Professional Documents
Culture Documents
A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is
experiencing hypertonic uterine contractions. What is the top priority of the nurse?
A. Stop of Pitocin infusion
B. Perform a vaginal examination
C. Reposition the client
D. Administer oxygen by face mask at 8 to 10 L/min
2.
A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the physicians orders and would expect to note
which of the following prescribed treatments for this condition?
A. Medication that will provide sedation
B. Increased hydration
C. Oxytocin (Pitocin) infusion
D. Administration of a tocolytic medication
3. A nurse in the labor room is preparing to care for a client with hypertonic uterine
dysfunction. The nurse is told that the client is experiencing uncoordinated contractions
that are erratic in their frequency, duration, and intensity. The priority nursing intervention
would be to:
A. Monitor the Pitocin infusion closely
B. Provide pain relief measures
C. Prepare the client for an amniotomy
D. Promote ambulation every 30 minutes
4. A nurse is developing a plan of care for a client experiencing dystocia and includes
several nursing interventions in the plan of care. The nurse prioritizes the plan of care
and selects which of the following nursing interventions as the highest priority?
A. Keeping the significant other informed of the progress of the labor
B. Providing comfort measures
C. Monitoring fetal heart rate
D. Changing the clients position frequently
5. A nurse in the postpartum unit is caring for a client who has just delivered a newborn
infant following a pregnancy with placenta previa. The nurse reviews the plan of care
and prepares to monitor the client for which of the following risks associated with
placenta previa?
A. Disseminated intravascular coagulation
B. Chronic hypertension
C. Infection
D. Hemorrhage
6. A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was
admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of
the following assessment findings would the nurse expect to note if this condition is
present?
A. Absence of abdominal pain
B. A soft abdomen
C. Uterine tenderness/pain
D. Painless, bright red vaginal bleeding
Chronic hypertension
Eclampsia
Gestational hypertension
Preeclampsia
10. After walking for 30 minutes, Mrs. Cruz now has blood tinged mucous on her underpad.
This indicates:
A. The fetus has had a bowel movement.
B. The amniotic sac has ruptured.
C. The client has fallen and sustained internal injury while walking.
D. The cervix is opening more rapidly.
11. The nurse plans to check Mrs. Cruz bladder. The rationale for this action is that the
urinary bladder should not be allowed to become distended primarily because a full
bladder tends to
A.
B.
C.
D.
12. The physician has ordered Betamethasone for the client. The nurse should explain to
the client that the purpose of betamethasone is to
A. Prevent the development of respiratory distress syndrome in the infant.
B. Stop the contractions in the mother.
C. Decrease the chance of intrauterine infection.
D. Prevent the development of hypoglycemia in the infant.
13. Which of the following statements best describes hyperemesis gravidarum?
A. Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the
absence of other medical problems.
B. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional
imbalances in the absence of other medical problems.
C. Loss of appetite and continuous vomiting that commonly results in dehydration
and ultimately decreasing maternal nutrients
D. Severe nausea and diarrhea that can cause gastrointestinal irritation and
possibly internal bleeding
14. Which of the following would the nurse identify as a classic sign of PIH?
A. Edema of the feet and ankles
B. Edema of the hands and face
C. Weight gain of 1 lb/week
D. Early morning headache
15. Which of the following factors would the nurse suspect as predisposing a client to
placenta previa?
A. Multiple gestation
B. Uterine anomalies
C. Abdominal trauma
D. Renal or vascular disease
Situation 1: Cora, 9 months pregnant, is admitted to the hospital with bleeding caused by
possible placenta previa. The laboratory technician takes blood samples and IV fluids are
begun.
16. A client with placenta previa is likely to present with:
A. Hard, tender uterus
B. Painless, bright-red vaginal bleeding after the 20th week of gestation
C. A sluggish fetus with weak heart sounds on auscultation
D. Bleeding during the first trimester
Answer: B
Rationale: With placenta previa, the client has painless, bright-red vaginal bleeding after the
20th week of gestation that starts without warning and stops spontaneously. Palpation
reveals a soft, non-tender uterus, and auscultation reveals an active fetus with good heart
sounds. Also, bleeding commonly occurs during the third trimester. (Straight As in MaternalNeonatal Nursing, 2nd Edition)
A.
B.
C.
D.
A.
B.
A.
B.
C.
D.
19. If a vaginal examination is to be performed on Cora, the nurse should be prepared for an
immediate:
Induction of labor
c. Forceps delivery
Cesarean delivery
d. X-ray examination
Answer: B
Rationale: Vaginal exam might precipitate severe bleeding, which could be life threatening to
the mother and infant and necessitate immediate CS delivery.
20. The care of a client with placenta previa includes:
Vital signs at least once per shift
A tap-water enema before delivery
Observation and recording of the bleeding
Limited ambulation until the bleeding stops
Answer: C
Rationale: Observation and documentation of bleeding are independent nursing functions
and necessary for implementing safe care, because hemorrhage and shock can be lifethreatening.
Situation 2: Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with
preeclampsia, moderate vaginal bleeding, and sudden abdominal pain. The results of the
ultrasound indicate that abruptio placenta is present.
21. Based on these findings, the nurse would prepare the client for:
A. Complete bed rest for the remainder of the pregnancy
B. Delivery of the fetus
C. Strict monitoring of intake and output
D. The need for weekly monitoring of coagulation studies until the time of delivery
Answer: B
Rationale: The goal of management in abruptio placenta is to control the hemorrhage and
deliver the fetus a soon as possible. Delivery is the treatment of choice if the fetus is at term
gestation, or if bleeding is moderate to severe, and the mother or fetus is in jeopardy.
(Saunders, 3rd Edition)
22. On Helens admission to the unit the nurse should observe for:
A. Decrease in size of uterus, cessation of contractions, visible or concealed hemorrhage
B. Firm and tender uterus, concealed or external hemorrhage, shock
C. Increase in size uterus, visible bleeding, no associated pain
D. Shock, decrease in size uterus, absence of external bleeding
Answer: B
Rationale: Signs of mild to moderate placental separation include uterine discomfort and
tenderness because of concealed bleeding. Visible bleeding maybe scant, moderate or
heavy
A.
B.
C.
D.
A.
B.
23. The nurse realizes that the abdominal pain associated with abruption placenta is caused
by:
Hemorrhagic shock
Inflammatory reactions
Blood in the uterine muscle
Concealed hemorrhage
Answer: D
Rationale: The blood cannot escape from behind the placenta. Thus the abdomen becomes
board like and painful because of the entrapment.
24. Helen is given a unit of blood. The realizes that this is necessary, since the bleeding
following severe abruptio placenta is usually caused by:
Hypofibrinogenemia c. Thrombocytopenia
Hyperglobulinemia
d. Polycythemia
Answer: A
Rationale: Clotting defects are common in moderate and severe abruption placentae
because of the loss of fibrinogen from severe internal bleeding.
25. A nurse is monitoring Helen for Disseminated Intravascular Coagulopathy. Which
assessment finding is least likely to be associated with DIC?
A. Swelling of the calf on one leg
B. Prolonged clotting times
C. Decreased platelet count
D. Petechiae, oozing from injection sites, and hematuria
Answer: A
Rationale: These signs are most likely associated with thrombophlebitis.
Situation 5: A pregnant client has delayed her first prenatal visit. She visits the prenatal clinic
only after she starts to experience edema of the feet and hands. The nurse takes a history and
physical assessment to begin Mrs. Barton's care.
26. The client's response to one of the nurse's questions is, This is my third pregnancy. I
miscarried twice, the first time I was 8 weeks pregnant, and the last time I was 26 weeks
A.
B.
pregnant. The nurse correctly records Mrs. Barton's pregnancy status as:
G2, P0, A1
c. G3, P0, A2
G2, P1, A1
d. G3, P1, A1
Answer: D
Rationale: G3 (total of 3 pregnancies: present pregnancy plus the two miscarriage); P1
(second miscarriage at 26 weeks AOG); A1 (first miscarriage at 8 weeks AOG). Gravida
pertains to the number of pregnancies regardless of the duration. Para pertains to the
number of pregnancies that lasted more than 20 weeks, regardless of the outcome. Abortion
pertains to the number of terminated pregnancies, not reaching the age of 20 weeks (age of
viability).
27. During the examination, while client is lying in a lithotomy position, the client complains
of dizziness and nausea. What would be an appropriate nursing action to relieve the
client's discomfort?
A. Administering an antiemetic ordered by the physician
B. Offering small sips of ginger ale
C. Assisting to a side-lying position temporarily
D. Discontinuing the examination
Answer: C
Rationale: Lying supine for a prolonged period of time, with the legs in a lithotomy position.
The weight of the growing uterus presses the vena cava against the vertebrae, obstructing
blood flow to the lower extremities. This causes a decrease ion blood return to the heart,
and consequently decreased cardiac output and hypotension, manifesting as nausea and
dizziness, lightheadedness, faintness and palpitations. Assisting the client in a side-lying
position relieves pressure on the vena cava, thus improving blood circulation.
A.
B.
C.
D.
A.
B.
A.
28. Diplopia was noted during the assessment of Mrs. Barton. This condition is described
as:
Elevated pigmentation of the skin
Double vision
Facial edema
Gingivitis
Answer: B
Rationale: Diplopia is described as having double vision. Women with PIH commonly report
spots before their eyes, or having double vision.
29. The physician asks the nurse to make sure his pregnant patient's next appointment is
scheduled correctly. The patient is in her 33rd week. Her next appointment should be in:
1 month
c. 2 weeks
3 weeks
d. 1 week
Answer: C
Rationale: First visit may be made as soon as the woman suspects she is pregnant.
Subsequent visits are as follows: monthly until the 8 th month; every 2 weeks during the 8 th
month, and weekly during the 9th month. More frequent visits are scheduled if problems
arise. The client is 8 months pregnant (33 weeks), so the next visit will be scheduled after
2 weeks.
30. Mrs. Barton reports that the last day of her last menstrual period was May 11, 2009. Her
menstruation lasted for 5 days. Her expected date of delivery will be:
February 14, 2010
c. August 4, 2010
B.
Rationale: Uterine contractions lasting longer than 70 seconds should be reported, because
contractions of this length begin to compromise fetal well-being by interfering with adequate
uterine artery filling. (Pillitteri, Maternal and Child Health Nursing, 5 th Edition)
34. You assess Nenes uterine contractions. In relation to the contraction, when does a late
deceleration begin?
a. 45 seconds after the contraction is over
b. 30 seconds after the start of a contraction
c. After every tenth or more contraction
d. After a typical contraction ends
Answer: B
Rationale: Late decelerations are those that are delayed until 30 to 45 seconds after the
onset of a contraction, and continue beyond the end of the contraction. This is an ominous
pattern in labor, because it suggests uteroplacental insufficiency. (Pillitteri, Maternal and
Child Health Nursing, 5th Edition)
35. Immediately after the membranes rupture, which of the following should the nurse
check?
a. Check the presence of infection
b. Assess for prolapsed umbilical cord
c. Check for maternal heart rate
d. Assess the color of the amniotic fluid
Answer: B
Rationale: When membranes rupture, amniotic fluid is allowed to escape. The nurse should
check for prolapse of the umbilical cord because there is a possibility that a loop of cord will
escape with the fluid, which can cu off the oxygen supply to the fetus.
Situation 7: Sexually Transmitted Diseases are important to identify during pregnancy because
of its potential effect on the pregnancy, fetus, or newborn. The following questions pertain to
STDs.
36. Frankie, a promiscuous woman in Manila, submits herself to the clinic for check-up. She
complains of vaginal irritation, redness and a thick cream cheese-like vaginal discharge.
As a nurse, you will suspect that Frankie is having a vaginal infection caused by:
a. Gardnerella vaginalis
b. Candida albicans
c. Treponema pallidum
d. Herpes simplex virus type 2
Answer: B
Rationale: Vaginal infection with Candida albicans (Candidiasis) is characterized by red and
irritated vagina, pruritus, and thick vaginal discharge that resemble cream cheese.
37. Cecil comes to the health center. Her doctor examines Cecils vaginal secretions and
finds out that she has Trichomoniasis infection. Trichomoniasis is diagnosed through
which of the following methods?
a. Vaginal secretions are examined in a wet slide that has been treated with potassium
hydroxide
b. Vaginal speculum is used to obtain secretions from the cervix
c. A litmus paper is used to test if the vaginal secretions are infected with Trichomoniasis
d. Vaginal secretions are examined on a wet slide treated with zephiram solution
Answer: A
Answer: C
Rationale: Therapeutic or spontaneous abortion causes mixing of the fetal blood (RH+) and
maternal blood (Rh-). This could trigger the production of maternal antibodies against the
circulating Rh+ blood. The circulating antibodies in the maternal blood will destroy future
pregnancies with a Rh+ blood. Rhogam is given 72 hours post delivery to prevent
production of maternal antibodies.
42. The breathing technique that the mother should be instructed to use as the fetus' head
is crowning is:
a. Blowing
c. Shallow
b. Slow chest
d. Accelerated-decelerated
Answer: A
Rationale: Blowing forcefully through the mouth controls the strong urge to push and allows
for a more controlled birth of the head.
43. When providing prenatal education to a pregnant woman with asthma, which of the
following would be important for the nurse to do?
a. Demonstrate how to assess her blood glucose levels
b. Teach correct administration of subcutaneous bronchodilators
c. Ensure she seeks treatment for any acute exacerbation
d. Explain that she should avoid steroids during her pregnancy
Answer: D
Rationale: Steroids cause cleft lip/palate in newborns.
44. Which of the following conditions would cause an insulin-dependent diabetic client the
most difficulty during her pregnancy?
a. Rh incompatibility
b. Placenta Previa
c. Hyperemesis Gravidarum
d. Abruptio Placenta
Answer: C
Rationale: Both conditions predispose the mother to accumulating high levels of ketone
bodies in the blood.
45. Which of the following would the nurse use as the basis for the teaching plan when
caring for a pregnant teenager concerned about gaining too much weight during
pregnancy?
a. 10 pounds per trimester
b. 1 pound per week for 40 weeks
c. pound per week for 40 weeks
d. A total gain of 25 to 30 pounds
Answer: D
Rationale: To ensure adequate fetal growth and development during pregnancy, a total
weight gain 25 to 30 lbs (other books: 25 to 35 lbs) pounds is recommended: 1 lb per month
in the first trimester; and 1 lb per week in the last two trimesters.
Situation12: Awareness of the complications that may accompany pregnancy is essential in
order to render apt nursing management.
46. In which of the following clients would the nurse suspect anemia?
A. Client in her first trimester with a hemoglobin level of 12 g/dL
B. Client in her second trimester with a hemoglobin level of 11 g/dL
C. Client in her third trimester with a hemoglobin level of 8 g/dL
D. Client in her first trimester with a hemoglobin level of 10.5 g/dL
Answer: C
Rationale: Anemia during pregnancy is described as a hemoglobin level of 10 g/dL or less
during the second and third trimesters. Thus, the nurse would suspect anemia in the client in
her third trimester with hemoglobin of 8 g/dL. Hemoglobin levels of 12 g/dL, 11 g/dL, and
10.5 g/dL are above the cut-off range for the diagnosis of anemia. (Lippincotts Review
Series: Maternal-Newborn Nursing, 4th Edition)
47. Which of the following would the nurse identify as a classic sign of PIH?
A. Edema of the feet and ankles
B. Edema of the hands and face
C. Weight gain of 1 lb/week
D. Early morning headache
Answer: B
Rationale: This is the classic sign of PIH.
48. Which of the following may happen if the uterus becomes overstimulated by oxytocin
during the induction of labor?
A. Weak contractions prolonged to more than 70 seconds
B. Tetanic contractions prolonged to more than 90 seconds
C. Increased pain with bright red vaginal bleeding
D. Increased restlessness and anxiety
Answer: B
Rationale: Hyperstimulation of the uterus such as with oxytocin during the induction of labor
may result in tetanic contractions prolonged to more than 90 seconds.
50. The nurse evaluates that the danger of a seizure in a woman with eclampsia subsides:
After labor begins
After delivery occurs
24 hours postpartum
48 hours postpartum
Answer: D
Rationale: The danger of a seizure in a woman with eclampsia subsides when postpartum
diuresis has occurred, usually 48 hours after delivery. The risk for seizures may remain for
up to two weeks after delivery. (Mosbys Comprehensive Review of Nursing for NCLEX-RN
Examination, 18th Edition)