Maternity Nursing (OB Maternal & Newborn) NCLEX Practice Quiz #1 | 75 Questions

Maternity Nursing (OB Maternal & Newborn) NCLEX Practice Quiz #1 | 75 Questions 1. 1. Question A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert? o A. Endometritis o B. Endometriosis o C. Salpingitis o D. Pelvic thrombophlebitis Incorrect Correct Answer: A. Endometritis Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Symptoms include swelling of the abdomen, abnormal vaginal bleeding or discharge, fever, discomfort with bowel movement, and pain in the lower abdomen or pelvic region. o Option B: Endometriosis does not occur after a strong labor and prolonged rupture of membranes. It is a painful disorder in which tissue similar to the tissue that normally lines the inside of the uterus grows outside of the uterus. o Option C: Salpingitis is a tubal infection and could occur if endometritis is not treated. It is an inflammation of the fallopian tubes caused by bacterial infection. o Option D: Pelvic thrombophlebitis involves a clot formation, but it is not a complication of prolonged rupture of membranes. It is an extremely rare condition that occurs after delivery when an infected blood clot, or thrombus, causes inflammation in the pelvic vein. 2. 2. Question A client at 36 weeks gestation is scheduled for a routine ultrasound prior to amniocentesis. After teaching the client about the purpose of the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? o A. The ultrasound will help to locate the placenta. o B. The ultrasound identifies blood flow through the umbilical cord. o C. The test will determine where to insert the needle. o D. The ultrasound locates a pool of amniotic fluid. Incorrect Correct Answer: B. The ultrasound identifies blood flow through the umbilical cord. Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this. o Option A: As early as 10 weeks, the placenta can be detected by an ultrasound. The normal placenta is discoid with uniform echogenicity and rounded margins. It is usually located along the anterior or posterior uterine walls, extending into the lateral walls. o Option C: Ultrasound is done before and during amniocentesis to ensure that the needle can safely pass through the walls of the abdomen and womb. o Option D: The sample of amniotic fluid is removed through a fine needle inserted into the uterus through the abdomen, under ultrasound guidance. 3. 3. Question While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy? o A. Calcium gluconate o B. Protamine sulfate o C. Methylergonovine (Methergine) o D. Nitrofurantoin (Macrodantin) Incorrect Correct Answer: B. Protamine sulfate Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications caused by heparin overdose. o Option A: Calcium gluconate is the calcium salt of gluconic acid, an intravenous medication used to treat conditions arising from calcium deficiencies such as hypocalcemic tetany and hypocalcemia. o Option C: Methylergonovine is used to prevent or treat bleeding from the uterus that can happen after childbirth or an abortion. o Option D: Nitrofurantoin is used to treat urinary tract infections. It is an antibiotic that works by killing bacteria that cause infection. 4. 4. Question When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following? o A. Turn the neonate every 6 hours o B. Encourage the mother to discontinue breastfeeding. o C. Notify the physician if the skin becomes bronze in color. o D. Check the vital signs every 2 to 4 hours. Incorrect Correct Answer: D. Check the vital signs every 2 to 4 hours While caring for an infant receiving phototherapy for treatment of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights. o Option A: Only one study reported the significance drop in serum bilirubin and shorter duration of phototherapy in the supine group. Keeping the jaundiced newborn in the supine position throughout phototherapy is as effective as turning them periodically based on appraised studies. o Option B: The baby may be breastfed without interruption during phototherapy. Jaundice in breastfed babies is not a reason to stop breastfeeding as long as a baby is feeding well, gaining weight, and otherwise growing. o Option C: Bronze baby syndrome is a rare complication seen in neonates with hyperbilirubinemia who are being treated with phototherapy. Affected neonates develop gray-brown skin, serum, and urine within a week of initiation of phototherapy. 5. 5. Question A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective? o A. Back o B. Abdomen o C. Fundus o D. Perineum Incorrect Correct Answer: D. Perineum A bilateral pudendal block is used for vaginal deliveries to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair. o Option A: A spinal anesthetic is given into the middle of the lower back and local anesthetic is injected through the needle into the fluid that surrounds the spinal cord. It numbs the nerves that supply the abdomen, hips, bottom, and legs. o Option B: General or regional anesthesia can be appropriate for patients undergoing abdominal surgery. Balanced anesthesia with inhalational anesthetics, opioids, and neuromuscular blockers are used in general anesthesia for abdominal surgical procedures. o Option C: Spinal anesthesia is one of the most preferred anesthetic methods during Cesarean section since it provides easy and rapid induction, effective sensory and motor block, and has little effect on the fetus. 6. 6. Question The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: o A. “Nausea and vomiting can be decreased if I eat a few crackers before rising.” o B. “If I start to leak colostrum, I should cleanse my nipples with soap and water.” o C. “If I have a vaginal discharge, I should wear nylon underwear.” o D. “Leg cramps can be alleviated if I put an ice pack on the area.” Incorrect Correct Answer: A. “Nausea and vomiting can be decreased if I eat a few crackers before arising” Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help. o Option B: Colostrum is a milky fluid that’s released by mammals that have recently given birth before breast milk production begins. o Option C: Cotton underwear is breathable and absorbent, which can help prevent yeast infections. o Option D: A heating pad or hot pack may help relieve tight muscles in leg cramps. 7. 7. Question Forty-eight hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following? o A. Taking in o B. Letting go o C. Taking hold o D. Resolution Incorrect Correct Answer: C. Taking hold Beginning after completion of the taking-in phase, the taking-hold phase lasts about 10 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills. o Option A: The taking-in phase usually sets 1 to 2 days after delivery. The woman prefers to talk about her experiences during labor and birth and also her pregnancy. The taking-in phase provides time for the woman to regain her physical strength and organize her rambling thoughts about her new role. o Option B: During the letting go phase, the woman finally accepts her new role and gives up her old roles like being a childless woman or just mother of one child. o Option D: The resolution phase or ending phase is the final stage of the nurse-client relationship. After the client’s problems or issues are addressed, the relationship needs to be completed before it can be terminated. 8. 8. Question A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? o A. Activity limited to bed rest. o B. Platelet infusion. o C. Immediate cesarean delivery. o D. Labor induction with oxytocin. Incorrect Correct Answer: A. Activity limited to bed rest Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client’s bleeding. o Option B: The greatest risk of placenta previa is hemorrhage. Bleeding often occurs as the lower part of the uterus thins during the third trimester of pregnancy in preparation for labor. This may require blood transfusion during Cesarean section. o Option C: In general, there is a higher Cesarean rate associated with placental edge-to-cervical os distances of less than 2 cm. o Option D: Labor induction is the stimulation of uterine contractions during pregnancy before labor begins on its own to achieve a vaginal birth. It is not an option for placenta previa. 9. 9. Question The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? o A. Feeding the neonate a maximum of 5 minutes per side on the first day. o B. Wearing a supportive brassiere with nipple shields. o C. Breastfeeding the neonate at frequent intervals. o D. Decreasing fluid intake for the first 24 to 48 hours. Incorrect Correct Answer: C. Breastfeeding the neonate at frequent intervals Prevention of breast engorgement is key. The best technique is to empty the breast regularly while feeding. Engorgement is less likely when the mother and neonate are together, as in single-room maternity care continuous rooming-in, because nursing can be done conveniently to meet the neonate’s and mother’s needs. o Option A: A newborn feeds every 2 to 3 hours. They should be breastfed 8-12 times per day for about the first month. Frequent feedings help stimulate your milk production during the first few weeks. o Option B: A nipple shield is usually meant to be used for a short time. When using a shield, help the baby to latch on by himself with a wide-open mouth. This will help the baby learn to breastfeed without a shield. o Option D: Breastfeeding women are recommended to increase fluid intake by 800 ml/day during the first 6 months postpartum. 10. 10. Question When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands open, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes? o A. Startle reflex o B. Babinski reflex o C. Grasping reflex o D. Tonic neck reflex Incorrect Correct Answer: A. Startle reflex The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months. o Option B: Babinski reflex occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toe fan out. o Option C: Palmar grasp reflex appears around 16 weeks of gestation and can be elicited in preterm infants as young as 25 weeks of postconceptional age. To elicit the reflex, the infant is laid in a symmetrical supine and the examiner strokes the palm of the infant with his or her index finger. The response to this stimulus comprises two phases: finger closing and clinging. o Option D: When a baby’s head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow. The tonic neck reflex lasts until the infant is about 5 to 7 months old. 11. 11. Question A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform: o A. Tailor sitting o B. Leg lifting o C. Shoulder circling o D. Squatting exercises Incorrect Correct Answer: A. Tailor sitting Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time. o Option B: The leg raise is a great way to strengthen the abdominal muscles. It targets the lower abdominal muscles and hip muscles. o Option C: This exercise can warm up the shoulders, specifically the muscles in the rotator cuff. o Option D: During pregnancy, squats are an excellent resistance exercise to maintain strength and range of motion in the hips, glutes, core, and pelvic floor muscles. 12. 12. Question Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision? o A. Notify the neonate’s pediatrician immediately. o B. Check the diaper and circumcision again in 30 minutes. o C. Secure the diaper tightly to apply pressure on the site. o D. Apply gentle pressure to the site with a sterile gauze pad. Incorrect Correct Answer: D. Apply gentle pressure to the site with a sterile gauze pad If bleeding occurs after circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs. o Option A: Immediate nursing intervention and assessment should be done first before notifying the physician. o Option B: 30 minutes is a long time to reassess. Addressing the bleeding immediately may save it from getting worse. o Option C: Tightening the diaper may elicit a case of diaper rash. Applying direct pressure on the bleeding site is more effective. 13. 13. Question Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta? o A. Excessive vaginal bleeding o B. Rigid, board-like abdomen o C. Tetanic uterine contractions o D. Premature rupture of membranes Incorrect Correct Answer: B. Rigid, board-like abdomen The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common. o Option A: It’s possible for the blood to become trapped inside the uterus, so even with a severe placental abruption, there might be no visible bleeding. o Option C: Uterine contractions are a common finding with placental abruption. Contractions progress as the abruption expands, and uterine hypertonus may be noted. Contractions are painful and palpable. o Option D: Increased frequency of placental abruption was found in patients with early rupture of membranes. The incidence was 50% and 44% when rupture of the membranes occurred before 20 weeks or between 20-24 weeks of pregnancy, respectively. 14. 14. Question While the client is in active labor with twins and the cervix is 5 cm dilated, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse’s most appropriate action? o A. Note the fetal heart rate patterns. o B. Notify the physician immediately. o C. Administer oxygen at 6 liters by mask. o D. Have the client pant-blow during the contractions. Incorrect Correct Answer: B. Notify the physician immediately. The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists. o Option A: A baby’s heart rate during labor should be between 110 and 160 beats per minute, but it may fluctuate above and below this rate for a variety of reasons. o Option C: Maternal oxygen is often given to laboring women to improve fetal metabolic status or in an attempt to alleviate non-reassuring fetal heart rate patterns. However, there are only two randomized trials investigating the use of maternal oxygen supplementation in laboring women. These studies did not find that supplementation is likely to benefit the fetus and may even be harmful. o Option D: During active labor, breathing should be as slow as possible, but it can be sped up as the intensity of the contraction increases. As the contraction peaks and the breathing rate increases, switch to light breathing both in and out the mouth, about one breath per second. 15. 15. Question A client tells the nurse, “I think my baby likes to hear me talk to him.” When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response? o A. High-pitched speech with tonal variations. o B. Low-pitched speech with a sameness of tone. o C. Cooing sounds rather than words. o D. Repeated stimulation with loud sounds. Incorrect Correct Answer: A. High-pitched speech with tonal variations Providing stimulation and speaking to neonates is important. Some authorities believe that speech is the most important type of sensory stimulation for a neonate. Neonates respond best to speech with tonal variations and a high-pitched voice. A neonate can hear all sound louder than about 55 decibels. o Option B: Low pitched speech is less effective for neonates because they can hear all sounds louder than about 55 decibels. o Option C: At about two months, the infant may start cooing and repeating vowel sounds. Imitate his cooing while also adding simple words and phrases over the first four to six months. o Option D: A baby’s hearing is very sensitive and can be easily damaged by loud sounds. It is recommended to keep sounds around the infant quieter than 60 decibels. 16. 16. Question A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in? o A. Active phase o B. Latent phase o C. Expulsive phase o D. Transitional phase Incorrect Correct Answer: D. Transitional phase The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. o Option A: The active phase extends from 4 to 7 cm; it is moderate for the patient. o Option B: The latent phase extends from 0 to 3 cm; it is mild in nature. o Option C: The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta. 17. 17. Question A pregnant patient asks the nurse if she can take castor oil for her constipation. How should the nurse respond? o A. “Yes, it produces no adverse effect.” o B. “No, it can initiate premature uterine contractions.” o C. “No, it can promote sodium retention.” o D. “No, it can lead to increased absorption of fat-soluble vitamins.” Incorrect Correct Answer: B. “No, it can initiate premature uterine contractions.” Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. o Option A: Castor oil is a harsh stimulant laxative that relieves constipation by forced bowel movements. Side effects may include nausea, stimulation of uterine activity, meconium-stained fluid, and amniotic fluid embolism. o Option C: There is no evidence that suggests that castor oil can promote sodium retention. o Option D: Castor oil is not known to increase absorption of fat-soluble vitamins, although laxatives, in general, may decrease absorption if intestinal motility is increased. 18. 18. Question A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this patient? o A. Knowledge deficit o B. Fluid volume deficit o C. Anticipatory grieving o D. Pain Incorrect Correct Answer: B. Fluid volume deficit If bleeding and clots are excessive, this patient may become hypovolemic. Pad count should be instituted. Blood volume expands during pregnancy, and a considerable portion of the weight of a pregnant woman is retained water. o Option A: Knowledge deficit is an appropriate nursing diagnosis because the woman might not have any knowledge on how to manage her symptoms. However, this is not a priority diagnosis. o Option C: Anticipatory grieving is the name given to the tumultuous set of feelings and reactions that occur when someone is expecting the death of a loved one. o Option D: Pain may be felt due to abdominal cramping accompanied by bleeding. This is not a cause of alarm since true labor pain includes strong and regular contractions and lower back pain. 19. 19. Question Immediately after delivery, the nurse-midwife assesses the neonate’s head for signs of molding. Which factors determine the type of molding? o A. Fetal body flexion or extension o B. Maternal age, body frame, and weight o C. Maternal and paternal ethnic backgrounds o D. Maternal parity and gravidity Incorrect Correct Answer: A. Fetal body flexion or extension Fetal attitude—the overall degree of body flexion or extension—determines the type of molding in the head of a neonate. o Option B: When a baby is born in a cephalic position, pressure on the head in the birth canal may mold the head into an oblong shape. The mother’s age, body frame, and weight do not affect the pressure. o Option C: There is research that indicates that infant head molding, the application of pressure or bindings to cranial bones to alter their shapes, is prevalent among various Caribbean, Latino, European, African American, Asian, and Native American groups. o Option D: Infants born by primiparous women showed significantly higher degrees of molding of the head than those born by multiparous women. 20. 20. Question For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? o A. The membranes must rupture. o B. The fetus must be at 0 station. o C. The cervix must be dilated fully. o D. The patient must receive anesthesia. Incorrect Correct Answer: A. The membranes must rupture. Internal fetal heart rate monitoring uses an electronic transducer connected directly to the fetal skin. A wire electrode is attached to the fetal scalp or other body parts through the cervical opening and is connected to the monitor. Internal EFM can be applied only after the patient’s membranes have ruptured when the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm. o Option B: An electrode will be attached to the part of the infant’s body that is closest to the cervical opening. o Option C: Dilation of at least 2 cm is adequate enough to insert the electrode through the cervical opening. o Option D: Although the patient may receive anesthesia, it is not required before application of an internal EFM device. 21. 21. Question A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in the early part of the first stage of labor. Her pain is likely to be most intense: o A. Around the pelvic girdle o B. Around the pelvic girdle and in the upper arms o C. Around the pelvic girdle and at the perineum o D. At the perineum Incorrect Correct Answer: A. Around the pelvic girdle During most of the first stage of labor, pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage, pain spreads to the upper legs and perineum. The pain of early labor is referred to T10-T12 dermatomes such that the pain is felt in the lower abdomen, sacrum, and back. This pain is dull in character and is not always sensitive to opioid drugs. o Option B: Upper arm pain is not common during any stage of labor. With each uterine contraction, pressure is transmitted to the cervix causing stretching and distension and activating excitatory nociceptive afferents. o Option C: Pain arises due to afferents that innervate the vaginal surface of the cervix, perineum, and vagina and occurs as a result of stretching, distention, ischemia, and injury of the pelvic floor, perineum, and vagina. o Option D: During the late part of the second stage and childbirth, intense pain occurs at the perineum. Somatic pain occurs closer to delivery, is sharp in character and easily localized to the vagina, perineum, and rectum. It radiates to the adjacent dermatomes T10 and L1 and compared to visceral pain, is more resistant to opioid drugs. 22. 22. Question A female adult patient is taking a progestin-only oral contraceptive or mini pill. Progestin use may increase the patient’s risk for: o A. Endometriosis o B. Female hypogonadism o C. Premenstrual syndrome o D. Tubal or ectopic pregnancy Incorrect Correct Answer: D. Tubal or ectopic pregnancy Women taking the mini pill have a higher incidence of tubal and ectopic pregnancies, possibly because progestin slows ovum transport through the fallopian tubes. o Option A: Progestins are widely regarded as effective treatments for the symptoms of endometriosis despite not all being indicated for the treatment of the disease. It is not yet fully understood how progestins relieve the symptoms of endometriosis, but they probably work by suppressing the growth of endometrial implants in some way, causing them to gradually waste away. o Option B: Hypogonadism is a condition in which the male testes or the female ovaries produce little or no sex hormones. Treatment may involve estrogen and progesterone pills or skin patches, GnRH injections, or HCG injections. o Option C: Premenstrual syndrome is defined as the recurrence of psychological and physical symptoms in the luteal phase, which remit in the follicular phase of the menstrual cycle. The rationale for the use of progesterone and progestogens in the management of premenstrual syndrome is based on the unsubstantiated premise that progesterone deficiency is the cause. 23. 23. Question A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms? o A. Proteinuria, headaches, vaginal bleeding o B. Headaches, double vision, vaginal bleeding o C. Proteinuria, headaches, double vision o D. Proteinuria, double vision, uterine contractions Incorrect Correct Answer: C. Proteinuria, headaches, double vision A patient with pregnancy-induced hypertension complains of a headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. o Option A: Pre-eclampsia increases the risk for placental abruption, a condition in which the placenta separates from the inner wall of the uterus before delivery. Severe abruption can cause heavy bleeding, which can be life-threatening for both the baby and the mother. o Option B: Any hypertensive disorder of pregnancy can result in preeclampsia. It occurs in up to 35% of women with gestational hypertension and up to 25% of those with chronic hypertension. The underlying pathophysiology that upholds this transition to, or superposition of, preeclampsia is not well understood; however, it is thought to be related to a mechanism of reduced placental perfusion inducing the systemic vascular endothelial dysfunction. o Option D: Symptoms of preeclampsia may include visual disturbances, typically scintillations and scotomata, presumed to be due to cerebral vasospasm. The woman may describe new-onset headache that is frontal, throbbing, or similar to a migraine headache, and gastrointestinal complaints of sudden, new-onset, constant epigastric pain that may be moderate to severe in intensity and due to hepatic swelling and inflammation, with stretch of the liver capsule. 24. 24. Question Because cervical effacement and dilation are not progressing in a patient in labor, the doctor orders I.V. administration of oxytocin (Pitocin). Why should the nurse monitor the patient’s fluid intake and output closely during oxytocin administration? o A. Oxytocin causes water intoxication. o B. Oxytocin causes excessive thirst. o C. Oxytocin is toxic to the kidneys. o D. Oxytocin has a diuretic effect. Incorrect Correct Answer: A. Oxytocin causes water intoxication. The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. In addition, oxytocin may cause water intoxication via an antidiuretic hormone-like activity when administered in excessive doses with electrolyte-free solution. o Option B: Excessive thirst results from the work of labor and limited oral fluid intake—not oxytocin. o Option C: Oxytocin, when given in rapid bolus, produces marked but short-lived hypotension and tachycardia. Sometimes, this abrupt and severe hemodynamic depression may need to be distinguished from placental abruption, myocardial infarction, or a pulmonary embolism in patients undergoing delivery. o Option D: Oxytocin is known to possess antidiuretic properties. It can function physiologically as an antidiuretic hormone, mimicking the short-term action of vasopressin on water permeability, albeit with somewhat lower potency. 25. 25. Question Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss? o A. Low room humidity o B. Cold weight scale o C. Cool incubator walls o D. Cool room temperature Incorrect Correct Answer: C. Cools incubator walls A common source of radiant heat loss includes cool incubator walls and windows. Radiant heat loss constitutes the transfer of heat from an infant’s warm skin, via infrared electromagnetic waves, to the cooler surrounding walls that absorb heat. o Option A: Low room humidity promotes evaporative heat loss. Evaporative heat loss occurs through the skin and the respiratory system. The driving force behind evaporation is the vapor pressure difference between the body surface and the environment. o Option B: When the skin directly contacts a cooler object, such as a cold weight scale, conductive heat loss may occur. Heat loss can occur by conduction of heat from the skin to the layer of still air around the body. o Option D: A cool room temperature may lead to convective heat loss. Convective heat loss is the transfer of heat from a body to moving molecules such as air or liquid. 26. 26. Question After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur? o A. Decreased peristalsis o B. Increase heart rate o C. Dry mucous membranes o D. Nausea and Vomiting Incorrect Correct Answer: D. Nausea and Vomiting Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Bethanechol directly stimulates cholinergic receptors in the parasympathetic nervous system while stimulating the ganglia to a lesser extent. o Option A: Peristalsis is increased rather than decreased. Stimulation of muscarinic receptors in the GI tract restores peristalsis, increases motility, and increases the resting lower esophageal sphincter pressure. o Option B: With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased the force of cardiac contraction, which may cause hypotension. o Option C: Salivation or sweating may gently increase because of its cholinergic effects. 27. 27. Question The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? o A. Active phase o B. Complete phase o C. Latent phase o D. Transitional phase Incorrect Correct Answer: D. Transitional phase The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds. o Option A: The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that start out moderately intense, grow stronger, and last about 60 seconds. o Option B: The complete phase occurs during the second, not first, stage of labor. o Option C: The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions. 28. 28. Question After 3 days of breastfeeding, a postpartum patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she: o A. Apply warm compresses to her nipples just before feeding. o B. Lubricate her nipples with expressed milk before feeding. o C. Dry her nipples with a soft towel after feeding. o D. Apply soap directly to her nipples, and then rinse. Incorrect Correct Answer: B. Lubricate her nipples with expressed milk before feeding Measures that help relieve nipple soreness in a breastfeeding patient include lubricating the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feeding, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples. o Option A: Cold compresses are applied instead of warm because it reduces swelling and pain. Use a piece of fabric between the skin and the cold compress. Never apply an ice pack directly to the skin. o Option C: Air drying prevents the clothing from sticking to and irritating the breast. o Option D: Soap removes the nipples’ natural lubricants and will dry them out. 29. 29. Question The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time? o A. Between 10 and 12 weeks’ gestation o B. Between 16 and 20 weeks’ gestation. o C. Between 21 and 23 weeks’ gestation. o D. Between 24 and 26 weeks’ gestation. Incorrect Correct Answer: B. Between 16 and 20 weeks’ gestation. A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks’ gestation. o Option A: Before 16 weeks, the fetus is not developed enough for the woman to detect movement. o Option C: After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins. o Option D: After 24 weeks, the fetus might be able to respond to familiar sounds such as its mother’s voice, with movement. It is spending most of its sleep time in rapid eye movement (REM). 30. 30. Question Normal lochial findings in the first 24 hours post-delivery include: o A. Bright red blood o B. Large clots or tissue fragments o C. A foul odor o D. The complete absence of lochia Incorrect Correct Answer: A. Bright red blood Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia. o Option B: The blood clots in the lochia should get smaller and happen less often as the bleeding gets less over the first few days. o Option C: Lochia with offensive odor may indicate infection. o Option D: Complete absence of lochia might be a sign of infection. 31. 31. Question Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that she is in labor and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first? o A. “Do you have any chronic illness?” o B. “Do you have any allergies?” o C. “What is your expected due date?” o D. “Who will be with you during labor?” Incorrect Correct Answer: C. “What is your expected due date?” When obtaining the history of a patient who may be in labor, the nurse’s highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illness, allergies, and support persons. o Option A: After asking for the expected due date, obtain the client’s problems during this or previous pregnancies. o Option B: Asking about any known allergies may be done after inquiring about prior ultrasonographic examinations and results, and bleeding during pregnancy or labor. o Option D: This may be asked if the client’s health history and present health history, which are some of the most important details, are already obtained. 32. 32. Question A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess her uterine contractions? o A. Every 5 minutes. o B. Every 15 minutes. o C. Every 30 minutes. o D. Every 60 minutes. Incorrect Correct Answer: B. Every 15 minutes During the second stage of labor, the nurse should assess the strength, frequency, and duration of contraction every 15 minutes. If maternal or fetal problems are detected, more frequent monitoring is necessary. o Option A: Second stage of labor starts when cervical dilatation reaches 10 cm and ends when the baby is delivered. At this stage, the patient feels an uncontrollable urge to push. Monitoring every 5 minutes would be too frequent and inconvenient for the laboring mother. o Option C: After cervical dilation is complete, the fetus descends into the vaginal canal with or without maternal pushing efforts. The fetus passes through the birth canal via 7 movements known as the cardinal movements. These include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. These movements may occur in a few minutes, so 30 minutes might be too long to assess for contractions. o Option D: Monitoring hourly would be too long and the nurse might miss the important details of assessment. 33. 33. Question A patient is in her last trimester of pregnancy. Nurse Vickie should instruct her to notify her primary health care provider immediately if she notices: o A. Blurred vision o B. Hemorrhoids o C. Increased vaginal mucus o D. Shortness of breath on exertion Incorrect Correct Answer: A. Blurred vision Blurred vision or other visual disturbance, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for both the patient and fetus. o Option B: Although hemorrhoids may be a problem during pregnancy, they do not require immediate attention. Hemorrhoids occur when the external hemorrhoidal veins become varicose (enlarged and swollen), which causes itching, burning, painful swellings at the anus, dyschezia (painful bowel movements), and bleeding. o Option C: Almost all women have more vaginal discharge in pregnancy. This is normal, and helps prevent any infections travelling up from the vagina to the womb. Towards the end of pregnancy, the amount of discharge increases further. In the last week or so of pregnancy, it may contain streaks of sticky, jelly-like pink mucus. o Option D: Dyspnea can begin before any upward displacement of the diaphragm, suggesting that factors other than mechanical pressure may be involved. It probably results from the subjective awareness of hyperventilation that is universally present in pregnancy. Hyperventilation in pregnancy is predominantly due to an increase in the depth of the tidal volume, with little change in the respiratory rate 34. 34. Question The nurse in-charge is reviewing a patient’s prenatal history. Which finding indicates a genetic risk factor? o A. The patient is 25 years old. o B. The patient has a child with cystic fibrosis. o C. The patient was exposed to rubella at 36 weeks’ gestation. o D. The patient has a history of preterm labor at 32 weeks’ gestation. Incorrect Correct Answer: B. The patient has a child with cystic fibrosis Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. o Option A: Maternal age is not a risk factor until age 35, when the incidence of chromosomal defects increases. o Option C: Maternal exposure to rubella during the first trimester may cause congenital defects. o Option D: Although a history or preterm labor may place the patient at risk for preterm labor, it does not correlate with genetic defects. 35. 35. Question An adult female patient is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by: o A. Return preovulatory basal body temperature. o B. Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd day of cycle. o C. 3 full days of elevated basal body temperature and clear, thin cervical mucus. o D. Breast tenderness and mittelschmerz. Incorrect Correct Answer: C. 3 full days of elevated basal body temperature and clear, thin cervical mucus. Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7 degrees F to 0.8 degrees F and clear, thin cervical mucus. o Option A: A return to the preovulatory body temperature indicates a safe period for sexual intercourse. o Option B: A slight rise in basal temperature early in the cycle is not significant. Ovulation may cause a slight increase in basal body temperature. o Option D: Breast tenderness and mittelschmerz are not reliable indicators of ovulation. Mittelschmerz is one-sided, lower abdominal pain associated with ovulation. It occurs midway through a menstrual cycle. 36. 36. Question During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge should instruct the client to push the control button at which time? o A. At the beginning of each fetal movement. o B. At the beginning of each contraction. o C. After every three fetal movements o D. At the end of fetal movement. Incorrect Correct Answer: A. At the beginning of each fetal movement An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with the FHR. o Option B: The FHR is assessed during uterine contractions in the oxytocin contraction test, not the NST. The Non-Stress Test (NST) is an assessment tool used from 32 weeks of gestation to term to evaluate fetal health through the use of electronic fetal monitors that continuously record the fetal heart rate (FHR). o Option C: Pushing the control button after every three fetal movements wouldn’t allow accurate comparison of fetal movement and FHR change. Fetal activity may be recorded by the patient using an event marker or noted by the staff performing the test. o Option D: The presence of fetal heart rate acceleration with fetal movement is the principle behind the non-stress test. It is vital to start monitoring the moment the client recognizes a fetal movement. The NST recognizes the coupling of fetal neurological status to cardiovascular reflex responses. It is one of the factors that tends to disappear earliest during progressive fetal compromise. 37. 37. Question When evaluating a client’s knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse in charge that the client understands the information given to her? o A. “I’ll report increased frequency of urination.” o B. “If I have blurred or double vision, I should call the clinic immediately.” o C. “If I feel tired after resting, I should report it immediately.” o D. “Nausea should be reported immediately.” Incorrect Correct Answer: B. “If I have blurred or double vision, I should call the clinic immediately.” Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. It can affect the visual pathways, from the anterior segment to the visual cortex. o Option A: Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. The anatomical and physiological changes affecting the lower urinary tract in pregnancy, as well as the hormonal milieu of pregnancy, have been postulated to underlie the pathogenesis of lower urinary symptoms in pregnancy o Option C: Clients generally experience fatigue during pregnancy. Pregnancy is accompanied by several psychological, emotional, and physical changes that may predispose the woman to fatigue, which can range from mild tiredness to severe exhaustion. o Option D: The pathophysiology of nausea and vomiting during early pregnancy is unknown, although metabolic, endocrine, GI, and psychologic factors probably all play a role. Estrogen may contribute because estrogen levels are elevated in patients with hyperemesis gravidarum. 38. 38. Question When assessing a client during her first prenatal visit, the nurse discovers that the client had a reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the nurse give to this mother regarding breastfeeding success? o A. “It’s contraindicated for you to breastfeed following this type of surgery.” o B. “I support your commitment; however, you may have to supplement each feeding with formula.” o C. “You should check with your surgeon to determine whether breast-feeding would be possible.” o D. “You should be able to breastfeed without difficulty.” Incorrect Correct Answer: B. “I support your commitment; however, you may have to supplement each feeding with formula.” Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so breastfeeding after surgery is possible. Still, it’s good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mother’s ability to meet all of her baby’s nutritional needs, and some supplemental feeding may be required. Preparing the mother for this possibility is extremely important because the client’s psychological adaptation to mothering may be dependent on how successfully she breast-feeds. o Option A: While there is evidence that both breastfeeding and breast reduction surgery are beneficial, it is unknown whether breast reduction surgery impacts breastfeeding and whether any breast reduction technique differentially preserves the ability to breastfeed. o Option C: Women considering breast reduction surgery should be told not only the name of the proposed breast reduction technique but its characteristics, including the extent the column of subareolar parenchyma will be preserved and pedicle width, to allow them to gain a better understanding of its impact on breastfeeding. o Option D: Breast reduction techniques have been in a continuous state of development since the early 1900s, with new techniques developed, refined, and modified by subsequent plastic surgeons. This has led to many diverse breast reduction techniques. Its effect on breastfeeding remains entirely unclear, so telling the client that she could breastfeed without difficulty would give her a false sense of reassurance. 39. 39. Question Following a precipitous delivery, examination of the client’s vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? o A. Applying cold to limit edema during the first 12 to 24 hours. o B. Instructing the client to use two or more peri pads to cushion the area. o C. Instructing the client on the use of sitz baths if ordered. o D. Instructing the client about the importance of perineal (Kegel) exercises. Incorrect Correct Answer: B. Instructing the client to use two or more peri pads to cushion the area Using two or more peripads would do little to reduce the pain or promote perineal healing. A fourth-degree perineal laceration is the injury to the perineum involving the anal sphincter complex and anorectal mucosa. o Option A: Ice packs can help reduce pain and swelling in the perineum. Use ice cubes in a clean, disposable glove. Wrapped in a damp cloth or place the ice pack inside a pad. Never apply directly on skin. Apply for 10-20 minutes. Repeat every 2-3 hours until pain and swelling decrease. o Option C: Hot sitz bath may help speed up the healing process. Use sitz baths a few times a day, 24 hours after giving birth. Sit in water that covers the vulvar area. o Option D: The muscles lie deep in the pelvis and support the pelvic organs and control the bladder and bowel function. The pelvic floor muscles attach to the pubic bone at the front, tail bone at the back, and from one sitting bone to the other sitting bone. It is important to retrain the muscles after a tear, to prevent problems such as incontinence. 40. 40. Question A client makes a routine visit to the prenatal clinic. Although she is 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy. Dr. Charles diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal: o A. An empty gestational sac. o B. Grapelike clusters. o C. A severely malformed fetus. o D. An extrauterine pregnancy. Incorrect Correct Answer: B. Grapelike clusters. In a client with gestational trophoblastic disease, an ultrasound performed after the 3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually, no embryo (and therefore no fetus) is present because it has been absorbed. o Option A: An anembryonic pregnancy is characterized by a gestational sac that forms and grows while an embryo fails to develop. Etiologies include morphological abnormalities of an embryo that prevents implantation or prevents long term survival of the embryo after implantation; chromosomal abnormalities that collectively include autosomal trisomy, polyploidy, sex chromosomal polysomy, and monosomy X likely represent the most common etiologies for early pregnancy loss; and other genetic and chromosomal abnormalities include translocations, inversions, single-gene perturbations, and placental mosaicism. o Option C: Congenital anomalies are also known as birth defects, congenital disorders or congenital malformations. Congenital anomalies can be defined as structural or functional anomalies (for example, a severely malformed fetus) that occur during intrauterine life and can be identified prenatally, at birth, or sometimes may only be detected later in infancy, such as hearing defects. o Option D: Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy is seen with an ectopic pregnancy. 41. 41. Question After completing a second vaginal examination of a client in labor, the nurse-midwife determines that the fetus is in the right occiput anterior position and at (–1) station. Based on these findings, the nurse-midwife knows that the fetal presenting part is: o A. 1 cm below the ischial spines. o B. Directly in line with the ischial spines. o C. 1 cm above the ischial spines. o D. In no relationship to the ischial spines. Incorrect Correct Answer: C. 1 cm above the ischial spines. Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as –1, –2, or –3. o Option A: A presenting part below the ischial spines, as +1, +2, or +3. o Option B: 0 station is when the baby’s head is even with the ischial spines. The baby is said to be “engaged” when the largest part of the head has entered the pelvis. o Option D: If the head is high and not yet engaged in the birth canal, it may float away from the physician’s fingers during the vaginal exam. 42. 42. Question Which of the following would be inappropriate to assess in a mother who’s breastfeeding? o A. The attachment of the baby to the breast. o B. The mother’s comfort level with positioning the baby. o C. Audible swallowing. o D. The baby’s lips smacking. Incorrect Correct Answer: D. The baby’s lips smacking Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who’s smacking his lips isn’t well attached and can injure the mother’s nipples. o Option A: A good attachment shows much of the areola and the tissues underneath it, including the larger ducts, are in the baby’s mouth; the breast is stretched out to form a long “teat”, but the nipple only forms about one-third of the “teat”; the baby’s tongue is forward over the lower gums, beneath the milk ducts; and the baby is suckling from the breast, not from the nipple. o Option B: To be well attached at the breast, a baby and his or her mother need to be appropriately positioned. The mother can be sitting or lying down, or standing, if she wishes. However, she needs to be relaxed and comfortable, and without strain, particularly of her back. The baby can breastfeed in several different positions in relation to the mother: across her chest and abdomen, under her arm, or alongside her body. o Option C: When the milk ejection reflex is triggered, the baby may swallow after every suck in order to handle the rapid flow of milk. You should hear suck, swallow, pause, suck, swallow, pause. Audible swallowing after every couple of sucks should continue for about ten minutes. 43. 43. Question During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done to identify fetal abnormalities. Between 18 and 40 weeks gestation, which procedure is used to detect fetal anomalies? o A. Amniocentesis o B. Chorionic villi sampling o C. Fetoscopy o D. Ultrasound Incorrect Correct Answer: D. Ultrasound Ultrasound is used between 18 and 40 weeks’ gestation to identify normal fetal growth and detect fetal anomalies and other problems. o Option A: Amniocentesis is done during the third trimester to determine fetal lung maturity. o Option B: Chorionic villi sampling is performed at 8 to 12 weeks’ gestation to detect genetic disease. o Option C: Fetoscopy is done at approximately 18 weeks’ gestation to observe the fetus directly and obtain a skin or blood sample. 44. 44. Question A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate? o A. The fetus should be delivered within 24 hours. o B. The client should repeat the test in 24 hours. o C. The fetus isn’t in distress at this time. o D. The client should repeat the test in 1 week. Incorrect Correct Answer: C. The fetus isn’t in distress at this time. The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn’t in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn’t within normal limits. o Option A: The biophysical profile is a test used to evaluate the well-being of the fetus. It is commonly done at the last trimester of pregnancy, but it does not indicate that the fetus should be delivered within 24 hours. o Option B: If the score is 6, the health care provider will likely repeat the test within 24 hours. o Option D: The test is most commonly done when there’s an increased risk of problems that could lead to complications or pregnancy loss. The health care provider will determine the necessity and timing of a biophysical profile based on whether the baby could survive if delivered early, the severity of the mother’s condition, and the risk of pregnancy loss. 45. 45. Question A client who is 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the client’s preparation for parenting, the nurse might ask which question? o A. “Are you planning to have epidural anesthesia?” o B. “Have you begun prenatal classes?” o C. “What changes have you made at home to get ready for the baby?” o D. “Can you tell me about the meals you typically eat each day?” Incorrect Correct Answer: C. “What changes have you made at home to get ready for the baby?” During the third trimester, the pregnant client typically perceives the fetus as a separate being. To verify that this has occurred, the nurse should ask whether she has made appropriate changes at home such as obtaining infant supplies and equipment. o Option A: The type of anesthesia planned doesn’t reflect the client’s preparation for parenting. o Option B: The client should have begun prenatal classes earlier in the pregnancy. o Option D: The nurse should have obtained dietary information during the first trimester to give the client time to make any necessary changes. 46. 46. Question A client who’s admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time? o A. Placing the client in bed to begin fetal monitoring. o B. Preparing for immediate delivery. o C. Checking for ruptured membranes. o D. Providing comfort measures. Incorrect Correct Answer: B. Preparing for immediate delivery. This question requires an understanding of station as part of the intrapartum assessment process. Based on the client’s assessment findings, this client is ready for delivery, which is the nurse’s top priority. o Option A: Fetal heart rate monitoring may help detect changes in the normal heart rate pattern during labor. If certain changes are detected, steps can be taken to help treat the underlying problem. Fetal heart rate monitoring also can help prevent treatments that are not needed. o Option C: The membranes can break by themselves. This is called a spontaneous rupture of the membranes. It most often happens after active labor has started. o Option D: Comfort measures may be given to the woman after ensuring all necessary measures to help her deliver successfully. 47. 47. Question The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? o A. Change the client’s position. o B. Prepare for an emergency cesarean section. o C. Check for placenta previa. o D. Administer oxygen. Incorrect Correct Answer: A. Change the client’s position. Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client’s position from supine to side-lying may immediately correct the problem. o Option B: An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. o Option C: Common causes of variable decelerations include vagal reflex triggered by head compression during pushing and cord compression such as that caused by short cord, nuchal cord, body entanglement, prolapsed cord, decreased amniotic fluid, and fetal descent. It does not include placenta previa. o Option D: Administering oxygen may be helpful, but the priority is to change the woman’s position and relieve cord compression. The fetus already has a surplus of oxygen due to high basal blood flow to its organs and vascular shunts. 48. 48. Question The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client? o A. Risk for deficient fluid volume related to hemorrhage. o B. Risk for infection related to the type of delivery. o C. Pain related to the type of incision. o D. Urinary retention related to periurethral edema. Incorrect Correct Answer: A. Risk for deficient fluid volume related to hemorrhage Hemorrhage jeopardizes the client’s oxygen supply — the first priority among human physiological needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over-diagnoses of Risk for Infection, Pain, and Urinary retention. o Option B: Episiotomy infections are classically reported as being rare at a rate of 0.1% and increasing up to 2% if a third or fourth-degree tear occurs. o Option C: Episiotomy pain may be relieved by an ice pack, warm or cold shallow baths or sitz baths, or medicated creams or local numbing sprays. o Option D: Postpartum urinary retention (PPUR) is an upsetting condition that has no standard literature definition. It has been variably defined as the abrupt onset of aching or inability to completely micturate, requiring urinary catheterization, over 12 hours after giving birth or not to void spontaneously within 6 hours of vaginal delivery. 49. 49. Question Which change would the nurse identify as a progressive physiological change in the postpartum period? o A. Lactation o B. Lochia o C. Uterine involution o D. Diuresis Incorrect Correct Answer: A. Lactation Lactation is an example of a progressive physiological change that occurs during the postpartum period. Lactation is the process of milk production. o Option B: Lochia is the vaginal discharge a woman has after a vaginal delivery. It has a stale, musty odor like menstrual discharge. Lochia for the first 3 days after delivery is dark red in color. For the fourth through tenth day after delivery, the lochia will be more watery and pinkish to brownish color. From about the seventh to tenth day through the fourteenth day after delivery, the lochia is creamy or yellowish in color. o Option C: Involution is the process by which the uterus is transformed from pregnant to non-pregnant state. This period is characterized by the restoration of ovarian function in order to prepare the body for a new pregnancy. o Option D: Diuresis is increased urination and the physiologic process that produces such an increase. It involves extra urine production in the kidneys as part of the body’s homeostatic maintenance of fluid balance. 50. 50. Question A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client’s complaint of vaginal bleeding? o A. Placenta previa o B. Abruptio placentae o C. Ectopic pregnancy o D. Spontaneous abortion Incorrect Correct Answer: B. Abruptio placentae The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first, not third, trimester abortion and abruptio placentae. The hypertension and increased levels of catecholamines caused by cocaine abuse are thought to be responsible for a vasospasm in the uterine bloo