EXAM 1 7.

The client tells the nurse that her last menstrual period

1. For the client who is using oral contraceptives, the nurse started on January 14 and ended on January 20. Using

informs the client about the need to take the pill at the same Nagele’s rule, the nurse determines her EDD to be which of

time each day to accomplish which of the following? the following?

A. Decrease the incidence of nausea A. September 27

B. Maintain hormonal levels B. October 21

C. Reduce side effects C. November 7

D. Prevent drug interactions D. December 27

2. When teaching a client about contraception. Which of the 8. When taking an obstetrical history on a pregnant client

following would the nurse include as the most effective who states, “I had a son born at 38 weeks gestation, a

method for preventing sexually transmitted infections? daughter born at 30 weeks gestation and I lost a baby at

A. Spermicides about 8 weeks,” the nurse should record her obstetrical

B. Diaphragm history as which of the following?

C. Condoms A. G2 T2 P0 A0 L2

D. Vasectomy B. G3 T1 P1 A0 L2

3. When preparing a woman who is 2 days postpartum for C. G3 T2 P0 A0 L2

discharge, recommendations for which of the following D. G4 T1 P1 A1 L2

contraceptive methods would be avoided? 9. When preparing to listen to the fetal heart rate at 12

A. Diaphragm weeks’ gestation, the nurse would use which of the

B. Female condom following?

C. Oral contraceptives A. Stethoscope placed midline at the umbilicus

D. Rhythm method B. Doppler placed midline at the suprapubic region

4. For which of the following clients would the nurse expect C. Fetoscope placed midway between the umbilicus and the

that an intrauterine device would not be recommended? xiphoid process

A. Woman over age 35 D. External electronic fetal monitor placed at the umbilicus

B. Nulliparous woman 10. When developing a plan of care for a client newly

C. Promiscuous young adult diagnosed with gestational diabetes, which of the following

D. Postpartum client instructions would be the priority?

5. A client in her third trimester tells the nurse, “I’m A. Dietary intake

constipated all the time!” Which of the following should the B. Medication

nurse recommend? C. Exercise

A. Daily enemas D. Glucose monitoring

B. Laxatives 11. A client at 24 weeks gestation has gained 6 pounds in 4

C. Increased fiber intake weeks. Which of the following would be the priority when

D. Decreased fluid intake assessing the client?

A. Glucosuria

6. Which of the following would the nurse use as the basis for B. Depression

the teaching plan when caring for a pregnant teenager C. Hand/face edema

concerned about gaining too much weight during D. Dietary intake

pregnancy? 12. A client 12 weeks’ pregnant come to the emergency

A. 10 pounds per trimester department with abdominal cramping and moderate

B. 1 pound per week for 40 weeks vaginal bleeding. Speculum examination reveals 2 to 3 cm

C. ½ pound per week for 40 weeks cervical dilation.The nurse would document these findings

D. A total gain of 25 to 30 pounds as which of the following?

A. Threatened abortion large, and not descending as normally expected. Which of the

B. Imminent abortion following should the nurse assess next?

C. Complete abortion A. Lochia

D. Missed abortion B. Breasts

13. Which of the following would be the priority nursing C. Incision

diagnosis for a client with an ectopic pregnancy? D. Urine

A. Risk for infection 19. Which of the following is the priority focus of nursing

B. Pain practice with the current early postpartum discharge?

C. Knowledge Deficit A. Promoting comfort and restoration of health

D. Anticipatory Grieving B. Exploring the emotional status of the family

14. Before assessing the postpartum client’s uterus for C. Facilitating safe and effective self and newborn care

firmness and position in relation to the umbilicus and D. Teaching about the importance of family planning

midline, which of the following should the nurse do first? 20. Which of the following actions would be least effective in

A. Assess the vital signs maintaining a neutral thermal environment for the

B. Administer analgesia newborn?

C. Ambulate her in the hall A. Placing infant under radiant warmer after bathing

D. Assist her to urinate B. Covering the scale with a warmed blanket prior to weighing

15. Which of the following should the nurse do when a C. Placing crib close to nursery window for family viewing

primipara who is lactating tells the nurse that she has sore D. Covering the infant’s head with a knit stockinette

nipples? 21. A newborn who has an asymmetrical Moro reflex

A. Tell her to breastfeed more frequently response should be further assessed for which of the

B. Administer a narcotic before breastfeeding following?

C. Encourage her to wear a nursing brassiere A. Talipes equinovarus

D. Use soap and water to clean the nipples B. Fractured clavicle

16. The nurse assesses the vital signs of a client, 4 C. Congenital hypothyroidism

hours’ postpartum that are as follows: BP 90/60; D. Increased intracranial pressure

temperature 100.4ºF; pulse 100 weak, thready; R 20 per 22. During the first 4 hours after a male circumcision,

minute. Which of the following should the nurse do first? assessing for which of the following is the priority?

A. Report the temperature to the physician A. Infection

B. Recheck the blood pressure with another cuff B. Hemorrhage

C. Assess the uterus for firmness and position C. Discomfort

D. Determine the amount of lochia D. Dehydration

23. The mother asks the nurse. “What’s wrong with my son’s

17. The nurse assesses the postpartum vaginal discharge breasts? Why are they so enlarged?” Whish of the following

(lochia) on four clients. Which of the following assessments would be the best response by the nurse?

would warrant notification of the physician? A. “The breast tissue is inflamed from the trauma experienced

A. A dark red discharge on a 2-day postpartum client with birth.”

B. A pink to brownish discharge on a client who is 5 B. “A decrease in material hormones present before birth causes

days postpartum enlargement,”

C. Almost colorless to creamy discharge on a client 2 weeks C. “You should discuss this with your doctor. It could be a

after delivery malignancy.”

D. A bright red discharge 5 days after delivery D. “The tissue has hypertrophied while the baby was in the

18. A postpartum client has a temperature of 101.4ºF, with a uterus.”

uterus that is tender when palpated, remains unusually

24. Immediately after birth the nurse notes the following on A. Daily weights

a male newborn: respirations 78; apical heart rate 160 BPM, B. Seizure precautions

nostril flaring; mild intercostal retractions; and grunting at C. Right lateral positioning

the end of expiration. Which of the following should the D. Stress reduction

nurse do? 30. A postpartum primipara asks the nurse, “When can we

A. Call the assessment data to the physician’s attention have sexual intercourse again?” Which of the following

B. Start oxygen per nasal cannula at 2 L/min. would be the nurse’s best response?

C. Suction the infant’s mouth and nares A. “Anytime you both want to.”

D. Recognize this as normal first period of reactivity B. “As soon as choose a contraceptive method.”

25. The nurse hears a mother telling a friend on the C. “When the discharge has stopped, and the incision is healed.”

telephone about umbilical cord care. Which of the following D. “After your 6 weeks examination.”

statements by the mother indicates effective teaching? 31. When preparing to administer the vitamin K injection to

A. “Daily soap and water cleansing is best.” a neonate, the nurse would select which of the following sites

B. ‘Alcohol helps it dry and kills germs.” as appropriate for the injection?

C. “An antibiotic ointment applied daily prevents infection.” A. Deltoid muscle

D. “He can have a tub bath each day.” B. Anterior femoris muscle

26. A newborn weighing 3000 grams and feeding every 4 C. Vastus lateralis muscle

hours needs 120 calories/kg of body weight every 24 hours D. Gluteus maximus muscle

for proper growth and development. How many ounces of 20 32. When performing a pelvic examination, the nurse

cals/oz formula should this newborn receive at each feeding observes a red swollen area on the right side of the vaginal

to meet nutritional needs? orifice. The nurse would document this as enlargement of

A. 2 ounces which of the following?

B. 3 ounces A. Clitoris

C. 4 ounces B. Parotid gland

D. 6 ounces C. Skene’s gland

27. The post-term neonate with meconium-stained amniotic D. Bartholin’s gland

fluid needs care designed to especially monitor for which of

the following? 33. To differentiate as a female, the hormonal stimulation of

A. Respiratory problems the embryo that must occur involves which of the following?

B. Gastrointestinal problems A. Increase in maternal estrogen secretion

C. Integumentary problems B. Decrease in maternal androgen secretion

D. Elimination problems C. Secretion of androgen by the fetal gonad

28. When measuring a client’s fundal height, which of the D. Secretion of estrogen by the fetal gonad

following techniques denotes the correct method of 34. A client at 8 weeks’ gestation calls complaining of slight

measurement used by the nurse? nausea in the morning hours. Which of the following client

A. From the xiphoid process to the umbilicus interventions should the nurse question?

B. From the symphysis pubis to the xiphoid process A. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of

C. From the symphysis pubis to the fundus water

D. From the fundus to the umbilicus B. Eating a few low-sodium crackers before getting out of bed

29. A client with severe preeclampsia is admitted with of BP C. Avoiding the intake of liquids in the morning hours

160/110, proteinuria, and severe pitting edema. Which of D. Eating six small meals a day instead of three large meals

the following would be most important to include in the

client’s plan of care?

35. The nurse documents positive ballottement in the 40. Which of the following would be the nurse’s most

client’s prenatal record. The nurse understands that this appropriate response to a client who asks why she must

indicates which of the following? have a cesarean delivery if she has a complete placenta

A. Palpable contractions on the abdomen previa?

B. Passive movement of the unengaged fetus A. “You will have to ask your physician when he returns.”

C. Fetal kicking felt by the client B. “You need a cesarean to prevent hemorrhage.”

D. Enlargement and softening of the uterus C. “The placenta is covering most of your cervix.”

36. During a pelvic exam, the nurse notes a purple-blue tinge D. “The placenta is covering the opening of the uterus and

of the cervix. The nurse documents this as which of the blocking your baby.”

following? 41. The nurse understands that the fetal head is in which of

A. Braxton-Hicks sign the following positions with a face presentation?

B. Chadwick’s sign A. Completely flexed

C. Goodell’s sign B. Completely extended

D. McDonald’s sign C. Partially extended

37. During a prenatal class, the nurse explains the rationale D. Partially flexed

for breathing techniques during preparation for labor based 42. With a fetus in the left anterior breech presentation, the

on the understanding that breathing techniques are most nurse would expect the fetal heart rate would be most

important in achieving which of the following? audible in which of the following areas?

A. Eliminate pain and give the expectant parents something to do A. Above the maternal umbilicus and to the right of midline

B. Reduce the risk of fetal distress by increasing uteroplacental B. In the lower-left maternal abdominal quadrant

perfusion C. In the lower-right maternal abdominal quadrant

C. Facilitate relaxation, possibly reducing the perception of pain D. Above the maternal umbilicus and to the left of midline

D. Eliminate pain so that less analgesia and anesthesia are needed 43. The amniotic fluid of a client has a greenish tint. The

38. After 4 hours of active labor, the nurse notes that the nurse interprets this to be the result of which of the

contractions of a primigravida client are not strong enough following?

to dilate the cervix. Which of the following would the nurse A. Lanugo

anticipate doing? B. Hydramnios

A. Obtaining an order to begin IV oxytocin infusion C. Meconium

B. Administering a light sedative to allow the patient to rest for D. Vernix

several hours 44. A patient is in labor and has just been told she has a

C. Preparing for a cesarean section for failure to progress breech presentation. The nurse should be particularly alert

D. Increasing the encouragement to the patient when pushing for which of the following?

begins A. Quickening

39. A multigravida at 38 weeks’ gestation is admitted with B. Ophthalmia neonatorum

painless, bright red bleeding and mild contractions every 7 C. Pica

to 10 minutes. Which of the following assessments should be D. Prolapsed umbilical cord

avoided? 45. When describing dizygotic twins to a couple, on which of

A. Maternal vital sign the following would the nurse base the explanation?

B. Fetal heart rate A. Two ova fertilized by separate sperm

C. Contraction monitoring B. Sharing of a common placenta

D. Cervical dilation C. Each ova with the same genotype

D. Sharing of a common chorion

 Answers and Rationale
46. Which of the following refers to the single cell that 1. Answer: B. Maintain hormonal levels
Regular timely ingestion of oral contraceptives is necessary to
reproduces itself after conception?
maintain hormonal levels of the drugs to suppress the action of
A. Chromosome the hypothalamus and anterior pituitary leading to inappropriate
secretion of FSH and LH. Therefore, follicles do not
B. Blastocyst mature, ovulation is inhibited, and pregnancy is prevented.
 Option A: The estrogen content of the oral site
C. Zygote
contraceptive may cause nausea, regardless of when the
D. Trophoblast pill is taken.
 Options C and D: Side effects and drug interactions may
47. In the late 1950s, consumers and health care occur with oral contraceptives regardless of the time
the pill is taken.
professionals began challenging the routine use of analgesics
2. Answer: C. Condoms
and anesthetics during childbirth. Which of the following Condoms, when used correctly and consistently, are the most
effective contraceptive method or barrier against bacterial and
was an outgrowth of this concept? viral sexually transmitted infections.
 Option A: Although spermicides kill sperm, they do not
A. Labor, delivery, recovery, postpartum (LDRP)
provide reliable protection against the spread of
B. Nurse-midwifery sexually transmitted infections, especially intracellular
organisms such as HIV.
C. Clinical nurse specialist  Option B: Insertion and removal of the diaphragm along
with the use of the spermicides may cause vaginal
D. Prepared childbirth
irritations, which could place the client at risk for
48. A client has a mid pelvic contracture from a previous infection transmission.
 Option D: Male sterilization eliminates spermatozoa
pelvic injury due to a motor vehicle accident as a teenager. from the ejaculate, but it does not eliminate bacterial
and/or viral microorganisms that can cause sexually
The nurse is aware that this could prevent a fetus from
transmitted infections.
passing through or around which structure during 3 Answer: A. Diaphragm
The diaphragm must be fitted individually to
childbirth? ensure effectiveness. Because of the changes to
the reproductive structures during pregnancy and
A. Symphysis pubis following delivery, the diaphragm must be refitted, usually at the
B. Sacral promontory 6 weeks’ examination following childbirth or after a weight
loss of 15 lbs or more. In addition, for maximum effectiveness,
C. Ischial spines the spermicidal jelly should be placed in the dome and around
the rim. However, the spermicidal jelly should not be inserted
D. Pubic arch into the vagina until involution is completed at approximately 6
weeks.
49. When teaching a group of adolescents about variations in
 Option B: Use of a female condom protects the
the length of the menstrual cycle, the nurse understands that reproductive system from the introduction of semen or
spermicides into the vagina and may be used after
the underlying mechanism is due to variations in which of childbirth.
the following phases?  Option C: Oral contraceptives may be started within the
first postpartum week to ensure suppression of
A. Menstrual phase ovulation.
 Option D: For the couple who has determined the
B. Proliferative phase female’s fertile period, using the rhythm method,
avoidance of intercourse during this period, is safe and
C. Secretory phase
effective.
D. Ischemic phase 4. Answer: C. Promiscuous young adult
An IUD may increase the risk of pelvic inflammatory disease,
especially in women with more than one sexual partner, because
of the increased risk of sexually transmitted infections. An IUD
50. When teaching a group of adolescents about male
should not be used if the woman has an active or chronic
hormone production, which of the following would the nurse pelvic infection, postpartum infection, endometrial hyperplasia
or carcinoma, or uterine abnormalities.
include as being produced by the Leydig cells?  Option A: Age is not a factor in determining the risks
associated with IUD use. Most IUD users are over the
A. Follicle-stimulating hormone
age of 30.
B. Testosterone  Option B: Although there is a slightly higher risk for
infertility in women who have never been pregnant, the
C. Luteinizing hormone IUD is an acceptable option as long as the risk-benefit
ratio is discussed.
D. Gonadotropin-releasing hormone
 Option D: IUDs may be inserted immediately
after delivery, but this is not recommended because of
the increased risk and rate of expulsion at this time.
5. Answer: C. Increased fiber intake
During the third trimester, the enlarging uterus places pressure
on the intestines. This coupled with the effect of hormones on
smooth muscle relaxation causes decreased intestinal motility
(peristalsis). Increasing fiber in the diet will help fecal matter
pass more quickly through the intestinal tract, thus decreasing
the amount of water that is absorbed. As a result, the stool is
softer and easier to pass.
 Option A: Enemas could precipitate preterm labor and
electrolyte loss and should be avoided.
 Option B: Laxatives may cause preterm labor by
stimulating peristalsis and may interfere with the
absorption of nutrients. Use for more than 1 week can
also lead to laxative dependency.
 Option D: Liquid in the diet helps provide a semisolid,
soft consistency to the stool. Eight to ten glasses of fluid
per day are essential to maintain hydration and
promote stool evacuation.
6. Answer: D. A total gain of 25 to 30 pounds
To ensure adequate fetal growth and development during the 40
weeks of a pregnancy, a total weight gain 25 to 30 pounds is
recommended:
 Option A: 1.5 pounds in the first 10 weeks; 9 pounds by
30 weeks; and 27.5 pounds by 40 weeks. The pregnant
woman should gain less weight in the first and second
trimester than in the third.
 Option B: During the first trimester, the client should
only gain 1.5 pounds in the first 10 weeks, not 1 pound
per week.
 Option C: A weight gain of ½ pound per week would be
20 pounds for the total pregnancy, less than the
recommended amount.
7. Answer: B. October 21
To calculate the EDD by Nagele’s rule, add 7 days to the first day
of the last menstrual period and count back 3 months, changing
the year appropriately.
 Option A: To obtain a date of September 27, 7 days have
been added to the last day of the LMP (rather than the
first day of the LMP), plus 4 months (instead of 3
months) were counted back.
 Option C: To obtain the date of November 7, 7 days have
been subtracted (instead of added) from the first day of
LMP plus November indicates counting back 2 months
(instead of 3 months) from January.
 Option D: To obtain the date of December 27, 7 days
were added to the last day of the LMP (rather than the
first day of the LMP) and December indicates counting
back only 1 month (instead of 3 months) from January.
8. Answer: D. G4 T1 P1 A1 L2
The client has been pregnant four times, including current
pregnancy (G). Birth at 38 weeks’ gestation is considered full
term (T), while birth form 20 weeks to 38 weeks is considered
preterm (P). A spontaneous abortion occurred at 8 weeks (A).
She has two living children (L).
9. Answer: B. Doppler placed midline at the suprapubic
region
At 12 weeks gestation, the uterus rises out of the pelvis and is
palpable above the symphysis pubis. The Doppler intensifies the
sound of the fetal pulse rate so it is audible. The uterus has
merely risen out of the pelvis into the abdominal cavity and is not
at the level of the umbilicus.
 Option A: The fetal heart rate at this age is not audible
with a stethoscope.
 Option C: The uterus at 12 weeks is just above the
symphysis pubis in the abdominal cavity, not midway
between the umbilicus and the xiphoid process. At 12
weeks the FHR would be difficult to auscultate with a
fetoscope.
 Option D: Although the external electronic fetal monitor
would project the FHR, the uterus has not risen to the
umbilicus at 12 weeks.
10. Answer: A. Dietary intake
Although all of the choices are important in the management
of diabetes, diet therapy is the mainstay of the treatment plan
and should always be the priority.
 Option B: Women diagnosed with
gestational diabetes generally need only diet therapy
without medication to control their blood sugar levels.
 Option C: Exercise, is important for all pregnant women
and especially for diabetic women, because it burns
up glucose, thus decreasing blood sugar. However,
dietary intake, not exercise, is the priority.
 Option D: All pregnant women with diabetes should
have periodic monitoring of serum glucose. However,
those with gestational diabetes generally do not need
daily glucose monitoring. The standard of care
recommends a fasting and 2-hour postprandial blood
sugar level every 2 weeks.
11. Answer: C. Hand/face edema
After 20 weeks’ gestation, when there is a rapid weight gain,
preeclampsia should be suspected, which may be caused by fluid
retention manifested by edema, especially of the hands and face.
The three classic signs of preeclampsia are hypertension, edema,
and proteinuria.
 Option A: Although urine is checked for glucose at each
clinic visit, this is not the priority.
 Option B: Depression may cause either anorexia or
excessive food intake, leading to excessive weight gain
or loss. This is not, however, the priority consideration
at this time.
 Option D: Weight gain thought to be caused by
excessive food intake would require a 24-hour diet
recall. However, excessive intake would not be the
primary consideration for this client at this time.
12. Answer: B. Imminent abortion
Cramping and vaginal bleeding coupled with cervical dilation
signifies that termination of the pregnancy is inevitable and
cannot be prevented. Thus, the nurse would document an
imminent abortion.
 Option A: In a threatened abortion, cramping and
vaginal bleeding are present, but there is no cervical
dilation. The symptoms may subside or progress to
abortion.
 Option C: In a complete abortion all the products of
conception are expelled.
 Option D: A missed abortion is early fetal intrauterine
death without expulsion of the products of conception.
13. Answer: B. Pain
For the client with an ectopic pregnancy, lower abdominal pain,
usually unilateral, is the primary symptom. Thus, pain is the
priority.
 Option A: Although the potential for infection is always
present, the risk is low in ectopic pregnancy because
pathogenic microorganisms have not been introduced
from external sources.
 Options C and D: The client may have a limited
knowledge of the pathology and treatment of the
condition and will most likely experience grieving, but
this is not the priority at this time.
14. Answer: D. Assist her to urinate
Before the uterine assessment is performed, it is essential that
the woman empties her bladder. A full bladder will interfere with
the accuracy of the assessment by elevating the uterus and
displacing to the side of the midline.
 Option A: Vital sign assessment is not necessary unless
an abnormality in uterine assessment is identified.
 Option B: Uterine assessment should not cause acute
pain that requires administration of analgesia.
 Option C: Ambulating the client is an essential
component of postpartum care, but is not necessary
prior to assessment of the uterus.
15. Answer: A. Tell her to breastfeed more frequently
Feeding more frequently, about every 2 hours, will decrease the
infant’s frantic, vigorous sucking from hunger and will decrease
breast engorgement, soften the breast, and promote ease of
correct latching on for feeding.
 Option B: Narcotics administered prior to breastfeeding
are passed through the breast milk to the infant, causing
excessive sleepiness. Nipple soreness is not severe
enough to warrant narcotic analgesia.
 Option C: All postpartum clients, especially lactating
mothers, should wear a supportive brassiere with wide
 cotton straps. This does not, however, prevent or
reduce nipple soreness.
 Option D: Soaps are drying to the skin of the nipples and
should not be used on the breasts of lactating mothers.
Dry nipple skin predisposes to cracks and fissures,
which can become sore and painful.
16. Answer: D. Determine the amount of lochia
A weak, thready pulse elevated to 100 BPM may indicate
impending hemorrhagic shock. An increased pulse is a
compensatory mechanism of the body in response to decreased
fluid volume. Thus, the nurse should check the amount
of lochia present.
 Option A: Temperatures up to 100.48F in the first 24
hours after birth are related to the dehydrating effects
of labor and are considered normal.
 Option B: Although rechecking the blood pressure may
be a correct choice of action; it is not the first action that
should be implemented in light of the other data. The
data indicate a potential impending hemorrhage.
 Option C: Assessing the uterus for firmness and position
in relation to the umbilicus and midline is important,
but the nurse should check the extent of
vaginal bleeding first. Then it would be appropriate to
check the uterus, which may be a possible cause of the
hemorrhage.
17. Answer: D. A bright red discharge 5 days after delivery
Any bright red vaginal discharge would be considered abnormal,
but especially 5 days after delivery, when the lochia is typically
pink to brownish. Lochia rubra, a dark red discharge, is present
for 2 to 3 days after delivery. Bright red vaginal bleeding at this
time suggests late postpartum hemorrhage, which occurs after
the first 24 hours following delivery and is generally caused by
retained placental fragments or bleedingdisorders.
 Option A: Lochia rubra is the normal dark red discharge
occurring in the first 2 to 3 days after delivery,
containing epithelial cells, erythrocyTes, leukocytes,
and decidua.
 Option B: Lochia serosa is a pink to brownish
serosanguineous discharge occurring from 3 to 10 days
after delivery that contains decidua, erythrocytes,
leukocytes, cervical mucus, and microorganisms.
 Option C: Lochia alba is an almost colorless to yellowish
discharge occurring from 10 days to 3 weeks
after delivery and containing leukocytes, decidua,
epithelial cells, fat, cervical mucus, cholesterol crystals,
and bacteria.
18. Answer: A. Lochia
The data suggests an infection of the endometrial lining of the
uterus. The lochia may be decreased or copious, dark brown in
appearance, and foul smelling, providing further evidence of a
possible infection.
 Option B: All the client’s data indicate a uterine
problem, not a breast problem. Typically,
transient fever, usually 101ºF, may be present with
breast engorgement. Symptoms of mastitis include
influenza-like manifestations.
 Option C: Localized infection of an episiotomy or C-
section incision rarely causes systemic symptoms, and
uterine involution would not be affected.
 Option D: The client data do not include dysuria,
frequency, or urgency, symptoms of urinary tract
infections, which would necessitate assessing the
client’s urine.
19. Answer: C. Facilitating safe and effective self and
newborn care
Because of early postpartum discharge and limited time for
teaching, the nurse’s priority is to facilitate the safe and effective
care of the client and newborn.
 Options A, B, and D: Although promoting comfort and
restoration of health, exploring the family’s emotional
status, and teaching about family planning are
important in postpartum/newborn nursing care, they
are not the priority focus in the limited time presented
by early postpartum discharge.
20. Answer: C. Placing crib close to nursery window for
family viewing
Heat loss by radiation occurs when the infant’s crib is placed too
near cold walls or windows. Thus placing the newborn’s crib
close to the viewing window would be least effective. Body heat
is lost through evaporation during bathing.
 Option A: Placing the infant under the radiant warmer
after bathing will assist the infant to be rewarmed.
 Option B: Covering the scale with a warmed blanket
prior to weighing prevents heat loss through
conduction.
 Option D: A knit cap prevents heat loss from the head a
large head, a large body surface area of the newborn’s
body.
21. Answer: B. Fractured clavicle
A fractured clavicle would prevent the normal Moro response of
symmetrical sequential extension and abduction of the arms
followed by flexion and adduction.
 Option A: In talipes equinovarus (clubfoot) the foot is
turned medially, and in plantar flexion, with the heel
elevated. The feet are not involved with the Moro reflex.
 Option C: Hypothyroidism has no effect on the primitive
reflexes.
 Option D: Absence of the Moro reflex is the most
significant single indicator of central nervous system
status, but it is not a sign of increased intracranial
pressure.
22. Answer: B. Hemorrhage
Hemorrhage is a potential risk following any surgical procedure.
Although the infant has been given vitamin K to facilitate clotting,
the prophylactic dose is often not sufficient to prevent bleeding.
 Option A: Although infection is a possibility, signs will
not appear within 4 hours after the surgical procedure.
 Option C: The primary discomfort of circumcision
occurs during the surgical procedure, not afterward.
 Option D: Although feedings are withheld prior to the
circumcision, the chances of dehydration are minimal.
23. Answer: B. “A decrease in material hormones present
before birth causes enlargement,”
The presence of excessive estrogen and progesterone in the
maternal-fetal blood followed by prompt withdrawal at birth
precipitates breast engorgement, which will spontaneously
resolve in 4 to 5 days after birth.
 Option A: The trauma of the birth process does not
cause inflammation of the newborn’s breast tissue.
 Option C: Newborns do not have breast malignancy.
This reply by the nurse would cause the mother to have
undue anxiety.
 Option D: Breast tissue does not hypertrophy in the
fetus or newborns.
24. Answer: D. Recognize this as normal first period of
reactivity
The first 15 minutes to 1 hour after birth is the first period of
reactivity involving respiratory and circulatory adaptation to
extrauterine life. The data given reflect the normal changes
during this time period.
 Options A and B: The infant’s assessment data reflect
normal adaptation. Thus, the physician does not need to
be notified and oxygen is not needed.
 Option C: The data do not indicate the presence of
choking, gagging or coughing, which are signs of
excessive secretions. Suctioning is not necessary.
25. Answer: B. ‘Alcohol helps it dry and kills germs”
Application of 70% isopropyl alcohol to the cord minimizes
microorganisms (germicidal) and promotes drying. The cord
should be kept dry until it falls off and the stump has healed.
 Option C: Antibiotic ointment should only be used to
treat an infection, not as a prophylaxis.
 Option D: Infants should not be submerged in a tub of
water until the cord falls off and the stump has
completely healed.
26. Answer: B. 3 ounces
To determine the amount of formula needed, do the following
mathematical calculation. 3 kg x 120 cal/kg per day = 360
calories/day feeding q 4 hours = 6 feedings per day = 60 calories
per feeding: 60 calories per feeding; 60 calories per feeding with
formula 20 cal/oz = 3 ounces per feeding. Based on the
calculation. 2, 4 or 6 ounces are incorrect.
27. Answer: A. Respiratory problems
Intrauterine anoxia may cause relaxation of the anal sphincter
and emptying of meconium into the amniotic fluid. At birth some
of the meconium fluid may be aspirated, causing mechanical
obstruction or chemical pneumonitis.
 Option B: The infant is not at increased risk for
gastrointestinal problems.
 Option C: Even though the skin is stained with
meconium, it is noninfectious (sterile) and
nonirritating.
 Option D: The post-term meconium-stained infant is not
at additional risk for bowel or urinary problems.
28. Answer: C. From the symphysis pubis to the fundus
The nurse should use a nonelastic, flexible, paper measuring tape,
placing the zero point on the superior border of the symphysis
pubis and stretching the tape across the abdomen at the midline
to the top of the fundus.
 Options A, B, and D: The xiphoid and umbilicus are not
appropriate landmarks to use when measuring the
height of the fundus (McDonald’s measurement).
29. Answer: B. Seizure precautions
Women hospitalized with severe preeclampsia need decreased
CNS stimulation to prevent a seizure. Seizure precautions provide
environmental safety should a seizureoccur.
 Option A: Because of edema, daily weight is important
but not the priority.
 Option C: Preclampsia causes vasospasm and therefore
can reduce utero-placental perfusion. The client should
be placed on her left side to maximize blood flow,
reduce blood pressure, and promote diuresis.
 Option D: Interventions to reduce stress and anxiety are
very important to facilitate coping and a sense of
control, but seizure precautions are the priority.
30. Answer: C. “When the discharge has stopped and the
incision is healed.”
Cessation of the lochial discharge signifies healing of the
endometrium. Risk of hemorrhage and infection are minimal 3
weeks after a normal vaginal delivery.
 Option A: Telling the client anytime is inappropriate
because this response does not provide the client with
the specific information she is requesting.
 Option B: Choice of a contraceptive method is
important, but not the specific criteria for safe
resumption of sexual activity.
 Option D: Culturally, the 6-weeks’ examination has been
used as the time frame for resuming sexual activity, but
it may be resumed earlier.
31. Answer: C. Vastus lateralis muscle
The middle third of the vastus lateralis is the preferred injection
site for vitamin K administration because it is free of blood
vessels and nerves and is large enough to absorb the medication.
 Option A: The deltoid muscle of a newborn is not large
enough for a newborn IM injection. Injections into this
muscle in a small child might cause damage to the radial
nerve.
 Option B: The anterior femoris muscle is the next safest
muscle to use in a newborn but is not the safest.
 Option D: Because of the proximity of the sciatic nerve,
the gluteus maximus muscle should not be until the
child has been walking 2 years.
32. Answer: D. Bartholin’s gland
Bartholin’s glands are the glands on either side of the vaginal
orifice.
 Option A: The clitoris is female erectile tissue found in
the perineal area above the urethra.
 Option B: The parotid glands are open into the mouth.
 Option C: Skene’s glands open into the posterior wall of
the female urinary meatus.
33. Answer: D. Secretion of estrogen by the fetal gonad
The fetal gonad must secrete estrogen for the embryo to
differentiate as a female.
 Option A: An increase in maternal estrogen secretion
does not effect differentiation of the embryo, and
maternal estrogen secretion occurs in every pregnancy.
 Option B: Maternal androgen secretion remains the
same as before pregnancy and does not affect
differentiation.
 Option C: Secretion of androgen by the fetal gonad
would produce a male fetus.
34. Answer: A. Taking 1 teaspoon of bicarbonate of soda in
an 8-ounce glass of water.
Using bicarbonate would increase the amount of sodium
ingested, which can cause complications.
 Option B: Eating low-sodium crackers would be
appropriate.
 Option C: Since liquids can increase nausea avoiding
them in the morning hours when nausea is usually the
strongest is appropriate.
 Option D: Eating six small meals a day would keep the
stomach full, which often decrease nausea.
35. Answer: B. Passive movement of the unengaged fetus
Ballottement indicates passive movement of the unengaged fetus.
 Option A: Ballottement is not a contraction.
 Option C: Fetal kicking felt by the client
represents quickening.
 Option D: Enlargement and softening of the uterus is
known as Piskacek’s sign.
36. Answer: B. Chadwick’s sign
Chadwick’s sign refers to the purple-blue tinge of the cervix.
 Option A: Braxton Hicks contractions are painless
contractions beginning around the 4th month.
 Option C: Goodell’s sign indicates softening of the
cervix.
 Option D: Flexibility of the uterus against the cervix is
known as McDonald’s sign.
37. Answer: C. Facilitate relaxation, possibly reducing the
perception of pain
Breathing techniques can raise the pain threshold and reduce the
perception of pain. They also promote relaxation.
 Options A, B, and D: Breathing techniques do not
eliminate pain, but they can reduce it. Positioning, not
breathing, increases uteroplacental perfusion.
38. Answer: A. Obtaining an order to begin IV oxytocin
infusion
The client’s labor is hypotonic. The nurse should call the physical
and obtain an order for an infusion of oxytocin, which will assist
the uterus to contract more forcefully in an attempt to dilate the
cervix.
 Option B: Administering light sedative would be done
for hypertonic uterine contractions.
 Option C: Preparing for cesarean section is unnecessary
at this time.
 Option D: Oxytocin would increase the uterine
contractions and hopefully progress labor before a
cesarean would be necessary. It is too early to anticipate
client pushing with contractions.
39. Answer: D. Cervical dilation
The signs indicate placenta previa and vaginal exam to determine
cervical dilation would not be done because it could cause
hemorrhage.
 Option A: Assessing maternal vital signs can help
determine maternal physiologic status.
 Option B: Fetal heart rate is important to assess fetal
well-being and should be done.
 Option C: Monitoring the contractions will help evaluate
the progress of labor.
40. Answer: D. “The placenta is covering the opening of the
uterus and blocking your baby.”
A complete placenta previa occurs when the placenta covers the
opening of the uterus, thus blocking the passageway for the baby.
This response explains what a complete previa is and the reason
the baby cannot come out except by cesarean delivery.
 Option A: Telling the client to ask the physician is a poor
response and would increase the patient’s anxiety.
 Option B: Although a cesarean would help to prevent
hemorrhage, the statement does not explain why the
hemorrhage could occur.
 Option C: With a complete previa, the placenta is
covering all the cervix, not just most of it.
50. Answer: B. Testosterone
Testosterone is produced by the Leydig cells in the seminiferous
tubules.
 Options A and C: Follicle-stimulating hormone
and luteinizing hormone are released by the anterior
pituitary gland.
 Option D: The hypothalamus is responsible for releasing
gonadotropin-releasing hormone.
https://nurseslabs.com/maternal-child-health-nursing-exam-5-
50-items/

41. Answer: B. Completely extended

With a face presentation, the head is completely extended.
 Options A and D: With a vertex presentation, the head is
completely or partially flexed.
 Option C: With a brow (forehead) presentation, the
head would be partially extended.
42. Answer: D. Above the maternal umbilicus and to the left
of midline
With this presentation, the fetal upper torso and back face the left
upper maternal abdominal wall. The fetal heart rate would be
most audible above the maternal umbilicus and to the left of the
middle. The other positions would be incorrect.
43. Answer: C. Meconium
The greenish tint is due to the presence of meconium.
 Option A: Lanugo is the soft, downy hair on the
shoulders and back of the fetus.
 Option B: Hydramnios represents excessive amniotic
fluid.
 Option D: Vernix is the white, cheesy substance
covering the fetus.
44. Answer: D. Prolapsed umbilical cord
In a breech position, because of the space between the presenting
part and the cervix, prolapse of the umbilical cord is common.
 Option A: Quickening is the woman’s first perception of
fetal movement.
 Option B: Ophthalmia neonatorum usually results from
maternal gonorrhea and is conjunctivitis.
 Option C: Pica refers to the oral intake of nonfood
substances.
45. Answer: A. Two ova fertilized by separate sperm
Dizygotic (fraternal) twins involve two ova fertilized by separate
sperm. Monozygotic (identical) twins involve a common placenta,
same genotype, and common chorion.
46. Answer: C. Zygote
The zygote is the single cell that reproduces itself after
conception.
 Option A: The chromosome is the material that makes
up the cell and is gained from each parent.
 Options B and D: Blastocyst and trophoblast are later
terms for the embryo after zygote.
47. Answer: D. Prepared childbirth
Prepared childbirth was the direct result of the 1950’s
challenging of the routine use of analgesic and anesthetics during
childbirth.
 Option A: The LDRP was a much later concept and was
not a direct result of the challenging of routine use of
analgesics and anesthetics during childbirth.
 Options B and C: Roles for the nurse midwives and
clinical nurse specialists did not develop from this
challenge.
48. Answer: C. Ischial spines
The ischial spines are located in the mid-pelvic region and could
be narrowed due to the previous pelvic injury.
 Options A, B, and D: The symphysis pubis, sacral
promontory, and pubic arch are not part of the mid-
pelvis.
49. Answer: B. Proliferative phase
Variations in the length of the menstrual cycle are due to
variations in the proliferative phase.
 Options A, C, and D: The menstrual, secretory, and
ischemic phases do not contribute to this variation.
EXAM 2
1. Accompanied by her husband, a patient seeks admission
to the labor and delivery area. The client states that she is
in labor and says she attended the hospital clinic for
prenatal care. Which question should the nurse ask her first?
A. “Do you have any chronic illness?”
B. “Do you have any allergies?”
C. “What is your expected due date?”
D. “Who will be with you during labor?”
2. A patient is in the second stage of labor. During this stage,
how frequently should the nurse in charge assess her uterine
contractions?
A. Every 5 minutes
B. Every 15 minutes
C. Every 30 minutes
D. Every 60 minutes
3. A patient is in her last trimester of pregnancy. Nurse
Vickie should instruct her to notify her primary health care
provider immediately if she notices:
A. Blurred vision
B. Hemorrhoids
C. Increased vaginal mucus
D. Shortness of breath on exertion
4. The nurse in-charge is reviewing a patient’s prenatal
history. Which finding indicates a genetic risk factor?
A. The patient is 25 years old
B. The patient has a child with cystic fibrosis
C. The patient was exposed to rubella at 36 weeks’ gestation
D. The patient has a history of preterm labor at 32 weeks’
gestation
5. An adult female patient is using the rhythm (calendar-
basal body temperature) method of family planning. In this
method, the unsafe period for sexual intercourse is indicated
by:
A. Return preovulatory basal body temperature
B. Basal body temperature increase of 0.1 degrees to 0.2 degrees
on the 2nd or 3rd day of cycle
C. 3 full days of elevated basal body temperature and clear, thin
cervical mucus
D. Breast tenderness and mittelschmerz
6. During a nonstress test (NST), the electronic tracing
displays a relatively flat line for fetal movement, making it
difficult to evaluate the fetal heart rate (FHR). To mark the
strip, the nurse in charge should instruct the client to push
the control button at which time?
A. At the beginning of each fetal movement
B. At the beginning of each contraction
C. After every three fetal movements
D. At the end of fetal movement
7. When evaluating a client’s knowledge of symptoms to
report during her pregnancy, which statement would
indicate to the nurse in charge that the client understands
the information given to her?
A. “I’ll report increased frequency of urination.”
B. “If I have blurred or double vision, I should call the clinic
immediately.”
C. “If I feel tired after resting, I should report it immediately.”
D. “Nausea should be reported immediately.”
8. When assessing a client during her first prenatal visit, the
nurse discovers that the client had a reduction
mammoplasty. The mother indicates she wants to breast-
feed. What information should the nurse give to this mother
regarding breastfeeding success?
A. “It’s contraindicated for you to breastfeed following this type
of surgery.”
B. “I support your commitment; however, you may have to
supplement each feeding with formula.”
C. “You should check with your surgeon to determine whether
breast-feeding would be possible.”
D. “You should be able to breastfeed without difficulty.”
9. Following a precipitous delivery, examination of the
client’s vagina reveals a fourth-degree laceration. Which of
the following would be contraindicated when caring for this
client?
A. Applying cold to limit edema during the first 12 to 24 hours
B. Instructing the client to use two or more peri pads to cushion
the area
C. Instructing the client on the use of sitz baths if ordered
D. Instructing the client about the importance of perineal (Kegel)
exercises
10. A client makes a routine visit to the prenatal clinic.
Although she is 14 weeks pregnant, the size of her uterus
approximates that in an 18- to 20-week pregnancy. Dr.
Charles diagnoses gestational trophoblastic disease and
orders ultrasonography. The nurse expects ultrasonography
to reveal:
A. an empty gestational sac.
B. grapelike clusters.
C. a severely malformed fetus.
D. an extrauterine pregnancy.
11. After completing a second vaginal examination of a client
in labor, the nurse-midwife determines that the fetus is in
the right occiput anterior position and at (–1) station. Based
on these findings, the nurse-midwife knows that the fetal
presenting part is:
A. 1 cm below the ischial spines.
B. directly in line with the ischial spines.
C. 1 cm above the ischial spines.
D. in no relationship to the ischial spines.
12. Which of the following would be inappropriate to assess
in a mother who’s breastfeeding?
A. The attachment of the baby to the breast.
B. The mother’s comfort level with positioning the baby.
C. Audible swallowing.
D. The baby’s lips smacking
13. During a prenatal visit at 4 months gestation, a pregnant
client asks whether tests can be done to identify fetal
abnormalities. Between 18 and 40 weeks gestation, which
procedure is used to detect fetal anomalies?
A. Amniocentesis.
B. Chorionic villi sampling.
C. Fetoscopy.
D. Ultrasound
14. A client, 30 weeks pregnant, is scheduled for a
biophysical profile (BPP) to evaluate the health of her fetus.
Her BPP score is 8. What does this score indicate?
A. The fetus should be delivered within 24 hours.
B. The client should repeat the test in 24 hours.
C. The fetus isn’t in distress at this time.
D. The client should repeat the test in 1 week.
15. A client who is 36 weeks pregnant comes to the clinic for
a prenatal checkup. To assess the client’s preparation for
parenting, the nurse might ask which question?
A. “Are you planning to have epidural anesthesia?”
B. “Have you begun prenatal classes?”
C. “What changes have you made at home to get ready for the
baby?”
D. “Can you tell me about the meals you typically eat each day?”
16. A client who’s admitted to labor and delivery has the
following assessment findings: gravida 2 para 1, estimated
40 weeks gestation, contractions 2 minutes apart, lasting 45
seconds, vertex +4 station. Which of the following would be
the priority at this time?
A. Placing the client in bed to begin fetal monitoring.
B. Preparing for immediate delivery.
C. Checking for ruptured membranes.
D. Providing comfort measures.
17. The nurse is caring for a client in labor. The external fetal
monitor shows a pattern of variable decelerations in fetal
heart rate. What should the nurse do first?
A. Change the client’s position.
B. Prepare for emergency cesarean section.
C. Check for placenta previa.
D. Administer oxygen.
18. The nurse in charge is caring for a postpartum client who
had a vaginal delivery with a midline episiotomy. Which
nursing diagnosis takes priority for this client?
A. Risk for deficient fluid volume related to hemorrhage
B. Risk for infection related to the type of delivery
C. Pain related to the type of incision
D. Urinary retention related to periurethral edema
19. Which change would the nurse identify as a progressive
physiological change in the postpartum period?
A. Lactation
B. Lochia
C. Uterine involution
D. Diuresis
20. A 39-year-old at 37 weeks gestation is admitted to the
hospital with complaints of vaginal bleeding following the
use of cocaine 1 hour earlier. Which complication is most
likely causing the client’s complaint of vaginal bleeding?
A. Placenta previa
B. Abruptio placentae
C. Ectopic pregnancy
D. Spontaneous abortion
21. A client with type 1 diabetes mellitus who is a
multigravida visits the clinic at 27 weeks gestation. The
nurse should instruct the client that for most pregnant
women with type 1 diabetes mellitus:
A. Weekly fetal movement counts are made by the mother.
B. Contraction stress testing is performed weekly.
C. Induction of labor is begun at 34 weeks’ gestation.
D. Nonstress testing is performed weekly until 32 weeks’
gestation
22. When administering magnesium sulfate to a client with
preeclampsia, the nurse understands that this drug is given
to:
A. Prevent seizures
B. Reduce blood pressure
C. Slow the process of labor
D. Increase dieresis
23. What is the approximate time that the blastocyst spends
traveling to the uterus for implantation?
A. 2 days
B. 7 days
C. 10 days
D. 14 weeks
24. After teaching a pregnant woman who is in labor about
the purpose of the episiotomy, which of the following
purposes stated by the client would indicate to the nurse
that the teaching was effective?
A. Shortens the second stage of labor
B. Enlarges the pelvic inlet
C. Prevents perineal edema
D. Ensures quick placenta delivery
25. A primigravida client at about 35 weeks gestation in
active labor has had no prenatal care and admitted to
cocaine use during the pregnancy. Which of the following
persons must the nurse notify?
A. Nursing unit manager so appropriate agencies can be notified
B. Head of the hospital’s security department
C. Chaplain in case the fetus dies in utero
D. Physician who will attend the delivery of the infant
26. When preparing a teaching plan for a client who is to
receive a rubella vaccine during the postpartum period, the
nurse in charge should include which of the following?
A. The vaccine prevents a future fetus from developing congenital
anomalies
B. Pregnancy should be avoided for 3 months after the
immunization
C. The client should avoid contact with children diagnosed with
rubella
D. The injection will provide immunity against the 7-day measles.
27. A client with eclampsia begins to experience a seizure.
Which of the following would the nurse in charge do first?
A. Pad the side rails
B. Place a pillow under the left buttock
C. Insert a padded tongue blade into the mouth
D. Maintain a patent airway
28. While caring for a multigravida client in early labor in a
birthing center, which of the following foods would be best if
the client requests a snack?
A. Yogurt
B. Cereal with milk
C. Vegetable soup
D. Peanut butter cookies
29. The multigravida mother with a history of rapid labor
who us in active labor calls out to the nurse, “The baby is
coming!” which of the following would be the nurse’s first
action?
A. Inspect the perineum
B. Time the contractions
C. Auscultate the fetal heart rate
D. Contact the birth attendant
30. While assessing a primipara during the
immediate postpartum period, the nurse in charge plans to
use both hands to assess the client’s fundus to:
A. Prevent uterine inversion
B. Promote uterine involution
C. Hasten the puerperium period
D. Determine the size of the fundus
ANSWERS AND RATIONALE
1. Answer: C. “What is your expected due date?”
When obtaining the history of a patient who may be in labor, the
nurse’s highest priority is to determine her current status,
particularly her due date, gravidity, and parity. Gravidity and
parity affect the duration of labor and the potential for labor
complications. Later, the nurse should ask about chronic illness,
allergies, and support persons.
2. Answer: B. Every 15 minutes
During the second stage of labor, the nurse should assess the
strength, frequency, and duration of contraction every 15
minutes. If maternal or fetal problems are detected, more
frequent monitoring is necessary.
 Options C and D: An interval of 30 to 60 minutes
between assessments is too long because of variations
in the length and duration of patient’s labor.
3. Answer: A. Blurred vision
Blurred vision or other visual disturbance, excessive weight gain,
edema, and increased blood pressure may signal severe
preeclampsia. This condition may lead to eclampsia, which has
potentially serious consequences for both the patient and fetus.
 Option B: Although hemorrhoids may be a problem
during pregnancy, they do not require immediate
attention.
 Options C and D: Increased vaginal mucus and dyspnea
on exertion are expected as pregnancy progress.
4. Answer: B. The patient has a child with cystic fibrosis
Cystic fibrosis is a recessive trait; each offspring has a one in four
chance of having the trait or the disorder.
 Option A: Maternal age is not a risk factor until age 35,
when the incidence of chromosomal defects increases.
 Option C: Maternal exposure to rubella during the first
trimester may cause congenital defects.
 Option D: Although a history or preterm labor may
place the patient at risk for preterm labor, it does not
correlate with genetic defects.
5. Answer: C. 3 full days of elevated basal body
temperature and clear, thin cervical mucus
Ovulation (the period when pregnancy can occur) is
accompanied by a basal body temperature increase of 0.7
degrees F to 0.8 degrees F and clear, thin cervical mucus.
 Option A: A return to the preovulatory body
temperature indicates a safe period for sexual
intercourse.
 Option B: A slight rise in basal temperature early in the
cycle is not significant.
 Option D: Breast tenderness and mittelschmerz are not
reliable indicators of ovulation.
6. Answer: A. At the beginning of each fetal movement
An NST assesses the FHR during fetal movement. In a healthy
fetus, the FHR accelerates with each movement. By pushing the
control button when a fetal movement starts, the client marks the
strip to allow easy correlation of fetal movement with the FHR.
 Option B: The FHR is assessed during uterine
contractions in the oxytocincontraction test, not the
NST.
 Options C and D: Pushing the control button after every
three fetal movements or at the end of fetal movement
wouldn’t allow accurate comparison of fetal movement
and FHR changes.
7. Answer: B. “If I have blurred or double vision, I should call
the clinic immediately.”
Blurred or double vision may indicate hypertension or
preeclampsia and should be reported immediately.
 Option A: Urinary frequency is a common problem
during pregnancy caused by increased weight pressure
on the bladder from the uterus.
 Options C and D: Clients generally
experience fatigue and nausea during pregnancy.
8. Answer: B. “I support your commitment; however, you
may have to supplement each feeding with formula.”
Recent breast reduction surgeries are done in a way to protect
the milk sacs and ducts, so breast-feeding after surgery is
possible. Still, it’s good to check with the surgeon to determine
what breast reduction procedure was done. There is the
possibility that reduction surgery may have decreased the
mother’s ability to meet all of her baby’s nutritional needs, and
some supplemental feeding may be required. Preparing the
mother for this possibility is extremely important because the
client’s psychological adaptation to mothering may be dependent
on how successfully she breast-feeds.
9. Answer: B. Instructing the client to use two or more peri
pads to cushion the area
Using two or more peripads would do little to reduce the pain or
promote perineal healing.
 Options A, C and D: Cold applications, sitz baths, and
Kegel exercises are important measures when the client
has a fourth-degree laceration.
10. Answer: B. grapelike clusters.
In a client with gestational trophoblastic disease, an ultrasound
performed after the 3rd month shows grapelike clusters of
transparent vesicles rather than a fetus. The vesicles contain a
clear fluid and may involve all or part of the decidual lining of the
uterus. Usually no embryo (and therefore no fetus) is present
because it has been absorbed. Because there is no fetus, there can
be no extrauterine pregnancy. An extrauterine pregnancy is seen
with an ectopic pregnancy.
11. Answer: C. 1 cm above the ischial spines.
Fetal station — the relationship of the fetal presenting part to the
maternal ischial spines — is described in the number of
centimeters above or below the spines. A presenting part above
the ischial spines is designated as –1, –2, or –3. A presenting part
below the ischial spines, as +1, +2, or +3.
12. Answer: D. The baby’s lips smacking
Assessing the attachment process for breast-feeding should
include all of the answers except the smacking of lips. A baby
who’s smacking his lips isn’t well attached and can injure the
mother’s nipples.
13. Answer: D. Ultrasound
Ultrasound is used between 18 and 40 weeks’ gestation to
identify normal fetal growth and detect fetal anomalies and other
problems.
 Option A: Amniocentesis is done during the third
trimester to determine fetal lung maturity.
 Option B: Chorionic villi sampling is performed at 8 to
12 weeks’ gestation to detect genetic disease.
 Option C: Fetoscopy is done at approximately 18 weeks’
gestation to observe the fetus directly and obtain a skin
or blood sample.
14. Answer: C. The fetus isn’t in distress at this time.
The BPP evaluates fetal health by assessing five variables: fetal
breathing movements, gross body movements, fetal tone,
reactive fetal heart rate, and qualitative amniotic fluid volume. A
normal response for each variable receives 2 points; an abnormal
response receives 0 points. A score between 8 and 10 is
considered normal, indicating that the fetus has a low risk of
oxygen deprivation and isn’t in distress. A fetus with a score of 6
or lower is at risk for asphyxia and premature birth; this score
warrants detailed investigation. The BPP may or may not be
repeated if the score isn’t within normal limits.
15. Answer: C. “What changes have you made at home to get
ready for the baby?”
During the third trimester, the pregnant client typically perceives
the fetus as a separate being. To verify that this has occurred, the
nurse should ask whether she has made appropriate changes at
home such as obtaining infant supplies and equipment.
 Option A: The type of anesthesia planned doesn’t reflect
the client’s preparation for parenting.
  Option B: The client should have begun prenatal classes 27. Answer: D. Maintain a patent airway
earlier in the pregnancy. The priority for the pregnant client having a seizure is to
 Option D: The nurse should have obtained dietary maintain a patent airway to ensure adequate oxygenation to the
information during the first trimester to give the client mother and the fetus. Additionally, oxygen may be administered
time to make any necessary changes. by face mask to prevent fetal hypoxia.
16. Answer: B. Preparing for immediate delivery. 28. Answer: A. Yogurt
This question requires an understanding of station as part of the In some birth settings, intravenous therapy is not used with low-
intrapartum assessment process. Based on the client’s risk clients. Thus, clients in early labor are encouraged to eat
assessment findings, this client is ready for delivery, which is the healthy snacks and drink fluid to avoid dehydration. Yogurt,
nurse’s top priority. which is an excellent source of calcium and riboflavin, is soft and
easily digested. During pregnancy, gastric emptying time is
 Options A, C, and D: Placing the client in bed, checking
for ruptured membranes, and providing comfort delayed. In most hospital settings, clients are allowed only ice
measures could be done, but the priority here is chips or clear liquids.
immediate delivery. 29. Answer: A. Inspect the perineum
When the client says the baby is coming, the nurse should first
17. Answer: A. Change the client’s position.
inspect the perineum and observe for crowning to validate the
Variable decelerations in fetal heart rate are an ominous sign,
client’s statement. If the client is not delivering precipitously, the
indicating compression of the umbilical cord. Changing the
nurse can calm her and use appropriate breathing techniques.
client’s position from supine to side-lying may immediately
30. Answer: A. Prevent uterine inversion
correct the problem.
Using both hands to assess the fundus is useful for
 Option B: An emergency cesarean section is necessary
preventing uterine inversion.
only if other measures, such as changing position and
amnioinfusion with sterile saline, prove unsuccessful.
 Option D: Administering oxygen may be helpful, but the
priority is to change the woman’s position and relieve
cord compression.
18. Answer: A. Risk for deficient fluid volume related to
hemorrhage
Hemorrhage jeopardizes the client’s oxygen supply — the first
priority among human physiologic needs. Therefore, the nursing
diagnosis of Risk for deficient fluid volumerelated to hemorrhage
takes priority over diagnoses of Risk for Infection, Pain,
and Urinary retention.
19. Answer: A. Lactation
Lactation is an example of a progressive physiological change
that occurs during the postpartum period.
20. Answer: B. Abruptio placentae
The major maternal adverse reactions from cocaine use in
pregnancy include spontaneous abortion first, not third,
trimester abortion and abruptio placentae.
21. Answer: D. Nonstress testing is performed weekly until
32 weeks’ gestation
For most clients with type 1 diabetes mellitus, non-stress testing
is done weekly until 32 weeks’ gestation and twice a week to
assess fetal well-being.
22. Answer: A. Prevent seizures
The chemical makeup of magnesium is similar to that
of calcium and, therefore, magnesium will act like calcium in the
body. As a result, magnesium will block seizureactivity in a
hyper-stimulated neurologic system by interfering with signal
transmission at the neuromuscular junction.
23. Answer: B. 7 days
The blastocyst takes approximately 1 week to travel to the uterus
for implantation.
24. Answer: A. Shortens the second stage of labor
An episiotomy serves several purposes. It shortens the
second stage of labor, substitutes a clean surgical incision for a
tear, and decreases undue stretching of perineal muscles. An
episiotomy helps prevent tearing of the rectum but it does not
necessarily relieves pressure on the rectum. Tearing may still
occur.
25. Answer: D. Physician who will attend the delivery of the
infant
The fetus of a cocaine-addicted mother is at risk for hypoxia,
meconium aspiration, and intrauterine growth retardation
(IUGR). Therefore, the nurse must notify the physician of the
client’s cocaine use because this knowledge will influence the
care of the client and neonate. The information is used only in
relation to the client’s care.
26. Answer: B. Pregnancy should be avoided for 3 months
after the immunization
After administration of rubella vaccine, the client should be
instructed to avoid pregnancy for at least 3 months to prevent
the possibility of the vaccines toxic effects to the fetus.