MATERNAL NEWBORN EXAM QUESTIONS WITH CORRECT AND VERIFIED ANSWERS 2023-2024, Exams of Nursing

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MATERNAL NEWBORN EXAM QUESTIONS WITH CORRECT

AND VERIFIED ANSWERS 2023-

1. A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to: A. Eat foods high in calories and fat B. Lie down for at least 20 minutes after meals C. Eat carbohydrates such as cereals, rice, and pasta Correct D. Consume primarily soups and liquids at mealtimes Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong odors should be eliminated from the diet, because food smells often incite nausea. A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective? E. Clonus is present. Incorrect F. Magnesium level is 10 mg/dL. G. Deep tendon reflexes are absent. H. The client experiences diuresis within 24 to 48 hours. Correct Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 mg/dL. Reflexes range from 1+ to 2+ but should not be absent. A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of: I. Vitamin K J. Protamine sulfate Incorrect K. Calcium gluconate (^) Correct L. Naloxone hydrochloride

Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of magnesium at the neuromuscular junction. It should be readily available whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the

antidote in cases of hemorrhage induced by the administration of heparin. Naloxone hydrochloride is administered to treat opioid-induced respiratory depression. A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid? M. Milk N. Steak O. Chicken P. Lima beans Correct Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein. A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. The nurse tells the mother to: Q. Avoid the use of shampoo on the infant’s scalp Incorrect R. Apply oil to the affected area on the infant’s scalp Correct S. Wash the infant’s scalp daily, using only tepid water T. Shampoo the infant’s scalp, avoiding the anterior fontanel area Rationale: Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is characterized by yellow, scaly, oily lesions. It sometimes results when parents do not wash over the anterior fontanel carefully for fear that they will hurt the infant. Treatment includes the application of oil (e.g., mineral oil) to the area to help soften the lesions followed by gentle removal of the scaly lesions with a comb before the head is shampooed. The nurse should teach the mother how to shampoo the scalp and explain that she will not damage the fontanel with normal gentle shampooing. The scalp should be rinsed well to remove all soap, which could cause irritation. A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client’s oxygen saturation on pulse oximetry is 92%. The nurse first: U. Notifies the registered nurse V. Documents the findings W. Instructs the client to take several deep breaths Correct X. Administers 100% oxygen by way of face mask Incorrect Rationale: If the client has been given an epidural opioid, the nurse should monitor the client’s respiratory status closely. If the oxygen saturation falls below 95%, the nurse instructs the client to take several deep breaths to increase the level. Although the finding would be documented, action is required to increase the oxygen saturation level. It is not necessary to contact the registered nurse. If

the deep breaths fail to increase the oxygen saturation level, the registered nurse is notified and may prescribe oxygen. A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. The nurse tells the client: Y. To perform a vaginal douche Z. To come to the clinic for a checkup Incorrect AA. That this is an indication of an infection AB. That this is a normal postpartum occurrence Correct Rationale: For the first 3 days following childbirth, lochia consists almost entirely of blood, with small particles of decidua and mucus, and is called lochia rubra because of its red color. The amount of blood decreases by about the fourth day, and which time the lochia changes from red to pink or brown-tinged; this stage is called lochia serosa. By about the 11th day, the erythrocyte component of lochia has decreased and the discharge becomes white or cream-colored. This final stage is known as lochia alba. Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria. It is present in most women until the third week after childbirth but may persist for as long as 6 weeks. Lochia alba is a normal finding during the postpartum course, and no intervention is required, so the other options are incorrect. A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse tells the client that: AC. A rubella vaccine must be administered immediately Incorrect AD. A rubella vaccine must be administered after childbirth Correct AE. She will not contract rubella if she is exposed to the disease AF. She does not need to be concerned about being exposed to rubella Rationale: A prenatal rubella antibody screen is performed in every pregnant woman to determine whether she is immune to rubella, which can cause serious fetal anomalies. If she is not immune, rubella vaccine is offered after childbirth to keep her from contracting rubella during subsequent pregnancies. The vaccine is a live virus, and defects might occur in the fetus if the vaccine were administered during pregnancy or if the mother were to become pregnant soon after it was administered. Administering a rubella vaccine immediately places the fetus at risk. Telling the client that she does not need to be concerned about being exposed to rubella is incorrect, because the possibility of exposure, which could be harmful to the fetus, does exist. A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client’s temperature and notes that it is 38 ° C (100.4° F). The most appropriate nursing action would be to: AG. Notify the registered nurse AH. Recheck the temperature in 1 hour Incorrect

AI. Encourage the intake of oral fluids Correct AJ. Tell the client that antibiotics will be prescribed Rationale: A temperature of 38 ° C (100.4° F) is common during the 24 hours after childbirth. It may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for longer than 24 hours or exceeds 38 ° C, infection is a possibility, and the fever is reported to the registered nurse. Because the client delivered her baby just 12 hours ago, the most appropriate nursing action is to encourage the intake of oral fluids. A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse: AK. Has the client void before the uterine assessment AL. Tells the woman to bear down during fundal message AM. Simultaneously provides pressure over the lower uterine segment Correct AN. Asks the client to take slow, deep breaths during fundal assessment Incorrect Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine inversion. A nurse is monitoring a client after vaginal delivery notes a constant trickle of bright-red blood from the client’s vagina. In which order would the nurse perform the following actions? Assign the number 1 to the first action and the number 5 to the last. Incorrect A. Assessing the client’s fundus B. Checking the client’s vital signs C. Changing the client’s peripads D. Contacting the physician E. Documenting the findings The correct order is: F. Assessing the client’s fundus G. Checking the client’s vital signs H. Contacting the physician I. Changing the client’s peripads J. Documenting the findings Rationale: A constant trickle of bright-red blood may indicate abnormal bleeding and requires immediate attention. The nurse first checks the client’s fundus. Once it has been determined that the

bleeding is not the result of a boggy uterus, the nurse should check the vital signs to determine whether the blood loss has compromised the client’s condition. Next the nurse would contact the physician and report the bleeding, fundal height and condition, and vital signs. After contacting the physician the nurse would attend to the client’s comfort needs, including, in this case, frequent changes of peripads. The nurse would document the findings once assessment and implementation had been completed and the client’s condition was considered stable. A nonstress test is performed, and the physician documents “accelerations lasting less than 15 seconds throughout fetal movement.” The nurse interprets these findings as: A. Normal B. Reactive Incorrect C. Nonreactive Correct D. Inconclusive Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period. A nonreactive test is an abnormal test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40-minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart rate recording. A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate? E. “I know how you feel.” F. “This must be hard for you.” Correct G. “Now you have an angel in heaven.” H. “You’re young. You can have other children.” Rationale: Therapeutic communication helps the mother, father, and other family members express their feelings and emotions. “This must be hard for you” is a caring and empathetic response, focused on feelings and encouraging communication. The other options are nontherapeutic and may devalue the family members' feelings. A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat? I. Water and pretzels J. Low-fat cheese omelet Incorrect K. Nachos and fried chicken L. Apple and whole-grain toast Correct

Rationale: The pregnant woman needs a well-balanced diet high in iron and protein and adequate in calories for weight gain. Iron supplements that are taken during pregnancy tend to cause constipation. Constipation causes the client to strain during defecation, inadvertently performing the Valsalva maneuver, which causes blood to rush to the heart and overload the cardiac system. The pregnant woman, then, should increase her intake of fluids and fiber. An unlimited intake of sodium (pretzels, cheese, nachos) could cause overload of the circulating blood volume and contribute to the cardiac condition. A nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which of the following clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)? Select all that apply. M. A client with septicemia N. A client with mild preeclampsia O. A client with diabetes mellitus who delivered a 10-lb baby Incorrect P. A client who had a cesarean section because of abruptio placentae Correct Q. A client who delivered 12 hours ago and has lost 475 mL of blood Rationale: DIC is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII. In the obstetric population, DIC occurs as a result of abruptio placentae, amniotic fluid embolism, dead fetus syndrome (in which the fetus has died but is retained in utero for at least 6 weeks), severe preeclampsia, septicemia, cardiopulmonary arrest, or hemorrhage. A loss of 475 mL is not considered hemorrhage .A mild case of preeclampsia is not a risk factor for DIC. It is not unusual for a client with diabetes mellitus to deliver a large baby, and this condition is unrelated to DIC. A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table, and the nurse positions the client: R. Prone S. In a semi-Fowler position T. In the Trendelenburg position U. Supine with a wedge under the right hip Correct Rationale: The pregnant client is positioned so that the uterus is displaced laterally to prevent compression of the inferior vena cava, which causes decreased placental perfusion. This is accomplished by placing a wedge under the hip. Positioning for abdominal surgery necessitates a supine position. The Trendelenburg position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler or prone position is not practical for this type of abdominal surgery. A nurse is preparing to perform the Leopold maneuvers on a pregnant client. The nurse should first: V. Locate the fetal heart tone Correct Incorrect

Rationale: Gently massaging the breasts during breast feeding will help empty the breasts. The mother should not avoid breastfeeding during the night; instead, she should breastfeed every 2 hours or pump the breasts. The nurse instructs the woman to apply ice packs, not heat packs, to the breasts between feedings to reduce swelling. It may be helpful for the mother to stand in a warm shower just before feeding to foster relaxation and letdown. W. Position the woman supine X. Ask the client to empty her bladder Correct Y. Count the fetal heart rate for 1 minute Rationale: In preparation for the Leopold maneuvers, the nurse first asks the woman to empty her bladder, which will contribute to the woman’s comfort during the examination. Next the nurse positions the client supine with a wedge placed under the hip to displace the uterus. Often the Leopold maneuvers are performed to aid the examiner in locating the fetal heart tones. Counting the fetal heart rate is not associated with Leopold maneuvers. A nurse is assessing the lochia of a client who delivered a viable newborn 1 hour ago. Which type of lochia would the nurse expect to note at this time? Z. Lochia alba AA. Lochial clots AB. Lochia serosa AC. Dark-red lochia rubra Rationale: When the perineum is assessed, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (1 to 4 hours after birth) is dark red (rubra). This is an expected occurrence until the third day after delivery. Then, from days 4 through 10, the discharge is brownish pink (serosa). Alba is a white discharge that occurs on days 11 to 14. A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to: AD. Take a cool shower just before breastfeeding AE. Avoid breastfeeding during the night time hours to ensure adequate rest AF. Gently massage the breasts during breastfeeding to help empty the breasts Correct AG.Apply heat packs to the breasts for 15 to 20 minutes between feedings to reduce swelling When, during the normal postpartum course, would the nurse expect to note the fundal assessment shown in the figure? Incorrect Correct

AH. 4 days after delivery Incorrect AI. The day after delivery AJ. Immediately after delivery Correct AK. When the client’s bladder is full Rationale: Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. Location of the fundus above the umbilicus may indicate the presence of blood clots in the uterus that need to be expelled by means of fundal massage. A fundus that is not located in the midline may indicate a full bladder. The fundus descends 1 or 2 cm every 24 hours, so it should be located farther below the umbilicus with every succeeding postpartum day. A nurse assists the primary healthcare provider in performing an amniotomy on a client in labor. In which order should the nurse perform the following actions after the amniotomy? Assign the number 1 to the first action and the number 5 to the last action. Incorrect A. Determining the fetal heart rate B. Taking the client’s temperature, pulse, and blood pressure C. Noting the quantity, color, and odor of the amniotic fluid D. Replacing soiled underpads from beneath the client’s buttocks E. Planning evaluation of the client for signs and symptoms of infection The correct order is: F. Determining the fetal heart rate G. Noting the quantity, color, and odor of the amniotic fluid H. Taking the client’s temperature, pulse, and blood pressure I. Replacing soiled underpads from beneath the client’s buttocks J. Planning evaluation of the client for signs and symptoms of infection Rationale: After amniotomy, the fetal heart rate is assessed for at least 1 full minute for changes associated with prolapse or compression of the umbilical cord and the characteristics of the fluid are noted as an indicator of fetal risk. After the fluid has been assessed, the next concern is evaluation of the maternal vital signs. The client’s comfort (i.e., the soiled underpads) is considered next. With the ruptured membranes comes an increased risk for maternal infection. For this reason, the client is frequently assessed for signs and symptoms of infection throughout the course of labor. A licensed practical nurse (LPN) is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the LPN to contact the registered nurse? A. Maternal fatigue B. Clear amniotic fluid C. Strong-smelling amniotic fluid Correct D. A fetal heart rate of 140 beats/min

Rationale: Signs associated with intrauterine infection includes fetal tachycardia (rising baseline or faster than 160 beats/min, a maternal fever (38° C or 100.4° F), foul or strong-smelling amniotic fluid, or cloudy or yellow amniotic fluid. The normal fetal heart rate is 110 to 160 beats/min. Clear amniotic fluid is normal. Maternal fatigue normally occurs during labor. A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in the care of this client? E. Providing pain relief Correct F. Preparing the client for amniotomy G. Monitoring the oxytocin (Pitocin) infusion closely Incorrect H. Encouraging the client to ambulate every 30 minutes Rationale: Management of hypertonic uterine dysfunction depends on the cause. Relief of pain is the primary intervention in promoting a normal labor pattern. Therapeutic management of hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate labor progression. The client with hypertonic uterine dysfunction would be encouraged to rest, not to ambulate every 30 minutes. A nurse is preparing to care for a client experiencing dystocia. To which of the following interventions does the nurse give priority? I. Monitoring fetal status Correct J. Providing comfort measures K. Changing the client’s position L. Informing the client’s partner of the progress of the labor Rationale: The priority intervention is monitoring fetal status. Once this is done, the nurse provides maternal comfort measures, including positioning the client, because this may decrease anxiety and hasten the progression of labor. Keeping the client’s partner informed of the progress of the labor is also an important aspect of client care during labor but is not an immediate priority. A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity: M. At any time Incorrect N. In 2 to 4 weeks Correct O. After the 6-week physician checkup P. When her normal menstrual period has resumed Rationale: Usually a woman may engage safely in sexual intercourse during the second to fourth week after childbirth as long as she experiences no discomfort during intercourse. The other options are incorrect. Engaging in intercourse too early in the postpartum course could result in further injury

Rationale: More than one medication may be used to prevent the growth of resistant organisms in the pregnant woman with tuberculosis. Treatment must be continued for a prolonged period. The preferred treatment for the pregnant woman is isoniazid plus rifampin for a total of 9 months. Ethambutol is added initially if drug resistance is suspected. Pyridoxine (vitamin B 6 ) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing of the infant should be repeated at 3 months, and isoniazid may be stopped if the result remains negative. If the result is positive, the infant should receive isoniazid for at least 6 months. If the mother’s sputum is free of organisms, the infant does not need to be isolated from the mother while in the hospital. to perineal tissues damaged during childbirth. It usually takes about 3 weeks for an episiotomy to heal; therefore, it is unnecessary to wait 6 weeks. Menstruation may not resume in a postpartum woman for 12 weeks to 6 months after childbirth. A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that: Q. The infant must be isolated from the mother after birth R. Maternal medication will not be started until the baby is born S. The infant will require medication therapy immediately after birth T. The mother may need to take isoniazid (INH), pyrazinamide, and rifampin(Rifadin) for a total of 9 months Correct A nurse midwife performs an assessment of a pregnant client and documents the station of the fetal head as it is reflected in the figure below. The nurse reviews the assessment findings and determines that the fetal presenting part is: U. At +1 station V. At – 1 station W. At zero station Correct X. Stationed at the bottom of the coccyx Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. It is measured in centimeters and is noted as a negative number above the line, a positive number below the line, and zero at the line. A nurse performing an assessment of a pregnant client is preparing to take the client’s blood pressure. The nurse positions the client: Y. Supine, on the left side Z. Supine, on the right side

AA. Lying down with the arm in a horizontal position at heart level AB. In a sitting position with the arm in a horizontal position at heart level Correct Rationale: Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. Blood pressure should be obtained with the client sitting position and the arm supported in a horizontal position at heart level. Supine on the right or left side and lying down with the arm in a horizontal position at heart level are both incorrect and could cause physiological stress that would affect the blood pressure. A nurse is performing an assessment of a client who is at 20 weeks of gestation. The nurse asks the client to void, then measures the fundal height in centimeters. Which approximate measurement does the nurse expect to see? AC. 20 cm Correct AD. 28 cm AE. 32 cm AF. 40 cm Rationale: During the second and third trimesters (weeks 18 to 30), the height of the fundus in centimeters is approximately the same as the number of weeks of gestation, if the woman’s bladder is empty at the time of measurement. If the fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause for the unexpectedly large uterine size. An unexpected increase in uterine size may indicate that the estimated date of delivery is incorrect and the pregnancy is more advanced than previously thought. If the estimated date of delivery is correct, more than one fetus may be present. A nurse teaching a pregnant client about the expectations and complications of pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions: AG. Indicate that labor has started AH. Must be reported to the physician AI. Are a common occurrence of pregnancy Correct AJ. Necessitate bed rest for the remainder of the pregnancy Rationale: Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions are a normal finding experienced by many pregnant women during pregnancy, the other options represent inaccurate assumptions and an unnecessary intervention. A nurse is assisting a physician in performing a physical examination of a client who has just been told that she is pregnant. The physician tells the nurse that the Goodell sign is present. The nurse understands that this sign is indicative of: AK. The presence of fetal movement

AL. A high risk for spontaneous abortion AM. An increase in vascularity and hyptertrophy of the cervix Correct AN. The presence of human chorionic gonadotropin (hCG) in the urine Rationale: In the early weeks of pregnancy, the cervix becomes more vascular and slightly hypertrophic; this is referred to as the Goodell sign. The edematous appearance of the cervix will be noted during pelvic examination by the examiner. hCG is noted in maternal urine in a urine pregnancy test. The Goodell sign does not indicate the presence of fetal movement or a risk for spontaneous abortion. A nurse performing an assessment of a pregnant client prepares to auscultate the fetal heart sounds, using a Doppler ultrasound stethoscope. By which week of gestation are fetal heart sounds audible with the use of this device? AO. 4 weeks AP. 6 weeks AQ. 8 weeks AR. 12 weeks (^) Correct Rationale: Fetal heart sounds can be heard with the use of a Doppler ultrasound stethoscope by 12 weeks of gestation and can be heard with a fetoscope by 18 to 20 weeks of gestation. The gestational times of 4, 6, and 8 weeks are incorrect because the fetal heart sounds cannot be heard with a Doppler ultrasound stethoscope this early in pregnancy. A nurse is assisting a midwife who is assessing a client for ballottement. Which action does the nurse anticipate that the midwife will employ to test for ballottement? AS. Assessing the cervix for thinning AT. Auscultating for fetal heart sounds AU. Performing a sudden tap on the cervix Correct AV. Palpating the abdomen for fetal movement Rationale: Near midpregnancy, a sudden tap on the cervix during a vaginal exam may cause the fetus to rise in the amniotic fluid and then rebound to its original position, a phenomenon known as ballottement. The examiner feels the rebound when the fetus falls back down. Ballottement has no relationship to cervical assessment findings, fetal heart sounds, or external palpation of fetal movement. After the delivery of a newborn, a nurse performs an initial assessment and determines that the Apgar score is 8. The nurse interprets this score as indicating that the infant: AW. Requires vigorous resuscitation AX. Is adjusting well to extrauterine life Correct

AY. Requires some resuscitative intervention AZ. Is having difficulty adjusting to extrauterine life Rationale: One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges from 0 to 10. A score of 7 to 10 indicates that the infant should have no difficulty adjusting to extrauterine life. A score of 4 to 6 indicates moderate difficulty that may require some resuscitative intervention. A score of 0 to 3 indicates severe distress and the need for vigorous resuscitation. A nurse teaching a pregnant client about measures to strengthen the pelvic floor instructs the client to: BA. Walk half a mile 3 times a week BB. Drink at least 2 quarts of fluid per day BC. Perform Kegel exercises in 10 repetitions, three times per day Correct BD. Perform pelvic tilt exercises in 10 repetitions, three times per day Rationale: Kegel exercises strengthen the pelvic floor (pubococcygeal muscle). The increased tone of this muscle is beneficial during pregnancy and afterward. Walking is a general healthy measure but does not specifically strengthen the pelvic floor. Fluid intake is an indicator of hydration, which is important for normal physiological function. Pelvic tilt exercises ease backache. A nurse is caring for a client in labor who has sickle cell anemia. Which intervention does the nurse implement to help prevent a sickling crisis? BE. Maintaining strict asepsis BF. Monitoring the maternal vital signs BG. Administering oxygen as prescribed Correct BH. Placing a wedge under the client’s hip Rationale: Oxygen is administered continuously during labor to the client with sickle cell anemia to help ensure adequate oxygenation and prevent sickling. Maintaining asepsis, monitoring vital signs, and placing a wedge under the hip are interventions required of all clients, with or without sickle cell anemia. Although they are appropriate nursing interventions, they are not used to prevent sickling crisis. A nurse teaches a new mother how to perform umbilical cord care and how to recognize the signs of a cord infection. Which of the following findings does the nurse tell the mother is an indicator of infection? BI. A darkened, drying cord BJ. Edema at the base of the cord Correct BK. A brownish-black cord with pinkness around the base

BL. A brownish-black cord with some moistness at the base Rationale: Symptoms of a cord infection include purulent drainage or redness or edema at the base of the cord. If symptoms of infection occur, the mother should be instructed to notify the healthcare provider, because antibiotics are necessary. The cord begins to dry shortly after birth. It turns a brownish black within 2 to 3 days and falls off within 10 to 14 days. A licensed practical nurse is performing assessments every 30 minutes on a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings would prompt the LPN to contact the registered nurse? BM. Urine output of 20 mL BN. Deep tendon reflexes of 2+ BO. Respirations of 10 breaths/min Correct BP. Fetal heart tone of 116 beats/min Rationale: Magnesium sulfate depresses the respiratory rate. If the rate is 12 breaths/min or slower, continuation of the medication must be reassessed. Acceptable urine output is 30 mL/hr or more. Urine output of 20 mL in 30 minutes is adequate. Deep tendon reflexes of 2+ are normal. The fetal heart tone is within normal limits for a resting fetus. A licensed practical nurse (LPN) is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the LPN to contact the registered nurse? BQ. Complaint of feeling hot BR. Enlargement of the breasts BS. Diaphoresis and tachycardia Correct BT. Periods of fetal movement followed by quiet periods Rationale: Disseminated intravascular coagulation (DIC) is a complication of preeclampsia. Physical examination reveals unusual bleeding, spontaneous bleeding from the woman’s gums or nose, or the presence of petechiae around a blood pressure cuff placed on the woman’s arm. Excessive bleeding may occur from a site of slight trauma such as a venipuncture site, an intramuscular or subcutaneous injection site, a nick sustained during shaving of the perineum or abdomen, or injury inflicted during insertion of a urinary catheter. Tachycardia and diaphoresis indicate impending shock as a result of blood loss. Breast enlargement, fetal movement with rest periods, and complaints of feeling hot are all normal occurrences in the last trimester of pregnancy. A pregnant client is seen in the clinic for the first time. This is the client’s first pregnancy, and the client tells the nurse that she has diabetes mellitus. The nurse provides instruction to the client regarding health care during pregnancy. Which statements by the client indicate the need for further instruction? Select all that apply. BU. “I need to follow the prescribed diabetic diet.”

BV. “I need to limit my exercise while I’m pregnant.” Correct BW. “I need to report signs of infection to my physician.” BX. “My insulin requirements may change while I’m pregnant.” BY. “I’ll come back for a prenatal visit every month during my first trimester.” Correct Rationale: Exercise is necessary for the pregnant diabetic client to help maintain control of her diabetes. Concepts related to the timing of exercise, control of food intake, and insulin around the time of exercise should be reviewed with the client. The prenatal visit schedule for clients with a history of diabetes mellitus is more frequent than the normal prenatal course. In the first and second trimesters, prenatal visits should be scheduled every 1 to 2 weeks. The remaining statements are correct, representing important information for the pregnant client with diabetes mellitus. During a prenatal visit, the nurse notes that an adolescent pregnant client with diabetes mellitus has lost 10 lb during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, “I don’t eat regular meals.” The appropriate response is: BZ. “Weight loss could hurt your baby.” CA. “Let’s make a list of what you’re eating.” Correct CB. “I’ll have the doctor review your diet history.” CC. “It’s all right to gain weight during pregnancy.” Rationale: It is important for the nurse to obtain additional information from the client. The nurse is using the therapeutic communication tool of validation and clarification to obtain more information about the client’s diet. The other options will block communication. The statement regarding harm to the baby devalues the client and shows disapproval. Informing the physician is avoiding the issue, and telling the client that it is all right to gain weight provides false reassurance. A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately: CD. Lie down CE. Contact the physician CF. Drink 8 oz of diet soda CG. Check her blood glucose level Correct Rationale: If signs and symptoms of hypoglycemia occur, the client should immediately check the blood glucose level. The results will determine the required treatment. If the blood glucose is less than 60 mg/dL, the client should immediately eat or drink something that contains 10 to 15 g of simple carbohydrate. Examples include a half cup (4 oz) of unsweetened fruit juice, a half cup (4 oz) of regular (not diet) soda, 5 or 6 LifeSavers candies, 1 tablespoon of honey or corn (Karo) syrup; 1 cup (8 oz) of milk; or 2 or 3 glucose tablets. The blood glucose is tested again 15 minutes after

intake of the carbohydrate. If the glucose level is still below 60 mg/dL, the client should eat or drink another 10 to 15 g of simple carbohydrate. The blood glucose is tested once again 15 minutes after intake of the carbohydrate, and the physician is notified immediately if it is still below 60 mg/dL, because further intervention is necessary. Lying down will not increase the blood glucose level and will delay necessary intervention. A nurse is reviewing the criteria for early discharge of a newborn infant. Which of the following, if noted in the infant, would indicate that the criteria for early discharge have been met? Select all that apply. CH. The infant has urinated. CI. The infant has passed 1 stool. CJ. Vital signs are documented as normal. Correct CK. The infant has completed one successful feeding. CL. The infant has shown no evidence of jaundice in the first 6 hours of life. Rationale: Criteria for early discharge in the newborn infant include no evidence of significant jaundice in the 24 hours after birth. The infant should have urinated and passed at least one stool, completed at least two successful feedings, and have normal vital signs for at least 12 hours. A client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a persistent nonreassuring fetal heart rate pattern is present. The appropriate nursing action in this situation is: CM. Preparing to induce labor CN. Turning the client on her left side CO. Preparing the client for a cesarean delivery Correct CP. Continuing to monitor the fetal heart rate pattern Rationale: Dystocia, failure of labor to progress, and a persistent nonreassuring fetal heart rate pattern are indications of the need for cesarean delivery. Induction of labor is not indicated in this case because the client has been in labor for 12 hours without progress and signs of fetal distress are present. Placing the client on her left side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava. However, this intervention would be implemented with any client in labor, not specifically with a client experiencing dystocia. Monitoring the fetal heart rate pattern is also appropriate for any client in labor and is not the appropriate nursing action in this situation. Immediately after the delivery of a newborn infant, the nurse prepares to deliver the placenta. The nurse initially: CQ. Pulls on the placenta as it enters the vaginal canal Correct Correct

CR. Pulls on the umbilical cord as the mother bears down CS. Applies strong traction on the cord when signs of separation occur CT. Instructs the mother to push when signs of separation have occurred Correct Rationale: To assist in the delivery of the placenta, the woman is instructed to push when signs of separation have occurred. If possible, the placenta should be expelled by means of maternal effort during a uterine contraction. Alternate compression and elevation of the fundus plus minimal controlled traction on the umbilical cord may be used to facilitate delivery of the placenta and amniotic membranes. A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is experiencing excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which assessment findings are indicative of complete uterine rupture? Select all that apply. CU. Fetal bradycardia Correct CV. Maternal tachypnea Correct CW. Excessive vaginal bleeding CX. Increased uterine contractions CY. Maternal complaint of sudden sharp abdominal pain Correct Rationale: In a complete uterine rupture, the woman may complain of sudden sharp, shooting abdominal pain and may state that she felt like “something gave way.” If she is in labor, her contractions will cease and the pain is relieved. In a complete uterine rupture, bleeding will be concealed, and therefore the client will exhibit signs of hypovolemic shock resulting from hemorrhage (hypotension, tachypnea, pallor, and cool, clammy skin). The fetus is the most common indicator of uterine rupture. Such changes in the fetal heart rate as late or variable decelerations, a decrease in baseline variability, or an increase or decrease in rate are commonly exhibited during a rupture. If the placenta separates, the fetal heart rate will be absent and fetal parts may be palpated through the abdomen. A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes, the client has a temperature of 100 ° F, and the client reports that she last ate 2 hours ago. The client also states that “everything happened so fast" and that she has had no preparation for the cesarean delivery. Which of the following actions should the nurse take first? CZ. Continuing to time the contractions DA. Beginning teaching about the cesarean delivery DB. Reporting the time of last food intake to the physician Correct DC. Giving acetaminophen (Tylenol) to lower the client’s temperature

Rationale: The nurse should report the time of last food intake to the physician. General anesthesia may be used for an emergency cesarean delivery. Gastric contents are very acidic and can produce chemical pneumonitis if aspirated. Continued monitoring and client instruction are correct nursing actions but are of lesser priority than reporting the time of last oral intake. Giving acetaminophen (Tylenol) is incorrect because it requires a physician’s prescription. A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician’s office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. The nurse immediately: DD. Positions the client on her side Correct DE. Calls the physician to see the client DF. Places a cool washcloth on the client’s forehead DG. Checks the client’s blood pressure, pulse, and respirations Rationale: Supine hypotension may occur during the second and third trimesters when a woman is placed in the lithotomy position, in which the weight of the abdominal contents may compress the vena cava and aorta, causing a drop in blood pressure and a feeling of faintness. Other signs and symptoms include pallor, dizziness, breathlessness, tachycardia, nausea, clammy (damp, cool) skin, and sweating. The nurse would immediately position the woman on her side. Placing a cool washcloth on the client’s forehead or checking the client’s vital signs will not eliminate this problem. The physician must be contacted if the symptoms do not subside, but this would not be the immediate action. A nurse is caring for a client in precipitous labor. In which position does the nurse place the client? DH. DI. DJ. DK. Correct Rationale: Priority nursing care of the woman in precipitous labor includes promotion of fetal oxygenation and maternal comfort. A side-lying (lateral Sims) position enhances placental blood flow and reduces the effects of aortocaval compression. Added benefits of this position are slowing of rapid fetal descent and minimization of perineal tearing. The lateral Sims position also places less stress on the perineum. Because the upper leg is supported, the perineum can be better visualized as well. The other options are not the most optimal positions. A nurse is caring for a postpartum client who had a low-lying placenta. The nurse assesses the client most closely for: DL. Seizures DM. Infection

DN. Hemorrhage Correct DO. A vaginal hematoma Rationale: The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, making this site more prone to bleeding. The client with a low-lying placenta is not at greater risk for seizures, postpartum infection, or vaginal hematoma. A nurse working in a prenatal clinic is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify as being at risk for abruptio placentae? Select all that apply. DP. A primipara DQ. A 36- year-old DR. A hypertensive client Correct DS. A pack-a-day smoker (^) Correct DT. A client who exercises regularly Rationale: The cause of abruptio placentae is unknown, but several risk factors have been identified. Maternal use of cocaine, which causes vasoconstriction of the endometrial arteries, is a leading cause. Other risk factors include hypertension, cigarette smoking, abdominal trauma, and a history of previous premature separation of the placenta. A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, the appropriate nursing action is: DU. Contacting the physician Correct DV. Documenting the findings DW. Continuing to monitor the client DX. Reassuring the client and her partner that labor is progressing normally Rationale: Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, persistently decreased variability, or an irregular FHR. The normal FHR is 110 to 160 beats/min. Therefore, because the finding is abnormal, the physician must be contacted. Continuing to monitor the client delays necessary intervention. Reassuring the client that labor is progressing normally is incorrect. The nurse would document the data, actions taken, and the client’s response, but, of the options provided, contacting the physician is the most appropriate. A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. The nurse tells the client that: DY. The exercises should be delayed for 1 month to allow healing

Rationale: Postpartum exercises may be started soon after birth, although the woman should be encouraged to begin with simple exercises and gradually progress to more strenuous ones. Abdominal exercises are postponed until approximately 4 weeks after a cesarean birth. Kegel exercises (alternated contraction and relaxation of the muscles of the perineal area) are extremely important in strengthening the muscle tone of the perineal area after vaginal birth. Kegel exercises help restore the muscle tone that is often lost as pelvic tissues are stretched and torn during pregnancy and birth. Women who maintain muscle strength may benefit years later, experiencing continued urinary continence. A nurse is assessing the respiratory rate of a newborn. Which finding would the nurse document as normal? DZ. Performing such exercises in the postpartum period may result in stress urinary incontinence EA. Alternating contraction and relaxation of the muscles of the perineal area should be practiced Correct EB. Abdominal exercises will be started while the client is in the hospital as a means of evaluating tolerance EC. 20 breaths/min ED. 25 breaths/min EE. 50 breaths/min Correct EF. 70 breaths/min Rationale: The normal respiratory rate for a newborn infant is 30 to 60 breaths/min. All of the other options are outside the normal range. A licensed practical nurse is monitoring a newborn who has been admitted to the nursery. The LPN notes that the anterior fontanel measures 4 cm across and bulges when the infant is at rest. In light of this observation, what is the most appropriate nursing action? EG. Notifying the registered nurse Correct EH. Documenting the finding EI. Assessing the infant’s blood pressure EJ. Reassessing the fontanel in 30 minutes Rationale: The anterior fontanel, which is diamond shaped, is located on the top of the head. It should be flat and soft. It measures 1 to 4 cm, varying as a result of molding and individual differences. It normally closes by 12 to 18 months of age. Although the anterior fontanel may bulge slightly when the infant cries, bulging at rest may indicate increased intracranial pressure. If this is suspected, the registered nurse is notified. The other options would delay necessary treatment.

Rationale: Gastroschisis is the herniation of the bowel through a defect in the abdominal wall to the right of the umbilical cord. The bowel is located outside the abdominal cavity and is not covered with a sac. Inside the abdominal cavity, under the dermis or skin, is the description of an umbilical hernia. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane is the description of an omphalocele. A nurse is assessing a newborn infant with a diagnosis of gastroschisis. The nurse expects to note that the bowel is located: EK. Inside the abdominal cavity, under the skin EL. Inside the abdominal cavity, under the dermis EM. Outside the abdominal cavity and not covered with a sac Correct EN. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane A nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia (CDH). Which assessment finding would the nurse specifically expect to note in the newborn? EO. Excessive oral secretions EP. Bowel sounds heard over the chest Correct EQ. Hiccupping and spitting up after a meal ER. Coughing, wheezing, and short periods of apnea Rationale: Clinical manifestations associated with CDH include diminished or an absence of breath sounds on the affected side, bowel sounds heard over the chest, cardiac sounds heard on the right side of the chest, and respiratory distress, including dyspnea, cyanosis, nasal flaring, tachypnea, retractions, and a scaphoid abdomen, that develops soon after birth. The presence of excessive oral secretions is a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Hiccups and spitting up after meals are clinical manifestations of gastroesophageal reflux. A hiatal hernia may be evidenced by coughing, wheezing, and short periods of apnea. A woman being seen in the prenatal clinic and complains of morning sickness that continues throughout the day. What does the nurse tell the client to do to overcome this discomfort? ES. Drink fluids with meals ET. Eliminate the morning meal EU. Eat fatty or spicy foods only at the noontime meal EV. Eat dry crackers every 2 hours to prevent an empty stomach Correct Rationale: Morning sickness, which is common during the first trimester of pregnancy, is associated with an increased level of human chorionic gonadotropin (hCG) and changes in carbohydrate metabolism. Morning sickness most often occurs when the pregnant woman arises (hence the name), although a few women experience it throughout the day. Self-care measures include eating

dry crackers or toast before getting out of bed, eating dry crackers every 2 hours to prevent an empty stomach, eating small frequent meals, avoiding fatty or spicy foods, consuming fluids separately from meals, and rising slowly from a lying or sitting position to help prevent orthostatic hypotension. The client should not eliminate meals. A client in the third trimester of pregnancy is complaining of urinary frequency, and the nurse instructs the client in measures to alleviate the discomfort. Which statement by the client indicates an understanding of these self-care measures? EW. “I need to drink at least 2000 mL of fluid a day.” Correct EX. “I should cut back on my fluid intake in the evening.” EY. “I need to avoid emptying my bladder so frequently.” EZ. “I should avoid drinking large amounts of fluids during the day.” Rationale: Urinary frequency is present in the first trimester and late in the third trimester because of the pressure exerted on the bladder by the enlarging uterus. Self-care measures for urinary frequency include frequent emptying of the bladder (every 2 hours) and drinking at least 2000 mL of fluid a day. Restricting fluid intake at any time is incorrect; it could lead to urinary stasis and fluid- volume deficit A licensed practical nurse (LPN) is assisting the registered nurse (RN) in assessing a pregnant client’s deep tendon reflexes and a reflex of 2+ is noted. Based on this finding, the LPN anticipates that the RN will take which action? FA. Document the finding Correct FB. Reassess the reflexes in 15 minutes FC. Report the finding to the registered nurse immediately FD. Ask another nurse to check the reflexes to verify the finding Rationale: The normal deep tendon reflex response is an extension and upward thrusting of the foot. A 1+ response indicates a diminished response; 2+ indicates normal response; 3+ indicates increased response, brisker than average; and 4 + indicates a very brisk, hyperactive response. The nurse would document the finding. The actions set forth in the remaining options are unnecessary. If the reflexes were 3+ or 4+, the registered nurse would be notified, because these findings suggest preeclampsia. A woman in labor suddenly experiences chest pain and dyspnea, and the nurse suspects the presence of amniotic fluid embolism (AFE). The nurse immediately: FE. Notifies the family FF. Prepares the client for intubation FG. Administers oxygen to the woman Correct FH. Attaches a cardiac monitor to the woman

Rationale: Uterine inversion occurs when the uterus turns completely or partially inside out, usually during the third stage of labor. The physician tries to replace the uterus, by way of the vagina, in a normal position. If this is not possible, laparotomy with replacement is performed. A hysterectomy may be required. Two intravenous lines are established to allow rapid fluid and blood replacement. A tocolytic medication or general anesthesia usually is needed to relax the uterus enough to replace it. To help ensure that the inverted fundus is not trapped in the cervix, oxytocin is not given until the uterus has been repositioned. Fundal massage should be avoided if possible, but, if it is prescribed, it should be conducted very carefully. A Foley catheter may be inserted to keep the bladder empty so that the uterus can contract well, but this is not the immediate action. Rationale: Discomfort and pain associated with true labor contractions typically begin in the lower abdomen and back, then radiate over the entire abdomen. Mild, irregular contractions and a lack of changes in the cervix are findings associated with false labor. A firm uterus is present when contractions occur. Rationale: Supportive interventions are instituted immediately to maintain cardiac and respiratory function, and oxygen is a necessary supportive therapy. The woman is intubated, and positive end expiratory pressure (PEEP) may be prescribed. The family should be notified; however, the nurse would first administer the oxygen, then prepare for intubation. A cardiac monitor may be needed, but this is not the initial action. After a vaginal delivery, a woman suddenly begins to complain of severe pelvic pain and extreme fullness in the vagina, and the nurse suspects uterine inversion. The nurse immediately prepares to: FI. Insert a Foley catheter FJ. Perform fundal massage FK. Administer oxytocin (Pitocin) FL. Assist in repositioning the uterus through the vagina into a normal position Correct A nurse is performing an assessment of a pregnant woman to determine whether labor has begun. For which sign of true labor does the nurse assess the client? FM. A lack of cervical changes FN. A soft uterus with indentable contractions FO. Contractions that are irregular in rhythm and duration FP. Contractions that begin in the lower abdomen and back and radiate over the entire abdomen Correct A nurse is preparing to assess the fetal heartbeat in a pregnant woman who is at gestational week

12. Which piece of equipment does the nurse use to assess the fetal heartbeat? FQ. Fetoscope FR. Adult stethoscope