HESI MATERNITY

1. A primigravida, when returning for the results of her multiple marker screening
(triple screen), asks the nurse how problems with her baby can be detected by the
test. What information will the nurse give to the client to describe best how the test
is interpreted?
A. If MSAFP (maternal serum alpha-fetoprotein) and estriol
levels are high and the human chorionic gonadotropin
(hCG) level is low, results are positive for a possible
chromosomal defect.
B. If MSAFP and estriol levels are low and the hCG level is
high, results are positive for a possible chromosomal
defect.
C. If MSAFP and estriol levels are within normal limits, there
is a guarantee that the baby is free of all structural
anomalies.
D. If MSAFP, estriol, and hCG are absent in the blood, the
results are interpreted as normal findings.

Rationale:
Low levels of MSAFP and estriol and elevated levels of hCG found in the maternal blood
sample are indications of possible chromosomal defects. High levels of MSAFP and estriol
in the blood sample after 15 weeks of gestation can indicate a neural tube defect, such as
spina bifida and anencephaly, not chromosomal defects. One of the limitations of the
multiple marker screening is that any defects covered by skin will not be evident in the
blood sampling. After 15 weeks of gestation, there will be traces of MSAFP, estriol, and
hCG in the blood sample.

2. The nurse is preparing a laboring client for an amniotomy. Immediately after the
procedure is completed, it is most important for the nurse to obtain which
information?
A. Maternal blood pressure
B. Maternal temperature
C. Fetal heart rate (FHR)
D. White blood cell count (WBC)

Rationale:
The FHR should be assessed before and after the procedure to detect changes that may
indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of
membranes [AROM]) is used to stimulate labor when the condition of the cervix is
favorable. The fluid should be assessed for color, odor, and consistency. Option A should be
assessed every 15 to 20 minutes during labor but is not specific for AROM. Option B is
monitored hourly after the membranes are ruptured to detect the development of
amnionitis. Option D should be determined for all clients in labor.

3.The nurse is preparing a laboring client for an amniotomy. Immediately after the
procedure is completed, it is most important for the nurse to obtain which information?
A. Maternal blood pressure
B. Maternal temperature
C. Fetal heart rate (FHR)
D. White blood cell count (WBC)

Rationale:
The FHR should be assessed before and after the procedure to detect changes that
may indicate the presence of cord compression or prolapse. An amniotomy
(artificial rupture of membranes [AROM]) is used to stimulate labor when the
condition of the cervix is favorable. The fluid should be assessed for color, odor,
and consistency. Option A should be assessed every 15 to 20 minutes during labor
but is not specific for AROM. Option B is monitored hourly after the membranes
are ruptured to detect the development of amnionitis. Option D should be
determined for all clients in labor.

4. Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after
spontaneous rupture of the membranes, the nurse notes several sudden decreases in
the fetal heart rate with quick return to baseline, with and without contractions.
Based on this fetal heart rate pattern, which intervention is best for the nurse to
implement?
A Turn the client to her side.
.
B. Begin oxygen by nasal cannula at 2 L/min.
C. Place the client in a slight Trendelenburg position.
D Assess for cervical dilation.
.

Rationale:
The goal is to relieve pressure on the umbilical cord, and placing the client in a
slight Trendelenburg position is most likely to relieve that pressure. The FHR
pattern is indicative of a variable fetal heart rate deceleration, which is typically
caused by cord compression and can occur with or without contractions. Option A
may be helpful but is not as likely to relieve the pressure as the Trendelenburg
position. Option B is not helpful with cord compression. Option D is not the priority
intervention at this time. After repositioning the client, a vaginal examination is
indicated to rule out cord prolapse and assess for cervical change.
 5. A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy
is prescribed. Which instruction should the nurse provide to this client?
A. Breastfeed the infant, ensuring that both breasts are
completely emptied.
B. Feed expressed breast milk to avoid the pain of the infant
latching onto the infected breast.
C. Breastfeed on the unaffected breast only until the mastitis
subsides.
D. Dilute expressed breast milk with sterile water to reduce
the antibiotic effect on the infant.

Rationale:
Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding
during mastitis facilitates the complete emptying of engorged breasts, eliminating the
pressure on the inflamed breast tissue. Option B is less painful but does not facilitate
complete emptying of the breast tissue. Option C will not relieve the engorgement on the
affected side. Option D will not decrease antibiotic effects on the infant.

6. A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being
prepared for discharge. Which nursing intervention should be included in this infant's
discharge teaching plan?
A. Observe the parents applying a Pavlik harness.
B. Provide a referral for an orthopedic surgeon.
C. Schedule a physical therapy follow-up home visit.
D. Teach the parents to check for hip joint mobility.

Rationale:
It is important that the hips of infants with hip dysplasia are maintained in an abducted
position, which can be accomplished by using the Pavlik harness; this keeps the hips and
knees flexed, the hips abducted, and the femoral head in the acetabulum. Early treatment
often negates the need for surgery, and option B is not indicated until approximately 6
months of age. Option C is not indicated for hip dysplasia. It is best for the pediatrician to
monitor hip joint mobility, and teaching the parents to perform this technique is likely to
increase their anxiety.
 7. A client who delivered by cesarean section 24 hours ago is using a patient-controlled
analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since
surgery. She is now complaining of nausea and bloating and states that because she
has had nothing to eat, she is too weak to breastfeed her infant. Which nursing
diagnosis has the highest priority?
A. Altered nutrition, less than body requirements for lactation
B. Alteration in comfort related to nausea and abdominal
distention
C. Impaired bowel motility related to pain medication and
immobility
D. Fatigue related to cesarean delivery and physical care
demands of infant

Rationale:
Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is
the priority nursing diagnosis and addresses the potential problem of a paralytic ileus.
Options A and B are both caused by impaired bowel motility. Option D is not as important as
impaired motility.

8. Which statement made by the client indicates that the mother understands the
limitations of breastfeeding her newborn?
A. "Breastfeeding my infant consistently every 3 to 4 hours
stops ovulation and my period."
B. "Breastfeeding my baby immediately after drinking
alcohol is safer than waiting for the alcohol to clear my
breast milk."
C. "I can start smoking cigarettes while breastfeeding
because it will not affect my breast milk."
D. "When I take a warm shower after I breastfeed, it relieves
the pain from being engorged between breastfeedings.
"

Rationale:
Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of
prolactin, which will suppress ovulation and menses, but is not completely effective as a
birth control method. Option B is incorrect because alcohol can immediately enter the breast
milk. Nicotine is transferred to the infant in breast milk. Taking a warm shower will
stimulate the production of milk, which will be more painful after breastfeedings.
 9. When preparing a class on newborn care for expectant parents, which is correct for
the nurse to teach concerning the newborn infant born at term gestation?
A. Milia are red marks made by forceps and will disappear
within 7 to 10 days.
B. Meconium is the first stool and is usually yellow gold in
color.
C. Vernix is a white cheesy substance, predominantly located
in the skin folds.
D. Pseudostrabismus found in newborns is treated by minor
surgery.

Rationale:
Vernix, found in the folds of the skin, is a characteristic of term infants. Milia are not red
marks made by forceps but are white pinpoint spots usually found over the nose and chin
that represent blockage of the sebaceous glands. Meconium is the first stool, but it is tarry
black, not yellow. Pseudostrabismus (crossed eyes) is normal at birth through the third or
fourth month and does not require surgery.

10. Client teaching is an important part of the perinatal nurse's role. Which factor has
the greatest influence on successful teaching of the pregnant client?
A The client's investment in what is being taught
.
B. The couple's highest levels of education
C. The order in which the information is presented
D The extent to which the pregnancy was planned
.

Rationale:
When teaching any client, readiness to learn is related to how much the client has invested
in what is being taught or how important the materials are to the client's particular life. For
example, the client with severe morning sickness in the first trimester may not be ready to
learn about labor and delivery but is probably very ready to learn about ways to relieve
morning sickness. Options B and C are factors that may influence learning but are not as
influential as option A. Even if a pregnancy is planned and very desirable, the client must be
ready to learn the content presented.
Which maternal behavior is the nurse most likely to see when a new mother receives her
infant for the first time?
A. She eagerly reaches for the infant, undresses the infant,
and examines the infant completely.
B. Her arms and hands receive the infant and she then traces
the infant's profile with her fingertips.
C. Her arms and hands receive the infant and she then
cuddles the infant to her own body.
D. She eagerly reaches for the infant and then holds the infant
close to her own body.

Rationale:
Attachment and bonding theory indicates that most mothers will demonstrate behaviors
described in option B during the first visit with the newborn, which may be at delivery or
later. After the first visit, the mother may exhibit different touching behaviors such as
eagerly reaching for the infant and cuddling the infant close to her.

A mother who is breastfeeding her baby receives instructions from the nurse. Which
instruction is most effective in preventing nipple soreness?
A. Wear a cotton bra with nonbinding support.
B. Increase nursing time gradually over several days.
C. Ensure that the baby is positioned correctly for latching
on.
D. Manually express a small amount of milk before nursing.

Rationale:
The most common cause of nipple soreness is incorrect positioning of the infant on the
breast for latching on. The baby's body is in alignment with the ears, shoulders, and hips in
a straight line, with the nose, cheeks, and chin touching the breast. Option A helps prevent
chafing, and nonbinding support aids in prevention of discomfort from the stretching of the
Cooper ligament. Option B is important but is not necessary for all women. Option D helps
soften an engorged breast and encourages correct infant latching on but is not the best
answer.

When assessing a client at 12 weeks of gestation, the nurse recommends that she and her
husband consider attending childbirth preparation classes. When is the best time for the
couple to attend these classes?
A. At 16 weeks of gestation
B. At 20 weeks of gestation
C. At 24 weeks of gestation
D. At 30 weeks of gestation

Rationale:
Learning is facilitated by an interested pupil. The couple is most interested in childbirth
toward the end of the pregnancy, when they are beginning to anticipate the onset of labor
and the birth of their child. Option D is closest to the time when parents would be ready for
such classes. Options A, B, and C are not the best times during a pregnancy for the couple
to attend childbirth education classes. At these times they will have other teaching needs.
Early pregnancy classes often include topics such as nutrition, physiologic changes, coping
with normal discomforts of pregnancy, fetal development, maternal and fetal risk factors,
and evolving roles of the mother and her significant others.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states that
she is constantly rubbing her abdomen and talking to the baby and that she actually
reprimands the baby when it moves too much. Which recommendation should the nurse
make to this expectant father?
A. Suggest that his wife seek professional counseling to deal
with her symptoms.
B. Explain that his wife is exhibiting ambivalence about the
pregnancy.
C. Ask him to report similar abnormal behaviors at the next
prenatal visit.
D. Reassure him that normal maternal-fetal bonding is
occurring.

Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence.
No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17
to 20 weeks of gestation and begins a new phase of prenatal bonding during the second
trimester. Options A and C are not necessary because the behaviors displayed are normal.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops
localized swelling on the right side of his head. In a newborn, what is the most likely cause
of this accumulation of blood between the periosteum and skull that does not cross the
suture line?
Rationale:
Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first
24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure
on the cranium during vaginal delivery, and is a common variation of the newborn. Options
B and D both involve intracranial bleeding and could not be detected by physical assessment
alone.
A. Cephalhematoma, which is caused by forceps trauma
B. Subarachnoid hematoma, which requires immediate
drainage
C. Molding, which is caused by pressure during labor
D. Subdural hematoma, which can result in lifelong damage
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous
abortion at 3 months of gestation. Which is the correct description of this client that should
be documented in the medical record?
Rationale:
This is the client's second pregnancy or second gravid event, so option C is correct. The
spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is
a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of gestation or
beyond. Option A does not take into account the current pregnancy, nor does option B,
which also counts the miscarriage as a "para," an incorrect recording. Although option D is
correct concerning gravidity, para 1 is incorrect.
A Gravida 1, para 0
.
B. Gravida 1, para 1
C. Gravida 2, para 0
D Gravida 2, para 1
.

PROOFING QUESTIONS: Maternity

Question 16 of 50
ID: 4_16
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A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation
in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg
subcutaneously, to stop her labor contractions. What are the primary side effects of
terbutaline sulfate?
Rationale:
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties
of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a
feeling of nervousness. Option A is not a side effect. Options B and D are side effects of
magnesium sulfate.
A. Drowsiness and paroxysmal bradycardia
B. Depressed reflexes and increased respirations
C. Tachycardia and a feeling of nervousness
D. A flushed warm feeling and dry mouth
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day
tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention
of pooling of blood in the lower extremities?
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure
on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and
increase venous return. Option A would increase venous return from varicose veins in the
lower extremities but would be of little help with swelling. Option B might be helpful with
generalized edema but is not specific for edematous lower extremities. Option D does not
address venous return, and there is no indication in the question that constrictive clothing is
a problem.
A. Wear support stockings.
B. Reduce salt in the diet.
C. Move about every hour.
D. Avoid constrictive clothing.
A new mother asks the nurse, "How do I know that my daughter is getting enough breast
milk?" Which explanation is appropriate?
Rationale:
The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if the infant is
adequately hydrated. Although a weight gain of 30 g/day is indicative of adequate nutrition,
most home scales do not measure this accurately, and the suggestion will likely make the
mother anxious. Option C causes nipple confusion and diminishes the mother's milk
production. Option D does not address the client's question.
A "Weigh the baby daily, and if she is gaining weight, she is
. getting enough to eat."
B. "Your milk is sufficient if the baby is voiding pale, straw-
colored urine six to ten times a day."
C. "Offer the baby extra bottled milk after her feeding and
see if she still seems hungry."
D "If you're concerned, you might consider bottle feeding so
. that you can monitor intake."

Prior to discharge, what instructions should the nurse give to parents regarding the
newborn's umbilical cord care at home?
Rationale:
Recent studies have indicated that air drying or plain water application may be equal to or
more effective than alcohol in the cord healing process. Options A, B, and D are incorrect
because they promote moisture and increase the potential for infection.
A Wash the cord frequently with mild soap and water.
.
B. Cover the cord with a sterile dressing.
C. Allow the cord to air-dry as much as possible.
D Apply baby lotion after the baby's daily bath.
.
During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client.
Which statement is most characteristic of an infant whose mother smoked during pregnancy
compared with the infant of a nonsmoking mother?
Rationale:
Smoking is associated with low-birth-weight infants. Therefore, mothers are encouraged not
to smoke during pregnancy. Options A, C, and D have not been clearly associated with
smoking during pregnancy, but there is a strong correlation between smoking and lower
birth weights.
A. Lower Apgar score recorded at delivery
B. Lower initial weight documented at birth
C. Higher oxygen use to stimulate breathing
D. Higher prevalence of congenital anomalies
On admission to the prenatal clinic, a client tells the nurse that her last menstrual period
began on February 15 and that previously her periods were regular (28-day cycle). Her
pregnancy test is positive. What is this client's expected date of birth (EDB)?
Rationale:
Option A correctly applies the Nägele rule for estimating the due date by counting back 3
months from the first day of the last menstrual period (January, December, November) and
adding 7 days (15 + 7 = 22). Options B, C, and D are not calculated correctly.
A November 22
.
B. November 8
C. December 22
D October 22
.
The nurse is counseling a client who wants to become pregnant. She tells the nurse that she
has a 36-day menstrual cycle and the first day of her last menstrual period was January 8.
When will the client's next fertile period occur?
Rationale:
This client can expect her next period to begin 36 days from the first day of her last
menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days
before the first day of the menstrual period. The client can expect ovulation to occur
January 29 to 30. Options A, B, and D are incorrect.
A January 14 to 15
.
B. January 22 to 23
C. January 29 to 30
D February 6 to 7
.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her
husband is screaming for someone to help his wife. Which intervention has the highest
priority?
Rationale:
Putting the newborn to the breast will help contract the uterus and prevent a postpartum
hemorrhage. This intervention has the highest priority. Option A is not necessary; the infant
can be transported attached to the placenta. Option B is an important psychosocial need but
does not have the priority of option D. Although the husband is an important part of family-
centered care, he is not the most important concern at this time.
A. Use thread to tie off the umbilical cord.
B. Provide privacy for the woman.
C. Reassure the husband and keep him calm.
D. Put the newborn to the breast immediately.
A new mother is having trouble breastfeeding her newborn. The child is making frantic
rooting motions and will not grasp the nipple. Which intervention should the nurse
implement?
Rationale:
The infant is becoming frustrated and so is the mother; both need a time out. The mother
should be encouraged to comfort the infant and to relax herself. After such a time out,
breastfeeding is often more successful. Options A and D would cause nipple confusion.
Option B would only cause the infant to be more resistant, resulting in the mother and
infant becoming more frustrated.
A. Encourage frequent use of a pacifier so that the infant
becomes accustomed to sucking.
B. Hold the infant's head firmly against the breast until he
latches onto the nipple.
C. Encourage the mother to stop feeding for a few minutes
and comfort the infant.
D. Provide formula for the infant until he becomes calm, and
then offer the breast again.

The nurse is teaching care of the newborn to a childbirth preparation class and describes the
need for administering antibiotic ointment into the eyes of the newborn. An expectant father
asks, "What type of disease causes infections in babies that can be prevented by using this
ointment?" Which response by the nurse is accurate?
Rationale:
Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after
birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion
conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these
bacteria when passing through the birth canal. Ophthalmic ointment is not effective against
option A, B, or D.
A. Herpes
B. Trichomonas
C. Gonorrhea
D. Syphilis

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most
important to include in the teaching plan?
Rationale:
Alcohol should be avoided while breastfeeding because it is excreted in breast milk and may
cause a variety of problems, including slower growth and cognitive impairment for the
infant. Options B, C, and D should also be included in diet teaching for a breastfeeding
mother; however, because these do not involve safety of the infant, they do not have the
same degree of importance as option A.
A. Avoid alcohol because it is excreted in breast milk.
B. Eat a high-roughage diet to help prevent constipation.
C. Increase caloric intake by approximately 500 cal/day.
D. Increase fluid intake to at least 3 quarts each day.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first
child, but I would like to try with this baby." Which intervention should the nurse implement
first?
Rationale:
Infants respond to breastfeeding best when feeding is initiated in the active phase soon
after delivery. Options A and B might provide interesting data, but gathering this
information is not as important as providing support and instructions to the new mother.
Although option C is also true, this response by the nurse might seem judgmental to a new
mother.
A. Assess the husband's feelings about his wife's decision to
breastfeed their baby.
B. Ask the woman to describe why she was unsuccessful with
breastfeeding her last child.
C. Encourage the woman to develop a positive attitude about
breastfeeding to help ensure success.
D. Provide assistance to the mother to begin breastfeeding as
soon as possible after delivery.

A client at 30 weeks of gestation is on bed rest at home because of increased blood

pressure. The home health nurse has taught her how to take her own blood pressure and
gave her parameters to judge a significant increase in blood pressure. When the client calls
the clinic complaining of indigestion, which instruction should the nurse provide?
Rationale:
Checking the blood pressure for an elevation is the best instruction to give at this time. A
blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can
be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational
hypertension. Additional data are needed to confirm an emergency situation as described in
option A. Options B and D ignore the threat to client safety posed by a significant increase
in blood pressure.
A. Lie on your left side and call 911 for emergency
assistance.
B. Take an antacid and call back if the pain has not subsided.
C. Take your blood pressure now, and if it is seriously
elevated, go to the hospital.
D. See your health care provider to obtain a prescription for a
histamine blocking agent.
The nurse is counseling a couple who has sought information about conceiving. The couple
asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is
correct?
Rationale:
Ovulation occurs 14 days before the first day of the menstrual period. Although ovulation
can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a
woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle
varies. Options B, C, and D are incorrect.
A. Two weeks before menstruation
B. Immediately after menstruation
C. Immediately before menstruation
D. Three weeks before menstruation

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to
complain of tingling fingers and dizziness. Which action should the nurse take?
Rationale:
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon
dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by
breathing into a paper bag or cupped hands. Option A is inappropriate because the carbon
dioxide level is low, not the oxygen level. Options B and D are not specific for this situation.
A Administer oxygen by facemask.
.
B. Notify the health care provider of the client's symptoms.
C. Have the client breathe into her cupped hands.
D Check the client's blood pressure and fetal heart rate.
.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's

blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the nurse take
immediately?
Rationale:
The nurse should immediately turn the client to a lateral position or place a pillow or wedge
under one hip to deflect the uterus. Other immediate interventions include increasing the
rate of the main line IV infusion and administering oxygen by facemask. If the blood
pressure remains low after these interventions or decreases further, the anesthesiologist or
health care provider should be notified immediately. To continue to monitor blood pressure
without taking further action could constitute malpractice. Option D may also be warranted,
but such action is based on hospital protocol.
A. Notify the health care provider or anesthesiologist.
B. Continue to assess the blood pressure every 5 minutes.
C. Place the client in a lateral position.
D. Turn off the continuous epidural.
A new mother who has just had her first baby says to the nurse, "I saw the baby in the
recovery room. She sure has a funny-looking head." Which response by the nurse is best?
Rationale:
Option C reassures the mother that this is normal in the newborn and provides correct
information regarding the return to a normal shape. Although option A is correct, it implies
that the client should not worry. Any implied or spoken "don't worry" is usually the wrong
answer. Option B is condescending and dismissing; the mother is seeking reassurance and
information. Option D is a negative statement and implies that molding is the mother's
fault.
A "This is not an unusually shaped head, especially for a first
. baby."
B. "It may look odd, but newborn babies are often born with
heads like that."
C. "That is normal. The head will return to a round shape
within 7 to 10 days."
D "Your pelvis was too small, so the head had to adjust to the
. birth canal."

In developing a teaching plan for expectant parents, the nurse decides to include
information about when the parents can expect the infant's fontanels to close. Which
statement is accurate regarding the timing of closure of an infant's fontanels that should be
included in this teaching plan?
Rationale:
In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the
posterior fontanel closes by the end of the second month. These growth and development
milestones are frequently included in questions on the licensure examination. Options A, B,
and C are incorrect.
A The anterior fontanel closes at 2 to 4 months and the
. posterior fontanel by the end of the first week.
B. The anterior fontanel closes at 5 to 7 months and the
posterior fontanel by the end of the second week.
C. The anterior fontanel closes at 8 to 11 months and the
posterior fontanel by the end of the first month.
D The anterior fontanel closes at 12 to 18 months and the
. posterior fontanel by the end of the second month.

A client at 28 weeks of gestation calls the antepartal clinic and states that she has just
experienced a small amount of vaginal bleeding, which she describes as bright red. The
bleeding has subsided. She further states that she is not experiencing any uterine
contractions or abdominal pain. What instruction should the nurse provide?
Rationale:
Third-trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding
may be intermittent, occur in gushes, or be continuous. Rarely is the first incident life
threatening or cause for hypovolemic shock. Diagnosis is confirmed by transabdominal
ultrasound. Bleeding that has a sudden onset and is accompanied by intense uterine pain
indicates abruptio placenta, which is life threatening to the mother and fetus. If those
symptoms were described, option B would be appropriate. Option C does not address the
cause of the symptoms. The client is not describing symptoms of a UTI.
A. Come to the clinic today for an ultrasound.
B. Go immediately to the emergency department.
C. Lie on your left side for about 1 hour and see if the
 bleeding stops.
D. Take a urine specimen to the laboratory to see if you have
a urinary tract infection (UTI).

A client in active labor is becoming increasingly fearful because her contractions are
occurring more often than she had expected. Her partner is also becoming anxious. Which
of the following should be the focus of the nurse's response?
Rationale:
Offering to remain with the client and her partner offers support without providing false
reassurance. The length of labor is not always predictable, but options A and B do not offer
the client the support that is needed at this time. Option D may be reassuring regarding the
fetal heart rate but does not provide the client the emotional support she needs at this time
during the labor process.
A. Telling the client and her partner that the labor process is
often unpredictable
B. Informing the client that this means she will give birth
sooner than expected
C. Asking the client and her partner if they would like the
nurse to stay in the room
D. Affirming that the fetal heart rate is remaining within
normal limits

The nurse observes that an antepartum client who is on bed rest for preterm labor is eating
ice rather than the food on her breakfast tray. The client states that she has a craving for
ice and then feels too full to eat anything else. Which is the best response by the nurse?
Rationale:
The health care provider should be notified when a client practices pica (craving for and
consumption of nonfood substances). The practice of pica may displace more nutritious
foods from the diet, and the client should be evaluated for anemia. Option A is overreacting
and may be perceived as punishment by the client. Option B allows the dietary department
to customize the client's tray but fails to address physiologic problems associated with not
consuming nutritious foods in pregnancy. Option C is judgmental and blocks further
communication.
A Remove all ice from the client's room.
.
B. Ask the client what foods she might consider eating.
C. Remind the client that what she eats affects her baby.
D Notify the health care provider.
.
One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is
96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's
hands shake. Which intervention should the nurse implement first?
Rationale:
This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body
temperature. The nurse should first determine the serum glucose level. Option A is an
intervention for a lethargic infant. Option B should be done based on the temperature, but
first the glucose level should be obtained. Option C helps raise the blood sugar, but first the
nurse should determine the glucose level.
A Stimulate the infant to cry.
.
B. Wrap the infant in warm blankets.
C. Feed the infant formula.
D Obtain a serum glucose level.
.

A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby
will become HIV-infected. Which explanation should the nurse provide?
Rationale:
All newborns of HIV-positive mothers receive passive HIV antibodies from the mother, so
the evaluation of an infant for the HIV virus is determined at 18 months of age, when all the
maternal antibodies are no longer in the infant's blood. Passive HIV antibodies disappear in
the infant within 18 months of age. Option B is inaccurate. Although administration of HIV
medication during pregnancy can significantly reduce the risk of vertical transmission,
treatment does not ensure that the virus will not become manifest in the infant.
A Most infants of HIV-positive women will continue to test
. positive for HIV antibodies.
B. Infants who have HIV-positive mothers carry the virus and
will eventually develop the disease.
C. Medication taken during pregnancy to reduce the mother's
viral load ensures that the infant is HIV-negative.
D HIV infection is determined at 18 months of age, when
. maternal HIV antibodies are no longer present.

The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse
determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact
membranes. The monitor indicates that the FHR decelerates at the onset of several
contractions and returns to baseline before each contraction ends. Which action should the
nurse take?
Rationale:
The fetal heart rate indicates early decelerations, which are not an ominous sign, so the
nurse should continue to monitor the labor progress and document the findings in the
client's record. There is no reason to reapply the external transducer if the FHR tracings are
being captured. Options B and C are not indicated at this time.
A. Reapply the external transducer.
B. Insert the intrauterine pressure catheter.
 C. Discontinue the oxytocin infusion.
D. Continue to monitor labor progress.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her
lochia is getting lighter in color. Which action should the nurse take?
Rationale:
The client is describing lochia serosa, a normal change in the lochial flow ©. Options A, B,
and D are not recommended for this normal finding.
A. Instruct the client to go to the emergency room.
B. Recommend vaginal douching.
C. Explain this is a normal finding.
D. Determine if ovulation has occurred.

The nurse calls a client who is 4 days postpartum to follow up about her transition with her
newborn son at home. The woman tells the nurse, "I don't know what is wrong. I love my
son, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should
the nurse determine the client is experiencing?
Rationale:
During the postpartum period, when serum hormone levels fall, women are emotionally
labile, often crying easily for no apparent reason. This phase is commonly called postpartum
blues, which peaks around the fifth postpartum day. The taking-in phase is the period
following birth when the mother focuses on her own psychological needs; typically, this
period lasts for 24 hours. Crying is not a maladaptive attachment response. It indicates a
normal physical and emotional response. The letting-go phase is when the mother sees the
child as a separate individual.
A. Taking-in phase
B. Postpartum blues
C. Attachment difficulty
D. Letting-go phase

A mother expresses fear about changing the infant's diaper after circumcision. What
information should the nurse include in the teaching plan?
Rationale:
With each diaper change, the glans penis should be washed with warm water to remove any
urine or feces, and petroleum ointment should be applied to prevent the diaper from
sticking to the healing surface. Prepackaged wipes often contain other products that may
irritate the site. The yellow exudate, which covers the glans penis as the area heals and
epithelializes, is not an infective process and should not be removed. If bleeding occurs at
home, the client should be instructed to apply gentle pressure to the site of the bleeding
with sterile gauze squares and call the health care provider.
A. Cleanse the penis with prepackaged diaper wipes every 3
to 4 hours.
B. Wash off the yellow exudate on the glans once every day
to prevent infection.
C. Place petroleum ointment around the glans with each
diaper change and cleansing.
 D. Apply pressure by squeezing the penis with the fingers for
5 minutes if bleeding occurs.

A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast
engorgement. Which instruction should the nurse provide?
Rationale:
The mother should be instructed to attempt feeding her infant every 2 hours while
massaging the breasts as the infant is feeding. If the infant does not feed adequately and
empty the breast, using a breast pump helps extract the milk and relieve some of the
discomfort. Dehydration irritates swollen breast tissue. Skipping feedings may cause further
engorgement and discomfort.
A Avoid using the breast pump.
.
B. Breastfeed the infant every 2 hours.
C. Reduce fluid intake for 24 hours.
D Skip feedings to let the sore breasts rest.
.

A nurse receives a shift change report for a newborn who is 12 hours post–vaginal delivery.
In developing a plan of care, the nurse should give the highest priority to which finding?
Rationale:
Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be
further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and
feet) is a common finding in newborns; it occurs because the capillary system is immature.
Milia are small white papules present on the nose and chin that are caused by sebaceous
gland blockage and disappear in a few weeks. Small red patches on the cheeks and trunk
are called erythema toxicum neonatorum, a common finding in newborns.
A Cyanosis of the hands and feet
.
B. Skin color that is slightly jaundiced
C. Tiny white papules on the nose or chin
D Red patches on the cheeks and trunk
.

A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are

firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate
increases with each contraction and returns to baseline after the contraction. Which action
should the nurse implement?
Rationale:
The goal of labor augmentation is to produce firm contractions that occur every 2 to 3
minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR
accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion
should be increased per protocol to stimulate the frequency and intensity of contractions.
Options A and C are indicated for fetal stress. A sterile vaginal examination places the client
at risk for infection and should be performed when the client exhibits signs of progressing
labor, which is not indicated at this time.
 A. Place a wedge under the client's left side.
B. Determine cervical dilation and effacement.
C. Administer 10 L of oxygen via facemask.
D. Increase the rate of the oxytocin (Pitocin) infusion.

During the transition phase of labor, a client complains of tingling and numbness in her
fingers and tells the nurse that she feels like she is going to pass out. What action should
the nurse take?
Rationale:
Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes
transient respiratory alkalosis, so the client should cup both her hands over her mouth and
nose so that she can rebreathe carbon dioxide. Options A, B, and C do not help restore
carbon dioxide levels as effectively as rebreathing air in the cupped hands or from a paper
bag.
A. Encourage her to pant between contractions and blow with
contractions.
B. Coach her to take a deep cleansing breath and then
refocus.
C. Instruct her to pant three times and then exhale through
pursed lips.
D. Have her cup both hands over her nose and mouth while
breathing.
The nurse is using the Silverman-Anderson index to assess an infant with respiratory
distress and determines that the infant is demonstrating marked nasal flaring, an audible
expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which
score should the nurse assign?
Rationale:
The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory
status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and
abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded
0, and a total of 10 indicates maximum respiratory distress. This infant is demonstrating
respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring,
grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is
a total score of 5. Options A, B, and D are not accurate.
A 3
.
B. 4
C. 5
D 8
.
Which findings are of most concern to the nurse when caring for a woman in the first
trimester of pregnancy? (Select all that apply.)
Rationale:
Options A and C are signs of a possible miscarriage. Cramping with bright red bleeding is a
sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the
breast is a sign that hormone levels have declined and that a miscarriage is imminent.
Option E could be a sign of an ectopic pregnancy, which could be fatal if not discovered in
time before rupture. Options B and D are normal signs during the first trimester of a
pregnancy.
A Cramping with bright red spotting
.
B. Extreme tenderness of the breast
C. Lack of tenderness of the breast
D Increased amounts of discharge
.
E. Increased right-side flank pain
Which findings are most critical for the nurse to report to the primary health care provider
when caring for the client during the last trimester of her pregnancy? (Select all that apply.)
Rationale:
Options A and E are possible signs of preeclampsia or eclampsia but can also be normal
signs of pregnancy. These signs should be reported to the health care provider for further
evaluation for the safety of the client and the fetus. Options B, C, and D are all normal signs
during the last trimester of pregnancy.
A Increased heartburn that is not relieved with doses of
. antacids
B. Increase of the fetal heart rate from 126 to 156 beats/min
from the last visit
C. Shoes and rings that are too tight because of peripheral
edema in extremities
D Decrease in ability for the client to sleep for more than 2
. hours at a time
E. Chronic headache that has been lingering for a week
behind the client's eyes

The client comes to the hospital assuming she is in labor. Which assessment findings by the
nurse would indicate that the client is in true labor? (Select all that apply.)
Rationale:
These are all signs of true labor. Options B and D are signs of false labor.
A. Pain in the lower back that radiates to abdomen
B. Contractions decreased in frequency with ambulation
C. Progressive cervical dilation and effacement
D. Discomfort localized in the abdomen
E. Regular and rhythmic painful contractions