2023 ATI Maternal Newborn Exam With Answers-134 Solved Questions

ATI Maternal Newborn EXAM 2023
GRADED A / 134 QUESTIONS AND ANSWERS WITH NGN
1. The nurse has learned that cultural rituals and practices during pregnancy seem to have one
purpose in common. What statement best describes this purpose?
a. They provide family unity
b. They ward off the evil eye.
c. They protect the mother and fetus
d. They appease the god of fertility
Answer: a, c
Rationale:
Different cultures have unique rituals and practices during pregnancy, but most share the
common purposes of ensuring the safety and well-being of the mother and fetus and promoting
family unity. Rituals and practices often involve the participation of family members,
strengthening familial bonds and support systems.
2. The nurse is caring for a patient who is 8 weeks pregnant and is not happy about being
pregnant. What is an appropriate nursing response?
a. "You need to talk this over with the doctor"
b. "Aren't you happy about this new life?"
c. "Your feelings are normal at this time."
d. "Tell me more about how you are feeling"
Answer: d
Rationale:
Open-ended questions like "Tell me more about how you are feeling" allow the patient to express
her emotions and concerns without feeling judged. This approach facilitates a supportive
environment and can help the nurse understand the patient's perspective better, offering
appropriate emotional support and resources.

3. The nurse recognizes the most significant barrier encountered by pregnant women in accessing
care is:
a. Lack of transportation
b. Other child care responsibilities
c. Inability to pay
d. Deficient knowledge about benefits of prenatal care
Answer: c
Rationale:
Inability to pay is often the most significant barrier to accessing prenatal care. Financial
constraints can prevent women from obtaining necessary medical care, leading to poor maternal
and fetal health outcomes. Addressing this issue involves connecting patients with financial
assistance programs and community resources.
4. The nurse has just finished teaching a class on weight gain during pregnancy. Which statement
by one of the mothers indicates she understands the teaching?
a. "My baby will make up most of my weight gain."
b. "Since I am overweight, I don't need to gain any weight."
c. "The fat I gain during pregnancy will disappear right after birth."
d. "My breasts will probably shrink and lead to weight loss."
Answer: a
Rationale:
The statement "My baby will make up most of my weight gain" indicates an understanding that
weight gain during pregnancy is primarily due to the growth and development of the baby, as
well as other pregnancy-related factors such as increased blood volume, amniotic fluid, and
uterine growth.
5. The nurse is caring for a patient who is scheduled for an amniocentesis to determine fetal lung
maturity. When the nurse checks the chart for results, which test result will she be looking for?
a. Lecithin/ Sphingomyelin (L/S ratio)
b. Indirect Coombs test
c. Kleinhaur-Berke Test

d. Alpha-fetoprotein
Answer: a
Rationale:
The Lecithin/Sphingomyelin (L/S) ratio is used to assess fetal lung maturity. A higher ratio
indicates mature lungs that are likely capable of functioning properly outside the womb. This test
is particularly important for determining the timing of delivery in high-risk pregnancies.
6. The nurse provides instructions to a malnourished pregnant client regarding Iron
supplementation. Which client statement indicates an understanding of the instructions?
a. "Iron supplements will give me diarrhea."
b. "Meat does not provide Iron and should be avoided."
c. "Iron is absorbed best if taken on an empty stomach."
d. "On the days I eat liver, I don't have to take my iron supplement."
Answer: c
Rationale:
Iron supplements are absorbed more effectively on an empty stomach. However, they can cause
gastrointestinal discomfort, so some individuals may need to take them with a small amount of
food. The other statements are incorrect as iron supplements are more likely to cause
constipation than diarrhea, meat is a good source of dietary iron, and consistency in taking
supplements is important regardless of diet.
7. A nurse is caring for a pregnant patient and needs to be aware that physical abuse during
pregnancy can result in?
a. Excessive weight gain due to stress
b. Use of alcohol or tobacco as a means of coping
c. Hypertension of pregnancy
d. Premature delivery or spontaneous abortion
Answer: d
Rationale:
Physical abuse during pregnancy can lead to serious complications including premature delivery,
low birth weight, and spontaneous abortion due to the stress and physical trauma inflicted on the

mother and fetus. While the other options can be consequences of stress and coping mechanisms,
the most direct and severe result of physical abuse is harm to the pregnancy itself.
8. The nurse who assesses the FHR is expecting to find the heart rate within which range?
a. 100-130 bpm
b. 110-160 bpm
c. 120-180 bpm
d. 130-160 bpm
Answer: b
Rationale:
The normal fetal heart rate (FHR) range is 110-160 beats per minute (bpm). This range indicates
a healthy and well-oxygenated fetus. Rates outside this range could indicate potential fetal
distress and would require further evaluation.
9. A nurse determines a pregnant patient needs further instruction about amniocentesis when the
patient states:
a. "I must report cramping or signs of infection to my doctor"
b. "I should drink lots of fluids for 24 hours following this procedure."
c. "I need to have a full bladder for this procedure."
d. "My amniotic fluid can be examined to tell me if my baby has downs syndrome"
Answer: c
Rationale:
A full bladder is not necessary for an amniocentesis; in fact, the procedure is typically performed
with the bladder empty to reduce the risk of bladder puncture. The other statements are accurate:
reporting cramping or infection, staying hydrated, and using amniotic fluid for genetic testing
(such as for Down syndrome) are all correct.
10. A nurse is caring for a client who is pregnant and states that her last menstrual period was
April 1st. Which of the following is the client's estimated date of delivery?
a. January 8
b. January 15

c. February 8
d. February 15
Answer: b
Rationale:
Using Naegele’s rule to estimate the due date: add one year, subtract three months, and add seven
days to the first day of the last menstrual period (LMP). For an LMP of April 1st, the estimated
due date is January 8th. This method is widely used to estimate the expected date of delivery
(EDD).
11. A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The
client's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this
information? (SATA)
a. client has delivered one newborn at term
b. client has experienced no preterm labor
c. client has been through active labor
d. client has had two prior pregnancies
e. client has one living child
Answer: a, d, e
Rationale:
a. The notation "T1" indicates that the client has delivered one newborn at term.
d. The "G3" notation means the client has had three pregnancies, including the current one,
implying two prior pregnancies.
e. "L1" means the client has one living child.
12. A nurse is reviewing the health record of a client who is pregnant. The provider indicated the
client exhibits probable signs of pregnancy. Which of the following findings should the nurse
expect? (SATA)
a. montogomery's glands
b. goodell's sign
c. ballottement
d. chadwick's sign

e. quickening
Answer: b, c, d
Rationale:
b. Goodell's sign refers to the softening of the cervix, a probable sign of pregnancy.
c. Ballottement is the rebounding of the fetus when the cervix is tapped, also a probable sign of
pregnancy.
d. Chadwick's sign is the bluish discoloration of the cervix, vagina, and labia resulting from
increased blood flow, another probable sign of pregnancy.
13. A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodes of
maternal hypotension. The client asks the nurse what causes these episodes. Which of the
following responses should the nurse make?
a. "This is due to an increase in blood volume."
b. "This is due to pressure from the uterus on the diaphragm."
c. "This is due to the weight of the uterus on the vena cava."
d. "This is due to increased cardiac output."
Answer: c
Rationale:
Maternal hypotension during pregnancy is often caused by the weight of the uterus pressing on
the vena cava when the woman is lying on her back, which reduces venous blood return to the
heart.
14. A nurse in a clinic receives a phone call from a client who believes she is pregnant and would
like to be tested in the clinic to confirm her pregnancy. Which of the following information
should the nurse provide to the client?
a. "You should wait until 4 weeks after conception to be tested."
b. "You should be off any medications for 24 hours prior to the test."
c. "You should be NPO for at least 8 hours prior to the test."
d. "You should collect urine from the first morning void."
Answer: d
Rationale:

For the most accurate pregnancy test results, it is recommended to collect urine from the first
morning void because it contains the highest concentration of human chorionic gonadotropin
(hCG).
15. A nurse is teaching a group of women who are pregnant about measures to relieve backache
during pregnancy. Which of the following measures should the nurse include in the teaching?
(SATA)
a. avoid any lifting
b. perform kegel exercises twice a day
c. perform the pelvic rock exercise every day
d. use proper body mechanics
e. avoid constrictive clothing
Answer: c, d
Rationale:
c. Performing the pelvic rock exercise every day can help relieve backache by strengthening the
muscles and reducing strain on the back.
d. Using proper body mechanics, such as bending at the knees and not the waist, helps prevent
strain on the back and can reduce backache during pregnancy.
16. A nurse is caring for a client who is pregnant and reviewing signs of complications the client
should promptly report to the provider. Which of the following complications should the nurse
include in the teaching?
a. vaginal bleeding
b. swelling of the ankles
c. heartburn after eating
d. light-headedness when lying on back
Answer: a
Rationale:
Vaginal bleeding can be a sign of a serious complication during pregnancy, such as placental
abruption or miscarriage, and should be reported to the provider promptly.

17. A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning.
Which of the following information should the nurse include in the teaching?
a. eat crackers or plain toast before getting out of bed
b. awaken during the night to eat a snack
c. skip breakfast and eat lunch after nausea has subsided
d. eat a large evening meal
Answer: a
Rationale:
Eating crackers or plain toast before getting out of bed can help alleviate morning sickness by
providing a bland, starchy food that is easy on the stomach.
18. A nurse is teaching a client who is at 6 weeks of gestation about common discomforts of
pregnancy. Which of the following findings should the nurse include in the teaching? (SATA)
a. breast tenderness
b. urinary frequency
c. epistaxis
d. dysuria
e. epigastric pain
Answer: a, b, c
Rationale:
a. Breast tenderness is a common discomfort of early pregnancy due to hormonal changes.
b. Urinary frequency can occur as the growing uterus puts pressure on the bladder.
c. Epistaxis (nosebleeds) can occur due to increased blood volume and hormonal changes during
pregnancy.
19. A client who is at 8 weeks of gestation tells the nurse that she isn't sure she is happy about
being pregnant. Which of the following responses should the nurse make?
a. "I will inform the provider that you are having these feelings."
b. "It is normal to have these feelings during the first few months of pregnancy."
c. "You should be happy that you are going to bring new life into the world."
d. "I am going to make an appointment with the counselor for you to discuss these thoughts."

Answer: b
Rationale:
It is normal for women to have mixed feelings about pregnancy, especially in the early stages.
Validating her feelings and reassuring her that it's normal can be comforting.
20. A nurse in a prenatal clinic is providing education to a client who is in the 8th week of
gestation. The client states that she does not like milk. Which of the following foods should the
nurse recommend as a good source of calcium?
a. dark green leafy vegetables
b. deep red or orange vegetables
c. white breads and rice
d. meat, poultry, and fish
Answer: a
Rationale:
Dark green leafy vegetables, such as spinach, kale, and broccoli, are good sources of calcium and
can be recommended as alternatives to milk for those who do not like or cannot consume dairy
products.
21. A nurse in a prenatal clinic is caring for four clients. Which of the following clients' weight
gain should the nurse report to the provider?
a. 1.8kg (4lb) weight gain and is in her first trimester
b. 3.6kg (8lb) weight gain and is in her first trimester
c. 6.8kg (15lb) weight gain and is in her second trimester
d. 11.3kg (25lb) weight gain and is in her third trimester
Answer: b
Rationale:
A weight gain of 3.6kg (8lb) in the first trimester may indicate excessive weight gain, which
could be a concern. The average weight gain in the first trimester is about 0.5-2kg (1-4.4lb),
making option b the most concerning and requiring further evaluation by the provider.

22. A nurse in a clinic is teaching a client of childbearing age about recommended folic acid
supplements. Which of the following defects can occur in the fetus or neonate as a result of folic
acid deficiency?
a. iron deficiency anemia
b. poor bone formation
c. macrosomic fetus
d. neural tube defects
Answer: d
Rationale:
Folic acid deficiency is associated with an increased risk of neural tube defects (NTDs) in the
fetus, such as spina bifida and anencephaly. Adequate folic acid intake before conception and
during early pregnancy can significantly reduce the risk of NTDs.
23. A nurse is reviewing a new prescription for iron supplements with a client who is in the 8th
week gestation and has iron deficiency anemia. Which of the following beverages should the
nurse instruct the client to take the iron supplements with?
a. ice water
b. low-fat or whole milk
c. tea or coffee
d. orange juice
Answer: d
Rationale:
Taking iron supplements with a source of vitamin C, such as orange juice, can enhance iron
absorption. Vitamin C helps convert iron into a form that is more easily absorbed by the body.
24. A nurse is reviewing postpartum nutrition needs with a group of new mothers who are
breastfeeding their newborns. Which of the following statements by a member of the group
indicates an understanding of the teaching?
a. "I am glad I can have my morning coffee."
b. "I should take folic acid to increase my milk supply."
c. "I will continue adding 330 calories per day to my diet."

d. "I will continue my calcium supplements because I don't like milk."
Answer: d
Rationale:
Calcium intake is important for breastfeeding mothers, as they need to maintain their own bone
health while providing for the needs of their newborn. If a mother does not consume enough
calcium-rich foods like milk, she should continue taking calcium supplements.
25. A nurse is reviewing findings of a client's biophysical profile (BPP). The nurse should expect
which of the following variables to be included in this test? (SATA)
a. fetal weight
b. fetal breathing movement
c. fetal tone
d. fetal position
e. amniotic fluid volume
Answer: b, c, e
Rationale:
The biophysical profile (BPP) assesses five variables: fetal breathing movements, fetal
movements of the body or limbs, fetal tone, amniotic fluid volume, and fetal heart rate. These
variables are used to assess fetal well-being and determine the need for further intervention.
26. A nurse is caring for a client who is in preterm labor and is scheduled to undergo an
amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung
maturity?
a. alpha-fetoprotein (AFP)
b. lecithin/sphingomyelin (L/S) ratio
c. kleihauer-betke test
d. indirect coombs' test
Answer: b
Rationale:

The lecithin/sphingomyelin (L/S) ratio is a test performed during amniocentesis to assess fetal
lung maturity. An L/S ratio of 2:1 or higher typically indicates that the fetal lungs are mature
enough to function well outside the womb.
27. A nurse is caring for a client who is pregnant and undergoing a non-stress test. The client
asks why the nurse is using an acoustic vibration device. Which of the following responses
should the nurse make?
a. "It is used to stimulate uterine contractions."
b. "It will decrease the incidence of uterine contractions."
c. "It lulls the fetus to sleep."
d. "It awakens a sleeping fetus."
Answer: d
Rationale:
An acoustic vibration device is used during a non-stress test to awaken a sleeping fetus. This can
help obtain a reactive non-stress test result, which indicates fetal well-being.
28. A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the
following statements should the nurse include in the teaching?
a. "You will lay on your right side during the procedure."
b. "You should not eat anything for 24 hours prior to the procedure."
c. "You should empty your bladder prior to the procedure."
d. "The test is done to determine gestational age."
Answer: c
Rationale:
The client should empty her bladder prior to an amniocentesis to reduce the risk of bladder
puncture. This is particularly important in the second and third trimesters.
29. A nurse is caring for a client who is pregnant and is to undergo a contraction stress test
(CST). Which of the following findings are indications for this procedure? (SATA)
a. decreased fetal movement
b. intrauterine growth restriction (IUGR)

c. post maturity
d. placenta previa
e. amniotic fluid emboli
Answer: a, b, c
Rationale:
A contraction stress test (CST) is indicated for assessing fetal well-being in cases of decreased
fetal movement, intrauterine growth restriction (IUGR), and post maturity. These conditions can
indicate potential fetal compromise, and a CST can help determine if the fetus can tolerate labor.
30. A nurse in the emergency department is caring for a client who reports abrupt, sharp, rightsided lower quadrant abdominal pain and bright red vaginal bleeding. The client states she
missed one menstrual cycle and cannot be pregnant because she has an intrauterine device. The
nurse should suspect which of the following?
a. missed abortion
b. ectopic pregnancy
c. severe preeclampsia
d. hydatidiform mole
Answer: b
Rationale:
The combination of right-sided lower quadrant pain, bright red vaginal bleeding, and a missed
menstrual cycle in a client with an intrauterine device suggests an ectopic pregnancy. Ectopic
pregnancies often present with these symptoms, especially in the presence of an IUD, which
increases the risk of this condition.
31. A nurse is providing care for a client who is diagnosed with a marginal abruptio placentae.
The nurse is aware that which of the following findings are risk factors for developing the
condition? (SATA)
a. fetal position
b. blunt abdominal trauma
c. cocaine use
d. maternal age

e. cigarette smoking
Answer: b, c, e
Rationale:
b. Blunt abdominal trauma can cause injury to the placenta, increasing the risk of abruptio
placentae.
c. Cocaine use is associated with vasoconstriction, which can lead to placental insufficiency and
increase the risk of abruptio placentae.
e. Cigarette smoking is a risk factor for placental abruption due to its association with decreased
placental perfusion.
32. A nurse is providing care for a client who is at 32 weeks of gestation and who has a placenta
previa. The nurse notes that the client is actively bleeding. Which of the following types of
medications should the nurse anticipate the provider will prescribe?
a. betamethasone
b. indomethacin
c. nifedipine
d. methylergonovine
Answer: a
Rationale:
Betamethasone is a corticosteroid given to promote fetal lung maturity in preterm labor
situations, such as with placenta previa and bleeding at 32 weeks.
33. A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The
client reports continued nausea and vomiting and scant, prune-colored discharge. She has
experienced no weight loss and has a fundal height larger than expected. Which of the following
complications should the nurse suspect?
a. hyperemesis gravidarum
b. threatened abortion
c. hydatidiform mole
d. preterm labor
Answer: c

Rationale:
The symptoms described are more indicative of a hydatidiform mole, which can present with
symptoms similar to pregnancy, including nausea, vomiting, and uterine enlargement, but with
vaginal bleeding.
34. A nurse is caring for a client who has a diagnosis of ruptured ectopic pregnancy. Which of the
following findings is seen with this condition?
a. no alteration in menses
b. transvaginal ultrasound indicating a fetus in the uterus
c. serum progesterone greater than the expected reference range
d. report of severe shoulder pain
Answer: d
Rationale:
Ruptured ectopic pregnancy is characterized by severe abdominal or pelvic pain, often
accompanied by shoulder pain due to irritation of the diaphragm from blood or fluid in the
abdomen.
35. A nurse is admitting a client who is in labor and has HIV. Which of the following
interventions should the nurse identify as contraindicated for this client? (SATA)
a. episiotomy
b. oxytocin infusion
c. forceps
d. cesarean birth
e. internal fetal monitoring
Answer: a, c, e
Rationale:
Episiotomy, forceps, and internal fetal monitoring can increase the risk of exposure to HIV due
to the potential for increased blood exposure. Oxytocin infusion and cesarean birth are not
contraindicated unless there are other medical reasons to avoid them.

36. A nurse in an antepartum clinic is assessing a client who has a TORCH infection. Which of
the following findings should the nurse expect? (SATA)
a. joint pain
b. malaise
c. rash
d. urinary frequency
e. tender lymph nodes
Answer: a, b, c, e
Rationale:
a. Joint pain: Joint pain is a common symptom of some TORCH infections, such as rubella.
b. Malaise: General feelings of discomfort or malaise can occur with TORCH infections.
c. Rash: Rashes are associated with several TORCH infections, including rubella and
cytomegalovirus.
e. Tender lymph nodes: Lymphadenopathy, or swollen and tender lymph nodes, is common in
TORCH infections.
37. A nurse is caring for a client who has gonorrhea. Which of the following medications should
the nurse anticipate the provider will prescribe?
a. ceftiaxone
b. fluconazole
c. metronidazole
d. zidovudine
Answer: a
Rationale:
This is the recommended antibiotic for the treatment of gonorrhea, often given as an
intramuscular injection.
38. A nurse is caring for a client who is in labor. The nurse should identify that which of the
following infections can be treated during labor or immediately following birth? (SATA)
a. gonorrhea
b. chlamydia

c. HIV
d. group B streptococcus beta-hemolytic
e. TORCH infection
Answer: a, b, c, d
Rationale:
a. Gonorrhea: Treated with antibiotics during labor to prevent transmission to the baby.
b. Chlamydia: Antibiotics can be administered to the mother to prevent neonatal infection.
c. HIV: Antiretroviral medications can be given during labor and postpartum to reduce the risk of
mother-to-child transmission.
d. Group B streptococcus beta-hemolytic: Intrapartum antibiotic prophylaxis can prevent
neonatal infection.
39. A nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a
group of newly licensed nurses. Which of the following statements by a nurse indicates
understanding of the teaching?
a. "Obtain an immunization against rubella early in pregnancy."
b. "Seek prophylactic treatment if cytomegalovirus is detected during pregnancy."
c. "A woman should avoid crowded places during pregnancy."
d. "A woman should avoid consuming undercooked meat while pregnant."
Answer: d
Rationale:
Toxoplasmosis, part of the TORCH infections, can be contracted from undercooked meat.
Avoiding such food can help prevent infection.
40. A nurse is caring for a client who is at 14 weeks gestation and has hyperemesis gravidarum.
The nurse should identify that which of the following are risk factors for the client? (SATA)
a. obesity
b. multifetal pregnancy
c. maternal age greater than 40
d. migraine headache
e. oligohydramnios

Answer: a, b, d
Rationale:
a. Obesity: Obesity is a recognized risk factor for hyperemesis gravidarum.
b. Multifetal pregnancy: Carrying more than one fetus increases the risk of hyperemesis
gravidarum due to higher levels of pregnancy hormones.
d. Migraine headache: A history of migraines is associated with an increased risk of hyperemesis
gravidarum.
41. A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the
client's laboratory reports. Which of the following findings is a manifestation of this condition?
a. Hgb 12.2g/dl
b. urine ketones present
c. alanine aminotransferase 20 IU/L
d. serum glucose 114 mg/dl
Answer: b
Rationale:
The presence of ketones in the urine indicates that the body is breaking down fat for energy due
to prolonged vomiting and insufficient carbohydrate intake, which is a common finding in
hyperemesis gravidarum.
42. A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for
seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (SATA)
a. respirations less than 12/min
b. urinary output less than 30 mL/hr
c. hyperreflexic deep-tendon reflexes
d. decreased level of consciousness
e. flushing and sweating
Answer: a, b, d
Rationale:
a. Respirations less than 12/min: Respiratory depression is a sign of magnesium sulfate toxicity.

b. Urinary output less than 30 mL/hr: Reduced urinary output can indicate magnesium sulfate
toxicity as the drug is excreted by the kidneys.
d. Decreased level of consciousness: This is another sign of central nervous system depression
due to magnesium sulfate toxicity.
43. A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following
medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected?
a. Nifedipine
b. Pyridoxine
c. Ferrous sulfate
d. Calcium gluconate
Answer: d
Rationale:
This is the antidote for magnesium sulfate toxicity and should be administered if toxicity is
suspected.
44. A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks of
gestation. Which of the following statements by the client indicates understanding of the
teaching?
a. "I will take this pill with my breakfast."
b. "I will take this medication with a glass of milk."
c. "I plan to drink more orange juice while taking this pill."
d. "I plan to add more calcium-rich foods to my diet while taking this medication."
Answer: c
Rationale:
Vitamin C (found in orange juice) enhances the absorption of iron, which is beneficial when
taking ferrous sulfate.
45. A nurse is caring for a client who reports indications of preterm labor. Which of the following
findings are risk factors of this condition? (SATA)
a. urinary tract infection

b. multifetal pregnancy
c. oligohydramnios
d. diabetes mellitus
e. uterine abnormalities
Answer: a, b, d, e
Rationale:
a. Urinary tract infection: Infections such as UTIs are known risk factors for preterm labor.
b. Multifetal pregnancy: Carrying more than one fetus increases the risk of preterm labor.
d. Diabetes mellitus: This condition is associated with a higher risk of preterm labor.
e. Uterine abnormalities: Structural abnormalities in the uterus can increase the likelihood of
preterm labor.
46. A nurse in labor and delivery is providing care for a client who is in preterm labor at 32
weeks of gestation. Which of the following medications should the nurse anticipate the provider
will prescribe to hasten fetal lung maturity?
a. calcium gluconate
b. indomethacin
c. nifedipine
d. betamethasone
Answer: d
Rationale:
This corticosteroid is administered to promote fetal lung maturity by accelerating the production
of surfactant, which is critical for proper lung function in premature infants.
47. A nurse is caring for a client who is receiving nifedipine for prevention of preterm labor. The
nurse should monitor the client for which of the following manifestations?
a. blood-tinged sputum
b. dizziness
c. pallor
d. somnolence
Answer: b

Rationale:
Nifedipine, a calcium channel blocker, can cause vasodilation, leading to dizziness as a common
side effect due to lowered blood pressure.
48. A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should
recognize that which of the following are contraindications for use of this medication? (SATA)
a. fetal distress
b. preterm labor
c. vaginal bleeding
d. cervical dilation greater than 6 cm
e. severe gestational hypertension
Answer: a, c, d
Rationale:
a. Fetal distress: Magnesium sulfate is contraindicated in the presence of fetal distress as it may
worsen the condition.
c. Vaginal bleeding: Significant vaginal bleeding can indicate placental issues, and magnesium
sulfate is contraindicated in such situations.
d. Cervical dilation greater than 6 cm: Magnesium sulfate is typically not used if cervical dilation
has progressed beyond 6 cm, as labor is considered too advanced for tocolytic therapy to be
effective.
49. A nurse is reviewing discharge teaching with a client who has premature rupture of
membranes at 26 weeks of gestation. Which of the following instructions should the nurse
include in the teaching?
a. use a condom with sexual intercourse
b. avoid bubble bath solution when taking a tub bath
c. wipe from the back to the front when performing perineal hygiene
d. keep a daily record of fetal kick counts
Answer: d
Rationale:

Monitoring fetal movements can help assess fetal well-being, especially in cases of premature
rupture of membranes where the risk of complications is higher.
50. A nurse in the labor and delivery unit receives a phone call from a client who reports that her
contractions started about 2 hours ago, did not go away when she had two glasses of water and
rested, and became stronger since she started walking. Her contractions occur every 10 minutes
and last about 30 seconds. She hasn't had any fluid leak from her vagina. However, she saw some
blood when she wiped after voiding. Based on this report, which of the following clinical
findings should the nurse recognize that the client is experiencing?
a. Braxton Hicks contractions
b. Rupture of membranes
c. Fetal descent
d. True contractions
Answer: d
Rationale:
True labor contractions are characterized by their persistence despite rest and hydration,
increasing intensity with activity (like walking), regular intervals, and often are accompanied by
bloody show (the blood seen when wiping).
51. A nurse in the labor and delivery unit is caring for a client in labor and applies an external
fetal monitor and tocotransducer. The FHR is around 140/min. Contractions are occurring every
8 min and 30-40 seconds in duration. The nurse performs a vaginal exam and finds the cervix 2
cm dilated, 50% effaced, and the fetus is at a -2 station. Which of the following stages and
phases of labor is this client experiencing?
a. first stage, latent phase
b. first stage, active phase
c. first stage, transition phase
d. second stage of labor
Answer: a
Rationale:

In the latent phase of the first stage of labor, contractions are typically mild and irregular, the
cervix dilates from 0 to about 3 cm, and effacement and descent of the fetus begin. This phase is
usually more comfortable for the mother and allows time for the cervix to thin and dilate.
52. A client experiences a large gush of fluid from her vagina while walking in the hallway of the
birthing unit. Which of the following actions should the nurse take first?
a. check the amniotic fluid for meconium
b. monitor FHR for distress
c. dry the client and make her comfortable
d. monitor uterine contractions
Answer: b
Rationale:
A sudden gush of fluid could indicate rupture of membranes, and monitoring the fetal heart rate
for distress is a priority to ensure the well-being of the fetus.
53. A nurse in labor and delivery unit is completing an admission assessment for a client who is
at 39 weeks of gestation. The client reports that she has been leaking fluid from her vagina for 2
days. Which of the following conditions is the client at risk for developing?
a. cord prolapse
b. infection
c. postpartum hemorrhage
d. hydramnios
Answer: b
Rationale:
Prolonged leakage of amniotic fluid (more than 24 hours) increases the risk of infection, such as
chorioamnionitis, for both the mother and the fetus.
54. A nurse is caring for a client who is in active labor and becomes nauseous and vomits. The
client is very irritable and feels the urge to have a bowel movement. She states, "I've had enough.
I can't do this anymore. I want to go home right now." Which of the following stages of labor is
the client experiencing?

a. second stage
b. fourth stage
c. transition phase
d. latent phase
Answer: c
Rationale:
The transition phase is the most intense part of labor, characterized by strong and frequent
contractions, increased irritability, nausea, and the urge to have a bowel movement. It is a sign
that labor is progressing towards the second stage.
55. A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions
every 3 to 5 min and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm
dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following
actions should the nurse take? (SATA)
a. encourage use of patterned breathing techniques
b. insert an indwelling urinary catheter
c. administer opioid analgesic medication
d. suggest application of cold
e. provide ice chips
Answer: a, c, d
Rationale:
a. Encourage use of patterned breathing techniques: Breathing techniques can help the client
manage pain and cope with labor.
c. Administer opioid analgesic medication: Opioid analgesics are commonly used for pain relief
during labor.
d. Suggest application of cold: Cold therapy, such as cold packs, can help provide comfort and
relief during labor.
56. A nurse is caring for a client who is in active labor. The client reports lower-back pain. The
nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of

the following non-pharmacological nursing interventions should the nurse recommend to the
client?
a. abdominal effleurage
b. sacral counterpressure
c. showering if not contraindicated
d. back rub and massage
Answer: b
Rationale:
This technique involves applying pressure to the sacrum, which can help alleviate lower back
pain associated with a persistent occiput posterior fetal position.
57. A nurse is caring for a client following the administration of an epidural block and is
preparing to administer an IV fluid bolus. The client's partner asks about the purpose of IV
fluids. Which of the following is an appropriate response for the nurse to make?
a. "It is needed to promote increased urine output."
b. "It is needed to counteract respiratory depression."
c. "It is needed to counteract hypotension."
d. "It is needed to prevent oligohydramnios."
Answer: c
Rationale:
IV fluids are commonly administered with epidural anesthesia to help prevent or counteract the
hypotension that can occur as a side effect of the epidural.
58. A nurse is caring for a client who is in the second stage of labor. The client's labor has been
progressing, and she is expected to deliver vaginally in 20 minutes. The provider is preparing to
administer lidocaine for pain relief and perform an episiotomy. The nurse should know that
which of the following types of regional anesthetic block is to be administered?
a. pudendal
b. epidural
c. spinal
d. paracervical

Answer: a
Rationale:
A pudendal block is a local anesthetic administered to the pudendal nerve for pain relief during
childbirth, particularly for the perineum and vaginal area. It is often used for episiotomies.
59. A nurse is caring for a client who is using patterned breathing during labor. The client reports
numbness and tingling of the fingers. Which of the following actions should the nurse take?
a. administer oxygen via nasal cannula at 2 L/min
b. apply a warm blanket
c. assist the client to a side-lying position
d. place an oxygen mask over the client's nose and mouth
Answer: d
Rationale:
Numbness and tingling of the fingers can be a sign of hyperventilation, which can occur with
patterned breathing. Providing oxygen can help correct the imbalance and alleviate the
symptoms.
60. A nurse is providing care for a client who is in active labor. Her cervix is dilated to 5 cm, and
her membranes are intact. Based on the use of external electronic fetal monitoring, the nurse
notes a FHR of 115 to 125/min with occasional increases up to 150 to 155/min that last for 25
seconds, and have beat-to-beat variability of 30/min. There is no slowing of FHR from the
baseline. The nurse should recognize that this client is exhibiting signs of which of the
following? (SATA)
a. moderate variability
b. FHR accelerations
c. FHR decelerations
d. normal baseline FHR
e. fetal tachycardia
Answer: a, b, d
Rationale:

a. Moderate variability: This indicates a normal response of the fetal heart rate to stimuli and is a
reassuring sign of fetal well-being.
b. FHR accelerations: Accelerations are temporary increases in the fetal heart rate, which are also
reassuring and indicative of fetal well-being.
d. Normal baseline FHR: The baseline fetal heart rate is within the normal range of 110 to 160
beats per minute, which is the case in this scenario.
61. A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the
following statements should the nurse include in the teaching? (SATA)
a. "It is considered a non-invasive procedure."
b. "It can detect abnormal fetal heart tones early."
c. "It can determine the amount of amniotic fluid you have."
d. "It allows for accurate readings with maternal movement."
e. "It can measure uterine contraction intensity."
Answer: b, d, e
Rationale:
b. "It can detect abnormal fetal heart tones early.": Internal fetal heart monitoring provides a
more direct and accurate assessment of the fetal heart rate, which can help detect abnormalities
earlier.
d. "It allows for accurate readings with maternal movement.": Internal monitoring is less affected
by maternal movement compared to external monitoring, providing more accurate readings.
e. "It can measure uterine contraction intensity.": Internal monitoring can measure the strength
and duration of uterine contractions, which is important in assessing labor progress and fetal
well-being.
62. A nurse is reviewing the electronic monitor tracing for a client who is in active labor. The
nurse should know that a fetus receives more oxygen when which of the following appears on
the tracing?
a. peak of the uterine contraction
b. moderate variability
c. FHR acceleration

d. relaxation between uterine contractions
Answer: d
Rationale:
During relaxation between uterine contractions, the uteroplacental blood flow increases, allowing
for more oxygen to be delivered to the fetus.
63. A nurse is caring for a client who is in labor and observes late decelerations on the electronic
fetal monitor. Which of the following is the first action the nurse should take?
a. assist the client into the left-lateral position
b. apply a fetal scalp electrode
c. insert an IV catheter
d. perform a vaginal exam
Answer: a
Rationale:
Late decelerations are often caused by uteroplacental insufficiency. Placing the client in a leftlateral position can improve placental perfusion and fetal oxygenation.
64. A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following
techniques should the nurse use to identify the fetal lie?
a. apply palms of both hands to sides of uterus
b. palpate the funds of the uterus
c. grasp lower uterine segment between thumb and fingers
d. stand facing client's feet with fingertips outlining cephalic prominence
Answer: b
Rationale:
Palpating the fundus of the uterus can help determine the fetal lie, which is the orientation of the
fetus in relation to the mother's spine.
65. A nurse is caring for a client and her partner during their second stage of labor. The client's
partner asks the nurse to explain how he will know when crowning occurs. Which of the
following responses should the nurse make?

a. "The placenta will protrude from the vagina."
b. "Your partner will report a decrease in the intensity of contractions."
c. "The vaginal area will bulge as the baby's head appears."
d. "Your partner will report less rectal pressure."
Answer: c
Rationale:
Crowning occurs when the baby's head is visible at the vaginal opening, causing the vaginal area
to bulge as the head emerges.
66. A nurse is caring for a client who is in the transition phase of labor and reports that she needs
to have a bowel movement with the peak of contractions. Which of the following actions should
the nurse make?
a. assist the client to the bathroom
b. prepare for an impending delivery
c. prepare to remove a fecal impaction
d. encourage the client to take deep, cleansing breaths
Answer: b
Rationale:
The urge to have a bowel movement during the transition phase of labor often indicates that the
client is fully dilated and ready to push, indicating that delivery is imminent.
67. A nurse is caring for a client in the third stage of labor. Which of the following findings
indicate the placental separation? (SATA)
a. lengthening of the umbilical cord
b. swift gush of clear amniotic fluid
c. softening of the lower uterine segment
d. appearance of dark blood from the vagina
e. fundus firm upon palpation
Answer: d, e
Rationale:

d. Appearance of dark blood from the vagina: This indicates the separation of the placenta from
the uterine wall.
e. Fundus firm upon palpation: After placental separation, the fundus of the uterus should be firm
and well-contracted.
68. A nurse in labor and delivery is planning care for a newly admitted client who reports she is
in labor and has been having vaginal bleeding for 2 weeks. Which of the following should the
nurse include in the plan of care?
a. inspect the introitus for a prolapsed cord
b. perform a test to identify the ferning pattern
c. monitor station of the presenting part
d. defer vaginal examinations
Answer: d
Rationale:
Vaginal bleeding for 2 weeks could indicate a placental issue or other complications, so vaginal
examinations should be deferred until the cause of bleeding is determined to avoid further
complications.
69. A nurse is caring for a client who is in the first stage of labor and is encouraging the client to
void every 2 hr. Which of the following statements should the nurse make?
a. "A full bladder increases the risk for fetal trauma."
b. "A full bladder increases the risk for bladder infections."
c. "A distended bladder will be traumatized by frequent pelvic exams."
d. "A distended bladder reduces pelvic space needed for birth."
Answer: d
Rationale:
A distended bladder can impede the descent of the fetus and reduce the space available for the
baby to move through the birth canal, potentially prolonging labor.
70. A nurse is caring for a client who is at 42 weeks of gestation and is admitted to the labor and
delivery unit. During an ultrasound, it is noted that the fetus is large for gestational age. The

nurse reviews the prescription from the provider to begin an amnioinfusion. Which of the
following conditions should the nurse plan to prepare an amnioinfusion? (SATA)
a. oligohydramnios
b. hydramnios
c. fetal cord compression
d. hydration
e. fetal immaturity
Answer: a, c
Rationale:
a. Oligohydramnios: Amnioinfusion may be used to treat oligohydramnios, which is a condition
where there is too little amniotic fluid around the fetus.
c. Fetal cord compression: Amnioinfusion can help relieve pressure on the umbilical cord in
cases of fetal cord compression.
71. A nurse is caring for a client who has been in labor for 12 hr, and her membranes are intact.
The provider has decided to perform an amniotomy in an effort to facilitate the progress of labor.
The nurse performs a vaginal examination to ensure which of the following prior to the
performance of the amniotomy?
a. fetal engagement
b. fetal lie
c. fetal attitude
d. fetal position
Answer: a
Rationale:
This refers to the baby's head entering the pelvic inlet. It is important to ensure fetal engagement
before performing an amniotomy to prevent prolapse of the umbilical cord.
72. A nurse is caring for a client who had no prenatal care, is Rh-negative, and will undergo an
external version at 37 weeks of gestation. Which of the following medication should the nurse
plan to administer prior to the version?
a. prostaglandin gel

b. magnesium sulfate
c. Rho(D) immune globulin
d. oxytocin
Answer: c
Rationale:
This should be administered to Rh-negative mothers to prevent sensitization to Rh-positive fetal
blood cells, which can occur during the external version procedure.
73. A nurse is caring for a client who is receiving oxytocin for induction of labor and has an
intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the
following contraction patterns should the nurse discontinue the infusion of oxytocin?
a. frequency of every 2 min
b. duration of 90 to 120 seconds
c. intensity of 60 to 90 mm Hg
d. resting tone of 15 mm Hg
Answer: b
Rationale:
Contractions lasting longer than 90-120 seconds can be associated with uterine hyperstimulation
and should prompt discontinuation of oxytocin.
74. A nurse educator in the labor and deliver unit is reviewing the use of chemical agents to
promote cervical ripening with a group of newly hired nurses. Which of the following statements
by a nurse indicates understudying of the teaching?
a. "They are administered in an oral form."
b. "They act by absorbing fluid from tissue."
c. "The promote dilation of the os."
d. "They include an amniotomy."
Answer: a
Rationale:
Chemical agents for cervical ripening are typically administered vaginally or intracervically, not
orally.

75. A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation
between hypertonic contractions. The nurse should identify that this contraction pattern increases
the risk for which of the following complications?
a. prolonged labor
b. reduced fetal oxygen supply
c. delayed cervical dilation
d. increased maternal stress
Answer: b
Rationale:
Incomplete uterine relaxation between contractions can lead to decreased blood flow to the
placenta, potentially reducing oxygen supply to the fetus.
76. A nurse is caring for a client who is in active labor and reports severe back pain. During
assessment, the fetus is noted to be in the occiput posterior positions. Which of the following
maternal positions should the nurse suggests to the client to facilitate normal labor progress?
a. hands and knees
b. lithotomy
c. trendelenburg
d. supine with a rolled towel under one hip
Answer: a
Rationale:
This position can help rotate the fetus to a more favorable position for delivery, potentially
relieving back pain associated with occiput posterior position.
77. A nurse is caring for a client who is admitted to the labor and delivery unit. With the use of
Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the
following possible complications should the nurse observe?
a. precipitous labor
b. premature rupture of membranes
c. post maturity syndrome

d. prolapsed umbilical cord
Answer: d
Rationale:
In a breech presentation, there is a higher risk of the umbilical cord slipping past the presenting
part of the fetus, leading to umbilical cord prolapse.
78. A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the
following findings is the fetus at risk for developing?
a. intrauterine growth restriction
b. hyperglycemia
c. meconium aspiration
d. polyhydramnios
Answer: c
Rationale:
Meconium aspiration syndrome can occur when a fetus passes stool (meconium) into the
amniotic fluid and then inhales it into the lungs, which can happen in post-term pregnancies.
79. A nurse is caring for a client in active labor. When last examined 2 hr ago, the client's cervix
was 3 cm dilated, 100% effaced, membranes intact and the fetus was at a -2 station. The client
suddenly states "My water broke." The monitor reveals a FHR of 80 to 85/min, and the nurse
performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the
client's vagina. Which of the following actions should the nurse perform first?
a. place the client in the trendelenburg position
b. apply pressure to the presenting part with her fingers
c. administer oxygen at 10 L/min via a face mask
d. call for assistance
Answer: d
Rationale:
This is the priority action to ensure the safety of the mother and the baby. Immediate help is
needed to address the umbilical cord prolapse.

80. A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes
there perineal pad for lochia. She notes the pad to be saturated approximately 12 cm with lochia
that is bright red and contains small clots. Which of the following findings should the nurse
document?
a. moderate lochia rubra
b. excessive blood loss
c. light lochia rubra
d. scant lochia serosa
Answer: a
Rationale:
This description indicates a normal amount of lochia rubra, which is expected in the early
postpartum period.
81. During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood
that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of
the umbilicus. Which of the following findings should the nurse interpret this data as being?
a. evidence of a possible vaginal hematoma
b. an indication of a cervical or perineal laceration
c. a normal postural discharge of lochia
d. abnormally excessive lochia rubra flow
Answer: c
Rationale:
This scenario describes a normal postpartum experience where ambulation can cause a
temporary increase in lochia flow due to the change in intra-abdominal pressure.
82. A nurse is completing postpartum discharge teaching to a client who had no immunity to
varicella and was given varicella vaccine. Which of the following statements by the client
indicates understanding of the teaching?
a. "I will need to use contraception for 3 months before considering pregnancy."
b. "I need a second vaccination at my postpartum visit."
c. "I was given the vaccine because my baby is O-positive."

d. "I will be tested in 3 months to see if I have developed immunity."
Answer: b
Rationale:
This statement indicates understanding because the varicella vaccine typically requires two doses
for full immunity.
83. A nurse is assessing a postpartum client for fundal height, location, and consistency. The
funds is noted to be displaced laterally to the right, and there is uterine atony. The nurse should
identify which of the following conditions as the cause of the uterine atony?
a. poor involution
b. urinary retention
c. hemorrhage
d. infection
Answer: b
Rationale:
This can cause a distended bladder, which can displace the uterus laterally and contribute to
uterine atony.
84. A nurse is caring for a client who is 1 hr postpartum following a vaginal birth and
experiencing uncontrollable shaking. The nurse should understand that the shaking is due to
which of the following factors? (SATA)
a. change in body fluids
b. metabolic effort of labor
c. diaphoresis
d. decreases in body temperature
e. decrease in prolactin levels
Answer: a, b
Rationale:
a. change in body fluids: During labor and birth, there can be shifts in body fluids, which can
contribute to shaking.

b. metabolic effort of labor: The body undergoes significant metabolic changes during labor,
which can lead to shaking as the body readjusts post-birth.
85. A nurse concludes that the father of an infant is not showing positive signs of parent-infant
bonding. He appears very anxious and nervous when the infant's mother asks him to bring her
the infant. Which of the following actions should the nurse use to promote father-infant bonding?
a. hand the father the infant, and suggest that he change the diaper
b. ask the father why he is so anxious and nervous
c. tell the father that he will grow accustomed to the infant
d. provide education about infant care when the father is present
Answer: d
Rationale:
This action can help the father feel more confident and involved in caring for the infant, which
can promote bonding.
86. A client in the early postpartum period is very excited and talkative. She is repeatedly telling
the nurse every detail of her labor and birth. Because the client will not stop talking, the nurse is
having difficulty completing the postpartum assessments. Which of the following actions should
the nurse take?
a. come back later when the client is more cooperative
b. give the client time to express her feelings
c. tell the client she needs to be quiet so the assessment can be completed
d. redirect the client's focus so that she will become quiet
Answer: b
Rationale:
This approach acknowledges the client's need to share her experiences and emotions, which is a
common and normal part of the postpartum period.
87. A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal
adaptation and mother-infant bonding. Which of the following behaviors by the client indicates a
need for the nurse to intervene? (SATA)

a. demonstrates apathy when the infant cries
b. touches the infant and maintains close physical proximity
c. views the infant's behavior as uncooperative during diaper changing
d. identifies and related infant's characteristics to those of family members
e. interprets the infant's behavior as meaningful and a way of expressing needs
Answer: a, c
Rationale:
a. demonstrates apathy when the infant cries: Apathy towards the infant's cries can indicate a
lack of maternal bonding and may require further assessment and intervention.
c. views the infant's behavior as uncooperative during diaper changing: Viewing the infant's
behavior as uncooperative may indicate a lack of understanding of normal infant behavior and
may require education and support.
88. A nurse is caring for a client who is 2 days postpartum. The client states, "My 4-year old son
was toilet trained and now he is frequently wetting himself." Which of the following statements
should the nurse provide to the client?
a. "Your son was probably not ready for toilet training and should wear training pants."
b. "Your son is showing an adverse sibling response."
c. "Your son may need counseling."
d. "You should try sending your son to preschool to resolve the behavior."
Answer: b
Rationale:
This statement acknowledges the client's concern and provides a potential explanation for the
behavior, which can help the client understand and address the issue.
89. A nurse in the delivery room is planning to promote maternal-infant bonding for a client who
just delivered. Which of the following is the priority action by the nurse?
a. encourage the parents to touch and explore the neonate's features
b. limit noise and interruption in the delivery room
c. place the neonate at the client's breast
d. position the neonate skin-to-skin on the client's chest

Answer: d
Rationale:
This is the priority action as it promotes immediate physical and emotional bonding between the
mother and infant, which is crucial for maternal-infant attachment.
90. A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding.
The client reports breast engorgement. Which of the following recommendations should the
nurse make?
a. "Apply cold compresses between feedings."
b. "Take a warm shower right after feedings."
c. "Apply breast milk to the nipples and allow them to air dry."
d. "Use the various infant positions for feedings."
Answer: a
Rationale:
This can help reduce swelling and discomfort associated with breast engorgement.
91. A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client
should contact her provider for which of the following client findings?
a. scant, non-odorous white vaginal discharge
b. uterine cramping during breastfeeding
c. sore nipple with cracks and fissures
d. decreased response with sexual activity
Answer: c
Rationale:
This finding can indicate a possible breast infection or improper latch during breastfeeding,
which may require treatment or correction.
92. A nurse is providing discharge teaching for a non-lactating client. Which of the following
instructions should the nurse include in the teaching?
a. "Wear a supportive bra continuously for the first 72 hours."
b. "Pump your breast every 4 hours to relieve discomfort."

c. "Use breast shells throughout the day to decrease milk supply."
d. "Apply warm compresses until milk suppression occurs."
Answer: a
Rationale:
This can help reduce discomfort and provide support to the breasts during the postpartum period.
93. A nurse is providing discharge instructions to a postpartum client following a cesarean birth.
The client reports leaking urine every time she sneezes or coughs. Which of the following
interventions should the nurse suggest?
a. sit-ups
b. pelvic tilt exercise
c. kegel exercises
d. abdominal crunches
Answer: c
Rationale:
Kegel exercises can help strengthen the pelvic floor muscles, which can reduce or prevent
urinary leakage in situations like sneezing or coughing.
94. A nurse is providing care to four clients on the postpartum unit. Which of the following
clients is at greatest risk for developing a postpartum infection?
a. a client who has an episiotomy that is erythematous and has extended into a third-degree
laceration
b. a client who does not wash her hands between perineal care and breastfeeding
c. a client who is not breastfeeding and is using measures to suppress lactation
d. a client who has a cesarean incision that is well-approximated with no drainage
Answer: b
Rationale:
Poor hand hygiene can lead to the introduction of pathogens, increasing the risk of infection.
95. A nurse is caring for a client who is postpartum. The nurse should identify which of the
following findings as an early indicator of hypovolemia caused by hemorrhage?

a. increasing pulse and decreasing blood pressure
b. dizziness and increasing respiratory rate
c. cool, clammy skin, and pale mucous membranes
d. altered mental status and level of consciousness
Answer: a
Rationale:
These are early signs of hypovolemia due to hemorrhage, indicating the body's compensatory
response to maintain perfusion.
96. A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage
with a group of nurses. Which of the following factors should the nurse include in the teaching?
(SATA)
a. precipitous delivery
b. obesity
c. inversion of the uterus
d. oligohydramnios
e. retained placental fragments
Answer: a, c, e
Rationale:
a. precipitous delivery: Rapid delivery can lead to inadequate uterine contractions and increased
risk of postpartum hemorrhage.
c. inversion of the uterus: This is a rare but serious complication that can lead to significant
bleeding.
e. retained placental fragments: Retained placental tissue can prevent the uterus from contracting
properly, leading to postpartum hemorrhage.
97. A nurse on the postpartum unit is performing a physical assessment of a client who is being
admitted with a suspected deep-vein thrombosis (DVT). Which of the following clinical findings
should the nurse expect? (SATA)
a. calf tenderness to palpation
b. mottling of the affected extremity

c. elevated temperature
d. area of warmth
e. report of nausea
Answer: a, c, d
Rationale:
a. calf tenderness to palpation: This is a common finding in DVT due to inflammation and clot
formation.
c. elevated temperature: Fever can be a sign of infection, which can be a complication of DVT.
d. area of warmth: Warmth in the affected area can indicate inflammation associated with DVT.
98. A nurse on the postpartum unit is planning care for a client who has thrombophlebitis. Which
of the following nursing interventions should the nurse include in the plan of care?
a. apply cold compresses to the affected extremity
b. massage the affected extremity
c. allow the client to ambulate
d. measure leg circumferences
Answer: d
Rationale:
Measuring leg circumferences can help monitor for changes in size, which can indicate
worsening thrombophlebitis.
99. A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which
of the following antepartum complications should the nurse understand is a risk factor for this
condition?
a. preeclampsia
b. thrombophlebitis
c. placenta previa
d. hyperemesis gravidarum
Answer: a
Rationale:
Preeclampsia is associated with abnormal clotting factors and can lead to DIC.

100. A nurse on the postpartum unit is caring for four clients. Which of the following clients
should the nurse recognize as the greatest risk for development of a postpartum infection?
a. a client who experienced a precipitous labor less than 3 hr in duration
b. a client who had premature rupture of membranes and prolonged labor
c. a client who delivered a large for gestational age infant
d. a client who had a boggy uterus that was not well-contracted
Answer: b
Rationale:
Prolonged rupture of membranes and labor can increase the risk of infection due to prolonged
exposure to bacteria.
101. A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following
responses should the nurse make?
a. "Limit the amount of time the infant nurses on each breast."
b. "Nurse the infant only on the unaffected breast until resolved."
c. "Completely empty each breast at each feeding or use a pump."
d. "Wear a tight-fitting bra until lactation has ceased."
Answer: c
Rationale:
Mastitis is often caused by milk stasis, so ensuring the breasts are fully emptied can help
alleviate symptoms and prevent recurrence.
102. A nurse is reviewing discharge teaching with a client who has a urinary tract infection.
Which of the following statements by the client indicates understanding of the teaching? (SATA)
a. "I will perform peri care and apply a perineal pad in a back-to-front direction."
b. "I will drink cranberry and prune juices to make my urine more acidic."
c. "I will drink large amounts of fluids to flush the bacteria from my urinary tract."
d. "I will go back to breastfeeding after I have finished taking the antibiotic."
e. "I will take Tylenol for any discomfort."
Answer: b, c, e

Rationale:
b. "I will drink cranberry and prune juices to make my urine more acidic.": Cranberry juice may
help prevent UTIs, and prune juice can help with constipation, which can contribute to UTIs.
c. "I will drink large amounts of fluids to flush the bacteria from my urinary tract.": Staying
hydrated can help flush bacteria from the urinary tract.
e. "I will take Tylenol for any discomfort.": Tylenol can help alleviate discomfort from a UTI.
103. A nurse is caring for a client who has mastitis. Which of the following is the typical
causative agent of mastitis?
a. staphylococcus aureus
b. chlamydia trachomatis
c. klebsiella pneumonia
d. clostridium perfringens
Answer: a
Rationale:
This bacterium is a common cause of mastitis, especially in breastfeeding women.
104. A nurse is discussing risk factors for urinary tract infections with a newly licensed nurse.
Which of the following conditions should the nurse include in the teaching? (SATA)
a. epidural anesthesia
b. urinary bladder catheterization
c. frequent pelvic examinations
d. history of UTIs
e. vaginal birth
Answer: a, b, c, d
Rationale:
a. epidural anesthesia: Epidural catheters can increase the risk of UTIs due to bladder
catheterization and decreased sensation of bladder fullness.
b. urinary bladder catheterization: Indwelling urinary catheters can introduce bacteria into the
urinary tract.

c. frequent pelvic examinations: Frequent pelvic exams can introduce bacteria into the urinary
tract.
d. history of UTIs: A history of UTIs can increase the likelihood of recurrent infections.
105. A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of
appetite, and a feeling of letdown. Which of the following conditions are associated with these
clinical findings?
a. postpartum fatigue
b. postpartum psychosis
c. letting-go phase
d. postpartum blues
Answer: d
Rationale:
These symptoms are common in postpartum blues, which is a mild, transient mood disorder that
occurs in the first few weeks after childbirth.
106. A nurse is caring for a postpartum client who delivered her third infant 2 days ago. The
nurse recognizes that which of the following findings are suggestive of postpartum depression?
(SATA)
a. fatigue
b. insomnia
c. euphoria
d. flat affect
e. delusions
Answer: a, b, d
Rationale:
a. fatigue: Fatigue is a common symptom of postpartum depression.
b. insomnia: Insomnia is often experienced by individuals with postpartum depression.
d. flat affect: A flat affect, or lack of emotional expression, can be indicative of postpartum
depression.

107. A nurse is assessing a client who has postpartum depression. The nurse should expect which
of the following findings? (SATA)
a. paranoia that her infant will be harmed
b. concerns about lack of income to pay bills
c. anxiety about assuming a new role as a mother
d. rapid decline in estrogen and progesterone
e. feeling of inadequacy with the new role as a mother
Answer: b, c, d, e
Rationale:
b. concerns about lack of income to pay bills: Postpartum depression can be accompanied by
financial worries.
c. anxiety about assuming a new role as a mother: Anxiety about the new responsibilities of
motherhood is common in postpartum depression.
d. rapid decline in estrogen and progesterone: Hormonal changes can contribute to postpartum
depression.
e. feeling of inadequacy with the new role as a mother: Feelings of inadequacy are common in
postpartum depression.
108. A nurse is caring for a client who has postpartum psychosis. Which of the following actions
is the nurse's priority?
a. reinforce the need to take antipsychotics as prescribed
b. ask the client if she has thoughts of harming herself or her infant
c. monitor the infant for indications of failure to thrive
d. review the client's medical record for a history of bipolar disorder
Answer: b
Rationale:
Safety is the priority when caring for a client with postpartum psychosis.
109. A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and
is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should
classify this neonate as which of the following?

a. low birth weight
b. appropriate for gestational age
c. small for gestational age
d. large for gestational age
Answer: b
Rationale:
A newborn is considered appropriate for gestational age if their weight falls between the 10th
and 90th percentiles for their gestational age.
110. A nurse is completing a newborn assessment and observes small white nodules on the roof
of the newborn's mouth. This finding is a characteristic of which of the following conditions?
a. mongolian spots
b. milia spots
c. erythema toxicum
d. epstein's pearls
Answer: d
Rationale:
Epstein's pearls are small, white, keratin-filled cysts that can appear on the gums or roof of the
mouth in newborns. They are a normal finding and typically resolve on their own.
111. A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse
should perform which of the following?
a. hold the newborn vertically under arms and allow one foot to touch table
b. stimulate the pads of the newborn's hands with stroking or massage
c. stimulate the soles of the newborn's feet not the outer lateral surface of each foot
d. hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall
backward
Answer: d
Rationale:
The Moro reflex, also known as the startle reflex, is elicited by allowing the newborn's head and
trunk to fall backward slightly while being held in a semi-sitting position. This reflex is

characterized by the newborn's arms and legs extending outward and then coming back together
as if embracing.
112. A nurse is completing an assessment. Which of the following data indicates the newborn is
adapting to extrauterine life? (SATA)
a. expiratory grunting
b. inspiratory nasal flaring
c. apnea for 10-second periods
d. obligatory nose breathing
e. crackles and wheezing
Answer: c, d
Rationale:
Adaptation to extrauterine life includes establishing regular respirations, which are indicated by
obligatory nose breathing (d) and absence of apnea for 10-second periods (c). Expiratory
grunting (a), inspiratory nasal flaring (b), and crackles and wheezing (e) are not normal findings
and may indicate respiratory distress or other issues.
113. A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish
marking across the newborn's lower back. The nurse should include which of the following
information in the teaching?
a. "This is frequently seen in newborns who have dark skin."
b. "This is a finding indicating hyperbilirubinemia."
c. "This is a forceps mark from an operative delivery."
d. "This is related to prolonged birth or trauma during delivery."
Answer: a
Rationale:
The bluish marking across the lower back is likely a Mongolian spot, which is a common
variation of normal pigmentation seen in newborns with darker skin tones. It is not related to
hyperbilirubinemia, forceps marks, or trauma during delivery.

114. A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent
ophthalmia neonatorum. Which of the following medications should the nurse anticipate
administering?
a. ofloxacin
b. nystatin
c. erythromycin
d. ceftriaxone
Answer: c
Rationale:
Prophylactic eye ointment to prevent ophthalmia neonatorum is typically administered using
erythromycin ointment. Ofloxacin, nystatin, and ceftriaxone are not used for this purpose.
115. A newborn was not dried completely after birth. Which of the following mechanisms should
the nurse understand causes heat loss?
a. conduction
b. convection
c. evaporation
d. radiation
Answer: c
Rationale:
Heat loss due to evaporation occurs when moisture on the newborn's skin evaporates, leading to
cooling. This can happen if the newborn is not dried completely after birth. Conduction involves
heat loss through direct contact with a cooler surface, convection involves heat loss through air
currents, and radiation involves heat loss to cooler surfaces not in direct contact with the
newborn.
116. A nurse is caring for a newborn immediately following birth. Which of the following
nursing interventions is the highest priority?
a. initiating breastfeeding
b. performing the initial bath
c. giving a vitamin K injection

d. covering the newborn's head with a cap
Answer: d
Rationale:
Covering the newborn's head with a cap is the highest priority as it helps prevent heat loss, which
is critical for maintaining the newborn's body temperature immediately after birth.
117. A nurse is preparing to administer a vitamin K (phytonadione) injection to a newborn.
Which of the following responses should the nurse make to the newborn's mother regarding why
this medication is given?
a. "It assists with blood clotting."
b. "It promotes maturation of the bowel."
c. "It is a preventative vaccine."
d. "It provides immunity."
Answer: a
Rationale:
Vitamin K (phytonadione) is given to newborns to assist with blood clotting. Newborns are born
with low levels of vitamin K, which puts them at risk for bleeding disorders, so this injection
helps prevent such issues.
118. A nurse is taking a newborn to a mother following a circumcision. Which of the following
actions should the nurse take for security purposes?
a. ask the mother to state her full name
b. look at the name on the newborn's bassinet
c. match the mother's identification band with the newborn's band
d. compare name on the bassinet and room number
Answer: c
Rationale:
Matching the mother's identification band with the newborn's band is crucial for security
purposes to ensure that the newborn is being returned to the correct mother after procedures like
circumcision.

119. A nurse is giving instructions to a mother about how to breastfeed her newborn. Which of
the following actions by the mother indicates understanding of the teaching?
a. the mother places a few drops of water on her nipple before feeding
b. the mother gently removes her nipple from the infant's mouth to break the suction
c. when she is ready to breastfeed, the mother gently strokes the newborn's neck with her finger
d. when latched on, the infant's nose, cheek, and chin are touching the breast
Answer: d
Rationale:
The correct latch during breastfeeding is indicated when the infant's nose, cheek, and chin are
touching the breast. This ensures a proper seal and effective milk transfer.
120. A nurse is teaching a group of new parents about proper techniques for bottle feeding.
Which of the following instructions should the nurse provide?
a. burp the newborn at the end of the feeding
b. hold the newborn close in a supine position
c. keep the nipple full of formula throughout the feeding
d. refrigerate any unused formula
Answer: c
Rationale:
Keeping the nipple full of formula throughout the feeding helps ensure that the newborn is
receiving a consistent flow of formula and reduces the likelihood of the newborn swallowing air,
which can lead to discomfort and gas.
121. A nurse is caring for a newborn. Which of the following actions by the newborn indicates
readiness to feed?
a. spits up clear mucus
b. attempts to place his hand in his mouth
c. turns his head toward sounds
d. lies quietly with his eyes open
Answer: b
Rationale:

A newborn attempting to place his hand in his mouth indicates readiness to feed. This behavior is
a natural instinct in newborns and can be an early sign of hunger.
122. A nurse is reviewing formula preparation with parents who plan to bottle-feed their
newborn. Which of the following information should the nurse include in the teaching? (SATA)
a. use a disinfectant wipe to clean the life of the formula can
b. store prepared formal in the refrigerator for up to 72 hr
c. place used bottles in the dishwasher
d. check the nipple for appropriate flow of formula
e. use tap water to dilute concentrated formula
Answer: c, d, e
Rationale:
c. Placing used bottles in the dishwasher helps ensure they are thoroughly cleaned and sanitized,
reducing the risk of contamination.
d. Checking the nipple for appropriate flow of formula helps ensure that the infant is able to feed
effectively without too much or too little effort.
e. Using tap water to dilute concentrated formula is safe as long as the water is potable (safe for
drinking). Boiling tap water for one minute and then allowing it to cool before mixing with
formula is recommended to reduce the risk of infections from contaminants in the water.
123. A nurse is reviewing breastfeeding positions with the mother of a newborn. Which of the
following positions should the nurse discuss?
a. over-the-shoulder
b. supine
c. chin-supported
d. cradle
Answer: d
Rationale:
Breastfeeding positions include the cradle hold, cross-cradle hold, football hold, and side-lying
position. The over-the-shoulder and supine positions are not commonly used for breastfeeding.

124. A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the
following instructions should the nurse include in the teaching?
a. cover the cord with a small gauze square
b. trickle clean water over the cord with each diaper change
c. apply hydrogen peroxide to the cord twice a day
d. keep the diaper folded below the cord
Answer: d
Rationale:
Keeping the diaper folded below the cord helps prevent irritation and allows air to circulate
around the cord, promoting healing. Covering the cord with a small gauze square, trickling clean
water over the cord, and applying hydrogen peroxide to the cord are not recommended practices
for umbilical cord care.
125. A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of
the following conditions are contraindications? (SATA)
a. hypospadias
b. hydrocele
c. family history of hemophilia
d. hyperbilirubinemia
e. epispadias
Answer: a, c, e
Rationale:
a. Hypospadias is a congenital condition where the opening of the urethra is on the underside of
the penis instead of at the tip. Circumcision in this condition can lead to complications and is
generally contraindicated.
c. A family history of hemophilia indicates a potential bleeding disorder, which could increase
the risk of bleeding complications from circumcision.
e. Epispadias is a rare congenital condition where the urethra opens on the upper side of the
penis. Circumcision in this condition can lead to complications and is generally contraindicated.

126. A nurse is providing discharge teaching to the parents of a newborn regarding circumcision
care. Which of the following statements made by a parent indicates an understanding of the
teaching?
a. "His circumcision will heal within a couple of days."
b. "I should remove the yellow mucus that will form."
c. "I will clean his penis with each diaper change."
d. "I will give him a tub bath within a couple of days."
Answer: c
Rationale:
Cleaning the penis with each diaper change is important to prevent infection and promote
healing. Circumcision typically takes about 7-10 days to heal, and the yellow mucus (a part of
the healing process) should not be removed. Tub baths should be avoided until the circumcision
has healed.
127. A nurse is caring for a newborn immediately following a circumcision using a Gomco
procedure. Which of the following actions should the nurse implement?
a. apply Gelfoam powder to the site
b. place the newborn in the prone position
c. apply petroleum gauze to the site
d. avoid changing the diaper until the first voiding
Answer: c
Rationale:
Applying petroleum gauze to the site helps protect the healing circumcision from sticking to the
diaper and promotes healing. The newborn should be placed on his back and diapers should be
changed regularly to prevent infection.
128. A nurse is reviewing car seat safety with the parents of a newborn. Which of the following
instructions should the nurse include in the teaching regarding car seat position?
a. front seat, rear-facing
b. front seat, forward-facing
c. back seat, rear-facing

d. back seat, forward-facing
Answer: c
Rationale:
The safest position for a newborn car seat is in the back seat, rear-facing. This position provides
the best protection for the newborn's head, neck, and spine in the event of a collision.
129. A nurse is caring for a client who is at 42 weeks gestation and in labor. The client asks the
nurse what she should expect because her baby is postmature. Which of the following statements
should the nurse make?
a. "Your baby will have excess body fat."
b. "Your baby will have flat areola without breast buds."
c. "Your baby's heels will easily move to his ears."
d. "Your baby's skin will have a leathery appearance."
Answer: d
Rationale:
Postmature infants often have a leathery, cracked, and wrinkled skin appearance due to decreased
vernix and amniotic fluid. They may also have less subcutaneous fat, making their appearance
different from that of full-term infants.
130. A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy.
Which of the following is the priority finding in the newborn?
a. conjunctivitis
b. bronze skin discoloration
c. sunken fontanels
d. maculopapular skin rash
Answer: c
Rationale:
Sunken fontanels indicate dehydration, which is a serious and potentially life-threatening
condition. While other findings such as conjunctivitis, bronze skin discoloration, and skin rashes
can occur with phototherapy, addressing dehydration is the highest priority.

131. A nurse is called to the birthing room to assist with the assessment of a newborn who was
born at 32 weeks of gestation. The newborn's birth weight is 1,100 g. Which of the following are
expected findings in this newborn? (SATA)
a. lanugo
b. long nails
c. weak grasp reflex
d. translucent skin
e. plump face
Answer: a, c, d
Rationale:
a. Lanugo is common in preterm infants, helping to protect their skin in utero.
c. A weak grasp reflex is expected due to immature neuromuscular development.
d. Translucent skin is typical due to the lack of full development of the skin layers.
132. A nurse is caring for a newborn who is preterm and has respiratory distress syndrome.
Which of the following should the nurse monitor to evaluate the newborn's conditions following
administration of synthetic surfactant?
a. oxygen saturation
b. body temperature
c. serum bilirubin
d. heart rate
Answer: a
Rationale:
After administration of synthetic surfactant, monitoring the newborn's oxygen saturation is
crucial. This helps assess the effectiveness of the treatment in improving lung function and gas
exchange.
133. A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of
the following statements by the newly licensed nurse indicate understanding of the teaching?
a. "The newborn will have decreased muscle tone."
b. "The newborn will have a continuous high-pitched cry."

c. "The newborn will sleep for 2 to 3 hours after a feeding."
d. "The newborn will have mild tremors when disturbed."
Answer: b
Rationale:
Newborns with neonatal abstinence syndrome often have a continuous high-pitched cry due to
withdrawal symptoms. They typically exhibit increased muscle tone, irritability, and disturbances
in sleep patterns, rather than the other options provided.
134. The nurse evaluates the knowledge of the patient concerning urinary tract infection during a
prenatal visit. The nurse knows the patient needs further instruction when she says which of the
following (choose all that apply)
a. "I drink about 1 quart of water a day"
b. "I have stopped taking bubble baths"
c. "I have started wearing underwear with a cotton crotch"
d. "I have stopped having intercourse with my husband"
e. "I will not get a bladder infection if I drink cranberry juice 3 times/day"
Answer: a, d, e
Rationale:
a. Adequate hydration is crucial for flushing out bacteria from the urinary tract.
d. Completely abstaining from intercourse is not necessary; proper hygiene practices are
important.
e. Drinking cranberry juice is helpful but not a foolproof method to prevent UTIs.