608 Exam Qs (copy)

Cervical insufficiency is best described as:

A.  Painless dilation of the cervix, typically in the second trimester, that can lead to pregnancy loss without contractions

B.  Sudden onset of painful contractions at term

C.  Complete placental separation from the uterine wall

D.  Excessive amniotic fluid volume

A.  Painless dilation of the cervix, typically in the second trimester, that can lead to pregnancy loss without contractions

Rationale: Cervical insufficiency (previously “incompetent cervix”) involves painless cervical dilation, typically in the second trimester, that can lead to preterm birth or pregnancy loss without contractions.

 A client has a cervical cerclage placed for cervical insufficiency. Which statement about this procedure is accurate?

A.  It is a purse-string suture placed around the cervix to keep it closed until near term  

B.  It is performed only after the cervix has fully dilated

C.  It eliminates the need for any further prenatal monitoring

D.  It is a permanent suture that is never removed

A.  It is a purse-string suture placed around the cervix to keep it closed until near term

Rationale: A cervical cerclage is a purse-string (often nonabsorbable) suture placed around the cervix to mechanically reinforce it and keep it closed until near term, when it is typically removed.

 A client at 9 weeks gestation reports cramping and light vaginal bleeding. On exam the cervix is closed and ultrasound shows a viable fetus. This is classified as:

A.  Complete abortion

B.  Threatened abortion

C.  Inevitable abortion

D.  Missed abortion

B.  Threatened abortion  

Rationale: Threatened abortion presents with bleeding/cramping but a closed cervix and a viable pregnancy on ultrasound; the pregnancy may continue.

A client at 7 weeks gestation presents with unilateral pelvic pain, vaginal spotting, tachycardia, and hypotension. The nurse should suspect:

A.  Threatened abortion

B.  Ruptured ectopic pregnancy

C.  Placenta previa

D.  Hydatidiform mole

B.  Ruptured ectopic pregnancy   ✓ CORRECT

Rationale: Unilateral pain, spotting, and signs of hypovolemic shock (tachycardia, hypotension) in early pregnancy suggest a ruptured ectopic pregnancy — a medical emergency.

Which location is the most common implantation site for an ectopic pregnancy?

A.  Ovary

B.  Cervix

C.  Fallopian tube

D.  Abdominal cavity

C.  Fallopian tube

Rationale: The fallopian tube (most often the ampulla) is the most common implantation site for an ectopic pregnancy.

 A client at 33 weeks gestation reports sudden, painless, bright red vaginal bleeding. The nurse's priority action is to:

A.  Perform a digital cervical exam to assess dilation

B.  Avoid vaginal examinations and assess fetal heart rate and maternal vital signs

C.  Encourage ambulation to assess the bleeding response

D.  Administer oxytocin per protocol

B.  Avoid vaginal examinations and assess fetal heart rate and maternal vital signs  

Rationale: With suspected placenta previa, digital vaginal exams are contraindicated due to the risk of provoking severe hemorrhage; the priority is monitoring fetal heart rate, maternal vital signs, and blood loss.

Placenta previa is best defined as:

A.  Premature separation of a normally implanted placenta

B.  Abnormal placental implantation over or near the cervical os

C.  Abnormal invasion of the placenta into the myometrium

D.  Retention of placental fragments after delivery

B.  Abnormal placental implantation over or near the cervical os

Rationale: Placenta previa occurs when the placenta implants in the lower uterine segment, covering or lying near the internal cervical os.

A client at 36 weeks gestation presents with sudden severe abdominal pain, a rigid board-like uterus, and dark red vaginal bleeding. The nurse suspects:

A.  Placenta previa

B.  Placental abruption

C.  Uterine rupture

D.  Vasa previa

B.  Placental abruption

Rationale: Sudden severe pain, uterine rigidity, and dark bleeding are classic signs of placental abruption — premature separation of a normally implanted placenta.

Which factor places a pregnant client at increased risk for placental abruption?

A.  Maternal hypertension

B.  Maternal hypotension

C.  Post-term pregnancy only

D.  Low maternal parity

A.  Maternal hypertension

Rationale: Maternal hypertension (chronic or gestational) is a major risk factor for placental abruption due to vascular changes affecting the placental bed.

Placenta accreta spectrum disorders involve which abnormality?

A.  Abnormally deep attachment of the placenta into the uterine wall, sometimes through the myometrium

B.  Complete detachment of the placenta prior to delivery

C.  Implantation of the placenta in the fallopian tube

D.  Excessive amniotic fluid surrounding the placenta

A.  Abnormally deep attachment of the placenta into the uterine wall, sometimes through the myometrium

Rationale: Placenta accreta spectrum disorders occur when placental villi attach too deeply into the uterine wall (accreta), invade the myometrium (increta), or penetrate through the uterine wall (percreta).

A client with confirmed placenta accreta is being counseled about delivery. Which statement reflects appropriate education?

A.  Vaginal birth is preferred to reduce bleeding risk

B.  A scheduled cesarean birth, often with hysterectomy, may be recommended to reduce hemorrhage risk

C.  This condition resolves spontaneously by term and requires no special planning

D.  Delivery must occur before 28 weeks regardless of maternal-fetal status

B.  A scheduled cesarean birth, often with hysterectomy, may be recommended to reduce hemorrhage risk

Rationale: Because of the high risk of massive hemorrhage, placenta accreta spectrum disorders are typically managed with a planned cesarean birth (often with hysterectomy) at a facility prepared for significant blood loss.

Which of the following is a recognized risk factor for preterm labor and birth?

A.  Multiple gestation

B.  Post-term pregnancy

C.  Grand multiparity only

D.  Maternal age 30–35 with no other risk factors

A.  Multiple gestation

Rationale: Multiple gestation is a well-established risk factor for preterm labor due to uterine overdistension.

Fetal fibronectin (fFN) testing is used in the evaluation of preterm labor primarily to:

A.  Confirm rupture of membranes

B.  Help predict the likelihood of preterm birth within the next 1–2 weeks

C.  Diagnose gestational diabetes

D.  Directly measure fetal lung maturity

B.  Help predict the likelihood of preterm birth within the next 1–2 weeks

Rationale: A negative fFN result has a strong negative predictive value, helping identify women unlikely to deliver within the next 1–2 weeks; it is used alongside cervical length assessment.

 A client receiving nifedipine (Procardia) for tocolysis has a heart rate of 128 bpm. What is the nurse's priority action?

A.  Administer the next scheduled dose as ordered

B.  Hold the medication and notify the provider  

C.  Increase the IV fluid rate

D.  Document as an expected finding requiring no action

B.  Hold the medication and notify the provider

Rationale: Nifedipine should be held if maternal heart rate exceeds 120 bpm, and the provider should be notified.

 Indomethacin (Indocin), a prostaglandin synthase inhibitor used for tocolysis, carries which fetal risk with prolonged or later-gestation use?

A.  Increased amniotic fluid volume

B.  Constriction of the ductus arteriosus with premature closure

C.  Macrosomia

D.  Improved fetal platelet counts

B.  Constriction of the ductus arteriosus with premature closure  

Rationale: Indomethacin used beyond 48 hours or after 32 weeks gestation carries risk of constriction/premature closure of the fetal ductus arteriosus and oligohydramnios; fluid volume should be monitored.

 A client receiving magnesium sulfate for tocolysis has: respiratory rate 10/min, absent deep tendon reflexes (DTRs), and urine output of 20 mL/hr. The nurse should:

A.  Increase the infusion rate

B.  Stop the infusion and prepare to administer calcium gluconate

C.  Continue the infusion and recheck in 2 hours

D.  Administer an additional 4–6 gm IV bolus

B.  Stop the infusion and prepare to administer calcium gluconate

Rationale: RR <12, absent DTRs, and oliguria (<30 mL/hr) are signs of magnesium toxicity; the infusion should be discontinued and calcium gluconate (the antidote) prepared.

 A client is receiving terbutaline (Brethine) for tocolysis. Which finding requires the nurse to withhold the medication and notify the provider immediately?

A.  Mild maternal tremors

B.  Maternal heart rate of 88 bpm

C.  Maternal chest pain and palpitations  

D.  Fetal heart rate of 145 bpm

C.  Maternal chest pain and palpitations  

Rationale: Terbutaline (a beta-adrenergic agonist) can cause maternal tachycardia, chest pain, and palpitations; chest pain warrants immediate notification as it may indicate cardiac compromise. It should not be given concurrently with magnesium sulfate due to risk of severe hypotension.

A client at 32 weeks gestation reports a sudden gush of clear fluid from the vagina. The nurse should first:

A.  Assist the client to ambulate to confirm continued leaking

B.  Assess fetal heart rate and test the fluid (e.g., nitrazine, ferning) to confirm rupture of membranes

C.  Administer oxytocin to induce labor

D.  Discharge the client home for outpatient follow-up

B.  Assess fetal heart rate and test the fluid (e.g., nitrazine, ferning) to confirm rupture of membranes

Rationale: The priority is to assess fetal wellbeing (FHR) and confirm rupture of membranes using nitrazine paper or the ferning test before further intervention.

Which is a priority concern with prelabor rupture of membranes (PROM) remote from term?

A.  Maternal hypertension

B.  Risk of infection (chorioamnionitis) and umbilical cord prolapse

C.  Postpartum hemorrhage

D.  Gestational diabetes

B.  Risk of infection (chorioamnionitis) and umbilical cord prolapse

Rationale: PROM increases the risk of ascending infection (chorioamnionitis) and, especially with preterm PROM, umbilical cord prolapse, both requiring close monitoring.

Gestational hypertension is defined as:

A.  Blood pressure ≥140/90 mmHg after 20 weeks gestation without proteinuria or other severe features, in a previously normotensive woman

B.  Blood pressure elevation present before pregnancy

C.  Hypertension accompanied by seizure activity

D.  Blood pressure elevation only in the postpartum period

A.  Blood pressure ≥140/90 mmHg after 20 weeks gestation without proteinuria or other severe features, in a previously normotensive woman

Rationale: Gestational hypertension is new-onset hypertension (≥140/90) after 20 weeks gestation without proteinuria or other diagnostic criteria for preeclampsia.

 A client at 34 weeks gestation has a blood pressure of 168/112 mmHg, 2+ proteinuria, and reports a severe headache and visual disturbances. The priority nursing action is to:

A.  Encourage ambulation

B.  Notify the provider and prepare for magnesium sulfate administration

C.  Document and reassess in 4 hours

D.  Administer a PRN antihypertensive without notifying the provider

B.  Notify the provider and prepare for magnesium sulfate administration

Rationale: Severe preeclampsia features (severe HTN, proteinuria, headache, visual changes) require prompt provider notification and preparation for seizure prophylaxis with magnesium sulfate.

Which laboratory pattern is consistent with HELLP syndrome?

A.  Elevated hemoglobin, low liver enzymes, elevated platelets

B.  Hemolysis, elevated liver enzymes, and a low platelet count

C.  Normal liver enzymes with elevated platelets

D.  Low hemoglobin only, with normal liver function

B.  Hemolysis, elevated liver enzymes, and a low platelet count

Rationale: HELLP syndrome, a severe variant of preeclampsia, is defined by Hemolysis, Elevated Liver enzymes, and a Low Platelet count.

A client receiving magnesium sulfate for severe preeclampsia begins to have a seizure. What is the nurse's priority action?

A.  Restrain the client to prevent injury

B.  Ensure a patent airway, turn the client to her side, and stay with the client

C.  Immediately increase the magnesium sulfate infusion rate

D.  Leave the room to call the provider

B.  Ensure a patent airway, turn the client to her side, and stay with the client Rationale: During an eclamptic seizure, the priority is maintaining a patent airway, positioning the client on her side to reduce aspiration risk, and staying with the client for continuous monitoring.

 A client at 34 weeks gestation is diagnosed with polyhydramnios. The nurse should assess for which commonly associated condition?

A.  Maternal diabetes or a fetal anomaly affecting swallowing

B.  Postterm pregnancy only

C.  Maternal hypotension

D.  Chronic hypertension exclusively

A.  Maternal diabetes or a fetal anomaly affecting swallowing

Rationale: Polyhydramnios (excess amniotic fluid) is associated with maternal diabetes and fetal anomalies that impair swallowing (e.g., esophageal atresia, neural tube defects).

A client pregnant with twins asks the nurse about associated risks. Teaching should include which of the following?

A.  Increased risk for preterm labor and gestational hypertension

B.  Decreased risk of anemia compared to a singleton pregnancy

C.  No increased need for prenatal visits

D.  Decreased risk of postpartum hemorrhage

A.  Increased risk for preterm labor and gestational hypertension

Rationale: Multiple gestation increases risk for preterm labor, gestational hypertension, anemia, and postpartum hemorrhage.

A client with hyperemesis gravidarum is admitted for severe dehydration. Which finding indicates the need for further intervention?

A.  Urine specific gravity within normal limits

B.  Ketones present in the urine  

C.  Weight gain since admission

D.  Improved skin turgor

B.  Ketones present in the urine

Rationale: Ketonuria indicates ongoing starvation/dehydration ketosis and the need for further intervention despite other improving signs.

At the first prenatal visit, which finding meets the diagnostic cutoff for overt (pregestational) diabetes?

A.  Fasting glucose of 100 mg/dL

B.  HgbA1C of 6%

C.  Fasting ≥126 mg/dL, HgbA1C >7%, or random ≥200 mg/dL

D.  Random glucose of 150 mg/dL

C.  Fasting ≥126 mg/dL, HgbA1C >7%, or random ≥200 mg/dL

Rationale: Overt/pregestational diabetes diagnosed at the first prenatal visit uses cutoffs of fasting ≥126 mg/dL, HgbA1C >7%, or random glucose ≥200 mg/dL.

Which of the following are recognized risk factors for gestational diabetes mellitus (GDM)?  (Select all that apply.)

A.  BMI ≥25  

B.  A previous infant weighing more than 9 lb

C.  Polycystic ovary syndrome (PCOS)  

D.  No family history of diabetes

E.  A first-degree relative with diabetes  

F.  Hypotension in early pregnancy

A.  BMI ≥25  

B.  A previous infant weighing more than 9 lb  

C.  Polycystic ovary syndrome (PCOS)  

E.  A first-degree relative with diabetes  

Rationale: GDM risk factors include overweight/obesity (BMI ≥25), a prior macrosomic infant, PCOS, and a first-degree relative with diabetes — not an unremarkable family history or hypotension.

Which maternal complications are associated with diabetes in pregnancy?  (Select all that apply.)

A.  Gestational hypertension and preeclampsia  

B.  Polyhydramnios  

C.  Diabetic ketoacidosis (DKA)

D.  Decreased risk of cesarean birth

E.  Postpartum hemorrhage

F.  Chronic monilial vaginitis  

A.  Gestational hypertension and preeclampsia

B.  Polyhydramnios  

C.  Diabetic ketoacidosis (DKA)

E.  Postpartum hemorrhage  

F.  Chronic monilial vaginitis  

Rationale: Diabetes in pregnancy increases risk for gestational hypertension, preeclampsia, polyhydramnios, DKA, postpartum hemorrhage, and chronic monilial vaginitis — and increases (not decreases) cesarean birth risk.

Which fetal/newborn complications are associated with maternal diabetes in pregnancy?  (Select all that apply.)

A.  Macrosomia  

B.  Neonatal hypoglycemia  

C.  Respiratory distress syndrome (RDS)  

D.  Decreased risk of congenital anomalies

E.  Polycythemia and hyperbilirubinemia

Which fetal/newborn complications are associated with maternal diabetes in pregnancy?  (Select all that apply.)

A.  Macrosomia  

B.  Neonatal hypoglycemia  

C.  Respiratory distress syndrome (RDS)  

E.  Polycythemia and hyperbilirubinemia  

Rationale: Maternal diabetes increases risk of fetal macrosomia, neonatal hypoglycemia, RDS, polycythemia, and hyperbilirubinemia; risk of congenital anomalies is increased (not decreased) with uncontrolled 1st-trimester diabetes.

Which nursing assessments are key newborn care takeaways for infants of diabetic mothers?  (Select all that apply.)

A.  Assess for macrosomia-related birth trauma

B.  Watch for respiratory distress

C.  Discourage breastfeeding

D.  Assess for jaundice and polycythemia  

A.  Assess for macrosomia-related birth trauma  

B.  Watch for respiratory distress  

D.  Assess for jaundice and polycythemia  

Rationale: Newborns of diabetic mothers should be assessed for macrosomia-related birth trauma, respiratory distress, jaundice, and polycythemia; breastfeeding is encouraged, not discouraged.

 What percentage of maternal deaths is attributed to cardiovascular disease (CVD)?

A.  5%

B.  10%

C.  25%

D.  50%

C.  25%  

Rationale: CVD is attributed to 25% of maternal deaths.

Which hemodynamic changes are expected during a normal pregnancy?  (Select all that apply.)

A.  Heart rate increases 10–15 bpm

B.  Blood pressure decreases through the 2nd trimester, returning toward baseline in the 3rd  

C.  Blood volume and cardiac output decrease

D.  Physiologic anemia develops due to hemodilution  

A.  Heart rate increases 10–15 bpm  

B.  Blood pressure decreases through the 2nd trimester, returning toward baseline in the 3rd  

D.  Physiologic anemia develops due to hemodilution  

Rationale: Normal pregnancy hemodynamics include increased HR, decreased BP through the 2nd trimester (returning toward baseline in the 3rd), increased (not decreased) blood volume/cardiac output, and physiologic anemia from hemodilution.

Cardiac disease risk in pregnancy is typically categorized using which classification system?

A.  Apgar scoring

B.  Class I to Class IV risk categories  

C.  Tanner staging

D.  Bishop scoring

B.  Class I to Class IV risk categories   ✓ CORRECT

Rationale: Cardiovascular disease risk in pregnancy is categorized using Class I to Class IV risk categories as part of preconception counseling.

Which finding is a cardiac warning sign to report during pregnancy or postpartum?

A.  Shortness of breath with little or no physical activity

B.  Mild fatigue after a flight of stairs

C.  Occasional mild ankle swelling at end of day only

D.  Slightly increased appetite

A.  Shortness of breath with little or no physical activity   ✓ CORRECT

Rationale: SOB with little or no activity is a cardiac warning sign, along with chest pain, palpitations, fainting, unusual fatigue, and edema.

 What is the primary goal of asthma management during pregnancy?

A.  Maintain maternal oxygenation to support fetal oxygenation

B.  Discontinue all asthma medications to protect the fetus

C.  Avoid all physical activity for the remainder of pregnancy

D.  Delay treatment until after delivery

A.  Maintain maternal oxygenation to support fetal oxygenation  

Rationale: The goal of asthma management in pregnancy is to maintain maternal oxygenation to support fetal oxygenation; medications are continued as prescribed.

 Which nursing actions are appropriate when caring for a pregnant client with asthma?  (Select all that apply.)

A.  Observe inhaler technique  

B.  Assess fetal heart rate  

C.  Encourage smoking as a stress reliever

D.  Monitor oxygen saturation during labor

 Which nursing actions are appropriate when caring for a pregnant client with asthma?  (Select all that apply.)

A.  Observe inhaler technique  

B.  Assess fetal heart rate

D.  Monitor oxygen saturation during labor  

Rationale: Appropriate asthma management includes observing inhaler technique, assessing FHR, and monitoring SpO2 during labor; smoking cessation — not encouragement — is part of asthma care.

 True anemia in pregnancy is defined as hemoglobin below which value in the 1st and 3rd trimesters?

A.  <11 g/dL  

B.  <10.5 g/dL

C.  <9 g/dL

D.  <12 g/dL

A.  <11 g/dL  

Rationale: Anemia is defined as Hgb <11 g/dL in the 1st/3rd trimesters and <10.5 g/dL in the 2nd trimester.

Which factors increase a pregnant client's risk for iron-deficiency anemia?  (Select all that apply.)

A.  Increased maternal blood volume  

B.  Expanded red blood cell mass and fetal/placental iron needs  

C.  Short pregnancy interval

D.  Decreased iron requirements during pregnancy

A.  Increased maternal blood volume

B.  Expanded red blood cell mass and fetal/placental iron needs  

C.  Short pregnancy interval

Rationale: Increased blood volume, expanded RBC mass, fetal/placental iron demands, and short pregnancy intervals all increase iron-deficiency anemia risk; iron requirements increase, not decrease, during pregnancy.

 A pregnant client with iron-deficiency anemia is being taught how to improve iron absorption. Which instruction is correct?

A.  Take the iron supplement with a glass of milk

B.  Take the iron supplement with a source of vitamin C  

C.  Take the iron supplement with coffee or tea

D.  Take the iron supplement with high-fiber cereal

B.  Take the iron supplement with a source of vitamin C

Rationale: Vitamin C enhances iron absorption; milk, coffee, tea, chocolate, and high-fiber foods should be avoided with iron dosing because they inhibit absorption.

 A pregnant client is counseled to avoid changing cat litter and to cook meat thoroughly. This teaching addresses prevention of which infection?

A.  Rubella

B.  Toxoplasmosis

C.  Cytomegalovirus

D.  Herpes simplex virus

B.  Toxoplasmosis

Rationale: Cat feces/litter boxes and undercooked meat are linked to toxoplasmosis transmission.

Congenital rubella infection poses the greatest fetal risk when maternal infection occurs during which window?

A.  The first 10 weeks of pregnancy

B.  The third trimester only

C.  During labor only

D.  Rubella poses no fetal risk

A.  The first 10 weeks of pregnancy  

Rationale: The greatest fetal risk from rubella occurs with infection in the first 10 weeks of pregnancy; congenital rubella can cause hearing loss, cataracts, heart defects, and developmental delay.

 A newborn presents with a “blueberry muffin” rash, fetal growth restriction, and CNS deficits. The nurse suspects congenital infection with which TORCH pathogen?

A.  Toxoplasmosis

B.  Rubella

C.  Cytomegalovirus (CMV)  

D.  Herpes simplex virus

C.  Cytomegalovirus (CMV)  

Rationale: Blueberry muffin rash, FGR/SGA, and CNS deficits are classic congenital CMV findings, with risk highest when maternal infection occurs in the first trimester.

 A pregnant client has an active herpes simplex virus (HSV) lesion at the time of labor. What is the recommended mode of delivery?

A.  Vaginal delivery with continuous fetal monitoring

B.  Cesarean delivery  

C.  Induction of labor regardless of lesion status

D.  Delivery mode is not affected by HSV lesion status

B.  Cesarean delivery  

Rationale: Cesarean delivery is recommended when active HSV lesions are present at the time of birth due to high transmission risk (encephalitis, vesicular lesions).

Hepatitis B and C viruses in pregnancy are primarily transmitted through which routes?  (Select all that apply.)

A.  Sexual contact

B.  Injection drug use  

C.  Contaminated blood

D.  Airborne droplets

A.  Sexual contact  

B.  Injection drug use

C.  Contaminated blood  

Rationale: Hepatitis B/C are transmitted through sexual contact, injection drug use, and contaminated blood, and both can be vertically transmitted to the fetus. They are not airborne infections.

Group B Streptococcus (GBS) rectovaginal screening is recommended at what gestational age?

A.  12–14 weeks

B.  20–24 weeks

C.  35–37 weeks

D.  At the first prenatal visit only

C.  35–37 weeks

Rationale: GBS rectovaginal culture screening occurs at 35–37 weeks' gestation; GBS colonizes 10–30% of pregnant women, most asymptomatically.

 A pregnant client with HIV is starting antiretroviral therapy (ART). At what gestational age is oral ART typically initiated (if not already on therapy) and continued until birth?

A.  6 weeks

B.  14 weeks

C.  28 weeks

D.  36 weeks

B.  14 weeks  

Rationale: Oral antiretroviral therapy is typically given twice daily starting at 14 weeks' gestation until birth, with IV administration added during labor.

A pregnant client with HIV has a viral load greater than 1,000 copies/mL near delivery. The client should be counseled to expect:

A.  Vaginal birth is preferred regardless of viral load

B.  Scheduled cesarean birth is recommended  

C.  No antiretroviral therapy is needed during labor

D.  Breastfeeding is always recommended regardless of viral load

B.  Scheduled cesarean birth is recommended

Rationale: Scheduled cesarean birth is recommended when HIV viral load is >1,000 copies/mL or unknown near delivery; mode of birth is based primarily on viral load.

Which maternal and fetal complications are associated with obesity in pregnancy?  (Select all that apply.)

A.  Gestational hypertension and preeclampsia

B.  Macrosomia and the infant being large for gestational age (LGA)

C.  Venous thromboembolism (VTE)  

D.  Decreased risk of cesarean delivery

A.  Gestational hypertension and preeclampsia  

B.  Macrosomia and the infant being large for gestational age (LGA)

C.  Venous thromboembolism (VTE)  

Rationale: Obesity in pregnancy increases risk for gestational hypertension, preeclampsia, macrosomia, LGA infants, and VTE — and increases (not decreases) cesarean delivery risk.

 A pregnant client with a history of substance misuse delivers a newborn with a positive toxicology screen. What is the appropriate nursing approach?

A.  Use a nonjudgmental approach; a positive newborn drug screen requires state protection agency investigation  

B.  Withhold information from the family to avoid conflict

C.  Assume the mother is unfit to care for the infant and recommend immediate separation

D.  No further action is required once the infant is medically stable

A.  Use a nonjudgmental approach; a positive newborn drug screen requires state protection agency investigation  

Rationale: Nursing management includes a nonjudgmental approach; a positive newborn drug screen triggers required state protection agency investigation, along with counseling and education.

 When fitting a child for axillary crutches, the top of the crutch should be positioned:

A.  Flush against the axilla

B.  2–3 fingerbreadths below the axilla  

C.  At the level of the hip

D.  Touching the underarm skin fold

B.  2–3 fingerbreadths below the axilla   ✓ CORRECT

Rationale: Crutches fitted 2–3 fingerbreadths below the axilla prevent pressure injury to the brachial plexus and axillary nerves.

A family asks at what age most children with Duchenne muscular dystrophy (DMD) typically transition to a wheelchair for mobility. The nurse's best response is:

A.  Ages 2–4

B.  Ages 5–7

C.  Ages 10–14  

D.  Ages 18–21

C.  Ages 10–14  

Rationale: Wheelchair transition in DMD typically occurs between ages 10–14 as proximal muscle weakness progresses.

During a school scoliosis screening, the nurse asks the child to bend forward with arms hanging freely. This maneuver assesses for:

A.  Hip dysplasia

B.  Asymmetry or a rib hump indicating spinal curvature  

C.  Leg length discrepancy only

D.  Muscle tone in the lower extremities

B.  Asymmetry or a rib hump indicating spinal curvature

Rationale: The forward bend test allows the nurse to visualize asymmetry or a rib hump, which indicates vertebral rotation from scoliosis.

 A nurse is caring for a child following spinal fusion surgery for scoliosis. Which technique should be used for every position change?

A.  Standard turning with pillows for support

B.  Log-roll technique to avoid spinal flexion  

C.  Allow the child to reposition independently

D.  Trendelenburg positioning

B.  Log-roll technique to avoid spinal flexion  

Rationale: The log-roll technique is used for every position change after spinal fusion to avoid spinal flexion and protect the surgical site.

A nurse notes that a 4-year-old's tonsils and lymph nodes appear proportionally larger than an adult's. How should the nurse interpret this finding?

A.  A sign of chronic infection

B.  An expected finding, not pathology, because lymphoid tissue is proportionally larger in children  

C.  An indication of lymphoma

D.  A sign of primary immunodeficiency

B.  An expected finding, not pathology, because lymphoid tissue is proportionally larger in children  

Rationale: Lymph nodes, tonsils, and thymus are relatively larger in children than adults — an expected finding, not pathology.

Which laboratory test is most specific for monitoring disease activity in a child with systemic lupus erythematosus (SLE)?

A.  C-reactive protein

B.  Anti-double-stranded DNA (anti-dsDNA) antibody  

C.  Rheumatoid factor

D.  Absolute neutrophil count

B.  Anti-double-stranded DNA (anti-dsDNA) antibody  

Rationale: Anti-dsDNA antibody is specific for SLE activity, while ANA is used as an initial screening test.

A child is diagnosed with polyarticular juvenile idiopathic arthritis (JIA). Based on this classification, how many joints are affected?

A.  1 joint

B.  ≤4 joints

C.  ≥5 joints  

D.  All joints including the spine only

C.  ≥5 joints  

Rationale: Polyarticular JIA is defined by involvement of ≥5 joints, compared to oligoarticular (≤4 joints) and systemic JIA (fever/rash plus joint involvement).

A nurse is caring for a child with HIV infection. Which assessment finding requires close ongoing monitoring due to its known association with pediatric HIV?

A.  Rapid weight gain

B.  Developmental delay or regression of milestones  

C.  Precocious puberty

D.  Improved cognitive function over time

B.  Developmental delay or regression of milestones  

Rationale: HIV infection in children often results in encephalopathy and developmental delay; closely monitor developmental milestone attainment.

Which findings are consistent with growth hormone (GH) deficiency in a child?  (Select all that apply.)

A.  Height below the 3rd percentile  

B.  Prominent, large forehead  

C.  Advanced bone age

D.  Higher weight-to-height ratio  

E.  Delayed sexual maturation  

F.  Increased muscle mass

A.  Height below the 3rd percentile  

B.  Prominent, large forehead  

D.  Higher weight-to-height ratio  

E.  Delayed sexual maturation  

Rationale: GH deficiency presents with height below the 3rd percentile, a prominent forehead, higher weight-to-height ratio, delayed sexual maturation, and decreased (not increased) muscle mass.

Central precocious puberty in boys is more likely than in girls to be caused by:

A.  Idiopathic causes with no identifiable etiology

B.  A CNS abnormality such as a brain tumor  

C.  Congenital adrenal hyperplasia

D.  An ovarian tumor

B.  A CNS abnormality such as a brain tumor  

Rationale: Central precocious puberty is usually idiopathic in girls but more likely caused by a CNS abnormality (tumor, infection, radiation) in boys.

Which nursing interventions are appropriate for a child with Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?  (Select all that apply.)

A.  Monitor neurologic status  

B.  Explain the need for fluid restriction  

C.  Encourage a high-fluid diet

D.  Obtain daily weights  

E.  Anticipate the need for a Foley catheter for accurate intake and output  

A.  Monitor neurologic status  

B.  Explain the need for fluid restriction  

D.  Obtain daily weights  

E.  Anticipate the need for a Foley catheter for accurate intake and output  

Rationale: SIADH management includes monitoring neuro status, fluid restriction (not a high-fluid diet), daily weights, and possibly a Foley catheter for accurate I&O.

 A newborn with congenital adrenal hyperplasia (CAH) develops a salt-wasting crisis. Which findings should the nurse anticipate?  (Select all that apply.)

A.  Vomiting  

B.  Hypertension

C.  Hyponatremia  

D.  Hyperkalemia  

E.  Dehydration  

A.  Vomiting  

C.  Hyponatremia  

D.  Hyperkalemia  

E.  Dehydration  

Rationale: Salt-wasting crisis in CAH presents with vomiting, dehydration, hypotension (not hypertension), hyponatremia, and hyperkalemia.

 The nurse is teaching a family of a child with type 1 diabetes about sick-day management. Which instruction is appropriate?

A.  Stop all insulin administration during illness

B.  Continue monitoring blood glucose and check urine ketones more frequently during illness  

C.  Insulin needs decrease significantly during any illness

D.  Sick-day management is only needed for gastrointestinal illness

B.  Continue monitoring blood glucose and check urine ketones more frequently during illness  

Rationale: During illness, blood glucose monitoring and urine ketone checks should increase in frequency; insulin is not stopped, and insulin needs often increase (not decrease) with illness/stress.

Which statement about learning disabilities in children is accurate?

A.  They affect up to 15% of children and occur despite average intelligence  

B.  They always occur alongside intellectual disability

C.  They are caused exclusively by inadequate parenting

D.  They cannot be identified until adulthood

A.  They affect up to 15% of children and occur despite average intelligence  

Rationale: Learning disabilities affect up to 15% of children who have average intelligence but difficulty with reading (dyslexia), math (dyscalculia), coordination (dyspraxia), or writing (dysgraphia).

Intellectual disability is best defined as:

A.  A learning disability affecting only reading skills

B.  Significant limitations in intellectual functioning and adaptive behavior originating before age 18–22  

C.  A temporary developmental delay that always resolves by school age

D.  A diagnosis based solely on IQ testing after age 21

B.  Significant limitations in intellectual functioning and adaptive behavior originating before age 18–22  

Rationale: Intellectual disability involves significant limitations in intellectual status and adaptive behavior originating before age 18–22, with severity ranging from mild to profound.

 A child engages in repetitive behaviors to reduce distress caused by unwanted, intrusive thoughts. This is most consistent with:

A.  Generalized anxiety disorder

B.  Social phobia

C.  Obsessive-compulsive disorder (OCD)  

D.  Separation anxiety disorder

C.  Obsessive-compulsive disorder (OCD)  

Rationale: OCD involves compulsions performed to reduce anxiety caused by unwanted, intrusive thoughts (obsessions).

A 15-month-old drinking 32 oz of cow's milk daily is diagnosed with iron-deficiency anemia. What is the most likely contributing factor?

A.  Excessive iron intake from milk

B.  Excessive cow's milk intake displacing iron-rich foods and causing GI blood loss  

C.  A genetic hemoglobinopathy

D.  Lead exposure

B.  Excessive cow's milk intake displacing iron-rich foods and causing GI blood loss  

Rationale: Excessive cow's milk intake in toddlers is a classic cause of iron-deficiency anemia — it displaces iron-rich foods and can cause occult GI blood loss.

A child is diagnosed with Von Willebrand disease. The nurse understands this condition involves:

A.  A deficiency of von Willebrand factor, with treatment similar to hemophilia  

B.  Excess platelet production

C.  Autoimmune destruction of red blood cells

D.  A deficiency of vitamin K

A.  A deficiency of von Willebrand factor, with treatment similar to hemophilia  

Rationale: Von Willebrand disease is a deficiency in von Willebrand factor, causing a bleeding risk managed similarly to hemophilia.

Which statement about Ewing sarcoma is accurate?

A.  It accounts for about 30% of childhood bone tumors and commonly presents with pain and fever at the site  

B.  It exclusively affects the retina

C.  It is treated with surgery alone, without chemotherapy

D.  It carries no risk of metastasis

A.  It accounts for about 30% of childhood bone tumors and commonly presents with pain and fever at the site  

Rationale: Ewing sarcoma accounts for about 30% of childhood bone tumors, commonly presents with site pain and fever, and is treated with surgery, chemotherapy, and sometimes radiation.

Which infection prevention measures are appropriate for a pediatric oncology patient with a central line?  (Select all that apply.)

A.  Positive pressure rooms  

B.  Daily showers or chlorhexidine wipe-downs  

C.  Sterile dressing changes weekly or as needed  

D.  Unrestricted visitor access

E.  Clean, safe technique when accessing lines  

A.  Positive pressure rooms  

B.  Daily showers or chlorhexidine wipe-downs  

C.  Sterile dressing changes weekly or as needed  

E.  Clean, safe technique when accessing lines  

Rationale: Infection prevention includes positive pressure rooms, daily chlorhexidine care, sterile/as-needed dressing changes, and clean line access technique; visitor access should be limited, not unrestricted.

21. A 4-week-old presents with projectile, non-bilious vomiting after feeds, is hungry immediately afterward, and has a palpable olive-shaped mass in the right upper quadrant. Prior to surgery, the nurse's priority is to:<br>A. Begin oral rehydration therapy immediately before any labs are drawn<br>B. Correct electrolyte imbalances (e.g., metabolic alkalosis) before surgery<br>C. Administer a bolus tube feeding to assess tolerance<br>D. Apply heat to the abdomen to relax the pylorus

B. Correct electrolyte imbalances (e.g., metabolic alkalosis) before surgery<br>Rationale: Pyloric stenosis classically causes a hypochloremic, hypokalemic metabolic alkalosis from repeated vomiting; electrolytes must be corrected before the curative Ramstedt pyloromyotomy.

22. A full-term newborn has not passed meconium by 48 hours of life and has abdominal distension. The nurse should suspect which condition, and what is the gold-standard diagnostic test?<br>A. GERD; upper Gl series<br>B. Hirschsprung disease; suction rectal biopsy<br>C. Intussusception; abdominal ultrasound<br>D. Pyloric stenosis; sweat chloride test

B. Hirschsprung disease; suction rectal biopsy<br>Rationale: Failure to pass meconium within 48 hours in a full-term newborn, with abdominal distension, suggests Hirschsprung disease (absent ganglion cells no peristalsis); suction rectal biopsy is the gold-standard diagnostic test.

23. A toddler is vomiting. Which characteristic of the emesis should prompt the nurse to suspect a bowel obstruction and require immediate escalation?<br>A. Non-bilious (clear or milky) vomiting<br>B. Bilious (green) vomiting<br>C. Vomiting that occurs only once after a large meal<br>D. Vomiting accompanied by a mild fever only

B. Bilious (green) vomiting<br>Rationale: Bilious (green) vomiting is a red-flag finding suggesting intestinal obstruction and requires immediate escalation; non-bilious vomiting is far more common and less concerning.

24. A 2-year-old presents with a barky cough and audible inspiratory stridor that is worse at night, with no drooling or high fever. The nurse anticipates a diagnosis of:<br>A. Epiglottitis, requiring emergency airway management<br>B. Croup (laryngotracheobronchitis), managed with racemic epinephrine and corticosteroids<br>C. Cystic fibrosis exacerbation<br>D. Foreign body aspiration

B. Croup (laryngotracheobronchitis), managed with racemic epinephrine and corticosteroids<br>Rationale: Croup typically affects children 3 months-3 years, is viral (parainfluenza), causes a barky cough and inspiratory stridor worse at night, and is treated with racemic epinephrine and corticosteroids unlike epiglottitis, which presents with high fever, drooling, and is a life-threatening bacterial (Hib) emergency.

25. A child is diagnosed with cystic fibrosis (CF). Which statement about diagnosis and management is accurate?<br>A. CF is diagnosed with a sweat chloride test, and children require pancreatic enzyme replacement with meals due to pancreatic insufficiency<br>B. CF is an autosomal dominant condition requiring only one defective gene<br>C. CF management includes a low-calorie, low-protein diet to reduce digestive burden<br>D. Chest physical therapy is contraindicated in children with CF

A. CF is diagnosed with a sweat chloride test, and children require pancreatic enzyme replacement with meals due to pancreatic insufficiency<br>Rationale: CF is diagnosed via sweat chloride testing and is autosomal recessive (a defective gene from each parent). Due to pancreatic insufficiency, children need pancreatic enzyme replacement with meals, a high-calorie/high-protein diet (150-200% RDA), and chest physical therapy/airway clearance therapy to manage pulmonary secretions.

26. A client at 18 weeks gestation is found to have painless cervical dilation on exam with no contractions. The nurse recognizes this presentation as most consistent with:<br>A. Preterm labor<br>B. Cervical insufficiency<br>C. Placental abruption<br>D. Placenta previa

B. Cervical insufficiency<br>Rationale: Painless cervical dilation without contractions, typically in the second trimester, is the classic presentation of cervical insufficiency.

27. Which of the following is a recognized risk factor for ectopic pregnancy?<br>A. Prior tubal surgery or pelvic infection<br>B. Nulliparity with no prior surgeries<br>C. Post-term pregnancy<br>D. Low maternal BMI

A. Prior tubal surgery or pelvic infection<br>Rationale: Prior tubal surgery, pelvic inflammatory disease, or tubal scarring increases the risk of ectopic implantation.

28. Which finding helps distinguish placenta previa from placental abruption?<br>A. Previa causes painless bright red bleeding; abruption causes painful bleeding with a rigid uterus<br>B. Previa always causes severe abdominal pain; abruption is painless<br>C. Both conditions present identically<br>D. Abruption is diagnosed only after delivery

A. Previa causes painless bright red bleeding; abruption causes painful bleeding with a rigid uterus<br>Rationale: Placenta previa classically presents with painless bright red bleeding, while placental abruption presents with sudden pain, uterine rigidity, and often darker bleeding.

29. Which factor most increases a client's risk for placenta accreta spectrum disorder?<br>A. A first pregnancy with no prior surgeries<br>B. Prior cesarean birth with placenta previa in the current pregnancy<br>C. A low-lying placenta with no prior surgical history<br>D. Multiple gestation alone

B. Prior cesarean birth with placenta previa in the current pregnancy<br>Rationale: The combination of a prior cesarean scar and a current placenta previa significantly raises the risk of abnormal placental attachment (accreta spectrum).

30. Which finding on transvaginal ultrasound is associated with increased risk for preterm birth?<br>A. Cervical length greater than 4 cm<br>B. A shortened cervical length (e.g., less than 2.5 cm)<br>C. A normal amniotic fluid index<br>D. Fundal height appropriate for gestational age

B. A shortened cervical length (e.g., less than 2.5 cm)<br>Rationale: A shortened cervical length on transvaginal ultrasound is associated with increased risk of preterm birth and is used along with fFN testing for risk prediction.

31. Terbutaline is contraindicated for concurrent use with which other tocolytic due to risk of severe hypotension?
    A. Nifedipine
    B. Magnesium sulfate
    C. Indomethacin
    D. Betamethasone

A. Nifedipine
Rationale: Terbutaline should be avoided in combination with magnesium sulfate due to risk of severe hypotension.

32. A client with preterm prelabor rupture of membranes (PPROM) at 30 weeks is being managed expectantly. Which finding should prompt immediate provider notification?
    A. Clear fluid continuing to leak
    B. Maternal temperature of 101.4°F (38.6°C)
    C. Fetal heart rate of 140 bpm
    D. Mild uterine tightening

B. Maternal temperature of 101.4°F (38.6°C)
Rationale: Maternal fever suggests chorioamnionitis, a serious infectious complication of PPROM requiring prompt provider notification.

33. Which assessment finding in a client with preeclampsia indicates impending eclampsia?
    A. Trace proteinuria
    B. Blood pressure of 138/88 mmHg
    C. Hyperreflexia with clonus and a severe headache
    D. Mild dependent edema

C. Hyperreflexia with clonus and a severe headache
Rationale: Hyperreflexia with clonus, severe headache, and visual disturbances are severe features suggesting impending eclampsia (seizure).

34. Oligohydramnios is most closely associated with which of the following?
    A. Maternal diabetes
    B. Fetal renal anomalies impairing urine production
    C. Esophageal atresia
    D. Neural tube defects

B. Fetal renal anomalies impairing urine production
Rationale: Because amniotic fluid in later pregnancy is largely fetal urine, oligohydramnios is often linked to fetal renal anomalies impairing urine production.

35. Which complication is a twin pregnancy at increased risk for, compared to a singleton pregnancy?
    A. Postterm birth
    B. Preterm labor
    C. Macrosomia in both twins
    D. Decreased risk of anemia

B. Preterm labor
Rationale: Multiple gestation significantly increases the risk of preterm labor due to uterine overdistension, along with gestational hypertension and anemia.

36. Which 2-hour value on the 75g oral glucose tolerance test (OGTT) meets the diagnostic cutoff for gestational diabetes?
    A. >120 mg/dL
    B. >140 mg/dL
    C. >153 mg/dL
    D. >180 mg/dL

C. >153 mg/dL
Rationale: The 75g OGTT 2-hour cutoff for gestational diabetes is >153 mg/dL (fasting >92, 1-hour >180).

37. Which maternal complications are associated with diabetes in pregnancy? (Select all that apply.)
    A. Chronic monilial vaginitis
    B. Urinary tract infection
    C. Decreased risk of preeclampsia
    D. Postpartum hemorrhage
    E. Premature labor

A. Chronic monilial vaginitis
B. Urinary tract infection
D. Postpartum hemorrhage
E. Premature labor
Rationale: Diabetes in pregnancy increases (not decreases) risk of preeclampsia, along with chronic monilial vaginitis, UTIs, postpartum hemorrhage, and premature labor.

38. Which hemodynamic change is expected during a normal pregnancy?
    A. Heart rate decreases 10-15 bpm
    B. Heart rate increases 10-15 bpm
    C. Blood volume decreases
    D. Cardiac output decreases

B. Heart rate increases 10-15 bpm
Rationale: Normal pregnancy hemodynamics include an increase in heart rate of 10-15 bpm, along with increased blood volume and cardiac output.

39. Nursing management of asthma in pregnancy focuses primarily on:
    A. Trigger avoidance and adherence to prescribed asthma medications
    B. Discontinuing all medications until postpartum
    C. Bed rest for the remainder of pregnancy
    D. Avoiding all physical activity

A. Trigger avoidance and adherence to prescribed asthma medications
Rationale: Asthma management in pregnancy focuses on trigger avoidance and continuing prescribed medications to maintain maternal oxygenation for fetal wellbeing.

40. Which of the following are causes of anemia in pregnancy discussed in the curriculum? (Select all that apply.)<br>A. Iron-deficiency anemia<br>B. Sickle cell disease<br>C. Thalassemia<br>D. Vitamin C toxicity

A. Iron-deficiency anemia<br>B. Sickle cell disease<br>C. Thalassemia<br>Rationale: Iron-deficiency anemia, sickle cell disease, and thalassemia are recognized causes of anemia in pregnancy; vitamin C toxicity is not a discussed cause.

41. Transplacental transmission of toxoplasmosis can result in which fetal findings? (Select all that apply.)<br>A. Chorioretinitis<br>B. Intracranial calcifications<br>C. Hydrocephalus<br>D. Improved platelet counts

A. Chorioretinitis<br>B. Intracranial calcifications<br>C. Hydrocephalus<br>Rationale: Congenital toxoplasmosis can cause chorioretinitis, intracranial calcifications, hydrocephalus, abnormal CSF, jaundice, thrombocytopenia (not improved platelets), and anemia.

42. A nonimmune postpartum client should receive which vaccine before discharge, along with teaching to avoid pregnancy for 4 weeks?<br>A. Hepatitis B vaccine<br>B. MMR (Measles, Mumps, Rubella) vaccine<br>C. Tdap vaccine<br>D. Influenza vaccine

B. MMR (Measles, Mumps, Rubella) vaccine<br>Rationale: Nonimmune postpartum clients receive the MMR vaccine before discharge and are taught to avoid pregnancy for 4 weeks afterward.

43. A client is Group B Streptococcus (GBS) positive at 36 weeks. What is the appropriate intrapartum management?<br>A. No treatment needed since GBS is normal flora<br>B. IV antibiotics during labor<br>C. Oral antibiotics 2 weeks before the due date<br>D. Cesarean birth is required

B. IV antibiotics during labor<br>Rationale: GBS-positive (or unknown status) clients receive IV antibiotics during labor to prevent vertical transmission to the newborn.

44. HIV may be transmitted to the newborn through which routes? (Select all that apply.)<br>A. Through the placenta<br>B. During birth<br>C. Through breast milk<br>D. Only through amniotic fluid, never postnatally

A. Through the placenta<br>B. During birth<br>C. Through breast milk<br>Rationale: HIV can be transmitted through the placenta, during birth, and through breast milk.

45. Which nursing interventions support a pregnant adolescent client? (Select all that apply.)<br>A. Future planning, including school/career counseling<br>B. Frequent evaluation of physical and emotional well-being<br>C. Discouraging any family involvement<br>D. Stress management and self-care education

A. Future planning, including school/career counseling<br>B. Frequent evaluation of physical and emotional well-being<br>D. Stress management and self-care education<br>Rationale: Nursing management of pregnant adolescents includes future planning, frequent physical/emotional evaluation, and stress management/education not discouraging family involvement.

46. A newborn's birth weight plots at the 5th percentile on the Fenton growth chart for gestational age. This newborn is classified as:<br>A. Appropriate for gestational age (AGA)<br>B. Small for gestational age (SGA)<br>C. Large for gestational age (LGA)<br>D. Postterm

B. Small for gestational age (SGA)<br>Rationale: SGA is defined as weight below the 10th percentile for gestational age on the Fenton growth chart; 5th percentile falls into this category.

47. The nurse strokes the lateral sole of a newborn's foot and observes fanning of the toes with dorsiflexion of the great toe. This is documentation of which reflex?<br>A. Moro reflex<br>B. Babinski reflex<br>C. Rooting reflex<br>D. Stepping reflex

B. Babinski reflex<br>Rationale: The Babinski reflex is elicited by stroking the lateral sole of the foot, producing toe fanning and great toe dorsiflexion; this is a normal newborn finding.

48. A non-breastfeeding postpartum client develops breast engorgement. Which instruction is appropriate?<br>A. Apply ice to the breasts and avoid expressing milk<br>B. Apply heat and express milk frequently<br>C. Wear a loose-fitting bra<br>D. Massage the breasts vigorously several times daily

A. Apply ice to the breasts and avoid expressing milk<br>Rationale: For non-breastfeeding clients with engorgement, apply ice, avoid expressing milk or applying heat (both stimulate further production), take analgesics as needed, and wear a tight, supportive bra.

49. The nurse assesses a postpartum client's perineal laceration using the REEDA acronym. Which components are included? (Select all that apply.)<br>A. Redness<br>B. Edema<br>C. Ecchymosis<br>D. Elevated blood pressure<br>E. Discharge<br>F. Approximation

A. Redness<br>B. Edema<br>C. Ecchymosis<br>E. Discharge<br>F. Approximation<br>Rationale: REEDA stands for Redness, Edema, Ecchymosis, Discharge, and Approximation elevated blood pressure is not part of this acronym.

50. Which postpartum interventions are appropriate for an Rh-negative mother who delivered an Rh-positive infant and is rubella nonimmune? (Select all that apply.)<br>A. Administer RhoGAM within 72 hours<br>B. Administer the MMR vaccine before discharge<br>C. Advise avoiding pregnancy for 4 weeks after the MMR vaccine<br>D. Withhold both RhoGAM and MMR until the 6-week visit

A. Administer RhoGAM within 72 hours<br>B. Administer the MMR vaccine before discharge<br>C. Advise avoiding pregnancy for 4 weeks after the MMR vaccine<br>Rationale: This client should receive RhoGAM within 72 hours (to prevent Rh sensitization) and the MMR vaccine before discharge (with counseling to avoid pregnancy for 4 weeks) not delayed until the 6-week visit.