Maternal and child nursing care with
complete questions and accurate solutions
The perinatal nurse providing care to a laboring woman
recognizes a nonreassuring fetal heart rate tracing. Which of the
following is the most appropriate initial action by the nurse?
A. Assist the woman to a left lateral position.
B. Decrease the rate of the intravenous solution.
C. Document the fetal heart rate and variability.
D. Request that the provider apply a fetal scalp electrode. Correct
Answer A
The perinatal nurse determines by vaginal examination that a
patient's cervix is fully dilated, and the fetal presenting part is
descending rapidly with the patient's pushing efforts. The most
appropriate nursing intervention at this time would be to do which
of the following?
A. Assist the patient with breathing patterns to slow down her
pushing.
B. Document the patient's progress and coping abilities in labor.
C. Notify the health-care provider to come now for the birth.
D. Provide information to the patient's partner about her stage of
labor. Correct Answer A
The perinatal nurse is providing care to a 32-year-old G1 TPAL
0000 at 34 weeks' gestation. Her blood pressure is 170/100 mm
Hg, reflexes are +3, urine is 2+ for protein, and the patient is
complaining of a headache. An intravenous solution of
magnesium sulfate is begun with an hourly dose of 2 g. Which
laboratory value would be assessed most carefully by the nurse?
A. Aspartate aminotransferase (AST)
B. Gamma-glutamyl transpeptidase
,C. Hematocrit
D. Neutrophil count Correct Answer A
The perinatal nurse is caring for a pre-eclamptic patient at 35
weeks' gestation. The patient's newest laboratory results include
the following: platelet count 98,000/mm3 and RBC 3.1 million/µL.
What action by the nurse is most appropriate?
A. Administer betamethasone (Celestone).
B. Increase the patient's IV fluids.
C. Maintain the patient on bedrest.
D. Notify the health-care provider immediately. Correct Answer D
The nurse is caring for a woman with a placental abruption and
suspects the patient has developed disseminated intravascular
coagulation (DIC). What interventions does the nurse anticipate?
A. Administering IV fibrinogen
B. Performing hourly vaginal exams to assess for cervical dilation
C. Performing blood pressure assessments every 4 hours
D. Obtaining consent for a cesarean birth Correct Answer A
The perinatal nurse is providing care to a 17-year-old G2 TPAL
0010 patient at 32 weeks' gestation. An ultrasound examination
confirms that she is experiencing an abruptio placentae. The
patient's vital signs are as follows: BP: 110/66 mm Hg, P: 92
beats/minute, R: 18 breaths/minute, fetal heart rate: 156
beats/minute. What assessment should the nurse include in this
patient's plan of care as a priority?
A. Hourly vital signs
B. Intake and output every 8 hours
C. Blood draw for complete blood count (CBC), prothrombin time
(PT), and electrolytes
D. Checks for perineal bleeding every 15 minutes Correct Answer
C
,A woman reports feeling uterine contractions that are strong, but
on subsequent cervical checks, the nurse does not note any
changes. What action by the nurse is most appropriate?
A. Assess the woman for causes of anxiety.
B. Attempt an external version of the fetus.
C. Instruct the woman on nipple stimulation.
D. Prepare to administer oxytocin (Pitocin). Correct Answer A
The nurse is preparing to admit a diabetic woman who is in labor.
The nurse plans care to assess carefully for which of the following
conditions in this patient?
A. Diminishing uterine contractions
B. Need for an epidural block
C. Onset of intrapartum hypertension
D. Overly strong, painful contractions Correct Answer A
A woman had an amniotomy 1 hour ago. Now she is complaining
of uterine tenderness. What action by the nurse is most
appropriate?
A. Increase the IV infusion rate.
B. Notify the health-care provider.
C. Perform a vaginal examination.
D. Take the woman's temperature. Correct Answer D
A nulliparous woman has been admitted to the labor and birth
unit. Her Bishop score is 4. What medication does the nurse plan
to administer?
A. Betamethasone (Celestone)
B. Hydromorphone (Dilaudid)
C. Misoprostol (Cytotec)
D. Oxytocin (Pitocin) Correct Answer C
A woman is receiving oxytocin (Pitocin) via infusion. The nurse
assesses the following: uterine contractions lasting 100 seconds
every 1.5 minutes, uterine resting tone 36 mm Hg, baseline fetal
, heart rate (FHR) 108 beats/minute with absent variability. What
action by the nurse takes priority?
A. Document the findings.
B. Notify the provider.
C. Reassess the FHR in 10 minutes.
D. Stop the infusion. Correct Answer D
The nurse manager of the perinatal services unit wants to
improve outcomes associated with perinatal loss. What action by
the manager would best help meet this goal?
A. Develop a unit specifically for this population.
B. Establish a multidisciplinary perinatal loss team.
C. Identify key nurses to care for these patients.
D. Provide debriefing services for the nursing staff. Correct
Answer B
The nurse is caring for a woman who is being admitted for an
induction with oxytocin (Pitocin). Which of the following findings
would indicate a potential contraindication to the use of this
medication in the laboring patient? Select all that apply.
A. "The patient is a primipara at 38 weeks' gestation with a Bishop
score of 2."
B. "The patient has been having occasional irregular
contractions."
C. "Leopold maneuver indicates a transverse lie."
D. "Blood pressure upon admission is 190/100." E! "Prior
cesarean section for fetal distress." Correct Answer A, C, D
A labor patient who has delivered is now experiencing increased
vaginal bleeding, blood pressure changes from 120/89 to 100/72,
and a spontaneous nosebleed. What therapeutic treatment should
the nurse anticipate that the physician will order? Select all that
apply.
A. "Administration of Pitocin."
B, "Type and screen for 4 units blood."
complete questions and accurate solutions
The perinatal nurse providing care to a laboring woman
recognizes a nonreassuring fetal heart rate tracing. Which of the
following is the most appropriate initial action by the nurse?
A. Assist the woman to a left lateral position.
B. Decrease the rate of the intravenous solution.
C. Document the fetal heart rate and variability.
D. Request that the provider apply a fetal scalp electrode. Correct
Answer A
The perinatal nurse determines by vaginal examination that a
patient's cervix is fully dilated, and the fetal presenting part is
descending rapidly with the patient's pushing efforts. The most
appropriate nursing intervention at this time would be to do which
of the following?
A. Assist the patient with breathing patterns to slow down her
pushing.
B. Document the patient's progress and coping abilities in labor.
C. Notify the health-care provider to come now for the birth.
D. Provide information to the patient's partner about her stage of
labor. Correct Answer A
The perinatal nurse is providing care to a 32-year-old G1 TPAL
0000 at 34 weeks' gestation. Her blood pressure is 170/100 mm
Hg, reflexes are +3, urine is 2+ for protein, and the patient is
complaining of a headache. An intravenous solution of
magnesium sulfate is begun with an hourly dose of 2 g. Which
laboratory value would be assessed most carefully by the nurse?
A. Aspartate aminotransferase (AST)
B. Gamma-glutamyl transpeptidase
,C. Hematocrit
D. Neutrophil count Correct Answer A
The perinatal nurse is caring for a pre-eclamptic patient at 35
weeks' gestation. The patient's newest laboratory results include
the following: platelet count 98,000/mm3 and RBC 3.1 million/µL.
What action by the nurse is most appropriate?
A. Administer betamethasone (Celestone).
B. Increase the patient's IV fluids.
C. Maintain the patient on bedrest.
D. Notify the health-care provider immediately. Correct Answer D
The nurse is caring for a woman with a placental abruption and
suspects the patient has developed disseminated intravascular
coagulation (DIC). What interventions does the nurse anticipate?
A. Administering IV fibrinogen
B. Performing hourly vaginal exams to assess for cervical dilation
C. Performing blood pressure assessments every 4 hours
D. Obtaining consent for a cesarean birth Correct Answer A
The perinatal nurse is providing care to a 17-year-old G2 TPAL
0010 patient at 32 weeks' gestation. An ultrasound examination
confirms that she is experiencing an abruptio placentae. The
patient's vital signs are as follows: BP: 110/66 mm Hg, P: 92
beats/minute, R: 18 breaths/minute, fetal heart rate: 156
beats/minute. What assessment should the nurse include in this
patient's plan of care as a priority?
A. Hourly vital signs
B. Intake and output every 8 hours
C. Blood draw for complete blood count (CBC), prothrombin time
(PT), and electrolytes
D. Checks for perineal bleeding every 15 minutes Correct Answer
C
,A woman reports feeling uterine contractions that are strong, but
on subsequent cervical checks, the nurse does not note any
changes. What action by the nurse is most appropriate?
A. Assess the woman for causes of anxiety.
B. Attempt an external version of the fetus.
C. Instruct the woman on nipple stimulation.
D. Prepare to administer oxytocin (Pitocin). Correct Answer A
The nurse is preparing to admit a diabetic woman who is in labor.
The nurse plans care to assess carefully for which of the following
conditions in this patient?
A. Diminishing uterine contractions
B. Need for an epidural block
C. Onset of intrapartum hypertension
D. Overly strong, painful contractions Correct Answer A
A woman had an amniotomy 1 hour ago. Now she is complaining
of uterine tenderness. What action by the nurse is most
appropriate?
A. Increase the IV infusion rate.
B. Notify the health-care provider.
C. Perform a vaginal examination.
D. Take the woman's temperature. Correct Answer D
A nulliparous woman has been admitted to the labor and birth
unit. Her Bishop score is 4. What medication does the nurse plan
to administer?
A. Betamethasone (Celestone)
B. Hydromorphone (Dilaudid)
C. Misoprostol (Cytotec)
D. Oxytocin (Pitocin) Correct Answer C
A woman is receiving oxytocin (Pitocin) via infusion. The nurse
assesses the following: uterine contractions lasting 100 seconds
every 1.5 minutes, uterine resting tone 36 mm Hg, baseline fetal
, heart rate (FHR) 108 beats/minute with absent variability. What
action by the nurse takes priority?
A. Document the findings.
B. Notify the provider.
C. Reassess the FHR in 10 minutes.
D. Stop the infusion. Correct Answer D
The nurse manager of the perinatal services unit wants to
improve outcomes associated with perinatal loss. What action by
the manager would best help meet this goal?
A. Develop a unit specifically for this population.
B. Establish a multidisciplinary perinatal loss team.
C. Identify key nurses to care for these patients.
D. Provide debriefing services for the nursing staff. Correct
Answer B
The nurse is caring for a woman who is being admitted for an
induction with oxytocin (Pitocin). Which of the following findings
would indicate a potential contraindication to the use of this
medication in the laboring patient? Select all that apply.
A. "The patient is a primipara at 38 weeks' gestation with a Bishop
score of 2."
B. "The patient has been having occasional irregular
contractions."
C. "Leopold maneuver indicates a transverse lie."
D. "Blood pressure upon admission is 190/100." E! "Prior
cesarean section for fetal distress." Correct Answer A, C, D
A labor patient who has delivered is now experiencing increased
vaginal bleeding, blood pressure changes from 120/89 to 100/72,
and a spontaneous nosebleed. What therapeutic treatment should
the nurse anticipate that the physician will order? Select all that
apply.
A. "Administration of Pitocin."
B, "Type and screen for 4 units blood."
