A 22 yr old client has come to the clinic because her menstrual period is 10 days
late. She tells the nurse "I'm sure I'm pregnant because my period is late and my
breasts are tender" Which of the following responses by the nurse would be most
accurate?
A. "those are positive signs of pregnancy"
B. "those are presumptive signs of pregnancy"
C. "those are probable signs of pregnancy"
D. "those are negative signs of pregnancy" - B. Breast tenderness and
missed menses are presumptive signs. Other presumptive signs include: N/V,
fatigue, urinary frequency and quickening
A client delivered a term infant 7 hours ago. Which of the following postpartum
assessment findings indicate normal postpartum progression?
A. Firm fundus at 1-2 fingerbreadths above the umbilicus with moderate lochia
rubra
B. Firm fundus at the umbilicus and midline with moderate rubra
C. Firm fundus at 1-2 fingerbreadths below umbilicus, deviated to the right side
with moderate lochia rubra
D. Soft fundus at 1-2 fingerbreadths below umbilicus with severe lochia rubra -
A. Within 12 hours, fundus can rise to approx. 1 cm above the umbilicus.
The fundus descends 1-2 cm every 24 hours. Located about halfway between
umbilicus and symphysis pubis, not longer palpable after 2 weeks, returned to
pre-pregnant state by 6 weeks pp
A client delivered at 39 weeks 6 hours ago. Upon assessment, the nurse palpated
a soft, boggy fundus deviated to the left side. Which action of the nurse would be
most appropriate?
,A. Massage the fundus until firm
B. Call HCP immediately
C. Assist woman to the restroom
D. Increase Pitocin per HCP order - C. A distended bladder can impede
uterine contractions which can lead to uterine atony which may lead to pp
hemorrhage if we don't intervene
**KEY WORDS: deviated to the left side**
A client is in active labor at term with cervical findings of 7/80/-1. The FHR
baseline is 130bpm. Four early decelerations were noted within the last hour.
Which of the following nursing actions would be most appropriate?
A. Position client on her back so the monitor gives more accurate results
B. perform vaginal exam
C. turn client on her left side
D. document and continue to monitor both FHR and laboring women - D.
early decelerations indicate head compression. It is benign and no interventions
are needed. just document and continue monitoring
**KNOW VEAL CHOP**
The nurse gives a 35 yr old primigravida client a RhoGAM injection for her 28th
week of pregnancy. Which of the following client situations requires the nurse to
take this action.
A. Rh + mother and Rh - father
B. Rh - mother and Rh + father
C. Rh + mother and Rh + father
, D. Rh - mother and Rh - father - B. RhoGAM is only needed if the mother is
Rh- and there is possibility of the baby being Rh+. If the father is not Rh+ then
there is no chance to have a Rh+ baby
A client has just started the third state of labor. Which of the following nursing
actions have priority at this time?
A. Encourage the client to push
B. Administer Pitocin
C. Place baby skin to skin on mom
D. Assess maternal vital signs Q1hr - C. skin to skin contact is contributes to
mother and baby bonding
**KEY WORDS: just started**
pitocin is administered after the placenta is delivered at the end of stage 3,
maternal vital signs are assessed Q15min after delivery for first 2 hours. Then
hourly assessments are done
A client's first day of her LMP was July 18, 2015. Which of the following should the
nurse tell the client is her EDB?
A. April 18, 2016
B. May 23, 2016
C. April 25, 2016
D. March 25, 2016 - C.
A primigravida woman delivered her baby boy 12 hours ago. She acquired a 3rd
degree midline episiotomy during labor. She expresses moderate discomfort and