1
Q
- When describing the menstrual cycle to a group of young women, the nurse explains that estrogen levels are highest during which phase of the endometrial cycle?
A. menstrual B. proliferative C. secretory
D. ischemic
A
Answer: B
Rationale: Estrogen levels are the highest during the proliferative phase of the endometrial cycle,
when the endometrial glands enlarge in response to increasing amounts of estrogen. Progesterone
is the predominant hormone of the secretory phase. Levels of estrogen and progesterone drop
sharply during the ischemic phase and fall during the menstrual phase.
2
Q
3. A client with a 28-day cycle reports that she ovulated on May a1b0irb. .Wcomh/etenst would the nurse expect the client's next menses to begin? A. May 24 B. May 26 C. May 30 D. June 1
A
Answer: A
Rationale: For a woman with a 28-day cycle, ovulation typically occurs on day 14. Therefore, her next menses would begin 14 days later, on May 24.
3
Q
- The nurse is reviewing the process of oocyte maturation and ovulation with a client. What occurs during the follicular phase of the ovarian cycle that the nurse should include in the teaching session?
A. Under the influence of follicle-stimulating hormone, several follicles begin to ripen, and the ovum with each begins to mature.
B. The empty ruptured graafian follicle becomes the corpus luteum, and it begins to secrete
progesterone and estrogen.
C. About day 14, a surge of hormones cause the ovum to burst through the ovary. D. The uterus prepares for implantation of an ovum.
D. The uterus prepares for implantation of an ovum.
A
- During this time, under the influence of follicle-stimulating hormone, several follicles begin to ripen and the ovum within each begins to mature. About day 14, a surge of hormones causes the ovum to burst
through the ovary; this act is called ovulation. During the luteal phase, the empty, ruptured Graafian follicle becomes the corpus , and it begins to secrete progesterone and estrogen.
Answer: A
The endometrium of the uterus has a similar cycle. It is called the uterine cycle or endometrial cycle. This process prepares the uterus for implantation of an ovum (egg).
4
Q
- A nurse has been invited to be a guest speaker for a female high school health class about the
menstrual cycle and reproduction. When describing the hormones involved in the menstrual
cycle, a nurse identifies which hormone as responsible for initiating the cycle?
A. estrogen
B. luteinizing hormone C. progesterone
D. prolactin
A
Answer: B
Rationale: With the initiation of the menstrual cycle, luteinizing hormone rises and stimulates the follicle to produce estrogen. As this hormone is produced by the follicle, estrogen levels rise, inhibiting the output of LH. Ovulation occurs after an LH surge damages the estrogen-producing estrogen and progesterone. These two levels rise, suppressing LH. Lack of LH promotes degeneration of the corpus luteum, which then leads to a decline in estrogen and progesterone. The decline of ovarian hormones ends their negative effect on the secretion of LH, which is then secreted and the menstrual cycle begins again. Prolactin is the hormone responsible for breast milk production.
5
Q
- When discussing contraceptive options, the nurse would recommend which option as being
the most reliable?
A. coitus interruptus
B. lactational amenorrheal method (LAM) C. natural family planning
D. intrauterine system
A
Answer: D
Rationale: An intrauterine system is the most reliable method because users have to consciously discontinue using them to become pregnant rather than making a proactive decision to avoid conception. Coitus interruptus, LAM, and natural family planninag are behavioral methods of contraception and require active participation of the couple to prevent pregnancy. These behavioral methods must be followed exactly as prescribed.
6
Q
4. The nurse discusses various contraceptive methods with a client and her partner. Which method would the nurse explain as being available only by prescription? A. condom B. spermicide C. diaphragm D. basal body temperature
A
Answer: C
Rationale: The diaphragm is available only by prescription and must be professionally fitted by a health care provider. Condoms and spermicides are available over the counter. Basal body
temperature requires the use of a special thermometer that is available over the counter.
6
Q
4. The nurse discusses various contraceptive methods with a client and her partner. Which method would the nurse explain as being available only by prescription? A. condom B. spermicide C. diaphragm D. basal body temperature
A
Answer: C
Rationale: The diaphragm is available only by prescription and must be professionally fitted by a health care provider. Condoms and spermicides are available over the counter. Basal body
temperature requires the use of a special thermometer that is available over the counter.
7
Q
- A primiparous client is being seen in the clinic for her first prenatal visit. It is determined that
she is 11 weeks pregnant. The nurse develops a teaching plan to educate the client about what
she will most likely experience during this period. Which possible effect would the nurse
include?
A
A. ankle edema
B. urinary frequency
C. backache
D. hemorrhoids
Answer: B
Rationale: The client is in her first trimester and would most likely experience urinary frequency
as the growing uterus presses on the bladder. Ankle edema, backache, and hemorrhoids would be
more common during the later stages of pregnancy.
8
Q
- A woman is at 20 weeks’ gestation. The nurse would expect to find the fundus at which area?
A. just above the symphysis pubis
B. midway between the pubis and umbilicus
C. at the level of the umbilicus
D. midway between the umbilicus and xiphoid process
A
Answer: C
Rationale: The uterus, which starts as a pear-shaped organ, becomes ovoid as length increases
over width. By 20 weeks’ gestation, the fundus, or top of the uterus, is at the level of the
umbilicus and measures 20 cm. A monthly measurement of the height of the top of the uterus in
centimeters, which corresponds to the number of gestational weeks, is commonly used to date
the pregnancy
9
Q
- A woman comes to the prenatal clinic for an evaluation because she thinks that she may be
pregnant. The nurse is assisting the health care provider with the vaginal examination. The exam
reveals a vaginal mucosa and cervix that are bluish-purple in color. Based on this information,
the nurse suspects that the client is most likely how many weeks pregnant?
A. 5 weeks
B. 6 weeks
C. 14 weeks
D. 16 weeks
A
Answer: B
Rationale: The finding indicates Chadwick’s sign, a bluish-purple discoloration of the vaginal
mucosa and cervix. This typically occurs between 6 to 8 weeks. Goodell’s sign (softening of the
cervix) occurs at about 5 weeks. Abdominal enlargement typically begins at about 14 weeks and
ballottement (when the examiner pushes against the woman’s cervix during a pelvic examination
and feels a rebound from the floating fetus) usually occurs at about 16 weeks.
10
Q
- A nurse is providing nutritional counseling to a pregnant woman and gives her suggestions
about consuming foods that are high in folic acid. As part of the plan of care, the client is to keep
a food diary that the client and nurse will review at the next visit. When reviewing the client’s
diary, which meals would indicate to the nurse that the client is increasing her intake of folic
acid? Select all that apply.
A. chicken breast with baked potato and broccoli
B. cheeseburger with spinach and baked beans
C. pork chop with mashed potatoes and green beans
D. strawberry walnut salad with romaine lettuce
E. fried chicken sandwich with mayonnaise and avocado
A
Answer: A, B, D
Rationale: Good food sources of folic acid include dark green vegetables, such as broccoli,
romaine lettuce, and spinach; baked beans; black-eyed peas; citrus fruits; peanuts; and liver. So
the meals containing chicken breast with baked potato and broccoli, cheeseburger with spinach
and baked beans, and the strawberry walnut salad with romaine lettuce demonstrate an intake of
foods high in folic acid.
11
Q
- A nurse is teaching a pregnant woman about ways to prevent the development of the foodborne illness listeriosis. The nurse determines that the teaching was successful when the woman
identifies the need to avoid which food(s)? Select all that apply.
A. Soft cheeses
B. Refrigerated meat spreads
C. Canned tuna fish
D. Store-made chicken salad
E. Pasteurized milk
A
Answer: A, B, D
Rationale: To prevent listeriosis, the woman should avoid soft cheeses such as feta, Brie,
Camembert, and blue-veined cheeses, refrigerated pâté or meat spreads, refrigerated smoked
seafood unless it is an ingredient in a cooked dish such as a casserole, salads made in the store
such as ham salad, chicken salad, egg salad, tuna salad, or seafood salad, and unpasteurized milk.
It is safe to eat canned or shelf-stable pâté and meat spreads and canned fish such as salmon and
tuna or shelf-stable smoked seafood.
12
Q
15. A biophysical profile has been completed on a pregnant woman. The nurse interprets which score as normal? A. 9 B. 7 C. 5 D. 3
A
Answer: A
Rationale: The biophysical profile is a scored test with five components, each worth 2 points if
present. A total score of 10 is possible if the NST is used. Overall, a score of 8 to 10 is
considered normal if the amniotic fluid volume is adequate. A score of 6 or below is suspicious,
possibly indicating a compromised fetus; further investigation of fetal well-being is needed.
13
Q
- The nurse is assessing the latest laboratory results of a pregnant client who is at 17 weeks
gestation. The nurse should prepare to teach the client about which possible defects after noting
the maternal serum alpha-fetoprotein level is elevated above normal?
A. fetal hypoxia
B. open spinal defects
C. Down syndrome
D. maternal hypertension
A
Answer: B
Rationale: Elevated MSAFP levels are associated with open neural tube defects, underestimation
of gestational age, the presence of multiple fetuses, gastrointestinal defects, low birth weight,
oligohydramnios, material age, diabetes, and decreased maternal weight. Lower-than-expected
MSAFP levels are seen when fetal gestational age is overestimated or in cases of fetal death,
hydatidiform mole, increased maternal weight, maternal type 1 diabetes, and fetal trisomy 21
(Down syndrome) or 18. Fetal hypoxia would be noted with fetal heart rate tracings and via
nonstress and contract
14
Q
- A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of
labor. When describing this stage to the client, which event would the nurse identify as the major
change occurring during this stage?
A. regular contractions
B. cervical dilation (dilatation)
C. fetal movement through the birth canal
D. placental separation
A
Answer: B
Rationale: The primary change occurring during the first stage of labor is progressive cervical
dilation (dilatation). Contractions occur during the first and second stages of labor. Fetal
movement through the birth canal is the major change during the second stage of labor. Placental
separation occurs during the third stage of labor.
15
Q
- A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse
prepares the client for this monitoring based on the understanding that which criterion must be
present?
A. intact membranes
B. cervical dilation of 2 cm or more
C. floating presenting fetal part
D. a neonatologist to insert the electrode
A
Answer: B
Rationale: For continuous internal electronic fetal monitoring, four criteria must be met: ruptured
membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow
placement of the electrode, and a skilled practitioner available to insert the electrode.
16
Q
- When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The
nurse interprets this finding as indicating which type of contraction?
A. intense
B. strong
C. moderate
D. mild
A
Answer: C
Rationale: A contraction that feels like the chin typically represents a moderate contraction. A
contraction described as feeling like the tip of the nose indicates a mild contraction. A strong or
intense contraction feels like the forehead.
17
Q
- A nurse palpates a woman’s fundus to determine contraction intensity. What would be most
appropriate for the nurse to use for palpation?
A. finger pads
B. palm of the hand
C. finger tips
D. back of the hand
A
Answer: A
Rationale: To palpate the fundus for contraction intensity, the nurse would place the pads of the
fingers on the fundus and describe how it feels. Using the finger tips, palm, or back of the hand
would be inappropriate.
18
Q
- A nurse is explaining the use of effleurage as a pain relief measure during labor. Which
statement would the nurse most likely use when explaining this measure?
A. “This technique focuses on manipulating body tissues.”
B. “The technique requires focusing on a specific stimulus.”
C. “This technique redirects energy fields that lead to pain.”
D. “The technique involves light stroking of the abdomen with breathing.”
A
Answer: D
Rationale: Effleurage involves light stroking of the abdomen in rhythm with breathing.
Therapeutic touch is an energy therapy and is based on the premise that the body contains energy
fields that lead to either good or ill health and that the hands can be used to redirect the energy
fields that lead to pain. Attention focusing and imagery involve focusing on a specific stimulus.
Massage focuses on manipulating body tissues.
19
Q
- A nurse is describing the different types of regional analgesia and anesthesia for labor to a
group of pregnant women. Which statement by the group indicates that the teaching was
successful?
A. “We can get up and walk around after receiving combined spinal–epidural analgesia.”
B. “Higher anesthetic doses are needed for patient-controlled epidural analgesia.”
C. “A pudendal nerve block is highly effective for pain relief in the first stage of labor.”
D. “Local infiltration using lidocaine is an appropriate method for controlling contraction pain.”
A
Answer: A
Rationale: When compared with traditional epidural or spinal analgesia, which often keeps the
woman lying in bed, combined spinal–epidural analgesia allows the woman to ambulate
(“walking epidural”). Patient-controlled epidural analgesia provides equivalent analgesia with
lower anesthetic use, lower rates of supplementation, and higher client satisfaction. Pudendal
nerve blocks are used for the second stage of labor, an episiotomy, or an operative vaginal birth
with outlet forceps or vacuum extractor. Local infiltration using lidocaine does not alter the pain
of uterine contractions, but it does numb the immediate area of the episiotomy or laceration.
20
Q
- A pregnant woman admitted to the labor and birth suite undergoes rapid HIV testing and is
found to be HIV-positive. Which action would the nurse expect to include when developing a
plan of care for this woman? Select all that apply.
A. administrating of penicillin G at the onset of labor
B. avoiding scalp electrodes for fetal monitoring
C. refraining from obtaining fetal scalp blood for pH testing
D. administering antiretroviral therapy at the onset of labor
E. electing for the use of forceps-assisted birth
A
Answer: B, C, D
Rationale: To reduce perinatal transmission, HIV-positive women are given a combination of
antiretroviral drugs. To further reduce the risk of perinatal transmission, ACOG and the U.S.
Public Health Service recommend that HIV-infected women with plasma viral loads of more
than 1,000 copies per milliliter be counseled regarding the benefits of elective cesarean birth.
Additional interventions to reduce the transmission risk would include avoiding use of scalp
electrode for fetal monitoring or doing a scalp blood sampling for fetal pH, delaying amniotomy,
encouraging formula feeding after birth, and avoiding invasive procedures such as forceps or
vacuum-assisted devices
21
Q
- Which suggestion by the nurse about pushing would be most appropriate to a woman in the
second stage of labor?
A. “Lying flat with your head elevated on two pillows makes pushing easier.”
B. “Choose whatever method you feel most comfortable with for pushing.”
C. “Let me help you decide when it is time to start pushing.”
D. “Bear down like you’re having a bowel movement with every contraction.”
A
Answer: B
Rationale: The role of the nurse should be to support the woman in her choice of pushing method
and to encourage confidence in her maternal instinct of when and how to push. In the absence of
any complications, nurses should not be controlling this stage of labor, but empowering women
to achieve a satisfying experience. Common practice in many labor units is still to coach women
to use closed glottis pushing with every contraction, starting at 10 cm of dilation, a practice that
is not supported by research. Research suggests that directed pushing during the second stage
may be accompanied by a significant decline in fetal pH and may cause maternal muscle and
nerve damage if done too early. Effective pushing can be achieved by assisting the woman to
assume a more upright or squatting position. Supporting spontaneous pushing and encouraging
women to choose their own method of pushing should be accepted as best clinical practice.
22
Q
- A nurse is performing Leopold maneuvers on a pregnant woman. The nurse determines
which information with the first maneuver?
A. Fetal presentation
B. Fetal position
C. Fetal attitude
D. Fetal flexion
A
Answer: A
Rationale: Leopold maneuvers are a method for determining the presentation, position, and lie of
the fetus through the use of four specific steps. The first maneuver determines presentation; the
second maneuver determines position; the third maneuver confirms presentation by feeling for
the presenting part; the fourth maneuver determines attitude based on whether the fetal head is
flexed and engaged in the pelvis.
23
Q
- A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first
stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action
by the nurse would be appropriate?
A. Check the pH to ensure the fluid is amniotic fluid.
B. Prepare to administer an antibiotic.
C. Notify the health care provider about possible meconium.
D. Check the maternal heart rate.
A
Answer: C
Rationale: Amniotic fluid should be clear when the membranes rupture. Green fluid may indicate
that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord
compression, intrauterine growth restriction, maternal hypertension, diabetes, or
chorioamnionitis. Therefore, the nurse would notify the health care provider. Antibiotic therapy
would be indicated if the fluid was cloudy or foul-smelling, suggesting an infection. Color of the
fluid has nothing to do with the pH of the fluid. Spontaneous rupture of membranes can lead to
cord compression, so checking fetal heart rate, not maternal heart rate, would be appropriate.
24
4. A nurse is reviewing a client's history and physical examination findings. Which information
would the nurse identify as contributing to the client's risk for an ectopic pregnancy?
A. use of oral contraceptives for 5 years
B. ovarian cyst 2 years ago
C. recurrent pelvic infections
D. heavy, irregular menses
Answer: C
Rationale: In the general population, most cases of ectopic pregnancy are the result of tubal
scarring secondary to pelvic inflammatory disease. Oral contraceptives, ovarian cysts, and heavy,
irregular menses are not considered risk factors for ectopic pregnancy
25
```
5. A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the
nurse identify as the priority?
A. hemorrhage
B. jaundice
C. edema
D. infection
```
ANS: A
Rationale: With a ruptured ectopic pregnancy, the woman is at high risk for hemorrhage.
Jaundice, edema, and infection are not associated with a ruptured ectopic pregnancy.
26
8. A client comes to the clinic for an evaluation. The client is at 22 weeks' gestation. After
reviewing a client's history, which factor would the nurse identify as placing her at risk for
preeclampsia?
A. Her mother had preeclampsia during pregnancy.
B. Client has a twin sister.
C. Her sister-in-law had gestational hypertension.
D. This is the client's second pregnancy.
Answer: A
Rationale: A family history of preeclampsia, such as a mother or sister, is considered a risk factor
for the client. Having a twin sister or having a sister-in-law with gestational hypertension would
not increase the client's risk. If the client had a history of preeclampsia in her first pregnancy,
then she would be at risk in her second pregnancy.
27
9. A client with hyperemesis gravidarum is admitted to the facility after being cared for at home
without success. What would the nurse expect to include in the client's plan of care?
A. clear liquid diet
B. total parenteral nutrition
C. nothing by mouth
D. administration of labetalol
Answer: C
Rationale: Typically, on admission, the woman with hyperemesis has oral food and fluids
withheld to rest the gut and receives parenteral fluids to rehydrate and reduce the symptoms.
Once the condition stabilizes, oral intake is gradually increased. Total parenteral nutrition may
be used if the client's condition does not improve with several days of bed rest, gut rest, IV
fluids, and antiemetics. Labetalol is an antihypertensive agent that may be used to treat
gestational hypertension, not hyperemesis.
28
12. A nurse is conducting an assessment of a woman who has experienced PROM. Which
amniotic fluid finding would lead the nurse to suspect infection as the cause of a client's PROM?
A. yellow-green fluid
B. blue color on Nitrazine testing
C. ferning
D. foul odor
Answer: D
Rationale: A foul odor of the amniotic fluid indicates infection. Yellow-green fluid would
suggest meconium. A blue color on Nitrazine testing and ferning indicate the presence of
amniotic fluid
29
14. While assessing a pregnant woman, the nurse suspects that the client may be at risk for
hydramnios. Which information would the nurse use to support this suspicion? Select all that
apply.
A. history of diabetes
B. reports of shortness of breath
C. identifiable fetal parts on abdominal palpation
D. difficulty obtaining fetal heart rate
E. fundal height below that for expected gestational age
Answer: A, B, D
Rationale: Factors such as maternal diabetes or multiple gestations place the woman at risk for
hydramnios. In addition, there is a discrepancy between fundal height and gestational age, such
that a rapid growth of the uterus is noted. Shortness of breath may result from overstretching of
the uterus due to the increased amount of amniotic fluid. Often, fetal parts are difficult to palpate
and fetal heart rate is difficult to obtain because of the excess fluid present.
30
20. The health care provider prescribes PGE2 for a woman to help evacuate the uterus following
a spontaneous abortion. Which action would be most important for the nurse to do?
A. Use clean technique to administer the drug.
B. Keep the gel cool until ready to use.
C. Maintain the client supine for 30 minutes after administration.
D. Administer intramuscularly into the deltoid area.
Answer: C
Rationale: When PGE2 is prescribed, the gel should come to room temperature before
administering it. Sterile technique should be used, and the client should remain supine for 30
minutes after administration. Rho(D) immune globulin is administered intramuscularly into the
deltoid area.
31
23. A woman with hyperemesis gravidarum asks the nurse about suggestions to minimize nausea
and vomiting. Which suggestion would be most appropriate for the nurse to make?
A. "Make sure that anything around your waist is quite snug."
B. "Try to eat three large meals a day with less snacking."
C. "Drink fluids in between meals rather than with meals."
D. "Lie down for about an hour after you eat."
Answer: C
Rationale: Suggestions to minimize nausea and vomiting include avoiding tight waistbands to
minimize pressure on the abdomen, eating small frequent meals throughout the day, separating
fluids from solids by consuming fluids in between meals; and avoiding lying down or reclining
for at least 2 hours after eating.
32
24. A woman with gestational hypertension develops eclampsia and experiences a seizure.
Which intervention would the nurse identify as the priority?
A. fluid replacement
B. oxygenation
C. control of hypertension
D. birth of the fetus
Answer: B
Rationale: As with any seizure, the priority is to clear the airway and maintain adequate
oxygenation both to the mother and the fetus. Fluids and control of hypertension are addressed
once the airway and oxygenation are maintained. Delivery of fetus is determined once the
seizures are controlled and the woman is stable.
33
2. A pregnant woman with diabetes at 10 weeks' gestation has a glycosylated hemoglobin
(HbA1c) level of 13%. At this time the nurse should be most concerned about which possible
fetal outcome?
A. congenital anomalies
B. incompetent cervix
C. placenta previa
D. placental abruption (abruptio placentae)
Answer: A
Rationale: A HbA1c level of 13% indicates poor glucose control. This, in conjunction with the
woman being in the first trimester, increases the risk for congenital anomalies in the fetus.
Elevated glucose levels are not associated with incompetent cervix, placenta previa, or placental
abruption (abruptio placentae).
34
19. A pregnant woman comes to the clinic for her first evaluation. The woman is screened for
hepatitis B (HBV) and tests positive. The nurse would anticipate administering which agent?
A. HBV immune globulin
B. HBV vaccine
C. acylcovir
D. valacyclovir
Answer: A
Rationale: If a woman tests positive for HBV, expect to administer HBV immune globulin. The
newborn will also receive HBV vaccine within 12 hours of birth. Acyclovir or valacyclovir
would be used to treat herpes simplex virus infection.
35
20. After teaching a pregnant woman with iron deficiency anemia about nutrition, the nurse
determines that the teaching was successful when the woman identifies which foods as being
good sources of iron in her diet? Select all that apply.
A. dried fruits
B. peanut butter
C. meats
D. milk
E. white bread
Answer: A, B, C
Rationale: Foods high in iron include meats, green leafy vegetables, legumes, dried fruits, whole
grains, peanut butter, bean dip, whole-wheat fortified breads, and cereals
36
21. A pregnant woman with gestational diabetes comes to the clinic for a fasting blood glucose
level. When reviewing the results, the nurse determines that the woman is achieving good
glucose control based on which result?
A. 88 mg/dL
B. 100 mg/dL
C. 110 mg/dL
D. 120 mg/dL
Answer: A
Rationale: For a pregnant woman with diabetes, the ADA and ACOG recommend maintaining a
fasting blood glucose level below 95 mg/dL, with postprandial levels below 140 mg/dL at 1
hour, below 120 mg/dL at 2 hours.
37
23. A nurse is providing care to several pregnant women at different weeks of gestation. The
nurse would expect to screen for group B streptococcus infection in the client who is at:
A. 16 weeks' gestation.
B. 28 weeks' gestation.
C. 32 weeks' gestation.
D. 36 weeks' gestation.
Answer: D
Rationale: Pregnant women between 36 and 37 weeks’ gestation should be universally screened
for GBS infection during a prenatal visit and if positive, receive appropriate intrapartum
antibiotic prophylaxis
38
2. A primigravida whose labor was initially progressing normally is now experiencing a decrease
in the frequency and intensity of her contractions. The nurse would assess the woman for which
condition?
A. a low-lying placenta
B. fetopelvic disproportion
C. contraction ring
D. uterine bleeding
Answer: B
Rationale: The woman is experiencing dystocia most likely due to hypotonic uterine dysfunction
and fetopelvic disproportion associated with a large fetus
39
15. A nurse is preparing an inservice education program for a group of nurses about dystocia
involving problems with the passenger. Which problem would the nurse likely include as the
most common?
A. macrosomia
B. breech presentation
C. persistent occiput posterior position
D. multifetal pregnancy
Answer: C
Rationale: Common problems involving the passenger include occiput posterior position, breech
presentation, multifetal pregnancy, excessive size (macrosomia) as it relates to cephalopelvic
disproportion (CPD), and structural anomalies. Of these, persistent occiput posterior is the most
common malposition, occurring in about 15% of laboring women.
40
16. A nurse is conducting a review course on tocolytic therapy for perinatal nurses. After
teaching the group, the nurse determines that the teaching was successful when they identify
which drugs as being used for tocolysis? Select all that apply.
A. nifedipine
B. magnesium sulfate
C. dinoprostone
D. misoprostol
E. indomethacin
Answer: A, B, E
Rationale: Medications most commonly used for tocolysis include magnesium sulfate (which
reduces the muscle's ability to contract), indomethacin (a prostaglandin synthetase inhibitor), and
nifedipine (a calcium channel blocker).
41
17. A nurse is teaching a pregnant woman at risk for preterm labor about what to do if she
experiences signs and symptoms. The nurse determines that the teaching was successful when
the woman makes which statement?
A. "I'll sit down to rest for 30 minutes."
B. "I'll try to move my bowels."
C. "I'll lie down with my legs raised."
D. "I'll drink several glasses of water."
Answer: D
Rationale: If the woman experiences any signs and symptoms of preterm labor, she should stop
what she is doing and rest for 1 hour, empty her bladder, lie down on her side, drink two to three
glasses of water, feel her abdomen and note the hardness of the contraction, and call her health
care provider and describe the contraction.
42
13. A postpartum client is experiencing subinvolution. When reviewing the woman's labor and
birth history, which factor would the nurse identify as being a significant contributor to this
condition?
A. early ambulation
B. short duration of labor
C. breastfeeding
D. use of anesthetics
Answer: D
Rationale: Factors that inhibit involution include prolonged labor and difficult birth, incomplete
expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine
muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which
displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles),
and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion
of amniotic membranes and placenta at birth, complication-free labor and birth process,
breastfeeding, and early ambulation.
43
```
23. A nurse is visiting a postpartum woman who gave birth to a healthy newborn 5 days ago.
Which finding would the nurse expect?
A. bright red discharge
B. pinkish brown discharge
C. deep red mucus-like discharge
D. creamy white discharge
```
Answer: B
Rationale: Lochia serosa is pinkish brown and is expelled 3 to 10 days postpartum. Lochia rubra
is a deep-red mixture of mucus, tissue debris, and blood that occurs for the first 3 to 4 days after
birth. Lochia alba is creamy white or light brown and consists of leukocytes, decidual tissue, and
reduced fluid content and occurs from days 10 to 14 but can last 3 to 6 weeks postpartum.
44
```
3. A postpartum client has a fourth-degree perineal laceration. The nurse would expect which
medication to be prescribed?
A. ferrous sulfate
B. methylergonovine
C. docusate
D. bromocriptine
```
Answer: C
Rationale: A stool softener such as docusate may promote bowel elimination in a woman with a
fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate
would be used to treat anemia. However, it is associated with constipation and would increase
the discomfort when the woman has a bowel movement. Methylergonovine would be used to
prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.
45
19. The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain
on the perineal pad. The nurse documents this finding as which description?
A. scant
B. light
C. moderate
D. large
Answer: B
Rationale: The amount of lochia is described as light or small for an approximately 4-inch stain.
Scant refers to a 1- to 2-inch stain of lochia; moderate refers to a 4- to 6-inch stain; and large or
heavy refers to a pad that is saturated within 1 hour after changing
46
```
13. When describing the neurologic development of a newborn to parents, the nurse would
explain that it occurs in which fashion?
A. head-to-toe
B. lateral-to-medial
C. outward-to-inward
D. distal-caudal
```
Answer: A
Rationale: Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal
(center to outside) pattern
47
16. The nurse observes the stool of a newborn who is being bottle-fed. The newborn is 2 days
old. What would the nurse expect to find?
A. greenish black, tarry stool
B. yellowish-brown, seedy stool
C. yellow-gold, stringy stool
D. yellowish-green, pasty stool
Answer: D
Rationale: The milk stools of the formula-fed newborn vary depending on the type of formula
ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in
consistency, and they have an unpleasant odor. After breast-feedings are initiated, a transitional
stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in
appearance. Meconium stool is greenish black and tarry. The last development in the stool
pattern is the milk stool. Milk stools of the breast-fed newborn are yellow-gold, loose, and
stringy to pasty in consistency, and typically sour-smelling.
48
```
17. The nurse observes the stool of a newborn who has begun to breastfeed. Which finding
would the nurse expect?
A. greenish black, tarry stool
B. yellowish-brown, seedy stool
C. yellow-gold, stringy stool
D. yellowish-green, pasty stool
```
Answer: B
Rationale: After feedings are initiated, a transitional stool develops, which is greenish brown to
yellowish brown, thinner in consistency, and seedy in appearance. Meconium stool is greenish
black and tarry. The last development in the stool pattern is the milk stool. Milk stools of the
breastfed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically soursmelling. The milk stools of the formula-fed newborn vary depending on the type of formula
ingested. They may be yellow, yellow-green, or g
49
24. A nurse is preparing a presentation about ways to minimize heat loss in the newborn. Which
measure would the nurse include to prevent heat loss through convection?
A. placing a cap on a newborn's head
B. working inside an isolette as much as possible.
C. placing the newborn skin-to-skin with the mother
D. using a radiant warmer to transport a newborn
Answer: B
Rationale: To prevent heat loss by convection, the nurse would keep the newborn out of direct
cool drafts (open doors, windows, fans, air conditioners) in the environment, work inside an
isolette as much as possible and minimize opening portholes that allow cold air to flow inside,
and warm any oxygen or humidified air that comes in contact with the newborn. Placing a cap on
the newborn’s head would help minimize heat loss through evaporation. Placing the newborn
skin-to-skin with the mother helps to prevent heat loss through conduction. Using a radiant
warmer to transport a newborn helps minimize heat loss through radiation.
50
4. Assessment of a newborn reveals a heart rate of 180 beats per minute. To determine whether
this finding is a common variation rather than a sign of distress, what else does the nurse need to
know?
A. How many hours old is this newborn?
B. How long ago did this newborn eat?
C. What was the newborn's birthweight?
D. Is acrocyanosis present?
Answer: A
Rationale: The typical heart rate of a newborn ranges from 110 to 160 beats per minute with
wide fluctuation during activity and sleep. Typically heart rate is assessed every 30 minutes until
stable for 2 hours after birth. The time of the newborn's last feeding and his birthweight would
have no effect on his heart rate. Acrocyanosis is a common normal finding in newborns
51
5. When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of
95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths
per minute. The nurse would identify which area as the priority?
A. hypothermia
B. impaired parenting
C. deficient fluid volume
D. risk for infection
Answer: A
Rationale: The newborn's heart rate is slightly below the accepted range of 120 to 160 beats per
minute; the respiratory rate is at the high end of the accepted range of 30 to 60 breaths per
minute. However, the newborn's temperature is significantly below the accepted range of 97.7 to
99.7? (36.5 to 37.6?). Therefore, the priority problem area is hypothermia. There is no
information to suggest impaired parenting. Additional information is needed to determine if there
is deficient fluid volume or a risk for infection.
52
8. While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning
bluish. What would the nurse do first?
A. Alert the primary care provider stat, and turn the newborn to her right side.
B. Administer oxygen via facial mask by positive pressure.
C. Lower the newborn's head to stimulate crying.
D. Aspirate the oral and nasal pharynx with a bulb syringe.
Answer: D
Rationale: The nurse's first action would be to suction the oral and nasal pharynx with a bulb
syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the
blockage due to secretions. Administering oxygen via positive pressure is not indicated at this
time. Lowering the newborn's head would be inappropriate.
53
13. The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and
chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets
this finding as:
A. harlequin sign.
B. nevus flames.
C. erythema toxicum.
D. port wine stain.
Answer: C
Rationale: Erythema toxicum (newborn rash) is a benign, idiopathic, generalized, transient rash
that occurs in up to 70% of all newborns during the first week of life. It consists of small papules
or pustules on the skin resembling flea bites. The rash is common on the face, chest, and back.
One of the chief characteristics of this rash is its lack of pattern. It is caused by the newborn's
eosinophils reacting to the environment as the immune system matures. Harlequin sign refers to
the dilation of blood vessels on only one side of the body, giving the newborn the appearance of
wearing a clown suit. It gives a distinct midline demarcation, which is described as pale on the
nondependent side and red on the opposite, dependent side. Nevus flammeus or port wine stain is
a capillary angioma located directly below the dermis. It is flat with sharp demarcations and is
purple–red. This skin lesion is made up of mature capillaries that are congested and dilated
54
17. The nurse is auscultating a newborn's heart and places the stethoscope at the point of
maximal impulse at which location?
A. just superior to the nipple, at the midsternum
B. lateral to the midclavicular line at the fourth intercostal space
C. at the fifth intercostal space to the left of the sternum
D. directly adjacent to the sternum at the second intercostals space
Answer: B
Rationale: The point of maximal impulse (PMI) in a newborn is a lateral to midclavicular line
located at the fourth intercostal space.
55
26. Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's
medical record. Which factor in the newborn's history would the nurse identify as playing a role
in this this condition?
A. vaginal birth
B. shortened labor
C. central nervous system depressant during labor
D. maternal hypertension
Answer: C
Rationale: Transient tachypnea of the newborn occurs when the fetal liquid in the lungs is
removed slowly or incompletely. This can be due to the lack of thoracic squeezing that occurs
during a cesarean birth or diminished respiratory effort if the mother received central nervous
system depressant medication. Prolonged labor, macrosomia of the fetus, and maternal asthma
also have been associated with this condition
56
1. Review of a primiparous woman's labor and birth record reveals a prolonged second stage of
labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse
would be especially alert for which condition?
A. retained placental fragments
B. hypertension
C. thrombophlebitis
D. uterine subinvolution
Answer: C
Rationale: The woman is at risk for thrombophlebitis due to the prolonged second stage of labor,
necessitating an increased amount of time in bed, and venous pooling that occurs when the
woman's legs are in stirrups for a long period of time. These findings are unrelated to retained
placental fragments, which would lead to uterine subinvolution, or hypertension.
57
3. A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After
further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain,
the nurse would question the woman about which symptom?
A. an inverted nipple on the affected breast
B. no breast milk in the affected breast
C. an ecchymotic area on the affected breast
D. hardening of an area in the affected breast
Answer: D
Rationale: Mastitis is characterized by a tender, hot, red, painful area on the affected breast. An
inverted nipple is not associated with mastitis. With mastitis, the breast is distended with milk,
the area is inflamed (not ecchymotic), and there is breast tenderness.
58
5. A multipara client develops thrombophlebitis after birth. Which assessment findings would
lead the nurse to intervene immediately?
A. dyspnea, diaphoresis, hypotension, and chest pain
B. dyspnea, bradycardia, hypertension, and confusion
C. weakness, anorexia, change in level of consciousness, and coma
D. pallor, tachycardia, seizures, and jaundice
Answer: A
Rationale: Sudden unexplained shortness of breath and reports of chest pain along with
diaphoresis and hypotension suggest pulmonary embolism, which requires immediate action.
Other signs and symptoms include tachycardia, apprehension, hemoptysis, syncope, and sudden
change in the woman's mental status secondary to hypoxemia. Anorexia, seizures, and jaundice
are unrelated to a pulmonary embolism.
59
10. A postpartum client is prescribed medication therapy as part of the treatment plan for
postpartum hemorrhage. Which medication would the nurse expect to administer in this
situation?
A. Magnesium sulfate
B. methylergonovine
C. Indomethacin
D. nifedipine
Answer: B
Rationale: Methylergonovine, along wiht oxytocin and carboprost are drugs used to manage
postpartum hemorrhage. Magnesium sulfate, indomethecin, and nifedipine are used to control
preterm labor.
60
11. A client is experiencing postpartum hemorrhage, and the nurse begins to massage her fundus.
Which action would be most appropriate for the nurse to do when massaging the woman's
fundus?
A. Place the hands on the sides of the abdomen to grasp the uterus.
B. Use an up-and-down motion to massage the uterus.
C. Wait until the uterus is firm to express clots.
D. Continue massaging the uterus for at least 5 minutes.
Answer: C
Rationale: The uterus must be firm before attempts to express clots are made because application
of firm pressure on an uncontracted uterus could lead to uterine inversion. One hand is placed on
the fundus and the other hand is placed on the area above the symphysis pubis. Circular motions
are used for massage. There is no specified amount of time for fundal massage. Uterine tissue
responds quickly to touch, so it is important not to over massage the fundus.
61
18. A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the
client and suspects that she is experiencing subinvolution based on which finding?
A. nonpalpable fundus
B. moderate lochia serosa
C. bruising on arms and legs
D. fever
Answer: B
Rationale: Subinvolution is usually identified at the woman's postpartum examination 4 to 6
weeks after birth. The clinical picture includes a postpartum fundal height that is higher than
expected, with a boggy uterus; the lochia fails to change colors from red to serosa to alba within
a few weeks. Normally, at 4 to 6 weeks, lochia alba or no lochia would be present and the fundus
would not be palpable. Thus evidence of lochia serosa suggests subinvolution. Bruising would
suggest a coagulopathy. Fever would suggest an infection.
62
22. A nurse is providing a refresher class for a group of postpartum nurses. The nurse reviews
the risk factors associated with postpartum hemorrhage. The group demonstrates understanding
of the information when they identify which risk factors associated with uterine tone? Select all
that apply.
A. rapid labor
B. retained blood clots
C. hydramnios
D. operative birth
E. fetal malpostion
Answer: A, C
Rationale: Risk factors associated with uterine tone include hydramnios, rapid or prolonged
labor, oxytocin use, maternal fever, or prolonged rupture of membranes. Retained blood clots are
a risk factor associated with tissue retained in the uterus. Fetal malposition and operative birth
are risk factors associated with trauma of the genital tract.
63
29. A nurse suspects that a client may be developing disseminated intravascular coagulation. The
woman has a history of placental abruption (abruptio placentae) during birth. Which finding
would help to support the nurse's suspicion?
A. severe uterine pain
B. board-like abdomen
C. appearance of petechiae
D. inversion of the uterus
Answer: C
Rationale: A complication of abruptio placentae is disseminated intravascular coagulation (DIC),
which is manifested by petechiae, ecchymoses, and other signs of impaired clotting. Severe
uterine pain, a board-like abdomen, and uterine inversion are not associated with DIC and
placental abruption
64
5. The nurse prepares to assess a newborn who is considered to be large-for-gestational-age
(LGA). Which characteristic would the nurse correlate with this gestational age variation?
A. strong, brisk motor skills
B. difficulty in arousing to a quiet alert state
C. birthweight of 7 lb, 14 oz (3,572 g)
D. wasted appearance of extremities
Answer: B
Rationale: LGA newborns typically are more difficult to arouse to a quiet alert state. They have
poor motor skills, have a large body that appears plump and full-sized, and usually weigh more
than 8 lb, 13 oz (3,997 g) at term.
65
10. After teaching the parents of a newborn with periventricular hemorrhage about the disorder
and treatment, which statement by the parents indicates that the teaching was successful?
A. "We'll make sure to cover both of his eyes to protect them."
B. "Our newborn could develop a learning disability later on."
C. "Once the bleeding ceases, there won't be any more worries."
D. "We need to get family members to donate blood for transfusion."
Answer: B
Rationale: Periventricular hemorrhage has long-term sequelae such as seizures, hydrocephalus,
periventricular leukomalacia, cerebral palsy, learning disabilities, vision or hearing deficits, and
intellectual disability. Covering the eyes is more appropriate for the newborn receiving
phototherapy. The bleeding in the brain can lead to serious long-term effects. Blood transfusions
are not used to treat periventricular hemorrhage.
66
20. A neonate born addicted to cocaine is now being treated with medication for acute neonatal
abstinence syndrome. Which medication will be prescribed to relieve withdrawal symptoms?
A. meperidine
B. adrenalin
C. naloxone
D. morphine sulphate
Answer: D
Rationale: Pharmacologic treatment is warranted if conservative measures are not adequate.
Common medications used in the management of newborn withdrawal include an opioid
(morphine or methadone) and phenobarbital as a second drug if the opiate does not adequately
control symptoms. The other drugs are not used in NAS treatment.
67
30. A newborn is exhibiting symptoms of withdrawal and toxicology test have been prescribed.
Which type of specimen should the nurse collect to obtain the most accurate results?
A. Meconium
B. Blood
C. Urine
D. Sputum
Answer: A
Rationale: Toxicology screening of a newborn can include testing from blood, urine and
meconium. These tests identify which drugs the newborn has been exposed to in utero. A
meconium sample can detect which drugs the mother has been using from the second trimester
of pregnancy until birth. It is the preferred method of testing. A urine screen identifies only the
drugs the mother has used recently. The nurse should be careful not to mix the meconium sample
with urine as it alters the results of the test. Blood samples can be taken and they will yield
results of current drugs in the newborn's system, but they are invasive and noninvasive testing
will provide the same results. If possible, testing on the mother is preferred. This testing provides
quick results of what drugs the mother has been exposing the fetus to in utero. This will help in
planning and providing care for the drug-exposed newborn. Sputum is not used for toxicology
studies.
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31. A neonate is diagnosed with Erb’s palsy after birth. The parents are concerned about their
neonate's limp arm. The nurse explains the neonate will be scheduled to receive what
recommended treatment for this condition first?
A. Physical therapy to the joint and extremity
B. Nothing but time and let nature take its course
C. Surgery to correct the joint and muscle alignment
D. Immobilization of the shoulder and arm
Answer: D
Rationale: Treatment for a neonate with Erb palsy usually involves immobilization of the upper
arm across the upper abdomen/chest to protect the shoulder from excessive motion for the first
week; then gentle passive range-of-motion exercises are performed daily to prevent contractures.
Surgery is not needed to regain function since there is no structural injury. Doing nothing will
not help the neonate regain function in the extremity
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A sex trade worker is seen at the sexual health clinic reporting dysuria, mucopurulent vaginal discharge with bleeding between periods, conjunctivitis, and a painful rectal area. What sexually transmitted infection would the nurse suspect?
A. syphilis
B. chlamydia
C. genital herpes D. gonorrhea
ANS : B
Chlamydial symptoms include dysuria, mucopurulent vaginal discharge, and dysfunctional uterine bleeding. It can cause inflammation of the rectum and conjunctiva. Syphilis
starts with a chancre on vulva or vagina but can develop in other parts of the body. Secondary
infection is maculopapular rash on hands and feet with a sore throat. Genital herpes symptoms
include itching, tingling, and pain in genital area followed by small pustules and blister-like
abirb.com/test
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30. A client has been diagnosed and treated for primary syphilis. What instruction should the
nurse give this client about follow-up testing?
A. "You will need to be retested again in 6 months."
B. "You also will need to be tested for HIV in 6 months."
abirb.com/test
C. "You do not need to be retested after treatment unless symptoms develop."
D. "You need to retested if you have a new sexual partner."
Answer: A
abirb.com/test
Rationale: For the client treated for primary or secondary syphilis, retesting needs to occur at 6
months and at 12 months. If the client was treated for latent syphilis, then testing needs to be
done at 6 months, 12 months, and 24 months. For latent syphilis, the testing also needs to include
testing for HIV. The client does not to be retested if there is a new sexual partner, but the client should be instructed in safer sex methods to prevent a sexually transmitted infection.
Unit 1
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