Name:_____________________________________________________________Date:_____________
1. A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath
and is unable to sleep unless she places three pillows under her head. After listening to the client's
concerns, the nurse should take which action?
a. Make an appointment because the dent needs to be evaluated.
b. Explain that these are expected problems for the latter stages of pregnancy.
c. Arrange for the dent to be admitted to the birth center and prepare for birth.
d. Tell the client to go to the hospital; she may be experiencing signs of heart failure.
RATIONALE: The nurse must distinguish between normal physiologic complaints of the latter stages of
pregnancy and those that need referral to the health care provider. In this case, the client indicates normal
physiologic changes caused by the growing uterus and pressure on the diaphragm. These signs don't
indicate heart failure. The client doesn't need to be seen or admitted to the birth center.
Reference: Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 230.
2. During the first trimester, a nurse evaluates a pregnant client for factors that suggest she might abuse a
child. Which parental characteristic is of most concern to the nurse?
a. The client didn’t graduate high school.
b. The client states she is stupid and ugly.
c. The client is carrying twins.
The client eats fast food every day.
RATIONALE: Typically, the abusive parent has low self-esteem, which may be evident by self-deprecating
statements, and many unmet needs. Lack of nurturing experience and inadequate knowledge of childhood
growth and development may also contribute to the potential for child abuse. A low educational level,
multiple gestations, and poor diet aren't direct risk factors for committing child abuse. REFERENCE:
Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1743.
3. A client in her 15th week of pregnancy has presented with abdominal cramping and vaginal bleeding for
the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this client?
a. Deficient knowledge of pregnancy
b. Deficient fluid volume
c. Anticipatory grieving
d. Acute pain
RATIONALE: If bleeding and clots are excessive, this client may become hypovolemic , leading to a nursing
diagnosis of Deficient fluid volume. Although Deficient knowledge (pregnancy), Anticipatory grieving,
and Acute pain are applicable to this client, they aren't the primary diagnosis
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 400.
4. A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether
the client is at risk for a TORCH infection , the nurse should ask:
a. “Have you ever had osteomyelitis?”
b. “Do you have any cats at home?
c. “Do you have any birds at home?’
d. “Have you recently had a rubeola vaccination?”
RATIONALE: Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus and agents
that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to
humans through contact with the feces of infected cats (which may occur when emptying a litter box),
through ingesting raw meat, or through contact with raw meat followed by improper hand washing.
Osteomyelitis , a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola
aren't TORCH infections
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 288.
5. A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help
confirm that she's in true labor, the nurse should assess for:
a. irregular contractions.
b. increased fetal movement.
c. changes in cervical effacement and dilation atter 1 to 2 hours.
, RATIONALE: True labor is characterized by progressive cervical effacement and dilation after 1 to 2 hours,
regular contractions, discomfort that moves from the back to the front of the abdomen and, possibly,
bloody show. False labor causes irregular contractions that are felt primarily in the abdomen and groin and
commonly decrease with walking, increased fetal movement, and lack of change in cervical effacement or
dilation even after 1 or 2 hours.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 227.
6. A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain
from her episiotomy . What should the nurse instruct the woman to do?
a. Apply an ice pack to her perineum.
b. Take a sitz bath.
c. Perform perineal care after voiding or a bowel movement.
d. Drink plenty of fluids.
RATIONALE: A cold pack applied to an episiotomy during the first 24 hours after chidbirth may reduce
edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a sitz bath may
reduce discomfort by promoting circulation and healing. Although perineal care should be performed after
each voiding and bowel movement, its purpose is to prevent infection — not reduce discomfort.
Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it doesn't relieve
perineal discomfort.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 637.
7. A client who's 24 weeks pregnant has sickle cell anemia . When preparing the care plan, the nurse should
identify which factor as a potential trigger for a sickle cell crisis during pregnancy?
a. Sedative use
b. Dehydration
c. Hypertension
d. Tachycardia
RATIONALE: Factors that may precipitate a sickle cell crisis during pregnancy include dehydration ,
infection , stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and
tachycardia aren't known to precipitate a sickle cell crisis
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 363.
8. A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her
decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase
called?
a. Taking-in phase
b. Taking-hold phase
c. Letting-go phase
d. Taking-over phase
RATIONALE: The taking-in phase is a normal first phase for a mother when she's feeling overwhelmed by
the responsibilities of caring for the neonate while still fatigued from childbirth. Taking hold is the next
phase, when the mother has rested and she can think and learn mothering skills with confidence. During
the letting-go or taking-over phase, the mother gives up her previous role. She separates herself from the
neonate, giving up the fantasy of birth, and readjusting to the reality of caring for the neonate. Depression
may occur during this stage.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 624.
9. Which intervention listed in the care plan for a client with an ectopic pregnancy requires revision?
a. Assessing vital signs
b. Providing for dietary needs
c. Managing pain
d. Providing emotional support
RATIONALE: Providing for the client's dietary needs isn't appropriate because the client shouldn't eat or
drink anything pending surgery. Assessing vital signs for indicators of potential shock , managing pain, and
providing emotional support are essential nursing interventions in caring for a client with an ectopic
pregnancy.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 409.
10. A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking
the client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal
, a. Edema
b. Pelvic adequacy
c. Rh factor changes
d. Hemoglobin alterations
RATIONALE: At each prenatal visit, the nurse should assess the client for edema because edema, increased
blood pressure, and proteinuria are cardinal signs of gestational hypertension. Pelvic measurements and
Rh typing are determined at the first visit only because they don't change. The nurse should monitor the
hemoglobin level on the client's first visit, at 24 to 28 weeks' gestation, and at 36 weeks' gestation.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 257.
11. A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this
client, the nurse's highest priority is to evaluate:
a. cervical effacement and dation.
b. maternal vital signs and fetal heart rate (FHR).
c. frequency and duration of contractions.
d. white blood cell (WBC) count.
RATIONALE: After premature rupture of the membranes (PROM), monitoring maternal vital signs and FHR
takes priority. Maternal vital signs, especially temperature and pulse, may suggest maternal infection
caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis
caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this
client because it requires a pelvic examination, which may introduce pathogens into the birth canal.
Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC
count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and
FHR can and therefore provides less current information
REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health Nursing. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 531.
12. A client is told that she needs to have a nonstress test to determine fetal well-being. After 20 minutes of
monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds.
What should the nurse do next ?
a. Continue to monitor the baby for fetal distress.
b. Notify the physician and transfer the mother to labor and delivery for imminent delivery.
c. Inform the physician and prepare for discharge: this client has a reassuring strip.
d. Ask the mother to eat something and return for a repeat test; the results are inconclusive.
RATIONALE: Fetal well-being is determined during a nonstress test by two accelerations occurring within
20 minutes that demonstrate a rise in heart rate of at least 15 beats. This fetus has successfully
demonstrated that the intrauterine environment is still favorable. The test results don't suggest fetal
distress, so immediate delivery is unnecessary. In research studies, eating foods or drinking fluids hasn't
been shown to influence the outcome of a nonstress test. REFERENCE: Pillitteri, A. Maternal & Child
Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams
& Wilkins, 2007, p. 203.
13. A nurse is caring for four clients who gave birth 12 hours ago. Which client is at greatest risk for
complications?
a. Gravida 2 para 2002, cesarean bith, incision site intact, hemoglobin level 9.8 g/dl
b. Gravida 2 para 1011, cesarean birth, incision site intact, pulse 84 beats/minute
c. Gravida 1 para 1001, vaginal delivery, midline episiotomy, temperature of 99.8° F (37.7C)
d. Gravida 1 para 1001, vaginal delivery, membranes ruptured 10 hours before birth
RATIONALE: Women who have anemia during pregnancy (defined as a hemoglobin less than 10 g/dl) may
experience more complications such as poor wound healing and inability to tolerate activity. An intact
incision site and a pulse of 84 beats/minute after a cesarean birth and a temperature of 99.8F after a
vaginal delivery with episiotomy are findings within normal limits. Dehydration can cause a slightly
elevated temperature. Although women whose membranes are ruptured more than 24 hours before birth
are more prone to developing chorioamnionitis, the client with anemia is at greater risk for complications.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 362.
14. Which measure included in the care plan for a client in the fourth stage of labor requires revision?
a. Check vital signs and fundal checks every 15 minutes.
b. Have the client spend time with the neonate to initiate breast-feeding.
c. Obtain an order for catheterization to protect the bladder from trauma.
d. Perform perineal assessments for swelling and bleeding.
1. A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath
and is unable to sleep unless she places three pillows under her head. After listening to the client's
concerns, the nurse should take which action?
a. Make an appointment because the dent needs to be evaluated.
b. Explain that these are expected problems for the latter stages of pregnancy.
c. Arrange for the dent to be admitted to the birth center and prepare for birth.
d. Tell the client to go to the hospital; she may be experiencing signs of heart failure.
RATIONALE: The nurse must distinguish between normal physiologic complaints of the latter stages of
pregnancy and those that need referral to the health care provider. In this case, the client indicates normal
physiologic changes caused by the growing uterus and pressure on the diaphragm. These signs don't
indicate heart failure. The client doesn't need to be seen or admitted to the birth center.
Reference: Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 230.
2. During the first trimester, a nurse evaluates a pregnant client for factors that suggest she might abuse a
child. Which parental characteristic is of most concern to the nurse?
a. The client didn’t graduate high school.
b. The client states she is stupid and ugly.
c. The client is carrying twins.
The client eats fast food every day.
RATIONALE: Typically, the abusive parent has low self-esteem, which may be evident by self-deprecating
statements, and many unmet needs. Lack of nurturing experience and inadequate knowledge of childhood
growth and development may also contribute to the potential for child abuse. A low educational level,
multiple gestations, and poor diet aren't direct risk factors for committing child abuse. REFERENCE:
Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1743.
3. A client in her 15th week of pregnancy has presented with abdominal cramping and vaginal bleeding for
the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this client?
a. Deficient knowledge of pregnancy
b. Deficient fluid volume
c. Anticipatory grieving
d. Acute pain
RATIONALE: If bleeding and clots are excessive, this client may become hypovolemic , leading to a nursing
diagnosis of Deficient fluid volume. Although Deficient knowledge (pregnancy), Anticipatory grieving,
and Acute pain are applicable to this client, they aren't the primary diagnosis
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 400.
4. A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether
the client is at risk for a TORCH infection , the nurse should ask:
a. “Have you ever had osteomyelitis?”
b. “Do you have any cats at home?
c. “Do you have any birds at home?’
d. “Have you recently had a rubeola vaccination?”
RATIONALE: Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus and agents
that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to
humans through contact with the feces of infected cats (which may occur when emptying a litter box),
through ingesting raw meat, or through contact with raw meat followed by improper hand washing.
Osteomyelitis , a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola
aren't TORCH infections
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 288.
5. A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help
confirm that she's in true labor, the nurse should assess for:
a. irregular contractions.
b. increased fetal movement.
c. changes in cervical effacement and dilation atter 1 to 2 hours.
, RATIONALE: True labor is characterized by progressive cervical effacement and dilation after 1 to 2 hours,
regular contractions, discomfort that moves from the back to the front of the abdomen and, possibly,
bloody show. False labor causes irregular contractions that are felt primarily in the abdomen and groin and
commonly decrease with walking, increased fetal movement, and lack of change in cervical effacement or
dilation even after 1 or 2 hours.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 227.
6. A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain
from her episiotomy . What should the nurse instruct the woman to do?
a. Apply an ice pack to her perineum.
b. Take a sitz bath.
c. Perform perineal care after voiding or a bowel movement.
d. Drink plenty of fluids.
RATIONALE: A cold pack applied to an episiotomy during the first 24 hours after chidbirth may reduce
edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a sitz bath may
reduce discomfort by promoting circulation and healing. Although perineal care should be performed after
each voiding and bowel movement, its purpose is to prevent infection — not reduce discomfort.
Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it doesn't relieve
perineal discomfort.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 637.
7. A client who's 24 weeks pregnant has sickle cell anemia . When preparing the care plan, the nurse should
identify which factor as a potential trigger for a sickle cell crisis during pregnancy?
a. Sedative use
b. Dehydration
c. Hypertension
d. Tachycardia
RATIONALE: Factors that may precipitate a sickle cell crisis during pregnancy include dehydration ,
infection , stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and
tachycardia aren't known to precipitate a sickle cell crisis
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 363.
8. A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her
decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase
called?
a. Taking-in phase
b. Taking-hold phase
c. Letting-go phase
d. Taking-over phase
RATIONALE: The taking-in phase is a normal first phase for a mother when she's feeling overwhelmed by
the responsibilities of caring for the neonate while still fatigued from childbirth. Taking hold is the next
phase, when the mother has rested and she can think and learn mothering skills with confidence. During
the letting-go or taking-over phase, the mother gives up her previous role. She separates herself from the
neonate, giving up the fantasy of birth, and readjusting to the reality of caring for the neonate. Depression
may occur during this stage.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 624.
9. Which intervention listed in the care plan for a client with an ectopic pregnancy requires revision?
a. Assessing vital signs
b. Providing for dietary needs
c. Managing pain
d. Providing emotional support
RATIONALE: Providing for the client's dietary needs isn't appropriate because the client shouldn't eat or
drink anything pending surgery. Assessing vital signs for indicators of potential shock , managing pain, and
providing emotional support are essential nursing interventions in caring for a client with an ectopic
pregnancy.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 409.
10. A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking
the client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal
, a. Edema
b. Pelvic adequacy
c. Rh factor changes
d. Hemoglobin alterations
RATIONALE: At each prenatal visit, the nurse should assess the client for edema because edema, increased
blood pressure, and proteinuria are cardinal signs of gestational hypertension. Pelvic measurements and
Rh typing are determined at the first visit only because they don't change. The nurse should monitor the
hemoglobin level on the client's first visit, at 24 to 28 weeks' gestation, and at 36 weeks' gestation.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 257.
11. A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this
client, the nurse's highest priority is to evaluate:
a. cervical effacement and dation.
b. maternal vital signs and fetal heart rate (FHR).
c. frequency and duration of contractions.
d. white blood cell (WBC) count.
RATIONALE: After premature rupture of the membranes (PROM), monitoring maternal vital signs and FHR
takes priority. Maternal vital signs, especially temperature and pulse, may suggest maternal infection
caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis
caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this
client because it requires a pelvic examination, which may introduce pathogens into the birth canal.
Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC
count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and
FHR can and therefore provides less current information
REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health Nursing. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 531.
12. A client is told that she needs to have a nonstress test to determine fetal well-being. After 20 minutes of
monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds.
What should the nurse do next ?
a. Continue to monitor the baby for fetal distress.
b. Notify the physician and transfer the mother to labor and delivery for imminent delivery.
c. Inform the physician and prepare for discharge: this client has a reassuring strip.
d. Ask the mother to eat something and return for a repeat test; the results are inconclusive.
RATIONALE: Fetal well-being is determined during a nonstress test by two accelerations occurring within
20 minutes that demonstrate a rise in heart rate of at least 15 beats. This fetus has successfully
demonstrated that the intrauterine environment is still favorable. The test results don't suggest fetal
distress, so immediate delivery is unnecessary. In research studies, eating foods or drinking fluids hasn't
been shown to influence the outcome of a nonstress test. REFERENCE: Pillitteri, A. Maternal & Child
Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams
& Wilkins, 2007, p. 203.
13. A nurse is caring for four clients who gave birth 12 hours ago. Which client is at greatest risk for
complications?
a. Gravida 2 para 2002, cesarean bith, incision site intact, hemoglobin level 9.8 g/dl
b. Gravida 2 para 1011, cesarean birth, incision site intact, pulse 84 beats/minute
c. Gravida 1 para 1001, vaginal delivery, midline episiotomy, temperature of 99.8° F (37.7C)
d. Gravida 1 para 1001, vaginal delivery, membranes ruptured 10 hours before birth
RATIONALE: Women who have anemia during pregnancy (defined as a hemoglobin less than 10 g/dl) may
experience more complications such as poor wound healing and inability to tolerate activity. An intact
incision site and a pulse of 84 beats/minute after a cesarean birth and a temperature of 99.8F after a
vaginal delivery with episiotomy are findings within normal limits. Dehydration can cause a slightly
elevated temperature. Although women whose membranes are ruptured more than 24 hours before birth
are more prone to developing chorioamnionitis, the client with anemia is at greater risk for complications.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 362.
14. Which measure included in the care plan for a client in the fourth stage of labor requires revision?
a. Check vital signs and fundal checks every 15 minutes.
b. Have the client spend time with the neonate to initiate breast-feeding.
c. Obtain an order for catheterization to protect the bladder from trauma.
d. Perform perineal assessments for swelling and bleeding.
