Detailed Answer Key
Maternity review test 1
1. A client at 40 weeks of gestation is about to undergo a biophysical profile. The nurse should explain that this
profile focuses on which of the following parameters? (Select all that apply.)
A. Fetal breathing
B. Fetal motion
C. Nuchal translucency
D. Amniotic fluid volume
E. Fetal gender
Rationale: Fetal breathing is correct. A biophysical profile includes evaluation of fetal breathing
movements.
Fetal motion is correct. A biophysical profile includes evaluation of gross body
movement of the fetus.
Nuchal transparency is incorrect. This screening technique measures fluid in the
nape of the fetal neck via ultrasound, but it is not a parameter of the biophysical
profile.
Amniotic fluid volume is correct. A biophysical profile includes a qualitative
evaluation of amniotic fluid volume.
Fetal gender is incorrect. Although ultrasonography can determine gender, the
biophysical profile measures fetal well-being, not gender.
CAA_DetailedAnswerKey created 05/15/2016 page 1 of 159
, Detailed Answer Key
Maternity review test 1
2. A client delivered a 34-week, 1,550-g newborn who has nasal flaring, intercostal retractions, expiratory
grunting, and mild cyanosis. The nurse should place the newborn in an incubator that will create a neutral
thermal environment because
A. he has a small body surface for his weight.
Rationale: Preterm newborns have a large body surface area for their weight.
B. heat increases flow of oxygen to his extremities.
Rationale: The goal is not simply to expose the infant to heat, but to an environment that
avoids not just hypothermia, but hyperthermia as well. In a neutral thermal
environment, oxygen consumption is minimal. Both hypothermia and hyperthermia
can adversely affect oxygenation.
C. his temperature control mechanism is immature.
Rationale: Preterm newborns have poor body control of temperature and needs immediate
attention to keep from losing heat. Reasons for heat loss include little subcutaneous
fat and poor insulation, large body surface for weight, immaturity of temperature
control, and lack of activity. They require an external heat source that regulates their
immediate environment via a sensor attached to the skin.
D. heat facilitates the drainage of mucus.
Rationale: Dry heat can impede the drainage of mucus.
CAA_DetailedAnswerKey created 05/15/2016 page 2 of 159
, Detailed Answer Key
Maternity review test 1
3. A nurse is caring a client who is 1 day postpartum and is attempting to breastfeed. Which of the following
findings indicate mastitis?
A. Swelling in both breasts
Rationale: Because the swelling is present in both breasts and there is no redness or pain, this
client is not likely to have mastitis. This client is more likely to have engorgement.
The nurse should assist the client to breastfeed frequently and use a well-fitting bra.
It also might help to use warmth, such as a warm shower. If the breasts are severely
engorged, it might help to express some milk to soften the breasts prior to nursing.
B. Cracked and bleeding nipples
Rationale: Cracked and bleeding nipples are not signs of mastitis. However, cracked nipples
are a risk for developing mastitis. Cracked and sore nipples may occur until the
woman’s nipples adapt to the friction from nursing. Cracked and sore nipples also
may indicate tissue damage from inadequate latching. The nurse should reinforce
appropriate breastfeeding techniques.
C. Red and painful area in one breast
Rationale: Mastitis often appears as a red, hard, and painful area. Although mastitis may occur
in both breasts, it is usually unilateral. After delivery, the nurse should monitor a
woman’s breasts for signs of mastitis and reinforce instruction for breast self-
examination.
D. Temperature of 38o C (100o F)
Rationale: A client may have an elevated temperature during the initial 24 hr postpartum. This
is due to fluid loss during labor and delivery, sleep deprivation, and physiologic
response to the birthing process. A temperature that persists after 24 hr postpartum
may indicate an infection.
CAA_DetailedAnswerKey created 05/15/2016 page 3 of 159
, Detailed Answer Key
Maternity review test 1
4. A nurse is caring for a client in the immediate postpartum period. The nurse realizes that the client is at risk for
postpartal hemorrhage due to uterine atony because she had a
A. midline episiotomy.
Rationale: A midline episiotomy does not cause uterine atony.
B. precipitous delivery.
Rationale: The risk of uterine atony increases whenever the uterus has been overstressed or
overstretched, as with a precipitous delivery (one that occurs in less than 2.5 hr).
C. vaginal delivery.
Rationale: The risk of hemorrhage does not increase after an uncomplicated vaginal delivery.
D. periurethral tear.
Rationale: This injury does not increase the risk of uterine atony.
CAA_DetailedAnswerKey created 05/15/2016 page 4 of 159
Maternity review test 1
1. A client at 40 weeks of gestation is about to undergo a biophysical profile. The nurse should explain that this
profile focuses on which of the following parameters? (Select all that apply.)
A. Fetal breathing
B. Fetal motion
C. Nuchal translucency
D. Amniotic fluid volume
E. Fetal gender
Rationale: Fetal breathing is correct. A biophysical profile includes evaluation of fetal breathing
movements.
Fetal motion is correct. A biophysical profile includes evaluation of gross body
movement of the fetus.
Nuchal transparency is incorrect. This screening technique measures fluid in the
nape of the fetal neck via ultrasound, but it is not a parameter of the biophysical
profile.
Amniotic fluid volume is correct. A biophysical profile includes a qualitative
evaluation of amniotic fluid volume.
Fetal gender is incorrect. Although ultrasonography can determine gender, the
biophysical profile measures fetal well-being, not gender.
CAA_DetailedAnswerKey created 05/15/2016 page 1 of 159
, Detailed Answer Key
Maternity review test 1
2. A client delivered a 34-week, 1,550-g newborn who has nasal flaring, intercostal retractions, expiratory
grunting, and mild cyanosis. The nurse should place the newborn in an incubator that will create a neutral
thermal environment because
A. he has a small body surface for his weight.
Rationale: Preterm newborns have a large body surface area for their weight.
B. heat increases flow of oxygen to his extremities.
Rationale: The goal is not simply to expose the infant to heat, but to an environment that
avoids not just hypothermia, but hyperthermia as well. In a neutral thermal
environment, oxygen consumption is minimal. Both hypothermia and hyperthermia
can adversely affect oxygenation.
C. his temperature control mechanism is immature.
Rationale: Preterm newborns have poor body control of temperature and needs immediate
attention to keep from losing heat. Reasons for heat loss include little subcutaneous
fat and poor insulation, large body surface for weight, immaturity of temperature
control, and lack of activity. They require an external heat source that regulates their
immediate environment via a sensor attached to the skin.
D. heat facilitates the drainage of mucus.
Rationale: Dry heat can impede the drainage of mucus.
CAA_DetailedAnswerKey created 05/15/2016 page 2 of 159
, Detailed Answer Key
Maternity review test 1
3. A nurse is caring a client who is 1 day postpartum and is attempting to breastfeed. Which of the following
findings indicate mastitis?
A. Swelling in both breasts
Rationale: Because the swelling is present in both breasts and there is no redness or pain, this
client is not likely to have mastitis. This client is more likely to have engorgement.
The nurse should assist the client to breastfeed frequently and use a well-fitting bra.
It also might help to use warmth, such as a warm shower. If the breasts are severely
engorged, it might help to express some milk to soften the breasts prior to nursing.
B. Cracked and bleeding nipples
Rationale: Cracked and bleeding nipples are not signs of mastitis. However, cracked nipples
are a risk for developing mastitis. Cracked and sore nipples may occur until the
woman’s nipples adapt to the friction from nursing. Cracked and sore nipples also
may indicate tissue damage from inadequate latching. The nurse should reinforce
appropriate breastfeeding techniques.
C. Red and painful area in one breast
Rationale: Mastitis often appears as a red, hard, and painful area. Although mastitis may occur
in both breasts, it is usually unilateral. After delivery, the nurse should monitor a
woman’s breasts for signs of mastitis and reinforce instruction for breast self-
examination.
D. Temperature of 38o C (100o F)
Rationale: A client may have an elevated temperature during the initial 24 hr postpartum. This
is due to fluid loss during labor and delivery, sleep deprivation, and physiologic
response to the birthing process. A temperature that persists after 24 hr postpartum
may indicate an infection.
CAA_DetailedAnswerKey created 05/15/2016 page 3 of 159
, Detailed Answer Key
Maternity review test 1
4. A nurse is caring for a client in the immediate postpartum period. The nurse realizes that the client is at risk for
postpartal hemorrhage due to uterine atony because she had a
A. midline episiotomy.
Rationale: A midline episiotomy does not cause uterine atony.
B. precipitous delivery.
Rationale: The risk of uterine atony increases whenever the uterus has been overstressed or
overstretched, as with a precipitous delivery (one that occurs in less than 2.5 hr).
C. vaginal delivery.
Rationale: The risk of hemorrhage does not increase after an uncomplicated vaginal delivery.
D. periurethral tear.
Rationale: This injury does not increase the risk of uterine atony.
CAA_DetailedAnswerKey created 05/15/2016 page 4 of 159
