INSTRUCTIONS: Read and understand the questions properly and choose the BEST answer among the four answer choices. By using the answer sheet provided. Good luck!
1. After receiving large doses of an ovulatory stimulant such as menotropins (Pergonal), a client comes in for her office visit. Assessment reveals the following: 6-lb (3-kg) weight gain, ascites, and pedal edema. This assessment indicates the client is: a. exhibiting normal signs of an ovulatory stimulant. c. is probably pregnant. b. demonstrating signs of hyperstimulation syndrome. d. is having a reaction to the menotropins. 2. When assessing a postpartum client, Nurse Addison notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should Addison take? a. Apply an ice pack to the perineum. c. Notify the physician. b. Massage the uterus every 15 minutes. d. Reassure the client that such bleeding is normal. 3. A client is experiencing an early postpartum hemorrhage. Which of the following actions would be inappropriate? a. Inserting an indwelling urinary catheter c. Administration of oxytoxics b. Fundal massage d. Pad count 4. Which of the following would be an inappropriate indication of placental detachment? a. An abrupt lengthening of the cord c. Relaxation of the uterus b. An increase in the number of contractions d. Increased vaginal bleeding 5. A client, age 19, goes into labor at 40 weeks' gestation. When assessing the fetal monitor strip, Nurse Arlene sees that the fetal heart rate (FHR) has decreased to 60 beats/minute and that the waveforms sometimes resemble a U and begin and end abruptly. Arlene should interpret this pattern as: a. variable decelerations. c. increased long-term variability. b. decreased short-term variability. d. early decelerations. 6. A primigravid client is admitted to the labor and delivery area, where Nurse Bert evaluates her. Which assessment finding may indicate the need for cesarean delivery? a. Insufficient perineal stretching c. Umbilical cord prolapse b. Rapid, progressive labor d. Fetal prematurity 7. When caring for a client who has had a cesarean section, which of the following actions is not appropriate for Nurse Bert to do? a. Removing the initial dressing for incision inspection b. Monitoring pain status and providing necessary relief c. Supporting self-esteem concerns about delivery d. Assisting with parental newborn bonding 8. Nurse Jenny demonstrates infant bathing to a primiparous client. Which statement by the client indicates a lack of understanding? a. "I'm going to bathe the baby in the kitchen because it's nice and warm there." b. "I have all kinds of pretty, scented soaps and lotions to bathe the baby with." c. "I'll sponge-bathe the baby until the cord area heals." d. "I'll wash the baby's eyes and face first." 9. At 39 weeks' gestation, a pregnant client is admitted to the labor and delivery area in active labor. During the admission interview, she reports that her membranes haven't ruptured. Her history reveals that this is her third pregnancy, she previously experienced a stillbirth at 38 weeks' gestation, and she has one child at home. Which of these findings indicates the need for electronic fetal monitoring (EFM)? a. Third pregnancy c. 39 weeks' gestation b. Intact membranes d. Previous stillbirth 10. The nurse is caring for a woman with a fetus with a brow presentation. Which intervention is appropriate for this client? a. Schedule a cesarean delivery. b. Have the mother stand to push c. Give a tocolytic to stop contractions. d. Put the mother in Trendelenburg's position to lessen pressure on the fetal head. 11. A client is in her second trimester of pregnancy. During her routine prenatal visit, she states that she frequently has calf pain when she walks, which of the following should the nurse assess to assist in identifying the origin of the discomfort? a. Chadwick’s Sign b. Leopold’s Sign c. Homan’s Sign d. Kernig’s Sign 12. A client comes to the hospital at 36 weeks complaining that her "water broke" but denying any contractions. Which of the following assessment data provides the most reliable indication of premature rupture of membranes? a. A dried specimen shows a microscopic fern pattern. b. Fluid from the perineum turns nitrazine paper dark blue. c. No membranes are felt on a sterile vaginal exam d. The client has a visible watery vaginal discharge 13. A client's amniotic fluid is greenish-tinged. The fetal presentation is vertex. Fetal heart rate (FHR) and uterine activity have remained within normal limits. At the time of delivery, the nurse should anticipate the need for: a. An infant laryngoscope and suction catheters c. A transport isolette

Place an indwelling Foley catheter c. flattening of the nipples 25. Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding 17. Which of the following actions is the most appropriate? a. Which of the following interventions would be most appropriate? a. Which of the following signs suggests she is probably pregnant? a. which of the following meals should the nurse recommend to her? a. Instruct her to continue her usual diet. A client in labor is admitted with blood flowing down her legs. Lightening of the areola. Forceps d. Which of the following is true of pregnancy test done on urine samples? a. Assess FHT d. Increased nipple size. Colostrum. Normal newborn b. Mrs. Loss of control 16. Congenital defects c. c. increased size c. She stopped taking oral contraceptives several months ago and now suspects she is pregnant. Emphasize the importance of limiting highly seasoned and salty foods c. The presence of chloasma 24. tingling sensation. corn pudding. 15. The nurse should instruct Mrs. Give her a list of foods to refer her in planning her meals b. Vaginal bleeding and 1+ albuminuria c. Mrs. Severe anemia leading to electrolyte. Stillborn d. Cervical lacerations b. She is being seen by her physician for the first time. Which of the following measures is most appropriate for this situation? a. The baby’s diagnosis at birth should most likely be: a. Infection d. green beans. Swelling of the face c. Severe nausea and vomiting leading to electrolyte. The nurse has just admitted a client in the labor-and-delivery unit who has been diagnosed by her physician as having DM. Omelet with mushrooms. Home pregnancy tests are not accurate. Ask the client about her most recent blood glucose level b. 19. Bleeding c. The nurse encourages limiting the number of vaginal examinations to minimize the client's risk of: a. Prepare client for CS SITUATION: Fernandez has been married for 1 ½ years. Fernandez to notify the physician immediately if which of the following symptoms occur? a. Chicken liver. Fernandez is concerned about eating the proper foods during her pregnancy. engorgement b. metabolic and nutritional imbalances in the absence of other medical problems c. the most important action is to: a. Increased bulk and fluid in the diet d. Regular use of mild laxative c. Limiting excessive weight gain b. 21. as she appears to be nutritionally fit 22. Place a clean underpad on the bed d. Prepare the client for cesarean delivery 18. and clients should be cautioned not to use them. tenderness. Fernandez is treated for syphilis during the first trimester with IM injections of Penicillin. Emergency cesarean set-up 14. Darkening of the areola.b. Fernandez: a. tossed salad dried fruits b. Ham sandwich. Premature newborn 26. Mrs. Enlarged and tender abdomen b. Which of the following symptoms would be considered normal if found while assessing Mrs. Fernandez to list her food intake for the last 3 days d. Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients d. darkening of the areola d. fruit d. metabolic and nutritional imbalances in the absence of other medical problems b. colostrum. A positive test is based on the excretion of chorionic gonadotropin in the urine d. Constipation in pregnancy is best prevented by: a. Frequent micturation d. Fernandez has neumerous common signs and symptoms associated with pregnancy. Mrs. Regular use of Bisacodil (Dulcolax) suppositories 27. Notify the neonatal intensvie care unit that you will be admitting a client with DM d. Which of the following changes is a pregnant woman most likely to notice in her breast? a. Which of the following statements best describes hyperemesis gravidarum? a. In the urine. Prepare oral hypoglycemic medications for administration during labor c. 1+ sugar and urinary frequency . Ask Mrs. Goodell’s sign 20. Listen to fetal heart tones b. They are 100% accurate if done to 10-14 days after fertilization c. Amenorrhea c. Observe the color and consistency of the amniotic fluid. When counseling her to increase her iron intake. tingling sensation. Reposition the mother on her left side c. sliced tomatoes. Increased vaginal discharge b. Hamburger. Frequent micturition d. spinach cup salad 23. Fernandez has a low hemoglobin . Following amniotomy. A positive test is based on increased estrogen excretion in the urine b. Perform vaginal examination b.

and rhythm of feral heart tones d. emotion. 9. Begins accelerated breathing c. The fetus is at 1+ station and left occiput anterior. Tell her to push with each contraction 38. aged 41 is admitted to the labor and delivery unit at 4:00 pm. 2009 b. Monitor temperature every 30 minutes d. The admitting vaginal exam reveals that Mrs. Her contractions are lasting 75 seconds and occurring every 2 minutes. Encourage her to bear down with the contraction b. Which of the following initial assessments would be least important during her admission? a. Is a person who finds sexual fulfillment with a member of his or her own sex. Place fingers on both sides of the uterus approximately 2 inches above the inguinal ligaments. Heterosexual b. Plateau d. Stand at the foot of the client. What is the most appropriate immediate action? a. using her AOG what is her estimate fundal height? a. Her eyes were treated prophylactically with 1% Erythromycin. Onset. Resolution 29. SITUATION: Diane Smith. While taking the history. Face the client and place the palms on each hand on either side of the abdomen c. facing her and place both hands flat on her abdomen b. The nurse instructs her to slow down her breathing and breathe into her cupped hands. Mrs. a. Bisexual d. Becomes irritable and frightened 37. 30 in b. Requests sacral pressure b. Dizziness and finger tingling subsides c. Her membranes ruptured in the car on the way to the hospital. 26. Neonatal Syphilis d. 41. 2. Grasp gently the lower portion of the abdomen just above the symphysis pubis between the thumb and index finger and try to press the thumb and finger d. A client’s AOG is 30 weeks AOG. She is accompanied by her husband. contractions occur every 3 minutes. Herpes Infection b. Feb. Homosexual c. 30 g b. Upon vaginal exam. 2008 a. Type of anesthesia requested for delivery c. Aug 9. Get blood and urine samples b. During the fourth stage of labor. Roll her on her side and tell her to breath slowly b. Chemical conjunctivitis c. a. She is having difficulty coping with her contractions. Excitement b. Smith’s cervix is 6 cm dilated and 100% effaced. until the urge passes c. when her last menstrual period was Nov. Nulligravida c. Smith begins to show symptoms of hyperventilation with her rapid panting during contractions. Show her husband how to apply firm pressure to her sacral area 36. Mrs. Client has never completed a pregnancy. rate. A client asks you how would she know her estimate EDD. strong intensity with a duration of 60 seconds. The nurse knows that Mrs. may or may not have aborted a. Smith is in the transition phase. Which of the following would best indicate effectiveness of this action? a. Feb.Oliguria and Glycosuria d. 41 AOG. Orgasm c. a 26 yrs old primigravida in her 40th week of pregnancy. Aug. What action would take the highest priority at this time? a. 26. Baby girl Smith weighed 6 lbs at birth and received routine care. The urge to push subsides 39. 2009 32. Amnesia between contractions lessens b. the nurse notes the following: gravid . This treatment is done to prevent? a. Do perineal prep and give enema . Swelling of the face and increased vaginal discharge 28. the nurse should include which of the following in a care plan? a. Massage the fundus constantly c. Mrs. Transexual 30. Smith has an uneventful vaginal delivery with a midline episiotomy done under local anesthesia. Requests pain medication d. 2009 d. Check the perineum for crowning c. Opthalmia Neonatorum SITUATION: Guiliana. 33. Maternal vital signs b. is admitted to the labor area. Explain the pushing will cause the cervix to swell and delay dilatation d. Nausea increases d. She has had no antepartal care. 30 m d. para 7. Which of these actions is appropriate during her next contraction? a. membranes ruptures at 10:00 am that day. Primigraida 31. She begins to grunt and says she has to push. Provide direct coaching using chest-abdominal breathing techniques d. 34. Palpate the uterus to check muscle tone every 15 minutes b. Tell her to blow out. Nullipara b. 2009 c. Sight. Primipara d. 30 cm c. the nurse finds her cervix is dilated 9 cm. What is the 3rd maneuver in Leopold’s maneuver? a. Smith is in the transition phase of labor when she: a. which are occurring every 3 minutes. Occurs with physical and psychological stimulation (ex. Location. Monitor BP every 5 minutes 40. sound or thought) that causes parasympathetic nerve stimulation. duration and frequency of contractions 35.

Head compression c. There is evidence of massive internal hemorrhage associated with disseminated intravascular coagulation (DIC). Subsequently. Emphasize that religious values are not important as saving lives c. Repeated hematocrit levels 54. Posterior presentation 49. It is estimated by ultrasound that the fetus is 42 weeks AOG. Guia to care for her episiotomy after discharge. Late decelerations. and both mother and fetus die. Premature rupture of membranes d. BP and pulse d. Uteroplacental insufficiency b. Tightening the perineal sphincter 47. Need to have infant tested for phenylketonuria b. Between contractions. Cord compression d. Closely monitor c. What is the most important assessment at this time? a. Hysterical reaction b. When preparing Mrs. Continue perineal care after toileting until healing occurs d. no variability SITUATION: Jaycee.c. Notify the physician immediately b. Family planning information c. During delivery. Referral to social service SITUATION: Mrs. good variability b. The nurse sees that there are many variable decelerations on a patients fetal monitor strip. the nurse should include as a priority. Remain with him for the next few minutes d. Why would she be considered at risk for development of post partal hemorrhage: a. The patient begins to experience contractions 2-3 minutes apart that last about 45 seconds. Discontinue the sitz bath once she is at home c. Softening of the incision site c. Avoid climbing for at least a few days after discharge SITUATION: The nurse-nurse assigned to the labor and delivery unit of the hospital is required to manage care for a group of clients. She is unresponsive. 50. Allow him privacy and leave him alone b. good variability d. The physician elects to rupture the membranes artificially. Which of the following conditions is suggested by these data? a. cyanosis and severe apprehension. Which of the following reading would be considered normal? a. Maternal blood pressure c. “Try not to feel guilty” . After 30 minutes. Fetal heart rate d. She is very impatient for the birth of this planned child. Cleansing the perineal area b. Jaycee is transferred to the ICU. What is the most important for the nurse to include in the discharge instructions? a. Amniotic fluid is clear. The nurse should? a. the husband joins his wife in the ICU. Determine extent of cervical dilatation 42. The husband remains in the waiting room. Level of consciousness c. instructions to: a. Jaycee experiences sudden onset of dysnea. Early decelerations. Promoting vasodilation d. Continue the sitz bath (Perilight) tid if it provides comfort b. This is followed by a severe chest pain. Ask the father if he wishes to consult with his family 53. Attach monitors to the client d. When caring for the patient during the post-partum period. no variability c. The use of electronic fetal monitoring has enhanced the assessment of fetal response to labor. Guiliana has just been given epidural anesthesia. Chart the rate as a normal response to contractions d. Which action by the nurse is least appropriate at this time? a. episiotomy was performed. Insist that he go to the ICU c. He refuses to talk to the resident and insists he will wait there for the safe delivery of his child. Fetal position 43. Observation of bleeding b. the husband agrees to life-saving measures and transfusions. Early decelerations. the nurse records a fetal heart rate of 100 beats per min. Newborn-care information d. yet the nurse must constantly apply knowledge to interpret the tracing. Guia was admitted to the OB ward in active labor 45. and her physician agrees. Variable decelerations most likely are due to: a. Anesthesia 44. Call the clergymen to speak with the father b. How could the nurse best meet his needs at this time? a. Grand multiparity c. aged 32 is admitted for induction of labor. the client’s status is best evaluated by which of the following? a. Post term delivery b. FHR is stable at 144 bpm. Acute myocardial infarction c. Maternal level of consciousness b. Massive infection 51. stunned. Pulmonary embolus d. Variable decelerations. Ask the attending physician to see him later 52. The physician orders immediate transfusion. but the husband refuses on religious grounds. However the client does not respond to therapy. the nurse encourages sitz bath (Perilight) tid for 15 minutes Sitz bath (Perilight) primarily aids the healing process by: a. 48. Guiliana has a normal spontaneous delivery. Which statement made by the distraught father by the nurse is most appropriate? a. The patient asks to be discharged after 24 hours. After discussion with the clergy and physicians. While awaiting the decision on the use of blood transfusion. “I’m so sorry” b. Clarify the physicians explanation of the situation d. Continue to monitor the fetal heart rate 46.

The client tells Nurse Ann that she wants to know the sex of the fetus as soon as it can be determined. Provides an exchange of nutrients and waste products between the mother and the fetus d. 55. Cushions and protects the fetus c. Maam Jane. 59. “I plan on doing pushups and sit ups when I return home” 57. 100 bpm c. A client asks the nurse about the purpose of the placenta. the fetus develops in the fallopian tubes d. due to the pressure on the bladder by the enlarging uterus. A nurse employed in a prenatal clinic reviews a client’s chart and notes that the physician documented that the client has gynecoid pelvis. estrogen and progesterone are secreted from the fallopian tube b. The student accurately responds by stating that: a. knowing that the sex of the fetus is recognizable as early as week: a. Is a wide pelvis with a short diameter b. 5 b. 20 64. FSH and LH are secreted by the adrenal gland d. a student nurse is assigned to a client in labor. Which of the following would be least helpful to Chloe? a. Engel. FSH and LH are secreted by the corpus luteum of the ovary c. 150 bpm d. a 5 y/o pregnant client on her first trimester comes to the prenatal clinic for her prenatal check up. A client in the class asks the nurse about the function of the fallopian tubes. Nurse Engel determines that the fetal heart rate is normal if which of the following is noted? a. 4 b. Nurse Diane should include in her plan of care the following interventions: a. Eating small. knowing that the fetal heart beat can first be heard with a fetoscope at gestational week: a.c. Stimulate the infant to suck by rubbing the check on the side closest to the nipple b.stimulating hormone (FSH) and leutinizing hormone (LH). Place most of the areola in the infants mouth 56. One of the discomforts during pregnancy is urinary frequency which occurs during the first and the third trimester of pregnancy. Which of the following statement by Chloe would indicate that she would need more teaching before her discharge? a. Connects the umbilical artery to the inferior vena cava b. The nurse plans care for this client knowing that this type of pelvis: a. the instructor asks Engel to describe the fetal circulation. Is the most favorable for labor and birth 60. “I need to increase my calorie intake by 500 calories” d. frequent. “At least you have other children at home” SITUATION: Chloe Rivera a primipara who is trying to breastfeed her infant for the first time. “It must be very difficult for you” d. low fat meals during the day b. is not favorable for labor c. FSH and LH are released from the anterior pituitary gland b. Use nipple rolling to get the nipple erect c. specifically the ductus venosus. 8 d. “I know how and when to bath the infant” b. All of the following are implementations to be taught by the nurse to the pregnant woman except: a. The nurse responds most appropriately by telling the client that the placenta: a. fertilization occurs in the fallopian tubes 58. prevents antibodies and viruses from passing to the fetus b. the fallopian tubes are the passageway for the fetus c. Maintains the body temperature of the fetus 61. 12 63. Maam Jane determines that he understands fetal circulation if the he states that the ductus venosus: a. The nurse tells the client that: a. 6 c. She complains of having nausea and vomiting. FSH and LH stimulate the formation of milk during pregnancy. has a narrow pubic arch d. Connects the umbilical vein to the inferior vena cava 62. A nurse is conducting a prenatal teaching class and is reviewing the functions of the female reproductive system. 16 d. She uses a fetoscope. Nurse Ann prepares to assess a fetal heart beat. Nurse Ann is caring for a client during the prenatal period. 10 c. Limiting fluid intake of the pregnant woman . “I know that if my lochia becomes bright red I will need to rest and call my doctor” c. Use a breast pump to bring the milk forward to the areola d. Melinda. Eating fried foods d. is an opening between the right and the left atria d. 80 bpm b. nurse Engel assesses the fetal heart rate. Nurse Ann responds to the client. Drinking soda/ cola in between meals 66. An instructor is discussing the menstrual cycle with a group of students to describe the follicle. 180 bpm 65. Drinking 2 quarts of fluid per day b. During a prenatal visit. Eating 3 large fatty meals per day c. Connects the pulmonary artery to the aorta c.

” c. 76. and tends to hyperventilate with contractions. c. Pushing 74. What is least likely to cause anxiety and stress at 18 weeks of gestation? a. Wearing perineal pads if necessary 67. c. remembering to ask questions when necessary.” b. measles.” 73. 10 units (IV or IM). Constipation usually occurs during the 2nd and 3rd trimester of pregnancy. Vaccinations aren’t needed if you breastfeed. The nurse is observing for signs of separation of the placenta. Two hours after birth. Making preparation for childbirth classes. and getting adequate rest. Comments that she has never been so happy to be “done with” a pregnancy. Voiding at regular interval d. A woman in labor is becoming less interactive with visitors and staff. Transitional d. Most accidental pregnancies in couples using “natural” family planning methods are related to unprotected intercourse before ovulation. 75. iron supplement 69. Exercising moderately. medication should be taken b. “Oh you still need to have the infant vaccinated against DPT. c. in which maternal location should the nurse anticipate finding the fetal heart tones (FHTs)? a. Secretory endometrium. d. c. d. Change in intra-family relationships. eating a high-carbohydrated diet. Ovum viability. Unfortunately. you should sit upright for 30 minutes following a meal 68. Has voided 75 mL. It is an abnormal finding caused by increased blood volume c. The umbilical cord is shortened. If a fetus is LOA. d. b. and minimizing physical exertion. d.c. Has a moderate amount of lochia rubra. A mother is in the third stage of labor. Prevent endometritis. c. Keeping appointments for prenatal visits. Minimize discomfort from “afterpains”. you didn’t start feeding the infant right away. Above the umbilicus on the right side. b. Latent b. caused by the displacement of the stomach by the enlarging uterus. It is a normal finding caused by decreased GIT motility. c. Mucoid discharge is increased. When explaining to Melissa about her condition. 70. drinking six glasses of milk daily. Melissa who is 28 weeks pregnant complains to nurse Ann about a burning sensation in the chest. b. Feelings of having to “compete” for attention. “The most protection comes from colostrums just after birth. decrease intestinal motility b. Which response demonstrates effective health teaching? a. is given following birth of the fetus and placenta to: a. 72. Below the umbilicus on the left side. hormonal changes d. In discussing “dos and don’ts. It is an abnormal finding which indicates hypertension. b. b. displacement of the intestines c. Taking multivitamins and iron. the nurse determines that further evaluation and possible intervention are needed when the new mother: a. Suppress lactation. . A new mother tells the nurse she is breastfeeding because she can’t stand the thought of the infant being vaccinated. she should include the following except: a. The uterus becomes globular. b. Nurse Ann should tell Melissa that: a. “You can only give temporary protection to the infant against the diseases you have had yourself. Which factor best explains why pregnancy may be achieved by unprotected intercourse during the preovulatory period? a. Spermatozoa viability. “That’s great. These signs occur most commonly during which phase? a. 77. it is a normal finding. you should lie down immediately after meals d. Increasing awareness of the need to be responsible for another individual (the infant). Maintain uterine tone. evidences a malar flush. The nurse explains to a nursing student that oxytocin (Pitocin). Above the umbilicus on the left side. The fundus appears at the introitus. Economic demands of having a child. which include: a. d. d. When Nurse Ann is explaining the causes of constipation to Melissa.” which health-teaching aspect should be emphasized as important for health maintenance during pregnancy? a. Tubal motility. States that her 4-year-old daughter is anxiously waiting to play with the new baby. Anticipatory guidance may be indicated to help expectant parents achieve the normal developmental tasks of the beginning family. c. b. and following the medical/nursing recommendations. and polio before the infant is 6 months old. 71. d.” d. Below the umbilicus on the right side. Active c.

IV antibiotic therapy. b. b. Check for vaginal bleeding and notify the physician of the possibility of abruptio placenta. Which of the following is not an effective nursing intervention for active labor? a. Constipation 79. b. Firm support of the breasts. 89. which of the following describes her present parity? a. which include: a. The mother is being given a trial of labor and was 7 cm dilated and 80% effaced at the last exam. The nurse determines that the client is entering transition when the nurse observes the client: a. What should the nurse do immediately? a. c. Third d.78. Breathing slowly and deeply with contractions. and eager to learn about her labor status. Encourage frequent voiding to prevent a full bladder from slowing the progress of labor. The nurse in labor and delivery is very carefully observing the behavior of a woman who is a primipara at term in active labor. Transitional d. Application of heat for comfort. Encourage relaxation in a sitting position to relieve pressure on leg veins and back pressure. Before administering the medication. First b. euphoric. Dissolved in tea. A woman who is pregnant is advised by the nurse to take an iron supplement: a. with milk every other day. The nurse should know that taking care of physical comfort needs is an important nursing intervention in labor. A woman appears excited. Narcotic dependency d. Lecithin-sphingomyelin (L/S) ratio. maternal and fetal vital signs must be closely monitored. each evening. in addition. Prodromal 88. In an enteric-coated form. Nonstress test c. before each meal. b. b. d. Amniocentesis d. The couple is concerned about what effect the disease may have on the fetus. 82. 0-2-2-2 b. 81. . with a bread product. Yelling at her coach to keep quite during a contraction. Butorphanol is a mixed narcotic agonist-antagonist compound. Comfort and reassure the mother that she is experiencing typical transition contractions. 80. Her behavior supports the nursing assessment that she is progressing through which phase of labor? a. The nurse should: a. One hour before breakfast. Active c. Her husband translates that she has a “terrible pain in her calf”. c. Second c. d. Respiratory rate of 18-22/min b. d. b. During the first stage of labor. Anytime the mother feels totally comfortable. and a spontaneous abortion at 12 weeks. The nurse questions orders for the treatment of mastitis in the breastfeeding woman when which of the following appears on the order sheet? a. 0-1-2-2 d. The best time to observe maternal vital signs is: a. birth of twins at 37 weeks. Inform the doctor that the woman has signs of abruptio placenta. c. Which indicator or test of fetal well-being should the nurse teach the couple to expect most commonly during the rest of the prenatal period? a. d. Immediately before a contraction. Check for rupture of membranes. c. With citrus juice 2 hours after a meal. A woman in labor suddenly screams and shouts in Spanish. Requesting to ambulate in the hallway. Fetal blood gases 84. Immediately after a contraction. c. Encourage hydration by monitoring IV intake and use of ice and lip balm to relieve dry mouth. the woman’s umbilicus is flushed with her abdominal skin. 2-0-2-2 c. 1-0-2-2 85. The nurse is providing nursing care to a mother who is in active labor with her second full-term infant. Assessment findings at 16 weeks of gestation include marked chloasma and secondary pigmented areola. Asking questions about fetal heart rate tracing between contractions. Hypertension c. b. Encourage ambulation to use the force of gravity to aid descent of the fetus and reduce the discomfort of lying in bed. 87. with citrus. A woman who is pregnant has a history that reveals one pregnancy. d. Check the fetal heart rate and notify the physician of the possibility of uterine rupture. Discontinuation of breastfeeding and emptying of the breasts. Her first delivery was by cesarean for cephalopelvic disproportion. During which trimester are these physical changes of pregnancy commonly found? a. 83. The mother complains of sudden sharp abdominal pain. terminated by elective abortion at 10 weeks. According to the TPAL system. Fourth 86. Latent b. the nurse reviews the client’s chart for a history of any contraindication. A woman has been diagnosed with mild preeclampsia. c. A woman in the first stage of labor requests medication for discomfort Butorphanol (Stadol) 1 mg IV is ordered. Between contractions d.

b. Refer her to a psychologist for counseling.” c. The nurse should know that the client understands the information when the client states: a. Active phase c. d. Nursing assessment of a woman in labor notes marked introspection. and there is a constant trickle of blood from the vagina. G4P1 94. A woman who is pregnant calls the labor and delivery unit to speak to the nurse. Administer nasal oxygen at 6 to 8 L. Second stage b. 92. 91. c. including the postpartum unit. don’t worry. G5P1 c. the nurse selects which of the following to describe her present gravidity and parity? a. A nurse on the postpartum unit has been ordered to discharge a mother who delivered the day before. Start an IV. irritability and inability to focus. If the contractions keep coming. “Many people feel frightened at this time. The first action by the nurse should be to: a.” c. “I can’t take it!” These behaviors are characteristic of which stage or phase of labor? a.” b. birth of twin girls at 37 weeks. Analyzing these data. making sure the mother has a car seat in which to take the infant home. Advise her to wait until her bag of water breaks before she comes to the hospital. She states that she is at term with her first infant and wants to know if she should come to the hospital. Her fundus is firm and smooth. where the mother can call to get questions answered. She is currently pregnant. because the site of her bleeding must be located. 1 year ago.” d. b. Immediately before a woman is to give birth. Straighten the woman’s knee and dorsiflex her foot. and the last 3 have been 5 minutes apart. c. Which action should the nurse take immediately? a. During a home visit to a mother who is 2-weeks postpartum and breastfeeding. “Because breastfeeding speeds the healing process after birth. Notify the physician. tingling. “After birth. She complains to the nurse that she cannot catch her breath and that she has pain in her ribs.” 97. Advise her to come immediately to the hospital because she is bleeding and that is abnormal. Turn the woman on her left side to increase placental perfusion. b. d.” d. c. then she should come to the hospital. Third stage . and fluctuating sexual desire? a. The nurse should: a. 93. and a spontaneous abortion at 12 weeks. No resources are needed because the nurse has no obligation. high-vitamin diet. you have to have a period before you can get pregnant again. Transitional phase d. “You’ll do fine. d. offering information about contraception and sexual activity. Recommend high-protein. Referral to a nursing agency for a home visit. “Think of your wife. you’ll forget about being afraid.” 96. and cries. A full set of pamphlets describing maternal and infant care. because the site of her bleeding must be located. the nurse is discussing the resumption of fertility. Advise her that she might be in labor and should try walking around. Reinforce positive feelings about the pregnancy. and her bag of waters has not broken. Notify the physician. She explains that she has had contractions for 12 hours. Administer oxygen by mask to expedite conversion of muscle lactic acid. Ask if she has asthma. G5P2 b. Advise her that she is not in labor if her contractions are not strong and close together after 12 hours. Administer oxytocin according to PRN order. so I don’t need any contraception until I stop breastfeeding. d. Validate normalcy of emotional lability. c. The nurse is concerned that the mother does not understand how to take care of herself and the infant. about five movements per hour. c. Reapply the perineal pad and evaluate the bleeding in 15 minutes. d. A woman’s history reveals a pregnancy at age 15 that was terminated by elective abortion at 10 weeks. c. The mother is not interested in discussing these topics or viewing videotapes. The infant has been moving less than usual. A list of phone numbers. tender breasts. G4P4 d. The most appropriate response the nurse could make would be: a. b. her husband expresses anxiety about staying with her. Administer oxytocin (Pitocin) IM. “Because I am breastfeeding and mu hormones are decreased. d. Which resources would adequately fulfill the nurse’s obligation to prepare the mother for discharge? a. She should lie down and try to sleep. I may need to use a vaginal lubricant when I have sex. I can have sex right away and not worry about infection. 90. “Breastfeeding protects me from pregnancy because it keeps my hormones down. Which nursing intervention should be implemented to reduce a woman’s stress in the first trimester regarding her feelings about mood swings. b. 98. No clots can be expressed when the fundus is massaged. How will she feel if you don’t stay?” b.b. 95. She is diaphoretic. A woman has just delivered her first full-term infant and is showing signs of placental separation. She has some bright-red spots of blood from her vagina. “Once things get going. She starts to cough. A new mother saturates her perineal pad in 15 minutes.

The client is on continuous fetal monitoring. the fetal heart rate has returned to the baseline.99. Document these observations as a normal contraction pattern with early decelerations. d. Suggest to the nurse manager that there is a high probability of a cesarean delivery. The nurse should: a. Leopold maneuvers . Contractions are 4 to 5 minutes apart. Auscultation of fetal heart tones d. Turn the client on her left side and administer nasal oxygen at 6 L flow. Fundal height c. At the peak of the last three contractions. Abdominal ultrasound b. with a range from 116 to 128. Which assessment finding provides data to confirm a pregnancy at 8-weeks gestation? a. c. the fetal heart rate has been 116. At the conclusion of each contraction. b. 100. Call the physician to report an ominous fetal heart rate tracing. The nurse in labor and delivery has assumed care of a woman who is a primipara at 39 2/7 weeks gestation and 5 cm dilation. The nurse noted that the fetal heart rate baseline is 120.