Focus Maternity Exam

The home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. What does the nurse tell the client to do?

A. Eat carbohydrates such as cereals, rice, and pasta

B. Lie down for at least 20 minutes after meals

C. Eat foods high in calories and fat

D. Consume primarily soups and liquids at mealtimes

ANS: A

The nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective?

A. Magnesium level is 10 mg/dL (4.11 mmol/L).

B. Clonus is present.

C. Deep tendon reflexes are absent.

D. The client experiences diuresis within 24 to 48 hours.

ANS: D

A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of:

A. Protamine sulfate

B. Naloxone hydrochloride

C. Vitamin K

D. Calcium gluconate

ANS: D

The maternity nurse is caring for a pregnant client with no history of preeclampsia who is receiving a magnesium sulfate infusion. Why is this client receiving this infusion?

A. To contract the uterus

B. To reverse extreme muscle weakness

C. To halt preterm labor contractions

D. To treat hypotension

ANS: C

The nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid?

A. Chicken

B. Steak

C. Lima beans

D. Milk

ANS: C

The nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. What does the nurse tell the mother to do?

A. Apply oil to the affected area on the infant's scalp

B. Avoid the use of shampoo on the infant's scalp

C. Shampoo the infant's scalp, avoiding the anterior fontanel area

D. Wash the infant's scalp daily, using only tepid water

ANS: A

The nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client’s oxygen saturation on pulse oximetry (Spo2) is 92%. What should the nurse do first?

A. Administers 100% oxygen by way of face mask

B. Documents the findings

C. Instructs the client to take several deep breaths

D. Contacts the primary health care provider

ANS: C

A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. What does the nurse tell the client?

A. That this is an indication of an infection

B. That this is a normal postpartum occurrence

C. To come to the clinic for a checkup

D. To perform a vaginal douche

ANS: B

A rubella antibody screen is performed on a pregnant client, and the results indicate that the client is not immune to rubella. What does the nurse tell the client to do?

A. A rubella vaccine must be administered immediately

B. She does not need to be concerned about being exposed to rubella

C. She will not contract rubella if she is exposed to the disease

D. A rubella vaccine must be administered after childbirth

ANS: D

The nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client’s temperature and notes that it is 38° C (100.4° F). What is the most appropriate nursing action?

A. Tell the client that antibiotics will be prescribed

B. Encourage the intake of oral fluids

C. Contact the primary health care provider

D. Recheck the temperature in 1 hour

ANS: B

The nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, what should the nurse do?

A. Ask the client to take slow, deep breaths during fundal assessment

B. Have the client void before the uterine assessment

C. Tell the woman to bear down during fundal message

D. Simultaneously provide pressure over the lower uterine segment

ANS: D

A nonstress test is performed, and the primary health care provider documents "accelerations lasting less than 15 seconds throughout fetal movement." How does the nurse interpret these findings?

A. Inconclusive

B. Normal

C. Reactive

D. Nonreactive

ANS: D

A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate?

A. “I know how you feel.”

B. “This must be hard for you.”

C. “Now you have an angel in heaven.”

D. “You’re young. You can have other children.”

ANS: B

The nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat?

A. Apple and whole-grain toast

B. Low-fat cheese omelet

C. Water and pretzels

D. Nachos and fried chicken

ANS: A

The delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table. How does the nurse position the client?

A. Supine with a wedge under the right hip

B. Prone

C. In a semi-Fowler position

D. In the Trendelenburg position

ANS: A

The nurse is preparing to perform the Leopold maneuvers on a pregnant client. What should the nurse do first?

A. Count the fetal heart rate for 1 minute

B. Locate the fetal heart tone

C. Ask the client to empty her bladder

D. Position the woman supine

ANS: C

The nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. What does the nurse tell the mother to do?

A. Take a cool shower just before breastfeeding

B. Apply heat packs to the breasts for 15 to 20 minutes between feedings to reduce swelling

C. Gently massage the breasts during breastfeeding to help empty the breasts

D. Avoid breastfeeding during the night time hours to ensure adequate rest

ANS: C

When, during the normal postpartum course, would the nurse expect to note the fundal assessment shown in the figure?

fundal height at the umbilicus

A. The day after delivery

B. Immediately after delivery

C. When the client's bladder is full

D. 4 days after delivery

ANS: B

The nurse is monitoring a client in labor for signs/symptoms of intrauterine infection. Which sign/symptom, indicative of infection, would prompt the nurse to contact the primary health care provider?

A. Clear amniotic fluid

B. Strong-smelling amniotic fluid

C. Maternal fatigue

D. A fetal heart rate of 140 beats/min

ANS: B

The nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in the care of this client?

A. Preparing the client for amniotomy

B. Providing pain relief

C. Monitoring the oxytocin infusion closely

D. Encouraging the client to ambulate every 30 minutes

ANS: B

The nurse is preparing to care for a client experiencing dystocia. To which intervention does the nurse give priority?

A. Informing the client’s partner of the progress of the labor

B. Monitoring fetal status

C. Changing the client’s position

D. Providing comfort measures

ANS: B

A postpartum client asks a nurse when she may safely resume sexual activity. What does the nurse tell the client when she may resume sexual activity?

A. When her normal menstrual period has resumed

B. After the 6-week primary health care provider checkup

C. At any time

D. In 2 to 4 weeks

ANS: D

A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother to do what?

A. The infant will require medication therapy immediately after birth

B. Maternal medication will not be started until the baby is born

C. The mother may need to take isoniazid, pyrazinamide, and rifampin for a total of 9 months

D. The infant must be isolated from the mother after birth

ANS: C

The nurse, performing an assessment of a pregnant client is preparing to take the client's blood pressure. How does the nurse position the client?

A. Lying down with the arm in a horizontal position at heart level

B. In a sitting position with the arm in a horizontal position at heart level

C. Supine, on the left side

D. Supine, on the right side

ANS: B

The nurse is teaching a pregnant client about the expectations and complications of pregnancy and is describing Braxton Hicks contractions. What does the nurse tell the client about these contractions?

A. Must be reported to the primary health care provider

B. Necessitate bed rest for the remainder of the pregnancy

C. Are a common occurrence of pregnancy

D. Indicate that labor has started

ANS: C

A nurse performing an assessment of a pregnant client prepares to auscultate the fetal heart sounds, using a Doppler ultrasound stethoscope. By which week of gestation are fetal heart sounds audible with the use of this device?

A. 4 weeks

B. 6 weeks

C. 12 weeks

D. 8 weeks

ANS: C

After the delivery of a newborn, the nurse performs an initial assessment and determines that the Apgar score is 8. The nurse interprets this score as indicating what about the infant?

A. Is having difficulty adjusting to extrauterine life

B. Requires some resuscitative intervention

C. Requires vigorous resuscitation

D. Is adjusting well to extrauterine life

ANS: D

The nurse is teaching a pregnant client about measures to strengthen the pelvic floor. What does the nurse instruct the client to do?

A. Drink at least 2 quarts of fluid per day

B. Perform Kegel exercises in 10 repetitions, three times per day

C. Perform pelvic tilt exercises in 10 repetitions, three times per day

D. Walk half a mile 3 times a week

ANS: B

The nurse is teaching a new mother how to perform umbilical cord care and how to recognize the signs/symptoms of a cord infection. Which finding does the nurse tell the mother is an indicator of infection?

A. Edema at the base of the cord

B. A brownish-black cord with some moistness at the base

C. A brownish-black cord with pinkness around the base

D. A darkened, drying cord

ANS: A

A nurse is performing assessments every 30 minutes on a client who is receiving magnesium sulfate for preeclampsia. Which finding would prompt the nurse to contact the primary health care provider?

A. Respirations of 10 breaths/min

B. Urine output of 20 mL

C. Deep tendon reflexes of 2+

D. Fetal heart tone of 116 beats/min

ANS: A

The nurse is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the nurse to contact the primary health care provider?

A. Periods of fetal movement followed by quiet periods

B. Enlargement of the breasts

C. Diaphoresis and tachycardia

D. Complaint of feeling hot

ANS: C

During a prenatal visit, the nurse notes that an adolescent pregnant client with diabetes mellitus has lost 10 lb (4.5 kg) during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, “I don’t eat regular meals.” What is the nurse’s most appropriate response?

A. “Let’s make a list of what you’re eating.”

B. “It’s all right to gain weight during pregnancy.”

C. “I’ll have the doctor review your diet history.”

D. “Weight loss could hurt your baby.”

ANS: A

The nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. What does the nurse tell the client what to immediately do if signs/symptoms of hypoglycemia occur?

A. Check her blood glucose level

B. Lie down

C. Drink 8 oz (240 ml) of diet soda

D. Contact the primary health care provider

ANS: A

A client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a persistent nonreassuring fetal heart rate pattern is present. What is the nurse’s most appropriate nursing action in this situation?

A. Preparing to induce labor

B. Turning the client on her left side

C. Preparing the client for a cesarean delivery

D. Continuing to monitor the fetal heart rate pattern

ANS: C

Immediately after the delivery of a newborn infant, the nurse prepares to deliver the placenta. What does the nurse initially do?

A. Apply strong traction on the cord when signs of separation occur

B. Instruct the mother to push when signs of separation have occurred

C. Pull on the placenta as it enters the vaginal canal

D. Pull on the umbilical cord as the mother bears down

ANS: B

A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes, the client has a temperature of 100° F (37.8° C), and the client reports that she last ate 2 hours ago. The client also states that “everything happened so fast" and that she has had no preparation for the cesarean delivery. Which action should the nurse take first?

A. Beginning teaching about the cesarean delivery

B. Reporting the time of last food intake to the primary health care provider

C. Continuing to time the contractions

D. Giving acetaminophen to lower the client’s temperature

ANS: B

A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician’s office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. What should the nurse immediately do?

A. Position the client on her side

B. Place a cool washcloth on the client’s forehead

C. Call the primary health care provider to see the client

D. Check the client’s blood pressure, pulse, and respirations

ANS: A

A nurse is caring for a client in precipitous labor. In which position does the nurse place the client?

Side-lying Sims position

A nurse is caring for a postpartum client who had a low-lying placenta. What does the nurse assess the client most closely for?

A. Seizures

B. A vaginal hematoma

C. Hemorrhage

D. Infection

ANS: C

A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, what is the most appropriate nursing action?

A. Continue to monitor the client

B. Reassure the client and her partner that labor is progressing normally

C. Contact the primary health care provider

D. Document the findings

ANS: C

A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. What does the nurse tell the client?

A. Performing such exercises in the postpartum period may result in stress urinary incontinence

B. Alternating contraction and relaxation of the muscles of the perineal area should be practiced

C. Abdominal exercises will be started while the client is in the hospital as a means of evaluating tolerance

D. Exercises should be delayed for 1 month to allow healing

ANS: B

A nurse is monitoring a newborn who has been admitted to the nursery. The nurse notes that the anterior fontanel measures 4 cm across and bulges when the infant is at rest. Based on this observation, what is the most appropriate nursing action?

A. Notifying the primary health care provider

B. Documenting the finding

C. Reassessing the fontanel in 30 minutes

D. Assessing the infant’s blood pressure

ANS: A

The nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia (CDH). Which assessment finding would the nurse specifically expect to note in the newborn?

A. Excessive oral secretions

B. Bowel sounds heard over the chest

C. Hiccupping and spitting up after a meal

D. Coughing, wheezing, and short periods of apnea

ANS: B

A woman is being seen in the prenatal clinic and complains of morning sickness that continues throughout the day. What does the nurse tell the client to do to overcome this discomfort?

A. Eat fatty or spicy foods only at the noontime meal

B. Eat dry crackers every 2 hours to prevent an empty stomach

C. Eliminate the morning meal

D. Drink fluids with meals

ANS: B

A client in the third trimester of pregnancy is complaining of urinary frequency, and the nurse instructs the client in measures to alleviate the discomfort. Which statement by the client indicates an understanding of these self-care measures?

A. "I need to avoid emptying my bladder so frequently."

B. "I need to drink at least 2000 mL of fluid a day."

C. "I should cut back on my fluid intake in the evening."

D. "I should avoid drinking large amounts of fluids during the day."

ANS: B

A nurse assessing a pregnant client's deep tendon reflexes notes a reflex of 2+. What should the nurse do?

A. Document the finding

B. Ask another nurse to check the reflexes to verify the finding

C. Reassess the reflexes in 15 minutes

D. Report the finding to the primary health care provider immediately

ANS: A

A woman in labor suddenly experiences chest pain and dyspnea, and the nurse suspects the presence of amniotic fluid embolism (AFE). What should the nurse immediately do?

A. Notify the family

B. Attach a cardiac monitor to the woman

C. Prepare the client for intubation

D. Administer oxygen to the woman

ANS: D

After a vaginal delivery, a woman suddenly begins to complain of severe pelvic pain and extreme fullness in the vagina, and the nurse suspects uterine inversion. What does the nurse immediately prepare to do?

A. Assist in repositioning the uterus through the vagina into a normal position

B. Administer oxytocin (Pitocin)

C. Perform fundal massage

D. Insert a Foley catheter

ANS: A

A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. What is the most appropriate response?

A. “Yes, the newborn will also have the virus.”

B. “HIV can only be transmitted through sexual contact.”

C. “The newborn does have a risk of contracting the infection.”

D. “The newborn will have signs/symptoms of HIV at birth if the virus has been transmitted.”

ANS: C

The delivery room nurse performing an initial assessment on a newborn notes that the ears are low set. Based on this finding, which nursing action is appropriate initially?

A. Covering the ears with gauze pads and taping the pads to the head

B. Documenting the finding

C. Notifying the primary health care provider

D. Taping the ears so they lie flat against the head

ANS: C

The nurse is reviewing the medical record of a pregnant client with sickle cell anemia. To which information related by the client would the nurse give the highest priority?

A. Occasional slight dizziness when standing up

B. Concern about her inability to care for her baby

C. Poor appetite

D. Drinking less than 4 glasses of fluid daily

ANS: D

The nurse is caring for a client receiving an intravenous infusion of oxytocin to stimulate labor. Which finding would prompt the nurse to stop the infusion?

A. Nonreassuring fetal heart rate pattern

B. Contractions every 3 minutes

C. Soft uterine tone palpated between contractions

D. The presence of three contractions every 10 minutes

ANS: A

The nurse is assessing a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the nurse perform in response to this observation?

A. Documenting the finding

B. Calling the primary health care provider

C. Taking the mother's vital signs

D. Repositioning the mother

ANS: A

The nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which situation would the nurse suspect based on this observation?

A. Umbilical cord compression

B. Adequate pacemaker activity of the fetal heart

C. Pressure on the fetal head during a contraction

D. Uteroplacental insufficiency during a contraction

ANS: C

The nurse caring for a client in the active stage of labor assesses the fetal status and notes a late deceleration on the monitor strip. Based on this finding, which nursing action is the priority?

A. Documenting the finding

B. Preparing for immediate birth

C. Increasing the rate of the oxytocin infusion

D. Administering oxygen by way of face mask

ANS: D

Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which finding would the nurse expect to note?

A. Uterine contractions every 3 to 5 minutes

B. Lack of uterine irritability or tetanic contractions

C. Abdomen soft to palpation

D. Uterine tender to palpation

ANS: D

The postpartum nurse instructs a new mother in how to bathe her newborn son. Which statement by the mother indicates a need for further instruction?

A. “I should bathe him after a feeding.”

B. “I should check the temperature of the water before using it to bathe him.”

C. “I need to keep him covered as much as possible while I’m giving him a bath.”

D. “I need to sponge-bathe him until the cord falls off.”

ANS: A

The nurse is monitoring a pregnant client with sepsis for signs/symptoms of disseminated intravascular coagulopathy (DIC). Which laboratory finding causes the nurse to suspect DIC?

A. Increased fibrinogen level

B. Increased platelet count

C. Increased fibrin degradation products

D. Shortened prothrombin time

ANS: C

The nurse caring for a hospitalized client with a diagnosis of abruptio placentae develops a nursing care plan incorporating interventions to be implemented in the event of shock. If signs/symptoms of shock develop, to promote tissue oxygenation, what would the nurse immediately do?

A. Monitor maternal vital signs

B. Turn the client on her side

C. Provide emotional support to reduce anxiety

D. Limit maternal activity

ANS: B

A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result of 155 mg/dL (8.6 mmol/L). What does the nurse tell the client?

A. Her glucose level is within normal limits

B. Additional tests will likely be performed to confirm gestational diabetes

C. A daily oral hypoglycemic agent will be prescribed

D. Daily NPH insulin will be needed

ANS: B

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. What does the nurse tell the client?

A. Liver function tests will be prescribed

B. She must be retested in 1 week

C. A repeat hepatitis screen will be performed during the pregnancy

D. The infant should receive both the vaccine and hepatitis immune globulin soon after birth

ANS: D

A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction?

A. “I need to stay in bed for the rest of my pregnancy.”

B. “I need to avoid having sex until the bleeding has stopped.”

C. “I need to watch for stuff that looks like tissue coming from my vagina.”

D. “I need to count the number of perineal pads that I use each day and make a note of the amount and color of blood on each pad.”

ANS: A

The nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse plan to place the infant?

A. Prone

B. On the back, in semi-Fowler

C. Supine

D. On the back, in Trendelenburg

ANS: A

The nurse is performing an assessment of a female client with suspected mittelschmerz. Which question does the nurse ask the client to elicit data specific to this disorder?

A. "Do you have pain at the beginning of your period?"

B. "Do you have sharp pain on the right or left side of your pelvis?"

C. "Do you have pain every time you have intercourse?"

D. "Do you have continuous heavy vaginal bleeding?"

ANS: B

The nurse is conducting a home visit with a mother and her 1-week-old infant, who is at risk for acquired neonatal congenital syphilis. Which finding specific to this disease does the nurse look for while assessing the infant?

A. A copper-colored rash

B. Vigorous feeding

C. Hypothermia

D. Diarrhea

ANS: A

The nurse provides instruction regarding prenatal care to a client with a history of heart disease. What does the nurse tell the client?

A. It is necessary to avoid contact with all individuals to help prevent infection

B. It is best to lie supine for sleep

C. Physical activity should be limited

D. The amount of weight gained is not important

ANS: C

The nurse is monitoring a pregnant client with placental abruption. Which pattern on the fetal monitor indicates to the nurse that fetal tissue perfusion is adequate?

Green strip with humps

A clinic nurse is developing a plan of care for a pregnant client with AIDS. Which problem does the nurse identify as the priority to be addressed in the plan of care?

A. Intake of fewer than 6 glasses of fluid daily

B. History of IV drug use

C. Inverted nipples

D. Poor hygiene

ANS: B

A woman with severe preeclampsia delivers a healthy newborn infant and continues to receive magnesium sulfate therapy in the postpartum period. Twenty-four hours after delivery, the client begins passing more than 100 mL of urine every hour. What does the nurse recognize this volume of urine output as an indication of?

A. Hyperkalemia

B. Diminished edema and vasoconstriction in the brain and kidneys

C. High-output renal failure

D. Imminent seizures

ANS: B

The nurse answers a call light in the room of a woman who was just admitted in early latent labor. The woman is lying flat on her back on the bed. The husband reports excitedly, "I think my wife is going into shock or something! She was just lying there, and then she turned so pale, and her hands are so clammy. She said she was dizzy and sick to her stomach." The nurse notes on the noninvasive blood pressure monitor that the woman's pulse is 58 beats/min and her blood pressure is 90/50 mm Hg. What does the nurse interpret these findings as indications of?

A. Altered tissue perfusion related to hypotensive syndrome (vena cava syndrome)

B. Anxiety related to the onset of labor

C. Progression from latent to active first-stage labor

D. Hyperventilation related to excitement at her first labor experience

ANS: A

The nurse is monitoring a fetal heart rate (FHR). How does the nurse document a reassuring FHR pattern in the record as noted as?

A. Variability of 6 to 25 beats/min

B. No change in FHR as a result of fetal activity

C. Late decelerations

D. An average baseline rate ranging between 80 and 100 beats/min

ANS: A

A pregnant woman at 38 weeks' gestation arrives at the emergency department, reporting bright-red vaginal bleeding but denying pain. On the basis of this information, what does the nurse determine that the client may be experiencing?

A. Placenta previa

B. Passage of the mucus plug

C. Abruptio placentae

D. Rupture of the amniotic sac

ANS: A

The nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. What does the nurse analyze the client’s behavior as most likely the result of?

A. Anxiety and the need for support

B. An undiagnosed psychiatric disorder

C. Emotional immaturity

D. A stubborn personality

ANS: A

A neonate is irritable, cries incessantly, and has a temperature of 99.4° F (37.4°C). The neonate is also tachypneic, diaphoretic, feeding poorly, and hyperactive in response to environmental stimuli. What does the nurse determine that these signs/symptoms are consistent with?

A. Sepsis

B. Neonatal abstinence syndrome

C. Intraventricular hemorrhage

D. Hypercalcemia

ANS: B

Rho(D) immune globulin is prescribed for a client after delivery. Before administering the medication, the nurse reviews the client’s history. Which finding is a contraindication to administration of the medication?

A. A previous hypersensitivity reaction to immune globulin

B. Known or suspected entry of Rh-positive fetal blood cells to the circulation of an Rh-negative woman

C. Amniocentesis in an Rh-negative woman carrying an Rh-positive fetus

D. Delivery of an Rh-positive infant by an Rh-negative woman

ANS: A

The nurse is caring for a client experiencing hypotonic labor contractions. The client is discouraged by the lack of progress with labor but refuses an amniotomy or oxytocin stimulation. What does the nurse determine that the client's behavior may be a result of?

A. The high level of pain caused by these contractions

B. The normal lack of control clients feel during the transition phase of labor

C. Inability to rest between the frequent contractions

D. Concern about her own and the baby's well-being

ANS: D

After an unplanned cesarean section, the nurse finds the client in emotional distress, tearfully expressing bewilderment, sadness, and feelings of failure and regret because she could not deliver vaginally. Which conclusion should the nurse make?

A. The client is experiencing an inability to manage the stressors of surgery.

B. The client is experiencing anger.

C. The client is experiencing extreme discomfort.

D. The client is experiencing low self-esteem.

ANS: D

A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat her urinary tract infection but expresses concern that her baby will be born with an infection. Which response should the nurse make to help ease these fears?

A. "Now that you have taken the medication as prescribed, we'll keep monitoring you closely and repeat the urine culture before you leave today."

B. "Your developing baby cannot acquire an infection from you during pregnancy."

C. "Urinary infections during pregnancy are common. Your baby will be fine."

D. "You shouldn't worry about this, because you had early prenatal care and are taking your prenatal vitamins."

ANS: A

The clinic nurse is performing an assessment of an HIV-positive pregnant woman during the 32nd week of gestation. Which finding requires further follow-up?

A. Weight gain of 22 lb (10 kg)

B. Increased shortness of breath and bilateral crackles in the lungs

C. Active fetal movement

D. Slight lower extremity edema

ANS: B

The nurse notes that the laboratory report of a pregnant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia, and an increased erythrocyte sedimentation rate. Which laboratory test that would further confirm the presence of HIV does the nurse anticipate that the primary health care provider will prescribe?

A. Glomerular filtration rate

B. Angiotensin level

C. Platelet count

D. T-lymphocyte determination

ANS: D

The nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)? Select all that apply.

A. A client with diabetes mellitus who delivered a 10-lb (4.5 kg) baby

B. A client with septicemia

C. A client with mild preeclampsia

D. A client who had a cesarean section because of abruptio placentae

E. A client who delivered 12 hours ago and has lost 475 mL of blood

ANS: B, D

The nurse is caring for a post-partum client with suspected endometritis. What manifestations of this condition would the nurse expect to note? Select all that apply.

A. Foul-smelling lochia

B. Tender uterus

C. Backache

D. Decreased pulse

E. Elevated red blood cell count

F. Nausea and vomiting

ANS: A, B, C

The maternity nurse is assessing a client who has progressed to Stage 2 of labor. What findings does the nurse expect to assess? Select all that apply.

A. Increase in bloody show

B. Cervical dilation is 50% complete

C. Progress of labor measured by descent of fetal head through birth canal or change in fetal station

D. Uterine contractions occur every 5 to 10 minutes, lasting 60 to 75 seconds, and of strong intensity

E. Mother feels urge to bear down

ANS: A, C, E

The clinic nurse is examining a 16 week pregnant client for suspected abortion. What manifestations does the nurse expect to note? Select all that apply.

Select all that apply.

A. Nausea and vomiting

B. Slowly progressing and intermittent vaginal bleeding

C. Low uterine cramping or contractions

D. Slight fever are findings in the client with suspected abortion

E. Blood clots or tissue through the vagina

ANS: C, E

The nurse is assisting a primary health care provider in performing a physical examination on a client who has just been told that she is pregnant. The nurse knows that what data indicate a positive sign of pregnancy? Select all that apply.

A. Feeling sick a week after ovulation

B. Fetal heart rate detected by nonelectronic device (fetoscope) at 20 weeks of gestation

C. Fetal heart rate detected by electronic device (Doppler transducer) at 6 to 10 weeks

D. Active fetal movements palpable by the examiner

E. An outline of the fetus by radiography or ultrasonography

F. No menses for 2 months

ANS: B, D, E

The nurse is educating a newly pregnant client who states that this is her first pregnancy. What does the nurse tell the client about amniotic fluid? Select all that apply.

A. Contains fetal bilirubin and is a measure of fetal liver function

B. Consists of 500 to 900 mL by end of pregnancy

C. Maintains the body temperature of the fetus

D. Fetus modifies or changes the amniotic fluid through the processes of swallowing, urinating, and movement through the respiratory tract

E. Surrounds, cushions, and protects the fetus and allows for fetal movement

ANS: C, D, E

The nurse educator is lecturing to a group of students about the probable signs of pregnancy. What signs does the nurse describe to the students? Select all that apply.

A. Braden High contractions

B. Positive pregnancy test for the presence of hCG

C. Hegar's sign

D. Uterine enlargement

E. Chadwick's sign

F. Goodfellow’s sign

ANS: B, C, D, E

The nurse is caring for a client in labor who has sickle cell anemia. What are some situations that can precipitate sickling? Select all that apply.

A. Hyperglycemia

B. Any condition that increases or alters the need and transport of oxygen

C. Fever

D. Dehydration

E. Anorexia

F. Emotional or physical stress

G. Hyponatremia

ANS: B, C, D, F

A pregnant client is seen in the clinic for the first time. This is the client’s first pregnancy, and the client tells the nurse that she has diabetes mellitus. The nurse provides instruction to the client regarding health care during pregnancy. Which statements by the client indicate the need for further instruction? Select all that apply.

A. "I need to report signs/symptoms of infection to my primary health care provider."

B. “I’ll come back for a prenatal visit every month during my first trimester.”

C. “I need to limit my exercise while I’m pregnant.”

D. “I need to follow the prescribed diabetic diet.”

E. “My insulin requirements may change while I’m pregnant.”

ANS: B, C

The nurse is reviewing the criteria for early discharge of a newborn infant. Which, if noted in the infant, would indicate that the criteria for early discharge have been met? Select all that apply.

A. The infant has completed one successful feeding.

B. The infant has passed 1 stool.

C. The infant has shown no evidence of jaundice in the first 6 hours of life.

D. The infant has urinated.

E. Vital signs are documented as normal.

ANS: B, D, E

A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is experiencing excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which assessment findings are indicative of complete uterine rupture? Select all that apply.

A. Increased uterine contractions

B. Maternal complaint of sudden sharp abdominal pain

C. Fetal bradycardia

D. Excessive vaginal bleeding

E. Maternal tachypnea

ANS: B, C, E

A nurse working in a prenatal clinic is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify as being at risk for abruptio placentae? Select all that apply.

A. A client who exercises regularly

B. A primipara

C. A hypertensive client

D. A pack-a-day smoker

E. A 36- year-old

ANS: C, D

The maternity nurse educator is lecturing to student nurses about respiratory physiological maternal changes. What maternal respiratory changes does the instructor state happen during pregnancy? Select all that apply.

A. The diaphragm is lowered

B. Obstructive sleep apnea may develop

C. Oxygen consumption increases by approximately 15% to 20%

D. Dry coughs

E. Shortness of breath may be experienced

F. Increased incidents of respiratory infections

ANS: C, E

A nurse is assessing a newborn infant with a diagnosis of gastroschisis. What are some problems associated with this condition? Select all that apply.

A. Surgery performed within several hours after birth.

B. Thin membrane covers the exposed bowel.

C. Herniation of intestine is lateral to umbilical ring.

D. Postoperatively, parenteral nutrition is not needed.

E. Postoperatively, most infants are asymptomatic.

F. Preoperatively, care similar to that for omphalocele.

ANS: A, C, E

The nurse is about to perform an assessment of a pregnant woman in the Labor Room. What does the nurse know about false labor? Select all that apply.

A. Progressive effacement

B. No lightening of fetus

C. Contractions resemble menstrual cramps

D. Contractions relieved after walking

E. Contractions felt in abdomen and groin

F. Indentable uterus

ANS: B, D, E, F

The nurse is assisting the primary health care provider with performing internal fetal monitoring. What are some manifestations of internal fetal monitoring?

Select all that apply.

A. Is invasive

B. A second primary health care provider does not have to be present

C. A unit of blood must be given at the same time.

D. An electrode is attached to the skull of the fetus

E. The client cannot be dilated

F. Requires rupturing of the membranes

ANS: A, B, F

The nurse is admitting a newly pregnant client to the clinic. The client asks the nurse about gonorrhea. What are some appropriate responses by the nurse? Select all that apply.

A. “I will obtain a blood sample during this initial prenatal exam to screen for gonorrhea."

B. “If you are at high risk for this infection, then another test should be repeated during your third trimester.”

C. “If infection is present, your partner must be treated, too.”

D. “Urinary frequency may occur.”

E. “You will have a slight fever.”

F. “Transmission of this organism is by sexual intercourse.”

ANS: B, C, D, F

The nurse is assisting the primary health care provider to perform a Fern test on a pregnant client. What are some manifestations of this test? Select all that apply.

A. A microscopic slide test

B. Client positioned in side-lying position

C. Determines presence of amniotic fluid leakage

D. Fernlike pattern produced by effects of salts of amniotic fluid showing presence of amniotic fluid

E. Tell client not to cough during test

F. Sterile technique not needed

ANS: A, C, D

The nurse is changing the diaper of a 1-day-old full-term female newborn. What assessment criteria of the labia does the nurse determine are normal? Select all that apply.

A. Presence of yellow mucous vaginal discharge

B. Small amounts of urine expelled from the vagina

C. Pseudomenstruation, caused by withdrawal of the maternal hormone estrogen, is possible (blood-tinged mucus)

D. Hymen tag may be visible

E. Labia may be edematous

F. Labia lighter than the surrounding skin

ANS: C, D, E

The nurse is assessing a newly delivered large for gestational age neonate. The nurse is aware of what manifestations of this neonate category? Select all that apply.

A. Provide stimulation, such as touch and cuddling

B. Respiratory distress occurs

C. Delay feedings for a day

D. Increased risk for infection

E. Newborn plotted at or above the 80th percentile on the intrauterine growth curve

F. Hyperglycemia is present

ANS: A, B, D