QUESTIONS AND ANSWERS, RATIONALES, 100% VERIFIED
NEWEST VERSION (2025/2026) UPDATE.
1. A nurse on the postpartum unit is caring for a pt. following a cesarean birth.
Which of the following assessments is the nurse's priority?
a. parent-child attachment
b. amount of lochia
c. patency of the IV catheter
d. quality and quantity of urine
Answers: b. amount of lochia
RATIONALE when using the ABCs approach to client care, the nurse should place
the priority in the immediate postpartum period on assessing the amount of
postpartum lochia. the greatest risk to the client is bleeding and postpartum
hemorrhage.
2. a nurse is caring for a client who is in labor and whose fetus is in the right
occiput posterior position. the client is dilated to 8cm and reports back pain.
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, which of the following actions should the nurse take?
a. apply sacral counter pressure
b. perform trancutaneous electrical nerve stimulation (TENS)
c. initiate slow-paced breathing
d. assist with biofeedback
Answers: a. apply sacral counter pressure
RATIONALE the nurse should apply sacral counter pressure to assist in relieving
back labor pain related to fetal posterior position
b. the nurse should perform TENS during the first stage of labor.
c. the nurse should transition a client to pattern-paced breathing during this stage
of labor.
d. The nurse should teach the client about biofeedback during the prenatal period
for it to be effective during labor.
3. a nurse is demonstrating to a client how to bathe her newborn. in which
order should the nurse perform the following actions
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, a. wipe the newborn's eyes from inner canthus outward
b. wash the newborn's legs and feet
c. wash the newborn's neck by lifting the newborn's chin
d. cleanse the skin around the newborn's umbilical stump
e. clean the newborn's diaper area
Answers: a. wipe the newborn's eyes from inner canthus outward
c. wash the newborn's neck by lifting the newborn's chin
d. cleanse the skin around the newborn's umbilical stump
b. wash the newborn's legs and feet
e. clean the newborn's diaper area
RATIONALE The nurse should demonstrate how to bathe a newborn by using a
head to toe, clean to dirty, approach.
4. a nurse is caring for a client and her partner who have experienced a fetal
death. which of the following actions should the nurse take?
a. take photos of the newborn to give to the parents
b. tell the parents that they can consider organ donation
c. encourage the parents to avoid allowing older children to visit them in the
hospital
d. explain to the parents the need to name the newborn
Answers: a. take photos of the newborn to give to the parents
RATIONALE the nurse should create a memory box that includes mementos of the
newborn (ex: photos, ID bands, newborn hat and blanket)
b. Organ donation can be considered if a newborn is delivered alive.
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, c. The nurse should encourage the client to allow older children to come to the
hospital as a beneficial part of the grieving process.
d. The nurse should explain to the client that naming the baby can be helpful during
the grieving process, but it is not a requirement.
5. a nurse is caring for a client who is 36 weeks gestation and has a positive
contraction stress test. the nurse should plan to prepare the clients for which
of the following diagnostic tests?
a. biophysical profile
b. amniocentesis
c. cordocentesis
d. Kleihauer- Burke test
Answers: a. biophysical profile
RATIONALE a positive contraction stress test indicate further evaluation of the
fetus is necessary. a biophysical profile will provide further evaluation with real-
time ultrasound
b. An amniocentesis is used to determine lung maturity, detect congenital anomalies,
and diagnose fetal hemolytic disease.
c. A cordocentesis is used to identify fetal blood type and RBC when there is a risk
of isoimmune hemolytic anemia.
d. The Kleihauer-Betke test is used to determine the amount of fetal blood in the
maternal circulation when there is a risk of Rh-isoimmunization.
6. a nurse is reviewing the medical record of a client who is postpartum and
has preeclampsia. which of the following laboratory results should the nurse
report to the provider?
a. hct 39%
b. serum albumin 4.5 g/dL
c. WBC 9,000/mm3
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