Detailed Answer Key
medical
1. A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of
the following findings support this diagnosis?
A. Painless red vaginal b
...
Detailed Answer Key
medical
1. A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of
the following findings support this diagnosis?
A. Painless red vaginal bleeding
Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the
uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless
vaginal bleeding occurs in the second and third trimester.
B. Increasing abdominal pain with a nonrelaxed uterus
Rationale: Abruptio placenta is separation of the placenta from the site of uterine implantation before
delivery of the fetus. When the placenta separates prematurely, there is internal bleeding, which
is painful, and the uterus is nonrelaxed or becomes rigid as the separation advances.
C. Abdominal pain with scant red vaginal bleeding
Rationale: Placenta previa involves minimal to severe bright red vaginal bleeding in the absence of
abdominal pain.
D. Intermittent abdominal pain following passage of bloody mucus
Rationale: Intermittent abdominal pain following passage of bloody mucus is a description of normal labor.
The passage of bloody mucus represents the loss of the cervical mucous plug, also referred to
as the "bloody show."
2. A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small
clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions
should the nurse take?
A. Document the findings and continue to monitor the client.
Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and
associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual
period. Small clots are common. The nurse should document the findings and continue to
monitor the client.
B. Notify the client’s provider.
Rationale: These are expected findings, so there is no need to notify the provider.
C. Increase the frequency of fundal massage.
Rationale: These are expected findings and the fundus is already firm. Increasing the frequency of fundal
massage is not indicated at this time.
D. Encourage the client to empty her bladder.
Rationale: These are expected findings, and the fundus is firm at the midline. If the fundus was deviated,
this would be an indication of a distended bladder and the client should be encouraged to void to
prevent uterine atony.
Created on:11/29/2018 Page 1Detailed Answer Key
medical
3. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority
nursing action?
A. Administer vitamin K.
Rationale: Administration of vitamin K is important, but it can be delayed until the newborn is held by the
mother and is breastfed. There is another, more important nursing action.
B. Dry the skin.
Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother’s
abdomen, and a cap applied to the newborn’s head to prevent cold stress. The newborn
responds to the cooler environment by increasing his respiratory rate, which can lead to
respiratory distress. Based on Maslow’s hierarchy of needs, this is the most important nursing
action after securing the airway.
C. Administer eye prophylaxis.
Rationale: Administration of eye prophylaxis should occur within the first hour after birth. There is another,
more important nursing action.
D. Place an identification bracelet.
Rationale: Correct identification of the newborn is important, but it can be delayed, as long as it is
completed prior to the mother and newborn leaving the delivery room. There is another, more
important nursing action.
4. A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency
and asks if this will continue until delivery. Which of the following responses should the nurse make?
A. "It's a minor inconvenience, which you should ignore."
Rationale: This is a nontherapeutic response that disregards the client’s concern and offers unwarranted
reassurance.
B. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone."
Rationale: The presence or absence of bladder tone has no bearing on urinary frequency during
pregnancy.
C. "There is no way to predict how long it will last in each individual client."
Rationale: This is a nontherapeutic response that does not provide appropriate information to the client.
D. "It occurs during the first trimester and near the end of the pregnancy."
Rationale: Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs
near the end of the pregnancy as the enlarging uterus places pressure on the bladder.
Created on:11/29/2018 Page 2Detailed Answer Key
medical
5. A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse
notices she does not have immunity to rubella. Which of the following times should the nurse understand is
recommended for rubella immunization?
A. Shortly after giving birth
Rationale: The rubella immunization should be offered to the client following birth, preferably prior to
discharge from the hospital. This prevents the client from contracting rubella during the current
or subsequent pregnancies, which would put her fetus at risk for rubella syndrome.
B. In the third trimester
Rationale: Because the rubella vaccine contains a live virus, immunizing the client at this point in
pregnancy would put her fetus at risk for developing rubella syndrome.
C. Immediately
Rationale: Because the rubella vaccine contains a live virus, immunizing the client during the first trimester
would put the fetus at risk for developing a severe manifestations of rubella syndrome.
D. During her next attempt to get pregnant
Rationale: Rubella immunization must be given at least 28 days prior to pregnancy to assure that the
developing fetus is not exposed to the virus and put at risk for rubella syndrome.
6. A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be
done first to care for the newborn?
A. Clear the respiratory tract.
Rationale: Clearing the airway of the infant is the first action the nurse should take immediately following
delivery.
B. Dry the infant off and cover the head.
Rationale: Drying the infant and covering the head should be done shortly after the delivery, but it is not the
first action the nurse should take.
C. Stimulate the infant to cry.
Rationale: Stimulating the infant to cry should be done shortly after the delivery, but it is not the first action
the nurse should take.
D. Cut the umbilical cord.
Rationale: Cutting the umbilical cord should be done shortly after the delivery, but it is not the first action
the nurse should take.
7. A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives.
The client states that she is nervous because she has never had a pelvic examination. Which of the following
responses should the nurse make?
Created on:11/29/2018 Page 3Detailed Answer Key
medical
A. "What part of the exam makes you most nervous?"
Rationale: This therapeutic response recognizes the client's feelings. It also uses the therapeutic technique
of clarification to encourage the client to tell the nurse more about her concerns.
B. "Don't worry, I will be with you during the exam."
Rationale: This closed-ended nontherapeutic response discounts the client's feelings and does not
encourage further discussion.
C. "All you need to do is relax."
Rationale: This closed-ended nontherapeutic response does not address the client's concerns and does
not encourage further discussion. It blocks communication by using a cliché and false
reassurance.
D. "A pelvic exam is required if you want birth control pills."
Rationale: This statement fails to address the client’s feelings that she shared with the nurse. It blocks
communication and does not encourage further discussion.
8. A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the
umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?
A. Two veins and one artery
Rationale: This is not the correct combination of vessels.
B. One artery and one vein
Rationale: This is not the correct combination of vessels.
C. Two arteries and one vein
Rationale: The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two
arteries returned the blood to the placenta.
D. Two arteries and two veins
Rationale: This is not the correct combination of vessels.
9. A nurse is caring for a client who is considering several methods of contraception. Which of the following methods
of contraception should the nurse identify as being most reliable?
A. A male condom
Rationale: This method of contraception has 11 to 16 failures for every 100 users.
B. An intrauterine device (IUD)
Rationale: An IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most
Created on:11/29/2018 Page 4Detailed Answer Key
medical
reliable methods of contraception.
C. An oral contraceptive
Rationale: This method of contraception has about 8 failures for every 100 users, due to failure to take pill
consistently and decreased efficacy when taken with certain medications.
D. A diaphragm with spermicide.
Rationale: This method of contraception has about 16 failures for every 100 users during the first year of
use.
10.A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the
following is the correct interpretation of this data?
A. The client is not experiencing a rubella infection at this time.
Rationale: A negative rubella titer indicates the client is susceptible to the rubella virus. It does not
indicate the presence or absence of a rubella infection.
B. The client is immune to the rubella virus.
Rationale: A negative rubella titer indicates the client is susceptible to the rubella virus.
C. The client requires a rubella vaccination at this time.
Rationale: Rubella vaccination during pregnancy is contraindicated because of possible injury to the
developing fetus.
D. The client requires a rubella immunization following delivery.
Rationale: A negative rubella titer indicates that the client is susceptible to the rubella virus and needs
vaccination following delivery. Immunization during pregnancy is contraindicated because of
possible injury to the developing fetus. Following rubella immunization, the client should be
cautioned not to conceive for 1 month.
11.A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless,
bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min
and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min,
respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action?
A. Insert an indwelling urinary catheter.
Rationale: An indwelling urinary catheter can be inserted in the delivery room just prior to delivery. This is
not the priority nursing action.
B. Initiate IV access.
Rationale: Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood
rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be
administered quickly if hypovolemia develops.
Created on:11/29/2018 Page 5Detailed Answer Key
medical
C. Witness the signature for informed consent for surgery.
Rationale: Rationale C. This is not the nurse's priority action at this time. A family member can sign the
consent form if needed.
D. Prepare the abdominal and perineal areas.
Rationale: Skin preparation can be delayed until just prior to a cesarean delivery. This is no the priority
nursing action.
12.A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the
following findings should the nurse expect to observe in this client?
A. Rapid decline in human chorionic gonadotropin (hCG) levels
Rationale: A client who has a hydatidiform mole usually has an elevated serum hCG level.
B. Profuse, clear vaginal discharge
Rationale: A client who has a hydatidiform mole often has vaginal bleeding later in the pregnancy. This
discharge can be dark brown, bright red, scant, or profuse.
C. Irregular fetal heart rate
Rationale: When a client has a hydatidiform mole, fetal heart tones are not heard since there is no
developing fetus.
D. Excessive uterine enlargement
Rationale: A hydatidiform mole is a rare tumor that forms inside the uterus at the beginning of a pregnancy
and results in the over-production of tissue that would normally develop into the placenta. This
tissue consists of fluid-filled vesicles. A rapidly enlarging uterus is a classic finding in clients
who have a molar pregnancy. It is often accompanied by severe nausea and vomiting, elevated
human chorionic gonadotropin levels, signs of hyperthyroidism, and early onset of
preeclampsia.
13.A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following
statements is a therapeutic response by the nurse?
A. "I will call your primary care provider to report your concerns."
Rationale: This is an inappropriate response by the nurse because it does not address the client's feelings
of concern.
B. "I will take your baby to the nursery for further examination."
Rationale: It is not necessary for the nurse to complete additional examination of the newborn. This also
does not address the client’s concerns.
C. "This occurs because newborns lack muscle control to regulate eye movement."
Rationale:
Created on:11/29/2018 Page 6Detailed Answer Key
medical
This addresses the client’s concerns because it provides information that addresses her
concerns. The eyes of newborns are structurally incomplete and muscle control is not fully
developed for 3 months.
D. "This is a concern, but strabismus is easily treated with patching."
Rationale: This is an inappropriate statement by the nurse because it offers unwarranted reassurance.
The nurse is making an assumption that that should be addressed by the provider.
14.A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to
150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse
perform?
A. Immediately report the situation to the client's provider and prepare the client for induction of labor.
Rationale: The fetus might not be moving because it is asleep, or there might be another benign reason.
B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring.
Rationale: Having the client walk is not likely to promote fetal movement.
C. Offer the client a snack of orange juice and crackers.
Rationale: A nonstress test depends upon fetal movement, and this fetus is most likely asleep. Most
fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the
mother a snack will promote fetal movement.
D. Turn the client onto her left side.
Rationale: Turning the client onto her left side increases the placental perfusion of oxygen to the fetus, but
the FHR of 130 to 150/min is not indicative of fetal distress.
15.A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the
contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal
heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following
is the priority action for the nurse to take?
A. Notify the provider of the findings.
Rationale: Calling the provider may be appropriate; however, this is not the priority intervention.
B. Position the client with one hip elevated.
Rationale: Based on Maslow’s hierarchy of needs, the client's need for an adequate blood pressure to
perfuse herself and her fetus is a physiological need that requires immediate intervention.
Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By
turning the client on her side and retaking her blood pressure, the nurse is attempting to correct
the low blood pressure and reassess.
C. Ask the client if she needs pain medication.
Rationale:
Created on:11/29/2018 Page 7Detailed Answer Key
medical
The client's comfort should be addressed; however, this is not the priority intervention.
D. Have the client void.
Rationale: The client should be encouraged to empty her bladder every 2 hr during labor; however, this is
not the priority intervention.
16.A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not
really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?
A. Rupture of the membranes
Rationale: The membranes can rupture spontaneously long before the onset of labor.
B. Changes in the cervix
Rationale: Assessment of progressive changes in the effacement and dilation of the cervix is the most
accurate indication of true labor.
C. Station of the presenting part
Rationale: A client who is a primigravida will typically engage before labor and can enter labor at -1, 0, or
even +1 station.
D. Pattern of contractions
Rationale: A client can have regular contractions for a significant period of time prior to the onset of true
labor.
17.A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of
the following is the priority nursing assessment for this client?
A. Temperature
Rationale: Although the use of magnesium sulfate in a client experiencing preterm labor can result in
hypothermia, this assessment is not the nurse’s priority assessment.
B. Fetal heart rate (FHR)
Rationale: It is important to monitor the FHR of any client experiencing labor; however, this assessment is
not the nurse’s priority assessment.
C. Bowel sounds
Rationale: Although the use of magnesium sulfate in a client experiencing preterm labor can result in
ileus, this assessment is not the nurse’s priority assessment.
D. Respiratory rate
Rationale: Magnesium sulfate is typically administered to a client in preterm labor to achieve the tocolytic
(uterine relaxation) effect. Magnesium sulfate depresses the function of the central nervous
Created on:11/29/2018 Page 8Detailed Answer Key
medical
system, causing respiratory depression. Baseline assessment of respiratory status, checking
the respiratory rate frequently, and reassessment of respiratory status with each change in
dosage of magnesium sulfate is the primary focus when assessing the client. There is a narrow
margin between what is considered a therapeutic dose and a toxic dose of magnesium sulfate.
18.A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination
indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included
in the newborn’s plan of care?
A. Observe for meconium in respiratory secretions.
Rationale: When a fetus is SGA, there is an increased risk for intrauterine hypoxia due to the presence of
meconium in the amniotic fluid. The nurse should observe for meconium in respiratory
secretions when suctioning the newborn at delivery. Newborns who are SGA are at risk for
perinatal asphyxia due to the stress of labor and are often depressed. They require careful
resuscitation and suctioning at delivery.
B. Monitor for hyperglycemia.
Rationale: Newborns who are SGA have difficulty maintaining normal blood glucose levels and are at high
risk for hypoglycemia, not hyperglycemia.
C. Identify manifestations of anemia.
Rationale: Infants who are SGA have polycythemia, which means there are too many red blood cells,
rather than anemia, in which there are too few red blood cells.
D. Monitor for hyperthermia.
Rationale: Infants who are SGA have difficulty maintaining normal body temperature and are at high risk
for hypothermia, not hyperthermia.
19.A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of
giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include
in the teaching?
A. Limit alcohol consumption.
Rationale: Alcohol consumption has no effect on the incidence of neural tube defects. It is related to the
incidence of other congenital defects and fetal alcohol syndrome (FAS) in newborns of clients
who consume alcohol during pregnancy.
B. Increase intake of iron-rich foods.
Rationale: Iron intake has no effect on the incidence of neural tube defects. A diet low in iron places a
client who is pregnant at risk for preterm labor and postpartum hemorrhage.
C. Consume foods fortified with folic acid.
Rationale: Increased consumption of folic acid in the 3 months prior to conception, as well as throughout
the pregnancy, reduces the incidence of neural tube defects in the developing fetus.
Created on:11/29/2018 Page 9Detailed Answer Key
medical
D. Avoid foods containing aspartame.
Rationale: Aspartame in the diet has no effect on the incidence of neural tube defects in a fetus. Clients
who have phenylketonuria should be advised to avoid aspartame since it contains
phenylalanine.
20.A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and
curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching?
A. Vaginal intercourse can be resumed after 2 weeks.
Rationale: The client should avoid vaginal intercourse and the use of tampons for 2 weeks following
discharge.
B. Products of conception will be present in vaginal bleeding.
Rationale: The products of conception are surgically removed during a D&C.
C. Increased intake of zinc-rich foods is recommended.
Rationale: The client is encouraged to consume foods high in iron and protein to replace red blood cells
and repair uterine tissue.
D. Aspirin may be taken for cramps.
Rationale: Aspirin for pain management of cramps should be avoided because of its anticoagulant
property. NSAIDS, such as ibuprofen, are recommended as they are an antiprostaglandin
agent and reduce the discomfort of cramping.
21.A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38
weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as
inconsistent with preeclampsia?
A. 1+ pitting sacral edema
Rationale: This finding is consistent with the diagnosis of preeclampsia.
B. 3+ protein in the urine
Rationale: This finding indicates proteinuria, a finding that is consistent with the diagnosis of
preeclampsia.
C. Blood pressure 148/98 mm Hg
Rationale: This finding is consistent with the diagnosis of preeclampsia.
D. Deep tendon reflexes of +1
Rationale: Deep tendon reflexes of +1 are decreased. In a client who has preeclampsia, the nurse should
expect to find an increased, rather than a decreased, deep tendon reflex.
Created on:11/29/2018 Page 10Detailed Answer Key
medical
22.A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse
expect? (Select all that apply.)
A. Cracked, peeling skin
B. Positive Moro reflex
C. Short, soft fingernails
D. Abundant lanugo
E. Vernix in the folds and creases
Rationale: Cracked, peeling skin is correct. Physical findings that indicate postmaturity in a
newborn (gestational age of greater than 42 weeks) include cracked, peeling
skin.
Positive Moro reflex is correct. Reflexes that are present in a postmature
newborn are the same as those that are present in a mature newborn. These reflexes include a
positive Moro reflex.
Short, soft fingernails is incorrect. Short, soft fingernails
are not characteristic of the postmature newborn. They appear long and are
hard.
Abundant lanugo is incorrect. Abundant lanugo is seen in preterm
(gestational age of less than 37 weeks) newborns.
Vernix in folds and creases is
incorrect Vernix in the folds and creases is seen in mature, term newborns.
23.A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to
exercise during pregnancy. Which of the following responses by the nurse is appropriate?
A. "Exercising during pregnancy is not recommended."
Rationale: Physical activity during pregnancy improves circulation, rest, and relieves boredom. However,
risky activities that require precise balance and coordination should be avoided.
B. "Daily jogging for up to 30 minutes is fine throughout the pregnancy."
Rationale: While weight-bearing exercises might become uncomfortable in the last trimester, they are
generally not contraindicated, providing the client stays hydrated and avoids becoming
overheated for extended periods.
C. "Activities that raise the body temperature, such as saunas and hot tubs, are safe until the third trimester."
Rationale: Prolonged or repeated elevations of maternal and fetal temperature can result in birth defects,
especially during the first trimester of pregnancy.
D. "It is recommended that pregnant clients limit their exercise routine to stretching activities on a mat several
times a week."
Rationale: Daily moderate exercise throughout pregnancy is recommended. After the fourth month of
pregnancy, clients should avoid exercising flat on their back due to the risk of vena cava
syndrome.
Created on:11/29/2018 Page 11Detailed Answer Key
medical
24.A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding
from the vagina. Which of the following actions should the nurse perform first?
A. Cover the cord with a sterile, moist saline dressing.
Rationale: While this is appropriate, it is not the first action the nurse should take.
B. Prepare the client for an immediate birth.
Rationale: Although an emergency vaginal or cesarean birth might be necessary to deliver the fetus
safely, this is not the first action the nurse should take.
C. Place the client in knee-chest position.
Rationale: Although this is appropriate, it is not the first action the nurse should take.
D. Insert a gloved hand into the vagina to relieve pressure on the cord.
Rationale: This is the first nursing action because it is essential to prevent any pressure on the umbilical
cord to promote oxygenation of the fetus.
25.A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse
that she is upset because, although she and her husband planned this pregnancy, she has been having many
doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate
response by the nurse?
A. "Ambivalent feelings are quite common for women early in pregnancy."
Rationale: This response uses the therapeutic communication technique of providing information while
addressing the client's concerns and feelings. This statement is true and gives the client the
information she needs; many antepartum women experience similar feelings in early
pregnancy.
B. "Perhaps you should see a counselor to discuss these feelings further."
Rationale: This nontherapeutic response puts the client's feelings on hold by referring her to another
person.
C. "Have you spoken to your mother about these feelings?"
Rationale: This is a closed-ended response that is nontherapeutic because it anticipates a "yes" or "no"
reply from the client and refers her to an inappropriate person.
D. "Don't worry. You will be fine once the baby is born."
Rationale: This nontherapeutic response devalues the client's feelings.
26.A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the
client for which of the following adverse effects that should be reported to the provider?
A. Headaches
Rationale:
Created on:11/29/2018 Page 12Detailed Answer Key
medical
Headaches are a common, nonlife-threatening adverse effect related to terbutaline therapy.
B. Nervousness
Rationale: Nervousness, or anxiety, is a common, nonlife-threatening adverse effect related to terbutaline
therapy.
C. Tremors
Rationale: Tremors, or shakiness, are a common, nonlife-threatening adverse effect related to terbutaline
therapy.
D. Dyspnea
Rationale: The presence of dyspnea is a manifestation of pulmonary edema, which is a potentially
life-threatening complication of terbutaline. This finding should be reported to the provider
immediately.
27.A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to
which of the following clients?
A. A client who is experiencing fetal death at 32 weeks of gestation
Rationale: If fetal death has occurred, regardless of gestational age, there is no need to prevent
contractions from occurring. Tocolytic medications are not indicated.
B. A client who is experiencing preterm labor at 26 weeks of gestation
Rationale: Tocolytic medications, such as terbutaline, indomethacin, and nifedipine are used to relax the
uterus in preterm labor. A client who is in preterm labor at 26 weeks of gestation is a candidate
for tocolytic therapy.
C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation
Rationale: The use of a tocolytic medication is contraindicated in a client at a gestational age of 36 weeks
or more.
D. A client who has a post-term pregnancy at 42 weeks of gestation
Rationale: Tocolytic medications are not administered to stimulate labor.
28.A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings
indicates that the medication was effective?
A. Fundus firm to palpation
Rationale: Methylergonovine is an oxytocic medication that is administered to promote uterine
contractions. This medication is indicated for treatment of postpartum hemorrhage caused by
uterine atony or subinvolution; the desired effect is an increase in uterine tone.
B. Increase in blood pressure
Rationale:
Created on:11/29/2018 Page 13Detailed Answer Key
medical
A rise in blood pressure is an adverse effect of the medication.
C. Increase in lochia
Rationale: This finding would indicate the medication was not effective.
D. Report of absent breast pain
Rationale: Methylergonovine has no effect on breast discomfort.
29.A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho (D)
immunoglobulin. Which of the following should be included in the teaching?
A. It prevents the formation of Rh antibodies in mothers who are Rh negative.
Rationale: Rho (D) immunoglobulin prevents the immune system of a client who is Rh negative from
reacting to accidental exposure to fetal blood during pregnancy or delivery. If the client has
another Rh positive fetus in the future, these antibodies can destroy the blood cells of the fetus.
Rho (D) immunoglobulin is administered routinely to Rh negative mothers at 28 weeks of
gestation and following any pregnancy outcome (including birth or any planned or unintentional
fetal loss).
B. It destroys Rh antibodies in mothers who are Rh negative.
Rationale: This is not the purpose of this injection.
C. It destroys Rh antibodies in newborns who are Rh positive.
Rationale: This is not the purpose of this injection.
D. It prevents the formation of Rh antibodies in newborns who are Rh positive.
Rationale: This is not the purpose of this medication.
30.A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal
bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is
not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse
should explain to the client that the purpose of the ultrasound is to determine which of the following?
A. Fetal lung maturity
Rationale: This is not the purpose of this examination.
B. Location of the placenta
Rationale: Painless, spontaneous vaginal bleeding might indicate that the client has placenta previa.
Placenta previa is a condition in which the placenta is implanted low in the uterus, sometimes
to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. The
ultrasound will show the location of the placenta and help to determine what sort of delivery the
client requires and how emergent it is.
Created on:11/29/2018 Page 14Detailed Answer Key
medical
C. Viability of the fetus
Rationale: This is not the purpose of this examination.
D. The biparietal diameter
Rationale: This is not the purpose of this examination.
31.A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The
mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a
response the nurse should make?
A. "You might want to offer water supplements between feedings."
Rationale: This is not an explanation for weight loss. Water supplements are not recommended at this
time. The nurse should review the newborn’s pattern of breast feeding, the mother’s breast
feeding technique, and factors that can influence decreased milk production.
B. "It is due to the newborn’s loss of the influence of the maternal hormones."
Rationale: This is not an explanation for weight loss. Breastfed newborns typically lose 5% to 6% of body
weight before gaining weight. A delayed period of weight gain might be due to a slower
transition from early breast milk to mature milk.
C. "This might be related to your baby having 3 stools a day."
Rationale: This is not an explanation for weight loss. The newborn who is being breastfed typically has 3
or more stools per day during the first few weeks.
D. "The cause might be too short or infrequent feedings."
Rationale: Breastfed newborns typically lose 5% to 6% of body weight before gaining weight. Slow weight
gain might be due to inadequate breastfeeding, incorrect feeding techniques, or maternal
factors such as breasts not emptying, stress, and fatigue.
32.A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse,
"Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following
responses should the nurse provide?
A. "The primary consideration is what type of incision was performed this time."
Rationale: The most common type of incision during a cesarean birth is transverse, which is made across
the lower, thinner part of the uterus. It is the primary criteria that permits a vaginal birth after a
cesarean (VBAC). Other types of incisions increase the risk of uterine rupture. Additional
criteria for VBAC include an adequate maternal pelvis, no uterine scars or history of rupture,
the availability of a provider to monitor labor, and personnel to perform a cesarean birth if
needed.
B. "There are so many variables that you'll have to ask your obstetrician."
Rationale: This nontherapeutic reply avoids addressing the client's concerns. A nurse in the labor and
Created on:11/29/2018 Page 15Detailed Answer Key
medical
delivery suite or the postpartum unit should be able to provide the client with information that
answers her question.
C. "It's too soon for you to be worrying about this now."
Rationale: This nontherapeutic reply devalues the client's concerns and avoids addressing them. A nurse
in the labor and delivery suite or the postpartum unit should be able to provide the client with
information that answers her question.
D. "A repeat cesarean birth is safer for both you and your baby."
Rationale: Research has shown that, a vaginal birth after cesarean (VBAC) is safe for both the client and
the fetus if specific criteria are met and labor is managed closely by nurses and health care
providers.
33.A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she
can expect to experience quickening. Which of the following responses should the nurse make?
A. "This will occur during the last trimester of pregnancy."
Rationale: A primigravida client should detect fetal movement earlier than the last weeks of pregnancy.
B. "This will happen by the end of the first trimester of pregnancy."
Rationale: This is too early in the pregnancy for a primigravida client to detect fetal movement.
C. "This will occur between the fourth and fifth months of pregnancy."
Rationale: Quickening is defined as the first time the client is able to feel her fetus move. In a primigravida
client, this usually occurs at 18 weeks of gestation or later. In a multigravida client, this can
occur as early as 14 to 16 weeks.
D. "This will happen once the uterus begins to rise out of the pelvis."
Rationale: The uterus rises out of the pelvis at 12 to 14 weeks of gestation, which is too early for a
primigravida client to notice fetal movement.
34.A nurse is instructing a female client about how to check basal temperature in order to determine if the client is
ovulating. The nurse should instruct the client to check her temperature at which of the following times?
A. Every morning before arising
Rationale: To measure basal temperature, the client must take her temperature every morning at the
same exact time before getting out of bed. The client must try not to move too much, as any
activity can raise the body temperature slightly.
B. On days 13 to 17 of her menstrual cycle
Rationale: The client should take her basal temperature every day of the month to accurately map the
decrease in temperature that occurs at ovulation and the subsequent elevation in temperature
that occurs until menses begin.
Created on:11/29/2018 Page 16Detailed Answer Key
medical
C. 1 hour following intercourse
Rationale: Measuring the temperature after intercourse would not be accurate, as any activity can raise
the body temperature slightly.
D. Before going to bed every night
Rationale: Measuring the temperature after a full day's activity would not be accurate, as any activity can
raise the body temperature slightly.
35.A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's
respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse
take?
A. Discontinue the medication infusion.
Rationale: Magnesium toxicity is manifested by bradypnea (respiratory rate less than 12/min) and absent
deep tendon reflexes. The magnesium sulfate infusion should be discontinued and calcium
gluconate administered via IV.
B. Prepare for an emergency cesarean birth.
Rationale: There is no indication for a cesarean birth at this time.
C. Assess maternal blood glucose.
Rationale: This intervention is not indicated.
D. Place the client in Trendelenburg position.
Rationale: Trendelenburg position is used for clients in shock who are hypotensive. This position is not
indicated for this client.
36.A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my
baby be okay?" Which of the following responses should the nurse offer?
A. "You must be feeling scared and powerless."
Rationale: This response illustrates the therapeutic communication technique of restatement. The nurse
shows empathy for the client by recognizing that the client is concerned about the safety of the
fetus and is powerless to do anything about the situation. This open-ended statement
encourages further communication by the client.
B. "Everyone worries about her baby when she’s in labor."
Rationale: This is a nontherapeutic response that is stereotypical as it oversimplifies and generalizes the
client’s concern.
C. "Your pregnancy is advanced so your baby should be fine."
Rationale: This nontherapeutic response offers false reassurance. The nurse is making a promise about
Created on:11/29/2018 Page 17Detailed Answer Key
medical
a situation in which she has no control.
D. "We have a neonatal unit here that’s equipped to handle emergencies."
Rationale: This is a closed-ended nontherapeutic response. It discourages further discussion by the client
about her concerns.
37.A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late
decelerations on the monitor strip and interprets them as indicating which of the following?
A. Uteroplacental insufficiency
Rationale: The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late
decelerations are the result of uteroplacental insufficiency and the fetus becomes hypoxemic.
They are an ominous sign if they cannot be corrected and place the fetus at risk for a low
Apgar score.
B. Maternal bradycardia
Rationale: A fetal monitor evaluates the fetal heart rate, not the maternal heart rate.
C. Umbilical cord compression
Rationale: Umbilical cord compression is identified by the presence of variable decelerations on the fetal
monitor strip.
D. Fetal head compression
Rationale: Fetal head compression is identified by the presence of early decelerations on the fetal monitor
strip.
38.A nurse is caring for an adolescent client who has pelvic inflammatory disease as a consequence of a sexually
transmitted infection, and will need intravenous antibiotic therapy. The client tells the nurse, "My parents think I am
a virgin. I don't think I can tell them I have this kind of an infection." Which of the following responses should the
nurse make?
A. "Give your parents a chance; they'll understand."
Rationale: This response is nontherapeutic because it offers false reassurance using a cliché and makes
a promise that the nurse cannot keep. The nurse does not know if the adolescent's parents will
be supportive.
B. "If you want me to, I can tell your parents for you."
Rationale: This response is nontherapeutic because the nurse is giving advice. It also changes the topic
instead of focusing on the issue of the client's fear of telling her parents that she is sexually
active.
C. "You seem scared to talk to your parents."
Rationale: This is an open-ended therapeutic statement that focuses on the adolescent's concern and
Created on:11/29/2018 Page 18Detailed Answer Key
medical
allows for further exploration of the client's fear of telling her parents that she is sexually active.
D. "Your parents will have to be told why you are being admitted."
Rationale: This response is nontherapeutic because it changes the subject. The issue is not why the client
is being admitted, it is her fear of telling her parents that she is sexually active.
39.A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. Which of the
following statements should the nurse include in the teaching?
A. "This medication promotes softening of the cervix."
Rationale: Dinoprostone is used to prepare (or ripen) the cervix for the induction of labor in clients who are
at term.
B. "This medication is used to treat preeclampsia."
Rationale: Dinoprostone is not used in the treatment of preeclampsia.
C. "It causes relaxation of the uterine muscles."
Rationale: Dinoprostone stimulates uterine contractions.
D. "It is used to treat genital herpes simplex virus."
Rationale: Dinoprostone is not used in the treatment of genital herpes simplex virus.
40.A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of
gestation. The nurse provides which of the following explanations about this test to the client?
A. This test assesses fetal lung maturity.
Rationale: Fetal lung maturity is evaluated by an amniocentesis to examine amniotic fluid for the presence
of phosphatidylglycerol (PG) and the lecithin/sphingomyelin (L/S) ratio.
B. It assesses various markers of fetal well-being.
Rationale: A biophysical profile includes a review of fetal breathing movements, gross body movement,
fetal tone, reactive fetal heart rate, and amniotic fluid volume to provide an assessment of
physical and physiological characteristics of the developing fetus.
C. This test identifies an Rh incompatibility between the mother and fetus.
Rationale: An indirect Coombs test identifies Rh incompatibility between the mother and fetus.
D. It is a screening test for spinal defects in the fetus.
Rationale: The maternal serum alpha-fetoprotein (MSAFP) screening test is used to identify suspected
neural tube defects (NTDs) and abdominal wall defects. These include spina bifida,
microcephaly, and anencephaly. This tool is the basis for further testing, such as
amniocentesis and specialized ultrasounds.
Created on:11/29/2018 Page 19Detailed Answer Key
medical
41.A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common
discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should
instruct the client to call the clinic if she experiences which of the following manifestations?
A. Leukorrhea
Rationale: Leukorrhea is a common discomfort in the first trimester and might be present throughout the
pregnancy. The client is instructed to call the provider if she notices changes in the leukorrhea,
such as presence of itching, foul odor, and altered characteristics or color.
B. Urinary frequency
Rationale: Urinary frequency, caused by pressure of the uterus on the bladder and changes in hormones,
is a common discomfort of pregnancy in the first trimester. The client is instructed to call the
provider if she notices burning or pain with urination.
C. Nausea and vomiting
Rationale: Nausea and vomiting is a common discomfort of pregnancy in the first trimester and occurs as
a response to increased human chorionic gonadotropin (hCG) levels in pregnancy. The client is
instructed to call the provider if vomiting becomes severe, as this can indicate hyperemesis
gravidarum.
D. Facial edema
Rationale: Facial edema is a warning sign of a hypertensive condition or preeclampsia and should be
reported immediately to the provider.
42.A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the
following manifestations should the nurse expect to identify as consistent with the diagnosis?
A. Severe nausea and vomiting
Rationale: Nausea and vomiting is a common discomfort during the first trimester of pregnancy. Severe
vomiting is consistent with a diagnosis of hyperemesis gravidarum.
B. Large amount of vaginal bleeding
Rationale: A large amount of vaginal bleeding is usually not a finding in ectopic pregnancy. More
commonly, the client might have a small amount of vaginal spotting that occurs 6 to 8 weeks
after the client’s last normal menstrual period.
C. Unilateral, cramp-like abdominal pain
Rationale: An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus
and the placenta and fetus begin to develop in this area. The most common site is within a
fallopian tube; however, ectopic pregnancies can occur in the ovary, the abdomen, and in the
cervix.
D. Uterine enlargement greater than expected for gestational age
Rationale: An ectopic pregnancy is rarely associated with uterine enlargement because the products of
Created on:11/29/2018 Page 20Detailed Answer Key
medical
conception are outside of the uterus.
43.A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia.
Which of the following information about nutrition should be included in the teaching?
A. Consume 40 to 50 g of protein daily.
Rationale: The client who has mild preeclampsia is encouraged to consume 60 to 70 g of protein, 1200
mg of calcium, 400 mcg of folic acid, and 2 to 6 g of zinc and sodium in her daily diet. Protein is
needed for tissue integrity and calories.
B. Avoid salting of foods during cooking.
Rationale: The client who has preeclampsia is instructed to salt foods to taste, and limit consumption of
foods that are high in sodium, such as chips, pretzels, processed meats, and pickles.
C. Drink 48 to 64 ounces of water daily.
Rationale: The client who has preeclampsia is encouraged to drink six to eight 8-ounce glasses of water
(48 to 64 ounces) per day. She should avoid alcohol and limit intake of caffeinated beverages.
D. Limit intake of whole grains, raw fruits, and vegetables.
Rationale: The client who has preeclampsia requires additional fiber in the diet, which should come from
whole grain foods, raw fruits, and vegetables.
44.A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority
in the care of this infant?
A. Maintain the integrity of the sac.
Rationale: Myelomeningocele is a congenital disorder that causes the spine and spinal canal to not close
prior to birth, which results in the spinal cord, meninges, and nerve roots protruding out of the
child's back in a fluid-filled sac. Before surgery, the infant must be handled carefully to reduce
damage to the exposed spinal cord and to maintain the integrity of the sac.
B. Promote maternal-infant bonding.
Rationale: Although promoting maternal-infant bonding is important, there is a higher priority during the
preoperative phase of care.
C. Educate the parents about the defect.
Rationale: Although parental education is important, there is a higher priority during the preoperative
phase of care.
D. Provide age-appropriate stimulation.
Rationale: Although providing age-appropriate stimulation is important, there is a higher priority during the
preoperative phase of care.
Created on:11/29/2018 Page 21Detailed Answer Key
medical
45.A nurse in a college health clinic is speaking to a group of adolescents about toxic shock syndrome (TSS). Which
of the following should the nurse include in the teaching as increasing the risk for contracting TSS?
A. High-absorbency tampons
Rationale: Toxic shock syndrome, a severe disease caused by a toxin made by Staphylococcus aureus, is
characterized by shock and multiple organ dysfunction. Approximately 50% of all cases involve
menstruating women using highly absorbent tampons.
B. Mosquito bites
Rationale: Mosquito bites are not associated with TSS.
C. Travel to foreign countries
Rationale: Travel to foreign countries is not associated with TSS.
D. Multiple sexual partners
Rationale: Multiple sexual partners is not associated with TSS.
46.A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth
(EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD.
For example, July 27 is 0727)
0504
Correct Rationale: Using Nägele's rule, the nurse subtracts three months from the date of the last menstrual
period, then adds 7 days. July minus 3 months equals April. There are 30 days in April,
so 27 + 7 = May 4. The client's EDB is May 4, which would be written as 0504 in the
MMDD format.
InCorrect Rationale: Using Nägele's rule, the nurse subtracts three months from the date of the last
menstrual period, then adds 7 days. July minus 3 months
[Show More]
.png)
