MATERNITY-PEDS- SAUNDERS ON
EVOLVE EXAM QUESTIONS AND
ANSWERS
Supine position with a wedge under the right hip - ANSWER-The client who is being
prepared for a cesarean delivery is brought to the delivery room. To maintain the
optimal perfusion of oxygenated blood to the fetus, the nurse should place the client
in which position?
mastitis instructions - ANSWER-1. Rest during the acute phase.
2. Wear a supportive, non-underwire bra.
3.Maintain a fluid intake of at least 3000 mL.
4.Continue to breastfeed if the breasts are not too sore.
abnormal and should be reported.
rationale: bright red bleeding with a firm fundus is not normal, and could be a
laceration from the episiotomy - ANSWER-After episiotomy and the delivery of a
newborn, the nurse performs a perineal check on the mother. The nurse notes a
trickle of bright red blood coming from the perineum. The nurse checks the fundus
and notes that it is firm. Which determination should the nurse make?
involution - ANSWER-The progressive descent of the uterus into the pelvic cavity
after birth, which occurs at a rate of approximately 1 cm/day
breast engorgement comfort measures - ANSWER-1. massaging before feeding to
stimulate let-down,
2. wearing a supportive and well-fitting bra
3. taking a warm shower or applying warm compresses 4. alternating breasts during
feeding.
At the level of the umbilicus - ANSWER-After delivery the nurse checks the height of
the uterine fundus. Which position of the fundus should the nurse expect to note?
report to doctor
rationale: temp may rise after birth as result of dehydration but temp 2 degrees
above average may indicate infection - ANSWER-The nurse is caring for a
postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9°
C). Which is the appropriate nursing action?
ambulate often - ANSWER-The nurse is assigned to care for the client after a
cesarean section. To prevent thrombophlebitis, the nurse should encourage the
woman to take which priority action?
blood glucose
, rationale: most common complication in post-term newborn is hypoglycemia -
ANSWER-The nurse is assisting in caring for a post-term neonate immediately after
admission to the nursery. The priority nursing action should be to monitor which
clinical parameter?
Midway between the symphysis pubis and the umbilicus - ANSWER-The nurse is
reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse
should expect to document that the fundus of the uterus is located at which area?
early deceleration (normal) - ANSWER-gradual decrease in and return to baseline
FHR in response to compression of the fetal head
week 5 - ANSWER-fetal heart is beating at what gestational week?
Fertilization - ANSWER-occurs in the outer third of the fallopian tubes
Nuts and green, leafy vegetables - ANSWER-Which mid-afternoon snack should be
recommended to supply folic acid?
Avoid exposure to litter boxes used by cats. - ANSWER-A perinatal client is at risk
for toxoplasmosis. Which instruction should the nurse reinforce with the client to
prevent exposure to this disease?
Pulmonary embolism s/s - ANSWER-dyspnea/tachypnea
tachycardia,
hemoptysis
a feeling of impending doom
increase fluids - ANSWER-The mother of a 6-year-old child who has type 1 diabetes
mellitus calls a clinic nurse and tells the nurse that the child has been sick. The
mother reports that she checked the child's urine and it was positive for ketones. The
nurse should instruct the mother to take which action?
high calorie, high protein - ANSWER-diet for cystic fibrosis?
down and back - ANSWER-When administering eardrops to a child who is younger
than 3 years old, the ear should be pulled
place baby in knee chest position
rationale: improves systemic arterial oxygen saturation by decreasing venous return
- ANSWER-The nurse was caring for an infant who had come to the nursing unit for
treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen
saturation reading drops to 60%. The nurse should perform which action first?
nephrotic syndrome s/s - ANSWER-ascites
anorexia
proteinuria
facial edema
EVOLVE EXAM QUESTIONS AND
ANSWERS
Supine position with a wedge under the right hip - ANSWER-The client who is being
prepared for a cesarean delivery is brought to the delivery room. To maintain the
optimal perfusion of oxygenated blood to the fetus, the nurse should place the client
in which position?
mastitis instructions - ANSWER-1. Rest during the acute phase.
2. Wear a supportive, non-underwire bra.
3.Maintain a fluid intake of at least 3000 mL.
4.Continue to breastfeed if the breasts are not too sore.
abnormal and should be reported.
rationale: bright red bleeding with a firm fundus is not normal, and could be a
laceration from the episiotomy - ANSWER-After episiotomy and the delivery of a
newborn, the nurse performs a perineal check on the mother. The nurse notes a
trickle of bright red blood coming from the perineum. The nurse checks the fundus
and notes that it is firm. Which determination should the nurse make?
involution - ANSWER-The progressive descent of the uterus into the pelvic cavity
after birth, which occurs at a rate of approximately 1 cm/day
breast engorgement comfort measures - ANSWER-1. massaging before feeding to
stimulate let-down,
2. wearing a supportive and well-fitting bra
3. taking a warm shower or applying warm compresses 4. alternating breasts during
feeding.
At the level of the umbilicus - ANSWER-After delivery the nurse checks the height of
the uterine fundus. Which position of the fundus should the nurse expect to note?
report to doctor
rationale: temp may rise after birth as result of dehydration but temp 2 degrees
above average may indicate infection - ANSWER-The nurse is caring for a
postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9°
C). Which is the appropriate nursing action?
ambulate often - ANSWER-The nurse is assigned to care for the client after a
cesarean section. To prevent thrombophlebitis, the nurse should encourage the
woman to take which priority action?
blood glucose
, rationale: most common complication in post-term newborn is hypoglycemia -
ANSWER-The nurse is assisting in caring for a post-term neonate immediately after
admission to the nursery. The priority nursing action should be to monitor which
clinical parameter?
Midway between the symphysis pubis and the umbilicus - ANSWER-The nurse is
reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse
should expect to document that the fundus of the uterus is located at which area?
early deceleration (normal) - ANSWER-gradual decrease in and return to baseline
FHR in response to compression of the fetal head
week 5 - ANSWER-fetal heart is beating at what gestational week?
Fertilization - ANSWER-occurs in the outer third of the fallopian tubes
Nuts and green, leafy vegetables - ANSWER-Which mid-afternoon snack should be
recommended to supply folic acid?
Avoid exposure to litter boxes used by cats. - ANSWER-A perinatal client is at risk
for toxoplasmosis. Which instruction should the nurse reinforce with the client to
prevent exposure to this disease?
Pulmonary embolism s/s - ANSWER-dyspnea/tachypnea
tachycardia,
hemoptysis
a feeling of impending doom
increase fluids - ANSWER-The mother of a 6-year-old child who has type 1 diabetes
mellitus calls a clinic nurse and tells the nurse that the child has been sick. The
mother reports that she checked the child's urine and it was positive for ketones. The
nurse should instruct the mother to take which action?
high calorie, high protein - ANSWER-diet for cystic fibrosis?
down and back - ANSWER-When administering eardrops to a child who is younger
than 3 years old, the ear should be pulled
place baby in knee chest position
rationale: improves systemic arterial oxygen saturation by decreasing venous return
- ANSWER-The nurse was caring for an infant who had come to the nursing unit for
treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen
saturation reading drops to 60%. The nurse should perform which action first?
nephrotic syndrome s/s - ANSWER-ascites
anorexia
proteinuria
facial edema
