1. Mrs.

Diez in her first trimester of pregnancy asks about her nutritional needs, if she needs to double her daily dietary servings. What is your best response? a. eat just enough b. double your food intake to ensure proper nutrition c. do not increase your calories in the first trimester but to add 300 calories during the 2nd and 3rd trimester d. take some foods essential for the baby’s growth always. 2. During the antepartal stage, the nurse recognizes that the placenta is formed from the: a. decidua capsularis b. decidua basalis and decidua vera c. chorionic villi and decidua basalis d. chorionic villi and decidua vera 3. During a mother’s class, a pregnant mother asks at what stage is sex of offspring determined? a. oogenesis b. capacitation c. miosis d. fertilization 4. A nurse is doing assessment of a pregnant at risk client. She knows that preterm birth least likely has a record of: a. gestational age of 12 to 16 weeks b. intact membranes with clinical effacement of 50% or more c. gestational age of 20 to 37 weeks d. uterine contractions of four in 20 min 5. The nurse assess the pregnant woman. She refers the client to the hospital, and said she cannot give birth at home. She must be: a. on her 5th pregnancy b. full term c. cephalic presentation d. primigravida 6. It was one of the prenatal visits that Mrs. Maragas learned about subtle signs of preterm labor. Aside from the sudden increase in hourly contractions within the 24 hr period, which among these should she least expect: a. rhythmic dull backache or pelvic ache with “heavy feeling”

b. uterine and intestinal cramping c. recurrent stabbing abdominal pains d. menstrual-like abdominal aches or thigh croup 7. Mrs. Osias is wheeled to the Delivery room at 10cms dilatation and the head is fast emerging. Awaiting the arrival of the attending physician, what is the initial action of the nurse? a. support the head while the rest of the body is spontaneously delivered b. push down on the fundus it helps expel the infant c. call the doctor STAT d. deliver the shoulder by turning the presenting part to internal rotation 8. Mrs. Osias is kept informed of the progress of her delivery, after the delivery of the baby, the nurse expects to deliver the placenta. Expected time to deliver the placenta should be: a. 10 -15 mins b. 3 – 10 mins c. 15 -20 mins d. 1 -3 mins 9. Mrs. Pantaleon is experiencing true labor contractions. She describes the discomforts as: a. starting over the fundus, radiating downward to the cervix b. radiating upward and downward from the umbilicus c. localized over the fundus of the uterus d. beginning at the lower back and abdomen radiating over entire abdomen 10. The nurse is preparing the pregnant client for delivery. Care of the client includes positioning the client. The client is expected to assume: a. sims or semi- sitting position b. lying on the side with head elevated c. any position d. lithotomy position 11. The nurse doing vaginal exam on a woman in labor records: 25% cm, -1. The nurse understands it to be: a. fetal presenting part is 1cm above the ischial spines b. cervical dilation is 25% completed

Janice should add to her meals: a. progress of effacement is 5 cm completed d. when lump is detected by self examination 15. The nurse expects Rica’s brachial blood pressure reading is highest when is: a. once a year for women older than 50 years d. bluish cervix b. facial chloasma d. lying on the left side Situation : Regular prenatal check-up is important to assess the progress of pregnancy and to correct abnormalities. Nurse Lisa is doing an assessment of a woman who thinks she is pregnant. 3 weeks d. Mrs. 6 weeks b. supine c. the nurse instructs women to submit regularly for mammogram. fetal heart tones c. 10 weeks 14. Janice. Mrs. is on her fifth monthly prenatal check-up. sitting d. lying on the right side b. the nurse noted that Rica has slightly increased BP.c. Its important to schedule mammogram: a. fetal presenting part is 1cm 12. a pregnant mother attends a nutrition class. When they first become sexually active b. During the last three visits. rice and vegetables b. once on a regular yearly basis c. Lisa is positive that the woman is pregnant if she notes: a. beans and rice d. 16. Janice is placed on a high protein diet. Rapas has just delivered a handsome baby boy. tenderness of the breast . During the mother’s class. 1 week c. fruits and vegetable c. potato and carrots 13. Rapas asks when she resume work? The nurse’s appropriate response is: a. Rica.

assisting the client with pushing ensuring the clients legs are positioned appropriately allowing the client clear liquid d. probable sign 18. 20 ml c. positive sign d. 400ml d. the nurse checks for retained placenta. negative sign b. During one of the health center visits. uterine massage d. d. cloudy with particles b. a pregnant woman asks what to do with complaints of morning sickness. uterine contraction b. c. which of the following actions would be least appropriate? a. dark yellow 20.17. 300ml 19. monitoring fetal heart rate 22. The nurse’s initial response is for the pregnant woman to take: . The nurse is aware that one of the complications of pregnancy is maternal death due to postpartal hemorrhage. During assessment . crystallized ferming pattern d. the client claims she is pregnant because she feels the baby “flattering around”. presumptive sign c. b. What is the nurse’s immediate response for retained placenta? a. 500 ml b. Nurse Annie immediately considers this sign as a: a. When caring for a client during the 2nd stage of labor. the nurse expects these findings: a. When assessing Sharon’s amniotic fluid. administer stimulants 21. vaginal packing c. odorless c. The nurse’s best judgment of postpartal hemorrhage is bleeding of: a. After delivery.

call the physician c. the nurse notes that the respiratory status and expects the respiration to be. bring the newborn to the client d. aspirating mucus from the infants nose and mouth b. full dilatation of the cervix c. rupture of membranes d. side-lying position b. drying the infant to stabilize infant's temperature c. 2 months pregnant for complaints of nocturia. a. While doing assessment. A nurse prepares a 24 hour old newborn for discharge. fowler’s position 24.The first stage of labor begins with a. The nurse is doing an assessment on Josie. supine position d. One day old mother is alarmed when she saw baby holding his breath for a few seconds and seemingly has stopped breathing. Which of the following should be the nurse initial action immediately following the birth of the baby? a. The nurse advised her to slow down on fluids at night. iced tea b. delivery of the baby . irregular in rate and depth d. true labor contractions b. with crackles on auscultation 25. What is the nurse’s initial response? a.a. promoting parenteral bonding d. reassure parents that this is an expected pattern of breathing for a newborn b. identifying the newborn 27. sitting position c. grunting c. it is also best for Josie to assume: a. crackers 23. While in bed. ice milk d. buttered bread c. shallow and regular b. inform the parents to ignore this observation as their baby is healthy 26.

what body structure is responsible for the production of Follicle Stimulating Hormone (FSH) ? The nurse’s responses will likely be. c. explain to the mother that the stool called meconium is characteristic of newborn’s first bowel stools b. d. storage for spermatozoa c. The nurse shows a mother how to change the diaper of her 18-hr old newborn. He seeks consultation at the school clinic. site of spermatogenesis b. The nurse’s appropriate actions is to: a. b. He asks the doctor. The mother then expresses concern about the bowel movement that is dark black-green in color. babies are less exposed to harmful microorganism d. b. their immune system is still undeveloped b. c. The nurse is correct when she says: a. delivery of the baby full dilatation rupture of the membrane true labor contractions 29.28. 32. The second stage of labor begins with a. inform the mother that the stool may harbor parasites d. conduit for spermatozoa . 31. d. submit the stool for occult blood test 30. One of the mothers attending a mother’s class asks why babies are prone to infection. all babies have antibodies from their mothers c. skin of babies are quite intact Situation: Allan is a high school student who wants to know more about the reproductive system. a. inquire if she took iron during pregnancy c. testes hypothalamus anterior pituitary gland kidney Which of the function of vas deferens? a. Another nurse’s responsibility is prevention of disease.

The following are characteristics of normal sperms. storage for spermatozoa conduit for spermatozoa site of spermatozoa production passageway for semen 38. sertoli cells . is synthesized and released by. a. Which one is not included? a. b. c.d. b. b. a. d. The normal volume and sperm content of seminal fluid per ejaculation to be considered fertile is. c. The male hormone testosterone. b. life span is 72 hrs normal count is 60 – 120 million per ml pH is acidic volume per ejaculation in 3-5ml 34. cowper’s gland prostate gland seminal vesicles testes 35. Which part of the testes is responsible in the production of spermatozoa? a. d. passage way for semen 33. seminiferous tubules b. semeniferous tubules sertoli’s cells seminal vesicles leydig’s cells 37. The vas deferens is a. d. a. which maintains spermatogenesis. 1ml/100 million sperm cells 3ml/300 million sperm cells 3ml/30 million sperm cells 1ml/ 20 million sperm cells 36. c. A male gland located behind the bladder that is the source of about 60% of seminal fluid? a. b. c. d. d. c.

b. b. b. c. c. d. In the menstrual cycle. b. a. An adolescent girl asked how much blood is usually lost every menstruation. d. from from from from 2 to 4 tbsp of blood 2 to 4 tsp of blood 20 – 40 tbsp of blood 20 to 40 tsp of blood. c. c. d. progesterone estrogen human chorionic gonadotropin corpus luteum 43. ovaries hypothalamus uterus pituitary gland 41. Which of the following follicles are actively producing hormones? a. cortex d. She is currently discussing the menstrual cycle. fertilization ovulation conception none of these 40. day is the. b. c. Primordial follicles and Graafian follicles Corpus Luteum and corpus albicans Corpus luteum and Graafian follicles Primordial follicle and corpus albicans 41.c. 39. a. Which of the following organs is not involved in hormone secretion? a. leydig cells Situation : Ms. The correct response to this question is: a. d. In counting the days of menstrual cycle. Emma Castillo is giving a lecture on Maternity nursing to a group of graduating nursing students. d. the proliferative phase which is characterized by the growth of endometrium is under the influence of. . The maturation and release of ovum is called. 42.

progesterone withdrawal progestin stimulation estrogen withdrawal estrogen stimulation 48. proliferative phase of the endometrial cycle . c. d. it occurs between ages 11 to 14 it is a sign of puberty all of these it is indicative of sexual maturity 49. b. b. b. d. b. Production of progesterone in a nonpregnant woman is a function of: a. d. d. d. Menstruation is ultimately due to: a. Which of the following regarding menarche is correct? a.a. mittelschmerz spinnbarkheit both of these none of these 45. The follicular phase of the ovarian cycle may be said to be synonymous with: a. thermogenic effect of progesterone intraperitoneal irritation of the released ovum thermogenic effect of estrogen and FSH can be due to infection 46. first day of menstruation last day of menstruation day of ovulation a day before ovulation 44. c. all of these corpus luteum ovum graafian 47. c. The sign of ovulation where the cervical mucus can be stretched 10 to 12 cm is known as: a. c. b. The temperature elevation seen just before or during ovulation is caused by the: a. c. c. b. d.

The nurse should suspect? a. The nurse explains that it is especially needed primarily because it: a. rupture of the uterus d. The nurse should advise intake of: a. . Fetal distress is noted on the monitor. shedding of blood during the menstrual cycle.b. the infant is protected by immunoglobulin in the breast milk b. perform vaginal examination and apply upward digital pressure to the presenting part while having the mother assume a knee-chest position 53. The most appropriate intervention is to: a. . assists in growth of heart and lungs b. B12 c. helps in coagulation of RBC c. precipitate labor b. postovulatory phase of the ovarian cycle c. call the physician immediately b. Vit. The nurse should explain that: a. . 50. During augmentation of labor with IV oxytoxin. amniotic fluid embolus c. place a moist clean towel over the cord to prevent drying c. Vit D d. immediately turn the client on her side and listen to FHR d. Vit. is essential for cell and RBC formation d. secretory phase of the endometrial cycle d. In a nutrition class. uterine prolapse 54. Vit A 51. A mother with mastitis is concerned about breast feeding while she has an active infection. helps in maternal circulation 52. a multiparous client becomes pale and diaphoretic and complains of severe lower abdominal pain with a tearing sensation. . A pregnant woman was advised by the doctor to take folic acid. The nurse discovers a loop of the umbilical cord protruding through the vagina when preparing to perform vaginal examination. the infant is not susceptible to the organism that cause mastitis . Amy a pregnant mother from a sectarian group claims to be on strict vegetarian diet. C b.

apply vitamin E cream to soften nipple b. palpate the fundus daily to make sure it is soft d. bruising 56. oral temp of 99. Upon assessment of postpartal client the nurse observes symptoms of infection. Which of the following interventions is appropriate to help a lactating client prevent mastitis? a. uterine atony d. report any decrease in the amount of brownish red lochia c. the organisms that cause mastitis is not passed in the milk d. lacerations b. heat and swelling d. the organisms will be inactivated by gastric acid 55.2 F 59. Which of the following symptoms indicate infection? a. After the delivery of a large for gestational age infant. local tenderness . muscle soreness in her legs after exercise b. offer the infant a bottle d. retained fragments of conception . Her fundus is firm and located in the midline. Which of the following instruction should be included in the discharge teaching plan to assist the postpartal client early signs of complications? a. varicose veins in her legs c. bradycardia c. hematoma c. abdominal tenderness d.c. What is the most likely cause of the bleeding? a. wear a tight supportive bra c. encourage the client to breastfed her infant frequently 58. when the client’s nipple is sore. pinkish lochia b. notify the health care provider for any increase in the amount of lochia or a return to a bright red bleeding 57. the passage of clots as large as an orange is expected b. a client is noted to have bright red blood continuously tricking from the vagina. Which of the following signs of thrombophlebitis must the nurse educate the postpartal client to assess at home after discharge from the hospital? a.

polyhydramnios . the test will help to determine if your baby is in good position for delivery b. At 24 weeks the doctor notes that her uterus is enlarged to size consistent with her at 24 weeks the doctor notes that her uterus is enlarged to size inconsistent with her estimated twins. occasional nausea and vomiting c. Which of the following. is scheduled for an abdominal ultrasound.60. leucorrhea c. the nurse should tell the client which of the following? a. When explaining the reason for early pregnancy ultrasound. 62. breast tenderness b. Polyhydramnious is also noted. Her chances of having a premature delivery are further increased by: a. the test will help to determine if you have enough amniotic fluid 61. no BM for 3 days d. recurrent vaginal infections d. the test will help to determine if you have an intrauterine growth restriction d. if reported would indicate that the client understood the teaching? a. an excessive weight gain b. gravida 3 para 2 is first seen in the antepartal clinic at 16 weeks gestation. dizziness and blurred vision b. Because of the presence of twins. urinary tract infections 63.vulvar varicosities c. ankle edema Questions 62 – 64 A 35 year old woman. the nurse would expect the patient to have a greater than the usual likelihood of which discomfort of pregnancy? a. The doctor tells the patient that her delivery will probably be slightly premature because this is very common with twins. A client who is in the 1st trimester. varicose veins d. The client’s prenatal education includes danger signs to report. the test will help to determine how many weeks you have been pregnant c.

vaginal bleeding b. She states that she was hospitalized in her seventh month for a bleeding episode. the client has a history of preterm labor at 32 weeks gestation 68. the client is 25 yr old b. A client in the 13th week of pregnancy develops hyperemesis gravidarum.010 b. 65. Which of the following complications of labor would the nurse anticipate because of her polyhydramnios? a. the client was exposed to rubella at 25 weeks gestation d. serum sodium 140 mEq/dl d. Placenta previa c. dystocia d. urine specific gravity of 1. ketones in the urine 67. She does not have any pain associated with the bleeding. Which finding indicates a genetic risk factor? a. a post partum client asks the nurse when she can expect her menstrual period to return. While bottle feeding her neonate. The pastient goes into premature labor at 35 weeks. ineffective uterine contractions c.64. The nurse is reviewing the client’s prenatal history. in 1 – 2 weeks . Upon the patient’s admission to the labor room. decrease in fetal heart rate d. the nurse should plan the interventions on the assumptions that the patient’s diagnosis is most: a. she found herself lying in a pool of blood. the client has a child with cystic fibrosis c. cephalopelvic disproportion Questions 65 – 56 A 28 year old woman is 8 months pregnant. serum potassium level of 4Eq/dl c. Which laboratory finding indicates the need for intervention? a. When she awakened this morning. abruption placenta b.ruptured uterus 66. How should the midwife respond? a.

b. in 3 – 4 weeks c. estimated 40 weeks gestation. copious discharge of clear mucous and prolonged epigastric pain 70. Which of the following would be the priority at this time? a. which of the following actions would be inappropriate during the second stage of labor? a. hyperemesis and weight loss c. A client is 8 weeks pregnant. mother’s needs being met first b. providing comfort measures 71. common discomforts of pregnancy . in 10 – 12 weeks 69. breathing techniques during labor b. assessing for rupture of membrane 73. A client who is being admitted to labor and delivery room has the following assessment findins: gravida 2 para 1. kissing embracing and caring for the child d. placing the client in bed to begin in fetal monitoring b. preparing for immediate delivery c. An early detection of ectopic pregnancy is paramount to preventing a life threatening-rupture. Which teaching topic is most appropriate at this time? a. abdominal pain. talking about the baby 72. vertex +4 station. checking for ruptured membranes d. And a positive pregnancy b. Which symptoms should the nurse to the possibility of an ectopic pregnancy? a. vaginal bleeding. in 7 – 9 weeks d. looking at the infant c. contractions 2 minutes apart. preparing for the delivery of the baby c. assessing vital signs every 15 mins d. amenorrhea and negative pregnancy test d. For a client who is fully dilated. lasting 45 seconds. In the maternal attachment process. positioning the mother for effective pushing b. which of the following best describes an anticipated actions in the taking hold phase? a.

uterine atony b. umbilical cord prolapse 77. the slowing of peristalsis in the GIT d. notify the physician immediately about the gush of fluid from the vagina b. begin when the client learns that she is pregnant and end after delivery d. Weng begins labor close to her expected date of delivery and is admitted to the hospital. complete cervical dilatation c. During an annual check-up a client tells the nurse that she and her husband have decided to start a family . Ideally when should the nurse plan for childbirth education to begin and end? a. After checking the FHR the nurse should: a. begin early in the 3rd trimester and end 1 month after delivery b. begin at 5 months gestation and end at facility discharge 76. offer support by reviewing the short pant form of breathing b. administer a narcotic analgesia per doctor’s order c. placental expulsion d. watch for the rupture of the membrane 75. the nurse should include which of the following as priority care? a. The nurse should explain that constipation frequently occurs during pregnancy because of: a. begin before conception and end 3 months after delivery c. changes in the metabolic rate 78. neonatal nutrition 74. The nurse notices a gush of fluid from the client’s vagina. place the client on her side and obtain her BP .c. During the 4th stage of labor the client should be carefully assessed for: a. Weng complains of constipation. place the client in modified lithotomy position and inspect the perineum c. pressure of the growing uterus on the anus b. increased intake of milk as recommended during pregnancy c. allow the mother to walk around the unit d. infant care responsibilities d. keep the client flat in bed and elevate the legs d. A client who is moving into active phase of labor.

The dark nipples and the dark line from her navel to her pubis. The nurse explains that these adaptations are caused by the hyperactivity of the: a. 80. After several hours of labor the physician orders oxytocin. the placenta is permeable to specific substances c. shut off the IV in the presence of hypertonic contractions and report to the nurse d. Jane complains of morning sickness. progesterone c. request her physician to prescribe her anti-emetic d. take an antacid before bedtime c. luteinizing hormone d. obtain a physician order to slow the IV in the presence of hypertonic contractions b.79. The nurse can help Jane overcome morning sickness by suggesting she: a.84 Jane 2 ½ months pregnant comes to the prenatal clinic for the first time. The nurse’s answer reflects the following knowledge: a. fetal and maternal circulation are separated by the placental barrier b. smoking relieves tension and the fetus responds accordingly d. vasoconstriction will affect both fetal and maternal blood vessels 81. The nurse realizes that a predisposing factor that causes morning sickness during the 1 st trimester of pregnancy is the adaptation to increased level of: a. estrogen b. Jane is concerned about the mask of pregnancy. ovaries d. adrenal gland b. When a client in labor is being infused with oxytocin. pituitary gland 82. chorionic gonadotropin 83. monitor fetal heart tones every 2 hours Questions 80. thyroid gland c. eat dry toasted bread before arising . it is the nurse’s role: a. flush the IV tubing if the flow slows with the staff nurse permission c. Jane asks the clinic nurse how smoking will affect the baby. eat morning until the nausea subsides b.

Which of the following should be the nurse initial action immediately following the birth of the baby? a. aspirating mucus from the infants nose and mouth b. Jane delivers a healthy baby boy. no because the vaccine can be given only during 1st trimester of pregnancy 86. allow Jane time with the baby to cuddle him before she leaves but emphasize that the baby is a minor and legally must remain until orders for discharge are received. When caring for a client during the 2nd stage of labor. and you should consider pregnancy termination because rubella has a teratogenic effect d. c. tell Jane that under the circumstances hospital policy prevents the staff from releasing the infant into her care. c. drying the infant to stabilize infants temperature c. Jane decided to ask for discharge out of the hospital. assisting the client with pushing b. explain to Jane that her infant must remain in the hospital until discharged by the physician. Appropriate action would be: a. ensuring the clients legs are positioned appropriately c. a client who is 5 months pregnant tells the nurse that she was exposed rubella during the past week and asks whether she can be immunized now. No.84. but immunization against rubella requires a physician order b. after receiving a phone call from her babysitter informing her that her 2 yr old has been very upset since her admission to the hospital and not eating. but she will be informed when he is discharged d. How would the nurse respond? a. 85. Staff members have been unable to contact her physician. which of the following actions would be least appropriate? a. yes. yes. give the baby to Jane to take home making sure she receives information regarding care and feeding of a 2 day old infant and any potential problem that may develop. Two days postpartum. because the live viral vaccine is contraindicated during pregnancy. b. allowing the client clear liquid d. promoting parenteral bonding . During her 4th clinic visit. Jane is ready to leave and asks that her infant to be given to her to dress and take home. monitoring fetal heart rate 87.

no associated pain d. absence of external bleeding 89. age 21 is 37 weeks pregnant. The laboratory technician takes blood samples and IV fluids are begun. identifying the newborn Question 88 . visible or concealed hemorrhage b.d. shock c. The nurse is attending with a client with oxygen by mask. She is admitted to the hospital with preeclampsia and sudden abdominal pain. decrease in size uterus. inflammatory reactions c. concealed or external hemorrhage. you are wrong you will have other children c. it is God’s will we have to have faith that it was for the best b. visible bleeding. 9 months pregnant is admitted to the hospital with bleeding caused by possible placenta previa.90 Cathy. concealed hemorrhage 90. since only the physician should explain why treatment are being done . The nurse realizes that the abdominal pain associated with abruption placenta is caused by: a. blood in the uterine muscle d. decrease in size of uterus. the nurse best response to an expression of anger from Cathy would be: a. you maybe wondering if something you did caused this Questions 91 .93 Christine . Cathy delivers a stillborn babygirl. increase in size uterus. cessation of contractions. correct. firm and tender uterus. The nurse statements are: a. The nurse tells her not to worry that she is going to be all right and everything is under control. The client’s apprehension is increasing and she asked the nurse what is happening. hemorrhagic shock b. this is often happens when something is wrong with the baby d. On Cathy’s admission to the unit the nurse should observe for: a. shock. To foster a healthy grieving response to the birth of stillborn child. 88. 91.

Intervention of a women in premature labor includes: a. the nurse should be prepared for an immediate: a. avoiding all extraneous stimuli 93. Normal hemodynamics of pregnancy that affect the pregnant cardiac client include the: a. Shortly after admission. since the client’s anxieties would be increased if she knew the dangers c. decrease in the number of RBC b. 94. Audril goes into labor.95 Audril is 27 yr old. administer sodium IV infusion with the IV nurse d. encouraging ambulation and supervision c. If a vaginal examination is to be performed on Christine. withholding foods and fluids b. position Audril on her side with shoulders elevated b. gradually increasing size of the uterus d. gravida 1 para o with a childhood history of rheumatic fever. x-ray examination Questions 94 . since the client has the right to know what treatment is being given and why 92. inspecting the hemorrhage d. questionable. proper. adequate. rise in cardiac output after the 34th week c. reassuring that the situation is under control .. She has been admitted to the hospital at 35 weeks gestation because of shortness of breath. forceps delivery d.b. To prevent cardiac decompensation during labor the nurse should: a. administer oxytocin to strengthen contractions with doctor’s order 96. cardiac acceleration in the last half of pregnancy 95. d. Care for Christine includes: a. induction of labor b. cesarean section c. since all preparations are routine and need no explanation. maintain an IV infusion of potassium chloride c.

irregular pulse b. notify the surgical team so that an operative delivery can be planned d.b. A woman who is gravida 1 is in the active phase of labor. encouraging her not to bear down d. a small segment of the umbilical cord 100. She is 8cm dilated. To support her during this phase of labor the nurse should: a. keeping her NPO to prevent abdominal distention 97. hypovolemic shock 98. offer her sips of oral fluid d. respiratory distress c. a small amount of greenish fluid d. provide her with warm blanket 99. and scalp ph . a large amount of bloody fluid b. The nurse should observe the client carefully for signs of: a. a moderate amount of clear to straw colored fluid c. assess to determine if the client’s bladder is distended b. send the client for x-ray to determine fetal size c. A woman’s cervix is completely dilated with the head at -2 station. What is the most appropriate initial assessment for the nurse to make? a. increased vaginal bleeding d. the nurse should expect to see: a. During the post partal period it is not uncommon for a new mother to have an increased cardiac output with tachycardia. explaining why pain medication is kept at a minimum c. The fetal position is LOA. including fetal heart tones . offer her back rub during contraction c. The nurse is caring for a woman who is in labor. When the membranes rupture . assess fetal status. leave her alone most of the time b. The head has not descended in the past hour.

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