Ob Drills With Ratio Edited BL

WOMEN’S HEALTH AND OBSTETRIC NURSING
ANTEPARTUM
SITUATION: From the time just before conception, and then for the following 10 lunar months, the woman’s
body undergoes many complex alterations that prepare her to nurture a new life.
1. Amanda comes to the clinic for a check-up. She suspects that she might be pregnant since her menstrual cycle
has always been regular and she’s 5 days delayed now. Knowing this, which diagnostic test is appropriate to yield
a reliable result?
a. Immunologic Test (Urinalysis)
b. Hormone Level Analysis
c. Radio-immunoassay Test
d. Either A and C can be used since they both analyze HCG levels present early in pregnancy
ANSWER: C
This test analyses serum HCG levels. Radioimmunoassay is 100% reliable even if the woman is delayed by only
one day. Trace amounts of HCG appear in the serum as early as 24 hours to 48 hours after implantation. They
reach measurable level (about 50 mIU/ml) 7 to 9 days after conception. Levels peak at about 100mIU/ml
between 60th and 80th day of gestation.
Urine, formerly used extensively for pregnancy testing, is now used only rarely in health care setting, because
blood serum tests given earlier results. Urine testing for HCG is more reliable at a later time about 10 or more
days without menstruation.
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition. Page 222-223.
2. Amenorrhea in pregnancy occurs due to the rising levels of which of the following hormones?
a. Estrogen
b. HCG
c. FSH
d. Progesterone
ANSWER: A
The rising level of estrogen causes the suppression of follicle stimulating hormone. This is the reason for the
absence of menstruation or amenorrhea during pregnancy. Progesterone as well rises during pregnancy but has
no direct causation to amenorrhea and is contributory to the ovarian, breast, and other systemic changes in
pregnancy.
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition. Page 227.
3. Psychological adjustment to pregnancy includes working through developmental tasks. Which of the following
statements would make you believe a woman is doing this?
a. “My mother and I are closer than ever before.”
b. “I don't care what sex baby I have as long as it's healthy.”
c. “I'm thinking about everything I eat these days.”
d. “There are a lot of allergies in my husband's family.”
ANSWER: A
A developmental task for a woman during pregnancy is to review and restructure her relationship with her
mother.
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition.
4. Which of the following tasks is the most important task of the first trimester of pregnancy?
a. Accepting the pregnancy.
c. Making plans for the baby.
b. Accepting a coming child.
d. Sharing time with a significant other.
ANSWER: A
Before a fetus moves, adjusting to pregnancy is a primary task; later, adjusting to having a baby becomes the
primary task.
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition.
5. Respiratory changes occur during the early stage of pregnancy. One of the changes is a decrease partial
carbon dioxide to about 27 to 32 mm Hg. Which of the following statements best explain the cause of this
decrease?
a. It occurs as a result of hyperventilation to blow off excess CO2
b. The decreased of PCO2 is caused by increase progesterone level during pregnancy setting new level of
acceptable carbon dioxide
c. Occurs due to decrease residual volume by the pressure exerted by the diaphragm
d. None of these
ANSWER: B
The increased level of progesterone during pregnancy appears to set a new level in the hypothalamus for
acceptable blood carbon dioxide levels (PCO2) because during pregnancy, a woman’s body tends to maintain a
PCO2 at closer to 32 mm Hg than the normal 40 mm Hg. This low PCO2 level causes a favorable CO2 gradient at
the placenta (the fetal CO2 level is higher than that in the mother, allowing CO2 to cross readily from the fetus to
the mother
Option A- is the adaptation to keep the mother’s pH level from becoming acid due to the load of CO2 being
shifted to her by the fetus, increase ventilation (mild hyperventilation) to blow off excess CO2 begins early in
pregnancy. This increased ventilation may become so extreme that the woman develops a respiratory alkalosis.
To compensate, kidneys excrete plasma bicarbonate in urine. This results in increased urination or polyuria, an
early sign of pregnancy.
Decrease of the residual volume of 20% due to pressure of the diaphragm is the caused of the shortness of
breath that the woman experienced during the last trimester, and relieve after lightening occurs
6. Nurse Tintin is an obstetric nurse in R. Papa Maternity Clinic. She is aware of the expected changes in a
pregnant client’s vital signs. Who among the following patients will be reported immediately to the physician?
a. Mrs. Sus, 24-week of gestation has 5 mm Hg decrease in her systolic blood pressure
b. Mrs. Meh, 14-weeks of gestation with a temperature of 99.6 degree Fahrenheit
c. Mrs. Aru, 28- weeks of gestation who has an increased in respiratory rate of about 2 to 3 per minute
d. Mrs. Jasku, 36-weeks of gestation with prepregnant blood pressure
ANSWER: C
Respiratory changes during pregnancy include an increase in the respiratory rate of 1 to 2 per minute due to the
pressure of the gravid uterus. Option A: In most women, blood pressure actually decreases slightly during the
second trimester because the peripheral resistance to circulation is lowered as the placenta expands rapidly.
Option B: Early in pregnancy, body temperature increases slightly because of the secretion of progesterone from
the corpus luteum (the temperature, which increased at ovulation, remains elevated). As the placenta takes over
the function of the corpus luteum at about 16 weeks, the temperature usually decreases to normal. Option D:
During the third trimester, the blood pressure rise again to first trimester level
7. Early in pregnancy, frequent urination results mainly from which of the following?
a. Pressure on the bladder from the uterus.
c. Addition of fetal urine to maternal urine.
b. Increased concentration of urine.
d. Decreased glomerular selectivity.
ANSWER: A
Early in pregnancy, the expanding uterus presses on the bladder. Later, it rises above the bladder so that
pressure is relieved.
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition. Page
8. Which of the following would you advise a woman about breast self-examination during pregnancy?
a. There is no reason to continue this during pregnancy.
b. Self-exams are nonproductive during pregnancy.
c. She should choose a date each month to do this.
d. She should do it weekly, because she no longer has menstrual periods.
ANSWER: C
Nonpregnant women use their menstrual period as a reminder to do a self-exam. Without this reminder,
pregnant women need to use another system, such as a certain day each month.
9. In light of the high incidence of some illnesses in women, which of the following questions is most important to
include in a review of systems for a pregnant woman?
a. “Have you ever had a heart attack?”
c. “Have you had any urinary tract infections?”
b. “Do you have a peptic ulcer?”
d. “Have you had any neurologic diseases?”
ANSWER: C
Urinary tract infections occur at a greater incidence in pregnant women than in others because stasis of urine
results from pressure on the ureters; the trace of glucose often present in urine helps bacteria grow.
10. A pregnant mother gained 3 pounds during the 1st trimester and gained 2 pounds per week on her 2nd
trimester. Which of the following statements is correct?
a. The pregnant mother’s weight gain is what is normally expected during pregnancy
b. The normal weight gain during the 2nd trimester would be 10 to 12 pounds
c. The pregnant mother is gaining more weight than what is normal
d. Both B and C
ANSWER: D
Weight gain in pregnancy occurs from both fetal growth and accumulation of maternal stores and occurs at
approximately 0.4kg (1 lb) per month during the first trimester and then 0.4kg (1 lb) per week during the last
two trimesters (a trimester pattern of 3-12-12). As a general rule, in the average woman, weight gain is
considered excessive if it is more than 3 kg (6.6 lb) a month during the second and third trimester.
The pregnant mother is gaining more weight than what is normal since she is gaining 2 pounds every week for 3
months exceeding the total normal weight gain of 10 to 12 pounds (1 pound every week) in the 2nd trimester.
11. A woman has come to the clinic for her first prenatal visit. Which of the following would be the most effective
way to initiate data gathering for a health history?
a. Ask her to complete a written questionnaire concerning her past and present status.
b. Conduct an interview in a private room to obtain her health history.
c. Wait until she is in the examining room and prepared for her physical examination.
d. Ask her some basic questions in the waiting room before taking her to the examining room.
ANSWER: B
Health interviewing is always conducted best in a quiet, private setting before examination procedures begin.
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition
12. A client who smokes asks what effect tobacco might have on her baby. Which response would be best?
a. "Evidence supports a negative effect of smoking on the baby."
b. "Increasing your calories may offset the effects of the tobacco."
c. "Smoking is safe if you limit tobacco use to one pack a day."
d. "Smoking may cause the baby to have brain damage from decreased oxygen."
ANSWER: A
Neonates born of mothers who smoke have an increased incidence of low birth weight, premature birth, sudden
infant death syndrome, apneic episodes. Option B: Nothing other than smoking cessation will offset the effects of
tobacco. Option C: Nothing other than smoking cessation will offset the effects of tobacco. Option D: Research
has not indicated this.
Reference: Littleton. Maternity Nursing Care 8ed page 292
13. A pregnant client's history states that she is a gravida 2 para 0. Which statement is true about this client?
a. She has had a spontaneous or induced abortion.
c. She has never been pregnant before.
b. She has had an induced abortion.
d. She has one living child.
ANSWER: A
She has had 2 pregnancies (including the present one) and no births after 20 weeks gestation (the age of
viability). Option B: The abortion could have been spontaneous or induced. Option C: Gravida 2 means she has
been pregnant twice. Option D: Para 0 means she has had no births after 20 weeks gestation or the age of
viability.
Reference: Littleton. Maternity Nursing Care 8ed page 314-315
14. During dietary counseling, the best initial intervention by the nurse would be to:
a. Assess the client's food and eating habits
c. Refer the client to a dietitian
b. List the client's nutritional risk factors
d. Teach the client the basics of good
nutrition
ANSWER: A
Assessment is the first step in the nursing process and is used to collect and analyze the data, so that a plan can
be developed appropriate for the client. Option B: This is not possible until assessment is performed. Option C:
This usually is not necessary, and basic prenatal nutrition teaching is the responsibility of the nurse. Option D:
Teaching should not be performed until after the assessment is made.
15. The nurse explains to a pregnant client that for energy requirements and building and maintaining tissue, the
recommended dietary caloric increase during pregnancy is
a. 100 calories a day
b. 300 calories a day
c. 500 calories a day
d. 1,000 calories a day
ANSWER: B
During pregnancy the caloric intake should be increased by 300 kcal per day.
16. A woman asks you if she can take an over-the-counter vitamin during pregnancy rather than her prescription
prenatal vitamin. A chief ingredient in prenatal vitamins that makes them important for pregnancy nutrition is:
a. Vitamin B12.
b. Vitamin C.
c. Potassium.
d. Folic acid.
ANSWER: D
Because folic acid is important during pregnancy to reduce the incidence of spinal cord lesions, prevent abortion,
and prevent megaloblastic anemia, it is added at greater strengths to prenatal vitamins.
17. During pregnancy, women should drink at least eight glasses of fluid daily. For a woman on bed rest at home,
which of the following would be the best method to encourage her to drink this amount?
a. She drinks the eight glasses before her husband leaves for work in the morning.
b. She gets up every hour, stretches, and gets a drink from the refrigerator.
c. She drinks primarily cool liquids and avoids hot liquids, because they increase thirst.
d. She keeps a pitcher of fluid readily available beside her on a table.
ANSWER: D
Ready access to fluids is important to allow the client to maintain bed rest. Getting out of bed would defeat the
purpose of bed rest; drinking eight glasses at once would be uncomfortable.
18. Nurse Hannah will use Haase’s rule to estimate the client’s fetal length. The client is at 7 months in her
pregnancy. Nurse Hannah expects the fetal length to be at:
a. 28 cm
b. 32 cm
c. 35 cm
d. 56 cm
ANSWER: C
Haase’s rule estimates fetal length in centimeters from 1 to 5 lunar months by multiplying the given lunar month
with the number of the month (e.g., 2 lunar months x 2 = 4cm). From 6 months onwards, fetal length is
estimated by multiplying the given lunar month by 5. Thus fetal length at 7 months is 35 cm (7 lunar months x 5
= 35 cm)
19. When discussing rest and sleep with a pregnant woman, which of the following positions would you suggest
that she use for napping?
a. On her stomach with a pillow under her breasts.
c. On her back with a pillow under her knees and hips.
b. On her side with the weight of the uterus on the bed.
d. On her back with a pillow under her head.
ANSWER: B
Resting on the side prevents pressure from the uterus against the vena cava and therefore allows blood to return
to the uterus.
20. A pregnant woman experiences frequent leg cramps. Which of the following would you include in her teaching
plan as a relief measure?
a. Elevating her leg on two pillows.
c. Plantarflexing her foot and wiggling her toes.
b. Bending her knee and dorsiflexing her foot.
d. Extending her knee and dorsiflexing her foot.
ANSWER: D
Dorsiflexing the foot with the knee extended is an effective method for relieving cramps in the calf muscle, the
most frequently affected muscle.
21. A pregnant woman enjoys exercising at a local health spa once a week. Which of the following comments
would lead you to believe she needs additional health teaching?
a. “I limit exercising to low-impact aerobics.”
c. “I'm learning to play table tennis.”
b. “Nothing feels nicer than a hot sauna after exercise.”
d. “The gym gets hot and stuffy by midmorning.”
ANSWER: B
Hyperthermia may be associated with fetal anomalies and should be avoided during pregnancy. Exercise should
be limited to low-impact activities.
22. A client pregnant with her first child is concerned that she has not felt the baby move yet. She is 16 weeks
pregnant. The nurse should:
a. Reassure her that this is normal
c. Place her on a fetal monitor
b. Notify the client's health care provider
d. Listen for fetal heart tones
ANSWER: A
Quickening usually is felt between 18 and 20 weeks in primagravidas. Option B: Because quickening usually is
not felt until 18 to 20 weeks, there is no reason for alarm. Option C: Fetal monitors are used to determine the
fetal heart tones, which normally are not heard until the 18th to the 20th week of gestation. Option D: Fetal
heart tones normally are not auscultated until 18 to 20 weeks gestation.
Reference: Littleton. Maternity Nursing Care 8ed page 271-272
23. A client who is 36 weeks pregnant tells the nurse that she felt dizzy during the examination while the doctor
was listening to the baby's heartbeat. Nurse Isabel recognizes that this client was probably experiencing which of
the following?
a. Hypoglycemia
c. A rise in blood pressure due to position
b. A cardiac arrhythmia
d. Vena cava syndrome
ANSWER: D
Also referred to as supine hypotension, this occurs in women close to term due to decreased blood flow to the
right atria secondary to uterine pressure against the vena cava when the client is supine.
24. A pregnant client is complaining of "morning sickness." The nurse advises her to
a. Avoid fluids
c. Eat high-protein foods
b. Eat dry carbohydrate before arising
d. Eat small frequent meals
ANSWER: B
This action will help prevent the nausea and vomiting triggered by getting out of bed in the morning, which is
how the term “morning sickness” came about. Option A: Drinking soups and liquids in between meals and
drinking ginger ale help relieve nausea and vomiting of pregnancy. Option C: This will not help relieve morning
sickness. Option D: This will help relieve nausea and vomiting associated with pregnancy, but not the nausea and
vomiting associated with getting up in the morning.
25. A pregnant client at 35 weeks' gestation makes this statement to Nurse Mishal: "My baby has been very
active up until yesterday when I hardly remember him moving." Nurse Mishal should:
a. Bring the information to the attention of the physician
b. Listen to the fetal heart tones and reassure the client
c. Send the client home with instructions to monitor fetal movement
d. Tell the client that babies often quit movement close to term
ANSWER: A
A dramatic decrease or complete lack of fetal movement needs to be reported immediately to the health care
provider for follow-up, as it may signal a serious fetal problem. Option B: Although these actions are appropriate,
they are not the most significant. Option C: This is an inappropriate and irresponsible nursing intervention in this
situation. Option D: This is a false and irresponsible action.
Reference: Littleton. Maternity Nursing Care 8ed
26. The physician wants to perform an amniocentesis on a client. She asks about the purpose of the test. The
nurse explains that:
a. It is used to determine if the mother has gestational diabetes
b. It is used to confirm the position and lie of the fetus
c. It is used to identify chromosomal aberrations and fetal maturity
d. It is used to confirm the gestational age of the fetus
ANSWER: C
Amniocentesis is the withdrawal of the amniotic fluid through the abdominal wall for analysis. This test is usually
done at week 14-16 of pregnancy. New techniques of amniocentesis allow it to be done as early as the 12th week
of pregnancy (although less amniotic fluid can be removed at this time but it is enough for genetic testing). This
test is carried out to determine chromosomal abnormalities. For the procedure, a pocket of amniotic fluid is
located by sonography. Then, a needle is inserted intra-abdominally and fluid is aspirated. Skin cells in the fluid
are karyotyped for chromosomal number and structure. The level of alphafetoprotein (AFP) is analyzed. Some
chromosomal disorders that can be detected by amniocentesis are: trisomy 18, trisomy 13, Down syndrome,
Klinefelter syndrome and Turner’s syndrome. This is also used late in pregnancy to test for fetal lung maturity.
Reference: Pilliterri, A.(2003) Maternal and Child Health Nursing: Care of the Childbearing and Childrearing
Family. 4th ed. Page 197
27. A mother who will undergo an ultrasound during her early pregnancy is advised to:
a. Decompress the bladder to ensure the accuracy of ultrasound results
b. Drink a lot of water the void immediately before the procedure
c. Drink 6 glasses of water before the procedure and should not empty the bladder before the procedure
d. Restrict fluid intake so that the bladder, which is anterior to the uterus, will not affect the accuracy of the
results of the ultrasound
ANSWER: C
An ultrasound or a sonogram is a much used tool in obstetrics. It can be used to diagnose pregnancy as early as
6 weeks gestation, confirm the presence, size and location of the placenta and the amniotic fluid, establish the
presentation and position of the fetus (sex can be diagnosed if a penis is revealed), predict maturity by
measurement of the biparietal diameter, used to discover complications of pregnancy. Before the procedure, the
woman needs a complete explanation of what will happen during the procedure. For the sound waves to reflect
best and the uterus to be held stable, it is helpful if the mother has a full bladder at the time of the procedure. To
ensure this, she should drink a full glass of water every 15 minutes beginning an hour and half before the
procedure (6 glasses) and not void before the procedure.
28. A pregnant mother undergoes a non-stress test. When is a nonstress test considered non-reactive?
a. One acceleration of fetal heart rate lasting for 15 seconds occur after movement within the chosen time period
b. Two accelerations of fetal heart rate lasting for 15 seconds occur after movement within the chosen time period
c. Three accelerations of fetal heart rate lasting for 15 seconds occur after movement within the chosen time period
d. There is low short term fetal heart rate variability
ANSWER: D
A nonstress test measures the response of the fetal heart rate to the fetal movement. The woman is positioned
and the fetal heart rate and uterine contractions monitors are attached as for obtaining a rhythm strip. When the
fetus moves, the fetal heart rate should increase about 15 beats per minute and remain elevated for about 15
seconds. It should decrease to its average rate again as the fetus quiets. This test is usually done for 10-20
minutes. A test is reactive if two accelerations of fetal heart rate (15 beats or more) lasting for 15 seconds occur
after movement within the chosen time period. The test is nonreactive if no accelerations occur with the fetal
movements or if there is low short term fetal heart rate variability (less than 6 beats per minute).
Family. 4th ed. 192
29. The client’s LMP is July 1, 2008. Using Nagele’s rule, the expected date of delivery (EDD) is:
a. April 8, 2009
b. May 8, 2009
c. July 8, 2009
d. October 8 , 2009
ANSWER: A
To calculate the date of birth by this rule, count backward 3 calendar months from the first day of the last
menstrual period and add 7 days.
July 1, 2008 + 1 year – 3 months + 7 days = April 8, 2009
30. The nurse measures the fundic height of the client to be 20 cm. Using McDonald’s rule, the nurse estimates
the AOG to be:
a. 5 months
b. 6 months
c. 7 months
d. 8 months
ANSWER: A
McDonald’s rule is a method of determining, during mid-pregnancy, that the fetus is growing in utero by
measuring the fundal height. Typically, the distance from the fundus to the symphysis pubis in centimeters is
equal to the week of gestation between the 20th and the 31st week of pregnancy. This measurement is made from
the notch of the symphysis pubis to over the top of the uterine fundus as the woman lies supine. McDonald’s rule
becomes inaccurate during the 3rd trimester of pregnancy because the fetus is growing more in weight than in
height during this time.
31. Mrs. Concepcion, a 35-year-old pregnant client, visits the clinic for her first pre-natal check-up. She has a 2year-old son born at
40 weeks, a 5-year-old daughter born at 38 weeks and 7-year-old twin daughters delivered
at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. Using the more comprehensive GTPALM
format, the nurse identifies that the client is:
a. Gravida 4 Para 32141
b. Gravida 5 Para 22141
c. Gravida 5 Para 21140
d. Gravida 4 Para 31141
ANSWER: B
She has been pregnant 5 times, Gravida – 5
Infants who reached term – 2, preterm – 2, abortion – 1, living-4, multiple gestation-1
Gravida- The number of times the woman has been pregnant including the present pregnancy
Parity- The number of children above the age of viability she has previously birthed (regardless whether the
infant was born alive or not)
Note: Viabilty is the earliest age at which fetuses could survive if they were born at that time generally accepted
at 24 weeks.
Term-The number of full term infants (above 37 weeks)
Preterm-The number of preterm infants born before 37 weeks
Abortion- The number of spontaneous or induced abortions
Live Births- The number of living children
Multiple pregnancies – 1
32. Ambivalence towards the pregnancy is a normal feeling of the mother occurring during which trimester?
a. 1st trimester
b. 2nd trimester
c. 3rd trimester
d. 4th trimester
ANSWER: A
A common reaction of mothers during the 1st trimester is ambivalence.
The Psychological tasks of pregnancy
1st trimester – (Accepting the pregnancy) the mother feels ambivalent or feeling both pleased and not pleased at
the pregnancy. It is important to emphasize that ambivalence is normal.
2nd trimester - (Accepting the baby) Woman and partner concentrate on what it feels like to be a parent. Role
playing and increased dreaming are common.
3rd trimester – (Preparing for parenthood) Woman and partner grow impatient with the pregnancy as they ready
themselves for birth.
Family. 4th ed.Page 209
33. Smoking is contraindicated in pregnancy because:
a. Carbon monoxide binds with the hemoglobin of the mother which reduces the available hemoglobin for the fetus
b. Nicotine causes vasodilation of the mother’s blood vessels
c. Nicotine causes vasoconstriction of the mother’s uterine blood vessels
d. The smoke will cause the mother and the fetus to feel dizzy
ANSWER: C
Cigarette smoking by a pregnant woman has been shown to have teratogenic effects on the fetus especially
growth retardation. In addition, these children are at risk for sudden infant death syndrome (SIDS). This results
from the vasoconstriction of the uterine vessels, an effect of nicotine that limits blood supply to the fetus.
Family. 4th ed.
34. At what age of gestation does the fetal heart sound become readily perceptible using an ordinary
stethoscope?
a. 8 weeks
b. 12 weeks
c. 16 weeks
d. 20 weeks
ANSWER: D
The presence of a fetal heart can be demonstrated by hearing its sound (on auscultation) or seeing it beating on
an ultrasound examination. Although the fetal heart has been beating since the 24th day after conception, it is
only audible by auscultation using a normal stethoscope only about 18 to 20 weeks of pregnancy.
Family. 4th ed.
35. An expectant mother, 17 weeks pregnant, asks the nurse on what to use to clean the breasts of colostrum.
The nurse’s appropriate response is:
a. Clean the breasts with clear tap water and soap
c. Do not clean it to prevent further irritation
b. Clean the breasts with clear tap water only
d. Clean it with hydrogen peroxide
ANSWER: B
Women should use clear tap water only without soap to clean their breasts as soaps can be drying. Option C is
incorrect because it should be cleaned and dried well to minimize the risk of infection. Hydrogen peroxide is not
recommended because it may lead to further irritation.
Family. 4th ed.
36. Mona asks the nurse what is the recommended weight gain during pregnancy. The nurse is correct in saying
that the average weight gain in pregnancy is:
a. 10-20 lbs
b. 15-25 lbs
c. 25-40 lbs
d. 40-60 lbs
ANSWER: C
A weight gain of 11.2 to 16 kilograms or 25-40 lbs is currently recommended as an average weight gain in
pregnancy. Weight gain in pregnancy occurs from both fetal growth and accumulation of maternal stores and
occurs approximately 1 lb per month during the first trimester and then 1 lb per week during the last two
trimesters. Women can be assured that most of the weight gained during pregnancy will be lost afterward.
37. A woman in her second trimester wants to know how will she determine of her baby is doing well. The nurse
instructs the patient to count fetal movements daily. The nurse knows that fetal movements at this time should
be felt how many times a day?
a. 2-5 times a day
b. 5-7 times a day
c. 7-9 times a day
d. 10 or more times a day
ANSWER: D
Fetuses have active sleep cycles and movement should be felt at least 10 times a day at various times.
38. An expected pulmonary adaptation experienced by most pregnant women is:
a. Orthopnea at rest
b. Progressive pulmonary edema
c. Shortness of breath
d. Bradypnea
ANSWER: C
As the uterus enlarges during pregnancy, a great deal of pressure is put on the diaphragm and ultimately on the
lungs. The diaphragm may be displaced by as must as 4 cm upward. This crowding of the chest cavity causes an
acute sensation of shortness of breath as the pregnancy progresses until lightening relieves the pressure.
39. What condition can occur if the woman rests in a supine position?
a. Couvade syndrome
c. Sudden infant death syndrome (SIDS)
b. Supine hypotension syndrome
d. Postperfusion syndrome
ANSWER: B
To obtain enough sleep and rest during pregnancy, the pregnant woman should assume a modified sim’s
position. The knees and elbows should be slightly bent, the muscles limp and the breathing slow and regular. This
puts the weight of the fetus on the bed and not on the woman and allows good circulation in the lower
extremities. They should avoid resting in a supine position otherwise, they will develop supine hypotension
syndrome. This is characterized by faintness, diaphoresis and hypotension from the pressure of the expanding
uterus to the inferior vena cava. Couvade syndrome happens when the husband experience physical symptoms
such as nausea, vomiting and backache to the same degree or even more intensely than their wives do. Sudden
infant death syndrome (SIDS) is a sudden unexplained death of an infant under 1 year of age. Postperfusion
syndrome is a syndrome which may occur 3-12 weeks after surgery of a child who has undergone cardiac
surgery. This is characterized by fever, malaise, leucocytosis and splenomegaly.
40. Physiologic anemia during pregnancy is a result of:
a. Decreased dietary intake of iron
b. Decreased erythropoesis after the first trimester
c. Increased plasma volume of the mother
d. Increased detoxification demands on the liver of the mother
ANSWER: C
This is due to the increased plasma volume of the mother. As the plasma volume increases, the concentration of
hemoglobin and erythrocytes may decline giving the woman pseudoanemia. The woman’s body compensates for
this change by producing more red blood cells, creating nearly normal levels of red blood cells again by the
second trimester.
41. The nurse is aware that a normal adaptation of pregnancy is an increased blood supply to the pelvic region
that results in a purplish discoloration of the vaginal mucosa. This is known as:
a. Chadwick’s sign
b. Goodel’s sign
c. Hegar’s sign
d. Braxton Hick’s sign
ANSWER: A
Chadwick’s sign is described as a color change of the vaginal mucosa from pink to violet (Probable sign of
pregnancy)
Goodel’s sign – Softening of the cervix
Hegar’s sign – Softening of the lower uterine segment
Braxton Hick’s sign – Periodic uterine tightening occurs.
42. A client presents in the emergency room after a motor vehicle accident. The client states that she is 22 weeks
pregnant. The nurse measures her fundus and finds that it measures 29 cm. This is:
a. A normal finding at this stage of pregnancy
c. An indication of possible small for gestational age infant
b. An indication of anencephaly
d. An indication of possible polyhydramnios
ANSWER: D
Using McDonald’s rule, the distance from the fundus to the symphysis in centimeters is equal to the week of
gestation. The fundal height is greater than the standard (22 cm – approx 22 weeks) suggests possible
polyhydramnios, multiple pregnancy, miscalculated due date, large for gestational age infant or hydatidiform
mole. A fundal height less than the standard suggests that either the fetus is failing to thrive, small for
gestational age, or an anomaly such as anencephaly is developing.
Family. 4th ed.
43. During a physical examination of a woman who suspects she is pregnant, the nurse records the following:
darkening of nipples and areola; Hegar’s, Goodel’s, and Chadwick’s signs present. These findings would be
considered what kind of pregnancy changes?
a. Probable
b. Presumptive
c. Positive
d. Pre-probable
ANSWER: A
These are all probable changes of pregnancy-objective findings highly suggestive of but not diagnostic
pregnancy.
Presumptive-Amenorrhea, nausea and vomiting, frequent urination, breast changes, uterine enlargement,
quickening, linea nigra, melasma, striae gravidarum
Probable- Chadwick’s sign, Goodel’s sign, Hegar’s sign, Ballotement, Braxton Hick’s sign, fetal outline felt by the
examiner
Positive- Visualization of the fetus by ultrasound, fetal movements felt by the examiner, fetal heart sounds
audible
44. Which of the following laboratory results indicate that the pregnant woman might be having true anemia?
a. 11.5 g/dl Hgb
b. 10.5 g/dl Hgb
c. 12 g/dl Hgb
d. 12.5 g/dl Hgb
ANSWER: B
A hemoglobin concentration of less than 11.5 g/dl or a hematocrit level below 30% is generally considered true
anemia for which iron therapy above normal supplementation is implemented.
Family. 4th ed.
45. What exercise in child bearing is done by alternately tightening and relaxing the muscles around her urethra,
vagina, rectum and entire perineum?
a. Pelvic rocking
b. Squatting
c. Kegel’s
d. Tailor sitting
ANSWER: C
Kegel exercises are designed to strengthen the pelvic floor muscles that surround the openings of the urethra,
vagina and rectum. To do Kegel's exercises, a woman squeezes or tightens the vaginal muscles normally used to
stop urination. This is accomplished by tightening the buttocks (gluteus maximus muscles) and pulling the
perineum up toward the abdomen. This is also called "core training". Some women have poor sensation in the
lower pelvis.
Family. 4th ed.
SITUATION: One of the most important nursing responsibility is to provide prenatal care. This includes
knowledge about the growing fetus, physiologic and psychological changes during pregnancy and health
assessments during this period.
46. A pregnancy test based on the ELISA testing method can detect human chronic gonadotropin (HCG) in the
urine as early as:
a. 7 to 9 days after conception
c. 2 to 3 weeks after conception
b. 1 week after the first menstrual period is missed
d. During the second trimester
ANSWER: A
In the non pregnant client, no units are detectable since there are no trophoblasts cells producing the
hCG. In the pregnant woman, trace amounts of hCG appear in the serum as early as 1-2 days after implantation
and reaches a measurable level 7-9 days after conception.
Family. 5th ed. 223
47. A maternal serum alpha-fetoprotein (MsAFP) test is performed at 14 to 16 weeks’ gestation. An elevated level
has been associated with which of the following conditions?
a. Down syndrome
c. Cardiac defects
b. Sickle-cell anemia
d. Open neural tube defects (spina bifida)
ANSWER: D
Response a, is associated with decreased levels; b and c are not detected with MsAFP testing. Elevated AFP levels
are indicates that the fetus may have an open spinal or abdominal defect.
Family. 5th ed. 207
48. A pregnant woman at 15 weeks gestation is scheduled for an ultrasound to assess fetal size and confirm the
estimated date of birth. Which of the following is an appropriate nursing measure for this test?
a. Instruct the woman to take the medicine for pain for any contractions caused by the test
b. Instruct the woman to drink 1 to 1 ½ liters of water within 1 ½ hours before the test
c. Instruct the woman to void before the test
d. Instruct the woman not to eat or drink for 6 hours prior to the test
ANSWER: B
For the sound waves to reflect best and the uterus to be held stable, it is helpful if the mother has a full bladder
at the time of the procedure. To ensure this, she should drink a full glass of water (up to 1 ½ L) 90 minutes
before the procedure and should not void before the procedure. No GI preparation is needed.
Family. 5th ed.204
49. Nurse Jennette is performing assessment on a client at 22-weeks gestation. The nurse measures the fundal
height in centimeters and expects to find which of the following?
a. 22 cm
b. 28 cm
c. 32 cm
d. 40 cm
ANSWER: A
From 20 weeks until term, the fundal height measured in centimeters is roughly the gestational age of the fetus
in weeks. If the fundal height exceeds weeks of gestation, additional assessment is necessary to investigate the
cause for the unexpected uterine size. If an unexpected increase in uterine size is present, it may be that the
estimated date of delivery is incorrect and the pregnancy is further advanced than previously thought. If the
estimated date of delivery is correct, more than one fetus may be present.
Remember: McDonald’s rule
Family. 5th ed.200
50. The pregnant client is at 16 weeks gestation. The nurse would expect the fundus of the client’s uterus is at
which of the following areas?
a. At the umbilicus
c. Midway between the symphysis pubis and the umbilicus
b. At the level of the xiphoid process
d. Above the symphysis pubis
ANSWER: C
At 12 weeks' gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis
pubis. At 16 weeks, the fundus reaches midway between the symphysis pubis and the umbilicus. At 20 weeks,
the fundus is located at the umbilicus. By 36 weeks, the fundus reaches its highest level at the xiphoid process.
Family. 5th ed. 200
51. In measuring the fundal height of a pregnant client, the nurse should place the client on which of the
following positions?
a. Prone position with the head of the bed elevated
c. Standing position
b. Prone position
d. Supine position
ANSWER: D
When measuring fundal height, the client lies in a supine position and the nurse should instruct the client to turn
onto her left side, or the nurse can elevate the left buttock by placing a pillow under the area. Options a, b, and c
are incorrect client positions for measuring fundal height.
Perry, A. (2004). Maternity & women’s health care (8th ed.) St. Louis: Mosby.
52. The pregnant client in 26-weeks gestation tells the nurse that she frequently experiences backaches. Which
instruction should the nurse give to the client in order to ease backache?
a. Eat small frequent meals
c. Sleep in a supine position
b. Elevate the legs
d. Use good posture and proper body mechanics
ANSWER: D
To provide relief from backache, the nurse would advise the client to use good posture and body mechanics,
perform pelvic rock exercises, and to wear flat supportive shoes. The client would also be instructed to avoid
overexertion and to sleep in the lateral position on a firm mattress. Back massage is also helpful. Eating small
meals would more specifically assist in the relief of gastric reflux and dyspnea. Leg elevation assists the client
with varicosities.
53. The nurse is providing health teaching to a pregnant client in her third trimester about relief measures related
to heartburn. The nurse should tell the client to:
a. Eat foods high in fat
c. Eat less frequently
b. Eat three large meals a day
d. Do not lie down immediately after eating
ANSWER: D
Measures to provide relief of heartburn include small frequent meals, avoiding fatty fried foods, coffee, and
cigarettes. Frequent sips of milk, hot tea, or water is helpful as well as not lying down immediately after eating
and sleeping with two pillows.
Family. 5th ed. 315
54. Mrs. Morayta complains about her morning sickness. The nurse provides health teachings to the client. Which
of the following statements made my Mrs. Morayta indicates a need for further instruction by the nurse?
a. “I will avoid spicy or fatty foods”
c. “z will eat small frequent meals”
b. “I will postpone eating until supper”
d. “I will eat crackers and dry toast before arising”
ANSWER: B
Standard measures for control of morning sickness include eating crackers or toast before arising from bed in the
morning, eating small frequent meals, avoiding fatty and spicy foods, and arising slowly to avoid orthostatic
hypotension. Delaying eating until suppertime does not promote proper nutrition for the pregnant woman and
fetus.
Family. 5th ed.
55. Which of the following is true regarding chorionic villi sampling (CSV)?
a. It is usually performed at appropriately 16 weeks gestation
b. Results are obtained in 3 to 4 weeks
c. Fetal limb defects, such as missing digits, can occur
d. One purpose of the test is to determine the extent of spinal cord abnormalities
ANSWER: C
Chorionic villi sampling is a diagnostic technique that involves the retrieval and analysis of chorionic villi for
chromosome or DNA analysis. This procedure is performed between 8 to 10 weeks’ gestation with results
obtained as soon as the next day (chorionic villi cells are rapidly dividing). There also have been some instances
of children being born with missing limbs after the procedure (limb reduction syndrome). This has occurred with a
high enough frequency that the woman needs to be well informed of the risk beforehand. This test does not
reveal the extent of spinal cord abnormalities.
Family. 5th ed. 173
56. Nurse Maggie is reviewing the screening tests ordered for the pregnant client. She knows that which of the
following tests will provide information regarding the potential for the development of erythroblastosis fetalis?
a. Alpha fetoprotein (AFP) levels
c. Complete blood count, Hgb and Hct levels
b. ABO and Rh types with antibody screening
d. Diabetic screening tests
ANSWER: B
Erythroblastosis fetalis is a hemolytic disease of the fetus or newborn resulting in excessive destruction of red
blood cells (RBC) and stimulation of immature erythrocytes. It occurs in the majority of cases as a result of ABO
incompatibilities or the failure to prevent maternal production of Rh antibodies. All pregnant women should be
tested for Rh types, ABO groups, and screened for antibodies to these and other RBC antigens during the
antenatal period. Hemoglobin and hematocrit levels measure maternal parameters. The diabetic screening test
assists in the identification of the gestational diabetic, and the AFP screens for the potential of fetal neural tube
defects or genetic abnormality such as trisomy 21.
Family. 5th ed.
57. The type of crisis represented by the typical role and responsibility changes related to pregnancy and
parenting is termed as:
a. Maturational
b. Gestational
c. Situational
d. Family
ANSWER: A
Situational crisis would occur if there were a change in circumstances or unexpected events such as illness of a
family member, loss of job, or preterm labor. Responses b and d are not terms used to describe a crisis.
Reference: Rollant, P.D. & Piotrowski, K. (1996) Maternity Nursing. Mosby.
58. A pregnant adolescent may have difficulty accomplishing the developmental tasks of pregnancy. Behaviors
reflective of this difficulty would include all except which of the following?
a. Denial of the pregnancy
b. Participation in early and ongoing prenatal care
c. Limitation of nutritional intake to conceal pregnancy
d. Refusal to alter habits that could be harmful to the developing fetus
ANSWER: B
Adolescents are more likely to deny pregnancy and as a result they may delay entry into prenatal care and try to
conceal or prevent the body changes. Immaturity may limit their ability to follow through on healthy lifestyle
practices.
Reference: Rollant, P.D. & Piotrowski, K. (1996) Maternity Nursing. Mosby.
59. The husband of the expectant mother tells the nurse that he also experiences physical symptoms such as
nausea and vomiting as his wife does. The nurse recognizes that this behavior is most likely a reflection of:
a. Limited interest in the well being of his wife
c. Couvade syndrome
b. Embarrassment
d. Ambivalence regarding the pregnancy
ANSWER: C
Many men also experience the physical symptoms that their partners experience such as nausea, vomiting and
backache to the same degree or even more intensely than their partners do during pregnancy. These symptoms
apparently results from stress, anxiety and empathy for their wives. This is common enough that it has been
given a name: couvades syndrome.
Family. 5th ed. 221
60. Nurse Angel is sharing her knowledge about fetal development. She asks her smart nursing students: “When
is the time the developing cells becomes a fetus?” Which of the following statements from her students indicates
that they remember Nurse Angel’s sharing?
a. “The developing cells are called a fetus from the end of the second week to the onset of labor.”
b. “The developing cells are called a fetus from the implantation of the fertilized ovum.”
c. “The developing cells are called a fetus from the time the fetal heart rate sound is heard.”
d. “The developing cells become a fetus from the eight week to the time of birth.”
ANSWER: D
Gestation is divided into three stages – blastocyst, embryo and fetus. Option a is wrong because it must be until
birth. At the time of implantation, the group of developing cells is called a blastocyst. The fetal heart is heard
between the 18th and 20th weeks; known as a fetus at the end of the 8th week.
Reference: Mosby’s Comprehensive Review of Nursing 12th edition by D.F. Saxton, P.M. Nugent and P.K. Pelikan;
p.750
61. Teacher Yamato asks his nursing students the term for the first fetal movements felt by the mother. His
students’ reply must be:
a. Ballottement
b. Lightening
c. Engagement
d. Quickening
ANSWER: D
D – The word originates from the Middle English word “quik” which means alive.
A – Ballottement is the bouncing of fetus in the amniotic fluid against the examiner’s hand.
B – Engagement is when the presenting part is at the level of the ischial spine.
C – Lightening is the descent of the fetus into the birth canal.
p.750
62. The nurse is performing an assessment on a pregnant client and is assessing for the presence of
ballottement. The nurse knows that she will implement which of the following to test for the presence of
ballottement?
a. Assess the cervix for thinning
c. Palpate the abdomen for fetal movement
b. Auscultate for fetal heart sounds
d. Initiate a sudden tap on the cervix
ANSWER: D
Near midpregnancy, a sudden tap on the cervix during a vaginal exam may cause the fetus to rise in the amniotic
fluid and then rebound to its original position. When the cervix is tapped, the fetus floats upward in the amniotic
fluid. The examiner feels a rebound when the fetus falls down.
63. Growth is most rapid during the phase of prenatal development known as:
a. Implantation
b. First trimester
c. Second trimester
d. Third trimester
ANSWER: D
D – This is the period in which the fetus stores deposits of fat.
A – This is the period of the blastocyst, when initial cell division takes place.
B – The first trimester is the period of organogenesis, when cells differentiate into major organ systems.
C – Growth is occurring, but fat deposition does not occur in this period.
p.750
64. Research indicates that:
a. Ambivalence and anxiety about mothering are common
b. A rejected pregnancy will result in a rejected infant
c. A good mother experiences neither ambivalence nor anxiety about mothering
d. Maternal love is fully developed within the first week after birth
ANSWER: A
A – Because mothering is not an inborn instinct, almost all mothers, including multiparas report some
ambivalence and anxiety about their ability to be good mothers.
B – Untrue; very often the maternal instinct is nurtured at the sight of the infant.
C – Untrue; ambivalent feelings are universal in response to the infant.
D – Untrue; may take a much longer time.
p.751
65. The blood vessels in the umbilical cord consist of:
a. Two arteries and one vein
c. One artery and two veins
b. Two arteries and two veins
d. One artery and one vein
ANSWER: A
A – Two umbilical arteries arise from the fetus and go to the placenta, where waste products are exchanged for
oxygen and nutrients and then returned via one umbilical vein to the baby.
B – This is an anomalous number; there are two arteries and one vein.
C – This is an anomalous number; there are two arteries and one vein.
D – This is an anomalous number; there are two arteries and one vein.
p.751
66. Physiologic anemia during pregnancy is a result of:
a. Increased blood volume of the mother
c. Decreased erythropoiesis after first trimester
b. Decreased dietary intake of iron
d. Increased detoxification demands of the mother’s liver
ANSWER: A
A – There is a 30% to 50% increase in maternal blood volume at the end of the first trimester, leading to a
decrease in the concentration of hemoglobin and erythrocytes.
B – This is not physiologic but is caused by lack of iron intake.
C – Erythropoiesis is increased.
D – Detoxification demands are unchanged during pregnancy.
p.752
67. The nurse is developing a plan of care for the client to strengthen the pelvic floor and decrease the incidence
of incontinence later in life. The nurse will include which of the following as part of the client’s health care plan?
a. Drink 8 glasses of water everyday
b. Perform pelvic tilt exercises, 10 repetitions, 3x/day
c. Perform Kegel exercises, 10 repetitions, 3x/day
d. Wipe the perineal area from front to back after toileting
ANSWER: C
Kegel exercises strengthen the pelvic floor (pubococcygeal muscle). The increased tone of this muscle is
beneficial during pregnancy and afterward. Option A relates to hydration, which is important for normal
physiologic body functioning. Option d will help prevent urinary tract infections. Pelvic-tilt exercises will reduce a
backache.
SITUATION: Nurses should be knowledgeable in describing common psychological and physiologic changes that
occur with pregnancy and the relationship of the changes to pregnancy diagnosis.
68. A pregnant client is scheduled for amniocentesis. Nurse Isabel will develop a plan of care for this client based
on which information?
1. The amniocentesis will identify chromosomal abnormalities.
2. The amniocentesis will determine fetal lung maturity
3. It will visualize the fetus and help in the assessment of fetal well-being
4. It is not done until 14th to 16th week of pregnancy
a. All except 3
b. All except 4
c. All except 2
d. All of the above
ANSWER: A
Amniocentesis (also referred to as amniotic fluid test or AFT), is a medical procedure used in prenatal diagnosis
of chromosomal abnormalities and fetal infections, in which a small amount of amniotic fluid, which contains fetal
tissues, is extracted from the amnion or amniotic sac surrounding a developing fetus, and the fetal DNA is
examined for genetic abnormalities. It is usually done not until 14th-16th week of pregnancy. Amniotic fluid
analysis will also help determine fetal lung maturity by measuring the L/S ratio at 22nd to 24th weeks of
pregnancy. Fetoscopy will inspect the fetus through fetoscope to assess fetal well being.
Reference: Pilliterri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. 6th
ed. Page 162,213-214
69. The nurse will advise a pregnant client, who is scheduled for amniocentesis, to perform which of the
following?
a. Increase the fluid intake to help aspirate more amniotic fluid during the procedure
b. Lie in side lying-position to avoid supine hypotension during the procedure
c. Ask the client to take a deep breath and hold it during insertion of needle
d. Rest for 30 minutes after the procedure
ANSWER: D
Amniocentesis is a technically easy procedure, but it can be frightening to a woman. In preparation for
amniocentesis, ask the woman to void to reduce the size of the bladder and prevent an inadvertent puncture.
Place her in supine position with a folded towel under her right buttock to tip her body slightly to the left and
move the uterus off the vena cava to prevent supine hypotension. Do not suggest to the client to take a deep
breath and hold it as a distraction against discomfort during insertion; this lowers the diaphragm against the
uterus and shifts intrauterine contents. After the needle is removed, the woman rests quietly for about 30
minutes. The nurse monitors the fetal heart rate during and for 30 minutes afterward.
ed. Page 213-214
70. Before the planned ultrasound, the pregnant client is asked to:
a. Void to ensure accurate results
b. Increase fluid intake and void immediately before the procedure
c. Drink 6 glasses of water before the procedure and do not void before the procedure
d. Not to take anything by mouth 6 hours before the procedure
ANSWER: C
An ultrasound or a sonogram is a much used tool in obstetrics. It can be used to diagnose pregnancy as early as
6 weeks gestation, confirm the presence, size and location of the placenta and the amniotic fluid, establish the
presentation and position of the fetus (sex can be diagnosed if a penis is revealed), predict maturity by
measurement of the biparietal diameter, used to discover complications of pregnancy. Before the procedure, the
woman needs a complete explanation of what will happen during the procedure. For the sound waves to reflect
best and the uterus to be held stable, it is helpful if the mother has a full bladder at the time of the procedure. To
ensure this, she should drink a full glass of water every 15 minutes beginning an hour and half before the
procedure (6 glasses) and not void before the procedure.
ed. Page 210
71. A high-risk pregnant client will go through a non-stress test. The result indicates a reactive non-stress test.
The client asks the nurse what it means. The nurse aptly replies by saying:
a. “The fetus is receiving adequate oxygen”
b. “The fetal heart rate is decreasing, instead of increasing, with every contraction”
c. “There is no fetal movement during stimulation”
d. “You are at risk for premature labor; the doctor may prescribe tocolytic drug”
ANSWER: A
A non-stress test measures the response of fetal heart rate to fetal movement. When the fetus moves, the FHR
should increase about 15 beats per minute and remain elevated for 15 seconds. It should decrease to its average
rate again as the fetus quiets. If no increase in beats per minute is noticeable on fetal movement, poor oxygen
perfusion of the fetus is suggested. The test is said to be reactive if two accelerations of fetal heart rate (by 15
beats or more) lasting for 15 seconds occur after movement within chosen time period. The test is non-reactive if
no accelerations occur with the fetal movements. Other options are incorrect statement.
ed. Page 208
72. An adolescent comes to the clinic complaining of nausea and vomiting, breast tenderness, and amenorrhea.
Assessment reveals a positive pregnancy test. The client reports she had her last menstrual period on April 2,
2010. Using the Nagele’s Rule, her estimated date of delivery would be on:
a. December 9, 2010
b. December 2 2010
c. January 2, 2011
d. January 9, 2011
ANSWER: D
To calculate the date of birth by this rule, count backward 3 calendar months from the first day of the last
menstrual period and add 7 days.
April – 3 months = January
2 + 7 days = 9
2010 + 1 = 2011
The EDD is January 9, 2011
ed. Page 205
73. A 20-week pregnant client comes for a routine prenatal check up. Nurse Isabel expects to find the client’s
fundus at which level?
a. Over the symphysis pubis
c. At the xiphoid process
b. At the umbilicus
d. Between umbilicus and symphysis pubis
ANSWER: B
McDonald’s rule, a symphysis-fundal height measurement, although not documented to be thoroughly reliable, is
an easy method of determining during midpregnancy that a fetus is growing in utero. At 12 weeks, the fundus is
found over the symphysis pubis; at 16 weeks, between umbilicus and symphysis pubis; 20 weeks, at the
umbilicus; and 36 weeks at the xiphoid process.
ed. Page 205
74. A first time pregnant client asks Nurse Hannah about the physiologic changes that occur during pregnancy.
The client is particularly concerned about her urination. Nurse Hannah should stress that the most frequently
experienced urinary symptoms during first trimester is:
a. Dysuria
b. Frequency
c. Incontinence
d. Burning
ANSWER: B
Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing
urinary frequency. Dysuria, incontinence, and burning are symptoms associated with urinary tract infections.
ed. Page 240
75. The client’s heartburn and flatulence, common in the second trimester, are most likely the result of which of
the following?
a. Increased plasma HCG levels
c. Decreased gastric acidity
b. Decreased intestinal motility
d. Elevated estrogen levels
ANSWER: C
During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus
and smooth muscle relaxation, can cause heartburn and flatulence. HCG level increases in the first trimester, not
the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating.
Estrogen level is decrease in the second trimester.
ed. Page 237
76. On which of the following areas would the nurse expect to observe chloasma?
a. Breast, areola, and nipples
c. Abdomen, breast, and thighs
b. Chest, neck, arms, and legs
d. Cheeks, forehead, and nose
ANSWER: D
Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented area found on the face, particularly
the cheeks and across the nose. It is not seen on the breasts, areola, nipples, chest, neck, arms, legs, abdomen,
or thighs.
ed. Page 234
77. Cervical softening and uterine souffle are classified as which of the following?
a. Diagnostic signs
b. Presumptive signs
c. Probable signs
d. Positive signs
ANSWER: C
Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy. Probable signs are
objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of
the lower uterine segment; Chadwick’s sign, which is the color changes of vagina from pink to violet; serum
laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs
are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and
changes; excessive fatigue; uterine enlargement; and quickening.
ed. Page 228
78. Which of the following would the nurse identify as a presumptive sign of pregnancy?
a. Hegar’s sign
b. Nausea and vomiting
c. Ballotement
d. Positive serum pregnancy test
ANSWER: B
Presumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are
presumptive signs. Hegar’s sign and ballottement are considered probable signs of pregnancy. Positive serum
pregnancy test is considered a positive sign which is strongly suggests pregnancy.
ed. Page 228
79. Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the
first trimester?
a. Introversion, egocentrism, narcissism
c. Anxiety, passivity, extroversion
b. Awkwardness, clumsiness, and unattractiveness
d. Ambivalence, fear, fantasies
ANSWER: D
During the first trimester, common emotional reactions include ambivalence, fear, fantasies, or anxiety. The
second trimester is a period of well-being accompanied by the increased need to learn about fetal growth and
development. Common emotional reactions during this trimester include narcissism, passivity, or introversion. At
times the woman may seem egocentric and self-centered. During the third trimester, the woman typically feels
awkward, clumsy, and unattractive, often becoming more introverted or reflective of her own childhood.
ed. Page 221-225
80. Nurse Hannah is planning care for a pregnant client. Physiologic changes, fetal development, sexuality during
pregnancy, and nutrition should be taught during which stage of pregnancy?
a. Pre-pregnant period
b. First trimester
c. Second trimester
d. Third trimester
ANSWER: B
First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality
during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester
classes may focus on preparation for birth, parenting, and newborn care.
ed. Page
81. Assessment of a pregnant client reveals that she feels very anxious because of a lack of knowledge about
giving birth. The client is in her third trimester. Which nursing intervention is most appropriate for this client?
a. Provide her with the information and teach her the skills she'll need to understand and cope during birth.
b. Provide her with written information about the birthing process.
c. Have a more experienced pregnant woman assist her.
d. Do nothing in hopes that she'll begin coping as the pregnancy progresses.
ANSWER: A
Because the client is in her third trimester, the nurse has ample time to establish a trusting relationship with her
and to teach her in a style that fits her needs. Written information would be effective only in conjunction with
teaching sessions. Introducing her to another pregnant client may be helpful, but the nurse still needs to teach
the client about giving birth. Doing nothing won't address the client's needs.
Reference: Pillitteri, A. (2007) Maternal and Child Health Nursing: Care of the Childbearing and Childbearing
Family. 5th Edition. Vol. 1. Page 284-286
82. When preparing to listen to the fetal heart rate at 12 weeks’ gestation, the nurse would use which of the
following?
a. Stethoscope placed midline at the umbilicus
b. Doppler placed midline at the suprapubic region
c. Fetoscope placed midway between the umbilicus and the xiphoid process
d. External electronic fetal monitor placed at the umbilicus
ANSWER: B
At 12 weeks gestation, the uterus rises out of the pelvis and is palpable above the symphysis pubis. The Doppler
intensifies the sound of the fetal pulse rate so it is audible. The uterus has merely risen out of the pelvis into the
abdominal cavity and is not at the level of the umbilicus. The fetal heart rate at this age is not audible with a
stethoscope. The uterus at 12 weeks is just above the symphysis pubis in the abdominal cavity, not midway
between the umbilicus and the xiphoid process. At 12 weeks the FHR would be difficult to auscultate with a
fetoscope. Although the external electronic fetal monitor would project the FHR, the uterus has not risen to the
umbilicus at 12 weeks.
ed. Page 203
83. Nurse Hannah explains to a pregnant client that nasal congestion during pregnancy is associated with:
a. Increased level of estrogen
c. Decreased intake of fluids during pregnancy
b. Increased progesterone level
d. Decreased level of estrogen and progesterone
ANSWER: A
The increased level of estrogen associated with pregnancy may cause nasal congestion or the appearance of
swollen membranes.
ed. Page 257
84. A pregnant woman has external hemorrhoids and varicosities of the vulva that are painful at times. To help
relive the varicosities, which of the following suggestions should the nurse give to the woman?
a. “Lie down with a pillow under your hips for a few minutes several times a day”
b. “Lie on your abdomen and expose the affected areas to the air for 10 minutes three to four times a day”
c. “Apply pressure tot eh perineum with a perineal pad.”
d. “Massage the affected areas with lanolin – based cream after each voiding and stool.”
ANSWER: A
The treatment for varicosities of the vulva is to place a pillow under the buttocks several times a day to elevate
the pelvis or to assume an elevated Sim’s position. Option B: A pregnant woman will be unable to lie prone due
to her gravid uterus. Option C: No pressure should be applied to the perineum. Varicosities can be relieved by
lying down as often as possible and minimizing standing. Option D: Lanolin cream is applied to cracked nipples in
the breastfeeding mother. It is not used in the treatment of varicosities.
ed. Page 284
85. Which of the following statements, if made by a woman who is 12 weeks pregnant, would be essential for a
nurse to further evaluate?
a. “I thought I wanted to be pregnant, but now I don’t know”
c. “Being pregnant makes me feel very tried”
b. “My husband is angry because I got pregnant”
d. “I don’t want to get too fat while I’m pregnant”
ANSWER: B
The most important person to the pregnant woman is generally the father of the child. A major need during a
woman’s pregnancy is to secure her partner’s acceptance of the child and assimilate the child into the family.
Option A: Ambivalence is a normal response to pregnancy. Even woman who are please to be pregnant may
experience feelings of hostility toward the pregnancy or unborn child from time to time. It these feelings intensify
and persist through the third trimester, this may indicate unresolved conflict with the motherhood role. Option C:
Fatigue is common in early pregnancy. Option D: For most women the feeling of liking or not liking their
bodies during pregnancy is temporary and does not cause permanent changes in their perceptions of themselves.
ed. Page
86. When addressing the concerns of a primipara who is eight weeks pregnant, a nurse would provide the woman
with which of the following information?
a. Dysuria is a normal finding in pregnancy.
b. Vaginal spotting is common throughout pregnancy.
c. A 10 lb (4.5 kg) weight gain is anticipated during the first trimester of pregnancy.
d. Quickening can be expected to occur between 16 and 20 weeks of pregnancy.
ANSWER: D
Quickening is the first fetal movement felt by the pregnant woman, usually between 16 and 18 weeks gestation.
A weight gain of 3 pounds is expected in the first trimester. Dysuria and vaginal spotting are not common during
pregnancy.
ed. Page
87. Which of the following is considered a warning sign of a problem that needs immediate attention during the
first trimester?
a. Absence of fetal movement
b. Nausea after meals
c. Urinary frequency
d. Vaginal bleeding
ANSWER: D
Vaginal bleeding in the first trimester may indicate threatened or actual abortion and needs to be assessed by the
HCP. There are also benign situations when bleeding occurs in the first trimester, but more serious problems
need to be ruled out. Fetal movement is not felt in the first trimester. Nausea and urinary frequency are expected
during this time.
ed. Page
88. To boost the body’s natural defense mechanisms, a client who has recurrent infections prior to and during
pregnancy should be instructed to eat diet rich in:
a. The fat-soluble vitamins
c. Low fat with essential fatty acids
b. Dietary fiber and oat bran
d. Vitamins A, C and E and selenium
ANSWER: D
The intake of vitamins as a daily dietary supplement has become so common that their importance may be
underestimated by some women. Requirements for both fat-soluble and water-soluble vitamins increase during
pregnancy to support the growth of new fetal cells. Vitamins A, C and E and selenium are immune-stimulating
nutrients
Option A – too much emphasis on the fat-soluble vitamins could result in an inadequate intake of importance
water-soluble vitamins and minerals
Option B – is used to prevent constipation
Option C – essential to prevent build up of too much cholesterol causing hypertension to a pregnant women
Options B and C – have no known effect on natural defenses
89. Mrs. Selena complains of morning sickness during the first trimester of pregnancy. A nurse would suggest
that she take which of the following measures to help alleviate the symptoms?
a. Consume a clear liquid diet
c. Eat foods that are low in protein
b. Take prenatal vitamins with milk
d. Avoid exposure to noxious odors
ANSWER: D
The nurse should instruct the patient to avoid odorous food if morning sickness occurs. Options A, B and C:
Morning sickness is due to fluctuating hormone levels. Dry foods such as crackers before arising seem to alleviate
some of the nausea.
ed. Page 311
90. Nurse Hannah is caring for Mrs. Clarete who is at 24th weeks of uncomplicated pregnancy. Nurse Hannah
suggested childbirth preparation class to Mrs. Clarete. The client states “I don’t really need to go to one” Nurse
Hannah should respond by saying:
a. “Why is that?”
c. “I know what’s best for you”
b. “Okay, you know best”
d. “Okay, they cost too much anyway”
ANSWER: A
It is important for couples to attend preparation for labor classes but, also, is easy to ignore the reasons clients
present for not wanting to attend them. Careful listening often reveals that time or money concerns are reasons
why couples choose not to attend a course. Helping to investigate the many options is the beginning of problem
solving.
ed. Page 325
91. Nurse Isabel is teaching a group of pregnant women at the childbirth preparation class. In addition to
encouraging an overall exercise program, she teaches specific exercises to strengthen pelvic and abdominal
muscles. One of which is Tailor Sitting exercise. She correctly demonstrates tailor sitting if she performs which
actions?
a. She sits with one ankle on top of the other, while gently pushing her knees toward the floor.
b. She arches her back trying to stretch the spine. She holds the position for 1 minute, then hollows her back.
c. She squats with her feet flat on the floor for 15 minutes.
d. She sits with her legs in front of the other.
ANSWER: D
Although many women may be familiar with tailor sitting, they may have to be re-taught the position so it is
done in a way that stretches perineal muscles without occluding the blood supply to the lower legs. A woman
should not put one ankle on top of the other but should place one leg in front of the other. As she sits in this
position, she should gently push on her knees toward the floor until she feels her perineum stretch. This is a good
position to use to watch television or read. Option B: Pelvic rocking exercise. Option C: Squatting exercise.
ed. Page 329
92. Which of the following is the appropriate pregnancy classification for Mrs. Ligaya who is pregnant for the third
time. Her first pregnancy ended in a miscarriage at 8 weeks and second pregnancy was a cesarian delivery at 37
weeks of gestation and the child is 4 years old now:
a. Gravida 3 para 3-2-0-1-0
b. Gravida 3 para 1-0-1-1
c. Gravida 2 para 2-1-1-0
d. Gravida 2 para 2-1-0-0
ANSWER: B
This client has conceived three times and has delivered a term infant and has one living child. An eight week
miscarriage is a spontaneous abortion.
ed. Page 253
SITUATION: Managing the antepartal patient is difficult and challenging problem. Decisions regarding
intervention have potentially grave consequences and should never be made on one parameter alone without
knowledge of gestational age and maturity or maternal condition.
93. A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy.
Which response is best for the nurse to provide?
a. Herbs are a cornerstone of good health to include in your treatment.
b. Touch is also therapeutic in relieving discomfort and anxiety.
c. Your healthcare provider should direct treatment options for herbal therapy.
d. It is important that you want to take part in your care.
ANSWER: D
The emphasis of alternative and complementary therapies, such as herbal therapy, is that the client is viewed as
a whole being, capable of decision-making and an integral part of the health care team, so (D) recognizes the
client's request. Options A and B provide little support for the client's comment about herbal therapy. Although
the healthcare provider should address the client's request, (option C) dismisses the discussion and assumes the
client is not an integral part of the healthcare team.
Family. 5th ed.
94. A pregnant woman at 15 weeks gestation is scheduled for an ultrasound to assess fetal size and confirm the
estimated date of birth. Which of the following is an appropriate nursing measure for this test?
a. Instruct the woman to take the medicine for pain for any contractions caused by the test
b. Instruct the woman to drink 1 to 1 ½ liters of water within 1 ½ hours before the test
c. Instruct the woman to void before the test
d. Instruct the woman not to eat or drink for 6 hours prior to the test
ANSWER: B
For the sound waves to reflect best and the uterus to be held stable, it is helpful if the mother has a full bladder
at the time of the procedure. To ensure this, she should drink a full glass of water (up to 1 ½ L) 90 minutes
before the procedure and should not void before the procedure. No GI preparation is needed.
95. Nurse Gina is performing assessment on a client at 28-weeks gestation. The nurse measures the fundal
height in centimeters and expects to find which of the following?
a. 22 cm
b. 24 cm
c. 28 cm
d. 32 cm
ANSWER: A
From 20 weeks until term, the fundal height measured in centimeters is roughly the gestational age of the fetus
in weeks. If the fundal height exceeds weeks of gestation, additional assessment is necessary to investigate the
cause for the unexpected uterine size. If an unexpected increase in uterine size is present, it may be that the
estimated date of delivery is incorrect and the pregnancy is further advanced than previously thought. If the
estimated date of delivery is correct, more than one fetus may be present.
Remember: McDonald’s rule
96. When developing a meal-planning guide about foods rich in riboflavin for a primigravid client, the nurse would
expect to instruct the client to include at least two daily servings of:
a. Potatoes
b. Enriched cereals
c. Prunes
d. Fresh fruits
ANSWER: B
Riboflavin forms coenzymes needed to release energy. Enriched grain products (e.g., cereals, breads), deep
green leafy vegetables, milk, veal, beef and cheddar cheese are rich sources of riboflavin.
Option D – is rich in Vitamin C
Option C – prunes are rich in iron, fiber, and vitamin C
Option A – potatoes are a source of vitamin C and carbohydrates
Reference: Pillitteri, A. (2007). Maternal and Child Health Nursing: Care of the childbearing and
childrearing family. Volume. 5th edition. Lippincot William & Wilkins. Page 304.
97. In measuring the fundal height of a pregnant client, the nurse should place the client on which of the
following positions?
a. Prone position with the head of the bed elevated
b. Prone position
c. Standing position
d. Supine position
ANSWER: D
When measuring fundal height, the client lies in a supine position and the nurse should instruct the client to turn
onto her left side, or the nurse can elevate the left buttock by placing a pillow under the area. Options a, b, and c
are incorrect client positions for measuring fundal height.
Family. 5th ed.
98. A pregnant client asks Nurse Kara why her obstetrician has prescribed iron supplements. Nurse Kara
prepares her response based on what understanding?
a. Iron absorption is decreased in the GI tract during pregnancy.
b. Supplementary iron is more efficiently utilized during pregnancy.
c. It is difficult to consume 30 mg of additional iron by diet alone.
d. Iron is needed to prevent megaloblastic anemia in the last trimester.
ANSWER: C
The DRI for iron for pregnant women is 30 mg. An average diet supplies about 6 mg iron per 1,000 calories. If a
woman eats a 2,500-calorie diet daily, her daily intake, therefore, is about 15 mg iron. Because only 10% to 20%
of dietary iron is absorbed, she is actually taking in less than this amount (closer to 1.5 mg to 3 mg). Therefore,
dietary supplementation with 15 mg iron per day helps ensure that adequate iron is ingested and absorbed.
Stress to women that iron supplementation is intended as a supplement to, not a replacement for, iron-rich
foods.
Option A - Iron absorption occurs readily during pregnancy, and is not decreased within the GI tract
Option B - Dietary iron is just as "good" as iron in tablet form.
Option D - Megaloblastic anemia is caused by folic acid deficiency.
99. Nurse Mayo explains to a pregnant client that the absorption of supplemental iron can be increased by taking
it with which of the following beverages?
a. Coffee
b. Flavored-water
c. Hot cocoa
d. Orange juice
ANSWER: D
Absorption of supplemental iron and non meat sources of iron is enhanced by combining them with meat or a
good source of vitamin C to enhanced absorption.
100. A client in 12-weeks gestation asks the nurse if it is really necessary for her to stop drinking coffee, tea and
eating chocolate during the whole duration of her pregnancy. The client admitted to the nurse that she will have
a great deal of difficulty in omitting these beverages. What is the best response of the nurse in the client’s
concern?
a. “You may reduce your intake of coffee of 8 cups a day.”
b. “It is better to take longer tea brews and green tea because both have less caffeine content.”
c. “Less caffeine content can be found in Instant coffee from that of the brewed coffee.”
d. “It is absolutely necessary for you to stop consuming soft drinks as it naturally contained caffeine.”
ANSWER: C
If a woman has difficulty omitting these common foods from her diet, she can still reduce the amount of caffeine
she ingests by modifying their preparation, For example, instant coffee has less caffeine than brewed coffee;
percolated coffee has less caffeine than dripped coffee, therefore option C is the correct answer.
Option A – coffee intake of 8 cups or more is associated with an increased rate of stillbirth
Option B – The longer tea brews, the greater the caffeine content. Green tea has less caffeine than black tea
Option D – Soft drinks do not naturally contain caffeine, it is added to improve their appeal. To limit the amount
of caffeine consumed, encourage pregnant women to choose caffeine-free types.
Reference: Adelle Pillitteri, Maternal and Child Nursing, 5th Edition. Chapter 11, page 306.
FOUNDATION OF MATERNAL AND CHILD HEALTH NURSING
SITUATION: Sexuality is a multidimensional phenomenon that includes feelings, attitudes and actions. It
encompasses and gives direction to a person’s physical, emotional, social, and intellectual responses throughout
life.
1. Knowledge of sexual functioning is defined as the extent of understanding conveyed about sexual
development and responsible sexual practices. The following are specific indicators that suggest that this
outcome has been achieved except:
a. Ability of the client to describe effective contraception
b. The client was able to describe the societal influences on sexual behavior
c. The client was able to describe the inner sense of his/her identity
d. The client was able to describe measures to prevent sexually transmitted diseases
ANSWER: C
Gender identity or sexual identity is the inner sense a person has of being male or female, which may be the
same as or different from biologic gender.
Options A, B and D are all indicators that the outcome had been achieved if the client’s has the ability to
describe the following
Reference: Adelle Pillitteri. Maternal and Child Health Nursing. 5th Edition. Page 88.
2. To preserve the reproductive health of the woman and man, guidelines for safer sex practices were
established. Which of the following statements is not included?
a. The use of condoms is the best protection against infection. Condoms are latex, use oil-based lubricant rather
than water-based lubricant because it can weaken the rubber
b. Be selective in choosing sexual partners
c. For safer oral-vaginal sex, a condom split in two or a plastic dental dam covering the mouth should be used
to protect against the exchange of body fluids
d. Use oil lubricants for anal penetration to keep bleeding and condom resistance to a minimum
ANSWER: A
Condoms should be latex; the chance of the condom tearing is less if it is a pre-lubricated brand. Use of waterbased lubricants such
as KY jelly on condoms made aid its smooth penetration, the use of oil-based lubricant
may cause weakening of the rubber making condom lose it strength and may tear eventually.
Options B, C and D are all correct safe sex practices
SITUATION: According to Master and John who conducted a research on sexual responses, they described the
human sexual responses as a cycle with four discrete stages: excitement, plateau, orgasm and resolution.
3. Excitement phase occurs with physical and psychological stimulation that cause changes in the body of the
sexual partners. Which of the following changes does not occur during this sexual phase?
a. Increased blood supply leading to vasocongestion and increasing muscular tension
b. The vagina widens in diameter and increase in length
c. In woman clitoris is drawn forward and retracts under the clitoral prepuce
d. In men, scrotal thickening and elevation of testes occurs
ANSWER: C
This change occurs during the plateau stage before orgasm is reached, in woman – the clitoris is drawn forward
and retracts under the clitoral prepuce; the lower part of the vagina becomes extremely congested (formation
of the orgasmic platform)
Excitement occurs with physical and psychological stimulation that causes parasympathetic stimulation. This
leads to arterial dilation and venous constriction in the genital area. The resulting blood increased blood supply
leads to vasocongestion and increase muscular tension.
In women, this vasocongestion causes the clitoris to increase in size and mucoid fluid to appear on vaginal walls
as lubrication.
The vagina widens in diameter and increase in length
In men, penile erection occurs as well as scrotal thickening and elevation of the testes
4. Which of the following sexual stages is considered to be the shortest according to Masters and Johnson?
a. Excitement
b. Plateau
c. Orgasm
d. Resolution
ANSWER: C
Orgasm is the shortest stage in sexual response cycle; orgasm is usually experienced as intense pleasure
affecting the whole body, not just the pelvic. It is also a highly personal experience; descriptions of orgasm vary
greatly from person to person.
Excitement - occurs with physical and psychological stimulation that causes parasympathetic stimulation
Plateau – is reached just before orgasm
Resolution – this period usually takes 30 minutes for both men and women
5. Because people are individuals, types of sexual expression are individualized. Malan Dee is a masochist. Who
among these men cannot be partnered with her because serious injury may result?
a. Mali Bo-og who is obtaining sexual arousal by looking at other’s person’s body
b. Mr. Uma Rayka who loves to inflict pain to achieve sexual arousal
c. Mabo Su who loves to see visual materials to achieve arousal
d. Mahi – Leeg who loves to masturbate
ANSWER: B
A masochist loves to receive pain to achieve sexual satisfaction, while a sadist wants to inflict pain to achieve
sexual satisfaction. If they will engaged in the sexual act together, the sadist will not achieved the sexual
satisfaction he seeks because his partner can endure the pain, thus inflict more pain that may endanger the
masochist.
SITUATION: The reproductive system or genital system is a system of organs within an organism which work
together for the purpose of reproduction. Many non-living substances such as fluids, hormones, and
pheromones are also important accessories to the reproductive system. Unlike most organ systems, the sexes
of differentiated species often have significant differences.
6. Regardless of whether someone is planning on childbearing, everyone is wiser by being familiar with
reproductive anatomy and physiology and his or her own body’s reproductive and sexual health. Which of the
following is true about the reproductive development?
a. Male and female reproductive systems arise from the same embryonic origin
b. The sex of an individual is determined 10 weeks after conception
c. If testosterone is not present at 5 weeks, the gonadal tissue differentiates into ovaries
d. Estrogen influences the enlargement of the labia majora and clitoris
ANSWER: A
Although the structures of the female and male reproductive systems differ greatly in both appearance and
function, they are homologous—that is, they arise from the same or matched embryonic origin. Option B: The
sex of an individual is determined at the moment of conception by the chromosome information supplied by the
particular ovum and sperm. Option C: If testosterone is not present at 10 weeks, the gondola tissue
differentiates into ovaries. Option D: Testosterone, not estrogen, influences the enlargement of the labia majora
and clitoris and formation of axillary and pubic hair.
ed. Page 86
7. Nurse Mian was tasked by the local health office to teach adolescents about pubertal development. Which of
the following information is least likely being included in her teaching?
a. A girl must reach a critical mass of body fat to trigger puberty
b. In girls, the breast development precedes the onset of menstruation
c. Ovulation is established at the onset of menstruation
d. Spermatogenesis begins at puberty
ANSWER: C
The average age at which menarche occurs is 12.4 years. It may occur as early as age 9 or as late as age 17,
however, and still be within a normal age range. Irregular menstrual periods are the rule rather than the
exception until ovulation consistently occurs within them (menstruation is not dependent on ovulation), and this
does not tend to happen until 1 to 2 years after menarche. This is one reason why estrogen-based oral
contraceptives are not commonly recommended until a girl’s menstrual periods have become stabilized or are
ovulatory (to prevent administering a compound to halt ovulation before it is firmly established. Other options
are correct.
ed. Page 86-87
8. Gonadotropin-releasing hormone (GnRH) is a neurohormone central to initiation of the reproductive hormone
cascade. It is released by the pituitary gland under the regulation of the:
a. Ovaries
b. Thalamus
c. Hypothalamus
d. Testes
ANSWER: C
Gonadotropin-releasing hormone is a peptide hormone responsible for the release of FSH and LH (Gonadotropic
hormones) from the anterior pituitary gland. GnRH is synthesized and released by the hypothalamus.
9. The release of GnRH by the hypopthalamus initiates the menstrual cycle. Which pituitary hormone is
responsible for the maturation of the ovum during the menstrual cycle?
a. Follicle-Stimulating Hormone
c. Luteinizing hormones-releasing hormone (LHRH)
b. Luteinizing hormone
d. Oxytocin
ANSWER: A
Follicle stimulating hormone (FSH) is a hormone secreted from the anterior pituitary gland. In women, FSH
stimulates production and maturation of ovarian follicles (eggs) and estradiol (another reproductive hormone)
during the first half of the menstrual cycle. Oxytocin causes the uterus to contract and initiate labor. LHRH is
also called GnRH.
ed. Page 100
10. During the secretory phase of menstrual cycle, the glands of the uterine endometrium becomes corkscrew
in appearance and dilated with quantities of glycogen and mucin. This activity is stimulated by which hormone?
a. Progesterone
b. Estrogen
c. Glycogen
d. Prolactin
ANSWER: A
After ovulation, the formation of progesterone in the corpus luteum (under the direction of LH) causes the
glands of the uterine endometrium to become corkscrew or twisted in appearance and dilated with quantities of
glycogen and mucin (a protein).
ed. Page 101
11. Increased levels of GnRH stimulate the anterior pituitary to secrete:
a. Progesterone
b. LH
c. Oxytocin
d. LHRH
ANSWER: B
GnRH (also called luteinizing hormone releasing hormone) induces the release of both FSH and LH. Folliclestimulating hormone (FSH)
is a hormone that is active in the cycle and is responsible for the maturation of the
ovum. Luteinizing hormone (LH) is a hormone that becomes most active at the midpoint of the cycle and is
responsible for the ovulation or release of the matured egg cell from the ovary and growth of uterine lining
during the second half of the menstrual cycle.
ed. Page 100
12. The development of pubic and axillary hair because of androgen stimulation is termed as:
a. Andrenarche
b. Mamarche
c. Menarche
d. Thelarche
ANSWER: D
Andrenarche is the development of axillary and pubic hair due to androgen stimulation. Thelarche is the
beginning of breast development. Menarche is the first menstrual period. Mamarche is non-existent.
ed. Page 86
13. During the reproductive development teaching, Nurse Isabel would include which statement about
ovulation?
a. After ovulation, progesterone raises the body temperature by 1 degree F
b. Follicle-stimulating hormone stimulates ovulation
c. Ovulation occurs at the midpoint of menstrual cycle
d. All of the above
ANSWER: A
The basal body temperature of a woman drops slightly (by 0.5 to 1 deg F) just before the day of ovulation,
because of the extremely low level of progesterone that is present at that time. It rises by 1 deg F on the day
after ovulation, because of the concentration of progesterone (which is thermogenic) that is present at that
time. The woman’s temperature remains at this level until approximately day 24 of the menstrual cycle, when
the progesterone level again decreases. Option B: LH stimulates ovulation. Option C: Ovulation occurs on
approximately the 14th day before the onset of the next cycle. Because ovulation happens at the midpoint of a
28-day cycle, many women think incorrectly that the midpoint of their cycle is the day of ovulation. If their
cycle is 20 days long, however, the day of their ovulation would be day 6 not on day 10 which is the midpoint of
their cycle. If the woman’s cycle is 32 days long, the day of their ovulation is on day 18 and not day 16.
ed. Page 100
14. Nurse Gina is obtaining assessment data on a healthy looking 20-year old patient who states not
experiencing any menstruation since puberty. Which of the following terms will she use in her documentation to
describe the absence of her menstrual flow?
a. Primary amenorrhea
b. Secondary amenorrhea
c. Menorrhagia
d. Metrorrhagia
ANSWER: A
Amenorrhea is the absence of a menstrual period in a woman of reproductive age. Primary amenorrhea
(menstruation cycles never starting) may be caused by developmental problems such as the congenital absence
of the uterus, or failure of the ovary to receive or maintain egg cells. Also, delay in pubertal development will
lead to primary amenorrhea. It is defined as an absence of secondary sexual characteristics by age 14 with no
menarche or normal secondary sexual characteristics but no menarche by 16 years of age. Secondary
amenorrhea (menstruation cycles ceasing) is often caused by hormonal disturbances from the hypothalamus
and the pituitary gland, from premature menopause or intrauterine scar formation. It is defined as the absence
of menses for three months in a woman with previously normal menstruation or nine months for women with a
history of oligomenorrhea.
ed. Page
15. It is the longest portion of the fallopian tube in which fertilization normally occurs:
a. Ampulla
b. Fimbriae
c. Isthmus
d. Interstitial
ANSWER: A
The egg & the sperm meet in the outer half of the fallopian tube, called the ampulla. Fertilization occurs here,
after which the fertilized egg now called an embryo its way down the tube towards the uterus.
ed. Page 94
16. Ultrasound findings revealed a retroverted uterus. The nurse correctly interprets this as:
a. The uterus is tipped far forward
b. The entire uterus is tipped backward
c. A condition in which the body of the uterus is bent sharply forward at the junction with the cervix
d. A condition in which the body is bent sharply backward just above the cervix
ANSWER: B
Option B accurately describes retroverted uterus. Option A: Antersion. Option C: Anteflexion. Option D:
Retroflexion.
ed. Page 97
SITUATION: Women and their partners who are planning for childbearing may be especially curious about
reproductive physiology and the changes a male and female is undergoing. Therefore, one of the biggest
contributions nurses can make is to encourage clients to ask questions about sexual and reproductive
functioning.
17. Puberty is the stage of life at which secondary sex changes begin. In girls, pubertal changes typically occur
in a sequence. Which order of the following developmental changes is in correct sequence?
i. Breast development
v. Onset of menstruation
ii. Growth Spurt
vi. Growth of pubic hair
iii. Growth of axillary hair
vii. Vaginal secretions
iv. Increase in the tranverse diameter of the pelvis
a. ii, iv, i, iii, v, vi, vii
b. ii, i, iv, vi, v, iii, vii
c. ii, iv, i, vi, v, iii, vii
d. ii, i, iv, vi, iii, v, vii
ANSWER: C
Pubertal changes in girls follows this sequence: (a) growth spurt (b) increase in the transverse diameter of the
pelvis (c) breast development (d) growth of pubic hair (e) onset of menstruation (f) growth of axillary hair (g)
vaginal secretions
18. Miley Cyrus is 11-years old and on her 6th grade. She already had her first menstrual period or menarche.
Which of the following is not a correct statement about this stage of puberty in girls?
a. Menstrual irregularities for the first year after the onset of menarche is a rule
b. Menstruation is highly dependent on ovulation
c. Oral contraceptives are not commonly recommended until the girl’s menstrual periods have become stabilized
d. Regular menstruation is expected to happen 1 to 2 years after menarche
ANSWER: B
Menstrual periods do not become regular until ovulation consistently occurs with them (menstruation is not
dependent on ovulation), and this does not happen until 1 to 2 years after menarche. This is one reason why
estrogen-based oral contraceptives are not commonly recommended until a girl’s menstrual periods have
become stabilized or an ovulatory (to prevent administration of a compound to halt ovulation before it is firmly
established).
Option A- irregular menstrual periods are the rule rather than the exception for the first year
19. Androgenic hormones are the hormones responsible for muscular development, physical growth, and the
increase in sebaceous gland secretions. Testosterone is the primary androgenic hormone. Which of the following
is incorrect about this hormone?
a. Low levels of this hormone in males until puberty causes short statute of the males
b. This hormone influences the enlargement of the labia majora and clitoris
c. Androgenic hormones are produced by the adrenal cortex both in males and females
d. None of these
ANSWER: A
Levels of the primary androgenic hormone, testosterone, are low in males until puberty (approximately age 12
to 14 years. This low level will delay the early closure of the growth in long bones which is essential for increase
in height.
Options B and C are true information about androgenic hormones
20. This is the portion of the uterus whose important characteristic is to stretch during vaginal birth:
a. Intrenal os
b. Corpus
c. Fundus
d. Cervix
ANSWER: D
Circular muscle fibers in the cervix stretch to allow for passage of the product of conception. The corpus is the
body of the uterus which is contractile that helps in the expulsion of the uterus; the fundus is the top portion of
the uterus where implantation takes place; and the internal os is the portion of the cervix closest to the uterus.
21. The ovaries produce estrogen and progesterone and initiate and regulate menstrual cycle. Estrogen is
important to prevent some diseases. The following diseases can be prevented by this hormone except:
a. Cardiovascular disease
b. Osteoporosis
c. Breast cancer
d. Both A and C
ANSWER: C
Estrogen is attributed to the occurrence of breast cancer that’s why estrogen supplementation is no longer
routinely recommended to menopause women
Option A – because cholesterol is incorporated into estrogen, the production of estrogen is thought to keep
cholesterol levels reduced, thus limiting the effects of atherosclerosis.
Option B – estrogen secreted by the ovaries is important to prevent osteoporosis because it prevents the
withdrawal of calcium from the bones
22. Fallopian tubes function to convey the ovum from the ovaries to the uterus and to provide place for
fertilization of the ovum by sperm. It is anatomically divided into four parts. This portion is only about 1cm in
length and the lumen is only 1 mm in diameter. This refers to the part of the uterus called:
a. Interstitial
b. Isthmus
c. Ampulla
d. Infundibulum
ANSWER: A
The most proximal division of the fallopian tube is the interstitial portion, is that part of the tube that lies within
the uterine wall. This portion is only about 1 cm in length; the lumen of the tube is only 1 mm in diameter at
this point.
Option B – is the next distal portion, it is extremely narrow; this segment is approximately 2 cm in length. This
portion the portion f the tube that is being cut or sealed in a tubal ligation
Option C – is the third and also the longest portion of the tube, it is approximately 5 cm in length
Option D – is the most distal segment of the tube, it is approximately 2 cm long and is funnel-shaped
23. Anatomically, the uterus consists of three divisions: the body, the isthmus and the cervix. All but one is the
significance of fundus:
a. It is the portion that can be palpated abdominally to determine the amount of uterine growth
b. Use to measure the force of uterine contraction
c. It is palpated to assess that the uterus is returning to its non-pregnant state after childbirth
d. It is the part being cut during cesarean section
ANSWER: D
The isthmus of the uterus is a short segment between the body and the cervix. During pregnancy this portion is
also enlarges greatly to accommodate the growing fetus. It is the portion of the uterus that is most commonly
cut when a fetus is born by cesarean section
Option A, B and C are all correct
24. Nurse Annie Purong-bakal is caring for a woman in labor. The doctor is concern about the possibility of
rupture of the uterus. With the knowledge of the female reproductive organs, which part of the uterus requires
priority assessment because it is the thinnest part of the uterus?
a. Fundus
b. Lower uterine segment
c. Corpus
d. Inner cervical os
ANSWER: B
The body or corpus of the uterus is the uppermost part and forms the bulk of the organ. The body of the uterus
is the portion of the structure that expands to contain the growing fetus. The fundus is the portion that can be
palpated abdominally to determine the amount of uterine growth occurring during pregnancy, to measure the
force of uterine contractions during labor, and to assess that the uterus is returning to its prepregnant state for
childbirth. The isthmus of the uterus is a short segment between the body and the cervix. This part is noncontractile and the thinnest
part of the uterus. It is the portion that is most commonly cut when a fetus is born
by a caesarean section. Inner cervical os is the opening of the canal at the junction of the cervix and isthmus.
SITUATION: Growth and development over the lifespan is explored with a primary focus on females, and
special issues related to male development.
25. The clear, viscid alkaline mucus that improves the viability and motility of sperm is secreted by the:
a. Bartholin’s glands.
b. Paraurethral glands.
c. Sebaceous glands.
d. Skene’s glands.
ANSWER: A
Bartholin’s glands secrete a clear, viscid, odorless, alkaline mucus that improves the viability and motility of
sperm along the female reproductive tract. The paraurethral glands (also known as Skene’s glands) provide
lubrication to protect the skin around the urethra. The sebaceous gland secretions are bactericidal and aid in
lubrication.
Reference: A. Pilitteri. Maternal and Child Health Nursing 5th edition
26. Which of the following statements is true regarding the penis?
a. The urethral meatus is located on the ventral side of the penis.
b. The prepuce is the fold of foreskin covering the shaft of the penis.
c. The penis is composed of two cylindrical columns of erectile tissue.
d. The corpus spongiosum expands into a cone of erectile tissue called the glans.
ANSWER: D
The penis is composed of three cylindrical columns of erectile tissue. At the distal end of the shaft, the corpus
spongiosum expands into a cone of erectile tissue, the glans.
27. A male patient with possible fertility problems asks the nurse where sperm is produced. The nurse knows
that sperm production occurs in the:
a. Testes.
b. Prostate.
c. Epididymis.
d. Vas deferens.
ANSWER: A
Sperm production occurs in the testes.
28. The area located between the two skinfolds of the labia minora is known as the:
a. Labia majora.
b. Perineum.
c. Mons pubis.
d. Vestibule.
ANSWER: D
The vestibule is the area between the two skin folds of the labia minora. The vestibule is a boat-shaped area
that contains the urethral meatus, openings of the Skene’s glands, hymen, openings of the Bartholin’s glands,
and vaginal introitus. The labia minora is located within the labia majora. The perineum is located between the
fourchette and the anus. The mons pubis is located over the pubic bone.
29. A pregnant client tells you that when she stands up suddenly, she notices a sharp pain in her lower
abdomen. This is probably a result of tension on which ligament?
a. Broad ligament.
b. Round ligament.
c. Cardinal ligament.
d. Sacral-pubic ligament.
ANSWER: B
The purpose of the round ligament is to stabilize the uterus. Sudden tension can produce pain.
SITUATION: Understanding the anatomy and physiology of both the reproductive system of a man and a
woman may serve as a basis for the health care being rendered to these groups especially during the
reproductive years. It is more significantly important to be well-verse to the reproductive health of a woman as
a baseline data for comparison between the normal and abnormal changes during pregnancy.
30. A client has a midpelvic contracture from a previous pelvic injury due to a motor vehicle accident as a
teenager. The nurse is aware that this could prevent a fetus from passing through or around which structure
during childbirth?
a. Symphysis pubis
b. Sacrococcygeal joint
c. Ischial spines
d. Ischial tuberosity
ANSWER: C
The ischial spines are located in the mid-pelvic region and could be narrowed due to the previous pelvic injury;
this is small projections that extend from the lateral aspects into the pelvic cavity. The level of the ischial spines
marks the midplane or midpoint of the pelvis. This marker is used to assess the level to which the fetus has
descended into the birth canal during labor. Due to pelvic injury it may be hard for the fetus to pass through it
during delivery. The symphysis pubis, Sacrococcygeal joint, and Ischial tuberosity are not part of the midpelvis.
Option A – is the pubic bone joint this can be found beneath the mons veneris which is a pad of adipose tissue
Option B – it provides degree of movement, as it permits the coccyx to be pressed backward, allowing more
room for the fetal head as it presses through the bony pelvic ring at birth
Option D - portion of the bone on which a person sits these projection is important markers used to determine
lower pelvic width
childrearing family. Volume. 5th edition. Lippincot William & Wilkins. Page 81-82.
31. When performing a pelvic examination, the nurse observes a red swollen area on the right side
of
the
vaginal orifice. The nurse would document this as enlargement of:
a. Clitoris
b. Parotid gland
c. Skene’s gland
d. Bartholin’s gland
ANSWER: D
Bartholin’s glands are the glands on either side of the vaginal orifice.
Option A - The clitoris is female erectile tissue found in the perineal area above the urethra.
Option B - The parotid glands are open into the mouth.
Option C - Skene’s glands open into the posterior wall of the female urinary meatus.
childrearing family. Volume. 5th edition. Lippincot William & Wilkins. Page73-74.
32. When performing a vaginal examination on a pregnant client, the nurse determines that the biparietal
diameter of the fetal head has reached the pelvic inlet. Which statement best describes the position of the fetus
at this time based on the anatomical position of the woman’s pelvis?
a. It's at the ischial spines.
b. It's at first station.
c. It's engaged.
d. It's floating.
ANSWER: C
The largest part of the fetus's head, the presenting part, is marked by the biparietal diameter. The largest part
of the head is accommodated by the largest part of the passage — the pelvic inlet. Engagement refers to entry
of the fetus's head or presenting part into the superior pelvic strait, which is marked by the pelvic inlet. When
the fetus's head is at the level of the ischial spines, it's at the pelvic outlet. The ischial spines are designated as
zero station. A floating fetus hasn't yet entered the pelvic inlet.
SITUATION: The nurse should know the basic principles about inherited disorders and about the necessary
assessments, care and guidance for counseling the woman and her family if a possibility of a genetic disorder is
suspected in her infant.
33. A female carries the gene for hemophilia on one of her X chromosomes. Now that she is pregnant, she asks
the nurse how this might affect her baby. The nurse should tell her that:
a. A female baby has a 50 % chance of also being a carrier
b. A male baby can be a carrier or have hemophilia
c. Female babies are never affected by this disorder
d. Hemophilia is always expressed if a male inherits the defective gene
ANSWER: D
Hemophilia is an X-linked inherited disorder, wherein females who inherit the affected gene will be
heterozygous, and because the normal gene is present, the expression of the disease will be blocked. On the
other hand, because males have only one X chromosome, the disease will be manifested in any male children
who receive the affected gene from their mother. There is a 25% chance females will be carriers. If the males
inherit the defective X chromosome, the disorder will be expressed and they can transmit the gene to female
offsprings. Females are affected if they receive a gene from both parent but most likely dies during or just after
birth (means that both the X-chromosomes are affected by the defective gene from the mother and father).
Family. 5th ed. 164.
34. This chromosomal abnormality affects males, having extra “X” chromosomes. Knowing what syndrome it is,
which of the following defines this defect?
a. The child is short in stature; the neck is low-set and may appear to be webbed and short.
b. Muscle tone is poor this could be so lax that gives the child the ability to touch his/her nose with his/her toes.
c. It is not noticeable at birth, but during puberty secondary sex characteristics fails to develop.
d. The child has maladaptive behaviors such as hyperactivity and autism
ANSWER: C
Option A refers to child with Turner syndrome (gonadal dysgenesis; 45XO) has only one functional X
chromosomes. Option B describes child with Down Syndrome (Trisomy 21), this ability is not possible in the
average mature inborn) Option D is referring to Fragile X syndrome in which one long arm of an X chromosome
is defective. Klinefelters syndrome has a chromosomal pattern of XXY (47XXY) and definitely affects males.
Family. 5th ed. 176-177.
35. Saida, a patient who is new to the genetic clinic, asks you” What do you call the picture breakdown of the
number and size of a person’s chromosomes?” The nurse’s correct response is:
a. Karyotype
b. Pedigree
c. Pictograph
d. Partogram
ANSWER: A
A karyotype is a pictorial analysis of the number, form, and size of an individual’s chromosomes or the visual
presentation of chromosomes.
Other options are incorrect.
SITUATION: The nurse should have enough knowledge on reproductive health to be able to provide health
education and quality care.
36. The school nurse is teaching a group of female high school students about menstrual health. Which of the
following instructions made by the nurse is incorrect?
a. “You need iron supplementation to replace the iron lost in menses”
b. “Do not exercise during menses because it can cause amenorrhea”
c. “More rest may be helpful if dysmenorrhea interferes with sleep at night”
d. “You may apply local heat when you experience local pain”
ANSWER: B
Education about menstruation is an important component of sex education and an important nursing
responsibility. Girls who are well prepared for menstruation and view it as a positive occurrence are more likely
to cope up with the menstrual discomforts of pain effectively. Option B is the correct answer because exercise is
not contraindicated. It is recommended to continue moderate exercise during menses for a general sense of
well-being. It is only sustained excessive exercise (note the term) such as what professional athletes do that
can cause amenorrhea.
In this question, options a, c and d are all correct health teaching about menstrual health.
Family. 5th ed. 86-87.
37. A couple seeks fertility counseling because the woman has not been able to conceive, they were referred to
a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure
complaint indicates that the fallopian tubes are patent?
a. Back pain
b. Abdominal pain
c. Shoulder pain
d. Leg cramps
ANSWER: C
Hysterosalpingography (uterosalpingography), a radiologic examination of the fallopian tubes using a
radiopaque medium, is the most frequently used method of assessing tubal patency.
If the tubes are patent (open), pain is referred to the shoulder from a subdiaphragmatic collection of peritoneal
dye/gas. Option B - could be caused by uterine cramping, but might also be indicative of gas/dye collecting in
the uterus due to occluded tubes. Abdominal pain should be further evaluated; it would not be normal after
hysterosalpingography.
Options A and D are not related to the procedure.
38. A student asks the nurse about the amount of blood lost during menstruation. The nurse is correct in saying
that the blood loss per cycle amounts to:
a. 30 to 80 ml
b. 100 to 200 ml
c. 250 ml
d. 500 ml
ANSWER: A
Contrary to common belief, blood loss is only 30 to 80 ml of blood. It seems like there is more because of the
accompanying mucus and endometrial shreds. Options b, c and d are incorrect.
Family. 5th ed. 85.
39. A couple verbalizes to the clinic nurse that they experience problems whenever they engage in sexual
intercourse. They tell the nurse that the male partner ejaculates before he desires and before the partner’s
sexual satisfaction has been achieved. The nurse knows that this sexual dysfunction is referred to as:
a. Dyspareunia
b. Vaginismus
c. Erectile dysfunction
d. Premature ejaculation
ANSWER: D
Premature ejaculation is ejaculation before penile-vaginal contact. It is also used to refer to mean ejaculation
before the sexual partner’s satisfaction has been achieved. Premature ejaculation can be unsatisfactory and
frustrating for both partners. Sexual counseling for both partners to reduce stress and other concerns may be
helpful in alleviating the problem. Dyspareunia is pain during coitus while vaginismus is an involuntary
contraction of the muscles at the outlet of the vagina when coitus is attempted. Erectile dysfunction is the
inability of the male partner to maintain an erection.
Family. 5th ed.99.
40. Which of the following statements is true about fertility studies?
a. Initial testing involves only the partner suspected of infertility
b. Fertility studies should be undertaken more quickly with younger women
c. Women younger than 35 years of age should be referred for evaluation after 6 months of infertility
d. If a couple is very anxious about infertility, studies should not be delayed regardless of the couple’s age
ANSWER: D
If the couple is extremely anxious about infertility or know of a specific problem, studies should never be
delayed regardless of the couple’s age.
Option A - is incorrect because initial fertility assessment begins with a health history and physical examination
of both sexual partners.
Options B and C - is also incorrect because it is usually undertaken more quickly with older women. As a rule of
thumb, if the woman is younger than 35 years of age, she should be referred for evaluation after 1 year of
infertility. If she is older than 35 years, she should be referred after 6 months of infertility. Referral is
recommended sooner for older women because of possible age limitations associated with adoption, IVF and
embryo transfer which are common alternatives to natural childbearing.
SITUATION: Nurse Paula Abdul is working in the Baog Barangay Health Center assigned in the Maternity
Clinic. She is offering reproductive counseling to the group of reproductive women regarding menstrual cycle
and the physiologic changes that occur during this stage.
41. Her previous menstrual period was October 22 to 26 and her last menstrual period started November 20.
How many days is her menstrual cycle?
a. 28
b. 29
c. 30
d. 31
ANSWER: B
Estimating the menstrual cycle of the woman is done by counting the first day of the woman is done by
counting the first day of the woman’s last menstrual period (LMP) as day 1 and counting the first day of the
next menstrual period as the last day. Counting from October 22 as day 1 of menstruation up to November 20
as her last day, it can be derived that her menstrual cycle is 30 days.
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition. Page 84 – 85.
42. She was advised to observe her ovulation period which usually occurs during:
a. On the 4th day after she noticed a rise in her basal body temperature
b. Sixteen days from the first day of her cycle
c. Fourteen days from the first day of her cycle
d. Ten days after the cessation of her menstruation
ANSWER: B
To get the date of ovulation, 14 days is subtracted from the number of days of menstrual cycle since the day of
ovulation occurs on the 14th day before the next menstruation.
43. Which of the following statements is incorrect about ovulation?
a. At the time of the ovulation, the basal temperature can be seen to dip slightly, rise and stays at that level for
3-4 days until the next menstrual flow
b. There is an upsurge of the luteinizing hormone (LH) during ovulation
c. The midpoint of a woman’s cycle is the day of their ovulation
d. During ovulation, the ovum is set free and swept to the open end of the fallopian tube
ANSWER: C
Options a, b and d are all correct statements about ovulation. Option C is the answer because ovulation occurs
on approximately the 14th day before the onset of the next cycle. Because ovulation happens at the midpoint of
a 28-day cycle, many women think incorrectly that the midpoint of their cycle is the day of ovulation. If their
cycle is 20 days long, however, the day of their ovulation would be day 6 not on day 10 which is the midpoint of
their cycle. If the woman’s cycle is 32 days long, the day of their ovulation is on day 18 and not day 16.
44. The following statements are true about cervical mucus changes that occur as a signal of ovulation except
one:
a. The cervical mucus forms a fern like pattern when estrogen levels in the body are high
b. The cervical mucus forms fernlike patterns when progesterone levels in the body are high
c. Women who do not ovulate continue to show fern like pattern throughout their menstrual cycle.
d. None of the above
ANSWER: B
Ferning or arborization of cervical mucus occurs with high level of estrogen. These patterns become
unobservable at the beginning of the luteal phase, as it is just after ovulation, when progesterone becomes
dominant. Women who do not ovulate either continue to manifest with Ferning throughout the entire cycle
since progesterone never becomes dominant or never show Ferning because their estrogen levels constantly
remain low.
SITUATION: Menstrual cycle can be defined as episodic uterine bleeding in response to cyclic hormonal
changes. It is the process that allows for conception and implantation of a new life.
45. You are a clinical instructor in PRN School of Great Nurses, and conducting a lecture about the menstrual
cycle. Part of your evaluation you asked the students about the phase of menstrual cycle where ovulation
occurs. The student’s correct response is:
a. Proliferative
b. Secretory
c. Ischemic
d. Menstrual
ANSWER: A
Immediately after a menstrual flow (which occurs during the first 4 or 5 days of a cycle), the endometrium, or
lining of the uterus, is very thin, approximately one cell layer in depth. As the ovary begins to produce estrogen
(in the follicular fluid, under the direction of the pituitary FSH), the endometrium begins to proliferate. This
increase continues for the first half of the menstrual cycle (from approximately day 5 to day 14). This is where
ovulation takes place. During the Secretory phase the formation of progesterone in the corpus luteum causes
the thickening of the endometrial lining to get ready for possible implantation. If fertilization does not occur, the
corpus luteum in the ovary begins to regress after8 to 10 days. As it regresses, the production of estrogen and
progesterone decreases, this is known as the ischemic phase. The final phase of a menstrual cycle is the
discharged from the uterus as the menstrual flow or menses: blood from the ruptured capillaries, Mucin from
the glands, fragments of endometrial tissue and the microscopic, atrophied and unfertilized ovum.
46. One of your students asks what phase of the menstrual cycle is ideal for implantation of a fertilized egg:
a. Ischemic
b. Menstrual
c. Proliferative
d. Secretory
ANSWER: D
During the secretory phase, the uterine lining grows and becomes more vascular. It’s rich in glycogen, and
progesterone levels are high to help maintain a fertilized ovum. During the ischemic phase, the blood supply to
the uterus is diminished, and the endometrium becomes necrotic. During the menstrual phase, blood flow
occurs, and the lining of the uterus isn’t ready for implantation. During the proliferative phase, the
endometrium is inadequately perfuse, which doesn’t favor successful implantation.
47. Which phase of the menstrual cycle is characterized by a surge in luteinizing hormone (LH) from the
pituitary gland?
a. Proliferative
b. Ischemic
c. Menstrual
d. Secretory
ANSWER: D
After ovulation, the formation of progesterone in the corpus luteum, under the direction of LH (hence being
called the luteal phase), causes the endometrium to further increase its supply of glycogen, arterial blood,
secretory glands, amino acids, and water. Estrogen is increased during the proliferative phase under the
influence of the follicle-stimulating hormone. During the ischemic phase, estrogen and progesterone decrease if
fertilization does not occur. Menstrual flow discharges blood, mucus, tissues and the unfertilized ovum from the
uterus.
48. Which of the following is/are sign/s that estrogen is at its highest?
i. Breast tenderness
ii. Stretchability of cervical mucus to a length of 10 to 13 cm
iii. A rise in Basal Body Temperature
iv. Thick cervical mucus
a. i
b. i, ii
c. i, ii, iii
d. i, ii, iii, iv
ANSWER: B
Breast tenderness and stretchability of cervical mucus to a length of 10 to 13 cm are both indicative that
estrogen is at its highest. Breast changes are due to the increased stimulation of breast tissue by the high
estrogen level in the body. The cervical mucosa becomes thin, clear, watery and more favorable to
spermatozoa. The rise in BBT and thickening of cervical mucus is attributed to the influence of increasing levels
of progesterone in the body.
SITUATION: The care of childbearing and child rearing families is a major focus of nursing practice. Both
preconceptual and prenatal care are essential contributions to the health of a woman
49. A clinical instructor is discussing the menstrual cycle to a group of nursing students. The instructor asks the
nursing students to describe the follicle stimulating hormone and the luteinizing hormone and they accurately
respond by stating that:
a. FSH and LH are released from the anterior pituitary gland.
b. FSH and LH are secreted by the corpus luteum of the ovary.
c. FSH and LH are secreted by the adrenal gland.
d. FSH and LH stimulate the formation of milk during pregnancy.
ANSWER: A
FSH and LH, when stimulated by GnRH from the hypothalamus, are released from the anterior pituitary gland to
stimulate follicular growth and development, growth of the graffian follicle, and the production of progesterone.
Options BCD are incorrect.
Reference: Pillitteri, A. (2007). Maternal and Child Health Nursing: Care of the childbearing and childrearing
family. Volume. 5th edition. Lippincot William & Wilkins. Page 85-86
50. Nurse Jack, who works in a prenatal clinic, reviews Mrs. Miranda’s chart and notes the physician
documented that the client has a gynecoid pelvis. Nurse Jack then plans care for this client knowing that this
type of pelvis:
a. Is not favorable for labor.
c. Is a wide pelvis with a short diameter.
b. Has a narrow pubic arch.
d. Is the most favorable for labor and birth.
ANSWER: D
A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth.
Android would not be favorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet
that is adequate, with a normal or moderately narrow pubic arch. The platypelloid diameter is short, making the
outlet inadequate.
family. Volume. 5th edition. Lippincot William & Wilkins. Page 263
51. Mrs. Miranda tells Nurse Jack that she wants to know the sex of the fetus as soon as it can be determined.
Nurse Jack responds to the client, knowing that the sex of the fetus can be visually recognized as early as
week:
a. 4
b. 6
c. 8
d. 12
ANSWER: D
By the end of 12 week, the external genitalia of the fetus have developed to such a degree that the sex of the
fetus can be visually determined.
family. Volume. 5th edition. Lippincot William & Wilkins. Page 181-210.
52. Nurse Jack prepares to assess a fetal heart beat. She uses a fetoscope, knowing that the fetal heart beat
can first be heard with a fetoscope at what weeks of gestation?
a. 5
b. 10
c. 16
d. 20
ANSWER: D
The fetal heart beat can be heard with a fetoscope at 18 to 20 weeks of gestation. If a Doppler ultrasound is
used, the fetal heart rate can be detected as early as 8 to 12 weeks of gestation.
53. Nurse Jack determines that the fetal heart rate is normal if which of the following is noted?
a. 80 beats per minute.
b. 100 beats per minute.
c. 150 beats per minute.
d. 180 beats per minute.
ANSWER: C
The normal fetal heart rate is 120-160 beats per minute. If the fetal heart rate is less than 120 beats per
minute or more than 160 beats per minute with uterus at rest, the fetus may be in distress. Options a and b
indicates bradycardia, option d indicates tachycardia.
family. Volume. 5th edition. Lippincot William & Wilkins. Page 190, 191
54. A woman complains of having heavier bleeding than normal during her menstrual periods. The nurse
documents this subjective information in the client's chart as
a. Metrorrhagia
b. Menorrhagia
c. Polymenorrhea
d. Hypomenorrhea
ANSWER: B
Menorrhagia, or hypermenorrhea, refers to excessive menstrual bleeding. Metrorrhagia is bleeding of normal
amount, but at irregular intervals. Polymenorrhea refers to frequent menstrual cycles of less than 21 days.
Hypomenorrhea refers to decreased menstrual bleeding.
Reference: Littleton. Maternity Nursing care 8ed page 165
55. Selena is 11-years old and on her 6th grade. She already had her first menstrual period or menarche.
Which of the following is not a correct statement about this stage of puberty in girls?
a. Menstrual irregularities for the first year after the onset of menarche is a rule
b. Menstruation is highly dependent on ovulation
c. Oral contraceptives are not commonly recommended until the girl’s menstrual periods have become stabilized
d. Regular menstruation is expected to happen 1 to 2 years after menarche
ANSWER: B
Menstrual periods do not become regular until ovulation consistently occurs with them (menstruation is not
dependent on ovulation), and this does not happen until 1 to 2 years after menarche. This is one reason why
estrogen-based oral contraceptives are not commonly recommended until a girl’s menstrual periods have
become stabilized or an ovulatory (to prevent administration of a compound to halt ovulation before it is firmly
established).
Option A- irregular menstrual periods are the rule rather than the exception for the first year
56. When teaching an adolescent about ovulation, you would include that ovulation is initiated by a surge in
which of the following?
a. Luteinizing hormone.
b. Progesterone.
c. Follicle-stimulating hormone.
d. Estrogen.
ANSWER: A
Luteinizing hormone is released from the pituitary gland to stimulate ovulation on approximately the 14th day
of a typical cycle.
Reference: Adelle Pillitteri. Maternal and Child Health Nursing. 5th Edition. Page
SITUATION: A client comes to the reproductive health clinic seeking contraception. She says she is interested
in birth control but needs more information before making the decision.
57. Kara Dioguardi is a newlywed client with a paternal history of diabetes mellitus type 2. She asks what would
be the best contraception method for her. Which of the following method is considered most advisable for her?
a. IUD
b. Pills or COC’s
c. Subcutaneous implanted progestin
d. None of these
ANSWER: C
These forms of contraceptives are free of estrogen-related side effects. Pills or COC’s are not advisable since the
estrogen in the contraceptives may cause an increase in levels of lipid and cholesterol. The progesterone in oral
contraceptives, which interferes with insulin activity, increases blood glucose levels. Intrauterine devices are not
usually advised for diabetic mothers since they are at high risk for developing pelvic inflammatory disease due
to their difficulty in fighting infections.
58. A woman who decided to use natural family planning as a means of contraception states; “The ovum is
fertile for 48 hours after ovulation, the same as the sperm.” The nurse best response is:
a. “Correct; avoid intercourse during this time.”
b. “Sperm are fertile for 48 hours while the ovum is fertile for 24 hours.”
c. “Actually the ovum is fertile for 36 hours and sperm for 24 hours.”
d. “Let me explain again the ovum may be fertile up to 72 hours.”
ANSWER: B
Usually only one ovum reaches maturity each month. Once it is released, fertilization occurs fairly quickly
because an ovum is capable of fertilization for only 24 hours. After that time, it atrophies and becomes non-functional. Because the
functional life of a spermatozoon is about 48 hours, possibly as long as 72 hours, the
total critical time span during which sexual relations must occur for fertilization to be successful is bout 72
hours (84 hours before ovulation plus 24 hours afterward)
59. A client with a history of toxic shock syndrome comes to the reproductive health clinic seeking
contraception. Based on this information, which method is contraindicated for this client?
a. Female condom
b. Spermicide
c. Cervical cap
d. Norplant
ANSWER: C
Cervical cap is a barrier method of contraception it is made up of soft rubber, are shaped like a thimble, and fit
snugly over the uterine cervix. Contraindications fro the use of caps are as follows: abnormally short or long
cervix, previous abnormal pap smear, history of TSS (Toxic Shock Syndrome), an allergy to latex or spermicide,
history of PID, cervicitis, or papillomavirus infection, a history of cervical cancer and undiagnosed vaginal
bleeding. Other contraceptive methods that cannot be recommended to client with history of TSS are IUD and
diaphragm.
60. A woman tells the nurse, “I don’t need to use any contraception because I plan on breastfeeding
exclusively.” Based on which knowledge should the nurse respond?
a. Breast-feeding women should not use contraception because it will decrease their milk supply.
b. Women who exclusively breast-feed do not ovulate
c. Ovulation can occur even in the absence of menstruation.
d. The birth control pill is the best form of contraception for breast feeding women.
ANSWER: C
As long as a woman is breastfeeding the infant, there is some natural suppression of ovulation. However,
women using the LAM (lactated Amenorrhea Method) may still ovulate but not menstruate while breast feeding,
the woman may still be fertile even if she has not had a period since childbirth. Oral contraceptive pills
especially with high estrogen content are still not recommended with breastfeeding women until their milk
supply is well establish. And early studies found that breast-fed infants had lower weight gains when the mother
is taking Oral contraceptive containing high level of estrogen during breast feeding because estrogens
decreases the woman’s milk production.
SITUATION: Mrs. X comes to the reproductive health clinic seeking contraception. She says she is interested in
birth control but needs more information before making the decision.
61. The risk of ectopic pregnancy is the greatest with the use of what contraceptive measures?
a. Combination pill
b. Norplant
c. Progesterone IUD
d. Tubal ligation
ANSWER: C
Ectopic pregnancy, as well as infection, accidental pregnancy, and expulsion of the device, are adverse effects
of the progesterone IUD. The primary risk for COCs is the risk of thrombus formation. Ectopic pregnancy is not
a risk from Norplant. Ectopic pregnancy is not a risk from tubal ligation.
Reference: Littleton. Maternity Nursing Care 8 ed page 219, 224, 851
62. Mrs. X has a history of toxic shock syndrome. Based on this information, which method is contraindicated
for this client?
a. Female condom
b. Spermicide
c. Cervical cap
d. Norplant
ANSWER: C
Cervical cap is a barrier method of contraception it is made up of soft rubber, are shaped like a thimble, and fit
snugly over the uterine cervix. Contraindications fro the use of caps are as follows: abnormally short or long
cervix, previous abnormal pap smear, history of TSS (Toxic Shock Syndrome), an allergy to latex or spermicide,
history of PID, cervicitis, or papillomavirus infection, a history of cervical cancer and undiagnosed vaginal
bleeding. Other contraceptive methods that cannot be recommended to client with history of TSS are IUD and
diaphragm.
63. Mrs. X says she heard from a friend that you stop having periods once you are on "the pill." The most
appropriate response would be:
a. "If your friend has missed her period, she should stop taking the pills and get a pregnancy test as soon as possible."
b. "Missed periods can be very dangerous and may lead to the formation of precancerous cells."
c."The pill prevents the uterus from making much endometrial lining; that is why periods may often be scant or
skipped occasionally."
d. "The pill should cause a normal menstrual period every month. It sounds like your friend has not been taking
the pills properly."
ANSWER: C
This is a true statement and an appropriate response by the nurse. Option A: Because this can occur as a
normal effect of oral contraceptives, this statement is not an appropriate nursing response. Option B: Because
this can occur as a normal effect of oral contraceptives and a noncontraceptive benefit of COCs is protection
against ovarian and endometrial cancer, this statement is not an appropriate nursing response. Option D:
Because this can occur as a normal effect of oral contraceptives, this statement is not an appropriate nursing
response.
Reference: Littleton. Maternity Nursing Care 8 ed page 217-218
64. Mrs. X chooses to use Depo-Provera. Which information would be most important to provide to Mrs. X?
a. Amenorrhea seldom occurs with the use of DMPA.
c. DMPA provides protection against STDs.
b. Menstrual changes are a common side effect of DMPA.
d. DMPA injections must be administered every month.
ANSWER: B Menstrual changes are very common for the duration of the use of DMPA. Option A: Heavy and irregular
bleeding, not amenorrhea, are common adverse effects of DMPA. Option C: This is a false statement. Option D:
DMPA injections are administered every 3 months.
Reference: Littleton. Maternity Nursing Care 8 ed page 230-231
SITUATION: Sexuality is a multidimensional phenomenon that includes feelings, attitudes, and actions.
65. A client expresses concern about his son who is a homosexual. He states, "Nag-aalala ako sa kanya, alam
ko sa impyerno ang tuloy nya.” In responding to this client, the nurse should consider which of the following
important information?
a. Sexual development is genetically determined and not affected by environment.
b. What constitutes normal sexual expression varies among cultures and religions.
c. Normal sexuality is described as whatever behaviors give pleasure and satisfaction to those adults involved.
d. Since alternative lifestyles are now so well accepted in society, this parent should not feel so much concern.
ANSWER: B
This nurse should remember that culture and religion have a big impact upon what a person believes to be
normal sexual behavior. Even though many consider whatever activity gives pleasure and satisfaction to the
involved adults to be normal, some cultures and religions do not hold that belief. While alternative lifestyles are
well accepted in some cultures, apparently that is not true in this parent's belief patterns. Sexual development
has both genetic and environmental components.
Reference: Kozier and Erb’s Fundamentals of Nursing 8th edition page 1025-1026
66. Mrs. Pampam is very concerned about her 20-month old baby who frequently touches his genitals every
diaper changes. How should Nurse Hannah respond to her concern?
a. This should be discouraged
c. At 18 months this touching is not a sexual experience.
b. Masturbation is normal at this age
d. Genital stimulation should not be occurring until the age of 2 1/2 or 3.
ANSWER: C
At 18 months, exploration and touching of the genital area is no different than exploration and touching of
fingers and toes. This touching is not considered a sexual experience. Masturbation to orgasm can occur as
early as age 3, although males do not ejaculate until after puberty. At around age 2-1/2 or 3 the child begins to
differentiate between genital differences and to identify as a male or female. There is no need to discourage
genital exploration at 18 months.
67. Nurse Rhea is devising ways to teach the young girls in relieving menstrual cramps. Her strategy should
focus on:
a. Avoiding uterine contraction
c. Decrease in estrogen production
b. Ways to minimize menstrual flow
d. Increasing the blood flow to the uterine muscle
ANSWER:D
Menstrual cramping is a result of the muscle ischemia that occurs when the client experiences powerful uterine
contractions. Increase of blood flow to the uterine muscle through rest, some exercises, application of heat to
the abdomen, and presence of milder uterine contractions (such as those associated with orgasm) can decrease
pain and cramping. There is no connection between the actual amount of flow and pain. Estrogen production
should follow normal patterns and should not be altered.
68. A conservative mother expresses concern about the school planning a class on sexuality for preschoolers.
The nurse should include which concept in discussing her concerns?
a. Children are sexual beings from before birth.
c. During this age sexuality education should come from parents.
b. Sexual activity begins at an earlier age.
d. Understanding sexuality is a part of growth and development.
ANSWER: C
While all of these statements are true, the primary consideration is that early childhood education on sex should
come primarily from parents.
Reference: Kozier and Erb’s Fundamentals of Nursing 8th edition page 1025
SITUATION: As a result of changing social values and lifestyles, many women are interested in reproductive
life planning and so are able to talk easily about types and methods today.
69. A nurse teaches the patient who is inquiring about a diaphragm. Which information will be more likely
included in her teaching?
a. The diaphragm comes in one size
b. After use, it should be washed, dried and applied with powder to keep moist from forming
c. The diaphragm can stay for more than 24 hours after coitus
d. Spermicide use will increase its effectiveness
ANSWER: D
Although the use of spermicide is not required for diaphragm, use of of spermicidal gel with a diaphragm
combines a barrier and a chemical method of contraception. With this, the failure rate of the diaphragm is as
low as 6% (ideal) to 16% (typical use). The diaphragm should be refitted if the client gain or loses weight and
after giving birth. Do not keep the diaphragm in for longer than 24 hours because of the risk of toxic shock
syndrome. After coitus, wash the diaphragm with warm water and mild soap after removing it. Thoroughly dry
it and store it in its container. Do not use talcum or baby powder on the diaphragm because these products can
break down the rubber.
ed. Page 132-133
70. The nurse working in a family planning clinic is aware that oral contraceptives are not contraindicated for
which of the following patients?
a. A 30-year old woman who smokes more than 15 cigarettes a day
b. A 30-year old diabetic woman
c. A 10 week postpartum client who is not breastfeeding
d. A client who experiences migraine with aura
ANSWER: C
One contraindication for OCs use is those who are breastfeeding and those clients who are less than 6 weeks
postpartum. Therefore option C is the correct answer since the client is at 10 weeks postpartum and does not
breastfeed. Other options are contraindicated.
ed. Page 125
71. The lactational amenorrhea method (LAM) is a method of avoiding pregnancies which is based on the
natural postnatal infertility that occurs when a woman is amenorrheic. LAM is 98% - 99.5% effective if the
woman meet the criteria. Which is not included?
a. Breastfeeding must be the infant’s only (or almost only) source of nutrition
b. Infant must be less than 6 months
c. The infant must feed every 4 hours during the day and every 6 hours during night
d. None of the above
ANSWER: D
For women who meet the criteria (listed below), LAM is 98% - 99.5% effective during the first six months
postpartum:
•
Breastfeeding must be the infant’s only (or almost only) source of nutrition. Feeding formula, pumping
instead of nursing, and feeding solids all reduce the effectiveness of LAM.
•
The infant must breastfeed at least every four hours during the day and at least every six hours at
night.
•
The infant must be less than six months old.
•
The mother must not have had a period after 56 days post-partum (when determining fertility, bleeding
prior to 56 days post-partum can be ignored).
Reference: "Comparison of Effectiveness". Planned Parenthood. April 2005.
http://www.plannedparenthood.org/birth-control-pregnancy/birth-control/effectiveness.htm.
:Hatcher, RA; Trussel J, Stewart F, et al. (2000). Contraceptive Technology (18th ed.)
ed. Page 123
72. Mrs. Milagring is planning to breastfeed after giving birth. She had history of thrombophlebitis. The
appropriate birth control method for this client are?
1. Combination Oral Contraceptives (COC)
3. Diaphragm
5. Depo-provera
2. Mini-pills
4. Condom
a. All except 1 and 2
b. All except 1
c. 3 and 4
d. All of the above
ANSWER: B
Because both Mini-pills and Depo-provera contains only progesterone, it can be used during breastfeeding.
Depo-provera and mini-pills are safe to use for client with thrombophlebitis. COCs (containing estrogen and
progesterone) are contraindicated for client with history of thrombophlebitis. Condoms can be used anytime,
and are commonly used temporarily while breastfeeding or to space out babies. Diaphragms and cervical caps
need to be re-fitted at 6 weeks postpartum.
ed. Page 126, 129
73. An Intrauterine device is being fitted to a client. The nurse understands that IUD prevents pregnancy by:
a. Creating a sterile inflammatory process that prevents implantation
b. Suppressing secretion of FSH and LH
c. Blocking the fallopian tube to prevent entry of the ovum
d. Killing the spermatozoa before they can enter the cervix
ANSWER: A
The intrauterine device (IUD) is a small plastic object that is inserted into the uterus through the vagina. Today,
the IUD is thought to be preventing fertilization as well as creating a local sterile inflammatory condition that
prevents implantation. When copper is added to the device, sperm mobility appears to be affected. These
decrease the possibility that the sperm will successfully cross the uterine space and reach the ovum. In some
IUD’s (not copper based) there is a drug reservoir of progesterone in the stem. This drug reservoir gradually
diffuses into the uterus through the plastic. It both prevents endometrium proliferation and thickens cervical
mucus. Option B: COCs. Option C: Incorrect. Option D: Action of the spermicides.
ed. Page 129-130
74. A woman, who is sexually active and has been taking pills for 6 months, calls the clinic and tells the nurse
that she forgot to take her pill on the fourth row yesterday. The nurse instructs the client to:
a. Ignore it just take the next pill on time the next day
b. Discard the whole pack, use an alternative form of birth control
c. Take the forgotten pill immediately plus the pill scheduled for that day
d. Throw out the rest of the pack and start a new pack of pills
ANSWER: A
Each packet contains 21 hormonal tablets (the first three rows) and 7 placebo tablets (4th row), non hormonal
and usually containing iron, . Each of the 21 hormonal tablets contains the same amount of estrogen and
progesterone. If the pill omitted was one of the placebo ones, ignore it and just take the next pill on time the
next day.
ed. Page 125
SITUATION: According to Master and John who conducted a research on sexual responses, they described the
human sexual responses as a cycle with four discrete stages: excitement, plateau, orgasm and resolution.
75. Excitement phase occurs with physical and psychological stimulation that cause changes in the body of the
sexual partners. Which of the following changes does not occur during this sexual phase?
a. Increased blood supply leading to vasocongestion and increasing muscular tension
b. The vagina widens in diameter and increase in length
c. In woman clitoris is drawn forward and retracts under the clitoral prepuce
d. In men, scrotal thickening and elevation of testes occurs
ANSWER: C
This change occurs during the plateau stage before orgasm is reached, in woman – the clitoris is drawn forward
and retracts under the clitoral prepuce; the lower part of the vagina becomes extremely congested (formation
of the orgasmic platform)
Excitement occurs with physical and psychological stimulation that causes parasympathetic stimulation. This
leads to arterial dilation and venous constriction in the genital area. The resulting blood increased blood supply
leads to vasocongestion and increase muscular tension.
In women, this vasocongestion causes the clitoris to increase in size and mucoid fluid to appear on vaginal walls
as lubrication.
The vagina widens in diameter and increase in length
In men, penile erection occurs as well as scrotal thickening and elevation of the testes
76. Which of the following sexual stages is considered to be the shortest according to Masters and Johnson?
a. Excitement
b. Plateau
c. Orgasm
d. Resolution
ANSWER: C
Orgasm is the shortest stage in sexual response cycle; orgasm is usually experienced as intense pleasure
affecting the whole body, not just the pelvic. It is also a highly personal experience; descriptions of orgasm vary
greatly from person to person.
Excitement - occurs with physical and psychological stimulation that causes parasympathetic stimulation
Plateau – is reached just before orgasm
Resolution – this period usually takes 30 minutes for both men and women
77. Because people are individuals, types of sexual expression are individualized. Malan Dee is a masochist.
Who among these men cannot be partnered with her because serious injury may result?
a. Mali Bo-og who is obtaining sexual arousal by looking at other’s person’s body
b. Mr. Uma Rayka who loves to inflict pain to achieve sexual arousal
c. Mabo Su who loves to see visual materials to achieve arousal
d. Majileg who loves to masturbate
ANSWER: B
A masochist loves to receive pain to achieve sexual satisfaction, while a sadist wants to inflict pain to achieve
sexual satisfaction. If they will engaged in the sexual act together, the sadist will not achieved the sexual
satisfaction he seeks because his partner can endure the pain, thus inflict more pain that may endanger the
masochist.
78. A female client asks the nurse how long will it take for her husband to be aroused again after an orgasm.
Based on the nurse’s knowledge about sexual response cycle, sexual arousal will be possible in:
a. 30 minutes after an orgasm
c. 15 minutes after an orgasm
b. 10 minutes after an orgasm
d. 3 minutes after an orgasm
ANSWER: A
During the Resolution phase, the body slowly returns to its normal level of functioning, and swelled and erect
body parts return to their previous size and color. This phase is marked by a general sense of well-being,
enhanced intimacy and, often, fatigue. Some women are capable of a rapid return to the orgasm phase with
further sexual stimulation and may experience multiple orgasms. Men need recovery time after orgasm, called a
refractory period, during which they cannot reach orgasm again. The duration of the refractory period varies
among men and changes with age. But the average for all men is half-an hour.
Reference: Adelle Pillitteri. Maternal and Child Health Nursing. 5th Edition. Page 109
SITUATION: Maternal and child health nursing is family-centered; assessment must include both family and
individual assessment data.
79. Nurse Hannah who is encouraging a woman to always come for her prenatal care is doing which phase of
health care?
a. Health promotion
b. Health maintenance
c. Health restoration
d. Health rehabilitation
ANSWER: B
The nurse is performing health maintenance. Health maintenance is defined as intervening to maintain health
when risk of illness is present. Health restoration is when educating clients to be aware of good health through
teaching and role modeling. Health restoration is prompt diagnosis and treating of illness using interventions
that will return client to wellness most rapidly. Health rehabilitation is preventing further complications form an
illness.
Reference: A. Pillitteri. Maternal and Child Health Nursing 6th edition Page 7
80. A nursing student asks her clinical instructor (CI) whether maternal and child health nursing is a profession.
What qualifies an activity as a profession?
a. Members supervise other people
c. Members enjoy good working conditions
b. Members use a distinct body of knowledge
d. Members receive relatively high pay
ANSWER: B
One of the requirements of a profession (together with other critical determinants, such as member-set
standards, monitoring of practice quality, and participation in research) is that the concentration of a discipline’s
knowledge flows from a base of established theory.
81. A client comes to the women's clinic, stating she has had a positive home pregnancy test. The client states
that her last menstrual cycle was 2 months ago. According to this time frame, the client would be in which of
the following?
a. Embryonic phase
b. Fetal phase
c. Second trimester
d. Third trimester
Answer: A
Traditionally, pregnancy has been divided into three periods called trimesters, each of which lasts 3 months.
The embryonic phase is the period during which the fertilized ovum develops into an organism with most of the
features of the human. This period is considered to encompass the first 8 weeks of pregnancy. The fetal phase
of development is characterized by a period of rapid growth in the size of the fetus and corresponds to the
second trimester of pregnancy. The third trimester is the last 3 months of the pregnancy period.
Reference: Kozier and Erb’s Fundamentals of Nursing 8th edition Page 367
82. A nurse is working with a particular cultural group in which it is not uncommon for grandparents to live with
their married children and to assist with child rearing and discipline issues. This is an example of which of the
following?
a. Blended family
b. Traditional family
c. Two-career family
d. Intragenerational family
Answer: D
In some cultures and as people live longer, more than two generations may live together in an intragenerational
setting, as described. A two-career family is one where both partners are employed. A blended family occurs
when existing family units join together to form new families. A traditional family is viewed as an autonomous
unit in which both parents reside in the home.
Reference: Kozier and Erb’s Fundamentals of Nursing 8th edition Page 430
83. A nurse is conducting a family assessment and is focusing, for the moment, on the family members'
communication patterns. Which of the following indicate that there are existing or potential problems with
family communication?
a. Disagreements are not addressed among members, rather ignored by the person who does the most talking.
b. All members are participating in the discussion equally, some quite vocally.
c. The verbal communication is congruent with the nonverbal messages.
d. A few of the members just sit and listen.
ANSWER: A
This option describes an authoritarian setting where other members may be cautious in expressing their
feelings because of power struggles, hostility, or anger. Nurses should pay special attention to who does the
talking for the family, which members are silent, how disagreements are handled, and how well the members
listen to one another and encourage the participation of others. Nonverbal communication is important because
it gives valuable clues about what people are feeling. Even though some members are more vocal, at least all
are participating in the discussion. Verbal communication should be congruent with nonverbal cues. Listening is
an art, and not all members of a family need to speak in the same setting.
Reference: Kozier and Erb’s Fundamentals of Nursing 8th edition Page 434-435
84. Nurse Isabel is conducting a family assessment to a pregnant client and asks the following question: "How,
as a family, do you deal with disappointments or stressful changes that occur and affect the members of your
family?" The nurse is trying to identify:
a. Health beliefs
b. Family communication patterns
c. Family coping mechanisms
d. Potential family problems
ANSWER: C
Family coping mechanisms are behaviors that families use to deal with stress or changes imposed from either
within or without. The coping mechanisms families and individuals develop reflect their individual
resourcefulness. The assessment of coping mechanisms is a way to determine how families relate to stress.
Reference: Kozier and Erb’s Fundamentals of Nursing 8th edition Page 434-435
85. Nurse Klara is discussing the female reproductive system to her first year nursing students. Which of the
following statements if made by a student requires further teaching?
a. “Clitoris, which is a non-erectile tissue, is the primary site of sexual arousal among women.”
b. “Labia majora are two-folds of pigmented skin extending from the mons pubis to the perineum.
c. “Hymen is a membranous tissue circling the vaginal introitus.”
d. “Vagina is the organ of copulation of females.”
ANSWER: A
Clitoris is an erectile tissue which is said to be the primary site of sexual arousal among women. Labia majora
are longitudinal skin folds of pigmented skin extending from the mons pubis to the perineum. Labia minora are
soft longitudinal skin folds located in between the labia majora. Hymen is a membranous tissue circling the
vaginal introitus. When torn during coitus, bleeding may result. Vagina is the organ of copulation of females. It
also serves as the birth canal of the fetus during delivery. Vaginal canal is acidic with a pH of 4.5.
Reference: Maternal Newborn Nursing 4th edition by Barbara R. Stright; p.15
86. Fertilization of the mature ovum occurs in which of the following areas?
a. In the ovary
b. In the uterus
c. In the distal third of the fallopian tube
d. In the wall of the myometrium
ANSWER: C
The muscular action of the fallopian tube and movement of the cilia within the tube transport the mature ovum
through the fallopian tube. Fertilization normally occurs in the distal third of the fallopian tube near the ovaries.
The ovum, fertilized or not, enters the uterus about 3 days after its release from the ovary. The other options
are incorrect.
87. A woman comes to the clinic asking to be tested if she is pregnant. Which of the following hormones found
in her urine would confirm the diagnosis?
a. Follicle stimulating hormone
b. Human chorionic gonadotropin
c. Prolactin
d. Progestin
ANSWER: B
Human chorionic gonadotropin is the first hormone to be produced. This hormone can be found in the maternal
blood and urine as early as the first missed menstrual period through about the 100th day of pregnancy.
Reference: Pillitteri, A. (2007) Maternal and Child Health Nursing: Care of the Childbearing and Childbearing
Family. 5th Edition. Vol. 1. Page 180
88. The nurse is teaching a pregnant client about the hormones of pregnancy and the woman asks about the
purpose of estrogen. The nurse is correct in saying that:
a. Estrogen maintains the uterine lining for implantation
b. Estrogen prevents the involution of the corpus luteum and maintains the production of progesterone until the
placenta is formed
c. Estrogen stimulates the uterine development to provide an environment for the fetus and stimulates the
breasts to prepare for implantation
d. Estrogen stimulates the metabolism of glucose and the conversion of glucose to fat
ANSWER: C
Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to
prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle.
Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat. Human
chorionic gonadotropin (hCG) prevents involution of the corpus luteum and maintains the production of
progesterone until the placenta is formed.
89. The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the
nurse should know that ovulation usually occurs:
a. two weeks before menstruation.
c. immediately before menstruation.
b. immediately after menstruation.
d. three weeks before menstruation.
ANSWER: A
Ovulation occurs 14 days before the first day of the menstrual period (A). While ovulation can occur in the
middle of the cycle, or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day
cycle. For many women, the length of their menstrual cycle varies.
Family. 5th ed.
90. Nurse Isabel asks his nursing students: “What structure secretes progesterone in relatively large
quantities?” Her students deserve a treat to McDonalds if they answer which of the following?
a. Corpus luteum
b. Adrenal cortex
c. Endometrium
d. Anterior pituitary gland
ANSWER: A
Progesterone is secreted mainly by the corpus luteum. It helps prepare the endometrium for possible
implantation of a fertilized ovum. If the egg is not fertilized, the corpus luteum stops secreting progesterone
and decays (after approximately 14 days in humans). It then degenerates into a corpus albicans, which is a
mass of fibrous scar tissue. Adrenal cortex secretions contain only minute quantities of progesterone.
Endometrium is influenced by progesterone secretion but does not secrete it.
Pituitary gland secretions stimulate the target gland (e.g., corpus luteum of the ovary) to secrete progesterone.
91. The nurse is sharing her knowledge about family planning and contraceptive methods to a group of
adolescents. Which of the following statements regarding oral contraceptives is incorrect?
a. “Oral contraceptives are not recommended to women who smoke cigarettes.”
b. “Oral contraceptives are effective only during the month by which they are taken.”
c. “Oral contraceptives do not put a risk for women to develop embolism.”
d. “Breast feeding mothers are not good candidates to use oral contraceptives.”
ANSWER: C
Oral contraceptives are combined estrogen and progesterone preparation in tablet form; inhibit the release of
FSH, LH and ovum. The tablets are taken daily and are available in numerous hormone combinations. Biphasic
and triphasic contraceptives closely mirror normal hormonal fluctuations of the menstrual cycle. They are about
97% effective. They are among the most reliable contraceptive methods and are convenient to use. They are
protective against ovarian and endometrial cancer, benign breast disease, ovarian cysts, ectopic pregnancy, PID
and anemia. Oral contraceptives tend to decrease menstrual cramps and pain.
They should not be used by women who smoke or by women with a history of thrombophlebitis, circulatory
disease, varicosities, diabetes, or liver disease. They offer no protection against STIs. Side effects may include
breakthrough bleeding, nausea, vomiting, susceptibility to vaginal infections, thrombus formation, edema,
weight gain, irritability, headache, shortness of breath and pain in the calf. Breastfeeding is contraindicated.
Reference: Maternal Newborn Nursing 4th edition by Barbara R. Stright; pp.37-38
92. For a client taking oral contraceptives, the nurse should stress the importance of increasing her dietary
intake of:
a. Calcium
b. Potassium
c. Vitamin E
d. Vitamin B6
ANSWER: D
Oral contraceptives may cause deficiencies of vitamins C, B6, and B9 (folic acid)
Option A – it is unnecessary to increase the intake of calcium when taking oral contraceptives
Option B – there is no interrelationship between oral contraceptives and dietary intake and potassium
Option C – there is no clinical evidence that links oral contraceptives and a deficiency in this vitamin
childrearing family. Volume. 5th edition. Lippincot William & Wilkins. Page 111 – 113.
93. The school nurse is teaching a group of female high school students about menstrual health. Which of the
following instructions made by the nurse is incorrect?
a. “You need iron supplementation to replace the iron lost in menses”
b. “Do not exercise during menses because it can cause amenorrhea”
c. “More rest may be helpful if dysmenorrhea interferes with sleep at night”
d. “You may apply local heat when you experience local pain”
ANSWER: B
Education about menstruation is an important component of sex education and an important nursing
responsibility. Girls who are well prepared for menstruation and view it as a positive occurrence are more likely
to cope up with the menstrual discomforts of pain effectively. Option B is the correct answer because exercise is
not contraindicated. It is recommended to continue moderate exercise during menses for a general sense of
well-being. It is only sustained excessive exercise (note the term) such as what professional athletes do that
can cause amenorrhea.
In this question, options a, c and d are all correct health teaching about menstrual health.
Family. 5th ed. Page 86-87.
SITUATION: The more women know about fetal development, the easier it is for them to begin to think of the
pregnancy not as something interesting happening to them, but an act that is producing a separate life. The
following questions refer to the growth and development and assessment of fetal health.
94. Alicia is a 17-year-old primigravida, asks the nurse how the fetus gets its oxygen for breathing. The nurse
should correctly state that the mechanism used to transport this element along with the carbon dioxide, and
some electrolytes such as sodium and chloride is:
a. Diffusion
b. Facilitated diffusion
c. Active transport
d. Pinocytosis
ANSWER: A
Oxygen, carbon dioxide, sodium and chloride cross the placenta by this method. It occurs when there is a
greater concentration of a substance on one side of a semipermeable membrane than on the other, substances
of correct molecular weight cross the membrane from the area of higher concentration to the area of lower
concentration.
Facilitated diffusion – to ensure that the fetus receives enough concentrations of necessary growth substances,
some substances cross the placenta more rapidly or more easily without the expenditure of energy than would
occur if only if only simple diffusion were operating. Glucose is an example of a substance that crosses by this
process
Active transport – this process requires energy and action of an enzymes to facilitate transport. Amino acid
concentrations in the fetal plasma are twice what they are in the mother, a situation that must occur to provide
building substances for active fetal growth.
Pinocytosis – is the absorption by the cellular membrane of microdroplets of plasma and dissolved substances.
Gamma globulin, lipoproteins, phospholipids, and other molecular structures those are too large for diffusion
and that cannot participate in active transport cross this manner.
95. Nurse Selya is working in the neonatal care unit. She received a 3-day old infant diagnosed to have
diaphragmatic hernia. She knows that this anatomical problem arises at what age of the fetus in the utero?
a. End of 3rd week of intrauterine life
c. End of 7th week of intrauterine life
b. End of 24th week of intrauterine life
d. End of 4th week of intrauterine life
ANSWER: C
Until the 7th week of life, the diaphragm does not completely divide the thoracic cavity from the abdomen. This
means that during the 6th week of life lung buds may extend down into the abdomen, re-entering the chest
only as the chest’s longitudinal dimension increases and the diaphragm becomes complete (at the end of the
7th week). If the diaphragm fails to close completely, the stomach, spleen, liver or intestines may enter the
thoracic cavity. This causes the child to be born with a diaphragmatic hernia.
Option A – at the 3rd week of intrauterine life, the respiratory and digestive tracts exists as a single tube./
Option B – alveoli and capillaries begin to form between the 24th and 28th weeks
Option D – by the end of the 4th week, a septum begins to divide the esophagus from the trachea. At the same
time, lung buds appear on the trachea.
96. Mrs. Yolanda, an expectant mother, asks Simon, a student nurse, how long will she refer to her baby as an
embryo. Which of the following statements is the best explanation by the student nurse?
a. From the time of implantation until 5-8 weeks, the baby is called an embryo
b. After the 20th week of pregnancy, the baby is called a zygote
c. The baby will be called a fetus as soon as the placenta forms
d. The term is used during the time before fertilization
ANSWER: A
The fertilized ovum is called the zygote. One implanted, the zygote is already called an embryo. The human
embryo is a rapidly growing formation of cells but does not resemble a human being yet. This takes about 5-8
weeks from the time of implantation. After 8 weeks until term, it is already referred to as the fetus.
Family. 4th ed. 176
97. During the first eight weeks of gestation, progesterone and estrogen are produced principally by the:
a. Trophoblasts
b. Placenta
c. Anterior pituitary
d. Corpus luteum
ANSWER: D
Some spontaneous abortions occur at this time (8 to 12 weeks), when hormonal production by corpus luteum
decreases, and this function should be taken up b y the developing placenta. Answers a, b, and c are incorrect
because trophoblasts and anterior pituitary do not produce progesterone and estrogen and the placenta is not
yet mature enough in this time period.
Family. 4th ed.
98. 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.
c. The right ventricle to the aorta.
b. The aorta to the pulmonary veins.
d. The pulmonary artery to the aorta.
ANSWER: D
Because the fetal lungs are not inflated, blood must be diverted past them. The ductus arteriosus helps to do
this by shunting blood from the pulmonary artery to the aorta.
ed.
99. In early pregnancy, a woman is scheduled for a sonogram for detection of the gestational sac. As part of
your instructions before this study, you would tell her:
a. Not to drink any fluid 1 hour before the study.
b. To be prepared for a catheter to be inserted before the study.
c. To empty her bladder just before the study.
d. To drink a large amount of fluid before the study.
ANSWER: D
A full bladder before a sonogram helps to stabilize the uterus and best transmit the sound waves to the uterine
cavity.
ed.
100. A pregnant woman is scheduled for an amniocentesis. She asks you how the physician can be certain the
placenta is not punctured during this. Your best response is:
a. “Placentas always form on the posterior uterine wall.”
c. “A sonogram to locate it will be done first.”
b. “It would not be harmful even if it were punctured.”
d. “A uterus feels soft over the placenta site.”
ANSWER: C
A sonogram is usually taken before amniocentesis to locate the placenta to avoid accidental puncture.
ed.
HIGH RISK PREGNANCY/COMPLICATIONS OF PREGNANCY
SITUATION: A high risk pregnancy is one in which some condition puts the mother, the developing fetus, or
both at higher-than-normal risk for complications during or after the pregnancy and birth.
1. Which of the following measures would be least effective in reducing the stress associated with a high risk
pregnancy?
a. Educate the woman and her family regarding health problem complicating pregnancy and the components of
the treatment plan.
b. Encourage the participation of both the woman and her family in the plan of care
c. Arrange for home care if possible
d. Reducing visitor hours, if hospitalization is required, to facilitate rest and relaxation
ANSWER: D
Women experiencing a high risk pregnancy often need the diversion and support that visitors can offer.
Therefore, visiting hours should be individualized to meet the needs of the high risk pregnant woman
Reference: Adele Pillitteri. Maternal and Child Health Nursing 5th edition Page
2. A pregnant woman at 10 weeks gestation calls the prenatal clinic to report that she is experiencing vaginal
bleeding. What should the nurse’s initial response be?
a. “Describe your bleeding in terms of amount, duration, and characteristics”
b. “Go to bed and rest for the remainder of the day and call if the bleeding continues”
c. “Come o the clinic as soon as you can, so I can check you”
d. “You are probably miscarrying. Bring in all your pads and come to the clinic now”
ANSWER: A
Since the woman has provided very little information, the nurse must obtain specific data regarding the bleeding
in order to determine the appropriate action. Option B and C may be recommended depending on the data
collected. While spontaneous abortion is certainly a possibility there is not yet enough information to make this
judgment
3. When assessing a pregnant woman, the nurse must be alert for risk factors associated with pregnancy-induced
hypertension. Which of the following would be a risk factor for PIH?
a. Multigravida
c. Diabetes mellitus
b. Age between 25 and 32 years
d. Dietary deficiency of iron and magnesium
ANSWER: C
PIH are more common with first exposure to chorionic villi (primigravida) or increased amount of chorionic villi as
with multiple gestations. Age of risk is <20 or >35 years. Protein and calcium deficiency have been associated
with PIH
Reference: Adele Pillitteri. Maternal and Child Health Nursing 5th edition Page 426
4. A woman with severe preeclampsia is being treated with an IV infusion of MgSO4. This treatment will be
evaluated as successful if:
a. BP is reduced to prepregnant baseline
c. Seizures do not occur
b. Deep tendon reflexes become hypotonic
d. Diuresis reduces fluid retention
ANSWER: C
Magnesium sulfate is a CNS depressant given primarily to prevent seizures. A temporary decrease in BP can
occur but it is not the purpose for giving medication. Hypotonia is a sign of an excessive serum level of
magnesium. Diuresis is not expected outcome form magnesium administration
5. A pregnant woman in pre-eclampsia is to receive magnesium sulfate IV. Which assessment would be most
important to make before administrations of a new dose of this?
a. Blood pressure
b. Patellar reflex
c. Pulse rate
d. Anxiety level
ANSWER: B
The most evident symptoms of overdose form magnesium sulfate administration include decreased urine output,
depressed respirations, reduced consciousness, and decreased deep tendon reflexes. The nurse must assess this
symptoms before administering magnesium sulfate to avoid toxicity. Urine output should be 25 to 30 ml/hr;
respirations should be above 12 per minute; and deep tendon reflexes should be present.
6. A patient with a history of PIH asks the nurse if she will have PIH in a subsequent pregnancy. The nurse
responds by saying:
a. “Having PIH puts you into a risk group for having PIH again”
b. “There is no relationship between one pregnancy and another”
c. “You will definitely have PIH with each pregnancy”
d. “You will have a more severe PIH than the previous one”
ANSWER: A
Pre-eclampsia is more likely to happen in a second pregnancy if one has suffered it before. Mild pre-eclampsia at
term is less likely to recur (5-10%) and when it does it's usually mild again. After severe pre-eclampsia
recurrence rate is about 20-25% in subsequent pregnancies. After eclampsia, about 25-30% of subsequent
pregnancies will be complicated by pre-eclampsia, but only 2% with eclampsia again. Chronic hypertension is
more common after pre-eclampsia, affecting about 15% at 2 years. It is more likely after eclampsia or severe
pre-eclampsia (especially if recurrent or occuring during the 2nd trimester), affecting 30-50% of women.
7. Which of the following is an early sign of magnesium sulfate toxicity:
a. Decreased BP
b. Decreased reflexes
c. Decreased respiration
d. Increased urinary output
ANSWER: B
Magnesium levels, respiratory rate, reflexes, and urine output must be monitored to detect magnesium toxicity.
Magnesium sulfate is mostly excreted in the urine, and therefore urine output needs to be closely monitored. If
urine output falls below 20 mL/h, the magnesium infusion should be stopped. Magnesium toxicity can be easily
assessed by clinical examination; the first sign of toxicity is often a loss of deep tendon reflexes, followed by
respiratory depression. If signs of toxicity are present, the magnesium sulfate infusion should be stopped.
Calcium gluconate can be given over 10 minutes to reverse the effects.
8. A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms?
a. Proteinuria, headaches, vaginal bleeding
c. Proteinuria, headaches, double vision
b. Headaches, double vision, vaginal bleeding
d. Proteinuria, double vision, uterine contractions
ANSWER: C
A patient with pregnancy-induced hypertension complains of headache, double vision, and sudden weight gain. A
urine specimen reveals proteinuria. Vaginal bleeding and uterine contractions are not associated with pregnancyinduces hypertension.
9. When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is
given to:
a. Prevent seizures
b. Reduce blood pressure
c. Slow the process of labor
d. Increase dieresis
ANSWER: A
The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium
in the body. As a result, magnesium will block seizure activity in a hyper stimulated neurologic system by
interfering with signal transmission at the neuromascular junction.
10. A client with eclampsia begins to experience a seizure. Which of the following would the nurse in charge do
first?
a. Pad the side rails
c. Insert a padded tongue blade into the mouth
b. Place a pillow under the left buttock
d. Maintain a patent airway
ANSWER: D
The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate
oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal
hypoxia.
11. A client with type 1 diabetes mellitus who’s a multigravida visits the clinic at 27 weeks gestation. The nurse
should instruct the client that for most pregnant women with type 1 diabetes mellitus:
a. Weekly fetal movement counts are made by the mother.
b. Contraction stress testing is performed weekly.
c. Induction of labor is begun at 34 weeks’ gestation.
d. Lecithin-sphingomyelin ratio is assessed at 36 weeks
ANSWER: D
The lecithin-sphingomyelin ratio by amniocentesis is performed by week 36 of pregnancy to assess fetal maturity.
In pregnancies complicated by diabetes, this ratio tends not to show maturity as early as in other pregnancies
because the synthesis of phosphatidyl glycerol, the compound that stabilizes surfactant, is delayed in a diabetescomplicated
pregnancy. Option A: A woman may be asked to self-monitor fetal well being by recording how many
movements occur an hour not weekly. Option B: In patients who are at lower risk, most centers begin formal
fetal testing by 34 weeks. Contraction stress test is done weekly beginning at 34 weeks. Option C: caesrian birth
is performed at 37 weeks.
Reference: Adele Pillitteri. Maternal and Child Health Nursing 5th edition Page 382-383
: http://emedicine.medscape.com/article/127547-treatment
12. Identifying gestational diabetes is part of the prenatal care. When would the nurse schedule a patient for a
glucose tolerance test:
a. 6th week of pregnancy
c. 24th week of pregnancy
b. 12th week of pregnancy
d. 32nd week of pregnancy
ANSWER: C
Because diabetes is such a serious complication in pregnancy, all women should be screened during pregnancy
for gestational diabetes. This is usually done using a 50g oral glucose challenge test at week 24 to 28 of
pregnancy. Women who are considered at high risk for developing gestational diabetes are screened at their first
prenatal visit again at 24 to 28 weeks.
13. The nurse is teaching a client with diabetes about insulin requirements during pregnancy. Which statement is
true regarding insulin requirements during pregnancy?
a. Insulin needs increase early in the first trimester
c. Insulin needs decrease early in the third trimester
b. Insulin needs increase late in the first trimester
d. Insulin needs decrease late in the third trimester
ANSWER: B
Insulin needs increase late in the first trimester and in the third trimester. Insulin needs decrease early in the
first trimester.
14. A prenatal client with diabetes asks the nurse about pregnancy-related complications for her baby from
diabetes. What is the baby at risk for when the mother has diabetes?
a. Retardation
b. Hyperactivity
c. Microsomia
d. Polycythemia
ANSWER: D
The infant of a diabetic mother is at risk for polycythemia. Retardation, hyperactivity, and microsomia are not
risks for newborns whose mother has diabetes. Infants of a diabetic mother are at risk for macrosomia, not
microsomia. Polycythemia occurs in 0.4-12% of neonates. Infants of mothers with diabetes have an incidence of
more than 40%, and those born to mothers with gestational diabetes have an incidence of more than 30%.
Polycythemia is also common in infants who have experienced delayed clamping of the umbilical cord.
Hyperviscosity occurs in 6.7% of infants.
Reference: http://emedicine.medscape.com/article/976319-overview
SITUATION: Knowing the symptoms of common postpartum complications may help nurses to identify them
earlier and treat them more effectively.
15. Which of the following is an expected assessment finding of a ruptured ectopic pregnancy in the fallopian
tube?
a. Sharp, bilateral abdominal pain
c. Tender abdominal mass
b. Heavy bright red bleeding with the passage of large clots
d. Elevated BP and slow bounding pulse
ANSWER: C
Unilateral pelvic-abdominal pain, often referred to the shoulder is expected. Bleeding is massive but internal, and
accumulates in the abdominal activity. Signs of hemorrhagic shock may appear with an increasing, thread pulse
and a decrease BP
Reference: Adele Pillitteri. Maternala and Child Health Nursing 5th edition Page 409
16. A woman is hospitalized with possible ectopic pregnancy. In addition to the classic symptoms of abdominal
pain, amenorrhea, and abnormal vaginal bleeding, Nurse Hannah knows that which of the following factors in the
woman’s history may be associated with this condition?
a. Multiparity
b. Age under 20
c. Pelvic Inflammatory Disease
d. Habitual spontaneous abortion
ANSWER: C
Ectopic pregnancy is the second most frequent cause of bleeding in early pregnancy. The incidence is increasing
because of increasing rate of PID, which leads to tubal scarring. IUD may also contribute to the occurrence of
ectopic pregnancy.
17. A woman is admitted to your hospital unit with a diagnosis of ectopic pregnancy. Which intervention would
you anticipate and begin preparations for?
a. Bed rest for the next 4 weeks
c. Intravenous administrations of tocolytic
b. Immediate surgery
d. Internal uterine monitoring
ANSWER: B
Although some ectopic pregnancy spontaneously end and then are reabsorbed , requiring no treatment, it is
difficult to predict when this will happen, so when an ectopic pregnancy is revealed by an early sonogram, some
action is taken. A woman usually experiences sharp, stabbing pain in one of her lower quadrant at the time of
rupture, followed by a scant vaginal spotting. The therapy for ruptured ectopic pregnancy is to remove or repair
the damaged fallopian tube.
18. Signs of a threatened abortion are noted in a woman at 8 weeks gestation. Which of the following is an
appropriate management approach for this type of abortion?
a. Prepare the woman for a D&C
b. Place the woman on bedrest for at least one week and reevaluate
c. Prepare the woman for a sonogram to determine the integrity of the gestational sac
d. Comfort the woman by telling her that if she loses this baby she can try to get pregnant again in about one month
ANSWER: C
A woman may be asked to come to the clinic to have the fetal heart sounds assessed or a sonogram done to
evaluate the viability of the fetus. Options A D and C is not considered until inevitable abortion or expulsion of
uterine contents is incomplete. Bed rest is recommended for 48 hours initially. Telling a woman she can get
pregnant again soon is not a therapeutic response, since it discounts the importance of this pregnancy. If the
pregnancy is lost she must be helped through the grieving process
19. Marian calls her pre-natal clinic to report that she had intermittent lower abdominal cramping and occasional
spotting for the last 24 hrs. Her last menstrual period was eight weeks ago. Two weeks ago she had a positive
pregnancy test. Vaginal examination reveals no cervical dilation. The most likely diagnosis for Marian's condition
on the basis of the information presented is:
a. Inevitable miscarriage
c. Threatened miscarriage
b. Incomplete miscarriage
d. Spontaneous miscarriage
ANSWER: C
A threatened miscarriage is manifested by vaginal bleeding, initially beginning as scant bleeding, and usually
bright red. There may be slight cramping, but no cervical dilation present on vaginal examination. Inevitable
(Imminent) miscarriage occur when uterine contractions and cervical dilatation occur. In incomplete miscarriage,
part of the conceptus is expelled, but membrane or placenta is retained in the uterus. Spontaneous miscarriage is
pregnancy interruption due to a natural cause
20. The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at
8-weeks gestation. What type of emotional response should the nurse anticipate?
a. Grief related to her perceptions about the loss of this child.
b. Relief of ambivalent feelings experienced with this pregnancy.
c. Shock because she may not have realized that she was pregnant.
d. Guilt because she had not followed her healthcare provider's instructions.
ANSWER: A
Grief/loss response occurs at all stages of pregnancy loss. Option B: Ambivalence toward the pregnancy normally
occurs up to 20-weeks and contributes to guilt experienced following pregnancy loss. Option C: Shock due to
denial of pregnancy might be a factor with this client, but it is not likely to influence the grieving process. Option
D: Although data was not provided to support, compliance with medical instructions does not prevent guilt that
can be associated with other behaviors the client may have exhibited (such as smoking) during the first
trimester.
21. A client makes a routine visit to the prenatal clinic. Although she’s 14 weeks pregnant, the size of her uterus
approximates that in an 18- to 20-week pregnancy. Dr. Diaz diagnoses gestational trophoblastic disease and
orders ultrasonography. The nurse expects ultrasonography to reveal:
a. Fetal Heart Rate of 180
c. A severely malformed fetus
b. Grapelike clusters
d. An extrauterine pregnancy
ANSWER: B
In a client with gestational trophoblastic disease, an ultrasound performed after the 3rd month shows grapelike
clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part
of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been
absorbed. Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy is seen
with an ectopic pregnancy.
22. During discharge teaching for a patient who had a hydatidiform mole the nurse must include:
a. Avoid pregnancy for 1 year
c. Avoid taking birth control pills
b. A hysterectomy will be required in the future
d. No specific restrictions are indicated
ANSWER: A
A woman should be instructed to use reliable contraceptive method such as an oral contraceptive agent for 12
months so that a positive pregnancy test resulting from a new pregnancy will not be confused with increasing
levels and a developing malignancy.
23. The nurse is giving discharge instructions for a client following a suction curettage for hydatidiform mole. The
client asks why oral contraceptives are being recommended for the next 12 months. What information should the
nurse provide?
a. Oral contraceptives prevent a reoccurrence of a molar pregnancy.
b. Pregnancy within 1 year decreases the chances of a future successful pregnancy.
c. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy.
d. Molar reoccurrences are higher if conception occurs within 1 year after an initial mutation.
ANSWER: C
The major risk after a molar pregnancy is the development of choriocarcinoma, which is detected by measuring
the same hormone (hCG) that the body produces during pregnancy. Continued elevated hCG levels may be either
from choriocarcinoma or a subsequent pregnancy making diagnosis and treatment difficult, so oral contraceptives
are prescribed to prevent pregnancy for a year since it interferes with monitoring the return of hCG levels to
normal. Options A, B, and D are inaccurate.
24. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the
client that the usual treatment for partial placenta previa is which of the following?
a. Activity limited to bed rest
c. Immediate cesarean delivery
b. Platelet infusion
d. Labor induction with oxytocin
ANSWER: A
Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client’s bleeding.
If labor has begun, bleeding is continuing, or the fetus is being compromised, birth must be accomplished
regardless of gestational age. If the bleeding has stopped, the fetal heart sounds are of good quality, maternal
vital signs are good, and the fetus is not yet 36 weeks of age, a woman is usually managed by expectant
watching
25. Which of the following is uncharacteristic of placenta previa?
a. Implantation of the placenta in the lower uterine segment
b. Severe pelvic pain
c. Separation of the placenta as the cervix ripens
d. Bright red bleeding, with amount dependent on degree of placental separation
ANSWER: B
Pain is not characteristic of this type of placental abnormality. Note that placenta previa typically involves
painless bleeding. The bleeding in abruption placenta is usually painful
26. A pregnant woman at 36 weeks gestation is diagnosed with abruptio placenta. Assessment findings would
include:
a. Placental location in the lower uterine segment
c. Abdominal pain of increasing severity
b. Massive loss of bright red blood through vagina
d. Rupture of membranes
ANSWER: C
The placenta is located in the fundal portion of the uterus. Blood loss depends on degree of separation and may
be overt or concealed depending on the location of separation. Blood will appear dark red. Pain increases with
continuing separation. Rupture of membranes is not associated with abruption placenta
27. Which of the following would the nurse Isay most likely expect to find when assessing a pregnant client with
abruption placenta?
a. Excessive vaginal bleeding
c. Tetanic uterine contractions
b. Rigid, boardlike abdomen
d. Premature rupture of membranes
ANSWER: B
The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain,
usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is
common.
28. A pregnant client is diagnosed with hydramnios at 35 weeks gestation. The nurse should be awrae that the
presence of hydramnios might indicate that the fetus has the potential for:
a. Renal dysfunction
b. Cardiac anomalies
c. Fetal growth retardation
d. GI malformation
ANSWER: D
Hydramnios is a condition during pregnancy characterized by too much amniotic fluid. It is also known as
amniotic fluid disorder or polyhydramnios. Accumulation of amniotic fluid suggests difficulty with fetus’ ability to
swallow or absorb or else excessive urine production. Inability to swallow occurs in infants who are anencephalic
or who have tacheoesophageal fistula with stenosis or obstruction. Options A, B and C are not associated with
hydramnios.
SITUATION: Nurse Stephanie has been working as a nurse in maternity hospital where she encounters clients
with abortion case.
29. Mrs. Griselda, a patient in her 14th week of pregnancy, has presented an abdominal cramping and moderate
vaginal bleeding for the past 8 hours. She has passed several clots. On further assessment, the speculum
examination revealed 2 to 3 cm cervical dilation. Nurse Stephanie would document these findings as:
a. Threatened abortion
b. Imminent abortion
c. Complete abortion
d. Missed abortion
ANSWER: B
Cramping and vaginal bleeding coupled with cervical dilation signifies that termination of the pregnancy is
inevitable and cannot be prevented. Thus, the nurse would document an imminent abortion. Imminent abortion
is also called imminent or inevitable miscarriage. In a threatened abortion, cramping and vaginal bleeding are
present, but there is no cervical dilation. The symptoms may subside or progress to abortion. In a complete
abortion all the products of conception are expelled. A missed abortion is early fetal intrauterine death without
expulsion of the products of conception.
family. Volume. 5th edition. Lippincott William & Wilkins. Page 405
30. Based on the situation of Mrs. Griselda, Nurse Stephanie would choose which nursing diagnosis as priority at
this time?
a. Knowledge deficit
b. Fluid volume deficit
c. Anticipatory grieving
d. Pain
ANSWER: B
If bleeding and cloth are excessive, this patient may become hypovolemic. Pad count should be instituted.
Although the other diagnoses are applicable to this patient, they are not the primary diagnosis.
31. Nurse Stephanie is providing information she knows about ectopic pregnancy to the client. When explaining
to Mrs. Griselda and her husband about an ectopic pregnancy, which of the following would be included as the
most common site of implantation?
a. Fallopian tube.
b. Intestine.
c. Interstitial lining.
d. Ovary.
ANSWER: A
An ectopic pregnancy is defined as any gestation located outside the uterus. About 95% of ectopic pregnancy
occurs in the fallopian tube. Ectopic pregnancies are the second most common cause of bleeding early in
pregnancy; they are commonly associated with pelvic inflammatory disease and scars from tubal surgery. An
intestinal implantation is rare, occurring in less than 1% of ectopic pregnancies. Ovarian implantation is
extremely rae, occurring in fewer than 1% of ectopic pregnancies.
32. Nurse Stephanie anticipates that, because the client’s fallopian tube has not yet ruptured, which of the
following may be ordered?
a. Progestin contraceptives.
b. Depo-Provera.
c. Methotraxate.
d. Dyphylline.
ANSWER: C
Because the fallopian tube has not yet ruptured, methotrexate may be given, followed by leucovorin. This
chemotherapeutic agent attacks the fast-growing zygote and trophoblast cells. A hysterosalphingogram is usually
performed after chemotherapy to determine whether the tube is still patent. Progestin-only contraceptives and
depo-poveras are ineffective in clearing the fallopian tube. Option D is a bronchodilator and is not used.
33. Before surgery to remove an ectopic pregnancy, which of the following would alert Nurse Stephanie to the
possibility of a tubal rupture?
a. Amount of vaginal bleeding and discharge.
c. Slow, bounding pulse rate of 80 bpm.
b. Falling hematocrit and hemoglobin levels.
d. Marked abdominal edema.
ANSWER: B
Falling hematocrit and hemoglobin levels indicate shock, which occur if the tube ruptures. Other common
symptoms of tubal rupture include severe knife-like lower quadrant pain and referred shoulder pain. The amount
of vaginal bleeding that is evident is a poor estimate of actual blood loss. Slight vaginal bleeding, commonly
described as spotting, is common. A rapid, thready pulse, a symptom of shock, is more common with tubal
rupture rather than a slow, bounding pulse. Abdominal edema is a late sign of tubal rupture in ectopic pregnancy.
34. Another multigravida client is diagnosed with a probable ruptured ectopic pregnancy and is scheduled for
emergency surgery. In addition to monitoring the client’s blood pressure before the surgery, which of the
following would Nurse Stephanie assess?
a. Uterine cramping.
b. Abdominal distention.
c. Hemoglobin and hematocrit.
d. Pulse rate.
ANSWER: D
Fallopian tube rupture is an emergency situation because of extensive bleeding into the peritoneal cavity. Shock
soon develops if precautionary measures are not taken. The nurse readying a client for surgery should be
especially careful to monitor blood pressure and pulse rate for signs of impending shock. The nurse should be
prepared to administer fluids, blood, or plasma expanders as necessary through an intravenous line that should
already be in place. Because the fertilized ovum has implanted outside the uterus, uterine camping is unlikely.
However, abdominal tenderness or knife-like pain may occur. Abdominal fullness may be present, but abdominal
distention is rare unless peritonitis has developed. Although the hemoglobin and hematocrit may be checked
routinely before surgery, the laboratory results may not truly reflect the presence or degree of acute
hemorrhage.
35. When obtaining the client’s history, which of the following would be most important to identify as a
predisposing factor?
a. Urinary tract infection.
c. Episodes of Pelvic inflammatory disease.
b. Marijuana use during pregnancy.
d. Use of estrogen-progestin contraceptives.
ANSWER: C
Anything that causes a narrowing or constriction in the fallopian tube so that a fertilized ovum cannot be properly
transported to the uterus for implantation predisposes an ectopic pregnancy. Pelvic inflammatory disease is the
most common cause of constricted or narrow tubes. Developmental defects are other possible causes. Ectopic
pregnancy is not related to UTI. Use of marijuana during a pregnancy is not associated with ectopic pregnancy,
but its use can result in cognitive reduction if the mother’s use during pregnancy is extensive. Progestin-only
contraceptives and IUD have been associated with ectopic pregnancy.
36. Mrs. Romualdes had an operation to remove a ruptured fallopian tube. As part of discharge plan, Nurse
Stephanie explained about the possible complications that she should report to her physician. Which of the
following, if stated by the client as a complication, indicates a need for additional teaching?
a. Pain.
b. Headache.
c. Fever.
d. Bleeding.
ANSWER: B
A client should not experience headache or dizziness. Symptoms that the client should report include pain
(caused by stretching the tube), temperature elevation (suggesting infection), and bleeding (suggesting
hemorrhage). The client should also be instructed that infertility may occur as a result of the removal of one
fallopian tube.
37. Which of the following factors found in a prenatal client's history would place her at increased risk for ectopic
pregnancy?
a. Android pelvis
b. Endometriosis
c. Late menarche
d. Previous cesarean
ANSWER: B
Rationale: Previous endometriosis may cause scar tissue formation that may block the normal passage of a
fertilized ovum through the fallopian tube. The other options would not interfere with movement of the ovum.
SITUATION: Slight spotting late in pregnancy can be caused by trauma from a pelvic examination or coitus, so
this could be an innocent finding. Bleeding during late pregnancy usually occurs, however, from placenta previa,
premature separation of the placenta (abruptio placentae), or preterm labor, all of which are serious conditions.
38. When assessing a 34-year-old multigravid client at 34 weeks’ gestation who experiences moderate vaginal
bleeding, which of the following would most likely alert the nurse that placenta previa is present?
a. Painless vaginal bleeding.
c. Intermittent pain with spotting.
b. Uterine tetany.
d. Dull lower back pain.
ANSWER: A
The most common assessment finding associated with placenta previa is painless vaginal bleeding. With placenta
previa, the placenta is abnormally implanted covering a portion or all of the cervical os. Uterine tetany,
intermittent pain with spotting, and dull lower back pain are not associated with placenta previa. Uterine tetany is
associated with oxytocin administration. Intermittent pain with spotting commonly is associated with a
spontaneous abortion. Dull lower back pain is commonly associated with poor maternal posture or urinary tract
infection with renal involvement.
39. After giving instruction about the cause of the vaginal bleeding in placenta previa to Mrs. Martha, the nurse
determines that the teaching has been effective when the client says that the bleeding results from:
a. Diminished clotting factor.
c. Increased platelet levels.
b. Exposure of maternal blood sinuses.
d. A large-for-gestational-age fetus.
ANSWER: B
Bleeding precipitated by placenta previa results from the exposure of the maternal sinuses when placental villi
are torn from the uterine wall as lower uterine segment contracts and dilates in the later weeks of pregnancy.
The bleeding is not intiated because f diminished clotting factors. Diminished clotting factors are associated with
DIC. Increased platelet levels would suggest an increased risk for clotting. A large fo gestational age fetus may
be related to hereditary factors or diabetes.
40. Which of the following would be the nurse’s most appropriate response to a client who asks why she must
have a cesarean delivery if she has a complete placenta previa?
a. “You will have to ask your physician when he returns.”
b. “You need a cesarean to prevent hemorrhage.”
c. “The placenta is covering most of your cervix.”
d. “The placenta is covering the opening of the uterus and blocking your baby.”
ANSWER: D
A complete placenta previa occurs when the placenta covers the opening of the uterus, thus blocking the
passageway for the baby. This response explains what a complete previa is and the reason the baby cannot come
out except by cesarean delivery. Telling the client to ask the physician is a poor response and would increase the
patient’s anxiety. Although a cesarean would help to prevent hemorrhage, the statement does not explain why
the hemorrhage could occur. With a complete previa, the placenta is covering the entire cervix, not just most of
it.
SITUATION: Mrs. Ursula, a primigravid client who is at 8th weeks’ gestation has consulted the prenatal clinic
because of persistent vomiting and is admitted for treatment.
41. Mrs. Ursula says, “I couldn’t take anything down for a week now.” Nurse Mariel knows that the client is
experiencing severe morning sickness and because of that she plans to assess the client for signs and symptoms
of:
a. Hypercalcemia.
b. Hypobilirubenemia.
c. Hypokalemia.
d. Hyperglycemia.
ANSWER: C
GI secretion losses from excessive vomiting, diarrhea, and excessive perspiration can result in Hypokalemia,
hyponatremia, decreased chloride level, metabolic alkalosis, and eventual acidosis if precautionary measures are
not taken. Ketones may be present in urine. Dehydration can lead to poor maternal and fetal outcomes.
Persistent vomiting can lead to poor maternal and fetal outcomes. Persistent vomiting can lead to hypocalcemia,
not Hypercalcemia. Hyperbilrubinemia, not hypobilirubenemia, is typical in clients with hyperemesis.
Hypoglycemia, not hyperglycemia, may occur as a result of decreased intake of food and fluids, decreased
metabolism of nutrients, and excessive vomiting.
42. Nurse Mariel should explain to Mrs. Ursula that hyperemesis gravidarum is thought to be related to high
levels of which of the following hormones?
a. Progesterone.
b. Estrogen.
c. Somtotropin.
d. Aldosterone.
ANSWER: B
Although the cause of hyperemesis is still unknown, it is thought to be related with high estrogen and human
chorionic gonadotropin levels or to trophoblastic activity o gonadotropin production. Hyperemesis is also
associated with infectious conditions, such as hepatitis or encephalitis, intestinal obstruction, peptic ulcer, and
hyatidiform mole. Progesterone is a relaxant used during pregnancy and would not stimulate vomiting.
Somatotropin is a growth hormone used in children. Aldosterone is a male hormone.
43. Mrs. Ursula will be placed on nothing-by-mouth (NPO) status and receive intravenous therapy. Which of the
following would Nurse Mariel most likely include when explaining to her about oral intake of food and fluids?
a. Withholding them indefinitely until acidosis is corrected.
b. Giving them in small quantities whenever the client desires.
c. Providing them as clear liquids after 24 hours if vomiting subsides.
d. Withholding them until total parenteral nutrition replaces lost electrolytes.
ANSWER: C
Usually the client remains NPO for at least 24 hours with intravenous therapy. TPN is started only if other
measures fail. If the client is not vomiting after 24 hours, she may be offered clear liquids. If she tolerates
liquids, then dry toast, crackers, or cereal may be given every 2 to 3 hours. The client should be given a choice of
foods. The temperature of the food and fluids should be appropriate (hot food should be served hot; cold foods
should be served cold).
44. After giving instruction to Mrs. Ursula about the measures to overcome early morning nausea and vomiting,
which of the following statements from her would indicate the need for additional teaching?
a. “I’ll eat dry crackers before arising in the morning.”
b. “I’ll drink adequate fluids separate from my meals or snacks.”
c. “I’ll eat two large meals daily with frequent protein snacks.”
d. “I’ll snack on a small amount of carbohydrates throughout the day.”
ANSWER: C
The client needs further teaching when she says she should eat two meals a day with frequent protein snacks to
decrease nausea and vomiting. The client should eat more frequent, smaller meals, with frequent carbohydrate
snacks to decrease nausea and vomiting. Eating dry crackers before arising, and avoiding spicy foods may also
help to decrease nausea and vomiting.
SITUATION: Mrs. Kristine, a pregnant client at 15 weeks’ gestation is admitted with dark vaginal bleeding and
continuous nausea and vomiting. Her blood pressure is 145/100 mm Hg and a fundal height of 19 cm. She is
suffering from molar pregnancy.
45. After the admission of Mrs. Kristine, the nurse would assess the client for signs and symptoms of:
a. Pregnancy-induced hypertension.
b. Gestational diabetes.
c. Hypothyroidism.
d. Polycythemia.
ANSWER: A
H. mole is suspected when the following are present: PIH before 24th weeks’ gestation, brownish o prune-colored
vaginal bleeding, anemia, absence of fetal heart tones, passage of hydropic vessels, uterine enlargement greater
than expected for gestational age, and increased human chorionic gonadotropin levels. Gestational diabetes is
related to an increased risk of preeclampsia and UTI, but not with H. mole. Polycythemia is not related to H.
mole. rater, anemia is associated with molar pregnancy.
46. After a dilatation and curettage to evacuate a molar pregnancy, assessing the clients for signs and symptoms
of which of the following would be most important?
a. Urinary tract infection.
b. Hemorrhage.
c. Abdominal distention.
d. Chorioamnionitis.
ANSWER: B
After the D&C, the nurse should monitor for the vital signs and signs of hemorrhage, because the surgical
procedure may have traumatized the uterine lining. UTI is most commonly related with urinary catheterization.
Typically urinary catheters are not used during evacuation of molar pregnancy. The client should not experience
abdominal distention because the content of the uterus have been removed. Chorioamnionitis is an inflammation
of the amniotic fluid membranes. With complete mole, no embryonic or fetal tissue or membranes are present.
47. The nurse is preparing Mrs. Ursula for discharge after undergoing evacuation of a hyatidiform mole and
explains the need for follow-up check-up care. The nurse determines that Mrs. Ursula understands the instruction
when she says that she is at risk for developing what condition?
a. Ectopic pregnancy.
b. Choriocarcinoma.
c. Twins pregnancies.
d. Infertility.
ANSWER: B
A client who has experienced a molar pregnancy is at risk for development of choriocarcinoma and requires close
monitoring of human chorionic gonadotropin levels. Pregnancy would interfere with monitoring these levels. High
hCg titers are common for up to 7 weeks after the evacuation of the mole, but then these levels gradually begin
to decline. Client should have pelvic examination and a blood test for hCG titers every months for 6 months and
then every 2 months for 1 year. Gradually declining hCG levels suggest no complications. Increasing levels are
indicative of a malignancy and should be treated with methotrexate. If after 1 year the hCG levels are negative,
the client is theoretically free of the risk of a malignancy developing and could plan another pregnancy.
48. Part of the health teaching to Mrs. Ursula is to avoid becoming pregnant for at least:
a. 6 months.
b. 12 months.
c. 18 months.
d. 24 months.
ANSWER: B
A client with H. mole removed should have regular checkups to rule out the presence of choriocarcinoma, which
may complicate the client’s clinical picture. The client’s hCG levels are monitored for 1 year. During this time, she
should be advised not to become pregnant because this will be reflected in rising hCG levels. Ectopic or multifetal
pregnancy is not associated with H. mole. Women who have molar pregnancies have fertility rates similar to the
genral population.
SITUATION: Mulan Dee, a 16-year-old, unmarried, primigravida client is seen in the clinic for her prenatal
check-up. She is having hard time with her pregnancy because of preeclampsia. Nurses assisting in Ms. Dee’s
situation should have understanding of this pregnancy complication.
49. Mulan Dee, a client at 34 weeks gestation is diagnosed with mild preeclampsia. Assessment reveals that she
gained 2 lb in the past week and her current blood pressure is 130/87 mm Hg. Which of the following assessment
findings would provide further evidence to support the client’s diagnosis?
a. Pounding headache after reading.
c. Frequent voiding in large amounts.
b. History of urinary tract infection.
d. Mild edema in hands and face.
ANSWER: D
The diagnosis of mild preeclampsia is further confirmed if the client exhibits mild edema in the hands, fingers, or
face resulting from fluid retention. A pounding headache after reading may indicate
that a more severe form of
preeclampsia is developing. UTI history is not related to preeclampsia as well as r=frequent voiding. Women at
third trimester commonly void frequently at large amounts because of increased fluid intake and pressure of the uterus
on the bladder.
50. When developing the teaching plan for Ms. Dee, which of the following would the nurse identify as the most
appropriate client-centered goal?
a. Return visit to the prenatal clinic approximately 4 weeks.
b. Decreased edema after 1 week of low protein and low fiber diet.
c. Bed rest on the left side during the day, with bathroom privileges.
d. Immediate reporting of adverse reactions to magnesium sulfate therapy.
ANSWER: C
Mild preeclampsia is most commonly treated at home with activity restriction. Bed rest for most of the day with
the client lying in the left lateral recumbent position is recommended. This position helps to decrease pressure on
the vena cava, thus increasing the venous return, circulatory volume, and renal and placental perfusion.
Option A- the patient is usually visited at home or goes to clinic every two weeks until 36 weeks’ of gestation.
Then every week or often if needed.
Option B The client needs to be well balanced, with ample protein intake.
Option D- If magnesium sulfate is necessary as in severe preeclampsia, the drug is usually administered IV, and
the client is carefully monitored in the hospital setting because of the risk of seizure.
51. After instructing Ms. Mulan Dee about how preeclampsia can affect her and the growing fetus, the nurse
realizes that Ms. Dee needs additional instruction when she says that preeclampsia can lead to:
a. Hydrocephallic infant.
c. Intrauterine growth retardation
b. Abruptio placentae.
d. Poor placental perfusion.
ANSWER: A
Congenital anomaly such as hydrocephalus is not associated with preeclampsia. Still births, abruption placentae,
intrauterine growth retardation, and poor placental perfusion are associated with preeclampsia. Options BD are
associated with the vasoconstriction that occurs in preeclampsia. Option C is possible owing to poor placental
perfusion.
52. The nurse is instructing Ms. Dee about monitoring the movements of her fetus to determine fetal well-being.
Which statement by the client indicates that she needs further instruction about when to call the health care
provider concerning fetal movement?
a. “If the fetus is becoming less active than before.”
b. “If it takes longer each day for the fetus to move 10 times.”
c. “If the fetus stops moving for 12 hours.”
d. “If the fetus moves more than 3 times an hour.”
ANSWER: D
The fetus is considered well if it moves more often than 3 times in one hour. Daily fetal movement counting is
part of all high-risk assessments and is a non-invasive, inexpensive method of monitoring fetal well-being. The
health care provider should be notified if there is gradual slowing over time of fetal activity, if each day it takes
longer for the fetus to move a minimum of 10 times, or if the fetus stops moving for 12 hours or longer.
53. When teaching Ms. Mulan Dee about nutritional needs, which of the following types of diet should the nurse
discuss?
a. High-residue diet.
b. Low-sodium diet.
c. Regular diet.
d. High-protein diet.
ANSWER: C
For clients with mild preeclampsia, a regular diet with ample protein and calories is recommended. If the client
experiences constipation, she should increase the fiber in her diet, such as by eating raw fruits and vegetables,
and increase fluid intake. A high-residue diet is not a nutritional need in preeclampsia. Sodium and fluid intake
should not be restricted or increased. A high-protein diet is unnecessary.
54. Ms. Mulan Dee was hospitalized when her BP shoots up to 160/104 mm Hg and her reflexes is +3 but without
clonus. When developing the plan of care for Ms. Dee who is receiving intravenous magnesium sulfate, which of
the following would the nurse identify as the priority to achieve?
a. Decreased generalized edema within 8 hours.
b. Decreased urinary output during the first 24 hours.
c. Sedation and decreased Reflex excitability within 48 hours.
d. Absence of any seizure activity during the first 48 hours.
ANSWER: D
The highest priority for a client with severe preeclampsia is to prevent seizures, thereby minimizing the possibility
of adverse effects on the mother and fetus, and then to deliver the infant safely. Other options are desirable but
not as important as preventing seizures.
55. As the nurse enters the room of Ms. Dee, she notices her to begin experience seizure. Which of the following
should the nurse do first?
a. Insert airway to improve oxygenation.
c. Call for immediate assistance.
b. Note the time when the seizure begins and ends.
d. Turn the client to her left side.
ANSWER: C
If the client begins to have seizure, the first action by the nurse is to remain with the client and call for
immediate assistance. The nurse needs some assistance in managing the client. After the seizure, the client
needs intensive monitoring. An airway can be inserted after the seizure ends. Other options should be done after
assistance is obtained.
56. Ms. Dee, who is suffering from severe preeclampsia, is now at 37 weeks’ gestation and is in early active labor
when her blood pressure becomes 164/110 mm Hg. Which of the following would alert the nurse that the client
may be about to experience a seizure?
a. Decreased contraction intensity.
c. Epigastric pain.
b. Decreased temperature.
d. Hyporeflexia.
ANSWER: C
Epigastric pain or acute right upper quadrant pain is associated with the development of eclampsia and an
impending seizure; this is thought to be related to liver ischemia. Decreased contraction intensity is unrelated to
the severity of the preeclampsia. Typically, the client’s temperature will increase due to increase cerebral
pressure. Decreased in temperature is unrelated to an impending seizure. Typically, the client would exhibit
hyperreflexia.
SITUATION: The pregnant woman is in danger because of this increase in circulatory volume. The pregnant
woman's heart may become overwhelmed that it may not delivery blood properly. When this happens, oxygen
and nutrients (both of which are carried by the blood) are not delivered to the cells and the fetus adequately.
This condition may endanger the life of both the mother and the infant.
57. Mrs. Amelita, a 30 year old multigravid client at 39 weeks’ gestation admitted to the hospital in active labor,
has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during
labor, the nurse plans to encourage the client to do:
a. Breathe slowly after each contraction.
c. Remain in a side-lying position with the head elevated.
b. Avoid the use of analgesics for the labor pain.
d. Request local anesthesia for vaginal delivery.
ANSWER: C
The multigravid client with class II heart disease has a slight limitation of physical activity and may become
fatigue with ordinary physical activity. A side-lying pr semi fowler’s with the head elevated helps to ensure
cardiac emptying and adequate oxygenation.
Option A may assist with oxygenation, it would not have effect on cardiac emptying. It is essential that a laboring
woman with cardiac disease be relieved with discomfort and anxiety.
Option B may reduce the workload as much as 20% only.
Option D is effective only on the second stage of labor.
family. Volume. 5th edition. Lippincot William & Wilkins.
58. Mrs. Amelita, during the history taking tells to the nurse that she has had prosthetic valve replacement
before. When developing a plan of care for this client, Nurse Renee should anticipate that the physician will most
likely prescribed:
a. Anticoagulants.
b. Antibiotics.
c. Diuretics.
d. Folic acid supplements.
ANSWER: B
The client, because of her diagnosis and placement of prosthetic valve replacement, is most likely to have an
antibiotic order to prevent the development of bacterial endocarditis and bacteremia.
Option A is usually discontinued during labor and delivery because of the potential for hemorrhage.
Option C is generally not prescribed for clients with class I or class II heart disease. It is not usually necessary
and may result in potassium depletion.
Option D is usually prescribe for clients with megaloblastic anemia and is also included in many prenatal vitamins
and can help to prevent neural tube defec in the fetus.
59. When developing the plan of care for a multigravid client with class II heart disease, which of the following
signs should the nurse expect to assess frequently?
a. Dehydration
c. Iron deficiency anemia
d. Tachycardia
ANSWER: D
Assessing for signs and symptoms associated with cardiac decompensation is the priority. Class III heart disease
during pregnancy has 25% to 50% mortality. These clients are markedly compromised, with marked limitation of
physical activity. They frequently experience fatigue, palpitation, dyspnea, or angina pain.
Pr of more
than100bpm or a RR greater than 25 breaths per minute may indicate cardiac decompensation that could result
in cardiac arrest.
60. When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the following
instructions would be the priority?
a. Dietary intake
b. Medication
c. Exercise
d. Glucose monitoring
ANSWER: A
Although all of the choices are important in the management of diabetes, diet therapy is the mainstay of the
treatment plan and should always be the priority. Women diagnosed with gestational diabetes generally need
only diet therapy without medication to control their blood sugar levels. Exercise, is important for all pregnant
women and especially for diabetic women, because it burns up glucose, thus decreasing blood sugar. However,
dietary intake, not exercise, is the priority. All pregnant women with diabetes should have periodic monitoring of
serum glucose. However, those with gestational diabetes generally do not need daily glucose monitoring. The
standard of care recommends a fasting and 2-hour postprandial blood sugar level every 2 weeks.
family. Volume. 5th edition. Lippincott William & Wilkins. Page378-379
61. A pre-natal client, Mariposa, has been diagnosed with a vaginal infection from the organism Candida Albicans.
Which of the following findings would the expect to note upon assessment of the client?
a. Absence of any signs and symptoms
c. Proteinuria, hematuria, edema, and hypertension
b. Pain, itching, and vaginal discharge
d, Costovertebral angle pain
ANSWER: B
Clinical manifestations of a Candida infection include pain, itching, and a thick, white vaginal discharge.
Proteinuria and costovertebral angle pain are clinical manifestations associated with urinary tract infections.
Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p.
208
62. A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the priority
when assessing the client?
a. Glycosuria
b. Depression
c. Hand/face edema
d. Dietary intake
ANSWER: C
After 20 weeks’ gestation, when there is a rapid weight gain, preeclampsia should be suspected, which may be
caused by fluid retention manifested by edema, especially of the hands and face. The three classic signs of
preeclampsia are hypertension, edema, and proteinuria. Although urine is checked for glucose at each clinic visit,
this is not the priority. Depression may cause either anorexia or excessive food intake, leading to excessive
weight gain or loss. This is not, however, the priority consideration at this time. Weight gain thought to be caused
by excessive food intake would require a 24-hour diet recall. However, excessive intake would not be the primary
consideration for this client at this time.
63. Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?
a. Risk for infection
b. Pain
c. Knowledge Deficit
d. Anticipatory Grieving
ANSWER: B
For the client with an ectopic pregnancy, lower abdominal pain, usually unilateral, is the primary symptom. Thus,
pain is the priority. Although the potential for infection is always present, the risk is low in ectopic pregnancy
because pathogenic microorganisms have not been introduced from external sources. The client may have a
limited knowledge of the pathology and treatment of the condition and will most likely experience grieving, but
this is not the priority at this time.
family. Volume. 5th edition. Lippincott William & Wilkins. Page 408-410
64. The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the result of:
a. Lanugo
b. Hydramnios
c. Meconium
d. Vernix
ANSWER: C
The greenish tint is due to the presence of meconium. Lanugo is the soft, downy hair on the shoulders and back
of the fetus. Hydramnios represents excessive amniotic fluid. Vernix is the white, cheesy substance covering the
fetus.
65. A client is in labor and has just been told she has a breech presentation. The nurse should be particularly
alert for which of the following?
a. Quickening
b. Ophthalmia neonatorum
c. Pica
d. Prolapsed umbilical cord
ANSWER: D
In a breech position, because of the space between the presenting part and the cervix, prolapse of the umbilical
cord is common. Quickening is the woman’s first perception of fetal movement. Ophthalmia neonatorum usually
results from maternal gonorrhea and is conjunctivitis. Pica refers to the oral intake of nonfood substances.
SITUATION: Infection with the human immunodeficiency virus (HIV), the organism responsible for acquired
immunodeficiency syndrome (AIDS), is the most serious of the STIs because it can be fatal to both mother and
child.
66. The goal of therapy in pregnant mothers with HIV infection is to maintain the CD4 cell count at greater than
500 cells/mm3 giving one or more protease inhibitors. After providing health teaching to an HIV-positive
pregnant mother, which of the following statements indicate full understanding by the mother?
a. “My baby will not have AIDS.”
b. “I will need to take a drug throughout my entire pregnancy.”
c. “They will start giving me a drug for HIV when I am ready to deliver.”
d. “I will need to continue taking the HIV drug the entire time I breast feed.”
ANSWER: B
Antiretroviral drugs should be taken throughout the pregnancy and not started at the onset of labor. The
newborn will be considered infected and will be given treatment until 18 months of age, when the infant can
seroconvert to a negative status. It is unknown if the infant will develop AIDS. To lower the risk of transmission
to the newborn, breastfeeding is not allowed.
Reference: Adelle Pilliterri. Maternal and Child Nursing. 5th Edition. Page 352.
67. When planning care for a client in labor who is a drug abuser and tested positive for HIV, the nurse should
know that:
a. Client will need invasive fetal monitoring
b. Client has acquired immunodeficiency syndrome
c. HIV virus is transmitted primarily through body fluids
d. Incidence of HIV/AIDS is unaffected by the type of birth
ANSWER: C
HIV is known to be transmitted through body fluids such as blood, semen, and vaginal secretions.
Option A – invasive fetal monitoring is avoided to prevent vertical transmission
Option B – HIV is the virus, not the disease, the diagnosis of AIDS is determined when the CD4T cell count drops
below 200 per microliter
Option D – studies indicate that the type of delivery does not influence the transmission of HIV from mother to
fetus; the fetus is exposed to the mother’s body fluids in utero
68. Test results indicate that your patient is HIV positive. The patient has stated that her choice of infant feeding
is breast milk. Your postpartum plan of care should be based on the knowledge that
a. Breastfeeding should be encouraged for all new mothers to foster maternal child bonding.
b. Formula- feeding should be encouraged because the mother is not likely to live long enough to successfully
breastfeed the infant.
c. The mother’s HIV status should not influence her decision on how to feed her infant.
d. Breastfeeding is contraindicated for HIV positive mothers.
ANSWER:D
Transmission of HIV to the fetus or neonate can occur transplacetally and less often by blood and vaginal
secretions during delivery and / or via breast milk. Option A: Breastfeeding would be contraindicated because of
the possibility of transmitting the virus through the milk. Option B: Formula- feeding would be encouraged to
prevent transmission of HIV, not because the mother may die. Option C: The mother should consider her HIV
status when deciding whether or not breastfeed her infant
69. A pregnant woman who has tested positive for the human immunodeficiency virus (HIV) is admitted to the
labor unit. Which of the following statements, if made by the woman, would indicate that she has an accurate
understanding of labor management?
a. “I will receive antibiotics during my labor”
c. “My baby will have to be monitored internally”
b. “My baby will be delivered by cesarean section”
d. “I plan to have an epidural to help ease the pain”
ANSWER: B
Cesarean birth is preferred because it is thought that the virus may be less likely to be transmitted to the infant
through this route than through the vaginal route. Option A: NO antibiotics are needed as a result of the patient’s
HIV status. Option C: External monitoring is preferred to internal monitoring. Option D: Epidural anesthesia is not
contraindicated for this patient.
70. When planning care for a 14- year- old female who is pregnant, a nurse should recognize that the adolescent
is at risk for:
a. Glucose intolerance
c. Incompetent cervix
b. Fetal chromosomal abnormalities
d. Iron deficiency anemia
ANSWER: D
Adolescents to have inadequate diets that are especially lacking in iron and folic acid. Option A: Pregnant
adolescents are not at risk for glucose intolerance. Option B: A diet deficient in folic acid has been linked to
neural tube defects but not fetal chromosomal abnormalities. Option C:. Pregnant adolescents are not at risk for
incompetent cervix.
71. To reduce the risk of fetal neural tube defects, a nurse would evaluate the childbearing woman’s need for
which of the following nutrient supplement?
a. Ferrous sulfate (Feosol)
c. Folic acid (Folvite)
b. Calcium carbonate (Tums)
d. Ascorbic acid (Vitamin C)
ANSWER: C
Diets deficient in folate have been implicated as a risk factor in the development of neural tube defects in the
fetus. Ferrous sulfate, calcium carbonate and ascorbic acid deficiencies have not been implicated in development
of neural tube defects.
72. The nurse should instruct a client who has a diagnosis of folic acid deficiency anemia to increase intake of
which of the following foods?
a. Dairy products
b. Green, leafy vegetables
c. Citrus juices
d. Fish and poultry
ANSWER: B
Foods high in folic acid include green and yellow vegetables, liver, citrus fruits, whole grains yeast and legumes.
Options A, C and D: Dairy products, citrus juices, and fish and poultry are not high in folic acid.
73. Mrs. Mansanilla asks if there is a danger of this problem (Rh incompatibility) occurring in the future in
pregnancies. Which of these understanding about Rh factors is most important for the nurse to communicate to
Mrs. Mansanilla?
a. Administration of RhoGAM will provide life-long immunity against fetal Rh disease
b. If Mrs. Mansanilla delivers another Rh positive infant, she will require a subsequent dose of RhoGAM
c. The protective antibodies formed during this pregnancies increase the risk of hemolytic diseases in the future
d. It is safe to assume that the future Rh positive infants have 0% chance of being affected
ANSWER: B
Because RhIG is passive antibody protection, it is transient, and in two weeks to 2 months, the passive antibodies
are destroyed. Only those few antibodies that were formed during pregnancy are left. For this reason, every
pregnancy is like first pregnancy in terms of the number of antibodies present, ensuring a safe intrauterine for
any future pregnancies.
Reference: Adele Pilitteri. Maternala and Child Health Nursing 5th edition Page 438
74. A woman you care for has an RH-negative blood type. Following the birth of her infant, you administer her
RHIG (D immune globulin). The purpose of this is to
a. Promote maternal D antibody formation
c. Stimulate maternal D immune antigens
b. Prevent maternal D antibody formation
d. Prevent fetal RH blood formation
ANSWER: B
To reduce the number of Rh (D) antibodies being formed, Rh (D) immune globulin (RhIG), a commercial
preparation of passive Rh (D) antibodies against the Rh factor, is administered to women at 28 weeks of
pregnancy.
Reference: Adele Pilitteri. Maternala and Child Health Nursing 5th edition Page 437
SITUATION: A woman with cardiovascular disease needs a team approach during pregnancy.
75. Ideally, a client should visit her obstetrician before conception so her health care team can be familiar with
her health state and evaluate her heart function. A pregnant client with cardiac classification of III is:
a. A woman who has no limitation of physical activity, her ordinary physical activities cause no discomfort, and
she has no symptoms of cardiac insufficiency and no anginal pain
b. A woman who has moderate to marked limitation of physical activity. Her less than ordinary activities are
enough for her to experience excessive fatigue, palpitation and dyspnea or anginal pain
c. A woman who has a slight limitation of physical activity. Her ordinary physical activities can cause excessive
fatigue, palpitation and dyspnea or anginal pain
d. A woman who is unable to carry out any physical activity with experiencing discomfort. Even at rest she
experiences symptoms of cardiac insufficiency of anginal pain
ANSWER: B
Women in class III can complete a pregnancy and birth. The pregnant women is markedly compromised. Women
have a moderate to marked limitation of physical activity. During less than ordinary activity, they experience
excessive fatigue, palpitations, dyspnea or anginal pain.
Option A – Uncompromised. Women have no limitation of physical activity. Ordinary physical activity causes no
discomfort. They have no symptoms of cardiac insufficiency and no anginal pain
Option B – Slightly compromised. Women have slight limitation of physical limitation. Ordinary physical activity
causes excessive fatigue, palpitation, and dyspnea or anginal pain
Option D – Severely compromised. Women are unable to carry out any physical activity without experiencing
discomfort. Even at rest they experience symptoms of cardiac insufficiency or anginal pain. Women with class IV
heart disease are poor candidates for pregnancy because they are in cardiac failure even at rest and when they
are not pregnant; they are usually advised to avoid pregnancy.
Reference: Adelle Pillitteri, Maternal and Child Nursing, 5th Edition. Page 354.
76. When developing the collaborative plan of care for a multigravid client at 10 weeks’ gestation who has a
history of cardiac disease who being treated with digitalis therapy before this pregnancy. Which of the following
would the nurse anticipate happening with the client’s drug therapy regimen?
a. Need for an increased dosage
c. Switching to a different medication
b. Continuation of the same dosage
d. Addition of a diuretic to the regimen
ANSWER: B
Unless the client has cardiac decompensation during the pregnancy. She will most likely be able to continue
taking the same dose of medication. The client may be prescribed prophylactic antibiotics, particularly if she has
had rheumatic fever. The medication would be switched only if digitalis toxicity occurs. A diuretic is added only if
congestive heart failure is not controlled by sodium and activity restrictions.
Reference: Adelle Pillitteri, Maternal and Child Nursing, 5th Edition, page 359.
SITUATION: Ms. Angie is 28-year-old pregnant woman, who is known to have Cardiac problem Class III. She is
currently in her 32-weeks of gestation, she is anxious about the coming labor and delivery and asks the nurse the
prognosis of thee extraneous process to her cardiac condition. The following questions refer to this situation.
77. To facilitate delivery a Ms. Angie with class III heart disease, the nurse would expect that the physician will
probably order:
a. Use Pitocin induction
c. Schedule CS delivery
b. Use forceps for delivery
d. Do nothing and let nature proceed
ANSWER: B
Maternal indications for forceps assisted delivery include the need to shorten the second stage of labor in the
event of dystocia or to comprensate for the woman’s deficient expulsive efforts, or to reverse a dangerous
condition such as cardiac compensation. Shortening the second stage of labor decreases the workload of the
heart. The woman’s childbirth preparation method should be supported to the degree that is feasible for her
cardiac condition.
Reference: Adelle Pillitteri, Maternal and Child Nursing, 5th Edition, page 354, 359.
78. Which of the following drugs are contraindicated in a client with cardiac disease because of its teratogenic
effect to the fetus?
a. Digoxin
b. Captopril
c. Nitroglycerin
d. Propanolol
ANSWER: B
Captopril (Angiotensin-converting enzyme {ACE} inhibitors) is used to reduce hypertension but it does not given
to pregnant client because it can cause oligohydramnios that may predispose the fetus to increase risk for injury
due to decrease amount od amniotic fluid that cushion it
Option A – Digoxin is sometimes administered to a woman during pregnancy to slow the fetal heart if fetal
tachycardia is present
Option C – Nitrogycerin, a compound often prescribed for angina, is also a category C drug but is apparently safe
to be given in pregnant client
Option D – Propanolol (Inderal)
a beta-adrenergic blocker frequently used to treat cardiac arrhythmias, is
a pregnancy category C drug (unstudied in pregnancy) but apparently does not cause fetal abnormalities
Reference:
Adelle
Pillitteri,
Maternal
and
Child
Nursing,5thEdition.291,359
79. Angie asks the nurse if she will be given an anesthetic during her labor and delivery. The nurse considering
the client’s condition will correctly respond which of the following anesthetic is ideal to be given to this type of
client?
a. Epidural
b. Spinal
c. Narcotic analgesics
d. All of these
ANSWER: A
The anesthetic of choice during labor for women with heart disease is an epidural, because this can make both
labor and birth less taxing. Many women with heart disease should not push with contractions; pushing requires
more effort than they should expend. If an epidural anesthetic is used, low forceps or a vacuum extractor can be
used for birth. A woman may be disappointed that her birth is not more “natural”. Stress that these measures
can help her achieve her iltimate goals, which are a healthy newborn and a motherable to care for her new baby.
Reference: Adelle Pillitteri, Maternal and Child Nursing, 5th Edition. 359.
80. A G1 client at 20 weeks gestation is at the clinic for a prenatal visit. She tells the nurse that she has been
reading about “group B strep disease” on the Internet. She asks when she can expect to be checked for the
bacteria. How does the nurse best reply?
a. “I’m glad that you asked. You will be getting the culture done today.”
b. “You were checked during your first prenatal visit. Let me get those results for you.”
c. “You are only checked for group B strep if you have risk factors fort he infection.”
d. “The obstetrician normally cultures for group B strep after 35 weeks and before delivery.”
ANSWER: D
The Center for Disease Control and Prevention (CDC) recommends that all pregnant women be screened for
streptococcus B at 35 to 38 weeks of pregnancy. This screening is important, because approximately 40 to 70%
of neonates whose mothers have an active infection at the time of birth will become infected from placental
transfer or from direct contact with the organisms. Infected neonates may develop severe pneumonia, sepsis,
respiratory distress syndrome, or meningitis.
SITUATION: Gestational diabetes is the third type of diabetes which occurs during pregnancy may be caused
from inadequate insulin response to carbohydrate or from excessive resistance to insulin; or a combination of
both. The following questions refer to nursing care in pregnant client with this condition.
81. A 30-year-old multigravid client at 8 weeks’ gestation has a history of insulin-dependent diabetes since age
20. When explaining about the importance of blood glucose control during pregnancy, which of the following
should the nurse expect to occur regarding the client’s insulin needs during the first trimester?
a. They will increase
c. They will remain constant
b. They will decrease
d. They will be unpredictable
ANSWER: B
During the first trimester, it is not unusual for insulin needs to decrease, because the fetus is using so much
glucose for rapid cell growth. Later in pregnancy, she will need an increased amount because her metabolic rate
and need increase. Progressive insulin resistance is characteristic of pregnancy, particularly in the second half of
pregnancy. It is not unusual for insulin needs to increase by as much as four times the nonpregnant dose after
about the 24th week of gestation. This resistance is caused by the production of human placental lactogen, also
called human chorionic somatotropin, by the placenta and by other hormones, such as estrogen and
progesterone, which are insulin antagonists.
82. After teaching a diabetic mother about symptoms of hyperglycemia and hypoglycemia, the nurse determines
that the client understands the instruction when she says that hyperglycemia is be manifested by:
a. Dehydration
b. Pallor
c. Sweating
d. Nervousness
ANSWER: A
Dehydration, polyuria, fatigue, flushed hot skin, dry mouth, and drowsiness are manifestations of hyperglycemia.
Hyperglycemia is a medical emergency and requires immediate action to prevent maternal and fetal mortality.
Pallor, sweating and nervousness are early signs of hypoglycemia, not hyperglycemia.
83. At 38 weeks’ gestation, a primigravid client with poorly controlled diabetes and severe preeclampsia is
admitted for a caesarean delivery. The nurse explains to the client that delivery helps to prevent:
a. Neonatal hyperbilirubinemia
b. Congenital anomalies
c. Perinatal asphyxia
d. Stillbirth
ANSWER: D
Stillbirths caused by placental insufficiency occur with increased frequency in women with diabetes and severe
preeclampsia. Clients with poorly controlled diabetes may experience unanticipated stillbirth as a result of
premature aging of the placenta. Therefore, labor is commonly induced in these clients before term. If induction
and caesarean delivery do not prevent neonatal hyperbilirubinemia, congenital anomalies, or perinatal asphyxia.
84. When developing a teaching plan for a primigravid client with insulin-dependent diabetes about monitoring
blood glucose control and insulin dosages at home, what would the nurse expect to include as a desired target
range for blood glucose levels?
a. 40 to 60 mg/dl between 2:00 and 4:00pm
c. 110 to 140 mg/dl before meals and bedtime snacks
b. 60 to 100 mg/dl before meals and bedtime snacks
d. 140 to 160 mg/dl 1 hour after meals
ANSWER: B
The goal is to maintain blood plasma glucose levels at 60 to 100 mg/dl before meals and bedtime snacks. A
range of 40 to 60 mg/dl indicates hypoglycemia. A range of 100 to 140 mg/dl suggests hyperglycemia. A range
of 140 to 169 mg/dl hour after meals suggests hyperglycemia. The target range 1 hour after meals is 100 t o120
mg/dl.
SITUATION: Newborns may have increase indirect bilirubin levels due to Rh or ABO incompatibility. To prevent
these conditions; knowledge of the mother’s blood type may help to determine the conditions before it will affect
the woman and fetus health.
85. Laboratory studies reveal that a pregnant client’s blood type is O and Rh positive. Problems related to
incompatibility may develop in her infant if the infant is:
a. Rh negative
b. Type A or B
c. Born preterm
d. Type O, Rh positive
ANSWER: B
An ABO incompatibility may develop even in first-born infants since the mother has antibodies against the
antigens of the A and B blood cells; these antibodies are transferred across the placenta and produce hemolysis
of the fetal RBC’s; if the infant were AB, an incompatibility may also occur.
86. The nurse is aware that an ABO incompatibility is most common when the mother has a blood type of:
a. Type A
b. Type B
c. Type O
d. Type AB
ANSWER: C
Mothers with type O blood have anti-A and anti-B antibodies that are transferred across the placenta; this is the
most common incompatibility because the mother is type O in 20% of all pregnancies
Options A, B and D is not a problem
87. A client at 12-weeks gestation expels the products of conception. Since the client’s blood type is Rh negative,
the nurse should:
a. Administer RhoGAM within 72 hours after delivery
b. Administer RhoGAM immediately after delivery
c. Not give RhoGAM because the gestation was only 12 weeks
d. Not give RhoGAM because it is not used when the fetus is dead
ANSWER: A
If the mother’s blood type is Rh (D) negative and the fetal blood type is Rh positive (contains the D antigen), the
introduction of fetal blood causes sensitization to occur, and the mother begins to form antibodies against the D
antigen. Few antibodies form this way, however. Most form in the mother’s bloodstream in the first 72 hours
after birth because there is an active exchange of fetal-maternal blood as placental villi loosen and the placenta is
delivered, therefore RhoGAM is administer 72 hours after delivery.
88. Before the administration of RhIg, the nurse reviews the laboratory data of a pregnant client. RhIg is given to
pregnant women who are found to have:
a. Rh positive and Coomb’s positive
c. Rh positive and Coomb’s negative
c. Rh negative and Coomb’s positive
d. Rh negative and Coomb’s negative
ANSWER: D
RhIg is given to prevent active formation of antibodies when an Rh-negative individual is at risk for sensitization;
if given to an Rh-positive person, an injection of RhIg would cause hemolysis of RBCs
Option A – RhIg is never given to an individual with Rh antibodies because its too late at this time and the
woman had already developed antibodies against Rh positive and may endangered the next pregnancy
Option B – a positive Coomb’s test indicates that the woman has Rh antibodies; RhIg is never given to an
individual with RH antibodies
Option C – administration of RhIg to an Rh-positive woman causes hemolysis of RBCs
SITUATION: Juvenile rheumatoid arthritis is a disease of connective tissues with joint inflammation and
contracture and is most likely the result of an autoimmune response. Women with this condition frequently take
corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) to prevent joint pain and loss of mobility.
89. Pregnant patients with rheumatoid arthritis should be advised to limit or discontinue taking NSAIDs
particularly Aspirin because of:
a. Prolonged pregnancy
b. Late closure of the ductus arteriosus in the child
c. Increased incidence of formation of blood clot in both mother and child
d. Potent carcinogen to the mother
ANSWER: A
Large amounts of salicylates may lead to increased bleeding at birth or prolonged pregnancy. Because salicylates
interferes with prostaglandin sythesis, so labor contractions are not initiated. The infant may be born with a
bleeding defect and may also experience premature closure of the ductus arteriosus due to the drug’s effects. For
this reason, a woman is asked to decrease her intake of salicylates approximately 2 weeks before term. An
NSAID is not a carcinogen.
90. On her first visit to the prenatal clinic, a client with rheumatic heart disease asks the nurse if she will have a
special nutritional need. The nurse should respond that in addition to the regular pregnancy diet, she probably
will need supplemental of:
a. Vitamins C and D
b. Iron and folic acid
c. Vitamins B2 and B12
d. Calcium and magnesium
ANSWER: B
Because pregnant women with heart disease are more prone to anemia, there may be an additional need for iron
and folic acid
Options A, C and D - if the pregnant client with heart disease is eating the recommended pregnancy diet and
taking prenatal vitamin and mineral supplements, there is no additional need for these nutrients.
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition. Page 231, 362.
91. Dietary counselling for a pregnant client with sickle cell anemia should include supplemental folic acid. The
nurse recognizes that this is important because of:
a. Prevents sickle cell crises
c. Lessens the oxygen needs of cells
b. Decreases the sickling of RBCs
d. Compensates for a rapid turnover of RBCs
ANSWER: D
Folic acid is needed to produce heme for haemoglobin and to keep the new cells produced from being
megaloblastic. As a rule, women with sickle cell disease are not given iron supplement during pregnancy, the
cells cannot incorporate iron in the usual manner that normal cells can, so excessive iron build up may result.
Option A – folic acid may reduce the risk of a sequestration crisis, but it will not prevent it
Option B – there is no relationship between folic acid and the reduction of sickling
Option C – there is no change in needs; sickling decreases the oxygen-carrying capacity of haemoglobin
92. When a pregnant client with sickle cell anemia comes to the clinic each month, in addition to the routine
observations, the nurse should also assess her for:
a. Signs of hypothyroidism
c. Symptoms of pyelonephritis
b. Hyperemesis gravidarum
d. Complaints related to hypoglycemia
ANSWER: C
Because a pregnant woman with sickle cell anemia is more susceptible to bacteriuria than other women, a clean
catch urine specimen is collected periodically during pregnancy to detect developing bacteriuria while a woman is
still asymptomatic especially urinary tract infections.
Option A – hypothyroidism affects 1 in 1500 women during pregnancy; women with sickle cell anemia are not at
any risk for hypothyroidism
Option B – women with sickle cell anemia is not at increase risk for this condition
Option D – not a risk for this client
SITUATION: A female client is being treated in a methadone maintenance program, on her next visit to the
clinic she tells the counsellor that she is three months pregnant and is receiving prenatal care.
93. The client has been taking 40 mg of methadone daily for treatment of an opiate addiction. The nurse should
inform the client to do which of the following with regards to her medication treatment as per doctor’s order?
a. Continue with the methadone as prescribed to prevent withdrawal symptoms
b. Discontinue the methadone immediately to improve fetal and neonatal outcome
c. Discontinue the methadone slowly over the next two weeks to block drug cravings
d. Withdraw from the methadone maintenance program while she is pregnant and reenter when she has
delivered
ANSWER: A
Infants of opiate-abusing women tend to be small for gestational age and have an increased incidence of fetal
distress and meconium aspiration. Therefore, an opiate-dependent woman should be enrolled in a methadone
maintenance program during pregnancy. Methadone is the only medication currently approved for the treatment
of the pregnant woman with an opiate addiction; although the drug crosses the placenta, it is considered safer for
the fetus than acute opiate detoxification if the methadone is not administered.
94. Aware of the client’s history of opiate abuse, the nurse’s initial plans for providing pain relief measures during
labor should include:
a. Scheduling pain medication at regular intervals
b. Administering the medication only when the pain is severe
c. Avoiding the administration of medication unless it is requested
d. Recognizing that she will not need as much pain medication as others
ANSWER: A
This client will have lower tolerance for pain and greater need for pain relief thus pain medication should be given
at regular intervals.
Option B – larger doses may be needed if this principle is done
Option C – delays increase anxiety and discomfort, and larger doses are needed
Option D – individuals who abuse drugs need more medication than do others because of tolerance
95. The nurse should be aware that a postpartum client with a history of drug abuse may be experiencing drug
withdrawal if she develops:
a. Paranoia and evasiveness
c. Depression and tearfulness
b. Extreme hunger and thirst
d. Irritability and muscle tremors
ANSWER: D
The earliest sign of drug withdrawal is CNS overestimation. Withdrawal symptoms may begin as soon as 6 hours
after the last drug dose and can continue for several days. Withdrawal symptoms include nausea, vomiting,
diarrhea, abdominal pain, hypertension, restlessness, shivering, insomnia, body aches and muscle jerks.
Option A – these are related to drug use, not withdrawal
Option B – these have no relation to drug abuse, most postpartum women are hungry and thirsty
Option C – it may be observed in postpartum women after delivery is a manifestation of postpartum blues.
96. Another client name Rose tells the nurse that she takes methamphetamine almost daily. A fetus of a drugaddicted mother
receives approximately what percentage of the mother’s drug concentration?
a. 20%
b. 50%
c. 70%
d. 100%
ANSWER: B
A fetus receives about 50% of the drug dose of the mother. Newborns whose mothers used the drug show
jitteriness and poor feeding at birth and may be growth restricted.
97. The nurse caring for newborns whose mothers are drug abuser wants to conduct a study. The hypothesis of
her study is stated as “infants born to heroine addicted mother have lower birth weight than infants with nonaddicted mothers”. Her
hypothesis is an example of which type of research?
a. Complex and Directional
c. Complex and Non-directional
b. Simple and Directional
d. Simple and Non-directional
ANSWER: B
It is simple because it only predicts the relationship of one independent variable and one dependent variable and
it is directional because it predicts not only that there is a relationship but also specify what it is (infants born to
heroine addicted mother have lower birth weight than infants with non-addicted mother).
Venzon, L. Introduction to Nursing Research: Quest for Quality Nursing. Page 59.
98. A client who has admitted to heavy alcohol use throughout her pregnancy just delivered a 6-pound baby.
Which sign or symptom in the mother should the nurse anticipate in the 12-48-hour postpartum period?
1. Seizures
3. Delirium tremens
2. Neonatal abstinence syndrome
4. Fetal alcohol syndrome
a. 1 and 2
b. 3 and 4
c. 1 and 3
d. 2 and 4
ANSWER: C
As a result of alcohol dependence, the woman may have withdrawal seizures as early as 12-48 hours after she
stops drinking. Delirium tremens may occur in the postpartal period, and the newborn may suffer a withdrawal
syndrome. Neonatal abstinence and fetal alcohol syndrome are not maternal symptoms.
99. A postpartum client who admits to heavy alcohol use asks the nurse about breastfeeding her baby. The nurse
correctly teaches this client that excessive alcohol consumption while breastfeeding may:
a. Cause seizure disorders in the newborn.
c. Cause mental retardation in the newborn.
b. Decrease the maternal milk letdown reflex.
d. Increase the maternal letdown reflex.
ANSWER: B
Excessive alcohol consumption while breastfeeding may decrease, not increase, the maternal milk ejection reflex.
Fetuses exposed to heroin in utero may experience seizure disorders as newborns. Mental retardation in the
newborn may result from alcohol exposure in utero, not through consumption of breast milk.
: Julie Mennella, Ph. D. Alcohol’s Effect on Lactation (http://pubs.niaaa.nih.gov/publications/arh25-3/230234.htm)
100. Nurse Daniel is caring for an infant. During his assessment he noted a flattened philtrum, short palpebral
fissures, and birth weight and head circumference below the fifth percentile for gestational age. The infant has a
poor suck. Which of the following is the best interpretation of this data?
a. Down syndrome
b. Fetal alcohol syndrome
c. Turner syndrome
d. Congenital syphilis
ANSWER: B
Although a medical diagnosis cannot be made from assessment data, all of the findings noted are commonly seen
in infants with fetal alcohol syndrome. Option A: Down syndrome’s physical feature includes broad and flat nose,
eyelids have an extra fold of tissue at inner canthus and the palpebral sissure tends to slant laterally upward,
tongue may protrude, the back of the head is flat, short neck, low-set ears. Option C: Clinical signs of Turner
syndrome includes short stature, streak gonads, webbed neck. Option D: Infants with congenital syphilis are
deaf, cognitively challenged, with osteochondritis. Fetal death are possible.
Reference: Pillitteri. Maternal and Child Health Nursing. 4th edition Page 277
COMPLICATIONS OF LABOR AND DELIVERY
SITUATION: Preterm labor is the labor that occurs before the end of 37 weeks and is always considered
serious. Common symptoms include persistent, dull, low, backache; vaginal spotting; a feeling of pelvic pressure
or abdominal tightening; menstrual-like cramping; increased vaginal discharge; uterine contraction; and
intestinal cramping.
1. Lisa, in her 34 weeks’ of gestation who is in preterm labor, was admitted to the hospital. As the nurse
attending to Lisa, which should be your initial intervention?
a. Obtain a complete history and update the physician
c. Obtain fetal fibronectin and CBC
b. Monitor for contractions and fetal well-being
d. Administer tocolytic ASAP and begin intravenous hydration
ANSWER: B
Priority is given to monitoring of contractions and fetal well-being during suspected preterm labor order to ensure
good uterine blood flow. Continuous contractions may lead to fetal distress. The initial intervention of assessing
fetal well-being will drive the rest of the plan of care
2. Nurse Bernice determined that Loisa, another client at 28 weeks’ gestation, has no fetal fibronectin present.
Nurse Bernice should expect for which of the following outcome in the next week?
a. The client will develop preeclampsia
c. The client will not likely develop preterm labor
b. The fetus will develop mature lungs
d. The fetus will not develop gestational diabetes
ANSWER: C
Fetal fibronectin is a glycoprotein that plays a part in helping the placenta attach to the uterine deciduas. It can
be found in abundant amounts in the amniotic fluid. Early in pregnancy, it can be assessed in the woman’s
cervical and mucus, but the amount then fades until, after 20 weeks of pregnancy, it is no longer present. As
labor approaches and cervical dilation begins, it can be assessed again in cervical or vaginal fluid. Damage to the
fetal membranes releases a great deal of the substance, so detection of fibronectin in the amniotic fluid or in the
mother’s vagina can serve as an announcement that preterm labor may be beginning. The absence of fetal
fibronectin in a vaginal swab between 22 to 37 weeks’ gestation indicates there is less than 1% risk of developing
preterm labor in the next week. Fetal fibronectin is an extra cellular protein normally found in fetal membranes
and deciduas and has no correlation with preeclampsia, feta lung maturity, or gestational diabetes.
3. Loisa, asks Nurse Bernice what causes preterm labor. After giving instruction about various risks for preterm
labor, the nurse determines that additional explanation is needed when the client says that preterm labor is
commonly associated with:
a. Age older than 30 years
b. Polyhydramnios
c. Chronic hypertension
d. Multifetal gestation
ANSWER: A
Although the exact cause of preterm labor has not been determined, various risk factors are associated with this
condition. Age younger than 19 or older than 40 years has been associated with preterm labor. Other factors
associated with preterm labor include polyhydramnios, poor pregnancy weight gain, chronic hypertension,
multifetal gestation, prior preterm delivery, cervical incompetence, reproductive tract infection, urinary tract
infection and renal disease.
4. Lily, a multigravid client at 34 weeks’ gestation is being treated with indomethacin (Indocin) to halt preterm
labor. If the client should deliver a preterm infant, Nurse Bernice would notify the nurse in the NICU about this
therapy because of the possibility for:
a. Pulmonary hypertension
c. Hyperbilirubinemia
b. Respiratory distress syndrome
d. Cardiomyopathy
ANSWER: A
Indomethacin (Indocin) has been successfully used to halt preterm labor. However, if the client should deliver a
preterm infant, the nurse would notify the nursery personnel about the tocolytic therapy because this drug can
lead to premature closure of the fetal ductus arteriosus, resulting in pulmonary hypertension.
Option B - Prematurity is associated with RDS is not a result of indomethacin
Option C – Hyperbilirubinemia is more common in preterm infants but not related to Indomethacin therapy
Option D – use of indomethacin to halt labor is not associated with cardiomyopathy in the infant
5. After Lily gave birth to a preterm neonate through vaginal delivery, the preterm is to receive oxygen via mask.
While administering the oxygen, the nurse would place the neonate in which of the following positions?
a. Left side, with the neck slightly flex
c. Abdomen, with the head down
b. Back, with head turned to the left side
d. Back, with the neck slightly extended
ANSWER: D
When receiving oxygen mask, the neonate is placed on the back with the neck slightly extended, in the “sniffing”
or neutral position. This position optimizes lung expansion and places the upper respiratory tract in the best
position for receiving oxygen. Placing a small rolled towel under the neonate’s shoulders helps to extend the neck
properly without overextending it. Once stabilized and transferred to an isolette in the intensive care unit, the
neonate can be positioned in the prone position.
Option A – placing the neonate in the left side does not allow for maximum lung expansion, also slightly flexing
the neck interferes with opening the airway.
Option B – placing the neonate on the back with the head turned to the left side does not allow for lung
expansion
Option C – placing the neonate on the abdomen interferes with proper positioning of the oxygen
SITUATION: Multiple gestation is considered a complication of pregnancy because a woman’s body must adjust
to the effects of more than one fetus.
6. The nurse determines the fundal height of a client at 16-weeks gestation to be one fingerbreadth above the
umbilicus. The nurse should:
a. Assess for two distinct fetal heart rates
b. Ascertain birth weights of children of any siblings
c. Inform the client that she is mistaken about her dates
d. Instruct the client about appropriate weight gain during pregnancy
ANSWER: A
Twins should be suspected with a more rapid increase in fundal height than normal; the nurse should assess for
two distinct heart beats
Option B – fundal height, not the size of the fetus, should lead the nurse to suspect a multiple pregnancy
Option C – this cannot be determined until an ultrasound is done
Option D – weight gain will not influence the height of the fetus
7. The nurse is aware that a critical outcome that would facilitate an uncomplicated recovery after a multiple birth
is the woman’s:
a. Uterus being contracted and in midline
c. Request for sources of information on parenting twins
b. Capacity to breast feed the babies immediately
d. Ability to rest comfortably and discuss the birth of the babies
ANSWER: A
A tightly contracted uterus in the midline reflects normal physiologic functioning following birth of the fetuses and
expulsion of the placenta; an atonic uterus is a common complication of a multiple birth
Option B – the woman may have complications but can still breastfeed her infants
Option C – when considering recovery following a multiple birth, physiologic stabilization takes precedence over
psychologic concern
Option D – resting comfortably does not indicate an uncomplicated birth; a client can be resting quietly while
hemorrhaging
Reference: Adelle Pilliterri. Maternal and Child Nursing. 5th Edition. Page 434, 657.
SITUATION: It is important to document presentation and position, because the presentation of a body part
other than the vertex position could put a fetus at risk: it implies a proportion difference between the fetus and
the pelvis (perhaps the pelvis is too narrow to allow the fetus to pass through). The following questions refer to
nursing care for these unusual presentations.
8. When a breech presentation is suspected, the nurse should diligently observe the client for signs of:
a. Precipitate labor
b. Prolapse of the cord
c. Primary uterine inertia
d. Progression of normal labor
ANSWER: B
The feet or buttocks are not effective in blocking the cervical opening, and the cord may slip through and be
compressed
Option A – rapid dilation and precipitate labor can occur with infants in cephalic positions as well
Option C – uterine inertia may result from fatigue or cephalopelvic disproportion and is not necessarily related to
fetal position
Option D – this is not specific to breech labors
9. The membranes of a client whose fetus is in a breech position rupture spontaneously. The nurse then notes
fresh meconium in the vaginal introitus and realizes that this indicates:
a. Indicates that the cord will prolapse
c. Is a common occurrence in breech presentation
b. Is evidence of fetal heart abnormalities
d. Requires immediate notification of the physician
ANSWER: C
The inevitable contraction of the fetal buttocks from cervical pressure often causes meconium to be extruded into
the amniotic fluid before birth. This, unlike meconium staining that occurs due to fetal anoxia, is not a sign of
fetal distress but is expected from the buttocks pressure.
Option A – cord prolapse is not an absolute, but it may occur if the presenting part does not fill the pelvic cavity
Option B – fetal heart abnormalities are identified by auscultation or continuous electronic fetal monitoring, not
by the presence of meconium
Option D – this is unnecessary; this is a normal occurrence caused by pressure on the fetal abdomen during
contractions when the fetus is in the breech presentation
10. A laboring client is admitted and assessment revealed that the fetus is in a footling breech position. The
nurse should be aware to expect:
a. Meconium in the amniotic fluid is a sign of fetal hypoxia
b. Severe back discomfort occurs with the fetus in this position
c. The length of the labor often is shortened with fetus in this position
d. Because of the presentation, the client will probably deliver by caesarean birth
ANSWER: D
A caesarean birth may be performed when the fetus is in the breech presentation because there is an increased
risk of morbidity and mortality
Option A – meconium is a common finding in the amniotic fluid of a client whose fetus is in a breech presentation
because contractions compress the fetal intestinal tract causing release of meconium
Option B – vertex presentations with occiput posterior cause back discomfort
Option C – labors are usually longer with a fetus in the breech presentation because the buttocks are not as
effective as the head as a dilating wedge
11. The occurrence of shoulder dystocia during labor most likely indicates:
a. Preterm birth
b. Polyhydramnios
c. Macrosomia
d. Maternal age greater than 35
ANSWER: C
A large-for-getational age (macrosomia) infant has a birth weight above the 90th percentile on the growth chart
for that gestational age. Such large size, when not detected early during pregnancy, would pose the infant’s
shoulders to experience difficulty in passing through the pelvic outlet. Shoulder dystocia is not a complication in
preterm birth, polyhydramnios, or maternal age greater than 35.
12. To determine whether a primigravida client in labor with a fetus in the left occipitoanterior (LOA) position is
completely dilated, the nurse performs a vaginal examination. During the examination the nurse would expect to
palpate which of the following cranial sutures?
a. Sagittal
b. Lambdoidal
c. Coronal
d. Frontal
ANSWER: A
The sagittal suture (joints the two parietal bones) is the most readily felt during a vaginal examination. When the
fetus is in the LOA position, the occiput faces the mother’s left.
Option B – the lambdoid suture is on the side of the skull
Option C – the coronal suture is a horizontal suture across the front portion of the fetal skull that forms the
anterior fontanel. It may be felt with a brow presentation.
Option D – the frontal suture may be felt with a brow or face presentation
13. Lani is currently in labor and assessment reveals cervical dilation at 8 cm and complete effacement. She
complains of severe back pain during this phase of labor. The nurse explains that the client’s severe back pain is
most likely caused by the fetal occiput being in a position that is identified as:
a. Breech
b. Transverse
c. Posterior
d. Anterior
ANSWER: C
When the client complains of sever back pain during labor, the fetus is most likely in an occipitoposterior position.
This means that the fetal head presses against the client’s sacrum, causing marked discomfort during
contractions. These sensations may be so intense that the client requests medication for relief of the back pain
rather than the contractions.
Options A and B– breech presentation and transverse lie are usually known prior to 8 cm dilation and a cesarean
section is performed
Option D – fetal occiput anterior position does not increase the pain felt during labor
SITUATION: Rose Anne is at her 40 weeks’ gestation was admitted to the labor unit because today is her
expected date of delivery. Her vaginal examination reveals 3 cm cervical dilatation, although uterine contractions
are not continuous and membranes are still intact. An amniotomy was ordered by the obstetric doctor to
increase the efficiency of contractions.
14. The nurse prepares Rose Anne who is in labor for an amniotomy. Which of the following would the nurse
assess before the procedure?
a. Fetal heart rate
b. Fetal scalp sampling
c. Maternal heart rate
d. Maternal blood pressure
ANSWER: A
Amniotomy is the artificial rupturing of membranes. Rupturing the membranes if they do not rupture
spontaneously allows the fetal head to contact the cervix more directly and may increase the efficiency of
contractions. For this, the woman’s cervix must be dilated for at least 3 cm. Fetal well-being must be confirmed
before and after amniotomy. Fetal heart rate should be checked by Doppler or by the application of the external
fetal monitor. Although maternal vital signs may be assessed, fetal heart rate is the priority. A fetal scalp
sampling cannot be done when the membranes are intact.
15. After administering amniotomy to Rose Anne, which of the following would be an important nursing
assessment?
a. Ask her if her pain level is tolerable post procedure
b. Assess maternal heart rate to detect possible bleeding
c. Assess fetal heart rate to detect possible cord prolapse
d. Document the amount of amniotic fluid that has been lost
ANSWER: C
When the membranes are torn, and amniotic fluid is allowed to escape. This puts a fetus momentarily at risk for
cord prolapse, because there is a possibility that a loop of cord will escape with the fluid compromising the fetal
oxygen supply. Always measure the FHR immediately after the rupture of membranes to determine that this did
not happen.
SITUATION: Oxytocin administration is meant to start a labor artificially or to assist labor that has started
spontaneously to be more effective. The following questions refer to the principles and appropriate nursing
interventions upon the administration of the medication.
16. Before the administration of oxytocin, determination of the cervical ripening is essential to be able to respond
to the induction of the medication. Angelica a woman in labor has cervical dilatation of 3 cm and effaced at 60%,
the fetus is at station (- 0), a soft feeling cervix in posterior portion. Based on the assessment, is the client a
good candidate for induction of labor?
a. Yes, because it passed the criterion set by the scale
b. No, because the fetus is not yet engaged
c. No, because the cervix is positioned posteriorly
d. Yes, because the cervix is now 3cm dilated and 60% effaced
ANSWER: A
Cervical ripening, or an change in the cervical consistency from firm to soft, is the first step the uterus must
complete in early labor. Until this has occurred, dilatation and coordination of uterine contractions will not occur.
To determine whether the cervix is ”ripe”, or ready for dilatation. Bishop (1964) established criteria for scoring.
Using this scale, if a woman’s total score is 8 or greater, the cervix is considered ready for birth and should
respond to induction.
SCORING OF THE CERVIX FOR READINESS FOR ELECTIVE INDUCTION
SCORE
Scoring Factor
0
1
2
3
Dilatation (cm)
0
1-2
3–4
3 -4
Effacement (%)
0 - 30
40 – 50
60 - 70
80
Station
-3
-2
-1 -0
+1 +2
Consistency
Firm
Medium
Soft
Position
Posterior
Mid-position
Anterior
17. There are various methods that can be instituted to ripen the cervix. Which of the following method can
predispose the client to have inadvertent rupture of membranes and possibility of infection if membranes should
rupture?
a. Prostagladin gel
b. Stripping of the membranes
c. Hygroscopic suppositories
d. All of the above
ANSWER: B
Stripping the membranes or separating the membranes from the lower uterine segment manually, using a gloved
finger in the cervix. This is an easy procedure performed during an office visit. Possible complications of this
mechanical method include bleeding from an undetected low-lying placenta, inadvertent rupture of membranes,
and the possibility of infection if membranes should rupture.
Option A – a commonly used method of speeding cervical ripening, applied to the interior surface of the cervix by
a catheter or suppository, or to the external surface by applying it to a diaphragm and then placing the
diaphragm against the cervix
Option C – is a suppositories of seaweed that swell on contact with cervical secretions, is a time-honored method
that is still used. These suppositories can be inserted to gradually and gently urge dilatation (laminaria
technique). They are held in place by gauze sponges saturated with povidone-iodine or an antifungal cream.
18. A multigravid client at 39 weeks’ gestation diagnosed with insulin-dependent diabetes is admitted for
induction of labor with oxytocin (Pitocin). Which of the following should the nurse include in the teaching plan as
a possible disadvantage of this procedure?
a. Urinary frequency
b. Maternal hypoglycemia
c. Preterm birth
d. Neonatal Jaundice
ANSWER: D
One of the potential disadvantages of oxytocin induction is neonatal jaundice or hyperbilirubinemia. Oxytocin
decrease the elimination of bilirubin from the neonate. Other adverse effects include maternal hypertension and
frontal headache, which disappear when the drug is discontinued. The drug has antidiuretic properties that can
lead to maternal water intoxication. Dangerous effects of this powerful drug include uterine hyperstimulation or
titanic contractions, which can result in abruptio placenta and uterine rupture.
Urinary frequency, maternal hypertension and preterm birth are not associated with oxytocin administration.
Ultrasound procedures are used to estimate gestational age to prevent preterm delivery. Clients who are diabetic
commonly deliver before term because the placenta begins to deteriorate, which can result in stillbirth.
19. Which of the following nursing diagnoses would be the priority for the client above who is scheduled for labor
induction with oxytocin (Pitocin)?
a. Risk for deficiency fluid volume related to oxytocin infusion
b. Pain related to prolonged labor and uterine ischemia
c. Fear related to possible need for cesarean delivery
d. Risk for injury, maternal or fetal, related to potential uterine hyperstimulation
ANSWER: D
The highest priority nursing diagnosis for the client at this time is Risk for injury, maternal or fetal related to
uterine hyperstimulation. Diabetic mothers have a higher incidence of pregnancy-induced hypertension,
polyhydramnios, preterm birth, and larger-than-average fetuses and commonly have decreased placental
perfusion. Infants of diabetic mothers may have polycythemia, congenital anomalies, and respiratory distress.
Option A - Because of its antidiuretic properties, oxytocin infusion poses a risk of fluid overload not fluid deficit
Option B – there is no information to support the diagnosis of Pain related to prolonged labor, for multigravid
clients, labor is commonly shorter than 12 hours would indicate a prolonged labor.
Option C – there is no indication that the client will require cesarean delivery at this time
20. During the first hour after a precipitous delivery, and the nurse should monitor a multiparous client for signs
and symptoms of:
a. Postpartum “blues”
b. Uterine atony
c. Intrauterine infection
d. Urinary tract infection]
ANSWER: B
Because delivery occurs so rapidly and the fetus is propelled quickly through the birth canal, the major
complication of a precipitous delivery is a boggy fundus, or uterine atony. The neonate should be put to the
breast, if the mother permits, to allow for the release of natural oxytocin. In a hospital setting, the physician will
probably order administration of oxytocin. The nurse should gently massage the fundus to ensure that it is firm.
Options A and C– there is no relationship between a precipitous delivery and postpartum blues or intrauterine
infection. Postpartum blues usually does not occur until about 3 days postpartum, and symptoms of postpartum
infection usually occur after the first 24 hours.
Option D – there is no relationship between a precipitous delivery and urinary tract infection even though the
delivery has been accomplished under clean rather than sterile technique. Symptoms of urinary tract infection
typically begin on the first or second postpartum day
SITUATION: The passage refers to the route a fetus must travel from the uterus through the cervix and vagina
to the external perineum. The following questions refer to problems with this component of labor.
21. Rose Oyster has prolonged labor. What is the most common cause for arrest of descent during the second
stage of labor?
a. Cephalopelvic disproportion
c. The fetus is asleep during labor
b. Maternal calcium deficiency
d. The maternal outlet is narrow
ANSWER: A
Arrest of decent results when no descent has occurred for 1 hour in a multipara or 2 hours in a nulipara. Failure
of descent has occurred when expected descent of the fetus does not begin. The most likely cause for arrest of
descent during the second stage is cephalopelvic disproportion. Cesarean birth usually is necessary.
22. A client who is having a difficult labor is diagnosed with cephalopelvic disproportion. The nurse would
question which of the following medical order?
a. Maintain NPO status
c. Record fetal heart tones every 15 minutes
b. Start peripheral IV D5 ¼ NS
d. Add 10 units of Oxytocin (Pitocin) to 1000ml of IV solution
ANSWER: D
When there is a cephalopelvic disproportion, a caesarean birth is indicated; infusing oxytocin at this time could
result in fetal distress and even uterine rupture
Option A – the NPO status would be appropriate in anticipation of a caesarean delivery
Option B – the peripheral IV is needed not only for hydration but as a venous access if medications are required
Option C – the client probably has an electronic monitor recording the FHR and uterine contractions; these
assessments should be documented regularly according to hospital protocol
23. Nurse Adora is taking care of a client who was admitted 12 hours ago. The client is experiencing contractions
every 3 minutes and has remained at station 0 until now. The fetal heart rate upon admission is 140 bpm and
regular. Now, the fetal heart rate is decreasing and a persistent non-reassuring pattern is present. The nurse
should do which of the following?
a. Continue to monitor the fetal heart pattern
c. Prepare to induce labor
b. Turn the client to the right side
d. Prepare for a caesarian delivery
ANSWER: D
Dystocia, failure of labor to progress, and a persistent nonreassuring fetal heart rate pattern are indications of
the need to perform a cesarean delivery. Inducing labor is inappropriate in this situation because the client has
been in labor for 12 hours without progress and with the presence of fetal distress. Placing the client on the left
side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava. The
intervention would be implemented with any client in labor. Monitoring the fetal heart rate pattern also is
appropriate for any client in labor but will delay necessary intervention in this situation.
SITUATION: Lulu is in her 39 weeks’ gestation was admitted to the emergency unit due to premature rupture of
membrane.
24. Which of the following conditions can compromise Lulu’ s condition and may require her to deliver thru
cesarean section?
a. Cord prolapse
b. Hypertonic contractions
c. Amniotic fluid embolism
d. Precipitate labor
ANSWER: A
In umbilical cord prolapse, a loop of the umbilical cord slips down in front of the presenting fetal part. Prolapse
may occur at any time after the membranes rupture if the presenting part is not fitted firmly into the cervix. It
tends to occur most often with the following: premature rupture of membranes, fetal presentation other than
cephalic, placenta previa, a small fetus, hydramnios, CPD preventing firm engagement and multiple gestation
25. Based on your answer on the previous question, the priority nursing action should be directed towards:
a. Monitoring the fetal heart rate
c. Holding the cord away from the presenting part
b. Covering the cord with a wet saline dressing
d. Keeping the presenting part away from the cord
ANSWER: D
Cord prolapsed automatically leads to cord compression, because the fetal presenting part presses against the
cord at the pelvic brim. Management is aimed toward relieving the compression and the resulting fetal anoxia.
This may be done by placing a gloved hand in the vagina and manually elevating the fetal head off the cord
Option A – the priority is maintaining cord circulation; although monitoring is important, it does not alter the
emergency
Option B – keeping the cord moist is secondary; keeping the presenting part off it to maintain cord circulation is
more important
Option C – holding the cord may increase pressure on the cord and further reduce oxygen to the fetus
26. When PROM occurs, which of the following provides evidence of the nurse’s understanding of the client’s
immediate needs?
a. The chorion and amnion rupture 4 hours before the onset of labor.
b. PROM removes the fetus most effective defense against infection
c. Nursing care is based on fetal viability and gestational age.
d. PROM may lead to malpresentation and possibly incompetent cervix
ANSWER: B
Premature rupture of membranes is rupture of fetal membranes with loss of amniotic fluid during pregnancy
before 37 weeks. PROM can precipitate many potential and actual problems; one of the most serious is the fetus
loss of an effective defense against infection thus may lead to chorioamionitis. This is the client’s most immediate
need at this time. Typically, PROM occurs about 1 hour, not 4 hours, before labor begins. Fetal viability and
gestational age are less immediate considerations that affect the plan of care. Malpresentation and an
incompetent cervix may be causes of PROM.
27. A client who has had a premature rupture of membranes (PROM) is highly at risk for:
a. C-section delivery
b. Hypertension
c. Infection
d. Abruptio placenta
ANSWER: C
Premature rupture of membranes (PROM) is rupture of fetal membranes with the loss of amniotic fluid during
pregnancy. The cause of this is unknown but it is associated with the infection of the membranes. PROM
eliminates the protective membrane and allows infectious agents to penetrate. If rupture occurs early in the
pregnancy, it poses a major threat to the fetus. After the rupture, the seal to the fetus is lost and fetal infection
may occur.
Family. 4th ed. 403
28. A 35 weeks pregnant client comes to the ED suspected of premature rupture of membrane. She is not in
labor and she describes a sudden gush of fluid from her vagina while watching TV. To confirm if it is amniotic
fluid, the nurse would perform which procedure?
a. Place small drops of vaginal fluid in Nitrazine paper. Red color indicates amniotic fluid
b. Place small drops of vaginal fluid in Nitrazine paper. Blue color indicates amniotic fluid
c. Place small drops of vaginal fluid in Nitrazine paper. Yellow color indicates amniotic fluid
d. Place small drops of vaginal fluid in white cloth and observe for halo signs
ANSWER: B
The most common test for diagnosing ruptured membranes is the Nitrazine test. To perform this test, place small
amounts (a drop or two) of vaginal fluid onto paper strips prepared with Nitrazine dye. A chemical reaction occurs
and the strips change color, indicating the pH of the vaginal fluid. If the color shows the pH is greater than 6.5
(blue), it's likely the membranes have ruptured. False readings can occur, however. Women with blood-tinged
mucus, for example, can test positive on the Nitrazine test because blood has a pH closer to amniotic fluid than
vaginal fluid. Some vaginal infections can also increase the pH of fluid in the vagina, and so can recent
intercourse, because semen has a high pH. If it causes an acidic reaction, the paper will turn yellow, indicating
that the fluid is urine. Option D: Incorrect.
SITUATION: Premature labor is labor that occurs before the end of 37 weeks’ of gestation. It occurs in
approximately 9% to 11% of all pregnancies. To halt this condition, different therapeutic managements are
established.
29. A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She
is started on an IV of ritodrine hydrochloride (Yutopar). What are the highest priority readings that the nurse
should monitor frequently during the administration of this drug?
a. Maternal blood pressure and respirations.
c. Hourly urinary output
b. Maternal and fetal heart rates
d. Deep tendon reflexes.
ANSWER: B
Monitoring the maternal and fetal heart rates is most important when ritodrine is being administered. Ritodrine is
a sympathomimetic agent that stimulates both beta 1 and beta 2 receptors. Stimulation of beta 1 receptors
causes tachycardia (side effect of the drug) and stimulation of beta 2 receptors causes uterine relaxation (desired
effect of the drug). While monitoring of (A, C, and D) is also helpful, these do not have the priority of
monitoringthe maternal and fetal heart rates when IV ritodrine hydrochloride (Yutopar) is administered.
30. The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this
prescription, it is most important for the nurse to assess the client for:
a. Gestational diabetes
b. Elevated blood pressure
c. Urinary tract infection
d. Swelling in lower extremities.
ANSWER: A
The nurse should evaluate the client for gestational diabetes because terbutaline (Brethine) increases blood
glucose levels.
Option B - could be related to the client being in preterm labor, however, terbutaline (Brethine) can cause a
decrease in blood pressure which results from dilatation of the blood vessels
Option C - can cause uterine irritability, which can result in preterm labor that should be treated by first resolving
the infection rather than by administering a tocolytic agent such as terbutaline (Brethine).
Option D - is a common pregnancy complaint.
SITUATION: A normal spontaneous delivery has 4 major components that are all essential in the process of
labor and delivery and in the promotion of safe and healthy newborn.
31. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate would be
most audible in:
a. Above the maternal umbilicus and to the right of midline
b. In the lower-left maternal abdominal quadrant
c. In the lower-right maternal abdominal quadrant
d. Above the maternal umbilicus and midline to the left
ANSWER: D
Fetal heart sounds are transmitted best through the convex portion of a fetus, because that is the part that lies in
closest contact with the uterine wall. In a vertex or breech presentation, fetal heart sounds are usually best heard
through the fetal back; in a face presentation, the back becomes concave so the sounds are best heard through
the more convex thorax. In breech presentations, fetal heart sounds are heard most clearly high in the uterus, at
the woman’s umbilicus or above. In cephalic presentations, they are heard loudest low in the abdomen. In a ROA
position, the sounds are heard best in the right lower quadrant; in a LOA position, in the left lower quadrant. In
posterior positions, hear sounds are loudest on a woman’s side.
32. The nurse understands that the fetal head is in which of the following positions with a face presentation?
a. Completely flexed
b. Completely extended
c. Partially extended
d. Partially flexed
ANSWER: B
If a fetus is in poor flexion, the back is arched, the neck is extended, and a fetus is in complete extension,
presenting the occipitomental diameter of the head to the birth canal (face presentation). From this position,
extreme edema and distortion of the face may occur. The presenting diameter is so wide that birth may be
impossible.
Options A and D – refers to a vertex presentation, the head is completely or partially flexed.
Option C - With a brow (forehead) presentation, the head would be partially extended.
childrearing family. Volume. 5th edition. Lippincot William & Wilkins. Page 493, 495.
33. Which of the following factors is the underlying cause of shoulder dystocia?
a. Nutritional
b. Mechanical
c. Environmental
d.Medical
ANSWER: B
Soulder dystocia is a birth problem that is increasing in incidence along with the increasing average weight of
newborns. The problem occurs at the second stage of labor, when the fetal head is born but the shoulders are too
broad to enter the and be born through the pelvic outlet. Therefore, the problem is mechanically induced as the
fetus was not able to complete the mechanisms of labor as this condition requires cesarean section to prevent
fetal distress or even death due to delayd delivery because cord might be compressed between the fetal body
and the bony pelvis. Nutritional, environment, and medical factors may contribute to the mechanical factors that
cause dystocia.
SITUATION: A normal spontaneous delivery has 4 major components that are all essential in the process of
labor and delivery and in the promotion of safe and healthy newborn.
34. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate would be
most audible in:
a. Above the maternal umbilicus and to the right of midline
b. In the lower-left maternal abdominal quadrant
c. In the lower-right maternal abdominal quadrant
d. Above the maternal umbilicus and midline to the left
ANSWER: D
Fetal heart sounds are transmitted best through the convex portion of a fetus, because that is the part that lies in
closest contact with the uterine wall. In a vertex or breech presentation, fetal heart sounds are usually best heard
through the fetal back; in a face presentation, the back becomes concave so the sounds are best heard through
the more convex thorax. In breech presentations, fetal heart sounds are heard most clearly high in the uterus, at
the woman’s umbilicus or above. In cephalic presentations, they are heard loudest low in the abdomen. In a ROA
position, the sounds are heard best in the right lower quadrant; in a LOA position, in the left lower quadrant. In
posterior positions, hear sounds are loudest on a woman’s side.
35. The nurse understands that the fetal head is in which of the following positions with a face presentation?
a. Completely flexed
b. Completely extended
c. Partially extended
d. Partially flexed
ANSWER: B
If a fetus is in poor flexion, the back is arched, the neck is extended, and a fetus is in complete extension,
presenting the occipitomental diameter of the head to the birth canal (face presentation). From this position,
extreme edema and distortion of the face may occur. The presenting diameter is so wide that birth may be
impossible.
Options A and D – refers to a vertex presentation, the head is completely or partially flexed.
Option C - With a brow (forehead) presentation, the head would be partially extended.
childrearing family. Volume. 5th edition. Lippincot William & Wilkins. Page 493, 495.
36. Which of the following factors is the underlying cause of shoulder dystocia?
a. Nutritional
b. Mechanical
c. Environmental
d.Medical
ANSWER: B
Soulder dystocia is a birth problem that is increasing in incidence along with the increasing average weight of
newborns. The problem occurs at the second stage of labor, when the fetal head is born but the shoulders are too
broad to enter the and be born through the pelvic outlet. Therefore, the problem is mechanically induced as the
fetus was not able to complete the mechanisms of labor as this condition requires cesarean section to prevent
fetal distress or even death due to delayd delivery because cord might be compressed between the fetal body
and the bony pelvis. Nutritional, environment, and medical factors may contribute to the mechanical factors that
cause dystocia.
37. A woman who has cervical cerclage for incompetent cervix is being instructed by the nurse. The nurse should
include which of the following?
a. Avoid sexual intercourse during the third trimester
b. Come to the hospital two days prior to the due date
c. Come to the hospital at the first signs of labor
d. Come to the hospital when having contractions that are five minutes apart
ANSWER: C
With a cervical cerclage, the cervix cannot dilate. It must be removed at the earliest sign of labor so the fetus
may be delivered vaginally. However, when a transabdominal approach is used, the sutures may be left in place
and a cesarian birth is performed. Sexual intercourse can already be assumed after after the rest period after
having cerclage surgery.
Family. 4th ed.
38. During an examination, the client is noted to have cervical motion tenderness. This finding is consistent with:
a. Toxic shock syndrome
c. Pelvic inflammatory disease
b. Ectopic pregnancy
d. Uterine fibroids
ANSWER: C
Cervical motion tenderness (CMT) is a classic sign in Pelvic inflammatory disease (PID). This refers to the
presence of pain when the cervix is moved. This condition refers to the infection of the pelvic organs (uterus,
fallopian tubes, oviaries and their supporting structures)The infection can extend to cause pelvic peritonitis. The
client usually notices severe pain in the lower abdomen. There is also fever as the infection progresses. During a
pelvic examination, any manipulation of the cervix causes severe pain.
39. A client who has had a premature rupture of membranes (PROM) is highly at risk for:
a. C-section delivery
b. Hypertension
c. Infection
d. Abruptio placenta
ANSWER: C
Premature rupture of membranes (PROM) is rupture of fetal membranes with the loss of amniotic fluid during
pregnancy. The cause of this is unknown but it is associated with the infection of the membranes. PROM
eliminates the protective membrane and allows infectious agents to penetrate. If rupture occurs early in the
pregnancy, it poses a major threat to the fetus. After the rupture, the seal to the fetus is lost and fetal infection
may occur.
40. The nurse is assessing the client for rupture of membranes. The nurse would perform a nitrazine paper test
to:
a. Determine if blood is present in the amniotic fluid
b. Distinguish between amniotic fluid and vaginal secretions by testing the pH
c. Distinguish between maternal feces and meconium
d. Determine the specific gravity of urine
ANSWER: B
Nitrazine test paper evaluates the pH of fluid thereby helping to distinguish between amniotic fluid (turns paper
dark blue-alkaline) or vaginal secretions only. Vaginal secretions are usually obtained by a cotton tipped
applicator and tested with a strip of Nitrazine paper. Vaginal secretions are acidic while amniotic fluid is alkaline.
If amniotic fluid has passed through the vaginal recently, the pH of the vaginal fluid will probably be alkaline (pH
> 6.5) when tested by Nitrazine paper (color appears blue green to deep blue). Note: pH of amniotic fluid
Family. 4th ed. 491
41. The nurse is assisting with the delivery and is monitoring the client for placental separation following delivery
of the newborn. After placental delivery, the nurse notes that the placenta appears shiny and glistening from the
fetal membranes. This type of placenta is known as:
a. Braxton
b. Duncan
c. Goodell
d. Schultze
ANSWER: D
It is a Schultze’s placenta is it appears shiny and glistening from the fetal membranes. Eighty percent of
placentas separate and presents this way. If the placenta separates first at its edges it slides along the uterine
surface and presents at the vagina with maternal surface evident. It looks raw, red with irregular edges. This is
called Duncan’s placenta. (Note: Schultze – shiny – fetal membrane surface / Duncan – dirty – irregular maternal
surface)
Additional: Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood
from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to globular shape. The
client may experience vaginal fullness, but not sudden and sharp abdominal pain.
Family. 4th ed
42. The birth hazard not associated with breech delivery is:
a. Intracranial hemorrhage
c. Compression of cord
b. Cephalhematoma
d. Separation of placenta prior to delivery of head
ANSWER: B
B – In a breech delivery the head is not the presenting part bearing the brunt of the pressure against the pelvic
floor during delivery.
A – May occur if there is difficulty in delivering the head after the body is born.
C – The cord may prolapse; and pressure of the baby can cause cord compression, resulting in fetal hypoxia.
D – This commonly occurs in breech deliveries.
p.753
43. A nurse is teaching a class on cesarean birth. What activity is the most appropriate for the nurse to include in
this class?
a. Participating in the choice of anesthesia
c. Deciding on support persons
b. Planning initial contact with their newborn
d. Discussing methods of contraception
ANSWER: A
Participating in the choice of anesthesia is the most important activity for the family having a cesarean section.
Planning initial contact with their newborn and deciding on support persons are appropriate topics for all births.
Discussing methods of contraception would not be appropriate to include in a childbirth education class.
44. A nurse is teaching a class on the methods of pain relief during labor. What is a benefit of using a whirlpool
(jet hydrotherapy)?
a. Increased diuresis
c. Decreased contractions
b. Increased heart rate for mother and baby
d. Decreased tearing of the perineum
ANSWER: A
Increased diuresis is a benefit of using a whirlpool. Increased heart rate for mother and baby is a risk if it causes
tachycardia. Decreased contractions are a risk, especially if used before active labor. Decreased tearing of the
perineum is true regarding episiotomy and massage, not of the whirlpool.
45. A nurse is teaching a group of pregnant women about the benefits and risks of activity during labor. For what
complication is the woman at risk she walks during the last stage of labor?
a. Cord prolapse
b. Placenta previa
c. Abruptio placentae
d. Incompetent cervix
ANSWER: A
Cord prolapse is a risk from ambulation during the last stage of labor if the fetus is not engaged, but placenta
previa, abruptio placentae and incompetent cervix are not.
46. A primigravida client at 30 weeks’ gestation has been admitted to the hospital with premature rupture of
membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. In response to the assessment
noted to the client, what would be the priority assessment?
a. Red blood cell count
b. Degree of discomforts
c. Urinary output
d. Temperature
ANSWER: D
Premature rupture of membranes is commonly associated with chorioamnionitis, or an infection. A priority
assessment for the nurse to make is to document the client’s temperature every 2 to 4 hours. Temperature
elevation may indicate an infection. Lethargy and an elevated white blood cell count also indicate an infection
Option A – the red blood cell count would provide information related to anemia not infection
Option B – the client is not in labor, therefore assessing the degree of discomfort is not the priority at this time
Option C – urinary output is not a reliable indicator of an infection such as chorioamnionitis
47. A woman who has experienced a precipitate labor is at risk for:
a. Uterine atony
b. Placenta accreta
c. Uterine rupture
d. Placenta previa
ANSWER: A
Uterine atony is a risk in clients with a history of rapid (labor of 2 hours of less) or precipitous delivery. Option B:
This is a low-risk complication for precipitate labor. Option C: This is a low-risk complication for precipitate labor.
Option D: This is a low-risk complication for precipitate labor.
Reference: Littleton. Maternity Nursing Care 8ed page 567, 583
48. What is the nursing action that has the highest priority for a client experiencing hypertonic contractions
during oxytocin stimulation of labor?
a. Open up the IV.
c. Stop the oxytocin infusion.
b. Start oxygen per face mask.
d. Turn the client on her left side.
ANSWER: C
The highest priority intervention is to stop the oxytocin, which is probably the cause of the hypertonicity. Option
A: This will increase the oxytocin rate and aggravate the hypertonicity. Option B: This may be appropriate to deal
with the hyperprofusion that can occur with hypertonicity, but is not the priority. Option D: This will not address
the hypertonicity.
49. When obtaining information about the initial appearance
pregnancy, Nurse Mian expects to report the manifestation of
a. About the sixth week of pregnancy
b. At the beginning of the last trimester
ANSWER: A
of the symptoms of a client with suspected ectopic

symptoms:
c. Midway through the second trimester
d. Immediately after implantation occurred
An Ectopic pregnancy is one which implantation occurs outside the uterine cavity. With Ectopic pregnancy, there
are no unusual symptoms at the time of implantation. At weeks 6 to 12 of pregnancy (2 to 8 weeks after a
missed menstruation period), the zygote grows large enough to rupture the slender fallopian tube or the
trophoblast cells break through the narrow base.
Option B and C – tubal patencies are unable to advance to this stage because of the tube’s inability to expand
with the growing pregnancy
Option D – the size of the fertilized egg at this time is minuscule and would cause no problem
50. Nurse Bina should include which instruction to a client with cervical cerclage for incompetent cervix?
a. Avoid sexual intercourse during the third trimester
b. Come to the hospital two days prior to the due date
c. Come to the hospital at the first signs of labor
d. Come to the hospital when having contractions that are five minutes apart
ANSWER: C
With a cervical cerclage, the cervix cannot dilate. It must be removed at the earliest sign of labor so the fetus
may be delivered vaginally. However, when a transabdominal approach is used, the sutures may be left in place
and a cesarian birth is performed. Sexual intercourse can already be assumed after the rest period after having
cerclage surgery.
Family. 4th ed.
51. When planning care for a 14- year- old female who is pregnant, a nurse should recognize that the adolescent
is at risk for:
a. Glucose intolerance
c. Incompetent cervix
b. Fetal chromosomal abnormalities
d. Iron deficiency anemia
ANSWER: D
Adolescents to have inadequate diets that are especially lacking in iron and folic acid. Option A: Pregnant
adolescents are not at risk for glucose intolerance. Option B: A diet deficient in folic acid has been linked to
neural tube defects but not fetal chromosomal abnormalities. Option C:. Pregnant adolescents are not at risk for
incompetent cervix.
52. A nurse would recognize that a woman who has had a cesarean delivery with a classical incision may not be
allowed to deliver vaginally for subsequent births because of
a. the presence of peritoneal adhesions
c. the risk for uterine rupture
b. loss of abdominal muscle tone
d. damage to the pelvic nerve innervation
ANSWER: C
Due to the risk of uterine rupture, labor and vaginal birth are not recommended in women who have had a
previous fundal classical scar. The risk for uterine rupture is the prime reason for cesarean section.
53. A woman who has had premature rupture of membranes (PROM) is at risk for:
a. Infection
b. C-section delivery
c. Hypertension
d. Placenta abruption
ANSWER: A
If rupture occurs early in the pregnancy, it poses a major threat to the fetus. After rupture, the seal to the fetus
is lost and uterine and fetal infection may occur.
54. Nurse Hannah is caring for a 29-year old client who has had high spinal cord injury due to an automobile
accident. During the immediate postpartum period, the client begins to exhibit signs of autonomic dysreflexia.
Nurse Hannah should immediately:
a. Administer an antihypertensive medication
c. Catheterize the client
b. Elevate the client’s head
d. Ask the client to take several deep breaths
ANSWER: B
In a woman who has a high spinal cord injury, observe for autonomic dysreflexia during pregnancy, labor, and
immediate postpartum period. This is an exaggerated autonomic response. Any irritating condition, such as
distended bladder, increasing uterine size, labor contractions, or breastfeeding may initiate the response.
Symptoms include severe hypertension, throbbing headache, flushing of the skin and profuse diaphoresis above
the level of spinal lesion. The first nursing action when autonomic dysreflexia occurs is to elevate the client’s
head to reduce cerebral pressure and locate the irritating stimulus (usually a distended bladder or bowel). Option
C: although a full bladder require catheterization, the first nursing action is to elevate the client’s head.
55. The nurse is caring for a pregnant client who is receiving ritodrine hydrochloride (yutopar) to halt preterm
labor at 30 weeks gestation. A priority assessment for the nurse to make for this client is to assess for the
presence of:
a. Headache
b. Rales
c. Nausea and vomiting
d. Hypercalcemia
ANSWER: B
A dangerous side effect of Ritodrine is pulmonary edema, so priority assessment is to determine if rales is
present in the lungs. Option A and C may be present, but it is not a priority assessment. Option D: Hypocalcemia,
not hypercalcemia, may occur
SITUATION: If labor does not start on its own, practitioner can use medication and other techniques to bring on
(or induce) contractions. There are different methods that can be use to augment, or speed up labor if it stops
progressing for some reason.
56. Mrs. Helena, a mutigravid client at 39 weeks’ gestation diagnosed with insulin dependent diabetes, is
admitted for the induction of labor with oxytocin (Pitocin). Which of the following should the nurse include in the
teaching plan as a possible disadvantage of this procedure?
a. Urinary frequency.
b. Maternal hypoglycemia.
c. Preterm birth.
d. Neonatal jaundice.
ANSWER: D
Oxytocin decreases the elimination of biliriubin from the neonate. Other adverse effects include maternal
hypotension, frontal headache, which disappears when the drug is discontinued. The drug has antidiuretic
properties that can lead to maternal water intoxication. Dangerous effects of this powerful drug include uterine
hyperstimulation or titanic contractions, which can result in abruption placenta and uterine rupture. Urinary
frequency, option b, and option c are not associated with oxytocin administration.
57. Which of the following nursing diagnoses would be the priority for Mrs. Helena who is scheduled for labor
induction with oxytocin (Pitocin)?
a. Risk for deficient fluid volume related to oxytocin infusion.
b. Pain related to prolonged labor and uterine ischemia.
c. Fear related to possible need for cesarean delivery.
d. Risk for injury, maternal or fetal, r/t potential uterine hyper stimulation.
ANSWER: D
Diabetic mothers have a higher incidence of pregnancy induced hypertension, polyhydramios, preterm birth, and
macrosomic baby and commonly have decreased placenta perfusion. Infants of diabetic mothers may have
polycythemia, congenital anomalies, and respiratory distress. There are no evidence supporting for options ABC.
58. A multigravid client is receiving oxytocin (pitocin) augmentation. When the client’s cervix is dilated to 6 cm,
her membranes rupture spontaneously with meconium-stained amniotic fluid. Which of the following actions
should the nurse do next?
a. Increase the rate of the oxytocin infusion.
c. Assess cervical dilation and effacement.
b. Turn the client to a knee-to-chest position.
d. Monitor the fetal heart rate continuously.
ANSWER: D
A common sign of fetal distress related to an inadequate transfer of oxygen to the fetus is meconium stained
fluid.
Because the fetus has suffered hypoxia, close fetal heart rate monitoring is necessary. All clients are monitored
continuously after rupture of membranes for fetal distress caused by cord prolapsed. if there are increasing signs
of fetal distress, the physician should be notified. Cesarean delivery may be performed for fetal distress.
Option A could lead to further fetal distress.
Option B, the mother should be placed in left side rather than knee chest position to improve placental perfusion.
Option C- The physician may wish to determine the extent of cervical dilation to make a decision about whether
cesarean delivery is warranted but option D is still essential to determine fetal status.
59. A primigravid client who has had a prolonged labor but now is completely dilated has received epidural
anesthesia. Which of the following should the nurse expect to include in the teaching plan about pushing?
a. The client needs to push for at least 1 to 3 minutes.
b. Pushing is most effective when the client holds her breath.
c. The client should be urged to push with an open glottis.
d. Pushing is limited to times when she feels the urge.
ANSWER: C
The client should be urged to push with an open glottis to prevent valsalva maneuver. Pushing with close glottis
increases intrathoracic pressure, preventing venous return. BP also falls, and CO also decreases. Pushing for at
least 1 to 3 minutes is too long which can lead to fatigue and reduced blood flow. Pushing while holding the
breath results in valsalva. Because the client has had an epidural anesthetic, she may not feel the urge to push
and may need coaching during the pushing phase.
60. Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Balderama orders I.V.
administration of oxytocin (Pitocin). Which of the following reasons why the nurse must monitor the client’s fluid
intake and output closely during oxytocin administration?
a. Oxytocin causes water intoxication
c. Oxytocin is toxic to the kidneys
b. Oxytocin causes excessive thirst
d. Oxytocin has a diuretic effect
ANSWER: A
The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water
intoxication, leading to seizures, coma, and death. Excessive thirst results from the work of labor and limited oral
fluid intake—not oxytocin. Oxytocin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic
effect.
family. Volume. 5th edition. Lippincot William & Wilkins. Page 613.
SITUATION: During pregnancy, the unborn baby (fetus) is surrounded and cushioned by a liquid called amniotic
fluid. This fluid, along with the fetus and the placenta, is enclosed within a sac called the amniotic membrane.
The amniotic fluid is important for several reasons.
61. Mrs. Agua Cristi, a primigravid client at 34 weeks’ gestation, is experiencing contractions every 3 to 4
minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the
client’s vital signs, the client says “I think my bag of water just broke.” Which of the following would the nurse do
first?
a. Check the status of fetal heart rate.
c. Test the leaking fluid with nitrazine paper.
b. Turn the client to her right side.
d. Perform a sterile vaginal examination.
ANSWER: A
The priority is to determine whether a prolapsed cord has occurred as a result of the spontaneous rupture of
membranes. The nurse’s first action should be to check the status of the fetal heart rate. Complications of PROM
include a prolapsed cord or increased pressure on the fetal umbilical cord inhibiting fetal nutrient supply. Variable
deceleration or fetal bradycardia may be seen on the external fetal monitor. The cord also may be visible. Turning
the client to her right side is not necessary. If the cord does prolapsed, the client should be placed in a knee-tochest or
Trendelenburg’s position. Checking the fluid with nitrazine paper and vaginal examination are
appropriate once the status of the fetus has been evaluated.
62. Mrs. Agua is to be discharged home on bed rest with follow-up by the home health nurse. After instruction
about care while at home, which of the following client statements indicates effective teaching?
a. “It is permissible to douche if the fluid irritates my vaginal area.”
b. “I can take either a tub bath or a shower when I feel like it.”
c. “I should limit my fluid intake to less than 1 quart daily.”
d. “I should contact the doctor if my temperature is 38 degree Celsius or higher.”
ANSWER: D
Because of the client’s increased risk for infection, successful teaching is indicated when the client states that she
will contact the doctor if her temperature is 38 degree Celsius or greater. The client should be instructed to
monitor her temperature twice daily. The client should refrain coitus, douching, and tub bathing, which can
increase the potential for infection. Showering is permitted because water in the shower doesn’t enter the vagina
and increase the risk of infection. A fluid intake of at least 2L daily is recommended to prevent potential urinary
tract infection.
63. The physician orders an amnioinfusion for a primigravid client at term who is diagniosed with
oligohydramnios. Which of the following should the nurse include in the client’s teaching plan about the purpose
of this procedure?
a. To decrease the frequency and severity of variable decelerations.
b. To minimize the possibility of fetal metabolic alkalosis.
c. To increase the fetal heart rate accelerations during a contraction.
d. To raise the amniotic fluid index to more than 15cm.
ANSWER: A
Oligohydramnios or a decrease in the volume of amniotic fluid is associated with variable fetal heart rate
decelerations due to cord compression. Maintenance of an adequate amniotic fluid volume during labor provides
protective cushioning of the umbilical cord and minimizes cord compression. Cord compression may lead to
metabolic acidosis. Amnioinfusion is used to minimize cord compression, not to increase the fetal heart rate
acceleration during contraction. the goal is to maintain the amniotic index at 8 cm.
64. A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect
should the nurse monitor for during the infusion of Pitocin?
a. Dehydration.
b. Hyperstimulation.
c. Galactorrhea.
d. Fetal tachycardia.
ANSWER: B
Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the client is at risk for
hyperstimulation (option B) which can lead to tetanic contractions, uterine rupture, and fetal distress or demise.
Dehydration (option A) and galactorrhea (option C) are not adverse effects associated with the administration of
Pitocin. Fetal tachycardia (option D) is an initial response to any stressor, including an increase in maternal
temperature or intrauterine infection, but fetal decelerations indicate distress following tetanic contractions.
Reference: A. Pillitteri. Maternal and Child Health Nursing 6th edition Page
65. After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong
enough to dilate the cervix. Which of the following would the nurse anticipate doing?
a. Obtaining an order to begin IV oxytocin infusion
b. Administering a light sedative to allow the patient to rest for several hour
c. Preparing for a cesarean section for failure to progress
d. Increasing the encouragement to the patient when pushing begins
ANSWER: A
The client’s labor is hypotonic. The nurse should call the physical and obtain an order for an infusion of oxytocin,
which will assist the uterus to contact more forcefully in an attempt to dilate the cervix. Administering light
sedative would be done for hypertonic uterine contractions. Preparing for cesarean section is unnecessary at this
time. Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be
necessary. It is too early to anticipate client pushing with contractions.
family. Volume. 5th edition. Lippincot William & Wilkins. Page
66. A woman who is in transient stage of labor is positioned for birth by the physician. To avoid the risk of
thrombophlebitis the nurse expects the physician to:
a. Place the client in lithotomy position for less than 90 minutes
b. Pad the stirrups if there is ankle edema
c. Don sterile mask, gown, and gloves
d. Raise both woman’s legs at the same time during positioning
ANSWER: B
If there is ankle edema, pad the stirrups to prevent thrombophlebitis. Be certain there is no pressure on her
calves. Option A: Lying in lithotomy position for more than 1 hour leads to intense pelvic congestion, because
blood flow to the lower extremeties is impeded. It may lead to an increase risk of thrombophlebitis in the
postpartal period. For these reason, the client’s leg should be placed in lithotomy position only at the last
moment. Option C: Donning sterile mask, gloves, and gown are needed to prevent infection, not
thrombophlebitis. Option D: This action will prevent the back and abdominal muscles.
67. To effectively promote pushing during second stage of labor, the nurse should:
a. Encourage the client hold breath while pushing during contraction
b. Ask her to breathe out during pushing
c. Ask the woman to pant with every contractions
d. Perform Ritgen maneuver
ANSWER: B
The client should push with contractions and rest between them. Pushing is usually best done in semi-Fowler’s,
squatting, or “all-fours” position rather than lying flat, to allow gravity to aid the effort. To promote effective
pushing, ask the client to breath out during a pushing effort. Avoid holding the breath during contraction because
it temporarily impede blood flow to the heart because of increased intrathoracic pressure. This could also
interfere with blood supply to the uterus. Asking the woman to pant with every contractions will actually prevent
the second stage of labor from moving too fast. Because it is difficult to push effectively when the client is using
her diaphragm for panting, this limits pushing. Ritgen maneuver is done to help the fetus achieve extension, so
that the head is born with the smallest diameter presenting.
Reference: A. Pillitteri. Maternal and Child Health Nursing 6th edition Page 385, 389
68. A client asks the nurse what is the purpose of a doula in labor. The nurse’s best answer would be:
a. “She can time contractions to keep them from becoming too long”
b. “She can cook you something to keep you from becoming dehydrated”
c. “She can serve as a support person and coach during your labor”
d. “She replaces your husband as your support person during labor”
ANSWER: C
A doula is a woman who is experienced in childbirth, but without professional credentials, who guides and assists
women in labor. Having a doula can increase a woman’s self-esteem as well as decrease rates of oxytocin
augmentation, epidural anesthesia, and CS birth.
69. Nurse Hannah anticipates “crowning” to occur at what stage of labor?
a. First stage
b. Second stage
c. Third stage
d. Fourth stage
ANSWER: B
Crowing, which occurs when the newborn’s head or presenting part appears at the vaginal opening, occurs during
the second stage of labor. During the first stage of labor, cervical dilation and effacement occur. During the third
stage of labor, the newborn and placenta are delivered. The fourth stage of labor lasts from 1 to 4 hours after
birth, during which time the mother and newborn recover from the physical process of birth and the mother’s
organs undergo the initial readjustment to the nonpregnant state.
70. During the third stage of labor, Nurse Debora would perform which of the following nursing interventions?
a. Assess uterine contractions every 30 minutes.
c. Promote parent-newborn interaction.
b. Obtain a urine specimen and other laboratory tests.
d. Coach for effective client pushing
ANSWER: C
During the third stage of labor, which begins with the delivery of the newborn, the nurse would promote parentnewborn interaction by
placing the newborn on the mother’s abdomen and encouraging the parents to touch the
newborn. Collecting a urine specimen and other laboratory tests is done on admission during the first stage of
labor. Assessing uterine contractions every 30 minutes is performed during the latent phase of the first stage of
labor. Coaching the client to push effectively is appropriate during the second stage of labor.
71. After being in labor for six hours, a client is admitted to the birthing room. The client is 5cm dilated and at -1
station. In the next hour, her contractions gradually become irregular but are more uncomfortable. When caring
for her, the nurse should first check for:
a. False labor
b. A full bladder
c. Uterine dysfunction
d. A breech presentation
ANSWER: B
A full bladder or bowel can impede fetal descent, so encourage the woman to void, if possible, at least every 2 to
4 hours. You need to remind the woman to do this during labor, because she may mistakenly interpret the
discomfort of a full bladder as part of the sensations of labor.
Option A – the client’s cervix has been dilating, and therefore it is in true, not false, labor
Option C – before this conclusion is considered, the client’s bladder should be emptied to relieve the pressure of
the presenting part on the uterus; the client can then be observed to see whether regular contractions resume
Option D – this would have been established in the admission examination
72. After receiving epidural anesthesia the client begins to feel nauseous and looking pale and clammy. The nurse
should first implement which action?
a. Raise the foot of the bed.
b. Assess for vaginal bleeding
c. Evaluate FHR
d. Take the client's BP
ANSWER: A
The chief concern with epidural anesthesia is its tendency to cause hypotension because of its blocking effect on
the sympathetic nerve fibers in the epidural space. Raising the foot of the bed will increase venous return and
provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring
that the client is in a lateral position are also appropriate interventions.
Options B and C - will not raise the maternal blood pressure.
Option D - Since the symptoms are common side effects of epidural anesthesia and suggest hypotension, thus
taking the client’s BP can wait until positioning is implemented.
73. A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain
relief. Which assessment finding is most important for the nurse to report to the healthcare provider?
a. Cervical dilation of 5 cm with 90% effacement.
c. Hemoglobin of 12 mg/dl and hematocrit of 38%.
b. White blood cell count of 12,000/mm3.
d. A platelet count of 67,000/mm3.
ANSWER: D
Administration of epidural anesthesia involves the insertion of a needle through the epidural space between the
L4-5, L3-4 or L2-3. A client with thrombocytopenia (low platelet count) should be reported to the healthcare
provider because it places the client at risk for bleeding when an epidural is administred.
Options A, B, and C are within the normal parameters for a client in active labor and is not contraindicated for the
placement of an epidural.
74. When preparing a client for cesarean delivery, which of the following key concepts should be considered when
implementing nursing care?
a. Instruct the mother’s support person to remain in the family lounge until after the delivery
b. Arrange for a staff member of the anesthesia department to explain what to expect postoperatively
c. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth
d. Explain the surgery, expected outcome, and kind of anesthetics
ANSWER: C
A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching
to meet the needs of either a planned or emergency cesarean birth, the depth and breadth of instruction will
depend on circumstances and time available. Allowing the mother’s support person to remain with her as much
as possible is an important concept, although doing so depends on many variables. Arranging for necessary
explanations by various staff members to be involved with the client’s care is a nursing responsibility. The nurse
is responsible for reinforcing the explanations about the surgery, expected outcome, and type of anesthetic to be
used. The obstetrician is responsible for explaining about the surgery and outcome and the anesthesiology staff is
responsible for explanations about the type of anesthesia to be used.
75. A multiparous woman in the latent phase of the first stage of labor has a cervical dilatation of 3 cm. The
latent phase in multiparous clients lasts approximately:
a. 4.5 hours
b. 6 hours
c. 8 hours
d. 12 hours
ANSWER: A
The average duration of the latent phase of the first stage of labor is 4 ½ hours for multiparous women and
about 6 hours for nulliparous women. This gets prolonged when analgesia is given to early in labor or a
cephalopelvic disproportion exists.
Family. 4th ed. 484
76. Nurse Isabela is caring for a client who is in first stage of labor. In the last vaginal exam, the client was fully
effaced, 8 cm dilated, vertex presentation and at station -1. Which observation would indicate that the fetus is in
fetal distress?
a. The fetal heart rate slowly decreases to 110 bpm during strong contractions recovering to 138 bpm
immediately afterwards
b. Fresh thick meconium is passed with a small gush of fluid and the fetal monitor shows late decelerations with a
variable descending baseline
c. Fresh meconium is found in the examiners gloved fingers after the vaginal exam and the fetal monitor pattern
remains essentially unchanged
d. Vaginal exam continues to reveal old meconium staining and the fetal monitor demonstrates a u-shaped
pattern of decelerations during contractions recovering to a baseline of 140 bpm.
ANSWER: B
Meconium staining alone is not a sign of fetal distress. Meconium passage is a normal physiological function,
frequently noted with a fetus over 38 weeks’ gestation. Old meconium staining may be the result of a prenatal
trauma that is resolved. It is not unusual for the fetal heart rate to drop below the 140 to 160 beats per minute
range in late labor during contractions, and in a healthy fetus the feta heart rate will recover between
contractions. Fresh meconium in combination with late decelerations and a variable descending baseline is an
ominous signal of fetal distress caused by fetal hypoxia.
Family. 4th ed.
77. The nurse is caring for a client who is in the active phase of the first stage of labor. The nurse is monitoring
the fetal status and notes late decelerations. Based on this observation, the priority action of the nurse should
be:
a. Administer oxygen via facemask
c. Call the physician
b. Document the findings
d. Prepare for immediate birth
ANSWER: A
Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen
transfer to the fetus through the intervillous space during the uterine contractions. This causes hypoxemia;
therefore, oxygen is necessary. Late decelerations are considered an ominous sign but do not necessarily require
immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The
oxytocin would cause further hypoxemia because the medication stimulates contractions and leads to increased
uteroplacental insufficiency. Although the finding needs to be documented, documentation is not the priority
action in this situation.
Family. 4th ed.
78. Which of the following factors could negatively affect the labor?
a. The maternal pelvis is gynecoid
c. The presenting part is the sacrum
b. The fetal attitude is in general flexion
d. The fetal lie is longitudinal
ANSWER: C
With the sacrum as the presenting part, the fetus is in breech presentation. Breech presentation is the most
common form of malpresentation, which is considered a complication of labor. A longitudinal fetal lie, general
flexion, and gynecoid maternal pelvis are considered normal.
Reference: Lowdermilk, D.L. Maternal and Women’s Health Care 8th edition
79. Mrs. Labrador presents to the labor room with the fetus in vertex presentation. Nurse Hannah expects the
seven cardinal movements of labor to occur in which of the following order?
1. Descent
3. Flexion
5. Extension
7. Internal rotation
2. Engagement
4. Expulsion
6. External rotation
a. 1, 2, 3, 7, 5, 6, 4
b. 2, 1, 3, 7, 5, 6, 4
c. 2, 1, 3, 6, 5, 7, 4
d. 1, 2, 3, 6, 5, 7, 4
ANSWER: B
The 7 cardinal movements of the mechanism of labor that occur in a vertex presentation are engagement,
descent, flexion, internal rotation, extension, external rotation, and expulsion.
80. Which of the following nursing actions reflects application of the gate control theory during labor?
a. Turn the client onto her left side
c. Administer the prescribed medication when the client is dilated to 4 cm
b. Massage the client’s back
d. Encourage the client to rest between contractions
ANSWER: B
According to the gate control theory, pain sensations, travel along nerve pathways to the brain. Only a limited
number of sensations can travel along these pathways at one time. Distraction techniques, such as massage,
reduce or block the nerve pathways transmitting pain. Although other nursing actions are appropriate for a
laboring client who is experiencing discomfort, they do not address the gate control theory.
81. When evaluating a fetal heart rate (FHR) pattern on an external electronic fetal monitor, the nurse notes that
the FHR begins to decelerate after the contraction has started and the lowest point of the deceleration occurs
after the peak of the contraction. What is the nurse’s first priority?
a. Insert the scalp electrode
c. Document the findings as benign decelerations
b. Prepare for an amnioinfusion
d. Change the client’s position
ANSWER: D
Although a scalp electrode may need to be inserted for a more accurate internal assessment, the client’s position
should be changed first in order to displace the weight of the uterus off the vena cava. This increases maternal
circulation to the placenta. Amnioinfusion is indicated for umbilical cord compression, decreased amniotic fluid, or
to dilute meconium-stained amniotic fluid.
82. After vaginal examination, assessment of a laboring client is documented as 3 cm, 30%, and -1. The nurse’s
interpretation of this assessment is which of the following?
a. The cervix is effaced 3 cm, it is dilated 30% and the presenting part is 1 cm above the ischial spines
b. The cervix is effaced 3 cm, it is dilated 30% and the presenting part is 1 cm below the ischial spines
c. The cervix is dilated 3 cm, it is effaced 30% and the presenting part is 1 cm below the ischial spines
d. The cervix is dilated 3 cm, it is effaced 30% and the presenting part is 1 cm above the ischial spines
ANSWER: D
Dilation of the cervix is the widening of the cervical opening measured in cm from closed to approximately 10 cm
(full dilation). Effacement refers to the shortening and thinning of the cervix. Degree of effacement is stated I
terms of percentage from 0 to 100%. Station is the relation of the presenting part of the fetus to an imaginary
line drawn between the ischial spines in the maternal pelvis. The degree of descent is noted in cm that is either
above, below, or at the level of ischial spines. If the station is -1, then the presenting part is 1 cm above the
ischial spines.
83. A woman in the first stage of labor is using pattern-paced breathing. She complains of feeling lightheaded
and states that her fingers are tingling. Which of the following actions should the nurse take?
a. Notify the client’s physician
c. Tell the client to slow the rate of her breathing
b. Administer oxygen via nasal cannula
d. Help the client breathe into a paper bag
ANSWER: D
The client is experiencing symptoms of respiratory alkalosis due to hyperventilation. The client needs to
rebreathe carbon dioxide and replace the bicarbonate ion rather than receive more oxygen. It is not necessary to
notify the doctor at this time. Telling the client to slow her breathing rate will not help relive her symptoms.
84. The nurse is caring for a client who is receiving intravenous infusion of oxytocin (Pitocin) to stimulate labor.
The nurse notifies the physician if which of the following are noted?
a. Adequate resting tone between contractions
c. Presence of three contractions every ten minutes
b. Fetal tachycardia
d. Soft uterine tone palpated between contractions
ANSWER: B
The goal of labor augmentation is to achieve three good quality contractions (appropriate intensity and duration)
in a 10 minute period. The uterus should return to resting tone between contractions and there should be no
evidence of fetal distress. Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should
be decreased in the presence of fetal tachycardia from excessive uterine activity. The nurse should also assure
that the uterus maintains an adequate resting tone between contractions.
a. Dehydration
b. Hyperstimulation
c. Galactorrhea
d. Fetal tachycardia
ANSWER: B
hyperstimulation (B) which can lead to tetanic contractions, uterine rupture, and fetal distress or demise.
Dehydration (A) and galactorrhea (C) are not adverse effects associated with the administration of Pitocin. Fetal
tachycardia (D) is an initial response to any stressor, including an increase in maternal temperature or
intrauterine infection, but fetal decelerations indicate distress following tetanic contractions.
Family. 4th ed. Page
86. A client is complaining of cramps in her right leg while in active labor. What intervention should the nurse
implement?
a. Massage the calf and foot.
c. Lower the leg off the side of the bed.
b. Extend the leg and dorsiflex the foot.
d. Elevate the leg above the heart.
ANSWER: B
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable) (B), and
putting the heel of the foot on the floor is the best means of relieving leg cramps. Option A is ineffective for leg
cramps caused by phosphorous/calcium imbalances and may dislodge small thrombi. Option C would not be
helpful. Option D is used to promote venous return, but is not indicated for leg cramps.
87. The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when
carrying out this procedure?
a. A gravida 6, para 5 who is 38 years of age and in early labor.
b. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1 station.
c. A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of labor due to post dates.
d. A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.
ANSWER: D
When the presenting part is ballottable (D), it is floating out of the pelvis. In such a situation, the cord can
descend before the fetus causing a prolapsed cord, which is an emergency situation. Options A, B, and C do not
present problems with administration of an enema.
88. The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red
vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm
dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
a. Insert an internal fetal monitor.
c. Monitor bleeding from IV sites.
b. Assess for cervical changes q1h.
d. Perform Leopold's maneuvers.
ANSWER: C
Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of
placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruptio,
characterized by abnormal bleeding. Invasive vaginal procedures (A and B) or (D) can increase the abruption and
bleeding, so these interventions are contraindicated.
89. Four hours after spontaneous vaginal delivery under local anesthesia, a patient tells the nurse that she has to
urinate. Which of the following actions should the nurse take?
a. Obtain a bedside commode for the patient
c. Ambulate the patient to the bathroom
b. Offer the patient a bedpan
d. Catheterize the patient
ANSWER: C
Since the patient delivered under local anesthesia, she should be able to ambulate at this time. The nurse should,
however, assist the patient to the bathroom to make sure that she is able to safety ambulate. Options A and C:
Using a bedpan or using a bedside commode is not necessary for this patient. The patient should be fully mobile
four hours after delivery. Option D: Catheterizing a patient post-delivery should only be done when all other
measures are not effective.
90. Mrs. Dimaano is scheduled for a non-stress test. After the test, the result documented on the chart is no
accelerations during the 40 minute observation. The nurse interprets these findings as:
a. A reactive stress test
c. An unsatisfactory stress test
b. A non-reactive stress test
d. The results are inconclusive
ANSWER: B
A reactive nonstress test (normal/negative) indicates a healthy fetus. It is described as two or more fetal heart
rate (FHR) accelerations of at least 15 beats or more lasting at least 15 seconds from the beginning of the
acceleration to the end in association with fetal movement, during a 20 minute period. A nonreactive nonstress
test (abnormal) is described as no accelerations or accelerations of less than 6 beats per minute or lasting less
than 15 seconds in duration for a chosen time period. An unsatisfactory test cannot be interpreted because of
the poor quality of the FHR. The results are conclusive as nonreactive.
Family. 5th ed.
91. Another client had a non-stress test for the past few weeks and the results were reactive. A few minutes ago,
the results were non-reactive. The nurse anticipates that the client will be prepared for:
a. A return appointment in 2 to 7 days to repeat the nonstress test
b. A contraction stress test
c. Hospital admission with continuous fetal monitoring
d. Immediate induction of labor
ANSWER: B
A non-reactive nonstress test needs further assessment. There is not enough data in the question to indicate that
the procedures in options c and d are necessary at this time. To send the client home for 2 to 7 days may place
the fetus in jeopardy as in option a. A contraction stress test is the next test needed to further assess the fetal
status.
Family. 5th ed. 203
ANSWER: B
Family. 4th ed.501
93. Nurse Adora is taking care of a client who was admitted 12 hours ago. The client is experiencing contractions
every 3 minutes and has remained at station 0 until now. The fetal heart rate upon admission is 140 bpm and
regular. Now, the fetal heart rate is decreasing and a persistent non-reassuring pattern is present. The nurse
should:
a. Continue to monitor the fetal heart pattern
c. Prepare to induce labor
b. Turn the client to the right side
d. Prepare for a caesarian delivery
ANSWER: D
Dystocia, failure of labor to progress, and a persistent nonreassuring fetal heart rate pattern are indications of
the need to perform a cesarean delivery. Inducing labor is inappropriate in this situation because the client has
been in labor for 12 hours without progress and with the presence of fetal distress. Placing the client on the left
side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava. The
intervention would be implemented with any client in labor. Monitoring the fetal heart rate pattern also is
appropriate for any client in labor but will delay necessary intervention in this situation.
Family. 4th ed.542
94. The ischial spines are designated as an important landmark in labor and delivery because the distance
between the spines is:
a. A measurement of the floor of the pelvis
c. The widest measurement of the pelvis
b. A measurement of the inlet of the birth canal
d. The narrowest diameter of the pelvis
ANSWER: D
A determination of the station (descent) of the fetus is based on the relationship of the presenting part and the
spine. If too small, delivery cannot occur. The measurement of the pelvic floor is not involved with the fetus’
descent into the birth canal. Option b refers to measurement of the pelvic outlet. The distance between the ischial
spines is the narrowest measurement of the pelvis.
p.750
95. Which of the following nursing diagnoses would be given priority in the care of a laboring woman who is
about to receive epidural analgesia?
b. Anxiety
c. Fluid volume deficit
d. Activity intolerance
ANSWER: C
Increasing fluid volume prior to the administration of epidural anesthesia can help to decrease the possibility of
hypotension, a frequent complication of the anesthesia due to peripheral vasodilatation. The woman can be given
with 500 to 1000 ml of Ringer’s Lactated before the anesthetic. Option A: Adequate teaching regarding the
effects of epidural anesthesia would decrease the likelihood of the patient having a knowledge deficit. Option B:
Adequate teaching regarding the effects of epidural anesthesia would decrease the likelihood o the patient having
anxiety. Option D: Patients receiving an epidural anesthetic must be on bed rest due to decreased sensation in
the lower extremities, but this is not a long- term problem in activity intolerance.
96. Because a woman is receiving oxytocin (Pitocin) for induction of labor, it is essential for the nurse to monitor:
a. Fundal height
b. Patellar reflexes
c. Cervical changes
d. Level of consciousness
ANSWER: C
The goal of induction with Pitocin is to increase cervical dilation. Pitocin stimulates uterine contractions. Once a
woman’s cervix reaches five to six centimeters and labor is established, the Pitocin should be decreased. The fetal
heart rate, uterine resting tone and frequency, duration and intensity on contractions are monitored continuously.
Option A: Fundal height is not part of the nursing assessment of a patient receiving Pitocin. Option B: Patellar
reflexes are monitored in patients with pregnancy-induced hypertension or preeclampsia. Option D: The level of
consciousness is monitored and is of particular concern for patients receiving magnesium sulfate.
97. A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse
implement?
ANSWER: B
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable) (option B),
and putting the heel of the foot on the floor is the best means of relieving leg cramps. Option A is ineffective for
leg cramps caused by phosphorous/calcium imbalances and may dislodge small thrombus. Option C would not be
Reference: A. Pillitteri. Maternal and Child Health Nursing 6th edition
98. The nurse is monitoring a client in labor room. Following epidural anesthesia, the client complains of metallic
taste and blurred vision. The nurse should make which of the following statement to the client?
a. “I will call the doctor you may have an emergency situation”
b. “This is normal, I will continue to monitor your progress”
c. “I will ask the doctor to increase the IV rate”
d. “This is normal, I will give you ice chips to relieve the discomfort”
ANSWER: A
In rare instances, the anesthetic enters the blood circulation. This occurrence is manifested as drowsiness, a
metallic taste on the tongue, slurred speech, blurred vision, unconsciousness and seizure leading to cardiac
arrest. If such symptoms occur, it is an emergency situation. The woman needs oxygen and an anticonvulsant,
such as diazepam (Valium) or thiopental (Penthotal) IV, followed by prompt birth of fetus.
99. At 15 weeks' gestation, a client is scheduled for a serum alpha-fetoprotein (AFP) test. Which maternal
history finding best explains the need for this test?
a. Family history of spina bifida in a sister
b. Family history of Down syndrome on the father's side
c. History of gestational diabetes during a previous pregnancy
d. History of spotting during the 1st month of the current pregnancy
ANSWER: A
An abnormally high AFP level in the client's serum or amniotic fluid suggests a neural tube defect such as spina
bifida. A family history of such defects increases the risk of carrying a fetus with a neural tube defect.
Option B - Although a low AFP level has been correlated with Down syndrome, it isn't the most accurate indicator.
Option C and D - No known correlation exists between gestational diabetes or early vaginal spotting and a certain
AFP level at 15 to 20 weeks' gestation.
Pillitteri, A.. (2007). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. 5th Edition,
Vol. 1 Page 207
100. In spontaneous abortion, if membranes have ruptured and the cervix is open, it is known as:
a. Inevitable
b. Complete
c. Threatened
d. Incomplete
ANSWER: A
Inevitable abortion if there is uterine contractions and cervical dilation. With cervical dilation, the loss of the
products of conception cannot be halted.
Option B – complete abortion when the entire products of conception (fetus, membranes and placenta) are
expelled spontaneously without any assistance.
Option C – threatened abortion is manifested by vaginal bleeding but no cervical dilatation.
Option D – in an incomplete abortion, part of the conceptus (usually the fetus) is expelled but membrane and
placenta is retained in the uterus.
Pillitteri, A.. (2007). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. 5th Edition,
Vol. 1 Page 403-405
INTRAPARTUM
SITUATION: Labor is a series of events by which uterine contractions and abdominal pressure expel a fetus and
placenta from a woman’s body. Labor and birth require a woman to use all the psychological and physical coping
methods she has available
1. Lilia wants to learn Lamaze breathing techniques. The principle of Lamaze childbirth is best explained as:
a. Pain can be interrupted before it registers in the brain as pain
b. Labor contractions are not pain; they’re muscle inflammation
c. “Brown pain” like labor contractions can be lessened
d. Labor contraction are intensified by abdominal massage
ANSWER: A
The Lamaze method of prepared childbirth, based on the gating control theory of pain relief, is the one most
often taught. This method is based on the theory that through stimulus-response conditioning, women can learn
to use controlled breathing to reduce pain during labor.
Other options are incorrect.
2. Which of the following would be a major disadvantage of any pain relief method that also affects awareness of
the mother?
a. The father's coaching role may be disrupted at times.
b. The infant may show increased drowsiness.
c. The mother may have continued memory loss postpartum.
d. The mother may have difficulty working effectively with contractions.
ANSWER: D
Breathing and relaxation techniques can speed labor. An inability of the woman to do these as a result of pain
relief measures can slow labor.
3. During labor Nurse Pat encourages the client to void. She recognizes that an over distended urinary bladder
during labor can cause:
a. Interfere with the delivery of the placenta
c. Prevent the diagnosis of cephalopelvic disproportion
b. Interfere with the assessment of cervical dilation
d. Predispose to uterine hemorrhage immediately after birth
ANSWER: D
An over distended urinary bladder prevents the uterus from contracting after birth, contraction of the uterus
constricts blood vessels, preventing hemorrhage. Option A : This does not interfere with the third stage of labor.
Option B: A digital examination to assess vaginal dilation does not require an empty urinary bladder to be
accurate. Option C: An over distended urinary bladder may impede descent but does not interfere with the
diagnosis
4. The fetus of a client in labor is in LOP position. To lessen some of the discomfort caused by this type of labor,
Nurse Mian should counsel the husband to:
a. Encourage the client to sleep between contractions
b. Elevate the head of the client’s bed to a 45-degree angle
c. Instruct the client to take deeper breaths during contractions
d. Apply pressure to the client’s sacral area during contractions
ANSWER: D
Position is important, because it influences the process and efficiency of labor. Posterior positions may also be
more painful for the mother, because the rotation of the fetal head puts pressure on the sacral nerves, causing
sharp back pain. Therefore, pressure on the sacral area during a contraction provides counterpressure to the
gravitational force of the fetal head in the occiput posterior position. Option A – this may promote relaxation but
will not relieve the back pain caused by the force of the fetal head during contraction. Option B – this may
aggravate the back pain because it increases the pressure of the fetal head on the sacral area. Option C – this
will do nothing to alleviate the back pain caused by the force of the fetal head during a contraction
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition. Page 284, 497,
5. Observation of a client in labor reveals that she is entering the transition phase of the first stage of labor. The
nurse would recognize this by identifying:
a. Redness of the face and an urge to push
c. Increased bloody show, irritability and shaking
b. A bulging perineum, crowning and caput
d. Contractions that are longer and more frequent
ANSWER: C
During the transition phase, contractions reach their peak of intensity, occurring every 2 to 3 minutes with a
duration of 60 to 90 seconds and causing maximum dilatation of 8 to 10 cm. The membrane will eventually
ruptured as a rule at full dilatation, therefore show occurs as the last of the mucus plug from the cervix is
released. During phase a woman may experience intense discomfort, so strong that it is accompanied by nausea
and vomiting. She may also experience a feeling of loss of control, anxiety, panic, or irritability
6. Shaina, has just entered the second stage of labor. Nurse Bea is caring for her and routinely checking her vital
signs and laboratory studies to ensure a safe delivery. Upon assessment, which of the following requires
immediate report to the physician?
a. Increase in the systolic blood pressure by 15 mm Hg with each contraction
b. A 100% increase in the total oxygen consumption
c. A WBC level of more than 10, 000 cells/mm3
d. Specific gravity is 1.010
ANSWER: D
With the decrease in fluid intake during labor and the increase insensible water loss, the kidneys begin to
concentrate urine to preserve both fluid and electrolytes. Specific gravity may rise to a high normal level of 1.020
to 1.030. A low specific gravity indicates the kidneys are not able to conserve the woman’s fluids and electrolytes
thus predisposing the client to be dehydrated that may lead to increase demand of oxygen that may predisposed
the fetus into distress
Option A – with the increased cardiac output caused by contractions, systolic blood pressure rises an average of
15 mm Hg with each contraction. Higher increases could be a sing of pathology
Option B – Whenever there is an increase in cardiovascular parameters, the body responds by increasing the
respiratory rate to supple additional oxygen. This could result to hyperventilation. Total oxygen consumption
increases by about 100% during the second stage of labor.
Option C – the major change in the blood forming system that occurs during birth is the development of
leukocytosis, or a sharp increase in the number of circulating white blood cells, possibly as a result of stress and
heavy exertion. At the end of labor, the average woman has a white blood cell count of 25, 000 to 30, 000
cells/mm3, compared with a normal count of 5,000 to 10, 000 cells/mm3
7. The painful phenomenon known as "back labor" occurs in a client whose fetus is in what position?
a. Breech
b. Brow
c. LOP
d. ROA
ANSWER: C
Because the pressure of the occiput is against the sacral nerves with posterior presentations, contractions with
the LOP or ROP are felt primarily in the lower back. Option A: A breech presentation does not produce labor
contractions felt primarily in the back. Option B: A brow presentation is very rare, because the normal position of
the fetus is flexion. Option D: With anterior presentations (LOA or ROA), the contractions are felt primarily in the
front.
Reference: Littleton. Maternity Nursing Care. 8ed page 458
8. A woman's husband expresses concern about risk for paralysis from an epidural block being given to his wife.
Which of the following would be the most appropriate response?
a. “An injury is unlikely because of expert professional care given.”
b. “I have never read or heard of this happening.”
c. “The injection is given in the space outside the spinal cord.”
d. “The injection is given at the third or fourth thoracic vertebrae, so that paralysis is not a problem.”
ANSWER: C
An epidural block, as the name implies, does not enter the spinal cord, but only the epidural space outside the
cord.
9. A client in active labor was rushed from the emergency service to the labor and delivery room screaming,
“Knock me out.” Examination reveals that her cervix is 9cm dilated. While trying to calm her, the nurse should
respond:
a. “I’ll rub your back which will help ease your pain.”
b. “You will get a shot when you reach the birthing room”
c. “I’m sure you’re in pain, but try to bear with if for the baby’s sake”
d. “Medication may interfere with the baby’s first breaths, try to bear the pain.”
ANSWER: D
Analgesia crosses the placental barrier; since birth of the fetus is imminent, it can cause respiratory depression in
the newborn.
Option A – the client is exhibiting fear and panic; a back rub at this time would not be effective and probably
would be rejected
Option B – this is incorrect information and provides false reassurance
Option C – although this is an empathetic response, an explanation as to why medication cannot be given is more
appropriate
10. A client is to receive an epidural anesthetic during labor. After the client is anesthetized, the nurse should
monitor the client for:
a. Lightheadedness
b. Urinary retention
c. Decreased temperature
d. Decreased LOC
ANSWER: B
Anesthesia blocks the sensory pathways so that the mother does not sense bladder distention and may be unable
to void.
Option A – this is a side effect of spinal not epidural anesthesia
Option C – an epidural anesthetic does not influence body temperature
Option D – this occurs with general anesthesia, not epidural anesthesia, general anesthesia is used only in
emergencies
11. During a vaginal examination, the nurse palpates the fetal posterior fontanel. Which describes the fetal lie?
a. Flexion
b. Occiput
c. Transverse
d. Longitudinal
ANSWER: D
Longitudinal lie is the long axis along the long axis of the mother. Option A: This describes fetal attitude. Option
B: This describes fetal position. Option C: Transverse lie refers to the fetal lie with a shoulder presentation.
12. At the peak of a contraction, meconium-stained fluid gushes from a client's vagina. Nurse Rachel should
immediately:
a. Call the physician
c. Check the fetal heart rate
b. Change the bedding
d. Position the client on her right side
ANSWER: C
Meconium-stained amniotic fluid is an indication of fetal distress, so the fetal heart tones should be assessed by
the nurse immediately. Option A: Although the health care provider should be notified, this is not the first action
the nurse should take. Option B: This is not the first action the nurse should take. Option D: Maternal position
should be changed to the left lateral position.
13. Nurse MJ notes that when palpating the abdomen during a contraction, it is not possible to indent the uterine
wall. The intensity of this contraction would be termed:
a. Mild
b. Slight
c. Strong
d. Moderate
ANSWER: C
During strong contractions, the fundus resists indentation by the slightly spread fingertips of the nurse. Option A:
During mild contractions, the fundus can be indented. Option B: Slight is not a term used to describe uterine
contractions. Option D: During moderate contractions, the fundus can be indented, but not as easily as with mild
contractions.
14. Nurse Maria teaches a client how to determine the duration of a contraction. Which is the correct information?
a. Time the contraction from its peak to the end of the same contraction.
b. Time the contraction from the beginning of the contraction to the peak of the same contraction.
c. Time the contraction from the beginning to the end of the same contraction.
d. Time the contraction from the beginning of a contraction to the beginning of the next contraction.
ANSWER: C
This is the definition of the duration of a contraction. Option D: Frequency of contraction.
15. While caring for a woman in labor, the fetal heart monitor demonstrates late decelerations. The most
common cause for their occurrence is:
a. Cord compression.
b. Maternal hypotension.
c. Maternal fatigue.
d. Uteroplacental insufficiency.
ANSWER: D
Late decelerations are a negative sign. They typically indicate decreased blood flow to the uterus during the
contractions.
16. Nene is scheduled for contraction stress test. Nursing care for pregnant client having an oxytocin stimulatedcontraction test
should include:
a. Having the client empty her bladder
c. Keeping the client on nothing by mouth
b. Placing the client in a supine position
d. Preparing the client for insertion of internal monitors
ANSWER: A
Once the test is initiated the client will require continuous electronic monitoring and will be confined to bed;
contractions are more uncomfortable with a full bladder
Option B – the client should be in the semi-fowler’s position to avoid supine hypotension by preventing the uterus
from compressing the vena cava
Option C – the client should eat so that the fetus does not become hyperactive
Option D – only external monitoring is done
17. Nurse Kris understands that when a contraction stress test is interpreted as negative it means which of the
following?
a. The fetus at this time has oxygen reserves but the test should be repeated weekly
b. The test should be repeated in 24 hours because examination results indicate hyperstimulation
c. Immediate birth should be considered because there is no fetal heart acceleration with fetal movement
d. A trial induction should be started because fetal heart rate acceleration with movement is indicative of a false result
ANSWER: A
Contraction stress test measures the response of fetal heart rate in relation to uterine contractions produced by
nipple stimulation. A normal finding is the absence of late decelerations with contractions. The test is negative
(normal) if no fetal heart rate decelerations. It is positive (abnormal) if 50% or more of contractions cause a late
deceleration (a dip in fetal heart rate that occurs toward the end of a contraction and continues after the
contraction)
Option B – interpretable data did not show signs of hyperstimulation if a negative result was reported
Option C – A positive test reveals that the fetus has late decelerations with contractions; it may indicate a fetus
at risk
Option D – fetal heart rate accelerations with movement are reassuring; an expeditious birth is not indicated
18. The fetal monitor has shown several late decelerations over the past 10 minutes. Nurse Mariel determines
that this pattern indicates?
a. Umbilical cord compression
b. Head compression
c. Fetal hypoxia
d. Maternal fever
ANSWER: C
A pattern of late decelerations indicates fetal hypoxia, caused primarily by uteroplacental insufficiency. Variable
decelerations are caused by umbilical cord compression. Early decelerations are caused by head compression.
Maternal fever may contribute to fetal tachycardia.
19. A woman states that she does not want any medication for pain relief during labor. Her doctor has approved
this for her. What is your best response to her concerning this choice?
a. “That's wonderful. Medication during labor is not good for the baby.”
b. “Your doctor (a man) has never been in labor; he may be underestimating the pain you will have.”
c. “I respect your preference whether it is to have medication or not.”
d. “Let me get you something for relaxation if you don't want anything for pain.”
ANSWER: C
Individualizing care to meet women's specific needs is a nursing responsibility.
20. Nurse Sheila is assigned at the local birthing unit. She is caring for a client following an amniotomy. What is
an appropriate nursing intervention?
a. Assess cervical dilation every 2 hours.
c. Encourage ambulation every 1-2 hours.
b. Monitor temperature every 2 hours.
d. Replace expelled amniotic fluid every 1-2 hours.
ANSWER: B
Due to an increased risk of infection, the nurse should monitor temperature every 2 hours following an
amniotomy. Vaginal exams are kept to a minimum to decrease the chance of infection. Bedrest is maintained
unless the presenting part is engaged. Replacing expelled amniotic fluid every 1-2 hours is unnecessary, as
amniotic fluid is constantly produced.
21. Nurse Hannah assesses a laboring client whose contractions occur every 5-7 minutes and last for 30 seconds.
This contraction pattern is expected in which phase of labor?
a. Latent
b. Active
c. Transition
b. Second
ANSWER: A
Latent phase of labor is when contractions occur every 5-7 minutes and last for 30 seconds. In the active phase,
contractions should occur every 3-5 minutes. In the transition phase, contractions should occur every 2 to 3
minutes. There is no second phase.
22. A laboring client is complaining of severe nausea and increased rectal pressure. She is thrashing about and
cries, “I can’t do this anymore. Please help me!” This client is most likely in which phase of labor?
a. Latent
b. Active
c. Transition
b. Second
ANSWER: C
These symptoms and behaviors indicate the transitional labor phase. During this phase, a woman may experience
a feeling of loss of control, anxiety, panic, iiritability. Option A is incorrect; latent phase labor symptoms are very
unlikely to be this intense. Option D is incorrect, the second stage of labor is usually characterized by the urge to
push. Option B is incorrect; clients usually feel that they can deal with contractions during the active phase.
23. A nurse is caring for a client in active labor. The vaginal exam reveals that the cervix is 4 cm and 100%
effaced. The membranes are bulging and the fetal head is floating. The nurse must be alert for what potential
complication?
a. Uterine hyperstimulation
b. Cord prolapse
c. Abruptio placentae
d. Labor dystocia
ANSWER: B
Option B is correct; the client is at increased risk for a cord prolapse if the membranes rupture when the head is
not engaged. Option A is incorrect; there is no association between bulging membranes, a high fetal station, and
hyperstimulation. Option C is incorrect; there is no association between bulging membranes, a high fetal station,
and an increased risk of placental abruption. Option D is incorrect; there is no relationship between bulging
membranes, a high fetal station, and labor dystocia.
24. A laboring client at 37 weeks gestation asks the nurse, “What does my baby feel during labor?” The nurse’s
correct response is:
a. “Your pain medicine goes through to the baby, so it is getting relief during labor as well.”
b. “You do not need to worry about this; the labor pains do not affect the baby at all.”
c. “We aren’t sure, but we know that term fetuses respond to light, touch, sound, and pressure.”
d. “As long as we maintain this soothing environment, your baby should not be distressed.”
ANSWER: C
Term fetuses do experience these sensations. Option A is incorrect; it is unknown if the fetus experiences pain
relief from maternal anesthesia or analgesia. Option B is incorrect; the nurse is assuming the mother’s question
is about pain. Option D is incorrect; although a soothing environment may alleviate maternal stress, fetal
outcomes are determined by multiple factors.
25. A nurse is receiving a report on four clients in the public hospital. Which client should the nurse anticipate
giving birth first?
a. G1P0, 4 cm dilated, and 80% effaced
c. G6P0, 6 cm dilated, and 50% effaced
b. G2P1, 5 cm dilated, and 40% effaced
d. G5P4, 5 cm dilated, and 40% effaced
ANSWER: D
The client who is G5P4, 5 cm dilated, and 40% effaced probably will be the first to deliver. Multiparas usually
progress faster than nulliparas. A gravida 6 with no prior delivery likely will not progress as rapidly as the woman
who is gravida 5 para 4.
26. A nurse is planning to perform Leopold's maneuvers on a laboring client. What should be the nurse's initial
action?
a. Position client in a supine position
c. Wash hands in warm water
b. Have the client void
d. Apply sterile lubricant to the abdomen
ANSWER: B
Having the client void before performing Leopold's maneuvers provides for improved comfort during the
evaluation for the laboring client. Positioning the client on her back is the correct position, but this is not the
initial action. The examiner's hands should be warm, but this is not the initial action. Applying sterile lubricant to
the abdomen is not part of the procedure.
27. A nurse is auscultating the heart rate of a fetus in a cephalic presentation. In which location should the nurse
place her stethoscope so that she would hear the heart rate most clearly?
a. The lower quadrant of the maternal abdomen
c. The upper quadrant of the maternal abdomen
b. Level of the maternal umbilicus
d. Above the apex of the fetal heart
ANSWER: A
The lower quadrant of the maternal abdomen is where the nurse should hear the fetal heart rate (FHR) in a
cephalic presentation. Hearing the FHR at the level of the maternal umbilicus is expected of the fetus in a
transverse presentation. Hearing the FHR in the upper quadrant of the maternal abdomen is appropriate for a
breech presentation. FHR is heard most clearly along the back of the fetus, not at the apex of the fetal heart.
28. The fetal monitor has shown several late decelerations over the past 10 minutes. The nurse determines that
this pattern indicates?
a. Umbilical cord compression
b. Head compression
c. Fetal hypoxia
d. Maternal fever
ANSWER: C
A pattern of late decelerations indicates fetal hypoxia, caused primarily by uteroplacental insufficiency. Variable
decelerations are caused by umbilical cord compression. Early decelerations are caused by head compression.
Maternal fever may contribute to fetal tachycardia.
29. A laboring client is lying in the supine position with a blood pressure of 88/60. The initial nursing action is to:
a. Notify the physician or midwife
c. Administer oxygen at 8 L via mask
b. Reevaluate the blood pressure
d. Position the client on her left side
ANSWER: D
Placing the client on her left side reduces aortocaval compression and improves utero-placental perfusion. Option
A is incorrect; the nursing priority is to correct the aortocaval compression, although notifying the physician or
midwife is an appropriate action. Option C is incorrect; there is no information indicating a need for supplemental
oxygen, although this is appropriate in the event of utero-placental insufficiency. Option B is incorrect; the first
priority is to reduce the compression, and the blood pressure can be assessed following the position change.
30. The client asks the nurse, “The doctor says my baby is floating. What does that mean?” The nurse correctly
responds:
a. “Floating means there is sufficient fluid to cushion the baby as your labor progresses.”
b. “Floating means that the baby’s head is still above the pelvic inlet.”
c. “Floating means that the baby’s head is at the pelvic inlet but can be pushed out easily.”
d. “Floating means that your baby’s head is at the level of the ischial spines.”
ANSWER: B
The fetal head is floating when it is directed down toward the pelvis but can still be pushed out. Option A is
incorrect; floating is not related to the amount of amniotic fluid that is present. Option C is incorrect; dipping is
when the baby’s head is at the inlet but can be pushed out. Option D is incorrect; the level of the ischial spines is
referred to as “zero station.”
31. During a childbirth class on the physiology of labor, which client statement would indicate the need for further
teaching?
a. “Effacement is the thinning of the cervix.”
b. “Lightening is the loss of one or two pounds before labor starts.”
c. “Ripening is the softening of the cervix.”
d. “Dilatation is when the cervix opens up.”
ANSWER: B
Option B indicates the need for more teaching; lightening describes the effect of the fetus settling into the pelvis.
Option A is the correct description of effacement and indicates correct client understanding. Option C is the
correct description of ripening and indicates correct client understanding. Option D adequately describes cervical
dilatation and indicates correct client understanding.
32. A client asks how to tell the difference between true and false labor. The nurse correctly responds:
1. “True labor contractions usually occur at regular intervals.”
2. “True labor contractions often feel like period cramps.”
3. “False labor contractions do not usually increase in duration and intensity.”
4. “False labor contractions usually go away with rest.”
a.1, 3, 4
b. 1, 2, 3
c. All except 1
d. All of the above
ANSWER: A
1, 3 and 4 are correct; true labor contractions are usually regular, and are felt most strongly in the back and
radiate to the abdomen. They do not usually decrease with rest. False labor contractions will often decrease with
rest. Option 2 is incorrect; false labor contractions usually occur in the lower abdomen.
33. A G1P0 client at 38 weeks gestation complains of leg cramps, increased pelvic pressure, and increased
urinary frequency. The nurse recognizes:
a. The client may be having preterm labor.
c. The client may need more iron in her diet.
b. The client may have a urinary tract infection.
d. The client is most likely experiencing lightening.
ANSWER: D
Option D is correct. Lightening describes the effects of the fetus moving down in the pelvis, and leg cramps,
increased pelvic pressure, and increased urinary frequency are common symptoms associated with lightening. In
a client with a preterm gestation, these symptoms would warrant further evaluation. Option A is incorrect; in this
case, the client is at term. Option B is incorrect; frequency is a common pregnancy symptom in the first and third
trimesters. Option C is incorrect; leg cramps are not associated with iron deficiency, but it is theorized that leg
cramps may be associated with a calcium and phosphorus imbalance.
34. A nurse is caring for a client in the delivery room. A few minutes after birth, there is a rise in the fundus, a
short, rapid gush of blood from the vagina, and a lengthening umbilical cord. The nurse recognizes these to be
signs of:
a. Postpartum hemorrhage.
c. Cord prolapse.
b. Marginal placental abruption.
d. Placental separation
ANSWER: D
These are signs that the placenta is getting ready to separate. Option A is incorrect; postpartum hemorrhage is
usually characterized by a boggy fundus and sustained bleeding. Option B is incorrect: a marginal abruption is a
partial separation of the placenta and occurs during labor. Option C is incorrect; a cord prolapse means the cord
has descended before the presenting part; this occurs before birth, not after birth.
35. A client is in the latent phase of labor and desires an unmedicated childbirth. She is using relaxation and
breathing techniques and resting quietly between contractions. The client’s baseline blood pressure was 110/60
on admission and is now staying in the 150/90 range. The nurse determines:
a. The client is experiencing pain but has a stoic nature; no action is needed at present.
b. Blood pressure normally increases during labor; no action is needed at present.
c. The client is experiencing pain; an anesthesia consult is required as soon as possible.
d. The physician or midwife must be notified; this is an abnormal increase in blood pressure.
ANSWER: D
A normal blood pressure value during the first stage of labor will show a systolic increase of 35 mm and a
diastolic increase of 25 mm which returns to baseline between contractions. The increase noted in this situation
requires further evaluation. Option A is incorrect; the nurse is making an assumption about the client’s stoicism.
Option B is incorrect; although blood pressure will increase during labor, an abnormal increase requires further
action. Option C is incorrect; although the client may be experiencing pain, an anesthesia consult may be offered
to the client but is not required.
36. A client has been complaining of severe back pain throughout labor and has now been pushing for 2 hours
with very little change in station noted. Which of the following presentations are associated with this situation?
1. Left occiput anterior
3. Right occiput posterior
2. Left mentum transverse
4. Left occiput posterior
a. 1 only
b. 2 only
c. 3 and 4
d. All except 1
ANSWER: C
Occiput posterior positions are associated with increased back pain and prolonged pushing during labor. Option 1
is incorrect: the left occiput anterior presentation is favorable for pushing. Option 2 is incorrect; a mentum
transverse presentation is not associated with increased back pain.
37. A laboring client states, “I have a lot of pain, but I am afraid the medicine will hurt the baby.” The nurse’s
best response is:
a. “We can resuscitate your baby after delivery if there are any problems.”
b. “Medications do affect babies, but so do pain and stress.”
c. “Your doctor has only ordered a small amount of medication.”
d. “Medications are much safer today than they used to be.”
ANSWER: B
It is possible for maternal pain and stress to result in decreased oxygenation of the fetus, while there are some
medications that are relatively safe for the baby. Option A is incorrect; while resuscitative measures are usually
successful, this idea may frighten the mother unnecessarily. Option C is incorrect; the amount of medication
ordered will not matter to the mother as much as its action and effect. Option D is incorrect; while most current
medications are safe, they do have side effects that affect the fetus. The nurse’s role is to educate the mother,
acknowledge her concerns, and support her decisions.
38. A client has just received an epidural. Which fetal heart rate pattern alerts the nurse that a serious problem is
developing?
a. Average variability and persistent early decelerations
b. Decreased variability and occasional early decelerations
c. Decreased variability and persistent late decelerations
d. Decreased variability and occasional accelerations
ANSWER: C
Minimal variability and late decelerations indicate decreased utero-placental perfusion and may be related to
maternal hypotension. Option A is incorrect; average variability and persistent early decelerations do not indicate
the development of a serious problem. Option B is incorrect; decreased variability and occasional early
decelerations do not indicate the development of a serious problem. Option D is incorrect; decreased variability
and occasional accelerations do not indicate the development of a serious problem.
39. A nurse is preparing a client to receive an epidural block. Which of the following actions is most important in
preventing maternal hypotension?
a. Monitor the blood pressure every 5 minutes
c. Administer a 500 to 1000 cc IV fluid bolus
b. Record the fetal heart rate every 15 minutes
d. Instruct the client to remain on her left side
ANSWER: C
Administering an IV fluid bolus of 500-1000 cc normal saline helps to prevent maternal hypotension from the
vasodilation that occurs with an epidural placement. Option A is incorrect; monitoring blood pressure will not
prevent hypotension. Option b is correct; monitoring the fetal heart rate will not prevent hypotension. Option D is
incorrect; positioning the client in left uterine displacement will assist in preventing hypotension after the epidural
placement.
40. A nurse in the birthing unit is caring for a client following an amniotomy. What is an appropriate nursing
intervention?
a. Assess cervical dilation every 2 hours.
c. Encourage ambulation every 1-2 hours.
b. Monitor temperature every 2 hours.
d. Replace expelled amniotic fluid every 1-2 hours.
ANSWER: B
Due to an increased risk of infection, the nurse should monitor temperature every 2 hours following an
amniotomy. Vaginal exams are kept to a minimum to decrease the chance of infection. Bedrest is maintained
unless the presenting part is engaged. Replacing expelled amniotic fluid every 1-2 hours is unnecessary, as
amniotic fluid is constantly produced.
41. A nurse is caring for a client with an oxytocin infusion. What is the correct nursing action prior to increasing
the oxytocin rate?
a. Assess cervical dilation.
c. Evaluate the need for analgesia.
b. Monitor fetal heart tones.
d. Assess maternal temperature.
ANSWER: B
Monitoring fetal heart tones before increasing the oxytocin rate is crucial when caring for a client with an oxytocin
infusion. Assessing cervical dilatation is done after contractions have been established. When evaluating the need
for analgesia, a vaginal exam should be performed to avoid giving the medication too early. Maternal blood
pressure and pulse, not maternal temperature, should be measured to assess the effects of oxytocin.
Reference: Adele Pillitteri. Maternal and Child Health Nursing 5th edition Page 526, 610
42. A nurse is caring for a laboring client who just received an epidural block. What is the major adverse effect
for which the nurse should observe?
a. Hypotension
b. Unilateral block
c. Hypertension
d. Pruritus
ANSWER: A
Hypotension due to vasodilation from the initial effects of the epidural may be prevented with a pre-load bolus of
500cc IV solution. Unilateral block and pruritus are less common adverse effects. Hypertension may be a
complication of pregnancy-induced hypertension and oxytocin inductions.
43. Nurse Hannah is caring for a client who received a spinal anesthesia for a cesarean birth. Nurse Hannah must
make sure to remind the client to do which of the following to prevent the postpartal dural puncture headache:
a. Lie flat on bed for 6 hours
c. Encourage the patient to lie prone
b. Increase fluid intake
d. Decrease fluid intake
ANSWER: B
A late complication of spinal anesthesia is a postpartal dural puncture headache (PDPH) or “spinal headache”.
This occurs because of continuous leakage of CSF from the needle insertion and possibly from the irritation of a
small amount of air that enters at the injection site. The incidence of such headaches is reduced if a small-gauge
needle is used for the injection and the woman drinks a quantity of fluid afterward, because high fluid intake
rapidly provides replacement of spinal fluid. Although it is encouraged, asking a woman to remain flat on bed
may not be necessary because of the routine use of small-gauge needles.
44. The nurse is caring for four laboring clients. Which client would be the most appropriate candidate for an
epidural anesthesia?
a. G1P0 dilated 2-3 cm
b. G3P2 dilated 5-6 cm
c. G2P0 dilated 1-2 cm
d. G5P4 dilated 7-8 cm
ANSWER: B
The epidural block may be administered as soon as active labor is established and the fetal vertex is engaged
(zero station), which would be the G3P2 client dilated to 5-6 cm. In a grand multipara (G5P4) dilated 7-8 cm,
there would be insufficient time to place the epidural, as birth is imminent.
45. The nurse is caring for a 16-year-old in active labor. The client is very controlled and asks few questions. The
nurse is having trouble communicating and recognizes:
a. The client has regressed and is afraid to share her feelings.
b. Adolescent clients are often angry and unresponsive toward caregivers.
c. While frustrating, this client’s behavior is developmentally appropriate.
d. The client clearly knows a lot about childbirth and is trying to “save face.”
ANSWER: C
The middle adolescent often acts in a nonchalant and stoic fashion. Option A is incorrect; during transitional labor
a young adolescent may become withdrawn and inexpressive. Option B is incorrect; this is a misleading
generalization. Option D is incorrect; “saving face” is a frequent behavior in older adolescents.
Reference: Marcia London, Patricia Ladewig, Jane Ball, Ruth Bindler. Maternal & Child Nursing Care. Second
Edition
SITUATION: Mrs. Gabana is a primigravid client on her 37 weeks of gestation and is scheduled for non-stress
test. Nurse Dolcie is assisting the client all throughout the procedure.
46. While preparing Mrs. Gabana for a nonstress test, she asks the nurse about the procedure. Nurse Dolcie
responds appropriately by telling the client that:
a. The test is an invasive procedure and requires that an informed consent be signed.
b. The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed.
c. An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is
heard most clearly.
d. The fetus is challenged or stressed by the uterine contractions to obtain the necessary information.
ANSWER:
C
Option A- the term is nonstress because it consists of monitoring only; the fetus is not challenged or stressed by
uterine contractions to obtain the necessary data. It is a noninvasive procedure, and an ultrasound transducer
that records fetal heart activity is secured over the maternal abdomen where the fetal heart is heard most
clearly. A tocotransducer that detect uterine activity and fetal movement is also secured to the maternal
abdomen.
Fetal
heart
activity
and
movements
are
recorded.
47. Nurse Dolcie is reviewing the documentation related to the results of the test. She notes that the physician
documented the test results as reactive. She interprets that this result indicates:
a. Normal findings.
c. The need for further evaluation.
b. Abnormal findings
d. The findings on the monitor were difficult to interpret.
ANSWER: A
A reactive nonstress test is a normal result. To be considered reactive, the baseline fetal heart rate must be
within normal range with good long term variability. In addition, there must be two or more FHR accelerations of
at least 15 beats per minute, each with duration of at least 1 second, in a 20 minute interval.
48. If the nonstress test result is a nonreactive finding, the physician would most probably prescribe a contraction
stress test. After the test is performed, Nurse Dolcie notes that the physician has documented the results of the
contraction stress test as negative. The nurse interprets this finding as indicating:
a. A high risk for fetal demise.
c. The need for cesarean delivery.
b. A normal test result.
d. An abnormal test result.
ANSWER: B
Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A
negative test results indicates that no late decelerations occurred in the fetal heart rate, although the fetus was
stressed by three contractions of at least 40 seconds duration in a 10-minute period.
SITUATION: Many women are uncertain about the birthing process and feel overwhelmed and even frightened
by it. However, understanding how birth occurs can make birth less frightening, intense, and may give a
wonderful birthing experience. Nurses attending to these clients should know which action should be done, so the
pregnant client might somehow feel safe.
49. A client is seen in the emergency room, shouting, “I’m going to give birth. I feel my baby coming out.” Upon
assessment of the client, the nurse determines that the client is in true labor when:
a. Her uterine contractions are regular
c. The fetus drops into the brim of the pelvis
b. Her membranes fail to rupture spontaneously
d. A mucous plug in the cervical canal is expelled
ANSWER: A
The following are signs of true labor:
Contractions – regular with increasing frequency (shortened intervals), duration, and intensity
Discomfort radiates from back around the abdomen
Contractions do no decrease with rest
Cervix progressively effaced and dilated
False labor:
Discomfort radiates from back around the abdomen
Contractions – irregularity with usually no change in frequency, duration, or intensity
Discomfort is usually abdominal
Contractions may lessen with activity or rest
Cervical changes do not occur
Reference: R. Bangui, ed (2010). Course Audit Learning Resource Book. Page 212.
50. When evaluating a client in labor, the nurse determines that the client is a primipara . The nurse knows that
primagravida mothers normally are not taken to the delivery room until:
a. The cervix is dilated to 6 to 8 cm
c. The intensity of contractions is decreased
b. Contractions are 3 to 5 minutes apart
d. The perineum is bulging
ANSWER: D
Crowning, which occurs when the newborn’s head or presenting part appears at the vaginal opening, occurs
during the second stage of labor as the cervix becomes fully dilated and effaced.. During the first stage of labor,
cervical dilation and effacement occur. During the third stage of labor, the newborn and placenta are delivered.
The fourth stage of labor lasts from 1 to 4 hours after birth, during which time the mother and newborn recover
from the physical process of birth and the mother’s organs undergo the initial readjustment to the nonpregnant
state.
family.
5th
edition.
Lippincot
William
&
Wilkins.
Page
507.
51. Accurate recording of the client’s progress during labor is essential. The term used to describe the period
when the uterus begins a contraction until the contraction ends is called as:
a. Interval
b. Intensity
c. Duration
d. Frequency
ANSWER: C
Duration
is
being
measured
by
timing
from
the
beginning
of
one
contraction
to
the
end
of
the
next
contraction
Frequency
By
measuring
the
time
from
the
beginning
of
one
contraction
to
the
beginning
of
the
next
Interval
By
measuring
the
time
from
the
end
of
one
contraction
to
the
beginning
of
the
next
Intensity
–
is
the
degree
of
contraction
Reference: Adelle Pillitteri. Maternal and Child Health Nursing. 5th Edition. Page 519-520.
52. Mrs. Lovely, a 20-year-old obese, primigravid client at 40 weeks’ age of gestation who is in the first stage of
labor, is admitted in a birthing center. The physician orders intermittent fetal heart rate monitoring. The nurse
would monitor the fetal heart rate pattern at which of the following intervals?
a. Every 15 minutes during the latent phase.
c. Every 60 minutes during the initial phase.
b. Every 30 minutes during the active phase.
d. Every 2 hours during the transition phase.
ANSWER: B
During the active stage of labor, intermittent fetal monitoring is performed every 30 minutes to detect changes in
fetal heart rate such as bradycardia, tachycardia, or decelerations. If complications develop, more frequent or
continues electronic fetal monitoring may be needed.
Latent phase, intermittent monitoring is usually performed every 2 hours because contractions during this time
are usually less frequent. During the transition phase, intermittent monitoring is performed every 5 to 15 minutes
because the client is getting closer to delivery of the baby. There is no initial phase of labor.
53. The nurse explains to Mrs. Lovely that, according to the gate-control theory of pain, a closed gate means that
the client should experience:
a. No pain.
b. Sharp pain.
c. Light pain.
d. Moderate pain.
ANSWER: A
Accdg. to the gate control theory of pain, a closed gate means that the client should feel no pain.
54. Assessment of Mrs. Lovely, who is in active labor with no analgesia or anesthesia, reveals complete cervical
effacement, dilation of 8 cm, and the fetus at 0 station. Which of the following behaviors would the nurse
anticipate that the client will exhibit during this phase of labor?
a. Excitement.
b. Loss of control.
c. Numbness of the legs.
d. Feelings of relief.
ANSWER: B
Assessment findings indicate that the client is in the transition phase of labor. During this phase, it is not unusual
for clients to exhibit a loss of control or irritability. Leg tremors, nausea, vomiting, and an urge to bear down also
are common. Excitement is associated with the latent phase of labor. Feelings of relief generally occur during the
second stage, when the client begins bearing-down efforts.
55. After a while, assessment reveals that the fetus is at +1 station. The nurse interprets this finding as
indicating that the fetal presenting part is positioned at:
a. 1 cm above the ischial spine.
c. 1 cm above the ischial tuberosities.
b. 1 cm below the ischial spines.
d. 1 cm below the sacral promontory.
ANSWER: B
The ischial spines are used as landmarks to determine the descent of the fetal presenting part. The station +1
means that the preenting part is 1 cm below the level of schial spines. The station -1 means that the presenting
par is 1 cm above the level of ischial spines. Options C and D are not used to determine the fetal station.
56. To determine whether Mrs. Lovely, a client in labor with a fetus in the left occipitoanterior (LOA) position, is
completely dilated, the nurse performs a vaginal examination. During the examination the nurse would expect to
palpate which of the following cranial sutures?
a. Sagittal.
b. Lamboidal.
c. Coronal.
d. Frontal.
ANSWER: A
The sagittal suture is the most readily felt during a vaginal examination. When the fetus is in LOA position, the
occiput faces the mother’s left. The lamboidal suture is on the side of the skull. The coronal suture is a horizontal
suture across the front portion of the fetal skull that forms the anterior fontanel. It may be felt with a brow
presentation. The frontal suture may be felt with a brow or face presentation.
57. Which of the following would indicate that the client has moved into the second stage of labor?
a. The client has an uncontrollable urge to bear down.
c. The client becomes increasingly talkative.
b. The client has decrease in bloody show.
d. The client takes three deep cleansing breaths.
ANSWER: A
During the second stage of labor the client has tendency to push or bear down because of the frequency of
contraction and because the client is already fully dilated.
Reference: Course Audit Learning Resource Book, Edited by Ronald Bangui, Chapter 8 Women’s Health and
Perinatal Care, p. 215.
SITUATION: Labor and delivery require a woman to use all the psychological and physical coping methods she
has available.
58. Nurse Isabel is admitting a pregnant client in labor who reports pinkish vaginal discharge mixed with mucus.
Nurse Isabel should:
a. Prepare for immediate cesarian delivery
c. Acquire a specimen for blood studies
b. Proceed with admission procedure
d. Inform the doctor
ANSWER: B
The client is describing a bloody show, a normal finding in a mother in labor. Women need to be aware of this
event so that they do not think they are bleeding abnormally.
59. Nurse Mian is assessing a pregnant client to confirm true labor. Which of the following assessment findings
indicate to the nurse that the client is experiencing true labor?
a. Contraction that disappear with ambulation
b. The contractions does not increase in intensity and frequency
c. Contraction is felt first in lower back and sweep around to the abdomen
d. Contractions remain irregular
ANSWER: C
Discomfort and pain associated with true labor contractions typically begins in the lower abdomen and back and
then radiates over the entire abdomen. Options A, B, and D identify findings associated with false labor.
60. Nurse Heart is caring for a woman who is admitted to the hospital in active labor. What information is most
important for Nurse Heart to assess to avoid respiratory complications during labor and delivery?
a. Family history of lung disease
c. Number of cigarettes smoked daily
b. Food or drug allergies
d. When the client last ate
ANSWER: D
Gastric motility is decreased during pregnancy. Food eaten several hours prior to the onset of labor may still be
in the stomach undigested. This will influence the type of anesthesia the client may receive. Inhalation of vomitus
from pressure of the uterus on the stomach can be fatal if a woman’s airway becomes occluded by the foreign
matter. Some anesthesiologists may order IV ranitidine or an oral antacid such as cimetidine to be given before
general anesthesia is administered, to reduce the level of acid in stomach contents should aspiration occur.
61. Mrs. Evangelista, who is gravid 1, is in the active phase of stage 1 labor. The fetal position is LOA. What
should the nurse expect to see when the membranes rupture?
a. Large amount of bloody fluid
c. Small amount of greenish fluid
b. Moderate amount of clear to straw-colored fluid
d. Small segment of the umbilical cord
ANSWER: B
With the baby in the vertex, LOA presentation and no other indications of distress, amniotic fluid should be clear
to straw-colored.
62. Mrs. Pilapil is admitted to the hospital in labor. Vaginal examination reveals that she is 8 cm dilated. At this
point in her labor, which of the following statements would the nurse expect her to make?
a. “I can’t decide what to name my baby”
c. “Take your hand off my stomach when I have a contraction”
b. “It feels good to push with each contraction”
d. “This isn’t as bad as I expected”
ANSWER: C
At 8 cm dilated is in the transition stage of her labor. Many women experience hyperesthesia of the skin at this
time and would not want to be touched during a contraction.
63. Nurse Pilar is caring for a woman who is in labor. She is 8 cm dilated. How will the nurse best support the
woman during this phase of her labor?
a. Leave her alone most of the time
c. Offer her sips of oral fluids
b. Offer her a back rub during contraction
d. Provide her with warm blankets
ANSWER: B
Massage is another pain relief method that can be taught to a woman and her support person during labor. It
may be especially useful if a woman is experiencing back pain from labor, because rubbing or massaging the
sacral area often alleviates back pain. Firm counterpressure on the lower back, thighs, feet, hands, or shoulders
can provide a relaxing distraction from the sensation of internal pressure and pain.
64. During labor, Nurse Hannah observes variable decelerations on the external fetal monitor. What is the best
action for the nurse to take at this time?
a. Apply an oxygen mask
c. Get the woman out of bed and walk her around
b. Change the woman’s position to left side-lying
d. Move the woman to the delivery room
ANSWER: B
Variable decelerations are frequently caused by transient fetal pressure on the cord and are not a sign of fetal
distress. A change in the mother’s position will usually relieve the problem.
65. Using Leopold’s Maneuvers to determine fetal position, the nurse finds that the fetus is in a vertex position
with the back on the left side. Where is the best place for the nurse to listen for fetal heart tones?
a. In the RUQ of the mother’s abdomen
c. In the RLQ of the mother’s abdomen
b. In the LUQ of the mother’s abdomen
d. In the LLQ of the mother’s abdomen
ANSWER: D
The left lower quadrant is the correct location since the back is on the left and the vertex is in the pelvis.
66. Nurse Isabel is observing the FHR of laboring woman. Which of the following findings would she consider as
abnormal for a client in active labor?
a. A rate of 160 with no significant changes through a contraction
b. A rate of 130 with accelerations to 150 with fetal movement
c. A rate that varies between 120 and 130
d. A rate of 170 with a drop to 140 during a contraction
ANSWER: D
A rate of 170 is suggestive of fetal tachycardia. A drop to 140 during a contraction represents some periodic
change, which is not a normal finding. Other options are normal findings.
Reference: A. Pillitteri. Maternal and Child Health Nursing 6th edition Page 378-380
67. A woman arrives at the emergency room in active labor. On examination, the cervix is 5 cm dilated,
membranes intact and bulging, and the presenting part at – 1 station. The woman asks if she can go for a walk.
What is the best response for the nurse to give?
a. “I think it would be best for you to remain in bed at this time because of the risk of cord prolapsed”
b. “It’s fine for you to walk, but please stay nearby. If you feel a gush of fluid, I will need to check you and your baby”
c. “It will be fine for you to walk because that will assist the natural body forces to bring the baby down the birth canal”
d. “I would be glad to get you a bean bag chair or rocker instead”
ANSWER: B
Although there is always some risk of complications when membranes rupture, it is safe for this woman to
ambulate as long as she is rechecked if rupture of membranes occurs. Reassure the woman that she may move
about as she wants. A woman whose membranes have ruptured should lie on her side unti a fetal monitor shows
good baseline variability and no variable decelerations or until she has been checked by a physician. , unless the
head of the fetus is well engaged, the umbilical cord may prolapsed into the vagina as she walks.
68. Nurse Hannah is developing a plan of care for a client in first stage of labor. Which of the following nursing
interventions is least appropriate to include?
a. Promote voiding
c. Teaching the client proper breathing technique
b. Assist the client to lie in her left side
d. Encourage the client to push with each contraction
ANSWER: D
Option D is appropriate at the second stage of labor (from full dilatation to cervical effacement)
Reference: A. Pillitteri. Maternal and Child Health Nursing 6th edition Page 382-383
69. To successfully plan care for a client during second stage of labor, Nurse Hannah should recognize the start of
the second stage of labor, which is:
a. When the cervix is fully dilated
c. The placental separation
b. When the client complains of increasing discomfort
d. Contraction lasting for more than 40 seconds
ANSWER: A
The second stage of labor begins from full cervical dilatation and cervical effacement to the birth of the infant;
with uncomplicated birth, this stage takes about 1 hour.
70. To manually measure the intensity of uterine contractions, Nurse Hannah should:
a. Gently place the hand over the symphysis pubis and indent using the fingertips
b. Rest the hand on the woman’s abdomen at the fundus very gently to sense the gradual tensing
c. Gently indent the fundus over the uterus with fingertips and feel the contraction
d. Use light touch when timing from the beginning of one contraction to the beginning of the next
ANSWER: C
On a monitor, this is the height of the waveform. If you are assessing manually, rate a contraction as mild if the
uterus does not feel more than minimally tense, as moderate if the uterus feels firm, and as strong if the uterus
feels as hard as wooden board at the peak of contraction. With strong contraction, you will also not be able to
indent the uterus with your fingertips.
71. The nurse is caring for a client in the fourth stage of labor. The initial priority nursing assessment in this
stage of labor is:
a. Assisting the client to breastfeed
c. Encouraging food and fluid intake
b. Assessing vital signs and the uterine fundus
d. Providing privacy for the parents with their newborn
ANSWER: B
The fourth stage of labor is the stage of physical recovery for the mother and infant. It lasts from the delivery of
the placenta through the first 1 to 4 hours after birth. A potential complication after delivery is hemorrhage. The
most significant source of bleeding is the site where the placenta was implanted. It is critical that the uterus
remain contracted and that the nurse monitors vital signs, vaginal blood flow every 15 minutes for the first 1 to 2
hours, assess uterine fundus and the lochia. The other options are not the priority at this time.
Family. 4th ed 516
72. Nurse Isabel is monitoring a laboring client following continuous epidural anesthesia. After 15 minutes, the
client’s blood pressure drops from 120/80 to 90/60 mm Hg. Nurse Isabel should:
a. Inform the doctor or anesthesiologist immediately.
c. Place the client in side-lying position.
b. Continue to assess the blood pressure every 15 minutes.
d. Turn off the continuous epidural.
ANSWER: C
The nurse should immediately turn the woman to a lateral position (option C), place a pillow or wedge under the
right hip to deflect the uterus, increase the rate of the main line IV infusion, and administer oxygen by face mask
at 10-12 L/min. If the blood pressure remains low, especially if it further decreases, the
anesthesiologist/healthcare provider should be notified immediately (option A). Continued assessment of (option
B), without taking any further action would constitute malpractice. Option D may also be warranted, but such
action is based on hospital protocol.
73. Which of the following nursing diagnoses would be given priority in the care of a laboring woman who is
about to receive epidural analgesia?
b. Anxiety
c. Fluid volume deficit
d. Activity intolerance
ANSWER: C
Increasing fluid volume prior to the administration of epidural anesthesia can help to decrease the possibility of
hypotension, a frequent complication of the anesthesia due to peripheral vasodilatation. The woman can be given
with 500 to 1000 ml of Ringer’s Lactated before the anesthetic. Option A: Adequate teaching regarding the
effects of epidural anesthesia would decrease the likelihood of the patient having a knowledge deficit. Option B:
Adequate teaching regarding the effects of epidural anesthesia would decrease the likelihood o the patient having
anxiety. Option D: Patients receiving an epidural anesthetic must be on bed rest due to decreased sensation in
the lower extremities, but this is not a long- term problem in activity intolerance.
74. Because a woman is receiving oxytocin (Pitocin) for induction of labor, it is essential for the nurse to monitor:
a. Fundal height
b. Patellar reflexes
c. Cervical changes
d. Level of consciousness
ANSWER: C
The goal of induction with Pitocin is to increase cervical dilation. Pitocin stimulates uterine contractions. Once a
woman’s cervix reaches five to six centimeters and labor is established, the Pitocin should be decreased. The fetal
heart rate, uterine resting tone and frequency, duration and intensity on contractions are monitored continuously.
Option A: Fundal height is not part of the nursing assessment of a patient receiving Pitocin. Option B: Patellar
reflexes are monitored in patients with pregnancy-induced hypertension or preeclampsia. Option D: The level of
consciousness is monitored and is of particular concern for patients receiving magnesium sulfate.
75. A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse
implement?
ANSWER: B
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable) (option B),
and putting the heel of the foot on the floor is the best means of relieving leg cramps. Option A is ineffective for
leg cramps caused by phosphorous/calcium imbalances and may dislodge small thrombus. Option C would not be
76. The nurse is monitoring a client in labor room. Following epidural anesthesia, the client complains of metallic
taste and blurred vision. The nurse should make which of the following statement to the client?
a. “I will call the doctor you may have an emergency situation”
b. “This is normal, I will continue to monitor your progress”
c. “I will ask the doctor to increase the IV rate”
d. “This is normal, I will give you ice chips to relieve the discomfort”
ANSWER: A
In rare instances, the anesthetic enters the blood circulation. This occurrence is manifested as drowsiness, a
metallic taste on the tongue, slurred speech, blurred vision, unconsciousness and seizure leading to cardiac
arrest. If such symptoms occur, it is an emergency situation. The woman needs oxygen and an anticonvulsant,
such as diazepam (Valium) or thiopental (Penthotal) IV, followed by prompt birth of fetus.
a. Dehydration.
b. Hyperstimulation.
c. Galactorrhea.
d. Fetal tachycardia.
ANSWER: B
hyperstimulation (option B) which can lead to tetanic contractions, uterine rupture, and fetal distress or demise.
Dehydration (option A) and galactorrhea (option C) are not adverse effects associated with the administration of
Pitocin. Fetal tachycardia (option D) is an initial response to any stressor, including an increase in maternal
temperature or intrauterine infection, but fetal decelerations indicate distress following tetanic contractions.
Reference: A. Pillitteri. Maternal and Child Health Nursing 6th edition Page
78. After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong
enough to dilate the cervix. Which of the following would the nurse anticipate doing?
a. Obtaining an order to begin IV oxytocin infusion
b. Administering a light sedative to allow the patient to rest for several hour
c. Preparing for a cesarean section for failure to progress
d. Increasing the encouragement to the patient when pushing begins
ANSWER: A
The client’s labor is hypotonic. The nurse should call the physical and obtain an order for an infusion of oxytocin,
which will assist the uterus to contact more forcefully in an attempt to dilate the cervix. Administering light
sedative would be done for hypertonic uterine contractions. Preparing for cesarean section is unnecessary at this
time. Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be
necessary. It is too early to anticipate client pushing with contractions.
family. Volume. 5th edition. Lippincot William & Wilkins. Page
79. A woman who is in transient stage of labor is positioned for birth by the physician. To avoid the risk of
thrombophlebitis the nurse expects the physician to:
a. Place the client in lithotomy position for less than 90 minutes
b. Pad the stirrups if there is ankle edema
c. Don sterile mask, gown, and gloves
d. Raise both woman’s legs at the same time during positioning
ANSWER: B
If there is ankle edema, pad the stirrups to prevent thrombophlebitis. Be certain there is no pressure on her
calves. Option A: Lying in lithotomy position for more than 1 hour leads to intense pelvic congestion, because
blood flow to the lower extremeties is impeded. It may lead to an increase risk of thrombophlebitis in the
postpartal period. For these reason, the client’s leg should be placed in lithotomy position only at the last
moment. Option C: Donning sterile mask, gloves, and gown are needed to prevent infection, not
thrombophlebitis. Option D: This action will prevent the back and abdominal muscles.
80. To effectively promote pushing during second stage of labor, the nurse should:
a. Encourage the client hold breath while pushing during contraction
b. Ask her to breathe out during pushing
c. Ask the woman to pant with every contractions
d. Perform Ritgen maneuver
ANSWER: B
The client should push with contractions and rest between them. Pushing is usually best done in semi-Fowler’s,
squatting, or “all-fours” position rather than lying flat, to allow gravity to aid the effort. To promote effective
pushing, ask the client to breath out during a pushing effort. Avoid holding the breath during contraction because
it temporarily impede blood flow to the heart because of increased intrathoracic pressure. This could also
interfere with blood supply to the uterus. Asking the woman to pant with every contractions will actually prevent
the second stage of labor from moving too fast. Because it is difficult to push effectively when the client is using
her diaphragm for panting, this limits pushing. Ritgen maneuver is done to help the fetus achieve extension, so
that the head is born with the smallest diameter presenting.
Reference: A. Pillitteri. Maternal and Child Health Nursing 6th edition Page 385, 389
81. A client asks the nurse what is the purpose of a doula in labor. The nurse’s best answer would be:
a. “She can time contractions to keep them from becoming too long”
b. “She can cook you something to keep you from becoming dehydrated”
c. “She can serve as a support person and coach during your labor”
d. “She replaces your husband as your support person during labor”
ANSWER: C
A doula is a woman who is experienced in childbirth, but without professional credentials, who guides and assists
women in labor. Having a doula can increase a woman’s self-esteem as well as decrease rates of oxytocin
augmentation, epidural anesthesia, and CS birth.
82. Nurse Hannah anticipates “crowning” to occur at what stage of labor?
a. First stage
b. Second stage
c. Third stage
d. Fourth stage
ANSWER: B
Crowing, which occurs when the newborn’s head or presenting part appears at the vaginal opening, occurs during
the second stage of labor. During the first stage of labor, cervical dilation and effacement occur. During the third
stage of labor, the newborn and placenta are delivered. The fourth stage of labor lasts from 1 to 4 hours after
birth, during which time the mother and newborn recover from the physical process of birth and the mother’s
organs undergo the initial readjustment to the nonpregnant state.
83. During the third stage of labor, Nurse Debora would perform which of the following nursing interventions?
a. Assess uterine contractions every 30 minutes.
c. Promote parent-newborn interaction.
b. Obtain a urine specimen and other laboratory tests.
d. Coach for effective client pushing
ANSWER: C
During the third stage of labor, which begins with the delivery of the newborn, the nurse would promote parentnewborn interaction by
placing the newborn on the mother’s abdomen and encouraging the parents to touch the
newborn. Collecting a urine specimen and other laboratory tests is done on admission during the first stage of
labor. Assessing uterine contractions every 30 minutes is performed during the latent phase of the first stage of
labor. Coaching the client to push effectively is appropriate during the second stage of labor.
84. After receiving epidural anesthesia the client begins to feel nauseous and looking pale and clammy. The nurse
should first implement which action?
a. Raise the foot of the bed.
b. Assess for vaginal bleeding
c. Evaluate FHR
d. Take the client's BP
ANSWER: A
The chief concern with epidural anesthesia is its tendency to cause hypotension because of its blocking effect on
the sympathetic nerve fibers in the epidural space. Raising the foot of the bed will increase venous return and
provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring
that the client is in a lateral position are also appropriate interventions.
Options B and C - will not raise the maternal blood pressure.
Option D - Since the symptoms are common side effects of epidural anesthesia and suggest hypotension, thus
taking the client’s BP can wait until positioning is implemented.
85. A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain
relief. Which assessment finding is most important for the nurse to report to the healthcare provider?
a. Cervical dilation of 5 cm with 90% effacement.
c. Hemoglobin of 12 mg/dl and hematocrit of 38%.
b. White blood cell count of 12,000/mm3.
d. A platelet count of 67,000/mm3.
ANSWER: D
Administration of epidural anesthesia involves the insertion of a needle through the epidural space between the
L4-5, L3-4 or L2-3. A client with thrombocytopenia (low platelet count) should be reported to the healthcare
provider because it places the client at risk for bleeding when an epidural is administred.
Options A, B, and C are within the normal parameters for a client in active labor and is not contraindicated for the
placement of an epidural.
86. When preparing a client for cesarean delivery, which of the following key concepts should be considered when
implementing nursing care?
a. Instruct the mother’s support person to remain in the family lounge until after the delivery
b. Arrange for a staff member of the anesthesia department to explain what to expect postoperatively
c. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth
d. Explain the surgery, expected outcome, and kind of anesthetics
ANSWER: C
A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching
to meet the needs of either a planned or emergency cesarean birth, the depth and breadth of instruction will
depend on circumstances and time available. Allowing the mother’s support person to remain with her as much
as possible is an important concept, although doing so depends on many variables. Arranging for necessary
explanations by various staff members to be involved with the client’s care is a nursing responsibility. The nurse
is responsible for reinforcing the explanations about the surgery, expected outcome, and type of anesthetic to be
used. The obstetrician is responsible for explaining about the surgery and outcome and the anesthesiology staff is
responsible for explanations about the type of anesthesia to be used.
87. A multiparous woman in the latent phase of the first stage of labor has a cervical dilatation of 3 cm. The
latent phase in multiparous clients lasts approximately:
a. 4.5 hours
b. 6 hours
c. 8 hours
d. 12 hours
ANSWER: A
The average duration of the latent phase of the first stage of labor is 4 ½ hours for multiparous women and
about 6 hours for nulliparous women. This gets prolonged when analgesia is given to early in labor or a
cephalopelvic disproportion exists.
Family. 4th ed. 484
88. Nurse Isabela is caring for a client who is in first stage of labor. In the last vaginal exam, the client was fully
effaced, 8 cm dilated, vertex presentation and at station -1. Which observation would indicate that the fetus is in
fetal distress?
a. The fetal heart rate slowly decreases to 110 bpm during strong contractions recovering to 138 bpm
immediately afterwards
b. Fresh thick meconium is passed with a small gush of fluid and the fetal monitor shows late decelerations with a
variable descending baseline
c. Fresh meconium is found in the examiners gloved fingers after the vaginal exam and the fetal monitor pattern
remains essentially unchanged
d. Vaginal exam continues to reveal old meconium staining and the fetal monitor demonstrates a u-shaped
pattern of decelerations during contractions recovering to a baseline of 140 bpm.
ANSWER: B
Meconium staining alone is not a sign of fetal distress. Meconium passage is a normal physiological function,
frequently noted with a fetus over 38 weeks’ gestation. Old meconium staining may be the result of a prenatal
trauma that is resolved. It is not unusual for the fetal heart rate to drop below the 140 to 160 beats per minute
range in late labor during contractions, and in a healthy fetus the feta heart rate will recover between
contractions. Fresh meconium in combination with late decelerations and a variable descending baseline is an
ominous signal of fetal distress caused by fetal hypoxia.
Family. 4th ed.
89. The nurse is caring for a client who is in the active phase of the first stage of labor. The nurse is monitoring
the fetal status and notes late decelerations. Based on this observation, the priority action of the nurse should
be:
a. Administer oxygen via facemask
c. Call the physician
b. Document the findings
d. Prepare for immediate birth
ANSWER: A
Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen
transfer to the fetus through the intervillous space during the uterine contractions. This causes hypoxemia;
therefore, oxygen is necessary. Late decelerations are considered an ominous sign but do not necessarily require
immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The
oxytocin would cause further hypoxemia because the medication stimulates contractions and leads to increased
uteroplacental insufficiency. Although the finding needs to be documented, documentation is not the priority
action in this situation.
Family. 4th ed.
90. Which of the following factors could negatively affect the labor?
a. The maternal pelvis is gynecoid
c. The presenting part is the sacrum
b. The fetal attitude is in general flexion
d. The fetal lie is longitudinal
ANSWER: C
With the sacrum as the presenting part, the fetus is in breech presentation. Breech presentation is the most
common form of malpresentation, which is considered a complication of labor. A longitudinal fetal lie, general
flexion, and gynecoid maternal pelvis are considered normal.
91. Mrs. Labrador presents to the labor room with the fetus in vertex presentation. Nurse Hannah expects the
seven cardinal movements of labor to occur in which of the following order?
1. Descent
3. Flexion
5. Extension
7. Internal rotation
2. Engagement
4. Expulsion
6. External rotation
a. 1, 2, 3, 7, 5, 6, 4
b. 2, 1, 3, 7, 5, 6, 4
c. 2, 1, 3, 6, 5, 7, 4
d. 1, 2, 3, 6, 5, 7, 4
ANSWER: B
The 7 cardinal movements of the mechanism of labor that occur in a vertex presentation are engagement,
descent, flexion, internal rotation, extension, external rotation, and expulsion.
92. Which of the following nursing actions reflects application of the gate control theory during labor?
a. Turn the client onto her left side
c. Administer the prescribed medication when the client is dilated to 4 cm
b. Massage the client’s back
d. Encourage the client to rest between contractions
ANSWER: B
According to the gate control theory, pain sensations, travel along nerve pathways to the brain. Only a limited
number of sensations can travel along these pathways at one time. Distraction techniques, such as massage,
reduce or block the nerve pathways transmitting pain. Although other nursing actions are appropriate for a
laboring client who is experiencing discomfort, they do not address the gate control theory.
93. When evaluating a fetal heart rate (FHR) pattern on an external electronic fetal monitor, the nurse notes that
the FHR begins to decelerate after the contraction has started and the lowest point of the deceleration occurs
after the peak of the contraction. What is the nurse’s first priority?
a. Insert the scalp electrode
c. Document the findings as benign decelerations
b. Prepare for an amnioinfusion
d. Change the client’s position
ANSWER: D
Although a scalp electrode may need to be inserted for a more accurate internal assessment, the client’s position
should be changed first in order to displace the weight of the uterus off the vena cava. This increases maternal
circulation to the placenta. Amnioinfusion is indicated for umbilical cord compression, decreased amniotic fluid, or
to dilute meconium-stained amniotic fluid.
94. After vaginal examination, assessment of a laboring client is documented as 3 cm, 30%, and -1. The nurse’s
interpretation of this assessment is which of the following?
a. The cervix is effaced 3 cm, it is dilated 30% and the presenting part is 1 cm above the ischial spines
b. The cervix is effaced 3 cm, it is dilated 30% and the presenting part is 1 cm below the ischial spines
c. The cervix is dilated 3 cm, it is effaced 30% and the presenting part is 1 cm below the ischial spines
d. The cervix is dilated 3 cm, it is effaced 30% and the presenting part is 1 cm above the ischial spines
ANSWER: D
Dilation of the cervix is the widening of the cervical opening measured in cm from closed to approximately 10 cm
(full dilation). Effacement refers to the shortening and thinning of the cervix. Degree of effacement is stated I
terms of percentage from 0 to 100%. Station is the relation of the presenting part of the fetus to an imaginary
line drawn between the ischial spines in the maternal pelvis. The degree of descent is noted in cm that is either
above, below, or at the level of ischial spines. If the station is -1, then the presenting part is 1 cm above the
ischial spines.
95. A woman in the first stage of labor is using pattern-paced breathing. She complains of feeling lightheaded
and states that her fingers are tingling. Which of the following actions should the nurse take?
a. Notify the client’s physician
c. Tell the client to slow the rate of her breathing
b. Administer oxygen via nasal cannula
d. Help the client breathe into a paper bag
ANSWER: D
The client is experiencing symptoms of respiratory alkalosis due to hyperventilation. The client needs to
rebreathe carbon dioxide and replace the bicarbonate ion rather than receive more oxygen. It is not necessary to
notify the doctor at this time. Telling the client to slow her breathing rate will not help relive her symptoms.
ANSWER: B
97. Four hours after spontaneous vaginal delivery under local anesthesia, a patient tells the nurse that she has to
urinate. Which of the following actions should the nurse take?
a. Obtain a bedside commode for the patient
c. Ambulate the patient to the bathroom
b. Offer the patient a bedpan
d. Catheterize the patient
ANSWER: C
Since the patient delivered under local anesthesia, she should be able to ambulate at this time. The nurse should,
however, assist the patient to the bathroom to make sure that she is able to safety ambulate. Options A and C:
Using a bedpan or using a bedside commode is not necessary for this patient. The patient should be fully mobile
four hours after delivery. Option D: Catheterizing a patient post-delivery should only be done when all other
measures are not effective.
98. A client is complaining of cramps in her right leg while in active labor. What intervention should the nurse
implement?
ANSWER: B
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable) (B), and
putting the heel of the foot on the floor is the best means of relieving leg cramps. Option A is ineffective for leg
cramps caused by phosphorous/calcium imbalances and may dislodge small thrombi. Option C would not be
99. The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when
carrying out this procedure?
a. A gravida 6, para 5 who is 38 years of age and in early labor.
b. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1 station.
c. A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of labor due to post dates.
d. A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.
ANSWER: D
When the presenting part is ballottable (D), it is floating out of the pelvis. In such a situation, the cord can
descend before the fetus causing a prolapsed cord, which is an emergency situation. Options A, B, and C do not
present problems with administration of an enema.
100. The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red
vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm
dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
a. Insert an internal fetal monitor.
c. Monitor bleeding from IV sites.
b. Assess for cervical changes q1h.
d. Perform Leopold's maneuvers.
ANSWER: C
Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of
placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruptio,
characterized by abnormal bleeding. Invasive vaginal procedures (A and B) or (D) can increase the abruption and
bleeding, so these interventions are contraindicated.
COMPLICATIONS OF POSTPARTUM AND NEWBORN CARE
SITUATION: Nurse Maha Root is working as an obstetric nurse in the PRN General Hospital. She is also a nurse
researcher in the unit, and currently studying the cause and effect of postpartum infections, prevention of
puerperal infections and nursing care rendered for these cases.
1. Nurse Maha Root understands that the postpartum client who is at the highest risk for developing a puerperal
infection would be a:
a. Woman who has lost 350ml of blood during delivery
b. Primipara who has delivered an infant weighing 8 ½ pounds
c. Multipara who had a haemoglobin level of 11 g on admission to the hospital
d. Woman who has been voiding in amounts of 75 to 80 ml and requires catheterization
ANSWER: D
Residual urine and catheterization increase the chance of introducing and promoting bacterial growth
Option A – a loss of 250 to 500 ml of blood is considered acceptable during delivery
Option B – the size of the newborn does not predispose the mother to postpartum infection
Option C – this does not reflect the highest risk for infection; a haemoglobin of 11 g is at the low end of the
acceptable range
Reference: Adelle Pilliterri. Maternal and Child Nursing. 5th Edition. Page 664
2. Nurse Maha is discussing basic principles of asepsis and infection control standards to the unit. This new nurse
shows a clear understanding of the highest priority intervention in preventing infection through which statement?
a.“I must use barrier isolation.”
c. “I must use individual client care equipment.”
b.“I must wear a gown and gloves.”
d. “I must practice frequent hand washing.”
ANSWER: D
Frequent hand washing is the highest priority intervention. The nurse can emphasize, monitor, and ensure this
strategy for all who come in contact with a client. The use of gowns and gloves are appropriate for specific
situations only. Individuals client care equipment is a nursing responsibility but commonly depends on multiple
factors related to budgeting within the hospital system and is not directly under the control of the nurse.
3. Which of the following events most likely contributes to development of a puerperal infection?
a. Prolonged first stage of labor (more than 12 hours)
c. Midline episiotomy
b. Prolonged rupture of membranes (more than 24 hours)
d. Multiparity status
ANSWER: B
Rupture of the membranes more than 24 hours may lead to chorioamnionitis as the bacteria may have started to
invade the uterus while the fetus was still in the utero.
Option A – isn’t associated with puerperial infection unless numerous vaginal examinations were performed
Option C – is a potential source of infection but, under normal circumstances, the episiotomy heals without
complications
Option D – multiparity status has no influence on the incidence of puerperal infection
SITUATION: Hemorrhage, one of the most important causes of maternal mortality associated with childbearing,
poses a possible threat throughout pregnancy and is a major potential danger in the immediate postpartum
period. The following questions refer to managing this postpartal complication.
4. Priority nursing care for a client who has just delivered her fifth child should include:
a. Palpating her fundus because she is at risk for uterine atony
b. Offering her fluids because multiparas generally lose more fluid during labor
c. Assessing her bladder tone because she is at increase risk for urinary tract infection
d. Performing passive range of motion exercises on her extremities because she is at risk for thrombophlebitis
ANSWER: A
Because the client’s multiple parity postpartum uterine contractions may be ineffective therefore alternative
methods to stimulate the uterus to contract will be necessary
Option B –primiparas would become more dehydrated because their labor process is usually longer
Option C – there is no evidence of an increased risk for urinary tract infection; routine assessment of bladder
tone should be performed
Option D – clients are encouraged to ambulate soon after delivery it is to soon to be concerned about the
immobility
Reference: Adelle Pilliterri. Maternal and Child Nursing. 5th Edition. Page 658-659.
5. Four days after a vaginal delivery, the client visits the clinic complaining of excessive lochia rubra with clots.
The physician orders methylergonovine maleate (Methergine), 0.2 mg intramuscularly. Before administering this
drug, the nurse needs to assess:
a. Blood pressure
b. Pulse rate
c. Breath sounds
d. Bowel sounds
ANSWER: A
Methylergonovine maleate (Methergine) can cause hypertension, so the nurse should assess the client’s blood
pressure before and after administration. This drug should not b administered to clients who are hypertensive.
Assessing pulse, respiration, and temperature is important for all postpartum clients to provide evidence of
possible complications, such as infection. Tachycardia and diminished breath sounds are associated with
pulmonary embolism, but these signs are not specific to methylergonovine (Methergine) administration.
Assessing breath sounds would be important for a client who has had pregnancy-induced hypertension and
received magnesium sulfate before delivery. However, by the fourth postpartum day, the effects of magnesium
sulfate should have disappeared. Bowel sounds should be assessed after an operative delivery to determine
whether peristalsis has begun so that the client can begin to drink clear liquids or eat soft foods.
6. During the first hour after delivery, assessment of a multiparous client who delivered a neonate weighing
4,593 g (10lb, 2 oz) by cesarean delivery reveals lochia rubra. Which of the following would the nurse expect to
include in the client’s plan of care?
a. Administration of intravenous oxytocin.
c. Rigorous fundal massage every 5 minutes.
b. Placement of the client in a side-lying position.
d. Preparation for an emergency hysteromyomectomy.
ANSWER: A
The client exhibiting signs of early postpartal hemorrhage, defined as blood loss greater than 500 ml in the first
24 hours postpartum. Rapid intravenous oxytocin infusion of 40 to 80 units in 1,000 ml of normal saline, oxygen
therapy, and gentle fundal massage to contract the uterus is usually effective. If bleeding persists, the nurse
should inspect the cervix and vagina for lacerations. Intramascular or intravenous methylergonovine may be
administered, but this drug elevates the blood pressure. Other pharmacologic interventions include prostaglandin
(Hembate, Prostin, PGF2a) I.M. and misoprostol (Cytotec) rectally or vaginally. Severe uncontrolled hemorrhage
may require bimanual uterine compression, a dilation and curettage to remove any retained placental tissue, or a
hysterectomy to prevent maternal death from hemorrhage.
Option B - The client should be placed supine position to allow evaluation of the fundus. The side-lying position is
not helpful in controlling postpartum hemorrhage.
Option C - Vigorous fundal massage every 5 minutes is unnecessary. In addition, it can be very painful for the
mother. Rather, gentle massage along with oxytocin administration is used to use to stimulate the uterus to
contract.
Option D - A hysteromyomectomy is used to remove fibroid tumors. With massive hemorrhage, a hysterectomy
(removal of uterus) may be necessary to control the bleeding.
7. A multiparous client visits the urgent care center 5 days after a vaginal delivery experiencing persistent lochia
rubra in a moderate to heavy amount. The client asks the nurse, “Why am I continuing to bleed like this?” the
nurse should instruct the client this type of postpartum bleeding is usually caused by:
a.Uterine atony
b. Cervical lacerations
c. Vaginal lacerations
d. Retained placental fragments
ANSWER: D
The most likely cause of delayed postpartum hemorrhage is retained placental fragments. The client may be
scheduled for a dilatation and curettage to remove remaining placental fragments. Uterine atony, cervical
lacerations, and vaginal lacerations are commonly associated with early, not late, postpartum hemorrhage.
8. A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is
diagnosed with early postpartum hemorrhage at 1 hour after a cesarean delivery. The client asks, “Why am I
bleeding so much?” The nurse responds based on the understanding that most likely cause of uterine atony in
this client is which of the following?
a. Trauma during labor and delivery.
c. Lengthy and prolonged second stage of labor.
b. Moderate fundal massage after delivery.
d. Overdistention of the uterus from hydramnios.
ANSWER: D
The most likely cause of this client’s uterine atony is overdistention of the uterus caused by the hydramnios. As a
result, the stretched uterine musculature contracts less vigorously. Besides hydramnios, a large infant, bleeding
from abrupio placentae or placenta previa, and rapid labor and delivery can also contribute to uterine atony
during the postpartum. Option A - Trauma during labor and delivery is not a likely cause. In addition, no evidence
of excessive trauma was described in the scenario.
Option B - Moderate fundal massage helps to contract the uterus, not contribute to uterine atony.
Option C - Although a lengthy or prolonged labor can contribute to uterine atony, this client had a cesarean
delivery for breach presentation. Therefore, it is unlikely that she had a long labor.
SITUATION: The nurse is monitoring a client with severe pregnancy induced hypertension (PIH) for signs of
disseminated intravascular coagulation (DIC).
9. Which of the following indicates an early sign of DIC?
a. Hypertension
b. Peripheral edema
c. Petechiae
d. Protenuria
ANSWER: C
Disseminated intravascular coagulation (DIC) is a life-threatening defect in coagulation. Severe PIH is one
complication of pregnancy that can lead to DIC. Other causes include missed abortion or retained dead fetus,
abruptio placentae, amniotic fluid embolism, and sepsis. Petechiae or bleeding from any vulnerable area such as
intravenous sites, incisions, or the gums or nose are signs of DIC. Options a, b, and d are signs of PIH.
10. After being treated with intravenous heparin therapy for disseminated intravascular coagulation, the client
asks the nurse if she can take this drug orally. What is the nurse’s best response?
a. “Yes, but you may experienced nausea and vomiting and may lead you to dehydration that may worsen your
condition”
b. “No, because it may cause bleeding disorders to the fetus.”
c. “No, because it is being destroyed by gastrointestinal secretions.”
d. “Yes, but it will cost you more than enough.”
ANSWER: C
Heparin cannot be administered orally, as it is destroyed by gastrointestinal secretions. Because heparin does not
cross the placenta, the newborn should have no more tendency for a blood coagulation disorder at birth than any
other infant.
Option A – it does not cause nausea and vomiting
Option B – it does not cause bleeding disorders to the fetus
Option D – there is no oral form of this drug, if the anticoagulant that can be taken orally is warfarin but is not
recommended
SITUATION: Endometriosis is an infection of the endometrium, the lining of the uterus. Bacteria gain access to
the uterus through the vagina and enter the uterus either at the time of birth or during the postpartal period.
Seon Dok is a multiparous client was diagnosed with endometriosis due to B-hemolytic streptococcus.
11. When assessing Seon Dok, which of the following would the nurse expect to find?
a. Profuse amounts of lochia.
c. Nausea and vomiting.
b. Abdominal distention.
d. Odorless vaginal discharge.
ANSWER: D
Scant and odorless vaginal discharge is associated with endometritis due to b-hemolytic streptococcus. The
client also will exhibit “sawtooth” temperature spikes between 101 and 104 F(38.3 to 40 C), tachycardia, and
chills. The classic symptom of foul-smelling lochia is not associated with this type of endometritis.
Option A - Profuse and foul-smelling lochia is associated with classical endometritis from pathogens such as
Chlamydia or staphylococcus, not group B hemolytic streptococcus.
Option B - Abdominal distension is associated with parametritis as a pelvic cellulitis advanced and spreads,
causing severe pain and distention.
Option C - Nausea and vomiting are associated with parametritis resulting from an abscess and advancing pelvic
cellulitis.
12. Upon diagnosis of Ms. Seon Dok of having endometriosis, she is to receive intravenous antibiotic therapy with
ampicillin sodium (Polycillin). Before administering this drug, the nurse must:
a. Ask the client if she has any drug allergies.
c. Place the client in a side-lying position.
b. Assess the client’s pulse rate.
d. Check the client’s perineal pad.
ANSWER: A
Before administering ampicillin sodium (polycillin) intravenously, the nurse should ask the client if she has any
drug allergies, especially to penicillin. Antibiotic therapy can cause adverse effects, such as rash or even
anaphylaxis. If the client is allergic to penicillin, the physician should be notified and ampicillin should not be
given.
Options B and C – are not necessary
Option D – is an important intervention for all postpartum clients but is not necessary before antibiotic therapy
13. Which of the following would be the most important for the nurse to encourage Seon Dok client diagnosed
with endometritis who is receiving intravenous antibiotic therapy?
a. Ambulate to the bathroom frequently.
c. Maintain bed rest in Fowler’s position.
b. Discontinue breast-feeding temporarily.
d. Restrict visitors to prevent contamination.
ANSWER: C
Sitting in a Fowler’s position or walking encourages lochia drainage by gravity and helps prevent pooling of
infected secretions.
Option A - Endometriosis can make the client feel extremely uncomfortable and fatigued, so ambulation during
intravenous therapy is not as important at this time
Option B – typically, breastfeeding would be discontinued only if the mother lacks the necessary energy
Option D – visitors’ do not be need to be restricted to prevent contamination because the client is not considered
to be contagious, the nurse should maintain the client’s need for privacy and rest and should maintain the client’s
wishes related to visitors.
SITUATION: A 26-year-old primiparous client is seen in the urgent care clinic 2 weeks after delivering a viable
female neonate. The client, who is breast-feeding, is diagnosed with infectious mastitis of the right breast.
14. The client asks the nurse, “Can I continue breast-feeding?” Which of the following responses would be most
appropriate?
a. “You can continue to breast-feed, feeding your baby more frequently.”
b. “You can continue once your symptoms begin to decrease.”
c. “You must discontinue breast-feeding until antibiotic therapy is completed.”
d. “You must stop breast-feeding because the breast is contaminated.”
ANSWER: A
The client being treated for the infectious mastitis should continue to breast-feed often, or at least every 2 to 3
hours. Treatment also includes bed rest. Increased fluid intake. Local heat application, analgesics, and antibiotic
therapy. Continually emptying the breasts decreases the risk of engorgement or breast abscess. The client should
not discontinue breast-feeding unless she choose to do so. The client may continue breast-feeding while receiving
antibiotic therapy. Generally, the breast milk is not contaminated by the offending organism and is safe for the
neonate.
15. After teaching a primiparous client about treatment and self-care of infectious mastitis of the right breast, the
nurse determines that the client needs further instruction when she states:
a. “I can apply localized heat to the infected area.”
b. “I should increase my fluid intake to 2,000 ml per day.”
c. “I’ll need to take antibiotics for 7 to 10 days before I am cured.”
d. “I should begin breast-feeding on the right side to decrease the pain.”
ANSWER: D
The client needs further instruction when she says that she should begin feeding on the right (painful) breast to
decrease the pain. Stating the feeding on the unaffected (left) breast can stimulate the milk ejection reflex in the
right breast and thereby decrease the pain. Frequent nursing or pumping is recommended to empty the breast.
For some mothers, mastitis is so painful that they choose to discontinue breast-feeding, so these mother need a
great deal of support. Applying heat to the infected area before starting to feed is appropriate because heat
stimulates circulation and promotes comfort. Increasing fluid intake is advised to ensure adequate hydration.
Antibiotics need to be taken until all medication has been used, usually 7 to 10 days to ensure eradication of the
infection.
SITUATION: The nurse is caring for a primiparous client who is diagnosed with cystitis on the second
postpartum day.
16. The client has been requesting medication for back pain every 3 to 4 hours. Which of the following would be
an appropriate nursing diagnosis for the client at this time?
a. Fear related to intravenous therapy and outcome.
c. Ineffective role performance related to prolonged bed rest.
b. Ineffective coping to prolonged hospitalization.
d. Pain related to dysuria and urinary frequency.
ANSWER: D
Because the client has been requesting medication for back pain every 3 to 4 hours, the priority nursing diagnosis
at this time is pain related to dysuria and urinary frequency. There are no data to suggest fear as a diagnosis,
which would be evidenced by expression of feelings such as, “I’m afraid of needles.” There are no data to suggest
ineffective coping as a diagnosis. This diagnosis would be appropriate if the client expressed concerns about her
children or husband and their abilities related to functioning at home while the client is hospitalized. Ineffective
role performance would be appropriate if the client expresses an inability to perform her normal roles at home.
17. Which of the following measures would the nurse expect to include in the teaching plan for this client who
delivered 48 hours ago and is receiving intravenous antibiotic therapy for cystitis?
a. Limiting fluid intake to 1 L daily to prevent overload.
b. Emptying the bladder every 2 to 4 hours while awake.
c. Washing the perineum with povidone iodine (Betadine) after voiding.
d. Avoiding the intake to acidic fruit juices until the treatment is discontinued.
ANSWER: B
The client diagnosed with cystitis needs to avoid every 2 to 4 hours while awake to keep her bladder empty. In
addition, she should maintain adequate fluid intake; 3,000 ml per day is recommended. Intake of acidic fruit
juices (e.g., cranberry, apricot) is recommended because of their association with reducing the risk for infection.
The client should wear cotton underwear and avoid tight fitting slacks. She does not need to wash with povidone
iodine (betadine) after voiding. Plain warm water is sufficient to keep the perineal area clean.
SITUATION: Post partum women are risk to develop thrombophlebitis and deep vein thrombosis when
ambulation is limited during the first 24 hours and they have stayed in the obstetric stirrups for a long time
during the process of labor and delivery. The following questions refer to nursing management and teaching
interventions to post partum clients.
18. Which of the following would be most appropriate for the nurse to do after assessing Ida at 24 hours
postpartum who demonstrates a positive Homan’s sign with discomfort?
a. Place a cold pack on the client’s perineal area
c. Notify the client’s physician immediately
b. Place a client in a semi-Fowler’s position
d. Ask the client to ambulate around the room
ANSWER: C
A positive Homan’s sign, discomfort behind the knee or in the upper calf area on dorsiflexion of the foot, and may
be indicative of thrombophlebitis. Other signs include edema and redness at the site and may be more reliable as
an indicator of thrombophlebitis. The nurse should notify the physician immediately and ask the client to remain
in bed to minimize the risk for pulmonary embolus, a serious consequences of thrombophlebitis should a clot
dislodge. The Homan sign is observed on the client’s legs, so placing an ice pack on the perineal area is
inappropriate. However, ice to the perineum would be useful for episiotomy pain and swelling. The client does not
need to be positioned in a semi-Fowler’s position but should remain on bed rest to prevent dislodgement of a
potential clot.
19. Prophylactic heparin therapy is ordered to treat Ida’s thrombophlebitis. After instructing the client about
medication, the nurse determines that she understands the instructions regarding the purpose of the drug when
she states:
a. To thin the blood clots.
c. To increase the perspiration for dieresis.
b. To increase the lochial flow.
d. To prevent further blood clot formation.
ANSWER: D
Heparin therapy is ordered to prevent further clot formation by inhibiting further thrombus and clot formation.
Heparin, an anticoagulant, does not make blood clots thinner. An adverse effect of heparin therapy during the
puerperium is increased lochia flow, so the nurse must be observant for symptoms of hemorrhage, such as heavy
lochial flow. Heparin does not increase diaphoresis, which is normal for the postpartum client.
20. Nurse Love is caring for Lorna who is diagnosed with deep vein thrombosis at 48 hours postpartum who is
receiving treatment with bed rest and intravenous heparin therapy. The nurse would contact the client’s physician
immediately if the client exhibited:
a. Pain in her calf.
b. Dyspnea
c. Hypertension
d. Bradycardia
ANSWER: B
A major complication of deep vein thrombosis is pulmonary embolism. Signs and symptoms, which may occur
suddenly and require immediate treatment, include dyspnea, severe chest pain, apprehension, cough (possibly
accompanied by hemoptysis), tachycardia, fever, hypotension, diaphoresis, pallor, shortness of breath, and
friction rub. Pain in the calf is common with a diagnosis of deep vein thrombosis. Hypotension, not hypertension,
would suggest a possible pulmonary embolism. It also could suggest possible hemorrhage secondary to
intravenous herapin therapy. Bradycardia for the first 7 days in the postpartum period is normal.
21. Fe who is already in her 3rd day postpartum, is to be discharged on heparin therapy. After teaching her about
possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when
she states that the adverse effects include:
a.Epistaxis
b. Bleeding gums
c. Slow pulse
d. Petechiae
ANSWER: C
A slow pulse (bradycardia) is normal for the first 7 days postpartum as the body begins to adjust to the decrease
in blood volume and return to the pregnant state. Adverse effects of heparin therapy suggesting prolonged
bleeding include hematuria, epistaxis, increased lochial flow, and bleeding gums. Typically, tachycardia, not
bradycardia, would be associate with hemorrhage. Petechiae indicate bleeding under the skin or in subcutaneous
tissue.
Reference: Adelle Pilliterri. Maternal and Child Nursing. 5th Edition. Page 632
SITUATION: Any woman who is extremely stressed or who gives birth to an infant who in any way does not
meet her expectations may have difficulty bonding with the infant. The following are questions refer to
psychological response of postpartum women.
22. Nurse Lara is reviewing discharge instructions with Mrs. Bernice. Which of the following symptoms is least
important in characterizing post partum “blues”?
a. Crying easily and feeling despondent
c. Altered body image
b. Loss of appetite and anxiety
d. Difficulty sleeping; poor concentration
ANSWER: C
Perceiving al altered body image is normal in pregnancy and the postpartum period because of physiologic
changes that take place at these times. A variety of symptoms characterized postpartum blues, including loss of
appetite, crying easily and inability to stop crying, despondency, difficulty concentrating, feeling let down,
extreme fatigue and anxiety.
23. In reviewing discharge instructions with Mrs. Bernice, nurse Lara is aware that a higher incidence of
postpartum “blues” can result from:
a. Fatigue
b. Subinvolution
c. Neonatal jaundice
d. PIH
ANSWER: A
Feelings of sadness of almost every woman (post partum blues) after birth. This probably occurs as a response to
the anticlimactic feeling after birth, fatigue during the labor and delivery process and probably is related to
hormonal shifts as the level of estrogen, progesterone, and gonadotropin-releasing hormone in her body decline
or rise.
Therefore, it is important to encourage adequate rest and nutrition. Mothers who experience more fatigue often
don’t perceive themselves as competent in delivering infant care.
Options B, C and D are not associated with postpartum blues
24. During a home visit to a primiparous client who delivered vaginally 14 days ago, the client says, “I’ve been
crying a lot the few days. I just feel as awful. I am a rotten mother. I just don’t have any energy. Plus, my
husband just got laid off his job.” The nurse observes that the client’s appearance is disheveled. Which of the
following would be the nurse’s best response?
a. “These feelings commonly indicate symptoms of postpartum blues and are normal. They’ll go away in a few days.”
b. “I think you’re probably overreacting to the labor and delivery process. You’re doing the best you can as a mother.”
c. “It’s not unusual for some mothers to feel depressed after the birth of a baby. I think I should contact your doctor.”
d. “This may be a symptom of a serious mental illness. I think you should probably go to hospital.”
ANSWER: C
The client is probably experiencing postpartum depression, and the doctor should be contacted. Postpartum
depression is usually treated with psychotherapy, social support groups, and antidepressant medications.
Contributing factors include hormonal fluctuations, a history of depression, and environmental factors (e.g., job
loss). An estimated 50% to 70% of women experience some degree of postpartum “blues”, but these feelings of
sadness disappear within 1 to 2 weeks after birth. However, the client is voicing more than just sadness. Telling
her that she is overreacting is not helpful and may make her feel even less worthy. She is not exhibiting
symptoms of a serious mental illness (loss of contact with reality) and does not need hospitalization.
25. Which statement by the client is most suggestive of a woman developing postpartal psychosis?
a. “I wish my baby had more hair”
c. “I feel exhausted since birth”
b. “My baby has the devil’s eye”
d. “Breastfeeding is harder than I thought”
ANSWER: B
A woman with postpartal psychosis usually appears exceptionally sad. By definition, psychosis exists when a
person has lost contact with reality. Seeing the newborn having a devil’s eye which is apart to the reality it may
signal psychosis, not intact in reality. Also, a woman with postpartal psychosis may deny that she has had a
child, and when the child is brought to her, insist that she was never pregnant. She may voice thoughts of
infanticide or that her infant is possessed.
Other options are normally seen in postpartum women.
SITUATION: Newborns undergo profound physiologic changes at the moment of birth as they are released from
a warm, snug, dark, liquid-filled environment that has met all of their basic needs. A nurse in the nursery should
be critical in assessing the newborns status as they are still in a fragile state.
26. Which of the following when present in the newborn’s urine may cause a reddish stain on the diaper of a
newborn?
a. Mucus
b. Uric acid crystals
c. Bilirubin
d. Excess iron
ANSWER: B
Uric acid crystals that were formed in the bladder in utero found in the urine may produce the reddish “brick
dust” stain on the diaper. Mucus would not produce a stain. Bilirubin and iron are from hepatic adaptation.
27. The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. What
further assessment should the nurse perform?
a. Elicit a positive scarf sign on the affected side.
c. Watch for swelling of fingers on the affected side.
b. Observe for an asymmetrical Moro (startle) reflex.
d. Note paralysis of affected extremity and muscles.
ANSWER: B
The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant
may be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the affected arm,
malposition of the arm, an asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or
cries when the arm is moved. Option A - Eliciting scarf sign (extending arm across the chest toward the opposite
shoulder) is contraindicated if a fractured clavicle is present.
Options C and D on the affected side require follow-up, but are not indicative of a fractured clavicle.
28. A 24-hour-old newborn is assessed to have a pink papular rash with vesicles superimposed on the thorax,
back, and abdomen. After assessment, what action should the nurse implement?
a. Notify the healthcare provider.
c. Document the finding in the infant's record.
b. Move the newborn to an isolation nursery.
d. Obtain a culture of the vesicles.
ANSWER: C
Erythema toxicum (or erythema neonatorum) is a newborn rash that is commonly referred to as "flea bites," but
is a normal finding that is documented in the infant's record. This usually appears in the first to fourth day of life,
but may appear up to 2 weeks of age. It begins with a papule, increases in severity to become erythema by the
second day, and then disappears by the third day. It occurs sporadically and unpredictably, and may last hours
rather than days. It is caused by a newborn’s eosinophils reacting to the environment as the immune system
matures and requires no further action (A, B, and D).
29. The total bilirubin level of a breastfed newborn delivered 36 hours ago is 14 mg/dl. Based on this finding,
which intervention should the nurse implement?
a. Provide phototherapy for 30 minutes q8h.
c. Encourage the mother to breastfeed frequently.
b. Feed the newborn sterile water hourly.
d. Assess the newborn's blood glucose level.
ANSWER: C
The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. This hyperbilirubinemia occurs because the
high red blood cells count built up in utero is destroyed, and heme and globin are released. Althouhgh in the
situation, the infant's bilirubin is beginning to climb and the infant should be monitored to prevent further
complications. Treatment for physiologic jaundice or the routine rise in bilirubin in newborns is rarely necessary
except for measures such as early feeding (Breast milk provides calories and enhances GI motility), to speed
passage of feces through the intestine and prevent reabsorption of bilirubin from the bowel
Option A - is not indicated at this level.
Option B - would limit caloric intake, which is essential in preventing jaundice.
Option D - is not related to bilirubin levels.
30. The nurse is assisting with the delivery and monitoring the client for placental separation following delivery of
the newborn. After placental delivery, the nurse notes that the placenta appears shiny and glistening from the
fetal membranes. This type of placenta is known as:
a. Braxton
b. Duncan
c. Goodell
d.Schultze
ANSWER: D
It is a Schultze’s placenta is it appears shiny and glistening from the fetal membranes. Eighty percent of
placentas separate and presents this way. If the placenta separates first at its edges it slides along the uterine
surface and presents at the vagina with maternal surface evident. It looks raw, red with irregular edges. This is
called Duncan’s placenta. (Note: Schultze – shiny – fetal membrane surface / Duncan – dirty – irregular maternal
surface)
Additional: Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood
from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to globular shape. The
client may experience vaginal fullness, but not sudden and sharp abdominal pain.
Family. 4th ed 508.
SITUATION: Hannah Montana, a 22-year-old gravida 1, vaginally delivered a full-tem infant without
complications except for a midline episiotomy. The following questions refer to this situation.
31. To prevent swelling and discomfort of the perineal site immediately after delivery, the nurse caring for Mrs.
Hannah should:
a. Apply dry heat therapy to the perineal area
b. Set up the portable sitz bath for the patient’s use
c. Assist the patient on the bedpan and squirt warm water over the perineal area
d. Apply an ice bag to the perineal area for 30 minutes
ANSWER: D
Applying an ice or cold pack to the perineum during the first 24 hours reduces perineal edema and the possibility
of hematoma formation, thereby reducing pain and promoting healing and comfort. Be certain not to place ice or
plastic directly on the woman’s perineum. Wrap the ice bag first in a towel or disposable pad, to decrease the
chance of a thermal burn (risk for injury increases because the perineum has decreased sensation from edema
after birth. Use of warm water may dissolve the absorbent suture if any making it ineffective and can cause
dehiscence of the episiotomy.
32. In preparing a sitz bath for Mrs. Hannah, the nurse should remember that normal water temperature should
be maintained at:
a. 980 F (34.70 C)
b. 990 F (37.20 C)
c. 1010F (38.30 C)
d. 1060 F (41.1 C)
ANSWER: C
Sitz baths are used to relieve perineal discomfort and edema and to promote perineal hygiene. To promote the
therapeutic nature of the sitz bath, the water temperature should be maintained between 100 and 105 F (37,8
and 40.5). Temperatures above 105 F may burn the perineal area. Temperatures below 100 F may not be
provide therapeutic relief.
SITUATION: Marian Rivera, a primipara delivered vaginally to a 4,250g (9.35 lbs) infant. She had a midline
episiotomy and experienced a third-degree laceration.
33. The nurse understands that this type of laceration:
a. Extends into the anterior wall of the rectum
c. Extends into the anal sphincter muscle
b. Extends into the perineal muscle
d. Extends to the perineal skin and other superficial structures
ANSWER: C
Lacerations are tears that occur during childbirth. A third-degree laceration extends into the anal sphincter
muscle. A first-degree laceration is limited to the perineal skin and other superficial structures such as the labia.
A second-degree laceration reaches the perineal muscles, and fourth-degree laceration involves the anterior
rectal wall.
34. When Marian is receiving discharge instructions from the nurse, she asks the nurse when she can resume
sexual intercourse. The nurse states that sexual intercourse can be resumed:
a. When the lochia has stopped
c. With the doctor approval
b. At the man’s discretion
d .6 weeks after giving birth
ANSWER: A
Sexual intercourse can be resumed when the lochia has ceased and the perineal and episiotomy area is healed
and not painful. Lochia usually ceases about 2 to 4 weeks after birth, and this is when most women can resume
sexual intercourse. As long as the lochia continues, the placental site isn’t completely healed. It’s important not
to introduce any bacteria into the vaginal canal that may infiltrate the placental site and cause an infection.
Sexual intercourse should be resumed at the woman’s discretion according to lochia status, perineal intactness;
and personal desire. The woman should be encouraged to ask her doctor any questions she may have concerning
intercourse but don’t nee the approval of a doctor.
SITUATION: Although the puerperium is usually a period of health, complications can occur. When they do,
immediate intervention is essential to prevent long-term disability and interference with parent-child
relationships.
35. Uterine atony, a condition in which the uterus is unable to maintain a state of firmness, is a common cause of
hemorrhage in the postpartum period. In providing patient care for the client, the nurse is aware that uterine
atony can result from:
a. Hypertension
b. Endometritis
c. Cervical and vaginal tears
d. Urinary retention
ANSWER: D
Uterine atony is associated with urinary retention; therefore the nurse should offer a bedpan or assist the woman
with ambulating to the bathroom at least every 4 hours to keep her bladder empty. A full bladder pushes an
uncontracted uterus into an even more uncontracted state. To reduce bladder pressure, insertion of a urinary
catheter may be ordered. Options A, B and C are not predisposing factors causing the condition.
Reference: Adelle Pillitteri, Maternal and Child Nursing, 5th Edition. Page 622, 628-629, 637.
36. The nurse assesses a 4 hour postpartum client with the vital signs as follows: BP 90/60; temperature
100.4ºF; pulse 100 weak, thready; R 20 per minute. Upon assessment, which of the following should the nurse
do first?
a. Report the temperature to the physician
c. Assess the uterus for firmness and position
b. Recheck the blood pressure with another cuff
d. Determine the amount of lochia
ANSWER: D
A weak, thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. An increased pulse is a
compensatory mechanism of the body in response to decreased fluid volume. Thus, the nurse should check the
amount of lochia present. Temperatures up to 100.48F in the first 24 hours after birth are related to the
dehydrating effects of labor and are considered normal. Although rechecking the blood pressure may be a correct
choice of action, it is not the first action that should be implemented in light of the other data. The data indicate a
potential impending hemorrhage. Assessing the uterus for firmness and position in relation to the umbilicus and
midline is important, but the nurse should check the extent of vaginal bleeding first. Then it would be appropriate
to check the uterus, which may be a possible cause
of the hemorrhage.
37. During an assessment of a multiparous client who delivered an 8-lb 7-oz infant 4 hours ago, the nurse notes
the client's perineal pad is completely saturated within 15 minutes. What action should the nurse implement
next?
a. Perform fundal massage
c. Notify the healthcare provider
b. Assess blood pressure
d. Encourage the client to void.
ANSWER: A
It is difficult to estimate the amount of blood a postpartal woman has lost, because it is difficult to estimate the
amount of blood it takes to saturate a perineal pad. By counting the number of perineal pads saturated in given
lengths of time you can form a rough estimate of blood loss. Perineal pad saturation within 15 minutes during the
early post partum period is indicative of bleeding, which is commonly due to uterine atony and can lead to postpartum hemorrhage.
Option A - Fundal assessment and massage should be performed first to control bleeding.
Options B, C, and D are actions implemented after manually stimulating the fundus to contract.
38. The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following
assessments would warrant notification of the physician?
a. A dark red discharge on a 2-day postpartum client
b. A pink to brownish discharge on a client who is 5 days postpartum
c. Almost colorless to creamy discharge on a client 2 weeks after delivery
d. A bright red discharge 5 days after delivery
ANSWER: D
Any bright red vaginal discharge would be considered abnormal, but especially 5 days after delivery, when the
lochia is typically pink to brownish. Lochia rubra, a dark red discharge, is present for 2 to 3 days after delivery.
Bright red vaginal bleeding at this time suggests late postpartum hemorrhage, which occurs after the first 24
hours following delivery and is generally caused by retained placental fragments or bleeding disorders. Lochia
rubra is the normal dark red discharge occurring in the first 2 to 3 days after delivery, containing epithelial cells,
erythrocyes, leukocytes and decidua. Lochia serosa is a pink to brownish serosanguineous
discharge
occurring from 3 to 10 days after delivery that contains decidua, erythrocytes, leukocytes, cervical mucus, and
microorganisms. Lochia alba is an almost colorless to yellowish discharge occurring from 10 days to 3 weeks after
delivery and containing leukocytes, decidua, epithelial cells, fat, cervical mucus, cholesterol crystals, and
bacteria.
SITUATION: All postpartum clients are at increase risk to develop thromboembolic disorders after the
extraneous and exhausting labor and delivery. Therefore, postpartum clients are encouraged to be mobile or
ambulate as early as possible to prevent the occurrence of thromboembolic disorders. Early ambulation is the
best preventive measure.
39. A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse
that her feet have begun to swell. What instruction would be most effective in preventing pooling of blood in the
lower extremities?
a. Wear support stockings
c. Move about every hour
b. Reduce salt in her diet
d. void constrictive clothing
ANSWER: C
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins.
Moving about every hour will straighten out the pelvic veins and increase venous return.
Option A - increase venous return from varicose veins in the lower extremities, but are little help with swelling.
Option B - might be helpful with generalized edema (which could be an indication of PIH) but is not specific for
edematous lower extremities.
Option D - does not specifically address venous return in this particular case.
40. The risk of postpartum thromboembolism occurs because of a physiologic increase in:
a. Coagulation factors
b. Heart rate
c. Diuresis
d. Blood pressure
ANSWER: A
Thrombophlebitis is the inflammation with the formation of blood clots. It tends to occur for the following reasons
(a) the level of circulating fibrinogen, a constituent of the blood that is necessary for clotting increases as much
as 50% during pregnancy, probably because of the increased level of estrogen and remain elevated from
delivery, leading to increased blood clotting (b) dilatation of lower extremity veins is still present as a result of
pressure of the fetal head during pregnancy and birth (c) the relative inactivity of the period or a prolonged time
spent in delivery or birthing room stirrups leads to pooling, stasis, and clotting of blood in the lower extremities.
family. Volume. 5th edition. Lippincot William & Wilkins. 232, 667.
41. Which of the following best describes thrombophlebitis?
a. Inflammation and clot formation that result when blood components combine to form an aggregate body
b. Inflammation and blood clots that eventually become lodged within the pulmonary blood vessels
c. Inflammation and blood clots that eventually become lodged within the femoral vein
d. Inflammation of the vascular endothelium with clot formation on the vessel wall
ANSWER: D
Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the wall of the
vessel. Blood components combining to form an aggregate body describe a thrombus or thrombosis. Clots
lodging in the pulmonary vasculature refers to pulmonary embolism; in the femoral vein, femoral
thrombophlebitis.
42. Which of the following assessment findings would the nurse expect if the client develops DVT?
a. Midcalf pain, tenderness and redness along the vein
b. Chills, fever, malaise, occurring 2 weeks after delivery
c. Muscle pain the presence of Homans sign, and swelling in the affected limb
d. Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery
ANSWER: C
Classic symptoms of DVT include muscle pain, the presence of Homans sign, and swelling of the affected limb.
Midcalf pain, tenderness, and redness, along the vein reflect superficial thrombophlebitis. Chills, fever and
malaise occurring 2 weeks after delivery reflect pelvic thrombophlebitis. Chills, fever, stiffness and pain occurring
10 to 14 days after delivery suggest femoral thrombophlebitis.
SITUATION: In some instances, some women develops postpartal puerperial complications. These complications
put the woman’s at risk from three points view: her own health, her future childbearing potential, and her ability
to bond with her new infant.
43. Which of the following should the nurse do when a lactating primipara client tells the nurse that she has sore
nipples?
a. Tell her to breast feed more frequently
c. Encourage her to wear a nursing brassiere
b. Administer a narcotic before breast feeding
d. Use soap and water to clean the nipples
ANSWER: A
Feeding more frequently, about every 2 hours, will decrease the infant’s frantic, vigorous sucking from hunger
and will decrease breast engorgement, soften the breast, and promote ease of correct latching-on for feeding.
Narcotics administered prior to breast feeding are passed through the breast milk to the infant, causing excessive
sleepiness. Nipple soreness is not severe enough to warrant narcotic analgesia. All postpartum clients, especially
lactating mothers, should wear a supportive brassiere with wide cotton straps. This does not, however, prevent
or reduce nipple soreness. Soaps are drying to the skin of the nipples and should not be used on the breasts of
lactating mothers. Dry nipple skin predisposes to cracks and fissures, which can become sore and painful.
44. Which of the following is the primary predisposing factor related to mastitis?
a. Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts
b. Endemic infection occurring randomly and localizing in the periglandular connective tissue
c. Temporary urinary retention due to decreased perception of the urge to avoid
d. Breast injury caused by overdistention, stasis, and cracking of the nipples
ANSWER: D
With mastitis, injury to the breast, such as overdistention, stasis, and cracking of the nipples, is the primary
predisposing factor as organisms causing infection enters to these impaired parts of the breast. Epidemic and
endemic infections are probable sources of infection for mastitis. Temporary urinary retention due to decreased
perception of the urge to void is a contributory factor to the development of urinary tract infection, not mastitis.
45. A client who had a normal vaginal delivery 10 days ago is re-hospitalized for lethargy and increased lochia
flow with a foul odor. Initial assessment reveals a pulse rate of 94 beats/minute, a temperature of 102.2° F,
chills, pelvic pain, and uterine tenderness, that put the client at great danger after a few minutes. The nurse
assigned to the client acts accordingly based on the standard nursing procedures and interventions and done
every possible actions to preserve the clients life. Which of the following ethical principles governs the nurse’s
actions?
a. Principalism
b. Deontological
c. Non-maleficence
d. Telelogical
ANSWER: B
This theory emphasizes the duties human beings owe one another based on commitments, and the dignity of
human life. It looks at the intention of an action, not just the outcome. Deontological approach upholds the use of
universal code and principle when making ethical decisions in nursing practice. It is ethical when the nursing
action is in line with the universal code and not ethical when it is against it.
Option A – this theory incorporates several existing principals and attempts to resolve conflicts by applying one or
more them to a given situation.
Option C – non-maleficence is an ethical principle that states one should do no harm.
Option D – this theory derives rules for conduct from the consequences of one’s actions, whereby good actions
are those that have good consequences, and bad actions have bad consequences. What makes an action right or
wrong is its utility, and bringing the greatest amount of good into a situation.
Reference: Venzon, L.M. and Venzon R.M. (2005) Professional Nursing in the Philippines, 10th edition. Page 9699.
46. Which of the following are the most commonly assessed findings in cystitis?
a. Frequency, urgency, dehydration, nausea, chills, and flank pain
b. Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain
c. Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever
d. High fever, chills, flank pain nausea, vomiting, dysuria, and frequency
ANSWER: B
Manifestations of cystitis include, frequency, urgency, dysuria, hematuria nocturia, fever, and suprapubic pain.
Dehydration, hypertension, and chills are not typically associated with cystitis. High fever chills, flank pain,
nausea, vomiting, dysuria, and frequency are associated with pvelonephritis.
47. The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse
take?
a. Ask the mother why she won't look at the infant.
c. Examine the newborn's eyes for the ability to focus.
b. Observe the mother for other attachment behaviors.
d. Recognize this as a common reaction in new mothers.
ANSWER: B
Parent-infant bonding or attachment is based on a mutual relationship between parent and infant and is
commonly established by the "enface position," which is demonstrated by the mother's and infant's eyes meeting
in the same plane. To assess for other attachment behaviors, continued observation of the new mother's
interactions with her infant (B) helps the nurse determine problems in attachment.
Option A - may cause undue confusion, stress, or impact the mother's self-confidence.
Option C - is not indicated.
Option D -The "enface position" is significant, early behavior that leads to the formation of affectional ties and
should be encouraged, it is too soon to conclude this without further observation
48. When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse
include in the teaching plan?
a. Mood swings
b. Panic attacks
c. Decreased need for sleep
d. Disinterest in the infant.
ANSWER: A
"Postpartum blues" is a common emotional response related to the rapid decrease in placental hormones after
delivery and include mood swings (A), tearfulness, feeling low, emotional, and fatigued.
Options B, C and D - are more characteristic of postpartum depression that typically occurs 3 to 7 days later than
postpartum blues.
49. Which of the following best reflects the frequency of reported postpartum “blues”?
a. Between 10% and 40% of all new mothers report some form of postpartum blues
b. Between 30% and 50% of all new mothers report some form of postpartum blues
c. Between 50% and 80% of all new mothers report some form of postpartum blues
d. Between 25% and 70% of all new mothers report some form of postpartum blues
ANSWER: C
According to statistical reports, between 50% and 80% of all new mothers report some form of postpartum
blues. The ranges of 10% to 40%, 30% to 50%, and 25% to 70% are incorrect.
50. A predisposing factor in determining whether a woman will have a postpartum hemorrhage is the knowledge
that:
a. Her uterus is over distended
c. The duration of her labor was very short
b. She has had more than five pregnancies
d. She is over 40 years of age
ANSWER: A
A – Overdistention of the uterus because of a large baby, multiple gestation, or hydramnios predisposes a woman
to uterine atony which may cause postpartum hemorrhage.
B – Unless uterine atony is present, hemorrhage should not occur; a grand multipara is at risk for placenta
previa.
C – This leads to precipitous delivery (potentially harmful to the fetus) but does not affect uterine contractions
after delivery.
D – Not a factor in involution of the uterus.
p.753
51. The nurse receives an order to administer methylergonovine (Methergine) to a postpartum client with uterine
atony. The nurse would contact the physician to verify the order if which of the following conditions is present in
the client?
a. Difficulty locating the uterine fundus
b. Excessive bleeding
c. Excessive lochia
d. Hypertension
ANSWER: D
Methergine is an ergot alkaloid that stimulates uterine contractions. It is primarily used to prevent and treat
postpartum hemorrhage due to uterine atony. It is contraindicated for the hypertensive woman (It causes
hypertension by vasoconstriction - do not give if blood pressure is 140/90 mmHg or greater), individuals with
severe hepatic or renal disease, and during the third stage of labor. A uterine fundus that is difficult to locate,
excessive bleeding, and excessive lochia are clinical manifestations of uterine atony indicating the need for
methylergonovine.
Family. 4th ed.516
52. Which of the following assessments would lead you to believe a postpartal woman is developing a urinary
complication?
a. At 8 hours postdelivery, she has voided a total of 100 mL in four small voidings.
b. She has voided a total of 1,000 mL in two voidings, each spaced 1 hour apart.
c. She tells you she is extremely thirsty.
d. Her perineum is obviously edematous on inspection.
ANSWER: A
Postpartal women who void in small amounts may be experiencing bladder overflow from retention.
Reference: Adelle Pilliterri. Maternal and Child Nursing. 5th Edition
53. A postpartal woman is placed on an anticoagulant to prevent further clot formation. She asks you if she will
be able to continue breastfeeding. Your best response would be that
a. All anticoagulants pass in breast milk, so she will have to stop.
b. Anticoagulants pass in breast milk, but not in amounts great enough to cause harm.
c. The effect of anticoagulants is counteracted by infant gastric juices.
d. Your answer depends on the type of anticoagulant she is taking.
ANSWER: D
Advice will differ based on the drug prescribed. Heparin, for example, does not pass into breast milk, yet warfarin
(Coumadin) does.
54. Nurse Isabel is giving discharge teaching to a postpartal client. Nurse Isabel should instruct the client to
return immediately for evaluation if which of the following occurs?
a. Small hemorrhoids
c. Slight swelling in the lower legs without pain or redness
b. Temperature of 37.2 degree C
d. Bleeding becomes heavier than a heavy period
ANSWER: D
Bleeding heavier than a period after discharge indicates hemorrhage and warrants evaluation. A temperature
under 38 deg C is insignificant. Slight swelling in the lower leg without redness or pain is a normal variant after
delivery, due to excess fluids. The development of small hemorrhoids is a normal finding during the postpartum
period.
Reference: Adele Pilitteri. Maternal and Child Health Nursing 5th edition Page
55. A postpartal client’s complete blood count reflects a white blood cell count immediately after delivery to be
14,000 per cubed mm. The nurse reports this as:
a. Abnormal and indicating an infection is present
c. Elevated but normal after delivery
b. An atypically low level
d. Within the normal range
ANSWER: C
An increase in the white blood count is a protective mechanism after delivery. It helps to protect the client form
infection and is in response to the stress associated with labor.
56. While caring to a postpartal client, nurse Hannah noticed an increase in her respirations and the client is
complaining of chest pain. Nurse Hannah should first:
a. Notify the physician
b. Assess vital signs
c. Obtain an order for antianxiety
d. Provide supportive care
ANSWER: A
The woman is experiencing pulmonary embolism, the nurse should promptly notify the physician. Pulmonary
embolism is an emergency. A woman needs oxygen administered immediately and is at high-risk for cardiopulmonary arrest. Other
signs of PE are tachycardia, orthopnea, and cyanosis. Because of the seriousness of the
condition, a woman with PE is transferred immediately to an ICU for continuing care.
Reference: Adele Pilitteri. Maternal and Child Health Nursing 5th edition Page 689
57. A client after a vaginal delivery is at risk for postpartum hemorrhage. Nursing teaching to prevent postpartum
hemorrhage is based on the knowledge that priority explanation for the cause is:
a. Uterine rupture
b. High parity
c. Uterine atony
d. Laceration of the perineal area
ANSWER: C
About 75% of all hemorrhage are due to uterine atony, which is lack of uterine tone. Laceration of the perineal
area, uterine rupture, and high parity are other causes of hemorrhage but they are not as likely.
58. The nurse is reviewing a postpartal client’s record for factors that may put the client at high risk for
thrombophlebitis. Which is not included?
a. Obesity
b. Smoking
c. Primipara at 30-years of age
d. Presence of varicose veins
ANSWER: D
Women most prone to thrombophlebitis are those who smoke cigarettes, are obese, have varicose veins, have
had previous thrombophlebitis, are older than 35 years of age with increased parity, or have a high incidence
of thrombophlebitis in their family, relative inactivity during postpartum can also lead to thrombophlebitis.
59. A woman, who is 10 days postpartum, notices an elevation in her temperature, pain and tenderness in her
right leg. The nurse suspects thrombophlebitis based on which assessment?
a. There is pain in the calf of the left leg on the dorsiflexion of the foot
b. There is pain in the calf of the affected leg on the dorsiflexion of the foot
c. There is pain in the calf of the left leg on the plantar flexion of the foot
d. There is pain in the calf of the affected leg on the plantar flexion of the foot
ANSWER: B
Homans’ sign is positive when there is pain in the calf of the affected leg on the dorsiflexion of the foot; however,
a negative Homans’ sign does not rule out obstruction. Doppler ultrasound or contrast venography is usually
ordered to confirm the diagnosis.
60. Nurse Katoy should evaluate each postpartum woman for factors that increase her risk for hemorrhage.
Which of the following postpartum women is at low risk for postpartum hemorrhage?
a. Multiparous woman who experienced a precipitous labor and birth
b. Primiparous woman who gave birth to an 8 lbs newborn
c. Multiparous woman who gave birth to her sixth child
d. Primiparous woman who continues to receive infusion of magnesium sulfate for preeclampsia
ANSWER: B
Women described in options A, C and D all exhibit risk factors associated with postpartum hemorrhage, since
each factor interferes with ability of the uterus to contract
61. Early postpartum hemorrhage—hemorrhage that occurs within the first 24 hours after birth—is least likely to
occur as a result of:
a. Subinvolution of the uterus, especially the placental site
b. Uterine atony
c. Laceration of the labia, perineum, vagina, or cervix
d. Hematoma formation within the tissue of the pelvis and genitalia
ANSWER: A
Subinvolution is most closely associated with late postpartum hemorrhage (2nd day until 28th day) along with
retained placental fragments and infection
62. A client is currently experiencing an early postpartum hemorrhage. Which action would be inappropriate?
a. Inserting an indwelling urinary catheter
c. Administration of oxytocics
b. Fundal massage
d. Pad count
ANSWER: D
By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary
catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is
appropriate to ensure that the uterus is well contracted, and oxytocics may be ordered to promote sustained
uterine contraction.
Family. 4th ed.
63. A client is receiving ergonovine (Ergotrate Maleate) to treat postpartum hemorrhage. When planning the
client's care, the nurse anticipates monitoring for which common adverse reactions to ergonovine and other ergot
alkaloids?
a. Abdominal cramps and diarrhea
c. Headache and facial flushing
d. Blurred vision and dizziness
ANSWER: B
Nausea and vomiting are the most common adverse reactions to ergot alkaloids such as ergonovine. Less
commonly, these drugs cause headache, dizziness, tinnitus, diaphoresis, palpitations, transient chest pain, and
dyspnea.
Family. 4th ed.
64. Which of the following factors presents the lowest risk for postpartum infection?
a. 14 hour labor followed by a spontaneous vaginal birth
b. Membranes ruptured for 28 hours prior to birth
c. Vacuum extractor used to assist with internal rotation and birth of the fetal head
d. Internal monitors applied to assess FHR patterns and intrauterine pressure
ANSWER: A
Of the four options listed, option A represents the lowest risk because 14 hours is an average duration for labor
and a spontaneous birth, without the use of forceps or vacuum extractor is the expected outcome. Option B is a
risk factor because the rate of infection increases dramatically once 24 hours have passed since the membranes
have ruptured; option C and D increases risk because they are invasive procedures
65. A breastfeeding woman calls the clinic 3 weeks after childbirth because she has fever and swelling and pain in
her right breast. She has come to the clinic for an evaluation. Which of the following teaching should be included
in the plan?
a. Decrease fluid intake to reduce further inflammation of the breast
b. Discontinue breastfeeding while on antibiotic
c. Doxycycline will be given treat the infection
d. Continue to breastfeed on the affected breast
ANSWER: D
Continue breastfeeding unless there is obvious pus, in which case pump and discard from the infected breast and
continue breastfeeding from the other breast. Option A: Increase fluid intake to promote breastmilk formation
and to prevent further dehydration from fever. Option B: Breastfeeding is still encouraged during antibiotic
therapy. Option C: doxycycline is contraindicated for breastfeeding mother.
66. Mrs. K, a 35 year old gravida 5 para 4, complains of severe pain and edema of her right leg and thigh on the
second day after a cesarean delivery. The physician suspects femoral thrombophlebitis. Which sign should the
nurse attempt to solicit to help determine if Mrs. K has femoral thrombophlebitis?
a. Kernig's sign
b. Psoas sign
c. Homan's sign
d. Hegar's sign
ANSWER: C
Homans' sign is a sign of deep vein thrombosis (DVT). A positive sign is present when there is pain in the calf or
popliteal region with examiner's abrupt dorsiflexion of the patient's foot at the ankle while the knee is flexed to
90 degrees
67. A client is diagnosed with thrombophlebitis and 5,000 units of heparin are ordered Q 12h, SQ. The client asks
why she is on heparin. The nurse explains:
a. This will decrease your risk of developing DIC
c. This will cause the clot dissolve
b. This will prevent additional clot formation
d. This will increase the clotting factors in your blood
ANSWER: B
Heparin blocks the conversion of prothrombin to thrombin and of fibrinogen to fibrin, decreasing clotting ability
and resulting in inhibition of thrombus and clot formation. It is used to prevent and treat thrombosis and
pulmonary embolism.
68. While the postpartum client is receiving herapin for thrombophlebitis, which of the following drugs would the
nurse Mica expect to administer if the client develops complications related to heparin therapy?
a. Calcium gluconate
b. Protamine sulfate
c. Methylegonovine (Methergine)
d. Nitrofurantoin (macrodantin)
ANSWER: B
Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications cause by
heparin overdose.
69. A postpartal woman complains of severe pain in the perineal area. The nurse inspects the area and noted
perineal hematoma. The nurse would plan her interventions on the knowledge that:
a. Hematomas are absorbed over the next 3 or 4 days
b. Hematomas are life-threatening
c. Heparin will be give to prevent further clotting
d. Warm compress will prevent further bleeding
ANSWER: A
A perineal hematoma is a collection of blood in the subcutaneous layer of tissue of the perineum. Such blood
collections may be caused by injury to blood vessels in the perineum during birth. Usually the hematoma is
absorbed over the next 3 or 4 days. Interventions include: Administering analgesics for pain relief, and applying
ice pack to prevent further bleeding.
70. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the
following would the nurse be alert?
a. Endometritis
b. Endometriosis
c. Salpingitis
d. Pelvic thrombophlebitis
ANSWER: A
Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes.
Endometriosis does not occur after a strong labor and prolonged rupture of membranes. Salpingitis is a tubal
infection and could occur if endometritis is not treated. Pelvic thrombophlebitis involves a clot formation but it is
not a complication of prolonged rupture of membranes.
71. The risk of postpartum thromboembolism occurs because of a physiologic increase in:
a. Coagulation factors
b. Heart rate
c. Diuresis
d. Blood pressure
ANSWER: A
Thrombophlebitis is the inflammation with the formation of blood clots. It tends to occur for the following reasons
(a) the level of circulating fibrinogen, a constituent of the blood that is necessary for clotting increases as much
as 50% during pregnancy, probably because of the increased level of estrogen and remain elevated from
delivery, leading to increased blood clotting (b) dilatation of lower extremity veins is still present as a result of
pressure of the fetal head during pregnancy and birth (c) the relative inactivity of the period or a prolonged time
spent in delivery or birthing room stirrups leads to pooling, stasis, and clotting of blood in the lower extremities.
family. Volume. 5th edition. Lippincot William & Wilkins. 232, 667.
72. When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse
include in the teaching plan?
1. Mood swings.
3. Tearfulness.
5. Disinterest in the infant.
2. Panic attacks.
4. Decreased need for sleep.
a. 1 and 3
b. 2 and 4
c. 1, 2, 4, 5
d. All of the above
ANSWER: A
"Postpartum blues" is a common emotional response related to the rapid decrease in placental hormones after
delivery and include mood swings (A), tearfulness (C), feeling low, emotional, and fatigued. (B, D, and E) are
more characteristic of postpartum depression that typically occurs 3 to 7 days later than postpartum blues.
73. A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She
is started on an IV of ritodrine hydrochloride (Yutopar). What are the highest priority readings that the nurse
should monitor frequently during the administration of this drug?
a. Maternal blood pressure and respirations.
c. Hourly urinary output.
b. Maternal and fetal heart rates.
d. Deep tendon reflexes.
ANSWER: B
Monitoring the maternal and fetal heart rates (B) is most important when ritodrine is being administered.
Ritodrine is a sympathomimetic agent that stimulates both beta 1 and beta 2 receptors. Stimulation of beta 1
receptors causes tachycardia (side effect of the drug) and stimulation of beta 2 receptors causes uterine
relaxation (desired effect of the drug). While monitoring of (A, C, and D) is also helpful, these do not have the
priority of monitoring (B) when IV ritodrine hydrochloride (Yutopar) is administered.
childrearing family. Volume. 5th edition. Lippincot William & Wilkins. Page
74. Immediately after a laboring client’s membrane rupture, which of the following is the priority nursing care?
a. Time the client’s contractions
c. Assess the fetal heart rate pattern
b. Assess the client’s blood pressure
d. Take the client’s temperature
ANSWER: C
Fetal heart rate is of primary concern because the environment for the fetus has changed. There is an increased
risk for prolapsed of the umbilical cord immediately after rupture of membranes. The client’s blood pressure and
the temperature should not be affected by rupture of the membranes. Although frequency of contractions may
increase after rupture of membranes, the fetal response is of primary concern.
75. An 8-week postpartum client presents with the following signs and symptoms: fatigue, weakness, tremors,
hyperreflexia, palpitations, and angina. The client is diagnosed with postpartum thyroiditis. Which of the following
may be relevant?
1. It is a permanent condition
2. Presentation of this condition is initially that of hyperthyroidism
3. Woman with this disorder may be at future risk for thyroid disease
4. Most women recover spontaneously, but it may reoccur with future pregnancies
a. All except 1
b. All except 2
3. All except 3
d. All except 4
ANSWER: A
Psotpartum thyroiditis is a transient condition affecting up to 5% of women. It frequently occurs 8-12 weeks
postpartum. The initial presentation is that of hyperthyroidism. Women usually recover spontaneously from
postpartum thyroiditis, but it can reoccur in future pregnancies. Women who have this condition may be at risk
for future thyroid disease. This condition is not permanent.
76. If a nurse observes an increased pulse rate and decreased blood pressure in a new postpartum client, the
nurse should suspect the client has developed which of these conditions?
a. Positive Homans’ sign
b. Postpartum hemorrhage
c. Dehydration
d. Uterine distention
ANSWER: B
Postpartum hemorrhage and urinary tract infection are two complications related to urinary retention and bladder
overdistension. A full bladder displaces the uterus and causes excessive bleeding.
Reference: Littleton. Maternity Nursing Care 8ed
77. A postpartal woman has a fourth-degree perineal laceration. Which of the following physician orders would
you question?
a. Urging her to drink all the milk on her tray.
c. Administration of a sitz bath.
b. Administration of acetaminophen and codeine for pain.
d. Administration of an enema.
ANSWER: D
A fourth-degree perineal laceration involves the anus; a hard object, such as an enema tip, could tear a suture.
SITUATION: The discomforts and pain that accompany labor and birth dominate a pregnant woman’s thoughts
throughout this extraneous process. Thus pharmacologic management is now offered to reduce and alleviate this
discomfort during the birthing process, commonly used is the administration of epidural anesthesia. The following
questions refer to nursing care of the postpartum women who had epidural anesthesia.
78. “The discomforts and pain that accompany labor and birth dominate a pregnant woman’s thoughts
throughout this extraneous process”. If you will conduct a study with this statement, which of the following will
be your independent variable?
a. Discomforts and pain
c. Labor and delivery
b. Pregnant woman’s thought
d. Discomforts and pain due labor and delivery
ANSWER: C
Independent variables are known to be the cause of a certain phenomenon, these variables can stand alone and
stimulates the dependent variable. In the situation, the process of labor and delivery causes the feeling of
discomforts and pain of a laboring woman.
Option A – is the dependent variable, the effects of labor and delivery
Option C – is the external variable that can vary depending upon the level of pain tolerance of each laboring
women
Option D – is incorrect
Reference: Beck, C.T. and Polit, D.F (2005) Nursing Research Principles and Methods. 7th Edition. Page 30-31
79. The nurse is caring for a group of postpartum clients. Who among the following clients the nurse should
observe most closely?
a. Primipara who has had an 8-pound baby
b. Grand multipara whpo experienced a labor of only one hour
c. Primipara who received 100 mg Demerol during her labor
d. Multipara whose placenta separated and who delivered in 10 minutes
ANSWER: B
Multiple parity contributes to an increased incidence of uterine atomy because the uterine muscle may not be
contract effectively, thus leading to postpartal hemorrhage; a one-hour labor in a grand multipara is not
uncommon
Option A – a primiparas should maintain a well-contracted uterus because with only one pregnancy the uterus
usually maintains its tone
Option C – 100 mg of Demerol is not considered excessive for a primiparas and would not contribute to uterine
atony
Option D – the birth of the placenta 10 minutes after birth of the fetus is normal and would not affect tone of the
uterus; multiparity contributes to uterine atony, so the woman who is a grand multipara is at higher risk for
hemorrhage
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition. Page 656- 657.
80. On the first postpartum day, the primiparous client complains of perineal pain that is unrelieved by ibuprofen
800 mg given 2 hours ago. The nurse would assess for:
a. Puerperal infection
b. Vaginal lacerations
c. History of drug abuse
d. Perineal hematoma
ANSWER: D
If the client continues to complain of perineal pain after an analgesic medication has been given, the nurse should
inspect the client’s perineum for a hematoma, because this is the usual cause of such discomfort. Ibuprofen is a
nonsteroidal anti-inflammatory medication used to relieve mild pain. Pain from a perinela hematoma can be
moderate to sever possibly requiring a stronger analgesic such as Acetaminophen with codeine (Tylenol with
codeine). Ice is applied to the perineum during the first 24 hours postpartum may decrease the severity of
hematoma formation. Application of warm heat, such as a sitz bath three times a daily for 20 minutes, also can
help to relieve the discomfort when implemented after the first 24 hours. Typically hematomas resolve
themselves within 6 week
Option A – a puerperal infection would be indicated if the client’s temperature were 100.4 degree F or higher.
Also, lochia most likely would be foul smelling
Option B – a continuous trickle of lochia rubra would suggest a possible vaginal lacerations
Option C – no evidence is presented to suggest a history of drug abuse
SITUATION: Nurse Belo is an advance beginner pediatric nurse in the neonatal care unit. She routinely assesses
all the newborns in the area; provide them necessary care and reports unusual symptoms. The following
questions refer to newborn care.
81. Approximately 90 minutes after birth, nurse Belo encourages Katrina, the mother of baby Hayden, to do
a. Feed the neonate
c. Get to know the neonate
b. Allow the neonate to sleep
d. Change the neonate’s diaper
ANSWER: B
As part of the neonate’s physiologic adaptation to birth, at 90 minutes after birth the neonate typically is in the
rest or sleep phase. During this time, the heart and respiratory rates slow and the neonate sleeps, unresponsive
to stimuli. At this time, the mother should rest and allow the neonate to sleep.
Option A - Feedings should be given during the first period of reactivity, considered the first 30 minutes after
birth. During this period, the neonate’s respirations and heart rate are elevated
Option C – getting to know the neonate typically occurs within the first hour after birth and then when the
neonate is awake and during feedings
Option D – changing the neonate’s diaper can occur at nay time, but at 90 minutes after birth the neonate is
usually in a deep sleep, unresponsive and probably hasn’t passed any meconium
82. Baby Maricar who was delivered at 30 weeks gestation and weighed 2,000g is admitted to the neonatal
intensive care unit. What nursing measure will decrease insensible water loss in a neonate?
a. Bathing the baby as soon after birth as possible
c. Use of humidity in the incubator
b. Use of eye patches with phototherapy
d. Use of a radiant warmer
ANSWER: C
Adding humidity to the incubator adds moisture to the ambient air, which helps to decrease the insensible water
loss.
Option A and B – bathing and the use of eye patches has no impact on insensible water loss
Option D – the use of radiant warmer will increase the insensible water loss by drawing moisture out of the skin
83. Nurse Belo is teaching Katrina about the neonate’s need for sensory and visual stimulation. Nurse Belo knows
that the most highly developed sense in the neonate would be:
a. Taste
b. Hearing
c. Touch
d. Vision
ANSWER: C
The sense of touch is believed to be the most highly developed sense at birth. It is probably for this reason that
neonates respond well to touch.
Auditory sense typically is relatively immature in the neonate, as evidenced by the neonate’s selective response
to the human voice. By 4 months, the neonate shoud turn his eyes and head toward a sound coming from
behind.
Visual sense tends to be relatively immature. At birth visual acuity is estimated at approximately 20/100 to
20/150, but it improves rapidly during infancy and Toddlerhood.
Taste is well developed with a preference toward glucose; however, touch is more developed at birth
SITUATION: Lea, who is primipara has given birth to twins via CS with no underlying complications. After 2
days of stay in the hospital she noted to be recovering positively thus the doctor ordered for her discharge. You
as her nurse conducted a discharge teaching for this new mother.
84. While cuddling her first infant during feeding, Lea noticed a reddish rash consist of sporadic pinpoint papules
to her child Leo. She begun to worry, and immediately phone you (the nurse). As the nurse what would you tell
Mrs. Alwina to do?
a. Ask the mother to come to the clinic immediately because this might indicate eosinophils reacting to the
environment.
b. Instruct the mother to apply a cold compress to the rashes to minimize its erythema.
c. Document the finding and tell the mother that it is normal.
d. Instruct the mother to lance the lesion so that they will drain.
ANSWER: C
The newborn’s rash is caused erythema toxicum which is most normal in mature infants. This usually appears in
the first to fourth day of life but may appear up to 2 weeks of age. It is sometimes called a flea- bite rash
because the lesions are so minuscule. One of the chief characteristics of the rash is its lack of pattern.
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition Page 693.
85. Cesar the father of the twins on the other hand, noticed a small, whitish, pinpoint spots over the nose of their
son Leon. You as the nurse know that these are caused by retained sebaceous secretions. You correctly identify
these as:
a. Milia
b. Lanugo
c. White heads
d. Mongolian spots
ANSWER: A
Lanugo is a fine, downy hair that covers a newborn’s shoulders, back and upper arms, maybe found also on the
fore head and ears. Mongolian Spots are collection of pigment cells (melanocytes) that appear as slate-gray
patches across the sacrum or buttocks and possibly on the arms and legs. White head are not normally seen in
newborns.
86. He asks you, what could be a necessary therapy for this whitish, pinpoint spots?
a. Ice packs to reduce inflammation
c. No therapy is necessary
b. Warm heat to increase circulation
d. Lancing the lesions so they drain
ANSWER: C
Milia are immature sebaceous glands which will open and drain without therapy. Though health teaching is
necessary to parents, they should avoid scratching or squeezing the papules to prevent secondary infections.
SITUATION: Republic Act 7600 advocates the practice of breastfeeding the infant, because it provides numerous
health benefits to both the mother and the infant. The following questions refer to appropriate and acceptable
breastfeeding practices?
87. A breastfeeding primiparous client with a midline episiotomy is prescribed with ibuprofen 200 mg orally. The
nurse instructs the client to take the medication during:
a. Before going to bed
c. Immediately after a feeding
b. Midway between feedings
d. When providing supplemental formula
ANSWER: C
Taking ibuprofen 200mg orally immediately after breast-feeding helps minimize the neonate’s exposure to the
drug because drugs are most highly concentrated in the body soon after they are taken. Most mothers breastfeed
on demand or every 2 to 3 hours, so the effects of the ibuprofen should be decrease by the next feeding session.
Option A – taking the medication before going to bed is inappropriate because, although the mother may go to
bed at a certain time, the neonate may wish to breast feed soon after the mother goes to bed.
Option B – if the mother takes the medication midway between feedings, then its peak action may occur midway
between feedings.
Option D – Breastmilk is sufficient for the neonate’s nutritional needs. Most breast-feeding mothers should not be
encouraged to provide supplemental feedings to the infant because this may result in nipple confusion
88. The nurse provides teaching to breast feeding mothers about diet and nutritional needs during lactation
period. Which of the following client statements indicates a need for further additional teaching?
a. “I need to increase my intake of vitamin D.”
c. “I need to get an extra 500 calories per day.”
b. “I should drink at least five glasses of fluid daily.”
d. “I need to make sure I have enough calcium in my diet.”
ANSWER: B
For the breast feeding client, drinking at least 8 to 10 glasses of fluid a day is recommended. Breast feeding
wpomen need an increased intake of vitamin D for calcium absorption. A breast-feeding mother requires an extra
500 calories a day above the recommended nonpregnancy intake to produce quality breast milk. Breast feeding
women need adequate calcium for blood clotting and strong bones and teeth
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition Page 739-740.
89. A breast feeding primiparous client asks the nurse how breast milk differs from cow’s milk. The nurse respond
correctly by saying that breast milk is higher in:
a. Fat
b. Iron
c. Sodium
d. Calcium
ANSWER: A
Breast milk has a higher fat content than cow’s milk. Thirty percent to 55% of the calories is breast milk are from
fat. Braestmilk contains less iron than cow’s milk does. However, the iron absorption from Breastmilk is greater in
the neonate than cow’s milk. Breastmilk contains less sodium and calcium than cow’s milk.
90. The nurse is performing an APGAR scoring on a newborn shortly after birth. The nurse notes the following:
heart rate greater that 100 bpm, the respiratory effort is irregular and the infant has a weak cry, muscle tone is
active and the newborn grimaces when suctioned by the bulb syringe and the skin color is pale. The nurse would
document which of the following scores for the newborn?
a. 5
b. 6
c. 7
d. 8
ANSWER: B
One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges
from 0 to 10. It uses five criteria to measure the infant’s adaptation.
Heart rate: absent, 0; less than 100, 1; greater than 100, 2.
Respiratory effort: absent, 0; slow or irregular weak cry, 1; good, crying lustily, 2.
Muscle tone: limp or hypotonic, 0; some extremity flexion, 1; active, moving, and well flexed, 2.
Irritability or reflexes (measured by bulb suctioning): no response, 0; grimace, 1; cough, sneeze, or vigorous cry,
2.
Color: cyanotic or pale, 0; acrocyanotic, cyanosis of extremities, 1; pink, 2.
91. Based on your answer in number 90, you know that the infant:
a. Is in serious danger
c. Is in good condition
b. May need clearing of the airway and supplementary oxygen
d. Needs resuscitation
ANSWER: B
The APGAR score of the infant in #1 is 6. For infants with an APGAR score of 4-6 this means that their condition
is guarded and the infant needs clearing of the airway and supplemental oxygen. Option a and d is true for scores
below 4 while option C refers to a score of 7-10.
92. When the head of the fetus is delivered, the nurse suctions the airway. The mouth is suctioned first before
the nose. The reason for this is:
a. Suctioning the mouth first prevents a gasp reflex and aspiration of the oral secretions
b. Suctioning the mouth first removes more infectious secretions
c. Suctioning the nose last allows the child to breathe through the mouth
d. Suctioning the nose last prevents the occlusion of the oral airway
ANSWER: A
Mucus should be suctioned from a newborn’s mouth by a bulb syringe as soon as the infant’s head is born. As
soon as the body is born, he or she should be held for w few seconds with the head slightly dependent for further
drainage of secretions. It is important that the mucus be removed from the mouth first before the nose to
prevent aspiration of secretions.
93. Nurse Amanda is about to administer Vitamin K to the newborn. She will administer it to which of the
following sites?
a. Gluteus maximus muscle
c. Gluteus medius muscle
b. Vastus lateralis muscle
d. Deltoid muscle
ANSWER: B
The vastus lateralis muscle is the largest and most developed muscle in the newborn.
94. Encouraging the parents to hold their infant following delivery is done due to which of the following reasons?
a. Holding the infant at this time decreases the chance that the mother may have postpartum depression
b. The presence of the neonate to the mother will stimulate the release of oxytocin
c. The neonate is usually stable right after birth and therefore it is safe to leave the baby with their parents
d. The neonate is in an alert state after birth and bonding can take place
ANSWER: D
The neonate is usually in an alert state immediately following birth then will sleep for several hours afterwards.
Parent-child bonding should be initiated during the most alert periods.
95. During assessment of the newborn, the nurse notes a wide and bulging fontanel. The nurse is aware that this
finding is indicative of:
a. Dehydration
b. Brain damage
c. Increased ICP
d. Fever
ANSWER: C
The presence of a bulging fontanel may indicate increased intracranial pressure as the fluid builds up in the brain.
Family. 4th ed.
96. The nurse observes that the newborn is born with one umbilical artery. The nurse should do which of the
following?
a. Document this as a normal finding
b. Check to see if the child has 2 umbilical veins
c. Release the cord clamp
d. Notify the physician as this may indicate other abnormalities
ANSWER: D
This is an abnormal finding and should be reported immediately to the physician.
Note: AVA – two arteries and one vein (expected finding)
Family. 4th ed.
97. A nurse is conducting a physical examination on a neonate. At which pulse point on a neonate would the
absence of a palpable pulse indicate a possible coarctation of the aorta?
a. Femoral
b. Brachial
c. Radial
d. Carotid
ANSWER: A
With coarctation of the aorta, the nurse should note bounding pulses and increased blood pressure in the upper
extremities, as well as decreased or absent pulses and lower blood pressure in the lower extremities. This is due
to the narrowing of the aortic arch.
98. The nurse is assessing baby Shiena who was delivered 24 hours ago. Which of the following is an expected
finding?
a. Sticky, blackish-green and odorless stool
c. Light yellow stool, sweet smelling
b. Green and loose stool
d. Bright yellow stool with noticeable odor
ANSWER: A
The first stool of the newborn is usually passed within the first 24 hours after birth. It consists of meconium
characterized by sticky, tar-like, blackish-greenish and odorless formed from the mucus, vernix, lanugo
hormones and carbohydrates that accumulated during the intrauterine life. A newborn who does not pass a
meconium stool by 24-48 hours after birth should be examined for the possibility of meconium ileus, imperforate
anus or bowel obstruction.
99. During the newborn screening test for PKU (Phenylketonuria), the nurse knows that:
a. The blood from the newborn must be collected from the brachial site
b. The infant should be placed on NPO prior to the test
c. Blood samples must be taken within 24 hours of age after receiving breast milk
d. Blood samples must be arterial
ANSWER: C
Blood sample must be taken after the infant has ingested protein either in breast milk or formula. Providing an
intake of phenylalanine, an essential amino acid found in milk before the test of PKU will be accurate.
100. Nurse Josie is assessing the newborn. Which of the following would indicate rectal patency in the newborn?
a. Auscultating the bowel sounds
c. Passage of meconium
b. Observing the anus
d. Inserting the middle finger
ANSWER: C
Passage of meconium can occur only if the anus is patent. If the newborn does not do so in the first 24 hours, the
nurse must suspect imperforate anus or meconium ileus. The nurse can check for anal patency by gently
inserting the tip of the little finger (gloved and lubricated). The nurse should also note the time after birth that
the infant passes meconium.
POSTPARTUM
SITUATION: The discomforts and pain that accompany labor and birth dominate a pregnant woman’s thoughts
throughout this extraneous process. Thus pharmacologic management is now offered to reduce and alleviate this
discomfort during the birthing process, commonly used is the administration of epidural anesthesia. The following
questions refer to nursing care of the postpartum women who had epidural anesthesia.
1. “The discomforts and pain that accompany labor and birth dominate a pregnant woman’s thoughts throughout
this extraneous process”. If you will conduct a study with this statement, which of the following will be your
independent variable?
a. Discomforts and pain
c. Labor and delivery
b. Pregnant woman’s thought
d. Discomforts and pain due labor and delivery
ANSWER: C
Independent variables are known to be the cause of a certain phenomenon, these variables can stand alone and
stimulates the dependent variable. In the situation, the process of labor and delivery causes the feeling of
discomforts and pain of a laboring woman.
Option A – is the dependent variable, the effects of labor and delivery
Option C – is the external variable that can vary depending upon the level of pain tolerance of each laboring
women
Option D – is incorrect
Reference: Beck, C.T. and Polit, D.F (2005) Nursing Research Principles and Methods. 7th Edition. Page 30-31
2. The nurse is caring for a group of postpartum clients. Who among the following clients the nurse should
observe most closely?
a. Primipara who has had an 8-pound baby
b. Grand multipara whpo experienced a labor of only one hour
c. Primipara who received 100 mg Demerol during her labor
d. Multipara whose placenta separated and who delivered in 10 minutes
ANSWER: B
Multiple parity contributes to an increased incidence of uterine atomy because the uterine muscle may not be
contract effectively, thus leading to postpartal hemorrhage; a one-hour labor in a grand multipara is not
uncommon
Option A – a primiparas should maintain a well-contracted uterus because with only one pregnancy the uterus
usually maintains its tone
Option C – 100 mg of Demerol is not considered excessive for a primiparas and would not contribute to uterine
atony
Option D – the birth of the placenta 10 minutes after birth of the fetus is normal and would not affect tone of the
uterus; multiparity contributes to uterine atony, so the woman who is a grand multipara is at higher risk for
hemorrhage
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition. Page 656- 657.
3. On the first postpartum day, the primiparous client complains of perineal pain that is unrelieved by ibuprofen
800 mg given 2 hours ago. The nurse would assess for:
a. Puerperal infection
b. Vaginal lacerations
c. History of drug abuse
d. Perineal hematoma
ANSWER: D
If the client continues to complain of perineal pain after an analgesic medication has been given, the nurse should
inspect the client’s perineum for a hematoma, because this is the usual cause of such discomfort. Ibuprofen is a
nonsteroidal anti-inflammatory medication used to relieve mild pain. Pain from a perinela hematoma can be
moderate to sever possibly requiring a stronger analgesic such as Acetaminophen with codeine (Tylenol with
codeine). Ice is applied to the perineum during the first 24 hours postpartum may decrease the severity of
hematoma formation. Application of warm heat, such as a sitz bath three times a daily for 20 minutes, also can
help to relieve the discomfort when implemented after the first 24 hours. Typically hematomas resolve
themselves within 6 week
Option A – a puerperal infection would be indicated if the client’s temperature were 100.4 degree F or higher.
Also, lochia most likely would be foul smelling
Option B – a continuous trickle of lochia rubra would suggest a possible vaginal lacerations
Option C – no evidence is presented to suggest a history of drug abuse
SITUATION: Nurse Belo is an advance beginner pediatric nurse in the neonatal care unit. She routinely assesses
all the newborns in the area; provide them necessary care and reports unusual symptoms. The following
questions refer to newborn care.
4. Approximately 90 minutes after birth, nurse Belo encourages Katrina, the mother of baby Hayden, to do which
of the following?
a. Feed the neonate
ANSWER: B
5. Baby Maricar who was delivered at 30 weeks gestation and weighed 2,000g is admitted to the neonatal
intensive care unit. What nursing measure will decrease insensible water loss in a neonate?
ANSWER: C
loss.
6. Nurse Belo is teaching Katrina about the neonate’s need for sensory and visual stimulation. Nurse Belo knows
that the most highly developed sense in the neonate would be:
a. Taste
b. Hearing
c. Touch
d. Vision
ANSWER: C
behind.
SITUATION: Lea, who is primipara has given birth to twins via CS with no underlying complications. After 2
days of stay in the hospital she noted to be recovering positively thus the doctor ordered for her discharge. You
as her nurse conducted a discharge teaching for this new mother.
7. While cuddling her first infant during feeding, Lea noticed a reddish rash consist of sporadic pinpoint papules
to her child Leo. She begun to worry, and immediately phone you (the nurse). As the nurse what would you tell
Mrs. Alwina to do?
a. Ask the mother to come to the clinic immediately because this might indicate eosinophils reacting to the environment.
b. Instruct the mother to apply a cold compress to the rashes to minimize its erythema.
c. Document the finding and tell the mother that it is normal.
d. Instruct the mother to lance the lesion so that they will drain.
ANSWER: C
8. Cesar the father of the twins on the other hand, noticed a small, whitish, pinpoint spots over the nose of their
son Leon. You as the nurse know that these are caused by retained sebaceous secretions. You correctly identify
these as:
a. Milia
b. Lanugo
c. White heads
d. Mongolian spots
ANSWER: A
Lanugo is a fine, downy hair that covers a newborn’s shoulders, back and upper arms, maybe found also on the
fore head and ears. Mongolian Spots are collection of pigment cells (melanocytes) that appear as slate-gray
patches across the sacrum or buttocks and possibly on the arms and legs. White head are not normally seen in
newborns.
9. He asks you, what could be a necessary therapy for this whitish, pinpoint spots?
a. Ice packs to reduce inflammation
c. No therapy is necessary
b. Warm heat to increase circulation
d. Lancing the lesions so they drain
ANSWER: C
Milia are immature sebaceous glands which will open and drain without therapy. Though health teaching is
necessary to parents, they should avoid scratching or squeezing the papules to prevent secondary infections.
SITUATION: Republic Act 7600 advocates the practice of breastfeeding the infant, because it provides numerous
health benefits to both the mother and the infant. The following questions refer to appropriate and acceptable
breastfeeding practices?
10. A breastfeeding primiparous client with a midline episiotomy is prescribed with ibuprofen 200 mg orally. The
nurse instructs the client to take the medication during:
a. Before going to bed
c. Immediately after a feeding
b. Midway between feedings
d. When providing supplemental formula
ANSWER: C
Taking ibuprofen 200mg orally immediately after breast-feeding helps minimize the neonate’s exposure to the
drug because drugs are most highly concentrated in the body soon after they are taken. Most mothers breastfeed
on demand or every 2 to 3 hours, so the effects of the ibuprofen should be decrease by the next feeding session.
Option A – taking the medication before going to bed is inappropriate because, although the mother may go to
bed at a certain time, the neonate may wish to breast feed soon after the mother goes to bed.
Option B – if the mother takes the medication midway between feedings, then its peak action may occur midway
between feedings.
Option D – Breastmilk is sufficient for the neonate’s nutritional needs. Most breast-feeding mothers should not be
encouraged to provide supplemental feedings to the infant because this may result in nipple confusion
11. The nurse provides teaching to breast feeding mothers about diet and nutritional needs during lactation
period. Which of the following client statements indicates a need for further additional teaching?
a. “I need to increase my intake of vitamin D.”
c. “I need to get an extra 500 calories per day.”
b. “I should drink at least five glasses of fluid daily.”
d. “I need to make sure I have enough calcium in my diet.”
ANSWER: B
For the breast feeding client, drinking at least 8 to 10 glasses of fluid a day is recommended. Breast feeding
wpomen need an increased intake of vitamin D for calcium absorption. A breast-feeding mother requires an extra
500 calories a day above the recommended nonpregnancy intake to produce quality breast milk. Breast feeding
women need adequate calcium for blood clotting and strong bones and teeth
12. A breast feeding primiparous client asks the nurse how breast milk differs from cow’s milk. The nurse respond
correctly by saying that breast milk is higher in:
a. Fat
b. Iron
c. Sodium
d. Calcium
ANSWER: A
Breast milk has a higher fat content than cow’s milk. Thirty percent to 55% of the calories is breast milk are from
fat. Braestmilk contains less iron than cow’s milk does. However, the iron absorption from Breastmilk is greater in
the neonate than cow’s milk. Breastmilk contains less sodium and calcium than cow’s milk.
13. The nurse is performing an APGAR scoring on a newborn shortly after birth. The nurse notes the following:
heart rate greater that 100 bpm, the respiratory effort is irregular and the infant has a weak cry, muscle tone is
active and the newborn grimaces when suctioned by the bulb syringe and the skin color is pale. The nurse would
document which of the following scores for the newborn?
a. 5
b. 6
c. 7
d. 8
ANSWER: B
from 0 to 10. It uses five criteria to measure the infant’s adaptation.
Heart rate: absent, 0; less than 100, 1; greater than 100, 2.
Respiratory effort: absent, 0; slow or irregular weak cry, 1; good, crying lustily, 2.
Muscle tone: limp or hypotonic, 0; some extremity flexion, 1; active, moving, and well flexed, 2.
Irritability or reflexes (measured by bulb suctioning): no response, 0; grimace, 1; cough, sneeze, or vigorous cry,
2.
Color: cyanotic or pale, 0; acrocyanotic, cyanosis of extremities, 1; pink, 2.
14. Based on your answer in number 1, you know that the infant:
a. Is in serious danger
c. Is in good condition
b. May need clearing of the airway and supplementary oxygen
d. Needs resuscitation
ANSWER: B
The APGAR score of the infant in #1 is 6. For infants with an APGAR score of 4-6 this means that their condition
is guarded and the infant needs clearing of the airway and supplemental oxygen. Option a and d is true for scores
below 4 while option C refers to a score of 7-10.
15. When the head of the fetus is delivered, the nurse suctions the airway. The mouth is suctioned first before
the nose. The reason for this is:
a. Suctioning the mouth first prevents a gasp reflex and aspiration of the oral secretions
b. Suctioning the mouth first removes more infectious secretions
c. Suctioning the nose last allows the child to breathe through the mouth
d. Suctioning the nose last prevents the occlusion of the oral airway
ANSWER: A
Mucus should be suctioned from a newborn’s mouth by a bulb syringe as soon as the infant’s head is born. As
soon as the body is born, he or she should be held for w few seconds with the head slightly dependent for further
drainage of secretions. It is important that the mucus be removed from the mouth first before the nose to
prevent aspiration of secretions.
16. Nurse Amanda is about to administer Vitamin K to the newborn. She will administer it to which of the
following sites?
a. Gluteus maximus muscle
b. Vastus lateralis muscle
c. Gluteus medius muscle
d. Deltoid muscle
ANSWER: B
The vastus lateralis muscle is the largest and most developed muscle in the newborn.
17. Encouraging the parents to hold their infant following delivery is done due to which of the following reasons?
a. Holding the infant at this time decreases the chance that the mother may have postpartum depression
b. The presence of the neonate to the mother will stimulate the release of oxytocin
c. The neonate is usually stable right after birth and therefore it is safe to leave the baby with their parents
d. The neonate is in an alert state after birth and bonding can take place
ANSWER: D
The neonate is usually in an alert state immediately following birth then will sleep for several hours afterwards.
Parent-child bonding should be initiated during the most alert periods.
18. During assessment of the newborn, the nurse notes a wide and bulging fontanel. The nurse is aware that this
finding is indicative of:
a. Dehydration
b. Brain damage
c. Increased ICP
d. Fever
ANSWER: C
The presence of a bulging fontanel may indicate increased intracranial pressure as the fluid builds up in the brain.
Family. 4th ed.
19. The nurse observes that the newborn is born with one umbilical artery. The nurse should do which of the
following?
a. Document this as a normal finding
c. Release the cord clamp
b. Check to see if the child has 2 umbilical veins
d. Notify the physician as this may indicate other abnormalities
ANSWER: D
This is an abnormal finding and should be reported immediately to the physician.
Note: AVA – two arteries and one vein (expected finding)
Family. 4th ed.
20. A nurse is conducting a physical examination on a neonate. At which pulse point on a neonate would the
absence of a palpable pulse indicate a possible coarctation of the aorta?
a. Femoral
b. Brachial
c. Radial
d. Carotid
ANSWER: A
With coarctation of the aorta, the nurse should note bounding pulses and increased blood pressure in the upper
extremities, as well as decreased or absent pulses and lower blood pressure in the lower extremities. This is due
to the narrowing of the aortic arch.
21. The nurse is assessing baby Shiena who was delivered 24 hours ago. Which of the following is an expected
finding?
a. Sticky, blackish-green and odorless stool
c. Light yellow stool, sweet smelling
b. Green and loose stool
d. Bright yellow stool with noticeable odor
ANSWER: A
The first stool of the newborn is usually passed within the first 24 hours after birth. It consists of meconium
characterized by sticky, tar-like, blackish-greenish and odorless formed from the mucus, vernix, lanugo
hormones and carbohydrates that accumulated during the intrauterine life. A newborn who does not pass a
meconium stool by 24-48 hours after birth should be examined for the possibility of meconium ileus, imperforate
anus or bowel obstruction.
22. During the newborn screening test for PKU (Phenylketonuria), the nurse knows that:
a. The blood from the newborn must be collected from the brachial site
b. The infant should be placed on NPO prior to the test
c. Blood samples must be taken within 24 hours of age after receiving breast milk
d. Blood samples must be arterial
ANSWER: C
Blood sample must be taken after the infant has ingested protein either in breast milk or formula. Providing an
intake of phenylalanine, an essential amino acid found in milk before the test of PKU will be accurate.
23. Nurse Josie is assessing the newborn. Which of the following would indicate rectal patency in the newborn?
a. Auscultating the bowel sounds
c. Passage of meconium
b. Observing the anus
d. Inserting the middle finger
ANSWER: C
Passage of meconium can occur only if the anus is patent. If the newborn does not do so in the first 24 hours, the
nurse must suspect imperforate anus or meconium ileus. The nurse can check for anal patency by gently
inserting the tip of the little finger (gloved and lubricated). The nurse should also note the time after birth that
the infant passes meconium.
24. The baby develops hyperbilirubinemia. Which of the following is the method used to treat hyperbilirubinemia
in the newborn?
a. Administration of stimulants
c. Keeping the infants in a warm and dark environment
b. Early feeding to speed up the passage of meconium
d. Gentle exercise to stop muscle breakdown
ANSWER: B
The mother should breastfeed frequently in the immediate birth period because colostrums is a natural laxative
and helps the passage of meconium and bile.
25. According to Rubin’s theory of maternal role adaptation, the pregnant woman undergoes which of the
following phases during puerperium?
a. Acceptance and maternal-fetal bonding
c. Personal, formal and informal
b. Anticipatory, formal and informal
d. Taking in, taking hold and letting go
ANSWER: D
Reva Rubin divided the puerperium into three separate phases: taking in, taking hold and letting go. In the
taking in phase, it is the time of reflection for a woman. During this period, the woman is largely passive. This
encompasses the first 2-3 days postpartum. In the second phase, the taking hold phase, the woman begins to
initiate actions after the time of passive independence. In the letting go phase, the woman finally redefines her
new role. This is extended and continues during the child’s growing years.
26. The nursing student is assigned to care for a postpartum client. The clinical instructor asks the student what
uterine involution is. Which response by the student nurse gives an accurate description of this process?
a. It refers to the gradual reversal of the uterine muscle into the abdominal cavity
b. It refers to the descent of the uterus into the pelvic cavity occurring at a rate of 3 cm daily
c. It is the progressive descent of the uterus into the pelvic cavity occurring at 1 cm/day
d. It refers to an inverted uterus which is beginning to return to normal
ANSWER: C
Involution is a progressive descent of the uterus into the pelvic cavity. After birth, descent occurs approximately
1 fingerbreadth or approximately 1 cm per day. The other options are incorrect.
27. Mrs. Dimaculangan delivered to a healthy baby boy a few hours ago. She asks the nurse how to decrease
breast engorgement. The nurse should tell Mrs. Dimaculangan to:
a. Apply warm compress followed by cold compress
b. Apply warm compress only
c. Apply cold compress only
d. Apply cold compress followed by warm compress
ANSWER: D
Cold compresses decrease edema then warm compresses stimulate the release of milk. If the breast is
edematous the release of milk is difficult.
Family. 4th ed.
28. A breast-feeding baby will turn his head toward the mother's breast in a natural instinct to find food. What is
the name of this reflex?
a. Tonic neck reflex
b. Moro's reflex
c. Grasp reflex
d. Rooting reflex
ANSWER: D
The rooting reflex is an infant's response to having his cheek stroked. The infant will turn his head to the side of
the stroked cheek and will open his mouth in anticipation of having a nipple placed in it. The tonic neck reflex is
elicited by turning the neonate's head to the side when he's lying on his back. The extremities on the same side
extend and those on the other side flex. Moro's reflex is the startle reflex. For example, when the neonate's crib
is jolted, the neonate abducts his arms and extends them. The grasp reflex occurs when the neonate curls his
fingers around another person's fingers.
Family. 4th ed.
29. Mrs. Rivera delivered a 6.5 lbs baby girl by vaginal delivery. She has a 2nd degree laceration in the perineum.
Which of the following nursing interventions should be the priority during the first 24 hours?
a. Double the peripads
c. Apply ice packs to the perineum
b. Warm Sitz bath
d. Apply antibiotic ointment to the laceration
ANSWER: C
Ice packs will prevent swelling. Preventing the swelling of the perineum will allow for faster healing time. This is
done in the first 24 hours. After the first 24 hours, this is no longer therapeutic. After this time, healing increases
best if circulation to the area is encouraged through the use of heat (e.g. Sitz bath)
30. During the postpartum period, the nurse should assess for signs of normal involution. Which statement would
indicate that the client is progressing normally?
a. The uterus is descending at the rate of one fingerbreadth per day.
b. Blood pressure drops as a result of the birth and changed circulatory load.
c. Urine output remains about the same as in the client's prenatal period.
d. Pad usage remains at 10 to 15 per day.
ANSWER: A
During the normal involutional process, the uterus will descend approximately one fingerbreadth per day. Blood
pressure doesn't change during the postpartum period. Urine output typically increases after delivery. Usually,
the client will need six to seven perineal pads per day at this time.
Family. 4th ed.
SITUATION: The nurse should maintain close observation of the mother and infant in the postpartum period.
31. The client delivered a viable infant yesterday. The nurse assesses the fundus and the character of the lochia.
The nurse would note the lochia to be:
a. Red colored
b. Brown colored
c. Pink colored
d. White colored
ANSWER: A
When checking the perineum, the lochia is monitored for amount, color, and the presence of clots.
(Note: Lochia rubra (red) 1-3 days postpartum, Lochia serosa (pink) 3-10 days postpartum, lochia alba (white)
10-14 days post partum)
Family. 4th ed. 603
32. By the second day postpartum, where on the client’s abdomen would the nurse expect to palpate a woman’s
fundus?
a. 1 cm below the umbilicus
c. 2 inches below the umbilicus
b. 2 cm below the umbilicus
d. Cannot be detected my abdominal palpation
ANSWER: B
By the second day postpartum, the woman’s fundus is typically 2 fingerbreadths or 2 cm below the umbilicus. It
cannot already be detected by abdominal palpation during the ninth or tenth day postpartum.
Family. 4th ed. 603
33. The nurse is teaching the postpartum client about the sitz bath. The nurse tells the client that sitz baths are
prescribed to:
a. Cleanse the perineum and prevent hemorrhoids
c. Reduce infection and stimulate peristalsis
b. Reduce edema and numb the tissue
d. Promote healing and provide comfort
ANSWER: D
Warm, moist heat is employed after the first 24 hours following a vaginal birth to provide comfort, promote
healing, and reduce the incidence of infection. Ice is used the first 24 hours to reduce the edema and numb the
tissue. Stimulation of peristalsis is better achieved by ambulation. A sitz bath may provide comfort for
hemorrhoids but does not prevent them.
Family. 4th ed. 612
34. The nurse should teach the lactating postpartum client to do which of the following?
a. Limit intake of water a day to prevent breast engorgement
b. Resume pre-pregnancy diet
c. Increase caloric intake by 500 calories/day
d. Continue folate and iron supplements at the same level during the pregnancy
ANSWER: C
Lactating women will require at least 500 additional calories above that consumed during pregnancy to ensure an
adequate milk supply. Women are encouraged to increase their normal fluid intake (6 to 8 eight ounce glasses
per day). Folate and iron requirements are lower than during pregnancy.
Family. 4th ed.
35. After delivering the neonate, the nurse performs the initial assessment and determines that the neonate’s
APGAR score is 9. This indicates that:
a. The infant is adjusting well to extra-uterine life
b. The infant is having difficulty adjusting to extra-uterine life
c. The infant requires some resuscitative intervention
d. The infant requires vigorous resuscitation
ANSWER: A
from 0 to 10. A score of 8 to 10 indicates that the infant is adjusting well to extrauterine life. A score of 5 to 7
often indicates an infant who requires some resuscitative intervention. Scores of less than 5 indicate infants who
are having difficulty adjusting to extrauterine life and require vigorous resuscitation.
Scores of less than 4 require vigorous resuscitation. A score of 4-6 requires some resuscitative intervention,
clearing of the airway and supplementary oxygen. Scores 7-10 indicate that an infant is adjusting well to extrauterine life.
Family. 4th ed 649
36. The mother asks the nurse how much weight will her newborn lose during the first few days of life. The nurse
is correct in saying that:
a. “The newborn normally loses about 5-10% of birth weight during the first few days after birth”
b. “The newborn normally loses about 15-20% of birth weight during the first few days after birth”
c. “The newborn normally loses about 20-30% of birth weight during the first few days after birth”
d. “There is no weight loss in the newborn”
ANSWER: A
The newborn loses 5 – 10% of birth weight during the first few days after birth. This weight loss occurs because
the newborn is no longer under the influence of salt and fluid retaining maternal hormones. A newborn also voids
and passes stool. After this initial loss of weight, the newborn has 1 day of stable weight. The breastfed newborn
recaptures birth weight within 10 days; a formula-fed infant accomplishes this gain within 7 days. After this, the
newborn will begin to gain about 2lbs/month for the first 6 months of life.
Family. 4th ed. 631
37. The neonate born at 36 weeks gestation is described as:
a. Small for gestational age
b. Preterm infant
c. Term infant
d. Post term infant
ANSWER: B
A neonate born before the end of 37 weeks' gestation is considered preterm, regardless of weight. The small for
gestational age neonate is designated by a weight that is below the 10th percentile or is two standard deviations
below normal. A term newborn is older than 37 weeks, born between the beginning of week 38 and the end of
week 41. A post-term newborn is born at week 42 or after.
Family. 4th ed
38. The nurse is performing assessment on a post-term infant. The nurse expects to note which of the following?
a. Lanugo covering the entire body
c. Smooth soles without creases
b. Peeling of the skin
d. Vernix that covers the body in a thick layer
ANSWER: B
The post-term infant (born after the 42nd week of gestation) exhibits dry, peeling, cracked, almost leather-like
skin over the body, which is called desquamation. The preterm infant (born between 24 to 37 weeks of gestation)
exhibits thick vernix covering the body, smooth soles without creases, and lanugo covering the entire body.
Family. 4th ed
39. The nurse is preparing to administer Vitamin K to the newborn. When administering the injection, the nurse
would select which site?
a. The gluteal muscle
b. The lower aspect of the rectus femoris muscle
c. The lateral aspect of the middle third of the vastus lateralis muscle
The medial aspect of the upper third of the deltoid muscle
ANSWER: C
The preferred injection site for vitamin K in the newborn is the lateral aspect of the middle third of the vastus
lateralis muscle in the newborn’s thigh. This muscle is the preferred injection site because it is free of major
blood vessels and nerves and is large enough to absorb the medication.
Family. 4th ed. 662
40. The mother asks the nurse what is the purpose of administering Vitamin K injection to her newborn. The
most appropriate response of the nurse is:
a. The newborn has acquired infections during transit in the birth canal and requires Vitamin K
b. The newborn has a small liver and unable to produce Vitamin K
c. The newborn’s GI tract is sterile and unable to produce Vitamin K
d. The newborn has small blood vessels
ANSWER: C
The absence of normal flora needed to synthesize vitamin K in the normal newborn gut results in low levels of
vitamin K and creates a transient blood coagulation deficiency between the second and fifth day of life. From a
low point at about 2 to 3 days after birth, these coagulation factors rise slowly, but do not approach normal adult
levels until 9 months of age or later. Increasing levels of these vitamin K–dependent factors indicate a response
to dietary intake and bacterial colonization of the intestines. An injection of vitamin K (Aqua-MEPHYTON) is
administered prophylactically on the day of birth to combat the deficiency. It is used for the prophylaxis and
treatment of hemorrhagic disease in the newborn. It is a necessary component for the production of certain
coagulation factors produced by microorganisms in the intestinal tract. The other options are incorrect.
Family. 4th ed. 662
41. After the delivery, assessment and initial care of the neonate, the nurse allows ample bonding time with the
mother before administering the eye ointment to the newborn. The nurse takes this action in order to:
a. Promote maternal awareness of health promotion issues with her child
b. Protect the infant from external environmental stimuli acting on the eye
c. Prevent Neisseria gonorrheae infections acquired during the birth process
d. Allow maternal-child interaction before the instillation of drops that may temporarily diminish the infant’s
vision and attention span
ANSWER: D
Administration of eye drops may irritate the infant’s eyes, cause discomfort, and interrupt the quality of the initial
bonding interaction. Postponing the administration of the drops until after the initial maternal-child interaction
occurs will promote the bonding process.
Family. 4th ed. 660
42. The nurse prepares to administer ophthalmic ointment (Erythromycin) to the neonate after delivery. The
nurse understand that this ointment:
a. Must be administered at room temperature to prevent side effects
b. Is effective in protecting the newborn from Chlamydia trachomatis and Neisseria gonorrheae
c. Is staining to the infant’s skin and must be wiped off immediately
d. Is irritating to the eyes of the neonate
ANSWER: B
Erythromycin is effective in protecting the newborn from against both Neisseria gonorrhea and Chlamydia
trachomatis. It does not stain, and may be administered at any safe temperature.
Family. 4th ed. 660
43. Nurse Mandy is checking the reflexes of the neonate. In eliciting the Moro reflex, Nurse Mandy would perform
a. Clap the hands
c. Stimulate the pads of the hands by firm pressure
b. Stimulate the ball of the foot by firm pressure
d. Stimulate the sides of the mouth with a finger
ANSWER: A
The Moro reflex is elicited by startling the infant with a loud noise, such as a hand clap or a slap on the mattress.
The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and
adduction of the limbs. Their fingers assume a typical “C” position. This reflex disappears at age 4-5 months. The
rooting reflex is elicited by stimulating the sides of the mouth or perioral area with the finger. The palmar grasp
reflex is elicited by stimulating the palm of the hand by firm pressure, and the plantar grasp reflex is elicited by
stimulating the ball of the foot by firm pressure.
Family. 4th ed.637
44. The nurse is caring for Baby Matilda, a post-term infant whose serum bilirubin level is 14 mg/dL at 10 hours
of age. Based on this results, the nurse determines this to be indicative of:
a. Pathologic jaundice
c. Breast milk jaundice
b. Physiologic jaundice
d. True breast milk jaundice
ANSWER: A
Total bilirubin levels in a term infant that rise above 12 mg/dL in less than 24 hours after birth is considered
pathologic. Pathologic jaundice is of concern because of its association with kernicterus. Physiologic jaundice is
usually occurs on the second or third day of life as a result of the breakdown of fetal red blood cells. Breast milk
jaundice is usually associated with insufficient intake due to a sleepy infant, one who has a poor suck reflex, or is
nursing on an infrequent schedule. This prevents the infant from receiving enough colostrum, which acts like a
natural laxative, thus facilitating the passage of meconium stools that contain high levels of bilirubin. The cause
of true breast milk jaundice is different from inadequate intake. The exact cause is not known but seems to be
the combination of several factors that cause the bilirubin level to rise.
Family. 4th ed.640
45. The nurse is caring for an infant with physiologic jaundice. The nurse assesses one of the symptoms
associated with this condition by:
a. The lack of lanugo in the infant
c. Looking for the presence of cephalhematoma
b. Evaluating the infant’s urine output
d. Performing a guaiac test on the infant’s meconium stool
ANSWER: C
The principal source of bilirubin is the hemolysis of erythrocytes. A cephalhematoma contains a large number of
erythrocytes. As the red blood cells break down in the bruised area, they add to the bilirubin load. All meconium
stools will be guaiac positive because meconium contains old red blood cells. Evaluating the urine output will not
be significant unless there is a suspicion that the jaundice is related to inadequate intake, which is primarily
associated with breast milk jaundice. Option a is irrelevant.
Family. 4th ed.640
46. Nurse Cora is evaluating the mother-infant bonding process during the postpartum period. An indication of
maladaptive interaction would be:
a. The mother talks to the baby
b. The mother tells the nurse to feed the baby because she is too tired
c. The mother expressed discomfort with the role of mother hood
d. The mother showed that she was willing to care for the umbilical cord
ANSWER: B
An indication of a maladaptive interaction is refusal to interact with or care for the infant. Options a and d identify
situations in which the mother plans to or is demonstrating interaction with the infant. Expressing discomfort with
the role of motherhood is not maladaptive.
Family. 4th ed.
47. The postpartum mother who wishes to breastfeed tells that nurse that her breasts are swelling and is
engorged. The nurse should teach the client that an effective method for relieving engorgement is:
a. Apply warm packs 20 minutes before breastfeeding
b. Wearing firm fitting bras make the breasts more engorged
c. Avoiding massage to begin milk flow
d. Taking an anti-inflammatory drug to reduce the inflammation
ANSWER: A
On the 3rd or 4th day when breast milk forms, some women may notice breast distention with swelling, hardness,
tenderness and perhaps heat in their breasts. This is called primary engorgement and is caused by vascular and
lymphatic congestion arising from an increases in blood and lymph supply to the breasts. Some mothers find that
warm packs applied for about 20 minutes before feeding gives the most relief. In addition, a good-fitting bra
prevents a pulling, heavy feeling. Warm packs applied to both breaths can be combined with a massage to begin
milk flow. Manual expression of the use of a breast pump can to complete emptying of the breast after the baby
has nursed can help maintain and promote a good milk supply during the period of engorgement. Reference:
Pilliterri, A.(2003) Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family. 4th
ed.683
48. Immunity transferred to the fetus from an immune mother through the placenta is:
a. Active natural immunity
c. Passive natural immunity
b. Active artificial immunity
d. Passive artificial immunity
ANSWER: C
C – The immunity is that which has developed from an antigen-antibody response in the mother and is passed to
the fetus.
A – Acquired by an individual in response to a disease or an infection.
B – Acquired by an individual in response to small amounts of antigenic material (e.g., vaccination).
D – Conferred by the injection of antibodies already prepared in another host.
p.754
SITUATION: Postpartum care begins immediately after childbirth. During this time, the nurse assists the new
mother in learning how to care for herself and her baby.
49. While caring for a new mother on her second day postpartum, you notice that she handles her newborn
tentatively, not kissing her child during the time she holds him. Which of the following would you suspect as the
probable reason for this?
a. She is disappointed in the child's sex.
c. She is reacting normally to accepting a new child.
b. She has difficulty accepting her role change.
d. Her cultural customs do not include kissing children.
ANSWER: C
Many new mothers approach a newborn tentatively, so this is typical behavior for a second postpartum day.
Reference: A. Pillitteri. Maternal And Child Health Nursing 5th edition
50. Which of the following actions would most make you believe that a postpartum woman is accepting a child
well?
a. She states she has named the child after a well-loved friend.
b. She turns her face to meet the infant's eyes when she holds her.
c. She comments that her baby has the most hair of any in the nursery.
d. She asks you to use her camera to take a photo of the child.
ANSWER: B
An “enface” position is a mark of a woman who is interacting warmly with a newborn.
51. Nurse Hannah would expect a postpartum client’s uterine and vaginal discharge on the 4th postpartum day to
be lochia:
a. Absent
b. Alba
c. Rubra
d. Serosa
ANSWER: D
Lochia, the uterine or vaginal discharge after delivery, is initially bright red, then changes to pink or pinkish
brown, and finally becomes a yellowish-white color. It has a musty odor, but should not have a foul odor. Foul
odor may be a sign of infection. Lochia rubra lasts 3 days and is mostly blood that is bright red. Lochia serosa
begins at approximately 4 days and is a pink to pinkish-brown color. After 10 days, lochia alba begins, and the
discharge becomes a yellowish-white color and may last 6 weeks.
52. A postpartum client has a midline episiotomy and states there is a great deal of discomfort whenever she
moves. To decrease the discomfort, the nurse should instruct the client to:
a. Ask for medication as needed
b. Sit on a large pillow at all times
c. Walk around frequently to restore circulation
d. Tighten the buttocks and perineum before sitting and relax the area once seated
ANSWER: D
Assess the episiotomy for redness, ecchymosis, edema, discharge, and approximation of suture line. Encourage
client to tighten the buttocks and perineum before sitting, and once seated, relax the area to decrease the stress
placed on the incision line.
53. A postpartum client who is breastfeeding asks the nurse when her menstrual period will return. Which of
these responses should the nurse make?
a. “It will largely depend on your breastfeeding pattern.”
b. “It will occur within 3 months after the birth.”
c. “It usually returns by 120 days postpartum.”
d. “It usually takes place between 27 days and 2 months after birth.”
ANSWER: A
Ovulation in women who are breastfeeding usually returns by 190 days postpartum, but largely depends on the
breastfeeding pattern.
54. A client who is breastfeeding experiences engorgement on the 4th postpartum day. The nurse should explain
to the client that engorgement is the result of:
a. A blocked milk duct
b. Milk stasis that has resulted in inflammation of the breast
c. The breasts beginning to fill with colostrum
d. Vasocongestion of breast tissues as milk production begins
ANSWER: D
Engorgement of the breasts occurs at day 3 or 4. If the breasts are not emptied, the engorgement will
spontaneously disappear and discomfort will decrease in 24 to 48 hours. This is a result of vasocongestion of
breast tissues as milk production begins or “let down” occurs.
55. A postpartal woman asks you about perineal care. Which of the following recommendations would you give?
a. Avoid using soap in her perineal care.
c. Use an alcohol wipe to wash her suture line.
b. Wash her perineum with her daily shower.
d. Refrain from washing lochia from the suture line.
ANSWER: B
A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a
shower will help to do this.
56. Minet has not yet voided 4 hours since vaginal delivery. Feeling has returned to her perineal area and she
had ambulated to the bathroom to attempt to void twice. Nurse Perla palpated the uterus and it is 3
fingerbreadths above the umbilicus, deviated to the right and firm only when massage. What would be the
priority nursing action?
a. Evaluate the client with a bladder scan
b. Insert a Foley catheter
c. Medicate the client with NSAIDs
d. Massage until it is firm and perform a one-time catheterization on the client
ANSWER: D
Uterine massage enables immediate contraction of the uterus to prevent bleeding. In and out catheterization
relieves bladder distention, eliminates displacement, firms the uterus and prevents uterine bleeding.
Option A – a bladder scan is not necessary because the nurse is able palpate the full bladder and the mere
position of the uterus indicates a full bladder
Option B – an indwelling urinary catheter is not necessary because most clients spontaneously void within 12
hours.
Option C – the use of NSAID will help reduce the inflammation that may be present but its action is not
immediate and the status of the client’s fundus warrants more immediate interventions because of the risk of
postpartum hemorrhage associated with a full bladder
SITUATION: Nurse Tekla is caring for Mrs. Tikoy following cesarean birth.
57. Which of the following would be the most important assessment to make?
a. Whether her abdomen is soft or not.
c. If her breasts fill by the third day.
b. Whether her perineum is edematous.
d. If she wants to breast-feed or not.
ANSWER: A
A tense, “guarded” abdomen is one of the first signs of peritonitis.
58. On the second day postpartum following a cesarean birth, at which of the following locations would Nurse
Tekla expect to palpate Mrs. Tikoy’s fundus?
a. Two fingers above the umbilicus.
c. Two fingers below the umbilicus.
b. At the umbilicus.
d. Four fingers below the umbilicus.
ANSWER: C
Following a cesarean birth, uterine contraction and return to prepregnant state occur at the same rate as after a
vaginal birth.
59. Mrs. Tikoy asks Nurse Tekla if she will have any difficulty breast-feeding following a cesarean birth. Her best
response would be that:
a. You do not recommend she try to breast-feed following a cesarean birth.
b. Although she can try, it is hard to find a comfortable position to hold a newborn to breast-feed.
c. She will need too much analgesia postoperatively to make breast-feeding safe.
d. You will help her find a comfortable position for breast-feeding her infant.
ANSWER: D
Most women can breast-feed satisfactorily following cesarean birth.
60. To prevent thrombophlebitis following a cesarean birth, which of the following would be most important to
implement?
a. Urge Mrs. Tikoy to cough and take deep breaths.
b. Encourage Mrs. Tikoy to ambulate.
c. Urge Mrs. Tikoy not to dislodge the IV fluid line.
d. Instruct Mrs. Tikoy to press inward on her abdomen periodically.
ANSWER: B
Ambulation increases circulatory function, helping decrease blood clotting.
SITUATION: After ensuring that the neonate is physiologically stable, the infant’s nurse plays a pivotal role in
preserving and protecting this most special time by not intruding or allowing any interruptions as the new family
becomes acquainted.
61. Approximately 90 minutes after birth, Nurse Bimbi encourages Kris, the mother of baby James, to do which
of the following?
a. Feed the neonate
ANSWER: B
62. Baby Rica who was delivered at 30 weeks gestation and weighed 2,000g is admitted to the neonatal intensive
care unit. What nursing measure will decrease insensible water loss in a neonate?
ANSWER: C
loss.
63. Nurse Hannah is teaching a mother about the neonate’s need for sensory and visual stimulation. Nurse
Hannah knows that the most highly developed sense in the neonate would be:
a. Taste
b. Hearing
c. Touch
d. Vision
ANSWER: C
behind.
64. An infant admitted to the newborn nursery has generalized swelling of the scalp. The nurse should recognize
this condition as:
a. Caput succedaneum, which generally requires no treatment
b. Cephalhematoma, which will require aspiration of blood from the scalp
c. An early sign of hydrocephalus, which requires no treatment
d. An early sign of an intracranial hemorrhage
ANSWER: A
Caput succedaneum is edema of the newborn’s scalp, which may cross the suture lines. It is caused by
compression against the cervix. No treatment is needed.
65. When caring for a newborn several hours after birth, you assess his respiratory rate. In a normal newborn,
this would be:
a. 12 to 16 breaths/minute. b. 16 to 20 breaths/minute. c. 20 to 30 breaths/minute. d. 30 to 60 breaths/minute.
ANSWER: D
Newborns typically breathe more rapidly than adults or older children, at a rate of 30 to 60 breaths/minute.
66. In a term newborn, Nurse Isabel would expect to find which of the following patterns of sole creases?
a. Creases covering one fourth of the foot.
c. Creases on three fourths of the foot.
b. Longitudinal but no horizontal creases.
d. Heel but no anterior creases.
ANSWER: C
As an infant matures in utero, sole creases become prominent to a greater amount. The term infant has two
thirds of the foot covered by creases.
67. The nurse is about to instill the tetracycline eye ointment into the infant’s eye. How is this done?
a. Apply from the inner canthus to the outer canthus of each eye
b. Apply from the outer canthus to inner canthus of both eyes
c. Apply from the left to the right eye
d. Apply from the outer canthus of the left eye to the inner canthus of the right eye
ANSWER: A
The eye ointment should be applied from the inner to the outer canthus of each eye. This should not be
administered to the infant until after parents has had a chance to see their infant.
68. Nurse Belat uses the new Ballard score to estimate a newborn’s gestational age. Which of the following
characteristics would indicate that the infant is at 37 weeks’ gestational age?
a. A 30-degree square window of the wrist
c. Descended testes with few rugae present
b. Creases on two-thirds of the soles of the feet
d. A soft pinna that stays folded
ANSWER: B
The Ballard tool looks at external physical characteristics and neuromuscular maturity. During the first 12 hours
of life, plantar creases are reliable signs of gestational age. Creases cover two-thirds of the sole by 37 weeks and
cover the entire sole at 40 weeks’ gestation.
Reference: White. Foundations of Nursing 3rd edition
69. A newborn is noticeably jaundiced on the third day of life. Which of the following responses would be most
appropriate?
a. “He may have a blood incompatibility developing.”
c. “He will need an evaluation for bile duct disease.”
b. “This is from a normal breakdown of red blood cells.”
d. “No one understands why newborn jaundice occurs.”
ANSWER: B
Almost all newborns begin to break down the overload of red blood cells they formed in utero immediately after
birth. Jaundice from released bilirubin becomes apparent on the third day (physiologic jaundice).
70. While cuddling her first infant during feeding, Marian noticed a reddish rash consist of sporadic pinpoint
papules to her child Angel. She begun to worry, and immediately calls Nurse Karyl . Nurse Karyl would tell Mrs.
Marian to:
a. Come to the clinic immediately because this might indicate eosinophils reacting to the environment.
b. Apply a cold compress to the rashes to minimize its erythema.
c. Document the finding and tell her that it is normal.
d. Lance the lesion so that they will drain.
ANSWER: C
71. The nurse performing a newborn assessment in the admission nursery finds that the cord contains one vein
and two arteries. She should:
a. Check the delivery room record for their findings immediately after birth
c. Notify the pediatrician
b. Examine the infant for other anomalies
d. Record the findings as normal
ANSWER: D
This is a normal finding and needs to be documented. Option A: Because the finding is normal, there is only a
need to document the findings. Option B: Although the neonate will be assessed for anomalies, the vascular cord
finding is normal. Option C: This implies that the finding is abnormal, which is false.
72. To avoid heat loss by evaporation, the nurse should:
a. Avoid placing the baby on a cold, metal surface
c. Keep the baby away from drafts
b. Dry the baby immediately after delivery
d. Use antiseptic foam rather than washing hands
ANSWER: B
This action is the intervention to help prevent heat loss in the neonate from evaporation. Option A: Although this
will facilitate hypothermia, it is not because of heat loss from evaporation, but rather conduction. Option C:
Although this is appropriate, it prevents heat loss through convection. Option D: This action is not appropriate for
thermoregulation of the neonate.
73. Which order would you question in the newborn nursery?
a. Do not bathe infant if axillary temp. less than 97 degrees Fahrenheit.
b. Erythromycin ophthalmic ointment both eyes x 1.
c. Notify pediatrician for Dextrostix less than 35.
d. Vitamin K 1 mg IM upper outer quadrant of buttocks x 1.
ANSWER: D
The posterior gluteal intramuscular site should not be used until the child is at least a toddler who is walking. The
vastus lateralis muscle should be used. Option A: This is appropriate, because bathing a neonate with a body
temperature of 97 degrees would place the baby at risk for hypothermia secondary to evaporation. Option B: This
is the appropriate prophylaxis for ophthalmia neonatorum. Option C: This is appropriate, because the normal
neonatal glucose is 40 mg/dl to 80 mg/dL.
74. On the second day postpartum, Nurse Gina asks the new mother to describe her vaginal bleeding. What
description does Nurse Gina expect the client to say?
a. Red and moderate
b. Red with clots
c. Scant and brown
d. Thin and white
ANSWER: A
Lochia rubra is moderate red discharge and is present for the first 2-3 days postpartum. Lochia serosa is pinkish
brown, days 4-10, mostly serum, some blood, tissue debris. Lochia Alba is yellowish white, days 11-21 up to 6
weeks; mostly leukocytes, with deciduas, epithelial cells and mucus. Option B indicates hemorrhage and needs
further evaluation.
75. A woman delivers a 6.5 lbs baby boy. Which of the following statements would indicate to the nurse that the
mother has begun to integrate her new baby into the family?
a. “All this baby does is cry. He’s not like my other child”
c. “My parents wanted a granddaughter”
b. “I wish he had curly hair like my husband”
d. “When he yawns, he looks just like his brother”
ANSWER: D
Family identification of the newborn is an important part of attachment. The first step in identification is defined
in terms of likeness to family members. Other options are incorrect.
76. A diabetic woman plans to breatfeed her baby. Because the woman is hyperglycemic, what explanation will
the nurse give?
a. The glucose content of her breast milk may be high
c. Her baby will receive insulin in the milk
b. The production of milk may be impaired
d. Her baby will not grow well
ANSWER: A
Glucose can be transferred from the serum to the breast, and hyperglycemia may be reflected in the breast milk.
Reference: Rebecca Caldwell Oglesby. NSNA 6th edition
77. What complaint would be a common occurrence for a woman after delivery of her third child?
a. Chest pain
b. Afterbirth cramps
c. Burning on urination
d. Chills
ANSWER: B
Afterbirth cramps are most common in nursing mothers and multiparas. This mother is both. The release of
oxytocin from the posterior pituitary for the “let-down” reflex of lactation causes the afterbirth cramping of the
uterus.
78. To prevent cracked nipples while she is breastfeeding, what should the mother be taught?
a. Apply a soothing cream prior to feeding
c. Use plastic bra liners
b. Nurse at least 20 minutes on each breast each feeding
d. Wash the nipples with water only
ANSWER: D
Nipples should be washed with water only (no soap) to prevent drying. Do not use soap on nipples or areola.
Expose the nipples to air to toughen them. Option A is not correct. Options B and C: Does not help in preventing
cracked nipples.
79. Which of the following observations in the postpartum period would be of most concern to the nurse?
a. After delivery, the mother touches the newborn with her fingertips
b. The new parents asked the nurse to recommend a good baby care book
c. A new father holds his son in the en face position while visiting
d. A new mother sits in bed while her newborn lies awake in the crib
ANSWER: D
During the early postpartum period, evidence of maladaptive mothering may include limited handling or smiling
at the infant; studies have shown that a predictable group of reciprocal interactions between mother and baby
should take place with each encounter to foster and reinforce attachment.
80. A woman had a normal vaginal delivery 12 hours ago and is to be discharged from the hospital. Which
statement by the client demonstrates understanding about the teaching related to the episiotomy and perineal
area?
a. “I know the stitches will be removed at my postpartum clinic visit”
b. “The ice pack should be removed for 10 minutes before replacing it”
c. “The anesthetic spray, then the heat lamp, will help a lot”
d. “The water for Sitz bath should be warm about 45-47 degrees C”
ANSWER: B
To attain maximum effect of reducing edema and providing numbness of the tissues, the ice pack should remain
in place approximately 20 minutes and then removed or about 10 minutes before replacing it. Option A: Stitches
are absorbable and does not need to be removed in the clinic. Option C: Heat lamp is only indicated few hours
after delivery and anesthetic spray is not indicated. Option D: The temperature is too hot, the woman may
experience burn. Temperature should be 38-41 deg C.
81. A woman delivered her baby 12 hours ago. During the postpartum assessment, the uterus is found to be
boggy with a heavy lochia flow. What should be the initial action of the nurse?
a. Notify the physician
c. Encourage the woman to increase ambulation
b. Administer prn oxytocin
d. Massage the uterus until firm
ANSWER: D
A soft, boggy uterus should be massaged until firm; clots may be expressed during massage and this often tends
to contract the uterus more effectively. If the uterus cannot remain contracted, the physician will order a dilute
IV pitocin to help the uterus maintain tone.
82. A mother who had a vaginal delivery of her first baby 6 weeks ago is seen for her postpartum visit. She is
feeling well and is bottle-feeding her infant successfully. During the physical assessment, what normal finding
would the nurse expect?
a. Fundus palpated 6 cm below the umbilicus
c. Striae pink but beginning to fade
b. Breast tender, some milk expressed
d. Creamy, yellow vaginal discharge
ANSWER: C
At 2 weeks’ postpartum, striae (stretch marks) are pink and obvious; by 6 weeks they are beginning to fade but
may not achieve a silvery appearance for several more weeks. Option A: At the 9th to 10th day, the fundus should
no longer be palpated. Option B: There should be no breast tenderness. Option D: Abnormal finding and should
be investigated.
83. When assessing a postpartum client, Nurse Isabelle notes a continuous flow of bright red blood from the
vagina. The uterus is firm and no clots can be expressed. Which action should Nurse Isabelle take?
a. Massage the uterus
c. Tell the client that it is expected and normal
b. Notify the doctor
b. Apply ice pack to the perineal area
ANSWER: B
The nurse should notify the physician because a continuous flow of bright red blood from the vagina and a firm,
contracted uterus indicate laceration of the birth canal. Ice application doesn't slow bleeding. Massage isn't
necessary because the client's fundus is firm. Telling the client that bleeding is normal would be misleading and
would give her a false sense of security.
84. The most important aspect of nursing care during postpartum period is:
a. Involving the family in the teaching
b. Providing group discussions on baby care
c. Monitoring the normal progression of lochia
d. Supporting the mother's ability to successfully feed and care for her infant
ANSWER: D
Most of the nursing interventions during the postpartum period are directed toward helping the mother
successfully adapt to the parenting role. Although family involvement in teaching, group discussions on baby
care, and lochia monitoring are important aspects of care, the mother's ability to feed and care for her infant
takes priority.
85. A postpartum client has a need of education regarding breast-feeding. The primary method for relieving
breast engorgement is to instruct the mother to:
a. Make use of a breast pump
c. Have the infant suck more often
b. Apply warm compress to the breast
d. Wear bra 24 hours a day
ANSWER: C
Frequent breast-feeding empties the breasts and increases circulation, helping to remove fluid that may lead to
engorgement. If the infant isn't ill or physically impaired and can breast-feed, the client shouldn't use a breast
pump because this deprives the infant of optimal sucking and skin-to-skin contact with the mother. Applying
warm, moist compresses stimulates the let-down reflex and causes the breasts to fill, which may lead to
engorgement. A brassiere supports the breasts but doesn't prevent engorgement unless the client breast-feeds
frequently.
86. A breast-feeding baby will turn his head toward the mother's breast in a natural instinct to find food. This is
known as:
a. Tonic neck reflex
b. Rooting reflex
c. Moro's reflex
d. Grasp reflex
ANSWER: B
The rooting reflex is an infant's response to having his cheek stroked. The infant will turn his head to the side of
the stroked cheek and will open his mouth in anticipation of having a nipple placed in it. The tonic neck reflex is
elicited by turning the neonate's head to the side when he's lying on his back. The extremities on the same side
extend and those on the other side flex. Moro's reflex is the startle reflex. For example, when the neonate's crib
is jolted, the neonate abducts his arms and extends them. The grasp reflex occurs when the neonate curls his
fingers around another person's fingers.
87. Nurse Hannah is teaching a client to perform Kegel exercise. Nurse Hannah should instruct the client to do
a. Tighten the leg muscles continuously
c. Repeated extension and flexion of leg
b. Contract and relax the abdomen 5 to 10 times in succession
d. Contract the perineum 5 to 10 times in succession
ANSWER: D
Kegel exercises is done by contracting and relaxing the muscles of perineum 5 to 10 times in succession as if
trying to stop voiding.
88. On the 2nd day postpartum, Nurse Rebecca assesses the client's temperature to be 99.6 degrees F. What
nursing action is most appropriate?
a. Administer paracetamol PO
c. Encourage the mother to breastfeed
b. Assess further for signs or symptoms of infection
d. No action is needed, since this is normal after delivery
ANSWER: B
A woman may show a slight increase in temperature during the first 24 hours after birth because dehydration
that occurred during labor. If she receives adequate fluid during the first 24 hours, this temperature elevation will
return to normal. A woman whose oral temperature rises above 100 degrees F, excluding the first 24 hour period,
is considered to be febrile. In such cases, a postpartal infection may be present. Pain medication and breast
feeding will not lower the temperature.
SITUATION: The physical care a woman receives during the postpartal period can influence her health for the
rest of her life.
89. During the first 30 to 60 minutes after birth, which attachment takes place between parent and child?
a. Bonding
b. Claiming
c. Engrossment
d. Entrainment
ANSWER: A
Bonding is a rapid process of attachment that takes place during the first 30 to 60 minutes after birth. The
bonding is enhanced when parent and infant touch and interact with each other.
Reference: Louis White. Foundations of Maternal and Pediatric Nursing 2nd edition
90. When a client is 12 hours postpartum, the nurse would expect the client’s fundus to be in which of these
positions?
a. At the level of the umbilicus
c. 1 centimeter above the umbilicus
b. Below the symphysis pubis and no longer palpable
d. 1 centimeter below the umbilicus
ANSWER: A
Note the size, consistency, and placement of the uterus. It should be the size of a grapefruit, firm, and in the
midline. It should descend approximately one fingerbreadth each day. At 12 hours postpartum, the fundus should
be approximately at the level of the umbilicus.
91. During the first 24 hours postpartum, a client states her vaginal discharge is bright red with small pieces of
mucus. Which of these actions should the nurse take?
a. Hold her NPO, and immediately notify her health care provider.
b. Observe the sanitary pad, and document your findings.
c. Verify that the amount and appearance are normal at this time.
d. Compress her fundus vigorously to express clots.
ANSWER: A
Palpate the bladder to assess for distention and position. A distended bladder may cause hemorrhage. If the
bladder is off to the side or the fundus is higher than usual, it is distended. Keep the client NPO, and immediately
notify her health care provider.
92. During the immediate postpartum period, a client’s fundus is firmly contracted, midline, and at the
appropriate level, but she is exhibiting an excessive amount of bleeding. The nurse should suspect the cause of
bleeding to be:
a. A full bladder
b. Ambulation
c. Breastfeeding
d. Cervical or vaginal tears
ANSWER: D
Postpartum hemorrhage can occur rapidly and may not be recognized until the client is in shock. It can either be
early, within the first 24 hours, or late, within the first 1 to 2 weeks after birth, but may occur up to 6 weeks
after the birth. It can be caused by cervical or vaginal tears, prolonged labor, clotting disorders, manual removal
of the placenta, or overdistention of the uterus.
93. What are the usual causes of maternal after-pains?
a. Cesarean delivery and prolonged labor
c. Postpartal hemorrhage and puerperal infection
b. Multiparity and breastfeeding
d. Uterine involution and breast engorgement
ANSWER: B
The causes of maternal afterpains may be related to the contracting uterus, the “let-down reflex” of
breastfeeding, or multiparity.
94. A client 6 hours’ postpartum is having difficulty voiding. The nurse identifies a nursing diagnosis of impaired
urinary elimination that is secondary to which condition?
a. Excessive blood loss during delivery
b. Third-degree laceration
c. Rapid labor
d. Multiparity
ANSWER: B
Lacerations are a common cause of urinary retention during early postpartum. Option A:Excessive blood loss may
lead to deficient fluid volume but not urinary retention. Option C: Rapid labor is not a risk factor for postpartum
urinary retention. Option D: Multiparity is not a risk factor for postpartum urinary retention.
Reference: Littleton. Maternity Nursing Care 8th edition page 630
95. A woman who is one hour postpartum after a vaginal delivery is experiencing heavy vaginal bleeding. Which
of the following actions would a nurse take first?
a. Initiate a perineal pad count
c. Massage the uterine fundus
b. Assess the location of the bladder
d. Obtain vital signs
ANSWER: C
During the first three days after delivery, vaginal discharge is usually bright red. Abnormal bleeding from
lacerations usually spurts, rather than trickles. In the first hour postpartum the bleeding will be bright red or
rubra. The amount of bleeding is more significant than the color at this time. The priority treatment is massage of
the uterus to increase tone and decrease bleeding. Option A: A pad count is a good intervention, but the priority
to locate the cause of the bleeding. Option B: If the bladder is distended, it may interfere with the ability of the
uterus to contract and, therefore, decrease bleeding. Option D: Vital signs are important but the priority must be
to massage the uterus to increase muscle tone and decrease bleeding.
Reference: A. Pillitteri. Maternal and Child Nursing. 5th Edition. Page 636
96. During a routine postpartum assessment following a normal vaginal delivery, the nurse notes the fundus to
be slightly boggy. Which action should the nurse take to decrease the risk of uterine inversion during uterine
massage?
a. Ask the client to ambulate to the bathroom to empty her bladder.
b. Massage only until cramping begins.
c. Place one hand on the abdomen above the symphysis pubis.
d. Position the client in a slight Trendelenburg position.
ANSWER: C
This is the proper hand position for uterine massage to support and hold the lower part of the uterus to prevent
inversion. Option A: This is not an appropriate action for fundal massage. Option B: The fundus should be
massaged to firm. Option D: This is not an appropriate position for the mother during fundal massage.
Reference: Littleton. Maternity Nursing Care 8th edition page 429.
97. Which nursing action would be appropriate to include in a nursing care plan that reflects anticipated client
needs in the “Taking Hold” phase?
a. Ask dad to feed infant while mom is in the shower.
b. Encourage participation in diaper changes and circumcision care.
c. Keep room lights off to allow for adequate rest.
d. Return infant to nursery during the 11 to 7 shift.
ANSWER: B
Because in “taking hold” the mother is interested in participating in the neonate’s care, this would be an
appropriate nursing action. Option A: This will not assist the mother with “taking hold,” which is characterized by
increased interest by the mother for participating in the neonate’s care. Option C: This would be more
appropriate for the “taking in” phase. Option D: This would be more appropriate for the “taking in” phase.
98. On postpartum day 3 a client who is bottle-feeding complains that her breasts are filling with milk and are
starting to hurt. What would be an appropriate nursing action?
a. Call the physician to request a medication order for Parlodel.
b. Recommend that the client place ice packs on the sides of her breasts under the axilla.
c. Show the client how to use a breast pump to remove milk.
d. Suggest the client soothe breasts under a warm relaxing shower.
ANSWER: B
Ice packs will help decrease breast stimulation and decrease engorgement. Option A: This is not an appropriate
action for the nurse. Acetaminophen would be a medication choice at this time. Option C: This action would
increase breast stimulation, engorgement, and pain. Option D: Warm water will stimulate milk production and
engorgement through vascular dilation.
99. Which assessment finding would alert the nurse to the strong possibility that the client may provide an
inadequate supply of milk to the baby?
a. Baby weighs 10 pounds 4 ounces.
c. Mom is more than 40 years of age.
b. There is a history of breast-reduction surgery.
d. Mom prefers skim to whole milk.
ANSWER: B
Reduction mammoplasty can interfere with milk supply, because this surgery involves interruptions of the milk
ducts. Option A: With adequate stimulation from the infant and adequate maternal fluid intake, infant size will not
result in an inadequate milk supply. Option C: With adequate stimulation from the infant and adequate maternal
fluid intake, maternal age over 40 will not result in an inadequate milk supply. Option D: With adequate
stimulation from the infant and adequate maternal fluid intake, the type of fluid consumed will not result in an
inadequate milk supply.
100. The client asks the nurse how she will know if her baby is getting enough breast milk. Initially, which
response by the nurse would be most helpful?
a. "Your baby should have at least 8 to 10 wet diapers per day."
b. "If the baby nurses four times a day, she is getting enough milk."
c. "Your baby should have a stool once a day."
d. "If the baby is sleeping soundly through the night, she is getting enough milk."
ANSWER: A
The infant’s output is a reflection of the intake and eight to ten wet diapers a day reflects adequate intake. Option
B: Breastfed infants usually eat 8 to 12 times a day for the first 3 to 4 weeks. Option C: Most breastfed infants
stool with every void or every other void. Option D: This is not an appropriate measure for adequate nutrition.

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WOMEN’S HEALTH AND OBSTETRIC NURSING

of the symptoms of a client with suspected ectopic

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