2025 LATEST VERSIONS EXAM WITH
ACTUAL QUESTIONS AND VERIFIED
ANSWER| ALREADY GRADED A+
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to
augment early labor. the nurse should discontinue the oxytocin infusion for which
pattern of contractions?
A. Transition labor with contractions every 2 minutes, lasting 90 seconds each
B. Early labor with contractions every 5 minutes, lasting 40 seconds each
C. Active labor with contractions every 31 minutes, lasting 60 seconds each
D. Active labor with contractions every 3 to 3 minutes, lasting 70 to 80 seconds each -
ANSWER-A. Transition labor with contractions every 2 minutes, lasting 90 seconds
each
A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic
agents are discontinued. Which intervention is most important for the nurse to
implement?
A. Describe diet changes that can improve the management of her diabetes
B. Inform the client that oral hypoglycemic agents are teratogenic during pregnancy
C. Demonstrate self-administration of insulin
D. Evaluate the client's ability to do glucose monitoring - ANSWER-A. Describe diet
changes that can improve the management of her diabetes
A client is admitted with the diagnosis of total placenta previa. Which finding is most
important for the nurse to report to the healthcare provider immediately?
A. Heart rate of 100 beats/minute
B. Variable fetal heart rate
C. Onset of uterine contractions
D. Burning on urination - ANSWER-C. Onset of uterine contractions
,Total (complete) placenta previa involves the placenta covering the entire cervical os
(opening). The onset of uterine contractions places the client at risk for dilation and
placental separation, which causes painless hemorrhaging.
When oxytocin causes uterine hyperstimulation as evidence by inadequate resting time
between contractions, the oxytocin infusion should be discontinued because placental
perfusion is impeded
Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized edema on the right side of his head. The nurse knows that, in the
newborn, an accumulation of blood between the periosteum and skull which does not
cross the suture line is a newborn variation known as
A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks
B. a subarachnoid hematoma, which requires immediate drainage to prevent further
complications
C. molding, caused by pressure during labor and will disappear withinn 2 to 3 days
D. a subdural hematoma which can result in lifelong damage - ANSWER-A. a
cephalhematoma, caused by forceps trauma and may last up to 8 weeks
Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the
first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and the skull.
The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn
nursery. Which assessment finding should the nurse report to the healthcare provider?
A. Yellowish tinge to the skin
B. Babinski reflex present bilaterally
C. Pink papular rash on the face
D. Moro reflex noted after a loud noise - ANSWER-A. Yellowish tinge to the skin
Cephalohematomas are characterized by bleeding between the bone and its covering,
the periosteum. Due to the breakdown of the red blood cells within a hematoma, the
infant is at a greater risk for jaundice, so a yellowish tinge to the skin should be
reported.
After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil
Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider
changes the neonate's formula to Simialc Soy Isomil formula, a soy protein isolate
based infant formula. What information should the nurse provide to the mother about
the newly prescribed formula?
A. The new formula is a coconut milk formula used with babies with impaired fat
absorption
B. enfamil Formula is a demineralized whey formula that is needed with diarrhea
C. The new formula is a casein protein source that is low in phenylalanine
,D. Similac Soy Isomil Formula is a soy-based formula that contains sucrose -
ANSWER-D. Similac Soy Isomil Formula is a soy-based formula that contains sucrose
The nurse should explain that the newborn's feeding intolerance may be related to the
lactose found in cow's milk formula and is being replaced with the soy-based formula
that contains sucrose, which is well-tolerated in infants with milk allergies and lactose
intolerance.
A full term infant is transferred to the nursery from labor and delivery. Which information
is most important for the nurse to receive when planning immediate care for the
newborn?
A. Length of labor and method of delivery
B. Infant's condition at birth and treatment received
C. Feeding method chosen by the parents
D. History of drugs given to the mother during labor - ANSWER-B. Infant's condition at
birth and treatment received
Immediate care is most dependent on the infant's current status (i.e., Apgar scores at 1
and 5 minutes) and any treatment or resuscitation that was indicated.
Client teaching is an important part of the maternity nurse's role. Which factor has the
greatest influence on successful teaching of the gravid client?
A. The client's readiness to learn
B. The client's educational background
C. The order in which the information is presented
D. The extent to which the pregnancy was planned - ANSWER-A. The client's readiness
to learn
When teaching any client, readiness to learn is the most important criterion. For
example, the client with severe morning sickness in the first trimester may not be "ready
to learn" about labor and delivery, but is probably very "ready to learn" about ways to
relieve morning sickness.
Diet modifications are effective in managing Type 2 diabetes during pregnancy, and
describing the necessary diet changes is the most important intervention for the nurse
to implement with this client.
A healthcare provider informs the charge nurse of a labor and delivery unit that a client
is coming to the unit with suspected abruptio placentae. What findings should the
charge nurse expect the client to demonstrate? (Select all that apply)
A. Dark, red vaginal bleeding
B. Lower back pain
C. Premature rupture of membranes
, D. Increased uterine irritability
E. Bilateral pitting edema
F. A rigid abdomen - ANSWER-A. Dark, red vaginal bleeding
D. Increased uterine irritability
F. A rigid abdomen
The nurse caring for a laboring client encourages her to void at least q2h, and records
each time the client empties her bladder. What is the primary reason for implementing
this nursing intervention?
A. Emptying the bladder during delivery is difficult because of the position of the
presenting fetal part
B. An over-distended bladder could be traumatized during labor, as well as prolong the
progress of labor
C. Urine specimens for glucose and protein must be obtained at certain intervals
throughout labor
D. Frequent voiding minimizes the need for catheterization which increases the chance
of bladder infection - ANSWER-B. An over-distended bladder could be traumatized
during labor, as well as prolong the progress of labor
A full bladder can impair the efficiency of the uterine contractions and impede descent
of the fetus during labor. Also, because of the close proximity of the bladder to the
uterus, the bladder can be traumatized by the descent of the fetus.
The nurse identifies crepitus when examining the chest of a newborn who was delivered
vaginally. Which further assessment should the nurse perform?
A. Elicit a positive scarf sign on the affected side
B. Observe for an asymmetrical Moro (startle) reflex
C. Watch for swelling of fingers on the affected side
D. Note paralysis of affected extremity and muscles - ANSWER-B. Observe for an
asymmetrical Moro (startle) reflex
The most common neonatal birth trauma due to a vaginal delivery is fracture of the
clavicle. Although an infant may be asymptomatic, a fractured clavicle should be
suspected if an infant has limited use of the affected arm, malposition of the arm, an
asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or cries
when the arm is moved.
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation
in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which
assessment is the highest priority for the nurse to monitor during the administration of
this drug?
A. Materna blood pressure and respirations
B. Maternal and fetal heart rates
C. Hourly urinary output