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ATI RN MATERNAL NEWBORN
1. A nurse is caring for a client who is at 32 weeks gestation and is experiencing preterm labor. What medication should the nurse plan to administer? A. Misoprostol B. Betamethasone C. Poractant alfa D. Methylergonovine
Rationale: Betamethasone promotes fetal lung maturity when preterm labor occurs. Misoprostol and methylergonovine stimulate uterine contractions, which are contraindicated. Poractant alfa is a surfactant used in neonates, not the mother.
2. A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant. What lab test will confirm her pregnancy? A. Urine test for presence of hCG B. Urine test for presence of HCS C. Blood test for presence of estrogen D. Blood test for circulating progesterone
Rationale: The presence of human chorionic gonadotropin (hCG) confirms pregnancy. Other hormones may rise but are not diagnostic of pregnancy.
3. A nurse is caring for a client who believes she may be pregnant. What finding should the nurse identify as a positive sign of pregnancy? A. Palpable fetal movement B. Amenorrhea C. Chadwick’s sign D. Positive pregnancy test
Rationale: Positive signs of pregnancy include fetal heart tones, fetal movement palpated by the examiner, and visualization of the fetus. Presumptive signs (amenorrhea) and probable signs (Chadwick’s sign, pregnancy test) are not conclusive.
4. A nurse is caring for a client who has oligohydramnios. What fetal anomaly should the nurse expect? A. Renal agenesis B. Atrial septal defect C. Spina bifida D. Hydrocephalus
Rationale: Oligohydramnios is often linked to fetal renal anomalies, such as renal agenesis, which reduce urine output and therefore amniotic fluid volume.
5. A nurse is assessing a client at 37 weeks gestation with a suspected pelvic fracture due to blunt abdominal trauma. What finding should the nurse expect?
A. Uterine contractions B. Bradycardia C. Seizures D. Bradypnea
Rationale: Abdominal trauma may stimulate uterine contractions. Bradycardia, seizures, and bradypnea are unrelated findings.
6. A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. What finding should the nurse expect? A. Hypothermia B. Dark brown vaginal discharge C. Fetal heart tones D. Decreased urinary output
Rationale: A molar pregnancy often presents with dark brown, “prune juice-like” discharge containing vesicles. No viable fetus or fetal heart tones are present.
7. A nurse is caring for a client who is at 35 weeks gestation and has mild gestational hypertension. Which finding should the nurse identify as the priority? A. Urine output of 480 mL in 24 hours B. 1+ protein in urine C. +2 edema of feet D. Blood pressure 144/92 mmHg
Rationale: Oliguria (<30 mL/hr) may indicate worsening preeclampsia with renal impairment. While hypertension and proteinuria are concerning, decreased urine output signals immediate risk.
8. A nurse is teaching a client who is at 12 weeks gestation and has HIV. What should the nurse include in the teaching? A. You will be in isolation after delivery B. Abstain from sexual intercourse throughout pregnancy C. Breastfeed your newborn to provide passive immunity D. You should continue to take zidovudine throughout pregnancy
Rationale: Antiretroviral therapy reduces the risk of perinatal transmission of HIV. Breastfeeding is contraindicated due to transmission risk. Isolation and abstinence are not required.
9. A nurse is providing teaching to a client who is at 8 weeks gestation about manifestations to report. Which should the nurse include? A. Nausea upon awakening B. Blurred or double vision C. Increased white vaginal discharge D. Leg cramps during sleep
A. Instruct the client to obtain a rubella immunization after delivery B. Request an antibiotic until delivery C. Inform the client cesarean birth is required D. Administer Rho(D) immune globulin
Rationale: Rubella vaccine is contraindicated in pregnancy and should be given postpartum. Group B strep is treated at delivery, and Rhogam is indicated only if sensitization risk is present.
15. A nurse is reviewing the record of a client at 39 weeks gestation with polyhydramnios. What finding should the nurse expect? A. Total pregnancy weight gain of 3.6 kg B. Fetal gastrointestinal anomaly C. Gestational hypertension D. Fundal height of 34 cm
Rationale: Polyhydramnios is commonly associated with fetal GI malformations such as esophageal or duodenal atresia, which impair swallowing of amniotic fluid.
16. A nurse is teaching a client with preeclampsia about magnesium sulfate infusion. What adverse effect should the nurse include? A. Elevated blood pressure B. Feeling of warmth C. Generalized pruritus D. Hyperactivity
Rationale: A common side effect of magnesium sulfate is flushing and warmth. Serious complications include respiratory depression and diminished reflexes.
17. A nurse is caring for a client in the latent phase of labor with low back pain. What should the nurse do? A. Position the client supine with legs elevated B. Instruct the client to pant during contractions C. Encourage a warm bath D. Apply pressure to the sacral area during contractions
Rationale: Counterpressure relieves discomfort from occiput posterior fetal position and back labor. Supine positioning and panting are not effective.
18. A nurse is teaching a client at 12 weeks gestation about complications to report. Which should she include? A. Intermittent nausea B. White vaginal discharge C. Swelling of the face D. Urinary frequency
Rationale: Facial swelling suggests preeclampsia and must be reported. Nausea, leukorrhea, and urinary frequency are common in early pregnancy.
19. A nurse is teaching a client at 10 weeks gestation about an abdominal ultrasound. What should the nurse include? A. You will have a non-stress test before the ultrasound B. You will need to have a full bladder during the ultrasound C. The ultrasound will measure cervical length D. You will experience uterine cramping during the ultrasound
Rationale: A full bladder elevates the uterus for clearer imaging in first-trimester ultrasounds. Cervical length is not the primary focus at this stage.
20. A nurse is assessing a client who is 34 weeks gestation with mild placental abruption. What finding should the nurse expect? A. Decreased urinary output B. Fetal distress C. Dark red vaginal bleeding D. Increased platelet count
Rationale: Placental abruption causes painful, dark red bleeding. Fetal distress may occur with severe cases. Urinary output and platelets are not hallmark findings.
21. A nurse is caring for a client who is using patterned-paced breathing during the first stage of labor. The client reports lightheadedness and tingling of her fingers. Which action should the nurse take? A. Instruct the client to hold her breath and bear down B. Ensure that the client’s breathing rate is more than twice her normal rate C. Apply counter-pressure to the client’s lower back D. Have the client breathe into a paper bag
Rationale: Rapid patterned breathing can cause respiratory alkalosis, leading to symptoms such as dizziness, tingling, and lightheadedness. The nurse should intervene by helping the client rebreathe exhaled carbon dioxide using a paper bag, which corrects the alkalosis. Counter- pressure is useful for back pain, but it does not address the client’s current symptoms. Instructing her to bear down or increasing her breathing rate would worsen her hyperventilation, increasing maternal distress and potentially decreasing fetal oxygenation.
22. A nurse is teaching a parent of a newborn how to care for the umbilical cord stump. Which instruction should the nurse include? A. Cover the cord with the edge of the diaper B. Clean the cord stump with tap water C. Apply a damp cloth over the stump once a day D. Tug on the cord stump if it has not fallen off by day five
procedure itself. Proper pre-procedure teaching ensures accuracy of results and reduces maternal anxiety during the test.
26. A nurse is caring for a client in active labor who is experiencing hypotension following epidural placement. Which action should the nurse take? A. Decrease IV fluids B. Give oxygen at 2 L/min via nasal cannula C. Place the client in a lateral position D. Administer indomethacin
Rationale: Hypotension is a common complication of epidural anesthesia due to vasodilation. The first nursing intervention is to reposition the client laterally, which promotes uteroplacental perfusion and improves blood pressure. Supplemental oxygen may be administered, but it does not correct the underlying cause as effectively as repositioning. Reducing IV fluids is inappropriate, as fluids are needed to maintain blood pressure. Indomethacin is a tocolytic and unrelated to the management of hypotension. Prompt intervention protects both maternal and fetal well-being.
27. A nurse is teaching a client about preventing engorgement who is planning to formula- feed her newborn. Which instruction should the nurse include? A. Apply ice packs to your breasts B. Hand express milk three times daily C. Avoid wearing a bra throughout the day D. Request medication to suppress lactation
Rationale: To prevent engorgement in clients who are not breastfeeding, supportive measures such as wearing a well-fitted bra and applying cold packs reduce breast discomfort and promote suppression of lactation. Expressing milk or stimulating the breasts will increase milk production and delay suppression. Avoiding a bra provides no support and can worsen discomfort. Medications for lactation suppression are rarely used due to side effects. Conservative management with ice, breast binding, and analgesics is the evidence-based practice.
28. A nurse is caring for a newborn born to a client with a narcotic use disorder. Which nursing action is contraindicated? A. Promoting maternal-newborn bonding B. Tight swaddling of the newborn C. Small, frequent meals D. Frequent stimulation
Rationale: Neonates with opioid withdrawal are irritable and sensitive to stimuli. The nurse should minimize handling and provide a quiet environment with swaddling and small, frequent feedings to promote rest and stability. Frequent stimulation can worsen irritability, lead to tremors, and increase the risk of seizures. Promoting bonding remains appropriate if the mother is stable. Tight swaddling reduces excess movement and provides comfort. Care should focus on reducing environmental stressors and supporting physiologic regulation during withdrawal.
29. A nurse is caring for a client at 12 weeks gestation with a BMI of 45. Which recommendation should the nurse provide regarding weight gain? A. You should plan to gain no more than 20 pounds during your pregnancy B. You should gain 25 to 35 pounds during pregnancy C. You should not gain any weight during pregnancy D. You should plan to gain 45 to 50 pounds
Rationale: For clients with obesity (BMI ≥30), the Institute of Medicine recommends a weight gain of 11–20 pounds to minimize complications such as gestational diabetes, hypertension, and cesarean birth. Gaining 25–35 pounds is appropriate for normal BMI clients, while 45– 50 pounds is excessive and increases risks. Advising no weight gain is unrealistic and can harm fetal growth. Counseling should balance maternal health with adequate fetal development.
30. A nurse is caring for a client in active labor with meconium-stained amniotic fluid. The FHR is reassuring. What action should the nurse perform? A. Prepare the client for ultrasound B. Prepare the client for emergency cesarean birth C. Prepare equipment for newborn resuscitation D. Perform endotracheal suctioning as soon as the head is delivered
Rationale: The current guideline is to prepare for resuscitation but avoid routine suctioning unless the newborn is depressed at birth. If the newborn is vigorous, routine care suffices. In the presence of meconium, emergency cesarean is not indicated unless there are signs of fetal distress. Ultrasound does not aid management in this scenario. Readiness for resuscitation ensures prompt response if the infant exhibits respiratory compromise at delivery.
31. A nurse is assessing a postpartum client following a vacuum-assisted birth. Which finding suggests a cervical laceration? A. Continuous lochia flow with a flaccid uterus B. Increasing perineal pain and pressure C. Slow trickle of bright red bleeding with a firm fundus D. Gush of rubra lochia when the uterus is massaged
Rationale: Bright red bleeding with a firm uterus indicates trauma such as a cervical laceration. Uterine atony would cause excessive bleeding with a boggy fundus. Pain and pressure may suggest a hematoma. A gush of lochia after massage can be normal. Prompt recognition of cervical laceration is crucial because bleeding can continue despite a firm fundus, and surgical repair may be needed to prevent hypovolemic shock.
32. A nurse is teaching a client with preeclampsia who is scheduled to receive magnesium sulfate. Which adverse effect should the nurse include? A. Elevated blood pressure B. Feeling of warmth C. Hyperactivity D. Generalized pruritus
36. A nurse is caring for a client who experienced spontaneous rupture of membranes. Which finding requires intervention? A. Intense contractions lasting less than 30 seconds B. Rest periods between contractions lasting more than 90 seconds C. Fetal heart rate decreased by 15/min D. Maternal temperature of 37.8°C (100°F)
Rationale: A decrease in fetal heart rate after rupture of membranes suggests umbilical cord compression or prolapse, a medical emergency. Immediate interventions, such as repositioning the client and preparing for delivery, are needed. Short contractions or long rest periods are not emergencies. A maternal temperature of 37.8°C is slightly elevated but not a fever requiring urgent action. Prompt recognition of FHR abnormalities is crucial to prevent fetal hypoxia.
37. A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5 kg. Available: morphine oral solution 0.4 mg/mL. How many mL should the nurse administer? Answer: 0.25 mL
Rationale: The correct dose is calculated by multiplying 0.04 mg × 2.5 kg = 0.1 mg. Using the available concentration of 0.4 mg/mL, divide 0.1 ÷ 0.4 = 0.25 mL. Accurate medication calculation prevents overdose in neonates, who are highly sensitive to narcotics and at risk for respiratory depression. Double-checking with another nurse ensures safe administration.
38. A nurse is discussing expected pregnancy changes with a client at 8 weeks gestation. Which finding should the client report during the first trimester? A. Breast tenderness B. Urinary frequency C. Persistent vomiting D. No fetal movement
Rationale: Persistent vomiting in early pregnancy can indicate hyperemesis gravidarum, a condition that can cause dehydration, electrolyte imbalances, and weight loss. This should be reported promptly for evaluation. Breast tenderness and urinary frequency are normal discomforts. Fetal movement is not typically felt until 16–20 weeks. Recognizing warning signs helps the nurse educate clients about when to seek medical attention and ensures early intervention for complications.
39. A nurse is teaching a client with pregestational diabetes about dietary changes. Which statement should the nurse include? A. Carbohydrates should make up 55% of your diet B. Protein should make up 70% of your diet C. Fats should make up 45% of your diet D. Fiber should make up 10% of your diet
Rationale: Carbohydrates should constitute about 50–55% of the diet to maintain stable blood glucose levels during pregnancy. Adequate protein and fats are also essential, but not at the
exaggerated percentages listed. Fiber should be included but not as a major proportion. Proper carbohydrate distribution across meals and snacks helps prevent hypoglycemia and hyperglycemia, reducing risks to both mother and fetus.
40. A nurse is caring for a preterm infant in the NICU. Which action promotes optimal development? A. Avoiding swaddling B. Placing infant supine only C. Providing physical care at frequent intervals D. Reducing ambient noise and lighting
Rationale: Preterm infants benefit from developmental care that mimics the womb environment. Reducing light and noise minimizes stress, conserves energy, and promotes neurologic maturation. Swaddling and clustering care into longer intervals, not frequent handling, also help. Supine position is safe for sleep but does not by itself enhance development. The NICU environment should support quiet, gentle care to improve growth, regulation, and long-term outcomes.
41. A nurse is caring for a client in labor who has received epidural analgesia. The client’s blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which action should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Increase the rate of the primary IV infusion C. Position the client in semi-Fowler’s position D. Provide glucose via oral hydration or IV
Rationale: Hypotension after epidural anesthesia decreases uteroplacental perfusion, causing late decelerations. The immediate priority is to restore maternal circulation by increasing the IV fluid rate. This expands intravascular volume and helps improve blood pressure and fetal oxygenation. Semi-Fowler’s positioning does not enhance perfusion as effectively as a lateral position. Bladder emptying may be needed later, but it is not the priority during hypotension. Glucose administration does not address the cause of hypotension.
42. A nurse is assessing a postpartum client with preeclampsia who has a boggy uterus and excessive bleeding. Which medication should the nurse plan to administer? A. Terbutaline B. Magnesium sulfate C. Oxytocin D. Methylergonovine
Rationale: Oxytocin stimulates uterine contractions, which is the first-line treatment for postpartum hemorrhage due to uterine atony. Terbutaline is a tocolytic used to stop contractions, not start them. Magnesium sulfate is an anticonvulsant used in preeclampsia management, not hemorrhage. Methylergonovine is effective in controlling hemorrhage but is contraindicated in hypertensive clients because it elevates blood pressure. Administering oxytocin restores uterine tone, reduces bleeding, and prevents hypovolemic shock.
B. Positive home pregnancy test C. Cervical sensitivity noted on exam D. Gestational sac seen on ultrasound
Rationale: Presumptive signs are subjective symptoms experienced by the client, such as nausea, fatigue, or breast tenderness. Probable signs are objective findings such as a positive pregnancy test or cervical changes. Positive signs are diagnostic, such as ultrasound visualization of a fetus or auscultated fetal heart tones. Recognizing the classification of pregnancy indicators ensures proper patient teaching and prevents misinterpretation of early signs.
47. A nurse is monitoring the fetal heart rate tracings of a client in labor. Which finding should the nurse report? A. Baseline FHR 110–130/min B. Moderate baseline variability C. Accelerations with fetal movement D. Late decelerations with fetal bradycardia
Rationale: Late decelerations accompanied by bradycardia indicate uteroplacental insufficiency and possible fetal hypoxia. This is an ominous sign requiring immediate intervention such as maternal repositioning, oxygen administration, and discontinuation of oxytocin. A baseline of 110 – 130 is normal, variability is reassuring, and accelerations are expected. Prompt recognition of concerning FHR patterns ensures fetal safety and prevents adverse outcomes.
48. A nurse is reviewing the medical record of a client at 39 weeks gestation with polyhydramnios. Which finding should the nurse expect? A. Fundal height of 34 cm B. Pregnancy weight gain of 3.6 kg C. Gestational hypertension D. Fetal gastrointestinal anomaly
Rationale: Polyhydramnios often results from fetal conditions that impair swallowing, such as gastrointestinal anomalies (e.g., esophageal atresia). Excess amniotic fluid accumulates because the fetus cannot recycle it effectively. Fundal height is typically increased, not decreased. Weight gain of 3.6 kg is too low for late pregnancy. Hypertension is not directly associated with polyhydramnios. Recognizing this association allows nurses to anticipate possible complications and prepare for specialized neonatal care after delivery.
49. A nurse is assessing a 2-day-old newborn who has an egg-shaped, bluish swelling that does not cross suture lines. Which information should the nurse provide to the mother? A. This will resolve in 3 to 6 weeks without treatment B. This will disappear in 3–4 days C. The provider will drain the area with a syringe D. This is normal at birth and not a concern
Rationale: The finding described is a cephalohematoma, a collection of blood beneath the periosteum that does not cross suture lines. It typically resolves spontaneously within 3–6 weeks
as the blood reabsorbs. Unlike caput succedaneum, which resolves in days, cephalohematomas take longer. Aspiration or drainage is not indicated because of infection risk. Parental education reassures caregivers and prevents unnecessary anxiety while ensuring they monitor for complications such as jaundice from blood breakdown.
50. A nurse is preparing to obtain a newborn’s temperature. Which method should the nurse use? A. Axillary B. Temporal C. Tympanic D. Rectal
Rationale: The axillary method is safest and recommended for newborns because it avoids rectal trauma and reduces infection risk. Temporal and tympanic methods are less reliable due to immature ear canals and skin perfusion in neonates. Rectal temperatures may cause injury or stimulate the vagus nerve, leading to bradycardia. Teaching caregivers proper technique ensures safe and accurate temperature monitoring at home.
51. A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which finding should the nurse report to the provider? A. Frequent headaches B. Leukorrhea C. Epistaxis D. Numbness of fingers
Rationale: Frequent headaches may indicate elevated blood pressure or developing preeclampsia, which requires evaluation. Leukorrhea (increased vaginal discharge) and epistaxis (nosebleeds) are normal pregnancy changes due to hormonal influences. Occasional finger numbness may result from carpal tunnel syndrome. Distinguishing normal discomforts from warning signs ensures early recognition of complications and protects maternal and fetal health.
52. A nurse is teaching a pregnant client about exercise. Which information should the nurse include? A. Continue all sports and activities from before pregnancy B. Exercise intermittently throughout the day C. Limit exercise to walking only if you did not previously exercise D. Avoid vigorous exercise in hot, humid weather
Rationale: Pregnant women can remain active, but vigorous activity in hot, humid environments increases the risk of dehydration and hyperthermia, which may harm the fetus. Walking is a safe choice, but women who were active before pregnancy can continue modified exercise. Intermittent activity is not as beneficial as sustained moderate activity. Teaching promotes maternal fitness while minimizing risks such as overheating, falls, or trauma.
53. A nurse is caring for a newborn directly after birth. Which medication should the nurse administer within 1–2 hours of delivery?
Rationale: By two weeks postpartum, the uterus has returned into the pelvic cavity and is no longer palpable abdominally. Immediately after birth, the fundus is at or slightly above the umbilicus and gradually descends by about 1 cm per day. By day 6, it is midway between the umbilicus and pubis. Teaching mothers about uterine involution helps them recognize normal recovery versus warning signs such as subinvolution or infection.
57. A nurse is reviewing laboratory results for a client at 37 weeks gestation. The client is rubella non-immune, positive for group A strep, and has blood type O negative. What action should the nurse take? A. Administer Rho(D) immune globulin B. Request an antibiotic until delivery C. Instruct the client to obtain a rubella immunization after delivery D. Inform the client that a cesarean delivery is required
Rationale: The rubella vaccine is a live virus vaccine and is contraindicated during pregnancy. It should be administered postpartum to protect future pregnancies. Group B strep is treated with intrapartum antibiotics, not prophylactically at 37 weeks. Rho(D) immune globulin is indicated if the mother is Rh-negative and unsensitized with a risk of exposure. Cesarean delivery is not required. Teaching ensures safe maternal care and prevention of congenital rubella in future pregnancies.
58. A nurse is assessing a large-for-gestational-age newborn who becomes jittery, lethargic, and hypotonic with a weak cry. What action should the nurse take? A. Perform a heel stick to check blood glucose B. Obtain serum substance screening C. Provide sterile water feeding D. Screen for phenylketonuria (PKU)
Rationale: LGA newborns are at risk for hypoglycemia due to hyperinsulinemia, particularly if the mother had diabetes. Symptoms such as jitteriness and lethargy suggest hypoglycemia, which requires immediate glucose testing. Providing sterile water is inappropriate, as it can worsen hypoglycemia. PKU screening is routine but not urgent in this case. Serum drug screening is unrelated unless maternal history suggests exposure. Early recognition and correction of hypoglycemia prevent neurologic damage.
59. A nurse is caring for a laboring client whose membranes ruptured. The fetal monitor shows late decelerations. What action should the nurse take first? A. Turn the client onto her left side B. Palpate the uterus C. Administer oxygen D. Increase IV fluids
Rationale: Late decelerations indicate uteroplacental insufficiency. The first action is to improve circulation and oxygen delivery by repositioning the client laterally. This relieves pressure on the vena cava and enhances perfusion. Oxygen and IV fluids may follow, but repositioning is the immediate priority. Palpating the uterus is not a corrective measure. Prioritizing maternal
position change can quickly improve fetal oxygenation and prevent progression to hypoxic injury.
60. A nurse is assessing a pregnant client who reports increased nasal stuffiness. Which hormone is responsible for this discomfort? A. Relaxin B. Estrogen C. Progesterone D. Human chorionic somatomammotropin (hCS)
Rationale: Estrogen causes vascular engorgement and hyperemia of the nasal mucosa, leading to congestion and nosebleeds during pregnancy. Progesterone relaxes smooth muscle, contributing to constipation and reflux. Relaxin loosens pelvic joints. hCS influences maternal metabolism to provide nutrients for the fetus. Recognizing hormonal causes of discomfort allows the nurse to reassure clients and provide relief strategies, such as humidification or saline sprays.
61. A nurse is caring for a client receiving magnesium sulfate by continuous IV infusion. Which medication should the nurse keep at the bedside? A. Naloxone B. Calcium gluconate C. Protamine sulfate D. Atropine
Rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity. Signs of toxicity include respiratory depression, diminished reflexes, and cardiac dysrhythmias. Immediate availability of calcium gluconate allows rapid reversal of life-threatening complications. Naloxone is used for opioid overdose, protamine sulfate for heparin reversal, and atropine for bradycardia. Safety measures with high-alert medications like magnesium sulfate include continuous monitoring of respiratory status, deep tendon reflexes, and urine output to detect early signs of toxicity.
62. A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which method should the nurse recommend? A. Copper intrauterine device (IUD) B. Combination oral contraceptive pill C. Vaginal ring D. Medroxyprogesterone injection
Rationale: Estrogen-containing contraceptives, such as combination pills or vaginal rings, increase the risk of thromboembolism and are contraindicated in clients with a history of thrombophlebitis. Medroxyprogesterone (Depo-Provera) may also increase clot risk. A copper IUD is non-hormonal and provides long-term contraception without increasing thrombotic risk, making it the safest option for this client. Careful contraceptive counseling ensures safety while meeting the client’s reproductive goals.
C. Across-the-lap D. Cross-cradle
Rationale: The side-lying position minimizes perineal pressure, which reduces pain from the hematoma while allowing effective breastfeeding. Across-the-lap and cross-cradle positions put direct pressure on the perineum and increase discomfort. The clutch hold may also be uncomfortable in certain positions. Providing a position that supports breastfeeding while minimizing maternal pain promotes bonding and successful lactation while allowing perineal healing.
67. A nurse is teaching a client about toxoplasmosis prevention during pregnancy. Which instruction should the nurse include? A. Receive the MMR vaccine during pregnancy B. Avoid gardening to reduce risk of contracting toxoplasmosis C. Expect a rash if infected D. Know that toxoplasmosis is transmitted through mosquito bites
Rationale: Toxoplasmosis is a parasitic infection transmitted through contaminated soil, undercooked meat, and cat feces. Pregnant women should avoid gardening or handling cat litter to reduce exposure. The MMR vaccine does not prevent toxoplasmosis and is contraindicated in pregnancy. Toxoplasmosis often presents with mild or asymptomatic infection, not necessarily a rash. It is not vector-borne like malaria. Preventive education is crucial, as toxoplasmosis can cause severe congenital anomalies.
68. A nurse is caring for a client in early labor with severe preeclampsia. Which intervention should the nurse implement? A. Assess FHR and contractions hourly B. Encourage oral intake of clear fluids C. Instruct the client to ambulate in early labor D. Implement seizure precautions
Rationale: Severe preeclampsia places the client at high risk for eclampsia and seizures. The nurse should implement seizure precautions, including padded side rails, suction equipment, and oxygen availability. Hourly FHR assessment is insufficient; continuous monitoring is required. Ambulation and oral fluids are not safe in severe preeclampsia due to seizure and aspiration risk. Safety interventions prioritize maternal stabilization and prevention of life-threatening complications.
69. A nurse is teaching a client scheduled for an external cephalic version at 37 weeks. Which statement should the nurse make? A. The provider will insert a hand into your uterus and turn your baby B. You will receive a medication to relax your uterus before the procedure C. This procedure will be done at your next clinic visit D. Your baby’s heartbeat will be checked occasionally during the procedure
Rationale: External cephalic version involves manually turning a breech fetus to cephalic presentation. Tocolytics are administered to relax the uterus, and the procedure is performed in a hospital setting where fetal monitoring and emergency interventions are available. The provider does not insert a hand into the uterus; the procedure is external. Continuous, not occasional, monitoring of the FHR ensures safety. Proper teaching reduces maternal anxiety and promotes informed consent.
70. A nurse is caring for a client in labor who received meperidine for pain 1 hour prior to the second stage. What should the nurse assess for in the newborn after delivery? A. Reflexes B. Respiratory depression C. Bradycardia D. Signs of opiate withdrawal
Rationale: Meperidine crosses the placenta and may depress neonatal respiration if administered close to delivery. The nurse should prepare resuscitation equipment and monitor the infant closely. Reflexes are not immediately affected, and bradycardia is not the main concern. Withdrawal occurs in neonates exposed to chronic maternal opioid use, not single doses. Anticipating respiratory compromise ensures prompt intervention and reduces neonatal morbidity.
71. A nurse is performing a nonstress test (NST) on a client at 41 weeks gestation. The client asks the purpose of the test. Which response should the nurse provide? A. This test predicts whether you will deliver this week B. This test helps determine if your baby is healthy C. This test shows how your baby responds to contractions D. This test will show if your baby’s lungs are mature
Rationale: The NST evaluates fetal heart rate accelerations in response to fetal movement, indicating adequate oxygenation and neurologic function. It does not predict delivery timing or assess lung maturity. Contraction stress testing evaluates fetal response to contractions, not the NST. Educating the client about the purpose of testing fosters cooperation, reduces anxiety, and ensures timely recognition of fetal compromise.
72. A nurse is assessing a client who missed two menstrual cycles and suspects pregnancy. Which finding is a positive sign of pregnancy? A. Quickening B. Breast tenderness C. Uterine enlargement D. Auscultation of fetal heart rate
Rationale: Positive signs of pregnancy are those that provide direct evidence of a fetus, such as fetal heart sounds, ultrasound visualization, or examiner palpation of fetal movement. Quickening, breast tenderness, and uterine enlargement are presumptive or probable signs but are not conclusive. Teaching the difference between presumptive, probable, and positive signs helps clients understand the diagnostic process of pregnancy confirmation.
