1.

You performed the Leopolds maneuver and found the following: breech presentation,
fetal back at the right side of the mother. Based on these findings, you can hear the fetal
heart beat (PMI) BEST in which location?
A. Left lower quadrant
B. Right lower quadrant
C. Left upper quadrant
D. Right upper quadrant
2. In Leopolds maneuver step #1, you palpated a soft broad mass that moves with the rest
of the mass. The correct interpretation of this finding is:
A. The mass palpated at the fundal part is the head part.
B. The presentation is breech.
C. The mass palpated is the back
D. The mass palpated is the buttocks.
3. In Leopolds maneuver step # 3 you palpated a hard round movable mass at the supra
pubic area. The correct interpretation is that the mass palpated is:
A. The buttocks because the presentation is breech.
B. The mass palpated is the head.
C. The mass is the fetal back.
D. The mass palpated is the fetal small part
4. The hormone responsible for a positive pregnancy test is:
A. Estrogen
B. Progesterone
C. Human Chorionic Gonadotropin
D. Follicle Stimulating hormone
5. The hormone responsible for the maturation of the graafian follicle is:
A. Follicle stimulating hormone
B. Progesterone
C. Estrogen
D. Luteinizing hormone
6. The most common normal position of the fetus in utero is:
A. Transverse position
B. Vertical position
C. Oblique position
D. None of the above

7. In the later part of the 3rd trimester, the mother may experience shortness of breath.
This complaint maybe explained as:
A. A normal occurrence in pregnancy because the fetus is using more oxygen
B. The fundus of the uterus is high pushing the diaphragm upwards
C. The woman is having allergic reaction to the pregnancy and its hormones
D. The woman maybe experiencing complication of pregnancy
8. Which of the following findings in a woman would be consistent with a pregnancy of two
months duration?
A. Weight gain of 6-10 lbs. and presence of striae gravidarum
B. Fullness of the breast and urinary frequency
C. Braxton Hicks contractions and quickening
D. Increased respiratory rate and ballottement
9. Which of the following is a positive sign of pregnancy?
A. Fetal movement felt by mother
B. Enlargement of the uterus
C. (+) pregnancy test
D. (+) ultrasound
10. What event occurring in the second trimester helps the expectant mother to accept the
pregnancy?
A. Lightening
B. Ballotment
C. Pseudocyesis
D. Quickening
11. Shoes with low, broad heels, plus a good posture will prevent which prenatal
discomfort?
A. Backache
B. Vertigo
C. Leg cramps
D. Nausea
12. When a pregnant woman experiences leg cramps, the correct nursing intervention to
relieve the muscle cramps is:
A. Allow the woman to exercise
B. Let the woman walk for a while
C. Let the woman lie down and dorsiflex the foot towards the knees
D. Ask the woman to raise her legs

13. From the 33rd week of gestation till full term, a healthy mother should have prenatal
check up every:
A. week
B. 2 weeks
C. 3 weeks
D. 4 weeks
14. The expected weight gain in a normal pregnancy during the 3rd trimester is
A. 1 pound a week
B. 2 pounds a week
C. 10 lbs a month
D. 10 lbs total weight gain in the 3rd trimester
15. In the Bartholomews rule of 4, when the level of the fundus is midway between the
umbilicus and xyphoid process the estimated age of gestation (AOG) is:
A. 5th month
B. 6th month
C. 7th month
D. 8th month
16. The following are ways of determining expected date of delivery (EDD) when the LMP
is unknown EXCEPT:
A. Naegeles rule
B. Quickening
C. McDonalds rule
D. Batholomews rule of 4
17. If the LMP is Jan. 30, the expected date of delivery (EDD) is
A. Oct. 7
B. Oct. 24
C. Nov. 7
D. Nov. 8
18. Kegels exercise is done in pregnancy in order to:
A. Strengthen perineal muscles
B. Relieve backache
C. Strengthen abdominal muscles
D. Prevent leg varicosities and edema
19. Pelvic rocking is an appropriate exercise in pregnancy to relieve which discomfort?

A. Leg cramps
B. Urinary frequency
C. Orthostatic hypotension
D. Backache
20. The main reason for an expected increased need for iron in pregnancy is:
A. The mother may have physiologic anemia due to the increased need for red blood cell mass as
well as the fetal requires about 350-400 mg of iron to grow
B. The mother may suffer anemia because of poor appetite
C. The fetus has an increased need for RBC which the mother must supply
D. The mother may have a problem of digestion because of pica
21. The diet that is appropriate in normal pregnancy should be high in
A. Protein, minerals and vitamins
B. Carbohydrates and vitamins
C. Proteins, carbohydrates and fats
D. Fats and minerals
22. Which of the following signs will require a mother to seek immediate medical attention?
A. When the first fetal movement is felt
B. No fetal movement is felt on the 6th month
C. Mild uterine contraction
D. Slight dyspnea on the last month of gestation
23. You want to perform a pelvic examination on one of your pregnant clients. You prepare
your client for the procedure by:
A. Asking her to void
B. Taking her vital signs and recording the readings
C. Giving the client a perineal care
D. Doing a vaginal prep
24. When preparing the mother who is on her 4th month of pregnancy for abdominal
ultrasound, the nurse should instruct her to:
A. Observe NPO from midnight to avoid vomiting
B. Do perineal flushing properly before the procedure
C. Drink at least 2 liters of fluid 2 hours before the procedure and not void until the procedure is
done
D. Void immediately before the procedure for better visualization
25. The nursing intervention to relieve morning sickness in a pregnant woman is by
giving

A. Dry carbohydrate food like crackers

B. Low sodium diet
C. Intravenous infusion
D. Antacid
26. The common normal site of nidation/implantation in the uterus is
A. Upper uterine portion
B. Mid-uterine area
C. Lower uterine segment
D. Lower cervical segment
27. Mrs. Santos is on her 5th pregnancy and has a history of abortion in the 4th pregnancy
and the first pregnancy was a twin. She is considered to be
A. G 4 P 3
B. G 5 P 3
C. G 5 P 4
D. G 4 P 4
28. The following are skin changes in pregnancy EXCEPT:
A. Chloasma
B. Striae gravidarum
C. Linea negra
D. Chadwicks sign
29. Which of the following statements is TRUE of conception?
A. Within 2-4 hours after intercourse conception is possible in a fertile woman
B. Generally, fertilization is possible 4 days after ovulation
C. Conception is possible during menstruation in a long menstrual cycle
D. To avoid conception, intercourse must be avoided 5 days before and 3 days after menstruation
30. Which of the following are the functions of amniotic fluid?
1. Cushions the fetus from abdominal trauma
2. Serves as the fluid for the fetus
3. Maintains the internal temperature
4. Facilitates fetal movement
A. 1 & 3
B. 1, 3, 4
C. 1, 2, 3
D. All of the above

31. You are performing abdominal exam on a 9th month pregnant woman. While lying
supine, she felt breathless, had pallor, tachycardia, and cold clammy skin. The correct
assessment of the womans condition is that she is:
A. Experiencing the beginning of labor
B. Having supine hypotension
C. Having sudden elevation of BP
D. Going into shock
32. Smoking is contraindicated in pregnancy because
A. Nicotine causes vasodilation of the mothers blood vessels
B. Carbon monoxide binds with the hemoglobin of the mother reducing available hemoglobin for
the fetus
C. The smoke will make the fetus and the mother feel dizzy
D. Nicotine will cause vasoconstriction of the fetal blood vessels
33. Which of the following is the most likely effect on the fetus if the woman is severely
anemic during pregnancy?
A. Large for gestational age (LGA) fetus
B. Hemorrhage
C. Small for gestational age (SGA) baby
D. Erythroblastosis fetalis
34. Which of the following signs and symptoms will most likely make the nurse suspect that
the patient is having hydatidiform mole?
A. Slight bleeding
B. Passage of clear vesicular mass per vagina
C. Absence of fetal heart beat
D. Enlargement of the uterus
35. Upon assessment the nurse found the following: fundus at 2 fingerbreadths above the
umbilicus, last menstrual period (LMP) 5 months ago, fetal heart beat (FHB) not
appreciated. Which of the following is the most possible diagnosis of this condition?
A. Hydatidiform mole
B. Missed abortion
C. Pelvic inflammatory disease
D. Ectopic pregnancy
36. When a pregnant woman goes into a convulsive seizure, the MOST immediate action of
the nurse to ensure safety of the patient is:

A. Apply restraint so that the patient will not fall out of bed
B. Put a mouth gag so that the patient will not bite her tongue and the tongue will not fall back
C. Position the mother on her side to allow the secretions to drain from her mouth and prevent
aspiration
D. Check if the woman is also having a precipitate labor
37. A gravidocardiac mother is advised to observe bed rest primarily to
A. Allow the fetus to achieve normal intrauterine growth
B. Minimize oxygen consumption which can aggravate the condition of the compromised heart
of the mother
C. Prevent perinatal infection
D. Reduce incidence of premature labor
38. A pregnant mother is admitted to the hospital with the chief complaint of profuse
vaginal bleeding, AOG 36 wks, not in labor. The nurse must always consider which of the
following precautions:
A. The internal exam is done only at the delivery under strict asepsis with a double set-up
B. The preferred manner of delivering the baby is vaginal
C. An emergency delivery set for vaginal delivery must be made ready before examining the
patient
D. Internal exam must be done following routine procedure
39. Which of the following signs will distinguish threatened abortion from imminent
abortion?
A. Severity of bleeding
B. Dilation of the cervix
C. Nature and location of pain
D. Presence of uterine contraction
40. The nursing measure to relieve fetal distress due to maternal supine hypotension is:
A. Place the mother on semi-fowlers position
B. Put the mother on left side lying position
C. Place mother on a knee chest position
D. Any of the above
41. To prevent preterm labor from progressing, drugs are usually prescribed to halt the
labor. The drugs commonly given are:
A. Magnesium sulfate and terbutaline
B. Prostaglandin and oxytocin
C. Progesterone and estrogen
D. Dexamethasone and prostaglandin

42. In placenta praevia marginalis, the placenta is found at the:

A. Internal cervical os partly covering the opening
B. External cervical os slightly covering the opening
C. Lower segment of the uterus with the edges near the internal cervical os
D. Lower portion of the uterus completely covering the cervix
43. In which of the following conditions can the causative agent pass through the placenta
and affect the fetus in utero?
A. Gonorrhea
B. Rubella
C. Candidiasis
D. moniliasis
44. Which of the following can lead to infertility in adult males?
A. German measles
B. Orchitis
C. Chicken pox
D. Rubella
45. Papanicolaou smear is usually done to determine cancer of
A. Cervix
B. Ovaries
C. Fallopian tubes
D. Breast
46. Which of the following causes of infertility in the female is primarily psychological in
origin?
A. Vaginismus
B. Dyspareunia
C. Endometriosis
D. Impotence
47. Before giving a repeat dose of magnesium sulfate to a pre-eclamptic patient, the nurse
should assess the patients condition. Which of the following conditions will require the
nurse to temporarily suspend a repeat dose of magnesium sulfate?
A. 100 cC. urine output in 4 hours
B. Knee jerk reflex is (+)2
C. Serum magnesium level is 10mEg/L.
D. Respiratory rate of 16/min

48. Which of the following is TRUE in Rh incompatibility?

A. The condition can occur if the mother is Rh(+) and the fetus is Rh(-)
B. Every pregnancy of an Rh(-) mother will result to erythroblastosis fetalis
C. On the first pregnancy of the Rh(-) mother, the fetus will not be affected
D. RhoGam is given only during the first pregnancy to prevent incompatibility
49. Which of the following are the most commonly assessed findings in cystitis?
A. Frequency, urgency, dehydration, nausea, chills, and flank pain
B. Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain
C. Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever
D. High fever, chills, flank pain nausea, vomiting, dysuria, and frequency
50. Which of the following best reflects the frequency of reported postpartum blues?
A. Between 10% and 40% of all new mothers report some form of postpartum blues
B. Between 30% and 50% of all new mothers report some form of postpartum blues
C. Between 50% and 80% of all new mothers report some form of postpartum blues
D. Between 25% and 70% of all new mothers report some form of postpartum blues

Answers and Rationale

Here are the answers and rationale for this exam. Counter check your answers to those below and
tell us your scores. If you have any disputes or need more clarification to a certain question,
please direct them to the comments section.
1. Answer: (B) Right lower quadrant
Right lower quadrant. The landmark to look for when looking for PMI is the location of the fetal
back in relation to the right or left side of the mother and the presentation, whether cephalic or
breech. The best site is the fetal back nearest the head.
2. Answer: (D) The mass palpated is the buttocks.
The palpated mass is the fetal buttocks since it is broad and soft and moves with the rest of the
mass.
3. Answer: (B) The mass palpated is the head.
When the mass palpated is hard round and movable, it is the fetal head.
4. Answer: (C) Human Chorionic Gonadotropin
Human chorionic gonadotropin (HCG) is the hormone secreted by the chorionic villi which is the
precursor of the placenta. In the early stage of pregnancy, while the placenta is not yet fully
developed, the major hormone that sustains the pregnancy is HCG.
5. Answer: (A) Follicle stimulating hormone
The hormone that stimulates the maturation if the of the graafian follicle is the Follicle
Stimulating Hormone which is released by the anterior pituitary gland.
6. Answer: (B) Vertical position
Vertical position means the fetal spine is parallel to the maternal spine thus making it easy for the
fetus to go out the birth canal. If transverse or oblique, the fetus cant be delivered normally per
vagina.
7. Answer: (B) The fundus of the uterus is high pushing the diaphragm upwards
From the 32nd week of the pregnancy, the fundus of the enlarged uterus is pushing the
respiratory diaphragm upwards. Thus, the lungs have reduced space for expansion consequently
reducing the oxygen supply.
8. Answer: (B) Fullness of the breast and urinary frequency
Fullness of the breast is due to the increased amount of progesterone in pregnancy. The urinary
frequency is caused by the compression of the urinary bladder by the gravid uterus which is still
within the pelvic cavity during the first trimester.
9. Answer: (D) (+) ultrasound
A positive ultrasound will definitely confirm that a woman is pregnant since the fetus in utero is
directly visualized.

10. Answer: (D) Quickening

Quickening is the first fetal movement felt by the mother makes the woman realize that she is
truly pregnant. In early pregnancy, the fetus is moving but too weak to be felt by the mother. In
the 18th-20th week of gestation, the fetal movements become stronger thus the mother already
feels the movements.
11. Answer: (A) Backache
Backache usually occurs in the lumbar area and becomes more problematic as the uterus
enlarges. The pregnant woman in her third trimester usually assumes a lordotic posture to
maintain balance causing an exaggeration of the lumbar curvature. Low broad heels provide the
pregnant woman with a good support.
12. Answer: (C) Let the woman lie down and dorsiflex the foot towards the knees
Leg cramps is caused by the contraction of the gastrocnimeus (leg muscle). Thus, the
intervention is to stretch the muscle by dosiflexing the foot of the affected leg towards the knee.
13. Answer: (A) week
In the 9th month of pregnancy the mother needs to have a weekly visit to the prenatal clinic to
monitor fetal condition and to ensure that she is adequately prepared for the impending labor and
delivery.
14. Answer: (A) 1 pound a week
During the 3rd trimester the fetus is gaining more subcutaneous fat and is growing fast in
preparation for extra uterine life. Thus, one pound a week is expected.
15. Answer: (C) 7th month
In Bartholomews Rule of 4, the landmarks used are the symphysis pubis, umbilicus and xyphoid
process. At the level of the umbilicus, the AOG is approximately 5 months and at the level of the
xyphoid process 9 months. Thus, midway between these two landmarks would be considered as
7 months AOG.
16. Answer: (A) Naegeles rule
Naegeles Rule is determined based on the last menstrual period of the woman.
17. Answer: (C) Nov. 7
Based on the last menstrual period, the expected date of delivery is Nov. 7. The formula for the
Naegeles Rule is subtract 3 from the month and add 7 to the day.
18. Answer: (A) Strengthen perineal muscles
Kegels exercise is done by contracting and relaxing the muscles surrounding the vagina and
anus in order to strengthen the perineal muscles
19.Answer: (D) Backache
Backache is caused by the stretching of the muscles of the lower back because of the pregnancy.
Pelvic rocking is good to relieve backache.

20. Answer: (A) The mother may have physiologic anemia due to the increased need for red
blood cell mass as well as the fetal requires about 350-400 mg of iron to grow
About 400 mgs of Iron is needed by the mother in order to produce more RBC mass to be able to
provide the needed increase in blood supply for the fetus. Also, about 350-400 mgs of iron is
need for the normal growth of the fetus. Thus, about 750-800 mgs iron supplementation is
needed by the mother to meet this additional requirement.
21. Answer: (A) Protein, minerals and vitamins
In normal pregnancy there is a higher demand for protein (body building foods), vitamins (esp.
vitamin A, B, C, folic acid) and minerals (esp. iron, calcium, phosphorous, zinc, iodine,
magnesium) because of the need of the growing fetus.
22. Answer: (B) No fetal movement is felt on the 6th month
Fetal movement is usually felt by the mother during 4.5 5 months. If the pregnancy is already
in its 6th month and no fetal movement is felt, the pregnancy is not normal either the fetus is
already dead intra-uterine or it is an H-mole.
23. Answer: (A) Asking her to void
A pelvic examination includes abdominal palpation. If the pregnant woman has a full bladder,
the manipulation may cause discomfort and accidental urination because of the pressure applied
during the abdominal palpation. Also, a full bladder can impede the accuracy of the examination
because the bladder (which is located in front of the uterus) can block the uterus.
24. Answer: (C) Drink at least 2 liters of fluid 2 hours before the procedure and not void
until the procedure is done
Drinking at least 2 liters of water 2 hours before the procedure will result to a distended bladder.
A full bladder is needed when doing an abdominal ultrasound to serve as a window for the
ultrasonic sound waves to pass through and allow visualization of the uterus (located behind the
urinary bladder).
25. Answer: (A) Dry carbohydrate food like crackers
Morning sickness maybe caused by hypoglycemia early in the morning thus giving carbohydrate
food will help.
26. Answer: (A) Upper uterine portion
The embryos normal nidation site is the upper portion of the uterus. If the implantation is in the
lower segment, this is an abnormal condition called placenta previa.
27. Answer: (B) G 5 P 3
Gravida refers to the total number of pregnancies including the current one. Para refers to the
number of pregnancies that have reached viability. Thus, if the woman has had one abortion, she
would be considered Para 3. Twin pregnancy is counted only as 1.
28. Answer: (D) Chadwicks sign
Chadwicks sign is bluish discoloration of the vaginal mucosa as a result of the increased
vascularization in the area.

29.Answer: (A) Within 2-4 hours after intercourse conception is possible in a fertile woman
The sperms when deposited near the cervical os will be able to reach the fallopian tubes within 4
hours. If the woman has just ovulated (within 24hours after the rupture of the graafian follicle),
fertilization is possible.
30. Answer: (D) All of the above
All the four functions enumerated are true of amniotic fluid.
31. Answer: (B) Having supine hypotension
Supine hypotension is characterized by breathlessness, pallor, tachycardia and cold clammy skin.
This is due to the compression of the abdominal aorta by the gravid uterus when the woman is on
a supine position.
32. Answer: (B) Carbon monoxide binds with the hemoglobin of the mother reducing
available hemoglobin for the fetus
Carbon monoxide is one of the substances found in cigarette smoke. This substance diminishes
the ability of the hemoglobin to bind with oxygen thus reducing the amount of oxygenated blood
reaching the fetus.
33. Answer: (C) Small for gestational age (SGA) baby
Anemia is a condition where there is a reduced amount of hemoglobin. Hemoglobin is needed to
supply the fetus with adequate oxygen. Oxygen is needed for normal growth and development of
the fetus.
34. Answer: (B) Passage of clear vesicular mass per vagina
Hydatidiform mole (H-mole) is characterized by the degeneration of the chorionic villi wherein
the villi becomes vesicle-like. These vesicle-like substances when expelled per vagina and is a
definite sign that the woman has H-mole.
35. Answer: (A) Hydatidiform mole
Hydatidiform mole begins as a pregnancy but early in the development of the embryo
degeneration occurs. The proliferation of the vesicle-like substances is rapid causing the uterus to
enlarge bigger than the expected size based on ages of gestation (AOG). In the situation given,
the pregnancy is only 5 months but the size of the uterus is already above the umbilicus which is
compatible with 7 months AOG. Also, no fetal heart beat is appreciated because the pregnancy
degenerated thus there is no appreciable fetal heart beat.
36. Answer: (C) Position the mother on her side to allow the secretions to drain from her
mouth and prevent aspiration
Positioning the mother on her side will allow the secretions that may accumulate in her mouth to
drain by gravity thus preventing aspiration pneumonia. Putting a mouth gag is not safe since
during the convulsive seizure the jaw will immediately lock. The mother may go into labor also
during the seizure but the immediate concern of the nurse is the safety of the baby. After the
seizure, check the perineum for signs of precipitate labor.

37. Answer: (B) Minimize oxygen consumption which can aggravate the condition of the
compromised heart of the mother
Activity of the mother will require more oxygen consumption. Since the heart of a gravidocardiac is compromised, there is a need to put a mother on bedrest to reduce the need for oxygen.
38. Answer: (A) The internal exam is done only at the delivery under strict asepsis with a
double set-up
Painless vaginal bleeding during the third trimester maybe a sign of placenta praevia. If internal
examination is done in this kind of condition, this can lead to even more bleeding and may
require immediate delivery of the baby by cesarean section. If the bleeding is due to soft tissue
injury in the birth canal, immediate vaginal delivery may still be possible so the set up for
vaginal delivery will be used. A double set-up means there is a set up for cesarean section and a
set-up for vaginal delivery to accommodate immediately the necessary type of delivery needed.
In both cases, strict asepsis must be observed.
39. Answer: (B) Dilation of the cervix
In imminent abortion, the pregnancy will definitely be terminated because the cervix is already
open unlike in threatened abortion where the cervix is still closed.
40. Answer: (B) Put the mother on left side lying position
When a pregnant woman lies on supine position, the weight of the gravid uterus would be
compressing on the vena cava against the vertebrae obstructing blood flow from the lower
extremities. This causes a decrease in blood return to the heart and consequently immediate
decreased cardiac output and hypotension. Hence, putting the mother on side lying will relieve
the pressure exerted by the gravid uterus on the vena cava.
41. Answer: (A) Magnesium sulfate and terbutaline
Magnesium sulfate acts as a CNS depressant as well as a smooth muscle relaxant. Terbutaline is
a drug that inhibits the uterine smooth muscles from contracting. On the other hand, oxytocin
and prostaglandin stimulates contraction of smooth muscles.
42. Answer: (C) Lower segment of the uterus with the edges near the internal cervical os
Placenta marginalis is a type of placenta previa wherein the placenta is implanted at the lower
segment of the uterus thus the edges of the placenta are touching the internal cervical opening/os.
The normal site of placental implantation is the upper portion of the uterus.
43. Answer: (B) Rubella
Rubella is caused by a virus and viruses have low molecular weight thus can pass through the
placental barrier. Gonorrhea, candidiasis and moniliasis are conditions that can affect the fetus as
it passes through the vaginal canal during the delivery process.
44. Answer: (B) Orchitis
Orchitis is a complication that may accompany mumps in adult males. This condition is
characterized by unilateral inflammation of one of the testes which can lead to atrophy of the
affected testis. About 20-30% of males who gets mumps after puberty may develop this
complication.

45. Answer: (A) Cervix

Papanicolaou (Paps) smear is done to detect cervical cancer. It cant detect cancer in ovaries and
fallopian tubes because these organs are outside of the uterus and the abnormal cells from these
organs will not be detected from a smear done on the cervix.
46. Answer: (A) Vaginismus
Vaginismus is primarily psychological in origin. Endometriosis is a condition that is caused by
organic abnormalities. Dyspareunia is usually caused by infection, endometriosis or hormonal
changes in menopause although may sometimes be psychological in origin.
47. Answer: (A) 100 cc. urine output in 4 hours
The minimum urine output expected for a repeat dose of MgSO4 is 30 cc/hr. If in 4 hours the
urine output is only 100 cc this is low and can lead to poor excretion of Magnesium with a
possible cumulative effect, which can be dangerous to the mother.
48. Answer: (C) On the first pregnancy of the Rh(-) mother, the fetus will not be affected
On the first pregnancy, the mother still has no contact with Rh(+) blood thus it has not antibodies
against Rh(+). After the first pregnancy, even if terminated into an abortion, there is already the
possibility of mixing of maternal and fetal blood so this can trigger the maternal blood to
produce antibodies against Rh(+) blood. The fetus takes its blood type usually form the father.
49. Answer: (B) Manifestations of cystitis include, frequency, urgency, dysuria, hematuria
nocturia, fever, and suprapubic pain.
Dehydration, hypertension, and chills are not typically associated with cystitis. High fever chills,
flank pain, nausea, vomiting, dysuria, and frequency are associated with pvelonephritis.
50. Answer: (C) According to statistical reports, between 50% and 80% of all new mothers
report some form of postpartum blues. The ranges of 10% to 40%, 30% to 50%, and 25% to
70% are incorrect.

1. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24
hours. For which of the following would the nurse be alert?
a. Endometritis
b. Endometriosis
c. Salpingitis
d. Pelvic thrombophlebitis
2. A client at 36 weeks gestation is schedule for a routine ultrasound prior to an
amniocentesis. After teaching the client about the purpose for the ultrasound, which of the
following client statements would indicate to the nurse in charge that the client needs
further instruction?
a. The ultrasound will help to locate the placenta
b. The ultrasound identifies blood flow through the umbilical cord
c. The test will determine where to insert the needle
d. The ultrasound locates a pool of amniotic fluid
3. While the postpartum client is receiving heparin for thrombophlebitis, which of the
following drugs would the nurse expect to administer if the client develops complications
related to heparin therapy?
a. Calcium gluconate
b. Protamine sulfate
c. Methylergonovine (Methergine)
d. Nitrofurantoin (macrodantin)
4. When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the
nurse in charge would expect to do which of the following?
a. Turn the neonate every 6 hours
b. Encourage the mother to discontinue breast-feeding
c. Notify the physician if the skin becomes bronze in color
d. Check the vital signs every 2 to 4 hours
5. A primigravida in active labor is about 9 days post-term. The client desires a bilateral
pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia
to the client, which of the following locations identified by the client as the area of relief
would indicate to the nurse that the teaching was effective?
a. Back
b. Abdomen

c. Fundus
d. Perineum
6. The nurse is caring for a primigravida at about 2 months and 1 week gestation. After
explaining self-care measures for common discomforts of pregnancy, the nurse determines
that the client understands the instructions when she says:
a. Nausea and vomiting can be decreased if I eat a few crackers before arising
b. If I start to leak colostrum, I should cleanse my nipples with soap and water
c. If I have a vaginal discharge, I should wear nylon underwear
d. Leg cramps can be alleviated if I put an ice pack on the area
7. Thirty hours after delivery, the nurse in charge plans discharge teaching for the client
about infant care. By this time, the nurse expects that the phase of postpartum
psychological adaptation that the client would be in would be termed which of the
following?
a. Taking in
b. Letting go
c. Taking hold
d. Resolution
8. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis,
the nurse tells the client that the usual treatment for partial placenta previa is which of the
following?
a. Activity limited to bed rest
b. Platelet infusion
c. Immediate cesarean delivery
d. Labor induction with oxytocin
9. The nurse plans to instruct the postpartum client about methods to prevent breast
engorgement. Which of the following measures would the nurse include in the teaching
plan?
a. Feeding the neonate a maximum of 5 minutes per side on the first day
b. Wearing a supportive brassiere with nipple shields
c. Breast-feeding the neonate at frequent intervals
d. Decreasing fluid intake for the first 24 to 48 hours

10. When the nurse on duty accidentally bumps the bassinet, the neonate throws out its
arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of
which of the following reflexes?
a. Startle reflex
b. Babinski reflex
c. Grasping reflex
d. Tonic neck reflex
11. A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her
lower back aches when she arrives home from work. The nurse should suggest that the
client perform:
a. Tailor sitting
b. Leg lifting
c. Shoulder circling
d. Squatting exercises
12. Which of the following would the nurse in charge do first after observing a 2-cm circle
of bright red bleeding on the diaper of a neonate who just had a circumcision?
a. Notify the neonates pediatrician immediately
b. Check the diaper and circumcision again in 30 minutes
c. Secure the diaper tightly to apply pressure on the site
d. Apply gentle pressure to the site with a sterile gauze pad
13. Which of the following would the nurse most likely expect to find when assessing a
pregnant client with abruption placenta?
a. Excessive vaginal bleeding
b. Rigid, board-like abdomen
c. Titanic uterine contractions
d. Premature rupture of membranes
14. While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse
observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period.
Which of the following would be the nurses most appropriate action?
a. Note the fetal heart rate patterns
b. Notify the physician immediately
c. Administer oxygen at 6 liters by mask
d. Have the client pant-blow during the contractions

15. A client tells the nurse, I think my baby likes to hear me talk to him. When discussing
neonates and stimulation with sound, which of the following would the nurse include as a
means to elicit the best response?
a. High-pitched speech with tonal variations
b. Low-pitched speech with a sameness of tone
c. Cooing sounds rather than words
d. Repeated stimulation with loud sounds
16. A 31-year-old multipara is admitted to the birthing room after initial examination
reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase
of labor is she in?
a. Active phase
b. Latent phase
c. Expulsive phase
d. Transitional phase
17. A pregnant patient asks the nurse if she can take castor oil for her constipation. How
should the nurse respond?
a. Yes, it produces no adverse effect.
b. No, it can initiate premature uterine contractions.
c. No, it can promote sodium retention.
d. No, it can lead to increased absorption of fat-soluble vitamins.
18. A patient in her 14th week of pregnancy has presented with abdominal cramping and
vaginal bleeding for the past 8 hours. She has passed several cloth. What is the primary
nursing diagnosis for this patient?
a. Knowledge deficit
b. Fluid volume deficit
c. Anticipatory grieving
d. Pain
19. Immediately after a delivery, the nurse-midwife assesses the neonates head for signs of
molding. Which factors determine the type of molding?
a. Fetal body flexion or extension
b. Maternal age, body frame, and weight
c. Maternal and paternal ethnic backgrounds
d. Maternal parity and gravidity

20. For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal
monitoring (EFM) device. What must occur before the internal EFM can be applied?
a. The membranes must rupture
b. The fetus must be at 0 station
c. The cervix must be dilated fully
d. The patient must receive anesthesia
21. A primigravida patient is admitted to the labor delivery area. Assessment reveals that
she is in early part of the first stage of labor. Her pain is likely to be most intense:
a. Around the pelvic girdle
b. Around the pelvic girdle and in the upper arms
c. Around the pelvic girdle and at the perineum
d. At the perineum
22. A female adult patient is taking a progestin-only oral contraceptive, or mini pill.
Progestin use may increase the patients risk for:
a. Endometriosis
b. Female hypogonadism
c. Premenstrual syndrome
d. Tubal or ectopic pregnancy
23. A patient with pregnancy-induced hypertension probably exhibits which of the
following symptoms?
a. Proteinuria, headaches, vaginal bleeding
b. Headaches, double vision, vaginal bleeding
c. Proteinuria, headaches, double vision
d. Proteinuria, double vision, uterine contractions
24. Because cervical effacement and dilation are not progressing in a patient in labor,the
doctor orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the
patients fluid intake and output closely during oxytocin administration?
a. Oxytocin causes water intoxication
b. Oxytocin causes excessive thirst
c. Oxytocin is toxic to the kidneys
d. Oxytocin has a diuretic effect

25. Five hours after birth, a neonate is transferred to the nursery, where the nurse
intervenes to prevent hypothermia. What is a common source of radiant heat loss?
a. Low room humidity
b. Cold weight scale
c. Cools incubator walls
d. Cool room temperature
26. After administering bethanechol to a patient with urine retention, the nurse in charge
monitors the patient for adverse effects. Which is most likely to occur?
a. Decreased peristalsis
b. Increase heart rate
c. Dry mucous membranes
d. Nausea and Vomiting
27. The nurse in charge is caring for a patient who is in the first stage of labor. What is the
shortest but most difficult part of this stage?
a. Active phase
b. Complete phase
c. Latent phase
d. Transitional phase
28. After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve
her discomfort, the nurse should suggest that she:
a. Apply warm compresses to her nipples just before feedings
b. Lubricate her nipples with expressed milk before feeding
c. Dry her nipples with a soft towel after feedings
d. Apply soap directly to her nipples, and then rinse
29. The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The
nurse should tell the patient that she can expect to feel the fetus move at which time?
a. Between 10 and 12 weeks gestation
b. Between 16 and 20 weeks gestation
c. Between 21 and 23 weeks gestation
d. Between 24 and 26 weeks gestation
30. Normal lochial findings in the first 24 hours post-delivery include:

a. Bright red blood

b. Large clots or tissue fragments
c. A foul odor
d. The complete absence of lochia

Answers and Rationale

1. Answer A.
Endometritis is an infection of the uterine lining and can occur after prolonged rupture of
membranes. Endometriosis does not occur after a strong labor and prolonged rupture of
membranes. Salpingitis is a tubal infection and could occur if endometritis is not treated. Pelvic
thrombophlebitis involves a clot formation but it is not a complication of prolonged rupture of
membranes.
2. Answer B.
Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of
amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging
ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not
accomplish this.
3. Answer B.
Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding
complications cause by heparin overdose.

4. Answer D.
While caring for an infant receiving phototherapy for treatment of jaundice, vital signs are
checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights.
5. Answer D.
A bilateral pudendal block is used for vaginal deliveries to relieve pain primarily in the perineum
and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair.
6. Answer A.
Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and
vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also
help.
7. Answer C.
Beginning after completion of the taking-in phase, the taking-hold phase lasts about 10 days.
During this phase, the client is concerned with her need to resume control of all facets of her life
in a competent manner. At this time, she is ready to learn self-care and infant care skills.
8. Answer A.
Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the
clients bleeding.
9. Answer C.
Prevention of breast engorgement is key. The best technique is to empty the breast regularly with
feeding. Engorgement is less likely when the mother and neonate are together, as in single room
maternity care continuous rooming in, because nursing can be done conveniently to meet the
neonates and mothers needs.
10. Answer A.
The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms,
hands open, and then moving the arms in an embracing motion. The Moro reflex, present at
birth, disappears at about age 3 months.
11. Answer A.
Tailor sitting is an excellent exercise that helps to strengthen the clients back muscles and also
prepares the client for the process of labor. The client should be encouraged to rest periodically
during the day and avoid standing or sitting in one position for a long time.
12. Answer D.
If bleeding occurs after circumcision, the nurse should first apply gently pressure on the area
with sterile gauze. Bleeding is not common but requires attention when it occurs.

13. Answer B.
The most common assessment finding in a client with abruption placenta is a rigid or boardlike
abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the
initial separation, also is common.
14. Answer B.
The nurse should contact the physician immediately because the client is most likely
experiencing hypotonic uterine contractions. These contractions tend to be painful but
ineffective. The usual treatment is oxytocin augmentation, unless cephalopelvic disproportion
exists.
15. Answer A.
Providing stimulation and speaking to neonates is important. Some authorities believe that
speech is the most important type of sensory stimulation for a neonate. Neonates respond best to
speech with tonal variations and a high-pitched voice. A neonate can hear all sound louder than
about 55 decibels.
16. Answer D.
The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and
intense for the patient. The latent phase extends from 0 to 3 cm; it is mild in nature. The active
phase extends from 4 to 7 cm; it is moderate for the patient. The expulsive phase begins
immediately after the birth and ends with separation and expulsion of the placenta.
17. Answer B.
Castor oil can initiate premature uterine contractions in pregnant women. It also can produce
other adverse effects, but it does not promote sodium retention. Castor oils is not known to
increase absorption of fat-soluble vitamins, although laxatives in general may decrease
absorption if intestinal motility is increased.
18. Answer B.
If bleeding and clots are excessive, this patient may become hypovolemic. Pad count should be
instituted. Although the other diagnoses are applicable to this patient, they are not the primary
diagnosis.
19. Answer A.
Fetal attitudethe overall degree of body flexion or extensiondetermines the type of molding
in the head a neonate. Molding is not influenced by maternal age, body frame, weight, parity, and
gravidity or by maternal and paternal ethnic backgrounds.
20. Answer A.
Internal EFM can be applied only after the patients membranes have ruptured, when the fetus is

at least at the -1 station, and when the cervix is dilated at least 2 cm. although the patient may
receive anesthesia, it is not required before application of an internal EFM device.
21. Answer A.
During most of the first stage of labor, pain centers around the pelvic girdle. During the late part
of this stage and the early part of the second stage, pain spreads to the upper legs and perineum.
During the late part of the second stage and during childbirth, intense pain occurs at the
perineum. Upper arm pain is not common during any stage of labor.
22. Answer D.
Women taking the minipill have a higher incidence of tubal and ectopic pregnancies, possibly
because progestin slows ovum transport through the fallopian tubes. Endometriosis, female
hypogonadism, and premenstrual syndrome are not associated with progestin-only oral
contraceptives.
23. Answer C.
A patient with pregnancy-induced hypertension complains of headache, double vision, and
sudden weight gain. A urine specimen reveals proteinuria. Vaginal bleeding and uterine
contractions are not associated with pregnancy-induced hypertension.
24. Answer A.
The nurse should monitor fluid intake and output because prolonged oxytocin infusion may
cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results
from the work of labor and limited oral fluid intakenot oxytocin. Oxytocin has no nephrotoxic
or diuretic effects. In fact, it produces an antidiuretic effect.
25. Answer C.
Common source of radiant heat loss includes cool incubator walls and windows. Low room
humidity promotes evaporative heat loss. When the skin directly contacts a cooler object, such as
a cold weight scale, conductive heat loss may occur. A cool room temperature may lead to
convective heat loss.
26. Answer D.
Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal
cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of
bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and
decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating
may gently increase.
27. Answer D.
The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first

stage of labor. This phase is characterized by intense uterine contractions that occur every 1 to
2 minutes and last 45 to 90 seconds. The active phase lasts 4 to 6 hours; it is characterized by
contractions that starts out moderately intense, grow stronger, and last about 60 seconds. The
complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8
hours and is marked by mild, short, irregular contractions.
28. Answer B.
Measures that help relieve nipple soreness in a breast-feeding patient include lubrication the
nipples with a few drops of expressed milk before feedings, applying ice compresses just before
feeding, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples.
29. Answer B.
A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks
gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect
movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce
surfactant, the brain is grossly formed, and myelination of the spinal cord begins.
30. Answer A.
Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal
infection, as may absence of lochia.

1. A nurse is caring for a client in labor. The nurse determines that the client is beginning in
the 2nd stage of labor when which of the following assessments is noted?
1. The client begins to expel clear vaginal fluid
2. The contractions are regular
3. The membranes have ruptured
4. The cervix is dilated completely
2. A nurse in the labor room is caring for a client in the active phases of labor. The nurse is
assessing the fetal patterns and notes a late deceleration on the monitor strip. The most
appropriate nursing action is to:
1. Place the mother in the supine position
2. Document the findings and continue to monitor the fetal patterns
3. Administer oxygen via face mask
4. Increase the rate of pitocin IV infusion
3. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery.
Which assessment finding would indicate a need to contact the physician?
1. Fetal heart rate of 180 beats per minute
2. White blood cell count of 12,000
3. Maternal pulse rate of 85 beats per minute
4. Hemoglobin of 11.0 g/dL
4. A client in labor is transported to the delivery room and is prepared for a cesarean
delivery. The client is transferred to the delivery room table, and the nurse places the client
in the:
1. Trendelenburgs position with the legs in stirrups
2. Semi-Fowler position with a pillow under the knees
3. Prone position with the legs separated and elevated
4. Supine position with a wedge under the right hip
5. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by
using a Doppler ultrasound device. The nurse most accurately determines that the fetal
heart sounds are heard by:
1. Noting if the heart rate is greater than 140 BPM
2. Placing the diaphragm of the Doppler on the mother abdomen
3. Performing Leopolds maneuvers first to determine the location of the fetal heart
4. Palpating the maternal radial pulse while listening to the fetal heart rate

6. A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate
uterine contractions. Which assessment finding would indicate to the nurse that the
infusion needs to be discontinued?
1. Three contractions occurring within a 10-minute period
2. A fetal heart rate of 90 beats per minute
3. Adequate resting tone of the uterus palpated between contractions
4. Increased urinary output
7. A nurse is beginning to care for a client in labor. The physician has prescribed an IV
infusion of Pitocin. The nurse ensures that which of the following is implemented before
initiating the infusion?
1. Placing the client on complete bed rest
2. Continuous electronic fetal monitoring
3. An IV infusion of antibiotics
4. Placing a code cart at the clients bedside
8. A nurse is monitoring a client in active labor and notes that the client is having
contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate
between contractions is 100 BPM. Which of the following nursing actions is most
appropriate?
1. Encourage the clients coach to continue to encourage breathing exercises
2. Encourage the client to continue pushing with each contraction
3. Continue monitoring the fetal heart rate
4. Notify the physician or nurse midwife
9. A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The
nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing.
Which of the following actions is most appropriate?
1. Document the findings and tell the mother that the monitor indicates fetal well-being
2. Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen.
3. Notify the physician or nurse midwife of the findings.
4. Reposition the mother and check the monitor for changes in the fetal tracing
10. A nurse is admitting a pregnant client to the labor room and attaches an external
electronic fetal monitor to the clients abdomen. After attachment of the monitor, the initial
nursing assessment is which of the following?

1. Identifying the types of accelerations

2. Assessing the baseline fetal heart rate
3. Determining the frequency of the contractions
4. Determining the intensity of the contractions
11. A nurse is reviewing the record of a client in the labor room and notes that the nurse
midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal
presenting part is:
1. 1 cm above the ischial spine
2. 1 fingerbreadth below the symphysis pubis
3. 1 inch below the coccyx
4. 1 inch below the iliac crest
12. A pregnant client is admitted to the labor room. An assessment is performed, and the
nurse notes that the clients hemoglobin and hematocrit levels are low, indicating anemia.
The nurse determines that the client is at risk for which of the following?
1. A loud mouth
2. Low self-esteem
3. Hemorrhage
4. Postpartum infections
13. A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse
observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse
documents these observations as signs of:
1. Hematoma
2. Placenta previa
3. Uterine atony
4. Placental separation
14. A client arrives at a birthing center in active labor. Her membranes are still intact, and
the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nursemidwife explains to the client that after this procedure, she will most likely have:
1. Less pressure on her cervix
2. Increased efficiency of contractions
3. Decreased number of contractions
4. The need for increased maternal blood pressure monitoring

15. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression
if which of the following is noted on the external monitor tracing during a contraction?
1. Early decelerations
2. Variable decelerations
3. Late decelerations
4. Short-term variability
16. A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the
client that effleurage is:
1. A form of biofeedback to enhance bearing down efforts during delivery
2. Light stroking of the abdomen to facilitate relaxation during labor and provide tactile
stimulation to the fetus
3. The application of pressure to the sacrum to relieve a backache
4. Performed to stimulate uterine activity by contracting a specific muscle group while other
parts of the body rest
17. A nurse is caring for a client in the second stage of labor. The client is experiencing
uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse
recognizes this behavior as:
1. Exhaustion
2. Fear of losing control
3. Involuntary grunting
4. Valsalvas maneuver
18. A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client
is experiencing hypertonic uterine contractions. List in order of priority the actions that the
nurse takes.
1. Stop of Pitocin infusion
2. Perform a vaginal examination
3. Reposition the client
4. Check the clients blood pressure and heart rate
5. Administer oxygen by face mask at 8 to 10 L/min
19. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the physicians orders and would expect to note
which of the following prescribed treatments for this condition?

1. Medication that will provide sedation

2. Increased hydration
3. Oxytocin (Pitocin) infusion
4. Administration of a tocolytic medication
20. A nurse in the labor room is preparing to care for a client with hypertonic uterine
dysfunction. The nurse is told that the client is experiencing uncoordinated contractions
that are erratic in their frequency, duration, and intensity. The priority nursing
intervention would be to:
1. Monitor the Pitocin infusion closely
2. Provide pain relief measures
3. Prepare the client for an amniotomy
4. Promote ambulation every 30 minutes
21. A nurse is developing a plan of care for a client experiencing dystocia and includes
several nursing interventions in the plan of care. The nurse prioritizes the plan of care and
selects which of the following nursing interventions as the highest priority?
1. Keeping the significant other informed of the progress of the labor
2. Providing comfort measures
3. Monitoring fetal heart rate
4. Changing the clients position frequently
22. A maternity nurse is preparing to care for a pregnant client in labor who will be
delivering twins. The nurse monitors the fetal heart rates by placing the external fetal
monitor:
1. Over the fetus that is most anterior to the mothers abdomen
2. Over the fetus that is most posterior to the mothers abdomen
3. So that each fetal heart rate is monitored separately
4. So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring
period for the second fetus
23. A nurse in the postpartum unit is caring for a client who has just delivered a newborn
infant following a pregnancy with placenta previa. The nurse reviews the plan of care and
prepares to monitor the client for which of the following risks associated with placenta
previa?
1. Disseminated intravascular coagulation
2. Chronic hypertension

3. Infection
4. Hemorrhage
24. A nurse in the delivery room is assisting with the delivery of a newborn infant. After the
delivery of the newborn, the nurse assists in delivering the placenta. Which observation
would indicate that the placenta has separated from the uterine wall and is ready for
delivery?
1. The umbilical cord shortens in length and changes in color
2. A soft and boggy uterus
3. Maternal complaints of severe uterine cramping
4. Changes in the shape of the uterus
25. A nurse in the labor room is performing a vaginal assessment on a pregnant client in
labor. The nurse notes the presence of the umbilical cord protruding from the vagina.
Which of the following would be the initial nursing action?
1. Place the client in Trendelenburgs position
2. Call the delivery room to notify the staff that the client will be transported immediately
3. Gently push the cord into the vagina
4. Find the closest telephone and stat page the physician
26. A maternity nurse is caring for a client with abruptio placenta and is monitoring the
client for disseminated intravascular coagulopathy. Which assessment finding is least likely
to be associated with disseminated intravascular coagulation?
1. Swelling of the calf in one leg
2. Prolonged clotting times
3. Decreased platelet count
4. Petechiae, oozing from injection sites, and hematuria
27. A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was
admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of
the following assessment findings would the nurse expect to note if this condition is
present?
1. Absence of abdominal pain
2. A soft abdomen
3. Uterine tenderness/pain
4. Painless, bright red vaginal bleeding

28. A maternity nurse is preparing for the admission of a client in the 3rd trimester of
pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta
previa. The nurse reviews the physicians orders and would question which order?
1. Prepare the client for an ultrasound
2. Obtain equipment for external electronic fetal heart monitoring
3. Obtain equipment for a manual pelvic examination
4. Prepare to draw a Hgb and Hct blood sample
29. An ultrasound is performed on a client at term gestation that is experiencing moderate
vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is
present. Based on these findings, the nurse would prepare the client for:
1. Complete bed rest for the remainder of the pregnancy
2. Delivery of the fetus
3. Strict monitoring of intake and output
4. The need for weekly monitoring of coagulation studies until the time of delivery
30. A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The
nurse would monitor the client closely for the risk of uterine rupture if which of the
following occurred?
1. Hypotonic contractions
2. Forceps delivery
3. Schultz delivery
4. Weak bearing down efforts
31. A client is admitted to the birthing suite in early active labor. The priority nursing
intervention on admission of this client would be:
1. Auscultating the fetal heart
2. Taking an obstetric history
3. Asking the client when she last ate
4. Ascertaining whether the membranes were ruptured
32. A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and
she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus head is:
1. Not yet engaged
2. Entering the pelvic inlet
3. Below the ischial spines
4. Visible at the vaginal opening

33. After doing Leopolds maneuvers, the nurse determines that the fetus is in the ROP
position. To best auscultate the fetal heart tones, the Doppler is placed:
1. Above the umbilicus at the midline
2. Above the umbilicus on the left side
3. Below the umbilicus on the right side
4. Below the umbilicus near the left groin
34. The physician asks the nurse the frequency of a laboring clients contractions. The
nurse assesses the clients contractions by timing from the beginning of one contraction:
1. Until the time it is completely over
2. To the end of a second contraction
3. To the beginning of the next contraction
4. Until the time that the uterus becomes very firm
35. The nurse observes the clients amniotic fluid and decides that it appears normal,
because it is:
1. Clear and dark amber in color
2. Milky, greenish yellow, containing shreds of mucus
3. Clear, almost colorless, and containing little white specks
4. Cloudy, greenish-yellow, and containing little white specks
36. At 38 weeks gestation, a client is having late decelerations. The fetal pulse oximeter
shows 75% to 85%. The nurse should:
1. Discontinue the catheter, if the reading is not above 80%
2. Discontinue the catheter, if the reading does not go below 30%
3. Advance the catheter until the reading is above 90% and continue monitoring
4. Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring
37. When examining the fetal monitor strip after rupture of the membranes in a laboring
client, the nurse notes variable decelerations in the fetal heart rate. The nurse should:
1. Stop the oxytocin infusion
2. Change the clients position
3. Prepare for immediate delivery
4. Take the clients blood pressure

38. When monitoring the fetal heart rate of a client in labor, the nurse identifies an
elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds.
This should be documented as:
1. An acceleration
2. An early elevation
3. A sonographic motion
4. A tachycardic heart rate
39. A laboring client complains of low back pain. The nurse replies that this pain occurs
most when the position of the fetus is:
1. Breech
2. Transverse
3. Occiput anterior
4. Occiput posterior
40. The breathing technique that the mother should be instructed to use as the fetus head
is crowning is:
1. Blowing
2. Slow chest
3. Shallow
4. Accelerated-decelerated
41. During the period of induction of labor, a client should be observed carefully for signs
of:
1. Severe pain
2. Uterine tetany
3. Hypoglycemia
4. Umbilical cord prolapse
42. A client arrives at the hospital in the second stage of labor. The fetus head is crowning,
the client is bearing down, and the birth appears imminent. The nurse should:
1. Transfer her immediately by stretcher to the birthing unit
2. Tell her to breathe through her mouth and not to bear down
3. Instruct the client to pant during contractions and to breathe through her mouth
4. Support the perineum with the hand to prevent tearing and tell the client to pant

43. A laboring client is to have a pudendal block. The nurse plans to tell the client that once
the block is working she:
1. Will not feel the episiotomy
2. May lose bladder sensation
3. May lose the ability to push
4. Will no longer feel contractions
44. Which of the following observations indicates fetal distress?
1. Fetal scalp pH of 7.14
2. Fetal heart rate of 144 beats/minute
3. Acceleration of fetal heart rate with contractions
4. Presence of long term variability
45. Which of the following fetal positions is most favorable for birth?
1. Vertex presentation
2. Transverse lie
3. Frank breech presentation
4. Posterior position of the fetal head
46. A laboring client has external electronic fetal monitoring in place. Which of the
following assessment data can be determined by examining the fetal heart rate strip
produced by the external electronic fetal monitor?
1. Gender of the fetus
2. Fetal position
3. Labor progress
4. Oxygenation
47. A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in
cervical dilation. In which of the following phases of the first stage does cervical dilation
occur most rapidly?
1. Preparatory phase
2. Latent phase
3. Active phase
4. Transition phase
48. A multiparous client who has been in labor for 2 hours states that she feels the urge to
move her bowels. How should the nurse respond?

1. Let the client get up to use the potty

2. Allow the client to use a bedpan
3. Perform a pelvic examination
4. Check the fetal heart rate
49. Labor is a series of events affected by the coordination of the five essential factors. One
of these is the passenger (fetus). Which are the other four factors?
1. Contractions, passageway, placental position and function, pattern of care
2. Contractions, maternal response, placental position, psychological response
3. Passageway, contractions, placental position and function, psychological response
4. Passageway, placental position and function, paternal response, psychological response
50. Fetal presentation refers to which of the following descriptions?
1. Fetal body part that enters the maternal pelvis first
2. Relationship of the presenting part to the maternal pelvis
3. Relationship of the long axis of the fetus to the long axis of the mother
4. A classification according to the fetal part
51. A client is admitted to the L & D suite at 36 weeks gestation. She has a history of Csection and complains of severe abdominal pain that started less than 1 hour earlier. When
the nurse palpates tetanic contractions, the client again complains of severe pain. After the
client vomits, she states that the pain is better and then passes out. Which is the probable
cause of her signs and symptoms?
1. Hysteria compounded by the flu
2. Placental abruption
3. Uterine rupture
4. Dysfunctional labor
52. Upon completion of a vaginal examination on a laboring woman, the nurse records:
50%, 6 cm, -1. Which of the following is a correct interpretation of the data?
1. Fetal presenting part is 1 cm above the ischial spines
2. Effacement is 4 cm from completion
3. Dilation is 50% completed
4. Fetus has achieved passage through the ischial spines
53. Which of the following findings meets the criteria of a reassuring FHR pattern?

1. FHR does not change as a result of fetal activity

2. Average baseline rate ranges between 100 140 BPM
3. Mild late deceleration patterns occur with some contractions
4. Variability averages between 6 10 BPM
54. Late deceleration patterns are noted when assessing the monitor tracing of a woman
whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying
position, and her vital signs are stable and fall within a normal range. Contractions are
intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurses immediate action
would be to:
1. Change the womans position
2. Stop the Pitocin
3. Elevate the womans legs
4. Administer oxygen via a tight mask at 8 to 10 liters/minute
55. The nurse should realize that the most common and potentially harmful maternal
complication of epidural anesthesia would be:
1. Severe postpartum headache
2. Limited perception of bladder fullness
3. Increase in respiratory rate
4. Hypotension
56. Perineal care is an important infection control measure. When evaluating a
postpartum womans perineal care technique, the nurse would recognize the need for
further instruction if the woman:
1. Uses soap and warm water to wash the vulva and perineum
2. Washes from symphysis pubis back to episiotomy
3. Changes her perineal pad every 2 3 hours
4. Uses the peribottle to rinse upward into her vagina
57. Which measure would be least effective in preventing postpartum hemorrhage?
1. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered
2. Encourage the woman to void every 2 hours
3. Massage the fundus every hour for the first 24 hours following birth
4. Teach the woman the importance of rest and nutrition to enhance healing
58. When making a visit to the home of a postpartum woman one week after birth, the
nurse should recognize that the woman would characteristically:

1. Express a strong need to review events and her behavior during the process of labor and birth
2. Exhibit a reduced attention span, limiting readiness to learn
3. Vacillate between the desire to have her own nurturing needs met and the need to take charge
of her own care and that of her newborn
4. Have reestablished her role as a spouse/partner
59. Four hours after a difficult labor and birth, a primiparous woman refuses to feed her
baby, stating that she is too tired and just wants to sleep. The nurse should:
1. Tell the woman she can rest after she feeds her baby
2. Recognize this as a behavior of the taking-hold stage
3. Record the behavior as ineffective maternal-newborn attachment
4. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time
60. Parents can facilitate the adjustment of their other children to a new baby by:
1. Having the children choose or make a gift to give to the new baby upon its arrival home
2. Emphasizing activities that keep the new baby and other children together
3. Having the mother carry the new baby into the home so she can show the other children the
new baby
4. Reducing stress on other children by limiting their involvement in the care of the new baby

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. The cervix is dilated completely. The second stage of labor begins when the
cervix is dilated completely and ends with the birth of the neonate.
2. Answer: 3. Administer oxygen via face mask. Late decelerations are due to uteroplacental
insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine
contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is
avoided because it decreases uterine blood flow to the fetus. The client should be turned to her
side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin
infusion is discontinued when a late deceleration is noted.
3. Answer: 1. Fetal heart rate of 180 beats per minute. A normal fetal heart rate is 120-160
beats per minute. A count of 180 beats per minute could indicate fetal distress and would warrant
physician notification. By full term, a normal maternal hemoglobin range is 11-13 g/dL as a
result of the hemodilution caused by an increase in plasma volume during pregnancy.
4. Answer: 4. Supine position with a wedge under the right hip. Vena cava and descending
aorta compression by the pregnant uterus impedes blood return from the lower trunk and
extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus
and the fetus. The best position to prevent this would be side-lying with the uterus displaced off
of abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however,
a wedge placed under the right hip provides displacement of the uterus.
5. Answer: 4. Palpating the maternal radial pulse while listening to the fetal heart rate. The
nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal
heart rate to differentiate the two. If the fetal and maternal heart rates are similar, the nurse may
mistake the maternal heart rate for the fetal heart rate. Leopolds maneuvers may help the
examiner locate the position of the fetus but will not ensure a distinction between the two rates.
6. Answer: 2. A fetal heart rate of 90 beats per minute. A normal fetal heart rate is 120-160
BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to
discontinue to pitocin. The goal of labor augmentation is to achieve three good-quality
contractions in a 10-minute period.

7. Answer: 2. Continuous electronic fetal monitoring. Continuous electronic fetal monitoring

should be implemented during an IV infusion of Pitocin.
8. Answer: 4. Notify the physician or nurse midwife. A normal fetal heart rate is 120-160 beats
per minute. Fetal bradycardia between contractions may indicate the need for immediate medical
management, and the physician or nurse midwife needs to be notified.
9. Answer: 1. Document the findings and tell the mother that the monitor indicates fetal
well-being. Accelerations are transient increases in the fetal heart rate that often accompany
contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of
fetal-well being and adequate oxygen reserve.
10. Answer: 2. Assessing the baseline fetal heart rate. Assessing the baseline fetal heart rate is
important so that abnormal variations of the baseline rate will be identified if they occur. Options
1 and 3 are important to assess, but not as the first priority.
11. Answer: 1. 1 cm above the ischial spine. Station is the relationship of the presenting part to
an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a
negative number above the line and a positive number below the line. At -1 station, the fetal
presenting part is 1 cm above the ischial spines.
12. Answer: 4. Postpartum infections. Anemic women have a greater likelihood of cardiac
decompensation during labor, postpartum infection, and poor wound healing. Anemia does not
specifically present a risk for hemorrhage.
13. Answer: 4. Placental separation. As the placenta separates, it settles downward into the
lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood
appears.
14. Answer: 2. Increased efficiency of contractions. Amniotomy can be used to induce labor
when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to
slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may
increase the efficiency of contractions.
15. Answer: 2. Variable decelerations. Variable decelerations occur if the umbilical cord
becomes compressed, thus reducing blood flow between the placenta and the fetus. Early
decelerations result from pressure on the fetal head during a contraction. Late decelerations are
an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction.
Short-term variability refers to the beat-to-beat range in the fetal heart rate.
16. Answer: 2. Light stroking of the abdomen to facilitate relaxation during labor and
provide tactile stimulation to the fetus. Effleurage is a specific type of cutaneous stimulation

involving light stroking of the abdomen and is used before transition to promote relaxation and
relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus.
17. Answer: 2. Fear of losing control. Pains, helplessness, panicking, and fear of losing control
are possible behaviors in the 2nd stage of labor.
18. Answer: 1, 4, 2. 5, 3. If uterine hypertonicity occurs, the nurse immediately would intervene
to reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin
infusion and increase the rate of the nonadditive solution, check maternal BP for hyper or
hypotension, position the woman in a side-lying position, and administer oxygen by snug face
mask at 8-10 L/min. The nurse then would attempt to determine the cause of the uterine
hypertonicity and perform a vaginal exam to check for prolapsed cord.
19. Answer: 3. Oxytocin (Pitocin) infusion. Therapeutic management for hypotonic uterine
dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows.
20. Answer: 2. Provide pain relief measures. Management of hypertonic labor depends on the
cause. Relief of pain is the primary intervention to promote a normal labor pattern.
21. Answer: 3. Monitoring fetal heart rate. The priority is to monitor the fetal heart rate.
22. Answer: 3. So that each fetal heart rate is monitored separately. In a client with a multifetal pregnancy, each fetal heart rate is monitored separately.
23. Answer: 4. Hemorrhage. Because the placenta is implanted in the lower uterine segment,
which does not contain the same intertwining musculature as the fundus of the uterus, this site is
more prone to bleeding.
24. Answer: 4. Changes in the shape of the uterus. Signs of placental separation include
lengthening of the umbilical cord, a sudden gush of dark blood from the introitus (vagina), a
firmly contracted uterus, and the uterus changing from a discoid (like a disk) to a globular (like a
globe) shape. The client may experience vaginal fullness, but not severe uterine cramping.
25. Answer: 1. Place the client in Trendelenburgs position. When cord prolapse occurs,
prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother
should be positioned with the hips higher than the head to shift the fetal presenting part toward
the diaphragm. The nurse should push the call light to summon help, and other staff members
should call the physician and notify the delivery room. No attempt should be made to replace the
cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting
part off of the umbilical cord. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to
increase fetal oxygenation.

26. Answer: 1. Swelling of the calf in one leg. DIC is a state of diffuse clotting in which
clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because
they are consumed by the process; coagulation studies show no clot formation (and are thus
normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an
isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs
associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated
with thrombophlebitis.
27. 3. Uterine tenderness/pain. In abruptio placentae, acute abdominal pain is present. Uterine
tenderness and pain accompanies placental abruption, especially with a central abruption and
trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the
blood penetrates the myometrium and causes uterine irritability. Observation of the fetal
monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in
attempt to constrict blood vessels and control bleeding.
28. Answer: 3. Obtain equipment for a manual pelvic examination. Manual pelvic
examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a
diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to
maternal and fetal hemorrhage. A diagnosis of placenta previa is made by ultrasound. The H/H
levels are monitored, and external electronic fetal heart rate monitoring is initiated. External fetal
monitoring is crucial in evaluating the fetus that is at risk for severe hypoxia.
29. Answer: 2. Delivery of the fetus. The goal of management in abruptio placentae is to
control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of
choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or
fetus is in jeopardy.
30. Answer: 2. Forceps delivery. Excessive fundal pressure, forceps delivery, violent bearing
down efforts, tumultuous labor, and shoulder dystocia can place a woman at risk for traumatic
uterine rupture. Hypotonic contractions and weak bearing down efforts do not alone add to the
risk of rupture because they do not add to the stress on the uterine wall.
31. Answer: 1. Auscultating the fetal heart. Determining the fetal well-being supersedes all
other measures. If the FHR is absent or persistently decelerating, immediate intervention is
required.
32. Answer: 3. Below the ischial spines. A station of +1 indicates that the fetal head is 1 cm
below the ischial spines.

33. Answer: 3. Below the umbilicus on the right side. Fetal heart tones are best auscultated
through the fetal back; because the position is ROP (right occiput presenting), the back would be
below the umbilicus and on the right side.
34. Answer: 3. To the beginning of the next contraction. This is the way to determine the
frequency of the contractions
35. Answer: 3. Clear, almost colorless, and containing little white specks. By 36 weeks
gestation, normal amniotic fluid is colorless with small particles of vernix caseosa present.
36. Answer: 4. Reposition the catheter, recheck the reading, and if it is 55%, keep
monitoring. Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be
between 30% and 70%. 75% to 85% would indicate maternal readings.
37. Answer: 2. Change the clients position. Variable decelerations usually are seen as a result
of cord compression; a change of position will relieve pressure on the cord.
38. Answer: 1. An acceleration. An acceleration is an abrupt elevation above the baseline of 15
beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is
considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute.
39. Answer: 4. Occiput posterior. A persistent occiput-posterior position causes intense back
pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal
position and does not cause back pain.
40. Answer: 1. Blowing. Blowing forcefully through the mouth controls the strong urge to push
and allows for a more controlled birth of the head.
41. Answer: 2. Uterine tetany. Uterine tetany could result from the use of oxytocin to induce
labor. Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The
oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise.
42. Answer: 4. Support the perineum with the hand to prevent tearing and tell the client to
pant. Gentle pressure is applied to the babys head as it emerges so it is not born too rapidly. The
head is never held back, and it should be supported as it emerges so there will be no vaginal
lacerations. It is impossible to push and pant at the same time.
43. Answer: 1. May lose the ability to push. A pudendal block provides anesthesia to the
perineum.
44. Answer: 1. Fetal scalp pH of 7.14. A fetal scalp pH below 7.25 indicates acidosis and fetal
hypoxia.

45. Answer: 1. Vertex presentation. Vertex presentation (flexion of the fetal head) is the
optimal presentation for passage through the birth canal. Transverse lie is an unacceptable fetal
position for vaginal birth and requires a C-section. Frank breech presentation, in which the
buttocks present first, can be a difficult vaginal delivery. Posterior positioning of the fetal head
can make it difficult for the fetal head to pass under the maternal symphysis pubis.
46. Answer: 4. Oxygenation. Oxygenation of the fetus may be indirectly assessed through fetal
monitoring by closely examining the fetal heart rate strip. Accelerations in the fetal heart rate
strip indicate good oxygenation, while decelerations in the fetal heart rate sometimes indicate
poor fetal oxygenation.
47. Answer: 3. Active phase. Cervical dilation occurs more rapidly during the active phase than
any of the previous phases. The active phase is characterized by cervical dilation that progresses
from 4 to 7 cm. The preparatory, or latent, phase begins with the onset of regular uterine
contractions and ends when rapid cervical dilation begins. Transition is defined as cervical
dilation beginning at 8 cm and lasting until 10 cm or complete dilation.
48. Answer: 3. Perform a pelvic examination. A complaint of rectal pressure usually indicates
a low presenting fetal part, signaling imminent delivery. The nurse should perform a pelvic
examination to assess the dilation of the cervix and station of the presenting fetal part.
49. Answer: 3. Passageway, contractions, placental position and function, psychological
response. The five essential factors (5 Ps) are passenger (fetus), passageway (pelvis), powers
(contractions), placental position and function, and psyche (psychological response of the
mother).
50. Answer: 1. Fetal body part that enters the maternal pelvis first. Presentation is the fetal
body part that enters the pelvis first; its classified by the presenting part; the three main
presentations are cephalic/occipital, breech, and shoulder. The relationship of the presenting fetal
part to the maternal pelvis refers to fetal position. The relationship of the long axis to the fetus to
the long axis of the mother refers to fetal lie; the three possible lies are longitudinal, transverse,
and oblique.
51. Answer: 3. Uterine rupture. Uterine rupture is a medical emergency that may occur before
or during labor. Signs and symptoms typically include abdominal pain that may ease after uterine
rupture, vomiting, vaginal bleeding, hypovolemic shock, and fetal distress. With placental
abruption, the client typically complains of vaginal bleeding and constant abdominal pain.
52. Answer: 1. Fetal presenting part is 1 cm above the ischial spines. Station of 1 indicates
that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic
inlet. A station of zero would indicate that the presenting part has passed through the inlet and is

at the level of the ischial spines or is engaged. Passage through the ischial spines with internal
rotation would be indicated by a plus station, such as + 1. Progress of effacement is referred to
by percentages with 100% indicating full effacement and dilation by centimeters (cm) with 10
cm indicating full dilation.
53. Answer: 4. Variability averages between 6 10 BPM. Variability indicates a well
oxygenated fetus with a functioning autonomic nervous system. FHR should accelerate with fetal
movement. Baseline range for the FHR is 120 to 160 beats per minute. Late deceleration
patterns are never reassuring, though early and mild variable decelerations are expected,
reassuring findings.
54. Answer: 2. Stop the Pitocin. Late deceleration patterns noted are most likely related to
alteration in uteroplacental perfusion associated with the strong contractions described. The
immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocic which
stimulates the uterus to contract. The woman is already in an appropriate position for
uteroplacental perfusion. Elevation of her legs would be appropriate if hypotension were present.
Oxygen is appropriate but not the immediate action.
55. Answer: 4. Hypotension. Epidural anesthesia can lead to vasodilation and a drop in blood
pressure that could interfere with adequate placental perfusion. The woman must be well
hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate
blood pressure. Headache is not a side effect since the spinal fluid is not disturbed by this
anesthetic as it would be with a low spinal (saddle block) anesthesia; 2 is an effect of epidural
anesthesia but is not the most harmful. Respiratory depression is a potentially serious
complication.
56. Answer: 4. Uses the peribottle to rinse upward into her vagina. Responses 1, 2, and 3 are
all appropriate measures. The peri bottle should be used in a backward direction over the
perineum. The flow should never be directed upward into the vagina since debris would be
forced upward into the uterus through the still-open cervix.
57. Answer: 3. Massage the fundus every hour for the first 24 hours following birth. The
fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to
relax. Responses 1, 2, and 4 are all effective measures to enhance and maintain contraction of
the uterus and to facilitate healing.
58. Answer: 3. Vacillate between the desire to have her own nurturing needs met and the
need to take charge of her own care and that of her newborn. One week after birth the
woman should exhibit behaviors characteristic of the taking-hold stage as described in response
3. This stage lasts for as long as 4 to 5 weeks after birth. Responses 1 and 2 are characteristic of

the taking-in stage, which lasts for the first few days after birth. Response 4 reflects the lettinggo stage, which indicates that psychosocial recovery is complete.
59. Answer: 4. Take the baby back to the nursery, reassuring the woman that her rest is a
priority at this time. Response 1 does not take into consideration the need for the new mother to
be nurtured and have her needs met during the taking-in stage. The behavior described is typical
of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers
need to reestablish their own well-being in order to effectively care for their baby.
60. Answer: 1. Having the children choose or make a gift to give to the new baby upon its
arrival home. Special time should be set aside just for the other children without interruption
from the newborn. Someone other than the mother should carry the baby into the home so she
can give full attention to greeting her other children. Children should be actively involved in the
care of the baby according to their ability without overwhelming them.