Maternal Notes Google Docs

‭Name:_____________________________________________________________Date:_____________‬
‭1. A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath‬
‭and is unable to sleep unless she places three pillows under her head. After listening to the client's‬
‭concerns, the nurse should take which action?‬
‭a. Make an appointment because the dent needs to be evaluated.‬
‭b. Explain that these are expected problems for the latter stages of pregnancy.‬
‭c. Arrange for the dent to be admitted to the birth center and prepare for birth.‬
‭d. Tell the client to go to the hospital; she may be experiencing signs of heart failure.‬
‭RATIONALE:‬‭The nurse must distinguish between normal‬‭physiologic complaints of the latter stages of‬
‭pregnancy and those that need referral to the health care provider. In this case, the client indicates‬
‭normal physiologic changes caused by the growing uterus and pressure on the diaphragm. These signs‬
‭don't indicate heart failure. The client doesn't need to be seen or admitted to the birth center.‬
‭Reference: Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed.‬
‭Philadelphia: Lippincott Williams & Wilkins, 2007, p. 230.‬
‭2. During the first trimester, a nurse evaluates a pregnant client for factors that suggest she might abuse a‬
‭child. Which parental characteristic is of most concern to the nurse?‬
‭a. The client didn’t graduate high school.‬
‭b. The client states she is stupid and ugly.‬
‭c. The client is carrying twins.‬
‭The client eats fast food every day.‬
‭RATIONALE:‬‭Typically, the abusive parent has low self-esteem,‬‭which may be evident by self-deprecating‬
‭statements, and many unmet needs. Lack of nurturing experience and inadequate knowledge of‬
‭childhood growth and development may also contribute to the potential for child abuse. A low‬
‭educational level, multiple gestations, and poor diet aren't direct risk factors for committing child abuse.‬
‭REFERENCE:‬‭Pillitteri, A. Maternal & Child Health‬‭Nursing: Care of the Childbearing and Childrearing‬
‭Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1743.‬
‭3. A client in her 15th week of pregnancy has presented with abdominal cramping and vaginal bleeding for‬
‭the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this client? a.‬
‭Deficient knowledge of pregnancy‬
‭b‬‭. Deficient fluid volume‬
‭c. Anticipatory grieving‬
‭d. Acute pain‬
‭RATIONALE:‬‭If bleeding and clots are excessive, this‬‭client may become hypovolemic , leading to a‬
‭nursing diagnosis of Deficient fluid volume. Although Deficient knowledge (pregnancy), Anticipatory‬
‭grieving, and Acute pain are applicable to this client, they aren't the primary diagnosis‬
‭Family 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 400.‬
‭4. A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether‬
‭the client is at risk for a TORCH infection , the nurse should ask:‬
‭a. “Have you ever had osteomyelitis?”‬
‭b. “‬‭Do you have any cats at home?‬
‭c. “Do you have any birds at home?’‬
‭d. “Have you recently had a rubeola vaccination?”‬
‭RATIONALE:‬‭Toxoplasmosis, Other Rubella virus, Cytomegalovirus,‬‭and Herpes simplex virus and agents‬
‭that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to humans‬
‭through contact with the feces of infected cats (which may occur when emptying a litter box), through‬
‭ingesting raw meat, or through contact with raw meat followed by improper hand washing. Osteomyelitis ,‬
‭a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH‬
‭infections‬
‭5. A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help‬
‭confirm that she's in true labor, the nurse should assess for:‬
‭a. irregular contractions.‬
‭b. increased fetal movement.‬
‭c. changes in cervical effacement and dilation atter 1 to 2 hours.‬
‭d. contractions that feel like pressure in the abdomen and qroin.‬
‭1‬
‭ ATIONALE:‬‭True labor is characterized by progressive‬‭cervical effacement and dilation after 1 to 2 hours,‬
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‭regular contractions, discomfort that moves from the back to the front of the abdomen and, possibly,‬
‭bloody show. False labor causes irregular contractions that are felt primarily in the abdomen and groin‬
‭and commonly decrease with walking, increased fetal movement, and lack of change in cervical‬
‭effacement or dilation even after 1 or 2 hours.‬
‭6. A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain‬
‭from her episiotomy . What should the nurse instruct the woman to do?‬
‭a.‬‭Apply an ice pack to her perineum.‬
‭b. Take a sitz bath.‬
‭c. Perform perineal care after voiding or a bowel movement.‬
‭d. Drink plenty of fluids.‬
‭RATIONALE:‬‭A‬‭cold‬‭pack‬‭applied‬‭to‬‭an‬‭episiotomy‬‭during‬‭the‬‭first‬‭24‬‭hours‬‭after‬‭chidbirth‬‭may‬‭reduce‬
‭edema‬‭and‬‭tension‬‭on‬‭the‬‭incision‬‭line,‬‭thereby‬‭reducing‬‭pain.‬‭After‬‭the‬‭first‬‭24‬‭hours,‬‭a‬‭sitz‬‭bath‬‭may‬
‭reduce discomfort by promoting circulation and healing. Although perineal care should be performed‬
‭after each voiding and bowel movement, its purpose is to prevent infection — not reduce‬
‭discomfort. Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it‬
‭doesn't relieve perineal discomfort.‬
‭7. A client who's 24 weeks pregnant has sickle cell anemia . When preparing the care plan, the nurse should‬
‭identify which factor as a potential trigger for a sickle cell crisis during pregnancy? a. Sedative use‬
‭b. Dehydration‬
‭c. Hypertension‬
‭d. Tachycardia‬
‭RATIONALE:‬‭Factors that may precipitate a sickle cell‬‭crisis during pregnancy include dehydration ,‬
‭infection , stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and‬
‭tachycardia aren't known to precipitate a sickle cell crisis‬
‭8.‬‭A‬‭nurse‬‭is‬‭caring‬‭for‬‭a‬‭1-day‬‭postpartum‬‭mother‬‭who's‬‭very‬‭talkative‬‭but‬‭isn't‬‭confident‬‭in‬‭her‬‭decision‬
‭making‬‭skills.‬‭The‬‭nurse‬‭is‬‭aware‬‭that‬‭this‬‭is‬‭a‬‭normal‬‭phase‬‭for‬‭the‬‭mother.‬‭What‬‭is‬‭this‬‭phase‬‭called?‬
‭a. Taking-in phase‬
‭b. Taking-hold phase‬
‭c. Letting-go phase‬
‭d. Taking-over phase‬
‭RATIONALE:‬‭The taking-in phase is a normal first phase‬‭for a mother when she's feeling overwhelmed by‬
‭the responsibilities of caring for the neonate while still fatigued from childbirth. Taking hold is the next‬
‭phase, when the mother has rested and she can think and learn mothering skills with confidence. During‬
‭the letting-go or taking-over phase, the mother gives up her previous role. She separates herself from the‬
‭neonate, giving up the fantasy of birth, and readjusting to the reality of caring for the neonate.‬
‭Depression may occur during this stage.‬
‭9. Which intervention listed in the care plan for a client with an ectopic pregnancy requires revision? a.‬
‭Assessing vital signs‬
‭b. Providing for dietary needs‬
‭c. Managing pain‬
‭d. Providing emotional support‬
‭RATIONALE:‬‭Providing for the client's dietary needs‬‭isn't appropriate because the client shouldn't eat or‬
‭drink anything pending surgery. Assessing vital signs for indicators of potential shock , managing pain,‬
‭and providing emotional support are essential nursing interventions in caring for a client with an ectopic‬
‭pregnancy.‬
‭10. A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking‬
‭the client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal‬
‭visit?‬
‭2‬
a‭ .‬‭Edema‬
‭b. Pelvic adequacy‬
‭c. Rh factor changes‬
‭d. Hemoglobin alterations‬
‭RATIONALE: At each prenatal visit, the nurse should assess the client for edema because edema,‬
‭increased blood pressure, and proteinuria are cardinal signs of gestational hypertension. Pelvic‬
‭measurements and Rh typing are determined at the first visit only because they don't change. The nurse‬
‭should monitor the hemoglobin level on the client's first visit, at 24 to 28 weeks' gestation, and at 36‬
‭weeks' gestation.‬
‭REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing‬
‭11. A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this‬
‭client, the nurse's highest priority is to evaluate:‬
‭a. cervical effacement and dation.‬
‭b. maternal vital signs and fetal heart rate (FHR).‬
‭c. frequency and duration of contractions.‬
‭d. white blood cell (WBC) count.‬
‭RATIONALE:‬‭After premature rupture of the membranes‬‭(PROM), monitoring maternal vital signs and FHR‬
‭takes priority. Maternal vital signs, especially temperature and pulse, may suggest maternal infection‬
‭caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis‬
‭caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this‬
‭client because it requires a pelvic examination, which may introduce pathogens into the birth canal.‬
‭Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC‬
‭count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and‬
‭FHR can and therefore provides less current information‬
‭REFERENCE:‬‭Ricci, S.S. Essentials of Maternity, Newborn,‬‭and Women’s Health Nursing. Philadelphia:‬
‭Lippincott Williams & Wilkins, 2007, p. 531.‬
‭12. A client is told that she needs to have a nonstress test to determine fetal well-being. After 20 minutes of‬
‭monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds.‬
‭What should the nurse do next ?‬
‭a. Continue to monitor the baby for fetal distress.‬
‭b. Notify the physician and transfer the mother to labor and delivery for imminent delivery.‬ ‭c. Inform‬‭the‬
‭physician and prepare for discharge: this client has a reassuring strip.‬ ‭d. Ask the mother to eat‬
‭something and return for a repeat test; the results are inconclusive.‬ ‭RATIONALE:‬‭Fetal well-being is‬
‭determined during a nonstress test by two accelerations occurring within 20 minutes that demonstrate a‬
‭rise in heart rate of at least 15 beats. This fetus has successfully demonstrated that the intrauterine‬
‭environment is still favorable. The test results don't suggest fetal distress, so immediate delivery is‬
‭unnecessary. In research studies, eating foods or drinking fluids hasn't been shown to influence the‬
‭outcome of a nonstress test.‬‭REFERENCE:‬‭Pillitteri,‬‭A. Maternal & Child Health Nursing: Care of the‬
‭Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 203.‬
‭13. A nurse is caring for four clients who gave birth 12 hours ago. Which client is at greatest risk for‬
‭complications?‬
‭a. Gravida 2 para 2002, cesarean bith, incision site intact, hemoglobin level 9.8 g/dl‬
‭b. Gravida 2 para 1011, cesarean birth, incision site intact, pulse 84 beats/minute‬
‭c. Gravida 1 para 1001, vaginal delivery, midline episiotomy, temperature of 99.8° F (37.7C) d. Gravida 1‬
‭para 1001, vaginal delivery, membranes ruptured 10 hours before birth‬ ‭RATIONALE:‬‭Women who have‬
‭anemia during pregnancy (defined as a hemoglobin less than 10 g/dl) may experience more complications‬
‭such as poor wound healing and inability to tolerate activity. An intact incision site and a pulse of 84‬
‭beats/minute after a cesarean birth and a temperature of 99.8F after a vaginal delivery with episiotomy‬
‭are findings within normal limits. Dehydration can cause a slightly elevated temperature. Although women‬
‭whose membranes are ruptured more than 24 hours before birth are more prone to developing‬
‭chorioamnionitis, the client with anemia is at greater risk for complications.‬ ‭REFERENCE:‬‭Pillitteri, A.‬
‭Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia:‬
‭14. Which measure included in the care plan for a client in the fourth stage of labor requires revision?‬
‭a. Check vital signs and fundal checks every 15 minutes.‬
‭b. Have the client spend time with the neonate to initiate breast-feeding.‬
‭c. Obtain an order for catheterization to protect the bladder from trauma.‬
‭d. Perform perineal assessments for swelling and bleeding.‬
‭3‬
‭ ATIONALE:‬‭Catheterization isn't routinely done to‬‭protect the bladder from trauma. It's done, however,‬
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‭for a postpartum complication of urinary retention. The other options are appropriate measures to‬
‭include in the care plan during the fourth stage of labor. CLIENT NEEDS CATEGORY: Physiological integrity‬
‭Basic care and comfort‬
‭REFERENCE:‬‭Ricci, S.S. Essentials of Maternity, Newborn,‬‭and Women’s Health Nursing. Philadelphia:‬
‭15. A client who's 4 weeks pregnant comes to the clinic for her first prenatal visit. When obtaining her health‬
‭history, the nurse explores her use of drugs, alcohol, and cigarettes. Which client outcome identifies a‬
‭safe level of alcohol intake for this client?‬
‭a. “The clent consumes no more than 2 oz of alcohol dady.”‬
‭b. “The client consumes no more than 4 oz of alcohol dady.”‬
‭c. “The client consumes 2 to 6 oz of alcohol daily, dependlng on body weight."‬
‭d. “The client consumes no alcohol.”‬
‭RATIONALE:‬‭A safe level of alcohol intake during pregnancy‬‭hasn't been established. Therefore,‬
‭authorities recommend that pregnant women abstain from alcohol entirely. Excessive alcohol intake has‬
‭serious harmful effects on the fetus, especially between the 16th and 18th weeks of pregnancy. Affected‬
‭neonates exhibit fetal alcohol syndrome, which includes microcephaly, growth retardation, short‬
‭palpebral fissures, and maxillary hypoplasia. Alcohol intake may also affect the client's nutrition and may‬
‭predispose her to complications in early pregnancy.‬‭REFERENCE:‬‭Pillitteri, A. Maternal & Child Health‬
‭Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams &‬
‭Wilkins, 2007, p. 291.‬
‭16. A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in‬
‭a row, the nurse should instruct the client to:‬
‭a. take all the missed doses as soon as she discovers the oversight.‬
‭b. take two pills for the next 2 days and use an alternative contraceptive method until the next cycle. c.‬
‭take three pills for the next 3 days and use an alternative contraceptive method until the next cycle.‬ ‭d.‬
‭discard the pack, use an atternative contraceptive method untii her period begins, and start a new‬
‭pack on the regular schedule.‬
‭RATIONALE:‬‭A client who misses three or more pills‬‭in a row should discard the pack, use an alternative‬
‭contraceptive method until her period begins, and start a new pack on the regular schedule. Taking all the‬
‭missed doses, taking two pills for the next 2 days, or taking three pills for the next 3 days doesn't ensure‬
‭effectiveness and can increase the risk of adverse reactions.‬‭REFERENCE:‬‭Pillitteri, A. Maternal & Child‬
‭Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams‬
‭& Wilkins, 2007, p. 112.‬
‭17. A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations‬
‭in fetal heart rate. What should the nurse do first ?‬
‭a. Change the client's position.‬
‭b. Prepare for emergency cesarean birth.‬
‭c. Check for placenta previa.‬
‭d. Administer oxygen.‬
‭RATIONALE:‬‭Variable decelerations in fetal heart rate‬‭are an ominous sign, indicating compression of the‬
‭umbilical cord. Changing the client's position may immediately correct the problem. An emergency‬
‭cesarean birth is necessary only if other measures, such as changing position and amnioinfusion with‬
‭sterile saline, prove unsuccessful. Placenta previa doesn't cause variable decelerations. Administering‬
‭oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression‬
‭18. Normal lochial findings in the first 24 hours after birth include:‬
‭a. Bright red blood.‬
‭b. large- or tissue fragments.‬
‭c. A foul odor.‬
‭d. the complete absence of lochia.‬
‭RATIONALE:‬‭Bright‬‭red‬‭blood‬‭is‬‭a‬‭normal‬‭lochial‬‭finding‬‭in‬‭the‬‭first‬‭24‬‭hours‬‭after‬‭birth.‬‭Lochia‬‭should‬
‭never‬‭contain‬‭large‬‭clots,‬‭tissue‬‭fragments,‬‭or‬‭membranes.‬‭A‬‭foul‬‭odor‬‭or‬‭absence‬‭of‬‭lochia‬‭may‬‭signal‬
‭infection .‬
‭19. A nurse is performing a physical examination of a primigravid client who's 8 weeks pregnant. At this‬
‭time, the nurse expects to assess:‬
‭4‬
a‭ . Hegar's sign.‬
‭b. fetal outline‬
‭c. balottement.‬
‭d.quickening‬
‭RATIONALE: When performing a vaginal or rectovaginal examination, the nurse may assess Hegar's sign‬
‭(softening of the uterine isthmus) between the 6th and 8th weeks of pregnancy. The fetal outline may be‬
‭palpated after 24 weeks. Ballottement isn't elicited until the fourth or fifth month of pregnancy.‬
‭Quickening typically is reported after 16 to 20 weeks.‬
‭20. A client asks how long she and her husband can safely continue sexual activity during pregnancy. How‬
‭should the nurse respond?‬
‭a. “Unti the end of the frst trimester.”‬
‭b. "Unti the end of the second trrmester.”‬
‭c. "Unti the end of the thid trimester.”‬
‭d. "As long as you wish, if the pregnancy is normal.”‬
‭RATIONALE:‬‭During a normal pregnancy, the client and‬‭her partner need not discontinue sexual activity. If‬
‭the client develops complications that could lead to preterm labor, she and her partner should consult‬
‭with a health practitioner for advice on the safety of sexual activity.‬‭REFERENCE:‬‭Pillitteri, A. Maternal‬‭&‬
‭Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott‬
‭Williams & Wilkins, 2007, p. 275.‬
‭21. A stillborn infant 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?‬
‭a. “What have you named your baby?”‬
‭b. “We need to take the baby from you now so that you can get some sleep.”‬
‭c. “Don’t worry; there is nothing you could have done to prevent this from happening.” d. “We will‬
‭see to it that you have an early discharge so that you don’t have to be reminded of this‬
‭experience.”‬
‭RATIONALE:‬‭Nurses should be able to explore measures‬‭that help the family create memories of the‬
‭newborn infant so that the existence of the child is confirmed and the parents can complete the grieving‬
‭process. Option 1 provides this support and demonstrates a caring and empathetic response. Options 2, 3,‬
‭and 4 are blocks to communication and devalue the parents’ feelings.‬
‭REFERENCES:‬‭Wong, D., Perry, S., Hockenberry, M.,‬‭et al. (2006)‬
‭Maternal child nursing care‬
‭(3rd ed., pp. 681-683). St. Louis: Mosby.‬
‭22.‬‭A‬‭nurse‬‭is‬‭caring‬‭for‬‭a‬‭pregnant‬‭client‬‭with‬‭preeclampsia.‬‭The‬‭nurse‬‭prepares‬‭a‬‭plan‬‭of‬‭care‬‭for‬‭the‬‭client‬
‭and‬‭documents‬‭in‬‭the‬‭plan‬‭that‬‭if‬‭the‬‭client‬‭progresses‬‭from‬‭preeclampsia‬‭to‬‭eclampsia,‬‭the‬‭nurse’s‬‭first‬
‭action should be to:‬
‭a. Administer oxygen by face mask.‬
‭b.‬‭Clear and maintain an open airway.‬
‭c. Administer magnesium sulfate intravenously.‬
‭d. Assess the blood pressure and fetal heart rate.‬
‭RATIONALE:‬‭The immediate care during a seizure (eclampsia)‬‭is to ensure a patent airway. Options 1, 3,‬
‭and 4 are actions that follow or are implemented after the seizure has ceased.‬
‭REFERENCES:‬‭Wong, D., Perry, S., Hockenberry, M.,‬‭et al. (2006).‬
‭(3rd ed., p. 385). St. Louis: Mosby.‬
‭23. 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:‬
‭a. Enlargement of the breasts‬
‭b. Complaints of feeling hot when the room is cool‬
‭c. Periods of fetal movement followed by quiet periods‬
‭ . Evidence of bleeding, such as in the gums, petechiae, and purpura‬
d
‭RATIONALE:‬‭Severe preeclampsia can trigger disseminated‬‭intravascular coagulation (DIC) because of the‬
‭widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the‬
‭5‬
‭health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last‬
t‭ rimester of pregnancy.‬
‭REFERENCES:‬‭Lowdermilk, D., & Perry, A. (2004).‬
‭Maternity and women’s health care‬
‭(8th ed., pp. 852, 878). St. Louis: Mosby.‬
‭24. Immediately after an amniotomy has been performed, the nurse should first assess:‬
‭a. For bladder distention‬
‭b. For cervical dilation‬
‭c. The maternal blood pressure‬
‭d. The fetal heart rate (FHR) pattern‬
‭RATIONALE:‬‭The FHR is assessed immediately after amniotomy‬‭to detect any changes that may indicate‬
‭cord compression or prolapse. Bladder distention or maternal blood pressure would not be the first things‬
‭to check after an amniotomy. Once the membranes are ruptured, minimal vaginal examinations will be‬
‭done because of the risk of infection.‬
‭REFERENCES:‬‭Lowdermilk, D., & Perry, S. (2004).‬
‭(8th ed., p. 1009). St. Louis: Mosby.‬
‭25. A nurse in the labor room is caring for a client in the active stage of labor. The nurse is assessing the fetal‬
‭patterns and notes a late deceleration on the monitor strip. The appropriate nursing action is to:‬‭a.‬
‭Administer oxygen via face mask.‬
‭b. Place the mother in a supine position.‬
‭c. Increase the rate of the oxytocin (Pitocin) IV infusion.‬
‭d. Document the findings and continue to monitor the fetal patterns.‬
‭RATIONALE:‬‭Late decelerations are the result of uteroplacental‬‭insufficiency 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 onto her side to displace pressure of the gravid uterus on the inferior vena‬
‭cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin‬
‭would cause further hypoxemia because of increased uteroplacental insufficiency resulting from‬
‭stimulation of contractions by this medication. Option 4 would delay necessary treatment.‬‭REFERENCES:‬
‭Lowdermilk, D., & Perry, S. (2006).‬
‭Maternity nursing (7th ed., p. 386). St. Louis: Mosby.‬
‭26. 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?‬
‭a. Hemoglobin of 11.0 g/dL‬
‭b.‬‭Fetal heart rate of 180 beats/min‬
‭c. Maternal pulse rate of 85 beats/min‬
‭d. White blood cell count of 12,000/mm3‬
‭RATIONALE:‬‭A normal fetal heart rate is 120 to 160‬‭beats/min. A count of 180 beats/min could indicate‬
‭fetal distress and would warrant physician notification. White blood cell counts in a normal pregnancy‬
‭begin to rise in the second trimester and peak in the third trimester, with a normal range of 11,000 to‬
‭15,000/mm3‬
‭, up to 18,000/mm3. During the immediate postpartum period, the count may be as high as 25,000 to‬
‭30,000/mm3 as a result of increased leukocytosis during delivery. By full term, a normal maternal‬
‭hemoglobin range is 11 to 13 g/dL as a result of the hemodilution caused by an increase in plasma volume‬
‭during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/min over‬
‭prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration.‬
‭REFERENCES:‬‭Lowdermilk, D., & Perry, S. (2004). Maternity‬‭and women’s health care (8th ed., pp. 356,‬
‭358, 518). St. Louis: Mosby.‬
‭27. A nurse has provided discharge instructions to a client who delivered a healthy newborn infant by‬
‭cesarean delivery. Which statement, if made by the client, indicates a need for further instructions?‬
‭a.‬‭“I will begin abdominal exercises immediately.”‬
‭b. “I will notify the physician if I develop a fever.”‬
‭c. “I will turn on my side and push up with my arms to get out of bed.”‬
‭ . “I will lift nothing heavier than the newborn infant for at least 2 weeks.”‬
d
‭RATIONALE:‬‭Abdominal exercises should not start immediately‬‭following abdominal surgery, and the‬
‭client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3,‬
‭and 4 are appropriate instructions for the client following a cesarean delivery.‬
‭REFERENCES:‬‭Lowdermilk, D., & Perry, S. (2006). Maternity‬‭nursing (7th ed., p. 804). St. Louis: Mosby.‬
‭6‬
‭28. A nurse is caring for a client in labor who is receiving oxytocin (Pitocin) by intravenous infusion to‬
‭stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion‬
‭needs to be discontinued?‬
‭a. Increased urinary output‬
‭b. A fetal heart rate of 90 beats/min‬
‭c. Three contractions occurring within a 10-minute period‬
‭d. Adequate resting tone of the uterus palpated between contractions‬
‭RATIONALE:‬‭A normal fetal heart rate is 120 to 160‬‭beats/min. Bradycardia or late or variable‬
‭decelerations indicate fetal distress and the need to discontinue the oxytocin. The goal of labor‬
‭augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-‬
‭minute period. The uterus should return to resting tone between contractions, and there should be no‬
‭evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.‬‭REFERENCES:‬
‭McKinney, E., James, S., Murray, S., & Ashwill, J. (2005).‬
‭Maternal-child nursing‬
‭(2nd ed., p. 448). St. Louis: W.B. Saunders.‬
‭29. 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?‬
‭a. Late decelerations‬
‭b. Early decelerations‬
‭c. Short-term variability‬
‭d. Variable decelerations‬
‭RATIONALE:‬‭Variable decelerations occur if the umbilical‬‭cord 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 they suggest uteroplacental‬
‭insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart‬
‭rate.‬
‭Maternity nursing‬
‭30. A labor and delivery room nurse has just received report on four clients. The nurse should assess which‬
‭client first?‬
‭a. A primiparous client in the active stage of labor‬
‭b. A multiparous client who was admitted for induction of labor‬
‭c. A client who is not contracting, but has suspected premature rupture of the membranes‬‭d. A client‬
‭who has just received an IV loading dose of magnesium sulfate to stop preterm labor RATIONALE:‬
‭Magnesium sulfate is a central nervous system (CNS) depressant and the client could experience‬
‭adverse effects that includes depressed respiratory rate (below 12 breaths/min), severe hypotension,‬
‭and absent deep tendon reflexes (DTRs). This client should be seen before the clients in options 1, 2,‬
‭and 3 because these clients conditions represent stable ones.‬
‭Maternity nurs‬
‭ing (7th ed., p. 778). St. Louis: Mosby.‬
‭31. A nurse is reviewing the physician’s orders for a client admitted for premature rupture of the membranes.‬
‭Gestational age of the fetus is determined to be 37 weeks. Which physician’s order should the nurse‬
‭question?‬
‭a. Perform a vaginal examination every shift.‬
‭b. Monitor maternal vital signs every 4 hours.‬
‭c. Monitor fetal heart rate (FHR) continuously.‬
‭d. Administer ampicillin 1 gm as an intravenous piggyback (IVPB) every 6 hours.‬
‭RATIONALE:‬‭Vaginal examinations should not be done‬‭routinely on a client with premature rupture of the‬
‭membranes because of the risk of infection. The nurse would expect to administer an antibiotic, monitor‬
‭maternal vital signs, and monitor the FHR.‬
‭32. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what‬
‭other intervention should be done?‬
‭a. Slow the intravenous (IV) flow rate.‬
‭b. Place the client in a high-Fowler’s position.‬
‭7‬
c‭ . Continue the oxytocin (Pitocin) drip if infusing.‬
‭d. Administer oxygen at 8 to 10 L/min via face mask.‬
‭RATIONALE:‬‭Oxygen is administered at 8 to 10 L/min‬‭via face mask to optimize oxygenation of the‬
‭circulating blood. Option 1 is incorrect because the IV infusion should be increased to increase the‬
‭maternal blood volume. Option 2 is incorrect because the client is placed in the lateral position with her‬
‭legs raised to increase maternal blood volume and improve fetal perfusion. Option 3 is incorrect because‬
‭the oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason.‬
‭Maternity nursing‬
‭33. A 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. Which of the following is the initial nursing‬
‭action?‬
‭a. Gently push the cord into the vagina.‬
‭b. Place the client in Trendelenburg’s position.‬
‭c. Find the closest telephone and page the physician stat.‬
‭d.‬‭Call the delivery room to notify the staff that‬‭the client will be transported immediately.‬‭RATIONALE:‬
‭When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal‬
‭oxygenation. The client 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. If the cord is protruding from the‬
‭vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce‬
‭blood flow. The examiner, however, may place a gloved hand into the vagina and hold the presenting part‬
‭off the umbilical cord. Oxygen at 8 to 10 L/min by face mask is administered to the client to increase fetal‬
‭oxygenation.‬
‭REFERENCES:‬‭Lowdermilk, D., & Perry, S. (2006).Maternity‬‭nursing (7th ed., p. 811). St. Louis: Mosby.‬
‭34. A maternity nurse is caring for a client with abruptio placentae and is monitoring the client for‬
‭disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with‬
‭disseminated intravascular coagulation?‬
‭a. Prolonged clotting times‬
‭b. Decreased platelet count‬
‭c. Swelling of the calf of one leg‬
‭d.‬‭Petechiae, oozing from injection sites, and hematuria‬
‭RATIONALE:‬‭Disseminated intravascular coagulation‬‭(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 thrombophlebitis.‬
‭REFERENCES:‬‭Mattson, S., & Smith, J. (2004).‬
‭Core curriculum for maternal-newborn nursing‬
‭(4th ed., p. 838). Philadelphia: W.B. Saunders.‬
‭35.‬‭A‬‭nurse‬‭is‬‭assessing‬‭a‬‭pregnant‬‭client‬‭in‬‭the‬‭second‬‭trimester‬‭of‬‭pregnancy‬‭who‬‭was‬‭admitted‬‭to‬‭the‬
‭maternity‬‭unit‬‭with‬‭a‬‭suspected‬‭diagnosis‬‭of‬‭abruptio‬‭placentae.‬‭Which‬‭of‬‭the‬‭following‬‭assessment‬
‭findings would the nurse expect to note if this condition is present?‬
‭a. A soft abdomen‬
‭b. Uterine tenderness‬
‭c. Absence of abdominal pain‬
‭d. Painless, bright red vaginal bleeding‬
‭RATIONALE:‬‭Painless, bright red vaginal bleeding in‬‭the second or third trimester of pregnancy is a sign of‬
‭placenta previa. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies‬
‭placental abruption, especially with a central abruption and trapped blood behind the placenta. The‬
‭abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes‬
‭uterine irritability. Observation of the fetal monitor often reveals increased uterine resting tone, caused‬
‭ y failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding.‬
b
‭8‬
‭36. A maternity nurse is preparing for the admission of a client in the third 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?‬
‭a. Prepare the client for an ultrasound.‬
‭b. Obtain equipment for a manual pelvic examination.‬
‭c. Prepare to draw a hemoglobin and hematocrit blood sample.‬
‭d. Obtain equipment for external electronic fetal heart rate monitoring.‬
‭ ATIONALE:‬‭Manual pelvic examinations are contraindicated‬‭when vaginal bleeding is apparent in the‬

R
‭third trimester until a diagnosis is made and placenta 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
‭hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is‬
‭initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus that is at risk‬
‭for severe hypoxia.‬
‭Maternity and women’s health c‬
‭are (8th ed., pp. 872, 874-875). St. Louis: Mosby.‬
‭37. An ultrasound is performed on a client at term gestation that 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:‬
‭a. Delivery of the fetus‬
‭b. Strict monitoring of intake and output‬
‭c. Complete bed rest for the remainder of the pregnancy‬
‭d. The need for weekly monitoring of coagulation studies until the time of delivery‬‭RATIONALE:‬‭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. Because delivery of the fetus is necessary,‬
‭options 2, 3, and 4 are incorrect regarding management of the client with abruptio placentae.‬
‭38. A clinic nurse is performing a prenatal assessment on a pregnant client. The nurse would implement‬
‭teaching related to the risk of abruptio placentae if which of the following information was obtained on‬
‭assessment?‬
‭a. The client is 28 years of age.‬
‭b. This is the second pregnancy.‬
‭c. The client has a history of hypertension.‬
‭d.‬‭The client performs moderate exercise on a regular‬‭daily schedule.‬
‭RATIONALE:‬‭Abruptio placentae is associated with conditions‬‭characterized 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.‬
‭Maternal child nursing ca‬
‭re. (3rd ed., p. 404). St. Louis: Mosby.‬
‭39. A nurse is caring for a client who is experiencing a precipitous birth. The nurse is waiting for the physician‬
‭to arrive. When the infant’s head crowns, the nurse would instruct the client to:‬
‭a. Bear down.‬
‭b. Hold her breath.‬
c‭ . Breathe rapidly (pant).‬
‭d. Push with each contraction.‬
‭RATIONALE:‬‭During‬‭a‬‭precipitous‬‭birth,‬‭when‬‭the‬‭infant’s‬‭head‬‭crowns,‬‭the‬‭nurse‬‭instructs‬‭the‬‭client‬‭to‬
‭ reathe‬‭rapidly‬‭to‬‭decrease‬‭the‬‭urge‬‭to‬‭push.‬‭The‬‭client‬‭is‬‭not‬‭instructed‬‭to‬‭push‬‭or‬‭bear‬‭down.‬‭Holding‬
b
‭the breath decreases the amount of oxygen to the mother and to the fetus.‬
‭REFERENCES:‬‭Murray, S., & McKinney, E. (2006).‬
‭9‬
F‭ oundations of maternal-newborn nursing‬
‭40. 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?‬
‭a. Increased hydration‬
‭b. Oxytocin (Pitocin) infusion‬
‭c. Medication that will provide sedation‬
‭d. Administration of a tocolytic medication‬
‭RATIONALE:‬‭Therapeutic management for hypotonic uterine‬‭dysfunction includes oxytocin augmentation‬
‭and amniotomy to stimulate a labor that slows. A cesarean birth will be performed if no progress in labor‬
‭occurs. Options 1, 3, and 4 identify therapeutic measures for a client with hypertonic dysfunction.‬
‭Foundations of maternal-newborn nursing‬
‭(4th ed., p. 698-699). Philadelphia: W.B. Saunders.‬
‭41. 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 urinate and empty her bladder.‬
‭c. Massage the fundus gently before determining the level of the fundus.‬
‭d. Ask the client to lie flat on her back with the knees and legs flat and straight.‬
‭RATIONALE:‬‭Before starting the fundal assessment,‬‭the nurse should ask the client to empty her bladder‬
‭so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse‬
‭asks the client 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.‬
‭42. A nurse is caring for four 1-day postpartum clients. Which client has an abnormal finding that would‬
‭require further intervention?‬
‭a. The client with mild afterpains‬
‭b. The client with a pulse rate of 60 beats/min‬
‭c. The client with colostrum discharge from both breasts‬
‭d. The client with lochia that is red and has a foul-smelling odor‬
‭RATIONALE:‬‭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.‬
‭43. A postpartum nurse is taking the vital signs of a client who delivered a healthy newborn infant 4 hours‬
‭ago. The nurse notes that the client’s temperature is 100.2° F. Which of the following actions would be‬
‭appropriate?‬
‭a. Notify the physician.‬
‭b. Document the findings.‬
‭c. Retake the temperature in 15 minutes.‬
‭d.‬‭Increase hydration by encouraging oral fluids‬‭.‬
‭RATIONALE:‬‭The client’s temperature should be taken‬‭every 4 hours while she is awake. Temperatures up‬
‭to 100.4° F (38.0° C) in the first 24 hours after birth often are related to the dehydrating effects of labor.‬
T‭ he 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 the hydration. Contacting the physician is not necessary. Taking the‬
‭temperature in another 15 minutes is not a necessary action.‬
‭(4th ed., pp. 405, 409, 419). Philadelphia: W.B. Saunders.‬
‭10‬
‭44. A nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn‬
‭infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following‬
‭nursing actions would be most appropriate?‬
‭a. Elevate the client’s legs.‬
‭b. Determine hemoglobin and hematocrit levels.‬
‭c. Instruct the client to request help when getting out of bed.‬
‭d. Inform the nursery room nurse to avoid bringing the newborn infant to the client until the feelings of‬
‭lightheadedness and dizziness have subsided.‬
‭RATIONALE:‬‭Orthostatic hypotension may be evident‬‭during the first 8 hours after birth. Feelings of‬
‭faintness or dizziness are signs that caution the nurse to beware for the client’s safety. The nurse should‬
‭advise the client to get help the first few times the mother gets out of bed. Option 1 is not the most‬
‭appropriate or helpful action in this situation. Option 2 requires a physician’s order. Option 4 is‬
‭unnecessary.‬
‭45. A postpartum nurse is providing instructions to a client after delivery of a healthy newborn infant. The‬
‭nurse instructs the client that she should expect normal bowel elimination to return:‬‭a. 3 days‬
‭postpartum‬
‭b. 7 days postpartum‬
‭c. On the day of delivery‬
‭d.‬‭Within 2 weeks postpartum‬
‭RATIONALE:‬‭After birth, the nurse should auscultate‬‭the 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.‬
‭46. A 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 diagnosis for this client? a.‬
‭Acute pain‬
‭b. Disturbed body image‬
‭c. Impaired urinary elimination‬
‭d. Risk for imbalanced fluid volume‬
‭RATIONALE:‬‭The priority nursing diagnosis for a client‬‭who delivered 2 hours ago and who has a midline‬
‭episiotomy and hemorrhoids is acute pain. Most clients have some degree of discomfort during the‬
‭immediate postpartum period. There is no data in the question that indicate the presence of Disturbed‬
‭body image, Impaired urinary elimination, Risk for imbalanced fluid volume.‬
‭47. 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 not necessary while breastfeeding.‬
‭RATIONALE:‬‭The diet for a breast-feeding client should‬‭include additional fluids. Prenatal vitamins should‬
‭be taken as prescribed, and soap should not be used on the breast because it tends to remove natural‬
‭ ils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraception, so‬
o
‭birth control measures should be resumed.‬
‭(3rd ed., p. 781). St. Louis: Mosby.‬
‭48. A postpartum client is diagnosed with cystitis. The nurse plans for which priority nursing intervention in‬
‭the care of the client?‬
‭a. Providing sitz baths‬
‭b. Encouraging fluid intake‬
‭c. Placing ice on the perineum‬
‭11‬
‭ . Monitoring hemoglobin and hematocrit levels‬
d
‭RATIONALE:‬‭Cystitis is an infection of the bladder.‬‭The client should consume 3000 mL of fluids per day.‬
‭Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and‬
‭hematocrit levels would be monitored with hemorrhage.‬
‭(4th ed., p. 749). St. Louis: W.B. Saunders.‬
‭49. A nurse is monitoring a postpartum client who received epidural anesthesia for the presence of a vulvar‬
‭hematoma. Which of the following assessment findings would best indicate the presence of a hematoma?‬
‭a. Changes in vital signs‬
‭b. Signs of heavy bruising‬
‭c. Complaints of intense pain‬
‭d. Complaints of a tearing sensation‬
‭RATIONALE:‬‭Because the client has had epidural anesthesia‬‭and is anesthetized, she cannot feel pain,‬
‭pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in the anesthetized‬
‭postpartum woman with vulvar hematoma. Option 2 (heavy bruising) may be visualized, but vital sign‬
‭changes indicate hematoma caused by blood collection in the perineal tissues.‬
‭Use the process of elimination, noting the strategic words epidural anesthesia. With this in mind,‬
‭eliminate options 3 and 4. From the remaining options, use the ABCs—airway, breathing, and‬
‭circulation—to direct you to option 1. Review the signs of a vulvar hematoma in a client who had epidural‬
‭anesthesia if you had difficulty with this question.‬
‭50. A nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast‬
‭feeding her newborn. Which of the following, if stated by the client, would indicate a need for further‬
‭instructions?‬
‭a. “I should breast-feed every 2 to 3 hours.”‬
‭b. “I should change the breast pads frequently.”‬
‭c. “I should wash my hands well before breast-feeding.”‬
‭d. “I should wash my nipples daily with soap and water.”‬
‭RATIONALE:‬‭Mastitis generally is caused by an organism‬‭that 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 mother should be instructed to avoid the use of soap on the‬
‭nipples during breast-feeding. The mother is taught about the importance of hand washing and that she‬
‭should breast-feed every 2 to 3 hours.‬
‭REFERENCES:‬‭Murray, S., & Gorrie, T. (2006).‬
‭51. A client in the postpartum care unit who is recovering from disseminated intravascular coagulopathy is to‬
‭be discharged on low dosages of an anticoagulant medication. In developing home care instructions for‬
‭this client, the nurse includes which priority safety instruction regarding this medication? a. Avoid all‬
‭activities because bruising injuries can occur.‬
‭b. Avoid walking long distances and climbing stairs.‬
‭c. Avoid taking acetylsalicylic acid (aspirin).‬
‭d. Avoid brushing the teeth.‬
‭RATIONALE:‬‭Aspirin can interact with the anticoagulant‬‭medication to increase clotting time beyond‬
t‭ herapeutic ranges. Avoiding aspirin is a priority. Not all activities need to be avoided. Walking and‬
‭climbing stairs are acceptable activities. The client does not need to avoid brushing the teeth; however,‬
‭the client should be instructed to use a soft toothbrush.‬
‭REFERENCES:‬‭Kee, J., Hayes, E., & McCuistion, L. (2006).‬
‭Pharmacology: A nursing process approach‬
‭52. The uterus returns to the pelvic cavity in which time frame?‬
‭a. 7 to 9 days postpartum‬
‭b. 2 weeks postpartum‬
‭c. 6 weeks postpartum‬
‭d. When the lochia changes to alba‬
‭12‬
‭ ATIONALE:‬‭The normal involutional process returns‬‭the uterus to the pelvic cavity in 7 to 9 days. A‬
R
‭significant involutional complication is the failure of the uterus to return to the pelvic cavity within the‬
‭ordered time period. This is known as subinvolution.‬
‭REFERENCE:‬‭Pillitteri, A. Maternal & Child Health‬‭Nursing: Care of the Childbearing and Childrearing‬
‭Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 628.‬
‭53. A postpartum client asks the nurse about the rhythm (symptothermal) method of family planning. The‬
‭nurse explains that this method involves:‬
‭a. using chemical barriers that act as spermicidal agents.‬
‭b. using hormones that prevent ovulation.‬
‭c. using mechanical barriers that prevent sperm from reaching the cervix.‬
‭d. determining the fertile period to identify safe times for sexual intercourse.‬
‭RATIONALE:‬‭The symptothermal method of family planning‬‭combines basal body temperature‬
‭measurement with analysis of cervical mucus changes to determine the fertile period more accurately and‬
‭thus identify safe and unsafe periods for sexual intercourse. A natural family planning method, it doesn't‬
‭involve use of chemical barriers, hormones, or mechanical barriers.‬‭REFERENCE:‬‭Pillitteri, A. Maternal‬
‭& Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia:‬
‭54. A nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which‬
‭precaution should the nurse plan to take for this procedure?‬
‭a. washing the hands‬
‭b. washing the hands and wearing latex gloves‬
‭c. washing the hands and wearing latex gloves and a barrier gown‬
‭d. washing the hands and wearing latex gloves, a barrier gown, and protective eyewear‬ ‭RATIONALE:‬
‭During a postpartum assessment, the nurse is likely to come into contact with the client's blood or body‬
‭fluids, especially when examining the perineal region. Therefore, the nurse must wear latex gloves; hand‬
‭washing alone would neither provide adequate protection nor comply with universal precautions. The‬
‭nurse should wear a barrier gown and protective eyewear in addition to latex gloves only when‬
‭anticipating splashing of blood or body fluids such as during childbirth. Splashing isn't likely to occur‬
‭during a postpartum assessment.‬
‭REFERENCE:‬‭Craven, R.F., and Hirnle, C.J. Fundamentals‬‭of Nursing: Human Health and Function,‬
‭5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 531.‬
‭55. A nurse in a prenatal clinic is assessing a client who's 24 weeks pregnant. Which findings lead this nurse to‬
‭suspect that the client has mild preeclampsia?‬
‭a. Glycosuria, hypertension, seizures‬
‭b. Hematuria, blurry vision, reduced urine output‬
‭c. Burning on urination, hypotension, abdominal pain‬
‭d. Hypertension, edema, proteinuria‬
‭RATIONALE:‬‭The typical findings of mild preeclampsia‬‭are hypertension, edema, and proteinuria.‬
‭Abdominal pain, blurry vision, and reduced urine output are signs of severe preeclampsia. Seizures are a‬
‭sign of eclampsia. The other findings aren't typically found in women with preeclampsia.‬ ‭REFERENCE:‬
‭Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family,‬
‭5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 427.‬
‭56. On her second visit to the prenatal facility, a client states, "I guess I really am pregnant. I've missed two‬
‭periods now." Based on this statement, the nurse determines that the client has accomplished which‬
‭psychological task of pregnancy?‬
‭a. Identifying the fetus as a separate being‬
‭ . Assuming caretaking responsibility for the neonate‬
b
‭c. Preparing to relinquish the neonate through labor‬
‭d. Accepting the biological fact of pregnancy‬
‭RATIONALE:‬‭The first maternal psychological task of‬‭pregnancy is to accept the pregnancy as a biological‬
‭fact. If the client doesn't accept that she's pregnant, she's unlikely to seek prenatal care. Identifying the‬
‭fetus as a separate being usually occurs after the client feels fetal movements. Assuming caretaking‬
‭responsibility for the neonate should occur during the postpartum period. Preparing to relinquish the‬
‭neonate through labor normally occurs during the third trimester.‬
‭57. On the second postpartum day a gravida 6, para 5 complains of intermittent abdominal cramping. The‬
‭nurse should assess for:‬
‭13‬
a‭ . endometritis.‬
‭b. postpartum hemorrhage.‬
‭c. subinvolution.‬
‭d. afterpains.‬
‭RATIONALE:‬‭In‬‭a‬‭multiparous‬‭client,‬‭decreased‬‭uterine‬‭muscle‬‭tone‬‭causes‬‭alternating‬‭relaxation‬‭and‬
‭contraction‬‭during‬‭uterine‬‭involution,‬‭which‬‭leads‬‭to‬‭afterpains.‬‭The‬‭client's‬‭symptoms‬‭don't‬‭suggest‬
‭endometritis, hemorrhage, or subinvolution.‬
‭58. A client is 8 weeks pregnant. Which teaching topic is most appropriate at this time?‬
‭a. Breathing techniques during labor‬
‭b. Common discomforts of pregnancy‬
‭c. Infant care responsibilities?‬
‭d. Neonatal nutrition‬
‭RATIONALE:‬‭During the first trimester, a pregnant‬‭client is most concerned with her own needs. Because‬
‭she's likely to experience discomforts of pregnancy, such as morning sickness, fatigue, and urinary‬
‭frequency, the nurse should teach her how to relieve these discomforts. The nurse should teach labor‬
‭breathing techniques during the second half of the pregnancy, when the client is most strongly motivated‬
‭to learn them. The postpartum period is the best time to teach about infant care responsibilities and‬
‭neonatal nutrition if the client didn't attend prenatal classes. Otherwise, infant care is taught during the‬
‭third trimester and reinforced in the postpartum period.‬
‭59. Certain drugs used during the postpartum period may affect blood pressure. Which drug decreases a‬
‭postpartum client's blood pressure?‬
‭a. Oxytocin (Pitocin)‬
‭b. Codeine phosphate‬
‭c. Ergonovine (Ergotrate Maleate)‬
‭d. Methylergonovine (Methergine)‬
‭RATIONALE:‬‭Codeine phosphate, given to relieve postpartum‬‭pain, may cause a decrease in blood‬
‭pressure. Oxytocin reduces postpartum bleeding after expulsion of the placenta and may cause‬
‭hypertension. Ergonovine and methylergonovine prevent or treat postpartum hemorrhage from uterine‬
‭atony or subinvolution and may cause an increase in blood pressure.‬‭REFERENCE:‬‭Pillitteri, A.‬
‭Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed.‬
‭60. During the first 3 months, which hormone is responsible for maintaining pregnancy?‬
‭a. Human chorionic gonadotropin (hCG)‬
‭b. Progesterone‬
‭c. Estrogen‬
‭d. Relaxin‬
‭RATIONALE:‬‭The hormone hCG is responsible for maintaining‬‭the pregnancy until the placenta is in place‬
‭and functioning. Serial hCG levels are used to determine the status of the pregnancy in clients with‬
‭complications. Progesterone and estrogen are important hormones responsible for many of the body's‬
‭changes during pregnancy. Relaxin is an ovarian hormone that causes the mother to feel tired, thus‬
‭promoting her to seek rest.‬
‭61. A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds‬
‭that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first‬
‭action the nurse should take?‬
‭a. Ask the client to get out of bed and try to urinate.‬
‭b. Call the physician for a methylergonovine (Methergine) order.‬
‭c. Assess the fundus and massage it if it's boggy.‬
‭d. Give the client a new pad and check her in 30 minutes.‬
‭RATIONALE:‬‭The nurse should first assess the fundus‬‭to determine if clots are present or if uterine‬
‭involution has occurred. Clots, no uterine involution, and the saturation of two perineal pads within 30‬
‭minutes could indicate postpartum hemorrhage. If the fundus is boggy, massaging it will suppress‬
‭bleeding by encouraging the uterus to contract upon itself and the open vessels that were attached to the‬
‭placenta. Massaging also helps to expel clots or tissue remaining from the birth. If the nurse assesses a‬
‭14‬
‭ rm‬‭fundus,‬‭she‬‭should‬‭next‬‭assess‬‭for‬‭a‬‭full‬‭bladder‬‭and‬‭then‬‭ask‬‭the‬‭client‬‭to‬‭try‬‭to‬‭urinate.‬‭If‬‭the‬‭uterus‬
fi
‭remains‬‭boggy‬‭after‬‭massage,‬‭the‬‭nurse‬‭should‬‭obtain‬‭an‬‭order‬‭from‬‭the‬‭physician‬‭for‬‭methylergonovine.‬
‭Waiting 30 minutes without intervening could contribute to uterine hemorrhage.‬
‭62. A client in labor is receiving oxytocin (Pitocin). The electronic fetal monitoring strip shows contractions‬
‭occurring every 30 seconds to 2 minutes, with an intensity of 90 mm Hg and increasing resting tone. How‬
‭should the nurse respond to these findings?‬
‭a. Administer oxygen as ordered.‬
‭b. Call the physician.‬
‭c. Check the fetal heart rate (FHR).‬
‭d. Discontinue the oxytocin infusion.‬
‭RATIONALE:‬‭Oxytocin should be discontinued when contractions‬‭occur less than 2 minutes apart or last‬
‭longer than 90 seconds. The nurse can stop oxytocin infusion independently without seeking permission‬
‭from the physician - an action that would waste valuable time. This client isn't oxygen deprived and,‬
‭therefore, doesn't need supplemental oxygen. Checking the FHR isn't appropriate in this situation because‬
‭the decelerations occur and resolve with each contraction, independent of oxytocin administration.‬
‭REFERENCE:‬‭Ricci, S.S. Essentials of Maternity,‬‭Newborn, and Women’s Health Nursing.‬
‭63. When assessing the fetal heart rate tracing, a nurse assesses the fetal heart rate at 170 beats/minute. This‬
‭rate is considered fetal tachycardia if:‬
‭a. the fetal heart rate remains at greater than 160 beats/minute for 5 minutes.‬
‭b. the fetal heart rate remains at greater than 160 beats/minute for 10 minutes.‬
‭c. the fetal heart rate remains at greater than 160 beats/minute for more than 20 minutes.‬
‭d. the fetal heart rate is at least 170 beats/minute at any time.‬
‭RATIONALE:‬‭The normal parameter for the fetal heart‬‭rate is 120 to 160 beats/minute. Fetal tachycardia‬
‭is defined as a fetal heart rate greater than 160 beats/minute for more than 10 minutes. This definition‬
‭takes into account the difference between tachycardia and acceleration.‬‭REFERENCE:‬‭Pillitteri, A.‬
‭64. A client asks about complementary therapies for relief of discomforts related to pregnancy. Which‬
‭comfort measure mentioned by the client indicates a need for further teaching?‬
‭a. Meditation‬
‭b. Music therapy‬
‭c. Acupuncture‬
‭d. Herbal remedies‬
‭RATIONALE:‬‭A pregnant woman should avoid all medication‬‭unless her physician instructs her to use it.‬
‭This includes herbal remedies because their effects on the fetus haven't been identified. Meditation,‬
‭music therapy, and acupuncture have all proven to enhance relaxation without harm to the mother or‬
‭baby.‬
‭65. Which factor is the most important in nursing care in the postpartum period?‬
‭a. Supporting the mother's ability to successfully feed and care for her neonate‬
‭ . Involving the family in the teaching‬
b
‭c. Providing group discussions on neonatal care‬
‭RATIONALE:‬‭Most of the nursing interventions during‬‭the postpartum period are directed toward helping‬
‭the mother successfully adapt to the parenting role. Although family involvement in teaching, group‬
‭discussions on neonatal care, and lochia monitoring are important aspects of care, the mother's ability to‬
‭feed and care for her neonate takes priority.‬
‭66. A client has her first prenatal visit at 15 weeks' gestation. Which finding requires further investigation?‬
‭a. Fundal height of 18 cm‬
‭b. Blood pressure of 124/72 mm Hg‬
‭c. Urine negative for protein‬
‭d. Weight of 144 lb (65.kg)‬
‭15‬
‭ ATIONALE:‬‭Fundal height (in centimeters) should equal‬‭the number of weeks' gestation. This client‬
R
‭should have a fundal height of 15 to 16 cm. The blood pressure, urine, and weight findings are within‬
‭normal limits for this client.‬
‭67. A client who gave birth 24 hours ago continues to experience urine retention after several‬
‭catheterizations. The physician orders bethanechol (Urecholine), 10 mg by mouth three times per day.‬
‭The client asks, "How does bethanechol act on the bladder ?" How should the nurse respond? a. “It‬
‭constricts the urinary sphincter.”‬
‭b. "It dilates the urethra.”‬
‭c. “It stimulates the smooth muscle of the bladder.”‬
‭d. “It inhibits the skeletal muscle of the bladder.”‬
‭RATIONALE:‬‭Bethanechol stimulates the smooth muscle‬‭of the bladder, causing it to release retained‬
‭urine. Bethanechol doesn't act on the urinary sphincter or dilate the urethra. The bladder contains‬
‭smooth muscle, not skeletal muscle.‬
‭REFERENCE:‬‭Springhouse Nurse’s Drug Guide 2007 Philadelphia:‬‭Lippincott Williams & Wilkins, 2007, p.‬
‭215.‬
‭68. A client 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 to preovulatory basal body temperature.‬
‭b. basal body temperature increase of 0.1° F to 0.2° F (0.06° C to 0.11° C) on the 2nd or 3rd day‬
‭of the cycle.‬
‭c. 3 full days of elevated basal body temperature and clear, thin cervical mucus.‬
‭d. breast tenderness and mittelschmerz‬
‭RATIONALE:‬‭Ovulation (the period when pregnancy can‬‭occur) is accompanied by a basal body‬
‭temperature increase of 0.7F to 0.8F (0.39C to 0.44 C) 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 isn't significant. Breast tenderness and mittelschmerz aren't reliable‬
‭indicators of ovulation.‬
‭69. A pregnant client comes to the facility for her first prenatal visit. After obtaining her health history and‬
‭performing a physical examination, the nurse reviews the client's laboratory test results. Which findings‬
‭suggest iron deficiency anemia?‬
‭a. Hemoglobin (Hb) 15 g/L; hematocrit (HCT) 35%‬
‭b. Hb 13 g/L; HCT 32%‬
‭c. Hb 10 g/L; HCT 35%‬
‭d. Hb 9 g/L; HCT 30%‬
‭RATIONALE:‬‭With iron deficiency anemia, the Hb level‬‭is below 12 g/L and HCT drops below 33%.‬
‭70. A client who's breast-feeding has a temperature of 102° F (38.9° C) and complains that her‬
‭breasts are engorged. Her breasts are swollen, hard, and red. Which action by the client requires‬
i‭ntervention?‬
‭a. Applying frozen cabbage leaves to the breasts‬
‭b. Showering with her back to the water‬
‭c. nursing her baby frequently‬
‭d. Applying a breast binder to support the breasts‬
‭RATIONALE:‬‭Engorgement in a breast-feeding woman requires‬‭careful management to preserve the milk‬
‭supply while managing the increased blood flow to the breasts. Binding the breasts isn't appropriate‬
‭because the constriction will diminish the milk supply. Frozen cabbage leaves work well to reduce the pain‬
‭and swelling and should be applied every 4 hours. Facing the shower head can stimulate the breasts and‬
‭intensify the problem. Frequent feedings will permit the breasts to empty fully and establish the supply‬
‭demand cycle that is appropriate for the infant.‬‭REFERENCE:‬‭Ricci, S.S. Essentials of Maternity,‬
‭Newborn, and Women’s Health Nursing. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 414.‬
‭71. A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding‬
‭indicates the need for intervention?‬
‭a. Urine specific gravity 1.010‬
‭b. Serum potassium 4 mEq/L‬
‭16‬
‭c. Serum sodium 140 mEq/L‬
‭ . Ketones in the urine‬
d
‭RATIONALE:‬‭Ketones in the urine of a client with hyperemesis‬‭gravidarum indicate that the body is‬
‭breaking down stores of fat and protein to provide for growth needs. A urine specific gravity of 1.010, a‬
‭serum potassium level of 4 mEq/L, and a serum sodium level of 140 mEq/L are all within normal limits.‬
‭72. During the sixth month of pregnancy, a client reports intermittent earaches and a constant feeling of‬
‭fullness in the ears. What is the most likely cause of these symptoms?‬
‭a. A serious neurologic disorder‬
‭b. Eustachian tube vascularization‬
‭c. Increasing progesterone levels‬
‭d. An ear infection‬
‭RATIONALE:‬‭During pregnancy, increasing levels of‬‭estrogen — not progesterone — cause‬
‭vascularization of the eustachian tubes, leading to such problems as earaches, impaired hearing, and a‬
‭constant feeling of fullness in the ears. The client's symptoms don't suggest a serious neurologic disorder‬
‭or an ear infection.‬
‭REFERENCE:‬‭Ricci, S.S. Essentials of Maternity,‬‭Newborn, and Women’s Health Nursing.‬
‭73.‬‭A‬‭client‬‭says‬‭she‬‭wants‬‭to‬‭practice‬‭natural‬‭family‬‭planning.‬‭The‬‭nurse‬‭teaches‬‭her‬‭how‬‭to‬‭use‬‭the‬‭calendar‬
‭method‬‭to‬‭determine‬‭when‬‭she's‬‭fertile‬‭and‬‭advises‬‭her‬‭to‬‭avoid‬‭unprotected‬‭intercourse.‬‭When‬‭teaching‬
‭her how to determine her fertile period , the nurse should instruct her to:‬
‭a. abstain from unprotected intercourse between days 14 and 16 of the menstrual cycle. b. subtract 11‬
‭days from her shortest menstrual cycle and 18 days from her longest cycle.‬ ‭c. subtract 18 days from‬‭her‬
‭shortest menstrual cycle and 11 days from her longest cycle.‬‭d. add 25 days to the first day of her last‬
‭menstrual period and abstain from unprotected intercourse for the next 5 days.‬
‭RATIONALE:‬‭To determine the fertile period, the client‬‭should subtract 18 days from her shortest‬
‭menstrual cycle and 11 days from her longest cycle; if she doesn't wish to become pregnant, she should‬
‭abstain from unprotected intercourse between the days calculated. For example, if her menstrual cycles‬
‭range from 28 to 30 days, her fertile period encompasses days 10 to 19 of her cycle. Abstaining from‬
‭unprotected intercourse on certain days doesn't determine the fertile period.‬
‭74. What is the primary nursing diagnosis for a client with a ruptured ectopic pregnancy?‬
‭a. Anxiety‬
‭b. Acute pain‬
‭c. Deficient fluid volume‬
‭d. Anticipatory grieving‬
‭RATIONALE:‬‭Ruptured ectopic pregnancy is associated‬‭with hemorrhage and requires immediate surgical‬
‭intervention; therefore, Deficient fluid volume is the primary diagnosis. Anxiety, Acute pain,‬
‭and Anticipatory grieving are appropriate for this client, but none of these diagnoses would be‬
‭considered the primary nursing diagnosis. This client is probably experiencing anxiety because this is a‬
‭surgical emergency. Pain is also present and should be addressed as warranted. The client with ruptured‬
e‭ ctopic pregnancy may experience anticipatory grieving at the loss of her fetus.‬
‭75. A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum</!gloss>. She tells‬
‭the nurse she has never known anyone who had such severe morning sickness. The nurse understands‬
‭that hyperemesis gravidarum results from:‬
‭a. a neurologic disorder.‬
‭b. inadequate nutrition.‬
‭c. an unknown cause.‬
‭d. hemolysis of fetal red blood cells‬
‭RATIONALE:‬‭The cause of hyperemesis gravidarum isn't‬‭known. However, etiologic theories implicate‬
‭hormonal alterations and allergic or psychosomatic conditions. No evidence suggests that hyperemesis‬
‭gravidarum results from a neurologic disorder, inadequate nutrition, or hemolysis of fetal RBCs.‬
‭17‬
‭76. A client is scheduled for amniocentesis. When <!hint>preparing her for the procedure, the nurse should:‬‭a.‬
‭ask the client to void.‬
‭b. instruct the client to drink 1 L of fluid.‬
‭c. prepare the client for I.V. anesthesia.‬
‭d. place the client on her left side.‬
‭RATIONALE:‬‭To prepare a client for amniocentesis,‬‭the nurse should ask her to empty her bladder to‬
‭reduce the risk of bladder perforation. Before transabdominal ultrasound, the nurse may instruct the‬
‭client to drink 1 L of fluid to fill the bladder (unless ultrasound is done before amniocentesis to locate the‬
‭placenta). I.V. anesthesia isn't given for amniocentesis. The client should be supine during the procedure;‬
‭afterward, she should be placed on her left side to avoid supine hypotension, promote venous return, and‬
‭ensure adequate cardiac output</!gloss>.‬‭REFERENCE:‬‭Pillitteri, A. Maternal & Child Health Nursing:‬
‭Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins,‬
‭2007, p. 207.‬
‭77. A client is 24 hours postpartum . The nurse anticipates that the client's body is returning to homeostasis.‬
‭Which assessment finding requires immediate intervention?‬
‭a. Maternal chills‬
‭b. Elevated temperature‬
‭c. Bradycardia‬
‭d. Positive Homans' sign‬
‭RATIONALE:‬‭A positive Homans' sign indicates thrombosis,‬‭which is abnormal for a postpartum client.‬
‭This sign requires immediate intervention. Maternal chills are a normal vasomotor response to the birth.‬
‭An elevated temperature in the first 24 hours is also normal. Bradycardia</!gloss> in the postpartum‬
‭period is common as the body adjusts to the decreased cardiac output and begins to eliminate fluid.‬
‭78. A nurse assesses a client who gave birth 24 hours earlier. Which finding reveals the need for further‬
‭evaluation?‬
‭a. Chills‬
‭b. Scant lochia rubra‬
‭c. Thirst and fatigue‬
‭d. Temperature of 100.2° F (37.90 C)‬
‭RATIONALE:‬‭During the early postpartum period, lochia‬‭rubra</!gloss> should be moderate to significant.‬
‭Scant lochia rubra suggests that large clots are blocking the lochial flow. After birth, vasomotor changes‬
‭may cause a shaking chill, this is a normal finding. Thirst, fatigue, and a temperature of up to 100.4 F (38 C)‬
‭also are common at 24 hours postpartum.‬
‭79. Which nursing action is required before a client in labor receives epidural anesthesia?‬
‭a. Give a fluid bolus of 500 ml.‬
‭b. Check for maternal pupil dilation.‬
‭c. Assess maternal reflexes.‬
‭d. Assess maternal gait.‬
‭RATIONALE‬‭: One of the major adverse effects of epidural‬‭administration is hypotension. Therefore, a 500-‬
‭ l fluid bolus is usually administered to prevent hypotension in the client who wishes to receive an‬
m
‭epidural for pain relief. Assessing maternal reflexes, pupil response, and gait isn't necessary.‬ ‭REFERENCE:‬
‭Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th‬
‭ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 552.‬
‭80. A nursing assistant escorts a client in the early stages of labor to the bathroom. When the nurse enters‬
‭the client's room, she detects a strange odor coming from the bathroom and suspects the client has been‬
‭smoking marijuana. What should the nurse do next ?‬
‭a. Tell the client that smoking is prohibited in the facility, and that if she smokes agan, she’ll be‬
‭discharged.‬
‭b. Explain to the client that smoking poses a danger of explosion because oxygen tanks are stored close‬
‭by.‬
‭c. Notify the physician and security immediately.‬
‭d. Ask the nursing assistant to dispose of the marijuana so that the client can't smoke anymore.‬
‭RATIONALE:‬‭The nurse should immediately notify the‬‭physician and security. The physician must be‬
‭informed because illegal drugs can interfere with the labor process and affect the neonate after delivery.‬
‭Moreover, the client might have consumed other illegal drugs. The nurse should also inform security‬
‭18‬
‭ ecause they're specially trained to handle such situations. Most hospitals prohibit smoking. The nurse‬
b
‭needs to alert others about the client's illegal drug use, not simply explain to the client that smoking is‬
‭prohibited. Smoking is dangerous around oxygen and it's fine for the nurse to explain the hazard to the‬
‭client; however, the nurse must first notify the physician and security. The nursing assistant shouldn't be‬
‭asked to dispose of the marijuana.‬‭REFERENCE:‬‭Ricci,‬‭S.S. Essentials of Maternity, Newborn, and‬
‭Women’s Health Nursing. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 574.‬
‭81. A woman in her 34th week of pregnancy presents with sudden onset of bright red vaginal bleeding. Her‬
‭uterus is soft, and she's experiencing no pain. Fetal heart rate is 120 beats/minute. Based on this history,‬
‭the nurse should suspect:‬
‭a. abruptio placentae.‬
‭b. preterm labor.‬
‭c. placenta previa.‬
‭d. threatened abortion.‬
‭RATIONALE:‬‭Placenta previa</!gloss> is associated‬‭with painless vaginal bleeding that occurs when the‬
‭placenta or a portion of the placenta covers the cervical os. In abruptio placentae</!gloss>, the placenta‬
‭tears away from the wall of the uterus before birth; the client usually has pain and a boardlike uterus.‬
‭Preterm labor is associated with contractions and shouldn't involve bright red bleeding. By definition,‬
‭threatened abortion occurs during the first 20 weeks' gestation.‬
‭82. When providing health teaching to a primigravid client, the nurse tells the client that she's likely to‬
‭experience Braxton Hicks contractions. When does a client typically start to feel these contractions?‬
‭a. Between 18 and 22 weeks’ gestation‬
‭b. Between 23 and 27 weeks' gestation‬
‭c. Between 28 and 31 weeks' gestation‬
‭d. Between 32 and 35 weeks' gestation‬
‭RATIONALE:‬‭Pregnant clients typically start to feel‬‭Braxton Hicks contractions between 23 and 27 weeks'‬
‭gestation. Fetal rebound is possible between 18 and 22 weeks. The fetal outline becomes palpable and‬
‭the fetus is highly mobile between 28 and 31 weeks. Braxton Hicks contractions increase in frequency and‬
‭intensity between 32 and 35 weeks.‬
‭83. Which finding requires further intervention in a mother who's breast-feeding?‬

‭a. The neonate latches easily to the breast.‬
‭b. The mother is comfortable positioning the neonate.‬
‭c. The neonate makes swallowing noises when breast-feeding.‬
‭d. The neonate's lips smack.‬
‭RATIONALE:‬‭A neonate who smacks his lips isn't properly‬‭latched to the breast. A neonate who latches on‬
‭easily and makes audible swallowing noises and a mother who is comfortable positioning the neonate‬
‭indicate successful breast-feeding.‬
‭84. A client who's 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting.‬
‭She's admitted for treatment of an ectopic pregnancy. The nurse should give the highest priority to‬
‭which nursing diagnosis?‬
‭a. Risk for deficient fluid volume‬
‭b. Anxiety‬
‭c. Acute pain‬
‭d. Impaired gas exchange‬
‭RATIONALE:‬‭A ruptured ectopic pregnancy is a medical‬‭emergency because of the large quantity of blood‬
‭that may be lost in the pelvic and abdominal cavities. Shock</!gloss> may develop from blood loss, and‬
‭large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically‬
‭controlled. Although the other nursing diagnoses are relevant for a woman with an ectopic pregnancy,‬
‭fluid volume loss through hemorrhage is the greatest threat to her physiological integrity and must be‬
‭stopped. Anxiety may result from such factors as the risk of dying and the fear of future infertility.‬
‭Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity.‬
‭19‬
<‭ i>Impaired gas exchange may result from the loss of oxygen-carrying hemoglobin through blood loss.‬
‭85. During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to‬
‭relieve it. Which client statement indicates <!hint>understanding of the nurse's instructions? a. “I’ll‬
‭decrease my intake of green, leafy vegetables.”‬
‭b. "I’ll limit fluid intake to four 8-oz glasses.”‬
‭c. "I’ll increase my intake of unrefined grains.”‬
‭d. "I’ll take iron supplements regularly.”‬
‭RATIONALE:‬‭To increase peristalsis and relieve constipation,‬‭the client should increase her intake of high‬
‭fiber foods (such as green, leafy vegetables; unrefined grains; and fruits) and fluids. The use of iron‬
‭supplements can cause — rather than relieve — constipation.‬‭REFERENCE:‬‭Pillitteri, A.‬
‭86. A client at 28 weeks' gestation is complaining of contractions. Following admission and hydration, the‬
‭physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to:‬
‭a. slow contractions.‬
‭b. enhance fetal growth.‬
‭c. prevent infection.‬
‭d. promote fetal lung maturity.‬
‭RATIONALE:‬‭Betamethasone is given to promote fetal‬‭lung maturity by enhancing the production of‬
‭surface-active lipoproteins. The drug has no effect on contractions, fetal growth, or infection.‬
‭87. A client with diabetes mellitus who is in labor tells the nurse she has had trouble controlling her blood‬
‭glucose level recently. She says she didn't take her insulin when the contractions began because she felt‬
‭nauseated; about an hour later, when she felt better, she ate some soup and crackers but didn't take‬
‭insulin. Now, she reports increased nausea and a flushed feeling. The nurse notes a fruity odor to her‬
‭breath. What do these findings suggest?‬
‭a. Diabetic ketoacidosis‬
‭b. Hypoglycemia‬
‭c. Infection‬
‭d. Transition to the active phase of labor‬
‭RATIONALE:‬‭Signs and symptoms of diabetic ketoacidosis</!gloss>‬‭include nausea and vomiting, a fruity‬
‭or acetone breath odor, signs of dehydration</!gloss> (such as flushed, dry skin),‬
‭hyperglycemia</!gloss>, ketonuria, hypotension, deep and rapid respirations, and a decreased level of‬
‭consciousness. In contrast, hypoglycemia</!gloss> causes sweating, tremors, palpitations, and behavioral‬
‭changes. Infection</!gloss> causes a fever. Transition to the active phase of labor is signaled by cervical‬
‭dilation of up to 7 cm and contractions every 2 to 5 minutes.‬
‭88. An expected fetal adverse reaction to meperidine (Demerol) during labor is:‬
‭a. decreased fetal heart rate variability.‬
‭b. bradycardia.‬
‭c. late decelerations.‬
‭d. increased movement‬
‭RATIONALE:‬‭Possible‬‭fetal‬‭adverse‬‭reactions‬‭include‬‭moderate‬‭central‬‭nervous‬‭system‬‭depression‬‭and‬
‭decreased‬ ‭fetal‬ ‭heart‬ ‭rate‬ ‭variability</!gloss>.‬ ‭Bradycardia</!gloss>,‬‭late‬‭decelerations</!gloss>,‬‭and‬
‭increased fetal movement don't occur as a result of meperidine administration.‬
‭89. A client who gave birth to her first child 6 weeks ago seems overwhelmed by her new role as a mother.‬
‭She tells the nurse, "I can't keep up with my housework any more because I spend so much time caring‬
‭for the baby." The nurse should:‬
‭a. help the client break down large tasks into smaller ones.‬
‭b. encourage the client to work faster.‬
‭c. reassure the client that her feelings will soon pass.‬
‭d. help the client accept her new role.‬
‭20‬
‭ ATIONALE:‬‭If a client feels overwhelmed by the additional‬‭tasks brought on by her new role as a mother,‬
R
‭the nurse should help her break down large tasks into smaller, more manageable ones. Encouraging her‬
‭to work faster or reassuring her that her feelings will soon pass wouldn't address her needs. The nurse‬
‭can't help the client accept her new role if the client feels overwhelmed.‬
‭REFERENCE:‬‭Ricci, S.S., Essentials of Maternity,‬‭Newborn, and Women’s Health Nursing.‬
‭90. A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client's health‬
‭history for risk factors for this abnormal condition, the nurse expects to find:‬
‭a. a history of pelvic inflammatory disease.‬
‭b. grand multiparity (five or more births).‬
‭c. use of an intrauterine device for 1 year.‬
‭d. use of a hormonal contraceptive for 5 years.‬
‭RATIONALE:‬‭Pelvic inflammatory disease with accompanying‬‭salpingitis is commonly implicated in cases‬
‭of tubal obstruction, the primary cause of ectopic pregnancy. Ectopic pregnancy isn't associated with‬
‭grand multiparity or hormonal contraceptive use. Ectopic pregnancy is associated with use of an‬
‭intrauterine device for 2 years or more.‬
‭91. Because cervical effacement and dilation aren't progressing in a client in labor, the physician orders I.V.‬
‭administration of oxytocin (Pitocin). Why must the nurse monitor the client's fluid intake and output‬
‭closely during oxytocin administration?‬
‭a. Oxytocin causes water intoxication.‬
‭b. Oxytocin causes excessive thirst.‬
‭c. Oxytocin toxic to the kidneys.‬
‭d. Oxytocin has a diuretic effect.‬
‭RATIONALE:‬‭The nurse should monitor fluid intake and‬‭output because prolonged oxytocin infusion may‬
‭cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results from the‬
‭work of labor and limited oral fluid intake — not oxytocin. Oxytocin has no nephrotoxic or‬
‭diuretic</!gloss> effects. In fact, it produces an antidiuretic effect.‬‭REFERENCE:‬‭Pillitteri, A. Maternal‬
‭& Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia:‬
‭92. A nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What‬
‭should the nurse do to prevent hypotension ?‬
‭a. Administer ephedrine to raise her blood pressure.‬
‭b. Administer oxygen using a mask.‬
‭c. Place the woman supine with her legs raised.‬
‭d. Ensure adequate hydration before the anesthetic is administered.‬
‭RATIONALE:‬‭Administration of an epidural anesthetic‬‭may lead to hypotension because blocking the‬
‭sympathetic fibers in the epidural space reduces peripheral resistance. Administering fluids I.V. before the‬
‭epidural anesthetic is given may prevent hypotension. Ephedrine may be administered after an epidural‬
‭ lock if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However,‬
b
‭ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes‬
‭hypotensive, but it won't prevent hypotension. Placing a pregnant woman in the supine position can‬
‭contribute to hypotension because of uterine pressure on the great vessels‬
‭93. A client gives birth to a stillborn neonate at 36 weeks' gestation. When caring for this client, which‬
‭strategy by the nurse would be most helpful?‬
‭a. Be selective in providing the information that the client seeks.‬
‭b. Encourage the client to see, touch, and hold the dead neonate.‬
‭c. Provide information about possible causes of the stillbirth only if the client requests‬
‭d. Let the child’s father decide what information the client receives.‬
‭RATIONALE:‬‭When caring for a client who has suffered‬‭perinatal loss, the nurse should provide an‬
‭opportunity for the client to bond with the dead neonate and allow the neonate to become part of the‬
‭family unit. Parents who aren't given such a chance may experience fantasies about the neonate, which‬
‭may be worse than the reality. If the neonate has gross deformities, the nurse should prepare the client‬
‭for these. If the client doesn't ask about her neonate, the nurse should encourage her to do so and‬
‭provide any information she seems ready to hear. The client needs a full explanation of all factors related‬
‭to the experience so she can grieve appropriately. Letting the neonate's father decide which information‬
‭the client receives is inappropriate.‬‭REFERENCE:‬‭Pillitteri,‬‭A. Maternal & Child Health Nursing: Care of‬
‭21‬
t‭ he Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.‬
‭439.‬
‭94. A woman gave birth 1 hour ago to a full-term boy. The nurse's assessment reveals a well-contracted‬
‭uterus that's midline, and at the level of the umbilicus. The client is bleeding heavily. What should the‬
‭nurse do next?‬
‭a. Firmly massage the uterus.‬
‭b. Request an order for oxytocin.‬
‭c. Assess for a distended bladder.‬
‭d. Report the bleeding to the physician.‬
‭RATIONALE:‬‭Heavy bleeding can signal uterine or vaginal‬‭lacerations. The nurse should report this finding‬
‭to the physician. Massaging a contracted uterus may cause uterine atony. The nurse should assess for a‬
‭distended bladder if the uterus is soft or boggy. This client's uterus is contracted‬
‭95. A client in early labor is connected to an external fetal monitor. The physician hasn't noted any‬
‭restrictions on her chart. The client tells the nurse that she needs to go to the bathroom frequently and‬
‭that her partner can help her. How should the nurse respond?‬
‭a. "Because you're connected to the monitor, you can't get out of bed. You’lI need to use the bedpan.”‬
‭b. “II show your partner how to disconnect the transducer so you can walk to the bathroom.”‬ ‭c.‬
‭“Please press the call button. I’ll disconnect you from the monitor so you can get out of bed.”‬ ‭d.‬‭"I’ll‬
‭insert a urinary catheter: then you won't need to get out of bed."‬
‭RATIONALE:‬‭The nurse should instruct the client to‬‭use the call button when she needs to use the‬
‭bathroom. The nurse will need to disconnect the fetal monitor and mark the strip to indicate the activity.‬
‭If the client's partner disconnects and reconnects the monitor, the nurse can't determine if the readings‬
‭are accurate. Inserting a catheter without a physician's order or not allowing the client to get out of bed‬
‭isn't acceptable nursing practice.‬
‭96. A client who has been in the latent phase of the first stage of labor is transitioning to the active phase.‬
‭During the transition , the nurse expects to see which client behavior?‬
‭a. A desire for personal contact and touch‬
‭b. A full response to teaching‬
‭c. Fatigue, a desire for touch, and quietness‬
‭d. Withdrawal, irritability, and resistance to touch‬
‭RATIONALE:‬‭During the transition to the active phase‬‭of the first stage of labor, increased pain typically‬
‭makes the client withdrawn, irritable, and resistant to touch. During the latent phase (the early part of the‬
‭first stage of labor), when contractions aren't intensely painful, the client typically desires personal‬
‭contact and touch and responds to teaching and interventions. Fatigue, a desire for touch, and quietness‬
‭are common during the third and fourth stages of labor.‬
‭ EFERENCE:‬‭Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing‬
R
‭97. A client recently gave birth to a boy. Two minutes before <!hint>breast-feeding the baby, she‬
‭administers one nasal spray (40 units/ml) of oxytocin (Syntocinon) into each nostril. Why is the client‬
‭using this drug?‬
‭a. To stimulate lactation‬
‭b. To treat eclampsia‬
‭c. To reduce postpartum bleeding‬
‭d. To treat erythroblastosis‬
‭RATIONALE‬‭: Oxytocin is administered as a nasal spray‬‭before breast-feeding to stimulate lactation. When‬
‭oxytocin is used to treat eclampsia, reduce postpartum‬
‭REFERENCE:‬‭Springhouse Nurse’s Drug Guide 2007.‬‭Philadelphia: Lippincott Williams & Wilkins,‬
‭2007, p. 963.‬
‭98. On her third postpartum day, a client complains of chills and aches. Her chart shows that she has had a‬
‭temperature of 100.6F (38.1C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What‬
‭should the nurse do next?‬
‭22‬
a‭ . Recheck the client’s temperature in 4 hours.‬
‭b. Assess the client's breasts for engorgement.‬
‭c. Anticipate that the physician will order laboratory tests and cultures.‬
‭d. Call the physician and request an order for antibiotics.‬
‭RATIONALE:‬‭Signs and symptoms of localized infection</!gloss>‬‭include a morbid temperature, chills,‬
‭malaise, generalized pain or discomfort, and foul-smelling, yellow lochia. The physician may order‬
‭laboratory tests, including a complete blood count and cultures, to confirm an infection and the causative‬
‭organisms. Rechecking the client's temperature in 4 hours isn't appropriate because the client requires‬
‭intervention now. The client's signs and symptoms don't suggest breast engorgement. Laboratory work‬
‭should be done before starting antibiotics.‬
‭99. Which instruction should a nurse include in a home-safety teaching plan for a <!hint>pregnant client?‬
‭a. Place a nonskid mat on the floor of the tub or shower.‬
‭b. It’s OK to clean your cat’s litter box.‬
‭c. It's OK to wear high heels.‬
‭d. Avoid having area rugs around your house.‬
‭RATIONALE:‬‭Using a mat for the floor of the shower‬‭or tub will prevent slipping. The client shouldn't clean‬
‭the cat's litter box because doing so puts her at risk for toxoplasmosis</!gloss>. Wearing high heels may‬
‭make the client lose balance and fall. The client doesn't need to completely avoid having area rugs around‬
‭her house. Nonslip rugs can be used to prevent tripping or falling.‬
‭REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing‬
‭100. A nurse is assessing a pregnant woman. Which signs or symptoms indicate a hydatidiform mole? a.‬
‭Rapid fetal heart tones‬
‭b. Abnormally high human chorionic gonadotropin (hCG) levels‬
‭c. Slow uterine growth‬
‭d. Lack of symptoms of pregnancy‬
‭RATIONALE:‬‭In a pregnant woman with a hydatidiform‬‭mole, the trophoblast villi proliferate and then‬
‭degenerate. Proliferating trophoblast cells produce abnormally high hCG levels. No fetal heart tones are‬
‭heard because there is no viable fetus. Because there is rapid proliferation of the trophoblast cells, the‬
‭uterus grows fast and is larger than expected for a given gestational date. Because of the greatly elevated‬
‭hCG levels, a woman with hydatidiform mole often has marked nausea and vomiting.‬ ‭REFERENCE:‬
‭Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th‬
‭ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 411.‬
‭23‬

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‭Name:_________________________________________________Date:_‬

‭ ATIONALE:‬‭Manual pelvic examinations are contraindicated‬‭when vaginal bleeding is apparent in the‬

‭83. Which finding requires further intervention in a mother who's breast-feeding?‬

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