,Q1 APPLY PRINCIPLES OF FAMILY-CENTERED CARE IN MATERNITY SETTINGS
A client at 32 weeks gestation presents with painless, bright red vaginal bleeding.
Ultrasound reveals placenta previa. Which nursing intervention is the priority?
A. Perform a sterile vaginal examination to assess cervical dilation.
B. Initiate continuous external fetal monitoring and assess maternal vital signs. CORRECT
C. Administer a tocolytic to prevent preterm labor.
D. Prepare the client for an immediate cesarean birth.
RATIONALE: With placenta previa, vaginal exams are contraindicated due to risk of hemorrhage.
The priority is to assess fetal and maternal status via monitoring and vital signs. Tocolytics may
be used if contractions present, but not the priority. Cesarean is indicated for unstable clients or
fetal compromise, but not immediate for all.
Q2 APPLY PRINCIPLES OF FAMILY-CENTERED CARE IN MATERNITY SETTINGS
A postpartum client who delivered vaginally 6 hours ago has a fundus that is
boggy and displaced to the right. Which action should the nurse take first?
A. Administer methylergonovine as prescribed.
B. Assist the client to void. CORRECT
C. Massage the fundus firmly.
D. Document the findings and recheck in 30 minutes.
RATIONALE: A boggy fundus displaced to the right suggests a distended bladder. The nurse
should first assist the client to void to relieve the displacement. After voiding, reassess the
fundus; if still boggy, massage and then consider oxytocics. Administering methylergonovine
before addressing the bladder may not correct the displacement and could cause uterine tetany.
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,Q3 APPLY PRINCIPLES OF FAMILY-CENTERED CARE IN MATERNITY SETTINGS
A nurse is assessing a client at 28 weeks gestation with a history of type 1
diabetes mellitus. Which laboratory value indicates a need to adjust insulin
therapy?
A. Hemoglobin A1c of 5.8%
B. 2-hour postprandial glucose of 140 mg/dL
C. Fasting blood glucose of 95 mg/dL
D. Glycosylated hemoglobin of 7.2% CORRECT
RATIONALE: In pregnancy, target A1c is <6% to reduce congenital anomalies. A value of 7.2% is
elevated and indicates poor glycemic control, necessitating insulin adjustment. The other values
are within acceptable ranges for pregnancy.
Q4 APPLY PRINCIPLES OF FAMILY-CENTERED CARE IN MATERNITY SETTINGS
A client in active labor receives epidural analgesia. Which finding requires
immediate intervention?
A. Fetal heart rate decelerations to 110 bpm with recovery to baseline.
B. Maternal blood pressure of 90/60 mm Hg with no symptoms. CORRECT
C. Pruritus of the face and neck.
D. Decreased uterine contraction frequency to every 4 minutes.
RATIONALE: A blood pressure of 90/60 may indicate hypotension from sympathetic blockade,
which can compromise placental perfusion. Even without symptoms, it requires intervention (IV
fluids, positioning, possibly ephedrine). FHR decelerations to 110 with recovery are benign.
Pruritus is a common side effect. Contraction frequency every 4 minutes is acceptable in active
labor.
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, Q5 APPLY PRINCIPLES OF FAMILY-CENTERED CARE IN MATERNITY SETTINGS
A nurse is providing education to a client with preeclampsia who is receiving
magnesium sulfate. Which statement indicates the need for further teaching?
A. I will notify the nurse if I experience flushing or warmth.
B. I should report any difficulty breathing or chest pain.
C. I can stop taking the medication if my headache improves. CORRECT
D. I will call for assistance when getting out of bed.
RATIONALE: Magnesium sulfate is a central nervous system depressant used to prevent
seizures; it must be continued as prescribed until discontinued by the provider. Stopping it due to
symptom improvement is dangerous. Flushing is a common side effect, respiratory depression
and chest pain are adverse effects to report, and assistance with ambulation is needed due to
muscle weakness.
Q6 APPLY PRINCIPLES OF FAMILY-CENTERED CARE IN MATERNITY SETTINGS
A client at 39 weeks gestation is in the active phase of labor. Her cervix is 5 cm
dilated, 100% effaced, and the fetus is in LOA position. Which nursing action is
most appropriate?
A. Encourage the client to push with contractions.
B. Apply the fetal scalp electrode for continuous monitoring.
C. Offer the client an epidural if she desires. CORRECT
D. Prepare for an amniotomy.
RATIONALE: Active labor is an appropriate time to offer analgesia, including an epidural.
Pushing is not indicated until full dilation. Fetal scalp electrode is used for inadequate external
monitoring, not routine. Amniotomy is not necessary unless indicated for labor augmentation or
monitoring.
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A client at 32 weeks gestation presents with painless, bright red vaginal bleeding.
Ultrasound reveals placenta previa. Which nursing intervention is the priority?
A. Perform a sterile vaginal examination to assess cervical dilation.
B. Initiate continuous external fetal monitoring and assess maternal vital signs. CORRECT
C. Administer a tocolytic to prevent preterm labor.
D. Prepare the client for an immediate cesarean birth.
RATIONALE: With placenta previa, vaginal exams are contraindicated due to risk of hemorrhage.
The priority is to assess fetal and maternal status via monitoring and vital signs. Tocolytics may
be used if contractions present, but not the priority. Cesarean is indicated for unstable clients or
fetal compromise, but not immediate for all.
Q2 APPLY PRINCIPLES OF FAMILY-CENTERED CARE IN MATERNITY SETTINGS
A postpartum client who delivered vaginally 6 hours ago has a fundus that is
boggy and displaced to the right. Which action should the nurse take first?
A. Administer methylergonovine as prescribed.
B. Assist the client to void. CORRECT
C. Massage the fundus firmly.
D. Document the findings and recheck in 30 minutes.
RATIONALE: A boggy fundus displaced to the right suggests a distended bladder. The nurse
should first assist the client to void to relieve the displacement. After voiding, reassess the
fundus; if still boggy, massage and then consider oxytocics. Administering methylergonovine
before addressing the bladder may not correct the displacement and could cause uterine tetany.
Page 2
,Q3 APPLY PRINCIPLES OF FAMILY-CENTERED CARE IN MATERNITY SETTINGS
A nurse is assessing a client at 28 weeks gestation with a history of type 1
diabetes mellitus. Which laboratory value indicates a need to adjust insulin
therapy?
A. Hemoglobin A1c of 5.8%
B. 2-hour postprandial glucose of 140 mg/dL
C. Fasting blood glucose of 95 mg/dL
D. Glycosylated hemoglobin of 7.2% CORRECT
RATIONALE: In pregnancy, target A1c is <6% to reduce congenital anomalies. A value of 7.2% is
elevated and indicates poor glycemic control, necessitating insulin adjustment. The other values
are within acceptable ranges for pregnancy.
Q4 APPLY PRINCIPLES OF FAMILY-CENTERED CARE IN MATERNITY SETTINGS
A client in active labor receives epidural analgesia. Which finding requires
immediate intervention?
A. Fetal heart rate decelerations to 110 bpm with recovery to baseline.
B. Maternal blood pressure of 90/60 mm Hg with no symptoms. CORRECT
C. Pruritus of the face and neck.
D. Decreased uterine contraction frequency to every 4 minutes.
RATIONALE: A blood pressure of 90/60 may indicate hypotension from sympathetic blockade,
which can compromise placental perfusion. Even without symptoms, it requires intervention (IV
fluids, positioning, possibly ephedrine). FHR decelerations to 110 with recovery are benign.
Pruritus is a common side effect. Contraction frequency every 4 minutes is acceptable in active
labor.
Page 3
, Q5 APPLY PRINCIPLES OF FAMILY-CENTERED CARE IN MATERNITY SETTINGS
A nurse is providing education to a client with preeclampsia who is receiving
magnesium sulfate. Which statement indicates the need for further teaching?
A. I will notify the nurse if I experience flushing or warmth.
B. I should report any difficulty breathing or chest pain.
C. I can stop taking the medication if my headache improves. CORRECT
D. I will call for assistance when getting out of bed.
RATIONALE: Magnesium sulfate is a central nervous system depressant used to prevent
seizures; it must be continued as prescribed until discontinued by the provider. Stopping it due to
symptom improvement is dangerous. Flushing is a common side effect, respiratory depression
and chest pain are adverse effects to report, and assistance with ambulation is needed due to
muscle weakness.
Q6 APPLY PRINCIPLES OF FAMILY-CENTERED CARE IN MATERNITY SETTINGS
A client at 39 weeks gestation is in the active phase of labor. Her cervix is 5 cm
dilated, 100% effaced, and the fetus is in LOA position. Which nursing action is
most appropriate?
A. Encourage the client to push with contractions.
B. Apply the fetal scalp electrode for continuous monitoring.
C. Offer the client an epidural if she desires. CORRECT
D. Prepare for an amniotomy.
RATIONALE: Active labor is an appropriate time to offer analgesia, including an epidural.
Pushing is not indicated until full dilation. Fetal scalp electrode is used for inadequate external
monitoring, not routine. Amniotomy is not necessary unless indicated for labor augmentation or
monitoring.
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