maternal Newborn Nursing - Exam 1 ./. ./. ./. ./. ./.
A patient experiences a large gush of fluid from her vagina whi
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le walking in the hallway of the birthing unit. The nurse's first
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nursing action after establishing that the fluid is amniotic fluid
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
should be to ./. ./.
A. prepare the patient for anesthesia because a cesarean deliver
./. ./. ./. ./. ./. ./. ./. ./. ./.
y will be necessary.
./. ./. ./.
B. contact the patient's physician and report that rupture of me
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mbranes has occurred. ./. ./.
C. time the patient's contractions to determine what stage of lab
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or the patient is in.
./. ./. ./. ./.
D. monitor the fetal heart rate for signs of distress. -
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correct answer ✔ ✔
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D. monitor the fetal heart rate for signs of distress.
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A nurse in L&D is completing an admission history for a client
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who is at 39 weeks of gestation. The client reports that she has
/. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. .
, been leaking fluid from her vagina for 2 days. The nurse know
/. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
s that this client is at risk for
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A. pre-term labor.
./. ./.
B. gestational diabetes.
./. ./.
C. infection.
./.
D. preeclampsia. - correct answer ✔ ✔ C. infection
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A nurse is performing Leopold maneuvers on a client who is in
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labor. Which of the following techniques is not part of this pro
/. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
cess?
A. Palpate the fundus of the uterus.
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B. Palpate laterally to determine which side is the back.
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C. Palpate the cervix to determine the degree of dilation.
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D. Palpate the presenting part to determine its extension into th
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
e pelvis. - correct answer ✔ ✔
./. ./. ./. ./. ./.
C. Palpate the cervix to determine the degree of dilation.
./. ./. ./. ./. ./. ./. ./. ./. ./.
A nurse is caring for a postpartum client and encourages the cli
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ent to void every 2 hr. The nurse explains the reason for this is
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A. a distended bladder can interfere with the involution of the
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uterus.
, B. a catheter may need to be inserted if the client refused to vo
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
id regularly.
./.
C. the bladder has likely been injured during delivery and need
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
s to be encouraged to return to normal function.
./. ./. ./. ./. ./. ./. ./. ./.
D. a distended bladder increases the risk of postpartum hemorr
./. ./. ./. ./. ./. ./. ./. ./. ./.
hage. - correct answer ✔ ✔ ./. ./. ./. ./.
A. a distended bladder can interfere with the involution of the
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
uterus.
./.
A nurse is performing a fundal assessment for a client in her se
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cond postpartum day and observes the client's perineal pad for l
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ochia. She notes the pad to be saturated approximately 12 cm
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with lochia that is bright red in color and contains small clots.
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
The nurse knows that this finding should be charted as
./. ./. ./. ./. ./. ./. ./. ./. ./.
A. scant lochia alba
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B. moderate lochia rubra
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C. moderate lochia serosa
./. ./. ./.
D. excessive lochia rubra - correct answer ✔ ✔
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B. moderate lochia rubra
./. ./. ./.
During ambulation to the bathroom, a postpartum client experie
./. ./. ./. ./. ./. ./. ./. ./.
nces a gush of dark red blood that soon stops. On assessment, a
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
A patient experiences a large gush of fluid from her vagina whi
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
le walking in the hallway of the birthing unit. The nurse's first
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
nursing action after establishing that the fluid is amniotic fluid
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
should be to ./. ./.
A. prepare the patient for anesthesia because a cesarean deliver
./. ./. ./. ./. ./. ./. ./. ./. ./.
y will be necessary.
./. ./. ./.
B. contact the patient's physician and report that rupture of me
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
mbranes has occurred. ./. ./.
C. time the patient's contractions to determine what stage of lab
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
or the patient is in.
./. ./. ./. ./.
D. monitor the fetal heart rate for signs of distress. -
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
correct answer ✔ ✔
./. ./. ./.
D. monitor the fetal heart rate for signs of distress.
./. ./. ./. ./. ./. ./. ./. ./. ./.
A nurse in L&D is completing an admission history for a client
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. .
who is at 39 weeks of gestation. The client reports that she has
/. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. .
, been leaking fluid from her vagina for 2 days. The nurse know
/. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
s that this client is at risk for
./. ./. ./. ./. ./. ./. ./.
A. pre-term labor.
./. ./.
B. gestational diabetes.
./. ./.
C. infection.
./.
D. preeclampsia. - correct answer ✔ ✔ C. infection
./. ./. ./. ./. ./. ./.
A nurse is performing Leopold maneuvers on a client who is in
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. .
labor. Which of the following techniques is not part of this pro
/. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
cess?
A. Palpate the fundus of the uterus.
./. ./. ./. ./. ./. ./.
B. Palpate laterally to determine which side is the back.
./. ./. ./. ./. ./. ./. ./. ./. ./.
C. Palpate the cervix to determine the degree of dilation.
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
D. Palpate the presenting part to determine its extension into th
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
e pelvis. - correct answer ✔ ✔
./. ./. ./. ./. ./.
C. Palpate the cervix to determine the degree of dilation.
./. ./. ./. ./. ./. ./. ./. ./. ./.
A nurse is caring for a postpartum client and encourages the cli
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
ent to void every 2 hr. The nurse explains the reason for this is
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
A. a distended bladder can interfere with the involution of the
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
uterus.
, B. a catheter may need to be inserted if the client refused to vo
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
id regularly.
./.
C. the bladder has likely been injured during delivery and need
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
s to be encouraged to return to normal function.
./. ./. ./. ./. ./. ./. ./. ./.
D. a distended bladder increases the risk of postpartum hemorr
./. ./. ./. ./. ./. ./. ./. ./. ./.
hage. - correct answer ✔ ✔ ./. ./. ./. ./.
A. a distended bladder can interfere with the involution of the
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
uterus.
./.
A nurse is performing a fundal assessment for a client in her se
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
cond postpartum day and observes the client's perineal pad for l
./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
ochia. She notes the pad to be saturated approximately 12 cm
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
with lochia that is bright red in color and contains small clots.
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
The nurse knows that this finding should be charted as
./. ./. ./. ./. ./. ./. ./. ./. ./.
A. scant lochia alba
./. ./. ./.
B. moderate lochia rubra
./. ./. ./.
C. moderate lochia serosa
./. ./. ./.
D. excessive lochia rubra - correct answer ✔ ✔
./. ./. ./. ./. ./. ./. ./.
B. moderate lochia rubra
./. ./. ./.
During ambulation to the bathroom, a postpartum client experie
./. ./. ./. ./. ./. ./. ./. ./.
nces a gush of dark red blood that soon stops. On assessment, a
./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./. ./.
