R.A.

SIBALA TUTORIAL SERVICES COMPREHENSIVE EXAM MATERNAL NURSING

Situation: Julia, a primagravida is brought to the labor room with the following PE findings: Cervical dilation 8cm, fully effaced +1, AOG: 39-40 weeks. 1. When is the first stage of labor considered to be achieved? a. presenting part is at station +1 b. cervix is 10 cm dilated c. uterine contractions occur every 2-3 min. interval d. cervix is gully effaced 2. Upon admission to the labor room, which of the following is not a routine procedure considering her cervical dilation? a. mini prep of the perineal area b. keep on NPO c. monitor vital signs and FHT d. cleansing enema Enema is not a routine procedure in the preparation of woman in labor. Commonly used enemas are tap water enema, fleet enema and pre-packed disposable type enema. Soap suds enema is not recommended because they have been associated with several complications. Suppositories are also included. Enema is a procedure of emptying the colon of fecal matter to: prevent infection - expulsion of feces during the second stage predispose mother and infant infection facilitate descent of fetus stimulate uterine contractions Contraindication to Enema not given during active phase vaginal bleeding ruptured bag of water abnormal fetal presentation and position fetus not yet engaged premature labor because of the danger of cord prolapse abnormal fetal heart rate pattern 3. Which of the following observation requires the nurse to refer stat to the obstetricians? a. frequent urination b. blood-streak mucus in the vaginal discharge c. sudden gush of amniotic fluid from the vagina d. FHT is 110 during uterine contractions but returns to 130 after 10 seconds following contract When the bag of water has ruptured, the nurse should call the physician. Remember, the first action to take when the bag of water has ruptured is to check the FHT as the danger at this time is cord prolapse and compression. The abnormal signs that should be reported to the physician are: 1. Signs of fetal distress (tachycardia, bradycardia) 2. Red stained amniotic fluid (abruptio placenta) 3. cord prolapse 4. Maternal tachy cardia, hypertension and hypotension (PIH) 5. Pallor, cold clammy skin 6. Elevated temperature, foul smelling vaginal discharge (chrioamnionitis) 7. bleeding Blood streaked mucus is show and it is a normal signs of labor. It is normal for a woman to have frequency of urination. It is expected for the FHT to decrease during uterine contraction. This is an effect of fetal head compression when the uterus contracts. 4. Which of the following signs indicate that delivery is near? 1. Julie verbalized her desire to defecate 2. Uterine contractions increased in frequency duration and intensity 3. The perineum is bulging 4. Bloody show is increased a. 1,2,3,4 b. 1,2,3 c. 1,2,4 d. 1,3,4 All signs that delivery is near. The desire to defecate is due to the stimulation of the sacral nerves as the fecal head presses against the sacrum. Uterine contractions reach its maximum intensity during the transition and second stage of labor. The bulging of perineum is due to the fetal pushing behind it. Show

is increased as the remaining operculum is dislodged by the complete dilatation of the cervix. 5. After the delivery of the baby, which of the following indicate placental separation? 1. protrusion of three or more inches of the umbilical cord 2. gradual descent of the uterus further into the pelvis 3. uterus becomes more firm and rounded 4. sudden spurt of blood from the vagina a. 1,3,4 b. 1,2,4 c. 2,3,4 d. 1,2,3 The signs of placental separation usually appear within 5 minutes after baby's birth. Situation: Mrs. O, G2p1, is admitted to the labor and delivery area in labor. Initial assessment reveals cervical dilatation of 5 cm; cervical effacement 80%; station negative 3; frequency of contractions every 5-8 mins; duration of contractions 40 to 50 seconds; membranes ruptured spontaneously 1 hour before admission; presentation is vertex with LOA position. 6. Based om Mrs. O's initial assessment findings, the fetal presenting part is: a. at the level of the pelvic inlet b. at the level of the ischial spines c. 1 cm below the ischial spines d. at the perineum 7. The FHR should be most audible in which quadrant of Mrs. O's abdomen? a. LLQ b. LUQ c. RLQ d. RUQ 8. The physician places Mrs. O. on bed rest. Which assessment finding necessitates this action? a. 5 cm cervical dilatation b. 80& cervical effacement c. contractions every 5-8 mins d. negative 3 station 9. When should the nurse assess Mrs. O's blood pressure? a. during the increment of contraction b. between the contractions c. during the decrement of the contraction d. during the acme of a contraction 10. Which factor would be most helpful in assessing the adequacy of Mrs. O's placental perfusion? a. the duration and intensity of her contractions b. her ability to cope with the discomfort of labor c. the duration of the rest phases between contractions d. the effectiveness of her breathing techniques during the contractions 11. The client is in active phase of labor. The physician has administered epidural anesthesia. Which of the following nursing actions should be given highest priority by the nurse? a. ensuring patent IV access line b. checking for rupture of membrane c. monitoring duration of each contraction d. providing food and fluids Epidural anesthesia causes hypotension. A patent IV line should be established for administration of ephedrine if hypotension occurs. 12. The client is on her twelfth-week of pregnancy. She had been diagnosed to have ruptured ectopic pregnancy. Which of the following signs and symptoms are characteristic of the condition? a. profuse bright red vaginal bleeding b. spotting, abdominal pain that radiates to the shoulder c. elevated hemoglobin and hematocrit level d. leukopenia, decreased body temperature The bleeding occurs in the abdominal cavity, not within the uterus. Therefore, spotting and not profuse bleeding may occur. When a client is bleeding, the hemoglobin and hematocrit levels will be low. Leukocytosis occurs in response to activation of protective mechanisms of the body. 13.You are assessing a 32-week pregnant woman. Which of the following is a biophysical nursing diagnosis? a) body image disturbance b) knowledge deficit c) ambivalence d) alteration in nutrition Biophysical/physiologic nursing diagnosis is D. Choices A, B, and C are psychosocial nursing diagnosis.

14. A nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement when made by the client would indicate an understanding of the instructions? a) the iron is best taken on empty stomach b) meat does not provide iron and should be avoided c) iron supplements will give me diarrhea d) my body has all iron it needs and I don't need to take supplement Ferrous fumurate and ferrous gluconate are the most commonly used iron supplement. They are best absorbed on empty stomach. 15. Which of the following would cause a false-positive result on a pregnancy test? a. The test was performed less than 10 days after an abortion b. The test was performed too early or too late in the pregnancy c. The urine sample was stored too long at room temperature d. A spontaneous abortion or a missed abortion is impending A false-positive reaction can occur if the pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false-negative results. Situation: Andrea is a 32 yr. old primigravida admitted at term to a hospital at 8 am with the following signs: contractions which began at 3am coming now every 10 mins. Lasting 30 seconds, and causing little discomfort: intact membranes; no blood show, stable vital signs; fetal hear rate, 130/bpm. Examination reveals that the cervix is 3 cm dilated, 80% effaced, with the vertex presenting at minus 1 station. 16. On the basis of the data presented above, the nurse caring for Andrea could conclude that Andrea is: a. false labor b. in the latent phase of labor c. in the active phase of labor d. in the transitional phase of labor 17. Artificial rupturing of membranes probably would not be employed to stimulate Andrea's labor because: a. cervical dilatation is only 3 cm b. her contractions are not occurring frequently c. the presenting part is at minus 1 station d. all of these 18. An intravenous drip pitocin 10 units in 1000 ml of D5 water is started for Andrea. Possible side effects of oxytocin administration include all of the following except: a. water intoxication b. hypertension c. tonic uterine contractions d. diuresis 19. Which of the following findings by the nurse indicates that Methergine injection to a client, who had delivered 3 hours ago, is effective? a) uterus is 2 fingerbreadths below the umbilicus b) uterus is boggy and at the level of the umbilicus c) uterus is palpated on the right side of the abdomen d) uterus is 2 fingerbreadths above the umbilicus Methergine causes uterine contraction and prevents postpartum bleeding. Option A indicates uterine contraction. 20. Which of the following statements when made by the premenopausal woman indicates that she understands the health teachings on breast self-examination (BSE)? a. I will perform breast self-examination every first day of the month b. I will perform breast self-examination 5 days after menstruation c. I will perform breast self-examination 2 to 3 days after the cycle d. I will perform breast self-examination during menstrual period BSE among premenopausal women is best done after menstruation. BSE is done on the same day of the month, e.g., every first day of the month among postmenopausal women. The procedure should not be done during menstruation and during ovulation, because the tissues in the breast may feel hard during these periods.

21. Which of the following signs and symptoms indicates amniotic fluid embolism? a. sudden onset of respiratory distress, chest pain, BP 90/60 mmHg, RR 26/min, PR 98bpm b. restlessness, chest pain, BP 140/80 mmHg, RR 24/min, PR 70 bpm c. difficulty of breathing, cold, clammy skin, BP 90/60 mmHg, RR 12/min, PR 70 bpm d. chest pain, shortness of breath, BP 160/90 mmHg, RR 28/min, PR 120 bpm Amniotic fluid embolism results to pulmonary embolism and possibly shock. Hypotension, tachypnea, tachycardia characterized early stage of the condition. Onset of symptoms is sudden. 22. The client is in active labor, cervix is 8 cm dilated, is nauseated, and irritable. Which of the following is appropriate nursing action? a. encourage the client to do pant-blow breathing exercises b. encourage the client to push with each contractions c. encourage the client to walk d. encourage the client to turn to the right side Pant-blow breathing exercises will prevent sudden expulsion of the fetus, thereby preventing cervical laceration and hematoma. Pushing is to be done only when there is full cervical dilatation (10 cm). The client should be on bedrest at this stage of labor. It is best for the client to turn to the left side to relieve compression of the vena cava. 23. The client is in active labor. She is on oxytocin per IV infusion drip. Which of the following situations would require that the infusion be stopped? a. the cervix is 8 cm, dilated, contractions occur every 3-5 minutes b. contractions occur at less than 2 minute intervals or last for longer than 90 seconds c. the cervix is 6 cm, dilated, partially effaced, duration of contractions is 50 to 60 seconds d. contractions occur every 3-5 minutes, last 50 to 60 seconds Contractions occurring at less than 2-minute intervals and lasting longer than 90 seconds may lead to tetanic uterine contractions and therefore, uterine rupture. Fetal distress may occur. 24. Janice who G3P2, is in active labor. Vaginal examination reveals that she is 5 cm dilated and 100% effaced at minus 1 station. At the peak of contraction, fluid gushes suddenly. The nurse should immediately a. notify the attending physician b. change Janice's linens and see that she is dry and comfortable c. check the perineal area to see if the presenting part is showing d. determine fetal heart rate and check for regularity 25. Lochia is a post partum vaginal discharge that contains 1. RBC 3. WBC 2. Mucus 4. decidual remnants a. 1,3,4 b. 1,2,3 c. 1,4 d. all of these 26. A nurse caring for the woman in the taking-in phase of the puerperium should be sure to a. instruct her on how to bath an infant b. allow her as much rest as needed c. have her begin postpartum exercises d. all of the above 27. When a tubal ligation is performed on a woman of childbearing age, she can expect sterility: a. without menopausal symptoms b. with menopausal symptoms c. resulting in loss of libido d. that can be readily reversed by surgery 28. Which of the following would be the most accurate description of the occurrence of the ovulation in the menstrual cycle? a. midway in the cycle, regardless of the length of the cycle b. two weeks after the onset of menses c. two weeks before the onset of menses d. ten days after the cessation of the menstrual flow

29. The LOA position means that the: a. lie is longitudinal and the fetal occiput is directed toward the left posterior portion of the maternal pelvis b. lie is transverse and the fetal mentum is directed toward the left posterior portion of the maternal pelvis c. lie is longitudinal and the fetal occiput is directed toward the left anterior portion of the maternal pelvis d. lie is oblique and the fetal anterior fontanel is directed toward the left posterior portion of the maternal pelvis 30. The most common cause of early postpartum uterine bleeding is: a. inertia c. subinvolution b. lacerations d. atony 31. Suppose a woman experiences a uterine inversion and the placenta is still attached. What would be your best action? a. Remove the placenta manually so that the uterus contracts. b. Attempt to replace the uterus so that it becomes compressed c. Increase womens intravenous fluid to help restore blood loss d. Give an emergency bolus of an oxytocin such as Pitocin IV 32. A woman you care for has an RH-negative blood type. Following the birth of her infant, you administer her RHIG (D immune globulin). The purpose of this is to a. promote maternal D antibody formation b. prevent maternal D antibody formation c. stimulate maternal D immune antigens d. prevent fetal RH blood formation 33. A woman who is Rh negative asks you how many children she will be able to have before Rh incompatibility causes them to die in utero. Your best response would be: a. no more than 3 children b. as long as she receives RHIG there is no limit c. only her next child will be affected d. she will have to ask her physician 34. A pregnant woman in pre-eclampsia is to receive magnesium sulfate IV. Which assessment would be most important to make before administrations of a new dose of this? a. blood pressure b. patellar reflex c. pulse rate d. anxiety level 35. The best nursing diagnosis in relation to a woman with hypertension of pregnancy would be: a. fluid volume deficit related to vasospasm of arteries b. altered tissue perfusion related to poor heart contraction c. potential for injury related to fetal distress d. altered nutrition relation to decrease sodium levels 36. Mrs. A's blood is Rh negative. The physician would schedule administration of human Rho (D) immune globulin (RhoGAM) at the 28th week of gestation if Mrs. A had a: a. negative direct Coombs test result b. negative indirect Coombs test result c. positive Coombs test result d. positive indirect Coombs test result 37. Disseminated Intravascular Coagulation (DIC) is a possible complication of PIH. Which assessment finding would indicate that the patient has developed DIC? a. bleeding of the nose and gums b. joint pain c. rapid clotting at the puncture site d. increased central venous pressure 38. Which of the following best describes how RhoGAM acts in the maternal system? a. it attaches to maternal anti-Rh antibodies and directly destroy them b. it suppresses the immunological production of maternal antibodies c. it destroy fetal Rh positive RBC in the maternal circulation d. it prevents fetal-maternal bleeding episodes from a occurring at the former placental site 39. A pregnant woman is being given magnesium sulfate per slow IV drip. This medication is intended to control a. embolism c. bleeding b. seizures d. uterine contractions

Magnesium sulfate is a CNS depressant. It is given to a client with PIH to prevent seizure. 40. Abnormal fetal lie and position were noted. Which of the following procedures does the nurse expect to be arranged first, before external rotation (version) is done? a. amniocentesis b. ultrasound c. fetal heart rate monitoring d. x-ray Fetal heart rate monitoring should be done before external version procedure is done to correct breech presentation to cephalic presentation. This is to ensure that the fetus can tolerate the stress of the procedure. 41. Suzanne Mattthews typically has a menstrual cycle of 34 days. She tells you she had coitus on days 8,10,15, and 20 of her last cycle. Which is the day on which she most like conceived? a. The 8th day c. Day 15 b. The 10th day d. Day 20 42. Why is it important to ask Sandra about past surgery on a pregnancy health history? a. To test her recent and long term memory b. Adhesion from the surgery could limit uterine growth c. To assess whether she could be allergic to any medication d. To determine if she has effective health insurance 43. Which condition would make a pregnant woman more prone to developing a Candida infection during pregnancy? a. She usually drinks tomato juice for breakfast b. She was over 35 when she became pregnant c. Her husband play golf 6 days a week d. She has developed gestational diabetes 44. Beverly was diagnosed to have an ectopic pregnancy. What advice would you give her? a. Most ectopic pregnancies go to completion, although the newborn is small b. If she must have a fallopian tube removed, she will be sterile afterward c. She will have a continuous nagging pain through the rest of pregnancy d. Ectopic pregnancy can be either medically or surgically treated 45. When a client asked about her pregnancy, you should include personal common discomforts. Which of the following is an indication for prompt professional supervision? a. Constipation and hemorrhoids b. Backache c. Facial edema d. Frequent urination *Facial edema is NOT NORMAL. Facial edema is one sign of MILD PRE ECLAMPSIA and prompt professional supervision is needed to lower down the client's blood pressure. Blood pressure in Mild Pre Eclampsia is around 140/90 and 160/110 in severe. Treatment involves bed rest, Magnesium sulfate, Hydralazine, Diazoxide and Diazepam [ usually a combination of Magsul + Apresoline [ Hydralazine ] ] Calcium gluconate is always at the client's bed side when magnesium toxicity occurs. It works by exchanging Calcium ions for magnesium ions. A,B and D are all physiologic change in pregnancy that do not need prompt professional supervision. Frequent urination will disappear as soon as the pressure of the uterus is released against the bladder and as soon as the client's blood volume has returned to normal. Backache is a common complaint of women with an OCCIPUT POSTERIOR presentation due to pressure on the back. Intervention includes pelvic rocking or running a tennis ball at the client's back. Constipation and hemorrhoids are relieved by increasing fluid intake and hot sitz bath. 46. A client begins preterm labor and the physician orders terbutaline sulfate (Brethine). After its administration, the nurse assesses the client for the therapeutic effect of: a. Reduction of pain in the perineal area b. Decrease in blood pressure from 120/80 to 90/60 c. Decrease in frequency and duration of contractions d. Dilation of the cervix from 1 to 1.5 cm for every hour of labor Terbutaline sulfate (Brethine) is a beta-mimetic drug that acts on the smooth muscles of the uterus to reduce contractilitiy, which in turns inhibits dilation and contractions. It has no

analgesic effects, does not act to decrease blood pressure, acts to arrest preterm labor by relaxing the uterus; this would result in stopping cervical dilation rather than increasing it. 47. To determine fetal position using Leopold's maneuvers, the first maneuver is to: a. Determine degree of cephalic flexion and engagement b. Determine part of fetus presenting into pelvis c. Locate the back,arms and legs d. Determine what part of fetus is in the fundus Leopold's one determines what is it in the fundus. This determines whether the fetal head or breech is in the fundus. A head is round and hard. Breech is less well defined. 48. The nurse recognizes that an expected change in the hematologic system that occurs during the second trimester of pregnancy is: a. A decrease in WBCs c. An increase in blood volume b. An decrease in blood volume d. A decrease in sedimentation rate 1. White blood cell values remain stable during the antepartum period. 2. The hematocrit decreases as a result of hemodilution. 3. The blood volume increases by approximately 50% during pregnancy. Peak blood volume occurs between 30 and 34 weeks of gestation. 4. The sedimentation rate increases because of a decrease in plasma proteins. 49. During prenatal development, fetal weight gain is greatest in the: a. First Trimester c. Second Trimester b. Third Trimester d. Implantation Period 1. The first trimester is the period of organogenesis, when cells differentiate into major organ systems. 2. This is the period in which the fetus sores deposits of fat fetal weight gain is greatest. 3. Growth is occurring, but fat deposition does not occur in this period. 4. This is the period of the blastocyst, when initial cell division takes place. 50. A client at 38 weeks' gestation is admitted for induction of labor. She has a history of ruptured membranes for the past 12 hours. She has no other symptoms of labor. The nurse is aware that if the proper conditions exist, the physician will prescribe: a. Progesterone c. Estrogen b. Oxytocin (Pitocin) d. Ergonovine maleate Oxytocin is a small polypeptide hormone normally synthesized in the hypothalamus and secreted from the neurohypophysis during parturition or suckling; the synthetic form promotes powerful uterine (smooth muscle) contracitons and thus is used to induce labor. Progesterone builds up the endometrium; it does not initiate uterine contractions. Lututrin no drug by this name for this purpose. Ergonovine can lead to sustained contractions, which would be undesirable labor. 51. A client, whose husband is overseas in the military, is admitted to the hospital with vaginal staining but no pain. The client's history reveals amenorrhea for the last 2 months and pregnancy confirmation by her physician after her first missed period. She is admitted for observation with a possible diagnosis of : a. Missed abortion c. Inevitable abortion b. Ectopic pregnancy d. Threatened abortion 1. This may not cause any outward symptoms, only the signs of pregnancy disappearing. 2. This is usually accompanied by severe pain radiating to the shoulder on the affected side. 3. This can be confirmed only if vaginal examination reveals cervical dilation. 4. Spotting in the firs trimester may indicate that the client may be having a threatened abortion; any client with the possibility of hemorrhage should not be left alone; therefore admitting this client for observation is safe medical practice; abortion is usually inevitable if accompanied by pain and cervical dilation. 52. When caring for a client who is having a prolonged labor, the nurse must be aware that the client is very concerned when her labor deviates from what she sees as the norm. A response conveying acceptance of the client's expressions of frustration and hostility would be: a. "I'll rub your back; tell me if it helps." b. "I'll leave as you can talk to your husband." c. "All women get weary and frustrated during labor." d. "Would you like to talk about what's bothering you?" 1. This response provides the client with a comfort measure while giving her an opportunity to get verbalize her fears about

having a prolonged labor. 2. This closes off communication with the client. 3. This is of no help to the client; she is concerned with what is happening to her. 4. This can be answered "yes" or "no" and leaves no further avenue for discussion. 53. A pregnant client has encouraged her husband to attend prenatal classes with her. During the prenatal class, the couple expressed fear of pain during labor and delivery. The use of touch and soothing voice often promotes comfort to the laboring patient. This physical intervention is effective because: a. Pain perception is interrupted b. Gate control fibers are open c. It distracts the client away from the pain d. Empathy is communicated by a caring person Touch and soothing voice promotes pain distraction. Instead of thinking too much of the pain in labor, The mother is diverted away from the pain sensation by the use of touch and voice. Pain perception is not interrupted, pain is still present. When gate control fibers are open, Pain is felt according to the gate control theory of pain. Although empathy is communicated by the caring person, this is not the reason why touch and voice promotes comfort to a laboring patient. 54. A 16-year-old comes to the prenatal clinic because she has missed three menstrual periods. Before her physical examination, the client says. "I don't know what the problem is, but I can't be pregnant." The nurse's most therapeutic response to this statement would be: a. "The doctor will let you know shortly." b. "What brought you to the prenatal clinic then?" c. "Many young women are irregular at your age." d. "If you have had intercourse, you are probably pregnant." 1. This response would close off any future communication with the client. 2. This response points out reality and allow the client to elaborate. 3. This may be true statement, but it does not allow for much discussion to follow. 4. This response sounds rather critical or judgmental and would probably cut off further discussion with the client. 55. After an 8-hour, uneventful labor a client gives birth to a baby boy spontaneously under epidural block anesthesia. As the nurse places the baby in the mother's arms immediately after the birth, the mother asks, "is he normal?" The most appropriate response by the nurse would be: a. "Most babies are normal; of course he is" b. "He must be all right, he has such a good strong cry." c. "Yes, because your pregnancy and labor were so normal." d. "Shall we unwrap him so you can look him over for yourself?" 1. This is false reassurance; this comment closes off communication with the mother at a very opportune moment. 2. Crying is not indicative of congenital defects; a strong cry does not ensure "normalcy". 3. The "normalcy" of the mother's pregnancy and labor does not always have a relationship to the "normalcy" of the infant. 4. Mothers need to explore their infants visually and through touch to assure themselves that the infants are normal in all respects. 56. Which of the following could be considered as a positive sign of pregnancy ? a. Amenorrhea, nausea, vomiting b. Frequency of urination c. Braxton Hicks contraction d. Fetal outline by sonography Fetal outline by sonography or other imaging devices is considered a positive sign of pregnancy along with the presence of fetal heart rate and movement felt by a qualified examiner. All those signs with the discoverer's name on them [ chadwick, hegars, braxton hicks, goodells ] are considered probable and All the physiologic changes brought about by pregnancy like hyperpigmentation, fatgiue, uterine enlargement, nausea, vomiting, breast changes, frequent urination are considered presumptive. Sonographic evidence of the gestational sac is not POSITIVE sign but rather, PROBABLE. 57. In dealing with a couple identified as having an infertility problem, the nurse knows that: a. Infertility is usually psycholigic in origin b. Infertility and sterilty are essentially the same problem

c. The couple have been unable to have a child after trying for a year d. One partner has a problem that makes that person unable to have children 1. Infertility may be psychogenic; however, statistics show that physiologic problems are more often the cause. 2. This is untrue; infertility may be corrected, but sterility is irreversible. 3. Infertility is the inability of a couple to conceive after at least 1 year of adequate exposure to the possibility of pregnancy. 4. This may or may not be true; it is possible that there is a problem with both. 58. Which of the following assessment findings about the uterus would the nurse expect to find in a primipara client 6 hours post delivery of an average-for-gestational-age infant? a. Fundus firm, midline, 2 fingerbreadths below the umbilicus b. Fundus firm, midline, at the level of the umbilicus c. Fundus firm, to the right of the midline, at the umbilical level d. Fundus soft, to the right of the midline, 2 fingerbreadths above the umbilicus One hour after birth, the fundus rises to the level of the umbilicus, where it remains for approximately 24 hours. It should be firm and in the middle. The fundus should be firm and midline, but should not be 2 fingerbreadths below the umbilicus on the day of delivery. A fundus that is to the right of the midline denotes urinary bladder distention. The fundus should be firm to provide hemostasis. The fundus is up too far in the abdomen and is deviated to the right, denoting a distended bladder. 59. During the taking-hold phase, the nurse would expect the new mother to: a. Talk about the baby b. Call the baby by name c. Touch the baby with her fingertips d. Be passively involved with the baby 1. This may occur in either phase. 2. The mother has completed the taking-in phase (the mother's needs predominate) and has moved into taking-hold the takinghold phase (active maternal involvement with self and infant) when she calls the baby by name. 3. This is the initial early action of the taking-in phase. 4. This is part of the taking-in phase. 60. Which of the following instructions would be included in a client's postpartum teaching plan about performing Kegel exercises to restore perineal muscle tone? a. Alternately flexing and extending each foot while raising her leg 6 inches off the bed b. Contracting and relaxing perineal muscles as if stopping and starting a urinary stream c. Contracting the abdominal muscles while raising her legs 1 inch off the bed d. Taking deep breaths and slowly exhaling while compressing the buttocks together Kegel exercises require contracting the pubococcygeal muscle, the major muscle of the pelvic floor, to increase muscle tone and provide support to the vaginal wall, bladder, and rectum. Alternate flexing and extending the foot with raising will facilitate venous return and help prevent thrombophlebitis. However, this exercise will not affect perineal muscle tone. Contracting the abdominal muscles with leg raises will increase abdominal, but not perineal, muscle tone. Deep breathing expands the lungs. Contracting gluteal muscles will not affect the perineal, muscle tone. 61. Which of the following mothers needs RHOGAM? a. RH + mother who delivered an RH - fetus b. RH - mother who delivered an RH + fetus c. RH + mother who delivered an RH + fetus D d. RH - mother who delivered an RH - fetus Rhogam is given to That delivers an . Rhogam prevents ISOIMMUNIZATION or the development of maternal antibodies against the fetal blood due to RH incompatibility. Once the mother already develops an antibody against the fetus, Rhogam will not anymore be benificial and the mother is advised no to have anymore pregnancies. Rhogam is given within 72 hours after delivery. 62. Which of the following patterns of weight gain is normal for a client who weighed 100 pounds before becoming pregnant?

a. 110 pounds by 10 weeks' gestation b. 112 pounds by 20 weeks' gestation c. 115 pounds by 30 weeks' gestation d. 135 pounds by 40 weeks' gestation During pregnancy, the woman should gain 25 to 35 pounds. Thus, the client should weigh around 135 pounds at 40 weeks' gestation. By 12 weeks, the client typically should have gained 3.5 to 5 pounds. By 20 weeks, the client typically should have gained 10 pounds. By 30 weeks, the client typically should have gained 10 pounds. By 40 weeks, the client typically should have gained 10 pounds. Typical weight gain is 3.5 to 5 pounds during the first trimester, followed by an average gain of 1 pound per week during the last two trimesters. 63. Which of the following areas would be the priority for client education in the first trimester? a. Constipation b. Danger signs c. Lactation d. Leg cramps Education in the first trimester should focus on the possible danger signs of pregnancy. In fact, this information should be addressed on the first health care visit. The signs signify impending danger and indicate a need for medical attention. Constipation most frequently occurs in the second and third trimesters and should be addressed then. Infant-feeding techniques should be introduced during the early prenatal period and discussed again nearer to the end of the pregnancy. Leg cramps occur most commonly in the third trimester and should be addressed just prior to the client beginning the third trimester. 64. Katherine, a 32 year old primigravida at 39-40 weeks AOG was admitted to the labor room due to hypogastric and lumbosacral pains. IE revealed a fully dilated, fully effaced cervix. Station 0. She is immediately transferred to the DR table. Which of the following conditions signify that delivery is near? I - A desire to defecate II - Begins to bear down with uterine contraction III - Perineum bulges IV - Uterine contraction occur 2-3 minutes intervals at 50 seconds duration a. I,II,III b. I,II,III,IV c. I,III,IV d. II,III,IV Again, lifted word per word from Pillitteri and this is from the NLE. is the right answer. A woman near labor experiences desire to defecate because of the pressure of the fetal head that forces the stool out from the anus. She cannot help but bear down with each of the contractions and as crowning occurs, The perineum bulges. A woman with a 50 second contraction is still at the labor [ 40 to 60 seconds duration, 3 to 5 minutes interval ] Women who are about to give birth experience 60-90 seconds contraction occuring at 2-3 minutes interval. 65. The nurse determines that a client understands the natural cervical mucus contraceptive method when the client describes the cervical mucus during her fertile period as which of the following? a. Clear, wet, and sticky b. Cloudy, white, and sticky c. Thick and cloudy d. Yellow and sticky Explanation: In response to high estrogen and progesterone levels during the fertile period, the mucus is clear, wet, and sticky and slippery (like an egg white) and is more abundant. Cloudy white and sticky mucus occurs after ovulation. Thick cloudy mucus is present in the postovulatory phase. The mucus has a yellowish color in the preovulatory phase. 66. Which of the following denotes the correct technique for fundal massage for a postpartum client exhibiting a large amount of blood on the perineal pad? a. Compressing the fundus on one side while supporting the other side of the uterus b. Massaging above the symphysis pubis while one hand supports the uterine fundus c. Pressing deeply into the abdomen while compressing the fundus with both hands d. Supporting the fundus while massaging the uterus just above the symphysis pubis

Supporting the fundus while massaging the uterus just above the symphysis pubis provides support to the lower uterine segment while stimulating contraction of the fundus. It also prevents inversion of the uterus, which is an obstetric emergency. The top (fundus) of the uterus is massaged, not the sides. Massaging at the symphysis pubis would not provide effective uterine contractions. One hand is used to massage the fundus. It is not necessary to press deep into the abdomen. 67. When teaching a childbirth education class on infection prevention after delivery, the nurse would instruct the woman to perform perineal care how often? a. After each voiding or defecation b. Every 8 hours c. Once each day d. When she has perineal pain Cleansing the perineum reduces the number of perianal microorganisms present. It also removes lochia and moisture, favorable for the growth of bacteria. Every 8 hours is not frequent enough. Any excreta need to be removed quickly to prevent infection. Once-daily cleansing will not be effective in preventing bacterial growth. Perineal care provides cleanliness and promotes comfort, but it does not relieve pain. Additionally, pain is not an adequate indicator for the need to perform perineal care. 68. Using the five-digit system, which of the following denotes the correct obstetric history for a client who is 6 weeks pregnant, and has a son born at 36 weeks' gestation and a daughter born at 40 weeks' gestation? 1. G2 T1 P1 A0 L2 2. G2 T2 P0 A0 L2 3. G3 T1 P1 A0 L2 4. G3 T2 P0 A0 L2 This is the client's third pregnancy (G3). One child was born at term (40 weeks; T1) and one was delivered prior to 38 weeks' gestation (preterm; P1). There is no history of abortions (A0) and both children are living (L2). G2 represents a client who has been pregnant two times. This client has been pregnant three times. 69. A client calls the clinic because she has forgotten to take her oral contraceptive for the past 2 days. Which of the following should the nurse advise the client to do? a. Continue to take the remaining pills for the rest of the cycle b. Discontinue the pills for the rest of the cycle and use condoms c. Take two pills for the next 2 days and use condoms the rest of the cycle d. Take two pills immediately and change to condoms for the rest of the cycle To maintain hormone levels, the client should take the two pills for the next 2 days (to compensate for the missed pills) and then complete the rest of the pills. To decrease the risk of pregnancy, the client should also use an alternative method of contraception such as condoms for the rest of cycle. When two pills have been missed, an alternative form of contraception must be used. Discontinuing the pills for the rest of the cycle would cause a drop in estrogen and progesterone levels with resultant physiologic effects. Taking two pills immediately and then changing to condoms would cause a drop in the levels of estrogen and progesterone with resultant physiologic effects. 70. Artificial rupture of the membrane is done. Which of the following nursing diagnoses is the priority? a. High risk for infection related to membrane rupture b. Potential for injury related to prolapsed cord c. Alteration in comfort related to increasing strength of uterine contraction d. Anxiety related to unfamiliar procedure Nursing diagnosis is frequently ask. In any case that INFECTION was one of the choices, remove it as soon as you see it in ALL CASES during the intra and pre operative nursing care. Infection will only occur after 48 hours of operation or event. is much more immediate and more likely to occur than , and is much more . Prioritization and Appropriateness is the key in correctly answering this question. High risk for infection is an appropriate nursing diagnosis, but as I said, Infection will occur in much later time and not as immediate as Readily remove and because

physiologic needs of the mother and fetus take precedence over comfort measures and psychosocial needs. 71. When explaining to a client about the primary cause of constipation during pregnancy, the nurse would include which of the following? a. Decreased water reabsorption b. Delayed gastric emptying time c. Increased peristalsis d. Relaxation of GI tract muscle During pregnancy, hormonal influences and subsequent relaxation of the smooth muscle lining the bowel lead to decreased motility and constipation. Decreased water reabsorption would cause liquid stools. Although present during pregnancy, decreased gastric emptying time does not cause constipation. Increased peristalsis would lead to decreased water absorption and liquid stools. 72. During the initial interview of a pregnant client, the nurse uses Naegele's rule to determine the estimated date of delivery (EDD). Which of the following questions would be essential to ask? a. "On what day did your previous menstrual period stop?" b. "What type of contraception are you using at this time?" c. "When was the first day of your last menstrual period?" d. "When was the last time that you had sexual intercourse?" Naegele's rule assumes the woman has a 28-day cycle and that the pregnancy occurred on the 14th day. To calculate the EDD, the nurse must know the first day of the client's last menstrual period, add 7 days, and then subtract 3 months. Using the last day of the previous cycle and following Nigele's rule, conception would have occurred before ovulation. The question is unrelated to the determination of the EDD. Pregnancy has already been confirmed if the nurse is calculating the EDD. The client could have had intercourse after conception. 73. A patient delivers a baby boy spontaneous delivery. Her fundus is firm and she has moderate rubra lochia. Upon palpation 30 minutes later, the nurse finds the fundus displaced to the right. What nursing intervention would be appropriate at this time? a. give her a bedpan to void b. call the doctor c. massage the fundus d. encourage breast-feeding 74. The obstetrician performed a routine episiotomy on a newly delivered patient. Which of the following reasons would not be appropriate to perform an episiotomy? a. shortened recovery time from the 3rd stage of labor b. prevent perineal lacerations c. avoid 3rd degree tearing of perineum d. shorten the 2nd stage of labor 75. During discharge teaching for a patient who had a hydatidiform mole the nurse must include: a. avoid pregnancy for 1 year b. a hysterectomy will be required in the future c. avoid taking birth control pills d. no specific restrictions are indicated 76. When a prolapsed cord is the presenting part the nurse would not: a. cover the cord with saline soaked gauze b. change the maternal position c. continue monitoring the FHR d. try to push the cord back into the vagina 77. A patient with a history of PIH asks the nurse if she will have PIH in a subsequent pregnancy. The nurse responds by saying a. having PIH puts you into a risk group for having PIH again b. there is no relationship between one pregnancy and another c. you will definitely have PIH with each pregnancy d. you have the same chance a t the general population 78. A woman in labor has been pushing for 1 1/2 hours with no progress in decent of the fetus. The doctor recommends a rest period. During the rest period the fetus baseline heart rate becomes 170's which of the following interventions would be indicated a. left side lying position with supplemental oxygen b. a C-section

c. increase pitocin d. an enema 79. Which of the following is an early sign of magnesium sulfate toxicity: a. decreased BP c. decreased respiration b. decreased reflexes d. increased urinary output 80. Identifying gestational diabetes is part of the prenatal care. When would the nurse schedule a patient for a glucose tolerance test: a. 6th week of pregnancy c. 24th week of pregnancy b. 12th week of pregnancy d. 32nd week of pregnancy 81. A laboring patient has begun to have late decelerations. The nurse has turned the mother on her left side. What other intervention should be nurse employ at this time: a. give a bolus of IV fluid b. stop the pitocin c. have the mother pant breathe d. turn the lights off in the room and let the mother rest 82. A woman who has had PROM (premature rupture of membranes) is at risk for a. infection c. hypertension b. C-section delivery d. placenta abruption 83. Which of the following positions should the nurse place the patient who has been diagnosed with a prolapsed cord a. supine c. left lateral recumbent b. trendelenberg d. high fowlers 84. A 23 year old primigravida arrives at the clinic for a check up. She is complaining of nausea and vomiting upon rising and increase urination. She reports that her last menstrual period was 2 months ago. A blood test confirms that she is pregnant. Which of the following findings would be considered abnormal? a. a bluish tinge to the vagina upon cervical exam b. a white, non-malodorous discharge from the vagina c. mild contractions radiating from back to the abdomen d. increase vascularity, sensitivity and fullness of the breasts 85. A client is admitted for preterm labor and is stable. She is sent home on oral terbutaline. The purpose of the drug for use in preterm labor is to; a. decrease the chance of pulmonary edema b. relax uterine muscles and inhibit uterine contractions c. acts a bronchodilator d. decrease tachycardia from anxiety caused by preterm labor 86. Women who develop gestational diabetes are at risk for which of the following: a. placenta previa, DKA and hypoglycemia b. polyhydramnios, macrosomia and pre-eclampsia c. HELLP syndrome, mitral valve prolapse and placenta abruption d. diabetic coma, hypotension and multiple gestation 87. In teaching a client about the onset of labor, the nurse should include: a. you should go to the hospital as soon as contractions begin b. you should wait to go to the hospital until the contractions are 3 minutes apart c. if your membranes are ruptured you should take a warm bath d. bloody vaginal discharge is a sign of impending labor 88. A 35 week pregnant woman has severe PIH with BP 198/114, 4+ proteinuria and is placed on MgSO4 (Magnesium sulfate). Her husband wants to know how will this medication help his wife. The nurse explains MgSO4 will: a. decrease the body's sensitivity to calcium, therefore reducing the chance of a seizure b. increase the body's sensitivity to calcium therefore reducing the chance of a seizure c. reduce systemic vascular resistance therefore reducing blood pressure d. decrease neuromuscular irritability 89. If a patient receiving MgSO4 for preeclampsia begins to seizure the most appropriate nursing action would be to: a. begin chest compression b. assess fetal heart tones c. decrease the MgSO4 d. establish and maintain a patent airway 90. A patient with preeclampsia begins to complain of epigastric pain. The nurse knows this is a sign of:

a. preterm labor c. placental abruption b. seizure d. indigestion 91. During seizure in an eclamptic patient the nurse should do the following intervention first: a. increase the MgSO4 b. call the doctor c. turn the patient on her side d. ask the husband to leave the room 92. A laboring patient is walking in the hallway. She is 80% effaced and at 0 station. She suddenly experiences a gush of fluid. Which of the following actions should the nurse take first: a. have the patient return to her bed to assess the fetal heart b. call the doctor c. perform a vaginal exam to determine the dilation d. place the patient in trendelenburg to prevent cord prolapsed 93. A patient in labor is examined and is told she is 100% effaced, 5cm dilated and at +1 station. Her husband asks what does this mean. The nurse explains: a. she is in active labor, but the head is not yet engaged b. she is active labor, and the head is engaged c. she is transitional labor and about to deliver d. she is in the latent phase, the head is fully engaged 94. During labor the patient is sometimes catheterized. The rationale is: a. to prevent urinary stasis b. to encourage fetal descent c. minimize discomfort d. prevent the patient from having to get up to void 95. A laboring patient suddenly feels the urge to have a bowel movement. Vaginal exam shows she is 8 cm dilated. Which of the following nursing interventions would receive top priority: a. encourage patient to pant breath b. encourage patient to bear down because she is going to deliver c. give her a bedpan d. allow the patient to go to the bathroom 96. When uterine rupture occurs, which of the following would be the priority? a. Limiting hypovolemic shock b. Obtaining blood specimens c. Instituting complete bed rest d. Inserting a urinary catheter 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. 97. Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage? a. More than 200 ml c. More than 400 ml b. More than 300 ml d. More than 500 ml Postpartum hemorrhage is defined as blood loss of more than 500 ml following birth. Any amount less than this not considered postpartum hemorrhage. 98. 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 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.

99. 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 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. 100. 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 c. Contraction monitoring b. Fetal heart rate d. Cervical dilation 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.