MATERNITY NURSING Part 1

13. Which of the following would be disadvantage of breast feeding?

a. Involution occurs more rapidly
b. The incidence of allergies increases due to maternal antibodies
c. The father may resent the infant’s demands on the mother’s body
d. There is a greater chance for error during preparation
15. FHR can be auscultated with a fetoscope as early as which of the following?
a. 5 weeks gestation
b. 10 weeks gestation
c. 15 weeks gestation
d. 20 weeks gestation
17. Which of the following fundal heights indicates less than 12 weeks’ gestation when the date of
the LMP is unknown?
a. Uterus in the pelvis
b. Uterus at the xiphoid
c. Uterus in the abdomen
d. Uterus at the umbilicus
18. Which of the following danger signs should be reported promptly during the antepartum period?
a. Constipation
b. Breast tenderness
c. Nasal stuffiness
d. Leaking amniotic fluid
19. Which of the following prenatal laboratory test values would the nurse consider as significant?
a. Hematocrit 33.5%
b. Rubella titer less than 1:8
c. White blood cells 8,000/mm3
d. One hour glucose challenge test 110 g/dL
20. Which of the following characteristics of contractions would the nurse expect to find in a client
experiencing true labor?
a. Occurring at irregular intervals
b. Starting mainly in the abdomen
c. Gradually increasing intervals
d. Increasing intensity with walking
21. During which of the following stages of labor would the nurse assess “crowning”?
a. First stage
b. Second stage
c. Third stage
d. Fourth stage
22. Barbiturates are usually not given for pain relief during active labor for which of the following
reasons?
a. The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and
reluctance to feed for the first few days.
b. These drugs readily cross the placental barrier, causing depressive effects in the newborn
2 to 3 hours after intramuscular injection.
c. They rapidly transfer across the placenta, and lack of an antagonist make them generally
inappropriate during labor.
d. Adverse reactions may include maternal hypotension, allergic or toxic reaction or partial or
total respiratory failure
23. Which of the following nursing interventions would the nurse perform during the third stage of
labor?
a. Obtain a urine specimen and other laboratory tests.
b. Assess uterine contractions every 30 minutes.
c. Coach for effective client pushing
d. Promote parent-newborn interaction.
25. Immediately before expulsion, which of the following cardinal movements occur?
a. Descent
b. Flexion
c. Extension
d. External rotation
32. Which of the following statements best describes hyperemesis gravidarum?
a. Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the
absence of other medical problems.
b. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances
in the absence of other medical problems.
c. Loss of appetite and continuous vomiting that commonly results in dehydration and
ultimately decreasing maternal nutrients
d. Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal
bleeding
33. Which of the following would the nurse identify as a classic sign of PIH?
a. Edema of the feet and ankles
b. Edema of the hands and face
c. Weight gain of 1 lb/week
d. Early morning headache
34. In which of the following types of spontaneous abortions would the nurse assess dark brown
vaginal discharge and a negative pregnancy tests?
a. Threatened
b. Imminent
c. Missed
d. Incomplete
35. Which of the following factors would the nurse suspect as predisposing a client to placenta
previa?
a. Multiple gestation
b. Uterine anomalies
c. Abdominal trauma
d. Renal or vascular disease
36. Which of the following would the nurse assess in a client experiencing abruptio placenta?
a. Bright red, painless vaginal bleeding
b. Concealed or external dark red bleeding
c. Palpable fetal outline
d. Soft and nontender abdomen
37. Which of the following is described as premature separation of a normally implanted placenta
during the second half of pregnancy, usually with severe hemorrhage?
a. Placenta previa
b. Ectopic pregnancy
c. Incompetent cervix
d. Abruptio placentae
38. Which of the following may happen if the uterus becomes overstimulated by oxytocin during the
induction of labor?
a. Weak contraction prolonged to more than 70 seconds
b. Tetanic contractions prolonged to more than 90 seconds
c. Increased pain with bright red vaginal bleeding
d. Increased restlessness and anxiety
39. When preparing a client for cesarean delivery, which of the following key concepts should be
considered when implementing nursing care?
a. Instruct the mother’s support person to remain in the family lounge until after the delivery
b. Arrange for a staff member of the anesthesia department to explain what to expect
postoperatively
c. Modify preoperative teaching to meet the needs of either a planned or emergency
cesarean birth
d. Explain the surgery, expected outcome, and kind of anesthetics
40. Which of the following best describes preterm labor?
a. Labor that begins after 20 weeks gestation and before 37 weeks gestation
b. Labor that begins after 15 weeks gestation and before 37 weeks gestation
c. Labor that begins after 24 weeks gestation and before 28 weeks gestation
d. Labor that begins after 28 weeks gestation and before 40 weeks gestation
41. When PROM occurs, which of the following provides evidence of the nurse’s understanding of the
client’s immediate needs?
a. The chorion and amnion rupture 4 hours before the onset of labor.
b. PROM removes the fetus most effective defense against infection
 c. Nursing care is based on fetal viability and gestational age.
d. PROM is associated with malpresentation and possibly incompetent cervix
42. Which of the following factors is the underlying cause of dystocia?
a. Nurtional
b. Mechanical
c. Environmental
d. Medical
43. When uterine rupture occurs, which of the following would be the priority?
a. Limiting hypovolemic shock
b. Obtaining blood specimens
c. Instituting complete bed rest
d. Inserting a urinary catheter
44. Which of the following is the nurse’s initial action when umbilical cord prolapse occurs?
a. Begin monitoring maternal vital signs and FHR
b. Place the client in a knee-chest position in bed
c. Notify the physician and prepare the client for delivery
d. Apply a sterile warm saline dressing to the exposed cord
47. Which of the following best describes thrombophlebitis?
a. Inflammation and clot formation that result when blood components combine to form an
aggregate body
b. Inflammation and blood clots that eventually become lodged within the pulmonary blood
vessels
c. Inflammation and blood clots that eventually become lodged within the femoral vein
d. Inflammation of the vascular endothelium with clot formation on the vessel wall
48. Which of the following assessment findings would the nurse expect if the client develops DVT?
a. Midcalf pain, tenderness and redness along the vein
b. Chills, fever, malaise, occurring 2 weeks after delivery
c. Muscle pain the presence of Homans sign, and swelling in the affected limb
d. Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery
59. When preparing to listen to the fetal heart rate at 12 weeks’ gestation, the nurse would use which
of the following?
a. Stethoscope placed midline at the umbilicus
b. Doppler placed midline at the suprapubic region
c. Fetoscope placed midway between the umbilicus and the xiphoid process
d. External electronic fetal monitor placed at the umbilicus
60. When developing a plan of care for a client newly diagnosed with gestational diabetes, which
of the following instructions would be the priority?
a. Dietary intake
b. Medication
c. Exercise
d. Glucose monitoring
61. A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be
the priority when assessing the client?
a. Glucosuria
b. Depression
c. Hand/face edema
d. Dietary intake
62. A client 12 weeks’ pregnant come to the emergency department with abdominal cramping and
moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms cervical dilation. The nurse
would document these findings as which of the following?
a. Threatened abortion
b. Imminent abortion
c. Complete abortion
d. Missed abortion
63. Which of the following would be the priority nursing diagnosis for a client with an ectopic
pregnancy?
a. Risk for infection
b. Pain
c. Knowledge Deficit
d. Anticipatory Grieving
78. When measuring a client’s fundal height, which of the following techniques denotes the correct
method of measurement used by the nurse?
a. From the xiphoid process to the umbilicus
b. From the symphysis pubis to the xiphoid process
c. From the symphysis pubis to the fundus
d. From the fundus to the umbilicus
79. A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe
pitting edema. Which of the following would be most important to include in the client’s plan of
care?
a. Daily weights
b. Seizure precautions
c. Right lateral positioning
d. Stress reduction
84. A client at 8 weeks’ gestation calls complaining of slight nausea in the morning hours. Which of
the following client interventions should the nurse question?
a. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water
b. Eating a few low-sodium crackers before getting out of bed
c. Avoiding the intake of liquids in the morning hours
d. Eating six small meals a day instead of thee large meals
87. During a prenatal class, the nurse explains the rationale for breathing techniques during
preparation for labor based on the understanding that breathing techniques are most important
in achieving which of the following?
a. Eliminate pain and give the expectant parents 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
88. 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
89. 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
90. 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.”
91. The nurse understands that the fetal head is in which of the following positions with a face
presentation?
a. Completely flexed
b. Completely extended
c. Partially extended
d. Partially flexed
92. 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
93. 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
b. Hydramnio
 c. Meconium
d. Vernix
94. 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
98. A client has a midpelvic contracture from a previous pelvic injury due to a motor vehicle accident
as a teenager. The nurse is aware that this could prevent a fetus from passing through or around
which structure during childbirth?
a. Symphysis pubis
b. Sacral promontory
c. Ischial spines
d. Pubic arch

ANSWERS and RATIONALES for MATERNITY NURSING Part 1

13.C. With breast feeding, the father’s body is not capable of providing the milk for the newborn,
which may interfere with feeding the newborn, providing fewer chances for bonding, or he may
be jealous of the infant’s demands on his wife’s time and body. Breast feeding is advantageous
because uterine involution occurs more rapidly, thus minimizing blood loss. The presence of
maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. A
greater chance for error is associated with bottle feeding. No preparation is required for breast
feeding.
15.D. The FHR can be auscultated with a fetoscope at about 20 week’s gestation. FHR usually is
ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12
week’s gestation. FHR, cannot be heard any earlier than 10 weeks’ gestation.
17.A. When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or
position (fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks’
gestation. At approximately 12 to 14 weeks, the fundus is out of the pelvis above the symphysis
pubis. The fundus is at the level of the umbilicus at approximately 20 weeks’ gestation and
reaches the xiphoid at term or 40 weeks.
18.D. Danger signs that require prompt reporting leaking of amniotic fluid, vaginal bleeding, blurred
vision, rapid weight gain, and elevated blood pressure. Constipation, breast tenderness, and nasal
stuffiness are common discomforts associated with pregnancy.
19.B. A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant,
indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white
blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal
parameters.
20.D. With true labor, contractions increase in intensity with walking. In addition, true labor
contractions occur at regular intervals, usually starting in the back and sweeping around to the
abdomen. The interval of true labor contractions gradually shortens.
21.B. Crowing, which occurs when the newborn’s head or presenting part appears at the vaginal
opening, occurs during the second stage of labor. During the first stage of labor, cervical dilation
and effacement occur. During the third stage of labor, the newborn and placenta are delivered.
The fourth stage of labor lasts from 1 to 4 hours after birth, during which time the mother and
newborn recover from the physical process of birth and the mother’s organs undergo the initial
readjustment to the nonpregnant state.
22.C. Barbiturates are rapidly transferred across the placental barrier, and lack of an antagonist
makes them generally inappropriate during active labor. Neonatal side effects of barbiturates
include central nervous system depression, prolonged drowsiness, delayed establishment of
feeding (e.g. due to poor sucking reflex or poor sucking pressure). Tranquilizers are associated
with neonatal effects such as hypotonia, hypothermia, generalized drowsiness, and reluctance to
feed for the first few days. Narcotic analgesic readily cross the placental barrier, causing
depressive effects in the newborn 2 to 3 hours after intramuscular injection. Regional anesthesia
is associated with adverse reactions such as maternal hypotension, allergic or toxic reaction, or
partial or total respiratory failure.
23.D. During the third stage of labor, which begins with the delivery of the newborn, the nurse would
promote parent-newborn interaction by placing the newborn on the mother’s abdomen and
 encouraging the parents to touch the newborn. Collecting a urine specimen and other laboratory
tests is done on admission during the first stage of labor. Assessing uterine contractions every 30
minutes is performed during the latent phase of the first stage of labor. Coaching the client to
push effectively is appropriate during the second stage of labor.
25.D. Immediately before expulsion or birth of the rest of the body, the cardinal movement of
external rotation occurs. Descent flexion, internal rotation, extension, and restitution (in this
order) occur before external rotation.
32.B. The description of hyperemesis gravidarum includes severe nausea and vomiting, leading to
electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.
Hyperemesis is not a form of anemia. Loss of appetite may occur secondary to the nausea and
vomiting of hyperemesis, which, if it continues, can deplete the nutrients transported to the fetus.
Diarrhea does not occur with hyperemesis.
33.B. Edema of the hands and face is a classic sign of PIH. Many healthy pregnant woman
experience foot and ankle edema. A weight gain of 2 lb or more per week indicates a problem.
Early morning headache is not a classic sign of PIH.
34.C. In a missed abortion, there is early fetal intrauterine death, and products of conception are not
expelled. The cervix remains closed; there may be a dark brown vaginal discharge, negative
pregnancy test, and cessation of uterine growth and breast tenderness. A threatened abortion is
evidenced with cramping and vaginal bleeding in early pregnancy, with no cervical dilation. An
incomplete abortion presents with bleeding, cramping, and cervical dilation. An incomplete
abortion involves only expulsion of part of the products of conception and bleeding occurs with
cervical dilation.
35.A. Multiple gestation is one of the predisposing factors that may cause placenta previa. Uterine
anomalies abdominal trauma, and renal or vascular disease may predispose a client to abruptio
placentae.
36.B. A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting
sudden intense localized uterine pain. The uterus is typically firm to boardlike, and the fetal
presenting part may be engaged. Bright red, painless vaginal bleeding, a palpable fetal outline
and a soft nontender abdomen are manifestations of placenta previa.
37.D. Abruptio placentae is described as premature separation of a normally implanted placenta
during the second half of pregnancy, usually with severe hemorrhage. Placenta previa refers to
implantation of the placenta in the lower uterine segment, causing painless bleeding in the third
trimester of pregnancy. Ectopic pregnancy refers to the implantation of the products of
conception in a site other than the endometrium. Incompetent cervix is a conduction
characterized by painful dilation of the cervical os without uterine contractions.
38.B. Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result
in tetanic contractions prolonged to more than 90seconds, which could lead to such
complications as fetal distress, abruptio placentae, amniotic fluid embolism, laceration of the
cervix, and uterine rupture. Weak contractions would not occur. Pain, bright red vaginal bleeding,
and increased restlessness and anxiety are not associated with hyperstimulation.
39.C. A key point to consider when preparing the client for a cesarean delivery is to modify the
preoperative teaching to meet the needs of either a planned or emergency cesarean birth, the
depth and breadth of instruction will depend on circumstances and time available. Allowing the
mother’s support person to remain with her as much as possible is an important concept,
although doing so depends on many variables. Arranging for necessary explanations by various
staff members to be involved with the client’s care is a nursing responsibility. The nurse is
responsible for reinforcing the explanations about the surgery, expected outcome, and type of
anesthetic to be used. The obstetrician is responsible for explaining about the surgery and
outcome and the anesthesiology staff is responsible for explanations about the type of anesthesia
to be used.
40.A. Preterm labor is best described as labor that begins after 20 weeks’ gestation and before 37
weeks’ gestation. The other time periods are inaccurate.
41.B. PROM can precipitate many potential and actual problems; one of the most serious is the fetus
loss of an effective defense against infection. This is the client’s most immediate need at this
time. Typically, PROM occurs about 1 hour, not 4 hours, before labor begins. Fetal viability and
gestational age are less immediate considerations that affect the plan of care. Malpresentation
and an incompetent cervix may be causes of PROM.
42.B. Dystocia is difficult, painful, prolonged labor due to mechanical factors involving the fetus
(passenger), uterus (powers), pelvis (passage), or psyche. Nutritional, environment, and medical
factors may contribute to the mechanical factors that cause dystocia.
43.A. With uterine rupture, the client is at risk for hypovolemic shock. Therefore, the priority is to
prevent and limit hypovolemic shock. Immediate steps should include giving oxygen, replacing
lost fluids, providing drug therapy as needed, evaluating fetal responses and preparing for
surgery. Obtaining blood specimens, instituting complete bed rest, and inserting a urinary
catheter are necessary in preparation for surgery to remedy the rupture.
44.B. The immediate priority is to minimize pressure on the cord. Thus the nurse’s initial action
involves placing the client on bed rest and then placing the client in a knee-chest position or
lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the
pressure on the cord. Monitoring maternal vital signs and FHR, notifying the physician and
preparing the client for delivery, and wrapping the cord with sterile saline soaked warm gauze are
important. But these actions have no effect on minimizing the pressure on the cord.
47.D. Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on
the wall of the vessel. Blood components combining to form an aggregate body describe a
thrombus or thrombosis. Clots lodging in the pulmonary vasculature refers to pulmonary
embolism; in the femoral vein, femoral thrombophlebitis.
48.C. Classic symptoms of DVT include muscle pain, the presence of Homans sign, and swelling of
the affected limb. Midcalf pain, tenderness, and redness, along the vein reflect superficial
thrombophlebitis. Chills, fever and malaise occurring 2 weeks after delivery reflect pelvic
thrombophlebitis. Chills, fever, stiffness and pain occurring 10 to 14 days after delivery suggest
femoral thrombophlebitis.
59.B. At 12 weeks gestation, the uterus rises out of the pelvis and is palpable above the symphysis
pubis. The Doppler intensifies the sound of the fetal pulse rate so it is audible. The uterus has
merely risen out of the pelvis into the abdominal cavity and is not at the level of the umbilicus.
The fetal heart rate at this age is not audible with a stethoscope. The uterus at 12 weeks is just
above the symphysis pubis in the abdominal cavity, not midway between the umbilicus and the
xiphoid process. At 12 weeks the FHR would be difficult to auscultate with a fetoscope. Although
the external electronic fetal monitor would project the FHR, the uterus has not risen to the
umbilicus at 12 weeks.
60.A. Although all of the choices are important in the management of diabetes, diet therapy is the
mainstay of the treatment plan and should always be the priority. Women diagnosed with
gestational diabetes generally need only diet therapy without medication to control their blood
sugar levels. Exercise, is important for all pregnant women and especially for diabetic women,
because it burns up glucose, thus decreasing blood sugar. However, dietary intake, not exercise,
is the priority. All pregnant women with diabetes should have periodic monitoring of serum
glucose. However, those with gestational diabetes generally do not need daily glucose
monitoring. The standard of care recommends a fasting and 2-hour postprandial blood sugar level
every 2 weeks.
61.C. After 20 weeks’ gestation, when there is a rapid weight gain, preeclampsia should be
suspected, which may be caused by fluid retention manifested by edema, especially of the hands
and face. The three classic signs of preeclampsia are hypertension, edema, and proteinuria.
Although urine is checked for glucose at each clinic visit, this is not the priority. Depression may
cause either anorexia or excessive food intake, leading to excessive weight gain or loss. This is
not, however, the priority consideration at this time. Weight gain thought to be caused by
excessive food intake would require a 24-hour diet recall. However, excessive intake would not be
the primary consideration for this client at this time.
62.B. Cramping and vaginal bleeding coupled with cervical dilation signifies that termination of the
pregnancy is inevitable and cannot be prevented. Thus, the nurse would document an imminent
abortion. In a threatened abortion, cramping and vaginal bleeding are present, but there is no
cervical dilation. The symptoms may subside or progress to abortion. In a complete abortion all
the products of conception are expelled. A missed abortion is early fetal intrauterine death
without expulsion of the products of conception.
63.B. For the client with an ectopic pregnancy, lower abdominal pain, usually unilateral, is the
primary symptom. Thus, pain is the priority. Although the potential for infection is always present,
the risk is low in ectopic pregnancy because pathogenic microorganisms have not been
introduced from external sources. The client may have a limited knowledge of the pathology and
treatment of the condition and will most likely experience grieving, but this is not the priority at
this time.
77.A. Intrauterine anoxia may cause relaxation of the anal sphincter and emptying of meconium
into the amniotic fluid. At birth some of the meconium fluid may be aspirated, causing
mechanical obstruction or chemical pneumonitis. The infant is not at increased risk for
 gastrointestinal problems. Even though the skin is stained with meconium, it is noninfectious
(sterile) and nonirritating. The postterm meconium-stained infant is not at additional risk for
bowel or urinary problems.
78.C. The nurse should use a nonelastic, flexible, paper measuring tape, placing the zero point on
the superior border of the symphysis pubis and stretching the tape across the abdomen at the
midline to the top of the fundus. The xiphoid and umbilicus are not appropriate landmarks to use
when measuring the height of the fundus (McDonald’s measurement).
79.B. Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a
seizure. Seizure precautions provide environmental safety should a seizure occur. Because of
edema, daily weight is important but not the priority. Preclampsia causes vasospasm and
therefore can reduce utero-placental perfusion. The client should be placed on her left side to
maximize blood flow, reduce blood pressure, and promote diuresis. Interventions to reduce stress
and anxiety are very important to facilitate coping and a sense of control, but seizure precautions
are the priority.
84.A. Using bicarbonate would increase the amount of sodium ingested, which can cause
complications. Eating low-sodium crackers would be appropriate. Since liquids can increase
nausea avoiding them in the morning hours when nausea is usually the strongest is appropriate.
Eating six small meals a day would keep the stomach full, which often decrease nausea.
87.C. Breathing techniques can raise the pain threshold and reduce the perception of pain. They also
promote relaxation. Breathing techniques do not eliminate pain, but they can reduce it.
Positioning, not breathing, increases uteroplacental perfusion.
88.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. Administering light sedative would be done for hypertonic uterine contractions.
Preparing for cesarean section is unnecessary at this time. 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.
89.D. The signs indicate placenta previa and vaginal exam to determine cervical dilation would not
be done because it could cause hemorrhage. Assessing maternal vital signs can help determine
maternal physiologic status. Fetal heart rate is important to assess fetal well-being and should be
done. Monitoring the contractions will help evaluate the progress of labor.
90.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. Telling the client to ask the
physician is a poor response and would increase the patient’s anxiety. Although a cesarean would
help to prevent hemorrhage, the statement does not explain why the hemorrhage could occur.
With a complete previa, the placenta is covering all the cervix, not just most of it.
91.B. With a face presentation, the head is completely extended. With a vertex presentation, the
head is completely or partially flexed. With a brow (forehead) presentation, the head would be
partially extended.
92.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.
93.C. The greenish tint is due to the presence of meconium. Lanugo is the soft, downy hair on the
shoulders and back of the fetus. Hydramnios represents excessive amniotic fluid. Vernix is the
white, cheesy substance covering the fetus.
94.D. In a breech position, because of the space between the presenting part and the cervix,
prolapse of the umbilical cord is common. Quickening is the woman’s first perception of fetal
movement. Ophthalmia neonatorum usually results from maternal gonorrhea and is
conjunctivitis. Pica refers to the oral intake of nonfood substances.
98. C. The ischial spines are located in the mid-pelvic region and could be narrowed due to the
previous pelvic injury. The symphysis pubis, sacral promontory, and pubic arch are not part of the
mid-pelvis.