Name: Saunders Comprehensive Review for the NCLEX-RN Examination, 5th Edition By Linda Anne Silvestri -Test Bank
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Complete Test Bank With Answers

Sample Questions Posted Below

1. 2. Silvestri: Saunders Comprehensive Review for the NCLEX-RN®

Examination, 5th Edition

Maternity

Test Bank

MULTIPLE CHOICE

The nurse is assisting in conducting a prenatal session with a group of expectant parents.

One of the expectant parents asks, “How does the milk get secreted from the breast?” The

best response by the nurse should be:

1. 2. 3. 4. “Testosterone stimulates the secretion of milk, which is called lactogenesis.”

“Oxytocin stimulates the secretion of milk, which is called lactogenesis.”

“Prolactin stimulates the secretion of milk, which is called lactogenesis.”

“Progesterone stimulates the secretion of milk, which is called lactogenesis.”

ANS: 3

Rationale: Prolactin stimulates the secretion of milk, which is called lactogenesis.

Oxytocin stimulates contractions during birth and stimulates postpartum contractions to

compress uterine vessels and control bleeding. Testosterone is produced by the adrenal

glands in the female and induces the growth of pubic and axillary hair at puberty.

Progesterone stimulates the secretions of the endometrial glands, causing endometrial

vessels to become highly dilated and tortuous in preparation for possible embryo

implantation.

Test-Taking Strategy: Knowledge regarding the functions of the various hormones in the

female reproductive system is required to answer this question. Note the relationship

between the secretion of milk and the hormone prolactin in the correct option. If you had

difficulty with this question, review the functions of the various hormones of the female

reproductive system.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

A nurse implements a teaching plan for a pregnant client who is newly diagnosed with

gestational diabetes mellitus. Which statement, if made by the client, indicates a need for

further education?

1. 2. “I need to stay on the diabetic diet.”

“I will perform glucose monitoring at home.”

3. 4. “I need to avoid exercise because of the negative effects on insulin production.”

“I need to be aware of any infections and report signs of infection immediately

to my health care provider.”

ANS: 3

Rationale: Exercise is safe for the client with gestational diabetes mellitus and is helpful

in lowering the blood glucose level. Dietary modifications are the mainstay of treatment,

and the client is placed on a standard diabetic diet. Many women are taught to perform

blood glucose monitoring. If the woman is not performing the blood glucose monitoring

at home, then it will be performed at the clinic or health care provider’s office. Signs of

infection need to be reported to the health care provider.

Test-Taking Strategy: Use the process of elimination, noting the strategic words “need

for further education.” These words indicate a negative event query and the need to select

the incorrect option. Noting these strategic words, including the word “avoid,” in the

correct option will assist in answering the question. If you had difficulty with this

question, review the teaching points for a client with gestational diabetes mellitus.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed.). St.

Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

A client has been seen in the clinic and has been diagnosed with endometriosis. The client

asks the nurse to describe this condition. The best response by the nurse should be:

1. 2. 3. 4. “It causes the cessation of menstruation.”

“It is also known as primary dysmenorrhea.”

“It is pain that occurs during ovulation.”

“It is the presence of tissue outside the uterus that resembles the endometrium.”

ANS: 4

Rationale: Endometriosis is defined as the presence of tissue outside the uterus that

resembles the endometrium in both structure and function. The response of this tissue to

the stimulation of estrogen and progesterone during the menstrual cycle is identical to

that of the endometrium. Primary dysmenorrhea refers to menstrual pain without

identified pathology. Mittelschmerz refers to pelvic pain that occurs midway between

menstrual periods, and amenorrhea is the cessation of menstruation for at least three

cycles or 6 months in a woman who has an established a pattern of menstruation.

Amenorrhea can be caused by a variety of causes.

Test-Taking Strategy: Use the process of elimination. Note the relationship between the

diagnosis and the correct option. If you had difficulty with this question and are

unfamiliar with this disorder, review the description of endometriosis.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

A client calls the physician’s office to schedule an appointment because a home

pregnancy test was performed and the results were positive. The nurse determines that the

home pregnancy test identified the presence of which of the following in the urine?

1. Estrogen

2. Progesterone

3. Human chorionic gonadotropin (hCG)

4. Follicle-stimulating hormone (FSH)

ANS: 3

Rationale: In early pregnancy, hCG is produced by trophoblastic cells that surround the

developing embryo. This hormone is responsible for positive pregnancy tests. The other

options are not hormones found in urine that indicate pregnancy.

Test-Taking Strategy: Knowledge regarding the changes caused by placental hormones in

early pregnancy will direct you to the correction option, “human chorionic gonadotropin

(hCG)”. Remember that hCG is responsible for positive pregnancy tests. If you are

unfamiliar with this pregnancy test, review this content.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is teaching a pregnant client about the physiological effects and hormonal

changes that occur during pregnancy. The client asks the nurse about the purpose of

estrogen. The nurse bases the response on which of the following purposes of estrogen?

1. 2. 3. It maintains the uterine lining for implantation.

It stimulates metabolism of glucose and converts the glucose to fat.

It prevents the involution of the corpus luteum and maintains the production of

progesterone until the placenta is formed.

4. It stimulates uterine development to provide an environment for the fetus and

stimulates the breasts to prepare for lactation.

ANS: 4

Rationale: Estrogen stimulates uterine development to provide an environment for the

fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the

uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen

stimulates the metabolism of glucose and converts the glucose to fat; it is antagonistic to

insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and

maintains the production of progesterone until the placenta is formed.

Test-Taking Strategy: Knowledge regarding the functions of various hormones related to

pregnancy will direct you to the correct option. Remember that estrogen stimulates

uterine development to provide an environment for the fetus and stimulates the breasts to

prepare for lactation. If you had difficulty with this question or are unfamiliar with these

hormones, review this content.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

A client is seen in the health care clinic with a diagnosis of mild anemia. The anemia is

believed to be a result of her menstrual period. The client asks the nurse how much blood

is lost during a menstrual period. The nurse bases the response on which of the following

amounts of blood lost during this time?

1. 40 mL

2. 60 mL

3. 80 mL

4. 100 mL

ANS: 1

Rationale: During a menstrual period, a woman loses about 40 mL of blood. Because of

the recurrent loss of blood, many women are mildly anemic during their reproductive

years, especially if their diets are low in iron.

Test-Taking Strategy: Knowledge regarding the phases of the menstrual cycle and the

amount of blood lost during a menstrual period will direct you to the correct option.

Remember that during a menstrual period, a woman loses about 40 mL of blood. If you

are unfamiliar with the phases of the menstrual cycle, review this content.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

The rubella vaccine has been prescribed for a new mother. Which of the following

statements should the postpartum nurse make when providing information about the

vaccine to the client?

1. 2. “You will need a second vaccination at your 6-week postpartum visit.”

“You should avoid sexual intercourse for 2 weeks after the administration of the

vaccine.”

3. “You should not become pregnant for 1 to 3 months after the administration of

the vaccine.”

4. “You should avoid heat and extreme temperature changes for a week after the

administration of the vaccine.”

ANS: 3

Rationale: Rubella vaccine is a live attenuated virus that provides immunity for 15 years.

Because rubella is a live vaccine, it will act as a virus and is potentially harmful to the

organogenesis phase of fetal development. The client should be informed about the

potential effects of this vaccine and the need to avoid becoming pregnant for 1 to 3

months after administration of the vaccine. Abstinence from sexual intercourse is

unnecessary. A second vaccination is not required to attain immunity. Warmth and

temperature or extreme changes in temperature have no effect on the person who has

been vaccinated.

Test-Taking Strategy: Use the process of elimination. Recall that most vaccines are either

contraindicated or administered with caution during pregnancy and that viruses can cross

the placental barrier; this will help you choose the option “You should not become

pregnant for 1 to 3 months after the administration of the vaccine.” over the other

options. If you had difficulty with this question, review the potential risks associated with

administration of the rubella vaccine.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Teaching and Learning

The nurse is collecting data from a client during the first prenatal visit. The client is

anxious to know the gender of the fetus and asks the nurse when she will be able to know.

The nurse responds to the client by telling her that the gender of the fetus can be

determined by weeks:

1. 6 to 8

2. 8 to 10

3. 13 to 16

4. 20 to 22

ANS: 3

Rationale: By the end of the twelfth week of gestation, the fetal gender can be

determined by the appearance of the external genitalia on ultrasound. Therefore, the other

options are incorrect.

Test-Taking Strategy: Focus on the strategic words “gender of the fetus.” Thinking about

the process of fetal development will direct you to the correct option. If you had difficulty

with this question, review fetal development.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse is collecting data from a client seen in the health care clinic for a first prenatal

visit. The nurse asks the client when the first day of her last menstrual period was and the

client reports February 9, 2012. Using Nägele’s rule, the nurse determines that the

estimated date of confinement (delivery) is:

1. October 16, 2012

2. November 16, 2012

3. October 7, 2012

4. November 7, 2012

ANS: 2

Rationale: Nägele’s rule determines the estimated date of birth and works on the premise

that the woman has a 28-day menstrual cycle. To calculate the estimated date of

confinement, subtract 3 months from the first day of the last menstrual period, add 7

days, and then add 1 year to that date; alternatively, count forward 9 months and add 7

days to the first day of the last menstrual period. Therefore, first day of last menstrual

period, February 9, 2012; subtract 3 months, November 9, 2011; add 7 days, November

16, 2011; and add 1 year, November 16, 2012.

Test-Taking Strategy: Knowing how to use Nägele’s rule is required to answer this

question. Be careful when following the steps of this rule to determine the estimated date

of confinement. Avoid taking shortcuts, particularly when math is involved. Read all the

options carefully, noting the dates and years before selecting an option. Review Nägele’s

rule if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Assessment

A pregnant client is seen in the health care clinic. During the prenatal visit, the client

informs the nurse that she is experiencing pain in her calf when she walks. Which of the

following is the appropriate nursing action?

1. 2. 3. 4. Instruct the client to avoid walking.

Assess for signs of venous thrombosis.

Tell the client that this is normal during pregnancy.

Instruct the client to elevate her legs consistently throughout the day.

ANS: 2

Rationale: If a woman complains of calf pain during walking, it could be an indication of

venous thrombosis of the lower extremities. The appropriate nursing action would be to

check for the presence of additional signs of venous thrombosis. It is not appropriate to

tell the mother that this is normal during pregnancy. Ambulation is a necessary exercise,

and the woman should be encouraged to ambulate during pregnancy. Although it is

important to elevate the legs during pregnancy, elevating the legs consistently is not the

appropriate nursing action.

Test-Taking Strategy: Use the nursing process to assist in answering the question.

“Assess for signs of venous thrombosis” is the only option that addresses assessment.

Review normal and abnormal expectations in the prenatal period if you had difficulty

with this question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Assessment

A client in her second trimester of pregnancy is seen at the health care clinic. The nurse

collects data from the client and notes that the fetal heart rate is 90 beats/min. Which of

the following nursing actions is appropriate?

1. Document the findings.

2. Notify the physician.

3. Inform the client that everything is normal and fine.

4. Instruct the client to return to the clinic in 1 week for reevaluation of the fetal

heart rate.

ANS: 2

Rationale: The fetal heart rate should be 120 to 160 beats/min during pregnancy. A fetal

heart rate of 90 beats/min would require that the physician be notified and the client be

further evaluated. The other options are inappropriate. “Document the findings” and

“inform the client that everything is normal and fine” are comparable or alike and can be

eliminated first. “Instruct the client to return to the clinic in 1 week for reevaluation of the

fetal heart rate” is an inaccurate nursing action.

Test-Taking Strategy: Knowledge of the normal fetal heart rate is required to answer this

question. Knowing that the limits for the fetal heart rate are between 120 and 160

beats/min will easily direct you to the correct option. If you had difficulty with this

question, review the normal findings in the pregnant client.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse is caring for a pregnant client who has herpes genitalis. The nurse provides

instructions to the client about treatment modalities that may be necessary for treatment

of this condition. Which of the following statements, if made by the client, indicates an

understanding of these treatment measures?

1. “I do not need to abstain from sexual intercourse.”

2. “I need to use vaginal creams after I douche every day.”

3. “I need to douche and perform a sitz bath three times a day.”

4. “It may be necessary to have a cesarean section for delivery.”

ANS: 4

Rationale: If a client has an active lesion, either recurrent or primary at the time of labor,

delivery should be by cesarean. Clients are advised to abstain from sexual contact while

the lesions are present. If it is an initial infection, the client should continue to abstain

from sexual intercourse until the cultures are negative because prolonged viral shedding

may occur. Douches are contraindicated, and the genital area should be kept clean and

dry to promote healing.

Test-Taking Strategy: Use the process of elimination to assist in directing you to “It may

be necessary to have a cesarean section for delivery.” The options “I need to use vaginal

creams after I douche every day.” and “I need to douche and perform a sitz bath three

times a day.” can be eliminated first because they are comparable or alike. Next,

eliminate the option “I do not need to abstain from sexual intercourse.” because of the

strategic words “do not.” If you are unfamiliar with the treatment measures associated

with this infection, review this content.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Safe and Effective Care Environment

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Evaluation

A pregnant client tests positive for the hepatitis B virus (HBV). The client asks the nurse

if she will be able to breast-feed the baby as planned after delivery. Which of the

following responses by the nurse is most appropriate?

1. “Breast-feeding is allowed after the baby has been vaccinated with immune

globulin.”

2. “Breast-feeding is not advised, and you should seriously consider bottle-feeding

the baby.”

3. 4. “You will not be able to breast-feed the baby until 6 months after delivery.”

“Breast-feeding is not a problem, and you will be able to breast-feed

immediately after delivery.”

ANS: 1

Rationale: Although HBV is transmitted in breast milk, after immune globulin has been

administered to the newborn, the woman may breast-feed without risk to the newborn.

The remaining options are incorrect responses.

Test-Taking Strategy: Knowledge of the pathophysiology associated with HBV and its

effects on the fetus and newborn is required to answer this question. Knowing that the

client will be able to continue to breast-feed after the infant has received immune

globulin will assist in directing you to the correct option. Additionally, use therapeutic

communication techniques to assist in eliminating the incorrect options. Review content

regarding HBV during pregnancy if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Safe and Effective Care Environment

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse is collecting data from a client who is at 32 weeks’ gestation. The nurse

measures the fundal height in centimeters and expects the findings to be which of the

following?

1. 22 cm

2. 28 cm

3. 32 cm

4. 40 cm

ANS: 3

Rationale: From 22 weeks until term, the fundal height measured in centimeters is

roughly plus or minus 2 cm of the gestational age of the fetus in weeks. If the fundal

height exceeds weeks of gestation, additional assessment is necessary to investigate the

cause for the unexpected uterine size. If an unexpected increase in uterine size is present,

it may be that the estimated date of delivery is incorrect and the pregnancy is further

advanced than previously thought. If the estimated date of delivery is correct, it may be

possible that more than one fetus is present.

Test-Taking Strategy: Noting the strategic words “32 weeks” in the question will direct

you to 32 cm. If you are unfamiliar with assessing fundal height, review this content.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Assessment

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client

tells the nurse that she is experiencing irregular contractions. The nurse determines that

the client is experiencing Braxton Hicks contractions. Which of the following nursing

actions would be appropriate?

1. Contact the physician.

2. Instruct the client to maintain bed rest for the remainder of the pregnancy.

3. Instruct the client that these are common and may occur throughout the

pregnancy.

4. Call the maternity unit and inform them that the client will be admitted in a

prelabor condition.

ANS: 3

Rationale: Braxton Hicks contractions are irregular painless contractions that occur

throughout pregnancy, although many expectant mothers do not notice them until the

third trimester. Because Braxton Hicks contractions may occur and are normal in some

pregnant women during pregnancy, the other options are unnecessary and inaccurate.

Test-Taking Strategy: Knowledge regarding the assessment findings in Braxton Hicks

contractions and their significance is required to answer this question. The options

“Contact the physician” and “Call the maternity unit and inform them that the client will

be admitted in a prelabor condition” are comparable or alike and can be eliminated first.

For the remaining options, knowing that Braxton Hicks contractions can occur

throughout pregnancy will assist in directing you to “Instruct the client that these are

common and may occur throughout the pregnancy”. If you had difficulty with this

question, review the physiology associated with Braxton Hicks contractions.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse is reviewing the record of a client who has just been told that her pregnancy

test is positive. The physician has documented the presence of Goodell’s sign. The nurse

determines that this sign is indicative of:

1. 2. 3. 4. A softening of the cervix

The presence of fetal movement

The presence of human chorionic gonadotropin (hCG) in the urine

A soft blowing sound that corresponds to the maternal pulse while auscultating

the uterus

ANS: 1

Rationale: In the early weeks of pregnancy, the cervix becomes softer as a result of

pelvic vasoconstriction, causing Goodell’s sign. Cervical softening is noted by the

examiner during pelvic examination. A soft blowing sound that corresponds to the

maternal pulse may be auscultated over the uterus and is caused by blood circulation

through the placenta. The presence of hCG is noted in the maternal urine in a urine

pregnancy test. Goodell’s sign does not indicate the presence of fetal movement.

Test-Taking Strategy: Use the process of elimination. Remember that Goodell’s sign is a

softening of the cervix. If you had difficulty with this question, review the changes in the

cervix that occur during pregnancy.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Assessment

The nursing instructor asks a nursing student to describe the process of quickening.

Which of the following statements, if made by the student, indicates an understanding of

this term?

1. 2. 3. 4. “It is the thinning of the lower uterine segment.”

“It is the fetal movement that is felt by the mother.”

“It is irregular painless contractions that occur throughout pregnancy.”

“It is the soft blowing sound that can be heard when the uterus is auscultated.”

ANS: 2

Rationale: Quickening is fetal movement and is not perceived until the second trimester.

Between 16 and 20 weeks’ gestation, the expectant client first notices subtle fetal

movements that gradually increase in intensity. A soft blowing sound that corresponds to

the maternal pulse may be auscultated over the uterus, known as uterine soufflé. This

sound is caused by the blood circulation to the placenta and corresponds to the maternal

pulse. Braxton Hicks contractions are irregular painless contractions that occur

throughout pregnancy, although many expectant mothers do not notice them until the

third trimester. A thinning of the lower uterine segment occurs at about 6 weeks’ of

gestation and is called Hegar’s sign.

Test-Taking Strategy: Knowledge regarding the strategic word “quickening” will direct

you to the correct option. Remember that quickening is fetal movement. If you are

unfamiliar with this sign associated with pregnancy, review this content.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

A pregnant client asks the nurse in the clinic when she will be able to start feeling the

fetus move. The nurse responds by telling the client that fetal movements will be noted

between _____ weeks’ gestation.

1. 6 and 8

2. 8 and 10

3. 12 and 14

4. 16 and 20

ANS: 4

Rationale: Fetal movement, called quickening, is not perceived until the second

trimester. Between 16 and 20 weeks’ gestation, the expectant client first notices subtle

fetal movements that gradually increase in intensity.

Test-Taking Strategy: Knowledge regarding quickening and the detection of fetal

movement by the client is required to answer this question. Use the process of

elimination; in this situation, it is best to select the option that indicates the longest

duration of gestation. If you are unfamiliar with the process of quickening, review this

content.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Implementation

A rubella titer is performed on a client who has just been told that she is pregnant. The

results of the titer indicate that the client is not immune to rubella. Which of the following

would the nurse anticipate to be prescribed for this client?

1. Immunization with rubella

2. 3. 4. Retesting rubella titer during pregnancy

Counseling the mother regarding therapeutic abortion

Antibiotics, to be taken throughout the pregnancy

ANS: 2

Rationale: A rubella titer is performed to determine immunity to rubella. If the client’s

titer is less than 1:8, the mother is not immune. A retest during pregnancy is prescribed,

and the mother is immunized postpartum if she is not immune. Antibiotics are not

prescribed. Counseling the client regarding therapeutic abortion is an inaccurate option.

Test-Taking Strategy: Note the strategic words “not immune to rubella.” Knowledge

regarding immunity and the rubella titer during pregnancy will direct you to the correct

option. If you had difficulty with this question, review the purpose of the rubella titer and

treatment measures for the client who is not immune.

PTS: 1

DIF: REF: Level of Cognitive Ability: Analyzing

McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Planning

The nursing instructor is reviewing a plan of care formulated by a nursing student who is

preparing to instruct a pregnant client in performing Kegel exercises. The nursing

instructor asks the student the purpose of the Kegel exercises. Which of the following

responses, made by the student, indicates an understanding of the purpose of these types

of exercises?

1. 2. 3. 4. “The exercises will help reduce backaches.”

“The exercises will help prevent ankle edema.”

“The exercises will help prevent urinary tract infections.”

“The exercises will help strengthen the pelvic floor in preparation for delivery.”

ANS: 4

Rationale: Kegel exercises will assist in strengthening the pelvic floor. Pelvic tilt

exercises will help reduce backaches. Instructing a client to drink 8 oz of fluids six times

a day will help prevent urinary tract infections. Leg elevation will assist in preventing

ankle edema.

Test-Taking Strategy: Focus on the subject of the question, and use the process of

elimination to answer the question. Knowing that Kegel exercises will help strengthen the

perineal floor muscles will assist in directing you to the correct option. If you had

difficulty with this question, review the purpose of the Kegel exercises.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

The nurse in a health care clinic is instructing a client how to perform kick counts. Which

of the following statements, if made by the client, indicates a need for further education?

1. 2. 3. 4. “I should lie on my back to perform the procedure.”

“I will use a clock or a timer and record the number of movements or kicks.”

“I should count the fetal movements for 30 to 60 minutes three times a day.”

“I should place my hands on the largest part of my abdomen and concentrate on

the fetal movements to count the kicks.”

ANS: 1

Rationale: In general, a client is advised to count the fetal movements for 30 to

60 minutes three times a day. The client should lie on her side. The client is instructed to

place her hands on the largest part of her abdomen and to concentrate on the fetal

movements. The client should use a timer or a clock, and should record the number of

movements felt during that time.

Test-Taking Strategy: Use the process of elimination to assist in answering the question.

Note the strategic words “a need for further education.” These words indicate a negative

event query and the need to select the incorrect option. Recalling that the risk of vena

cava syndrome exists when the client lies on her back will assist in directing you to the

correct option. The client should be advised not to lie in the supine position to prevent

this syndrome from occurring. Review the procedure for performing kick counts if you

had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the

procedure. Which of the following information will the nurse provide to the client?

1. “The fetus is challenged by uterine contractions to obtain the necessary

information.”

2. “The test is an invasive procedure and requires that you sign an informed

consent.”

3. “The test will take about 2 hours and will require close monitoring for 2 hours

after the procedure is completed.”

4. “An ultrasound transducer that records fetal heart activity is secured over the

abdomen where the fetal heart is heard most clearly.”

ANS: 4

Rationale: The nonstress test takes about 30 to 40 minutes. The test is termed nonstress

because it consists of monitoring only; the fetus is not challenged or stressed by uterine

contractions to obtain the necessary data. It is a noninvasive test, and an ultrasound

transducer that records fetal heart activity is secured over the maternal abdomen where

the fetal heart is heard most clearly. A tocotransducer that detects uterine activity and

fetal movement is then secured to the maternal abdomen. Fetal heart activity and

movements are recorded.

Test-Taking Strategy: Focus on the subject, the nonstress test. Knowing that the test is

noninvasive will assist in eliminating the incorrect options. If you are unfamiliar with this

test, review its procedure.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Implementation

A client in the second trimester of pregnancy is seen in the health care clinic. The client

tells the nurse that she is a hostess at a local restaurant and is on her feet most of the day.

She states that she has frequent low back pains and ankle edema by the end of the day.

The nurse provides instructions to the woman about measures to relieve the discomfort.

Which of the following statements, made by the client, indicates an understanding of how

to relieve these discomforts?

1. “When I get home I should lie on my left side, with my feet in a dorsiflexed

position.”

2. “I should soak in a tub bath of hot water when I get home and then perform

pelvic tilt exercises.”

3. “When I get home I should lie on my right side, with my feet elevated on a

pillow, and put a heating pad on my back.”

4. “When I get home I should lie on the floor, with my legs elevated onto a couch,

and turn my hips and knees at right angles.”

ANS: 4

Rationale: Lying on the floor with the legs elevated onto a couch, with the hips and

knees at right angles, will produce a posture of pelvic tilt while countering gravity, which

is the force that leads to edema of the lower extremities. Although the other options might

seem useful, remember that heat needs to be prescribed by a physician. Lying on the left

side with the feet dorsiflexed may help with the reduction of hemorrhoids.

Test-Taking Strategy: Use the process of elimination in answering the question, focusing

on the client’s complaints. Avoid measures that require physician prescriptions, such as

those that relate to heat. This concept will assist in eliminating the options “I should soak

in a tub bath of hot water when I get home and then perform pelvic tilt exercises.” and

“When I get home I should lie on my right side, with my feet elevated on a pillow, and

put a heating pad on my back.” Next, visualize the remaining options to direct you to the

correct option. If you had difficulty with this question, review measures for the prenatal

client with discomforts of back pain and ankle edema.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Evaluation

A pregnant client calls the nurse at the physician’s office and reports that she has noticed

a thin, colorless, vaginal drainage. Which of the following information would be most

appropriate for the nurse to provide to the client?

1. 2. 3. 4. Come to the clinic immediately.

Report to the emergency department at the maternity center immediately.

The vaginal discharge may be bothersome but is a normal occurrence.

Use tampons if the discharge is bothersome but be sure to change the tampons

every 2 hours.

ANS: 3

Rationale: Many pregnant clients notice an increased thin, colorless or yellow vaginal

discharge throughout pregnancy. The increase in the amount of discharge may be

bothersome, but it is usually a normal occurrence. This occurrence does not require that

the client report to the health care clinic or the emergency department immediately. If

vaginal discharge is profuse, panty liners may be desirable; the client should not wear

tampons, however, because they may increase the likelihood for development of an

infection or toxic shock syndrome. If panty liners are used, they should be changed

frequently.

Test-Taking Strategy: Use the process of elimination to assist in answering this question.

Note that the options “come to the clinic immediately” and “report to the emergency

department at the maternity center immediately” are comparable or alike, and eliminate

these options first. For the remaining two options, recalling either that this manifestation

is a normal physiological occurrence or that tampons should be avoided will assist in

directing you to the correct option. Review the normal occurrences related to vaginal

discharge in a pregnant woman if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse has assisted in performing a nonstress test on a pregnant client and is

reviewing the documentation related to the results of the test. The nurse notes that the

physician has documented the test results as reactive. The nurse interprets that this result

indicates:

1. Normal findings

2. Abnormal findings

3. The need for further evaluation

4. That the findings on the monitor were difficult to interpret

ANS: 1

Rationale: A reactive nonstress test is a normal result. To be considered reactive, the

baseline must be within normal range (110 to 160 beats/min with good long-term

variability), and there must be two or more fetal heart rate accelerations of at least

15 beats/min, each with a duration of at least 15 seconds, in a 20-minute interval.

Therefore, the other options are incorrect.

Test-Taking Strategy: Knowledge of the interpretation of the results of the nonstress test

is required to answer this question. Use the process of elimination, noting that the options

“abnormal findings”, “the need for further evaluation”, and “that the findings on the

monitor were difficult to interpret” are comparable or alike. If you had difficulty with this

question and are unfamiliar with the interpretation of the results of a nonstress test,

review this content.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Analysis

The pregnant client calls the clinic and tells the nurse that she is experiencing leg cramps

and is awakened by the cramps at night. The nurse would tell the client to _____ the knee

when the cramps occur.

1. 2. 3. 4. Dorsiflex the foot while extending

Dorsiflex the foot while flexing

Plantar flex the foot while flexing

Plantar flex the foot while extending

ANS: 1

Rationale: Leg cramps occur when the pregnant client stretches the leg and plantar flexes

the foot. Dorsiflexing the foot while extending the knee stretches the affected muscle,

prevents the muscle from contracting, and stops the cramping.

Test-Taking Strategy: Knowledge about the actions that will alleviate muscle cramps will

assist in answering this question. Visualize each description in the options to assist in

directing you to the correct option. If you had difficulty with this question, review

measures that will assist in reducing muscle cramps in the client.

PTS: 1

DIF: REF: Level of Cognitive Ability: Applying

Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse is providing instructions about treatment for hemorrhoids to the client who is

in the second trimester of pregnancy. Which of the following statements, if made by the

client, indicates a need for further instruction?

1. 2. 3. 4. “I should perform Kegel exercises as you have instructed.”

“Cool sitz baths will help in relieving the discomfort.”

“I should apply heat packs to the hemorrhoids to help them shrink.”

“I can apply ice packs to the hemorrhoids to assist in relieving discomfort.”

ANS: 3

Rationale: Remedies for the symptoms of hemorrhoids include ice packs; warm or cold

sitz baths; gentle cleansing; or topical ointments and anesthetic agents. Kegel exercises

help strengthen the perineum. Hot packs will increase the blood flow to the area and

worsen the discomfort from hemorrhoids.

Test-Taking Strategy: Use the process of elimination, noting the strategic words “need

for further instruction.” These words indicate a negative event query and the need to

select the incorrect option. Eliminate the options “Cool sitz baths will help in relieving

the discomfort.” and “I can apply ice packs to the hemorrhoids to assist in relieving

discomfort.” first because they are comparable or alike. Also, use knowledge of the

principles of heat and cold to assist in directing you to the correct option. If you had

difficulty with this question, review the remedies for the treatment of hemorrhoids.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

The clinic nurse is discussing nutrition with a pregnant client who has lactose intolerance.

The nurse would instruct the client to supplement the dietary source of calcium by eating

which of the following foods?

1. Dried fruits

2. Creamed spinach

3. Hard cheese

4. Fresh squeezed orange juice

ANS: 1

Rationale: The best source of calcium is dairy products. Women with lactose intolerance

need other sources of calcium. Calcium is present in dark green leafy vegetables,

broccoli, legumes, nuts, and dried fruits. Spinach contains calcium, but it also contains

oxalates that decrease calcium availability. Additionally, creamed spinach may not be

tolerated by a client with a lactose intolerance. Orange juice does not contain significant

amounts of calcium unless it has been fortified with calcium. Cheese is a dairy product

and cannot be eaten when the client has lactose intolerance.

Test-Taking Strategy: Focus on the subject of the question and the client’s diagnosis.

Knowledge that a client with lactose intolerance cannot tolerate dairy products will assist

in eliminating the options “creamed spinach” and “hard cheese”. For the remaining

options, recalling that orange juice does not contain calcium unless it has been fortified

with calcium will assist in directing you to the correction option, “dried fruits”. Review

food items high in calcium that can be tolerated by a client with lactose intolerance if you

had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

The nurse is providing instructions to a pregnant client visiting the antenatal clinic about

foods that are rich in folic acid. The nurse would encourage the client to increase intake

of which of the following foods that are highest in folic acid?

1. Cheese

2. Chicken

3. Rice

4. Green leafy vegetables

ANS: 4

Rationale: Of the choices available, green leafy vegetables are highest in folic acid.

Other sources of folic acid include whole grains, fruits, liver, dried peas, and beans.

Chicken, rice, and cheese are not high in folic acid. Cheese is high in calcium, and rice

and chicken are good sources of iron.

Test-Taking Strategy: Knowledge of food items high in folic acid is needed to answer

this question. Remember that green leafy vegetables are high in folic acid to help you

choose the correction option, “green leafy vegetables”. If you had difficulty with this

question, review food items high in folic acid.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Implementation

The pregnant client asks the nurse about the type of exercises that are allowable during

her pregnancy. The nurse would instruct the client that the safest exercise to engage in is

which of the following?

1. Swimming

2. Water skiing

3. Aerobic exercising

4. Downhill skiing

ANS: 1

Rationale: Competitive or high-risk sports, such as scuba diving, water skiing, downhill

skiing, horseback riding, basketball, volleyball, aerobic exercising, and gymnastics,

should be avoided. Non–weight-bearing exercises are preferable to weight-bearing

exercises. Exercises to avoid are shoulder standing and bicycling with the legs in the air

because the use of the knee-chest position should be avoided. Non–weight-bearing

exercise, such as swimming, is allowable.

Test-Taking Strategy: Use the process of elimination to assist in answering the question.

Identify those activities or exercises that could cause or produce an injury to the fetus.

This should easily direct you to the correct option, “swimming.” If you had difficulty

with this question, review teaching points related to exercises that are safe for a client

who is pregnant.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

A pregnant client reports to the health care clinic complaining of loss of appetite, weight

loss, and fatigue. Following assessment, tuberculosis is suspected. A sputum culture is

obtained, and Mycobacterium tuberculosis is identified in the sputum. The nurse provides

instructions to the client regarding therapeutic management of tuberculosis. Which of the

following instructions does the nurse provide to the client?

1. The need for therapeutic abortion is required.

2. Medication will not be started until after delivery of the fetus.

3. Isoniazid (INH) plus rifampin (Rifadin) will be required for a total of 9 months.

4. The newborn must receive medication therapy immediately following birth.

ANS: 3

Rationale: More than one medication may be used to prevent the growth of resistant

organisms in the pregnant client with tuberculosis. Treatment must continue for a

prolonged period. The preferred treatment for pregnant clients is isoniazid plus rifampin

daily for a total of 9 months. Ethambutol is added initially if drug resistance is suspected.

Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal

neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid

therapy. Skin testing on the infant should be repeated at 3 months, and isoniazid may be

stopped if the skin test result remains negative. If the skin test result converts to positive,

a full course of isoniazid would be given.

Test-Taking Strategy: Recalling the risks associated with tuberculosis and that this

communicable disease is treated with medication will direct you to the correct option. If

you had difficulty with this question, review treatment measures for the mother with

tuberculosis.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse has provided home care instructions to a client with a history of cardiac disease

who has just been told that she is pregnant. Which of the following statements, if made

by the client, indicates a need for further education?

1. 2. “It is best that I rest on my left side to promote blood return to the heart.”

“I need to avoid excessive weight gain to prevent increased demands on my

heart.”

3. “I need to try to avoid stressful situations because stress increases the workload

on the heart.”

4. “During the pregnancy, I need to avoid contact with other individuals as much as

possible to prevent infection.”

ANS: 4

Rationale: To avoid infections, visitors with active infections should not be allowed to

visit the client. Otherwise, restrictions are not required. Stress causes increased workload

on the heart, and the client should be instructed to avoid stress. Too much weight gain can

place further demands on the heart. Resting should be done while lying on the left side to

promote blood return.

Test-Taking Strategy: Use the process of elimination to assist in answering the question.

Note the strategic words “cardiac disease” and “need for further education” in the

question. Using principles related to the therapeutic management of cardiac disease in

general will assist in directing you to the correct option. If you had difficulty with this

question, review measures for the client with cardiac disease.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

A nurse is collecting data on a pregnant client in the first trimester of pregnancy whose

medical record indicates the presence of iron deficiency anemia. The nurse would

monitor the client to detect which of the following signs indicating that this problem has

not yet resolved?

1. Increased vaginal secretions

2. Pink mucous membranes

3. Complaints of increased frequency of voiding

4. Complaints of daily headaches and fatigue

ANS: 4

Rationale: Anemia is one of the most common problems in pregnancy, and iron

deficiency anemia and folic acid deficiency anemia are two of the most common types. It

is estimated that between 20% and 60% of all women are anemic at some point during

pregnancy (hemoglobin concentration lower than 10.5 to 11.0 g/dL). Complaints of daily

headaches and fatigue are abnormal findings and may reflect complications caused by

decreased O2 supply to vital organs, thus supporting laboratory findings. The incorrect

options are expected findings in the first trimester of pregnancy.

Test-Taking Strategy: Note the strategic words “first trimester of pregnancy and has not

yet resolved in the question.” Use the process of elimination and knowledge of abnormal

and normal findings to assist in directing you to the correct option. Knowing that the

other options are normal findings during the first trimester of pregnancy helps you

eliminate each of them. “Complaints of daily headaches and fatigue” is abnormal and

may reflect decreased O2 supply to vital organs, thus supporting laboratory findings.

Review the clinical manifestations associated with anemia if you had difficulty with this

question.

PTS: 1

DIF: REF: Level of Cognitive Ability: Applying

Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Assessment

A nurse has just received the intershift report. After reviewing the client assignment and

the appropriate medical records, the nurse determines that which of the following clients

is most at risk for developing postdelivery endometritis?

1. 2. 3. 4. A primigravida with a normal spontaneous vaginal delivery

A gravida II who delivered vaginally following an 18-hour labor

A client experiencing an elective cesarean delivery at 38 weeks’ gestation

An adolescent experiencing an emergency cesarean delivery for fetal distress

ANS: 4

Rationale: Endometritis is an acute infection of the uterine mucous lining immediately

after delivery and is still a leading cause of mortality for childbearing women in the

United States. Cesarean delivery is the primary risk factor for uterine infection, especially

after emergency procedures. Other risk factors include prolonged rupture of membranes,

multiple vaginal examinations, and an excessive length of labor. The other options do not

describe the client most at risk to develop endometritis following delivery.

Test-Taking Strategy: Note the strategic words “most at risk” in the question. Use the

process of elimination and knowledge about the cause of endometritis to assist in

answering the question. Noting the strategic words “fetal distress” in the correct option

will assist in directing you to this option. If you had difficulty with this question or are

unfamiliar with the cause associated with this condition, review this content.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Analysis

A nurse is conducting a routine screening to detect a client’s risk for toxoplasmosis

parasite infection during pregnancy. The nurse would ask the client about which of the

following items to determine this risk?

1. 2. 3. 4. Number of sexual partners during pregnancy

Presence in the home of cats who use a kitty litter box for elimination

Exposure to children with rashes or gastrointestinal symptoms

History of high fevers or unusual rashes during the first 6 weeks of pregnancy

ANS: 2

Rationale: Toxoplasmosis is a systemic (and usually asymptomatic) illness caused by a

protozoan parasite. Approximately one third of all women in the United States have

positive antibody titers for toxoplasmosis, thus confirming prior exposure. Humans

acquire the infection by consuming inadequately cooked meat, eggs, or milk; by ingesting

or inhaling the oocyst stage excreted in feline feces or in contaminated soil; or from

receiving contaminated blood products. Other than transplacental infection, this disease is

rarely transmitted from human to human. During pregnancy, the parasite may be

transmitted across the placenta and cause severe infection in the developing embryo or

fetus. The other options are questions unrelated to toxoplasmosis.

Test-Taking Strategy: Remember that toxoplasmosis can be contracted from

contaminated kitty litter. Eliminate each of the incorrect options because they identify

possible transmission routes for other known sexually transmitted diseases or viral

infections. If you had difficulty with this question, review the cause of toxoplasmosis.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is preparing to care for a client who is being admitted to the hospital with a

possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client

and determines that which of the following is the priority nursing action?

1. Monitoring daily weight

2. Assessing for edema

3. Monitoring the temperature

4. Monitoring the apical pulse

ANS: 4

Rationale: Nursing care for the client with a possible ectopic pregnancy is focused on

preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate

is an indicator of shock. Weight and edema are priority interventions for the client with

preeclampsia, and an elevated temperature is an indicator of infection.

Test-Taking Strategy: Focus on the diagnosis of the client, and note the strategic word

priority. Recalling that bleeding and hypovolemic shock are the concerns will assist in

directing you to the correct option, which is the only assessment associated with the

presence of shock. Also, “monitoring the apical pulse” relates to the ABCs of airway,

breathing, and circulation. Review care of the client with ectopic pregnancy if you had

difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Planning

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the

first prenatal visit. Which of the following data, if noted on the client’s record, would

alert the nurse that the client is at risk for developing gestational diabetes during this

pregnancy?

1. The client’s previous deliveries were by cesarean section.

2. The client’s last baby weighed 10 lb at birth.

3. The client has a family history of type 1 diabetes.

4. The client is 5 feet, 3 inches tall and weighs 165 lb.

ANS: 2

Rationale: Known risk factors that increase the risk of developing gestational diabetes

include obesity (over 198 lb), chronic hypertension, family history of type 2 diabetes,

previous birth of a large infant (over 4000 g), and gestational diabetes in a previous

pregnancy. The other options are not risk factors associated with the development of

gestational diabetes.

Test-Taking Strategy: Focus on the subject of the question, risk factors associated with

the development of gestational diabetes. Use the process of elimination and knowledge of

these risk factors to assist in directing you to the correct option. Remember that the

previous birth of a large infant is a risk factor. If you are unfamiliar with the risk factors

associated with gestational diabetes, review this content.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is teaching a diabetic pregnant client about nutrition and insulin needs during

pregnancy. The nurse determines that the client understands dietary and insulin needs if

the client states that the second half of pregnancy may require:

1. Increased insulin

2. Decreased insulin

3. Increased caloric intake

4. Decreased caloric intake

ANS: 1

Rationale: Glucose crosses the placenta, but insulin does not. High fetal demands for

glucose, combined with the insulin resistance caused by hormonal changes in the last half

of pregnancy, can result in elevation of maternal blood glucose levels. This increases the

mother’s demand for insulin and is referred to as the diabetogenic effect of pregnancy.

Caloric requirements are not affected by diabetes.

Test-Taking Strategy: Use the process of elimination and knowledge of the

pathophysiology associated with diabetes to assist in answering the question. Eliminate

the options “increased caloric intake” and “decreased caloric intake” first because

diabetes does not change caloric requirements. Recalling that the need for insulin may

decrease in the first half of pregnancy and increase in the second half of pregnancy will

easily direct you to “increased insulin”. Review the effects of diabetes on pregnancy and

insulin needs if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Evaluation

The nurse has provided instructions to a pregnant client who is preparing to take iron

supplements. The nurse determines that the client understands the instructions if the client

states that she will take the supplements with which of the following?

1. Milk

2. Tea

3. Coffee

4. Orange juice

ANS: 4

Rationale: Foods containing ascorbic acid will increase the absorption of iron. Calcium

and phosphorus in milk and tannin in tea decrease iron absorption. Coffee binds iron and

prevents it from being fully absorbed. Orange juice is the only item that contains ascorbic

acid and will increase the absorption of iron supplements.

Test-Taking Strategy: Use the process of elimination to answer the question. Recalling

that ascorbic acid increases the absorption of iron and knowledge of the food items that

contain ascorbic acid will easily direct you to the correct option. Review client teaching

points related to the administration of iron if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Evaluation

The nurse is caring for a client in labor. The nurse determines that the client is beginning

the second stage of labor when which of the following is documented in the client’s

record?

1. The contractions are regular.

2. The membranes have ruptured.

3. The cervix is completely dilated.

4. The client begins to expel clear vaginal fluid.

ANS: 3

Rationale: The second stage of labor begins when the cervix is completely dilated and

ends with birth of the infant. The other options are not specific assessment findings of the

second stage of labor.

Test-Taking Strategy: Use the process of elimination and knowledge regarding the stages

of labor to assist in answering the question. Eliminate the options “the contractions are

regular” and “the client begins to expel clear vaginal fluid” first because they are

comparable or alike. For the remaining two options, recalling that regular contractions

occur prior to the second stage of labor will easily direct you to the correct option.

Review the stages of labor if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is assisting in caring for a client in the active stage of labor. The nurse is told

that the fetal patterns show a late deceleration on the monitor strip. Based on this finding,

the nurse prepares for which most appropriate nursing actions?

1. 2. 3. 4. Placing the mother in a supine position

Administering oxygen via face mask

Increasing the rate of the intravenous (IV) oxytocin infusion

Documenting the findings and continuing to monitor the fetal patterns

ANS: 2

Rationale: Late decelerations are caused by uteroplacental insufficiency as the result of

decreased blood flow and oxygen to the fetus during the uterine contractions. This causes

hypoxemia; therefore, oxygen is necessary. The supine position is avoided because it

decreases uterine blood flow to the fetus. The client should be turned onto her side to

displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion

is discontinued when a late deceleration is noted; otherwise, the oxytocin would cause

further hypoxemia because of increased uteroplacental insufficiency caused by

stimulation of contractions caused by the oxytocin. “Documenting the findings and

continuing to monitor the fetal patterns” would delay necessary treatment.

Test-Taking Strategy: Knowledge related to the significance of a late deceleration is

required to answer this question. Use the ABCs—airway, breathing, and circulation—to

assist in answering the question. Review content related to late decelerations if you had

difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Planning

The nurse is assisting the nurse midwife in preparing to perform Leopold’s maneuver on

a pregnant client. The nurse instructs the client about the procedure and then:

1. 2. 3. 4. Asks the client to urinate

Asks the client to drink 8 oz of water

Locates the fetal heart tones with a fetoscope

Warms the sonogram gel before placing it on the client’s abdomen

ANS: 1

Rationale: An empty bladder contributes to a woman’s comfort during this examination.

Drinking water to fill the bladder and warming sonogram gel may be performed prior to a

sonography (ultrasound). Often, Leopold’s maneuver is performed to aid the examiner in

locating the fetal heart tones.

Test-Taking Strategy: Focus on the subject of the question, Leopold’s maneuver. Use

knowledge regarding this maneuver to assist in answering the question. Recalling that it

is often used to help locate fetal heart tones will assist in eliminating “Locates the fetal

heart tones with a fetoscope”. Eliminate “asks the client to drink 8 oz of water” and

“warms the sonogram gel before placing it on the client’s abdomen” next because they

both relate to a sonogram. Review the procedure and purpose of Leopold’s maneuver if

you had difficulty with this question.

PTS: 1

43. DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Implementation

A client in labor is receiving oxytocin (Pitocin) by intravenous infusion to stimulate

uterine contractions. Which of the following findings indicates that the rate of the

infusion needs to be decreased?

1. Increased urinary output

2. A fetal heart rate of 180 beats/min

3. Three contractions occurring in a 10-minute period

4. Adequate resting tone of the uterus palpated between contractions

ANS: 2

Rationale: A normal fetal heart rate is 120 to 160 beats/min. Acute hypoxia is a common

cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of

fetal tachycardia, which can occur from excessive uterine activity. The goal of labor

augmentation is to achieve three good-quality contractions (appropriate intensity and

duration) in a 10-minute period. The uterus should return to resting tone between

contractions, and there should be no evidence of fetal distress. Increased urinary output is

unrelated to the use of oxytocin.

Test-Taking Strategy: Use the process of elimination and knowledge regarding the

nursing considerations related to the use of oxytocin to answer this question. Eliminate

the options “three contractions occurring in a 10-minute period” and “adequate resting

tone of the uterus palpated between contractions”first because these are normal and

expected findings. Eliminate the option “increased urinary output” next because it is

unrelated to the use of oxytocin. Review care of the client receiving an oxytocin infusion

if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is monitoring a client in labor whose membranes ruptured spontaneously. The

initial nursing action is to:

1. 2. 3. Take the client’s blood pressure.

Provide peripads to the client.

Determine the fetal heart rate.

4. Note the amount, color, and odor of the amniotic fluid.

ANS: 3

Rationale: When the membranes rupture in the birth setting, the nurse immediately

assesses the fetal heart rate to detect changes associated with prolapse or compression of

the umbilical cord. “Take the client’s blood pressure.” and “Note the amount, color, and

odor of the amniotic fluid.” are also appropriate actions, but are not the initial actions in

this situation. The nurse may assist the client in cleaning and changing clothing, but

determining the fetal heart rate is the initial action.

Test-Taking Strategy: Use principles of prioritizing when answering this question and the

ABCs—airway, breathing, and circulation. Fetal heart rate is associated with fetal

breathing and circulation. If you had difficulty with this question, review initial nursing

actions when ruptured membranes occur.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse

observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse

documents these observations as signs of:

1. Hematoma

2. Placenta previa

3. Uterine atony

4. Placental separation

ANS: 4

Rationale: As the placenta separates, it settles downward into the lower uterine segment.

The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. The other

options are incorrect.

Test-Taking Strategy: The options “hematoma,” “placenta previa,” and “uterine atony”

are comparable or alike in that they identify complications of pregnancy. The option

“placental separation” indicates a normal finding following vaginal delivery of the

newborn and is the correct option. Review this stage of labor if you had difficulty with

this question.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is preparing to care for a client in labor. The physician has prescribed an

intravenous (IV) infusion of oxytocin (Pitocin). The nurse ensures that which of the

following is implemented prior to the beginning of the infusion?

1. Placing the client on complete bed rest

2. Continuous electronic fetal monitoring

3. An IV infusion of antibiotics

4. Placing a code cart at the client’s bedside

ANS: 2

Rationale: Continuous electronic fetal monitoring should be implemented during an IV

infusion of oxytocin. There are no data in the question that indicate the need for complete

bed rest or the need for antibiotics. It is not necessary to place a code cart at the bedside

of a client receiving an oxytocin infusion.

Test-Taking Strategy: Use the process of elimination and the ABCs—airway, breathing,

and circulation—to assist in answering the question. The option “continuous electronic

fetal monitoring” is the only one that addresses oxygenation and circulation. If you had

difficulty with this question, review the nursing considerations related to the

administration of oxytocin.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse provides a list of discharge instructions to the client who has delivered a

healthy newborn by cesarean delivery. Which statement by the client indicates the need

for further instructions?

1. Begin abdominal exercises immediately.

2. Notify the physician if I develop a fever.

3. Lift nothing heavier than the newborn for at least 2 weeks.

4. Turn on my side and push up with my arms to get out of bed.

ANS: 1

Rationale: Abdominal exercises should not start immediately following abdominal

surgery until 3 to 4 weeks postoperatively to allow for healing of the incision. The other

options are appropriate instructions for the client following a cesarean delivery.

Test-Taking Strategy: Note the strategic words “need for further instructions” in the

question. These words indicate a negative event query and the need to select the incorrect

option. Use the process of elimination, keeping in mind that the client had a cesarean

delivery. Noting the word “immediately” in “begin abdominal exercises immediately”

will assist in directing you to this option. Review home care instructions for the client

following cesarean delivery if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Teaching and Learning

The nurse is assisting in the care of a client in labor who is having an amniotomy

performed. The nurse assesses that the amniotic fluid is normal if it has which of the

following characteristics?

1. 2. 3. 4. Clear and dark amber color

Light green color with no odor

Thick white color with no odor

Straw-colored, with flecks of vernix

ANS: 4

Rationale: Amniotic fluid is normally a pale straw color and may contain flecks of vernix

caseosa. It should have a thin watery consistency and may have a mild odor. The other

options are not descriptions of normal amniotic fluid.

Test-Taking Strategy: Knowledge of the characteristics of normal amniotic fluid is

required to answer this question. Remember that the amniotic fluid is straw-colored, with

flecks of vernix caseosa, to choose the correct option easily. If you are unfamiliar with

the characteristics of amniotic fluid, review this content.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse has developed a plan of care for a client experiencing dystocia and includes

several nursing interventions in the plan. The nurse prioritizes the plan and selects which

of the following nursing interventions as the highest priority?

1. Monitoring fetal status

2. Providing comfort measures

3. Changing the client’s position frequently

4. Keeping the significant other informed of the progress of the labor

ANS: 1

Rationale: The priority in the plan of care would include the intervention that addresses

the physiological integrity of the fetus. Although providing comfort measures, changing

the client’s position frequently, and keeping the significant other informed of the progress

of the labor are components of the plan of care, fetal status is the priority.

Test-Taking Strategy: Note the strategic words “highest priority.” Use Maslow’s

Hierarchy of Needs theory and the ABCs—airway, breathing, and circulation—to assist

in answering the question. Remember that physiological integrity is the priority. Review

priority nursing interventions for the client with dystocia if you had difficulty with this

question.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Planning

The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal

compromise. Which of the following findings would alert the nurse to a compromise?

1. Maternal fatigue

2. Coordinated uterine contractions

3. The passage of meconium

4. Progressive changes in the cervix

ANS: 3

Rationale: Signs of fetal or maternal compromise include a persistent, nonreassuring

fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and

infection can occur if the labor is prolonged but does not indicate fetal or maternal

compromise. Progressive changes in the cervix and coordinated uterine contractions are a

reassuring pattern in labor.

Test-Taking Strategy: Focus on the subject of the question, signs of fetal or maternal

compromise. Use the process of elimination, noting that the options “maternal fatigue,”

“coordinated uterine contractions”, and “progressive changes in the cervix” are normal

expectations during labor. Review the findings that indicate fetal or maternal compromise

if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the

client is experiencing uncoordinated contractions that are erratic in their frequency,

duration, and intensity. The priority nursing intervention in caring for the client is to:

1. Provide pain relief measures.

2. Promote ambulation every 30 minutes.

3. Prepare the client for an amniotomy.

4. Monitor the oxytocin (Pitocin) infusion closely.

ANS: 1

Rationale: Management of hypertonic labor depends on the cause. Relief of pain is the

primary intervention to promote a normal labor pattern. Therapeutic management for

hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to

stimulate a labor that slows. The client with hypertonic uterine dysfunction would not be

encouraged to ambulate every 30 minutes but would be encouraged to rest.

Test-Taking Strategy: Use the process of elimination, focusing on the strategic word

“hypertonic.” This strategic word and knowledge of the therapeutic management for

hypertonic labor will easily assist in directing you to the correct option. The other options

are therapeutic measures for hypotonic dysfunction. If you had difficulty with this

question, review the therapeutic management for hypertonic uterine dysfunction.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the

nurse notes the presence of the umbilical cord protruding from the vagina. Which of the

following is the initial nursing action?

1. Place the client in Trendelenburg’s position.

2. 3. 4. Gently push the cord into the vagina.

Find the closest telephone, and page the physician stat.

Call the delivery room to notify the staff that the client will be transported

immediately.

ANS: 1

Rationale: When cord prolapse occurs, prompt actions are taken to relieve cord

compression and increase fetal oxygenation. The mother should be positioned with her

hips higher than her head to shift the fetal presenting part toward the diaphragm. The

nurse should push the call light to summon help, and other staff members should call the

physician and notify the delivery room. If the cord is protruding from the vagina, no

attempt should be made to replace it because that could traumatize it and further reduce

blood flow. Oxygen at 8 to 10 L/min by face mask is administered to the mother to

increase fetal oxygenation.

Test-Taking Strategy: Use the process of elimination, noting the strategic words

“umbilical cord protruding from the vagina.” The options “find the closest telephone, and

page the physician stat” and “call the delivery room to notify the staff that the client will

be transported immediately” can be eliminated first because these actions delay necessary

and immediate treatment. Knowledge that the cord should not be pushed back into the

vagina will easily direct you to the correct option. Review priority nursing measures for

prolapsed cord if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse is caring for a client who has just delivered a newborn following a pregnancy

with a placenta previa. The nurse reviews the plan of care and prepares to monitor the

client for which of the following risks associated with placenta previa?

1. Hemorrhage

2. Infection

3. Chronic hypertension

4. Disseminated intravascular coagulation

ANS: 1

Rationale: Because the placenta is implanted in the lower uterine segment, which does

not contain the same intertwining musculature as the fundus of the uterus, this site is

more prone to bleeding. The other options are not risks that are specifically related to

placenta previa.

Test-Taking Strategy: Knowledge regarding the risk factors associated with placenta

previa is required to answer this question. Think about the pathophysiology associated

with this condition. Remember hemorrhage is associated with placenta previa. Review

the complications associated with placenta previa if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Planning

The nurse is caring for a client during the second stage of labor. On assessment, the nurse

notes a slowing of the fetal heart rate and a loss of variability. The initial nursing action

would be which of the following?

1. Turn the client on her back, and administer oxygen by nasal cannula at 2 to

4 L/min.

2. Turn the client on her side, and administer oxygen by face mask at 8 to

10 L/min.

3. Turn the client on her back, and administer oxygen by face mask at 8 to

10 L/min.

4. Turn the client on her side, and administer oxygen by nasal cannula at 2 to

4 L/min.

ANS: 2

Rationale: If a fetal heart rate begins to slow or a loss of variability is observed, this

could indicate fetal distress. To facilitate oxygen to the mother and her fetus, the mother

is turned to her side, which reduces the pressure of the uterus on the ascending vena cava

and descending aorta. Oxygen at 8 to 10 L/min is applied to the mother by face mask.

Test-Taking Strategy: Knowledge of the signs of fetal distress and the appropriate

nursing actions to take is needed to answer this question. Eliminate both options that

begin “Turn the client on her back” first because the mother would not be turned on her

back. From the remaining options, select “Turn the client on her side, and administer

oxygen by face mask at 8 to 10 L/min” because this option would provide the most

oxygen to both mother and fetus. Review the appropriate nursing interventions to take

when fetal distress occurs if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Implementation

An ultrasound is performed on a client with suspected abruptio placentae, and the results

indicate that a placental abruption is present. The nurse would prepare the client for:

1. Delivery of the fetus

2. 3. 4. Strict monitoring of intake and output

Complete bed rest for the remainder of the pregnancy

The need for weekly monitoring of coagulation studies until the time of delivery

ANS: 1

Rationale: The goal of management in abruptio placentae is to control the hemorrhage

and deliver the fetus as soon as possible. Because delivery of the fetus is necessary, the

remaining options are incorrect regarding management of the client with abruptio

placentae.

Test-Taking Strategy: Think about the pathophysiology associated with abruptio

placentae and use knowledge regarding the management of abruptio placentae to answer

the question. Knowing that the goal is to deliver the fetus will easily direct you to the

correct option. If you had difficulty with this question or are unfamiliar with the

management of abruptio placentae, review this content.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Planning

The nurse is monitoring a client who is in the active phase of labor. The client has been

experiencing contractions that are short, irregular, and weak. The nurse documents that

the client is experiencing which type of labor dystocia?

1. Hypotonic

2. Precipitate

3. Hypertonic

4. Preterm labor

ANS: 1

Rationale: Hypotonic labor contractions are short, irregular, weak, and usually occur

during the active phase of labor. Hypertonic dysfunction usually occurs during the latent

phase of labor. Precipitate labor is that which lasts in its entirety for 3 hours or less.

Preterm labor is the onset of labor after 20 weeks of gestation and before the beginning of

the 38th week of gestation.

Test-Taking Strategy: Use the process of elimination to answer the question. Note the

relationship between the words “short,” “irregular,” and “weak” in the question and

“hypotonic” in the correct option. If you are unfamiliar with dysfunctional labor

(dystocia), review this content.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse has collected the following data on a client in labor: the fetal heart rate (FHR)

is 154 beats/min and is regular; and contractions have moderate intensity, occur every 5

minutes, and have a duration of 35 seconds. Using this information, the nurse should take

which most appropriate action?

1. Prepare for imminent delivery.

2. Continue to monitor the client.

3. Report the findings to the obstetrician.

4. Report the FHR to the anesthesiologist on call.

ANS: 2

Rationale: The data collected by the nurse are within normal limits and require no further

action on the part of the nurse other than continued monitoring. The FHR is normally 120

to 160 beats/min. Signs of potential complications of labor include contractions

consistently lasting 90 seconds or longer; contractions consistently occurring 2 minutes

or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and

irregular FHR.

Test-Taking Strategy: Knowledge of the normal findings and the potential complications

of labor is required to answer this question. Eliminate the options “report the findings to

the obstetrician” and “report the FHR to the anesthesiologist on call” first because they

are comparable or alike. Knowledge of the expected findings during labor will easily

direct you to the correct option. Review expected data in a client in labor if you had

difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Implementation

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94

beats/min and the umbilical cord protruding from the vagina. The client states that her

“water broke” before coming to the hospital. The most appropriate nursing action would

be to:

1. 2. 3. 4. Sit the client in a high Fowler’s position.

Call the pharmacy for a tocolytic medication.

Get intravenous (IV) therapy equipment and solution from the storage area.

Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.

ANS: 4

Rationale: When an umbilical cord is protruding, the cord must be protected from drying

out and from becoming compressed. Wrapping the cord with a sterile, saline-soaked

towel will help accomplish this. The nurse must also help reduce compression of the cord

by placing the client in an extreme Trendelenburg’s or modified Sims position. A

tocolytic would be used if the client had inadequate uterine relaxation. IV solutions may

be administered but are not the priority item with the information given.

Test-Taking Strategy: Knowledge of appropriate nursing interventions to treat umbilical

cord protrusion is needed to answer this question. Note the relationship of the data in the

question and the correct option. If you are unfamiliar with these nursing interventions or

had difficulty answering this question, review this content.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse

understands that the initial nursing action when performing this assessment is which of

the following?

1. 2. 3. 4. Ask the client to turn on her side.

Ask the client to urinate and empty her bladder.

Ask the client to lie flat on her back, with her knees and legs flat and straight.

Massage the fundus gently prior to determining the level of the fundus.

ANS: 2

Rationale: Before fundal assessment is started, the nurse should ask the mother to empty

her bladder so that an accurate assessment can be done. The nurse can then assess the

bladder for complete emptying and accurately assess uterine involution. When

performing fundal assessment, the woman is asked to lie flat on her back, with the knees

flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, and

then it should be massaged gently until firm.

Test-Taking Strategy: Use the process of elimination to assist in answering the question.

Note the strategic words “initial nursing action” in the question. Attempt to visualize the

procedure when answering the question; this should easily direct you to the correct

option. If you had difficulty with this question, review fundal assessment in the

postpartum period.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is preparing to care for a client in the immediate postpartum period who has

just delivered a healthy newborn. The nurse plans to take the client’s vital signs every:

1. 2. Hour for the first 2 hours and then every 4 hours

15 minutes during the first hour and then every 30 minutes for the next

2 hours

3. 4. 30 minutes during the first hour and then every hour for the next 2 hours

5 minutes for the first 30 minutes and then every hour for the next 4 hours

ANS: 2

Rationale: During the immediate postpartum period, vital signs are taken every

15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every

hour for the next 2 to 6 hours. Vital signs are monitored thereafter every 4 hours for 24

hours and every 8 to 12 hours for the remainder of the hospital stay.

Test-Taking Strategy: Use the process of elimination to answer this question, noting that

the nurse is caring for the client in the immediate postpartum period. Read each option

carefully. It is not necessary to take vital signs every 5 minutes unless an alteration in

physiological integrity has occurred during the labor period. Taking the client’s vital signs

every “hour for the first 2 hours and then every 4 hours” or every “5 minutes for the first

30 minutes and then every hour for the next 4 hours” can be eliminated next because the

time frames are not frequent enough to monitor the immediate postpartum status. If you

had difficulty with this question, review postpartum assessment.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is providing nutritional counseling to a new client who is breast-feeding her

newborn. The nurse instructs the client that her calorie needs need to increase by

approximately how many calories a day?

1. 100

2. 300

3. 500

4. 1000

ANS: 3

Rationale: If the client is breast-feeding, her calorie needs increase by approximately 500

cal/day. The client should also be instructed regarding the need for increased fluids and

the need for prenatal vitamins and iron supplements.

Test-Taking Strategy: Remember that calorie needs in the breast-feeding client increase

by 500 cal/day. If you are unfamiliar with the nutritional needs in the breast-feeding

client, review this content.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Implementation

The postpartum client asks the nurse about the occurrence of afterpains. The nurse

informs the client that afterpains will be especially noticeable:

1. When ambulating

2. During breast-feeding

3. While taking sitz baths

4. When the client arrives home and activities are increased

ANS: 2

Rationale: Afterpains are a normal occurrence and result from contractions of the uterus

as it reduces in size during involution. Afterpains may be especially noticeable during

breast-feeding because oxytocin is released in response to the infant’s sucking. The other

options are incorrect.

Test-Taking Strategy: Note that the subject of the question relates to afterpains and their

occurrence. Eliminate the options “when ambulating” and “when the client arrives home

and activities are increased” because they are comparable or alike. For the remaining

options, recalling the action of oxytocin and that oxytocin is released in breast-feeding

will assist in directing you to the correct option. If you had difficulty with this question,

review the physiology associated with afterpains.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Implementation

The nursing instructor is reviewing the plan of care with a student regarding care of a

postpartum client. The instructor asks the nursing student about the taking-in phase

according to Rubin’s phases of regeneration. The student is asked about client behaviors

that are most likely to occur during this phase. Which of the following responses, made

by the student, indicates an understanding of this phase?

1. “The client would be independent.”

2. “The client initiates activities on her own.”

3. “The client participates in mothering tasks.”

4. “The client is self-focused and talks to others about labor.”

ANS: 4

Rationale: Rubin has identified three phases of regeneration during the postpartum

period. The taking-in phase occurs in the first 3 days postpartum, and the taking-hold

phase occurs between days 3 to 10. During the taking-in phase, the new client is

attempting to integrate her labor and birth experience. She tends to need sleep and feels

fatigued, talks about labor, and is self-focused and dependent. In the taking-hold phase,

the client is more active, independent, initiates activities, and partakes in mothering tasks.

In the letting-go phase, the mother may grieve over the separation of the baby from part

of her body.

Test-Taking Strategy: Knowledge regarding Rubin’s stages of regeneration during

puerperium and the characteristics that occur in each of the phases is required to answer

the question. Note that the subject of the question focuses on the taking-in phase. This

will assist in directing you to the correct option. If you had difficulty with this question,

review these phases of regeneration.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Psychosocial Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Teaching and Learning

The nurse is assisting a new client with learning how to care for her newborn. The nurse

notes that the client is very fearful and reluctant to handle the newborn and notes that this

is the client’s first child. Which of the following nursing interventions will least likely

assist in promoting mother-infant interaction and bonding?

1. Accepting the client’s feelings

2. Acknowledging the client’s apprehension

3. Leaving the infant with the client so that she will be required to provide the care

4. Assisting the client with giving the baths to allow her to become more at ease

ANS: 3

Rationale: A client with no experience of handling infants may be fearful and reluctant to

handle her newborn or to take on physical care on her own. Acceptance of her feelings

and acknowledgment of the apprehension can help an unsure client begin to participate in

caring for her newborn. Assistance will help the client become more at ease. Leaving the

infant with the client so that she will be required to provide the care will produce

additional apprehension.

Test-Taking Strategy: Note the strategic words “least likely” in the question. Read each

option carefully, noting that the option “leaving the infant with the client so that she will

be required to provide the care” is the only one that will promote more fear and anxiety in

the woman. Review promotion of mother-infant interaction and bonding if you had

difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Psychosocial Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The

nurse will plan to instruct the client to:

1. 2. 3. 4. Apply a heating pad to breasts for comfort.

Wear a breast shield to correct nipple inversion.

Wear a supportive brassiere continuously for 72 hours.

Use the manual breast pump provided to express milk.

ANS: 3

Rationale: Wearing a supportive brassiere continuously for 72 hours postpartum will

minimize breast engorgement. Any stimulation of the breasts (expression of milk, infant

sucking) or increase in circulation (heating pad) will increase milk production or cause

the blood vessels and lymphatics to engorge. Correction of nipple inversion will not be

necessary if the mother chooses not to breast-feed her infant.

Test-Taking Strategy: Note the strategic words “formula-feed.” Knowledge of the

lactation process will allow you to eliminate the options “apply a heating pad to breasts

for comfort” and “use the manual breast pump provided to express milk” because these

actions are breast stimulants. The correction of nipple inversion is not necessary if the

client is formula-feeding her infant. Review instructions for the client who is formula-

feeding if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Teaching and Learning

The postpartum client who had a vaginal delivery of a healthy newborn has a prescription

for a sitz bath. The nurse who is assisting the client tells the client that the sitz bath will:

1. Numb the tissue.

2. Stimulate a bowel movement.

3. Reduce the edema and swelling.

4. Promote healing and provide comfort.

ANS: 4

Rationale: Warm, moist heat is used after the first 24 hours following tissue trauma from

a vaginal birth to provide comfort, promote healing, and reduce the incidence of

infection. This is done with a sitz bath. Ice is used in the first 24 hours to reduce edema

and to numb the tissue. Promoting a bowel movement is best achieved by ambulation.

Test-Taking Strategy: Focus on the subject of the question, the purpose for a sitz bath.

Use the process of elimination to assist in directing you to the correct option. If you had

difficulty with this question, review the purpose of a sitz bath following vaginal delivery.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse is monitoring a new client in the fourth stage of labor for signs of hemorrhage.

Which of the following signs, if noted in the mother, would indicate an early sign of

excessive blood loss?

1. 2. 3. 4. A temperature of 100.4º F

An increased pulse rate of 88 to 102 beats/min

A blood pressure change from 130/88 to 124/80 mm Hg

An increase in the respiratory rate from 18 to 22 breaths/min

ANS: 2

Rationale: During the fourth stage of labor, the maternal blood pressure, pulse, and

respiration should be checked every 15 minutes during the first hour. A rising pulse is an

early sign of excessive blood loss, because the heart pumps faster to compensate for

reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a

decreased blood pressure would not be the earliest sign of hemorrhage.

Test-Taking Strategy: Use the process of elimination to answer this question, noting the

strategic word “early” in the question. Think about the physiological occurrences of

shock and the expected findings in the postpartum period. This should assist in directing

you to the correct option. Review signs of early hemorrhage if you had difficulty with

this question.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is providing instructions to the client who has been diagnosed with mastitis.

Which of the following statements, if made by the client, indicates a need for further

education?

1. 2. 3. 4. “I need to wear a supportive bra to relieve the discomfort.”

“I need to stop breast-feeding until this condition resolves.”

“I can use analgesics to assist in alleviating some of the discomfort.”

“I need to take antibiotics, and I should begin to feel better in 24 to 48 hours.”

ANS: 2

Rationale: In most cases, the client can continue to breast-feed with both breasts. If the

affected breast is too sore, the client can pump the breast gently. Regular emptying of the

breast is important in order to prevent abscess formation. Antibiotic therapy assists in

resolving the mastitis within 24 to 48 hours. Additional supportive measures include ice

packs, breast supports, and analgesics.

Test-Taking Strategy: Note the strategic words “need for further education.” These words

indicate a negative event query and the need to select the incorrect client statement. Think

about the pathophysiology associated with mastitis to assist in answering the question.

This knowledge will assist in eliminating the options “I need to wear a supportive bra to

relieve the discomfort,” “I can use analgesics to assist in alleviating some of the

discomfort,” and “I need to take antibiotics, and I should begin to feel better in 24 to 48

hours.” Review measures for the client with mastitis if you had difficulty with this

question.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Teaching and Learning

The nurse is collecting data on clients who are in their first trimester of pregnancy. The

nurse is concerned with identifying clients who may be at risk for the development of

postpartum complications. Which of the following clients would be least likely at risk for

the development of thrombophlebitis in the postpartum period?

1. A 35-year-old client who reports that she smokes

2. A 26-year-old client with a family history of thrombophlebitis

3. A 37-year-old client in her fourth pregnancy who is overweight

4. A 22-year-old client in her first pregnancy who states that oral contraceptives

taken in the past have caused thrombophlebitis

ANS: 2

Rationale: Certain factors create a risk for the development of thrombophlebitis. These

factors include smoking; varicose veins; obesity; a history of thrombophlebitis; women

who are older than 35 years or have had more than three pregnancies; and women who

have had a cesarean birth. The client described in the correct option is least likely at risk

for the development of a thromboembolic disorder because this client has a family history

rather than a personal history of thrombophlebitis.

Test-Taking Strategy: Note the strategic words “least likely” in the question. Use the

process of elimination and knowledge regarding the pathophysiology and risks associated

with thrombophlebitis to assist in answering the question. Noting the strategic words

“family history” in the correct option will direct you to this option. If you had difficulty

with this question, review the predisposing factors and risks associated with

thrombophlebitis.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is monitoring the client for signs of postpartum depression. Which of the

following, if noted in the client, would indicate the need for further assessment related to

this form of depression?

1. 2. 3. 4. The client demonstrates an interest in the surroundings.

The client is caring for the infant in a loving manner.

The client constantly complains of tiredness and fatigue.

The client looks forward to visits from the father of the newborn.

ANS: 3

Rationale: Postpartum depression is not the normal depression that many new mothers

experience from time to time. The client experiencing depression shows less interest in

her surroundings and a loss of her usual emotional response toward the family. The client

also is unable to show pleasure or love and may have intense feelings of unworthiness,

guilt, and shame. The client often expresses a sense of loss of self. Generalized fatigue,

complaints of ill health, and difficulty in concentrating also are present. The client would

have little interest in food and experience sleep disturbances.

Test-Taking Strategy: Focus on the subject of the question to assist in answering. Note

the strategic words “need for further assessment.” Use the process of elimination, noting

that the incorrect options identify positive maternal behaviors. If you had difficulty with

this question, review the clinical manifestations of postpartum depression.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Psychosocial Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse caring for a client with a diagnosis of subinvolution understands that which of

the following is a primary cause of this diagnosis?

1. Afterpains

2. Retained placental fragments from delivery

3. Increased progesterone levels

4. Increased estrogen levels

ANS: 2

Rationale: Retained placental fragments and infections are the primary causes of

subinvolution. When either of these processes is present, the uterus has difficulty

contracting. The presence of afterpains is an expected finding following delivery. The

options “increased progesterone levels” and “increased estrogen levels” are not causes of

subinvolution.

Test-Taking Strategy: Use the process of elimination. Focusing on the pathophysiology

of subinvolution will direct you to the correct option. If you had difficulty with this

question, review the causes of subinvolution.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse has determined that a postpartum client has physical findings consistent with

uterine atony. The nurse plans to take which action first?

1. 2. 3. 4. Massage the uterus until firm.

Take the client’s blood pressure.

Ask the client about the presence of pain.

Recheck the amount of drainage on the peripad.

ANS: 1

Rationale: When uterine atony occurs, the first nursing action would be to massage the

uterus until firm. If this does not assist in controlling blood loss, then the physician is

notified. Additionally, once bleeding is under control, the nurse would monitor the vital

signs and estimate the amount of blood loss.

Test-Taking Strategy: Knowledge regarding the initial nursing intervention when uterine

atony occurs is required to answer this question. Note the strategic word “first” in the

question. Also, focusing on the word “atony” will assist in directing you to the correct

option. If you had difficulty with this question, review nursing interventions related to

uterine atony.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Implementation

When participating in the planning of care of a postpartum client who plans to breast-feed

her infant, the nurse realizes the importance of including which of the following in the

teaching plan to prevent the development of mastitis?

1. 2. 3. 4. Offer only one breast at each feeding.

Massage distended areas as the infant nurses.

Cleanse nipples with a mild antibacterial soap before and after infant feedings.

Express and discard milk from the affected breast at the first signs of mastitis.

ANS: 2

Rationale: Massaging the distended areas as the infant nurses will encourage complete

emptying of the breast and prevent milk stasis. Soap should not be used on the nipples

because of the risk of drying or cracking. Each breast should be offered at each feeding to

prevent milk stasis and to ensure adequate milk supply. If early signs of mastitis occur,

the client usually will be instructed to nurse the infant more frequently, because infant

sucking is thought to empty the breast more completely.

Test-Taking Strategy: Note the strategic words “breast-feed” and “importance.” Also

think about the pathophysiology associated with mastitis and use knowledge regarding

the prevention of mastitis to direct you to the correct option. Review the early signs of

mastitis if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Planning

The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs

the procedure and notes that the heart rate is normal if which of the following is noted?

1. 2. 3. 4. A heart rate of 100 beats/min

A heart rate of 140 beats/min

A heart rate of 180 beats/min

A heart rate of 190 beats/min

ANS: 2

Rationale: The normal heart rate in a newborn is 120 to 160 beats/min. The other options

are incorrect.

Test-Taking Strategy: Use the process of elimination. Remember the normal heart rate

for a newborn is 120 to 160 beats/min. If you are unfamiliar with this normal finding,

review this content.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is preparing to check the respirations of a newborn who was just delivered. The

nurse performs the procedure and determines that the respiratory rate is normal if which

of the following is noted?

1. 2. 3. 4. A respiratory rate of 20 breaths/min

A respiratory rate of 40 breaths/min

A respiratory rate of 70 breaths/min

A respiratory rate of 80 breaths/min

ANS: 2

Rationale: Normal respiratory rate varies from 30 to 60 breaths/min when the infant is

not crying. Respirations should be counted for 1 full minute to ensure an accurate

measurement because the newborn is a periodic breather. Observing and palpating

respirations while the infant is quiet promote accurate data collection.

Test-Taking Strategy: Use the process of elimination. Remember that the normal

respiration rate in a newborn infant is 30 to 60 breaths/min. If you had difficulty with this

question, review the normal vital signs in a newborn.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is performing an assessment on a neonate. The nurse is preparing to measure

the head circumference of the neonate. The nurse would:

1. Wrap the paper tape around the newborn’s head, and measure just above the

eyebrows.

2. Place the paper tape under the newborn’s head, wrap around the occiput, and

measure just above the eyes.

3. Place the paper tape at the back of the head, wrap across the ears, and measure

across the newborn’s mouth.

4. Place the paper tape under the newborn’s head at the base of the skull, and wrap

around to the front, just above the eyes.

ANS: 2

Rationale: To measure head circumference, the nurse should place the paper tape under

the newborn’s head and wrap the tape around the newborn’s head, measuring just above

the eyebrows so that the largest area of the occiput is included.

Test-Taking Strategy: Use the process of elimination. Visualizing each of the descriptions

in the options will direct you to the correct option. If you had difficulty with this

question, review measuring head circumference in a newborn.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is checking the reflexes of a neonate. In eliciting the Moro reflex, the nurse

would do which of the following?

1. 2. 3. 4. Stimulate the perioral cavity with a finger.

Clap hands, or slap the mattress.

Stimulate the ball of the infant’s foot with firm pressure.

Stimulate the pads of the infant’s hands with firm pressure.

ANS: 2

Rationale: The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on

the mattress. The neonate should respond (in sequence) with extension and abduction of

the limbs, followed by flexion and abduction of the limbs and then by flexion and

adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is

elicited by stimulating the perioral area with the finger. The palmar grasp reflex is elicited

by stimulating the palm of the hand with firm pressure, and the plantar grasp reflex is

elicited by stimulating the ball of the foot with firm pressure.

Test-Taking Strategy: Use the process of elimination to assist in answering the question.

The options “stimulate the ball of the infant’s foot with firm pressure” and “stimulate the

pads of the infant’s hands with firm pressure” are comparable or alike and should be

eliminated first. Focusing on the subject of the question, Moro reflex, and thinking about

the procedure for testing this reflex will assist in directing you to the correct option.

Review assessment of neonatal reflexes if you had difficulty with this question.

PTS: 1

DIF: REF: Level of Cognitive Ability: Applying

McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is planning to administer an injection of vitamin K to a newborn. In preparing

to administer the injection, the nurse would select which of the following injection sites?

1. The gluteal muscle

2. 3. 4. The lower aspect of the rectus femoris muscle

The medial aspect of the upper third of the vastus lateralis muscle

The lateral aspect of the middle third of the vastus lateralis muscle

ANS: 4

Rationale: The preferred injection site for vitamin K in the newborn is the lateral aspect

of the middle third of the vastus lateralis muscle in the newborn’s thigh. This is the

preferred injection site because it is free of major blood vessels and nerves and is large

enough to absorb the medication.

Test-Taking Strategy: Remember that the preferred injection site for a newborn is the

middle third of the vastus lateralis muscle. If you had difficulty with this question, review

the procedure for administering vitamin K in the newborn.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Planning

The nurse is preparing to assist in administering neonatal resuscitation with a ventilation

bag and mask because the newborn is apneic, is gasping, and has a heart rate below 100

beats/min. The nurse understands that the number of ventilations per minute that will be

delivered to this neonate is _____ breaths/min.

1. 20 to 40

2. 40 to 60

3. 70 to 80

4. 80 to 100

ANS: 2

Rationale: If the infant is apneic or has gasping respirations after stimulation, or the heart

rate is below 100 beats/min, positive pressure ventilation by bag and mask can be given.

The anesthesia bag used for neonatal resuscitation should have a pressure gauge.

Ventilations should be given at a rate of 40 to 60 breaths/min at pressures of 15 to 20 cm

H2O.

Test-Taking Strategy: Focus on the subject, administering neonatal resuscitation.

Remember that the normal respiratory ventilation breaths delivered to a neonate who is

apneic or gasping is 40 to 60 breaths/min. Also remembering that the normal respiratory

rate varies from 30 to 60 breaths/min when the infant is not crying will assist in

answering correctly. If you had difficulty with this question, review the technique for

resuscitating a newborn.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse is performing an initial assessment on a newborn. On assessment of the

newborn’s head, the nurse notes that the ears are low-set. Which of the following nursing

actions would be most appropriate initially?

1. Notify the physician.

2. Document the findings.

3. Arrange for hearing testing.

4. Cover the ears with gauze pads.

ANS: 1

Rationale: Low or oddly placed ears are associated with a variety of congenital defects

and should be reported immediately. Although the findings would be documented, the

most appropriate action would be to notify the physician. The options “arrange for

hearing testing” and “cover the ears with gauze pads” are inaccurate and inappropriate

nursing actions. “Document the findings” is not an initial action.

Test-Taking Strategy: Knowledge regarding the normal assessment findings in a newborn

is required to answer this question. Recalling that low-set ears are an abnormal finding

will easily direct you to the correct option. Review normal assessment findings in a

newborn if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Implementation

The nurse has provided instructions to a client on how to bathe her newborn. The nurse

demonstrates the procedure to the client and on the following day asks the client to

perform the procedure. Which of the following observations, if made by the nurse,

indicates that the client is performing the procedure correctly?

1. The client cleans the newborn’s ears and then moves to the eyes and the face.

2. The client begins to wash the newborn by starting with the eyes and face.

3. The client washes the arms, chest, and back, followed by the neck, arms, and

face.

4. The client washes the entire newborn’s body and then washes the eyes, face, and

scalp.

ANS: 2

Rationale: Bathing should start at the eyes and face and with the cleanest area first. Next,

the external ears and behind the ears are cleaned. The newborn’s neck should be washed

because formula, lint, or breast milk will often accumulate in the folds. Hands and arms

are next, then the legs, with the diaper area washed last.

Test-Taking Strategy: Remember the basic techniques of bathing a client to assist in

answering this question. Always start with the cleanest area of the body first and proceed

to the dirtiest area. Use techniques related to washing an adult to assist in answering this

question. If you had difficulty with this question, review home care measures related to

the care of the newborn.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Evaluation

The nurse is providing instructions to the client regarding cord care. Which of the

following statements, if made by the client, indicates a need for further education?

1. 2. 3. 4. “Alcohol may be used if prescribed to clean the cord.”

“The cord will fall off in 1 to 2 weeks.”

“I should clean the cord two or three times a day.”

“I need to fold the diaper above the cord to prevent infection.”

ANS: 4

Rationale: The cord should be kept clean and dry to decrease bacterial growth. The

diaper should be folded below the cord to keep urine away from the cord. The cord

should be cleaned two or three times a day using alcohol or other prescribed solution.

Cord care is required until the cord dries up and falls off, usually between 7 and 14 days

postpartum.

Test-Taking Strategy: Use the process of elimination to answer this question. Read each

option carefully, and visualize the descriptions in each of the options. Also, note the

strategic words “need for further education” in the question; these words indicate a

negative event query and the need to select the incorrect client statement. Knowing that

the option “I need to fold the diaper above the cord to prevent infection.” suggests folding

the diaper above the cord should assist in directing you to this option, because the cord

can become saturated and contaminated with urine this way. Review concepts related to

cord care if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Teaching and Learning

The nurse is providing instructions to the client of a breast-fed newborn who has

hyperbilirubinemia. Which of the following instructions does the nurse provide to the

client?

1. Increase the frequency of the breast-feeding.

2. Stop the breast-feedings, and switch to bottle-feeding permanently.

3. Provide bottled water feedings between the breast-feeding sessions.

4. Switch to bottle-feeding the baby during the period of high bilirubin levels, and

feed less frequently.

ANS: 1

Rationale: Breast-feeding should be initiated within 2 hours after birth and every 2 to 3

hours thereafter. Supplementation with water does not reduce hyperbilirubinemia and

should be discouraged because supplemental feedings with water do not promote stool

excretion. The infant should not be fed less frequently. It is not necessary to stop breast-

feeding permanently.

Test-Taking Strategy: Use the process of elimination to assist in answering the question.

Note that the options “stop the breast-feedings, and switch to bottle-feeding

permanently,” “provide bottled water feedings between the breast-feeding sessions,” and

“switch to bottle-feeding the baby during the period of high bilirubin levels, and feed less

frequently” are comparable or alike. These options discourage the continuation of breast-

feeding. Review client instructions related to hyperbilirubinemia in the newborn if you

had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Teaching and Learning

The nurse is monitoring a newborn that was born to a client who abuses alcohol. Which

of the following findings would the nurse expect to note when assessing this newborn?

1. Lethargy

2. Irritability

3. Higher than normal birth weight

4. A greater than normal appetite when feeding

ANS: 2

Rationale: Characteristic behaviors of the fetal alcohol syndrome (FAS) newborn are

similar to the behaviors common to the drug-exposed newborn. These behaviors include

irritability, tremors, poor feeding, and hypersensitivity to stimuli. Newborns with FAS are

smaller at birth and present with failure to thrive. Head circumference and weight are

most affected.

Test-Taking Strategy: Knowledge regarding the clinical manifestations of the newborn of

a client who abuses alcohol is required to answer this question. Remember that irritability

is characteristic of an FAS newborn. If you had difficulty with this question, review the

characteristics of the newborn with FAS.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS).

Which of the following findings, if noted in the newborn, would alert the nurse to the

possibility of this syndrome?

1. Hypotension and bradycardia

2. Tachypnea and retractions

3. Acrocyanosis and grunting

4. The presence of a barrel chest, with acrocyanosis

ANS: 2

Rationale: The neonate with RDS may present with clinical signs of cyanosis; tachypnea

or apnea; nasal flaring; chest wall retractions; or audible expiratory grunts. Acrocyanosis

is the bluish discoloration of the hands and feet and is not uncommon in the first few

hours of life. The options “hypotension and bradycardia,” “acrocyanosis and grunting,”

and “the presence of a barrel chest, with acrocyanosis” do not indicate clinical signs of

respiratory distress syndrome.

Test-Taking Strategy: Use the process of elimination to answer this question. Recalling

that acrocyanosis is a normal sign in a newborn will assist in eliminating the options

“acrocyanosis and grunting” and “the presence of a barrel chest, with acrocyanosis”. For

the remaining options, it is necessary to be familiar with the signs of RDS. Also, note the

relationship between the diagnosis and signs noted in the correct option. If you had

difficulty with this question, review the signs of respiratory distress syndrome.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is checking a newborn’s 1-minute Apgar score based on the following

assessment. The heart rate is 160 beats/min; he has positive respiratory effort with a

vigorous cry; his muscle tone is active and well-flexed; he has a strong gag reflex and

cries with stimulus to the soles of his feet; his body is pink, with his hands and feet

cyanotic. What is the newborn’s 1-minute Apgar score?

1. 7

2. 9

3. 8

4. 10

ANS: 2

Rationale: The newborn has a score of 9 because his heart rate, respiratory effort, muscle

tone, and reflex irritability all have a score of 2, with color having a score of 1 because of

the acrocyanosis.

Test-Taking Strategy: Focus on the subject, a 1-minute Apgar score. Recalling the

procedure for determining the Apgar score will direct you to the correct option. Review

this scoring procedure if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The clinic nurse is instructing a pregnant client in her first trimester about nutrition. The

nurse would correct which of the following misunderstandings on the part of the client

about nutrition during pregnancy?

1. 2. 3. 4. Iron supplements should be taken throughout pregnancy.

Pregnancy greatly increases the risk of malnourishment for the mother.

Calcium intake should be increased for the duration of the pregnancy.

The maternal diet significantly influences fetal growth and development.

ANS: 2

Rationale: Although pregnancy poses some nutritional risk for the mother, the client is

not at risk of becoming malnourished. Calcium is critical during the third trimester but

must be increased from the onset of pregnancy. Intake of dietary iron is usually

insufficient for most pregnant women, and iron supplements are routinely encouraged.

Good nutrition during pregnancy significantly and positively influences fetal growth and

development.

Test-Taking Strategy: Focus on the subject, the client’s misunderstanding about nutrition.

Remember that although pregnancy poses some nutritional risk for the mother, the client

is not at risk of becoming malnourished. If you had difficulty with this question, review

the principles of nutrition during pregnancy.

PTS: 1

DIF: Level of Cognitive Ability: Evaluating

REF: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed.). St.

Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Teaching and Learning

MULTIPLE RESPONSE

A vaginal examination of a client in labor would specifically determine which of the

following? Select all that apply.

1. Effacement

2. Dilation

3. Station

4. Bloody show

5. Contraction effort

ANS: 1, 2, 3

Rationale: The vaginal examination for a client in labor specifically determines

effacement 0 to 100%, dilation 0 to 10 cm, and station -5 cm (above the maternal ischial

spine) to + 5 cm (below the maternal ischial spine). Bloody show is the brownish or

blood-tinged cervical mucus that may be passed preceding labor and is not a specific part

of the assessment when performing a vaginal examination. Contraction effort is not

determined by vaginal examination.

Test-Taking Skills: Knowledge of the vaginal exam and what the nurse will be checking

when she performs this assessment is vital to answer this question. Noting the strategic

word specifically will direct you to the correct options. If you had difficulty with this

question, review the findings of a vaginal examination.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Intrapartum

MSC: Integrated Process: Nursing Process—Assessment

Which of the following are modes of heat loss in the newborn? Select all that apply.

1. Convection

2. Radiation

3. Conduction

4. Urination

5. Evaporation

ANS: 1, 2, 3, 5

Rationale: The newborn can lose heat through convection, radiation, conduction, and

evaporation. Heat is not lost through urination.

Test-Taking Strategy: Focus on the subject, the modes of heat loss in a newborn. This

knowledge will direct you to the correct options. If you had difficulty with this question,

review these methods of heat loss.

PTS: 1

DIF: Level of Cognitive Ability: Understanding

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse is collecting data from a pregnant client in the second trimester of pregnancy

who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae.

Which of the following findings are associated with abruptio placentae? Select all that

apply.

1. Acute abdominal pain

2. A hard, “board-like” abdomen

3. Painless, bright red vaginal bleeding

4. Increased uterine resting tone on fetal monitoring

5. Uterine tenderness

ANS: 1, 2, 4, 5

Rationale: Painless, bright red vaginal bleeding in the second or third trimester of

pregnancy is a sign of placenta previa. In abruptio placentae, acute abdominal pain is

present. Uterine tenderness accompanies placental abruption, especially with a central

abruption and trapped blood behind the placenta. The abdomen will feel hard and board-

like on palpation as the blood penetrates the myometrium and causes uterine irritability.

Observation of the fetal monitoring often reveals increased uterine resting tone, caused

by placental abruption.

Test-Taking Strategy: Focus on the subject, the signs of abruptio placentae. Remember

that the difference between placenta previa and abruptio placentae involves uterine pain

and tenderness with an abruption as opposed to painless bleeding with a previa. “Acute

abdominal pain,” “a hard, “board-like” abdomen,” “increased uterine resting tone on fetal

monitoring,” and “uterine tenderness” all describe the presence of abruptio placentae,

whereas “painless, bright red vaginal bleeding” is the only option that describes placenta

previa. Review the signs of abruptio placentae if you had difficulty with this question.

PTS: 1

DIF: Level of Cognitive Ability: Analyzing

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Antepartum

MSC: Integrated Process: Nursing Process—Assessment

The nurse provides which instructions to the client following delivery regarding care of

the episiotomy site to prevent infection? Select all that apply.

1. 2. 3. 4. Change the perineum pads three times a day.

Take a warm sitz baths three times a day.

Wipe the perineum from front to back after voiding and defecation.

Use warm water to rinse the perineum after elimination.

5. Report a foul-smelling discharge.

ANS: 2, 3, 4, 5

Rationale: Warm sitz baths and cleansing with warm water are helpful for relieving pain,

and these measures will promote cleanliness in the perineal area to prevent infection. The

client should also be instructed to wipe the perineum from front to back after voiding and

defecation to decrease the risk for contamination with microorganisms from the anus to

the vagina. Warm water should be used to rinse the perineum after elimination. The client

also should be instructed that the perineal pad should be changed after each elimination

and may be changed in between.

Test-Taking Strategy: Use the process of elimination. Think about each option in terms

of infection as you use the process of elimination. Recalling that the perineal pad should

be changed after each elimination will assist in eliminating “change the perineum pads

three times a day.” Review client instructions for care to the episiotomy site if you had

difficulty with the question.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Teaching and Learning

The nurse visits a client at home who delivered a healthy newborn 2 days ago. The client

is complaining of breast discomfort. The nurse notes that the client is experiencing breast

engorgement. The nurse provides which instructions to the client regarding relief of the

engorgement? Select all that apply.

1. Feed the infant at least every 2 hours for 15 to 20 minutes on each side.

2. Avoid breast-feeding during the time of breast engorgement.

3. Apply moist heat to both breasts for about 20 minutes before a feeding.

4. Massage the breasts gently during a feeding, from the outer areas to the nipples.

5. Wear a supportive bra between feedings.

ANS: 1, 3, 4, 5

Rationale: During breast engorgement, the client should be advised to feed the infant

frequently, at least every 2 hours, for 15 to 20 minutes on each side. The infant will have

an easier time latching on if the client softens her breast and expresses her milk before a

feeding. Instruct the client to apply moist heat to both breasts for about 20 minutes before

a feeding. This can be done in the shower or with warm wet towels. During a feeding, it

is helpful to massage the breast gently from the outer area to the nipple. This helps

stimulate the let-down and flow of milk. The client also should be instructed to wear a

supportive bra between feedings.

Test-Taking Strategy: Read each option carefully. Think about the pathophysiology

associated with breast engorgement to determine the measures that will relieve the

discomfort. If you had difficulty with this question, review the measures for breast

engorgement.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal child

nursing care (4th ed.). St. Louis: Mosby.

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Teaching and Learning

On the second postpartum day, a client complains of burning, urgency, and frequency of

urination. A urinalysis is obtained, and the results indicate the presence of a urinary tract

infection. The nurse instructs the client regarding which measures to take for the

prevention and treatment of the infection? Select all that apply.

1. Urinate frequently throughout the day.

2. Fluid intake should be increased to at least 3000 mL/day.

3. Prescribed medication must be taken until it is completed.

4. Foods and fluids that will increase urine alkalinity should be consumed.

5. Wipe the perineal area from front to back after urinating.

ANS: 1, 2, 3, 5

Rationale: The woman with a urinary tract infection must be encouraged to take the

medication for the entire time it is prescribed. The woman also should be instructed to

drink at least 3000 mL of fluid each day to flush the infection from the bladder and to

urinate frequently throughout the day. Foods and fluids that acidify the urine need to be

encouraged. The client is also taught to wipe the perineal area from front to back after

urinating or having a bowel movement.

Test-Taking Strategy: Knowledge regarding the treatment measures for urinary tract

infection is required to answer this question. Use the process of elimination, recalling that

foods and fluids that acidify the urine should be consumed, rather than foods and fluids

that cause urine alkalinity. If you had difficulty with this question, review with the

measures to prevent and treat a urinary tract infection.

PTS: 1

DIF: Level of Cognitive Ability: Applying

REF: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing

(3rd ed.). St. Louis: Saunders.

OBJ: Client Needs: Physiological Integrity

TOP: Content Area: Maternity/Postpartum

MSC: Integrated Process: Teaching and Learning

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