VERSION WITH QUESTION AND ANSWERS (VERIFIED AND WELL
DETAILED ANSWERS) LATEST UPDATE 2025
A nurse is caring for a client who is in labor and experiences abruptio placenta.
Which of the following findings should the nurse expect?
A. Hypertension.
B. Uterine tenderness.
C. Fetal tachycardia.
D. Leukorrhea. - CORRECT ANSWER- Uterine tenderness
Uterine tenderness is a common symptom of abruptio placentae
A nurse is caring for a client who is at 28 weeks of gestation and received no
immunizations during childhood.
Which of the following vaccines should the nurse plan to administer?
A. Human papillomavirus.
B. Rubella.
C. Tetanus.
,D. Varicella. - CORRECT ANSWER- Tetanus
Tetanus vaccine is safe and recommended during pregnancy
A nurse is assessing a newborn who was born via a forceps-assisted birth.
Which of the following findings should the nurse identify as an injury caused by
the forceps?
A. Depressed anterior fontanel.
B. Uneven gluteal skinfolds.
C. Epicanthal folds.
D. Facial asymmetry. - CORRECT ANSWER- Facial asymmetry
Facial asymmetry can occur due to pressure from the forceps on the facial nerves
during delivery.
A nurse is caring for a client who is taking an oral contraceptive.
The nurse should instruct the client to report which of the following findings to the
provider immediately?
A. Breast tenderness.
B. Persistent headaches.
C. Vaginal itching.
,D. Painful intercourse. - CORRECT ANSWER- Persistent headaches
Persistent headaches can be a sign of a serious side effect such as a stroke or blood
clot and should be reported immediately.
A nurse is caring for a client who is postpartum and just delivered a newborn who
weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse
recognize as a potential sign of hemorrhage?
A. Blood pressure 88/40 mm Hg.
B. Urinary output 40 mL/hr.
C. Moderate rubra lochia.
D. Heart rate 90/min. - CORRECT ANSWER- Blood pressure 88/40 mm Hg
A blood pressure of 88/40 mm Hg is lower than the normal range (90/60 to 120/80
mm Hg) and could indicate hemorrhage.
A nurse is caring for a client who is in labor. Which of the following findings
should prompt the nurse to reassess the client?
A. Intense contractions lasting 45 to 60 seconds.
B. An urge to have a bowel movement during contractions.
C. A sense of excitement and warm, flushed skin.
D. Progressive sacral discomfort during contractions. - CORRECT ANSWER-
An urge to have a bowel movement during contractions.
, An urge to have a bowel movement during contractions could indicate that the
baby's head is descending into the birth canal, which may require immediate
attention.
A nurse is providing teaching to the parents of a newborn about the Plastibell
circumcision technique.
Which of the following information should the nurse include?
A. "Yellow exudate will form at the surgical site in 24 hours.".
B. "Notify the provider if the end of your baby's penis appears dark red.".
C. "The Plastibell will be removed 4 hours after the procedure.".
D. "Make sure the newborn's diaper is snug.". - CORRECT ANSWER- "Yellow
exudate will form at the surgical site in 24 hours."
The nurse should include that "yellow exudate will form at the surgical site in 24
hours" as part of the teaching to the parents. This is because the yellow exudate is a
normal sign of healing and should not be confused with infection.
A nurse is caring for a client who is postpartum and has a perineal laceration.
Which of the following findings places the client at risk for delayed wound
healing?
A. The client is changing the perineal pad once daily.
B. The client is using witch hazel pads on the perineum.
C. The client cleans the perineum with a squeeze bottle after urinating.