MATERNAL NURSING BOARD-SENSITIVE CLOSE-DOOR COACHING

EXPECTED AND UNEXPECTED NLE HOTCHEATS

PREPARED AND SCREENED BY: PROF. GERYLANDO A. HISU RN,BSEd,MAN
PNLE NOV 11-12 2023

1. A woman has a 30 day menstrual cycle. If she had her menses last Aug. 15-18, she will probably be ovulation on:
A. Aug. 31 B. Aug 27 C. Aug 12 D. Sept 2

2. If a woman had her menstruation July 1- 4 and her cycle is usually 30 days, her expected next menstrual period is:
A. July 31 B. Aug. 01 C. Aug. 02 D. Aug. 03

3. If a woman ovulated July 27, following the natural family planning calendar method, her fertile period be:
A. July 20-26 B. July 24 - Aug 01 C. July 27 -30 D. July 22 - Aug 01

4. Ovulation takes place during which of the following phases of the menstrual cycle?
A. Luteal phase B. Ischemic c. Proliferative phase D. Secretory phase

5. The phases of the normal menstrual cycle, in order of their occurrence are:
A. sloughing, secretory, luteal, endometrial
B. sloughing, secretory, luteal, ischemic
C. sloughing, proliferative, secretory, ischemic
D. follicular, luteal, ischemic, sloughing

6. When a couple would like to enhance their fertility, the following means can be done:
1. Monitor the basal body temperature of the woman everyday to determine peak period of fertility
2. have adequate rest and nutrition
3. have sexual contact only during the "dry" period of the woman
4. undergo a complete medical check-up to rule out any debilitating disease

A. 1 only B. 1 & 4 C. 1, 2, 4 D. 1, 2, 3, 4

7. When teaching a class of young adolescents about menstruation and menstrual cycle, the nurse explains that
ovulation occurs due to:

A. Estrogen
B. Human chorionic gonadotrophin hormone
C. Luteinizing hormone
D. Follicle stimulating hormone

8. It is important that the nurse understands the hormonal effects on basal temperature in relation to ovulation. Which
of the following responses related to ovulation is correct?

A. After ovulation occurs, progesterone is produced and causes a rise in basal temperature
B. After ovulation occurs, progesterone is produced and causes a drop in basal temperature
C. After ovulation occurs, estrogen production is increased and causes a rise in temperature
D. After ovulation occurs, estrogen production is increased and causes a drop in basal temperature

9. The endometrium of uterus is thinnest at what time?

A. Just before ovulation
B. Between ovulation and menstruation
C. At the beginning of menstruation
D. Just after menstruation

10. Hanna came to the clinic to ask matters regarding her menstrual cycle. She is about to get married so she is
concern of conceiving a baby. If her menstrual cycle is 32 day, and she menstruate last 8th day of the month,
what day is the best time to fertilize an ovum?
A. 10th -13th day C. 25th – 28st day
B. 14th-17th day D. 18th – 21st day

SITUATION: Obstetrical assessment entails knowledge of both normal and abnormal findings that would help both
mother and fetus to go along pregnancy safely up to learn.
11. Mrs. Dinah Makabuka arrives at the pre natal clinic for the first prenatal assessment. She tells Nurse Santiago that
the first day of her last menstrual period was June 20, 2022. Using the Nagel’s rule, Nurse Rafael determines the
estimated date of confinement (EDC) as:
A. March 13, 2023 B. March 27, 2024 C. April 27, 2023 D. April 26, 2023

12. Alvin Mambu Buso is also collecting data during an admission assessment of Mrs. Patrick Sy Lip who is pregnant
with twins , has a healthy 5 year old child and does not have history of any type of abortion or fetal demise. Nurse
mambu Buso would document which gravida and para status for this client?

A. Gravida 111, Para 11 B. Gravida 11, para 11 C. Gravida1, Para 1 D. Gravida 11, Para 1

13. Mrs. Wakwak asks the nurse, “ When will I feel my baby moving”?. The nurse responds by telling her that fetal
movement will be noted between?
A. 6 and 8 weeks B. 8 and 10 weeks C. 10 and 12 weeks D. 16 and 20 weeks

14. Which of the following would the nurse expect to occur with respect to the client’s insulin needs during the first
trimester?
A. They will increase B. They will decrease C. They will remain constant D. They will unpredictable

15. The nurse provides health teachings to Mrs. Mala Man . Which of the following statements by the client regarding
chorionic villi sampling indicates effective teaching about the procedure?
A. “ A fiberoptic fetoscope will be inserted through a small incision into my uterus.”
B. “I can’t have anything to eat of drink after midnight on the day of the procedure.”
C. “ The procedure involves the insertion of a thin catheter into my uterus through the vagina.”
D. “ I need to drink 32 to 40 ounces of fluids 1-2 hours before the procedure.”

16. Mrs. Rubi has been constipated and unable to defecate everyday like before when she was not yet pregnant. She
reads about the use of castor oil in the internet so she asks the nurse if she can take castor oil for her constipation.
How should response to the client?

A. “ Yes, it produces no adverse effect.”

B. “ No, it can initiate premature uterine contraction.”
C. “No, it can promote sodium retention.”
D. “No, it can lead to increased absorption of fat-soluble vitamins.”

17. When measuring the fundic height, which of the following techniques demotes the correct method of measurement
used by Nurse Jillian?
A. From the xyphoid process to the umbilicus C. From the symphasis pubis to the uterine fundus
B. From the xyphoid process to the symphasis pubis D. From the fundus to the umbilicus

18. Hisu Cute is measuring the fundic height of a client who is 36 weeks gestation when the client’s complains of
feeling light headed. She determines that the client’s complaint is most likely caused by:
A. Fear B. Compression of the vena cava C. A full bladder D. Anemia

19. Mrs. Patrick Malih Bhog typically has menstrual cycle of 35 days. She tells you she had coitus in days 8,10, 12, 15
and 20 of her last cycle.Which is the day on which she most likely conceived?
A. day 8 B. day 15 C. day 10 D. day 20

20. Panginoong Andrade ,a sexually hyperactive nurse should explain to Mrs. Caridad that hyperemesis gravidarum is
thought to be related to high level of which of the following hormones?
A. Progesterone B. HCG C. Somatotropin D. Aldosterone

21. Robert the Explorer expresses concern about having occasional heartburn. Which of the following measures will
the nurse advice most likely?
A. take a cup of tea after meals
B. take one tablet of Simeco three times daily
C. decrease intake of fluids to 1 liter a day
D. eat smaller and more frequent meals

22. Alvin Mapanghinala will likely notice which of the following normal physiologic changes in pregnancy?
A. blurring of vision B. increased blood pressure C. palpitations D. Increase in plasma blood volume

23. The early symptoms that cause a woman to suspect that she might be pregnant include all of the following except:
A. amenorrhea B. increase appetite C. nausea D. abdominal enlargement

24. Increased absorption of phosphorus is thought to be responsible for which of the following discomforts of
pregnancy?
A. constipation B. heartburn C. back ache D. leg cramps
25. A mother is on her 32nd week of gestation and her weight on her last prenatal check up 4 weeks ago was 104 lbs.
What is the expected normal weight at this time?

A. 108 lbs B. 110 lbs C. 112 lbs D. 115 lbs

26. Mrs. Laway is on her 4th pregnancy and has a history of one abortion. She is considered to be:
A. G4 P3 B. G4 P2 C. G5 P4 D. G5 P3
27. Which of the following nursing statements is TRUE about the sex of the unborn child?
A. "Sex of the fetus is determined after implantation."
B. "The sex of your child can only be determined after complete organ development."
C. "At the moment of fertilization, the sex is determined."
D. "Before sex can be determined, cleavage must occur."

28. When teaching a group of pre-conception adolescents, the nurse includes which of the following recommendations
to decrease the risk of neural tube defects?

A. 500 mg Vitamin C daily

B. 0.4 mg Folic acid daily
C. 1,500 mg calcium daily
D. 600 mg Vitamin A daily .

29. Subjective changes of pregnancy include which of the following?

A. Hegar's sign
B. Chloasma
C. Uterine enlargement and breast tenderness
D. Amenorrhea and quickening

30. The nurse teaches a prenatal client to elevate her legs frequently because the pressure of the gravid uterus on the
blood vessels can lead to:
A. Hypotension, nausea and vomiting
B. Varicosities, hypertension and nausea
C. Dependent edema and varicosities
D. Hypotension and vomiting

31. Using TPAL system, how would the nurse record the obstetric history of a client who is currently pregnant and had
1 child born 38 wks, 1 abortion and one child born 28 weeks.
A. Gravida 4: 1 1 1 2 B. Gravida 4: 0 1 1 2 C. Gravida 3: 1 1 1 2 D. Gravida 3: 0 1 1 2

32. The nurse should assess the mother's knowledge of danger signs of pregnancy. Which of the following statements
of the client indicate a need for further teaching?
A. "Any urinary burning should be reported to the nurse-midwife."
B. "Fluid leaking from my vagina maybe my bag of waters."
C. "The baby will have quiet days when he will not move."
D. "Blurred vision may mean that my blood pressure is high."

33. A 36 year old primigravida client at 22 weeks age of gestation without any complications to date is being seen in
the clinic for a routine visit. The nurse expects to assess the client’s fundal height for which of the following
reasons?
A. Determine the level of uterine activity. C. Identifying the need for increased weight gain.
B. Assessing the location of the placenta. D. Estimating the fetal gestational age.

SITUATION: Mrs. De Makakibo is a primigravida client on her 37 weeks of gestation and is scheduled for non-stress
test. Nurse Katakutan is assisting the client all througnout the procedure.

34. While preparing Mrs. De Makakibo for a non-stress test , she asks the nurse about the procedure. Nurse Katakutan
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 2 hours hours and will require close monitoring for 2 hours after the procedure is completed.
C. An ultrasound transducer that records the fetal heart activity is secured over the abdomen where the
fetal heart is most clearly heard.
D. The fetus is challenged or stressed by the uterine contractions to obtain the necessary information.

35. Nurse Katakutan is reviewing the documentation related to the results of the test. She notes that the physician
documented thetest results as reactive. She interprets that this result indicates:
A, A normal findings C. The need for further evaluation
B. Abnormal findings D. The findings on the monitor were difficult to interpret.
36. If the non stress test result is a non reactive finding, the physician would most probably prescribe a contraction
stress test. After the test is performed , Nurse Katakutan 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

37. A pregnant woman, in the first trimester, is to have a transabdominal ultrasound. The nurse would include which of
the following instructions?
A. Nothing by mouth (NPO) from 6:00 A.M. the morning of the test
B. Drink one to two quarts of water and do not urinate before the test
C. Come to the clinic first for injection of the contrast dye
D. No special instructions are needed for this test

38. A patient who is new to the genetic clinic, asks the nurse, “ Why do my baby’s face seems to resembles my
husband and not me?” The nurse’s correct response by saying that this is due to:
A. Pictograph C. Phenotype
B. Genotype D. Hologram

39. A woman is her 38th week of pregnancy is to have an amniocentesis to evaluate fetal maturity. The L/S
(lecithin/sphingomyelin) ratio is 2:1. The nurse knows that this finding indicates.
A. Fetal lung maturity C. That labor can be induced
B. The fetus is not viable D. a non-stress test is indicated

40. A client is scheduled for amniocentesis and is concerned that the needle will puncture the placenta. An appropriate
nursing response is:

A. Because the placenta is in the fundus and the needle is inserted below the umbilicus, there is no danger.
B. The placental membrane is fibrous and cannot be penetrated by the needle.
C. Ultrasound locates the placenta and guides the doctor do the procedure.
D. Even if the placenta is penetrated there will be no adverse effect.

41. During a childbirth preparation class, a primigravid client, Mona at 36 weeks’ gestation tells Nurse Diana: “My
lower back has really been bothering me lately.” Which of the following exercises suggested by Nurse Diana
would be most helpful?
A. Pelvic rocking C. Tailor sitting
B. Deep breathing D. Squatting

42. In clients with diabetes in pregnancy, urine test for sugar is not done to test the level of glucose in the blood. The
nurse understands that in pregnancy the glucose level in the urine is not indicative of actual blood glucose level
because

A. The kidneys are not functioning well because of the pressure of the gravid uterus.
B. There is decreased renal threshold so that glucose may be spilled at unusually low glucose serum levels
C. There is hypoglycemia and the fetus maybe reacting to the low level of glucose
D. The fetal pancreas are normal thus there is enough insulin in the maternal circulating blood

43. Which of the following conditions in the mother will transmit the disease to the fetus during vaginal delivery?
A. Staphylococcus B. Candidiasis C. German measles D. Chronic cervicitis

44. In premature rupture of the membranes one objective of care is to prevent infection. A nursing intervention to
achieve this objective is:

A. Ask the patient to observe bedrest

B. Teach the patient to observe proper pericare
C. Place the patient on trendellenberg position
D. Put the patient on side lying position

45. Placenta accreta is described as:

A. Normally implanted but abnormally adherent placenta
B. Implanted in the lower segment of the uterus
C. Placenta that covers the internal cervical os
D. The placenta is normally implanted but detaches early

46. When there is a cord coil around the fetal neck, which of the following are the correct actions of the nurse to
release the cord?
1. Release the cord coil around the fetal head and neck if loose enough
2. Pull the head down to deliver the neck
 3. If the coil is tight, cut the cord between two clamps
4. Attempt to deliver the posterior shoulder to release the cord coil

A. 1 & 2 B. 2 & 3 C. 1 & 3 D. 2 & 4

47. A pregnant client is a negative CST. Which of the following statements describes negative CST results?
A. Persistent late decelerations in fetal heartbeat occurred, with at least three contractions in a 20 minute
period.
B. Accelerations of fetal heartbeat of at least 15 beats/minute, lasting 15 to 30 seconds in a 20-minute period.
C. Accelerations of fetal heartbeat were absent or didn’t increase by 15 beats/minutes for 15 to 30
seconds in a 20 minute period.
D. There was good fetal heart rate variability and no decelerations from contraction in a 10-minute period in
which there were three contractions

48. A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the
nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the
uterine wall and is ready for delivery?
A. The umbilical cord shortens in length and changes in color
B. A soft and boggy uterus
C. Maternal complaints of severe uterine cramping
D. Changes in the shape of the uterus

49. What is the most common alarming symptoms of imminent abortion?

A. Vaginal cramping B. Vaginal spotting C. Cervical dilatation D. Nausea and vomiting

50. You are assessing a pregnant woman in her 6th month and she is complaining of irregular, painless uterine
contractions. She is worried that she maybe experiencing a complication of pregnancy. The correct response of
the nurse is:

A. The painless irregular uterine contractions are normal

B. The contractions maybe an early sign of labor and she must consult her obstetrician
C. She is having premature labor and must seek immediate consultation
D. She needs to observe bedrest and refer to the doctor

51. After the neonate’s umbilical cord has been clamped, the nurse notes a sudden gush of blood (about 250 ml) and
lengthening of the cord from Mrs. G.’s vagina. These events indicate:
A. early postpartal hemorrhage C. uterine rupture
B. placental separation D. uterine atony

52. From the 33rd week of gestation till full term, a healthy mother should have prenatal check up every:
A. week B. 2 weeks C. 3 weeks D. 4 weeks

53. The expected weight gain in a normal pregnancy during the 3rd trimester is
A. 1 pound a week C. 2 pounds a week
B. 10 lbs a month D. 10 lbs total weight gain in the 3rd trimester

54. In the Batholonew’s rule of 4, when the level of the fundus is midway between the umbilicus and xyphoid
process the estimated age of gestation (AOG) is:
A. 5th month B. 6th month C. 7th month D. 8th month

55. Mrs. Seguinda Mano , a 30 year old multigravida client at 39 weeks gestation admitted to the hospital in active
labor, has been diagnosed with 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. Avoid the use of analgesics for the labor pain.
B. Remain in side-lying position with the head elevated. D. Request local anesthesia for vaginal delivery.

56. When preparing a plan of care for a multigravida client with heart disease, which of the following signs should the
nurse expect to assess frequently?
A. Dehydration B. Nausea and vomiting C. Iron deficiency anemia D. Tachycardia

57. Which of the following is the most likely effect on the fetus if he woman is severely anemic during pregnancy?
A. Large of gestational age (LGA) fetus
B. Hemorrhage
C. Small of gestational age (SGA) fetus
D. Erythroblastosis fetalis

58. When the bag of waters of the pregnant woman has ruptured, the nurse must immediately do which of the
 following?

A. If the woman is ambulatory, ask the woman to lie down and check for possible cord prolapse and take fetal
heart rate
B. The woman is asked to void to ensure faster descent of the fetal head
C. If the woman is on bed, ask the woman to lie on her left side to ensure better tissue perfusion
D. Ask the woman to wear a maternity pad so the nurse can monitor the amount of amniotic fluid released per
vagina

59. A client is in labor and has been told she has a breech presentation. The nurse should be particularly alert for which
of the following?
A. Quickening B. Opthalmia neonatorum C. Pica D. Prolapsed umbilical cord

60. When PROM occurs , which of the following provides evidence that the nurse fully understands the client’s
immediate needs at this point of time due to her present condition?
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 vialbility and gestational age.
D. PROM could be treated through D and C.

61. Which of the following is NOT a sign of placental separation?

A. Lengthening of the cord
B. Sudden gush of blood
C. Uterus becomes globular and fundus rises up the abdomen
D. Lower uterine segment is soft and relax

62. Mrs. Lee has undergone Chorionic Villi Sampling for genetic screening. The nurse is aware that this procedure is
done in the early pregnancy but with the following complications?
A. Abruptio placenta C. Placenta previa
B. Incompetent cervix D. Fetal limb defect

63. Rh- incompatibility is suspected once the women is Rh negative having an Rh positive husband. If the newborn is
positive for blood test and negative for direct coomb,s test. What should the nurse anticipate:

A. Administer RhoGam 300 mg IM first 72 hours.

B. Submit the newborn to indirect coomb,s test.
C. RhoGam is already useless.
D. Terminate the pregnancy.

64. The nurse is aware that the purpose of administering RhoGam in a newborn having negative direct coomb’s test is
to:
A. Prevent erythroblastosis fetalis C. Protect the succeeding pregnancy
B. To promote immunization of the fetus D. Prevent sterility after delivery of the fetus.

65. In Rh incompatibility, the pathology is described as:

A. the Rh (+) antigen of the fetus invades the maternal circulation destroying maternal RBC
B. The Rh(-) antigen of the mother destroys fetal RBC
C. Rh (+) antibodies developed by the mother destroys fetal RBC
D. Rh (+) blood of the mother destroys the Rh (-) blood of fetus

66. The nurse is assessing a newborn for a client who delivered vaginally with a breech presentation. What type of
complication breech newborns most likely to experience?
A. Genetic abnormality B. Cephalhematoma C. Head injury D. Clavicular fracture

67. After reviewing the physician’s explanation of amniocentesis with a multigravid client, Marian, which of the
following if reported by Marian as a primary risk of the procedure would indicate successful teaching?
A. Premature rupture of membranes C. Fetal limb malformations
B. Possible premature labor D. Fetal organ malformations

68. Nurse Robert Tatlongtainga is caring for Mrs. Alvin Tatlong-ilong who has a previous ceasarean delivery on her
first baby. The patient ask if she could have a normal delivery on her 2nd baby. Nurse Robert is aware that if she
would be allowed the danger complication would be:
A. Prolong labor B. Cephalhematoma C. Uterine rupture D. Abruptio placenta

69. A primigravid client, Leila, at 28-weeks’ gestation tells Nurse Yumilka that she and her husband wish to drive to
visit relatives in Baguio. Which of the following recommendations by Nurse Yumilka would be best?
A. “Try to avoid travelling anywhere in the car during your third trimester.”
B. “Limit the time you spend in the car to a maximum of 4 to 5 hours.”
 C. “Taking the trip is okay if you stop every 1 to 2 hours and walk.”
D. “Avoid wearing your seat belt in the car to prevent injury to the fetus

70. During childbirth preparation classes for a group of adolescent primigravid clients, one of the clients, Mahal, asks:
“How does the baby breathe inside of me?” Nurse Biboy responds by explaining fetal circulation, stating that
circulation of oxygenated blood from the placenta begins with which of the following?
A. Umbilical artery C. Ductus arteriosus
B. Foramen ovale D. Umbilical vein

71. The fetal presentation is breech and when the bag of waters ruptured the color of the amniotic fluid is greenish.
The nurse understands that greenish amniotic fluid in breech presentation maybe:

A. Greenish because of the compression of the presenting part which is the buttocks and a small amount of
meconium is squeezed into the amniotic fluid
B. This a sign of fetal distress because the fetus will have anal constriction
C. Normally the color of amniotic fluid is clear and slightly yellow
D. Whether the presentation is breech or cephalic, greenish amniotic fluid is always a sign of abnormality

72. An appropriate nursing intervention for a postpartum mother with thrombophlebitis is:
A. Encourage the mother to ambulate to relieve pain in the leg
B. Instruct the mother to apply elastic bandage from the foot going towards the knee to improve venous return
flow
C. Apply warm compress on the affected leg to relieve the pain
D. Elevate the affected leg and keep the patient on bedrest

73. The diet that is appropriate in normal pregnancy should be high in

A. Protein, minerals and vitamins
B. Carbohydrates and vitamins
C. Proteins, carbohydrates and fats
D. Fats and minerals

74. In a pregnant woman diagnosed to have chronic hypertensive vascular disease, which of the following fetal
problem will be likely considered?

A. Fetal lung immaturity C. Intrauterine growth retardation

B. Congenital deformity D. Congenital hypertension

75. In the later part of the 3rd trimester, the mother may experience shortness of breath. This complaint maybe
explained as:
A. A normal occurrence in pregnancy because the fetus is using more oxygen
B. The fundus of the uterus is high pushing the diaphragm upwards
C. The woman is having allergic reaction to the pregnancy and its hormones
D. The woman maybe experiencing complication of pregnancy

76. 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

77. To prevent preterm labor from progressing, drugs are usually prescribed to halt the labor. The drug commonly
given are:
A. Magnesium sulfate and terbutaline C. Prostaglandin and oxytocin
B. Progesterone and estrogen D. Dexamethasone and prostaglandin

78. You are performing abdominal exam on a 9th month pregnant woman. While lying supine, she felt breathless,had
pallor, tachycardia, and cold clammy skin. The correct assessment of the woman’s condition is that she is

A. Experiencing the beginning of labor. C. Having supine hypotension

B. Having sudden elevation of BP D. Going into shock

79. Mrs. D. is 36 weeks gestation and the nurse is talking with her during a prenatal visit. Which statement indicates
that Mrs. D. understands the onset of labor?
A. “I need to go to the hospital as soon as the contractions become painful.”
B. “If I experience bright red vaginal bleeding I know that I am about to deliver.”
C. “I need to go to the hospital when I am having regular contractions and bloody show.”
D. “My labor will not start until after my membranes rupture and I gush fluid.”

80. A client is progressing through the first stage of labor. Which finding signals the beginning of the second stage of
labor?
A. Passage of the mucus plug B. Bearing-down reflex C. Change in uterine shape D. Gush of dark blood
81. Which of the following best describes pre-term labor?
A. Labor that begins after 20 weeks gestation and before 37 weeks gestation.
B. Labor that begins after 15 weeks gestation and before 37 weeks gestation.
C. Labor that begins after 24 weeks gestation and before 28 weeks gestation.
D. Labor that begins after 28 weeks gestation and before 40 weeks gestation.
82. Which of the following is the best way for the nurse to assess contractions in a client presenting to the labor and
delivery area?
A. Place the client on the electronic fetal monitor with the labor loco of the fundus
B. Ask the client to describe the frequency, duration, and strength of her contractions
C. Use Leopold’s maneuvers to determine the quality of the uterine contractions
D. Place the fingertips of one hand on the fundus to determine frequency, duration and strength of her
contractions

83. Upon assessment the midwife found the following: fundus at 2 fingerbreadths above the umbilicus, last menstrual
period (LMP) 5 months ago, fetal heart beat (FHB) not appreciated. Which of the following is the most possible
diagnosis of this condition?

A. Hydatidiform mole C. Missed abortion

B. Pelvic inflammatory disease D. Ectopic pregnancy

84. The nurse is providing care to Ms. C. during the most recent vaginal examination the nurse feels the cervix 6 cm
dilated, 100% effaced, with the vertex at –1 station. What is the best interpretation of this information? The
woman is in
A. active labor with the head as presenting part not yet engaged
B. transition with the backside as presenting part fully engaged
C. latent phase labor with the backside as presenting part fully engaged
D. active labor with the head as presenting part fully engaged

85. Mrs. M. is completely dilated and at +2 station. Her contractions are strong and last 50 – 70 seconds. Based on this
information, the nurse should know that Mrs. M. is in which stage of labor?
A. First stage B. second stage C. third stage D. fourth stage

86. A 28-year-old primigravida is admitted to the labor room. She is 8 cm dilated, 90% effaced, and the head is at 0
station. Contractions are every 1-2 minutes lasting 35– 60 seconds. Membranes are intact. Admitting vital signs
are: blood pressure 110/70, pulse 78, respirations 16, temperature 98.80F, and fetal heart rate 144. The nurse plans
to monitor
A. blood pressure and contractions hourly and fetal heart rate every 15 minutes
B. temperature, blood pressure, and contractions every 4 hours and fetal heart rate hourly
C. contractions, effacement, and dilation of cervix, and fetal heart rate every hour
D. contractions, blood pressure and fetal heart rate every 15 minutes

87. Mrs. H.’s cervix is completely dilated with the head at –2 station. The head has not descended in the past hour.
What is the most appropriate initial assessment for the nurse to make?
A. Assess to determine if Mrs. H.’s bladder is distended
B. Send Mrs. H. for x-rays to determine fetal size
C. Notify the surgical team so that an operative delivery can be planned
D. Assess fetal status, including fetal heart tones, and scalp Ph

88. Ms. N. has been in labor for six hours. She is now 9 cm dilated and has intense contractions every one to two
minutes. Ms. N is anxious and feels the need to bear down with her contractions. What is the best action for the
nurse to take?
A. Allow Ms. N to push so that delivery can be expedited
B. Encourage panting breathing through contractions to prevent pushing
C. Reposition Ms. N in a squatting position to make her more comfortable
D. Provide back rubs during contractions to distract Ms. N.

89. Mrs. C. is scheduled for a cesarean section delivery due to a transverse fetal lie. What is the best way for the nurse
to evaluate that Mrs. C. understands the procedure?
A. Ask Mrs. C. about the help she will have at home after her delivery
B. Give Mrs. C a diagram of the body and ask her to draw the procedure for you
C. Ask Mrs. C. to tell you what she knows about the scheduled surgery
D. Provide Mrs. C. with a booklet explaining cesarean deliveries when she arrives at the hospital

90. Which of the following signs and symptoms is most likely expected for a client with Hyatidiform mole?

A. Uterine size would be larger than one would expect based on age of gestation.
B. Excesive nausea and vomiting.
C. Absence of fetal heart beat on ultrasound.
D. All of the above.
91. A client is admitted to the labor and delivery area. The nurse-midwife checks for fetal descent, flexion, internal
rotation, extension, external rotation, and expulsion. What do these terms describe?
A. Phases of the first stage of labor
B. Cardinal movements of labor
C. Factors affecting labor
D. Factors that determine fetal position

92. 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 membrane fails to rupture spontaneously. D. A mucous plug in the cervical canal is expelled.

93. When evaluating the client in labor, the nurse determines that the client is a primipara. The nurse knows that
primipara mothers normally are not taken to the delivery room until:

A. The cervix is dilated 6 to 8 cm. C. The intensity of the contraction is increase.

B. Contractions are 3 to 5 minutes apart D. The perineum is bulging.

94. Mrs. Lava Boh, a 20 year old obese, primigravida client at 40 weeks age of gestation who is in the first
stage of labor, is admitted in the birthing center. The physician ordered intermittent fetal heart rate
monitoring. The nurse would monitor fetal heart rate pattern at which of the following intervals?

A. Every 15 minutes during the latent phase. C. Every 90 minutes during the initial phase
B. Every 30 minutes during the active phase D. Every 2 hours during the transitional phase

95. 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 has decrease in bloody show.
B. The client becomes increasingly talkative. D. The client takes 3 depth cleansing breaths.

96. Because cervical effacement and dilatation are not progressing in a patient in labor,. Dr. Balderama orders
IV administration (Pitocin). Which of the following reasons why the nurse must monitor the clients fluid
intake and output closely during oxytocin administration?

A. Oxytocin causes water intoxication C. Oxytocin is toxic to the kidney

B. Oxytocin causes excessive thirst D. Oxytocin has a diuretic effect

97. At what stage of labor and delivery does the primigravida differ mainly from multigravida?
A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

98. To diagnose gestational trophoblastic disease and the physician orders ultrasonography. The nurse expects
ultrasonography to reveal:
A. Embryonic gestational sac. C. A severely malformed fetus
B. Grape-like clusters D. An extrauterine pregnancy

99. Because a woman is receiving magnesium sulfate for pregnancy induce hypertension, it is issential for the nurse to
assess the woman’s:
A. Urine chemistry B. Platelet count C. Apical heart rate D. Respiratory rate

100. The ultrasound findings reveal that the fetus is frank breech in presentation. The nurse interprets this finding as the
presenting part is/are:

A. The buttocks
B. Both the buttocks and the feet
C. Both feet with one slightly lower than the other
D. Any part of the lower trunk of the fetus