2022-2023 ATI Maternal Newborn Proctored Exam With Answers-94 Solved Questions

ATI PROCTORED EXAM - MATERNAL NEWBORN GRADED A LATEST
2022/2023 COMPLETE EXAM
1. A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin
level. Which of the following actions should the nurse take?
A. Cover the newborn's eyes with a protective shield.
B. Maintain the newborn's temperature between 97.7°F and 99.5°F (36.5°C to 37.5°C).
C. Change the newborn's position every 2 hours.
D. Use a photometer to monitor the lamp's energy
Answer: D. Use a photometer to monitor the lamp's energy
Explanation:
The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is
receiving the appropriate amount to be effective.
Incorrect Answers:
A. emphasizes the importance of eye protection during phototherapy.
B. focuses on maintaining the newborn’s temperature to prevent complications.
C. highlights the need for regular repositioning to maximize light exposure.
2. A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which
of the following findings should the nurse expect?
A. Severe abdominal pain.
B. Fetal heart rate irregularities.
C. Uterine tenderness or rigidity.
D. Dark red vaginal bleeding
Answer: D. Dark red vaginal bleeding
Explanation:
The nurse should expect this client with a mild placental abruption to have minimal dark red
vaginal bleeding.
Incorrect Answers:

A. addresses the potential for abdominal pain, which may or may not be severe depending on the
degree of abruption.
B. notes that fetal heart rate irregularities can indicate a problem but may not be present in mild
cases.
C. highlights uterine tenderness as a possible finding associated with placental abruption.
3. A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of
the following actions should the nurse perform?
A. The nurse should not obtain a rectal temperature from a newborn due to the risk of rectal
perforation. Instead, the nurse should obtain an axillary temperature.
B. Assess the newborn's blood glucose level
C. Bathing a newborn will increase heat loss. The infant should not be bathed until the
temperature has stabilized within the normal range.
D. Placing the infant in front of a heater vent can incur heat loss through convection. Additionally,
there is a potential fire risk from the bassinet linens and the vent.
Answer: B. Assess the newborn's blood glucose level
Explanation:
Infants who become cold attempt to generate heat through increased muscular and metabolic
activity. This process increases glucose consumption and puts the newborn at risk of
hypoglycemia.
Incorrect Answers:
A. The nurse should not obtain a rectal temperature from a newborn due to the risk of rectal
perforation. Instead, the nurse should obtain an axillary temperature.
C. Bathing a newborn will increase heat loss. The infant should not be bathed until the
temperature has stabilized within the normal range.
D. Placing the infant in front of a heater vent can incur heat loss through convection. Additionally,
there is a potential fire risk from the bassinet linens and the vent.
4. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The
client begins to show indications of magnesium sulfate toxicity. Which of the following
medications should the nurse prepare to administer?

A. Protamine sulfate helps reverse the effects of heparin, not magnesium sulfate.
B. Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium sulfate.
C. Calcium gluconate
D. Flumazenil reverses the effects of benzodiazepines such as lorazepam and alprazolam, not
magnesium sulfate.
Answer: C. Calcium gluconate
Explanation:
The nurse should discontinue the magnesium sulfate infusion immediately and prepare to
administer calcium gluconate IV to reverse the effects of magnesium sulfate and to prevent
cardiac and respiratory arrest.
Incorrect Answers:
A. Protamine sulfate helps reverse the effects of heparin, not magnesium sulfate.
B. Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium sulfate.
D. Flumazenil reverses the effects of benzodiazepines such as lorazepam and alprazolam, not
magnesium sulfate.
5. A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast
discomfort relief measures. Which of the following pieces of information should the nurse
include?
A. The client should be instructed to wear a tight-fitting bra or breast binders to alleviate
engorgement and swelling.
B. "Place fresh cabbage leaves on your breasts."
C. Application of warmth to the breasts should be avoided because heat can stimulate milk
production. An ice pack should be used to relieve engorged breasts.
D. Milk should not be expressed from the breasts. This intervention would increase milk
production rather than decrease it.
Answer: B. "Place fresh cabbage leaves on your breasts."
Explanation:
After 3 days postpartum, the client's breasts can become swollen and distended because of
congestion of the vascular structures of the breasts.
Fresh cabbage leaves can be applied to engorged breasts to help

relieve breast discomfort.
The coolness of the leaves and the phytoestrogens exert a
therapeutic effect on engorged breasts.
Leaves should be replaced when they become wilted.
Incorrect Answers:
A. The client should be instructed to wear a tight-fitting bra or breast binders to alleviate
engorgement and swelling.
C. Application of warmth to the breasts should be avoided because heat can stimulate milk
production. An ice pack should be used to relieve engorged breasts.
D. Milk should not be expressed from the breasts. This intervention would increase milk
production rather than decrease it.
6. A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and
vomiting. Which of the following statements should the nurse include in the teaching?
A. The nurse should instruct the client to eat foods served at cool temperatures to decrease nausea
and vomiting.
B. The nurse should instruct the client to avoid brushing her teeth
immediately after eating to decrease vomiting.
C. The nurse should instruct the client to eat salty and tart foods during periods of nausea.
D. "You should eat dry foods that are high in carbohydrates when you wake up."
Answer: D. "You should eat dry foods that are high in carbohydrates when you wake up."
Explanation:
The nurse should instruct the client to eat foods that are high in carbohydrates such as dry toast or
crackers upon waking or when nausea occurs.
Incorrect Answers:
A. The nurse should instruct the client to eat foods served at cool temperatures to decrease nausea
and vomiting.
B. The nurse should instruct the client to avoid brushing her teeth
immediately after eating to decrease vomiting.
C. The nurse should instruct the client to eat salty and tart foods during periods of nausea.

7. A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client
states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the
following responses should the nurse make?
A. Breastfeeding can inhibit ovulation or prolong menstruation; however, it is not a reliable and
effective means of birth control. The client may experience an unplanned pregnancy if she waits
until her periods resume before considering birth control options.
B. Estrogen-containing birth control pills, implants, patches, and vaginal rings are not
recommended for clients who are breastfeeding due to the risk of inhibiting breast milk
production and supply.
C. Condoms and other non-hormonal birth control methods are appropriate for clients who are
breastfeeding; however, there are other methods that are also appropriate.
D. "A progestin-only pill or injection is available for use while you are breastfeeding."
Answer: D. "A progestin-only pill or injection is available for use while you are breastfeeding."
Explanation:
Progestin-only injections, implants, and birth control pills are acceptable options for clients who
are breastfeeding, although some experts recommend waiting until 6 weeks postpartum to initiate
the medication.
Incorrect Answers:
A. Breastfeeding can inhibit ovulation or prolong menstruation; however, it is not a reliable and
effective means of birth control. The client may experience an unplanned pregnancy if she waits
until her periods resume before considering birth control options.
B. Estrogen-containing birth control pills, implants, patches, and vaginal rings are not
recommended for clients who are breastfeeding due to the risk of inhibiting breast milk
production and supply.
C. Condoms and other non-hormonal birth control methods are appropriate for clients who are
breastfeeding; however, there are other methods that are also appropriate.
8. A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia
(PCA) pump following a caesarean birth. Which of the following findings should the nurse report
to the provider?

A. Opioid analgesics can cause respiratory depression. However, this respiratory rate is within the
expected reference range.
B. This temperature is within the expected reference range.
C. Dizziness is a common adverse effect of receiving opioid analgesics. The nurse should instruct
the client to sit on the side of the bed before getting up, assist the client with ambulation, and
implement general safety measures. However, it is not necessary to report this finding to the
provider.
D. Urine output 20 mL/hr
Answer: D. Urine output 20 mL/hr
Explanation:
Opioid analgesics such as morphine can cause urinary retention. The client should have a urinary
output of at least 30 mL/hr. The nurse should report this finding to the provider.
Incorrect Answers:
A. Opioid analgesics can cause respiratory depression. However, this respiratory rate is within the
expected reference range.
B. This temperature is within the expected reference range.
C. Dizziness is a common adverse effect of receiving opioid analgesics. The nurse should instruct
the client to sit on the side of the bed before getting up, assist the client with ambulation, and
implement general safety measures. However, it is not necessary to report this finding to the
provider.
9. A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is
scheduled for an external cephalic version. Which of the following statements should the nurse
make?
A. This action is appropriate for internal version. With external version, the provider attempts to
turn the fetus around externally and not internally.
B. "You will receive a medication to relax your uterus prior to the procedure."
C. External version is a high-risk procedure that is performed in a hospital setting in the event of
an emergency.

D. During the external version, the fetal heart-rate pattern is monitored continuously because the
fetus is at risk of bradycardia and variable decelerations. The nurse also monitors the fetal heart
rate for at least 60 minutes following the procedure.
Answer: B. "You will receive a medication to relax your uterus prior to the procedure."
Explanation:
A client who is scheduled to undergo an external cephalic version often receives a tocolytic prior
to the procedure to allow the uterus to relax. A relaxed uterus allows an easier version by the
provider.
Incorrect Answers:
A. This action is appropriate for internal version. With external version, the provider attempts to
turn the fetus around externally and not internally.
C. External version is a high-risk procedure that is performed in a hospital setting in the event of
an emergency.
D. During the external version, the fetal heart-rate pattern is monitored continuously because the
fetus is at risk of bradycardia and variable decelerations. The nurse also monitors the fetal heart
rate for at least 60 minutes following the procedure.
10. A postpartum nurse is caring for a client who reports excessive sweating during the first night
after delivery. Which of the following statements should the nurse make?
A. Postpartum diuresis is attributed to decreased estrogen levels, the removal of increased venous
pressure in the lower extremities, and the loss of the remaining pregnancy-induced increase in
blood volume.
B. Postpartum diuresis is caused by decreased estrogen levels. Fluid loss by urination and
perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum
period.
C. Postpartum diuresis is caused, in part, by the removal of increased venous pressure in the
lower extremities. Urine output can exceed 3000 mL/day during the first 2 to 3 days postpartum.
D. "This is a source of your fluid loss after delivery."
Answer: D. "This is a source of your fluid loss after delivery."
Explanation:

Postpartum diuresis is the loss of the remaining pregnancy induced increase in blood volume. The
loss of excess tissue fluid begins within 12 hours after birth. Fluid loss by urination and
perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum
period.
Incorrect Answers:
A. Postpartum diuresis is attributed to decreased estrogen levels, the removal of increased venous
pressure in the lower extremities, and the loss of the remaining pregnancy-induced increase in
blood volume.
B. Postpartum diuresis is caused by decreased estrogen levels. Fluid loss by urination and
perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum
period.
C. Postpartum diuresis is caused, in part, by the removal of increased venous pressure in the
lower extremities. Urine output can exceed 3000 mL/day during the first 2 to 3 days postpartum.
11. The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child
could have the same condition. The nurse should base the response on which of the following
inheritance patterns responsible for PKU?
A. Autosomal dominant
B. X-linked recessive
C. Autosomal recessive
D. Mitochondrial inheritance
Answer: C. Autosomal recessive
Explanation:
PKU is inherited by autosomal-recessive gene patterns. In these types of disorders, neither parent
may actually have the disorder, but both mother and father must carry and contribute a variant
gene for it to occur. Other autosomal-recessive disorders are cystic fibrosis and sickle cell anemia.
Incorrect Answers:
A. PKU does not have an X-linked recessive pattern of inheritance. In X-linked recessive
disorders, the abnormal gene is carried on the X chromosome. In males, only 1 copy of the
abnormal gene is required for the disorder to be expressed in males since the Y chromosome does

not carry the disorder. Females must have 2 copies of the gene. Examples of this type of disorder
are hemophilia and color blindness.
B. PKU does not have an X-linked dominant pattern of inheritance. In X-linked dominant
disorders, the abnormal gene is carried on the X chromosome. Only 1 copy of the abnormal gene
is necessary for the disorder to occur. However, males are more likely to be severely affected due
to the homozygous expression. There are only a few disorders that follow this pattern of
inheritance. Examples include vitamin D-resistant rickets and Rett syndrome.
D. PKU does not have an autosomal-dominant pattern of inheritance. In these disorders, only 1
copy of the variant gene is necessary for the disorder to occur. Examples of this type of disorder
are neurofibromatosis and Treacher Collins syndrome.
12. A nurse is teaching a client about physiological changes that can occur with menopause.
Which of the following changes should the nurse include?
A. The nurse should teach the client that urinary frequency, not hesitancy, can occur due to the
shrinking of the uterus, vulva, and distal portion of the urethra.
B. The nurse should teach the client that hematuria is a manifestation of irritation to the bladder
mucosa and might indicate a urinary tract infection. It is not an expected change associated with
menopause.
C. Stress incontinence
D. The nurse should teach the client that vaginal dryness can occur with menopause due to the
vaginal walls becoming thinner and drier, delaying lubrication. This can lead to painful
intercourse.
Answer: C. Stress incontinence
Explanation:
The nurse should teach the client that stress incontinence can occur due to the shrinking of the
uterus, vulva, and distal portion of the urethra. Urinary incontinence and uterine displacement can
occur because of common age-related changes but are not necessarily a result of menopauserelated changes.
Incorrect Answers:
A. The nurse should teach the client that urinary frequency, not hesitancy, can occur due to the
shrinking of the uterus, vulva, and distal portion of the urethra.

B. The nurse should teach the client that hematuria is a manifestation of irritation to the bladder
mucosa and might indicate a urinary tract infection. It is not an expected change associated with
menopause.
D. The nurse should teach the client that vaginal dryness can occur with menopause due to the
vaginal walls becoming thinner and drier, delaying lubrication. This can lead to painful
intercourse.
13. A nurse is providing education about newborn skin care for a group of new parents. Which of
the following instructions should the nurse include?
A. In uncircumcised males, the foreskin adheres to the glans of the penis. Parents should not
attempt to retract the foreskin before the age of 3 years. Parents should wash the penis with soap
and water.
B. Sponge bathe the newborn every other day
C. The parents should avoid using antimicrobial soaps and instead use soap with a neutral pH and
no preservatives to protect the acid mantle of the newborn's skin.
D. The parents should maintain the bath water temperature between 38° and 40°C (100° and
104°F).
Answer: B. Sponge bathe the newborn every other day
Explanation:
Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The
parents should sponge bathe the infant until the cord stump has detached and the area has healed.
Incorrect Answers:
A. In uncircumcised males, the foreskin adheres to the glans of the penis. Parents should not
attempt to retract the foreskin before the age of 3 years. Parents should wash the penis with soap
and water.
C. The parents should avoid using antimicrobial soaps and instead use soap with a neutral pH and
no preservatives to protect the acid mantle of the newborn's skin.
D. The parents should maintain the bath water temperature between 38° and 40°C (100° and
104°F).

14. A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful thirddegree perineal laceration. Which of the following interventions should the nurse take?
A. Warm sitz baths are appropriate after the first 24 hours postpartum. A cool sitz bath is
recommended within the first 24 hours to reduce edema and promote comfort.
B. The nurse should encourage the client to sit on firm surfaces. The client should avoid soft
pillows and donut pillows because they separate the buttocks and decrease venous blood flow,
resulting in more pain and discomfort to the perineal area.
C. Apply cold ice packs to the client's perineum
D. The use of suppositories or enemas is contraindicated for a client who has a third-degree
perineal laceration due to the severity of the laceration.
Answer: C. Apply cold ice packs to the client's perineum
Explanation:
A third-degree laceration extends from the perineum to the external sphincter of the rectum. This
can cause severe discomfort. Cold ice packs are used on the perineal area during the first 24 hours
to decrease edema, pain, and discomfort.
Incorrect Answers:
A. Warm sitz baths are appropriate after the first 24 hours postpartum. A cool sitz bath is
recommended within the first 24 hours to reduce edema and promote comfort.
B. The nurse should encourage the client to sit on firm surfaces. The client should avoid soft
pillows and donut pillows because they separate the buttocks and decrease venous blood flow,
resulting in more pain and discomfort to the perineal area.
D. The use of suppositories or enemas is contraindicated for a client who has a third-degree
perineal laceration due to the severity of the laceration.
15. A nurse is providing teaching to the parents of a newborn about home safety. Which of the
following statements by the parents indicates an understanding of the teaching?
A. "I will place my baby on his back when putting him to sleep."
B. The parents should not place the newborn's crib close to a heat source due to the risk of the
crib linen catching on fire.
C. The parents should always place the newborn in an approved car seat while driving with the
newborn. Infant carriers are no the approved safety seats for motor vehicles.

D. The parents should never tie any type of string or cord around the newborn's neck due to the
risk of strangulation.
Answer: A. "I will place my baby on his back when putting him to sleep."
Explanation:
Newborns should always sleep on the back to prevent sudden infant death syndrome.
Incorrect Answers:
B. The parents should not place the newborn's crib close to a heat source due to the risk of the
crib linen catching on fire.
C. The parents should always place the newborn in an approved car seat while driving with the
newborn. Infant carriers are no the approved safety seats for motor vehicles.
D. The parents should never tie any type of string or cord around the newborn's neck due to the
risk of strangulation.
16. A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the
following findings should the nurse expect?
A. Abundant lanugo
B. Newborns who are premature demonstrate hypotonia and a relaxed posture. Full-term
newborns demonstrate moderate flexion of the arms and legs.
C. Newborns who are premature have few heel creases. Full-term newborns have heel creases
that cover most of the bottom of the feet.
D. Newborns who are premature have abundant vernix caseosa, a thick whitish substance,
covering and protecting their skin in utero. Post-mature newborns are likely to have dry,
parchment-like skin.
Answer: A. Abundant lanugo
Explanation:
Newborns who are premature have abundant lanugo (fine hair), especially over their back. A fullterm newborn typically has minimal lanugo present only on the shoulders, pinna, and forehead.
Incorrect Answers:
B. Newborns who are premature demonstrate hypotonia and a relaxed posture. Full-term
newborns demonstrate moderate flexion of the arms and legs.

C. Newborns who are premature have few heel creases. Full-term newborns have heel creases
that cover most of the bottom of the feet.
D. Newborns who are premature have abundant vernix caseosa, a thick whitish substance,
covering and protecting their skin in utero. Post-mature newborns are likely to have dry,
parchment-like skin.
17. A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to
entering the second stage of labor. Which of the following actions should the nurse take?
A. Meperidine does not affect the client's reflexes. It reduces the transmission of pain impulses
through stimulation of the mu and kappa opioid receptors.
B. Assess the newborn for respiratory depression
C. Meperidine can cause tachycardia, nausea, vomiting, dizziness, and altered mental status.
D. Neonatal abstinence syndrome occurs in newborns who are exposed to opioids over a long
period of time during pregnancy.
Answer: B. Assess the newborn for respiratory depression
Explanation:
Meperidine should not be administered to laboring clients who are expected to deliver within 4
hours of the medication administration.
This medication crosses the placenta and causes respiratory depression in the newborn, which
peaks in 2 to 3 hours after administration. Narcan is ineffective at reversing the respiratory
depression caused by this medication.
Incorrect Answers:
A. Meperidine does not affect the client's reflexes. It reduces the transmission of pain impulses
through stimulation of the mu and kappa opioid receptors.
C. Meperidine can cause tachycardia, nausea, vomiting, dizziness, and altered mental status.
D. Neonatal abstinence syndrome occurs in newborns who are exposed to opioids over a long
period of time during pregnancy.
18. A client receiving an opiate during labor would not lead to opiate dependence in the newborn.
A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings
should the nurse expect?

A. Breast engorgement does not generally become problematic until 3 to 5 days after birth.
B. Hypothermia is unlikely during the fourth stage of labor. The nurse should measure the client's
temperature at this time, then every 4 hours for the first 8 hours, and then at least every 8 hours
after that. The client might feel chilly during this stage; if so, the nurse should provide a warmed
blanket.
C. Urinary retention
D. Rupture of membranes occurs spontaneously or via amniotomy prior to the second stage of
labor.
Answer: C. Urinary retention
Explanation:
After delivery, many clients have a reduced urge to urinate. This can result from birth trauma, a
larger bladder capacity after birth, analgesia, pelvic soreness, an episiotomy, and other factors.
Incorrect Answers:
A. Breast engorgement does not generally become problematic until 3 to 5 days after birth.
B. Hypothermia is unlikely during the fourth stage of labor. The nurse should measure the client's
temperature at this time, then every 4 hours for the first 8 hours, and then at least every 8 hours
after that. The client might feel chilly during this stage; if so, the nurse should provide a warmed
blanket.
D. Rupture of membranes occurs spontaneously or via amniotomy prior to the second stage of
labor.
19. A nurse is reviewing the medical record of a client at 39 weeks gestation who has
polyhydramnios. Which of the following R findings should the nurse expect?
A. Polyhydramnios will result in a fundal height greater than expected for gestational age.
B. Polyhydramnios will result in an increase in weight gain, not a decrease.
C. Gestational hypertension causes oligohydramnios, which is a decrease in the amount of
amniotic fluid surrounding the fetus.
D. Fetal gastrointestinal anomaly
Answer: D. Fetal gastrointestinal anomaly
Explanation:.

Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus.
Gastrointestinal malformations and neurological disorders are expected findings for a fetus
experiencing the effects of polyhydramnios.
Incorrect Answers:
A. Polyhydramnios will result in a fundal height greater than expected for gestational age.
B. Polyhydramnios will result in an increase in weight gain, not a decrease.
C. Gestational hypertension causes oligohydramnios, which is a decrease in the amount of
amniotic fluid surrounding the fetus.
20. A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus
gravidarum. Which of the following pieces of information should the nurse provide?
A. "You should slightly increase your exposure to sunlight."
B. Pruritus gravidarum is a condition of pregnancy that causes generalized itching that occurs due
to the stretching of the skin. It will resolve without extensive treatment after delivery.
C. Pruritus gravidarum is a condition of pregnancy that will go away after delivery. It has no
effect on the liver. Therefore, the client will not require weekly liver function studies.
D. Isotretinoin cream is used to treat acne. It should not be prescribed to a client who is pregnant
due to its teratogenic effects on the fetus.
Answer: A. "You should slightly increase your exposure to sunlight."
Explanation:
Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the
presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce
itching.
Incorrect Answers:
B. Pruritus gravidarum is a condition of pregnancy that causes generalized itching that occurs due
to the stretching of the skin. It will resolve without extensive treatment after delivery.
C. Pruritus gravidarum is a condition of pregnancy that will go away after delivery. It has no
effect on the liver. Therefore, the client will not require weekly liver function studies.
D. Isotretinoin cream is used to treat acne. It should not be prescribed to a client who is pregnant
due to its teratogenic effects on the fetus.

21. A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which
of the following findings is a risk factor for an ectopic pregnancy?
A. Anemia does not place the client at increased risk of an ectopic pregnancy.
B. Frequent urinary tract infections do not increase the risk of ectopic pregnancy.
C. A previous cesarean birth does not place the client at increased risk of an ectopic pregnancy.
D. Pelvic inflammatory disease (PID)
Answer: D. Pelvic inflammatory disease (PID)
Explanation:
An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and
the placenta, and the fetus begin to develop in this area.
The most common site is within a fallopian tube, but ectopic pregnancies can occur in the ovary
or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal
surgery. Therefore, PID places the client at risk of an ectopic pregnancy.
Incorrect Answers:
A. Anemia does not place the client at increased risk of an ectopic pregnancy.
B. Frequent urinary tract infections do not increase the risk of ectopic pregnancy.
C. A previous cesarean birth does not place the client at increased risk of an ectopic pregnancy.
22. A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. Which
of the following findings should the nurse expect? Show Explanation
A. The nurse should expect the client's temperature to be within the expected reference range
because a hydatidiform mole does not lead to hypothermia.
B. Dark brown vaginal discharge
C. The nurse should expect the client to have increased urinary output due to the elevated
maternal blood volume and pressure of the uterus on the maternal bladder.
D. The nurse should not expect to hear fetal heart tones because a viable embryo or fetus is not
present.
Answer: B. Dark brown vaginal discharge
Explanation:
A hydatidiform mole (a molar pregnancy) is a benign proliferative growth of the chorionic villi
that gives rise to multiple cysts. The products of conception transform into a large number of

edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually
dark brown and can contain grape-like clusters.
Incorrect Answers:
A. The nurse should expect the client's temperature to be within the expected reference range
because a hydatidiform mole does not lead to hypothermia.
C. The nurse should expect the client to have increased urinary output due to the elevated
maternal blood volume and pressure of the uterus on the maternal bladder.
D. The nurse should not expect to hear fetal heart tones because a viable embryo or fetus is not
present.
23. A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of
the following findings should the nurse report to the provider? Show Explanation
A. Frequent headaches
B. Leukorrhea is a common discomfort of pregnancy and is an abundant amount of vaginal
mucus that may occur throughout pregnancy.
C. Epistaxis is a common discomfort of pregnancy related to the increase of estrogen.
D. Periodic numbness of the fingers is a common discomfort of pregnancy due to compression of
the nerves and does not need to be reported to the provider.
Answer: A. Frequent headaches
Explanation:
The nurse should report frequent headaches to the provider. Frequent headaches, swelling of the
face and fingers, visual disturbances, and epigastric pain are associated with preeclampsia.
Incorrect Answers:
B. Leukorrhea is a common discomfort of pregnancy and is an abundant amount of vaginal
mucus that may occur throughout pregnancy.
C. Epistaxis is a common discomfort of pregnancy related to the increase of estrogen.
D. Periodic numbness of the fingers is a common discomfort of pregnancy due to compression of
the nerves and does not need to be reported to the provider.
24. A nurse is caring for a client who has oligohydramnios. Which of the following fetal
anomalies should the nurse expect?

A. Fetal cardiac anomalies do not affect the volume of amniotic fluid.
B. Renal agenesis
C. Fetal neural tube defects do not affect the volume of amniotic fluid.
D. Fetal hydrocephalus does not affect the volume of amniotic fluid.
Answer: B. Renal agenesis
Explanation:
Oligohydramnios is a volume of amniotic fluid that is < 300 mL during the third trimester of
pregnancy. This occurs when there is a renal system dysfunction or obstructive uropathy. The
absence of fetal kidneys will cause oligohydramnios.
Incorrect Answers:
A. Fetal cardiac anomalies do not affect the volume of amniotic fluid.
C. Fetal neural tube defects do not affect the volume of amniotic fluid.
D. Fetal hydrocephalus does not affect the volume of amniotic fluid.
25. A nurse is assessing a client on the first postpartum day. Findings include the following:
fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra
with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following
actions should the nurse take? Show Explanation
A. A slight maternal temperature increase is commonly seen in the first 6 to 10 days postpartum.
A pulse of 52/minute is within the expected reference range.
B. The nurse should massage the fundus when it is boggy.
C. Ask the client when she last voided
D. Administering an oxytocic agent is not an appropriate intervention. Oxytocic agents are given
to clients who have increased lochia rubra or a boggy fundus to promote uterine contractions.
Answer: C. Ask the client when she last voided
Explanation:
Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is
easily displaced when the bladder is full. The fundus should be firm at the midline. A deviated,
firm fundus indicates a full bladder. The nurse should assist the client to void.
Incorrect Answers:

A. A slight maternal temperature increase is commonly seen in the first 6 to 10 days postpartum.
A pulse of 52/minute is within the expected reference range.
B. The nurse should massage the fundus when it is boggy.
D. Administering an oxytocic agent is not an appropriate intervention. Oxytocic agents are given
to clients who have increased lochia rubra or a boggy fundus to promote uterine contractions.
26. A nurse is monitoring a client who is receiving spinal anesthesia. The nurse should identify
which of the following findings as a complication of the infusion? Show Explanation
A. Maternal hypotension
B. Spinal anesthesia is more likely to cause fetal bradycardia than fetal tachycardia.
C. Spinal anesthesia is more likely to cause minimal or a lack of fetal heart rate variability than
increased fetal heart rate variability.
D. Spinal anesthesia is more likely to cause a fever than hypothermia.
Answer: A. Maternal hypotension
Explanation:
Maternal hypotension is a common adverse effect of a spinal block. To prevent supine
hypotension, the client should lie on a side or lie supine with a wedge under a hip to displace the
uterus.
Incorrect Answers:
B. Spinal anesthesia is more likely to cause fetal bradycardia than fetal tachycardia.
C. Spinal anesthesia is more likely to cause minimal or a lack of fetal heart rate variability than
increased fetal heart rate variability.
D. Spinal anesthesia is more likely to cause a fever than hypothermia.
27. A nurse is caring for a client at 35 weeks gestation who has severe pre-eclampsia. Which of
the following assessments provides the most accurate information regarding the client's fluid and
electrolyte status? Show Explanation
A. The nurse should assess the client's blood pressure to evaluate circulatory status. However,
evidence-based practice indicates that another assessment provides more accurate information.
B. The nurse should assess the client's intake and output to evaluate fluid status. However,
evidence-based practice indicates that another assessment provides more accurate information.

C. Daily weight
D. The nurse should assess the severity of the client's edema to evaluate fluid status. However,
evidence-based practice indicates that another assessment provides more accurate information.
Answer: C. Daily weight
Explanation:
Evidence-based practice indicates that daily weight is the most accurate assessment to determine
a client's fluid and electrolyte status.
Incorrect Answers:
A. The nurse should assess the client's blood pressure to evaluate circulatory status. However,
evidence-based practice indicates that another assessment provides more accurate information.
B. The nurse should assess the client's intake and output to evaluate fluid status. However,
evidence-based practice indicates that another assessment provides more accurate information.
D. The nurse should assess the severity of the client's edema to evaluate fluid status. However,
evidence-based practice indicates that another assessment provides more accurate information.
28. A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad
has a large amount of lochia rubra with several clots. Which of the following actions should the
nurse perform first? Show Explanation
A. A full bladder can cause uterine atony. However, there is another action the nurse should take
first.
B. Massage the fundus
C. Vital signs are important but will not help in identifying the reason for this client's bleeding.
There is another action that the nurse should take first.
D. Administering carbo-prost is an appropriate action for managing postpartum haemorrhage.
However, there is another action the nurse should take first.
Answer: B. Massage the fundus
Explanation:
The nurse should apply the safety and risk-reduction priority setting framework, which assigns
priority to the factor or situation posing the greatest safety risk to the client.

When there are several risks to client safety, the one posing the greatest threat is the highest
priority. The primary cause of early postpartum bleeding is uterine atony, which is manifested by
a relaxed, boggy uterus.
Thus, the greatest risk for this client is hemorrhage. The nurse should massage the client's fundus
first. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework,
and/or nursing knowledge to identify which risk poses the greatest threat to the client.
Incorrect Answers:
A. A full bladder can cause uterine atony. However, there is another action the nurse should take
first.
C. Vital signs are important but will not help in identifying the reason for this client's bleeding.
There is another action that the nurse should take first.
D. Administering carboprost is an appropriate action for managing postpartum hemorrhage.
However, there is another action the nurse should take first.
29. A nurse is caring for a client who is postpartum and reports that her episiotomy incision is
pulling and stinging. Which of the following actions should the nurse take? Show Explanation
A. Provide a sitz bath with warm water for the client
B. Encourage the client to change positions frequently to alleviate pressure on the perineal area.
C. The nurse should instruct the client to perform Kegel exercises to strengthen perineal muscles
following a vaginal delivery. However, these exercises do not decrease episiotomy discomfort.
D. The nurse should administer prescribed analgesics, including topical anesthetic cream.
However, the cream should be applied no more than three to four times per day.
Answer: A. Provide a sitz bath with warm water for the client
Explanation:
The nurse should provide a client who is postpartum with a sitz bath to decrease episiotomy
discomfort. The use of a sitz bath provides warm, moist, direct heat to the incision area, which
helps relieve the pulling and stinging associated with the healing incision. The warm water
increases blood flow to the area through vasodilatation, which also promotes healing and comfort.
Incorrect Answers:

B. While changing positions may help reduce discomfort from pressure, it does not specifically
address the pulling and stinging sensations related to the episiotomy. This option may offer some
benefit, but it is less effective compared to a sitz bath in providing direct relief.
C. The nurse should instruct the client to perform Kegel exercises to strengthen perineal muscles
following a vaginal delivery. However, these exercises do not decrease episiotomy discomfort.
D. The nurse should administer prescribed analgesics, including topical anesthetic cream.
However, the cream should be applied no more than three to four times per day.
30. A nurse is caring for a client who is in labor and is reporting intense pain during contractions.
The client has no previous knowledge of nonpharmacological comfort measures. Which of the
following nursing interventions should the nurse implement?
A. Guided imagery
B. Aromatherapy
C. Distraction techniques
D. Slow-paced breathing
Answer: D. Slow-paced breathing
Explanation:
Slow-paced breathing is an easy technique for the client to learn quickly and practice
immediately. It provides distraction, which can help reduce the perception of pain. The pattern is
In-2-34/Out-2-3-4/In-2-3-4/Out-2-3-4. Repeating this cycle slows the client's breathing to about
half of its usual rate, which can help relax the client and improve oxygenation.
Incorrect Answers:
A. Self-hypnosis can help relieve labor pain, but clients might not be able to perform it if they
haven't already learned from specially trained practitioners.
B. Biofeedback can help relieve labor pain, but clients might not be able to implement it if they
haven't already learned from specially trained practitioners.
C. Specially trained practitioners perform acupuncture, so this is not something the nurse can
initiate.
31. A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion.
Which of the following medications should the nurse have available at the client's bedside?

A. The nurse should have naloxone available for a client who is receiving opioid medication in
case of respiratory depression.
B. Calcium gluconate
C. The nurse should have protamine sulfate available for a client who is receiving heparin in case
of hemorrhage.
D. The nurse should have atropine available for a client who is receiving medications that can
lead to asystole or sinus bradycardia, such as beta-adrenergic blockers.
Answer: B. Calcium gluconate
Explanation:
The nurse should have calcium gluconate available for a client who is receiving magnesium
sulfate by continuous IV infusion in case of magnesium sulfate toxicity. The nurse should monitor
the client for a respiratory rate of ≤12/min, muscle weakness, and depressed deep-tendon reflexes.
Incorrect Answers:
A. The nurse should have naloxone available for a client who is receiving opioid medication in
case of respiratory depression.
C. The nurse should have protamine sulfate available for a client who is receiving heparin in case
of hemorrhage.
D. The nurse should have atropine available for a client who is receiving medications that can
lead to asystole or sinus bradycardia, such as beta-adrenergic blockers.
32. A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The
nurse should monitor the client for which of the following potential adverse effects?
A. Diarrhea is not an adverse effect of oxytocin administration. Oxytocin can have adverse effects
that include fetal asphyxia, water intoxication, hypotension, and abruptio placentae.
B. Thromboembolism is not an adverse effect of oxytocin administration.
C. Fetal asphyxia
D. Oliguria is not a likely complication of oxytocin administration.
Answer: C. Fetal asphyxia
Explanation:
Oxytocin may cause tachysystole, which can lead to uteroplacental insufficiency. Inadequate
oxygen transfer to the placenta will result in fetal asphyxia.

Incorrect Answers:
A. Diarrhea is not an adverse effect of oxytocin administration. Oxytocin can have adverse effects
that include fetal asphyxia, water intoxication, hypotension, and abruptio placentae.
B. Thromboembolism is not an adverse effect of oxytocin administration.
D. Oliguria is not a likely complication of oxytocin administration.
33. A nurse is caring for a client who is receiving magnesium sulfate IV. Which of the following
medications should the nurse have available as an antidote to magnesium sulfate? Show
Explanation
A. Betamethasone is administered to help mature the lungs of the premature fetus before delivery.
It is not an antidote to magnesium sulfate.
B. Terbutaline is a smooth muscle relaxer administered to inhibit uterine contractions in
premature labor. It is not an antidote to magnesium sulfate.
C. Calcium gluconate
D. Indomethacin relaxes uterine smooth muscle and is administered to stop preterm labor. It is not
an antidote to magnesium sulfate.
Answer: C. Calcium gluconate
Explanation:
Calcium gluconate should be kept available as the antidote for magnesium sulfate toxicity.
Incorrect Answers:
A. Betamethasone is administered to help mature the lungs of the premature fetus before delivery.
It is not an antidote to magnesium sulfate.
B. Terbutaline is a smooth muscle relaxer administered to inhibit uterine contractions in
premature labor. It is not an antidote to magnesium sulfate.
D. Indomethacin relaxes uterine smooth muscle and is administered to stop preterm labor. It is not
an antidote to magnesium sulfate.
34. A nurse is teaching a client about breastfeeding. Which of the following client statements
indicates an understanding of the teaching? Show Explanation
A. A client who is breastfeeding requires an additional 500 calories per day to support
lactogenesis.

B. The client should not introduce an artificial nipple to the newborn until breastfeeding is well
established (in approximately 3 or 4 weeks).
C. "I may notice increased cramping when I am feeding my baby."
D. The client should breastfeed on demand, not place the newborn on a strict feeding schedule.
Forcing a newborn to wait for a feeding can lead to weight loss and failure to thrive.
Answer: C. "I may notice increased cramping when I am feeding my baby."
Explanation:
The client may notice an increase in uterine cramping while breastfeeding due to the release of
oxytocin, which causes uterine muscle contraction.
Incorrect Answers:
A. A client who is breastfeeding requires an additional 500 calories per day to support
lactogenesis.
B. The client should not introduce an artificial nipple to the newborn until breastfeeding is well
established (in approximately 3 or 4 weeks).
D. The client should breastfeed on demand, not place the newborn on a strict feeding schedule.
Forcing a newborn to wait for a feeding can lead to weight loss and failure to thrive.
35. A nurse is discussing contraceptive choices with a client who has a history of
thrombophlebitis. Which of the following methods of contraception should the nurse
recommend? Show Explanation
A. Copper intrauterine device
B. A history of thrombophlebitis is a contraindication for taking oral contraceptives. Safer
methods of contraception for this client include barrier methods and spermicides.
C. A history of thrombophlebitis is a contraindication for a vaginal insert that releases hormones
continuously. Safer methods of contraception for this client include barrier methods and
spermicides.
D. A history of thrombophlebitis is a contraindication for injectable progestins. Safer methods of
contraception for this client include barrier methods and spermicides.
Answer: A. Copper intrauterine device
Explanation:

A history of thrombophlebitis is a contraindication for the use of hormonal contraceptive methods
such as oral combinations of estrogen and progesterone in pill form, vaginal inserts that release
hormones continuously, and injectable progestins. A copper intrauterine device that does not
contain hormones is a safer choice for this client. Other options for this client include barrier
methods and spermicides.
Incorrect Answers:
B. A history of thrombophlebitis is a contraindication for taking oral contraceptives. Safer
methods of contraception for this client include barrier methods and spermicides.
C. A history of thrombophlebitis is a contraindication for a vaginal insert that releases hormones
continuously. Safer methods of contraception for this client include barrier methods and
spermicides.
D. A history of thrombophlebitis is a contraindication for injectable progestins. Safer methods of
contraception for this client include barrier methods and spermicides.
36. A nurse is teaching a client about a nonstress test. Which of the following statements by the
client indicates an understanding of the teaching? Show Explanation
A. There is no reason for the client to be NPO for this test. The client is encouraged to eat prior to
the test in order for the fetus to be more active. When the fetus is asleep, the nurse often offers the
client orange juice to stimulate the fetus.
B. The client does not need medication to induce contractions. Oxytocin is used to induce
contractions for an oxytocin challenge test.
C. “I should press the button on the handheld marker when my baby moves.”
D. The client does not need to perform nipple stimulation to induce contractions; this is needed
for a contraction stress test.
Answer: C. “I should press the button on the handheld marker when my baby moves.”
Explanation:
The purpose of the test is to assess fetal wellbeing. The client should press the button on the
handheld marker when she feels fetal movement.
Incorrect Answers:

A. There is no reason for the client to be NPO for this test. The client is encouraged to eat prior to
the test in order for the fetus to be more active. When the fetus is asleep, the nurse often offers the
client orange juice to stimulate the fetus.
B. The client does not need medication to induce contractions. Oxytocin is used to induce
contractions for an oxytocin challenge test.
D. The client does not need to perform nipple stimulation to induce contractions; this is needed
for a contraction stress test.
37. A nurse is teaching a client who is pregnant about nonstress testing. Which of the following
pieces of information should the nurse include?
A. Nonstress testing is non-invasive and causes no risk to either the client or the fetus. It can be
used as a screening procedure in all pregnancies.
B. "If the test is positive, that means your baby's heart rate is healthy."
C. The test measures the response of the fetal heart rate to fetal movement. The fetal heart rate
should increase by about 15 beats/min when the fetus moves and should remain increased for
about 15 seconds.
D. The test would be identified as nonreactive if there is no fetal movement during the testing
period or if the fetal heart rate variability is under 6 beats/min.
Answer: B. "If the test is positive, that means your baby's heart rate is healthy."
Explanation:
The fetal heart rate is considered healthy if the results of nonstress testing are positive. If the test
is negative, fetal health may be affected, and further testing may be necessary to rule out poor
oxygen perfusion of the fetus.
Incorrect Answers:
A. Nonstress testing is noninvasive and causes no risk to either the client or the fetus. It can be
used as a screening procedure in all pregnancies.
C. The test measures the response of the fetal heart rate to fetal movement. The fetal heart rate
should increase by about 15 beats/min when the fetus moves and should remain increased for
about 15 seconds.
D. The test would be identified as nonreactive if there is no fetal movement during the testing
period or if the fetal heart rate variability is under 6 beats/min.

38. A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy.
Which of the following psychological tasks should the nurse expect the client to accomplish
during this trimester?
A. Accepting the pregnancy
B. Preparing for the end of pregnancy is a psychological task that the client is expected to
accomplish during the third trimester.
C. Preparing for parenthood is a psychological task that the client is expected to accomplish
during the third trimester.
D. Accepting the baby is a psychological task that the client is expected to accomplish during the
second trimester.
Answer: A. Accepting the pregnancy
Explanation:
Accepting the pregnancy is a psychological task that the client is expected to accomplish during
the first trimester.
Incorrect Answers:
B. Preparing for the end of pregnancy is a psychological task that the client is expected to
accomplish during the third trimester.
C. Preparing for parenthood is a psychological task that the client is expected to accomplish
during the third trimester.
D. Accepting the baby is a psychological task that the client is expected to accomplish during the
second trimester.
39. A nurse is assessing a client who has placenta previa. Which of the following findings should
the nurse expect?
A. Painless, bright red bleeding
B. Uterine hypertonicity is a manifestation of placental abruption, not placenta previa.
C. Uterine tonicity is normal with placenta previa; it does not cause contractions.
D. Abdominal tenderness or pain is a manifestation of placental abruption, not placenta previa.
Answer: A. Painless, bright red bleeding
Explanation:

Placenta previa is the placement of the placenta low in the uterus. Depending on the severity,
manifestations include bright red vaginal bleeding and a fundal height higher than expected for
the gestational age. The presenting part is higher due to the placenta taking up space inside the
lower part of the uterus.
Incorrect Answers:
B. Uterine hypertonicity is a manifestation of placental abruption, not placenta previa.
C. Uterine tonicity is normal with placenta previa; it does not cause contractions.
D. Abdominal tenderness or pain is a manifestation of placental abruption, not placenta previa.
40. A nurse is calculating a pregnant client's estimated date of delivery using Naegele's rule. The
client's last menstrual period started on January 20. Which of the following is the client's expected
date of delivery? Show Explanation
A. An expected date of delivery of October 13 would follow a last menstrual period date of
January 6.
B. An expected date of delivery of November 13 would follow a last menstrual period date of
February 6.
C. October 27
D. An expected date of delivery of November 27 would follow a last menstrual period date of
February 20.
Answer: C. October 27
Explanation:
Naegele's rule involves subtracting 3 months from the first day of the last menstrual period and
adding 7 days.
Incorrect Answers:
A. An expected date of delivery of October 13 would follow a last menstrual period date of
January 6.
B. An expected date of delivery of November 13 would follow a last menstrual period date of
February 6.
D. An expected date of delivery of November 27 would follow a last menstrual period date of
February 20.

41. A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections
should be reported to the public health department? Show Explanation
A. Bacterial vaginosis, also known as vaginitis, is the most common vaginal infection.
Manifestations include client report of a "fishy odor" and vaginal discharge that appears thin,
watery, gray, white, or milky. The client might also report pruritus. This vaginal infection does not
require reporting; however, it should be treated with metronidazole or clindamycin cream.
B. Trichomoniasis can be asymptomatic. Manifestations include greenish to yellowish
mucopurulent, frothy, malodorous discharge. This vaginal infection does not require reporting.
C. Candidiasis, also known as a yeast infection, is the second most common vaginal infection.
Manifestations include a client report of thick, cottage cheese-like discharge and vaginal itching.
This vaginal infection does not require reporting.
D. Gonorrhea
Answer: D. Gonorrhea
Explanation:
Gonorrhea is often asymptomatic. The client might have purulent endocervical discharge.
Gonorrhea is one of the infectious conditions on the Nationally Notifiable Infections list and
should be reported by the nurse to the community health department, which will report the
infection to the CDC.
Incorrect Answers:
A. Bacterial vaginosis, also known as vaginitis, is the most common vaginal infection.
Manifestations include client report of a "fishy odor" and vaginal discharge that appears thin,
watery, gray, white, or milky. The client might also report pruritus. This vaginal infection does not
require reporting; however, it should be treated with metronidazole or clindamycin cream.
B. Trichomoniasis can be asymptomatic. Manifestations include greenish to yellowish
mucopurulent, frothy, malodorous discharge. This vaginal infection does not require reporting.
C. Candidiasis, also known as a yeast infection, is the second most common vaginal infection.
Manifestations include a client report of thick, cottage cheese-like discharge and vaginal itching.
This vaginal infection does not require reporting.
42. A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is
common during pregnancy. Which of the following responses should the nurse make?

A. This is a close-ended response that discourages further communication.
B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections
more common."
C. This is a close-ended response that discourages further communication and is both
nontherapeutic and inaccurate.
D. Asking "why" questions typically makes clients feel defensive.
Answer: B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast
infections more common."
Explanation:
This is an information-seeking question; therefore, the therapeutic response is an answer that
provides the client with the information she requested.
Incorrect Answers:
A. This is a close-ended response that discourages further communication.
C. This is a close-ended response that discourages further communication and is both
nontherapeutic and inaccurate.
D. Asking "why" questions typically makes clients feel defensive.
43. A nurse is planning care for a client in labor who is positive for HIV. Which of the following
actions should the nurse take after the baby is born? Show Explanation
A. In the United States and Canada, breastfeeding should be avoided by mothers who are HIV
positive.
B. Administer the hepatitis B vaccine prior to discharge
C. The nurse should use standard precautions when caring for a newborn who has been exposed
to HIV.
D. To test a newborn for the presence of HIV, a sample of the newborn's blood must be obtained.
Maternal antibodies will be present in the cord blood and can affect the test results.
Answer: B. Administer the hepatitis B vaccine prior to discharge
Explanation:
Infants who are exposed to HIV should receive all routine vaccinations. Infants who are infected
with HIV can receive all inactivated vaccinations.
Incorrect Answers:

A. In the United States and Canada, breastfeeding should be avoided by mothers who are HIV
positive.
C. The nurse should use standard precautions when caring for a newborn who has been exposed
to HIV.
D. To test a newborn for the presence of HIV, a sample of the newborn's blood must be obtained.
Maternal antibodies will be present in the cord blood and can affect the test results.
44. A nurse is assessing a client who is at 36 weeks of gestation. Which of the following
manifestations should the nurse recognize as a potential prenatal complication and report to the
provider?
A. Varicose veins are a common manifestation associated with pregnancy. They are caused by the
relaxation of the smooth muscle walls of the veins and pelvic Vaso congestion.
B. Double vision
C. Leukorrhea is a hormonal production of an abundant amount of mucus. It is a common
manifestation associated with pregnancy.
D. Flatulence is a common manifestation associated with pregnancy. Progesterone causes reduced
gastrointestinal motility.
Answer: B. Double vision
Explanation:
Double vision, blurred vision, or visual disturbances are signs of potential complications
associated with preeclampsia. The nurse should report this finding to the provider.
Incorrect Answers:
A. Varicose veins are a common manifestation associated with pregnancy. They are caused by the
relaxation of the smooth muscle walls of the veins and pelvic Vaso congestion.
C. Leukorrhea is a hormonal production of an abundant amount of mucus. It is a common
manifestation associated with pregnancy.
D. Flatulence is a common manifestation associated with pregnancy. Progesterone causes reduced
gastrointestinal motility.
45. A nurse is caring for a client who had a precipitous delivery. Which of the following
assessments is the priority during the fourth stage of labor?

A. The nurse should monitor the client's temperature during the fourth stage of labor; however,
another assessment is the priority.
B. The nurse should assess the client's perineum, especially if an episiotomy or laceration is
present; however, another assessment is the priority.
C. Palpating the client's fundus
D. The nurse should check the client for hemorrhoids during the fourth stage of labor; however,
another assessment is the priority.
Answer: C. Palpating the client's fundus
Explanation:
The nurse should apply the safety and risk-reduction priority setting framework, which assigns
priority to the factor or situation posing the greatest safety risk to the client. When there are
several risks to client safety, the one posing the greatest threat is the highest priority.
The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or
nursing knowledge to identify which risk poses the greatest threat to the client. A precipitous
delivery follows a labor of 100/min; a score of 2 for a good, strong cry,
which shows normal respiratory effort; a score of 2 for well-flexed extremities, which shows
normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a
score of 1 for blue hands and feet, which is known as acrocyanosis.
Incorrect Answers:
A. 7 is not the correct Apgar score for this newborn.
B. 8 is not the correct Apgar score for this newborn.
D. 10 is not the correct Apgar score for this newborn.
78. A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her
newborn. During an examination of the client's breasts, the nurse notes that they are warm and
firm. Which of the following actions should the nurse plan to take?
A. If the client pumps her breasts, milk production will increase. A client who is formula-feeding
her newborn needs to decrease milk production.
B. Taking warm showers will increase milk production.
C. Breast massage will not only be uncomfortable but also will increase milk production.
D. Instruct the client to apply cold compresses
Answer: D. Instruct the client to apply cold compresses
Explanation:
To help relieve breast engorgement, the client should apply cold compresses for about 15 minutes
every hour. The client can also try applying fresh, cold cabbage leaves to the breasts.
Incorrect Answers:
A. If the client pumps her breasts, milk production will increase. A client who is formula-feeding
her newborn needs to decrease milk production.
B. Taking warm showers will increase milk production.
C. Breast massage will not only be uncomfortable but also will increase milk production.
79. A nurse is teaching a client during the client's first prenatal visit. Which of the following
instructions should the nurse include?
A. The nurse should be able to hear fetal heart tones with a fetoscope by the end of the sixteenth
week of gestation.

B. Typically, the sex of the fetus is distinguishable on a sonogram by the end of the twelfth week.
C. "A Doppler device can detect your baby's heart rate at 12 weeks."
D. Quickening (feeling fetal movement) is typically possible at 14 to 16 weeks in multiparous
clients; however, it is sometimes not possible until week 18 or later in nulliparous clients.
Answer: C. "A Doppler device can detect your baby's heart rate at 12 weeks."
Explanation:
The nurse should be able to detect the fetal heartbeat with a Doppler device toward the end of the
first trimester, often as early as 10 weeks of gestation.
Incorrect Answers:
A. The nurse should be able to hear fetal heart tones with a fetoscope by the end of the sixteenth
week of gestation.
B. Typically, the sex of the fetus is distinguishable on a sonogram by the end of the twelfth week.
D. Quickening (feeling fetal movement) is typically possible at 14 to 16 weeks in multiparous
clients; however, it is sometimes not possible until week 18 or later in nulliparous clients.
80. A nurse is caring for a client who believes she may be pregnant. Which of the following
findings should the nurse identify as a positive sign of pregnancy?
A. Palpable fetal movement
B. Chadwick's sign is a bluish discoloration of the cervix, vagina, and vulva that occurs at 6 to 8
weeks of pregnancy. This is a probable sign of pregnancy. After the client's first pregnancy, this
discoloration can remain, reducing its value as an indicator in subsequent pregnancies.
C. A positive pregnancy test is a probable sign of pregnancy. A client can also have a positive
pregnancy test due to menopause, choriocarcinoma, and hydatidiform mole.
D. Amenorrhea, or lack of a menstrual period, is a presumptive sign of pregnancy. A client also
can have amenorrhea due to stress, endocrine disorders, and significant weight loss.
Answer: A. Palpable fetal movement
Explanation:
Palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal
movement, is a presumptive sign of pregnancy.
Incorrect Answers:
A. Palpable fetal movement

B. Chadwick's sign is a bluish discoloration of the cervix, vagina, and vulva that occurs at 6 to 8
weeks of pregnancy. This is a probable sign of pregnancy. After the client's first pregnancy, this
discoloration can remain, reducing its value as an indicator in subsequent pregnancies.
C. A positive pregnancy test is a probable sign of pregnancy. A client can also have a positive
pregnancy test due to menopause, choriocarcinoma, and hydatidiform mole.
D. Amenorrhea, or lack of a menstrual period, is a presumptive sign of pregnancy. A client also
can have amenorrhea due to stress, endocrine disorders, and significant weight loss.
81. A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which
of the following medications should the nurse plan to administer?
A. Betamethasone
B. The nurse should administer misoprostol to stimulate uterine contractions for a client who is
undergoing labor induction.
C. The nurse should administer methylergonovine to stimulate uterine contractions for a client
who is experiencing postpartum hemorrhage.
D. The nurse should administer poractant alfa, a synthetic lung surfactant, to a preterm newborn
who is experiencing respiratory distress.
Answer: A. Betamethasone
Explanation:
The nurse should plan to administer betamethasone IM, a glucocorticoid, to stimulate fetal lung
maturity and prevent respiratory depression.
Incorrect Answers:
B. The nurse should administer misoprostol to stimulate uterine contractions for a client who is
undergoing labor induction.
C. The nurse should administer methylergonovine to stimulate uterine contractions for a client
who is experiencing postpartum hemorrhage.
D. The nurse should administer poractant alfa, a synthetic lung surfactant, to a preterm newborn
who is experiencing respiratory distress.
82. A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her
newborn. Which of the following instructions should the nurse include in the teaching?

A. Warm water running over the breasts can stimulate milk production.
B. "Place ice packs on your breasts."
C. The client should wear a well-fitting, supportive bra to provide comfort as the breasts fill with
milk.
D. The client should drink 2 to 3 L of fluid per day to promote normal bowel function.
Answer: B. "Place ice packs on your breasts."
Explanation:
The nurse should instruct the client to place ice packs on her breasts using a "15 minutes on and
45 minutes off" schedule to decrease swelling of the breast tissue as the body produces milk.
Incorrect Answers:
A. Warm water running over the breasts can stimulate milk production.
C. The client should wear a well-fitting, supportive bra to provide comfort as the breasts fill with
milk.
D. The client should drink 2 to 3 L of fluid per day to promote normal bowel function.
83. A nurse is assessing a postpartum client who reports strong contractions whenever she
breastfeeds her newborn. The nurse should respond with which of the following statements?
A. "This is unusual and you should be concerned."
B. "You need to relax; stress can increase uterine contractions."
C. "Try to breastfeed more frequently to help your uterus contract."
D. "The same hormone that is released in response to the baby's sucking and causes milk to flow
also makes the uterus contract."
Answer: D. "The same hormone that is released in response to the baby's sucking and causes
milk to flow also makes the uterus contract."
Explanation:
Oxytocin is released in response to breastfeeding. This hormone also causes the uterus to
contract, which decreases the risk for postpartum hemorrhage and increases involution.
Incorrect Answers:
A. This response may cause unnecessary anxiety. While strong contractions can be surprising,
they are a normal physiological response to breastfeeding due to oxytocin release.

B. While relaxation is important, this response does not address the physiological reason for the
contractions. It may also imply that the client is causing the contractions through stress, which is
misleading.
D. Although breastfeeding does stimulate uterine contractions, suggesting more frequent
breastfeeding could mislead the client into thinking they should be uncomfortable for the benefit
of uterine contraction, rather than understanding that the contractions are a normal part of the
breastfeeding process.
84. A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of
the following actions should the nurse take to promote development?
A. The nurse should assess the newborn to determine how well she will tolerate feedings and
gradually make changes. Rapidly advancing feedings can lead to fluid retention, hyponatremia,
vomiting, diarrhea, and apnea.
B. Position the naked newborn on the parent's bare chest
C. Newborns need uninterrupted periods of sleep to promote self-regulation. Light and sounds are
adverse stimuli and can increase stress in a newborn who is premature.
D. Nonnutritive sucking can decrease oxygen use and energy, which can lead to decreased
restlessness.
Answer: B. Position the naked newborn on the parent's bare chest
Explanation:
Positioning the naked newborn on the parent's bare chest can decrease stress in the parent and the
newborn. This action can help maintain thermal stability, raise oxygen saturation, increase
feeding strength, and promote breastfeeding.
Incorrect Answers:
A. The nurse should assess the newborn to determine how well she will tolerate feedings and
gradually make changes. Rapidly advancing feedings can lead to fluid retention, hyponatremia,
vomiting, diarrhea, and apnea.
C. Newborns need uninterrupted periods of sleep to promote self-regulation. Light and sounds are
adverse stimuli and can increase stress in a newborn who is premature.
D. Nonnutritive sucking can decrease oxygen use and energy, which can lead to decreased
restlessness.

85. A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which
of the following assessments will indicate whether the bleeding is caused by placenta previa or an
abruptio placenta?
A. Uterine tone
B. Fetal distress may be present in both abruptio placenta and placenta previa.
C. Hypotension may be present in both conditions.
D. The amount of blood loss is not diagnostic of the cause of the bleeding.
Answer: A. Uterine tone
Explanation:
The uterus will be relaxed, soft, and painless if the bleeding is caused by placenta previa.
With abruptio placenta, the uterus will be firm and board-like, and the client will complain of
pain.
Incorrect Answers:
B. Fetal distress may be present in both abruptio placenta and placenta previa.
C. Hypotension may be present in both conditions.
D. The amount of blood loss is not diagnostic of the cause of the bleeding.
86. A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor.
Which of the following actions should the nurse take?
A. Promote active movement in and out of bed
B. Having the client hold her breath while pushing increases intrathoracic and cardiovascular
pressure and decreases the amount of oxygen that reaches the fetus.
C. The nurse should assess the client's vital signs every 5 to 30 minutes while the client is in the
second stage of labor.
D. The client should remain on bedrest during this stage of labor due to impending delivery.
Answer: A. Promote active movement in and out of bed
Explanation:
During the early stages of labor, the nurse should encourage activity through walking, kneeling,
squatting, being on hands and knees, or whatever the client prefers. This can help shorten the
earlier stage. During the second stage, the client should remain in bed if her membranes have

ruptured or if she has received analgesics. In bed, she should lie on her left side often but shift
positions frequently for comfort and to promote the progression of labor.
Incorrect Answers:
B. Having the client hold her breath while pushing increases intrathoracic and cardiovascular
pressure and decreases the amount of oxygen that reaches the fetus.
C. The nurse should assess the client's vital signs every 5 to 30 minutes while the client is in the
second stage of labor.
D. The client should remain on bedrest during this stage of labor due to impending delivery.
87. A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors
places the client at risk of uterine atony? (Select all that apply.)
A. Magnesium sulfate infusion
B. Distended bladder
C. Use of a tocolytic agent during labor.
D. Prolonged labor
Answer: A. Magnesium sulfate infusion
B. Distended bladder
D. Prolonged labor
Explanation:
Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the
uterus. After birth, clients can experience a decreased urge to void due to birth-induced trauma,
increased bladder capacity, and anesthetics, which can result in a distended bladder. A distended
bladder displaces the uterus and can prevent adequate contraction of the uterus. Also, prolonged
labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus
from contracting.
Incorrect Answers:
C. This option is marked incorrect because, while tocolytic agents are used to stop contractions
during labor, they are not typically highlighted as a direct risk factor for uterine atony after
delivery in the same way as magnesium sulfate or a distended bladder. Tocolytics primarily
prevent premature labor rather than contributing to uterine atony post-delivery. Although they
may have an indirect effect, they are not as clearly associated with uterine atony compared to the

other factors listed. Thus, while they can influence uterine function, they are not a primary risk
factor for uterine atony like magnesium sulfate, a distended bladder, or prolonged labor.
88. A nurse is providing teaching to the parents of a newborn about how to care for his
circumcision at home. Which of the following instructions should the nurse include in the
teaching?
A. Clean the circumcision site with warm water during diaper changes.
B. Apply a thin layer of petroleum jelly to the circumcision site.
C. Watch for signs of infection, such as increased redness or discharge.
D. Encourage non-nutritive sucking for pain relief
Answer: D. Encourage non-nutritive sucking for pain relief
Explanation:
Allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain
management.
Incorrect Answers:
A. This is an important instruction. Keeping the circumcision site clean helps prevent infection.
Parents should be advised to gently clean the area with warm water, avoiding soap or other
irritants until the site is fully healed.
B. This is also a common recommendation. Applying a thin layer of petroleum jelly can help
protect the healing skin and prevent the diaper from sticking to the site, reducing discomfort
during diaper changes.
C. Parents should be instructed to monitor the circumcision site for any signs of infection. This
includes increased redness, swelling, discharge, or a fever, which would necessitate contacting a
healthcare provider.
89. A nurse is counseling a female client who expresses a desire to conceive in the near future.
Which of the following dietary recommendations should the nurse make to prevent neural tube
defects?
A. Increase intake of iron-rich foods.
B. Consume more dairy products for calcium.
C. Eat a diet high in complex carbohydrates.

D. Begin taking a folic acid supplement
Answer: D. Begin taking a folic acid supplement
Explanation:
Adequate amounts of folic acid are necessary for fetal neural tube development. All women of
child-bearing age and intention should take a folic acid supplement of 0.4 mg.
Incorrect Answers:
A. While increasing iron intake is important for overall health and is particularly critical during
pregnancy to prevent anemia, it does not specifically prevent neural tube defects. Iron is essential
for the development of the fetus and the mother’s blood volume, but it is not directly linked to the
prevention of neural tube defects.
B. Calcium is important for bone health and fetal development, but like iron, it does not
specifically prevent neural tube defects. While dairy products are beneficial in a balanced diet,
they do not address the risk of neural tube defects.
C. A diet high in complex carbohydrates is generally beneficial for health, providing energy and
fiber, but it does not specifically target the prevention of neural tube defects. While a balanced
diet is important, complex carbohydrates alone won't address the risk.
90. A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the
following pieces of information should the nurse include in the teaching?
A. "You should nurse your baby every 2 to 3 hours to establish a good milk supply."
B. "You can stop breastfeeding if it becomes too painful."
C. "Your milk supply will noticeably increase in volume around the third or fourth day after
delivery."
D. "You should drink plenty of fluids to stay hydrated while breastfeeding."
Answer: C. "Your milk supply will noticeably increase in volume around the third or fourth day
after delivery."
Explanation:
As the colostrum transitions to mature breast milk, the volume of milk produced will also
increase. Typically, the postpartum client will notice that 72 to 96 hours after delivery her breasts
feel fuller and firmer and that milk is leaking from her nipples.
Incorrect Answers:

A. This is an important recommendation for breastfeeding mothers. Frequent nursing stimulates
the production of breast milk and helps establish a strong milk supply. Nursing every 2 to 3 hours
is generally recommended, especially in the early days postpartum, to ensure the baby gets
enough nourishment and to signal the body to produce more milk.
B. This statement is misleading. While breastfeeding can be uncomfortable initially, pain should
not be a reason to stop altogether. The nurse should encourage the client to seek help if she
experiences significant pain, as proper latch and positioning can often resolve discomfort.
D. This is a crucial piece of advice for breastfeeding mothers. Staying hydrated is important for
maintaining an adequate milk supply and overall health. Increased fluid intake can help support
lactation, so the nurse should encourage the client to drink water and other fluids regularly while
breastfeeding.
91. A nurse is providing teaching for new parents about formula feeding. Which of the following
instructions should the nurse include?
A. "Prepare formula according to the instructions on the label."
B. Discard opened cans of formula after 48 hr refrigeration.
C. "Warming the formula in the microwave is a safe method."
D. "Always check the temperature of the formula before feeding."
Answer: B. Discard opened cans of formula after 48 hr refrigeration.
Explanation:
Opened cans and prepared bottles of formula must be refrigerated and discarded after 48 hours
due to the risk of bacterial contamination.
Incorrect Answers:
A. This instruction is critical for ensuring the formula is mixed correctly, providing the
appropriate nutrition for the infant. Parents should follow the manufacturer's guidelines for
preparing, mixing, and storing formula to ensure the baby's safety and health.
C. This is an incorrect instruction. Microwaving formula can create hot spots that could burn the
baby’s mouth. Instead, parents should warm formula by placing the bottle in a bowl of warm
water or using a bottle warmer to ensure even heating.
D. This is an important safety measure. Before feeding the baby, parents should check the
temperature of the formula by dripping a few drops on the inside of their wrist to ensure it is not

too hot. This helps prevent burns and ensures the formula is at a comfortable temperature for the
infant.
92. A nurse is performing an admission assessment of a client who just arrived at the labor and
delivery unit. Which of the following findings should the nurse identify as the priority?
A. Maternal blood pressure is 160/100 mmHg.
B. The client reports severe abdominal pain.
C. The client is experiencing strong contractions every 2 minutes.
D. The fetal heart rate is 90/min.
Answer: D. The fetal heart rate is 90/min.
Explanation:
Fetal bradycardia indicates that this client is at greatest risk for fetal consequences due to a
cardiac disorder or infection, leading to hypoxia and asphyxiation; therefore, this is the priority
finding.
Incorrect Answers:
A. This finding indicates hypertension, which can lead to serious complications for both the
mother and the fetus, such as preeclampsia or gestational hypertension. High blood pressure
needs to be addressed promptly to ensure the safety of both mother and baby.
B. Severe abdominal pain could indicate a serious condition, such as placental abruption or
uterine rupture, which requires immediate evaluation and intervention. It is crucial to assess the
cause of the pain to prevent complications.
C. Frequent, strong contractions may indicate that the labor is progressing quickly, which could
lead to complications, such as fetal distress or rapid labor. This finding requires monitoring to
ensure both maternal and fetal well-being.
93. A nurse is preparing a client who is in labor for the insertion of an intrauterine pressure
catheter. The client asks why this type of monitoring is needed. Which of the following responses
should the nurse make?
A. Although the intrauterine pressure catheter will show the frequency of contractions, the
external toco transducer is also an adequate and noninvasive method of timing contractions.

B. Intrauterine pressure catheters are invasive monitoring equipment and used only when deemed
necessary for high-risk labors.
C. An intrauterine pressure catheter monitors the frequency, intensity, and duration of
contractions. The ultrasound transducer and spiral electrode will monitor fetal heart tones.
D. "This type of monitoring will allow us to measure the intensity of your contractions."
Answer: D. "This type of monitoring will allow us to measure the intensity of your contractions."
Explanation:
A Toc transducer can monitor the frequency and duration of contractions, but only an intrauterine
pressure catheter can monitor the intensity of contractions.
Incorrect Answers:
A. Although the intrauterine pressure catheter will show the frequency of contractions, the
external Toc transducer is also an adequate and non-invasive method of timing contractions.
B. Intrauterine pressure catheters are invasive monitoring equipment and used only when deemed
necessary for high-risk labors.
C. An intrauterine pressure catheter monitors the frequency, intensity, and duration of
contractions. The ultrasound transducer and spiral electrode will monitor fetal heart tones.
94. A nurse is discussing contraceptive choices with a client who has a history of
thrombophlebitis. Which of the following methods of contraception should the nurse
recommend?
A. Copper intrauterine device
B. Combined oral contraceptives (COCs).
C. Progestin-only pills (mini-pills).
D. Hormonal implants (e.g., Nexplanon).
Answer: A. Copper intrauterine device
Explanation:
A history of thrombophlebitis is a contraindication for the use of hormonal contraceptive methods
such as oral combinations of estrogen and progesterone in pill form, vaginal inserts that release
hormones continuously, and injectable progestins.
A copper intrauterine device that does not contain hormones is a safer choice for this client. Other
options for this client include barrier methods and spermicides.

Incorrect Answers:
B. This option is not recommended for a client with a history of thrombophlebitis. Combined oral
contraceptives contain estrogen, which can increase the risk of thromboembolic events.
Therefore, this method would pose a significant risk to the client.
C. Progestin-only pills may be safer than combined oral contraceptives for someone with a
history of thrombophlebitis, as they do not contain estrogen. However, they may still have some
risks and may not be as effective for all individuals. It's essential to evaluate the specific health
history and risks before recommending this option.
D. Hormonal implants release progestin and do not contain estrogen, making them a safer choice
for individuals with a history of thrombophlebitis. However, they may still carry some risk of
thrombosis, and the nurse should ensure this option aligns with the client’s overall health status
and preferences.