partner should wear a condom to prevent
MATERNAL QUESTIONS
Assessment of a 16-year-old nulligravid client who
visits the clinic and asks for information on
contraceptives reveals a menstrual cycle of 28
days. The nurse formulates a nursing diagnosis of
Deficient Knowledge related to ovulation and
fertility management. Which of the following
would be important to include in the teaching plan
for the client?
A) The ovum survives for 96 hours after ovulation,
making conception possible during this time.
B) The basal body temperature falls at least 0.2°F
after ovulation has occurred.
C) Ovulation usually occurs on day 14, plus or
minus 2 days, before the onset of the next
menstrual cycle.
D) Most women can tell they have ovulated
because of severe pain and thick, scant cervical
mucus.
Answer: C
For a client with a menstrual cycle of 28 days,
ovulation usually occurs on day 14, plus or minus 2
days, before the onset of the next menstrual cycle.
Stated another way, the menstrual period begins
about 2 weeks after ovulation has occurred.
Ovulation does not usually occur during the
menses component of the cycle when the uterine
lining is being shed. In most women, the ovum
survives for about 12 to 24 hours after ovulation,
during which time conception is possible. The basal
body temperature rises 0.5° to 1.0°F when
ovulation occurs. Although some women
experience some pelvic discomfort during
ovulation (mittelschmerz), severe or unusual pain is
rare. After ovulation, the cervical mucus is thin and
copious.
Which of the following instructions about activities
during menstruation would the nurse include when
counseling an adolescent who has just begun to
menstruate?
A) Take a mild analgesic if needed for menstrual
pain.
B) Avoid cold foods if menstrual pain persists.
C) Stop exercise while menstruating.
D) Avoid sexual intercourse during menstruation.
Answer: A
The nurse should instruct the client to take a mild
analgesic, such as ibuprofen, if menstrual pain or
"cramps" are present. The client should also eat
foods rich in iron and should continue moderate
exercise during menstruation, which increases
abdominal tone. Avoiding cold foods will not
decrease dysmenorrhea. Sexual intercourse is not
prohibited during menstruation, but the male
exposure to blood.
Before advising a 24-year-old client desiring oral
contraceptives for family planning, the nurse would
assess the client for signs and symptoms of which
of the following?
A) Anemia.
B) Hypertension.
C) Dysmenorrhea.
D) Acne vulgaris.
Answer: B
Before advising a client about oral contraceptives,
the nurse needs to assess the client for signs and
symptoms of hypertension. Clients who have
hypertension, thrombophlebitis, obesity, or a
family history of cerebral or cardiovascular
accident are poor candidates for oral
contraceptives. In addition, women who smoke,
are older than 40 years of age, or have a history of
pulmonary disease should be advised to use a
different method. Iron-deficiency anemia,
dysmenorrhea, and acne are not contraindications
for the use of oral contraceptives. Iron-deficiency
anemia is a common disorder in young women.
Oral contraceptives decrease the amount of
menstrual flow and thus decrease the amount of
iron lost through menses, thereby providing a
beneficial effect when used by clients with anemia.
Low-dose oral contraceptives to prevent ovulation
may be effective in decreasing the severity of
dysmenorrhea (painful menstruation).
Dysmenorrhea is thought to be caused by the
release of prostaglandins in response to tissue
destruction during the ischemic phase of the
menstrual cycle. Use of oral contraceptives often
improves facial acne
A 22-year-old nulligravid client tells the nurse that
she and her husband have been considering using
condoms for family planning. Which of the
following instructions would the nurse include
about the use of condoms as a method for family
planning?
A) Using a spermicide with the condom offers
added protection against pregnancy.
B) Natural skin condoms protect against sexually
transmitted diseases.
C) The typical failure rate for couples using
condoms is about 25%.
D) Condom users frequently report penile gland
sensitivity
Answer: A
The typical failure rate of a condom is
approximately 12% to 14%. Adding a spermicide
can decrease this potential failure rate because it
offers additional protection against pregnancy.
Natural skin condoms do not offer the same
protection against sexually transmitted diseases
caused by viruses as latex condoms do. Unlike latex
condoms, natural skin (membrane) condoms do
not prevent the passage of viruses. Most condom
users report decreased penile gland sensitivity.
However, some users do report an increased
sensitivity or allergic reaction (such as a rash) to
latex, necessitating the use of another method of
family planning or a switch to a natural skin
condom.
Which of the following would the nurse include in
the teaching plan for a 32-year-old female client
requesting information about using a diaphragm
for family planning?
A) Douching with an acidic solution after
intercourse is recommended.
B) Diaphragms should not be used if the client
develops acute cervicitis.
C) The diaphragm should be washed in a weak
solution of bleach and water.
D) The diaphragm should be left in place for 2
hours after intercourse.
Answer: B
The teaching plan should include a caution that
diaphragms should not be used if the client
develops acute cervicitis, possibly aggravated by
contact with the rubber of the diaphragm. Some
studies have also associated diaphragm use with
increased incidence of urinary tract infections.
Douching after use of a diaphragm and intercourse
is not recommended because pregnancy could
occur. The diaphragm should be inspected and
washed with mild soap and water after each use. A
diaphragm should be left in place for at least 6
hours but no longer than 24 hours after
intercourse. More spermicidal jelly or cream should
be used if intercourse is repeated during this
period.
After being examined and fitted for a diaphragm, a
24-year-old client receives instructions about its
use. Which of the following client statements
indicates a need for further teaching?
A) "I can continue to use the diaphragm for about 2
to 3 years if I keep it protected in the case."
B) "If I get pregnant, I will have to be refitted for
another diaphragm after the delivery."
C) "Before inserting the diaphragm I should coat
the rim with contraceptive jelly."
D) "If I gain or lose 20 pounds, I can still use the
same diaphragm."
Answer: D
A client would need additional instructions when
she says that she can still use the same diaphragm
if she gains or loses 20 pounds. Gaining or losing
more than 15 pounds can change the pelvic and
vaginal contours to such a degree that the
diaphragm will no longer protect the client against
pregnancy. The diaphragm can be used for 2 to 3
years if it is cared for and well protected in its case.
The client should be refitted for another diaphragm
after pregnancy and delivery of a newborn because
weight changes and physiologic changes of
pregnancy can alter the pelvic and vaginal
contours, thus affecting the effectiveness of the
diaphragm. The client should use a spermicidal jelly
or cream before inserting the diaphragm.
A 20-year-old woman desiring to use a cervical cap
for family planning is instructed on its use. Which
of the following client statements would indicate to
the nurse that the client needs further instruction?
A) "Cervical caps can be left in place longer than a
diaphragm."
B) "Using a cervical cap may increase the risk of
irritation."
C) "Cervical caps usually fit better than a
diaphragm."
D) "Many women are unable to use cervical caps."
Answer: C
The client needs further instruction when she says
that cervical caps fit better than the diaphragm.
Many women are unable to use cervical caps
because their cervix is too short for the cap to fit
the cervix properly. A cervical cap may remain in
place for up to 48 hours after intercourse, whereas
it is recommended that a diaphragm be left in place
for only 24 hours. The cervical cap is associated
with cervical irritation.
A 23-year-old nulliparous client visiting the clinic
for a routine examination tells the nurse that she
desires to use the basal body temperature method
for family planning. The nurse should instruct the
client to do which of the following?
A) Check the cervical mucus to see if it is thick and
sparse.
B) Take her temperature at the same time every
morning.
C) Document ovulation when the temperature
decreases at least 1°F.
D) Avoid coitus for 10 days after a slight rise in
temperature.
Answer: B
The basal body temperature method requires that
the client take her temperature each morning
before arising, preferably at the same time each
day before eating or any other activity. Just before
the day of ovulation, the temperature falls by
0.5°F. At the time of ovulation, the temperature
rises 0.4° to 0.8°F because of increased
progesterone secretion in response to the
luteinizing hormone. The temperature remains
higher for the rest of the menstrual cycle. The
client should keep a diary of about 6 months of
menstrual cycles to calculate "safe" days. There is
no mucus for the first 3 or 4 days after menses, and
then thick, sticky mucus begins to appear. As
estrogen increases, the mucus changes to clear,
slippery, and stretchy. This condition, termed
spinnbarkeit, is present during ovulation. After
ovulation, the mucus decreases in amount and
becomes thick and sticky again until menses.
Because the ovum typically survives about 24 hours
and sperm can survive up to 72 hours, couples
must avoid coitus when the cervical mucus is
copious and for about 3 to 4 days before and after
ovulation to avoid a pregnancy.
A 19-year-old nulligravid client visiting the clinic
for a routine examination asks the nurse about
cervical mucus changes that occur during the
menstrual cycle. Which of the following statements
would the nurse expect to include in the client's
teaching plan?
a) About midway through the menstrual cycle,
cervical mucus is thick and sticky.
b) During ovulation, the cervix remains dry without
any mucus production.
c) As ovulation approaches, cervical mucus is
abundant and clear.
d) Cervical mucus disappears immediately after
ovulation, resuming with menses.
Answer: C
As ovulation approaches, cervical mucus is
abundant and clear, resembling raw egg white.
Ovulation generally occurs 14 days (plus or minus 2
days) before the beginning of menses. During the
luteal phase of the cycle, which occurs after
ovulation, the cervical mucus is thick and sticky,
making it difficult for sperm to pass. Changes in the
cervical mucus are related to the influences of
estrogen and progesterone. Cervical mucus is
always present.
A multigravid client will be using
medroxyprogesterone acetate (Depo-Provera) as a
family planning method. After the nurse instructs
the client about this method, which of the
following client statements indicates effective
teaching?
a) "This method of family planning requires
monthly injections."
b) "I should have my first injection during my
menstrual cycle."
c) "One possible side effect is absence of a
menstrual period."
d) "This drug will be given by subcutaneous
injections."
Answer: C
With medroxyprogesterone acetate, irregular
menstrual cycles and amenorrhea are common
side effects. Other side effects include weight gain,
breakthrough bleeding, headaches, and
depression. This method requires deep
intramuscular injections every 3 months. The first
injection should occur within 5 days after menses.
Which of the following would the nurse expect to
include in the teaching plan for a 30-year-old
multiparous client who will be using an intrauterine
device (IUD) for family planning?
a) Amenorrhea is a common side effect of IUDs.
b) The client needs to use additional protection for
conception.
c) IUDs are more costly than other forms of
contraception.
d) Severe cramping may occur when the IUD is
inserted.
Answer: D
Severe cramping and pain may occur as the device
is passed through the internal cervical os. The
insertion of the device is generally done when the
client is having her menses, because it is unlikely
that she is pregnant at that time. Common side
effects of IUDs are heavy menstrual bleeding and
subsequent anemia, not amenorrhea. Uterine
infection or ectopic pregnancy may occur. The IUD
has an effectiveness rate of 98%. Therefore,
additional protection is not necessary to prevent
pregnancy. IUDs generally are less costly than
other forms of contraception because they do not
require additional expense. Only one insertion is
necessary, in comparison to daily doses of oral
contraceptives or the need for spermicides in
conjunction with diaphragm use.
Estrogen, one of the hormones regulating cyclic
activities in female reproductive system is
responsible for which effect?
a. Increases the quantity and pH of cervical mucus,
causing it to become thin and watery and can be
stretched to a distance of 10-13 cm.
b. Inhibits the production of LH
c. Increases endometrial tortuosity
d. All of the above
Answer: A
Effects of estrogen:
• Inhibits the production of FSH
• Causes hypertrophy of the myometrium
• Increases the quantity and pH of cervical mucus,
causing it to become thin and watery and can be
stretched to a distance of 10-13 cm.
Effects of Progesterone
• Inhibits the production of LH
• Increases endometrial tortuosity
• Increased endometrial secretions
• Facilitates transport of the fertilized ovum
through the fallopian tubes
Jessa, 17 years old, is bleeding between periods of
less than two weeks. This condition is an
abnormality in the menstrual cycle known as:
a. Metrorrhagia
b. Menorrhagia
c. Amenorrhea
d. Dysmenorrheal
Answer: A
Abnormalities of Menstruation
1. Amenorrhea - absence of menstrual flow
2. Dysmenorrhea - painful menstruation
3. Oligomenorrhea - scanty menstruation
4. Menorrhagia -excessive menstrual bleeding
5. Metrorrhagia - bleeding between periods of less
than 2 weeks
A nurse is reviewing a basal body temperature
chart with a couple. Which change would indicate
probable ovulation?
a) A decrease in temperature followed by an
increase for several days
b) An increase in temperature followed by a
decrease for several days
c) A decrease in temperature that remains until
menses begins
d) A steadily increasing temperature over seven
days
Answer: A
At ovulation body temperature drops, then rises
sharply and remains elevated for several days.
A 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
Answer: C
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. A return to the preovulatory body
temperature indicates a safe period for sexual
intercourse. A slight rise in basal temperature early
in the cycle is not significant. Breast tenderness
and mittelschmerz are not reliable indicators of
ovulation.
Which of the following instructions should be
included in the nurse's teaching regarding oral
contraceptives?
a. Weight gain should be reported to the physician.
b. An alternate method of birth control is needed
when taking antibiotics.
c. If the client misses one or more pills, two pills
should be taken per day for 1 week.
d. Changes in the menstrual flow should be
reported to the physician.
Answer: B
When the client is taking oral contraceptives and
begins antibiotics, another method of birth control
should be used. Antibiotics decrease the
effectiveness of oral contraceptives. Approximately
5-10 pounds of weight gain is not unusual, so
answer A is incorrect. If the client misses a birth
control pill, she should be instructed to take the pill
as soon as she remembers the pill. Answer C is
incorrect. If she misses two, she should take two; if
she misses more than two, she should take the
missed pills but use another method of birth
control for the remainder of the cycle. Answer D is
incorrect because changes in menstrual flow are
expected in clients using oral contraceptives. Often
these clients have lighter menses.
A nursing student is preparing a prenatal class on
the process of fetal circulation. The nursing
instructor asks the student specifically to describe
the process through the umbilical cord. Which of
the following statements from the student is
correct?
1. The one artery carries freshly oxygenated blood
and nutrient-rich blood back from the placenta to
the fetus.
2. The two arteries carry freshly oxygenated blood
and nutrient rich blood back from the placenta to
the fetus
3. The two arteries in the umbilical cord carry
deoxygenated blood and waste products away
from the fetus to the placenta.
4. The two veins in the umbilical cord carry blood
that is high in carbon dioxide and other waste
products away from the fetus to the placenta
3.
Rationale
Blood pumped by the embryo's heart leaves the
embryo through two umbilical arteries. When
oxygenated, the blood is returned by one umbilical
vein. Arteries carry deoxygenated blood and waste
products from the fetus, and veins carry
oxygenated blood and provide oxygen and
nutrients to the fetus.
A pregnant client tells the clinic nurse that she
wants to know the sex of her baby as soon as it can
be determined. The nurse understands that the
client should be able to find out at 12 weeks
gestation because by the end of the twelfth week:
1. the sex of the fetus can be determined by the
appearance of the external genitalia
2. the sex of the fetus can be determined because
the external genitatlia begins to differentiate
3. The sex of the fetus can be determined because
the testes are descended into the scrotal sac.
4. The sex of the fetus can be determined because
the internal differences in males and females
becomes apparent.
3. blood pumped by the embryo's heart leaves the
embryo through two umbilical arteries. When
oxygenatedthe blood is returned by one umbilical
vein. Arteries carry deoxygenated blood and waste
products from the fetus, and veins carry
oxygenated blood and provide oxygen and
nutrients to the fetus.
A nurse is performing an assessment on a client
who is at 38 weeks gestation and notes that the
fetal herat rate is 174 beats/min. On the basis of
this finding, the appropriate nursing action is to:
1. Notify the physician
2. Document the finding
3. Check the mother's heart rate
4. Tell the client that the fetal heart rate is normal.
1. The fetal heart rate depends on gestational age
and rages from 160 to 170 bpm in the first
trimester, but slows with fetal growth to 120 to
160 bpm with the uterus at rest. the fetus may be
in distress. Because the FHR is increased from the
reference range, the nurse notify the physician.
A nursing student is assigned to care for a client in
labor. A nursing instructor asks the student to
describe fetal circulation. specifically the ductus
venosus. The nursing instructor determines that
the student understands fetal circulation if the
student states that the ductus venosus
3. the ductus venosus connects the umbilical vein o
the inferior vena cava.
A nurse is conducting a prenatal class on the
female reproductive system. When a client in the
class asks why the fertilized ovum stays in the
fallopian tube for 3 days, the nurse responds that
the reason for this is that it:
1. promotes the fertilized ovums chance of survivial
2. promotes the fertilized ovums exposure to
estrogen and progesterone
3. promotes the fertlized normal implantation in
the top portion of the uterus
4. promotes the fertilized ovum's exposure to
luteinizing hormone and follicle-stimulating
hormone
3. the tubal isthums remains contracted until 3
days after conception to allow the fertilized ovum
to develop within the tube. This initial growth of
the fertilzied ovum promotes its normal
implantation in the fundal portion of the uterine
corpus. Estrogen is a hormone produced by the
ovarian folllicles, corpus luteum, adrenal cortex,
and placenta during pregnancy. LH and FSH are
excreted by the anterior pituitary gland. The
survival of the fertilized ovum doesn't depend on it
staying the fallopian tube for 3 days.
A nurse instructor is reiewing the menstual cycle
with a nursing student who will be conducting a
prenal teaching session. The instructor asks the
student to describe the FSH and the luteinizing
hormone. The student accurately responds by
stating that:
1. FSH and LH are secreted by the adrenal gland
2. FSH and LH are released from the anterior
pituitary gland.
3. FSH and LH are secretd by the corpus luteium of
the ovary.
4. FSH and LH stimulate the formation of milk
during pregnancy
2. FSH and LH when stimulated by gonadotropin
releash hormone from the hypothalamus, are
released from the antrior pituitary gland to
stimulate follicular growth and development,
growht of the graafian follice, and productionof
progesterone.
A couple comes to the family planning clinic and
asks about sterilization procedures. Which question
by the nurse would deterine if this method of
family planning would be appropriate?
1. Has either of you ever had surgery
2. Do you plan to have any other children
3. Does either of you have DM
4. Does either of you have problems with high bp?
2. Sterilization is a method of contraception for
couples who have completed their families. It
should be considered a permenent end to fertility
becuase reversal surgery is not always successful.
The nurse would ask the cuple about their plans for
having children in the future.
A nurse should explain which of the following to a
pregnant client found to have a gynecoid pelvis?
1. That her type of pelvis has a narrow pubic arch
2. that her type of pelvis is the most favorable for
labor and birth
3. that her type of pelvis is a wide pelvis, but has a
shorter diameter
4. that she will need a cesarean section because
this type of pelvis is not favorable for a normal
labor and vaginal delivery
2. A gynecoid pelvis is a normal femal pelvis and is
the most favorable for successful labor and birth.

A nurse explains some of the purposes of the
placenta to a client during a prenatal visit. The
nurse determines that the client understands some
of these purposes when the client states that the
placenta:
1. Cushions and protects the baby
2. Maintains the temp of the baby
3. Is the way the baby gets food and oxygen
4. Prevents all antibodies and viruses from passing
to the baby.
3. the placenta provides an exchange of oxygen,
nutrients and waste products between the mother
and the fetus. The amniotic fluid surrounds,
cushions and protects the fetus and maintans the
body temp of the fetus. Nutrients, drugs antibodies
and viruses can pass through the placenta.
A nurse instructor asks a nursing student to list the
functions of the amniotic fluid. The student
responds correctly by stating that which of the
folowing
1. Allows for fetal movement
2. Is a measure of kidney function
3. Surrounds,cushions, and protects the fetus
4. Maintains the body temp of the fetus
5. Prevents large particles such as bacteria from
passing to the fetus
6. Provides an exchange of nutrients and waste
products between the mother and fetus
The amniotic fluid surrounds, cusions, and protects
the fetus. It allows the fetus to move freely,
maintains the body temperature of the fetus, and
helps assess kidney function because it contains
urine from the fetus. The placenta prevents large
particles such as bacteria from passingto the fetus
and provides an exchange of nutrients and waste
products between the mother and the fetus.
The nurse is performing an assessment of a
pregnant client who is at 28 weeks gestation. The
nurse measures the fundal height in centimeters
and expects which finding?
1. 22 cm
2. 30 cm
3. 36 cm
4. 40 cm
2. 30 cm
During the second and third trimesters, fundal
height in centimeters approximately equals the
fetuses age in weeks.
The nurse is assisting in performing an assessment
on a client who suspects that she is pregnant and is
checking the client for probable signs of pregnancy.
Which are probable signs? Select all that apply.
1. Ballottement
2. Chadwick's sign
3. Uterine enlargement
4. Braxton Hicks contractions
5. Fetal heart rate detected by a nonelectronic
device
6. Outline of fetus via radiography or
ultasonography
1. Ballottement
2. Chadwick's sign
3. Uterine enlargement
4. Braxton Hicks contractions
The probable signs of pregnancy include uterine
enlargement, Hegar's sign (compressibility and
softening of the lower uterine segment that occurs
at about week 6), Goodell's sign (softening of the
cervix), Chadwick's sign (violet coloration of the
cervix, vagina, and vulva), ballottement
(rebounding of the fetus against the examiner's
fingers), Braxton Hicks contractions, and positive
pregnancy test.
A pregnant client is seen for a regular prenatal visit
and tells the nurse that she is experiencing
irregular contractions. The nurse determines that
she is experiencing Braxton Hicks contractions. On
the basis of this finding which nursing action is
most appropriate?
1. Contact the health care provider
2. Instruct the client to maintain bed rest for the
remainder of the pregnancy
3. Inform the client that these contractions are
common and may occur throughout the pregnancy
4. Call the maternity unit and inform them that the
client will be admitted in a prelabor condition
3. Inform the client that these contractions are
common and may occur throughout the pregnancy
The nurse is providing instructions to a pregnant
client with genital herpes about the measures that
are needed to protect the fetus. Which instructions
should the nurse provide for the client?
1. Total abstinence from sexual intercourse is
necessary during the entire pregnancy
2. Sitz baths need to be taken every 4 hours while
awake if vaginal lesions are present
3. Daily administration of acyclovir is necessary
during the entire pregnancy
4. A C-section will be necessary if vaginal lesions
are present at the time of labor
4. A C-section will be necessary if vaginal lesions
are present at the time of labor
The nurse is reviewing the record of a client who
has just been told that a pregnancy test is positive.
The health care provider has documented the
presence of Goodell's sign. This finding is most
closely associated with which characteristic?
1. A softening of the cervix
2. The presence of fetal movement
3. The presence of HCG in the urine
4. A soft blowing sound that corresponds to the
maternal pulse during auscultation of the uterus
1. A softening of the cervix
A client arrives at the clinic for the first prenatal
assessment. She tells the nurse that the first day of
her last menstrual period was October 19, 2014.
Using Nagele's rule, which expected date of
delivery should the nurse document in the client's
chart?
1. July 12, 2014
2. July 26, 2015
3. August 12, 2015
4. August 26, 2015
2. July 26, 2015
The HCP is assessing the client for the presence of
ballottement. To make this determination, the HCP
should take which action?
1. Auscultate for fetal heart sounds
2. Assess the cervix for compressibility
3. Palpate the abdomen for fetal movement
4. Initiate a gentle upward tap on the cervix
4. Initiate a gentle upward tap on the cervix
Ballottement is a technique of palpating a floating
structure by bouncing it gently and feeling it
rebound.
A pregnant client asks the nurse in the clinic when
she will be able to begin to feel the fetus move.
The nurse responds by telling the mother that fetal
movements will be noted between which weeks of
gestation?
1. 6 and 8
2. 8 and 10
3. 10 and 12
4. 14 and 18
4. 14 and 18
The nurse is performing an assessment of a
primigravida who is being evaluated in a clinic
during her second trimester of pregnancy. Which
finding concerns the nurse and indicates the need
for follow-up?
1. Quickening
2. Braxton Hicks contractions
3. Fetal heart rate of 180 bpm
4. Consistent increased fundal height
3. Fetal heart rate of 180 bpm
The nurse is collecting data during an admission
assessment of a client who is pregnant with twins.
The client has a healthy 5-year-old child who was
delivered at 38 weeks and tells the nurse that she
does not have a history of any type of abortion or
fetal demise. Using GTPAL, what should the nurse
document?
1. G3T2P0A0L1
2. G2T1P0A0L1
3. G1T1P1A0L1
4. G2T0P0A0L1
2. G2T1P0A0L1
The nurse is providing instructions to a pregnant
client who is scheduled for an amniocentesis. What
instruction should the nurse provide?
1. Strict bed rest is required after the procedure
2. Hospitalization is necessary for 24 hours after
the procedure
3. An informed consent needs to be signed before
the procedure
4. A fever is expected after the procedure because
of the trauma to the abdomen
3. An informed consent needs to be signed before
the procedure
An informed consent needs to be obtained before
the procedure. After the procedure the client is
instructed to rest, but may resume light activity
after the cramping subsides.
A pregnant client in the first trimester calls the
nurse at a health care clinic and reports that she
has noticed a thin, colorless vaginal drainage. The
nurse should make which statement to the client?
1. "Come to the clinic immediately"
2. "The vaginal discharge may be bothersome, but
it is a normal occurrence"
3. "Report to the emergency department at the
maternity center immediately"
4. "Use tampons if the discharge is bothersome,
but be sure to change the tampon every 2 hours"
2. "The vaginal discharge may be bothersome, but
it is a normal occurrence"
Leukorrhea begins during the first trimester. The
client should not wear tampons because of the risk
for infection, the client should wear panty liners
and change them frequently.
The nurse has performed a nonstress test on a
pregnant client and is reviewing the fetal monitor
strip. The nurse interprets the test is reactive. How
should the nurse document the finding?
1. Normal
2. Abnormal
3. The need for further evaluation
4. That findings were difficult to interpret
1. Normal
A reactive nonstress test is a normal result. To be
considered reactive, the baseline fetal heart rate
must be within the normal range (120-160 bpm)
with good long term variability. In addition, two or
more fetal heart rate accelerations of at least 15
bpm must occur, each with a duration of at least 15
seconds, in a 20 minute interval.
A nonstress test is performed on a client who is
pregnant, and the results of the test indicate
nonreactive findings. The healthcare provider
prescribes a contraction stress test, and the results
are documented as negative. How should the nurse
document the findings?
1. A normal test result
2. An abnormal test result
3. A high risk for fetal demise
4. The need for cesarean delivery
1. A normal test result
Contraction stress test results may be interpreted
as negative (normal), positive (abnormal), or
equivocal. A negative test indicates that no late
decelerations occurred in the fetal heart rate,
although the fetus was stressed by three
contractions of at least 40 seconds duration in a 10
minute period.
A pregnant client tells the nurse that she has been
craving "unusual foods." The nurse gathers
additional assessment data and discovers that the
client has been ingesting daily amounts of white
clay dirt from her backyard. Laboratory studies are
performed and the nurse determines that which
finding indicates a physiological consequence of
the client's practice?
1. Hematocrit 38%
2. Glucose 86 mg/dL
3. Hemoglobin 9.1 g/dL
4. White blood cell count 12,400 cells/mm
3. Hemoglobin 9.1 g/dL
Pica often leads to iron deficiency anemia, resulting
in a decreased hemoglobin level. The lab results in
options 1, 2, and 4 are normal for the pregnant
client.
A pregnant client asks the nurse about the types of
exercises that are allowable during pregnancy. The
nurse should tell the client that which exercise is
safest?
1. Swimming
2. Scuba diving
3. Low-impact gymnastics
4. Bicycling with the legs in the air
1. Swimming
Non weight bearing exercises are preferable to
weight bearing exercises.
A health care provider has prescribed transvaginal
ultrasonography for the client in the first trimester
of pregnancy and the client asks the nurse about
the procedure. How should the nurse respond to
the client?
1. "The procedure takes about 2 hours"
2. "It will be necessary to drink 1-2 quarts of water
before the examination"
3. "The probe that will be inserted into the vagina
will be covered with a disposable cover and coated
with a gel"
4. "Gel is spread over the abdomen, and a round
disk transducer will be moved over the abdomen to
obtain the picture"
3. "The probe that will be inserted into the vagina
will be covered with a disposable cover and coated
with a gel"
Transvaginal ultrasonography allows clear visibility
of the uterus, gestational sac, embryo, and deep
pelvic structures, such as the ovaries and fallopian
tubes. The client is placed in the lithotomy position
and a probe, encased in a disposable cover and
coated with gel is inserted into the vagina. The
procedure takes about 10-15 minutes.
The nurse has instructed a pregnant client in
measures to prevent varicose veins during
pregnancy. Which statement by the client indicates
a need for further instruction?
1. "I should wear panty hose"
2. "I should wear support hose"
3. "I should wear flat nonslip shoes that have good
support"
4. "I should wear knee high hose, but I should not
leave them on longer than 8 hours"
4. "I should wear knee high hose, but I should not
leave them on longer than 8 hours"
Varicose veins often develop in the lower
extremities during pregnancy. Any constrictive
clothing impedes venous return from the lower
legs and places the client at risk for developing
varicosities.
A pregnant client calls a clinic and tells the nurse
that she is experiencing leg cramps that awaken
her at night. What should the nurse tell the client
to provide relief from the leg cramps?
1. "Bend your foot toward your body while flexing
the knee when the cramps occur"
2. "Bend your foot toward your body while
extending the knee when the cramps occur"
3. "Point your foot away from your body while
flexing the knee when the cramps occur"
4. "Point your foot away from your body while
extending the knee when the cramps occur"
2. "Bend your foot toward your body while
extending the knee when the cramps occur"
A rubella titer result of a 1-day postpartum client is
less than 1:8, and a rubella virus vaccine is
prescribed to be administered before discharge.
The nurse provides which information to the client
about the vaccine? Select all the apply.
1. Breast-feeding needs to be stopped for 3 months
2. Pregnancy needs to be avoided for 1-3 months
3. The vaccine is administered by the SQ route
4. Exposure to immunosuppressed individuals
needs to be avoided
5. A hypersensitivity reaction can occur if the client
has an egg allergy
6. The area of the injection needs to be covered
with sterile gauze for one week
2. Pregnancy needs to be avoided for 1-3 months
3. The vaccine is administered by the SQ route
4. Exposure to immunosuppressed individuals
needs to be avoided
5. A hypersensitivity reaction can occur if the client
has an egg allergy
The nurse in a health care clinic is instructing a
pregnant client how to perform "kick counts."
Which statement by the client indicates a need for
further instructions?
1. "I will record the number of movements or kicks"
2. "I need to lie flat on my back to perform the
procedure"
3. "If I count fewer than 10 kicks in a 2-hour period
I should count the kicks again over the next 2
hours"
4. "I should place my hands on the largest part of
my abdomen and concentrate on the fetal
movements to count the kicks"
2. "I need to lie flat on my back to perform the
procedure"
The client should sit or lie quietly on her side to
perform the kick counts.
The nurse is providing instructions regarding
treatment of hemorrhoids to a client who is in the
second trimester of pregnancy. Which statement
by the client indicates a need for further
instruction?
1. "I should avoid straining during bowel
movements"
2. "I can gently replace the hemorrhoids into the
rectum"
3. "I can apply ice packs to the hemorrhoids to
reduce the swelling"
4. "I should apply heat packs to the hemorrhoids to
help them shrink"
4. "I should apply heat packs to the hemorrhoids to
help them shrink"
Measures to provide relief from hemorrhoids
include avoiding constipation and straining during
bowel movements, applying ice packs, gently
replacing hemorrhoids into the rectum, using stool
softeners, ointments, or sprays as prescribed, and
assuming certain positions to relieve pressure.
The nurse is providing instructions to a client in the
first trimester of pregnancy regarding measures to
assist in reducing breast tenderness. Which
instruction should the nurse provide?
1. Avoid wearing a bra
2. Wash the breasts with warm water and keep
them dry
3. Wear tight-fitting blouses or dresses to provide
support
4. Wash the nipples and areolar area daily with
soap, and massage the breasts with lotion.
2. Wash the breasts with warm water and keep
them dry
The nurse is describing cardiovascular system
changes the occur during pregnancy to a client and
understands that which finding would be normal
for a client in the second trimester?
1. Increase in pulse rate
2. Increase in BP
3. Frequent bowel elimination
4. Decrease in red blood cell production
1. Increase in pulse rate
Between 14-20 weeks gestation the pulse rate
increases about 10-15 bpm, which then persists to
term.
The clinic nurse is providing instructions to a
pregnant client regarding measures that assist in
alleviating heartburn. Which statement by the
client indicates an understanding of the
instructions?
1. "I should avoid between meal snacks"
2. "I should lie down for an hour after eating"
3. "I should use spices for cooking rather than salt"
4. "I should avoid eating foods that produce gas
and fatty foods"
4. "I should avoid eating foods that produce gas
and fatty foods"
The nurse is providing instructions to a pregnant
client with HIV regarding care to the newborn after
delivery. The client asks the nurse about the
feeding options that are available. Which response
should the nurse make to the client?
1. "You will need to bottle feed your newborn"
2. "You will need to feed your newborn by NG tube
feeding"
3. "You will be able to breastfeed for 6-months and
then you will need to switch to bottle feeding"
4. "You will be able to breastfeed for 9 months and
then will need to switch to bottle feeding"
1. "You will need to bottle feed your newborn"
The home care nurse visits a pregnant client who
has a diagnosis of mild preeclampsia. Which
assessment finding indicates a worsening of the
preeclampsia and the need to notify the health
care provider?
1. Urinary output has decreased
2. Dependent edema has resolved
3. BP is at the prenatal baseline
4. The client complains of a headache and blurred
vision
4. The client complains of a headache and blurred
vision
A stillborn baby was delivered in the birthing suite
a few hours ago. After the delivery, the family
remained together, holding and touching the baby.
Which statement by the nurse would assist the
family in their initial period of grief?
1. "What can I do for you?"
2. "Now you have an angel in heaven"
3. "Don't worry, there is nothing you could have
done to prevent this"
4. "We will see to it that you have an early
discharge so that you don't have to be reminded of
this experience"
1. "What can I do for you?"
The nurse implements a teaching plan for a
pregnant client who is newly diagnosed with
gestational diabetes mellitus. Which statement
made by the client indicates a need for further
teaching?
1. "I should stay on a diabetic diet"
2. "I should perform glucose monitoring at home"
3. "I should avoid exercise because of the negative
effect on insulin production"
4. "I should be aware of any infections and report
signs of infections immediately to my HCP"
3. "I should avoid exercise because of the negative
effect on insulin production"
The nurse is performing an assessment on a
pregnant client with severe preeclampsia. The
nurse reviews the assessment findings and
determines that which finding is most closely
associated with a complication of this diagnosis?
1. Enlargement of the breasts
2. Complaints of feeling hot when the room is cool
3. Periods of fetal movement followed by quiet
periods
4. Evidence of bleeding, such as in the gums,
petechiae, and purpura
4. Evidence of bleeding, such as in the gums,
petechiae, and purpura
Severe preeclampsia can trigger DIC because of the
widespread damage to vascular integrity. Bleeding
is an early sign of DIC and should be reported
immediately.
The nurse in a maternity unit is reviewing the
client's records. Which client would the nurse
identify as being the most risk for developing DIC?
1. A primigravida with mild preeclampsia
2. A primigravida who delivered a 10 lb infant 3
hours ago
3. A gravida II who has just been diagnosed with
dead fetus syndrome
4. A gravida IV who delivered 8 hours ago and has
lost 500 mL of blood
3. A gravida II who has just been diagnosed with
dead fetus syndrome
Dead fetus syndrome, severe preeclampsia, and
hemorrhage (500 mL is not considered
hemorrhage) are considered a risk factors for DIC.
A home care nurse is monitoring a pregnant with
gestational HTN who is at risk for preeclampsia. At
each home care visit, the nurse assesses the client
for which classic sign of preeclampsia? Select all
that apply.
1. Proteinuria
2. HTN
3. Low-grade fever
4. Generalized edema
5. Increased pulse
6. Increased respirations
1. Proteinuria
2. HTN
4. Generalized edema
The nurse is assessing a pregnant client with type 1
DM about her understanding regarding changing
insulin needs during pregnancy. The nurse
determines that further teaching is needed if the
client makes which statement?
1. "I will need to increase my insulin dosage during
the first 3 months of pregnancy"
2. "My insulin dose will likely need to be increased
during the second and third trimesters"
3. "Episodes of hypoglycemia are more likely to
occur during the first 3 months of pregnancy"
4. "My insulin needs should return to normal
within 7-10 days after birth if I am bottle feeding"
1. "I will need to increase my insulin dosage during
the first
3 months of pregnancy"
Insulin needs decrease in the first trimester
because of increased insulin production by the
pancreas and increased peripheral sensitivity to
insulin.
A pregnant client reports to a health care clinic
complaining of loss of appetite, weight loss, and
fatigue. After assessment of the client, tuberculosis
is suspected. A sputum culture is obtained and
identifies Myobacterium tuberculosis. Which
instruction should the nurse include in the client's
teaching plan?
1. Therapeutic abortion is required
2. She will have to stay at home until the treatment
is completed
3. Medication will not be started until after delivery
4. Isoniazid plus rifampin will be required for 9
months
4. Isoniazid plus rifampin will be required for 9
months
The nurse is providing instructions to a maternity
client with a history of cardiac disease regarding
appropriate dietary measures. Which statement, if
made by the client, indicates an understanding of
the information provided by the nurse?
1. "I should increase my sodium intake during
pregnancy"
2. "I should lower my blood volume by limiting my
fluids"
3. "I should maintain a low calorie diet to prevent
any weight gain"
4. "I should drink adequate fluids an increase my
intake of high fiber foods"
4. "I should drink adequate fluids an increase my
intake of high fiber foods"
The valsalva maneuver should be avoided in a
client with cardiac disease because it can cause
blood to rush to the heart and overload the cardiac
system.
The clinic is performing a psychosocial assessment
of a client who has been told that she is pregnant.
Which assessment finding indicates to the nurse
that the client is at risk for contracting HIV?
1. A client has a history of IV drug use
2. A client who has a significant other who is
heterosexual
3. A client who has a history of STI's
4. A client who has had one sexual partner for the
past 10 years
1. A client has a history of IV drug use
The nurse in a maternity unit is providing
emotional support to a client and her husband who
are preparing to be discharged from the hospital
after the birth of a dead fetus. Which statement
made by the client indicates a component of the
normal grieving process?
1. "We want to attend a support group"
2. "We never want to try to have a baby again"
3. "We are going to try and adopt a child
immediately"
4. "We are okay and we are going to try and have
another baby immediately"
1. "We want to attend a support group"
The nurse evaluates the ability of a hepatitis-B
positive mother to provide safe bottle-feeding to
her newborn. Which maternal action best
exemplifies the mother's knowledge of potential
disease transmission to the newborn?
1. The mother requests that the window be closed
before feeding
2. The mother holds the newborn properly during
feeding and burping
3. The mother tests the temperature of the
formula before initiating feeding
4. The mother washes and dries her hands before
and after self care of the perineum and asks for a
pair of gloves before feeding
4. The mother washes and dries her hands before
and after self care of the perineum and asks for a
pair of gloves before feeding
A client in the first trimester of pregnancy arrives at
a health care clinic and reports that she has been
experiencing vaginal bleeding. A threatened
abortion is suspected, and the nurse instructs the
client regarding the management of care. Which
statement made by the client indicates a need for
further teaching?
1. "I will watch for the evidence of the passage of
tissue"
2. "I will maintain strict bed rest throughout the
remainder of the pregnancy"
3. "I will count the number of perineal pads used
on a daily basis and not the amount and color of
the blood on the pad"
4. "I will avoid sexual intercourse until the bleeding
has stopped, and for 2 weeks following the last
evidence of bleeding"
2. "I will maintain strict bed rest throughout the
remainder of the pregnancy"
The nurse is monitoring a client who is receiving
oxytocin to induce labor. Which assessment finding
would cause the nurse to immediately discontinue
the oxytocin infusion?
1. Fatigue
2. Drowsiness
3. Uterine hyperstimulation
4. Early decelerations of the fetal heart rate
3. Uterine hyperstimulation
A pregnant client is receiving magnesium sulfate
for the management of preeclampsia. The nurse
determines that the client is experiencing toxicity
from the medication if which finding is noted?
1. Proteinuria +3
2. Respirations of 10 breaths per minute
3. Presence of deep tendon reflexes
4. Serum magnesium level of 6 mEq/L
2. Respirations of 10 breaths per minute
Signs of magnesium toxicity relate to the CNS
depressant effects of the medication and include
respiratory depression, loss of deep tendon
reflexes, and sudden decline in FHR, maternal heart
rate, and blood pressure.
The nurse is monitoring a client in preterm labor
who is receiving IV magnesium sulfate. The nurse
should monitor for which adverse effects of this
medication? Select all the apply.
1. Flushing
2. HTN
3. Increased urine output
4. Depressed respirations
5. Extreme muscle weakness
6. Hyperactive deep tendon reflexes
1. Flushing
4. Depressed respirations
5. Extreme muscle weakness
Adverse effects of magnesium sulfate include
flushing, depressed respirations, depressed deep
tendon reflexes, hypotension, extreme muscle
weakness, decreased urine output, pulmonary
edema, and elevated serum magnesium levels.
The nursing instructor asks a nursing student to
describe the procedure for administering
erythromycin ointment to the eyes of a newborn.
Which statement indicates a need for further
teaching?
1. "I will flush the eyes after instilling the ointment"
2. "I will clean the newborn's eyes before instilling
the ointment"
3. "I need to administer the ointment within 1 hour
after delivery"
4. "I will instill eye ointment into each of the
newborn's conjuctival sacs"
1. "I will flush the eyes after instilling the ointment"
Eye prophylaxis protects the newborn against
gonorrhea and chlamydia.
A client in preterm labor (31 weeks) who is dilated
to 4 cm has been started on magnesium sulfate
and contractions have stopped. If the client labor
can be inhibited for the next 48 hours, the nurse
anticipates a prescription for which medication?
1. Nalbuphine
2. Betamethasone (Celestone)
3. RhoGAM
4. Dinoprostone (Cervidil vaginal insert)
2. Betamethasone (Celestone)
Betamethasone, a glucocorticoid, is given to
increase the production of surfactant to stimulate
fetal lung maturation. It is administered between
28-32 weeks if labor can be inhibited for 48 hours.
Methylergonovine is prescribed for a women to
treat postpartum hemorrhage. Before
administration, what is the priority nursing
assessment?
1. Uterine tone
2. BP
3. Amount of lochia
4. Deep tendon reflexes
2. BP
The nurse is preparing to administer beractant
(Survanta) to a premature infant who has
respiratory distress syndrome. The nurse plans to
administer the medication by which route?
1. Intradermal
2. Intratracheal
3. SQ
4. IM
2. Intratracheal
An opioid analgesic is administered to a client in
labor. The nurse assigned to care for the client
ensures that which medication is readily available if
respiratory distress occurs?
1. Naloxone
2. Morphine sulfate
3. Betamethasone
4. Meperidine hydrochloride
1. Naloxone
RhoGAM is prescribed for a client after delivery
and the nurse provides information to the client
about the purpose of the medication. The nurse
determines that the woman understands the
purpose if the woman states that it will protect her
next baby from which condition?
1. Having Rh+ blood
2. Developing a rubella infection
3. Developing physiological jaundice
4. Being affected by Rh incompatibility
4. Being affected by Rh incompatibility
Methylergonovine is prescribed for a client with
postpartum hemorrhage. Before administering the
medication, the nurse contacts the health care
provider who prescribed the medication if which
condition is documented in the client's medical
record?
1. Hypotension
2. Hypothyroidism
3. DM
4. Peripheral vascular disease
4. Peripheral vascular disease
Methylergonovine is an ergot alkaloid, which are
contraindicated in client with significant CVD,
peripheral vascular disease, hypertension,
preeclampsia, or eclampsia.
The nursing student is preparing to teach a
prenatal class about fetal circulation. Which
statement should be included in the teaching plan?
1. "One artery carries oxygenated blood from the
placenta to the fetus"
2. "Two arteries carry oxygenated blood from the
placenta to the fetus"
3. "Two arteries carry deoxygenated blood and
waste products away from the fetus to the
placenta"
4. "Two veins carry blood that is high in carbon
dioxide and other waste products away from the
fetus to the placenta"
3. "Two arteries carry deoxygenated blood and
waste products away from the fetus to the
placenta"
A nursing student is assigned to care for a client in
labor. The nursing instructor asks the student to
describe fetal circulation, specifically the ductus
venosus. Which statement is correct regarding the
ductus venosus?
1. Connects the pulmonary artery to the aorta
2. Is an opening between the right and left atria
3. Connects the umbilical vein to the inferior vena
cava
4. Connects the umbilical artery to the inferior vena
cava
3. Connects the umbilical vein to the inferior vena
cava
The foramen ovale is a temporary opening
between the right and left atria. The ductus
arteriosus joins the aorta and the pulmonary
artery.
A pregnant client tells the clinic nurse that she
want to know the gender of her baby as soon as it
can be determined. The nurse understands that the
client should be able to find out the gender at 12
weeks gestation because of which factor?
1. The appearance of external genitalia
2. The beginning of the differentiation in the fetal
groin
3. The fetal testes are descended into the scrotal
sac
4. The internal differences in males and females
become apparent
1. The appearance of external genitalia
The nurse is performing an assessment on a client
who is at 38 weeks gestation and notes that the
fetal heart rate is 174 bpm. On the basis of this
finding, what is the priority nursing assessment?
1. Document the findings
2. Check the mother's heart rate
3. Notify the HCP
4. Tell the client that the fetal heart rate is normal
3. Notify the HCP
The nurse is conducting a prenatal class on the
female reproductive system. When a client in the
class asks why the fertilized ovum stays in the
fallopian tubes for 3 days, what is the nurse's best
response?
1. "It promotes the fertilized ovum's chances of
survivial"
2. "It promotes the fertilized ovum's exposure to
estrogen and progesterone"
3. "It promotes the fertilized ovum's normal
implantation in the top portion of the uterus"
4. "It promotes the fertilized ovum's exposure to
lutenizing hormone and follicle-stimulating
hormone"
3. "It promotes the fertilized ovum's normal
implantation in the top portion of the uterus"
The nurse instructor asks a nursing student to list
the characteristics of the amniotic fluid. The
student responds correctly by listing which as
characteristics of amniotic fluid? Select all the
apply.
1. Allows for fetal movement
2. Surrounds, cushions, and protects the fetus
3. Maintains the body temperature of the fetus
4. Can be used to measure fetal kidney function
5. Prevents large particles such as bacteria from
passing to the fetus
6. Provides an exchange of nutrients and waste
products between the mother and fetus
1. Allows for fetal movement
2. Surrounds, cushions, and protects the fetus
3. Maintains the body temperature of the fetus
4. Can be used to measure fetal kidney function
A couple comes to the family planning clinic and
asks about sterilization procedures. Which question
by the nurse would determine whether this
method of family planning would be most
appropriate?
1. "Has either of you ever had surgery"
2. "Do you plan to have any other children"
3. "Do either of you have DM"
4. "Do either of you have problems with high blood
pressure"
2. "Do you plan to have any other children"
The nurse should include which statement to a
pregnant client found to have a gynecoid pelvis?
1. "Your type of pelvis has a narrow pelvic arch"
2. "Your type of pelvis is most favorable for labor
and birth"
3. "Your type of pelvis is a wide pelvis, but has a
short diameter"
4. "You will need a C-section because this type of
pelvis is not favorable for vaginal birth"
2. "Your type of pelvis is most favorable for labor
and birth"
An android pelvis (resembling a male pelvis) would
be unfavorable for labor because of the narrow
pelvic planes. An anthropoid pelvis has an outlet
that is adequate with a normal or moderately
narrow pubic arch. A platypelloid pelvis (flat pelvis)
has a wide transverse diameter, but the
anteroposterior diameter is short, making the
outlet inadequate.
Which explanation should the nurse provide to the
prenatal client about the purpose of the placenta?
1. It cushions and protects the baby
2. It maintains the temperature of the baby
3. It is the way the baby gets food and oxygen
4. It prevents all antibodies and viruses from
passing to the baby
3. It is the way the baby gets food and oxygen
A 55-year-old male client confides in the nurse that
he in concerned about his sexual function. What is
the nurses best response?
1. "How often do you have sexual relations"
2. "Please share with me more about your
concerns"
3. "You are still young and have nothing to be
concerned about"
4. "You should not have a decline in testosterone
until you are in your 80's"
2. "Please share with me more about your
concerns"
The nursing student is preparing to teach a
prenatal class about fetal circulation. Which
statement should be included in the teaching plan?
1. "One artery carries oxygenated blood from the
placenta to the fetus."
2. "Two arteries carry oxygenated blood from the
placenta to the fetus."
3. "Two arteries carry deoxygenated blood and
waste products away from the fetus to the
placenta."
4. "Two veins carry blood that is high in carbon
dioxide and other waste products away from the
fetus to the placenta."
3. "Two arteries carry deoxygenated blood and
waste products away from the fetus to the
placenta."
A pregnant client tells the clinic nurse that she
wants to know the gender of her baby as soon as it
can be determined. The nurse understands that the
client should be able to find out the gender at 12
weeks' gestation because of which factor?
1. The appearance of the fetal external genitalia
2. The beginning of differentiation in the fetal groin
3. The fetal testes are descended into the scrotal
sac
4. The internal differences in males and females
become apparent
1. The appearance of the fetal external genitalia
The nurse is performing an assessment on a client
who is at 38 weeks' gestation and notes that the
fetal heart rate is 174 beats/minute. On the basis
of this finding, what is the priority nursing action?
1. Document the finding.
2. Check the mother's heart rate.
3. Notify the health care provider (HCP).
4. Tell the client that the fetal heart rate is normal.
3. Notify the health care provider (HCP).
The nurse is conducting a prenatal class on the
female reproductive system. When a client in the
class asks why the fertilized ovum stays in the
fallopian tube for 3 days, what is the nurse's best
response?
1. "It promotes the fertilized ovum's chances of
survival."
2. "It promotes the fertilized ovum's exposure to
estrogen and progesterone."
3. "It promotes the fertilized ovum's normal
implantation in the top portion of the uterus."
4. "It promotes the fertilized ovum's exposure to
luteinizing hormone and follicle-stimulating
hormone."
3. "It promotes the fertilized ovum's normal
implantation in the top portion of the uterus."
The nursing instructor asks a nursing student to list
the characteristics of the amniotic fluid. The
student responds correctly by listing which as
characteristics of amniotic fluid? Select all that
apply.
1. Allows for fetal movement
2. Surrounds, cushions, and protects the fetus
3. Maintains the body temperature of the fetus
4. Can be used to measure fetal kidney function
5. Prevents large particles such as bacteria from
passing to the fetus
1. Allows for fetal movement
2. Surrounds, cushions, and protects the fetus
3. Maintains the body temperature of the fetus
4. Can be used to measure fetal kidney function
A couple comes to the family planning clinic and
asks about sterilization procedures. Which question
by the nurse would determine whether this
method of family planning would be most
appropriate?
1. "Has either of you ever had surgery?"
2. "Do you plan to have any other children?"
3. "Do either of you have diabetes mellitus?"
4. "Do either of you have problems with high blood
pressure?"
2. "Do you plan to have any other children?"
The nurse should include which statement to a
pregnant client found to have a gynecoid pelvis?
1. "Your type of pelvis has a narrow pubic arch."
2. "Your type of pelvis is the most favorable for
labor and birth."
3. "Your type of pelvis is a wide pelvis, but has a
short diameter."
4. "You will need a cesarean section because this
type of pelvis is not favorable for a vaginal
delivery."
2. "Your type of pelvis is the most favorable for
labor and birth."
Which explanation should the nurse provide to the
prenatal client about the purpose of the placenta?
1. It cushions and protects the baby.
2. It maintains the temperature of the baby.
3. It is the way the baby gets food and oxygen.
4. It prevents all antibodies and viruses from
passing to the baby.
3. It is the way the baby gets food and oxygen.
The nurse is performing an assessment of a
pregnant client who is at 28 weeks of gestation.
The nurse measures the fundal height in
centimeters and expects which finding?
1. 22 cm
2. 30 cm
3. 36 cm
4. 40 cm
2. 30 cm
The nurse is assisting in performing an assessment
on a client who suspects that she is pregnant and is
checking the client for probable signs of pregnancy.
Which are probable signs of pregnancy? Select all
that apply.
1. Ballottement
2. Chadwick's sign
3. Uterine enlargement
4. Braxton Hicks contractions
5. Fetal heart rate detected by a nonelectronic
device
6. Outline of fetus via radiography or
ultrasonography
1. Ballottement
2. Chadwick's sign
3. Uterine enlargement
4. Braxton Hicks contractions
A pregnant client is seen for a regular prenatal visit
and tells the nurse that she is experiencing
irregular contractions. The nurse determines that
she is experiencing Braxton Hicks contractions. On
the basis of this finding, which nursing action
is most appropriate?
1. Contact the health care provider.
2. Instruct the client to maintain bed rest for the
remainder of the pregnancy.
3. Inform the client that these contractions are
common and may occur throughout the pregnancy.
4. Call the maternity unit and inform them that the
client will be admitted in a prelabor condition.
3. Inform the client that these contractions are
common and may occur throughout the pregnancy.
The nurse is providing instructions to a pregnant
client with genital herpes about the measures that
are needed to protect the fetus. Which instruction
should the nurse provide to the client?
1. Total abstinence from sexual intercourse is
necessary during the entire pregnancy.
2. Sitz baths need to be taken every 4 hours while
awake if vaginal lesions are present.
3. Daily administration of acyclovir (Zovirax) is
necessary during the entire pregnancy.
4. A cesarean section will be necessary if vaginal
lesions are present at the time of labor.
4. A cesarean section will be necessary if vaginal
lesions are present at the time of labor.
The nurse is reviewing the record of a client who
has just been told that a pregnancy test is positive.
The health care provider has documented the
presence of Goodell's sign. This finding is most
closely associated with which characteristic?
1. A softening of the cervix
2. The presence of fetal movement
3. The presence of human chorionic gonadotropin
in the urine
4. A soft blowing sound that corresponds to the
maternal pulse during auscultation of the uterus
1. A softening of the cervix
A client arrives at the clinic for the first prenatal
assessment. She tells the nurse that the first day of
her last menstrual period was October 19, 2014.
Using Nägele's rule, which expected date of
delivery should the nurse document in the client's
chart?
1. July 12, 2014
2. July 26, 2015
3. August 12, 2015
4. August 26, 2015
2. July 26, 2015
The health care provider (HCP) is assessing the
client for the presence of ballottement. To make
this determination, the HCP should take which
action?
1. Auscultate for fetal heart sounds.
2. Assess the cervix for compressibility.
3. Palpate the abdomen for fetal movement.
4. Initiate a gentle upward tap on the cervix.
4. Initiate a gentle upward tap on the cervix.
A pregnant client asks the nurse in the clinic when
she will be able to begin to feel the fetus move.
The nurse responds by telling the mother that fetal
movements will be noted between which weeks of
gestation?
1. 6 and 8
2. 8 and 10
3. 10 and 12
4. 14 and 18
4. 14 and 18
The nurse is performing an assessment of a
primigravida who is being evaluated in a clinic
during her second trimester of pregnancy. Which
finding concerns the nurse and indicates the need
for follow-up?
1. Quickening
2. Braxton Hicks contractions
3. Fetal heart rate of 180 beats/minute
4. Consistent increase in fundal height
3. Fetal heart rate of 180 beats/minute
The nurse is collecting data during an admission
assessment of a client who is pregnant with twins.
The client has a healthy 5-year-old child who was
delivered at 38 weeks and tells the nurse that she
does not have a history of any type of abortion or
fetal demise. Using GTPAL, what should the nurse
document in the client's chart?
1. G = 3, T = 2, P = 0, A = 0, L = 1
2. G = 2, T = 1, P = 0, A = 0, L = 1
3. G = 1, T = 1, P = 1, A = 0, L = 1
4. G = 2, T = 0, P = 0, A = 0, L = 1
2. G = 2, T = 1, P = 0, A = 0, L = 1
The nurse is providing instructions to a pregnant
client who is scheduled for an amniocentesis. What
instruction should the nurse provide?
1. Strict bed rest is required after the procedure.
2. Hospitalization is necessary for 24 hours after
the procedure.
3. An informed consent needs to be signed before
the procedure.
4. A fever is expected after the procedure because
of the trauma to the abdomen.
3. An informed consent needs to be signed before
the procedure.
A pregnant client in the first trimester calls the
nurse at a health care clinic and reports that she
has noticed a thin, colorless vaginal drainage. The
nurse should make which statement to the client?
1. "Come to the clinic immediately."
2. "The vaginal discharge may be bothersome, but
is a normal occurrence."
3. "Report to the emergency department at the
maternity center immediately."
4. "Use tampons if the discharge is bothersome,
but to be sure to change the tampons every 2
hours."
2. "The vaginal discharge may be bothersome, but
is a normal occurrence."
The nurse has performed a nonstress test on a
pregnant client and is reviewing the fetal monitor
strip. The nurse interprets the test as reactive. How
should the nurse document this finding?
1. Normal
2. Abnormal
3. The need for further evaluation
4. That findings were difficult to interpret
1. Normal
A nonstress test is performed on a client who is
pregnant, and the results of the test indicate
nonreactive findings. The health care provider
prescribes a contraction stress test, and the results
are documented as negative. How should the nurse
document this finding?
1. A normal test result
2. An abnormal test result
3. A high risk for fetal demise
4. The need for a cesarean delivery
1. A normal test result
A pregnant client tells the nurse that she has been
craving "unusual foods." The nurse gathers
additional assessment data and discovers that the
client has been ingesting daily amounts of white
clay dirt from her backyard. Laboratory studies are
performed and the nurse determines that which
finding indicates a physiological consequence of
the client's practice?
1. Hematocrit 38%
2. Glucose 86 mg/dL
3. Hemoglobin 9.1 g/dL
4. White blood cell count 12,400 cells/mm3
3. Hemoglobin 9.1 g/dL
A pregnant client asks the nurse about the types of
exercises that are allowable during pregnancy. The
nurse should tell that client that which exercise is
safest?
1. Swimming
2. Scuba diving
3. Low-impact gymnastics
4. Bicycling with the legs in the air
1. Swimming
A health care provider has prescribed transvaginal
ultrasonography for a client in the first trimester of
pregnancy and the client asks the nurse about the
procedure. How should the nurse respond to the
client?
1. "The procedure takes about 2 hours."
2. "It will be necessary to drink 1 to 2 quarts of
water before the examination."
3. "The probe that will be inserted into the vagina
will be covered with a disposable cover and coated
with a gel."
4. "Gel is spread over the abdomen, and a round
disk transducer will be moved over the abdomen to
obtain the picture."
3. "The probe that will be inserted into the vagina
will be covered with a disposable cover and coated
with a gel."
The nurse has instructed a pregnant client in
measures to prevent varicose veins during
pregnancy. Which statement by the client indicates
a need for further instructions?
1. "I should wear panty hose."
2. "I should wear support hose."
3. "I should wear flat nonslip shoes that have good
support."
4. "I should wear knee-high hose, but I should not
leave them on longer than 8 hours."
4. "I should wear knee-high hose, but I should not
leave them on longer than 8 hours."
A pregnant client calls a clinic and tells the nurse
that she is experiencing leg cramps that awaken
her at night. What should the nurse tell the client
to provide relief from the leg cramps?
1. "Bend your foot toward your body while flexing
the knee when the cramps occur."
2. "Bend your foot toward your body while
extending the knee when the cramps occur."
3. "Point your foot away from your body while
flexing the knee when the cramps occur."
4. "Point your foot away from your body while
extending the knee when the cramps occur."
2. "Bend your foot toward your body while
extending the knee when the cramps occur."
The nurse in a health care clinic is instructing a
pregnant client how to perform "kick counts."
Which statement by the client indicates a need for
further instructions?
1. "I will record the number of movements or
kicks."
2. "I need to lie flat on my back to perform the
procedure."
3. "If I count fewer than 10 kicks in a 2-hour period
I should count the kicks again over the next 2
hours."
4. "I should place my hands on the largest part of
my abdomen and concentrate on the fetal
movements to count the kicks."
2. "I need to lie flat on my back to perform the
procedure."
The nurse is providing instructions regarding
treatment of hemorrhoids to a client who is in the
second trimester of pregnancy. Which statement
by the client indicates a need for further
instruction?
1. "I should avoid straining during bowel
movements."
2. "I can gently replace the hemorrhoids into the
rectum."
3. "I can apply ice packs to the hemorrhoids to
reduce the swelling."
4. "I should apply heat packs to the hemorrhoids to
help the hemorrhoids shrink."
4. "I should apply heat packs to the hemorrhoids to
help the hemorrhoids shrink."
The nurse is providing instructions to a client in the
first trimester of pregnancy regarding measures to
assist in reducing breast tenderness. Which
instruction should the nurse provide?
1. Avoid wearing a bra.
2. Wash the breasts with warm water and keep
them dry.
3. Wear tight-fitting blouses or dresses to provide
support.
4. Wash the nipples and areolar area daily with
soap, and massage the breasts with lotion.
2. Wash the breasts with warm water and keep
them dry.
The nurse is describing cardiovascular system
changes that occur during pregnancy to a client
and understands that which finding would be
normal for a client in the second trimester?
1. Increase in pulse rate
2. Increase in blood pressure
3. Frequent bowel elimination
4. Decrease in red blood cell production
1. Increase in pulse rate
The clinic nurse is providing instructions to a
pregnant client regarding measures that assist in
alleviating heartburn. Which statement by the
client indicates an understanding of the
instructions?
1. "I should avoid between-meal snacks."
2. "I should lie down for an hour after eating."
3. "I should use spices for cooking rather than using
salt."
4. "I should avoid eating foods that produce gas
and fatty foods."
4. "I should avoid eating foods that produce gas
and fatty foods."
The home care nurse visits a pregnant client who
has a diagnosis of mild preeclampsia. Which
assessment finding indicates a worsening of the
preeclampsia and the need to notify the health
care provider?
1. Urinary output has increased.
2. Dependent edema has resolved.
3. Blood pressure reading is at the prenatal
baseline.
4. The client complains of a headache and blurred
vision.
4. The client complains of a headache and blurred
vision.
The nurse implements a teaching plan for a
pregnant client who is newly diagnosed with
gestational diabetes mellitus. Which statement
made by the client indicates a need for further
teaching?
1. "I should stay on the diabetic diet."
2. "I should perform glucose monitoring at home."
3. "I should avoid exercise because of the negative
effects on insulin production."
4. "I should be aware of any infections and report
signs of infection immediately to my health care
provider."
3. "I should avoid exercise because of the negative
effects on insulin production."
The nurse is performing an assessment on a
pregnant client with a diagnosis of severe
preeclampsia. The nurse reviews the assessment
findings and determines that which finding is most
closely associated with a complication of this
diagnosis?
1. Enlargement of the breasts
2. Complaints of feeling hot when the room is cool
3. Periods of fetal movement followed by quiet
periods
4. Evidence of bleeding, such as in the gums,
petechiae, and purpura
4. Evidence of bleeding, such as in the gums,
petechiae, and purpura
The home care nurse is monitoring a pregnant
client with gestational hypertension who is at risk
for preeclampsia. At each home care visit, the
nurse assesses the client for which classic signs of
preeclampsia? Select all that apply.
1. Proteinuria
2. Hypertension
3. Low-grade fever
4. Generalized edema
5. Increased pulse rate
6. Increased respiratory rate
 1. Proteinuria
 2. Hypertension
 4. Generalized edema
The nurse is assessing a pregnant client with type 1
diabetes mellitus about her understanding
regarding changing insulin needs during pregnancy.
The nurse determines that further teaching is
needed if the client makes which statement?
1. "I will need to increase my insulin dosage during
the first 3 months of pregnancy."
2. "My insulin dose will likely need to be increased
during the second and third trimesters."
3. "Episodes of hypoglycemia are more likely to
occur during the first 3 months of pregnancy."
4. "My insulin needs should return to normal
within 7 to 10 days after birth if I am bottle-
feeding."
1. "I will need to increase my insulin dosage during
the first 3 months of pregnancy."
A pregnant client reports to a health care clinic,
complaining of loss of appetite, weight loss, and
fatigue. After assessment of the client, tuberculosis
is suspected. A sputum culture is obtained and
identifies Mycobacterium tuberculosis. Which
instruction should the nurse include in the client's
teaching plan?
1. Therapeutic abortion is required.
2. She will have to stay at home until treatment is
completed.
3. Medication will not be started until after delivery
of the fetus.
4. Isoniazid plus rifampin (Rifadin) will be required
for 9 months.
4. Isoniazid plus rifampin (Rifadin) will be required
for 9 months.
The nurse is providing instructions to a maternity
client with a history of cardiac disease regarding
appropriate dietary measures. Which statement, if
made by the client, indicates an understanding of
the information provided by the nurse?
1. "I should increase my sodium intake during
pregnancy."
2. "I should lower my blood volume by limiting my
fluids."
3. "I should maintain a low-calorie diet to prevent
any weight gain."
4. "I should drink adequate fluids and increase my
intake of high-fiber foods."
4. "I should drink adequate fluids and increase my
intake of high-fiber foods."
The clinic nurse is performing a psychosocial
assessment of a client who has been told that she
is pregnant. Which assessment finding indicates to
the nurse that the client is at risk for contracting
human immunodeficiency virus (HIV)?
1. A client who has a history of intravenous drug
use
2. A client who has a significant other who is
heterosexual
3. A client who has a history of sexually transmitted
infections
4. A client who has had one sexual partner for the
past 10 years
1. A client who has a history of intravenous drug
use
A client in the first trimester of pregnancy arrives
at a health care clinic and reports that she has been
experiencing vaginal bleeding. A threatened
abortion is suspected, and the nurse instructs the
client regarding management of care. Which
statement made by the client indicates a need for
further instruction?
1. "I will watch for the evidence of the passage of
tissue."
2. "I will maintain strict bed rest throughout the
remainder of the pregnancy."
3. "I will count the number of perineal pads used
on a daily basis and note the amount and color of
blood on the pad."
4. "I will avoid sexual intercourse until the bleeding
has stopped, and for 2 weeks following the last
evidence of bleeding."
2. "I will maintain strict bed rest throughout the
remainder of the pregnancy."
The nurse is performing an initial assessment on a
client who has just been told that a pregnancy test
is positive. Which assessment finding indicates that
the client is at risk for preterm labor?
1. The client is a 35-year-old primigravida
2. The client has a history of cardiac disease
3. The client's hemoglobin level is 13.5 g/dL
4. The client is a 20-year-old primigravida of
average weight and height
2. The client has a history of cardiac disease
The nurse provides instructions to a malnourished
pregnant client regarding iron supplementation.
Which client statement indicates an understanding
of the instructions?
1. "Iron supplements will give me diarrhea."
2. "Meat does not provide iron and should be
avoided."
3. "The iron is best absorbed if taken on an empty
stomach."
4. "On the days that I eat green leafy vegetables or
calf liver I can omit taking the iron supplement."
3. "The iron is best absorbed if taken on an empty
stomach."
A pregnant client at 10 weeks' gestation calls the
prenatal clinic to report a recent exposure to a
child with rubella. The nurse reviews the client's
chart. What is the nurse's best response to the
client?Refer to chart.
1. "You should avoid all school-age children during
pregnancy."
2. "There is no need to be concerned if you don't
have a fever or rash within the next 2 days."
3. "You were wise to call. Your rubella titer
indicates that you are immune and your baby is not
at risk."
4. "Be sure to tell the health care provider in 2
weeks as additional screening will be prescribed
during your second trimester."
3. "You were wise to call. Your rubella titer
indicates that you are immune and your baby is not
at risk."
During a routine prenatal visit, a client complains of
gums that bleed easily with brushing. The nurse
performs an assessment and teaches the client
about proper nutrition to minimize this problem.
Which client statement indicates an understanding
of the proper nutrition to minimize this problem?
1. "I will drink 8 oz of water with each meal."
2. "I will eat three servings of cracked wheat bread
each day."
3. "I will eat two saltine crackers before I get up
each morning."
4. "I will eat fresh fruits and vegetables for snacks
and for dessert each day."
4. "I will eat fresh fruits and vegetables for snacks
and for dessert each day."
The nursing instructor asks the nursing student
about the physiology related to the cessation of
ovulation that occurs during pregnancy. Which
response, if made by the student, indicates an
understanding of this physiological process?
1. "Ovulation ceases during pregnancy because the
circulating levels of estrogen and progesterone are
high."
2. "Ovulation ceases during pregnancy because the
circulating levels of estrogen and progesterone are
low."
3. "The low levels of estrogen and progesterone
increase the release of the follicle-stimulating
hormone and luteinizing hormone."
4. "The high levels of estrogen and progesterone
promote the release of the follicle-stimulating
hormone and luteinizing hormone."
1. "Ovulation ceases during pregnancy because the
circulating levels of estrogen and progesterone are
high."
The nurse encourages a pregnant human
immunodeficiency virus (HIV)–positive client to
report any early signs of vaginal discharge or
perineal tenderness to the health care provider
immediately. The client asks the nurse about the
importance of this action, and the nurse responds
by telling the client which accurate statement?
1. "This is necessary to relieve anxiety for the
pregnant client."
2. "This is necessary to eliminate the need for
further uncomfortable screenings."
3. "This is necessary to minimize the financial cost
of caring for an HIV-positive client."
4. "This is necessary to assist in identifying
potential infections that may need to be treated."
4. "This is necessary to assist in identifying
potential infections that may need to be treated."
A pregnant client who is anemic tells the nurse
that she is concerned about her infant's condition
after delivery. Which nursing response would best
support the client?
1. "You should not worry about your baby's
condition after the delivery because complications
are rare."
2. "Your baby will probably need to spend a few
days in the neonatal intensive care unit after
delivery."
3. "You will not have any problems if you follow all
the advice the health care provider has given you."
4. "The effects of anemia on your baby are difficult
to predict, but let's review your plan of care to
ensure you are providing the best nutrition and
growth potential."
4. "The effects of anemia on your baby are difficult
to predict, but let's review your plan of care to
ensure you are providing the best nutrition and
growth potential."
The nurse is performing an assessment on a
pregnant client at 16 weeks of gestation. On
assessment, the nurse expects the fundus of the
uterus to be located at which area?
1. At the umbilicus
2. Just above the symphysis pubis
3. At the level of the xiphoid process
4. Midway between the symphysis pubis and the
umbilicus
4. Midway between the symphysis pubis and the
umbilicus
The clinic nurse is performing a prenatal
assessment on a pregnant client. The nurse should
plan to implement teaching related to the risk of
abruptio placentae if which information is obtained
on assessment?
1. The client is 28 years of age.
2. This is the second pregnancy.
3. The client has a history of hypertension.
4. The client performs moderate exercise on a
regular daily schedule.
3. The client has a history of hypertension.
During a prenatal visit, a nurse is explaining dietary
management to a client with pre-existing diabetes
mellitus. The nurse determines that teaching has
been effective if the client makes which statement?
1. "Diet and insulin needs change during
pregnancy."
2. "I will plan my diet based on the results of urine
glucose testing."
3. "I will need to eat 600 more calories every day
because I am pregnant."
4. "I can continue with the same diet as before
pregnancy, as long as it is well balanced."
1. "Diet and insulin needs change during
pregnancy."
The clinic nurse has provided home care
instructions to a client with a history of cardiac
disease who has just been told that she is
pregnant. Which statement, if made by the client,
indicates a need for further instructions?
1. "It is best that I rest lying on my side to promote
blood return to the heart."
2. "I need to avoid excessive weight gain to prevent
increased demands on my heart."
3. "I need to try to avoid stressful situations
because stress increases the workload on the
heart."
4. "During the pregnancy, I need to avoid contact
with other individuals as much as possible to
prevent infection."
4. "During the pregnancy, I need to avoid contact
with other individuals as much as possible to
prevent infection."
The nurse assists a pregnant client with cardiac
disease to identify resources to help her care for
her 18-month-old child during the last trimester of
pregnancy. The nurse encourages the pregnant
client to use these resources primarily for which
reason?
1. Reduce excessive maternal stress and fatigue.
2. Help the mother prepare for labor and delivery.
3. Avoid exposure to potential pathogens and
resulting infections.
4. Prepare the 18-month-old child for maternal
separation during hospitalization.
1. Reduce excessive maternal stress and fatigue.
The nurse is instructing a pregnant client regarding
measures to increase iron in the diet. The nurse
should tell the client to consume which food that
contains the highest source of dietary iron?
1. Milk
2. Potatoes
3. Cantaloupe
4. Whole-grain cereal
4. Whole-grain cereal
The nurse is reviewing a nutritional plan of care
with a pregnant client and is identifying the food
items highest in folic acid. The nurse determines
that the client understands the foods that supply
the highest amounts of folic acid if the client states
that she will include which item in the daily diet?
1. Milk
2. Yogurt
3. Bananas
4. Leafy green vegetables
4. Leafy green vegetables
A pregnant client who is at 30 weeks' gestation
comes to the clinic for a routine visit, and the nurse
performs an assessment on her. Which observation
made by the nurse during the assessment indicates
a need for further teaching?
1. The client is wearing sneakers.
2. The client is wearing knee-high hose.
3. The client is wearing flat shoes with rubber soles.
4. The client is wearing pants with an elastic
waistband.
2. The client is wearing knee-high hose.
A pregnant client visits a clinic for a scheduled
prenatal appointment. The client tells the nurse
that she frequently has a backache, and the nurse
provides instructions regarding measures that will
assist in relieving the backache. Which statement
by the client indicates a need for further
instructions?
1. "I should wear flat-heeled shoes."
2. "I should sleep on a firm mattress."
3. "I should try to maintain good posture."
4. "I should do more exercises to strengthen my
back muscles."
4. "I should do more exercises to strengthen my
back muscles."
A nonstress test is prescribed for a pregnant client,
and she asks the nurse about the procedure. How
should the nurse respond?
1. "The test is a procedure that will require an
informed consent to be signed."
2. "The test will take about 2 hours and will require
close monitoring for 2 hours after the procedure is
completed."
3. "The test is done to see if the baby can handle
the stress of labor, and that medicine is given to
make the uterus contract."
4. "A round, hard plastic disk called an ultrasound
transducer picks up and marks the fetal heart
activity on the recording paper and is secured over
the abdomen."
4. "A round, hard plastic disk called an ultrasound
transducer picks up and marks the fetal heart
activity on the recording paper and is secured over
the abdomen."
The nurse is developing a plan of care for a
pregnant client who is complaining of intermittent
episodes of constipation. To help alleviate this
problem, the nurse should instruct the client to
take which measure?
1. Consume a low-fiber diet.
2. Drink 8 glasses of water per day.
3. Use a Fleet enema when the episodes occur.
4. Take a mild stool softener daily in the evening.
2. Drink 8 glasses of water per day.
A pregnant client in the prenatal clinic is scheduled
for a biophysical profile. The client asks the nurse
what this test involves. The nurse should make
which appropriate response?
1. "This test measures your ability to tolerate the
pregnancy."
2. "This test measures amniotic fluid volume and
fetal activity."
3. "This test measures your cardiac status and
ability to tolerate labor."
4. "This test only measures the amount of amniotic
fluid present in the uterus."
2. "This test measures amniotic fluid volume and
fetal activity."
The nurse in the prenatal clinic is taking a
nutritional history from a 16-year-old pregnant
adolescent. Which statement, if made by the
adolescent, would alert the nurse to a potential
psychosocial problem?
1. "I don't like dairy products."
2. "I will continue drinking my afternoon
milkshake."
3. "I'm not used to eating so much food, but I will
try."
4. "I only want to gain 10 pounds because I want to
have a small, petite baby."
4. "I only want to gain 10 pounds because I want to
have a small, petite baby."
The nurse in the prenatal clinic is conducting a
session about nutrition to a group of adolescents
who are pregnant. Which measure is most
appropriate to teach these adolescents?
1. Eat only when hungry.
2. Eliminate snacks during the day.
3. Avoid meals in fast-food restaurants.
4. Monitor for appropriate weight gain patterns.
4. Monitor for appropriate weight gain patterns.
The clinic nurse is discussing nutrition with a
pregnant client who has lactose intolerance. The
nurse should instruct the client to supplement the
dietary source of calcium by eating which food?
1. Hard cheese
2. Dried fruits
3. Creamed spinach
4. Fresh-squeezed orange juice
2. Dried fruits
The nurse has provided instructions to a pregnant
client who is preparing to take iron supplements.
The nurse determines that the client understands
the instructions if she states that she will take the
supplements with which item?
1. Milk
2. Tea
3. Coffee
4. Orange juice
4. Orange juice
A client arrives at the health care clinic and tells
the nurse that her last menstrual period was 9
weeks ago. The client tells the nurse that a home
pregnancy test was positive but that she began to
have mild cramps and is now having moderate
vaginal bleeding. On physical examination of the
client, it is noted that she has a dilated cervix. The
nurse determines that the client is experiencing
which type of abortion?
1. Septic
2. Inevitable
3. Incomplete
4. Threatened
2. Inevitable
The nurse is reviewing the record of a pregnant
client seen in the health care clinic for the first
prenatal visit. Which data, if noted on the client's
record, would alert the nurse that the client is at
risk for a spontaneous abortion?
1. Age of 35 years
2. History of syphilis
3. History of genital herpes
4. History of diabetes mellitus
2. History of syphilis
The nurse is preparing to care for a client who is
being admitted to the hospital with a possible
diagnosis of ectopic pregnancy. The nurse develops
a plan of care for the client and determines that
which nursing action is the priority?
1. Checking for edema
2. Monitoring daily weight
3. Monitoring the apical pulse
4. Monitoring the temperature
3. Monitoring the apical pulse
The nurse reviews the laboratory results for a client
with a suspected ectopic pregnancy. The nurse
would expect which result of the beta subunit of
human chorionic gonadotropin (β-hCG) if the client
had an ectopic pregnancy?
1. Not present
2. Present in low levels
3. Present in high levels
4. Within normal limits
2. Present in low levels
The nurse is reviewing the record of a pregnant
client seen in the health care clinic for the first
prenatal visit. Which data if noted on the client's
record would alert the nurse that the client is at
risk for developing gestational diabetes during this
pregnancy?
1. The client's last baby weighed 10 pounds at
birth.
2. The client's previous deliveries were by cesarean
birth.
3. The client has a family history of cardiovascular
disease.
4. The client is 5 feet 3 inches in height and weighs
165 pounds.
1. The client's last baby weighed 10 pounds at
birth.
The nurse is teaching a diabetic pregnant client
about nutrition and insulin needs during
pregnancy. The nurse determines that the client
understands dietary and insulin needs if the client
states that the second half of pregnancy may
require which treatment?
1. Increased insulin
2. Increased caloric intake
3. Decreased protein intake
4. Decreased insulin
1. Increased insulin
The nurse is assessing a client with a diagnosis of
gestational trophoblastic disease (hydatidiform
mole). The nurse understands that which findings
are associated with this condition? Select all that
apply.
1. Vaginal bleeding
2. Excessive fetal activity
3. Excessive nausea and vomiting
4. Larger-than-normal uterus for gestational age
5. Elevated levels of human chorionic gonadotropin
(hCG)
 1. Vaginal bleeding
 3. Excessive nausea and vomiting
 4. Larger-than-normal uterus for gestational
age
 5. Elevated levels of human chorionic
gonadotropin (hCG)
The nurse in the prenatal clinic is providing
nutritional counseling to a pregnant client. The
nurse instructs the client to increase the intake of
folic acid and tells the client that which food item is
highest in folic acid?
1. Pork
2. Cheese
3. Chicken
4. Green leafy vegetables
4. Green leafy vegetables
A client reports to the health care clinic and says
that it has been 6 weeks since her last menstrual
period. The nurse performs a pregnancy test and
should expect to note the presence of which
hormone in the blood test results if the client is
pregnant?
1. Estrogen
2. Progesterone
3. Follicle-stimulating hormone (FSH)
4. Human chorionic gonadotropin (hCG)
4. Human chorionic gonadotropin (hCG)
A client in the prenatal clinic asks the nurse about
the delivery date. The nurse notes that the client's
record indicates that the client began her last
menses on March 7, 2015, and ended the menses
on March 14, 2015. Using Nägele's rule, the nurse
should tell the client that the estimated date of
delivery is which date?
1. January 14, 2014
2. January 21, 2014
3. December 21, 2015
4. December 14, 2015
4. December 14, 2015
The prenatal clinic nurse asks a coassigned nursing
student to identify the physiological adaptations of
the cardiovascular system that occur during
pregnancy. The nurse determines that the student
understands these physiological changes if he or
she makes which statement?
1. "An increase in pulse rate occurs."
2. "A decrease in blood volume occurs."
3. "A decrease in cardiac output occurs."
4. "The systolic and diastolic blood pressures
increase by 20 mm Hg."
1. "An increase in pulse rate occurs."
The prenatal client asks the nurse about substances
that can cross the placental barrier and potentially
affect the fetus. The nurse most appropriately
explains that which substances can cross this
barrier? Select all that apply.
1. Viruses
2. Bacteria
3. Nutrients
4. Medications
5. Antibodies
 1. Viruses
 3. Nutrients
 4. Medications
 5. Antibodies
A client who is 8 weeks pregnant calls the prenatal
clinic and tells the nurse that she is experiencing
nausea and vomiting every morning. The nurse
should suggest which measure that will best
promote relief of the symptoms?
1. Eating a high-fat diet
2. Increasing fluids with meals
3. Eating a high-carbohydrate diet
4. Eating dry crackers before arising
4. Eating dry crackers before arising
The home care nurse is visiting a prenatal client
who has a history of heart disease. The nurse
provides instructions to the client regarding home
care measures to promote a healthy pregnancy.
Home care for this client should include which
measure?
1. Increase daily calories to ensure weight gain.
2. Maintain a supine position during rest periods.
3. Restrict visitors who may have an active
infection.
4. Avoid becoming concerned about placing stress
on the heart.
3. Restrict visitors who may have an active
infection.
A home care nurse is visiting a pregnant client with
a diagnosis of mild preeclampsia. What is the
priority nursing intervention during the home visit?
1. Monitor for fetal movement.
2. Monitor the maternal blood glucose.
3. Instruct the client to maintain complete bed rest.
4. Instruct the client to restrict dietary sodium and
any food items that contain sodium.
1. Monitor for fetal movement.
A maternity unit nurse is developing a plan of care
for a client with severe preeclampsia who will be
admitted to the nursing unit. The nurse should
include which nursing intervention in the plan?
1. Restrict food and fluids.
2. Reduce external stimuli.
3. Monitor blood glucose levels.
4. Maintain the client in a supine position.
2. Reduce external stimuli.
A client with severe preeclampsia is admitted to
the maternity department. Which room
assignment would be most appropriate for this
client?
1. A private room across from the elevator
2. A semiprivate room across from the nurses'
station
3. A private room two doors away from the nurses'
station
4. A semiprivate room with another client who
enjoys watching television
3. A private room two doors away from the nurses'
station
A couple is seen in the fertility clinic. After several
tests, it has been determined that the husband is
not sterile and that the wife has nonpatent
fallopian tubes. The nurse is preparing the woman
and her husband for an in vitro fertilization. Which
statement by the woman or her spouse would
indicate a need for further information about the
procedure?
1. "Ova and sperm are collected and allowed to
incubate."
2. "A fertilized ovum is transferred into the
woman's uterus."
3. "The procedure is a method of medically assisted
reproduction."
4. "The procedure is performed using artificial
insemination of sperm instilled through the
vagina."
4. "The procedure is performed using artificial
insemination of sperm instilled through the
vagina."
The nurse in the gynecology clinic is reviewing the
record of a pregnant client after the first prenatal
visit. The nurse notes that the health care provider
has documented that the woman has a platypelloid
pelvis. On the basis of this documentation, the
nurse plans care, knowing that this type of pelvis
has which characteristic?
1. Is heart-shaped
2. Has a flat shape
3. Has an oval shape
4. Is a normal female pelvis
2. Has a flat shape
The nurse is counseling a pregnant woman
diagnosed with gestational diabetes at 29 weeks of
gestation. Which information should the nurse
discuss with the client? Select all that apply.
1. Plan induction at 35 weeks.
2. Plan amniocentesis at this time.
3. Schedule biophysical profile immediately.
4. Plan for weekly non-stress test at 32 weeks.
5. Obtain nutritional counseling with a dietitian.
  4. Plan for weekly non-stress test at 32
weeks.
 5. Obtain nutritional counseling with a
dietitian.
A nurse provides dietary instructions to a pregnant
woman regarding food items that contain folic
acid. Which food item should the nurse
recommend as a good source of folic acid?
1. Cheese
2. Spinach
3. Potatoes
4. Bananas
2. Spinach
The nurse is caring for a client with preeclampsia.
The client is receiving an intravenous (IV) infusion
of magnesium sulfate. When gathering items to be
available for the client, which highest priority item
should the nurse obtain?
1. Tongue blade
2. Percussion hammer
3. Potassium chloride injection
4. Calcium gluconate injection
4. Calcium gluconate injection
A pregnant client has been diagnosed with a
vaginal infection from the organism Candida
albicans. Which finding should the nurse expect to
note when assessing this client?
1. Costovertebral angle pain
2. Pain, itching, and vaginal discharge
3. Absence of any signs and symptoms
4. Proteinuria, hematuria, edema, and
hypertension
2. Pain, itching, and vaginal discharge
The nurse is performing an assessment on a client
seen in the health care clinic for a first prenatal
visit. The client reports February 9 as the first day
of the last menstrual period (LMP). Using Nägele's
rule, what date later that same year will the nurse
relay as the client's due date?
1. October 7
2. October 16
3. November 7
4. November 16
4. November 16
The nurse is performing a measurement of fundal
height in a client whose pregnancy has reached 36
weeks of gestation. During the measurement the
client begins to feel lightheaded. On the basis of
knowledge of the physiological changes of
pregnancy, the nurse understands that which is the
cause of the lightheadedness?
1. A full bladder
2. Emotional instability
3. Insufficient iron intake
4. Compression of the vena cava
4. Compression of the vena cava
A pregnant client has been instructed on the
prevention of genital tract infections. Which client
statement indicates an understanding of these
preventive measures?
1. "I can douche anytime I want."
2. "I can wear my tight-fitting jeans."
3. "I should avoid the use of condoms."
4. "I should wear underwear with a cotton panel
liner."
4. "I should wear underwear with a cotton panel
liner."
The nurse is reviewing the results of the rubella
screening (titer) with a pregnant client. The test
results are positive, and the mother asks if it is safe
for her toddler to receive the vaccine. What is the
nurse's best response?
1. "Most children do not receive the vaccine until
they are 5 years of age."
2. "You are still susceptible to rubella, so your
toddler should receive the vaccine."
3. "It is not advised for children of pregnant women
to be vaccinated during their mother's pregnancy."
4. "Your titer supports your immunity to rubella,
and it is safe for your toddler to receive the vaccine
at this time."
4. "Your titer supports your immunity to rubella,
and it is safe for your toddler to receive the vaccine
at this time."
A clinic nurse is explaining the changes in the
integumentary system that occur during pregnancy
to a client and should tell the client that which
change may persist after she gives birth?
1. Epulis
2. Chloasma
3. Telangiectasia
4. Striae gravidarum
4. Striae gravidarum
A clinic nurse is instructing a pregnant client
regarding dietary measures to promote a healthy
pregnancy. The nurse tells the client about the
importance of an adequate daily fluid intake.
Which client statement best indicates an
understanding of the daily fluid requirement?
1. "I should drink 12 glasses of fruit juices and milk
every day."
2. "I should drink 8 to 10 glasses of fluid a day, and
I can drink as many diet soft drinks as I want."
3. "I should drink 12 glasses of fluid a day, and I can
include the coffee or tea that I drink in the count."
4. "I should drink at least 8 to 10 glasses of fluid
each day, of which at least 6 glasses should be
water."
4. "I should drink at least 8 to 10 glasses of fluid
each day, of which at least 6 glasses should be
water."
A prenatal clinic nurse is providing instructions to a
group of pregnant women regarding measures to
prevent toxoplasmosis. Which client statement
indicates a need for further instruction?
1. "I should cook meat thoroughly."
2. "I should drink unpasteurized milk only."
3. "I should avoid contact with materials that are
possibly contaminated with cat feces."
4. "I should avoid touching mucous membranes of
the mouth or eyes while handling raw meat."
2. "I should drink unpasteurized milk only."
A home care nurse is monitoring a 16-year-old
primigravida who is at 36 weeks' gestation and has
gestational hypertension. Her blood pressure
during the past 3 weeks has been averaging in the
130/90 mm Hg range. She has had some swelling in
the lower extremities and has had mild proteinuria.
Which statement by the woman should alert the
nurse to the worsening of gestational
hypertension?
1. "My vision the past 2 days has been really fuzzy."
2. "The swelling in my hands and ankles has gone
down."
3. "I had heartburn yesterday after I ate some spicy
foods."
4. "I had a headache yesterday, but I took some
acetaminophen (Tylenol) and it went away."
1. "My vision the past 2 days has been really fuzzy."
A primigravida is receiving magnesium sulfate for
the treatment of gestational hypertension. The
nurse who is caring for the client is performing
assessments every 30 minutes. Which finding
would be of most concern to the nurse?
1. Urinary output of 20 mL
2. Deep tendon reflexes of 2+
3. Fetal heart rate of 120 beats/min
4. Respiratory rate of 10 breaths per minute
4. Respiratory rate of 10 breaths per minute
The nurse is reviewing fetal development with a
client who is at 36 weeks gestation. Which
statements describe the characteristics that
develop in a fetus at this time? Select all that
apply.
1. Eyelids begin to fuse.
2. Fetal heart begins to beat.
3. The fetal skin is transparent.
4. The fetus weighs approximately 1200 g.
5. The fetus is approximately 42 to 48 cm long.
6. The lecithin-sphingomyelin (L/S) ratio is greater
than 2:1
 5. The fetus is approximately 42 to 48 cm
long.
 6. The lecithin-sphingomyelin (L/S) ratio is
greater than 2:1
A client who has just been told that she is pregnant
wants to know when the baby's heart will be
completely developed and beating. The nurse
reads in the client's chart that the health care
provider has determined the client to be at 6
weeks' gestation. What is the
nurse's best response?
1. "Your baby's heart right now consists of two
parallel tubes, so we can't hear it today."
2. "Your baby's heart right now is beginning to
partition into four chambers and has begun to
beat, so we should be able to hear it with a
Doppler."
3. "Your baby's heart right now is beginning to
partition into four chambers and has begun to
beat, so we should be able to hear it with a
fetoscope."
4. "Your baby's heart right now has double heart
chambers and has begun to beat, so we should be
able to see it beat using an ultrasound machine."
4. "Your baby's heart right now has double heart
chambers and has begun to beat, so we should be
able to see it beat using an ultrasound machine."
During a woman's 38-week prenatal visit, the nurse
assesses the fetal heart rate. Which finding would
the nurse note as normal?
1. 80 beats/minute
2. 100 beats/minute
3. 150 beats/minute
4. 180 beats/minute
3. 150 beats/minute
The clinic nurse is reviewing the medical record of
a woman scheduled for her weekly prenatal
appointment. The nurse notes that the woman has
been diagnosed with mild preeclampsia. Of the
following interventions, which should the nurse list
as having the lowest priority in planning nursing
care for this client?
1. Assess blood pressure.
2. Discuss the need for hospitalization.
3. Assess deep tendon reflexes and edema.
4. Teach the importance of keeping track of a daily
weight.
2. Discuss the need for hospitalization.
During a woman's prenatal visit, the nurse is
measuring fundal height. The nurse knows that the
woman is at 20 weeks' gestation. Based on this
information, the nurse expects the fundus to be
found at what area of the abdomen?
1. At the umbilicus
2. At the xiphoid process
3. Midway between the umbilicus and the xiphoid
process
4. Midway between the symphysis pubis and the
umbilicus
1. At the umbilicus
The nurse is teaching a woman in her first
trimester measures to alleviate nausea and
vomiting. Which statement by the woman would
indicate that further teaching is required?
1. "I will avoid fried foods."
2. "I will eat five or six small meals a day."
3. "I will contact the clinic if the vomiting does not
subside."
4. "I will eat dry crackers after arising out of bed in
the morning."
4. "I will eat dry crackers after arising out of bed in
the morning."
The nursing instructor asks a nursing student who
is preparing to assist with the assessment of a
pregnant woman to describe the process of
quickening. Which statement if made by the
student indicates an understanding of this term?
1. "It is the thinning of the lower uterine segment."
2. "It is the fetal movement that is felt by the
mother."
3. "It is the irregular, painless contractions that
occur throughout pregnancy."
4. "It is the soft blowing sound that can be heard
when the uterus is auscultated."
2. "It is the fetal movement that is felt by the
mother."
The nurse is interviewing a 16-year-old client
during her initial prenatal clinic visit. The client is
beginning week 18 of her first pregnancy. Which
statement, if made by the client, indicates
an immediate need for further investigation?
1. "I don't like my figure anymore. My clothes are
all too tight."
2. "I don't like my breasts anymore. These silver
lines are ugly."
3. "I don't like my stomach anymore. That brown
line is disgusting."
4. "I don't like my face any more. I always look like I
have been crying."
4. "I don't like my face any more. I always look like I
have been crying."
The nurse reviews the plan of care for a woman at
37 weeks' gestation who has sickle cell anemia. The
nurse determines that which problem listed on the
nursing care plan will receive the highest priority?
1. Pain
2. Disturbed body image
3. Insufficient fluid volume
4. Inability to tolerate activity
3. Insufficient fluid volume
The nurse provides instructions to a malnourished
client regarding iron supplementation during
pregnancy. Which statement, if made by the client,
would indicate an understanding of the
instructions?
1. "Iron supplements will give me diarrhea."
2. "Meat does not provide iron and should be
avoided."
3. "The iron is best absorbed if taken on an empty
stomach."
4. "My body has all the iron it needs, and I don't
need to take supplements."
3. "The iron is best absorbed if taken on an empty
stomach."
A pregnant woman in her second trimester calls
the prenatal clinic nurse to report a recent
exposure to a child with rubella. Which response by
the nurse would be most appropriate and
supportive to the woman?
1. "You should avoid all school-age children during
pregnancy."
2. "There is no need to be concerned if you don't
have a fever or rash within the next 2 days."
3. "Be sure to tell the health care provider on your
next prenatal visit, but there is little risk in the
second trimester."
4. "You were wise to call. I will check your rubella
titer screening results, and we can immediately
identify whether future interventions are needed."
4. "You were wise to call. I will check your rubella
titer screening results, and we can immediately
identify whether future interventions are needed."
A pregnant woman has a positive history of
genital herpes but has not had lesions during this
pregnancy. What should the nurse should plan to
tell the client?
1. "You will be isolated from your newborn infant
after delivery."
2. "Vaginal deliveries can reduce neonatal infection
risks, even if you have an active lesion at the time."
3. "There is little risk to your newborn infant during
this pregnancy, during the birth, and after
delivery."
4. "You will be evaluated at the time of delivery for
herpetic genital tract lesions, and if any are
present, a cesarean delivery will be needed."
4. "You will be evaluated at the time of delivery for
herpetic genital tract lesions, and if any are
present, a cesarean delivery will be needed."
A pregnant woman is seen in the health care clinic
and asks the nurse what causes the breasts to
change in size and appearance during pregnancy.
The nurse plans to base the response on which
facts?
1. The breasts become stretched because of the
weight gain.
2. The increased metabolic rate causes the breasts
to become larger.
3. The breast changes occur because of the
secretion of estrogen and progesterone.
4. Cortisol secreted by the adrenal glands plays a
role in increasing the size and appearance of the
breasts.
3. The breast changes occur because of the
secretion of estrogen and progesterone.
The nurse is conducting a prepared childbirth class
and is instructing pregnant women about the
method of effleurage. The nurse instructs the
women to perform the procedure by doing which
action?
1. Contracting and then consciously relaxing
different muscle groups
2. Massaging the abdomen during contractions,
using both hands in a circular motion
3. Instructing her partner to stroke or massage a
tightened muscle by the use of touch
4. Contracting an area of the body, such as an arm
or leg, and then concentrating on letting tension go
from the rest of the body
2. Massaging the abdomen during contractions,
using both hands in a circular motion
During a routine prenatal visit, a client complains of
gums that bleed easily with brushing. The nurse
performs an assessment and then teaches the
client about proper nutrition to minimize this
problem. Which statement, if made by the client,
would indicate an understanding of the proper
nutritional measures to minimize this problem?
1. "I will drink 8 ounces of water with each meal."
2. "I will eat three servings of cracked wheat bread
each day."
3. "I will eat two saltine crackers before I get up
each morning."
4. "I will eat fresh fruits and vegetables for snacks
and for dessert each day."
4. "I will eat fresh fruits and vegetables for snacks
and for dessert each day."
A prenatal woman with a history of heart disease
has been instructed on care at home. Which
statement, if made by the woman, would indicate
that she understands her needs?
1. "My weight gain is not important."
2. "I should avoid stressful situations."
3. "I should rest by lying on my back."
4. "There is no restriction on people who visit me."
2. "I should avoid stressful situations."
The nurse is reviewing the record of a pregnant
woman and notes that the health care provider has
documented the presence of Chadwick's sign. The
nurse understands that which hormone is
responsible for the development of this sign?
1. Prolactin
2. Estrogen
3. Progesterone
4. Human chorionic gonadotropin
2. Estrogen
A contraction stress test is scheduled for a
pregnant woman, and she asks the nurse to
describe the test. What should the nurse tell the
woman?
1. Uterine contractions are stimulated by Leopold's
maneuvers.
2. An external fetal monitor is attached, and the
woman ambulates on a treadmill until contractions
begin.
3. The uterus is stimulated to contract by the
administration of small amounts of oxytocin
(Pitocin) or by nipple stimulation.
4. Small amounts of oxytocin (Pitocin) are
administered during internal fetal monitoring to
stimulate uterine contractions.
3. The uterus is stimulated to contract by the
administration of small amounts of oxytocin
(Pitocin) or by nipple stimulation.
A nonstress test is performed on a client who is
pregnant, and the results of the test indicate
nonreactive findings. The health care provider
(HCP) prescribes a contraction stress test. The test
is performed, and the nurse notes that the HCP has
documented the results as negative. How should
the nurse interpret this finding?
1. A normal test result
2. An abnormal test result
3. A high risk for fetal demise
4. The need for a cesarean delivery
1. A normal test result
 A pregnant woman seen in the health care clinic
has tested positive for human immunodeficiency
virus (HIV). What can the nurse determine based
on this information?
1. The woman has the herpes simplex virus (HSV).
2. This woman has contracted an airborne disease.
3. The neonate will definitely develop this disease
after birth.
4. HIV antibodies are detected by the enzyme-
linked immunosorbent assay (ELISA) test.
4. HIV antibodies are detected by the enzyme-
linked immunosorbent assay (ELISA) test.
In the prenatal clinic, the nurse is interviewing a
new client and obtaining health history
information. Which action should the nurse plan to
do to elicit the most accurate responses to the
questions that refer to sexually transmitted
infections?
1. Establish a therapeutic relationship.
2. Use specific closed-ended questions.
3. Omit these types of questions because they are
highly personal.
4. Apologize for the embarrassment that these
questions will cause the client.
1. Establish a therapeutic relationship.
The clinic nurse is teaching a pregnant woman
about the warning signs in pregnancy. Which, if
identified as a warning sign by the woman, would
indicate a need for further education?
1. Rapid weight gain
2. Visual disturbances
3. Generalized or facial edema
4. Presence of irregular painless contractions
4. Presence of irregular painless contractions
The nurse is performing a physical assessment on a
client during her first prenatal visit to the clinic. The
nurse takes the client's temperature and notes that
the temperature is 99.2° F. Based on this finding,
which nursing action is most appropriate?
1. Document the temperature.
2. Notify the health care provider.
3. Retake the temperature by the rectal route.
4. Inform the client that the temperature is
elevated and antibiotics may be required.
1. Document the temperature.
A 39-week-gestation pregnant client calls the
maternity unit stating, "My baby has not moved
very much in the past few days. Should I be
concerned?" Which would be the best response
made by the nurse?
1. "Six to eight fetal movements in a 24-hour
period are adequate to determine that the fetus is
healthy."
2. "Fetal movement is a sign of fetal health. Even if
the amount has decreased, the fetus is still
healthy."
3. "Continue to count fetal movements for the next
24 hours and call your health care provider if the
number of movements continues to decrease."
4. "Fetal movements do not decrease as a woman
nears term; therefore you should be seen by your
health care provider for further evaluation."
4. "Fetal movements do not decrease as a woman
nears term; therefore you should be seen by your
health care provider for further evaluation."
A 25-year-old woman arrives on the maternity unit
on February 2. She states that her estimated date
of delivery (EDD) is March 22. She is verbalizing
complaints of dull lower back pain, pelvic
heaviness, and diarrhea for the past few days. On
admission for observation, the client's blood
pressure is 128/80 mm Hg, pulse is 100
beats/minute, respirations are 16 breaths per
minute, and temperature is 99° F. The nurse plans
care based on which interpretation?
1. The woman requires further evaluation for
preterm labor.
2. The woman is suffering from an intestinal
bacterial infection.
3. The woman is exhibiting signs and symptoms of
gestational hypertension.
4. The woman needs instruction on pelvic tilts to
decrease her lower back pain.
1. The woman requires further evaluation for
preterm labor.
The nurse in an obstetrical clinic is reviewing
current prenatal laboratory results of a pregnant
client who is being seen for a routine prenatal visit.
The nurse discovers the client's 1-hour oral glucose
tolerance test (OGTT) result to be 163 mg/dL.
Which would be the nurse's best response to the
client?
1. "Your OGTT results indicate that your baby is at
high risk for macrosomia and special considerations
may be necessary at delivery."
2. "Your OGTT results are within normal limits, but
continuing your prenatal visits remains essential to
monitor fetal growth and development."
3. "The OGTT is a screening tool for gestational
diabetes, and you will need further testing to
confirm a diagnosis owing to your results being
elevated."
4. "Your OGTT results indicate that you are positive
for gestational diabetes. You will be scheduled for a
dietitian consultation to plan your daily dietary
intake."
3. "The OGTT is a screening tool for gestational
diabetes, and you will need further testing to
confirm a diagnosis owing to your results being
elevated."
A 35-week-gestation pregnant woman is
transferred to the maternity unit from the
emergency department, where she was treated for
minor injuries sustained in a motor vehicle crash.
The maternal nurse's priority will be to assess for
which complication?
1. Placenta previa
2. Polyhydramnios
3. Abruptio placentae
4. Gestational hypertension
3. Abruptio placentae
The result of a biophysical profile (BPP) of a 28-
year-old client at 36 weeks' gestation after the
ultrasound components is 8. Based on this result,
the nurse should take which action?
1. Notify the health care provider.
2. Prepare the client for labor induction.
3. Place the fetal heart monitor on the client in
order to do a nonstress test (NST).
4. Provide the client with information regarding
warning signs and symptoms of pregnancy and
discharge her to home.
3. Place the fetal heart monitor on the client in
order to do a nonstress test (NST).
A client in week 35 of her pregnancy is placed on
the fetal heart monitor (FHM) for a nonstress test
(NST) as a result of her complaints of decreased
fetal movement. Twenty minutes after placing the
client on the monitor, the nurse sees the following
monitor strip and makes what conclusion regarding
the NST?
1. The fetal heart rate (FHR) is positive, with a
baseline of 130 beats/min, moderate variability,
and no decelerations.
2. The FHR is reactive, with a baseline of 130
beats/min, moderate variability, and no
decelerations.
3. The FHR is nonreactive, with a baseline of 130
beats/min, moderate variability, and small episodic
decelerations.
4. The FHR is negative, with a baseline of 130
beats/min, moderate variability, and no
decelerations.
2. The FHR is reactive, with a baseline of 130
beats/min, moderate variability, and no
decelerations.
The charge nurse on a labor and delivery unit has
numerous admissions of laboring clients and must
transfer one of the clients to the
postpartum/gynecological unit, where the nurse-
to-client ratio will be 1:4. Which antepartum client
would be the most appropriate one to transfer?
1. The 36-year-old, gravida I, para 0 client who is at
24 weeks' gestation and is being monitored for
preterm labor
2. The 26-year-old, gravida I, para 0 client who is at
10 weeks' gestation and is experiencing vaginal
bleeding
3. The 40-year-old, gravida III, para 0 client who is
at 38 weeks' gestation and is complaining of
decreased fetal movement
4. The 29-year-old, gravida I, para 0 client who is at
42 weeks' gestation and had a biophysical profile
score of 5 earlier today
2. The 26-year-old, gravida I, para 0 client who is at
10 weeks' gestation and is experiencing vaginal
bleeding
A nurse working in an infertility clinic reviews the
medical history of a 35-year-old woman who is
currently taking fertility medications and is
planning a pregnancy. Which medication, if present
in the client's history, would indicate a need for
teaching related to the woman's potential risk for
carrying a fetus with a congenital cleft lip or cleft
palate?
1. Methyldopa
2. Folic acid (Folvite)
3. Phenytoin (Dilantin)
4. Bupropion (Wellbutrin SR)
3. Phenytoin (Dilantin)
A nurse is caring for a client with a diagnosis of
placenta previa. The nurse collects data knowing
that which is a characteristic of placenta previa?
1. A tender and rigid uterus
2. Painless, bright red vaginal bleeding
3. Greenish discoloration of the amniotic fluid
4. Vaginal bleeding accompanied by abdominal
pain
2. Painless, bright red vaginal bleeding
A nulliparous woman asks the nurse when she will
begin to feel fetal movements. The nurse responds
by telling the woman that the first recognition of
fetal movement will occur at approximately how
many weeks of gestation?
1. 5 weeks
2. 9 weeks
3. 13 weeks
4. 18 weeks
4. 18 weeks
A nurse is assessing a woman in the second
trimester of pregnancy who was admitted to the
maternity unit with a suspected diagnosis of
abruptio placentae. Which finding would the nurse
expect to note if abruptio placentae is present?
1. Soft uterus
2. Abdominal pain
3. Nontender uterus
4. Painless vaginal bleeding
2. Abdominal pain
A woman in the third trimester of pregnancy with a
diagnosis of mild preeclampsia is being monitored
at home. The home care nurse teaches the woman
about the signs that need to be reported to the
health care provider. The nurse should tell the
woman to call the health care provider if which
occurs?
1. Urine tests negative for protein.
2. Fetal movements are more than four per hour.
3. Weight increases by more than 1 pound in a
week.
4. The blood pressure reading is ranging between
122/80 and 132/88 mm Hg.
3. Weight increases by more than 1 pound in a
week.
A woman in the third trimester of pregnancy visits
the clinic for a scheduled prenatal appointment.
The woman tells the nurse that she frequently has
leg cramps, primarily when she is reclining. Once
thrombophlebitis has been ruled out, the nurse
should tell the woman to implement which
measure to alleviate the leg cramps?
1. Apply heat to the affected area.
2. Take acetaminophen (Tylenol) every 4 hours.
3. Self-administer calcium carbonate tablets three
times daily.
4. Purchase a chewable antacid that contains
calcium and take a tablet with each meal.
1. Apply heat to the affected area.
A nurse is preparing a pregnant woman for a
transvaginal ultrasound examination. The nurse
should tell the woman that which will occur?
1. She will feel some pain during the procedure.
2. She will be placed in a supine left side-lying
position.
3. She will feel some pressure when the vaginal
probe is moved.
4. She will need to drink 2 quarts of water to attain
a full bladder.
3. She will feel some pressure when the vaginal
probe is moved.
A nurse is assisting in conducting a prenatal session
with a group of expectant parents. One of the
expectant parents asks, "How does the milk get
secreted from the breast?" What is the nurse's best
response?
1. "Prolactin stimulates the secretion of milk, which
is called lactogenesis."
2. "Oxytocin stimulates the secretion of milk, which
is called lactogenesis."
3. "Progesterone stimulates the secretion of milk,
which is called lactogenesis."
4. "Testosterone stimulates the secretion of milk,
which is called lactogenesis."
1. "Prolactin stimulates the secretion of milk, which
is called lactogenesis."
A nurse implements a teaching plan for a pregnant
client who is newly diagnosed with gestational
diabetes mellitus. Which statement by the client
indicates a need for further teaching?
1. "I need to stay on the diabetic diet."
2. "I will perform glucose monitoring at home."
3. "I cannot exercise because of the negative
effects on insulin production."
4. "I will report signs of infection immediately to
my health care provider."
3. "I cannot exercise because of the negative
effects on insulin production."
The nurse is caring for a client with a diagnosis of
endometriosis. The client asks the nurse to
describe this condition. What is the best response
by the nurse?
1. "It causes the cessation of menstruation."
2. "It is pain that occurs during ovulation."
3. "It is the presence of tissue outside the uterus
that resembles the endometrium."
4. "It is also known as primary dysmenorrhea and
causes lower abdominal discomfort."
3. "It is the presence of tissue outside the uterus
that resembles the endometrium."
A client calls the health care provider's office to
schedule an appointment because a home
pregnancy test was performed and the results
were positive. The nurse should expect which
hormone to be present in the urine?
1. Estrogen
2. Progesterone
3. Follicle-stimulating hormone (FSH)
4. Human chorionic gonadotropin (hCG)
4. Human chorionic gonadotropin (hCG)
The nurse is teaching a pregnant client about the
physiological effects and hormonal changes that
occur during pregnancy. The client asks the nurse
about the purpose of estrogen. Which response
should the nurse give the client for the purpose of
estrogen?
1. It maintains and relaxes the uterine lining for
implantation.
2. It stimulates metabolism of glucose and converts
the glucose to fat.
3. It prevents the involution of the corpus luteum
and maintains the production of progesterone until
the placenta is formed.
4. It stimulates uterine development to provide an
environment for the fetus and stimulates the
breasts to prepare for lactation.
4. It stimulates uterine development to provide an
environment for the fetus and stimulates the
breasts to prepare for lactation.
The nurse is collecting data from a client during the
first prenatal visit. The client is anxious to know the
gender of the fetus and asks the nurse when she
will be able to know. The nurse should respond to
the client knowing that the gender of the fetus is
determined by which weeks?
1. 6 to 8
2. 8 to 10
3. 13 to 16
4. 20 to 22
3. 13 to 16
The nurse is collecting data from a client seen in
the health care clinic for a first prenatal visit. The
nurse asks the client when the first day of her last
menstrual period was and the client reports
February 9, 2015. Using Nägele's rule, the nurse
determines what is the estimated date of
confinement (delivery)?
1. October 7, 2015
2. October 16, 2015
3. November 7, 2015
4. November 16, 2015
4. November 16, 2015
A pregnant client is seen in the health care clinic.
During the prenatal visit, the client informs the
nurse that she is experiencing pain in her calf when
she walks. Which is the most appropriate nursing
action?
1. Instruct the client to avoid walking.
2. Assess for signs of venous thrombosis.
3. Instruct to elevate the legs throughout the day.
4. Tell the client that this is normal during
pregnancy.
2. Assess for signs of venous thrombosis.
A client in her second trimester of pregnancy is
seen at the health care clinic. The nurse collects
data from the client and notes that the fetal heart
rate is 90 beats/min. Which nursing action is
appropriate?
1. Document the findings.
2. Notify the health care provider (HCP).
3. Inform the client that everything is normal and
fine.
4. Instruct the client to return to the clinic in 1
week for reevaluation of the fetal heart rate.
2. Notify the health care provider (HCP).
A nurse is caring for a pregnant woman who has
herpes genitalis. The nurse provides instructions to
the woman about treatment modalities that may
be necessary for this condition. Which statement
made by the woman indicates an understanding of
these treatment measures?
1. "I do not need to abstain from sexual
intercourse."
2. "I need to use vaginal creams after I douche
every day."
3. "I need to douche and perform a sitz bath three
times a day."
4. "It may be necessary to have a cesarean section
for delivery."
4. "It may be necessary to have a cesarean section
for delivery."
A pregnant woman tests positive for the hepatitis
B virus (HBV). The woman asks the nurse if she will
be able to breast-feed the baby as planned after
delivery. Which response by the nurse is most
appropriate?
1. "You will not be able to breast-feed the baby
until 6 months after delivery."
2. "Breast-feeding is allowed after the baby has
been vaccinated with immune globulin."
3. "Breast-feeding is not advised, and you should
seriously consider bottle-feeding the baby."
4. "Breast-feeding is not a problem, and you will be
able to breast-feed immediately after delivery."
2. "Breast-feeding is allowed after the baby has
been vaccinated with immune globulin."
A nurse is collecting data from a client who is at 32
weeks gestation. The nurse measures the fundal
height in centimeters and expects the findings to
be how many centimeters (cm)?
1. 22 cm
2. 28 cm
3. 32 cm
4. 40 cm
3. 32 cm
A pregnant client is seen in the health care clinic
for a regular prenatal visit. The client tells the nurse
that she is experiencing irregular contractions. The
nurse determines that the client is experiencing
Braxton Hicks contractions. Which nursing action
should the nurse implement?
1. Contact the health care provider.
2. Instruct the client to maintain bed rest for the
remainder of the pregnancy.
3. Instruct the client that these are common and
may occur throughout the pregnancy.
4. Call the maternity unit and inform them that the
client will be admitted in a prelabor condition.
3. Instruct the client that these are common and
may occur throughout the pregnancy.
A nurse is reviewing the record of a client who has
just been told that her pregnancy test is positive.
The health care provider has documented the
presence of Goodell's sign. What should the nurse
determine that this sign indicates?
1. A softening of the cervix
2. The presence of fetal movement
3. The presence of human chorionic gonadotropin
(hCG) in the urine
4. A soft blowing sound that corresponds to the
maternal pulse while auscultating the uterus
1. A softening of the cervix
A nursing instructor asks a nursing student to
describe the process of quickening. Which
statement by the student indicates an
understanding of this term?
1. "It is the thinning of the lower uterine segment."
2. "It is the fetal movement that is felt by the
mother."
3. "It is irregular painless contractions that occur
throughout pregnancy."
4. "It is the soft blowing sound that can be heard
when the uterus is auscultated."
2. "It is the fetal movement that is felt by the
mother."
A pregnant client asks the nurse in the clinic,
"When will I begin to feel fetal movement?" Which
response should the nurse make?
1. Between 6 and 8 weeks
2. Between 8 and 10 weeks
3. Between 12 and 14 weeks
4. Between 16 and 20 weeks
4. Between 16 and 20 weeks
A rubella titer is performed on a client who has just
been told that she is pregnant. The results of the
titer indicate that the client is not immune to
rubella. Which should the nurse anticipate to be
prescribed for this client?
1. Immunization with rubella
2. Retesting rubella titer during pregnancy
3. Antibiotics to be taken throughout the
pregnancy
4. Counseling the mother regarding therapeutic
abortion
2. Retesting rubella titer during pregnancy
A nursing student is preparing to instruct a
pregnant client in performing Kegel exercises. The
nursing instructor asks the student the purpose of
Kegel exercises. Which response made by the
student indicates an understanding of the
purpose?
1. "The exercises will help reduce backaches."
2. "The exercises will help prevent ankle edema."
3. "The exercises will help prevent urinary tract
infections."
4. "The exercises will help strengthen the pelvic
floor in preparation for delivery."
4. "The exercises will help strengthen the pelvic
floor in preparation for delivery."
The nurse in a health care clinic is instructing a
client how to perform kick counts. Which
statement made by the client indicates a need for
further teaching?
1. "I should lie on my back to perform the
procedure."
2. "I will use a clock or a timer and record the
number of movements or kicks."
3. "I should count the fetal movements for 30 to 60
minutes three times a day."
4. "I should place my hands on the largest part of
my abdomen and concentrate on the fetal
movements to count the kicks."
1. "I should lie on my back to perform the
procedure."
A pregnant client asks the nurse, "What should I
expect during a nonstress test?" Which information
should the nurse provide to the client?
1. "The test is an invasive procedure and requires
that you sign an informed consent."
2. "The fetus is challenged by uterine contractions
to obtain the necessary information."
3. "The test will take about 2 hours and will require
close monitoring for 2 hours after the procedure is
completed."
4. "An ultrasound transducer that records fetal
heart activity is secured over the abdomen where
the fetal heart is heard most clearly."
4. "An ultrasound transducer that records fetal
heart activity is secured over the abdomen where
the fetal heart is heard most clearly."
A nurse provides teaching regarding how to
relieve discomfort to a client in her second
trimester of pregnancy that is having frequent low
back pain and ankle edema at the end of the day.
Which statement made by the client indicates an
understanding of the teaching?
1. "When I get home I should lie on my left side,
with my feet in a dorsiflexed position."
2. "I should soak in a tub bath of hot water when I
get home and then perform pelvic tilt exercises."
3. "When I get home I should lie on my right side,
with my feet elevated on a pillow, and put a
heating pad on my back."
4. "When I get home I should lie on the floor, with
my legs elevated onto a couch, and turn my hips
and knees at right angles."
4. "When I get home I should lie on the floor, with
my legs elevated onto a couch, and turn my hips
and knees at right angles."
A pregnant client calls the nurse at the health care
provider's office and reports that she has noticed a
thin, colorless, vaginal drainage. Which information
is most appropriate for the nurse to provide to the
client?
1. Come to the clinic immediately.
2. The vaginal discharge may be bothersome, but is
a normal occurrence.
3. Report to the emergency department at the
maternity center immediately.
4. Use tampons if the discharge is bothersome but
be sure to change the tampons every 2 hours.
2. The vaginal discharge may be bothersome, but is
a normal occurrence.
The nurse has assisted in performing a nonstress
test on a pregnant client and is reviewing the
documentation related to the results of the test.
The nurse notes that the health care provider has
documented the test results as reactive. How
should the nurse interpret this result?
1. Normal findings
2. Abnormal findings
3. The need for further evaluation
4. That the findings on the monitor were difficult to
interpret
1. Normal findings
A pregnant client calls the clinic and tells the
nurse that she is experiencing leg cramps and is
awakened by the cramps at night. Which activity
should the nurse tell the client to perform when
the cramps occur?
1. Dorsiflex the foot while flexing
2. Dorsiflex the foot while extending
3. Plantar flex the foot while flexing
4. Plantar flex the foot while extending
2. Dorsiflex the foot while extending
The nurse is providing instructions about treatment
for hemorrhoids to a client in the second trimester
of pregnancy. Which statement made by the client
indicates a need for further teaching?
1. "Cool sitz baths will help in relieving the
discomfort."
2. "I should perform Kegel exercises as you have
instructed."
3. "I should apply heat packs to the hemorrhoids to
help them shrink."
4. "I can apply ice packs to the hemorrhoids to
assist in relieving discomfort."
3. "I should apply heat packs to the hemorrhoids to
help them shrink."
The clinic nurse is discussing nutrition with a
pregnant client who has lactose intolerance. Which
food should the nurse instruct the client to eat to
supplement the dietary source of calcium?
1. Dried fruits
2. Hard cheese
3. Creamed spinach
4. Fresh squeezed orange juice
1. Dried fruits
A nurse is providing instructions to a pregnant
client visiting the antenatal clinic about foods that
are rich in folic acid. Which food should the nurse
encourage the client to consume because it is
highest in folic acid?
1. Rice
2. Cheese
3. Chicken
4. Green leafy vegetables
4. Green leafy vegetables
A pregnant client asks the nurse about the type of
exercises that are allowable during pregnancy.
Which exercise should the nurse instruct the client
to engage in?
1. Swimming
2. Water skiing
3. Downhill skiing
4. Aerobic exercising
1. Swimming
A pregnant client reports to the health care clinic
complaining of loss of appetite, weight loss, and
fatigue. A sputum culture is obtained,
andMycobacterium tuberculosis is identified in the
sputum. Which instruction should the nurse
provide to the client regarding therapeutic
management of tuberculosis?
1. The need for therapeutic abortion is required.
2. Medication will not be started until after delivery
of the fetus.
3. Isoniazid plus rifampin (Rifadin) will be required
for a total of 9 months.
4. The newborn must receive medication therapy
immediately following birth.
3. Isoniazid plus rifampin (Rifadin) will be required
for a total of 9 months.
The nurse provides home care instructions to a
pregnant client with a history of cardiac disease.
Which statement made by the client indicates a
need for further teaching?
1. "It is best that I rest on my left side to promote
blood return to the heart."
2. "I need to avoid excessive weight gain to prevent
increased demands on my heart."
3. "I need to try to avoid stressful situations
because stress increases the workload on the
heart."
4. "During the pregnancy, I need to avoid contact
with other individuals as much as possible to
prevent infection."
4. "During the pregnancy, I need to avoid contact
with other individuals as much as possible to
prevent infection."
A nurse is collecting data on a pregnant client in
the first trimester of pregnancy diagnosed with
iron deficiency anemia. The nurse should monitor
the client to detect which sign/symptom indicating
that this problem has not yet resolved?
1. Pink mucous membranes
2. Increased vaginal secretions
3. Complaints of daily headaches and fatigue
4. Complaints of increased frequency of voiding
3. Complaints of daily headaches and fatigue
The nurse is conducting a routine screening to
detect a client's risk for toxoplasmosis parasite
infection during pregnancy. Which factor should
the nurse ask the client about to determine this
risk?
1. Presence of cats in the home
2. Number of sexual partners during pregnancy
3. Exposure to children with rashes or
gastrointestinal symptoms
4. History of high fevers or unusual rashes during
the first 6 weeks of pregnancy
1. Presence of cats in the home
A nurse is preparing to care for a client being
admitted to the hospital with a possible diagnosis
of ectopic pregnancy. The nurse develops a plan of
care for the client and determines that which is the
priority nursing action?
1. Assessing for edema
2. Monitoring daily weight
3. Monitoring the apical pulse
4. Monitoring the temperature
3. Monitoring the apical pulse
A nurse is reviewing the record of a pregnant client
seen in the health care clinic for the first prenatal
visit. Which data should alert the nurse that the
client is at risk for developing gestational diabetes
during this pregnancy?
1. The client's last baby weighed 10 lb at birth.
2. The client has a family history of type 1 diabetes.
3. The client is 5 feet, 3 inches tall and weighs 165
lb.
4. The client's previous deliveries were by cesarean
section.
1. The client's last baby weighed 10 lb at birth.
A nurse is teaching a diabetic pregnant client
about nutrition and insulin needs during
pregnancy. The nurse determines that the client
understands dietary and insulin needs if the client
states that which may be required during the
second half of pregnancy?
1. Increased insulin
2. Decreased insulin
3. Increased caloric intake
4. Decreased caloric intake
1. Increased insulin
A nurse is providing instructions about taking iron
supplements to a pregnant client. The nurse
determines that the client understands the
instructions if the client states she will take the
supplements with which drink?
1. Tea
2. Milk
3. Coffee
4. Orange juice
4. Orange juice
A nurse is assisting the health care provider to
perform Leopold's maneuvers on a pregnant client.
Which action should the nurse perform before the
procedure?
1. Ask the client to urinate.
2. Ask the client to drink 8 oz of water.
3. Locate the fetal heart tones with a fetoscope.
4. Warm the sonogram gel before placing it on the
client's abdomen.
1. Ask the client to urinate.
A nurse is collecting data on clients who are in
their first trimester of pregnancy. The nurse is
concerned with identifying clients who may be at
risk for the development of postpartum
complications. Which client would be least likely at
risk for the development of thrombophlebitis in the
postpartum period?
1. A 35-year-old client who reports that she smokes
2. A 26-year-old client with a family history of
thrombophlebitis
3. A 37-year-old client in her fourth pregnancy who
is overweight
4. A 22-year-old client in her first pregnancy who
states that oral contraceptives taken in the past
have caused thrombophlebitis
2. A 26-year-old client with a family history of
thrombophlebitis
The clinic nurse is instructing a pregnant client in
her first trimester about nutrition. The nurse
should determine that the client needs further
teaching if the client believes which is true about
nutrition during pregnancy?
1. Iron supplements should be taken throughout
pregnancy.
2. Calcium intake should be increased for the
duration of the pregnancy.
3. Pregnancy greatly increases the risk of
malnourishment for the mother.
4. The maternal diet significantly influences fetal
growth and development.
3. Pregnancy greatly increases the risk of
malnourishment for the mother.
The nurse is providing instructions to a pregnant
client with genital herpes about the measures that
are needed to protect the fetus. Which instruction
should the nurse provide to the client?
1. Total abstinence from sexual intercourse is
necessary during the entire pregnancy.
2. Sitz baths need to be taken every 4 hours while
awake if vaginal lesions are present.
3. Daily administration of acyclovir (Zovirax) is
necessary during the entire pregnancy.
4. A cesarean section will be necessary if vaginal
lesions are present at the time of labor.
4. A cesarean section will be necessary if vaginal
lesions are present at the time of labor.
The home care nurse visits a pregnant client who
has a diagnosis of mild preeclampsia. Which
assessment finding indicates a worsening of the
preeclampsia and the need to notify the health
care provider?
1. Urinary output has increased.
2. Dependent edema has resolved.
3. Blood pressure reading is at the prenatal
baseline.
4. The client complains of a headache and blurred
vision.
4. The client complains of a headache and blurred
vision.
The nurse implements a teaching plan for a
pregnant client who is newly diagnosed with
gestational diabetes mellitus. Which statement
made by the client indicates a need for further
teaching?
1. "I should stay on the diabetic diet."
2. "I should perform glucose monitoring at home."
3. "I should avoid exercise because of the negative
effects on insulin production."
4. "I should be aware of any infections and report
signs of infection immediately to my health care
provider."
3. "I should avoid exercise because of the negative
effects on insulin production."
The nurse is performing an assessment on a
pregnant client with a diagnosis of severe
preeclampsia. The nurse reviews the assessment
findings and determines that which finding is most
closely associated with a complication of this
diagnosis?
1. Enlargement of the breasts
2. Complaints of feeling hot when the room is cool
3. Periods of fetal movement followed by quiet
periods
4. Evidence of bleeding, such as in the gums,
petechiae, and purpura
4. Evidence of bleeding, such as in the gums,
petechiae, and purpura
The home care nurse is monitoring a pregnant
client with gestational hypertension who is at risk
for preeclampsia. At each home care visit, the
nurse assesses the client for which classic signs of
preeclampsia? Select all that apply.
1. Proteinuria
2. Hypertension
3. Low-grade fever
4. Generalized edema
5. Increased pulse rate
6. Increased respiratory rate
1. Proteinuria
2. Hypertension
4. Generalized edema
he nurse is assessing a pregnant client with type 1
diabetes mellitus about her understanding
regarding changing insulin needs during pregnancy.
The nurse determines that further teaching is
needed if the client makes which statement?
1. "I will need to increase my insulin dosage during
the first 3 months of pregnancy."
2. "My insulin dose will likely need to be increased
during the second and third trimesters."
3. "Episodes of hypoglycemia are more likely to
occur during the first 3 months of pregnancy."
4. "My insulin needs should return to normal
within 7 to 10 days after birth if I am bottle-
feeding."
1. "I will need to increase my insulin dosage during
the first 3 months of pregnancy."
A pregnant client reports to a health care clinic,
complaining of loss of appetite, weight loss, and
fatigue. After assessment of the client, tuberculosis
is suspected. A sputum culture is obtained and
identifies Mycobacterium tuberculosis. Which
instruction should the nurse include in the client's
teaching plan?
1. Therapeutic abortion is required.
2. She will have to stay at home until treatment is
completed.
3. Medication will not be started until after delivery
of the fetus.
4. Isoniazid plus rifampin (Rifadin) will be required
for 9 months.
4. Isoniazid plus rifampin (Rifadin) will be required
for 9 months.
The nurse is providing instructions to a maternity
client with a history of cardiac disease regarding
appropriate dietary measures. Which statement, if
made by the client, indicates an understanding of
the information provided by the nurse?
1. "I should increase my sodium intake during
pregnancy."
2. "I should lower my blood volume by limiting my
fluids."
3. "I should maintain a low-calorie diet to prevent
any weight gain."
4. "I should drink adequate fluids and increase my
intake of high-fiber foods."
4. "I should drink adequate fluids and increase my
intake of high-fiber foods."
A client in the first trimester of pregnancy arrives at
a health care clinic and reports that she has been
experiencing vaginal bleeding. A threatened
abortion is suspected, and the nurse instructs the
client regarding management of care. Which
statement made by the client indicates a need for
further instruction?
1. "I will watch for the evidence of the passage of
tissue."
2. "I will maintain strict bed rest throughout the
remainder of the pregnancy."
3. "I will count the number of perineal pads used
on a daily basis and note the amount and color of
blood on the pad."
4. "I will avoid sexual intercourse until the bleeding
has stopped, and for 2 weeks following the last
evidence of bleeding."
2. "I will maintain strict bed rest throughout the
remainder of the pregnancy."
The clinic nurse is performing a prenatal
assessment on a pregnant client. The nurse should
plan to implement teaching related to the risk of
abruptio placentae if which information is obtained
on assessment?
1. The client is 28 years of age.
2. This is the second pregnancy.
3. The client has a history of hypertension.
4. The client performs moderate exercise on a
regular daily schedule.
3. The client has a history of hypertension.
During a prenatal visit, a nurse is explaining dietary
management to a client with pre-existing diabetes
mellitus. The nurse determines that teaching has
been effective if the client makes which statement?
1. "Diet and insulin needs change during
pregnancy."
2. "I will plan my diet based on the results of urine
glucose testing."
3. "I will need to eat 600 more calories every day
because I am pregnant."
4. "I can continue with the same diet as before
pregnancy, as long as it is well balanced."
1. "Diet and insulin needs change during
pregnancy."
The clinic nurse has provided home care
instructions to a client with a history of cardiac
disease who has just been told that she is
pregnant. Which statement, if made by the client,
indicates a need for further instructions?
1. "It is best that I rest lying on my side to promote
blood return to the heart."
2. "I need to avoid excessive weight gain to prevent
increased demands on my heart."
3. "I need to try to avoid stressful situations
because stress increases the workload on the
heart."
4. "During the pregnancy, I need to avoid contact
with other individuals as much as possible to
prevent infection."
4. "During the pregnancy, I need to avoid contact
with other individuals as much as possible to
prevent infection."
The nurse is reviewing the record of a pregnant
client seen in the health care clinic for the first
prenatal visit. Which data, if noted on the client's
record, would alert the nurse that the client is at
risk for a spontaneous abortion?
1. Age of 35 years
2. History of syphilis
3. History of genital herpes
4. History of diabetes mellitus
2. History of syphilis
The nurse is preparing to care for a client who is
being admitted to the hospital with a possible
diagnosis of ectopic pregnancy. The nurse develops
a plan of care for the client and determines that
which nursing action is the priority?
1. Checking for edema
2. Monitoring daily weight
3. Monitoring the apical pulse
4. Monitoring the temperature
3. Monitoring the apical pulse
The nurse is reviewing the record of a pregnant
client seen in the health care clinic for the first
prenatal visit. Which data if noted on the client's
record would alert the nurse that the client is at
risk for developing gestational diabetes during this
pregnancy?
1. The client's last baby weighed 10 pounds at
birth.
2. The client's previous deliveries were by cesarean
birth.
3. The client has a family history of cardiovascular
disease.
4. The client is 5 feet 3 inches in height and weighs
165 pounds.
1. The client's last baby weighed 10 pounds at
birth.
The nurse is teaching a diabetic pregnant client
about nutrition and insulin needs during
pregnancy. The nurse determines that the client
understands dietary and insulin needs if the client
states that the second half of pregnancy may
require which treatment?
1. Increased insulin
2. Increased caloric intake
3. Decreased protein intake
4. Decreased insulin
1. Increased insulin
The nurse is assessing a client with a diagnosis of
gestational trophoblastic disease (hydatidiform
mole). The nurse understands that which findings
are associated with this condition? Select all that
apply.
1. Vaginal bleeding
2. Excessive fetal activity
3. Excessive nausea and vomiting
4. Larger-than-normal uterus for gestational age
5. Elevated levels of human chorionic gonadotropin
(hCG)
1. Vaginal bleeding
3. Excessive nausea and vomiting
4. Larger-than-normal uterus for gestational age
5. Elevated levels of human chorionic gonadotropin
(hCG)
A home care nurse is visiting a pregnant client with
a diagnosis of mild preeclampsia. What is the
priority nursing intervention during the home visit?
1. Monitor for fetal movement.
2. Monitor the maternal blood glucose.
3. Instruct the client to maintain complete bed rest.
4. Instruct the client to restrict dietary sodium and
any food items that contain sodium.
1. Monitor for fetal movement.
A maternity unit nurse is developing a plan of care
for a client with severe preeclampsia who will be
admitted to the nursing unit. The nurse should
include which nursing intervention in the plan?
1. Restrict food and fluids.
2. Reduce external stimuli.
3. Monitor blood glucose levels.
4. Maintain the client in a supine position.
2. Reduce external stimuli.
A client with severe preeclampsia is admitted to
the maternity department. Which room
assignment would be most appropriate for this
client?
1. A private room across from the elevator
2. A semiprivate room across from the nurses'
station
3. A private room two doors away from the nurses'
station
4. A semiprivate room with another client who
enjoys watching television
3. A private room two doors away from the nurses'
station
The nurse is counseling a pregnant woman
diagnosed with gestational diabetes at 29 weeks of
gestation. Which information should the nurse
discuss with the client? Select all that apply.
1. Plan induction at 35 weeks.
2. Plan amniocentesis at this time.
3. Schedule biophysical profile immediately.
4. Plan for weekly non-stress test at 32 weeks.
5. Obtain nutritional counseling with a dietitian.
4. Plan for weekly non-stress test at 32 weeks.
5. Obtain nutritional counseling with a dietitian.
The nurse is caring for a client with preeclampsia.
The client is receiving an intravenous (IV) infusion
of magnesium sulfate. When gathering items to be
available for the client, which highest priority item
should the nurse obtain?
1. Tongue blade
2. Percussion hammer
3. Potassium chloride injection
4. Calcium gluconate injection
4. Calcium gluconate injection
A home care nurse is monitoring a 16-year-old
primigravida who is at 36 weeks' gestation and has
gestational hypertension. Her blood pressure
during the past 3 weeks has been averaging in the
130/90 mm Hg range. She has had some swelling in
the lower extremities and has had mild proteinuria.
Which statement by the woman should alert the
nurse to the worsening of gestational
hypertension?
1. "My vision the past 2 days has been really fuzzy."
2. "The swelling in my hands and ankles has gone
down."
3. "I had heartburn yesterday after I ate some spicy
foods."
4. "I had a headache yesterday, but I took some
acetaminophen (Tylenol) and it went away."
1. "My vision the past 2 days has been really fuzzy."
A primigravida is receiving magnesium sulfate for
the treatment of gestational hypertension. The
nurse who is caring for the client is performing
assessments every 30 minutes. Which finding
would be of most concern to the nurse?
1. Urinary output of 20 mL
2. Deep tendon reflexes of 2+
3. Fetal heart rate of 120 beats/min
4. Respiratory rate of 10 breaths per minute
4. Respiratory rate of 10 breaths per minute
The clinic nurse is reviewing the medical record of a
woman scheduled for her weekly prenatal
appointment. The nurse notes that the woman has
been diagnosed with mild preeclampsia. Of the
following interventions, which should the nurse list
as having the lowest priority in planning nursing
care for this client?
1. Assess blood pressure.
2. Discuss the need for hospitalization.
3. Assess deep tendon reflexes and edema.
4. Teach the importance of keeping track of a daily
weight.
2. Discuss the need for hospitalization.
A pregnant woman has a positive history of genital
herpes but has not had lesions during this
pregnancy. What should the nurse should plan to
tell the client?
1. "You will be isolated from your newborn infant
after delivery."
2. "Vaginal deliveries can reduce neonatal infection
risks, even if you have an active lesion at the time."
3. "There is little risk to your newborn infant during
this pregnancy, during the birth, and after
delivery."
4. "You will be evaluated at the time of delivery for
herpetic genital tract lesions, and if any are
present, a cesarean delivery will be needed."
4. "You will be evaluated at the time of delivery for
herpetic genital tract lesions, and if any are
present, a cesarean delivery will be needed."
A 25-year-old woman arrives on the maternity unit
on February 2. She states that her estimated date
of delivery (EDD) is March 22. She is verbalizing
complaints of dull lower back pain, pelvic
heaviness, and diarrhea for the past few days. On
admission for observation, the client's blood
pressure is 128/80 mm Hg, pulse is 100
beats/minute, respirations are 16 breaths per
minute, and temperature is 99° F. The nurse plans
care based on which interpretation?
1. The woman requires further evaluation for
preterm labor.
2. The woman is suffering from an intestinal
bacterial infection.
3. The woman is exhibiting signs and symptoms of
gestational hypertension.
4. The woman needs instruction on pelvic tilts to
decrease her lower back pain.
1. The woman requires further evaluation for
preterm labor.
The nurse in an obstetrical clinic is reviewing
current prenatal laboratory results of a pregnant
client who is being seen for a routine prenatal visit.
The nurse discovers the client's 1-hour oral glucose
tolerance test (OGTT) result to be 163 mg/dL.
Which would be the nurse's best response to the
client?
1. "Your OGTT results indicate that your baby is at
high risk for macrosomia and special considerations
may be necessary at delivery."
2. "Your OGTT results are within normal limits, but
continuing your prenatal visits remains essential to
monitor fetal growth and development."
3. "The OGTT is a screening tool for gestational
diabetes, and you will need further testing to
confirm a diagnosis owing to your results being
elevated."
4. "Your OGTT results indicate that you are positive
for gestational diabetes. You will be scheduled for a
dietitian consultation to plan your daily dietary
intake."
3. "The OGTT is a screening tool for gestational
diabetes, and you will need further testing to
confirm a diagnosis owing to your results being
elevated."
A 35-week-gestation pregnant woman is
transferred to the maternity unit from the
emergency department, where she was treated for
minor injuries sustained in a motor vehicle crash.
The maternal nurse's priority will be to assess for
which complication?
1. Placenta previa
2. Polyhydramnios
3. Abruptio placentae
4. Gestational hypertension
3. Abruptio placentae
A nurse is caring for a client with a diagnosis of
placenta previa. The nurse collects data knowing
that which is a characteristic of placenta previa?
1. A tender and rigid uterus
2. Painless, bright red vaginal bleeding
3. Greenish discoloration of the amniotic fluid
4. Vaginal bleeding accompanied by abdominal
pain
2. Painless, bright red vaginal bleeding
A nurse is assessing a woman in the second
trimester of pregnancy who was admitted to the
maternity unit with a suspected diagnosis of
abruptio placentae. Which finding would the nurse
expect to note if abruptio placentae is present?
1. Soft uterus
2. Abdominal pain
3. Nontender uterus
4. Painless vaginal bleeding
2. Abdominal pain
A woman in the third trimester of pregnancy with a
diagnosis of mild preeclampsia is being monitored
at home. The home care nurse teaches the woman
about the signs that need to be reported to the
health care provider. The nurse should tell the
woman to call the health care provider if which
occurs?
1. Urine tests negative for protein.
2. Fetal movements are more than four per hour.
3. Weight increases by more than 1 pound in a
week.
4. The blood pressure reading is ranging between
122/80 and 132/88 mm Hg.
3. Weight increases by more than 1 pound in a
week.
A nurse implements a teaching plan for a pregnant
client who is newly diagnosed with gestational
diabetes mellitus. Which statement by the client
indicates a need for further teaching?
1. "I need to stay on the diabetic diet."
2. "I will perform glucose monitoring at home."
3. "I cannot exercise because of the negative
effects on insulin production."
4. "I will report signs of infection immediately to
my health care provider."
3. "I cannot exercise because of the negative
effects on insulin production."
A nurse is caring for a pregnant woman who has
herpes genitalis. The nurse provides instructions to
the woman about treatment modalities that may
be necessary for this condition. Which statement
made by the woman indicates an understanding of
these treatment measures?
1. "I do not need to abstain from sexual
intercourse."
2. "I need to use vaginal creams after I douche
every day."
3. "I need to douche and perform a sitz bath three
times a day."
4. "It may be necessary to have a cesarean section
for delivery."
4. "It may be necessary to have a cesarean section
for delivery."
A nurse is reviewing the record of a pregnant client
seen in the health care clinic for the first prenatal
visit. Which data should alert the nurse that the
client is at risk for developing gestational diabetes
during this pregnancy?
1. The client's last baby weighed 10 lb at birth.
2. The client has a family history of type 1 diabetes.
3. The client is 5 feet, 3 inches tall and weighs 165
lb.
4. The client's previous deliveries were by cesarean
section.
1. The client's last baby weighed 10 lb at birth.
A nurse is teaching a diabetic pregnant client about
nutrition and insulin needs during pregnancy. The
nurse determines that the client understands
dietary and insulin needs if the client states that
which may be required during the second half of
pregnancy?
1. Increased insulin
2. Decreased insulin
3. Increased caloric intake
4. Decreased caloric intake
1. Increased insulin
A pregnant client in the last trimester has been
admitted to the hospital with a diagnosis of severe
preeclampsia. A nurse monitors for complications
associated with the diagnosis and assesses the
client for:
1.Any bleeding, such as in the gums, petechiae, and
purpura.
2.Enlargement of the breasts
3.Periods of fetal movement followed by quiet
periods
4.Complaints of feeling hot when the room is cool
1. Severe Preeclampsia can trigger disseminated
intravascular coagulation (DIC; remember the Peds
lecture?) because of the widespread damage to
vascular integrity. Bleeding is an early sign of DIC
and should be reported to the M.D
A homecare nurse visits a pregnant client who has
a diagnosis of mild Preeclampsia and who is being
monitored for pregnancy induced hypertension
(PIH). Which assessment finding indicates a
worsening of the Preeclampsia and the need to
notify the physician?
1.Blood pressure reading is at the prenatal baseline
2.Urinary output has increased
3.The client complains of a headache and blurred
vision
4.Dependent edema has resolved
3. If the client complains of a headache and blurred
vision, the physician should be notified because
these are signs of worsening Preeclampsia.
A primagravida is receiving magnesium sulfate for
the treatment of pregnancy induced hypertension
(PIH). The nurse who is caring for the client is
performing assessments every 30 minutes. Which
assessment finding would be of most concern to
the nurse?
A.Urinary output of 20 ml since the previous
assessment
B.Deep tendon reflexes of 2+
C.Respiratory rate of 10 BPM
D.Fetal heart rate of 120 BPM
C. Magnesium sulfate depresses the respiratory
rate. If the respiratory rate is less than 12 breaths
per minute, the physician or other health care
provider needs to be notified, and continuation of
the medication needs to be reassessed. A urinary
output of 20 ml in a 30 minute period is adequate;
less than 30 ml in one hour needs to be reported.
Deep tendon reflexes of 2+ are normal. The fetal
heart rate is WNL for a resting fetus.
A nurse is caring for a pregnant client with
Preeclampsia. The nurse prepares a plan of care for
the client and documents in the plan that if the
client progresses from Preeclampsia to eclampsia,
the nurse's first action is to:
A.Administer magnesium sulfate intravenously
B.Assess the blood pressure and fetal heart rate
C.Clean and maintain an open airway
D.Administer oxygen by face mask
C. The immediate care during a seizure (eclampsia)
is to ensure a patent airway. The other options are
actions that follow or will be implemented after the
seizure has ceased.
A nurse is monitoring a pregnant client with
pregnancy induced hypertension who is at risk for
Preeclampsia. The nurse checks the client for which
specific signs of Preeclampsia (select all that
apply)?
A.Elevated blood pressure
B.Negative urinary protein
C.Facial edema
D.Increased respirations
A and C. The three classic signs of preeclampsia are
hypertension, generalized edema, and protenuria.
Increased respirations are not a sign of
preeclampsia
A pregnant client is receiving magnesium sulfate
for the management of preeclampsia. A nurse
determines the client is experiencing toxicity from
the medication if which of the following is noted on
assessment?
A.Presence of deep tendon reflexes
B.Serum magnesium level of 6 mEq/L
C.Proteinuria of +3
D.Respirations of 10 per minute
D. Magnesium toxicity can occur from magnesium
sulfate therapy. Signs of toxicity relate to the
central nervous system depressant effects of the
medication and include respiratory depression, loss
of deep tendon reflexes, and a sudden drop in the
fetal heart rate and maternal heart rate and blood
pressure. Therapeutic levels of magnesium are 4-7
mEq/L. Proteinuria of +3 would be noted in a client
with preeclampsia.
A woman with preeclampsia is receiving
magnesium sulfate. The nurse assigned to care for
the client determines that the magnesium therapy
is effective if:
A.Ankle clonus in noted
B.The blood pressure decreases
C.Seizures do not occur
D.Scotoma's are present
C. For a client with preeclampsia, the goal of care is
directed at preventing eclampsia (seizures).
Magnesium sulfate is an anticonvulsant, not an
antihypertensive agent. Although a decrease in
blood pressure may be noted initially, this effect is
usually transient. Ankle clonus indicated
hyperrelexia and may precede the onset of
eclampsia. Scotomas are areas of complete or
partial blindness. Visual disturbances, such as
scotomas, often precede an eclamptic seizure.
nurse is caring for a pregnant client with severe
preeclampsia who is receiving IV magnesium
sulfate. Select all nursing interventions that apply
in the care for the client.
1.Monitor maternal vital signs every 2 hours
2.Notify the physician if respirations are less than
18 per minute.
3.Monitor renal function and cardiac function
closely
4.Keep calcium gluconate on hand in case of a
magnesium sulfate overdose
5.Monitor deep tendon reflexes hourly
6.Monitor I and O's hourly
7.Notify the physician if urinary output is less than
30 ml per hour.
3, 4, 5, 6, and 7. When caring for a client receiving
magnesium sulfate therapy, the nurse would
monitor maternal vital signs, especially
respirations, every 30-60 minutes and notify the
physician if respirations are less than 12, because
this would indicate respiratory depression. Calcium
gluconate is kept on hand in case of magnesium
sulfate overdose, because calcium gluconate is the
antidote for magnesium sulfate toxicity. Deep
tendon reflexes are assessed hourly. Cardiac and
renal function is monitored closely. The urine
output should be maintained at 30 ml per hour
because the medication is eliminated through the
kidneys.
The antagonist for magnesium sulfate should be
readily available to any client receiving IV
magnesium. Which of the following drugs is the
antidote for magnesium toxicity?
A.Calcium gluconate
B.Hydralazine (Apresoline)
C.Narcan
D.RhoGAM
A. Calcium gluconate is the antidote for magnesium
toxicity. Ten ml of 10% calcium gluconate is given
IV push over 3-5 minutes. Hydralazine is given for
sustained elevated blood pressures in preeclamptic
clients.
A client who is 32 weeks pregnant is being
monitored in the antepartum unit for PIH. She
suddenly complains of continuous abdominal pain
and vaginal bleeding. Which of the following
nursing internventions should be included in the
care of this client? Check all that apply
1. Evaluate VS
2. Prepare for vaginal delivery
3. Reassure client that she'll be able to continue
pregnancy
4. Evaluate FHT
5. Monitor amt of vaginal bleed
6. Monitor I&O
1. Evaluate VS
4. Evaluate FHT
5. Monitor amt of vaginal bleed
6. Monitor I&O
The clients Sx indicate that she's experiencing
abruptio placenta.
The nurse must immed eval the moms well being
by eval VS, FWB, by auscultation of heart tones,
monitoring amt of blood loss and eval the vol
status by measuring I&O.
After the severity of the abruption has been
determined and blood and fluid have been
replaced, prompt C-SECTION delivery of the fetus
(not vaginal) is indicated if the fetus is in distress
A home care nurse visits a pregnant client who ad a
diagnosis of mild preeclampsia. Which assessment
finding indicates a worsening of the preeclampsia
and the need to notify the physician?
1. Urinary output as increased
2. Dependent edema has resolved
3. BP reading is at the prenatal baseline
4. The client complains of a headache and blurred
vision.
4. The client complains of a headache and blurred
vision.
A home care nurse is monitoring a pregnant client
with gestational HTN who is at risk for
preeclampsia. At each home care visit, the nurse
assess the client for which classic signs of
preeclampsia? SELECT ALL THAT APPLY.
1. Proteinuria
2. HTN
3. Low grade fever
4. Generalized edema
5. Increased pulse rate
6. Increased respirator rate
1. Proteinuria
2. HTN
4. Generalized edema
A nurse is assessing a pregant client in the 2nd
trimester of pregnancy who was admitted to the
maternity unit with a suspected diagnosis of
abruptio placentae. Which of the following
assessment findings would the nurse expect to
note if this condition is present?
1. Soft abdomen
2. Uterine tenderness
3. Absence of abdominal pain
4. Painless, bright red vaginal bleeding
2. Uterine tenderness
A maternity nurse is preparing for the admission of
a client in the 3rd trimester of pregnancy who is
experiencing vaginal bleeding and has a suspected
diagnosis of placenta previa. The nurse review the
physican's prescriptions and would question which
prescription?
1. Prepare the client for an ultrasound
2. Obtain equipment for a manual pelvic
examination
3. Prepare to draw a hemoglobin and hematocrit
blood sample
4. Obtain equipment for external electronic FHR
monitoring.
2. Obtain equipment for a manual pelvic
examination
An ultrasound is performed on a client at term
gestation who is experiencing moderate vaginal
bleeding. The results of the ultrasound indicate
that abruptio placentae is present. Based on these
findings, the nurse would prepare the client for:
1. Delivery of the fetus
2. Strict monitoring of I/O
3. Complete bedrest for the remainder of the
pregnancy
4. The need for weekly monitoring of coagulation
studies until the time of delivery
1. Delivery of the fetus
A nurse in the postpartum unit is caring for a client
who has just delivered a newborn infant following
a placenta previa. The nurse reviews the plan of
care and prepares to monitor the client for which
risk associated with placenta previa?
1. Infection
2. Hemorrhage
3. Chronic HTN
4. DIC
2. Hemorrhage
A nurse is performing an assessment on a client
diagnosed with placenta previa. Which of these
assessment findings would the nurse expect to
note? SELECT ALL THAT APPLY.
1. Uterine rigidity
2. Uterine tenderness
3. Severe abdominal pain
4. Bright red vaginal bleeding
5. Soft, relaxed, nontender uterus
6. Fundal height may be greater than expected for
gestational age.
4. Bright red vaginal bleeding
5. Soft, relaxed, nontender uterus
6. Fundal height may be greater than expected for
gestational age.
A 32-week gestation client was last seen in the
prenatal clinic at 28 weeks' gestation. Which of the
following changes should the nurse bring to the
attention of the Certified Nurse's Midwife?
1. Weight change from 128 pounds to 132 pounds
2. Pulse changes from 88 bpm to 92 bpm
3. Blood pressure changes from 110/70 to 140/90
4. Respiratory change from 16 rpm to 20 rpm
3. Blood pressure changes from 110/70 to 140/90
A blood pressure elevation to 140/90 is a sign of
mild pre-eclampsia
A client with a 4+ protein and 4+ reflexes is
admitted to the hospital with a diagnosis of severe
preeclampsia. The nurse must closely monitor the
woman for which of the following?
1. High leukocyte count
2. Explosive diarrhea
3. Fractured pelvis
4. Low platelet count
4. Low platelet count
Low platelet count is one of the signs associated
with HELLP syndrome (Hemolysis, Elevated Liver
enzymes, Low Platelets)
Which of the following S&S would the nurse expect
to see in a woman with concealed abruption
placentae?
1. Increasing abdominal girth measurements
2. Profuse vaginal bleeding
3. Bradycardia with an aortic thrill
4. Hypothermia with chills
1. Increasing abdominal girth measurements
The nurse would expect to see increasing
abdominal girth measurements
A patient, 32 weeks pregnant with severe
headache, is admitted to the hospital with
preeclampsia. In addition to obtaining baseline vital
signs and placing the client on bed rest, the
physician ordered the following four items. Which
of the orders should the nurse perform first?
1. Assess deep tendon reflexes.
2. Obtain complete blood count.
3. Assess baseline weight.
4. Obtain routine urinalysis.
1. The nurse should check the client's patellar
reflexes. The most common way to assess the deep
tendon reflexes is-to-assess the patellar reflexes.
Preeclampsia is a very serious complication of
pregnancy. The nurse must assess for changes in
the blood count, for evidence of marked weight
gain, and for changes in the urinalysis. By assessing
the patellar reflexes first, however, the nurse can
make a preliminary assessment of the severity of
the preeclampsia. For example, if the reflexes are
+2, the client would be much less likely to become
eclamptic than a client who has +4 reflexes with
clonus.
When counseling a preeclamptic client about her
diet, what should the nurse encourage the woman
to do?
1. Restrict sodium intake.
2. Increase intake of fluids.
3. Eat a well-balanced diet.
4. Avoid simple sugars.
3. It is important for the client to eat a well-
balanced diet.
Clients with preeclampsia are losing albumin
through their urine. They should eat a well-
balanced diet with sufficient protein to replace the
lost protein. Even though preeclamptic clients are
hypertensive, it is not recommended that they
restrict salt-they should have a normal salt intake-
because during pregnancy the kidney is salt
sparing. When salt is restricted, the kidneys
become stressed.
The nurse is evaluating the effectiveness of bed
rest for a client with mild preeclampsia. Which of
the following signs/symptoms would the nurse
determine is a positive finding?
1. Weight loss.
2. 2+ proteinuria.
3. Decrease in plasma protein.
4. 3 + patellar reflexes.
1. Weight loss is a positive sign.
The key to answering this question is the test
taker's ability to interpret the meaning of mild
preeclampsia and to realize that this is an
evaluation question. There are two levels of
preeclampsia. Mild preeclampsia is characterized
by the following signs/symptoms: blood pressure
140/90, urine protein +2, patellar reflexes + 3, and
weight gain. As can be seen, the values included in
answers 2 and 4 are the same as those in the
diagnosis. They, therefore, are not signs that the
preeclampsia is resolving. Similarly, loss of protein
is not a sign of resolution of the disease.
A 24-week-gravid client is being seen in the
prenatal clinic. She states, "I have had a terrible
headache for the past 2 days." Which of the
following is the most appropriate action for the
nurse to perform next?
1. Inquire whether or not the client has allergies.
2. Take the woman's blood pressure.
3. Assess the woman's fundal height.
4. Ask the woman about stressors at work.
2. The nurse should assess the client's blood
pressure.
Headache is a symptom of preeclampsia.
Preeclampsia, a serious complication, is a
hypertensive disease of pregnancy. In order to
determine whether or not the client is
preeclamptic, the next action by the nurse would
be to assess the woman's blood pressure.
A nurse remarks to a 38-week-gravid client, "It
looks like your face and hands are swollen." The
client responds, "Yes, you're right. Why do you
ask?" The nurse's response is based on the fact
that the changes may be caused by which of the
following?
1. Altered glomerular filtration.
2. Cardiac failure.
3. Hepatic insufficiency.
4. Altered splenic circulation.
1. Altered glomerular filtration leads to protein loss
and, subsequently, to fluid retention, which can
lead to swelling in the face and hands.
The hypertension associated with preeclampsia
results in poor perfusion of the kidneys. When the
kidneys are poorly perfused, the glomerlular
filtration is altered, allowing large molecules, most
notably the protein albumin, to be lost through the
urine. With the loss of protein, the colloidal
pressure drops in the vascular tree, allowing fluid
to third space. The body gets the message to retain
fluids, exacerbating the problem. One of the early
signs of the third spacing is the swelling of a client's
hands and face.
A client has severe preeclampsia. The nurse would
expect the primary health care practitioner to
order tests to assess the fetus for which of the
following?
1. Severe anemia.
2. Hypoprothrombinemia.
3. Craniosynostosis.
4. Intrauterine growth restriction.
4. The fetus should be assessed for intrauterine
growth restriction.
TIP: Perfusion to the placenta drops when clients
are preeclamptic because the client's hypertension
impairs adequate blood flow. When the placenta is
poorly perfused, the baby is poorly nourished.
Without the nourishment provided by the mother
through the umbilical vein, the fetus' growth is
affected.
A client with 4+ protein and 4+ reflexes is admitted
to the hospital with severe preeclampsia. The
nurse must closely monitor the woman for which
of the following?
1. Grand mal seizure.
2. High platelet count.
3. Explosive diarrhea.
4. Fractured pelvis.
1. Clients with severe preeclampsia are high risk for
seizure.
A client who is diagnosed with severe preeclampsia
is high risk for becoming eclamptic. Clients who
become eclamptic have had at least one seizure.
A 26-week-gestation woman is diagnosed with
severe preeclampsia with HELLP syndrome. The
nurse will assess for which of the following
signs/symptoms?
1. Low serum creatinine.
2. High serum protein.
3. Bloody stools.
4. Epigastric pain.
4. Epigastric pain is associated with the liver
involvement of HELLP syndrome. TEST-TAKING TIP:
When the liver is deprived of sufficient blood
supply, as can occur with severe preeclampsia, the
organ becomes ischemic. The client experiences
pain at the site of the liver as a result of the
hypoxia in the liver.
A 29-week-gestation woman diagnosed with severe
preeclampsia is noted to have blood pressure of
170/112, 4+ proteinuria, and a weight gain of 10
pounds over the last 2 days. Which of the following
signs/symptoms would the nurse also expect to
see?
1. Fundal height of 32 cm.
2. Papilledema.
3. Patellar reflexes of +2.
4. Nystagmus.
2. The nurse would expect to see papilledema.
TEST-TAKING TIP: Intracranial pressure (ICP) is
present in a client with severe preeclampsia
because she is third spacing large quantities of
fluid. As a result of the ICP, the optic disk swells
and papilledema is seen when the disk is viewed
through an ophthalmoscope.
A client with mild preeclampsia, who has been
advised to be on bed rest at home, asks why it is
necessary. Which of the following is the best
response for the nurse to give the client?
1. "Bed rest will help you to conserve energy for
your labor."
2. "Bed rest will help to relieve your nausea and
anorexia."
3. "Reclining will increase the amount of oxygen
that your baby gets."
4. "The position change will prevent the placenta
from separating."
3. Bed rest, especially side-lying, helps to improve
perfusion to the placenta.
TEST-TAKING TIP: This question requires the nurse
to have a clear understanding of the pathology of
preeclampsia. Only with an understanding of the
underlying disease, can the test taker be able to
remember the rationale for many aspects of client
care. The vital organs of preeclamptic clients are
being poorly perfused as a result of the abnormally
high blood pressure. When a woman lies on her
side, blood return to the heart is improved and the
cardiac output is also improved. With improved
cardiac output, perfusion to the placenta and other
organs is improved
The nurse has assessed four primigravid clients in
the prenatal clinic. Which of the women would the
nurse refer to the nurse midwife for further
assessment?
1. 10 weeks' gestation, complains of fatigue with
nausea and vomiting.
2. 26 weeks' gestation, complains of ankle edema
and chloasma.
3. 32 weeks' gestation, complains of epigastric pain
and facial edema.
4. 37 weeks' gestation, complains of bleeding gums
and urinary frequency
3. Epigastric pain and facial edema are not normal.
This client should be referred to the nurse midwife.
The nurse must be prepared to identify clients with
symptoms that are unexpected. This question
requires the test taker to differentiate between
normal signs and symptoms of pregnancy at a
variety of gestational ages and those that could
indicate a serious complication of pregnancy.
A client's 32-week clinic assessment was: BP 90/60;
TPR 98.6°F, P 92, R 20; weight 145 lb; and urine
negative for protein. Which of the following
findings at the 34-week appointment should the
nurse highlight for the certified nurse midwife?
1. BP 110/70; TPR 99.2°F, 88, 20.
2. Weight 155 lb; urine protein +2.
3. Urine protein trace; BP 88/56.
4. Weight 147 lb; TPR 99.0°F, 76,
2. There has been a 10-lb weight gain in 2 weeks
and a significant amount of protein is being spilled
in the urine. This client should be brought to the
attention of the primary caregiver.
There is a great deal of information included in this
question. The test taker must methodically assess
each of the pieces of data. Important things to
attend to are the timing of the appointments-2
weeks apart; changes in vital signs-it is normal for
pulse and respiratory rate to increase slightly and
BP to drop slightly; changes in urinary protein-trace
is normal, +2 is not normal; and changes in weight-
2-lb increase over 2 weeks is normal, a 10-lb
increase is not normal.
Which finding should the nurse expect when
assessing a client with placenta previa?
1. Severe occipital headache.
2. History of renal disease.
3. Previous premature delivery.
4. Painless vaginal bleeding.
4. Painless vaginal bleeding is often the only
symptom of placenta previa. There are three
different forms of placenta previa: low-lying
placenta-one that lies adjacent to, but not over,
the internal cervical os; partial-one that partially
covers the internal cervical os; and complete-a
placenta that completely covers the internal
cervical os. There is no way to deliver a live baby
vaginally when a client has a complete previa,
although there are cases when live babies have
been delivered when the clients had low-lying or
partial previas.
A nurse in the labor room is caring for a client in
the active phases of labor. The nurse is assessing
the fetal patterns and notes a late deceleration on
the monitor strip. The most appropriate nursing
action is to:
1.Place the mother in the supine position
2.Document the findings and continue to monitor
the fetal patterns
3.Administer oxygen via face mask
4.Increase the rate of pitocin IV infusion
3. Late decelerations are due to uteroplacental
insufficiency as the result of decreased blood flow
and oxygen to the fetus during the uterine
contractions. This causes hypoxemia; therefore
oxygen is necessary. The supine position is avoided
because it decreases uterine blood flow to the
fetus. The client should be turned to her side to
displace pressure of the gravid uterus on the
inferior vena cava. An intravenous pitocin infusion
is discontinued when a late deceleration is noted.
A nurse is performing an assessment of a client
who is scheduled for a cesarean delivery. Which
assessment finding would indicate a need to
contact the physician?
1.Fetal heart rate of 180 beats per minute
2.White blood cell count of 12,000
3.Maternal pulse rate of 85 beats per minute
4.Hemoglobin of 11.0 g/dL
1. A normal fetal heart rate is 120-160 beats per
minute. A count of 180 beats per minute could
indicate fetal distress and would warrant physician
notification. By full term, a normal maternal
hemoglobin range is 11-13 g/dL as a result of the
hemodilution caused by an increase in plasma
volume during pregnancy.
A nurse is caring for a client in labor who is
receiving Pitocin by IV infusion to stimulate uterine
contractions. Which assessment finding would
indicate to the nurse that the infusion needs to be
discontinued?
1.Three contractions occurring within a 10-minute
period
2.A fetal heart rate of 90 beats per minute
3.Adequate resting tone of the uterus palpated
between contractions
4.Increased urinary output
2. A normal fetal heart rate is 120-160 BPM.
Bradycardia or late or variable decelerations
indicate fetal distress and the need to discontinue
to pitocin. The goal of labor augmentation is to
achieve three good-quality contractions in a 10-
minute period.
A nurse is beginning to care for a client in labor.
The physician has prescribed an IV infusion of
Pitocin. The nurse ensures that which of the
following is implemented before initiating the
infusion?
1.Placing the client on complete bed rest
2.Continuous electronic fetal monitoring
3.An IV infusion of antibiotics
4.Placing a code cart at the client's bedside
2. Continuous electronic fetal monitoring should be
implemented during an IV infusion of Pitocin.
A nurse is caring for a client in labor and is
monitoring the fetal heart rate patterns. The nurse
notes the presence of episodic accelerations on the
electronic fetal monitor tracing. Which of the
following actions is most appropriate?
1.Document the findings and tell the mother that
the monitor indicates fetal well-being
2.Take the mothers vital signs and tell the mother
that bed rest is required to conserve oxygen.
3.Notify the physician or nurse mid-wife of the
findings.
4.Reposition the mother and check the monitor for
changes in the fetal tracing
1. Accelerations are transient increases in the fetal
heart rate that often accompany contractions or
are caused by fetal movement. Episodic
accelerations are thought to be a sign of fetal-well
being and adequate oxygen reserve.
A nurse is admitting a pregnant client to the labor
room and attaches an external electronic fetal
monitor to the client's abdomen. After attachment
of the monitor, the initial nursing assessment is
which of the following?
1.Identifying the types of accelerations
2.Assessing the baseline fetal heart rate
3.Determining the frequency of the contractions
4.Determining the intensity of the contractions
2. Assessing the baseline fetal heart rate is
important so that abnormal variations of the
baseline rate will be identified if they occur.
Options 1 and 3 are important to assess, but not as
the first priority.
A nurse is reviewing the record of a client in the
labor room and notes that the nurse midwife has
documented that the fetus is at -1 station. The
nurse determines that the fetal presenting part is:
1.1 cm above the ischial spine
2.1 fingerbreadth below the symphysis pubis
3.1 inch below the coccyx
4.1 inch below the iliac crest
1. Station is the relationship of the presenting part
to an imaginary line drawn between the ischial
spines, is measured in centimeters, and is noted as
a negative number above the line and a positive
number below the line. At -1 station, the fetal
presenting part is 1 cm above the ischial spines.
A client arrives at a birthing center in active labor.
Her membranes are still intact, and the nurse-
midwife prepares to perform an amniotomy. A
nurse who is assisting the nurse-midwife explains
to the client that after this procedure, she will most
likely have:
1.Less pressure on her cervix
2.Increased efficiency of contractions
3.Decreased number of contractions
4.The need for increased maternal blood pressure
monitoring
2. Amniotomy can be used to induce labor when
the condition of the cervix is favorable (ripe) or to
augment labor if the process begins to slow.
Rupturing of membranes allows the fetal head to
contact the cervix more directly and may increase
the efficiency of contractions.
A nurse is monitoring a client in labor. The nurse
suspects umbilical cord compression if which of the
following is noted on the external monitor tracing
during a contraction?
1.Early decelerations
2.Variable decelerations
3.Late decelerations
4.Short-term variability
2. Variable decelerations occur if the umbilical cord
becomes compressed, thus reducing blood flow
between the placenta and the fetus. Early
decelerations result from pressure on the fetal
head during a contraction. Late decelerations are
an ominous pattern in labor because it suggests
uteroplacental insufficiency during a contraction.
Short-term variability refers to the beat-to-beat
range in the fetal heart rate.
REMEMBER VEAL CHOP
A nurse is assigned to care for a client with
hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the
physician's orders and would expect to note which
of the following prescribed treatments for this
condition?
1.Medication that will provide sedation
2.Increased hydration
3.Oxytocin (Pitocin) infusion
4.Administration of a tocolytic medication
3. Therapeutic management for hypotonic uterine
dysfunction includes oxytocin augmentation and
amniotomy to stimulate a labor that slows.
A nurse in the postpartum unit is caring for a client
who has just delivered a newborn infant following
a pregnancy with placenta previa. The nurse
reviews the plan of care and prepares to monitor
the client for which of the following risks
associated with placenta previa?
1.Disseminated intravascular coagulation
2.Chronic hypertension
3.Infection
4.Hemorrhage
4. Because the placenta is implanted in the lower
uterine segment, which does not contain the same
intertwining musculature as the fundus of the
uterus, this site is more prone to bleeding.
A maternity nurse is preparing for the admission of
a client in the 3rd trimester of pregnancy that is
experiencing vaginal bleeding and has a suspected
diagnosis of placenta previa. The nurse reviews the
physician's orders and would question which
order?
1.Prepare the client for an ultrasound
2.Obtain equipment for external electronic fetal
heart monitoring
3.Obtain equipment for a manual pelvic
examination
4.Prepare to draw a Hgb and Hct blood sample
3. Manual pelvic examinations are contraindicated
when vaginal bleeding is apparent in the 3rd
trimester until a diagnosis is made and placental
previa is ruled out. Digital examination of the cervix
can lead to maternal and fetal hemorrhage. A
diagnosis of placenta previa is made by ultrasound.
The H/H levels are monitored, and external
electronic fetal heart rate monitoring is initiated.
External fetal monitoring is crucial in evaluating the
fetus that is at risk for severe hypoxia
A client is admitted to the birthing suite in early
active labor. The priority nursing intervention on
admission of this client would be:
1.Auscultating the fetal heart
2.Taking an obstetric history
3.Asking the client when she last ate
4.Ascertaining whether the membranes were
ruptured
1. Determining the fetal well-being supersedes all
other measures. If the FHR is absent or persistently
decelerating, immediate intervention is required.
A client who is gravida 1, para 0 is admitted in
labor. Her cervix is 100% effaced, and she is dilated
to 3 cm. Her fetus is at +1 station. The nurse is
aware that the fetus' head is:
1.Not yet engaged
2.Entering the pelvic inlet
3.Below the ischial spines
4.Visible at the vaginal opening
3. A station of +1 indicates that the fetal head is 1
cm below the ischial spines.
The physician asks the nurse the frequency of a
laboring client's contractions. The nurse assesses
the client's contractions by timing from the
beginning of one contraction:
1.Until the time it is completely over
2.To the end of a second contraction
3.To the beginning of the next contraction
4.Until the time that the uterus becomes very firm
3. This is the way to determine the frequency of
the contractions
The nurse observes the client's amniotic fluid and
decides that it appears normal, because it is:
1.Clear and dark amber in color
2.Milky, greenish yellow, containing shreds of
mucus
3.Clear, almost colorless, and containing little white
specks
4.Cloudy, greenish-yellow, and containing little
white specks
3. by 36 weeks' gestation, normal amniotic fluid is
colorless with small particles of vernix caseosa
present.
GREEN=MECONIUM
When examining the fetal monitor strip after
rupture of the membranes in a laboring client, the
nurse notes variable decelerations in the fetal
heart rate. The nurse should:
1.Stop the oxytocin infusion
2.Change the client's position
3.Prepare for immediate delivery
4.Take the client's blood pressure
2. Variable decelerations usually are seen as a
result of cord compression; a change of position
will relieve pressure on the cord.
When monitoring the fetal heart rate of a client in
labor, the nurse identifies an elevation of 15 beats
above the baseline rate of 135 beats per minute
lasting for 15 seconds. This should be documented
as:
1.An acceleration
2.An early elevation
3.A sonographic motion
4.A tachycardic heart rate
1. An acceleration is an abrupt elevation above the
baseline of 15 beats per minute for 15 seconds; if
the acceleration persists for more than 10 minutes
it is considered a change in baseline rate. A
tachycardic FHR is above 160 beats per minute
A laboring client is to have a pudendal block. The
nurse plans to tell the client that once the block is
working she:
A. Will not feel the episiotomy
B. May lose bladder sensation
C. May lose the ability to push
D. Will no longer feel contractions
Answer: A. May lose the ability to push.
A pudendal block provides anesthesia to the
perineum.
A laboring client has external electronic fetal
monitoring in place. Which of the following
assessment data can be determined by examining
the fetal heart rate strip produced by the external
electronic fetal monitor?
A. Gender of the fetus
B. Fetal position
C. Labor progress
D. Oxygenation
Answer: D. Oxygenation.
Oxygenation of the fetus may be indirectly
assessed through fetal monitoring by closely
examining the fetal heart rate strip. Accelerations
in the fetal heart rate strip indicate good
oxygenation, while decelerations in the fetal heart
rate sometimes indicate poor fetal oxygenation.
A laboring client is in the first stage of labor and
has progressed from 4 to 7 cm in cervical dilation.
In which of the following phases of the first stage
does cervical dilation occur most rapidly?
A. Preparatory phase
B. Latent phase
C. Active phase
D. Transition phase
Answer: C. Active phase.
Cervical dilation occurs more rapidly during the
active phase than any of the previous phases. The
active phase is characterized by cervical dilation
that progresses from 4 to 7 cm.
Options A and B: The preparatory, or latent, phase
begins with the onset of regular uterine
contractions and ends when rapid cervical dilation
begins.
Option D: Transition is defined as cervical dilation
beginning at 8 cm and lasting until 10 cm or
complete dilation.
Upon completion of a vaginal examination on a
laboring woman, the nurse records 50%, 6 cm, -1.
Which of the following is a correct interpretation of
the data?
A. Fetal presenting part is 1 cm above the ischial
spines
B. Effacement is 4 cm from completion
C. Dilation is 50% completed
D. Fetus has achieved passage through the ischial
spines
Answer: A. Fetal presenting part is 1 cm above the
ischial spines.
Station of - 1 indicates that the fetal presenting
part is above the ischial spines and has not yet
passed through the pelvic inlet. A station of zero
would indicate that the presenting part has passed
through the inlet and is at the level of the ischial
spines or is engaged.
Options B and C: Progress of effacement is referred
to by percentages with 100% indicating full
effacement and dilation by centimeters (cm) with
10 cm indicating full dilation.
Option D: Passage through the ischial spines with
internal rotation would be indicated by a plus
station, such as + 1.
Late deceleration patterns are noted when
assessing the monitor tracing of a woman whose
labor is being induced with an infusion of Pitocin.
The woman is in a side-lying position, and her vital
signs are stable and fall within a normal range.
Contractions are intense, last 90 seconds, and
occur every 1 1/2 to 2 minutes. The nurse's
immediate action would be to:
A. Change the woman's position
B. Stop the Pitocin
C. Elevate the woman's legs
D. Administer oxygen via a tight mask at 8 to 10
liters/minute
Answer: B. Stop the Pitocin.
Late deceleration patterns noted are most likely
related to alteration in uteroplacental perfusion
associated with the strong contractions described.
The immediate action would be to stop the Pitocin
infusion since Pitocin is an oxytocin which
stimulates the uterus to contract.
Option A: The woman is already in an appropriate
position for uteroplacental perfusion.
Option C: Elevation of her legs would be
appropriate if hypotension were present.
Option D: Oxygen is appropriate but not the
immediate action.
The nurse should realize that the most common
and potentially harmful maternal complication of
epidural anesthesia would be:
A. Severe postpartum headache
B. Limited perception of bladder fullness
C. Increase in respiratory rate
D. Hypotension
Answer: D. Hypotension.
Epidural anesthesia can lead to vasodilation and a
drop in blood pressure that could interfere with
adequate placental perfusion. The woman must be
well hydrated before and during epidural
anesthesia to prevent this problem and maintain
an adequate blood pressure.
Option A: Headache is not a side effect since the
spinal fluid is not disturbed by this anesthetic as it
would be with a low spinal (saddle block)
anesthesia;
Option B is an effect of epidural anesthesia but is
not the most harmful.
Option C: Respiratory depression is a potentially
serious complication.
Four hours after a difficult labor and birth, a
primiparous woman refuses to feed her baby,
stating that she is too tired and just wants to sleep.
The nurse should:
A. Tell the woman she can rest after she feeds her
baby
B. Recognize this as a behavior of the taking-hold
stage
C. Record the behavior as ineffective maternal-
newborn attachment
D. Take the baby back to the nursery, reassuring
the woman that her rest is a priority at this time
Answer: D. Take the baby back to the nursery,
reassuring the woman that her rest is a priority at
this time.
Response 1 does not take into consideration the
need for the new mother to be nurtured and have
her needs met during the taking-in stage. The
behavior described is typical of this stage and not a
reflection of ineffective attachment unless the
behavior persists. Mothers need to reestablish
their own well-being in order to effectively care for
their baby.
A client arrives at a prenatal clinic for the first
prenatal assessment. The client tells a nurse that
the first day of her last menstrual period was
September 19th, 2005. Using Nagele's rule, the
nurse determines the estimated date of
confinement as:
1.July 26, 2006
2.June 12, 2007
3.June 26, 2006
4.July 12, 2007
3. Accurate use of Nagele's rule requires that the
woman have a regular 28-day menstrual cycle. Add
7 days to the first day of the last menstrual period,
subtract three months, and then add one year to
that date.
A nurse is collecting data during an admission
assessment of a client who is pregnant with twins.
The client has a healthy 5-year old child that was
delivered at 36 weeks and tells the nurse that she
doesn't have any history of abortion or fetal
demise. The nurse would document the GTPAL for
this client as:
1.G = 3, T = 2, P = 0, A = 0, L =1
2.G = 2, T = 0, P = 1, A = 0, L =1
3.G = 1, T = 1. P = 1, A = 0, L = 1
4.G = 2, T = 0, P = 0, A = 0, L = 1
2. Pregnancy outcomes can be described with the
acronym GTPAL. G is gravidity, the number of
pregnancies. T is term births, the number born at
term (38-41 weeks). P is preterm births, the
number born before 38 weeks gestation. A is
abortions or miscarriages (included in gravida if
before 20 weeks gestation; included in parity if
past 20 weeks gestation). L is live births, the
number of live births or living children. Therefore, a
woman who is pregnant with twins and has a child
has a gravida of 2. Because the child was delivered
at 36 weeks, the number of preterm births is 1, and
the number of term births is 0. The number of
abortions is 0, and the number of live births is 1.
A nurse is reviewing the record of a client who has
just been told that a pregnancy test is positive. The
physician has documented the presence of a
Goodell's sign. The nurse determines this sign
indicates:
1.A softening of the cervix
2.A soft blowing sound that corresponds to the
maternal pulse during auscultation of the uterus.
3.The presence of hCG in the urine
4.The presence of fetal movement
1. In the early weeks of pregnancy the cervix
becomes softer as a result of increased vascularity
and hyperplasia, which causes the Goodell's sign
A nursing instructor asks a nursing student who is
preparing to assist with the assessment of a
pregnant client to describe the process of
quickening. Which of the following statements if
made by the student indicates an understanding of
this term?
1."It is the irregular, painless contractions that
occur throughout pregnancy."
2."It is the soft blowing sound that can be heard
when the uterus is auscultated."
3."It is the fetal movement that is felt by the
mother."
4."It is the thinning of the lower uterine segment."
3. Quickening is fetal movement and may occur as
early as the 16th and 18th week of gestation, and
the mother first notices subtle fetal movements
that gradually increase in intensity. Braxton Hicks
contractions are irregular, painless contractions
that may occur throughout the pregnancy. A
thinning of the lower uterine segment occurs about
the 6th week of pregnancy and is called Hegar's
sign.
A nurse midwife is performing an assessment of a
pregnant client and is assessing the client for the
presence of ballottement. Which of the following
would the nurse implement to test for the
presence of ballottement?
1.Auscultating for fetal heart sounds
2.Palpating the abdomen for fetal movement
3.Assessing the cervix for thinning
4.Initiating a gentle upward tap on the cervix
4. Ballottement is a technique of palpating a
floating structure by bouncing it gently and feeling
it rebound. In the technique used to palpate the
fetus, the examiner places a finger in the vagina
and taps gently upward, causing the fetus to rise.
The fetus then sinks, and the examiner feels a
gentle tap on the finger.
A nurse is assisting in performing an assessment on
a client who suspects that she is pregnant and is
checking the client for probable signs of pregnancy.
Select all probable signs of pregnancy.
1.Uterine enlargement
2.Fetal heart rate detected by nonelectric device
3.Outline of the fetus via radiography or ultrasound
4.Chadwick's sign
5.Braxton Hicks contractions
6.Ballottement
1, 4, 5, and 6. The probable signs of pregnancy
include uterine enlargement, Hegar's sign
(softening and thinning of the uterine segment that
occurs at week 6), Goodell's sign (softening of the
cervix that occurs at the beginning of the 2nd
month), Chadwick's sign (bluish coloration of the
mucous membranes of the cervix, vagina, and
vulva that occurs at week 6), ballottement
(rebounding of the fetus against the examiners
fingers of palpation), Braxton Hicks contractions
and a positive pregnancy test measuring for hCG.
Positive signs of pregnancy include fetal heart rate
detected by electronic device (Doppler) at 10-12
weeks and by nonelectronic device (fetoscope) at
20 weeks gestation, active fetal movements
palpable by the examiner, and an outline of the
fetus via radiography or ultrasound.
A client in the first trimester of pregnancy arrives at
a health care clinic and reports that she has been
experiencing vaginal bleeding. A threatened
abortion is suspected, and the nurse instructs the
client regarding management of care. Which
statement, if made by the client, indicates a need
for further education?
1."I will maintain strict bedrest throughout the
remainder of pregnancy."
2."I will avoid sexual intercourse until the bleeding
has stopped, and for 2 weeks following the last
evidence of bleeding."
3."I will count the number of perineal pads used on
a daily basis and note the amount and color of
blood on the pad."
4."I will watch for the evidence of the passage of
tissue."
1. Strict bed rest throughout the remainder of
pregnancy is not required. The woman is advised to
curtail sexual activities until the bleeding has
ceased, and for 2 weeks following the last evidence
of bleeding or as recommended by the physician.
The woman is instructed to count the number of
perineal pads used daily and to note the quantity
and color of blood on the pad. The woman also
should watch for the evidence of the passage of
tissue.
A homecare nurse visits a pregnant client who has
a diagnosis of mild Preeclampsia and who is being
monitored for pregnancy induced hypertension
(PIH). Which assessment finding indicates a
worsening of the Preeclampsia and the need to
notify the physician?
1.Blood pressure reading is at the prenatal baseline
2.Urinary output has increased
3.The client complains of a headache and blurred
vision
4.Dependent edema has resolved
3. If the client complains of a headache and blurred
vision, the physician should be notified because
these are signs of worsening Preeclampsia.
3 main symptoms: HEADACHE, BLURRED VISION,
RIGHT EPIGASTRIC PAIN
A nurse implements a teaching plan for a pregnant
client who is newly diagnosed with gestational
diabetes. Which statement if made by the client
indicates a need for further education?
A."I need to stay on the diabetic diet."
B."I will perform glucose monitoring at home."
C."I need to avoid exercise because of the negative
effects of insulin production."
D."I need to be aware of any infections and report
signs of infection immediately to my health care
provider."
C. Exercise is safe for the client with gestational
diabetes and is helpful in lowering the blood
glucose level.
A primagravida is receiving magnesium sulfate for
the treatment of pregnancy induced hypertension
(PIH). The nurse who is caring for the client is
performing assessments every 30 minutes. Which
assessment finding would be of most concern to
the nurse?
A.Urinary output of 20 ml since the previous
assessment
B.Deep tendon reflexes of 2+
C.Respiratory rate of 10 BPM
D.Fetal heart rate of 120 BPM
C. Magnesium sulfate depresses the respiratory
rate. If the respiratory rate is less than 12 breaths
per minute, the physician or other health care
provider needs to be notified, and continuation of
the medication needs to be reassessed. A urinary
output of 20 ml in a 30 minute period is adequate;
less than 30 ml in one hour needs to be reported.
Deep tendon reflexes of 2+ are normal. The fetal
heart rate is WNL for a resting fetus.
A nurse is caring for a pregnant client with
Preeclampsia. The nurse prepares a plan of care for
the client and documents in the plan that if the
client progresses from Preeclampsia to eclampsia,
the nurse's first action is to:
A.Administer magnesium sulfate intravenously
B.Assess the blood pressure and fetal heart rate
C.Clean and maintain an open airway
D.Administer oxygen by face mask
C. The immediate care during a seizure (eclampsia)
is to ensure a patent airway. The other options are
actions that follow or will be implemented after the
seizure has ceased.
A nurse is monitoring a pregnant client with
pregnancy induced hypertension who is at risk for
Preeclampsia. The nurse checks the client for which
specific signs of Preeclampsia (select all that
apply)?
A.Elevated blood pressure
B.Negative urinary protein
C.Facial edema
D.Increased respirations
A and C. The three classic signs of preeclampsia are
hypertension, generalized edema, and protenuria.
Increased respirations are not a sign of
preeclampsia
A woman with preeclampsia is receiving
magnesium sulfate. The nurse assigned to care for
the client determines that the magnesium therapy
is effective if:
A.Ankle clonus in noted
B.The blood pressure decreases
C.Seizures do not occur
D.Scotoma's are present
C. For a client with preeclampsia, the goal of care is
directed at preventing eclampsia (seizures).
Magnesium sulfate is an anticonvulsant, not an
antihypertensive agent. Although a decrease in
blood pressure may be noted initially, this effect is
usually transient. Ankle clonus indicated
hyperrelexia and may precede the onset of
eclampsia. Scotomas are areas of complete or
partial blindness. Visual disturbances, such as
scotomas, often precede an eclamptic seizure.
A nurse is caring for a pregnant client with severe
preeclampsia who is receiving IV magnesium
sulfate. Select all nursing interventions that apply
in the care for the client.
1.Monitor maternal vital signs every 2 hours
2.Notify the physician if respirations are less than
18 per minute.
3.Monitor renal function and cardiac function
closely
4.Keep calcium gluconate on hand in case of a
magnesium sulfate overdose
5.Monitor deep tendon reflexes hourly
6.Monitor I and O's hourly
7.Notify the physician if urinary output is less than
30 ml per hour.
3, 4, 5, 6, and 7. When caring for a client receiving
magnesium sulfate therapy, the nurse would
monitor maternal vital signs, especially
respirations, every 30-60 minutes and notify the
physician if respirations are less than 12, because
this would indicate respiratory depression. Calcium
gluconate is kept on hand in case of magnesium
sulfate overdose, because calcium gluconate is the
antidote for magnesium sulfate toxicity. Deep
tendon reflexes are assessed hourly. Cardiac and
renal function is monitored closely. The urine
output should be maintained at 30 ml per hour
because the medication is eliminated through the
kidneys.
The nurse recognizes that an expected change in
the hematologic system that occurs during the 2nd
trimester of pregnancy is:
A.A decrease in WBC's
B.In increase in hematocrit
C.An increase in blood volume
D.A decrease in sedimentation rate
C. The blood volume increases by approximately
40-50% during pregnancy. The peak blood volume
occurs between 30 and 34 weeks of gestation. The
hematocrit decreases as a result of the increased
blood volume.
The nurse is aware than an adaptation of
pregnancy is an increased blood supply to the
pelvic region that results in a purplish discoloration
of the vaginal mucosa, which is known as:
A.Ladin's sign
B.Hegar's sign
C.Goodell's sign
D.Chadwick's sign
D. A purplish color results from the increased
vascularity and blood vessel engorgement of the
vagina.
A pregnant client is making her first Antepartal
visit. She has a two year old son born at 40 weeks,
a 5 year old daughter born at 38 weeks, and 7 year
old twin daughters born at 35 weeks. She had a
spontaneous abortion 3 years ago at 10 weeks.
Using the GTPAL format, the nurse should identify
that the client is:
A.G4 T3 P2 A1 L4
B.G5 T2 P2 A1 L4
C.G5 T2 P1 A1 L4
D.G4 T3 P1 A1 L4
C. 5 pregnancies; 2 term births; twins count as 1;
one abortion; 4 living children.
An expected cardiopulmonary adaptation
experienced by most pregnant women is:
A.Tachycardia
B.Dyspnea at rest
C.Progression of dependent edema
D.Shortness of breath on exertion
D. This is an expected cardiopulmonary adaptation
during pregnancy; it is caused by an increased
ventricular rate and elevated diaphragm
Nutritional planning for a newly pregnant woman
of average height and weighing 145 pounds should
include:
A.A decrease of 200 calories a day
B.An increase of 300 calories a day
C.An increase of 500 calories a day
D.A maintenance of her present caloric intake per
day
B. This is the recommended caloric increase for
adult women to meet the increased metabolic
demands of pregnancy.
At a prenatal visit at 36 weeks' gestation, a client
complains of discomfort with irregularly occurring
contractions. The nurse instructs the client to:
A.Lie down until they stop
B.Walk around until they subside
C.Time contraction for 30 minutes
D.Take 10 grains of aspirin for the discomfort
B. Ambulation relieves Braxton Hicks.
The nurse teaches a pregnant woman to avoid lying
on her back. The nurse has based this statement on
the knowledge that the supine position can:
A.Unduly prolong labor
B.Cause decreased placental perfusion
C.Lead to transient episodes of hypotension
D.Interfere with free movement of the coccyx
B. This is because impedance of venous return by
the gravid uterus, which causes hypotension and
decreased systemic perfusion.
Which of the following conditions is common in
pregnant women in the 2nd trimester of
pregnancy?
A.Mastitis
B.Metabolic alkalosis
C.Physiologic anemia
D.Respiratory acidosis
C. Hemoglobin and hematocrit levels decrease
during pregnancy as the increase in plasma volume
exceeds the increase in red blood cell production.
A 21-year old client, 6 weeks' pregnant is
diagnosed with hyperemesis gravidarum. This
excessive vomiting during pregnancy will often
result in which of the following conditions?
A.Bowel perforation
B.Electrolyte imbalance
C.Miscarriage
D.Pregnancy induced hypertension (PIH)
B. Excessive vomiting in clients with hyperemesis
gravidarum often causes weight loss and fluid,
electrolyte, and acid-base imbalances.
Clients with gestational diabetes are usually
managed by which of the following therapies?
A.Diet
B.NPH insulin (long-acting)
C.Oral hypoglycemic drugs
D.Oral hypoglycemic drugs and insulin
A. Clients with gestational diabetes are usually
managed by diet alone to control their glucose
intolerance. Oral hypoglycemic agents are
contraindicated in pregnancy. NPH isn't usually
needed for blood glucose control for GDM.
The antagonist for magnesium sulfate should be
readily available to any client receiving IV
magnesium. Which of the following drugs is the
antidote for magnesium toxicity?
A.Calcium gluconate
B.Hydralazine (Apresoline)
C.Narcan
D.RhoGAM
A. Calcium gluconate is the antidote for magnesium
toxicity. Ten ml of 10% calcium gluconate is given
IV push over 3-5 minutes. Hydralazine is given for
sustained elevated blood pressures in preeclamptic
clients.
A pregnant woman at 32 weeks' gestation
complains of feeling dizzy and lightheaded while
her fundal height is being measured. Her skin is
pale and moist. The nurse's initial response would
be to:
A.Assess the woman's blood pressure and pulse
B.Have the woman breathe into a paper bag
C.Raise the woman's legs
D.Turn the woman on her side.
D. During a fundal height measurement the woman
is placed in a supine position. This woman is
experiencing supine hypotension as a result of
uterine compression of the vena cava and
abdominal aorta. Turning her on her side will
remove the compression and restore cardiac
output and blood pressure. Then vital signs can be
assessed. Raising her legs will not solve the
problem since pressure will still remain on the
major abdominal blood vessels, thereby continuing
to impede cardiac output. Breathing into a paper
bag is the solution for dizziness related to
respiratory alkalosis associated with
hyperventilation.
A pregnant woman's last menstrual period began
on April 8, 2005, and ended on April 13. Using
Nägele's rule her estimated date of birth would be:
A.January 15, 2006
B.January 20, 2006
C.July 1, 2006
D.November 5, 2005
A. Nägele's rule requires subtracting 3 months and
adding 7 days and 1 year if appropriate to the first
day of a pregnant woman's last menstrual period.
When this rule, is used with April 8, 2005, the
estimated date of birth is January 15, 2006.
A nurse is caring for a client in labor who is
receiving Pitocin by IV infusion to stimulate uterine
contractions. Which assessment finding would
indicate to the nurse that the infusion needs to be
discontinued?
1.Three contractions occurring within a 10-minute
period
2.A fetal heart rate of 90 beats per minute
3.Adequate resting tone of the uterus palpated
between contractions
4.Increased urinary output
2. A normal fetal heart rate is 120-160 BPM.
Bradycardia or late or variable decelerations
indicate fetal distress and the need to discontinue
to pitocin. The goal of labor augmentation is to
achieve three good-quality contractions in a 10-
minute period.
A nurse is beginning to care for a client in labor.
The physician has prescribed an IV infusion of
Pitocin. The nurse ensures that which of the
following is implemented before initiating the
infusion?
1.Placing the client on complete bed rest
2.Continuous electronic fetal monitoring
3.An IV infusion of antibiotics
4.Placing a code cart at the client's bedside
2. Continuous electronic fetal monitoring should be
implemented during an IV infusion of Pitocin.
A nurse is monitoring a client in active labor and
notes that the client is having contractions every 3
minutes that last 45 seconds. The nurse notes that
the fetal heart rate between contractions is 100
BPM. Which of the following nursing actions is
most appropriate?
1.Encourage the client's coach to continue to
encourage breathing exercises
2.Encourage the client to continue pushing with
each contraction
3.Continue monitoring the fetal heart rate
4.Notify the physician or nurse mid-wife
4. A normal fetal heart rate is 120-160 beats per
minute. Fetal bradycardia between contractions
may indicate the need for immediate medical
management, and the physician or nurse mid-wife
needs to be notified.
A nurse is monitoring a client in labor who is
receiving Pitocin and notes that the client is
experiencing hypertonic uterine contractions. List
in order of priority the actions that the nurse takes.
1.Stop of Pitocin infusion
2.Perform a vaginal examination
3.Reposition the client
4.Check the client's blood pressure and heart rate
5.Administer oxygen by face mask at 8 to 10 L/min
1, 4, 2. 5, 3.
If uterine hypertonicity occurs, the nurse
immediately would intervene to reduce uterine
activity and increase fetal oxygenation. The nurse
would stop the Pitocin infusion and increase the
rate of the nonadditive solution, check maternal BP
for hyper or hypotension, position the woman in a
side-lying position, and administer oxygen by snug
face mask at 8-10 L/min. The nurse then would
attempt to determine the cause of the uterine
hypertonicity and perform a vaginal exam to check
for prolapsed cord
A nurse is assigned to care for a client with
hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the
physician's orders and would expect to note which
of the following prescribed treatments for this
condition?
1.Medication that will provide sedation
2.Increased hydration
3.Oxytocin (Pitocin) infusion
4.Administration of a tocolytic medication
3. Therapeutic management for hypotonic uterine
dysfunction includes oxytocin augmentation and
amniotomy to stimulate a labor that slows.
A nurse in the labor room is preparing to care for a
client with hypertonic uterine dysfunction. The
nurse is told that the client is experiencing
uncoordinated contractions that are erratic in their
frequency, duration, and intensity. The priority
nursing intervention would be to:
1.Monitor the Pitocin infusion closely
2.Provide pain relief measures
3.Prepare the client for an amniotomy
4.Promote ambulation every 30 minutes
2. Management of hypertonic labor depends on
the cause. Relief of pain is the primary intervention
to promote a normal labor pattern.
A nurse is developing a plan of care for a client
experiencing dystocia and includes several nursing
interventions in the plan of care. The nurse
prioritizes the plan of care and selects which of the
following nursing interventions as the highest
priority?
1.Keeping the significant other informed of the
progress of the labor
2.Providing comfort measures
3.Monitoring fetal heart rate
4.Changing the client's position frequently
3. The priority is to monitor the fetal heart rate.
A nurse in the labor room is performing a vaginal
assessment on a pregnant client in labor. The nurse
notes the presence of the umbilical cord protruding
from the vagina. Which of the following would be
the initial nursing action?
1.Place the client in Trendelenburg's position
2.Call the delivery room to notify the staff that the
client will be transported immediately
3.Gently push the cord into the vagina
4.Find the closest telephone and stat page the
physician
1. When cord prolapse occurs, prompt actions are
taken to relieve cord compression and increase
fetal oxygenation. The mother should be
positioned with the hips higher than the head to
shift the fetal presenting part toward the
diaphragm. The nurse should push the call light to
summon help, and other staff members should call
the physician and notify the delivery room. No
attempt should be made to replace the cord. The
examiner, however, may place a gloved hand into
the vagina and hold the presenting part off of the
umbilical cord. Oxygen at 8 to 10 L/min by face
mask is delivered to the mother to increase fetal
oxygenation.
A maternity nurse is caring for a client with
abruptio placenta and is monitoring the client for
disseminated intravascular coagulopathy. Which
assessment finding is least likely to be associated
with disseminated intravascular coagulation?
1.Swelling of the calf in one leg
2.Prolonged clotting times
3.Decreased platelet count
4.Petechiae, oozing from injection sites, and
hematuria
1. DIC is a state of diffuse clotting in which clotting
factors are consumed, leading to widespread
bleeding. Platelets are decreased because they are
consumed by the process; coagulation studies
show no clot formation (and are thus normal to
prolonged); and fibrin plugs may clog the
microvasculature diffusely, rather than in an
isolated area. The presence of petechiae, oozing
from injection sites, and hematuria are signs
associated with DIC. Swelling and pain in the calf of
one leg are more likely to be associated with
thrombophebitis.
A nurse is assessing a pregnant client in the 2nd
trimester of pregnancy who was admitted to the
maternity unit with a suspected diagnosis of
abruptio placentae. Which of the following
assessment findings would the nurse expect to
note if this condition is present?
1.Absence of abdominal pain
2.A soft abdomen
3.Uterine tenderness/pain
4.Painless, bright red vaginal bleeding
3. In abruptio placentae, acute abdominal pain is
present. Uterine tenderness and pain accompanies
placental abruption, especially with a central
abruption and trapped blood behind the placenta.
The abdomen will feel hard and boardlike on
palpation as the blood penetrates the myometrium
and causes uterine irritability. Observation of the
fetal monitoring often reveals increased uterine
resting tone, caused by failure of the uterus to
relax in attempt to constrict blood vessels and
control bleeding.
A maternity nurse is preparing for the admission of
a client in the 3rd trimester of pregnancy that is
experiencing vaginal bleeding and has a suspected
diagnosis of placenta previa. The nurse reviews the
physician's orders and would question which
order?
1.Prepare the client for an ultrasound
2.Obtain equipment for external electronic fetal
heart monitoring
3.Obtain equipment for a manual pelvic
examination
4.Prepare to draw a Hgb and Hct blood sample
3. Manual pelvic examinations are contraindicated
when vaginal bleeding is apparent in the 3rd
trimester until a diagnosis is made and placental
previa is ruled out. Digital examination of the cervix
can lead to maternal and fetal hemorrhage. A
diagnosis of placenta previa is made by ultrasound.
The H/H levels are monitored, and external
electronic fetal heart rate monitoring is initiated.
External fetal monitoring is crucial in evaluating the
fetus that is at risk for severe hypoxia
An ultrasound is performed on a client at term
gestation that is experiencing moderate vaginal
bleeding. The results of the ultrasound indicate
that an abruptio placenta is present. Based on
these findings, the nurse would prepare the client
for:
1.Complete bed rest for the remainder of the
pregnancy
2.Delivery of the fetus
3.Strict monitoring of intake and output
4.The need for weekly monitoring of coagulation
studies until the time of delivery
2. The goal of management in abruptio placentae is
to control the hemorrhage and deliver the fetus as
soon as possible. Delivery is the treatment of
choice if the fetus is at term gestation or if the
bleeding is moderate to severe and the mother or
fetus is in jeopardy.
A nurse in a labor room is assisting with the vaginal
delivery of a newborn infant. The nurse would
monitor the client closely for the risk of uterine
rupture if which of the following occurred?
1.Hypotonic contractions
2.Forceps delivery
3.Schultz delivery
4.Weak bearing down efforts
2. Excessive fundal pressure, forceps delivery,
violent bearing down efforts, tumultuous labor,
and shoulder dystocia can place a woman at risk
for traumatic uterine rupture. Hypotonic
contractions and weak bearing down efforts do not
alone add to the risk of rupture because they do
not add to the stress on the uterine wall.
During the period of induction of labor, a client
should be observed carefully for signs of:
1.Severe pain
2.Uterine tetany
3.Hypoglycemia
4.Umbilical cord prolapse
2. Uterine tetany could result from the use of
oxytocin to induce labor. Because oxytocin
promotes powerful uterine contractions,
uterine tetany may occur. The oxytocin
infusion must be stopped to prevent
uterine rupture and fetal compromise.
The nurse in a maternity unit is reviewing the
clients' records. Which clients should the nurse
identify as being at the most risk for developing
disseminated intravascular coagulation (DIC)?
Select all that apply.
1.A primigravida with mild preeclampsia
2.A primigravida who delivered a 10-lb infant 3
hours ago
3.A gravida II who has just been diagnosed with
dead fetus syndrome
4.A gravida IV who delivered 8 hours ago and has
lost 500 mL of blood
5.A primigravida at 29 weeks of gestation who was
recently diagnosed with severe preeclampsia
3.A gravida II who has just been diagnosed with
dead fetus syndrome
5.A primigravida at 29 weeks of gestation who was
recently diagnosed with severe preeclampsia
Rationale:
In a pregnant client, DIC is a condition in which the
clotting cascade is activated, resulting in the
formation of clots in the microcirculation. Dead
fetus syndrome is considered a risk factor for DIC.
Severe preeclampsia is considered a risk factor for
DIC; a mild case is not. Delivering a large newborn
is not considered a risk factor for DIC. Hemorrhage
is a risk factor for DIC; however, a loss of 500 mL is
not considered hemorrhage.
The nurse is performing an assessment on a
pregnant client in the last trimester with a
diagnosis of severe preeclampsia. The nurse
reviews the assessment findings and determines
that which finding is most closely associated with a
complication of this diagnosis?
1.Enlargement of the breasts
2.Complaints of feeling hot when the room is cool
3.Periods of fetal movement followed by quiet
periods
4.Evidence of bleeding, such as in the gums,
petechiae, and purpura
4.Evidence of bleeding, such as in the gums,
petechiae, and purpura
Rationale:
Severe preeclampsia can trigger disseminated
intravascular coagulation (DIC) because of the
widespread damage to vascular integrity. Bleeding
is an early sign of DIC and should be reported to
the health care provider if noted on assessment.
Options 1, 2, and 3 are normal occurrences in the
last trimester of pregnancy.
The nurse is assessing a pregnant client with type 1
diabetes mellitus about her understanding
regarding changing insulin needs during pregnancy.
The nurse determines that further teaching is
needed if the client makes which statement?
1."I will need to increase my insulin dosage during
the first 3 months of pregnancy."
2."My insulin dose will likely need to be increased
during the second and third trimesters."
3."Episodes of hypoglycemia are more likely to
occur during the first 3 months of pregnancy."
4."My insulin needs should return to prepregnant
levels within 7 to 10 days after birth if I am bottle-
feeding."
1."I will need to increase my insulin dosage during
the first 3 months of pregnancy."
Rationale:
Insulin needs decrease in the first trimester of
pregnancy because of increased insulin production
by the pancreas and increased peripheral
sensitivity to insulin. The statements in options 2,
3, and 4 are accurate and signify that the client
understands control of her diabetes during
pregnancy.
The nurse is performing a prenatal assessment on a
pregnant client. The nurse should plan to
implement teaching related to risk for abruptio
placentae if which information is obtained on
assessment?
1.The client is 28 years of age.
2.This is the second pregnancy.
3.The client has a history of hypertension.
4.The client performs moderate exercise on a
regular daily schedule.
3.The client has a history of hypertension.
Rationale:
Abruptio placentae is the premature separation of
the placenta from the uterine wall after the 20th
week of gestation and before the fetus is delivered.
Abruptio placentae is associated with conditions
characterized by poor uteroplacental circulation,
such as hypertension, smoking, and alcohol or
cocaine abuse. The condition also is associated
with physical and mechanical factors, such as
overdistention of the uterus, which occurs with
multiple gestation or polyhydramnios. In addition,
a short umbilical cord, physical trauma, and
increased maternal age and parity are risk factors.
The nurse is reviewing the record of a pregnant
client seen in the health care clinic for the first
prenatal visit. Which data, if noted on the client's
record, should alert the nurse that the client is at
risk for a spontaneous abortion?
1.Age 35 years
2.History of syphilis
3.History of genital herpes
4.History of diabetes mellitus
2.History of syphilis
Rationale:
Maternal infections such as syphilis, toxoplasmosis,
and rubella are causes of spontaneous abortion.
There is no evidence that genital herpes is a
causative agent in abortion, although the presence
of active lesions at the time of birth presents
concerns. Maternal age greater than 40 years and
diabetes mellitus are considered high-risk factors in
a pregnancy but are related to an increased risk of
congenital malformations, not abortions.
The nurse is preparing to care for a client who is
being admitted to the hospital with a possible
diagnosis of ectopic pregnancy. The nurse develops
a plan of care for the client and determines that
which nursing action is the priority?
1.Checking for edema
2.Monitoring daily weight
3.Monitoring the apical pulse
4.Monitoring the temperature
3.Monitoring the apical pulse
Rationale:
Nursing care for the client with a possible ectopic
pregnancy is focused on preventing or identifying
hypovolemic shock and controlling pain. An
elevated pulse rate is an indicator of shock. Edema
and weight gain are more of a concern for the
client with preeclampsia or gestational
hypertension, and an elevated temperature is an
indicator of infection.
The nurse reviews the assessment history for a
client with a suspected ectopic pregnancy. Which
assessment findings predispose the client to an
ectopic pregnancy? Select all that apply.
1.Use of diaphragm
2.Use of fertility medications
3.History of Chlamydia
4.Use of an intrauterine device
5.History of pelvic inflammatory disease (PID)
2.Use of fertility medications
3.History of Chlamydia
4.Use of an intrauterine device
5.History of pelvic inflammatory disease (PID)
Rationale:
An ectopic pregnancy is one that establishes itself
somewhere other than inside the uterus. Multiple
factors may predispose a woman to an ectopic
pregnancy. Fertility medications, history of sexually
transmitted infections, intrauterine devices, and
PID have all been associated with ectopic
pregnancy. There are no data to support any
additional risk for ectopic pregnancy with the use
of the diaphragm.
The nurse is teaching a pregnant client with
diabetes about nutrition and insulin needs during
pregnancy. The nurse determines that the client
understands dietary and insulin needs if the client
states that the second half of pregnancy may
require which treatment?
1.Increased insulin
2.Decreased insulin
3.Increased caloric intake
4.Decreased protein intake
1.Increased insulin
Rationale:
Glucose crosses the placenta, but insulin does not.
High fetal demands for glucose, combined with the
insulin resistance caused by hormonal changes in
the last half of pregnancy, can result in elevation of
maternal blood glucose levels. This increases the
mother's demand for insulin. This is referred to as
the diabetogenic effect of pregnancy. Caloric and
protein intake is not affected by diabetes.
The nurse is assessing a client with a diagnosis of
gestational trophoblastic disease (hydatidiform
mole). The nurse understands that which findings
are associated with this condition? Select all that
apply.
1.Vaginal bleeding
2.Excessive fetal activity
3.Excessive nausea and vomiting
4.Larger-than-normal uterus for gestational age
5.Elevated levels of human chorionic gonadotropin
(hCG)
1.Vaginal bleeding
3.Excessive nausea and vomiting
4.Larger-than-normal uterus for gestational age
5.Elevated levels of human chorionic gonadotropin
(hCG)
Rationale: The most common findings of
gestational trophoblastic disease (hydatidiform
mole) include vaginal bleeding, excessive nausea
and vomiting, larger-than-normal uterus for
gestational age, elevated levels of hCG, failure to
detect fetal heart activity even with sensitive
instruments, and early development of gestational
hypertension. Fetal activity would not be noted.
The nurse is counseling a pregnant woman
diagnosed with gestational diabetes at 29 weeks'
gestation. Which information should the nurse
discuss with the client? Select all that apply.
1.Plan induction at 35 weeks.
2.Plan amniocentesis at this time.
3.Schedule a biophysical profile immediately.
4.Plan for weekly nonstress tests at 32 weeks.
5.Obtain nutritional counseling with a dietitian.
4.Plan for weekly nonstress tests at 32 weeks.
5.Obtain nutritional counseling with a dietitian.
Rationale:
Gestational diabetes can result in delayed lung
maturity and complications, and carrying the baby
until full term is the goal. The nurse should discuss
nonstress testing procedures, the plan for
nutritional counseling, and the plan for delivery.
Amniocentesis is not indicated at this time.
Biophysical profile is done at 32 to 36 weeks'
gestation.
A 35-week-gestation pregnant woman is
transferred to the maternity unit from the
emergency department, where she was treated for
minor injuries sustained in a motor vehicle crash.
The maternity nurse's priority will be to assess for
which complication?
1.Placenta previa
2.Polyhydramnios
3.Abruptio placentae
4.Gestational hypertension
3.Abruptio placentae
Rationale:
Trauma increases the incidence of miscarriage,
preterm labor, abruptio placentae, and stillbirth.
Careful evaluation of mother and fetus after any
incident of trauma is essential. Placenta previa
indicates that a placenta is implanted in the lower
uterine segment near or over the internal cervical
os. Risk factors that may precipitate placenta
previa are not related to a traumatic event.
Polyhydramnios is a term for excessive amniotic
fluid, which would develop over time and not be a
result of trauma. Although a motor vehicle crash
may increase a woman's blood pressure, she would
not be a candidate for gestational hypertension
only because of the traumatic event.
The nurse is caring for a client with a diagnosis of
placenta previa. The nurse collects data knowing
that which are characteristic of placenta previa?
Select all that apply.
1.A tender and rigid uterus
2.Painless, bright red vaginal bleeding
3.Location in the lower uterine segment
4.Greenish discoloration of the amniotic fluid
5.Vaginal bleeding accompanied by abdominal pain
2.Painless, bright red vaginal bleeding
3.Location in the lower uterine segment
Rationale:
Placenta previa is a condition in which the placenta
is located in the lower uterine segment. It does not
cause pain but does cause bright red vaginal
bleeding. This occurs because the placenta is
overriding the cervical os, and as the cervix dilates
the placental vessels bleed. Abruptio placenta is
painful and results in a rigid and tender uterus.
Greenish discoloration of the amniotic fluid occurs
as a result of meconium staining.

1. A nurse is caring for a client in labor. The nurse
determines that the client is beginning in the 2nd
stage of labor when which of the following
assessments is noted?
1. The client begins to expel clear vaginal fluid
2. The contractions are regular
3. The membranes have ruptured
4. The cervix is dilated completely
4. The second stage of labor begins when the cervix
is dilated completely and ends with the birth of the
neonate.
2. A nurse in the labor room is caring for a client in
the active phases of labor. The nurse is assessing
the fetal patterns and notes a late deceleration on
the monitor strip. The most appropriate nursing
action is to:
1. Place the mother in the supine position
2. Document the findings and continue to monitor
the fetal patterns
3. Administer oxygen via face mask
4. Increase the rate of pitocin IV infusion
3. Late decelerations are due to uteroplacental
insufficiency as the result of decreased blood flow
and oxygen to the fetus during the uterine
contractions. This causes hypoxemia; therefore
oxygen is necessary. The supine position is avoided
because it decreases uterine blood flow to the
fetus. The client should be turned to her side to
displace pressure of the gravid uterus on the
inferior vena cava. An intravenous pitocin infusion
is discontinued when a late deceleration is noted.
3. A nurse is performing an assessment of a client
who is scheduled for a cesarean delivery. Which
assessment finding would indicate a need to
contact the physician?
1. Fetal heart rate of 180 beats per minute
2. White blood cell count of 12,000
3. Maternal pulse rate of 85 beats per minute
4. Hemoglobin of 11.0 g/dL
1. A normal fetal heart rate is 120-160 beats per
minute. A count of 180 beats per minute could
indicate fetal distress and would warrant physician
notification. By full term, a normal maternal
hemoglobin range is 11-13 g/dL as a result of the
hemodilution caused by an increase in plasma
volume during pregnancy.
4. A client in labor is transported to the delivery
room and is prepared for a cesarean delivery. The
client is transferred to the delivery room table, and
the nurse places the client in the:
1. Trendelenburg's position with the legs in stirrups
2. Semi-Fowler position with a pillow under the
knees
3. Prone position with the legs separated and
elevated
4. Supine position with a wedge under the right hip
4. Vena cava and descending aorta compression by
the pregnant uterus impedes blood return from the
lower trunk and extremities. This leads to
decreasing cardiac return, cardiac output, and
blood flow to the uterus and the fetus. The best
position to prevent this would be side-lying with
the uterus displaced off of abdominal vessels.
Positioning for abdominal surgery necessitates a
supine position; however, a wedge placed under
the right hip provides displacement of the uterus.
5. A nurse is caring for a client in labor and
prepares to auscultate the fetal heart rate by using
a Doppler ultrasound device. The nurse most
accurately determines that the fetal heart sounds
are heard by:
1. Noting if the heart rate is greater than 140 BPM
2. Placing the diaphragm of the Doppler on the
mother abdomen
3. Performing Leopold's maneuvers first to
determine the location of the fetal heart
4. Palpating the maternal radial pulse while
listening to the fetal heart rate
4. The nurse simultaneously should palpate the
maternal radial or carotid pulse and auscultate the
fetal heart rate to differentiate the two. If the fetal
and maternal heart rates are similar, the nurse may
mistake the maternal heart rate for the fetal heart
rate. Leopold's maneuvers may help the examiner
locate the position of the fetus but will not ensure
a distinction between the two rates.
6. A nurse is caring for a client in labor who is
receiving Pitocin by IV infusion to stimulate uterine
contractions. Which assessment finding would
indicate to the nurse that the infusion needs to be
discontinued?
1. Three contractions occurring within a 10-minute
period
2. A fetal heart rate of 90 beats per minute
3. Adequate resting tone of the uterus palpated
between contractions
4. Increased urinary output
2. A normal fetal heart rate is 120-160 BPM.
Bradycardia or late or variable decelerations
indicate fetal distress and the need to discontinue
to pitocin. The goal of labor augmentation is to
achieve three good-quality contractions in a 10-
minute period.
7. A nurse is beginning to care for a client in labor.
The physician has prescribed an IV infusion of
Pitocin. The nurse ensures that which of the
following is implemented before initiating the
infusion?
1. Placing the client on complete bed rest
2. Continuous electronic fetal monitoring
3. An IV infusion of antibiotics
4. Placing a code cart at the client's bedside
2. Continuous electronic fetal monitoring should be
implemented during an IV infusion of Pitocin.
8. A nurse is monitoring a client in active labor and
notes that the client is having contractions every 3
minutes that last 45 seconds. The nurse notes that
the fetal heart rate between contractions is 100
BPM. Which of the following nursing actions is
most appropriate?
1. Encourage the client's coach to continue to
encourage breathing exercises
2. Encourage the client to continue pushing with
each contraction
3. Continue monitoring the fetal heart rate
4. Notify the physician or nurse mid-wife
4. A normal fetal heart rate is 120-160 beats per
minute. Fetal bradycardia between contractions
may indicate the need for immediate medical
management, and the physician or nurse mid-wife
needs to be notified.
9. A nurse is caring for a client in labor and is
monitoring the fetal heart rate patterns. The nurse
notes the presence of episodic accelerations on the
electronic fetal monitor tracing. Which of the
following actions is most appropriate?
1. Document the findings and tell the mother that
the monitor indicates fetal well-being
2. Take the mothers vital signs and tell the mother
that bed rest is required to conserve oxygen.
3. Notify the physician or nurse mid-wife of the
findings.
4. Reposition the mother and check the monitor for
changes in the fetal tracing
1. Accelerations are transient increases in the fetal
heart rate that often accompany contractions or
are caused by fetal movement. Episodic
accelerations are thought to be a sign of fetal-well
being and adequate oxygen reserve.
10. A nurse is admitting a pregnant client to the
labor room and attaches an external electronic
fetal monitor to the client's abdomen. After
attachment of the monitor, the initial nursing
assessment is which of the following?
1. Identifying the types of accelerations
2. Assessing the baseline fetal heart rate
3. Determining the frequency of the contractions
4. Determining the intensity of the contractions
2. Assessing the baseline fetal heart rate is
important so that abnormal variations of the
baseline rate will be identified if they occur.
Options 1 and 3 are important to assess, but not as
the first priority.
11. A nurse is reviewing the record of a client in the
labor room and notes that the nurse midwife has
documented that the fetus is at -1 station. The
nurse determines that the fetal presenting part is:
1. 1 cm above the ischial spine
2. 1 fingerbreadth below the symphysis pubis
3. 1 inch below the coccyx
4. 1 inch below the iliac crest
1. Station is the relationship of the presenting part
to an imaginary line drawn between the ischial
spines, is measured in centimeters, and is noted as
a negative number above the line and a positive
number below the line. At -1 station, the fetal
presenting part is 1 cm above the ischial spines.
12. A pregnant client is admitted to the labor room.
An assessment is performed, and the nurse notes
that the client's hemoglobin and hematocrit levels
are low, indicating anemia. The nurse determines
that the client is at risk for which of the following?
1. A loud mouth
2. Low self-esteem
3. Hemorrhage
4. Postpartum infections
4. Anemic women have a greater likelihood of
cardiac decompensation during labor, postpartum
infection, and poor wound healing. Anemia does
not specifically present a risk for hemorrhage.
Having a loud mouth is only related to the person
typing up this test.
13. A nurse assists in the vaginal delivery of a
newborn infant. After the delivery, the nurse
observes the umbilical cord lengthen and a spurt of
blood from the vagina. The nurse documents these
observations as signs of:
1. Hematoma
2. Placenta previa
3. Uterine atony
4. Placental separation
4. As the placenta separates, it settles downward
into the lower uterine segment. The umbilical cord
lengthens, and a sudden trickle or spurt of blood
appears.
14. A client arrives at a birthing center in active
labor. Her membranes are still intact, and the
nurse-midwife prepares to perform an amniotomy.
A nurse who is assisting the nurse-midwife explains
to the client that after this procedure, she will most
likely have:
1. Less pressure on her cervix
2. Increased efficiency of contractions
3. Decreased number of contractions
4. The need for increased maternal blood pressure
monitoring
2. Amniotomy can be used to induce labor when
the condition of the cervix is favorable (ripe) or to
augment labor if the process begins to slow.
Rupturing of membranes allows the fetal head to
contact the cervix more directly and may increase
the efficiency of contractions.
15. A nurse is monitoring a client in labor. The
nurse suspects umbilical cord compression if which
of the following is noted on the external monitor
tracing during a contraction?
1. Early decelerations
2. Variable decelerations
3. Late decelerations
4. Short-term variability
2. Variable decelerations occur if the umbilical cord
becomes compressed, thus reducing blood flow
between the placenta and the fetus. Early
decelerations result from pressure on the fetal
head during a contraction. Late decelerations are
an ominous pattern in labor because it suggests
uteroplacental insufficiency during a contraction.
Short-term variability refers to the beat-to-beat
range in the fetal heart rate.
16. A nurse explains the purpose of effleurage to a
client in early labor. The nurse tells the client that
effleurage is:
1. A form of biofeedback to enhance bearing down
efforts during delivery
2. Light stroking of the abdomen to facilitate
relaxation during labor and provide tactile
stimulation to the fetus
3. The application of pressure to the sacrum to
relieve a backache
4. Performed to stimulate uterine activity by
contracting a specific muscle group while other
parts of the body rest
. 2. Effleurage is a specific type of cutaneous
stimulation involving light stroking of the abdomen
and is used before transition to promote relaxation
and relieve mild to moderate pain. Effleurage
provides tactile stimulation to the fetus.
17. A nurse is caring for a client in the second stage
of labor. The client is experiencing uterine
contractions every 2 minutes and cries out in pain
with each contraction. The nurse recognizes this
behavior as:
1. Exhaustion
2. Fear of losing control
3. Involuntary grunting
4. Valsalva's maneuver
2. Pains, helplessness, panicking, and fear of losing
control are possible behaviors in the 2nd stage of
labor.
18. A nurse is monitoring a client in labor who is
receiving Pitocin and notes that the client is
experiencing hypertonic uterine contractions. List
in order of priority the actions that the nurse takes.
1. Stop of Pitocin infusion
2. Perform a vaginal examination
3. Reposition the client
4. Check the client's blood pressure and heart rate
5. Administer oxygen by face mask at 8 to 10 L/min
1, 4, 2. 5, 3. If uterine hypertonicity occurs, the
nurse immediately would intervene to reduce
uterine activity and increase fetal oxygenation. The
nurse would stop the Pitocin infusion and increase
the rate of the nonadditive solution, check
maternal BP for hyper or hypotension, position the
woman in a side-lying position, and administer
oxygen by snug face mask at 8-10 L/min. The nurse
then would attempt to determine the cause of the
uterine hypertonicity and perform a vaginal exam
to check for prolapsed cord.
19. A nurse is assigned to care for a client with
hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the
physician's orders and would expect to note which
of the following prescribed treatments for this
condition?
1. Medication that will provide sedation
2. Increased hydration
3. Oxytocin (Pitocin) infusion
4. Administration of a tocolytic medication
3. Therapeutic management for hypotonic uterine
dysfunction includes oxytocin augmentation and
amniotomy to stimulate a labor that slows.
20. A nurse in the labor room is preparing to care
for a client with hypertonic uterine dysfunction.
The nurse is told that the client is experiencing
uncoordinated contractions that are erratic in their
frequency, duration, and intensity. The priority
nursing intervention would be to:
1. Monitor the Pitocin infusion closely
2. Provide pain relief measures
3. Prepare the client for an amniotomy
4. Promote ambulation every 30 minutes
2. Management of hypertonic labor depends on
the cause. Relief of pain is the primary intervention
to promote a normal labor pattern.
21. A nurse is developing a plan of care for a client
experiencing dystocia and includes several nursing
interventions in the plan of care. The nurse
prioritizes the plan of care and selects which of the
following nursing interventions as the highest
priority?
1. Keeping the significant other informed of the
progress of the labor
2. Providing comfort measures
3. Monitoring fetal heart rate
4. Changing the client's position frequently
3. The priority is to monitor the fetal heart rate.
22. A maternity nurse is preparing to care for a
pregnant client in labor who will be delivering
twins. The nurse monitors the fetal heart rates by
placing the external fetal monitor:
1. Over the fetus that is most anterior to the
mothers abdomen
2. Over the fetus that is most posterior to the
mothers abdomen
3. So that each fetal heart rate is monitored
separately
4. So that one fetus is monitored for a 15-minute
period followed by a 15 minute fetal monitoring
period for the second fetus
. 3. In a client with a multi-fetal pregnancy, each
fetal heart rate is monitored separately.
23. A nurse in the postpartum unit is caring for a
client who has just delivered a newborn infant
following a pregnancy with placenta previa. The
nurse reviews the plan of care and prepares to
monitor the client for which of the following risks
associated with placenta previa?
1. Disseminated intravascular coagulation
2. Chronic hypertension
3. Infection
4. Hemorrhage
4. Because the placenta is implanted in the lower
uterine segment, which does not contain the same
intertwining musculature as the fundus of the
uterus, this site is more prone to bleeding.
24. A nurse in the delivery room is assisting with
the delivery of a newborn infant. After the delivery
of the newborn, the nurse assists in delivering the
placenta. Which observation would indicate that
the placenta has separated from the uterine wall
and is ready for delivery?
1. The umbilical cord shortens in length and
changes in color
2. A soft and boggy uterus
3. Maternal complaints of severe uterine cramping
4. Changes in the shape of the uterus
4. Signs of placental separation include lengthening
of the umbilical cord, a sudden gush of dark blood
from the introitus (vagina), a firmly contracted
uterus, and the uterus changing from a discoid (like
a disk) to a globular (like a globe) shape. The client
may experience vaginal fullness, but not severe
uterine cramping. I am going to look more into this
answer. According to our book on page 584, this is
not one of our options.
25. A nurse in the labor room is performing a
vaginal assessment on a pregnant client in labor.
The nurse notes the presence of the umbilical cord
protruding from the vagina. Which of the following
would be the initial nursing action?
1. Place the client in Trendelenburg's position
2. Call the delivery room to notify the staff that the
client will be transported immediately
3. Gently push the cord into the vagina
4. Find the closest telephone and stat page the
physician
1. When cord prolapse occurs, prompt actions are
taken to relieve cord compression and increase
fetal oxygenation. The mother should be
positioned with the hips higher than the head to
shift the fetal presenting part toward the
diaphragm. The nurse should push the call light to
summon help, and other staff members should call
the physician and notify the delivery room. No
attempt should be made to replace the cord. The
examiner, however, may place a gloved hand into
the vagina and hold the presenting part off of the
umbilical cord. Oxygen at 8 to 10 L/min by face
mask is delivered to the mother to increase fetal
oxygenation.
26. A maternity nurse is caring for a client with
abruptio placenta and is monitoring the client for
disseminated intravascular coagulopathy. Which
assessment finding is least likely to be associated
with disseminated intravascular coagulation?
1. Swelling of the calf in one leg
2. Prolonged clotting times
3. Decreased platelet count
4. Petechiae, oozing from injection sites, and
hematuria
1. DIC is a state of diffuse clotting in which clotting
factors are consumed, leading to widespread
bleeding. Platelets are decreased because they are
consumed by the process; coagulation studies
show no clot formation (and are thus normal to
prolonged); and fibrin plugs may clog the
microvasculature diffusely, rather than in an
isolated area. The presence of petechiae, oozing
from injection sites, and hematuria are signs
associated with DIC. Swelling and pain in the calf of
one leg are more likely to be associated with
thrombophebitis.
27. A nurse is assessing a pregnant client in the 2nd
trimester of pregnancy who was admitted to the
maternity unit with a suspected diagnosis of
abruptio placentae. Which of the following
assessment findings would the nurse expect to
note if this condition is present?
1. Absence of abdominal pain
2. A soft abdomen
3. Uterine tenderness/pain
4. Painless, bright red vaginal bleeding
3. In abruptio placentae, acute abdominal pain is
present. Uterine tenderness and pain accompanies
placental abruption, especially with a central
abruption and trapped blood behind the placenta.
The abdomen will feel hard and boardlike on
palpation as the blood penetrates the myometrium
and causes uterine irritability. Observation of the
fetal monitoring often reveals increased uterine
resting tone, caused by failure of the uterus to
relax in attempt to constrict blood vessels and
control bleeding.
28. A maternity nurse is preparing for the
admission of a client in the 3rd trimester of
pregnancy that is experiencing vaginal bleeding and
has a suspected diagnosis of placenta previa. The
nurse reviews the physician's orders and would
question which order?
1. Prepare the client for an ultrasound
2. Obtain equipment for external electronic fetal
heart monitoring
3. Obtain equipment for a manual pelvic
examination
4. Prepare to draw a Hgb and Hct blood sample
3. Manual pelvic examinations are contraindicated
when vaginal bleeding is apparent in the 3rd
trimester until a diagnosis is made and placental
previa is ruled out. Digital examination of the cervix
can lead to maternal and fetal hemorrhage. A
diagnosis of placenta previa is made by ultrasound.
The H/H levels are monitored, and external
electronic fetal heart rate monitoring is initiated.
External fetal monitoring is crucial in evaluating the
fetus that is at risk for severe hypoxia.
29. An ultrasound is performed on a client at term
gestation that is experiencing moderate vaginal
bleeding. The results of the ultrasound indicate
that an abruptio placenta is present. Based on
these findings, the nurse would prepare the client
for:
1. Complete bed rest for the remainder of the
pregnancy
2. Delivery of the fetus
3. Strict monitoring of intake and output
4. The need for weekly monitoring of coagulation
studies until the time of delivery
2. The goal of management in abruptio placentae is
to control the hemorrhage and deliver the fetus as
soon as possible. Delivery is the treatment of
choice if the fetus is at term gestation or if the
bleeding is moderate to severe and the mother or
fetus is in jeopardy.
30. A nurse in a labor room is assisting with the
vaginal delivery of a newborn infant. The nurse
would monitor the client closely for the risk of
uterine rupture if which of the following occurred?
1. Hypotonic contractions
2. Forceps delivery
3. Schultz delivery
4. Weak bearing down efforts
2. Excessive fundal pressure, forceps delivery,
violent bearing down efforts, tumultuous labor,
and shoulder dystocia can place a woman at risk
for traumatic uterine rupture. Hypotonic
contractions and weak bearing down efforts do not
alone add to the risk of rupture because they do
not add to the stress on the uterine wall.
31. A client is admitted to the birthing suite in early
active labor. The priority nursing intervention on
admission of this client would be:
1. Auscultating the fetal heart
2. Taking an obstetric history
3. Asking the client when she last ate
4. Ascertaining whether the membranes were
ruptured
1. Determining the fetal well-being supersedes all
other measures. If the FHR is absent or persistently
decelerating, immediate intervention is required.
32. A client who is gravida 1, para 0 is admitted in
labor. Her cervix is 100% effaced, and she is dilated
to 3 cm. Her fetus is at +1 station. The nurse is
aware that the fetus' head is:
1. Not yet engaged
2. Entering the pelvic inlet
3. Below the ischial spines
4. Visible at the vaginal opening
3. A station of +1 indicates that the fetal head is 1
cm below the ischial spines.
33. After doing Leopold's maneuvers, the nurse
determines that the fetus is in the ROP position. To
best auscultate the fetal heart tones, the Doppler is
placed:
1. Above the umbilicus at the midline
2. Above the umbilicus on the left side
3. Below the umbilicus on the right side
4. Below the umbilicus near the left groin
3. Fetal heart tones are best auscultated through
the fetal back; because the position is ROP (right
occiput presenting), the back would be below the
umbilicus and on the right side.
34. The physician asks the nurse the frequency of a
laboring client's contractions. The nurse assesses
the client's contractions by timing from the
beginning of one contraction:
1. Until the time it is completely over
2. To the end of a second contraction
3. To the beginning of the next contraction
4. Until the time that the uterus becomes very firm
3. This is the way to determine the frequency of
the contractions
35. The nurse observes the client's amniotic fluid
and decides that it appears normal, because it is:
1. Clear and dark amber in color
2. Milky, greenish yellow, containing shreds of
mucus
3. Clear, almost colorless, and containing little
white specks
4. Cloudy, greenish-yellow, and containing little
white specks
3. by 36 weeks' gestation, normal amniotic fluid is
colorless with small particles of vernix caseosa
present.
36. At 38 weeks' gestation, a client is having late
decelerations. The fetal pulse oximeter shows 75%
to 85%. The nurse should:
1. Discontinue the catheter, if the reading is not
above 80%
2. Discontinue the catheter, if the reading does not
go below 30%
3. Advance the catheter until the reading is above
90% and continue monitoring
4. Reposition the catheter, recheck the reading,
and if it is 55%, keep monitoring
. 4. Adjusting the catheter would be indicated.
Normal fetal pulse oximetry should be between
30% and 70%. 75% to 85% would indicate maternal
readings.
37. When examining the fetal monitor strip after
rupture of the membranes in a laboring client, the
nurse notes variable decelerations in the fetal
heart rate. The nurse should:
1. Stop the oxytocin infusion
2. Change the client's position
3. Prepare for immediate delivery
4. Take the client's blood pressure
2. Variable decelerations usually are seen as a
result of cord compression; a change of position
will relieve pressure on the cord.
38. When monitoring the fetal heart rate of a client
in labor, the nurse identifies an elevation of 15
beats above the baseline rate of 135 beats per
minute lasting for 15 seconds. This should be
documented as:
1. An acceleration
2. An early elevation
3. A sonographic motion
4. A tachycardic heart rate
1. An acceleration is an abrupt elevation above the
baseline of 15 beats per minute for 15 seconds; if
the acceleration persists for more than 10 minutes
it is considered a change in baseline rate. A
tachycardic FHR is above 160 beats per minute.
39. A laboring client complains of low back pain.
The nurse replies that this pain occurs most when
the position of the fetus is:
1. Breech
2. Transverse
3. Occiput anterior
4. Occiput posterior
4. A persistent occiput-posterior position causes
intense back pain because of fetal compression of
the sacral nerves. Occiput anterior is the most
common fetal position and does not cause back
pain.
40. The breathing technique that the mother
should be instructed to use as the fetus' head is
crowning is:
1. Blowing
2. Slow chest
3. Shallow
4. Accelerated-decelerated
1. Blowing forcefully through the mouth controls
the strong urge to push and allows for a more
controlled birth of the head.
41. During the period of induction of labor, a client
should be observed carefully for signs of:
1. Severe pain
2. Uterine tetany
3. Hypoglycemia
4. Umbilical cord prolapse
2. Uterine tetany could result from the use of
oxytocin to induce labor. Because oxytocin
promotes powerful uterine contractions, uterine
tetany may occur. The oxytocin infusion must be
stopped to prevent uterine rupture and fetal
compromise.
42. A client arrives at the hospital in the second
stage of labor. The fetus' head is crowning, the
client is bearing down, and the birth appears
imminent. The nurse should:

1. Transfer her immediately by stretcher to the
birthing unit
2. Tell her to breathe through her mouth and not
to bear down
3. Instruct the client to pant during contractions
and to breathe through her mouth
4. Support the perineum with the hand to prevent
tearing and tell the client to pant
4. Gentle pressure is applied to the baby's head as
it emerges so it is not born too rapidly. The head is
never held back, and it should be supported as it
emerges so there will be no vaginal lacerations. It is
impossible to push and pant at the same time.
43. A laboring client is to have a pudendal block.
The nurse plans to tell the client that once the
block is working she:
1. Will not feel the episiotomy
2. May lose bladder sensation
3. May lose the ability to push
4. Will no longer feel contractions
1. A pudendal block provides anesthesia to the
perineum.
44. Which of the following observations indicates
fetal distress?
1. Fetal scalp pH of 7.14
2. Fetal heart rate of 144 beats/minute
3. Acceleration of fetal heart rate with contractions
4. Presence of long term variability
1. A fetal scalp pH below 7.25 indicates acidosis
and fetal hypoxia.
45. Which of the following fetal positions is most
favorable for birth?
1. Vertex presentation
2. Transverse lie
3. Frank breech presentation
4. Posterior position of the fetal head
1. Vertex presentation (flexion of the fetal head) is
the optimal presentation for passage through the
birth canal. Transverse lie is an unacceptable fetal
position for vaginal birth and requires a C-section.
Frank breech presentation, in which the buttocks
present first, can be a difficult vaginal delivery.
Posterior positioning of the fetal head can make it
difficult for the fetal head to pass under the
maternal symphysis pubis.
46. A laboring client has external electronic fetal
monitoring in place. Which of the following
assessment data can be determined by examining
the fetal heart rate strip produced by the external
electronic fetal monitor?
1. Gender of the fetus
2. Fetal position
3. Labor progress
4. Oxygenation
4. Oxygenation of the fetus may be indirectly
assessed through fetal monitoring by closely
examining the fetal heart rate strip. Accelerations
in the fetal heart rate strip indicate good
oxygenation, while decelerations in the fetal heart
rate sometimes indicate poor fetal oxygenation.
47. A laboring client is in the first stage of labor and
has progressed from 4 to 7 cm in cervical dilation.
In which of the following phases of the first stage
does cervical dilation occur most rapidly?
1. Preparatory phase
2. Latent phase
3. Active phase
4. Transition phase
3. Cervical dilation occurs more rapidly during the
active phase than any of the previous phases. The
active phase is characterized by cervical dilation
that progresses from 4 to 7 cm. The preparatory, or
latent, phase begins with the onset of regular
uterine contractions and ends when rapid cervical
dilation begins. Transition is defined as cervical
dilation beginning at 8 cm and lasting until 10 cm
or complete dilation.
48. A multiparous client who has been in labor for
2 hours states that she feels the urge to move her
bowels. How should the nurse respond?
1. Let the client get up to use the potty
2. Allow the client to use a bedpan
3. Perform a pelvic examination
4. Check the fetal heart rate
3. A complaint of rectal pressure usually indicates a
low presenting fetal part, signaling imminent
delivery. The nurse should perform a pelvic
examination to assess the dilation of the cervix and
station of the presenting fetal part. Don't let the
client use the potty or bedpan before she is
examined because she could birth that there baby
right there in that darn potty.
49. Labor is a series of events affected by the
coordination of the five essential factors. One of
these is the passenger (fetus). Which are the other
four factors?
1. Contractions, passageway, placental position and
function, pattern of care
2. Contractions, maternal response, placental
position, psychological response
3. Passageway, contractions, placental position and
function, psychological response
4. Passageway, placental position and function,
paternal response, psychological response

3. The five essential factors (5 P's) are passenger
(fetus), passageway (pelvis), powers (contractions),
placental position and function, and psyche
(psychological response of the mother).
50. Fetal presentation refers to which of the
following descriptions?
1. Fetal body part that enters the maternal pelvis
first
2. Relationship of the presenting part to the
maternal pelvis
3. Relationship of the long axis of the fetus to the
long axis of the mother
4. A classification according to the fetal part
1. Presentation is the fetal body part that enters
the pelvis first; it's classified by the presenting part;
the three main presentations are
cephalic/occipital, breech, and shoulder. The
relationship of the presenting fetal part to the
maternal pelvis refers to fetal position. The
relationship of the long axis to the fetus to the long
axis of the mother refers to fetal lie; the three
possible lies are longitudinal, transverse, and
oblique.
51. A client is admitted to the L & D suite at 36
weeks' gestation. She has a history of C-section and
complains of severe abdominal pain that started
less than 1 hour earlier. When the nurse palpates
titanic contractions, the client again complains of
severe pain. After the client vomits, she states that
the pain is better and then passes out. Which is the
probable cause of her signs and symptoms?
1. Hysteria compounded by the flu
2. Placental abruption
3. Uterine rupture
4. Dysfunctional labor
3. Uterine rupture is a medical emergency that may
occur before or during labor. Signs and symptoms
typically include abdominal pain that may ease
after uterine rupture, vomiting, vaginal bleeding,
hypovolemic shock, and fetal distress. With
placental abruption, the client typically complains
of vaginal bleeding and constant abdominal pain.
52. Upon completion of a vaginal examination on a
laboring woman, the nurse records: 50%, 6 cm, -1.
Which of the following is a correct interpretation of
the data?
1. Fetal presenting part is 1 cm above the ischial
spines
2. Effacement is 4 cm from completion
3. Dilation is 50% completed
4. Fetus has achieved passage through the ischial
spines
1. Station of - 1 indicates that the fetal presenting
part is above the ischial spines and has not yet
passed through the pelvic inlet. A station of zero
would indicate that the presenting part has passed
through the inlet and is at the level of the ischial
spines or is engaged. Passage through the ischial
spines with internal rotation would be indicated by
a plus station, such as + 1. Progress of effacement
is referred to by percentages with 100% indicating
full effacement and dilation by centimeters (cm)
with 10 cm indicating full dilation.
53. Which of the following findings meets the
criteria of a reassuring FHR pattern?
1. FHR does not change as a result of fetal activity
2. Average baseline rate ranges between 100 - 140
BPM
3. Mild late deceleration patterns occur with some
contractions
4. Variability averages between 6 - 10 BPM
4. Variability indicates a well oxygenated fetus with
a functioning autonomic nervous system. FHR
should accelerate with fetal movement. Baseline
range for the FHR is 120 to 160 beats per minute.
Late deceleration patterns are never reassuring,
though early and mild variable decelerations are
expected, reassuring findings.
54. Late deceleration patterns are noted when
assessing the monitor tracing of a woman whose
labor is being induced with an infusion of Pitocin.
The woman is in a side-lying position, and her vital
signs are stable and fall within a normal range.
Contractions are intense, last 90 seconds, and
occur every 1 1/2 to 2 minutes. The nurse's
immediate action would be to:
1. Change the woman's position
2. Stop the Pitocin
3. Elevate the woman's legs
4. Administer oxygen via a tight mask at 8 to 10
liters/minute
2. Late deceleration patterns noted are most likely
related to alteration in uteroplacental perfusion
associated with the strong contractions described.
The immediate action would be to stop the Pitocin
infusion since Pitocin is an oxytocic which
stimulates the uterus to contract. The woman is
already in an appropriate position for
uteroplacental perfusion. Elevation of her legs
would be appropriate if hypotension were present.
Oxygen is appropriate but not the immediate
action.
55. The nurse should realize that the most common
and potentially harmful maternal complication of
epidural anesthesia would be:
1. Severe postpartum headache
2. Limited perception of bladder fullness
3. Increase in respiratory rate
4. Hypotension
3. Epidural anesthesia can lead to vasodilation
and a drop in blood pressure that could
interfere with adequate placental
perfusion. The woman must be well
hydrated before and during epidural
anesthesia to prevent this problem and
maintain an adequate blood pressure.
Headache is not a side effect since the
spinal fluid is not disturbed by this
anesthetic as it would be with a low spinal
(saddle block) anesthetic; 2 is an effect of
epidural anesthesia but is not the most
harmful. Respiratory depression is a
potentially serious complication.
A rubella titer result of a 1-day postpartum client is
less than 1:8, and a rubella virus vaccine is
prescribed to be administered before discharge.
The nurse provides which information to the client
about the vaccine? Select all that apply.
1.Breast-feeding needs to be stopped for 3 months.
2.Pregnancy needs to be avoided for 1 to 3
months.
3.The vaccine is administered by the subcutaneous
route.
4.Exposure to immunosuppressed individuals
needs to be avoided.
5.A hypersensitivity reaction can occur if the client
has an allergy to eggs.
6.The area of the injection needs to be covered
with a sterile gauze for 1 week.
2, 3, 4, 5
Rubella vaccine is administered to women who
have not had rubella or women who are not
serologically immune. The vaccine may be
administered in the immediate postpartum period
to prevent the possibility of contracting rubella in
future pregnancies. The live attenuated rubella
virus is not communicable in breast milk; breast-
feeding does not need to be stopped. The client is
counseled not to become pregnant for 1 to 3
months after immunization as specified by the
health care provider because of a possible risk to a
fetus from the live virus vaccine; the client must be
using effective birth control at the time of the
immunization. The client should avoid contact with
immunosuppressed individuals because of their
low immunity toward live viruses and because the
virus is shed in the urine and other body fluids. The
vaccine is administered by the subcutaneous route.
A hypersensitivity reaction can occur if the client
has an allergy to eggs because the vaccine is made
from duck eggs. There is no useful or necessary
reason for covering the area of the injection with a
sterile gauze.
The nurse is providing instructions to a pregnant
client with human immunodeficiency virus (HIV)
infection regarding care to the newborn after
delivery. The client asks the nurse about the
feeding options that are available. Which response
should the nurse make to the client?
1."You will need to bottle-feed your newborn."
2."You will need to feed your newborn by
nasogastric tube feeding."
3."You will be able to breast-feed for 6 months and
then will need to switch to bottle-feeding."
4."You will be able to breast-feed for 9 months and
then will need to switch to bottle-feeding."
1
Perinatal transmission of human immunodeficiency
virus (HIV) can occur during the antepartum period,
during labor and birth, or in the postpartum period
if the mother is breast-feeding. Clients who have
HIV are advised not to breast-feed. There is no
physiological reason why the newborn needs to be
fed by nasogastric tube.
A stillborn baby was delivered in the birthing suite
a few hours ago. After the delivery, the family
remained together, holding and touching the baby.
Which statement by the nurse would further assist
the family in their initial period of grief?
1."What can I do for you?"
2."Now you have an angel in heaven."
3."Don't worry, there is nothing you could have
done to prevent this from happening."
4."We will see to it that you have an early
discharge so that you don't have to be reminded of
this experience."
1
When a loss or death occurs, the nurse should
ensure that parents have been honestly told about
the situation by their health care provider or others
on the health care team. It is important for the
nurse to be with the parents at this time and to use
therapeutic communication techniques. The nurse
must also consider cultural and religious practices
and beliefs. The correct option provides a
supportive, giving, and caring response. Options 2,
3, and 4 are blocks to communication and devalue
the parents' feelings.
The nurse in a maternity unit is providing
emotional support to a client and her husband who
are preparing to be discharged from the hospital
after the birth of a dead fetus. Which statement
made by the client indicates a component of the
normal grieving process?
1."We want to attend a support group."
2."We never want to try to have a baby again."
3."We are going to try to adopt a child
immediately."
4."We are okay, and we are going to try to have
another baby immediately."
1 healing of the incision. Options 2, 3, and 4 are
A support group can help the parents work through
their pain by nonjudgmental sharing of feelings.
The correct option identifies a statement that
would indicate positive, normal grieving. Although
the other options may indicate reactions of the
client and significant other, they are not specifically
a part of the normal grieving process.
The nurse evaluates the ability of a hepatitis B-
positive mother to provide safe bottle-feeding to
her newborn during postpartum hospitalization.
Which maternal action best exemplifies the
mother's knowledge of potential disease
transmission to the newborn?
1.The mother requests that the window be closed
before feeding.
2.The mother holds the newborn properly during
feeding and burping.
3.The mother tests the temperature of the formula
before initiating feeding.
4.The mother washes and dries her hands before
and after self-care of the perineum and asks for a
pair of gloves before feeding.
4 infant. Options 1, 3, and 4 do not acknowledge the
Hepatitis B virus is highly contagious and is
transmitted by direct contact with blood and body
fluids of infected persons. The rationale for
identifying childbearing clients with this disease is
to provide adequate protection of the fetus and
the newborn, to minimize transmission to other
individuals, and to reduce maternal complications.
The correct option provides the best evaluation of
maternal understanding of disease transmission.
Option 1 will not affect disease transmission.
Options 2 and 3 are appropriate feeding techniques
for bottle-feeding, but do not minimize disease
transmission for hepatitis B.
The nurse has provided discharge instructions to a
client who delivered a healthy newborn by
cesarean delivery. Which statement made by the
client indicates a need for further instruction?
1."I will begin abdominal exercises immediately."
2."I will notify the health care provider if I develop
a fever."
3."I will turn on my side and push up with my arms
to get out of bed."
4."I will lift nothing heavier than my newborn baby
for at least 2 weeks."
1 is 100.2° F. What is the priority nursing action?
A cesarean delivery requires an incision made
through the abdominal wall and into the uterus.
Abdominal exercises should not start immediately
after abdominal surgery; the client should wait at
least 3 to 4 weeks postoperatively to allow for
appropriate instructions for the client after a
cesarean delivery.
After a precipitous delivery, the nurse notes that
the new mother is passive and only touches her
newborn infant briefly with her fingertips. What
should the nurse do to help the woman process the
delivery?
1.Encourage the mother to breast-feed soon after
birth.
2.Support the mother in her reaction to the
newborn infant.
3.Tell the mother that it is important to hold the
newborn infant.
4.Document a complete account of the mother's
reaction on the birth record.
2
Precipitous labor is labor that lasts 3 hours or less.
Women who have experienced precipitous labor
often describe feelings of disbelief that their labor
progressed so rapidly. To assist the client to
process what has happened, the best option is to
support the client in her reaction to the newborn
client's feelings.
The nurse in the postpartum unit is caring for a
client who has just delivered a newborn infant
following a pregnancy with a placenta previa. The
nurse reviews the plan of care and prepares to
monitor the client for which risk associated with
placenta previa?
1.Infection
2.Hemorrhage
3.Chronic hypertension
4.Disseminated intravascular coagulation
2
In placenta previa, the placenta is implanted in the
lower uterine segment. The lower uterine segment
does not contain the same intertwining
musculature as the fundus of the uterus, and this
site is more prone to bleeding. Options 1, 3, and 4
are not risks that are related specifically to
placenta previa.
The postpartum nurse is taking the vital signs of a
client who delivered a healthy newborn 4 hours
ago. The nurse notes that the client's temperature
1.Document the findings.
2.Retake the temperature in 15 minutes.
3.Notify the health care provider (HCP).
4.Increase hydration by encouraging oral fluids.
4 who had a vaginal delivery 2 hours ago. The client
The client's temperature should be taken every 4
hours while she is awake. Temperatures up to
100.4° F (38° C) in the first 24 hours after birth
often are related to the dehydrating effects of
labor. The appropriate action is to increase
hydration by encouraging oral fluids, which should
bring the temperature to a normal reading.
Although the nurse also would document the
findings, the appropriate action would be to
increase hydration. Taking the temperature in
another 15 minutes is an unnecessary action.
Contacting the HCP is not necessary.
The nurse is assessing a client who is 6 hours
postpartum after delivering a full-term healthy
newborn. The client complains to the nurse of
feelings of faintness and dizziness. Which nursing
action would be most appropriate?
1.Raise the head of the client's bed.
2.Obtain hemoglobin and hematocrit levels.
3.Instruct the client to request help when getting
out of bed.
4.Inform the nursery room nurse to avoid bringing
the newborn to the client until the mother's
symptoms have subsided.
3 2."Drinking alcohol can affect my milk supply."
Orthostatic hypotension may be evident during the
first 8 hours after birth. Feelings of faintness or
dizziness are signs that caution the nurse to focus
interventions on the client's safety. The nurse
should advise the client to get help the first few
times she gets out of bed. Option 1 is not a helpful
action in this situation and would not relieve the
symptoms. Option 2 requires a health care
provider's prescription. Option 4 is unnecessary.
The postpartum nurse is providing instructions to a
client after delivery of a healthy newborn. Which
time frame should the nurse relay to the client
regarding the return of bowel function?
1.3 days postpartum
2.7 days postpartum
3.On the day of delivery
4.Within 2 weeks postpartum
1 but should breast-feed frequently. Oral
After birth, the nurse should auscultate the client's
abdomen in all four quadrants to determine the
return of bowel sounds. Normal bowel elimination
usually returns 2 to 3 days postpartum. Surgery,
anesthesia, and the use of opioids and pain control
agents also contribute to the longer period of
altered bowel functions. Options 2, 3, and 4 are
incorrect.
The nurse is planning care for a postpartum client
had a midline episiotomy and has several
hemorrhoids. What is the priority nursing
consideration for this client?
1.Client pain level
2.Inadequate urinary output
3.Client perception of body changes
4.Potential for imbalanced body fluid volume
1
The priority nursing consideration for a client who
delivered 2 hours ago and who has a midline
episiotomy and hemorrhoids is client pain level.
Most clients have some degree of discomfort
during the immediate postpartum period. There
are no data in the question that indicate
inadequate urinary output, the presence of client
perception of body changes, and potential for
imbalanced body fluid volume.
The nurse is providing postpartum instructions to a
client who will be breast-feeding her newborn. The
nurse determines that the client has understood
the instructions if she makes which statements?
Select all that apply.
1."I should wear a bra that provides support."
3."The use of caffeine can decrease my milk
supply."
4."I will start my estrogen birth control pills again
as soon as I get home."
5."I know if my breasts get engorged I will limit my
breast-feeding and supplement the baby."
6."I plan on having bottled water available in the
refrigerator so I can get additional fluids easily."
1, 2, 3, 6
The postpartum client should wear a bra that is
well-fitted and supportive. Breasts may leak
between feedings or during coitus, and the client is
taught to place a breast pad in the bra. Breast-
feeding clients should increase their daily fluid
intake; having bottled water available indicates
that the postpartum client understands the
importance of increasing fluids. If engorgement
occurs, the client should not limit breast-feeding,
contraceptives containing estrogen are not
recommended for breast-feeding mothers.
Common causes of decreased milk supply include
formula use; inadequate rest or diet; smoking by
the mother or others in the home; and use of
caffeine, alcohol, or other medications.
The nurse is teaching a postpartum client about
breast-feeding. Which instruction should the nurse
include?
1.The diet should include additional fluids.
2.Prenatal vitamins should be discontinued.
3.Soap should be used to cleanse the breasts.
4.Birth control measures are unnecessary while
breast-feeding.
1
The diet for a breast-feeding client should include
additional fluids. Prenatal vitamins should be taken
as prescribed, and soap should not be used on the
breasts because it tends to remove natural oils,
which increases the chance of cracked nipples.
Breast-feeding is not a method of contraceptio
A nurse is preparing to assess the uterine fundus of
a client in the immediate postpartum period. After
locating the fundus, the nurse notes that the
uterus feels soft and boggy. Which nursing
intervention would be most appropriate?
1.Elevate the client's legs.
2.Massage the fundus until it is firm.
3.Ask the client to turn on her left side.
4.Push on the uterus to assist in expressing clots.
2 finding?
If the uterus is not contracted firmly, the initial
intervention is to massage the fundus until it is firm
and to express clots that may have accumulated in
the uterus. Pushing on an uncontracted uterus can
invert the uterus and cause massive hemorrhage.
Elevating the client's legs and positioning the client
on the side would not assist in managing uterine
atony.
The nurse is caring for four 1-day postpartum
clients. Which client would require further nursing
action?
1.The client with mild afterpains
2.The client with a pulse rate of 60 beats/minute
3.The client with colostrum discharge from both
breasts
4.The client with lochia that is red and has a foul-
smelling odor
4 sign, if noted, would be an early sign of excessive
Lochia, the discharge present after birth, is red for
the first 1 to 3 days and gradually decreases in
amount. Normal lochia has a fleshy odor or an odor
similar to menstrual flow. Foul-smelling or purulent
lochia usually indicates infection, and these
findings are not normal. The other options are
normal findings for a 1-day postpartum client.
When performing a postpartum assessment on a
client, a nurse notes the presence of clots in the
lochia. The nurse examines the clots and notes that
they are larger than 1 cm. Which nursing action is
most appropriate?
1.Document the findings.
2.Reassess the client in 2 hours.
3.Notify the health care provider.
4.Encourage increased oral intake of fluids.
3
Normally, a few small clots may be noted in the
lochia in the first 1 to 2 days after birth from
pooling of blood in the vagina. Clots larger than 1
cm are considered abnormal. The cause of these
clots, such as uterine atony or retained placental
fragments, needs to be determined and treated to
prevent further blood loss. Although the findings
would be documented, the appropriate action is to
notify the HCP. Reassessing the client in 2 hours
would delay necessary treatment. Increasing oral
intake of fluids would not be a helpful action in this
situation.
The nurse is monitoring the amount of lochia
drainage in a client who is 2 hours postpartum and
notes that the client has saturated a perineal pad in
1 hour. How should the nurse document this
1.Scant
2.Light
3.Heavy
4.Excessive
3
Lochia is the discharge from the uterus in the
postpartum period; it consists of blood from the
vessels of the placental site and debris from the
decidua. The following can be used as a guide to
determine the amount of flow: scant = less than
2.5 cm (<1 inch) on menstrual pad in 1 hour; light =
less than 10 cm (<4 inches) on menstrual pad in 1
hour; moderate = less than 15 cm (<6 inches) on
menstrual pad in 1 hour; heavy = saturated
menstrual pad in 1 hour; and excessive = menstrual
pad saturated in 15 minutes.
The nurse is monitoring a client in the immediate
postpartum period for signs of hemorrhage. Which
blood loss?
1.A temperature of 100.4° F
2.An increase in the pulse rate from 88 to 102
beats/minute
3.A blood pressure change from 130/88 to 124/80
mm Hg
4.An increase in the respiratory rate from 18 to 22
breaths/minute

2 development of mastitis include changing nursing
During the fourth stage of labor, the maternal
blood pressure, pulse, and respiration should be
checked every 15 minutes during the first hour. An
increasing pulse is an early sign of excessive blood
loss because the heart pumps faster to compensate
for reduced blood volume. A slight increase in
temperature is normal. The blood pressure
decreases as the blood volume diminishes, but a
decreased blood pressure would not be the earliest
sign of hemorrhage. The respiratory rate is slightly
increased from normal.
The nurse is preparing a list of self-care instructions
for a postpartum client who was diagnosed with
mastitis. Which instructions should be included on
the list? Select all that apply.
1.Wear a supportive bra.
2.Rest during the acute phase.
3.Maintain a fluid intake of at least 3000 mL.
4.Continue to breast-feed if the breasts are not too
sore.
5.Take the prescribed antibiotics until the soreness
subsides.
6.Avoid decompression of the breasts by breast-
feeding or breast pump.
1, 2, 3, 4
Mastitis is an infection of the lactating breast.
Client instructions include resting during the acute
phase, maintaining a fluid intake of at least 3000
mL/day (if not contraindicated), and taking
analgesics to relieve discomfort. Antibiotics may be
prescribed and are taken until the complete
prescribed course is finished. They are not stopped
when the soreness subsides. Additional supportive
measures include the use of moist heat or ice packs
and wearing a supportive bra. Continued
decompression of the breast by breast-feeding or
breast pump is important to empty the breast and
prevent the formation of an abscess.
The nurse is providing instructions about measures
to prevent postpartum mastitis to a client who is
breast-feeding her newborn. Which client
statement would indicate a need for further
instruction?
1."I should breast-feed every 2 to 3 hours."
2."I should change the breast pads frequently."
3."I should wash my hands well before breast-
feeding."
4."I should wash my nipples daily with soap and
water."
4 labor and notes that the fundus is firm, but that
Mastitis is inflammation of the breast as a result of
infection. It generally is caused by an organism that
enters through an injured area of the nipples, such
as a crack or blister. Measures to prevent the
pads when they are wet and avoiding continuous
pressure on the breasts. Soap is drying and could
lead to cracking of the nipples, and the client
should be instructed to avoid using soap on the
nipples. The mother is taught about the
importance of hand-washing and that she should
breast-feed every 2 to 3 hours.
The postpartum nurse is assessing a client who
delivered a healthy infant by cesarean section for
signs and symptoms of superficial venous
thrombosis. Which sign would the nurse note if
superficial venous thrombosis were present?
1.Paleness of the calf area
2.Coolness of the calf area
3.Enlarged, hardened veins
4.Palpable dorsalis pedis pulses
3
Thrombosis of superficial veins usually is
accompanied by signs and symptoms of
inflammation, including swelling, redness,
tenderness, and warmth of the involved extremity.
It also may be possible to palpate the enlarged,
hard vein. Clients sometimes experience pain when
they walk. Palpable dorsalis pedis pulses is a
normal finding.
A client in a postpartum unit complains of sudden
sharp chest pain and dyspnea. The nurse notes that
the client is tachycardic and the respiratory rate is
elevated. The nurse suspects a pulmonary
embolism. Which should be the initial nursing
action?
1.Initiate an intravenous line.
2.Assess the client's blood pressure.
3.Prepare to administer morphine sulfate.
4.Administer oxygen, 8 to 10 L/minute, by face
mask.
4
If pulmonary embolism is suspected, oxygen should
be administered, 8 to 10 L/minute, by face mask.
Oxygen is used to decrease hypoxia. The client also
is kept on bed rest with the head of the bed slightly
elevated to reduce dyspnea. Morphine sulfate may
be prescribed for the client, but this would not be
the initial nursing action. An intravenous line also
will be required, and vital signs need to be
monitored, but these actions would follow the
administration of oxygen.
The nurse is assessing a client in the fourth stage of
bleeding is excessive. Which should be the initial
nursing action?
1.Record the findings.
2.Massage the fundus.
3.Notify the health care provider (HCP).
4.Place the client in Trendelenburg's position.
3 received epidural anesthesia for delivery for the
If bleeding is excessive, the cause may be
laceration of the cervix or birth canal. Massaging
the fundus if it is firm would not assist in
controlling the bleeding. Trendelenburg's position
should be avoided because it may interfere with
cardiac and respiratory function. Although the
nurse would record the findings, the initial nursing
action would be to notify the HCP.
The nurse is preparing to care for four assigned
clients. Which client is at highest risk for
hemorrhage?
1.A primiparous client who delivered 4 hours ago
2.A multiparous client who delivered 6 hours ago
3.A primiparous client who delivered 6 hours ago
and had epidural anesthesia
4.A multiparous client who delivered a large baby
after oxytocin (Pitocin) induction
4 The nurse should include which specific action
The causes of postpartum hemorrhage include
uterine atony; laceration of the vagina; hematoma
development in the cervix, perineum, or labia; and
retained placental fragments. Predisposing factors
for hemorrhage include a previous history of
postpartum hemorrhage, placenta previa, abruptio
placentae, overdistention of the uterus from
polyhydramnios, multiple gestation, a large
neonate, infection, multiparity, dystocia or labor
that is prolonged, operative delivery such as a
cesarean or forceps delivery, and intrauterine
manipulation. The multiparous client who
delivered a large fetus after oxytocin induction has
more risk factors associated with postpartum
hemorrhage than the other clients. In addition,
there are no specific data in the client descriptions
in options 1, 2, and 3 that present the risk for
hemorrhage.
A postpartum client is diagnosed with cystitis. The
nurse should plan for which priority nursing action
in the care of the client?
1.Providing sitz baths
2.Encouraging fluid intake
3.Placing ice on the perineum
4.Monitoring hemoglobin and hematocrit levels
2 3."My fluid intake should be increased to at least
Cystitis is an infection of the bladder. The client
should consume 3000 mL of fluids per day if not
contraindicated. Sitz baths and ice would be
appropriate interventions for perineal discomfort.
Hemoglobin and hematocrit levels would be
monitored with hemorrhage.
The nurse is monitoring a postpartum client who
presence of a vulvar hematoma. Which assessment
finding would best indicate the presence of a
hematoma?
1.Changes in vital signs
2.Signs of heavy bruising
3.Complaints of intense pain
4.Complaints of a tearing sensation
1
Because the client has had epidural anesthesia and
is anesthetized, she cannot feel pain, pressure, or a
tearing sensation. Changes in vital signs indicate
hypovolemia in an anesthetized postpartum client
with vulvar hematoma. Option 2 (heavy bruising)
may be seen, but vital sign changes indicate
hematoma caused by blood coll
The nurse is developing a plan of care for a
postpartum client with a small vulvar hematoma.
during the first 12 hours after delivery?
1.Assess vital signs every 4 hours.
2.Measure fundal height every 4 hours.
3.Prepare an ice pack for application to the area.
4.Inform the health care provider of assessment
findings.
3
A hematoma is a localized collection of blood into
the tissues of the reproductive sac after delivery.
Vulvar hematoma is the most common. Application
of ice reduces swelling caused by hematoma
formation in the vulvar area. Options 1, 2, and 4
are not interventions that are specific to the plan of
care for a client with a small vulvar hematoma.
On the second postpartum day, a client complains
of burning on urination, urgency, and frequency of
urination. A urinalysis indicates the presence of a
urinary tract infection. The nurse instructs the
client regarding measures to take for the treatment
of the infection. Which client statement indicates
to the nurse the need for further instruction?
1."I need to urinate frequently throughout the
day."
2."The prescribed medication must be taken until it
is finished."
3000 mL daily."
4."Foods and fluids that will increase urine
alkalinity should be consumed."
4
A client with a urinary tract infection must be
encouraged to take the medication for the entire
time it is prescribed. The client should also be
instructed to drink at least 3000 mL of fluid each
day to flush the infection from the bladder and to
urinate frequently throughout the day. Foods and
fluids that acidify the urine need to be encouraged.
The nurse is assessing a client for signs of
postpartum depression. Which observation, if
noted in the new mother, would indicate the need
for further assessment related to this form of
depression?
1.The mother is caring for the infant in a loving
manner.
2.The mother demonstrates an interest in the
surroundings.
3.The mother constantly complains of tiredness
and fatigue.
4.The mother looks forward to visits from the
father of the newborn.
3 breast-fed in the past."
Postpartum depression is not the normal
depression that many new mothers experience
from time to time. The woman experiencing
depression shows less interest in her surroundings
and a loss of her usual emotional response toward
the family. The woman is also unable to show
pleasure or love and may have intense feelings of
unworthiness, guilt, and shame. The woman often
expresses a sense of loss of self. Generalized
fatigue, complaints of ill health, and difficulty in
concentrating are also present. The mother would
have little interest in food and would experience
sleep disturbances.
A postpartum client is attempting to breast-feed
for the first time. The nurse notes that the client
has inverted nipples. What nursing action should
the nurse take to assist the client in breast-feeding
the newborn infant?
1.Massage the breasts, applying gentle pressure on
the areolas with the thumb and forefinger.
2.Have the mother grasp her areola between the
thumb and forefinger and tug firmly to get the
nipple to protrude.
3.Encourage taking a cool shower, allowing the
water to run over the breasts, because this will
encourage the nipples to protrude.
4.Provide breast shells and assist the mother with
using a breast pump before each feeding to make
the nipples easier for the newborn infant to grasp.
4 thrombophlebitis. Additionally, bed rest promotes
Wearing breast shells and using a breast pump
before each feeding will make it easier for the
newborn infant to grasp the nipple. Massaging the
breast is an appropriate instruction for the mother
with engorgement but will not help with resolving
inverted nipples. True inverted nipples will retract
if the areola is pressed between the thumb and
forefinger. Having the client take a cool shower will
only make the mother cold, and it has no effect on
inverted nipples.
A new mother is seen in a health care clinic 2
weeks after giving birth to a healthy newborn
infant. The mother is complaining that she feels as
though she has the flu and complains of fatigue
and aching muscles. On further assessment the
nurse notes a localized area of redness on the left
breast, and the mother is diagnosed with mastitis.
The mother asks the nurse about the condition.
The nurse should make which response?
1."Mastitis usually involves both breasts."
2."Mastitis can occur at any time during breast-
feeding."
3."Mastitis usually is caused by wearing a
supportive bra."
4."Mastitis is most common for women who have
2
Mastitis is an infection of the lactating breasts and
occurs most often during the second and third
weeks after birth, although it may develop at any
time during breast-feeding. Mastitis is more
common in mothers nursing for the first time and
usually affects one breast. A supportive bra will not
cause mastitis; however, constriction of the breasts
from a bra that is too tight may interfere with the
emptying of all the ducts and may lead to infection.
The nurse is developing a plan of care for a client
recovering from a cesarean delivery. Which action
should the nurse encourage the client to do to
prevent thrombophlebitis?
1.Elevate her legs.
2.Remain on bed rest.
3.Ambulate frequently.
4.Apply warm, moist packs to the legs.
3
Stasis is believed to be a predisposing factor in the
development of thrombophlebitis. Because
cesarean delivery is also a risk factor for
thrombophlebitis, new mothers should ambulate
early and frequently to promote circulation and
prevent stasis. The other options may be
interventions for the client diagnosed with
stasis.
The nurse performs an assessment on a client who
is 4 hours postpartum. The nurse notes that the
client has cool, clammy skin and is restless and
excessively thirsty. What immediate action should
the nurse take?
1.Provide oral fluids and begin fundal massage.
2.Begin hourly pad counts and reassure the client.
3.Elevate the head of the bed and assess vital signs.
4.Assess for hypovolemia and notify the health
care provider (HCP).
4 Additional supportive measures include ice packs,
Symptoms of hypovolemia include cool, clammy,
pale skin, sensations of anxiety or impending
doom, restlessness, and thirst. When these
symptoms are present, the nurse should further
assess for hypovolemia and notify the HCP.
Providing oral fluids and beginning fundal massage
and beginning hourly pad counts and reassuring
the client will delay necessary treatment. Also, the
question gives no indication of the cause of the
hypovolemia or that the client is hemorrhaging and
that fundal massage is needed. The head of the
bed is not elevated in a hypovolemic condition.
The nurse is monitoring a postpartum client in the
fourth stage of labor. Which finding, if noted by the
nurse, would indicate a complication related to a
laceration of the birth canal?
1.Presence of dark red lochia
2.Palpation of the uterus as a firm contracted ball
3.The saturation of more than one peripad per
hour
4.Palpation of the fundus at the level of the
umbilicus
3 the client makes which statement?
Saturation of more than one peripad per hour is
considered excessive even in the early postpartum
period. In the first 24 hours after birth, the uterus
will feel like a firmly contracted ball, roughly the
size of a large grapefruit. One easily can locate the
uterus at the level of the umbilicus. Lochia should
be dark red and moderate in amount.
The nurse is providing instructions to a client who
has been diagnosed with mastitis. Which
statement, if made by the client, indicates a need
for further instructions?
1."I need to wear a supportive bra to relieve the
discomfort."
2."I need to stop breast-feeding until this condition
resolves."
3."I can use analgesics to assist in alleviating some
of the discomfort."
4."I need to take antibiotics, and I should begin to
feel better in 24 to 48 hours."
2 care measures after surgical evacuation and repair
Mastitis is an infection of the lactating breasts and
occurs most often during the second and third
weeks after birth, although it may develop at any
time during breast-feeding. In most cases, the
mother can continue to breast-feed with both
breasts. If the affected breast is too sore, the
mother can pump the breast gently. Regular
emptying of the breast is important to prevent
abscess formation. Antibiotic therapy assists in
resolving the mastitis within 24 to 48 hours.
breast supports, and analgesics.
A postpartum client with deep vein thrombosis is
being treated with anticoagulant therapy. The
nurse understands that the client's response to
treatment will be evaluated by regularly assessing
the client for which symptoms?
1.Dysuria, ecchymosis, and vertigo
2.Epistaxis, hematuria, and dysuria
3.Hematuria, ecchymosis, and vertigo
4.Hematuria, ecchymosis, and epistaxis
4
The treatment for deep vein thrombosis is
anticoagulant therapy. The nurse assesses for
bleeding, which is an adverse effect of
anticoagulants. This includes hematuria,
ecchymosis, and epistaxis. Dysuria and vertigo are
not associated specifically with bleeding.
After surgical evacuation and repair of a
paravaginal hematoma, a client is discharged 3
days postpartum. The nurse determines that the
client needs further discharge instructions when
1."I will probably need my mother to help me with
housekeeping."
2."Because I am so sore, I will nurse the baby while
lying on my side."
3."My husband and I will not have intercourse until
the stitches are healed."
4."The only medications I will take are prenatal
vitamins and stool softeners."
4
A hematoma is a localized collection of blood into
the tissues of the reproductive sac after delivery. A
vulvar hematoma is the most common type. The
postoperative client will need an antibiotic because
she is at increased risk for infection as a result of
the break in skin integrity and collection of blood at
the hematoma site. Stating that she will need only
prenatal vitamins and stool softeners indicates that
she requires further teaching. All other options
indicate that the mother understands the home
of a paravaginal hematoma.
The nurse is developing a plan of care for a
postpartum client who was diagnosed with
superficial venous thrombosis. The nurse
anticipates that which intervention will be
prescribed?
1.Administration of anticoagulants
2.Elevation of the affected extremity
3.Ambulation eight to ten times daily
4.Application of ice packs to the affected area
2 taught good hand washing techniques and how to
Thrombosis that is limited to the superficial veins
of the saphenous system is treated with analgesics,
rest, and elastic support stockings. Elevation of the
affected lower extremity to improve venous return
also may be recommended. Warm packs may be
prescribed to be applied to the affected area to
promote healing. There is usually no need for
anticoagulants or anti-inflammatory agents unless
the condition persists. Bed rest or limited activity
may be prescribed depending on health care
provider preference.
A new mother received epidural anesthesia during
labor and had a forceps delivery after pushing for 2
hours. At 6 hours postpartum her systolic blood
pressure has dropped 20 points, her diastolic blood
pressure has dropped 10 points, and her pulse is
120 beats/min. The client is anxious and restless.
On further assessment, a vulvar hematoma is
verified. After notifying the health care provider,
what is the nurse's next action?
1.Reassure the client.
2.Monitor fundal height.
3.Apply perineal pressure.
4.Prepare the client for surgery.
4 personal health. The data given do not support lack
A hematoma is a localized collection of blood into
the tissues of the reproductive sac after delivery. A
vulvar hematoma is the most common type . The
use of an epidural, prolonged second-stage labor,
and forceps delivery are predisposing factors for
hematoma formation, and a collection of up to 500
mL of blood can occur in the vaginal area. Although
the other options may be implemented, the
immediate action is to prepare the client for
surgery to stop the bleeding.
The home care nurse visits a client who has
delivered a healthy newborn infant via vaginal
delivery. An episiotomy was performed, and the
woman has developed a wound infection at the
episiotomy site. The nurse provides instructions to
the client regarding care related to the infection.
Which statement, if made by the mother, indicates
a need for further instructions?
1."I need to take the antibiotics as prescribed."
2."I need to take warm sitz baths to promote
healing."
3."I need to apply warm compresses to provide
comfort."
4."I need to isolate the infant for 48 hours after
beginning the antibiotics."
4
The infant is not isolated routinely from the mother
with a wound infection, but the mother must be
protect the infant from contact with contaminated
articles. If the mother has a wound infection,
broad-spectrum antibiotics will be prescribed for
the mother, and she should be instructed to take
the antibiotics as prescribed. Analgesics are often
necessary, and warm compresses or sitz baths may
be used to provide comfort in the area.
A client has just had surgery to deliver a nonviable
fetus resulting from abruptio placentae. As a result
of the abruptio placentae, the client develops
disseminated intravascular coagulation (DIC) and is
told about the complication. The client begins to
cry and screams, "God, just let me die now!" Which
client problem should be the priority for the client
at this time?
1.Lack of power about the situation
2.Grieving because of the loss of the baby
3.Lack of knowledge regarding what occurred
4.Concern about the loss of the baby and personal
health
4
The client expresses that there is no way out of the
situation except for death; therefore the client
exhibits concern about the loss of the baby and
of power. Grieving is a possible client problem at a
later time; however, at this time, the concern over
the loss should take priority. Lack of knowledge is a
possible problem later, but not enough data
support it at this point, and it is not the priority.
The rubella vaccine has been prescribed for a new
mother. Which statement should the postpartum
nurse make when providing information about the
vaccine to the client?
1."You should avoid sexual intercourse for 2 weeks
after administration of the vaccine."
2."You should not become pregnant for 2 to 3
months after administration of the vaccine."
3."You should avoid heat and extreme temperature
changes for 1 week after administration of the
vaccine."
4."You must sign an informed consent because
anaphylactic reactions can occur with the
administration of this vaccine."
2 4
Rubella vaccine is a live attenuated virus that
provides immunity for approximately 15 years.
Because rubella is a live vaccine, it will act as a virus
and is potentially harmful to the organogenesis
phase of fetal development. Informed consent for
rubella and varicella vaccination in the postpartum
period includes information about possible side
effects and the risk of teratogenic effects. The
client should be informed about the potential
effects of this vaccine and the need to avoid
becoming pregnant for 2 to 3 months (or as
indicated by the health care provider) after
administration of the vaccine. Abstinence from
sexual intercourse is unnecessary. Heat or extreme
changes in temperature have no effect on the
person who has been vaccinated. The vaccine is
not known to cause anaphylactic reactions.
The nursing student is assigned to care for a client
in the postpartum unit. The coassigned nurse asks
the student to identify the most objective method
to assess the amount of lochial flow in the client.
Which statement, if made by the student, indicates
an understanding of this method?
1."I can estimate the amount of blood loss by
gauging the amount of staining on a perineal pad."
2.I should ask the client to keep a record and
document every time the perineal pad is changed."
3."I should weigh the perineal pad before and after
use and note the amount of time between each
pad change."
4."I can look at the perineal pad and gauge the
amount of staining and relate it to the amount of
time between pad changes."
3 at risk of developing postpartum endometritis.
To gather accurate data for comparison, the
perineal pads must be weighed both before and
after use. Once these weights are gathered, the
amount of lochia flow can be accurately
determined. Noting the time frame between pad
changes and the number of pads used also is an
important factor. Gauging the amount of staining
does not provide accurate data. Asking the client to
obtain the information also may not provide
accurate data.
The nurse in the postpartum unit is observing the
mother-infant bonding process in a client. Which
observation, if made by the nurse, indicates the
potential for a maladaptive interaction?
1.The mother is observed talking to the newborn.
2.The mother performs cord care for the newborn.
3.The mother verbalizes discomfort with the new
role of motherhood.
4.The mother requests that the nurse feed the
newborn because she is feeling fatigued.
The nurse should be alert to maladaptive
interaction in the maternal-infant bonding
processes. If the nurse notes that the mother is
avoiding interaction with the newborn or is
avoiding caring for the newborn, the nurse should
suspect the potential for a maladaptive interaction.
Talking to the newborn or willingness to perform
cord care does not indicate a maladaptive
response. Expressing discomfort with the new role
of motherhood is a normal, expected process, and
it is important for the mother to verbalize
concerns.
The postpartum nurse is caring for a woman who
just delivered a healthy newborn. The nurse should
be most concerned with the presence of
subinvolution if which occurs?
1.The presence of afterpains
2.Retained placental fragments from delivery
3.An oral temperature of 99.0° F following delivery
4.Increased estrogen and progesterone levels as
noted on laboratory analysis
2
Retained placental fragments and infection are the
primary causes of subinvolution. When either of
these processes is present, the uterus will have
difficulty contracting. An oral temperature of 99.0°
F after delivery and the presence of afterpains are
expected findings following delivery. Option 4 is
not a cause of subinvolution and is unrelated to the
subject of the question.
The nurse is monitoring a postpartum client who is
Which finding, if noted during the first 24 hours
after delivery, would support a diagnosis of
postpartum endometritis?
1.Abdominal tenderness and chills
2.Increased perspiration and appetite
3.Maternal oral temperature of 100.2° F
4.Uterus two fingerbreadths below midline and
firm
1
Signs and symptoms in the postpartum period
heralding endometritis include delayed uterine
involution, foul-smelling lochia, tachycardia,
abdominal tenderness, and temperature elevations
up to 104° F. This intrauterine infection may lead to
further maternal complications, such as infections
of the fallopian tubes, ovaries, and blood (sepsis).
Options 2, 3, and 4 represent normal maternal
physiological responses in the immediate
postpartum period.
Which nursing intervention would be most
appropriate for a postpartum client with a
diagnosis of endometritis to facilitate participation
in newborn care?
1.Limit fluid intake.
2.Maintain the client in a supine position.
3.Ask family members to care for the newborn.
4.Encourage the client to take pain medication as
prescribed.
4 2.Encourage the mother to hold the infant when
Nursing responsibilities for the care of the client
with endometritis include maintaining adequate
hydration (3000 to 4000 mL/day), bed rest in
Fowler's position to facilitate drainage and lessen
congestion, providing appropriate analgesia to
lessen the pain, and administering antibiotics as
prescribed. If the client's pain is relieved, she will
be more likely to participate in newborn care.
Asking family members to care for the newborn
will not facilitate client participation in newborn
care.
The nurse is caring for a client in the postpartum
period immediately after delivery. The nurse
performs an assessment on the client and prepares
to assess uterine involution by taking which action?
1.Monitoring the vital signs
2.Palpating the uterine fundus
3.Auscultating the bowel sounds
4.Assessing the amount of drainage on the peripad
2 instructions?
To assess uterine involution, the nurse would
palpate the fundal height. Fundal height is
measured in fingerbreadths or centimeters in
relation to the umbilicus, and this measurement is
used to assess the rate of uterine involution. Vital
signs and the amount of drainage on the peripad
do not indicate uterine involution. Bowel sounds,
although they may be diminished in the
postpartum period, are not helpful in assessing
uterine involution.
The nurse is assessing a client in the postpartum
period and suspects the presence of uterine atony.
Which is the initial nursing action?
1.Massage the uterus until firm.
2.Take the client's blood pressure.
3.Contact the health care provider (HCP).
4.Assess the amount of drainage on the peripad.
1 assessment, the nurse notes that the client is
When uterine atony occurs, the initial nursing
action would be to massage the uterus until it is
firm. If this does not assist in controlling blood loss,
then the nurse would contact the HCP.
Additionally, once bleeding is under control, the
nurse would monitor the vital signs and estimate
the amount of blood loss.
The postpartum unit nurse is developing a plan of
care for a first-time mother and identifies the need
for measures that will promote parent-infant
bonding. Which measure should the nurse include
in the plan?
1.Use a low-pitched voice to speak to the infant.
the infant cries.
3.Encourage the parents to allow the infant to
sleep in the parental bed.
4.Encourage the mother to allow the nursing staff
to care for the infant during her hospital stay until
she is discharged.
2
Holding the infant close and allowing the infant to
feel the warmth will initiate a positive experience
for the mother and will console the infant. The use
of a high-pitched voice and participating in infant
care are additional methods of promoting parental-
infant attachment. Infants should not be allowed to
sleep in the parental bed. The parents require time
alone as a couple. Additionally, the danger of
suffocation of the infant exists if the infant is
allowed to sleep between parents.
The postpartum unit nurse has provided discharge
instructions to a client planning to breast-feed her
normal, healthy infant. Which statement by the
client indicates an understanding of the
1."If I experience any sweating during the night, I
should call the health care provider."
2."If I have uterine cramping while breast-feeding, I
should contact the health care provider."
3."If I'm still having bloody vaginal drainage in a
week, I should contact the health care provider."
4."If I notice any pain, redness, or swelling in my
breasts, I should contact the health care provider."
4
Signs of infection include pain, redness, heat, and
swelling of a localized area of the breast. If these
symptoms occur, the client needs to contact the
HCP. Options 1, 2, and 3 are normal changes that
occur in the postpartum period.
A client arrives at the postpartum unit after
delivery of her infant. On performing an
shaking uncontrollably. Which nursing action would
be appropriate?
1.Massage the fundus.
2.Contact the health care provider.
3.Cover the client with a warm blanket.
4.Place the client in Trendelenburg's position.
3 Pushing on an uncontracted uterus could invert the
In the postpartum period, a woman may
experience a shaking, uncontrollable chill
immediately after birth. The exact cause of this
fairly common event is not known; however, it is
thought to be associated with a nervous system
reaction such as a vasovagal response. If the chill is
not associated with an elevated temperature, it is
of no clinical significance. The appropriate nursing
action would be to provide a warm blanket to the
client and a warm drink if this is not
contraindicated.
The postpartum unit nurse has provided
information regarding performing a sitz bath to a
new mother after a vaginal delivery. The client
demonstrates understanding of the purpose of the
sitz bath by stating that the sitz bath will promote
which action?
1.Numb the tissue.
2.Stimulate a bowel movement.
3.the edema and swelling.
4.Assist in healing and provide comfort.
4 for the next 6 weeks."
Warm, moist heat is used after the first 24 hours
after tissue trauma from a vaginal birth to provide
comfort and promote healing and reduce the
incidence of infection. This warm, moist heat is
provided via a sitz bath. Ice is used in the first 24
hours to reduce edema and numb the tissue.
Promoting a bowel movement is best achieved by
ambulation.
A nurse is assessing the fundus in a postpartum
woman and notes that the uterus is soft and
spongy and is not firmly contracted. The nurse
should prepare to implement which interventions?
Select all that apply.
1.Massaging the uterus
2.Pushing gently on the uterus
3.Assisting the woman to urinate
4.Rechecking the uterus in 1 hour
5.Checking for a distended bladder
6.Calling the delivery room to schedule an
abdominal hysterectomy
1, 3, 5
If the uterus is soft and spongy and is not firmly
contracted, the initial nursing action is to massage
the fundus gently until it is firm; this will express
clots that may have accumulated in the uterus. If
the uterus does not remain contracted as a result
of massage, the problem may be a distended
bladder, which lifts and displaces the uterus and
prevents effective contraction of the uterine
muscles. The nurse would then check for a
distended bladder and assist the woman to urinate.
uterus, potentially causing massive hemorrhage
and rapid shock. Waiting for 1 hour without
intervention could result in bleeding. The health
care provider will need to be notified if uterine
massage is not helpful. Pharmacological measures
may be necessary to maintain firm contraction of
the uterus. An abdominal hysterectomy may need
to be performed for massive hemorrhage that is
uncontrollable. The question presents no data
indicating that hemorrhage is a problem.
Additionally, the nurse would not schedule an
operative procedure.
A woman infected with the human
immunodeficiency virus (HIV) has given birth to a
normal-appearing infant, and the nurse provides
instructions about newborn infant care. Which
statement by the mother indicates a need for
further instruction?
1."I'm going to breast-feed my baby starting right
away."
2."I need to wash my hands before and after
bathroom use."
3."My baby needs to be on antiviral medications
4."I am going to contact some support groups
listed in my take-home material to help me with
everything I'll have to deal with when I get home."
1
Perinatal transmission of HIV to the fetus or
neonate of an HIV-positive woman can occur
during the antenatal, intrapartal, or postpartum
period. HIV transmission can occur during breast-
feeding; therefore HIV-positive clients should be
encouraged to bottle-feed their neonates.
Frequent hand washing is encouraged. Support
groups and community agencies can be identified
to assist the parents with the newborn's home
care, the impact of the diagnosis of HIV infection,
and available financial resources. It is
recommended that newborn infants of HIV-positive
clients receive antiviral medications for the first 6
weeks of life.
A client with known cardiac disease has been
admitted to the postpartum care unit after an
uneventful delivery. The unit nurse instructs the
client to use the call button for assistance
whenever she needs to get out of bed or wishes to
care for her infant. Which postpartum complication
is the nurse most concerned about for this client?
1.Postpartum infection
2.Maternal attachment
3.Maternal overexertion
4.Postpartum newborn-mother bonding
3 thrombophlebitis. Which nursing action is indicated
The immediate postpartum period is associated
with increased risks for the cardiac client.
Hormonal changes and fluid shifts from
extravascular tissues to the circulatory system
cause additional stress on cardiac functioning.
Although options 1, 2, and 4 are appropriate
nursing concerns during the postpartum period,
the primary concern for the cardiac client is to
maintain a safe environment because of the
potential for cardiac compromise.
A postpartum care unit nurse is reviewing the
records of 4 new mothers admitted to the unit. The
nurse determines that which mother would be
least likely at risk for developing a puerperal
infection?
1.A mother who had ten vaginal exams during
labor
2.A mother with a history of previous puerperal
infections
3.A mother who gave birth vaginally to a 3200
gram infant
4.A mother who experienced prolonged rupture of
the membranes
3
Risk factors associated for puerperal infection
include a history of previous puerperal infections,
cesarean births, trauma, prolonged rupture of the
membranes, prolonged labor, multiple vaginal
exams, and retained placental fragments.
A postpartum unit nurse is preparing to care for a
client who has just delivered a healthy newborn. In
the immediate postpartum period what is the
recommended frequency for the nurse to assess
the client's vital signs?
1.Every hour for the first 2 hours and then every 4
hours
2.Every 30 minutes during the first hour and then
every hour for the next 2 hours
3.Every 5 minutes for the first 30 minutes and then
every hour for the next 4 hours
4.Every 15 minutes during the first hour and then
every 30 minutes for the next 2 hours
4 being used.
During the immediate postpartum period, the
nurse takes vital signs every 15 minutes in the first
hour after birth, every 30 minutes for the next 2
hours, and every hour for the next 2 to 6 hours.
The nurse monitors vital signs thereafter every 4
hours for 24 hours and every 8 to 12 hours for the
remainder of the hospital stay.
The postpartum unit nurse is performing an
assessment on a client who is at risk for
in assessing for thrombophlebitis?
1.Palpate for pedal pulses.
2.Ask the client about pain in the calf area.
3.Assess for the presence of vaginal hematoma.
4.Ask the client to ambulate and assess for the
presence of pain.
2
Thrombophlebitis is a potential complication in the
postpartum period. The client with
thrombophlebitis may experience pain in the calf.
The remaining options would not determine the
presence of thrombophlebitis. Palpating pulses
assesses circulation. The presence of a hematoma
does not indicate thrombophlebitis. The nurse
should not ask the client to ambulate if
thrombophlebitis is suspected.
The rubella vaccine is prescribed to be
administered to a client 2 days after delivery of her
child. The nurse preparing to administer the
vaccine develops a list of the potential risks
associated with this vaccine. The nurse reviews the
list with the client and cautions the client to avoid
which situation?
1.Sunlight for 3 days
2.Scratching the injection site
3.Pregnancy for 2 to 3 months after the vaccination
4.Sexual intercourse for 2 to 3 months after the
vaccination
3
Rubella vaccine is a live attenuated virus that
evokes an antibody response, which provides
immunity for 15 years. Because rubella is a live
vaccine, it will act as the virus and is potentially
teratogenic in the organogenesis phase of fetal
development. The client needs to be informed
about the potential effects of this vaccine and the
need to avoid becoming pregnant for 2 to 3
months after receiving the vaccine. Sunlight has no
effect on the client who is vaccinated.
The vaccine may cause local or systemic reactions,
but all of these are mild and short-lived. Abstinence
from sexual intercourse is not necessary unless
another form of effective contraception is not
On the second postpartum day, a woman
complains of burning on urination, urgency, and
frequency of urination. A urinalysis is done, and the
results indicate the presence of a urinary tract
infection. The nurse instructs the new mother
regarding measures to take for treatment of the
infection. Which statement, if made by the mother,
would indicate a need for further instructions?
1."I need to urinate frequently throughout the
day."
2."The prescribed medication must be taken until it
is finished."
3."My fluid intake should be increased to at least
3000 mL daily."
4."Foods and fluids that will increase urine
alkalinity should be consumed."
4
Foods and fluids that acidify, not alkalinize the
urine should be encouraged. The woman should be
encouraged to urinate frequently throughout the
day, instructed to take the medication for the
entire time it is prescribed, and encouraged to
drink at least 3000 mL of fluid each day to flush the
infection from the bladder.
A pregnant woman who is infected with the human
immunodeficiency virus (HIV) delivers a newborn
infant, and the nurse provides instructions to help
the mother regarding care of the infant. Which
statement by the client would indicate the need for
further instructions?
1."I will be sure to wash my hands before and after
bathroom use."
2."I need to breast-feed, especially for the first 6
weeks postpartum."
3."Support groups are available to assist me with
understanding my diagnosis of HIV."
4."My newborn infant should be on antiviral
medications for the first 6 weeks after delivery."
2 4.A 22-year-old woman with a first pregnancy who
Perinatal transmission of HIV to the fetus or
neonate of an HIV-positive woman can occur
during the antenatal, intrapartal, or postpartum
period. HIV transmission can occur during breast-
feeding. Therefore HIV-positive clients should be
encouraged to bottle-feed their neonates.
Frequent handwashing is encouraged. Support
groups and community agencies can be identified
to assist clients with home care of the newborn
infant, the impact of the diagnosis of HIV infection,
and finding available financial resources. It is
recommended that newborn infants of HIV-positive
clients receive antiviral medications for their first 6
weeks of life.
The home care nurse's assignment is to visit a new
mother at home 24 to 48 hours after discharge.
What should the nurse expect to note in a healthy
mother who is breast-feeding her newborn infant?
1.The mother has cracked nipples and feeds the
infant with a supplemental bottle.
2.The mother complains of breast engorgement,
and the infant demonstrates difficulty in latching
onto the breast.
3.The mother is breast-feeding the infant with the
infant's head turned toward her breast and the
body flat in her arms; the mother has sore nipples,
and the infant has a suck blister.
4.The mother is breast-feeding with the infant in a
tummy-to-tummy position without signs of cracked
nipples; the baby demonstrates bursts of sucking,
followed by a pause and swallow.
4
The infant should be positioned completely facing
the mother with head, neck, and spine aligned.
Poor positioning increases the number of attempts
for latching on. The infant's head turned toward
the breast and the body flat in the mother's arms is
incorrect because it demonstrates improper
positioning. Breast engorgement, sore nipples, and
cracked nipples are all complications that are the
result of improper positioning.
The nurse who is employed in a prenatal clinic is
performing prenatal assessments on clients who
are in their first trimester of pregnancy. The nurse
is concerned with identifying clients who may be at
risk for the development of postpartum
complications. Which client would be at the lowest
risk for development of postpartum
thromboembolic disorders?
1.A 39-year-old woman who reports that she
smokes
2.A 26-year-old woman with a family history of
thrombophlebitis
3.A 37-year-old woman in her fourth pregnancy
who is overweight
states that oral contraceptives taken in the past
have caused thrombophlebitis
2
Certain factors create a risk for the development of
thromboembolic disorders. These include smoking,
varicose veins, obesity, a history of
thrombophlebitis, women older than 35 years or
who have had more than three pregnancies, and
women who have had a cesarean birth. From the
options presented, a 26-year-old woman with a
family history of thrombophlebitis is least likely to
develop thromboembolic disorders in the
postpartum period
The nurse has provided instructions for a
postpartum client at risk for thrombosis regarding
measures to prevent its occurrence. Which
statement, if made by the client, indicates a need
for further education?
1."I should apply my antiembolism stockings after
breakfast."
2."I should avoid prolonged standing or sitting in
one position."
3."I should perform regularly scheduled exercise
such as walking."
4."I should avoid using pillows under my knees to
prevent pressure in the back of my knee area."
1 massaging the uterine fundus. Options 1, 2, and 4
The nurse should instruct the client to apply
antiembolism stockings before the client rises in
the morning to prevent the venous congestion that
will begin as soon as the mother gets up.
Circulation can be improved with a regular
schedule of activity, preferably walking, and the
mother should be instructed to avoid prolonged
standing or sitting in one position and avoid placing
pillows under the knees because of the risk venous
stasis in the lower extremities. The mother also
should be encouraged to maintain a fluid intake of
at least 2500 mL/day to prevent dehydration and
consequent sluggish circulation.
The discharge nurse is discussing mastitis with a
postpartum client. Which statement made by the
client indicates a need for further instruction?
1."If I develop a hot, reddened, triangle-shaped
area on my breast, I should contact my health care
provider."
2."Antibiotics, rest, warm compresses, and
adequate fluid intake are all important for the
treatment of mastitis."
3."If I develop a fever, chills, or body aches at any
time after discharge, I should stop breast-feeding
immediately."
4."I may develop mastitis if I wear underwire bras,
experience excessive fatigue, or suddenly decrease
the number of feedings."
3 a heavy menstrual period. After that time, the
The mother should not discontinue breast-feeding
even if mastitis occurs. Mastitis, a breast infection,
is best characterized by a sudden onset of flulike
symptoms, localized breast pain and tenderness,
and a hot, reddened area on the breast that often
resembles the shape of a pie wedge. Treatment
usually includes antibiotics, but the mother should
be instructed to feed the baby or pump frequently
to adequately empty the affected breast.
On assessment of a client who is 30 minutes into
the fourth stage of labor, the nurse finds the
client's perineal pad saturated in blood and blood
soaked into the bed linen under the client's
buttocks. Which is the nurse's initial action?
1.Call the health care provider.
2.Assess the client's vital signs.
3.Gently message the uterine fundus.
4.Administer a 300-mL bolus of a 20 units/L
oxytocin (Pitocin) solution.
3 ruptures into the ducts of the breast, breast-
The most frequent cause of excessive bleeding
after childbirth is uterine atony. A major
intervention to restore adequate tone is
stimulation of the uterine muscle via gently
may be necessary but they are not initial actions.
The initial action is to alleviate the problem.
Additionally a health care provider's prescription is
needed to administer a medication.
After receiving report at the beginning of the 0700
shift, the nurse must decide in what order the
clients should be assessed. How would the nurse
plan assessments? Arrange the clients in the order
that they should be assessed. All options must be
used.
Drag the text in the left column to the correct order
in the right column.
A nurse is checking lochia discharge in a woman in
the immediate postpartum period. The nurse notes
that the lochia is bright red and contains some
small clots. Based on this data, the nurse should
make which interpretation?
1.The client is hemorrhaging.
2.The client needs to increase oral fluids.
3.The client is experiencing normal lochia
discharge.
4.The client's health care provider needs to be
notified of the finding.
3
Lochia, the uterine discharge present after birth,
initially is bright red and may contain small clots.
During the first 2 hours after birth, the amount of
uterine discharge should be approximately that of
lochial flow should steadily decrease, and the color
of the discharge should change to a pinkish red or
reddish brown. Because this is a normal, expected
occurrence, options 1, 2, and 4 are incorrect.
A postpartum woman with mastitis in the right
breast complains that the breast is too sore for her
to breast-feed her infant. The nurse should tell the
client to implement which measure?
1.Pump both breasts and discard the milk.
2.Bottle-feed the infant on a temporary basis.
3.Breast-feed from the left breast and gently pump
the right breast.
4.Stop breast-feeding from both breasts until this
condition resolves.
3
In most cases, the mother can continue to breast-
feed with both breasts. If the affected breast is too
sore, the mother can pump the breast gently.
Regular emptying of the breast is important to
prevent abscess formation. If an abscess forms and
feeding will need to be discontinued and a pump
should be used to empty the breast (but the milk
should be discarded). Options 1, 2, and 4 are
incorrect.
A nurse has just received an intershift report. After
reviewing the client assignment and the
appropriate medical records, the nurse determines
that which client is most at risk for developing
postdelivery endometritis?
1.A primigravida with a normal spontaneous
vaginal delivery
2.A gravida II who delivered vaginally following an
18-hour labor
3.A client experiencing an elective cesarean
delivery at 38 weeks' gestation
4.An adolescent experiencing an emergency
cesarean delivery for fetal distress
4 2.Ask the client to urinate and empty her bladder.
Endometritis is an acute infection of the uterine
mucous lining immediately after delivery and is still
a leading cause of mortality for childbearing
women in the United States. Cesarean delivery is
the primary risk factor for uterine infection,
especially after emergency procedures. Other risk
factors include prolonged rupture of membranes,
multiple vaginal examinations, and an excessive
length of labor. The other options do not describe
the client most at risk to develop endometritis
following delivery.
A nurse provides a list of discharge instructions to a
client who has delivered a healthy newborn by
cesarean delivery. Which statement by the client
indicates the need for further teaching?
1."I can begin abdominal exercises immediately."
2."I need to notify the health care provider if I
develop a fever."
3."I can't lift anything heavier than my newborn for
at least 2 weeks."
4."I need to turn on my side and push up with my
arms to get out of bed."
1 4.1000
Abdominal exercises should not start immediately
following abdominal surgery until 3 to 4 weeks
postoperatively to allow for healing of the incision.
The other options are appropriate instructions for
the client following a cesarean delivery.
A nurse is caring for a client who has just delivered
a newborn following a pregnancy with a placenta
previa. When reviewing the plan of care, the nurse
should prepare to monitor the client for which risk
that is associated with placenta previa?
1.Infection
2.Hemorrhage
3.Chronic hypertension
4.Disseminated intravascular coagulation
2
Because the placenta is implanted in the lower
uterine segment, which does not contain the same
intertwining musculature as the fundus of the
uterus, this site is more prone to bleeding. The
other options are not risks that are specifically
related to placenta previa.
The nurse is preparing to perform a fundal
assessment on a postpartum client. The nurse
understands that which is the initial nursing action
when performing this assessment?
1.Ask the client to turn on her side.
3.Massage the fundus gently before determining
the level of the fundus.
4.Ask the client to lie flat on her back, with her
knees and legs flat and straight.
2
Before fundal assessment is started, the nurse
should ask the mother to empty her bladder so
that an accurate assessment can be done. The
nurse can then assess the bladder for complete
emptying and accurately assess uterine involution.
When performing fundal assessment, the woman is
asked to lie flat on her back, with the knees flexed.
Massaging the fundus is not appropriate unless the
fundus is boggy or soft, and then it should be
massaged gently until firm.
The nurse is providing nutritional counseling to a
new mother who is breast-feeding her newborn.
The nurse should instruct the client that her calorie
needs should increase by approximately how many
calories a day?
1.100
2.300
3.500
3
If the client is breast-feeding, her calorie needs
increase by approximately 500 cal/day. The client
should also be instructed regarding the need for
increased fluids and the need for prenatal vitamins
and iron supplements.
The postpartum client asks the nurse about the
occurrence of afterpains. The nurse informs the
client that afterpains will be especially noticeable
during which activity?
1.Ambulating
2.Breast-feeding
3.Taking sitz baths
4.Arriving home and activities are increased
2 unsure mother begin to participate in caring for her
Afterpains are a normal occurrence and result from
contractions of the uterus as it reduces in size
during involution. Afterpains may be especially
noticeable during breast-feeding because oxytocin
is released in response to the infant's sucking. The
other options are incorrect.
The nursing instructor is reviewing the plan of care
with a student regarding care of a postpartum
client. The instructor asks the nursing student
about the taking-in phase according to Rubin's
phases of regeneration and the client behaviors
that are most likely to occur during this phase.
Which response made by the student indicates an
understanding of this phase?
1."The client would be independent."
2."The client initiates activities on her own."
3."The client participates in mothering tasks."
4."The client is self-focused and talks to others
about labor."
4 lymphatics to engorge. Correction of nipple
Rubin has identified three phases of regeneration
during the postpartum period. The taking-in phase
occurs in the first 3 days postpartum, and the
taking-hold phase occurs between days 3 to 10.
During the taking-in phase, the new mother is
attempting to integrate her labor and birth
experience. She tends to need sleep and feels
fatigued, talks about labor, and is self-focused and
dependent. In the taking-hold phase, the client is
more active, independent, initiates activities, and
partakes in mothering tasks. In the letting-go
phase, the mother may grieve over the separation
of the baby from part of her body.
The nurse is teaching a new mother how to care for
her newborn. The nurse notes that the client is
very fearful and reluctant to handle the newborn
and notes that this is the client's first child. Which
nursing intervention is least appropriate in assisting
the promotion of mother-infant interaction and
bonding?
1.Accepting the client's feelings
2.Acknowledging the client's apprehension
3.Assisting the client with giving the baths to allow
her to become more at ease
4.Leaving the infant with the client so that she will
be required to provide the care
4 teaching?
A client with no experience of handling infants may
be fearful and reluctant to handle her newborn or
to take on physical care on her own. Leaving the
infant with the mother so that she will be required
to provide the care will produce additional
apprehension. Acceptance of her feelings and
acknowledgment of the apprehension can help an
newborn. Assistance will help the client become
more at ease.
The nurse is assigned to care for a client who has
chosen to formula-feed her infant. The nurse
should plan to provide which instruction to the
client?
1.Apply a heating pad to breasts for comfort.
2.Wear a breast shield to correct nipple inversion.
3.Wear a supportive brassiere continuously for 72
hours.
4.Use the manual breast pump provided to express
milk.
3
Wearing a supportive brassiere continuously for 72
hours postpartum will minimize breast
engorgement. Any stimulation of the breasts
(expression of milk, infant sucking) or increase in
circulation (heating pad) will increase milk
production or cause the blood vessels and
inversion will not be necessary if the mother
chooses not to breast-feed her infant.
A nurse is monitoring a new mother in the fourth
stage of labor for signs of hemorrhage. Which
indicates an early sign of excessive blood loss?
1.A temperature of 100.4º F
2.An increased pulse rate of 88 to 102 beats/min
3.A blood pressure change from 130/88 to 124/80
mm Hg
4.An increase in the respiratory rate from 18 to 22
breaths/min
2
During the fourth stage of labor, the maternal
blood pressure, pulse, and respiration should be
checked every 15 minutes during the first hour. A
rising pulse is an early sign of excessive blood loss,
because the heart pumps faster to compensate for
reduced blood volume. The blood pressure will fall
as the blood volume diminishes, but a decreased
blood pressure would not be the earliest sign of
hemorrhage.
A nurse is providing instructions to a client who has
been diagnosed with mastitis. Which statement
made by the client indicates a need for further
1."I need to wear a supportive bra to relieve the
discomfort."
2."I need to stop breast-feeding until this condition
resolves."
3."I can use analgesics to assist in alleviating some
of the discomfort."
4."I need to take antibiotics, and I should begin to
feel better in 24 to 48 hours."
2 mastitis?
In most cases, the client can continue to breast-
feed with both breasts. If the affected breast is too
sore, the client can pump the breast gently.
Regular emptying of the breast is important to
prevent abscess formation. Antibiotic therapy
assists in resolving the mastitis within 24 to 48
hours. Additional supportive measures include ice
packs, breast supports, and analgesics.
A nurse is monitoring the client for signs of
postpartum depression. Which would indicate the
need for further assessment related to this form of
depression?
1.The client is caring for the infant in a loving
manner.
2.The client demonstrates an interest in the
surroundings.
3.The client constantly complains of tiredness and
fatigue.
4.The client looks forward to visits from the father
of the newborn.
3 apply.
Postpartum depression is not the normal
depression that many new mothers experience
from time to time. The client experiencing
depression shows less interest in her surroundings
and a loss of her usual emotional response toward
the family. The client also is unable to show
pleasure or love and may have intense feelings of
unworthiness, guilt, and shame. The client often
expresses a sense of loss of self. Generalized
fatigue, complaints of ill health and difficulty in
concentrating also are present. The client would
have little interest in food and experience sleep
disturbances.
The nurse caring for a client with a diagnosis of
subinvolution should understand that which is a
primary cause of this diagnosis?
1.Afterpains
2.Increased estrogen levels
3.Increased progesterone levels
4.Retained placental fragments from delivery
4 A nurse visits a client at home who delivered a
Retained placental fragments and infections are
the primary causes of subinvolution. When either
of these processes is present, the uterus has
difficulty contracting. The presence of afterpains is
an expected finding following delivery. Options 2
and 3 are not causes of subinvolution.
When planning care for a postpartum client that
plans to breast-feed her infant, which important
piece of information should the nurse include in
the teaching plan to prevent the development of
1.Offer only one breast at each feeding.
2.Massage distended areas as the infant nurses.
3.Cleanse nipples with a mild antibacterial soap
before and after infant feedings.
4.Express and discard milk from the affected breast
at the first signs of mastitis.
2
Massaging the distended areas as the infant nurses
will encourage complete emptying of the breast
and prevent milk stasis. Each breast should be
offered at each feeding to prevent milk stasis and
ensure adequate milk supply. Soap should not be
used on the nipples because of the risk of drying or
cracking. If early signs of mastitis occur, the client
usually will be instructed to nurse the infant more
frequently, because infant sucking is thought to
empty the breast more completely.
Which instructions should a nurse provide to a
client following delivery regarding care of the
episiotomy site to prevent infection? Select all that
1.Report a foul-smelling discharge.
2.Take a warm sitz baths three times a day.
3.Change the perineum pads three times a day.
4.Use warm water to rinse the perineum after
elimination.
5.Wipe the perineum from front to back after
voiding and defecation.
1, 2, 4, 5
Warm sitz baths and cleansing with warm water
are helpful for relieving pain, and these measures
will promote cleanliness in the perineal area to
prevent infection. The client should also be
instructed to wipe the perineum from front to back
after voiding and defecation to decrease the risk
for contamination with microorganisms from the
anus to the vagina. Warm water should be used to
rinse the perineum after elimination. The client
also should be instructed that the perineal pad
should be changed after each elimination and may
be changed in between.
healthy newborn 2 days ago. The client is
complaining of breast discomfort. The nurse notes
that the client is experiencing breast engorgement.
Which instructions should the nurse provide to the
client regarding relief of the engorgement? Select
all that apply.
1.Wear a supportive bra between feedings.
2.Avoid breast-feeding during the time of breast
engorgement.
3.Feed the infant at least every 2 hours for 15 to 20
minutes on each side.
4.Apply moist heat to both breasts for about 20
minutes before a feeding.
5.Massage the breasts gently during a feeding,
from the outer areas to the nipples.
1, 3, 4, 5
During breast engorgement, the client should be
advised to feed the infant frequently, at least every
2 hours, for 15 to 20 minutes on each side. The
infant will have an easier time latching on if the
client softens her breast and expresses her milk
before a feeding. Instruct the client to apply moist
heat to both breasts for about 20 minutes before a
feeding. This can be done in the shower or with
warm wet towels. During a feeding, it is helpful to
massage the breast gently from the outer area to
the nipple. This helps stimulate the let-down and
flow of milk. The client should also be instructed to
wear a supportive bra between feedings.
The postpartum nurse is taking the vitals of client
who delivered a healthy newborn 4 hours ago. The
nurse notes that the client's temperature is 100.2
F. What is the priority nursing action?
1. Document the findings
2. Retake the temperature in 15 mintues
3. Notify HCP
4. Increase hydration by encouraging oral fluids
4 The nurse is teaching a postpartum client about
The nurse is assessing a client who is 6 hours
postpartum after delivering a full term healthy
newborn. The client complains to the nurse of
feelings of faintness and dizziness. Which nursing
action is most appropriate?
1. Raise the head of the client's bed
2. Obtain Hgb and Hct levels
3. Instruct the client to request help when getting
out of bed
4. Inform nursery room nurse to avoid bringing the
newborn to the client until the client's symptoms
have subsided
3
The postpartum nurse is providing instructions to a
client after birth of a healthy newborn. Which time
frame should the nurse relay to the client regarding
the return of bowel function?
1. 3 days postpartum
2. 7 days postpartum
3. On the day of birth
4. Within 2 weeks postpartum
1
The nurse is planning care for a postpartum client
who had a vaginal delivery 2 hours ago. The client
required an episiotomy and has several
hemorrhoids. What is the priority nursing
consideration for this client?
1. Client pain level
2. Inadequate urinary output
3. Client perception of body changes
4. Potential for imbalanced body fluid volume
1
The nurse is providing postpartum instructions for
a client who will be breast feeding her newborn.
The nurse determines that the client understands
the instructions if she makes which statement?
Select all that apply.
1. "I should wear a bra that provides support"
2. "Drinking alcohol can affect my milk supply"
3. "The use of caffeine can decrease my milk
supply"
4. "I will start my estrogen birth control pills again
as soon as I get home"
5. "I know if my breasts get engorged, I will limit
my BF and supplement the baby"
5. "I plan on having bottled water available in the
refrigerator so I can get additional fluids easily"
1, 2, 3, 6
breastfeeding. Which instruction should the nurse
include?
1. The diet should include additional fluids
2. Prenatal vitamins should be discontinued
3. Soap should be used to cleanse the breasts
4. Birth control measures are unnecessary while BF
1
The nurse is preparing to assess the uterine fundus
of a client in the immediate postpartum period.
After locating the fundus, the nurse notes that the
uterus feels soft and boggy. Which nursing
intervention is appropriate?
1. Elevate the client's legs
2. Massage the fundus until it is firm
3. Ask the client to turn on her left side
4. Push on the uterus to assist in expressing clots
2
The nurse is caring for four 1-day postpartum
clients. Which client assessment requires the need
for follow-up?
1. The client with mild afterpains
2. The client with a pulse rate of 60 bpm
3. The client with colostrum discharge form both
breasts
4. The client with lochia that is red and has a foul
smelling odor
4 2. A increase in pulse rate from 88 to 102 bpm
When performing a postpartum assessment on a
client, the nurse notes the presence of clots in the
lochia. The nurse examines the clot and notes that
they are larger than 1 cm. Which nursing action is
most appropriate?
1. Document findings
2. Reassess client in 2 hours
3. Notify HCP
4. Encourage increased oral intake of fluids
3 2. Rest during the active phase
The nurse is monitoring the amount of lochia
drainage in a client who is 2 hours postpartum and
notes that the client has saturated a perineal pad in
15 minutes. How should the nurse respond to this
finding initially?
1. Document the finding
2. Encourage the client to ambulate
3. Encourage the client to increase fluid intae
4. Contact HCP and inform of the finding
4 breastfeeding her newborn. Which statement
The nurse has provided discharge instructions to a
client who delivered a healthy newborn by c-
section. Which statement by the client indicates a
need for further instruction?
1. "I will begin abdominal exercises immediately"
2. "I will notify the HCP if I develop a fever"
3. "I will turn on my side and push with my arms to
get out of bed"
4. "I will lift nothing heavier than my newborn baby
for at least 2 weeks"
1 sign should the nurse note if superficial venous
After a precipitous delivery, the nurse notes that
the new mother is passive and touches her
newborn infant only briefly with her fingertips.
What should the nurse do to help the woman
process the delivery?
1. Encourage the mother to BF soon after birth
2. Support the mother in her reaction to the
newborn infant
3. Tell the mother that it is important to hold the
newborn infant
4. Document a complete account of the mother's
reaction on the birth record
2
The nurse is monitoring a client in the immediate
postpartum period for signs of hemorrhage. Which
sign, if noted, would be an early sign of excessive
blood loss?
1. A temperature of 100.4 F (38 C)
3. A BP change from 130/88 to 124/80 mmHg
4. An increase in the respiratory rate from 18 to 22
BPM
2
The nurse is preparing a list of self care instructions
for a postpartum client who was diagnosed with
mastitis. Which instructions should be included on
the list? Select all that apply.
1. Wear a supportive bra
3. Maintain a fluid intake of at least 3000 mL/day
4. Continue to breastfeed if the breasts are not
sore
5. Take the prescribed antibiotics until the soreness
subsides
6. Avoid decompression of the breasts by
breastfeeding or breast pump
1, 2, 3, 4
The nurse is providing instructions about measures
to prevent postpartum mastitis to a client who is
would indicate the need for further instruction?
1. "I should breastfeed every 2-3 hours"
2. "I should change the breast pads frequently"
3. "I should wash my hands well before BF"
4. "I should wash my nipples daily with soap and
water"
4
The postpartum nurse is assessing a client who
delivered a healthy infant by c-section for signs and
symptoms of superficial venous thrombosis. Which
thrombosis were present?
1. Paleness of the calf area
2. Coolness of the calf area
3. Enlarged, hardened veins
4. Palpable dorsalis pedis pulses
3
A client in postpartum unit complains of sudden
sharp chest pain and dyspnea. The nurse notes that
the client is tachycardia and the respiratory rate is
elevated. The nurse suspects a pulmonary
embolism. Which should be the initial nursing
action?
1. Start an IV line
2. Assess the client's BP
3. Prepare to administer morphine sulfate
4. Administer oxygen 8-10 L/minute by face mask
4 On assessment of a postpartum client, the nurse
The nurse is assessing a client in the fourth stage of
labor and notes the fundus is firm, but the bleeding
is excessive. Which should bee the initial nursing
action?
1. Record the findings
2. Massage the fundus
3. Notify HCP
4. Place client in Trendelenburg
3 receiving Pitocin by IV infusion to stimulate uterine
The nurse is preparing to care for four assigned
clients. Which client is most at risk for
hemorrhage?
1. A primiparous client who delivered 4 hours ago
2. A primiparous client who delivered 6 hours ago
3. A multiparous client who delivered a large baby
after oxytocin induction
4. A primiparous client who delivered 6 hours ago
and had epidural anesthesia
3 Bradycardia or late or variable decelerations
A postpartum client is diagnosed with cystitis. The
nurse should plan for which priority action in the
care of the client?
1. Providing sitz baths
2. Encouraging fluid intake
3. Placing ice on the perineum
4. Monitoring Hcg and Hct levels
2
The nurse is monitoring a postpartum client who
received epidural anesthesia for delivery for the
presence of vulvar hematoma. Which assessment
finding would best indicate the presence of a
hematoma?
1. Changes in vitals
2. Signs of heavy bruising
3. Complaints of intense pain
4. Complaints of tearing sensation
1 BPM. Which of the following nursing actions is
The nurse is creating a plan of care for a
postpartum client with a small vulvar hematoma.
The nurse should include which specific action
during the first 12 hours after delivery?
1. Encourage hourly ambulation
2. Assess vitals every 4 hours
3. Measure fundal height every 4 hours
4. Prepare an icepack for application to the area
4
notes that the uterus feels soft and boggy. The
nurse should be taking which initial action?
1. Document the findings
2. Elevate the client's legs
3. Massage the fundus until it is firm
4. Push on the uterus to assist in expressing clots
3
A nurse is caring for a client in labor who is
contractions. Which assessment finding would
indicate to the nurse that the infusion needs to be
discontinued?
1.Three contractions occurring within a 10-minute
period
2.A fetal heart rate of 90 beats per minute
3.Adequate resting tone of the uterus palpated
between contractions
4.Increased urinary output
2. A normal fetal heart rate is 120-160 BPM.
indicate fetal distress and the need to discontinue
to pitocin. The goal of labor augmentation is to
achieve three good-quality contractions in a 10-
minute period.
A nurse is beginning to care for a client in labor.
The physician has prescribed an IV infusion of
Pitocin. The nurse ensures that which of the
following is implemented before initiating the
infusion?
1.Placing the client on complete bed rest
2.Continuous electronic fetal monitoring
3.An IV infusion of antibiotics
4.Placing a code cart at the client's bedside
2. Continuous electronic fetal monitoring should be
implemented during an IV infusion of Pitocin.
A nurse is monitoring a client in active labor and
notes that the client is having contractions every 3
minutes that last 45 seconds. The nurse notes that
the fetal heart rate between contractions is 100
most appropriate?
1.Encourage the client's coach to continue to
encourage breathing exercises
2.Encourage the client to continue pushing with
each contraction
3.Continue monitoring the fetal heart rate
4.Notify the physician or nurse mid-wife
4. A normal fetal heart rate is 120-160 beats per
minute. Fetal bradycardia between contractions
may indicate the need for immediate medical
management, and the physician or nurse mid-wife
needs to be notified.
A nurse is monitoring a client in labor who is
receiving Pitocin and notes that the client is
experiencing hypertonic uterine contractions. List
in order of priority the actions that the nurse takes.
1.Stop of Pitocin infusion
2.Perform a vaginal examination
3.Reposition the client
4.Check the client's blood pressure and heart rate
5.Administer oxygen by face mask at 8 to 10 L/min
1, 4, 2. 5, 3.
If uterine hypertonicity occurs, the nurse
immediately would intervene to reduce uterine
activity and increase fetal oxygenation. The nurse
would stop the Pitocin infusion and increase the
rate of the nonadditive solution, check maternal BP
for hyper or hypotension, position the woman in a
side-lying position, and administer oxygen by snug
face mask at 8-10 L/min. The nurse then would
attempt to determine the cause of the uterine
hypertonicity and perform a vaginal exam to check
for prolapsed cord
A nurse is assigned to care for a client with
hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the
physician's orders and would expect to note which
of the following prescribed treatments for this
condition?
1.Medication that will provide sedation
2.Increased hydration
3.Oxytocin (Pitocin) infusion
4.Administration of a tocolytic medication
3. Therapeutic management for hypotonic uterine
dysfunction includes oxytocin augmentation and
amniotomy to stimulate a labor that slows.
A nurse in the labor room is preparing to care for a
client with hypertonic uterine dysfunction. The
nurse is told that the client is experiencing
uncoordinated contractions that are erratic in their
frequency, duration, and intensity. The priority
nursing intervention would be to:
1.Monitor the Pitocin infusion closely
2.Provide pain relief measures
3.Prepare the client for an amniotomy
4.Promote ambulation every 30 minutes
2. Management of hypertonic labor depends on
the cause. Relief of pain is the primary intervention
to promote a normal labor pattern.
A nurse is developing a plan of care for a client
experiencing dystocia and includes several nursing
interventions in the plan of care. The nurse
prioritizes the plan of care and selects which of the
following nursing interventions as the highest
priority?
1.Keeping the significant other informed of the
progress of the labor
2.Providing comfort measures
3.Monitoring fetal heart rate
4.Changing the client's position frequently
3. The priority is to monitor the fetal heart rate.
A nurse in the labor room is performing a vaginal
assessment on a pregnant client in labor. The nurse
notes the presence of the umbilical cord protruding
from the vagina. Which of the following would be
the initial nursing action?
1.Place the client in Trendelenburg's position
2.Call the delivery room to notify the staff that the
client will be transported immediately
3.Gently push the cord into the vagina
4.Find the closest telephone and stat page the
physician
1. When cord prolapse occurs, prompt actions are
taken to relieve cord compression and increase
fetal oxygenation. The mother should be
positioned with the hips higher than the head to
shift the fetal presenting part toward the
diaphragm. The nurse should push the call light to
summon help, and other staff members should call
the physician and notify the delivery room. No
attempt should be made to replace the cord. The
examiner, however, may place a gloved hand into
the vagina and hold the presenting part off of the
umbilical cord. Oxygen at 8 to 10 L/min by face
mask is delivered to the mother to increase fetal
oxygenation.
A maternity nurse is caring for a client with
abruptio placenta and is monitoring the client for
disseminated intravascular coagulopathy. Which
assessment finding is least likely to be associated
with disseminated intravascular coagulation?
1.Swelling of the calf in one leg
2.Prolonged clotting times
3.Decreased platelet count
4.Petechiae, oozing from injection sites, and
hematuria
1. DIC is a state of diffuse clotting in which clotting
factors are consumed, leading to widespread
bleeding. Platelets are decreased because they are
consumed by the process; coagulation studies
show no clot formation (and are thus normal to
prolonged); and fibrin plugs may clog the
microvasculature diffusely, rather than in an
isolated area. The presence of petechiae, oozing
from injection sites, and hematuria are signs
associated with DIC. Swelling and pain in the calf of
one leg are more likely to be associated with
thrombophebitis.
A nurse is assessing a pregnant client in the 2nd
trimester of pregnancy who was admitted to the
maternity unit with a suspected diagnosis of
abruptio placentae. Which of the following
assessment findings would the nurse expect to
note if this condition is present?
1.Absence of abdominal pain
2.A soft abdomen
3.Uterine tenderness/pain
4.Painless, bright red vaginal bleeding
3. In abruptio placentae, acute abdominal pain is
present. Uterine tenderness and pain accompanies
placental abruption, especially with a central
abruption and trapped blood behind the placenta.
The abdomen will feel hard and boardlike on
palpation as the blood penetrates the myometrium
and causes uterine irritability. Observation of the
fetal monitoring often reveals increased uterine
resting tone, caused by failure of the uterus to
relax in attempt to constrict blood vessels and
control bleeding.
A maternity nurse is preparing for the admission of
a client in the 3rd trimester of pregnancy that is
experiencing vaginal bleeding and has a suspected
diagnosis of placenta previa. The nurse reviews the
physician's orders and would question which
order?
1.Prepare the client for an ultrasound
2.Obtain equipment for external electronic fetal
heart monitoring
3.Obtain equipment for a manual pelvic
examination
4.Prepare to draw a Hgb and Hct blood sample
3. Manual pelvic examinations are contraindicated
when vaginal bleeding is apparent in the 3rd
trimester until a diagnosis is made and placental
previa is ruled out. Digital examination of the cervix
can lead to maternal and fetal hemorrhage. A
diagnosis of placenta previa is made by ultrasound.
The H/H levels are monitored, and external
electronic fetal heart rate monitoring is initiated.
External fetal monitoring is crucial in evaluating the
fetus that is at risk for severe hypoxia
An ultrasound is performed on a client at term
gestation that is experiencing moderate vaginal
bleeding. The results of the ultrasound indicate
that an abruptio placenta is present. Based on
these findings, the nurse would prepare the client
for:
1.Complete bed rest for the remainder of the
pregnancy
2.Delivery of the fetus
3.Strict monitoring of intake and output
4.The need for weekly monitoring of coagulation
studies until the time of delivery
2. The goal of management in abruptio placentae is
to control the hemorrhage and deliver the fetus as
soon as possible. Delivery is the treatment of
choice if the fetus is at term gestation or if the
bleeding is moderate to severe and the mother or
fetus is in jeopardy.
A nurse in a labor room is assisting with the vaginal
delivery of a newborn infant. The nurse would
monitor the client closely for the risk of uterine
rupture if which of the following occurred?
1.Hypotonic contractions
2.Forceps delivery
3.Schultz delivery
4.Weak bearing down efforts
2. Excessive fundal pressure, forceps delivery,
violent bearing down efforts, tumultuous labor,
and shoulder dystocia can place a woman at risk
for traumatic uterine rupture. Hypotonic
contractions and weak bearing down efforts do not
alone add to the risk of rupture because they do
not add to the stress on the uterine wall.
During the period of induction of labor, a client
should be observed carefully for signs of:
1.Severe pain
2.Uterine tetany
3.Hypoglycemia
4.Umbilical cord prolapse
2. Uterine tetany could result from the use of
oxytocin to induce labor. Because oxytocin
promotes powerful uterine contractions,
uterine tetany may occur. The oxytocin
infusion must be stopped to prevent
uterine rupture and fetal compromise.
320. The postpartum nurse is taking the vital signs
of a client who delivered a healthy newborn 4
hours ago. The nurse notes that the client's
temperature is 100.2 ° F. What is the priority
nursing action?
1. Document the findings.
2. Retake the temperature in 15 minutes.
3. Notify the health care provider (HCP).
4. Increase hydration by encouraging oral fluids.
4. Increase hydration by encouraging oral fluids.
The client's temperature should be taken every 4
hours while she is awake. Temperatures up to
100.4 ° F (38 ° C) in the first 24 hours after birth
often are related to the dehydrating effects of
labor. The appropriate action is to increase
hydration by encouraging oral fluids, which should
bring the temperature to a normal reading.
Although the nurse also would document the
findings, the appropriate action would be to
increase hydration. Taking the temperature in
another 15 minutes is an unnecessary action.
Contacting the HCP is not necessary.
321. The nurse is assessing a client who is 6 hours
postpartum after delivering a full-term healthy
newborn. The client complains to the nurse of
feelings of faintness and dizziness. Which nursing
action would be most appropriate?
1. Raise the head of the client's bed.
2. Obtain hemoglobin and hematocrit levels.
3. Instruct the client to request help when getting
out of bed.
4. Inform the nursery room nurse to avoid bringing
the newborn to the client until the mother's
symptoms have subsided. 3
3. Instruct the client to request help when getting
out of bed.
Orthostatic hypotension may be evident during the
first 8 hours after birth. Feelings of faintness or
dizziness are signs that caution the nurse to focus
interventions on the client's safety. The nurse
should advise the client to get help the first few
times she gets out of bed. Option 1 is not a helpful
action in this situation and would not relieve the
symptoms. Option 2 requires a health care
provider's prescription. Option 4 is unnecessary.
22. The postpartum nurse is providing instructions
to a client after delivery of a healthy newborn.
Which time frame should the nurse relay to the
client regarding the return of bowel function?
1. 3 days postpartum
2. 7 days postpartum
3. On the day of delivery
4. Within 2 weeks postpartum
1. 3 days postpartum
After birth, the nurse should auscultate the client's
abdomen in all four quadrants to determine the
return of bowel sounds. Normal bowel elimination
usually returns 2 to 3 days postpartum. Surgery,
anesthesia, and the use of opioids and pain control
agents also contribute to the longer period of
altered bowel functions. Options 2, 3, and 4 are
incorrect.
323. The nurse is planning care for a postpartum
client who had a vaginal delivery 2 hours ago. The
client had a midline episiotomy and has several
hemorrhoids. What is the priority nursing
consideration for this client?
1. Client pain level
2. Inadequate urinary output
3. Client perception of body changes
4. Potential for imbalanced body fluid volume
1. Client pain level
The priority nursing consideration for a client who
delivered 2 hours ago and who has a midline
episiotomy and hemorrhoids is client pain level.
Most clients have some degree of discomfort
during the immediate postpartum period. There
are no data in the question that indicate
inadequate urinary output, the presence of client
perception of body changes, and potential for
imbalanced body fluid volume.
324. The nurse is providing postpartum instructions
to a client who will be breast-feeding her newborn.
The nurse determines that the client has
understood the instructions if she makes which
statement( s)? Select all that apply.
1. "I should wear a bra that provides support." **
2. "Drinking alcohol can affect my milk supply." **
3. "The use of caffeine can decrease my milk
supply." **
4. "I will start my estrogen birth control pills again
as soon as I get home."
5. "I know if my breasts get engorged I will limit my
breast-feeding and supplement the baby."
6. "I plan on having bottled water available in the
refrigerator so I can get additional fluids easily."**
324. 1, 2, 3, 6 Rationale: The postpartum client
should wear a bra that is well-fitted and supportive.
Breasts may leak between feedings or during
coitus, and the client is taught to place a breast pad
in the bra. Breast-feeding clients should increase
their daily fluid intake; having bottled water
available indicates that the postpartum client
understands the importance of increasing fluids. If
engorgement occurs, the client should not limit
breast-feeding, but should breast-feed frequently.
Oral contraceptives containing estrogen are not
recommended for breast-feeding mothers.
Common causes of decreased milk supply include
formula use; inadequate rest or diet; smoking by
the mother or others in the home; and use of
caffeine, alcohol, or other medications.
325. The nurse is teaching a postpartum client
about breast-feeding. Which instruction should the
nurse include?
1. The diet should include additional fluids.
2. Prenatal vitamins should be discontinued.
3. Soap should be used to cleanse the breasts.
4. Birth control measures are unnecessary while
breast-feeding.
1. The diet should include additional fluids.
The diet for a breast-feeding client should include
additional fluids. Prenatal vitamins should be taken
as prescribed, and soap should not be used on the
breasts because it tends to remove natural oils,
which increases the chance of cracked nipples.
Breast-feeding is not a method of contraception, so
birth control measures should be resumed.
326. A nurse is preparing to assess the uterine
fundus of a client in the immediate postpartum
period. After locating the fundus, the nurse notes
that the uterus feels soft and boggy. Which nursing
intervention would be most appropriate?
1. Elevate the client's legs.
2. Massage the fundus until it is firm.
3. Ask the client to turn on her left side.
4. Push on the uterus to assist in expressing clots.
2. Massage the fundus until it is firm.
If the uterus is not contracted firmly, the initial
intervention is to massage the fundus until it is firm
and to express clots that may have accumulated in
the uterus. Pushing on an uncontracted uterus can
invert the uterus and cause massive hemorrhage.
Elevating the client's legs and positioning the client
on the side would not assist in managing uterine
atony.
327. The nurse is caring for four 1-day postpartum
clients. Which client would require further nursing
action?
1. The client with mild afterpains
2. The client with a pulse rate of 60 beats/ minute
3. The client with colostrum discharge from both
breasts
4. The client with lochia that is red and has a foul-
smelling odor.
4. The client with lochia that is red and has a foul-
smelling odor.
Lochia, the discharge present after birth, is red for
the first 1 to 3 days and gradually decreases in
amount. Normal lochia has a fleshy odor or an odor
similar to menstrual flow. Foul-smelling or purulent
lochia usually indicates infection, and these
findings are not normal. The other options are
normal findings for a 1-day postpartum client.
328. When performing a postpartum assessment
on a client, a nurse notes the presence of clots in
the lochia. The nurse examines the clots and notes
that they are larger than 1 cm. Which nursing
action is most appropriate?
1. Document the findings.
2. Reassess the client in 2 hours.
3. Notify the health care provider.
4. Encourage increased oral intake of fluids.
3. Notify the health care provider.
Normally, a few small clots may be noted in the
lochia in the first 1 to 2 days after birth from
pooling of blood in the vagina. Clots larger than 1
cm are considered abnormal. The cause of these
clots, such as uterine atony or retained placental
fragments, needs to be determined and treated to
prevent further blood loss. Although the findings
would be documented, the appropriate action is to
notify the HCP. Reassessing the client in 2 hours
would delay necessary treatment. Increasing oral
intake of fluids would not be a helpful action in this
situation.
329. The nurse is monitoring the amount of lochia
drainage in a client who is 2 hours postpartum and
notes that the client has saturated a perineal pad in
1 hour. How should the nurse document this
finding?
1. Scant
2. Light
3. Heavy
4. Excessive
3. Heavy
Lochia is the discharge from the uterus in
the postpartum period; it consists of blood
from the vessels of the placental site and
debris from the decidua. The following can
be used as a guide to determine the
amount of flow: scant = less than 2.5 cm (<
1 inch) on menstrual pad in 1 hour; light =
less than 10 cm (< 4 inches) on menstrual
pad in 1 hour; moderate = less than 15 cm
(< 6 inches) on menstrual pad in 1 hour;
heavy = saturated menstrual pad in 1 hour;
and excessive = menstrual pad saturated in
15 minutes. Test-Taking Strategy: Focus on
the subject, a saturated perineal pad in 1
hour. The data and the use of guidelines to
determine the amount of lochial flow will
direct you to the correct option.
330. The nurse is monitoring a client in the
immediate postpartum period for signs of
hemorrhage. Which sign, if noted, would be an
early sign of excessive blood loss?
1. A temperature of 100.4 ° F
2. An increase in the pulse rate from 88 to 102
beats/ minute
3. A blood pressure change from 130/ 88 to 124/
80 mm Hg
4. An increase in the respiratory rate from 18 to 22
breaths/ minute
2. An increase in the pulse rate from 88 to 102
beats/ minute
During the fourth stage of labor, the maternal
blood pressure, pulse, and respiration should be
checked every 15 minutes during the first hour. An
increasing pulse is an early sign of excessive blood
loss because the heart pumps faster to compensate
for reduced blood volume. A slight increase in
temperature is normal. The blood pressure
decreases as the blood volume diminishes, but a
decreased blood pressure would not be the earliest
sign of hemorrhage. The respiratory rate is slightly
increased from normal.
331. The nurse is preparing a list of self-care
instructions for a postpartum client who was
diagnosed with mastitis. Which instructions should
be included on the list? Select all that apply.
1. Wear a supportive bra. **
2. Rest during the acute phase. **
3. Maintain a fluid intake of at least 3000 mL. **
4. Continue to breast-feed if the breasts are not
too sore. ***
5. Take the prescribed antibiotics until the soreness
subsides.
6. Avoid decompression of the breasts by breast-
feeding or breast pump.
331. 1, 2, 3, 4 Rationale: Mastitis is an infection of
the lactating breast. Client instructions include
resting during the acute phase, maintaining a fluid
intake of at least 3000 mL/ day (if not
contraindicated), and taking analgesics to relieve
discomfort. Antibiotics may be prescribed and are
taken until the complete prescribed course is
finished. They are not stopped when the soreness
subsides. Additional supportive measures include
the use of moist heat or ice packs and wearing a
supportive bra. Continued decompression of the
breast by breast-feeding or breast pump is
important to empty the breast and prevent the
formation of an abscess.
332. The nurse is providing instructions about
measures to prevent postpartum mastitis to a
client who is breast-feeding her newborn. Which
client statement would indicate a need for further
instruction?
1. "I should breast-feed every 2 to 3 hours."
2. "I should change the breast pads frequently."
3. "I should wash my hands well before breast-
feeding."
4. "I should wash my nipples daily with soap and
water."
4. "I should wash my nipples daily with soap and
water."
Mastitis is inflammation of the breast as a result of
infection. It generally is caused by an organism that
enters through an injured area of the nipples, such
as a crack or blister. Measures to prevent the
development of mastitis include changing nursing
pads when they are wet and avoiding continuous
pressure on the breasts. Soap is drying and could
lead to cracking of the nipples, and the client
should be instructed to avoid using soap on the
nipples. The mother is taught about the
importance of hand-washing and that she should
breast-feed every 2 to 3 hours.
333. The postpartum nurse is assessing a client
who delivered a healthy infant by cesarean section
for signs and symptoms of superficial venous
thrombosis. Which sign would the nurse note if
superficial venous thrombosis were present?
1. Paleness of the calf area
2. Coolness of the calf area
3. Enlarged, hardened veins
4. Palpable dorsalis pedis pulses
3. Enlarged, hardened veins
Thrombosis of superficial veins usually is
accompanied by signs and symptoms of
inflammation, including swelling, redness,
tenderness, and warmth of the involved extremity.
It also may be possible to palpate the enlarged,
hard vein. Clients sometimes experience pain when
they walk. Palpable dorsalis pedis pulses is a
normal finding.
334. A client in a postpartum unit complains of
sudden sharp chest pain and dyspnea. The nurse
notes that the client is tachycardic and the
respiratory rate is elevated. The nurse suspects a
pulmonary embolism. Which should be the initial
nursing action?
1. Initiate an intravenous line.
2. Assess the client's blood pressure.
3. Prepare to administer morphine sulfate.
4. Administer oxygen, 8 to 10 L/ minute, by face
mask.
4. Administer oxygen, 8 to 10 L/ minute, by face
mask.
If pulmonary embolism is suspected, oxygen should
be administered, 8 to 10 L/ minute, by face mask.
Oxygen is used to decrease hypoxia. The client also
is kept on bed rest with the head of the bed slightly
elevated to reduce dyspnea. Morphine sulfate may
be prescribed for the client, but this would not be
the initial nursing action. An intravenous line also
will be required, and vital signs need to be
monitored, but these actions would follow the
administration of oxygen.
335. The nurse is assessing a client in the fourth
stage of labor and notes that the fundus is firm, but
that bleeding is excessive. Which should be the
initial nursing action?
1. Record the findings.
2. Massage the fundus.
3. Notify the health care provider (HCP).
4. Place the client in Trendelenburg's position.
3. Notify the health care provider (HCP).
If bleeding is excessive, the cause may be
laceration of the cervix or birth canal. Massaging
the fundus if it is firm would not assist in
controlling the bleeding. Trendelenburg's position
should be avoided because it may interfere with
cardiac and respiratory function. Although the
nurse would record the findings, the initial nursing
action would be to notify the HCP.
336. The nurse is preparing to care for four
assigned clients. Which client is at highest risk for
hemorrhage?
1. A primiparous client who delivered 4 hours ago
2. A multiparous client who delivered 6 hours ago
3. A primiparous client who delivered 6 hours ago
and had epidural anesthesia
4. A multiparous client who delivered a large baby
after oxytocin (Pitocin) induction
4. A multiparous client who delivered a large baby
after oxytocin (Pitocin) induction
The causes of postpartum hemorrhage include
uterine atony; laceration of the vagina; hematoma
development in the cervix, perineum, or labia; and
retained placental fragments. Predisposing factors
for hemorrhage include a previous history of
postpartum hemorrhage, placenta previa, abruptio
placentae, overdistention of the uterus from
polyhydramnios, multiple gestation, a large
neonate, infection, multiparity, dystocia or labor
that is prolonged, operative delivery such as a
cesarean or forceps delivery, and intrauterine
manipulation. The multiparous client who
delivered a large fetus after oxytocin induction has
more risk factors associated with postpartum
hemorrhage than the other clients. In addition,
there are no specific data in the client descriptions
in options 1, 2, and 3 that present the risk for
hemorrhage.
337. A postpartum client is diagnosed with cystitis.
The nurse should plan for which priority nursing
action in the care of the client?
1. Providing sitz baths
2. Encouraging fluid intake
3. Placing ice on the perineum
4. Monitoring hemoglobin and hematocrit levels
2. Encouraging fluid intake
Cystitis is an infection of the bladder. The client
should consume 3000 mL of fluids per day if not
contraindicated. Sitz baths and ice would be
appropriate interventions for perineal discomfort.
Hemoglobin and hematocrit levels would be
monitored with hemorrhage.
338. The nurse is monitoring a postpartum client
who received epidural anesthesia for delivery for
the presence of a vulvar hematoma. Which
assessment finding would best indicate the
presence of a hematoma?
1. Changes in vital signs
2. Signs of heavy bruising
3. Complaints of intense pain
4. Complaints of a tearing sensation
1. Changes in vital signs
Because the client has had epidural anesthesia and
is anesthetized, she cannot feel pain, pressure, or a
tearing sensation. Changes in vital signs indicate
hypovolemia in an anesthetized postpartum client
with vulvar hematoma. Option 2 (heavy bruising)
may be seen, but vital sign changes indicate
hematoma caused by blood collection in the
perineal tissues.
339. The nurse is developing a plan of care for a
postpartum client with a small vulvar hematoma.
The nurse should include which specific action
during the first 12 hours after delivery?
1. Assess vital signs every 4 hours.
2. Measure fundal height every 4 hours.
3. Prepare an ice pack for application to the area.
4. Inform the health care provider of assessment
findings.
3. Prepare an ice pack for application to the area.
A hematoma is a localized collection of blood into
the tissues of the reproductive sac after delivery.
Vulvar hematoma is the most common. Application
of ice reduces swelling caused by hematoma
formation in the vulvar area. Options 1, 2, and 4
are not interventions that are specific to the plan of
care for a client with a small vulvar hematoma.
340. On assessment of a postpartum client, the
nurse notes that the uterus feels soft and boggy.
The nurse should take which initial action?
1. Elevate the client's legs.
2. Document the findings.
3. Massage the fundus until it is firm.
4. Push on the uterus to assist in expressing clots.
3. Massage the fundus until it is firm.
If the uterus is not contracted firmly (i.e., it is soft
and boggy), the initial intervention is to massage
the fundus until it is firm and to express clots that
may have accumulated in the uterus. Elevating the
client's legs would not assist in managing uterine
atony. Documenting the findings is an appropriate
action but is not the initial action. Pushing on an
uncontracted uterus can invert the uterus and
cause massive hemorrhage.