HESI RN EXIT Exam Questions and Answers
100% correct latest student guide 2022, Exams for Nursing
Women & Newborn Health
ATI – Form A
1. A client and her partner ask the nurse for information about permanent contraception. Which
of the following statements should the nurse include in the counseling?
a. Most sterilization procedures are considered irreversible
b. A woman should use contraception for 1-2 months after a tubal ligation
c. A man is usually sterile immediately after a vasectomy
d. The menstrual cycle is shorter after a tubal ligation
Answer: a. Most sterilization procedures are considered irreversible
2. A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the
following interventions should the nurse include in the plan of care?
a. Swaddle the newborn in a flexed position
b. Weigh the newborn every other day
c. Increase the newborn’s visual stimulation
d. Discourage parental interaction until after a social service evaluation
Answer: a. Swaddle the newborn in a flexed position
3. A nurse is providing teaching about increasing dietary fiber to an antepartum client who
reports constipation. Which of the following food selections has the highest fiber content per
cup?
a. Lentils
b. Oatmeal
c. Cabbage
d. Asparagus
Answer: a. Lentils
4. A nurse is teaching a client who is pregnant about a new prescription for iron supplements.
Which of the following instructions should the nurse include in the teaching?
a. Increase intake of foods rich in vitamin C
b. Take an extra pill if you miss a dose
c. Report black stools to the provider
d. Drink 8 ox of milk with each pill
Answer: a. Increase intake of foods rich in vitamin C
5. A nurse is caring for a preterm newborn immediately after delivery. Which of the following
actions should the nurse take first?
a. Dry the infant under the radiant warmer
b. Take the infant’s temperature
c. Weigh the infant
d. Obtain the infant’s blood glucose
Answer: a. Dry the infant under the radiant warmer
6. A nurse is discussing family planning with a client who has a history of DVT. The nurse
should inform the client that this condition is a contraindication for which of the following birth
control methods?
a. Oral contraceptive
b. Cervical cap
c. Diaphragm
d. Intrauterine device
Answer: a. Oral contraceptive
7. A nurse is teaching a client who is postpartum about car seat safety. Which of the following
statements indicates and understanding of the instructions?
a. I will make sure the retainer clip is at the level of my baby’s abdomen
b. I will position the car seat in the front passenger seat facing the font of the car
c. I will adjust the angle of the car seat so that my baby sits at a 90-degre angle
d. I will place the shoulder harness slightly below my baby’s shoulders
Answer: a. Oral contraceptive
8. A nurse is monitoring a newborn whose mother reports recent opiate use for neonatal
abstinence syndrome. Which of the following findings indicates narcotic withdrawl?
a. Excessive Crying
b. Unequal pupils
c. Respiratory rate of 50/min
d. Hypotonia
Answer: a. Excessive Crying
9. A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine
position, which of the following methods should the nurse use to elicit the Moro reflex?
a. Make a loud noise above the newborn
b. Touch the newborn’s cheek with a finger
c. Turn the newborn’s head to one side
d. Tap the newborn’s forehead with a finger
Answer: a. Make a loud noise above the newborn
10. A nurse is providing teaching to a client who is postpartum about her car seat safety. Which
of the following statements by the client indicates an understanding of the teaching?
a. I will ensure that my baby is at a 45-degree angle in the car seat
b. I will put my baby facing forward in the middle of the back seat of the car
c. I will fasten the harness clip 1 inch above my baby’s underarms
d. I will swaddle my baby in a blanket before placing her in the car seat
Answer: a. I will ensure that my baby is at a 45-degree angle in the car seat
11. A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following
statements by the client indicates an understanding of the teaching?
a. I should apply a warm compress after feeding
b. I should apply lanolin to the infection site daily
c. I should use a nipple shield while breastfeeding
d. I should stop breastfeeding until the infection has healed
Answer: a. I should apply a warm compress after feeding
12. A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the
following statements should the nurse make?
a. You can bathe and dress your baby if you’d like to
b. You should name the baby so he can have an identity
c. If you don’t hold the baby, it will make letting go much harder
d. Im sure you will be able to have another baby when you’re ready
Answer: a. You can bathe and dress your baby if you’d like to
13. A nurse is performing an initial assessment of a newborn who was delivered with a nuchal
cord. Which of the following clinical findings should the nurse expect?
a. Facial petechiae
b. Erythema toxicum
c. Periauricular papillomas
d. Telangilectatic nevi
Answer: a. Facial petechiae
14. A charge nurse is discussing STIs with a newly licensed nurse. Which of the following
infections should the nurse include in the teaching as an indication for a cesarean birth?
a. HIV
b. Chlamydia
c. Gonorrhea
d. Syphilis
Answer: a. HIV
15. A nurse is reviewing the medication prescriptions for a newborn who is 6 hours old and
whose mother is HBsAg-positive. The nurse should anticipate administering which of the
following medications?
a. Hepatitis B Immune Globulin
b. Hepatitis A immune globulin
c. Haemophilus inflenzae type B vaccine
d. Hepatitis A vaccine
Answer: a. Hepatitis B Immune Globulin
16. A nurse is assessing a client immediately following the placement of an epidural. The nurse
obtains a maternal blood pressure of 96/54 and a fetal HR of 102/min. Which of the following
actions should the nurse take?
a. Position the client in a lateral position
b. OR administer naloxone to the client
c. Prepare the client for an amnioinfusion
d. Place the client in knee-chest position
Answer: a. Position the client in a lateral position
b. OR administer naloxone to the client
17. A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the
following actions should the nurse include in the plan of care?
a. Avoid using lotion or ointment on the newborn’s skin
b. Dress the newborn in lightweight clothing
c. Keep the newborn supine throughout treatment
d. Measure the newborn’s temperature every 8 hours
Answer: a. Avoid using lotion or ointment on the newborn’s skin
18. A nurse on the labor and delivery unit is caring for a client who is at 33 weeks of gestation
and was admitted with placenta previa. Which of the following interventions should the nurse
include in the client’s plan of care?
a. Administration of magnesium sulfate
b. Routine vaginal exams
c. Ambulation as tolerated
d. Nonstress test twice weekly
Answer: a. Administration of magnesium sulfate
19. A nurse is admitting a client who is in preterm labor to the labor and delivery unit. The nurse
should anticipate which of the following tests to assess for fetal lung maturity?
a. L/S ratio
b. Direct coombs test
c. Biophysical prophile
d. Chorionic villus sampling
Answer: a. L/S ratio
20. A nurse is caring for a client who is in labor and prescribed an amnioinfusion. Which of the
following findings is an indication for this?
a. Variable decelerations
b. Early decelerations
c. Fetal macrosomia
d. Increased uterine tone
Answer: a. Variable decelerations
21. A nurse is caring for a client who is postpartum following repair of a vaginal laceration. The
client has a firm fundus, moderate lochia rubra, and reports moderate perineal discomfort and
pressure. Which of the following actions should the nurse take?
a. Check the perineal area
b. Perform deep fundal massage
c. Obtain vaginal culture
d. Administer methylergonovide 0.2 mg IM
Answer: a. Check the perineal area
22. A nurse is assessing a full-term newborn 1 hr following a vaginal birth. Which of the
following is an expected assessment finding?
a. The newborn’s anterior fontanel bulges when he is quiet
b. The newborn’s head circumference is greater than the chest circumference
c. The newborn exhibits apneic episodes of 30 seconds
d. The newborn has a heart rate of 70/min while sleeping
Answer: b. The newborn’s head circumference is greater than the chest circumference
23. A nurse is providing discharge teaching to the parent of a newborn about surgical site care
following circumcision using a clamp technique. Which of the following statements by the
parent indicates an understanding of the teaching?
a. I will check the site hourly for bleeding
b. I will remove the crust with each diaper change
c. I will wash the penis with soap and water daily
d. I will apply petroleum jelly to the area with each diaper change
Answer: d. I will apply petroleum jelly to the area with each diaper change
24. A nurse in a provider’s office is caring for a 20-year-old client who is 12 weeks of gestation
and requests an amniocentesis to determine the gender of the fetus. Which of the following
responses should the nurse make?
a. You cannot have an amniocentesis until you are at least 35 year of age
b. This procedure determines if your baby has genetic or congenital disorders
c. Your provider will schedule a chorionic villus sampling to determine the sex of your baby
d. We can schedule the procedure for later today if you’d like
Answer: b. This procedure determines if your baby has genetic or congenital disorders
25. A nurse is teaching a prenatal client about listeriosis and dietary modifications during
pregnancy. Which of the following statements by the client indicates an understanding of the
teaching?
a. I can have a mid-day snack with soft cheese
b. I can purchase a seafood salad from the grocery store
c. I can still have a hot dog at the ballpark
d. I can eat grilled chicken on a bun at lunch time
Answer: d. I can eat grilled chicken on a bun at lunch time
26. A nurse is providing education to a client who is to receive misoprostol for induction of labor.
Which of the following instructions should the nurse include in the teaching?
a. You will lie on your side for 40 minutes after I administer the medication
b. I will insert a urinary catheter before I administer the medication
c. I will begin an oxytocin infusion within 2 hours of your last dose of medication
d. You will receive an antacid containing magnesium before the medication
Answer: a. You will lie on your side for 40 minutes after I administer the medication
27. A nurse is reviewing the laboratory findings of a client who is 10 weeks gestation. Which of
the following findings should the nurse report to the provider?
a. WBC 10,000
b. Hemoglobin 12 g/dL
c. Creatinine 0.5 mg/dL
d. Platelets 100,000
Answer: d. Platelets 100,000
28. A nurse on the postpartum unit is reviewing prevention of newborn diaper rash with a client.
Which of the following statements indicates an understanding of the teaching?
a. I will allow the diaper area to dry before applying a clean diaper
b. I will wash the diaper area with an antibacterial soap with each diaper change
c. I will clean the diaper area with a scented baby wipe
d. I will apply a thin layer of talc to the diaper area twice a day
Answer: a. I will allow the diaper area to dry before applying a clean diaper
29. A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV
bolus for pain. Which of the following findings should the nurse report to the provider following
this medication?
a. Respiratory rate 10/min
b. Moderate fetal heart rate variability
c. Urinary output 120mL in 2 hr
d. Blood pressure 136/88
Answer: a. Respiratory rate 10/min
30. A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The
client reports sore nipples. Which of the following actions should the nurse take?
a. Have the client limit the length of breastfeeding to 5 min per breast
b. Assess the newborn’s latch while breastfeeding
c. Instruct the client to wait 4 hours between daytime feedings
d. Offer supplemental formula between the newborn’s feedings
Answer: b. Assess the newborn’s latch while breastfeeding
31. A nurse is caring for a client who is in the second stage of labor. The nurse observes the fetal
head retract against the client’s perineum immediately following emergence. Which of the
following actions should the nurse take?
a. Assess fetal position using Leopold maneuvers
b. Apply pressure to the client’s suprapubic area
c. Reposition the client in the left lateral position
d. Empty the bladder using crede maneuver
Answer: b. Apply pressure to the client’s suprapubic area
32. A nurse is admitting a client to the birthing unit who reports her contractions started 1 hour
ago. The nurse determines the client is 80% and 8cm. The nurse realizes that the client is at risk
for which of the following conditions
a. Ectopic pregnancy
b. Postpartum Hemorrhage
c. Incompetent cervix
d. Hyperemesis gravidarum
Answer: b. Postpartum Hemorrhage
33. A nurse is assessing a client who is at 37 weeks gestation. Which of the following statements
by the client requires immediate intervention by the nurse?
a. I have been seeing spots this morning
b. My feet are really swollen today
c. I didn’t have lunch today, but I had breakfast this morning
d. It burns when I urinate
Answer: a. I have been seeing spots this morning
34. A nurse is caring for a client who is in the second stage of labor. Which of the following
manifestations should the nurse expect?
a. The client expels the placenta
b. The client delivers the newborn
c. The client begins having regular contractions
d. The client experiences gradual dilation of the cervix
Answer: b. The client delivers the newborn
35. A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When
using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in
synchronization with the fetal heartbeat. Which of the following terms should the nurse use to
document this finding?
a. Goodell’s sign
b. Funic soufflé
c. Hegar’s sign
d. Quickening
Answer: b. Funic soufflé
36. A nurse at an antepartum clinic is caring for four clients. Which of the following clients
should the nurse assess first?
a. A client who is at 36 weeks of gestation and reports back pain following intercourse
b. A client who is at 10 weeks of gestation and reports frequent urination
c. A client who is at 24 weeks of gestation and reports periodic tingling of the fingers
d. A client who is at 8 weeks of gestation and reports severe vomiting
Answer: d. A client who is at 8 weeks of gestation and reports severe vomiting
37. A nurse is caring for four clients. For which of the following clients should the nurse
auscultate the fetal heart rate during the prenatal visit?
a. A client who has a crown-rump length of 7 weeks of gestation
b. A client who has an ultrasound that confirms a molar pregnancy
c. A client who has felt quickening for the first time
d. A client who has a positive urine pregnancy test 1 week after missed menses
Answer: a. A client who has a crown-rump length of 7 weeks of gestation
38. A nurse is assessing a newborn who is 2 hours old. Which of the following findings should
the nurse report to the provider?
a. Transient nystagmus
b. Overlapping sutures with molding
c. Single transverse palmar crease bilaterally
d. Lanugo on the pinna of the ears
Answer: c. Single transverse palmar crease bilaterally
39. A nurse is reviewing the laboratory report of a client who is 24 hrs postpartum vaginal
delivery. The client has a hemoglobin level of 9.0 g/dL and hematocrit of 25%. Which of the
following actions should the nurse take?
a. Prepare the client for a blood transfusion
b. Initiate IV access for isotonic solution with an 18-gauge catheter
c. Administer an iron supplement to the client
d. Instruct the client that the provider will check for placental fragments
Answer: a. Prepare the client for a blood transfusion
40. A nurse is caring for a client who is at 24 weeks of gestation and has a glucose screening test
result of 150 mg/dL. Which of the following actions should the nurse take?
a. Perform a urine screen for ketones
b. Repeat the glucose screening test in 15 min to verify results
c. Schedule the client for a 3 hr oral glucose tolerance test
d. Determine if the client has fasted
Answer: c. Schedule the client for a 3 hr oral glucose tolerance test
41. A nurse is assessing the results of a non-stress test for an antepartal client at 35 weeks of
gestation. Which of the following findings should indicate to the nruse the need for further
diagnostic testing?
a. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in
response to fetal movement within a 40-min testing period
b. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client
c. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds
in duration within a 10-min testing period
d. Three fetal movements perceived by the client in a 20-min testing period
Answer: c. No late decelerations in the fetal heart rate noted with three uterine contractions of
60 seconds in duration within a 10-min testing period
42. A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should
discontinue the oxytocin if which of the following occurs?
a. Six contractions in 10 min
b. Nonrepetitive early decelerations
c. Moderate variability of the fetal heart rate
d. Contractions last 60 seconds
Answer: a. Six contractions in 10 min
43. A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor
for which of the following findings as an adverse effect?
a. Decreased ability to bear down
b. Uterine hyper-stimulation
c. Fetal bradycardia
d. Maternal hypertension
Answer: a. Decreased ability to bear down
44. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings
should the nurse report to the provider?
a. Bulging fontanels
b. Subconjunctival hemorrhage
c. Milia
d. Caput succedaneum
Answer: b. Subconjunctival hemorrhage
45. A nurse is caring for a client who is 1 day postpartum following the birth of her first baby.
The client’s partner states, “I’ve been having nightmares that we are homeless and the baby is
starving.” Which of the following is an appropriate response by the nurse?
a. This is just the beginning of the worrying you will do as a parent
b. I know you’re worried, but everything is going to be okay
c. What do you think it will be like to be responsible for a baby?
d. Why would you worry about being homeless when you have a good job?
Answer: b. I know you’re worried, but everything is going to be okay
46. A nurse is providing discharge instructions to a client who delivered a newborn via cesarean
birth 4 days ago. The nurse should instruct the client to contact the provider for which of the
following findings?
a. The newborn’s cord stump is still attached after 1 week
b. The newborn has fewer than four wet diapers in 24 hr
c. The newborn has loose stools
d. The newborn sleeps 16 hr a day
Answer: b. The newborn has fewer than four wet diapers in 24 hr
47. A nurse is caring for a newborn. Which of the following assessment findings should indicate
to the nurse that suctioning of the nasopharynx is needed?
a. The newborn is beginning to cough
b. The newborn’s respiratory rate is irregular
c. The newborn’s pulse oximetry is 91%
d. The newborn’s respiratory rate is 32/min
Answer: a. The newborn is beginning to cough
48. A nurse is performing a physical examination of a term newborn upon admission to the
nursery. In which order should the nurse perform the following assessments? (Move the steps
into the box on the right, placing them in the selected order of performance. Use all the steps.)
Answer: PUT THEM IN ORDER
Observe the newborn’s respirations
Auscultate the newborn’s heart rate
Auscultate the newborn’s abdomen
Test the newborn’s reflexes
49. A nurse in a prenatal clinic is discussing quickening with a client who is in the first trimester
of her first pregnancy. Which of the following statements by the client indicates understanding of
the teaching?
a. I will plan to have a blood test when quickening occurs
b. I will feel movement at about 16 to 20 weeks
c. I will begin scheduling appointments every 2 weeks
d. I will take two ibuprofen capsules for the discomfort
Answer: b. I will feel movement at about 16 to 20 weeks
50. A nurse is assessing a full-term newborn upon admission to the nursery. Which of the
following clinical findings should the nurse report to the provider?
a. Rust-stained urine
b. Transient circumoral cyanosis
c. Subconjunctival hemorrhage
d. Single palmar creases
Answer: c. Subconjunctival hemorrhage
51. A nurse is assessing a client who is in her second trimester for common physiological
changes during pregnancy. The nurse notes a blotchy discoloration on the client’s forehead, nose,
and cheeks. Which of the following changes should the nurse document?
a. Striae gravidarum
b. Epulis
c. Chloasma
d. Linea nigra
Answer: c. Chloasma
52. A nurse is conducting a class for a group of clients about birth control. Which of the
following information should the nurse include in the teaching?
a. You should have an annual examination to assess your diaphragm
b. You should use spermicide 3 hours prior to sexual intercourse
c. Your fertility will return 6 months after your provider removes your IUD
d. You will not need to use birth control for 1 month after receiving emergency contraception
Answer: a. You should have an annual examination to assess your diaphragm
53. A nurse is caring for a client who is in the first stage of labor and the fetal head is in a
posterior position. The client reports pressure and pain in her lower back. Which of the following
nonpharmacological comfort measures should the nurse suggest first?
a. Guided imagery
b. Effleurage
c. Patterned breathing
d. Counterpressure
Answer: d. Counterpressure
54. A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by
continuous IV infusion. Which of the following findings should the nurse report to the provider?
a. Urinary output 20 mL/hr
b. 2+ deep tendon reflexes
c. Blood pressure 148/94 mm Hg
d. Respiratory rate 14/min
Answer: a. Urinary output 20 mL/hr
55. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate by
continuous IV infusion. The nurse should monitor for which of the following adverse effects?
a. Hypertonia
b. Elevated blood pressure
c. Polyuria
d. Absence of deep tendon reflexes
Answer: d. Absence of deep tendon reflexes
56. A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision
technique. Which of the following information should the nurse include?
a. Yellow exudate will form at the surgical site in 24 hours
b. The Plastibell will be removed 4 hours after the procedure
c. Make sure the newborn’s diaper is snug
d. Notify the provider if the end of your baby’s penis appears dark red
Answer: a. Yellow exudate will form at the surgical site in 24 hours
57. A nurse is reviewing a client’s rubella titer of 1:8 at her second prenatal visit. Which of the
following statements by the nurse is appropriate?
a. You will need a rubella immunization at your next prenatal visit
b. Your titer indicates that you are susceptible to rubella
c. Because rubella is a live vaccine, you will not be able to breastfeed your newborn
d. During your third trimester, you will need to repeat a blood test for the titer
Answer: d. During your third trimester, you will need to repeat a blood test for the titer
58. A nurse is caring for a client who is in active labor and is receiving oxytocin via IV infusion.
The nurse has applied an internal fetal heart monitor and recognizes an early deceleration of the
fetal heart rate tracing. Which of the following actions should the nurse take?
a. Discontinue the oxytocin
b. Assist the client to lay on her right side
c. Administer oxygen at 8 L/min per mask
d. Continue to monitor the client
Answer: d. Continue to monitor the client
59. A nurse in a postpartum unit is caring for several clients. Which of the following tasks should
the nurse delegate to assistive personnel?
a. Help the client with perineal care
b. Demonstrate to a client how to change a diaper
c. Check the saturation of the perineal pad
d. Provide the client with a dose of magnesium hydroxide
Answer: c. Check the saturation of the perineal pad
60. A nurse is providing discharge teaching to a client following tubal ligation. Which of the
following statements by the client indicates an understanding of the teaching?
a. Premenstrual tension will no longer be present
b. Ovulation will remain the same
c. Hormone replacements will be needed following this procedure
d. My monthly menstrual period will be shorter
Answer: b. Ovulation will remain the same
61. A nurse is caring for a client who is in the latent phase of the first stage of labor and is in
pain. Which of the following nursing interventions are appropriate to reduce pain? (Select all that
apply.)
a. Administer 70% nitrous oxide mixed with oxygen
b. Perform Leopold maneuvers
c. Have the client sit in a tub of warm water
d. Ambulate the client in the hallway
e. Apply counterpressure to the sacral area
Answer: a. Administer 70% nitrous oxide mixed with oxygen
c. Have the client sit in a tub of warm water
e. Apply counterpressure to the sacral area
62. A nurse in a provider’s office is assessing a client at her first antepartum visit. The client
states that the first day of her last menstrual period was March 8. Use Nagele’s rule to calculate
the estimated date of delivery. (Use the MMDD format with four numerals and no spaces or
punctuation.)
Answer: 1215
63. A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks
of gestation. Which of the following actions should the nurse take? (Click on the “Exhibit”
button for additional information about the client. There are three tabs that contain separate
categories of data.)
THIS QUESTION REQUIRES “EXHIBIT” HEARING, SO SINCE YOU CAN’T LISTEN,
USE YOUR BEST JUDGMENT TO ANSWER THIS, POSSIBLY.
a. Administer rubella vaccine
b. Obtain a blood culture
c. Administer ceftriaxone IM
d. Obtain a maternal serum alpha-fetoprotein specimen
Answer: c. Administer ceftriaxone IM
64. A nurse is providing discharge instructions to a client who is breastfeeding her newborn.
Which of the following instructions should the nurse include?
a. Expect two to four wet diapers every 24 hr
b. Offer the newborn 30 mL (1 oz) of water between feedings
c. Feed the newborn 5 to 10 min per breast
d. Allow the baby to feed at least every 3 hr
Answer: d. Allow the baby to feed at least every 3 hr
65. A nurse is assessing a client who is 1 hr postpartum. The nurse notes a large amount of
vaginal bleeding with several large blood clots on the client’s peripad. The client’s blood
pressure is 70/42 mm Hg and her heart rate is 150/min. Which of the following actions should
the nurse take first?
a. Massage the fundus
b. Apply oxygen at 10 to 12 L/min
c. Elevate the legs
d. Administer an IV bolus of oxytocin
Answer: c. Elevate the legs
66. A nurse is assisting the provider to administer a dinoprostone (Cervidil) insert to induce labor
for a client. Which of the following actions should the nurse take?
a. Instruct the client to avoid urinary elimination until after administration
b. Allow the medication to reach room temperature prior to administration
c. Place the client in a semi-Fowler’s position for 1 hr after administration
d. Verify that the informed consent is obtained prior to administratin
Answer: d. Verify that the informed consent is obtained prior to administratin
67. A nurse is planning care for a newborn who is large for gestational age due to maternal
gestational diabetes mellitus. The nurse should recognize that the newborn is at risk for which of
the following conditions? (Select all that apply.)
a. Hyperbilirubinemia
b. Hypercalcemia
c. Polycythemia
d. Hypomagnesemia
e. Hypoglycemia
Answer: a. Hyperbilirubinemia
e. Hypoglycemia
68. A nurse is providing prenatal teaching to a group of clients who are in their third trimester of
pregnancy. Which of the following statements by a client indicates an understanding of the
teaching?
a. I should lie on my back as much as possible during the labor process
b. Panting will help me control the urge to push when my cervix is not completely dilated
c. I will be allowed to start to push once my cervix is dilated to 5 centimeters
d. Once my water has broken, I will not be able to have epidural anesthesia
Answer: d. Once my water has broken, I will not be able to have epidural anesthesia
69. A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses
about maternal cytomegalovirus. Which of the following information should the nurse manager
include in the teaching?
a. Mothers will receive prophylactic treatment with acyclovir prior to delivery
b. Lesions are visible on the mother’s genitalia
c. Transmission can occur via the saliva and urine of the newborn
d. This infection requires airborne precautions are initiated for the newborn
Answer: c. Transmission can occur via the saliva and urine of the newborn
Type B
1. A nurse is assessing a postpartum client who is receiving oxytocin 1 hr. after a normal
spontaneous delivery. During the assessment, the nurse notes that the client perineal pad is fully
saturated. which of the following actions should the nurse anticipate taking?
a. Insert vaginal packing
b. Discontinue the oxytocin infusion
c. Administer terbutaline sulfate
d. Massage the uterus until firm
Answer: d. Massage the uterus until firm
2. A nurse is providing teaching to a client who has mild preeclampsia and will be caring for
herself which statement by the clients indicates an understanding of the teaching?
a. I will check my urine for protein only
b. I will consume 50 grams of proteins daily
c. I will alternate the arm I use to check my blood pressure
d. I will count my baby kicks every other day
Answer: a. I will check my urine for protein only
3. A nurse is assessing a client and observes the umbilical cord protruding from the vaginal , after
calling
a. Administer oxygen via nonrebreather facemask
b. Wrap the cord with a sterile towel saturated in normal saline
c. Place a rolled towel under the clients right hip.
d. Apply upward pressure against the presenting part.
Answer: d. Apply upward pressure against the presenting part.
4. A nurse is reviewing the laboratory results of a client who is at 20 weeks of gestation and has
type 1 diabetes mellitus. Which of the following report to the provider?
a. Hct 34%
b. Platelets 170,000/mm3
c. BUN 25 mg/dL
d. HbA1c 6%
Answer: c. BUN 25 mg/dL
5. A nurse on the labor and delivery unit is assessing four clients. Which of the following clients
is a candidate for an induction of labour
a. A client who has gestational diabetes mellitus
b. A client who has placenta plavia
c. A client who has active genital herpes
d. A client who has a previous uterine incision.
Answer: a. A client who has gestational diabetes mellitus
6. A nurse is providing discharge instructions to a client who is breastfeeding her newborn.
Which of the following
a. Allow the baby to feed at least every 3 hr.
b. Offer the new born 30ml (1 oz.) of water between feeding
c. Feed the newborn 5 to 10 min per breast
d. Expect two to four wet diapers every 24 hrs
Answer: a. Allow the baby to feed at least every 3 hr.
7. A nurse is caring for a client who is at 8 weeks of gestation and has an ectopic pregnancy.
a. Bright, red vaginal discharge
b. Scaphoid abdomen
c. Elevated blood pressure
d. Sharp pelvic pain
Answer: d. Sharp pelvic pain
8. A nurse is providing education about RH(D) immune globulin to a client who is pregnant.
What indicate for administering RH(D)immune globulin?
a. The client delivers an Rh-negative newborn
b. The client has a history of placenta previa
c. The client had a spontaneous abortion
d. The client is at 16 weeks of gestation.
Answer: c. The client had a spontaneous abortion
9. A nurse is providing teaching to a client who is 2 days postpartum.
a. You should store your diaphragm in sterile water after each use
b. You should use an oil based vaginal lubricant when inserting your diaphragm
c. You should have your provider refit you for a new diaphragm
d. You should keep the diaphragm in place for at least 4 hours after intercourse.
Answer: c. You should have your provider refit you for a new diaphragm
10. A nurse is caring for a client who is 12hr. postpartum and has a fourth degree laceration of
the perineum
a. Apply a moist , warm compress to the perineum
b. Apply provide iodine to the client perineum after the voids
c. Provide the client with a cool sitz bath
d. Administer methyfergenevine 0.2 mg
Answer: c. Provide the client with a cool sitz bath
11. A nurse is assessing four newborns. Which of the following clinical findings
a. A 2 day old infant who is excreting a thin, white discharge from both nipples
b. A 2 day old infant who has a respiratory rate of 70/mims
c. A 16 hr old infant who has a blood glucose level of 50 mg/dl
d. A 16 hr old infant who has yet to pass a meconium stool
Answer: b. A 2 day old infant who has a respiratory rate of 70/mims
12. A nurse is performing an initial assessment of a new born who was delivered with a nuchal
cord.
a. Telanglectatic nevi
b. Facial petechiae
c. Erythema toxicum
d. Periauricular papilloma
Answer: b. Facial petechiae
13. A nurse is assisting the provider to administer a dinoprostone insert to induce labor
a. Verify that the informed consent is obtained prior to administration
b. Place the client in a semi fowler position for 1 hr. after administration.
c. Instruct the client to avoid urinary elimination until after administration
d. Allow the mediation to reach room temp. prior to administration.
Answer: a. Verify that the informed consent is obtained prior to administration
14. A nurse is assessing a new born 2 hr. after delivery. Which of the following findings in these
image.
a. Cyanosis of the hands and feet
b. A soft, flat fontanelle
c. A heart rate of 160 beats per minute
d. A bulging fontanelle
Answer: a. Cyanosis of the hands and feet
15. A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which
of the following findings should the nurse expected?
a. malodorous
b. Urinary frequency
c. vulva lesions
d. Thick, white vaginal discharge.
Answer: a. malodorous
16. A nurse is teaching a group of women who are pregnant about actions to take if they are
suspect they are experiencing preterm labor the nurse provides.
a. call your doctor if you have contractions every 20 minutes for at least 1 hour
b. expect to have a small amount of fluid leaking from the vagina
c. empty your bladder
d. lie on your back for 2 hrs.
Answer: c. empty your bladder
17. A nurse is admitting a client to the birthing unit who reports her contraction started 1hrs. ago.
The nurse determine realizes that the client is at risk for which of the following conditions.
a. Hyperremesis gravidarum
b. Ectopic pregnancy
c. Incompetent cervix
d. postpartum hemorrhage.
Answer: d. postpartum hemorrhage.
18. A nurse is providing teaching to a postpartum client who has a prescription for a rubella
immunization. Which of the
a. I should avoid breastfeeding for 2 weeks following the immunization
b. I will receive a series of three immunization and each one will be a month apart
c. I should avoid becoming pregnant for at least 1 month following the immunization
d. I will report joint pain that develop after the immunization to my provider immediately.
Answer: c. I should avoid becoming pregnant for at least 1 month following the immunization
19. A nurse is caring for a newborn who is 2 days old. Which of the following finding should the
nurse report.
a. Edema of the scalp that crosses lines
b. Bilirubin 17 mg/dl
c. heart rate 180 min when crying
d. presence of a babinski reflex
Answer: a. Edema of the scalp that crosses lines
20. Teaching a client and her partner about the techniques of counter pressure during labor.
Which of the following statement by the nurse is appropriate
a. your partner will apply upward pressure on your lower abdomen between contractions
b. Your partner will apply steady pressure with a tennis ball to your lower back
c. your partner will apply continuous, film pressure between your thumb and index finger
d. your partner will apply pressure to the top of your uterus during contraction.
Answer: b. Your partner will apply steady pressure with a tennis ball to your lower back
21. A nurse is preparing the plan of care for a term newborn who was asymptomatic at birth and
whose mother had hepatitis
b. which intervention should the nurse include in the plan of care
a. Administer hepatitis B immune globulin IM to the newborn
b. initiate airborne precaution
c. wait at least 24hrs. before bathing the new born
d. instructs the mother to delay breast feeding for one week
Answer: a. Administer hepatitis B immune globulin IM to the newborn
22. A nurse is caring for a client who has preeclampsia and receiving magnesium sulfate. Which
of the following clinic?
a. increased fetal movement
b. incresased urinary output
c. increased respiratory rate
d. increased muscle weakness.
Answer: d. increased muscle weakness.
23. A nurse is creating a plan of care for a client who is in active labor and has mitral valve
stenosis. Which of the following actions should the nurse include in the plan of care?
a. administer 500ml of 0.9% sodium chloride solution every hour
b. maintain the client in the lithotomy position during labor.
c. prepare the client for vacuum of forceps assisted birth
d. Give the client 0.25g of terbutaline subcutaneously every 6 hrs.
Answer: c. prepare the client for vacuum of forceps assisted birth
24. A nurse is caring for a client who is at 28wks of gestation and received no immunization.
What to administer?
a. tetanus
b. rubella
c. variella
d. human papillomavirus
Answer: a. tetanus
25. A nurse in a provider office is caring for a 20yrs old client who is at 12wks of gestation ……
the following responses should the nurse make
a. we can schedule the procedure for later today if you’d like
b. you cannot have an amniocentesis until you are at least 35yrs of age
c. this procedure determines if your body has genetics or congenital disorders
d. your provider will schedule a chorionic villus sampling to determine the sex
Answer: c. this procedure determines if your body has genetics or congenital disorders
26. A nurse is receiving the laboratory report of a client who is 24hr postpartum vaginal delivery.
Which of the following actions should the nurse take first?
a. initiate IV access for isotonic solution with an 18 gauge catherter
b. prepare the client for a blood transfusion
c. Instruct the client that the provider will check for placental fragment
d. Administer an iron supplement to the client.
Answer: d. Administer an iron supplement to the client.
27. A nurse is assessing a full term newborn upon admission to the ……………….
a. Rust stained urine
b. Transient circumoral cyanosis
c. subconjunctival hemorrhage
d. single palmer creases
Answer: d. single palmer creases
28. A nurse is caring for a client who is in preterm labor and receiving magnesium sulfate by
review during tocolytic therapy.
a. serum medication level
b. Uric add level
c. liver enzymes
d. indirect coombs test.
Answer: a. serum medication level
29. A nurse is teaching a newly licensed nurse about the use of ultrasonography in the first
trimester. The nurse indicates an understanding of the teaching.
a. Ultrasound is used to observe for placental maturity in the first trimester
b. Ultrasound is used to detect intrauterine growth restriction in the first trimester
c. Ultrasound is used to determine gestational age in the first semester.
d. ultrasound is used to perform a biophysical profile in the first triemester.
Answer: c. Ultrasound is used to determine gestational age in the first semester.
30. A nurse is preparing to perform a non-stress test for a client who is at 34 week of gestation.
Which …………………..
a. Place the client in the supine position at the beginning of the test
b. administer oxygen via facemask during the test
c. Insert a peripheral IV catheter into the right arm before the test
d. Record the fetal heart rate for 20 mins during the test.
Answer: d. Record the fetal heart rate for 20 mins during the test.
31. A nurse is caring for a preterm newborn 18hrs. following delivery. After reviewing the
newborn. On the exhibit button for additional information about the newborn . there are 3 tabs
a. initiate phototherapy or
b. initiate gavage feeding
c. administer oxygen
d. administer an antibiotic
Answer: a. initiate phototherapy or
Look into the exhibit first: Tab 1: heat rate is 136/mins., Respiratory rate is 44/mins, Axillary
temperature 36.6 . Tab 2: can’t see what is there Likewise Tab 3.
32. A nurse is providing teaching to a client who has phenylketonuria and wants to become
pregnant. which of the following information should the nurse
a. your doctor will monitor your phenylalanine levels twice weekly throughout your pregnancy
b. your doctor will perform an amniocentesis right before delivery to test your baby for
phenylketonuria
c. you will need to increase your protein intake to 50 percent of your daily caloric intake
d. you will need to undergo labor induction with oxytocin at 38 weeks of gestation.
Answer: a. your doctor will monitor your phenylalanine levels twice weekly throughout your
pregnancy
33. A nurse is providing discharge teaching to a client whose new born is 2 days old. Which of
the following statements by the client indicates an understanding
a. l need to place the car seat facing forward in the back seat.
b. I will suction my baby mouth before suctioning her nose
c. l should apply alcohol to the area around my baby umbilical cord daily.
d. I will be sure that my baby has at least 10 wet diapers per day
Answer: b. I will suction my baby mouth before suctioning her nose
34. A nurse is discussing nonpharmacological pain management during labor with a client.
Which of the following statement by the client indicates an understanding of the teaching.?
a. The temperature of the water should be between 36 to 37 degrees Celsius when using
hydrotherapy.
b. I should use effleurage when I am pushing
c. My partner can apply counter pressure to my upper abdomen for 10 seconds at a time
d. I can apply a TENS unit to my lower abdomen to decrease the pain of my contractions
Answer: a. The temperature of the water should be between 36 to 37 degrees Celsius when using
hydrotherapy.
35. A nurse is assessing a client during her first prenatal visit. The client reports March 20 as her
last menstrual period. Use Nagele rule to calculate the estimated date delivery. (use the MMDD
format with four numerals and no spaces or punctuations
Answer: Dec. 27… ..... 1227
36. A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the
following actions should the
a. Provide a stimulating environment
b. Monitor blood glucose level every hr.
c. initiate seizure precautions
d. place the infant on his back with legs extended Interventions: swaddle the newborn in a flexed
position.
Answer: c. initiate seizure precautions
37. A nurse is reviewing a fetal heart monitor trading for a client who is at 39 weeks of gestation
and is in labor. Which of the following will report to the provider?
a. 130/mins. With moderate variability
b. 150/min with absent variability
c. 135/min with accelerations
d. 155/min with occasional early deceleration
Answer: b. 150/min with absent variability
38. A nurse on the postpartum unit is caring for four clients. Which of the following clients
should receive RH(D)
a. An Rh-positive mother who has an Rh-negative infant
b. An Rh-positive mother who has an Rh-positive infant
c. An Rh-negative mother who has an Rh-positive infant
d. An Rh-negative mother who has an Rh-negative infant
Answer: c. An Rh-negative mother who has an Rh-positive infant
Special immune globulins, called RhoGAM, are now used to prevent RH incompatibility in
mothers who are Rh-negative. If the father of the infant is Rh-positive or if his blood type is not
known, the mother is given an injection of RhoGAM during the second trimester
39. A nurse is reviewing the medial record of a client who is requesting an oral contraceptive for
birth control. The nurse should contraindication to the use of oral contraceptives for the client.
a. Fasting blood glucose 100 mg/dl
b. Heart rate 72/mins
c. Blood pressure 118/78mmhg
d. Aspartate aminotransferase 55 unit/s/l
Answer: d. Aspartate aminotransferase 55 unit/s/l
Typically the range for normal AST is reported between 10 to 40 units per liter and ALT between
7 to 56 units per lite blood clots, high blood pressure, certain types of cancers, heart attack,
stroke, liver disease, gallbladder disease, undiagnosed uterine bleeding, cardiac problems,
epilepsy, sickle cell disease, chronic renal disease, smokers, prior to elective surgery, suspected
pregnancy, obese women, certain types of migraine headaches, or uncontrolled diabetes.
40. A nurse is receiving report on four postpartum clients. Which of the following clients should
the nurse plans to attend to
a. A client who reports abdominal pain during breastfeeding
b. A client who has a urine output of 250 mL in 6hrs.
c. A client who reports changing her perineal pad every 2 hrs
d. A client who has hyporeflexia while receiving IV magnesium sulfate
Answer: d. A client who has hyporeflexia while receiving IV magnesium sulfate
41. A nurse is providing teaching to a client who is primigravid and is scheduled to have an
abdominal ultrasound understanding of the teaching
a. I won’t apply perfumed lotion to my abdomen before the test.
b. I will drink water before the test until my bladder feels full.
c. I need to take a stool softener the night before the test
d. I can’t have anything to eat after midnight
Answer: b. I will drink water before the test until my bladder feels full.
42. A nurse in a prenatal clinic is caring for a group of clients. The nurse should recognize that
which of the following client has a contradiction
a. A client who has gestational diabetes mellitus
b. A client who had a previous stillbirth
c. A client who had a non-reactive nonstress test
d. A client who has a previous classical incision.
Answer: d. A client who has a previous classical incision.
43. A nurse is caring for a newborn who was delivered 12 hrs ago. Which of the following
findings indicate hypoglycemia? (select all that apply)
a. Difficulty feeding
b. Hypertonia
c. jitteriness
d. Acrocyanosis
e. Blood glucose 75 mg/dl
Answer: a. Difficulty feeding
b. Hypertonia
c. jitteriness
44. A nurse is reviewing laboratory result for a client who is pregnant. Which of the following
laboratory values to increase
a. Bun
b. Bilirubin
c. fasting blood glucose
d. RBC count
Answer: a. Bun
45. A nurse is assessing a client following an amniocentesis. Which of the following should
a. urinary tract infection
b. polyhydracmnios
c. leakage of amniotic fluid
d. pretem labor
e. amnionitis
Answer: c. leakage of amniotic fluid
46. A nurse is caring for a client who is in pretem labor and receiving magnesium sulfate by
continuous IV infusion. Which of the following indicates that the client is experiencing an
adverse effect of the medication.
a. Urinary output 20ml/hr
b. Magnesium 7.2 Meg/l
c. respiratory rate 15/mins
d. Blood pressure 180/96 mmhg
Answer: a. Urinary output 20ml/hr
47. A nurse is providing teaching about prenatal laboratory tests to a client who is 8 weeks of
gestation. identify the sequence of routine screening (move the steps into the box on the right,
placing them in the selected order of performance. Use all the step.
3. Maternal serum alpha fetoprotein level
4. Vaginal and anal culture form B streptococcus & hemolytics
1. Testing for rubella titer
2. 1-hour glucose tolerance tets.
Answer:
1. Testing for rubella titer
2. 1-hour glucose tolerance tets.
3. Maternal serum alpha fetoprotein level
4. Vaginal and anal culture form B streptococcus & hemolytics
48. A nurse is assessing a newborn whose mother has cocaine use order. Which of the following
newborn finding should the nurse.
a. Increased head circumference
b. increased cardiac output
c. hypotention
d. increased startle reflex.
Answer: d. increased startle reflex.
Remained 66 to 70 update you later
ATI Women & Newborn Health
ATI – Form C
1. A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth. Which of
the following clinical findings should the nurse identify as an indication of postpartum infection?
a. Persistent abdominal striae
b. Unilateral breast pain
c. WBC count 12,000/mm3
d. Lochia alba
Answer: b. Unilateral breast pain
2. A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the
following should the nurse report to the provider?
a. Blood glucose 110 mg/dL
b. Urine protein of 3+
c. Hemoglobin 13 g/dL
d. Deep tendon reflexes of 2+
Answer: b. Urine protein of 3+
3. A nurse is providing teaching about the expected effects of magnesium sulfate to a client who
is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse
is appropriate?
a. This medication prevents seizures
b. This medication stabilizes the fetal heart rate
c. This medication increases cardiac output
d. This medication improves tissue perfusion
Answer: a. This medication prevents seizures
4. A nurse is teaching a prenatal class regarding false labor. Which of the following information
should the nurse include?
a. You will have dilation and effacement of the cervix
b. Your contractions will become temporarily regular
c. You will have bloody show
d. Your contractions will become more intense when walking
Answer: b. Your contractions will become temporarily regular
5. A nurse manager is revising a maternal unit policy to ensure proper identification of newborns.
Which of the following should the nurse include in the policy?
a. Check the newborn’s identification using the crib card
b. Replace the infant’s identification band after his name has been recorded
c. Require visitors to wear an identification band
d. Obtain an imprint of the infant’s feet prior to taking him to the nursery
Answer: d. Obtain an imprint of the infant’s feet prior to taking him to the nursery
6. A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a
steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following
actions should the nurse take?
a. Replace the surgical dressing
b. Administer 500 mL lactated ringer’s IV bolus
c. Apply an ice pack to the incision site
d. Evaluate urinary output
Answer: b. Administer 500 mL lactated ringer’s IV bolus
7. A nurse is providing discharge instructions to a client who is postpartum and has engorged
breasts. Which of the following nonpharmacological comfort measures should the nurse include
in the teaching?
a. Wear nipple shields during the feeding
b. Apply cabbage leaves after feedings
c. Use a breast binder for 2 days
d. Use plastic-lined breast pads
Answer: b. Apply cabbage leaves after feedings
8. A nurse is calculating the estimated date of birth using Nagele’s rule for a client who is
pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated
date of delivery in the next year?
a. March 14
b. March 28
c. March 21
d. April 4
Answer: b. March 28
9. A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of
the following actions should the nurse take?
a. Prepare the client for what to expect the fetus to look like
b. Instruct the client that an autopsy should be performed within 24 hr
c. Inform the client that the law requires her to name the fetus
d. Limit the amount of time the fetus is in the client’s room
Answer: a. Prepare the client for what to expect the fetus to look like
10. A nurse is observing an adolescent client who is offering her newborn a bottle while he is
lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client’s
arms, the mother states, “No, the baby is too tired to be held.” Which of the following actions
should the nurse take?
a. Offer to take the newborn to the nursery to finish his feeding
b. Persuade the client to breastfeed the newborn to promote bonding
c. Insist that the mother pick up the newborn to feed him
d. Demonstrate how to hold the newborn and allow the client to practice
Answer: d. Demonstrate how to hold the newborn and allow the client to practice
11. A nurse is caring for a client who is in labor. Which of the following findings should prompt
the nurse to reassess the client?
a. A sense of excitement and warm, flushed skin
b. An urge to have a bowel movement during contractions
c. Intense contractions lasting 45 to 60 seconds
d. Progressive sacral discomfort during contractions
Answer: b. An urge to have a bowel movement during contractions
12. A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of
the following findings should the nurse report to the provider?
a. Hemoglobin 14.8 g/dL
b. Platelet count 60,000/mm3
c. Urine protein concentration 200 mg/24 hr
d. Creatinine 0.8 mg/dL
Answer: b. Platelet count 60,000/mm3
13. A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant.
Which of the following actions should the nurse take?
a. Place the client in a left-lateral position to obtain the measurement
b. Measure from the upper border of the symphysis pubis to the upper border of the fundus
c. Ensure that the client has a full bladder before taking the measurement
d. Lay the tape measure horizontally over the middle of the client’s abdomen
Answer: b. Measure from the upper border of the symphysis pubis to the upper border of the
fundus
14. A nurse is caring for a client who is at 20 weeks of gestation and reports constipation. Which
of the following recommendations should the nurse make to help relieve this common
discomfort of pregnancy?
a. Take 60 mL of magnesium hydroxide once daily
b. Drink 2 to 3 L of water each day
c. Include 18 g of fiber in the diet each day
d. Add 30 mL or mineral oil to each meal
Answer: b. Drink 2 to 3 L of water each day
15. A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When
using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in
synchronization with the fetal heartbeat. Which of the following terms should the nurse use to
document this finding?
a. Funic soufflé
b. Quickening
c. Hegar’s sign
d. Goodell’s sign
Answer: a. Funic soufflé
16. A nurse manager in a newborn nursery is reviewing infection control procedures with a group
of newly hired nurses. Which of the following instructions should the nurse manager include in
the teaching?
a. Allow parents to enter the nursery if they are wearing a mask
b. Place newborn bassinets at least 3 feet apart
c. Place the newborn’s foot on a sterile field during a heel stick
d. Maintain airborne precautions in the nursery
Answer: a. Allow parents to enter the nursery if they are wearing a mask
17. A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion.
The nurse notes a respiratory rate of 8/min and absent deep-tendon reflexes. Which of the
following medications should the nurse administer?
a. Acetylcysteine
b. Phytonadione
c. Protamine sulfate
d. Calcium gluconate
Answer: d. Calcium gluconate
18. A nurse is caring for a client who is 8 hr postpartum following vaginal delivery and is unable
to void. Which of the following interventions should the nurse use to promote voiding?
a. Encourage the client to void in the shower
b. Insert an indwelling urinary catheter
c. Apply suprapubic pressure
d. Administer a diuretic to the client
Answer: b. Insert an indwelling urinary catheter
19. A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses
about maternal cytomegalovirus. Which of the following information should the nurse manager
include in the teaching?
a. Transmission can occur via the saliva and urine of the newborn
b. This infection requires airborne precautions are initiated for the newborn
c. Lesions are visible on the mother’s genitalia
d. Mothers will receive prophylactic treatment with acyclovir prior to delivery
Answer: a. Transmission can occur via the saliva and urine of the newborn
20. A nurse in a prenatal clinic is caring for a client who has hyperemesis gravidarum. Which of
the following is the initial laboratory test used to evaluate this condition?
a. Liver enzymes
b. Complete blood count
c. Thyroid levels
d. Urine ketones
Answer: d. Urine ketones
21. A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks
of gestation. Which of the following actions should the nurse take? (Click on the Exhibit button
for additional information about the client. There are three tabs that contain separate categories
of data.)
Try your best guess and judgment!
a. Administer rubella vaccine – NO, never
b. Obtain a blood culture – indicated for blood infections (sepsis)
c. Administer ceftriaxone IM – treats gonorrhea
d. Obtain a maternal serum alpha-fetoprotein specimen – NO, test occurs between 15-22 wks.
Answer: d. Obtain a maternal serum alpha-fetoprotein specimen – NO, test occurs between 1522 wks.
22. A nurse is teaching a client about the basal body temperature method of contraception. Which
of the following statements should the nurse include in the teaching?
a. Your temperature may increase slightly immediately prior to ovulation
b. You should take your temperature before getting up for the day
c. You should abstain from intercourse when your temperature is above 100 F
d. Your risk of pregnancy is greatest on days 21 to 28 of your cycle
Answer: b. You should take your temperature before getting up for the day
23. A nurse is providing education to a client who is to receive misoprostol for induction of labor.
Which of the following instructions should the nurse include in the teaching?
a. I will insert a urinary catheter before I administer the medication
b. You will receive an antacid containing magnesium before the medication
c. You will lie on your side for 40 minutes after I administer the medication
d. I will begin an oxytocin infusion within 2 hours of your last dose of medication
Answer: c. You will lie on your side for 40 minutes after I administer the medication
24. A nurse is planning care for a client in the postpartum unit. Which of the following goals
should the nurse identify for the client to accomplish during the taking-in phase of postpartum
adjustment?
a. The client will verbalize appropriate car seat safety
b. The client will identify individual family member roles
c. The client will demonstrate proper bathing of the infant
d. The client will have adequate nutritional intake
Answer: d. The client will have adequate nutritional intake
25. A nurse in the antepartum clinic is teaching a client who is at 28 weeks of gestation and has
preeclampsia. Which of the following instructions should the nurse include in the teaching?
a. Alternate arms each time you check your BP
b. Reduce your calcium intake to less than 1 g per day
c. Count your baby’s movements daily
d. Limit your fluid intake to four 8 oz glasses per day
Answer: c. Count your baby’s movements daily
26. A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B
Streptococcus B-hemolytic (GBS). The client is multigravida and multipara with no history of
GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the
following is an appropriate response by the nurse?
a. There was no indication of GBS in your earlier prenatal testing
b. You didn’t report any symptoms of GBS during your pregnancy
c. Your previous deliveries were all negative for GBS
d. We need to know if you are positive for GBS at the time of delivery
Answer: d. We need to know if you are positive for GBS at the time of delivery
27. A nurse is assessing a full-term newborn upon admission to the nursery. Which of the
following clinical findings should the nurse report to the provider?
a. Rust-stained urine - normal
b. Single palmar creases – downs syndrome indication
c. Subconjunctival hemorrhage – broken blood vessel in eye
d. Transient circumoral cyanosis – decreased oxygenation
Answer: d. Transient circumoral cyanosis – decreased oxygenation
28. A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which
of the following findings should the nurse expect?
a. Urine output 30 mL/hr
b. Respiratory rate 18/min
c. Bounding pulses
d. Cool, clammy skin
Answer: d. Cool, clammy skin
29. A nurse is teaching a client who is at 8 weeks of gestation about self-care during pregnancy.
Which of the following statements should the nurse make?
a. You can take black cohost once a day for insomnia
b. You should limit your daily fluid intake to 1,000 mL per day
c. You can take 400 mg of ibuprofen for discomfort
d. You should take 600 mcg of folic acid per day
Answer: d. You should take 600 mcg of folic acid per day
30. A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for
labor induction. Which of the following interventions should the nurse include in the plan?
a. Limit IV intake to 4 L per 24 hr
b. Titrate the infusion rate by 4 milliunits/min
c. Maintain the client in a supine position?? Best Answer?
d. Increase the infusion rate every 30 to 60 min
Answer: c. Maintain the client in a supine position?? Best Answer?
31. A nurse is providing teaching about expected changes during pregnancy to a client who is at
24 weeks of gestation. Which of the following information should the nurse include?
a. Your nipples will become lighter in color
b. Your stomach will empty radily
c. You should anticipate nasal stuffiness
d. You should expect your uterus to double in size
Answer: c. You should anticipate nasal stuffiness
32. A nurse is assisting the provider to administer a dinoprostone (Cervidil) insert to induce labor
for a client. Which of the following actions should the nurse take?
a. Allow the medication to reach room temperature prior to administration
b. Place the client in a semi-Fowler’s position for 1 hr after administration
c. Verify that the informed consent is obtained prior to administration
d. Instruct the client to avoid urinary elimination until after administration
Answer: c. Verify that the informed consent is obtained prior to administration
33. A nurse is preparing to administer metronidazole 2 g PO to a client who has pelvic
inflammatory disease. Available is metronidazole 500 mg tablets. How many tablets should the
nurse administer? (Round the answer to the nearest whole number.)
Answer: 4 Tablets 500mg x 4 = 2000mg (2 g)
34. A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients
should the nurse recommend for an interdisciplinary care conference?
a. A client who is at 37 weeks of gestation and has an L/S ratio of 2:1
b. A client who is at 39 weeks of gestation and has a negative contraction stress test
c. A client who is at 35 weeks of gestation and has a biophysical profile of 6
d. A client who is at 28 weeks of gestation and has a negative Coomb’s titer
Answer: c. A client who is at 35 weeks of gestation and has a biophysical profile of 6
35. A nurse is planning to teach a group of clients who are pregnant about breastfeeding after
returning to work. Which of the following information should the nurse include in the teaching?
a. Thawed breast milk that is unused can be refrozen
b. Breast milk can be stored in a deep freezer for 12 months
c. Breast milk can be stored at room temperature for up to 12 hours
d. Thawed breast milk can be refrigerated for up to 72 hours
Answer: b. Breast milk can be stored in a deep freezer for 12 months
36. A nurse is performing an initial assessment of a newborn who was delivered with a nuchal
cord. Which of the following clinical findings should the nurse expect?
a. Facial petechiae
b. Erythema toxicum – normal newborn rash
c. Teiangiectatic nevi – stork bite, normal
d. Periauricular papillomas
Answer: a. Facial petechiae
37. A nurse is assessing a newborn upon admission to the nursery. Which of the following
findings should the nurse expect?
a. Chest circumference 2 cm (0.5 in) smaller than the head circumference
b. Length from head to heel of 40 cm (15.7 in)
c. Bulging fontanels
d. Nasal flaring
Answer: a. Chest circumference 2 cm (0.5 in) smaller than the head circumference
38. A nurse is assisting with a precipitous delivery of a term newborn. After the head emerges,
the nurse palpates the cord around the newborn’s neck. Which of the following actions should
the nurse take?
a. Apply a water-based lubricant to the cord
b. Apply fundal pressure
c. Place the client in the knee-chest position
d. Slip the cord over the newborn’s head
Answer: d. Slip the cord over the newborn’s head
39. A nurse is planning care for a newborn who is to undergo a circumcision using a plastic bell
device. Which of the following interventions should the nurse include in the plan of care?
a. Monitor for bleeding every 15 min for the first hour
b. Remove the yellow drainage on the second postoperative day
c. Take off the plastic bell 2 hours after the procedure
d. Wash the circumcision site with mild soap and water 2 hours following the procedure
Answer: a. Monitor for bleeding every 15 min for the first hour
40. A nurse is providing discharge instructions to a client who is 24 hours postpartum and has
decided not to breastfeed. Which of the following instructions should the nurse include in the
teaching?
a. Pump your breasts twice daily to relieve discomfort from engorgement
b. Shower daily, allowing warm water to run directly over your breasts
c. Apply ice packs to your breasts using a 15 minutes on, 45 minutes off schedule
d. Wear a loose-fitting, nonbinding bra for 72 hours
Answer: c. Apply ice packs to your breasts using a 15 minutes on, 45 minutes off schedule
41. A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hours
postpartum and has a boggy uterus. For which of the following assessment findings should the
nurse withhold the medication?
a. Blood pressure 142/92 mm Hg
b. Urine output 100 mL in 3 hours
c. Respiratory rate 14/min
d. Pulse rate 58/min
Answer: a. Blood pressure 142/92 mm Hg
42. A nurse is caring for four newborns. Which of the following findings should the nurse report
to the provider?
a. A newborn who has a high-pitched cry with exaggerated Moro reflex
b. A female newborn who has blood-tinged vaginal discharge
c. A male newborn who has scrotal edema
d. A newborn who has molding with overlapping suture lines
Answer: a. A newborn who has a high-pitched cry with exaggerated Moro reflex
43. A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of
gestation and requests an amniocentesis to determine the gender of the fetus. Which of the
following responses should the nurse make?
a. We can schedule the procedure for later today if you’d like
b. This procedure determines if your baby has genetic or congenital disorders
c. You cannot have an amniocentesis until you are at least 35 years of age
d. Your provider will schedule a chorionic villus sampling to determine the sex of your baby
Answer: b. This procedure determines if your baby has genetic or congenital disorders
44. A nurse is caring for a client who is postpartum. The client reports no relief in perineal pain
following the administration of oxycodone/acetaminophen. Which of the following actions
should the nurse take first?
a. Reposition the client
b. Assess the client’s perineal area for swelling
c. Administer ibuprofen to the client
d. Apply an ice pack to the client’s perineum
Answer:
45. A nurse is caring for a client who is in active labor and has gonorrhea. For which of the
following potential complications of gonorrhea should the nurse monitor?
a. Oligohydramnios
b. Vaginal laceration during birth
c. Excessive bleeding after birth
d. Chorioamnionitis
Answer: d. Chorioamnionitis
46. A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal
heart rate on the external fetal monitor. After placing the client in a side-lying position, which of
the following actions should the nurse take?
a. Administer oxygen via a face mask
b. Elevate the client’s head
c. Perform fetal scalp stimulation
d. Decrease the rate of IV fluids
Answer: a. Administer oxygen via a face mask
47. A nurse is caring for a newborn who has exstrophy of the bladder. Which of the following
actions should the nurse take prior to the beginning of surgical correction?
a. Exert gentle pressure on the newborn’s bladder with sterile gauze
b. Restrict the newborn’s fluid intake
c. Cover the newborn’s bladder with a sterile, non-adherent dressing
d. Keep the newborn in a side-lying position
Answer: c. Cover the newborn’s bladder with a sterile, non-adherent dressing
48. A nurse is reviewing the laboratory report of a client who is 24 hrs postpartum vaginal
delivery. The client has a hemoglobin level of 9.0 g/dL and hematocrit of 25%. Which of the
following actions should the nurse take?
a. Administer an iron supplement to the client
b. Instruct the client that the provider will check for placental fragments
c. Initiate IV access for isotonic solution with an 18-gauge catheter
d. Prepare the client for a blood transfusion
Answer: c. Initiate IV access for isotonic solution with an 18-gauge catheter
49. A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion
for sever preeclampsia. Which of the following findings should the nurse report to the provider?
a. Absence of clonus
b. Deep tendon reflex +2
c. Facial flushing
d. Urine output 20 mL/hr
Answer: d. Urine output 20 mL/hr
50. A nurse is performing a heel stick on a newborn. Which of the following actions should the
nurse take?
a. Place an ice pack on the newborn’s heel 5 min before the procedure
b. Cleanse the newborn’s heel with an alcohol swab after the procedure
c. Puncture the heel on the inner aspect of the foot
d. Use an automatic puncture device on the heel
Answer: d. Use an automatic puncture device on the heel
51. A nurse is caring for a client who has bladder distention following a vaginal birth. Which of
the following actions should the nurse take first?
a. Insert a urinary catheter
b. Offer the client a sitz bath
c. Pour warm water over the client’s perineum
d. Assist the client to the bathroom
Answer: d. Assist the client to the bathroom
52. A nurse is providing teaching about increasing dietary fiber to an antepartum client who
reports constipation. Which of the following food selections has the highest fiber content per
cup?
a. Oatmeal
b. Lentils
c. Cabbage
d. Asparagus
Answer: b. Lentils
53. A nurse is caring for a client following an amniocentesis. The nurse should observe the client
for which of the following complications?
a. Hemorrhage
b. Hyperemesis
c. Hypoxia
d. Proteinuria
Answer: a. Hemorrhage
54. A nurse in a clinic is caring for a client who is in her second trimester of pregnancy. The
client expresses concern about preparing her 2-year-old child for a new sibling. Which of the
following is an appropriate response by the nurse?
a. Let your toddler see you carrying the baby into the home for the first time
b. Require scheduled interactions between the toddler and the baby
c. Move your toddler to his new bed 2 months before the baby comes home??
d. Avoid brining your toddler to prenatal visits
Answer: b. Require scheduled interactions between the toddler and the baby
55. A nurse is assessing current medication use with a client who is at 6 weeks of gestation. The
nurse should recognize that pregnancy is a contraindication to the administration of which of the
following medications?
a. Diphenhydramine
b. Azithromycin
c. Metformin
d. Isotretinoin
Answer: d. Isotretinoin
56. A nurse is reviewing the immunization status of a client who is pregnant. The nurse should
inform the client that it is safe for her to receive which of the following immunizations during
pregnancy?
a. Tetanus
b. Rubeola
c. Varicella
d. Rubella
Answer: a. Tetanus
57. A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which
of the following findings should the nurse report to the provider?
a. Creatinine 0.9 mg/dL
b. Hematocrit 35%
c. Fasting blood glucose 180 mg/dL
d. WBC count 11,000/mm3
Answer: c. Fasting blood glucose 180 mg/dL
58. A nurse is caring for a client who is at 35 weeks of gestation and on bed rest due to severe
preeclampsia. Which of the following is an appropriate action for the nurse to take?
a. Obtain BP every 8 hr
b. Maintain NPO status
c. Auscultate fetal heart tones twice per day
d. Keep the lights dimmed in the room
Answer: d. Keep the lights dimmed in the room
59. A nurse is caring for a client who is 2 days postpartum and states, “I want to continue
breastfeeding, but my nipples are so sore.” Which of the following responses should the nurse
make?
a. Removing breast shields from your bra will decrease discomfort
b. Allow expressed milk to air dry on the nipples after feeding your infant
c. You should switch your infant to formula until the soreness goes away
d. Apply an antibiotic ointment to the nipples prior to each feeding
Answer: b. Allow expressed milk to air dry on the nipples after feeding your infant
60. A nurse is caring for a newborn immediately following birth and notes a large amount of
mucus in the newborn’s mouth and nose. Identify the sequence the nurse should follow when
performing suction with a bulb syringe. (Move the steps into the box on the right, placing them
in the selected order of performance. Use all the steps.)
Answer:
Compress the bulb syringe
Place the bulb syringe in newborn’s mouth
Use bulb syringe to suction newborn’s nose
Assess the newborn for reflex bradycardia
61. A nurse is receiving report on four postpartum clients. Which of the following clients should
the nurse plan to attend to first?
a. A client who has hyporeflexia while receiving IV magnesium sulfate – hyporeflexia = absent
b. A client who reports abdominal pain during breastfeeding
c. A client who reports changing her perineal pad every 2 hours – heavy not extreme
d. A client who has a urine output of 250 mL in 6 hours
Answer: a. A client who has hyporeflexia while receiving IV magnesium sulfate – hyporeflexia
= absent
c. A client who reports changing her perineal pad every 2 hours – heavy not extreme
62. A nurse is teaching a client about using a diaphragm. Which of the following instructions
should the nurse include in the teaching?
a. Insert the diaphragm up to 12 hours before intercourse
b. Replace the diaphragm every 2 years
c. Use 2 teaspoons of baby oil to lubricate the diaphragm before insertion
d. Remove the diaphragm 2 hours after intercourse
Answer: b. Replace the diaphragm every 2 years
63. A nurse is admitting a client to the birthing unit who reports her contractions started 1 hour
ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the
client is at risk for which of the following conditions?
a. Ectopic pregnancy
b. Hyperemesis gravidarum
c. Incompetent cervix
d. Postpartum hemorrhage
Answer: d. Postpartum hemorrhage
64. A nurse is providing vehicle safety education to the parents of a premature newborn. Which
of the following statements should the nurse include in the teaching?
a. Your newborn will need to have a car seat test prior to discharge
b. Place your newborn in a front-facing at seat in the back seat of the vehicle
c. Position the retainer clip at the level of your newborn’s abdomen
d. You should secure your newborn’s car seat at a 60-degree angle
Answer: a. Your newborn will need to have a car seat test prior to discharge
65. A nurse is providing discharge instructions to a client who is breastfeeding her newborn.
Which of the following instructions should the nurse include?
a. Offer the newborn 30 mL (1 oz) of water between feedings
b. Feed the newborn 5 to 10 min per breast
c. Allow the baby to feed at least every 3 hours
d. Expect two to four wet diapers every 24 hours
Answer: c. Allow the baby to feed at least every 3 hours
66. A nurse is assessing a client who is 2 days postpartum. Which of the following findings
indicates a complication?
a. Platelet count 370,000/mm3
b. Hct 36%
c. Hypotonic uterus
d. Perineal edema
Answer: c. Hypotonic uterus
67. A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hours ago.
Which of the following findings place the client at risk for postpartum hemorrhage? (Select all
that apply.)
a. Newborn weight 2.948 kg (6 lb 8 oz)
b. History of human papillomavirus
c. Labor induction with oxytocin
d. History of uterine atony
e. Vacuum-assisted delivery
Answer: c. Labor induction with oxytocin
d. History of uterine atony
68. A nurse is assessing a full-term newborn. Which of the following findings should the nurse
report to the provider?
a. Blood pressure 80/50 mm Hg
b. Respiratory rate 55/min
c. Temperature 36.5 C (97.7 F)
d. Heart rate 72/min
Answer: d. Heart rate 72/min
69. A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via
continuous IV infusion. Which of the following findings should the nurse report to the provider?
(Select all that apply.)
a. Urine output 130 mL/4 hr
b. Respiratory rate 11/min
c. Deep-tendon reflexes absent
d. Flushing of the face → adverse effects but not toxicity signs
e. Fetal heart rate 120/min
Answer: b. Respiratory rate 11/min
c. Deep-tendon reflexes absent
