2025 Exam
At 10-weeks gestation, a high-risk multiparous client with a family history of Down
syndrome is admitted for observation following a chorionic villi sampling (CVS)
procedure. What assessment finding requires immediate intervention? - ANSWERS--A.
Uterine cramping
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is
most important to include in the teaching plan? - ANSWERS--A. Avoid alcohol because
it is excreted in breast milk
A client states, "During the three months I've been pregnant, it seems like I have had to
go to the bathroom every five minutes." Which explanation should the nurse provide to
this client? - ANSWERS--D. The growing uterus is putting pressure on the bladder.
The nurse assesses a male newborn and determines that he has the following vital
signs: axillary temperature 95.1 F, heart rate 136 beats/minute, and a respiratory rate
48 breaths/minute. Based on these findings, which action should the nurse take first? -
ANSWERS--C. Assess the infant's blood glucose level
An infant in respiratory distress is placed on pulse ox. The O2 sat is 85%. What is the
priority nursing intervention? - ANSWERS--B. Begin humidified oxygen via hood
When assessing a newborn infant's heart rate, which technique is most important for the
nurse to use? - ANSWERS--C. Count the heart rate for at least one full minute
The nurse prepares to administer an injection of vitamin K to a newborn infant. The
mother tells the nurse, "Wait! I don't want my baby to have a shot." Which response
, would be best for the nurse to make? - ANSWERS--B. Explore the mother's concerns
about the infant receiving an injection of vitamin K
Which nursing intervention best enhances maternal-infant bonding during the fourth
stage of labor? - ANSWERS--D. Encourage early initiation of breast of formula feeding
A client at 8-weeks gestation asks the nurse about the risk fora congenital heart defect
(CHD) in her baby. Which response best explains when a CHD may occur? -
ANSWERS--D. The heart develops in the third to fifth weeks after conception
A client at 8-months gestation tells the nurse that she knows her baby listens to her, but
her husband thinks she is imagining things. What information should the nurse provide?
- ANSWERS--B. The fetus in utero is capable of hearing and does respond to the
mother's voice
A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last
week and her baby jumped in response to the noise. What information should the nurse
provide? - ANSWERS--B. The fetus can respond to sound by 24-weeks gestation
A woman whose pregnancy is confirmed asks the nurse what the function of the
placenta is in early pregnancy. What information supports the explanation that the nurse
should provide? - ANSWERS--C. Secretes both estrogen and progesterone
Which cardiovascular findings should the nurse assess further in a client who is at 20-
weeks gestation? - ANSWERS--A. Decrease in pulse rate
A client in her second trimester of pregnancy asks if it is safe for her to have a drink with
dinner. How should the nurse respond to the client? - ANSWERS--D. Abstinence is
strongly recommended throughout the pregnancy
A 31-year-old woman uses an over-the-counter (OTC) pregnancy test that is positive
one week after a missed period. At the clinic, the client tells the nurse she takes
phenytoin (Dilantin) for epilepsy, has a history of irregular periods, is under stress at
work, and is not sleeping well. The client's physical examination and ultrasound do not
indicate that she is pregnant. How should the nurse explain the most likely cause for
obtaining false-positive pregnancy test results? - ANSWERS--B. Using an
anticonvulsant for epilepsy
Which gastrointestinal findings should the nurse be concerned about in a client at 28-
weeks gestation? - ANSWERS--A. PICA
During a preconception counseling session for women trying to get pregnant in 3 to 6
months, what information should the nurse provide? - ANSWERS--B. Make sure to
include adequate folic acid in the diet