,1.
A.
B.
C.
D.
Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two
or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the
acceleration to the end, in association with fetal movement, during a 20-minute period. A nonreactive test is an abnormal
test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40-
minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart
rate recording.
Test-Taking Strategy: Use the process of elimination. Eliminate a reactive nonstress test and a normal nonstress test first
because they are comparable or alike. To select from the remaining options, note the relationship between “less than 15
seconds” in the question and “nonreactive” in the correct option. If you had difficulty answering this question, review the
interpretation of nonstress test results.
2.
A.
B.
C.
D.
Rationale: Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer,
contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, persistently decreased
variability, or an irregular FHR. The normal FHR is 110 to 160 beats/min. Therefore, because the finding is abnormal, the
physician must be contacted. Continuing to monitor the client delays necessary intervention. Reassuring the client that
labor is progressing normally is incorrect. The nurse would document the data, actions taken, and the client’s response,
but, of the options provided, contacting the physician is the most appropriate.
Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Eliminate the options that are
comparable or alike and indicate that the data in the question are normal findings. Review normal assessment findings
during the labor process if you had difficulty with this question.
3.
A.
,B.
C.
, Rationale: Therapeutic communication helps the mother, father, and other family members express their feelings and
emotions. “This must be hard for you” is a caring and empathetic response, focused on feelings and encouraging
communication. The other options are nontherapeutic and may devalue the family members' feelings.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option
that is focused on the family members’ feelings. Review therapeutic communication techniques if you had difficulty with
this question.
D.
4.
A.
B.
C.
D.
Rationale: A prenatal rubella antibody screen is performed in every pregnant woman to determine whether she is immune
to rubella, which can cause serious fetal anomalies. If she is not immune, rubella vaccine is offered after childbirth to keep
her from contracting rubella during subsequent pregnancies. The vaccine is a live virus, and defects might occur in the
fetus if the vaccine were administered during pregnancy or if the mother were to become pregnant soon after it was
administered. Administering a rubella vaccine immediately places the fetus at risk. Telling the client that she does not
need to be concerned about being exposed to rubella is incorrect, because the possibility of exposure, which could be
harmful to the fetus, does exist.
Test-Taking Strategy: Use the process of elimination. Eliminate first the options that are comparable or alike (i.e., the
client will not acquire rubella and does not need to be concerned about exposure). To select from the remaining options,
recall that rubella vaccine is a live virus; this will direct you to the correct option. Review rubella vaccine and its
implications during pregnancy if you had difficulty with this question.
5.
A.
B.
C.
D.
A.
B.
C.
D.
Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two
or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the
acceleration to the end, in association with fetal movement, during a 20-minute period. A nonreactive test is an abnormal
test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40-
minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart
rate recording.
Test-Taking Strategy: Use the process of elimination. Eliminate a reactive nonstress test and a normal nonstress test first
because they are comparable or alike. To select from the remaining options, note the relationship between “less than 15
seconds” in the question and “nonreactive” in the correct option. If you had difficulty answering this question, review the
interpretation of nonstress test results.
2.
A.
B.
C.
D.
Rationale: Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer,
contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, persistently decreased
variability, or an irregular FHR. The normal FHR is 110 to 160 beats/min. Therefore, because the finding is abnormal, the
physician must be contacted. Continuing to monitor the client delays necessary intervention. Reassuring the client that
labor is progressing normally is incorrect. The nurse would document the data, actions taken, and the client’s response,
but, of the options provided, contacting the physician is the most appropriate.
Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Eliminate the options that are
comparable or alike and indicate that the data in the question are normal findings. Review normal assessment findings
during the labor process if you had difficulty with this question.
3.
A.
,B.
C.
, Rationale: Therapeutic communication helps the mother, father, and other family members express their feelings and
emotions. “This must be hard for you” is a caring and empathetic response, focused on feelings and encouraging
communication. The other options are nontherapeutic and may devalue the family members' feelings.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option
that is focused on the family members’ feelings. Review therapeutic communication techniques if you had difficulty with
this question.
D.
4.
A.
B.
C.
D.
Rationale: A prenatal rubella antibody screen is performed in every pregnant woman to determine whether she is immune
to rubella, which can cause serious fetal anomalies. If she is not immune, rubella vaccine is offered after childbirth to keep
her from contracting rubella during subsequent pregnancies. The vaccine is a live virus, and defects might occur in the
fetus if the vaccine were administered during pregnancy or if the mother were to become pregnant soon after it was
administered. Administering a rubella vaccine immediately places the fetus at risk. Telling the client that she does not
need to be concerned about being exposed to rubella is incorrect, because the possibility of exposure, which could be
harmful to the fetus, does exist.
Test-Taking Strategy: Use the process of elimination. Eliminate first the options that are comparable or alike (i.e., the
client will not acquire rubella and does not need to be concerned about exposure). To select from the remaining options,
recall that rubella vaccine is a live virus; this will direct you to the correct option. Review rubella vaccine and its
implications during pregnancy if you had difficulty with this question.
5.
A.
B.
C.
D.
