## Maternal-Newborn Nursing
and Women's Health (Part 4)
### Question 1
A patient at 38 weeks gestation is experiencing contractions every 5 minutes that are increasing in
intensity. The patient's cervix is 4 cm dilated and 80% effaced. Which phase of labor is the patient in?
A. Latent phase of the first stage
B. Active phase of the first stage
C. Transition phase of the first stage
D. Second stage of labor
💫RATIONALE✔️✔️: The active phase of the first stage of labor is characterized by cervical dilation
from 4-7 cm, more frequent contractions (every 3-5 minutes), and increasing intensity. The latent phase
is 0-3 cm dilation, and transition is 8-10 cm. The second stage begins with complete cervical dilation (10
cm). The patient is in active labor, and the nurse should prepare for continued cervical dilation.
💫ANSWER✔️✔️: B. Active phase of the first stage
,---
### Question 2
The nurse is assessing a patient who is 6 hours postpartum. The patient's fundus is firm and at the level
of the umbilicus. The patient has moderate lochia rubra with small clots. Which action should the nurse
take?
A. Continue to monitor the patient
B. Notify the healthcare provider
C. Massage the fundus vigorously
D. Administer oxytocin as prescribed
💫RATIONALE✔️✔️: A firm fundus at the level of the umbilicus with moderate lochia rubra is a
normal finding at 6 hours postpartum. The nurse should continue to monitor the patient. The fundus
should remain firm, and lochia should not be excessive. Massaging a firm fundus is not indicated and
may cause discomfort. Oxytocin should only be administered if the fundus is boggy.
💫ANSWER✔️✔️: A. Continue to monitor the patient
---
### Question 3
A patient who is 34 weeks pregnant is diagnosed with preeclampsia. The nurse notes that the patient's
blood pressure is 160/100 mmHg and she has 3+ proteinuria. Which finding indicates the patient may be
developing severe preeclampsia?
, A. Blood pressure of 160/100 mmHg
B. 3+ proteinuria
C. Headache and visual changes
D. Mild edema of the lower extremities
💫RATIONALE✔️✔️: Headache and visual changes (such as scotomata or blurred vision) are signs of
severe preeclampsia and may indicate impending eclampsia. These are neurological symptoms that
require immediate intervention and monitoring. Blood pressure of 160/100 mmHg and 3+ proteinuria
also indicate preeclampsia but may not necessarily indicate severe features.
💫ANSWER✔️✔️: C. Headache and visual changes
---
### Question 4
The nurse is providing education to a patient who is 32 weeks pregnant about signs of preterm labor.
Which symptom should the nurse instruct the patient to report?
A. Low back pain that is constant or intermittent
B. Increased fetal movement
C. Mild pelvic pressure
D. Occasional Braxton-Hicks contractions
💫RATIONALE✔️✔️: Low back pain that is constant or intermittent can be a sign of preterm labor.
The patient should be instructed to report this symptom along with other signs such as regular
contractions, vaginal bleeding, or a change in vaginal discharge. Increased fetal movement and
occasional Braxton-Hicks contractions are normal.
and Women's Health (Part 4)
### Question 1
A patient at 38 weeks gestation is experiencing contractions every 5 minutes that are increasing in
intensity. The patient's cervix is 4 cm dilated and 80% effaced. Which phase of labor is the patient in?
A. Latent phase of the first stage
B. Active phase of the first stage
C. Transition phase of the first stage
D. Second stage of labor
💫RATIONALE✔️✔️: The active phase of the first stage of labor is characterized by cervical dilation
from 4-7 cm, more frequent contractions (every 3-5 minutes), and increasing intensity. The latent phase
is 0-3 cm dilation, and transition is 8-10 cm. The second stage begins with complete cervical dilation (10
cm). The patient is in active labor, and the nurse should prepare for continued cervical dilation.
💫ANSWER✔️✔️: B. Active phase of the first stage
,---
### Question 2
The nurse is assessing a patient who is 6 hours postpartum. The patient's fundus is firm and at the level
of the umbilicus. The patient has moderate lochia rubra with small clots. Which action should the nurse
take?
A. Continue to monitor the patient
B. Notify the healthcare provider
C. Massage the fundus vigorously
D. Administer oxytocin as prescribed
💫RATIONALE✔️✔️: A firm fundus at the level of the umbilicus with moderate lochia rubra is a
normal finding at 6 hours postpartum. The nurse should continue to monitor the patient. The fundus
should remain firm, and lochia should not be excessive. Massaging a firm fundus is not indicated and
may cause discomfort. Oxytocin should only be administered if the fundus is boggy.
💫ANSWER✔️✔️: A. Continue to monitor the patient
---
### Question 3
A patient who is 34 weeks pregnant is diagnosed with preeclampsia. The nurse notes that the patient's
blood pressure is 160/100 mmHg and she has 3+ proteinuria. Which finding indicates the patient may be
developing severe preeclampsia?
, A. Blood pressure of 160/100 mmHg
B. 3+ proteinuria
C. Headache and visual changes
D. Mild edema of the lower extremities
💫RATIONALE✔️✔️: Headache and visual changes (such as scotomata or blurred vision) are signs of
severe preeclampsia and may indicate impending eclampsia. These are neurological symptoms that
require immediate intervention and monitoring. Blood pressure of 160/100 mmHg and 3+ proteinuria
also indicate preeclampsia but may not necessarily indicate severe features.
💫ANSWER✔️✔️: C. Headache and visual changes
---
### Question 4
The nurse is providing education to a patient who is 32 weeks pregnant about signs of preterm labor.
Which symptom should the nurse instruct the patient to report?
A. Low back pain that is constant or intermittent
B. Increased fetal movement
C. Mild pelvic pressure
D. Occasional Braxton-Hicks contractions
💫RATIONALE✔️✔️: Low back pain that is constant or intermittent can be a sign of preterm labor.
The patient should be instructed to report this symptom along with other signs such as regular
contractions, vaginal bleeding, or a change in vaginal discharge. Increased fetal movement and
occasional Braxton-Hicks contractions are normal.
