MATERNAL AND CHILD NURSING 7.

Thirty hours after delivery, the nurse in charge plans discharge

teaching for the client about infant care. By this time, the nurse
Test I. expects that the phase of postpartal psychological adaptation
that the client would be in would be termed which of the
following?
1. A postpartum patient was in labor for 30 hours and had
ruptured membranes for 24 hours. For which of the following
would the nurse be alert? A. Taking in
B. Letting go
C. Taking hold
A. Endometritis D. Resolution
B. Endometriosis 8. A pregnant client is diagnosed with partial placenta previa. In
C. Salpingitis explaining the diagnosis, the nurse tells the client that the usual
D. Pelvic thrombophlebitis treatment for partial placenta previa is which of the following?
2. A client at 36 weeks’ gestation is schedule for a routine
ultrasound prior to an amniocentesis. After teaching the client
about the purpose for the ultrasound, which of the following A. Activity limited to bed rest
client statements would indicate to the nurse in charge that the B. Platelet infusion
client needs further instruction? C. Immediate cesarean delivery
D. Labor induction with oxytocin
9. Nurse Julia plans to instruct the postpartum client about
A. The ultrasound will help to locate the placenta methods to prevent breast engorgement. Which of the following
B. The ultrasound identifies blood flow through the measures would the nurse include in the teaching plan?
umbilical cord
C. The test will determine where to insert the needle
D. The ultrasound locates a pool of amniotic fluid A. Feeding the neonate a maximum of 5 minutes per
3. While the postpartum client is receiving herapin for side on the first day
thrombophlebitis, which of the following drugs would the nurse B. Wearing a supportive brassiere with nipple shields
Mica expect to administer if the client develops complications C. Breast-feeding the neonate at frequent intervals
related to heparin therapy? D. Decreasing fluid intake for the first 24 to 48 hours
10. When the nurse on duty accidentally bumps the bassinet, the
neonate throws out its arms, hands opened, and begins to cry.
A. Calcium gluconate The nurse interprets this reaction as indicative of which of the
B. Protamine sulfate following reflexes?
C. Methylegonovine (Methergine)
D. Nitrofurantoin (macrodantin)
4. When caring for a 3-day-old neonate who is receiving A. Startle reflex
phototherapy to treat jaundice, the nurse in charge would B. Babinski reflex
expect to do which of the following? C. Grasping reflex
D. Tonic neck reflex
11. A primigravida client at 25 weeks’ gestation visits the clinic
A. Turn the neonate every 6 hours and tells the nurse that her lower back aches when she arrives
B. Encourage the mother to discontinue breast- home from work. The nurse should suggest that the client
feeding perform:
C. Notify the physician if the skin becomes bronze in
color
D. Check the vital signs every 2 to 4 hours A. Tailor sitting
5. A primigravida in active labor is about 9 days post-term. The B. Leg lifting
client desires a bilateral pudendal block anesthesia before C. Shoulder circling
delivery. After the nurse explains this type of anesthesia to the D. Squatting exercises
client, which of the following locations identified by the client as 12. Which of the following would the nurse in charge do first
the area of relief would indicate to the nurse that the teaching after observing a 2-cm circle of bright red bleeding on the diaper
was effective? of a neonate who just had a circumcision?

A. Back A. Notify the neonate’s pediatrician immediately

B. Abdomen B. Check the diaper and circumcision again in 30
C. Fundus minutes
D. Perineum C. Secure the diaper tightly to apply pressure on the
6. The nurse is caring for a primigravida at about 2 months and 1 site
week gestation. After explaining self-care measures for common D. Apply gently pressure to the site with a sterile
discomforts of pregnancy, the nurse determines that the client gauze pad
understands the instructions when she says: 13. Which of the following would the nurse Sandra most likely
expect to find when assessing a pregnant client with abruption
placenta?
A. “Nausea and vomiting can be decreased if I eat a
few crackers before arising”
B. “If I start to leak colostrum, I should cleanse my A. Excessive vaginal bleeding
nipples with soap and water” B. Rigid, boardlike abdomen
C. “If I have a vaginal discharge, I should wear nylon C. Titanic uterine contractions
underwear” D. Premature rupture of membranes
D. “Leg cramps can be alleviated if I put an ice pack 14. While the client is in active labor with twins and the cervix is
on the area” 5 cm dilates, the nurse observes contractions occurring at a rate
of every 7 to 8 minutes in a 30-minute period. Which of the 22. A female adult patient is taking a progestin-only oral
following would be the nurse’s most appropriate action? contraceptive, or minipill. Progestin use may increase the
patient’s risk for:
A. Note the fetal heart rate patterns
B. Notify the physician immediately A. Endometriosis
C. Administer oxygen at 6 liters by mask B. Female hypogonadism
D. Have the client pant-blow during the contractions C. Premenstrual syndrome
15. A client tells the nurse, “I think my baby likes to hear me talk D. Tubal or ectopic pregnancy
to him.” When discussing neonates and stimulation with sound, 23. A patient with pregnancy-induced hypertension probably
which of the following would the nurse include as a means to exhibits which of the following symptoms?
elicit the best response?
A. Proteinuria, headaches, vaginal bleeding
A. High-pitched speech with tonal variations B. Headaches, double vision, vaginal bleeding
B. Low-pitched speech with a sameness of tone C. Proteinuria, headaches, double vision
C. Cooing sounds rather than words D. Proteinuria, double vision, uterine contractions
D. Repeated stimulation with loud sounds 24. Because cervical effacement and dilation are not progressing
16. A 31-year-old multipara is admitted to the birthing room in a patient in labor, Dr. Smith orders I.V. administration of
after initial examination reveals her cervix to be at 8 cm, oxytocin (Pitocin). Why must the nurse monitor the patient’s
completely effaced (100 %), and at 0 station. What phase of fluid intake and output closely during oxytocin administration?
labor is she in?
A. Oxytoxin causes water intoxication
A. Active phase B. Oxytocin causes excessive thirst
B. Latent phase C. Oxytoxin is toxic to the kidneys
C. Expulsive phase D. Oxytoxin has a diuretic effect
D. Transitional phase 25. Five hours after birth, a neonate is transferred to the nursery,
17. A pregnant patient asks the nurse Kate if she can take castor where the nurse intervenes to prevent hypothermia. What is a
oil for her constipation. How should the nurse respond? common source of radiant heat loss?

A. “Yes, it produces no adverse effect.” A. Low room humidity

B. “No, it can initiate premature uterine B. Cold weight scale
contractions.” C. Cools incubator walls
C. “No, it can promote sodium retention.” D. Cool room temperature
D. “No, it can lead to increased absorption of fat- 26. After administering bethanechol to a patient with urine
soluble vitamins.” retention, the nurse in charge monitors the patient for adverse
18. A patient in her 14th week of pregnancy has presented with effects. Which is most likely to occur?
abdominal cramping and vaginal bleeding for the past 8 hours.
She has passed several cloth. What is the primary nursing A. Decreased peristalsis
diagnosis for this patient? B. Increase heart rate
C. Dry mucous membranes
A. Knowledge deficit D. Nausea and Vomiting
B. Fluid volume deficit 27. The nurse in charge is caring for a patient who is in the first
C. Anticipatory grieving stage of labor. What is the shortest but most difficult part of this
D. Pain stage?
19. Immediately after a delivery, the nurse-midwife assesses the
neonate’s head for signs of molding. Which factors determine A. Active phase
the type of molding? B. Complete phase
C. Latent phase
A. Fetal body flexion or extension D. Transitional phase
B. Maternal age, body frame, and weight 28. After 3 days of breast-feeding, a postpartal patient reports
C. Maternal and paternal ethnic backgrounds nipple soreness. To relieve her discomfort, the nurse should
D. Maternal parity and gravidity suggest that she:
20. For a patient in active labor, the nurse-midwife plans to use
an internal electronic fetal monitoring (EFM) device. What must A. Apply warm compresses to her nipples just before
occur before the internal EFM can be applied? feedings
B. Lubricate her nipples with expressed milk before
A. The membranes must rupture feeding
B. The fetus must be at 0 station C. Dry her nipples with a soft towel after feedings
C. The cervix must be dilated fully D. Apply soap directly to her nipples, and then rinse
D. The patient must receive anesthesia 29. The nurse is developing a teaching plan for a patient who is 8
21. A primigravida patient is admitted to the labor delivery area. weeks pregnant. The nurse should tell the patient that she can
Assessment reveals that she is in early part of the first stage of expect to feel the fetus move at which time?
labor. Her pain is likely to be most intense:
A. Between 10 and 12 weeks’ gestation
A. Around the pelvic girdle B. Between 16 and 20 weeks’ gestation
B. Around the pelvic girdle and in the upper arms C. Between 21 and 23 weeks’ gestation
C. Around the pelvic girdle and at the perineum D. Between 24 and 26 weeks’ gestation
D. At the perineum
30. Normal lochial findings in the first 24 hours post-delivery nurse in charge that the client understands the information given
include: to her?

A. Bright red blood A. “I’ll report increased frequency of urination.”

B. Large clots or tissue fragments B. “If I have blurred or double vision, I should call the
C. A foul odor clinic immediately.”
D. The complete absence of lochia C. “If I feel tired after resting, I should report it
immediately.”
D. “Nausea should be reported immediately.”
Test II. 8. When assessing a client during her first prenatal visit, the
1. Accompanied by her husband, a patient seeks admission to nurse discovers that the client had a reduction mammoplasty.
the labor and delivery area. The client states that she is in labor, The mother indicates she wants to breast-feed. What
and says she attended the hospital clinic for prenatal care. Which information should the nurse give to this mother regarding
question should the nurse ask her first? breast-feeding success?

A. “Do you have any chronic illness?” A. “It’s contraindicated for you to breast-feed
B. “Do you have any allergies?” following this type of surgery.”
C. “What is your expected due date?” B. “I support your commitment; however, you may
D. “Who will be with you during labor?” have to supplement each feeding with formula.”
2. A patient is in the second stage of labor. During this stage, C. “You should check with your surgeon to
how frequently should the nurse in charge assess her uterine determine whether breast-feeding would be
contractions? possible.”
D. “You should be able to breast-feed without
A. Every 5 minutes difficulty.”
B. Every 15 minutes 9. Following a precipitous delivery, examination of the client’s
C. Every 30 minutes vagina reveals a fourth-degree laceration. Which of the following
D. Every 60 minutes would be contraindicated when caring for this client?
3. A patient is in last trimester of pregnancy. Nurse Jane should
instruct her to notify her primary health care provider A. Applying cold to limit edema during the first 12 to
immediately if she notices: 24 hours
B. Instructing the client to use two or more peripads
A. Blurred vision to cushion the area
B. Hemorrhoids C. Instructing the client on the use of sitz baths if
C. Increased vaginal mucus ordered
D. Shortness of breath on exertion D. Instructing the client about the importance of
4. The nurse in charge is reviewing a patient’s prenatal history. perineal (Kegel) exercises
Which finding indicates a genetic risk factor? 10. A client makes a routine visit to the prenatal clinic. Although
she’s 14 weeks pregnant, the size of her uterus approximates
that in an 18- to 20-week pregnancy. Dr. Diaz diagnoses
A. The patient is 25 years old gestational trophoblastic disease and orders ultrasonography.
B. The patient has a child with cystic fibrosis The nurse expects ultrasonography to reveal:
C. The patient was exposed to rubella at 36 weeks’
gestation
D. The patient has a history of preterm labor at 32 A. an empty gestational sac.
weeks’ gestation B. grapelike clusters.
5. A adult female patient is using the rhythm (calendar-basal C. a severely malformed fetus.
body temperature) method of family planning. In this method, D. an extrauterine pregnancy.
the unsafe period for sexual intercourse is indicated by; 11. After completing a second vaginal examination of a client in
labor, the nurse-midwife determines that the fetus is in the right
occiput anterior position and at –1 station. Based on these
A. Return preovulatory basal body temperature findings, the nurse-midwife knows that the fetal presenting part
B. Basal body temperature increase of 0.1 degrees to is:
0.2 degrees on the 2nd or 3rd day of cycle
C. 3 full days of elevated basal body temperature
and clear, thin cervical mucus A. 1 cm below the ischial spines.
D. Breast tenderness and mittelschmerz B. directly in line with the ischial spines.
6. During a nonstress test (NST), the electronic tracing displays a C. 1 cm above the ischial spines.
relatively flat line for fetal movement, making it difficult to D. in no relationship to the ischial spines.
evaluate the fetal heart rate (FHR). To mark the strip, the nurse 12. Which of the following would be inappropriate to assess in a
in charge should instruct the client to push the control button at mother who’s breast-feeding?
which time?
A. The attachment of the baby to the breast.
A. At the beginning of each fetal movement B. The mother’s comfort level with positioning the
B. At the beginning of each contraction baby.
C. After every three fetal movements C. Audible swallowing.
D. At the end of fetal movement D. The baby’s lips smacking
7. When evaluating a client’s knowledge of symptoms to report 13. During a prenatal visit at 4 months gestation, a pregnant
during her pregnancy, which statement would indicate to the client asks whether tests can be done to identify fetal
abnormalities. Between 18 and 40 weeks’ gestation, which D. Spontaneous abortion
procedure is used to detect fetal anomalies? 21. A client with type 1 diabetes mellitus who’s a multigravida
visits the clinic at 27 weeks gestation. The nurse should instruct
A. Amniocentesis. the client that for most pregnant women with type 1 diabetes
B. Chorionic villi sampling. mellitus:
C. Fetoscopy.
D. Ultrasound A. Weekly fetal movement counts are made by the
14. A client, 30 weeks pregnant, is scheduled for a biophysical mother.
profile (BPP) to evaluate the health of her fetus. Her BPP score is B. Contraction stress testing is performed weekly.
8. What does this score indicate? C. Induction of labor is begun at 34 weeks’ gestation.
D. Nonstress testing is performed weekly until 32
A. The fetus should be delivered within 24 hours. weeks’ gestation
B. The client should repeat the test in 24 hours. 22. When administering magnesium sulfate to a client with
C. The fetus isn’t in distress at this time. preeclampsia, the nurse understands that this drug is given to:
D. The client should repeat the test in 1 week.
15. A client who’s 36 weeks pregnant comes to the clinic for a A. Prevent seizures
prenatal checkup. To assess the client’s preparation for B. Reduce blood pressure
parenting, the nurse might ask which question? C. Slow the process of labor
D. Increase dieresis
A. “Are you planning to have epidural anesthesia?” 23. What’s the approximate time that the blastocyst spends
B. “Have you begun prenatal classes?” traveling to the uterus for implantation?
C. “What changes have you made at home to get
ready for the baby?” A. 2 days
D. “Can you tell me about the meals you typically eat B. 7 days
each day?” C. 10 days
16. A client who’s admitted to labor and delivery has the D. 14 weeks
following assessment findings: gravida 2 para 1, estimated 40 24. After teaching a pregnant woman who is in labor about the
weeks’ gestation, contractions 2 minutes apart, lasting 45 purpose of the episiotomy, which of the following purposes
seconds, vertex +4 station. Which of the following would be the stated by the client would indicate to the nurse that the teaching
priority at this time? was effective?

A. Placing the client in bed to begin fetal monitoring. A. Shortens the second stage of labor
B. Preparing for immediate delivery. B. Enlarges the pelvic inlet
C. Checking for ruptured membranes. C. Prevents perineal edema
D. Providing comfort measures. D. Ensures quick placenta delivery
17. Nurse Roy is caring for a client in labor. The external fetal 25. A primigravida client at about 35 weeks gestation in active
monitor shows a pattern of variable decelerations in fetal heart labor has had no prenatal care and admits to cocaine use during
rate. What should the nurse do first? the pregnancy. Which of the following persons must the nurse
notify?
A. Change the client’s position.
B. Prepare for emergency cesarean section. A. Nursing unit manager so appropriate agencies can
C. Check for placenta previa. be notified
D. Administer oxygen. B. Head of the hospital’s security department
18. The nurse in charge is caring for a postpartum client who had C. Chaplain in case the fetus dies in utero
a vaginal delivery with a midline episiotomy. Which nursing D. Physician who will attend the delivery of the
diagnosis takes priority for this client? infant
26. When preparing a teaching plan for a client who is to receive
A. Risk for deficient fluid volume related to a rubella vaccine during the postpartum period, the nurse in
hemorrhage charge should include which of the following?
B. Risk for infection related to the type of delivery
C. Pain related to the type of incision A. The vaccine prevents a future fetus from
D. Urinary retention related to periurethral edema developing congenital anomalies
19. Which change would the nurse identify as a progressive B. Pregnancy should be avoided for 3 months after
physiological change in postpartum period? the immunization
C. The client should avoid contact with children
A. Lactation diagnosed with rubella
B. Lochia D. The injection will provide immunity against the 7-
C. Uterine involution day measles.
D. Diuresis 27. A client with eclampsia begins to experience a seizure. Which
20. A 39-year-old at 37 weeks’ gestation is admitted to the of the following would the nurse in charge do first?
hospital with complaints of vaginal bleeding following the use of
cocaine 1 hour earlier. Which complication is most likely causing A. Pad the side rails
the client’s complaint of vaginal bleeding? B. Place a pillow under the left buttock
C. Insert a padded tongue blade into the mouth
A. Placenta previa D. Maintain a patent airway
B. Abruptio placentae
C. Ectopic pregnancy
28. While caring for a multigravida client in early labor in a 5. A nurse is collecting data during an admission assessment of a
birthing center, which of the following foods would be best if the client who is pregnant with twins. The client has a healthy 5-year
client requests a snack? old child that was delivered at 37 weeks and tells the nurse that
she doesn’t have any history of abortion or fetal demise. The
A. Yogurt nurse would document the GTPAL for this client as:
B. Cereal with milk
C. Vegetable soup A. G = 3, T = 2, P = 0, A = 0, L =1
D. Peanut butter cookies B. G = 2, T = 0, P = 1, A = 0, L =1
29. The multigravida mother with a history of rapid labor who us C. G = 1, T = 1. P = 1, A = 0, L = 1
in active labor calls out to the nurse, “The baby is coming!” D. G = 2, T = 0, P = 0, A = 0, L = 1
which of the following would be the nurse’s first action? 6. A nurse is performing an assessment of a primipara who is
being evaluated in a clinic during her second trimester of
A. Inspect the perineum pregnancy. Which of the following indicates an abnormal
B. Time the contractions physical finding necessitating further testing?
C. Auscultate the fetal heart rate
D. Contact the birth attendant A. Consistent increase in fundal height
30. While assessing a primipara during the immediate B. Fetal heart rate of 180 BPM
postpartum period, the nurse in charge plans to use both hands C. Braxton hicks contractions
to assess the client’s fundus to: D. Quickening
7. A nurse is reviewing the record of a client who has just been
A. Prevent uterine inversion told that a pregnancy test is positive. The physician has
B. Promote uterine involution documented the presence of a Goodell’s sign. The nurse
C. Hasten the puerperium period determines this sign indicates:
D. Determine the size of the fundus
A. A softening of the cervix
B. A soft blowing sound that corresponds to the
Test III. ANTEPARTUM maternal pulse during auscultation of the uterus.
C. The presence of hCG in the urine
1. A nursing instructor is conducting lecture and is reviewing the D. The presence of fetal movement
functions of the female reproductive system. She asks Mark to 8. A nursing instructor asks a nursing student who is preparing to
describe the follicle-stimulating hormone (FSH) and the assist with the assessment of a pregnant client to describe the
luteinizing hormone (LH). Mark accurately responds by stating process of quickening. Which of the following statements if
that: made by the student indicates an understanding of this term?

A. FSH and LH are released from the anterior A. “It is the irregular, painless contractions that occur
pituitary gland. throughout pregnancy.”
B. FSH and LH are secreted by the corpus luteum of B. “It is the soft blowing sound that can be heard
the ovary when the uterus is auscultated.”
C. FSH and LH are secreted by the adrenal glands C. “It is the fetal movement that is felt by the
D. FSH and LH stimulate the formation of milk during mother.”
pregnancy. D. “It is the thinning of the lower uterine segment.”
2. A nurse is describing the process of fetal circulation to a client 9. A nurse midwife is performing an assessment of a pregnant
during a prenatal visit. The nurse accurately tells the client that client and is assessing the client for the presence of
fetal circulation consists of: ballottement. Which of the following would the nurse
implement to test for the presence of ballottement?
A. Two umbilical veins and one umbilical artery
B. Two umbilical arteries and one umbilical vein A. Auscultating for fetal heart sounds
C. Arteries carrying oxygenated blood to the fetus B. Palpating the abdomen for fetal movement
D. Veins carrying deoxygenated blood to the fetus C. Assessing the cervix for thinning
3. During a prenatal visit at 38 weeks, a nurse assesses the fetal D. Initiating a gentle upward tap on the cervix
heart rate. The nurse determines that the fetal heart rate is 10. A nurse is assisting in performing an assessment on a client
normal if which of the following is noted? who suspects that she is pregnant and is checking the client for
probable signs of pregnancy. Select all probable signs of
A. 80 BPM pregnancy.
B. 100 BPM
C. 150 BPM A. Uterine enlargement
D. 180 BPM B. Fetal heart rate detected by nonelectric device
4. A client arrives at a prenatal clinic for the first prenatal C. Outline of the fetus via radiography or ultrasound
assessment. The client tells a nurse that the first day of her last D. Chadwick’s sign
menstrual period was September 19th, 2013. Using Naegele’s E. Braxton Hicks contractions
rule, the nurse determines the estimated date of confinement F. Ballottement
as: 11. A pregnant client calls the clinic and tells a nurse that she is
experiencing leg cramps and is awakened by the cramps at night.
A. July 26, 2013 To provide relief from the leg cramps, the nurse tells the client
B. June 12, 2014 to:
C. June 26, 2014
D. July 12, 2014
 A. Dorsiflex the foot while extending the knee when D. Dependent edema has resolved
the cramps occur 17. A nurse implements a teaching plan for a pregnant client
B. Dorsiflex the foot while flexing the knee when the who is newly diagnosed with gestational diabetes. Which
cramps occur statement if made by the client indicates a need for further
C. Plantar flex the foot while flexing the knee when education?
the cramps occur
D. Plantar flex the foot while extending the knee A. “I need to stay on the diabetic diet.”
when the cramps occur. B. “I will perform glucose monitoring at home.”
12. A nurse is providing instructions to a client in the first C. “I need to avoid exercise because of the negative
trimester of pregnancy regarding measures to assist in reducing effects of insulin production.”
breast tenderness. The nurse tells the client to: D. “I need to be aware of any infections and report
signs of infection immediately to my health care
A. Avoid wearing a bra provider.”
B. Wash the nipples and areola area daily with soap, 18. A primigravida is receiving magnesium sulfate for the
and massage the breasts with lotion. treatment of pregnancy induced hypertension (PIH). The nurse
C. Wear tight-fitting blouses or dresses to provide who is caring for the client is performing assessments every 30
support minutes. Which assessment finding would be of most concern to
D. Wash the breasts with warm water and keep the nurse?
them dry
13. A pregnant client in the last trimester has been admitted to A. Urinary output of 20 ml since the previous
the hospital with a diagnosis of severe preeclampsia. A nurse assessment
monitors for complications associated with the diagnosis and B. Deep tendon reflexes of 2+
assesses the client for: C. Respiratory rate of 10 BPM
D. Fetal heart rate of 120 BPM
A. Any bleeding, such as in the gums, petechiae, and 19. A nurse is caring for a pregnant client with Preeclampsia. The
purpura. nurse prepares a plan of care for the client and documents in the
B. Enlargement of the breasts plan that if the client progresses from Preeclampsia to
C. Periods of fetal movement followed by quiet eclampsia, the nurse’s first action is to:
periods
D. Complaints of feeling hot when the room is cool A. Administer magnesium sulfate intravenously
14. A client in the first trimester of pregnancy arrives at a health B. Assess the blood pressure and fetal heart rate
care clinic and reports that she has been experiencing vaginal C. Clean and maintain an open airway
bleeding. A threatened abortion is suspected, and the nurse D. Administer oxygen by face mask
instructs the client regarding management of care. Which 20. A nurse is monitoring a pregnant client with pregnancy
statement, if made by the client, indicates a need for further induced hypertension who is at risk for Preeclampsia. The nurse
education? checks the client for which specific signs of Preeclampsia (select
all that apply)?
A. “I will maintain strict bedrest throughout the
remainder of pregnancy.” A. Elevated blood pressure
B. “I will avoid sexual intercourse until the bleeding B. Negative urinary protein
has stopped, and for 2 weeks following the last C. Facial edema
evidence of bleeding.” D. Increased respirations
C. “I will count the number of perineal pads used on 21. Rho (D) immune globulin (RhoGAM) is prescribed for a
a daily basis and note the amount and color of woman following delivery of a newborn infant and the nurse
blood on the pad.” provides information to the woman about the purpose of the
D. “I will watch for the evidence of the passage of medication. The nurse determines that the woman understands
tissue.” the purpose of the medication if the woman states that it will
15. A prenatal nurse is providing instructions to a group of protect her next baby from which of the following?
pregnant client regarding measures to prevent toxoplasmosis.
Which statement if made by one of the clients indicates a need
for further instructions? A. Being affected by Rh incompatibility
B. Having Rh positive blood
C. Developing a rubella infection
A. “I need to cook meat thoroughly.” D. Developing physiological jaundice
B. “I need to avoid touching mucous membranes of 22. A pregnant client is receiving magnesium sulfate for the
the mouth or eyes while handling raw meat.” management of preeclampsia. A nurse determines the client is
C. “I need to drink unpasteurized milk only.” experiencing toxicity from the medication if which of the
D. “I need to avoid contact with materials that are following is noted on assessment?
possibly contaminated with cat feces.”
16. A homecare nurse visits a pregnant client who has a
diagnosis of mild Preeclampsia and who is being monitored for A. Presence of deep tendon reflexes
pregnancy induced hypertension (PIH). Which assessment B. Serum magnesium level of 6 mEq/L
finding indicates a worsening of the Preeclampsia and the need C. Proteinuria of +3
to notify the physician? D. Respirations of 10 per minute
23. A woman with preeclampsia is receiving magnesium sulfate.
The nurse assigned to care for the client determines that the
A. Blood pressure reading is at the prenatal baseline magnesium therapy is effective if:
B. Urinary output has increased
C. The client complains of a headache and blurred
vision A. Ankle clonus in noted
 B. The blood pressure decreases 31. The nurse is aware than an adaptation of pregnancy is an
C. Seizures do not occur increased blood supply to the pelvic region that results in a
D. Scotomas are present purplish discoloration of the vaginal mucosa, which is known as:
24. A nurse is caring for a pregnant client with severe
preeclampsia who is receiving IV magnesium sulfate. A. Ladin’s sign
Select all nursing interventions that apply in the care for the B. Hegar’s sign
client. C. Goodell’s sign
D. Chadwick’s sign
A. Monitor maternal vital signs every 2 hours 32. A pregnant client is making her first Antepartum visit. She
B. Notify the physician if respirations are less than 18 has a two year old son born at 40 weeks, a 5 year old daughter
per minute. born at 38 weeks, and 7 year old twin daughters born at 35
C. Monitor renal function and cardiac function weeks. She had a spontaneous abortion 3 years ago at 10 weeks.
closely Using the GTPAL format, the nurse should identify that the client
D. Keep calcium gluconate on hand in case of a is:
magnesium sulfate overdose
E. Monitor deep tendon reflexes hourly A. G4 T3 P2 A1 L4
F. Monitor I and O’s hourly B. G5 T2 P2 A1 L4
G. Notify the physician if urinary output is less than C. G5 T2 P1 A1 L4
30 ml per hour. D. G4 T3 P1 A1 L4
25. In the 12th week of gestation, a client completely expels the 33. An expected cardiopulmonary adaptation experienced by
products of conception. Because the client is Rh negative, the most pregnant women is:
nurse must:

A. Tachycardia
A. Administer RhoGAM within 72 hours B. Dyspnea at rest
B. Make certain she receives RhoGAM on her first C. Progression of dependent edema
clinic visit D. Shortness of breath on exertion
C. Not give RhoGAM, since it is not used with the 34. Nutritional planning for a newly pregnant woman of average
birth of a stillborn height and weighing 145 pounds should include:
D. Make certain the client does not receive RhoGAM,
since the gestation only lasted 12 weeks.
26. In a lecture on sexual functioning, the nurse plans to include A. A decrease of 200 calories a day
the fact that ovulation occurs when the: B. An increase of 300 calories a day
C. An increase of 500 calories a day
D. A maintenance of her present caloric intake per
A. Oxytocin is too high day
B. Blood level of LH is too high 35. During a prenatal examination, the nurse draws blood from a
C. Progesterone level is high young Rh negative client and explain that an indirect Coombs
D. Endometrial wall is sloughed off. test will be performed to predict whether the fetus is at risk for:
27. The chief function of progesterone is the:

A. Acute hemolytic disease

A. Development of the female reproductive system B. Respiratory distress syndrome
B. Stimulation of the follicles for ovulation to occur C. Protein metabolic deficiency
C. Preparation of the uterus to receive a fertilized D. Physiologic hyperbilirubinemia
egg 36. When involved in prenatal teaching, the nurse should advise
D. Establishment of secondary male sex the clients that an increase in vaginal secretions during
characteristics pregnancy is called leukorrhea and is caused by increased:
28. The developing cells are called a fetus from the:

A. Metabolic rates
A. Time the fetal heart is heard B. Production of estrogen
B. Eighth week to the time of birth C. Functioning of the Bartholin glands
C. Implantation of the fertilized ovum D. Supply of sodium chloride to the cells of the
D. End of the send week to the onset of labor vagina
29. After the first four months of pregnancy, the chief source of 37. A 26-year old multigravida is 14 weeks’ pregnant and is
estrogen and progesterone is the: scheduled for an alpha-fetoprotein test. She asks the nurse,
“What does the alpha-fetoprotein test indicate?” The nurse
A. Placenta bases a response on the knowledge that this test can detect:
B. Adrenal cortex
C. Corpus luteum A. Kidney defects
D. Anterior hypophysis B. Cardiac defects
30. The nurse recognizes that an expected change in the C. Neural tube defects
hematologic system that occurs during the 2nd trimester of D. Urinary tract defects
pregnancy is: 38. At a prenatal visit at 36 weeks’ gestation, a client complains
of discomfort with irregularly occurring contractions. The nurse
A. A decrease in WBC’s instructs the client to:
B. In increase in hematocrit
C. An increase in blood volume A. Lie down until they stop
D. A decrease in sedimentation rate B. Walk around until they subside
C. Time contraction for 30 minutes
 D. Take 10 grains of aspirin for the discomfort A. Conception
39. The nurse teaches a pregnant woman to avoid lying on her B. 9 weeks’ gestation, when the fetal heart is well
back. The nurse has based this statement on the knowledge that developed
the supine position can: C. 32-34 weeks gestation
D. maternal and fetal blood are never exchanged
A. Unduly prolong labor 48. Gravida refers to which of the following descriptions?
B. Cause decreased placental perfusion
C. Lead to transient episodes of hypotension A. A serious pregnancy
D. Interfere with free movement of the coccyx B. Number of times a female has been pregnant
40. The pituitary hormone that stimulates the secretion of milk C. Number of children a female has delivered
from the mammary glands is: D. Number of term pregnancies a female has had.
49. A pregnant woman at 32 weeks’ gestation complains of
A. Prolactin feeling dizzy and lightheaded while her fundal height is being
B. Oxytocin measured. Her skin is pale and moist. The nurse’s initial
C. Estrogen response would be to:
D. Progesterone
41. Which of the following symptoms occurs with a hydatidiform A. Assess the woman’s blood pressure and pulse
mole? B. Have the woman breathe into a paper bag
C. Raise the woman’s legs
A. Heavy, bright red bleeding every 21 days D. Turn the woman on her side.
B. Fetal cardiac motion after 6 weeks gestation 50. A pregnant woman’s last menstrual period began on April 8,
C. Benign tumors found in the smooth muscle of the 2005, and ended on April 13. Using Naegele’s rule her estimated
uterus date of birth would be:
D. “Snowstorm” pattern on ultrasound with no fetus
or gestational sac A. January 15, 2006
42. Which of the following terms applies to the tiny, blanched, B. January 20, 2006
slightly raised end arterioles found on the face, neck, arms, and C. July 1, 2006
chest during pregnancy? D. November 5, 2005

A. Epulis Test IV. INTRAPARTUM

B. Linea nigra
C. Striae gravidarum 1. A nurse is caring for a client in labor. The nurse determines
D. Telangiectasias that the client is beginning in the 2nd stage of labor when which
43. Which of the following conditions is common in pregnant of the following assessments is noted?
women in the 2nd trimester of pregnancy?
A. The client begins to expel clear vaginal fluid
A. Mastitis B. The contractions are regular
B. Metabolic alkalosis C. The membranes have ruptured
C. Physiologic anemia D. The cervix is dilated completely
D. Respiratory acidosis 2. A nurse in the labor room is caring for a client in the active
44. A 21-year-old client, 6 weeks’ pregnant is diagnosed with phases of labor. The nurse is assessing the fetal patterns and
hyperemesis gravidarum. This excessive vomiting during notes a late deceleration on the monitor strip. The most
pregnancy will often result in which of the following conditions? appropriate nursing action is to:

A. Bowel perforation A. Place the mother in the supine position

B. Electrolyte imbalance B. Document the findings and continue to monitor
C. Miscarriage the fetal patterns
D. Pregnancy induced hypertension (PIH) C. Administer oxygen via face mask
45. Clients with gestational diabetes are usually managed by D. Increase the rate of pitocin IV infusion
which of the following therapies? 3. A nurse is performing an assessment of a client who is
scheduled for a cesarean delivery. Which assessment finding
would indicate a need to contact the physician?
A. Diet
B. NPH insulin (long-acting)
C. Oral hypoglycemic drugs A. Fetal heart rate of 180 beats per minute
D. Oral hypoglycemic drugs and insulin B. White blood cell count of 12,000
46. The antagonist for magnesium sulfate should be readily C. Maternal pulse rate of 85 beats per minute
available to any client receiving IV magnesium. Which of the D. Hemoglobin of 11.0 g/dL
following drugs is the antidote for magnesium toxicity? 4. A client in labor is transported to the delivery room and is
prepared for a cesarean delivery. The client is transferred to the
delivery room table, and the nurse places the client in the:
A. Calcium gluconate
B. Hydralazine (Apresoline)
C. Narcan A. Trendelenburg’s position with the legs in stirrups
D. RhoGAM B. Semi-Fowler position with a pillow under the
47. Which of the following answers best describes the stage of knees
pregnancy in which maternal and fetal blood are exchanged? C. Prone position with the legs separated and
elevated
D. Supine position with a wedge under the right hip
5. A nurse is caring for a client in labor and prepares to 11. A nurse is reviewing the record of a client in the labor room
auscultate the fetal heart rate by using a Doppler ultrasound and notes that the nurse midwife has documented that the fetus
device. The nurse most accurately determines that the fetal is at (-1) station. The nurse determines that the fetal presenting
heart sounds are heard by: part is:

A. Noting if the heart rate is greater than 140 BPM A. 1 cm above the ischial spine
B. Placing the diaphragm of the Doppler on the B. 1 fingerbreadth below the symphysis pubis
mother abdomen C. 1 inch below the coccyx
C. Performing Leopold’s maneuvers first to D. 1 inch below the iliac crest
determine the location of the fetal heart 12. A pregnant client is admitted to the labor room. An
D. Palpating the maternal radial pulse while listening assessment is performed, and the nurse notes that the client’s
to the fetal heart rate hemoglobin and hematocrit levels are low, indicating anemia.
6. A nurse is caring for a client in labor who is receiving Pitocin by The nurse determines that the client is at risk for which of the
IV infusion to stimulate uterine contractions. Which assessment following?
finding would indicate to the nurse that the infusion needs to be
discontinued? A. A loud mouth
B. Low self-esteem
A. Three contractions occurring within a 10-minute C. Hemorrhage
period D. Postpartum infections
B. A fetal heart rate of 90 beats per minute 13. A nurse assists in the vaginal delivery of a newborn infant.
C. Adequate resting tone of the uterus palpated After the delivery, the nurse observes the umbilical cord
between contractions lengthen and a spurt of blood from the vagina. The nurse
D. Increased urinary output documents these observations as signs of:
7. A nurse is beginning to care for a client in labor. The physician
has prescribed an IV infusion of Pitocin. The nurse ensures that A. Hematoma
which of the following is implemented before initiating the B. Placenta previa
infusion? C. Uterine atony
D. Placental separation
A. Placing the client on complete bed rest 14. A client arrives at a birthing center in active labor. Her
B. Continuous electronic fetal monitoring membranes are still intact, and the nurse-midwife prepares to
C. An IV infusion of antibiotics perform an amniotomy. A nurse who is assisting the nurse-
D. Placing a code cart at the client’s bedside midwife explains to the client that after this procedure, she will
8. A nurse is monitoring a client in active labor and notes that most likely have:
the client is having contractions every 3 minutes that last 45
seconds. The nurse notes that the fetal heart rate between A. Less pressure on her cervix
contractions is 100 BPM. Which of the following nursing actions B. Increased efficiency of contractions
is most appropriate? C. Decreased number of contractions
D. The need for increased maternal blood pressure
A. Encourage the client’s coach to continue to monitoring
encourage breathing exercises 15. A nurse is monitoring a client in labor. The nurse suspects
B. Encourage the client to continue pushing with umbilical cord compression if which of the following is noted on
each contraction the external monitor tracing during a contraction?
C. Continue monitoring the fetal heart rate
D. Notify the physician or nurse midwife A. Early decelerations
9. A nurse is caring for a client in labor and is monitoring the B. Variable decelerations
fetal heart rate patterns. The nurse notes the presence of C. Late decelerations
episodic accelerations on the electronic fetal monitor tracing. D. Short-term variability
Which of the following actions is most appropriate? 16. A nurse explains the purpose of effleurage to a client in early
labor. The nurse tells the client that effleurage is:
A. Document the findings and tell the mother that
the monitor indicates fetal well-being A. A form of biofeedback to enhance bearing down
B. Take the mother’s vital signs and tell the mother efforts during delivery
that bed rest is required to conserve oxygen. B. Light stroking of the abdomen to facilitate
C. Notify the physician or nurse midwife of the relaxation during labor and provide tactile
findings. stimulation to the fetus
D. Reposition the mother and check the monitor for C. The application of pressure to the sacrum to
changes in the fetal tracing relieve a backache
10. A nurse is admitting a pregnant client to the labor room and D. Performed to stimulate uterine activity by
attaches an external electronic fetal monitor to the client’s contracting a specific muscle group while other
abdomen. After attachment of the monitor, the initial nursing parts of the body rest
assessment is which of the following? 17. A nurse is caring for a client in the second stage of labor. The
client is experiencing uterine contractions every 2 minutes and
A. Identifying the types of accelerations cries out in pain with each contraction. The nurse recognizes this
B. Assessing the baseline fetal heart rate behavior as:
C. Determining the frequency of the contractions
D. Determining the intensity of the contractions A. Exhaustion
B. Fear of losing control
 C. Involuntary grunting indicate that the placenta has separated from the uterine wall
D. Valsalva’s maneuver and is ready for delivery?
18. A nurse is monitoring a client in labor who is receiving Pitocin
and notes that the client is experiencing hypertonic uterine A. The umbilical cord shortens in length and changes
contractions. List in order of priority the actions that the nurse in color
takes. B. A soft and boggy uterus
C. Maternal complaints of severe uterine cramping
A. Stop of Pitocin infusion 1 D. Changes in the shape of the uterus
B. Perform a vaginal examination 3 25. A nurse in the labor room is performing a vaginal assessment
C. Reposition the client 5 on a pregnant client in labor. The nurse notes the presence of
D. Check the client’s blood pressure and heart rate 2 the umbilical cord protruding from the vagina. Which of the
E. Administer oxygen by face mask at 8 to 10 L/min 4 following would be the initial nursing action?
19. A nurse is assigned to care for a client with hypotonic uterine
dysfunction and signs of a slowing labor. The nurse is reviewing A. Place the client in Trendelenburg’s position
the physician’s orders and would expect to note which of the B. Call the delivery room to notify the staff that the
following prescribed treatments for this condition? client will be transported immediately
C. Gently push the cord into the vagina
A. Medication that will provide sedation D. Find the closest telephone and stat page the
B. Increased hydration physician
C. Oxytocin (Pitocin) infusion 26. A maternity nurse is caring for a client with abruptio placenta
D. Administration of a tocolytic medication and is monitoring the client for disseminated intravascular
20. A nurse in the labor room is preparing to care for a client coagulopathy. Which assessment finding is least likely to be
with hypertonic uterine dysfunction. The nurse is told that the associated with disseminated intravascular coagulation?
client is experiencing uncoordinated contractions that are erratic
in their frequency, duration, and intensity. The priority nursing A. Swelling of the calf in one leg
intervention would be to: B. Prolonged clotting times
C. Decreased platelet count
A. Monitor the Pitocin infusion closely D. Petechiae, oozing from injection sites, and
B. Provide pain relief measures hematuria
C. Prepare the client for an amniotomy 27. A nurse is assessing a pregnant client in the 2nd trimester of
D. Promote ambulation every 30 minutes pregnancy who was admitted to the maternity unit with a
21. A nurse is developing a plan of care for a client experiencing suspected diagnosis of abruptio placentae. Which of the
dystocia and includes several nursing interventions in the plan of following assessment findings would the nurse expect to note if
care. The nurse prioritizes the plan of care and selects which of this condition is present?
the following nursing interventions as the highest priority?
A. Absence of abdominal pain
A. Keeping the significant other informed of the B. A soft abdomen
progress of the labor C. Uterine tenderness/pain
B. Providing comfort measures D. Painless, bright red vaginal bleeding
C. Monitoring fetal heart rate 28. A maternity nurse is preparing for the admission of a client in
D. Changing the client’s position frequently the 3rd trimester of pregnancy that is experiencing vaginal
22. A maternity nurse is preparing to care for a pregnant client in bleeding and has a suspected diagnosis of placenta previa. The
labor who will be delivering twins. The nurse monitors the fetal nurse reviews the physician’s orders and would question which
heart rates by placing the external fetal monitor: order?

A. Over the fetus that is most anterior to the A. Prepare the client for an ultrasound
mother’s abdomen B. Obtain equipment for external electronic fetal
B. Over the fetus that is most posterior to the heart monitoring
mother’s abdomen C. Obtain equipment for a manual pelvic
C. So that each fetal heart rate is monitored examination
separately D. Prepare to draw a Hgb and Hct blood sample
D. So that one fetus is monitored for a 15-minute 29. An ultrasound is performed on a client at term gestation that
period followed by a 15 minute fetal monitoring is experiencing moderate vaginal bleeding. The results of the
period for the second fetus ultrasound indicate that an abruptio placenta is present. Based
23. A nurse in the postpartum unit is caring for a client who has on these findings, the nurse would prepare the client for:
just delivered a newborn infant following a pregnancy with
placenta previa. The nurse reviews the plan of care and prepares A. Complete bed rest for the remainder of the
to monitor the client for which of the following risks associated pregnancy
with placenta previa? B. Delivery of the fetus
C. Strict monitoring of intake and output
A. Disseminated intravascular coagulation D. The need for weekly monitoring of coagulation
B. Chronic hypertension studies until the time of delivery
C. Infection 30. A nurse in a labor room is assisting with the vaginal delivery
D. Hemorrhage of a newborn infant. The nurse would monitor the client closely
24. A nurse in the delivery room is assisting with the delivery of a for the risk of uterine rupture if which of the following occurred?
newborn infant. After the delivery of the newborn, the nurse
assists in delivering the placenta. Which observation would A. Hypotonic contractions
 B. Forceps delivery of 135 beats per minute lasting for 15 seconds. This should be
C. Schultz delivery documented as:
D. Weak bearing down efforts
31. A client is admitted to the birthing suite in early active labor. A. An acceleration
The priority nursing intervention on admission of this client B. An early elevation
would be: C. A sonographic motion
D. A tachycardic heart rate
A. Auscultating the fetal heart 39. A laboring client complains of low back pain. The nurse
B. Taking an obstetric history replies that this pain occurs most when the position of the fetus
C. Asking the client when she last ate is:
D. Ascertaining whether the membranes were
ruptured A. Breech
32. A client who is gravida 1, para 0 is admitted in labor. Her B. Transverse
cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at C. Occiput anterior
+1 station. The nurse is aware that the fetus’ head is: D. Occiput posterior
40. The breathing technique that the mother should be
A. Not yet engaged instructed to use as the fetus’ head is crowning is:
B. Entering the pelvic inlet
C. Below the ischial spines A. Blowing
D. Visible at the vaginal opening B. Slow chest
33. After doing Leopold’s maneuvers, the nurse determines that C. Shallow
the fetus is in the ROP position. To best auscultate the fetal D. Accelerated-decelerated
heart tones, the Doppler is placed: 41. During the period of induction of labor, a client should be
observed carefully for signs of:
A. Above the umbilicus at the midline
B. Above the umbilicus on the left side A. Severe pain
C. Below the umbilicus on the right side B. Uterine tetany
D. Below the umbilicus near the left groin C. Hypoglycemia
34. The physician asks the nurse the frequency of a laboring D. Umbilical cord prolapse
client’s contractions. The nurse assesses the client’s contractions 42. A client arrives at the hospital in the second stage of labor.
by timing from the beginning of one contraction: The fetus’ head is crowning, the client is bearing down, and the
birth appears imminent. The nurse should:
A. Until the time it is completely over
B. To the end of a second contraction A. Transfer her immediately by stretcher to the
C. To the beginning of the next contraction birthing unit
D. Until the time that the uterus becomes very firm B. Tell her to breathe through her mouth and not to
35. The nurse observes the client’s amniotic fluid and decides bear down
that it appears normal, because it is: C. Instruct the client to pant during contractions and
to breathe through her mouth
A. Clear and dark amber in color D. Support the perineum with the hand to prevent
B. Milky, greenish yellow, containing shreds of tearing and tell the client to pant
mucus 43. A laboring client is to have a pudendal block. The nurse plans
C. Clear, almost colorless, and containing little white to tell the client that once the block is working she:
specks
D. Cloudy, greenish-yellow, and containing little A. Will not feel the episiotomy
white specks B. May lose bladder sensation
36. At 38 weeks gestation, a client is having late decelerations. C. May lose the ability to push
The fetal pulse oximeter shows 75% to 85%. The nurse should: D. Will no longer feel contractions
44. Which of the following observations indicates fetal distress?
A. Discontinue the catheter, if the reading is not
above 80% A. Fetal scalp pH of 7.14
B. Discontinue the catheter, if the reading does not B. Fetal heart rate of 144 beats/minute
go below 30% C. Acceleration of fetal heart rate with contractions
C. Advance the catheter until the reading is above D. Presence of long term variability
90% and continue monitoring 45. Which of the following fetal positions is most favorable for
D. Reposition the catheter, recheck the reading, and birth?
if it is 55%, keep monitoring
37. When examining the fetal monitor strip after rupture of the
membranes in a laboring client, the nurse notes variable A. Vertex presentation
decelerations in the fetal heart rate. The nurse should: B. Transverse lie
C. Frank breech presentation
D. Posterior position of the fetal head
A. Stop the oxytocin infusion 46. A laboring client has external electronic fetal monitoring in
B. Change the client’s position place. Which of the following assessment data can be
C. Prepare for immediate delivery determined by examining the fetal heart rate strip produced by
D. Take the client’s blood pressure the external electronic fetal monitor?
38. When monitoring the fetal heart rate of a client in labor, the
nurse identifies an elevation of 15 beats above the baseline rate
 A. Gender of the fetus A. FHR does not change as a result of fetal activity
B. Fetal position B. Average baseline rate ranges between 100 – 140
C. Labor progress BPM
D. Oxygenation C. Mild late deceleration patterns occur with some
47. A laboring client is in the first stage of labor and has contractions
progressed from 4 to 7 cm in cervical dilation. In which of the D. Variability averages between 6 – 10 BPM
following phases of the first stage does cervical dilation occur 54. Late deceleration patterns are noted when assessing the
most rapidly? monitor tracing of a woman whose labor is being induced with
an infusion of Pitocin. The woman is in a side-lying position, and
A. Preparatory phase her vital signs are stable and fall within a normal
B. Latent phase range. Contractions are intense, last 90 seconds, and occur every
C. Active phase 1 1/2 to 2 minutes. The nurse’s immediate action would be to:
D. Transition phase
48. A multiparous client who has been in labor for 2 hours states A. Change the woman’s position
that she feels the urge to move her bowels. How should the B. Stop the Pitocin
nurse respond? C. Elevate the woman’s legs
D. Administer oxygen via a tight mask at 8 to 10
A. Let the client get up to use the potty liters/minute
B. Allow the client to use a bedpan 55. The nurse should realize that the most common and
C. Perform a pelvic examination potentially harmful maternal complication of epidural anesthesia
D. Check the fetal heart rate would be:
49. Labor is a series of events affected by the coordination of the
five essential factors. One of these is the passenger (fetus). A. Severe postpartum headache
Which are the other four factors? B. Limited perception of bladder fullness
C. Increase in respiratory rate
A. Contractions, passageway, placental position and D. Hypotension
function, pattern of care 56. Perineal care is an important infection control
B. Contractions, maternal response, placental measure. When evaluating a postpartum woman’s perineal care
position, psychological response technique, the nurse would recognize the need for further
C. Passageway, contractions, placental position and instruction if the woman:
function, psychological response
D. Passageway, placental position and function, A. Uses soap and warm water to wash the vulva and
paternal response, psychological response perineum
50. Fetal presentation refers to which of the following B. Washes from symphysis pubis back to episiotomy
descriptions? C. Changes her perineal pad every 2 – 3 hours
D. Uses the peribottle to rinse upward into her
A. Fetal body part that enters the maternal pelvis vagina
first 57. Which measure would be least effective in preventing
B. Relationship of the presenting part to the postpartum hemorrhage?
maternal pelvis
C. Relationship of the long axis of the fetus to the A. Administer Methergine 0.2 mg every 6 hours for 4
long axis of the mother doses as ordered
D. A classification according to the fetal part B. Encourage the woman to void every 2 hours
51. A client is admitted to the L & D suite at 36 weeks’ gestation. C. Massage the fundus every hour for the first 24
She has a history of C-section and complains of severe abdominal hours following birth
pain that started less than 1 hour earlier. When the nurse D. Teach the woman the importance of rest and
palpates tetanic contractions, the client again complains of nutrition to enhance healing
severe pain. After the client vomits, she states that the pain is 58. When making a visit to the home of a postpartum woman
better and then passes out. Which is the probable cause of her one week after birth, the nurse should recognize that the woman
signs and symptoms? would characteristically:

A. Hysteria compounded by the flu A. Express a strong need to review events and her
B. Placental abruption behavior during the process of labor and birth
C. Uterine rupture B. Exhibit a reduced attention span, limiting
D. Dysfunctional labor readiness to learn
52. Upon completion of a vaginal examination on a laboring C. Vacillate between the desire to have her own
woman, the nurse records: 50%, 6 cm, -1. Which of the following nurturing needs met and the need to take charge
is a correct interpretation of the data? of her own care and that of her newborn
D. Have reestablished her role as a spouse/partner
A. Fetal presenting part is 1 cm above the ischial 59. Four hours after a difficult labor and birth, a primiparous
spines woman refuses to feed her baby, stating that she is too tired and
B. Effacement is 4 cm from completion just wants to sleep. The nurse should:
C. Dilation is 50% completed
D. Fetus has achieved passage through the ischial A. Tell the woman she can rest after she feeds her
spines baby
53. Which of the following findings meets the criteria of a B. Recognize this as a behavior of the taking-hold
reassuring FHR pattern? stage
 C. Record the behavior as ineffective maternal- B. Stop the breast feedings and switch to bottle-
newborn attachment feeding permanently
D. Take the baby back to the nursery, reassuring the C. Feed the newborn infant less frequently
woman that her rest is a priority at this time D. Continue to breast-feed every 2-4 hours
60. Parents can facilitate the adjustment of their other children 6) A nurse on the newborn nursery floor is caring for a neonate.
to a new baby by: On assessment the infant is exhibiting signs of cyanosis,
A. Having the children choose or make a gift to give tachypnea, nasal flaring, and grunting. Respiratory distress
to the new baby upon its arrival home syndrome is diagnosed, and the physician prescribes surfactant
B. Emphasizing activities that keep the new baby and replacement therapy. The nurse would prepare to administer
other children together this therapy by:
C. Having the mother carry the new baby into the
home so she can show the other children the new A. Subcutaneous injection
baby B. Intravenous injection
D. Reducing stress on other children by limiting their C. Instillation of the preparation into the lungs
involvement in the care of the new baby through an endotracheal tube
D. Intramuscular injection
7) A nurse is assessing a newborn infant who was born to a
Test V. NEWBORN CARE mother who is addicted to drugs. Which of the following
assessment findings would the nurse expect to note during the
1) A nurse in a delivery room is assisting with the delivery of a assessment of this newborn?
newborn infant. After the delivery, the nurse prepares to
prevent heat loss in the newborn resulting from evaporation by:
A. Sleepiness
B. Cuddles when being held
A. Warming the crib pad C. Lethargy
B. Turning on the overhead radiant warmer D. Incessant crying
C. Closing the doors to the room 8) A nurse prepares to administer a vitamin K injection to a
D. Drying the infant in a warm blanket newborn infant. The mother asks the nurse why her newborn
2) A nurse is assessing a newborn infant following infant needs the injection. The best response by the nurse would
circumcision and notes that the circumcised area is red with a be:
small amount of bloody drainage. Which of the following nursing
actions would be most appropriate?
A. “You infant needs vitamin K to develop
immunity.”
A. Document the findings B. “The vitamin K will protect your infant from being
B. Contact the physician jaundiced.”
C. Circle the amount of bloody drainage on the C. “Newborn infants are deficient in vitamin K, and
dressing and reassess in 30 minutes this injection prevents your infant from abnormal
D. Reinforce the dressing bleeding.”
3) A nurse in the newborn nursery is monitoring a preterm D. “Newborn infants have sterile bowels, and vitamin
newborn infant for respiratory distress syndrome. Which K promotes the growth of bacteria in the bowel.”
assessment signs if noted in the newborn infant would alert the 9) A nurse in a newborn nursery receives a phone call to prepare
nurse to the possibility of this syndrome? for the admission of a 43-week-gestation newborn with Apgar
scores of 1 and 4. In planning for the admission of this infant, the
A. Hypotension and Bradycardia nurse’s highest priority should be to:
B. Tachypnea and retractions
C. Acrocyanosis and grunting A. Connect the resuscitation bag to the oxygen
D. The presence of a barrel chest with grunting outlet
4) A nurse in a newborn nursery is performing an assessment of B. Turn on the apnea and cardiorespiratory monitors
a newborn infant. The nurse is preparing to measure the head C. Set up the intravenous line with 5% dextrose in
circumference of the infant. The nurse would most water
appropriately: D. Set the radiant warmer control temperature at
36.5* C (97.6*F)
A. Wrap the tape measure around the infant’s head 10) Vitamin K is prescribed for a neonate. A nurse prepares to
and measure just above the eyebrows. administer the medication in which muscle site?
B. Place the tape measure under the infants head at
the base of the skull and wrap around to the front A. Deltoid
just above the eyes B. Triceps
C. Place the tape measure under the infants head, C. Vastus lateralis
wrap around the occiput, and measure just above D. Biceps
the eyes 11) A nursing instructor asks a nursing student to describe the
D. Place the tape measure at the back of the infant’s procedure for administering erythromycin ointment into the
head, wrap around across the ears, and measure eyes if a neonate. The instructor determines that the student
across the infant’s mouth. needs to research this procedure further if the student states:
5) A postpartum nurse is providing instructions to the mother of
a newborn infant with hyperbilirubinemia who is being
breastfed. The nurse provides which most appropriate A. “I will cleanse the neonate’s eyes before instilling
instructions to the mother? ointment.”
B. “I will flush the eyes after instilling the ointment.”
A. Switch to bottle feeding the baby for 2 weeks
 C. “I will instill the eye ointment into each of the B. Lanugo
neonate’s conjunctival sacs within one hour after C. Whiteheads
birth.” D. Mongolian spots
D. “Administration of the eye ointment may be 20) When newborns have been on formula for 36-48 hours,
delayed until an hour or so after birth so that eye they should have a:
contact and parent-infant attachment and
bonding can occur.” A. Screening for PKU
12) A baby is born precipitously in the ER. The nurses initial B. Vitamin K injection
action should be to: C. Test for necrotizing enterocolitis
D. Heel stick for blood glucose level
A. Establish an airway for the baby 21) The nurse decides on a teaching plan for a new mother and
B. Ascertain the condition of the fundus her infant. The plan should include:
C. Quickly tie and cut the umbilical cord
D. Move mother and baby to the birthing unit A. Discussing the matter with her in a non-
13) The primary critical observation for Apgar scoring is the: threatening manner
B. Showing by example and explanation how to care
A. Heart rate for the infant
B. Respiratory rate C. Setting up a schedule for teaching the mother
C. Presence of meconium how to care for her baby
D. Evaluation of the Moro reflex D. Supplying the emotional support to the mother
14) When performing a newborn assessment, the nurse should and encouraging her independence
measure the vital signs in the following sequence: 22) Which action best explains the main role of surfactant in the
neonate?
A. Pulse, respirations, temperature
B. Temperature, pulse, respirations A. Assists with ciliary body maturation in the upper
C. Respirations, temperature, pulse airways
D. Respirations, pulse, temperature B. Helps maintain a rhythmic breathing pattern
15) Within 3 minutes after birth the normal heart rate of the C. Promotes clearing mucus from the respiratory
infant may range between: tract
D. Helps the lungs remain expanded after the
A. 100 and 180 initiation of breathing
B. 130 and 170 23) While assessing a 2-hour old neonate, the nurse observes
C. 120 and 160 the neonate to have acrocyanosis. Which of the following
D. 100 and 130 nursing actions should be performed initially?
16) The expected respiratory rate of a neonate within 3 minutes
of birth may be as high as: A. Activate the code blue or emergency system
B. Do nothing because acrocyanosis is normal in the
A. 50 neonate
B. 60 C. Immediately take the newborn’s temperature
C. 80 according to hospital policy
D. 100 D. Notify the physician of the need for a cardiac
17) The nurse is aware that a healthy newborn’s respirations consult
are: 24) The nurse is aware that a neonate of a mother with
diabetes is at risk for what complication?

A. Regular, abdominal, 40-50 per minute, deep

B. Irregular, abdominal, 30-60 per minute, shallow A. Anemia
C. Irregular, initiated by chest wall, 30-60 per B. Hypoglycemia
minute, deep C. Nitrogen loss
D. Regular, initiated by the chest wall, 40-60 per D. Thrombosis
minute, shallow 25) A client with group AB blood whose husband has group O
18) To help limit the development of hyperbilirubinemia in the has just given birth. The major sign of ABO blood incompatibility
neonate, the plan of care should include: in the neonate is which complication or test result?

A. Monitoring for the passage of meconium each A. Negative Coombs test

shift B. Bleeding from the nose and ear
B. Instituting phototherapy for 30 minutes every 6 C. Jaundice after the first 24 hours of life
hours D. Jaundice within the first 24 hours of life
C. Substituting breastfeeding for formula during the 26) A client has just given birth at 42 weeks’ gestation. When
2nd day after birth assessing the neonate, which physical finding is expected?
D. Supplementing breastfeeding with glucose water
during the first 24 hours A. A sleepy, lethargic baby
19) A newborn has small, whitish, pinpoint spots over the nose, B. Lanugo covering the body
which the nurse knows are caused by retained sebaceous C. Desquamation of the epidermis
secretions. When charting this observation, the nurse identifies D. Vernix caseosa covering the body
it as: 27) After reviewing the client’s maternal history of magnesium
sulfate during labor, which condition would the nurse anticipate
A. Milia as a potential problem in the neonate?
 A. Hypoglycemia 36) When performing nursing care for a neonate after a birth,
B. Jitteriness which intervention has the highest nursing priority?
C. Respiratory depression
D. Tachycardia A. Obtain a dextrostix
28) Neonates of mothers with diabetes are at risk for which B. Give the initial bath
complication following birth? C. Give the vitamin K injection
D. Cover the neonates head with a cap
A. Atelectasis 37) When performing an assessment on a neonate, which
B. Microcephaly assessment finding is most suggestive of hypothermia?
C. Pneumothorax
D. Macrosomia A. Bradycardia
29) By keeping the nursery temperature warm and wrapping B. Hyperglycemia
the neonate in blankets, the nurse is preventing which type of C. Metabolic alkalosis
heat loss? D. Shivering
38) A woman delivers a 3.250 g neonate at 42 weeks’ gestation.
A. Conduction Which physical finding is expected during an examination if this
B. Convection neonate?
C. Evaporation
D. Radiation A. Abundant lanugo
30) A neonate has been diagnosed with caput succedaneum. B. Absence of sole creases
Which statement is correct about this condition? C. Breast bud of 1-2 mm in diameter
D. Leathery, cracked, and wrinkled skin
A. It usually resolves in 3-6 weeks 39) A healthy term neonate born by C-section was admitted to
B. It doesn’t cross the cranial suture line the transitional nursery 30 minutes ago and placed under a
C. It’s a collection of blood between the skull and the radiant warmer. The neonate has an axillary temperature of
periosteum 99.5*F, a respiratory rate of 80 breaths/minute, and a heel stick
D. It involves swelling of tissue over the presenting glucose value of 60 mg/dl. Which action should the nurse take?
part of the presenting head
31) The most common neonatal sepsis and meningitis infections A. Wrap the neonate warmly and place her in an
seen within 24 hours after birth are caused by which organism? open crib
B. Administer an oral glucose feeding of 10%
A. Candida albicans dextrose in water
B. Chlamydia trachomatis C. Increase the temperature setting on the radiant
C. Escherichia coli warmer
D. Group B beta-hemolytic streptococci D. Obtain an order for IV fluid administration
32) When attempting to interact with a neonate experiencing 40) Which neonatal behavior is most commonly associated with
drug withdrawal, which behavior would indicate that the fetal alcohol syndrome (FAS)?
neonate is willing to interact?
A. Hypoactivity
A. Gaze aversion B. High birth weight
B. Hiccups C. Poor wake and sleep patterns
C. Quiet alert state D. High threshold of stimulation
D. Yawning
33) When teaching umbilical cord care to a new mother, the
nurse would include which information?

A. Apply peroxide to the cord with each diaper

change
B. Cover the cord with petroleum jelly after bathing
C. Keep the cord dry and open to air
D. Wash the cord with soap and water each day
during a tub bath
34) A mother of a term neonate asks what the thick, white,
cheesy coating is on his skin. Which correctly describes this
finding?

A. Lanugo
B. Milia
C. Nevus flammeus
D. Vernix
35) Which condition or treatment best ensures lung maturity in
an infant?

A. Meconium in the amniotic fluid

B. Glucocorticoid treatment just before delivery
C. Lecithin to sphingomyelin ratio more than 2:1
D. Absence of phosphatidylglycerol in amniotic fluid