MATERNITY EVOLVE - EXAMINATION COMPLETE
QUESTIONS AND DETAILED SOLUTIONS LATEST
UPDATE THIS YEAR JUST RELEASED
Anurseisassistingaphysicianinperformingaphysical examinationof aclient whohasjust
beentoldthat sheispregnant. Thephysiciantellsthenursethat theGoodell signispresent.
The nurseunderstandsthat thissignisindicativeof:
A. Thepresenceof fetal movement
B. Ahighriskforspontaneousabortion
C. Anincreaseinvascularityandhyptertrophyof
thecervix
D. Thepresenceof humanchorionicgonadotropin(hCG)intheurine Incorrect
Rationale: In the early weeks of pregnancy, the cervix becomes more vascular and slightly hypertrophic; this is referred to as the
Goodell sign. The edematous appearance of the cervix will be noted during pelvic examination by the examiner. hCG is noted in
maternal urine in a urine pregnancy test. The Goodell sign does not indicate the presence of fetal movement or a risk for
spontaneous abortion.
Test-Taking Strategy: Knowledge regarding the Goodell sign is required to answer this question. It is necessary to know that the sign
consists of increased vascularity and hypertrophy of the cervix. If you had difficulty with this question, review the changes in the
cervix that occur during pregnancy.
• Anurseismonitoringaclient inlaborforsignsof intrauterineinfection. Whichsign,
indicativeof infection, would prompt thenursetocontact the healthcareprovider?
A. Maternal fatigue
B. Clearamnioticfluid
C. Strong-smelling amnioticfluid
, D. Afetal heart rateof 140beats/min
Rationale: Signs associated with intrauterine infection includes fetal tachycardia (rising baseline or faster than 160 beats/min, a
maternal fever (38° C or 100.4° F), foul or strong-smelling amniotic fluid, or cloudy or yellow amniotic fluid. The normal fetal heart
rate is 110 to 160 beats/min. Clear amniotic fluid is normal. Maternal fatigue normally occurs during labor.
Test-Taking Strategy: Focus on the subject of the question, a sign of intrauterine infection. Eliminate the options that are comparable
or alike in that they are normal expectations during labor. Review the signs of intrauterine infection if you had difficulty with this
question.
• Anurseisassessingtheuterinefundusof aclient whohasjust deliveredababy
andnotesthat thefundusisboggy. Thenursemassagesthefundus, and
thenpressestoexpel clotsfromthe uterus. Toprevent uterine inversionduring
thisprocedure, thenurse:
A. Hastheclient voidbeforetheuterineassessment
B. Tellsthewomantobeardownduringfundal message
C. Simultaneously providespressureoverthelower uterinesegment
Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse
must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the
clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having
the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse
performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine
inversion.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, prevention of uterine inversion. Visualizing each of the
actions in the options and relating the action to the subject of the question will direct you to the correct option. Review fundal
assessment and massage if you had difficulty with this question.
• Anonstresstest isperformed, andthephysiciandocuments“accelerationslasting
,3|Page
lessthan15secondsthroughout fetal movement.”
Thenurseinterpretsthesefindingsas:
A. Normal
B. Reactive
C. Nonreactive
D. Inconclusive
Rationale: Areactivenonstresstest isanormal, ornegative, result andindicatesahealthyfetus.
The result requirestwoormorefetal heart rateaccelerationsof at least 15beats/minlasting at
least 15 secondsfromthebeginning of theaccelerationt
otheend, inassociationwithfetal movement, during a 20-minuteperiod. Anonreactivetest isan
abnormal test, showing noaccelerationsor accelerationsof lessthan15beats/minor lasting lessthan15
secondsduring a 40minuteobservation. An inconclusiveresult isonethat cannot beinterpreted
because of thepoor quality of thefetal heart raterecording.
Test-TakingStrategy: Usetheprocessof elimination. Eliminateareactivenonstresstest andanormal
nonstresstest first becausethey arecomparableoralike. Toselect fromtheremaining options, notethe
relationshipbetween“lessthan15seconds” inthequestionand“nonreactive” inthecorrect option. If you
haddifficultyansweringthisquestion, reviewtheinterpretationof nonstresstest results.
• Anursecaring for a client inlabor performsanassessment. Theclient ishaving consistent
contractionslessthan2 minutesapart. Thefetal heart rate(FHR)is170beats/min, andfetal
monitoringindicatesapatternof decreasedvariability. Inlight of thesefindings,
theappropriate nursing actionis:
A. Contactingthephysician
,4|Page
B. Documentingthefindings
C. Continuingtomonitortheclient
QUESTIONS AND DETAILED SOLUTIONS LATEST
UPDATE THIS YEAR JUST RELEASED
Anurseisassistingaphysicianinperformingaphysical examinationof aclient whohasjust
beentoldthat sheispregnant. Thephysiciantellsthenursethat theGoodell signispresent.
The nurseunderstandsthat thissignisindicativeof:
A. Thepresenceof fetal movement
B. Ahighriskforspontaneousabortion
C. Anincreaseinvascularityandhyptertrophyof
thecervix
D. Thepresenceof humanchorionicgonadotropin(hCG)intheurine Incorrect
Rationale: In the early weeks of pregnancy, the cervix becomes more vascular and slightly hypertrophic; this is referred to as the
Goodell sign. The edematous appearance of the cervix will be noted during pelvic examination by the examiner. hCG is noted in
maternal urine in a urine pregnancy test. The Goodell sign does not indicate the presence of fetal movement or a risk for
spontaneous abortion.
Test-Taking Strategy: Knowledge regarding the Goodell sign is required to answer this question. It is necessary to know that the sign
consists of increased vascularity and hypertrophy of the cervix. If you had difficulty with this question, review the changes in the
cervix that occur during pregnancy.
• Anurseismonitoringaclient inlaborforsignsof intrauterineinfection. Whichsign,
indicativeof infection, would prompt thenursetocontact the healthcareprovider?
A. Maternal fatigue
B. Clearamnioticfluid
C. Strong-smelling amnioticfluid
, D. Afetal heart rateof 140beats/min
Rationale: Signs associated with intrauterine infection includes fetal tachycardia (rising baseline or faster than 160 beats/min, a
maternal fever (38° C or 100.4° F), foul or strong-smelling amniotic fluid, or cloudy or yellow amniotic fluid. The normal fetal heart
rate is 110 to 160 beats/min. Clear amniotic fluid is normal. Maternal fatigue normally occurs during labor.
Test-Taking Strategy: Focus on the subject of the question, a sign of intrauterine infection. Eliminate the options that are comparable
or alike in that they are normal expectations during labor. Review the signs of intrauterine infection if you had difficulty with this
question.
• Anurseisassessingtheuterinefundusof aclient whohasjust deliveredababy
andnotesthat thefundusisboggy. Thenursemassagesthefundus, and
thenpressestoexpel clotsfromthe uterus. Toprevent uterine inversionduring
thisprocedure, thenurse:
A. Hastheclient voidbeforetheuterineassessment
B. Tellsthewomantobeardownduringfundal message
C. Simultaneously providespressureoverthelower uterinesegment
Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse
must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the
clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having
the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse
performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine
inversion.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, prevention of uterine inversion. Visualizing each of the
actions in the options and relating the action to the subject of the question will direct you to the correct option. Review fundal
assessment and massage if you had difficulty with this question.
• Anonstresstest isperformed, andthephysiciandocuments“accelerationslasting
,3|Page
lessthan15secondsthroughout fetal movement.”
Thenurseinterpretsthesefindingsas:
A. Normal
B. Reactive
C. Nonreactive
D. Inconclusive
Rationale: Areactivenonstresstest isanormal, ornegative, result andindicatesahealthyfetus.
The result requirestwoormorefetal heart rateaccelerationsof at least 15beats/minlasting at
least 15 secondsfromthebeginning of theaccelerationt
otheend, inassociationwithfetal movement, during a 20-minuteperiod. Anonreactivetest isan
abnormal test, showing noaccelerationsor accelerationsof lessthan15beats/minor lasting lessthan15
secondsduring a 40minuteobservation. An inconclusiveresult isonethat cannot beinterpreted
because of thepoor quality of thefetal heart raterecording.
Test-TakingStrategy: Usetheprocessof elimination. Eliminateareactivenonstresstest andanormal
nonstresstest first becausethey arecomparableoralike. Toselect fromtheremaining options, notethe
relationshipbetween“lessthan15seconds” inthequestionand“nonreactive” inthecorrect option. If you
haddifficultyansweringthisquestion, reviewtheinterpretationof nonstresstest results.
• Anursecaring for a client inlabor performsanassessment. Theclient ishaving consistent
contractionslessthan2 minutesapart. Thefetal heart rate(FHR)is170beats/min, andfetal
monitoringindicatesapatternof decreasedvariability. Inlight of thesefindings,
theappropriate nursing actionis:
A. Contactingthephysician
,4|Page
B. Documentingthefindings
C. Continuingtomonitortheclient
