• Mental Health Care 09/15/2026
Test Bank for Medical-Surgical Nursing: Concepts for
Clinical Judgment and Collaborative Care, 11th Edition by
Donna D. Ignatavicius | Complete Chapters 1-65 | Questions
& Answers with NCLEX®-Style | Next Generation NCLEX®
(NGN) Prep
A contraction stress test is scheduled, and the nurse provides instructions to the client regarding the test. Which
of the following pieces of information should the nurse give to the client? Select all that apply.
A) An internal fetal monitor is attached.
B) The client will walk on a treadmill until contractions begin.
C) A positive test result indicates a need for further evaluation.
D) Special body movements will be performed to stimulate contractions.
E) The client may be asked to massage one or both nipples to stimulate uterine contractions. –
P 1
, • Mental Health Care 09/15/2026
Correct Answer :Answer: C, E
Rationale: A contraction stress test is used to assess placental oxygenation and function, determine the fetus'
capacity to tolerate labor, and determine fetal well-being; it is performed if the nonstress test result is abnormal.
The fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under
simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline
strip is recorded. The uterus is stimulated to contract either with the administration of a dilute dose of oxytocin
(Pitocin) or by having the mother stimulate the nipples until three palpable contractions with a duration of 40
seconds or more in a 10-minute period have been achieved. Frequent maternal blood pressure readings are
taken, and the client is monitored closely if increasing doses of oxytocin are given. A positive contraction stress
test result indicates that the fetus may be compromised and requires continued monitoring and further
evaluation. A negative result indicates fetal well-being.
A nurse is assessing a client during her first prenatal visit to the clinic. The nurse takes the client's temperature:
100.8° F. Which of the following actions on the part of the nurse is appropriate?
A) Notifying the physician
B) Documenting the temperature
C) Retaking the temperature rectally
D) Informing the client that a temperature of 100.8 °F is normal during pregnancy –
Correct Answer :Answer: A
Rationale: The normal temperature during pregnancy is 98° to 99.6° F (36.2° to 37.6° C). A higher temperature
requires physician notification, because it may indicate an infection that requires medical management. The
temperature would be documented, but this is not the most appropriate action, because the temperature is
abnormal. Taking the temperature rectally is an unnecessarily invasive way of reassessing the client's
temperature. The nurse could retake the temperature again orally to make sure that the original reading was
correct. A temperature of 100.8° F is not normal during pregnancy. Therefore the most appropriate nursing
action is notification of the physician.
A clinic nurse reviews the record of a pregnant client and notes that the physician has documented that the
client exhibits the Hegar sign. The nurse understands that:
A) Fetal movement is being felt by the mother
B) A soft blowing sound can be heard when the uterus is auscultated
C) Softening and compressibility of the lower uterine segment has been detected
D) The client is experiencing irregular painless contractions during the pregnancy –
P 2
, • Mental Health Care 09/15/2026
Correct Answer :Answer: C
Rationale: Softening and compressibility of the lower uterine segment, occurring around the sixth week of
pregnancy, is called the Hegar sign. Quickening, or fetal movement, is not perceived until the second trimester.
Braxton Hicks contractions are irregular painless contractions that occur throughout pregnancy, although many
expectant mothers do not notice them until the third trimester. A soft blowing sound, corresponding to the
maternal pulse, that is auscultated over the uterus is known as uterine souffle. This sound is the result of blood
circulation to the placenta and corresponds to the maternal pulse.
A nurse is caring for a client with preeclampsia who suddenly progresses to an eclamptic state. In which order
should the nurse perform the following actions? Use the number 1 to denote the first action and the number 5
the last.
~Administering oxygen by way of face mask
~Turning the woman on her side
~Beginning an intravenous (IV) infusion of magnesium sulfate solution
~Assessing the maternal blood pressure
~Contacting the physician –
Correct Answer :The correct order is:
Turning the woman on her side
Administering oxygen by way of face mask
Contacting the physician
Assessing the maternal blood pressure
Beginning an intravenous (IV) infusion of magnesium sulfate solution
Rationale: If a client has a seizure (eclampsia), the initial nursing action is ensuring a patent airway. This is done
by turning the woman on her side, because a side-lying position permits greater circulation through the placenta
and helps prevent aspiration. The nurse must remain with the woman and press the emergency bell for
assistance. Applying oxygen is not useful if the client's airway is blocked, so this would be done after the client
has been turned. The physician would be notified, vital signs assessed, and a magnesium sulfate infusion started
per the physician's prescription.
A nurse is providing dietary instructions to a pregnant client with diabetes mellitus. The nurse tells the client that:
P 3
, • Mental Health Care 09/15/2026
A) Fat intake must be increased to ensure that the baby gains weight
B) A high-protein, high-fat diet is necessary to help control the blood glucose level
C) Glucose must be increased in the diet because additional calories are needed during pregnancy
D) It is important to increase fiber in the diet to help control the blood glucose level and prevent constipation –
Correct Answer :Answer: D
Rationale: An increase in calories is needed with pregnancy, but additional glucose should be avoided because it
may cause hyperglycemia. Approximately 50% to 60% of the total calories should be carbohydrate, at least 250
g/day. Protein intake should constitute 12% to 20% of the total kilocalories. Twenty percent to 30% of the daily
caloric intake should come from fat, with no more than 10% saturated fats. High-fiber foods will cause the blood
glucose level to rise more slowly by delaying gastrointestinal absorption. High-fiber foods also aid in the
prevention of constipation.
A nurse is performing an initial assessment of a pregnant adolescent client with diabetes mellitus. The client says
to the nurse, "I've stopped my insulin and cut back on my food." Which client concern does the nurse recognize
as the priority?
A) Concern about gaining weight
B) Concern about getting stretch marks
C) Concern about being able to care for the infant
D) Concern about what her friends might think about her wearing maternity clothes –
Correct Answer :Answer: A
Rationale: The decrease in nutritional intake during the pregnancy will place the mother and fetus at risk.
Because she is diabetic, the mother is at risk for ketoacidosis, which can be harmful to the fetus. Also,
deficiencies of specific nutrients, such as folic acid, may produce fetal anomalies. Body image disturbance is a
problem for this client; however, nutrition is a higher priority. Most adolescent mothers are not developmentally,
emotionally, psychologically, or financially prepared for the responsibilities of parenthood, but this is a concern
that may be addressed as a later time, for it does not put the fetus or the mother at immediate risk.
A nurse is monitoring a client in precipitous labor. The nurse would contact the physician on noting:
A) Fetal descent of 1 cm/hr
B) A reassuring fetal monitoring pattern
C) Cervical dilation of 2 to 4 cm/hr during the active phase
P 4
Test Bank for Medical-Surgical Nursing: Concepts for
Clinical Judgment and Collaborative Care, 11th Edition by
Donna D. Ignatavicius | Complete Chapters 1-65 | Questions
& Answers with NCLEX®-Style | Next Generation NCLEX®
(NGN) Prep
A contraction stress test is scheduled, and the nurse provides instructions to the client regarding the test. Which
of the following pieces of information should the nurse give to the client? Select all that apply.
A) An internal fetal monitor is attached.
B) The client will walk on a treadmill until contractions begin.
C) A positive test result indicates a need for further evaluation.
D) Special body movements will be performed to stimulate contractions.
E) The client may be asked to massage one or both nipples to stimulate uterine contractions. –
P 1
, • Mental Health Care 09/15/2026
Correct Answer :Answer: C, E
Rationale: A contraction stress test is used to assess placental oxygenation and function, determine the fetus'
capacity to tolerate labor, and determine fetal well-being; it is performed if the nonstress test result is abnormal.
The fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under
simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline
strip is recorded. The uterus is stimulated to contract either with the administration of a dilute dose of oxytocin
(Pitocin) or by having the mother stimulate the nipples until three palpable contractions with a duration of 40
seconds or more in a 10-minute period have been achieved. Frequent maternal blood pressure readings are
taken, and the client is monitored closely if increasing doses of oxytocin are given. A positive contraction stress
test result indicates that the fetus may be compromised and requires continued monitoring and further
evaluation. A negative result indicates fetal well-being.
A nurse is assessing a client during her first prenatal visit to the clinic. The nurse takes the client's temperature:
100.8° F. Which of the following actions on the part of the nurse is appropriate?
A) Notifying the physician
B) Documenting the temperature
C) Retaking the temperature rectally
D) Informing the client that a temperature of 100.8 °F is normal during pregnancy –
Correct Answer :Answer: A
Rationale: The normal temperature during pregnancy is 98° to 99.6° F (36.2° to 37.6° C). A higher temperature
requires physician notification, because it may indicate an infection that requires medical management. The
temperature would be documented, but this is not the most appropriate action, because the temperature is
abnormal. Taking the temperature rectally is an unnecessarily invasive way of reassessing the client's
temperature. The nurse could retake the temperature again orally to make sure that the original reading was
correct. A temperature of 100.8° F is not normal during pregnancy. Therefore the most appropriate nursing
action is notification of the physician.
A clinic nurse reviews the record of a pregnant client and notes that the physician has documented that the
client exhibits the Hegar sign. The nurse understands that:
A) Fetal movement is being felt by the mother
B) A soft blowing sound can be heard when the uterus is auscultated
C) Softening and compressibility of the lower uterine segment has been detected
D) The client is experiencing irregular painless contractions during the pregnancy –
P 2
, • Mental Health Care 09/15/2026
Correct Answer :Answer: C
Rationale: Softening and compressibility of the lower uterine segment, occurring around the sixth week of
pregnancy, is called the Hegar sign. Quickening, or fetal movement, is not perceived until the second trimester.
Braxton Hicks contractions are irregular painless contractions that occur throughout pregnancy, although many
expectant mothers do not notice them until the third trimester. A soft blowing sound, corresponding to the
maternal pulse, that is auscultated over the uterus is known as uterine souffle. This sound is the result of blood
circulation to the placenta and corresponds to the maternal pulse.
A nurse is caring for a client with preeclampsia who suddenly progresses to an eclamptic state. In which order
should the nurse perform the following actions? Use the number 1 to denote the first action and the number 5
the last.
~Administering oxygen by way of face mask
~Turning the woman on her side
~Beginning an intravenous (IV) infusion of magnesium sulfate solution
~Assessing the maternal blood pressure
~Contacting the physician –
Correct Answer :The correct order is:
Turning the woman on her side
Administering oxygen by way of face mask
Contacting the physician
Assessing the maternal blood pressure
Beginning an intravenous (IV) infusion of magnesium sulfate solution
Rationale: If a client has a seizure (eclampsia), the initial nursing action is ensuring a patent airway. This is done
by turning the woman on her side, because a side-lying position permits greater circulation through the placenta
and helps prevent aspiration. The nurse must remain with the woman and press the emergency bell for
assistance. Applying oxygen is not useful if the client's airway is blocked, so this would be done after the client
has been turned. The physician would be notified, vital signs assessed, and a magnesium sulfate infusion started
per the physician's prescription.
A nurse is providing dietary instructions to a pregnant client with diabetes mellitus. The nurse tells the client that:
P 3
, • Mental Health Care 09/15/2026
A) Fat intake must be increased to ensure that the baby gains weight
B) A high-protein, high-fat diet is necessary to help control the blood glucose level
C) Glucose must be increased in the diet because additional calories are needed during pregnancy
D) It is important to increase fiber in the diet to help control the blood glucose level and prevent constipation –
Correct Answer :Answer: D
Rationale: An increase in calories is needed with pregnancy, but additional glucose should be avoided because it
may cause hyperglycemia. Approximately 50% to 60% of the total calories should be carbohydrate, at least 250
g/day. Protein intake should constitute 12% to 20% of the total kilocalories. Twenty percent to 30% of the daily
caloric intake should come from fat, with no more than 10% saturated fats. High-fiber foods will cause the blood
glucose level to rise more slowly by delaying gastrointestinal absorption. High-fiber foods also aid in the
prevention of constipation.
A nurse is performing an initial assessment of a pregnant adolescent client with diabetes mellitus. The client says
to the nurse, "I've stopped my insulin and cut back on my food." Which client concern does the nurse recognize
as the priority?
A) Concern about gaining weight
B) Concern about getting stretch marks
C) Concern about being able to care for the infant
D) Concern about what her friends might think about her wearing maternity clothes –
Correct Answer :Answer: A
Rationale: The decrease in nutritional intake during the pregnancy will place the mother and fetus at risk.
Because she is diabetic, the mother is at risk for ketoacidosis, which can be harmful to the fetus. Also,
deficiencies of specific nutrients, such as folic acid, may produce fetal anomalies. Body image disturbance is a
problem for this client; however, nutrition is a higher priority. Most adolescent mothers are not developmentally,
emotionally, psychologically, or financially prepared for the responsibilities of parenthood, but this is a concern
that may be addressed as a later time, for it does not put the fetus or the mother at immediate risk.
A nurse is monitoring a client in precipitous labor. The nurse would contact the physician on noting:
A) Fetal descent of 1 cm/hr
B) A reassuring fetal monitoring pattern
C) Cervical dilation of 2 to 4 cm/hr during the active phase
P 4
