2023 ATI Maternal Newborn Proctored Exam With Answers-301 Solved Questions

ATI PROCTORED EXAM - MATERNAL NEWBORN GRADED A -ALL
ANSWERS CORRECT-301 QUESTIONS AND ANSWERS
1. A nurse is caring for a client who has oligohydraminios. What fetal anomalies should the nurse
expect?
A. renal agenesis
B. atrial septal defect
C. spina bifida
D. hydrocephalus
Answer: A. renal agenesis
2. A nurse is assessing a client who is at 37 wks gestation and has a suspected pelvic fracture due
to blunt abd trauma. What findings should the nurse expect?
A. uterine contractions
B. bradycardia
C. seizures
D. bradypnea
Answer: A. uterine contractions
Explanation:
The nurse should expect the client to be experiencing uterine contractions due to abdominal
trauma.
3. A nurse is assessing a client who is at 12 wks gestation and has hydatidiform mole. What
findings should the nurse expect?
A. hypothermia
B. dark brown vaginal discharge
C. fetal heart tones
D. decreased urinary output
Answer: B. dark brown vaginal discharge
Explanation:

A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the chorionic
villi, which gives rise to multiple cysts. The products of conception transform into a large
number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge
is usually dark brown and can contain grapelike clusters.
4. A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational HTN.
What finding should the nurse identify as the priority?
A. 480 mL urine output in 24 hrs
B. 1+ protein in the urine
C. +2 edema of the feet
D. BP 144/92
Answer: A. 480 mL urine output in 24 hrs
Explanation:
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the
priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine output
in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with
severe features, which requires immediate intervention. Therefore, this is the priority finding.
5. A nurse is teaching a client who is at 12 wks gestation and has HIV. What statement should the
nurse include in the teaching?
A. you will be in isolation after delivery
B. abstain from sexual intercourse throughout pregnancy
C. breastfeed your newborn to provide passive immunity
D. you should continue to take zidovudine throughout the pregnancy
Answer: D. you should continue to take zidovudine throughout the pregnancy
Explanation:
• can be transmitted through breastfeeding
• she can continue to have sex
The nurse should inform the client that taking prescription antiviral medication every day
decreases the risk of transmission of HIV to her newborn.

6. A nurse is providing teaching to a client who is at 8 wks gestation about manifestations to
report to the provider during pregnancy. What info should the nurse include in the teaching?
A. nausea upon awakening
B. blurred or double vision
C. increase in white vaginal discharge
D. leg cramps when sleeping
Answer: B. blurred or double vision
7. A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via
continuous IV infusion. The nurse notes that the client is having contractions every 2 min which
last 100-110 seconds that the fetal heart rate is reassuring. What action should the nurse take?
A. decrease the dose of oxytocin by half
B. administer oxygen via nonrebreather mask
C. decrease the infusion rate of the maintenance IV fluid
D. administer terbutaline 0.25mg subq
Answer: A. decrease the dose of oxytocin by half
Explanation:
The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine
tachysystole.
8. A nurse is caring for a client who is in active labor and has meconium staining of the amniotic
fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. What action
should the nurse take?
A. prepare the client for emergency c-section
B. perform endotrach suctioning as soon as the fetal head is delivered
C. prepare equipment needed for newborn resuscitation
D. prepare the client for an ultrasound exam
Answer: C. prepare equipment needed for newborn resuscitation
Explanation:
The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn
are readily available for every delivery. Endotracheal suctioning is recommended in cases of

meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and
bradycardia after delivery.
9. A nurse is reviewing the medical record of a client who is at 33 wks gestation and has placenta
previa and bleeding. What scripts should the nurse clarify with the provider?
A. insert a large-bore IV catheter
B. perform a vaginal exam
C. perform continuous external fetal monitoring
D. obtain a blood sample for lab testing
Answer: B. perform a vaginal exam
When a client has a placenta previa, the placenta implants in the lower part of the uterus and
obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription
because any manipulation can cause tearing of the placenta and increased bleeding.
10. A nurse is caring for a client who is at 37 wks gestation and is undergoing a nonstress test.
The FHR is 130 without accelerations for the past 10 min. What action should the nurse take?
A. request a script for an internal fetal scalp electrode
B. auscultate the FHR with a doppler transducer
C. report the nonreactive test result to the provider immediately
D. use vibroacoustic stim on the client's abd for 3 seconds
Answer: D. use vibroacoustic stim on the client's abd for 3 seconds
The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity
because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR.
11. A nurse is reviewing lab results for a client who is at 37 wks gestation. The nurse notes that
the client is rubella non-immune, positive for group A beta-hemolytic strep, and has a blood type
O neg. What action should the nurse take?
A. instruct the client to obtain a rubella immunization after delivery
B. request a script for an antibiotic until delivery
C. inform the client that she will have to deliver via c-section
D. administer a dose of Pho(D) immune globulin

Answer: A. instruct the client to obtain a rubella immunization after delivery
12. A nurse is reviewing the med record of a client who is at 39 wks gestation and has
polyhydramnios. What finding should the nurse expect?
A. total pregnancy wt gain of 3.6 kg
B. fetal GI anomaly
C. gestational HTN
D. fundal height of 34 cm
Answer: B. fetal GI anomaly
Explanation:
Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus.
Gastrointestinal malformations and neurologic disorders are expected findings for a fetus
experiencing the effects of polyhydramnios.
13. A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via
continuous IV infusion about expected adverse effects. What adverse effects should the nurse
include in the teaching?
A. elevated BP
B. feeling of warmth
C. generalized pruritis
D. hyperactivity
Answer: B. feeling of warmth
Explanation:
The nurse should tell the client to expect the feeling of warmth all over her body while the
magnesium sulfate is infusing.
14. A nurse is caring for a client who is in the latent phase of labor and is experiencing low back
pain. What action should the nurse take?
A. position the client supine with legs elevated
B. instruct the client to pant during contractions
C. encourage the client to soak in a warm bath

D. apply pressure to the client's sacral area during contractions
Answer: D. apply pressure to the client's sacral area during contractions
15. A nurse is teaching a client who is at 12 wks gestation about manifestations of potential
complications that she should report to her provider. What info should the nurse include in the
teaching?
A. intermittent nausea
B. white vaginal discharge
C. swelling of the face
D. urinary frequency
Answer: C. swelling of the face
16. A nurse is teaching a client who is at 10 wks gestation about an abd. ultrasound in the first
trimester. What info should the nurse include in the teaching?
A. you will need to have a full bladder during the ultrasound
B. you will have a non stress test prior to the ultrasound
C. the ultrasound will determine the length of your cervix
D. you will experience uterine cramping during the ultrasound
Answer: A. you will need to have a full bladder during the ultrasound
Explanation:
The nurse should tell the client that a full bladder helps to lift the gravid uterus out of the pelvis
during the examination. Therefore, it is important to ensure that the client has a full bladder to
obtain the most accurate image of the fetus.
17. A nurse is assessing a client who is 34 wks gestation and has mild placental abruption. What
finding should the nurse expect?
A. decreased urinary output
B. fetal distress
C. dark red vaginal bleeding
D. increased platelet count
Answer: C. dark red vaginal bleeding

Explanation:
The nurse should expect the client who has a mild placental abruption to have minimal dark red
vaginal bleeding.
18. A nurse is caring for a client whose last menstrual period began july 8. Using Nageles rule,
the nurse should identify the client's estimated DOB as what?
A. oct 15
B. april 15
C. oct 1
D. april 1
Answer: B. april 15
19. A nurse is caring for a client who is at 39 wks gestation and is in the active phase of labor.
The nurse observes late decels in the FHR. What finding should the nurse identify as the cause of
late decels?
A. umbilical cord compression
B. fetal head compression
C. uteroplacental insufficiency
D. fetal ventricular septal defect
Answer: C. uteroplacental insufficiency
20. A nurse is assessing a client who is at 35 wks gestation and is receiving magnesium sulfate
via continuous IV infusion for severe pre-eclampsia. What finding should the nurse report to the
provider?
A. DTR 2+
B. resp 16
C. BP 150/96
D. urinary output 20 mL/hr
Answer: D. urinary output 20 mL/hr
Explanation:

The nurse should report a urinary output of 20 mL/hr because this can indicate inadequate renal
perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also
indicate a decrease in renal perfusion secondary to a worsening of the client's pre-eclampsia.
21. A nurse is teaching a client who is at 13 wks gestation about the treatment of incompetent
cervix with cervical cerclage. What statement by the client indicates an understanding of
teaching?
A. I should go to the hospital if I think I may be in labor
B. I should expect bright red bleeding while the cerclage is in place
C. I am sad that I won't be able to get pregnant again
D. I can resume having sex as soon as I feel up to it
Answer: A. I should go to the hospital if I think I may be in labor
Explanation:
Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should
immediately go to a facility for evaluation if she experiences any manifestations of labor while
the cerclage is in place. If the client experiences preterm uterine contractions she might require
tocolytic therapy.
22. A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal
bleeding. What action should the nurse take?
A. obtain blood samples for baseline lab values
B. place a spiral electrode on the fetal presenting part
C. prepare the client for a transvaginal ultrasound
D. perform a vaginal exam to determine cervical dilation
Answer: A. obtain blood samples for baseline lab values
Explanation:
The nurse should obtain samples of the client's blood for baseline testing of hemoglobin and
hematocrit levels.
23. A nurse is caring for a client who is at 38 wks of gestation and reports no fetal movement for
24 hr. What action should the nurse take?

A. auscultate for a FHR
B. reassure the client that a term fetus is less active
C. have the client drink orange juice
D. palpate the uterus for fetal movement
Answer: A. auscultate for a FHR
Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should
auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the
priority nursing action.
24. A nurse is caring for a client who is at 35 wks gestation and has severe preeclampsia. What
assessment provides the most accurate info regarding the client's fluid and electrolyte status.
A. daily wt
B. bp
C. severity of edema
D. I&O
Answer: A. daily wt
25. A nurse is teaching a client who is at 30 wks gestation about warning signs of complications
that she should report to her provider. What finding should the nurse include in the teaching?
A. 10 fetal movements per hour
B. mild constipation
C. vaginal bleeding
D. nasal congestion
Answer: C. vaginal bleeding
Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a
complication such as placental abruption, placenta previa, or preterm labor.
26. A nurse is teaching a client who is at 8 wks gestation and has a uterine fibroid about potential
effects of the fibroid during pregnancy. What info should the nurse include?
A. you will have to undergo a c-section birth because of the fibroid
B. the fibroid can increase the risk for postpartum hemorrhage

C. the fibroid will shrink during pregnancy
D. you will receive an injection of medroxyprogesterone acetate to shrink the fibroid
Answer: B. the fibroid can increase the risk for postpartum hemorrhage
27. A nurse is caring for a client who is at 26 wks gestation and reports constipation.What
responses by the nurse is appropriate?
A. you should drink 1 ounce of mineral oil q morning
B. you should eat at least 3 ounces of red meat/day
C. you should walk for at least 30 minutes q day
D. you should stop taking your prenatal
Answer: C. you should walk for at least 30 minutes q day
The nurse should encourage the client to participate in moderate physical activity, such as
walking or swimming, every day. This activity increases intestinal peristalsis, which will help
alleviate constipation.
28. A nurse is planning care for a newborn who is receiving phototherapy for an elevated
bilirubin level. What action should the nurse take?
A. apply barrier ointment to the newborn's perianal region
B. offer the newborn glucose water between feedings
C. use photometer to monitor the lamp's energy
D. keep the newborn's eye patches on during feedings
Answer: C. use photometer to monitor the lamp's energy
The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is
receiving the appropriate amount to be effective.
29. A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are
cool and slightly blue What action should the nurse take?
A. check the newborns temp using temporal thermometer
B. place the naked newborn on the mothers bare chest and cover both with a blanket
C. apply an o2 hood over the newborns head and neck
D. give the newborn glucose water between feedings

Answer: B. place the naked newborn on the mothers bare chest and cover both with a blanket
Explanation:
Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a
bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his
temperature and promotes bonding.
30. A nurse is caring for a newborn immediately following delivery. What actions should the
nurse take first?
A. place the newborn directly on the client's chest
B. administer erythromycin ophthalmic ointment
C. give the newborn vit K IM
D. perform a detailed physical assessment
Answer: A. place the newborn directly on the client's chest
Explanation:
The greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose.
Placing the newborn directly on the client's chest will help maintain the newborn's temperature.
31. A nurse is providing teaching to the parents of a newborn about home safety. What statement
by the parents indicates an understanding of the teaching?
A. I will use an infant carrier when I drive to places close to the house
B. I will tie my baby's pacifier around his neck with a piece of yarn
C. I will place my baby on his back when it is time for him to sleep
D. I will keep my babys crib close to heat vents to keep him warm
Answer: C. I will place my baby on his back when it is time for him to sleep
32. A nurse is assessing a newborn 1 min after birth andnotes a hr of 136/min, resp 36, well
flexed extremities, responding to stimuli with a cry, blue hands and feet. What Apgar score
should the nurse assign to the newborn?
A. 10
B. 9
C. 8

D. 7
Answer: B. 9
33. A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration.
The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The
client reports a gush of blood when she ambulates and no bm since delivery. What action should
the nurse take?
A. notify the provider about the elevated temp
B. massage the client's fundus
C. administer bisacodyl supp
D. assist the client to empty her bladder
Answer: D. assist the client to empty her bladder
Explanation:
When the client's fundus is deviated to the right or left it can indicate that her bladder is full. The
nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia.
34. A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who
weighs 2.5kg. The amount available is 0.4 mg/ml. how many ml should the nurse administer?
Answer: 0.25
35. A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
Answer: "You should press the handheld button when you feel your baby move."
36. A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow respirations
and periods of apnea lasting up to 10 seconds. What action should the nurse take?
A. continue routine monitoring
B. place newborn prone
C. request a script for supplemental o2
D. perform chest percussion
Answer: A. continue routine monitoring

Explanation:
The nurse should continue routine monitoring because the newborn's assessments findings
indicate he is adapting to extrauterine life. placing in sidelying or supine
37. A nurse is caring for a client who reports intestinal gas pain following a c-section. What
action should the nurse take?
A. encourage client to drink carbonated beverages
B. instruct the client to splint the incision with a pillow
C. have the client drink fluids through a straw
D. assist the client to ambulate in the hallway
Answer: D. assist the client to ambulate in the hallway
Explanation:
Walking can help stimulate peristalsis, which will promote expulsion of gas.
38. A nurse is caring for a newborn who is premature at 30 wks gestation. What finding should
the nurse expect?
A. heel creases covering the bottom of the feet
B. good flexion
C. abundant lanugo
D. dry, parchment-like skin
Answer: C. abundant lanugo
Explanation:
Newborns who are premature have abundant lanugo, fine hair, especially over their back. A fullterm newborn typically has minimal lanugo present only on the shoulders, pinnas, and forehead.
39. A nurse is assessing a newborn 1 hr after birth. What assessment findings should the nurse
report to the provider?
A. acrocyanosis
B. jaundice of the sclera
C. resp rate 50
D. cbg 60

Answer: B. jaundice of the sclera
Explanation:
If the newborn has jaundice within the first 24 hr of life, this can indicate a potential pathological
process such as hemolytic disease. Pathologic jaundice can result in high levels of bilirubin that
can cause damage to the neonatal brain.
40. A nurse is providing teaching to the parents of a newborn about bottle feeding. What
instructions should the nurse include?
A. discard unused refrigerated formula after 72 hrs
B. prop the bottle with a blanket for the last feeding of the day
C. dilute ready-to-feed formula if the newborn is gaining wt too quickly
D. boil water for powdered formula for 1-2 min
Answer: D. boil water for powdered formula for 1-2 min
Explanation:
The parents should run tap water for 2 min and then boil it for 1 to 2 min before mixing it with
the formula to decrease the risk of contamination.
41. A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following
a vaginal birth. What assessment findings should the nurse monitor to evaluate the effectiveness
of the med?
A. pulse rate
B. bp
C. fundal consistency
D. output
Answer: C. fundal consistency
Explanation:
Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should
palpate the uterine fundus to determine consistency or tone to determine if the medication is
effective.

42. A nurse is caring for a newborn who is premature in the neonatal ICU. what action should the
nurse take to promote development?
A. discourage the use of pacifiers
B. position the naked newborn on the parents bare chest
C. provide frequent periods of visual and auditory stimulation
D. rapidly advance oral feedings
Answer: B. position the naked newborn on the parents bare chest
43. A nurse is caring for a postpartum client 8hrs after delivery. What factors place the client at
risk for uterine atony? select all
A. oxytocin infusion
B. prolonged labor
C. mag sulfate infusion
D. small for gestational age newborn
E. distended bladder
Answer: B. prolonged labor
Explanation:
B. Prolonged labor can stretch out the musculature of the uterus and cause fatigue, which
prevents the uterus from contracting.
C. mag sulfate infusion
Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the
uterus.
E. distended bladder
After birth, clients can experience a decreased urge to void due to birth-induced trauma,
increased bladder capacity, and anesthetics, which can result in a distended bladder. The
distended bladder displaces the uterus and can prevent adequate contraction of the uterus.
44. A nurse is assessing a newborn for congenital hip dysplasia. What finding should the nurse
expect?
A. temp of one leg differing from that of the other
B. symmetrical gluteal folds

C. limited abduction of one hip
D. legs that are shorter than the arms
Answer: C. limited abduction of one hip
A newborn who has congenital hip dysplasia can have limited abduction because the head of the
femur might have slipped out of the acetabulum. asymmetrical gluteal folds
45. A nurse is testing the reflexes of a newborn to assess neurologic maturity. What reflexes is
the nurse assessing when she quickly and gently turns the newborn's head to one side?
A. moro
B. babinski
C. rooting
D. tonic neck
Answer: D. tonic neck
To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one
side when he is sleeping or falling asleep. The newborn's arm and leg should extend outward to
the same side that the nurse turned his head while the opposite arm and leg flex. This reflex
persists for about 3 to 4 months.
46. A nurse is assessing a newborn who was born at 39 wks gestation. What finding should the
nurse expect?
A. symmetric rib cage
B. lanugo abundant on the back
C. dry, wrinkled skin
D. vernix over the entire body
Answer: A. symmetric rib cage
A newborn who is born at 39 weeks of gestation is full-term and should have normal, smooth
skin with good turgor and the presence of subcutaneous fat pockets. A postmature newborn,
greater than 42 weeks of gestation, will have dry, cracked skin with a wrinkled appearance.

47. A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish
discoloration that does not cross the suture line. What pieces of info should the nurse provide to
the mother when she inquires about the finding?
A. this will resolve within 3-6 wks without treatment
B. this will resolve on its own within 3-4 days
C. this is expected at birth so you don't need to worry about it
D. the provider might drain this area with a syringe
Answer: A. this will resolve within 3-6 wks without treatment
48. A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For what
finding should the nurse monitor to identify a cervical laceration?
A. a gush of rubra lochia when the nurse massages the uterus
B. continuous lochia flow and flaccid uterus
C. slow trickle of bright vaginal bleeding and a firm fundus
D. report of increasing pain and pressure in the perineal area
Answer: C. slow trickle of bright vaginal bleeding and a firm fundus
Explanation:
The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding,
and a firm fundus to identify a cervical laceration.
49. A nurse is planning care for a client who is postpartum and has cardiac disease. For what
script should the nurse seek clarification?
A. initiate bedrest with HOB elevated
B. initiate high-fiber diet for client
C. monitor clients wt wkly
D. monitor client's I&O
Answer: C. monitor clients wt wkly
Explanation:
The nurse should weigh the client daily to monitor for fluid overload.

50. A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed
her newborn. What instructions should the nurse include in the teaching?
A. stand under hot shower with your breasts exposed
B. place ice packs on your breasts
C. limit fluid intake to 1 L per day
D. wear a loose-fitting, comfortable bra
Answer: B. place ice packs on your breasts
Explanation:
The nurse should instruct the client to place ice packs on her breasts using a 15 min on and 45
min off schedule, to decrease swelling of the breast tissue as the body produces milk.
51. A nurse is caring for a newborn directly after birth. What medications should the nurse
administer to the newborn within 1-2 hr of delivery?
A. poractant alpha
B. rotavirus immunization
C. naloxone
D. erythromycin ophthalmic ointment
Answer: D. erythromycin ophthalmic ointment
Explanation:
Every newborn born in the United States should receive erythromycin ophthalmic ointment to
prevent gonorrheal or chlamydial infections that the newborn can contract during birth.
52. A nurse is caring for a newborn who weighs 4lb. How many kg does the newborn weigh?
Answer: 1.8
53. A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The
client becomes frightened when she has a gush of dark red blood from her vagina. What
following statements should the nurse make?
A. blood pools in the vagina when you are lying a bed
B. the amount of blood flow will increase during the first few days after giving birth
C. you might have retained placental fragments in your uterus

D. you might have a damaged blood vessel
Answer: A. blood pools in the vagina when you are lying a bed
Explanation:
In the early postpartum period, lochia will pool in the vagina when the client is lying in bed and
will flow out of the vagina when the client stands up. After the initial gush, the bleeding will
slow down to a trickle of bright red lochia.
54. A nurse is providing teaching to a client who is planning to breastfeed her newborn. What
statement by the client indicates an understanding of the teaching?
A. I must drink milk every day in order to assure good quality breast milk
B. drinking lots of fluids will increase my breast milk production
C. it is normal for my baby to sometimes feed every hr for several hours in a row
D. after the first few weeks, my nipples will toughen up and breastfeeding won’t hurt anymore
Answer: C. it is normal for my baby to sometimes feed every hr for several hours in a row
Explanation:
Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should
follow her newborn's cues and feed her 8 to 12 times per day.
55. A nurse is caring for a client who is receiving mag sulphate by continuous IV. What meds
should the nurse have available at bedside?
A. naloxone
B. protamine sulphate
C. calcium gluconate
D. atropine
Answer: C. calcium gluconate
Explanation:
The nurse should have calcium gluconate available to give to 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 less than or equal to 12/min, muscle
weakness, and depressed deep-tendon reflexes.

56. A nurse is caring for a client who has a soft uterus and increased lochia. What meds should
the nurse plan to administer to promote uterine contractions?
A. mag sulphate
B. methylergonovine
C. terbutaline
D. nifedipine
Answer: B. methylergonovine
Explanation:
The nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine
contractions.
57. A nurse is administering a rubella immunization to a client who is 2 days postpartum. What
statement indicates to the nurse the client needs further instruction?
A. I cannot receive rubella immunization during pregnancy
B. I can conceive anytime I want after 10 days
C. I can continue to breastfeed
D. I will still need to have my provider perform a rubella titer with my next pregnancy
Answer: B. I can conceive anytime i want after 10 days
Explanation:
A client who receives a rubella immunization should not conceive for at least 1 month after
receiving the rubella immunization to prevent injury to the fetus.
58. A nurse is providing teaching to the parents of a newborn about how to care for his
circumcision at home. What instructions should the nurse include in the teaching?
A. use prepackaged commercial wipes to clean the circumcision site
B. encourage nonnutritive sucking for pain relief
C. remove the yellow exudate with each diaper change
D. apply the diaper tightly over the circumcision area
Answer: B. encourage nonnutritive sucking for pain relief
Explanation:

Allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain
management
59. A nurse is assessing a client on the first postpartum day. Findings include 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. Report the vital signs to the provider.
B. Massage the fundus.
C. Ask the client when she last voided.
D. Administer an oxytocic agent.
Answer: C. Ask the client when she last voided
Explanation:
Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is
easily displaced when the bladder is full. The fundus should be found firm at midline. A
deviated, firm fundus indicates a full bladder. The nurse should assist the client to void.
60. A nurse is preparing to administer naloxone to a newborn. Which of the following conditions
can require administration of this medication?
A. IV narcotics administered to the mother during labor
B. Maternal drug use
C. Hyaline membrane disease
D. Meconium aspiration
Answer: A. IV narcotics administered to the mother during labor
Explanation:
The nurse should administer naloxone to reverse respiratory depression due to acute narcotic
toxicity, which can result from IV narcotics administration during labor.
61. A nurse is discussing epidural anesthesia with a client who is receiving oxytocin for induction
of labor. Which of the following statements should the nurse make?
A. "An epidural given too early during labor can cause maternal hypertension."

B. "An epidural given too early during labor will not be effective in active labor."
C. "An epidural given too early can cause fetal depression."
D. "An epidural given too early can prolong labor."
Answer: D. An epidural given too early can prolong labor
Explanation:
Clients who receive anesthesia before the active phase of labor usually find the progression of
their labor to slow. The medication depresses the central nervous system. Therefore, it will take
longer for the cervix to dilate and efface.
62. A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the
following instructions should the nurse provide the client?
A. "You should eat some crackers before rising from bed in the morning."
B. "You should eat foods served at warm temperatures."
C. "You should sip whole milk with breakfast."
D. "You should brush your teeth immediately after meals."
Answer: A. You should eat some crackers before rising from bed in the morning
Explanation:
Morning sickness is caused by the buildup of human chorionic gonadotropin (hCG) in the
mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea
in clients who are pregnant.
63. A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the
following situations should the nurse administer Rh(D) Immune Globulin?
A. While the client is in labor
B. Following an episode of influenza during pregnancy
C. Prior to a blood transfusion
D. At 28 weeks of gestation
Answer: D. At 28 weeks of gestion
Explanation:
The nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rhnegative blood at 28 weeks of gestation. Rh(D) Immune Globulin consists of passive antibodies

against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block
maternal antibody production.
64. A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm
labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the
magnesium sulfate therapy?
A. Respiratory depression
B. Hypothermia
C. Hypoglycemia
D. Jaundice
Answer: A. Respiratory depression
Explanation:
Magnesium sulfate can cause respiratory and neuromuscular depression in the newborn. The
nurse should monitor the newborn for clinical manifestations of respiratory depression.
65. A nurse is caring for a newborn who was born to a client who has a narcotic use disorder.
Which of the following nursing actions should the nurse identify as a contraindication for the
care of the newborn?
A. Promoting maternal-newborn bonding
B. Tight swaddling of the newborn
C. Small frequent feedings
D. Frequent stimulation
Answer: D. Frequent stimulation
Explanation:
This newborn needs a quiet, calm environment with minimal stimulation to promote rest and
reduce stress. A stimulating environment can trigger irritability and hyperactive behaviors.
66. A nurse is caring for a client who is in labor. A vaginal examination reveals the following
information: 2cm, 50%, +1, right occiput anterior. Based on this information, which of the
following position should the nurse document in the medical record?
A. Transverse

B. Breech
C. Vertex
D. Mentum
Answer: D. Vertex
Explanation:
ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this
case, the occipital bone is the presenting part and is located anteriorly in the client's right side.
Based on the presentation of the fetus, the position is vertex.
67. A nurse is caring for a client who desires an intrauterine device (IUD) for contraception.
Which of the following findings is a contraindication for the use of this device?
A. Hypertension
B. Menorrhagia
C. History of multiple gestations
D. History of thromboembolic disease
Answer: B. Menorrhagia
Explanation:
An IUD is a small plastic or copper device placed inside the uterus that changes the uterine
environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia,
severe dysmenorrhea, or history of ectopic pregnancy.
68. A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which of
the following actions should the nurse include in the plan of care?
A. Keep four side rails up while the client is in bed.
B. Monitor fetal heart rate every hour.
C. Insert an indwelling urinary catheter.
D. Check the cervix prior to analgesic administration.
Answer: D. Check the cervix prior to analgesic administration
Explanation:

Prior to administering an analgesic during active labor, the nurse must know how many
centimeters the cervix is dilated. If administered too close to the time of delivery, the analgesic
could cause respiratory depression in the newborn.
69. A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole.
Which of the following instructions should the nurse provide to the client about the treatment
plan?
A. "Your partner needs to be cultured and be treated with metronidazole only if his cultures are
positive."
B. "You and your partner need to take the medication and use a condom during intercourse until
cultures are negative."
C. "If both you and your partner are treated simultaneously, you may continue to engage in
sexual intercourse."
D. "Only you will need to take the metronidazole, but you should not have intercourse until your
culture is negative."
Answer: B. You and your partner need to take the medication and use a condom during
intercourse until cultures are negative
Explanation:
Trichomonas vaginalis is the organism that causes the sexually transmitted infection
trichomoniasis. Both men and women can be infected with trichomoniasis. Clinical findings
include yellowish to greenish, frothy, mucopurulent, copious discharge with an unpleasant odor,
as well as itching, burning, or redness of the vulva and vagina. Trichomoniasis can be treated
easily with metronidazole. However, for the treatment to work, it is important to make sure both
sexual partners receive treatment to prevent reinfection. Instruct the client to use condoms during
sexual intercourse while being treated.
70. A nurse is caring for four newborns. Which of the following newborns is at greatest risk for
hypoglycemia?
A. A newborn who is large for gestational age
B. A newborn who has an Rh incompatibility
C. A newborn who has pathologic jaundice

D. A newborn who has fetal alcohol syndrome
Answer: A. A newborn who is large for gestational age
Explanation:
Large for gestational age (LGA) newborns are those newborns whose weight is at or above the
90th percentile. One of the most common etiologies of LGA newborns is a mother who is
diabetic. LGA newborns, especially those born to mothers who have diabetes, are at increased
risk for hypoglycemia. Other newborns at risk for hypoglycemia are small for gestational age
(SGA) newborns (those below the 10th percentile), premature newborns, and newborns who
have perinatal hypoxia.
71. A nurse is caring for a client who is 2 hours 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 take first?
A. Check for a full bladder.
B. Massage the fundus.
C. Measure vital signs.
D. Administer carboprost IM.
Answer: B. Massage the fundus
Explanation:
The primary cause of early postpartum bleeding is uterine atony manifested by a relaxed, boggy
uterus. Thus, the greatest risk for the client is hemorrhage. The nurse should massage the client's
fundus first.
72. A nurse is caring for a client whose membranes have ruptured and is in active labor. The fetal
monitor tracing reveals late decelerations. Which of the following actions should the nurse take
first?
A. Turn the client onto her left side.
B. Palpate the client's uterus.
C. Administer oxygen to the client.
D. Increase the client's IV fluids.
Answer: A. Turn the client onto her left side

Explanation:
Late decelerations indicate that the client is experiencing uteroplacental insufficiency. The client
might be experiencing pressure on the inferior vena cava, which decreases the oxygen to the
placenta and thus to the fetus. Turning the client onto her left side will relieve the pressure and
facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply.
73. A nurse is planning care for a client who has a prescription for oxytocin. Which of the
following is a contraindication for the use of this medication?
A. Prolonged rupture of membranes at 38 weeks of gestation
B. Intrauterine growth restriction
C. Postterm pregnancy
D. Active genital herpes
Answer: Active genital herpes
Explanation:
The use of oxytocin is contraindicated for clients who have an active genital herpes infection.
The newborn can acquire the infection as they pass through the birth canal. Therefore, a cesarean
birth is recommended for clients who have an active genital herpes infection.
74. A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the
following clinical findings should the nurse expect?
A. Extended periods of sleep
B. Poor muscle tone
C. Respiratory rate 50/min
D. Exaggerated reflexes
Answer: D. Exaggerated reflexes
Explanation:
A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of
hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of
CNS irritability.

75. A nurse receives report on a client who is in labor and is experiencing contractions 4 minutes
apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?
A. Contractions that last for 60 seconds each with a 4-min rest between contractions
B. Contractions that last for 60 seconds each with a 3-min rest between contractions
C. A contraction that lasts 4 min followed by a period of relaxation
D. Contractions that last 45 seconds each with a 3-min rest between contractions
Answer: B. Contractions that last for 60 seconds each with a 3-minute rest between contractions
Explanation:
A contraction interval is how often a uterine contraction occurs. The nurse will measure the
interval from the beginning of one contraction to the beginning of the next contraction. A
contraction lasting 60 seconds with a relaxation period of 3 min is equivalent to contractions
every 4 min.
76. A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which
of the following findings is a risk factor for an ectopic pregnancy?
A. Anemia
B. Frequent urinary tract infections
C. Previous cesarean birth
D. Pelvic inflammatory disease (PID)
Answer: D. Pelvic inflammatory disease (PID)
Explanation:
An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and
the placenta and fetus begin to develop there. The most common site is within a fallopian tube,
but ectopic pregnancies can occasionally 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 for an ectopic pregnancy.
77. A nurse is caring for a client who is at 8 weeks of gestation with twins and primigravida. The
client states that even though she and her husband planned this pregnancy, she is experiencing
many ambivalent feelings about it. Which of the following responses should the nurse make?
A. "Have you told your husband about these feelings?"

B. "These feelings are quite normal at the beginning of pregnancy."
C. "Perhaps you should see a counselor to discuss these feelings."
D. "I am quite concerned about these feelings. Could you explain more?"
Answer: B. These feelings are quite normal at the beginning of pregnancy
Explanation:
This client needs reassurance that these feelings are normal and there is no reason for concern.
78. A nurse is assessing a newborn who is 12 hours old and notes mild jaundice of the face and
trunk. Which of the following actions should the nurse take?
A. Administer phytonadione IM.
B. Obtain a stat prescription for a bilirubin level.
C. Obtain a bagged urine specimen.
D. Perform a gestational age assessment.
Answer: B. Obtain a stat prescription for a bilirubin level
Explanation:
Jaundice in the first 24 hr of life is pathologic. The nurse should notify the provider and obtain a
stat prescription for a bilirubin level.
79. A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the
following statements should the nurse include in the teaching?
A. "You will have a cesarean birth prior to the onset of labor."
B. "Your baby will receive erythromycin eye ointment after birth to treat the infection."
C. "You should take oral metronidazole for 7 days prior to 37 weeks of gestation."
D. "You should schedule a cesarean birth after your water breaks."
Answer: A. You will have a cesarean birth prior to the onset of labor
Explanation:
Whenever possible, the cesarean birth should be scheduled prior to the onset of labor or rupture
of membranes to reduce the risk of neonatal transmission of herpes.
80. A nurse is caring for a client who has a prescription for naloxone. Which of the following is
the intended action of the medication in relation to the central nervous system?

A. Accentuate effects of narcotics on the CNS
B. Depress activity of the CNS
C. Block effects of narcotics on the CNS
D. Stimulate activity of the CNS
Answer: C. Blocks effects of narcotics on the CNS
Explanation:
By blocking the effects of narcotics on the CNS, naloxone prevents CNS and respiratory
depression in the newborn following delivery.
81. A nurse in a prenatal clinic is caring for a client who is within the recommended guidelines
for weight. The client asks the nurse how much weight is safe for her to gain during her
pregnancy. Which of the following responses should the nurse make?
A. "Your provider can discuss an appropriate amount of weight gain with you."
B. "A weight gain of about 14 pounds each trimester is suggested."
C. "If you eat nutritious foods when you feel hungry, the amount of weight gain is insignificant."
D. "A weight gain of about 25 to 35 pounds is good."
Answer: D. weight gain of about 25-35 pounds is good
Explanation:
A weight gain of 25 to 35 lb is associated with good fetal outcome. A gain of 4 lb in the first
trimester and 12 lb each for the second and third trimester is recommended.
82. A nurse is caring for a client who is in labor and has an epidural for pain relief. Which of the
following is a complication from the epidural block?
A. Nausea and vomiting
B. Tachycardia
C. Hypotension
D. Respiratory depression
Answer: C Hypotension
Explanation:

Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an
IV fluid bolus prior to the placement of epidural anesthesia in order to decrease the likelihood of
this complication.
83. A nurse is providing discharge teaching to a client following the removal of a hydatidiform
mole. Which of the following statements should the nurse include in the teaching?
A. "Do not become pregnant for at least 1 year."
B. "Seek genetic counseling for yourself and your partner prior to getting pregnant again."
C. "You should have an hCG level drawn in 6 weeks."
D. "Have your blood pressure checked weekly for the next month."
Answer: A. Do not become pregnant for at least 1 year
Explanation:
Hydatidiform moles are uncontrolled growths in the uterus arising from placental or fetal tissue
in early pregnancy. There is an increased incidence of choriocarcinoma associated with molar
pregnancies. Pregnancy must be avoided for 1 year so the client can be closely monitored for
manifestations of this condition.
84. A nurse is planning care for a client who is at 35 weeks of gestation. Which of the following
laboratory tests should the nurse obtain?
A. Rubella titer
B. Blood type
C. Group B streptococcus ß-hemolytic
D. 1-hour glucose tolerance test
Answer: c Group B streptococcus Bhemolytic
Explanation:
The nurse should obtain a vaginal/anal group B streptococcus ß-hemolytic (GBS) culture at 35 to
37 weeks of gestation to screen for infection. Prophylactic antibiotics should be given during
labor to the client who is positive for GBS.
85. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
terbutaline for preterm labor. Which of the following statements by the client is the priority?

A. "My ankles are swollen at the end of the day."
B. "I can feel the baby kicking my ribs, and it is very uncomfortable."
C. "I'm growing more and more worried every day."
D. "My heart feels as if it is racing."
Answer: D. My heart feels as if it is racing
Explanation:
The primary action of terbutaline is to cause bronchodilation and relax smooth muscles.
However, an adverse effect is tachycardia. If the pulse is greater than 130/min, the terbutaline
needs to be held until the provider is notified.
86. A nurse is planning care for a newborn who requires phototherapy for hyperbilirubinemia.
Which of the following actions should the nurse include in the plan of care?
A. Swaddle the newborn in a receiving blanket during the treatment.
B. Maintain NPO status until the newborn's bilirubin is within the expected reference range.
C. Ensure the newborn's eyes are closed before applying the eye shield.
D. Apply lotion to the newborn's skin twice per day.
Answer: C. Ensure the newborns eyes are closed before applying the eye shield
Explanation:
Overexposure to the lights during treatment can cause damage to the newborn's corneas.
Therefore, the nurse should gently close the newborn's eyes prior to applying the eye shield.
87. A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal
lung maturity. Which planning care for the newborn, which of the following conditions should
the nurse identify as an adverse effect of this medication?
A. Hyperthermia
B. Decreased blood glucose
C. Rapid pulse rate
D. Irritability
Answer: B. Decreased blood glucose
Explanation:

Betamethasone causes hyperglycemia in the client, which predisposes the newborn to
hypoglycemia in the first hours after delivery. It is important to assess the newborn's blood
glucose level within the first hour following birth and frequently thereafter until blood glucose
levels are stable.
88. A nurse is caring for a client who is at 16 weeks of gestation and has severe iron deficiency
anaemia. The provider prescribes an injection of iron dextran IM. Which of the following
methods should the nurse use to administer the medication?
A. Use a 20-gauge needle, and administer the medication using the Z-track method.
B. Use a 22-gauge needle, and administer the medication deep into the thigh.
C. Use a 25-gauge needle, and administer the medication into the deltoid muscle.
D. Use an 18-gauge needle, and administer the medication into the rectus femoris muscle
Answer: A. Use a 20-guage needle, and administer the medication using the Z track method
Explanation:
The nurse should administer iron using the Z-track method to prevent staining of tissue. A 20gauge needle is the correct size.
89. A nurse in an antepartum clinic answers a phone call from a client who is at 37 weeks of
gestation and reports, "I become very dizzy while lying in bed this morning, but the feeling went
away when I turned on my side." Which of the following actions should the nurse take?
A. Instruct the client about vena cava syndrome and measures to prevent it.
B. Arrange for the client to come to the clinic for an assessment.
C. Check the client's chart for gestational diabetes mellitus.
D. Schedule a nonstress test for the client.
Answer: A. Instruct the client about vena cava syndrome and measures to prevent it
Explanation:
This is the typical finding of vena cava syndrome, or hypotension that occurs in clients who are
pregnant upon assuming a supine position. It is caused by compression of the inferior vena cava
by the gravid uterus with a consequent reduction in venous return. A side lying position promotes
uterine perfusion and fetoplacental oxygenation.

90. 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. "I know not to eat anything after midnight."
B. "I will have medication given to me to cause contractions."
C. "I should press the button on the handheld marker when my baby moves."
D. "I will have to stimulate my breast to cause contractions."
Answer: C. I should press the button on the handheld marker when my baby moves
Explanation:
The purpose of the test is to assess fetal well-being. The client should press the button on the
handheld marker when she feels fetal movement.
91. A nurse is caring for a client who is at 36 weeks of gestation and has preeclampsia. Which of
the following findings should the nurse identify as the priority?
A. 1+ proteinuria
B. Blood pressure 140/98 mm Hg
C. Nonreactive nonstress test
D. Fundal height 33 cm
Answer: C. Nonreactive nonstress test
Explanation:
In a nonreactive nonstress test, there are no accelerations. Absence of FHR accelerations
suggests that the fetus might be going into distress.
92. A nurse is caring for a client who is in labor. The client questions the application of an
internal fetal scalp monitor. Which of the following responses should the nurse make?
A. "Don't worry. Your baby is fine."
B. "You will need to ask your provider."
C. "Your provider feels it would be best."
D. "We need to observe your baby more closely."
Answer: D. We need to observe your baby more closely
Explanation:

The client has asked an information-seeking question. This therapeutic response provides
information to the client in an honest, nonthreatening manner. The use of an internal fetal scalp
monitor, or an internal spiral electrode, provides a more accurate assessment of fetal well-being
during labor.
93. A nurse is assessing a client who is receiving magnesium sulfate as treatment for
preeclampsia. Which of the following clinical findings is the nurse's priority?
A. Respirations 16/min
B. Urinary output 40 mL in 2 hr
C. Reflexes +2
D. Fetal heart rate 158/min
Answer: B. Urinary output 40ml in 2 hours
Explanation:
Urinary output is critical to the excretion of magnesium from the body. The nurse should
discontinue the magnesium sulfate if the hourly output is less than 30 mL/hr
94. A nurse is speaking with an expectant father who says that he feels resentful of the added
attention others are giving to his wife since the pregnancy was announced several weeks ago.
Which of the following responses should the nurse make?
A. "Has your wife sensed your anger toward her and the baby?"
B. "These feelings are common to expectant fathers in early pregnancy."
C. "I'm sure that it's really hard to accept this when it's your baby, too."
D. "It would be wise for you to speak to a therapist about these feelings."
Answer: B. These feelings are common to expectant fathers in early pregnancy
95. A nurse is caring for a client who is receiving oxytocin for induction of labor. Which of the
following actions should the nurse take?
A. Perform continuous fetal heart rate monitoring.
B. Measure maternal temperature every hour.
C. Evaluate maternal contraction pattern every hour.
D. Check blood pressure every 5 min.

Answer: A. Perform continuous fetal heart rate monitoring
Explanation:
When oxytocin is administered to an antepartum client, the fetal monitor must be used to
continuously monitor the fetal heart rate and maternal contractions.
96. A nurse is discussing diaphragm use with a client. Which of the following statements by the
client indicates an understanding of the teaching?
A. "I should clean my diaphragm with alcohol each time I use it."
B. "I should leave the diaphragm in place 4 hours after intercourse."
C. "I should replace my diaphragm every 2 years."
D. "I should use a vaginal lubricant to insert my diaphragm."
Answer: C. I should replace my diaphragm every 2 years
Explanation:
The diaphragm is a flexible rubber cup that is filled with spermicide and is inserted over the
cervix prior to intercourse. The diaphragm is a prescribed device fitted by the provider. It should
be replaced every 2 years.
97. A nurse is caring for a newborn who has irregular respirations of 52/minute with several
periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis.
Which of the following actions should the nurse take?
A. Administer oxygen.
B. Place the newborn in an isolette.
C. Continue to routinely monitor the newborn.
D. Assess the newborn's blood glucose.
Answer: C. Continue to routinely monitor the newborn
98. A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the
following findings should the nurse identify as a potential complication from the oxygen
therapy?
A. Atelectasis
B. Retinopathy

C. Interstitial emphysema
D. Necrotizing enterocolitis
Answer: B. Retinopathy
Explanation:
Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a
disorder of retinal blood vessel development in the premature newborn. In newborns who
develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel
that fills the back of the eye. It can reduce vision or result in complete blindness.
99. A nurse is assessing a client who has gestational diabetes mellitus and is experiencing
hyperglycemia. Which of the following findings should the nurse expect?
Answer: Reports increased urinary output
100. A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of
the following actions should the nurse take?
Answer: Report the client's condition to the local health department
101. A nurse is providing teaching for a client who has a new prescription for combined oral
contraceptives. Which of the following findings should the nurse include as an adverse effect of
this medication?
Answer: Depression
102. A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new
prescription for misoprostol. Which of the following instructions should the nurse include in the
teaching?
Answer: "I can administer oxytocin 4 hours after the insertion of the medication"
103. A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the
following actions should the nurse take?
Answer: Schedule an ultrasound examination

104. A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of
the following techniques should the nurse use to help minimize the pain of the procedure for the
newborn
Answer: Place the newborn skin to skin on the mothers chest
105. A nurse is performing a vaginal exam on a client who is in labor and observes the umbilical
cord protruding from the vagina. After calling for assistance, which of the following actions
should the nurse take?
Answer: Insert two gloved fingers into the vagina and apply upward pressure to the presenting
part
106. A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental
abruption. Which of the following laboratory tests should the nurse expect the provider to
prescribe?
Answer: Kleihauer-Betke test
107. A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For
which of the following complications should the nurse assess?
Answer: Abruptio placenta
108. A nurse is assessing a client who has severe preeclampsia. Which of the following
manifestations should the nurse expect?
Answer: Blurred Vision
109. A nurse is providing education about family bonding to parents who recently adopted a
newborn. The nurse should make which of the following suggestions to aid the family's 7-yearold in accepting the new family member?
Answer: Obtain an gift from the newborn to present to the sibling

110. A nurse is assessing a client who is receiving morphine via IV bolus for pain following a Csection. The nurse notes a respiratory rate of 8/min. Which of the following medications should
be administered?
Answer: Naloxone
111. A nurse is teaching a client who is at 10 weeks of gestation about nutrition during
pregnancy. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: "I should take 600 micrograms of folic acid every day"
112. A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations
should the nurse report to the provider?
Answer: Jaundice
113. A nurse is observing a new parent caring for her crying newborn who is bottle feeding.
Which of the following actions by the parent should the nurse recognize as a positive parenting
behavior?
Answer: Lays the newborn across her lap and gently sways
114. A nurse is teaching a newly licensed nurse about collecting a specimen for the universal
newborn screening. Which of the following statements should the nurse include in the teaching?
Answer: "Ensure that the newborn has been receiving feeding for 24 hours prior to obtaining the
specimen"
115. A nurse is caring for a client who has uterine atony and is experiencing postpartum
haemorrhage. Which of the following actions is the nurse priority?
Answer: Massage the client's fundus
116. A nurse is performing a physical assessment of a newborn upon admission to the nursery.
Which of the following manifestations should the nurse expect?
Answer: Acrocyanosis

Positive Babinski reflex
Two umbilical arteries visible is correct
117. A nurse is demonstrating to a client how to bathe their newborn. In which order should the
nurse perform the following actions?
Answer: Wipe eyes
Wash Neck
Cleanse skin around umbilical cord stump
Wash legs and feet
Clean diaper area
118. A nurse is assessing a client who received carboprost for postpartum hemorrhage.
Which of the following findings is an adverse effect of this medication?
Answer: Hypertension
119. A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress
test that reveals a variable deceleration in the FHR. Which of the following actions should the
nurse take?
Answer: Have the client change positions
120. A nurse is caring for a client who is at 38 weeks of gestation. Which of the following
actions should the nurse take prior to applying an external transducer for fetal monitoring?
Answer: Perform Leopold Maneuvers
121. A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients
should the nurse see first?
Answer: A client who is at 11 weeks of gestation and reports abdominal cramping
122. A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse
should identify that the client is at an increased risk for which of the following complications?
Answer: Premature rupture of membranes

123. A nurse is assessing four newborns. Which of the following findings should the nurse report
to the provider?
Answer: A newborn who is 18 hr old and has an axillary temperature of 99.9°F
124. A nurse is caring for a postpartum client who is receiving heparin via a continuous IV
infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse
take?
Answer: Maintain the client of bed rest
125. A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago.
Which of the following instructions should the nurse include?
Answer: "You can still become pregnant if you are breastfeeding"
126. A nurse is performing a physical assessment of a newborn. Which of the following clinical
finding should the nurse expect?
Answer: Heart Rate 154/ min
Respiratory rate 58/ min
Weight 2,600 g (5lb 12 oz)
127. A nurse is performing a routine assessment on a client who is at 18 weeks of gestation.
Which of the following findings should the nurse expect?
Answer: FHR 152/min
128. A nurse is reviewing the prenatal laboratory value for a client who is at 12 weeks of
gestation following an initial prenatal visit. Which of the following laboratory findings should
the nurse report to the provider
Answer: Hemoglobin 10 g/dL
129. A nurse is developing a plan of care for a newborn who is to undergo phototherapy for
hyperbillirubinemia. Which of the following actions should the nurse include in the plan?

Answer: Remove all clothing form the newborn except the diaper
130. A nurse is caring for a client who is at 15 weeks gestation, is Rh-negative, and has just had
an amniocentesis. Which of the following interventions is the nurse's priority following the
procedure?
Answer: Monitor the FHR
131. A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which
of the following findings should the nurse report to the provider?
Answer: Reports of decreased fetal movement
132. A nurse is admitting a client to the labor and delivery unit when the client states, "My water
just broke". Which of the following interventions is the nurse's priority?
Answer: Begin FHR monitoring
133. A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction
stress test. The nurse should plan to prepare the client for which of the following diagnostic test?
Answer: Biophysicial profile
134. A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm
labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse
should set the IV infusion pump to administer how many mL/hr?
Answer: 50 ml/hr
135. A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid
replacement. Which of the following findings should the nurse report to the provider?
Answer: BUN 25 mg/dL
136. A nurse is assessing a late preterm newborn. Which of the following manifestations is an
indication of hypoglycemia?
Answer: Respiratory distress

137. A nurse in a provider's office is reviewing the medical record of a client who is in the first
trimester of pregnancy. Which of the following should the nurse identify as a risk factor for the
development of preeclampsia
Answer: Pregestational Diabetes Mellitus
138. A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of
gestation. Upon reviewing the client's medical record, which of the following findings should the
nurse report to the provider?
Answer: Fundal Height Measurement
139. A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the
nurse report to the provider?
Answer: Substernal Retractions
140. A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse
enters the room and observes the client having a seizure. After turning the client head to the side,
which of the following actions should the nurse take immediately after the seizure?
Answer: Administer oxygen via a nonrebreather mask
141. A nurse is providing teaching about nonpharmological pain management to a client who is
breastfeeding and has engorgement. The nurse should recommend the application of which of the
following items?
Answer: Cold cabbage leaves
142. A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma.
Which of the following manifestations should the nurse expect?
Answer: Vaginal pressure
143. A nurse is assessing a newborn who was born at 26 weeks of gestation using the New
Ballard Score. Which of the following findings should the nurse expect?

Answer: Minimal arm recoil
144. A nurse is providing teaching for a client who have birth 2 hr ago about the facility policy
for newborn safety. Which of the following client statements indicates an understanding of the
teaching?
Answer: the person who comes to take my baby's pictures will be wearing a photo identification
badge
145. A nurse is assessing a client who is at 36 weeks of gestation. Which of the following
findings should the nurse report to the provider?
Answer: Report of visual disturbances
146. A nurse is providing teaching to a client about the physiological changes that occur during
pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference
range. Which of the following client statements indicates an understanding of the teaching?
Answer: "I will likely need to use alternative positions for sexual intercourse".
147. A nurse is caring for a client who is anaemic at 32 weeks of gestation and is in preterm
labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes
should the nurse expect?
Answer: A reduction in respiratory distress in the newborn
148. A nurse is caring for a client who is experiencing preeclampsia and has a new prescription
for IV magnesium sulphate. Which of the following medications should the nurse anticipate
administering if the client develops magnesium toxicity?
Answer: Calcium Gluconate
149. A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for
magnesium sulphate IV to treat preterm labor. The nurse should notify the provider of which of
the following adverse effects?
Answer: Respiratory rate 10/min

150. A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the
following findings contraindicates the infusion of the oxytocin infusion and should be reported to
the provider?
Answer: Late Decelerations
151. A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal
cord. Which of the following findings should the nurse expect?
Answer: Petechiae over the head
152. A nurse is transporting a newborn back to the parent's room following a procedure. Which
of the following actions should the nurse take?
Answer: Verify that the parent's identification band matches the newborn's identification band
153. A nurse is creating a plan of care who is postpartum and adheres to traditional Hispanic
cultural beliefs. Which of the following cultural practices should the nurse include in the plan of
care?
Answer: Protects the client's head and feet from cold air
154. A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to
perform Loopoid manoeuvres. Which of the following images indicates the first step of Leopoid
maneuvers?
Answer: Picture of nurse palpating top of belly; to determine which fetal part is in the fundus
(the uppermost part of the uterus) is the first step of Leopold maneuvers.
155. A nurse is developing a plan of care for a client who has preeclampsia and is receiving
magnesium sulfate via a continuous IV infusion. Which of the following interventions should the
nurse include in the plan?
Answer: Monitor the FHR continously

156. A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit.
Which of the following findings should the nurse report to the provider?
Answer: Weight gain of 2.2 kg (4.8 lb)
157. A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an
amniocentesis. For which of the following reasons should the nurse prepare the client for an
ultrasound?
Answer: To locate the pocket of fluid
158. A nurse is teaching a client who has a new prescription for combined oral contraceptives
about potential adverse effects of the medication. For which of the following findings should the
nurse instruct the client to notify the provider?
A. Shortness of breath
B. Breakthrough bleeding
C. Vomiting
D. Breast tenderness
Answer: A. Shortness of breath
Explanation:
A. Shortness of breath
The nurse should instruct the client to notify the provider immediately of any shortness of breath.
Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction.
Also, the nurse should instruct the client to notify the provider of other adverse effects that can
indicate potential complications, including abdominal pain, sudden or persistent headaches,
blurred vision, and severe leg pain.
B. Breakthrough bleeding
Breakthrough bleeding outside the menstrual period is a common adverse effect of combined
oral contraceptives.
C. Vomiting
Nausea and vomiting are common adverse effects of combined oral contraceptives.
D. Breast tenderness
Breast tenderness is a common adverse effect of combined oral contraceptives.

159. A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of
the following findings should the nurse report to the provider as a potential complication?
A. Increased fetal movement
B. Leakage of fluid from the vagina
C. Upper abdominal discomfort
D. Urinary frequency
Answer: B. Leakage of fluid from the vagina
Explanation:
A. Increased fetal movement
Decreased fetal movement is a potential complication that should be reported to the provider.
B. Leakage of fluid from the vagina
Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should
be reported to the provider.
C. Upper abdominal discomfort
Upper abdominal discomfort is not a potential complication associated with an amniocentesis.
D. Urinary frequency
Urinary frequency is not a potential complication associated with an amniocentesis.
160. A nurse is calculating a client's expected date of birth using Nagele's rule. The client tells
the nurse that her last menstrual cycle started on November 27th. Which of the following dates is
the client's expected date of birth?
Answer: September 3rd
Explanation:
When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should
subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days.
November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September
3rd.
161. A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction
stress test. For which of the following diagnostic tests should the nurse prepare the client?

A. Percutaneous umbilical blood sampling
B. Amnioinfusion
C. Biophysical profile (BPP)
D. Chorionic villus sampling (CVS)
Answer: C. Biophysical profile (BPP)
Explanation:
A. Percutaneous umbilical blood sampling
Percutaneous umbilical blood sampling, commonly called cordocentesis, is the most common
method used for fetal blood sampling and transfusion. This is not a diagnostic test used for
clients who have a positive contraction stress test.
B. Amnioinfusion
An amnioinfusion of normal saline or lactated Ringer's is instilled into the amniotic cavity
through a transcervical catheter introduced into the uterus to supplement the amount of amniotic
fluid. The instillation reduces the severity of variable decelerations caused by cord compression
for clients who are in labor. This is not a diagnostic test used for clients who have a positive
contraction stress test.
C. Biophysical profile (BPP)
The nurse should prepare the client for a BPP to further assess fetal well-being. A positive
contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real
time ultrasound to visualize physical and physiological characteristics of the fetus and observe
for fetal biophysical responses to stimuli.
D. Chorionic villus sampling (CVS)
CVS is the assessment of a portion of the developing placenta, which is aspirated through a thin
sterile catheter inserted through the abdominal wall or intravaginally through the cervix under
ultrasound guidance. This procedure is done during the first trimester. This is not a diagnostic
test used for clients who have a positive contraction stress test.
162. A nurse is teaching a new parent about newborn safety. Which of the following instructions
should the nurse include in the teaching?
A. "You can share your room with your baby for the next few weeks."
B. "Cover your baby with a light blanket while sleeping."

C. "Check the temperature of your baby's bath water with your hand."
D. "Your baby can nap in the car seat during the daytime."
Answer: A. "You can share your room with your baby for the next few weeks."
Explanation:
A. "You can share your room with your baby for the next few weeks."
The nurse should recommend room-sharing during the first few weeks. This allows the parent to
be readily available to the newborn and learn the newborn's cues. However, the nurse should
instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden
infant death syndrome.
B. "Cover your baby with a light blanket while sleeping."
The nurse should instruct the parents to place the newborn in a sleep sack or a one-piece sleeper.
Covering the newborn with a blanket or quilt increases the risk for sudden infant death
syndrome.
C. "Check the temperature of your baby's bath water with your hand."
The nurse should instruct the parents to check the temperature of the newborn's bath water with
their elbow, which is more sensitive to temperature than the hand. The hot water heater should be
set at or below 49° C (120.2° F) to prevent burns.
D. "Your baby can nap in the car seat during the daytime."
The nurse should instruct the parents to lay the newborn in a bassinet or crib on her back to
sleep. Sleeping in a supine position on a firm mattress decreases the risk of sudden infant death
syndrome.
163. A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior
position. The client is dilated to 8 cm and reports back pain. Which of the following actions
should the nurse take?
A. Apply sacral counterpressure.
B. Perform transcutaneous electrical nerve stimulation (TENS).
C. Initiate slow-paced breathing.
D. Assist with biofeedback.
Answer: A. Apply sacral counterpressure.
Explanation:

A. Apply sacral counterpressure.
The nurse should apply sacral counterpressure to assist in relieving back labor pain related to
fetal posterior position.
B. Perform transcutaneous electrical nerve stimulation (TENS).
The nurse should perform TENS during the first stage of labor.
C. Initiate slow-paced breathing.
The nurse should transition a client to pattern-paced breathing during this stage of labor.
D. Assist with biofeedback.
The nurse should teach the client about biofeedback during the prenatal period for it to be
effective during labor.
164. A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia.
Which of the following actions should the nurse take?
A. Cover the newborn's eyes while under the phototherapy light.
B. Keep the newborn in a shirt while under the phototherapy light.
C. Apply a light moisturizing lotion to the newborn's skin.
D. Turn and reposition the newborn every 4 hr while undergoing phototherapy.
Answer: A. Cover the newborn's eyes while under the phototherapy light.
Explanation:
A. Cover the newborn's eyes while under the phototherapy light.
Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the
phototherapy light.
B. Keep the newborn in a shirt while under the phototherapy light.
It is acceptable for the nurse to keep a diaper or other covering over the newborn's genitals and
buttocks, but the nurse should remove all other clothing and blankets to expose as much body
surface area as possible to the phototherapy light.
C. Apply a light moisturizing lotion to the newborn's skin.
The nurse should not apply any cream or moisture to the newborn's skin because it can absorb
heat and cause burns.
D. Turn and reposition the newborn every 4 hr while undergoing phototherapy.

The nurse should turn and reposition the newborn every 2 to 3 hr to allow for maximum
exposure of body surfaces to the phototherapy light.
165. A nurse is performing a vaginal examination on a client who is in labor and observes the
umbilical cord protruding from the vagina. After calling for assistance, which of the following
actions should the nurse take next?
A. Place a rolled towel beneath one of the client's hips.
B. Apply internal upward pressure to the presenting part using two gloved fingers.
C. Administer oxygen to the client via a nonrebreather mask at 10 L/min.
D. Increase the IV infusion rate.
Answer: B. Apply internal upward pressure to the presenting part using two gloved fingers.
Explanation:
A. Place a rolled towel beneath one of the client's hips.
The nurse should place a rolled towel under the client's left or right hip to alleviate some of the
pressure; however, evidence-based practice indicates that the nurse should take a different action
first.
B. Apply internal upward pressure to the presenting part using two gloved fingers.
Using evidence-based practice, the first action the nurse should take is to apply internal upward
pressure to the presenting part. Prolapse of the umbilical cord during labor can result in
decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse
should relieve the compression on the umbilical cord by applying upward internal pressure on
the presenting part with two gloved fingers. The nurse should not move their hand.
C. Administer oxygen to the client via a nonrebreather mask at 10 L/min.
Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which
can lead to hypoxia. The nurse should administer oxygen via a nonrebreather mask at 10 L/min;
however, evidence-based practice indicates that the nurse should take a different action first.
D. Increase the IV infusion rate.
The nurse should increase the IV infusion rate; however, evidence-based practice indicates that
the nurse should take a different action first.

166. A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the
following findings is an indication for the administration of the medication? (SATA)
A. Flaccid uterus
B. Cervical laceration
C. Excess vaginal bleeding
D. Increased afterbirth cramping
E. Increased maternal temperature
Answer: A. Flaccid uterus
Explanation:
A. Flaccid uterus is correct. Oxytocin increases the contractility of the uterus.
B. Cervical laceration is incorrect. Bleeding resulting from a cervical laceration continues even
when the uterus is contracted and firm. It will require repair by the provider.
C. Excess vaginal bleeding is correct.
Oxytocin enhances uterine contractility, decreasing vaginal bleeding.
D. Increased afterbirth cramping is incorrect.
The use of oxytocin will increase, rather than decrease, afterbirth cramping.
E. Increased maternal temperature is incorrect.
The use of oxytocin will have no effect on maternal temperature.
167. A nurse is teaching a postpartum client about steps the nurses will take to promote the
security and safety of the client's newborn. Which of the following statements should the nurse
make?
A. "The nurse will carry your newborn to the nursery for procedures."
B. "We will document the relationship of visitors in your medical record."
C. "Your baby will stay in the nursery while you are asleep."
D. "Staff members who take care of your baby will be wearing a photo identification badge."
Answer: D. "Staff members who take care of your baby will be wearing a photo identification
badge."
Explanation:
A. "The nurse will carry your newborn to the nursery for procedures."

The nurse should instruct the client that newborns will be transported in their bassinets and never
carried outside the client's room to reduce the risk for falls.
B. "We will document the relationship of visitors in your medical record."
The nurse should instruct the client that they can have anyone visit them on the unit. There is no
documentation of a visitor's relationship to the client entered into the medical record.
C. "Your baby will stay in the nursery while you are asleep."
The nurse should instruct the client to place the baby in the bassinet on the side of the bed
furthest from the door while she is sleeping.
D. "Staff members who take care of your baby will be wearing a photo identification badge."
The nurse should instruct the client that all staff members that care for newborns are required to
wear a photo identification badge so that the client will be reassured of the newborn's safety.
Some units' staff members wear special badges or a specific color scrubs.
168. A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor
(SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an
indication of withdrawal from an SSRI?
A. Large for gestational age
B. Hyperglycemia
C. Bradypnea
D. Vomiting
Answer: D. Vomiting
Explanation:
A. Large for gestational age
Low birth weight is an expected manifestation of fetal exposure to SSRIs.
B. Hyperglycemia
Hypoglycemia is an expected manifestation of fetal exposure to SSRIs.
C. Bradypnea
Tachypnea is an expected manifestation of fetal exposure to SSRIs.
D. Vomiting
Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation,
tremors, diarrhea, and vomiting. These manifestations typically last 2 days.

169. A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined
the fetal position as left occipital anterior. To which of the following areas of the client's
abdomen should the nurse apply the ultrasound transducer to assess the point of maximum
intensity of the fetal heart?
A. Left upper quadrant
B. Right upper quadrant
C. Left lower quadrant
D. Right lower quadrant
Answer: A. Left lower quadrant
Explanation:
A. Left upper quadrant
The fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper
quadrant.
B. Right upper quadrant
The fetal heart tones of a fetus in the right sacrum anterior position are best heard in the right
upper quadrant.
C. Left lower quadrant
The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left
lower quadrant.
D. Right lower quadrant
The fetal heart tones of a fetus in the right occipital anterior position are best heard in the right
lower quadrant.
170. A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's
secretions. Which of the following instructions should the nurse include?
A. Insert the syringe tip before compressing the bulb.
B. Suction each of the nares before suctioning the mouth.
C. Insert the tip of the syringe into the center of the newborn's mouth.
D. Stop suctioning when the newborn's cry sounds clear.
Answer: D. Stop suctioning when the newborn's cry sounds clear.

Explanation:
A. Insert the syringe tip before compressing the bulb.
The client should compress the bulb before inserting the syringe tip. Compressing the bulb after
it is in the newborn's nares or mouth could push the secretions and mucus further inside.
B. Suction each of the nares before suctioning the mouth.
The client should suction the mouth before suctioning the nares. Otherwise, the newborn could
gasp and inhale pharyngeal secretions when the syringe tip touches the nares.
C. Insert the tip of the syringe into the center of the newborn's mouth.
The client should insert the tip of the syringe into the side of the newborn's mouth. Inserting it
into the center of the newborn's mouth can trigger the gag reflex.
D. Stop suctioning when the newborn's cry sounds clear.
The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds
like it is coming through a bubble of fluid or mucus.
171. A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia.
Which of the following laboratory results should the nurse report to the provider?
A. Hct 39%
B. Serum albumin 4.5 g/dL
C. WBC 9,000/mm3
D. Platelets 50,000/mm3
Answer: D. Platelets 50,000/mm3
Explanation:
A. Hct 39%
An Hct of 39% is within the expected reference range and does not indicate a postpartum
complication.
B. Serum albumin 4.5 g/dL
A serum albumin level of 4.5 g/dL is within the expected reference range. This finding is
consistent with mild preeclampsia and does not indicate a worsening of the condition.
C. WBC 9,000/mm3
A WBC of 9,000/mm3 is within the expected reference range and does not indicate a postpartum
complication.

D. Platelets 50,000/mm3
A platelet count of 50,000/mm3 is below the expected reference range, which can indicate
disseminated intravascular coagulation. The nurse should report this result to the provider.
172. A nurse is performing a newborn assessment. Which of the following images should the
nurse identify as an indication of spina bifida occulta?
A. The nurse should identify this as an image of spina bifida occulta.
B. The nurse should identify this as an image of spina bifida manifesta in the form of a
myelomeningocele that is closed
C. The nurse should identify this as an image of spina bifida manifesta in the form of a
myelomeningocele that is open.
D. The nurse should identify this as an image of Mongolian spots
Answer: A. The nurse should identify this as an image of spina bifida occulta.
Explanation:
A. The nurse should identify this as an image of spina bifida occulta.
External indications of this neural tube defect include a dimpled area over the defect and the
presence of a birthmark or hairy patch above the area.
B. The nurse should identify this as an image of spina bifida manifesta in the form of a
myelomeningocele that is closed. External indications of this neural tube defect include a
herniated sac over the site of the defect that is covered with skin.
C. The nurse should identify this as an image of spina bifida manifesta in the form of a
myelomeningocele that is open. External indications of this neural tube defect include an open
area over the defect that allows for leakage of cerebrospinal fluid and entry of microorganisms.
D. The nurse should identify this as an image of Mongolian spots. These bluish black pigmented
areas are most commonly found on the buttocks and back of newborns of Mediterranean, Asian,
African, and Latin American ethnicity and can be incorrectly identified as areas of ecchymosis.
173. A nurse on an antepartum unit is caring for four clients. Which of the following clients
should the nurse identify as the priority?
A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL
B. A client who is at 34 weeks of gestation and reports epigastric pain

C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL
D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria
Answer: B. A client who is at 34 weeks of gestation and reports epigastric pain
Explanation:
A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL
A fasting blood glucose of 120 mg/dL is above the expected reference range for a client who has
gestational diabetes, which is a nonurgent finding. Therefore, another client is the nurse's
priority.
B. A client who is at 34 weeks of gestation and reports epigastric pain
When using the urgent vs nonurgent approach to client care, the nurse should assess the client
who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates
hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client
as the priority.
C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL
This finding is a manifestation of anemia in a client who is pregnant, which is a nonurgent
condition. Therefore, another client is the nurse's priority.
D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria
Dysuria can indicate a urinary tract infection, which can cause preterm labor. Dysuria in a client
who is at 39 weeks of gestation is a nonurgent condition which will require antibiotics.
Therefore, another client is the nurse's priority.
174. A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of
the following statements by the client indicated an understanding of the teaching?
A. "I will eat foods that taste good instead of balancing my meals."
B. "I will avoid having a snack before I go to bed each night."
C. "I will have a cup of hot tea with each meal."
D. "I will eliminate products that contain dairy from my diet."
Answer: A. "I will eat foods that taste good instead of balancing my meals."
Explanation:
A. "I will eat foods that taste good instead of balancing my meals."

Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea,
rather than trying to consume a well-balanced diet.
B. "I will avoid having a snack before I go to bed each night."
Clients who have hyperemesis gravidarum should avoid going to bed with an empty stomach.
The nurse should instruct the client to eat a healthy snack before going to bed.
C. "I will have a cup of hot tea with each meal."
Clients who have hyperemesis gravidarum should alternate liquids and solids every 2 to 3 hr to
avoid an empty stomach and over filling at each meal.
D. "I will eliminate products that contain dairy from my diet."
Clients who have hyperemesis gravidarum do not need to eliminate dairy products from their
diet. The client should be encouraged to consume dairy products, because they are less likely to
cause nausea than other foods.
175. A nurse is planning care for a client who is 2 hr postpartum. Which of the following
interventions should the nurse plan to implement during the taking-hold phase of postpartum
behavioral adjustment?
A. Discuss contraceptive options with the client and her partner.
B. Repeat information to ensure client understanding.
C. Listen to the client and her partner as they reflect upon the birth experience.
D. Demonstrate to the client how to perform a newborn bath.
Answer: D. Demonstrate to the client how to perform a newborn bath.
Explanation:
A. Discuss contraceptive options with the client and her partner.
The discussing of contraceptive options occurs during the letting-go phase. This phase focuses
on moving forward as a family with interchanging members.
B. Repeat information to ensure client understanding.
The repeating of information to ensure client understanding occurs during the taking-in phase.
During this phase, which is experienced on the first postpartum day, the client displays
dependent and passive behaviors. Due to excitement and fatigue, the client is unable to retain
information. Therefore, the nurse should repeat instructions to ensure that the client understands
what is being said.

C. Listen to the client and her partner as they reflect upon the birth experience.
Listening to the client and her partner reflect upon the birth experience occurs during the takingin phase. During this phase, the new mother is focused on herself and meeting her basic needs.
There is also much excitement about the newborn and the birth experience. Therefore, the nurse
should allow the client to reflect, ensuring a healthy transition and a successful adaptation into
the new family unit.
D. Demonstrate to the client how to perform a newborn bath.
Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase.
The new parent moves from being passively dependent to taking a stronger interest in her new
role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The
nurse should provide positive reinforcement during this phase to give the new parent confidence
and promote maternal adjustment.
176. A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit.
Which of the following findings should the nurse report to the provider?
A. Swelling of the face
B. Varicose veins in the calves
C. Nonpitting 1+ ankle edema
D. Hyperpigmentation of the cheeks
Answer: A. Swelling of the face
Explanation:
A. Swelling of the face
Swelling of the face, sacral area, and fingers can indicate gestational hypertension or
preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out
of the intravascular compartment into the tissues, causing edema.
B. Varicose veins in the calves
Varicose veins are an expected finding in the second trimester. The increase in hormones during
pregnancy causes the relaxation of the smooth muscle of the vascular system, leading to vessel
dilation and Vaso congestion. Additionally, the weight of the enlarging uterus on the pelvic veins
decreases the return of blood from the lower extremities.
C. Nonpitting 1+ ankle edema

Nonpitting edema of the lower extremities is an expected finding in the third trimester. Warm
weather, sitting or standing for prolonged periods of time, and tight clothing can increase edema.
D. Hyperpigmentation of the cheeks
Hyperpigmentation of the cheeks, areola, vulva, and linea nigra are expected findings in the
second trimester. The anterior pituitary increases the production of melanocyte-stimulating
hormone, which leads to hyperpigmentation of the skin.
177. A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following
findings should the nurse expect?
A. Jitteriness
B. Hypertonia
C. Abdominal distention
D. Mottling
Answer: A. Jitteriness
Explanation:
A. Jitteriness
Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea,
abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who
are small or large for gestational age and late preterm newborns are at an increased risk for
hypoglycemia.
B. Hypertonia
Hypotonia, rather than hypertonia, is a manifestation of hypoglycemia. Hypertonia is a
manifestation of opioid withdrawal.
C. Abdominal distention
Abdominal distention is not a manifestation of hypoglycemia. Abdominal distention is a finding
in newborns who have hypocalcemia.
D. Mottling
Mottling is not a manifestation of hypoglycemia. It can be a normal variation seen in newborns.
Also, it is a manifestation of opioid withdrawal.

178. A nurse is teaching a client who is in preterm labor about terbutaline. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I will get injections of the medication once daily until my labor stops."
B. "My blood sugar may be low while I'm on this medication."
C. "I will have blood tests because my potassium might decrease."
D. "My blood pressure may increase while I'm on this medication."
Answer: C. "I will have blood tests because my potassium might decrease."
Explanation:
A. "I will get injections of the medication once daily until my labor stops."
Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr.
B. "My blood sugar may be low while I'm on this medication." An adverse effect of terbutaline is
hyperglycemia.
C. "I will have blood tests because my potassium might decrease." An adverse effect of
terbutaline is hypokalemia.
D. "My blood pressure may increase while I'm on this medication." An adverse effect of
terbutaline is hypotension.
179. A nurse is planning care for a client who is in labor and is having an amniotomy. Which of
the following assessments should the nurse identify as the priority?
A. O2 saturation
B. Temperature
C. Blood pressure
D. Urinary output
Answer: B. Temperature
Explanation:
A. O2 saturation
Assessing the client's O2 saturation is important during labor. However, another assessment is the
nurse's priority.
B. Temperature
The greatest risk for a client following amniotomy is infection. Therefore, the nurse should
identify that the priority assessment is the client's temperature.

C. Blood pressure
Assessing the client's blood pressure is important. However, another assessment is the nurse's
priority.
D. Urinary output
Assessing the client's urinary output is important during labor. However, another assessment is
the nurse's priority.
180. A nurse is planning discharge for a client who is 3 days postpartum. Which of the following
non-pharmacological interventions should the nurse include in the plan of care for lactation
suppression?
A. Place warm, moist packs on the breasts.
B. Apply cabbage leaves to the breasts.
C. Wear a loose-fitting bra.
D. Put green tea bags on the breasts.
Answer: B. Apply cabbage leaves to the breasts.
Explanation:
A. Place warm, moist packs on the breasts.
The client can use cold compresses to decrease breast discomfort during lactation suppression.
B. Apply cabbage leaves to the breasts.
Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort
caused by breast engorgement.
C. Wear a loose-fitting bra.
A tight-fitting bra will provide support to the breasts during engorgement, which can decrease
pain.
D. Put green tea bags on the breasts.
Tea bags are used to relieve nipple soreness in breastfeeding clients.
181. A nurse is caring for a client who becomes unresponsive upon delivery of the placenta.
Which of the following actions should the nurse take first?
A. Determine respiratory function.
B. Increase the IV fluid rate.

C. Access emergency medications from cart.
D. Collect a maternal blood sample for coagulopathy studies.
Answer: A. Determine respiratory function.
Explanation:
A. Determine respiratory function.
The priority action the nurse should take when using the airway, breathing, circulation approach
to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.
B. Increase the IV fluid rate.
The nurse should increase the IV fluid rate to maintain circulation. However, this is not the first
action the nurse should take.
C. Access emergency medications from cart.
The nurse should access emergency medication to assist in resuscitative efforts. However, this is
not the first action the nurse should take.
D. Collect a maternal blood sample for coagulopathy studies.
The nurse should collect a maternal blood sample in preparation for a blood transfusion.
However, this is not the first action the nurse should take.
182. A nurse is teaching a client who has pregestational type 1 diabetes mellitus about
management during pregnancy. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I should have a goal of maintaining my fasting blood glucose between 100 and 120."
B. "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater."
C. "I will continue taking my insulin if I experience nausea and vomiting."
D. "I will ensure that my bedtime snack is high in refined sugar."
Answer: C. "I will continue taking my insulin if I experience nausea and vomiting."
Explanation:
A. "I should have a goal of maintaining my fasting blood glucose between 100 and 120."
The nurse should teach the client to maintain her fasting blood glucose level between 60 and 99
mg/dL.
B. "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater."

The nurse should teach the client to avoid exercise during periods of hyperglycemia and when
positive urine ketones are present.
C. "I will continue taking my insulin if I experience nausea and vomiting."
The nurse should teach the client to continue to take her insulin as prescribed during illness to
prevent hypoglycemic and hyperglycemic episodes.
D. "I will ensure that my bedtime snack is high in refined sugar."
The nurse should teach the client to avoid snacks and foods that are high in refined sugar.
183. A nurse is assessing a newborn following a circumcision. Which of the following findings
should the nurse identify as an indication that the newborn is experiencing pain?
A. Decreased heart rate
B. Chin quivering
C. Pinpoint pupils
D. Slowed respirations
Answer: B. Chin quivering
Explanation:
A. Decreased heart rate
The heart rate will increase when a newborn is experiencing pain.
B. Chin quivering
Behavioral responses to a newborn's pain include facial expressions such as chin quivering,
grimacing, and furrowing of the brow.
C. Pinpoint pupils
When experiencing pain, a newborn's pupils typically dilate.
D. Slowed respirations
When experiencing pain, a newborn's respirations are typically rapid and shallow.
184. A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client
states that she is, "happy one minute and crying the next." The nurse should interperate the
client's statement as an indication of which of the following?
A. Emotional lability
B. Focusing phase

C. Cognitive restructuring
D. Couvade syndrome
Answer: A. Emotional lability
Explanation:
A. Emotional lability
The nurse should recognize and interpret the client's statement as an indication of emotional
lability. Many clients experience rapid and unpredictable changes in mood during pregnancy.
Intense hormonal changes may be responsible for mood changes that occur during pregnancy.
Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.
B. Focusing phase
The focusing phase is the third phase of the father's emotional response to the pregnancy. It is
characterized by his active involvement in the pregnancy and his relationship with the child.
C. Cognitive restructuring
Cognitive restructuring is accepting the idea of pregnancy and assimilating it into the woman's
life. The degree of acceptance is shown in the mother's emotional responses.
D. Couvade syndrome
Couvade syndrome is pregnancy-like manifestations experienced by the expectant father.
Manifestations include nausea, weight gain, and other physical manifestations of pregnancy.
185. A nurse in a family planning clinic is caring for a client who requests an oral contraceptive.
Which of the following findings in the client's hx should the nurse recognize as a
contraindication to oral contraceptives? (SATA)
A. Cholecystitis
B. Hypertension
C. Human papillomavirus
D. Migraine headaches
E. Anxiety disorder
Answer: A. Cholecystitis
Explanation:
A. Cholecystitis
A history of gallbladder disease is a contraindication for the use of oral contraceptives.

B. Hypertension is correct.
Hypertension is a contraindication for the use of oral contraceptives.
C. Human papillomavirus is incorrect.
The presence of human papillomavirus is not a contraindication for the use of oral
contraceptives.
D. Migraine headaches is correct. A history of migraine headaches is a contraindication for the
use of oral contraceptives.
E. Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for
the use of oral contraceptives.
186. A school nurse is providing teaching to an adolescent about levonorgestrel contraception.
Which of the following information should the nurse include in the teaching?
A. "You should take the medication within 72 hours following unprotected sexual intercourse."
B. "You should avoid taking this medication if you are on an oral contraceptive."
C. "If you don't start your period within 5 days of taking this medication, you will need a
pregnancy test."
D. "One dose of this medication will prevent you from becoming pregnant for 14 days after
taking it."
Answer: A. "You should take the medication within 72 hours following unprotected sexual
intercourse."
Explanation:
A. "You should take the medication within 72 hours following unprotected sexual intercourse."
Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception.
The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr
after unprotected sexual intercourse.
B. "You should avoid taking this medication if you are on an oral contraceptive."
Levonorgestrel, an emergency contraceptive, has no effect on the other oral contraceptive the
adolescent might be taking. To prevent pregnancy, this medication should be taken if an
adolescent misses a dose of oral contraception.
C. "If you don't start your period within 5 days of taking this medication, you will need a
pregnancy test."

The adolescent should be evaluated for pregnancy if she does not menstruate within 21 days
following administration of this medication.
D. "One dose of this medication will prevent you from becoming pregnant for 14 days after
taking it."
Levonorgestrel is an emergency contraceptive that prevents or delays ovulation. Therefore, the
nurse should inform the client that she will not be protected from pregnancy if she has
unprotected sexual intercourse in the days and weeks after receiving this medication.
187. A nurse is providing discharge teaching to the parents of a newborn about car seat safety.
Which of the following instructions should the nurse include?
A. Place the shoulder harness in the slots above the newborn's shoulders.
B. Place the retainer clip at the level of the newborn's armpits.
C. Place the newborn at a 60° angle in the car seat.
D. Place the newborn in a blanket before securing them in the car seat.
Answer: B. Place the retainer clip at the level of the newborn's armpits.
Explanation:
A. Place the shoulder harness in the slots above the newborn's shoulders.
The nurse should instruct the parents to place the shoulder harness in the slots that are at or just
below the newborn's shoulders.
B. Place the retainer clip at the level of the newborn's armpits.
The nurse should instruct the parents to place the newborn in a federally approved car seat with
the retainer clip snugly at the level of the newborn's armpits.
C. Place the newborn at a 60° angle in the car seat.
The nurse should instruct the parents to position the newborn at a 45° angle to minimize the risk
of airway obstruction from slumping forward.
D. Place the newborn in a blanket before securing them in the car seat.
The nurse should instruct the parents to refrain from placing extra padding, including blankets,
between the newborn and the straps of the car seat. Extra padding creates air pockets that
decrease the effectiveness of the restraint and can lead to injuries.

188. A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of
magnesium sulfate IV. Which of the following actions should the nurse take?
A. Restrict hourly fluid intake to 150 mL/hr.
B. Have calcium gluconate readily available.
C. Assess deep tendon reflexes every 6 hr.
D. Monitor intake and output every 4 hr.
Answer: B. Have calcium gluconate readily available
Explanation:
A. Restrict hourly fluid intake to 150 mL/hr.
The nurse should restrict hourly fluid intake to no more than 125 mL/hr. The client's urine output
should be 30 mL/hr or greater.
B. Have calcium gluconate readily available.
The nurse should have calcium gluconate readily available to prevent cardiac or respiratory
arrest in the event the client experiences magnesium toxicity.
C. Assess deep tendon reflexes every 6 hr.
The nurse should assess deep tendon reflexes every 1 to 4 hr during continuous infusion of
magnesium sulfate.
D. Monitor intake and output every 4 hr.
The nurse should monitor intake and output hourly for clients who are receiving a continuous
infusion of magnesium sulfate.
189. A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the
nurse should follow. (Move the steps into the box on the right, placing them in order of
performance. Use all the steps.)
A. The first step the nurse should take when performing Leopold maneuvers is to palpate the
client's fundus to identify the fetal part.
B. Second, the nurse should determine the location of the fetal back.
C. Third, the nurse should palpate for the fetal part presenting at the inlet.
D. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.
Answer: A. The first step the nurse should take when performing Leopold maneuvers is to
palpate the client's fundus to identify the fetal part.

B. Second, the nurse should determine the location of the fetal back.
C. Third, the nurse should palpate for the fetal part presenting at the inlet.
D. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.
190. A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential
pregnancy complications to report to the provider. Which of the following manifestations should
the nurse include?
A. Shortness of breath when climbing stairs
B. Swelling of feet and ankles at the end of the day
C. Headache that is unrelieved by analgesia
D. Braxton Hicks contractions
Answer: C. Headache that is unrelieved by analgesia
Explanation:
A. Shortness of breath when climbing stairs
Shortness of breath is related to the enlarging uterus interfering with the expansion of the
diaphragm and is an expected manifestation at 35 weeks of gestation.
B. Swelling of feet and ankles at the end of the day
Swelling of feet and ankles is due to the enlarging uterus interfering with blood return to the
heart and is an expected manifestation at 35 weeks of gestation.
C. Headache that is unrelieved by analgesia
A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to
the provider.
D. Braxton Hicks contractions
Braxton Hicks contractions are an indication that the uterus is preparing for labor and is an
expected manifestation at 35 weeks of gestation.
191. A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock.
After notifying the provider, which of the following actions should the nurse take next?
A. Massage the client's fundus.
B. Insert an indwelling urinary catheter.
C. Administer oxygen at 10 L/min.

D. Elevate the client's right hip.
Answer: A. Massage the client's fundus.
Explanation:
A. Massage the client's fundus.
The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is
to massage the client's fundus to expel clots and promote contractions.
B. Insert an indwelling urinary catheter.
The nurse should insert an indwelling urinary catheter to monitor perfusion of the kidneys.
However, this is not the next action the nurse should take.
C. Administer oxygen at 10 L/min.
The nurse should administer oxygen at 10 L/min via rebreather face mask to enhance perfusion.
However, this is not the next action the nurse should take.
D. Elevate the client's right hip.
The nurse should elevate the client's right hip to enhance perfusion. However, this is not the next
action the nurse should take.
192. A nurse is caring for a client who is pregnant and is at the end of her first trimester. The
nurse should place the Doppler ultrasound stethoscope in which of the following locations to
begin assessing for the fetal heart tones (FHT)?
A. Just above the umbilicus
B. Just above the symphysis pubis
C. The right lower quadrant
D. The left lower quadrant
Answer: B. Just above the symphysis pubis
Explanation:
A. Just above the umbilicus
The nurse should assess FHT using the Doppler stethoscope just above the umbilicus if the fetus
is in a transverse or breech presentation and the client is at a minimum of 22 weeks of gestation.
B. Just above the symphysis pubis

At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a
grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the
nurse should begin assessing for FHT just above the symphysis pubis.
C. The right lower quadrant
At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a
grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the
nurse might not hear FHT in the right lower quadrant.
D. The left lower quadrant
At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a
grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the
nurse might not hear FHT in the left lower quadrant.
193. A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a
nonstress test. Which of the following statements should the nurse include in the teaching?
A. "You will receive IV fluids prior to this test."
B. "The procedure will take approximately 10 to 15 minutes."
C. "You will be offered orange juice to drink during the test."
D. "You will need to sign an informed consent form each time you have this test."
Answer: C. "You will be offered orange juice to drink during the test."
Explanation:
A. "You will receive IV fluids prior to this test."
The nurse should state that IV fluids are initiated for an oxytocin-stimulated contraction test,
rather than a nonstress test.
B. "The procedure will take approximately 10 to 15 minutes."
The nurse should instruct the client that the procedure will take 20 to 40 min.
C. "You will be offered orange juice to drink during the test."
A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or
another beverage high in glucose, will stimulate fetal movements during the procedure, helping
to obtain results.
D. "You will need to sign an informed consent form each time you have this test."

A nonstress test is a noninvasive procedure. Therefore, the client does not need to provide
informed consent.
194. A nurse is planning care for a client who is to undergo a nonstress test. Which of the
following actions should the nurse include in the plan of care?
A. Maintain the client NPO throughout the procedure.
B. Place the client in a supine position.
C. Instruct the client to massage the abdomen to stimulate fetal movement.
D. Instruct the client to press the provided button each time fetal movement is detected.
Answer: D. Instruct the client to press the provided button each time fetal movement is detected.
Explanation:
A. Maintain the client NPO throughout the procedure.
There is no indication for the client to be NPO. Sometimes clients are encouraged to drink
liquids to promote adequate hydration.
B. Place the client in a supine position.
The client should be placed in a semi-Fowler's or sitting position and tilted to the right or left to
promote uterine perfusion and prevent supine hypotension.
C. Instruct the client to massage the abdomen to stimulate fetal movement.
Massaging the abdomen does not stimulate fetal movement.
D. Instruct the client to press the provided button each time fetal movement is detected.
Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to
press the button when she detects fetal movement will ensure that the fetal movement is noted.
195. A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2
weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the
following responses should the nurse make?
A. "You can miss your period for several other reasons. Describe your typical menstrual cycle."
B. "If you have been sexually active and haven't used protection, it is likely that you are
pregnant."
C. "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal
enlargement yet?"

D. "Because you have missed your period, you should try taking a home pregnancy test before
you start worrying."
Answer: A. "You can miss your period for several other reasons. Describe your typical
menstrual cycle."
Explanation:
A. "You can miss your period for several other reasons. Describe your typical menstrual cycle."
Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should
explore the client's menstrual cycle to determine other necessary interventions.
B. "If you have been sexually active and haven't used protection, it is likely that you are
pregnant."
The nurse's response is assuming and confirming that the client is pregnant based only on the
client's statement, which can increase the client's anxiety level.
C. "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal
enlargement yet?"
The nurse's response is making a false assumption that the client is pregnant based only on the
client's statement. The nurse should gather more information from the client before making any
false assumptions.
D. "Because you have missed your period, you should try taking a home pregnancy test before
you start worrying."
The nurse's response dismisses the client's concerns and does not answer or address the client's
question, which can increase the client's anxiety level.
196. A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the
blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse
take?
A. Tell the client to follow up with a dermatologist.
B. Explain to the client this is an expected occurrence.
C. Instruct the client to increase her intake of vitamin D.
D. Inform the client she might have an allergy to her skin care products.
Answer: B. Explain to the client this is an expected occurrence.
Explanation:

A. Tell the client to follow up with a dermatologist.
An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an
increase in the pigmentation of the skin during pregnancy. Treatment by a dermatologist will not
affect the client's condition.
B. Explain to the client this is an expected occurrence.
Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of
the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is
caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks
of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse
should reassure the client that this is an expected occurrence which usually fades after delivery.
C. Instruct the client to increase her intake of vitamin D.
An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an
increase in the pigmentation of the skin during pregnancy. Increasing her vitamin D intake will
not affect the client's condition.
D. Inform the client she might have an allergy to her skin care products.
An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an
increase in the pigmentation of the skin during pregnancy. Changing skin care products will not
affect the client's condition.
197. A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation
and has a positive chlamydia culture. The prescription states "Administer azithromycin 1g orally
now." Available is 250 mg tablets. How may tablets should the nurse administer?
Answer: 4
198. A nurse is caring for a client who is in active labor and has had no cervical change in the last
4 hr. Which of the following statements should the nurse make?
A. "Let me help you into a comfortable pushing position so you can begin bearing down."
B. "I am going to call the doctor to get a prescription for medication to ripen your cervix."
C. "I will give you some IV pain medicine to strengthen your contractions."
D. "Your provider will insert an intrauterine pressure catheter to monitor the strength of your
contractions."

Answer: D. "Your provider will insert an intrauterine pressure catheter to monitor the strength of
your contractions."
Explanation:
A. "Let me help you into a comfortable pushing position so you can begin bearing down."
The nurse should not instruct the client to start bearing down until the second stage of labor.
B. "I am going to call the doctor to get a prescription for medication to ripen your cervix."
A cervical ripening agent is not used during the active stage of labor.
C. "I will give you some IV pain medicine to strengthen your contractions."
Administering IV pain medication can decrease the intensity of uterine contractions.
D. "Your provider will insert an intrauterine pressure catheter to monitor the strength of your
contractions."
Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction
intensity, frequency, and duration which will identify whether the contractions are adequate for
progression of labor.
199. A nurse is caring for a newborn who was transferred to the nursery 30 min after birth
because of mild respiratory distress. Which of the following actions should the nurse take first?
A. Confirm the newborn's Apgar score.
B. Verify the newborn's identification.
C. Administer vitamin K to the newborn.
D. Determine obstetrical risk factors.
Answer: B. Verify the newborn's identification.
Explanation:
A. Confirm the newborn's Apgar score.
The Apgar score is a physiological assessment that occurs 1 min following birth and again at 5
min. The nurse should confirm the score when the newborn arrives in the nursery. However,
there is another action the nurse should take first.
B. Verify the newborn's identification.
When using the safety/risk reduction approach to client care, the first action the nurse should
take is to verify the newborn's identity upon arrival to the nursery.
C. Administer vitamin K to the newborn.

The nurse should administer IM vitamin K to the newborn soon after birth to increase clotting
factors and prevent bleeding. However, the injection can be delayed until after initial bonding
time and the first breastfeeding if necessary.
Therefore, there is another action the nurse should take first.
D. Determine obstetrical risk factors.
The nurse should identify obstetrical risk factors to determine if interventions are required for the
newborn. However, there is another action the nurse should take first.
200. A nurse is reviewing the laboratory results for a client who is at 10 weeks of gestation.
Which of the following laboratory findings should the nurse report to the provider?
A. Hemoglobin 10 g/dL
B. WBC count 15,000/mm3
C. RBC count 5.8 million/mm3
D. Hematocrit 34%
Answer: A. Hemoglobin 10 g/dL
Explanation:
A. Hemoglobin 10 g/dL
A hemoglobin level of 10 g/dL is below the expected reference range of greater than 11 g/dL for
a client who is pregnant. The nurse should report this laboratory finding to the provider.
B. WBC count 15,000/mm3
This white blood cell count is within the expected reference range of 5,000 to 15,000/mm3 for a
client who is pregnant. This finding is does not require reporting.
C. RBC count 5.8 million/mm3
This red blood cell count is within the expected reference range of 5 to 6.25 million/mm3 for a
client who is pregnant and does not require reporting. This count increases by 20% to 30%
during pregnancy.
D. Hematocrit 34%
This hematocrit is within the expected reference range of greater than 33% for a client who is
pregnant and does not require reporting.

201. A nurse is speaking with a client who is trying to make a decision about tubal ligation. The
client asks, "What effects will this procedure have on my sex life?" Which of the following
responses should the nurse make?
A. "There may be no significant changes to your sexual desire or function, but it's important to
discuss any concerns with your healthcare provider."
B. "This procedure should have no effect on your sexual performance or adequacy."
C. "You'll be fine. I can't imagine you and your partner will have any problems with sexual
function."
D. "If this concerns you, perhaps you should reconsider and use another form of contraception."
Answer: B. "This procedure should have no effect on your sexual performance or adequacy."
Explanation:
A. "There may be no significant changes to your sexual desire or function, but it's important to
discuss any concerns with your healthcare provider."
The nurse is dismissing the client's question, providing no information to help the client make an
informed decision.
B. "This procedure should have no effect on your sexual performance or adequacy."
The nurse is giving the client the information she is seeking. Sexual function depends on various
hormonal and psychological factors. Therefore, tubal occlusion should have no physiological
effect on sexual function.
C. "You'll be fine. I can't imagine you and your partner will have any problems with sexual
function."
The nurse is giving the client unwarranted reassurance without addressing the information the
client is seeking.
D. "If this concerns you, perhaps you should reconsider and use another form of contraception."
The nurse is giving the client unwarranted advice which might imply that there is a reason to be
concerned about the effect of the procedure on sexual function.
202. A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and
has a prescription for bedamethasone. Which of the following statements should the nurse make
about the indication for medication administration?
A. "This medication will stop your labor."

B. "This medication stimulates fetal lung maturity."
C. "This medication will decrease your risk for uterine infections."
D. "This medication will increase your baby's weight."
Answer: B. "This medication stimulates fetal lung maturity."
Explanation:
A. "This medication will stop your labor."
Betamethasone is not a tocolytic and does not stop labor.
B. "This medication stimulates fetal lung maturity."
The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal
lung maturity by promoting the release of enzymes that release lung surfactant.
C. "This medication will decrease your risk for uterine infections."
Betamethasone is not given to decrease the client's risk for uterine infections.
D. "This medication will increase your baby's weight."
Betamethasone does not increase fetal weight.
203. A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which
of the following action should the nurse take?
A. Perform a vaginal exam to determine cervical dilation every 2 hr.
B. Instruct the client to ambulate in the hallway once every 4 hr.
C. Administer betamethasone to the client via IM injection.
D. Initiate continuous external fetal monitoring.
Answer: D. Initiate continuous external fetal monitoring.
Explanation:
A. Perform a vaginal exam to determine cervical dilation every 2 hr.
A client who has a placenta previa and is actively bleeding is at an increased risk for preterm
labor and hemorrhage. The nurse should place the client on pelvic rest and should not perform
vaginal or rectal examinations.
B. Instruct the client to ambulate in the hallway once every 4 hr.
A client who has a placenta previa and is actively bleeding is at an increased risk for preterm
labor and hemorrhage. Ambulating frequently could potentially stimulate labor and increase

vaginal bleeding. Therefore, the nurse should place the client on bed rest with bathroom
privileges.
C. Administer betamethasone to the client via IM injection.
Betamethasone is given to enhance fetal lung maturity for clients who are experiencing preterm
labor. It is given to clients between 24 and 34 weeks of gestation.
D. Initiate continuous external fetal monitoring.
The nurse should identify that a client who has a placenta previa and is actively bleeding is at an
increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as
bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and
the presence of contractions. The nurse should obtain IV access and monitor laboratory values.
Also, the nurse should implement interventions to prepare for an emergency birth.
204. A nurse is providing discharge teaching to a client who is postpartum. For which of the
following manifestations should the nurse instruct the client to monitor and report to the
provider?
A. Persistent abdominal striae
B. Temperature 37.8°C (100°F)
C. Unilateral breast pain
D. Brownish-red discharge on day 5
Answer: C. Unilateral breast pain
Explanation:
A. Persistent abdominal striae
Persistent abdominal striae are caused by the separation of the underlying connective tissue and
are an expected postpartum finding.
B. Temperature 37.8°C (100°F)
The nurse should instruct the client to report a temperature of 38°C (100.4°F) or higher because
it could be an indication of infection.
C. Unilateral breast pain
Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain can be
indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to
report this manifestation to the provider.

D. Brownish-red discharge on day 5
Brownish-red discharge is an expected manifestation during days 3 to 10. The client should
report a large amount of lochia and large clots to the provider.
205. A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation.
Based on the chart findings and documentation, the nursing plan of care should include which of
the following actions?
Exhibit 1: Diagnostic Results
Lecithin/sphingomyelin (L/S) ratio 1.4:1Phosphatidylglycerol (PG) absentABO-Rh B-negative
Exhibit 2: Medication Administration Record
Terbutaline 0.25 mg SQ every hr PRN contractionsRho(D) immune globulin 300 mcg IM
onceNalbuphine 10 mg IV every 3 hr PRN pain
Exhibit 3: Progress Report
1655 - Amniocentesis completed, tocotransducer and external fetal monitor applied1700 - Fetal
heart rate 130/min with moderate variability Uterine contractions q 5 to 8 min lasting 30 to 60
sec durationUterine contractions palpated at 1+ intensity Client reports uterine contraction pain
of 2 on a scale of 0 to 10
A. Administer terbutaline.
B. Discuss possible genetic anomalies with the client.
C. Administer nalbuphine.
D. Discontinue external fetal monitoring.
Answer: A. Administer terbutaline.
Explanation:
A. Administer terbutaline.
The nurse should administer terbutaline to stop contractions because the laboratory results
indicate that the fetus's lungs are not mature enough for birth.
B. Discuss possible genetic anomalies with the client.
There is no indication of genetic anomalies based on the results of the amniocentesis.
C. Administer nalbuphine.
Nalbuphine is an analgesic used for moderate to severe pain. A report of 2 on a scale of 0 to 10 is
mild pain.

D. Discontinue external fetal monitoring.
The nurse should not discontinue external fetal monitoring. Because the client is exhibiting
manifestations of preterm labor, fetal well-being and contraction patterns should be continuously
monitored to continue to assess for preterm labor and provide necessary interventions to stop
contractions.
206. A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the
following findings should the nurse report to the provider?
A. Bilirubin 9 mg/dL
B. Hemoglobin 18 g/dL
C. Platelets 175,0000/mm3
D. Hematocrit 45%
Answer: A. Bilirubin 9 mg/dL
Explanation:
A. Bilirubin 9 mg/dL
A bilirubin level of 9 mg/dL is above the expected reference range for a newborn who is 4 hr old.
The expected reference range for a newborn who is less than 24 hr old is 2 to 6 mg/dL. The nurse
should report this finding to the provider.
B. Haemoglobin 18 g/dL
This haemoglobin level is within the expected reference range of 14 to 24 g/dL for a newborn
and does not require reporting.
C. Platelets 175,0000/mm3
This platelet count is within the expected reference range of 150,000 to 300,000/mm3 for a
newborn and does not require reporting.
D. Haematocrit 45%
This haematocrit level is within the expected reference range of 44% to 64% for a newborn and
does not require reporting.
207. A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia
purpura (ITP). Which of the following findings should the nurse expect?
A. Decreased platelet count

B. Increased erythrocyte sedimentation rate (ESR)
C. Decreased megakaryocytes
D. Increased WBC
Answer: A. Decreased platelet count
Explanation:
A. Decreased platelet count
A client who has ITP has an autoimmune response that results in a decreased platelet count.
B. Increased erythrocyte sedimentation rate (ESR)
An increased ESR is an indication of chronic renal failure.
C. Decreased megakaryocytes
A client who has ITP will have megakaryocytes within the expected reference range.
D. Increased WBC
An increased WBC is an indication of infection.
208. A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the
following results should the nurse report to the provider?
A. Hgb 20 g/dL
B. Total bilirubin 5 mg/dL
C. Blood glucose 30 mg/dL
D. WBC count 20,000/mm3
Answer: B. Blood glucose 30 mg/dL
Explanation:
A. Hgb 20 g/dL
This value is within the expected reference range of 14 to 24 g/dL for a newborn who is 24 hr
old.
B. Total bilirubin 5 mg/dL
This value is within the expected reference range of 2 to 6 mg/dL for a newborn who is 24 hr old.
C. Blood glucose 30 mg/dL
Newborns less than 24 hr old should have a blood glucose of 40 to 60 mg/dL. Newborns who are
greater than 24 hr old should have a blood glucose of 50 to 90 mg/dL. A blood glucose level of

30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be
reported to the provider.
D. WBC count 20,000/mm3
This value is within the expected reference range of 9,000 to 30,000/mm3 for a newborn who is
24 hr old.
209. A nurse is providing teaching about family planning to a client who has a new prescription
for a diaphragm. Which of the following statements should the nurse include in the teaching?
A. "You should replace the diaphragm every 5 years."
B. "You should leave the diaphragm in place for at least 6 hours after intercourse."
C. "You should use an oil-based product as a lubricant when inserting the diaphragm."
D. "You should insert the diaphragm when your bladder is full."
Answer: B. "You should leave the diaphragm in place for at least 6 hours after intercourse."
Explanation:
A. "You should replace the diaphragm every 5 years."
The client should replace the diaphragm every 2 years.
B. "You should leave the diaphragm in place for at least 6 hours after intercourse."
The client should keep the diaphragm in place for at least 6 hr after intercourse to provide
protection against pregnancy.
C. "You should use an oil-based product as a lubricant when inserting the diaphragm."
The client should avoid using oil-based products because they can weaken the rubber in the
diaphragm.
D. "You should insert the diaphragm when your bladder is full."
The client should have an empty bladder prior to inserting the diaphragm.
210. A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of
the following statements by the client indicated an understanding of the teaching?
A. "I will receive this medication if my baby is Rh-negative."
B."I will receive this medication when I am in labor."
C. "I will need a second dose of this medication when my baby is 6 weeks old."
D. "I will need this medication if I have an amniocentesis."

Answer: D. "I will need this medication if I have an amniocentesis."
Explanation:
A. "I will receive this medication if my baby is Rh-negative."
Rho(D) immune globulin is administered to a client who is Rh-negative and gives birth to a Rhpositive newborn.
B."I will receive this medication when I am in labor."
Rho(D) immune globulin is administered at 28 weeks of gestation or after birth if the newborn is
Rh-positive.
C. "I will need a second dose of this medication when my baby is 6 weeks old."
Rho(D) immune globulin is administered at 28 weeks of gestation to clients who are Rh-negative
and following the birth of a newborn who is Rh-positive.
D. "I will need this medication if I have an amniocentesis."
Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis
because of the potential of fetal RBCs entering the maternal circulation.
211. A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of
gestation. Which of the following conditions is an indication for fetal assessment using electronic
fetal monitoring?
A. Oligohydramnios
B. Hyperemesis gravidarum
C. Leukorrhea
D. Periodic tingling of the fingers
Answer: A. Oligohydramnios
Explanation:
A. Oligohydramnios
The nurse should identify that oligohydramnios requires further fetal assessment using electronic
fetal monitoring. Other conditions that require further assessment include hypertension, diabetes,
intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death,
post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.
B. Hyperemesis gravidarum

Hyperemesis gravidarum is not an indication for further fetal assessment using electronic fetal
monitoring unless complications occur.
C. Leukorrhea
Leukorrhea is a common finding during pregnancy and is not an indication for further fetal
assessment using electronic fetal monitoring unless complications occur.
D. Periodic tingling of the fingers
Periodic tingling of the fingers is a common finding during pregnancy and is not an indication
for further fetal assessment using electronic fetal monitoring.
212. A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose
tolerance test. Which of the following statements should the nurse include in the teaching?
A. "You will need to drink the glucose solution 2 hours prior to the test."
B. "Limit your carbohydrate intake for 3 days prior to the test."
C. "A blood glucose of 130 to 140 is considered a positive screening result."
D. "You will need to fast for 12 hours prior to the test."
Answer: C. "A blood glucose of 130 to 140 is considered a positive screening result."
Explanation:
A. "You will need to drink the glucose solution 2 hours prior to the test."
The nurse should instruct the client to drink the glucose solution 1 hr prior to the test.
B. "Limit your carbohydrate intake for 3 days prior to the test."
The nurse should instruct the client that she should not limit her carbohydrate intake.
C. "A blood glucose of 130 to 140 is considered a positive screening result."
The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered
a positive screening. If the client receives a positive result, she will need to undergo a 3-hr
glucose tolerance test to confirm if she has gestational diabetes mellitus.
D. "You will need to fast for 12 hours prior to the test."
The nurse should instruct the client that fasting is not required for a 1-hr glucose tolerance test.
213. A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to
the right above the unbilicus. Which of the following interventions should the nurse perform?
A. Reassess the client in 2 hr.

B. Administer simethicone.
C. Assist the client to empty her bladder.
D. Instruct the client to lie on her right side.
Answer: C. Assist the client to empty her bladder.
Explanation:
A. Reassess the client in 2 hr.
The nurse should assess the client more frequently after birth to determine the position of the
uterus and to intervene as soon as possible if necessary.
B. Administer simethicone.
The nurse should administer simethicone to reduce bloating, discomfort, or pain caused by
excessive gas.
C. Assist the client to empty her bladder.
The nurse should assist the client to empty her bladder because the assessment findings indicate
that the client's bladder is distended. This can prevent the uterus from contracting, resulting in
increased vaginal bleeding or postpartum haemorrhage.
D. Instruct the client to lie on her right side.
Lying on her right side will not resolve the client's displaced uterus.
214. A nurse in a women's health clinic is providing teaching about nutritional intake to a client
who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of
which of the following nutrients?
A. Calcium
B. Vitamin E
C. Iron
D. Vitamin D
Answer: C. Iron
Explanation:
A. Calcium
The recommendation for calcium intake during pregnancy is the same as that for women who are
not pregnant: 1,300 mg/day for women younger than 19 years old and 1,000 mg/day for women
between the ages of 19 and 50 years old.

B. Vitamin E
The recommendation for vitamin E intake during pregnancy is 15 mg/day, the same as that for
women who are not pregnant.
C. Iron
The recommendation for iron intake during pregnancy is higher than that for women who are not
pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is
15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of
19 and 50 years old.
D. Vitamin D
The recommendation for vitamin D intake during pregnancy is 600 IU/day, the same as that for
women who are not pregnant.
215. A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is
experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal
examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is
in which of the following phases of labor?
A. Active
B. Transition
C. Latent
D. Descent
Answer: B. Transition
Explanation:
A. Active
The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions
every 3 to 5 min, each lasting 40 to 70 seconds.
B. Transition
The nurse should identify that the client is in the transition phase of labor. This phase is
characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each
lasting 45 to 90 seconds.
C. Latent

The latent phase of labor is characterized by cervical dilation of 0 to 3 cm and contractions every
5 to 30 min, each lasting 30 to 45 seconds.
D. Descent
The descent phase of labor is characterized by active pushing with contractions every 1 to 2 min,
each lasting for 90 seconds.
216. A nurse is planning care for a client who is in labor and is requesting epidural anaesthesia
for pain control. Which of the following actions should the nurse include in the plan of care?
A. Place the client in a supine position for 30 min following the first dose of aesthetic solution.
B. Administer 1,000 mL of dextrose 5% in water prior to the first dose of aesthetic solution.
C. Monitor the client's blood pressure every 5 min following the first dose of aesthetic solution.
D. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose
of aesthetic solution.
Answer: C. Monitor the client's blood pressure every 5 min following the first dose of aesthetic
solution.
Explanation:
A. Place the client in a supine position for 30 min following the first dose of aesthetic solution.
The nurse should plan to position the client upright to allow the aesthetic solution to flow
downward. If additional pain management is needed for a caesarean birth, the nurse can place the
client supine with her head and shoulders elevated and at a lateral tilt to increase perfusion to the
fetus.
B. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anaesthetic solution.
The nurse should plan to administer 500 to 1,000 mL of lactated Ringer's or 0.9% sodium
chloride 15 to 30 min prior to the administration of the first dose of anesthetic solution to
decrease the maternal risk for hypotension. The nurse should not administer dextrose because it
can cause maternal hyperglycemia and neonatal hypoglycemia.
C. Monitor the client's blood pressure every 5 min following the first dose of anaesthetic
solution.
The nurse should plan to obtain a baseline blood pressure prior to the initiation of aesthetic
solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min
to assess for maternal hypotension caused by the anaesthetic solution.

D. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose
of aesthetic solution.
The nurse should not plan to restrict the client's intake prior to the epidural placement and the
first dose of anaesthetic solution because NPO status is not indicated for this procedure.
217. A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations
requires intervention by the nurse?
A. Acrocyanosis of the extremities
B. Murmur at the left sternal border
C. Substernal chest retractions while sleeping
D. Positive Babinski reflex
Answer: C. Substernal chest retractions while sleeping
Explanation:
A. Acrocyanosis of the extremities
Acrocyanosis of the extremities is an expected manifestation in newborns. Acrocyanosis is a
bluish discoloration of the newborn's hands and feet.
B. Murmur at the left sternal border
An audible murmur heard at the left sternal border is an expected manifestation in newborns.
C. Substernal chest retractions while sleeping
Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This
manifestation requires further assessment and intervention by the nurse.
D. Positive Babinski reflex
A positive Babinski reflex is an expected manifestation in newborns. This reflex is elicited when
a newborn's sole is stroked with a finger upward along the lateral aspect of the sole and then
across the ball of the foot and, in response, the toes hyperextend, and the large toe dorsiflexes.
218. FHR can be heard by a doppler at
Answer: 10-12 weeks gestation
219. When should a nurse start measuring a woman's fundal height?
Answer: after 12 weeks gestation

220. Between 18-30 weeks the fundal height should measure what?
Answer: it should equal the week of gestation
221. MSAFP screening is done at
Answer: 15-22 weeks gestation
222. Smoking tobacco during pregnancy is associated with
Answer: low birth weight
223. Pregnant women should consume how much water each day?
Answer: 2-3 Liters of water each day
224. Regarding kick counts what are the signs the woman needs further evaluation?
Answer: there are less than 3 kicks in one hour or there are no signs of foetal movement for 12
hours
225. Recommended weight gain during pregnancy
Answer: 25-30 pounds, 3-4 pounds first trimester and 1 pound per week last two trimesters
226. Foods high in folic acid
Answer: leafy greens, dried peas, dried beans, seeds, orange juice
227. Recommended amount of folic acid intake during pregnancy
Answer: 600 mcg
228. Recommended folic acid intake for lactating pregnant women
Answer: 500 mcg
229. What vitamin increases absorption of iron
Answer: vitamin c

230. Client's bladder needs to be ____ before an ultrasound
Answer: full
231. BPP normal score
Answer: 8-10
232. BPP abnormal score
Answer: less than 4
233. If a BPP comes back as a 6
Answer: it should be retested
234. BPP assesses for
Answer: fetal well being
235. Non stress test (NST)
Answer: assesses fetal well-being during third trimester
236. Reactive NST
Answer: normal FHR baseline with moderate variability and two accelerations 15 beats per
minute for at least 15 seconds over 20 minute period
237. Non-reactive NST indicates
Answer: FHR did not accelerate adequately with fetal movement
238. Positive contraction stress test (CST) is
Answer: abnormal and indicates late decelerations on more than half of the contractions
239. When is amniocentesis is performed
Answer: after 14 weeks gestation

240. AFP can be measured from amniotic fluid between
Answer: 16-18 weeks
241. PG on fetal lung test indicates
Answer: respiratory distress
242. CVS can be done at
Answer: 10-12 weeks gestation
243. When can a quad screen be done
Answer: 15-20 weeks gestation
244. MSAFP can be done when
Answer: 16-18 weeks gestation
245. Amniocentesis requires the bladder to be
Answer: empty
246. Labor occurs ___ hours after ROM
Answer: 24 hours
247. First stage of labor
Answer: 1-1.5 cm
248. Latent phase of labor
Answer: 0-3 cm, mild to moderate contractions q5-30 min lasting 30-40 seconds
249. Active phase of labor
Answer: 4-7 cm, moderate to strong contractions q3-5 min lasting 40-70 seconds

250. Transition phase of labor
Answer: 8-10 cm, strong contractions q2-3 min lasting 45-90 seconds
251. Second stage of labor
Answer: birth
252. Third stage of labor
Answer: delivery of placenta
253. Fourth stage of labor
Answer: stabilization of vital signs first four hours postpartum
254. Minimal variability
Answer: less than 5 contractions per min
255. Moderate variability
Answer: 6-25 contractions per min, normal
256. Marked variability
Answer: more than 25 contractions per min
257. Fetal bradycardia
Answer: less than 60 beats per min
258. Fetal tachycardia
Answer: more than 110 beats per min
259. First degree laceration
Answer: skin of perineum
260. Second degree laceration

Answer: skin and muscles of perineum
261. Third degree laceration
Answer: skin and muscles of perineum and anal sphincter
262. Fourth degree laceration
Answer: skin and muscles of perineum and anal sphincter and anterior rectal wall
263. High risk of ____ with external cephalic version
Answer: cord prolapse
264. BISHOP score when ready for labor
Answer: nuliparas 9 multipara greater than 5
265. Dystocia
Answer: prolonged and difficult labor
266. Before administering pictocin where should the fetus be?
Answer: 0 station
267. Discontinue oxytocin if
Answer: contraction frequency more than every 2 min and last longer than 90 seconds with no
relaxation period between contractions
268. Amnioinfusion used to
Answer: reduce variable decelerations and dilute meconium stained amniotic fluid
269. Cold cabbage leaves
Answer: decreases swelling and relieves breast soreness
270. Postpartum mother should not lift anything heavier than

Answer: the newborn
271. Postpartum mother should consume ___ mL of water each day
Answer: 2000-3000 mL
272. Postpartum lactating women should consume additional ___ calories per day
Answer: 500 calories
273. Avoid sexual intercourse until
Answer: laceration has healed and vaginal discharge has turned white
274. Thrombophlebitis arm positioning
Answer: above the level of the heart
275. Postpartum hemorrhage blood loss
Answer: vaginal more than 500 mL and c-section more than 1000 mL
276. Complications of postpartum hemorrhage
Answer: hypovolemic shock and anaemia
277. Postpartum hemorrhage vital signs
Answer: hypotension and tachycardia
278. Meds given for postpartum hemorrhage
Answer: oxytocin, methergen, cytotec, hembate
279. Subinvolution
Answer: uterus fails to return to normal size
280. APGAR score less than 3
Answer: severe distress

281. APGAR score 4-6
Answer: moderate distress
282. APGAR score greater than 7
Answer: stable newborn
283. Normal newborn weight
Answer: 2500-4000g
284. Low birth weight
Answer: less than 2500g
285. Signs of respiratory distress
Answer: grunting, nasal flaring, chest retractions
286. Normal newborn BP
Answer: 60-80/40-50
287. Normal newborn temp
Answer: 97.7-98;9
288. Milia
Answer: raised white spots (normal)
289. Mongolian spots
Answer: purple spots of pigmentation
290. Telangectiatic nevi
Answer: flat pink or red marks that easily blanch

291. Nevus flamues (port wine stains)
Answer: capillary angioma purple or red on newborns face that does not go away
292. Erythema toxicum
Answer: newborn rash during first 3 weeks
293. Normal newborn respiratory rate
Answer: 30-60 breaths per minute
294. When can bathing immersion be done?
Answer: when the umbilical cord has fallen off and the circumcision site has completely healed
295. How long should the newborn nurse?
Answer: 15-20 min
296. Formula fed newborns should be burped
Answer: every 15-30 mL
297. Newborns should have how many wet diapers per day?
Answer: 6-8 wet diapers and 3-4 stools per day
298. GBS can be tested when?
Answer: 35-37 weeks gestation
299. Terbutaline (brethine)
Answer: relaxes uterine smooth muscle to stop uterine contractions
300. Indomethacin
Answer: NSAID that suppresses preterm labor and uterine contractions
301. Betamethasone
Answer: glucocorticosteroid given to enhance fetal lung maturity