Test Bank 1 Newest 2026-2027 With Complete 100
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Question 1.
A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of the following
assessments is the nurse’s priority?
Amount of lochia
RATIONALE- When using the airway, breathing, circulation approach to client care, the
nurse should place the priority in the immediate postpartum period on assessing the amount
of postpartum lochia. The greatest risk to the client is bleeding and postpartum hemorrhage.
Question 2.
A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position.
The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse
take?
Apply sacral counterpressure
RATIONALE-- Sacral counterpressure assists in relieving back labor pain related to fetal
posterior position.
Question 3.
A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform
the following actions?
Wipe the newborn’s eyes from the inner canthus outward. Wash the newborn’s neck by lifting the
newborn’s chin. Cleanse the skin around the newborn’s umbilical cord stump. Wash the newborn’s legs
and feet. Clean the newborn’s diaper area.
RATIONALE-- Use a head to toe, clean to dirty approach when washing a newborn.
Question 4.
A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following
,actions should the nurse take?
Take photos of the newborn to give to the parents.
, RATIONALE-- The nurse should create a memory box that includes mementos of the newborn(ex:
photos, the newborn’s ID bands, the newborn’s hat, & the newborn’s blanket).
Question 5.
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The
nurse should plan to prepare the client for which of the following diagnostic tests?
Biophysical profile
RATIONALE-- A positive contraction stress test indicates that further evaluation of the fetus is
necessary (baby’s heart slowed or showed abnormality during contraction). A biophysical
profile will provide further evaluation with real-time ultrasound.
Question 6.
A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of
the following laboratory results should the nurse report to the provider?
Platelets 50,000/mm3
RATIONALE-- A platelet count of 50,000/mm3 is below the expected reference range, which can
indicate disseminated intravascular coagulation. The nurse should report this result to the
provider.
Question 7.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which
of the following findings should the nurse expect?
Minimal arm recoil
RATIONALE-- The nurse should expect a newborn who was born at 26 weeks gestation to
havedecreased muscular tone, or minimal arm recoil.
Question 8.
A nurse is assessing a newborn following circumcision. Which of the following findings should the nurse
identify as an indication that the newborn is experiencing pain?
Chin quivering
, RATIONALE-- Behavioral responses to a newborn’s pain include facial expressions (ex:
chinquivering, grimacing, & furrowing of the brow).
Question 10.
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI)
during pregnancy. Which of the following manifestations should the nurse identify as an indication of
withdrawal from an SSRI?
Vomiting
RATIONALE-- Expected clinical manifestations associated with fetal exposure to SSRIs
includeirritability, agitation, tremors, diarrhea, & vomiting. These usually last 2 days.
Question 11.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia.
Which of the following actions should the nurse include in the plan?
Remove all clothing from the newborn except the diaper.
RATIONALE-- The nurse should remove all of the newborn’s clothing except the diaper while
under phototherapy. Maximum skin exposure to the ultraviolet light is needed tobreak down the
excess bilirubin.
Question 12.
A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic
cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care?
Protect the client’s head and feet from cold air.
RATIONALE-- Protecting the client’s head and feet from cold air should be included in the planof
care because this is a traditional Hispanic practice during the postpartum period. Hispanic
practices also include delaying bathing for 14 days, bed rest for3 days, and drinking warm
beverages following delivery.
Question 13.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the
nurse take prior to applying an external transducer for fetal monitoring?