GRP 4 MCN Answer

Week 4
ANSWER & RATIONALE:

SET A
1. Correct answer - A - folic acid
Because folic acid is important during pregnancy to reduce the incidence of spinal cord
lesions, prevent abortion, and prevent megaloblastic anemia, it is added at greater
strengths to prenatal vitamins.
2. Correct answer - B - Contains linoleic acid

Linoleic acid is a fat important for skin integrity in the mother and for fetal growth.
3. Correct answer - B - Beef

B12 is found almost exclusively in animal sources; therefore beef would be the best
choice.
4. Correct answer - B - A woman with a 1-year-old son

Pregnancy depletes nutritional stores. A woman who enters a second pregnancy
almost immediately after a first can enter the second pregnancy with nutritional
shortages.
5. Correct answer - B - increased fiber intake

Increasing fiber intake is helpful in relieving constipation because it increases
peristalsis. Mineral oil is contraindicated because it prevents the absorption of fat-
soluble vitamins.
6. Correct answer - B - Twenty-five to thirty-five pounds is ideal

A weight gain of 25 to 35 lbs. encourages fetal growth yet does not lead to a
maternal weight gain post pregnancy.
7. Correct answer - D - Anticipate needing a vitamin B12 supplement during

pregnancy
Vitamin B12 is found almost solely in meat so it may need to be supplemented in a
vegetarian diet.
8. Correct answer - A - Eat small meals and do not lie down after meals
Pyrosis, or heartburn, occurs in pregnancy because the uterine pressure against the
stomach causes regurgitation into the esophagus. Eating small meals and remaining
upright limits the possibility of regurgitation.
9. Correct answer - C Suggest she have a hemoglobin assessment done because

of the association between pica and iron-deficiency anemia
Craving nonfood substances is called pica. This is associated with iron-deficiency
anemia.
10. Correct answer - D - Ask the patient to describe intake for the last 24 hours.
The best method for assessing a woman's nutritional intake during pregnancy is to ask
the patient to list all the food eaten within the past 24 hours, starting with waking up
until going to sleep. This method of history taking yields much more accurate
information than asking a patient how often a specific food is eaten. Assessing skin
status may provide more information about hydration that nutritional status. Assessing
a total intake for a week would be too extreme for the patient to recall. Assessing the
patient from a list of foods does not identify what the patient has most recently eaten.
11. Correct answer - C - Eight glasses

Extra amounts of water are needed during pregnancy to promote kidney function
because a woman must excrete waste products for two. Eight glasses of fluid daily is a
common recommendation. Two or four glasses of fluid would not be an adequate
amount. Ten glasses of fluid might be too much for the patient to consume each day.
12. Correct answer - A, B, E - Shiny hair, Smooth tongue, Normal muscle reflexes
Evidence of an adequate nutritional intake while pregnant includes shiny hair, smooth
tongue, and normal muscle reflexes. Pale conjunctiva could indicate iron deficiency.
Chipped fingernails could indicate inadequate protein intake.
13. Correct answer - C - Delay breakfast until midmorning

The traditional solution for preventing nausea is for the pregnant patient to keep dry
crackers, such as saltines, by the bedside and eat a few before rising because
increasing carbohydrate intake seems to relieve nausea better than any other nutrition
remedy. The patient can then eat a light breakfast or delay breakfast until 10 or 11 AM,
which is past the time nausea seems to persist. Aspirin is irritating to the stomach and
should not be taken. Delaying toothbrushing does not affect nausea. A teaspoon of
baking soda should not be suggested because this could adversely affect the patient's
electrolyte status.
14. Correct answer - B, C, E - Take prenatal vitamins as prescribed, Ensure a daily

intake of foods with folic acid, Maintain adequate nutrition before becoming
pregnant
Information that the nurse should include that supports the 2020 National Health Goals
for nutrition in pregnancy include taking prenatal vitamins as prescribed because these
will contain iron and folic acid. The nurse should also teach the participants to have a
daily intake of foods with folic acid and to maintain adequate nutrition before becoming
pregnant so that those entering pregnancy will have adequate nutritional stores. There
are no specific foods that a pregnant patient should avoid such as those high in fat and
calories. All pregnant patients do not need to limit the intake of foods high in simple
carbohydrates.
15. Correct answer - D - Patient is able to ingest a regular diet after progressing
through clear liquids and soft foods
The pregnant patient with hyperemesis gravidarum may be hospitalized and treated
with intravenous fluids. If there is no vomiting after the first 24 hours of oral restriction,
small amounts of clear fluid can be started, and the woman discharged home. If able to
take clear fluid without vomiting, small quantities of dry toast, crackers, or cereal can
be added every 2 or 3 hours, then the woman may be gradually advanced to a soft diet
and then to a regular diet. If vomiting returns at any point, enteral or total parenteral
nutrition may be prescribed to ensure she receives adequate nutrition. Vomiting
episodes in the morning or tolerating clear liquids or soft foods between vomiting
episodes indicates that teaching has not been effective.
16. Correct answer - A serum creatinine: 1.2 mg/100 mL (106 mol/L)
During pregnancy, the urinary system undergoes many physiologic changes, including
alterations in fluid retention and renal, ureter, and bladder function. Glomerular filtration
rate increases by 50%, BUN decreases by 25%, and creatinine decreases. A serum
creatinine greater than 1 mg/100 mL (88.40 mol/L) is abnormal and would be a cause
for concern. A BUN of 15 mg/100 mL (5.35 mmol/L) or higher is abnormal. A creatinine
clearance should be 90 to 180 mL/min (1.50 to 3.01 mL/s/m2 ) in a 24-hour urine
sample.
17. Correct answer - C It is caused by pressure on the bladder from the uterus
A pregnant woman may notice an increase in urinary frequency during the first 3
months of pregnancy, until the uterus rises out of the pelvis and relieves pressure on
the bladder. An increase in urination early in pregnancy is not caused by concentrated
urine or a decrease in the glomerular cells of the kidney. The fetus is not adding urine
to the patient's bladder.
18. Correct answer - D darkened breast areola
As the pregnancy progresses, the areola of the nipples darkens, and its diameter
increases. Enlarged lymph nodes; slack, soft breast tissue; and deeply fissured nipples
are not expected breast changes in a pregnant patient.
19. Correct answer- A “My mother and I are closer than ever before.”
For the first time in her life, a woman during pregnancy can begin to empathize with the
way her mother used to worry. This can make her own mother become more important
to her and a new, more equal relationship develops. Thinking about diet, allergies, and
the baby's sex are not developmental tasks for the pregnant patient.
20. Correct answer- C Arrange for prenatal care if the test is positive.
Home pregnancy testing can be accurate as soon as a period is missed; it should not
take the place of prenatal care.
21. Correct answer- D darkened breast areola
As part of the pigment changes that occur with pregnancy, breast areola become
darker.
22. Correct answer- D “Milk will strengthen your fingernails as well as be good for
the baby.”
There is a tendency to organize health instructions during pregnancy around the baby;
however, this approach may be inappropriate early in pregnancy, before the fetus stirs,
and before a woman is convinced not only she is pregnant but also there is a baby
inside her. At early stages, a woman may be much more interested in doing things for
herself because it is her body, her tiredness, and her well-being that will be directly
affected. The nurse should instruct the patient to drink more milk to improve fingernail
strength. The statements that address fetal development are inappropriate for the
nurse to use for health teaching at this time.
23. Correct answer- A Immunologic activity is decreased during pregnancy
Immunologic competency during pregnancy decreases, probably to prevent a woman's

body from rejecting the fetus as if it were a transplanted organ. Aldosterone does not
impact the production of IgG antibodies. The kidneys do not influence an allergic
response. Adrenal gland activity increases during pregnancy.
24. Correct answer- B Lactose may be spilling into the urine
Because reabsorption of glucose by the tubule cells occurs at a fixed rate, this causes
some accidental spilling of glucose into the urine during pregnancy. Lactose, which is
being produced by the mammary glands but is not used during pregnancy, will also be
spilled into the urine. If more than a trace amount of glucose is found in the pregnant
patient's urine, this could indicate gestational diabetes. The increase of glucose in the
urine is not because of eating excessive calories. The glomerular filtration rate
increases in pregnancy.
25. Correct answer- D A new baby will make our family bigger but not change our
love for you.”
Preschool-age children may need to be assured periodically during pregnancy that a

new baby will be an addition to the family and will not replace them in their parents'
affection. Explaining that the mother will have less time for the child, equating the new
baby as ―fun,‖ and taking away a bed for the baby will not help the child accept the
new baby into the family.
26. Correct answer- A “My mother and I are closer than ever before.”
A developmental task for a woman during pregnancy is to review and restructure her
relationship with her mother.
27. Correct answer- A,C,E Stop smoking, Eat a healthy diet, Limit alcohol intake
Nurses can help the nation achieve the 2020 National Health Goals for pregnancy by
ensuring certain women receive counseling in nutrition and low uses of alcohol and
tobacco before pregnancy so they can enter intended pregnancies in the best health
possible. Increasing exercise and reducing work hours are not interventions that would
support the 2020 National Health Goals for pregnancy.
28. Correct answer - B
The statement that the patient needs to get back to work after delivery could indicate
that the patient feels the pregnancy is robbing her of financial stability or ruining
chances of a promotion. Desiring to lose weight after pregnancy does not indicate that
the patient is not adjusting emotionally to being pregnant. The statements about
parental support do not indicate that the patient is not adjusting emotionally to being
pregnant.
Quickening, or feeling the baby move inside the body, is such a dramatic event that it
can cause a woman's perceptions about the pregnancy to change
30. Correct answer - A
A step in preparing for parenthood is role-playing or fantasizing about what it will be

like to be a parent. This is done by a pregnant woman spending time with other
pregnant women or mothers of young children to learn how to be a mother. The
pregnant patient's behavior does not indicate narcissism. Spending time with a mother
of a small child is not reworking developmental tasks. This behavior does not
demonstrate ambivalence about being pregnant.
31. Correct answer- B. It prevents hyperventilation
Cleansing breaths are important because they limit the possibility of either
hyperventilation or hypoventilation, both of which can happen with rapid breathing
patterns. Cleansing breaths do not ensure fetal perfusion or promote cervical dilation.
32. Correct Answer- D. It stretches perineal muscles.
Supple perineal muscles allow the opening to the vagina to expand for childbirth
without tearing. Tailor sitting is an exercise that helps accomplish this.
33. Correct answer - C. It helps relieve backache
Backache is a frequent symptom of pregnancy. Pelvic rocking can help to relieve

this.
34. Correct answer - A) "I'll squeeze my muscles around my vagina, as if I'm

stopping my urine stream."
Kegel exercises (tightening perineal muscles) are instrumental in preventing urinary

incontinence following childbirth. They include starting and stopping a urine stream.
The woman should squeeze the muscles surrounding the vagina as if stopping the flow
of urine and hold for 3 seconds, not 10 seconds.
35. Correct answer - B. Engaging in pushing as an exercise.
Women should not practice pushing during pregnancy or if in labor before the end of
the first stage because the possibility they could rupture membranes by doing this is
too great. They can practice assuming a good position for pushing (e.g., squatting,
sitting upright, leaning (on partner) but should always be cautioned not to actually bear
down and push.
36. Correct answer - A. Abdominal breathing allows the uterus to expand freely.
Relaxation and breathing exercises allow the abdominal wall to relax and not
interfere with uterine contractions. Prepared childbirth does not make labor pain free. It
prepares women to manage the pain of contractions. Distraction alters how pain is
perceived, such that if the cells of the brain that register the pain impulse are
preoccupied with other stimuli, the pain impulse cannot register. Therefore distraction
interferes with, not aids in, the perception of pain.
37. Correct answer -B. Hospital births are conducted with more safeguards for
sterility than home births tend to use.
The danger of infection is a great concern to hospitals. Maintaining standard

precautions is a primary action to reduce this risk.
38. Correct answer - A. Lightly tracing a pattern on her abdomen with her fingertips.
Effleurage is a light massage that helps offer pain relief in labor.
39. Correct answer- A. Important participant in a successful labor.

The presence of a coach in labor can help a great deal to make childbirth a positive
event.
40. Correct Answer - B. Beginning newborn care.
Expectant parents' classes are designed to teach about pregnancy as well as

beginning child care.
41. Correct Answer - C. “I'm interested in learning as much as I can about birth and
what I need to do.”
Women who plan to deliver at home must be well informed about the process and
what responsibility they must undertake to make home birth safe
42. Correct Answer - B. Birth is viewed as a wellness event.
A birthing center admits only women who are at low risk for complications. At
birthing centers, birth is viewed as a wellness event.
43. Correct Answer - D. Security of knowing emergency equipment is on hand.
A major advantage of hospital birth is that emergency equipment and personnel both
are readily available.
44. Correct answer- C. Fear of having an emergency delivery before reaching the
hospital.
Women's reasons for wanting home birth vary. If a reason is because of inadequate
transportation, a solution that provides transportation will often convert them to
planning birth in a more structured setting.
45. Correct answer- D. "My muscles will be able to stretch more easily during labor."
Women can practice specific exercises to strengthen pelvic and abdominal muscles
to make these muscles stronger and suppler for labor. If perineal muscles are supple,
this allows for stretching during birth, reduces discomfort, and helps perineal muscles
function more efficiently after childbirth, which helps reduce the possibility of urinary
incontinence
46. Correct answer - C A woman may spend time thinking about what is happening
to her
Women need a support person with them during all stages of labor.
47. Correct answer - B The newborn drips urine throughout the shift
Infants without innervation to the lower spinal cord do not have bladder control and
thus void continually as the urine is made by the kidneys. Frequent diapering is
needed. The newborn would not be placed on the back due to the myelomeningocele.
Newborns have difficulty visualizing. It is appropriate to have a normal tonic-neck
reflex.
48. Correct answer - C floating

A fetus is not engaged until the presenting part reaches the ischial spines.
49. Correct answer - D hydrocephalus

Surgery includes removing a portion of the meninges; without the surface to absorb
cerebral spinal fluid, hydrocephalus can result.
50. Correct answer - C on the stomach (prone)

Placing the infant prone prevents direct trauma to the lesion and reduces the chance
that feces will contaminate the lesion.
51. Correct answer - A the beginning of one contraction to the beginning of the nex
Measuring from the beginning of one contraction to the next marks the time between
contractions.
52. Correct answer - C Lie on her side so she is comfortable.
The best position for all women during labor is on their side.
53. Correct answer D - Fetal heart rate declining late with contractions and
remaining depressed
Lack of blood supply to the fetus because of poor placental filling prevents the fetal
heart rate from recovering immediately following a contraction.
54. Correct answer B - Turn her or ask her to turn to her side
The most common cause of uteroplacental insufficiency is compression of the vena

cava; turning the woman to her side removes the compression.
55. Correct answer- B - “It relieves pressure on the fetal head.”
An episiotomy widens the vaginal opening, decreasing pressure on the fetal head
56. Correct answer - A - feelings of being frightened by the change in contractions
The nature of contractions changes so drastically– the urge to push is very strong–that
this can be frightening.
57. Correct answer- D - Assess fetal heart rate for fetal safety.
Rupture of the membranes may lead to a prolapsed cord. Assessment of FHR detects
this.
58. Correct answer- D - turning inward to concentrate on body sensations
Second-stage contractions are so unusual that most women are unable to think of
things other than what is happening inside their body.
59. Correct answer- C - head elevated, grasping knees, breathing out
An important point is to be certain the woman does not hold her breath, as this puts
pressure on the vena cava, reducing blood return.
60. Correct answer- C - “I want this baby to be a boy.”
Women with preset images of their child may have difficulty accepting an image
other than the one they have created.
61. Correct answer- D - Measure a daily head circumference

Because some meningocele absorbing surface is removed with surgery, cerebrospinal
fluid can accumulate and lead to hydrocephalus.
62. Correct answer - B - Meconium-stained amniotic fluid

Meconium staining indicates the fetus has suffered anoxia.
63. Correct answer - C - 8 to 10 cm

Full dilation of the cervix is 8 to 10 cm.
64. Correct answer - B - Check the child frequently for sweating

One adverse effect of oxybutynin chloride is sweating. Sweating can cause a rise in
body temperature. The parents should be encouraged to restrict the child from being
exposed to high temperatures. Adverse effects of this medication include drowsiness,
dizziness, blurred vision, and sweating. Appointments with the health care provider
should be frequent so the effects of this medication can be evaluated. The medication
should be taken as prescribed and not only when the child's urinary output is sluggish
65. Correct answer - C - white sclera showing above the pupils

As accumulating cerebrospinal fluid puts pressure on the posterior surface of the eye
globes, they tip downward; white sclera shows above the pupils.
66. Correct answer - C - nutrition

An infant with a cleft lip is unable to suck effectively, so obtaining adequate nutrition is
a major concern.
67. Correct answer - C - Preventing crust formation on the suture line

If crust forms on the suture line, the suture line can be pushed apart and a large scar
could result. A prone position is avoided.
68. Correct answer - C - Offer the child sips from a small glass
Offering sips from a glass allows the child to ingest fluid and not disturb the suture line.
Using a straw or spoon could injure the suture line; children generally do better with
small rather than large (6-8 ounce) amounts.
69. Correct answer - C - Risk for impaired skin integrity

The patient is at risk for impaired skin integrity related to gastrostomy tube insertion
site. Acidic gastric secretions can leak onto the skin from the gastrostomy site, leading
to skin irritation. The nurse should plan interventions to protect the skin by using a
cream or commercial skin protection system or consult with a wound, ostomy, and
continence therapy nurse to reduce the possibility of skin irritation and infection. With
the placement of the gastrostomy tube, the patient is at less risk for imbalanced
nutrition and deficient fluid volume. The gastrostomy tube will not affect the patient's
gas exchange.
70. Correct answer - A - Hydramnios

Esophageal atresia must be ruled out in any infant born to a woman with hydramnios
or excessive amniotic fluid. Normally, a fetus swallows amniotic fluid during intrauterine
life. With esophageal atresia, the fetus cannot swallow so the amount of amniotic fluid
grows abnormally large, leading to hydramnios. Oligohydramnios, a difficult second
stage of labor, or bleeding at 32 weeks of pregnancy does not indicate that esophageal
atresia was developing during fetal development.
71. Correct answer - D - Keeping the head of the infant level with the body
Keeping the infant's head fairly even with the rest of the body prevents gravity from
moving more fluid into the shunt than necessary.
72. Correct answer - A - The child may have increased episodes of otitis media
Surgery for cleft palate changes the slant of the eustachian tube, allowing bacteria from
the posterior throat to enter the middle ear easily.
73. Correct answer - B - hydramnios

Because a fetus swallows amniotic fluid, when there is an obstruction of the
esophagus, amniotic fluid accumulates, leading to hydramnios.
74. Correct answer - C - Voiding pattern

A myelomeningocele is the defect that is equated with “spina bifida” and is the most
common birth defect affecting the c
entral nervous system. In a meningomyelocele, the meninges protrude through the
vertebrae and the spinal cord usually ends at the point of protrusion. Motor and
sensory function will be decreased or absent beyond this point. The child will have loss
of bowel and bladder control and urine, and stools will continually dribble because of
lack of sphincter control. This defect is not known to affect vision. Assessing for pain is
not a priority with this defect. This defect does not affect the neck region of the spinal
cord.
75. Correct answer - C - Intercostal retractions

A steadily increasing respiratory rate, grunting, and nasal flaring are often the first
signs of obstruction or respiratory compromise in newborns. If these are present,
undress the baby's chest and look for intercostal retractions, which reflect the degree of
difficulty the newborn is having in drawing in air. Oxygen saturation of 96% is within
normal limits and does not indicate respiratory distress.
76. Correct answer - B - If he breathed spontaneously at birth

Although all this are important, inability to breath spontaneously at birth has the
potential to have the most long- term consequences
77. Correct answer - A - abduction

Infants with shallow acetabulums are unable to abduct their hips.
78. Correct answer - B - One-fourth his total length

Newborn heads are large in proportion to their body, or one-fourth of their total length
79. Correct answer: C. - Follows a light to the midline

Newborns do not usually follow past the midline until 3 months of age. They do not
tear.
80. Correct answer: B - above the knee

A cast for a talipes deformity typically extends above the knee to stabilize the knee, ankle, and
foot.
81. Correct answer: B - Flicking the soles of the feet and observing the response
Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or
evaluating the response to a catheter passed in the nose.
82. Correct answer: A - Keeping it dry

Keeping the umbilical cord dry and open to air help prevent infection.
83. Correct answer: A - Plot the weight on the gestational age graph
A newborn’s weight is important because it helps to determine maturity as well as
establish a baseline against which all other weights can be compared. The birth weight
of newborns varies depending on the racial, nutritonal, intrauterine, and genetic factors
that were present during conception and pregnancy. The weight in the relation to
gestational age should be plotted on a standard neonatal graph. The nurse does not
need to ask a physician to examine the newborn. There is no evidence to suggest that
the infant needs a cholesterol level drawn. The weight does not influence if the
newborn neds to be placed in a radiant heat warmer.
84. Correct answer: C - Head one fourth of the total length

A newborn’s head usually appears disproportionately large because it is about one
fourth of the total body length. The newborn’s head is not one half, one sixth, or one
eighth of the total body length.
85. Correct answer: D - Retracting the foreskin over the glans to assess for
secretions
In most male newborns, the foreskin slides back poorly from the meatal opening, so
the nurse should not try to retract it. The nurse should inspect the area for irritated skin,
inspect the urethral opening, and palpate the testes in the scrotal sac.
86. Correct Answer - B - Follows a light to the midline

Instruct parents that the newborn cannot follow an object past the midline or appears to
lose tract of objects easily so there is nothing wrong with the eyesight. The newborn
will not produce tears because the lacrimal ducts are not fully functioning. The parents
will not be able to assess for a red reflex. The infant will not be able to follow a finger
for a full 180 degrees.
87. Correct Answer - B - It is caused by the mother’s hormones

In both male and female infants, the breast may be engorged because of the influence
of maternal hormones during pregnancy. At times, the breast of newborn babies
secrete a thin, watery fluid termed with’s milk. As soon as the hormones are cleared
from the infant’s system in about a week, the engorgement and any fluid that is present
will subside. The discharge from the baby’s breast is not caused by exposue to cold
air. The baby does not need chromosomal studies nor is this a sign that the baby has a
pituitary tumor.
88. Correct Answer - C - 8

An Apgar score between 7 and 10 indicates that the infant scored as high as 70% to
90% of all infants at 1 and 5 minutes after birth and is adjusting well to exttrauterine
life. A score of 4 to 6 indicates a guarded condition, and the newborn may need
clearing the airway and supplementary oxygen, A score <4 indicates serious danger of
respiratory or cardiovascular failure and the newborn needs resuscitation. Ten is the
maximum number on the Apgar scoring system.
89. Correct Answer - B - Health-seeking behaviors

The new mother is asking the nurse for help with breastfeeding , which’s supports the
nursing diagnosis of health-seeking behaviors.. The patient requesting help with
breastfeeding does not indicate powerlessness, readiness for enhanced coping, or
anxiety related to breastfeeding.
90. Correct Answer - C - Both the mother and infant have identification bands that
need to match
Hospitals have an identification banding system where the mother’s and the infant’s
identification bands are to match. Only people with proper hospital identification should
be permitted into the nursery. Keeping the baby in the mother’s room at all times could
be dangerous because the baby could be left unattended, permitting someone an
opportunity to abduct the infant. Security does not routinely question everyone before
permitting them access to the hospital.
91. Correct answer - C - Stress the importance of taking prenatal folic acid as
prescribed
Nurses can help the nation achieve the 2020 National Health Goals by urging patients
to enter pregnancy with an adequate folic acid level. Extreme physical activity,
exercise, calcium, and water are not identified interventions to prevent birth defects in
the developing fetus.
92. Correct answer - D - breast milk normally comes in on the third or fourth
postpartum day
Colostrum has been forming since the fourth month of pregnancy; milk forms on the
third or fourth postpartum day.
93. Correct answer - C - Encouraging her to continue regular breastfeeding

Engorgement (a feeling of fullness in the breasts) can be alleviated by the infant
breastfeeding.
94. Correct answer - A - 50 to 55

Newborns have rapid metabolisms and need proportionally more calories per pound
than adults.
95. Correct answer - B - 20 calories per ounce

Twenty calories per ounce is not only the calorie content of breast milk but also that of
commercial formulas.
96. Correct answer - B - the stools of breastfed infants are normally loose
Until infants begin to eat solid food, their stools are yellow and slightly loose.
97. Correct answer - B - Breastfeeding offers a good chance for bonding with the
infant
Breastfeeding reduces the risk of breast cancer and enhances uterine involution. It
provides the opportunity for mother-infant bonding.
98. Correct answer - B - Breast milk contains antibodies and thus decreases the
possibility of gastrointestinal illnesses
Breast milk contains antibodies that are instrumental in reducing gastrointestinal
infections.
99. Correct answer - C - “This is a common concern. The size of breasts, however,
does not reflect the number of milk glands present.”
As the size of breasts is largely determined by the number of fat cells present, this
does not influence the number or size of milk glands or milk ducts present.
100. Correct answer - C - Exposing her nipples to air after each feeding
should help
Longer periods of sucking might irritate nipples; exposing the nipples to air can help.
SET B
101. Correct answer - C - “The infant should gain weight and have six wet
diapers daily.”
An infant who is voiding adequately is undoubtedly receiving adequate fluid.
102. Correct answer - A - Almost all drugs are excreted to some extent in
breast milk
Almost all drugs are excreted in breast milk, over-the-counter as well as prescription.
103. Correct answer - A - Immediately after birth

Breastfeeding should begin as soon after birth as possible, ideally while the woman is
still in the birthing room and while the infant is in the first reactivity period.
Breastfeeding should not wait until the baby rests. Twenty-four hours is too long to wait
to begin breastfeeding. Mixing breastfeeding and formula feeding is not recommended.
104. Correct answer - B,D - For the first 3 to 4 days, the breast milk is
colostrum, and True breast milk comes in by the 10th day after giving birth.
For the first 3 to 4 days after delivery, the breast milk is colostrum. The consistency
changes to true breast milk by the 10th postpartum day. Colostrum is thin, yellow, and
watery. Uterine cramping occurs as a result of oxytocin released during breastfeeding
and is not a contraindication to breastfeeding but an expected occurrence. Most
mothers do not have breast milk by the first day after giving birth.
105. Correct answer - A, E - Mother washes hands using warm, soapy water &
Mother washes around the child's urinary meatus with warm, soapy water
A common suggestion to relieve breast engorgement is to empty the breasts of milk by
having the infant suck more often or at least continue to suck as much as before.
Breastfeeding should not be discontinued. Applying cream to the breasts will not help
with engorgement. The mother does not need to be placed on a fluid restriction.
106. Correct answer - C - Assessing fetal heart tones by use of an external
monitor
Not disrupting the placenta is a prime responsibility. An internal monitor, a vaginal

examination, and remaining ambulatory could all do this and thus are contraindicated.
107. Correct answer - B - low placental implantation
The cause of placenta previa is usually unknown, but for some reason the placenta is
implanted low instead of high on the uterus.
108. Correct answer - A - sharp fundal pain and discomfort between

contractions
An abruptio placentae refers to premature separation of the placenta from the uterus. As the
placenta loosens, it causes sharp pain. Labor begins with a continuing nagging sensation.
109. Correct answer - A - premature separation of the placenta
Premature separation of the placenta begins with sharp fundal pain, usually followed by vaginal
bleeding. Placenta previa usually produces painless bleeding; labor contractions are more
often described as cramping. .
110. Correct answer - B - prevent maternal D antibody formation
Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the
woman from forming long-lasting antibodies.
111. Correct answer - A - The child looks in the direction of the affected
muscle
To relieve torticollis, parents need to begin a program of passive stretching exercises, laying
the infant on a flat surface and rotating the head through a full range of motion. Parents should
always encourage the infant to look in the direction of the affected muscle. They can encourage
this by holding the child to feed in such a position the child must look in the desired direction. If
manual stretching is begun early and performed consistently by parents, further treatment
usually is not necessary. If extreme injury to the muscle occurred, torticollis can lead to the
continued elevation of one shoulder. Any observations where the child is looking in the
direction opposite of the affected muscle indicates that teaching has not been successful.
112. Correct answer - A - Prepare her for epidural anesthesia

A consequence of the HELLP syndrome is poor blood coagulation. Epidural anesthesia is not
recommended when blood coagulation is in doubt.
113. Correct answer - A, B, C, E

Treatment for a meconium plug includes the administration of 5 ml saline enema, rectal
instillation of acetylcysteine, a gastrografin enema, and a barium enema used to diagnose the
disorder. A tap water enema should never be used in newborns because it can cause water
intoxication.
114. Correct answer - A - Cervical dilation of 5 cm
If cervical dilation has progressed too far already, labor cannot be halted. Tocolytics usually are
not begun if cervical dilation is over 3 to 4 cm.
115. Correct answer - C - Bleeding spontaneously stops within 24 to 48 hours
For a threatened miscarriage, an outcome for care would be that all bleeding would
spontaneously stop within 24 to 48 hours. Bed rest is not recommended for a threatened
miscarriage because blood will pool in the vagina. Vaginal bleeding that saturates a perineal
pad in 1 hour is an emergency and could indicate an incomplete or complete miscarriage.
Normal coitus should be withheld for 2 weeks after a threatened miscarriage.
116. Correct answer - C - In the back private room
With severe preeclampsia, hospitalization is required so that bed rest can be enforced and the
patient can be observed more closely. A patient with severe preeclampsia is admitted to a
private room so that rest is undisturbed. Noises such as a baby crying, elevator doors opening
and closing, and conversation from the nurse's station is sufficient to trigger a seizure. A private
room will help reduce the likelihood of seizure development.
117. Correct answer - C - Stop the current infusion
When infusing magnesium sulfate, the nurse should stop the infusion if deep tendon reflexes
are absent. Checking the fetal heart rate and measuring blood pressure could waste time and
provide the patient with more magnesium sulfate. The infusion rate should not be increased
because this could lead to cardiac dysrhythmias and respiratory depression.
118. Correct answer - A - Immediate surgery
An ectopic pregnancy is one in which implantation occurred outside the uterine cavity, usually
within the fallopian tube. As the embryo grows, the fallopian tube can rupture. The therapy for
ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or
repair the damaged fallopian tube. There is no reason to begin uterine monitoring. The patient
does not need to be on bed rest for 4 weeks. A tocolytic is not needed because the patient is
not in labor.
119. Correct answer - A,E
The patient with premature rupture of membranes is at risk for developing an infection. The
nurse should instruct the patient to avoid douching and measure oral temperature twice a day.
Coitus and tub baths should be avoided because these could introduce an infection into the
uterus. A malodorous vaginal discharge could indicate infection and should be reported to the
health care provider.
120. Correct answer- A,C,D,E
Polyhydramnios is an excessive amount of amniotic fluid. The first sign of this disorder may be
a rapid enlargement of the uterus. The uterus becomes tense, and the patient experiences
shortness of breath because of the uterus pressing on the diaphragm. Auscultating the fetal
heart rate can be difficult because of depth of the increased amount of fluid surrounding the
fetus. The uterus will be larger than expected for the patient's gestational week.
121. Correct answer- C

Because exercise uses up glucose, women with diabetes should take a sustaining-
carbohydrate snack before hard exercise to prevent hypoglycemia.
122. Correct answer- B, E
Because of the potential difficulty with absorbing nutrients, the pregnant patient with
inflammatory bowel disease needs careful monitoring for weight gain during
pregnancy. Anti-inflammatory medication may be continued during pregnancy without
fetal injury. The patient does not need a cesarean birth for this health problem. Foods
and fluids should not be restricted because the patient has difficulty absorbing nutrients
anyway. Gamma globulin injections are not indicated for this disorder

Amoxicillin, ampicillin, and cephalosporins are effective against most organisms
causing UTIs and are safe antibiotics during pregnancy. Tetracyclines are
contraindicated during pregnancy because they cause retardation of bone growth and
staining of the fetal teeth.
124. Correct answer- A
The fluid status of a pregnant patient with sickle-cell anemia is important because
dehydration can precipitate a crisis. The patient should drink at least eight glasses of
fluid each day to prevent dehydration. Patients with sickle-cell anemia should not take
an iron supplement because the sickled cells cannot incorporate iron in the same way
as nonsickled cells. Standing for long periods of time can cause red cell destruction in
the patient with sickle-cell anemia. The patient should sit with the legs elevated to
encourage venous return of blood from the lower extremities.
125. Correct answer- D
Phenytoin (Dilantin) is believed to cause a fetal syndrome that includes vitamin K

deficiency. To counteract the vitamin K deficiency and prevent hemorrhage in the
newborn, the patient may be prescribed vitamin K during the last 4 weeks of gestation.
Vitamins C, D, or E have no impact on the pregnant patient who is taking phenytoin
(Dilantin) for a seizure disorder.
126. Correct answer- D
Assessing serum glucose reveals both hyperglycemia and hypoglycemia.

Because exercise uses up glucose, women with diabetes should take a sustaining-
carbohydrate snack before hard exercise to prevent hypoglycemia.
Sickle cell anemia is an autosomal recessive disease requiring that the person have
two genes for the disease, one from each parent. If one parent has the disease and the
other is free of the disease and trait, the chance of the child inheriting the disease is
zero. If the woman has the disease and her partner has the trait, there is a 50% chance
that the child will be born with the disease. If both parents have the disease, then all of
their children also will have the disease.
129. Correct answer - C
Women with artificial heart valves have an increased risk of subacute bacterial
endocarditis following delivery because some bacteria enter the bloodstream from the
denuded placental surface. Such bacteria settle in the eddying blood surrounding
cardiac shunts or valves.
Methimazole is the preferred drug to treat pregnant patients with hyperthyroidism

because it appears to cross the placenta less easily. Propylthiouracil crosses the
placenta and can lead to congenital hypothyroidism and an enlarged thyroid gland in
the fetus. Cephalosporin is an antibiotic that is not used in the treatment of
hyperthyroidism. Levothyroxine is thyroid hormone and is used in the treatment of
hypothyroidism.
As a rule, patients can receive chemotherapy in the second and third trimesters without
adverse fetal effects. Radiation therapy puts the fetus at risk throughout pregnancy if
the fetus is directly exposed. Chelation and anticoagulants are not therapies
associated with cancer treatment.
132. Correct answer - D
During the postpartum period, there may be an acute exacerbation of systemic lupus
erythematosus symptoms because corticosteroid levels are returning to normal.
Symptoms are not increased because the fetus was keeping the symptoms in check.
The stress of delivery is not causing the symptoms to increase. The symptoms are not
because of a spike in maternal hormone levels.

Tuberculosis lesions are contained by calcium “walls” in the lungs. Pregnant women
need to ingest a high calcium intake to prevent these “walls” from breaking down to
supply calcium for the fetus.
During pregnancy, the insulin levels change in response to the production of HPL. The
client needs to alert her provider if she is not able to eat or hold down appropriate
amounts of nutrition. The client is at risk for episodes of hypoglycemia during the first
trimester. She should never discontinue insulin therapy without her provider's
directions. The increase of carbohydrates needs to be balanced with protein, and
smaller meals would result in hypoglycemia rather than hyperglycemia.
Patients with diabetes who become pregnant develop insulin resistance as the
pregnancy progresses, or insulin does not seem as effective during pregnancy. This
phenomenon is believed to be caused by the presence of the hormone human
placental lactogen and high levels of cortisol, estrogen, progesterone, and
catecholamines. The increased need for insulin is not because of the fetus using
insulin to maintain blood glucose level in utero. The patient's increased circulating
blood volume is not deactivating insulin. The patient's change in diet might necessitate
an adjustment in insulin dosage, but this would vary according to blood glucose level.
136. Correct answer - B, C, E
Prior to using forceps for a delivery, the cervix must be fully dilated, the patient's
bladder must be empty, and the patient's membranes must have ruptured. The patient
does not need oxygen for a forceps delivery. The patient does not need an intravenous
infusion prior to a forceps delivery.
The clinical picture of an amniotic fluid embolism is dramatic. The patient suddenly
experiences sharp chest pain and is unable to breathe as pulmonary artery constriction
occurs. The immediate management is oxygen administration by face mask or
cannula. Intravenous fluids; pressure on the fundus, or taking short, shallow breaths is
not going to help the manifestations of an amniotic fluid embolism.
Because the fetal head rotates against the sacrum in the occiput posterior position. the
patient may experience pressure and pain in the lower back because of sacral nerve
compression. Applying counter pressure on the sacrum by a back rub may be helpful in
relieving a portion of the pain. The patient does not need to be placed in the prone or
Trendelenburg positions. Ice packs are not indicated to reduce this pain.
A placenta succenturiata is a placenta that has one or more accessory lobes

connected to the main placenta by blood vessels. This disorder needs to be recognized
because the small lobes may be retained in the uterus after birth, leading to severe
maternal hemorrhage. Once the remaining lobes are recognized and removed from the
uterus manually, the uterus will contract with no adverse maternal effects. Uterine
lavage is not a treatment for this disorder. This disorder is not specifically associated
with an episiotomy. No fetal abnormality is associated with this disorder.
140. Correct Answer - A
With a prolonged descent, intravenous oxytocin may be used to induce the uterus to
contract effectively. Fluid replacement, pain management, and activity will not cause
the fetus to descend quicker.
141. Correct Answer - C
With a breech presentation, fetal heart sounds usually are heard high in the abdomen.
In a breech presentation, fetal heart sounds will not be heard low in the abdomen or
over the left or right lateral abdominal regions.
Babies born after a face presentation have a great deal of facial edema and may be
purple from bruising. The infant must be observed closely for a patent airway, which is
the priority. A face presentation does not affect the cardiovascular or genitourinary
systems. If lip edema is severe, the newborn might need gavage feedings until the
edema subsides and sucking can occur.
Nurses can help the nation achieve the 2020 National Health Goals for complications
of labor by being alert to the preliminary symptoms of uterine rupture, which accounts
for a substantial number of maternal deaths during labor, Hypotonic and hypertonic
contractions and prolapsed fetal cord are not identified as specific complications of
labor within the 2020 National Health Goals.

Contractions should last no longer than 70 seconds. If contractions become longer in
duration, stop the IV infusion and seek help immediately. The infusion needs to be
discontinued and not slowed. Increasing the flow rate could cause fetal distress. The
patient needs to be assessed more frequently than every 2 hours.
145. Correct answer- B

A side effect of oxytocin is that it can result in decreased urine flow, possibly
leading to water intoxication. This is first manifested by headache and vomiting. If

these are dangerous signs are observed 1 in the patient during induction of labor,
report them immediately and halt the infusion. Assessing the vagina for dilation,
increasing respirations, and administering orange juice for potassium will not help with
water intoxication.
When administering oxytocin, the infusion should be "piggybacked" to a maintenance

IV solution and add the piggyback to the main infusion at the port closest to the patient.
If the oxytocin needs to be discontinued quickly during the induction, little solution
remains in the tubing to still infuse, and the main IV line can still be maintained.
Oxytocin is not administered as an intravenous bolus, as intramuscular injections, nor
is it diluted in the main intravenous fluid.
Prolapsed cord is always an emergency situation because the pressure of the fetal
head against the cord at the pelvic brim leads to cord compression and decreased
oxygenation to the fetus. Pressure on the cord must be relieved, which is done by
placing the patient in a knee-chest or Trendelenburg position to cause the fetal head to
fall back from the cord. Tuming the patient onto the left side will not relieve pressure on
the fetal cord. Any amount of prolapsed cord should not be reinserted into the patient.
Exposed cord should be covered with sterile saline compresses to prevent drying.
Many patients react negatively to the idea of IV fluid therapy during labor to restore
body fluid. Assure the patient that being out of bed and walking, turning freely,
squatting, sitting. or using whatever position preferred during labor will not disrupt the
IV line or the infusion. The nurse should not tell the patient to lie on the back or to lie
perfectly still. The patient should also he encouraged to get out of bed if that is
permitted and desired by the patient in labor.

A danger of hypertonic contractions is that the lack of relaxation between contractions
may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the
latent phase of labor. The best intervention is to encourage the patient to rest between
contractions. Oxytocin will not help strengthen hypertonic contractions. Walking will not
help make the contractions more regular. These are hypertonic and not hypotonic
contractions.
150. Correct answer - A, C, D, E
Reasons for the breech presentation include multiple fetuses, lax abdominal muscles,
fetal birth defects such as hydrocephalus, and fetal age less than 40 weeks. Maternal
diabetes is not identified as cause for a fetal breech presentation.
151. Ans: A
A tense, “guarded” abdomen is one of the first signs of peritonitis.
152. Ans: C
Following a cesarean birth, uterine contraction and a return to prepregnant state occurs
at the same rate as with vaginal birth.
153. Ans: A
Because the bladder is handled during surgery, it may not empty well following
surgery, necessitating an indwelling catheter.
154. Ans: D
A side-lying position both helps prevent hypotension syndrome and positions her for
anesthetic administration.
155. Correct answer: D
Most women can breastfeed satisfactorily following cesarean birth

Patient-controlled analgesia is well documented as an effective pain-relief measure
following cesarean birth.
157. Correct answer-C
Childbirth should be a shared experience to the maximum extent possible.
158. Correct answer-C

The return of bowel sounds is an indication that bowel function has returned
159. Ans: B
Ambulation increases circulatory function, helping decrease blood clotting.
160. Correct answer-B
Cesarean birth reduces pressure on the fetal head because the head does not
participate in cervical dilation.
161. Correct answer-B

A low cervical incision provides the best access to the fetus and the best cosmetic
appearance to the mother.
Low cervical incisions allow for vaginal birth following cesarean birth because they do
not involve the fundal portion of the uterus.
The area and type of pain being experienced should be evaluated. This will aid in the
early determination of potential surgical complications
The shape and size of the pelvis of a woman does not change with subsequent
pregnancies. If a woman is unable to give birth vaginally because of cephalopelvic
disproportion, she most likely will experience the same complication during future
pregnancies.
165. Correct answer - BONUS
Negativism, a normal part of a child's psychosocial development, is the means by

which a toddler attempts to control his environment. An effective way of coping with a
child who always responds to questions by saying "No" is to give the child choices and
limit the number of questions. For example, the caregiver might say, "You can have
peanut butter crackers or a tuna fish sandwich for lunch today," which gives the child a
choice and avoids posing a question. Ignoring the child's negativism does not allow the
caregiver to set limits or help the child to learn self-discipline. Trying to avoid asking the
child questions is unrealistic. Explaining in detail that saying "No" is not always
appropriate is unrealistic because of the toddler's cognitive level and limited attention
span.

To have a suggested idea of the location of the bleeding, the nurse would need to
assess the fundus of the client first.
A fourth-degree perineal laceration involves the anus; a hard object, such as an enema
tip, could tear a suture.
The sign of weak and rapid pulse in the body is a compensatory mechanism attempting
to increase the blood circulation. This finding needs to be reported to the health care
provider and RN as soon as possible..
As the fetal head passes behind the bladder, bladder edema with loss of sensation can
result..
Postpartal women who void in small amounts may be experiencing bladder overflow
from retention.
Methylergonovine elevates blood pressure. It is important to assess that it is not

already elevated before administration.
A uterus involutes at a rate of one finger width daily. On the third postpartal day, it is
normally three finger widths below the umbilicus.
A temperature over 100.4° F (38° C) past the first day postpartum is suggestive of
infection.
The most common site for a postpartum infection is the reproductive tract. This is
important for teaching and education of clients.
An antibiotic can lead to overgrowth of fungal organisms; it can also lead to

underproduction of vitamin K and difficulty with blood clotting.
Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are
caused by an inflammatory process and obstruction of venous return.
Advice will differ based on the drug prescribed. Heparin, for example, does not pass
into breast milk, yet warfarin does.
Any restriction including tight fitting clothes or blankets on the leg can interfere with
blood circulation. Uncovering or removing the constriction relieves the pain. Ice impairs
circulation further exacerbating pain. Massaging the leg or encouraging ambulation
could cause a clot to move and become a pulmonary embolus.
Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of
possible infection.
Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Mastitis
needs to be assessed and treated with antibiotic therapy.
181. Correct answer: C

Because preterm babies continue to grow at their intrauterine rate, they need more
calories per ounce than full-term newborns. Iron formulas and those which included
rice cereal are not a first choice as they may not be tolerated.

A ventriculoperitoneal shunt reaches from the anterior ventricles to the peritoneum, so it
will need to be replaced with a longer shunt as the child grows. Daily flushing or access to the
shunt is not needed. This is a closed system. The shunt is not removed due to anemia and
daily assessment of sodium loss is necessary in long time management.
Preterm infants must be protected from chilling during all procedures, because
maintaining warmth is a major concern because of immaturity.
Preterm infants may be hospitalized for an extended time, so parents need to be

encouraged to touch and interact with the infant to begin bonding.
Excess pressure in the alveoli stimulates the ductus arteriosus to remain open,
compromising efficient cardiovascular function.
Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on

expiration (so they require less energy expenditure to reopen).

Positive end-expiratory pressure, like expiratory grunting, prevents alveoli from fully
closing on expiration and reduces the respiratory effort needed for inspiration.
Retinal capillaries can be damaged by excessive oxygen levels. Keeping the Pa02
level under 100 mm Hg helps prevent this.
Preterm infants are able to focus at short distances before they can see well at long
distances. A mobile offers short-distance stimulation.
Newborns use a great many calories in their effort to achieve effective respirations.
Infants who had difficulty establishing respirations need to be assessed for
hypoglycemia.

Hypoglycemia (reduced glucose serum level) usually presents with jitteriness.
Because newborns do not manifest symptoms of a reduced glucose level until it

decreases well below adult levels, a finding below 40 mg/100 mL whole blood is
considered hypoglycemia.
If air is entering the lungs of a newborn, his or her chest muscles are so elastic that the
chest can be seen rising and falling with bag compression.
194. Correct answer: C
Slightly extending the neck best opens the airway (a “sniffing” position). Trendelenburg
is rarely used with newborns because it increases cerebral vascular pressure.
195. Correct answer: A
Congenital rubella (German measles) is strongly associated with hearing disorders.
196. Correct answer: C.
The caloric concentration of formulas used for preterm infants is usually 22 calories per
ounce compared with 20 calories per ounce for a term baby. Glucose water will not
provide the infant with adequate calories. Iron supplementation will depend on
laboratory values.
197. Correct answer: A.
Respiratory distress syndrome (RDS) of the newborn most often occurs in preterm
infants. Pulmonary surfactant is not present in preterm infant. Surfactant is needed to
prevent alveolar collapse upon expiration. RDS rarely occurs in mature infants. Dating
a pregnancy by sonogram and by documenting the level of lecithin in surfactant
obtained from amniotic fluid exceeds that of sphingomyelin by a 2:1 ratio are both
important ways to be certain that an infant is mature enough that RDS is not likely to
occur. RDS does not present as bronchial constriction from room air, wheezing from
excess fluid accumulation, or inspiratory constriction from air
contaminants.
198. Correct answer: A.
Placing the preterm infant in a radiant heat warmer is addressing the diagnosis of
ineffective thermoregulation related to immaturity. Interventions regarding intake would
be appropriate for the diagnosis of risk for imbalanced nutrition. Interventions related to
intravenous fluids would be appropriate for the diagnosis of risk for deficient fluid
volume. Interventions related to oxygenation would be appropriate for the diagnosis of
impaired gas exchange.
199. Correct answer: A, B, C, E.
Nurses can help the nation achieve the 2020 National Health Goals for preterm
births by teaching women the symptoms of preterm labor so that birth can be delayed
until infants reach term. Nurses also need to be prepared for resuscitation at birth of
high-risk infants and to plan developmental care that can help prevent conditions such
as apnea and intraventricular hemorrhage. Actions to prevent maternal hypotension
would not help achieve the 2020 National Health Goals for preterm labor.
200. Correct answer: A, B, C, E
Developmental care for a preterm infant in the neonatal intensive care unit should
include audio stimulation, stop procedures at signs of distress, provide a nest of
blankets for security, and provide consistent care so sleep/wake cycles develop.
Tactile stimulation should be provided by gentle back rubbing or massage. Tickling the
feet would be too harsh for this young patient.
REFERENCE:
1. Maternal & Child Health Nursing, Care of the Childbearing and Childrearing Family 8th
Edition, Chapter 13: The Nursing Role in Promoting Nutritional Health During Pregnancy
pg. 305, JoAnne Silbert-Flagg, Adele Pilitterri
pg. 292-293, JoAnne Silbert-Flagg, Adele Pilitterri

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Week 4

ANSWER & RATIONALE:

2. Correct answer - B - Contains linoleic acid

3. Correct answer - B - Beef

4. Correct answer - B - A woman with a 1-year-old son

5. Correct answer - B - increased fiber intake

6. Correct answer - B - Twenty-five to thirty-five pounds is ideal

7. Correct answer - D - Anticipate needing a vitamin B12 supplement during

9. Correct answer - C Suggest she have a hemoglobin assessment done because

11. Correct answer - C - Eight glasses

13. Correct answer - C - Delay breakfast until midmorning

14. Correct answer - B, C, E - Take prenatal vitamins as prescribed, Ensure a daily

16. Correct answer - A serum creatinine: 1.2 mg/100 mL (106 mol/L)

18. Correct answer - D darkened breast areola

23. Correct answer- A Immunologic activity is decreased during pregnancy

Immunologic competency during pregnancy decreases, probably to prevent a woman's

24. Correct answer- B Lactose may be spilling into the urine

Preschool-age children may need to be assured periodically during pregnancy that a

28. Correct answer - B

29. Correct answer - B

30. Correct answer - A

A step in preparing for parenthood is role-playing or fantasizing about what it will be

31. Correct answer- B. It prevents hyperventilation

32. Correct Answer- D. It stretches perineal muscles.

33. Correct answer - C. It helps relieve backache

Backache is a frequent symptom of pregnancy. Pelvic rocking can help to relieve

34. Correct answer - A) "I'll squeeze my muscles around my vagina, as if I'm

Kegel exercises (tightening perineal muscles) are instrumental in preventing urinary

35. Correct answer - B. Engaging in pushing as an exercise.

The danger of infection is a great concern to hospitals. Maintaining standard

Effleurage is a light massage that helps offer pain relief in labor.

39. Correct answer- A. Important participant in a successful labor.

40. Correct Answer - B. Beginning newborn care.

Expectant parents' classes are designed to teach about pregnancy as well as

42. Correct Answer - B. Birth is viewed as a wellness event.

43. Correct Answer - D. Security of knowing emergency equipment is on hand.

48. Correct answer - C floating

49. Correct answer - D hydrocephalus

50. Correct answer - C on the stomach (prone)

52. Correct answer - C Lie on her side so she is comfortable.

The most common cause of uteroplacental insufficiency is compression of the vena

55. Correct answer- B - “It relieves pressure on the fetal head.”

56. Correct answer - A - feelings of being frightened by the change in contractions

58. Correct answer- D - turning inward to concentrate on body sensations

59. Correct answer- C - head elevated, grasping knees, breathing out

60. Correct answer- C - “I want this baby to be a boy.”

61. Correct answer- D - Measure a daily head circumference

62. Correct answer - B - Meconium-stained amniotic fluid

63. Correct answer - C - 8 to 10 cm

64. Correct answer - B - Check the child frequently for sweating

65. Correct answer - C - white sclera showing above the pupils

66. Correct answer - C - nutrition

67. Correct answer - C - Preventing crust formation on the suture line

69. Correct answer - C - Risk for impaired skin integrity

70. Correct answer - A - Hydramnios

73. Correct answer - B - hydramnios

74. Correct answer - C - Voiding pattern

75. Correct answer - C - Intercostal retractions

76. Correct answer - B - If he breathed spontaneously at birth

77. Correct answer - A - abduction

78. Correct answer - B - One-fourth his total length

79. Correct answer: C. - Follows a light to the midline

80. Correct answer: B - above the knee