Final Coaching – Maternal Health Nursing

Melanie Tapnio, RN, MAN

Tricia is a newly registered nurse who is assigned to conduct a lecture on fertility awareness among young
women.
1. Tricia discussed the signs and symptoms of ovulation. Which of the following is NOT included?
a. Weight gain
b. Increased quantity and ph of the cervical secretions
c. Breast tenderness
d. Rise in basal temperature

2. One of the participants asks “when does ovulation take place?”. Tricia’s answer will MOST likely be
_______.
a. At the time her basal body temperature drops steadily.
b. As soon as menstruation stops
c. On the 14th day before the next menstruation
d. On the 4th day of her cycle
3. Melissa, one of the participants, asks how many days is her menstrual cycle if she had her previous
menstrual flow last March 26-30 and her last menstrual period last April 24th. MOST likely, the nurse’s
response will be _______days.
a. 29 c. 28
b. 30 d. 31
4. The function of estrogen hormone is, which of the following?
a. Promotes lactation
b. Inhibit uterine contractility
c. Promotes female secondary sex characteristics
d. Elevates body temperature during ovulation
5. The space of the menstrual cycle that promotes the uterine lining to grow and thicken to an 8-10-fold
rate is, which of the following?
a. Menstruation c. Secretory
b. Proliferative d. Ischemic

Hormone Functions

Nurse Angie is conducting a mothers’ class at barangay Riles Rural Health Unit. One of the participants
asked about contraceptive pills.
6. As part of the teaching plan, Nurse Angie teaches that oral contraceptives contain estrogen. Which of
the following is the ACTION of estrogen? It inhibits the _____.
a. GnRH thereby inhibiting FSH and LH production
b. Luteinizing hormone (LH) thereby inhibiting ovulation
c. Follicle stimulating hormone (FHS) thereby inhibiting maturation of ovum
d. Testosterone production
7. Nurse Angie added that oral contraceptives also contain, progesterone. Which of the following is the
action of progesterone in contraception? It inhibits _______.
a. Follicle stimulating hormone (FSH) thereby inhibiting maturation of ovum
b. Testosterone production
c. Luteinizing hormone (LH) thereby inhibiting ovulation
d. GnRH thereby inhibiting FSH and LH production
8. Nurse Angie included that contraceptives that have estrogen-like and /or progesterone-like
compounds are prepared in a variety of forms. These are the following ______.
1. Oral contraceptive 4. Foam spermicides

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 2. Diaphragms 5. Norplant
3. Cervical caps 6. Intrauterine devise
a. 1, 4, 6 c. 1, 5, 6
b. 3, 5, 6 d. 2, 3, 5
9. A biphasic anti-ovulatory medication of combined progestin and estrogen is prescribed for a female
patient. What should the nurse include when teaching about this oral contraceptive?
a. Have bi-monthly Pap smears. c. Increase the intake of calcium.
b. Report any irregular vaginal bleeding d. Restrict sexual activity temporarily.
10. Which danger sign would warrant stoppage of pills?
a. Elevation of blood pressure c. Simple colds
b. Clear vision d. Decrease blood pressure

Patient Edraline, 29 years old, visit the OB clinic accompanied by her husband Victor for a pregnancy test.
The nurse in the clinic took her history which says that Edraline missed her periods for three (3) weeks.
11. Which of the following is the PRIMARY purpose of pregnancy test?
a. It enables the husband to follow the desires of the wife.
b. It allows for counseling on nutrition.
c. It allows for early initiation of care.
d. It may help in a decision to stop working at home.

12. Human chorionic gonadotropin (Hcg), the biologic marker on which pregnancy tests are based, can
be detected in the BLOOD as early as which number of DAYS after the last menstrual period?
a. 20 c. 15
b. 5 d. 10
13. What is the BEST urine sample to be used for an accurate result of pregnancy test done at home?
a. First-voided evening urine c. First-voided morning urine
b. Mid-afternoon urine sample d. Random urine sample
14. Which of the following is NOT included among the factors that should be considered by the nurse or
the pregnant woman in interpreting results of pregnancy test?
a. Type of pregnancy test c. Last menstrual period
b. Menstrual cycle length d. Previous pregnancy
15. Which of the following medications may produce a false-negative pregnancy result?
a. Anticonvulsants c. Tranquilizers
b. Anti-hypertensive d. Diuretics

16. A client at 8 months gestation is diagnosed with oligohydramnios. She asks the nurse if this can harm the
fetus. The nurse’s best response is:
A. “Yes, oligohydramnios can lead to umbilical cord compression.”
B. “Yes, it means the fetus swallowed too much fluid.”
C. “No, this commonly occurs toward the end of pregnancy.”
D. “No, this is a sign that the lungs are maturing.”

17. A fetus is able to maintain blood circulation in utero by the presence of circulatory shunts. The ductus
arteriosus in utero shunts blood from
A. the left to right heart atria.
B. the umbilical vein and inferior venal cave.
C. the right ventricle to the aorta.
D. the pulmonary artery to the aorta.

18. Jackielyn’s prenatal antibody titer shows that she is not immune to rubella and will receive the
immunization after delivery. You would include which of the following instructions in your teaching plan?
A. Breastfeeding should be postponed for 5 days after the injection
B. Another immunization should be administered in the next pregnancy
C. Pregnancy must be avoided for the next 3 months
D. An injection will be needed after each succeeding pregnancy
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19. Because of some reasons which Mrs. Frana refuse to reveal to the nurse, she expresses her concerns
of some infections that might affect her baby through the placenta. The nurse clarified the causative
agent that could pass through the placenta to her baby would be___
A. Moniliasis C. HIV
B. Gonorrhea D. candidiasis
SITUATION You are conducting a mother’s class at the Barangay Health Station and the participants are in
varying periods of pregnancy. After the class session, the mothers started asking more information from you.
20. At 36 weeks gestation, Nina tells the nurse that she has been experiencing shortness of breath. Which of
the following suggestions would be most helpful?
A. Warm shower before sleeping C. Sleep with extra pillows
B. Empty bladder regularly D. Avoid gas producing food

21. The nurse was able to determine that the mothers were able to understand her instructions when they
stated that they would call the nurse immediately to report which of the following symptoms?
a. Abdominal pain
b. On and off painless contractions
c. Whitish vaginal discharge
d. Swelling of the ankles every night

22. An understanding of physiologic adaptations to pregnancy is important. The following changes in

pregnancy are important to keep in mind in order to address client’s needs EXCEPT:
A. Cardiac output increases by 25% to 50 % during pregnancy
B. The posterior pituitary gland secretes oxytocin late in pregnancy
C. The temperature decrease slightly early in pregnancy
D. The circulating fibrinogen level decreases as much as 50% during pregnancy

23. Which statement by a client indicates that further teaching about nausea and vomiting of pregnancy
needs to be done by the nurse?
a. “I need to drink an extra glass of water with every meal.”
b. “I hope that taking a nap when I get home from work makes me feel better.”
c. “I will ask my husband not to wear aftershave because it upsets my stomach.”
d. “I will try to eat at five of six smaller meals during the day.”

24. Which change in the cardiac system is NOT expected during pregnancy is increased?
a. Blood volume C. cardiac load
b. Fibrinogen level in the blood D. pulse rate and blood pressure

25. During a childbirth preparation class, a primigravid client at 36 weeks' gestation tells the nurse, "My lower
back has really been bothering me lately." Which of the following exercises suggested by the nurse would
be most helpful?
A. Pelvic rocking. C. Tailor sitting.
B. Deep breathing. D. Squatting.

tailor sitting squatting

Normal signs Danger signs

26. Amanda is now 16 weeks pregnant. If the pregnancy is progressing as expected, where would the
practitioner find the uterine fundus?
a. Halfway between the pubic bone and the umbilicus.
b. Just above the pubic bone
c. The uterine fundus would not be palpable at 16 weeks
d. At the umbilicus

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27. You are teaching Amanda about proper diet during pregnancy. If Amanda understands your instructions,
how will she reply when you ask her approximately how many more calories per day she needs now that
she is pregnant?
a. “I should not increase my calories while I’m pregnant.”
b. “About 300”
c. “I need to double my calories because I’m eating for two.”
d. “Approximately 500”

28. A twenty-year-old client visits Nurse Jojie at her Nursing Prenatal Clinic because she suspects that she is
pregnant. She tells Nurse Jojie that she missed one menstrual period and that she experienced nausea
and vomiting, urinary frequency, and fatigue. Based on her assessment, Nurse Jojie suspects that her
client has signs of pregnancy categorized as which of the following?
a. Positive C. Probable
b. Predictive D. Presumptive

29. When performing Leopold’s Maneuver to a “primigravida” client, Nurse Jojie is aware that to make her
client more comfortable during the procedure, she should prepare the client by asking her to:
a. Avoid eating immediately before the examination.
b. Hyperventilate for a short time before beginning the procedure.
c. Empty her bladder prior to the procedure.
d. Lie on her left side during the procedure.

30. While doing Leopold’s Maneuver on a client, nurse Jojie notes the presence of a firm round prominence
over the pubic symphysis, a smooth convex structure down her right side, and irregular lump down her
left side, and soft roundness in the fundus. Nurse Jojie here should conclude that the fetal position is:
a. LOP (left occiput anterior) C. RSA (right shoulder anterior)
b. ROA (right occiput anterior) D. LOA (left occiput anterior)

31. A client, about 8 weeks pregnant, asks the nurse when she will be able to hear the fetal heartbeat. The
nurse would respond by telling the client that the fetal heartbeat can be heard with a Doppler ultrasound
device when the gestation is as early as which of the following?
A. 8 weeks C. 15 weeks.
B. 4 weeks D. 18 weeks.

32. Which of the following signs should the nurse expect to find during physical assessment of primigravida
her 8th week gestation?
A. Ballottement C. Palpation of fetal outline
B. Quickening D. Hegar’s sign

33. During the first clinic visit, the client reports that her last menstrual period (LMP) began on September 12,
based on Nagel’s rule, what is the client’s estimated date of delivery (EDD)?
A. June 1 C. July 10
B. June 19 D. July 29

34. The nurse is performing assessment of pregnant client who is 28 weeks of gestation. The nurse
measures the fundal height in centimeters and expects which finding?
a. 22 cm C. 36 cm
b. 30 cm D. 40 cm

35. Based from obstetrical history taken by Nurse Jill, Michelle 21 years old had her first pregnancy at age
19, which ended up in abortion at 21 weeks. Her second pregnancy was to identical twins. Her third
pregnancy was delivered at 38 weeks. Which of the statements below CORRECTLY applies, given this
obstetrical history of Michelle?

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 a. Since there has been a twin, Michelle is G5P4
b. Since there was an abortion, Michelle is G3P3
c. Michelle is Gravida 4 Para 3 (G4P3)
d. Michelle is Gravida 3 Para 2 (G3P2)
G
T
P
A
L
M

36. Nurse Betty is assisting in performing an assessment on a pregnant client Nor during her first
prenatal visit. She is 23 weeks pregnant for second child. Her first pregnancy is a preterm delivered
by 36 weeks. Which of the following shows PROPER documentation by Nurse Betty of the patient’s
obstetrical history?
a. Gravida 2, Term 0, Preterm 1, Abortion 0, Living 1
b. Gravida 2, Term 0, Preterm 2, Abortion 0, Living 2
c. Gravida 2, Term 1, Preterm 1, Abortion 1, Living 1
d. Gravida 1, Term 1, Preterm 0, Abortion 1, Living 2
37. A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should do which
of the following?
a. Ask her to void C. prepare her for I.V. anesthesia
b. Instruct her to drink 1 L of fluid D. place her on her left side

38. A desire for which of the following diagnostic tests would be most important to ascertain for a primigravid
client in the second trimester of her pregnancy?
A. a-Fetoprotein (AFP) testing. C. Chorionic villus sampling

B. Culdocentesis to detect abnormalities. D. Ultrasound testing.

39. A nonstress test is performed on a client who is pregnant and the results of the test indicate a reactive
findings. The physician orders a contraction stress test to be done and the results are documented as
negative. The nurse interprets this finding as indicating:
a. An abnormal test result
b. A normal test result
c. A high risk for fetal demise
d. The need for a cesarean delivery
40. Which of the following is true in describing contraction stress test?
a. The mother will experience severe pain during contractions due to oxytocin administration
b. Testing usually lasts for 1 hour
c. If the mother is not having contractions, she will be asked to rub one of her nipples for a brief
time
d. The test should be done with a full bladder

41. Which sign would likely indicate fetal distress?

a. FHR of 140 beats/minute
b. Short-term variability of 7 beats/minute
c. Early deceleration
d. Severe variable decelerations

42. In Biophysical profile, the following are observed, except:

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 A. Fetal movement
B. Fetal muscle tone
C. Contraction
D. Amniotic fluid
43. Rhoda asks why she could not feel fetal movements all the time. Your most appropriate response is that
fetal movements:
A. Decrease as the mother’s activity decreases. C. Increase if mother drinks alcohol.
B. Decrease as the mother nears her term. D. Are usually not present during the
fetal sleep cycle.

44. Which of the following nursing actions would take priority when caring for the woman with a suspected
ectopic pregnancy?
A. Administering oxygen C. Obtaining surgical consent
B. Monitoring vital signs D. Providing emotional support

45. The nurse is monitoring the patient who is experiencing an ectopic pregnancy. She notes that vaginal
bleeding is scanty while the patient is showing signs of hypovolemic shock. She evaluates that:
a. Shock signs are misleading in this case
b. Infection could cause signs of shock
c. Level of pain is causing signs of shock
d. Bleeding into the pelvic cavity is occurring

46. A client at 10 weeks gestation comes to the prenatal clinic because she is having some dark brown
vaginal spotting and is experiencing severe nausea and vomiting. What condition does these symptoms
suggest?
a. Gestational trophoblastic disease c. Placenta previa
b. Hyperemesis gravidarum d. Pregnancy-induced psychosis

47. A client is admitted to the hospital because of vaginal staining and without pain. Her obstetrical history
reveals amenorrhea for the last two months and pregnancy confirmation after her first missed period. A
few hours after admission, the client begins to experience bearing-down sensations and expels the
products of conception in bed. What should the nurse do FIRST?
a. Notify the midwife of the hospital
b. Administer a sedative according to physician’s order
c. Check the client’s fundus for firmness
d. Transport her to the delivery room

48. The client asks, “What is the cause of abortion?” The MOST appropriate response of the nurse is that it
is due to___
a. Unresolved stress C. congenital defects
b. Physical trauma D. embryonic defects

49. Which is the number ONE microorganism that is responsible for infection for infection after miscarriage?
a. Escherichia coli C. streptococcus
b. Staphylococcus D. pneumococcus

50. What is the MOST likely tentative diagnosis?

a. Threatened abortion C. missed abortion
b. Incomplete abortion D. inevitable abortion

51. What is the MOST important advice that the nurse should give the client? It is on the risk of _____
a. Massive bleeding C. ectopic pregnancy
b. Rupture of membranes D. infection

52. A client at 16 weeks gestation was diagnosed of premature dilatation of cervix due to a structural defect
of her cervix. The following are the recommended treatment for this condition. Select all that apply:
1. Bed rest
2. Permanent cerclage is Mcdonald’s
3. After shirodkar procedure delivery is NSD
4. Permanent cerclage is Shirodkar
5. Avoid heavy lifting
A. 1, 2, 3, 4 B. 1, 2, 3, 4, 5 C. 1, 4, 5 D. 2, 3, 4, 5

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53. A nurse is teaching a client who’s 28 weeks pregnant and has gestational diabetes how to control her
blood glucose levels. Diet therapy alone has been unsuccessful in controlling this client’s blood glucose
levels, so she has started insulin therapy. The nurse should consider the teaching effective when the
client says:
a. “I won’t use insulin if I’m sick.”
b. “I need to use insulin each day.”
c. “If I give myself an insulin injection, I don’t need to watch what I eat.”
d. “I’ll monitor my blood glucose levels twice a week.”

54. A diabetic mother named Maffie plans to breastfeed her baby. You explained that, if Maffie is
hyperglycemic,
A. The production of milk maybe impaired C. Her baby will receive insulin in the milk
B. The baby will not grow well D. The glucose content of her milk may be
high

55. The nurse is caring for a primiparous client and her neonate immediately after delivery. The neonate was
born at 41 weeks' gestation and weighs 4082 g (9 pounds). Signs and symptoms of which of the following
would be a priority assessment in the neonate?
A. Hypoglycemia C. Anemia
B. Delayed meconium D. Elevated bilirubin
56. At 32 weeks gestation, patient Ana, 16 year old primigravid, 5 feet tall gained a total of 20 pounds, with a
one pound gain in the last 2 weeks. Urinalysis reveal negative for glucose and a trace of protein. She
came to the clinic for consultation. Which will BEST describe Ana risk for preeclampsia
a. Proteinuria C. total weight gain
b. Short stature D. adolescent age group

57. A primigravid client at 37 weeks' gestation who has been diagnosed with pregnancy-induced
hypertension is to be admitted to the labor and delivery area. Which of the following client care rooms
would the nurse determine to be most appropriate for this client?
A. A darkened private room as close to the nurse's station as possible
B. A brightly lit private room at the end of the hall from the nurse's station
C. A semiprivate room midway down the hall from the nurse's station
D. A private room with many windows that is near the operating room

58. The pregnant woman was brought to the labor room for magnesium sulfate medication. The primary
purpose for its administration is to _____
a. Increase the central nervous system response to stimuli
b. Increase calcium absorption by the muscles
c. Decrease neuromuscular irritability
d. Reduce peripheral vascular resistance to lower blood pressure

59. 16-year-old primigravid client admitted at 38 weeks' gestation with severe pregnancy-induced
hypertension is given intravenous magnesium sulfate and lactated Ringer's solution. Which of the
following would the nurse expect to assess?
A. Blood pressure every 6 hours

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 B. Urinary output every 8 hours
C. Deep tendon reflexes every shift
D. Respiratory rate every hour

60. The client, a multigravida in her 39th week of gestation, is diagnosed with PIH and HELLP syndrome. The
nurse’s top priority is to assess the client’s:
A. WBC C. Plasma levels
B. Blood glucose levels D. Platelet count

61. The nurse might suspect early preeclampsia if the patient complains
a. “I am bleeding very heavily”
b. “I got dizzy and had to lie down”
c. I get very depressed and cry easily”
d. “I can’t wear my wedding ring anymore”

Situation: Mrs. M, 24 years old client, Gravida three ( 3 ) , Para one ( 1 ) , 32 weeks gestation, is admitted to
the
hospital because of vaginal bleeding
62. After reviewing Mrs. M obstetrical history, which of the following factors might lead the nurse to suspect
abruption
placenta?
A. History of cocaine
B. one induced abortion
C. several hypotension episodes
D. previous low transverse caesarean section

63. Abruptio placenta threatened fetal well being primarily because it _____
A. increases intrauterine pressure
B. increases the risk of umbilical cord prolapse
C. decreases the number of placental oxygen exchange sites
D. decreases uterine tone

64. On which understanding of the pathology of placenta previa will the nurse base her appropriate
intervention? Placenta
previa is ______
A. Premature separation of the normally implanted placenta from the uterine wall
B. trauma on the umbilical cord causing hemorrhage
C. tearing away from the cervical os that results in fetal hemorrhage
D. rupturing of membranes along the uterine wall

65. Disseminated intravascular coagulation (DIC) is the possible complication of abruptio placenta. Which
assessment
finding would indicate that Mrs. M has developed DIC.
A. Joint pain
B. increased central venous pressure
C. rapid clotting of venipuncture sites
D. bleeding of the nose and gums

66. When caring for Mrs. M which of the following would the nurse anticipate to administer intravenously if
she develops
disseminated intravascular coagulation (DIC)?
A. 5% dextrose solution
B. Ringer’s lactate solution
C. Fresh frozen platelets
D. Warfarin sodium (Coumadin)

PLACENTA PREVIA ABRUPTIO PLACENTA

67. A client with a known placenta previa is admitted at 30 weeks with painless vaginal bleeding. The nurse
weighs the client’s peri-pads to monitor blood loss. An increased weight of 50 g would indicate
approximately how much blood loss?
a. 0.5 mL B. 50 ml C. 5 mL D. 500 mL

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68. The nurse caring for a patient in pre-term labor may exhibit which of the following side effects when
administered intravenous terbutaline sulfate (Brethine)?
a. uterine hypertonia C. epistaxis
b. tachycardia d. dysuria

Drug Indication Side effect/complication Nursing intervention

69. The client’s vaginal examination reveals: 3 centimeters dilated, 80 percent effaced, vertex at a – 1 station.
The woman is talkative and appears excited. The nurse determines the client to be in which stage and
phase of labor?
a. First stage, latent phase c. Second stage, latent phase
b. First stage, active phase d. Third stage, transition phase

70. Mrs. True labor is differentiated from false labor because in true labor contractions will _______
a. Be relieved in the side lying position
b. Bring about progressive cervical dilatation
c. Not stop when the client is encouraged to walk
d. Occur immediately after rupture of membranes

TRUE LABOR FALSE LABOR

Situation 3 – Patient Haydee, 23 years old, G2 P1 and is in her 9th month of pregnancy. First, she calls the
hospital to receive validation that it is alright for her to come for evaluation or admission.
71. During the first contact of the patient with the nurse, the latter should demonstrate the following
behavior, with the EXCEPTION of _________.
a. Encouraging c. Compelling
b. Caring d. Comforting
72. Patient Haydee asks how she could distinguish between true and false labor? which is NOT
INCLUDED among the factors in which the nurse should base her answer from?
a. Engagement of fetus c. Contractions
b. Vital signs d. Cervix by vaginal examination
73. Patient Haydee comes to the perinatal unit of Hospital Dee. Nurse Arcee does a through
SCREENING assessment. Which is the LEAST screening assessment to be used by the nurse?
a. Physical examination c. Radiologic procedures
b. Laboratory review d. Interview
74. During admission, the nurse needs to take the patient’s obstetrical data. Which of the following the
MOST important?
a. Prenatal check-up records c. Previous pregnancy experience
b. Diagnostic test results d. Laboratory results
75. Every pregnant woman preparing for labor and delivery have a birth plan. What is the PRIMARY
objective of a birth plan? It describes _______.
a. The cultural and religious requirement related to care of mother, newborn

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 b. Her psychosocial data that is necessary in her hospitalization
c. The repertoire of comfort and relaxation measures
d. Options on her wishes and preferences about her labor, delivery and puerperium

76. The nurse determines teaching has been effective when a client with a fetus in a frank breech position
says, “My baby’s hips are:
a. “Flexed and the knees are flexed.” C. “Extended and the knees are flexed.”
b. “Flexed and the knees are extended.” D. “Extended and the knees are
extended.”

77. Several factors affect labor. Which of the following factors refers to the passageway?
a. Size of the fetal head and its ability to mold to the maternal pelvis.
b. The presentation of the fetus in correction to the maternal pelvis.
c. Structure of the maternal pelvis.
d. The fetal attitude and the relationship of the fetal parts to one another.

78. The nurse understands that the woman in labor needs more support and encouragement during the
PEAK and MOST painful phase of uterine contractions, which is called____
a. Decrescendo C. increment
b. Decrement D. acme

79. Betty asks the nurse what station – 1 means. Which of the following statement of the nurse id correct?
a. “The presentation part of the fetus is 1 cm above the ischial spines.”
b. “The presentation part of the fetus is 1 cm below the ischial spines.”
c. “The head of the baby of near the outlet.”
d. “The buttock of the baby is at the level of the ischial spines.”

80. Before the INITIAL vaginal examination commonly referred to as internal examination, what must the
nurse check FIRST?
a. Blood pressure for hypotension
b. Heart rate of mother for chest compression
c. Abdominal palpation for signs of fetal distress
d. Abdominal palpation for fetal lie and position and fetal heart tone

81. The occurrence of which of the following conditions would warrant the nurse discontinuing Mrs. Olga’s IV
infusion of oxytocin?
a. Increase in show.
b. Rupture of the membranes.
c. Tetanic uterine contractions.
d. Fetal heart rate of 120 during a contraction.

82. Amor, 35 years old and 36 weeks pregnant, G1P0, goes to the hospital reporting a feeling of “wanting to
push”, lower back pains, abdominal cramps and passage of mucous with some blood. With the
presenting symptoms of the client, Nurse Elsa suspects that the client is having:
a. Spontaneous abortion C. Abruptio placenta
b. Preterm labor D. Threatened abortion

83. After the premature rupture of membranes without uterine contractions, what should be the priority
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 assessment?
a. Red blood cell count c. Urinary output
b. Degree of discomfort d. Temperature

84. The nurse discovers a loop of the umbilical cord protruding through the vagina when preparing to perform
a vaginal examination. The most appropriate intervention is to:
a. Call the physician immediately.
b. Place a moist clean towel over the cord to prevent drying.
c. Immediately turn the client on her side and listen to the fetal heart rate.
d. Relieve pressure from the cord by letting the mother assume knee-chest position.

85. During the fourth stage of labor, if the nurse feels that mother’s fundus is not well contracted and is
shifted to the right she should realize that this is due mainly to:
A. A solid mass C. a full bladder
B. a clotted blood D. retained placental fragment

86. What nursing action must she take?

A. Ignore the condition
B. Notify the doctor so it would not worsen
C. Massage fundus and/or express blood clots
D. Encourage mother to void

87. The nurse assesses Lydia after delivery. What data would suggest that Lydia is at increased risk for
hemorrhage?
A. Infant birth weight of 7 lbs 11 oz (3487 g) C. 8 hours length of labor
B. Gravid 7 Para 5 D. History of gestational diabetes

88. A client has a temperature of 100.2 oF 4 hours after delivery. What is the appropriate action for the nurse
to take?
a. Encourage increased fluid intake.
b. Do nothing since this is an expected finding at this time.
c. Check the physician’s order for an antibiotic to treat the client’s infection.
d. Medicate the client for pain.
VS Postpartum

89. Which laboratory finding should the nurse assess further in a client 24 hours after delivery?
a. Hemoglobin 7.2 g/dL
b. White blood cell count 20,000/mm3
c. Trace to 1+ proteinuria

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 d. Hematocrit 35%

90. A client is to be discharged 12 hours after delivery. The nurse should delay the discharge and notify the
physician if which of the following is observed?
a. Moderate lochia rubra c. Fundus firm at umbilicus
b. Pulse 62 beats per minute d. Three voidings totalling 240 cc in 12
hours.

91. When palpating for fundal height on a postpartal woman, which technique is preferable?
a. Placing one hand at the base of the uterus, one on the fundus.
b. Placing one hand on the fundus, one on the perineum.
c. Resting both hands on the fundus.
d. Palpating the fundus with only fingertip pressure.

92. Which of the following finding would make Nurse Edna think that Pamela is developing a postpartum
complication?
a. Lochia appearing brown on the third day
b. Red-colored lochia for the first 24 hours
c. Lochia that is the color of menstrual blood
d. An absence of lochia

93. Another postpartum woman had post-partum bleeding. Which areas would the nurse need to assess
before the woman ambulates?
a. Height, level of orientation, support system
b. Degree of responsiveness, respiratory rate, fundus location
c. Blood pressure, pulse, complaints of dizziness
d. Attachment, lochia color, complete blood cell count
94. A postpartal woman calls you into her room because she is having a very heavy lochia flow containing
large clots. Your first action would be to
a. assess her blood pressure. C. palpate her fundus.
b. have her turn to her left side. D. assess her perineum.

95. Suppose a postpartal woman has a retained placental fragment that is causing extensive postpartal
bleeding. What hormone test would you anticipate being ordered to detect whether placenta is still
present?
A. Placental and cord blood estrogen. C. Progesterone from the placenta.
B. Human chorionic gonadotropin hormone. D. Systemic prolactin (a pituitary hormone).

Aira, student, 18 years old, primigravida, delivered to a baby boy forty hours ago. Transition from being
single to being a mother entails strengths and courage. The response to change may be different for every
person.
96. The patient has been seen crying and irritable. As her nurse, you know that Aira is experiencing
“baby blues”. Which is the BEST description of her condition? It is a condition in which the patient
experiences some feelings of ______.
a. Excitement c. Sadness
b. Euphoria d. Anxiety
97. Which of the following is TRUE about baby blues? It is ________.
a. A condition that begins 6 to 12 months post-partum
b. Related to childhood poverty
c. A serious condition that would warrant antidepressant therapy
d. Related to hormonal changes
98. In planning to help Aira, the nurse has explained to her on the cause of baby blues, which ONE is
these?
a. Status quo in estrogen and progesterone.
b. Total decrease in estrogen and progesterone.
c. Total increase in estrogen and progesterone.
d. Increase or decrease on the levels of estrogen and progesterone.
99. As nurse, you should know the manifestations that Aira can present anytime. These are the
following:
1. Crying 4. Isolation
2. Anorexia 5. Disturbed
3. Feeling of inadequacy 6. Mood swings
a. 1, 2, 3, 5, 6 c. 2, 3, 4, 5
b. 3, 4, 5, 6 d. 2, 3, 4, 5, 6

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100. Which of the following nursing measures can help Aira in her condition?
a. Psychotherapy c. Counseling
b. Support d. Mild anti-depressant

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