1. A client is admitted to the birthing suite in early active
It refers to the degree of the presenting part of the
the priority nursing intervention on admission of this
client would be:
- Auscultating the fetal heart
2. A nurse is reviewing the record of a client in the labor
room and notes that the nurse midwife has
documented that the fetus is a at (-1) station. The
nurse determines that the fetal presenting part is:
-1 cm above the ischial spine
3. When measuring a client’s fundal height, which of
the following techniques denotes the correct method of
measurement used by the nurse?
- From the symphysis pubis to the fundus
4. The nurse documents positive ballottement in the
clients prenatal. The nurse understands that this
indicates which of the following?
- Passive movement of the unengaged fetus
5. Labor is a series of events affected by the
coordination of the five essential factors. One of these
is the passenger (fetus). Which are the other four
factors?
- Passageway, contractions, placental position, and
function, psychological response
6. Mechanism of labor, also known as the cardinal
movement, refers to the sequencing of events involved
in posturing and positioning that allows the baby to find
the easiest to come out of the birth arrange the
following mechanisms of labor in the order during the
course of labor and fetal delivery.
- Engagement, descent, flexion, internal rotation,
extension, external rotation, expulsion,
7. A client who is gravida 1, para 0 is admitted in labor.
Her cervix is 100% effaced, and she is dilated to 3 her
fetus is at +1 station. The nurse is aware that the fetus
head is:
- Below the ischial spines
8. After doing Leopold’s maneuvers, the nurse
determines that the fetus is in the ROP position. To
best auscultate the fetal heart tones, the Doppler is
placed:
- Below the umbilicus on the right side
9. A client in her third trimester tells the nurse, “I’m
constipated all the time!” Which of the following should
the nurse recommend?
- Increased fiber intake
10.
fetus, measured in centimeters from the ischial spines.
- Station
11. On which of the following areas would the nurse
expect to observe chloasma?
- Cheeks, forehead, and nose
12. Your laboring patient has transitioned to stage 2 of
labor. What changes in the perineum indicate the birth
of the baby is imminent
- Bulging perineum and rectum with an increase in
bloody show
13. The mother has delivered the You note that the
shiny surface of the placenta was delivered first. What
delivery mechanism is this known as AND is this the
maternal or baby’s surface of the placenta?
- Schultze mechanism, baby
14. When doing perineal care in preparation for
delivery, the nurse should observe the following,
EXCEPT?
- Paint the inner thighs going towards the perineal area
15. After birth, where do you expect to assess fundal
height?
- At or near the umbilicus
16. The nurse observes the client’s amniotic fluid and
decides that it appears normal, because it is:
- Clear, almost colorless, and containing little white
specks
17. In stage 1 of labor, during the active phase, the
cervix dilates.?
- 4-7 cm
18. Which of the following fetal positions is most
favorable for birth?
- Vertex presentation
19. A full-term newborn was just born. Which nursing
intervention is important for the nurse to perform first?
- Remove wet blankets
20. When the baby’s head is out the immediate action
of the nurse is
- Check if there is a cord coiled around the neck
21. While assessing a 2-hour old neonate, the nurse
observes for signs of distress. Which of the following
are the signs?
- Nasal flaring, chest retractions, skin color, <30 or <60
breaths per minute
22. As soon as the placenta is delivered, the nurse
must do which of the following actions?
- Inspect the placenta for completeness including the
membranes
23. You note that when a finger is placed under the
toes of a newborn, the toes will curl. This is known as
the____?
- Planter grasp reflex
24. When teaching umbilical cord care to a new
mother, the nurse would include which information?
- Keep the cord dry and open to air
25. The partograph is a tool used to monitor labor. The
maternal parameters measured/monitored are the
following, EXCEPT?
- Fluid intake and output
26. A newborn's mother is alarmed to find small
amounts of blood on her infant girl's. When the nurse
checks the infant's urine it is straw-colored and has no
offensive odor. Which explanation to the newborn's
mother is most appropriate?
- Some infants experience menstruation like bleeding
when hormones from the mother are not available
27. The Ideal site for vitamin K injection in the newborn
is?
- Middle third of the thigh
28. At what APGAR score at 5 minutes after birth
should resuscitation be initiated?
-1-3
29. Right after birth, when the skin of the baby’s trunk
is pinkish, but the soles of the feet and palm of the
hands are bluish this is called:
- Acrocyanosis
30. This procedure is done to prevent ophthalmia
neonatorum is:
- Crede’s method
31. Which of the following actions demonstrates the
nurse’s understanding of the newborn’s
thermoregulatory ability?
- Placing the newborn under a radiant warmer
32. Which of the following is true regarding the
fontanels of the newborn?
-The anterior is large in size when compared to the
posterior fontanel
33. As a part of the recommended nursing care of a
woman and family during the first 24 hours after birth,
which of the following can provide pain relief for post-
partum pains?
-Administer Acetaminophen as prescribed as has anti-
inflammatory
34. This refers to the is the process whereby the
reproductive organs return to their nonpregnant by the
time this is completed (6 weeks), the uterus is
completely return to its pre-pregnancy state, which is
referred to as:
- Involution
35. Which of the following describes the Babinski
reflex?
- The newborn’s toes will hyperextend and fan apart
from the dorsiflexion of the big toe when one side of
the foot is stroked upward form the ball of the heel and
across the ball of the foot
36. What is the uterine flow that consist of blood,
fragments of decidua, white blood cells, mucus, and
some bacteria is the portion of the uterus where the
placenta was not attached is so fully cleansed by this
sloughing process that it will be in a reproductive state
in about 3 weeks’ time?
- Lochia
37. The normal respiration of a newborn immediately
after birth is characterized as:
- Shallow and irregular with short periods of apnea
lasting not longer than 15 seconds, 30-60 breaths per
minute
38. Which of the following statements is true about the
vagina after normal spontaneous delivery?
-The hymen is permanently torn and heals with small,
separate tags of tissue
39. Postpartal patients are particularly prone to a
uterine infection because of lochia, if allowed to dry or
harden on the vulva and perineum, furnishes a rich bed
for bacterial growth, which then can spread to the
uterus. To reduce these risks, there will be a need for
more health teaching if the client will demonstrate;
- Performing perineal care if the lochia is no longer
present
40. Sarissa just delivered her baby thru normal 49. The following are interventions to relieve
spontaneous delivery, and she asked the nurse on duty episiotomy wound pain, except?
when her baby return to the pre-pregnant state. As a
a. Perineal care
nurse, implementing a teaching plan about postpartum
body changes should include which among the listed b. Sitz bath
information below?
c. Giving analgesic as ordered.
- Menstrual flow will return within 6 to 10 weeks after
delivery unless Sarissa is breastfeeding her baby d. Perineal heat

41. A postpartum nurse is preparing to care for a 50. The nurse should anticipate that hemorrhage
woman who has just delivered a healthy newborn related to uterine atony may occur postnatally if this
infant. In the immediate postpartum period, the nurse condition was present during the delivery.
plans to take the woman’s vital sign: - Excessive analgesia was given to the mother
- Every 15 minutes during the first hour and then every
30 minutes for the next two hours.
42. Which of the following is the primary predisposing
factor related to mastitis?
- Breast injury caused by overdistention, stasis, and
cracking of the nipples
43. The nurse observes Dalton holding her newborn.
Which position would best reassure the nurse that
interventions aimed at promoting bonding have been
successful?
- (?)
44. Nurse Wendell understands that this will help a
postpartal woman during the first 24 hours reduces
perineal edema and the possibility of hematoma
formation, which thereby reducing pain and promoting
healing and comfort.
- applying an ice or cold pack to the perineum
45. When performing a postpartum assessment on a
client, the nurse notes the presence of clots in the
lochia. The nurse examines the clots and notes that
they are larger than 1 cm. Which of the following
nursing actions is most appropriate?
- Notify the physician
46. According to Rubin’s theory of maternal role
adaptation, the mother will go through 3 stages during
the postpartum period. These stages are:
-Taking-in, taking hold and letting go
47. The following are nursing measures to stimulate
lactation, EXCEPT:
- Application of cold compress on the breast
48. The following are interventions to make the fundus
contract post partially, ECXPECT:
- Massage the fundus vigorously for 15 minutes until
contracted