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Name:_____________________________________________________________Date:_____________

1. A client, now 37 weeks pregnant, calls the clinic because she's concerned about
being short of breath and is unable to sleep unless she places three pillows under her
head. After listening to the client's concerns, the nurse should take which action?
a. Make an appointment because the dent needs to be evaluated.
b. Explain that these are expected problems for the latter stages of
pregnancy.
c. Arrange for the dent to be admitted to the birth center and prepare for birth.
d. Tell the client to go to the hospital; she may be experiencing signs of heart failure.
RATIONALE: The nurse must distinguish between normal physiologic complaints of
the latter stages of pregnancy and those that need referral to the health care
provider. In this case, the client indicates normal physiologic changes caused by the
growing uterus and pressure on the diaphragm. These signs don't indicate heart
failure. The client doesn't need to be seen or admitted to the birth center.
Reference: Maternal & Child Health Nursing: Care of the Childbearing and
Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 230.

2. During the first trimester, a nurse evaluates a pregnant client for factors that suggest
she might abuse a child. Which parental characteristic is of most concern to the
nurse?
a. The client didn’t graduate high school.
b. The client states she is stupid and ugly.
c. The client is carrying twins.
The client eats fast food every day.
RATIONALE: Typically, the abusive parent has low self-esteem, which may be
evident by self-deprecating statements, and many unmet needs. Lack of nurturing
experience and inadequate knowledge of childhood growth and development may
also contribute to the potential for child abuse. A low educational level, multiple
gestations, and poor diet aren't direct risk factors for committing child abuse.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
1743.

3. A client in her 15th week of pregnancy has presented with abdominal cramping and
vaginal bleeding for the past 8 hours. She has passed several clots. What is the
primary nursing diagnosis for this client?
a. Deficient knowledge of pregnancy
b. Deficient fluid volume
c. Anticipatory grieving
d. Acute pain
RATIONALE: If bleeding and clots are excessive, this client may become
hypovolemic , leading to a nursing diagnosis of Deficient fluid volume. Although
Deficient knowledge (pregnancy), Anticipatory grieving, and Acute pain are
applicable to this client, they aren't the primary diagnosis
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
400.

4. A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help
determine whether the client is at risk for a TORCH infection , the nurse should
ask:
a. “Have you ever had osteomyelitis?”
b. “Do you have any cats at home?
c. “Do you have any birds at home?’
d. “Have you recently had a rubeola vaccination?”
RATIONALE: Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes
simplex virus and agents that may infect the fetus or neonate, causing numerous ill
effects. Toxoplasmosis is transmitted to humans through contact with the feces of
infected cats (which may occur when emptying a litter box), through ingesting raw
meat, or through contact with raw meat followed by improper hand washing.
Osteomyelitis , a serious bone infection; histoplasmosis, which can be transmitted by
birds; and rubeola aren't TORCH infections
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
288.

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5. A client, 38 weeks pregnant, arrives in the emergency department complaining of
contractions. To help confirm that she's in true labor, the nurse should assess for:
a. irregular contractions.
b. increased fetal movement.
c. changes in cervical effacement and dilation atter 1 to 2 hours.
d. contractions that feel like pressure in the abdomen and qroin.
RATIONALE: True labor is characterized by progressive cervical effacement and
dilation after 1 to 2 hours, regular contractions, discomfort that moves from the back
to the front of the abdomen and, possibly, bloody show. False labor causes irregular
contractions that are felt primarily in the abdomen and groin and commonly decrease
with walking, increased fetal movement, and lack of change in cervical effacement or
dilation even after 1 or 2 hours.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
227.

6. A nurse is caring for a client during the first postpartum day. The client asks the
nurse how to relieve pain from her episiotomy . What should the nurse instruct the
woman to do?
a. Apply an ice pack to her perineum.
b. Take a sitz bath.
c. Perform perineal care after voiding or a bowel movement.
d. Drink plenty of fluids.
RATIONALE: A cold pack applied to an episiotomy during the first 24 hours after
chidbirth may reduce edema and tension on the incision line, thereby reducing pain.
After the first 24 hours, a sitz bath may reduce discomfort by promoting circulation
and healing. Although perineal care should be performed after each voiding and
bowel movement, its purpose is to prevent infection — not reduce
discomfort. Drinking plenty of fluids is also important, especially for the breast-
feeding woman, but it doesn't relieve perineal discomfort.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
637.
7. A client who's 24 weeks pregnant has sickle cell anemia . When preparing the care
plan, the nurse should identify which factor as a potential trigger for a sickle cell
crisis during pregnancy?
a. Sedative use
b. Dehydration
c. Hypertension
d. Tachycardia
RATIONALE: Factors that may precipitate a sickle cell crisis during pregnancy
include dehydration , infection , stress, trauma, fever, fatigue, and strenuous
activity. Sedative use, hypertension, and tachycardia aren't known to precipitate a
sickle cell crisis
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
363.
8. A nurse is caring for a 1-day postpartum mother who's very talkative but isn't
confident in her decision-making skills. The nurse is aware that this is a normal
phase for the mother. What is this phase called?
a. Taking-in phase
b. Taking-hold phase
c. Letting-go phase
d. Taking-over phase
RATIONALE: The taking-in phase is a normal first phase for a mother when she's
feeling overwhelmed by the responsibilities of caring for the neonate while still
fatigued from childbirth. Taking hold is the next phase, when the mother has rested
and she can think and learn mothering skills with confidence. During the letting-go or
taking-over phase, the mother gives up her previous role. She separates herself from
the neonate, giving up the fantasy of birth, and readjusting to the reality of caring for
the neonate. Depression may occur during this stage.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
624.

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9. Which intervention listed in the care plan for a client with an ectopic pregnancy
requires revision?
a. Assessing vital signs
b. Providing for dietary needs
c. Managing pain
d. Providing emotional support
RATIONALE: Providing for the client's dietary needs isn't appropriate because the
client shouldn't eat or drink anything pending surgery. Assessing vital signs for
indicators of potential shock , managing pain, and providing emotional support are
essential nursing interventions in caring for a client with an ectopic pregnancy.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
409.

10. A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In
addition to checking the client's fundal height, weight, and blood pressure, what
should the nurse assess for at each prenatal visit?
a. Edema
b. Pelvic adequacy
c. Rh factor changes
d. Hemoglobin alterations
RATIONALE: At each prenatal visit, the nurse should assess the client for edema
because edema, increased blood pressure, and proteinuria are cardinal signs of
gestational hypertension. Pelvic measurements and Rh typing are determined at the
first visit only because they don't change. The nurse should monitor the hemoglobin
level on the client's first visit, at 24 to 28 weeks' gestation, and at 36 weeks'
gestation.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
257.

11. A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago.
When assessing this client, the nurse's highest priority is to evaluate:
a. cervical effacement and dation.
b. maternal vital signs and fetal heart rate (FHR).
c. frequency and duration of contractions.
d. white blood cell (WBC) count.
RATIONALE: After premature rupture of the membranes (PROM), monitoring
maternal vital signs and FHR takes priority. Maternal vital signs, especially
temperature and pulse, may suggest maternal infection caused by PROM. FHR is the
most accurate indicator of fetal status after PROM and may suggest sepsis caused by
ascending pathogens. Assessing cervical effacement and dilation should be avoided
in this client because it requires a pelvic examination, which may introduce
pathogens into the birth canal. Evaluating the frequency and duration of contractions
doesn't provide insight into fetal status. The WBC count may suggest maternal
infection; however, it can't be measured as often as maternal vital signs and FHR can
and therefore provides less current information
REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health
Nursing. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 531.

12. A client is told that she needs to have a nonstress test to determine fetal well-being.
After 20 minutes of monitoring, the nurse reviews the strip and finds two 15-beat
accelerations that lasted for 15 seconds. What should the nurse do next ?
a. Continue to monitor the baby for fetal distress.
b. Notify the physician and transfer the mother to labor and delivery for imminent
delivery.
c. Inform the physician and prepare for discharge: this client has a
reassuring strip.
d. Ask the mother to eat something and return for a repeat test; the results are
inconclusive.
RATIONALE: Fetal well-being is determined during a nonstress test by two
accelerations occurring within 20 minutes that demonstrate a rise in heart rate of at
least 15 beats. This fetus has successfully demonstrated that the intrauterine
environment is still favorable. The test results don't suggest fetal distress, so
immediate delivery is unnecessary. In research studies, eating foods or drinking
fluids hasn't been shown to influence the outcome of a nonstress test. REFERENCE:

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Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and
Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 203.

13. A nurse is caring for four clients who gave birth 12 hours ago. Which client is at
greatest risk for complications?
a. Gravida 2 para 2002, cesarean bith, incision site intact, hemoglobin level
9.8 g/dl
b. Gravida 2 para 1011, cesarean birth, incision site intact, pulse 84 beats/minute
c. Gravida 1 para 1001, vaginal delivery, midline episiotomy, temperature of 99.8° F
(37.7C)
d. Gravida 1 para 1001, vaginal delivery, membranes ruptured 10 hours before birth
RATIONALE: Women who have anemia during pregnancy (defined as a hemoglobin
less than 10 g/dl) may experience more complications such as poor wound healing
and inability to tolerate activity. An intact incision site and a pulse of 84 beats/minute
after a cesarean birth and a temperature of 99.8F after a vaginal delivery with
episiotomy are findings within normal limits. Dehydration can cause a slightly
elevated temperature. Although women whose membranes are ruptured more than
24 hours before birth are more prone to developing chorioamnionitis, the client with
anemia is at greater risk for complications.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
362.

14. Which measure included in the care plan for a client in the fourth stage of labor
requires revision?
a. Check vital signs and fundal checks every 15 minutes.
b. Have the client spend time with the neonate to initiate breast-feeding.
c. Obtain an order for catheterization to protect the bladder from trauma.
d. Perform perineal assessments for swelling and bleeding.
RATIONALE: Catheterization isn't routinely done to protect the bladder from trauma.
It's done, however, for a postpartum complication of urinary retention. The other
options are appropriate measures to include in the care plan during the fourth stage
of labor. CLIENT NEEDS CATEGORY: Physiological integrity Basic care and comfort
REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health
Nursing. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 370.

15. A client who's 4 weeks pregnant comes to the clinic for her first prenatal visit. When
obtaining her health history, the nurse explores her use of drugs, alcohol, and
cigarettes. Which client outcome identifies a safe level of alcohol intake for this
client?
a. “The clent consumes no more than 2 oz of alcohol dady.”
b. “The client consumes no more than 4 oz of alcohol dady.”
c. “The client consumes 2 to 6 oz of alcohol daily, dependlng on body weight."
d. “The client consumes no alcohol.”
RATIONALE: A safe level of alcohol intake during pregnancy hasn't been
established. Therefore, authorities recommend that pregnant women abstain from
alcohol entirely. Excessive alcohol intake has serious harmful effects on the fetus,
especially between the 16th and 18th weeks of pregnancy. Affected neonates exhibit
fetal alcohol syndrome, which includes microcephaly, growth retardation, short
palpebral fissures, and maxillary hypoplasia. Alcohol intake may also affect the
client's nutrition and may predispose her to complications in early pregnancy.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
291.

16. A nurse is teaching a client about hormonal contraceptive therapy. If a client misses
three or more pills in a row, the nurse should instruct the client to:
a. take all the missed doses as soon as she discovers the oversight.
b. take two pills for the next 2 days and use an alternative contraceptive method
until the next cycle.
c. take three pills for the next 3 days and use an alternative contraceptive method
until the next cycle.
d. discard the pack, use an atternative contraceptive method untii her
period begins, and start a new pack on the regular schedule.
RATIONALE: A client who misses three or more pills in a row should discard the
pack, use an alternative contraceptive method until her period begins, and start a
new pack on the regular schedule. Taking all the missed doses, taking two pills for

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the next 2 days, or taking three pills for the next 3 days doesn't ensure effectiveness
and can increase the risk of adverse reactions. REFERENCE: Pillitteri, A. Maternal
& Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 112.

17. A nurse is caring for a client in labor. The external fetal monitor shows a pattern of
variable decelerations in fetal heart rate. What should the nurse do first ?
a. Change the client's position.
b. Prepare for emergency cesarean birth.
c. Check for placenta previa.
d. Administer oxygen.
RATIONALE: Variable decelerations in fetal heart rate are an ominous sign,
indicating compression of the umbilical cord. Changing the client's position may
immediately correct the problem. An emergency cesarean birth is necessary only if
other measures, such as changing position and amnioinfusion with sterile saline,
prove unsuccessful. Placenta previa doesn't cause variable decelerations.
Administering oxygen may be helpful, but the priority is to change the woman's
position and relieve cord compression
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
526.

18. Normal lochial findings in the first 24 hours after birth include:
a. Bright red blood.
b. large- or tissue fragments.
c. A foul odor.
d. the complete absence of lochia.
RATIONALE: Bright red blood is a normal lochial finding in the first 24 hours after
birth. Lochia should never contain large clots, tissue fragments, or membranes. A
foul odor or absence of lochia may signal infection .
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
630.

19. A nurse is performing a physical examination of a primigravid client who's 8 weeks


pregnant. At this time, the nurse expects to assess:
a. Hegar's sign.
b. fetal outline
c. balottement.
d.quickening
RATIONALE: When performing a vaginal or rectovaginal examination, the nurse may
assess Hegar's sign (softening of the uterine isthmus) between the 6th and 8th
weeks of pregnancy. The fetal outline may be palpated after 24 weeks. Ballottement
isn't elicited until the fourth or fifth month of pregnancy. Quickening typically is
reported after 16 to 20 weeks.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
227.

20. A client asks how long she and her husband can safely continue sexual activity
during pregnancy. How should the nurse respond?
a. “Unti the end of the frst trimester.”
b. "Unti the end of the second trrmester.”
c. "Unti the end of the thid trimester.”
d. "As long as you wish, if the pregnancy is normal.”
RATIONALE: During a normal pregnancy, the client and her partner need not
discontinue sexual activity. If the client develops complications that could lead to
preterm labor, she and her partner should consult with a health practitioner for
advice on the safety of sexual activity. REFERENCE: Pillitteri, A. Maternal & Child
Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 275.

21. A stillborn infant was delivered in the birthing suite a few hours ago. After the
delivery, the family remained together, holding and touching the baby. Which
statement by the nurse would further assist the family in their initial period of grief?
a. “What have you named your baby?”
b. “We need to take the baby from you now so that you can get some sleep.”

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c. “Don’t worry; there is nothing you could have done to prevent this from
happening.”
d. “We will see to it that you have an early discharge so that you don’t have to be
reminded of this experience.”
RATIONALE: Nurses should be able to explore measures that help the family create
memories of the newborn infant so that the existence of the child is confirmed and
the parents can complete the grieving process. Option 1 provides this support and
demonstrates a caring and empathetic response. Options 2, 3, and 4 are blocks to
communication and devalue the parents’ feelings.
REFERENCES: Wong, D., Perry, S., Hockenberry, M., et al. (2006)
Maternal child nursing care
(3rd ed., pp. 681-683). St. Louis: Mosby.

22. A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan
of care for the client and documents in the plan that if the client progresses from
preeclampsia to eclampsia, the nurse’s first action should be to:
a. Administer oxygen by face mask.
b. Clear and maintain an open airway.
c. Administer magnesium sulfate intravenously.
d. Assess the blood pressure and fetal heart rate.
RATIONALE: The immediate care during a seizure (eclampsia) is to ensure a patent
airway. Options 1, 3, and 4 are actions that follow or are implemented after the
seizure has ceased.
REFERENCES: Wong, D., Perry, S., Hockenberry, M., et al. (2006).
Maternal child nursing care
(3rd ed., p. 385). St. Louis: Mosby.

1. A pregnant client in the last trimester has been admitted to the hospital with a
diagnosis of severe preeclampsia. A nurse monitors for complications associated with
the diagnosis and assesses the client for:
a. Enlargement of the breasts
b. Complaints of feeling hot when the room is cool
c. Periods of fetal movement followed by quiet periods
d. Evidence of bleeding, such as in the gums, petechiae, and purpura
RATIONALE: Severe preeclampsia can trigger disseminated intravascular
coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding
is an early sign of DIC and should be reported to the health care provider if noted on
assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of
pregnancy.
REFERENCES: Lowdermilk, D., & Perry, A. (2004).
Maternity and women’s health care
(8th ed., pp. 852, 878). St. Louis: Mosby.

1. Immediately after an amniotomy has been performed, the nurse should first assess:
a. For bladder distention
b. For cervical dilation
c. The maternal blood pressure
d. The fetal heart rate (FHR) pattern
RATIONALE: The FHR is assessed immediately after amniotomy to detect any
changes that may indicate cord compression or prolapse. Bladder distention or
maternal blood pressure would not be the first things to check after an amniotomy.
Once the membranes are ruptured, minimal vaginal examinations will be done
because of the risk of infection.
REFERENCES: Lowdermilk, D., & Perry, S. (2004).
Maternity and women’s health care
(8th ed., p. 1009). St. Louis: Mosby.

1. A nurse in the labor room is caring for a client in the active stage of labor. The nurse
is assessing the fetal patterns and notes a late deceleration on the monitor strip. The
appropriate nursing action is to:
a. Administer oxygen via face mask.
b. Place the mother in a supine position.
c. Increase the rate of the oxytocin (Pitocin) IV infusion.
d. Document the findings and continue to monitor the fetal patterns.

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RATIONALE: Late decelerations are the result of uteroplacental insufficiency as the
result of decreased blood flow and oxygen to the fetus during the uterine
contractions. This causes hypoxemia; therefore, oxygen is necessary. The supine
position is avoided because it decreases uterine blood flow to the fetus. The client
should be turned onto her side to displace pressure of the gravid uterus on the
inferior vena cava. An intravenous oxytocin infusion is discontinued when a late
deceleration is noted. The oxytocin would cause further hypoxemia because of
increased uteroplacental insufficiency resulting from stimulation of contractions by
this medication. Option 4 would delay necessary treatment.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).
Maternity nursing (7th ed., p. 386). St. Louis: Mosby.

1. A nurse is performing an assessment of a client who is scheduled for a cesarean


delivery. Which assessment finding would indicate a need to contact the physician?
a. Hemoglobin of 11.0 g/dL
b. Fetal heart rate of 180 beats/min
c. Maternal pulse rate of 85 beats/min
d. White blood cell count of 12,000/mm3
RATIONALE: A normal fetal heart rate is 120 to 160 beats/min. A count of 180
beats/min could indicate fetal distress and would warrant physician notification.
White blood cell counts in a normal pregnancy begin to rise in the second trimester
and peak in the third trimester, with a normal range of 11,000 to 15,000/mm3
, up to 18,000/mm3. During the immediate postpartum period, the count may be as
high as 25,000 to 30,000/mm3 as a result of increased leukocytosis during delivery.
By full term, a normal maternal hemoglobin range is 11 to 13 g/dL as a result of the
hemodilution caused by an increase in plasma volume during pregnancy. The
maternal pulse rate during pregnancy increases 10 to 15 beats/min over
prepregnancy readings to facilitate increased cardiac output, oxygen transport, and
kidney filtration.
REFERENCES: Lowdermilk, D., & Perry, S. (2004). Maternity and women’s health
care (8th ed., pp. 356, 358, 518). St. Louis: Mosby.

1. A nurse has provided discharge instructions to a client who delivered a healthy


newborn infant by cesarean delivery. Which statement, if made by the client,
indicates a need for further instructions?
a. “I will begin abdominal exercises immediately.”
b. “I will notify the physician if I develop a fever.”
c. “I will turn on my side and push up with my arms to get out of bed.”
d. “I will lift nothing heavier than the newborn infant for at least 2 weeks.”
RATIONALE: Abdominal exercises should not start immediately following abdominal
surgery, and the client should wait at least 3 to 4 weeks postoperatively to allow for
healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client
following a cesarean delivery.
REFERENCES: Lowdermilk, D., & Perry, S. (2006). Maternity nursing (7th ed., p.
804). St. Louis: Mosby.

1. A nurse is caring for a client in labor who is receiving oxytocin (Pitocin) by


intravenous infusion to stimulate uterine contractions. Which assessment finding
would indicate to the nurse that the infusion needs to be discontinued?
a. Increased urinary output
b. A fetal heart rate of 90 beats/min
c. Three contractions occurring within a 10-minute period
d. Adequate resting tone of the uterus palpated between contractions
RATIONALE: A normal fetal heart rate is 120 to 160 beats/min. Bradycardia or late
or variable decelerations indicate fetal distress and the need to discontinue the
oxytocin. The goal of labor augmentation is to achieve three good-quality
contractions (appropriate intensity and duration) in a 10-minute period. The uterus
should return to resting tone between contractions, and there should be no evidence
of fetal distress. Increased urinary output is unrelated to the use of oxytocin.
REFERENCES: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005).
Maternal-child nursing
(2nd ed., p. 448). St. Louis: W.B. Saunders.

1. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression
if which of the following is noted on the external monitor tracing during a
contraction?

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a. Late decelerations
b. Early decelerations
c. Short-term variability
d. Variable decelerations
RATIONALE: Variable decelerations occur if the umbilical cord becomes
compressed, thus reducing blood flow between the placenta and the fetus. Early
decelerations result from pressure on the fetal head during a contraction. Late
decelerations are an ominous pattern in labor because they suggest uteroplacental
insufficiency during a contraction. Short-term variability refers to the beat-to-beat
range in the fetal heart rate.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).
Maternity nursing
(7th ed., p. 378). St. Louis: Mosby.

1. A labor and delivery room nurse has just received report on four clients. The nurse
should assess which client first?
a. A primiparous client in the active stage of labor
b. A multiparous client who was admitted for induction of labor
c. A client who is not contracting, but has suspected premature rupture of the
membranes
d. A client who has just received an IV loading dose of magnesium sulfate
to stop preterm labor
RATIONALE: Magnesium sulfate is a central nervous system (CNS) depressant and
the client could experience adverse effects that includes depressed respiratory rate
(below 12 breaths/min), severe hypotension, and absent deep tendon reflexes
(DTRs). This client should be seen before the clients in options 1, 2, and 3 because
these clients conditions represent stable ones.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).
Maternity nurs
ing (7th ed., p. 778). St. Louis: Mosby.

1. A nurse is reviewing the physician’s orders for a client admitted for premature
rupture of the membranes. Gestational age of the fetus is determined to be 37
weeks. Which physician’s order should the nurse question?
a. Perform a vaginal examination every shift.
b. Monitor maternal vital signs every 4 hours.
c. Monitor fetal heart rate (FHR) continuously.
d. Administer ampicillin 1 gm as an intravenous piggyback (IVPB) every 6 hours.
RATIONALE: Vaginal examinations should not be done routinely on a client with
premature rupture of the membranes because of the risk of infection. The nurse
would expect to administer an antibiotic, monitor maternal vital signs, and monitor
the FHR.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).
Maternity nurs
ing (7th ed., p. 782). St. Louis: Mosby.

1. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a
cesarean birth, what other intervention should be done?
a. Slow the intravenous (IV) flow rate.
b. Place the client in a high-Fowler’s position.
c. Continue the oxytocin (Pitocin) drip if infusing.
d. Administer oxygen at 8 to 10 L/min via face mask.
RATIONALE: Oxygen is administered at 8 to 10 L/min via face mask to optimize
oxygenation of the circulating blood. Option 1 is incorrect because the IV infusion
should be increased to increase the maternal blood volume. Option 2 is incorrect
because the client is placed in the lateral position with her legs raised to increase
maternal blood volume and improve fetal perfusion. Option 3 is incorrect because the
oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change
for any reason.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).
Maternity nursing
(7th ed., p. 386). St. Louis: Mosby.

1. A nurse in a labor room is performing a vaginal assessment on a pregnant client in


labor. The nurse notes the presence of the umbilical cord protruding from the vagina.
Which of the following is the initial nursing action?
a. Gently push the cord into the vagina.

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b. Place the client in Trendelenburg’s position.
c. Find the closest telephone and page the physician stat.
d. Call the delivery room to notify the staff that the client will be transported
immediately.
RATIONALE: When cord prolapse occurs, prompt actions are taken to relieve cord
compression and increase fetal oxygenation. The client should be positioned with the
hips higher than the head to shift the fetal presenting part toward the diaphragm.
The nurse should push the call light to summon help, and other staff members should
call the physician and notify the delivery room. If the cord is protruding from the
vagina, no attempt should be made to replace it because to do so could traumatize it
and further reduce blood flow. The examiner, however, may place a gloved hand into
the vagina and hold the presenting part off the umbilical cord. Oxygen at 8 to 10
L/min by face mask is administered to the client to increase fetal oxygenation.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).Maternity nursing (7th ed., p. 811).
St. Louis: Mosby.

1. 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. Prolonged clotting times
b. Decreased platelet count
c. Swelling of the calf of one leg
d. Petechiae, oozing from injection sites, and hematuria
RATIONALE: Disseminated intravascular coagulation (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.
REFERENCES: Mattson, S., & Smith, J. (2004).
Core curriculum for maternal-newborn nursing
(4th ed., p. 838). Philadelphia: W.B. Saunders.

1. A nurse is assessing a pregnant client in the second 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. A soft abdomen
b. Uterine tenderness
c. Absence of abdominal pain
d. Painless, bright red vaginal bleeding
RATIONALE: Painless, bright red vaginal bleeding in the second or third trimester of
pregnancy is a sign of placenta previa. In abruptio placentae, acute abdominal pain is
present. Uterine tenderness accompanies 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 monitor often reveals increased uterine
resting tone, caused by failure of the uterus to relax in an attempt to constrict blood
vessels and control bleeding.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).
Maternity nurs
ing (7th ed., p. 753). St. Louis: Mosby.

1. A maternity nurse is preparing for the admission of a client in the third trimester of
pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of
placenta previa. The nurse reviews the physician’s orders and would question which
order?
a. Prepare the client for an ultrasound.
b. Obtain equipment for a manual pelvic examination.
c. Prepare to draw a hemoglobin and hematocrit blood sample.
d. Obtain equipment for external electronic fetal heart rate monitoring.

RATIONALE: Manual pelvic examinations are contraindicated when vaginal bleeding


is apparent in the third trimester until a diagnosis is made and placenta previa is
ruled out. Digital examination of the cervix can lead to maternal and fetal

9
hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin
and hematocrit levels are monitored, and external electronic fetal heart rate
monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating
the status of the fetus that is at risk for severe hypoxia.
REFERENCES: Lowdermilk, D., & Perry, S. (2004).
Maternity and women’s health c
are (8th ed., pp. 872, 874-875). St. Louis: Mosby.

1. An ultrasound is performed on a client at term gestation that is experiencing


moderate vaginal bleeding. The results of the ultrasound indicate that abruptio
placentae is present. Based on these findings, the nurse would prepare the client for:
a. Delivery of the fetus
b. Strict monitoring of intake and output
c. Complete bed rest for the remainder of the pregnancy
d. The need for weekly monitoring of coagulation studies until the time of delivery
RATIONALE: 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. Because delivery of the fetus is necessary, options
2, 3, and 4 are incorrect regarding management of the client with abruptio placentae.
REFERENCES: Lowdermilk, D., & Perry, S. (2004).
Maternity and women’s health care
(8th ed., p. 877). St. Louis: Mosby.

1. A clinic nurse is performing a prenatal assessment on a pregnant client. The nurse


would implement teaching related to the risk of abruptio placentae if which of the
following information was obtained on assessment?
a. The client is 28 years of age.
b. This is the second pregnancy.
c. The client has a history of hypertension.
d. The client performs moderate exercise on a regular daily schedule.
RATIONALE: Abruptio placentae is associated with conditions characterized by poor
uteroplacental circulation, such as hypertension, smoking, and alcohol or cocaine
abuse. The condition also is associated with physical and mechanical factors, such as
overdistention of the uterus, which occurs with multiple gestation or polyhydramnios.
In addition, a short umbilical cord, physical trauma, and increased maternal age and
parity are risk factors.
REFERENCES: Wong, D., Perry, S., Hockenberry, M., et al. (2006).
Maternal child nursing ca
re. (3rd ed., p. 404). St. Louis: Mosby.

1. A nurse is caring for a client who is experiencing a precipitous birth. The nurse is
waiting for the physician to arrive. When the infant’s head crowns, the nurse would
instruct the client to:
a. Bear down.
b. Hold her breath.
c. Breathe rapidly (pant).
d. Push with each contraction.

RATIONALE: During a precipitous birth, when the infant’s head crowns, the nurse
instructs the client to breathe rapidly to decrease the urge to push. The client is not
instructed to push or bear down. Holding the breath decreases the amount of oxygen
to the mother and to the fetus.
REFERENCES: Murray, S., & McKinney, E. (2006).
Foundations of maternal-newborn nursing
(4th ed., p. 706). Philadelphia: W.B. Saunders.

1. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs
of a slowing labor. The nurse is reviewing the physician’s orders and would expect to
note which of the following prescribed treatments for this condition?
a. Increased hydration
b. Oxytocin (Pitocin) infusion
c. Medication that will provide sedation

10
d. Administration of a tocolytic medication
RATIONALE: Therapeutic management for hypotonic uterine dysfunction includes
oxytocin augmentation and amniotomy to stimulate a labor that slows. A cesarean
birth will be performed if no progress in labor occurs. Options 1, 3, and 4 identify
therapeutic measures for a client with hypertonic dysfunction.
REFERENCES: Murray, S., & McKinney, E. (2006).
Foundations of maternal-newborn nursing
(4th ed., p. 698-699). Philadelphia: W.B. Saunders.

1. A nurse is preparing to perform a fundal assessment on a postpartum client. The


initial nursing action in performing this assessment is which of the following?
a. Ask the client to turn on her side.
b. Ask the client to urinate and empty her bladder.
c. Massage the fundus gently before determining the level of the fundus.
d. Ask the client to lie flat on her back with the knees and legs flat and straight.
RATIONALE: Before starting the fundal assessment, the nurse should ask the client
to empty her bladder so that an accurate assessment can be done. When the nurse is
performing fundal assessment, the nurse asks the client to lie flat on her back with
the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy
or soft, and then it should be massaged gently until firm.
REFERENCES: Murray, S., & McKinney, E. (2006).
Foundations of maternal-newborn nursing
(4th ed., p. 410). Philadelphia: W.B. Saunders.

1. A nurse is caring for four 1-day postpartum clients. Which client has an abnormal
finding that would require further intervention?
a. The client with mild afterpains
b. The client with a pulse rate of 60 beats/min
c. The client with colostrum discharge from both breasts
d. The client with lochia that is red and has a foul-smelling odor
RATIONALE: Lochia, the discharge present after birth, is red for the first 1 to 3 days
and gradually decreases in amount. Normal lochia has a fleshy odor or an odor
similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection,
and these findings are not normal. The other options are normal findings for a 1-day
postpartum client.
REFERENCES: Lowdermilk, D., & Perry, S. (2004).
Maternity and women’s health care
(8th ed., p. 627). St. Louis: Mosby.

1. A postpartum nurse is taking the vital signs of a client who delivered a healthy
newborn infant 4 hours ago. The nurse notes that the client’s temperature is 100.2°
F. Which of the following actions would be appropriate?
a. Notify the physician.
b. Document the findings.
c. Retake the temperature in 15 minutes.
d. Increase hydration by encouraging oral fluids.
RATIONALE: The client’s temperature should be taken every 4 hours while she is
awake. Temperatures up to 100.4° F (38.0° C) in the first 24 hours after birth often
are related to the dehydrating effects of labor. The appropriate action is to increase
hydration by encouraging oral fluids, which should bring the temperature to a normal
reading. Although the nurse also would document the findings, the appropriate action
would be to increase the hydration. Contacting the physician is not necessary. Taking
the temperature in another 15 minutes is not a necessary action.
REFERENCES: Murray, S., & McKinney, E. (2006).
Foundations of maternal-newborn nursing
(4th ed., pp. 405, 409, 419). Philadelphia: W.B. Saunders.

1. A nurse is assessing a client who is 6 hours postpartum after delivering a full-term


healthy newborn infant. The client complains to the nurse of feelings of faintness and
dizziness. Which of the following nursing actions would be most appropriate?
a. Elevate the client’s legs.
b. Determine hemoglobin and hematocrit levels.
c. Instruct the client to request help when getting out of bed.
d. Inform the nursery room nurse to avoid bringing the newborn infant to the client
until the feelings of lightheadedness and dizziness have subsided.
RATIONALE: Orthostatic hypotension may be evident during the first 8 hours after
birth. Feelings of faintness or dizziness are signs that caution the nurse to beware for

11
the client’s safety. The nurse should advise the client to get help the first few times
the mother gets out of bed. Option 1 is not the most appropriate or helpful action in
this situation. Option 2 requires a physician’s order. Option 4 is unnecessary.
REFERENCES: Murray, S., & McKinney, E. (2006).
Foundations of maternal-newborn nursing
(4th ed., p. 407). Philadelphia: W.B. Saunders.

1. A postpartum nurse is providing instructions to a client after delivery of a healthy


newborn infant. The nurse instructs the client that she should expect normal bowel
elimination to return:
a. 3 days postpartum
b. 7 days postpartum
c. On the day of delivery
d. Within 2 weeks postpartum
RATIONALE: After birth, the nurse should auscultate the client’s abdomen in all four
quadrants to determine the return of bowel sounds. Normal bowel elimination usually
returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain
control agents also contribute to the longer period of altered bowel functions. Options
2, 3, and 4 are incorrect.
REFERENCES: Murray, S., & McKinney, E. (2006).
Foundations of maternal-newborn nursing
(4th ed., p. 389). Philadelphia: W.B. Saunders.

1. A nurse is planning care for a postpartum client who had a vaginal delivery 2 hours
ago. The client had a midline episiotomy and has several hemorrhoids. What is the
priority nursing diagnosis for this client?
a. Acute pain
b. Disturbed body image
c. Impaired urinary elimination
d. Risk for imbalanced fluid volume
RATIONALE: The priority nursing diagnosis for a client who delivered 2 hours ago
and who has a midline episiotomy and hemorrhoids is acute pain. Most clients have
some degree of discomfort during the immediate postpartum period. There is no data
in the question that indicate the presence of Disturbed body image, Impaired urinary
elimination, Risk for imbalanced fluid volume.
REFERENCES: Lowdermilk, D., & Perry, S. (2004).
Maternity and women’s health care
(8th ed., p. 632). St. Louis: Mosby.

1. A nurse is teaching a postpartum client about breast-feeding. Which of the following


instructions should the nurse include?
a. The diet should include additional fluids.
b. Prenatal vitamins should be discontinued.
c. Soap should be used to cleanse the breasts.
d. Birth control measures are not necessary while breastfeeding.
RATIONALE: The diet for a breast-feeding client should include additional fluids.
Prenatal vitamins should be taken as prescribed, and soap should not be used on the
breast because it tends to remove natural oils, which increases the chance of cracked
nipples. Breast-feeding is not a method of contraception, so birth control measures
should be resumed.
REFERENCES: Wong, D., Perry, S., Hockenberry, M., et al. (2006).
Maternal child nursing care
(3rd ed., p. 781). St. Louis: Mosby.

1. A postpartum client is diagnosed with cystitis. The nurse plans for which priority
nursing intervention in the care of the client?
a. Providing sitz baths
b. Encouraging fluid intake
c. Placing ice on the perineum
d. Monitoring hemoglobin and hematocrit levels
RATIONALE: Cystitis is an infection of the bladder. The client should consume 3000
mL of fluids per day. Sitz baths and ice would be appropriate interventions for
perineal discomfort. Hemoglobin and hematocrit levels would be monitored with
hemorrhage.
REFERENCES: Murray, S., & McKinney, E. (2006).
Foundations of maternal-newborn nursing
(4th ed., p. 749). St. Louis: W.B. Saunders.

12
1. A nurse is monitoring a postpartum client who received epidural anesthesia for the
presence of a vulvar hematoma. Which of the following assessment findings would
best indicate the presence of a hematoma?
a. Changes in vital signs
b. Signs of heavy bruising
c. Complaints of intense pain
d. Complaints of a tearing sensation
RATIONALE: Because the client has had epidural anesthesia and is anesthetized,
she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate
hypovolemia in the anesthetized postpartum woman with vulvar hematoma. Option 2
(heavy bruising) may be visualized, but vital sign changes indicate hematoma caused
by blood collection in the perineal tissues.
Use the process of elimination, noting the strategic words epidural anesthesia. With
this in mind, eliminate options 3 and 4. From the remaining options, use the ABCs—
airway, breathing, and circulation—to direct you to option 1. Review the signs of a
vulvar hematoma in a client who had epidural anesthesia if you had difficulty with
this question.
REFERENCES: Lowdermilk, D., & Perry, S. (2004).
Maternity and women’s health care
(8th ed., p. 1037). St. Louis: Mosby.

1. A nurse is providing instructions about measures to prevent postpartum mastitis to a


client who is breast-feeding her newborn. Which of the following, if stated by the
client, would indicate a need for further instructions?
a. “I should breast-feed every 2 to 3 hours.”
b. “I should change the breast pads frequently.”
c. “I should wash my hands well before breast-feeding.”
d. “I should wash my nipples daily with soap and water.”
RATIONALE: Mastitis generally is caused by an organism that enters through an
injured area of the nipples, such as a crack or blister. Measures to prevent the
development of mastitis include changing nursing pads when they are wet and
avoiding continuous pressure on the breasts. Soap is drying and could lead to
cracking of the nipples, and the mother should be instructed to avoid the use of soap
on the nipples during breast-feeding. The mother is taught about the importance of
hand washing and that she should breast-feed every 2 to 3 hours.
REFERENCES: Murray, S., & Gorrie, T. (2006).
Foundations of maternal-newborn nursing
(4th ed., p. 750). Philadelphia: W.B. Saunders.

1. A client in the postpartum care unit who is recovering from disseminated


intravascular coagulopathy is to be discharged on low dosages of an anticoagulant
medication. In developing home care instructions for this client, the nurse includes
which priority safety instruction regarding this medication?
a. Avoid all activities because bruising injuries can occur.
b. Avoid walking long distances and climbing stairs.
c. Avoid taking acetylsalicylic acid (aspirin).
d. Avoid brushing the teeth.
RATIONALE: Aspirin can interact with the anticoagulant medication to increase
clotting time beyond therapeutic ranges. Avoiding aspirin is a priority. Not all
activities need to be avoided. Walking and climbing stairs are acceptable activities.
The client does not need to avoid brushing the teeth; however, the client should be
instructed to use a soft toothbrush.
REFERENCES: Kee, J., Hayes, E., & McCuistion, L. (2006).
Pharmacology: A nursing process approach
(5th ed., p. 666). Philadelphia: W.B. Saunders.

1. The uterus returns to the pelvic cavity in which time frame?


a. 7 to 9 days postpartum
b. 2 weeks postpartum
c. 6 weeks postpartum
d. When the lochia changes to alba
RATIONALE: The normal involutional process returns the uterus to the pelvic cavity
in 7 to 9 days. A significant involutional complication is the failure of the uterus to
return to the pelvic cavity within the ordered time period. This is known as
subinvolution.

13
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 628.

2. A postpartum client asks the nurse about the rhythm (symptothermal) method of
family planning. The nurse explains that this method involves:
a. using chemical barriers that act as spermicidal agents.
b. using hormones that prevent ovulation.
c. using mechanical barriers that prevent sperm from reaching the cervix.
d. determining the fertile period to identify safe times for sexual
intercourse.
RATIONALE: The symptothermal method of family planning combines basal body
temperature measurement with analysis of cervical mucus changes to determine the
fertile period more accurately and thus identify safe and unsafe periods for sexual
intercourse. A natural family planning method, it doesn't involve use of chemical
barriers, hormones, or mechanical barriers. REFERENCE: Pillitteri, A. <i>Maternal
& Child Health Nursing: Care of the Childbearing and Childrearing Family,</i> 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 109.

3. A nurse is preparing to perform a postpartum assessment on a client who gave


birth 5 hours ago. Which precaution should the nurse plan to take for this procedure?
a. washing the hands
b. washing the hands and wearing latex gloves
c. washing the hands and wearing latex gloves and a barrier gown
d. washing the hands and wearing latex gloves, a barrier gown, and protective
eyewear
RATIONALE: During a postpartum assessment, the nurse is likely to come into
contact with the client's blood or body fluids, especially when examining the perineal
region. Therefore, the nurse must wear latex gloves; hand washing alone would
neither provide adequate protection nor comply with universal precautions. The
nurse should wear a barrier gown and protective eyewear in addition to latex gloves
only when anticipating splashing of blood or body fluids such as during childbirth.
Splashing isn't likely to occur during a postpartum assessment.
REFERENCE: Craven, R.F., and Hirnle, C.J. <i>Fundamentals of Nursing: Human
Health and Function,</i> 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
531.

4. A nurse in a prenatal clinic is assessing a client who's 24 weeks pregnant. Which


findings lead this nurse to suspect that the client has mild preeclampsia?
a. Glycosuria, hypertension, seizures
b. Hematuria, blurry vision, reduced urine output
c. Burning on urination, hypotension, abdominal pain
d. Hypertension, edema, proteinuria
RATIONALE: The typical findings of mild preeclampsia are hypertension, edema, and
proteinuria. Abdominal pain, blurry vision, and reduced urine output are signs of
severe preeclampsia. Seizures are a sign of eclampsia. The other findings aren't
typically found in women with preeclampsia.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 427.

5. On her second visit to the prenatal facility, a client states, "I guess I really am
pregnant. I've missed two periods now." Based on this statement, the nurse
determines that the client has accomplished which psychological task of pregnancy?
a. Identifying the fetus as a separate being
b. Assuming caretaking responsibility for the neonate
c. Preparing to relinquish the neonate through labor
d. Accepting the biological fact of pregnancy
RATIONALE: The first maternal psychological task of pregnancy is to accept the
pregnancy as a biological fact. If the client doesn't accept that she's pregnant, she's
unlikely to seek prenatal care. Identifying the fetus as a separate being usually
occurs after the client feels fetal movements. Assuming caretaking responsibility for
the neonate should occur during the postpartum period. Preparing to relinquish the
neonate through labor normally occurs during the third trimester.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 215.

14
6. On the second postpartum day a gravida 6, para 5 complains of intermittent
abdominal cramping. The nurse should assess for:
a. endometritis.
b. postpartum hemorrhage.
c. subinvolution.
d. afterpains.
RATIONALE: In a multiparous client, decreased uterine muscle tone causes
alternating relaxation and contraction during uterine involution, which leads to
afterpains. The client's symptoms don't suggest endometritis, hemorrhage, or
subinvolution.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 629.

7. A client is 8 weeks pregnant. Which teaching topic is most appropriate at this time?
a. Breathing techniques during labor
b. Common discomforts of pregnancy
c. Infant care responsibilities?
d. Neonatal nutrition
RATIONALE: During the first trimester, a pregnant client is most concerned with her
own needs. Because she's likely to experience discomforts of pregnancy, such as
morning sickness, fatigue, and urinary frequency, the nurse should teach her how to
relieve these discomforts. The nurse should teach labor breathing techniques during
the second half of the pregnancy, when the client is most strongly motivated to learn
them. The postpartum period is the best time to teach about infant care
responsibilities and neonatal nutrition if the client didn't attend prenatal classes.
Otherwise, infant care is taught during the third trimester and reinforced in the
postpartum period.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 245.

8. Certain drugs used during the postpartum period may affect blood pressure. Which
drug decreases a postpartum client's blood pressure?
a. Oxytocin (Pitocin)
b. Codeine phosphate
c. Ergonovine (Ergotrate Maleate)
d. Methylergonovine (Methergine)
RATIONALE: Codeine phosphate, given to relieve postpartum pain, may cause a
decrease in blood pressure. Oxytocin reduces postpartum bleeding after expulsion of
the placenta and may cause hypertension. Ergonovine and methylergonovine
prevent or treat postpartum hemorrhage from uterine atony or subinvolution and
may cause an increase in blood pressure. REFERENCE: Pillitteri, A. <i>Maternal &
Child Health Nursing: Care of the Childbearing and Childrearing Family,</i> 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 639.

9. During the first 3 months, which hormone is responsible for maintaining pregnancy?
a. Human chorionic gonadotropin (hCG)
b. Progesterone
c. Estrogen
d. Relaxin
RATIONALE: The hormone hCG is responsible for maintaining the pregnancy until
the placenta is in place and functioning. Serial hCG levels are used to determine the
status of the pregnancy in clients with complications. Progesterone and estrogen are
important hormones responsible for many of the body's changes during pregnancy.
Relaxin is an ovarian hormone that causes the mother to feel tired, thus promoting
her to seek rest.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 187.

10. A nurse coming onto the night shift assesses a client who gave birth vaginally that
morning. The nurse finds that the client's vaginal bleeding has saturated two perineal
pads within 30 minutes. What is the first action the nurse should take?

15
a. Ask the client to get out of bed and try to urinate.
b. Call the physician for a methylergonovine (Methergine) order.
c. Assess the fundus and massage it if it's boggy.
d. Give the client a new pad and check her in 30 minutes.
RATIONALE: The nurse should first assess the fundus to determine if clots are
present or if uterine involution has occurred. Clots, no uterine involution, and the
saturation of two perineal pads within 30 minutes could indicate postpartum
hemorrhage. If the fundus is boggy, massaging it will suppress bleeding by
encouraging the uterus to contract upon itself and the open vessels that were
attached to the placenta. Massaging also helps to expel clots or tissue remaining
from the birth. If the nurse assesses a firm fundus, she should next assess for a full
bladder and then ask the client to try to urinate. If the uterus remains boggy after
massage, the nurse should obtain an order from the physician for methylergonovine.
Waiting 30 minutes without intervening could contribute to uterine hemorrhage.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 656.

11. A client in labor is receiving oxytocin (Pitocin). The electronic fetal monitoring strip
shows contractions occurring every 30 seconds to 2 minutes, with an intensity of 90
mm Hg and increasing resting tone. How should the nurse respond to these findings?
a. Administer oxygen as ordered.
b. Call the physician.
c. Check the fetal heart rate (FHR).
d. Discontinue the oxytocin infusion.
RATIONALE: Oxytocin should be discontinued when contractions occur less than 2
minutes apart or last longer than 90 seconds. The nurse can stop oxytocin infusion
independently without seeking permission from the physician - an action that would
waste valuable time. This client isn't oxygen deprived and, therefore, doesn't need
supplemental oxygen. Checking the FHR isn't appropriate in this situation because
the decelerations occur and resolve with each contraction, independent of oxytocin
administration.
REFERENCE: Ricci, S.S. <i>Essentials of Maternity, Newborn, and Women’s Health
Nursing.</i> Philadelphia: Lippincott Williams & Wilkins, 2007, p. 599.

12. When assessing the fetal heart rate tracing, a nurse assesses the fetal heart rate at
170 beats/minute. This rate is considered fetal tachycardia if:
a. the fetal heart rate remains at greater than 160 beats/minute for 5 minutes.
b. the fetal heart rate remains at greater than 160 beats/minute for 10
minutes.
c. the fetal heart rate remains at greater than 160 beats/minute for more than 20
minutes.
d. the fetal heart rate is at least 170 beats/minute at any time.
RATIONALE: The normal parameter for the fetal heart rate is 120 to 160
beats/minute. Fetal tachycardia is defined as a fetal heart rate greater than 160
beats/minute for more than 10 minutes. This definition takes into account the
difference between tachycardia and acceleration. REFERENCE: Pillitteri, A.
<i>Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family,</i> 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 525.

13. A client asks about complementary therapies for relief of discomforts related to
pregnancy. Which comfort measure mentioned by the client indicates a need for
further teaching?
a. Meditation
b. Music therapy
c. Acupuncture
d. Herbal remedies
RATIONALE: A pregnant woman should avoid all medication unless her physician
instructs her to use it. This includes herbal remedies because their effects on the
fetus haven't been identified. Meditation, music therapy, and acupuncture have all
proven to enhance relaxation without harm to the mother or baby.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 290.

14. Which factor is the most important in nursing care in the postpartum period?

16
a. Supporting the mother's ability to successfully feed and care for her
neonate
b. Involving the family in the teaching
c. Providing group discussions on neonatal care
RATIONALE: Most of the nursing interventions during the postpartum period are
directed toward helping the mother successfully adapt to the parenting role.
Although family involvement in teaching, group discussions on neonatal care, and
lochia monitoring are important aspects of care, the mother's ability to feed and care
for her neonate takes priority.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 622.

15. A client has her first prenatal visit at 15 weeks' gestation. Which finding requires
further investigation?
a. Fundal height of 18 cm
b. Blood pressure of 124/72 mm Hg
c. Urine negative for protein
d. Weight of 144 lb (65.kg)
RATIONALE: Fundal height (in centimeters) should equal the number of weeks'
gestation. This client should have a fundal height of 15 to 16 cm. The blood pressure,
urine, and weight findings are within normal limits for this client.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 200.

16. A client who gave birth 24 hours ago continues to experience urine retention after
several catheterizations. The physician orders bethanechol (Urecholine), 10 mg by
mouth three times per day. The client asks, "How does bethanechol act on the
bladder ?" How should the nurse respond?
a. “It constricts the urinary sphincter.”
b. "It dilates the urethra.”
c. “It stimulates the smooth muscle of the bladder.”
d. “It inhibits the skeletal muscle of the bladder.”
RATIONALE: Bethanechol stimulates the smooth muscle of the bladder, causing it to
release retained urine. Bethanechol doesn't act on the urinary sphincter or dilate the
urethra. The bladder contains smooth muscle, not skeletal muscle.
REFERENCE: Springhouse Nurse’s Drug Guide 2007 Philadelphia: Lippincott Williams
& Wilkins, 2007, p. 215.

17. A client is using the rhythm (calendar-basal body temperature) method of family
planning. In this method, the unsafe period for sexual intercourse is indicated by:
a. return to preovulatory basal body temperature.
b. basal body temperature increase of 0.1° F to 0.2° F (0.06° C to 0.11° C) on the 2nd
or 3rd day of the cycle.
c. 3 full days of elevated basal body temperature and clear, thin cervical
mucus.
d. breast tenderness and mittelschmerz
RATIONALE: Ovulation (the period when pregnancy can occur) is accompanied by a
basal body temperature increase of 0.7F to 0.8F (0.39C to 0.44 C) and clear, thin
cervical mucus. A return to the preovulatory body temperature indicates a safe
period for sexual intercourse. A slight rise in basal temperature early in the cycle isn't
significant. Breast tenderness and mittelschmerz aren't reliable indicators of
ovulation.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 109.

18. A pregnant client comes to the facility for her first prenatal visit. After obtaining her
health history and performing a physical examination, the nurse reviews the client's
laboratory test results. Which findings suggest iron deficiency anemia?
a. Hemoglobin (Hb) 15 g/L; hematocrit (HCT) 35%
b. Hb 13 g/L; HCT 32%
c. Hb 10 g/L; HCT 35%
d. Hb 9 g/L; HCT 30%
RATIONALE: With iron deficiency anemia, the Hb level is below 12 g/L and HCT
drops below 33%.

17
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 362.

19. A client who's breast-feeding has a temperature of 102&#176; F (38.9&#176; C) and


complains that her breasts are engorged. Her breasts are swollen, hard, and red.
Which action by the client requires intervention?
a. Applying frozen cabbage leaves to the breasts
b. Showering with her back to the water
c. nursing her baby frequently
d. Applying a breast binder to support the breasts
RATIONALE: Engorgement in a breast-feeding woman requires careful management
to preserve the milk supply while managing the increased blood flow to the breasts.
Binding the breasts isn't appropriate because the constriction will diminish the milk
supply. Frozen cabbage leaves work well to reduce the pain and swelling and should
be applied every 4 hours. Facing the shower head can stimulate the breasts and
intensify the problem. Frequent feedings will permit the breasts to empty fully and
establish the supply-demand cycle that is appropriate for the infant. REFERENCE:
Ricci, S.S. <i>Essentials of Maternity, Newborn, and Women’s Health Nursing.</i>
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 414.

20. A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which
laboratory finding indicates the need for intervention?
a. Urine specific gravity 1.010
b. Serum potassium 4 mEq/L
c. Serum sodium 140 mEq/L
d. Ketones in the urine
RATIONALE: Ketones in the urine of a client with hyperemesis gravidarum indicate
that the body is breaking down stores of fat and protein to provide for growth needs.
A urine specific gravity of 1.010, a serum potassium level of 4 mEq/L, and a serum
sodium level of 140 mEq/L are all within normal limits.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 320.

21. During the sixth month of pregnancy, a client reports intermittent earaches and a
constant feeling of fullness in the ears. What is the most likely cause of these
symptoms?
a. A serious neurologic disorder
b. Eustachian tube vascularization
c. Increasing progesterone levels
d. An ear infection
RATIONALE: During pregnancy, increasing levels of estrogen &#8212; not
progesterone &#8212; cause vascularization of the eustachian tubes, leading to such
problems as earaches, impaired hearing, and a constant feeling of fullness in the
ears. The client's symptoms don't suggest a serious neurologic disorder or an ear
infection.
REFERENCE: Ricci, S.S. <i>Essentials of Maternity, Newborn, and Women’s Health
Nursing.</i> Philadelphia: Lippincott Williams & Wilkins, 2007, p. 245.

22. A client says she wants to practice natural family planning. The nurse teaches her
how to use the calendar method to determine when she's fertile and advises her to
avoid unprotected intercourse. When teaching her how to determine her fertile
period , the nurse should instruct her to:
a. abstain from unprotected intercourse between days 14 and 16 of the menstrual
cycle.
b. subtract 11 days from her shortest menstrual cycle and 18 days from her longest
cycle.
c. subtract 18 days from her shortest menstrual cycle and 11 days from her
longest cycle.
d. add 25 days to the first day of her last menstrual period and abstain from
unprotected intercourse for the next 5 days.
RATIONALE: To determine the fertile period, the client should subtract 18 days from
her shortest menstrual cycle and 11 days from her longest cycle; if she doesn't wish
to become pregnant, she should abstain from unprotected intercourse between the
days calculated. For example, if her menstrual cycles range from 28 to 30 days, her

18
fertile period encompasses days 10 to 19 of her cycle. Abstaining from unprotected
intercourse on certain days doesn't determine the fertile period.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 109.

23. What is the primary nursing diagnosis for a client with a ruptured ectopic
pregnancy?
a. Anxiety
b. Acute pain
c. Deficient fluid volume
d. Anticipatory grieving
RATIONALE: Ruptured ectopic pregnancy is associated with hemorrhage and
requires immediate surgical intervention; therefore, <i>Deficient fluid volume</i> is
the primary diagnosis. <i>Anxiety, Acute pain,</i> and <i>Anticipatory grieving</i>
are appropriate for this client, but none of these diagnoses would be considered the
primary nursing diagnosis. This client is probably experiencing anxiety because this
is a surgical emergency. Pain is also present and should be addressed as warranted.
The client with ruptured ectopic pregnancy may experience anticipatory grieving at
the loss of her fetus.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 409.

24. A client, 11 weeks pregnant, is admitted to the facility with hyperemesis


gravidarum</!gloss>. She tells the nurse she has never known anyone who had such
severe morning sickness. The nurse understands that hyperemesis gravidarum
results from:
a. a neurologic disorder.
b. inadequate nutrition.
c. an unknown cause.
d. hemolysis of fetal red blood cells
RATIONALE: The cause of hyperemesis gravidarum isn't known. However, etiologic
theories implicate hormonal alterations and allergic or psychosomatic conditions. No
evidence suggests that hyperemesis gravidarum results from a neurologic disorder,
inadequate nutrition, or hemolysis of fetal RBCs. REFERENCE: Pillitteri, A.
<i>Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family,</i> 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 320.

25. A client is scheduled for amniocentesis. When <!hint>preparing her for the
procedure, the nurse should:
a. ask the client to void.
b. instruct the client to drink 1 L of fluid.
c. prepare the client for I.V. anesthesia.
d. place the client on her left side.
RATIONALE: To prepare a client for amniocentesis, the nurse should ask her to
empty her bladder to reduce the risk of bladder perforation. Before transabdominal
ultrasound, the nurse may instruct the client to drink 1 L of fluid to fill the bladder
(unless ultrasound is done before amniocentesis to locate the placenta). I.V.
anesthesia isn't given for amniocentesis. The client should be supine during the
procedure; afterward, she should be placed on her left side to avoid supine
hypotension, promote venous return, and ensure adequate cardiac output</!gloss>.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 207.

26. A client is 24 hours postpartum . The nurse anticipates that the client's body is
returning to homeostasis. Which assessment finding requires immediate
intervention?
a. Maternal chills
b. Elevated temperature
c. Bradycardia
d. Positive Homans' sign
RATIONALE: A positive Homans' sign indicates thrombosis, which is abnormal for a
postpartum client. This sign requires immediate intervention. Maternal chills are a
normal vasomotor response to the birth. An elevated temperature in the first 24

19
hours is also normal. Bradycardia</!gloss> in the postpartum period is common as
the body adjusts to the decreased cardiac output and begins to eliminate fluid.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 668.

27. A nurse assesses a client who gave birth 24 hours earlier. Which finding reveals the
need for further evaluation?
a. Chills
b. Scant lochia rubra
c. Thirst and fatigue
d. Temperature of 100.2° F (37.90 C)
RATIONALE: During the early postpartum period, lochia rubra</!gloss> should be
moderate to significant. Scant lochia rubra suggests that large clots are blocking the
lochial flow. After birth, vasomotor changes may cause a shaking chill, this is a
normal finding. Thirst, fatigue, and a temperature of up to 100.4 F (38 C) also are
common at 24 hours postpartum.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 630.

28. Which nursing action is required before a client in labor receives epidural
anesthesia?
a. Give a fluid bolus of 500 ml.
b. Check for maternal pupil dilation.
c. Assess maternal reflexes.
d. Assess maternal gait.
RATIONALE: One of the major adverse effects of epidural administration is
hypotension. Therefore, a 500-ml fluid bolus is usually administered to prevent
hypotension in the client who wishes to receive an epidural for pain relief. Assessing
maternal reflexes, pupil response, and gait isn't necessary.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 552.

29. A nursing assistant escorts a client in the early stages of labor to the bathroom.
When the nurse enters the client's room, she detects a strange odor coming from the
bathroom and suspects the client has been smoking marijuana. What should the
nurse do next ?
a. Tell the client that smoking is prohibited in the facility, and that if she smokes
agan, she’ll be discharged.
b. Explain to the client that smoking poses a danger of explosion because oxygen
tanks are stored close by.
c. Notify the physician and security immediately.
d. Ask the nursing assistant to dispose of the marijuana so that the client can't smoke
anymore.
RATIONALE: The nurse should immediately notify the physician and security. The
physician must be informed because illegal drugs can interfere with the labor process
and affect the neonate after delivery. Moreover, the client might have consumed
other illegal drugs. The nurse should also inform security because they're specially
trained to handle such situations. Most hospitals prohibit smoking. The nurse needs
to alert others about the client's illegal drug use, not simply explain to the client that
smoking is prohibited. Smoking is dangerous around oxygen and it's fine for the
nurse to explain the hazard to the client; however, the nurse must first notify the
physician and security. The nursing assistant shouldn't be asked to dispose of the
marijuana. REFERENCE: Ricci, S.S. <i>Essentials of Maternity, Newborn, and
Women’s Health Nursing.</i> Philadelphia: Lippincott Williams & Wilkins, 2007, p.
574.

30. A woman in her 34th week of pregnancy presents with sudden onset of bright red
vaginal bleeding. Her uterus is soft, and she's experiencing no pain. Fetal heart rate
is 120 beats/minute. Based on this history, the nurse should suspect:
a. abruptio placentae.
b. preterm labor.
c. placenta previa.
d. threatened abortion.

20
RATIONALE: Placenta previa</!gloss> is associated with painless vaginal bleeding
that occurs when the placenta or a portion of the placenta covers the cervical os. In
abruptio placentae</!gloss>, the placenta tears away from the wall of the uterus
before birth; the client usually has pain and a boardlike uterus. Preterm labor is
associated with contractions and shouldn't involve bright red bleeding. By definition,
threatened abortion occurs during the first 20 weeks' gestation.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 413.

31. When providing health teaching to a primigravid client, the nurse tells the client that
she's likely to experience Braxton Hicks contractions. When does a client typically
start to feel these contractions?
a. Between 18 and 22 weeks’ gestation
b. Between 23 and 27 weeks' gestation
c. Between 28 and 31 weeks' gestation
d. Between 32 and 35 weeks' gestation
RATIONALE: Pregnant clients typically start to feel Braxton Hicks contractions
between 23 and 27 weeks' gestation. Fetal rebound is possible between 18 and 22
weeks. The fetal outline becomes palpable and the fetus is highly mobile between 28
and 31 weeks. Braxton Hicks contractions increase in frequency and intensity
between 32 and 35 weeks.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 286.

32. Which finding requires further intervention in a mother who's breast-feeding?


a. The neonate latches easily to the breast.
b. The mother is comfortable positioning the neonate.
c. The neonate makes swallowing noises when breast-feeding.
d. The neonate's lips smack.
RATIONALE: A neonate who smacks his lips isn't properly latched to the breast. A
neonate who latches on easily and makes audible swallowing noises and a mother
who is comfortable positioning the neonate indicate successful breast-feeding.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 733.

33. A client who's 12 weeks pregnant is complaining of severe left lower quadrant pain
and vaginal spotting. She's admitted for treatment of an ectopic pregnancy. The
nurse should give the highest priority to which nursing diagnosis?
a. Risk for deficient fluid volume
b. Anxiety
c. Acute pain
d. Impaired gas exchange
RATIONALE: A ruptured ectopic pregnancy is a medical emergency because of the
large quantity of blood that may be lost in the pelvic and abdominal cavities.
Shock</!gloss> may develop from blood loss, and large quantities of I.V. fluids are
needed to restore intravascular volume until the bleeding is surgically controlled.
Although the other nursing diagnoses are relevant for a woman with an ectopic
pregnancy, fluid volume loss through hemorrhage is the greatest threat to her
physiological integrity and must be stopped. <i>Anxiety</i> may result from such
factors as the risk of dying and the fear of future infertility. <i>Pain</i> may be
caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity.
<i>Impaired gas exchange</i> may result from the loss of oxygen-carrying
hemoglobin through blood loss. REFERENCE: Pillitteri, A. <i>Maternal & Child
Health Nursing: Care of the Childbearing and Childrearing Family,</i> 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 409.

34. During a routine prenatal visit, a pregnant client reports constipation, and the nurse
teaches her how to relieve it. Which client statement indicates <!hint>understanding
of the nurse's instructions?

21
a. “I’ll decrease my intake of green, leafy vegetables.”
b. "I’ll limit fluid intake to four 8-oz glasses.”
c. "I’ll increase my intake of unrefined grains.”
d. "I’ll take iron supplements regularly.”
RATIONALE: To increase peristalsis and relieve constipation, the client should
increase her intake of high-fiber foods (such as green, leafy vegetables; unrefined
grains; and fruits) and fluids. The use of iron supplements can cause &#8212; rather
than relieve &#8212; constipation. REFERENCE: Pillitteri, A. <i>Maternal & Child
Health Nursing: Care of the Childbearing and Childrearing Family,</i> 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 280.

35. A client at 28 weeks' gestation is complaining of contractions. Following admission


and hydration, the physician writes an order for the nurse to give 12 mg of
betamethasone I.M. This medication is given to:
a. slow contractions.
b. enhance fetal growth.
c. prevent infection.
d. promote fetal lung maturity.
RATIONALE: Betamethasone is given to promote fetal lung maturity by enhancing
the production of surface-active lipoproteins. The drug has no effect on contractions,
fetal growth, or infection.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 414.

36. A client with diabetes mellitus who is in labor tells the nurse she has had trouble
controlling her blood glucose level recently. She says she didn't take her insulin when
the contractions began because she felt nauseated; about an hour later, when she
felt better, she ate some soup and crackers but didn't take insulin. Now, she reports
increased nausea and a flushed feeling. The nurse notes a fruity odor to her breath.
What do these findings suggest?
a. Diabetic ketoacidosis
b. Hypoglycemia
c. Infection
d. Transition to the active phase of labor
RATIONALE: Signs and symptoms of diabetic ketoacidosis</!gloss> include nausea
and vomiting, a fruity or acetone breath odor, signs of dehydration</!gloss> (such
as flushed, dry skin), hyperglycemia</!gloss>, ketonuria, hypotension, deep and
rapid respirations, and a decreased level of consciousness. In contrast,
hypoglycemia</!gloss> causes sweating, tremors, palpitations, and behavioral
changes. Infection</!gloss> causes a fever. Transition to the active phase of labor is
signaled by cervical dilation of up to 7 cm and contractions every 2 to 5 minutes.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 377.

37. An expected fetal adverse reaction to meperidine (Demerol) during labor is:
a. decreased fetal heart rate variability.
b. bradycardia.
c. late decelerations.
d. increased movement
RATIONALE: Possible fetal adverse reactions include moderate central nervous
system depression and decreased fetal heart rate variability</!gloss>.
Bradycardia</!gloss>, late decelerations</!gloss>, and increased fetal movement
don't occur as a result of meperidine administration.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 550.

38. A client who gave birth to her first child 6 weeks ago seems overwhelmed by her
new role as a mother. She tells the nurse, "I can't keep up with my housework any
more because I spend so much time caring for the baby." The nurse should:
a. help the client break down large tasks into smaller ones.
b. encourage the client to work faster.
c. reassure the client that her feelings will soon pass.
d. help the client accept her new role.

22
RATIONALE: If a client feels overwhelmed by the additional tasks brought on by her
new role as a mother, the nurse should help her break down large tasks into smaller,
more manageable ones. Encouraging her to work faster or reassuring her that her
feelings will soon pass wouldn't address her needs. The nurse can't help the client
accept her new role if the client feels overwhelmed.
REFERENCE: Ricci, S.S., <i>Essentials of Maternity, Newborn, and Women’s Health
Nursing.</i> Philadelphia: Lippincott Williams & Wilkins, 2007, p. 629.

39. A client is admitted to the facility with a suspected ectopic pregnancy. When
reviewing the client's health history for risk factors for this abnormal condition, the
nurse expects to find:
a. a history of pelvic inflammatory disease.
b. grand multiparity (five or more births).
c. use of an intrauterine device for 1 year.
d. use of a hormonal contraceptive for 5 years.
RATIONALE: Pelvic inflammatory disease with accompanying salpingitis is
commonly implicated in cases of tubal obstruction, the primary cause of ectopic
pregnancy. Ectopic pregnancy isn't associated with grand multiparity or hormonal
contraceptive use. Ectopic pregnancy is associated with use of an intrauterine device
for 2 years or more.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 408.

40. Because cervical effacement and dilation aren't progressing in a client in labor, the
physician orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor
the client's fluid intake and output closely during oxytocin administration?
a. Oxytocin causes water intoxication.
b. Oxytocin causes excessive thirst.
c. Oxytocin toxic to the kidneys.
d. Oxytocin has a diuretic effect.
RATIONALE: The nurse should monitor fluid intake and output because prolonged
oxytocin infusion may cause severe water intoxication, leading to seizures, coma,
and death. Excessive thirst results from the work of labor and limited oral fluid intake
&#8212; not oxytocin. Oxytocin has no nephrotoxic or diuretic</!gloss> effects. In
fact, it produces an antidiuretic effect. REFERENCE: Pillitteri, A. <i>Maternal &
Child Health Nursing: Care of the Childbearing and Childrearing Family,</i> 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 610.

41. A nurse is caring for a woman receiving a lumbar epidural anesthetic block to control
labor pain. What should the nurse do to prevent hypotension ?
a. Administer ephedrine to raise her blood pressure.
b. Administer oxygen using a mask.
c. Place the woman supine with her legs raised.
d. Ensure adequate hydration before the anesthetic is administered.
RATIONALE: Administration of an epidural anesthetic may lead to hypotension
because blocking the sympathetic fibers in the epidural space reduces peripheral
resistance. Administering fluids I.V. before the epidural anesthetic is given may
prevent hypotension. Ephedrine may be administered after an epidural block if a
woman becomes hypotensive and shows evidence of cardiovascular
decompensation. However, ephedrine isn't administered to prevent hypotension.
Oxygen is administered to a woman who becomes hypotensive, but it won't prevent
hypotension. Placing a pregnant woman in the supine position can contribute to
hypotension because of uterine pressure on the great vessels
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 552.

42. A client gives birth to a stillborn neonate at 36 weeks' gestation. When caring for this
client, which strategy by the nurse would be most helpful?
a. Be selective in providing the information that the client seeks.
b. Encourage the client to see, touch, and hold the dead neonate.
c. Provide information about possible causes of the stillbirth only if the client requests

d. Let the child’s father decide what information the client receives.
RATIONALE: When caring for a client who has suffered perinatal loss, the nurse
should provide an opportunity for the client to bond with the dead neonate and allow

23
the neonate to become part of the family unit. Parents who aren't given such a
chance may experience fantasies about the neonate, which may be worse than the
reality. If the neonate has gross deformities, the nurse should prepare the client for
these. If the client doesn't ask about her neonate, the nurse should encourage her to
do so and provide any information she seems ready to hear. The client needs a full
explanation of all factors related to the experience so she can grieve appropriately.
Letting the neonate's father decide which information the client receives is
inappropriate. REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care
of the Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott
Williams & Wilkins, 2007, p. 439.

43. A woman gave birth 1 hour ago to a full-term boy. The nurse's assessment reveals a
well-contracted uterus that's midline, and at the level of the umbilicus. The client is
bleeding heavily. What should the nurse do next?
a. Firmly massage the uterus.
b. Request an order for oxytocin.
c. Assess for a distended bladder.
d. Report the bleeding to the physician.
RATIONALE: Heavy bleeding can signal uterine or vaginal lacerations. The nurse
should report this finding to the physician. Massaging a contracted uterus may cause
uterine atony. The nurse should assess for a distended bladder if the uterus is soft or
boggy. This client's uterus is contracted
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 661.

44. A client in early labor is connected to an external fetal monitor. The physician hasn't
noted any restrictions on her chart. The client tells the nurse that she needs to go to
the bathroom frequently and that her partner can help her. How should the nurse
respond?
a. "Because you're connected to the monitor, you can't get out of bed. You’lI need to
use the bedpan.”
b. “II show your partner how to disconnect the transducer so you can walk to the
bathroom.”
c. “Please press the call button. I’ll disconnect you from the monitor so you
can get out of bed.”
d. "I’ll insert a urinary catheter: then you won't need to get out of bed."
RATIONALE: The nurse should instruct the client to use the call button when she
needs to use the bathroom. The nurse will need to disconnect the fetal monitor and
mark the strip to indicate the activity. If the client's partner disconnects and
reconnects the monitor, the nurse can't determine if the readings are accurate.
Inserting a catheter without a physician's order or not allowing the client to get out of
bed isn't acceptable nursing practice.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 520.

45. A client who has been in the latent phase of the first stage of labor is transitioning to
the active phase. During the transition , the nurse expects to see which client
behavior?
a. A desire for personal contact and touch
b. A full response to teaching
c. Fatigue, a desire for touch, and quietness
d. Withdrawal, irritability, and resistance to touch
RATIONALE: During the transition to the active phase of the first stage of labor,
increased pain typically makes the client withdrawn, irritable, and resistant to touch.
During the latent phase (the early part of the first stage of labor), when contractions
aren't intensely painful, the client typically desires personal contact and touch and
responds to teaching and interventions. Fatigue, a desire for touch, and quietness are
common during the third and fourth stages of labor.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 505.

24
46. A client recently gave birth to a boy. Two minutes before <!hint>breast-feeding the
baby, she administers one nasal spray (40 units/ml) of oxytocin (Syntocinon) into
each nostril. Why is the client using this drug?
a. To stimulate lactation
b. To treat eclampsia
c. To reduce postpartum bleeding
d. To treat erythroblastosis
RATIONALE: Oxytocin is administered as a nasal spray before breast-feeding to
stimulate lactation. When oxytocin is used to treat eclampsia, reduce postpartum
REFERENCE: <i>Springhouse Nurse’s Drug Guide 2007.</i> Philadelphia: Lippincott
Williams & Wilkins, 2007, p. 963.

47. On her third postpartum day, a client complains of chills and aches. Her chart shows
that she has had a temperature of 100.6F (38.1C) for the past 2 days. The nurse
assesses foul-smelling, yellow lochia. What should the nurse do next?
a. Recheck the client’s temperature in 4 hours.
b. Assess the client's breasts for engorgement.
c. Anticipate that the physician will order laboratory tests and cultures.
d. Call the physician and request an order for antibiotics.
RATIONALE: Signs and symptoms of localized infection</!gloss> include a morbid
temperature, chills, malaise, generalized pain or discomfort, and foul-smelling, yellow
lochia. The physician may order laboratory tests, including a complete blood count
and cultures, to confirm an infection and the causative organisms. Rechecking the
client's temperature in 4 hours isn't appropriate because the client requires
intervention now. The client's signs and symptoms don't suggest breast
engorgement. Laboratory work should be done before starting antibiotics.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 639.

48. Which instruction should a nurse include in a home-safety teaching plan for a <!
hint>pregnant client?
a. Place a nonskid mat on the floor of the tub or shower.
b. It’s OK to clean your cat’s litter box.
c. It's OK to wear high heels.
d. Avoid having area rugs around your house.
RATIONALE: Using a mat for the floor of the shower or tub will prevent slipping. The
client shouldn't clean the cat's litter box because doing so puts her at risk for
toxoplasmosis</!gloss>. Wearing high heels may make the client lose balance and
fall. The client doesn't need to completely avoid having area rugs around her house.
Nonslip rugs can be used to prevent tripping or falling.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 384.

49. A nurse is assessing a pregnant woman. Which signs or symptoms indicate a


hydatidiform mole?
a. Rapid fetal heart tones
b. Abnormally high human chorionic gonadotropin (hCG) levels
c. Slow uterine growth
d. Lack of symptoms of pregnancy
RATIONALE: In a pregnant woman with a hydatidiform mole, the trophoblast villi
proliferate and then degenerate. Proliferating trophoblast cells produce abnormally
high hCG levels. No fetal heart tones are heard because there is no viable fetus.
Because there is rapid proliferation of the trophoblast cells, the uterus grows fast and
is larger than expected for a given gestational date. Because of the greatly elevated
hCG levels, a woman with hydatidiform mole often has marked nausea and vomiting.
REFERENCE: Pillitteri, A. <i>Maternal & Child Health Nursing: Care of the
Childbearing and Childrearing Family,</i> 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 411.

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