expulsion.
4. Must be removed in the event of pregnancy.
5. Contraindicated in active pelvic infection, abnormal uterine bleeding, severe uterine
distortion; for copper IUD also Wilsons disease and copper allergy.
4. A nurse is providing education to a new mother regarding storage of breast milk. Identify five
(5) teaching points to discuss with the new mother regarding storage of breast milk.
Answer:
1. Teach the parents that breast milk must be stored according to guidelines for proper
containers, labeling, refrigerating, and freezing.
2. It can be stored at room temperature under very clean conditions for up to 8 hrs. It can be
refrigerated in sterile bottles for use within 8 days, or can be froen in sterile containers in the
freezer compartment of a refrigerator for up to 6 months. Breast milk can be stored in a deep
freezer for 12 months.
3. Thawing the milk in the refrigerator for 24 hours is the best way to preserve the
immunoglobulins present in it. It can also be thawed in lukewarm water, but do not shake it.
4. Do not refreeze thawed milk.
5. Used portions of breast milk must be discarded.
5. A nurse is providing care for an uncircumcised male newborn and his mother. What
information should be provided during discharge regarding bathing of the penile area of the
newborn male?
Answer:
1. Teach the parents to keep the area clean. Change the newborns diaper at least every 4 hours
and clean the penis with warm water with each diaper change. With clamp procedures, apply
petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the
diaper from adhering to the penis.
2. Avoid wrapping the penis in tight gauze, which can impair circulation to the glans.
3. A tub bath should not be given until the circumcision is healed. Until then warm water should
be trickled gently over the penis.
4. Do not wash off the yellowish mucus that forms around the glans on day two.
6. What are five (5) adverse effects noted with epidural analgesia administration during labor?
Answer:
1. Decreased gastric emptying resulting in nausea and vomiting
2. Inhibition of bowel and bladder elimination sensations
3. Bradycardia or tachycardia
4. Hypotension
5. Respiratory depression
6. Allergic reaction and pruritus
7. Elevated temperature
7. What are two (2) contraindications for the administration of terbutaline during labor?
Answer: Use with caution with hypotension, hepatic or renal disease, or acute MI. Avoid
concurrent use with magnesium sulfate or terbutaline.
8. What are the causes of early decelerations of the fetal heart rate? What are the nursing
interventions to take if these occur?
Answer:
1. Compression of the fetal head resulting from uterine contraction
2. Uterine contractions
3. Vaginal exam
4. Fundal pressure
5. No interventions required
9. The mother of a newborn asks the nurse what is the soft swollen mass located on her infant’s
scalp after a non-traumatic vaginal delivery. The nurse does not note any discoloration. How
should the nurse respond?
Answer:
1. Caput Succedaneum – Localized swelling of the soft tissues of the scalp caused by pressure on
the head during labor. Can be palpated as a soft edematous mass and can cross of the suture line.
Usually resolves in 3-4 days and does not require tx.
(Cephalohematoma is from trauma)
10. The nurse is assessing an expectant female who is suspected to have varicella-zoster (VZV).
What assessment findings would indicate VZV and what complications should be monitored for
if VZV is present? (Information found in the Nursing Care of Children and Maternal Newborn
RM)
Answer:
1. Assessment finding include pain along sensory nerves in addition to a region of patchy
erythema, regional lymphadenopathy, grouped vesicles, and pruritus. The are involved may be
tender to palpation.
2. Complications that should be monitored for include preterm labor, encephalitis, and varicella
pneumonia.
MATERNITY ATI
VERSION 4
1. A nurse in the labor and delivery unit receives a phone call from a client who reports that her
contractions started about 2 hr. ago, did not go away when she had two glasses of water and
rested, and became stronger since she started walking. Her contractions occur every 10 min and
last about 30 seconds. She hasn't had a fluid leak form her vagina. However, she saw some blood
when she wiped after voiding. Based on this report, which of the following clinical findings
should the nurse recognize that the client is experiencing
a. Braxton hick's contractions
b. Rupture of membranes
c. Fetal descent
d. True contractions
Answer: d. True contractions
2. A nurse in the labor and delivery unit is caring for a client in labor and applies an external fetal
monitor and Toc transducer. The FHR is around 140/min. contractions are occurring every 8 min
and 30 to 40 seconds in duration. The nurse performs a vaginal exam and finds the cervix is 2 cm
dilated, 50% effaced, and the fetus is at a -2 station. Which of the following stages and phases of
labor is the client experiencing
a. First stage, latent phase
b. First stage, active phase
c. First stage, transition phase
d. Second stage of labor
Answer: a. First stage, latent phase
3. A client experiences a large gush of fluid from her vagina while walking in the hallway of the
birthing unit. Which of the following actions should the nurse take first?
a. Check the amniotic fluid for meconium
b. Monitor FHR for distress
c. Dry the client and make her comfortable
d. Monitor uterine contractions
Answer: b. Monitor FHR for distress
4. A nurse in labor and delivery unit is completing an admission assessment for a client who is at
39 weeks of gestation. The client reports that she has been leaking fluid from her vagina for 2
days. Which of the following conditions is the client at risk for developing
a. Cord prolapse
b. Infection
c. Postpartum hemorrhage
d. Hydramnios
Answer: b. Infection
5. A nurse is caring for a client who is in active labor and becomes nauseous and vomits. The
client is very irritable and feels the urge to have a bowel movement. She states, "I've had enough.
I can't do this anymore. I want to go home right now" which stage of labor is the client
experiencing?
a. Second stage
b. Fourth state
c. Transition phase
d. Latent phase
Answer: c. Transition phase
1. A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions
every 3 to 5 minutes and becoming stronger. A vaginal exam reveals that the clients cervix is 3
cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the
following actions should the nurse take? (select all that apply)
a. Encourage the use of patterned breathing techniques
b. Insert an indwelling urinary catheter
c. Administer opioid analgesic medication
d. Suggest application of cold
e. Provide ice chips
Answer: a. Encourage the use of patterned breathing techniques
c. Administer opioid analgesic medication
d. Suggest application of cold
2. A nurse is caring for a client who is in active labor. The client reports lower back pain. The
nurse suspects this pain is related to a persistent occiput posterior fetal position which of the
following nonpharm nursing interventions should the nurse recommend to the client?
a. An abdominal effleurage
b. Sacral counterpressure
c. Showering if not contraindicated
d. Back rub and massage
Answer: b. Sacral counterpressure
3. A nurse is caring for a client following the administration of an epidural block and is preparing
to administer an IV fluid bolus. The clients partner asks about the purpose of the IV fluids.
Which of the following is an appropriate response for the nurse to make?
a. It is needed to promote increased urine output
b. It is needed to counteract respiratory depression
c. It is needed to counteract hypotension
d. It is needed to prevent oligohydramnios
Answer: c. It is needed to counteract hypotension
4. A nurse is caring for a client who is in the second stage of labor. The clients labor has been
progressing, and she is expected to deliver vaginally in 20 min. the provider is preparing to
administer lidocaine for pain relief and perform an episiotomy. The nurse should know that
which of the following types of regional anesthetic block is to be administered?
a. Pudendal
b. Epidural
c. Spinal
d. Paracervical
Answer: a. Pudendal
5. A nurse is caring for a client who is using patterned breathing during labor. The client reports
numbness and tingling of the fingers. Which of the following actions should the nurse take?
a. Administer oxygen via nasal cannula at 2 L/min
b. Apply a warm blanket
c. Assist the client to a side-lying position
d. Place an oxygen mask over the clients nose and mouth
Answer: d. Place an oxygen mask over the clients nose and mouth
1. A nurse is providing care for a client who is in active labor. Her cervix is dilated to 5 cm, and
her membranes are intact. Based on the sue of external electronic fetal monitoring, the nurse
notes a FHR of 115 to 125/min with occasional increases up to 150/155 per min that last for 25
seconds and have the beat to beat variability of 20/min. there is no slowing of FHR from the
baseline. The nurse should recognize that this client is exhibiting signs of which of the
following? (select all that apply)
a. Moderate variability
b. FHR accelerations
c. FHR decelerations
d. Normal baseline FHR
e. Fetal tachycardia
Answer: a. Moderate variability
b. FHR accelerations
d. Normal baseline FHR
2. A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the
following should the nurse include in the teaching? (select all that apply)
a. It is considered a non-invasive procedure
b. It can detect abnormal fetal heart tones early
c. It can determine the amount of amniotic fluid you have
d. It allows for accurate readings with maternal movement
e. It can measure uterine contraction intensity
Answer: b. It can detect abnormal fetal heart tones early
d. It allows for accurate readings with maternal movement
e. It can measure uterine contraction intensity
3. A nurse is reviewing the electronic monitor tracing of a client who is in active labor. The nurse
should know that fetus receives more oxygen when which of the following appears on the
tracing?
a. Peak of the uterine contraction
b. Moderate variability
c. FHR acceleration
d. Relaxation between uterine contractions
Answer: d. Relaxation between uterine contractions
4. A nurse is caring for a client who is in labor and observes late decelerations on the electronic
fetal monitor. Which of the following is the first action the nurse should take?
a. Assist the client into the left lateral position
b. Apply a fetal scalp electrode
c. Insert an IV catheter
d. Perform a vaginal exam
Answer: a. Assist the client into the left lateral position
5. A nurse is performing Leopold maneuvers to a client who is in labor. Which of the following
techniques should the nurse use to identify the fetal lie?
a. Apply palms of both hands to sides of uterus
b. Palpate the fundus of the uterus
c. Grasp lower uterine segment between thumb and fingers
d. Stand facing client's feet with finger tips outlining cephalic prominence
Answer: b. Palpate the fundus of the uterus
1. A nurse is caring for a client and her partner during the second stage of labor. T e clients
partner asks the nurse to explain how he will know when crowing occurs. Which of the following
responses should the nurse make?
a. The placenta will protrude from the vagina
b. Your partner will report a decrease in the intensity of contractions
c. The vaginal area will bulge as the baby's head appears
d. Your partner will report less rectal pressure
Answer: c. The vaginal area will bulge as the baby's head appears
2. A nurse is caring for a client who is in the transition phase of labor and reports that she needs
to have a bowel movement with the peak of contractions. Which of the following actions should
the nurse make?
a. Assist the client to the bathroom
b. Prepare for an impending delivery
c. Prepare to remove a fecal impaction
d. Encourage the client to take deep breaths
Answer: b. Prepare for an impending delivery
3. A nurse is caring for a client in the third stage of labor. Which of the following findings
indicate that placental separation has occurred? (select all that apply)
a. Lengthening of the umbilical cord
b. Swift gush of clear amniotic fluid
c. Softening of the lower uterine segment
d. Appearance of dark blood from the vagina
e. Fundus firm upon palpation
Answer: a. Lengthening of the umbilical cord
d. Appearance of dark blood from the vagina
e. Fundus firm upon palpation
4. A nurse in labor and delivery is planning care for a newly admitted client who reports she is in
labor and has been having g vaginal bleeding for 2 weeks. Which of the following should the
nurse include in the plan of care?
a. Inspect the introitus for a prolapsed cord
b. Perform a test to identify the feming pattern
c. Monitor station of the presenting part
d. Defer vaginal examinations
Answer: d. Defer vaginal examinations
5. A nurse is caring for a client who is in the first stage of labor and is encouraging the client to
void every 2 hr. which of the following statements should the nurse make?
a. A full bladder increases the risk for fetal trauma
b. A full bladder increases the risk for bladder infections
c. A distended bladder will be traumatized by frequent pelvic exams
d. A distended bladder reduces pelvic space needed for birth
Answer: d. A distended bladder reduces pelvic space needed for birth
1. A nurse is caring for a client who is at 42 weeks of gestation and is admitted to the labor and
delivery unit. During and ultrasound, it is noted that the fetus is large for gestational age. The
nurse reviews the prescription from the provider to be an amnioinfusion. Which of the following
conditions should the nurse plan to prepare an amnioinfusion? (select all that apply)
a. Oligohydramnios
b. Hydramnios
c. Fetal cord compression
d. Hydration
e. Fetal immaturity
Answer: a. Oligohydramnios
c. Fetal cord compression
2. A nurse is caring for a client who has been in labor for 12 hr. and her membranes are intact.
The provider has decided to perform an amniotomy in an effort to facilitate the progress of labor.
The nurse performs a vaginal examination to ensure which of the following prior to the
performance of the amniotomy?
a. Fetal engagement
b. Fetal lie
c. Fetal attitude
d. Fetal position
Answer: a. Fetal engagement
3. A nurse is caring for a client who had no prenatal care, is rH negative and will undergo an
external version at 37 weeks of gestation. Which of the following medication should the nurse
plan to administer prior to the version?
a. Prostaglandin gel
b. Magnesium sulfate
c. Rho (D) immune globulin
d. Oxytocin
Answer: c. Rho (D) immune globulin
4. A nurse is caring for a client who is receiving oxytocin for induction of labor and has an
intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the
following contraction patterns should the nurse discontinue the infusion of oxytocin?
a. Frequency of every 2 min
b. Duration of 90-120 seconds
c. Intensity of 60-90 mmHg
d. Resting tone of 15 mmHg
Answer: b. Duration of 90-120 seconds
5. A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to
promote cervical ripening with a group of newly hired nurses. Which of the following statements
by a nurse indicates understanding of the teaching?
a. They are administered in an oral form
b. They act by absorbing fluid from tissues
c. They promote dilation of the os
d. They include an amniotomy
Answer: a. They are administered in an oral form
1. A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation
between hypertonic contractions. The nurse should identify that this contraction pattern increases
the risk for which of the following complications?
a. Prolonged labor
b. Reduced fetal oxygen supply
c. Delayed cervical dilation
d. Increased maternal stress
Answer: b. Reduced fetal oxygen supply
2. A nurse is caring for a client who is in active labor and reports severe back pain. During
assessment, the fetus is noted to be in the occiput posterior position. Which of the following
maternal positions should the nurse suggest to the client to facilitate normal labor progress?
a. Hands and knees
b. Lithotomy
c. Trendelenburg
d. Supine with a rolled towel under one hip
Answer: a. Hands and knees
3. A nurse is caring for a client who is admitted to the labor and delivery unit. With the use of
Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the
following possible complications should the nurse observe?
a. Precipitous labor
b. Premature rupture of membranes
c. Post maturity syndrome
d. Prolapsed umbilical cord
Answer: d. Prolapsed umbilical cord
4. A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the
following findings is the fetus at risk for developing?
a. Intrauterine growth restriction
b. Hyperglycemia
c. Meconium aspiration
d. Polyhydramnios
Answer: c. Meconium aspiration
5. A nurse is caring for a client in active labor. When last examined 2 hr. ago, the clients cervix
was 3 cm dilated, 100% effaced, membranes intact and the fetus was at -2 station. The client
suddenly states "my water broke" the monitor reveals a FHR of 80 to 85 per min, and the nurse
performs a vaginal examination, noticing clear fluid and pulsing loop of umbilical cord in the
client's vagina. Which of the following actions should the nurse perform first?
a. Place the client in Trendelenburg position
b. Apply pressure to the presenting par with her fingers
c. Administer oxygen at 10 L/min via a face mask
d. Call for assistance
Answer: d. Call for assistance
VERSION 5
ANTEPARTUM
Stages of Pregnancy
• The third through eighth weeks after conception are called the embryonic stage.
• The fetal period starts 9 weeks after conception and lasts through the end of gestation.
Fetal Development: Embryonic Stage
Week 1
• Free-floating blastocyst
Weeks 2 to 3
• The embryo is 1.5 to 2 mm long.
• Lung buds appear.
• Blood circulation begins.
• The heart is tubular.
• The neural plate becomes the brain and spinal cord.
Week 5
• The embryo is 0.4 to 0.5 cm long
• The embryo weighs 0.4 g.
• Double heart chambers are visible.
• The heart beats.
• Limb buds begin to form.
Week 8
• The embryo is 3 cm long.
• The embryo weighs 2 g.
• The eyelids begin to fuse.
• The circulatory system through the umbilical cord is well established.
• Every organ system is present.
Week 12
• Fetus is 6 to 9 cm long.
• Fetus weighs 19 g.
• Face is well formed.
• Limbs are long and slender.
• Kidneys begin to form urine.
• Spontaneous movements occur.
• Heartbeat is detectable with a Doppler transducer between 10 and 12 weeks.
• Sex is visually recognizable.
Week 16
• Fetus is 11.5 to 13.5 cm long.
• Fetus weighs 100 g.
• Active movements are present.
• Skin is transparent.
• Lanugo hair begins to develop.
• Skeletal ossification takes place.
Week 20
• Fetus is 16 to 18.5 cm long.
• Fetus weighs 300 g.
• Lanugo covers the entire body.
• Fetus has fingernails and toenails.
• Muscles are developed.
• Enamel and dentin are being deposited.
• Heartbeat is detectable with a regular (nonelectronic) fetoscope.
Week 24
• Fetus is 23 cm long.
• Fetus weighs 600 g.
• Hair on head is well formed.
• Skin is reddish and wrinkled.
• Reflex hand grasp is functioning.
• Vernix caseosa covers the entire body.
• Fetus can hear.
Week 28
• Fetus is 27 cm long.
• Fetus weighs 1100 g.
• Limbs are well flexed.
• Brain is developing rapidly.
• Eyelids open and close.
• Lungs are developed sufficiently to provide gas exchange (lecithin forming).
• If born at this time, neonate can breathe.
Week 32
• Fetus is 31 cm long.
• Fetus weighs 1800 to 2100 g.
• Bones are fully developed.
• Subcutaneous fat has accumulated.
• Lecithin-to-sphingomyelin (L/S) ratio is 2:1.
Week 36
• Fetus is 35 cm long.
• Fetus weighs 2200 to 2900 g.
• Skin is pink and the body rounded.
• Skin is less wrinkled.
Week 40
• Fetus is 40 cm long.
• Fetus weighs 3200 g or more. 3Kg
• Skin is pinkish and smooth.
Present because of the fetus’ nonfunctioning lungs, bypasses must
• Lanugo remains on the upper
close after birth to allow blood to flow through the lungs and the
arms and shoulders.
liver.
• Vernix caseosa coverage
decreases.
• Fingernails extend beyond fingertips.
• Sole (plantar) creases run down to the heels.
• Testes are in the scrotum.
• Labia majora are well developed.
Fetal Circulation
• Lanugo is disappearing.
• L/S ratio is higher than 2:1.
Umbilical Cord
• Cord contains two arteries and one vein.
• Arteries carry deoxygenated blood and waste products from the fetus.
• Vein carries oxygenated blood and provides oxygen and nutrients to the fetus.
•
The ductus arteriosus connects the
pulmonary artery to the aorta, bypassing
the lungs.
•
The ductus venosus connects the
umbilical vein and the inferior vena cava,
bypassing the liver.
•
The foramen ovale is the opening
between the right and the left atria of the
heart, bypassing the lungs
Remember AVA: two arteries and one vein.
• The arteries carry deoxygenated blood and waste products away from the fetus to the
placenta, where these substances are transferred to the mother's circulation.
• The umbilical vein carries freshly oxygenated and nutrient-laden blood from the placenta
back to the fetus.
Fetal HR: 160 to 170 beats/min in the first
Nagele's rule : Used to determine the estimated date
of delivery/confinement.
trimester but slowing with fetal growth to 120
to 160 beats/min near or at term.
❖ Subtract 3 months from the first day of the last menstrual period (LMP), add 7 days, and then
adjust the year as necessary.
Positive signs
• Fetal heart rate, detectable with an electronic device (Doppler transducer) at 10 to 12 weeks
and with a nonelectronic device (fetoscope) at 20 weeks of gestation
• Active fetal movements palpable by examiner
• Outline of fetus on ultrasound
Fundal Height: The fundal height is measured to help gauge the fetus' gestational age.
**fundal height in centimeters approximately equals the fetus's age in weeks, plus or minus 2
cm.**
In the early weeks of pregnancy, the cervix softens as a result of pelvic congestion (Goodell
sign). Cervical softening is noted on physical examination. The presence of the Goodell sign is a
probable indication of pregnancy. Another probable indication of pregnancy is the Chadwick
sign, in which the cervix changes from pink to a violet color. Presumptive indications of
pregnancy are also termed subjective changes because they are experienced and reported by the
woman. Positive indications of pregnancy include auscultation of fetal heart sounds, fetal
movement felt by the examiner, and visualization of the fetus on ultrasonography.
When a pregnant woman is in the supine position, particularly during the second and third
trimesters, the weight of the gravid uterus partially occludes the vena cava and descending aorta.
The occlusion impedes return of blood from the lower extremities and consequently reduces
cardiac return, cardiac output, and blood pressure. This is known as supine hypotensive
syndrome. Symptoms include faintness, light-headedness, dizziness, and agitation. A lateral
recumbent position alleviates the pressure on the blood vessels and quickly corrects supine
hypotension. Although the nurse may take the woman's blood pressure, this is not the action to
take immediately. It is not necessary to call the obstetrician to the examining room. Placing a
cool cloth on the woman's forehead will not alleviate the problem.
Urinalysis and Urine Culture
• A urine specimen for glucose and protein determinations should be obtained at every prenatal
visit.
• Glycosuria is a common result of the decreased renal threshold that occurs during pregnancy.
• Persistent glycosuria may indicate diabetes.
• White blood cells in the urine may indicate infection.
• Ketonuria may result from insufficient food intake or vomiting.
• Levels of 2+ to 4+ protein in the urine may indicate infection or preeclampsia.
If the client is Rh negative and the result of an antibody screen is negative, she will need repeat
antibody screens and should receive Rh immune globulin around 28 weeks' gestation to prevent
the formation of anti-Rh antibodies. An Rh-negative woman should also receive Rh immune
globulin within 72 hours of delivery if her newborn is Rh-positive. On the basis of the data
provided in the question, the other options are incorrect.
Amniocentesis is a relatively simple and safe procedure that permits the diagnosis of many fetal
anomalies and confirms fetal maturity. It is a relatively painless procedure that takes only a short
amount of time. Ultrasonography is used to locate the fetus and placenta and identify the largest
pockets of amniotic fluid that can safely be sampled. A small amount of local anesthetic may be
injected into the skin. The woman may feel pressure as the needle is inserted and mild cramping
as the needle enters the myometrium. Informed consent will need to be provided by the client
before the procedure. Although risks are associated with the procedure, the need for several
informed consents to be signed is not warranted.
Maternity
Nursing 214
1. A nurse is caring for a client who is pregnant and states that her last menstrual period was
April 1, 2013. Which of the following is the client’s estimated date of delivery?
a. Jan. 8, 2014
b. Jan. 15, 2014
c. Feb. 8, 2014
d. Feb. 15, 2014
Answer: a. Jan. 8, 2014
2. A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The
client's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this
information? (Select all that apply)
a. Client has delivered one newborn at terms.
b. Client has experienced no preterm labor.
c. Client has been through active labor.
d. Client has had two prior pregnancies.
e. Client has one living child.
Answer:
a. Client has delivered one newborn at terms.
d. Client has had two prior pregnancies.
e. Client has one living child.
3. A nurse is reviewing the health record of a client who is pregnant. The provider indicated the
client exhibits probable signs of pregnancy. Which of the following would be included? (Select
all that apply)
a. Montgomery's glands
b. Goodall's sign
c. Ballottement
d. Chadwick's sign
e. Quickening
Answer:
b. Goodall's sign
c. Ballottement
d. Chadwick's sign
4. A nurse in a prenatal clinic is caring for client who is pregnant and experiencing episodes of
maternal hypotension. The client asks the nurse what causes these episodes. Which of the
following is an appropriate response by the nurse?
a. "This is due to an increase in blood volume."
b. "This is due to pressure from the uterus on the diaphragm"
c. "This is due to the weight of the uterus on the vena cava."
d. "This is due to increased cardiac output."
Answer: c. "This is due to the weight of the uterus on the vena cava."
5. A nurse in a clinic receives a phone call from a client who believes she is pregnant and would
like to be tested in the clinic to confirm her pregnancy. Which of the following information
should the nurse provide to the client?
a. "You should wait until 4 weeks after conception to be tested."
b. "You should be off any medication for 24 hours prior to the test."
c. "You should be NPO for at least 8 hours prior to the test."
d. "You should collect urine from the first morning void."
Answer: d. "You should collect urine from the first morning void."
6. A nurse is teaching a group of women who are pregnant about measures to relieve backache
during pregnancy. The nurse should should teach the women which of the following? (Select all
that apply)
a. Avoid any lifting
b. Perform Kegel exercises twice a day.
c. Perform the pelvic rock exercise every day.
d. Use proper body mechanics.
e. Avoid constrictive clothing.
Answer:
c. Perform the pelvic rock exercise every day.
d. Use proper body mechanics.
7. A client who is at 8 weeks of gestation tells the nurse that she isn't sure she is happy about
being pregnant. Which of the following is an appropriate response by the nurse to the client's
statement?
a. "I will inform the provider that you are having these feelings."
b. "It is normal to have these feelings during the first few months of pregnancy."
c. "You should be happy that you are going to bring new life into the world."
d. "I am going to make an appointment with the counselor for you to discuss these thoughts."
Answer: b. "It is normal to have these feelings during the first few months of pregnancy."
8. A nurse is caring for a client who is pregnant and reviewing signs of complications that should
be promptly reported to the provider. Which of the following should be included?
a. Vaginal bleeding
b. Swelling
c. Heartburn after eating
d. Light headedness when lying on back
Answer: a. Vaginal bleeding
9. A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning.
The nurse in the prenatal clinic provides teaching that should include which of the following?
a. Eat crackers or plain toast before getting out of bed.
b. Awaken during the night to eat a snack
c. Skip breakfast and eat lunch after nausea has subsided
d. Eat a large evening meal.
Answer: a. Eat crackers or plain toast before getting out of bed.
10. A nurse is teaching a group of clients who are pregnant about behaviors to avoid during
pregnancy. Which of the following statements by a client indicates a need for further instruction?
a. "I can have a glass of wine with dinner."
b. "Smoking is a cause of low birth weight in babies."
c. "Signs of infection should be reported to my doctor."
d. "I should not take over-the-counter medications without checking with my obstetrician."
Answer: a. "I can have a glass of wine with dinner."
11. A nurse in a prenatal clinic is providing education to a client who is in the 8th week of
gestation, The client states that she does not like milk. What is a good source of calcium that the
nurse can recommend to the client?
a. Dark green, leafy vegetables
b. Deep red or orange vegetables
c. White bread and rice
d. Meat, poultry, and fish
Answer: a. Dark green, leafy vegetables
12. A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients
should the nurse be concerned about regarding weight gain?
a. 1.8kg (4lb) weight gain and is in her first trimester
b. 3.6kg (8lb) weight gain and is in her first trimester
c. 6.8kg (15lb) weight gain and is in her second trimester
d. 11.3kg (25lb) weight gain and is in her third trimester
Answer: b. 3.6kg (8lb) weight gain and is in her first trimester
13. A nurse in clinic is teaching a client of childbearing age about recommended folic acid
supplements. Which of the following defects can occur in the fetus or neonate as a result of folic
acid deficiency?
a. Iron deficiency anemia
b. Poor bone formation
c. Macro somic fetus
d. Neural tube defects
Answer: d. Neural tube defects
14. A nurse is reviewing a new prescription for iron supplements with a client who is in the 8th
week of gestation and has iron deficiency anemia. The nurse should advise the client to take the
iron supplements with which of the following?
a. Ice water
b. Low-fat or whole milk
c. Tea or coffee
d. Orange juice
Answer: d. Orange juice
15. A nurse is reviewing postpartum nutrition needs with a group of new mothers who are
breastfeeding their newborns. Which of the following statements by a member of the group
requires clarification?
a. "I am glad I can have my morning coffee."
b. "I know that certain foods that I eat will affect my baby."
c. "I will continue adding 330 calories per day to my diet."
d. "I will continue my calcium supplements because I don't like milk."
Answer: a. "I am glad I can have my morning coffee."
16. A nurse is caring for a client and reviewing the findings of the client's biophysical profile
(BPP). Which of the following variables are included in this test? (Select all that apply)
a. Fetal weight
b. Fetal breathing movement
c. Fetal tone
d. Reactive FHR
e. Amniotic fluid volume
Answer: b. Fetal breathing movement
c. Fetal tone
d. Reactive FHR
e. Amniotic fluid volume
17. A nurse is caring for a client who is in preterm labor and is scheduled to undergo an
amniocentesis to assess fetal lung maturity. Which of the following is a test for fetal lung
maturity?
a. Alpha-fetoprotein (AFP)
b. Lecithin/sphingomyelin (L/S) ratio
c. Kleihauer-Betke test
d. Indirect Coomb's test
Answer: b. Lecithin/sphingomyelin (L/S) ratio
18. A nurse is caring for a client who is pregnant and undergoing a nonusers test. The client asks
why the nurse is using an acoustic vibration device. Which of following is an appropriate
response by the nurse?
a. "It is used to stimulate uterine contractions."
b. "It will decrease the incidence of uterine contractions."
c. "It lulls the fetus to sleep."
d. "It awaken a sleeping fetus."
Answer: d. "It awaken a sleeping fetus."
19. A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the
following statements by the client requires clarification?
a. "I will report cramping or signs of infection to the physician."
b. "I should drink lots of fluids during the 24 hours following the procedure."
c. "I need to have a full bladder at the time of the procedure."
d. "The test is done to detect genetic abnormalities."
Answer: c. "I need to have a full bladder at the time of the procedure."
20. A nurse is caring for a client who is pregnant and is to undergo a contraction stress test
(CST). Which of the following findings are indications for the procedure? (Select all that apply)
a. Decreased fetal movement
b. Intrauterine growth restriction (IUGR)
c. Post maturity
d. Advanced maternal age
e. Amniotic fluid emboli
Answer: a. Decreased fetal movement
b. Intrauterine growth restriction (IUGR)
c. Post maturity
d. Advanced materal age
21. A nurse in L&D receives a phone call from a client who reports that her contractions started
about 2 hrs ago, did not go away when she had 2 glasses of water and rested, and became
stronger since she started walking. Her contractions occur every 10 mins and last about 30
seconds. She hasn't had much fluid leak from her vagina. However, she saw some blood when
she wiped after voiding. Based on this report the nurse should recognize that the client is
experiencing
a. Braxton Hicks contractions
b. rupture of membranes
c. fetal decent
d. true contractions
Answer: d. True contractions
22. A nurse in L&D is caring for a client in labor and applies an external fetal monitor and to co
tranducer. The FHR is around 140/min. Contractions are every 8 min and 30-40 seconds in
duration. The nurse performs a vaginal exam and finds the cervix is 2cm dilated, 50% effaced,
and the fetus is at -2 station. Which of the following stages and phases of labor is this client
experiencing?
a. The 1st stage, latent phase
b. The 1st stage, active phase
c. The 1st stage, transition phase
d. The 2nd stage of labor
Answer: a. The 1st stage, latent phase
23. A client experiences a large gush of fluid from her vagina while walking in the hallway of the
birthing unit. The nurse's first action after establishing that the fluid is amniotic fluid should be to
a. Asses the amniotic fluid for meconium
b. Monitor the FHR for distress
c. Dry the client and make her comfortable
d. Monitor the client's uterine contractions.
Answer: b. Monitor the FHR for distress
24. A nurse in L&D is completing an admission history for a client who is at 39 weeks of
gestation. The client reports that she has been leaking fluid from her vagina for 2 days. The nurse
knows that this client is at risk for
a. Cord Prolapse
b. Infection
C, Postpartum hemorrhage
d. Hydramnios
Answer: b. Infection
25. A nurse is caring for a client who is in active labor and becomes nauseous and vomits. The
client is very irritable and feels the urge to have a bowel movement. She states, "I've had enough.
I can't do this anymore. I want to go home right now." the nurse knows that these signs indication
the client is in the
a. 2nd stage of labor
b. 4th stage of labor
c. transition phase of labor
d. latent phase of labor
Answer: c. transition phase of labor
26. A nurse is caring for a client at 40 weeks of gestation who is experiencing contraction every 3
to 5 min and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated,
80% effaced and -1 station. The client asks for pain medication. Which of the following actions
should the nurse take at the time? (Select all that apply)
a. Encourage the use of patterned breathing techniques
b. Insert an indwelling urinary catheter
c. Administer opioid analgestic medication as prescribed
d. Suggest application of cold
e. Provide ice chips.
Answer: a. Encourage the use of patterned breathing techniques
c. Administer opioid analgestic medication as prescribed
d. Suggest application of cold
27. A nurse is caring for a client who is in active labor. The client reports lower back pain. The
nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of
the following nonpharmocological nursing interventions is appropriate?
a. abdominal effleurage
b. sacral counterpressure
c. showing if not contraindicated
d. back rub and massage
Answer: b. sacral counterpressure
28. A nurse is caring for a client following the administration of an epidural block and is
preparing to administer a prescribed IV fluid bolus. The client's partner asks about the purpose of
the IV fluids. Which of the following is an appropriate response by the nurse?
a. "It is needed to promote increased urine output."
b. "It is needed to counteract respiratory depression."
c. "It is needed to counteract hypotension."
d. "It is needed to prevent olihohyramnios"
Answer: C "It is needed to counteract hypotension."
29. A nurse in L&D is caring for a client who is in the 2nd stage of labor. The client's labor has
been progressing and she is expected to deliver vaginally in 20 mins. The provider is preparing to
administer lidocaine (Xylocaine) for pain relief and perform an episiotomy. The nurse should
know that the type of regional anesthetic block that is to be administered is which of the
following?
a. Pudendal block
b. Epidural block
c. Spinal block
d. Paracervical black
Answer: a. Pudendal block
30. A nurse in L&D is caring for a client who is using patterned breathing during labor. The
client reports numbness and tingling of the fingers. Which of the following actions should the
nurse take?
a. Administer oxygen via nasal cannula at 2L
b. Apply a warm blanket
c. Assist the client to a side-lying position
d. Place an oxygen mask over the client's nose and mouth.
Answer: d. Place an oxygen mask over the client's nose and mouth.
31. A nurse is providing care for client who is in active labor. Her cervix is dilated to 5cm, and
her membranes are intact. Based on the use of external fetal monitoring, the nurse notes a FHR
of 115 to 125/min with occasional increases up to 150-155/min that last for 25 seconds and have
beat-to-beat variability of 20/min. There is no showing of FHR from the baseline. The nurse
should recognize that this client is exhibiting signs of which of the following? (Select all the
apply)
a. Moderate variability
b. FHR accelerations
c. FHR decelerations
d. Normal baseline FHR
e. Fetal tachycardia
Answer: a. Moderate variability
b. FHR accelerations
d. Normal baseline FHR
32. A nurse is caring for a client who is having an induction of labor. Based on the use of external
electronic fetal monitoring, the nurse notes that the FHR variability is decreased and resembles a
straight line. The client has not received pain meds. Which of the following should occur first
before the nurse can apply an internal scalp electrode?
a. Dilation
b. Rupture of the membranes
c. Effacement
d. Engagement
Answer: b. Rupture of the membranes
33. A nurse is reviewing the electronic monitor tracing of a client who is in active labor. The
nurse knows that a fetus received more oxygen when which of the following appears on the
tracing?
a. Peak of the uterine contraction
b. Moderate variability
c. FHR acceleration
d. Relaxation between uterine contractions
Answer: d. Relaxation between uterine contractions
34. A nurse is caring for a client who is in labor and observes late decelerations on the electronic
fetal monitor. Which of the following is the first action the nurse should take?
a. Assist the client into the left-lateral position
b. Apply a fetal scalp electrode
c. Insert and IV catheter
d. Perform a vaginal exam
Answer: a. Assist the client into the left-lateral position
35. A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following
techniques should the nurse use to identify the fetal lie?
a. Apply palms of both hands to sides of uterus.
b. Palpate the fundus of the uterus
c. Grasp lower uterine segment between thumb and fingers.
d. Stand facing client's feet with fingertips outlining cephalic prominence.
Answer: b. Palpate the fundus of the uterus
36. A nurse is caring for a client and her partner during the second stage of labor. The client's
partner asks the nurse to explain how he will know when crowning occurs. Which of the
following is an appropriate response by the nurse?
a. "The placenta will protrude from the vagina."
b. "Your partner will report a decrease in the intensity of contractions."
c. "The vaginal area will bulge as the baby's head appears."
d. "Your partner will report less rectal pressure."
Answer: c. "The vaginal area will bulge as the baby's head appears."
37. A nurse is caring for a client in the third stage of labor. Which of the following findings
indicate that placental separation has occurred? (select all that apply)
a. Lengthening of the umbilical cord.
b. Swift gush of clear amniotic fluid.
c. Softening of the lower uterine segment.
d. Appearance of dark blood from the vagina.
e. Fundus is firm upon palpation.
Answer: a. Lengthening of the umbilical cord.
d. Appearance of dark blood from the vagina.
e. Fundus is firm upon palpation.
38. A nurse is caring for a client who is in the transition phase of labor and reports that she needs
to have a bowel movement with the peak of contractions. Which of the following is an
appropriate nursing intervention?
a. Assist the client to the bathroom.
b. Prepare for an impending delivery.
c. Prepare to remove a fecal impaction.
d. Encourage the client to take a deep, cleansing breaths.
Answer: b. Prepare for an impending delivery.
39. A nurse in L&D is planning care for a newly admitted client who reports she is in labor and
has been having vaginal bleeding for 2 weeks. Which of the following should the nurse include
in the plan of care?
a. Inspect the introits for a prolapsed cord.
b. Perform a test to identify the ferning pattern.
c. Monitor station of presenting part.
d. Defer vaginal exam.
Answer: b. Prepare for an impending delivery.
40. A nurse is caring for a client who is in the 1st stage of labor and encourages the client to void
every 2 hours. The nurse explains that a
a. full bladder increased the risk for fetal trauma.
b. full bladder increased the risk for bladder infection.
c. distended bladder will be traumatized by frequent pelvic exams.
d. distended bladder reduces pelvic space needed for birth.
Answer: d. distended bladder reduces pelvic space needed for birth.
41. A nurse is caring for a client who is at 42 weeks of gestation and is admitted to the labor and
delivery unit. During an ultrasound, it is noted that the fetus is large for gestational age. The
nurse reviews the prescription from the provider to begin an amnioinfusion. The nurse should
know that an amnioinfusion is indicated for which of the following reasons? (Select all that
apply)
a. Oligohydramnios
b. Hydramnios
c. Fetal cord compression
d. Hydration
e. Fetal immaturity
Answer: a. Oligohydramnios
c. Fetal cord compression
42. A nurse is caring for a client who has been in labor for 12 hours, and her membranes are
intact. The provider has decided to perform an amniotomy in an effort to facilitate the progress of
labor. The nurse performs a vaginal exam to ensure which of the following prior to the
performance of the amniotomy?
a. Fetal engagement
b. Fetal lie
c. Fetal attitude
d. Fetal position
Answer: a. Fetal engagement
43. A nurse is caring for a client who had no prenatal care, is rH-negatibe and will undergo an
external version at 37 weeks of gestation. The nurse anticipates a prescription for which of the
following medications to be administered prior to the version?
a. Prostaglandin gel (Cervidil)
b. Magnesium sulfate
c. RhoGAM
d. Oxytocin (pitocin)
Answer: c. RhoGAM
44. A nurse is caring for a client who is receiving oxytocin (pitocin) for induction of labor and
has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of
the following contractions patterns should the nurse discontinue the infusion of oxytocin?
a. Frequency every 2 min
b. Duration of 90-120 seconds
c. Intensity of 60-90 mm Hg
d. Resting tone of 15 mm Hg
Answer: b. Duration of 90-120 seconds
45. A nurse educator in L&D is reviewing the use of chemical agents to promote cervical
ripening with a group of newly hired nurses. Which of the following statements by a nurse
indicates understanding of the teaching?
a. "They are administered in an oral form"
b. "They act by absorbing fluid from tissues."
c. "They promote dilation of the os."
d. "They include and amniotomy."
Answer: a. "They are administered in an oral form"
46. A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation
between hypertonic contractions. The nurse recognizes that adverse effect of this contraction
pattern is
a. prolonged labor.
b. reduced fetal oxygen supply.
c. delayed cervical dilation.
d. increased maternal stress
Answer: b. reduced fetal oxygen supply.
47. A nurse is caring for a client who is in active labor and reports severe back pain. During
assessment, the fetus is noted to be in the occiput posterior position. Which of the following
maternal positions should the nurse suggest to the client to facilitate normal labor progress?
a. Hands and knees
b. Lithotomy
c. Trendelenburg
d. Supine with a rolled towel under one hip
Answer: a. Hands and knees
48. A nurse is caring for a client who is admitted to L&D. With the use of Leopold maneuvers, it
is noted that the fetus is in the breech presentation. For which of the following possible
complications should the nurse observe?
a. Precipitous labor
b. Premature rupture of membranes
c. Post maturity syndrome
d. Prolapsed umbilical cord
Answer: d. Prolapsed umbilical cord
49. A nurse is caring for a client who is at 42 weeks of gestation and in active labor. The nurse
should understand that the fetus is at risk for which of the following?
a. Intrauterine growth restriction
b. Hyperglycemia
c. Meconium aspiration
d. Poly hydramnious
Answer: c. Meconium aspiration
50. A nurse is caring for a client in active labor. When last examined 2 hr ago, the client's cervix
was 3cm dilated, 100% effaced, membrane intact and the fetus was at -2 station. The client
suddenly states "my water broke." The monitor reveals a FHR of 80-85/min, and the nurse
performs a vaginal exam noticing clear fluid and a pulsing loop of the umbilical cord in the
client's vagina. Which of the following actions should the nurse perform first?
a. Place the client in trendelenburg
b. Apply pressure to the presenting part with her fingers.
c. Administer oxygen
d. Call for assistance
Answer: d. Call for assistance
51. A nurse is performing a fundal assessment for a client in her second postpartum day and
observes the client's perineal road for loch. She notes the pad to be saturated approx 12 cm with
loch that is bright red in color and contains small clots. The nurse knows that this finding is
a. moderate lochia rubra
b. excessive lochia rubra
c. light loch rubra
d. scant lochia serosa
Answer: a. moderate lochia rubra
52. During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood
that soon stops. On assessment, a nurse finds the client's uterus to be firm and midline and at the
level of the umbilicus. The nurse interprets this finding as
a. evidence of a possible vaginal hematoma
b. an indication of cervical or perineal laceration.
c. a normal postural discharge of lochia.
d. abnormally excessive lochia rubra flow.
Answer: c. a normal postural discharge of loch.
53. A nurse is assessing a postpartum client for fundal height, location, and consistency. The
funds is found to be displaced laterally to the right and their is uterine atony. Which of the
following is the cause of the uterine atony?
a. Poor involution
b. Urinary retention
c. Hemorrhage
d. Infection
Answer: b. Urinary retention
54. A nurse is completing postpartum discharge teaching to a client who had no immunity to
varicella vaccine. Which of the following statements by the client indicates understanding of the
teaching?
a. "I will need to use contraception for 3 months before considering pregnancy."
b. "I need a second vaccination at my postpartum visit."
c. "I was given the vaccine because my baby is O+"
d. "I will be tested in 3 months to see if I have developed immunity."
Answer: b. "I need a second vaccination at my postpartum visit."
55. A nurse is caring for a client who is 1 hr following a vaginal birth and experiencing
uncontrollable shaking. The nurse should understand that the shaking is due to which of the
following? (Select all that apply)
a. A change in body fluids
b. The metabolic effort of labor
c. Diaphoresis
d. A decrease in body temperature
e. A decrease in prolactin level
Answer: a. A change in body fluids
b. The metabolic effort of labor
56. A nurse concludes that the father of an infant is not showing positive signs of parent infant
bonding and appears to be very anxious and nervous when the infant's mother asks him to bring
her the infant. Which of the following is an appropriate nursing intervention to promote fatherinfant bonding?
a. Hand the father the infant and suggest he change the diaper.
b. Ask the father why he is son anxious and nervous
c. Tell the gather that he will grow accustomed to the infant.
d. Provide education about infant care when the father is present
Answer: d. Provide education about infant care when the father is present
57. A client in the early postpartum period is very excited and talkative. She is repeatedly telling
the nurse every detail of her labor and birth. Because the client will not stop talking, the nurse is
having difficulty completing the postpartum assessments. The appropriate action by the nurse is
to
a. come back later when the client is more cooperative.
b. give the client time to express her feelings.
c. tell the client she needs to be quiet so the assessment can be completed
d. redirect the client's focus so that she will become quiet
Answer: b. give the client time to express her feelings.
58. A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal
adaptation and mother-infant bonding. Which of the following behaviors by the client indicates a
need for the nurse to intervene? (Select all that apply)
a. Demonstrates apathy when the infant cries
b. Touches the infant and maintains close physical proximity
c. Views the infant's behavior as uncooperative during diaper changing
d. Identifies and relates infant's characteristics to those of family members.
e. Interprets the infant's behavior as meaningful and a way of expressing needs
Answer: a. Demonstrates apathy when the infant cries
c. Views the infant's behavior as uncooperative during diaper changing
59. A home-health nurse is conducting a visit to the home of a client who has a 2-month-old
infant and a 4-year-old son. The client expresses frustration about the behavior of the 4year-old
who was previously toilet trained and is now frequently wetting himself. The nurse should
provide education and explains to the client that
a. her son was probably not ready for toilet training and should wear training pants.
b. her son is showing an adverse sibling response.
c. the indicates the child requires counseling.
d. this can be resolved by sending the child to preschool.
Answer: b. her son is showing an adverse sibling response.
60. A nurse in the delivery room is planning to promote maternal-infant bonding for a client who
just delivered. Which of the following is the priority action by the nurse?
a. Encourage the parents to touch and explore the neonate's features.
b. Limit noise and interruptions in the delivery room.
c. Place the neonate at the client's breast.
d. Place the neonate skin-to-skin on the clients chest.
Answer: d. Place the neonate skin-to-skin on the clients chest.
61. A nurse is conducting a home visit for a client who is 2 weeks postpartum and breastfeeding.
The client reports breast engorgement. Which of the following recommendations should the
nurse make?
a. "Apply cold compresses between feedings."
b. "Take a warm shower right after feedings."
c. "Apply breast milk to the nipples and allow them to air dry."
d. "Use the various infant positions for feedings."
Answer: a. "Apply cold compresses between feedings."
62. A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client
should contact her provider for which of the following client findings?
a. Scant, nonodorous white vaginal discharge.
b. Uterine cramping during breastfeeding.
c. Sore nipple with cracks and fissures.
d. Decreased response with sexual activity
Answer: c. Sore nipple with cracks and fissures.
63. A nurse is conducting a home visit with a client who is 3 months postpartum and
breastfeeding. Menses has not yet resumed. The client is discussing contraception with the nurse,
stating that she does not want another child for a couple years. The nurse understands that the
client needs further instruction if the client makes which of the following statements?
a. "I have already started using the mini pill for protection."
b. "Because of our beliefs, we are going to use the rhythm method."
c. "I am being refitted for a diaphragm by my doctor next week,:
d. "I will begin using birth control when I stop breastfeeding."
Answer: d. "I will begin using birth control when I stop breastfeeding."
64. A nurse is providing care to multiple clients on the postpartum unit. Which of the following
clients is at the greatest risk for developing a puerperal infection?
a. A client who has an episiotomy that is erythematous and has extended into a third-degree
laceration.
b. A client who does not wash her hands between perineal care and breastfeeding.
c. A client who is not breastfeeding and is using measure to suppress lactation.
d. A client who has a cesarean incision that is well-approximated with no drainage.
Answer: b. A client who does not wash her hands between perineal care and breastfeeding.
65. A nurse is providing discharge instructions to a postpartum client following a cesarean birth.
The client reports leaking urine every time she sneezes or coughs. Which of the following should
the nurse suggest?
a. Performing sit-ups
b. Performing pelvic tilt exercises
c. Doing Kegal exercises
d. Doing abdominal crunches
Answer: c. Doing Kegal exercises
66. A nurse in the ED is caring for a client who reports abrupt, sharp, right-sided lower quadrant
abdominal pain and bright red vaginal bleeding. The client states she missed one menstrual cycle
and cannot be pregnant beaches she has an IUD. The nurse should suspect which of the
following?
a. Missed abortion
b. Ectopic pregnancy
c. Severe preeclampsia
d. Hydatidiform mole
Answer: b. Ectopic pregnancy
67. A nurse at an antepartum clinic is caring for a client who is at 4 months gestation. The client
reports continued nausea and vomiting and scant, prune colored discharge. She has experienced
no weight loss and has a fundal height larger than expected. Which of the following
complications should the nurse suspect?
a. Hyperemesis gravidarum
b. Threatened abortion
c. Hydatidiform mole
d. Preterm Labor
Answer: c. Hydatidiform mole
68. A nurse is providing care for a client who is diagnosed with a marginal abrupt placenta. The
nurse is aware that which of the following findings are risk factors for developing the condition?
(Select all the apply)
a. Maternal hypertension
b. Blunt abdominal trauma
c. Cocaine use
d. Maternal age
e. Cigarette smoking
Answer:
a. Maternal hypertension
b. Blunt abdominal trauma
c. Cocaine use
e. Cigarette smoking
69. A nurse is providing care for a client who is at 32 weeks of gestation and who has a placenta
previa. The nurse notes that the client is actively bleeding. Which of the following types of
medications should the nurse anticipate the provider will prescribe?
a. Betamethasone (Celestone)
b. Indomethacin (Indocin)
c. Nifedipine (Adalat)
d. Methylergonovine (Methergine)
Answer: a. Betamethasone (Celestone)
70. A nurse is caring for a client who has a diagnosis of ruptured ectopic pregnancy. Which of the
following is an expected finding?
a. No alteration in menses
b. Transvaginal ultrasound indicating a fetus in the uterus
c. Serum progesterone great than the expected reference range
d. Report of severe shoulder pain
Answer: d. Report of severe shoulder pain
71. A nurse on the obstetrical unit is admitting a client who is in labor. The client has a positive
HIV status. The nurse is aware that which of following is contraindicated for this client? (Select
all that apply)
a. Episiotomy
b. Vacuum extraction
c. Forceps
d. C-section
e. Internal fetal monitoring
Answer:
a. Episiotomy
b. Vacuum extraction
c. Forceps
e. Internal fetal monitoring
72. A nurse in an antepartum clinic is providing care for a client. Which of the following are
suggestive of a TORCH infection? (select all the apply)
a. Joint pain
b. Malaise
c. Rash
d. Urinary frequency
e. Tender lymph nodes
Answer:
a. Joint pain
b. Malaise
c. Rash
e. Tender lymph nodes
73. A nurse is caring for a client who has a diagnosis of gonorrhea. Which of the following
medications should the nurse anticipate the provider will prescribe?
a. Ceftriaxone (Rocephin)
b. Fluconazole (Diflucan)
c. Metronidazole (Flagyl)
d. Zidovudine (Retrovir)
Answer: a. Ceftriaxone (Rocephin)
74. A nurse is caring for ac client who is in labor. The nurse is aware that which of the following
conditions have medications that can be prescribe as prophylactic treatment during labor or
immediately following delivery? (Select all that apply)
a. Gonorrhea
b. Chlamydia
c. HIV
d. Group B Strep
e. TORCH
Answer:
a. Gonorrhea
b. Chlamydia
c. HIV
d. Group B Strep
75. A nurse manager in a prenatal clinic is reviewing ways to prevent a TORCH infection during
pregnancy with a group of newly licensed nurse during an education program. Which of the
following statements by a nurse indicates understanding of the teaching?
a. "Obtain a vaccination against rubella early in pregnancy."
b. "Seek prophylactic treatment if cytomegalovirus is detected"
c. "A woman should avoid handling dog feces."
d. "A woman should avoid consuming undercooked meat."
Answer: d. "A woman should avoid consuming undercooked meat."
76. A nurse is caring for a client at 14 weeks gestation who has hyperemesis gravidarum. The
nurse is is aware that which of the following are risk factors for the client? (select all the apply)
a. Obesity
b. Multifetal pregnancy
c. Maternal age greater than 40
d. Migraine headache
e. Oligohydramnios
Answer:
a. Obesity
b. Multifetal pregnancy
d. Migraine headache
77. A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for
seizures prophylaxis. Which of the following indicates magnesium sulfate toxicity? (select all the
apply)
a. Respiration fewer than 12/min
b. Urinary output less than 30mL/hr
c. Hyperreflexic deep-tendon reflexes
d. Decreased level of consciousness
e. Flushing and sweating
Answer:
a. Respiration fewer than 12/min
b. Urinary output less than 30mL/hr
d. Decreased level of consciousness
78. A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following
medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected?
a. Nifedipine (Adalat)
b. Pyridoxine (Vitamin B6)
c. Ferrous sulfate
d. Calcium gluconate
Answer: d. Calcium gluconate
79. A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks
gestation. Which of the following statements by the client indicates understanding of the
teaching?
a. "I will take this pill with my breakfast."
b. "I will take this medication with a glass of milk."
c. "I plan to drink more orange juice while taking this pill."
d. "I plan to add more calcium-rich foods to my diet while taking this medication."
Answer: c. "I plan to drink more orange juice while taking this pill."
80. A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the
client's laboratory reports. Which of the following findings is a clinical manifestation of this
condition?
a. Hgb 12.2g/dL
b. Urine ketones present
c. Alanine aminotransferase (ALT) 20IU/L
d. Serum glucose 114mg/dL
Answer: b. Urine ketones present
81. A nurse is L&D is providing care for a client who is in preterm labor at 32 weeks gestation.
Which of the doling medications should the nurse anticipate the provider will prescribe to hasten
fetal lung maturity?
a. Calcium gluconate
b. Indomethacin (Indocin)
c. Nifedipine (procardia)
d. Bethmethasone (Celestone)
Answer: d. Bethmethasone (Celestone)
82. A nurse is caring for a client who is receiving nifedipine (Procardia) for prevention of
preterm labor. The nurse should monitor the client for which of the following clinical
manifestations?
a. Blood-tinged sputum
b. Dizziness
c. Pallor
d. Somnolence
Answer: b. Dizziness
83. A nurse is caring for a client who has prescription magnesium sulfate. The nurse should
recognize that which of the following are contraindications for use of this medication. (Select all
the apply)
a. Acute fetal distress
b. Preterm labor
c. Vaginal bleeding
d. Cervical dilation greater than 6cm
e. Severe gestational hypertension
Answer:
a. Acute fetal distress
c. Vaginal bleeding
d. Cervical dilation greater than 6cm
84. A nurse is reviewing discharge teaching with a client who has premature rupture of
membranes at 26 weeks of gestation. Which of the following should be included in the teaching?
a. Use a condom with sexual intercourse.
b. Avoid bubble bath solution when taking a bath.
c. Wipe from the back to front when performing perineal hygiene.
d. Keep daily record of fetal kick counts.
Answer: d. Keep daily record of fetal kick counts.
85. A nurse is caring for a postpartum client. The nurse should understand that which of the
following findings are the earliest indication of hypovolemia caused by hemorrhage?
a. Increasing pulse and decreasing blood pressure
b. Dizziness and increasing respiratory rate
c. Cool, clammy skin and pale mucous membranes
d. Altered mental status and level of consciousness
Answer: a. Increasing pulse and decreasing blood pressure
86. A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage
with a group of nurses. Which of the following should be included in the discussion? (select all
that apply)
a. Precipitous delivery
b. Lacerations
c. Inversion of the uterus
d. Oligohydramnios
e. Retained placental fragments
Answer:
a. Precipitous delivery
b. Lacerations
c. Inversion of the uterus
e. Retained placental fragments
87. A nurse on the postpartum unit is performing a physical assessment of a client who is being
admitted with a suspected DVT. Which of the following clinical findings should the nurse
anticipate the client will exhibit? (Select all that apply)
a. Calf tenderness to palpation
b. Swelling of the extremity
c. Elevated temperature
d. Area of warmth
e. Report of nausea
Answer:
a. Calf tenderness to palpation
b. Swelling of the extremity
c. Elevated temperature
d. Area of warmth
88. A nurse on the postpartum unit is planning care of client who has thrombophlebitis. Which of
the following nursing interventions should the nurse include in the plan of care?
a. Apply cold compresses to the affected extremity.
b. Massage the affected extremity.
c. Allow the client to ambulate.
d. Measure the leg circumference.
Answer: d. Measure the leg circumference.
89. A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of
the following antepartum complications should the nurse understand is a risk factor for this
client?
a. Preeclampsia
b. Thrombophlebitis
c. Placent previa
d. Hyperemesis gravidarum
Answer: a. Preeclampsia
90. A nurse on the postpartum unit is caring for several clients. The nurse should recognize that
the greatest risk for development of a postpartum infection is the client who
a. experienced a precipitous labor less than 3hrs in duration
b. had premature rupture of membranes and prolonged labor.
c. delivered a large for gestational age infant.
d. had a boggy uterus that was not well-contracted.
Answer: b. had premature rupture of membranes and prolonged labor.
91. A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following is
an appropriate statement by the nurse?
a. "Limit the amount of time the infant nurses on each breast."
b. "Nurse the infant only on the unaffected breast until resolved."
c. "Completely empty each breast at each feeding or use a pump."
d. "Wear a tight fitting bra until lactation has ceased."
Answer: c. "Completely empty each breast at each feeding or use a pump."
92. A nurse is reviewing discharge teaching with a client who has a urinary tract infection. Which
of the following statements by the client indicates understanding of the teaching? (Select all the
apply)
a. "I will perform peri care and apply perineal pad in the back to front direction."
b. "I will drink cranberry and prune juices to make my urine more acidic."
c. "I will drink large amounts of fluids to flush the bacteria from my urinary tract."
d. "I will of back to breastfeeding after i have finished the antibiotic."
e. "I will take tylenol for any discomfort."
Answer:
b. "I will drink cranberry and prune juices to make my urine more acidic."
c. "I will drink large amounts of fluids to flush the bacteria from my urinary tract."
e. "I will take tylenol for any discomfort."
93. A nurse is caring for a client who has mastitis. Which of the following is the typical causative
agent of mastitis?
a. Staphyolcoccus aureus
b. Chlamydia trachomatis
c. Klebsiella pneumonia
d. Clotridium perfringens
Answer: a. Staphyolcoccus aureus
94. A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of
appetite, and a feeling of letdown. The nurse knows these findings are characteristic of
a. postpartum fatigue
b. postpartum psychosis
c. the letting-go phase
d. postpartum depression
Answer: d. postpartum depression
95. A nurse is caring for a client who has postpartum depression. Which of the following are
expected findings? (select all that apply)
a. Disappointment in the characteristics of the infant
b. Concerns about lack of income to pay bills
c. Anxiety about assuming new role as a mother
d. Rapid decline in estrogen and progesterone
e. Postpartum physical discomfort and/or pain
Answer:
b. Concerns about lack of income to pay bills
c. Anxiety about assuming new role as a mother
d. Rapid decline in estrogen and progesterone
e. Postpartum physical discomfort and/or pain
96. A nurse is caring for a postpartum client who delivered her third infant 2 days ago. The nurse
recognizes that which of the following findings are suggestive of postpartum depression? (Select
all that apply)
a. Fatigue
b. Insomnia
c. Euphoria
d. Flat affect
e. Crying
Answer:
b. Insomnia
c. Euphoria
d. Flat affect
e. Crying
97. A nurse is caring for a newborn who was born at 38 weeks of gestation, weighing 3200 g, and
is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should
classify this neonate as
a. low birth weight
b. appropriate for gestational age.
c. small for gestational age.
d. large for gestational age.
Answer: b. appropriate for gestational age.
98. A nurse is completing a newborn assessment and observes small white nodules on the roof of
the newborn's mouth. This finding is characteristic of which of the following conditions?
a. Mongolian spots
b. Milia spots
c. Erythema toxicum
d. Epstein's pearls
Answer: d. Epstein's pearls
99. A nurse is assessing the reflexes of a newborn. In checking the Moro reflex, the nurse should
perform which of the following?
a. Make a loud noise such as clapping hands together over the newborn's crib.
b. Stimulate the pads of the newborn's hands with stroking or massage.
c. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot.
d. Hold the newborn in a semi sitting position, then allow the newborn's head and truck to fall
backward.
Answer: d. Hold the newborn in a semi sitting position, then allow the newborn's head and truck
to fall backward.
100. A nurse is completing an assessment. Which of the following data indicate the newborn is
adapting to extrauterine life? (Select all that apply)
a. Expiratory grunting
b. Inspiratory nasal flares
c. Apnea for 10-second periods
d. Obligatory nose breathing
e. Crackles and wheezing
Answer:
c. Apnea for 10-second periods
d. Obligatory nose breathing
101. A nurse is preparing to bathe a newborn and observes bluish marking across the newborn's
lower back. The nurse should understand that this mark is
a. frequently seen in newborns who have dark skin.
b. a finding indicating hyperilirubinemia
c. a forceps mark from an operative delivery.
d. related to prolonged birth or trauma during delivery
Answer: a. frequently seen in newborns who have dark skin.
102. A nurse is preparing to administer prophylactic eye ointment to a newborn to treat
ophthalmia neonatorum. Which of the following medications should the nurse anticipate
administering?
a. Ofloxacin (Floxin)
b. Nystatin (Mycostatin)
c. Erthtomycin (Romycin)
d. Ceftriaxone (Rocephin)
Answer: c. Erthtomycin (Romycin)
103. A newborn was not dried off completely after delivery. The nurse should understand that
which of the following mechanisms causes the newborn to lose heat?
a. Conduction
b. Convection
c. Evaporation
d. Radiation
Answer: c. Evaporation
104. When performing nursing care for a newborn after birth, which of the following nursing
interventions is the highest priority?
a. initiating breastfeeding
b. performing the initial bath
c. giving a vit K injection
d. covering the newborn's head with a cap
Answer: d. covering the newborn's head with a cap
105. A nurse is preparing to administer a vit K (aquamephyton) injection to a newborn. Which of
the following is an appropriate response by the nurse to the newborn's mother regarding why this
medication is given?
a. "It assists with blood clotting."
b. "It promotes maturation of the bowel."
c. "It is a preventative vaccine."
d. "It provides immunity."
Answer: a. "It assists with blood clotting."
106. A nurse is taking a newborn to a mother for breastfeeding. Which of the following is an
appropriate action for the nurse to take for security purposes?
a. Ask the mother to state her full name.
b. Look at the name on the newborn's bassinet.
c. Match the mother's identification band with the newborn's band.
d. Compare the name on the bassinet with the room number.
Answer: c. Match the mother's identification band with the newborn's band.
107. A nurse is reviewing care of the umbilical cord with the parents of a newborn. Which of the
following should be included in the teaching?
a. Cover the corn with small gauze square.
b. Trickle clean water over the cord with each diaper change.
c. Apply hydrogen peroxide to the cord twice a day.
d. Keep the diaper folded below the cord.
Answer: d. Keep the diaper folded below the cord.
108. A nurse is providing discharge teaching to the parents of a newborn regarding circumcision
care. Which of the following statements made by the parent indicates a need for further
clarification?
a. "His circumcision will heal within a couple of weeks."
b. "I do not need to remove the yellow mucus that will form."
c. "I will clean his penis with each diaper change."
d. "I will give him a tub bath within a couple of days."
Answer: d. "I will give him a tub bath within a couple of days."
109. A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of
the following are contraindications? (select all that apply)
a. Hypospadias
b. Hydrocele
c. Familiar history for hemophilia
d. Hypebilirubinemia
e. Episadias
Answer:
a. Hypospadias
c. Familiar history for hemophilia
e. Episodias
110. A nurse is caring for a newborn immediately following a circumcision using a Gomco
procedure. Which of the following is an appropriate nursing intervention?
a. Apply Gelfoam powder to the site.
b. Place the newborn in the prone position.
c. Apply petroleum gauze to the site.
d. Aviod changing the diaper until the first void.
Answer: c. Apply petroleum gauze to the site
111. A nurse is reviewing car sear safety with the parents of a newborn. The nurse instructs the
parent to restrain the newborn in a car seat in the
a. front seat, rear-facing position.
b. front seat, forward-facing position.
c. back seat, rear-facing position.
d. back seat, forward-facing position.
Answer: c. back seat, rear-facing position.
112. A nurse is called to the birthing room to assist with the assessment of a newborn who was
born at 32 weeks of gestation. The newborn's birth weight is 1,100g. Which of the following are
expected findings in this newborn? (Select all the apply)
a. Lanugo
b. Long nails
c. Weak grasp reflex
d. Translucent skin
e. Plump face
Answer:
a. Lanugo
c. Weak grasp reflex
d. Translucent skin
113. A nurse is examining an infant who was just deliver at 41 weeks gestation. Which of the
following characteristics indicates that this infant is post term?
a. Excess body fat
b. Flat areola without breast buds
c. Heels movable fully to the ears
d. Leathery skin
Answer: d. Leathery skin
114. A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy.
Which of the following is the priority finding in the newborn?
a. Conjunctivitis
b. Bronze skin discoloration
c. Sunken fontanels
d. Maculopapular rash
Answer: c. Sunken fontanels
115. A nurse is caring for a newborn who is preterm and has respiratory distress syndrome.
Which of the following should the nurse monitor to evaluate the newborn's condition following
administration of synthetic surfactant?
a. Oxygen saturation
b. Body temperature
c. Serum bilirubin
d. Heart rate
Answer: a. Oxygen saturation
116. A nurse is caring for a newborn who has suspected neonatal abstinence syndrome. Which of
the following findings support this diagnosis?
a. Decreased muscle tone
b. Continuous high-pitched cry
c. Sleeps for 2 hrs after feeding
d. Milk tremors when disturbed
Answer: b. Continuous high-pitched cry
117. What factors would change during a pregnancy if the hormone progesterone were reduced
or withdrawn?
a. The woman’s gums would become red and swollen and would bleed easily.
b. The uterus would contract more and peristalsis would increase.
c. Morning sickness would increase and would be prolonged.
d. The secretion of prolactin by the pituitary gland would be inhibited. Term
Answer: b. The uterus would contract more and peristalsis would increase.
118. Which of the following is a presumptive sign or symptom of pregnancy?
a. Restlessness
b. Elevated mood
c. Urinary frequency
d. Low Back pain
Answer: c. Urinary frequency
119. When obtaining a blood test for pregnancy, which hormone would the nurse expect the test
to measure?
a. Human Chorionic Gonadotropin (hCG)
b. Human placental lactogen (hPL)
c. Follicle-stimulating hormone (FSH)
d. Luteinizing hormone (LH)
Answer: a. Human Chorionic Gonadotropin (hCG)
120. During pregnancy, which of the following should the expectant mother reduce or avoid?
a. Raw meat or uncooked shellfish
b. Fresh, washed fruits and vegetables
c. Whole grains
d. Protein and iron from meat sources
Answer: a. Raw meat or uncooked shellfish
121. A feeling expressed by most women upon learning they are pregnant is:
a. Acceptance
b. Depression
c. Jealousy
d. Ambivalence
Answer: d. Ambivalence
122. Reva Rubin identified four major tasks that the pregnant woman undertakes to form a
mutually gratifying relationship with her infant. What is "binding in"?
a. Ensuring safe passage through pregnancy, labor and birth
b. Seeking acceptance of this infant by others
c. Seeking acceptance of self as mother to the infant
d. Learning to give of oneself on behalf of the infant
Answer: c. Seeking acceptance of self as mother to the infant
123. Which of the following biophysical profile findings indicate poor oxygenation to the fetus?
a. Two pockets of amniotic fluid
b. Well-flexed arms and legs
c. Nonreactive fetal heart rate
d. Fetal breathing movements noted Term
Answer: c. Nonreactive fetal heart rate
124. The nurse teaches the pregnant client how to perform Kegel exercises as a way to
accomplish which of the following?
a. Prevent perineal lacerations
b. Stimulate labor contractions
c. Increase pelvic muscle tone
d. Lose pregnancy weight quickly
Answer: c. Increase pelvic muscle tone
125. During a clinic visit, a pregnant client at 30 weeks’ gestation tells the nurse, “I’ve had some
mild cramps that are pretty irregular. What does this mean?” The cramps are probably
a. The beginning of labor in the very early stages
b. An ominous finding indicating that the client is about to have a miscarriage
c. Related to overhydration of the woman
d. Braxton Hicks contractions, which occur throughout pregnancy
Answer: d. Braxton Hicks contractions, which occur throughout pregnancy
126. The nurse is preparing her teaching plan for a woman who has just had her pregnancy
confirmed. Which of the following should be included in it? Select all that apply.
a. Prevent constipation by taking a daily laxative
b. Balance your dietary intake by increasing your calories by 300 to 500 daily
c. Continue your daily walking routine just as you did before this pregnancy
d. Tetanus, measles, mumps, and rubella vaccines will be given to you now
e. Avoid tub baths now that you are pregnant to prevent vaginal infections
f. Sexual activity is permitted as long as your membranes are intact g. Increase your consumption
of milk to meet your iron needs
Answer:
b. Balance your dietary intake by increasing your calories by 300 to 500 daily
c. Continue your daily walking routine just as you did before this pregnancy
e. Avoid tub baths now that you are pregnant to prevent vaginal infections
f. Sexual activity is permitted as long as your membranes are intact g. Increase your consumption
of milk to meet your iron needs
127. A pregnant client’s last normal menstrual period was on August 10. Using Nagele’s rule, the
nurse calculates that her estimated date of birth (EDB) will be which of the following?
a. June 23
b. July 10
c. July 30
d. May 17
Answer: d. May 17
128. When determining the frequency of contractions, the nurse would measure which of the
following?
a. Start of one contraction to the start of the next contraction
b. Beginning of one contraction to the end of the same contraction
c. Peak of one contraction to the peak of the next contraction
d. End of one contraction to the beginning of the next contraction Term
Answer: a. Start of one contraction to the start of the next contraction
129. Which fetal lie is most conducive to a spontaneous vaginal birth?
a. Transverse
b. Longitudinal
c. Perpendicular
d. Oblique
Answer: b. Longitudinal
130. Which of the following observations would suggest that placental separation is occurring?
a. Uterus stops contracting altogether.
b. Umbilical cord pulsations stop.
c. Uterine shape changes to globular.
d. Maternal blood pressure drops.
Answer: c. Uterine shape changes to globular.
131. As the nurse is explaining the difference between true versus false labor to her childbirth
class, she states that the major difference between them is:
a. Discomfort level is greater with false labor.
b. Progressive cervical changes occur in true labor.
c. There is a feeling of nausea with false labor.
d. There is more fetal movement with true labor
Answer: b. Progressive cervical changes occur in true labor.
132. The shortest but most intense phase of labor is the:
a. Latent phase
b. Active phase
c. Transition phase
d. Placental expulsion phase
Answer: c. Transition phase
133. A laboring woman is admitted to the labor and birth suite at 6-cm dilation. She would be in
which phase of the first stage of labor?
a. Latent
b. Active
c. Transition
d. Early
Answer: b. Active
134. Which assessment would indicate that a woman is in true labor?
a. Membranes are ruptured and fluid is clear
b. Presenting part is engaged and not floating.
c. Cervix is 4 cm dilated, 90% effaced.
d. Contractions last 30 seconds, every 5 to 10 minutes.
Answer: c. Cervix is 4 cm dilated, 90% effaced.
135. When a client in labor is fully dilated, which instruction would be most effective to assist
her in encouraging effective pushing?
a. Hold your breath and push through entire contraction.
b. Use chest-breathing with the contraction.
c. Pant and blow during each contraction.
d. Instruct her to wait until she feels the urge to push.
Answer: d. Instruct her to wait until she feels the urge to push.
136. During the fourth stage of labor, the nurse assesses the woman at frequent intervals after
giving childbirth. What assessment data would cause the nurse the most concern?
a. Moderate amount of dark red lochia drainage on peripad
b. Uterine fundus palpated to the right of the umbilicus
c. An oral temperature reading of 100.6° F
d. Perineal area bruised and edematous beneath her ice pack
Answer: b. Uterine fundus palpated to the right of the umbilicus
137. When managing a client’s pain during labor, nurses should:
a. Make sure the agents given do not prolong labor
b. Know that all pain relief measures are similar
c. Support the client’s decisions and requests
d. Not recommend nonpharmacologic methods
Answer: c. Support the client’s decisions and requests
138. The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip.
Which intervention would be most appropriate?
a. Reposition the client on the left side.
b. Begin 100% oxygen via face mask.
c. Document this normal pattern.
d. Call the health care provider immediately.
Answer: c. Document this normal pattern.
139. Postpartum breast engorgement occurs 48 to 72 hours after giving birth. What physiologic
change influences breast engorgement?
a. An increase in blood and lymph supply to the breasts
b. An increase in estrogen and progesterone levels
c. Colostrum production increases dramatically
d. Fluid retention in the breasts due to the intravenous fluids given during labor
Answer: a. An increase in blood and lymph supply to the breasts
140. In the taking-in maternal role phase described by Rubin (1984), the nurse would expect the
woman’s behavior to be characterized as which of the following?
a. Gaining self-confidence
b. Adjusting to her new relationships
c. Being passive and dependent
d. Resuming control over her life
Answer: b. Adjusting to her new relationships
141. The nurse is explaining to a postpartum woman 48 hours after her giving childbirth that the
afterpains she is experiencing can be the result of which of the following?
a. Abdominal cramping is a sign of endometriosis
b. A small infant weighing less than 8 lb
c. Pregnancies that were too closely spaced
d. Contractions of the uterus after birth
Answer: d. Contractions of the uterus after birth
142. The nurse would expect a postpartum woman to demonstrate lochia in which sequence?
a. Rubra, alba, serosa
b. Rubra, serosa, alba
c. Serosa, alba, rubra
d. Alba, rubra, serosa Term
Answer: b. Rubra, serosa, alba
143. The nurse is assessing Ms. Smith, who gave birth to her first child 5 days ago. What
findings by the nurse would be expected?
a. Cream-colored lochia; uterus above the umbilicus
b. Bright-red lochia with clots; uterus 2 fingerbreadths below umbilicus
c. Light pink or brown lochia; uterus 4 to 5 fingerbreadths below umbilicus
d. Yellow, mucousy lochia; uterus at the level of the umbilicus
Answer: c. Light pink or brown lochia; uterus 4 to 5 fingerbreadths below umbilicus
144. Prioritize the postpartum mother’s needs 4 hours after giving birth by placing a number 1, 2,
3, or 4 in the blank before each need
a. _________ Learn how to hold and cuddle the infant.
b. _________ Watch a baby bath demonstration given by the nurse.
c. _________ Sleep and rest without being disturbed for a few hours.
d. _________ Interaction time (first 30 minutes) with the infant to facilitate bonding.
Answer:
d. _________ Interaction time (first 30 minutes) with the infant to facilitate bonding.
c. _________ Sleep and rest without being disturbed for a few hours.
a. _________ Learn how to hold and cuddle the infant.
b. _________ Watch a baby bath demonstration given by the nurse.
145. When assessing a postpartum woman, which of the following would lead the nurse to
suspect postpartum blues?
a. Panic attacks and suicidal thoughts
b. Anger toward self and infant
c. Periodic crying and insomnia
d. Obsessive thoughts and hallucinations Term
Answer: c. Periodic crying and insomnia
146. Which of these activities would best help the postpartum nurse to provide culturally
sensitive care for the childbearing family?
a. Taking a transcultural course
b. Caring for only families of his or her cultural origin
c. Teaching Western beliefs to culturally diverse families
d. Educating himself or herself about diverse cultural practices
Answer: d. Educating himself or herself about diverse cultural practices
147. Which of the following suggestions would be most appropriate to include in the teaching
plan for a postpartum woman who needs to lose weight?
a. Increase fluid intake and acid-producing foods in her diet
b. Avoid empty-calorie foods and increase exercise.
c. Start a high-protein diet and restrict fluids .
d. Eat no snacks or carbohydrates.
Answer: b. Avoid empty-calorie foods and increase exercise.
148. After teaching a group of breast-feeding women about nutritional needs, the nurse
determines that the teaching was successful when the women state that they need to increase
their intake of which nutrients?
a. Carbohydrates and fiber
b. Fats and vitamins
c. Calories and protein
d. Iron-rich foods and minerals
Answer: c. Calories and protein
149. Which of the following would lead the nurse to suspect that a postpartum woman was
developing a complication?
a. Fatigue and irritability
b. Perineal discomfort and pink discharge
c. Pulse rate of 60 bpm
d. Swollen, tender, hot area on breast
Answer: d. Swollen, tender, hot area on breast
150. Which of the following would the nurse assess as indicating positive bonding between the
parents and their newborn?
a. Holding the infant close to the body
b. Having visitors hold the infant
c. Buying expensive infant clothes
d. Requesting that the nurses care for the infant Term
Answer: a. Holding the infant close to the body
151. Which activity would the nurse include in the teaching plan for parents with a newborn and
an older child to reduce sibling rivalry when the newborn is brought home?
a. Punishing the older child for bedwetting behavior
b. Sending the sibling to the grandparents’ house
c. Planning a daily “special time” for the older sibling
d. Allowing the sibling to share a room with the infant
Answer: c. Planning a daily “special time” for the older sibling
152. The major purpose of the first postpartum homecare visit is to:
a. Identify complications that require interventions
b. Obtain a blood specimen for PKU testing
c. Complete the official birth certificate
d. Support the new parents in their parenting roles
Answer: a. Identify complications that require interventions
153. When assessing the term newborn, the following are observed: newborn is alert, heart and
respiratory rates have stabilized, and meconium has been passed. The nurse determines that the
newborn is exhibiting behaviors indicating:
a. Initial period of reactivity
b. Second period of reactivity
c. Decreased responsiveness period
d. Sleep period for newborns
Answer: b. Second period of reactivity
154. A nurse observes a 3-day-old term newborn who is starting to appear mildly jaundiced.
What might explain this condition?
a. Physiologic jaundice secondary to breast-feeding
b. Hemolytic disease of the newborn due to blood incompatibility
c. Exposing the newborn to high levels of oxygen
d. Overfeeding the newborn with too much glucose water
Answer: c. Exposing the newborn to high levels of oxygen
155. After teaching a group of nursing students about thermoregulation and appropriate measures
to prevent heat loss by evaporation, which of the following student behaviors would indicate
successful teaching?
a. Transporting the newborn in an isolette
b. Maintaining a warm room temperature
c. Placing the newborn on a warmed surface
d. Drying the newborn immediately after birth
Answer: d. Drying the newborn immediately after birth
156. After birth, the nurse would expect which fetal structure to close as a result of increases in
the pressure gradients on the left side of the heart?
a. Foramen ovale
b. Ductus arteriosus
c. Ductus venosus
d. Umbilical vein
Answer: a. Foramen ovale
157. Which of the following newborns could be described as breathing normally?
a. Newborn A is breathing deeply, with a regular rhythm, at a rate of 20 bpm.
b. Newborn B is breathing diaphragmatically with sternal retractions, at a rate of 70 bpm.
c. Newborn C is breathing shallowly, with 40-second periods of apnea and cyanosis.
d. Newborn D is breathing shallowly, at a rate of 36 bpm, with short periods of apnea.
Answer: d. Newborn D is breathing shallowly, at a rate of 36 bpm, with short periods of apnea.
158. When assessing a term newborn (6 hours old), the nurse auscultates bowel sounds and
documents recent passing of meconium. These findings would indicate
a. Abnormal gastrointestinal newborn transition and needs to be reported
b. An intestinal anomaly that needs immediate surgery
c. A patent anus with no bowel obstruction and normal peristalsis
d. A malabsorption syndrome resulting in fatty stools
Answer: c. A patent anus with no bowel obstruction and normal peristalsis
159. At birth, a newborn’s assessment reveals the following: heart rate of 140 bpm, loud crying,
some flexion of extremities, crying when bulb syringe is introduced into the nares, and a pink
body with blue extremities. The nurse would document the newborn’s Apgar score as:
a. 5 points
b. 6 points
c. 7 points
d. 8 points
Answer: d. 8 points
160. The nurse is explaining phototherapy to the parents of a newborn. The nurse would include
which of the following as the purpose?
a. Increase surfactant levels
b. Stabilize the newborn’s temperature
c. Destroy Rh-negative antibodies
d. Oxidize bilirubin on the skin
Answer: d. Oxidize bilirubin on the skin
161. The nurse administers a single dose of vitamin K intramuscularly to a newborn after birth to
promote:
a. Conjugation of bilirubin
b. Blood clotting
c. Foreman ovale closure
d. Digestion of complex proteins Term
Answer: b. Blood clotting
162. A prophylactic agent is instilled in both eyes of all newborns to prevent which of the
following conditions?
a. Gonorrhea and chlamydia
b. Thrush and Enterobacter
c. Staphylococcus and syphilis
d. Hepatitis B and herpes
Answer: a. Gonorrhea and chlamydia
163. The AAP recommends that all newborns be placed on their backs to sleep to reduce the risk
of:
a. Respiratory distress syndrome
b. Bottle mouth syndrome
c. Sudden infant death syndrome
d. GI regurgitation syndrome
Answer: c. Sudden infant death syndrome
164. Which one of the following immunizations is most commonly received by newborns before
hospital discharge?
a. Pneumococcus
b. Varicella
c. Hepatitis A
d. Hepatitis B
Answer: d. Hepatitis B
165. Which condition would be missed if a newborn were screened before he had tolerated
protein feedings for at least 48 hours?
a. Hypothyroidism
b. Cystic fibrosis
c. Phenylketonuria
d. Sickle cell disease
Answer: c. Phenylketonuria
166. A woman diagnosed with preeclampsia is to receive magnesium sulfate. The rationale for
this drug is to:
a. Reduce CNS irritability to prevent seizures
b. Provide supplementation of an important mineral she needs
c. Prevent constipation during and after the birthing process
d. Decrease musculoskeletal tone to augment labor
Answer: a. Reduce CNS irritability to prevent seizures
167. A woman is suspected of having abruptio placentae. Which of the following would the
nurse expect to assess as a classic symptom?
a. Painless, bright-red bleeding
b. “Knife-like” abdominal pain
c. Excessive nausea and vomiting
d. Hypertension and headache
Answer: b. “Knife-like” abdominal pain
168. RhoGAM is given to Rh-negative women to prevent maternal sensitization. In addition to
pregnancy, Rh-negative women would also receive this medication after which of the following?
a. Therapeutic or spontaneous abortion
b. Head injury from a car accident
c. Blood transfusion after a hemorrhage
d. Unsuccessful artificial insemination procedure
Answer: a. Therapeutic or spontaneous abortion
169. After teaching a woman about hyperemesis gravidarum and how it differs from the typical
nausea and vomiting of pregnancy, which statement by the woman indicates that the teaching
was successful?
a. “I can expect the nausea to last through my second trimester.”
b. “I should drink fluids with my meals instead of in between them.”
c. “I need to avoid strong odors, perfumes, or flavors.”
d. “I should lie down after I eat for about 2 hours.”
Answer: c. “I need to avoid strong odors, perfumes, or flavors.”
170. A pregnant woman, approximately 12 weeks’ gestation, comes to the emergency department
after calling her health care provider’s office and reporting moderate vaginal bleeding.
Assessment reveals cervical dilation and moderately strong abdominal cramps. She reports that
she has passed some tissue with the bleeding. The nurse interprets these findings to suggest
which of the following?
a. Threatened abortion
b. Inevitable abortion
c. Incomplete abortion
d. Missed abortion
Answer: b. Inevitable abortion
171. Which of the following would the nurse include when teaching a pregnant woman about the
pathophysiologic mechanisms associated with gestational diabetes?
a. Pregnancy fosters the development of carbohydrate cravings.
b. There is progressive resistance to the effects of insulin .
c. Hypoinsulinemia develops early in the first trimester.
d. Glucose levels decrease to accommodate fetal growth
Answer: b. There is progressive resistance to the effects of insulin
172. When providing prenatal education to a pregnant woman with asthma, which of the
following would be important for the nurse to do?
a. Explain that she should avoid steroids during her pregnancy.
b. Demonstrate how to assess her blood glucose levels.
c. Teach correct administration of subcutaneous bronchodilators.
d. Ensure she seeks treatment for any acute exacerbation.
Answer: d. Ensure she seeks treatment for any acute exacerbation.
173. Which of the following conditions would most likely cause a pregnant woman with type 1
diabetes the greatest difficulty during her pregnancy?
a. Placenta previa
b. Hyperemesis gravidarum
c. Abruptio placentae
d. Rh incompatibility
Answer: b. Hyperemesis gravidarum
174. Women who drink alcohol during pregnancy:
a. Often produce more alcohol dehydrogenase
b. Usually become intoxicated faster than before
c. Can give birth to an infant with fetal alcohol spectrum disorder
d. Gain fewer pounds throughout the gestation
Answer: c. Can give birth to an infant with fetal alcohol spectrum disorder
175. When explaining to a pregnant woman about HIV infection and transmission, which of the
following would the nurse include?
a. It primarily occurs when there is a large viral load in the blood.
b. HIV is most commonly transmitted via sexual contact.
c. It affects the majority of infants of mothers with HIV infection .
d. Nurses are most frequently affected due to needlesticks.
Answer: b. HIV is most commonly transmitted via sexual contact.
176. When reviewing the medical record of a client, the nurse notes that the woman has a
condition in which the fetus cannot physically pass through the maternal pelvis. The nurse
interprets this as:
a. Cervical insufficiency
b. Contracted pelvis
c. Maternal disproportion
d. Fetopelvic disproportion
Answer: d. Fetopelvic disproportion
177. The nurse would anticipate a cesarean birth for a client who has which active infection
present at the onset of labor?
a. Hepatitis
b. Herpes simplex virus
c. Toxoplasmosis
d. Human papillomavirus
Answer: b. Herpes simplex virus
178. After a vaginal examination, the nurse determines that the client’s fetus is in an occiput
posterior position. The nurse would anticipate that the client will have:
a. Intense back pain
b. Frequent leg cramps
c. Nausea and vomiting
d. A precipitous birth
Answer: a. Intense back pain
179. When assessing the following women, which would the nurse identify as being at the
greatest risk for preterm labor?
a. Woman who had twins in a previous pregnancy
b. Client living in a large city
c. Woman working full time as a computer programmer
d. Client with a history of a previous preterm birth
Answer: d. Client with a history of a previous preterm birth
180. The rationale for using a prostaglandin gel for a client prior to the induction of labor is to:
a. Stimulate uterine contractions
b. Numb cervical pain receptors
c. Prevent cervical lacerations
d. Soften and efface the cervix
Answer: d. Soften and efface the cervix
181. A client who was in active labor and whose cervix had dilated to 4 cm experiences a
weakening in the intensity and frequency of her contractions and exhibits no further progress in
labor. The nurse interprets this as a sign of:
a. Hypertonic labor
b. Precipitate labor
c. Hypotonic labor
d. Dysfunctional labor
Answer: c. Hypotonic labor
182. A postpartum mother appears very pale and states she is bleeding heavily. The nurse should
first:
a. Call the client’s health care provider immediately.
b. Immediately set up an intravenous infusion of magnesium sulfate.
c. Assess the fundus and ask her about her voiding status.
d. Reassure the mother that this is a normal finding after childbirth.
Answer: c. Assess the fundus and ask her about her voiding status.
183. A postpartum woman reports hearing voices and says, “The voices are telling me to do bad
things to my baby.” The clinic nurse interprets these findings as suggesting postpartum:
a. Psychosis
b. Anxiety disorder
c. Depression
d. Blues Term
Answer: a. Psychosis
184. When implementing the plan of care for a postpartum woman who gave birth just a few
hours ago, the nurse vigilantly monitors the client for which complication?
a. Deep venous thrombosis
b. Postpartum psychosis
c. Uterine infection
d. Postpartum hemorrhage
Answer: d. Postpartum hemorrhage
185. Which of the following would the nurse expect to include in the plan of care for a woman
with mastitis who is receiving antibiotic therapy?
a. Stop breast-feeding and apply lanolin.
b. Administer analgesics and bind both breasts.
c. Apply warm or cold compresses and administer analgesics.
d. Remove the nursing bra and expose the breast to fresh air.
Answer: c. Apply warm or cold compresses and administer analgesics
186. While assessing a postpartum multiparous woman, the nurse detects a boggy uterus midline
2 cm above the umbilicus. Which intervention would be the priority?
a. Assessing vital signs immediately
b. Measuring her next urinary output
c. Massaging her fundus
d. Notifying the woman’s obstetrician
Answer: c. Massaging her fundus
187. Methergine has been ordered for a postpartum woman because of excessive bleeding. The
nurse should question this order if which of the following is present?
a. Mild abdominal cramping
b. Tender inflamed breasts
c. Pulse rate of 68 beats per minute
d. Blood pressure of 158/96 mm Hg Term
Answer: d. Blood pressure of 158/96 mm Hg Term
