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Maternity Nursing Exam Test Bank: Questions and Answers Updated 2024, Exams of Nursing

A series of questions and answers related to maternity nursing. Topics covered include labor and delivery, newborn care, and assessment of maternal and fetal conditions. Students preparing for nursing exams or reviewing maternity nursing concepts may find this document useful.

Typology: Exams

2023/2024

Available from 02/18/2024

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Download Maternity Nursing Exam Test Bank: Questions and Answers Updated 2024 and more Exams Nursing in PDF only on Docsity! Maternity Evolve Exam Test Bank Updated 2024. Maternity Evolve Exam graded A 1. 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 C. Nonreactive Correct D. Inconclusive 2. 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: A. Contacting the physician Correct B. Documenting the findings C. Continuing to monitor the client D. Reassuring the client and her partner that labor is progressing normally 3. 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? 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 20­minute 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. Test­Taking Strategy: Use the process of elimination. Eliminate a reactive nonstress test and a normal nonstress test first because they are comparable or alike. To select from the remaining options, note the relationship between “less than 15 seconds” in the question and “nonreactive” in the correct option. If you had difficulty answering this question, review the interpretation of nonstress test results. 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. Test­Taking Strategy: Use the process of elimination and focus on the data in the question. Eliminate the options that are comparable or alike and indicate that the data in the question are normal findings. Review normal assessment findings during the labor process if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. A. “I know how you feel.” B. “This must be hard for you.” Correct C. “Now you have an angel in heaven.” Maternity Evolve Exam Test Bank Updated 2024. Rationale: Strict bed rest throughout the remainder of the pregnancy is not required. The woman is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding, as recommended by the physician or nurse­midwife. The woman is instructed to count the perineal pads she uses each day and to note the quantity and color of blood on each pad. The woman should also watch for the evidence of the passage of tissue. Test­Taking Strategy: Use the process of elimination. Note the strategic words “need for further instruction” in the question, which indicate a negative event query and the need to select the incorrect client statement. Noting the words “stay in bed for the rest of my pregnancy” will direct you to this option. Review therapeutic management for threatened abortion if you had difficulty with this question. 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. Test­Taking Strategy: Use the process of elimination. Note the relationship between the word “vaginally” in the question and “perineal area” in the correct option. Review the purpose and benefit of Kegel exercises if you had difficulty with this question. 6. A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. The nurse tells the client that: A. The exercises should be delayed for 1 month to allow healing B. Performing such exercises in the postpartum period may result in stress urinary incontinence C. Alternating contraction and relaxation of the muscles of the perineal area should be practiced Correct D. Abdominal exercises will be started while the client is in the hospital as a means of evaluating tolerance 7. A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction? A. “I need to stay in bed for the rest of my pregnancy.” Correct B. “I need to avoid having sex until the bleeding has stopped.” C. “I need to watch for stuff that looks like tissue coming from my vagina.” D. “I need to count the number of perineal pads that I use each day and make a note of the amount and color of blood on each pad.” 8. A nurse is assessing the respiratory rate of a newborn. Which finding would the nurse document as normal? A. 20 breaths/min B. 25 breaths/min breathing, and circulation — to answer the question. This will direct you to the correct option, the one that addresses oxygen. Review content on late decelerations if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. C. 50 breaths/min Correct D. 70 breaths/min 9. A nurse notes that the laboratory report of a pregnant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia, and an increased erythrocyte sedimentation rate. Which laboratory test that would further confirm the presence of HIV does the nurse anticipate that the physician will prescribe? A. Platelet count B. Angiotensin level C. Glomerular filtration rate D. T­lymphocyte determination Correct 10. A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. This nurse interprets this assessment data as: A. A normal finding Correct B. Indicative of dehydration C. Indicative of increased intracranial pressure D. Indicative of decreased intracranial pressure 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. Test­Taking Strategy: Knowledge regarding the normal respiratory rate of a newborn is required to answer this question. If you are unfamiliar with the normal ranges for newborn vital signs, review this content. Rationale: HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV for T­lymphocytes leads to significant cell destruction. Angiotensin is produced in the kidney and plays a role in blood pressure control. Glomerular filtration rate is an indicator of kidney function. The platelet count is important and may be used as an indicator of the effects of HIV, but the platelet count (thrombocytopenia) has already been addressed in the question. Test­Taking Strategy: Use the process of elimination, focusing on the subject, the presence of HIV. Eliminate the platelet count, because this has already been addressed in the question (thrombocytopenia). Next eliminate the options that are comparable or alike in that they are related to kidney function. If you had difficulty with this question, review the clinical manifestations and pathology of HIV infection. Rationale: The anterior fontanel, which is diamond shaped, is located on the top of the head. It measures 1 to 4 cm but varies because of molding and individual differences. It normally closes by 12 to 18 months of age. It may be described as soft, which is normal, or full and bulging, which may be indicative of increased intracranial pressure. Conversely, a depressed fontanel could mean that the neonate is dehydrated. Test­Taking Strategy: Use the process of elimination, noting the strategic words “feels soft” in the question. Remember that the anterior fontanel is soft in the neonate. If you had difficulty answering this question, review normal assessment findings in the neonate. Maternity Evolve Exam Test Bank Updated 2024. 11. 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: Maternity Evolve Exam Test Bank Updated 2024. D. Neonatal abstinence syndrome Correct 14. 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: A. The presence of fetal movement B. A high risk for spontaneous abortion C. An increase in vascularity and hyptertrophy of the cervix Correct D. The presence of human chorionic gonadotropin (hCG) in the urine Incorrect 15. A nurse is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the nurse to contact the healthcare provider? A. Maternal fatigue B. Clear amniotic fluid C. Strong­smelling amniotic fluid Correct D. A fetal heart rate of 140 beats/min Rationale: Neonatal abstinence syndrome is the term given to the group of signs and symptoms associated with drug withdrawal in the neonate. Drug withdrawal causes a hyperactive response in the infant because of the increased central nervous system (CNS) stimulation. This hyperactive response and the signs and symptoms of drug withdrawal seem to be most apparent around 1 week of age. Sepsis, hypercalcemia, and intraventricular hemorrhage cause symptoms of CNS depression. Test­Taking Strategy: Use the process of elimination, focusing on the data in the question. Note the strategic word “hyperactive,” which indicates CNS stimulation and should direct you to the correct option. If you had difficulty with this question, review the signs and symptoms of drug withdrawal in the neonate. 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. Test­Taking Strategy: Knowledge regarding the Goodell sign is required to answer this question. It is necessary to know that the sign consists of increased vascularity and hypertrophy of the cervix. If you had difficulty with this question, review the changes in the cervix that occur during pregnancy. Maternity Evolve Exam Test Bank Updated 2024. 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 strong­smelling 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. Test­Taking Strategy: Focus on the subject of the question, a sign of intrauterine infection. Eliminate the options that are comparable or alike in that they are normal expectations during labor. Review the signs of intrauterine infection if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. 16. 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: A. Has the client void before the uterine assessment B. Tells the woman to bear down during fundal message C. Simultaneously provides pressure over the lower uterine segment Correct D. Asks the client to take slow, deep breaths during fundal assessment 17. 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: A. Positions the client on her side Correct B. Calls the physician to see the client C. Places a cool washcloth on the client’s forehead D. Checks the client’s blood pressure, pulse, and respirations 18. A nurse is monitoring a newborn who has been admitted to the nursery. The nurse 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 appropriate nursing action? A. Notifying the physician Correct 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. Test­Taking Strategy: Use the process of elimination, focusing on the subject, prevention of uterine inversion. Visualizing each of the actions in the options and relating the action to the subject of the question will direct you to the correct option. Review fundal assessment and massage if you had difficulty with this question. 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. Test­Taking Strategy: Use the process of elimination and note the strategic word “immediately.” Focusing on the data in the question and determining that the client is experiencing supine hypotension will direct you to the correct option. Review the manifestations of supine hypotension and the interventions for treating this occurrence if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. 21. 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: Maternity Evolve Exam Test Bank Updated 2024. A. Contacts the physician B. Documents the findings C. Instructs the client to take several deep breaths Correct D. Administers 100% oxygen by way of face mask 22. A nurse is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the nurse to contact the physician? A. Complaint of feeling hot B. Enlargement of the breasts C. Diaphoresis and tachycardia Correct D. Periods of fetal movement followed by quiet periods 23. A nurse is monitoring a pregnant client with sepsis for signs of disseminated intravascular coagulopathy (DIC). Which of the following laboratory findings causes the nurse to suspect DIC? A. Increased platelet count B. Increased fibrinogen level C. Shortened prothrombin time D. Increased fibrin degradation products Correct 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 physician. If the deep breaths fail to increase the oxygen saturation level, the physician is notified and may prescribe oxygen. Test­Taking Strategy: Use the process of elimination and focus on the data in the question. Noting the oxygen saturation level will assist you in eliminating this option. Noting the strategic word “first” will direct you to the correct option. Review care of the client after a cesarean birth if you had difficulty with this question. 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. Test­Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they are normal occurrences in pregnancy. Review the complications associated with severe preeclampsia if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. Rationale: DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Petechiae, oozing from injection sites, and hematuria are indicative of DIC. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and therefore prolonged times); and fibrin plugs Maternity Evolve Exam Test Bank Updated 2024. 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 B6 ) 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. Test­Taking Strategy: Knowledge regarding the therapeutic management of the mother with tuberculosis and that of the infant is required to answer this question. Eliminate the options containing the closed­ended words “must,” “not,” and “immediately.” If you had difficulty with this question, review treatment measures for the mother with tuberculosis. A. The infant must be isolated from the mother after birth B. Maternal medication will not be started until the baby is born C. The infant will require medication therapy immediately after birth D. The mother may need to take isoniazid (INH), pyrazinamide, and rifampin (Rifadin) for a total of 9 months Correct 27. 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? A. 20 cm Correct B. 28 cm C. 32 cm D. 40 cm 28. 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: A. To perform a vaginal douche B. To come to the clinic for a checkup 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. Test­Taking Strategy: Knowledge regarding the expected findings in fundal height during the second or third trimester is required to answer this question. Remember that the height of the fundus in centimeters during the second and third trimesters is approximately the same as the number of weeks of gestation. If you are unfamiliar with the interpretation of fundal height, review this content. Maternity Evolve Exam Test Bank Updated 2024. C. That this is an indication of an infection D. That this is a normal postpartum occurrence Correct Maternity Evolve Exam Test Bank Updated 2024. 29. A nurse is caring for a client receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. Which of the following findings would prompt the nurse to stop the infusion? A. Contractions every 3 minutes B. Nonreassuring fetal heart rate pattern Correct C. Soft uterine tone palpated between contractions D. The presence of three contractions every 10 minutes 30. A nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which of the following situations would the nurse suspect in light of this observation? A. Umbilical cord compression B. Pressure on the fetal head during a contraction Correct C. Adequate pacemaker activity of the fetal heart D. Uteroplacental insufficiency during a contraction 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 brown­tinged; this stage is called lochia serosa. By about the 11th day, the erythrocyte component of lochia has decreased and the discharge becomes white or cream­colored. 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. Test­Taking Strategy: Use your knowledge of expected postpartum findings to answer the question. Recalling the normal expected occurrences in regard to vaginal discharge will direct you to the correct option. Also, noting that the incorrect options are comparable or alike will direct you to the correct option. Review normal postpartum findings in regard to lochia if you had difficulty with this question. Rationale: The goal of labor augmentation is to achieve three good­quality contractions (of appropriate intensity and duration) in a 10­minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. If a nonreassuring fetal heart rate pattern is detected, the oxytocin infusion is stopped. A nonreassuring fetal heart rate pattern is associated with fetal hypoxia. Test­Taking Strategy: Use the process of elimination and your knowledge of the ABCs (airway, breathing, and circulation). Eliminate the options that are comparable or alike (i.e., contractions every 3 minutes and occurrence of three contractions every 10 minutes). The correct option, of the two that remain, is the one that indicates a problem with circulation. Review the expected outcomes and the signs of complications associated with oxytocin infusion if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. 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. Test­Taking Strategy: Note the strategic words “contact the physician.” Use the process of elimination, noting the Maternity Evolve Exam Test Bank Updated 2024. 34. 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: A. Take a cool shower just before breastfeeding B. Avoid breastfeeding during the night time hours to ensure adequate rest C. Gently massage the breasts during breastfeeding to help empty the breasts Correct D. Apply heat packs to the breasts for 15 to 20 minutes between feedings to reduce swelling 35. A nurse is caring for a postpartum client who had a low­lying placenta. The nurse assesses the client most closely for: A. Seizures B. Infection C. Hemorrhage Correct D. A vaginal hematoma 36. When, during the normal postpartum course, would the nurse expect to note the fundal assessment shown in the figure? assessment finding that is abnormal and requires further intervention. Also, use your knowledge of the ABCs (airway, breathing, and circulation) to identify the correct option. Review assessment findings in preeclampsia and the effects of magnesium sulfate if you had difficulty with this question. 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. Test­Taking Strategy: Focus on the subject, breast engorgement, and think about its characteristics. Use the process of elimination and visualize each of the descriptions in the options to identify the measure that will be helpful. If you had difficulty answering the question, review the measures for breast engorgement. 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 low­lying placenta is not at greater risk for seizures, postpartum infection, or vaginal hematoma. Test­Taking Strategy: Focus on the client’s diagnosis, a low­lying placenta. Recalling the anatomy and physiology of the lower segment of the uterus will direct you to the correct option. Review the complications associated with a low­lying placenta if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. A. 4 days after delivery B. The day after delivery C. Immediately after delivery Correct D. When the client’s bladder is full 37. 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? A. Maintaining strict asepsis B. Monitoring the maternal vital signs C. Administering oxygen as prescribed Correct D. Placing a wedge under the client’s hip 38. A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 19, 2013. Using Nagele’s Rule, the nurse calculates the estimated date of 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. Test­Taking Strategy: Focus on the figure and note that the fundus is at the level of the umbilicus. Recalling normal postpartum assessment findings in the mother and recalling the normal anatomy will assist in directing you to the correct option. If you had difficulty with this question, review normal postpartum assessment findings in regard to involution. 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. Test­Taking Strategy: Use the process of elimination, focusing on the subject, prevention of sickling crisis. Also, use your knowledge of the ABCs (airway, breathing, and circulation). The correct option involves oxygenation. Review care of the client in labor who has sickle cell anemia if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. 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. Test­Taking Strategy: Use the process of elimination, focusing on the strategic words “hypertonic” and “priority.” This, plus knowledge of the management of this condition, should direct you to the correct option. Also eliminate the options that are therapeutic measures for hypotonic uterine dysfunction and would stimulate labor (i.e., oxytocin augmentation and amniotomy). If you had difficulty with this question, review the management of hypertonic uterine dysfunction. Maternity Evolve Exam Test Bank Updated 2024. 41. Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which of the following findings would the nurse expect to note? A. Abdomen soft to palpation B. Uterine tender to palpation Correct C. Uterine contractions every 3 to 5 minutes D. Lack of uterine irritability or tetanic contractions 42. 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: A. Preparing to induce labor B. Turning the client on her left side C. Preparing the client for a cesarean delivery Correct D. Continuing to monitor the fetal heart rate pattern 43. A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client’s behavior as most likely the result of: A. Emotional immaturity B. A stubborn personality Rationale: Vaginal bleeding in a pregnant client is most often caused by placenta previa or a placental abruption. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board­like on palpation as the blood penetrates the myometrium, causing uterine irritability and maternal tenderness. A normal uterine contraction pattern is unusual in the presence of a placental abruption. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax. Test­Taking Strategy: Focus on the diagnosis, placental abruption. Remember that uterine pain and tenderness occurs with an abruption. Review the characteristics of placental abruption if you had difficulty with this question. 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. Test­Taking Strategy: Focus on the data presented in the question. Eliminate turning the client on her left side and monitoring the fetal heart rate pattern first, because these are nursing actions for all clients in labor. Induction of labor is not indicated in this case, because the client has been in labor for 12 hours and the fetus is in distress. Review the indications for cesarean delivery if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. C. Anxiety and the need for support Correct D. An undiagnosed psychiatric disorder Maternity Evolve Exam Test Bank Updated 2024. B. Delivery of an Rh­positive infant by an Rh­negative woman C. Amniocentesis in an Rh­negative woman carrying an Rh­positive fetus D. Known or suspected entry of Rh­positive fetal blood cells to the circulation of an Rh­negative woman 47. 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? A. Assessing the cervix for thinning B. Auscultating for fetal heart sounds C. Performing a sudden tap on the cervix Correct D. Palpating the abdomen for fetal movement 48. 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? A. Fetoscope B. Adult stethoscope C. Electronic Doppler Correct D. Fetal heart monitor Rationale: One contraindication to the administration of Rho (D) immune globulin is previous hypersensitivity to immune globulin. Rho (D) immune globulin is indicated when an Rh­negative client is exposed to Rh­positive fetal blood cells in any way, including amniocentesis. The other options are all indications for administering RhoGam. Test­Taking Strategy: Use the process of elimination and focus on the subject, a contraindication. Read each option carefully and note the word “hypersensitivity” in the correct option. Review the contraindications to and precautions for the administration of this medication if you had difficulty with this question. 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. Test­Taking Strategy: Knowledge regarding the assessment of ballottement is required to answer this question. It is necessary to know that when the cervix is tapped, the fetus floats upward in the amniotic fluid and that the rebound is known as ballottement. If you are unfamiliar with this assessment technique, review this procedure. Maternity Evolve Exam Test Bank Updated 2024. Rationale: The fetal heartbeat can be heard with the use of a fetoscope at 18 to 20 weeks’ gestation. When an electronic Doppler ultrasound device is used, the fetal heartbeat can be detected as early as 10 weeks’ gestation. An adult stethoscope will not adequately produce the fetal heartbeat. A fetal heart monitor is used during labor or in other situations when the fetal heart rate requires continuous monitoring. Test­Taking Strategy: Use the process of elimination. Eliminate an adult stethoscope first by focusing on the subject, fetal heart rate. To select from the remaining options, note the words “gestational week 12,” which will direct you to the correct option. If you had difficulty with this question, review the methods of assessing the fetal heart rate. Maternity Evolve Exam Test Bank Updated 2024. 49. A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity: A. At any time B. In 2 to 4 weeks Correct C. After the 6­week physician checkup D. When her normal menstrual period has resumed 50. A clinic nurse is developing a plan of care for a pregnant client with AIDS. Which problem does the nurse identify as the priority to be addressed in the plan of care? A. Poor hygiene B. Inverted nipples C. History of IV drug use Correct D. Intake of fewer than 6 glasses of fluid daily 51. 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: 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 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. Test­Taking Strategy: Knowledge of the instructions given to a new mother regarding sexual activity after delivery is required to answer this question. Recalling that it takes about 3 weeks for an episiotomy to heal will direct you to the correct option. Review postpartum instructions if you had difficulty with this question. Rationale: AIDS is a breakdown in immune function caused by a retrovirus known as human immunodeficiency virus, or HIV. The infected person contracts opportunistic infections or malignancies that ultimately are fatal. For this reason, the prevention of infection is a priority of nursing care. Although poor hygiene may affect the client’s risk for infection, addressing and helping the client cease her use of IV drugs, which is an immediate contributor to the risk for infections, is priority. Inverted nipples and intake of less than 6 glasses of fluid daily are not specifically related to this syndrome. Test­Taking Strategy: Note the strategic word “priority.” Recalling that AIDS affects the body’s immune system and remembering the factors that increase the risk for infections will direct you to the correct option. If you had difficulty with this question, review the priority concerns related to the client with AIDS. Maternity Evolve Exam Test Bank Updated 2024. E. 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. Test­Taking Strategy: Use principles of prioritizing and your knowledge of the ABCs (airway, breathing, and circulation) to answer this question. Fetal heart rate is associated with fetal breathing and circulation. Once the fetal condition has been assessed, the focus is turned to the mother’s condition. The amniotic fluid is checked next because this action will take little time, followed by vital signs. Finally client comfort is provided, followed by the planning of further care. If you had difficulty with this question, review the priority nursing actions after amniotomy. Maternity Evolve Exam Test Bank Updated 2024. 51. A nurse assessing a pregnant client’s deep tendon reflexes notes a reflex of 2+. The nurse should: A. Document the finding Correct B. Reassess the reflexes in 15 minutes C. Report the finding to the physician immediately D. Ask another nurse to check the reflexes to verify the finding AY. Immediately after the delivery of a newborn infant, the nurse prepares to deliver the placenta. The nurse initially: A. Pulls on the placenta as it enters the vaginal canal B. Pulls on the umbilical cord as the mother bears down C. Applies strong traction on the cord when signs of separation occur D. Instructs the mother to push when signs of separation have occurred Correct AZ. 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? A. Clonus is present. B. Magnesium level is 10 mg/dL. C. Deep tendon reflexes are absent. D. The client experiences diuresis within 24 to 48 hours. Correct 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 physician would be notified, because these findings suggest preeclampsia. Test­Taking Strategy: Knowledge regarding assessment of the deep tendon reflexes and the interpretation of assessment findings is required to answer this question. Remember that 2+ is a normal response. Review this assessment technique if you had difficulty with this question. 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. Test­Taking Strategy: Use the process of elimination. Noting the strategic word “initially” and recalling that the placenta is attached to the uterine wall will direct you to the correct option. Pulling on the umbilical cord and placing excess traction on the cord when signs of separation occur may put the client at risk for uterine inversion. Review the procedure for placental delivery if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. 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 Maternity Evolve Exam Test Bank Updated 2024. 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. Test­Taking Strategy: Use the process of elimination. Eliminate first the options that are comparable or alike (i.e., under the skin and under the dermis). To select from the remaining options, it is necessary to recall the description of gastroschisis. Review the characteristics of gastroschisis if you are unfamiliar with it. D. Count the fetal heart rate for 1 minute BD.A nurse is assessing a newborn infant with a diagnosis of gastroschisis. The nurse expects to note that the bowel is located: A. Inside the abdominal cavity, under the skin B. Inside the abdominal cavity, under the dermis C. Outside the abdominal cavity and not covered with a sac Correct D. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane BE. A nurse answers a call light in the room of a woman who was just admitted in early latent labor. The woman is lying flat on her back on the bed. The husband reports excitedly, “I think my wife is going into shock or something! She was just lying there, and then she turned so pale, and her hands are so clammy. She said she was dizzy and sick to her stomach.” The nurse notes on the noninvasive blood pressure monitor that the woman’s pulse is 58 beats/min and her blood pressure is 90/50 mm Hg. The nurse interprets these findings as indications that the woman is experiencing: A. Anxiety related to the onset of labor B. Progression from latent to active first­stage labor C. Hyperventilation related to excitement at her first labor experience D. Altered tissue perfusion related to hypotensive syndrome (vena cava syndrome) Correct 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. Test­Taking Strategy: Note the strategic word “first.” Knowing that Leopold maneuvers are often used to help locate fetal heart tones and involve palpation will assist you in determining that asking the client to empty the bladder is the first action. Review the procedure for the Leopold maneuvers if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. Rationale: In a pregnant woman, the supine position adds gravity pressure to the inferior vena cava, which is already displaced and partially compressed by the full­term gravid uterus. The increased compression decreases cardiac output, leading to beginning tissue hypoxia, which brings on the signs and symptoms described in the question. The signs and symptoms identified in the question are not indicative of progression to active first­stage labor. There is no information in the question to indicate that the client is experiencing hyperventilation or anxiety. Test­Taking Strategy: Use the process of elimination, focusing on the data in the question. Recognizing that there is no information in the question to indicate that the client is experiencing hyperventilation or anxiety will assist you in eliminating these options. To select from the remaining options, note that the pulse and blood pressure are low and Maternity Evolve Exam Test Bank Updated 2024. BF. A nurse teaching a pregnant client about measures to strengthen the pelvic floor instructs the client to: A. Walk half a mile 3 times a week B. Drink at least 2 quarts of fluid per day C. Perform Kegel exercises in 10 repetitions, three times per day Correct D. Perform pelvic tilt exercises in 10 repetitions, three times per day BG. 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. A. A client with septicemia Correct B. A client with mild preeclampsia C. A client with diabetes mellitus who delivered a 10­lb baby D. A client who had a cesarean section because of abruptio placentae Correct E. A client who delivered 12 hours ago and has lost 475 mL of blood BH.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. remember the pathophysiology of hypotensive syndrome (vena cava syndrome), which will direct you to the correct option. Review the signs and symptoms of hypotensive syndrome (vena cava syndrome) if you had difficulty with this question. 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. Test­Taking Strategy: Use the process of elimination and focus on the subject, ways to strengthen the pelvic floor. This focus will direct you to the correct option. Remember that Kegel exercises help strengthen the pelvic floor muscles. If you had difficulty with this question, review the purpose of Kegel exercises. 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. Test­Taking Strategy: Use the process of elimination and focus on the subject, the client at risk for DIC. Thinking about the pathophysiology of DIC and the conditions listed in the options will assist in answering correctly. Review the risk factors associated with DIC if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. Rationale: HIV infection in a pregnant woman may result in both maternal and fetal complications. Fetal compromise may occur as a result of premature rupture of the membranes, preterm birth, or low birth weight. Potential maternal effects include an increased risk for opportunistic infections. Individuals in the later stages of HIV infection are susceptible to other invasive conditions, such as tuberculosis and a wide variety of bacterial infections. The assessment finding in the correct option could be indicative of an opportunistic infection and requires follow­up. Maternity Evolve Exam Test Bank Updated 2024. BK. 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: A. Contact the physician B. Recheck the temperature in 1 hour C. Encourage the intake of oral fluids Correct D. Tell the client that antibiotics will be prescribed BL. A pregnant woman at 38 weeks’ gestation arrives at the emergency department, reporting bright­red vaginal bleeding but denying pain. On the basis of this information, the nurse determines that the client may be experiencing: A. Placenta previa Correct B. Abruptio placentae C. Passage of the mucus plug D. Rupture of the amniotic sac BM. 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? A. Lochia alba B. Lochial clots C. Lochia serosa Test­Taking Strategy: Use the process of elimination. Eliminate the incorrect options because these are normal findings. Additionally, use your knowledge of the ABCs — airway, breathing, and circulation — to direct you to the correct option. Review care of the HIV­positive pregnant woman if you had difficulty with this question. 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 physician or nurse midwife. Because the client delivered her baby just 12 hours ago, the most appropriate nursing action is to encourage the intake of oral fluids. Test­Taking Strategy: Use the process of elimination. Note the strategic words “12 hours ago.” Recalling that a low­grade temperature is a common postpartum assessment finding will direct you to the correct option. Review normal vital sign findings during a postpartum assessment if you had difficulty with this question. Rationale: The primary symptom of placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. Findings of abruptio placentae include dark­red vaginal bleeding and abdominal pain. A ruptured amniotic sac is characterized by findings such as watery vaginal drainage. Passage of the mucus plug is manifested as pink or as blood­tinged mucus. Test­Taking Strategy: Use the process of elimination. Focus on the data in the question and recall that painless vaginal bleeding occurs in placenta previa. If you had difficulty with this question, review the assessment signs associated with the conditions identified in the options. Maternity Evolve Exam Test Bank Updated 2024. D. Dark­red lochia rubra Correct Maternity Evolve Exam Test Bank Updated 2024. A. B. C. D. Correct BQ. A nurse provides instruction regarding prenatal care to a client with a history of heart disease. The nurse tells the client that: A. It is best to lie supine for sleep B. Physical activity should be limited Correct C. The amount of weight gained is not important D. It is necessary to avoid contact with all individuals to help prevent infection Rationale: Priority nursing care of the woman in precipitous labor includes promotion of fetal oxygenation and maternal comfort. A side­lying (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. Test­Taking Strategy: Focus on the subject, a client in precipitous labor. Recalling that precipitous labor is one in which birth occurs within 3 hours of the onset of labor and visualizing each position in the options will direct you to the correct option. Review care of the client in precipitous labor if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. Rationale: Physical activity should be limited so that demand does not exceed the functional capacity of the heart. It is not necessary to avoid contact with all individuals as a means of preventing infection, but contact with individuals with active much weight gain causes an increase in body requirements and stress on the heart. The client should lie on the left side infections should be avoided. The client should avoid excessive weight gain, which increases demand on the heart. Too Maternity Evolve Exam Test Bank Updated 2024. BR.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: A. Insert a Foley catheter B. Perform fundal massage C. Administer oxytocin (Pitocin) D. Assist in repositioning the uterus through the vagina into a normal position Correct BS. A multigravida asks a nurse when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted as early as: A. 8 to 10 weeks of gestation B. 11 to 13 weeks of gestation C. 14 to 16 weeks of gestation Correct D. 18 to 20 weeks of gestation BT. A nurse is monitoring a client after vaginal delivery notes a constant trickle of bright­red blood from the client's vagina. In to promote blood return. Test­Taking Strategy: Use the process of elimination. Eliminate the options containing the closed­ended words “not” and “all.” To select from the remaining options, recall the concepts of blood return during pregnancy, which will assist you in answering correctly. If you had difficulty with this question, review care of the pregnant client with heart disease. 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. Test­Taking Strategy: Use the process of elimination and note the strategic word “immediately.” Note the relationship between the words “uterine inversion” in the question and the option in which the uterus is repositioned, through the vagina, in its normal place. Review nursing interventions for the client with uterine inversion if you had difficulty with this question. Rationale: The first recognition of fetal movements by the multigravida may occur as early as the 14th to 16th week of gestation. The primigravida may not notice these sensations until week 18 or later. Therefore the other options are incorrect. Test­Taking Strategy: Use the process of elimination and your knowledge regarding quickening and the detection of fetal movement by the mother. Note the strategic word “multigravida.” It is important to note that multigravidas usually detect fetal movements earlier in pregnancy than do primigravidas. If you are unfamiliar with the timing of quickening, review this assessment finding. Maternity Evolve Exam Test Bank Updated 2024. fears? A. “Urinary infections during pregnancy are common. Your baby will be fine.” Maternity Evolve Exam Test Bank Updated 2024. B. “Your developing baby cannot acquire an infection from you during pregnancy.” C. “You shouldn't worry about this, because you had early prenatal care and are taking your prenatal vitamins.” D. “Now that you have taken the medication as prescribed, we’ll keep monitoring you closely and repeat the urine culture before you leave today.” Correct AZ. A nurse is changing the diaper of a 1­day­old full­term female newborn. The nurse notes that the labia are edematous and darker than the surrounding skin and that a white mucous vaginal discharge is present. On the basis of these findings, the nurse determines that the appropriate action is: A. Notifying the physician B. Documenting the findings Correct C. Obtaining a specimen of the discharge for culture D. Reviewing the mother’s record to determine whether she has a history of gonorrhea BA. 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 self­care measures? A. “I need to drink at least 2000 mL of fluid a day.” Correct B. “I should cut back on my fluid intake in the evening.” C. “I need to avoid emptying my bladder so frequently.” D. “I should avoid drinking large amounts of fluids during the day.” Rationale: Symptomatic bacteriuria has been associated with an increased risk of neonatal sepsis after delivery. Appropriate antenatal care of a client with a urinary tract infection includes antibiotic treatment and follow­up with repeat urine cultures. The correct option is the only therapeutic response and is the response that presents accurate information. Test­Taking Strategy: Use the process of elimination and your knowledge of therapeutic communication techniques. This will direct you to the correct option. Review therapeutic communication techniques if you had difficulty with this question. Rationale: The labia of a newborn female may be darker in color than the surrounding skin; this is a normal finding, a result of exposure to the mother’s hormones before birth. Edema of the labia and a white mucous vaginal discharge are also normal. Therefore the nurse would document the findings. The other options are unnecessary. Test­Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling normal newborn findings and remembering that the findings noted in the question are normal will direct you to the correct option. If you had difficulty with this question, review normal newborn findings. Maternity Evolve Exam Test Bank Updated 2024. 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. Self­care 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 fluid­volume deficit Test­Taking Strategy: Use the process of elimination. Eliminate first the options that are comparable or alike (i.e., restricting fluid intake and avoiding large amounts of fluid). Realizing that it does not make sense to avoid emptying the Maternity Evolve Exam Test Bank Updated 2024. D. 12 weeks Correct BD.A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. The nurse tells the client that: A. She must be retested in 1 week B. Liver function tests will be prescribed C. A repeat hepatitis screen will be performed during the pregnancy D. The infant should receive both the vaccine and hepatitis immune globulin soon after birth Correct BE. A nurse performing an assessment of a pregnant client is preparing to take the client’s blood pressure. The nurse positions the client: A. Supine, on the left side B. Supine, on the right side C. Lying down with the arm in a horizontal position at heart level D. In a sitting position with the arm in a horizontal position at heart level 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. Test­Taking Strategy: Knowledge regarding the auscultation of fetal heart sounds and when they are audible during pregnancy is required to answer this question. Noting the strategic words “Doppler ultrasound stethoscope” in the question direct you to the correct option. If you are unfamiliar with the assessment of and auscultation of fetal heart sounds, review this procedure. Rationale: A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the infant should receive hepatitis immune globulin and a vaccine soon after birth. Repeating the screen and prescribing liver function tests are incorrect measures and are unnecessary. Test­Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they involve repeating the test. To select from the remaining options, recall that the concern is the effect on the fetus, which will direct you to the correct option. Review the purpose and significance of the hepatitis B screen if you had difficulty with this question. 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. Test­Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they involve indicate positioning the client lying down or supine. If you are unfamiliar with the procedure of taking a pregnant client’s blood pressure, review this procedure. Maternity Evolve Exam Test Bank Updated 2024. BF. A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. The appropriate response is: Maternity Evolve Exam Test Bank Updated 2024. A. “Yes, the newborn will also have the virus.” B. “HIV can only be transmitted through sexual contact.” C. “The newborn does have a risk of contracting the infection.” Correct D. “The newborn will have signs of HIV at birth if the virus has been transmitted.” BG. 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. A. A primipara B. A 36­ year­old C. A hypertensive client Correct D. A pack­a­day smoker Correct E. A client who exercises regularly BH.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: A. Avoid the use of shampoo on the infant’s scalp B. Apply oil to the affected area on the infant’s scalp Correct C. Wash the infant’s scalp daily, using only tepid water D. Shampoo the infant’s scalp, avoiding the anterior fontanel area Rationale: An infant born to an HIV­positive mother is at risk for contracting the infection. The modes of transmission are sexual, parenteral, and perinatal. Characteristically the newborn is asymptomatic at birth, but signs and symptoms in an infected child usually become obvious during the first year of life. Therefore the remaining options are incorrect. Test­Taking Strategy: Use the process of elimination. Simply knowing that the infant born to an HIV­positive mother is at risk for contracting the infection will direct you to the correct option. Review the risks associated with pregnancy in an HIV­ positive woman if you had difficulty with this question. 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. Test­Taking Strategy: Note the strategic words “at risk” and focus on the subject, abruptio placentae. The correct options identify situations that could be harmful. Review the risk factors for abruptio placentae if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. the client to elicit data specific to this disorder? A. “Do you have continuous heavy vaginal bleeding?” Maternity Evolve Exam Test Bank Updated 2024. B. “Do you have pain at the beginning of your period?” C. “Do you have pain every time you have intercourse?” D. “Do you have sharp pain on the right or left side of your pelvis?” Correct BL. 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: A. Indicate that labor has started B. Must be reported to the physician C. Are a common occurrence of pregnancy Correct D. Necessitate bed rest for the remainder of the pregnancy BM. A woman in labor suddenly experiences chest pain and dyspnea, and the nurse suspects the presence of amniotic fluid embolism (AFE). The nurse immediately: A. Notifies the family B. Prepares the client for intubation C. Administers oxygen to the woman Correct D. Attaches a cardiac monitor to the woman Rationale: Mittelschmerz ("middle pain") refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is due to growth of the dominant follicle within the ovary or to rupture of a follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain, which is fairly sharp, is felt on the right or left side of the pelvis. It generally lasts a few hours to 2 days, and slight (not profuse) vaginal bleeding may accompany the discomfort. The pain is not associated with intercourse. Test­Taking Strategy: Use the process of elimination. Recalling that mittelschmerz is “middle pain,” that this condition occurs as a result of growth or rupture of the follicle, and that it generally lasts a few hours to 2 days will assist you in answering correctly. If you are unfamiliar with this condition, review this content. 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. Test­Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike (i.e., labor has started and the physician must be contacted). To select from the remaining options, recall that Braxton Hicks contractions may occur throughout pregnancy; this will direct you to the correct option. If you had difficulty with this question, review the physiology of Braxton Hicks contractions. Maternity Evolve Exam Test Bank Updated 2024. 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. Test­Taking Strategy: Use your knowledge of the ABCs — airway, breathing, and circulation — to answer the question. Maternity Evolve Exam Test Bank Updated 2024. BQ. 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? A. A lack of cervical changes B. A soft uterus with indentable contractions C. Contractions that are irregular in rhythm and duration D. Contractions that begin in the lower abdomen and back and radiate over the entire abdomen Correct BR.A 1­hour oral glucose tolerance test is performed on a pregnant client, with a result of 155 mg/dL. The nurse tells the client that: A. Daily NPH insulin will be needed B. Her glucose level is within normal limits C. A daily oral hypoglycemic agent will be prescribed D. A 3­hour glucose tolerance test will likely be performed to confirm gestational diabetes Correct 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. Test­Taking Strategy: Use the process of elimination and focus on the clinical manifestations associated with infection. Noting the word “edema” will direct you to the correct option. Also, note that the incorrect options are comparable or alike in that they all involve a darkened cord. Review the signs of an infected umbilical cord if you had difficulty with this question. 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. Test­Taking Strategy: Note the subject, a sign associated with true labor. Eliminate a lack of cervical changes first, because cervical changes are expected in true labor. In true labor, contractions are regular, so contractions that are irregular in rhythm and duration are not a sign. A firm uterus (not soft) is present when contractions occur, so eliminate this option. If you had difficulty with this question, review the characteristics of true and false labor. Maternity Evolve Exam Test Bank Updated 2024. Rationale: A maternal 1­hour blood glucose test may be prescribed as a screen for gestational diabetes. If it is increased (140 mg/dL or greater), a 3­hour glucose­tolerance test may be recommended to confirm the presence of gestational diabetes. Oral hypoglycemics and insulin would not be prescribed solely on the basis of an increased maternal 1­hour glucose level. Additionally, oral hypoglycemic agents are contraindicated during pregnancy. A result of less than 140 mg/dL indicates no need for further glucose testing and continued routine prenatal care. Test­Taking Strategy: Use the steps of the nursing process and an understanding of the results and purpose of a 1­hour oral glucose tolerance test to address this question. Eliminate the daily oral hypoglycemic agent and daily NPH insulin options because they are comparable or alike in that they represent the administration of medication to treat the increased blood glucose. The correct option is the only one that identifies further assessment of the client because of an increased result on 1­hour glucose testing. Review measures to evaluate and treat increased blood glucose in a pregnant client if you had difficulty with this question. Maternity Evolve Exam Test Bank Updated 2024. BS. A postpartum nurse instructs a new mother in how to bathe her newborn. Which statement by the mother indicates a need for further instruction? A. “I should bathe him after a feeding.” Correct B. “I need to sponge­bathe him until the cord falls off.” C. “I should check the temperature of the water before using it to bathe him.” D. “I need to keep him covered as much as possible while I’m giving him a bath.” BT. A nurse is assessing a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which of the following actions should the nurse perform in response to this observation? A. Calling the physician B. Documenting the finding Correct C. Repositioning the mother D. Taking the mother’s vital signs BU. A nurse caring for a hospitalized client with a diagnosis of abruptio placentae and develops a nursing care plan incorporating interventions to be implemented in the event of shock. If signs of shock develop, to promote tissue oxygenation, the nurse would immediately: A. Limit maternal activity B. Turn the client on her side Correct C. Monitor maternal vital signs D. Provide emotional support to reduce anxiety Rationale: It is not advisable to bathe a newborn infant after a feeding, because handling the infant may cause regurgitation. Controlling heat loss during the bath to help conserve the infant’s energy and prevent cold stress is a priority, and the baby should be covered as much as possible during bathing. The baby should be given sponge bath until the cord falls off. Additionally, the mother should check the temperature of the water before using it to bathe the infant as a means of preventing burns. Test­Taking Strategy: Note the strategic words “need for further instruction,” which indicate a negative event query and the need to select the incorrect statements. Recalling that handling the infant could cause regurgitation will assist in directing you to the correct option. Review teaching points for bathing of a newborn if you had difficulty with this question. Rationale: Accelerations are transient increases in the fetal heart rate, normally caused by fetal movement or accompanying contractions. Accelerations are a sign of fetal well­being and adequate oxygen reserve. No intervention besides documentation is necessary in this situation. Test­Taking Strategy: Use the process of elimination. Recalling that the presence of accelerations indicates fetal well­ being will direct you to the correct option. Review the description of accelerations if you are unfamiliar with this content.