Maternity Answer Key

1. The process of implantation is characterized by which of following processes? Select all that apply.

1. The trophoblast attaches itself to the surface of the endometrium.2. The most frequent site of attachment is the lower part of the anterior uterine wall.3. Between 7 and 10 days, the zona pellucida disappears and the blastocyst implants itself in

the uterine lining.4. The lining of the uterus thins below the implanted blastocyst.5. The cells of the trophoblast grow down into the uterine lining, forming the chorionic villi.

Correct Answers: 1; 3; 5

2. The placenta produces hormones that are vital to the function of the fetus. Which hormone is primarily responsible for the maintenance of pregnancy past the eleventh week?

1. Human chorionic gonadotropin (hCG)2. Human placental lactogen (hPL)3. Estrogen4. Progesterone

Correct Answer: 4

3. A teaching plan for a client with premenstrual syndrome (PMS) should include a recommendation to restrict her intake of:

1. High-starch foods such as potatoes and spaghetti.2. Chicken, eggs, and fish.3. Breads, cereals, and beans.4. Coffee, colas, and chocolate cake.

Correct Answer: 4

4. A nonpregnant client reports a fishy-smelling, thin, white, watery vaginal discharge. She is diagnosed with bacterial vaginosis (BV). The nurse would be expecting to administer:

1. Penicillin G (Bicillin) 2 million units IM one time.2. Zithromax (Azithromycin) 1 mg p.o. b.i.d. for 2 weeks.3. Doxycycline (Vibramycin) 100 mg p.o. b.i.d. for a week.4. Metronidazole (Flagyl) 500 mg p.o. b.i.d. for a week.

Correct Answer: 4

5. During the initial visit with the nurse at the fertility clinic, the client asks what effect cigarette smoking has on the ability to conceive. The nurse’s best response is:

1. “Smoking has no effect.”2. “Only if you smoke more that one pack a day will you experience difficulty.”3. “After your first semen analysis, we will determine if there will be any difficulty.”4. “Smoking can affect sperm motility.”

Correct Answer: 4

6. The nurse is reviewing assessment data from several different male clients. Which one should receive information about causes of infertility?

1. Circumcised client2. Client with a history of premature ejaculation

3. Client with a history of measles at age 124. Client employed as an engineer

Correct Answer: 2

7. The nurse is planning to teach couples factors that influence fertility. Which of the following should not be included in the teaching plan?

1. Sexual intercourse should occur four times a week.2. Get up to urinate 1 hour after intercourse.3. Do not douche.4. Institute stress-reduction techniques.

Correct Answer: 1

8. While teaching a preconception class, the nurse includes which of the following recommendations to decrease the risk of neural tube defects?

1. 500 mg vitamin C every day2. 0.4 mg folate every day3. 1500 mg calcium every day4. 600 mg vitamin A every day

Correct Answer: 2

9. A client with a normal prepregnancy weight asks why she has been told to gain 25–35 pounds during her pregnancy but her underweight friend was told to gain more weight. The nurse should tell the client that recommended weight gain during pregnancy should be:

1. 25–35 pounds, regardless of a client’s prepregnant weight.2. More than 25–35 pounds for an overweight woman.3. Up to 40 pounds for an underweight woman.4. The same for a normal weight woman as for an overweight woman.

Correct Answer: 3

10. The nurse understands that a client’s pregnancy is progressing normally when which of the following physiologic changes are documented on the prenatal record of a woman at 36 weeks’ gestation? Select all that apply1. The joints of the pelvis have relaxed, causing a waddling gait.2. The cervix is firm and purplish–blue in color.3. The uterus vasculature contains one-sixth of the total maternal blood volume.4. Gastric emptying time is prolonged, and the client complains of constipation and bloating.5. Supine hypotension, creating dizziness, occurs when the client lies on her back.Correct Answer: 1; 3; 4; 5

11. It is one week before a pregnant client’s due date. The nurse notes on the chart that the client’s pulse rate was 74–80 before pregnancy. Today, the client’s pulse rate at rest is 90. The nurse should take which of the following actions?1. Chart the findings.2. Notify the physician of tachycardia.3. Prepare the client for an electrocardiogram (EKG).4. Prepare the client for transport to the hospital.

Correct Answer: 1

12. A pregnant client at 16 weeks’ gestation has a hematocrit of 35%. Her prepregnancy hematocrit was 40%. Which of the following statements by the nurse best explains this change?1. “Because of your pregnancy, you’re not making enough red blood cells.”2. Because your blood volume has increased, your hematocrit count is lower.”3. This change could indicate a serious problem that might harm your baby.”4. “You’re not eating enough iron-rich foods like meat.”Correct Answer: 2

13. A client complains that during her first months of pregnancy, “It seems like I have to go to the bathroom every five minutes.” The nurse relates to the client that this is because:1. The client probably has a urinary tract infection.2. Bladder capacity increases throughout pregnancy.3. The growing uterus puts pressure on the bladder.4. Some women are very sensitive to body function changes.Correct Answer: 3

14. A client who is in the second trimester of pregnancy tells the nurse that she has developed a darkening of the line in the midline of her abdomen from the symphysis pubis to the umbilicus. Which of the following are other expected changes during pregnancy that she also might notice?1. Lightening of the nipples and areolas2. Reddish streaks called striae on her abdomen3. A decrease in hair thickness4. Small purplish dots on her face and armsCorrect Answer: 2

15. The nurse is caring for a pregnant client who speaks little English. Which of the following actions should the nurse take to make certain that the client understands the plan of care?1. Write all of the instructions down and send them home with the client.2. Obtain a medical interpreter of the language the client speaks.3. Ask a housekeeper who speaks this language to interpret.4. Use gestures and facial expressions to get the plan across.Correct Answer: 2

16. Which of the following pieces of information that the nurse obtains from a pregnant client would indicate this client is at risk for preterm labor? 1. The client smokes two packs of cigarettes per day and delivered her last child at 34 weeks.2. The client has group B streptococcus in her urine, and is primiparous.3. The client had congenital hip dysplasia as a child and is 15 pounds overweight.4. The client lives in a second-floor apartment without stairs, and walks to work.Correct Answer: 1

17. When giving her obstetrical history, your pregnant client tells you that she has had two prior pregnancies. She had a miscarriage with the first pregnancy at 8 weeks. The second pregnancy

was twin girls who were born at 34 weeks, but died 3 days later. The nurse should record that the client is:1. Gravida 3 para 1.2. Gravida 3 para 0.3. Gravida 3 para 2.4. Gravida 2 para 3.Correct Answer: 1

18. The nurse is assessing a newly pregnant client. Which of the following findings does the nurse note as a normal psychosocial stage in this client’s first trimester?

1. An unlisted telephone number2. Reluctance to tell the partner of the pregnancy3. Parental disapproval of the woman’s partner4. Ambivalence about the pregnancy

Correct Answer: 4.

19. The clinic nurse is assisting with an initial prenatal assessment. The following findings are present: Spider nevi present on lower legs; dark pink, edematous nasal mucosa; mild enlargement of the thyroid gland; mottled skin and pallor of palms and nailbeds; heart rate 88 with murmur present. What is the best action for the nurse to take based on these findings?1. Document the findings on the prenatal chart.2. Have the physician see the client today.3. Instruct the client to avoid direct sunlight.4. Analyze previous thyroid hormone lab results.Correct Answer: 2

20. The primiparous client has completed her first prenatal clinic appointment. She is asking how often prenatal visits will be done if everything remains normal and she develops no complications. Which of the following statements best answers her question? “Prenatal visits are scheduled:1. "Every 2 weeks for the first 28 weeks, then every week.”2. 'Every 4 weeks until 30 weeks, every 3 weeks until 36 weeks, then every week.”3. 'Every 4 weeks until 28 weeks, every 2 weeks until 36 weeks, then every week.”4. "Every 4 weeks until 30 weeks, then every other week.”Correct Answer: 3

21. A client presents to the antepartum clinic with a history of a 20-pound weight loss. Her pregnancy test is positive. She is concerned about gaining the weight back, and asks the nurse if she can remain on her diet. The nurse’s best response would be:

1. “As long as you supplement your diet with the prenatal vitamin, the amount of weight you gain in pregnancy is not significant.”

2. “I understand that gaining weight after such an accomplishment must not look attractive, but weight gain during pregnancy is important for proper fetal growth.”

3. “Dieting during pregnancy is considered child neglect.”4. “Excessive weight gain in pregnancy is due to water retention, so weight loss

following birth will not be an issue.”

Correct Answer: 2

22. The pregnant client states she does not want “to take all these supplements.” What recommendations could the nurse make for the client? Select all that apply.

1. “Folic acid has been found to be essential for minimizing the risk of neural tube defects.”2. “You do not have to take these supplements if you think you are healthy enough.”3. “Most women do not have adequate intake of iron prepregnancy, and iron needs increase

with pregnancy.”4. “These medications do the same thing. I will call your physician to cancel one of your

medications.”Answers: 1; 3

23. Niacin intake should increase during pregnancy. Which of the following foods would the nurse suggest to the client to increase her intake of niacin?

1. Fish2. Apples3. Broccoli4. Lettuce

Correct Answer: 1

24. The pregnant client cannot tolerate milk or meat. What would the nurse recommend to the client to assist in meeting protein needs?

1. Wheat bread and pasta2. Ice cream and peanut butter3. Eggs and tofu4. Beans and potatoes

Correct Answer: 3

25. A pregnant client confides to the nurse that she is eating laundry starch daily. The nurse should assess the client for:

1. Alopecia.2. Weight loss.3. Iron-deficiency anemia.4. Fecal impaction.

Correct Answer: 3

26. A teenage pregnant client is diagnosed with iron-deficiency anemia. Which nutrient should the nurse encourage to increase iron absorption?

1. Vitamin A2. Vitamin C3. Vitamin D4. Vitamin E

Correct Answer: 2

27. When preparing nutritional instruction, which of the following pregnant clients would the nurse consider highest-priority?

1. 30-year-old G22. 22-year-old primigravida3. 35-year-old G44. 15-year-old nulligravida

Correct Answer: 4

28. When preparing nutritional instruction, which of the following pregnant clients would the nurse consider highest-priority?

1. 30-year-old G22. 22-year-old primigravida3. 35-year-old G44. 15-year-old nulligravida

Correct Answer: 4

29. A woman at 28 weeks’ gestation is asked to keep a fetal activity diary and to bring the results with her to her next clinic visit. One week later, she calls the clinic and anxiously tells the nurse that she has not felt the baby move for over 30 minutes. The most appropriate initial comment by the nurse would be:

1. “You need to come to the clinic right away for further evaluation.”2. “Have you been smoking?”3. “When did you eat last?”4. “Your baby might be asleep.”

Correct Answer: 4

30. Which client's indications most warrant fetal monitoring in the third trimester?1. Gravida 4, para 3, 39 weeks, with a history of one spontaneous abortion at 8 weeks2. Gravida 1, para 0, 40 weeks, with a history of endometriosis and a prior

appendectomy3. Gravida 3, para 2, with a history of gestational diabetes controlled by diet4. Gravida 2, para 1, 36 weeks, with hypertension disorder of pregnancy

Correct Answer: 4

31. A type 1 diabetic who is at 32 weeks’ gestation is having a nonstress test for fetal well-being, since she has been having problems with glucose control. Which of the following meets the criteria for her test to be considered reactive?1. Fetal heart rate baseline of 150 with two accelerations to 160 for 10 seconds within 20

minutes2. Fetal heart rate baseline of 140 with one acceleration to 160 for 15 seconds within 30

minutes3. Fetal heart rate baseline of 140 with two accelerations to 155 for 15 seconds within 20

minutes4. Fetal heart rate baseline of 130 with two accelerations to 140 for 15 seconds within 20

minutesCorrect Answer: 3

32. Of all the clients who have been scheduled to have a biophysical profile, the nurse would

clarify the order for which client?1. A gravida with intrauterine growth restriction2. A gravida with mild hypertension of pregnancy3. A gravida who is post-term4. A gravida who complains of decreased fetal movement for 2 days

Correct Answer: 2

33. During a nonstress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test, and last 20 seconds each. The nurse realizes these results will be interpreted as:

1. A negative test.2. A reactive test.3. A nonreactive test.4. An equivocal test.

Correct Answer: 3

34. Each of the following pregnant women is scheduled for a 14-week antepartal visit. In planning care, the nurse would give priority teaching on amniotic fluid alpha-fetoprotein (AFP) screening to which client?

1. 28-year-old with history of rheumatic heart disease2. 18-year-old with exposure to HIV3. 20-year-old with a history of preterm labor4. 35-year-old with a child with spina bifida

Correct Answer: 4

35. The nurse knows that a lecithin/sphingomyelin (L/S) ratio finding of 2:1 on amniotic fluid means:

1. Fetal lungs are still immature.2. The fetus has a congenital anomaly.3. Fetal lungs are mature.4. The fetus is small for gestational age.

Correct Answer: 3

36. A 20-year-old woman is at 28 weeks' gestation. Her prenatal history reveals previous drug abuse, and urine screening indicates that she has recently used heroin. The nurse should recognize that the woman is at increased risk for:

1. Erythroblastosis fetalis.2. Diabetes mellitus.3. Abruptio placentae.4. Pregnancy-induced hypertension.

Correct Answer: 4

37. A woman’s history and appearance suggest drug abuse. The nurse’s best approach would be to:

1. Ask the woman directly, “Do you use any street drugs?”2. Ask the woman if she would like to talk to a counselor.

3. Ask some questions about over-the-counter medications and avoid the mention of illicit drugs.

4. Explain how harmful drugs can be for her baby.Correct Answer: 1

38. The client has just been diagnosed as diabetic. The nurse knows teaching was effective when the client says:

1. “Ketones in my urine mean that my body is using the glucose appropriately.”2. “I should be urinating frequently and in large amounts to get rid of the extra sugar.”3. “My pancreas is making enough insulin, but my body isn’t using it correctly.”4. “I might be hungry frequently because the sugar isn’t getting into the tissues the way

it should.”Correct Answer: 4

39. A newly diagnosed type 1, well-controlled, insulin-dependent diabetic client at 20 weeks’ gestation asks the nurse how her diabetes will affect her baby. The best explanation would include:

1. “Your baby might be smaller than average at birth.”2. “Your baby will probably be larger than average at birth.”3. “As long as you control your blood sugar, your baby will not be affected at all.”4. “There are no effects until about 2 hours after birth, when your baby might have low

blood sugar.”Correct Answer: 2

40. A 26-year-old multipara is at 26 weeks’ gestation. Her previous births include two large-for-gestational-age babies and one unexplained stillbirth. The nurse suspects gestational diabetes. Which tests would the nurse anticipate as being most definitive in making a diagnosis?

1. A 50 g, 1-hour glucose screening test2. A single fasting glucose level3. A 100 g, 1-hour glucose tolerance test4. A 100 g, 3-hour glucose tolerance test

Correct Answer: 4

41. A 26-year-old multigravida at 28 weeks' gestation has developed gestational diabetes. She has a program of regular exercise that includes walking, bicycling, and swimming. What instructions should be included in a teaching plan for this client?

1. Exercise either just before meals or wait until 2 hours after a meal.2. Carry hard candy (or other simple sugar) when exercising.3. If your finger stick shows less than 120 mg/dL, ingest 20 g of carbohydrate.4. If your finger stick shows more than 120 mg/dL, drink a glass of whole milk or other

source of carbohydrate.Correct Answer: 2

42. A woman is married to an intravenous drug user. She had a negative HIV screening test just after missing her first menstrual period. Which of the following would indicate that the client needs to be retested for HIV?

1. A hemoglobin of 11 g/dL and a rapid weight gain2. Elevated blood pressure and ankle edema3. Shortness of breath and frequent urination4. Unusual fatigue and recurring candida vaginitis

Correct Answer: 4

43. A client admits to being HIV-positive, and that she is at about 16 weeks' gestation. Which statements made by the client indicate an understanding of the plan of care both during the pregnancy and postpartally? Select all that apply.

1. “I will take my Zidovudine (ZVD) at the same time every day.”2. “During labor and delivery, I can expect the Zidovudine (ZVD) to be given in my

IV.” 3. “After delivery, the dose of Zidovudine (ZVD) will be doubled to prevent further

infection.”4. “My baby will be started on Zidovudine (ZVD) within 12 hours of delivery.”


44. A client is at 12 weeks' gestation with her first baby. She has cardiac disease, class III. She states that she had been taking sodium warfarin (Coumadin), but her physician changed her to heparin. She asks the nurse why this was done. The nurse’s response should be:

1. “Heparin may be given by mouth, while Coumadin must be injected.”2. “Heparin is safer because it does not cross the placenta.”3. “They are the same drug, but heparin is less expensive.”4. “Coumadin interferes with iron absorption in the intestines.”

Correct Answer: 2

45. A woman is 16 weeks pregnant. She has had cramping, backache, and mild bleeding for the past 3 days. Her physician determines that her cervix is dilated to 2 centimeters, with 10% effacement, but membranes are still intact. She is crying, and says to the nurse, “Is my baby going to be okay?” In addition to acknowledging the client’s fear, the nurse should also say:

1. “Your baby will be fine. We’ll start IV, and get this stopped in no time at all.”2. “Your cervix is beginning to dilate. That is a serious sign. We will continue to

monitor you and the baby for now.”3. “You are going to miscarry. But you should be relieved, because most miscarriages

are the result of abnormalities in the fetus.”4. “I really can’t say. However, when your physician comes, I’ll ask her to talk to you

about it.”Correct Answer: 2

46. A woman is at 7 weeks' gestation, and is diagnosed with hyperemesis gravidarum. Which nursing diagnosis would receive priority?

1. Fluid volume deficit2. Decreased cardiac output3. Risk for injury4. Alteration in nutrition: less than body requirements

Correct Answer: 1

47. The following are assessment findings for a client with pre-eclampsia: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 11 on dipstick; edema of the hands, ankles, and feet. On the next hourly assessment, which new assessment finding would be an indication of worsening of the pre-eclampsia?

1. Blood pressure 158/1042. Urinary output 20 ml/hour3. Reflexes 214. Platelet count 150,000

Correct Answer: 2

48. A clinic nurse is planning when to administer Rh immune globulin (RhoGAM) to an Rh-negative pregnant client. When should the first dose of RhoGAM be administered?

1. After the birth of the infant2. 1 month postpartum3. During labor4. At 28 weeks’ gestation

Correct Answer: 4

49. A client is concerned because she has been told her blood type and her baby's are incompatible. The best response by the nurse would be:

1. "This is called ABO incompatibility, and if the baby becomes jaundiced, she can be treated with a special light treatment."

2. "This is a serious condition, and additional blood studies are currently in process to determine whether you need a medication to prevent it from occurring with a future pregnancy."

3. "This is a condition caused by a blood incompatibility between you and your husband, but does not affect the baby."

4. "This type of condition is very common, and the baby can receive a medication to prevent jaundice from occurring."

Correct Answer: 1

50. A woman has a hydatidiform mole (molar pregnancy) evacuated, and is prepared for discharge. The nurse should make certain that the client understands that it is essential that she:

1. Not become pregnant for at least 1 year.2. Receive RhoGAM with her next pregnancy and birth.3. Have her blood pressure checked weekly for the next 30 days.4. Seek genetic counseling with her partner before the next pregnancy.

Correct Answer: 1

51. A woman is 10 weeks pregnant. Her initial prenatal laboratory screening test for rubella showed an antibody titer of less than 1:6. The woman calls the clinic and tells the nurse that she has been exposed to measles. The nurse’s best response is:

1. “Since you are in your first trimester of pregnancy, this is not likely to be a problem.”2. “Would you like to see a counselor to talk about your options for the remainder of

your pregnancy?”

3. “You should come to the clinic in the next day or two for further evaluation.”4. “You need to have a rubella vaccination immediately. Can you get a ride to the clinic

today?”Correct Answer: 3

52. How would the nurse best analyze the results from a client’s sonogram that show the fetal shoulder as the presenting part?

1. Breech, transverse2. Breech, longitudinal3. Military, longitudinal4. Vertex, transverse

Correct Answer: 1

53. A nurse is aware that labor and birth will most likely proceed normally when the fetal position is:

1. Occiput posterior.2. Mentum anterior.3. Occiput anterior.4. Mentum posterior.

Correct Answer: 3

54. A primigravida client arrives in the labor and delivery unit and describes her contractions as occurring every 10–12 minutes, lasting 30 seconds. She is smiling and very excited about the possibility of being in labor. On exam, her cervix is dilated 2 cm, 100% effaced, and is a −2 station. What best describes this labor?

1. Second phase2. Latent phase3. Active phase4. Transition phase

Correct Answer: 2

55. A client is admitted to the labor and delivery unit with contractions that are 2 minutes apart, lasting 60 seconds. She reports that she had bloody show earlier that morning. A vaginal exam reveals that her cervix is 100 percent effaced and 8 cm dilated. The nurse knows that the client is in which phase of labor?

1. Active2. Latent3. Transition4. Fourth

Correct Answer: 3

56. To identify the duration of a contraction, the nurse would: 1. Start timing from the beginning of one contraction to the completion of the same

contraction.2. Time between the beginning of one contraction and the beginning of the next

contraction.

3. Palpate for the strength of the contraction at its peak.4. Time from the beginning of the contraction to the peak of the same contraction.

Correct Answer: 1

57. A client who is having false labor most likely would have: (Select all that apply.)1. Contractions that do not intensify while walking.2. An increase in the intensity and frequency of contractions.3. Progressive cervical effacement and dilatation.4. Pain in the abdomen that does not radiate.

Correct Answers: 1; 4

58. The labor nurse would not encourage a mother to bear down until the cervix is completely dilated to prevent: (Select all that apply.)

1. Maternal exhaustion.2. Cervical edema.3. Tearing and bruising of the cervix.4. Enhanced perineal thinning.


59. While caring for a labor client, you notice during a vaginal exam that the baby’s head has rotated internally. What would you expect the next set of cardinal movements for a baby in a vertex presentation to be?

1. Flexion, extension, restitution, external rotation, expulsion2. Expulsion, external rotation, restitution3. Restitution, flexion, external rotation, expulsion4. Extension, restitution, external rotation, expulsion

Correct Answer: 4

60. During maternal assessment, the nurse determines the fetus to be in a left occiput anterior (LOA) position. Auscultation of the fetal heart rate should begin in the:

1. Right upper quadrant.2. Left upper quadrant.3. Right lower quadrant. 4. Left lower quadrant.

Correct Answer: 4

61. Before performing Leopold’s maneuver, the nurse would: (Select all that apply.)1. Have the client empty her bladder.2. Place the client in Trendelenburg position.3. Have the client lie on her back with her feet on the bed and knees bent.4. Turn the client to her left side.

Answers: 1; 3

62. After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. You would interpret the decelerations to be consistent with:

1. Breech presentation.

2. Uteroplacental insufficiency.3. Compression of the fetal head.4. Umbilical cord comprehension.

Correct Answer: 4

63. The nurse is analyzing a fetal heart rate (FHR) monitor strip. The nurse notes that some early decelerations are present. The nurse explains to the client that early decelerations are most often related to:

1. Umbilical cord compression. 2. Fetal head compression.3. Uteroplacental insufficiency. 4. Fetal hypoxia.

Correct Answer: 2

64. A fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which of the following changes on the monitor strip?

1. Late decelerations2. Early decelerations3. Accelerations4. Increased long-term variability

Correct Answer: 3

65. A nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be:

1. Moderate long-term variability.2. Early decelerations.3. Late decelerations.4. Accelerations.

Correct Answer: 3

66. After noting meconium-stained amniotic fluid, fetal heart rate decelerations, and a fetal blood pH of 7.20, the physician diagnoses a severely depressed fetus. The appropriate nursing action at this time would be to:

1. Increase the mother’s oxygen rate. 2. Turn the mother to the left lateral position.3. Prepare the mother for a forceps or cesarean birth. 4. Increase the intravenous infusion rate.

Correct Answer: 3

67. A client delivered 30 minutes ago. Which postpartal assessment finding would require close nursing attention?

1. A soaked perineal pad since the last 15-minute check2. An edematous perineum3. A client with tremors4. A fundus located at the umbilicus

Correct Answer: 1

68. Two hours after delivery, a client’s fundus is boggy, and has risen to above the umbilicus. The first action the nurse would take is to:

1. Massage the fundus until firm. 2. Express retained clots. 3. Increase the intravenous solution. 4. Call the physician.

Correct Answer: 1

69. Oxytocin 20 units was administered at the time of placental delivery. This was done primarily to:

1. Contract the uterus and minimize bleeding. 2. Decrease breast milk production.3. Decrease maternal blood pressure.4. Increase maternal blood pressure.

Correct Answer: 1

70. Before applying a cord clamp, the nurse assesses the umbilical cord for the presence of vessels. The expected finding is:

1. One artery, one vein.2. Two arteries, one vein.3. Two veins, one artery.4. Two veins, two arteries.

Correct Answer: 2

71. A client’s labor has progressed so rapidly that a precipitous birth is occurring. The nurse should:

1. Go to the nurse’s station and immediately call the physician.2. Run to the delivery room for an emergency birth pack.3. Stay with the client and ask for auxiliary personnel for assistance.4. Try to delay the delivery of the infant’s head until the physician arrives.

Correct Answer: 3

72. Two hours after an epidural infusion has begun, a client complains of itching on the face and neck. The nurse should:

1. Remove the epidural catheter and place a Band-Aid at the injection site.2. Offer the client a cool cloth and let her know the itching is temporary.3. Recognize that this is a common side effect, and follow protocol for administration of

diphenhydramine (Benadryl).4. Call the anesthesia care provider to re-dose the epidural catheter.

Correct Answer: 3

73. Narcotic analgesia is administered to a laboring client at 10:00 A.M. The infant is delivered at 12:30 P.M. The nurse would anticipate that the narcotic analgesia could:

1. Be used in place of preoperative sedation.2. Result in neonatal respiratory depression.

3. Prevent the need for anesthesia with an episiotomy.4. Enhance uterine contractions.

Correct Answer: 2

74. After receiving nalbuphine hydrochloride (Nubain), labor progresses rapidly and the baby is born less than 1 hour later. The baby shows signs of respiratory depression. Which medication should the nurse be prepared to administer to the newborn?

1. Fentanyl (Sublimaze)2. Butorphanol tartrate (Stadol)3. Naloxone (Narcan)4. Pentobarbital (Nembutal)

Correct Answer: 3

75. Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring client in which position?

1. On her right side in the center of the bed, with her back curved2. Lying prone, with a pillow under her chest3. On her left side, with the bottom leg straight and the top leg slightly flexed4. Sitting on the edge of the bed, with her back slightly curved and her feet on a stool

Correct Answer: 4

76. A laboring client has received an order for epidural anesthesia. To prevent the most common complication associated with this procedure, the nurse would expect to:

1. Observe fetal heart rate variability. 2. Rapidly infuse 500–1000 ml of intravenous fluids.3. Place the client in a right lateral position.4. Teach the client appropriate breathing techniques.

Correct Answer: 2

77. A primigravida dilated to 5 cm has just received an epidural for pain. She complains of feeling lightheaded and dizzy within 10 minutes after the procedure. Her blood pressure before the procedure was 120/80 and is now 80/52. In addition to the bolus of fluids she has been given, which medication is preferred to use to increase her BP?

1. Epinephrine2. Terbutaline 3. Ephedrine4. Epifoam

Correct Answer: 3

78. A client is admitted to Labor and Delivery with a history of ruptured membranes for 2 hours. This is her sixth delivery; she is 40 years old, and smells of alcohol and cigarettes. This client is at risk for:1. Gestational diabetes.2. Placenta previa.3. Abruptio placentae.4. Placenta accreta.

Correct Answer: 3

79. A client was admitted to the labor area at 5 cm with ruptured membranes about 14 hours ago. The assessment data that would be most beneficial is:

1. Blood pressure.2. Temperature.3. Pulse.4. Respiration.

Correct Answer: 2

80. A pre-eclampsia patient is on magnesium sulfate. The nurse understands that magnesium sulfate will relax the smooth muscles, and should be alert for the development of:

1. Hypotension.2. Hypertension.3. Hypoglycemia.4. Hyperglycemia.

Correct Answer: 1

81. A preterm labor patient is receiving betamethasone. When the patient asks what this is for, the best response by the nurse would be:1. “It will help reduce uterine irritability.”2. “It is commonly used to prevent seizures.”3. “It will help reduce the severity of respiratory distress in your newborn.”4. “It will help to reduce softening of your cervix.”Correct Answer: 3

82. Which condition places a mother at risk for developing disseminating intravascular coagulation (DIC)?1. Diabetes mellitus2. Abruptio placentae3. Cesarean delivery4. MultiparityCorrect Answer: 2

83. A client at 32 weeks’ gestation is admitted with painless vaginal bleeding. Placenta previa has been confirmed by ultrasound. What should be included in the nursing plan? Select all that apply.1. No vaginal exams2. Encourage activity.3. No intravenous access until labor begins4. Evaluate fetal heart rate with an external monitor.5. Monitor blood loss, pain, and uterine contractility.Correct Answers: 1; 4; 5

84. A nurse is caring for a client with hydramnios. The nurse will watch for:1. Maternal chest pain, dyspnea, tachycardia, and hypotension.

2. Newborn congenital anomalies.3. Newborn postmaturity and renal malformations.4. Maternal prolonged labor.Correct Answer: 2

85. The nurse is caring for a newborn 30 minutes after birth. During an assessment of respiratory function, the following data are collected. Which of the following assessment findings would the nurse report as abnormal? Select all that apply.

1. Respiratory rate of 66 breaths per minute2. Periodic breathing with pauses of 25 seconds3. Chest and abdomen movements are synchronous.4. Grunting on expiration5. Nasal flaring6. Acrocyanosis


86. A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 bpm. What would be the most appropriate nursing action based on this assessment finding?

1. Call the physician.2. Administer oxygen. 3. Document the finding. 4. Place newborn under the radiant warmer.

Correct Answer: 3

87. A postpartum mother questions whether the environmental temperature should be warmer in the baby’s room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response by the nurse is based on which of the following newborn characteristics that affect the establishment of a neutral thermal environmental? Select all that apply.

1. Newborns have a decrease in subcutaneous fat. 2. Newborns have a thick epidermis layer. 3. Flexed posture of the term newborn4. Blood vessels are closer to the skin. 5. Newborns have an increase in subcutaneous fat.


88. Which of the following nursing interventions would protect the newborn from heat loss by convection?

1. Placing the newborn away from air currents2. Pre-warming the examination table3. Drying the newborn thoroughly4. Removing wet linens from the isolette

Correct Answer: 1

89. A new mother is concerned about a mass on the newborn’s head. The nurse assesses this to be a cephalhematoma. Which of the following characteristics would indicate a cephalhematoma? Select all that apply.

1. The mass appeared on the second day after birth.2. The mass appears larger when the newborn cries. 3. The head appears asymmetrical.4. The mass appears only on one side of the head.5. The mass overrides the suture line.

Correct Answers: 1; 4

90. A mother is concerned because the anterior fontanelle swells when the newborn cries. What would the nurse include in her teaching to a new mother about the normal findings concerning the fontanelles? Select all that apply.

1. The fontanelles can swell with crying.2. The fontanelles might be depressed.3. The fontanelles can pulsate with the heartbeat.4. The fontanelles might bulge.5. The fontanelles can swell when stool is passed.


91. In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn?

1. Eye prophylaxis medication2. Drying the newborn3. Vital signs4. Vitamin K injection

Correct Answer: 1

92. A nurse is instructing the nursing students about the procedure for vitamin K administration. What information should be included? Select all that apply.

1. Gently massage the site after injection.2. Use a 22 gauge 1-inch needle.3. Inject in the vastus lateralis muscle.4. Cleanse site with alcohol prior to injection.5. Inject at a 45-degree angle.6. Do not aspirate.


93. The nurse is caring for a postpartal client who is experiencing afterpains following the birth of her third child. Which of the following comfort measures should the nurse implement to decrease her pain? Select all that apply.

1. Offer warm blankets for her abdomen.2. Call the physician to report this finding.3. Inform her that this is not normal, and she will need an oxytocic agent.4. Massage the fundus of the uterus gently and observe lochia for clots.5. Administer a mild analgesic at bedtime to ensure rest.


94. The nurse would expect a physician to prescribe which of the following medications if a postpartum client were having heavy bleeding and a boggy uterus?

1. Methylergonovine maleate (Methergine)2. Rh immune globulin (RhoGAM)3. Terbutaline (Brethine)4. Docusate (Colace)

Correct Answer: 1

95. The postpartum client is concerned about mastitis because she experienced it with her last baby. Preventive measures the nurse could teach include:

1. Wearing a tight-fitting bra. 2. Limiting feedings to q.i.d. 3. Frequent breastfeeding. 4. Forcing fluids.

Correct Answer: 3

96. The most appropriate nursing diagnosis for a client with postpartum deep vein thrombosis is:1. Fluid volume excess related to tissue edema. 2. Sleep pattern disturbance related to tissue hypoxia. 3. Risk for infection related to obstructed venous return. 4. Ineffective tissue perfusion in the periphery related to obstructed venous return.

Correct Answer: 4

97. Which of the following would indicate the presence of a perineal wound infection? Select all that apply.

1. Redness2. Edema3. Vaginal bleeding 4. Warmth 5. Purulent drainage

Correct Answers: 1; 2; 4; 5

98. A postpartal client recovering from a deep vein thrombosis is being discharged. What areas of teaching on self-care and anticipatory guidance should the nurse discuss with the client? Select all that apply.

1. Avoid crossing her legs. 2. Avoid prolonged standing or sitting. 3. Take frequent walks. 4. Take a daily aspirin dose of 650 mg. 5. Avoid long car trips.


99. While being comforted in the Emergency Department, the 7-year-old sibling of a pediatric trauma victim blurts out to the nurse, “It’s all my fault! When we were fighting yesterday, I told

him I wished he was dead!” The nurse, realizing that the child is experiencing magical thinking, should respond by:

1. Asking the child if he would like to sit down and drink some water.2. Sitting the child down in an empty room with markers and paper so that he can draw

a picture.3. Calmly discussing the catheters, tubes, and equipment that the client requires, and

explaining to the sibling why the client needs them.4. Reassuring the child that it is normal to get angry and say things that we do not mean,

but that we have no control over whether an accident happens.Correct Answer: 4

100. The nurse talking with the parents of a toddler who is struggling with toilet training reassures them that their child is demonstrating a typical developmental stage that Erikson described as:

1. “Trust versus mistrust.”2. “Autonomy versus shame and doubt.”3. “Initiative versus guilt.”4. “Industry versus inferiority.”

Correct Answer: 2

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Maternity Answer Key