PNLE II for Maternal and Child Health

1. For the client who is using oral contraceptives, the nurse informs the client about the
need to take the pill at the same time each day to accomplish which of the following?
A. Decrease the incidence of nausea
B. Maintain hormonal levels
C. Reduce side effects
D. Prevent drug interactions
2. When teaching a client about contraception. Which of the following would the nurse
include as the most effective method for preventing sexually transmitted infections?
A. Spermicides
B. Diaphragm
C. Condoms
D. Vasectomy
3. When preparing a woman who is 2 days postpartum for discharge, recommendations
for which of the following contraceptive methods would be avoided?
A. Diaphragm
B. Female condom
C. Oral contraceptives
D. Rhythm method
4. For which of the following clients would the nurse expect that an intrauterine device
would not be recommended?
A. Woman over age 35
B. Nulliparous woman
C. Promiscuous young adult
D. Postpartum client
5. A client in her third trimester tells the nurse, “I’m constipated all the time!” Which of
the following should the nurse recommend?
A. Daily enemas
B. Laxatives
C. Increased fiber intake
D. Decreased fluid intake
6. Which of the following would the nurse use as the basis for the teaching plan when
caring for a pregnant teenager concerned about gaining too much weight during
pregnancy?
A. 10 pounds per trimester
B. 1 pound per week for 40 weeks
C. ½ pound per week for 40 weeks
D. A total gain of 25 to 30 pounds
7. The client tells the nurse that her last menstrual period started on January 14 and
ended on January 20. Using Nagele’s rule, the nurse determines her EDD to be which of
the following?
A. September 27
B. October 21
C. November 7
D. December 27
8. When taking an obstetrical history on a pregnant client who states, “I had a son born
at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about
8 weeks,” the nurse should record her obstetrical history as which of the following?
A. G2 T2 P0 A0 L2
B. G3 T1 P1 A0 L2
C. G3 T2 P0 A0 L2
D. G4 T1 P1 A1 L2
9. When preparing to listen to the fetal heart rate at 12 weeks’ gestation, the nurse
would use which of the following?
A. Stethoscope placed midline at the umbilicus
B. Doppler placed midline at the suprapubic region
C. Fetoscope placed midway between the umbilicus and the xiphoid process
D. External electronic fetal monitor placed at the umbilicus
10.When developing a plan of care for a client newly diagnosed with gestational
diabetes, which of the following instructions would be the priority?
A. Dietary intake
B. Medication
C. Exercise
D. Glucose monitoring
11.A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the
following would be the priority when assessing the client?
A. Glucosuria
B. Depression
C. Hand/face edema
D. Dietary intake
12. A client 12 weeks’ pregnant come to the emergency department with abdominal
cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms
cervical dilation. The nurse would document these findings as which of the following?
A. Threatened abortion
B. Imminent abortion
C. Complete abortion
D. Missed abortion
13.Which of the following would be the priority nursing diagnosis for a client with an
ectopic pregnancy?
A. Risk for infection
B. Pain
C. Knowledge Deficit
D. Anticipatory Grieving
14.Before assessing the postpartum client’s uterus for firmness and position in relation
to the umbilicus and midline, which of the following should the nurse do first?
A. Assess the vital signs
B. Administer analgesia
C. Ambulate her in the hall
D. Assist her to urinate
15.Which of the following should the nurse do when a primipara who is lactating tells
the nurse that she has sore nipples?
A. Tell her to breast feed more frequently
B. Administer a narcotic before breast feeding
C. Encourage her to wear a nursing brassiere
D. Use soap and water to clean the nipples
16.The nurse assesses the vital signs of a client, 4 hours’ postpartum that are as
follows: BP 90/60; temperature 100.4ºF; pulse 100 weak, thready; R 20 per minute.
Which of the following should the nurse do first?
A. Report the temperature to the physician
B. Recheck the blood pressure with another cuff
C. Assess the uterus for firmness and position
D. Determine the amount of lochia
17.The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which
of the following assessments would warrant notification of the physician?
A. A dark red discharge on a 2-day postpartum client
B. A pink to brownish discharge on a client who is 5 days postpartum
C. Almost colorless to creamy discharge on a client 2 weeks after delivery
D. A bright red discharge 5 days after delivery
18.A postpartum client has a temperature of 101.4ºF, with a uterus that is tender when
palpated, remains unusually large, and not descending as normally expected. Which of
the following should the nurse assess next?
A. Lochia
B. Breasts
C. Incision
D. Urine
19.Which of the following is the priority focus of nursing practice with the current early
postpartum discharge?
 A. Promoting comfort and restoration of health
B. Exploring the emotional status of the family
C. Facilitating safe and effective self-and newborn care
D. Teaching about the importance of family planning
20. Which of the following actions would be least effective in maintaining a neutral
thermal environment for the newborn?
A. Placing infant under radiant warmer after bathing
B. Covering the scale with a warmed blanket prior to weighing
C. Placing crib close to nursery window for family viewing
D. Covering the infant’s head with a knit stockinette
21.A newborn who has an asymmetrical Moro reflex response should be further
assessed for which of the following?
A. Talipes equinovarus
B. Fractured clavicle
C. Congenital hypothyroidism
D. Increased intracranial pressure
22.During the first 4 hours after a male circumcision, assessing for which of the
following is the priority?
A. Infection
B. Hemorrhage
C. Discomfort
D. Dehydration
23.The mother asks the nurse. “What’s wrong with my son’s breasts? Why are they so
enlarged?” Whish of the following would be the best response by the nurse?
A. “The breast tissue is inflamed from the trauma experienced with birth”
B. “A decrease in material hormones present before birth causes enlargement,”
C. “You should discuss this with your doctor. It could be a malignancy”
D. “The tissue has hypertrophied while the baby was in the uterus”
24. Immediately after birth the nurse notes the following on a male
newborn: respirations 78; apical hearth rate 160 BPM, nostril flaring; mild intercostal
retractions; and grunting at the end of expiration. Which of the following should the
nurse do?
A. Call the assessment data to the physician’s attention
B. Start oxygen per nasal cannula at 2 L/min.
C. Suction the infant’s mouth and nares
D. Recognize this as normal first period of reactivity
25.The nurse hears a mother telling a friend on the telephone about umbilical cord care.
Which of the following statements by the mother indicates effective teaching?
A. “Daily soap and water cleansing is best”
 B. ‘Alcohol helps it dry and kills germs”
C. “An antibiotic ointment applied daily prevents infection”
D. “He can have a tub bath each day”
26.A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/kg of
body weight every 24 hours for proper growth and development. How many ounces of
20 cal/oz formula should this newborn receive at each feeding to meet nutritional
needs?
A. 2 ounces
B. 3 ounces
C. 4 ounces
D. 6 ounces
27.The postterm neonate with meconium-stained amniotic fluid needs care designed to
especially monitor for which of the following?
A. Respiratory problems
B. Gastrointestinal problems
C. Integumentary problems
D. Elimination problems
28.When measuring a client’s fundal height, which of the following techniques denotes
the correct method of measurement used by the nurse?
A. From the xiphoid process to the umbilicus
B. From the symphysis pubis to the xiphoid process
C. From the symphysis pubis to the fundus
D. From the fundus to the umbilicus
29.A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and
severe pitting edema. Which of the following would be most important to include in the
client’s plan of care?
A. Daily weights
B. Seizure precautions
C. Right lateral positioning
D. Stress reduction
30. A postpartum primipara asks the nurse, “When can we have sexual intercourse
again?” Which of the following would be the nurse’s best response?
A. “Anytime you both want to.”
B. “As soon as choose a contraceptive method.”
C. “When the discharge has stopped and the incision is healed.”
D. “After your 6 weeks examination.”
31.When preparing to administer the vitamin K injection to a neonate, the nurse would
select which of the following sites as appropriate for the injection?
A. Deltoid muscle
B. Anterior femoris muscle
 C. Vastus lateralis muscle
D. Gluteus maximus muscle
32.When performing a pelvic examination, the nurse observes a red swollen area on the
right side of the vaginal orifice. The nurse would document this as enlargement of which
of the following?
A. Clitoris
B. Parotid gland
C. Skene’s gland
D. Bartholin’s gland
33.To differentiate as a female, the hormonal stimulation of the embryo that must occur
involves which of the following?
A. Increase in maternal estrogen secretion
B. Decrease in maternal androgen secretion
C. Secretion of androgen by the fetal gonad
D. Secretion of estrogen by the fetal gonad
34.A client at 8 weeks’ gestation calls complaining of slight nausea in the morning
hours. Which of the following client interventions should the nurse question?
A. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water
B. Eating a few low-sodium crackers before getting out of bed
C. Avoiding the intake of liquids in the morning hours
D. Eating six small meals a day instead of thee large meals
35.The nurse documents positive ballottement in the client’s prenatal record. The nurse
understands that this indicates which of the following?
A. Palpable contractions on the abdomen
B. Passive movement of the unengaged fetus
C. Fetal kicking felt by the client
D. Enlargement and softening of the uterus
36.During a pelvic exam the nurse notes a purple-blue tinge of the cervix. The nurse
documents this as which of the following?
A. Braxton-Hicks sign
B. Chadwick’s sign
C. Goodell’s sign
D. McDonald’s sign
37.During a prenatal class, the nurse explains the rationale for breathing techniques
during preparation for labor based on the understanding that breathing techniques are
most important in achieving which of the following?
A. Eliminate pain and give the expectant parents something to do
B. Reduce the risk of fetal distress by increasing uteroplacental perfusion
C. Facilitate relaxation, possibly reducing the perception of pain
D. Eliminate pain so that less analgesia and anesthesia are needed
38.After 4 hours of active labor, the nurse notes that the contractions of a primigravida
client are not strong enough to dilate the cervix. Which of the
following would the nurse anticipate doing?
A. Obtaining an order to begin IV oxytocin infusion
B. Administering a light sedative to allow the patient to rest for several hour
C. Preparing for a cesarean section for failure to progress
D. Increasing the encouragement to the patient when pushing begins
39.A multigravida at 38 weeks’ gestation is admitted with painless, bright red bleeding
and mild contractions every 7 to 10 minutes. Which of the following assessments
should be avoided?
A. Maternal vital sign
B. Fetal heart rate
C. Contraction monitoring
D. Cervical dilation
40.Which of the following would be the nurse’s most appropriate response to a client
who asks why she must have a cesarean delivery if she has a complete placenta previa?
A. “You will have to ask your physician when he returns.”
B. “You need a cesarean to prevent hemorrhage.”
C. “The placenta is covering most of your cervix.”
D. “The placenta is covering the opening of the uterus and blocking your baby.”
41.The nurse understands that the fetal head is in which of the following positions with
a face presentation?
A. Completely flexed
B. Completely extended
C. Partially extended
D. Partially flexed
42.With a fetus in the left-anterior breech presentation, the nurse would expect the fetal
heart rate would be most audible in which of the following areas?
A. Above the maternal umbilicus and to the right of midline
B. In the lower-left maternal abdominal quadrant
C. In the lower-right maternal abdominal quadrant
D. Above the maternal umbilicus and to the left of midline
43.The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the
result of which of the following?
A. Lanugo
B. Hydramnio
C. Meconium
D. Vernix
44.A patient is in labor and has just been told she has a breech presentation. The nurse
should be particularly alert for which of the following?
A. Quickening
B. Ophthalmia neonatorum
C. Pica
D. Prolapsed umbilical cord
45.When describing dizygotic twins to a couple, on which of the following would the
nurse base the explanation?
A. Two ova fertilized by separate sperm
B. Sharing of a common placenta
C. Each ova with the same genotype
D. Sharing of a common chorion
46.Which of the following refers to the single cell that reproduces itself
after conception?
A. Chromosome
B. Blastocyst
C. Zygote
D. Trophoblast
47.In the late 1950s, consumers and health care professionals began challenging the
routine use of analgesics and anesthetics during childbirth. Which of the following was
an outgrowth of this concept?
A. Labor, delivery, recovery, postpartum (LDRP)
B. Nurse-midwifery
C. Clinical nurse specialist
D. Prepared childbirth
48.A client has a midpelvic contracture from a previous pelvic injury due to a motor
vehicle accident as a teenager. The nurse is aware that this could
prevent a fetus from passing through or around which structure during childbirth?
A. Symphysis pubis
B. Sacral promontory
C. Ischial spines
D. Pubic arch
49.When teaching a group of adolescents about variations in the length of
the menstrual cycle, the nurse understands that the underlying mechanism is
due to variations in which of the following phases?
A. Menstrual phase
B. Proliferative phase
C. Secretory phase
D. Ischemic phase
50.When teaching a group of adolescents about male hormone production, which of the
following would the nurse include as being produced by the Leydig cells?
A. Follicle-stimulating hormone
B. Testosterone
C. Leuteinizing hormone
D. Gonadotropin releasing hormone
Answers and Rationales

1. B . Regular timely ingestion of oral contraceptives is necessary to

maintain hormonal levels of the drugs to suppress the action of the
hypothalamus and anterior pituitary leading to inappropriate secretion of
FSH and LH. Therefore, follicles do not mature, ovulation is inhibited, and
pregnancy is prevented. The estrogen content of the oral site contraceptive
may cause the nausea, regardless of when the pill is taken. Side effects and
drug interactions may occur with oral contraceptives regardless of the time
the pill is taken.
2. C . Condoms, when used correctly and consistently, are the most
effective contraceptive method or barrier against bacterial and viral
sexually transmitted infections. Although spermicides kill sperm, they do
not provide reliable protection against the spread of sexually
transmitted infections, especially intracellular organisms such as HIV.
Insertion and removal of the diaphragm along with the use of the
spermicides may cause vaginal irritations, which could place the client at risk
for infection transmission. Male sterilization eliminates spermatozoa from
the ejaculate, but it does not eliminate bacterial and/or viral microorganisms
that can cause sexually transmitted infections.
3. A . The diaphragm must be fitted individually to ensure
effectiveness. Because of the changes to the reproductive structures during
pregnancy and following delivery, the diaphragm must be refitted, usually at
the 6 weeks’ examination following childbirth or after a weight loss of 15 lbs
or more. In addition, for maximum effectiveness, spermicidal jelly should
be placed in the dome and around the rim. However, spermicidal jelly
should not be inserted into the vagina until involution is completed
at approximately 6 weeks. Use of a female condom protects the
reproductive system from the introduction of semen or spermicides into the
vagina and may be used after childbirth. Oral contraceptives may be started
within the first postpartum week to ensure suppression of ovulation. For the
couple who has determined the female’s fertile period, using the rhythm
method, avoidance of intercourse during this period, is safe and effective.
4. C . An IUD may increase the risk of pelvic inflammatory disease, especially in
women with more than one sexual partner, because of the increased risk of
sexually transmitted infections. An UID should not be used if the woman has
an active or chronic pelvic infection, postpartum infection, endometrial
hyperplasia or carcinoma, or uterine abnormalities. Age is not a factor in
 determining the risks associated with IUD use. Most IUD users are over the
age of 30. Although there is a slightly higher risk for infertility in women who
have never been pregnant, the IUD is an acceptable option as long as the
risk-benefit ratio is discussed. IUDs may be inserted immediately after
delivery, but this is not recommended because of the increased risk and rate
of expulsion at this time.
5. C . During the third trimester, the enlarging uterus places pressure on
the intestines. This coupled with the effect of hormones on smooth
muscle relaxation causes decreased intestinal motility (peristalsis).
Increasing fiber in the diet will help fecal matter pass more quickly through
the intestinal tract, thus decreasing the amount of water that is absorbed. As
a result, stool is softer and easier to pass. Enemas could precipitate
preterm labor and/or electrolyte loss and should be avoided. Laxatives may
cause preterm labor by stimulating peristalsis and may interfere with
the absorption of nutrients. Use for more than 1 week can also lead to
laxative dependency. Liquid in the diet helps provide a semisolid, soft
consistency to the stool. Eight to ten glasses of fluid per day are essential to
maintain hydration and promote stool evacuation.
6. D . To ensure adequate fetal growth and development during the 40 weeks of
a pregnancy, a total weight gain 25 to 30 pounds is recommended:
1.5 pounds in the first 10 weeks; 9 pounds by 30 weeks; and 27.5 pounds
by 40 weeks. The pregnant woman should gain less weight in the first
and second trimester than in the third. During the first trimester, the
client should only gain 1.5 pounds in the first 10 weeks, not 1 pound per
week. A weight gain of ½ pound per week would be 20 pounds for the
total pregnancy, less than the recommended amount.
7. B . To calculate the EDD by Nagele’s rule, add 7 days to the first day of
the last menstrual period and count back 3 months, changing the
year appropriately. To obtain a date of September 27, 7 days have been
added to the last day of the LMP (rather than the first day of the LMP), plus
4 months (instead of 3 months) were counted back. To obtain the date
of November 7, 7 days have been subtracted (instead of added) from the first
day of LMP plus November indicates counting back 2 months (instead of 3
months) from January. To obtain the date of December 27, 7 days were
added to the last day of the LMP (rather than the first day of the LMP) and
December indicates counting back only 1 month (instead of 3 months) from
January.
8. D. The client has been pregnant four times, including current pregnancy (G).
Birth at 38 weeks’ gestation is considered full term (T), while birth form 20
weeks to 38 weeks is considered preterm (P). A spontaneous abortion
occurred at 8 weeks (A). She has two living children (L).
9. B. At 12 weeks gestation, the uterus rises out of the pelvis and is
palpable above the symphysis pubis. The Doppler intensifies the sound of
the fetal pulse rate so it is audible. The uterus has merely risen out of the
 pelvis into the abdominal cavity and is not at the level of the umbilicus. The
fetal heart rate at this age is not audible with a stethoscope. The uterus at
12 weeks is just above the symphysis pubis in the abdominal cavity,
not midway between the umbilicus and the xiphoid process. At 12 weeks
the FHR would be difficult to auscultate with a fetoscope. Although
the external electronic fetal monitor would project the FHR, the uterus has
not risen to the umbilicus at 12 weeks.
10. A . Although all of the choices are important in the management of diabetes,
diet therapy is the mainstay of the treatment plan and should always be the
priority. Women diagnosed with gestational diabetes generally need only diet
therapy without medication to control their blood sugar levels. Exercise, is
important for all pregnant women and especially for diabetic women,
because it burns up glucose, thus decreasing blood sugar. However, dietary
intake, not exercise, is the priority. All pregnant women with diabetes should
have periodic monitoring of serum glucose. However, those with gestational
diabetes generally do not need daily glucose monitoring. The standard of
care recommends a fasting and 2- hour postprandial blood sugar level every
2 weeks.
11. C. After 20 weeks’ gestation, when there is a rapid weight gain, preeclampsia
should be suspected, which may be caused by fluid retention manifested by
edema, especially of the hands and face. The three classic signs of
preeclampsia are hypertension, edema, and proteinuria. Although urine is
checked for glucose at each clinic visit, this is not the priority. Depression
may cause either anorexia or excessive food intake, leading to excessive
weight gain or loss. This is not, however, the priority consideration at this
time. Weight gain thought to be caused by excessive food intake would
require a 24-hour diet recall. However, excessive intake would not be the
primary consideration for this client at this time.
12. B. Cramping and vaginal bleeding coupled with cervical dilation signifies that
termination of the pregnancy is inevitable and cannot be prevented. Thus, the
nurse would document an imminent abortion. In a threatened abortion,
cramping and vaginal bleeding are present, but there is no cervical dilation.
The symptoms may subside or progress to abortion. In a complete abortion
all the products of conception are expelled. A missed abortion is early fetal
intrauterine death without expulsion of the products of conception.
13. B . For the client with an ectopic pregnancy, lower abdominal pain,
usually unilateral, is the primary symptom. Thus, pain is the priority. Although
the potential for infection is always present, the risk is low in
ectopic pregnancy because pathogenic microorganisms have not been
introduced from external sources. The client may have a limited knowledge
of the pathology and treatment of the condition and will most likely
experience grieving, but this is not the priority at this time.
14. D. Before uterine assessment is performed, it is essential that the
woman empty her bladder. A full bladder will interfere with the accuracy of
 the assessment by elevating the uterus and displacing to the side of
the midline. Vital sign assessment is not necessary unless an abnormality
in uterine assessment is identified. Uterine assessment should not
cause acute pain that requires administration of analgesia. Ambulating the
client is an essential component of postpartum care, but is not necessary
prior to assessment of the uterus.
15. A. Feeding more frequently, about every 2 hours, will decrease the
infant’s frantic, vigorous sucking from hunger and will decrease
breast engorgement, soften the breast, and promote ease of correct
latching-on for feeding. Narcotics administered prior to breast feeding are
passed through the breast milk to the infant, causing excessive sleepiness.
Nipple soreness is not severe enough to warrant narcotic analgesia.
All postpartum clients, especially lactating mothers, should wear a
supportive brassiere with wide cotton straps. This does not, however, prevent
or reduce nipple soreness. Soaps are drying to the skin of the nipples
and should not be used on the breasts of lactating mothers. Dry nipple
skin predisposes to cracks and fissures, which can become sore and painful.
16. D. A weak, thready pulse elevated to 100 BPM may indicate
impending hemorrhagic shock. An increased pulse is a compensatory
mechanism of the body in response to decreased fluid volume. Thus, the
nurse should check the amount of lochia present. Temperatures up to
100.48F in the first 24 hours after birth are related to the dehydrating effects
of labor and are considered normal. Although rechecking the blood pressure
may be a correct choice of action, it is not the first action that should
be implemented in light of the other data. The data indicate a
potential impending hemorrhage. Assessing the uterus for firmness and
position in relation to the umbilicus and midline is important, but the nurse
should check the extent of vaginal bleeding first. Then it would be
appropriate to check the uterus, which may be a possible cause of the
hemorrhage.
17. D. Any bright red vaginal discharge would be considered abnormal,
but especially 5 days after delivery, when the lochia is typically pink
to brownish. Lochia rubra, a dark red discharge, is present for 2 to 3
days after delivery. Bright red vaginal bleeding at this time suggests
late postpartum hemorrhage, which occurs after the first 24 hours
following delivery and is generally caused by retained placental fragments
or bleeding disorders. Lochia rubra is the normal dark red
discharge occurring in the first 2 to 3 days after delivery, containing epithelial
cells, erythrocyes, leukocytes and decidua. Lochia serosa is a pink to
brownish serosanguineous discharge occurring from 3 to 10 days after
delivery that contains decidua, erythrocytes, leukocytes, cervical mucus,
and microorganisms. Lochia alba is an almost colorless to yellowish
discharge occurring from 10 days to 3 weeks after delivery and
 containing leukocytes, decidua, epithelial cells, fat, cervical mucus,
cholesterol crystals, and bacteria.
18. A. The data suggests an infection of the endometrial lining of the uterus. The
lochia may be decreased or copious, dark brown in appearance, and foul
smelling, providing further evidence of a possible infection. All the client’s
data indicate a uterine problem, not a breast problem. Typically, transient
fever, usually 101ºF, may be present with breast engorgement. Symptoms of
mastitis include influenza-like manifestations. Localized infection of an
episiotomy or C-section incision rarely causes systemic symptoms, and
uterine involution would not be affected. The client data do not include
dysuria, frequency, or urgency, symptoms of urinary tract infections, which
would necessitate assessing the client’s urine.
19. C. Because of early postpartum discharge and limited time for teaching, the
nurse’s priority is to facilitate the safe and effective care of the client and
newborn. Although promoting comfort and restoration of health, exploring
the family’s emotional status, and teaching about family planning are
important in postpartum/newborn nursing care, they are not the
priority focus in the limited time presented by early post-partum discharge.
20. C. Heat loss by radiation occurs when the infant’s crib is placed too near cold
walls or windows. Thus placing the newborn’s crib close to the viewing
window would be least effective. Body heat is lost through evaporation
during bathing. Placing the infant under the radiant warmer after bathing will
assist the infant to be rewarmed. Covering the scale with a warmed blanket
prior to weighing prevents heat loss through conduction. A knit cap prevents
heat loss from the head a large head, a large body surface area of the
newborn’s body.
21. B. A fractured clavicle would prevent the normal Moro response
of symmetrical sequential extension and abduction of the arms followed
by flexion and adduction. In talipes equinovarus (clubfoot) the foot is
turned medially, and in plantar flexion, with the heel elevated. The feet are
not involved with the Moro reflex. Hypothyroiddism has no effect on
the primitive reflexes. Absence of the Moror reflex is the most
significant single indicator of central nervous system status, but it is not a
sign of increased intracranial pressure.
22. B. Hemorrhage is a potential risk following any surgical procedure. Although
the infant has been given vitamin K to facilitate clotting, the prophylactic
dose is often not sufficient to prevent bleeding. Although infection is a
possibility, signs will not appear within 4 hours after the surgical procedure.
The primary discomfort of circumcision occurs during the surgical
procedure, not afterward. Although feedings are withheld prior to the
circumcision, the chances of dehydration are minimal.
23. B . The presence of excessive estrogen and progesterone in the maternal
fetal blood followed by prompt withdrawal at birth precipitates
breast engorgement, which will spontaneously resolve in 4 to 5 days after
 birth. The trauma of the birth process does not cause inflammation of
the newborn’s breast tissue. Newborns do not have breast malignancy.
This reply by the nurse would cause the mother to have undue anxiety.
Breast tissue does not hypertrophy in the fetus or newborns.
24. D . The first 15 minutes to 1 hour after birth is the first period of
reactivity involving respiratory and circulatory adaptation to extrauterine life.
The data given reflect the normal changes during this time period. The
infant’s assessment data reflect normal adaptation. Thus, the physician does
not need to be notified and oxygen is not needed. The data do not indicate
the presence of choking, gagging or coughing, which are signs of
excessive secretions. Suctioning is not necessary.
25. B. Application of 70% isopropyl alcohol to the cord
minimizes microorganisms (germicidal) and promotes drying. The cord
should be kept dry until it falls off and the stump has healed. Antibiotic
ointment should only be used to treat an infection, not as a prophylaxis.
Infants should not be submerged in a tub of water until the cord falls off and
the stump has completely healed.
26. B. To determine the amount of formula needed, do the
following mathematical calculation. 3 kg x 120 cal/kg per day = 360
calories/day feeding q 4 hours = 6 feedings per day = 60 calories per feeding:
60 calories per feeding; 60 calories per feeding with formula 20 cal/oz =
3 ounces per feeding. Based on the calculation. 2, 4 or 6 ounces
are incorrect.
27. A. Intrauterine anoxia may cause relaxation of the anal sphincter
and emptying of meconium into the amniotic fluid. At birth some of
the meconium fluid may be aspirated, causing mechanical obstruction
or chemical pneumonitis. The infant is not at increased risk
for gastrointestinal problems. Even though the skin is stained with
meconium, it is noninfectious (sterile) and nonirritating. The postterm
meconiumstained infant is not at additional risk for bowel or urinary
problems.
28. C . The nurse should use a nonelastic, flexible, paper measuring tape, placing
the zero point on the superior border of the symphysis pubis and stretching
the tape across the abdomen at the midline to the top of the fundus. The
xiphoid and umbilicus are not appropriate landmarks to use when measuring
the height of the fundus (McDonald’s measurement).
29. B . Women hospitalized with severe preeclampsia need decreased
CNS stimulation to prevent a seizure. Seizure precautions
provide environmental safety should a seizure occur. Because of edema,
daily weight is important but not the priority. Preclampsia causes
vasospasm and therefore can reduce utero-placental perfusion. The client
should be placed on her left side to maximize blood flow, reduce blood
pressure, and promote diuresis. Interventions to reduce stress and anxiety
 are very important to facilitate coping and a sense of control, but
seizure precautions are the priority.
30. C. Cessation of the lochial discharge signifies healing of the
endometrium. Risk of hemorrhage and infection are minimal 3 weeks after a
normal vaginal delivery. Telling the client anytime is inappropriate because
this response does not provide the client with the specific information she
is requesting. Choice of a contraceptive method is important, but not
the specific criteria for safe resumption of sexual activity. Culturally, the
6- weeks’ examination has been used as the time frame for resuming
sexual activity, but it may be resumed earlier.
31. C . The middle third of the vastus lateralis is the preferred injection site
for vitamin K administration because it is free of blood vessels and
nerves and is large enough to absorb the medication. The deltoid muscle of
a newborn is not large enough for a newborn IM injection. Injections into
this muscle in a small child might cause damage to the radial nerve.
The anterior femoris muscle is the next safest muscle to use in a newborn
but is not the safest. Because of the proximity of the sciatic nerve, the
gluteus maximus muscle should not be until the child has been walking 2
years.
32. D . Bartholin’s glands are the glands on either side of the vaginal orifice. The
clitoris is female erectile tissue found in the perineal area above the urethra.
The parotid glands are open into the mouth. Skene’s glands open into the
posterior wall of the female urinary meatus.
33. D . The fetal gonad must secrete estrogen for the embryo to differentiate as
a female. An increase in maternal estrogen secretion does not
effect differentiation of the embryo, and maternal estrogen secretion occurs
in every pregnancy. Maternal androgen secretion remains the same as before
pregnancy and does not effect differentiation. Secretion of androgen by the
fetal gonad would produce a male fetus.
34. A . Using bicarbonate would increase the amount of sodium ingested, which
can cause complications. Eating low-sodium crackers would be appropriate.
Since liquids can increase nausea avoiding them in the morning hours when
nausea is usually the strongest is appropriate. Eating six small meals a day
would keep the stomach full, which often decrease nausea.
35. B . Ballottement indicates passive movement of the unengaged
fetus. Ballottement is not a contraction. Fetal kicking felt by the client
represents quickening. Enlargement and softening of the uterus is known
as Piskacek’s sign.
36. B . Chadwick’s sign refers to the purple-blue tinge of the cervix.
Braxton Hicks contractions are painless contractions beginning around the
4th month. Goodell’s sign indicates softening of the cervix. Flexibility of
the uterus against the cervix is known as McDonald’s sign.
37. C . Breathing techniques can raise the pain threshold and reduce
the perception of pain. They also promote relaxation. Breathing techniques
 do not eliminate pain, but they can reduce it. Positioning, not
breathing, increases uteroplacental perfusion.
38. A . The client’s labor is hypotonic. The nurse should call the physical
and obtain an order for an infusion of oxytocin, which will assist the uterus
to contact more forcefully in an attempt to dilate the cervix.
Administering light sedative would be done for hypertonic uterine
contractions. Preparing for cesarean section is unnecessary at this time.
Oxytocin would increase the uterine contractions and hopefully progress
labor before a cesarean would be necessary. It is too early to anticipate client
pushing with contractions.
39. D . The signs indicate placenta previa and vaginal exam to
determine cervical dilation would not be done because it could cause
hemorrhage. Assessing maternal vital signs can help determine maternal
physiologic status. Fetal heart rate is important to assess fetal well-being
and should be done. Monitoring the contractions will help evaluate the
progress of labor.
40. D . A complete placenta previa occurs when the placenta covers the opening
of the uterus, thus blocking the passageway for the baby. This response
explains what a complete previa is and the reason the baby cannot come out
except by cesarean delivery. Telling the client to ask the physician is a poor
response and would increase the patient’s anxiety. Although a cesarean
would help to prevent hemorrhage, the statement does not explain why the
hemorrhage could occur. With a complete previa, the placenta is covering all
the cervix, not just most of it.
41. B . With a face presentation, the head is completely extended. With a vertex
presentation, the head is completely or partially flexed. With a
brow (forehead) presentation, the head would be partially extended.
42. D . With this presentation, the fetal upper torso and back face the left
upper maternal abdominal wall. The fetal heart rate would be most
audible above the maternal umbilicus and to the left of the middle. The
other positions would be incorrect.
43. C. The greenish tint is due to the presence of meconium. Lanugo is the soft,
downy hair on the shoulders and back of the fetus. Hydramnios represents
excessive amniotic fluid. Vernix is the white, cheesy substance covering the
fetus.
44. D . In a breech position, because of the space between the presenting
part and the cervix, prolapse of the umbilical cord is common. Quickening
is the woman’s first perception of fetal movement. Ophthalmia
neonatorum usually results from maternal gonorrhea and is conjunctivitis.
Pica refers to the oral intake of nonfood substances.
45. A . Dizygotic (fraternal) twins involve two ova fertilized by separate
sperm. Monozygotic (identical) twins involve a common placenta, same
genotype, and common chorion.
46. C . The zygote is the single cell that reproduces itself after conception.
The chromosome is the material that makes up the cell and is gained
from each parent. Blastocyst and trophoblast are later terms for the
embryo after zygote.
47. D . Prepared childbirth was the direct result of the 1950’s challenging of
the routine use of analgesic and anesthetics during childbirth. The LDRP
was a much later concept and was not a direct result of the challenging
of routine use of analgesics and anesthetics during childbirth. Roles
for nurse midwives and clinical nurse specialists did not develop from
this challenge.
48. C . The ischial spines are located in the mid-pelvic region and could
be narrowed due to the previous pelvic injury. The symphysis pubis,
sacral promontory, and pubic arch are not part of the mid-pelvis.
49. B . Variations in the length of the menstrual cycle are due to variations in the
proliferative phase. The menstrual, secretory and ischemic phases do not
contribute to this variation.
50. B . Testosterone is produced by the Leyding cells in the
seminiferous tubules. Follicle-stimulating hormone and leuteinzing hormone
are released by the anterior pituitary gland. The hypothalamus is
responsible for releasing gonadotropin-releasing hormone.