Chapter 20
indicates poor glucose control. This, in
1. The nurse is teaching a pregnant
woman with type 1 diabetes about her
diet during pregnancy. Which client
statement indicates that the nurse's
teaching was successful?
A. "I'll basically follow the same diet that
I was following before I became
pregnant."
B. "Because I need extra protein, I'll
have to increase my intake of milk and
meat."
C. "Pregnancy affects insulin production,
so I'll need to make adjustments in my
diet."
D. "I'll adjust my diet and insulin based
on the results of my urine tests for
glucose."
Rationale: In pregnancy, placental
hormones cause insulin resistance at a
level that tends to
parallel growth of the fetoplacental unit.
Nutritional management focuses on
maintaining
balanced glucose levels. Thus, the
woman will probably need to make
adjustments in her diet.
Protein needs increase during
pregnancy, but this is unrelated to
diabetes. Blood glucose
monitoring results typically guide
therapy.
2. A pregnant woman with diabetes at
10 weeks' gestation has a glycosylated
hemoglobin (HbA1c) level of 13%. At
this time the nurse should be most
concerned about which possible
fetal outcome?
A. congenital anomalies
B. incompetent cervix
C. placenta previa
D. placental abruption (abruptio
placentae)
Rationale: A HbA1c level of 13%
conjunction with the woman being in the
first trimester, increases the risk for
congenital anomalies in the fetus.
Elevated glucose levels are not
associated with incompetent cervix,
placenta previa, or placental
abruption (abruptio placentae).
3. A nurse is conducting a review class
for a group of perinatal nurses working
at the local clinic.
The clinic sees a high population of
women who are HIV positive. After
discussing the
recommendations for antiretroviral
therapy with the group, the nurse
determines that the teaching was
successful when the group identifies
which rationale as the underlying
principle for the
therapy?
A. reduction in viral loads in the blood
B. treatment of opportunistic infections
C. adjunct therapy to radiation and
chemotherapy
D. can cure acute HIV/AIDS infections
Rationale: Drug therapy is the mainstay
of treatment and is important in reducing
the viral load
as much as possible. Antiretroviral
agents do not treat opportunistic
infections and are not
adjunctive therapy. There is no cure for
HIV/AIDS.
4. Assessment of a pregnant woman
and her fetus reveals tachycardia and
hypertension. There is
also evidence suggesting
vasoconstriction. The nurse would
question the woman about use of
which substance?
A. marijuana
B. alcohol
C. heroin
D. cocaine
Rationale: Cocaine use produces
vasoconstriction, tachycardia, and
hypertension in both the
mother and fetus. The effects of
marijuana are not yet fully understood.
Alcohol ingestion would
lead to cognitive and behavioral
problems in the newborn. Heroin is a
central nervous system
depressant.
5. When teaching a class of pregnant
women about the effects of substance
use during pregnancy, the nurse would
include which effect?
A. low-birthweight infants
B. excessive weight gain
C. higher pain tolerance
D. longer gestational periods
Rationale: Substance use during
pregnancy is associated with low birth
weight infants, preterm
labor, abortion, intrauterine growth
restriction, abruptio placentae,
neurobehavioral
abnormalities, and long-term childhood
developmental consequences.
Excessive weight gain,
higher pain tolerance, and longer
gestational periods are not associated
with substance use.
6. A client who is HIV-positive is in her
second trimester and remains
asymptomatic. She voices concern
about her newborn's risk for the
infection. Which statement by the nurse
would be most
appropriate?
A. "You'll probably have a cesarean birth
to prevent exposing your newborn."
B. "Antibodies cross the placenta and
provide immunity to the newborn."
C. "Wait until after the infant is born, and
then something can be done."
D. "Antiretroviral medications are
available to help reduce the risk of
transmission."
Rationale: Drug therapy is the mainstay
of treatment for pregnant women
infected with HIV. The
goal of therapy is to reduce the viral
load as much as possible; this reduces
the risk of
transmission to the fetus. Decisions
about the method of birth should be
based on the woman's
viral load, duration of ruptured
membranes, progress of labor, and
other pertinent clinical factors.
The newborn is at risk for HIV because
of potential perinatal transmission.
Waiting until after
the infant is born may be too late.
7. When preparing a schedule of
follow-up visits for a pregnant woman
with chronic hypertension, which
schedule would be most appropriate?
A. monthly visits until 32 weeks, then
bi-monthly visits
B. bi-monthly visits until 28 weeks, then
weekly visits
C. monthly visits until 20 weeks, then
bi-monthly visits
D. bi-monthly visits until 36 weeks, then
weekly visits
Rationale: For the woman with chronic
hypertension, antepartum visits typically
occur every 2
weeks until 28 weeks' gestation and
then weekly to allow for frequent
maternal and fetal
surveillance.
8. A woman with a history of asthma
comes to the clinic for evaluation for
pregnancy. The
woman's pregnancy test is positive.
When reviewing the woman's
medication therapy regimen
for asthma, which medication would the
nurse identify as problematic for the
woman now that
she is pregnant?
A. ipratropium
B. albuterol
C. salmeterol
D. Prednisone
Rationale: Oral corticosteroids such as
prednisone are not preferred for the
long-term treatment
of asthma during pregnancy. Inhaled
steroids are the choice for maintenance
medications to
reduce inflammation that leads to
bronchospasm. Common ones
prescribed include
beclomethasone and salmeterol.
Rescue agents such as albuterol or
ipratropium provide
immediate symptomatic relief by
reducing acute bronchospasm.
9. A pregnant woman is diagnosed with
iron-deficiency anemia and is prescribed
an iron
supplement. After teaching her about
her prescribed iron supplement, which
statement indicates
successful teaching?
A. "I should take my iron with milk."
B. "I should avoid drinking orange juice."
C. "I need to eat foods high in fiber."
D. "I'll call the primary care provider if
my stool is black and tarry."
Rationale: Iron supplements can lead to
constipation, so the woman needs to
increase her intake
of fluids and high-fiber foods. Milk
inhibits absorption and should be
discouraged. Vitamin C-
containing fluids such as orange juice
are encouraged because they promote
absorption. Ideally the woman should
take the iron on an empty stomach to
improve absorption, but many women
cannot tolerate the gastrointestinal
discomfort it causes. In such cases, the
woman should take it with meals. Iron
typically causes the stool to become
black and tarry; there is no need for the
woman to notify her primary care
provider.
10. The nurse is assessing a newborn of
a woman who is suspected of abusing
alcohol. Which
newborn finding would provide
additional evidence to support this
suspicion?
A. wide, large eyes
B. thin upper lip
C. protruding jaw
D. elongated nose
Rationale: Newborn characteristics
suggesting fetal alcohol spectrum
disorder include thin upper
lip, small head circumference, small
eyes, receding jaw, and short nose.
Other features include a
low nasal bridge, short palpebral
fissures, flat midface, epicanthal folds,
and minor ear
abnormalities.
11. After teaching a group of nurses
working at the women's health clinic
about the impact of
pregnancy on the older woman, which
statement by the group indicates that
the teaching was
successful?
A. "The majority of women who become
pregnant over age 35 experience
complications."
B. "Women over the age of 35 who
become pregnant require a specialized
type of assessment."
C. "Women over age 35 and are
pregnant have an increased risk for
spontaneous abortions."
D. "Women over age 35 are more likely
to have a substance use disorder."

Rationale: Whether childbearing is
delayed by choice or by chance, women
starting a family at
age 35 or older are not doing so without
risk. Women in this age group may
already have chronic
health conditions that can put the
pregnancy at risk. In addition, numerous
studies have shown
that increasing maternal age is a risk
factor for infertility and spontaneous
abortions, gestational
diabetes, chronic hypertension,
postpartum hemorrhage, preeclampsia,
preterm labor and birth, multiple
pregnancy, genetic disorders and
chromosomal abnormalities, placenta
previa, fetal growth restriction, low
Apgar scores, and surgical births (Dillion
et al. 2019). However, even
though increased age implies increased
complications, most women today who
become pregnant
after age 34, have healthy pregnancies
and healthy newborns. Nursing
assessment of the
pregnant woman over age 35 is the
same as that for any pregnant woman.
Women of this age
have the same risk for a substance use
disorder as any other age group.
12. A nurse is conducting an in-service
presentation to a group of perinatal
nurses about sexually
transmitted infections and their effect on
pregnancy. The nurse determines that
the teaching was
successful when the group identifies
which infection as being responsible for
ophthalmia
neonatorum?
A. syphilis
B. gonorrhea
C. chlamydia
D. HPV
Rationale: Infection with gonorrhea
during pregnancy can cause ophthalmia
neonatorum in the
newborn from birth through an infected
birth canal. Infection with syphilis can
cause congenital
syphilis in the neonate. Infection with
chlamydia can lead to conjunctivitis or
pneumonia in the
newborn. Exposure to HPV during birth
is associated with laryngeal papillomas.
13. A nurse is preparing a presentation
for a group of young adult pregnant
women about
common infections and their effect on
pregnancy. When describing the
infections, which
infection would the nurse include as the
most common congenital and perinatal
viral infection in
the world?
A. rubella
B. hepatitis B
C. cytomegalovirus
D. parvovirus B19
Rationale: Although rubella, hepatitis B,
and parovirus B19 can affect pregnant
women and their
fetuses, cytomegalovirus (CMV) is the
most common congenital and perinatal
viral infection in
the world. CMV is the leading cause of
congenital infection, with morbidity and
mortality at birth and sequelae. Each
year approximately 1% to 7% of
pregnant women acquire a primary
CMV infection. Of these, about 30% to
40% transmits infection to their fetuses.
14. A pregnant woman asks the nurse,
"I'm a big coffee drinker. Will the caffeine
in my coffee hurt my baby?" Which
response by the nurse would be most
appropriate?
A. "The caffeine in coffee has been
linked to birth defects."
B. "Caffeine has been shown to restrict
growth in the fetus."
C. "Caffeine is a stimulant and needs to
be avoided completely."
D. "If you keep your intake to less than
200 mg/day, you should be okay."
Rationale: The effect of caffeine intake
during pregnancy on fetal growth and
development is still unclear. A recent
study found that caffeine intake of no
more than 200 mg/day during
pregnancy does not affect pregnancy
duration and the condition of the
newborn. Birth defects
have not been linked to caffeine
consumption, but maternal coffee
consumption decreases iron
absorption and may increase the risk of
anemia during pregnancy. It is not
known if there is a correlation between
high caffeine intake and miscarriage due
to lack of sufficient studies.
15. A neonate born to a mother who
was abusing heroin is exhibiting signs
and symptoms of
withdrawal. Which signs would the
nurse assess? Select all that apply.
A. low whimpering cry
B. hypertonicity
C. lethargy
D. excessive sneezing
E. overly vigorous sucking
F. tremors
Rationale: Signs and symptoms of
withdrawal, or neonatal abstinence
syndrome, include:
irritability, hypertonicity, excessive and
often high-pitched crying, vomiting,
diarrhea, feeding
disturbances, respiratory distress,
disturbed sleeping, excessive sneezing
and yawning, nasal
stuffiness, diaphoresis, fever, poor
sucking, tremors, and seizures.
16. A nurse has been invited to speak at
a local high school about adolescent
pregnancy. When
developing the presentation, the nurse
would incorporate information related to
which aspects?
Select all that apply.
A. peer pressure to become sexually
active
B. rise in teen birth rates over the years.
C. Asian Americans as having the
highest teen birth rate
D. loss of self-esteem as a major impact
E. about half occurring within a year of
first sexual intercourse
Rationale: Adolescent pregnancy has
emerged as one of the most significant
social problems
facing our society. Early pregnancies
among adolescents have major health
consequences for
mothers and their infants. The latest
estimates show that approximately 1
million teenagers
become pregnant each year in the
United States, accounting for 13% of all
U.S. births, but the
rates have been declining in the last
several years. Teen birth rates in the
United States have
declined but remain high,especially
among African American and Hispanic
teenagers and
adolescents in southern states. The
most important impact lies in the
psychosocial area as it
contributes to a loss of self-esteem, a
destruction of life projects, and the
maintenance of the
circle of poverty. Moreover, about half of
all teen pregnancies occur within 6
months of first
having sexual intercourse. About one in
four teen mothers under age 18 have a
second baby
within 2 years after the birth of the first
baby.

17. A nurse is counseling a pregnant
woman with rheumatoid arthritis about
medications that can
be used during pregnancy. The nurse
would emphasize the need to avoid
which medication at
this time?
A. hydroxychloroquine
B. nonsteroidal anti-inflammatory drugs
C. glucocorticoid
D. methotrexate
Rationale: Methotrexate is
contraindicated during pregnancy. For
rheumatoid arthritis,
medications are limited to
hydroxychloroquine, glucocorticoids,
and NSAIDS.
18. A nurse is preparing a teaching
program for a group of pregnant women
about preventing
infections during pregnancy. When
describing measures for preventing
cytomegalovirus
infection, which measure would the
nurse include as a priority?
A. frequent handwashing
B. immunization
C. prenatal screening
D. antibody titer screening
Rationale: Most women are
asymptomatic and do not know they
have been exposed to CMV.
Prenatal screening for CMV infection is
not routinely performed. Since there is
no therapy that
prevents or treats CMV infections,
nurses are responsible for educating
and supporting
childbearing-age women at risk for CMV
infection. Stressing the importance of
good handwashing and use of sound
hygiene practices can help to reduce
transmission of the virus.
There is no immunization for CMV.
Antibody titer levels would be useful for
identifying women
at risk for rubella.
19. A pregnant woman comes to the
clinic for her first evaluation. The woman
is screened for
hepatitis B (HBV) and tests positive. The
nurse would anticipate administering
which agent?
A. HBV immune globulin
B. HBV vaccine
C. acylcovir
D. valacyclovir
Rationale: If a woman tests positive for
HBV, expect to administer HBV immune
globulin. The
newborn will also receive HBV vaccine
within 12 hours of birth. Acyclovir or
valacyclovir
would be used to treat herpes simplex
virus infection.
20. After teaching a pregnant woman
with iron deficiency anemia about
nutrition, the nurse
determines that the teaching was
successful when the woman identifies
which foods as being
good sources of iron in her diet? Select
all that apply.
A. dried fruits
B. peanut butter
C. meats
D. milk
E. white bread
Rationale: Foods high in iron include
meats, green leafy vegetables, legumes,
dried fruits, whole
grains, peanut butter, bean dip,
whole-wheat fortified breads, and
cereals.
21. A pregnant woman with gestational
diabetes comes to the clinic for a fasting
blood glucose
\level. When reviewing the results, the
nurse determines that the woman is
achieving good glucose control based
on which result?
A. 88 mg/dL
B. 100 mg/dL
C. 110 mg/dL
D. 120 mg/dL
Rationale: For a pregnant woman with
diabetes, the ADA and ACOG
recommend maintaining a
fasting blood glucose level below 95
mg/dL, with postprandial levels below
140 mg/dL at 1
hour, below 120 mg/dL at 2 hours.
22. A nurse is conducting a program for
pregnant women with gestational
diabetes about
reducing complications. The nurse
determines that the teaching was
successful when the group
identifies which factor as being most
important in helping to reduce
complications associated
with pregnancy and diabetes?
A. stability of the woman's emotional
and psychological status
B. degree of blood glucose control
achieved during the pregnancy
C. reduction in retinopathy risk by
frequent ophthalmologic evaluations
D. control of blood urea nitrogen (BUN)
levels for optimal kidney function
Rationale: Therapeutic management
for the woman with diabetes focuses on
tight glucose
control, thereby minimizing the risks to
the mother, fetus, and neonate. The
woman's emotional
and psychological status is highly
variable and may or may not affect the
pregnancy. Evaluating
for long-term diabetic complications
such as retinopathy or nephropathy, as
evidenced by
laboratory testing such as BUN levels, is
an important aspect of preconception
care to ensure that
the mother enters the pregnancy in an
optimal state.
23. A nurse is providing care to several
pregnant women at different weeks of
gestation. The
nurse would expect to screen for group
B streptococcus infection in the client
who is at:
A. 16 weeks' gestation.
B. 28 weeks' gestation.
C. 32 weeks' gestation.
D. 36 weeks' gestation.
Rationale: Pregnant women between
36 and 37 weeks’ gestation should be
universally screened
for GBS infection during a prenatal visit
and if positive, receive appropriate
intrapartum
antibiotic prophylaxis.
24. A woman with a history of systemic
lupus erythematosus comes to the clinic
for evaluation.
The woman tells the nurse that she and
her partner would like to have a baby
but that they are
afraid her lupus will be a problem.
Which response would be most
appropriate for the nurse to
make?
A. "It's probably not a good idea for you
to get pregnant since you have lupus."
B. "Be sure that your lupus is stable or
in remission for 6 months before getting
pregnant."
C. "Your lupus will not have any effect
on your pregnancy whatsoever."
D. "If you get pregnant, we'll have to add
quite a few medications to your normal
treatment plan.

Rationale: The time at which the nurse
comes in contact with the woman in her
childbearing life
cycle will determine the focus of the
assessment. If the woman is
considering pregnancy, it is
recommended that she postpone
conception until the disease has been
stable or in remission for 6
months. Active disease at time of
conception and history of renal disease
increase the likelihood
of a poor pregnancy outcome
(Cunningham et al., 2018). In particular,
if pregnancy is planned
during periods of inactive or stable
disease, the result is often giving birth to
healthy full-term
babies without increased risks of
pregnancy complications. Nonetheless,
pregnancies with most
autoimmune diseases are still classified
as high risk because of the potential for
major complications. Preconception
counseling should include the medical
and obstetric risks of
spontaneous abortion, stillbirth, fetal
death, fetal growth restriction,
preeclampsia, preterm labor,
and neonatal death and the need for
more frequent visits for monitoring the
condition. Treatment
of SLE in pregnancy is generally limited
to NSAIDs (e.g., ibuprofen), prednisone,
and an antimalarial agent,
hydroxychloroquine. During pregnancy
in the woman with SLE, the goal is to
keep drug therapy to a minimum.
25. A nurse is conducting a presentation
for a group of pregnant women about
measures to prevent toxoplasmosis.
The nurse determines that additional
teaching is needed when the group
identifies which measure as preventive?
A. washing raw fruits and vegetables
before eating them
B. cooking all meat to an internal
temperature of 125° F (52° C)
C. wearing gardening gloves when
working in the soil
D. avoiding contact with a cat's litter box
Rationale: Meats should be cooked to
an internal temperature of 160° F
(71°C). Other measures to prevent
toxoplasmosis include peeling or
thoroughly washing all raw fruits and
vegetables before eating them, wearing
gardening gloves when in contact with
outdoor soil, and avoiding
the emptying or cleaning of a cat's litter
box.
26. A pregnant client with iron-deficiency
anemia is prescribed an iron
supplement. After
teaching the woman about using the
supplement, the nurse determines that
more teaching is
needed based on which client
statement?
A. "Taking the iron supplement with food
will help with the side effects."
B. "I will need to avoid coffee and tea
when I take this supplement."
C. "I will take the iron with milk instead
of orange or grapefruit juice."
D. "If I happen to miss a dose, I will take
it as soon as I remember."
Rationale: The pregnant client should
take the iron supplement with vitamin
C-containing fluids
such as orange juice, which will promote
absorption, rather than milk, which can
inhibit iron
absorption. Taking iron on an empty
stomach improves its absorption, but
many women cannot
tolerate the gastrointestinal discomfort it
causes. In such cases, the woman is
advised to take it
with meals. The woman also needs
instruction about adverse effects, which
are predominantly
gastrointestinal and include gastric
discomfort, nausea, vomiting, anorexia,
diarrhea, metallic
taste, and constipation. Taking the iron
supplement with meals and increasing
intake of fiber and
fluids helps overcome the most common
side effects. If the woman misses a
dose, she should
take a dose as soon as she remembers.
27. A client in her first trimester comes
to the clinic for an evaluation.
Assessment reveals
reports of fatigue, anorexia, and
frequent upper respiratory infections.
The client's skin is pale
and the client is slightly tachycardic. The
client also reports drinking about 6 cups
of coffee on
average each day. A diagnosis of
iron-deficiency anemia is suspected.
The client is scheduled for
laboratory testing and the results are as
follows:
• Hemoglobin 11.5 g/dL (115 g/L)
• Hematocrit 35% (0.35)
• Serum iron 32 µg/dL (5.73 µmol/L)
• Serum ferritin 90 ng/dL (90 µg/L
Which laboratory finding would the
nurse correlate with the suspected
diagnosis?
A. Hemoglobin
B. Hematocrit
C. Serum iron level
D. Serum ferritin level
Rationale: Laboratory tests for
iron-deficiency anemia usually reveal
low hemoglobin (less than
11 g/dL or 110 g/L), low hematocrit (less
than 35% or 0.35), low serum iron (less
than 30 µg/dL
or 5.37 µmol/L), microcytic and
hypochromic cells, and low serum
ferritin (less than 100 ng/dL
or 100 µg/L). The client's hemoglobin,
hematocrit, and serum iron levels are
borderline low
normal, but the client's serum ferritin is
below 100 ng/dL (100 µg/L), helping to
support the
diagnosis.
28. A young adult woman comes to the
clinic for a routine check-up. During the
visit, the woman
who works in a day care facility tells the
nurse that she and her partner are
considering having a
baby. "We are concerned that I might be
exposed to common childhood
illnesses." The woman
undergoes testing and finds out that she
is not immune from chickenpox. Based
on this
information, which information would the
nurse give to the client?
A. "You will need to be vaccinated now
and wait at least 1 month before getting
pregnant."
B. "It is very likely that you will need to
quit your job if you do get pregnant."
C. "Because chickenpox is so rare
nowadays, there is nothing to worry
about."
D. "You will need to take a leave of
absence during winter and spring
months."
Rationale: Preconception counseling is
important for preventing chickenpox
(varicella). A major component of
counseling involves determining the
woman's varicella immunity. Vaccination
is the cornerstone of prevention. The
vaccine is administered if needed.
Varicella vaccine is a live
attenuated viral vaccine. It should be
administered to all adolescents and
adults 13 years of age
and older who do not have evidence of
varicella immunity. Therefore, the
woman should be
vaccinated now before she becomes
pregnant and then wait at least 1 month
before getting
pregnant. The varicella vaccine is
contraindicated for pregnant women
because the effects of the
vaccine on the fetus are unknown.
There is no need for the woman to quit
her job once she is
immunized nor does she need to take a
leave of abscence during the winter and
spring months
when the incidence is highest.
Chickenpox does occur and is highly
contagious. Maternal
varicella can be transmitted to the fetus
through the placenta, leading to
congenital varicella
syndrome if the mother is infected
during the first half of pregnancy via an
ascending aorta.
29. A nurse is obtaining a medication
history from a pregnant client with a
history of systemic
lupus erythematosus (SLE). Which
medication(s) would the nurse expect
the woman to report to
be currently using? Select all that apply.
A. Ibuprofen
B. Hydroxychloroquine
C. Methotrexate
D. Leflunomide
E. Prednisone
Rationale: Treatment of SLE in
pregnancy is generally limited to
NSAIDs like ibuprofen,
prednisone, and an antimalarial agent,
hydroxychloroquine. Methotrexate and
leflunomide are
used to treat rheumatoid arthritis but are
contraindicated for use in pregnancy
because of the
potential for fetal toxicity.
30. The nurse reviews the medical
record of a woman who has come to the
clinic for an
evaluation. The client has a history of
mitral valve prolapse and is listed as risk
class II. During the visit, the woman
states, "We want to have a baby, but I
know I am at higher risk. But what is
my risk, really?" Which response by the
nurse would be appropriate?
A. "If you do get pregnant, you will need
to be seen by a cardiologist every other
month for
monitoring."
B. "Your risk during pregnancy is small,
but you should see your cardiologist first
before getting
pregnant."
C. "Your heart disease would put too
much strain on your heart if you were to
get pregnant."
D. "Your pregnancy would be
uneventful, but you would need
specialized care for labor and
birth."
Rationale: Typically, a woman with
class I or II cardiac disease can go
through a pregnancy
without major complications. For class I
disease, there is no detectable
increased risk of maternal
mortality and no increase or a mild
increase in morbidity. For class II
disease, there is a small
increased risk of maternal mortality or
moderate increase in morbidity and
cardiac consultation
should occur every trimester. It is best to
have the woman see her cardiologist
before becoming
pregnant. A woman with class III
disease needs frequent visits with the
cardiac care team
throughout pregnancy. There is a
significantly increased risk of maternal
mortality or severe
morbidity and cardiologist consult
should occur every other month with
prenatal care and
delivery occurring at an appropriate
level hospital. A woman with class IV
disease is typically
advised to avoid pregnancy.
31. A pregnant woman with chronic
hypertension is entering her second
trimester. The nurse is
providing anticipatory guidance to the
woman about measures to promote a
healthy outcome.
The nurse determines that the teaching
was successful based on which client
statement(s)? Select
all that apply.
A. "I will need to schedule follow-up
appointments every 2 weeks until I
reach 32 weeks'
gestation."
B. "I should try to lie down and rest on
my left side for about an hour each day."
C. "I will start doing daily counts of my
baby's activity at about 24 weeks'
gestation."
D. "I will need to have an ultrasound at
each visit beginning at 28 weeks'
gestation."
E. "I should take my blood pressure
frequently at home and report any high
readings."
Rationale: The woman with chronic
hypertension will be seen more
frequently (every 2 weeks
until 28 weeks' gestation and then
weekly until birth) to monitor her blood
pressure and to assess for any signs of
preeclampsia. At approximately 24
weeks’ gestation, the woman will be
instructed to document fetal movement.
At this same time, serial ultrasounds will
be prescribed to monitor fetal growth
and amniotic fluid volume. The woman
should also have daily periods of
rest (1 hour) in the left lateral recumbent
position to maximize placental perfusion
and use home blood pressure
monitoring devices frequently (daily
checks would be preferred), reporting
any elevations.
32. A pregnant client with type 1
diabetes is in labor. The client's blood
glucose levels are being monitored
every hour and she has a prescription
for an infusion of regular insulin as
needed based on the client's blood
glucose levels. Her levels are as follows:
1300: 105 mg/dL (5.83 mmol/L)
1400: 100 mg/dL (5.55 mmol/L)
1500: 120 mg/dL (6.66 mmol/L)1600:
106 mg/dl (5.88 mmol/L)
Based on the recorded blood glucose
levels, at which time would the nurse
likely administer the regular insulin
infusion?
Rationale: For the laboring woman with
diabetes, intravenous (IV) saline or
lactated Ringer's is given, and blood
glucose levels are monitored every 1 to
2 hours. Glucose levels are
maintained below 110 mg/dL (6.11
mmol/L) throughout labor to reduce the
likelihood of neonatal hypoglycemia. If
necessary, an infusion of regular insulin
may be given to maintain this level. The
insulin infusion would be given at 1500,
based on the blood glucose level being
higher than 110 mg/dL (6.11 mmol/L).
33. A pregnant client with iron-deficiency
anemia is prescribed an iron
supplement. After teaching the woman
about using the supplement, the nurse
determines that more teaching is
needed based on which client
statement?
"I will take the iron with milk instead of
orange or grapefruit juice."
Rationale: The pregnant client should
take the iron supplement with vitamin
C-containing fluids such as orange juice,
which will promote absorption, rather
than milk, which can inhibit iron
absorption. Taking iron on an empty
stomach improves its absorption, but
many women cannot tolerate the
gastrointestinal discomfort it causes. In
such cases, the woman is advised to
take it with meals. The woman also
needs instruction about adverse effects,
which are predominantly gastrointestinal
and include gastric discomfort, nausea,
vomiting, anorexia, diarrhea, metallic
taste, and constipation. Taking the iron
supplement with meals and increasing
intake of fiber and fluids helps overcome
the most common side effects. If the
woman misses a dose, she should take
a dose as soon as she remembers.
34. A 17-year-old primigravida with type
1 diabetes is at 37 weeks' gestation
comes to the clinic for an evaluation.
The nurse notes her blood sugar has
been poorly controlled and the health
care provider is suspecting the fetus has
macrosomia. The nurse predicts which
step will be completed next?
Preparing for amniocentesis and fetal
lung maturity assessment
Rationale: If the infant has macrosomia,
is large for gestation age, and the
mother has had poor blood-sugar
control, the provider will want further
information on the fetus and readiness
for delivery before making any decisions
on delivery. After determining the
readiness of the fetus, then plans for
delivery can be determined and
scheduled.
35. The nurse is assessing a pregnant
client with a known history of congestive
heart failure who is in her third trimester.
Which assessment findings should the
nurse prioritize?
dyspnea, crackles, and irregular weak
pulse
Rationale: The nurse should be alert for
signs of cardiac decompensation due to
congestive heart failure, which include
crackles in the lungs from fluid, difficulty
breathing, and weak pulse from heart
exhaustion. The heart rate would not be
regular, and a cough would not be dry.
The heart rate would increase rather
than decrease.
36. A woman with known cardiac
disease from childhood presents at the
obstetrician's office 6 weeks' pregnant.
What recommendations would the nurse
make to the client to address the known
cardiac problems for this pregnancy?
Select all that apply.
- Plan periods of rest into the workday.
- Receive pneumococcal and influenza
vaccines.
- Let the physician know if you become
short of breath or have a nighttime
cough.
Rationale: Women with known heart
conditions need to be closely followed
by both the obstetrician and a
cardiologist. Recommendations would
include rest periods, reduction of stress,
getting immunizations, and monitoring
for heart failure as demonstrated by a
nighttime cough and shortness of
breath. Consuming more sodium in the
diet is not recommended due of the
potential of developing hypertension.
Warfarin is contraindicated during
pregnancy since it crosses the placental
barrier and can cause spontaneous
abortion, stillbirth or preterm birth.
37. A young woman with scoliosis has
just learned that she is pregnant.
Several years ago, she had
stainless-steel rods surgically implanted
on both sides of her vertebrae to
strengthen and straighten her spine.
However, her pelvis is unaffected by the
condition. Which of the following does
the nurse anticipate in this woman's
pregnancy?
Potential for greater than usual back
pain
Rationale: Surgical correction of
scoliosis (lateral curvature of the spine)
involves implanting stainless-steel rods
on both sides of the vertebrae to
strengthen and straighten the spine.
Such rod implantations do not interfere
with pregnancy; a woman may notice
more than usual back pain, however,
from increased tension on back
muscles. If a woman's pelvis is distorted
due to scoliosis, a cesarean birth may
be scheduled to ensure a safe birth, but
this is not required in this scenario.
Vaginal birth, if permitted, requires the
same management as for any woman.
With the improved management of
scoliosis, the high maternal and
perinatal risks associated with the
disorder reported in earlier literature no
longer exist.
38. A client in week 38 of her pregnancy
arrives at the emergency room reporting
a sharp pain between her umbilicus and
the iliac crest in her lower right abdomen
that is increasing. She reports having
experienced intense nausea and
vomiting for the past 3 hours. Given
these symptoms, the nurse suspects
which of the following conditions?
Appendicitis
Rationale: With appendicitis, the
nausea and vomiting is much more
intense than with morning sickness and
the pain is sharp and localized at
McBurney's point (a point halfway
between the umbilicus and the iliac crest
on the lower right abdomen). With a
ruptured ectopic pregnancy, a woman
may experience abdominal pain that is
either diffuse or sharp, but it is less likely
to occur precisely at McBurney's point.
The symptoms described do not match
those of pulmonary embolism or
left-sided heart failure.
39. In women with cardiac failure, the
maternal blood pressure becomes
insufficient to provide an adequate
supply of blood to the placenta. The
infant will likely experience some
undesired effects, including which of the
following?
low birth weight
Rationale: Cardiac failure can affect
fetal growth at the point at which
maternal blood pressure becomes
insufficient to provide an adequate
supply of blood and nutrients to the
placenta. For this reason, the infant may
tend to have a low birth weight, be
preterm, and respond poorly to labor.
40. Which factor would contribute to a
high-risk pregnancy?
type 1 diabetes
Rationale: A woman with a history of
diabetes has an increased risk for
perinatal complications, including
hypertension, preeclampsia, and
neonatal hypoglycemia. The age of 33
without other risk factors does not
increase risk, nor does type O-positive
blood or environmental allergens.
41. A nurse is providing education to a
woman at 28 weeks' gestation who has
tested positive for gestational diabetes
mellitus (GDM). What would be
important for the nurse to include in the
client teaching?
She is at increased risk for type 2
diabetes mellitus after her baby is born.
Rationale: The woman who develops
GDM is at increased risk for developing
type 2 diabetes mellitus after pregnancy.
42. The maternal health nurse is caring
for a group of high-risk pregnant clients.
Which client condition will the nurse
identify as being the highest risk for
pregnancy?
Pulmonary hypertension
Rationale: Pulmonary hypertension is
considered the greatest risk to a
pregnancy because of the hypoxia that
is associated with the condition. The
remaining conditions represent potential
cardiac complications that may increase
the client's risk in pregnancy; however,
these do not present the greatest risk in
pregnancy.
43. A pregnant client with sickle cell
anemia is admitted in crisis. Which
nursing intervention should the nurse
prioritize?
IV fluids
Rationale: A sickle cell crisis during
pregnancy is usually managed by
exchange transfusion, oxygen, and IV
fluids. Antihypertensive drugs usually
aren't necessary. Diuretics would not be
used unless fluid overload resulted. The
client would be given antibiotics only if
there were evidence of an infection.
44. A mother is talking to the nurse and
is concerned about managing her
asthma while she is pregnant. Which
response to the nurse's teaching
indicates that the woman needs further
instruction?
"I need to begin taking allergy shots like
my friend to prevent me from having an
allergic reaction this spring."
Rationale: A pregnant woman with a
history of asthma needs to be proactive,
taking her inhalers and other asthma
medications to prevent an acute asthma
attack. She needs to understand that it
is far more dangerous to not take the
medications and have an asthma attack.
She also needs to monitor her peak flow
for decreases, be aware of triggers, and
avoid them if possible. However, a
pregnant woman should never begin
allergy shots if she has not been taking
them previously, due to the potential of
an adverse reaction.
45. The nurse is preparing information
for a client who has just been diagnosed
with gestational diabetes. Which
instruction should the nurse prioritize in
this information?
Maintain a daily blood glucose log
Rationale: Control of the blood glucose
throughout the pregnancy is the primary
goal to help decrease potential
complications to both the mother and
fetus. The mother should keep a daily
log of her blood glucose levels and bring
this log to each visit for the nurse to
evaluate. The other choices of reporting
possible signs of a UTI and working with
a dietitian to plan menus would also be
important but would be secondary to the
blood glucose control. It would be
inappropriate to discuss long-term goals
at this time. This would be handled at a
later time and would depend on the
mother's situation.
46. A 32-year-old woman with epilepsy
mentions to the nurse during a routine
well-visit that she would like to have
children and asks the nurse for advice.
Which response is most appropriate
from the nurse?
"I'll let the doctor know so you can
discuss your medications. In the
meantime, I'll give you a list of folate-rich
foods you can add to your diet."
Rationale: Any woman with epilepsy
needs to discuss the medication
management with her provider. The
current research indicates the
medications used for epileptic
management are the major cause of
birth defects for these patients. The
nurse should be careful about
mentioning that some epileptics are
teratogenic; some women may stop
taking their medications in order to get
pregnant. Suggesting adoption is
inappropriate as the mother has given
no indication she is interested in
adoption; also, the mother needs to
discuss this with the physician so that
she can get accurate information about
being on anti-seizure medications and
being pregnant. The nurse should not
share personal information as it does
not assist this client in making a serious
decision. The client should be referred
to the health care provider to help the
client make the best decision.
47. A pregnant woman with type 2
diabetes is scheduled for a laboratory
test of glycosylated hemoglobin
(HbA1C). What does the nurse tell the
client is a normal level for this test?
6%
Rationale: The upper normal level of
HbA1C is 6% of total hemoglobin.
48. A pregnant woman who has been
taking penicillin prophylactically because
she had rheumatic fever as a child tells
the nurse that she wants to stop taking it
now that she is pregnant. Which of the
following is the best response by the
nurse?
"You should continue taking this drug,
because penicillin is not known to be a
fetal teratogen."
Rationale: A woman taking penicillin
prophylactically because she had
rheumatic fever as a child and wants to
prevent a recurrence should continue
this drug during pregnancy. Penicillin is
not known to be a teratogen.
49. A nursing instructor is teaching
students about caring for a pregnant
patient with a pre-existing disease.
Which of the following does the
instructor suggest has added to an
increased incidence of pregnant women
with a pre-existing disease?
More women waiting until after age 30
years to get pregnant
Rationale: As more women wait until
they are older than 30 years to have
their first child, more also enter
pregnancy with a pre-existing disorder.
50. The nurse is teaching a pregnant
woman with type 1 diabetes about her
diet during pregnancy. Which client
statement indicates that the nurse's
teaching was successful?
"Pregnancy affects insulin production,
so I'll need to make adjustments in my
diet."
Rationale: In pregnancy, placental
hormones cause insulin resistance at a
level that tends to parallel growth of the
fetoplacental unit. Nutritional
management focuses on maintaining
balanced glucose levels. Thus, the
woman will probably need to make
adjustments in her diet. Protein needs
increase during pregnancy, but this is
unrelated to diabetes. Blood glucose
monitoring results typically guide
therapy.
51. The nurse is appraising the
laboratory results of a pregnant client
who is in her second trimester and notes
the following: thyroid stimulating
hormone (TSH) slightly elevated,
glucose in the urine, complete blood
count (CBC) low normal, and normal
electrolytes. The nurse prioritizes further
testing to rule out which condition?
Gestational diabetes
Rationale: Glycosuria, glucose in the
urine, may occur normally during
pregnancy; however, if it appears in the
urine, the client should be sent for
testing to rule out gestational diabetes.
Preeclampsia, anemia, and
hyperthyroidism are not related to
glucose nor to renal function. A slightly
elevated TSH would indicate possible
hypothyroidism instead of
hyperthyroidism. Anemia would be
indicated by below normal hematocrit. If
the client's CBC is low normal than the
nurse should monitor future results to
ensure the client's counts are not
dropping. It would also be appropriate
for the nurse to investigate possible
dietary issues. Preeclampsia would be
best monitored by the blood pressure
readings.
52. The maternal health nurse is caring
for a pregnant client with a history of
epilepsy. The client's antiepileptic drug
(AED) levels have been in the
non-therapeutic range the last two times
the labs were drawn. Which factor does
the nurse associate with this finding?
Drug metabolism changes during
pregnancy
Rationale: Drug metabolism changes
during pregnancy which may alter the
therapeutic AED levels in the pregnant
client. Some AEDs cannot be given in
pregnancy due to risk of harm to the
fetus; however, there are some that may
be given. Pregnant clients do not have
high rates of noncompliance and the
action of medications do not change in
pregnancy.
53. A pregnant client with a history of
asthma since childhood presents for a
prenatal visit. What statement by the
client would the nurse prioritize?
"I sometimes get a bit wheezy."
Rationale: Wheezing is a classic
symptom of asthma. This statement
should alert the nurse to the possibility
that the woman's asthma is not being
well-controlled and needs further
evaluation and possible intervention.
The other statements do not relate to
the typical presentation of this disease
in pregnancy.
54. A 38-year-old woman comes into the
obstetrician's office for prenatal care,
stating that she is about 12 weeks
pregnant with her first child. What
questions would the nurse ask this
client, considering her age and potential
sensitivity to being labeled an "older"
primipara?
Be nonjudgmental in your history
gathering and offer her pregnancy
resources to read and explore.
Rationale: Women are having babies
later in life and nurses must be
supportive of their choices to postpone
pregnancy. Most women realize the
increased risks for having a baby after
35 years of age and don't need constant
reminding of all the potentially bad
outcomes that can occur. The majority
of pregnancies to women over 35 years
of age end up with healthy babies and
mothers.
55. A woman with cardiac disease at 32
weeks' gestation reports she has been
having spells of light-headedness and
dizziness every few days. Which
instruction should the nurse prioritize?
Decrease activity and rest more often.
Rationale: If the client is developing
symptoms associated with her heart
condition, the first intervention is to
monitor activity levels, decrease activity,
and treat the symptoms. At 32 weeks'
gestation, the suggestion to induce labor
is not appropriate, and without
knowledge of the type of heart condition
one would not recommend an increase
of fluids or vitamins. Total bed rest may
be required if the symptoms do not
resolve with decreased activity.
56. The nurse is preparing to teach a
pregnant client with iron deficiency
anemia about the various iron-rich foods
to include in her diet. Which food should
the nurse point out will help increase the
absorption of her iron supplement?
Orange juice
Rationale: Anemia is a condition in
which the blood is deficient in red blood
cells, from an underlying cause. The
woman needs to take iron to
manufacture enough red blood cells.
Taking an iron supplement will help
improve her iron levels, and taking iron
with foods containing ascorbic acid,
such as orange juice, improves the
absorption of iron. Dried fruit (such as
apples), fortified grains, and dried beans
are additional food choices that are rich
in iron and should be included in her
daily diet.
57. A 29-year-old client has gestational
diabetes. The nurse is teaching her
about managing her glucose levels.
Which therapy would be most
appropriate for this client?
diet
Rationale: Clients with gestational
diabetes are usually managed by diet
alone to control their glucose
intolerance. Long-acting insulin usually
is not needed for blood glucose control
in the client with gestational diabetes.
Oral hypoglycemic drugs are
contraindicated in pregnancy. Glucagon
raises blood glucose and is used to treat
hypoglycemic reactions.
58. A pregnant woman with a history of
mitral valve stenosis is to be prescribed
medication as treatment. Which
medication class would the nurse expect
the client to be prescribed?
anticoagulant
Rationale: In mitral valve stenosis, it is
difficult for blood to leave the left atrium.
A secondary problem of thrombus
formation may develop as a result of
noncirculating blood. A woman may
need to be prescribed an anticoagulant
to prevent this complication.
Vasodilators are used for peripartum
cardiomyopathy. Inotropics are used for
heart failure. Angiotensin receptor
blockers are used for congestive heart
failure.
59. The nurse is caring for a pregnant
woman with diabetes mellitus. Which
potential fetal complications should the
nurse monitor the client for as she
presents for her scheduled visits? Select
all that apply.
congenital malformations
macrosomia
respiratory disorder
Rationale: Potential problems during
pregnancy involving maternal diabetes
mellitus include fetal death, macrosomia
(oversized fetus), a fetus with a
respiratory disorder, difficult labor,
preeclampsia or eclampsia,
polyhydramnios, and congenital
malformations.
60. The nurse is assessing a pregnant
client who has a history of heart
disease. The nurse will prioritize
assessments focusing on the heart
during which time frame?
28 to 32 weeks' gestation
Rationale: A pregnant woman with
heart disease is most vulnerable for
cardiac decompensation from 28 to 32
weeks' gestation, just after the blood
volume peaks. It would be important to
assess the client's heart at each visit;
however, the client's heart would be
more stressed at this time due to the
increased blood volume and identifying
a serious situation early provides the
best opportunity for treatment and
preventing complications.
61. A nurse is teaching a 30-year-old
gravida 1 who has sickle cell anemia.
Providing education on which topic is
the highest nursing priority?
avoidance of infection
Rationale: Prevention of crises, if
possible, is the focus of treatment for
the pregnant woman with sickle cell
anemia. Maintaining adequate
hydration, avoiding infection, getting
adequate rest, and eating a balanced
diet are all common-sense strategies
that decrease the risk of a crisis. Fat
intake does not need to be decreased
and immunoglobulins are not normally
administered. Constipation is not usually
a result of sickle cell anemia.
62. The clinic nurse teaches a
pregestational type 1 diabetic client that
constant insulin levels are very
important during pregnancy. The nurse
tells the client that the best way to
maintain a constant insulin level is to
use:
an insulin pump.
Rationale: Because a pregnant client
will have some periods of relative
hyperglycemia and hypoglycemia no
matter how carefully she maintains her
diet and balances her exercise levels,
an effective method to keep serum
glucose levels constant is to administer
insulin with a continuous pump during
pregnancy.
64. A client is diagnosed with peripartum
cardiomyopathy (PPCM). Which therapy
would the nurse expect to administer to
the client?
restricted sodium intake
Rationale: The client with peripartum
cardiomyopathy should be prescribed a
restricted sodium intake to control the
blood pressure. Monoamine oxidase
inhibitors are given to treat depression
in pregnancy, not peripartum
cardiomyopathy. Methadone is a drug
given for the treatment of a substance
use disorder during pregnancy.
Complementary therapies like ginger
therapy help in the alleviation of
hyperemesis gravidarum, not peripartum
cardiomyopathy.
65. A pregnant woman with diabetes at
10 weeks' gestation has a glycosylated
hemoglobin (HbA1c) level of 13%. At
this time the nurse should be most
concerned about which possible fetal
outcome?
congenital anomalies
Rationale: A HbA1c level of 13%
indicates poor glucose control. This, in
conjunction with the woman being in the
first trimester, increases the risk for
congenital anomalies in the fetus.
Elevated glucose levels are not
associated with incompetent cervix,
placenta previa, or placental abruption
(abruptio placentae).
66. The nurse is assessing a
35-year-old woman at 22 weeks'
gestation who has had recent laboratory
work. The nurse notes fasting blood
glucose 146 mg/dl (8.10 mmol/L),
hemoglobin 13 g/dl (130 g/L), and
hematocrit 37% (0.37). Based on these
results, which instruction should the
nurse prioritize?
Check blood sugar levels daily.
Rationale: An elevated blood glucose is
concerning for diabetes. A fasting blood
glucose level of greater than 140 mg/dl
(7.77 mmol/L) or random level of greater
than 200 mg/dl (11.10 mmol/L) is
concerning; this must be followed up to
ensure the client is not developing
gestational diabetes. The hemoglobin
and hematocrit are within normal limits
for this client. The values should be
hemoglobin greater than 11 g/dl (110
g/L) and hematocrit greater than 33%
(0.33). Values lower than that are
possible indications of anemia and
would necessitate further evaluation. An
individual with higher than normal blood
glucose levels is at risk for developing
urinary tract infection. This will usually
happen after the glucose levels are
elevated. Anemia can be treated by
increasing the consumption of
iron-enriched foods and taking a daily
iron supplement.
67. The health care provider of a newly
pregnant client determines the woman
also has mitral stenosis and will need
appropriate therapy. Which medication
should the nurse prepare to teach this
client to provide her with the best
possible care?
heparin
Rationale: This client has an increased
risk for developing blood clots. If an
anticoagulant is required, heparin is the
drug of choice as it does not cross the
placenta barrier. Warfarin crosses the
placenta and may have teratogenic
effects. Aspirin is not recommended in
this situation. Digoxin is not used to
prevent blood clots.
68. The nurse is caring for a pregnant
woman determined to be at high risk for
gestational diabetes. The nurse
prepares to rescreen this client at which
time frame?
24 to 28 weeks
Rationale: A woman identified as high
risk for gestational diabetes would
undergo rescreening between 24 and 28
weeks; however, some health care
providers can choose to conduct this
screening earlier.
69. A nurse is assessing a client in her
seventh month of pregnancy who has
an artificial valve prosthesis. The client
is taking an oral anticoagulant to prevent
the formation of clots at the valve site.
Which of the following nursing
interventions is most appropriate in this
situation?
Observe the client for signs of petechiae
and premature separation of the
placenta
Rationale: Subclinical bleeding from
continuous anticoagulant therapy in the
woman has the potential to cause
placental dislodgement. Observe a
woman who is taking an anticoagulant
for signs of petechiae and signs of
premature separation of the placenta,
therefore, during both pregnancy and
labor. The nurse should not urge the
client to discontinue the anticoagulant,
as this is not within the nurse's scope of
practice and, in any case, the client still
needs the anticoagulant to prevent clots.
Bed rest is prescribed for clients with a
thrombus, to prevent it from moving and
becoming a pulmonary embolus.
Avoiding the use of constrictive
knee-high stockings is to prevent
thrombus formation.
70. Which changes in pregnancy would
the nurse identify as a contributing
factor for arterial thrombosis, especially
for the woman with atrial fibrillation?
hypercoagulable state
Rationale: The nurse should identify
that the increased risk of arterial
thrombosis in atrial fibrillation is due to
the hypercoagulable state of pregnancy.
During pregnancy, there is a state of
hypercoagulation. This increases the
risk of arterial thrombosis in clients
having atrial fibrillation and artificial
valves. Increased cardiac output and
blood volume do not cause arterial
thrombosis. Elevation of the diaphragm
is due to the uterine distension, and it
causes a shift in the QRS axis and is not
associated with arterial thrombosis.
71. The nurse is caring for a pregnant
client with pregestational diabetes.
Which goal does the nurse identify as
priority during the client's pregnancy?
Maintain glycemic control
Rationale: The most important goal
when caring for a pregnant client with
pregestational diabetes is to maintain
glycemic control. The scenario does not
give enough information on the client's
weight to determine if the client should
gain only minimal weight during
pregnancy. Ensuring compliance of
glucose monitoring and monitoring for
associated complications are
appropriate nursing interventions;
however, these do not take priority.
72. A pregnant client with cystic fibrosis
(CF) comes to the office for a prenatal
visit. She asks the nurse for information
on breast-feeding. The best response by
the nurse is:
"Breast-feeding is not a good idea.
Because your breast milk is high in
sodium due to CF, there is a risk of the
infant receiving too much sodium."
Rationale: The milk of a nursing mother
with cystic fibrosis is high in sodium.
This potentially places the infant at risk
for hypernatremia, that is, too much
sodium. Provide the client with as much
correct information as possible, and
explain medical terms in layperson's
language.
73. When providing nutritional
counseling to a pregnant woman with
diabetes, the nurse would urge the client
to obtain most of her calories from which
source?
complex carbohydrates
Rationale: The pregnant woman with
diabetes is encouraged to eat three
meals a day plus three snacks, with
40% of calories derived from
good-quality complex carbohydrates,
35% of calories from protein sources,
and 35% of calories from unsaturated
fats. The intake of saturated fats should
be limited during pregnancy, just as they
should be for any person to reduce the
risk of heart disease.
74. The nurse is assessing a pregnant
client who has a long history of asthma.
She states, "I'm trying not to use my
asthma medications because I certainly
don't want my baby exposed to them."
What is the nurse's best response?
"Actually, having uncontrolled asthma is
much riskier for your baby than the
medication."
Rationale: It is important for pregnant
clients with asthma to keep taking their
medications because the risks of
exacerbations exceed the risks of the
medications.
75. A 17-year-old primigravida at 37
weeks' gestation has been unable to
maintain adequate control of her blood
glucose throughout her pregnancy. The
nurse should prioritize which action after
the health care provider suspects the
infant has macrosomia based on the
recent ultrasound?
Prepare for assessment of fetal lung
maturity.
Rationale: If the infant has macrosomia,
is large for gestational age, and the
mother has had poor blood sugar
control, the provider will want further
information on the fetus and readiness
for delivery before making any decisions
on delivery. This will best be
accomplished by an amniocentesis to
assess the fetal lung maturity.
Scheduling an induction of labor,
allowing the patient to continue without
plans for delivery, or scheduling a
cesarean delivery at 39 weeks would
not be appropriate nursing actions.
Scheduling an induction or a cesarean
section is not in the province of a nurse
without a physician's order.
76. A nurse informs a pregnant woman
with cardiac disease that she will need
two rest periods each day and a full
night's sleep. The nurse further instructs
the client that which position for this rest
is best?
left lateral recumbent
Rationale: The pregnant woman should
rest in the left lateral recumbent position
to prevent supine hypotension
syndrome and increased heart effort.
77. A pregnant client with deep vein
thrombosis has been diagnosed as
having systemic lupus erythematosus
(SLE). The nurse would monitor the
client closely for the development of
which complication?
Fetal malnutrition
Rationale: SLE is an autoimmune
disorder in which there is deposition of
immune complexes in the capillaries
and visceral structures. Clients with SLE
who become pregnant are at an
increased risk of fetal malnutrition due to
decreased placental circulation.
Pregnancy-related problems in SLE
include prematurity, stillbirth, decreased
placental weight and thinner placental
villi. In clients with SLE there is preterm
birth and decreased placental weight.
Fetal macrosomia is seen in clients
having gestational diabetes, not SLE.
Chapter 21
1. After spontaneous rupture of
membranes, the nurse notices a
prolapsed cord. The nurse
immediately places the woman in which
position?
A. supine
B. side-lying
C. sitting
D. knee–chest
Rationale: Pressure on the cord needs
to be relieved. Therefore, the nurse
would position the
woman in a modified Sims,
Trendelenburg, or knee–chest position.
Supine, side-lying, or sitting
would not provide relief of cord
compression.
2. A primigravida whose labor was
initially progressing normally is now
experiencing a decrease
in the frequency and intensity of her
contractions. The nurse would assess
the woman for which
condition?
A. a low-lying placenta
B. fetopelvic disproportion
C. contraction ring
D. uterine bleeding
Rationale: The woman is experiencing
dystocia most likely due to hypotonic
uterine dysfunction
and fetopelvic disproportion associated
with a large fetus. A low-lying placenta,
contraction ring,
or uterine bleeding would not be
associated with a change in labor
pattern.
3. Which assessment finding will alert
the nurse to be on the lookout for
possible placental
abruption during labor?
A. macrosomia
B. gestational hypertension
C. gestational diabetes
D. low parity
Rationale: Risk factors for placental
abruption include preeclampsia,
gestational hypertension,
seizure activity, uterine rupture, trauma,
smoking, cocaine use, coagulation
defects, previous
history of abruption, intimate partner
violence, and placental pathology.
Macrosomia, gestational
diabetes, and low parity are not
considered risk factors.
4. A woman in labor is experiencing
hypotonic uterine dysfunction.
Assessment reveals no
fetopelvic disproportion. Which group of
medications would the nurse expect to
administer?
A. sedatives
B. tocolytics
C. uterine stimulants
D. corticosteroids
Rationale: For hypotonic labor, a
uterine stimulant such as oxytocin may
be prescribed once fetopelvic
disproportion is ruled out. Sedatives
might be helpful for the woman with
hypertonic
uterine contractions to promote rest and
relaxation. Tocolytics would be ordered
to control preterm labor. Corticosteroids
may be given to enhance fetal lung
maturity for women
experiencing preterm labor.
5. A woman gave birth to a newborn via
vaginal birth with the use of a vacuum
extractor. The nurse would be alert for
which possible effect in the newborn?
A. asphyxia
B. clavicular fracture
C. cephalhematoma
D. central nervous system injury
Rationale: Use of forceps or a vacuum
extractor poses the risk of tissue
trauma, such as
ecchymoses, facial and scalp
lacerations, facial nerve injury,
cephalhematoma, and caput
succedaneum. Asphyxia may be related
to numerous causes, but it is not
associated with use of a
vacuum extractor. Clavicular fracture is
associated with shoulder dystocia.
Central nervous system injury is not
associated with the use of a vacuum
extractor.
6. A pregnant client undergoing labor
induction is receiving an oxytocin
infusion. Which finding
would require immediate intervention?
A. fetal heart rate of 150 beats/minute
B. contractions every 2 minutes, lasting
45 seconds
C. uterine resting tone of 14 mm Hg
D. urine output of 20 mL/hour
Rationale: Oxytocin can lead to water
intoxication. Therefore, a urine output of
20 mL/hour is
below acceptable limits of 30 mL/hour
and requires intervention. FHR of 150
beats/minute is
within the accepted range of 120 to 160
beats/minute. Contractions should occur
every 2 to 3
minutes, lasting 40 to 60 seconds. A
uterine resting tone greater than 20 mm
Hg would require
intervention.
7. A woman with a history of crack
cocaine use disorder is admitted to the
labor and birth area.
While caring for the client, the nurse
notes a sudden onset of fetal
bradycardia. Inspection of the
abdomen reveals an irregular wall
contour. The client also reports acute
abdominal pain that is
continuous. Which condition would the
nurse suspect?
A. amniotic fluid embolism
B. shoulder dystocia
C. uterine rupture
D. umbilical cord prolapse
Rationale: Uterine rupture is associated
with crack cocaine use disorder.
Generally, the first and
most reliable sign is sudden fetal
distress accompanied by acute
abdominal pain, vaginal
bleeding, hematuria, irregular wall
contour, and loss of station in the fetal
presenting part.
Amniotic fluid embolism often is
manifested with a sudden onset of
respiratory distress.
Shoulder dystocia is noted when
continued fetal descent is obstructed
after the fetal head is
delivered. Umbilical cord prolapse is
noted as the protrusion of the cord
alongside or ahead of
the presenting part of the fetus.
8. A woman receives magnesium sulfate
as treatment for preterm labor. The
nurse assess and
maintains the infusion at the prescribed
rate based on which finding?
A. Respiratory rate-16 breaths/minute
B. Decreased fetal heart rate variability
C. Urine output 22 mL/hour
D. Absent deep tendon reflexes
Rationale: A respiratory rate of 16
breaths per minute is appropriate and
within acceptable
parameters to continue the infusion.
When administering magnesium sulfate,
the nurse would
immediately report decreaed fetal heart
rate variability, a urine output less than
30 mL/hour, and
decreased or absent deep tendon
reflexes.
9. The nurse is reviewing the physical
examination findings for a client who is
to undergo labor
induction. Which finding would indicate
to the nurse that a woman's cervix is
ripe in preparation
for labor induction?
A. posterior position
B. firm
C. closed
D. shortened
Rationale: A ripe cervix is shortened,
centered (anterior), softened, and
partially dilated. An unripe cervix is long,
closed, posterior, and firm.
10. A woman with preterm labor is
receiving magnesium sulfate. Which
finding would require
the nurse to intervene immediately?
A. respiratory rate of 16 breaths per
minute
B. 1+ deep tendon reflexes
C. urine output of 45 mL/hour
D. alert level of consciousness
Rationale: Diminished deep tendon
reflexes (1+) suggest magnesium
toxicity, which requires
immediate intervention. Additional signs
of magnesium toxicity include a
respiratory rate less
than 12 breaths/minute, urine output
less than 30 mL/hour, and a decreased
level of
consciousness.
11. After teaching a couple about what
to expect with their planned cesarean
birth, which
statement indicates the need for
additional teaching?
A. "Holding a pillow against my incision
will help me when I cough."
B. "I'm going to have to wait a few days
before I can start breastfeeding."
C. "I guess the nurses will be getting me
up and out of bed rather quickly."
D. "I'll probably have a tube in my
bladder for about 24 hours or so."
Rationale: Typically, breastfeeding is
initiated early as soon as possible after
birth to promote bonding. The woman
may need to use alternate positioning
techniques to reduce incisional
discomfort. Splinting with pillows helps
to reduce the discomfort associated with
coughing. Early ambulation is
encouraged to prevent respiratory and
cardiovascular problems and promote
peristalsis. An indwelling urinary
catheter is typically inserted to drain the
bladder. It usually
remains in place for approximately 24
hours.
12. The nurse is providing care to
several pregnant women who may be
scheduled for labor
induction. The nurse identifies the
woman with which Bishop score as
having the best chance for
a successful induction and vaginal birth?
A. 11
B. 7
C. 5
D. 3
Rationale: The Bishop score helps
identify women who would be most
likely to achieve a
successful induction. The duration of
labor is inversely correlated with the
Bishop score: a score
over 8 indicates a successful vaginal
birth. Therefore the woman with a
Bishop score of 11
would have the greatest chance for
success. Bishop scores of less than 6
usually indicate that a
cervical ripening method should be used
prior to induction.
13. A nurse is reviewing the medical
record of a pregnant client. The nurse
suspects that the
client may be at risk for dystocia based
on which factors? Select all that apply.
A. plan for pudendal block anesthetic
use
B. multiparity
C. short maternal stature
D. Body mass index 30.2
E. breech fetal presentation
Rationale: Risk factors for dystocia
may include maternal short stature,
obesity, hydramnios,
uterine abnormalities, fetal
malpresentation, cephalopelvic
disproportion, overstimulation with
oxytocin, maternal exhaustion,
ineffective pushing, excessive size fetus,
poor maternal
positioning in labor, and maternal
anxiety and fear
14. A nurse is preparing an inservice
education program for a group of nurses
about dystocia
involving problems with the passenger.
Which problem would the nurse likely
include as the
most common?
A. macrosomia
B. breech presentation
C. persistent occiput posterior position
D. multifetal pregnancy
Rationale: Common problems involving
the passenger include occiput posterior
position, breech
presentation, multifetal pregnancy,
excessive size (macrosomia) as it
relates to cephalopelvic
disproportion (CPD), and structural
anomalies. Of these, persistent occiput
posterior is the most
common malposition, occurring in about
15% of laboring women.
15. A nurse is conducting a review
course on tocolytic therapy for perinatal
nurses. After
teaching the group, the nurse
determines that the teaching was
successful when they identify
which drugs as being used for tocolysis?
Select all that apply.
A. nifedipine
B. magnesium sulfate
C. dinoprostone
D. misoprostol
E. indomethacin
Rationale: Medications most commonly
used for tocolysis include magnesium
sulfate (which
reduces the muscle's ability to contract),
indomethacin (a prostaglandin
synthetase inhibitor), and
nifedipine (a calcium channel blocker).
These drugs are used "off label": this
means they are
effective for this purpose but have not
been officially tested and developed for
this purpose by
the FDA. Dinoprostone and misoprostol
are used to ripen the cervix.
16. A nurse is teaching a pregnant
woman at risk for preterm labor about
what to do if she
experiences signs and symptoms. The
nurse determines that the teaching was
successful when
the woman makes which statement?
A. "I'll sit down to rest for 30 minutes."
B. "I'll try to move my bowels."
C. "I'll lie down with my legs raised."
D. "I'll drink several glasses of water."
Rationale: If the woman experiences
any signs and symptoms of preterm
labor, she should stop
what she is doing and rest for 1 hour,
empty her bladder, lie down on her side,
drink two to three
glasses of water, feel her abdomen and
note the hardness of the contraction,
and call her health
care provider and describe the
contraction.
17. A nurse is describing the risks
associated with post-term pregnancies
as part of an inservice
presentation. The nurse determines
thatmore teaching is needed when the
group identifies which
factor as an underlying reason for
problems in the fetus?
A. aging of the placenta
B. increased amniotic fluid volume
C. meconium aspiration
D. cord compression
Rationale: Fetal risks associated with a
post-term pregnancy include
macrosomia, shoulder
dystocia, brachial plexus injuries, low
Apgar scores, postmaturity syndrome
(loss of subcutaneous fat and muscle
and meconium staining), and
cephalopelvic disproportion. As the
placenta ages, its perfusion decreases
and it becomes less efficient at
delivering oxygen and
nutrients to the fetus. Amniotic fluid
volume also begins to decline after 38
weeks’ gestation,
possibly leading to oligohydramnios,
subsequently resulting in fetal hypoxia
and an increased
risk of cord compression because the
cushioning effect offered by adequate
fluid is no longer
present. Hypoxia and oligohydramnios
predispose the fetus to aspiration of
meconium, which is
released by the fetus in response to a
hypoxic insult (Norwitz, 2019). All of
these issues can
compromise fetal well-being and lead to
fetal distress.
18. A nurse is explaining to a group of
nurses new to the labor and birth unit
about methods used
for cervical ripening. The group
demonstrates understanding of the
information when they
identify which method as a mechanical
one?
A. herbal agents
B. laminaria
C. membrane stripping
D. amniotomy
Rationale: Laminaria is a hygroscopic
dilator that is used as a mechanical
method for cervical
ripening. Herbal agents are a
nonpharmacologic method. Membrane
stripping and amniotomy
are considered surgical methods.
19. The nurse notifies the obstetrical
team immediately because the nurse
suspects that the
pregnant woman may be exhibiting
signs and symptoms of amniotic fluid
embolism. When
reporting this suspicion, which finding(s)
would the nurse include in the report?
Select all that apply.
A. significant difficulty breathing
B. hypertension
C. tachycardia
D. pulmonary edema
E. bleeding with bruising
Rationale: Anaphylactoid syndrome of
pregnancy (ASP), also known as
amniotic fluid embolism, is an
unforeseeablelife-threatening
complication of childbirth. The etiology
of ASP
remains an enigmatic, devastating
obstetric condition associated with
significant maternal and
newborn morbidity and mortality. It is a
rare and often fatal event characterized
by the sudden
onset of hypotension, cardiopulmonary
collapse, hypoxia, and coagulopathy.
ASP should be
suspected in any pregnant women with
an acute onset of dyspnea, hypotension,
and DIC. By
knowing how to intervene, the nurse can
promote a better chance of survival for
both the mother
and her newborn.
20. A nurse is conducting an in-service
program for a group of labor and birth
unit nurses about
cesarean birth. The group demonstrates
understanding of the information when
they identify which conditions as
appropriate indications? Select all that
apply.
A. active genital herpes infection
B. placenta previa
C. previous cesarean birth
D. prolonged labor
E. fetal distress
Rationale: The leading indications for
cesarean birth are previous cesarean
birth, breech
presentation, dystocia, and fetal
distress. Examples of specific
indications include active genital
herpes, fetal macrosomia, fetopelvic
disproportion, prolapsed umbilical cord,
placental
abnormality (placenta previa or
placental abruption), previous classic
uterine incision or scar,
gestational hypertension, diabetes,
positive human immunodeficiency virus
(HIV) status, and
dystocia. Fetal indications include
malpresentation (nonvertex
presentation), congenital
anomalies (fetal neural tube defects,
hydrocephalus, abdominal wall defects),
and fetal distress.
21. A pregnant woman is receiving
misoprostol to ripen her cervix and
induce labor. The nurse
assesses the woman closely for which
effect?
A. uterine hyperstimulation
B. headache
C. blurred vision
D. hypotension
Rationale: A major adverse effect of the
obstetric use of misoprostol is
hyperstimulation of the
uterus, which may progress to uterine
tetany with marked impairment of
uteroplacental blood
flow, uterine rupture (requiring surgical
repair, hysterectomy, and/or
salpingo-oophorectomy), or
amniotic fluid embolism. Headache,
blurred vision, and hypotension are
associated with
magnesium sulfate.
22. A nurse is teaching a woman about
measures to prevent preterm labor in
future pregnancies
because the woman just experienced
preterm labor with her most recent
pregnancy. The nurse
determines that the teaching was
successful based on which statement by
the woman?
A. "I'll make sure to limit the amount of
long distance traveling I do."
B. "Stress isn't a problem that is related
to preterm labor."
C. "Separating pregnancies by about a
year should be helpful."
D. "I'll need extra iron in my diet so I
have extra for the baby."
Rationale: Appropriate measures to
reduce the risk for preterm labor include:
avoiding travel for
long distances in cars, trains, planes or
buses; achieving adequate iron store
through balanced
nutrition (excess iron is not necessary);
waiting for at least 18 months between
pregnancies, and using stress
management techniques for stress.
23. A pregnant woman at 31-weeks'
gestation calls the clinic and tells the
nurse that she is having contractions
sporadically. Which instructions would
be most appropriate for the nurse to
give the woman? Select all that apply.
A. "Walk around the house for the next
half hour."
B. "Drink two or three glasses of water."
C. "Lie down on your back."
D. "Try emptying your bladder."
E. "Stop what you are doing and rest."
Rationale: Appropriate instructions for
the woman who may be experiencing
preterm labor
include having the client stop what she
is doing and rest for an hour, empty her
bladder, lie down
on her left side, and drink two to three
glasses of water.
24. A pregnant client has received
dinoprostone. Following administration
of this medication, the
nurse assesses the client and
determines that the client is
experiencing an adverse effect of the
medication based on which client
report? Select all that apply.
A. headache
B. nausea
C. diarrhea
D. tachycardia
E. hypotension
Rationale: Adverse effects associated
with dinoprostone include headache,
nauseas and
vomiting, and diarrhea. Tachycardia and
hypotension are not associated with this
drug.
25. A nurse is reading a journal article
about cesarean births and the
indications for them. Place
the indications for cesarean birth below
in the proper sequence from most
frequent to least
frequent. All options must be used.
A. Labor dystocia
B. Abnormal fetal heart rate tracing
C. Fetal malpresentation
D. Multiple gestation
E. Suspected macrosomia
Answer: A, B, C, D, E
Rationale: The most common
indications for primary cesarean births
include, in order of
frequency: labor dystocia as the labor
does not progress, abnormal fetal heart
rate tracing
indicating fetal distress, fetal
malpresentation making a difficult
progression of labor, multiple
gestation , and suspected macrosomia.
26. A nurse is taking a history on a
woman who is at 20 weeks' gestation.
The woman reports that she feels some
heaviness in her thighs since yesterday.
The nurse suspects that the woman
may be experiencing preterm labor
based on which additional assessment
findings? Select all
that apply.
A. dull low backache
B. viscous vaginal discharge
C. dysuria
D. constipation
E. occasional cramping
Rationale: Symptoms of preterm labor
are often subtle and may include
change or increase in
vaginal discharge with mucus, water, or
blood in it; pelvic pressure; low, dull
backache; nausea,
vomiting or diarrhea, and heaviness or
aching in the thighs. Constipation is not
known to be a
sign of preterm labor. Preterm labor is
assessed when there are more than six
contractions per
hour. Occasional asymptomatic
cramping can be normal.
27. A pregnant client at 24 weeks'
gestation comes to the clinic for an
evaluation. The client
called the clinic earlier in the day stating
that she had not felt the fetus moving
since yesterday
evening. Further assessment reveals
absent fetal heart tones. Intrauterine
fetal demise is
suspected. The nurse would expect to
prepare the client for which testing to
confirm the
suspicion?
A. Ultrasound
B. Amniocentesis
C. Human chorionic gonadotropin (hCG)
level
D. Triple marker screening
Rationale: A client experiencing an
intrauterine fetal demise (IUFD) is likely
to seek care when
she notices that the fetus is not moving
or when she experiences contractions,
loss of fluid, or
vaginal bleeding. History and physical
examination frequently are of limited
value in the
diagnosis of fetal death, since many
times the only history tends to be recent
absence of fetal
movement and no fetal heart beat
heard. An inability to obtain fetal heart
sounds on examination
suggests fetal demise, but an ultrasound
is necessary to confirm the absence of
fetal cardiac
activity. Once fetal demise is confirmed,
induction of labor or expectant
management is offered
to the client. An amniocentesis, hCG
level, or triple marker screening would
not be used to
confirm IUFD.
28. A 32-year-old black woman in her
second trimester has come to the clinic
for an evaluation.
While interviewing the client, she reports
a history of fibroids and urinary tract
infection. The client states, "I know
smoking is bad and I have tried to stop,
but it is impossible. I have cut
down quite a bit though, and I do not
drink alcohol." Complete blood count
results reveal a low
red blood cell count, low hemoglobin,
and low hematocrit. When planning this
client's care, which factor(s) would the
nurse identify as increasing the client's
risk for preterm labor? Select
all that apply.
A. African heritage
B. Maternal age
C. History of fibroids
D. Cigarette smoking
E. History of urinary tract infections
F. Complete blood count results
Rationale: For this client, risk factors
associated with preterm labor and birth
would include
African heritage, cigarette smoking,
uterine abnormalities, such as fibroids,
urinary tract
infection, and possible anemia based on
her complete blood count results.
Maternal age extremes
(younger than 16 years and older than
35 years) are also a risk factor but do
not apply to this
client.
29. A pregnant client at 30 weeks'
gestation calls the clinic because she
thinks that she may be in
labor. To determine if the client is
experiencing labor, which question(s)
would be appropriate
for the nurse to ask? Select all that
apply.
A. "Are you feeling any pressure or
heaviness in your pelvis?"
B. "Are you having contractions that
come and go, off and on?"
C. "Have you noticed any fluid leaking
from your vagina?"
D. "Are you having problems with
heartburn?"
E. "Have you been having any nausea
or vomiting?"
Rationale: Frequently, women are
unaware that uterine contractions,
effacement, and dilation are
occurring, thus making early intervention
ineffective in arresting preterm labor and
preventing the birth of a premature
newborn. The nurse should ask the
client about any signs/symptoms,
being alert for subtle symptoms of
preterm labor, which may include: a
change or increase in
vaginal discharge with mucous, water,
or blood in it; pelvic pressure
(pushing-down sensation);
low dull backache; menstrual-like
cramps; urinary tract infection
symptoms; feeling of pelvic
pressure or fullness; gastrointestinal
upset like nausea, vomiting, and
diarrhea; general sense of
discomfort or unease; heaviness or
aching in the thighs; uterine contractions
with or without
pain; more than six contractions per
hour; intestinal cramping with or without
diarrhea.
Contractions also must be persistent,
such that four contractions occur every
20 minutes or eight
contractions occur in 1 hour. A report of
heartburn is unrelated to preterm labor.
30. When describing the stages of labor
to a pregnant woman, which would the
nurse identify as
the major change occurring during the
first stage?
A. Regular contractions
B. Cervical dilation
C. Fetal movement through the birth
canal
D. Placental separation
Rationale: The primary change
occurring during the first stage of labor
is progressive cervical
dilation. Contractions occur during the
first and second stages of labor. Fetal
movement through the birth canal is the
major change during the second stage
of labor. Placental separation occurs
during the third stage of labor.
31. The nurse is appraising the medical
record of a pregnant client who is
resting in a darkened room and
receiving oxytocin and magnesium
sulfate. The nurse will continue to
monitor this client for progression to
which condition?
eclampsia
Rationale: This woman is in severe
preeclampsia and must be monitored for
progression to eclampsia. The
administration of magnesium sulfate is
to relax the skeletal muscles and raise
the threshold for a seizure. The
administration of oxytocin is to stimulate
uterine contractions to hasten birth. The
client has already progressed from mild
preeclampsia to severe preeclampsia,
and the nurse need to follow measures
to prevent advancement of the disease
process. Although preeclampsia results
in a high blood pressure, the scenario
described does not indicate a client with
hypertension.
32. A client reporting she recently had a
positive pregnancy test has reported to
the emergency department stating
one-sided lower abdominal pain. The
health care provider has prescribed a
series of tests. Which test will provide
the most definitive confirmation of an
ectopic pregnancy?
Abdominal ultrasound
Rationale: An ectopic pregnancy refers
to the implantation of the fertilized egg in
a location other than the uterus.
Potential sites include the cervix, uterus,
abdomen, and fallopian tubes. The
confirmation of the ectopic pregnancy
can be made by an ultrasound, which
would confirm that there was no uterine
pregnancy. A quantitative hCG level
may be completed in the diagnostic
plan. hCG levels in an ectopic
pregnancy are traditionally reduced.
While this would be an indication, it
would not provide a positive
confirmation. The qualitative hCG test
would provide evidence of a pregnancy,
but not the location of the pregnancy. A
pelvic exam would be included in the
diagnostic plan of care. It would likely
show an enlarged uterus and cause
potential discomfort to the client but
would not be a definitive finding.
33. A woman at 34 weeks' gestation
presents to labor and delivery with
vaginal bleeding. Which finding from the
obstetric examination would lead to a
diagnosis of placental abruption
(abruptio placentae)?
Onset of vaginal bleeding was sudden
and painful
Rationale: Sudden onset of abdominal
pain and vaginal bleeding with a rigid
uterus that does not relax are signs of a
placental abruption (abruptio placentae).
The other findings are consistent with a
diagnosis of placenta previa.
34. The nurse is caring for a woman at
32 weeks' gestation with severe
preeclampsia. Which assessment
finding should the nurse prioritize after
the administration of hydralazine to this
client?
Tachycardia
Rationale: Hydralazine reduces blood
pressure but is associated with adverse
effects such as palpitation, tachycardia,
headache, anorexia, nausea, vomiting,
and diarrhea. It does not cause
gastrointestinal bleeding, blurred vision
(halos around lights), or sweating.
Magnesium sulfate may cause
sweating.
35. A 24-year-old client presents in
labor. The nurse notes there is an order
to administer Rho(D) immune globulin
after the birth of her infant. When asked
by the client the reason for this injection,
which reason should the nurse point
out?
prevent maternal D antibody formation.
Rationale: Because Rho(D) immune
globulin contains passive antibodies, the
solution will prevent the woman from
forming long-lasting antibodies which
may harm a future fetus. The
administration of Rho(D) immune
globulin does not promote the formation
of maternal D antibodies; it does not
stimulate maternal D immune antigens
or prevent fetal Rh blood formation.
36. A nurse in the maternity triage unit is
caring for a client with a suspected
ectopic pregnancy. Which nursing
intervention should the nurse perform
first?
Assess the client's vital signs.
Rationale: A suspected ectopic
pregnancy can put the client at risk for
hypovolemic shock. The assessment of
vital signs should be performed first,
followed by any procedures to maintain
the ABCs. Providing emotional support
would also occur, as would obtaining a
surgical consent, if needed, but these
are not first steps.
37. A pregnant client at 32 weeks'
gestation is treated with magnesium
sulfate for seizure management. The
nurse assesses which of the following
for evidence of magnesium toxicity?
Absence of knee jerk response
Rationale: Magnesium sulfate toxicity is
characterized by absence of deep
tendon reflexes like the knee jerk reflex.
Urinary retention, and not frequency of
micturition, is seen with magnesium
sulfate toxicity. Magnesium sulfate is
given to treat seizures associated with
hypertension and proteinuria in
pregnancy, and therefore decreases the
blood pressure. It does not cause an
increase in blood pressure. There is
respiratory depression, and not an
increased rate of respiration, with
magnesium sulfate toxicity.
38. A client with severe preeclampsia is
receiving magnesium sulfate as part of
the treatment plan. To ensure the client's
safety, which compound would the nurse
have readily available?
calcium gluconate
Rationale: The woman is at risk for
magnesium toxicity. The antidote for
magnesium sulfate is calcium gluconate,
and this should be readily available in
case the woman has signs and
symptoms of magnesium toxicity.
39. A client is diagnosed with
gestational hypertension and is
receiving magnesium sulfate. The nurse
determines that the medication is at a
therapeutic level based on which
finding?
deep tendons reflexes 2+
Rationale: With magnesium sulfate,
deep tendon reflexes of 2+ would be
considered normal and therefore a
therapeutic level of the drug. Urinary
output of less than 30 mL, a respiratory
rate of less than 12 breaths/minute, and
a diminished level of consciousness
would indicate magnesium toxicity.
40. A woman at 8 weeks' gestation is
admitted for ectopic pregnancy. She is
asking why this has occurred. The nurse
knows that which factor is a known risk
factor for ectopic pregnancy?
use of IUD for contraception
Rationale: Use of an IUD with
progesterone has a known increased
risk for development of ectopic
pregnancies. The nurse needs to
complete a full history of the client to
determine if she had any other risk
factors for an ectopic pregnancy.
Adhesions, scarring, and narrowing of
the tubal lumen may block the zygote's
progress to the uterus. Any condition or
surgical procedure that can injure a
fallopian tube increases the risk.
Examples include salpingitis, infection of
the fallopian tube, endometriosis, history
of prior ectopic pregnancy, any type of
tubal surgery, congenital malformation of
the tube, and multiple elective abortions.
Conditions that inhibit peristalsis of the
tube can result in tubal pregnancy.
Hormonal factors may play a role
because tubal pregnancy occurs more
frequently in women who take fertility
drugs or who use progesterone
intrauterine contraceptive devices
(IUDs). A high number of pregnancies,
multiple gestation pregnancy, and the
use of oral contraceptives are not known
risk factors for ectopic pregnancy.
41. The nurse is appraising the medical
record of a pregnant client who is
resting in a darkened room and
receiving betamethasone and
magnesium sulfate. The nurse
recognizes the client is being treated for
which condition?
severe preeclampsia
Rationale: This woman is in severe
preeclampsia and must be monitored for
progression to eclampsia. The
administration of magnesium sulfate is
to relax the skeletal muscles and raise
the threshold for a seizure. The
administration of the betamethasone is
to try and hasten the maturity of the
fetus's lungs for birth for a preterm fetus.
The scenario described does not
indicate a client with hypertension,
gestational diabetes, or post-term (>42
weeks) pregnancy.
42. The following hourly assessments
are obtained by the nurse on a client
with preeclampsia receiving magnesium
sulfate: 97.3oF (36.2oC), HR 88, RR 12
breaths/min, BP 148/110 mm Hg. What
other priority physical assessments by
the nurse should be implemented to
assess for potential toxicity?
Reflexes
Rationale: Reflex assessment is part of
the standard assessment for clients on
magnesium sulfate. The first change
when developing magnesium toxicity
may be a decrease in reflex activity. The
health care provider needs to be notified
immediately. A change in lung sounds
and oxygen saturation are not indicative
of magnesium sulfate toxicity. Hourly
blood draws to gain information on the
magnesium sulfate level are not
indicated.
43. A client with a molar pregnancy is
scheduled for a dilatation and curettage
(D&C). The nurse is educating that
client about postoperative care. The
nurse will instruct the client that she will
have the first serum hCG level drawn at
how many hours after the D&C?
48
Rationale: A serum hCG level is drawn
48 hours after the procedure to assess if
the level is decreasing. Drawing it earlier
does not allow adequate time for the
body to begin clearing hCG after the
uterus is evacuated. Drawing it much
later may mask the effectiveness of the
D&C procedure.
44. A primigravida 28-year-old client is
noted to have Rh negative blood and
her husband is noted to be Rh positive.
The nurse should prepare to administer
RhoGAM after which diagnostic
procedure?
Amniocentesis
Rationale: Amniocentesis is a
procedure requiring a needle to enter
into the amniotic sac. There is a risk of
mixing of the fetal and maternal blood
which could result in blood
incompatibility. A contraction test, a
nonstress test, and biophysical profile
are not invasive, so there would be no
indication for Rho(D) immune globulin to
be administered.
45. A client with a history of cervical
insufficiency is seen for reports of
pink-tinged discharge and pelvic
pressure. The primary care provider
decides to perform a cervical cerclage.
The nurse teaches the client about the
procedure. Which client response
indicates that the teaching has been
effective?
"Purse-string sutures are placed in the
cervix to prevent it from dilating."
Rationale: The cerclage, or purse string
suture, is inserted into the cervix to
prevent preterm cervical dilation
(dilatation) and pregnancy loss. Staples,
glue, or a cervical cap will not prevent
the cervix from dilating.
46. A nurse suspects that a client is
developing HELLP syndrome. The
nurse notifies the health care provider
based on which finding?
elevated liver enzymes
Rationale: HELLP is an acronym for
hemolysis, elevated liver enzymes, and
low platelets. Hyperglycemia is not a
part of this syndrome. HELLP may
increase the woman's risk for DIC but it
is not an assessment finding.
47. After teaching a woman who has
had an evacuation for gestational
trophoblastic disease (hydatidiform mole
or molar pregnancy) about her
condition, which statement indicates that
the nurse's teaching was successful?
"I will be sure to avoid getting pregnant
for at least 1 year."
Rationale: After evacuation of
trophoblastic tissue (hydatiform mole),
long-term follow-up is necessary to
make sure any remaining trophoblastic
tissue does not become malignant.
Serial hCG levels are monitored closely
for 1 year, and the client is urged to
avoid pregnancy for 1 year because it
can interfere with the monitoring of hCG
levels. Iron intake and blood pressure
are not important aspects of follow up
after evacuation of a hydatiform mole.
Use of a reliable contraceptive is
strongly recommended so that
pregnancy is avoided.
48. The nurse is caring for a client who
has a multifetal pregnancy. What topic
should the nurse prioritize during health
education?
Signs of preterm labor
Rationale: The client with a multifetal
pregnancy must be made aware of the
risks posed by preterm labor. There is
no corresponding increase in the risk for
hypertension or blood incompatibilities.
Parenting skills are secondary to
physiologic needs at this point.
49. A woman at 31 weeks' gestation
presents to the emergency department
with bright red vaginal bleeding,
reporting that the onset of the bleeding
was sudden and without pain. Which
diagnostic test should the nurse
prioritize?
A transvaginal ultrasound
Rationale: For any pregnant woman
who presents with painless bleeding,
placenta previa needs to be ruled out by
either transvaginal or abdominal
ultrasound. A digital cervical exam is
contraindicated until placenta previa has
been ruled out, as digital manipulation of
placental tissue through the cervical os
can cause uncontrollable bleeding. The
nonstress test and electronic fetal
monitoring would be utilized after the
woman is stabilized and placenta previa
has either been diagnosed or ruled out.
50. A 28-year-old client with a history of
endometriosis presents to the
emergency department with severe
abdominal pain and nausea and
vomiting. The client also reports her
periods are irregular with the last one
being 2 months ago. The nurse
prepares to assess for which possible
cause for this client's complaints?
Ectopic pregnancy
Rationale: The most commonly
reported symptoms of ectopic
pregnancy are pelvic pain and/or vaginal
spotting. Other symptoms of early
pregnancy, such as breast tenderness,
nausea, and vomiting, may also be
present. The diagnosis is not always
immediately apparent because many
women present with complaints of
diffuse abdominal pain and minimal to
no vaginal bleeding. Steps are taken to
diagnose the disorder and rule out other
causes of abdominal pain. Given the
history of the client and the amount of
pain, the possibility of ectopic pregnancy
needs to be considered. A healthy
pregnancy would not present with
severe abdominal pain unless the client
were term and she was in labor. With a
molar pregnancy the woman typically
presents between 8 to 16 weeks'
gestation reporting painless (usually)
brown to bright red vaginal bleeding.
Placenta previa typically presents with
painless, bright red bleeding that begins
with no warning.
50. The nurse is transcribing messages
from the answering service. Which
phone message should the nurse return
first?
a 35-year-old, 21-week G3P2 client with
blood pressure of 160/110 mm Hg,
blurred vision, and whose last blood
pressure was 143/99 mm Hg and urine
dipstick showed a +2 proteinuria
Rationale: The nurse should call the
at-risk 35-year-old client first. She is 21
weeks and has symptoms (blurred
vision) of preeclampsia. She also had
an increase of protein in her urine (2+)
and a 15% increase in her BP. The
nurse will need more information to
determine if the 38-week client may be
in the early stages of labor, and if the
31-week client with flank pain has a
kidney infection. The client with malaise
and rhinitis will need to talk to the nurse
last to find out what over-the-counter
medication she is able to take.
51. A woman at 35 weeks' gestation
with severe hydramnios is admitted to
the hospital. The nurse recognizes that
which concern is greatest regarding this
client?
preterm rupture of membranes followed
by preterm birth
Rationale: Even with precautions, in
most instances of hydramnios, there will
be preterm rupture of the membranes
because of excessive pressure, followed
by preterm birth. The other answers are
less concerning than preterm birth in
this pregnancy.
52. Which medication will the nurse
anticipate the health care provider will
prescribe as treatment for an unruptured
ectopic pregnancy?
methotrexate
Rationale: Methotrexate, a folic acid
antagonist that inhibits cell division in
the developing embryo, is most
commonly used to treat ectopic
pregnancy. Oxytocin is used to stimulate
uterine contractions and would be
inappropriate for use with an ectopic
pregnancy. Promethazine and
ondansetron are antiemetics that may
be used to treat hyperemesis
gravidarum.
53. Current research indicates that
supplementation with what before
pregnancy may reduce the risk of
placental abruption?
Folic acid
Rationale: New research indicates that
folic acid supplementation before or
during pregnancy reduces the risk of
placental abruption. Neither
supplementation with vitamin C, iron,
nor calcium is associated with a
decreased risk for placental abruption.
54. A client at 25 weeks' gestation
presents with a blood pressure of
152/99 mm Hg, pulse 78 beats/min, no
edema, and urine negative for protein.
What would the nurse do next?
Notify the health care provider
Rationale: The client is exhibiting a sign
of gestational hypertension, elevated
blood pressure greater than or equal to
140/90 mm Hg that develops for the first
time during pregnancy. The health care
provider should be notified to assess the
client. Without the presence of edema or
protein in the urine, the client does not
have preeclampsia.
55. A woman in her 20s has
experienced a spontaneous abortion
(miscarriage) at 10 weeks' gestation and
asks the nurse at the hospital what went
wrong. She is concerned that she did
something that caused her to lose her
baby. The nurse can reassure the
woman by explaining that the most
common cause of miscarriage in the first
trimester is related to which factor?
Chromosomal defects in the fetus
Rationale: Fetal factors are the most
common cause of early miscarriages,
with chromosomal abnormalities in the
fetus being the most common reason.
This client fits the criteria for early
spontaneous abortion since she was
only 10 weeks' pregnant and early
miscarriage occurs before 12 weeks.
56. A client at 27 weeks' gestation is
admitted to the obstetric unit after
reporting headaches and edema of her
hands. Review of the prenatal notes
reveals blood pressure consistently
above 136/90 mm Hg. The nurse
anticipates the health care provider will
prescribe magnesium sulfate to
accomplish which primary goal?
Prevent maternal seizures
Rationale: The primary therapy goal for
any client with preeclampsia is to
prevent maternal seizures. Use of
magnesium sulfate is the drug therapy
of choice for severe preeclampsia and is
only used to manage and attempt to
prevent progression to eclampsia.
Magnesium sulfate therapy does not
have as a primary goal of decreasing
blood pressure, decreasing protein in
the urine, or reversing edema.
57. A nurse is reviewing a client's history
and physical examination findings.
Which information would the nurse
identify as contributing to the client's risk
for an ectopic pregnancy?
recurrent pelvic infections
Rationale: In the general population,
most cases of ectopic pregnancy are the
result of tubal scarring secondary to
pelvic inflammatory disease. Oral
contraceptives, ovarian cysts, and
heavy, irregular menses are not
considered risk factors for ectopic
pregnancy.
58. A client whose membranes have
prematurely ruptured is admitted to the
hospital. Which nursing intervention is a
priority?
Routine monitoring of vital signs
Rationale: Rupture of the membranes
without the onset of labor places the
woman at risk for infection. The priority
is to monitor temperature routinely by
the completion of vital signs. Antibiotic
therapy is often initiated as well,
depending upon closeness of labor
initiation (naturally or induced). The
fetus will be monitored on a regular
basis and then continuously when the
labor process occurs. Urine analysis
and strict intake and output are not
typically completed.
59. A pregnant client diagnosed with
hyperemesis gravidarum is prescribed
intravenous fluids for rehydration. When
preparing to administer this therapy,
which solution would the nurse
anticipate being prescribed initially?
normal saline
Rationale: For the client with
hyperemesis gravidarum, parenteral
fluids and drugs are prescribed to
rehydrate the client and reduce the
symptoms. The first choice for fluid
replacement is generally isotonic, such
as normal saline, which aids in
preventing hyponatremia, with vitamins
(pyridoxine, or vitamin B6) and
electrolytes added. Dextrose 5% and
water and 0.45% sodium chloride are
hypotonic solutions that would cause the
cells to swell and possibly burst.
Albumin could lead to fluid overload.
60. A pregnant women calls the clinic to
report a small amount of painless
vaginal bleeding. What response by the
nurse is best?
"Please come in now for an evaluation
by your health care provider."
Rationale: Bleeding during pregnancy
is always a deviation from normal and
should be evaluated carefully. It may be
life-threatening or it may be something
that is not a threat to the mother and/or
fetus. Regardless, it needs to be
evaluated quickly and carefully. Telling
the client it may be harmless is a
reassuring statement, but does not
suggest the need for urgent evaluation.
Having the mother lay on her left side
and drink water is indicated for
cramping.
61. A nurse is taking a history of a client
at 5 weeks' gestation in the prenatal
clinic; however, the client is reporting
dark brown vaginal discharge, nausea,
and vomiting. Which diagnosis should
the nurse suspect?
gestational trophoblastic disease
Rationale: This client has risk factors of
a "molar" pregnancy: nausea and
vomiting at an early gestational week
and dark brown vaginal discharge. The
early nausea/vomiting can be due to a
high hCG level, which is a sign of
gestational trophoblastic disease. There
is only one sign/symptom of
hyperemesis gravidarum. Placenta
previa is marked by bright red bleeding
and tends to happen later in gestation.
There are no data to support any
psychosis at this stage.
62. A woman who is 10 weeks' pregnant
calls the physician's office reporting
"morning sickness" but, when asked
about it, tells the nurse that she is
nauseated and vomiting all the time and
has lost 5 pounds. What interventions
would the nurse anticipate for this
client?
Lab work will be drawn to rule out
acid-base imbalances.
Rationale: Morning sickness that lasts
all day and is severe is called
hyperemesis gravidarum. It is much
more serious than "morning sickness"
and can lead to significant weight loss
and electrolyte imbalance. Lab work
needs to be drawn to determine the
extent of electrolyte loss and acid-base
balance. An ultrasound is performed but
it is done to determine if the mother is
experiencing a molar pregnancy.
Treatment for hyperemesis gravidarum
requires much more care than just rest,
drinking fluids and eating crackers.
63. A 35-year-old client is seen for her
2-week postoperative appointment after
a suction curettage was performed to
evacuate a hydatidiform mole. The
nurse explains that the human chorionic
gonadotropin (hCG) levels will be
reviewed every 2 weeks and teaches
about the need for reliable contraception
for the next 6 months to a year. The
client states, "I'm 35 already. Why do I
have to wait that long to get pregnant
again?" What is the nurse's best
response?
"A contraceptive is used so that a
positive pregnancy test resulting from a
new pregnancy will not be confused with
the increased level of hCG that occurs
with a developing malignancy."
Rationale: Because of the risk of
choriocarcinoma, the woman receives
extensive treatment. Therapy includes
baseline chest X-ray to detect lung
metastasis, plus a physical exam
(including a pelvic exam). Serum B-hCG
levels weekly until negative results are
obtained three consecutive times, then
monthly for 6 to 12 months. The woman
is cautioned to avoid pregnancy during
this time because the increasing B-hCG
levels associated with pregnancy would
cause confusion as to whether cancer
had developed. If after a year B-hCG
serum titers are within normal levels, a
normal pregnancy can be achieved.
65. During a routine prenatal visit, a
client is found to have proteinuria and a
blood pressure rise to 140/90 mm Hg.
The nurse recognizes that the client has
which condition?
mild preeclampsia
Rationale: A woman is said to have
gestational hypertension when she
develops an elevated blood pressure
(140/90 mm Hg) but has no proteinuria
or edema. If a seizure from gestational
hypertension occurs, a woman has
eclampsia, but any status above
gestational hypertension and below a
point of seizures is preeclampsia. A
woman is said to be mildly preeclamptic
when she has proteinuria and a blood
pressure rise to 140/90 mm Hg, taken
on two occasions at least 6 hours apart.
A woman has passed from mild to
severe preeclampsia when her blood
pressure rises to 160 mm Hg systolic
and 110 mm Hg diastolic or above on at
least two occasions 6 hours apart at bed
rest (the position in which blood
pressure is lowest) or her diastolic
pressure is 30 mm Hg above her
prepregnancy level. Marked proteinuria,
3+ or 4+ on a random urine sample or
more than 5 g in a 24-hour sample, and
extensive edema are also present. A
woman has passed into eclampsia when
cerebral edema is so acute a grand-mal
seizure (tonic-clonic) or coma has
occurred.
66. A pregnant woman with
preeclampsia is to receive magnesium
sulfate IV. Which assessment should the
nurse prioritize before administering a
new dose?
patellar reflex
Rationale: A symptom of magnesium
sulfate toxicity is loss of deep tendon
reflexes. Assessing for the patellar
reflex or ankle clonus before
administration is assurance the drug
administration will be safe. Assessing
the blood pressure, heart rate, or
anxiety level would not reveal a potential
magnesium toxicity.
67. The obstetric nurse is caring for a
pregnant client who has been diagnosed
with hydatidiform mole. What
assessment should the nurse prioritize?
Vaginal bleeding
Rationale: Molar pregnancies constitute
a major risk factor for vaginal bleeding.
The client does not normally have an
increased risk for nausea, pain, or
hypertension.
68. The nurse is teaching a client who is
diagnosed with preeclampsia how to
monitor her condition. The nurse
determines the client needs more
instruction after making which
statement?
"If I have changes in my vision, I will lie
down and rest."
Rationale: Changes in the visual field
may indicate the client has moved from
preeclampsia to severe preeclampsia
and is at risk for developing a seizure
due to changes in cerebral blood flow.
The client would require immediate
assessment and intervention. Gaining
weight is not necessarily a sign of
worsening preeclampsia. The other
choices are instructions which the client
may be given to follow.
69. The nurse is educating a group of
pregnant women about risk factors
associated with preterm labor. Which
factor would the nurse include in the
teaching? Select all that apply.
alcohol use during pregnancy
lack of prenatal care
victim of intimate partner violence
Rationale: The most common causes of
preterm labor include alcohol or drug
use during pregnancy, lack of or no
prenatal care, victim of intimate partner
violence, black race, in vitro fertilization,
and a lack of support. Hyperemesis
gravidarum and Asian descent are not
risk factors for preterm labor.
70. A client with a multiple gestation has
come to a health care facility for a
regular antenatal check-up. When
educating the client on pregnancy, about
which complication should the nurse
inform the client?
Placental dysfunction
Rationale: The nurse should inform the
client that placental dysfunction might
occur as a complication of multiple
pregnancies. Other complications of
multiple pregnancies include preterm
labor, hypertension, anemia, cord
abnormalities, congenital anomalies,
intrauterine growth restriction, and low
birth weight. Hypertension, and not
hypotension, is seen in multiple
pregnancies. Fetal macrosomia is not
seen in cases of multiple gestation.
Constipation, and not diarrhea, is also
seen as a complication of multiple
pregnancies. This is due to the
decreased functioning of the
gastrointestinal system in multiple
pregnancy.
71. After a regular prenatal visit, a
pregnant client asks the nurse to
describe the differences between
placental abruption (abruptio placentae)
and placenta previa. Which statement
will the nurse include in the teaching?
Placenta previa is an abnormally
implanted placenta that is too close to
the cervix.
Rationale: Placenta previa is a
condition of pregnancy in which the
placenta is implanted abnormally in the
lower part of the uterus and is the most
common cause of painless, bright red
bleeding in the third trimester. Placental
abruption is the premature separation of
a normally implanted placenta that pulls
away from the wall of the uterus either
during pregnancy or before the end of
labor. Placental abruption can result in
concealed or apparent dark red bleeding
and is painful. Immediate intervention is
required for placental abruption.
72. A nurse is caring for a client who just
experienced a spontaneous abortion
(miscarriage) in her first trimester. When
asked by the client why this happened,
which is the best response from the
nurse?
abnormal fetal development
Rationale: The most frequent cause of
spontaneous abortion (miscarriage) in
the first trimester of pregnancy is
abnormal fetal development, due either
to a teratogenic factor or to a
chromosomal aberration. In other
miscarriages, immunologic factors may
be present or rejection of the embryo
through an immune response may
occur. Another common cause of early
miscarriage involves implantation
abnormalities. Miscarriage may also
occur if the corpus luteum on the ovary
fails to produce enough progesterone to
maintain the decidua basalis.
73. A 24-year-old woman presents with
vague abdominal pains, nausea, and
vomiting. An urine hCG is positive after
the client mentioned that her last
menstrual period was 2 months ago.
The nurse should prepare the client for
which intervention if the transvaginal
ultrasound indicates a gestation sac is
found in the right lower quadrant?
Immediate surgery
Rationale: The client presents with the
signs and symptoms of an ectopic
pregnancy, which is confirmed by the
transvaginal ultrasound. Ectopic
pregnancy means an embryo has
implanted outside the uterus. Surgery is
necessary to remove the growing
structure before damage can occur to
the woman's internal organs. Bed rest, a
tocolytic, and internal uterine monitoring
will not correct the situation. The
growing structure must be removed
surgically.
74. A nurse is caring for a pregnant
client admitted with mild preeclampsia.
Which assessment finding should the
nurse prioritize?
urine output of less than 15 ml/hr
Rationale: Severe preeclampsia may
develop suddenly and bring with it high
blood pressure of more than 160/110
mm Hg, proteinuria of more than 500
mg in 24 hours, oliguria of less than 15
ml/hr, cerebral and visual symptoms,
and rapid weight gain. Mild facial edema
or hand edema occurs with mild
preeclampsia. A urinary output of 15
ml/hr would result in an output of 360
ml/24 hours, which would be below the
recommended range and should be
reported. Ankle edema of 1+ could be
related to regular pregnancy and not
necessarily just severe preeclampsia. A
finding of 3+ to 4+ pitting edema would
be more alarming and require
intervention.
75. The nurse is caring for a woman at
32 weeks' gestation with severe
preeclampsia. Which assessment
finding should the nurse prioritize after
the administration of hydralazine to this
client?
Tachycardia
Explanation:
Hydralazine reduces blood pressure but
is associated with adverse effects such
as palpitation, tachycardia, headache,
anorexia, nausea, vomiting, and
diarrhea. It does not cause
gastrointestinal bleeding, blurred vision
(halos around lights), or sweating.
Magnesium sulfate may cause
sweating.
76. A pregnant client with preeclampsia
with severe features has developed
HELLP syndrome. In addition to the
observations necessary for
preeclampsia, what other nursing
intervention is critical for this client?
observation for bleeding
Explanation:
Because of the low platelet count
associated with this condition, women
with HELLP syndrome need extremely
close observation for bleeding, in
addition to the observations necessary
for preeclampsia. Maintaining a patent
airway is a critical intervention needed
for a client with eclampsia while she is
having a seizure. Administration of a
tocolytic would be appropriate for halting
labor. Monitoring for infection is not a
priority intervention in this situation.
77. An 18-year-old pregnant client is
hospitalized as she recovers from
hyperemesis gravidarum. The client
reveals she wanted to have an abortion
(elective termination of pregnancy) but
her cultural background forbids it. She is
very unhappy about being pregnant and
even expresses a wish for a
miscarriage. Which action by the nurse
is most appropriate?
Contact the health care provider to
report the client's feelings.
Rationale: The client may be
experiencing a psychological situation
that needs intervention by a trained
professional in the area of mental
health. The hyperemesis gravidarum
may worsen her feelings toward the
pregnancy, so reporting her feelings to
the health care provider is the best
action at this time. Although the nurse
will continue to monitor the client's
hyperemesis gravidarum, this is not the
only action needed at this time and
there is a better action. Encouraging the
client to be positive about her situation
may obstruct therapeutic
communication. Sharing the information
with the client's family is not appropriate,
because the scenario described does
not indicate that the nurse has the
client's permission to share this
information with the family.
78. A client reporting she recently had a
positive pregnancy test has reported to
the emergency department stating
one-sided lower abdominal pain. The
health care provider has prescribed a
series of tests. Which test will provide
the most definitive confirmation of an
ectopic pregnancy?
Abdominal ultrasound
Rationale: An ectopic pregnancy refers
to the implantation of the fertilized egg in
a location other than the uterus.
Potential sites include the cervix, uterus,
abdomen, and fallopian tubes. The
confirmation of the ectopic pregnancy
can be made by an ultrasound, which
would confirm that there was no uterine
pregnancy. A quantitative hCG level
may be completed in the diagnostic
plan. hCG levels in an ectopic
pregnancy are traditionally reduced.
While this would be an indication, it
would not provide a positive
confirmation. The qualitative hCG test
would provide evidence of a pregnancy,
but not the location of the pregnancy. A
pelvic exam would be included in the
diagnostic plan of care. It would likely
show an enlarged uterus and cause
potential discomfort to the client but
would not be a definitive finding.
79. The following hourly assessments
are obtained by the nurse on a client
with preeclampsia receiving magnesium
sulfate: 97.3oF (36.2oC), HR 88, RR 12
breaths/min, BP 148/110 mm Hg. What
other priority physical assessments by
the nurse should be implemented to
assess for potential toxicity?
reflexes
Rationale: Reflex assessment is part of
the standard assessment for clients on
magnesium sulfate. The first change
when developing magnesium toxicity
may be a decrease in reflex activity. The
health care provider needs to be notified
immediately. A change in lung sounds
and oxygen saturation are not indicative
of magnesium sulfate toxicity. Hourly
blood draws to gain information on the
magnesium sulfate level are not
indicated.
80. A pregnant client diagnosed with
hyperemesis gravidarum is prescribed
intravenous fluids for rehydration. When
preparing to administer this therapy,
which solution would the nurse
anticipate being prescribed initially?
normal saline
Rationale: For the client with
hyperemesis gravidarum, parenteral
fluids and drugs are prescribed to
rehydrate the client and reduce the
symptoms. The first choice for fluid
replacement is generally isotonic, such
as normal saline, which aids in
preventing hyponatremia, with vitamins
(pyridoxine, or vitamin B6) and
electrolytes added. Dextrose 5% and
water and 0.45% sodium chloride are
hypotonic solutions that would cause the
cells to swell and possibly burst.
Albumin could lead to fluid overload.
81. A client tells that nurse in the
doctor's office that her friend developed
high blood pressure on her last
pregnancy. She is concerned that she
will have the same problem. What is the
standard of care for preeclampsia?
Have her blood pressure checked at
every prenatal visit.
Rationale: Preeclampsia and eclampsia
are common problems for pregnant
clients and require regular blood
pressure monitoring at all prenatal visits.
Antihypertensives are not prescribed
unless the client is already hypertensive.
Monitoring for headaches and swelling
is a good predictor of a problem but
doesn't address prevention—nor does it
predict who will have hypertension.
Taking aspirin has shown to reduce the
risk in women who have moderate to
high risk factors, but has shown no
effect on those women with low risk
factors.
82. A nurse in the maternity triage unit is
caring for a client with a suspected
ectopic pregnancy. Which nursing
intervention should the nurse perform
first?
Assess the client's vital signs.
Rationale: A suspected ectopic
pregnancy can put the client at risk for
hypovolemic shock. The assessment of
vital signs should be performed first,
followed by any procedures to maintain
the ABCs. Providing emotional support
would also occur, as would obtaining a
surgical consent, if needed, but these
are not first steps.
83. A client at 25 weeks' gestation
presents with a blood pressure of
152/99 mm Hg, pulse 78 beats/min, no
edema, and urine negative for protein.
What would the nurse do next?
Notify the health care provider
Explanation:
The client is exhibiting a sign of
gestational hypertension, elevated blood
pressure greater than or equal to 140/90
mm Hg that develops for the first time
during pregnancy. The health care
provider should be notified to assess the
client. Without the presence of edema or
protein in the urine, the client does not
have preeclampsia.
84. A woman at 34 weeks' gestation
presents to labor and delivery with
vaginal bleeding. Which finding from the
obstetric examination would lead to a
diagnosis of placental abruption
(abruptio placentae)?
Onset of vaginal bleeding was sudden
and painful
Explanation:
Sudden onset of abdominal pain and
vaginal bleeding with a rigid uterus that
does not relax are signs of a placental
abruption (abruptio placentae). The
other findings are consistent with a
diagnosis of placenta previa.
85. A woman in her 20s has
experienced a spontaneous abortion
(miscarriage) at 10 weeks' gestation and
asks the nurse at the hospital what went
wrong. She is concerned that she did
something that caused her to lose her
baby. The nurse can reassure the
woman by explaining that the most
common cause of miscarriage in the first
trimester is related to which factor?
Chromosomal defects in the fetus
Rationale: Fetal factors are the most
common cause of early miscarriages,
with chromosomal abnormalities in the
fetus being the most common reason.
This client fits the criteria for early
spontaneous abortion (miscarriage)
since she was only 10 weeks' pregnant
and early miscarriage occurs before 12
weeks.
85. A woman at 31 weeks' gestation
presents to the emergency department
with bright red vaginal bleeding,
reporting that the onset of the bleeding
was sudden and without pain. Which
diagnostic test should the nurse
prioritize?
A transvaginal ultrasound
Rationale: For any pregnant woman
who presents with painless bleeding,
placenta previa needs to be ruled out by
either transvaginal or abdominal
ultrasound. A digital cervical exam is
contraindicated until placenta previa has
been ruled out, as digital manipulation of
placental tissue through the cervical os
can cause uncontrollable bleeding. The
nonstress test and electronic fetal
monitoring would be utilized after the
woman is stabilized and placenta previa
has either been diagnosed or ruled out.
87. The nurse is teaching a client who is
diagnosed with preeclampsia how to
monitor her condition. The nurse
determines the client needs more
instruction after making which
statement?
"If I have changes in my vision, I will lie
down and rest."
Rationale: Changes in the visual field
may indicate the client has moved from
preeclampsia to severe preeclampsia
and is at risk for developing a seizure
due to changes in cerebral blood flow.
The client would require immediate
assessment and intervention. Gaining
weight is not necessarily a sign of
worsening preeclampsia. The other
choices are instructions which the client
may be given to follow.
88. The nurse is assessing a client at 12
weeks' gestation at a routine prenatal
visit who reports something doesn't feel
right. Which assessment findings should
the nurse prioritize?
gestational hypertension, hyperemesis
gravidarum, absence of FHR
Rationale:Rationale: The early
development of gestational
hypertension/preeclampsia,
hyperemesis gravidarum, and the
absence of FHR are suspicious for
gestational trophoblastic disease. The
elevated levels of hCG lead to the
severe morning sickness. There is no
fetus, so FHR, quickening, and evidence
of a fetal skeleton would not be seen.
The abdominal enlargement is greater
than expected for pregnancy dates, but
hCG, not hPL, levels are increased.
89. The nurse is caring for a client who
has a multifetal pregnancy. What topic
should the nurse prioritize during health
education?
signs of preterm labor
Rationale: The client with a multifetal
pregnancy must be made aware of the
risks posed by preterm labor. There is
no corresponding increase in the risk for
hypertension or blood incompatibilities.
Parenting skills are secondary to
physiologic needs at this point.
89. An 18-year-old pregnant client is
hospitalized as she recovers from
hyperemesis gravidarum. The client
reveals she wanted to have an abortion
(elective termination of pregnancy) but
her cultural background forbids it. She is
very unhappy about being pregnant and
even expresses a wish for a
spontaneous abortion (miscarriage).
Which action by the nurse is most
appropriate?
Contact the health care provider to
report the client's feelings.
Rationale: The client may be
experiencing a psychological situation
that needs intervention by a trained
professional in the area of mental
health. The hyperemesis gravidarum
may worsen her feelings toward the
pregnancy and needs to be monitored,
so reporting her feelings to the health
care provider is the best action at this
time. Although the nurse will continue to
monitor the client's hyperemesis
gravidarum, this is not the only action
needed at this time and there is a better
action. Encouraging the client to remain
silent about her feelings may obstruct
therapeutic communication. Sharing the
information with the client's family is not
appropriate because the scenario
described does not indicate that the
nurse has the client's permission to
share this information with her family.
90. A woman at 35 weeks' gestation
with severe polyhydramnios is admitted
to the hospital. The nurse recognizes
that which concern is greatest regarding
this client?
preterm rupture of membranes followed
by preterm birth
Rationale: Even with precautions, in
most instances of polyhydramnios, there
will be preterm rupture of the
membranes because of excessive
pressure, followed by preterm birth. The
other answers are less concerning than
preterm birth in this pregnancy.
91. A client in her 20th week of
gestation
develops HELLP syndrome. What are
features of HELLP syndrome? Select all
that apply.
elevated liver enzymes
hemolysis
low platelet count
Rationale: The HELLP syndrome is a
syndrome involving hemolysis
(microangiopathic hemolytic anemia),
elevated liver enzymes, and a low
platelet count. Hyperthermia and
leukocytosis are not features of HELLP
syndrome.
91. A pregnant women calls the clinic to
report a small amount of painless
vaginal bleeding. What response by the
nurse is best?
"Please come in now for an evaluation
by your health care provider."
Explanation:
Bleeding during pregnancy is always a
deviation from normal and should be
evaluated carefully. It may be
life-threatening or it may be something
that is not a threat to the mother and/or
fetus. Regardless, it needs to be
evaluated quickly and carefully. Telling
the client it may be harmless is a
reassuring statement, but does not
suggest the need for urgent evaluation.
Having the mother lay on her left side
and drink water is indicated for
cramping.
92. Nurses should be aware that HELLP
syndrome:
a) Is associated with preterm labor
but not perinatal mortality.
b) Is characterized by hemolysis,
elevated liver enzymes, and low
platelets.
c) Is a mild form of preeclampsia.
d) Can be diagnosed by a nurse
alert to its symptoms.
93. Magnesium sulfate is given to
women with preeclampsia and
eclampsia to:
a) Prevent a boggy uterus and lessen
lochial flow.
b) Improve patellar reflexes and
increase respiratory efficiency.
c) Prevent and treat convulsions.
d) Shorten the duration of labor.
94. A pregnant woman has been
receiving a magnesium sulfate infusion
for treatment of severe preeclampsia for
24 hours. On assessment the nurse
finds the following vital signs:
temperature of 37.3° C, pulse rate of 88
beats/min, respiratory rate of 10
breaths/min, blood pressure (BP) of
148/90 mm Hg, absent deep tendon
reflexes, and no ankle clonus. The
client's response to questions are
sluggish are hard to understand. The
nurse:
a) Calls for a stat magnesium
sulfate level.
b) Discontinues the magnesium
sulfate infusion.
c) Prepares to administer
hydralazine.
d) Administers oxygen.
95. The labor of a pregnant woman with
preeclampsia is going to be induced.
Before initiating the Pitocin infusion, the
nurse reviews the woman’s latest
laboratory test findings, which reveal an
hematocrit of 41%, a creatinine of 6.2, a
platelet count of 90,000, an elevated
aspartate transaminase (AST) level, and
decreased serum haptoglobin. The
nurse notifies the physician because the
laboratory results are indicative of:
a) Disseminated intravascular
coagulation (DIC).
b) Eclampsia.
c) HELLP syndrome.
d) Idiopathic thrombocytopenia.
97. A woman with severe preeclampsia
has been receiving magnesium sulfate
by intravenous infusion for 8 hours. The
nurse assesses the woman and
documents the following findings:
temperature of 37.1° C, pulse rate of 96
beats/min, respiratory rate of 24
breaths/min, blood pressure (BP) of
175/112 mm Hg, 3+ deep tendon
reflexes, and no ankle clonus. The
nurse calls the physician, anticipating an
order for:
a) Diazepam.
b) Hydralazine.
c) Calcium gluconate.
d) Magnesium sulfate bolus.
98. A primigravida is being monitored in
her prenatal clinic for preeclampsia.
What finding should concern her nurse?
a) Weight gain of 0.5 kg during the
past 2 weeks
b) Pitting pedal edema at the end of
the day
c) Blood pressure (BP) increase to
138/86 mm Hg
d) A dipstick value of 3+ for protein
in her urine
99. What nursing diagnosis would be
the most appropriate for a woman
experiencing severe preeclampsia?
a) Risk for injury to the fetus related
to uteroplacental insufficiency
b) Risk for eclampsia
c) Risk for deficient fluid volume
related to increased sodium retention
secondary to administration of MgSO4
d) Risk for increased cardiac output
related to use of antihypertensive drugs
100. A woman with preeclampsia has a
seizure. The nurse’s primary duty during
the seizure is to:
a) Administer oxygen by mask.
b) Suction the mouth to prevent
aspiration.
c) Stay with the client and call for
help.
d) Insert an oral airway.
101. A woman with severe preeclampsia
is receiving a magnesium sulfate
infusion. The nurse becomes concerned
after assessment when the woman
exhibits:
a) Absent ankle clonus.
b) A sleepy, sedated affect.
c) A respiratory rate of 10
breaths/min.
d) Deep tendon reflexes of 2.
102. Your client has been on
magnesium sulfate for 20 hours for
treatment of preeclampsia. She just
delivered a viable infant girl 30 minutes
ago. What uterine findings would you
expect to observe/assess in this client?
a) A fundus firm below the level of
the umbilicus
b) A boggy uterus with heavy lochia
flow
c) Scant lochia flow
d) Absence of uterine bleeding in
the postpartum period
103. A woman has been having
contractions since 4 A.M. At 8 A.M., her
cervix is dilated to 5 cm. At 10 am her
cervix is still 5 cm. Contractions are
frequent, and mild to moderate in
intensity. Cephalopelvic disproportion
(CPD) has been ruled out. The nurse
would anticipate preparing for:
a) Cesarean section.
b) Documentation your assessment
and assess again in an hour.
c) Increased intravenous infusion.
d) Oxytocin induction of labor.
105. A nurse is comparing advantages
of using active management of labor
(AMOL) with a less interventional
approach. The nurse knows that the
goal of AMOL is:
a) Preventing protracted labor and
arrest of progress.
b) Relieving the anxiety and fear
accompanying labor.
c) Detecting and intervening in
cases of precipitous labor.
d) Preventing infection from
prolonged rupture of membranes.
106. Which of the following is true with
respect to chorioamnionitis?
a) Once a woman who has had
chorioamnionitis has delivered the
antibiotics will be stopped.
b) If a woman has chorioamnionitis
she will be treated with broad spectrum
antibiotics and allowed to continue in
labor.
c) Most often chorioamnionitis is
caused by pathogens such as GBBS.
d) An epidural can cause maternal
fever and fetal tachycardia.
107. Which symptoms diagnose
chorioamnionitis? (Select all that apply)
a) Maternal or Fetal Tachycardia
b) Maternal fever > or = 38o C
c) Foul discharge
d) Uterine tenderness
108. Approximately 50% of all women
who give birth prematurely have no
identifiable risk factors, and about 50%
of preterm births could not be
prevented.
a) False
b) True
109. With regard to the care
management of preterm labor, nurses
should be aware that:
a) Because all women must be
considered at risk for preterm labor and
prediction is so hit-and-miss, teaching
pregnant women the symptoms
probably causes more harm through
false alarms.
b) Because preterm labor is likely to
be the start of an extended labor, a
woman with symptoms can wait several
hours before contacting the primary
caregiver.
c) Braxton Hicks contractions often
signal the onset of preterm labor
d) The diagnosis of preterm labor is
based on gestational age, uterine
activity, and progressive cervical
change.
110. A woman in preterm labor at 30
weeks of gestation receives two 12-mg
doses of betamethasone
intramuscularly. The purpose of this
pharmacologic treatment is to:
a) Stimulate fetal surfactant
production.
b) Suppress uterine contractions.
c) Maintain adequate maternal
respiratory effort and ventilation during
magnesium sulfate therapy.
d) Reduce maternal and fetal
tachycardia associated with ritodrine
administration.
111. Complications and risks associated
with cesarean births include (choose all
that apply):
a) Wound dehiscence.
b) Pulmonary edema.
c) Urinary tract infections.
d) Fetal injuries.
e) Hemorrhage.
112. During labor, the patient at 4 cm
suddenly becomes dyspneic, cyanotic,
and hypotensive. The nurse must
prepare immediately for: (Select all that
apply.)
a) CPR.
b) McRobert's maneuver.
c) Immediate vaginal delivery.
d) Cesarean delivery
113. Nurses should be aware that the
induction of labor:
a) Is also known as a trial of labor
(TOL).
b) Is rated for likelihood of induction
success by a Bishop score.
c) Is almost always done for
medical reasons.
d) Can be achieved by external and
internal version techniques
114. A client is in active labor. The nurse
determines that the fetus's position is
occiput posterior. Which nursing
diagnosis will apply to this woman's care
if the occiput posterior position becomes
persistent?
a) Risk for injury
b) Acute pain
c) Fluid volume deficit
d) Impaired gas exchange
115. A pregnant client was in an
automobile accident, and presents to
the labor suite from the Emergency
Department after she presented at the
ED with a deep gash on her forearm
from the crash. The client was not
wearing a seat belt, and was speeding.
She now seems highly agitated, is
pacing continuously, and is talking very
rapidly. The nurse should suspect that
this client has what type of
psychological disorder?
a) Schizophrenia
b) Social anxiety disorder
c) Obsessive-compulsive disorder
d) Bipolar disorder, manic phase
116. The most prevalent clinical
manifestation of abruptio placentae (as
opposed to placenta previa) is:
a) Intense abdominal pain.
b) Uterine activity.
c) Cramping.
d) Bleeding.
117. After delivery it is determined that
there is a placenta accreta. Which
intervention should the nurse anticipate?
a) Surgery with possible
Hysterectomy
b) 2 L oxygen by mask
c) Intravenous antibiotics
d) Intravenous oxytocin
118. Which of the following is true about
placenta previa.
a) Once placenta previa is
diagnosed by a 20 week ultrasound, it is
very likely the placenta previa will
resolve in the third trimester.
b) In evaluating the bleeding, a
vaginal exam would be done to
determine the cause of the bleeding.
c) Symptoms of placenta previa are
painful frequent contractions and bright
red vaginal bleeding
d) The bleeding from placenta
previa usually occurs late in pregnancy
at term.
118. With regard to the process of
inducing labor, nurses should be aware
that:
a) Ripening the cervix usually
results in a decreased success rate for
induction
b) Amniotomy can be used to make
the cervix more favorable for labor.
c) Oxytocin is less expensive than
prostaglandins and more effective but
creates greater health risks.
d) Labor sometimes can be induced
with balloon catheters or laminaria tents.
120. When the provider indicates a
shoulder dystocia is occurring during the
delivery of a macrosomic fetus, the
nurse would assist by:
a) Calling a second physician to
assist.
b) Utilizing fundal pressure to push
the fetus out.
c) Assisting the woman into
McRobert's maneuver.
d) Preparing for an immediate
cesarean delivery.
121. A primigravida is admitted to the
birth setting in early labor. She is 3 cm
dilated, -2 station, with intact
membranes and FHR of 150 bpm. Her
membranes rupture spontaneously, and
the FHR drops to 90 bpm with variable
decelerations. The initial response from
the nurse would be to:
a) Notify the physician.
b) Administer oxygen at 2 l per
nasal cannula.
c) Perform a vaginal exam.
d) Place the client in a left lateral
position
122. A multipara is having intense
uterine contractions with little uterine
relaxation between contractions. Vaginal
examination reveals rapid cervical
dilation and fetal descent. The nurse
should
a) Place the woman in knee—chest
position
b) Notify the physician of these
findings.
c) Turn off the lights to make it
easier for the woman to relax.
d) Assemble supplies to prepare for
a cesarean birth.
123. Which of the following is the correct
about care for a pregnant woman who
has experienced blunt trauma in a car
accident?
a) The two most common risks are
preterm labor and fetal death.
b) If the woman does not have more
than 6 ctx an hour she may go home
after 4 hours.
c) In the ER she is evaluated and
treated to hemodynamically stabilize
her, then she is evaluated with an
electronic fetal monitor for a minimum of
4 hours.
d) Rhogam is not necessary for rH
negative pregnant women after a blunt
force trauma.
124. A woman has been in labor for 16
hours. Her cervix is dilated to 3 cm and
is 80% effaced. The fetal presenting part
is not engaged. The nurse would
suspect:
a) Abruptio placentae
b) Breech malpresentation.
c) Fetal demise.
d) Cephalopelvic disproportion
(CPD).
125. For a woman at 42 weeks of
gestation, which finding would require
more assessment by the nurse?
a) Score of 8 on the biophysical
profile
b) One fetal movement noted in 1
hour of assessment by the mother
c) Cervix dilated 2 cm and 50%
effaced
d) Fetal heart rate of 116 beats/min
126. The nurse is caring for a client
whose labor is being augmented with
oxytocin. He or she recognizes that the
oxytocin should be discontinued
immediately if there is evidence of:
a) Rupture of the client’s amniotic
membranes.
b) Uterine contractions occurring
every 8 to 10 minutes
c) A fetal heart rate (FHR) of 180
with absence of variability.
d) The client needing to void.
127. In evaluating the effectiveness of
oxytocin induction, the nurse would
expect:
a) At least 30 mU/min of oxytocin
will be needed to achieve cervical
dilation
b) Contractions lasting 40 to 90 e) Position on her side and give her
seconds, 2 to 3 minutes apart. oxygen if the fetal heart rate was
c) The intensity of contractions to category II.
be at least 110 to 130 mm Hg.
d) Labor to progress at least 2 133. The nurse providing care for the
cm/hr dilation. laboring woman should understand that
amnioinfusion is used to treat
128. A pregnant woman’s amniotic a) Variable decelerations
membranes rupture. Prolapsed cord is (intermittent umbilical cord compression)
suspected. What intervention would be b) Fetal tachycardia.
the top priority? c) Late decelerations.
a) Preparing the woman for a d) Fetal bradycardia.
cesarean birth
b) Placing the woman in the
knee-chest position
c) Covering the cord in sterile gauze
soaked in saline
d) Starting oxygen by face mask

129. With regard to the use of tocolytic

therapy to suppress premature uterine
activity, nurses should be aware that:
a) There are no important maternal
(as opposed to fetal) contraindications.
b) Its most important function is to
afford the opportunity to administer
antenatal glucocorticoids.
c) The drugs can be given
efficaciously up to the designated
beginning of term at 37 weeks.
d) If the client develops pulmonary
edema while on tocolytics, intravenous
(IV) fluids should be given.

131. A woman arrive in the admission

area of L&D. She is complaining of
severe abdominal pain which she thinks
are contractions and vaginal bleeding.
You notice the sheet on the bed is about
1/3 covered with port wine fluid. You
would do all of the following EXCEPT:
a) NOtify the charge nurse and
patient's provider.
b) Put her on the monitor
c) Take a complete medical history
and measure her vital signs.
d) Start an IV
Chapter 22
1. Review of a primiparous woman's
labor and birth record reveals a
prolonged second stage of labor and
extended time in the stirrups. Based on
an interpretation of these findings, the
nurse would be especially alert for which
condition?
A. retained placental fragments
B. hypertension
C. thrombophlebitis
D. uterine subinvolution
2. The nurse is conducting a class for
postpartum women about mood
disorders. The nurse describes a
transient, self-limiting mood disorder
that affects mothers after birth. The
nurse determines that the women
understood the description when they
identify the condition as postpartum:
A. depression.
B. psychosis.
C. bipolar disorder.
D. blues.
3. A woman who is 2 weeks postpartum
calls the clinic and says, "My left breast
hurts." After
further assessment on the phone, the
nurse suspects the woman has mastitis.
In addition to pain,
the nurse would question the woman
about which symptom?
A. an inverted nipple on the affected
breast
B. no breast milk in the affected breast
C. an ecchymotic area on the affected
breast
D. hardening of an area in the affected
breast
4. A nurse is developing a program to
help reduce the risk of late postpartum
hemorrhage in
clients in the labor and birth unit. Which
measure would the nurse emphasize as
part of this
program?
A. administering broad-spectrum
antibiotics
B. inspecting the placenta after delivery
for intactness
C. manually removing the placenta at
birth
D. applying pressure to the umbilical
cord to remove the placenta
5. A multipara client develops
thrombophlebitis after birth. Which
assessment findings would
lead the nurse to intervene
immediately?
A. dyspnea, diaphoresis, hypotension,
and chest pain
B. dyspnea, bradycardia, hypertension,
and confusion
C. weakness, anorexia, change in level
of consciousness, and coma
D. pallor, tachycardia, seizures, and
jaundice
6. A client experienced prolonged labor
with prolonged premature rupture of
membranes. The
nurse would be alert for which condition
in the mother and the newborn?
A. infection
B. hemorrhage
C. trauma
D. hypovolemia
7. When assessing the postpartum
woman, the nurse uses indicators other
than pulse rate and
blood pressure for postpartum
hemorrhage because:
A. these measurements may not change
until after the blood loss is large.
B. the body's compensatory
mechanisms activate and prevent any
changes.
C. they relate more to change in 11. A client is experiencing postpartum
condition than to the amount of blood hemorrhage, and the nurse begins to
lost. massage her fundus.
D. maternal anxiety adversely affects Which action would be most appropriate
these vital signs. for the nurse to do when massaging the
woman's
8. A nurse is assessing a postpartum fundus?
client. Which finding would the cause A. Place the hands on the sides of the
the nurse the greatest abdomen to grasp the uterus.
concern? B. Use an up-and-down motion to
A. leg pain on ambulation with mild massage the uterus.
ankle edema C. Wait until the uterus is firm to express
B. calf pain with dorsiflexion of the foot clots.
C. perineal pain with swelling along the D. Continue massaging the uterus for at
episiotomy least 5 minutes.
D. sharp, stabbing chest pain with
shortness of breath 12. After teaching a woman with a
postpartum infection about care after
9. A woman who is experiencing discharge, which client
postpartum hemorrhage is extremely statement indicates the need for
apprehensive and additional teaching?
diaphoretic. The woman's extremities A. "I need to call my doctor if my
are cool and her capillary refill time is temperature goes above 100.4° F (38°
increased. Based on C).”
this assessment, the nurse suspects B. "When I put on a new pad, I'll start at
that the client is experiencing the back and go forward."
approximately how much blood C. "If I have chills or my discharge has a
loss? strange odor, I'll call my doctor."
A. 20% D. "I'll point the spray of the peri-bottle
B. 30% so it the water flows front to back."
C. 40%
D. 60% 13. A nurse is making a home visit to a
postpartum client. Which finding would
10. A postpartum client is prescribed lead the nurse to
medication therapy as part of the suspect that a woman is experiencing
treatment plan for postpartum psychosis?
postpartum hemorrhage. Which A. delirium
medication would the nurse expect to B. feelings of guilt
administer in this C. sadness
situation? D. insomnia
A. Magnesium sulfate
B. methylergonovine 14. A nurse is reviewing a journal article
C. Indomethacin on the causes of postpartum
D. nifedipine hemorrhage. Which
Answer: B condition would the nurse most likely
find as the most common cause?
A. labor augmentation
B. uterine atony
C. cervical or vaginal lacerations 18. A postpartum client comes to the
D. uterine inversion clinic for her routine 6-week visit. The
nurse assesses the
15. A postpartum woman is diagnosed client and suspects that she is
with endometritis. The nurse interprets experiencing subinvolution based on
this as an infection which finding?
involving which area? Select all that A. nonpalpable fundus
apply. B. moderate lochia serosa
A. endometrium C. bruising on arms and legs
B. decidua D. fever
C. myometrium
D. broad ligament 19. Assessment of a postpartum client
E. ovaries reveals a firm uterus with bright-red
F. fallopian tubes bleeding and a
localized bluish bulging area just under
16. A group of nurses are reviewing the skin at the perineum. The woman
information about mastitis and its also reports
causes in an effort to significant pelvic pain and is
develop a teaching program on experiencing problems with voiding. The
prevention for postpartum women. The nurse suspects which
nurses demonstrate condition?
understanding of the information when A. hematoma
they focus the teaching on ways to B. laceration
minimize risk of C. bladder distention
exposure to which organism? D. uterine atony
A. E. coli Answer: A
B. S. aureus
C. Proteus 20. A postpartum woman is prescribed
D. Klebsiella oxytocin to stimulate the uterus to
Answer: B contract. Which action
would be most important for the nurse to
17. A home health care nurse is do?
assessing a postpartum woman who A. Administer the drug as an IV bolus
was discharged 2 days ago. injection.
The woman tells the nurse that she has B. Give as a vaginal or rectal
a low-grade fever and feels "lousy." suppository.
Which finding would C. Piggyback the IV infusion into a
lead the nurse to suspect endometritis? primary line.
Select all that apply. D. Withhold the drug if the woman is
A. lower abdominal tenderness hypertensive.
B. urgency
C. flank pain 21. Assessment of a postpartum woman
D. breast tenderness experiencing postpartum hemorrhage
E. anorexia reveals mild
Answer: A, E shock. Which finding would the nurse
expect to assess? Select all that apply.
A. diaphoresis
B. tachycardia
C. oliguria
D. cool extremities
E. confusion
22. A nurse is providing a refresher
class for a group of postpartum nurses.
The nurse reviews
the risk factors associated with
postpartum hemorrhage. The group
demonstrates understanding
of the information when they identify
which risk factors associated with
uterine tone? Select all
that apply.
A. rapid labor
B. retained blood clots
C. hydramnios
D. operative birth
E. fetal malpostion
23. A nurse is massaging a postpartum
client's fundus and places the
nondominant hand on the
area above the symphysis pubis based
on the understanding that this action:
A. determines that the procedure is
effective.
B. helps support the lower uterine
segment.
C. aids in expressing accumulated clots.
D. prevents uterine muscle fatigue.
Answer: B
24. A nurse is developing a plan of care
for a woman who is at risk for
thromboembolism. Which
measure would the nurse include as the
most cost-effective method for
prevention?
A. prophylactic heparin administration
B. compression stockings
C. early ambulation
D. warm compresses
25. A postpartum woman who
developed deep vein thrombosis is
being discharged on
anticoagulant therapy. After teaching the
woman about this treatment, the nurse
determines that
additional teaching is needed when the
woman makes which statement?
A. "I will use a soft toothbrush to brush
my teeth."
B. "I can take ibuprofen if I have any
pain."
C. "I need to avoid drinking any alcohol."
D. "I will call my health care provider if
my stools are black and tarry."
26. The nurse is developing a discharge
teaching plan for a postpartum woman
who has
developed a postpartum infection.
Which measures would the nurse most
likely include in this
teaching plan? Select all that apply.
A. taking the prescribed antibiotic until it
is finished
B. checking temperature once a week
C. washing hands before and after
perineal care
D. handling perineal pads by the edges
E. directing peribottle to flow from back
to front
27. A nurse is assessing a postpartum
client who is at home. Which statement
by the client would
lead the nurse to suspect that the client
may be developing postpartum
depression?
A. "I just feel so overwhelmed and tired."
B. "I'm feeling so guilty and worthless
lately."
C. "It's strange, one minute I'm happy,
the next I'm sad."
D. "I keep hearing voices telling me to
take my baby to the river."
28. As part of an in-service program to a
group of home health care nurses who
care for
postpartum women, a nurse is
describing postpartum depression. The
nurse determines that the
teaching was successful when the group
identifies that this condition becomes
evident at which
time after birth of the newborn?
A. in the first week
B. within the first 2 weeks
C. in approximately 1 month
D. within the first 6 weeks
29. A nurse suspects that a client may
be developing disseminated
intravascular coagulation. The
woman has a history of placental
abruption (abruptio placentae) during
birth. Which finding
would help to support the nurse's
suspicion?
A. severe uterine pain
B. board-like abdomen
C. appearance of petechiae
D. inversion of the uterus
30. On a follow-up visit to the clinic, a
nurse suspects that a postpartum client
is experiencing
postpartum psychosis. Which finding
would most likely lead the nurse to
suspect this condition?
A. delusional beliefs
B. feelings of anxiety
C. sadness
D. insomnia
Answer: A
31. A nurse is assessing a client who
gave birth vaginally about 4 hours ago.
The client tells the
nurse that she changed her perineal pad
about an hour ago. On inspection, the
nurse notes that
the pad is now saturated. The uterus is
firm and approximately at the level of
the umbilicus.
Further inspection of the perineum
reveals an area, bluish in color and
bulging just under the skin
surface. Which action would the nurse
do next?
A. Apply warm soaks to the area.
B. Notify the health care provider.
C. Massage the uterine fundus.
D. Encourage the client to void.
32. A nurse is providing education to a
woman who is experiencing postpartum
hemorrhage and
is to receive a uterotonic agent. The
nurse determines that additional
teaching is needed when the
woman identifies which drug as possibly
being prescribed as treatment?
A. oxytocin
B. methylergonovine
C. carboprost
D. magnesium sulfate
1. An adolescent client in labor is dilated
4 cm and on admission asks for an
epidural. For cultural reasons, the
client's mother states that her daughter
"has to bite the bullet, just like I did." The
adolescent does not respond to the
mother's statement. What should the
nurse do to make sure the client's
request is honored?
a) Request that an anesthesiologist
administer the epidural at this time
because the client is uncomfortable and
has requested it
b) Knowing the client's cultural
background, suggest that the family call
a meeting to make the best decision for
the client
c) Follow the mother's request as the
client did not indicate a continued desire
for an epidural once the mother made
the request
d) Ask the client in a nonthreatening
way if she wishes to have an epidural,
and then speak with the primary health
care provider
2. A labor and delivery nurse is caring
for a woman with no prenatal care who
presented with vaginal bleeding and
abdominal pain. Late decelerations were
noted on the fetal heart monitor. Which
finding in the client history would cause
the nurse to suspect placental
abruption?
a) The client has had multiple sexual
partners and is positive for HIV
b) The client works 12-hour shifts in a
busy restaurant in the city
c) The client stated, "I use cocaine
about four times per week"
d) The client rides a motorcycle to and
from work
3. A pregnant client in the first trimester
is experiencing severe nausea. The
client asks the nurse if marijuana could
be used as a natural remedy to treat the
nausea. How does the nurse best
respond?
a) "Marijuana smoking is not
recommended; tinctures or edible
preparations have less risk"
b) "Marijuana use is illegal and should
not be used in pregnancy"
c) "Marijuana use may affect fetal
neurologic development and is not
recommended"
d) "Using small doses of marijuana is
believed to pose a low risk to the fetus"
4. A 41-year-old client at 11 weeks'
gestation has arrived for a prenatal visit.
When reviewing the client's past office
visit report, which assessment would the
nurse anticipate specifically related to
the client's age?
a) Nutrition assessment
b) Biophysical assessment
c) Chromosomal assessment
d) Mental health assessment
5. What is the first thing the nurse
should do when caring for a pregnant
woman with a disability?
a) Offer guidance for care measures
during pregnancy
b) Establish the impact of the disability
on a woman's lifestyle
c) Make arrangements for a home birth
d) Involve community and social
supports for the client
6. While in the waiting room of the clinic,
a pregnant client begins to choke on a
piece of food. Which action by the nurse
would be appropriate?
a) Insert a finger in the mouth to grasp
the object
b) Perform backward thrusts on the
chest with the fists
c) Place the client in a supine position
on the floor
d) Use two fingers to compress the
abdomen
7. What complication will the nurse be
alert for in the client who uses cocaine
during the pregnancy?
a) Placenta previa
b) Gestational diabetes
c) Hyperemesis gravidarum
d) Placental abruption (abruptio
placentae)
8. All of the following are commonly
seen in infants born to cocaine-addicted
mothers except:
a) Intracranial hemorrhage
b) Lethargy
c) Irritability
d) Muscle rigidity
9. A pregnant adolescent tells the
school nurse, "I want to go to the
primary health care provider and have
them check my baby, but I don't want to
tell my parents and the doctor probably
will not see me without them." What is
the best response by the nurse?
a) "You are considered emancipated
and may receive health care for you and
your baby without parental consent"
b) "You are probably correct. However,
you should tell your parents and have
them take you to see a health care
provider"
c) "I am sorry that you are in this
situation, but it is important for you to
see the health care provider"
d) "I am sure your parents will be upset
when they find out you are pregnant, but
they will surely take you for health care"
10. Which postpartum complication is
the nurse most likely to see in a mother
who abuses marijuana?
a) Infection
b) Postpartum hemorrhage
c) Hemorrhoids
d) Inadequate milk production
11. The nurse is caring for a pregnant
client considered at high risk for
pregnancy complications. What nursing
action(s) included in the plan of care
help achieve a positive outcome? Select
all that apply.
a) Make sure the client maintains bed
rest for the duration of the pregnancy
b) Provide educational pamphlets on
topics such as nutrition and exercise
c) Provide time for the client and support
person to ask questions
d) Inform the client of consequences
and potential negative outcomes
e) Stress the importance of attending
monthly health care provider
appointments
12. The nurse is preparing for a prenatal
visit with a pregnant woman who cannot
ambulate because of a thoracic spine
injury several years ago. What should
the nurse do first to prepare for this
client's visit?
a) Educate the client on the effects of
pregnancy and birth on women with
disabilities
b) Have assistants available to lift the
client onto the examining room table
c) Discuss the client's inability to provide
care for her child adequately
d) Assess the impact of the disability on
the client's lifestyle before offering
assistance
13. The nurse is eating lunch in the
hospital cafeteria when she notices a
pregnant woman, apparently in her third
trimester, choking on her food. After
assessing that the client cannot speak,
what should be the nurse's next
intervention?
a) Deliver back blows
b) Deliver abdominal thrusts
c) Deliver chest thrusts
d) Perform a blind finger sweep
14. The nurse is caring for a pregnant
client who has a preexisting spinal cord
injury. During labor, the client suddenly
experiences a headache and blood
pressure of 298/100 mm Hg. What is the
nurse's priority intervention?
a) Call for assistance
b) Elevate the client's head, maintaining
spinal precautions
c) Contact the health care provider
d) Rotate the client into the side-lying
position using the log-rolling method
15. The nurse is caring for a pregnant
adolescent client. Which complication(s)
of pregnancy is this client at increased
risk for due to age? Select all that apply.
a) Multiple gestation
b) Gestational diabetes
c) Iron-deficiency anemia
d) Preterm labor
e) Preeclampsia
16. A pregnant client at 22 weeks'
gestation is cut on the finger by some
rusty metal fencing. What medication(s)
will the nurse anticipate in the primary
health care provider's prescriptions for
this client? Select all that apply.
a) Hepatitis B vaccine
b) Hepatitis B immunoglobulin
c) Rh immunoglobulin
d) Tetanus, diphtheria, pertussis (Tdap)
vaccine
e) Tetanus immunoglobulin
17. The parent of a pregnant adolescent
says to the nurse, "I don't know what is
wrong with my daughter. I found her
eating chalk the other day and she says
she is craving it!" What information can
the nurse give to the parent?
a) "Gastrointestinal upset may be
causing this behavior. Is she having a lot
of morning sickness with her
pregnancy?"
b) "That is not so unusual. Pregnant
people often crave strange things during
pregnancy and this must just be a
craving"
c) "This could be related to a substance
use disorder. Do you know of any other
high-risk behavior?"
d) "We will check her hemoglobin level.
Often, iron deficiency anemia will cause
a craving for inedible substances"
18. The nurse is asking a pregnant
adolescent client about dietary intake.
The client states, "I eat well." How will
the nurse respond?
a) "When you say well, would you say
that includes fruits and vegetables but
not refined sugar?"
b) "If you are not eating fruits and
vegetables, you will need to take your
prenatal vitamins daily"
c) "Would you please tell me what you
ate in the last 24 hours? I would like a
clear idea of your intake"
d) "That is great. It is good to hear that
you know you will need to eat well for
you and the baby"
19. The nurse is caring for a pregnant
client with cerebral palsy who uses
forearm crutches for mobility. Which
question will help the nurse assess this
client's mobility needs as the pregnancy
progresses?
a) "How will you maintain intimacy with
your partner during the pregnancy?"
b) "Will you need a crib with an
adjustable side-rail to use for your
baby?"
c) "As your abdomen gets larger, what
will you need to maintain your mobility?"
d) "Do you have a wagon you can use to
transport your baby?"
20. A pregnant 16-year-old has decided
to have an amniocentesis for a positive
Down syndrome screen. How should the
nurse counsel this client?
a) "Because the father of the baby is
over 18, he can sign the consent form
for the procedure"
b) "Because you are not married, you
and the father of the baby have to sign
for the procedure"
c) "Because you are a minor, you will
need one of your parents to sign
consent for the procedure"
d) "This is ultimately your decision. You
do not need your parent's permission for
this procedure"
21. A nurse is conducting a class for
pregnant women about prevention of
unintentional (accidental) injury. The
nurse determines the teaching was
successful when the group makes which
statement? Select all that apply.
a) "If we use throw rugs, they need to
have non-skid backing on them"
b) "We need to have good lighting when
reading labels, especially ones on
medication containers"
c) "We need to take frequent rest
periods so we don't get overtired"
d) "It's okay to use a small step stool but
we shouldn't use any stepladders"
e) "It's important to stand for longer
periods of time so we don't have our
knees flexed so much"
22. A mother and her 17-year-old
daughter, who is in her first trimester,
arrive for the daughter's first prenatal
visit. The daughter will turn 18 in 2
weeks. The mother is visibly upset
about her daughter's pregnancy and
interrupts her daughter to answer the
nurse's questions that were addressed
to the daughter. The nurse says that she
would like to talk with the daughter
alone. The mother objects. Which of the
following should the nurse mention to
the mother?
a) The daughter can simply return in 2
weeks, when she is 18, and speak with
the nurse confidentially without the
mother's permission
b) The daughter is an emancipated
minor and has the right to speak with
the nurse confidentially
c) Because the daughter is still a minor,
the nurse may not speak with her alone
without the mother's permission
d) If the daughter acquires permission
from her father, she can speak with the
nurse confidentially without the mother's
permission
23. The nurse obtained a blood
pressure of 160/96 on a pregnant
adolescent at 32 weeks' gestation. A
baseline blood pressure of 130/60 was
obtained on her first visit. What
intervention does the nurse anticipate
advising the adolescent to begin?
a) She should reduce her sodium intake
b) She should begin taking a diuretic to
decrease the amount of fluid
accumulating
c) She should begin bed rest, preferably
in a side-lying position
d) She will need to prepare for a
cesarean birth immediately to deliver the
baby
24. A pregnant woman is in an
automobile accident and does not
survive the trauma. The spouse
requested that the physician do an
emergency postmortem cesarean birth.
Which conditions would most promote
infant survival?
a) The fetus is past 24 weeks and no
more than 30 minutes have passed
since the mother died
b) The fetus is past 20 weeks and no
more than 30 minutes have passed
since the mother died
c) The fetus is past 24 weeks and no
more than 5 minutes have passed since
the mother died
d) The fetus is past 32 weeks and no
more than 45 minutes have passed
since the mother died
25. A pregnant adolescent comes to the
clinic and reports that she "feels tired all
the time." The nurses assesses pale
mucous membranes. Laboratory tests
show a hemoglobin of 10.2 g/dl (102
g/L). The nurse is most correct to base
the plan of care off which anticipated
complication?
a) A physiologic illness such as
gastrointestinal bleeding from a peptic
ulcer
b) A lack of knowledge on which foods
to consume to have adequate iron
intake
c) Inadequate exercise to compensate
for the increased blood to the tissues
d) Unsure of how to maintain restful
sleep during pregnancy
26. The maternal health nurse is
developing the plan of care for an
adolescent client who is pregnant.
Which risk will the nurse prioritize in the
care plan?
a) Fetal injury
b) Imbalanced nutrition
c) Disruption of social interactions
d) Social isolation
27. Why is a young adolescent at higher
risk for postpartum hemorrhage?
a) Because of inadequate protein intake,
her body tissue integrity is weak and
feeble
b) A young adolescent is more likely to
be iron deficient
c) A young adolescent has a higher
likelihood of cephalopelvic disproportion
(CPD)
d) The uterus may not be fully
developed and may become
overdistended
28. The nurse is caring for a 16-year-old
client who has been in the first stage of
labor for 20 hours. Despite cervical
dilation, the client has had a lack of fetal
engagement with poor fetal descent. As
the client begins the 21st hour of labor,
the nurse suspects which complication
is affecting the client's labor
progression?
a) Cephalopelvic disproportion
b) High client anxiety
c) A short umbilical cord
d) Placenta previa
29. A pregnant client at the initial
prenatal visit reports using prescription
methadone maintenance. What will the
nurse include in the plan of care related
to this medication?
a) Buprenorphine should be substituted
for methadone due to lower
teratogenicity
b) Methadone use should be tapered
during pregnancy
c) Breastfeeding will be contraindicated
due to methadone use
d) The neonate should be observed
closely for abstinence symptoms after
birth
30. A 38-year-old woman at 15 weeks'
gestation comes in for a prenatal visit.
What test should the nurse offer at this
time to detect an open fetal spinal cord
or chromosomal defects?
a) A clean catch urinalysis and basic
metabolic panel (BMP) and human
chorionic gonadotropin (HCG) levels
b) A nonstress test using a fetal monitor
and serum human chorionic
gonadotropin (HCG), hemoglobin, and
hematocrit levels
c) Maternal serum alpha-fetoprotein,
human chorionic gonadotropin (HCG),
and unconjugated estriol levels
d) Screening for venereal diseases:
syphilis, gonorrhea, and human
immunodeficiency virus (HIV)
31. The nurse is caring for a 44-year-old
client experiencing postpartum
hemorrhage soon after birth. This is the
client's first child. The client has a
history of a sedentary lifestyle, anemia,
and poor nutritional intake. The client
did not obtain prenatal care until 32
weeks' gestation. Which piece of data
collected indicated to the nurse that the
woman was at risk of postpartum
hemorrhage?
a) A sedentary lifestyle
b) Age
c) Late prenatal care
d) Primigravida
The nurse is caring for a laboring client
whose urine drug screen is positive for
cocaine. The client has an epidural.
Which finding indicates to the nurse this
client has an actual substance
dependence?
The client becomes agitated, very
restless, and reports increased
discomfort when laying in the bed.
The nurse is preparing for a prenatal
visit with a pregnant woman who cannot
ambulate because of a thoracic spine
injury several years ago. What should
the nurse do first to prepare for this
client's visit?
Assess the impact of the disability on
the client's lifestyle before offering
A labor and delivery nurse is caring for a
woman with no prenatal care who
presented with vaginal bleeding and
abdominal pain. Late decelerations were
noted on the fetal heart monitor. Which
finding in the client history would cause
the nurse to suspect placental
abruption?
The client stated, "I use cocaine about
four times per week."
What is the first thing the nurse should
do when caring for a pregnant woman
with a disability?
Establish the impact of the disability on
a woman's lifestyle.
Which of the following statements is true
regarding trauma in pregnancy?
The uterus is a peripheral organ and will
see severely decreased blood flow in
the event of trauma.
The maternal health nurse is caring for a
pregnant woman with a physical
disability. Which action is the nurse's
priority when caring for the client?
Establish the impact of the disability on
the woman's lifestyle.
An adolescent client in labor is dilated 4
cm and on admission asks for an
epidural. For cultural reasons, the
client's mother states that her daughter
"has to bite the bullet, just like I did." The
adolescent does not respond to the
mother's statement. What should the
nurse do to make sure the client's
request is honored?
Ask the client in a nonthreatening way if
she wishes to have an epidural, and
then speak with the primary health care
provider.
At a prenatal visit, an adolescent client
expresses that recently she has had a
strange craving for chalk. When
considering this statement, which
diagnostic test would the nurse
anticipate the primary health care
provider prescribing?
complete blood count
Which postpartum complication is the
nurse most likely to see in a mother who
abuses marijuana?
inadequate milk production
A 41-year-old client at 11 weeks'
gestation has arrived for a prenatal visit.
When reviewing the client's past office
visit report, which assessment would the
nurse anticipate specifically related to
the client's age?
chromosomal assessment
The nurse is eating lunch in the hospital
cafeteria when she notices a pregnant
woman, apparently in her third trimester,
choking on her food. After assessing
that the client cannot speak, what
should be the nurse's next intervention?
Deliver chest thrusts.
A mother and her 17-year-old daughter,
who is in her first trimester, arrive for the
daughter's first prenatal visit. The
daughter will turn 18 in 2 weeks. The
mother is visibly upset about her
daughter's pregnancy and interrupts her
daughter to answer the nurse's
questions that were addressed to the
daughter. The nurse says that she
would like to talk with the daughter
alone. The mother objects. Which of the
following should the nurse mention to
the mother?
The daughter is an emancipated minor
and has the right to speak with the
nurse confidentially.
What is the best way for a woman with a
spinal cord injury who cannot feel labor
contractions to know that she is in
labor?
She will be able to palpate her
contractions with her hand.
The maternal health nurse is developing
the plan of care for an adolescent client
who is pregnant. Which risk will the
nurse prioritize in the care plan?
imbalanced nutrition
The nurse is caring for a pregnant client
considered at high risk for pregnancy
complications. What nursing action(s)
included in the plan of care help achieve
a positive outcome? Select all that
apply.
"Provide educational pamphlets on
topics such as nutrition and exercise."
"Stress the importance of attending
monthly health care provider
appointments."
"Provide time for the client and support
person to ask questions."
The nurse obtained a blood pressure of
160/96 on a pregnant adolescent at 32
weeks' gestation. A baseline blood
pressure of 130/60 was obtained on her
first visit. What intervention does the
nurse anticipate advising the adolescent
to begin?
She should begin bed rest, preferably in
a side-lying position.
The nurse is completing the first
prenatal visit assessment for a pregnant
adolescent in her second trimester of
pregnancy. The adolescent is homeless
and is currently staying with a friend.
Which nursing consideration is
important based on the client's
situation? Select all that apply.
"Nutritional assessment'"
"Screening for gestational hypertension"
"Laboratory tests for iron-deficiency
anemia"
"Measurement for cephalopelvic
disproportion"
"Safety and long-term planning"
The parent of a pregnant adolescent A client who is at 33 weeks' gestation
says to the nurse, "I don't know what is with twins presents to the emergency
wrong with my daughter. I found her room with a wrist injury and suspected
eating chalk the other day and she says fracture after a fall (above). What will the
she is craving it!" What information can nurse include in the care plan for this
the nurse give to the parent? client? Select all that apply.
"We will check her hemoglobin level. "Ensure abdominal shielding during
Often, iron deficiency anemia will cause diagnostic x-ray."
a craving for inedible substances." "Assess for signs of preterm labor."
"Assess for signs of preterm labor."
A 40-year-old primipara has been in
labor for 12 hours and is still only 6
centimeters dilated. What does the
nurse understand may be the cause for
this prolonged labor?
Cervical dilation (dilatation) may not
occur as spontaneously as in a younger
woman.

A pregnant adolescent tells the school

nurse, "I want to go to the primary health
care provider and have them check my
baby, but I don't want to tell my parents
and the doctor probably will not see me
without them." What is the best
response by the nurse?
"You are considered emancipated and
may receive health care for you and
your baby without parental consent."

A pregnant adolescent says to the

nurse, "I do not like this brown pigment
over my face. It makes me feel
self-conscious." What is the best
response by the nurse?
"This will usually fade after you have the
baby. You can use a cover makeup in
the meantime."

Chapter 23
1. The nurse is teaching a group of
parents who have preterm newborns
about the differences
between a full-term newborn and a
preterm newborn. Which characteristic
would the nurse
describe as associated with a preterm
newborn but not a term newborn?
A. fewer visible blood vessels through
the skin
B. more subcutaneous fat in the neck
and abdomen
C. well-developed flexor muscles in the
extremities
D. greater body surface area in
proportion to weight
2. A nurse is assessing a postterm
newborn. Which finding would the nurse
correlate with this
gestational age variation?
A. moist, supple, plum skin appearance
B. abundant lanugo and vernix
C. thin umbilical cord
D. absence of sole creases
3. The parents of a preterm newborn
being cared for in the neonatal intensive
care unit (NICU)
are coming to visit for the first time. The
newborn is receiving mechanical
ventilation,
intravenous fluids and medications and
is being monitored electronically by
various devices.
Which action by the nurse would be
most appropriate?
A. Suggest that the parents stay for just
a few minutes to reduce their anxiety.
B. Reassure them that their newborn is
progressing well.
C. Encourage the parents to touch their
preterm newborn.
D. Discuss the care they will be giving
the newborn upon discharge.
4. Rapid assessment of a newborn
indicates the need for resuscitation. The
newborn has copious
secretiohs. The newborn is dried and
placed under a radiant warmer. Which
action would the
nurse do next?
A. Intubate with an appropriate-sized
endotracheal tube.
B. Give chest compressions at a rate of
80 times per minute.
C. Administer epinephrine intravenously.
D. Clear the airway with a bulb syringe.
5. The nurse prepares to assess a
newborn who is considered to be
large-for-gestational-age
(LGA). Which characteristic would the
nurse correlate with this gestational age
variation?
A. strong, brisk motor skills
B. difficulty in arousing to a quiet alert
state
C. birthweight of 7 lb, 14 oz (3,572 g)
D. wasted appearance of extremities
6. A nurse is providing care to a large
for gestational age newborn. The
newborn's blood glucose
level was 32 mg/dL one hour ago.
Breast-feeding was initiated. The nurse
checks the newborn's
blood glucose level and finds it to be 23
mg/dL. Which action would the nurse do
next?
A. Administer intravenous glucose.
B. Feed the newborn 2 ounces of
formula.
C. Initiate blow-by oxygen therapy.
D. Place the newborn under a radiant
warmer.
7. A preterm newborn has received
large concentrations of oxygen therapy
during a 3-month stay
in the NICU. As the newborn is prepared
to be discharged home, the nurse
anticipates a referral
for which specialist?
A. ophthalmologist
B. nephrologist
C. cardiologist
D. neurologist
8. A nurse is developing the plan of care
for a small-for-gestational-age newborn.
Which action would the nurse determine
as a priority?
A. Preventing hypoglycemia with early
feedings
B. Observing for newborn reflexes
C. Promoting bonding between the
parents and the newborn
D. Monitoring vital signs every 2 hours
9. The nurse is providing care to a
newborn who was born at 36 weeks'
gestation. Based on the
nurse's understanding of gestational
age, the nurse identifies this newborn
as:
A. preterm.
B. late preterm.
C. term.
D. postterm.
10. Which intervention would be most
appropriate for the nurse to do when
assisting parents
who have experienced the loss of their
preterm newborn?
A. Avoid using the terms "death" or
"dying."
B. Provide opportunities for them to hold
the newborn.
C. Refrain from initiating conversations
with the parents.
D. Quickly refocus the parents to a more
pleasant topic.
11. A nurse is reviewing the maternal
history of a large-for-gestational-age
(LGA) newborn.
Which factor, if noted in the maternal
history, would the nurse identify as
possibly contributing
to the birth of this newborn?
A. substance use disorder
B. diabetes
C. preeclampsia
D. infection
12. A nurse is assessing a preterm
newborn. Which finding would alert the
nurse to suspect that a
preterm newborn is in pain?
A. bradycardia
B. oxygen saturation level of 94%
C. decreased muscle tone
D. sudden high-pitched cry
13. A group of pregnant women are
discussing high-risk newborn conditions
as part of a prenatal
class. When describing the
complications that can occur in these
newborns to the group, which
would the nurse include as being at
lowest risk?
A. small-for-gestational-age (SGA)
newborns
B. large-for-gestational-age (LGA)
newborns
C. appropriate-for-gestational-age
(AGA) newborns
D. low–birth-weight newborns
14. A nurse is conducting a class for
expectant parents about newborns. As
part of the class, the
nurse describes newborns with birth
weight variations. The nurse determines
that the teaching
was successful when the class identifies
which variation if a newborn weighs 5.2
lb (2,358 g) at
any gestational age?
A. small for gestational age
B. low birth weight
C. very low birth weight
D. extremely low birth weight
15. A nurse is assessing a newborn who
has been classified as small for
gestational age. Which
characteristics would the nurse expect
to find? Select all that apply.
A. wasted extremity appearance
B. increased amount of breast tissue
C. sunken abdomen
D. adequate muscle tone over buttocks
E. narrow skull sutures
16. A nurse is preparing a presentation
for a group of perinatal nurses about
common problems
associated with preterm birth. When
describing the preterm newborn's risk
for perinatal
asphyxia, the nurse includes which
factor as contributing to the newborn's
risk? Select all that
apply.
A. surfactant deficiency
B. placental deprivation
C. immaturity of the respiratory control
centers
D. decreased amounts of brown fat
E. depleted glycogen stores
17. After a rapid assessment determines
that a newborn is in need of
resuscitation, the nurse
would perform which action first?
A. Dry the newborn thoroughly.
B. Suction the airway.
C. Administer ventilations.
D. Give volume expanders.
18. A nurse suspects that a preterm
newborn is having problems with
thermal regulation. Which
findings would support the nurse's
suspicion? Select all that apply.
A. shallow, slow respirations
B. cyanotic hands and feet
C. irritability
D. hypertonicity
E. feeble cry
19. The nurse is assessing a preterm
newborn's fluid and hydration status.
Which finding would
alert the nurse to possible
overhydration?
A. decreased urine output
B. tachypnea
C. bulging fontanels
D. elevated temperature
20. The nurse is assessing a preterm
newborn who is in the neonatal
intensive care unit (NICU)
for signs and symptoms of
overstimulation. Which assessment
finding would the nurse correlate
with this situation?
A. increased respirations
B. flaying hands
C. eupnea
D. increased heart rate
21. A nurse is reviewing a journal article
about newborn pain prevention and
management.
Which information would the nurse most
likely find discussed in the article?
A. Newborn pain is frequently
recognized and treated.
B. Newborns rarely experience pain with
procedures.
C. Pain is frequently mistaken for
irritability or agitation.
D. Newborns may be less sensitive to
pain than adult.
22. A nurse is developing a plan of care
for a preterm newborn to address the
nursing diagnosis
of risk for delayed development. Which
measures would the nurse include?
Select all that apply.
A. clustering care to promote rest
B. positioning newborn in extension
C. using kangaroo care
D. loosely covering the newborn with
blankets
E. providing nonnutritive sucking
23. A nurse is assisting the anxious
parents of a preterm newborn to cope
with the situation.
Which statement by the nurse would be
least appropriate?
A. "I'll be here to help you all along the
way."
B. "What has helped you to deal with
stressful situations in the past?"
C. "Let me tell you about what you will
see when you visit your baby."
D. "Forget about what's happened in the
past, and focus on the now."
24. The nurse frequently assesses the
respiratory status of a preterm newborn
based on the
understanding that the newborn is at
increased risk for respiratory distress
syndrome because of
which factor?
A. inability to clear fluids
B. immature respiratory control center
C. deficiency of surfactant
D. smaller respiratory passages
25. An LGA newborn has a blood
glucose level of 30 mg/dL and is
exhibiting symptoms of
hypoglycemia. Which action would the
nurse do next?
A. Encourage frequent feedings
B. Feed the newborn 2 ounces of
dextrose water.
C. Initiate blow-by oxygen therapy.
D. Place the newborn under a radiant
warmer.
26. While caring for a preterm newborn
receiving oxygen therapy, the nurse
monitors the oxygen
therapy duration closely based on the
understanding that the newborn is at
risk for which
condition?
A. retinopathy of prematurity
B. metabolic acidosis
C. infection
D. cold stress
27. A woman gives birth to a newborn at
36 weeks' gestation. She tells the nurse,
"I'm so glad
that my baby isn't premature." Which
response by the nurse would be most
appropriate?
A. "You are lucky to have given birth to a
term newborn."
B. "We still need to monitor him closely
for problems."
C. "How do you feel about giving birth to
your baby at 36 weeks?"
D. "Your baby is premature and needs
monitoring in the NICU."
28. A 20-hour-old neonate is suspected
of having polycythemia. Which nursing
intervention(s)
will the nurse utilize to provide care for
this neonate? Select all that apply.
A. Obtain hemoglobin and hematocrit
laboratory tests
B. Provide early feedings to prevent
hypoglycemia
C. Maintain oxygen saturation
parameters
D. Monitor urinary output
E. Insert a peripheral IV
29. A nurse is developing a plan of care
for a preterm infant experiencing
respiratory distress.
Which measure will the nurse include in
this plan?
A. Stimulate the infant with frequent
handling.
B. Keep the newborn in an open
bassinet.
C. Administer oxygen using an oxygen
hood.
D. Give intermittent tube feedings.
30. A late preterm newborn is being
prepared for discharge to home after
being in the neonatal
intensive care unit for 4 days. The nurse
instructs the parents about the care of
their newborn and
emphasizes warning signs that should
be reported to the pediatrician
immediately. The nurse
determines that additional teaching is
needed based on which parental
statement?
A. "We will call 911 if we start to see that
our newborn's lips or skin are looking
bluish."
B. "If our newborn's skin turns yellow, it
is from the treatments and our newborn
is okay. "
C. "If our newborn does not have a wet
diaper in 12 hours, we will call our
pediatrician."
D. "We will let the pediatrician know if
our newborn's temperature goes above
100.4°F (38°C)."
A 26-year-old primigravida has brought
her doula to the birthing center for
support during her labor and birth. The
doula has been helping her through the
past 16 hours of labor. The laboring
woman is now 6 cm dilated. She
continues to report severe pain in her
back with each contraction. The client
finds it comforting when her doula uses
the ball of her hand to put
counterpressure on her lower back.
What is the likely cause of the woman's
back pain?
Occiput posterior position
Shoulder dystocia is a true medical
emergency that can cause fetal demise
because the baby cannot be born. Stuck
in the birth canal, the infant cannot take
its first breath. Which maneuver is first
attempted to deliver an infant with
shoulder dystocia?
McRoberts maneuver
After spontaneous rupture of
membranes, the nurse notices a
prolapsed cord. The nurse immediately
places the woman in which position?
knee-chest
A nursing student has learned that
precipitous labor is when the uterus
contracts so frequently and with such
intensity that a very rapid birth will take
place. This means the labor will be
completed in which span of time?
less than 3 hours
A client with a pendulous abdomen and
uterine fibroid tumors has just begun
labor and arrived at the hospital. After
examining the client, the primary care
provider informs the nurse that the fetus
appears to be malpositioned in the
uterus. Which fetal position or
presentation should the nurse most
expect in this woman?
transverse lie
Although many women envision a plan
of how labor will go, sometimes
complications happen, and their plan is
no longer achievable. When this
happens, what is the best question the
nurse can ask the woman at this time?
"What do you consider your primary
goal for the outcome of this pregnancy?"
A woman in labor is having very intense
contractions with a resting uterine tone
>20 mm Hg. The woman is screaming
out every time she has a contraction.
What is the highest priority fetal
assessment the health care provider
should focus on at this time?
Look for late decelerations on monitor,
which is associated with fetal anoxia.
A woman presents at Labor and
Delivery very upset. She reports that
she has not felt her baby moving for the
last 6 hours. The nurse listens for a fetal
heart rate and cannot find a heartbeat.
An ultrasound confirms fetal death and
labor induction is started. What
intervention by the nurse would be
appropriate for this mother at this time?
Offer to take pictures and footprints of
the infant once it is delivered.
A pregnant client at 24 weeks' gestation
comes to the clinic for an evaluation.
The client called the clinic earlier in the
day stating that she had not felt the
fetus moving since yesterday evening.
Further assessment reveals absent fetal
heart tones. Intrauterine fetal demise is
suspected. The nurse would expect to
prepare the client for which testing to
confirm the suspicion?
ultrasound
A pregnant client at 30 weeks' gestation
calls the clinic because she thinks that
she may be in labor. To determine if the
client is experiencing labor, which
question(s) would be appropriate for the
nurse to ask? Select all that apply.
"Are you feeling any pressure or
heaviness in your pelvis?"
"Are you having contractions that come
and go, off and on?"
"Have you noticed any fluid leaking from
your vagina?"
"Have you been having any nausea or
vomiting?"
What terminology would the nurse use
to document a newborn who weighs
4,000 grams (8.8 lb) or more at birth?
macrosomia
A nursing student is learning about fetal
presentation. The nursing instructor
realizes a need for further instruction
when the student makes which of the
following statements?
"Transverse lie is the same as when the
fetal buttocks present to the birth canal."
A laboring client has been pushing
without delivering the fetal shoulders.
The primary care provider determines
the fetus is experiencing shoulder
dystocia. What intervention can the
nurse assist with to help with the birth?
McRoberts maneuver
A 16-year-old client has been in the
active phase of labor for 14 hours. An
ultrasound reveals that the likely cause
of delay in dilation (dilatation) is
cephalopelvic disproportion. Which
intervention should the nurse most
expect in this case?
cesarean birth
A client's membranes have just
ruptured. Her fetus is presenting breech.
Which action should the nurse do
immediately to rule out prolapse of the
umbilical cord in this client?
Assess fetal heart sounds.
A woman in active labor with a history of
two previous cesarean births is being
monitored frequently as she tries to
have a vaginal birth. Suddenly, the
woman grabs the nurse's hand and
states, "Something inside me is tearing."
The nurse notes her blood pressure is
80/50 mm Hg, pulse rate is 130 bpm
and weak, the skin is cool and clammy,
and the fetal monitor shows
bradycardia. The nurse activates the
code team because the nurse suspects
the client may be experiencing which
complication?
uterine rupture
A woman at 39 weeks' gestation is
brought to the emergency department in
labor following blunt trauma from an
vehicle accident. The labor has been
progressing well after the epidural when
suddenly the woman reports severe
pain in her back and shoulders. Which
potential situation should the nurse
suspect?
Uterine rupture
A G2P1 woman is in labor attempting a
VBAC, when she suddenly complains of
light-headedness and dizziness. An
increase in pulse and decrease in blood
pressure is noted as a change from the
vital signs obtained 15 minutes prior.
The nurse should investigate further for
additional signs or symptoms of which
complication?
Uterine rupture
After only 45 minutes of labor, the client
feels the urge to push. She pushes once
and the baby's head is visible. With the
next push, the head emerges. What is
the immediate risk when the head is
delivered too fast?
Perineal tearing
The nurse cared for a client who gave
birth. The duration of labor from the
onset of contractions until the birth of
the baby was 2 hours. How will the
nurse document the client's labor in the
health record?
Precipitous labor
The nurse in a busy L & D unit is caring
for a woman beginning induction via
oxytocin drip. Which prescription should
the nurse question with regard to
titrating the infusion upward for
adequate contractions?
Begin infusion at 10 milliunits (mu)/min
and titrate every 15 minutes upward by
5 mu/min.
The nurse is assisting with a G2P1,
24-year-old client who has experienced
an uneventful pregnancy and is now
progressing well through labor. Which
action should be prioritized after noting
the fetal head has retracted into the
vagina after emerging?
Use McRoberts maneuver.
A laboring client is experiencing
dysfunctional labor or dystocia due to
the malfunction of one or more of the
"four Ps" of labor. Which scenario best
illustrates a power problem?
Uterine contractions are weak and
ineffective.
The nurse is monitoring the uterine
contractions of a woman in labor. The
nurse determines the woman is
experiencing hypertonic uterine
dysfunction based on which contraction
finding?
erratic
A client arrives in labor and delivery
following a motor vehicle accident. She
was sitting in the passenger seat and
wearing a seat belt. On admission the
nurse notes vaginal bleeding. The client
says she is 30 weeks' pregnant, but only
had an initial prenatal visit during which
the pregnancy was confirmed. The
external monitor shows irregular uterine
contractions and a fetal heart rate of
152. The provider orders an ultrasound
examination prior to establishing a plan
of care. What is the priority purpose for
an ultrasound examination in this
situation?
Determine placental location
A nurse assesses a client in labor and
suspects dysfunctional labor (hypotonic
uterine dysfunction). The woman's
membranes have ruptured and
fetopelvic disproportion is ruled out.
Which intervention would the nurse
expect to include in the plan of care for
this client?
administering oxytocin
A woman in labor is experiencing
hypotonic uterine dysfunction.
Assessment reveals no fetopelvic
disproportion. Which group of
medications would the nurse expect to
administer?
uterine stimulants
When caring for a client requiring a
forceps-assisted birth, the nurse would
be alert for:
potential lacerations and bleeding.
The nurse would prepare a client for
amnioinfusion when which action
occurs?
Severe variable decelerations occur and
are due to cord compression.
Which intervention would be most
important when caring for the client with
breech presentation confirmed by
ultrasound?
continuing to monitor maternal and fetal
status
A nursing instructor is teaching students
about fetal presentations during birth.
The most common cause for increased
incidence of shoulder dystocia is:
increasing birth weight.
A woman in active labor suddenly
experiences a sharp, excruciating low
abdominal pain, which the nurse
suspects may be a uterine rupture since
the shape of the abdomen has changed.
The nurse calls a code, and a cesarean
birth is performed stat, but the infant
does not survive the trauma. A few
hours later, after the woman has
stabilized, she asks to hold and touch
her infant, and the nurse arranges this.
Later, the nurse's documentation should
include which outcome statement?
The parents are beginning to
demonstrate positive grieving behaviors.
A woman has been in labor for the past
8 hours, and she has progressed to the
second stage of labor. However, after 2
hours with no further descent, the
provider diagnoses an "arrested
descent." The woman asks, "Why is this
happening?" Which response is the best
answer to this question?
"More than likely you have
cephalopelvic disproportion (CPD)
where baby's head cannot make it
through the canal."
A primigravida whose labor was initially
progressing normally is now
experiencing a decrease in the
frequency and intensity of her
contractions. The nurse would assess
the woman for which condition?
fetopelvic disproportion
A woman with a history of crack cocaine
use disorder is admitted to the labor and
birth area. While caring for the client, the
nurse notes a sudden onset of fetal
bradycardia. Inspection of the abdomen
reveals an irregular wall contour. The
client also reports acute abdominal pain
that is continuous. Which condition
would the nurse suspect?
uterine rupture
A nursing instructor identifies which of
the following as increasing the chances
of infection when coupled with
prolonged labor?
ruptured membranes
A nurse is caring for a client who is
diagnosed with a breech presentation
and in the transition stage of labor. The
nurse is aware that which is common at
birth?
A thick meconium
The nurse is caring for a client
suspected to have a uterine rupture.
The nurse predicts the fetal monitor will
exhibit which pattern if this is true?
Late decelerations
The nurse is caring for a client in active
labor. Which assessment finding should
the nurse prioritize and report to the
team?
Sudden shortness of breath
The nurse is assessing a woman who
had a forceps-assisted birth for
complications. Which condition would
the nurse assess in the fetus?
caput succedaneum
A client has arrived at the labor and
delivery suite for a scheduled induction
of labor. Which nursing intervention
should the nurse implement before
starting the oxytocin infusion?
Assessing for uterine contractions
The nursing student demonstrates an
understanding of dystocia with which
statement?
"Dystocia is diagnosed after labor has
progressed for a time."
Which finding would lead the nurse to
suspect that the fetus of a woman in
labor is in hypertonic uterine
dysfunction?
contractions most forceful in the middle
of uterus rather than the fundus
A multigravida client at 31 weeks'
gestation is admitted with confirmed
preterm labor. As the nurse continues to
monitor the client now receiving
magnesium sulfate, which assessment
findings will the nurse prioritize and
report immediately to the RN or health
care provider?
Respiratory depression, hypotension,
absent tendon reflexes
A client has been in labor for 10 hours,
with contractions occurring consistently
about 5 minutes apart. The resting tone
of the uterus remains at about 9 mm Hg,
and the strength of the contractions
averages 21 mm Hg. The nurse
recognizes which condition in this
client?
hypotonic contractions
A client is giving birth when shoulder
dystocia occurs in the fetus. The nurse
recognizes that which condition in the
client is likely to increase the risk for
shoulder dystocia?
diabetes
The nurse is caring for a client in the
transition stage of labor. In which
scenario would the nurse predict the use
of forceps may be used to assist with
the birth?
Abnormal position of the fetal head
A shoulder dystocia situation is called in
room 4. The nurse enters the room to
help and the health care provider says
to the nurse, "McRoberts maneuver."
What does the nurse do next?
Bring the client's knees back toward the
shoulders, causing hyperflexion of the
hips and rotation of the pubic symphysis
The nurse is caring for a woman
undergoing cervical dilation. Which
assessment finding would alert the
nurse to the complication of vasa
previa?
Painless bleeding at the beginning of
cervical dilation

A pregnant client's labor has been A woman receives magnesium sulfate

progressing slower than normal. The as treatment for preterm labor. The
client is visibly anxious and tense, telling nurse assess and maintains the infusion
the nurse, "I am so worried about what at the prescribed rate based on which
is going to happen. And I am so tired finding?
and feel so helpless." Other underlying Respiratory rate of 16 breaths/minute
issues that may be contributing to the
client's slow labor progress have been
ruled out. Which response(s) by the
nurse would be appropriate? Select all
that apply.
"Maybe dimming the lights or some soft
music will help you relax a bit."
"I will keep you updated often on how
you and your baby are doing."
"Things are moving along but
sometimes it can take a little longer."

Which statement describes why

hypertonic contractions tend to become
very painful?
The myometrium becomes sensitive
from the lack of relaxation and anoxia of
uterine cells.

The nurse is assessing a multipara

woman who presents to the hospital
after approximately 2 hours of labor and
notes the fetus is in a transverse lie.
After notifying the RN and primary care
provider, which action should the LPN
prioritize?
Prepare to assist with external version.

The fetus of a woman in labor is

determined to be in a persistent occiput
posterior position. Which intervention
would the nurse prioritize?
Pain relief measures
Chapter 24
1. A newborn with severe meconium
aspiration syndrome (MAS) is not
responding to
conventional treatment. Which measure
would the nurse anticipate as possibly
necessary for this
newborn?
A. extracorporeal membrane
oxygenation (ECMO)
B. respiratory support with a ventilator
C. insertion of a laryngoscope for deep
suctioning
D. replacement of an endotracheal tube
via X-ray
2. A nurse is providing care to a
newborn. The nurse suspects that the
newborn is developing
sepsis based on which assessment
finding?
A. increased urinary output
B. interest in feeding
C. temperature instability
D. wakefulness
3. A nurse is providing care to a
newborn who is receiving phototherapy.
Which action would
the nurse most likely include in the plan
of care?
A. keeping the newborn in the supine
position
B. covering the newborn's eyes while
under the bililights
C. ensuring that the newborn is covered
or clothed
D. reducing the amount of fluid intake to
8 ounces daily
4. A newborn has been diagnosed with
a group B streptococcal infection shortly
after birth. The
nurse understands that the newborn
most likely acquired this infection from
which cause?
A. improper hand washing
B. contaminated formula
C. nonsterile catheter insertion
D. mother's birth canal
5. Which action would be most
appropriate for the nurse to take when a
newborn has an
unexpected anomaly at birth?
A. Show the newborn to the parents as
soon as possible while explaining the
defect.
B. Remove the newborn from the
birthing area immediately.
C. Inform the parents that there is
nothing wrong at the moment.
D. Tell the parents that the newborn
must go to the nursery immediately.
6. The nurse prepares to administer a
gavage feeding for a newborn with
transient tachypnea
based on the understanding that this
type of feeding is necessary because:
A. lactase enzymatic activity is not
adequate.
B. oxygen demands need to be
reduced.
C. renal solute lead must be considered.
D. hyperbilirubinemia is likely to
develop.
Answer: B
7. Which information would the nurse
include when teaching a new mother
about the difference
between pathologic and physiologic
jaundice?
A. Physiologic jaundice results in
kernicterus.
B. Pathologic jaundice appears within
24 hours after birth.
C. Both are treated with exchange
transfusions of maternal O- blood.
D. Physiologic jaundice requires transfer
to the NICU.
8. A nurse is teaching the mother of a
newborn experiencing cocaine
withdrawal about caring for
the neonate at home. The mother
stopped using cocaine near the end of
her pregnancy. The nurse
determines that additional teaching is
needed when the mother identifies
which action as
appropriate for her newborn?
A. wrapping the newborn snugly in a
blanket
B. waking the newborn every hour
C. checking the newborn's fontanels
D. offering a pacifier
9. A newborn is suspected of having
fetal alcohol syndrome. Which finding
would the nurse
expect to assess?
A. bradypnea
B. hydrocephaly
C. flattened maxilla
D. hypoactivity
Answer: C
10. After teaching the parents of a
newborn with periventricular
hemorrhage about the disorder
and treatment, which statement by the
parents indicates that the teaching was
successful?
A. "We'll make sure to cover both of his
eyes to protect them."
B. "Our newborn could develop a
learning disability later on."
C. "Once the bleeding ceases, there
won't be any more worries."
D. "We need to get family members to
donate blood for transfusion."
12. While reviewing a newborn's
medical record, the nurse notes that the
chest X-ray shows a
ground glass pattern. The nurse
interprets this as indicative of:
A. respiratory distress syndrome.
B. transient tachypnea of the newborn.
C. asphyxia.
D. persistent pulmonary hypertension.
Answer: A
13. A newborn is suspected of
developing persistent pulmonary
hypertension. The nurse would
expect to prepare the newborn for which
procedure to confirm the suspicion?
A. chest X-ray
B. blood cultures
C. echocardiogram
D. stool for occult blood
14. A preterm newborn is receiving
enteral feedings. Which finding would
alert the nurse to
suspect that the newborn is developing
NEC?
A. irritability
B. sunken abdomen
C. clay-colored stools
D. feeding intolerance
Answer: D
15. A nurse is reviewing the plan of care
for a newborn who has been diagnosed
respiratory
distress syndrome. Which intervention
would the nurse closely monitor to
reduce the child's risk
for chronic lung disease?
A. Rescue surfactant therapy
B. Mechanical ventilation
C. Oxygen therapy
D. Radiant warmer use
16. A nurse is presenting a review class
for a group of neonatal nurses about
congenital
conditions in the newborn. The nurse
determines that the teaching was
effective based on which
statement made by the group?
A. "Usually a definitive cause can be
identified."
B. "Congenital conditions typically affect
a specific body system."
C. "A congenital condition is an anomaly
that develops immediately after birth."
D. "These conditions are responsible for
nearly half the deaths in term
newborns."
17. After teaching the parents of a
newborn with retinopathy of prematurity
(ROP) about the
disorder and treatment, which statement
by the parents indicates that the
teaching was
successful?
A. "Can we schedule follow-up vision
screenings with the pediatric
ophthalmologist now?"
B. "We can fix the problem with
surgery."
C. "We'll make sure to administer eye
drops each day for the next few weeks."
D. "I'm sure the baby will grow out of it."
19. A nurse is presenting a review class
for a group of neonatal nurses on the
different types of
congenital heart disease in infants. The
group demonstrates a need for
additional teaching when
they identify which condition as an
example of increased pulmonary blood
flow (left-to-right
shunting)?
A. atrial septal defect
B. tetralogy of Fallot
C. ventricular septal defect
D. patent ductus arteriosus
20. The nurse is assessing the newborn
of a mother who had gestational
diabetes. Which findings
would the nurse expect? Select all that
apply.
A. pale skin color
B. buffalo hump
C. distended upper abdomen
D. excessive subcutaneous fat

18. The nurse frequently assesses the

respiratory status of a preterm newborn
based on the
understanding that the newborn is at
increased risk for respiratory distress
syndrome because of:
A. inability to clear fluids.
B. immature respiratory control center.
C. deficiency of surfactant.
D. smaller respiratory passages.
CH 24
1. A client who was in labor for 32 hours
gave birth to a healthy newborn by
emergency cesarean section. Which
statement by this client would alert the
nurse that the client is having problems
with her self-esteem?
a) "I am surprised that I need a narcotic
pain medication. I am in more pain than
I expected"
b) "I feel like I'm not a real mother
because I could not give birth to my
baby the natural way"
c) "I feel like the event was such a
whirlwind as everything about the
delivery happened so fast"
d) "I'm disappointed that the labor did
not progress as expected. I am glad that
it is all over"
2. The nurse is caring for a client who is
being prepared for a cesarean birth due
to nonprogession of the labor process.
The nurse will direct the client to the
proper placement on the operating table
and abdominal preparation for which
type of incision?
a) Vertical incision
b) Low transverse incision ("bikini cut")
c) Low-abdominal incision
d) Classical incision
3. The client has been progressing well
through the labor process and the health
care provider prepares to deliver the
infant and performs an episiotomy. The
nurse predicts which situation is the
reason for this procedure?
a) Previous perineal laceration with her
last child
b) Client request so she does not tear
c) Prior episiotomy with last child
d) Shoulder dystocia
4. The nurse is monitoring a client at 41
weeks' gestation receiving IV oxytocin.
Which action should the nurse prioritize
if noticeable contractions are occurring
every 2 minutes, lasting 60 to 90
seconds on the fetal monitor?
a) Stop the IV oxytocin infusion
b) Change the client's position
c) Notify the health care provider
d) Administer oxygen 10L via face mask
5. The health care provider has ordered
a cesarean birth for an exhausted client
who has been in labor for many hours
with the fetus now showing increasing
signs of distress. As the client and
partner express disappointment in not
having a natural birth (and anxiety in not
knowing what will now happen), which
response will the nurse prioritize?
a) Briefly describe what will be
experienced, explain each procedure,
and encourage the partner to participate
b) Compare the risks of cesarean birth
with those of continuing to attempt
vaginal birth
c) Tell them firmly that the client must be
prepped for surgery and place an IV and
catheter
d) Calmly and confidently describe the
qualifications of the surgical team
6. A pregnant client tells the nurse,
"Labor and birth sounds so awful. Can't I
just schedule a cesarean birth instead?"
How will the nurse reply?
a) "Our hospital has anesthesiologists
on staff who can provide you with an
epidural for labor to limit pain"
b) "Can you tell me more about your
concerns regarding the labor and birth
processes?"
c) "Would you consider taking prenatal
classes to learn more about labor and
birth before making this decision?"
d) "Your primary health care provider
can review the risks of a cesarean birth
to determine if this is okay"
7. To prevent tearing of the perineum of
a client during birth, a physician
performs a mediolateral episiotomy. The
nurse recognizes that an advantage of a
mediolateral episiotomy over a midline
episiotomy is which of the following?
a) Less postpartal discomfort
b) Lower risk for rectal mucosal tear
c) Less blood loss
e) Easier healing
8. The nursing instructor is leading a
group discussion on the various types of
birth. The instructor determines the
session is successful when the students
correctly categorize forceps or
vacuum-assisted birth as what type?
a) Spontaneous vaginal birth
b) Surgical birth
c) Failed vaginal birth
d) Operative vaginal birth
9. A pregnant client who had a previous
cesarean birth for breech presentation is
planning a vaginal birth and asks the
nurse how to increase the chances of
having a vaginal birth. What will the
nurse include in the response? Select all
that apply.
a) Hire a doula for labor support
b) Choose exercises such as swimming
that promote a cephalic presentation
c) Seek out nurse-midwife care
d) Pray regularly for a positive outcome
e) Plan an unassisted birth without
intervention
10. A nurse is preparing a client for a
scheduled cesarean birth. The client is
getting on the stretcher to move from
the admission room to the surgical suite.
When placing the client on the stretcher,
which nursing intervention will be helpful
to prevent supine hypotension
syndrome in the client?
a) Ensure that the client is warm by
covering with a blanket or sheet
b) Place the client's newly inserted
Foley catheter lower on the frame of the
stretcher
c) Open the clamp on the intravenous
fluids (IV) to quickly infuse
d) Have the client lie on the left side
during transport
11. The nursing instructor is teaching a
group of student nurses about the
current use of episiotomies during the
labor process. The instructor determines
the session is successful when the
students correctly choose which
situation that may require the health
care provider to perform an episiotomy?
a) VBAC delivery
b) Persistent occiput anterior position
c) Shoulder dystocia
d) Multifetal births
12. The nurse cares for a client
scheduled for a cesarean birth for a
breech presentation. The client requests
general anesthesia instead of regional
anesthesia for the procedure because of
increased anxiety about being awake
during the surgery. How does the nurse
respond?
a) "The general anesthetic creates a
higher risk for your baby, so it is not
recommended"
b) "Can you tell me more about what
you are concerned about during the
surgery?"
c) "There will be a drape placed, so you
do not have to worry about seeing the
surgery"
d) "Would you like to have your
significant other present for the birth?"
13. Which of the following measures is
the most effective way for the nurse to
assist the woman recovering from
cesarean birth to stimulate lower
extremity circulation?
a) Help the woman to ambulate as soon
as possible
b) Have the client use a pillow to splint
the incision when moving about
c) Place ice packs on the woman's
calves
d) Apply TED hose
14. The nurse is instructing a primipara
who has concerns about the need for a
cesarean birth due to her sister's
obstetrical history. Which statement by
the client needs further instruction?
a) "My sister is tiny like me and was
unable to have the infant fit through the
pelvis"
b) "My sister's infant was breech and
was unable to be turned"
c) "My sister was in labor for 24 hours
and the labor did not progress"
d) "My sister had a cesarean birth with
the first infant and now needs it for all
subsequent pregnancies"
15. A woman arrives at labor and
delivery unit with contractions every 2-3
minutes lasting 30-45 seconds. After
several hours of labor have passed and
not making progress, the health care
provider prepares to perform an
amniotomy. The woman asks the nurse,
"How will this help my labor?" Which
response by the nurse would be
appropriate?
a) "This procedure helps to push your
baby through the birth canal"
b) "With this procedure, your body
sends out hormones that make labor
more effective"
c) "By doing this, the passageway for
your baby isn't blocked anymore"
d) "The fluid that comes out helps
flushes away any debris in the birth
canal"
16. A nurse is assisting with
preparations for a cesarean birth due to
nonprogression during labor. The
surgeon has arrived, as has the
anesthesiologist, a student assistant to
the surgeon, and multiple nurses. To
whom will the nurse hand the informed
consent paperwork, to be completed
prior to the procedure?
a) Anesthesiologist
b) Surgeon
c) Student assistant
d) Any of the nurses
17. Eight hours after a cesarean section,
a postpartum woman is having heavy
lochia. She informs the nurse, who
suspects which of the following causes?
a) Another cause other than the birth
b) Postpartum hemorrhage
c) Normal for a cesarean section
d) Infection
18. How should the nurse counsel a
client who has arrived for a scheduled
repeat cesarean birth?
a) "A Foley catheter will be inserted
before surgery and will be removed
once you arrive to the postpartum unit"
b) "You will undergo general anesthesia,
so you will be asleep during the
procedure"
c) "An IV catheter will be placed, and we
will do some preoperative blood work.
Then we will give you some antibiotics"
d) "After surgery, you will be
immediately transferred to the
postpartum unit"
19. A nurse is caring for a client who
requires a cesarean birth because of
labor dystocia. The woman's husband
signs the consent form. Which of the
following individuals is responsible for
obtaining the informed consent prior to a
cesarean birth?
a) Admitting nurse
b) Physician
c) Senior staff nurse
d) The client
20. The client plans to undergo a
vaginal birth after cesarean (VBAC) and
has recently begun labor. The labor
nurse is following the fetal monitor
closely. The results of which monitoring
will best help the nurse assess
contraction strength in the client?
a) Internal electronic monitoring
b) Fetal blood sampling
c) Maternal heart rate monitoring
d) Fetal oxygen saturation level
21. There is much discussion in the
medical community about vaginal birth
after a cesarean delivery (VBAC). When
a woman has had a previous
emergency cesarean delivery, she is at
high risk for a ruptured uterus. When is
VBAC contraindicated?
a) When a low cervical uterine incision
has been made previously
b) When a classical uterine incision has
been made previously
c) When a vertical abdominal incision
has been made previously
d) When a transverse abdominal
incision ("bikini cut") has been made
previously
22. The nurse is assessing a neonate
after a cesarean birth. Which most
common complication should the nurse
be prepared for?
a) Respiratory distress
b) Shoulder dystocia
c) A facial nerve injury
d) Hemorrhage
23. A 21-year-old has been in labor for 4
hours; her examination 2 hours ago
revealed 6 cm/100%/-3. During a
contraction, she spontaneously ruptures
her membranes. The doctor checks the
patient, finds her to be 9 cm/100%/-3,
and states that the cord is palpable.
What should the nurse do?
a) Call for help and prepare the client for
an emergency cesarean birth
b) Call the pediatricians into the room
for imminent vaginal delivery
c) Set up for imminent vacuum delivery
d) Set up for imminent forceps delivery
24. When counseling a client about
maternal risks and benefits of cesarean
birth, which of the following would not
apply?
a) "We will be giving you antibiotics
preoperatively, but it is still possible to
develop an infection at the incision site
after the birth"
b) "Complications that may occur
include hemorrhage, infection, and
damage to the bladder and bowel"
c) "Although unlikely, if severe
hemorrhage does occur, you may
require a hysterectomy"
d) "A surgical incision may be made at
the perineum to enlarge the vagina just
before the birth of the baby"
25. A client who planned an
unmedicated vaginal birth at a
freestanding birth center is transferred
to the hospital for a cesarean birth due
to cephalopelvic disproportion. The
client says to the nurse, "I feel like such
a failure. I could not even give my baby
the gentle start that I wanted!" How does
the nurse respond?
a) "It sounds like you are disappointed
by the outcome of the birth. Would you
like to talk more about this?"
b) "You tried your best, and sometimes
these things just do not turn out the way
we expect"
c) "You should focus on the positive
outcome and that you have a healthy
baby"
d) "I am concerned that you might be
experiencing postpartum depression.
Can we look at a screening
questionnaire?"
26. Which considerations are addressed
in the plan of care for a mother healing
from a cesarean birth? Select all that
apply.
a) Interference with organ function
b) Stress responses
c) Problems with self-image
d) Challenges in bonding with the infant
e) Circulatory complications
27. What will the nurse include in the
care plan of a client who underwent
cesarean birth to reduce the risk of
postoperative urinary tract infection?
a) Deep breathing and spirometry
exercises
b) Postoperative antibiotic prophylaxis
c) Early ambulation after the procedure
d) Removal of indwelling catheter as
soon as possible
28. What is not part of the discharge
planning for a woman who has had a
cesarean birth?
a) "Drink plenty of fluids—8 to 10
glasses of water a day"
b) "If you have severe abdominal pain or
a high fever, contact your health care
provider"
c) "If you have any vaginal bleeding, you
should contact your health care
provider"
d) "Rest when your baby rests, and don't
reject help from family and friends"
29. The client is 6 hours postoperative
from a cesarean birth where epidural
morphine was administered. What
assessment(s) will the nurse complete
related to this medication? Select all that
apply.
a) Lochia
b) Level of consciousness
c) Oxygen saturation
d) Fundal tone
e) Respiratory rate
29. The client is 6 hours postoperative
from a cesarean birth where epidural
morphine was administered. What
assessment(s) will the nurse complete
related to this medication? Select all that
apply.
a) Lochia
b) Level of consciousness
c) Oxygen saturation
d) Fundal tone
e) Respiratory rate
30. A woman has just entered the
recovery room after cesarean birth of a
baby weighing 9 lb 14 oz. After
connecting the client to the blood
pressure monitor, it is noted her heart
rate (HR) is 120 and blood pressure
(BP) is 80/40. What nursing action
should be a priority?
a) Call the MD
b) Assess for bleeding
c) Administer oxygen
d) Administer an IV bolus of fluids
31. A client is 6 hours post-cesarean
birth and is reluctant to ambulate. The
client tells the nurse "Won't it hurt? And I
need my rest to recover after surgery.
Can't I wait until tomorrow?" What
should the nurse include in the response
and education for this client? Select all
that apply.
a) "You will either need to ambulate or
you will need to take an anticoagulant
medication"
b) "If you ambulate and experience pain,
you can take a warm shower for
comfort"
c) "Additional analgesia can be provided
if this is needed for pain with
ambulation"
d) "Breastmilk production is enhanced
by early mobility, making mobility
important for you"
e) "Ambulation is important to decrease
the risk of complications after surgery"
32. A client in labor has just learned that
she will have to undergo a cesarean
birth due to failure to progress. The
woman looks frightened and stressed.
Which of the following is a physiological
stress response that the nurse would
expect to see in such a client?
a) Peripheral vasoconstriction
b) Decreased blood glucose level
c) Decreased heart rate
d) Bronchial constriction
33. The nurse is caring for a 45-year-old
client who will undergo cesarean birth.
Which age-related finding should the
nurse treat to reduce the client's surgical
risk?
a) Gestational diabetes
b) Poor nutritional status
c) Obesity
d) Venous stasis
35. The nurse is teaching a prenatal
class about a cesarean birth. What
benefit of a low transverse uterine
incision should the nurse point out in the
teaching?
a) Quickest way to deliver a baby
b) Easier to extend the incision in the
uterus if needed
c) Best way to deliver a premature
breech baby
d) Least likely to rupture during
subsequent labors
A woman is dilated 9 cm, and the fetus
is in an anterior position at +1 station.
The bag of water is ruptured. She has
been in labor for several hours and is
exhausted, so she asks the nurse, "My
friend was tired at the end of her labor,
and the doctor used forceps to help
deliver the baby. Could the doctor pull
the baby out with forceps so I can get
this over with?" What is the nurse's best
response?
"I don't see why not. Let me ask the
doctor."
"The cervix must be completely dilated
before forceps can be applied safely."
"No. Once the water bag ruptures, the
doctor cannot apply forceps."
"Forceps are too dangerous. I'll get a
vacuum extractor ready for your
delivery."
An elective induction is when the birth
attendant and the pregnant woman
agree to the induction of labor without
medical indications. What should the
birth attendant explain to the woman
before she can give informed consent to
induce her labor?
Induced labor can result in higher costs
for the delivery.
Induced labor decreases the need for
interventions during labor and delivery.
Induced labors are less painful and
progress faster.
Induced labor decreases the possibility
of cesarean birth.
Mrs. Atkins is 40 weeks' pregnant by
ultrasound, and the induction of labor is
being discussed by Mrs. Atkins and her
birth attendant. The birth attendant tells
Mrs. Atkins, "I am going to do a pelvic
exam so that I can assess your
readiness for labor. I will obtain what is
known as a Bishop Score, and it will tell
me how ready you are to go into labor."
What Bishop Score would indicate a
favorable response to oxytocin-induced
labor?
5 or below
6 or above
3 or below
8 or above
A cesarean delivery is a major surgery
and carries with it many risks for
complications. The most common
complication is infection. At what site is
the infection likely to occur?
Vagina
Urinary tract
Uterus
Rectus muscle wall
A primigravida whose baby is presenting
breech is scheduled to have a cesarean
birth. Which of the following would you
prepare her for postoperatively?
presence of an indwelling catheter
bed rest for the first 4 days
insertion of a nasogastric tube
separation from her infant for 72 hours
A woman whose fetus at 30 weeks'
gestation is failing to thrive in utero is
told her physician wants to deliver the
baby by cesarean birth today. She asks
the nurse why this would be preferred to
a vaginal birth. Which of the following
would be your best response?
"There's not an advantage; it's just more
convenient."
"Cesarean birth will reduce pressure on
the immature head."
"You will have reduced pain afterward."
"Cesarean birth allows the placenta to
deliver easier."
A woman who has had a cesarean birth
asks you if she will always need to have
cesarean births in the future. What
would be the nurse's best response?
"You will like cesarean birth so much
that you will want repeat cesarean births
in the future."
"There is no way to predict that; it will
depend on your individual uterine
anatomy."
"Yes. 'Once a cesarean always a
cesarean' is a well-known rule."
"Although there are some exceptions,
surgical techniques allow for vaginal
birth after cesarean birth."
A nursing student is asking the
instructor how to assess whether a
cervix is ready and favorable for labor
induction. The nurse informs the student
that a score is used known as which of
the following?
Braden scale
Bishop score
Norton scale
Apgar score
A student observing in labor and
delivery watches a physician introduce a
hard plastic instrument with a hook on
the end into the vagina during a digital
examination. The physician proceeds to
guide the hook to snag a hole into the
membranes. This process causes the
body to release prostaglandins, which
induces labor and is known as which of
the following?
membrane stripping
artificial rupture of membranes
mechanical dilatation
none of the above
A nursing student correctly identifies
that an episiotomy that extends straight
down into the true perineum is which of
the following?
mediolateral episiotomy
midline episiotomy
lateral episiotomy
unilateral episiotomy
Eight hours after a cesarean section, a
postpartum woman is having heavy
lochia. She informs the nurse, who
suspects which of the following causes?
normal for a cesarean section
postpartum hemorrhage
infection
another cause other than the birth
A nurse correctly recognizes which of
the following as a current trend within
the population of birthing women?
more natural births with fewer medical
interventions
increased public funds for using doulas
increased rates of cesarean sections
decreased use of epidurals
A patient who had a previous cesarean
birth asks the nurse if all future births
must occur the same way. Which
response should the nurse make to
support the 2020 National Health Goals
regarding cesarean births?
"All future births must be done through
cesarean."
"Not if you fulfill the criteria for vaginal
birth after cesarean."
"Your health care provider will let you
know what kind of birth you can have."
"Most women prefer cesarean births
because they are quicker and cause
less pain."
A patient who has been in labor for 20
hours is being prepared for an emergent
cesarean birth. Which action will help
ensure the patient's fluid status during
the procedure?
Provide with a clear liquid tray.
Encourage intake with ice chips.
Initial intravenous fluid therapy.
Administer an antiemetic as prescribed.
The physician has just examined the
patient and determined that she needs
to have a cesarean section. He notifies
the nurse that he will be doing a low
cervical vertical incision into the uterus.
The nurse knows that the physician has
chosen this type of incision over the
classical incision because the low
cervical vertical incision:
is larger than a classical incision and will
allow for easier delivery.
reduces the risk of uterine rupture.
is less complicated to perform.
has a lower risk of maternal injury.
The nursing instructor is conducting a
session exploring the various factors
related to induction of labor. The
instructor determines the session is
successful after the students correctly
choose which factors are used to
determine if the cervix is ripe enough for
induction?
Station, effacement, cervical
consistency, dilatation, and cervical
position
Dilatation, cervical consistency,
presentation, station, and effacement
Dilatation, cervical position,
presentation, station, and effacement
Effacement, dilatation, presentation,
attitude, and cervical position
The nursing instructor is conducting a
class presenting the various aspects of
a cesarean delivery. The instructor
determines the class is successful after
the students correctly choose which
complication as the most common
postoperative complication?
Thrombosis
Infection
Laceration of the uterine artery
Pneumonia
The nurse is assessing a neonate after
a cesarean delivery. Which most
common complication should the nurse
be prepared for?
Respiratory distress
Shoulder dystocia
A facial nerve injury
Hemorrhage
The maternal health nurse assists the
birth attendant in a forceps-assisted
birth. After the birth of the infant, what is
the nurse's priority?
Assess the infant for trauma
Increase the rate of oxytocin
Assess the mother for bleeding
Apply supplemental oxygen to the
mother
While the nurse is assessing the
prenatal client's understanding of the
information provided at a recent
appointment, the client states, "I want to
avoid the pain and long hours of labor,
so I'm electing to have a cesarean birth."
How should the nurse respond?
"A cesarean birth is a method to be
used when vaginal birth is not
possible—it is not a true option."
"It is important to inform the health care
provider of your decision so that we can
plan appropriately for when the birth
occurs."
"Cesarean birth is a low-risk surgery that
is the ideal option in many cases."
"Many women elect to have a cesarean
birth to avoid the risk of anoxia."
It was once thought that an episiotomy
made the birth less painful and heal
faster than a spontaneous laceration of
the perineum. Research has not shown
these assumptions to be true. What is
another finding in the research on
episiotomies?
Causes loss of bowel control after the
birth
Increases risk of blood loss immediately
after delivery
Suturing of episiotomy increases sexual
pleasure following delivery.
Decreases risk of infection after delivery
The nurse is caring for a woman who
has had a baby by cesarean birth.
Which of the following would be the
most important assessment to make?
whether her abdomen is soft or not
whether her perineum is edematous
if her breasts fill by the third day
if she wants to breastfeed or not
A woman having a cesarean birth will
have a low transverse incision ("bikini
cut"). Which of the following would the
nurse cite as an advantage?
The uterine incision will be vertical.
The skin incision will be just above her
pubic hair.
Because the cervix is cut, the operation
proceeds rapidly.
Because the fundus of the uterus is cut,
the infant can be resuscitated rapidly.
A 35-year-old P1001 has been admitted
for a scheduled repeat cesarean. As the
nurse prepares the client for surgery,
what is the best way to begin
preoperative teaching?
Ask her husband, who is fearful and
anxious, to wait outside.
Assess how much the woman already
knows about cesarean.
Start by going over the risks of cesarean
so she has enough time to go over each
one.
Wait until the physician and the
anesthesiologist have completed their
history and assessment, so the teaching
can be more focused and directed.
A nursing student correctly identifies
which of the following as medical
reasons to induce labor? Select all that
apply.
postdate pregnancy
pregnancy that persists beyond the due
date
gestational hypotension
premature rupture of membranes
without spontaneous labor
preeclampsia
To prevent tearing of the perineum of a
client during birth, a physician performs
a mediolateral episiotomy. The nurse
recognizes that an advantage of a
mediolateral episiotomy over a midline
episiotomy is which of the following?
lower rlsk for rectal mucosal tear
easier healing
less blood loss
less postpartal discomfort
The nurse is caring for a patient
recovering from a cesarean birth. Which
assessment should the nurse make a
priority for this patient?
Breast filling
Plan to breastfeed
Abdominal texture
Perineum for edema
A client is being admitted at 41-weeks
gestation with a cervix which is not
ready for labor and delivery. Which
procedure might the nurse prepare the
client for? (Select all that apply.)
membrane stripping
mechanical dilation
locally applied prostaglandins
artificial rupture of membranes
episiotomy
A client is being prepared for a
scheduled cesarean delivery by the
medical team. Which intervention will be
most critical for the team to monitor in
the first 24 hours post cesarean
delivery?
Urinary output
Administration of sodium citrate
Preparing for blood transfusion
Maintaining IV access
The nurse is instructing a primipara who
has concerns about the need for a
cesarean birth due to her sister's
obstetrical history. Which statement by
the client needs further instruction?
"My sister is tiny like me and was unable
to have the infant fit through the pelvis."
"My sister's infant was breech and was
unable to be turned."
"My sister was in labor for 24 hours and
the labor did not progress."
"My sister had a cesarean birth with the
first infant and now needs it for all
subsequent pregnancies."
A multigravid woman has been in labor
for several hours and has dilated to 8
cm. Her fetal membranes have not yet
ruptured and her contractions are not as
strong as the birth attendant would like
them to be. The decision is made to
artificially rupture the woman's
membranes. The LPN/LVN is new on
the unit. What is the LPN/LVN's role in
this procedure?
Obtain the amniohook and prepare the
woman for delivery.
Document fetal heart rate before and
after the procedure.
Get the delivery room ready.
Document the woman's vital signs
before and after the procedure.
A woman is scheduled to have epidural
anesthesia for a cesarean birth. Which
of the following would the nurse
anticipate including in the preoperative
plan of care while she waits for the
anesthetic?
encouraging her to ambulate
administering an oral antacid
administering morphine sulfate IM
keeping her turned on her side
Following a cesarean birth, a woman
has 3000 ml of intravenous fluid
ordered. The nurse anticipates in the
plan of care that she will be kept NPO
except for minimal ice chips until which
time?
until 24 hours post-procedure
until 48 hours post-procedure
until bowel sounds have returned
until her bladder tone has returned
How should the nurse counsel a client
who has arrived for a scheduled repeat
cesarean birth?
"You will undergo general anesthesia, so
you will be asleep during the
procedure."
"A Foley catheter will be inserted before
surgery and will be removed once you
arrive to the postpartum unit."
"After surgery, you will be immediately
transferred to the postpartum unit."
"An IV catheter will be placed, and we
will do some preoperative blood work.
Then we will give you some antibiotics."
A 21-year-old has been in labor for 4
hours; her examination 2 hours ago
revealed 6 cm/100%/-3. During a
contraction, she spontaneously ruptures
her membranes. The doctor checks the
patient, finds her to be 9 cm/100%/-3,
and states that the cord is palpable.
What should the nurse do?
Call for help and prepare the client for
an emergency cesarean birth.
Set up for imminent vacuum delivery.
Call the pediatricians into the room for
imminent vaginal delivery.
Set up for imminent forceps delivery.
When counseling a client about
maternal risks and benefits of cesarean
birth, which of the following would not
apply?
"Complications that may occur include
hemorrhage, infection, and damage to
the bladder and bowel."
"Although unlikely, if severe hemorrhage
does occur, you may require a
hysterectomy."
"We will be giving you antibiotics
preoperatively, but it is still possible to
develop an infection at the incision site
after the birth."
"A surgical incision may be made at the
perineum to enlarge the vagina just
before the birth of the baby."
A woman is scheduled to have epidural
anesthesia for a cesarean birth. What
should the nurse anticipate to include in
the preoperative plan of care while the
patient waits for the anesthetic?
Encouraging her to ambulate
Administering an oral antacid
Administering morphine sulfate
Keeping in a side-lying position
Following a cesarean birth, a patient is
prescribed to receive intravenous fluids.
At which time should the nurse
anticipate that this patient will be able to
resume an oral intake?
24 hours postprocedure
48 hours postprocedure
When bladder tone returns
When bowel sounds return
After learning about the need for a
cesarean birth, the pregnant patient
begins to cry and hyperventilate. Which
nursing diagnosis should the nurse use
to guide the care that the patient needs
at this time?
Fear related to impending surgery
Risk for infection related to a surgical
incision
Powerlessness related to medical need
for cesarean birth
Risk for impaired parent/infant
attachment related to unplanned method
of birth
A client presents at 41 weeks gestation
for induction of labor and an attempt at
VBAC. The nurse is aware that which
method would be contraindicated for this
client?
Oxytocin
Artificial rupture of membranes
Balloon catheter insertion
Dinoprostone vaginal insert
A new mother calls the clinic on her
fourth day after delivery and reports
difficulty urinating and defecating
because of the perineal pain. What does
the nurse suspect is causing these
problems?
trauma from a Foley catheter
trauma from a cesarean birth
episiotomy
infection
The maternal health nurse is caring for
multiple women who wish to attempt a
vaginal birth after cesarean (VBAC).
Which client will not be able to attempt a
VBAC due to contraindications?
28-year-old with a placenta previa
41-year-old with two previous cesarean
births
32-year-old with gestational diabetes
22-year-old with Rh-negative blood
The maternal health nurse is caring for a
group of pregnant clients. Which client
will the nurse determine is most ready
for labor?
The client whose Bishop score is 9
today.
The client whose cervical length via
endovaginal ultrasound has increased.
The client who is 41 weeks gestation
today.
The client whose cervical secretions are
negative for fetal fibronectin.
The nurse is caring for a postoperative
client who has experienced a cesarean
birth. Which physiologic response(s)
should the nurse anticipate? Select all
that apply.
Increased heart rate
Bronchodilation
Elevated blood glucose level
Peripheral vasoconstriction
Decreased blood pressure
A woman who underwent a primary
cesarean birth for a breech presentation
states that her neonate seems to have
so much more mucus than her first
baby. Concerned, she asks why this has
happened. How should the nurse
respond?
"Babies born by cesarean section have
more respiratory complications because
they do not have the benefit of having
the mucus in their lungs removed by the
pressure experienced in the birth canal."
"There is no scientific reason for this
occurrence."
"All babies are different so it is unwise to
make comparisons."
"The pain medication given during the
surgery may have contributed to the
mucus build up."
What is the most effective way to
stimulate circulation after cesarean
birth?
ambulation within 4 hours of birth
ambulation within 8 hours of birth
Venodyne boots
TEDS stockings
The nurse is teaching a prenatal class
about a cesarean delivery. What benefit
of a low transverse uterine incision
should the nurse point out in the
teaching?
Least likely to rupture during
subsequent labors.
Easier to extend the incision in the
uterus is needed.
Quickest way to delivery a baby.
Best way to deliver a premature breech
baby.
A woman has just arrived to the
recovery room after an emergency
cesarean delivery and is anxious to
begin breast-feeding her baby. What is
the best response from the nurse?
"Sure, let me help you with that."
"I need to monitor you closely for 30
minutes, first."
"Just as soon as you get to the
postpartum unit in an hour or 2."
"You will not be able to breastfeed until
you can get up and walk around."
The nurse is caring for a client who is
postoperative after a cesarean birth and
receiving treatment with antibiotics. For
which condition(s) should the nurse
monitor? Select all that apply.
Opportunistic infections
Renal insufficiency
Elevated liver enzymes
Hypokalemia
Tachycardia
A client underwent a cesarean birth due
to fetal distress. The medical records
reflect a low transverse uterine incision
was used. When speaking with the
nurse the client questions her ability to
give birth vaginally with her next
pregnancy. What response by the nurse
is most appropriate?
"You will be able to have a vaginal birth
with your next birthing experience."
"The type of incision used on your
uterus may hinder your ability to have a
vaginal birth with your next birthing
experience."
"The reason for your cesarean birth may
indicate an inability to have a vaginal
birth in the future."
"Having a cesarean birth does not mean
you will have a cesarean birth with
future births."
A pregnant woman who required labor
induction for a previous pregnancy says
the to nurse, "The last time the
practitioner used a score to see if I was
ready for induction. But I've heard of
other methods that have been
developed since then." The nurse
understands that the woman is referring
to cervical length measurements and
fetal fibronectin levels. When
responding to the woman, which
information would the nurse need to
keep in mind when telling the woman
about these methods?
The need for an amniocentesis to do
cervical length measurements.
Increased costs associated with both of
these 2 newer methods.
Shorter time need for obtaining the
Bishop score results
Increased level of predictabiity with fetal
fibronectin levels.
A patient having a cesarean birth will
have a low segment incision. What
should the nurse explain to the patient
as an advantage for this type of
incision?
The uterine incision will be vertical.
Vaginal deliveries can occur with future
births.
Because the cervix is cut, the operation
proceeds rapidly.
Because the fundus of the uterus is cut,
the infant can be resuscitated rapidly.
A woman is being seen in the clinic for
care during her first pregnancy and
birth. The nurse will educate this woman
and her significant other about their
planned cesarean delivery and what can
be expected. When should the nurse
provide this family education?
At a preset time one month prior to the
scheduled delivery
Only when she and her significant other
can come to the clinic together
When the client presents for admission
for the procedure
Each time the nurse sees the woman
before surgery
The maternal health nurse is assisting a
birth attendant in the use of low-outlet
forceps for a forceps-assisted birth. At
which point of the birth will the nurse
expect the use of the device?
When the fetus requires rotation to an
anterior position
When the fetal head can be seen in the
introitus
When the fetal station is equal or
greater than +2
When the fetal head is well engaged but
station is less than +2
A primigravida is admitted to the
labor-and-delivery suite for an elective
induction with oxytocin. The nurse
caring for this client knows that one of
the risks with oxytocin inductions is:
uterine hyperstimulation.
fetal distress.
maternal hypertension.
spontaneous rupture of membranes.
uterine hyperstimulation.
According to the National Vital Statistics
System (NVSS), what was the national
cesarean rate in 2014?
10%
15%
25%
32%
35%
Place the following events in order of
occurrence for administration of spinal
anesthesia before an elective primary
cesarean birth in a woman who is not in
labor.
1. The woman enters the OR.
5. The client lies down on the delivery
table, and a wedge is placed.
2. The nurse instructs the client to sit
and make a C-curve with her back.
3. The anesthesiologist cleanses the
back.
4. Spinal anesthesia is administered.
The type of skin incision done for a
cesarean section will indicate the type of
uterine incision.
true
false
The nurse is caring for a client who is
insisting on a vaginal delivery. For which
situation should the nurse explain a
vaginal delivery is contraindicated?
Select all that apply.
Spina bifida
Macrosomia
Transverse lie
Breech presentation
Preterm delivery
The nurse is caring for a group of clients
on the birthing unit. For which client(s)
should the nurse anticipate an
emergency cesarean birth? Select all
that apply.
Client with bright red, painless vaginal
bleeding
Client with a fetus exhibiting variable
decelerations
Client with abnormal amniotic fluid
volume
Client with three contractions in 20
minutes, lasting 35 seconds each, in
active phase of labor
Client whose labor pain is not
adequately controlled by epidural
analgesia
There is much discussion in the medical
community about vaginal birth after a
cesarean delivery (VBAC). When a
woman has had a previous emergency
cesarean delivery, she is at high risk for
a ruptured uterus. When is VBAC
contraindicated?
when a transverse abdominal incision
("bikini cut") has been made previously
when a classical uterine incision has
been made previously
when a vertical abdominal incision has
been made previously
when a low cervical uterine incision has
been made previously
when a classical uterine incision has
been made previously
The nurse is caring for a client who is
Jehovah's Witness and was expecting a
vaginal birth. The client needs a
cesarean birth during labor and is at
high risk for hemorrhage. Which action
should the nurse prioritize at this time?
Evaluate whether the client should be
cared for in another setting
Provide the client and family with a
private time to pray before surgery
Inform the client that certain life-saving
interventions may be required if
complications arise
Determine if chaplain services that align
with the client's beliefs are available

Which woman is most likely to have a

successful VBAC (vaginal birth after
cesarean)?
A 41-year-old who has had 1 previous
cesarean delivery and has gone into
labor spontaneously
A 20-year-old who has had 2 previous
cesarean deliveries
A 35-year-old who has had 1 previous
cesarean delivery and has been induced
with Pitocin
A 32-year-old who has had 1 previous
cesarean delivery, has gone into labor
spontaneously, and then has been
augmented with AROM

The nurse is monitoring the labor of a

woman attempting a vaginal birth after
cesarean (VBAC) delivery. The nurse
correctly suspects a uterine rupture
when which of the following occur?
Select all that apply.
Onset of fetal tachycardia
Excessive maternal pain
Increased vaginal bleeding
Unrelenting uterine contraction
Signs of maternal shock

Chapter 25
A client, 1 day postpartum (PP), is being
monitored carefully after a significant
postpartum hemorrhage. Which of the
following should the nurse report to the
obstetrician?
1. Urine output 200 mL for the past 8
hours.
2. Weight decrease of 2 pounds since
delivery.
3. Drop in hematocrit of 2% since
admission.
4. Pulse rate of 68 beats per minute
A mother, G1 P1, who delivered a 2,800
gram baby vaginally 30 minutes earlier,
is transferred to the postpartum unit.
She pushed for 45 minutes and the
placenta was delivered 10 minutes later.
She is receiving an intravenous with 20
units oxytocin added. The postpartum
nurse questions why the oxytocin was
added to the IV bag. Which of the
following responses by the transferring
nurse is most likely?
1. "The medication was added 10
minutes ago to prevent excess bleeding
during her transfer."
2. "The medication was added
immediately after the baby's birth to
promote placental delivery."
3. "The medication was added after the
placenta was delivered because of its
rapid separation."
4. "The medication was added while she
was pushing to speed up the baby's
birth."
A nurse is caring for the following four
laboring patients. Which clients should
the nurse be prepared to monitor closely
for signs of postpartum hemorrhage
(PPH)? Select all that apply.
1. G1 P0000, delivered a fetal demise at
29 weeks' gestation.
2. G2 P1001, prolonged first stage of
labor.
3. G2 P0010, delivered by cesarean
section for failure to progress.
4. G3 P0200, delivered vaginally a
42-week, 2,200-gram neonate.
5. G4 P3003, with a succenturiate
placenta.
A client just delivered the placenta
pictured below. For which of the
following complications should the nurse
carefully observe the woman?
1. Endometrial ischemia.
2. Postpartum hemorrhage.
3. Prolapsed uterus.
4. Vaginal hematoma.
Which of the following is a priority
nursing diagnosis for a woman, G10
P6226, who is PP1 from a spontaneous
vaginal delivery with a significant
postpartum hemorrhage?
1. Alteration in comfort related to
afterbirth pains.
2. Risk for altered parenting related to
grand multiparity.
3. Fluid volume deficit related to blood
loss.
4. Risk for sleep deprivation related to
mothering role.
A mother, G6 P6006, is 15 minutes
postpartum. Her baby weighed 4,595
grams at birth. For which of the following
complications should the nurse monitor
this client?
1. Seizures.
2. Hemorrhage.
3. Infection.
4. Thrombosis.
A breastfeeding woman has been
diagnosed with retained placental
fragments 4 days postdelivery. Which of
the following breastfeeding
complications would the nurse expect to
see?
1. Engorgement.
2. Mastitis.
3. Blocked milk duct.
4. Low milk supply.
A woman who has given birth to a
healthy neonate is being discharged. As
part of discharge teaching, the nurse
should instruct the client to observe
vaginal discharge for postpartum
hemorrhage and notify the health care
provider about:
1.Bleeding that becomes lighter each
day
2.Clots the size of golf balls
3.Saturating a pad in an hour
4.Lochia that lasts longer than 1 week
A client has experienced a postpartum
hemorrhage. The primary health care
provider verbally ordered carboprost
tromethamine (Hemabate) 0.25 mg IM
stat at the time of the hemorrhage and
this was given by the nurse. The primary
health care provider put a prescription
into the electronic medical record for
0.25 mg carboprost tromethamine IV
stat. When seeing the prescription, how
should the nurse administering the
carboprost tromethamine respond?
1.Ask the charge nurse to have a
discussion with the primary health care
provider about the prescription.
2.Initiate an incident report.
3.Call the primary health care provider,
discuss the prescription, and request
revision if heard correctly.
4.Wait until the primary health care
provider returns to the unit and discuss
the situation in person.
A multiparous client whose fundus is
firm and midline at the umbilicus 8 hours
after a vaginal birth tells the nurse that
when she ambulated to the bathroom
after sleeping for 4 hours, her dark red
lochia seemed heavier. Which of the
following would the nurse include when
explaining to the client about the
increased lochia on ambulation?
1.Her bleeding needs to be reported to
the physician immediately.
2.The increased lochia occurs from
lochia pooling in the vaginal vault.
3.The increase in lochia may be an early
sign of postpartum hemorrhage.
4.This increase in lochia usually
indicates retained placental fragments"
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
birth. The client asks, "Why am I
bleeding so much?" The nurse responds
based on the understanding that the
most likely cause of uterine atony in this
client is which of the following?
1.Trauma during labor and birth.
2.Moderate fundal massage after birth.
3.Lengthy and prolonged second stage
of labor.
4.Overdistention of the uterus from
hydramnios."
A multiparous client visits the urgent
care center 5 days after a vaginal birth,
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 that this type of
postpartum bleeding is usually caused
by which of the following?
1.Uterine atony.
2.Cervical lacerations.
3.Vaginal lacerations.
4.Retained placental fragments.
A primiparous client develops uterine
atony and postpartum hemorrhage 1
hour after a vaginal birth. The physician
has prescribed IM prostaglandin-F2a.
After administration of the medication,
the nurse should observe the client for
which of the following?
1.Tachycardia.
2.Hypotension.
3.Constipation.
4.Abdominal distention
A nurse on the labor-and-birth unit
transfers a primiparous client and her
term neonate to the mother-baby unit 2
hours after the client gave vaginal birth
to the neonate. Which of the following
information is a priority for the nurse to
report to the nurse receiving the client
on the mother-baby unit?
1.Firm fundus when gentle massage is
used.
2.Evidence of bonding well with the
neonate.
3.Labor that lasted 12 hours with a
1-hour second stage.
4.Temperature of 99°F (37.4°C) and
pulse rate of 80 bpm.
The nurse delegates the care of a
multiparous client who gave birth to a
viable term neonate vaginally 30 hours
ago and is preparing to be discharged to
a licensed practical nurse (LPN). The
nurse should instruct the LPN to notify
the nurse if the client exhibits which of
the following?
1.Pulse rate of 100 bpm.
2.Oral temperature of 99°F (36.8°C).
3.Excessive perspiration during the
assessment.
4.Frequent voiding in large amounts.
The nurse has been assigned to care for
several postpartum clients and their
neonates on a birthing unit. Which of the
following clients should the nurse
assess first?
1.A multiparous client at 48 hours
postpartum who is being discharged.
2.A primiparous client at 2 hours
postpartum who gave vaginal birth to a
term neonate.
3.A multiparous client at 24 hours
postpartum whose infant is in the
special care nursery.
4.A primiparous client at 48 hours after
cesarean birth of a term neonate.
1. A gestational diabetic client, who
delivered yesterday, is currently on the
postpartum unit. Which of the following
statements is appropriate for the nurse
to make at this time?
1. "Monitor your blood glucose five times
a day until your 6-week check-up."
2. "I will teach you how to inject insulin
before you are discharged."
3. "Daily exercise will help to prevent
you from becoming diabetic in the
future."
4. "Your baby should be assessed every
6 months for signs of juvenile diabetes."
A client, who is 2 weeks postpartum,
calls her obstetrician's nurse and states
that she has had a whitish discharge for
1 week but today she is, "Bleeding and
saturating a pad about every '12 hour."
Which of the following is an appropriate
response by the nurse?
1. "That is normal. You are starting to
menstruate again." 2. "You should stay
on complete bed rest until the bleeding
subsides."
3. "Pushing during a bowel movement
may have loosened your stitches."
4. "The physician should see you.
Please come in whenever you are
ready."
The nurse is performing a postpartum
assessment on a client who delivered 4
hours ago. The nurse notes a firm
uterus at the umbilicus with heavy
lochial flow. Which of the following
nursing actions is appropriate?
1. Massage the uterus.
2. Notify the obstetrician.
3. Administer an oxytocic as ordered.
4. Assist the client to the bathroom.
6. A client has been receiving
magnesium sulfate for severe
preeclampsia for 12 hours. Her reflexes
are 0 and her respiratory rate is 10.
Which of the following situations could
be a precipitating factor in these
findings?
1. Apical heart rate 104.
2. Urinary output 240 cc/12 hr.
3. Blood pressure 160/120.
4. Temperature 100°E
A client received general anesthesia
during her cesarean section 4 hours
ago. Which of the following postpartum
nursing interventions is important for the
nurse to make?
1. Place the client flat in bed.
2. Assess for dependent edema.
3. Auscultate lung fields.
4. Check patellar reflexes.
The nurse is caring for a postoperative
cesarean client. The woman is obese
and is an insulin-dependent diabetic.
For which of the following complications
should the nurse carefully monitor this
client?
1. Ineffective lactogenesis.
2. Dysfunctional parenting.
3. Wound dehiscence.
4. Projectile vomiting.
A woman, 26 weeks' gestation, has just
delivered a fetal demise. Which of the
following nursing actions is appropriate
at this time?
1. Remind the mother that she will be
able to have another baby in the future.
2. Dress the baby in a tee shirt and
swaddle the baby in a receiving blanket.
3. Ask the woman if she would like the
doctor to prescribe a sedative for her.
4. Remove the baby from the delivery
room as soon as possible.
A client, G1P0000, is PP1 from a normal
spontaneous delivery of a baby boy,
Apgar 5/6. Because the client exhibited
addictive behaviors, a toxicology
assessment was performed; the results
were positive for alcohol and cocaine.
Which of the following interventions is
appropriate for this postpartum client?
1. Strongly advise the client to
breastfeed her baby.
2. Perform hourly incentive spirometer
respiratory assessments.
3. Suggest that the nursery nurse feed
the baby in the nursery.
4. Provide the client with supervised
instruction on baby care skills.
A client is postpartum 24 hours from a
spontaneous vaginal delivery with
rupture of membranes for 42 hours.
Which of the following signs/symptoms
should the nurse report to the client's
health care practitioner?
1. Foul-smelling lochia.
2. Engorged breasts.
3. Cracked nipples.
4. Cluster of hemorrhoids.
A client, 1 day postpartum (PP), is being
monitored carefully after a significant
postpartum hemorrhage. Which of the
following should the nurse report to the
obstetrician?
1. Urine output 200 mL for last 8 hours.
2. Weight decrease of 2 pounds since
delivery.
3. Drop in hematocrit of 2% since
admission.
4. Pulse rate of 68 beats per minute.
A nurse is working on the postpartum
unit. Which of the following patients
should the nurse assess first?
1. PP1 from vaginal delivery complains
of burning on urination.
2. PP1 from forceps delivery with blood
loss of 500 mL at time of delivery.
3. PP3 from vacuum delivery with
hemoglobin of 7.2 g/dL. 4. P03 from
cesarean delivery complains of firm and
painful breasts.
A postpartum woman has been
diagnosed with postpartum psychosis.
Which of the following signs/symptoms
would the client exhibit?
1. Hallucinations.
2. Polyphagia.
3. Induced vomiting.
4. Weepy sadness.
The nurse is caring for a couple who are
in the labor/delivery room immediately
after the delivery of a dead baby with
visible defects. Which of the following
actions by the nurse is appropriate?
1. Discourage the parents from naming
the baby.
2. Advise the parents that the baby's
defects would be too upsetting for them
to see.
3. Transport the baby to the morgue as
soon as possible.
4. Give the parents a lock of the baby's
hair and a copy of the footprint sheet.
The nurse is circulating on a cesarean
delivery of a G5P4004. All of the client's
previous children were delivered via
cesarean section. The physician
declares after delivering the placenta
that it appears that the client has a
placenta accreta. Which of the following
maternal complications would be
consistent with this diagnosis?
1. Blood loss of 2000 mL.
2. Blood pressure of 160/110.
3. Jaundice skin color.
4. Shortened prothrombin time
A client is 1-day post cesarean delivery
for eclampsia. The client is receiving 5%
dextrose in 'h normal saline IV at 125
cc/hr and magnesium sulfate IV via
infusion pump. Which of the following
laboratory values should the nurse
report to the surgeon?
1. Serum magnesium 7 mg/dL.
2. Serum sodium 136 mg/dL.
3. Serum potassium 3.0 mg/dL.
4. Serum calcium 9 mg/dL.
The home health nurse is visiting a
client with HIV who is 6 weeks
postdelivery. Which of the following
findings would indicate that patient
teaching in the hospital was successful?
1. The client is breastfeeding her baby
every two hours.
2. The client is using a diaphragm for
family planning.
3. The client is taking her temperature
every morning.
4. The client is seeking care for a recent
weight loss.
A breastfeeding woman has been
diagnosed with retained placental
fragments 4 days postdelivery. Which of
the following breastfeeding
complications would the nurse expect to
see?
1. Engorgement.
2. Mastitis. .
3. Blocked milk duct.
4. Low milk supply.
A client is to receive a blood transfusion
after significant blood loss following a
placenta previa delivery. Which of the
following actions by the nurse is critical
prior to starting the infusion? Select all
that apply.
1. Look up the client's blood type in the
chart.
2. Check the client's arm bracelet.
3. Check the blood type on the infusion
bag.
4. Obtain an infusion bag of dextrose
and water.
5. Document the time the infusion
begins.
A nurse is caring for the following four
laboring patients. Which client should
the nurse be prepared to monitor closely
for signs of postpartum hemorrhage
(PPH)?
1. G1P0000, delivery at 29 weeks'
gestation.
2. G2P1001, prolonged first stage of
labor.
3. G2P0010, delivery by cesarean
section.
4. G3P0200, delivery of 2200-gram
neonate.
A home care nurse is visiting a
breastfeeding client who is 2 weeks
postdelivery of a 7-lb baby girl over a
midline episiotomy. Which of the
following findings should take priority?
1. Lochia is serosa.
2. Client cries throughout the visit.
3. Nipples are cracked.
4. Client yells at the baby for crying.
A client who is post-cesarean section for
severe preeclampsia is receiving
magnesium sulfate via IV pump and
morphine sulfate via patient-controlled
anesthesia (PCA) pump. The nurse
enters the room on rounds and notes
that the client is not breathing. Which of
the following actions should the nurse
perform first?
1. Give two breaths.
2. Discontinue medications.
3. Call a code.
4. Check carotid pulse.
A nurse massages the atonic uterus of a
woman who delivered 1 hour earlier.
The nurse identifies the nursing
diagnosis: Risk for injury related to
uterine atony. Which of the following
outcomes indicates that the client's
condition has improved?
1. Moderate lochia flow.
2. Decreased pain level.
3. Stable blood pressure.
4. Fundus above the umbilicus.
A postpartum woman has been
diagnosed with postpartum psychosis.
Which of the following is essential to be
included in the family teaching for this
client?
1. The woman should never be left
alone with her infant.
2. Symptoms rarely last more than one
week.
3. Clinical response to medications is
usually poor.
4. The woman must have her vitals
assessed every two days.
A couple, accompanied by their
5-year-old daughter, have been notified
that their 32-week-gestation fetus is
dead. The father is yelling at the staff.
The mother is crying uncontrollably. The
5-year-old is banging the head of her
doll on the floor. Which of the following
nursing actions is appropriate at this
time?
1. Tell the father that his behavior is
inappropriate.
2. Sit with the family and quietly
communicate sorrow at their loss.
3. Help the couple to understand that
their daughter is acting inappropriately.
4. Encourage the couple to send their
daughter to her grandparents.
The blood glucose of a client with type 1
diabetes 12 hours after delivery is 96
mg/dL. The client has received no
insulin since delivery. The drop in serum
levels of which of the following
hormones of pregnancy is responsible
for the glucose level?
1. Estrogen.
2. Progesterone.
3. Human placental lactogen (hPL).
4. Human chorionic gonadotropin
(hCG).
A couple has delivered a 28-week fetal
demise. Which of the following nursing
actions are appropriate to take? Select
all that apply.
1. Swaddle the baby in a baby blanket.
2. Discuss funeral options for the baby.
3. Encourage the couple to try to get
pregnant again soon.
4. Ask the couple whether or not they
would like to hold the baby.
5. Advise the couple that the baby's
death was probably for the best.
Which of the following is a priority
nursing diagnosis for a woman,
G10P6226, who is PP 1 from a
spontaneous vaginal delivery with a
significant postpartum hemorrhage? 1.
Alteration is comfort related to afterbirth
pains.
2. Risk for altered parenting related to
grand multiparity.
3. Fluid volume deficit related to blood
loss.
4. Risk for sleep deprivation related to
mothering role.
A woman has just had a macrosomic
baby after a 12-hour labor. For which of
the following complications should the
woman be carefully monitored?
1. Uterine atony.
2. Hypoprolactinemia.
3. Infection.
4. Mastitis.
A client is on magnesium sulfate via IV
pump for severe preeclampsia. Other
than patellar reflex assessments, which
of the following noninvasive
assessments should the nurse perform
to monitor the client for early signs of
magnesium sulfate toxicity?
1. Serial grip strengths.
2. Kernig assessments.
3. Pupillary responses.
4. Apical heart rate checks
In discussing obstetric emergencies with
a new registered nurse on Labor and
Delivery, you initiate a conversation
reviewing the common risk factors for
postpartum hemorrhage. Which of the
following is considered a risk factor?
a. Age > 25
b. Induction or augmentation of labor
c. Drug induced analgesia
d. Fetal intrauterine growth restriction
Which of the following is the best
strategy to prevent a postpartum
hemorrhage?
a. Active management of the third stage
of labor
b. Routine administration of a uterotonic
drug like oxytocin
c. Perform an operative vaginal delivery
d. Screen and treat for maternal anemia

Postpartum hemorrhage is a common

maternal morbidity in high resource
countries and is on the rise. Which one
of the following is the most common
cause of postpartum hemorrhage?
a. Retained placental tissue
b. Atonic uterus
c. Coagulopathy
d. Vaginal laceration

Which of the following is not a part of

the active management of the third
stage of labor?
a. Oxytocin soon after delivery
b. Continuous controlled cord traction
c. Transabdominal uterine massage
after placenta delivers
d. Delayed cord clamping

You are attending the delivery of a

36-year-old gravida 6 para 5 female at
term. Her pregnancy has been
uncomplicated, with the exception of
chronic hypertension treated with
Labetalol 100 mg po BID. After a normal
spontaneous vaginal delivery, you note
a large gush of blood, prompt delivery of
the placenta, and brisk vaginal bleeding.
In addition to uterine massage, which of
the following uterotonic agents should
not be used to treat postpartum
hemorrhage in this patient?
a. Misoprostol 800 mcg PR
b. Oxytocin 20 IU in 1000 mL normal
saline. Infuse 500 mL over 10 minutes
then 250 mL/hour
c. Carboprost 250 mcg IM
d. Methylergonovine 0.2 mg IM