1. A nurse in a delivery room is assisting with the delivery of a newborn infant.

After
the delivery, the nurse prepares to prevent heat loss in the newborn resulting from
evaporation by:
1. Warming the crib pad
2. Turning on the overhead radiant warmer
3. Closing the doors to the room
4. Drying the infant in a warm blanket
2. A nurse is assessing a newborn infant following circumcision and notes that the
circumcised area is red with a small amount of bloody drainage. Which of the
following nursing actions would be most appropriate?
1. Document the findings
2. Contact the physician
3. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
4. Reinforce the dressing
3. A nurse in the newborn nursery is monitoring a preterm newborn infant for
respiratory distress syndrome. Which assessment signs if noted in the newborn
infant would alert the nurse to the possibility of this syndrome?
1. Hypotension and Bradycardia
2. Tachypnea and retractions
3. Acrocyanosis and grunting
4. The presence of a barrel chest with grunting
4. A nurse in a newborn nursery is performing an assessment of a newborn infant.
The nurse is preparing to measure the head circumference of the infant. The nurse
would most appropriately:
1. Wrap the tape measure around the infants head and measure just above the eyebrows.
2. Place the tape measure under the infants head at the base of the skull and wrap around

to the front just above the eyes

3. Place the tape measure under the infants head, wrap around the occiput, and measure
just above the eyes
4. Place the tape measure at the back of the infants head, wrap around across the ears,
and measure across the infants mouth.
5. A postpartum nurse is providing instructions to the mother of a newborn infant
with hyperbilirubinemia who is being breastfed. The nurse provides which most
appropriate instructions to the mother?
1. Switch to bottle feeding the baby for 2 weeks
2. Stop the breast feedings and switch to bottle-feeding permanently
3. Feed the newborn infant less frequently
4. Continue to breast-feed every 2-4 hours
6. A nurse on the newborn nursery floor is caring for a neonate. On assessment the
infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting.
Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant
replacement therapy. The nurse would prepare to administer this therapy by:
1. Subcutaneous injection
2. Intravenous injection
3. Instillation of the preparation into the lungs through an endotracheal tube
4. Intramuscular injection
7. A nurse is assessing a newborn infant who was born to a mother who is addicted
to drugs. Which of the following assessment findings would the nurse expect to note
during the assessment of this newborn?
1. Sleepiness
2. Cuddles when being held

3. Lethargy
4. Incessant crying
8. A nurse prepares to administer a vitamin K injection to a newborn infant. The
mother asks the nurse why her newborn infant needs the injection. The best
response by the nurse would be:
1. You infant needs vitamin K to develop immunity.
2. The vitamin K will protect your infant from being jaundiced.
3. Newborn infants are deficient in vitamin K, and this injection prevents your infant from
abnormal bleeding.
4. Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in
the bowel.
9. A nurse in a newborn nursery receives a phone call to prepare for the admission of
a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the
admission of this infant, the nurses highest priority should be to:
1. Connect the resuscitation bag to the oxygen outlet
2. Turn on the apnea and cardiorespiratory monitors
3. Set up the intravenous line with 5% dextrose in water
4. Set the radiant warmer control temperature at 36.5* C (97.6*F)
10. Vitamin K is prescribed for a neonate. A nurse prepares to administer the
medication in which muscle site?
1. Deltoid
2. Triceps
3. Vastus lateralis
4. Biceps
11. A nursing instructor asks a nursing student to describe the procedure for
administering erythromycin ointment into the eyes if a neonate. The instructor

determines that the student needs to research this procedure further if the student
states:
1. I will cleanse the neonates eyes before instilling ointment.
2. I will flush the eyes after instilling the ointment.
3. I will instill the eye ointment into each of the neonates conjunctival sacs within one hour
after birth.
4. Administration of the eye ointment may be delayed until an hour or so after birth so that
eye contact and parent-infant attachment and bonding can occur.
12. A baby is born precipitously in the ER. The nurses initial action should be to:
1. Establish an airway for the baby
2. Ascertain the condition of the fundus
3. Quickly tie and cut the umbilical cord
4. Move mother and baby to the birthing unit
13. The primary critical observation for Apgar scoring is the:
1. Heart rate
2. Respiratory rate
3. Presence of meconium
4. Evaluation of the Moro reflex
14. When performing a newborn assessment, the nurse should measure the vital
signs in the following sequence:
1. Pulse, respirations, temperature
2. Temperature, pulse, respirations
3. Respirations, temperature, pulse
4. Respirations, pulse, temperature

15. Within 3 minutes after birth the normal heart rate of the infant may range
between:
1. 100 and 180
2. 130 and 170
3. 120 and 160
4. 100 and 130
16. The expected respiratory rate of a neonate within 3 minutes of birth may be as
high as:
1. 50
2. 60
3. 80
4. 100
17. The nurse is aware that a healthy newborns respirations are:
1. Regular, abdominal, 40-50 per minute, deep
2. Irregular, abdominal, 30-60 per minute, shallow
3. Irregular, initiated by chest wall, 30-60 per minute, deep
4. Regular, initiated by the chest wall, 40-60 per minute, shallow
18. To help limit the development of hyperbilirubinemia in the neonate, the plan of
care should include:
1. Monitoring for the passage of meconium each shift
2. Instituting phototherapy for 30 minutes every 6 hours
3. Substituting breastfeeding for formula during the 2nd day after birth
4. Supplementing breastfeeding with glucose water during the first 24 hours

19. A newborn has small, whitish, pinpoint spots over the nose, which the nurse
knows are caused by retained sebaceous secretions. When charting this
observation, the nurse identifies it as:
1. Milia
2. Lanugo
3. Whiteheads
4. Mongolian spots
20. When newborns have been on formula for 36-48 hours, they should have a:
1. Screening for PKU
2. Vitamin K injection
3. Test for necrotizing enterocolitis
4. Heel stick for blood glucose level
21. The nurse decides on a teaching plan for a new mother and her infant. The plan
should include:
1. Discussing the matter with her in a non-threatening manner
2. Showing by example and explanation how to care for the infant
3. Setting up a schedule for teaching the mother how to care for her baby
4. Supplying the emotional support to the mother and encouraging her independence
22. Which action best explains the main role of surfactant in the neonate?
1. Assists with ciliary body maturation in the upper airways
2. Helps maintain a rhythmic breathing pattern
3. Promotes clearing mucus from the respiratory tract
4. Helps the lungs remain expanded after the initiation of breathing
23. While assessing a 2-hour old neonate, the nurse observes the neonate to have
acrocyanosis. Which of the following nursing actions should be performed initially?

1. Activate the code blue or emergency system

2. Do nothing because acrocyanosis is normal in the neonate
3. Immediately take the newborns temperature according to hospital policy
4. Notify the physician of the need for a cardiac consult
24. The nurse is aware that a neonate of a mother with diabetes is at risk for what
complication?
1. Anemia
2. Hypoglycemia
3. Nitrogen loss
4. Thrombosis
25. A client with group AB blood whose husband has group O has just given birth.
The major sign of ABO blood incompatibility in the neonate is which complication or
test result?
1. Negative Coombs test
2. Bleeding from the nose and ear
3. Jaundice after the first 24 hours of life
4. Jaundice within the first 24 hours of life
26. A client has just given birth at 42 weeks gestation. When assessing the neonate,
which physical finding is expected?
1. A sleepy, lethargic baby
2. Lanugo covering the body
3. Desquamation of the epidermis
4. Vernix caseosa covering the body
27. After reviewing the clients maternal history of magnesium sulfate during labor,
which condition would the nurse anticipate as a potential problem in the neonate?

1. Hypoglycemia
2. Jitteriness
3. Respiratory depression
4. Tachycardia
28. Neonates of mothers with diabetes are at risk for which complication following
birth?
1. Atelectasis
2. Microcephaly
3. Pneumothorax
4. Macrosomia
29. By keeping the nursery temperature warm and wrapping the neonate in blankets,
the nurse is preventing which type of heat loss?
1. Conduction
2. Convection
3. Evaporation
4. Radiation
30. A neonate has been diagnosed with caput succedaneum. Which statement is
correct about this condition?
1. It usually resolves in 3-6 weeks
2. It doesnt cross the cranial suture line
3. Its a collection of blood between the skull and the periosteum
4. It involves swelling of tissue over the presenting part of the presenting head
31. The most common neonatal sepsis and meningitis infections seen within 24
hours after birth are caused by which organism?

1. Candida albicans
2. Chlamydia trachomatis
3. Escherichia coli
4. Group B beta-hemolytic streptococci
32. When attempting to interact with a neonate experiencing drug withdrawal, which
behavior would indicate that the neonate is willing to interact?
1. Gaze aversion
2. Hiccups
3. Quiet alert state
4. Yawning
33. When teaching umbilical cord care to a new mother, the nurse would include
which information?
1. Apply peroxide to the cord with each diaper change
2. Cover the cord with petroleum jelly after bathing
3. Keep the cord dry and open to air
4. Wash the cord with soap and water each day during a tub bath
34. A mother of a term neonate asks what the thick, white, cheesy coating is on his
skin. Which correctly describes this finding?
1. Lanugo
2. Milia
3. Nevus flammeus
4. Vernix
35. Which condition or treatment best ensures lung maturity in an infant?
1. Meconium in the amniotic fluid
2. Glucocorticoid treatment just before delivery

3. Lecithin to sphingomyelin ratio more than 2:1

4. Absence of phosphatidylglycerol in amniotic fluid
36. When performing nursing care for a neonate after a birth, which intervention has
the highest nursing priority?
1. Obtain a dextrostix
2. Give the initial bath
3. Give the vitamin K injection
4. Cover the neonates head with a cap
37. When performing an assessment on a neonate, which assessment finding is most
suggestive of hypothermia?
1. Bradycardia
2. Hyperglycemia
3. Metabolic alkalosis
4. Shivering
38. A woman delivers a 3.250 g neonate at 42 weeks gestation. Which physical
finding is expected during an examination if this neonate?
1. Abundant lanugo
2. Absence of sole creases
3. Breast bud of 1-2 mm in diameter
4. Leathery, cracked, and wrinkled skin
39. A healthy term neonate born by C-section was admitted to the transitional
nursery 30 minutes ago and placed under a radiant warmer. The neonate has an
axillary temperature of 99.5oF, a respiratory rate of 80 breaths/minute, and a heel
stick glucose value of 60 mg/dl. Which action should the nurse take?

1. Wrap the neonate warmly and place her in an open crib

2. Administer an oral glucose feeding of 10% dextrose in water
3. Increase the temperature setting on the radiant warmer
4. Obtain an order for IV fluid administration
40. Which neonatal behavior is most commonly associated with fetal alcohol
syndrome (FAS)?
1. Hypoactivity
2. High birth weight
3. Poor wake and sleep patterns
4. High threshold of stimulation
41. Which of the following behaviors would indicate that a client was bonding with
her baby?
1. The client asks her husband to give the baby a bottle of water.
2. The client talks to the baby and picks him up when he cries.
3. The client feeds the baby every three hours.
4. The client asks the nurse to recommend a good child care manual.
42. A newborns mother is alarmed to find small amounts of blood on her infant girls
diaper. When the nurse checks the infants urine it is straw colored and has no
offensive odor. Which explanation to the newborns mother is most appropriate?
1. It appears your baby has a kidney infection
2. Breast-fed babies often experience this type of bleeding problem due to lack of vitamin C
in the breast milk
3. The baby probably passed a small kidney stone
4. Some infants experience menstruation like bleeding when hormones from the mother
are not available

43. An insulin-dependent diabetic delivered a 10-pound male. When the baby is

brought to the nursery, the priority of care is to
1. clean the umbilical cord with Betadine to prevent infection
2. give the baby a bath
3. call the laboratory to collect a PKU screening test
4. check the babys serum glucose level and administer glucose if < 40 mg/dL
44. Soon after delivery a neonate is admitted to the central nursery. The nursery
nurse begins the initial assessment by
1. auscultate bowel sounds.
2. determining chest circumference.
3. inspecting the posture, color, and respiratory effort.
4. checking for identifying birthmarks.
45. The home health nurse visits the Cox family 2 weeks after hospital discharge. She
observes that the umbilical cord has dried and fallen off. The area appears healed
with no drainage or erythema present. The mother can be instructed to
1. cover the umbilicus with a band-aid.
2. continue to clean the stump with alcohol for one week.
3. apply an antibiotic ointment to the stump.
4. give him a bath in an infant tub now.
46. A neonate is admitted to a hospitals central nursery. The neonates vital signs
are: temperature = 96.5 degrees F., heart rate = 120 bpm, and respirations =
40/minute. The infant is pink with slight acrocyanosis. The priority nursing
diagnosis for the neonate is
1. Ineffective thermoregulation related to fluctuating environmental temperatures.
2. Potential for infection related to lack of immunity.

3. Altered nutrition, less than body requirements related to diminished sucking reflex.
4. Altered elimination pattern related to lack of nourishment.
47. The nurse hears the mother of a 5-pound neonate telling a friend on the
telephone, As soon as I get home, Ill give him some cereal to get him to gain
weight? The nurse recognizes the need for further instruction about infant feeding
and tells her
1. If you give the baby cereal, be sure to use Rice to prevent allergy.
2. The baby is not able to swallow cereal, because he is too small.
3. The infants digestive tract cannot handle complex carbohydrates like cereal.
4. If you want him to gain weight, just double his daily intake of formula.
48. The nurse instructs a primipara about safety considerations for the neonate. The
nurse determines that the client does not understand the instructions when she says
1. All neonates should be in an approved car seat when in an automobile.
2. Its acceptable to prop the infants bottle once in a while.
3. Pillows should not be used in the infants crib.
4. Infants should never be left unattended on an unguarded surface.
49. The nurse manager is presenting education to her staff to promote consistency in
the interventions used with lactating mothers. She emphasizes that the optimum time
to initiate lactation is
1. as soon as possible after the infants birth.
2. after the mother has rested for 4-6 hours.
3. during the infants second period of reactivity.
4. after the infant has taken sterile water without complications.
50. The nurse is preparing to discharge a multipara 24 hours after a vaginal delivery.
The client is breast-feeding her newborn. The nurse instructs the client that if
engorgement occurs the client should

1. wear a tight fitting bra or breast binder.

2. apply warm, moist heat to the breasts.
3. contact the nurse midwife for a lactation suppressant.
4. restrict fluid intake to 1000 ml. daily .

Answers and Rationale

Gauge your performance by counter checking your answers to the answers below. Learn
more about the question by reading the rationale. If you have any disputes or questions,
please direct them to the comments section.
1. Answer: 4. Drying the infant in a warm blanket. Evaporation of moisture from a wet
body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet
newborn infant will prevent hypothermia via evaporation.
2. Answer: 1. Document the findings. The penis is normally red during the healing
process. A yellow exudate may be noted in 24 hours, and this is a part of normal healing.
The nurse would expect that the area would be red with a small amount of bloody drainage.
If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If
bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse
would contact the physician. Because the findings identified in the question are normal, the
nurse would document the assessment.
3. Answer: 2. Acrocyanosis and grunting. The infant with respiratory distress syndrome
may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall
retractions, or audible grunts.
4. Answer: 3. Place the tape measure under the infants head, wrap around the
occiput, and measure just above the eyes. To measure the head circumference, the
nurse should place the tape measure under the infants head, wrap the tape around the
occiput, and measure just above the eyebrows so that the largest area of the occiput is
included.

5. Answer: 4. Continue to breastfeed every 2-4 hours. Breast feeding should be initiated
within 2 hours after birth and every 2-4 hours thereafter. The other options are not
necessary.
6. Answer: 3. Instillation of the preparation into the lungs through an endotracheal
tube. The aim of therapy in RDS is to support the disease until the disease runs its course
with the subsequent development of surfactant. The infant may benefit from surfactant
replacement therapy. In surfactant replacement, an exogenous surfactant preparation is
instilled into the lungs through an endotracheal tube.
7. Answer: 4. Incessant crying. A newborn infant born to a woman using drugs is irritable.
The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and
posture rather than cuddle when being held.
8. Answer: 3. Newborn infants are deficient in vitamin K, and this injection prevents
your infant from abnormal bleeding. Vitamin K is necessary for the body to synthesize
coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal
bleeding. Newborn infants are vitamin K deficient because the bowel does not have the
bacteria necessary for synthesizing fat-soluble vitamin K. The infants bowel does not have
support the production of vitamin K until bacteria adequately colonizes it by food ingestion.
9. Answer: 1. Connect the resuscitation bag to the oxygen outlet. The highest priority
on admission to the nursery for a newborn with low Apgar scores is airway, which would
involve preparing respiratory resuscitation equipment. The other options are also important,
although they are of lower priority.
10. Answer: 3. Vastus lateralis.
11. Answer: 2. I will flush the eyes after instilling the ointment. Eye prophylaxis
protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes
are not flushed after instillation of the medication because the flush will wash away the
administered medication.

12. Answer: 1. Establish an airway for the baby. The nurse should position the baby with
head lower than chest and rub the infants back to stimulate crying to promote oxygenation.
There is no haste in cutting the cord.
13. Answer: 1. Heart rate. The heart rate is vital for life and is the most critical observation
in Apgar scoring. Respiratory effect rather than rate is included in the Apgar score; the rate
is very erratic.
14. Answer: 4. Respirations, pulse, temperature. This sequence is least disturbing.
Touching with the stethoscope and inserting the thermometer increase anxiety and elevate
vital signs.
15. Answer: 3. 120 and 160. The heart rate varies with activity; crying will increase the rate,
whereas deep sleep will lower it; a rate between 120 and 160 is expected.
16. Answer: 2. 60. The respiratory rate is associated with activity and can be as rapid as 60
breaths per minute; over 60 breaths per minute are considered tachypneic in the infant.
17. Answer: 2. Irregular, abdominal, 30-60 per minute, shallow. Normally the newborns
breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60
breaths per minute.
18. Answer: 1. Monitoring for the passage of meconium each shift. Bilirubin is excreted
via the GI tract; if meconium is retained, the bilirubin is reabsorbed.
19. Answer: 1. Milia. Milia occur commonly, are not indicative of any illness, and eventually
disappear.
20. Answer: 1. Screening for PKU. By now the newborn will have ingested an ample
amount of the amino acid phenylalanine, which, if not metabolized because of a lack of the
liver enzyme, can deposit injurious metabolites into the bloodstream and brain; early
detection can determine if the liver enzyme is absent.

21. Answer: 2. Showing by example and explanation how to care for the
infant. Teaching the mother by example is a non-threatening approach that allows her to
proceed at her own pace.
22. Answer: 4. Helps the lungs remain expanded after the initiation of
breathing. Surfactant works by reducing surface tension in the lung. Surfactant allows the
lung to remain slightly expanded, decreasing the amount of work required for inspiration.
23. Answer: 2. Do nothing because acrocyanosis is normal in the
neonate. Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also
called peripheral cyanosis), is a normal finding and shouldnt last more than 24 hours after
birth.
24. Answer: 2. Hypoglycemia. Neonates of mothers with diabetes are at risk for
hypoglycemia due to increased insulin levels. During gestation, an increased amount of
glucose is transferred to the fetus across the placenta. The neonates liver cannot initially
adjust to the changing glucose levels after birth. This may result in an overabundance of
insulin in the neonate, resulting in hypoglycemia.
25. Answer: 4. Jaundice within the first 24 hours of life. The neonate with ABO blood
incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life.
The neonate would have a positive Coombs test result.
26. Answer: 3. Desquamation of the epidermis. Postdate fetuses lose the vernix
caseosa, and the epidermis may become desquamated. These neonates are usually very
alert. Lanugo is missing in the postdate neonate.
27. Answer: 3. Respiratory depression. Magnesium sulfate crosses the placenta and
adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia.
28. Answer: 4. Macrosomia. Neonates of mothers with diabetes are at increased risk for
macrosomia (excessive fetal growth) as a result of the combination of the increased supply
of maternal glucose and an increase in fetal insulin.

29. Answer: 2. Convection. Convection heat loss is the flow of heat from the body surface
to the cooler air.
30. Answer: 4. It involves swelling of tissue over the presenting part of the presenting
head. Caput succedaneum is the swelling of tissue over the presenting part of the fetal
scalp due to sustained pressure; it resolves in 3-4 days.
31. Answer: 4. Group B beta-hemolytic streptococci. Transmission of Group B betahemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to
septic shock.
32. Answer: 3. Quiet alert state. When caring for a neonate experiencing drug withdrawal,
the nurse needs to be alert for distress signals from the neonate. Stimuli should be
introduced one at a time when the neonate is in a quiet and alert state. Gaze aversion,
yawning, sneezing, hiccups, and body arching are distress signals that the neonate cannot
handle stimuli at that time.
33. Answer: 3. Keep the cord dry and open to air. Keeping the cord dry and open to air
helps reduce infection and hastens drying.
34. Answer: 4. Vernix.
35. Answer: 3. Lecithin to sphingomyelin ratio more than 2:1. Lecithin and
sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at
36 weeks and sphingomyelin concentrations remain stable.
36. Answer: 4. Cover the neonates head with a cap. Covering the neonates head with a
cap helps prevent cold stress due to excessive evaporative heat loss from the neonates wet
head. Vitamin K can be given up to 4 hours after birth.
37. Answer: 1. Bradycardia. Hypothermic neonates become bradycardic proportional to
the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.

38. Answer: 4. Leathery, cracked, and wrinkled skin. Neonatal skin thickens with
maturity and is often peeling by post term.
39. Answer: 4. Obtain an order for IV fluid administration. Assessment findings indicate
that the neonate is in respiratory distressmost likely from transient tachypnea, which is
common after cesarean delivery. A neonate with a rate of 80 breaths a minute shouldnt be
fed but should receive IV fluids until the respiratory rate returns to normal. To allow for close
observation for worsening respiratory distress, the neonate should be kept unclothed in the
radiant warmer.
40. Answer: 3. Poor wake and sleep patterns. Altered sleep patterns are caused by
disturbances in the CNS from alcohol exposure in utero. Hyperactivity is a characteristic
generally noted. Low birth weight is a physical defect seen in neonates with FAS. Neonates
with FAS generally have a low threshold for stimulation.
41. Answer: 2. The client talks to the baby and picks him up when he cries.
42. Answer: 4. Some infants experience menstruation like bleeding when hormones
from the mother are not available.
43. Answer: 4. check the babys serum glucose level and administer glucose if < 40
mg/dL.
44. Answer: 3. inspecting the posture, color, and respiratory effort.
45. Answer:4. give him a bath in an infant tub now.
46. Answer: 1. Ineffective thermoregulation related to fluctuating environmental
temperatures.
47. Answer: 3. The infants digestive tract cannot handle complex carbohydrates like
cereal.

48. Answer: 2. Its acceptable to prop the infants bottle once in a while.
49. Answer: 1. as soon as possible after the infants birth.
50. Answer: 2. apply warm, moist heat to the breasts.
1. The nurse is caring for the mother of a newborn. The nurse recognizes that the
mother needs more teaching regarding cord care because she
a. keeps the cord exposed to the air.
b. washes her hands before sponge bathing her baby.
c. washes the cord and surrounding area well with water at each diaper change.
d. checks it daily for bleeding and drainage.
2. A client telephones the clinic to ask about a home pregnancy test she used this
morning. The nurse understands that the presence of which hormone strongly
suggests a woman is pregnant?
a. Estrogen
b. HCG
c. Alpha-fetoprotein
d. Progesterone
3. The nurse is assessing a six-month-old child. Which developmental skills are
normal and should be expected?
a. Speaks in short sentences.
b. Sits alone.
c. Can feed self with a spoon.
d. Pulling up to a standing position.
4. While teaching a 10 year-old child about their impending heart surgery, the nurse
should

a. Provide a verbal explanation just prior to the surgery

b. Provide the child with a booklet to read about the surgery
c. Introduce the child to another child who had heart surgery three days ago
d. Explain the surgery using a model of the heart
5. When caring for an elderly client it is important to keep in mind the changes in
color vision that may occur. What colors are apt to be most difficult for the elderly to
distinguish?
a. Red and blue.
b. Blue and gold.
c. Red and green.
d. Blue and green.
6. While giving nursing care to a hospitalized adolescent, the nurse should be aware
that the MAJOR threat felt by the hospitalized adolescent is
a. Pain management
b. Restricted physical activity
c. Altered body image
d. Separation from family
7. A woman who is 32 years old and 35 weeks pregnant has had rupture of
membranes for eight hours and is 4 cm dilated. Since she is a candidate for infection,
the nurse should include which of the following in the care plan?
a. Universal precautions.
b. Oxytocin administration.
c. Frequent temperature monitoring.
d. More frequent vaginal examinations.

8. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic.
The mother asks the nurse to explain the purpose of the test. The BEST response is
to tell her that the test
a. Measures potential intelligence
b. Assesses a childs development
c. Evaluates psychological responses
d. Diagnoses specific problems
9. A 27-year-old woman has Type I diabetes mellitus. She and her husband want to
have a child so they consulted her diabetologist, who gave her information on
pregnancy and diabetes. Of primary importance for the diabetic woman who is
considering pregnancy should be
a. a review of the dietary modifications that will be necessary.
b. early prenatal medical care.
c. adoption instead of conception.
d. understanding that this is a major health risk to the mother.
10. The nurse is planning care for an 18 month-old child. Which of the following
should be included the in the childs care?
a. Hold and cuddle the child often
b. Encourage the child to feed himself finger food
c. Allow the child to walk independently on the nursing unit
d. Engage the child in games with other children
11. The nurse in an infertility clinic is discussing the treatment routine. The nurse
advises the couple that the major stressor for couples being treated for infertility is
usually
a. having to tell their families.
b. the cost of the interventions.

c. the inconvenience of multiple tests.

d. the right scheduling of sexual intercourse.
12. The nurse is assessing a four month-old infant. The nurse would anticipate
finding that the infant would be able to
a. Hold a rattle
b. Bang two blocks
c. Drink from a cup
d. Wave bye-bye
13. The nurse is evaluating a new mother feeding her newborn. Which observation
indicates the mother understands proper feeding methods for her newborn?
a. Holding the bottle so the nipple is always filled with formula.
b. Allowing her seven pound baby to sleep after taking 1 ounces from the bottle.
c. Burping the baby every ten minutes during the feeding.
d. Warming the formula bottle in the microwave for 15 seconds and giving it directly to the
baby.
14. The nurse is caring for a pregnant client. The client asks how the doctor could tell
she was pregnant just by looking inside. The nurse tells her the most likely
explanation is that she had a positive Chadwicks sign, which is a
a. Bluish coloration of the cervix and vaginal walls
b. Pronounced softening of the cervix
c. Clot of very thick mucous that obstructs the cervical canal
d. Slight rotation of the uterus to the right
15. When caring for an elderly client it is important to keep in mind the changes in
color vision that may occur. What colors are apt to be most difficult for the elderly to
distinguish?

a. Red and blue.

b. Blue and gold.
c. Red and green.
d. Blue and green.
16. The nurses FIRST step in nutritional counseling/teaching for a pregnant woman
is to
a. Teach her how to meet the needs of self and her family
b. Explain the changes in diet necessary for pregnant women
c. Question her understanding and use of the food pyramid
d. Conduct a diet history to determine her normal eating routines
17. A woman who is six months pregnant is seen in antepartal clinic. She states she
is having trouble with constipation. To minimize this condition, the nurse should
instruct her to
a. increase her fluid intake to three liters/day.
b. request a prescription for a laxative from her physician.
c. stop taking iron supplements.
d. take two tablespoons of mineral oil daily.
18. The nurse is observing children playing in the hospital playroom. She would
expect to see 4 year-old children playing
a. Competitive board games with older children
b. With their own toys along side with other children
c. Alone with hand held computer games
d. Cooperatively with other preschoolers
19. The nurse is caring for residents in a long term care setting for the elderly. Which
of the following activities will be MOST effective in meeting the growth and
development needs for persons in this age group?

a. Aerobic exercise classes

b. Transportation for shopping trips
c. Reminiscence groups
d. Regularly scheduled social activities
20. A pregnant woman is advised to alter her diet during pregnancy by increasing her
protein and Vitamin C to meet the needs of the growing fetus. Which diet BEST meets
the clients needs?
a. Scrambled egg, hash browned potatoes, half-glass of buttermilk, large nectarine
b. 3oz. chicken, C. corn, lettuce salad, small banana
c. 1 C. macaroni, C. peas, glass whole milk, medium pear
d. Beef, C. lima beans, glass of skim milk, C. strawberries

Answers and Rationale

1. Answer C.
Exposure to air helps dry the cord. Good hand washing is the prime mechanism for
preventing infection. Washing the surrounding area is fine but wetting the cord keeps it
moist and predisposes it to infection. It is important to check for complications of bleeding
and drainage that might occur.
2. Answer B.
Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are
based. Reliability is about 98%, but the test does not positively confirm pregnancy.
3. Answer B.
The child develops language skills between the ages of one and three. A six-month-old child
is learning to sit alone. The child begins to use a spoon at 12-15 months of age. The baby
pulls himself to a standing position about ten months of age.

4. Answer D.
According to Piaget, the school age child is in the concrete operations stage of cognitive
development. Using something concrete, like a model will help the child understand the
explanation of the heart surgery.
5. Answer D.
The elderly are better able to distinguish between red and blue because of the difference in
wavelengths. The elderly are better able to distinguish between blue and gold because of
the difference in wavelengths. The elderly are better able to distinguish between red and
green because of the difference in wavelengths. Red and green color blindness is an
inherited disorder that is unrelated to age. The elderly have poor blue-green discrimination.
The effects of age are greatest on short wavelengths. These changes are related to the
yellowing of the lens with age.
6. Answer C.
The hospitalized adolescent may see each of these as a threat, but the major threat that
they feel when hospitalized is the fear of altered body image, because of the emphasis on
physical appearance.
7. Answer C.
Universal precautions are necessary for all clients but a specific assessment of the clients
temperature will give an indication the client is becoming infected. Oxytocin may be needed
to induce labor if it is not progressing, but it is not done initially.Temperature elevation will
indicate beginning infection. This is the most important measure to help assess the client for
infections, since the lost mucous plug and the ruptured membranes increase the potential
for ascending bacteria from the reproductive tract. This will infect the fetus, membranes, and
uterine cavity. More frequent vaginal examinations are not recommended, as frequent
vaginal exams can increase chances of infection.
8. Answer B.
The Denver Developmental Test II is a screening test to assess children from birth through 6

years in personal/social, fine motor adaptive, language and gross motor development. A
child experiences the fun of play during the test.
9. Answer B.
A review of dietary modifications is important once the woman is pregnant. However, it is
not of primary importance when considering pregnancy. Pregnancy makes metabolic control
of diabetes more difficult. It is essential that the client start prenatal care early so that
potential complications can be controlled or minimized by the efforts of the client and health
care team. The alternative of adoption is not necessary just because the client is a diabetic.
Many diabetic women have pregnancies with successful outcomes if they receive good
care. While there is some risk to the pregnant diabetic woman, it is not considered a major
health risk. The greater risk is to the fetus.
10. Answer B.
According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The
nurse should encourage increasingly independent activities of daily living.
11. Answer D.
Having to tell families may also be a factor contributing to stress but is not the major
stressor. Cost may also be a contributing factor to stress but is not usually the major factor.
The inconvenience of multiple tests may also be a factor contributing to stress but is not
usually the major factor. Sexual activity on demand is the major cause of stress for most
infertile couples.
12. Answer A.
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.
13. Answer A.
Holding the bottle so the nipple is always filled with formula prevents the baby from sucking
air. Sucking air can cause gastric distention and intestinal gas pains. A seven-pound baby
should be getting 50 calories per pound: 350 calories per day. Standardized formulas have
20 calories per ounce. This seven-pound baby needs 17.5 ounces per day. 17.5 ounces per

day divided by 6-8 feedings equals 2-3 ounces per feeding. A normal newborn without
feeding problems could be burped halfway through the feeding and again at the end. If
burping needs to be at intervals, it should be done by ounces or half ounces, not minutes.
Microwaving is not recommended as a method of warming due to the uneven heating of the
formula. If used, the formula should be shaken after warming and the temperature then
checked with a drop on the wrist. The recommended method of warming is to place the
bottle in a pan of hot water to warm, and then check the temperature on the wrist before
feeding.
14. Answer A.
Chadwicks sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4
weeks of pregnancy, that is caused by vasocongestion.
15. Answer D.
The elderly are better able to distinguish between red and blue because of the difference in
wavelengths. Red and green color blindness is an inherited disorder that is unrelated to age.
The elderly have poor blue-green discrimination. The effects of age are greatest on short
wavelengths. These changes are related to the yellowing of the lens with age.
16. Answer D.
Assessment is always the first step in planning teaching for any client.
17. Answer A.
In pregnancy, constipation results from decreased gastric motility and increased water
reabsorption in the colon caused by increased levels of progesterone. Increasing fluid intake
to three liters a day will help prevent constipation. The client should increase fluid intake,
increase roughage in the diet, and increase exercise as tolerated. Laxatives are not
recommended because of the possible development of laxative dependence or abdominal
cramping. Iron supplements are necessary during pregnancy, as ordered, and should not be
discontinued. The client should increase fluid intake, increase roughage in the diet, and
increase exercise as tolerated. Laxatives are not recommended because of the possible
development of laxative dependence or abdominal cramping. Mineral oil is especially bad to

use as a laxative because it decreases the absorption of fat-soluble vitamins (A, D, E, K) if

taken near mealtimes.
18. Answer D.
Cooperative play is typical of the preschool period.
19. Answer C.
According to Eriksons theory, older adults need to find and accept the meaningfulness of
their lives, or they may become depressed, angry, and fear death. Reminiscing contributes
to successful adaptation by maintaining self-esteem, reaffirming identity, and working
through loss.
20. Answer D.
Beef and beans are an excellent source of protein as is skim milk. Strawberries are a good
source of Vitamin C.

291

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202

1. Accompanied by her husband, a patient seeks admission to the labor and

delivery area. The client states that she is in labor and says she attended the
hospital clinic for prenatal care. Which question should the nurse ask her
first?

a. Do you have any chronic illness?

b. Do you have any allergies?

c. What is your expected due date?

d. Who will be with you during labor?

2. A patient is in the second stage of labor. During this stage, how frequently
should the nurse in charge assess her uterine contractions?

a. Every 5 minutes
b. Every 15 minutes
c. Every 30 minutes
d. Every 60 minutes

3. A patient is in her last trimester of pregnancy. Nurse Vickie should instruct

her to notify her primary health care provider immediately if she notices:

a. Blurred vision
b. Hemorrhoids
c. Increased vaginal mucus
d. Shortness of breath on exertion

4. The nurse in-charge is reviewing a patients prenatal history. Which finding

indicates a genetic risk factor?

a. The patient is 25 years old

b. The patient has a child with cystic fibrosis
c. The patient was exposed to rubella at 36 weeks gestation
d. The patient has a history of preterm labor at 32 weeks gestation

5. A adult female patient is using the rhythm (calendar-basal body

temperature) method of family planning. In this method, the unsafe period for
sexual intercourse is indicated by:

a. Return preovulatory basal body temperature

b. Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd

day of cycle
c. 3 full days of elevated basal body temperature and clear, thin cervical mucus
d. Breast tenderness and mittelschmerz

6. During a nonstress test (NST), the electronic tracing displays a relatively flat
line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR).
To mark the strip, the nurse in charge should instruct the client to push the
control button at which time?

a. At the beginning of each fetal movement

b. At the beginning of each contraction
c. After every three fetal movements
d. At the end of fetal movement

7. When evaluating a clients knowledge of symptoms to report during her

pregnancy, which statement would indicate to the nurse in charge that the
client understands the information given to her?

a. Ill report increased frequency of urination.

b. If I have blurred or double vision, I should call the clinic immediately.
c. If I feel tired after resting, I should report it immediately.
d. Nausea should be reported immediately.

8. When assessing a client during her first prenatal visit, the nurse discovers
that the client had a reduction mammoplasty. The mother indicates she wants
to breast-feed. What information should the nurse give to this mother
regarding breastfeeding success?

a. Its contraindicated for you to breastfeed following this type of surgery.

b. I support your commitment; however, you may have to supplement each feeding
with formula.
c. You should check with your surgeon to determine whether breast-feeding would

be possible.
d. You should be able to breastfeed without difficulty.

9. Following a precipitous delivery, examination of the clients vagina reveals a

fourth-degree laceration. Which of the following would be contraindicated
when caring for this client?

a. Applying cold to limit edema during the first 12 to 24 hours

b. Instructing the client to use two or more peri pads to cushion the area
c. Instructing the client on the use of sitz baths if ordered
d. Instructing the client about the importance of perineal (Kegel) exercises

10. A client makes a routine visit to the prenatal clinic. Although she is 14
weeks pregnant, the size of her uterus approximates that in an 18- to 20-week
pregnancy. Dr. Charles diagnoses gestational trophoblastic disease and
orders ultrasonography. The nurse expects ultrasonography to reveal:

a. an empty gestational sac.

b. grapelike clusters.
c. a severely malformed fetus.
d. an extrauterine pregnancy.

11. After completing a second vaginal examination of a client in labor, the

nurse-midwife determines that the fetus is in the right occiput anterior position
and at (1) station. Based on these findings, the nurse-midwife knows that the
fetal presenting part is:

a. 1 cm below the ischial spines.

b. directly in line with the ischial spines.
c. 1 cm above the ischial spines.
d. in no relationship to the ischial spines.

12. Which of the following would be inappropriate to assess in a mother whos

breastfeeding?

a. The attachment of the baby to the breast.

b. The mothers comfort level with positioning the baby.
c. Audible swallowing.
d. The babys lips smacking

13. During a prenatal visit at 4 months gestation, a pregnant client asks

whether tests can be done to identify fetal abnormalities. Between 18 and 40
weeks gestation, which procedure is used to detect fetal anomalies?

a. Amniocentesis.
b. Chorionic villi sampling.
c. Fetoscopy.
d. Ultrasound

14. A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to

evaluate the health of her fetus. Her BPP score is 8. What does this score
indicate?

a. The fetus should be delivered within 24 hours.

b. The client should repeat the test in 24 hours.
c. The fetus isnt in distress at this time.
d. The client should repeat the test in 1 week.

15. A client who is 36 weeks pregnant comes to the clinic for a prenatal
checkup. To assess the clients preparation for parenting, the nurse might ask
which question?

a. Are you planning to have epidural anesthesia?

b. Have you begun prenatal classes?

c. What changes have you made at home to get ready for the baby?
d. Can you tell me about the meals you typically eat each day?

16. A client whos admitted to labor and delivery has the following assessment
findings: gravida 2 para 1, estimated 40 weeks gestation, contractions 2
minutes apart, lasting 45 seconds, vertex +4 station. Which of the following
would be the priority at this time?

a. Placing the client in bed to begin fetal monitoring.

b. Preparing for immediate delivery.
c. Checking for ruptured membranes.
d. Providing comfort measures.

17. The nurse is caring for a client in labor. The external fetal monitor shows a
pattern of variable decelerations in fetal heart rate. What should the nurse do
first?

a. Change the clients position.

b. Prepare for emergency cesarean section.
c. Check for placenta previa.
d. Administer oxygen.

18. The nurse in charge is caring for a postpartum client who had a vaginal
delivery with a midline episiotomy. Which nursing diagnosis takes priority for
this client?

a. Risk for deficient fluid volume related to hemorrhage

b. Risk for infection related to the type of delivery
c. Pain related to the type of incision
d. Urinary retention related to periurethral edema

19. Which change would the nurse identify as a progressive physiological

change in postpartum period?

a. Lactation
b. Lochia
c. Uterine involution
d. Diuresis

20. A 39-year-old at 37 weeks gestation is admitted to the hospital with

complaints of vaginal bleeding following the use of cocaine 1 hour earlier.
Which complication is most likely causing the clients complaint of vaginal
bleeding?

a. Placenta previa
b. Abruptio placentae
c. Ectopic pregnancy
d. Spontaneous abortion

21. A client with type 1 diabetes mellitus who is a multigravida visits the clinic
at 27 weeks gestation. The nurse should instruct the client that for most
pregnant women with type 1 diabetes mellitus:

a. Weekly fetal movement counts are made by the mother.

b. Contraction stress testing is performed weekly.
c. Induction of labor is begun at 34 weeks gestation.
d. Nonstress testing is performed weekly until 32 weeks gestation

22. When administering magnesium sulfate to a client with preeclampsia, the

nurse understands that this drug is given to:

a. Prevent seizures
b. Reduce blood pressure
c. Slow the process of labor
d. Increase dieresis

23. What is the approximate time that the blastocyst spends traveling to the
uterus for implantation?

a. 2 days
b. 7 days
c. 10 days
d. 14 weeks

24. After teaching a pregnant woman who is in labor about the purpose of the
episiotomy, which of the following purposes stated by the client would indicate
to the nurse that the teaching was effective?

a. Shortens the second stage of labor

b. Enlarges the pelvic inlet
c. Prevents perineal edema
d. Ensures quick placenta delivery

25. A primigravida client at about 35 weeks gestation in active labor has had
no prenatal care and admits to cocaine use during the pregnancy. Which of the
following persons must the nurse notify?

a. Nursing unit manager so appropriate agencies can be notified

b. Head of the hospitals security department
c. Chaplain in case the fetus dies in utero
d. Physician who will attend the delivery of the infant

26. When preparing a teaching plan for a client who is to receive a rubella
vaccine during the postpartum period, the nurse in charge should include
which of the following?

a. The vaccine prevents a future fetus from developing congenital anomalies

b. Pregnancy should be avoided for 3 months after the immunization

c. The client should avoid contact with children diagnosed with rubella
d. The injection will provide immunity against the 7-day measles.

27. A client with eclampsia begins to experience a seizure. Which of the

following would the nurse in charge do first?

a. Pad the side rails

b. Place a pillow under the left buttock
c. Insert a padded tongue blade into the mouth
d. Maintain a patent airway

28. While caring for a multigravida client in early labor in a birthing center,
which of the following foods would be best if the client requests a snack?

a. Yogurt
b. Cereal with milk
c. Vegetable soup
d. Peanut butter cookies

29. The multigravida mother with a history of rapid labor who us in active labor
calls out to the nurse, The baby is coming! which of the following would be
the nurses first action?

a. Inspect the perineum

b. Time the contractions
c. Auscultate the fetal heart rate
d. Contact the birth attendant

30. While assessing a primipara during the immediate postpartum period, the
nurse in charge plans to use both hands to assess the clients fundus to:

a. Prevent uterine inversion

b. Promote uterine involution

c. Hasten the puerperium period

d. Determine the size of the fundus

Answers and Rationale

1. Answer C.
When obtaining the history of a patient who may be in labor, the nurses highest
priority is to determine her current status, particularly her due date, gravidity, and
parity. Gravidity and parity affect the duration of labor and the potential for labor
complications. Later, the nurse should ask about chronic illness, allergies, and
support persons.

2. Answer B.
During the second stage of labor, the nurse should assess the strength, frequency,
and duration of contraction every 15 minutes. If maternal or fetal problems are
detected, more frequent monitoring is necessary. An interval of 30 to 60 minutes
between assessments is too long because of variations in the length and duration of
patients labor.

3. Answer A.
Blurred vision or other visual disturbance, excessive weight gain, edema, and
increased blood pressure may signal severe preeclampsia. This condition may lead
to eclampsia, which has potentially serious consequences for both the patient and
fetus. Although hemorrhoids may be a problem during pregnancy, they do not require
immediate attention. Increased vaginal mucus and dyspnea on exertion are expected
as pregnancy progresses.

4. Answer B.
Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having
the trait or the disorder. Maternal age is not a risk factor until age 35, when the
incidence of chromosomal defects increases. Maternal exposure to rubella during the

first trimester may cause congenital defects. Although a history or preterm labor may
place the patient at risk for preterm labor, it does not correlate with genetic defects.

5. Answer C.
Ovulation (the period when pregnancy can occur) is accompanied by a basal body
temperature increase of 0.7 degrees F to 0.8 degrees F and clear, thin cervical
mucus. A return to the preovulatory body temperature indicates a safe period for
sexual intercourse. A slight rise in basal temperature early in the cycle is not
significant. Breast tenderness and mittelschmerz are not reliable indicators of
ovulation.

6. Answer A.
An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR
accelerates with each movement. By pushing the control button when a fetal
movement starts, the client marks the strip to allow easy correlation of fetal
movement with the FHR. The FHR is assessed during uterine contractions in the
oxytocin contraction test, not the NST. Pushing the control button after every three
fetal movements or at the end of fetal movement wouldnt allow accurate comparison
of fetal movement and FHR changes.

7. Answer B.
Blurred or double vision may indicate hypertension or preeclampsia and should be
reported immediately. Urinary frequency is a common problem during pregnancy
caused by increased weight pressure on the bladder from the uterus. Clients
generally experience fatigue and nausea during pregnancy.

8. Answer B.
Recent breast reduction surgeries are done in a way to protect the milk sacs and
ducts, so breast-feeding after surgery is possible. Still, its good to check with the
surgeon to determine what breast reduction procedure was done. There is the
possibility that reduction surgery may have decreased the mothers ability to meet all
of her babys nutritional needs, and some supplemental feeding may be required.

Preparing the mother for this possibility is extremely important because the clients
psychological adaptation to mothering may be dependent on how successfully she
breast-feeds.

9. Answer B.
Using two or more peripads would do little to reduce the pain or promote perineal
healing. Cold applications, sitz baths, and Kegel exercises are important measures
when the client has a fourth-degree laceration.

10. Answer B.
In a client with gestational trophoblastic disease, an ultrasound performed after the
3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The
vesicles contain a clear fluid and may involve all or part of the decidual lining of the
uterus. Usually no embryo (and therefore no fetus) is present because it has been
absorbed. Because there is no fetus, there can be no extrauterine pregnancy. An
extrauterine pregnancy is seen with an ectopic pregnancy.

11. Answer C.
Fetal station the relationship of the fetal presenting part to the maternal ischial
spines is described in the number of centimeters above or below the spines. A
presenting part above the ischial spines is designated as 1, 2, or 3. A presenting
part below the ischial spines, as +1, +2, or +3.

12. Answer D.
Assessing the attachment process for breast-feeding should include all of the
answers except the smacking of lips. A baby whos smacking his lips isnt well
attached and can injure the mothers nipples.

13. Answer D.
Ultrasound is used between 18 and 40 weeks gestation to identify normal fetal
growth and detect fetal anomalies and other problems. Amniocentesis is done during
the third trimester to determine fetal lung maturity. Chorionic villi sampling is

performed at 8 to 12 weeks gestation to detect genetic disease. Fetoscopy is done

at approximately 18 weeks gestation to observe the fetus directly and obtain a skin
or blood sample.

14. Answer C.
The BPP evaluates fetal health by assessing five variables: fetal breathing
movements, gross body movements, fetal tone, reactive fetal heart rate, and
qualitative amniotic fluid volume. A normal response for each variable receives 2
points; an abnormal response receives 0 points. A score between 8 and 10 is
considered normal, indicating that the fetus has a low risk of oxygen deprivation and
isnt in distress. A fetus with a score of 6 or lower is at risk for asphyxia and
premature birth; this score warrants detailed investigation. The BPP may or may not
be repeated if the score isnt within normal limits.

15. Answer C.
During the third trimester, the pregnant client typically perceives the fetus as a
separate being. To verify that this has occurred, the nurse should ask whether she
has made appropriate changes at home such as obtaining infant supplies and
equipment. The type of anesthesia planned doesnt reflect the clients preparation for
parenting. The client should have begun prenatal classes earlier in the pregnancy.
The nurse should have obtained dietary information during the first trimester to give
the client time to make any necessary changes.

16. Answer B.
This question requires an understanding of station as part of the intrapartum
assessment process. Based on the clients assessment findings, this client is ready
for delivery, which is the nurses top priority. Placing the client in bed, checking for
ruptured membranes, and providing comfort measures could be done, but the priority
here is immediate delivery.

17. Answer A.
Variable decelerations in fetal heart rate are an ominous sign, indicating

compression of the umbilical cord. Changing the clients position from supine to sidelying may immediately correct the problem. An emergency cesarean section is
necessary only if other measures, such as changing position and amnioinfusion with
sterile saline, prove unsuccessful. Administering oxygen may be helpful, but the
priority is to change the womans position and relieve cord compression.

18. Answer A.
Hemorrhage jeopardizes the clients oxygen supply the first priority among human
physiologic needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume
related to hemorrhage takes priority over diagnoses of Risk for infection, Pain, and
Urinary retention.

19. Answer A.
Lactation is an example of a progressive physiological change that occurs during the
postpartum period.

20. Answer B.
The major maternal adverse reactions from cocaine use in pregnancy include
spontaneous abortion first, not third, trimester abortion and abruptio placentae.

21. Answer D.
For most clients with type 1 diabetes mellitus, nonstress testing is done weekly until
32 weeks gestation and twice a week to assess fetal well-being.

22. Answer A.
The chemical makeup of magnesium is similar to that of calcium and, therefore,
magnesium will act like calcium in the body. As a result, magnesium will block
seizure activity in a hyper stimulated neurologic system by interfering with signal
transmission at the neuromascular junction.

23. Answer B.
The blastocyst takes approximately 1 week to travel to the uterus for implantation.

24. Answer A.
An episiotomy serves several purposes. It shortens the second stage of labor,
substitutes a clean surgical incision for a tear, and decreases undue stretching of
perineal muscles. An episiotomy helps prevent tearing of the rectum but it does not
necessarily relieves pressure on the rectum. Tearing may still occur.

25. Answer D.
The fetus of a cocaine-addicted mother is at risk for hypoxia, meconium aspiration,
and intrauterine growth retardation (IUGR). Therefore, the nurse must notify the
physician of the clients cocaine use because this knowledge will influence the care
of the client and neonate. The information is used only in relation to the clients care.

26. Answer B.
After administration of rubella vaccine, the client should be instructed to avoid
pregnancy for at least 3 months to prevent the possibility of the vaccines toxic effects
to the fetus.

27. Answer D.
The priority for the pregnant client having a seizure is to maintain a patent airway to
ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may
be administered by face mask to prevent fetal hypoxia.

28. Answer A.
In some birth settings, intravenous therapy is not used with low-risk clients. Thus,
clients in early labor are encouraged to eat healthy snacks and drink fluid to avoid
dehydration. Yogurt, which is an excellent source of calcium and riboflavin, is soft
and easily digested. During pregnancy, gastric emptying time is delayed. In most
hospital settings, clients are allowed only ice chips or clear liquids.

29. Answer A.
When the client says the baby is coming, the nurse should first inspect the perineum
and observe for crowning to validate the clients statement. If the client is not

delivering precipitously, the nurse can calm her and use appropriate breathing
techniques.

30. Answer A.
Using both hands to assess the fundus is useful for preventing uterine inversion.