SITUATION: shame and doubt instead of having mastered

autonomy?
Erikson’s psychosocial theory states that
personalities develop in a series of stages, describing a. Dependency and constantly looking to others for
the impact of social experience across the whole approval
lifespan. Erikson was interested in how social
b. Sleep disturbance, crying, and vomiting
interaction and relationships played a role in the
development and growth of human beings. c. Always imitating others rather than using
imagination
1. Renz and Richa, who just had their first baby a
month ago, asked Nurse Rei on how they can meet d. Frequent crying, emotional outbursts, and whining
the basic needs of Baby Eri. Based on an
understanding of Erikson’s stages of psychosocial
development, Nurse Rei would tell them to? 4. The parent of an 8-year-old child tells the clinic
a. Provide the infant with entertainment and nurse of a concern that the child seems to be more
stimulation for psychological growth attentive to friends than anything else. Using
Erikson’s psychosocial development theory, the nurse
b. Talk with the infant during the times when the would plan to make which response?
infant is awake
a. “You need to be concerned.”
c. Hold the infant in a way the infant prefers
b. “You need to monitor the child’s behavior closely.”
d. Attend to the infant’s need for comfort, security,
predictability, food, and warmth c. “At this age, children are developing their own
personalities.”

d. “You need to provide more praise to the child to

2. After three years, Renz and Richa told Nurse Rei stop this behavior.”
about how their daughter, Eri, has been rebelling
constantly and having temper tantrums. Using
Erikson’s psychosocial development theory, which 5. In accordance with Erikson's theory, the main task
instructions should Nurse Rei provide Eri’s parents? associated with Nora, a 16 year-old female who
Select all that apply. refuses to do what her parents want her to do, who
a. Set limits on the child’s behavior. would be?
b. Ignore the child when this behavior occurs. a. establishing intimate bonds of love and friendship
c. Allow the behavior, because this is normal at
this age period. b. fulfilling life goals that involve family, career and
d. Provide a simple explanation of why the society.
behavior is unacceptable. c. looking back over one's life and accepting its
e. Punish the child every time the child says “no” meaning
to change the behavior.
d. developing a sense of identity
A. a & d

B. c & d
6. The nurse has noticed that her 5-year-old male
C. a, c & d patient does not recognize that his toy exists even
D. None of the above when it is outside his visual field. Noting this, what
action should the nurse perform?

a. Notify the physician about the observation.

3. Nurse Rei is assessing Eri’s psychosocial
developmental level using Erikson’s eight stages. b. Bring the toy within the child’s field of vision.
Which of the following behaviors would Nurse Rei c. Instruct the child to scan his environment carefully.
most likely find if Eri were demonstrating being in
d. Provide the child with access to the lighting during
playing.
7. The mother reported concern about her 6-year-old b. A 7-month-old who is beginning to vocalize during
son, who appeared more interested in his classmates play and pleasure.
than anything. Based on the mother’s concern, how
c. A 2-month-old who begins singing in the presence
should the nurse respond?
of familiar sounds.
a. You should be alarmed.
d. An 11-month-old who uses intentional gestures.
b. You need to monitor your son’s behavior.

c. At this age, children are currently developing their

11. Which vehicle safety equipment is appropriate
personalities.
for an 8-year-old who is 4 feet tall?
d. You need to give the child more praise to stop this
a. Booster seat
behavior.
b. Seat belt

c. Front-facing convertible seat = infant

8. Nurse Mara is observing the activity of a 5-year-old
patient. Which of the following is the most common d. Rear-facing convertible seat
observation in the play activity of this age group?

a. Plays alongside but not with playmates, using a

pounding bench and playing with a musical toy. 12. Using Erikson's eight phases, the nurse evaluates
a toddler's psychological development level. Which
b. Plays with others, abiding by rules, making up of the following would the nurse be most likely to
fictitious friends, and engaging in fantasy play. see if the child was exhibiting shame and doubt
rather than having learned autonomy?
c. Plays with puppets and participates in team sports.
a. Dependency and constantly looking to others for
d. Plays by themselves in a corner, engaged in putting
approval.
a puzzle together.
b. Sleep disturbance, crying, and vomiting.

c. Always imitating others rather than using

9. The nurse cares for a toddler patient who must
imagination
take medication every afternoon for five days. Which
of the following is the most age-appropriate d. Frequent crying, emotional outbursts, and whining.
explanation for the toddler?

a. Your mama will give you the medicine between 1:00

and 2:00 in the afternoon. Each day until your cough is 13. The mother of a breastfed newborn reported that
gone. her infant's feces is golden in color, pasty rather than
firm, and smells strongly of sour milk. What would be
b. You will take your medicine every afternoon after the best course of action for the nurse to take?
your lunch, until your cough is gone.
a. “You probably need to feed this baby some cereal
c. For a week, you will be taking your medicine in the to firm up the stool.”
afternoon.
b. “Cut back on your fluid intake and be careful what
d. Every day at 1:00 p.m., your mama will give you you eat, as you pass this on to the baby.”
your medicine until your cough is gone.
c. “I need to check your temperature and your breasts
to determine if you have a breast abscess.”
10. Which of the following four infants does the d. “This is a normal stool for a newborn who is breast-
nurse consider to have abnormal language fed.”
development?

a. A 9-month-old who uses two-syllable sounds such

as “mama.”
14. When planning to educate a class of mothers 17. Nurse Alvin is assessing a woman who thinks she
about introducing new meals during the first year of may be pregnant. Which information from the client
their infants, which of the following should the nurse is most significant in confirming the diagnosis of
include? pregnancy?

a. Place up to three foods on the spoon at one time a. The client is experiencing nausea before bedtime
with an old favorite on the front of the spoon and after meals.

b. Introduce fruits first; introduce one new fruit per b. The client says she has gained six pounds and her
day until all fruits are introduced slacks are tight.

c. Alternate between offering one spoonful of fruits c. The client has noticed it is difficult to sleep on her
and one spoonful of vegetables “stomach” because her breasts are tender.

d. Introduce one new food at a time at 7-day intervals d. The client has a history of regular menstrual periods
since age 13 and has a positive pregnancy test.

15. A mother is concerned about her 5-year-old

occasionally peeing in his undies rather than using 18. Nurse Alvin is performing an assessment on
the restroom. Which of the following questions Patient Wayne who suspects that she is pregnant.
should the nurse ask in order to ascertain whether Nurse Alvin should assess for which probable signs of
this is a typical occurrence? pregnancy? Select all that apply.

a. “Do you remind your child to go to the bathroom A. Ballottement

every 2 hours?” B. Chadwick’s sign
C. Uterine enlargement
b. “Is this your firstborn child?”
D. Positive pregnancy test
c. “Has your child started school already?” E. Fetal heart rate detected by an electronic
device
d. “Does this behavior occur when your child is F. F. Outline of fetus via radiography or
engaged in some activity?” ultrasonography

a. A, B, C, & D
16. What information should the nurse tell to a b. A, B, C,
mother when giving vitamins to a preschooler?
c. A, B, C, D, & E
a. Give the vitamins with sips of milk.
d. D, E & F
b. Give preschoolers half a vitamin.

c. Store the vitamins in a locked cabinet that the child

cannot access. 19. When Patient Wayne returned on her 38 weeks
gestation, Nurse Alvin notes that the fetal heart rate
d. Allow the child to be independent by self- (FHR) is 180 beats/minute. On the basis of this
administering the vitamins. finding, what is the priority nursing action?

a. Document the finding.

SITUATION: b. Check the mother’s heart rate.
The prenatal nurse monitors the health status of the c. Notify the health care provider (HCP).
mother and fetus, provides emotional support, and
teaches the pregnant woman and her family about d. Tell the client that the fetal heart rate is normal.
physiological and psychological changes during
pregnancy, fetal development, labor and childbirth,
and care for the newborn (International Council of 20. After a while, a nonstress test is performed on
Nurses). Patient Wayne, and the results of the test indicate
nonreactive findings. The health care provider
prescribes a contraction stress test, and the results d. August 26, 2019
are documented as negative. How should Nurse Alvin
document this finding?
24. During a prenatal visit, Nurse Justine evaluates
a. A normal test result
the fundal height of the uterus to be at the
b. An abnormal test result umbilicus. Nurse Justine should estimate the
gestation at
c. A high risk for fetal demise
a. 16 weeks = halfway between symphysis pubis and
d. The need for a cesarean section
umbilicus

b. 20 weeks.
21. While resting, Nurse Alvin decides to teach
c. 24 weeks.
Patient Wayne on how to perform “kick counts.”
Which statement by Patient Wayne indicates a need d. 28 weeks.
for further instruction?
36weeks = xiphoid
a. “I will record the number of movements or kicks.”

b. “I need to lie flat on my back to perform the

25. Nurse Justine is performing an assessment of a
procedure.”
pregnant client who is at 28 weeks of gestation.
c. “If I count fewer than 10 kicks in a 2-hour period, I Nurse Justine measures the fundal height in
should count the kicks again over the next 2 hours.” centimeters and notes that the fundal height is 30
cm. How should the nurse interpret this finding?
d. “I should place my hands on the largest part of my
abdomen and concentrate on the fetal movements to a. The client is measuring large for gestational age.
count the kicks.”
b. The client is measuring small for gestational age.

c. The client is measuring normal for gestational age.

22. Which of the following is the appropriate
d. More evidence is needed to determine size for
pregnancy classification for Vilmawho has had her
gestational age
first pregnancy ended in a miscarriage at 9 weeks,
second pregnancy delivered vaginally at 39 weeks of
gestation and the child is 3 years old now, and is
currently pregnant for the third time? 26. A 17-year-old primigravida client at term is in
active labor. Examination revealed cervical dilatation
a. Gravida 3 para 1 1-0-1-1 at 8cm with 100% cervical effacement. Which of the
following should the nurse assess the client for?
b. Gravida 2 para 1 2-1-1-0
a. Uterine inversion.
c. Gravida 3 para 2 3-2-0-1-0
b. Cephalopelvic disproportion (CPD).
d. Gravida 2 para 2 2-1-0-0
c. Rapid third stage of labor.

d. Decreased ability to push

23. Erma arrives at the clinic for the first prenatal
assessment. She tells Nurse Justine that the first day
of her last normal menstrual period was October 19,
2018. Using Naegele’s rule, which expected date of 27. A 23-year-old primigravida client at full term is in
delivery should the nurse document in the client’s active labor. Which of the following should be
chart? incorporated into the plan of care for this patient?

a. July 12, 2019 a. Oxygen saturation monitoring every half hour.

b. July 26, 2019 b. Supine positioning on back

c. August 12, 2019 c. Anesthesia/pain level assessment every 30 minutes.

d. Vaginal bleeding, rupture of membrane (ROM) 31. The nurse is caring for a client in labor. Which
assessment every shift. assessment findings indicate to the nurse that the
client is beginning the second stage of labor? Select
all that apply.
28. A primigravida client who is in active labor arrives
A. The contractions are regular.
at a birthing facility. Examination revealed that the
B. The membranes have ruptured.
client is at 1+ station, and the client's membranes are
C. The cervix is dilated completely.
still intact. The doctor prepares for an amniotomy.
D. The client begins to expel clear vaginal fluid.
What are the most likely outcomes of amniotomy?
E. The spontaneous urge to push is initiated from
I. Less pressure on the cervix perineal pressure.
II. Decreased number of contractions
A. C & E
III. Increased efficiency of contractions
IV. The need for increased maternal blood B. A & B
pressure monitoring.
C. C & D
V. The need for frequent fetal heart rate
monitoring to detect the presence of a D. A B D
prolapsed cord.

a. III, IV, V
32. The nurse is reviewing true and false labor signs
b. I, III with a multiparous client. The nurse determines that
the client understands the signs of true labor if she
c. I, II, III
makes which statement?
d. III, V
a. “I won’t be in labor until my baby drops.”

b. “My contractions will be felt in my abdominal area.”

29. A primigravida client in active labor is
c. “My contractions will not be as painful if I walk
experiencing contractions that last 50 seconds every
around.”
3 minutes. The fetal heart rate in between
contractions is 100 beats per minute. Which nursing d. “My contractions will increase in duration and
intervention is best to perform? intensity.”
a. Report to the primary health care provider (PHCP).

b. Continue to assess the contraction. 33. The nurse in the labor room is caring for a client
in the active stage of the first phase of labor. The
c. Encourage the client to continue pushing with each
nurse is assessing the fetal patterns and notes a late
contraction.
deceleration on the monitor strip. What is the most
d. Instruct the client’s coach to continue to encourage appropriate nursing action?
breathing techniques.
a. Administer oxygen via face mask.

b. Place the mother in a supine position.

30. A primigravida patient in active labor is
c. Increase the rate of the oxytocin intravenous
prescribed with scalp stimulation of the fetal head.
infusion.
What is the purpose of scalp stimulation?
d. Document the findings and continue to monitor the
a. Assessment of the fetal hematocrit level.
fetal patterns.
b. Increase in the strength of the contractions.

c. Increase in the fetal heart rate and variability.

34. A Client in labor is transported to the delivery
d. Assessment of fetal position. room and prepared for a cesarean delivery. After the
client is transferred to the delivery room table, the
nurse should place the client in which position?
a. Supine position with a wedge under the right hip epigastric pain and headache. What should Nurse
Mimay do initially?
b. Trendelenburg’s position with the legs in stirrups
a. Insert an indwelling catheter.
c. Prone position with the legs separated and elevated
b. Give Maalox 30 cc now.
d. Semi-Fowler’s position with a pillow under the
knees c. Contact the doctor stat with findings.

d. Provide supportive care for impending convulsion

35. A pregnant client asks the nurse when the

stretch marks will disappear. The most appropriate
38. Magnesium sulfate is ordered for Patient Jolina
response by the nurse is
for her pregnancy-induced hypertension (PIH). What
a. “They will disappear with the birth of the infant.” effects would Nurse Mimay expect to see as a result
of this medication?
b. “They will take up to 6 months to disappear.”
a. CNS depression
c. “They will fade but do not totally disappear.”
b. Decreased gastric acidity
d. “They will disappear with a nutritionally balanced
diet and exercise.” c. Onset of contractions

d. Decrease in number of bowel movements

SITUATION:

Gestational diabetes greatly raises preeclampsia risks 39. If Nurse Mimay were assessing a patient with
because the higher levels of sugar in the blood cause severe preeclampsia, which assessment findings
high blood pressure to develop (WFMC Health). would be most closely associated with a
Because preeclampsia and gestational diabetes may complication of this diagnosis?
cause lots of complications, it is important for nurses
a. Enlargement of the breasts
to keep an eye out for the signs and symptoms and
immediately refer findings to the physician. b. Complaints of feeling hot when the room is cool
36. Nurse Mimay is caring for Jolina who is at 30 c. Periods of fetal movement followed by quiet
weeks gestation, has gained 17 pounds during the periods
pregnancy, and has a blood pressure of 110/70.
Jolina states that she feels warmer than everyone d. Evidence of bleeding, such as in the gums,
around her. Which interpretation of these findings is petechiae, and purpura
most correct?

a. All of these findings are normal. SITUATION:

b. Her weight gain is excessive for this point in Prenatal nurses are empowered to promote healthy
pregnancy. habits among prospective mothers and assist
c. The blood pressure is abnormal. primary care providers in promoting healthy
outcomes (Regis College Master of Science in
d. She should be evaluated for a serious infection Nursing)
because pregnant women are usually cooler than
other people. 40. Which of the following should the nurse assess
for a newborn infant whose mother has type 2
diabetes?
37. Consequently, Nurse Mimay takes Patient Jolina’s a. Hypoglycemia
vital signs. Her blood pressure reads 160/94; pulse
rate of 88 bpm; respiration rate of 24 cpm; and b. Rh sensitization
temperature of 98°F. Additionally, Jolina complains of c. ABO incompatibility
d. Hypothermia b. “You will need to feed your newborn by nasogastric
tube feeding.”

c. “You will be able to breast/chest-feed for 6 months

41. Hypoglycemia may occur in a large-for-
and then will need to switch to bottle-feeding.”
gestational-age newborn as a result of which of the
following: d. “You will be able to breast/chest-feed for 9 months
and then will need to switch to bottle-feeding.”
a. Limited glycogen stores.

b. Hyperinsulinemia.
45. Maria, a 40-year-old woman who is 28 weeks
c. Large ratio of body surface to weight.
pregnant, comes to the emergency room with
d. Excessive brown fat stores. painless, bright red bleeding of 1.5 hours duration.
What condition does the nurse suspect Maria has?

a. Abruptio placenta = painful red bleeding

42. Based on the knowledge about gestational
diabetes. Which of the following should the nurse b. Placenta previa
assess in the newborn?
c. Hydatidiform mole
a. Heart abnormalities
d. Prolapsed cord
b. Group B beta-hemolytic strep pneumonia

c. Group B beta-hemolytic strep meningitis

46. Maria who is 28 weeks gestation comes to the
d. Inborn errors of metabolism emergency room with painless, bright red bleeding of
1.5 hours in duration. Which of the following would
the nurse expect during assessment of Maria?
43. When admitting a newborn to the nursery, a. Alterations in fetal heart rate
the nurse prepares to administer erythromycin
ointment to the newborn’s eyes to prevent blindness b. Board-like uterus
caused by which of the following? Select all that
c. Severe abdominal pain
apply:
d. Elevated temperature
I. Gonorrhea
II. Syphilis = penicillin
III. Herpes simplex virus
47. The common normal site of
IV. Hepatitis
nidation/implantation in the uterus is:
V. Chlamydia
VI. Human immunodeficiency virus (HIV) a. Upper uterine portion
a. I, II, V b. Mid-uterine area
b. I, II, III, IV, V, VI c. Lower uterine segment
c. II, III, V d. Lower cervical segment
d. I, V

48. The maternity nurse is preparing for the

admission of Leila who is in her third trimester of
44. A multigravida client with HIV who has recently
pregnancy and is experiencing vaginal bleeding and
delivered a newborn infant asks the nurse about the
has a suspected diagnosis of placenta previa. The
proper way to feed her newborn. Which of the
nurse reviews the health care provider’s
following is the correct response by the nurse:
prescriptions and should question which
a. “You will need to bottle-feed your newborn.” prescription?

a. Prepare the client for an ultrasound.

b. Obtain equipment for a manual pelvic examination. following findings are included in abruptio placenta?
SATA
c. Prepare to draw a hemoglobin and hematocrit
blood sample. A. Uterine pain
B. Bright red vaginal bleeding
d. Obtain equipment for external electronic fetal heart
C. Uterine rigidity. Soft uterus
rate monitoring.
D. Dark red vaginal bleeding Painless uterus

a. A, E, F
49. A nurse in the postpartum unit is caring for Leila
b. A, D, E
who has just delivered a newborn infant following a
pregnancy with placenta previa. The nurse reviews c. A, C, E
the plan of care and prepares to monitor the client
d. C, E, F
for which of the following risks associated with
placenta previa?

a. Disseminated intravascular coagulation = pre 53. Lei is hospitalized for vaginal bleeding from
eclampsia suspected abruptio placentae. Nurse Mitch bases the
appropriate interventions on which understanding of
b. Chronic hypertension
the pathology?
c. Infection
a. Placenta tears away from the cervical os during
d. Hemorrhage dilation and results in fetal hemorrhage

b. Placental abruption is umbilical cord hemorrhage

from trauma
50. Leila, who is a pregnant client, was diagnosed
with partial placenta previa. In explaining the c. Placental abruption is premature separation of the
diagnosis, the nurse tells the client that the usual normally implanted placenta from the uterine wall
treatment for partial placenta previa is which of the
d. Abruptio placentae is the rupturing of membranes
following?
along the uterine wall and the resulting loss of fetal
a. Bed rest blood and amniotic fluid

b. Platelet infusion

c. Immediate cesarean delivery 54. The nursing care plan for patient Lei who has
placenta abruptio should include careful assessment
d. Oxytocin-induced labor
for signs and symptoms of which of the following?

a. Jaundice
51. Nurse Mitch is assessing Lei in the second
b. Hypovolemic shock
trimester of pregnancy who was admitted to the
maternity unit with a suspected diagnosis of abruptio c. Impending convulsions
placentae. Which assessment finding should the
d. Hypertension
nurse expect to note if this condition is present?

a. Soft abdomen
55.Since Nurse Mitch is busy, she decides to delegate
b. Uterine tenderness
client assignments in a maternity unit. Which of the
c. Absence of abdominal pain following assignments should Nurse Mitch delegate
to a licensed practical nurse?
d. Bright red vaginal bleeding
a. Provide the care to a client suspected of having
abruptio placentae
52. To separate placenta previa from abruptio
b. Provide the care to a woman in her 37th week of
placenta, Nurse Mitch knows that which of the
gestation experiencing dyspnea
c. Teach a pregnancy class to a group of women c. 1-hour period each day.

d. Document the characteristics of a woman’s lochia d. 12-hour period each week.

56. The nurse is explaining to a preeclamptic client 60. Which of the following assessment results for the
how to keep track of her fetus' movements to assess patient receiving intravenous magnesium sulfate for
fetal well-being. Which of the client's statements severe preeclampsia would alert the nurse to suspect
suggests that she needs further guidance on when to hypermagnesemia?
contact the healthcare provider concerning fetal
a. Hypoactive deep tendon reflexes.
movement?
b. Decreased skin temperature.
a. If the fetus is less active than it was previously.
c. Rapid pulse rate.
b. If it takes longer each day for the fetus to move ten
times. d. Tingling in the toes.
c. When the fetus did not move for 12 hours.

d. If the fetal movement exceeds three times per hour. 61. A 33-week-old client with severe preeclampsia is
receiving intravenous magnesium sulfate. Which of
the following are the desired objectives for this
57. A 16-year-old primigravid client who is 5 feet, 1 treatment?
inches tall, and 30 weeks pregnant has gained 20 lbs,
I. T = 98 F, PR = 72, RR = 14.
with a gain of 1 lb in the last two weeks. Glucose
II. Urinary output less than 30 mL/h.
levels in the urine are negative, but a trace of protein
III. Fetal heart rate with late decelerations.
was seen. Which of the following factors increases
IV. DTR 2+.
the client's risk for preeclampsia?
V. Magnesium level = 5.6 mg/dL (2.8
a. Total weight gain. mmol/L).

b. Short stature. a. I, II, IV

c. Adolescent age group. b. III, IV, V

d. Proteinuria. c. I, IV, V

d. I, II, V

58. The nurse knows that the client needs further

education when she states that preeclampsia can
62. After having an eclamptic seizure, a 35-weeks
result in which of the following?
pregnant client starts to show signs of labor. The
a. Hydrocephalic infant. client should be assessed by the nurse for:

b. Abruptio placentae. a. Abruptio placentae.

c. Intrauterine growth retardation. b. Transverse lie.

d. Poor placental perfusion. c. Placenta accreta.

d. Uterine atony

59. The nurse determines that instruction was

effective when the multigravid client says she will
63. The nurse is looking over the records of a
count the number of times the baby moves during
multigravida client who is 39 weeks pregnant and
which of the following time periods?
may have HELLP syndrome. Which of the following
a. 30-minute period three times a day. test results should the nurse inform the doctor
about?
b. 45-minute period after lunch each day.
a. Platelets 200,000 mm3 (200 × 10 9 /L). multigravida client admitted to the hospital with
vaginal bleeding at 38 weeks' gestation if the client
b. Lactate dehydrogenase (LDH) greater than 200 U/L
develops disseminated intravascular coagulation
(3.34 μkat/L).
(DIC)?
c. Uric acid 3 mg/dL (178.4 μmol/L).
a. Ringer's lactate solution.
d. Aspartate aminotransferase (AST) 15 U/L (0.25
b. Fresh frozen platelets.
μkat/L)
c. 5% dextrose solution.

d. Warfarin sodium (Coumadin). DIC = HEPARIN

64. Which of the following would warn the nurse
that placenta previa is present while examining a
multigravida client at 33 weeks gestation who is
68. The nurse is caring for a 22-year-old G 2, P 2
having significant vaginal bleeding?
client who has disseminated intravascular
a. Painless vaginal bleeding coagulation after delivering a dead fetus. Which
finding is the highest priority to report to the health
b. Uterine tetany.
care provider?
c. Intermittent pain with spotting.
a. Activated partial thromboplastin time (APTT) of 30
d. Dull lower back pain seconds.

b. Hemoglobin of 11.5 g/dL (115 g/L).

65. A multigravida client at 33 weeks of gestation c. Urinary output of 25 mL in the past hour.
was admitted because of vaginal bleeding. After
d. Platelets at 149,000/mm3 (149 × 10 9 /L).
interviewing the client, which of the following factors
might lead the nurse to suspect abruptio placentae?

a. Several hypotensive episodes. 69. The nurse would put the ultrasound transducer
to monitor fetal heart rate in which of the following
b. Previous low transverse cesarean birth.
maternal positions if a fetus at 35 weeks of gestation
c. One induced abortion. is in the left occiput anterior position?

d. History of cocaine use. = vasoconstrictor a. Near the symphysis pubis

b. Two inches (5.1 cm) above the umbilicus.

66. A multigravida client at 34 weeks of gestation c. Below the umbilicus on the left side.
with abruptio placentae was prescribed to receive
d. At the level of the umbilicus.
whole blood replacement. Which of the following
should the nurse perform first before administering
the intravenous blood product?
70. A primigravida client at 35 weeks of gestation
a. Validate client information and the blood product went to the hospital because she believed her water
with another nurse. had been broken. After testing the leaking fluid with
nitrazine paper, which color confirms that the client's
b. Check the vital signs before transfusing over 5
membrane has ruptured?
hours.
a. Yellow.
c. Ask the client if she has ever had any allergies.
b. Green.
d. Administer 100 mL of 5% dextrose solution
intravenously. c. Blue.

d. Red.

67. Which of the following would the nurse expect

to deliver intravenously when caring for a
 71. At 30 weeks gestation, a primigravid client was 75. A 38-year-old multigravida patient was admitted
taken to the hospital due to an early rupture of the to the hospital due to ruptured ectopic pregnancy.
membranes without contractions. Her cervix is 50% Which of the following would be crucial for
effaced, and 2 cm dilated. The nurse needs to assess determining a predisposing factor when learning the
next: client's history? 3. Urinary output.

a. Red blood cell count. a. Recurrent urinary tract infection.

b. Degree of discomfort. b. Use of Marijuana during pregnancy.

c. Urinary output. c. History of pelvic inflammatory disease

d. Temperature. d. Use of estrogen-progestin contraceptives.

72. At 34 weeks gestation, a primigravid client has 76. A primigravida client was diagnosed with ectopic
35-second contractions every three to four minutes. pregnancy. Which of the following medications
Her cervix is 50% effaced, and 2 cm dilated. Which of should the nurse anticipate to be administered to the
the following would the nurse do first if the client patient?
said, "I think my bag of water just broke"?
a. Progestin contraceptives.
a. Check the status of the fetal heart rate.
b. Medroxyprogesterone.
b. Turn the client to her right side.
c. Methotrexate.
c. Test the leaking fluid with nitrazine paper.
d. Dyphylline.
d. Perform a sterile vaginal examination.

77. A multigravida client at 15 weeks of gestation

73. A 38-year-old multigravida patient was admitted was admitted to the hospital with a diagnosis of
to the hospital due to ruptured ectopic pregnancy. hydatidiform mole. Which of the following would the
Which of the following would be crucial for nurse assess?
determining a predisposing factor when learning the
a. Pregnancy-induced hypertension.
client's history? 3. Urinary output.
b. Gestational diabetes.
a. Recurrent urinary tract infection.
c. Hypothyroidism.
b. Use of Marijuana during pregnancy.
d. Polycythemia.
c. History of pelvic inflammatory disease.

d. Use of estrogen-progestin contraceptives.

78. Which of the following would be the most crucial
to assess for in the client following dilatation and
74. A primigravida client was diagnosed with ectopic curettage (D&C) to remove a molar pregnancy?
pregnancy. Which of the following medications
a. Urinary tract infection.
should the nurse anticipate to be administered to the
patient? b. Hemorrhage
a. Progestin contraceptives. c. Abdominal distention.
b. Medroxyprogesterone. d. Chorioamnionitis.
c. Methotrexate.

d. Dyphylline. 79. A multigravida client asks the nurse as to when

she can conceive after treatment with molar
pregnancy. The nurse should answer by not getting D. All of the above
pregnant for how long?

a. 6 months.
82. Nurse Tammy, then, provides instructions about
b. 12 months. measures to prevent postpartum mastitis in the
future for Jocelyn. Which response by Jocelyn would
c. 18 months.
indicate a need for further instruction?
d. 24 months
a. “I should breast-feed every 2 to 3 hours.”

b. “I should change the breast pads frequently.”

SITUATION:
c. “I should wash my hands well before breastfeeding.”
Postpartum nurses care for new mothers from the
d. “I should wash my nipples daily with soap and
time they leave the delivery room until they are
water.”
discharged home. In addition to providing support
for their patients' physical and emotional needs,
postpartum nurses offer education and guidance in
83. Meanwhile, Nurse Tammy is assessing Tina, who
caring for a newborn (Hamlin, 2022)
is in the fourth stage of labor, and notes that the
80. Nurse Tammy is monitoring Patient Jocelyn in the fundus is firm but that bleeding is excessive. Which
immediate postpartum period for signs of should be Nurse Tammy’s initial action?
hemorrhage. Which sign, if noted, would be an early
a. Record the findings.
sign of excessive blood loss?
b. Massage the fundus.
a. A temperature of 100.4 °F (38 °C)
c. Notify the health care provider (HCP).
b. An increase in the pulse rate from 88 to 102
beats/minute d. Place the client in Trendelenburg’s position.
c. A blood pressure change from 130/88 to 124/80
mm Hg
84. On the other hand, Nurse Tammy notes that
d. An increase in the respiratory rate from 18 to 22 Patient Susmita’s uterus feels soft and boggy. Which
breaths/minute action should Nurse Tammy take?

a. Document the findings.

81. Nurse Tammy is preparing a list of self-care b. Elevate the client’s legs.
instructions for Jocelyn who was diagnosed with
mastitis. Which instructions should be included on c. Massage the fundus until it is firm.
the list? Select all that apply. d. Push on the uterus to assist in expressing clots.
A. Wear a supportive bra.
B. Rest during the acute phase.
C. Maintain a fluid intake of at least 3000 SITUATION:
mL/day. D. Continue to breast-feed if the Nurses play critical roles in perinatal-neonatal care at
breasts are not too sore. all levels of the health system.
D. Take the prescribed antibiotics until the
soreness subsides. 85. Nurse Claire assisted with the birth of Patient
E. Avoid decompression of the breasts by breast- Gloria’s newborn, Fulgencio. Which nursing action is
feeding or breast pump. most effective in preventing heat loss by
evaporation?
A. A, B, C, & D
a. Warming the crib pad
B. C, D, E, F
b. Closing the doors to the room
C. A, D, F
c. Drying the infant with a warm blanket
d. Turning on the overhead radiant warmer 89. Which statement by Patient Gloria reflects a new
mother’s understanding of the teaching about the
prevention of newborn abduction?
86. Nurse Claire proceeds to administer erythromycin
a. “I will place my baby’s crib close to the door.”
ointment (0.5%) to the eyes of Fulgencio and Patient
Gloria asks her why this is performed. Which b. “Some health care personnel won’t have name
explanation is best for Nurse Claire to provide about badges.”
neonatal eye prophylaxis?
c. “I will ask the nurse to attend to my infant if I am
a. Protects the newborn’s eyes from possible napping and my husband is not here.”
infections acquired while hospitalized.
d. “It’s okay to allow the nurse assistant to carry my
b. Prevents cataracts in the newborn born to a woman newborn to the nursery.”
who is susceptible to rubella.

c. Minimizes the spread of microorganisms to the

90. After a while, Nurse Claire receives a telephone
newborn from invasive procedures during labor.
call to prepare for the admission of a 43-week
d. Prevents an infection called ophthalmia gestation newborn with Apgar scores of 1 and 4. In
neonatorum from occurring after birth in a newborn planning for admission of this newborn, what is the
born to a woman with an untreated gonococcal nurse’s highest priority?
infection
a. Turn on the apnea and cardiorespiratory monitors.

b. Connect the resuscitation bag to the oxygen outlet.

87. Nurse Claire prepares to administer a
c. Set up the intravenous line with 5% dextrose in
phytonadione (vitamin K) injection to a newborn.
water.
Being the curious mother that she is, Gloria asks her
why Fulgencio needs the injection. What’s Nurse d. Set the radiant warmer control temperature at 36.5
Claire’s best response? °C (97.6 °F).
a. “Your newborn needs the medicine to develop
immunity.”
91. After admission, Nurse Clairehas been monitoring
b. “The medicine will protect your newborn from the newborn for respiratory distress syndrome.
being jaundiced.” Which assessment findings should alert Nurse Claire
to the possibility of this syndrome? Select all that
c. “Newborns have sterile bowels, and the medicine
apply.
promotes the growth of bacteria in the bowel.”
A. Cyanosis
d. “Newborns are deficient in vitamin K, and this
B. Tachypnea
injection prevents your newborn from bleeding.”
C. Hypotension
D. Retractions
E. Audible grunts
88. After giving the essential newborn care, Nurse
F. Presence of a barrel chest
Claire assesses Fulgencio after circumcision and notes
that the circumcised area is red with a small amount a. A, B, D, & E
of bloody drainage. Which nursing action is most
b. B & F
appropriate?
c. A, B, D, E & F
a. Apply gentle pressure.
d. None of the above
b. Reinforce the dressing.

c. Document the findings.

92. After being discharged, Gloria calls the clinic and
d. Contact the health care provider (HCP).
reports that when cleaning the umbilical cord, she
noticed that Fulgencio’s cord was moist and that
discharge was present. What is the most appropriate d. Stop breast-feeding and switch to bottle-feeding
nursing instruction should Nurse Claire relay? permanently.

a. Bring the infant to the clinic.

b. This is a normal occurrence and no further action is 96. The nurse examines a collection of blood beneath
needed. the newborn's scalp that does not cross suture lines.
The nurse notes this as:
c. Increase the number of times that the cord is
cleaned per day. a. caput succedaneum.

d. Monitor the cord for another 24 to 48 hours and b. cephalohematoma.

call the clinic if the discharge continues.
c. occiput.

d. sinciput.
93. Meanwhile, Nurse Claire is planning care for a
newborn of a mother with diabetes mellitus. What is
the priority nursing consideration for this newborn? 97. A newborn is evaluated by the nurse after birth.
Which assessment findings reveal a problem and
a. Developmental delays because of excessive size
indicate the need for more evaluation?
b. Maintaining safety because of low blood glucose
a. Rosy skin color
levels
b. Heart rate of 138 beats per minute
c. Choking because of impaired suck and swallow
reflexes c. Noisy breath sounds = distress
d. Elevated body temperature because of excess fat d. An axillary temperature of 36.5°C, or 97.7°F
and glycogen

98. Which of the following reflexes is being evaluated

94. Additionally, Nurse Claire creates a plan of care by the nurse by elevating the infant's body slightly
for a woman with human immunodeficiency virus over the crib, lowering it abruptly, and then
(HIV) infection and her newborn. The nurse should observing for bilateral arm extension and leg flexion?
include which intervention in the plan of care?
a. Moro reflex
a. Monitoring the newborn’s vital signs routinely
b. Galant reflex
b. Maintaining standard precautions at all times while
caring for the newborn c. Palmar grasp

c. Initiating referral to evaluate for blindness, d. Babinski reflex

deafness, learning problems, or behavioral problems

d. Instructing the breast-feeding mother regarding the 99. The nurse is questioned by the parents of an
treatment of the nipples with nystatin ointment infant about the need to test their child for
phenylketonuria. The nurse should respond
appropriately by saying:
95. Nurse Claire is providing instructions to the
mother of a newborn with hyperbilirubinemia who is a. Prevent mental retardation.
being breast-fed. Which of the following should she b. Prevent chronic lung infections.
instruct the mother?
c. Treat conductive deafness effectively.
a. Feed the newborn less frequently.
d. Treat hematuria and proteinuria before
b. Continue to breast-feed every 2 to 4 hours. complications develop.
c. Switch to bottle-feeding the infant for 2 weeks.
100. The nurse is discussing the characteristics of
newborn and toddler stools with a group of pregnant
clients. Which of the following is the correct
statement by the nurse:

a. Infants who are breastfed have dark yellow or tan,

formed feces.

b. During the first week of life, the feces of the

newborn are brown, formed, and firm.

c. For the first 24 hours, the feces passed by the

newborn are black, tarry, and sticky.

d. Infants who are formula-fed have bright yellow or

golden-colored feces.