2022 ATI Maternity Proctored Exam With Answers-60 Solved Questions

ATI Maternity Proctored Exam Latest 2022 60 Verified
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Management Information Systems (Nevada State College)
1) A nurse in a woman's health clinic is providing teaching about nutritional intake to a client
who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of
which of the following nutrients?
• Calcium
The recommendation for calcium intake during pregnancy is the same as that for women who are
not pregnant: 1,300 mg/day for women younger than 19 years old and 1,000 mg/day for women
between the ages of 19 and 50 years old.
• Vitamin E
The recommendation for vitamin E intake during pregnancy is 15 mg/day, the same as that for
women who are not pregnant.
• Iron
The recommendation for iron intake during pregnancy is higher than that for women who are not
pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is
15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of
19 and 50 years old.
• Vitamin D
The recommendation for vitamin D intake during pregnancy is 600 IU/day, the same as
Answer: • Iron
The recommendation for iron intake during pregnancy is higher than that for women who are not
pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is
15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of
19 and 50 years old.
2) A nurse is caring for a client who has uterine hypotonicity and is experiencing postpartum
haemorrhage. Which of the following actions is the nurse's priority?
• Check the client's capillary refill.

It is important for the nurse to monitor capillary refill in order to track baseline data for this
client. However, another action is the nurse's priority.
• Massage the client's fundus.
Uterine hypotonicity and postpartum haemorrhage indicate that this client is at the greatest risk
for hypovolemic shock. This can compromise the perfusion to the client's vital organs, causing
death to occur. Therefore, the nurse's priority is to massage the client's fundus in order to
minimize blood loss.
• Insert an indwelling urinary catheter for the client.
It is important for the nurse to insert an indwelling urinary catheter in order to assess the client
for hypovolemia. However, another action is the nurse's priority.
• Prepare the client for a blood transfusion.
It is important for the nurse to prepare the client for a blood transfusion in order to replace the
amount of blood lost from postpartum haemorrhage. However, another action is the nurse's
priority.
Answer: • Massage the client's fundus.
Uterine hypotonicity and postpartum haemorrhage indicate that this client is at the greatest risk
for hypovolemic shock. This can compromise the perfusion to the client's vital organs, causing
death to occur. Therefore, the nurse's priority is to massage the client's fundus in order to
minimize blood loss.
3) A nurse is providing discharge teaching to a parent whose newborn has just had a
circumcision. Which of the following instructions should the nurse include?
• Apply slight pressure with a sterile gauze pad for mild bleeding.
The nurse should instruct the client to attempt to stop mild bleeding by applying pressure with
sterile gauze. If bleeding continues, the client should notify the provider.
• Inspect the circumcision site every 6 to 8 hr.
The client should change the newborn's diaper and examine the circumcision site at least every 4
hr.
• Use baby wipes containing alcohol to cleanse the penis with each diaper change.

Baby wipes containing alcohol can irritate the skin and should be avoided until the circumcision
has healed, which usually takes 5 to 6 days. During each diaper change, the penis should be
washed gently with warm water and have petroleum jelly applied to the glans.
• Remove yellow exudate daily using a warm, wet washcloth.
The client should not attempt to remove any yellow exudate from the circumcision site because it
is part of the healing process, which begins within 24 hr and continues for 2 to 3 days. Disrupting
it can cause pain and bleeding.
Answer: • Apply slight pressure with a sterile gauze pad for mild bleeding.
The nurse should instruct the client to attempt to stop mild bleeding by applying pressure with
sterile gauze. If bleeding continues, the client should notify the provider.
4) A nurse is teaching about effective breastfeeding to a client who is 3 days postpartum. Which
of the following information should the nurse include?
• "Your milk will replace colostrum in about 10 days."
The nurse should inform the client that milk production occurs 3 or 4 days postpartum. The
breasts will feel firm and heavy. The client should continue to feed the newborn on demand
during this period.
• "Your breasts should feel firm after breastfeeding."
The nurse should inform the client that her breasts should feel softer after feeding. This change
indicates that the newborn has emptied the breasts of milk.
• "Your newborn should urinate at least 10 times per day."
The nurse should inform the client that the newborn should void six to eight times per day. The
newborn should also have at least three stools per day. It is not uncommon for breastfed
newborns to have a stool with each feeding.
• "Your newborn should appear content after each feeding."
The nurse should inform the client that a baby who is sated will appear content after feedings. A
baby who continues to show indications of hunger (for example, rooting, sucking on the hands,
or crying) might not be effectively emptying the breasts during feedings.
Answer: • "Your newborn should appear content after each feeding."

The nurse should inform the client that a baby who is sated will appear content after feedings. A
baby who continues to show indications of hunger (for example, rooting, sucking on the hands,
or crying) might not be effectively emptying the breasts during feedings.
5) A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management
during pregnancy. Which of the following statements by the client indicates an understanding of
the teaching?
• "I should have a goal of maintaining my fasting blood glucose between 100 and 120."
The nurse should teach the client to maintain her fasting blood glucose level between 60 and 99
mg/dL.
• "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater."
The nurse should teach the client to avoid exercise during periods of hyperglycaemia and when
positive urine ketones are present.
• "I will continue taking my insulin if I experience nausea and vomiting."
The nurse should teach the client to continue to take her insulin as prescribed during illness to
prevent hypoglycaemic and hyperglycaemic episodes.
Answer: • "I will continue taking my insulin if I experience nausea and vomiting."
The nurse should teach the client to continue to take her insulin as prescribed during illness to
prevent hypoglycaemic and hyperglycaemic episodes.
6) A nurse is discussing the differences between true labor and false labor with a group of
expectant parents. Which of the following characteristics should the nurse include when
discussing true labor?
• Contractions become stronger with walking.
The contractions that occur during true labor become stronger and more regular with change in
activity, such as walking.
• Discomfort can be suppressed with a back massage.
The discomfort of false labor can be suppressed by using comfort measures, such as a back or
foot massage. With true labor, the client discomfort continues regardless of the use of comfort
measures.
• Contractions become irregular with a change in activity.

The contractions that occur during true labor will become stronger and more regular with a
change in activity.
• Discomfort is felt above the umbilicus.
The discomfort experienced during the contractions of true labor is felt in the lower back and
lower abdomen. Discomfort during false labor is usually felt above the umbilicus.
Answer: • Contractions become stronger with walking.
The contractions that occur during true labor become stronger and more regular with change in
activity, such as walking.
7) A nurse is teaching a group of parents about newborn safety. Which of the following
statements by a parent indicates an understanding of the teaching?
• "I will put a bib on my baby at night to keep her clothing dry."
The parents should avoid placing a bib around their newborns' necks at night to prevent choking
and suffocation.
• "I will cover the crib mattress with plastic to prevent staining."
The parents should avoid placing plastic over the crib mattress to prevent suffocation.
• "I will warm my baby's formula using the lowest setting in the microwave."
The parents should avoid heating the formula in a microwave to prevent uneven warming of the
formula.
• "I will dress my baby in flame-retardant clothing."
The parents should dress their newborns in flame-retardant clothing to prevent injury.
Answer: • "I will dress my baby in flame-retardant clothing."
The parents should dress their newborns in flame-retardant clothing to prevent injury.
8) A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura
(ITP). Which of the following findings should the nurse expect?
• Decreased platelet count
A client who has ITP has an autoimmune response that results in a decreased platelet count.
• Increased erythrocyte sedimentation rate (ESR)
An increased ESR is an indication of chronic renal failure.
• Decreased megakaryocytes

A client who has ITP will have megakaryocytes within the expected reference range. Increased
WBC
• An increased WBC is an indication of infection
Answer: • Decreased platelet count
A client who has ITP has an autoimmune response that results in a decreased platelet count.
9) A nurse is caring for a newborn who was transferred to the nursery 30 min after delivery.
Which of the following actions should the nurse take first?
• Confirm the newborn's Apgar score.
The Apgar score is a physiologic assessment that occurs 1 min following birth and again at 5
min. The nurse should confirm the score when the newborn arrives in the nursery. However,
there is another action the nurse should take first.
• Verify the newborn's identification.
When using the safety/risk reduction approach to client care, the first action the nurse should
take is to verify the newborn's identity upon arrival to the nursery.
• Administer vitamin K to the newborn.
The nurse should administer IM vitamin K to the newborn soon after birth to increase clotting
factors and prevent bleeding. However, the injection can be delayed until after initial bonding
time and the first breastfeeding if necessary. Therefore, there is another action the nurse should
take first.
• Determine obstetrical risk factors.
The nurse should identify obstetrical risk factors to determine if interventions are required for the
newborn. However, there is another action the nurse should take first.
Answer: • Verify the newborn's identification.
When using the safety/risk reduction approach to client care, the first action the nurse should
take is to verify the newborn's identity upon arrival to the nursery.
10) A nurse is assessing a client who is in active labor and notes early decelerations in the FHR
on the monitor tracing. The client is at 39 weeks of gestation and is receiving a continuous IV
infusion of oxytocin. Which of the following actions should the nurse take?
• Discontinue the oxytocin infusion.

Early decelerations in the FHR are considered benign. Early decelerations occur due to
compression of the fetal head during contractions, vaginal examinations, and pushing during the
second stage of labor. No interventions are necessary for early decelerations.
• Continue monitoring the client.
Early decelerations in the FHR are considered benign. Early decelerations occur due to
compression of the fetal head during contractions, vaginal examinations, and pushing during the
second stage of labor. No interventions are necessary for early decelerations. Therefore, the nurse
should continue to monitor the client.
• Request that the provider assess the client.
Early decelerations in the FHR are considered benign. Early decelerations occur due to
compression of the fetal head during contractions, vaginal examinations, and pushing during the
second stage of labor. No interventions are necessary for early decelerations.
• Increase the infusion rate of the maintenance IV fluid.
Early decelerations in the FHR are considered benign. Early decelerations occur due to
compression of the fetal head during contractions, vaginal examinations, and pushing during the
second stage of labor. No interventions are necessary for early decelerations.
Answer: • Continue monitoring the client.
Early decelerations in the FHR are considered benign. Early decelerations occur due to
compression of the fetal head during contractions, vaginal examinations, and pushing during the
second stage of labor. No interventions are necessary for early decelerations. Therefore, the nurse
should continue to monitor the client.
11) A nurse in a provider's office is reviewing the medical record of a client who is in her first
trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor
for the development of preeclampsia?
• Singleton pregnancy
Multifetal gestation, rather than a single fetus pregnancy, increases a client's risk for the
development of preeclampsia.
• BMI of 20
Having a BMI greater than 30 increases a client's risk for the development of preeclampsia.
• Maternal age 32 years

A maternal age of younger than 19 or older than 40 increases the client's risk for the development
of preeclampsia.
• Pregestational diabetes mellitus
Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia.
Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus,
and rheumatoid arthritis.
Answer: • Pregestational diabetes mellitus
Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia.
Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus,
and rheumatoid arthritis.
12) A nurse is assessing a client who received carboprost for postpartum haemorrhage. Which of
the following findings is an adverse effect of this medication?
• Hypertension
The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.
• Hypothermia
Fever is a common adverse effect of carboprost.
• Constipation
Diarrhoea is a common adverse effect of carboprost.
• Muscle weakness
Muscle weakness is not an adverse effect of carboprost.
Answer: • Hypertension
The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.
13) A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia.
Which of the following actions should the nurse take?
• Cover the newborn's eyes while under the phototherapy light.
Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the
phototherapy light.
• Keep the newborn in a shirt while under the phototherapy light.

It is acceptable for the nurse to keep a diaper or other covering over the newborn's genitals and
buttocks, but the nurse should remove all other clothing and blankets to expose as much body
surface area as possible to the phototherapy light.
• Apply a light moisturizing lotion to the newborn's skin.
The nurse should not apply any cream or moisture to the newborn's skin because it can absorb
heat and cause burns.
• Turn and reposition the newborn every 4 hr while undergoing phototherapy.
The nurse should turn and reposition the newborn every 2 to 3 hr to allow for maximum
exposure of body surfaces to the phototherapy light.
Answer: • Cover the newborn's eyes while under the phototherapy light.
Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the
phototherapy light.
14) A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is
experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal
examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is
in which of the following phases of labor?
• Active
The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions
every 3 to 5 min, each lasting 40 to 70 seconds.
• Transition
The nurse should identify that the client is in the transition phase of labor. This phase is
characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each
lasting 45 to 90 seconds.
• Latent
The latent phase of labor is characterized by cervical dilation of 0 to 3 cm and contractions every
5 to 30 min, each lasting 30 to 45 seconds.
• Descent
The descent phase of labor is characterized by active pushing with contractions every 1 to 2 min,
each lasting for 90 seconds.
Answer: • Transition

The nurse should identify that the client is in the transition phase of labor. This phase is
characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each
lasting 45 to 90 seconds.
15) A nurse in a family planning clinic is caring for a client who requests an oral contraceptive.
Which of the following findings in the client's history should the nurse recognize as a
contraindication to oral contraceptives? (Select all that apply.)
• Cholecystitis
Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral
contraceptive
• Hypertension
Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives.
• Human papillomavirus
Human papillomavirus is incorrect. The presence of human papillomavirus is not a
contraindication for the use of oral contraceptives.
• Migraine headaches
Migraine headaches is correct. A history of migraine headaches is a contraindication for the use
or oral contraceptives.
• Anxiety disorder
Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for
the use of oral contraceptives.
Answer: • Cholecystitis
Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral
contraceptive
• Hypertension
Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives.
• Migraine headaches
Migraine headaches is correct. A history of migraine headaches is a contraindication for the use
or oral contraceptives.

16) A nurse is assessing a client who is 12 hr postpartum. The client's fundus is two
fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than
previously noted. Which of the following actions should the nurse take?
• Place the client in a side-lying position.
Placing the client in a side-lying position is an action that the nurse should take for a client who
is experiencing hypovolemic shock.
• Assist the client to the bathroom to void.
A distended bladder inhibits the uterus from contracting normally and can cause uterine atony.
Therefore, the nurse should assist the client to void.
• Obtain a prescription for IV oxytocin.
Obtaining a prescription for IV oxytocin is an action that the nurse should take for a client who
requires labor induction and augmentation.
• Administer methylergonovine.
Administering methylergonovine is an action that the nurse should take for a client who is
experiencing postpartum haemorrhage.
Answer: • Assist the client to the bathroom to void.
A distended bladder inhibits the uterus from contracting normally and can cause uterine atony.
Therefore, the nurse should assist the client to void.
17) A nurse is performing a physical assessment of a newborn upon admission to the nursery.
Which of the following clinical manifestations should the nurse expect? (Select all that apply.)
• Yellow sclera
Yellow sclera is incorrect. Yellow sclera is an indication of hyperbilirubinemia and is not an
expected clinical manifestation.
• Creases over two-thirds of the soles of the feet
Creases over two-thirds of the soles of the feet is correct. Fewer creases over the soles of the feet
is an indication of prematurity. Creases over the entire soles of the feet is an indication of post
maturity.
• Posterior fontanel larger than the anterior fontanel
Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel is located
on the back of the newborn's head and is a small triangular shape. The anterior fontanel is

diamond shaped and approximately 5 cm. It is located on the top of the newborn's head and is
larger than the posterior fontanel.
• Molding of the head
Molding of the head is correct. Molding occurs during the birth process as the newborn travels
through the birth canal, resulting in compression of the soft bones of the skull.
• Lanugo on the shoulders
• Lanugo on the shoulders is correct. Absence of lanugo is an indication of post maturity.
Abundant lanugo is an indication of prematurity.
Answer: • Molding of the head
Molding of the head is correct. Molding occurs during the birth process as the newborn travels
through the birth canal, resulting in compression of the soft bones of the skull.
• Creases over two-thirds of the soles of the feet
Creases over two-thirds of the soles of the feet is correct. Fewer creases over the soles of the feet
is an indication of prematurity. Creases over the entire soles of the feet is an indication of post
maturity.
• Lanugo on the shoulders
Lanugo on the shoulders is correct. Absence of lanugo is an indication of post maturity.
Abundant lanugo is an indication of prematurity.
18) A nurse is developing an educational program for adolescents about nutrition during the third
trimester of pregnancy. Which of the following statements should the nurse include in the
program?
• "Consume three to four servings of dairy each day."
Calcium intake is especially important during an adolescent's pregnancy because bone absorption
of calcium is still occurring. Therefore, the nurse should instruct the adolescents to consume
three to four servings of dairy per day to meet their calcium needs.
• "Increase your daily caloric intake by 600 to 700 calories."
Consuming an additional 600 to 700 cal per day could lead to excessive weight gain, which
increases the adolescent's risk for complications related to pregnancy, labor, and delivery. The
nurse should instruct the adolescents that, if they have a BMI within the expected reference range

prior to pregnancy, they should increase their daily caloric intake by 340 cal in the first trimester
and 452 cal in the second and third trimesters.
• "Limit your daily sodium intake to less than 1 gram."
Sodium supports the increase in blood volume that occurs during pregnancy. An adequate
sodium intake is approximately 1.5 g per day. The nurse should instruct the adolescents that an
adequate intake of sodium is required during pregnancy.
• "Increase your protein intake to 40 to 50 grams each day."
Adequate protein intake is necessary to support the rapid growth of the fetus, maternal tissues,
increasing blood volume, and the formation of amniotic fluid. Therefore, the nurse should
instruct the adolescents to increase their daily intake of protein to approximately 71 g during the
second and third trimesters of pregnancy.
Answer: • "Consume three to four servings of dairy each day."
Calcium intake is especially important during an adolescent's pregnancy because bone absorption
of calcium is still occurring. Therefore, the nurse should instruct the adolescents to consume
three to four servings of dairy per day to meet their calcium needs.
19) A nurse is performing a vaginal exam on a client who is in labor and reports severe pressure
and pain in the lower back. The nurse notes that the fetal head is in a posterior position. The
nurse should identify that which of the following is the best nonpharmacological intervention to
perform to relieve the client's discomfort?
• Back rub
A back rub is an effective nonpharmacological intervention to assist the client with pain.
However, there is a better nonpharmacological intervention the nurse should use.
• Counter-pressure
According to evidence-based practice, counter-pressure is the best nonpharmacological
technique to use when relieving the client's discomfort from the fetus being in a posterior
position because this intervention lifts the fetal head off of the spinal nerve.
• Playing music
Playing music is an effective nonpharmacological intervention to assist the client with pain.
However, there is a better nonpharmacological intervention the nurse should use.
• Foot massage

A foot massage is an effective nonpharmacological intervention to assist the client with pain.
However, there is a better nonpharmacological intervention the nurse should use.
Answer: • Counter-pressure
According to evidence-based practice, counter-pressure is the best nonpharmacological
technique to use when relieving the client's discomfort from the fetus being in a posterior
position because this intervention lifts the fetal head off of the spinal nerve.
20) A nurse is developing a plan of care for a client who has preeclampsia and is receiving
magnesium sulphate via a continuous IV infusion. Which of the following interventions should
the nurse include in the plan?
• Monitor the client's blood pressure every hour.
The nurse should monitor the client's vital signs, including blood pressure, every 15 to 30 min.
Magnesium sulphate, which is used to prevent seizures in clients who have preeclampsia, is a
high-alert medication that requires close monitoring.
• Restrict the total hourly intake to 200 mL.
The nurse should restrict the client's total hourly intake to no more than 125 mL. Clients who
have preeclampsia can have an alteration in kidney function, leading to increases in edema.
• Monitor the FHR continuously.
Magnesium sulphate, which is used to prevent seizures in clients who have preeclampsia, is a
high-alert medication that requires close monitoring. The FHR and uterine contractions should be
monitored continuously while the client is receiving magnesium sulphate.
• Administer protamine sulphate for manifestations of toxicity.
The nurse should administer calcium gluconate if the client shows manifestations of magnesium
sulphate toxicity. Findings of toxicity include loss of deep-tendon reflexes, respiratory
depression, slurred speech, and cardiac arrest.
Answer: • Monitor the FHR continuously.
Magnesium sulphate, which is used to prevent seizures in clients who have preeclampsia, is a
high-alert medication that requires close monitoring. The FHR and uterine contractions should be
monitored continuously while the client is receiving magnesium sulphate.

21) A nurse is planning care for a client who is 2 hr postpartum. Which of the following
interventions should the nurse plan to implement during the taking-hold phase of postpartum
behavioral adjustment?
• Discuss contraceptive options with the client and her partner.
The discussing of contraceptive options occurs during the letting-go phase. This phase focuses
on moving forward as a family with interchanging members.
• Repeat information to ensure client understanding.
The repeating of information to ensure client understanding occurs during the taking- in phase.
During this phase, which is experienced on the first postpartum day, the client displays
dependent and passive behaviours. Due to excitement and fatigue, the client is unable to retain
information. Therefore, the nurse should repeat instructions to ensure that the client understands
what is being said.
• Listen to the client and her partner as they reflect upon the birth experience.
Listening to the client and her partner reflect upon the birth experience occurs during the takingin phase. During this phase, the new mother is focused on herself and meeting her basic needs.
There is also much excitement about the newborn and the birth experience. Therefore, the nurse
should allow the client to reflect, ensuring a healthy transition and a successful adaptation into
the new family unit.
• Demonstrate to the client how to perform a newborn bath.
Demonstrating to the client how to perform a newborn bath occurs during the taking- hold phase.
The new mother moves from being passively dependent to taking a stronger interest in her new
role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The
nurse should provide positive reinforcement during this phase to give the new mother confidence
and promote maternal adjustment.
Answer: • Demonstrate to the client how to perform a newborn bath.
Demonstrating to the client how to perform a newborn bath occurs during the taking- hold phase.
The new mother moves from being passively dependent to taking a stronger interest in her new
role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The
nurse should provide positive reinforcement during this phase to give the new mother confidence
and promote maternal adjustment.

22) A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of
the following techniques should the nurse use to help minimize the pain of the procedure for the
newborn?
• Apply a cool pack for 10 min to the heel prior to the puncture.
A cool pack will constrict the blood vessels, making it more difficult to obtain an adequate
specimen. The nurse should apply a warm pack prior to the puncture.
• Request a prescription for IM analgesic.
The pain experienced from a heel stick is too brief to warrant risking the adverse effects of
parenteral analgesia.
• Use a manual lance blade to pierce the skin.
A spring-loaded, automatic puncture device is recommended to minimize pain by ensuring that
the depth of the puncture is not too deep, avoiding injury to the newborn.
• Place the newborn skin to skin on the mother's chest.
Placing the newborn skin to skin on the mother's chest is an effective technique to significantly
decrease the newborn's pain level and anxiety. The nurse should implement this technique
before, during, and after the procedure.
Answer: • Place the newborn skin to skin on the mother's chest.
Placing the newborn skin to skin on the mother's chest is an effective technique to significantly
decrease the newborn's pain level and anxiety. The nurse should implement this technique
before, during, and after the procedure.
23) A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the
following findings contraindicates the initiation of the oxytocin infusion and should be reported
to the provider?
• Late decelerations
Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a
contraindication for the administration of oxytocin and should be reported to the provider.
• Moderate variability of the FHR
Moderate variability of the FHR is an expected assessment finding associated with normal fatal
acid base balance. It is not a contraindication to the administration of oxytocin.
• Cessation of uterine dilation

Cessation of uterine dilation is an indication for the initiation of an oxytocin infusion to augment
the client's labor progression.
• Prolonged active phase of labor
A prolonged active phase of labor is an indication for the initiation of an oxytocin infusion to
augment the client's labor progression.
Answer: • Late decelerations
Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a
contraindication for the administration of oxytocin and should be reported to the provider.
24) A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit.
Which of the following findings should the nurse report to the provider?
• Blood pressure 136/88 mm Hg
A blood pressure of 136/88 mm Hg is within the expected reference range for a client who is at
38 weeks of gestation. Therefore, this finding does not need to be reported to the provider.
• Report of insomnia
A regular occurrence of insomnia can be expected for a client who is at 38 weeks of gestation.
Therefore, this finding does not need to be reported to the provider.
• Weight gain of 2.2 kg (4.8 lb)
A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could
indicate complications. Therefore, this finding should be reported to the provider.
• Report of Braxton-Hicks contractions
Braxton-Hicks contractions can be expected for a client who is at 38 weeks of gestation.
Therefore, this finding does not need to be reported to the provide
Answer: • Weight gain of 2.2 kg (4.8 lb)
A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could
indicate complications. Therefore, this finding should be reported to the provider.
25) A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had
an amniocentesis. Which of the following interventions is the nurse's priority following the
procedure?
• Check the client's temperature.

The nurse should check the client's temperature to monitor for infection following an
amniocentesis. However, this is not the priority nursing intervention.
• Observe for uterine contractions.
The nurse should observe for uterine contractions to identify preterm labor following an
amniocentesis. However, this is not the priority nursing intervention.
• Administer Rho(D) immune globulin.
The nurse should administer Rho(D) immune globulin following an amniocentesis to prevent Rh
sensitization. However, this is not the priority nursing intervention.
• Monitor the FHR.
The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing
intervention is to monitor the FHR following an amniocentesis.
Answer: • Monitor the FHR.
The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing
intervention is to monitor the FHR following an amniocentesis.
26) A nurse is planning care for a client who is in labor and is requesting epidural anaesthesia for
pain control Which of the following actions should the nurse include in the plan of care?
• Place the client in a supine position for 30 min following the first dose of aesthetic
The nurse should plan to position the client upright in order to allow the aesthetic solution to
flow downward. If additional pain management is needed for a caesarean birth, the nurse can
place the client supine with her head and shoulders elevated and at a lateral tilt to increase
perfusion to the fetus.
• Administer 1,000 mL of dextrose 5% in water prior to the first dose of anaesthetic solution.
The nurse should plan to administer 500 to 1,000 mL of lactated Ringer's or 0.9% sodium
chloride 15 to 30 min prior to the administration of the first dose of anaesthetic solution in order
to decrease the maternal risk for hypotension. The nurse should not administer dextrose because
it can cause maternal hyperglycaemia and neonatal hypoglycaemia.
• Monitor the client's blood pressure every 5 min following the first dose of anaesthetic solution.
The nurse should plan to obtain a baseline blood pressure prior to the initiation of anaesthetic
solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min
to assess for maternal hypotension caused by the anaesthetic solution.

• Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of
anaesthetic solution.
The nurse should not plan to restrict the client's intake prior to the epidural placement
Answer: • Monitor the client's blood pressure every 5 min following the first dose of anaesthetic
solution.
The nurse should plan to obtain a baseline blood pressure prior to the initiation of anaesthetic
solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min
to assess for maternal hypotension caused by the anaesthetic solution.
27) A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's
secretions. Which of the following instructions should the nurse include?
• Insert the syringe tip before compressing the bulb.
The client should compress the bulb before inserting the syringe tip. Compressing the bulb after
it is in the newborn's nares or mouth could push the secretions and mucus further inside.
• Suction each of the nares before suctioning the mouth.
The client should suction the mouth before suctioning the nares. Otherwise, the newborn could
gasp and inhale pharyngeal secretions when the syringe tip touches the nares.
• Insert the tip of the syringe into the centre of the newborn's mouth.
The client should insert the tip of the syringe into the side of the newborn's mouth. Inserting it
into the centre of the newborn's mouth can trigger the gag reflex.
• Stop suctioning when the newborn's cry sounds clear.
The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds
like it is coming through a bubble of fluid or mucus.
Answer: • Stop suctioning when the newborn's cry sounds clear.
The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds
like it is coming through a bubble of fluid or mucus.
28) A nurse is assessing a late preterm newborn. Which of the following clinical manifestations
is an indication of hypoglycaemia?
• Hypertonia
A newborn who has hypoglycaemia can exhibit hypotonia.

• Increased feeding
A newborn who has hypoglycaemia can exhibit poor feeding behaviours.
• Hyperthermia
A newborn who has hypoglycaemia can exhibit hypothermia.
• Respiratory distress
Late preterm newborns are at an increased risk for hypoglycaemia due to decreased glycogen
stores and immature insulin secretion. Respiratory distress is a clinical manifestation of
hypoglycaemia. Other manifestations of hypoglycaemia include an abnormal l cry, jitteriness,
lethargy, poor feeding, apnea, and seizures.
Answer: • Respiratory distress
Late preterm newborns are at an increased risk for hypoglycaemia due to decreased glycogen
stores and immature insulin secretion. Respiratory distress is a clinical manifestation of
hypoglycaemia. Other manifestations of hypoglycaemia include an abnormal l cry, jitteriness,
lethargy, poor feeding, apnea, and seizures.
29) A nurse is assessing four newborns. Which of the following findings should the nurse report
to the provider?
• A newborn who is 26 hr old and has erythema toxicum on his face
Erythema toxicum is a transient rash that can appear anywhere on a newborn's body during the
first 24 to 72 hr following birth. This finding requires no treatment.
• A newborn who is 32 hr old and has not passed a meconium stool
A newborn should pass the first meconium stool within the first 24 to 48 hr following birth.
Failure to pass a meconium stool can indicate a bowel obstruction or congenital disorder. This
finding is within the expected reference range.
• A newborn who is 12 hr old and has pink-tinged urine
Pink-tinged urine is an indication of uric acid crystals and is an expected finding for a newborn
during the first week following birth.
• A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for
a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to
the provider.

Answer: • A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for
a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to
the provider.
30) A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the
nurse should follow. (Move the steps into the box on the right, placing them in the selected order
of performance. Use all the steps.)
•

Palpate the fundus to identify the fetal part.

•

Determine the location of the fetal back.

•

Palpate for the fetal part presenting at the inlet

•

Identify the attitude of the head.

Answer: The first step the nurse should take when performing Leopold maneuvers is to palpate
the client's fundus to identify the fetal part. Second, the nurse should determine the location of
the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the
nurse should palpate the cephalic prominence to identify the attitude of the head.
31) A nurse is admitting a client to the labor and delivery unit when the client states, "My water
just broke." Which of the following interventions is the nurse's priority?
• Perform Nitra zine testing.
The nurse should perform a Nitra zine test to determine the pH of the fluid. An alkaline pH can
indicate rupture of membranes. However, this is not the first action the nurse should take.
• Assess the fluid.
The nurse should observe the characteristics of the fluid to document colour, Odor, and amount.
However, this is not the first action the nurse should take.
• Check cervical dilation.
The nurse should check the client's cervical dilation to assess progress of labor. However, this is
not the first action the nurse should take.
• Begin FHR monitoring.

The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord
prolapse. The nurse should monitor the fetus closely to ensure well- being. Therefore, this is the
priority action the nurse should take.
Answer: • Begin FHR monitoring.
The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord
prolapse. The nurse should monitor the fetus closely to ensure well- being. Therefore, this is the
priority action the nurse should take.
32) A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of
the following statements by the client indicates an understanding of the teaching?
• "I will eat foods that appeal to my taste instead of trying to balance my meals."
Clients who have hyperemesis gravidarum should eat to taste to avoid nausea.
• "I will avoid having a snack at bedtime."
Clients who have hyperemesis gravidarum should avoid going to bed with an empty stomach.
The nurse should instruct the client to eat a healthy snack before going to bed.
• "I will have 8 ounces of hot tea with each meal."
Clients who have hyperemesis gravidarum should alternate liquids and solids every 2 to 3 hr to
avoid an empty stomach and over filling at each meal.
• "I will pair my sweets with a starch instead of eating them alone."
Clients who have hyperemesis gravidarum should eat protein following a sweet snack.
Answer: • "I will eat foods that appeal to my taste instead of trying to balance my meals."
Clients who have hyperemesis gravidarum should eat to taste to avoid nausea.
33) A nurse is providing discharge teaching to a client who is postpartum. For which of the
following clinical manifestations should the nurse instruct the client to monitor and report to the
provider?
• Persistent abdominal striae
Persistent abdominal striae are caused by the separation of the underlying connective tissue and
are an expected postpartum finding.
• Temperature 37.8° C (100.2° F)

The nurse should instruct the client to report a temperature of 38° C (100.4° F) or higher because
it could be an indication of infection.
• Unilateral breast pain
Chills, fever, malaise, and unilateral breast pain can be indications of mastitis, an infection of the
breast tissue. The nurse should instruct the client to report this clinical manifestation to the
provider.
• Brownish-red discharge on day 5
Brownish-red discharge is an expected clinical manifestation during days 3 to 10. The client
should report a large amount of lochia and large clots to the provider.
Answer: • Unilateral breast pain
Chills, fever, malaise, and unilateral breast pain can be indications of mastitis, an infection of the
breast tissue. The nurse should instruct the client to report this clinical manifestation to the
provider.
34) A nurse is assessing a client who is at 26 weeks of gestation. Which of the following clinical
manifestations should the nurse report to the provider?
• Leukorrhea
Leukorrhea is an expected clinical manifestation during all stages of pregnancy. It is a white
discharge that is the result of hormone secretion during pregnancy.
• Supine hypotension
Supine hypotension is an expected clinical manifestation during the second and third trimesters.
It is the result of pressure on the ascending vena cava from the gravid uterus.
• Periodic numbness of the fingers
Periodic numbness of the fingers is an expected clinical manifestation during the second and
third trimesters. It occurs from the slumping of the shoulders during pregnancy.
• Decreased urine output
Decreased urine output, increased blood pressure, proteinuria, and decreased fetal activity can be
indications of preeclampsia and should be reported to the provider.
Answer: • Decreased urine output
Decreased urine output, increased blood pressure, proteinuria, and decreased fetal activity can be
indications of preeclampsia and should be reported to the provider.

35) A nurse is caring for a client who is at 40 weeks of gestation and is in early labor. The client
has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following
treatment modalities should the nurse anticipate?
• Epidural analgesia
The placement of an epidural catheter places the client at risk for bleeding. Therefore, a low
platelet count is a contraindication for the placement of an epidural.
• Naloxone hydrochloride
Naloxone hydrochloride is an opioid antagonist used to reverse respiratory depression in
newborns.
• Attention-focusing
Attention-focusing and distraction techniques are types of nonpharmacological care that are
effective in relieving labor pain.
• Pudendal nerve block
A pudendal nerve block is administered during the third stage of labor for the repair of an
episiotomy or laceration.
Answer: • Attention-focusing
Attention-focusing and distraction techniques are types of nonpharmacological care that are
effective in relieving labor pain.
36) A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose
tolerance test. Which of the following statements should the nurse include in her teaching?
• "You will need to drink the glucose solution 2 hours prior to the test."
The nurse should instruct the client to drink the glucose solution 1 hr prior to the test.
• "Limit your carbohydrate intake for 3 days prior to the test."
The nurse should teach the client that she should not limit her carbohydrate intake.
• "A blood glucose of 130 to 140 is considered a positive screening result."
The nurse should teach the client that a blood glucose level of 130 to 140 mg/dL is considered a
positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose
tolerance test to confirm if she has gestational diabetes mellitus.
• "You will need to fast for 12 hours prior to the test."

The nurse should teach the client that fasting is not required for a 1-hr glucose tolerance test.
Answer: • "A blood glucose of 130 to 140 is considered a positive screening result."
The nurse should teach the client that a blood glucose level of 130 to 140 mg/dL is considered a
positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose
tolerance test to confirm if she has gestational diabetes mellitus.
37) A nurse is assessing a full-term newborn 15 min after birth. Which of the following findings
requires intervention by the nurse
• Heart rate 168/min
During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after
birth, a heart rate between 160 to 180/min is an expected clinical manifestation.
• Respiratory rate 18/min
During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after
birth, the respiratory rate can range between 20 to 100/min. A respiratory rate this low at this
time requires further evaluation and intervention by the nurse.
• Tremors
During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after
birth, the expected clinical manifestations include tremors, crying, and startling motions.
• Fine crackles
During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after
birth, fine crackles and nasal flaring are expected clinical manifestations.
Answer: • Respiratory rate 18/min
During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after
birth, the respiratory rate can range between 20 to 100/min. A respiratory rate this low at this
time requires further evaluation and intervention by the nurse.
38) A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a
nonstress test . Which of the following statements should the nurse include in the teaching?
•"You will receive IV fluid prior to this test."
The nurse should state that IV fluids are initiated for the oxytocin-stimulated contraction test.
•"The procedure will take approximately 10 to 15 minutes."

The nurse should instruct the client that the procedure will take 20 to 40 min.
•"You will be offered orange juice to drink during the test."
A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or
another beverage high in glucose, will stimulate the fetus during the procedure, helping to obtain
results.
• "You will need to sign an informed consent form each time you have this test."
A nonstress test is a non-invasive procedure. Therefore, informed consent does not need to be
obtained.
Answer: •"You will be offered orange juice to drink during the test."
A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or
another beverage high in glucose, will stimulate the fetus during the procedure, helping to obtain
results.
39) A nurse is caring for a client who has recently experienced a perinatal death. Which of the
following statements should the nurse make to the client?
• "It must be a comfort to know you have another child."
The nurse is making a statement that minimizes the significance of the death of the client's
newborn. This type of response from the nurse will not facilitate further communication.
• "I'm sad for you."
The nurse is offering empathy to the client to facilitate further communication about the perinatal
death.
• "There is usually something wrong with the baby."
The nurse is making a statement that minimizes the significance of the death of the client's
newborn. This type of response from the nurse will not facilitate further communication.
• "You will always have an angel in heaven."
The nurse is making a statement that uses a cliché. This type of response from the nurse will not
facilitate further communication
Answer: • "I'm sad for you."
The nurse is offering empathy to the client to facilitate further communication about the perinatal
death.

40) A nurse is planning care for a client who is at 24 weeks of gestation and reports daily mild
headaches. Which of the following instructions should the nurse include in the plan of care?
• Administer ibuprofen 400 mg twice each day.
Daily ibuprofen administration can lead to increased bleeding and premature closure of the
ductus arteriosus in the fetus.
• Recommend that the client perform conscious relaxation techniques daily.
The nurse should include conscious relaxation techniques in the plan of care as a way to relieve
tension and reduce stress, which can help to decrease and eliminate headaches.
• Give the client ginseng tea with each meal.
The nurse should not give the client ginseng tea with each meal because it is contraindicated for
use during pregnancy.
• Instruct the client to soak in a bath with a water temperature of 105° F for 15 min daily.
Soaking in a bath with a water temperature of 105° F for 15 min daily can cause maternal
hyperthermia, interfering with cell metabolism and possibly causing birth defects. The water
temperature should be maintained at 96.8° F to 98.6° F.
Answer: • Recommend that the client perform conscious relaxation techniques daily.
The nurse should include conscious relaxation techniques in the plan of care as a way to relieve
tension and reduce stress, which can help to decrease and eliminate headaches.
41) A nurse is performing a vaginal examination for a client who is in active labor and reports
back pain. The nurse determines that the client is 8 cm dilated, 100% effaced, -2 station, and that
the fetus is in the occiput posterior position. Which of the following actions should the nurse
take?
• Perform effleurage during contractions.
To perform effleurage, the nurse lightly strokes the client's abdomen as the client breaths through
the contractions. It is used during the first stage of labor to distract the client from the pain of
contractions, but it will not facilitate the rotation of the fetal head.
• Place the client in lithotomy position.
Placing the client in the lithotomy position will prevent the rotation of the fetal head. The client
will likely be placed in the lithotomy position once the fetus has rotated and she is ready to begin
pushing with contractions.

• Assist the client to the hands and knees position.
The nurse should assist the client into the hands and knees position during contractions. This
position can help relieve her back pain and it will enable the rotation of the fetus from the
posterior to an anterior occiput position.
• Apply a scalp electrode to the fetus.
Applying a scalp electrode to the fetus is an invasive procedure that is performed to monitor the
FHR. There is no indication for internal monitoring at this time.
Answer: • Assist the client to the hands and knees position.
The nurse should assist the client into the hands and knees position during contractions. This
position can help relieve her back pain and it will enable the rotation of the fetus from the
posterior to an anterior occiput position.
42) A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the
blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse
take?
• Tell the client to follow up with a dermatologist.
An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an
increase in the pigmentation of the skin during pregnancy. Treatment by a dermatologist will not
affect the client's condition.
• Explain to the client this is an expected occurrence.
Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of
the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is
caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks
of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse
should reassure the client that this is an expected occurrence which usually fades after delivery.
• Instruct the client to increase her intake of vitamin D.
An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an
increase in the pigmentation of the skin during pregnancy. Increasing her vitamin D intake will
not affect the client's condition.
• Inform the client she might have an allergy to her skin care products.

An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an
increase in the pigmentation of the skin during pregnancy. Changing skin care products will not
affect the client's condition.
Answer: • Explain to the client this is an expected occurrence.
Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of
the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is
caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks
of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse
should reassure the client that this is an expected occurrence which usually fades after delivery.
43) A nurse is preparing to administer magnesium sulphate 2 g/hr IV to a client who is in preterm
labor. Available is 20 g magnesium sulphate in 500 mL of dextrose 5% in water (D5W). The
nurse should set the IV infusion pump to administer how many mL/hr? (Round the answer to the
nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer:
Ratio and Proportion
STEP 1: What is the unit of measurement the nurse should calculate? mL
STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 2 g
STEP 3: What is the dose available? Dose available = Have 20 g
STEP 4: Should the nurse convert the units of measurement? No
STEP 5: What is the quantity of the dose available? 500 mL
STEP 6: Set up an equation and solve for X.
Have/Quantity = Desired/X 20
g/500 mL = 2 g/X mL X = 50
STEP 7: Round if necessary.
STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 20 g
of magnesium sulphate in 500 mL D5W and the prescription reads 2 g, it makes sense to
administer 50 mL. The nurse should administer magnesium sulphate 50 mL/hr IV.
Desired Over Have

STEP 1: What is the unit of measurement the nurse should calculate? mL
STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 2 g
STEP 3: What is the dose available? Dose available = Have 20 g
STEP 4: Should the nurse convert the units of measurement? No
STEP 5: What is the quantity of the dose available? 500 mL
STEP 6: Set up an equation and solve for X.
Desired x Quantity/Have = X 2
g x 500 mL/20 g = X mL
50 = X
STEP 7: Round if necessary.
STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 20 g
of magnesium sulphate in 500 mL D5W and the prescription reads 2 g, it makes sense to
administer 50 mL. The nurse should administer magnesium sulphate
50 mL/hr IV.
Dimensional Analysis
STEP 1: What is the unit of measurement the nurse should calculate? mL
STEP 2: What is the quantity of the dose available? 500 mL
STEP 3: What is the dose available? Dose available = Have 20 g
STEP 4: What is the dose the nurse should administer? Dose to administer = Desired 2 g
STEP 5: Should the nurse convert the units of measurement? No
STEP 6: Set up an equation and solve for X.
X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/ X
mL = 500 mL/20 g x 2 g/
X = 50
STEP 7: Round if necessary.
STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 20 g
of magnesium sulphate in 500 mL D5W and the prescription reads 2 g, it makes sense to
administer 50 mL. The nurse should administer magnesium sulphate 50 mL/hr IV.

44) A nurse is providing education about family bonding to parents who recently adopted a
newborn. The nurse should make which of the following suggestions to aid the family's 7-yearold child in accepting the new family member?
• Allow the sibling to hold the newborn during a bath.
Allowing the sibling to hold the newborn during a bath is not an appropriate activity for a
school-age child because of the safety risk. However, the parents could let the sibling assist with
other things in regard to caring for the baby.
• Make sure the sibling kisses the newborn each night.
Forcing interactions between the sibling and the adoptive newborn can cause anger on the part of
the sibling. It is more important to allow feelings to evolve naturally as the family unit bonds.
• Obtain a gift from the newborn to present to the sibling.
Presenting a gift from the newborn to the sibling is a strategy to facilitate a school- age sibling's
acceptance of a new family member. This ensures that the sibling does not feel left out and that
he understands his role in the family.
• Switch the sibling's room with the nursery.
Switching the sibling's room with the newborn's room might cause jealousy of the newborn or
cause the sibling to feel that the newborn is taking his belongings. Bottom of Form
Answer: • Obtain a gift from the newborn to present to the sibling.
Presenting a gift from the newborn to the sibling is a strategy to facilitate a school- age sibling's
acceptance of a new family member. This ensures that the sibling does not feel left out and that
he understands his role in the family.
45) A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined
the fetal position as left occipital anterior. To which of the following areas of the client's
abdomen should the nurse apply the ultrasound transducer in order to assess the point of
maximum intensity of the fetal heart?
• Lef upper quadrant
The fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper
quadrant.
• Right upper quadrant

The fetal heart tones of a fetus in the right sacrum anterior position are best heard in the right
upper quadrant.
• Left lower quadrant
The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left
lower quadrant.
• Right lower quadrant
The fetal heart tones of a fetus in the right occipital anterior position are best heard in the right
lower quadrant.
Answer: • Left lower quadrant
The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left
lower quadrant.
46) A school nurse is providing teaching to an adolescent about levonorgestrel contraception.
Which of the following information should the nurse include in the teaching?
• "You should take the medication within 72 hours following unprotected sexual intercourse."
Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception.
The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr
after unprotected sexual intercourse.
• "You should avoid taking this medication if you are on an oral contraceptive."
Levonorgestrel, an emergency contraceptive, has no effect on the other oral contraceptive the
adolescent might be taking. To prevent pregnancy, this medication should be taken if an
adolescent misses a dose of oral contraception.
• "If you don't start your period within 5 days of taking this medication, you will need a
pregnancy test."
The adolescent should be evaluated for pregnancy if she does not menstruate within 21 days
following administration of this medication.
• "One dose of this medication will prevent you from becoming pregnant for 14 days after taking
it."
Levonorgestrel is an emergency contraceptive that prevents or delays ovulation. Therefore, the
nurse should inform the client that she will not be protected from pregnancy if she has
unprotected sexual intercourse in the days and weeks after receiving this medication.

Answer: • "You should take the medication within 72 hours following unprotected sexual
intercourse."
Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception.
The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr
after unprotected sexual intercourse.
47) A nurse is teaching clients in a prenatal class about the importance of taking folic acid during
pregnancy. The nurse should instruct the clients to consume an adequate amount of folic acid
from various sources to prevent which of the following fetal abnormalities?
• Neural tube defect
The nurse should inform the clients that neural tube defects are more common in newborns born
to mothers who had inadequate folic acid intake. Food sources of folic acid include fortified
cereals and grain products, oranges, artichokes, liver, broccoli, and asparagus.
• Trisomy 21
Trisomy 21 occurs when two gametes (egg and sperm) combine and one gamete has an extra
chromosome. Babies who are born with this disorder have 47 chromosomes in most or all of
their cells.
• Clef lip
Cleft lips are more common in newborns born to mothers who have been exposed to
environmental factors, such as infection or smoking, or who have predisposing genetic factors.
• Atrial septal defect
An atrial septal defect is an abnormal opening between the atria. It is more common in newborns
born to mothers who have septal defects.
Answer: • Neural tube defect
The nurse should inform the clients that neural tube defects are more common in newborns born
to mothers who had inadequate folic acid intake. Food sources of folic acid include fortified
cereals and grain products, oranges, artichokes, liver, broccoli, and asparagus.
48) A nurse is performing a newborn assessment. Which of the following images should the
nurse identify as an indication of spina bifida occulta?

• The nurse should identify this as an image of spina bifida occulta. External indications of this
neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy
patch above the area.

• The nurse should identify this as an image of spina bifida manifests in the form of a
myelomeningocele that is closed. External indications of this neural tube defect include a
herniated sac over the site of the defect that is covered with skin.

• The nurse should identify this as an image of spina bifida manifest in the form of a
myelomeningocele that is open. External indications of this neural tube defect include an open
area over the defect that allows for leakage of cerebrospinal fluid and entry of microorganisms.

• The nurse should identify this as an image of Mongolian spots. These bluish-black pigmented
areas are most commonly found on the buttocks and back of newborns of Mediterranean, Asian,
African, and Latin American ethnicity and can be incorrectly identified as areas of ecchymosis.
Answer:

The nurse should identify this as an image of spina bifida occulta. External indications of this
neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy
patch above the area.
49) A nurse is providing discharge teaching to the parents of a newborn about using a car seat
properly. Which of the following instructions should the nurse include?
• Place the shoulder harness in the slots above the newborn's shoulders.

The nurse should instruct the parents to place the shoulder harness in the slots that are at or just
below the newborn's shoulders.
• Place the retainer clip at the level of the newborn's waist.
The nurse should instruct the parents to place the retainer clip at the level of the newborn's
axillae.
• Position the newborn at a 60º angle in the car seat.
The nurse should instruct the parents to position the newborn at a 45º angle to minimize the risk
of airway obstruction from slumping forward.
• Position the car seat rear-facing in the back seat of the vehicle.
The nurse should instruct the parents to position the car seat rear-facing in the back seat of the
vehicle because it avoids injury from front seat airbags and protects the newborn's heavy head
and weak neck in the event of a sudden stop or collision. Infants and toddlers should remain rearfacing in the backseat until they are 2 years old or reach the height and weight requirements of
the car seat manufacturer.
Answer: • Position the car seat rear-facing in the back seat of the vehicle.
The nurse should instruct the parents to position the car seat rear-facing in the back seat of the
vehicle because it avoids injury from front seat airbags and protects the newborn's heavy head
and weak neck in the event of a sudden stop or collision. Infants and toddlers should remain rearfacing in the backseat until they are 2 years old or reach the height and weight requirements of
the car seat manufacturer.
50) A nurse is providing teaching to a client about the physiological changes that occur during
pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference
range. Which of the following client statements indicates an understanding of the teaching?
• "I will not gain more than 15 to 20 pounds during my pregnancy."
The recommended weight gain for a woman who has a BMI within the expected reference range
is 25 to 35 lb. The recommended weight gain for a woman who has a BMI above the expected
reference range is 15 to 20 lb.
• "I will likely need to use alternative positions for sexual intercourse."

The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This
client statement indicates that she understands the nurse's teaching about the physiological
changes that occur during pregnancy.
• "I'm glad I had a breast reduction years ago so they will not enlarge with my pregnancy."
The mammary glands of the breasts grow during pregnancy, causing progressive enlargement
during the second and third trimesters of pregnancy. A breast reduction will not prevent this from
occurring.
• "I'm glad I have a light complexion and will not get any stretch marks."
Stretch marks can occur as a response to pregnancy regardless of the client's complexion.
Answer: • "I will likely need to use alternative positions for sexual intercourse."
The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This
client statement indicates that she understands the nurse's teaching about the physiological
changes that occur during pregnancy.
51) A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation.
Based on the chart findings and documentation, the nursing plan of care should include which of
the following actions? (Click on the "Exhibit" button for additional information about the client.
There are three tabs that contain separate categories of data.)
EXHIBIT
• Administer terbutaline.
The nurse should administer terbutaline to stop contractions because the laboratory results
indicate that the fetus's lungs are not mature enough for delivery.
• Discuss possible genetic anomalies with the client.
There is no indication of genetic anomalies based on the results of the amniocentesis.
• Administer nalbuphine.
Nalbuphine is an analgesic used for moderate to severe pain. A report of 2/10 is mild pain.
• Discontinue external fetal monitoring.
The nurse should not discontinue external fetal monitoring. Because the client is exhibiting
manifestations of preterm labor, fetal well-being and contraction patterns should be continuously
monitored.
Exhibit 1

Laboratory Results
Lecithin/sphingomyelin (L/S) ratio 1.4:1
Phosphatidylglycerol (PG) absent
ABO-Rh B-negative
Exhibit 2
Medication Administration Record
Terbutaline 0.25 mg SQ every hr PRN contractions
Rho(D) immune globulin 300 mcg IM once Nalbuphine 10
mg IV every 3 hr PRN pain
Exhibit 3
Progress Notes
1655 – Amniocentesis completed, Toc transducer and external fatal monitor applied
1700 – Fatal heart rate 130/min with moderate variability
Uterine contractions q 5 to 8 min lasting 30 to 60 sec duration
Uterine contractions palpated at 1 + intensity Client reports uterine contraction pain 2/10
Answer: • Administer terbutaline.
The nurse should administer terbutaline to stop contractions because the laboratory results
indicate that the fetus's lungs are not mature enough for delivery.
52) A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing
to administer pain medication to a client. The charge nurse should intervene when the newly
licensed nurse uses which of the following secondary identifiers to identify the client?
• The client's room number
Using the client's room number is not an acceptable identifier and places the client at risk for a
medication error. Therefore, the charge nurse should intervene.
• The client's telephone number
The nurse should use at least two acceptable identifiers to confirm the client's identity before
administering medication. Using the client's telephone number is an approved method for client
identification.

• The client's birth date
The nurse should use at least two acceptable identifiers to confirm the client's identity before
administering medication. Using the client's birth date is an approved method for client
identification.
• The client's medical record number
The nurse should use at least two acceptable identifiers to confirm the client's identity before
administering medication. Using the client's medical record number is an approved method for
client identification.
Answer: • The client's room number
Using the client's room number is not an acceptable identifier and places the client at risk for a
medication error. Therefore, the charge nurse should intervene.
53) A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal
cord. Which of the following clinical manifestations should the nurse expect?
• Bruising over the buttocks
A breech delivery can cause bruising over the buttocks and swollen genitalia.
• Hard modules on the roof of the mouth
Inclusion cysts, or hard modules on the roof of the mouth, can be an expected finding.
• Petechiae over the head
Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising
and petechiae over the face, head, and neck.
• Bilateral periauricular papilloma’s
Bilateral periauricular papilloma’s are benign skin tags that can be an expected finding.
Answer: • Petechiae over the head
Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising
and petechiae over the face, head, and neck.
54) A nurse is speaking with a client who is trying to make a decision about uterine tube
occlusion. The client asks, "What effects will this procedure have on my sex life?" Which of the
following responses should the nurse make?
•"I think that is something you should discuss with your doctor when she comes in."

The nurse is dismissing the client's question, providing no information to help the client make an
informed decision.
• "This process should have no effect on your sexual performance or adequacy."
The nurse is giving the client the information she is seeking. Sexual function depends on various
hormonal and psychological factors. Therefore, tubal occlusion should have no physiological
effect on sexual performance or adequacy. It can actually enhance enjoyment of sex because
there is no fear of pregnancy.
• "You'll be fine. I can't imagine you and your partner will have any problems with sexual
function."
The nurse is giving the client unwarranted reassurance without addressing the information the
client is seeking.
•"If this concerns you, perhaps you should reconsider and use another form of contraception."
The nurse is giving the client unwarranted advice which might imply that there is a reason to be
concerned about the effect of the procedure on sexual functions
Answer: • "This process should have no effect on your sexual performance or adequacy."
The nurse is giving the client the information she is seeking. Sexual function depends on various
hormonal and psychological factors. Therefore, tubal occlusion should have no physiological
effect on sexual performance or adequacy. It can actually enhance enjoyment of sex because
there is no fear of pregnancy.
55) A nurse is providing prenatal teaching to a client who is at 26 weeks of gestation. Which of
the following positions should the nurse recommend for the client to increase circulation to the
placenta?
• Supine
The supine position decreases blood return to the right atrium and the placenta.
• Fowler's
The Fowler's position compresses the vena cava, decreasing placental circulation.
• Side-lying
In order to increase placental circulation, the nurse should recommend the side-lying position to
a client who is pregnant, which avoids the compression of the vena cava. Decreased circulation
in the uterus can lead to having a child who is small for gestational age.

• Trendelenburg
The Trendelenburg position is used to provide postural drainage of the lower lung lobes. It is
accomplished when the head of the bed is lower than the foot of the bed, in a straight incline.
There is no indication this would be a recommended position for a client who is pregnant or that
it would increase circulation to the placenta.
Answer: • Side-lying
In order to increase placental circulation, the nurse should recommend the side-lying position to
a client who is pregnant, which avoids the compression of the vena cava. Decreased circulation
in the uterus can lead to having a child who is small for gestational age.
56) A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for
newborn safety. Which of the following client statements indicates an understanding of the
teaching?
• "My sister will be able to carry my baby from the nursery to my room when she arrives."
A newborn should always be transported in a bassinet when outside the mother's room.
• "The nurse will match my wrist band to my baby's crib card when she brings him to me."
The nurse will match the newborn's identification number with the mother's identification
number when she brings the baby to the mother's room.
• "The person who comes to take my baby's pictures will be wearing a photo identification
badge."
All personnel working on the unit should be wearing a photo identification badge. The nurse
should teach the mother to never allow anyone who is not wearing an identification badge to
come in contact with her newborn.
• "My baby doesn't need to wear the electronic security bracelet when he's in my room."
The newborn should wear the electronic security bracelet at all times. The bracelet is set to alarm
if anyone removes the bracelet or if the newborn is brought near an exit door.
Answer: • "The person who comes to take my baby's pictures will be wearing a photo
identification badge."
All personnel working on the unit should be wearing a photo identification badge. The nurse
should teach the mother to never allow anyone who is not wearing an identification badge to
come in contact with her newborn.

57) A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of
the following manifestations should the nurse expect?
• Lochia serosa vaginal drainage
A client who is 4 to 10 days postpartum will report lochia serosa.
• Vaginal pressure
The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina
due to the blood that leaked into the tissues.
• Intermittent vaginal pain
A client who has a vaginal hematoma will report persistent vaginal or rectal pain.
• Yellow exudate vaginal drainage
A client who is 1 day postpartum and has a vaginal hematoma will report lochia rubra.
Answer: • Vaginal pressure
The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina
due to the blood that leaked into the tissues.
58) A nurse is providing teaching about nonpharmacological pain management to a client who is
breastfeeding and has engorgement. The nurse should recommend the application of which of the
following items?
• Cold cabbage leaves
The application of fresh, raw cabbage leaves that have been chilled is an effective
nonpharmacological method to relieve the pain associated with engorgement. The nurse should
instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the
application for two to three sessions as needed. More frequent applications could decrease the
client's milk supply.
• Purified lanolin cream
Purified lanolin cream is an over-the-counter product that is recommended for the treatment of
sore nipples.
• A snug-fitting support bra

A snug-fitting support bra is recommended to suppress lactation for a client who is not
breastfeeding. The bra prevents strain on the breast muscles and places the breasts in proper
alignment to decrease engorgement.
• Breast shells
Breast shells are recommended for clients who are postpartum and have sore nipples. They are
used as a barrier to keep clothing away from the nipples and to allow air to circulate.
Answer: • Cold cabbage leaves
The application of fresh, raw cabbage leaves that have been chilled is an effective
nonpharmacological method to relieve the pain associated with engorgement. The nurse should
instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the
application for two to three sessions as needed. More frequent applications could decrease the
client's milk supply.
59) A nurse is providing discharge teaching to a client who had a caesarean birth 3 days ago.
Which of the following instructions should the nurse include?
• "You can resume sexual activity in 1 week."
The nurse should instruct the client that it is safe to resume sexual activity once all vaginal
bleeding has stopped and the incision has healed, which can take 2 to 6 weeks. However, it is
highly recommended that the client wait until after her 6-week follow-up with the provider
because the incision and healing process should be assessed before sexual activity is resumed.
• "You won't need to do Kegel exercises since you had a caesarean."
The nurse should instruct the client to continue to perform Kegel exercises in order to maintain
tone of the pelvic muscles. Maintaining tone of the pelvic floor muscles helps to maintain urinary
continence in the future.
• "You can still become pregnant if you are breastfeeding."
The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the
client can become pregnant. The nurse should discuss contraception that is safe to use while
breastfeeding.
• "You are safe to start adding sit-ups to your exercise routine in 2 weeks."

The nurse should instruct the client to avoid abdominal exercises for 4 to 6 weeks following a
caesarean birth. The nurse can instruct the client to perform other exercises (for example,
walking, arm raises, and leg rolls).
Answer: • "You can still become pregnant if you are breastfeeding."
The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the
client can become pregnant. The nurse should discuss contraception that is safe to use while
breastfeeding.
60) A nurse is assessing a newborn who is 12 hr old. Which of the following clinical
manifestations requires intervention by the nurse?
• Acrocyanosis of the extremities
Acrocyanosis of the extremities is an expected clinical manifestation in newborns. Acrocyanosis
is a bluish discoloration of the newborn's hands and feet.
• Murmur at the left sternal border
An audible murmur heard at the left sternal border is an expected clinical manifestation in
newborns.
• Substernal chest retractions while sleeping
Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This
clinical manifestation requires further assessment and intervention by the nurse.
• Positive Babinski reflex
A positive Babinski reflex is an expected clinical manifestation in newborns. This reflex is
elicited when a newborn's sole is stroked and, in response, the toes hyperextend and the large toe
dorsiflexes.
Answer: • Substernal chest retractions while sleeping
Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This
clinical manifestation requires further assessment and intervention by the nurse.