4.

Which of the following is a positive sign

of pregnancy?
a. Fetal movement felt by mother
b. Enlargement of the uterus
BSN 2_ P2 WEEK 1 POST TEST NUR c. (+) pregnancy test
195_MCN RLE d. (+) ultrasound
RATIONALE: A positive ultrasound will definitely
GENERAL INSTRUCTIONS: confirm that a woman is pregnant since the fetus in
Shade only those that apply to each question on your utero is directly visualized.
answer sheet.
Read the question carefully and choose the best 5. In the Batholonew’s rule of 4, when the level
answer. of the fundus is midway between the
STRICTLY NO ERASURES.
umbilicus and xyphoid process the estimated
1. You performed the leopold’s maneuver and
age of gestation (AOG) is:
found the following: breech presentation, fetal
a. 5th month
back at the right side of the mother. Based on
b. 6th month
these findings, you can hear the fetal heart
c. 7th month
beat (PMI) BEST in which location?
d. 8th month
a. Left lower quadrant
RATIONALE: In Bartholomew’s Rule of 4, the landmarks
b. Right lower quadrant
used are the symphysis pubis, umbilicus and xyphoid
c. Left upper quadrant
process. At the level of the umbilicus, the AOG is
d. Right upper quadrant
approximately 5 months and at the level of the xyphoid
RATIONALE: Right upper quadrant. The landmark to
process 9 months. Thus, midway between these two
look for when looking for PMI is the location of the fetal
landmarks would be considered as 7 months AOG.
back in relation to the right or left side of the mother
and the presentation, whether cephalic or breech. The
6. The following are ways of determining
best site is the fetal back nearest the head.
expected date of delivery (EDD) when the LMP
is unknown EXCEPT:
2. In Leopold’s maneuver #1, you palpated a soft
a. Naegele’s rule
broad mass that moves with the rest of the
b. Quickening
mass. The correct interpretation of this
c. Mc Donald’s rule
finding is:
d. Batholomew’s rule of 4
a. The mass palpated at the fundal part is the
RATIONALE: Naegele’s Rule is determined based on
head part.
the last menstrual period of the woman.
b. The presentation is breech.
c. The mass palpated is the back
7. If the LMP is Jan. 30, 2014 the expected date
d. The mass palpated is the buttocks.
of delivery (EDD) is
RATIONALE: The mass palpated is the buttocks.
a. Oct. 7, 2014
The palpated mass is the fetal buttocks since it is
b. Oct. 24, 2016
broad and soft and moves with the rest of the
c. Nov. 7, 2014
mass.
d. Nov. 8, 2015
RATIONALE: Based on the last menstrual period, the
3. In Leopold’s maneuver # 3 you palpated a
expected date of delivery is Nov. 7. The formula for the
hard round movable mass at the supra pubic
Naegele’s Rule is subtract 3 from the month and add 7
area. The correct interpretation is that the
to the day.
mass palpated is:
a. The buttocks because the presentation
8. The hormone responsible for a
is breech.
positive pregnancy test is:
b. The mass palpated is the head.
a. Estrogen
c. The mass is the fetal back.
b. Progesterone
d. The mass palpated is the fetal small part
c. Human Chorionic Gonadotropin
RATIONALE: The mass palpated is the head. When the
d. Follicle Stimulating Hormone
mass palpated is hard round and movable, it is the
fetal head.
RATIONALE: Human chorionic gonadotropin (HCG) is
the hormone secreted by the chorionic villi which is the
precursor of the placenta. In the early stage of
pregnancy. while the placenta is not yet fully
developed. the major hormone that sustains the
pregnancy is HCG.
9. The most common normal position of the
fetus in utero is:
a. Transverse Position
b. Vertical Position
c. Oblique Position
d. None of the Above
RATIONALE: Vertical position means the fetal spine
is parallel to the maternal spine thus making it easy
for the fetus to go out the birth canal. Options A and
C: If transverse or oblique. the fetus can’t be
delivered normally per vagina.
10. During a prenatal visit, a patient tells you her
last menstrual period was May 21, 2016.
Based on the Naegele's Rule, when is the
estimated due date of her baby?
a. February 27, 2016
b. March 19. 2017
c. February 28, 2017
d. April 16, 2016
11. The purpose of the 4th maneuver (also
known as Pawlick's grip) is to help determine
whether the fetal head (in a cephalic
presentation) has descended into the
mother's pelvis and engaged in the cervix,
TRUE OR FALSE.
a. FALSE
b. TRUE
12. Patient RD returns for a routine visit at 12
weeks of gestation. Which nursing assessment
could the nurse use to verify the estimated due
date (EDD) and estimate uterine/fetal growth?
a. Leopold maneuvers
b. Weight-gain pattern
c. Vital signs and fetal heart tones
d. Height of the fundus
13. Which of the following fundal heights
indicates less than 12 weeks’ gestation when
the date of the LMP is unknown?
a. Uterus in the pelvis
b. Uterus at the xiphoid
c. Uterus in the abdomen
d. Uterus at the umbilicus
14. It is a method used to palpate the gravid
uterus systematically and is of low cost, easy to
perform, and non-invasive. It is used to
determine the position, presentation, and
engagement of the fetus in utero.
a. Naegele's Rule
b. Leopold's Maneuver
c. Ritgen's Maneuver
d. Fundal height measurement
15. All of the following except, are the steps
in performing the Leopold's Maneuver:
a. Fundal Grip
b. Umbilical Grip
c. Fetal Position
d. Pawlik's Grip
e. Pelvic Grip
16. The uterine fundus right after delivery
of placenta is palpable at:
a. Level of Xyphoid process
b. Level of umbilicus
c. Level of symphysis pubis
d. Midway between umbilicus and
symphysis pubis
17. During a prenatal visit a patient tells you her
last menstrual period was August 28, 2016.
Based on the Naegele's Rule, when is the
estimated due date of her baby?*
a. July 4, 2017
b. June 3, 2017
c. June 4, 2017
d. July 1, 2016
18. During a prenatal visit a patient tells you her
last menstrual period was March 14, 2016.
Based on the Naegele's Rule, when is the
estimated due date of her baby?*
a. January 27, 2017
b. December 21, 2016
c. December 28, 2016
d. January 1, 2016
19. When measuring the fundal height of a
primigravida client, with 20 weeks gestation.
Nurse Irish would anticipate locating the
fundal height at which of the following points?
a. Halfway between the client's symphysis
pubis and umbilicus-during 16 weeks/3
months
b. At about the level of the client's umbilicus
c. Between the client's umbilicus and
xyphoid process
 d. Near the client's xyphoid process
and compressing the diaphragm

20. The nurse is performing an abdominal

examination to the pregnant client and she
performs Leopold's Maneuvers. The nurse
determines which of the following after the
first maneuver?
ANSWER: 4 / D
a. Locating the fetal back
b. Locating the fetal head or breech is in
25. Which of the following pictures depicts a fetus in
the fundus
the frank breech position?
c. Locating part of the fetus in the inlet
d. Determination of fetal attitude

21. Now at 5 months of pregnancy, adolescent

Rhian asks about her baby's length. Using the
Haase's Rule, the nurse calculates fetal length
to be approximately:
a. 20 cm
b. 25 cm
c. 30 cm
d. 50 cm
22. A nurse has just performed a vaginal examination
on a client in labor. The nurse palpates the baby’s
buttocks as facing the mother’s right side. Where
should the nurse place the external fetal monitor
electrode?
a. Left upper quadrant (LUQ)
b. Left lower quadrant (LLQ)
c. Right upper quadrant (RUQ)
d. Right lower quadrant (RLQ)
23. Which of the following pictures depicts a fetus in
the ROP position?
ANSWER: 1 / A
24. Which of the following pictures depicts a fetus in
the LSA position?
ANSWER: 3 / C
26. While performing Leopold’s maneuvers on a
woman in labor, the nurse palpates a hard round mass
in the fundal area, a flat surface on the left side, small
objects on the right side, and a soft round mass just
above the symphysis. Which of the following is a
reasonable conclusion by the nurse?
a. The fetal position is transverse
b. The fetal presentation is vertex
c. The fetal lie is vertical
d. The fetal attitude is flexed
27. The labor and delivery nurse performs Leopold’s
Maneuvers. A soft round mass is felt in the fundal
region. A flat object is noted on the left and small
objects are noted on the right of the uterus. A hard
round mass is noted above the symphysis. Which of
the following positions is consistent with these
findings?
a. Left occipital anterior (LOA)
b. Left sacral posterior (LSP)
c. Right mentum anterior (RMA)
d. Right sacral posterior (RSP)
28. During a vaginal examination, the nurse palpates
fetal buttocks that are facing the left posterior and
are 1cm above the ischial spines. Which of the
following is consistent with this assessment?
a. LOA -1 station
b. LSP - 1 station
c. LMP +1 station
 d. LSA + 1 station a. place the baby on a warm surface (skin to
skin on the mother’s chest after thorough
29. What stage of gestation would you expect a drying)
nulliparous woman to begin to feel fetal b. dry the wet baby immediately after birth
movements? and covering with a warm dry cloth,
a. 18-20 weeks c. warm environment (25 degrees Celsius)
b. 10-12 weeks d. The drought of cold air should be avoided.
c. 22-24 weeks
d. 14-16 weeks 36. Procedure to prevent heat loss via radiation.
a. place the baby on a warm surface (skin to
30. Fundal height of a pregnant woman is skin on the mother’s chest after thorough
measured from . drying)
a. the top of the pubic bone to the top of b. dry the wet baby immediately after birth
the uterus and covering with a warm dry cloth,
b. the top of the pubic bone to the middle of c. warm environment (25 degrees Celsius)
the uterus d. The drought of cold air should be avoided.
c. the middle of the pubic bone to the bottom
of the uterus 37. 37. It’s commonly used to remove placental
d. the bottom of the pubic bone to the top of fragments inside the uterus. It is also used as a
the uterus hemostat or to prevent the flow of blood from an
e. the middle of the pubic bone to the top of open blood vessel by compression of the vessel.
the uterus
A. Kelly Forcep
31. These are the basic aspects must be taken into B. Ovum Forcep
account for performing Leopold Maneuvers, C. Uterine Curette
EXCEPT D. Vaginal Speculum
a. The examiner for the patient’s right side.
b. The maneuvers are bimanual. 38. This Forceps are primarily used for clamping
c. In the first 3 maneuvers, the test is facing large blood vessels or manipulating heavy tissue.
the patient and, in the 4th maneuver the They may also be used for soft tissue dissection. This
back is turned to the patient. instrument can be used as a clam, heat sink, or third
d. the middle of the pubic bone to the top of hand.
the uterus
a. Kelly Forcep
32. After 30 seconds of drying position the newborn is b. Ovum Forcep
prone on the mother’s abdomen or chest for early c. Forcep
skin to skin contact. d. Holder Forcep
a. TRUE
b. FALSE 39. It is Commonly used to receive delivered
placenta for assessment after vaginal delivery or
33. It is a thick, cheesy substance made up of sebum cesarean section.
and shed epithelial cells; a greasy deposit covering
the skin of the baby at birth. a. Kidney Basin
a. vernix caseosa b. placental container
b. vernic casosa c. Medical container
c. meconium d. Medical Basin
d. lanugo
40. Gynecologists use it to open the walls of the
34. After the umbilical pulsations stopped, clamp the vagina and examine the vagina and cervix.
cord at 2 cm from the umbilical base, clamp again at
5 cm from the base. a. Vaginal Speculum
a. TRUE b. Sims Vaginal Spatula
b. FALSE c. Vaginal Retractor
d. transvaginal Ultrasound
35. Procedure to prevent heat loss via evaporation.

BSN 2_ P2 WEEK 2 POST TEST
NUR 195_MCN RLE
GENERAL INSTRUCTIONS:
Shade only those that apply to each question on your
answer sheet.
Read the question carefully and choose the best answer.
STRICTLY NO ERASURES.
1.A nurse is teaching a postpartum client about
breast-feeding. Which of the following
instructions should the nurse include?
A. The diet should include additional fluids
B. Prenatal vitamins should be discontinued
C. Soap should be used to cleanse the breasts.
D. Birth control measures are unnecessary
while breast-feeding.
RATIONALE: A diet for a breast-feeding patient should
include additional fluids. Prenatal vitamins should be
taken as prescribed and soap should not be used on the
breast because it removes natural oils which increases
the chance of cracked nipples. Breast-feeding is not a
sole method of contraception, so birth control measures
should be resumed.
2.A client who is breast-feeding her newborn infant
is experiencing nipple soreness. To relieve the
soreness, the nurse suggests that the client:
A. Avoid rotating breast-feeding positions.
B. Stop nursing until the nipples heal
C. Substitute a bottle-feeding until the nipples heal.
D. Position the infant with the ear, shoulder, and hip in
straight alignment with the infant's stomach against
the mother.
RATIONALE: The nurse would suggest the mother
position the infant in this manner. Rotating
breast-feeding positions; breaking suction with the little
finger; nursing frequently; begin feeding on the less sore
nipple; not allowing the newborn to chew on the nipple
or to sleep holding the nipple in the mouth and applying
tea bags soaked in warm water to the nipple are also
measures to alleviate nipple soreness.
3.A second-day postpartum client with diabetes
mellitus has scant lochia with a foul odor and a
temperature of
101.6 degrees F. The physician suspects infection and
writes orders to treat the client. Which of the following
orders written by the physician would the nurse
complete first?
A. Obtain culture and sensitivity of lochia and urine
B. Administer Ceftriaxone (Rocephin)
C. Check the client's temperature
D. Increase the intake of oral fluids.
RATIONALE: Culture and sensitivity results should be
obtained before any antibiotic therapy is begun to avoid
masking the microorganisms identified in the culture.
Options B and D are standard parts of therapy for this
type of infection but are not completed first. Although
the client's temperature is monitored, checking the
temperature is not the first action.The data in the
question indicate that the temperature has already
been checked.
4.A nurse obtains the vital signs on a mother who
delivered a healthy newborn infant 2 hours ago and
notes that the mother's temperature is 102 F. The
appropriate nursing action would be to:
A. Notify the physician
B. Remove the blanket from the client's bed
C. Document the finding and recheck the
temperature in 4 hours.
D. Administer Acetaminophen (Tylenol) and recheck
the temperature in 4 hours.
RATIONALE: Vital signs are to return to normal within
the first hour postpartum if no complication arise. If the
temperature is greater than 2F above normal this may
indicate infection, and the physician should be notified.
Options B, C, and D are inaccurate nursing interventions
for the client's temperature of 102F 2 hours following
delivery.
5.A 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. The nurse
reports the amount of lochial flow as:
A. Scant
B. Light
C. Heavy
D. Excessive
RATIONALE:Scant= <1 inch on pad in 1 hour
Light = <4 inches on pad in 1 hour
Moderate= <6 inches on pad in 1 hour
Heavy= Saturated pad in 1 hour
Excessive= Saturated pad in 15 minutes
6.A postpartum nurse is preparing to care for a woman
who has just delivered a healthy newborn infant. In the
immediate postpartum period, the nurse plans to take
the woman’s vital signs:
A. Every 30 minutes during the first hour and
then every hour for the next two hours.
B. Every 15 minutes during the first hour and then
every 30 minutes for the next two hours.
C. Every hour for the first 2 hours and then every
4 hours.
D. Every 5 minutes for the first 30 minutes and
then every hour for the next 4 hours.
RATIONALE: The initial or acute period involves the first
6–12 hours postpartum. This is a time of rapid change
with a potential for immediate crises such as
postpartum hemorrhage, uterine inversion, amniotic
fluid embolism, and eclampsia.
7. Your patient is 48 hours post-delivery. While
assessing fundal height, you would expect the fundal
height to be?
A. 1 cm above the umbilicus
B. 2 cm above the umbilicus
C. 1 cm below the umbilicus
D. 2 cm below the umbilicus
RATIONALE: The fundal height will decrease by 1 cm
per day below the umbilicus. Therefore, if the woman is
48 hours postpartum (2 days) the fundal height will be
2 cm BELOW the umbilicus.
8. You’re providing discharge teaching to a new mother
who is going home after a vaginal delivery. The
woman asks when the uterus will return to its pre-
pregnancy size. Your response is?
A. At about 14 days
B. At about 6 months
C. At about 6 weeks
D. At about 7 days
RATIONALE: The uterus will return to its pre-pregnancy
state at about 6 weeks.
9. A nursing student, who you are precepting
during their OB rotation, asks you when the fundus
of the uterus is no longer palpable. You answer:
A. at about 10 to 14 days
B. at about 7 days
C. at 6 weeks
D. 48 hours after the delivery of the baby.
RATIONALE: This is when the uterus has entered back
into the pelvic cavity and is no longer palpable.
10. One hour after delivery where do you expect to
find the fundus of the uterus?
A. 4 cm below the xiphoid process
B. right above the symphysis pubis
C. At the umbilicus
D. 2 cm below the umbilicus
11. A nurse is preparing to perform a fundal
assessment on a postpartum client. The initial nursing
action in performing this assessment is which of the
following?
A. Ask the client to turn on her side.
B. Ask the client to lie flat on her back with the
knees and legs flat and straight.
C. Ask the mother to urinate and empty her bladder.
D. Massage the fundus gently before determining
the level of the fundus.
RATIONALE: Before starting the fundal assessment, the
nurse should ask the mother to empty her bladder so
that an accurate assessment can be done. The
postpartum recovery period covers the time period
from birth until approximately six to eight weeks after
delivery. This is a time of healing and rejuvenation as
the mother’s body returns to prepregnancy states.
12. A nurse in a Postpartum unit is instructing a
mother regarding lochia and the amount of expected
lochia drainage. The nurse instructs the mother that
the normal amount of lochia may vary but should
never exceed the need for:
A. One peripad per day.
B. Two peripads per day.
C. Three peripads per day.
D. Eight peripads per day.
RATIONALE: The normal amount of lochia may vary
with the individual but should never exceed 4 to 8
peripads per day. The average number of peripads is 6
per day.
Postpartum hemorrhage is defined as excessive blood
loss during or after the third stage of labor. The average
blood loss is 500 mL at vaginal delivery and 1000 mL at almost 50%. Once the
cesarean delivery.

13. A Postpartum nurse is providing instructions to a

woman after delivery of a healthy newborn infant.
The nurse instructs the mother that she should expect
normal bowel elimination to return:

A. One the day of the delivery

B. 3 days
C. 7 days
D. within 2 weeks PP

RATIONALE: After birth, the nurse should auscultate the

woman’s abdomen in all four quadrants to determine
the return of bowel sounds. Normal bowel elimination
usually returns 2 to 3 days PP. Surgery, anesthesia, and
the use of narcotics and pain control agents also
contribute to the longer period of altered bowel
function.

14. The following are the physiological maternal

changes that occur during the PP period. Select all that
apply.

I. Cervical involution occurs.

II. Vaginal distention decreases slowly.
III. Fundus begins to descend into the pelvis after
24 hours.
IV. Cardiac output decreases with resultant
tachycardia in the first 24 hours.
V. Digestive processes slow immediately.

A. I,III B.I,II,III
C. II,III D. all of the above

rationale :After 1 week the muscle begins to regenerate

and the cervix feels firm and the external os, is the
width of a pencil. The fundus begins to descent into the
pelvic cavity after 24 hours, a process known as
involution.

15. The nurse monitors his or her postpartum clients

carefully because which of the following
physiological changes occurs during the early
postpartum period?

A.Decreased urinary output.

B.Increased estrogen level.
C.Increased blood pressure.
D.Decreased blood volume.

RATIONALE: The blood volume does drop

precipitously during the early postpartum period.
During pregnancy, the blood volume increased by
placenta is delivered, the client no longer needs the
added blood volume.

16. To prevent infection, the nurse teaches the

postpartum client to perform which of the
following tasks?

A. Void at least every two hours.

B. Spray the perineum with a povidone-iodine
solution after toileting.
C. Change the peripad at each voiding.
D. Apply antibiotic ointment to the perineum daily.

RATIONALE: Clients should be advised to change

their pads at each voiding.It is unnecessary to apply
antibiotic ointment to the perineum after
delivery.The clients should void about every 2 hours,
but this action is not an infection control measure.

17. The nurse examines a woman one hour after

birth. The woman’s fundus is boggy, midline, and 1
cm below the umbilicus. Her lochial flow is profuse,
with two plum-sized clots. The nurse’s initial action
would be to:

A. Place her on a bedpan to empty her bladder.

B. Massage her fundus
C. Call the physician
D. Administer Methergine 0.2 mg IM which has
been ordered prn.

RATIONALE:A boggy or soft fundus indicates that

uterine atony is present. If uterine atony occurs,
healthcare providers should be ready for initial
medical management which is directed to the use of
medications to improve tone and induce uterine
contractions. Massaging the uterus is also effective,
as is ensuring an empty cavity. This is confirmed by
the profuse lochia and passage of clots. The first
action would be to massage the fundus until firm,
followed by options C and D, especially if the fundus
does not become or remain firm with massage.

18. Perineal care is an important infection control

measure. When evaluating a postpartum woman’s
perineal care technique, the nurse would recognize
the need for further instruction if the woman:

A. Uses soap and warm water to wash the vulva

and perineum.
B. Washes from symphysis pubis back to episiotomy.
C. Changes her perineal pad every 2 – 3 hours.
D. Uses the peri bottle to rinse upward into her vagina.
19. Which measure would be least effective b. push on the lax fundus of her uterus to cause
in preventing postpartum hemorrhage? the placenta to loosen

A. Administer Methergine 0.2 mg every 6 hours for

4 doses as ordered.
B. Encourage the woman to void every 2 hours.
C. Massage the fundus every hour for the first 24 hours
following birth.
D. Teach the woman the importance of rest
and nutrition to enhance healing.

RATIONALE:The fundus should be massaged only when

boggy or soft. Massaging a firm fundus could cause it to
relax. Uterine atony refers to the corpus uteri
myometrial cells inadequate contraction in response to
endogenous oxytocin that is released in the course of
delivery.

20. When making a visit to the home of a

postpartum woman one week after birth, the nurse
should recognize that the woman would
characteristically:

A. Express a strong need to review events and

her behavior during the process of labor and
birth.
B. Exhibit a reduced attention span, limiting
readiness to learn.
C. Vacillate between the desire to have her own
nurturing needs met and the need to take charge of
her own care and that of her newborn.
D. Have reestablished her role as a spouse/partner.

21. Suppose KeyP is having long and hard uterine

contractions. What length of contraction would
the nurse report as indicative of a potential safety
risk?
a. any length of contraction over 30 seconds
a. a contraction over 70 seconds in length
b. a contraction that peaks at 20 seconds
c. a contraction that appears intensely painful.

RATIONALE: The nurse should report any contraction 70

seconds long as it is long enough to compromise fetal
oxygenation. In the context of labor, pain is not
necessarily indicative of pathophysiology.

22. KeyP is anxious for her placenta to deliver so she

can move to a rocking chair ad help relieve her back
pain. to best facilitate KeyP’s wishes, which action is
best?
a. tug gently on the umbilical cord until
the placenta comes loose.
a. ask KeyP to continue hard pushing as she did
to birth her baby
c. assure her that a placenta loosens quickly 26. A baby is just delivered. Which of the
so the waiting time will not be long. following physiological changes is of highest
priority?
RATIONALE: The nurse should assure the patient
that a placenta loosens quickly so waiting time will
not be long. pulling on the cord, pushing on the
uterine.

23. The nurse is caring for a Muslim woman in

labor. It would be appropriate for the nurse to
include which of the following in the plan of care?
a. Encourage the father to hold his partner’s
hand during labor.
b. Ask the woman if she would like to speak with
her priest.
c. Provide the woman with a long-sleeved
hospital gown.
d. Place an order for the woman’s
postpartum vegetarian diet.
RATIONALE: Muslim women are expected to have
their elbows covered at all times. A long-sleeved
gown, therefore, should be provided for them

24. A full-term newborn was just born. Which

nursing intervention is important for the nurse to
perform first?
a. Remove wet blankets.
b. Assess Apgar score.
c. Insert eye prophylaxis.
d. Elicit the Moro reflex.

RATIONALE: The nurse must know which action is

performed first. Because hypothermia can
compromise a neonate’s transition to extrauterine
life, it is essential to dry the baby immediately to
minimize heat loss through evaporation. It is
important for the test taker to review cold stress
syndrome

25. A breastfeeding baby is born with a tight

frenulum. Which of the following is an important
assessment for the nurse to make?
a. Integrity of the baby’s uvula.
b. Presence of maternal nipple damage.
c. Presence of neonatal tongue injury.
d. The baby’s breathing pattern.

RATIONALE: The baby’s tongue must perform many

actions in order to breastfeed successfully. One of
the first actions the tongue must make is to extend
past the gum line. A tight frenulum precludes the
baby from being able to fully extend his or her
tongue.
a. Thermoregulation.
b. Spontaneous respirations.
c. Extrauterine circulatory shift.
d. Successful feeding.
RATIONALE: If a baby does not breathe, the remaining
physiological transitions cannot successfully take place.
27. To decrease the possibility of a perineal
laceration during delivery, the nurse performs which
of the following interventions prior to the delivery?
a. Assists the woman into a squatting position.
b. Advises the woman to push only when she feels
the urge.
c. Encourages the woman to push slowly and steadily.
d. Massages the perineum with mineral oil.
RATIONALE: During labor, nurses and nurse midwives
often massage a woman’s perineum to increase the
elasticity of the tissue. Because the tissue is more
elastic, it is less inclined to tear during the delivery. In
addition, mothers are often encouraged to begin
massaging the tissue during their last trimester.
28. The nurse teaches pregnant woman to
perform Kegel’s exercise regularly for which
purpose?
a. Strengthen the perineal muscles
b. Prevents varicose veins in the perineum
c. Strengthen the abdominal wall muscles
d. Prevent varicose veins
RATIONALE: Kegel’s Exercise can help make the muscles
under the uterus, bladder, and bowel (large intestine)
stronger. They can help both men and women who
have problems with urine leakage or bowel control.
29. Jennylyn is so concerned about the development of
varicose veins. After providing health teachings
regarding the prevention of varicosities, Which of the
following statements by the client below indicate a
need for further education?
a. “I should wear support hose.”
b. “I should be wearing flat, non-slip shoes that have
an arch support.”
c. “I should avoid standing for a long period of time.”
d. “I can wear knee-high hose as long I don’t leave
them on longer than 8 hours.”
RATIONALE: Wearing knee-high hose or stockings for
more than 8 hours can cause varicose veins
30. Celine, a postpartum woman who had a repair
of her perineal laceration complained that she is
frequently constipated. Which of the following is not
done to relieve constipation?
a. Eat fruits and vegetable (papaya, camote tops etc.)
b. Eat plenty of high roughage foods
c. Aerobics for atleast 30 minutes 3 times a day
d. Increase fluid intake
RATIONALE: Postpartum women can still have
exercise but not the active type of exercise. This could
increase the risk of tearing the perineal repair
31. It strengthens bulbocavernous muscles of the
vagina that is helpful in promoting healing, increased
sexual responsiveness, help prevent stress
incontinence:
a. Grantly Dick-Read Method
b. Bradley Technique
c. Pelvic Floor Contractions
d. Pelvic Rocking
RATIONALE: Kegel’s Exercise or Pelvic Floor
Contractions strengthens bulbocavernous muscles of
the vagina that is helpful in promoting healing,
increased sexual responsiveness, help prevent stress
incontinence
31. This type of laceration extends into the muscle
that surrounds the anal sphincter.
a. First Degree Laceration
b. Second Degree Laceration
c. Third Degree Laceration
d. Fourth Degree Laceration
RATIONALE: Third degree Laceration extends into the
muscle that surrounds the anal sphincter. These tears
sometimes require repair with anesthesia in an
operating room — rather than the delivery room — and
might take longer than a few weeks to heal.
32. Celine, a postpartum woman who had a repair
of her perineal laceration complained that she is
frequently constipated. Which of the following is
not done to relieve constipation?
a. Eat fruits and vegetable (papaya, camote tops etc.)
b. Eat plenty of high roughage foods
c. Aerobics for atleast 30 minutes 3 times a day
d. Increase fluid intake
RATIONALE: Postpartum women can still have
exercise but not the active type of exercise. This could
increase the risk of tearing the perineal repair.
33. Similar to Dick-Read approach with the addition of
a labor coach that focuses on slow breathing & deep
relaxation for labor:
a. Grantly Dick-Read Method
b. Bradley Technique
c. Pelvic Floor Contractions
d. Pelvic Rocking
RATIONALE: Similar to Dick-Read approach with the
addition of a labor coach that focuses on slow breathing
& deep relaxation for labor
34. Which of the following nonpharmacological
interventions recommended by nurse-midwife may
help a client at full term to go into labor? Select all that
apply.
a. Engage in sexual intercourse.
b. Ingest evening primrose oil.
c. Perform yoga exercises.
d. Eat raw spinach.
e. Massage the breast and nipples.
RATIONALE: Nonpharmacological induction methods, he
or she could make some educated guesses by
remembering that pharmacological medications for
labor induction are prostaglandins and oxytocin.
35. The nurse is providing acupressure for pain relief
to a woman in labor. Where is the best location for the
acupressure to be applied? Select all that apply.
a. On the malleolus of the wrist.
b. Above the patella of the knee.
c. On the medial aspect of the lower leg.
d. At the top one-third of the sole of the foot.
e. Below the medial epicondyle of the elbow.
RATIONALE: Complementary therapies have been
shown to be of value in a number of clinical situations,
including labor. The specific acupressure point on the
leg is located about 3 cm above the inner malleolus in
the calf region. Acupressure has been shown to reduce
the pain of labor contractions.
36. To reduce the risk of hypoglycemia in a full-term
newborn weighing 2,900 grams, what should the
nurse do?
a. Maintain the infant’s temperature
above 97.7°F/36.5°C.
b. Feed the infant glucose water every 3 hours
until breastfeeding well.
c. Assess blood glucose levels every 3 hours for the
first twelve hours.
d. Encourage the mother to breastfeed every 4 hours.
RATIONALE: Hypoglycemia can result when a baby
develops cold stress syndrome because babies must
metabolize food to create heat. When they use up their
food stores, they become hypoglycemic.
37. The nursing instructor ask a nursing student to
explain the characteristics of the amniotic fluid.
The student responds correctly by explaining
which as characteristics of amniotic fluid?
a. Allows for fetal movement
b. Surrounds, cushions, and protects the fetus
c. Maintains the body temperature of the fetus
d. Can be used to measure fetal kidney function
e. Prevents large particles such as bacteria from
passing to the fetus
RATIONALE: The amniotic fluid surrounds, cushions,
and protects the fetus. It allows the fetus to move
freely and maintains the body temperature of the fetus.
In addition, the amniotic fluid contains urine from the
fetus and can be used to assess fetal kidney function.
38. Which purpose of placental functioning should
the nurse include in a prenatal class? Select all that
apply
a. It cushions and protects the baby
b. It maintains the temperature of the baby
c. It is the way the baby gets food and oxygen
d. It prevents all antibodies and viruses from passing
to the baby
e. It provides an exchange of nutrients and waste
products between the mother and the developing
fetus
RATIONALE: 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 maintains the body
temperature of the fetus. Nutrients. medications,
antibodies, and viruses can pass through the placenta
39. The nurse in a 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. What is the first nursing
action with this finding?
a. gently push the cord into the vagina
b. place the client in Trendelenburg position
c. Find the closest telephone and page the health
care provider stat
d. call the delivery room to notify the staff that
the client will be transported immediately
RATIONALE: When cord prolapse occurs, prompt
actions are taken to relieve cord compression.
40. A full-term newborn was just born. Which nursing
intervention is important for the nurse to perform
first?
a. Remove wet blankets.
b. Assess Apgar score.
c. Insert eye prophylaxis.
d. Elicit the Moro reflex

RATIONALE: The nurse must know which action is

performed first. Because hypothermia can compromise
a neonate’s transition to extrauterine life, it is essential
to dry the baby immediately to minimize heat loss
through evaporation. It is important for the test taker
to review cold stress syndrome increase fetal
oxygenation. The client should be positioned with the
hips higher than the head to shift the fetal presenting
part towards the diaphragm. The nurse should push the
call light to summon help, and the other staff members
should call the HCP and notify the delivery room.