MATERNITY NURSING

ANSWER AND RATIONALE

Post-Test Level II- June 2009

Situation 1: Nurse Gwen is an Independent

Nurse Practitioner following-up referred clients
in their respective homes. She handles Leah's
case, a postpartal mother. 1. D. Increasing oral fluid intake relieves
1. Leah is developing constipation from being constipation.
on bed rest. What measures would you suggest B. Walking increases peristalsis and may relieve
she take to help prevent this? constipation, but patient is on bed rest.
a. Eat more frequent small meals instead of
three large one daily
b. Walk for at least half an hour daily to stimulate
peristalsis
c. Drink more milk, increased calcium intake
prevents constipation
d. Drink eight full glasses of fluid such as water
daily

2. Which of the following actions would alert

Gwen that a Leah is entering a postpartal taking- 2. A. Taking-hold phase usually happens by the
hold phase? third postpartum day. It is characterized by
a. She urges the baby to stay awake so that she B and D happen during then taking-in phase.
can breast-feed him or her
b. She tells you she was in a lot of pain all during
labor
c. She says that she has not selected a name for
the baby as yet
d. She sleeps as if exhausted from the effort of
labor

3. At 6-week postpartum visit what should

Leah's fundic height be?
a. Inverted and palpable at the cervix
b. Six finger breadths below umbilicus
c. No longer palpable on her abdomen
d. One centimeter above the symphysis pubis
3. C. Involution of the uterus occurs at a rate of
1 finger breadth (1 cm) per postpartum day, until
by the end of the second week postpartum it is
already a pelvic organ and cannot be palpated
through the abdominal wall.
B. This is during the 6th postpartum day.

4. B. A lactating mom should have an additional

4. Leah wants to loose the weight she gained in intake of 500 kcal/day.
pregnancy, so she is reluctant to increase her
caloric intake for breast-feeding. By how much 5. A. The diaphragm must be fitted individually to
should a lactating mother increase her caloric ensure effectiveness. Because of the changes to the
intake during the first 6 months after birth? reproductive structures during pregnancy and
a. 350 kcal/day c. 200 kcal/day following delivery, the diaphragm must be refitted,
usually at the 6 weeks’ examination following childbirth
b. 500 kcal/day d. 1000 kcal/day or after a weight loss of 15 lbs or more. In addition, for
maximum effectiveness, spermicidal jelly should be
placed in the dome and around the rim. However,
spermicidal jelly should not be inserted into the vagina
until involution is completed at approximately 6 weeks.
B. Use of a female condom protects the reproductive
5. When preparing a woman who is for Leah,
system from the introduction of semen or spermicides into
recommendations for which of the following the vagina and may be used after childbirth.
contraceptive methods would be avoided? C. Oral contraceptives may be started within the first
a. Diaphragm c. Oral contraceptives postpartum week to ensure suppression of ovulation.
b. Female condom d. Rhythm method D. For the couple who has determined the female’s
fertile period, using the rhythm method, avoidance of
intercourse during this period, is safe and effective.
Situation 2: Nurse Zha is a Family Planning and

St. Louis Review Center, Inc-Davao Tel. no. (082) 224-2515 or 222-8732 1
Infertility Nurse Specialist and currently
attends to family planning clients and infertile
couples. The following conditions pertain to
meeting the nursing needs of this particular 6. C. Tubal ligation involves cutting of the
population group. fallopian tubes, and that it is considered
6. Dana, 17 years old, asks you how a tubal blocked, thus preventing the sperm from
ligation prevents pregnancy. Which would be the reaching the egg.
best answer? B. This is the mechanism of action of barrier
a. Prostaglandins released from the cut fallopian contraceptive devices such as the cervical caps and
tubes can kill sperm diaphragms. The cervical entrance is not blocked in
b. Sperm cannot enter the uterus because the tubal ligation.
cervical entrance is blocked. D. The ovary still releases an egg, but the sperm
c. Sperm can no longer reach the ova, because cannot meet and fertilize the egg, because the
the fallopian tubes are blocked fallopian tubes are already cut off.
d. The ovary no longer release ova as there is
no where for them to go.
7. C. Infertility exists when pregnancy has not
occurred after at least 1 year of engaging in
7. The Wong's are a couple undergoing testing unprotected coitus.
for infertility. Infertility is said to exist when:
a. A woman has no uterus
b. A woman has no children
c. A couple has been trying to conceive for 1
year
d. A couple has wanted a child for 6 months

8.A. In endometriosis, uterine

endometrium/nodules, regurgitate in locations
8. Another client named Lilia is diagnosed as outside the uterus (such as the fallopian tubes)
having endometriosis. This condition interferes and proliferate at the new site therefore
with fertility because: obstructing the tubes.
a. Endometrial implants can block the fallopian
tubes
b. The uterine cervix becomes inflamed and
swollen
c. The ovaries stop producing adequate
estrogen
d. Pressure on the pituitary leads to decreased
FSH levels

9. D. Hysterosalpingography is a radiologic
examination of the fallopian tubes using a
9. Lilia is scheduled to have a
radiopaque medium. It is the most frequently
hysterosalphingogram. Which of the following
used in assessing tubal patency. Because the
instructions would you give her regarding this
medium is thick, it distends the uterus and
procedure?
tubes slightly, causing momentary painful
a. She will not be able to conceive for 3 months
cramping.
after the procedure
b. The sonogram of the uterus will reveal any
tumors present
c. Many women experience mild bleeding as an
after effect
d. She may feel some cramping when the dye is
inserted

10. Lilia’s cousin on the other hand, knowing

nurse Zha’s specialization asks what artificial
insemination by donor entails. Which would be

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 your best answer if you were Nurse Zha?
a. Donor sperm are introduced vaginally into the
uterus or cervix
b. Donor sperm are injected intra-abdominally
into each ovary
c. Artificial sperm are injected vaginally to test
tubal patency
d. The husband’s sperm is administered
intravenously weekly

Situation 3: Nurse Joanna works as an OB Gyne

Nurse and attends to several high-risk
pregnancies particularly women with
preexisting or newly acquired illness.
11.D. Glucose-rich urine provides a good
medium for bacterial growth.
11. Bernadette is a 22-year old woman. Which
condition would make her more prone than
others to developing a Candida infection during
pregnancy?
a. Her husband plays golf 6 days a week
b. She was over 35 when she became pregnant
c. She usually drinks tomato juice for breakfast
d. She has developed gestational diabetes

12. D
12. Bernadette develops a deep vein thrombosis
following a car accident and is prescribed
heparin sub-Q. What should Joanna educate her
about in regard to this?
a. Some infants will be born with allergic
symptoms to heparin
b. Her infant will be born with scattered
petechiae on his trunk
c. Heparin can cause darkened skin in newborns
d. Heparin does not cross placenta and so does
not affect a fetus

13. A.
13. The cousin of Bernadette with sickle-cell B. Ferrous sulfate, 320 mg, one to three times a day
anemia alerted Joanna that she may need is usually advised.
further instruction on prenatal care. What C. Adequate hydration is necessary to prevent
statement signifies this fact? sickling.
a. I’ve stopped jogging so I don’t risk becoming D. Folic acid is an essential nutrient in RBC
dehydrated. formation.
b. I take an iron pill every day to help grow new
red blood cells
c. I am careful to drink at least eight glasses of
fluid every day
d. I understand why folic acid is important for red
cell formation

14. Bernadette routinely takes acetylsalicylic acid

10. A (aspirin) for arthritis. Why should she limit or
discontinue this toward the end of pregnancy?

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 a. Aspirin can lead to deep vein thrombosis
following birth
b. Newborns develop a red rash from salicylate
toxicity
c. Newborns develop withdrawal headaches
from salicylates
d. Salicylates can lead to increased maternal
bleeding at childbirth

15. B. The weight of the distended uterus puts

pressure on the veins returning blood from
15. Bernadette received a laceration on her leg the lower extremities.
from her automobile accident. Why are C. Fatigue occurs during during pregnancy probably
lacerations of lower extremities potentially more due to increased metabolic requirements, but it has
serious in pregnant women than others? nothing to do with laceration of the lower extremities
a. Lacerations can provoke allergic responses being potentially more serious in pregnant women.
because of gonadothropic hormone D. Healing is not impaired during pregnancy.
b. Increased bleeding can occur from uterine
pressure on leg veins
c. A woman is less able to keep the laceration
clean because of her fatigue
d. Healing is limited during pregnancy, so these
will not heal until after birth.

Situation 4: Nette, a nurse palpates the

abdomen of Mrs. Medina, a primigravida. She is
unsure of the date of her last menstrual period.
Leopold’s Maneuver is done. The obstetrician
told that she appears to be 20 weeks pregnant.
16. Nette explains this because the fundus is:
a. At the level of the umbilicus, and the fetal
heart can be heard with a fetoscope
b. 18 cm, and the baby is just about to move
c. Is just over the symphisis, and fetal heart
cannot be heard
d. 28 cm, and fetal heart can be heard with a
Doppler
16. A. According to Barthlomew's rule, fundus
located at the umbilicus is approximately 20
weeks AOG. Fetal heart can be heard using a
fetoscope by 18 to 20 weeks AOG.
B. This happens by 16 weeks AOG
C. This happens by 12 weeks AOG
D. Fetal heart rate can be heard using a doppler
by 12 weeks AOG.

17.
B. The hands of the nurse should be
warm so that abdominal muscles will not
contract and tighten on palpation.
17. In doing Leopold’s Maneuver palpation which A. The woman should lie in a supine position with
among the following is NOT considered a good her knees flexed slightly with head slightly
preparation: elevated to help her relax abdominal muscles.
a. The woman should lie in a supine position D. The woman empties her bladder before palpation
with her knees flexed slightly to reduce discomfort during palpation and make
b. The hands of the nurse should be cold so that fetal parts easier ti feel.
abdominal muscles would contract and tighten
c. Be certain that your hands are warm (by
washing them in warm water first if necessary)
d. The woman empties her bladder before
palpation

14. D 18. In her pregnancy, she experienced fatigue

and drowsiness. This probably occurs because:
a. Of high blood pressure
b. She is expressing pressure

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 c. The fetus utilizes her glucose stores and
leaves her with a low blood glucose
d. Of the rapid growth of the fetus
19. The nurse assesses the woman at 20 weeks
gestation and expects the woman to report:
a. Spotting related to fetal implantation
b. Symptoms of diabetes as human placental
lactogen is released
c. Feeling fetal kicks
d. Nausea and vomiting related HCG production
20. Mrs. Medina comes to you for check-up on
June 2, her EDC is June 11, what do you expect
during assessment?
a. Fundic height of 2 fingers below xyphoid
process, engaged
b. Cervix close, uneffaced, FH-midway between
the umbilicus and symphysis pubis
c. Cervix open, fundic height 2 fingers below
xyphoid process, floating
d. Fundic height at least at the level of the
xyphoid process, engaged
Situation 5: A professional nurse should know
how to respond in these varied health
situations.
21. RhoGAM is given to Rh-negative women to
prevent maternal sensitization from occurring.
The nurse is aware that in addition to pregnancy,
Rh-negative women would also receive this
medication after which of the following?
a. Unsuccessful artificial insemination procedure
b. Blood transfusion after hemorrhage
c. Therapeutic or spontaneous abortion
d. Head injury from a car accident
22. The breathing technique that the mother
should be instructed to use as the fetus' head is
crowning is:
a. Blowing c. shallow
b. slow chest d. accelerated decelerated
18. C
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19. C. Quickening is felt by 16 to 20 weeks AOG.
A and B are not abnormal findings during
pregnancy.
D. This is felt by 2 weeks AOG.
20. A. Around this time, the fetus has already
engaged (dropped into the maternal true pelvis)
as indicated by the fundus located 2 finger
breadths below the xiphoid process.
21. C. Therapeutic or spontaneous abortion
causes mixing of the fetal blood (RH+) and
maternal blood (Rh-). This could trigger the
production of maternal antibodies against the
circulating Rh+ blood. The circulating
antibodies in the maternal blood will destroy
future pregnancies with a Rh+ blood. Rhogam is
given 72 hours post delivery to prevent
production of maternal antibodies.
22. A. Blowing forcefully through the mouth
controls the strong urge to push and allows
for a more controlled birth of the had.
B. This is used during the latent phase of the first
stage of labor. It is not helpful in overcoming the
urge to push.
C. This breathing pattern does not help to control
expulsion.
D. This is used during active labor when the cervix
is 3 to 7 cm dilated. It is not helpful in overcoming
the urge to push.
23. When providing prenatal education to a
pregnant woman with asthma, which of the
following would be important for the nurse to do?
a. Demonstrate how to assess her blood glucose
5
 levels
b. Teach correct administration of subcutaneous
bronchodilators
c. Ensure she seeks treatment for any acute
exacerbation
d. Explain that she should avoid steroids during
her pregnancy

24. Which of the following conditions would 24. C. Both conditions predisposes the mother
cause an insulin-dependent diabetic client the to accumulating high levels of ketone bodies
most difficulty during her pregnancy? in the blood.
a. Rh incompatibility
b. Placenta Previa
c. Hyperemesis Gravidarum
d. Abruptio Placenta

25. Which of the following would the nurse use

25. D. To ensure adequate fetal growth and
as the basis for the teaching plan when caring
development during pregnancy, a total
for a pregnant teenager concerned about gaining
weight gain 25 to 30 lbs (other books: 25 to
too much weight during pregnancy?
35 lbs) pounds is recommended: 1 lb per
a. 10 pounds per trimester
month in the first trimester;and 1 lb per week
b. 1 pound per week for 40 weeks
in the last two trimesters.
c. ½ pound per week for 40 weeks
d. A total gain of 25 to 30 pounds

Situation 6: Maybelle, a 30-year-old client comes

to the office for a routine prenatal visit.
26. The chart entry says: “Patient is 11 weeks
pregnant; urine sample shows glycosuria.
Patient has a family history of diabetes.”The
nurse should prepare the client for which of the
following studies?
a. Triple screen
b. Indirect Coombs
c. 1-hour glucose tolerance test
d. Amniocentesis
26. C. This is recommended for gestational
diabetes if the client is obese, has glycosuria
or a family history of diabetes, or lost a fetus
for unexplained reasons, or gave birth to a
LGA neonate.
A. This tests for chromosomal abnormalities.
B. This screens maternal blood for red blood cell
antibodies, in case of Rh incompatibilities.
D. This is used to detect fetal abnormalities.

27. A. Ultrasound is used to identify

27. Maybelle is scheduled to have an polyhydramnios. Amniocenteses can be used
amniocentesis to test for fetal maturity.. The to treat polyhydramnios by removing excess
nurse knows that this test can be used to identify fluid.
the following characteristics or problems B, C and D. In early pregnancy, amniocentesis can
EXCEPT: be used to identify chromosomal and neural tube
a. Polyhydramnios defects and determine the sex of the fetus. It can
b. Chromosomal defects also be used to determine fetal lung maturity during
c. Neural tube defects the last trimester o pregnancy.
d. Sex of the fetus

23. D. Steroids cause cleft lip/palate in 28. Which instruction would you give her prior to
newborns. amniocentesis?
a. Void immediately before the procedure to
reduce your bladder size

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 b. No more amniotic fluid forms afterward, that is
why only a small amount is removed
c. The intravenous fluid infused to dilate your
uterus does not hurt the fetus
d. The x-ray used to reveal your fetus position
has no long-term effects

29. Maybelle is scheduled to have an ultrasound

examination. Which instruction would you give
her before her examination?
a. The intravenous fluid infused to dilate your
uterus does not hurt the fetus
b. You will need to drink at least 3 glasses of
fluid before the procedure
c. Void immediately before the procedure to
reduce your bladder size
d. You can have medicine for pain for any
contractions cause by the test
29. B. This is to distend the bladder, and push
the uterus upward for better visualization.
A. An intravenous fluid will not be required for the
procedure.
C. Client is instructed not to void until after the
procedure.
D. This test will normally not cause contractions of
the uterus.

30. At 41 weeks of pregnancy, Maybelle is about

to undergo a biophysical profile (BPP) to 30. D. Crown-rump length is used to assess
evaluate her fetus' well being. A nurse knows gestational age during the first trimester.
that the following are components of BPP A, B and C. A BPP is an ultrasound assessment
EXCEPT: of the fetal well-being that includes the following
a. Fetal tone components: nonstress test, fetal tone, fetal
b. Fetal breathing breathing, fetal motion and volume of amniotic
c. Amniotic fluid volume fluid. It is used to confirm the health of the fetus
d. Crown-rump length or identify abnormalities.

Situation 7: Awareness of the complications

that may accompany pregnancy is essential in
order to render apt nursing management.
31. A client who is 32 weeks pregnant is being
monitored in the antepartum unit for pregnancy-
induced hypertension. She suddenly complains
of continuous abdominal pain and vaginal
bleeding. The following interventions should be
applied EXCEPT:
a. Evaluate maternal vital signs
b. Prepare for vaginal delivery
c. Auscultate the fetal heart tones
d. Monitor the amount of vaginal bleeding
31. B. After the severity of the abruption has
been determined, and blood and fluid have
been replaced, a prompt cesarean delivery is
indicated if the fetus is in distress.
A, C and D. The client's symptoms indicate that she
is experiencing abruption placenta. The nurse must
immediately evaluate the mother's vital signs,
auscultate fetal heart tones, monitor the amount of
blood loss, and evaluate volume status by
monitoring intake and output.

32. D. Hyperemesis gravidarum is severe nausea and

32. During a prenatal visit, a physician decides to vomiting that persists after the first trimester. If
admit the client to the hospital. Patient is 16 untreated, it can lead to weight loss, starvation,
dehydration, fluid and electrolyte imbalances, and acid-
weeks pregnant and complains of thirst and base disturbances. The client may report thirst,
vertigo. Based on the nurse's admission note: hiccups, oliguria, vertigo and headache. A rapid pulse
“BP 120/70 mmHg, RR 20, PR 104 Temperature and elevated or subnormal temperature can also occur.
100oF. Patient had nothing to eat or drink for 24 A. Signs and symptoms of iron-deficiency anemia include
hours”, which complication of pregnancy would fatigue, pallor, and exercise intolerance.
the physician suspect? B. Placenta previa causes painless, bright red vaginal
bleeding after 20 weeks of pregnancy.
a. Iron-deficiency anemia
D. Pregnancy-induced hypertension usually develops
b. Placenta previa
c. Pregnancy-induced hypertension after 20 weeks of pregnancy. The client reports of
d. Hyperemesis gravidarum sudden weight gain and presence of hypertension.

28. A. This is to prevent accidental punctures 33. A pregnant client at 32 weeks' gestation has
on the urinary bladder during amniocentesis. mild preeclampsia. She is discharged home with
instructions to remain on bed rest. She is also

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 instructed to call her physician if she reduction in the glomerular filtration rate, and
experiences the following signs and symptoms decreased urine output.
EXCEPT: A, C and D. Headache, blurred vision, epigastric
a. Headache pain and severe nausea and vomiting can indicate
b. Increased urine output worsening preeclampsia.
c. Blurred vision
d. Epigastric pain

34. A mother with a history of varicose veins has 34. C. A client with embolus could be
just delivered her first baby. A nurse suspects hypotensive, not hypertensive.
that the mother has developed a pulmonary A, B and D are classic signs of pulmonary embolus.
embolus. The following will lead to this nursing
judgment EXCEPT:
a. Sudden dyspnea c. Hypertension
b. Diaphoresis d. Confusion

35. A. Blood loss from the uterus that exceeds

500 mL in 24 hours is considered postpartum
35. A nurse is caring for a client in the fourth hemorrhage. If uterine atony is the cause, the
stage of labor. Patient's 24-hour blood loss is uterus feels soft and relaxed. A full bladder can
600 mL. Uterus is soft and relaxed on palpation, prevent the uterus from contracting completely,
and patient has a full bladder. Which post- increasing the risk of hemorrhage.
partum complication has the patient developed? B. Puerperal infection is an infection of the uterus
a. Postpartum hemorrhage and structures above. Its characteristic sign is fever.
b. Puerperal infection C. Two major types of deep vein thrombosis occur
c. Deep vein thrombosis in postpartum period: pelvic and femoral. Each has
d. Mastitis different signs and symptoms, but both occur later in
the postpartum period.
D. Mastitis is an inflammation of the mammary
glands that disrupts normal lactation and usually
Situation 8: Felly is a DR nurse working at St. develops 1 to 4 weeks postpartum.
Mary's Medical Center. She is assigned during
the graveyard shift, and encountered the
following patients.

36. Vangie, 32 years old, is 36 weeks pregnant.
She is admitted due to premature rupture of
membranes (PROM). The following indicates
PROM has occurred EXCEPT:
a. Fernlike pattern when vaginal fluid is placed
on a glass slide and allowed to dry
b. Presence of amniotic fluid in the vagina
c. Cervical dilation of 6 cm
d. Alkaline pH of fluid when tested with nitrazine
paper
36. C. Cervical dilation is a sign of progressing
labor, but do not indicate PROM.
A. The fernlike pattern that occurs when vaginal
fluid is placed on a glass slide and allowed to dry is
a result of the high sodium and protein content of
the amniotic fluid.
B. The presence of amniotic fluid in the vagina
results from the expulsion of the fluid from the
amniotic sac.
D. Amniotic fluid tests as an alkaline fluid.

33. B. Decrease urine output is the concern 37. Vangie is in the first stage of labor. She is
because preeclampsia is associated with being monitored using an external fetal monitor.
decreased renal perfusion, leading to The nurse reviews the monitoring strip from the

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 client's chart, which shows late decelerations.
Which of the following positions should she
assist the client?
a. Left lateral c. Supine
b. Right lateral d. Prone
38. Kriya, 29 weeks pregnant comes to the labor
and delivery unit. She states that she's having
contractions every 8 minutes. The client is also 3
cm dilated. The nurse anticipates that the
following will be administered EXCEPT:
a. Folic acid (Folvite)
b. Terbutaline (Brethine)
c. Bethamethasone
d. IV fluids
39. Felly is monitoring a client who is receiving
oxytocin (Pitocin) to induce labor. The nurse
should observe for which of the following
maternal adverse reactions?
a. Hypertension c. Uterine tetany
b. Fluid overload d. Bradycardia
40. B. Early decelerations can result from head
40. Felly notices that the external fetal
monitoring strip of a client who is in labor shows
early decelerations. Which of the following
nursing interventions should be done?
a. Increase the IV fluid rate to boost
intravascular volume
b. Reassure the client that the fetus isn't at risk
c. Elevate the client's legs
d. Administer supplemental oxygen
Situation 9: Anne delivered a child two days
ago. She is breastfeeding her child.
41. To show Anne how to help her have good
attachment of the infant during breast feeding.
Which of the following statements should NOT
be included?
a. Place the infant in your most convenient
position
b. Touch the infant’s lips with her nipples
c. Wait until the infant’s mouth is widely open
d. Move the infant quickly onto her breast,
aiming the infant’s lips well below the nipple
37. A. Late decelerations indicate
ureteroplacental insufficiency and can lead
to fetal hypoxia and acidosis if the
underlying cause isn't corrected. The client
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should be turned onto her left side to
increase placental perfusion and decrease
contraction frequency. In addition, IV fluid rate
may be increased and oxygen administered.
B, C and D do not increase placental perfusion.
38. A. Folic acid is a mineral recommended
throughout the pregnancy (especially during
the first trimester) to decrease the risk of
neural tube defects.
B. Terbutaline, a beta2 agonist, will be administered
to halt contractions.
C. Bethamethasone, a corticosteroid, will be
administered to decrease the risk of respiratory
distress in the infant if preterm delivery occurs.
D. IV fluids will be given to expand the
intravascular volume and decrease contractions if
dehydration is the cause.
39. D. Adverse effect of oxytocin in the mother
include tachycardia, not bradycardia.
Bradycardia is an adverse reaction that may
occur in the neonate.
B. The antidiuretic effect of oxytocin increases renal
absorption of water, leading to fluid overload.
compression during normal labor and don't
indicate fetal distress. The nurse should
reassure the client, and monitor the fetal
heart rate.
41. A. The infant should be positioned in such a
away that the chin of the child is touching the
breast of the mother, for better latch-on
technique.
42. Which of the following signs of good
attachment should the nurse teach Anne?
a. The chin should touch the breast, the mouth is
wide open while the lower lip is turned inward,
9
 and more areola is visible above than below
b. The chin should touch the breast, the mouth is
wide open while the lower lip turned outward,
and more areola visible above than below
c. The chin should touch the breast, the mouth is
wide open while the lower lip turned outward,
and more areola visible below than above
43. d. The chin should touch the breast, the
mouth is wide open while the lower lip turned
inward, and more areola is visible below than
above. Which of the following instructions can
the nurse give to Anne?
a. Wear a good, well-supporting bra
b. Apply warm compresses to breast if too full
c. Apply cold compresses to breast if too full
d. Do not apply any soap to your nipples
areola visible above than below.
A. The chin should touch the breast, the mouth is
wide open while the lower lip is turned outward, and
more areola is visible above than below.
C. The chin should touch the breast, the mouth is
wide open while the lower lip turned outward,
and more areola visible above than below.
D. The chin should touch the breast, the mouth is
wide open while the lower lip turned outward, and
more areola is visible above than below.
43.A. A well-firring supportive bra with wide
straps can be recommended for a nursing
mother. The nursing mother's bra should have
front flaps over each breast for easy access
during nursing periods.

44. A. These symptoms are signs of infectious

mastitis, usually caused by Staphylococcus
44. Anne is visited by the home health nurse two aureus. A 10-day course of antibiotics is
weeks after delivery. The woman is febrile with needed.
flu-like symptoms. On assessment, the nurse B. In mastitis, an improved outcome, a decreased
notes a warm, reddened painful area of the right duration of symptoms, and decreased incidence of
breast. The best initial action of the nurse is to: breast abscess result if breasts continue to be
a. Contact the physician for an order of emptied by either nursing or pumping.
antibiotics C. It is important that breast feeding technique and
b. Advise the mother to stop breastfeeding and knowledge be assessed when mastitis has occurred
pumping because there have been found to be contributing
c. Assess the mother's feeding technique and factors for this complication. However it is not the
knowledge of breast care best initial action of the nurse.
d. Obtain a sample of the breast milk for culture D. Diagnosis and treatment of mastitis are usually
based on symptoms, and physical examination,
even while waiting for laboratory results. If there is
recurrence of mastitis, most experts agree that a
45. Anne has received treatment for a warm, culture should be obtained.
reddened, painful area in the breast as well as
cracked and fissured nipples The client 45. D. The baby should grasp both the nipple
expresses the desire to continue breastfeeding. and areola.
The following are instructions that the nurse A and B. These help keep the nipples dry and
should include to prevent recurrence of this prevent irritation.
condition EXCEPT: D. This reduces the chance of accidentally
a. Change the breast pads frequently introducing organisms into the breast.
b. Expose the nipples to air for part of each day
c. Was hands before handling the breast and
breastfeeding
d. Make sure that the baby grasps the nipple
only

Situation 10: Angel, 25 years old, is a 2-day

42. B. Signs of good latch-on technique include: postpartum client. She delivered a 6 lb 4 oz baby
chin touching the breast, the mouth is wide boy.
open; the lower lip turned outward; and more 46. Angel verbalizes her labor and delivery

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 experience, does not appear confident about
holding the baby or changing diapers. The nurse
identifies the the client is in which phase of the
postpartum period?
a. Letting go c. Holding out
b. Taking in d. Taking hold
47. When checking Angel's fundus, the nurse
observes that the fundus is above the umbilicus 47. B. A distended bladder will displace the
and displaced to the right. The nurse evaluates
that the client probably has:
a. A slow rate of involution
b. A full, overdistended bladder
c. Retained placental fragments
d. Overstretched uterine ligaments
48. During the postpartum period, Angel tells the
nurse she is having leg cramps. The nurse
should suggest that she should increase her
intake of:
a. Eggs and bacon
b. Liver and onions
c. Juices and water
d. Cheese and broccoli
49. When performing discharge teaching for
Angel, the nurse should inform her that:
a. The episiotomy sutures will be removed at the
first postpartum checkup
b. She may not have any bowel movements for
up to a week after the birth
c. She has to schedule a postpartum checkup
as soon as her menses returns
d. The perineal tightening exercises started
during pregnancy should be continued
indefinitely
50. Which of the following statements would
indicate to the nurse that Angel has begun to
integrate her new baby into the family structure?
a. All the baby does is cry. He's not like my other
child.
b. I wish he had curly hair like my husband
c. My parents wanted a granddaughter
d. When he yawns, he looks like just his brother
46. B. The taking-in phase is the first
postpartum phase. During this phase, the
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mother feels overwhelmed by the
responsibilities of the newborn care and is
still fatigued from delivery.
A. Letting go is the final phase, when the client
adapts to parenthood, her new role as a caregiver,
and her new baby as a separate entity.
D. Taking hold is the second phase, when the client
has rested and can learn mothering skills with
confidence.
fundus upward and laterally.
A. This would be manifested by a slow contraction
and uterine descent into the pelvis.
C. If this were true, in addition to being displaced,
the uterus would be boggy and vaginal bleeding
would be heavy.
D. From this assessment, the nurse cannot make a
judgment about overstretched uterine ligaments.
48. D. The leg cramps may be related to low
calcium intake. Cheese and broccoli both
have high calcium content.
A, B and C. These are inadequate sources of
calcium.
49. D. Kegel exercise can be resumed
immediately and should be done for the rest
of her lie.
A. Episiotomy sutures do no have to be removed
B. Bowel movements should spontaneously return
in 2 to3 days after giving birth; delayed bowel
movements promotes constipation, perineal
discomfort and trauma.
C. The usual postpartum examination is 6 weeks
after birth. Menses can return earlier or later than
this time period and should not be a factor when
scheduling an examination.
50. D. Family identification of the newborn is an
important part of attachment. The first step in
identification is done in terms of likeness to
family members.
A. The mother is emphasizing a negative
characteristic of the boy and comparing him
unfavorably to her other child.
B. The mother is wishing that he had curly hair like
her husband. She is not looking at a positive
characteristic of the baby that will fit in with the
family.
C. The mother is thinking that the baby should have
been a girl instead of a boy.
Situation 11: Rita, 27 years old, is a gravida 1 in
the active phase of labor. Fetal position is LOA,
and cervix is 6 cm dilated.
51. When planning comfort measures to help
11
 Rita in active labor to tolerate her pain, the nurse
must consider which of the following?
a. Early labor contractions are usually regular,
coordinated, and very painful
b. If women are properly prepared, they will
require no pain medication to manage their pain
c. Pain medication given during the latent phase
of labor is not likely to impair contractions
d. The acceleration phase of labor can be a time
of true discomfort and high anxiety
begin to cause true discomfort and high anxiety
as she realizes that labor is truly progressing
and her life is about to change forever.
A. Early labor contractions are mild thus causing
minimal discomfort.
C. Pain medication given too early during the latent
phase of labor impairs contractions and will prolong
the this phase.

52. The nurse locates fetal heart sounds in the 52. D. Fetal heart tones heard in the upper
upper left quadrant of the mother’s abdomen. quadrants of the mother indicates a breech
The nurse would recognize which of the presentation.
following?
a. Rita will probably deliver very quickly and
without problems
b. This indicates Rita will probably have a breech
delivery
c. The fetus is in the most common anterior fetal
positions
d. This position is referred to as being left
anteriopelvic
53. B. With the baby in a vertex LOA
presentation and no other indicators of fetal
53. When her membranes rupture, the nurse distress, amniotic fluid have a clear to straw-
should expect to see: colored appearance.
a. A large amount of bloody fluid A and C. Too much or too little amniotic fluid
b. A moderate amount of clear to straw-colored indicates congenital anomalies in the fetus.
fluid D. Cord prolapse may occur when membranes
c. A small amount of greenish fluid rupture, but it is associated with breech
d. A small segment of the umbilical cord presentations. The baby is in vertex LOA
presentation, and fetal bradycardia is not evident,
which may indicate cord prolapse.

54. C. Immediately after rupture of membranes

54. When her membranes rupture, the nurse's fetal heart tones should be checked, and then
first action should be to: checked again after the next contraction or after
a. Notify the physician because delivery is 5-10 minutes.
imminent A. Once the membranes have ruptured, delivery is
b. Measure the amount of fluid imminent, but checking and monitoring the fetal
c. Count the fetal heart rate heart rate is the priority.
d. Perform a vaginal exam D. With the child in LOA presentation, there is less
chance of prolapsed cord. However if the FHR
drops significantly, a sterile vaginal exam is
55. During the third stage of labor, the nurse may indicated to check for a prolapsed cord.
have which of the following responsibilities?
a. Administer intramuscular Oxytocin to facilitate 55. A. Oxytocin causes uterine contraction, thus
uterine contractility preventing hemorrhage.
b. Monitor for blood loss greater than 100 cc, B. A blood loss of greater than 100 cc does not
which would indicate gross hemorrhage indicate gross hemorrhage. Loss of more than 500
c. Note if the placenta makes a Schultz cc blood at the time of delivery or immediately
presentation, which is a sign of gross thereafter is considered postpartum hemorrhage.
complication C. Placenta delivered in a Schultz presentation is
d. Push down on the relaxed uterus to aid in the not a sign of gross complication.
removal of the placenta D. A relaxed uterus should not be pushed down. It
may result to uterine inversion
Situation 12: Vicki, 28 years old, has had
diabetes mellitus since she was an adolescent.
She is 8 weeks pregnant.
51. D. During the acceleration/active phase of 56. The action of hormones during pregnancy
labor, contractions grow strong, last longer and affects the body by:

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 a. Raising resistance to insulin
b. Blocking the release of insulin from the
pancreas
c. Preventing the liver from metabolizing
glycogen
d. Enhancing conversion of food to glucose
prevents blood sugar in the non-diabetic client
from falling to dangerous levels.
B. It does not affect the release of insulin.
C. Gluconeogenesis is not altered.
D. The conversion of food to glucose is not the
problem in pregnancy. The problem is rather the
utilization of glucose.

57. Hyperglycemia during Vicki's first trimester 57. C. Major congenital malformations are noted
will have what effect on the fetus? in the insulin-dependent diabetic mother with
a. Hyperinsulinemia poor metabolic control.
b. Excessive fetal size A. Hyperinsulinemia in the fetus occurs in the third
c. Malformed organs trimester.
d. Abnormal positioning B. Excessive fetal size develops as a result of high
maternal levels of glucose over the course of the
entire pregnancy.
D. Abnormal positioning is not a common problem
for the baby of a diabetic mother.

58. As the pregnancy continues, the nurse
should anticipate which change in her
medication needs?
a. A decrease in the need for short-acting
insulins
b. A steady increase in insulin requirements
c. Oral hypoglycemic agents will be given
several times daily
d. The variable pattern of insulin absorption
throughout pregnancy requires constant close
adjustment
58. B. During the first trimester of pregnancy,
there is little change insulin requirements. In the
second trimester, gradually increasing amounts
of insulin are needed, with the insulin dose
doubling by the end of the end of the gestation
period.
C. Oral hypoglycemic agents pass through the
placenta and can cause fetal damage.
D. Insulin absorption is not the problem.

59. A glycosylated hemoglobin level is ordered 59. C. Glycosylated hemoglobin measurements

for Vicki because it: can be used to assess prior glycemic control.
a. Is the most accurate method of determining A. They are not used to assess current blood
present insulin levels glucose levels.
b. Will predict how well the increase can respond B. They have no predictive capacity.
to the stress of pregnancy D. They provide a more clinical picture of diabetic
c. Gives diagnostic mean glucose level over a 1- control but not its complications.
to 3-month period
d. Gives a diagnostic information related to the
peripheral effects of diabetes

60. A. Glucose can be transferred from the

serum to the breast, and hyperglycemia may be
60. When Vicki already delivered her bay, she reflected in the breast milk.
plans to breastfeed her baby. The nurse explains B. The production of breast milk will not be
that, if she is hyperglycemic: impaired.
a. The glucose content of her breast milk may be C. The baby will not receive insulin in the milk.
impaired D. If the mother is hyperglycemic, her blood sugar
b. The production of milk may be impaired will be no more difficult to manage. However, the
c. Her baby will receive insulin in the milk nurse must stress the importance of keeping the
d. Her blood sugar will be extremely difficult to blood sugar close to normal as possible at all times.
manage
Situation 13: Gianne, 24 years old, visits your
clinic for her first prenatal checkup. She is in
her first trimester of pregnancy, and complains
56. A. Hormonal influences during pregnancy of various bodily discomforts.
cause a resistance to insulin utilization at the 61. Which of the following symptoms is LESS
cellular level. It allows sufficient glucose for commonly noted in EARLY pregnancy?
placental transport to the fetus, and also a. Frequency of urination

St. Louis Review Center, Inc-Davao Tel. no. (082) 224-2515 or 222-8732 13
 b. Ankle edema in the afternoon and in the evening with the legs
c. Varicosities elevated.
d. Braxton Hicks’ Contractions

62. Gianne should be taught to be careful to
avoid accidental injury. She is prone to falls for
which of the following reasons?
a. Additional weight from pregnancy may disturb
balance when walking
b. Fetal activity stimulates the nerves of the legs
and causes weakness
c. High levels of hormones often impair judgment
resulting in reckless behavior
d. Increased adrenalin released during
pregnancy causes women to move faster than
usual
62. A. As the pregnancy progresses, additional
weight from pregnancy changes the center of
gravity, which causes alterations in the posture
and walking gait, and disturbance in the balance
when walking.
C. High levels of an ovarian hormone (relaxin)
increases joint mobility on connective tissues. It
does not impair judgment resulting in reckless
behavior.

63. What are common discomforts experienced 64. C.

during the first trimester? 3.As the weight of the growing uterus presses
1. Hemorrhoids against the bowel, peristalsis slows, and client may
2. Breast tenderness 4. Menstrual “spotting” complain of constipation, not diarrhea.
3. Diarrhea 5. Frequent urination 4. Mernstrual spotting in any phase of the
a. 1, 2 and 3 c. 1, 2 and 5 pregnancy is abnormal. Some serious bleeding
b. 2, 3 and 5 d. 2, 3 and 4 complications of pregnancy begin only with slight
spotting.

64. Gianne reports feeling her heart skipping a

beat sometimes. The nurse recognizes this as 64. A. Heart palpitations are due to circulatory
heart palpitations and sets which of the following adjustments necessary to accommodate
goal criteria? She will: increased blood supply during pregnancy.
a. Demonstrate moving slowly from one position Palpitations are normal and to be expected on
to another occasion. Gradual, slow movements will help
b. Lie supine when sleeping to keep pressure on prevent from happening so frequently.
her vena cava
c. Plan a diet menu that includes high vitamin C
content
d. Verbalize intent to limit fluids to lower her
heart's workload

65. Gianne also complains of abdominal pains. 65. C. Pain must be carefully assessed.
The nurse should respond in which of the Abdominal pain, that may be localized to one
following ways to this information? side, during the first trimester may indicate
a. Encourage Gianne to put strong direct ectopic pregnancy.
pressure on her fundus and hold it for 15
minutes whenever she feels the pain
b. Inform Gianne that abdominal pain is
expected at this stage of her pregnancy and she
should learn to adjust to it
c. Inquire about the specific nature and location
of the pain Gianne reported because it could
indicate a complication.
d. Tell Gianne to lie on her side at night to relieve
the pressure on her intestinal tract and stomach
Situation 14:Physical and psychological
preparedness of a woman who is to give birth is
addressed in terms of exercises and
61. B. Ankle edema occurs duirng the middle to psychological techniques for pain control. A
late pregnancy. It is caused by reduced blood nurse must be aware of these exercises and
circulation. This can be relived by resting in a techniques.
side-lying position, and sitting for half an hour 66. Effleurage, a technique used to displace

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 pain, is described as: C. The prophylaxis method/Lamaze method focuses
a. Light abdominal massage on preventing pain in labor by the use of the mind. It
b. Focusing on an object to block sensory input is based on the theory that women can learn to use
c. The prophylaxis method controlled breathing to reduce pain during labor.
d. The psychosexual method D. The psychosexual method includes a program of
conscious relaxation and levels of progressive
breathing that encourages a woman to “flow with”
67. In consciously controlled breathing methods, rather than struggle against contraction.
level 5 behaviors are defined as: 67. B. In level 5 breathing, chest panting is
a. Slow chest breathing at a rate of 6 to 12 continuous; very shallow panting is about 60
breaths/minute breaths per minute.
b. Chest anting shallowly and continuously at a A. This is level 1.
rate of 60 breaths/minute or more (during strong C. This is level 4.
contractions) D. This is level 2.
c. Pant-blow rhythm intermittently with forceful
exhalations
d. Light breathing and expanding the rib cage, at 68. B. Pelvic rocking is done by alternate
a rate of up to 40 breaths/minute (during hollowing and arching of the back. It is helpful
transition contractions) in relieving backache during pregnancy and
labor.
A. Kegel exercising is done by tightening the muscle
68. Flexing the lumbar spine can relieve of the perineum as if stopping urine flow. This is
backache during pregnancy and early labor. This helpful in the postpartum period to reduce pain and
exercise is called: promote perineal healing.
a. Kegel exercising c. Squatting C. Squatting is done by placing the feet flat on the
b. Pelvic rocking d. Tailoring sitting floor. It is used to stretch the muscles of the pelvic
floor.
D. Tailoring sitting is done by sitting on the floor
with the legs parallel so that one leg does not
69. Nicole is attending a prenatal class at well- compress the other
baby health clinic. She understands that Dick-
Read method is best described as: 69. B. Dick-Read method is the so-called natural
a. A method of childbirth based on the belief that childbirth method. Its underlying concept is that
birth is a natural process that should include the knowledge diminishes fear that is key to pain.
husband during the entire birthing process Classes include information as well as practice
b. A method of childbirth based on the premise in relaxation and abdominal breathing
that fear leads to tension, which leads to pain techniques for labor.
c. A method of childbirth that teaches A. This describes Bradley method
replacement of usual responses to pain with C This describes Lamaze method, a
new, learned responses on order to block psychoprophylactic method based on the Pavlovian
recognition of pain theory of conditioned response.
d. A method that includes “sensate focus” D. This describes imaging.
inhibiting sensory input for reaching the cortex of 70. C. A method of childbirth based on the belief that
the brain. birth is a natural process that should include the
husband during the entire birthing process
A. Dick-Read method is the so-called natural childbirth
method. Its underlying concept is that knowledge
70. This pertains to a husband-coached diminishes fear that is key to pain. Classes include
childbirth that emphasizes working in harmony information as well as practice in relaxation and abdominal
with the body. breathing techniques for labor.
a. Dick-Read Method c. Bradley method B. Lamaze method is a psychoprophylactic method based
on the Pavlovian theory of conditioned response. It teaches
b. Lamaze method d. Leboyer method replacement of usual responses to pain with new, learned
responses on order to block recognition of pain
D. Leboyer method involves appropriate adjustment of the
environment during labor and delivery. The birthing room is
darkened; it is kept pleasantly warm; soft music is played;
or at least harsh noises are kept to a minimum.
Situation 15: Jodie, age 27 years old, married,
66. A. Effleurage, which is the French word for
and a mother of two children, is visiting the
light abdominal massage, is one technique used
health care center to attend the family planning
in Lamaze method. It is done with just enough
counseling.
pressure to avoid tickling. It serves as a
71. Jodie is correct in identifying that a
distraction technique and decreases sensory
procedure using carbon dioxide, and the
stimuli transmission from the abdominal wall.
coagulation and sealing of the fallopian tubes is
B. This describes imaging.

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 called: blocking, thereby preventing the passage of
a. Culdoscopy c. Hysterectomy both sperm and ova.
b. Tubal ligation d. Minilaparotomy A. Culdoscopy is a specific operation for tubal
ligation that makes use of a tube inserted through
C. Hysterectomy is the surgical removal of the
uterus.
D. In minilaparotomy, patient is under local
anesthesia. An 2- to 3-cm incision is made
transversely just above the pubic hair. The fallopian
72. What day of the week after the start of tubes are pulled to the surface and lifted out of the
menstruation flow should Jodie begin taking an incision. The fallopian tubes are sealed with metal
oral contraceptive? or plastic clips or rubber rings.
a. Sunday c. Wednesday
b. Monday d. Saturday 72. A. It is generally recommended that the first
pill be taken on a Sunday (the first Sunday
after the beginning of a menstrual flow),
although a woman may choose to begin on
any day.

73. Which of the following is thought to be a side

effect of Depo-Provera? 73. B. Weight gain averages about 4 lbs per
a. Thrombophlebitis year.
b. Weight gain A. Thrombophlebitis is a commonly associated
c. Excessive menstrual flow danger with estrogen-based pills, such as COCs.
d. Osteoporosis DMPA is a progesterone derivative (progestin).
C. Excessive menstrual flow (menorrhagia) is not
common with DMPA. There is, however,
breakthrough bleeding (spotting outside the
menstrual period), but amenorrhea occurs in 50% of
women in1 year.
74. Jodie is correct in identifying that taking an
oral contraceptive will cause the following side
74. B. Side effects associated with oral
effects:
contraceptives are nausea, headache, breast
1. Nausea
tenderness, depression, and weight gain.
2. Weight loss 4. Breast tenderness
3. Headache 5. Depression
a. 1, 2, 3 and 4 c. 1, 2 and 3
b. 1, 3, 4 and 5 d. 1, 2 and 4

75. The nurse correctly teaches Jodie that a

common problem associated with the use of IUD
is:
a. Perforation of the uterus
b. Discomfort associated with coitus
c. Development of vaginal infections
d. Spontaneous expulsion of the device
75. D. The IUD may cause irritability of the
myometrium, including contraction of the
uterus and expulsion of the device.
A. This is a rare occurrence.
B. Clients do not complain of discomfort during
coitus when an IUD is in place.
C. Increased vaginal infections are not reported with
the use of an IUD.

Situation 16: A woman and her partner undergo

71. B. Tubal ligation is a minor surgical psychological and physical changes during
procedure that uses carbon dioxide to lift the pregnancy The physiologic changes of
abdominal wall upward and out of the line of pregnancy are dynamic and extensive.
vision, whereby the fallopian tubes are 76. Helga, 24 years old, is pregnant with her first
occluded by cautery, crushing, clamping, or child. She is in her second trimester and
complains of problems with drooling. You would

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 explain that: the increased heart action takes care of the greater
a. She should be admitted to the hospital to amount of circulation blood.
assess the cause of this unusual symptom
b. This symptom shows a deficiency of sodium
and indicates she should increase her salt intake
c. Drooling is the body's way of eliminating
excess fluid to prevent high blood pressure
d. The drooling is called “hyperptyalism” and
may be due to her increased hormone levels 77. A. Ambivalence (interwoven feelings of
wanting and not wanting) is normal both for the
pregnant mother and her partner. Sometimes,
partners are afraid to voice out their concerns,
77. John, age 33, has just found out that his not wanting to compound the pregnant woman's
girlfriend Cecilia is 4 months pregnant. Which of anxieties by appearing anxious themselves.
the following might indicate that a teaching plan The nurse can help the couple resolve this by
is needed? providing an outlet for them to discuss
a. John has not expressed pleasure or concerns and offering parenting information at
displeasure regarding the pregnancy prenatal visits.
b. John refers to the fetus as “it” when talking to B. Using the term “fetus” or “it” does not necessarily
Cecilia about the pregnancy mean that the partner has not yet accepted his
c. John expresses great concern that if Cecilia girlfriend's pregnancy, or still considers the baby as
should breastfeed she would ruin her figure an inanimate object. Some believe that referring to
d. John says he hopes Cecilia will exercise more the child as “she” or “he” will bring bad luck or
so she might have an easy vaginal delivery disappointment if the child is of the opposite sex.
C. The knowledge that breastfeeding can ruin a
woman's figure needs correction, but the
expression of the partner's concerns should be
addressed first.
78. Which of the following is an example of
psychological tasks performed during the 78. B. In the second trimester, women
trimester discussed? experience “quickening”, which contributes
a. During the first trimester, women begin “nest- to acceptance of the baby.
building” activities A. During the third trimester, women begin “nest-
b. In the second trimester, women experience building” activities, such as planning the infant's
“quickening”, which contributes to acceptance of sleeping arrangements, buying clothes, choosing
the baby names for the infant, and ensuring safe passage by
c. During the third trimester, the father-to-be learning about birth.
usually begins the process of accepting the C. During the second trimester, the father-to-be
pregnancy usually begins the process of accepting the
d. During the first trimester, the father-to-be pregnancy.
begins preparing for parenthood D. During the third trimester, the father-to-be begins
preparing for parenthood.

79. Which of the following is a positive example

of reworking developmental tasks?
a. The father-to-be begins to fantasize about
being a carefree bachelor
b. An adolescent mother-to-be states she
understands why her mother made her come
home before dark
c. The father-to-be states his partner doesn't
care for him since her pregnancy
d. A 42-year-old mother-to-be role-plays life
before pregnancy
76. D. Hyperptyalism (excessive saliva
formation) is a local response to increased
levels of estrogen.
A. This is not a serious problem.
B. This is caused by increased estrogen levels, not
decreased sodium intake.
C. Blood pressure does not normally rise because
79. B. Reworking developmental tasks pertains
to working out previous life experiences.
This includes empathy with her mother and
the way her mother used to worry when she
came home later than expected.
80. Which of the following might indicate a
problem in adjustment to pregnancy?
a. A pregnant woman whose mother was
abusive to her refuses to think about or discuss it
b. Th pregnant woman reports an increase on
sexual desire and greater enjoyment of sex
c. The father-to-be reports that his pregnant wife

St. Louis Review Center, Inc-Davao Tel. no. (082) 224-2515 or 222-8732 17
 has frequent mood swings
d. The pregnant woman shows difficulty making sexual desire may remain high, or it may decrease
decisions at work and at home
Situation 17: A pregnant client has delayed her increased in estrogen and progesterone
first prenatal visit. She visits the prenatal clinic
only after she starts to experience edema of the
feet and hands. The nurse takes a history and
physical assessment to begin Mrs. Barton's
care.
81. The client's response to one of the nurse's
questions is, “This is my third pregnancy. I
miscarried twice, the first time I was 8 weeks
pregnant, and the last time I was 26 weeks
pregnant.” The nurse correctly records Mrs.
Barton's pregnancy status as:
a. G2, P0, A1 c. G3, P0, A2
b. G2, P1, A1 d. G3, P1, A1
enjoyment rise markedly. During the third trimester,
because of difficulty finding a comfortable position.
C. Mood swings are normal. They occur partly as a
manifestation of narcissism and partly because of
hormonal changes, particularly by sustained
81. D. G3 (total of 3 pregnancies: present
pregnancy plus the two miscarriage); P1
(second miscarriage at 26 weeks AOG); A1
(first miscarriage at 8 weeks AOG). Gravida
pertains to the number of pregnancies
regardless of the duration. Para pertains to the
number of pregnancies that lasted more than 20
weeks, regardless of the outcome. Abortion
pertains to the number of terminated
pregnancies, not reaching the age of 20 weeks
(age of viability).

82. C. Lying supine for a prolonged period of

82. During the examination, while client is lying
in a lithotomy position, the client complains of
dizziness and nausea. What would be an
appropriate nursing action to relieve the client's
discomfort?
a. Administering an antiemetic ordered by the
physician
b. Offering small sips of ginger ale
c. Assisting to a side-lying position temporarily
d. Discontinuing the examination
time, with the legs in a lithotomy position. The
weight of the growing uterus presses the vena
cava against the vertebrae, obstructing blood
flow to the lower extremities. This causes a
decrease ion blood return to the heart, and
consequently decreased cardiac output and
hypotension, manifesting as nausea and
dizziness, lightheadedness, faintness and
palpitations. Assisting the client in a side-lying
position relieves pressure on the vena cava,
thus improving blood circulation.

83. Diplopia was noted during the assessment of 83. B. Diplopia is described as having double
Mrs. Barton. This condition is described as: vision. Women with PIH commonly report
a. Elevated pigmentation of the skin spots before their eyes, or having double
b. Double vision vision.
c. Facial edema
d. Gingivitis

84. C. First visit may be made as soon as the

84. The physician asks the nurse to make sure
his pregnant patient's next appointment is
scheduled correctly. The patient is in her33rd
week. Her next appointment should be in:
a. 1 month c. 2 weeks
b. 3 weeks d. 1 week
80. A. Unless these feelings are resolved. They 85.
may continue to have negative effect on the
woman's views about becoming as mother.
B. This is normal. Women who formerly were
worried about becoming pregnant might truly enjoy
sex for the first tome during pregnancy. During the
second trimester, as blood flow to the pelvic area
increases the supply to placenta, libido and sexual
woman suspects she is pregnant.
Subsequent visits are as follows: monthly
until the 8th month; every 2 weeks during the
8th month, and weekly during the 9th month.
More frequent visits are scheduled if
problems arise. The client is 8 ¼ months
pregnant (33 weeks), so the next visit will be
scheduled after 2 weeks.
Mrs. Barton reports that the last day of her
last menstrual period was May 11, 2009. Her
menstruation lasted for 5 days. Her expected
date of delivery will be:
a. February 14, 2010 c. August 4, 2010
b. February 18, 2010 d. August 18, 2010

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Situation 18: A competent delivery nurse
upholds safe pregnancy and delivery.
86. The nurse documents positive ballottement
in the client’s prenatal record. The nurse
understands that this indicates which of the
following?
a. Palpable contractions on the abdomen
b. Passive movement of the unengaged fetus
c. Fetal kicking felt by the client
d. Enlargement and softening of the uterus
87. During a pelvic exam the nurse notes a
purple-blue tinge of the cervix. The nurse
documents this as which of the following?
a. Braxton-Hicks sign c. Goodell’s sign
b. Chadwick’s sign d. McDonald’s sign
88. During a prenatal class, the nurse explains
the rationale for breathing techniques during
preparation for labor based on the understanding A and D. Breathing techniques do not eliminate
that breathing techniques are most important in pain, but they can reduce it.
achieving which of the following?
a. Eliminate pain and give the expectant parents uteroplacental perfusion.
something to do
b. Reduce the risk of fetal distress by increasing
uteroplacental perfusion
c. Facilitate relaxation, possibly reducing the
perception of pain
d. Eliminate pain so that less analgesia and
anesthesia are needed
89. After 4 hours of active labor, the nurse notes
that the contractions of a primigravida client are
not strong enough to dilate the cervix. Which of
the following would the nurse anticipate doing?
a. Obtaining an order to begin IV oxytocin
infusion
b. Administering a light sedative to allow the
patient to rest for several hour
c. Preparing for a cesarean section for failure to
progress
d. Increasing the encouragement to the patient
when pushing begins
85. A. February 14, 2010
Her first day of LMP is May 7, 2009.
Use Naegel's rule: month-3; day+7; year+1
05 07 2009
-3 +7 +1
------------------------
02 14 2010
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86. B. Ballottement indicates passive movement
of the unengaged fetus.
A. Ballottement is not a contraction.
C. Fetal kicking felt by the client represents
quickening.
D. Enlargement and softening of the uterus is
known as Piskacek’s sign.
87. B. Chadwick’s sign refers to the purple-blue
tinge of the vagina and the cervix.
A. Braxton Hicks contractions are painless
contractions beginning around the 4th month.
C. Goodell’s sign indicates softening of the cervix.
D. Flexibility of the uterus against the cervix is
known as McDonald’s sign.
88. C. Breathing techniques can raise the pain
threshold and reduce the perception of pain.
They also promote relaxation.
B. Positioning, not breathing, increases
89. A. The client’s labor is hypotonic. The nurse
should call the physical and obtain an order
for an infusion of oxytocin, which will assist
the uterus to contact more forcefully in an
attempt to dilate the cervix.
B. Administering light sedative would be done for
hypertonic uterine contractions.
C. Preparing for cesarean section is unnecessary at
this time.
D. Oxytocin would increase the uterine contractions
and hopefully progress labor before a cesarean
would be necessary. It is too early to anticipate
client pushing with contractions.
90. A multigravida at 38 weeks’ gestation is
admitted with painless, bright red bleeding and
mild contractions every 7 to 10 minutes. Which
of the following assessments should be
avoided?
a. Maternal vital sign
b. Fetal heart rate
c. Contraction monitoring
d. Cervical dilation
19

Situation 19: Nurse Annie is aware that she has
obligations extending from antepartum to
postpartum care of the mother, as well as care
of the newborn.
91. Which of the following would be the nurse’s
most appropriate response to a client who asks
why she must have a cesarean delivery if she
has a complete placenta previa?
a. “You will have to ask your physician when he
returns.”
b. “You need a cesarean to prevent
hemorrhage.”
c. “The placenta is covering most of your cervix.”
d. “The placenta is covering the opening of the
uterus and blocking your baby.”
92. The nurse understands that the fetal head is
in which of the following positions with a face
presentation?
a. Completely flexed c. Partially extended
b. Completely extended d. Partially flexed
93. With a fetus in the left-anterior breech
presentation, the nurse would expect the fetal
heart rate would be most audible in which of the
following areas?
a. Above the maternal umbilicus and to the right
of midline
b. In the lower-left maternal abdominal quadrant
c. In the lower-right maternal abdominal
quadrant
d. Above the maternal umbilicus and to the left of
midline
94. The amniotic fluid of a client has a greenish
tint. The nurse interprets this to be the result of
which of the following?
a. Lanugo c. Meconium
b. Hydramnios d. Vernix
90. D. The signs indicate placenta previa and
vaginal exam to determine cervical dilation
would not be done because it could cause
hemorrhage.
A. Assessing maternal vital signs can help
determine maternal physiologic status.
B. Fetal heart rate is important to assess fetal well-
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being and should be done.
C. Monitoring the contractions will help evaluate the
progress of labor.
91. D. A complete placenta previa occurs when
the placenta covers the opening of the uterus,
thus blocking the passageway for the baby. This
response explains what a complete previa is
and the reason the baby cannot come out
except by cesarean delivery.
A. Telling the client to ask the physician is a poor
response and would increase the patient’s anxiety.
B. Although a cesarean would help to prevent
hemorrhage, the statement does not explain why
the hemorrhage could occur.
C. With a complete previa, the placenta is covering
all the cervix, not just most of it.
92. B. With a face presentation, the head is
completely extended.
A and D. With a vertex presentation, the head is
completely or partially flexed.
C. With a brow (forehead) presentation, the head
would be partially extended.
93. D. With this presentation, the fetal upper
torso and back face the left upper maternal
abdominal wall. The fetal heart rate would be
most audible above the maternal umbilicus and
to the left of the middle. The other positions would
be incorrect.
94. C. The greenish tint is due to the presence of
meconium.
A. Lanugo is the soft, downy hair on the shoulders
and back of the fetus.
B. Hydramnios represents excessive amniotic fluid.
D. Vernix is the white, cheesy substance covering
the fetus.
95. A patient is in labor and has just been told
she has a breech presentation. The nurse
should be particularly alert for which of the
following?
a. Quickening
b. Ophthalmia neonatorum
c. Pica
d. Prolapsed umbilical cord
20
 96. A. Dizygotic (fraternal) twins involve two ova
Situation 20: The Anatomy and Physiology of fertilized by separate sperm.
the Reproductive System is a basic knowledge B. C and D. Monozygotic (identical) twins involve a
that nurses must know. common placenta, same genotype, and common
96. When describing dizygotic twins to a couple, chorion.
on which of the following would the nurse base
the explanation?
a. Two ova fertilized by separate sperm
b. Sharing of a common placenta
c. Each ova with the same genotype
d. Sharing of a common chorion

97. C. The zygote is the single cell that

reproduces itself after conception.
A. The chromosome is the material that makes up
97. Which of the following refers to the single cell the cell and is gained from each parent.
that reproduces itself after conception B and D. Blastocyst and trophoblast are later terms
a. Chromosome c. Zygote for the embryo after zygote.
b. Blastocyst d. Trophoblast

98. C. The ischial spines are located in the mid-

98. A client has a midpelvic contracture from a pelvic region and could be narrowed due to the
previous pelvic injury due to a motor vehicle previous pelvic injury.
accident as a teenager. The nurse is aware that A, B and D. The symphysis pubis, sacral
this could prevent a fetus from passing through promontory, and pubic arch are not part of the mid-
or around which structure during childbirth? pelvis.
a. Symphysis pubis c. Ischial spines
b. Sacral promontory d. Pubic arch

99. When teaching a group of adolescents about 99. B. Variations in the length of the menstrual
variations in the length of the menstrual cycle, cycle are due to variations in the proliferative
the nurse understands that the underlying phase. A. C and D. The menstrual, secretory and
mechanism is due to variations in which of the ischemic phases do not contribute to this variation.
following phases?
a. Menstrual phase c. Secretory phase
b. Proliferative phase d. Ischemic phase

100. When teaching a group of adolescents about

100. B. Testosterone is produced by the Leyding
male hormone production, which of the following
cells in the seminiferous tubules.
would the nurse include as being produced by
A and C. Follicle-stimulating hormone and
the Leydig cells?
leuteinzing hormone are released by the anterior
a. Follicle-stimulating hormone
pituitary gland.
b. Testosterone
D. The hypothalamus is responsible for releasing
c. Leuteinizing hormone
gonadotropin-releasing hormone.
d. Gonadotropin releasing hormone
95. D. In a breech position, because of the
space between the presenting part and the
cervix, prolapse of the umbilical cord is
common.
A. Quickening is the woman’s first perception of
fetal movement.
B. Ophthalmia neonatorum usually results from
maternal gonorrhea and is conjunctivitis.
C. Pica refers to the oral intake of nonfood
substances.

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