final

Question 1

3. The nurse is caring for a client in early labor. Membranes ruptured approximately 2 hours
   earlier. This client is at increased risk for which complication?

Answer 1

Intrauterine infection

Question 2

5.Which action iscorrectwhen palpation is used to assess the characteristics and pattern of
uterine contractions?

Answer 2

Evaluating the intensity by pressing the fingertips into the uterine fundus

Question 3

7.The nurse performs a vaginal examination to assess a client’s labor progress. Which action
should the nurse take next?

Answer 3

Discuss the findings with the woman and her partner.

Question 4

18.Where is the point of maximal intensity (PMI) of the FHR located?

Answer 4

Heard lower and closer to the midline of the mother’s abdomen as the fetus descends and
internally rotates

Question 5

11.Which clinical finding indicates that the client has reached the second stage of labor?

Answer 5

Cervix cannot be felt during a vaginal examination.

Question 6

6.When assessing a woman in the first stage of labor, which clinical finding will alert the nurse
that uterine contractions are effective?

Answer 6

Dilation of the cervix

Question 7

25.A woman who has a history of sexual abuse may have a number of traumatic memories
triggered during labor. She may fight the labor process and react with pain or anger. The nurse
can implement a number of care measures to help her client view the childbirth experience in a
positive manner. Which intervention is key for the nurse to use while providing care?

Answer 7

Limit the number of procedures that invade her body.

Question 8

5.Which hormone remains elevated in the immediate postpartum period of the breastfeeding
woman?

Answer 8

Prolactin

Question 9

9.A client is concerned that her breasts are engorged and uncomfortable. What is the nurse’s
explanation for this physiologic change?

Answer 9

Congestion of veins and lymphatic vessels

Question 10

8.A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and
the estimated blood loss (EBL) was 1500 ml. When evaluating the woman’s vital signs, which
finding would be of greatest concern to the nurse?

Answer 10

Temperature 37.9° C, heart rate 120 beats per minute (bpm), respirations 20 breaths per
minute, and blood pressure 90/50 mm Hg

Question 11

1.The breast-feeding mother should be taught to expect which changes to the condition of the
breasts?(Select all that apply.)

Answer 11

Breast tenderness is likely to persist for approximately 1 week after the start of lactation.

b.
As lactation is established, a mass may form that can be distinguished from cancer by its
positional shift from day to day.

If suckling is never begun or is discontinued, then lactation ceases within a few days to a
week.

Question 12

13.The nurse should be cognizant of which postpartum physiologic alteration?

Answer 12

Respiratory function returns to nonpregnant levels by 6 to 8 weeks after childbirth.

Question 13

3.Nursing care measures are commonly offered to women in labor. Which nursing measure
reflects the application of the gate-control theory?

Answer 13

Massage the woman’s back.

Question 14

5.A laboring woman has received meperidine (Demerol) intravenously (IV), 90 minutes before
giving birth. Which medication should be available to reduce the postnatal effects of meperidine
on the neonate?

Answer 14

Naloxone (Narcan)

Question 15

13.Anxiety is commonly associated with pain during labor. Which statement regarding anxiety
is correct?

Answer 15

Severe anxiety increases tension, increases pain, and then, in turn, increases fear and
anxiety, and so on.

Question 16

1.What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern?

Answer 16

Altered fetal cerebral blood flow

Question 17

5.The nurse providing care for a high-risk laboring woman is alert for late FHR decelerations.
Which clinical finding might be the cause for these late decelerations?

Answer 17

Uteroplacental insufficiency

Question 18

7.Which FHR finding is the most concerning to the nurse who is providing care to a laboring
client?

Answer 18

Late decelerations

Question 19

11.The perinatal nurse realizes that an FHR that is tachycardic, bradycardic, has late
decelerations, or loss of variability is nonreassuring and is associated with which condition?

Answer 19

Hypoxemia

Question 20

13.Which statementbestdescribes a normal uterine activity pattern in labor?

Answer 20

Contractions every 2 to 5 minutes

Question 21

17. During labor a fetus displays an average FHR of 135 beats per minute over a 10-minute
    period. Which statementbestdescribes the status of this fetus?

Answer 21

Normal baseline heart rate

Question 22

23.Part of the nurse’s role is assisting with pushing and positioning. Which guidance should the
nurse provide to her client in active labor?

Answer 22

Encourage the woman’s cooperation in avoiding the supine position.

Question 23

22.Nurses should be able to teach breastfeeding mothers the signs that the infant has correctly
latched on. Which client statement indicates a poor latch?

Answer 23

“I hear a clicking or smacking sound.”

Question 24

7.Under the Newborns’ and Mothers’ Health Protection Act, all health plans are required to
allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a
normal vaginal birth and for _____ hours after a cesarean birth. What is thecorrectinterpretation
of this legislation?

Answer 24

c. 48; 96

Question 25

2.Which practices contribute to the prevention of postpartum infection?(Select all that apply.)

Answer 25

a. Not allowing the mother to walk barefoot at the hospital

Having staff members with conditions such as strep throat, conjunctivitis, and diarrhea stay
home

Instructing the mother to change her perineal pad from front to back each time she voids or
defecates

Question 26

16.The nurse observes several interactions between a postpartum woman and her new son. What
behavior, if exhibited by this woman, would the nurse identify as a possible maladaptive
behavior regarding parent-infant attachment?

Answer 26

She seldom makes eye contact with her son.

Question 27

3.The nurse observes that a first-time mother appears to ignore her newborn. Which strategy
should the nurse use to facilitate mother-infant attachment?

Answer 27

Show the mother how the infant initiates interaction and attends to her.

Question 28

10.In follow-up appointments or visits with parents and their new baby, it is useful if the nurse
can identify infant behaviors that can either facilitate or inhibit attachment. What is an inhibiting
behavior?

Answer 28

The infant seeks attention from any adult in the room.

Question 29

2.In the United States, the en faceposition is preferred immediately after birth. Which actions by
the nurse can facilitate this process?(Select all that apply.)

Answer 29

b. Placing the infant on the mother’s abdomen or breast with their heads on the same plane
c. Dimming the lights
d. Delaying the instillation of prophylactic antibiotic ointment in the infant’s eyes

Question 30

11.In addition to eye contact, other early sensual contacts between the infant and mother involve
sound and smell. What other statement regarding the senses iscorrect?

Answer 30

Infants can learn to distinguish their mother’s voice from others soon after birth.

Question 31

13.The postpartum nurse should be cognizant of what with regard to the adaptation of other
family members (primarily siblings and grandparents) to the newborn?

Answer 31

Participation in preparation classes helps both siblings and grandparents.

Question 32

14.While providing routine mother-baby care, which activities should the nurse encourage to
facilitate the parent-infant attachment?

Answer 32

An environment that fosters as much privacy as possible should be created.

Question 33

2.Part of the health assessment of a newborn is observing the infant’s breathing pattern. What is
the predominate pattern of newborn’s breathing?

Answer 33

Abdominal with synchronous chest movements

Question 34

8.What is the most critical physiologic change required of the newborn after birth?

Answer 34

Initiation and maintenance of respirations

Question 35

12.A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to
assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing
over him on high. The nurse instructs the mother that the fan should not be directed toward the
newborn and that the newborn should be wrapped in a blanket. The mother asks why. How
would the nurse respond?

Answer 35

“Your baby may lose heat by convection, which means that he will lose heat from his body
to the cooler ambient air. You should keep him wrapped, and should prevent cool air from
blowing on him.”

Question 36

13.A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, “What
is this black, sticky stuff in her diaper?” What is the nurse’sbestresponse?

Answer 36

“That’s meconium, which is your baby’s first stool. It’s normal.”

Question 37

17.Which infant response to cool environmental conditions is eithernoteffective ornotavailable
to them?

Answer 37

Unflexing from the normal position

Question 38

4.What is the rationale for the administration of vitamin K to the healthy full-term newborn?

Answer 38

Bacteria that synthesize vitamin K are not present in the newborn’s intestinal tract.

Question 39

8.The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which
intervention by the nurse iscorrect?

Answer 39

Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration

Question 40

17.The most serious complication of an infant heelstick is necrotizing osteochondritis resulting
from lancet penetration of the bone. What approach should the nurse take when performing the
test to prevent this complication?

Answer 40

Lancet should penetrate at the outer aspect of the heel.

Question 41

1.A new mother recalls from prenatal class that she should try to feed her newborn daughter
when she exhibits feeding readiness cues rather than waiting until the baby is frantically crying.
Which feeding cue would indicate that the baby is ready to eat?

Answer 41

Makes sucking motions

Question 42

4.A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as
soon as possible. How should the client be instructed to position the infant to facilitate correct
latch-on?

Answer 42

The infant’s head and body should be in alignment with the mother.

Question 43

6.At a 2-month well-baby examination, it was discovered that an exclusively breastfed infant had
only gained 10 ounces in the past 4 weeks. The mother and the nurse develop a feeding plan for
the infant to increase his weight gain. Which change in dietary management will assist the client
in meeting this goal?

Answer 43

Have one extra breastfeeding session every 24 hours.

Question 44

7.Parents have been asked by the neonatologist to provide breast milk for their newborn son,
who was born prematurely at 32 weeks of gestation. The nurse who instructs them regarding
pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which
statement is valid?

Answer 44

Premature infants more easily digest breast milk than formula.

Question 45

25.The nurse should be cognizant of which important information regarding the gastrointestinal
(GI) system of the newborn?

Answer 45

Regurgitation during the first day or two can be reduced by burping the infant and slightly
elevating the baby’s head.

Question 46

22.With regard to infants who are SGA and intrauterine growth restriction (IUGR), the nurse
should be aware of which information?

Answer 46

Infants with asymmetric IUGR have the potential for normal growth and development.

Question 47

16.A newly delivered mother who intends to breastfeed tells her nurse, “I am so relieved that this
pregnancy is over so that I can start smoking again.” The nurse encourages the client to refrain from smoking. However, this new mother is insistent that she will resume smoking. How will the
nurse adapt her health teaching with this new information?

Answer 47

The mother should always smoke in another room.

Question 48

1.A woman arrives at the clinic seeking confirmation that she is pregnant. The following
information is obtained: She is 24 years old with a body mass index (BMI) of 17.5. She admits to
having used cocaine “several times” during the past year and occasionally drinks alcohol. Her
blood pressure is 108/70 mm Hg. The family history is positive for diabetes mellitus and cancer.
Her sister recently gave birth to an infant with a neural tube defect (NTD). Which characteristics
places this client in a high-risk category?

Answer 48

d. Family history, BMI, drug and alcohol abuse

Question 49

7.An MSAFP screening indicates an elevated level of alpha-fetoprotein. The test is repeated, and
again the level is reported as higher than normal. What is the next step in the assessment
sequence to determine the well-being of the fetus?

Answer 49

b. Ultrasound for fetal anomalies

Question 50

14.Which information is thehighestpriority for the nurse to comprehend regarding the BPP?

Answer 50

BPP is an accurate indicator of impending fetal well-being.

Question 51

17.The nurse is planning the care for a laboring client with diabetes mellitus. This client is at
greater risk for which clinical finding?

Answer 51

Polyhydramnios

Question 52

1.A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is
ofgreatestconcern to the nurse?

Answer 52

Dipstick value of 3+ for protein in her urine

Question 53

8.The client is being induced in response to worsening preeclampsia. She is also receiving
magnesium sulfate. It appears that her labor has not become active, despite several hours of
oxytocin administration. She asks the nurse, “Why is this taking so long?” What is the
nurse’smostappropriate response?

Answer 53

“The magnesium is relaxing your uterus and competing with the oxytocin. It may increase
the duration of your labor.”

Question 54

2.The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the
oxytocin (Pitocin) infusion, the nurse reviews the woman’s latest laboratory test findings, which
reveal a platelet count of 90,000 mm3, an elevated aspartate aminotransaminase (AST) level, and
a falling hematocrit. The laboratory results are indicative of which condition?

Answer 54

Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome

Question 55

3.A woman with preeclampsia has a seizure. What is the nurse’shighestpriority during a
seizure?

Answer 55

To stay with the client and call for help

Question 56

11.Which intervention ismostimportant when planning care for a client with severe gestational
hypertension?

Answer 56

Induction of labor is likely, as near term as possible.

Question 57

7.The nurse who elects to practice in the area of women’s health must have a thorough
understanding of miscarriage. Which statement regarding this condition ismostaccurate?

Answer 57

If a miscarriage occurs before the 12th week of pregnancy, then it may be observed only as

moderate discomfort and blood loss.

Question 58

2.During a prenatal visit, the nurse is explaining dietary management to a woman with
pregestational diabetes. Which statement by the client reassures the nurse that teaching has been
effective?

Answer 58

“Diet and insulin needs change during pregnancy.”

Question 59

4.A 26-year-old primigravida has come to the clinic for her regular prenatal visit at 12 weeks.
She appears thin and somewhat nervous. She reports that she eats a well-balanced diet, although
her weight is 5 pounds less than it was at her last visit. The results of laboratory studies confirm
that she has a hyperthyroid condition. Based on the available data, the nurse formulates a plan of
care. Which nursing diagnosis ismostappropriate for the client at this time?

Answer 59

Imbalanced nutrition: less than body requirements

Question 60

10.Which statement regarding the laboratory test for glycosylated hemoglobin Alciscorrect?

Answer 60

This laboratory test measures the levels of hemoglobin Alc, which should remain at less
than 7%.

Question 61

12.An 18-year-old client who has reached 16 weeks of gestation was recently diagnosed with
pregestational diabetes. She attends her centering appointment accompanied by one of her
girlfriends. This young woman appears more concerned about how her pregnancy will affect her
social life than her recent diagnosis of diabetes. A number of nursing diagnoses are applicable to
assist in planning adequate care. What is themostappropriate diagnosis at this time?

Answer 61

Deficient knowledge, related to diabetic pregnancy management

Question 62

1.When caring for a pregnant woman with cardiac problems, the nurse must be alert for the signs
and symptoms of cardiac decompensation. Which critical findings would the nurse find on
assessment of the client experiencing this condition?

Answer 62

Dyspnea, crackles, and an irregular, weak pulse

Question 63

2.Which condition would require prophylaxis to prevent subacute bacterial endocarditis (SBE)
both antepartum and intrapartum?

Answer 63

Valvular heart disease

Question 64

3.Which information should the nurse take into consideration when planning care for a
postpartum client with cardiac disease?

Answer 64

The plan of care includes frequent ambulating, alternating with active range-of-motion
exercises.

Question 65

6.Which important component of nutritional counseling should the nurse include in health
teaching for a pregnant woman who is experiencing cholecystitis?

Answer 65

Instruct the woman to eat a low-fat diet and to avoid fried foods.

Question 66

7.Postoperative care of the pregnant woman who requires abdominal surgery for appendicitis
includes which additional assessment?

Answer 66

Fetal heart rate (FHR) and uterine activity

Question 67

10.Why might it be more difficult to diagnose appendicitis during pregnancy?

Answer 67

The appendix is displaced upward and laterally, high and to the right.

Question 68

12.The client makes an appointment for preconception counseling. The woman has a known
heart condition and is unsure if she should become pregnant. Which is theonlycardiac condition
that would cause concern?

Answer 68

Eisenmenger syndrome