CA ANSWER AND RATIONALES

A 22-year-old female client has missed two of her regular menstrual periods. Her doctor confirms an early
intrauterine pregnancy. This is her first pregnancy. To determine her expected due date, which of the
following assessments is most important?
a. Dates of first menstrual period
b. Date of last intercourse
c. Dates of the last normal menstrual period
d. Age at menarche
• This is important especially the first day of the last menstrual period because it is used to determine
the expected date of delivery thru the use of Naegele’s rule.

Which hormone is produced in high levels to prepare the endometrium for implantation just after ovulation
by the corpus luteum?
a. Estrogen
b. Prostaglandins
c. Prolactin
d. Progesterone
• Estrogen is responsible for the growth of the uterine lining during the first part of the menstrual
cycle.
• Before a period begins, the cells that form the lining of the uterus, also called endometrial cells,
begin to break down during menstruation and release large amounts of inflammatory
prostaglandins. These chemicals constrict the blood vessels in the uterus and make the muscle layer
contract, causing painful cramps.
• Prolactin – hormone responsible for milk production

A 24-year-old woman is pregnant with her first baby. During her seventh month, she complains of
backache. Which of the following would the nurse teach her to do?
a. Sleep on a soft mattress
b. Walk barefoot at least once a day
c. Perform Kegel exercise once a day
d. Wear low-heeled shoes
• The frequent cause of backache in the 3rd trimester of pregnancy is the combined effect of relaxation
of the sacro-iliac joints and the change of in the center of gravity of the pregnant woman due to the
enlarging uterus.
• Wearing a low-heeled shoe, especially when on her feet for extended periods of time, will help
minimize this discomfort.

A 25-year-old pregnant client has been coming to the prenatal clinic on a regular basis. She is on her 5th
month of pregnancy and been suffering from morning sickness since her early pregnancy. She is now
concerned about her feeling weak and exhausted because her vomiting continued. She was hospitalized and
diagnosed as having hyperemesis gravidarum. Fluid therapy was started and still vomited twice within the
last hour. As her nurse, what will be your immediate nursing intervention?
a. Notify her physician
b. Assist her with mouth care
c. Change the IV infusion to Lactated Ringers
d. Warm her food and serve to her
• Frequent vomiting irritates the oral mucosa and leaves the mouth very dry and foul tasting.
• The first nursing action should be aimed at relieving irritation and drying of the mouth by providing
mouth care

A woman in her 7th month of pregnancy has a hemoglobin of 10.5 gm. As her nurse, you teach her about
the proper nutrition during pregnancy. Which statement made by the client indicates that your teaching was
effective?
a. I’ll eat six small meals a day
b. I’ll have an orange for breakfast
c. I’ll eat pork liver once a week
d. I’ll have green leafy vegetable occasionally
• Liver contains more iron than any other food sources and pork liver is the best source of iron.

During an initial prenatal visit, a woman states that her LMP began on November 21; she also reports some
vaginal bleeding in December 19. Based on the given information, when will be the expected date of
delivery of the client?
a. July 21
b. August 28
c. September 26
d. October 1
• Last menstrual Period:
November 21 = Using the formula of the Naegele’s Rule
11 21
-3 + 7
8 28

Mrs. Garcia is making her first visit at the PNC. She has 2year-old-son born at 40 weeks, a 5-year-old
daughter born at 38 weeks, and 7year-old twin daughters born at 35 weeks. She had a spontaneous abortion
3 yrs. ago at 10 weeks. Using the GTFAL format, the nurse should identify that the client is:
a. G4T3P2A1L4
b. G5T2P2A1L4
c. G5T2P1A1L4
d. G4T3P1A1L4
• G T P A L
5 2 1 1 4
Pregnsncy Born @ 40wks born @ 10wks 4 living children
38 wks 35wks

After the first 3 months of pregnancy, which among the following is the chief source of estrogen and
progesterone?
a. Anterior hypophysis
b. Adrenal cortex
c. Placenta
d. Corpus luteum
• Anterior pituitary secretes luteinizing hormone (LH) and follicle-stimulating hormone (FSH),
thyroid-stimulating hormone (TSH)], [adrenocorticotropic hormone (ACTH)]
• Adrenal cortex - produces hormones that controls sex (androgens, estrogens), salt balance in the
blood (aldosterone), and sugar balance (cortisol)
• Corpus luteum – The corpus luteum is actually a temporary gland structure. It secretes the
hormones estrogen and progesterone to prepare the body for the possibility of conception

A 26-year-old woman comes to the clinic because she thinks she is pregnant. Which of the following is a
probable sign of pregnancy that the nurse would expect this client to have?
a. Fetal heart tones
b. Nausea and vomiting
c. Amenorrhea
d. Chadwick sign
• Fetal heart tone is a positive sign
• Nausea, vomiting and amenorrhea are presumptive signs

The client is entering the 20th week of gestation, knowing the normal changes of pregnancy, which normal
change would the nurse expect to find during assessment?
a. The fundus is just below the diaphragm
b. Pigment changes in the skin
c. Complaints of frequent urination
d. Blood pressure returning to pre-pregnant level
• From 20-24 weeks of gestation, pigment changes in skin may occur from the actions of hormones.
• This include the linea nigra, melasma on the face and striae gravidarum

A young woman had her pregnancy confirmed and has completed her first prenatal visit. Considering that
all data were found to be within normal limits, as the clinic nurse who examined her, when will you schedule
her next visit to your clinic?
a. After a week
b. After two weeks
c. After four weeks
d. After eight weeks
• In a low risk pregnancy, the recommended frequency of prenatal visits is :
• Every 4 weeks for the first 28 weeks
• Every 2 weeks until the 36th week
• Every week until birth

A young couple has just completed a preconception visit in the maternity clinic. Before leaving, the woman
asks the nurse why she was instructed not to take any over-the-counter medications. The nurse should reply:
a. “Research has found that many of these drugs have been linked to problems with getting pregnant”
b. “At conception, and in the first trimester, these drugs can be as dangerous to the fetus as prescription
drugs”
c. “You should only take drugs that the physician has ordered during pregnancy”
d. “Any drug is dangerous at this time and it won’t matter anymore later on in pregnancy”
• It is best to avoid any medication when planning a pregnancy and during the first trimester
• The greatest potential for gross abnormalities in the fetus occurs during the 1 st trimester when
organs are first developing.
• The greatest danger extends from day 31 after the last menstrual period until day 71

A parturient, 36 weeks gestation, is having a contraction stress test (CST) with an oxytocin IV infusion
pump. After 2 contractions, the uterus stays contracted. What is the best initial action of the nurse to do?
a. Help the client to turn on her left side
b. Turn off the infusion pump
c. Wait 3 minutes for the uterus to relax
d. Administer PRN Terbutaline Sulfate
• When IV oxytocin is used to stimulate uterine contractions in a contraction stress test, the oxytocin
infusion is stopped if the contractions occur more than every 2 minutes or last longer than 60
seconds, if uterine tetany takes place or if continued fetal heart rate decelerations are noted.

Mrs. Corpus, in her first trimester, is to have transabdominal ultrasound. The nurse would include which of
the following instruction?
a. Nothing by mouth (NPO) from 6:00am of the morning of the test
b. Come to the clinic first for the injection of the contrast dye
c. No special instructions are needed for this test
d. Drink one to two quarts of water and do not urinate before the test
• To obtain clearer images during the 1st trimester, women are required to drink 1-2 quarts of clear
liquid to fill the urinary bladder and thereby push the uterus higher into the abdomen where it can
be more accurately scanned.

Mrs. Cruz who is pregnant for the first time calls the clinic to say that she is bleeding. To obtain the
important information, what will the nurse ask next?
a. “When did you last felt the baby moved?”
b. “When was your pregnancy test done?”
c. “How long have you been pregnant?”
d. “Are you having any uterine cramping?”
• When a pregnant woman is bleeding vaginally, the nurse should ask her how many weeks or months
she is pregnant; management of bleeding differs in an early pregnancy and bleeding in the late
pregnancy. Additional information would include if tissue and amniotic fluid had been discharged
and other symptoms like cramps or pain are present.

Carina consulted a PNC clinic and she was confirmed six weeks pregnant. Before she got pregnant, she
was a chain smoker. After she had completed her first prenatal care, she asked the nurse why she was
advised to stop smoking. We all know that smoking in pregnancy is associated with:
a. Maternal hypertension
b. Fetal macrosomia
c. Low birth weight
d. Fetal microcephaly
• Nicotine in cigarettes causes blood vessel constriction. When maternal blood vessels constrict only
some nutrients will be supplied to the baby and that causes low birth weight.
• When a pregnant mother is smoking she loses appetite to eat.

In every stage of labor there is completion of action before going to the next stage. When is the second
stage of labor completed?
a. When the baby is delivered
b. When the cervix is fully dilated
c. When the placenta separates
d. When the placenta is delivered completely

The pregnant mother asks the nurse what is the purpose of prepared childbirth classes. The nurse’s best
response is:
a. “The main goal of most types of childbirth classes is to provide information that will help eliminate
fear and anxiety”
b. “The desired goal is childbirth without the use of analgesics”
c. “These classes help to reduce the pain of childbirth by exercise and relaxation method”
d. “The primary aim is to keep you and your baby healthy during pregnancy and after”
• All programs in prepared childbirth have some similarities: all have an educational component to
help eliminate fear

This refers to a period of life in which the reproductive organs undergo a surge in development and reach
maturity.
a. Menarche
b. Thelarche
c. Puberty
d. Gonadarche

Menstrual cycle is important to women because of the following, except:

a. It provides important body chemicals, called hormones
b. It prepares your body for pregnancy each month
c. It keeps the body healthy
d. It gives the woman an experience to feel dysmenorrhea

A woman is hospitalized with a possible ectopic pregnancy. In addition to the classic symptoms of
abdominal pain, amenorrhea and abnormal vaginal bleeding, the nurse knows that which of the following
factors in the woman’s history may be associated with this condition?
a. Multiparity
b. Age under 20
c. Pelvic Inflammatory Disease (PID)
d. Habitual spontaneous abortions
• The incidence of ectopic pregnancy has increased during the recent years. This is attributed
primarily to the growing number of women of childbearing age who experience PID and
endometriosis who use IUD or has had tubal surgery

A woman 40 weeks gestation is admitted to the labor and delivery unit with possible placenta previa. On
the admitting assessment, the nurse would expect to find:
a. Signs of Couvelaire uterus
b. Severe lower abdominal pain
c. Painless vaginal bleeding
d. A board-like abdomen
• Placenta Previa is when the placenta is implanted in the lower uterine segment, often is
characterized by sudden onset of bright red bleeding in the third trimester. Usually this bleeding is
painless and may or may not be accompanied by contractions.

A woman is being discharged after treatment of hydatidiform mole. The nurse should include which of the
following in the discharge teaching plan?
a. Do not become pregnant for at least one year
b. Have blood pressure checked weekly for 6 months
c. RhoGAM must be received with next pregnancy and delivery
d. An amniocentesis can detect a recurrence of this disorder in the future
• The follow-up protocol of critical importance after a molar pregnancy is the assessment of serum
chorionic gonadotropin (HCG); HCG is considered a highly specific tumor marker for gestational
trophoblastic disease (GTD). The HCG levels are assayed at interval for 1 year; a rise or plateau
necessitates further diagnostic assessment and usually treatment. Pregnancy would obscure or
conceal the evidence of choriocarcinoma by the normal secretion of HCG.

Marta, 32 weeks gestation, has developed mild PIH. The nurse evaluates that the client understands her
treatment regimen when she states that:
a. “It is most important not to miss any of my blood pressure medication.”
b. “I will watch my diet restrictions very carefully.”
c. “I will spend most of my time in bed, on my left side.”
d. “I’m happy that this only happens during the first pregnancy.”
• A modified bed rest in the left lateral position may be advised for the client with mild PIH. This
position improves venous return and placental and renal perfusion; urine output increases, and
blood pressure may stabilize or decrease.

Nurse Cherry includes the importance of self-monitoring of glucose in the care plan for a diabetic client
planning a pregnancy. The goal of this monitoring is to prevent:
a. Congenital malformations in the fetus
b. Maternal vasculopathy
c. Accelerated growth of the fetus
d. Delayed maturation of the fetal lungs
• Maternal diabetes has toxic effects on the development of the embryo and significantly increases
the risk of congenital malformations in humans.

A woman is hospitalized for the treatment of severe preeclampsia. Which of the following represents an
unusual finding for this condition?
a. Blood Pressure of 160/100
b. Proteinuria 3+
c. Generalized edema
d. Convulsions
• Convulsions are associated with an eclamptic condition
When caring for a client with episiotomy during postpartum period, the nurse encourages sitz bath three
times a day for 15 minutes. Sitz bath primarily aids the healing process of:
a. Promoting vasodilation
b. Softening of incision site
c. Cleansing the perineal area
d. Tightening the anal sphincter

The nurse is aware that an adaptation of pregnancy is an increased blood supply to the pelvic region that
results in a purplish discoloration of the vaginal mucosa, which is known as:
a. Ladin’s sign
b. Hegar’s sign
c. Goodell’s sign
d. Chadwick’s sign

The signs and symptoms of abruptio placenta depends on the amount of placental separation and type of
abruption. Which of the following would the nurse assess a classic symptom?
a. Painless bright-red bleeding
b. “Knife-like” abdominal pain
c. Excessive nausea and vomiting
d. Hypertension and headache

You are the duty nurse who is assessing a woman admitted for a possible ectopic pregnancy. You should
ask the woman about the presence of which of the following?
a. Profuse, bright red vaginal bleeding
b. Right or left colicky abdominal pain
c. Nausea and vomiting
d. Dyspareunia

Which of the following rationales best explains why a pregnant client should lie on her left side when
resting or sleeping in the later stages of pregnancy?
a. To facilitate digestion
b. To facilitate bladder emptying
c. To prevent compression of the vena cava
d. To avoid development of fetal anomalies

What would be the most appropriate recommendation to a pregnant client who complains of swelling in
her feet and ankles?
a. Limit fluid intake
b. Buy comfortable walking shoes
c. Sit and elevate the feet twice a day
d. Start taking diuretics as needed daily

A 32-year-old client is 38 weeks pregnant when admitted to the Labor Unit. According to the GTPAL
system, she is G5 P1212. Which description does this indicate?
a. Total of 5 pregnancies, 1 full-term pregnancy, 2 problematic pregnancies, 1 spontaneous abortion
and 2 live births
b. Total of 5 pregnancies, 1 full-term pregnancy, 2 problem pregnancies, 1 abortion and 2 live births
c. Total of 5 pregnancies, 1 full-term pregnancy, 2 preterm pregnancies, 1 abortion and 2 live births
d. Total of 5 problem pregnancies, 1 full-term pregnancy, 2 problem pregnancies, 1 abortion and 2
live births
A client in early labor is concerned about the pinkish “stretch marks” on her abdomen. Which of the
following observations by the nurse shows an accurate understanding of the marks on the client’s abdomen?
a. Striae are common in pregnancy and will fade away completely after the uterus returns to its pre-
pregnant state.
b. Striae are common in pregnancy, will fade after delivery but won’t disappear
c. Striae are common in pregnancy and will fade away after application of an emollient cream
d. This is a sign of separation of the rectus muscle and will require further assessment by the physician

A client who is pregnant is being prepared for a pelvic examination. The client complains of being very
tired and sick to her stomach, especially in the morning. What would be the best response that the nurse
will make?
a. “This is common and there is no need to worry.”
b. “Can you tell me how you feel in the morning?”
c. “Perhaps you can consult your OB so she can give you medication for that.”
d. “Let’s discuss some ways to deal with these common problems.”

A 36 weeks AOG client went to her prenatal check-up and complains of discomfort with irregularly
occurring contractions. What instruction will the nurse give in response to the complaint of the client?
a. Lie down until they stop
b. Walk around until they subside
c. Time the contractions for 30 minutes
d. Take 10 grains of Aspirin for the discomfort

37. Lenie on her fifth month of pregnancy was prescribed an ultrasonography by her OB. The result
indicated that the fetus is small for gestational age and there is evidence of a low-lying placenta. The nurse
would use this information in the last trimester of pregnancy by assessing the client for signs of possible:
a. Preterm labor
b. Placenta previa
c. Precipitate birth
d. Abruptio placenta

A client a 12 weeks gestation comes to the prenatal clinic complaining of severe nausea and frequent
vomiting. The nurse suspects that this client has hyperemesis gravidarum. The nurse knows that this
condition is frequently associated with:
a. Excessive amniotic fluid
b. A GI history of cholecystitis
c. High levels of chorionic gonadotropin
d. Slowed secretion of free hydrochloric acid

The nurse knows that the care of client with placenta previa includes which of the following?
a. Vital signs at least once every shift
b. A tap-water enema before delivery
c. Observation and recording of the bleeding
d. Limited ambulation until bleeding stops

Michelle, who is in the third trimester of pregnancy comes to the hospital with complaint of vaginal
bleeding. She states that she snorted cocaine approximately 3 hours ago. Which complication is most likely
causing Michelle’s vaginal bleeding?
a. Placenta previa
b. Ectopic pregnancy
c. Abruptio placenta
d. Spontaneous abortion

Nurse Grace is reviewing true and false labor signs with Mrs. Cruz, who is a multiparous client. Nurse
Grace determines that Mrs. Cruz understands the signs of true labor if she makes which of the following
statement?
a. “I won’t be in labor not until my baby engages.”
b. “My contractions will be felt mostly in the abdominal area.”
c. “My contractions will not be as painful if I walk around.”
d. “My contractions will increase in duration and intensity.”

Nurse Corrine is caring for a client in labor. She determines that the client is in the beginning of the second
stage of labor when which of the following assessments is noted?
a. The contractions are regular.
b. The membranes have ruptured.
c. The cervix is dilated completely.
d. The client begins to expel clear vaginal bleeding.

Nurse Cecilia is performing an assessment of a client who is scheduled for a cesarean delivery. Which
assessment finding would indicate an immediate need to contact the physician?
a. Hemoglobin of 11.0g/dl
b. Fetal heart tone of 180 bpm
c. Maternal pulse rate of 90 bpm
d. White blood cell count of 12, 000/mm3

A nurse has provided a discharge instruction to a client who delivered via cesarean delivery to a healthy
baby boy. When asked to restate the instructions, which statement if made by the client indicates a need for
further instruction?
a. “I will notify the physician if I develop a fever.”
b. “I will begin abdominal exercise to decrease the size.”
c. “I will turn on my sides and push up with my arms to get out of the bed.”
d. “I will lift nothing heavier than the newborn infant for at least two weeks.”

In the practice of your profession as a LDR nurse, you are performing a vaginal assessment on a pregnant
client in labor. You noted that the presence of the umbilical cord protruding from the vagina. Which of the
following is your initial nursing action?
a. Gently push the cord into the vagina.
b. Place a pillow under her buttocks.
c. Find the closest telephone and page the physician STAT.
d. Call the delivery room to notify the staff that a client will be transported.

A nurse is monitoring a client who is in the active stage of labor. The client has been experiencing
contractions that are short, irregular and weak. The nurse documents that the client is experiencing which
type of labor dystocia?
a. Hypertonic
b. Precipitous
c. Hypotonic
d. Preterm labor
True labor can be differentiated from false labor because in true labor, contractions will:
a. Bring about progressive effacement and dilatation of the cervix
b. Occur immediately after membrane ruptures
c. Stop when the client is encouraged to ambulate around
d. Be less uncomfortable if client is in a side lying position

A client who is a G1P0 is admitted in labor room. Her cervix is 100% effaced, has 3cm cervical dilatation.
Her fetus is at station +1. The nurse is very much aware that the fetal head is:
a. Not yet engaged
b. Entering the pelvic inlet
c. Below the ischial spine
d. Visible at the vaginal opening

Nurse Clara is doing her round in the postpartum ward. She checked on a client who delivered a day ago.
She noted that the client’s fundus is above the umbilicus and displaced to the right. The nurse evaluates that
the client probably has:
a. A slow rate of involution
b. Retained placental fragments
c. Over-stretched uterine ligaments
d. A full, over distended bladder

The nurse observes the client’s amniotic fluid and decides that it appears normal, because it is:
a. Clear and dark amber
b. Milky, greenish yellow and containing little white specks
c. Clear almost colorless and containing little white specks
d. Cloudy, greenish yellow and containing little white specks

Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which

symptoms should alert the nurse to the possibility of an ectopic pregnancy?
a. Hyperemesis and weight loss
b. Unilateral lower abdominal tenderness and positive pregnancy test
c. Amenorrhea and a negative pregnancy test
d. Copious discharge of clear mucous and prolonged epigastric pain

Nurse Ela is caring for a woman who is admitted to the hospital in active labor. What information is most
important for the nurse to assess to avoid respiratory complications during labor and delivery?
a. Family history of lung disease
b. Food or drug allergies
c. Number of cigarettes smoked daily
d. When the client last ate
• Gastric motility is decreased during pregnancy.
• Food eaten several hours prior to the onset of labor may still be in the stomach undigested
• This will influence the type of anesthesia the client may receive.

A woman, a gravida 1 is in the active phase of stage 1 labor. During history taking and assessment, she said
that she had been religiously going to the PNC on her time of appointment and no problems arise. The FHT
is 145bpm and the fetal position is LOA. When her membranes rupture, what will the nurse expect to see?
a. A large amount of bloody fluid
b. A moderate amount of clear to straw-colored fluid
c. A small amount of greenish
d. A small segment of the umbilical cord.
• With a baby in a vertex, LOA presentation and no other indication of stress, amniotic fluid should
be clear to straw-colored.

Nurse Ellen is caring for a woman in 1st stage of labor. The fetal position is LOA, when her membranes
ruptured, Nurse Ellen’s first action should be to:
a. Notify the physician
b. Measure the amount of fluid
c. Count the fetal heart rate
d. Perform a vaginal examination
• Immediately after the rupture of membranes, the fetal heart tones are checked to monitor for fetal
distress.
• They should be checked after the next contraction or after 5-10 minutes

Mrs. Carlos, a G3P2 has just delivered a 9lb. 10oz. baby boy. After delivery, Nurse Fe notices that Mrs.
Carlos is chilly and her fundus has relaxed. Nurse Fe administers the oxytocin ordered by the physician.
We can say that the expected effect of the medicine had been achieved when:
a. Mrs. Carlos states that she feels warmer now
b. Mrs. Carlos slept very well
c. The baby started breastfeeding
d. The uterus becomes firm and contracted
• Oxytocic medication such as Pitocin, Methergin and Ergotrate are administered to stimulate uterine
contractility and reverse fundal relaxation in the post-delivery client

An ultrasound is performed on a client at a full term G2P1 who is experiencing moderate vaginal bleeding
with pain. The results of the ultrasound indicate that an abruptio placentae is present. Based on these
findings, the nurse would prepare the client for:
A. Complete bed rest for the remainder of the pregnancy
B. Delivery of the fetus
C. Strict monitoring of intake and output
D. The need for weekly monitoring of coagulation studies until the time of delivery
• 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.

Which of the following is described as premature separation of a normally implanted placenta during the
second half of pregnancy, usually with severe hemorrhage?
A. Placenta previa
B. Ectopic pregnancy
C. Incompetent cervix
D. Abruptio placentae
• Abruptio placentae is described as premature separation of a normally implanted placenta during
the second half of pregnancy, usually with severe hemorrhage.
• Placenta previa refers to implantation of the placenta in the lower uterine segment, causing painless
bleeding in the third trimester of pregnancy.
• Ectopic pregnancy refers to the implantation of the products of conception in a site other than the
endometrium.
• Incompetent cervix is a conduction characterized by painful dilation of the cervical os without
uterine contractions.

A maternity nurse is caring for a client with abruptio placentae and is monitoring the client for disseminated
intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated
intravascular coagulation?
A. Swelling of the calf in one leg
B. Prolonged clotting times
C. Decreased platelet count
D. Petechiae, oozing from injection sites, and hematuria
• 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.

A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks’
gestation. She’s at risk for which of the following blood dyscrasias?
A. Thrombocytopenia.
B. Idiopathic thrombocytopenic purpura (ITP).
C. Disseminated intravascular coagulation (DIC).
D. Heparin-associated thrombosis and thrombocytopenia (HATT).
• Abruptio placentae is a cause of DIC because it activates the clotting cascade after hemorrhage.
• Option A: Thrombocytopenia results from decreased production of platelets.
• Option B: ITP doesn’t have a definitive cause.
• Option D: A patient with abruptio placentae wouldn’t get heparin and, as a result, wouldn’t be at
risk for HATT.

Which of the following would the nurse assess in a client experiencing abruptio placenta?
A. Bright red, painless vaginal bleeding
B. Concealed or external dark red bleeding
C. Palpable fetal outline
D. Soft and nontender abdomen
• A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting
sudden intense localized uterine pain. The uterus is typically firm to board-like, and the fetal
presenting part may be engaged.
• Bright red, painless vaginal bleeding, a palpable fetal outline and a soft nontender abdomen are
manifestations of placenta previa.

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?
A. Absence of abdominal pain
B. A soft abdomen
C. Uterine tenderness
D. Painless, bright red vaginal bleeding
• In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompany
placental abruption, especially with a central abruption and trapped blood behind the placenta. The
abdomen will feel hard and board-like 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 the failure of the uterus to relax in an attempt to constrict blood vessels and control
bleeding.

Mr. & Mrs. Torres wants to conceive but has been unsuccessful during the last 2 years has undergone many
diagnostic procedures. When discussing the situation with the nurse, Mrs. Torres states, “We know several
friends in our age group and all of them have their own child already, Why can’t we have one?”. Which of
the following would be the most pertinent nursing diagnosis for this couple?
A. Self-esteem disturbance related to infertility.
B. Ineffective family coping related to infertility.
C. Pain related to numerous procedures.
D. Fear related to the unknown
• Based on the partner’s statement, the couple is verbalizing feelings of inadequacy and negative
feelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem
 disturbance is most appropriate. Fear, pain, and ineffective family coping also may be present but
as secondary nursing diagnoses.

Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction
of labor?
A. Increased pain with bright red vaginal bleeding
B. Tetanic contractions prolonged to more than 90 seconds
C. Increased restlessness and anxiety
D. Weak contraction prolonged to more than 70 seconds
• Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in
tetanic contractions prolonged to more than 90seconds, which could lead to such complications as
fetal distress, abruptio placentae, amniotic fluid embolism, laceration of the cervix, and uterine
rupture.
• Weak contractions would not occur. Pain, bright red vaginal bleeding, and increased restlessness
and anxiety are not associated with hyperstimulation.

During which of the following would the focus of classes be mainly on physiologic changes, fetal
development, sexuality, during pregnancy, and nutrition?
A. Third trimester
B. Second trimester
C. First trimester
D. Prepregnant period
• First-trimester classes commonly focus on such issues as early physiologic changes, fetal
development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant
couples.
• Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.

Which of the following fundal heights indicates less than 12 weeks’ gestation when the date of the LMP is
unknown?
A. Uterus in the pelvis
B. Uterus in the abdomen
C. Uterus at the umbilicus
D. Uterus at the xiphoid
• When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or position
(fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks’ gestation.
• At approximately 12 to 14 weeks, the fundus is out of the pelvis above the symphysis pubis.
• The fundus is at the level of the umbilicus at approximately 20 weeks’ gestation and,
• Reaches the xiphoid at term or 40 weeks.

During which of the following stages of labor would the nurse assess “crowning”?
A. Third stage
B. Fourth stage
C. First stage
D. Second stage
• Crowing, which occurs when the newborn’s head or presenting part appears at the vaginal opening,
occurs during the second stage of labor.
• During the first stage of labor, cervical dilation and effacement occur.
• During the third stage of labor, the newborn and placenta are delivered.
• The fourth stage of labor lasts from 1 to 4 hours after birth, during which time the mother and
newborn recover from the physical process of birth and the mother’s organs undergo the initial
readjustment to the nonpregnant state.
Heartburn and flatulence, common in the second trimester, are most likely the result of which of the
following?
A. Elevated estrogen levels
B. Decreased intestinal motility
C. Decreased gastric acidity
D. Increased plasma HCG levels
• During the second trimester, the reduction in gastric acidity in conjunction with pressure from the
growing uterus and smooth muscle relaxation, can cause heartburn and flatulence.
• HCG levels increase in the first, not the second, trimester.
• Decrease intestinal motility would most likely be the cause of constipation and bloating.
• Estrogen levels decrease in the second trimester.

Which of the following amounts of blood loss following birth marks the criterion for describing postpartum
hemorrhage?
A. More than 200 ml
B. More than 500 ml
C. More than 400 ml
D. More than 300 ml
• Postpartum hemorrhage is defined as blood loss of more than 500 ml. following birth. Any amount
less than this not considered postpartum hemorrhage.

Which of the following common emotional reactions to pregnancy would the nurse expect to occur during
the first trimester?
A. Awkwardness, clumsiness, and unattractiveness
B. Ambivalence, fear, fantasies
C. Anxiety, passivity, extroversion
D. Introversion, egocentrism, narcissism
• During the first trimester, common emotional reactions include ambivalence, fear, fantasies, or
anxiety.
• The second trimester is a period of well-being accompanied by the increased need to learn about
fetal growth and development. Common emotional reactions during this trimester include
narcissism, passivity, or introversion. At times the woman may seem egocentric and self-centered.
• During the third trimester, the woman typically feels awkward, clumsy, and unattractive, often
becoming more introverted or reflective of her own childhood.

When PROM occurs, which of the following provides evidence of the nurse’s understanding of the client’s
immediate needs?
A. PROM removes the fetus most effective defense against infection
B. The chorion and amnion rupture 4 hours before the onset of labor.
C. Nursing care is based on fetal viability and gestational age.
D. PROM is associated with malpresentation and possibly incompetent cervix
• PROM can precipitate many potential and actual problems; one of the most serious is the fetus loss
of an effective defense against infection. This is the client’s most immediate need at this time.
• Typically, PROM occurs about 1 hour, not 4 hours, before labor begins.
• Fetal viability and gestational age are less immediate considerations that affect the plan of care.
• Malpresentation and an incompetent cervix may be causes of PROM.

When uterine rupture occurs, which of the following would be the priority?
A. Instituting complete bed rest
B. Inserting a urinary catheter
C. Obtaining blood specimens
D. Limiting hypovolemic shock
• With uterine rupture, the client is at risk for hypovolemic shock. Therefore, the priority is to prevent
and limit hypovolemic shock. Immediate steps should include giving oxygen, replacing lost fluids,
providing drug therapy as needed, evaluating fetal responses and preparing for surgery.
• Obtaining blood specimens, instituting complete bed rest, and inserting a urinary catheter are
necessary in preparation for surgery to remedy the rupture.

Nurse Andrea is talking with a pregnant client who is experiencing aching swollen, leg veins, the Nurse
Andrea would explain that this is most probably the result of which of the following?
A. Thrombophlebitis
B. Pregnancy-induced hypertension
C. Pressure on blood vessels from the enlarging uterus
D. The force of gravity pulling down on the uterus
• Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the
lower extremities. Subsequently, edema and varicose vein formation may occur.
• Thrombophlebitis is an inflammation of the veins due to thrombus formation.
• Pregnancy-induced hypertension is not associated with these symptoms.
• Gravity plays only a minor role with these symptoms.

Which of the following is true regarding the fontanels of the newborn?

A. The anterior is bulging; the posterior appears sunken.
B. The anterior is triangular shaped; the posterior is diamond shaped.
C. The posterior closes at 18 months; the anterior closes at 8 to 12 weeks.
D. The anterior is large in size when compared to the posterior fontanel.
• The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel,
which is diamond shaped, closes at 18 months, whereas the posterior fontanel, which is triangular
shaped, closes at 8 to 12 weeks.
• Neither fontanel should appear bulging, which may indicate increased intracranial pressure, or
sunken, which may indicate dehydration.

Mrs. Hope was diagnosed having hyperemesis gravidarum. Which of the following statements best
describes the condition?
A. Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the absence of other
medical problems.
B. Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately
decreasing maternal nutrients
C. Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding
D. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence
of other medical problems.
• The description of hyperemesis gravidarum includes severe nausea and vomiting, leading to
electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.
• Hyperemesis is not a form of anemia.
• Loss of appetite may occur secondary to the nausea and vomiting of hyperemesis, which, if it
continues, can deplete the nutrients transported to the fetus.
• Diarrhea does not occur with hyperemesis.

Lucia was admitted in the facility because of preterm labor. Which of the following best describes preterm
labor?
A. Labor that begins after 24 weeks gestation and before 28 weeks gestation
B. Labor that begins after 28 weeks gestation and before 40 weeks gestation
C. Labor that begins after 15 weeks gestation and before 37 weeks gestation
D. Labor that begins after 20 weeks gestation and before 37 weeks gestation
 • Preterm labor is best described as labor that begins after 20 weeks’ gestation and before 37 weeks’
gestation.
• The other time periods are inaccurate.

When assessing the newborn’s heart rate, which of the following ranges would be considered normal if the
newborn were sleeping?
A. 100 beats per minute
B. 80 beats per minute
C. 140 beats per minute
D. 120 beats per minute
• The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute.
• If the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute.

Cervical softening and uterine souffle are classified as which of the following?
A. Diagnostic signs
B. Positive signs
C. Probable signs
D. Presumptive sign
• Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy. Probable
signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar’s
sign, which is softening of the lower uterine segment
• Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary
frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.

Which of the following characteristics of contractions would the nurse expect to find in a client experiencing
true labor?
A. Starting mainly in the abdomen
B. Occurring at irregular intervals
C. Increasing intensity with walking
D. Gradually increasing intervals.
• With true labor, contractions increase in intensity with walking. In addition, true labor contractions
occur at regular intervals, usually starting in the back and sweeping around to the abdomen. The
interval of true labor contractions gradually shortens.

Which of the following nursing interventions would the nurse perform during the third stage of labor?
A. Coach for effective client pushing
B. Promote parent-newborn interaction.
C. Assess uterine contractions every 30 minutes.
D. Obtain a urine specimen and other laboratory tests
• During the third stage of labor, which begins with the delivery of the newborn, the nurse would
promote parent-newborn interaction by placing the newborn on the mother’s abdomen and
encouraging the parents to touch the newborn.
• Collecting a urine specimen and other laboratory tests is done on admission during the first stage
of labor.
• Assessing uterine contractions every 30 minutes is performed during the latent phase of the first
stage of labor.
• Coaching the client to push effectively is appropriate during the second stage of labor.

Maria, a G1P0 client went to you for her prenatal care. After your assessment, she asked when can she hear
the heartbeat of her baby. Based on what you have learned, FHT can be auscultated with a fetoscope as
early as which of the following?
A. 20 weeks gestation
B. 10 weeks gestation
C. 15 weeks gestation
D. 5 weeks gestation
• The FHT can be auscultated with a fetoscope at about 20 week’s gestation.
• FHT usually is auscultated at the midline suprapubic region with Doppler ultrasound transducer at
10 to 12 week’s gestation.
• FHT, cannot be heard any earlier than 10 weeks’ gestation.

Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn?
A. Excess iron
B. Bilirubin
C. Mucus
D. Uric acid crystal
• Uric acid crystals in the urine may produce the reddish “brick dust” stain on the diaper.
• Mucus would not produce a stain.
• Bilirubin and iron are from hepatic adaptation.