HESI Maternity (Maternal And Child Health Nursing) Exam

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HESI Maternity (Maternal And Child Health Nursing) Exam - Quiz

Welcome to Maternal and Child Health Nursing (HESI EXAMINATION). Maternity nursing is a form of intensive, informative and knowledgeable care provided by a maternity nurse. In most instances, the maternity nurse provides two related and integrated services. The first one is pre-birth care. The maternity nurse is there to help the mother and the family during their pregnancy and afterward. In maternity nursing, the provider prepares the family for the entire birthing experience. The second responsibility of the maternity nurse is post-birth. The nurse is also there after birth. In this role, he or she advises mothers on such things Read moreas post natal care of themselves and their newborns.


Questions and Answers
  • 1. 

    Ativan 0.5 mg IM every 1 hour as needed is prescribed for a client experiencing delirium tremens. The medication vial reads 2mg/mL of solution. How many mL should the LPN draw into the syringe for single-dose administration?

    Explanation
    2mg/mL= 0.5mg/xmL

    2x=0.5

    x=0.5/2

    x=0.25 mL

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  • 2. 

    A 36-year-old male client loses all function from his waist down after sustaining a spinal cord injury after falling off the roof of his house. The nurse asks the client how this injury will affect the different aspects of his life. The client replies, "It won't." This reaction exemplifies that the client is at what stage of the grieving process?

    Explanation
    Clients usually responds to the loss by following the stages of the grieving process. The paralyzed condition of the client is his loss. The client is denying that this loss will affect him or his life.

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  • 3. 

    A client is pregnant with her third child. Medical history of the client indicates a previous precipitate labor and birth. Which of the following interventions would NOT be expected during labor of the present pregnancy?

    • A.

      Use of magnesium sulfate

    • B.

      Close monitoring of the fetus for hypoxia

    • C.

      The nurse stays at the bedside constantly or as much as possible

    • D.

      Amnioinfusion will be performed

    Correct Answer
    D. Amnioinfusion will be performed
    Explanation
    Amnioinfusion is instillation of fluid into the amniotic sac within the uterus to treat oligohydraminios. This is not done to prevent precipitate labor and birth.

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  • 4. 

    The fetal heart is carefully monitored throughout pregnancy and during labor to assess fetal well being. Which of the following represents an appropriate fetal heart rate?

    • A.

      108

    • B.

      127

    • C.

      170

    • D.

      185

    Correct Answer
    B. 127
    Explanation
    The appropriate range of fetal heart rate is 120-160 beats per minute.

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  • 5. 

    A client suspects that she is pregnant and visits the clinic. Of the following changes caused by pregnancy, which is the only positive sign that the client is pregnant?

    • A.

      Enlarge abdomen

    • B.

      Positive pregnancy test

    • C.

      Detection of fetal heartbeat

    • D.

      Uterine contraction

    Correct Answer
    C. Detection of fetal heartbeat
    Explanation
    Positive signs of pregnancy are detected changes that provide objective, conclusive proof of pregnancy. 1. detection of fetal heartbeat 2. fetal movement palpated by a professional 3. visualization of the fetus by sonography The other choices are considered PROBABLE signs of pregnancy.

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  • 6. 

    The physcician orders epinephrine 0.1 mg SQ x 1 now. The constitution of epinephrine according to the vial is 1;1000, or 1 g of epinephrine per 1,000 mL of solution. How much solution should be drawn into the syringe by the LPN?

    • A.

      0.01 mL

    • B.

      0.1 mL

    • C.

      1.0 mL

    • D.

      10 mL

    Correct Answer
    B. 0.1 mL
    Explanation
    1000mg/1000mL = 0.1mg/x mL

    1000x=100

    x= 100/1000

    x=0.1 mL

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  • 7. 

    The LPN is preparing to administer Solu-Medrol 40 mg mixed in 150 mL of sodium chloride via intravenous piggyback. The medication is to be administered over 30 minutes. Using the tubing with a drop factor of 15 ggts/mL, what would the LPN calculate the rate to be in drops per minute?

    • A.

      40

    • B.

      50

    • C.

      75

    • D.

      150

    Correct Answer
    C. 75
    Explanation
    The LPN would calculate the rate to be 75 drops per minute by using the formula: (Volume in mL / Time in minutes) x Drop factor. In this case, the volume is 150 mL, the time is 30 minutes, and the drop factor is 15 ggts/mL. Plugging these values into the formula, we get (150 / 30) x 15 = 75 drops per minute.

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  • 8. 

    The LPN has initiated the administration of vancomycin via IV piggyback. In which of the following situations should the nurse recognize that the client may be experiencing a fatal reaction to this medication?

    • A.

      The client start coughing

    • B.

      The client complains of pain at the intravenous catheter insertion site

    • C.

      The nurse hears the client snoring from the hall

    • D.

      The nurse notices the client's neck and chest is bright red

    Correct Answer
    D. The nurse notices the client's neck and chest is bright red
    Explanation
    While administering vancomycin the LPN should know to monitor the client carefully for the development of Red Man Syndrome or anaphylactic shock. The common side effects of this medicine are pruritus, flushing and erythema to the head, neck, and upper body.

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  • 9. 

    Pediazole is a suspension medication that contains 200 mg erythromycin and 600 mg sulfisoxazole per 5 mL. The physician orders Pediazole 4 mL PO every 12 hours. How many mg of sulfisoxazole is this client receiving in a 24-hour period?

    • A.

      160 mg

    • B.

      320 mg

    • C.

      480 mg

    • D.

      960 mg

    Correct Answer
    D. 960 mg
    Explanation
    600 mg/ 5 mL = x mg/ 4 mL

    2400 = 5x

    x= 2400/5

    x= 480 mg per dose x 2 = 960 mg in 24 hours.

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  • 10. 

    During a lecture on reproduction, a student nurse asks the instructor what determines the sex of a fetus. Accurate information in response to this question would be:

    • A.

      "The sex of the fetus is not determined until the eighth week of gestation."

    • B.

      "The fertilization of the zygote is the point at which sex is determined."

    • C.

      "Males have one less pair of chromosomes than females."

    • D.

      "Sex is determined by the chromosomes contributed by the ovum."

    Correct Answer
    B. "The fertilization of the zygote is the point at which sex is determined."
    Explanation
    The sex of the fetus is determined at the point that the sperm fertilizes the ovum to form the zygote. Sex is ultimately determined by the chromosome contributed by the sperm.

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  • 11. 

    The nurse identifies substance abuse behaviors exhibited by a pregnant client during an initial prenatal screening. While promoting a therapeutic and accepting environment, the care managment by the nurse would be MOST appropriate if focused on which of the following?

    • A.

      Discouraging substance use during pregnancy

    • B.

      Termination of the pregnancy at an early stage

    • C.

      Eliminating substance use during pregnancy

    • D.

      Setting boundaries with the client in regards to substance use

    Correct Answer
    C. Eliminating substance use during pregnancy
    Explanation
    Use of substances during pregnancy can lead to severe fetal or neonatal abnormalities, complications, and death. The primary goal of nursing care should be prevention or elimination of substance use during pregnancy.

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  • 12. 

    A 25-year-old client with diabetes type I visits the clinic to discuss her and her husband's desire to start a family. This diabetic client 

    • A.

      Should be discouraged from becoming pregnant

    • B.

      Has a greater risk of complications during pregnancy

    • C.

      Should be informed about treatment for infertility

    • D.

      Will be able to carry out a completely normal pregnancy

    Correct Answer
    B. Has a greater risk of complications during pregnancy
    Explanation
    Clients with DM are at greater risk for developing maternal and fetal complications during pregnancy.

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  • 13. 

    During the prenatal visit, the client states that she has been experiencing heartburn frequently. The LPN provides instruction on the cause and prevention of heartburn. When she ask to verbalize understanding of the information, which of the following statements by the client indicates further instruction may be necessary?

    • A.

      "The sphincter that normally prevents stomach contents from going back up into the esophagus is relaxed."

    • B.

      "I should try to avoid drinking fluids while I'm eating."

    • C.

      "Eating six or seven small meals a day may help my symptoms."

    • D.

      "I'll eat enough to ensure that I am full at every meal."

    Correct Answer
    D. "I'll eat enough to ensure that I am full at every meal."
    Explanation
    It suggests that the instruction might need to be reinforced on preventing stomach distention.

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  • 14. 

    A nurse is collecting data from a client who suspects that she is pregnant. The nurse is checking the client for probable signs of pregnancy. Select all that apply.

    • A.

      Ballottement

    • B.

      Chadwick's sign

    • C.

      Uterine enlargement

    • D.

      Braxton Hicks contractions

    • E.

      Outline of fetus via radiography or ultrasound

    • F.

      Fetal heart rate detected by a non electronic device

    • G.

      Hegar's sign

    • H.

      Goodle's sign

    Correct Answer(s)
    A. Ballottement
    B. Chadwick's sign
    C. Uterine enlargement
    D. Braxton Hicks contractions
    G. Hegar's sign
    H. Goodle's sign
    Explanation
    Ballottement or rebound of the fetus against the examiner's fingers on palpation; Chadwick's sign or the bluish coloration of the mucus membrane of the cervix, Uterine enlargement, Goodle's sign or the softening of the cervix; Braxton Hicks contraction, and Hegar's sign the softening and thinning of the lower uterine segment are ALL PROBABLE SIGNS OF PREGNANCY.

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  • 15. 

    A nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse checks the client for which classic signs of preeclampsia? Select all that apply.

    • A.

      Proteinuria

    • B.

      Hypertension

    • C.

      Low grade fever

    • D.

      Generalized edema

    • E.

      Increase pulse rate

    • F.

      Increase respiratory rate

    Correct Answer(s)
    A. Proteinuria
    B. Hypertension
    D. Generalized edema
    Explanation
    The three classic signs of preeclampsia are hypertension, generalized edna, and proteinuria.

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  • 16. 

    A nurse is monitoring for the Physiological Maternal Changes relating to pregnancy for a primigravida patient. What are the normal changes that happens during pregnancy? Select all that apply.

    • A.

      Circulating blood volume increases

    • B.

      Sodium and water retention may occur, which can lead to weight gain

    • C.

      Shortness of breath may be experienced

    • D.

      Breast size atrophies

    • E.

      There is a decrease in vaginal secretions

    • F.

      Frequency of urination occurs during second trimester

    • G.

      Chloasma occurs

    Correct Answer(s)
    A. Circulating blood volume increases
    B. Sodium and water retention may occur, which can lead to weight gain
    C. Shortness of breath may be experienced
    G. Chloasma occurs
    Explanation
    During pregnancy, the circulating blood volume increases to support the growing fetus and provide adequate oxygen and nutrients. Sodium and water retention may occur, leading to weight gain. Shortness of breath may be experienced due to the increased demand for oxygen by the mother and the fetus. Chloasma, also known as the "mask of pregnancy," is a condition characterized by the darkening of the skin on the face. Breast size typically increases during pregnancy, rather than atrophying. Vaginal secretions may increase, rather than decrease. Frequency of urination commonly occurs during the first trimester, not the second.

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  • 17. 

    The nurse knows that there are psychological maternal changes that occurs during pregnancy in a primigravida patient. Select all  the normal psychological maternal changes that happens throughout pregnancy.  

    • A.

      Ambivalence

    • B.

      Breast tenderness

    • C.

      Emotional lability

    • D.

      Body image changes

    • E.

      Bonding or relationship with the fetus

    • F.

      Nausea and vomiting

    • G.

      Syncope

    • H.

      Urinary frequency

    Correct Answer(s)
    A. Ambivalence
    C. Emotional lability
    D. Body image changes
    E. Bonding or relationship with the fetus
    Explanation
    During pregnancy, it is normal for a primigravida patient to experience psychological maternal changes such as ambivalence, emotional lability, body image changes, and bonding or relationship with the fetus. These changes are a result of hormonal fluctuations and the anticipation of becoming a mother. Breast tenderness, nausea and vomiting, syncope, and urinary frequency are physiological changes that occur during pregnancy but are not specifically related to psychological maternal changes.

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  • 18. 

    A 36 weeks gestation pregnant woman is complaining of urinary urgency and frequency. The nurse explained that the enlarging fetus is pressing the bladder which causes frequent urination. This is normally occuring during the first and third trimesters of pregnancy. The nurse advices the patient to do the following measures to prevent urinary frequency. Select all the necessary measures that the nurse can provide to the patient. 

    • A.

      Drink 2 quarts of fluid during the day

    • B.

      Engaging in a regular exercise

    • C.

      Performing Kegel exercises

    • D.

      Soaking in a warm sitz bath

    • E.

      Limiting fluid intake during the evening

    Correct Answer(s)
    A. Drink 2 quarts of fluid during the day
    C. Performing Kegel exercises
    E. Limiting fluid intake during the evening
    Explanation
    During pregnancy, the enlarging fetus can press on the bladder, causing urinary urgency and frequency. To prevent this, the nurse advises the patient to drink 2 quarts of fluid during the day to stay hydrated. Performing Kegel exercises can help strengthen the pelvic floor muscles and improve bladder control. Limiting fluid intake during the evening can reduce the need to urinate at night. Engaging in regular exercise and soaking in a warm sitz bath are not necessary measures to prevent urinary frequency in this situation.

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  • 19. 

    Reddish purple strech marks that usually occur on the abdomen, breasts, thighs, and upper arm. As a nurse, you would document this correctly in the client's chart by using what medical terminology?

    Correct Answer(s)
    Striae gravidarum, striae gravidarum
    Explanation
    The correct medical terminology to document reddish purple stretch marks that occur on the abdomen, breasts, thighs, and upper arm is "striae gravidarum." This term specifically refers to stretch marks that occur during pregnancy.

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  • 20. 

    The OB/GYN physician required the LPN to perform different laboratory tests for the primigravida woman who is on her 20 weeks' gestation. As a nurse you would expect that the physician will order what types of laboratory testing for the pregnant woman?

    • A.

      Blood type and Rh factor

    • B.

      Pap's smear

    • C.

      Rubella titer

    • D.

      Urinalysis

    • E.

      Hemoglobin and hematocrit levels

    • F.

      Hepatitis B surface antigen

    Correct Answer(s)
    A. Blood type and Rh factor
    B. Pap's smear
    C. Rubella titer
    D. Urinalysis
    E. Hemoglobin and hematocrit levels
    F. Hepatitis B surface antigen
    Explanation
    The OB/GYN physician would order a variety of laboratory tests for the pregnant woman to ensure her health and the health of the fetus. Blood type and Rh factor testing is important to determine if the woman is Rh negative and at risk for Rh incompatibility. Pap's smear is done to screen for cervical cancer. Rubella titer is done to check if the woman is immune to rubella, as contracting rubella during pregnancy can be harmful to the fetus. Urinalysis is done to check for any urinary tract infections or other abnormalities. Hemoglobin and hematocrit levels are checked to monitor for anemia. Hepatitis B surface antigen testing is done to check for hepatitis B infection, which can be transmitted to the baby during delivery.

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  • 21. 

    The nurse is educating a primigravida patient who is 12 weeks pregnant about the danger signs of pregnancy. The information provided is clearly understood by the expectant mother if the client states the following danger signs of pregnancy: Slect all that apply.

    • A.

      Gush of vaginal discharge

    • B.

      Vaginal bleeding

    • C.

      Persistent vomiting

    • D.

      Constipation

    • E.

      Urinary frequency

    • F.

      Epigastric or abdominal pain

    • G.

      Fetal heart rate of 120

    Correct Answer(s)
    A. Gush of vaginal discharge
    B. Vaginal bleeding
    C. Persistent vomiting
    F. Epigastric or abdominal pain
    Explanation
    The correct answer is gush of vaginal discharge, vaginal bleeding, persistent vomiting, and epigastric or abdominal pain. These are all potential danger signs of pregnancy that the nurse is educating the patient about. Constipation and urinary frequency are not typically considered danger signs of pregnancy. Fetal heart rate of 120 is within the normal range and not a danger sign.

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  • 22. 

    What is the recommended drug for the prevention of maternal-fetal HIV transmission; it is usually administered orally beginning after 14 weeks' gestation, intravenously during labor, and in the form of syrup to the neonate after birth for 6 weeks?

    Correct Answer(s)
    Zidovudine, zidovudine
    Explanation
    Zidovudine is the recommended drug for the prevention of maternal-fetal HIV transmission. It is typically administered orally starting after 14 weeks of gestation, intravenously during labor, and in the form of syrup to the neonate after birth for 6 weeks. Zidovudine is an antiretroviral medication that helps reduce the risk of HIV transmission from mother to child during pregnancy, labor, and breastfeeding. By taking zidovudine as prescribed, the chances of vertical transmission of HIV can be significantly reduced.

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  • 23. 

    A nurse is collecting data during the admission asessment of a client who is pregnant with twins. The client also has 5 year old child. The nurse would document which gravida and para status on this client?

    • A.

      G1P1

    • B.

      G2P1

    • C.

      G2P2

    • D.

      G3P2

    Correct Answer
    B. G2P1
    Explanation
    The client is pregnant with twins, which means this is her second pregnancy (G2). She already has one child, so her para status is 1. Therefore, the nurse would document G2P1 to indicate that this is the client's second pregnancy and she has one living child.

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  • 24. 

    This is a dark streak down the midline of the abdomen that may appear as the uterus is enlarging. The LPN correctly describes this to the pregnant woman as?

    Correct Answer
    Linea nigra, linea nigra
    Explanation
    The LPN correctly describes the dark streak down the midline of the abdomen as "linea nigra." This is a common occurrence during pregnancy as the uterus enlarges. The darkening of the skin is caused by hormonal changes and increased pigmentation. The LPN is providing accurate information to the pregnant woman about this normal phenomenon.

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  • 25. 

    A nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply.

    • A.

      Allows for fetal movement

    • B.

      Is a measure of kidney function

    • C.

      Surrounds, cushions, and protects the fetus

    • D.

      Maintains the body temperature of the fetus

    • E.

      Prevents large particles such as bacteria from passing to the fetus

    • F.

      Provides an exchange of nutrients and waste products between the mother and the fetus

    Correct Answer(s)
    A. Allows for fetal movement
    B. Is a measure of kidney function
    C. Surrounds, cushions, and protects the fetus
    D. Maintains the body temperature of the fetus
    Explanation
    Amniotic fluid serves multiple functions during pregnancy. It allows for fetal movement, providing the necessary space for the fetus to move and develop. It also acts as a measure of kidney function, as the fetus excretes waste products into the amniotic fluid. Additionally, amniotic fluid surrounds, cushions, and protects the fetus, acting as a protective barrier against external pressures and impacts. It helps maintain the body temperature of the fetus, providing a stable and optimal environment for growth. Lastly, amniotic fluid facilitates the exchange of nutrients and waste products between the mother and the fetus, supporting the fetal development and ensuring proper nourishment.

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  • 26. 

    During a prenatal visit, the nurse checks the fetal heart rate of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which of the following heart rates is noted?

    • A.

      80 beats per minute

    • B.

      100 beats per minute

    • C.

      150 beats per minute

    • D.

      180 beats per minute

    Correct Answer
    C. 150 beats per minute
    Explanation
    During the third trimester of pregnancy, a normal fetal heart rate (FHR) is typically between 120 and 160 beats per minute. This range indicates that the baby's heart is functioning properly and receiving adequate oxygen and nutrients. Therefore, the correct answer is 150 beats per minute, as it falls within the normal range for FHR during the third trimester.

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  • 27. 

    During a prenatal visit, the nurse checks the fetal heart rate of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which of the following heart rates is noted?

    • A.

      80 beats per minute

    • B.

      100 beats per minute

    • C.

      150 beats per minute

    • D.

      180 beats per minute

    Correct Answer
    C. 150 beats per minute
    Explanation
    During the third trimester of pregnancy, a normal fetal heart rate (FHR) is typically around 120-160 beats per minute. A heart rate of 150 beats per minute falls within this range, indicating a normal FHR. Higher or lower heart rates may be a cause for concern and may require further evaluation.

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  • 28. 

    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

    Correct Answer
    B. The ultrasound identifies blood flow through the umbilical cord
    Explanation
    Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.

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  • 29. 

    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

    • D.

      Nitrofurantoin

    Correct Answer
    B. Protamine sulfate
    Explanation
    Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications cause by heparin overdose.

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  • 30. 

    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”

    Correct Answer
    A. “Nausea and vomiting can be decreased if I eat a few crackers before arising”
    Explanation
    Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.

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  • 31. 

     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

    Correct Answer
    A. Tailor sitting
    Explanation
    Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time.

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  • 32. 

    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.”

    Correct Answer
    B. “No, it can initiate premature uterine contractions.”
    Explanation
    Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oils is not known to increase absorption of fat-soluble vitamins, although laxatives in general may decrease absorption if intestinal motility is increased.

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  • 33. 

    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

    Correct Answer
    B. Fluid volume deficit
    Explanation
    If bleeding and cloth are excessive, this patient may become hypovolemic. Pad count should be instituted. Although the other diagnoses are applicable to this patient, they are not the primary diagnosis.

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  • 34. 

    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

    Correct Answer
    D. Nausea and Vomiting
    Explanation
    Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating may gently increase.

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  • 35. 

    The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The LPN 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

    Correct Answer
    B. Between 16 and 20 weeks’ gestation
    Explanation
    A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks’ gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.

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  • 36. 

    When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion? 

    • A.

      Sperm count

    • B.

      Sperm motility

    • C.

      Sperm maturity

    • D.

      Sperm volume

    Correct Answer
    B. Sperm motility
    Explanation
    Although all of the factors listed are important, sperm motility is the most significant criterion when assessing male infertility. Sperm count, sperm maturity, and semen volume are all significant, but they are not as significant sperm motility.

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  • 37. 

    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.

    Correct Answer
    D. Self-esteem disturbance related to infertility.
    Explanation
    Based on the partner’s statement, the couple is verbalizing feelings of inadequacy and negative feelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem disturbance is most appropriate. Fear, pain, and ineffective family coping also may be present but as secondary nursing diagnoses.

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  • 38. 

    Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester?

    • A.

      Dysuria

    • B.

      Frequency

    • C.

      Incontinence

    • D.

      Burning urination

    Correct Answer
    B. Frequency
    Explanation
    Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence, and burning are symptoms associated with urinary tract infections.

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  • 39. 

    Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following?

    • A.

      Increased plasma HCG levels

    • B.

      Decreased intestinal motility

    • C.

      Decrease gastric acidity

    • D.

      Elevated estrogen levels

    Correct Answer
    C. Decrease gastric acidity
    Explanation
    During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester.

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  • 40. 

    On which of the following areas would the nurse expect to observe chloasma?

    • A.

      Breast, areola, and nipples

    • B.

      Chest, neck, arms, and legs

    • C.

      Abdomen, breast, and thighs

    • D.

      Cheeks, forehead, and nose

    Correct Answer
    D. Cheeks, forehead, and nose
    Explanation
    Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented area found on the face. It is not seen on the breasts, areola, nipples, chest, neck, arms, legs, abdomen, or thighs.

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  • 41. 

    A pregnant client states that she “waddles” when she walks. The nurse’s explanation is based on which of the following as the cause?

    • A.

      The large size of the newborn

    • B.

      Pressure on the pelvic brim

    • C.

      Relaxation of the pelvic joints

    • D.

      Excessive weight gain

    Correct Answer
    C. Relaxation of the pelvic joints
    Explanation
    During pregnancy, hormonal changes cause relaxation of the pelvic joints, resulting in the typical “waddling” gait. Changes in posture are related to the growing fetus. Pressure on the surrounding muscles causing discomfort is due to the growing uterus. Weight gain has no effect on gait.

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  • 42. 

    Which of the following represents the average amount of weight gained during pregnancy?

    • A.

      12 to 2 lbs

    • B.

      15 to 25 lbs

    • C.

      25 to 35 lbs

    • D.

      25 to 40 lbs

    Correct Answer
    C. 25 to 35 lbs
    Explanation
    The average amount of weight gained during pregnancy is 25 to 35 lb. This weight gain consists of the following: fetus – 7.5 lb; placenta and membrane – 1.5 lb; amniotic fluid – 2 lb; uterus – 2.5 lb; breasts – 3 lb; and increased blood volume – 2 to 4 lb; extravascular fluid and fat – 4 to 9 lb. A gain of 12 to 22 lb is insufficient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered excessive.

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  • 43. 

    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

    Correct Answer
    C. Pressure on blood vessels from the enlarging uterus
    Explanation
    Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation. Pregnancy-induced hypertension is not associated with these symptoms. Gravity plays only a minor role with these symptoms.

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  • 44. 

    Cervical softening and uterine souffle are classified as which of the following?

    • A.

      Diagnostic signs

    • B.

      Presumptive signs

    • C.

      Probable signs

    • D.

      Positive signs

    Correct Answer
    C. Probable signs
    Explanation
    Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy.Probable signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign, which is enlargement and softening of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.

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  • 45. 

    Which of the following would the nurse identify as a presumptive sign of pregnancy?

    • A.

      Hegar sign

    • B.

      Nausea and vomiting

    • C.

      Skin pigmentation changes

    • D.

      Positive serum pregnancy test

    Correct Answer
    B. Nausea and vomiting
    Explanation
    resumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs. Hegar sign, skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.

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  • 46. 

    Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester?

    • A.

      Introversion, egocentrism, narcissism

    • B.

      Awkwardness, clumsiness, and unattractiveness

    • C.

      Anxiety, passivity, extroversion

    • D.

      Ambivalence, fear, fantasies

    Correct Answer
    D. Ambivalence, fear, fantasies
    Explanation
    During the first trimester, common emotional reactions include ambivalence, fear, fantasies, or anxiety. The second trimester is a period of well- being accompanied by the increased need to learn about fetal growth and development. Common emotional reactions during this trimester include narcissism, passivity, or introversion. At times the woman may seem egocentric and self-centered. During the third trimester, the woman typically feels awkward, clumsy, and unattractive, often becoming more introverted or reflective of her own childhood.

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  • 47. 

    During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition?

    • A.

      Post partum phase

    • B.

      First trimester

    • C.

      Second trimester

    • D.

      Third trimester

    Correct Answer
    B. First trimester
    Explanation
    First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.

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  • 48. 

    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

    Correct Answer
    A. The test was performed less than 10 days after an abortion
    Explanation
    A false-positive reaction can occur if the
    pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false- negative results.

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  • 49. 

     FHR can be auscultated with a fetoscope as early as which of the following?

    • A.

      5 weeks gestation

    • B.

      10 weeks gestation

    • C.

      13 weeks gestation

    • D.

      20 weeks gestation

    Correct Answer
    D. 20 weeks gestation
    Explanation
    The FHR can be auscultated with a fetoscope at about 20 week’s gestation. FHR usually is ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12 week’s gestation. FHR, cannot be heard any earlier than 10 weeks’ gestation.

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  • 50. 

    A client LMP began July 5. Her EDD should be which of the following?

    • A.

      January 2

    • B.

      March 28

    • C.

      April 12

    • D.

      October 12

    Correct Answer
    C. April 12
    Explanation
    To determine the EDD when the date of the client’s LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client’s EDD is April 12.

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Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • May 09, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • May 26, 2012
    Quiz Created by
    Nursejbv21
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