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Maternal Nursing

100 Questions
Maternal Nursing

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Questions and Answers
  • 1. 
    Which of the following describes the Babinski reflex?
    • A. 

      The newborn’s toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot.

    • B. 

      The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise.

    • C. 

      The newborn turns the head in the direction of stimulus, opens the mouth, and begins to suck when cheek, lip, or corner of mouth is touched.

    • D. 

      The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface

  • 2. 
    When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following?
    • A. 

      Thrombophlebitis

    • B. 

      Pregnancy-induced hypertension

    • C. 

      Pressure on blood vessels from the enlarging uterus

    • D. 

      The force of gravity pulling down on the uterus

  • 3. 
    FHR can be auscultated with a fetoscope as early as which of the following?
    • A. 

      5 weeks gestation

    • B. 

      10 weeks gestation

    • C. 

      15 weeks gestation

    • D. 

      20 weeks gestation

  • 4. 
    Which of the following is the nurse’s initial action when umbilical cord prolapse occurs?
    • A. 

      Begin monitoring maternal vital signs and FHR

    • B. 

      Place the client in a knee-chest position in bed

    • C. 

      Notify the physician and prepare the client for delivery

    • D. 

      Apply a sterile warm saline dressing to the exposed cord

  • 5. 
    Which of the following danger signs should be reported promptly during the antepartum period?
    • A. 

      Constipation

    • B. 

      Breast tenderness

    • C. 

      Nasal stuffiness

    • D. 

      Leaking amniotic fluid

  • 6. 
    Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood?
    • A. 

      Blink, cough, rooting, and gag

    • B. 

      Blink, cough, sneeze, gag

    • C. 

      Rooting, sneeze, swallowing, and cough

    • D. 

      Stepping, blink, cough, and sneeze

  • 7. 
    A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, “We know several friends in our age group and all of them have their own child already, Why can’t we have one?”. Which of the following would be the most pertinent nursing diagnosis for this couple?
    • A. 

      Fear related to the unknown

    • B. 

      Pain related to numerous procedures.

    • C. 

      Ineffective family coping related to infertility.

    • D. 

      Self-esteem disturbance related to infertility.

  • 8. 
    Which of the following best describes thrombophlebitis?
    • A. 

      Inflammation and clot formation that result when blood components combine to form an aggregate body

    • B. 

      Inflammation and blood clots that eventually become lodged within the pulmonary blood vessels

    • C. 

      Inflammation and blood clots that eventually become lodged within the femoral vein

    • D. 

      Inflammation of the vascular endothelium with clot formation on the vessel wall

  • 9. 
    Which of the following best reflects the frequency of reported postpartum “blues”?
    • A. 

      Between 10% and 40% of all new mothers report some form of postpartum blues

    • B. 

      Between 30% and 50% of all new mothers report some form of postpartum blues

    • C. 

      Between 50% and 80% of all new mothers report some form of postpartum blues

    • D. 

      Between 25% and 70% of all new mothers report some form of postpartum blues

  • 10. 
    When uterine rupture occurs, which of the following would be the priority?
    • A. 

      Limiting hypovolemic shock

    • B. 

      Obtaining blood specimens

    • C. 

      Instituting complete bed rest

    • D. 

      Inserting a urinary catheter

  • 11. 
    When preparing a client for cesarean delivery, which of the following key concepts should be considered when implementing nursing care?
    • A. 

      Instruct the mother’s support person to remain in the family lounge until after the delivery

    • B. 

      Arrange for a staff member of the anesthesia department to explain what to expect postoperatively

    • C. 

      Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth

    • D. 

      Explain the surgery, expected outcome, and kind of anesthetics

  • 12. 
    Which of the following is the primary predisposing factor related to mastitis?
    • A. 

      Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts

    • B. 

      Endemic infection occurring randomly and localizing in the periglandular connective tissue

    • C. 

      Temporary urinary retention due to decreased perception of the urge to avoid

    • D. 

      Breast injury caused by overdistention, stasis, and cracking of the nipples

  • 13. 
    Which of the following would cause a false-positive result on a pregnancy test?
    • A. 

      The test was performed less than 10 days after an abortion

    • B. 

      The test was performed too early or too late in the pregnancy

    • C. 

      The urine sample was stored too long at room temperature

    • D. 

      A spontaneous abortion or a missed abortion is impending

  • 14. 
    Barbiturates are usually not given for pain relief during active labor for which of the following reasons?
    • A. 

      The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days.

    • B. 

      These drugs readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection.

    • C. 

      They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.

    • D. 

      Adverse reactions may include maternal hypotension, allergic or toxic reaction or partial or total respiratory failure

  • 15. 
    Which of the following would the nurse identify as a classic sign of PIH?
    • A. 

      Edema of the feet and ankles

    • B. 

      Edema of the hands and face

    • C. 

      Weight gain of 1 lb/week

    • D. 

      Early morning headache

  • 16. 
    Which of the following best describes preterm labor?
    • A. 

      Labor that begins after 20 weeks gestation and before 37 weeks gestation

    • B. 

      Labor that begins after 15 weeks gestation and before 37 weeks gestation

    • C. 

      Labor that begins after 24 weeks gestation and before 28 weeks gestation

    • D. 

      Labor that begins after 28 weeks gestation and before 40 weeks gestation

  • 17. 
    Which of the following factors is the underlying cause of dystocia?
    • A. 

      Nurtional

    • B. 

      Mechanical

    • C. 

      Environmental

    • D. 

      Medical

  • 18. 
    Which of the following are the most commonly assessed findings in cystitis?
    • A. 

      Frequency, urgency, dehydration, nausea, chills, and flank pain

    • B. 

      Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain

    • C. 

      Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever

    • D. 

      High fever, chills, flank pain nausea, vomiting, dysuria, and frequency

  • 19. 
    Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor?
    • A. 

      Weak contraction prolonged to more than 70 seconds

    • B. 

      Tetanic contractions prolonged to more than 90 seconds

    • C. 

      Increased pain with bright red vaginal bleeding

    • D. 

      Increased restlessness and anxiety

  • 20. 
    Which of the following factors would the nurse suspect as predisposing a client to placenta previa?
    • A. 

      Multiple gestation

    • B. 

      Uterine anomalies

    • C. 

      Abdominal trauma

    • D. 

      Renal or vascular disease

  • 21. 
    When assessing the newborn’s heart rate, which of the following ranges would be considered normal if the newborn were sleeping?
    • A. 

      80 beats per minute

    • B. 

      100 beats per minute

    • C. 

      120 beats per minute

    • D. 

      140 beats per minute

  • 22. 
    Before birth, which of the following structures connects the right and left auricles of the heart?
    • A. 

      Umbilical vein

    • B. 

      Foramen ovale

    • C. 

      Ductus arteriosus

    • D. 

      Ductus venosus

  • 23. 
    Cervical softening and uterine souffle are classified as which of the following?
    • A. 

      Diagnostic signs

    • B. 

      Presumptive signs

    • C. 

      Probable signs

    • D. 

      Positive signs

  • 24. 
    A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert?
    • A. 

      Endometritis

    • B. 

      Endometriosis

    • C. 

      Salpingitis

    • D. 

      Pelvic thrombophlebitis

  • 25. 
    A client at 36 weeks’ gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? 
    • A. 

      The ultrasound will help to locate the placenta

    • B. 

      The ultrasound identifies blood flow through the umbilical cord

    • C. 

      The test will determine where to insert the needle

    • D. 

      The ultrasound locates a pool of amniotic fluid

  • 26. 
    While the postpartum client is receiving herapin for thrombophlebitis, which of the following drugs would the nurse Mica expect to administer if the client develops complications related to heparin therapy?
    • A. 

      Calcium gluconate

    • B. 

      Protamine sulfate

    • C. 

      Methylegonovine (Methergine)

    • D. 

      Nitrofurantoin (macrodantin)

  • 27. 
    When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following?
    • A. 

      Turn the neonate every 6 hours

    • B. 

      Encourage the mother to discontinue breast-feeding

    • C. 

      Notify the physician if the skin becomes bronze in color

    • D. 

      Check the vital signs every 2 to 4 hours

  • 28. 
    A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective? 
    • A. 

      Back

    • B. 

      Abdomen

    • C. 

      Fundus

    • D. 

      Perineum

  • 29. 
    The nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: 
    • A. 

      “Nausea and vomiting can be decreased if I eat a few crackers before arising”

    • B. 

      “If I start to leak colostrum, I should cleanse my nipples with soap and water”

    • C. 

      “If I have a vaginal discharge, I should wear nylon underwear”

    • D. 

      “Leg cramps can be alleviated if I put an ice pack on the area”

  • 30. 
    Thirty hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartal psychological adaptation that the client would be in would be termed which of the following? 
    • A. 

      Taking in

    • B. 

      Letting go

    • C. 

      Taking hold

    • D. 

      Resolution

  • 31. 
    A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? 
    • A. 

      Activity limited to bed rest

    • B. 

      Platelet infusion

    • C. 

      Immediate cesarean delivery

    • D. 

      Labor induction with oxytocin

  • 32. 
    Nurse Julia plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? 
    • A. 

      Feeding the neonate a maximum of 5 minutes per side on the first day

    • B. 

      Wearing a supportive brassiere with nipple shields

    • C. 

      Breast-feeding the neonate at frequent intervals

    • D. 

      Decreasing fluid intake for the first 24 to 48 hours

  • 33. 
    When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes?
    • A. 

      Startle reflex

    • B. 

      Babinski reflex

    • C. 

      Grasping reflex

    • D. 

      Tonic neck reflex

  • 34. 
    A primigravida client at 25 weeks’ gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform: 
    • A. 

      Tailor sitting

    • B. 

      Leg lifting

    • C. 

      Shoulder circling

    • D. 

      Squatting exercises

  • 35. 
    Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision? 
    • A. 

      Notify the neonate’s pediatrician immediately

    • B. 

      Check the diaper and circumcision again in 30 minutes

    • C. 

      Secure the diaper tightly to apply pressure on the site

    • D. 

      Apply gently pressure to the site with a sterile gauze pad

  • 36. 
    Which of the following would the nurse Sandra most likely expect to find when assessing a pregnant client with abruption placenta? 
    • A. 

      Excessive vaginal bleeding

    • B. 

      Rigid, boardlike abdomen

    • C. 

      Titanic uterine contractions

    • D. 

      Premature rupture of membranes

  • 37. 
    While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse’s most appropriate action?
    • A. 

      Note the fetal heart rate patterns

    • B. 

      Notify the physician immediately

    • C. 

      Administer oxygen at 6 liters by mask

    • D. 

      Have the client pant-blow during the contractions

  • 38. 
    A client tells the nurse, “I think my baby likes to hear me talk to him.” When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response? 
    • A. 

      High-pitched speech with tonal variations

    • B. 

      Low-pitched speech with a sameness of tone

    • C. 

      Cooing sounds rather than words

    • D. 

      Repeated stimulation with loud sounds

  • 39. 
    A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in?
    • A. 

      Active phase

    • B. 

      Latent phase

    • C. 

      Expulsive phase

    • D. 

      Transitional phase

  • 40. 
    A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the nurse respond? 
    • A. 

      “Yes, it produces no adverse effect.”

    • B. 

      “No, it can initiate premature uterine contractions.”

    • C. 

      “No, it can promote sodium retention.”

    • D. 

      “No, it can lead to increased absorption of fat-soluble vitamins.”

  • 41. 
    A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several cloth. What is the primary nursing diagnosis for this patient? 
    • A. 

      Knowledge deficit

    • B. 

      Fluid volume deficit

    • C. 

      Anticipatory grieving

    • D. 

      Pain

  • 42. 
    Immediately after a delivery, the nurse-midwife assesses the neonate’s head for signs of molding. Which factors determine the type of molding? 
    • A. 

      Fetal body flexion or extension

    • B. 

      Maternal age, body frame, and weight

    • C. 

      Maternal and paternal ethnic backgrounds

    • D. 

      Maternal parity and gravidity

  • 43. 
    For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? 
    • A. 

      The membranes must rupture

    • B. 

      The fetus must be at 0 station

    • C. 

      The cervix must be dilated fully

    • D. 

      The patient must receive anesthesia

  • 44. 
    A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in early part of the first stage of labor. Her pain is likely to be most intense: 
    • A. 

      Around the pelvic girdle

    • B. 

      Around the pelvic girdle and in the upper arms

    • C. 

      Around the pelvic girdle and at the perineum

    • D. 

      At the perineum

  • 45. 
    A female adult patient is taking a progestin-only oral contraceptive, or minipill. Progestin use may increase the patient’s risk for: 
    • A. 

      Endometriosis

    • B. 

      Female hypogonadism

    • C. 

      Premenstrual syndrome

    • D. 

      Tubal or ectopic pregnancy

  • 46. 
    A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms? 
    • A. 

      Proteinuria, headaches, vaginal bleeding

    • B. 

      Headaches, double vision, vaginal bleeding

    • C. 

      Proteinuria, headaches, double vision

    • D. 

      Proteinuria, double vision, uterine contractions

  • 47. 
    Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient’s fluid intake and output closely during oxytocin administration? 
    • A. 

      Oxytoxin causes water intoxication

    • B. 

      Oxytocin causes excessive thirst

    • C. 

      Oxytoxin is toxic to the kidneys

    • D. 

      Oxytoxin has a diuretic effect

  • 48. 
    Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss? 
    • A. 

      Low room humidity

    • B. 

      Cold weight scale

    • C. 

      Cools incubator walls

    • D. 

      Cool room temperature

  • 49. 
    After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur? 
    • A. 

      Decreased peristalsis

    • B. 

      Increase heart rate

    • C. 

      Dry mucous membranes

    • D. 

      Nausea and Vomiting

  • 50. 
    The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage?
    • A. 

      Active phase

    • B. 

      Complete phase

    • C. 

      Latent phase

    • D. 

      Transitional phase

  • 51. 
    After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she: 
    • A. 

      Apply warm compresses to her nipples just before feedings

    • B. 

      Lubricate her nipples with expressed milk before feeding

    • C. 

      Dry her nipples with a soft towel after feedings

    • D. 

      Apply soap directly to her nipples, and then rinse

  • 52. 
    The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time? 
    • A. 

      Between 10 and 12 weeks’ gestation

    • B. 

      Between 16 and 20 weeks’ gestation

    • C. 

      Between 21 and 23 weeks’ gestation

    • D. 

      Between 24 and 26 weeks’ gestation

  • 53. 
    Normal lochial findings in the first 24 hours post-delivery include: 
    • A. 

      Bright red blood

    • B. 

      Large clots or tissue fragments

    • C. 

      A foul odor

    • D. 

      The complete absence of lochia

  • 54. 
    Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that she is in labor, and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first?
    • A. 

      “Do you have any chronic illness?”

    • B. 

      “Do you have any allergies?”

    • C. 

      “What is your expected due date?”

    • D. 

      “Who will be with you during labor?”

  • 55. 
    A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess her uterine contractions? 
    • A. 

      Every 5 minutes

    • B. 

      Every 15 minutes

    • C. 

      Every 30 minutes

    • D. 

      Every 60 minutes

  • 56. 
    A patient is in last trimester of pregnancy. Nurse Jane should instruct her to notify her primary health care provider immediately if she notices: 
    • A. 

      Blurred vision

    • B. 

      Hemorrhoids

    • C. 

      Increased vaginal mucus

    • D. 

      Shortness of breath on exertion

  • 57. 
    The nurse in charge is reviewing a patient’s prenatal history. Which finding indicates a genetic risk factor? 
    • A. 

      The patient is 25 years old

    • B. 

      The patient has a child with cystic fibrosis

    • C. 

      The patient was exposed to rubella at 36 weeks’ gestation

    • D. 

      The patient has a history of preterm labor at 32 weeks’ gestation

  • 58. 
    During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge should instruct the client to push the control button at which time? 
    • A. 

      At the beginning of each fetal movement

    • B. 

      At the beginning of each contraction

    • C. 

      After every three fetal movements

    • D. 

      At the end of fetal movement

  • 59. 
    When evaluating a client’s knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse in charge that the client understands the information given to her? 
    • A. 

      “I’ll report increased frequency of urination.”

    • B. 

      “If I have blurred or double vision, I should call the clinic immediately.”

    • C. 

      “If I feel tired after resting, I should report it immediately.”

    • D. 

      “Nausea should be reported immediately.”

  • 60. 
    A client makes a routine visit to the prenatal clinic. Although she’s 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy. Dr. Diaz diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal:
    • A. 

      An empty gestational sac.

    • B. 

      Grapelike clusters.

    • C. 

      A severely malformed fetus.

    • D. 

      An extrauterine pregnancy.

  • 61. 
    Which of the following would be inappropriate to assess in a mother who’s breast-feeding? 
    • A. 

      The attachment of the baby to the breast.

    • B. 

      The mother’s comfort level with positioning the baby.

    • C. 

      Audible swallowing.

    • D. 

      The baby’s lips smacking

  • 62. 
    During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done to identify fetal abnormalities. Between 18 and 40 weeks’ gestation, which procedure is used to detect fetal anomalies?
    • A. 

      Amniocentesis.

    • B. 

      Chorionic villi sampling.

    • C. 

      Fetoscopy

    • D. 

      Ultrasound

  • 63. 
    A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate? 
    • A. 

      The fetus should be delivered within 24 hours.

    • B. 

      The client should repeat the test in 24 hours.

    • C. 

      The fetus isn’t in distress at this time.

    • D. 

      The client should repeat the test in 1 week.

  • 64. 
    A client who’s 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the client’s preparation for parenting, the nurse might ask which question? 
    • A. 

      “Are you planning to have epidural anesthesia?”

    • B. 

      “Have you begun prenatal classes?”

    • C. 

      “What changes have you made at home to get ready for the baby?”

    • D. 

      “Can you tell me about the meals you typically eat each day?”

  • 65. 
    A client who’s admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks’ gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time? 
    • A. 

      Placing the client in bed to begin fetal monitoring.

    • B. 

      Preparing for immediate delivery.

    • C. 

      Checking for ruptured membranes.

    • D. 

      Providing comfort measures.

  • 66. 
    Nurse Roy is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?
    • A. 

      Change the client’s position.

    • B. 

      Prepare for emergency cesarean section.

    • C. 

      Check for placenta previa.

    • D. 

      Administer oxygen.

  • 67. 
    The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client? 
    • A. 

      Risk for deficient fluid volume related to hemorrhage

    • B. 

      Risk for infection related to the type of delivery

    • C. 

      Pain related to the type of incision

    • D. 

      Urinary retention related to periurethral edema

  • 68. 
    Which change would the nurse identify as a progressive physiological change in postpartum period? 
    • A. 

      Lactation

    • B. 

      Lochia

    • C. 

      Uterine involution

    • D. 

      Diuresis

  • 69. 
    A 39-year-old at 37 weeks’ gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client’s complaint of vaginal bleeding?
    • A. 

      Placenta previa

    • B. 

      Abruptio placentae

    • C. 

      Ectopic pregnancy

    • D. 

      Spontaneous abortion

  • 70. 
    A client with type 1 diabetes mellitus who’s a multigravida visits the clinic at 27 weeks gestation. The nurse should instruct the client that for most pregnant women with type 1 diabetes mellitus: 
    • A. 

      Weekly fetal movement counts are made by the mother.

    • B. 

      Contraction stress testing is performed weekly.

    • C. 

      Induction of labor is begun at 34 weeks’ gestation.

    • D. 

      Nonstress testing is performed weekly until 32 weeks’ gestation

  • 71. 
    When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to: 
    • A. 

      Prevent seizures

    • B. 

      Reduce blood pressure

    • C. 

      Slow the process of labor

    • D. 

      Increase dieresis

  • 72. 
    What’s the approximate time that the blastocyst spends traveling to the uterus for implantation? 
    • A. 

      2 days

    • B. 

      7 days

    • C. 

      10 days

    • D. 

      14 weeks

  • 73. 
    After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which of the following purposes stated by the client would indicate to the nurse that the teaching was effective? 
    • A. 

      Shortens the second stage of labor

    • B. 

      Enlarges the pelvic inlet

    • C. 

      Prevents perineal edema

    • D. 

      Ensures quick placenta delivery

  • 74. 
    A primigravida client at about 35 weeks gestation in active labor has had no prenatal care and admits to cocaine use during the pregnancy. Which of the following persons must the nurse notify?
    • A. 

      Nursing unit manager so appropriate agencies can be notified

    • B. 

      Head of the hospital’s security department

    • C. 

      Chaplain in case the fetus dies in utero

    • D. 

      Physician who will attend the delivery of the infant

  • 75. 
    When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse in charge should include which of the following?
    • A. 

      The vaccine prevents a future fetus from developing congenital anomalies

    • B. 

      Pregnancy should be avoided for 3 months after the immunization

    • C. 

      The client should avoid contact with children diagnosed with rubella

    • D. 

      The injection will provide immunity against the 7-day measles.

  • 76. 
    A client with eclampsia begins to experience a seizure. Which of the following would the nurse in charge do first?
    • A. 

      Pad the side rails

    • B. 

      Place a pillow under the left buttock

    • C. 

      Insert a padded tongue blade into the mouth

    • D. 

      Maintain a patent airway

  • 77. 
    While caring for a multigravida client in early labor in a birthing center, which of the following foods would be best if the client requests a snack?
    • A. 

      Yogurt

    • B. 

      Cereal with milk

    • C. 

      Vegetable soup

    • D. 

      Peanut butter cookies

  • 78. 
    The multigravida mother with a history of rapid labor who us in active labor calls out to the nurse, “The baby is coming!” which of the following would be the nurse’s first action? 
    • A. 

      Inspect the perineum

    • B. 

      Time the contractions

    • C. 

      Auscultate the fetal heart rate

    • D. 

      Contact the birth attendant

  • 79. 
    While assessing a primipara during the immediate postpartum period, the nurse in charge plans to use both hands to assess the client’s fundus to: 
    • A. 

      Prevent uterine inversion

    • B. 

      Promote uterine involution

    • C. 

      Hasten the puerperium period

    • D. 

      Determine the size of the fundus

  • 80. 
    Nurse Jacob is assessing a 15 month old child with acute otitis media. Which of the following symptoms would the nurse anticipate finding?
    • A. 

      Periorbital edema, absent light reflex and translucent tympanic membrane

    • B. 

      Irritability, purulent drainage in middle ear, nasal congestion and cough

    • C. 

      Diarrhea, retracted tympanic membrane and enlarged parotid gland

    • D. 

      Vomiting, pulling at ears and pearly white tympanic membrane

  • 81. 
    Which of the following is the most appropriate intervention to reduce stress in a preterm infant at 33 weeks gestation?
    • A. 

      Sensory stimulation including several senses at a time

    • B. 

      Tactile stimulation until signs of over stimulation develop

    • C. 

      An attitude of extension when prone or side lying

    • D. 

      Kangaroo care

  • 82. 
    The parent of a client with albinism would need to be taught which preventive healthcare measure by the nurse:
    • A. 

      Ulcerative colitis diet

    • B. 

      Use of a high-SPF sunblock

    • C. 

      Hair loss monitoring

    • D. 

      Monitor for growth retardation

  • 83. 
    Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor and delivery. Her last 3 pregnancies in short stage one of labor. The nurses decide to observe her closely. The physician determines that Mrs. Abuel’s cervix is dilated to 6 cm. Mrs. Abuel states that she is extremely uncomfortable. To lessen Mrs. Abuel’s discomfort, the nurse can advise her to:
    • A. 

      Lie face down

    • B. 

      Not drink fluids

    • C. 

      Practice holding breaths between contractions

    • D. 

      Assume Sim’s position

  • 84. 
      Which is true regarding the fontanels of the newborn?
    • A. 

      The anterior is large in shape when compared to the posterior fontanel.

    • B. 

      The anterior is triangular shaped; the posterior is diamond shaped.

    • C. 

      The anterior is bulging; the posterior appears sunken.

    • D. 

      The posterior closes at 18 months; the anterior closes at 8 to 12 months.

  • 85. 
      Which of the following danger sings should be reported immediately during the antepartum period?
    • A. 

      Blurred vision

    • B. 

      Nasal stuffiness

    • C. 

      Breast tenderness

    • D. 

      Constipation

  • 86. 
    Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of nephroblastoma. Symptoms the nurse observes that suggest this problem include:
    • A. 

      Lymphedema and nerve palsy

    • B. 

      Hearing loss and ataxia

    • C. 

      Headaches and vomiting

    • D. 

      Abdominal mass and weakness

  • 87. 
    Alice, 10 years old was brought to the ER because of Asthma. She was immediately put under aerosol administration of Terbutaline. After sometime, you observe that the child does not show any relief from the treatment given. Upon assessment, you noticed that both the heart and respiratory rate are still elevated and the child shows difficulty of exhaling. You suspect:
    • A. 

      Bronchiectasis

    • B. 

      Atelectasis

    • C. 

      Epiglotitis

    • D. 

      Status Asthmaticus

  • 88. 
    Baby boy Villanueva, 4 months old, was seen at the pediatric clinic for his scheduled check-up. By this period, baby Villanueva has already increased his height by how many inches?  
    • A. 

      3 inches

    • B. 

      4 inches

    • C. 

      5 inches

    • D. 

      6 inches

  • 89. 
    Isabelle, a 2 year old girl loves to move around and oftentimes manifests negativism and temper tantrums. What is the best way to deal with her behavior?
    • A. 

      Tell her that she would not be loved by others is she behaves that way..

    • B. 

      Withholding giving her toys until she behaves properly.

    • C. 

      Ignore her behavior as long as she does not hurt herself and others.

    • D. 

      Ask her what she wants and give it to pacify her.

  • 90. 
    Which age group is with imaginative minds and creates imaginary friends?
    • A. 

      Toddler

    • B. 

      Preschool

    • C. 

      School

    • D. 

      Adolescence

  • 91. 
      Which of the following situations would alert you to a potentially developmental problem with a child?
    • A. 

      Pointing to body parts at 15 months of age.

    • B. 

      Using gesture to communicate at 18 months.

    • C. 

      Cooing at 3 months.

    • D. 

      Saying “mama” or “dada” for the first time at 18 months of age.

  • 92. 
    The infant with Down Syndrome should go through which of the Erikson’s developmental stages first?
    • A. 

      Initiative vs. Self doubt

    • B. 

      Industry vs. Inferiority

    • C. 

      Autonomy vs. Shame and doubt

    • D. 

      Trust vs. Mistrust

  • 93. 
    The child with phenylketonuria (PKU) must maintain a low phenylalanine diet to prevent which of the following complications?
    • A. 

      Irreversible brain damage

    • B. 

      Kidney failure

    • C. 

      Blindness

    • D. 

      Neutropenia

  • 94. 
    During the first hours following delivery, the post partum client is given IVF with oxytocin added to them. The nurse understands the primary reason for this is:
    • A. 

      To facilitate elimination

    • B. 

      To promote uterine contraction

    • C. 

      To promote analgesia

    • D. 

      To prevent infection

  • 95. 
    Nurse Luis is assessing the newborn’s heart rate. Which of the following would be considered normal if the newborn is sleeping?
    • A. 

      80 beats per minute

    • B. 

      100 beats per minute

    • C. 

      120 beats per minute

    • D. 

      140 beats per minute

  • 96. 
    Mrs. Quijones gave birth by spontaneous delivery to a full term baby boy. After a minute after birth, he is crying and moving actively. His birth weight is 6.8 lbs. What do you expect baby Quijones to weigh at 6 months?
    • A. 

      13 -14 lbs

    • B. 

      16 -17 lbs

    • C. 

      22 -23 lbs

    • D. 

      27 -28 lbs

  • 97. 
    The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following key concept should the nurse consider when implementing nursing care?
    • A. 

      Explain the surgery, expected outcome and kind of anesthetics.

    • B. 

      Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth.

    • C. 

      Arrange for a staff member of the anesthesia department to explain what to expect post-operatively.

    • D. 

      Instruct the mother’s support person to remain in the family lounge until after the delivery.

  • 98. 
    Bettine Gonzales is hospitalized for the treatment of severe preecplampsia. Which of the following represents an unusual finding for this condition?
    • A. 

      Generalized edema

    • B. 

      Proteinuria 4+

    • C. 

      Blood pressure of 160/110

    • D. 

      Convulsions

  • 99. 
    Mrs. Jimenez went to the health center for pre-natal check-up. the student nurse took her weight and revealed 142 lbs. She asked the student nurse how much should she gain weight in her pregnancy.
    • A. 

      20-30 lbs

    • B. 

      25-35 lbs

    • C. 

      30- 40 lbs

    • D. 

      10-15 lbs

  • 100. 
    Betina 30 weeks AOG discharged with a diagnosis of placenta previa. The nurse knows that the client understands her care at home when she says:
    • A. 

      I am happy to note that we can have sex occasionally when I have no bleeding.

    • B. 

      I am afraid I might have an operation when my due comes

    • C. 

      I will have to remain in bed until my due date comes

    • D. 

      I may go back to work since I stay only at the office.