Maternal
& Child Health Nursing NCLEX part 1
All our efforts are to help to get your knowledge in easy, convenient
and efficient way. Use our free study materials and help others to get these
materials. Wish you get success in your carrier.
Join our telegram: https://t.me/thebossacademynet
PDF format, Answers and Rationales are available at the end of this questions.
1. A postpartum patient was in labor for 30 hours and
had ruptured membranes for 24 hours. For which of the following would the nurse
be alert?
A. Endometritis
B. Endometriosis
C. Salpingitis
D. Pelvic thrombophlebitis
2. A client at 36 weeks gestation is scheduled for a
routine ultrasound prior to an amniocentesis. After teaching the client about
the purpose for the ultrasound, which of the following client statements would
indicate to the nurse in charge that the client needs further instruction?
A. The ultrasound will help to locate the placenta
B. The ultrasound identifies blood flow through the
umbilical cord
C. The test will determine where to insert the needle
D. The ultrasound locates a pool of amniotic fluid
3. While the postpartum client is receiving heparin
for thrombophlebitis, which of the following drugs would the nurse expect to
administer if the client develops complications related to heparin therapy?
A. Calcium gluconate
B. Protamine sulfate
C. Methylergonovine (Methergine)
D. Nitrofurantoin (Macrodantin)
4. When caring for a 3-day-old neonate who is
receiving phototherapy to treat jaundice, the nurse in charge would expect to
do which of the following?
A. Turn the neonate every 6 hours
B. Encourage the mother to discontinue breastfeeding
C. Notify the physician if the skin becomes bronze in
color
D. Check the vital signs every 2 to 4 hours
5. A primigravida in active labor is about 9 days
post-term. The client desires a bilateral pudendal block anesthesia before
delivery. After the nurse explains this type of anesthesia to the client, which
of the following locations identified by the client as the area of relief would
indicate to the nurse that the teaching was effective?
A. Back
B. Abdomen
C. Fundus
D. Perineum
6. The nurse is caring for a primigravida at about 2
months and 1-week gestation. After explaining self-care measures for common
discomforts of pregnancy, the nurse determines that the client understands the
instructions when she says:
A. “Nausea and vomiting can be decreased if I eat a
few crackers before arising.”
B. “If I start to leak colostrum, I should cleanse my
nipples with soap and water.”
C. “If I have a vaginal discharge, I should wear nylon
underwear.”
D. “Leg cramps can be alleviated if I put an ice pack
on the area.”
7. Forty-eight hours after delivery, the nurse in
charge plans discharge teaching for the client about infant care. By this time,
the nurse expects that the phase of postpartum psychological adaptation that
the client would be in would be termed which of the following?
A. Taking in
B. Letting go
C. Taking hold
D. Resolution
8. A pregnant client is diagnosed with partial
placenta previa. In explaining the diagnosis, the nurse tells the client that
the usual treatment for partial placenta previa is which of the following?
A. Activity limited to bed rest
B. Platelet infusion
C. Immediate cesarean delivery
D. Labor induction with oxytocin
9. The nurse plans to instruct the postpartum client
about methods to prevent breast engorgement. Which of the following measures
would the nurse include in the teaching plan?
A. Feeding the neonate a maximum of 5 minutes per side
on the first day
B. Wearing a supportive brassiere with nipple shields
C. Breast-feeding the neonate at frequent intervals
D. Decreasing fluid intake for the first 24 to 48
hours
10. When the nurse on duty accidentally bumps the
bassinet, the neonate throws out its arms, hands opened, and begins to cry. The
nurse interprets this reaction as indicative of which of the following
reflexes?
A. Startle reflex
B. Babinski reflex
C. Grasping reflex
D. Tonic neck reflex
11. A primigravida client at 25 weeks gestation visits
the clinic and tells the nurse that her lower back aches when she arrives home
from work. The nurse should suggest that the client perform:
A. Tailor sitting
B. Leg lifting
C. Shoulder circling
D. Squatting exercises
12. Which of the following would the nurse in charge
do first after observing a 2-cm circle of bright red bleeding on the diaper of
a neonate who just had a circumcision?
A. Notify the neonate’s pediatrician immediately
B. Check the diaper and circumcision again in 30
minutes
C. Secure the diaper tightly to apply pressure on the
site
D. Apply gentle pressure to the site with a sterile
gauze pad
13. Which of the following would the nurse most likely
expect to find when assessing a pregnant client with abruption placenta?
A. Excessive vaginal bleeding
B. Rigid, board-like abdomen
C. Titanic uterine contractions
D. Premature rupture of membranes
14. While the client is in active labor with twins and
the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate
of every 7 to 8 minutes in a 30-minute period. Which of the following would be
the nurse’s most appropriate action?
A. Note the fetal heart rate patterns
B. Notify the physician immediately
C. Administer oxygen at 6 liters by mask
D. Have the client pant-blow during the contractions
15. A client tells the nurse, “I think my baby likes
to hear me talk to him.” When discussing neonates and stimulation with sound,
which of the following would the nurse include as a means to elicit the best
response?
A. High-pitched speech with tonal variations
B. Low-pitched speech with a sameness of tone
C. Cooing sounds rather than words
D. Repeated stimulation with loud sounds
16. A 31-year-old multipara is admitted to the
birthing room after initial examination reveals her cervix to be at 8 cm,
completely effaced (100 %), and at 0 station. What phase of labor is she in?
A. Active phase
B. Latent phase
C. Expulsive phase
D. Transitional phase
17. A pregnant patient asks the nurse if she can take
castor oil for her constipation. How should the nurse respond?
A. “Yes, it produces no adverse effect.”
B. “No, it can initiate premature uterine
contractions.”
C. “No, it can promote sodium retention.”
D. “No, it can lead to increased absorption of
fat-soluble vitamins.”
18. A patient in her 14th week of pregnancy has
presented with abdominal cramping and vaginal bleeding for the past 8 hours.
She has passed several clots. What is the primary nursing diagnosis for this
patient?
A. Knowledge deficit
B. Fluid volume deficit
C. Anticipatory grieving
D. Pain
19. Immediately after delivery, the nurse-midwife
assesses the neonate’s head for signs of molding. Which factors determine the
type of molding?
A. Fetal body flexion or extension
B. Maternal age, body frame, and weight
C. Maternal and paternal ethnic backgrounds
D. Maternal parity and gravidity
20. For a patient in active labor, the nurse-midwife
plans to use an internal electronic fetal monitoring (EFM) device. What must
occur before the internal EFM can be applied?
A. The membranes must rupture
B. The fetus must be at 0 station
C. The cervix must be dilated fully
D. The patient must receive anesthesia
21. A primigravida patient is admitted to the labor
delivery area. Assessment reveals that she is in the early part of the first
stage of labor. Her pain is likely to be most intense:
A. Around the pelvic girdle
B. Around the pelvic girdle and in the upper arms
C. Around the pelvic girdle and at the perineum
D. At the perineum
22. A female adult patient is taking a progestin-only
oral contraceptive or mini pill. Progestin use may increase the patient’s risk
for:
A. Endometriosis
B. Female hypogonadism
C. Premenstrual syndrome
D. Tubal or ectopic pregnancy
23. A patient with pregnancy-induced hypertension
probably exhibits which of the following symptoms?
A. Proteinuria, headaches, vaginal bleeding
B. Headaches, double vision, vaginal bleeding
C. Proteinuria, headaches, double vision
D. Proteinuria, double vision, uterine contractions
24. Because cervical effacement and dilation are not
progressing in a patient in labor, the doctor orders I.V. administration of
oxytocin (Pitocin). Why must the nurse monitor the patient’s fluid intake and
output closely during oxytocin administration?
A. Oxytocin causes water intoxication
B. Oxytocin causes excessive thirst
C. Oxytocin is toxic to the kidneys
D. Oxytocin has a diuretic effect
25. Five hours after birth, a neonate is transferred
to the nursery, where the nurse intervenes to prevent hypothermia. What is a
common source of radiant heat loss?
A. Low room humidity
B. Cold weight scale
C. Cool incubator walls
D. Cool room temperature
26. After administering bethanechol to a patient with
urine retention, the nurse in charge monitors the patient for adverse effects.
Which is most likely to occur?
A. Decreased peristalsis
B. Increase heart rate
C. Dry mucous membranes
D. Nausea and Vomiting
27. The nurse in charge is caring for a patient who is
in the first stage of labor. What is the shortest but most difficult part of
this stage?
A. Active phase
B. Complete phase
C. Latent phase
D. Transitional phase
28. After 3 days of breastfeeding, a postpartal
patient reports nipple soreness. To relieve her discomfort, the nurse should
suggest that she:
A. Apply warm compresses to her nipples just before
feedings
B. Lubricate her nipples with expressed milk before
feeding
C. Dry her nipples with a soft towel after feedings
D. Apply soap directly to her nipples, and then rinse
29. The nurse is developing a teaching plan for a
patient who is 8 weeks pregnant. The nurse should tell the patient that she can
expect to feel the fetus move at which time?
A. Between 10 and 12 weeks’ gestation
B. Between 16 and 20 weeks’ gestation
C. Between 21 and 23 weeks’ gestation
D. Between 24 and 26 weeks’ gestation
30. Normal lochial findings in the first 24 hours
post-delivery include:
A. Bright red blood
B. Large clots or tissue fragments
C. A foul odor
D. The complete absence of lochia
31. Accompanied by her husband, a patient seeks
admission to the labor and delivery area. The client states that she is in
labor and says she attended the hospital clinic for prenatal care. Which
question should the nurse ask her first?
A. “Do you have any chronic illness?”
B. “Do you have any allergies?”
C. “What is your expected due date?”
D. “Who will be with you during labor?”
32. A patient is in the second stage of labor. During
this stage, how frequently should the nurse in charge assess her uterine
contractions?
A. Every 5 minutes
B. Every 15 minutes
C. Every 30 minutes
D. Every 60 minutes
33. A patient is in her last trimester of pregnancy.
Nurse Vickie should instruct her to notify her primary health care provider
immediately if she notices:
A. Blurred vision
B. Hemorrhoids
C. Increased vaginal mucus
D. Shortness of breath on exertion
34. The nurse in-charge is reviewing a patient’s
prenatal history. Which finding indicates a genetic risk factor?
A. The patient is 25 years old
B. The patient has a child with cystic fibrosis
C. The patient was exposed to rubella at 36 weeks’ gestation
D. The patient has a history of preterm labor at 32
weeks’ gestation
35. An adult female patient is using the rhythm
(calendar-basal body temperature) method of family planning. In this method,
the unsafe period for sexual intercourse is indicated by:
A. Return preovulatory basal body temperature
B. Basal body temperature increase of 0.1 degrees to
0.2 degrees on the 2nd or 3rd day of cycle
C. 3 full days of elevated basal body temperature and
clear, thin cervical mucus
D. Breast tenderness and mittelschmerz
36. During a nonstress test (NST), the electronic
tracing displays a relatively flat line for fetal movement, making it difficult
to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge
should instruct the client to push the control button at which time?
A. At the beginning of each fetal movement
B. At the beginning of each contraction
C. After every three fetal movements
D. At the end of fetal movement
37. When evaluating a client’s knowledge of symptoms
to report during her pregnancy, which statement would indicate to the nurse in
charge that the client understands the information given to her?
A. “I’ll report increased frequency of urination.”
B. “If I have blurred or double vision, I should call
the clinic immediately.”
C. “If I feel tired after resting, I should report it
immediately.”
D. “Nausea should be reported immediately.”
38. When assessing a client during her first prenatal
visit, the nurse discovers that the client had a reduction mammoplasty. The
mother indicates she wants to breast-feed. What information should the nurse
give to this mother regarding breastfeeding success?
A. “It’s contraindicated for you to breastfeed
following this type of surgery.”
B. “I support your commitment; however, you may have
to supplement each feeding with formula.”
C. “You should check with your surgeon to determine
whether breast-feeding would be possible.”
D. “You should be able to breastfeed without
difficulty.”
39. Following a precipitous delivery, examination of
the client’s vagina reveals a fourth-degree laceration. Which of the following
would be contraindicated when caring for this client?
A. Applying cold to limit edema during the first 12 to
24 hours
B. Instructing the client to use two or more peri pads
to cushion the area
C. Instructing the client on the use of sitz baths if
ordered
D. Instructing the client about the importance of
perineal (Kegel) exercises
40. A client makes a routine visit to the prenatal
clinic. Although she is 14 weeks pregnant, the size of her uterus approximates
that in an 18- to 20-week pregnancy. Dr. Charles diagnoses gestational
trophoblastic disease and orders ultrasonography. The nurse expects
ultrasonography to reveal:
A. an empty gestational sac.
B. grapelike clusters.
C. a severely malformed fetus.
D. an extrauterine pregnancy.
41. After completing a second vaginal examination of a
client in labor, the nurse-midwife determines that the fetus is in the right
occiput anterior position and at (–1) station. Based on these findings, the
nurse-midwife knows that the fetal presenting part is:
A. 1 cm below the ischial spines.
B. directly in line with the ischial spines.
C. 1 cm above the ischial spines.
D. in no relationship to the ischial spines.
42. Which of the following would be inappropriate to
assess in a mother who’s breastfeeding?
A. The attachment of the baby to the breast.
B. The mother’s comfort level with positioning the
baby.
C. Audible swallowing.
D. The baby’s lips smacking
43. During a prenatal visit at 4 months gestation, a
pregnant client asks whether tests can be done to identify fetal abnormalities.
Between 18 and 40 weeks gestation, which procedure is used to detect fetal
anomalies?
A. Amniocentesis.
B. Chorionic villi sampling.
C. Fetoscopy.
D. Ultrasound
44. A client, 30 weeks pregnant, is scheduled for a
biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is
8. What does this score indicate?
A. The fetus should be delivered within 24 hours.
B. The client should repeat the test in 24 hours.
C. The fetus isn’t in distress at this time.
D. The client should repeat the test in 1 week.
45. A client who is 36 weeks pregnant comes to the
clinic for a prenatal checkup. To assess the client’s preparation for
parenting, the nurse might ask which question?
A. “Are you planning to have epidural anesthesia?”
B. “Have you begun prenatal classes?”
C. “What changes have you made at home to get ready
for the baby?”
D. “Can you tell me about the meals you typically eat
each day?”
46. A client who’s admitted to labor and delivery has
the following assessment findings: gravida 2 para 1, estimated 40 weeks
gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station.
Which of the following would be the priority at this time?
A. Placing the client in bed to begin fetal
monitoring.
B. Preparing for immediate delivery.
C. Checking for ruptured membranes.
D. Providing comfort measures.
47. The nurse is caring for a client in labor. The
external fetal monitor shows a pattern of variable decelerations in fetal heart
rate. What should the nurse do first?
A. Change the client’s position.
B. Prepare for emergency cesarean section.
C. Check for placenta previa.
D. Administer oxygen.
48. The nurse in charge is caring for a postpartum
client who had a vaginal delivery with a midline episiotomy. Which nursing
diagnosis takes priority for this client?
A. Risk for deficient fluid volume related to
hemorrhage
B. Risk for infection related to the type of delivery
C. Pain related to the type of incision
D. Urinary retention related to periurethral edema
49. Which change would the nurse identify as a
progressive physiological change in the postpartum period?
A. Lactation
B. Lochia
C. Uterine involution
D. Diuresis
50. A 39-year-old at 37 weeks gestation is admitted to
the hospital with complaints of vaginal bleeding following the use of cocaine 1
hour earlier. Which complication is most likely causing the client’s complaint
of vaginal bleeding?
A. Placenta previa
B. Abruptio placentae
C. Ectopic pregnancy
D. Spontaneous abortion
51. A client with type 1 diabetes mellitus who is a
multigravida visits the clinic at 27 weeks gestation. The nurse should instruct
the client that for most pregnant women with type 1 diabetes mellitus:
A. Weekly fetal movement counts are made by the
mother.
B. Contraction stress testing is performed weekly.
C. Induction of labor is begun at 34 weeks’ gestation.
D. Nonstress testing is performed weekly until 32
weeks’ gestation
52. When administering magnesium sulfate to a client
with preeclampsia, the nurse understands that this drug is given to:
A. Prevent seizures
B. Reduce blood pressure
C. Slow the process of labor
D. Increase dieresis
53. What is the approximate time that the blastocyst
spends traveling to the uterus for implantation?
A. 2 days
B. 7 days
C. 10 days
D. 14 weeks
54. After teaching a pregnant woman who is in labor
about the purpose of the episiotomy, which of the following purposes stated by
the client would indicate to the nurse that the teaching was effective?
A. Shortens the second stage of labor
B. Enlarges the pelvic inlet
C. Prevents perineal edema
D. Ensures quick placenta delivery
55. A primigravida client at about 35 weeks gestation
in active labor has had no prenatal care and admitted to cocaine use during the
pregnancy. Which of the following persons must the nurse notify?
A. Nursing unit manager so appropriate agencies can be
notified
B. Head of the hospital’s security department
C. Chaplain in case the fetus dies in utero
D. Physician who will attend the delivery of the
infant
56. When preparing a teaching plan for a client who is
to receive a rubella vaccine during the postpartum period, the nurse in charge
should include which of the following?
A. The vaccine prevents a future fetus from developing
congenital anomalies
B. Pregnancy should be avoided for 3 months after the
immunization
C. The client should avoid contact with children
diagnosed with rubella
D. The injection will provide immunity against the
7-day measles.
57. A client with eclampsia begins to experience a
seizure. Which of the following would the nurse in charge do first?
A. Pad the side rails
B. Place a pillow under the left buttock
C. Insert a padded tongue blade into the mouth
D. Maintain a patent airway
58. While caring for a multigravida client in early
labor in a birthing center, which of the following foods would be best if the
client requests a snack?
A. Yogurt
B. Cereal with milk
C. Vegetable soup
D. Peanut butter cookies
59. The multigravida mother with a history of rapid
labor who us in active labor calls out to the nurse, “The baby is coming!”
which of the following would be the nurse’s first action?
A. Inspect the perineum
B. Time the contractions
C. Auscultate the fetal heart rate
D. Contact the birth attendant
60. While assessing a primipara during the immediate
postpartum period, the nurse in charge plans to use both hands to assess the
client’s fundus to:
A. Prevent uterine inversion
B. Promote uterine involution
C. Hasten the puerperium period
D. Determine the size of the fundus
61. Which behaviors would be exhibited during the
letting-go phase of maternal role adaptation. Select all that apply.
A. Emergence of family unit
B. Dependent behaviors
C. Sexual intimacy relationship continuing
D. Defining one’s individual roles
E. Being talkative and excited about becoming a mother
62. While making a visit to the home of a postpartum
woman 1 week after birth, the nurse should recognize that the woman would characteristically:
A. Express a strong need to review the events and her
behavior during the process of labor and birth.
B. Exhibit a reduced attention span, limiting
readiness to learn.
C. Vacillate between the desire to have her own
nurturing needs met and the need to take charge of her own care and that of her
newborn.
D. Have reestablished her role as a spouse or partner.
63. Which of the following is the most common kind of
placental adherence seen in pregnant women?
A. Accreta
B. Placenta previa
C. Percreta
D. Increta
64. A 40-year-old woman with a high body mass index
(BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to
her at this time?
A. Biophysical profile
B. Amniocentesis
C. Maternal serum alpha-fetoprotein (MSAFP)
D. Transvaginal ultrasound
65. A nurse providing care for the antepartum woman
should understand that the contraction stress test (CST):
A. Sometimes uses vibroacoustic stimulation.
B. Is an invasive test; however, contractions are
stimulated.
C. Is considered to have a negative result if no late
decelerations are observed with the contractions.
D. Is more effective than nonstress test (NST) if the
membranes have already been ruptured.
66. In the past, factors to determine whether a woman
was likely to have a high-risk pregnancy were evaluated primarily from a
medical point of view. A broader, more comprehensive approach to high-risk
pregnancy has been adopted. There are now four categories based on threats to
the health of the woman and the outcome of pregnancy. Which of the options
listed here is not included as a category?
A. Biophysical
B. Psychosocial
C. Geographic
D. Environmental
67. A woman who is at 36 weeks of gestation is having
a nonstress test. Which statement indicates her correct understanding of the
test?
A. “I will need to have a full bladder for the test to
be done accurately.”
B. “I should have my husband drive me home after the
test because I may be nauseated.”
C. “This test will help to determine whether the baby
has Down syndrome or a neural tube defect.”
D. “This test observes for fetal activity and an
acceleration of the fetal heart rate to determine the well-being of the baby.”
68. What is an appropriate indicator for performing a
contraction stress test?
A. Increased fetal movement and small for gestational
age
B. Maternal diabetes mellitus and postmaturity
C. Adolescent pregnancy and poor prenatal care
D. History of preterm labor and intrauterine growth
restriction
69. The nurse sees a woman for the first time when she
is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal
height measurements now are suggestive of growth restriction in the fetus. In
addition to ultrasound to measure fetal size, what would be another tool useful
in confirming the diagnosis?
A. Doppler blood flow analysis
B. Contraction stress test (CST)
C. Amniocentesis
D. Daily fetal movement counts
70. A nurse is providing instruction for an
obstetrical patient to perform a daily fetal movement count (DFMC). Which
instructions could be included in the plan of care? Select all that apply.
A. The fetal alarm signal is reached when there are no
fetal movements noted for 5 hours.
B. The patient can monitor fetal activity once daily
for a 60-minute period and note activity.
C. Monitor fetal activity two times a day either after
meals or before bed for a period of 2 hours or until 10 fetal movements are
noted.
D. Count all fetal movements in a 12-hour period daily
until 10 fetal movements are noted.
71. A patient has undergone an amniocentesis for
evaluation of fetal well-being. Which intervention would be included in the
nurse’s plan of care after the procedure? Select all that apply.
A. Perform ultrasound to determine fetal positioning.
B. Observe the patient for possible uterine
contractions.
C. Administer RhoGAM to the patient if she is Rh
negative.
D. Perform a mini catheterization to obtain a urine
specimen to assess for bleeding.
72. With regard to small-for-gestational-age (SGA)
infants and intrauterine growth restriction (IUGR), nurses should be aware
that:
A. In the first trimester, diseases or abnormalities
result in asymmetric IUGR.
B. Infants with asymmetric IUGR have the potential for
normal growth and development.
C. In asymmetric IUGR, weight is slightly more than
SGA, whereas length and head circumference are somewhat less than SGA.
D. Symmetric IUGR occurs in the later stages of
pregnancy.
73. A client who delivered by cesarean section 24
hours ago is using a patient-controlled analgesia (PCA) pump for pain control.
Her oral intake has been ice chips only since surgery. She is now complaining
of nausea and bloating, and states that because she had nothing to eat, she is
too weak to breastfeed her infant. Which nursing diagnosis has the highest
priority?
A. Altered nutrition, less than body requirements for
lactation
B. Alteration in comfort related to nausea and
abdominal distention
C. Impaired bowel motility related to pain medication
and immobility
D. Fatigue related to cesarean delivery and physical
care demands of infant
74. The nurse is teaching care of the newborn to a
childbirth preparation class and describes the need for administering
antibiotic ointment into the eyes of the newborn. An expectant father asks,
“What type of disease causes infections in babies that can be prevented by
using this ointment?” Which response by the nurse is accurate?
A. Herpes
B. Trichomonas
C. Gonorrhea
D. Syphilis
75. A new mother is having trouble breastfeeding her
newborn. The child is making frantic rooting motions and will not grasp the
nipple. Which intervention should the nurse implement?
A. Encourage frequent use of a pacifier so that the
infant becomes accustomed to sucking.
B. Hold the infant’s head firmly against the breast
until he latches onto the nipple.
C. Encourage the mother to stop feeding for a few
minutes and comfort the infant.
D. Provide a formula for the infant until he becomes
calm, and then offer the breast again.
76. The nurse is counseling a couple who has sought
information about conceiving. The couple asks the nurse to explain when
ovulation usually occurs. Which statement by the nurse is correct?
A. Two weeks before menstruation
B. Immediately after menstruation
C. Immediately before menstruation
D. Three weeks before menstruation
77. The nurse instructs a laboring client to use
accelerated blow breathing. The client begins to complain of tingling fingers
and dizziness. Which action should the nurse take?
A. Administer oxygen by face mask.
B. Notify the health care provider of the client’s
symptoms.
C. Have the client breathe into her cupped hands.
D. Check the client’s blood pressure and fetal heart
rate.
78. When assessing a client at 12 weeks of gestation,
the nurse recommends that she and her husband consider attending childbirth
preparation classes. When is the best time for the couple to attend these
classes?
A. At 16 weeks of gestation
B. At 20 weeks of gestation
C. At 24 weeks of gestation
D. At 30 weeks of gestation
79. One hour following a normal vaginal delivery, a
newborn infant boy’s axillary temperature is 96° F, his lower lip is shaking
and, when the nurse assesses for a Moro reflex, the boy’s hands shake. Which
intervention should the nurse implement first?
A. Stimulate the infant to cry.
B. Wrap the infant in warm blankets.
C. Feed the infant formula.
D. Obtain a serum glucose level.
80. Which statement made by the client indicates that
the mother understands the limitations of breastfeeding her newborn?
A. “Breastfeeding my infant consistently every 3 to 4
hours stops ovulation and my period.”
B. “Breastfeeding my baby immediately after drinking
alcohol is safer than waiting for the alcohol to clear my breast milk.”
C. “I can start smoking cigarettes while breastfeeding
because it will not affect my breast milk.”
D. “When I take a warm shower after I breastfeed, it
relieves the pain from being engorged between breastfeedings.”
81. When assessing the adequacy of sperm for
conception to occur, which of the following is the most useful criterion?
A. Sperm count
B. Sperm motility
C. Sperm maturity
D. Semen volume
82. A couple who wants to conceive but has been
unsuccessful during the last 2 years has undergone many diagnostic procedures.
When discussing the situation with the nurse, one partner states, “We know
several friends in our age group, and all of them have their own child already,
Why can’t we have one?”. Which of the following would be the most appropriate
nursing diagnosis for this couple?
A. Fear related to the unknown
B. Pain related to numerous procedures.
C. Ineffective family coping related to infertility.
D. Self-esteem disturbance related to infertility.
83. Which of the following urinary symptoms does the
pregnant woman most frequently experience during the first trimester?
A. Dysuria
B. Frequency
C. Incontinence
D. Burning
84. Heartburn and flatulence, common in the second
trimester, are most likely the result of which of the following?
A. Increased plasma HCG levels
B. Decreased intestinal motility
C. Decreased gastric acidity
D. Elevated estrogen levels
85. On which of the following areas would the nurse
expect to observe chloasma?
A. Breast, areola, and nipples
B. Chest, neck, arms, and legs
C. Abdomen, breast, and thighs
D. Cheeks, forehead, and nose
86. A pregnant client states that she “waddles” when
she walks. The nurse’s explanation is based on which of the following as the
cause?
A. The large size of the newborn
B. Pressure on the pelvic muscles
C. Relaxation of the pelvic joints
D. Excessive weight gain
87. Which of the following represents the average
amount of weight gained during pregnancy?
A. 12 to 22 lb
B 15 to 25 lb
C. 24 to 30 lb
D. 25 to 40 lb
88. When talking with a pregnant client who is
experiencing aching swollen, leg veins, the nurse would explain that this is
most probably the result of which of the following?
A. Thrombophlebitis
B. Pregnancy-induced hypertension
C. Pressure on blood vessels from the enlarging uterus
D. The force of gravity pulling down on the uterus
89. Cervical softening and uterine souffle are
classified as which of the following?
A. Diagnostic signs
B. Presumptive signs
C. Probable signs
D. Positive signs
90. Which of the following would the nurse identify as
a presumptive sign of pregnancy?
A. Hegar sign
B. Nausea and vomiting
C. Skin pigmentation changes
D. Positive serum pregnancy test
91. Which of the following common emotional reactions
to pregnancy would the nurse expect to occur during the first trimester?
A. Introversion, egocentrism, narcissism
B. Awkwardness, clumsiness, and unattractiveness
C. Anxiety, passivity, extroversion
D. Ambivalence, fear, fantasies
92. During which of the following would the focus of
classes be mainly on physiologic changes, fetal development, sexuality, during
pregnancy, and nutrition?
A. Prepregnant period
B. First trimester
C. Second trimester
D. Third trimester
93. Which of the following would be a disadvantage of
breastfeeding?
A. Involution occurs more rapidly
B. The incidence of allergies increases due to
maternal antibodies
C. The father may resent the infant’s demands on the
mother’s body
D. There is a greater chance for error during
preparation
94. Which of the following would cause a
false-positive result on a pregnancy test?
A. The test was performed less than 10 days after an
abortion
B. The test was performed too early or too late in the
pregnancy
C. The urine sample was stored too long at room
temperature
D. A spontaneous abortion or a missed abortion is
impending
95. FHR can be auscultated with a fetoscope as early
as which of the following?
A. 5 weeks gestation
B. 10 weeks gestation
C. 15 weeks gestation
D. 20 weeks gestation
96. A client LMP began July 5. Her EDD should be which
of the following?
A. January 2
B. March 28
C. April 12
D. October 12
97. Which of the following fundal heights indicates
less than 12 weeks’ gestation when the date of the LMP is unknown?
A. Uterus in the pelvis
B. Uterus at the xiphoid
C. Uterus in the abdomen
D. Uterus at the umbilicus
98. Which of the following danger signs should be
reported promptly during the antepartum period?
A. Constipation
B. Breast tenderness
C. Nasal stuffiness
D. Leaking amniotic fluid
99. Which of the following prenatal laboratory test
values would the nurse consider as significant?
A. Hematocrit 33.5%
B. Rubella titer less than 1:8
C. White blood cells 8,000/mm3
D. One hour glucose challenge test 110 g/dL
100. Which of the following characteristics of
contractions would the nurse expect to find in a client experiencing true
labor?
A. Occurring at irregular intervals
B. Starting mainly in the abdomen
C. Gradually increasing intervals
D. Increasing intensity with walking
Answers and Rationale
1. Answer: A. Endometritis
Endometritis is an infection of the uterine lining and
can occur after prolonged rupture of membranes.
Option A: Endometriosis does not occur after a strong
labor and prolonged rupture of membranes.
Option B: Salpingitis is a tubal infection and could
occur if endometritis is not treated.
Option C: Pelvic thrombophlebitis involves a clot
formation, but it is not a complication of prolonged rupture of membranes.
2. Answer: B. The ultrasound identifies blood flow
through the umbilical cord
Before amniocentesis, a routine ultrasound is valuable
in locating the placenta, locating a pool of amniotic fluid, and showing the
physician where to insert the needle. Color Doppler imaging ultrasonography
identifies blood flow through the umbilical cord. A routine ultrasound does not
accomplish this.
3. Answer: B. Protamine sulfate
Protamine sulfate is a heparin antagonist given
intravenously to counteract bleeding complications caused by heparin overdose.
4. Answer: D. Check the vital signs every 2 to 4 hours
While caring for an infant receiving phototherapy for
treatment of jaundice, vital signs are checked every 2 to 4 hours because
hyperthermia can occur due to the phototherapy lights.
5. Answer: D. Perineum
A bilateral pudendal block is used for vaginal
deliveries to relieve pain primarily in the perineum and vagina. Pudendal block
anesthesia is adequate for episiotomy and its repair.
6. Answer: A. “Nausea and vomiting can be decreased if
I eat a few crackers before arising”
Eating dry crackers before arising can assist in
decreasing the common discomfort of nausea and vomiting. Avoiding strong food
odors and eating a high-protein snack before bedtime can also help.
7. Answer: C. Taking hold
Beginning after completion of the taking-in phase, the
taking-hold phase lasts about 10 days. During this phase, the client is
concerned with her need to resume control of all facets of her life in a
competent manner. At this time, she is ready to learn self-care and infant care
skills.
8. Answer: A. Activity limited to bed rest
Treatment of partial placenta previa includes bed
rest, hydration, and careful monitoring of the client’s bleeding.
9. Answer: C. Breastfeeding the neonate at frequent
intervals
Prevention of breast engorgement is key. The best
technique is to empty the breast regularly with feeding. Engorgement is less
likely when the mother and neonate are together, as in single room maternity
care continuous rooming-in, because nursing can be done conveniently to meet
the neonate’s and mother’s needs.
10. Answer: A. Startle reflex
The Moro, or startle, reflex occurs when the neonate
responds to stimuli by extending the arms, hands open, and then moving the arms
in an embracing motion. The Moro reflex, present at birth, disappears at about
age 3 months.
11. Answer: A. Tailor sitting
Tailor sitting is an excellent exercise that helps to
strengthen the client’s back muscles and also prepares the client for the
process of labor. The client should be encouraged to rest periodically during
the day and avoid standing or sitting in one position for a long time.
12. Answer: D. Apply gentle pressure to the site with
a sterile gauze pad
If bleeding occurs after circumcision, the nurse
should first apply gently pressure on the area with sterile gauze. Bleeding is
not common but requires attention when it occurs.
13. Answer: B. Rigid, board-like abdomen
The most common assessment finding in a client with
abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a
sharp stabbing sensation high in the uterine fundus with the initial
separation, also is common.
14. Answer: B. Notify the physician immediately
The nurse should contact the physician immediately
because the client is most likely experiencing hypotonic uterine contractions.
These contractions tend to be painful but ineffective. The usual treatment is
oxytocin augmentation unless cephalopelvic disproportion exists.
15. Answer: A. High-pitched speech with tonal
variations
Providing stimulation and speaking to neonates is
important. Some authorities believe that speech is the most important type of
sensory stimulation for a neonate. Neonates respond best to speech with tonal
variations and a high-pitched voice. A neonate can hear all sound louder than
about 55 decibels.
16. Answer: D. Transitional phase
The transitional phase of labor extends from 8 to 10
cm; it is the shortest but most difficult and intense for the patient.
Option A: The active phase extends from 4 to 7 cm; it
is moderate for the patient.
Option B: The latent phase extends from 0 to 3 cm; it
is mild in nature.
Option C: The expulsive phase begins immediately after
the birth and ends with separation and expulsion of the placenta.
17. Answer: B. “No, it can initiate premature uterine
contractions.”
Castor oil can initiate premature uterine contractions
in pregnant women. It also can produce other adverse effects, but it does not
promote sodium retention. Castor oil is not known to increase absorption of
fat-soluble vitamins, although laxatives, in general, may decrease absorption
if intestinal motility is increased.
18. Answer: B. Fluid volume deficit
If bleeding and clots are excessive, this patient may
become hypovolemic. Pad count should be instituted.
Options A, C, and D: Although the other diagnoses
apply to this patient, they are not the primary diagnosis.
19. Answer: A. Fetal body flexion or extension
Fetal attitude—the overall degree of body flexion or
extension—determines the type of molding in the head a neonate.
Options B, C, and D: Molding, is not influenced by
maternal age, body frame, weight, parity, and gravidity or by maternal and
paternal ethnic backgrounds.
20. Answer: A. The membranes must rupture
Internal EFM can be applied only after the patient’s
membranes have ruptured when the fetus is at least at the -1 station, and when
the cervix is dilated at least 2 cm. Although the patient may receive
anesthesia, it is not required before application of an internal EFM device.
21. Answer: A. Around the pelvic girdle
During most of the first stage of labor, pain centers
around the pelvic girdle. During the late part of this stage and the early part
of the second stage, pain spreads to the upper legs and perineum. During the
late part of the second stage and childbirth, intense pain occurs at the
perineum. Upper arm pain is not common during any stage of labor.
22. Answer: D. Tubal or ectopic pregnancy
Women taking the mini pill have a higher incidence of
tubal and ectopic pregnancies, possibly because progestin slows ovum transport
through the fallopian tubes.
Options A, B, and C: Endometriosis, female
hypogonadism, and premenstrual syndrome are not associated with progestin-only
oral contraceptives.
23. Answer: C. Proteinuria, headaches, double vision
A patient with pregnancy-induced hypertension
complains of a headache, double vision, and sudden weight gain. A urine
specimen reveals proteinuria.
Options A, B, and D: Vaginal bleeding and uterine
contractions are not associated with pregnancy-induced hypertension.
24. Answer: A. Oxytocin causes water intoxication
The nurse should monitor fluid intake and output
because prolonged oxytocin infusion may cause severe water intoxication,
leading to seizures, coma, and death.
Option B: Excessive thirst results from the work of
labor and limited oral fluid intake—not oxytocin.
Options C and D: Oxytocin has no nephrotoxic or
diuretic effects. In fact, it produces an antidiuretic effect.
25. Answer: C. Cools incubator walls
A common source of radiant heat loss includes cool
incubator walls and windows.
Option A: Low room humidity promotes evaporative heat
loss.
Option B: When the skin directly contacts a cooler
object, such as a cold weight scale, conductive heat loss may occur.
Option D: A cool room temperature may lead to
convective heat loss.
26. Answer: D. Nausea and Vomiting
Bethanechol will increase GI motility, which may cause
nausea, belching, vomiting, intestinal cramps, and diarrhea.
Option A: Peristalsis is increased rather than
decreased.
Option B: With high doses of bethanechol,
cardiovascular responses may include vasodilation, decreased cardiac rate, and
decreased the force of cardiac contraction, which may cause hypotension.
Option C:
Salivation or sweating may gently increase.
27. Answer: D. Transitional phase
The transitional phase, which lasts 1 to 3 hours, is
the shortest but most difficult part of the first stage of labor. This phase is
characterized by intense uterine contractions that occur every 1 ½ to 2 minutes
and last 45 to 90 seconds.
Option A: The active phase lasts 4 ½ to 6 hours; it is
characterized by contractions that start out moderately intense, grow stronger,
and last about 60 seconds.
Option B: The complete phase occurs during the second,
not first, stage of labor.
Option C: The latent phase lasts 5 to 8 hours and is
marked by mild, short, irregular contractions.
28. Answer: B. Lubricate her nipples with expressed
milk before feeding
Measures that help relieve nipple soreness in a
breastfeeding patient include lubrication the nipples with a few drops of
expressed milk before feedings, applying ice compresses just before feeding,
letting the nipples air dry after feedings, and avoiding the use of soap on the
nipples.
29. Answer: B. Between 16 and 20 weeks’ gestation
A pregnant woman usually can detect fetal movement
(quickening) between 16 and 20 weeks’ gestation. Before 16 weeks, the fetus is
not developed enough for the woman to detect movement. After 20 weeks, the
fetus continues to gain weight steadily, the lungs start to produce surfactant,
the brain is grossly formed, and myelination of the spinal cord begins.
30. Answer: A. Bright red blood
Lochia should never contain large clots, tissue
fragments, or membranes. A foul odor may signal infection, as may absence of
lochia.
31. Answer: C. “What is your expected due date?”
When obtaining the history of a patient who may be in
labor, the nurse’s highest priority is to determine her current status,
particularly her due date, gravidity, and parity. Gravidity and parity affect
the duration of labor and the potential for labor complications. Later, the
nurse should ask about chronic illness, allergies, and support persons.
32. Answer: B. Every 15 minutes
During the second stage of labor, the nurse should
assess the strength, frequency, and duration of contraction every 15 minutes.
If maternal or fetal problems are detected, more frequent monitoring is
necessary.
Options C and D: An interval of 30 to 60 minutes
between assessments is too long because of variations in the length and
duration of patient’s labor.
33. Answer: A. Blurred vision
Blurred vision or other visual disturbance, excessive
weight gain, edema, and increased blood pressure may signal severe
preeclampsia. This condition may lead to eclampsia, which has potentially
serious consequences for both the patient and fetus.
Option B: Although hemorrhoids may be a problem during
pregnancy, they do not require immediate attention.
Options C and D: Increased vaginal mucus and dyspnea
on exertion are expected as pregnancy progress.
34. Answer: B. The patient has a child with cystic
fibrosis
Cystic fibrosis is a recessive trait; each offspring
has a one in four chance of having the trait or the disorder.
Option A: Maternal age is not a risk factor until age
35, when the incidence of chromosomal defects increases.
Option C: Maternal exposure to rubella during the
first trimester may cause congenital defects.
Option D: Although a history or preterm labor may
place the patient at risk for preterm labor, it does not correlate with genetic
defects.
35. Answer: C. 3 full days of elevated basal body
temperature and clear, thin cervical mucus
Ovulation (the period when pregnancy can occur) is
accompanied by a basal body temperature increase of 0.7 degrees F to 0.8
degrees F and clear, thin cervical mucus.
Option A: A return to the preovulatory body
temperature indicates a safe period for sexual intercourse.
Option B: A slight rise in basal temperature early in
the cycle is not significant.
Option D: Breast tenderness and mittelschmerz are not
reliable indicators of ovulation.
36. Answer: A. At the beginning of each fetal movement
An NST assesses the FHR during fetal movement. In a
healthy fetus, the FHR accelerates with each movement. By pushing the control
button when a fetal movement starts, the client marks the strip to allow easy
correlation of fetal movement with the FHR.
Option B: The FHR is assessed during uterine
contractions in the oxytocin contraction test, not the NST.
Options C and D: Pushing the control button after
every three fetal movements or at the end of fetal movement wouldn’t allow
accurate comparison of fetal movement and FHR changes.
37. Answer: B. “If I have blurred or double vision, I
should call the clinic immediately.”
Blurred or double vision may indicate hypertension or
preeclampsia and should be reported immediately.
Option A: Urinary frequency is a common problem during
pregnancy caused by increased weight pressure on the bladder from the uterus.
Options C and D: Clients generally experience fatigue
and nausea during pregnancy.
38. Answer: B. “I support your commitment; however,
you may have to supplement each feeding with formula.”
Recent breast reduction surgeries are done in a way to
protect the milk sacs and ducts, so breast-feeding after surgery is possible.
Still, it’s good to check with the surgeon to determine what breast reduction
procedure was done. There is the possibility that reduction surgery may have
decreased the mother’s ability to meet all of her baby’s nutritional needs, and
some supplemental feeding may be required. Preparing the mother for this
possibility is extremely important because the client’s psychological
adaptation to mothering may be dependent on how successfully she breast-feeds.
39. Answer: B. Instructing the client to use two or
more peri pads to cushion the area
Using two or more peripads would do little to reduce
the pain or promote perineal healing.
Options A, C and D: Cold applications, sitz baths, and
Kegel exercises are important measures when the client has a fourth-degree
laceration.
40. Answer: B. grapelike clusters.
In a client with gestational trophoblastic disease, an
ultrasound performed after the 3rd month shows grapelike clusters of
transparent vesicles rather than a fetus. The vesicles contain a clear fluid
and may involve all or part of the decidual lining of the uterus. Usually no
embryo (and therefore no fetus) is present because it has been absorbed.
Because there is no fetus, there can be no extrauterine pregnancy. An
extrauterine pregnancy is seen with an ectopic pregnancy.
41. Answer: C. 1 cm above the ischial spines.
Fetal station — the relationship of the fetal presenting
part to the maternal ischial spines — is described in the number of centimeters
above or below the spines. A presenting part above the ischial spines is
designated as –1, –2, or –3. A presenting part below the ischial spines, as +1,
+2, or +3.
42. Answer: D. The baby’s lips smacking
Assessing the attachment process for breast-feeding
should include all of the answers except the smacking of lips. A baby who’s
smacking his lips isn’t well attached and can injure the mother’s nipples.
43. Answer: D. Ultrasound
Ultrasound is used between 18 and 40 weeks’ gestation
to identify normal fetal growth and detect fetal anomalies and other problems.
Option A: Amniocentesis is done during the third
trimester to determine fetal lung maturity.
Option B: Chorionic villi sampling is performed at 8
to 12 weeks’ gestation to detect genetic disease.
Option C: Fetoscopy is done at approximately 18 weeks’
gestation to observe the fetus directly and obtain a skin or blood sample.
44. Answer: C. The fetus isn’t in distress at this
time.
The BPP evaluates fetal health by assessing five
variables: fetal breathing movements, gross body movements, fetal tone,
reactive fetal heart rate, and qualitative amniotic fluid volume. A normal
response for each variable receives 2 points; an abnormal response receives 0
points. A score between 8 and 10 is considered normal, indicating that the
fetus has a low risk of oxygen deprivation and isn’t in distress. A fetus with
a score of 6 or lower is at risk for asphyxia and premature birth; this score
warrants detailed investigation. The BPP may or may not be repeated if the
score isn’t within normal limits.
45. Answer: C. “What changes have you made at home to
get ready for the baby?”
During the third trimester, the pregnant client
typically perceives the fetus as a separate being. To verify that this has
occurred, the nurse should ask whether she has made appropriate changes at home
such as obtaining infant supplies and equipment.
Option A: The type of anesthesia planned doesn’t reflect
the client’s preparation for parenting.
Option B: The client should have begun prenatal
classes earlier in the pregnancy.
Option D: The nurse should have obtained dietary
information during the first trimester to give the client time to make any necessary
changes.
46. Answer: B. Preparing for immediate delivery.
This question requires an understanding of station as
part of the intrapartum assessment process. Based on the client’s assessment
findings, this client is ready for delivery, which is the nurse’s top priority.
Options A, C, and D: Placing the client in bed,
checking for ruptured membranes, and providing comfort measures could be done,
but the priority here is immediate delivery.
47. Answer: A. Change the client’s position.
Variable decelerations in fetal heart rate are an
ominous sign, indicating compression of the umbilical cord. Changing the
client’s position from supine to side-lying may immediately correct the
problem.
Option B: An emergency cesarean section is necessary
only if other measures, such as changing position and amnioinfusion with
sterile saline, prove unsuccessful.
Option D: Administering oxygen may be helpful, but the
priority is to change the woman’s position and relieve cord compression.
48. Answer: A. Risk for deficient fluid volume related
to hemorrhage
Hemorrhage jeopardizes the client’s oxygen supply —
the first priority among human physiologic needs. Therefore, the nursing
diagnosis of Risk for deficient fluid volume related to hemorrhage takes
priority over diagnoses of Risk for Infection, Pain, and Urinary retention.
49. Answer: A. Lactation
Lactation is an example of a progressive physiological
change that occurs during the postpartum period.
50. Answer: B. Abruptio placentae
The major maternal adverse reactions from cocaine use
in pregnancy include spontaneous abortion first, not third, trimester abortion
and abruptio placentae.
51. Answer: D. Nonstress testing is performed weekly
until 32 weeks’ gestation
For most clients with type 1 diabetes mellitus,
non-stress testing is done weekly until 32 weeks’ gestation and twice a week to
assess fetal well-being.
52. Answer: A. Prevent seizures
The chemical makeup of magnesium is similar to that of
calcium and, therefore, magnesium will act like calcium in the body. As a
result, magnesium will block seizure activity in a hyper-stimulated neurologic
system by interfering with signal transmission at the neuromuscular junction.
53. Answer: B. 7 days
The blastocyst takes approximately 1 week to travel to
the uterus for implantation.
54. Answer: A. Shortens the second stage of labor
An episiotomy serves several purposes. It shortens the
second stage of labor, substitutes a clean surgical incision for a tear, and
decreases undue stretching of perineal muscles. An episiotomy helps prevent
tearing of the rectum but it does not necessarily relieves pressure on the
rectum. Tearing may still occur.
55. Answer: D. Physician who will attend the delivery
of the infant
The fetus of a cocaine-addicted mother is at risk for
hypoxia, meconium aspiration, and intrauterine growth retardation (IUGR).
Therefore, the nurse must notify the physician of the client’s cocaine use
because this knowledge will influence the care of the client and neonate. The
information is used only in relation to the client’s care.
56. Answer: B. Pregnancy should be avoided for 3
months after the immunization
After administration of rubella vaccine, the client
should be instructed to avoid pregnancy for at least 3 months to prevent the
possibility of the vaccines toxic effects to the fetus.
57. Answer: D. Maintain a patent airway
The priority for the pregnant client having a seizure
is to maintain a patent airway to ensure adequate oxygenation to the mother and
the fetus. Additionally, oxygen may be administered by face mask to prevent
fetal hypoxia.
58. Answer: A. Yogurt
In some birth settings, intravenous therapy is not
used with low-risk clients. Thus, clients in early labor are encouraged to eat
healthy snacks and drink fluid to avoid dehydration. Yogurt, which is an
excellent source of calcium and riboflavin, is soft and easily digested. During
pregnancy, gastric emptying time is delayed. In most hospital settings, clients
are allowed only ice chips or clear liquids.
59. Answer: A. Inspect the perineum
When the client says the baby is coming, the nurse
should first inspect the perineum and observe for crowning to validate the
client’s statement. If the client is not delivering precipitously, the nurse
can calm her and use appropriate breathing techniques.
60. Answer: A. Prevent uterine inversion
Using both hands to assess the fundus is useful for
preventing uterine inversion.
61. Answer: A, C, and D
The emergence of family unit, sexual intimacy relationship
continuing and defining one’s individual roles represent interdependent
behaviors associated with the letting-go phase.
Option B: Dependent behaviors are exhibited in the
taking-in phase.
Option E: Being talkative and excited about becoming a
mother represents the taking-hold phase and is an example of
dependent-independent behaviors.
62. Answer: C. Vacillate between the desire to have
her own nurturing needs met and the need to take charge of her own care and
that of her newborn.
One week after birth the woman should exhibit
behaviors characteristic of the dependent-independent or taking-hold stage. She
still has needs for nurturing and acceptance by others.
Options A and B: Wanting to discuss the events of her
labor and delivery are characteristics of the taking-in stage, as are a limited
readiness to learn and reduced attention span; this stage lasts from the first
24 hours until 2 days after delivery.
Option D: Having reestablished her role as a spouse
reflects the letting-go stage, which indicates that psychosocial recovery is
complete.
63. Answer: A. Accreta
Placenta accreta is the most common kind of placental
adherence seen in pregnant women and is characterized by slight penetration of
myometrium.
Option B: In placenta previa, the placenta does not
embed correctly and results in what is known as a low-lying placenta. It can be
marginal, partial, or complete in how it covers the cervical os, and it
increases the patient’s risk for painless vaginal bleeding during the pregnancy
and/or delivery process.
Option C:
Placenta percreta leads to perforation of the uterus and is the most
serious and invasive of all types of accrete.
Option D: Placenta increta leads to deep penetration
of the myometrium.
64. Answer: D. Transvaginal ultrasound
An ultrasound is the method of biophysical assessment
of the infant that is performed at this gestational age. Transvaginal
ultrasound is especially useful for obese women, whose thick abdominal layers
cannot be penetrated adequately with the abdominal approach.
Option A: A biophysical profile is a method of
biophysical assessment of fetal well-being in the third trimester.
Option B: An amniocentesis is performed after the
fourteenth week of pregnancy.
Option C: A MSAFP test is performed from week 15 to
week 22 of the gestation (weeks 16 to 18 are ideal).
65. Answer: C. Is considered to have a negative result
if no late decelerations are observed with the contractions.
No late decelerations indicate a positive CST result.
Option A: Vibroacoustic stimulation is sometimes used
with NST.
Option B: CST is invasive if stimulation is performed
by IV oxytocin but not if by nipple stimulation.
Option D: CST is contraindicated if the membranes have
ruptured.
66. Answer: C. Geographic
The fourth category is correctly referred to as the
sociodemographic risk category.
67. Answer: D. “This test observes for fetal activity
and an acceleration of the fetal heart rate to determine the well-being of the
baby.”
The nonstress test is one of the most widely used
techniques to determine fetal well-being and is accomplished by monitoring
fetal heart rate in conjunction with fetal activity and movements.
Option A: An ultrasound requires a full bladder.
Option B: An amniocentesis is a test after which a
pregnant woman should be driven home.
Option C: A maternal serum alpha-fetoprotein test is
used in conjunction with unconjugated estriol levels and human chorionic
gonadotropin helps to detect Down syndrome.
68. Answer: B. Maternal diabetes mellitus and
postmaturity
Option A: Decreased fetal movement is an indicator for
performing a contraction stress test; the size (small for gestational age) is
not an indicator.
Option C: Although adolescent pregnancy and poor
prenatal care are risk factors for poor fetal outcomes, they are not indicators
for performing a contraction stress test.
Option D: Intrauterine growth restriction is an
indicator; history of a previous stillbirth, not preterm labor, is another
indicator.
69. Answer: A. Doppler blood flow analysis
Doppler blood flow analysis allows the examiner to
study the blood flow noninvasively in the fetus and the placenta. It is a
helpful tool in the management of high-risk pregnancy due to intrauterine
growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm
labor.
Option B: Because of the potential risk of inducing
labor and causing fetal distress, a CST is not performed on a woman whose fetus
is preterm.
Option C: Indications for an amniocentesis include
diagnosis of genetic disorders or congenital anomalies, assessment of the
pulmonary maturity, and the diagnosis of fetal hemolytic disease, not IUGR.
Option D: Fetal kick count monitoring is performed to
monitor the fetus in pregnancies complicated by conditions that may affect
fetal oxygenation. Although it may be a useful tool at some point later in this
woman’s pregnancy, it is not used to diagnose IUGR.
70. Answer: B, C, and D
The fetal alarm signal is reached when no fetal
movements are noted for a period of 12 hours.
71. Answer: B and C
Ultrasound is used prior to the procedure as a
visualization aid to assist with insertion of the transabdominal needle. There
is no need to assess the urine for bleeding as this is not considered to be a
typical presentation or complication.
72. Answer: B. Infants with asymmetric IUGR have the
potential for normal growth and development.
The infant with asymmetric IUGR has the potential for
normal growth and development.
SGA infants have reduced brain capacity. The
asymmetric form occurs in the later stages of pregnancy.
Option A: IUGR is either symmetric or asymmetric. The
symmetric form occurs in the first trimester, as a result of disease or
abnormalities.
Option C: Weight is less than the 10th percentile, but
the head circumference is greater than the 10th percentile (within normal
limits).
Option D: IUGR is either symmetric or asymmetric. The
symmetric form occurs in the first trimester, as a result of disease or
abnormalities;
73. Answer: C. Impaired bowel motility related to pain
medication and immobility
Impaired bowel motility caused by surgical anesthesia,
pain medication, and immobility is the priority nursing diagnosis and addresses
the potential problem of a paralytic ileus.
Options A and B are both caused by impaired bowel
motility.
Option D is not as important as impaired motility.
74. Answer: C. Gonorrhea
Erythromycin ointment is instilled into the lower
conjunctiva of each eye within 2 hours after birth to prevent ophthalmia
neonatorum, an infection caused by gonorrhea (C), and inclusion conjunctivitis,
an infection caused by Chlamydia. The infant may be exposed to these bacteria
when passing through the birth canal.
Options A, B, and D: Ophthalmic ointment is not
effective against Trichomonas, Gonorrhea, and Syphilis.
75. Answer: C. Encourage the mother to stop feeding
for a few minutes and comfort the infant.
The infant is becoming frustrated and so is the
mother; both need a time out. The mother should be encouraged to comfort the
infant and to relax herself. After such a time out, breastfeeding is often more
successful.
Options A and D would cause nipple confusion.
Option B would only cause the infant to be more
resistant, resulting in the mother and infant to become more frustrated.
76. Answer: A. Two weeks before menstruation
Ovulation occurs 14 days before the first day of the
menstrual period (A). Although ovulation can occur in the middle of the cycle
or 2 weeks after menstruation, this is only true for a woman who has a perfect
28-day cycle. For many women, the length of the menstrual cycle varies.
77. Answer: C. Have the client breathe into her cupped
hands.
Tingling fingers and dizziness are signs of
hyperventilation (blowing off too much carbon dioxide). Hyperventilation is
treated by retaining carbon dioxide. This can be facilitated by breathing into
a paper bag or cupped hands. (A) (B and D)
Option A is
inappropriate because the carbon dioxide level is low, not the oxygen level.
Options B and D are not specific for this situation.
78. Answer: D. At 30 weeks of gestation
Learning is facilitated by an interested pupil. The
couple is most interested in childbirth toward the end of the pregnancy when
they are beginning to anticipate the onset of labor and the birth of their
child. At 30 weeks, is closest to the time when parents would be ready for such
classes.
Options A, B, and C are not the best times during
pregnancy for the couple to attend childbirth education classes. At these times
they will have other teaching needs. Early pregnancy classes often include
topics such as nutrition, physiologic changes, coping with normal discomforts
of pregnancy, fetal development, maternal and fetal risk factors, and evolving
roles of the mother and her significant others.
79. Answer: D. Obtain a serum glucose level.
This infant is demonstrating signs of hypoglycemia,
possibly secondary to a low body temperature. The nurse should first, determine
the serum glucose level.
Option A is an
intervention for a lethargic infant.
Option B should be done based on the temperature, but
first the glucose level should be obtained.
Option C helps raise the blood sugar, but first, the
nurse should determine the glucose level.
80. Answer: A. “Breastfeeding my infant consistently
every 3 to 4 hours stops ovulation and my period.”
Continuous breastfeeding on a 3- to 4-hour schedule
during the day will cause a release of prolactin, which will suppress ovulation
and menses, but is not completely effective as a birth control method.
Option B is incorrect because alcohol can immediately
enter the breast milk.
Option C: Nicotine is transferred to the infant in
breast milk
Option D: Taking a warm shower will stimulate the
production of milk, which will be more painful after breast feedings
81. Answer: B. Sperm motility
Although all of the factors listed are important,
sperm motility is the most significant criterion when assessing male
infertility.
Options A, C, and D: Sperm count, sperm maturity, and
semen volume are all significant, but they are not as significant sperm
motility.
82. Answer: D. Self-esteem disturbance related to
infertility.
Based on the partner’s statement, the couple is
verbalizing feelings of inadequacy and negative feelings about themselves and
their capabilities. Thus, the nursing diagnosis of self-esteem disturbance is
most appropriate.
Options A, B, and D: Fear, pain, and ineffective
family coping also may be present but as secondary nursing diagnoses.
83. Answer: B. Frequency
Pressure and irritation of the bladder by the growing
uterus during the first trimester is responsible for causing urinary frequency.
Options A, C, and D: Dysuria, incontinence, and
burning are symptoms associated with urinary tract infections.
84. Answer: C. Decreased gastric acidity
During the second trimester, the reduction in gastric
acidity in conjunction with pressure from the growing uterus and smooth muscle
relaxation, can cause heartburn and flatulence.
Option A: HCG levels increase in the first, not the second,
trimester.
Option B: Decrease intestinal motility would most
likely be the cause of constipation and bloating.
Option D: Estrogen levels decrease in the second
trimester.
85. Answer: D. Cheeks, forehead, and nose
Chloasma also called the mask of pregnancy, is an
irregular hyperpigmented area found on the face. It is not seen on the breasts,
areola, nipples, chest, neck, arms, legs, abdomen, or thighs.
86. Answer: C. Relaxation of the pelvic joints
During pregnancy, hormonal changes cause relaxation of
the pelvic joints, resulting in the typical “waddling” gait.
Option A: Changes in posture are related to the
growing fetus.
Option B: Pressure on the surrounding muscles causing
discomfort is due to the growing uterus.
Option D: Weight gain has no effect on gait.
87. Answer: C. 24 to 30 lb
The average amount of weight gained during pregnancy
is 24 to 30 lb. This weight gain consists of the following: fetus – 7.5 lb;
placenta and membrane – 1.5 lb; amniotic fluid – 2 lb; uterus – 2.5 lb; breasts
– 3 lb; and increased blood volume – 2 to 4 lb; extravascular fluid and fat – 4
to 9 lb.
Option A: A gain of 12 to 22 lb is insufficient.
Option B: Whereas a weight gain of 15 to 25 lb is
marginal.
Option D: A weight gain of 25 to 40 lb is considered
excessive.
88. Answer: C. Pressure on blood vessels from the
enlarging uterus
The pressure of the growing uterus on blood vessels
results in an increased risk for venous stasis in the lower extremities.
Subsequently, edema and varicose vein formation may occur.
Option A: Thrombophlebitis is an inflammation of the
veins due to thrombus formation.
Option B: Pregnancy-induced hypertension is not
associated with these symptoms.
Option D: Gravity plays only a minor role with these
symptoms.
89. Answer: C. Probable signs
Cervical softening (Goodell sign) and uterine soufflé
are two probable signs of pregnancy. Probable signs are objective findings that
strongly suggest pregnancy. Other probable signs include Hegar sign, which is
softening of the lower uterine segment; Piskacek sign, which is an enlargement
and softening of the uterus; serum laboratory tests; changes in skin
pigmentation; and ultrasonic evidence of a gestational sac.
Option B: Presumptive signs are subjective signs and
include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness
and changes; excessive fatigue; uterine enlargement; and quickening.
90. Answer: B. Nausea and vomiting
Presumptive signs of pregnancy are subjective signs.
Of the signs listed, only nausea and vomiting are presumptive signs.
Options A, C, and D: Hegar sign, skin pigmentation
changes, and a positive serum pregnancy test are considered probably signs,
which are strongly suggestive of pregnancy.
91. Answer: D. Ambivalence, fear, fantasies
During the first trimester, common emotional reactions
include ambivalence, fear, fantasies, or anxiety.
Option A: The second trimester is a period of
well-being accompanied by the increased need to learn about fetal growth and
development. Common emotional reactions during this trimester include
narcissism, passivity, or introversion. At times the woman may seem egocentric
and self-centered.
Option B: During the third trimester, the woman
typically feels awkward, clumsy, and unattractive, often becoming more
introverted or reflective of her own childhood.
92. Answer: B. First trimester
First-trimester classes commonly focus on such issues
as early physiologic changes, fetal development, sexuality during pregnancy,
and nutrition. Some early classes may include pregnant couples.
Options C and D: Second and third-trimester classes
may focus on preparation for birth, parenting, and newborn care.
93. Answer: C. The father may resent the infant’s
demands on the mother’s body
With breastfeeding, the father’s body is not capable
of providing the milk for the newborn, which may interfere with feeding the
newborn, providing fewer chances for bonding, or he may be jealous of the
infant’s demands on his wife’s time and body.
Option A: Breastfeeding is advantageous because
uterine involution occurs more rapidly, thus minimizing blood loss.
Option B: The presence of maternal antibodies in
breast milk helps decrease the incidence of allergies in the newborn.
Option D: A
greater chance for error is associated with bottle feeding. No preparation is
required for breastfeeding.
94. Answer: A. The test was performed less than 10
days after an abortion
A false-positive reaction can occur if the pregnancy
test is performed less than 10 days after an abortion.
Options B, C, and D: Performing the tests too early or
too late in the pregnancy, storing the urine sample too long at room
temperature, or having a spontaneous or missed abortion impending can all
produce false-negative results.
95. Answer: D. 20 weeks gestation
The FHR can be auscultated with a fetoscope at about
20 week’s gestation. FHR usually is auscultated at the midline suprapubic
region with Doppler ultrasound transducer at 10 to 12 week’s gestation. FHR,
cannot be heard any earlier than 10 weeks’ gestation.
96. Answer: C. April 12
The FHR can be auscultated with a fetoscope at about
20 week’s gestation. FHR usually is auscultated at the midline suprapubic
region with Doppler ultrasound transducer at 10 to 12 week’s gestation. FHR,
cannot be heard any earlier than 10 weeks’ gestation.
97. Answer: A. Uterus in the pelvis
When the LMP is unknown, the gestational age of the
fetus is estimated by uterine size or position (fundal height). The presence of
the uterus in the pelvis indicates less than 12 weeks’ gestation. At
approximately 12 to 14 weeks, the fundus is out of the pelvis above the
symphysis pubis. The fundus is at the level of the umbilicus at approximately
20 weeks’ gestation and reaches the xiphoid at term or 40 weeks.
98. Answer: D. Leaking amniotic fluid
Danger signs that require prompt reporting leaking of
amniotic fluid, vaginal bleeding, blurred vision, rapid weight gain, and
elevated blood pressure.
Options A, B, and C: Constipation, breast tenderness,
and nasal stuffiness are common discomforts associated with pregnancy.
99. Answer: B. Rubella titer less than 1:8
A rubella titer should be 1:8 or greater. Thurs, a
finding of a titer less than 1:8 is significant, indicating that the client may
not possess immunity to rubella.
Options A and D: A hematocrit of 33.5% a white blood
cell count of 8,000/mm3, and a 1-hour glucose challenge test of 110 g/dl are
with normal parameters.
100. Answer: D. Increasing intensity with walking
With true labor, contractions increase in intensity
with walking. In addition, true labor contractions occur at regular intervals,
usually starting in the back and sweeping around to the abdomen. The interval
of true labor contractions gradually shortens.
Click below to download this question paper
PDF file will be updated soon
Thanks
Visit our sites for more updates
www.thebossacadmy.net for study materials, model previous year
question papers, books & journals.
0 Comments