MATERNITY PRACTICE EXAM - 50
QUESTIONS WITH VERIFIED ANSWERS
jDuring the transition phase of labor, a client complains of tingling and numbness in her fingers and tells
the nurse that she feels like she is going to pass out. What action should the nurse take? - Have her cup
both hands over her nose and mouth while breathing.
Rationale: Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes
transient respiratory alkalosis, so the client should cup both hands over her mouth and nose so she can
rebreathe carbon dioxide.
A client who delivered by cesarean section 24 hours ago is using a PCA pump for pain control. Her oral
intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states
that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis
has the highest priority? - Impaired bowel motility related to pain medication and immobility.Impaired
bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing
diagnosis and addresses the potential problem of a paralytic ileus.
A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which
explanation is appropriate? - "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10
times a day."
The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day) , if the infant is adequately
hydrated. Although a weight gain of 30 grams/day is indicative of adequate nutrition, most home scales
do not measure this accurately and this suggestion is likely to make the mother very anxious.
The nurse is counseling a couple who has sought information about conceiving. The couple asks the
nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? - Two weeks
before menstruation.
Ovulation occurs 14 days before the first day of the menstrual period . While ovulation can occur in the
middle of the cycle, or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-
day cycle. For many women, the length of their menstrual cycle varies.
The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines the
client is dilated 7 cm, is 100% effaced at 0 station, with intact membranes. The monitor indicates the
fetal heart rate (FHR) decelerates at the onset of several contractions and returns to baseline before
each contraction ends. What action should the nurse take? - Continue to monitor labor progress.
, The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should
continue to monitor the labor progress and document the findings in the client's record.
The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of
tingling fingers and dizziness. What action should the nurse take? - Have the client breathe into her
cupped hands.
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide).
Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper
bag or cupped hands .
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized
swelling on the right side of his head. What is the most likely cause of this accumulation of blood
between the periosteum and skull that does not cross the suture line in a newborn? - A
cephalhematoma, which is caused by forceps trauma.
Cephalhematoma , a slight abnormal variation of the newborn, usually arises within the first 24 hours
after delivery. Trauma from delivery causes capillary bleeding between the periosteum and the skull.
One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his
lower lip is shaking, and when the nurse assesses for a Moro reflex, his hands shake. What intervention
should the nurse implement first? - Obtain a serum glucose level.
This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The
nurse should first determine the serum glucose level .
A client in active labor is becoming increasingly fearful because her contractions are occurring more
often than she expected. Her partner is also becoming anxious. The nurse's response should focus on
which content? - Asking the client and her partner if they would like the nurse stay in the room.
Offering to remain with the client and her partner (C) offers support without providing false reassurance.
The length of labor is not always predictable, but (A and B) do not offer the client the support that is
needed at this time. (D) may be reassuring regarding the fetal heart rate, but it does not provide the
client the emotional support she needs at this time during the labor process.
A breastfeeding postpartum client is diagnosed with mastitis and antibiotic therapy is prescribed. What
instruction should the nurse provide to this client? - Breastfeed the infant, ensuring that both breasts are
completely emptied.
QUESTIONS WITH VERIFIED ANSWERS
jDuring the transition phase of labor, a client complains of tingling and numbness in her fingers and tells
the nurse that she feels like she is going to pass out. What action should the nurse take? - Have her cup
both hands over her nose and mouth while breathing.
Rationale: Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes
transient respiratory alkalosis, so the client should cup both hands over her mouth and nose so she can
rebreathe carbon dioxide.
A client who delivered by cesarean section 24 hours ago is using a PCA pump for pain control. Her oral
intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states
that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis
has the highest priority? - Impaired bowel motility related to pain medication and immobility.Impaired
bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing
diagnosis and addresses the potential problem of a paralytic ileus.
A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which
explanation is appropriate? - "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10
times a day."
The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day) , if the infant is adequately
hydrated. Although a weight gain of 30 grams/day is indicative of adequate nutrition, most home scales
do not measure this accurately and this suggestion is likely to make the mother very anxious.
The nurse is counseling a couple who has sought information about conceiving. The couple asks the
nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? - Two weeks
before menstruation.
Ovulation occurs 14 days before the first day of the menstrual period . While ovulation can occur in the
middle of the cycle, or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-
day cycle. For many women, the length of their menstrual cycle varies.
The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines the
client is dilated 7 cm, is 100% effaced at 0 station, with intact membranes. The monitor indicates the
fetal heart rate (FHR) decelerates at the onset of several contractions and returns to baseline before
each contraction ends. What action should the nurse take? - Continue to monitor labor progress.
, The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should
continue to monitor the labor progress and document the findings in the client's record.
The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of
tingling fingers and dizziness. What action should the nurse take? - Have the client breathe into her
cupped hands.
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide).
Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper
bag or cupped hands .
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized
swelling on the right side of his head. What is the most likely cause of this accumulation of blood
between the periosteum and skull that does not cross the suture line in a newborn? - A
cephalhematoma, which is caused by forceps trauma.
Cephalhematoma , a slight abnormal variation of the newborn, usually arises within the first 24 hours
after delivery. Trauma from delivery causes capillary bleeding between the periosteum and the skull.
One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his
lower lip is shaking, and when the nurse assesses for a Moro reflex, his hands shake. What intervention
should the nurse implement first? - Obtain a serum glucose level.
This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The
nurse should first determine the serum glucose level .
A client in active labor is becoming increasingly fearful because her contractions are occurring more
often than she expected. Her partner is also becoming anxious. The nurse's response should focus on
which content? - Asking the client and her partner if they would like the nurse stay in the room.
Offering to remain with the client and her partner (C) offers support without providing false reassurance.
The length of labor is not always predictable, but (A and B) do not offer the client the support that is
needed at this time. (D) may be reassuring regarding the fetal heart rate, but it does not provide the
client the emotional support she needs at this time during the labor process.
A breastfeeding postpartum client is diagnosed with mastitis and antibiotic therapy is prescribed. What
instruction should the nurse provide to this client? - Breastfeed the infant, ensuring that both breasts are
completely emptied.
