ATI Proctored Exam-Maternal Newborn Graded A-All Answers Correct-180
Questions and answers.
1. A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin
level. Which of the following actions should the nurse take?
A. Reposition the newborn every 4 hours.
B. Apply lotion to the newborn’s skin twice per day.
C. Keep the newborn in a shirt while under the phototherapy lamp.
D. Use a photometer to monitor the lamp's energy
Answer: D. Use a photometer to monitor the lamp's energy
Rationale:
The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is
receiving the appropriate amount to be effective.
2. A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which
of the following findings should the nurse expect?
A. Increased blood pressure
B. Decreased urine output
C. Fundal height 2 cm larger than expected
D. Dark red vaginal bleeding
Answer: D. Dark red vaginal bleeding
Rationale:
The nurse should expect this client with a mild placental abruption to have minimal dark red
vaginal bleeding.
3. A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of
the following actions should the nurse perform?
A. The nurse should not obtain a rectal temperature from a newborn due to the risk of rectal
perforation. Instead, the nurse should obtain an axillary temperature.
B. Assess the newborn's blood glucose level
C. Bathing a newborn will increase heat loss. The infant should not be bathed until the
temperature has stabilized within the normal range.
D. Placing the infant in front of a heater vent can incur heat loss through convection.
Additionally, there is a potential fire risk from the bassinet linens and the vent.
Answer: B. Assess the newborn's blood glucose level
Rationale:
Infants who become cold attempt to generate heat through increased muscular and metabolic
activity. This process increases glucose consumption and puts the newborn at risk of
hypoglycaemia.
4. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulphate. The
client begins to show indications of magnesium sulphate toxicity. Which of the following
medications should the nurse prepare to administer?
A. Protamine sulphate helps reverse the effects of heparin, not magnesium sulphate.
B. Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium sulphate.
C. Calcium gluconate
D. Flumazenil reverses the effects of benzodiazepines such as lorazepam and alprazolam, not
magnesium sulphate.
Answer: C. Calcium gluconate
Rationale:
The nurse should discontinue the magnesium sulphate infusion immediately and prepare to
administer calcium gluconate IV to reverse the effects of magnesium sulphate and to prevent
cardiac and respiratory arrest.
5. A nurse is providing postpartum discharge teaching to a client who is nonlactating about breast
discomfort relief measures. Which of the following pieces of information should the nurse
include?
A. The client should be instructed to wear a tight-fitting bra or breast binders to alleviate
engorgement and swelling.
B. "Place fresh cabbage leaves on your breasts."
C. Application of warmth to the breasts should be avoided because heat can stimulate milk
production. An ice pack should be used to relieve engorged breasts.
D. Milk should not be expressed from the breasts. This intervention would increase milk
production rather than decrease it.
Answer: B. "Place fresh cabbage leaves on your breasts."
Rationale:
After 3 days postpartum, the client's breasts can become swollen and distended because of
congestion of the vascular structures of the breasts.
Fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort.
The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts.
Leaves should be replaced when they become wilted.
6. A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and
vomiting. Which of the following statements should the nurse include in the teaching?
A. The nurse should instruct the client to eat foods served at cool temperatures to decrease
nausea and vomiting.
B. The nurse should instruct the client to avoid brushing her teeth immediately after eating to
decrease vomiting.
C. The nurse should instruct the client to eat salty and tart foods during periods of nausea.
D. "You should eat dry foods that are high in carbohydrates when you wake up."
Answer: D. "You should eat dry foods that are high in carbohydrates when you wake up."
Rationale:
The nurse should instruct the client to eat foods that are high in carbohydrates such as dry toast
or crackers upon waking or when nausea occurs.
7. A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The
client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the
following responses should the nurse make?
A. Breastfeeding can inhibit ovulation or prolong menstruation; however, it is not a reliable and
effective means of birth control. The client may experience an unplanned pregnancy if she waits
until her periods resume before considering birth control options.
B. Estrogen-containing birth control pills, implants, patches, and vaginal rings are not
recommended for clients who are breastfeeding due to the risk of inhibiting breast milk
production and supply.
C. Condoms and other non-hormonal birth control methods are appropriate for clients who are
breastfeeding; however, there are other methods that are also appropriate.
D. "A progestin-only pill or injection is available for use while you are breastfeeding."
Answer: D. "A progestin-only pill or injection is available for use while you are breastfeeding."
Rationale:
Progestin-only injections, implants, and birth control pills are acceptable options for clients who
are breastfeeding, although some experts recommend waiting until 6 weeks postpartum to initiate
the medication.
8. A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia
(PCA) pump following a caesarean birth. Which of the following findings should the nurse
report to the provider?
A. Opioid analgesics can cause respiratory depression. However, this respiratory rate is within
the expected reference range.
B. This temperature is within the expected reference range.
C. Dizziness is a common adverse effect of receiving opioid analgesics. The nurse should
instruct the client to sit on the side of the bed before getting up, assist the client with ambulation,
and implement general safety measures. However, it is not necessary to report this finding to the
provider.
D. Urine output 20 mL/hr
Answer: D. Urine output 20 mL/hr
Rationale:
Opioid analgesics such as morphine can cause urinary retention. The client should have a urinary
output of at least 30 mL/hr. The nurse should report this finding to the provider.
9. A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is
scheduled for an external cephalic version. Which of the following statements should the nurse
make?
A. This action is appropriate for internal version. With external version, the provider attempts to
turn the fetus around externally and not internally.
B. "You will receive a medication to relax your uterus prior to the procedure."
C. External version is a high-risk procedure that is performed in a hospital setting in the event of
an emergency.
D. During the external version, the fetal heart-rate pattern is monitored continuously because the
fetus is at risk of bradycardia and variable decelerations. The nurse also monitors the fetal heart
rate for at least 60 minutes following the procedure.
Answer: B. "You will receive a medication to relax your uterus prior to the procedure."
Rationale:
A client who is scheduled to undergo an external cephalic version often receives a tocolytic prior
to the procedure to allow the uterus to relax. A relaxed uterus allows an easier version by the
provider.
10. A postpartum nurse is caring for a client who reports excessive sweating during the first night
after delivery. Which of the following statements should the nurse make?
A. Postpartum diuresis is attributed to decreased estrogen levels, the removal of increased
venous pressure in the lower extremities, and the loss of the remaining pregnancy-induced
increase in blood volume.
B. Postpartum diuresis is caused by decreased estrogen levels. Fluid loss by urination and
perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum
period.
C. Postpartum diuresis is caused, in part, by the removal of increased venous pressure in the
lower extremities. Urine output can exceed 3000 mL/day during the first 2 to 3 days postpartum.
D. "This is a source of your fluid loss after delivery."
Answer: D. "This is a source of your fluid loss after delivery."
Rationale:
Postpartum diuresis is the loss of the remaining pregnancy-induced increase in blood volume.
The loss of excess tissue fluid begins within 12 hours after birth. Fluid loss by urination and
perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum
period.
11. The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child
could have the same condition. The nurse should base the response on which of the following
inheritance patterns responsible for PKU?
A. PKU does not have an X-linked recessive pattern of inheritance. In X-linked recessive
disorders, the abnormal gene is carried on the X chromosome. In males, only 1 copy of the
abnormal gene is required for the disorder to be expressed in males since the Y chromosome
does not carry the disorder. Females must have 2 copies of the gene. Examples of this type of
disorder are haemophilia and colour blindness.
B. PKU does not have an X-linked dominant pattern of inheritance. In X-linked dominant
disorders, the abnormal gene is carried on the X chromosome. Only 1 copy of the abnormal gene
is necessary for the disorder to occur. However, males are more likely to be severely affected due
to the homozygous expression. There are only a few disorders that follow this pattern of
inheritance. Examples include vitamin D-resistant rickets and Rett syndrome.
C. Autosomal recessive
D. PKU does not have an autosomal-dominant pattern of inheritance. In these disorders, only 1
copy of the variant gene is necessary for the disorder to occur. Examples of this type of disorder
are neurofibromatosis and Treacher Collins syndrome.
Answer: C. Autosomal recessive
Rationale:
PKU is inherited by autosomal-recessive gene patterns. In these types of disorders, neither parent
may actually have the disorder, but both mother and father must carry and contribute a variant
gene for it to occur. Other autosomal recessive disorders are cystic fibrosis and sickle cell
anaemia.
12. A nurse is teaching a client about physiological changes that can occur with menopause.
Which of the following changes should the nurse include?
A. The nurse should teach the client that urinary frequency, not hesitancy, can occur due to the
shrinking of the uterus, vulva, and distal portion of the urethra.
B. The nurse should teach the client that haematuria is a manifestation of irritation to the bladder
mucosa and might indicate a urinary tract infection. It is not an expected change associated with
menopause.
C. Stress incontinence
D. The nurse should teach the client that vaginal dryness can occur with menopause due to the
vaginal walls becoming thinner and drier, delaying lubrication. This can lead to painful
intercourse.
Answer: C. Stress incontinence
Rationale:
The nurse should teach the client that stress incontinence can occur due to the shrinking of the
uterus, vulva, and distal portion of the urethra.
Urinary incontinence and uterine displacement can occur because of common age-related
changes but are not necessarily a result of menopause-related changes.
13. A nurse is providing education about newborn skin care for a group of new parents. Which of
the following instructions should the nurse include?
A. In uncircumcised males, the foreskin adheres to the glans of the penis. Parents should not
attempt to retract the foreskin before the age of 3 years. Parents should wash the penis with soap
and water.
B. Sponge bathe the newborn every other day
C. The parents should avoid using antimicrobial soaps and instead use soap with a neutral pH
and no preservatives to protect the acid mantle of the newborn's skin.
D. The parents should maintain the bath water temperature between 38° and 40°C (100° and
104°F).
Answer: B. Sponge bathe the newborn every other day
Rationale:
Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The
parents should sponge bathe the infant until the cord stump has detached and the area has healed.
14. A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful thirddegree perineal laceration. Which of the following interventions should the nurse take?
A. Warm sitz baths are appropriate after the first 24 hours postpartum. A cool sitz bath is
recommended within the first 24 hours to reduce edema and promote comfort.
B. The nurse should encourage the client to sit on firm surfaces. The client should avoid soft
pillows and donut pillows because they separate the buttocks and decrease venous blood flow,
resulting in more pain and discomfort to the perineal area.
C. Apply cold ice packs to the client's perineum
D. The use of suppositories or enemas is contraindicated for a client who has a third-degree
perineal laceration due to the severity of the laceration.
Answer: C. Apply cold ice packs to the client's perineum
Rationale:
A third-degree laceration extends from the perineum to the external sphincter of the rectum. This
can cause severe discomfort. Cold ice packs are used on the perineal area during the first 24
hours to decrease edema, pain, and discomfort.
15. A nurse is providing teaching to the parents of a newborn about home safety. Which of the
following statements by the parents indicates an understanding of the teaching?
A. "I will place my baby on his back when putting him to sleep."
B. The parents should not place the newborn's crib close to a heat source due to the risk of the
crib linen catching on fire.
C. The parents should always place the newborn in an approved car seat while driving with the
newborn. Infant carriers are not approved safety seats for motor vehicles.
D. The parents should never tie any type of string or cord around the newborn's neck due to the
risk of strangulation.
Answer: A. "I will place my baby on his back when putting him to sleep."
Rationale:
Newborns should always sleep on the back to prevent sudden infant death syndrome.
16. A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the
following findings should the nurse expect?
A. Abundant lanugo
B. Newborns who are premature demonstrate hypotonia and a relaxed posture. Full-term
newborns demonstrate moderate flexion of the arms and legs.
C. Newborns who are premature have few heel creases. Full-term newborns have heel creases
that cover most of the bottom of the feet.
D. Newborns who are premature have abundant vernix caseosa, a thick whitish substance,
covering and protecting their skin in utero. Post-mature newborns are likely to have dry,
parchment-like skin.
Answer: A. Abundant lanugo
Rationale:
Newborns who are premature have abundant lanugo (fine hair), especially over their back. A fullterm newborn typically has minimal lanugo present only on the shoulders, pinna, and forehead.
17. A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to
entering the second stage of labor. Which of the following actions should the nurse take?
A. Meperidine does not affect the client's reflexes. It reduces the transmission of pain impulses
through stimulation of the mu and kappa opioid receptors.
B. Assess the newborn for respiratory depression
C. Meperidine can cause tachycardia, nausea, vomiting, dizziness, and altered mental status.
D. Neonatal abstinence syndrome occurs in newborns who are exposed to opioids over a long
period of time during pregnancy. A client receiving an opiate during labor would not lead to
opiate dependence in the newborn.
Answer: B. Assess the newborn for respiratory depression
Rationale:
Meperidine should not be administered to labouring clients who are expected to deliver within 4
hours of the medication administration.
This medication crosses the placenta and causes respiratory depression in the newborn, which
peaks in 2 to 3 hours after administration. Narcan is ineffective at reversing the respiratory
depression caused by this medication.
18. A nurse is assessing a client who is in the fourth stage of labor. Which of the following
findings should the nurse expect?
A. Breast engorgement does not generally become problematic until 3 to 5 days after birth.
B. Hypothermia is unlikely during the fourth stage of labor. The nurse should measure the
client's temperature at this time, then every 4 hours for the first 8 hours, and then at least every 8
hours after that. The client might feel chilly during this stage; if so, the nurse should provide a
warmed blanket.
C. Urinary retention
D. Rupture of membranes occurs spontaneously or via amniotomy prior to the second stage of
labor.
Answer: C. Urinary retention
Rationale:
After delivery, many clients have a reduced urge to urinate. This can result from birth trauma, a
larger bladder capacity after birth, analgesia, pelvic soreness, an episiotomy, and other factors.
19. A nurse is reviewing the medical record of a client at 39 weeks gestation who has
polyhydramnios. Which of the following findings should the nurse expect?
A. Polyhydramnios will result in a fundal height greater than expected for gestational age.
B. Polyhydramnios will result in an increase in weight gain, not a decrease.
C. Gestational hypertension causes oligohydramnios, which is a decrease in the amount of
amniotic fluid surrounding the fetus.
D. Fetal gastrointestinal anomaly
Answer: D. Fetal gastrointestinal anomaly
Rationale:
Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus.
Gastrointestinal malformations and neurological disorders are expected findings for a fetus
experiencing the effects of polyhydramnios.
20. A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus
gravidarum. Which of the following pieces of information should the nurse provide?
A. "You should slightly increase your exposure to sunlight."
B. Pruritus gravidarum is a condition of pregnancy that causes generalized itching that occurs
due to the stretching of the skin. It will resolve without extensive treatment after delivery.
C. Pruritus gravidarum is a condition of pregnancy that will go away after delivery. It has no
effect on the liver. Therefore, the client will not require weekly liver function studies.
D. Isotretinoin cream is used to treat acne. It should not be prescribed to a client who is pregnant
due to its teratogenic effects on the fetus.
Answer: A. "You should slightly increase your exposure to sunlight."
Rationale:
Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the
presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce
itching.
21. A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which
of the following findings is a risk factor for an ectopic pregnancy?
A. Anaemia does not place the client at increased risk of an ectopic pregnancy.
B. Frequent urinary tract infections do not increase the risk of ectopic pregnancy.
C. A previous caesarean birth does not place the client at increased risk of an ectopic pregnancy.
D. Pelvic inflammatory disease (PID)
Answer: D. Pelvic inflammatory disease (PID)
Rationale:
An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and
the placenta, and the fetus begin to develop in this area.
The most common site is within a fallopian tube, but ectopic pregnancies can occur in the ovary
or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal
surgery. Therefore, PID places the client at risk of an ectopic pregnancy.
22. A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole.
Which of the following findings should the nurse expect?
A. The nurse should expect the client's temperature to be within the expected reference range
because a hydatidiform mole does not lead to hypothermia.
B. Dark brown vaginal discharge
C. The nurse should expect the client to have increased urinary output due to the elevated
maternal blood volume and pressure of the uterus on the maternal bladder.
D. The nurse should not expect to hear fetal heart tones because a viable embryo or fetus is not
present.
Answer: B. Dark brown vaginal discharge
Rationale:
A hydatidiform mole (a molar pregnancy) is a benign proliferative growth of the chorionic villi
that gives rise to multiple cysts.
The products of conception transform into a large number of edematous, fluidfilled vesicles. As
cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters.
23. A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of
the following findings should the nurse report to the provider?
A. Frequent headaches
B. Leukorrhea is a common discomfort of pregnancy and is an abundant amount of vaginal
mucus that may occur throughout pregnancy.
C. Epistaxis is a common discomfort of pregnancy related to the increase of estrogen.
D. Periodic numbness of the fingers is a common discomfort of pregnancy due to compression of
the nerves and does not need to be reported to the provider.
Answer: A. Frequent headaches
Rationale:
The nurse should report frequent headaches to the provider. Frequent headaches, swelling of the
face and fingers, visual disturbances, and epigastric pain are associated with preeclampsia.
24. A nurse is caring for a client who has oligohydramnios. Which of the following fetal
anomalies should the nurse expect?
A. Fetal cardiac anomalies do not affect the volume of amniotic fluid.
B. Renal agenesis
C. Fetal neural tube defects do not affect the volume of amniotic fluid.
D. Fetal hydrocephalus does not affect the volume of amniotic fluid.
Answer: B. Renal agenesis
Rationale:
Oligohydramnios is a volume of amniotic fluid that is <300 mL during the third trimester of
pregnancy. This occurs when there is a renal system dysfunction or obstructive uropathy. The
absence of fetal kidneys will cause oligohydramnios.
25. A nurse is assessing a client on the first postpartum day. Findings include the following:
fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra
with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following
actions should the nurse take?
A. A slight maternal temperature increase is commonly seen in the first 6 to 10 days postpartum.
A pulse of 52/minute is within the expected reference range.
B. The nurse should massage the fundus when it is boggy.
C. Ask the client when she last voided
D. Administering an oxytocic agent is not an appropriate intervention. Oxytocic agents are given
to clients who have increased lochia rubra or a boggy fundus to promote uterine contractions.
Answer: C. Ask the client when she last voided
Rationale:
Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is
easily displaced when the bladder is full. The fundus should be firm at the midline. A deviated,
firm fundus indicates a full bladder. The nurse should assist the client to void.
26. A nurse is monitoring a client who is receiving spinal anaesthesia. The nurse should identify
which of the following findings as a complication of the infusion?
A. Maternal hypotension
B. Spinal anaesthesia is more likely to cause fetal bradycardia than fetal tachycardia.
C. Spinal anaesthesia is more likely to cause minimal or a lack of fetal heart rate variability than
increased fetal heart rate variability.
D. Spinal anaesthesia is more likely to cause a fever than hypothermia.
Answer: A. Maternal hypotension
Rationale:
Maternal hypotension is a common adverse effect of a spinal block. To prevent supine
hypotension, the client should lie on a side or lie supine with a wedge under a hip to displace the
uterus.
27. A nurse is caring for a client at 35 weeks gestation who has severe pre-eclampsia. Which of
the following assessments provides the most accurate information regarding the client's fluid and
electrolyte status?
A. The nurse should assess the client's blood pressure to evaluate circulatory status. However,
evidence-based practice indicates that another assessment provides more accurate information.
B. The nurse should assess the client's intake and output to evaluate fluid status. However,
evidence-based practice indicates that another assessment provides more accurate information.
C. Daily weight
D. The nurse should assess the severity of the client's edema to evaluate fluid status. However,
evidence-based practice indicates that another assessment provides more accurate information.
Answer: C. Daily weight
Rationale:
Evidence-based practice indicates that daily weight is the most accurate assessment to determine
a client's fluid and electrolyte status.
28. A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad
has a large amount of lochia rubra with several clots. Which of the following actions should the
nurse perform first?
A. A full bladder can cause uterine atony. However, there is another action the nurse should take
first.
B. Massage the fundus
C. Vital signs are important but will not help in identifying the reason for this client's bleeding.
There is another action that the nurse should take first.
D. Administering carboprost is an appropriate action for managing postpartum haemorrhage.
However, there is another action the nurse should take first.
Answer: B. Massage the fundus
Rationale:
The nurse should apply the safety and risk-reduction priority-setting framework, which assigns
priority to the factor or situation posing the greatest safety risk to the client.
When there are several risks to client safety, the one posing the greatest threat is the highest
priority. The primary cause of early postpartum bleeding is uterine atony, which is manifested by
a relaxed, boggy uterus.
Thus, the greatest risk for this client is haemorrhage. The nurse should massage the client's
fundus first. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting
framework, and/or nursing knowledge to identify which risk poses the greatest threat to the
client.
29. A nurse is caring for a client who is postpartum and reports that her episiotomy incision is
pulling and stinging. Which of the following actions should the nurse take?
A. Apply an ice pack to the perineal area for the first 24 hours postpartum.
B. Provide a sitz bath with warm water for the client
C. The nurse should instruct the client to perform Kegel exercises to strengthen perineal muscles
following a vaginal delivery. However, these exercises do not decrease episiotomy discomfort.
D. The nurse should administer prescribed analgesics, including topical aesthetic cream.
However, the cream should be applied no more than three to four times per day.
Answer: B. Provide a sitz bath with warm water for the client
Rationale:
The nurse should provide a client who is postpartum with a sitz bath to decrease episiotomy
discomfort. The use of a sitz bath provides warm, moist, direct heat to the incision area, which
helps relieve the pulling and stinging associated with the healing incision. The warm water
increases blood flow to the area through vasodilatation, which also promotes healing and
comfort.
30. A nurse is caring for a client who is in labor and is reporting intense pain during contractions.
The client has no previous knowledge of nonpharmacological comfort measures. Which of the
following nursing interventions should the nurse implement?
A. Self-hypnosis can help relieve labor pain, but clients might not be able to perform it if they
haven't already learned from specially trained practitioners.
B. Biofeedback can help relieve labor pain, but clients might not be able to implement it if they
haven't already learned from specially trained practitioners.
C. Specially trained practitioners perform acupuncture, so this is not something the nurse can
initiate.
D. Slow-paced breathing
Answer: D. Slow-paced breathing
Rationale:
Slow-paced breathing is an easy technique for the client to learn quickly and practice
immediately. It provides distraction, which can help reduce the perception of pain. The pattern is
In-2-3-4/Out-2-3-4/In-2-3-4/Out-2-3-4. Repeating this cycle slows the client's breathing to about
half of its usual rate, which can help relax the client and improve oxygenation.
31. A nurse is caring for a client who is receiving magnesium sulphate by continuous IV
infusion. Which of the following medications should the nurse have available at the client's
bedside?
A. The nurse should have naloxone available for a client who is receiving opioid medication in
case of respiratory depression.
B. Calcium gluconate
C. The nurse should have protamine sulphate available for a client who is receiving heparin in
case of haemorrhage.
D. The nurse should have atropine available for a client who is receiving medications that can
lead to asystole or sinus bradycardia, such as beta-adrenergic blockers.
Answer: B. Calcium gluconate
Rationale:
The nurse should have calcium gluconate available for a client who is receiving magnesium
sulphate by continuous IV infusion in case of magnesium sulphate toxicity. The nurse should
monitor the client for a respiratory rate of ≤12/min, muscle weakness, and depressed deeptendon reflexes.
32. A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The
nurse should monitor the client for which of the following potential adverse effects?
A. Diarrhoea is not an adverse effect of oxytocin administration. Oxytocin can have adverse
effects that include fetal asphyxia, water intoxication, hypotension, and abruptio placentae.
B. Thromboembolism is not an adverse effect of oxytocin administration.
C. Fetal asphyxia
D. Oliguria is not a likely complication of oxytocin administration.
Answer: C. Fetal asphyxia
Rationale:
Oxytocin may cause tachysystole, which can lead to uteroplacental insufficiency. Inadequate
oxygen transfer to the placenta will result in fetal asphyxia.
33. A nurse is caring for a client who is receiving magnesium sulphate IV. Which of the
following medications should the nurse have available as an antidote to magnesium sulphate?
A. Betamethasone is administered to help mature the lungs of the premature fetus before
delivery. It is not an antidote to magnesium sulfate.
B. Terbutaline is a smooth muscle relaxer administered to inhibit uterine contractions in
premature labor. It is not an antidote to magnesium sulphate.
C. Calcium gluconate
D. Indomethacin relaxes uterine smooth muscle and is administered to stop preterm labor. It is
not an antidote to magnesium sulphate.
Answer: C. Calcium gluconate
Rationale:
Calcium gluconate should be kept available as the antidote for magnesium sulphate toxicity.
34. A nurse is teaching a client about breastfeeding. Which of the following client statements
indicates an understanding of the teaching?
A. A client who is breastfeeding requires an additional 500 calories per day to support
lactogenesis.
B. The client should not introduce an artificial nipple to the newborn until breastfeeding is well
established (in approximately 3 or 4 weeks).
C. "I may notice increased cramping when I am feeding my baby."
D. The client should breastfeed on demand, not place the newborn on a strict feeding schedule.
Forcing a newborn to wait for a feeding can lead to weight loss and failure to thrive.
Answer: C. "I may notice increased cramping when I am feeding my baby."
Rationale:
The client may notice an increase in uterine cramping while breastfeeding due to the release of
oxytocin, which causes uterine muscle contraction.
35. A nurse is discussing contraceptive choices with a client who has a history of
thrombophlebitis. Which of the following methods of contraception should the nurse
recommend?
A. Copper intrauterine device
B. A history of thrombophlebitis is a contraindication for taking oral contraceptives. Safer
methods of contraception for this client include barrier methods and spermicides.
C. A history of thrombophlebitis is a contraindication for a vaginal insert that releases hormones
continuously. Safer methods of contraception for this client include barrier methods and
spermicides.
D. A history of thrombophlebitis is a contraindication for injectable progestins. Safer methods of
contraception for this client include barrier methods and spermicides.
Answer: A. Copper intrauterine device
Rationale:
A history of thrombophlebitis is a contraindication for the use of hormonal contraceptive
methods such as oral combinations of estrogen and progesterone in pill form, vaginal inserts that
release hormones continuously, and injectable progestins. A copper intrauterine device that does
not contain hormones is a safer choice for this client. Other options for this client include barrier
methods and spermicides.
36. A nurse is teaching a client about a nonstress test. Which of the following statements by the
client indicates an understanding of the teaching?
A. There is no reason for the client to be NPO for this test. The client is encouraged to eat prior
to the test in order for the fetus to be more active. When the fetus is asleep, the nurse often offers
the client orange juice to stimulate the fetus.
B. The client does not need medication to induce contractions. Oxytocin is used to induce
contractions for an oxytocin challenge test.
C. "I should press the button on the handheld marker when my baby moves."
D. The client does not need to perform nipple stimulation to induce contractions; this is needed
for a contraction stress test.
Answer: C. "I should press the button on the handheld marker when my baby moves."
Rationale:
The purpose of the test is to assess fetal wellbeing. The client should press the button on the
handheld marker when she feels fetal movement.
37. A nurse is teaching a client who is pregnant about nonstress testing. Which of the following
pieces of information should the nurse include?
A. Nonstress testing is non-invasive and causes no risk to either the client or the fetus. It can be
used as a screening procedure in all pregnancies.
B. "If the test is positive, that means your baby's heart rate is healthy."
C. The test measures the response of the fetal heart rate to fetal movement. The fetal heart rate
should increase by about 15 beats/min when the fetus moves and should remain increased for
about 15 seconds.
D. The test would be identified as nonreactive if there is no fetal movement during the testing
period or if the fetal heart rate variability is under 6 beats/min.
Answer: B. "If the test is positive, that means your baby's heart rate is healthy."
Rationale:
The fetal heart rate is considered healthy if the results of nonstress testing are positive. If the test
is negative, fetal health may be affected, and further testing may be necessary to rule out poor
oxygen perfusion of the fetus.
38. A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy.
Which of the following psychological tasks should the nurse expect the client to accomplish
during this trimester?
A. Accepting the pregnancy
B. Preparing for the end of pregnancy is a psychological task that the client is expected to
accomplish during the third trimester.
C. Preparing for parenthood is a psychological task that the client is expected to accomplish
during the third trimester.
D. Accepting the baby is a psychological task that the client is expected to accomplish during the
second trimester.
Answer: A. Accepting the pregnancy
Rationale:
Accepting the pregnancy is a psychological task that the client is expected to accomplish during
the first trimester.
39. A nurse is assessing a client who has placenta previa. Which of the following findings should
the nurse expect?
A. Painless, bright red bleeding
B. Uterine hypertonicity is a manifestation of placental abruption, not placenta previa.
C. Uterine tonicity is normal with placenta previa; it does not cause contractions.
D. Abdominal tenderness or pain is a manifestation of placental abruption, not placenta previa.
Answer: A. Painless, bright red bleeding
Rationale:
Placenta previa is the placement of the placenta low in the uterus. Depending on the severity,
manifestations include bright red vaginal bleeding and a fundal height higher than expected for
the gestational age. The presenting part is higher due to the placenta taking up space inside the
lower part of the uterus.
40. A nurse is calculating a pregnant client's estimated date of delivery using Naegele's rule. The
client's last menstrual period started on January 20. Which of the following is the client's
expected date of delivery?
A. An expected date of delivery of October 13 would follow a last menstrual period date of
January 6.
B. An expected date of delivery of November 13 would follow a last menstrual period date of
February 6.
C. October 27
D. An expected date of delivery of November 27 would follow a last menstrual period date of
February 20.
Answer: C. October 27
Rationale:
Naegele's rule involves subtracting 3 months from the first day of the last menstrual period and
adding 7 days.
41. A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections
should be reported to the public health department?
A. Bacterial vaginosis, also known as vaginitis, is the most common vaginal infection.
Manifestations include client report of a "fishy odor" and vaginal discharge that appears thin,
watery, gray, white, or milky. The client might also report pruritus. This vaginal infection does
not require reporting; however, it should be treated with metronidazole or clindamycin cream.
B. Trichomoniasis can be asymptomatic. Manifestations include greenish to yellowish
mucopurulent, frothy, malodorous discharge. This vaginal infection does not require reporting.
C. Candidiasis, also known as a yeast infection, is the second-most common vaginal infection.
Manifestations include a client report of thick, cottage cheese like discharge and vaginal itching.
This vaginal infection does not require reporting.
D. Gonorrhoea
Answer: D. Gonorrhoea
Rationale:
Gonorrhoea is often asymptomatic. The client might have purulent endocervical discharge.
Gonorrhoea is one of the infectious conditions on the Nationally Notifiable Infections list and
should be reported by the nurse to the community health department, which will report the
infection to the CDC.
42. A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is
common during pregnancy. Which of the following responses should the nurse make?
A. This is a close-ended response that discourages further communication.
B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections
more common."
C. This is a close-ended response that discourages further communication and is both
nontherapeutic and inaccurate.
D. Asking "why" questions typically makes clients feel defensive.
Answer: B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast
infections more common."
Rationale:
This is an information-seeking question; therefore, the therapeutic response is an answer that
provides the client with the information she requested.
43. A nurse is planning care for a client in labor who is positive for HIV. Which of the following
actions should the nurse take after the baby is born?
A. In the United States and Canada, breastfeeding should be avoided by mothers who are HIVpositive.
B. Administer the hepatitis B vaccine prior to discharge
C. The nurse should use standard precautions when caring for a newborn who has been exposed
to HIV.
D. To test a newborn for the presence of HIV, a sample of the newborn's blood must be obtained.
Maternal antibodies will be present in the cord blood and can affect the test results.
Answer: B. Administer the hepatitis B vaccine prior to discharge
Rationale:
Infants who are exposed to HIV should receive all routine vaccinations. Infants who are infected
with HIV can receive all inactivated vaccinations.
44. A nurse is assessing a client who is at 36 weeks of gestation. Which of the following
manifestations should the nurse recognize as a potential prenatal complication and report to the
provider?
A. Varicose veins are a common manifestation associated with pregnancy. They are caused by
the relaxation of the smooth muscle walls of the veins and pelvic Vaso congestion.
B. Double vision
C. Leukorrhea is a hormonal production of an abundant amount of mucus. It is a common
manifestation associated with pregnancy.
D. Flatulence is a common manifestation associated with pregnancy. Progesterone causes
reduced gastrointestinal motility.
Answer: B. Double vision
Rationale:
Double vision, blurred vision, or visual disturbances are signs of potential complications
associated with preeclampsia. The nurse should report this finding to the provider.
45. A nurse is caring for a client who had a precipitous delivery. Which of the following
assessments is the priority during the fourth stage of labor?
A. The nurse should monitor the client's temperature during the fourth stage of labor; however,
another assessment is the priority.
B. The nurse should assess the client's perineum, especially if an episiotomy or laceration is
present; however, another assessment is the priority.
C. Palpating the client's fundus
D. The nurse should check the client for haemorrhoids during the fourth stage of labor; however,
another assessment is the priority.
Answer: C. Palpating the client's fundus
Rationale:
The nurse should apply the safety and risk-reduction priority-setting framework, which assigns
priority to the factor or situation posing the greatest safety risk to the client. When there are
several risks to client safety, the one posing the greatest threat is the highest priority.
The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or
nursing knowledge to identify which risk poses the greatest threat to the client. A precipitous
delivery follows a labor of 100/min; a score of 2 for a good, strong
cry, which shows normal respiratory effort; a score of 2 for well flexed extremities, which shows
normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a
score of 1 for blue hands and feet, which is known as acrocyanosis.
78. A nurse is caring for a client who is 3 days postpartum and has chosen to formula feed her
newborn. During an examination of the client's breasts, the nurse notes that they are warm and
firm. Which of the following actions should the nurse plan to take?
A. If the client pumps her breasts, milk production will increase. A client who is formula-feeding
her newborn needs to decrease milk production.
B. Taking warm showers will increase milk production.
C. Breast massage will not only be uncomfortable but also will increase milk production.
D. Instruct the client to apply cold compresses
Answer: D. Instruct the client to apply cold compresses
Rationale:
To help relieve breast engorgement, the client should apply cold compresses for about 15
minutes every hour. The client can also try applying fresh, cold cabbage leaves to the breasts.
79. A nurse is teaching a client during the client's first prenatal visit. Which of the following
instructions should the nurse include?
A. The nurse should be able to hear fetal heart tones with a fetoscope by the end of the sixteenth
week of gestation.
B. Typically, the sex of the fetus is distinguishable on a sonogram by the end of the twelfth week.
C. "A Doppler device can detect your baby's heart rate at 12 weeks."
D. Quickening (feeling fetal movement) is typically possible at 14 to 16 weeks in multiparous
clients; however, it is sometimes not possible until week 18 or later in nulliparous clients.
Answer: C. "A Doppler device can detect your baby's heart rate at 12 weeks."
Rationale:
The nurse should be able to detect the fetal heartbeat with a Doppler device toward the end of the
first trimester, often as early as 10 weeks of gestation.
80. A nurse is caring for a client who believes she may be pregnant. Which of the following
findings should the nurse identify as a positive sign of pregnancy?
A. Palpable fetal movement
B. Chadwick's sign is a bluish discoloration of the cervix, vagina, and vulva that occurs at 6 to 8
weeks of pregnancy. This is a probable sign of pregnancy. After the client's first pregnancy, this
discoloration can remain, reducing its value as an indicator in subsequent pregnancies.
C. A positive pregnancy test is a probable sign of pregnancy. A client can also have a positive
pregnancy test due to menopause, choriocarcinoma, and hydatidiform mole.
D. Amenorrhea, or lack of a menstrual period, is a presumptive sign of pregnancy. A client also
can have amenorrhea due to stress, endocrine disorders, and significant weight loss.
Answer: A. Palpable fetal movement
Rationale:
Palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal
movement, is a presumptive sign of pregnancy.
81. A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which
of the following medications should the nurse plan to administer?
A. Betamethasone
B. The nurse should administer misoprostol to stimulate uterine contractions for a client who is
undergoing labor induction.
C. The nurse should administer methylergonovine to stimulate uterine contractions for a client
who is experiencing postpartum haemorrhage.
D. The nurse should administer poractant alfa, a synthetic lung surfactant, to a preterm newborn
who is experiencing respiratory distress.
Answer: A. Betamethasone
Rationale:
The nurse should plan to administer betamethasone IM, a glucocorticoid, to stimulate fetal lung
maturity and prevent respiratory depression.
82. A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed
her newborn. Which of the following instructions should the nurse include in the teaching?
A. Warm water running over the breasts can stimulate milk production.
B. "Place ice packs on your breasts."
C. The client should wear a well-fitting, supportive bra to provide comfort as the breasts fill with
milk.
D. The client should drink 2 to 3 L of fluid per day to promote normal bowel function.
Answer: B. "Place ice packs on your breasts."
Rationale:
The nurse should instruct the client to place ice packs on her breasts using a "15 minutes on and
45 minutes off" schedule to decrease swelling of the breast tissue as the body produces milk.
83. A nurse is assessing a postpartum client who reports strong contractions whenever she
breastfeeds her newborn. The nurse should respond with which of the following statements?
A. "These contractions are concerning; we should monitor you for any complications."
B. "This is unusual; let me check your uterus for any abnormalities."
C. "You may be experiencing these contractions due to stress; try to relax while feeding."
D. "The same hormone that is released in response to the baby's sucking and causes milk to flow
also makes the uterus contract."
Answer: D. "The same hormone that is released in response to the baby's sucking and causes
milk to flow also makes the uterus contract."
Rationale:
Oxytocin is released in response to breastfeeding. This hormone also causes the uterus to
contract, which decreases the risk for postpartum haemorrhage and increases involution.
84. A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which
of the following actions should the nurse take to promote development?
A. The nurse should assess the newborn to determine how well she will tolerate feedings and
gradually make changes. Rapidly advancing feedings can lead to fluid retention, hyponatremia,
vomiting, diarrhoea, and apnea.
B. Position the naked newborn on the parent's bare chest
C. Newborns need uninterrupted periods of sleep to promote self-regulation. Light and sounds
are adverse stimuli and can increase stress in a newborn who is premature.
D. Nonnutritive sucking can decrease oxygen use and energy, which can lead to decreased
restlessness.
Answer: B. Position the naked newborn on the parent's bare chest
Rationale:
Positioning the naked newborn on the parent's bare chest can decrease stress in the parent and the
newborn. This action can help maintain thermal stability, raise oxygen saturation, increase
feeding strength, and promote breastfeeding.
85. A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding.
Which of the following assessments will indicate whether the bleeding is caused by placenta
previa or an abruptio placenta?
A. Uterine tone
B. Fetal distress may be present in both abruptio placenta and placenta previa.
C. Hypotension may be present in both conditions.
D. The amount of blood loss is not diagnostic of the cause of the bleeding.
Answer: A. Uterine tone
Rationale:
The uterus will be relaxed, soft, and painless if the bleeding is caused by placenta previa. With
abruptio placenta, the uterus will be firm and board-like, and the client will complain of pain.
86. A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor.
Which of the following actions should the nurse take?
A. Promote active movement in and out of bed
B. Having the client hold her breath while pushing increases intrathoracic and cardiovascular
pressure and decreases the amount of oxygen that reaches the fetus.
C. The nurse should assess the client's vital signs every 5 to 30 minutes while the client is in the
second stage of labor.
D. The client should remain on bedrest during this stage of labor due to impending delivery.
Answer: A. Promote active movement in and out of bed
Rationale:
During the early stages of labor, the nurse should encourage activity through walking, kneeling,
squatting, being on hands and knees, or whatever the client prefers. This can help shorten the
earlier stage. During the second stage, the client should remain in bed if her membranes have
ruptured or if she has received analgesics. In bed, she should lie on her left side often but shift
positions frequently for comfort and to promote the progression of labor.
87. A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors
places the client at risk of uterine atony? (Select all that apply.)
A. Magnesium sulphate infusion
B. Distended bladder
C. High parity (having had multiple previous pregnancies)
D. Prolonged labor
Answer: A. Magnesium sulphate infusion
B. Distended bladder
D. Prolonged labor
Rationale:
Magnesium sulphate is a smooth muscle relaxant and can prevent adequate contraction of the
uterus. After birth, clients can experience a decreased urge to void due to birth-induced trauma,
increased bladder capacity, and anaesthetics, which can result in a distended bladder. A distended
bladder displaces the uterus and can prevent adequate contraction of the uterus. Also, prolonged
labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus
from contracting.
88. A nurse is providing teaching to the parents of a newborn about how to care for his
circumcision at home. Which of the following instructions should the nurse include in the
teaching?
A. "Clean the area gently with warm water during diaper changes, but avoid using soap for the
first week."
B. "Apply petroleum jelly to the area to prevent the diaper from sticking to the circumcision
site."
C. "Watch for signs of infection, such as increased redness, swelling, or discharge."
D. Encourage non-nutritive sucking for pain relief
Answer: D. Encourage non-nutritive sucking for pain relief
Rationale:
Allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain
management.
89. A nurse is counseling a female client who expresses a desire to conceive in the near future.
Which of the following dietary recommendations should the nurse make to prevent neural tube
defects?
A. "Increase your intake of dairy products to ensure adequate calcium levels."
B. "Consume more vitamin C-rich foods to enhance iron absorption."
C. "Incorporate whole grains and legumes into your diet for added fibre."
D. Begin taking a folic acid supplement
Answer: D. Begin taking a folic acid supplement
Rationale:
Adequate amounts of folic acid are necessary for fetal neural tube development. All women of
child-bearing age and intention should take a folic acid supplement of 0.4 mg.
90. A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the
following pieces of information should the nurse include in the teaching?
A. "You should limit breastfeeding to every 4 hours to ensure your breasts are full."
B. "It's normal for your baby to lose some weight in the first few days after birth."
C. "Your milk supply will noticeably increase in volume around the third or fourth day after
delivery."
D. "Breastfeeding can help your uterus contract and reduce postpartum bleeding."
Answer: C. "Your milk supply will noticeably increase in volume around the third or fourth day
after delivery."
Rationale:
As the colostrum transitions to mature breast milk, the volume of milk produced will also
increase. Typically, the postpartum client will notice that 72 to 96 hours after delivery her breasts
feel fuller and firmer and that milk is leaking from her nipples.
91. A nurse is providing teaching for new parents about formula feeding. Which of the following
instructions should the nurse include?
A. "You can heat the formula in the microwave to save time."
B. Discard opened cans of formula after 48 hr refrigeration.
C. "You should mix different types of formula together to ensure balanced nutrition."
D. "Once prepared, formula should be used within 1 hour if kept at room temperature."
Answer: B. Discard opened cans of formula after 48 hr refrigeration.
Rationale:
Opened cans and prepared bottles of formula must be refrigerated and discarded after 48 hours
due to the risk of bacterial contamination.
92. A nurse is performing an admission assessment of a client who just arrived at the labor and
delivery unit. Which of the following findings should the nurse identify as the priority?
A. Maternal blood pressure is 100/60 mm Hg.
B. The client is 3 cm dilated and having contractions every 5 minutes.
C. The client reports mild discomfort with contractions.
D. The fetal heart rate is 90/min.
Answer: D. The fetal heart rate is 90/min.
Rationale:
Fetal bradycardia indicates that this client is at greatest risk for fetal consequences due to a
cardiac disorder or infection, leading to hypoxia and asphyxiation; therefore, this is the priority
finding.
93. A nurse is preparing a client who is in labor for the insertion of an intrauterine pressure
catheter. The client asks why this type of monitoring is needed. Which of the following responses
should the nurse make?
A. Although the intrauterine pressure catheter will show the frequency of contractions, the
external Toc transducer is also an adequate and non-invasive method of timing contractions.
B. Intrauterine pressure catheters are invasive monitoring equipment and used only when
deemed necessary for high-risk labor.
C. An intrauterine pressure catheter monitors the frequency, intensity, and duration of
contractions. The ultrasound transducer and spiral electrode will monitor fetal heart tones.
D. "This type of monitoring will allow us to measure the intensity of your contractions."
Answer: D. "This type of monitoring will allow us to measure the intensity of your
contractions."
Rationale:
A Toc transducer can monitor the frequency and duration of contractions, but only an intrauterine
pressure catheter can monitor the intensity of contractions.
94. A nurse is discussing contraceptive choices with a client who has a history of
thrombophlebitis. Which of the following methods of contraception should the nurse
recommend?
A. Copper intrauterine device
B. Combined hormonal contraceptives (such as the pill, patch, or ring).
C. Hormonal intrauterine device (IUD).
D. Injectable contraceptives (such as Depo-Provera).
Answer: A. Copper intrauterine device
Rationale:
A history of thrombophlebitis is a contraindication for the use of hormonal contraceptive
methods such as oral combinations of estrogen and progesterone in pill form, vaginal inserts that
release hormones continuously, and injectable progestins.
A copper intrauterine device that does not contain hormones is a safer choice for this client.
Other options for this client include barrier methods and spermicides.
