OB Final

The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then: 1. Checks the vital signs 2. Begins fundal massage 3. Encourages ambulation 4. Encourages the client to drink fluids

1. Checks the vital signs Rationale: Symptoms of hypovolemia include cool, clammy, and pale skin; feelings of anxiety and restlessness; and thirst. The nurse would check the vital signs. The nurse would not ambulate the client or encourage fluids until specific prescriptions are given to do so. There is no information in the question to indicate the need for fundal massage. Test-Taking Strategy: Focus on the symptoms in the question. Use the ABCs —airway, breathing, and circulation—to direct you to the correct option. Review the nursing care of the client with hypovolemia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care References: Leifer, p. 236. 2011. McKinney, James, Murray, Ashwill, p. 701. 2009.

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20, 2012. Using Nägele's rule, the nurse determines the estimated date of birth to be: 1. July 12, 2013 2. July 27, 2013 3. August 12, 2013 4. August 27, 2013

2. July 27, 2013 Rationale: The accurate use of Nägele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months from the first day of the last menstrual period, add 7 days, and then adjust the year as appropriate. In this case, the first day of the LMP was October 20, 2012. When you subtract 3 months, you get July 20, 2012. If you add 7 days, you get July 27, 2012. Add 1 year to this, and you get the estimated date of birth: July 27, 2013. Test-Taking Strategy: Follow Nägele's rule to answer this question. Read all of the options carefully and note the dates and years in the options before selecting an answer. Review Nägele's rule if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Antepartum Reference: Christensen, Kockrow, p. 787. 2011. Foundations of nursing.

A client asks the nurse why her newborn baby needs an injection of vitamin K. The nurse makes which statement to the client? 1. "Your newborn needs vitamin K to develop immunity." 2. "The vitamin K will protect your newborn from becomingjaundiced." 3. "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." 4. "Newborns have sterile bowels. The vitamin K will colonize the bowel with the necessary bacteria."

3. "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." Rationale: Vitamin K is necessary for the body to synthesize coagulation factors, and it is administered to the newborn infant to prevent abnormal bleeding. It promotes the liver's formation of the clotting factors II, VII, IX, and X. Newborn infants are deficient in vitamin K, because the bowel does not have the bacteria necessary for synthesizing this fat-soluble vitamin. The normal flora in the intestinal tract produces vitamin K, but the newborn's bowel does not support the normal production of vitamin K until bacteria have adequately colonized it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced. Test-Taking Strategy: Use the process of elimination. Because jaundice and immunity are not related to the action of vitamin K, eliminate options 1 and 2. From the remaining options, recall the action of vitamin K to direct you to option 3. Review the purpose of vitamin K injection if you had difficulty with this question. Level of Cognitive Ability: Applying Client's Needs: Psychological Integrity Integrated Process: Nursing Process/Implementation Content Area: Newborn Reference: Leifer, p. 153. 2011.

Define: infant

A human born alive; also, a human from 28 days of age until the first birthday.

Define: gravida

A pregnant woman. The woman is called gravida I (or primigravida) during the first pregnancy, gravida II during the second, and so on.

Define: Hegar's sign

The compressibility and softening of the lower uterine segment. This occurs at about 6 weeks' gestation, and it is considered a probable sign of pregnancy.

Define: delivery

The actual event of birth. The expulsion or extraction of the neonate and the fetal membranes at birth.

Define: implantation

The embedding of the fertilized ovum in the uterine mucosa, which occurs 6 to 10 days after conception.

Define: amniotic fluid

The pale, straw-colored fluid that surrounds and protects the fetus. The fetus floats in the amniotic fluid, which serves as a cushion against injury from sudden blows or movements. It also helps maintain a constant body temperature for the fetus. The fetus modifies the amniotic fluid through the processes of swallowing, urinating, and movement through the respiratory tract.

Define: ballottement

The rebounding of the fetus against the examiner's finger on palpation. When the cervix is tapped, the fetus floats upward in the amniotic fluid. A rebound is felt by the examiner when the fetus falls back.

Define: Goodell's sign

The softening of the cervix. This occurs at the beginning of the second month of gestation and is considered a probable sign of pregnancy.

Define: fertilization

The union of an ovum and sperm. Fertilization occurs within 12 hours of ovulation and within 2 to 3 days of insemination, the average duration of viability of the ovum and the sperm.

Define: Chadwick's sign

The violet coloration of the vaginal mucous membranes that is visible from about 4 weeks ' gestation and presents as a result of increased vascularity. This is considered a probable sign of pregnancy.

A nursing student is asked to describe the size of the uterus in a no pregnant client. Which of the following responses, if made by the student, indicates an understanding of the anatomy of this structure? 1. "The uterus weighs about 2 ounces." 2. "The uterus weighs about 2.2 pounds." 3. "The uterus has a capacity of about 50 milliliters." 4. "The uterus is round in shape and weighs approximately 1000 grams."

1. "The uterus weighs about 2 ounces." Rationale: Before conception, the uterus is a small, pear-shaped organ that is contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 g (2 oz), and it has a capacity of about 10 mL (⅓ oz). At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 lb), and it has a capacity that is sufficient for the fetus, the placenta, and the amniotic fluid. Test-Taking Strategy: Note the strategic word "nonpregnant." Visualizing each of the items identified in the options will direct you to the correct option. Review the anatomy of the uterus if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/ Antepartum Reference: Leifer, p. 24. 2011.

The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse encourages the woman to take which priority action? 1. Ambulate frequently. 2. Wear support stockings. 3. Apply warm, moist packs to the legs. 4. Remain on bed rest, with the legs elevated.

1. Ambulate frequently. Rationale: Stasis is believed to be a major predisposing factor for the development of thrombophlebitis. Because cesarean delivery poses a risk factor, the client should ambulate early and frequently to promote circulation and prevent stasis. Options 2, 3, and 4 are implemented if thrombophlebitis occurs. Test-Taking Strategy: Focus on the subject of the question, the prevention of thrombophlebitis, and note the strategic word "priority." Options 3 and 4 are implemented if thrombophlebitis occurs. Although wearing support stockings may be prescribed in the postoperative period to promote venous return, ambulating frequently (option 1) is the priority preventive measure. Review the content related to the prevention of thrombophlebitis during the postoperative period if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, p. 210. 2011.

A 31-week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the client's labor can be inhibited for the next 48hours, what medication does the nurse anticipate will beprescribed? 1. Betamethasone 2. Nalbuphine (Nubain) 3. Misoprostol (Cytotec) 4. Rh0(D) immune globulin (RhoGAM)

1. Betamethasone Rationale: Betamethasone, which is a glucocorticoid, is given to stimulate fetal lung maturation. It is used for clients in preterm labor between 28 and 32 weeks' gestation if the labor can be inhibited for 48 hours. Nalbuphine (Nubain) is an opioid analgesic. Misoprostol (Cytotec) is a prostaglandin that is given to ripen and soften the cervix and to stimulate uterine contractions. Rh0(D) immune globulin (RhoGAM) is given to RH-negative clients to prevent sensitization. Test-Taking Strategy: Use the process of elimination. Noting the strategic words "31-week preterm labor client" and recalling that betamethasone is used to stimulate surfactant release will direct you to the correct option. Review the purpose and actions of the medications in the options if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Kee, Hayes, McCuistion, p. 823. 2009.

A primigravida's membranes rupture spontaneously. The nurse's first action is to: 1. Determine the fetal heart rate. 2. Prepare for immediate delivery. 3. Monitor the contraction pattern. 4. Note the amount, color, and odor of the amniotic fluid.

1. Determine the fetal heart rate. Rationale: When the membranes rupture, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or the compression of the umbilical cord. Monitoring the contraction pattern and noting the amount, color, and odor of the amniotic fluid may be performed, but these would not be the first actions. There is no information in the question that indicates the need to prepare the client for immediate delivery. Test-Taking Strategy: Note the strategic word "first." Use the ABCs— airway, breathing, and circulation. Fetal heart rate is associated with fetal circulation. Review the initial nursing interventions when the membranes rupture if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Intrapartum References: Christensen, Kockrow, p. 835. 2011. Foundations of nursing. Leifer, p. 129. 2011.

A nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse monitors for which adverse effect(s) of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

1. Flushing 4. Depressed respirations 5. Extreme muscle weakness Rationale: Magnesium sulfate is a central nervous system depressant, and it relaxes smooth muscle, including the uterus. It is used to stop preterm labor contractions, and it is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels. Test-Taking Strategy: Focus on the subject of adverse effects of magnesium sulfate. Recalling that this medication is a central nervous system depressant will assist you with answering correctly. Review the adverse effects of magnesium sulfate if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Hodgson, Kizior, p. 713. 2011.

The client at 38 weeks' gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which of the following as the lowest priority for the care of this client? 1. Measuring the fundal height 2. Attaching electronic fetal monitoring 3. Preparing the client for a possible cesarean section 4. Gathering equipment for starting an intravenous line

1. Measuring the fundal height Rationale: Option 1 is a low priority, because fundal height should be measured at each antepartal clinic visit; it is not a priority of care during the intrapartum period. Options 2, 3, and 4 are all high priorities. The twins should be monitored by dual electronic fetal monitoring, and any signs of distress should be reported. Many health care providers choose to perform a cesarean birth if either of the twins is breech. The mother should have an intravenous line in place in case fluid or blood replacement is required. Test-Taking Strategy: Note the strategic words "lowest priority." Use Maslow's Hierarchy of Needs theory and the ABCs— airway, breathing, and circulation— to prioritize and direct you to the correct option. Review the care of the pregnant client with a breech presentation if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Planning Content Area: Maternity/ Intrapartum References: Christensen, Kockrow, pp. 809- 810. 2011. Foundations of nursing. Leifer, pp. 189- 190. 2011.

The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse checks the client for which classic signs of preeclampsia? Select all that apply. 1. Proteinuria 2. Hypertension 3. Low-grade fever 4. Generalized edema 5. Increased pulse rate 6. Increased respiratory rate

1. Proteinuria 2. Hypertension 4. Generalized edema Rationale: The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. A low-grade fever, increased pulse rate, and increased respiratory rate are not associated with preeclampsia. Test-Taking Strategy: Focus on the subject— the classic signs of preeclampsia. Thinking about the pathophysiology associated with this disorder will direct you to the correct options. Remember that the classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Review the signs of preeclampsia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Antepartum Reference: Christensen, Kockrow, pp. 622, 896. 2011. Foundations of nursing.

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. The nurse expects the lochia to be: 1. Red 2. Pink 3. White 4. Serosanguineous

1. Red Rationale: The color of the lochia during the fourth stage of labor is bright red, and this may last from 1 to 3 days. The color of the lochia then changes to a pinkish brown, and occurs from day 4 to 10 postpartum. Finally, the lochia changes to a creamy white color that occurs from day 10 to 14 postpartum. Test-Taking Strategy: Focus on the strategic words "fourth stage of labor"; this will direct you to the correct option. In the immediate postpartum period, the lochia is red in color. Review the expected postpartum findings if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Leifer, pp. 201-202. 2011.

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse would initially check the: 1. Vital signs 2. Fundal height 3. Presence of calf pain 4. Level of consciousness (LOC)

1. Vital signs Rationale: Pulmonary embolism is a complication of thrombophlebitis. Changes in the vital signs are one of the first things to occur with pulmonary embolism, because pulmonary blood flow is compromised. Fundal height is unrelated to the subject of the question. Calf pain is an indicator of thrombophlebitis. Level of consciousness may change as the condition worsens; worsening would indicate hypoxia. Test-Taking Strategy: Note the strategic word "initially." Use the ABCs— airway, breathing, and circulation—to direct you to the correct option. Review the complications of thrombophlebitis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Critical Care References: Christensen, Kockrow, pp. 913-914. 2011. Foundations of nursing. Leifer, pp. 240-241. 2011.

A nursing student is assigned to care for an adolescent female client in the health care clinic, and the instructor reviews the menstrual cycle with the student. The instructor determines that the student understands the process of the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) if the student states: 1. "FSH and LH are secreted by the adrenal glands." 2. "FSH and LH are released from the anterior pituitary gland." 3. "FSH and LH are secreted by the corpus luteum of the ovary." 4. "FSH and LH stimulate the formation of milk during pregnancy."

2. "FSH and LH are released from the anterior pituitary gland." Rationale: FSH and LH are released from the anterior pituitary gland to stimulate follicular growth and development, growth of the Graafian follicle, and production of progesterone. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Option 4 can be eliminated because the case of the question does not address pregnancy. Use your knowledge related to anatomy and physiology of the reproductive system and the menstrual cycle to select the correct option. Review the menstrual cycle if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/ Antepartum Reference: Leifer, p. 27. 2011.

The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which of the following statements , if made by the client, would indicate successful learning? 1. "Iron supplements will give me diarrhea." 2. "The iron is needed for the red blood cells." 3. "Meat does not provide iron and should be avoided." 4. "My body has all the iron it needs, and I don't need to take supplements."

2. "The iron is needed for the red blood cells." Rationale: A nutritional supplement that is commonly needed during pregnancy for the red blood cells is iron. Anemia of pregnancy is primarily caused by iron deficiency. Iron supplements usually cause constipation. Meats are an excellent source of iron. Iron for the fetus comes from the maternal serum. Test-Taking Strategy: Use the process of elimination. Note the strategic word "malnourished." Eliminate options 3 and 4 because of the closed-ended words "not" and "all." Knowledge regarding the effects of iron supplements will assist you with eliminating option 1. Review the relationship of nutrition to anemia if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Evaluation Content Area: Maternity/ Antepartum Reference: Christensen, Kockrow, p. 622. 2011. Foundations of nursing.

During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which of the following heart rates is noted? 1. 80 beats per minute 2. 100 beats per minute 3. 150 beats per minute 4. 180 beats per minute

3. 150 beats per minute Rationale: Fetal heart rate depends on gestational age. It is normally 160 to 170 beats per minute during the first trimester, but it slows with fetal growth to 110 or 120 (low end) to 160 (high end) beats per minute near or at term. Test-Taking Strategy: Noting the strategic words "third trimester" will direct you to the correct option. Review the fetal heart rate if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Antepartum Reference: Leifer, p. 133. 2011.

A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states that it: 1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria 3. Connects the umbilical vein to the inferior vena cava 4. Connects the umbilical artery to the inferior vena cava

3. Connects the umbilical vein to the inferior vena cava Rationale: The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery. Test-Taking Strategy: Recall the anatomy of the fetal circulation to answer this question. Remember that the ductus venosus connects the umbilical vein to the inferior vena cava. Review the fetal circulation if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/ Antepartum Reference: Leifer, pp. 39- 40. 2011

The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which of the following data indicate that the GH is not resolving? 1. Urinary output has increased. 2. There is no evidence of dependent edema. 3. The client complains of a headache and blurred vision. 4. The blood pressure reading has returned to the prenatal baseline.

3. The client complains of a headache and blurred vision. Rationale: Options 1, 2, and 4 are all signs that the GH is being resolved. Option 3 is a symptom of the worsening of the GH. Test-Taking Strategy: Note the strategic words "not resolving." These words indicate a negative event query and the need to select a manifestation of GH. Recalling the signs of worsening GH will direct you to the correct option. Review these signs if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Evaluation Content Area: Maternity/ Antepartum Reference: Leifer, pp. 94- 95. 2011.

A nurse is caring for a client who is receiving oxytocin(Pitocin) to induce labor. The nurse discontinues the oxytocin infusion and notifies the registered nurse if which of the following is noted on data collection of the client? 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Early decelerations of the fetal heart rate

3. Uterine hyperstimulation Rationale: Oxytocin stimulates uterine contractions, and it is one of the common pharmacological methods used to induce labor. An adverse effect associated with the administration of the medication is the hyperstimulation of uterine contractions. Therefore, oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Fatigue and drowsiness may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress. Test-Taking Strategy: Use the process of elimination, and focus on the subject of an adverse effect to oxytocin. Options 1 and 2 can be eliminated first because they are comparable or alike. From the remaining options, recalling that early decelerations of the fetal heart rate are a reassuring sign will direct you to option 3. Review the nursing responsibilities associated with oxytocin if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum References: Hodgson, Kizior, pp. 879-880. 2011. Kee, Hayes, McCuistion, p. 850. 2009.

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. The nurse responds, knowing that this procedure: 1. Measures the height of the maternal fundus 2. Determines the "lie" and "attitude" of the fetus 3. Is a systematic method for palpating the fetus through the maternal back 4. Is a systematic method for palpating the fetus through the maternal abdominal wall

4. Is a systematic method for palpating the fetus through the maternal abdominal wall Rationale: Leopold's maneuvers comprise a systematic method for palpating the fetus through the maternal abdominal wall. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Knowledge of the purpose of and procedure for Leopold's maneuvers is required to answer this question. Visualizing this procedure will assist with directing you to the correct option. Review Leopold's maneuvers if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Intrapartum Reference: Leifer, pp. 47, 131. 2011.

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Choose the instructions that would be included on the list. Select all that apply. 1. Wear a supportive, non-underwire bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the sorenesssubsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.

1. Wear a supportive, non-underwire bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breast-feed if the breasts are not too sore. Rationale: Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL per day, and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and the wearing of a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess. Test-Taking Strategy: Think about the pathophysiology associated with mastitis. Recalling that supportive measures include rest, moist heat or ice packs, antibiotics, analgesics, increased fluid intake, breast support, and the decompression of the breasts will assist you with answering the question. Review the treatment of mastitis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Postpartum References: Christensen, Kockrow, pp. 901-902. 2011. Foundations of nursing. Leifer, pp. 242-244. 2011.

The nurse is collecting data from a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be which of the following? 1. 22 cm 2. 28 cm 3. 36 cm 4. 40 cm

2. 28 cm Rationale: During the second and third trimesters (18 to 30 weeks' gestation), the fundal height in centimeters approximately equals the fetus' age in weeks plus or minus 2 cm. At 14 to 16 weeks' gestation, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks' gestation, the fundus is at the umbilicus, and, at term, the fundus is at the xiphoid process. Test-Taking Strategy: Use the process of elimination. Remember that, during the second and third trimesters, the fundal height in centimeters approximately equals the fetus' age in weeks plus or minus 2 cm. Review fundal height if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Antepartum References: Christensen, Kockrow, p. 782. 2011. Foundations of nursing. Perry, Hockenberry, Lowdermilk, Wilson, p. 214. 2010.

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse would: 1. Maintain strict bedrest. 2. Monitor the vital signs every 2 hours. 3. Perform firm fundal massage every 2 hours. 4. Keep the client and her family members informed of her progress.

4. Keep the client and her family members informed of her progress. Rationale: Keeping the client and her family informed about her condition will help minimize fear and apprehension. Options 1, 2, and 3 identify physiological interventions. Test-Taking Strategy: Use the process of elimination. Focus on the strategic words "meet the psychosocial needs." Option 4 is the only option that addresses psychosocial needs. Review the interventions that will meet the psychosocial needs of the client if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Maternity/Postpartum Reference: McKinney, James, Murray, Ashwill, p. 700. 2009.

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. The nurse responds to the client, knowing that involution is: 1. The inverted uterus returning to normal 2. The gradual reversal of the uterine muscle into the abdominal cavity . The descent of the uterus into the pelvic cavity, which occurs at a rate of 2 cm/day 4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day Rationale: Involution is the progressive descent of the uterus into the pelvic cavity. After birth, descent occurs at a rate of approximately one fingerbreadth or 1 cm per day. The other options do not accurately describe involution. Test-Taking Strategy: Use your knowledge of medical terminology to help you to define the word involution. This will assist with directing you to the correct option. Review the process of involution if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum References: Leifer, pp. 200, 244. 2011. McKinney, James, Murray, Ashwill, p. 456. 2009.

A postpartum client is getting ready for discharge. The nurse suspects that the client is in need of further teaching related to breast-feeding when she states: 1. "I don't need birth control since I will be breast-feeding." 2. "I need to increase my caloric intake by 500 calories a day." 3. "I shouldn't use soap to wash my breasts since I will bebreast-feeding." 4. "I need to be sure that I increase my fluid intake and take my prenatal vitamins while breast-feeding."

1. "I don't need birth control since I will be breast-feeding." Rationale: Amenorrhea may occur during breast-feeding, but the client can still ovulate without menstruating. The use of soap on the breasts is avoided because it tends to remove natural oils, which can lead to cracked nipples. The caloric intake should be increased by 200 to 500 cal/day (per health care provider's prescription), and the diet should include additional fluids and prenatal vitamins, as prescribed. Test-Taking Strategy: Note the strategic words "need of further teaching." These words indicate a negative event query and the need to select the incorrect statement. Recalling the physiology related to amenorrhea and ovulation during breast-feeding will direct you to the correct option. Review teaching points for the woman who is breast-feeding if you had difficulty answering this question. Level of Cognitive Ability: Evaluating Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/Postpartum Reference: Leifer, p. 266. 2011.

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the physician has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of: 1. A softening of the cervix 2. The presence of fetal movement 3. The presence of human chorionic gonadotropin in the urine 4. A soft blowing sound that corresponds with the maternal pulse that is heard while auscultating the uterus

1. A softening of the cervix Rationale: During the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell's sign. Cervical softening is noted by the examiner during a pelvic examination. Goodell's sign does not indicate the presence of fetal movement. Human chorionic gonadotropin is noted in maternal urine with a positive urine pregnancy test. A soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus; it is the result of blood circulating through the placenta. Test-Taking Strategy: Use the process of elimination and your knowledge regarding the physiological findings of Goodell's sign to answer this question. Remember that Goodell's sign refers to a softening of the cervix. Review the changes in the cervix that occur during pregnancy if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Antepartum Reference: Leifer, p. 49. 2011.

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply. 1. Allows for fetal movement 2. Is a measure of kidney function 3. Surrounds, cushions, and protects the fetus 4. Maintains the body temperature of the fetus 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus

1. Allows for fetal movement 2. Is a measure of kidney function 3. Surrounds, cushions, and protects the fetus 4. Maintains the body temperature of the fetus Rationale: The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely, it maintains the body temperature of the fetus, and it helps to measure kidney function, because the amount of fluid is based on the amount of urination from the fetus. The placenta prevents large particles such as bacteria from passing to the fetus, and it provides an exchange of nutrients and waste products between the mother and the fetus. Test-Taking Strategy: Focus on the subject of the question: the functions of the amniotic fluid. Visualizing the anatomical location of the amniotic fluid will direct you to the correct options. Review the function of the amniotic fluid if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/ Antepartum Reference: Leifer, p. 35. 2011.

The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. What are the probable sign( s) of pregnancy that the nurse should recognize ? Select all that apply. 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions 5. Outline of fetus via radiography or ultrasound 6. Fetal heart rate detected by a nonelectronic device

1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions Rationale: The probable signs of pregnancy include uterine enlargement, Hegar's sign (the compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (the softening of the cervix that occurs at the beginning of the second month of pregnancy), Chadwick's sign (the violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (the rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test that measures for human chorionic gonadotropin. Positive signs of pregnancy include a fetal heart rate that is detected by an electronic device (Doppler transducer) at 10 to 12 weeks' gestation and by a nonelectronic device (fetoscope) at 20 weeks' gestation; active fetal movements that are palpable by the examiner; and an outline of the fetus via radiography or ultrasound. Test-Taking Strategy: Focusing on the subject of the probable signs of pregnancy will assist you with answering this question. Remember that the detection of the fetal heart rate and an outline of the fetus via radiography or ultrasound are positive signs of pregnancy. Review the probable signs of pregnancy if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Antepartum Reference: Leifer, p. 48. 2011.

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse tells the client that fetal circulation consists of: 1. Two umbilical veins and one umbilical artery 2. Two umbilical arteries and one umbilical vein 3. Arteries that carry oxygenated blood to the fetus 4. Veins that carry deoxygenated blood to the fetus

2. Two umbilical arteries and one umbilical vein Rationale: Blood pumped by the fetus' heart leaves the fetus through two umbilical arteries. After the blood is oxygenated, it is then returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen and nutrients to the fetus. Test-Taking Strategy: Recall the anatomy of fetal circulation to answer this question. Remember that there are three umbilical vessels within an umbilical cord (two arteries and one vein). Review the fetal circulation if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/ Antepartum Reference: Leifer, pp. 39- 40. 2011.

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. The most accurate description of the test includes which of the following? 1. "Uterine contractions are stimulated by Leopold's maneuvers." 2. "An internal fetal monitor is attached, and you will walk on a treadmill until contractions begin." 3. "The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation." 4. "Small amounts of oxytocin (Pitocin) are administered during internal fetal monitoring to stimulate uterine contractions."

3. "The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation." Rationale: A contraction stress test assesses placental oxygenation and function and determines the fetus' ability to tolerate labor as well as its well-being. The test is performed if the nonstress test result is abnormal. During the stress test, the fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract, either by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation, until three palpable contractions with a duration of 40 seconds or more during a 10 minute period have occurred. Frequent maternal blood pressure readings are performed, and the client is monitored closely while increasing doses of oxytocin are given. Leopold's maneuvers are performed to locate the position of the fetus. Test-Taking Strategy: Knowledge regarding the contraction stress test is required to answer the question. Remember that during both the nonstress test and the contraction stress test, external monitoring is performed. Review the contraction stress test if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Antepartum Reference: Leifer, p. 81. 2011.

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate? 1. Contact the health care provider. 2. Instruct the client to maintain bedrest for the remainder of the pregnancy. 3. Tell the client that these are common and they may occur throughout the pregnancy. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

3. Tell the client that these are common and they may occur throughout the pregnancy. Rationale: Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, options 1, 2, and 4 are unnecessary and inappropriate actions. Test-Taking Strategy: Use the process of elimination. Options 1 and 4 are comparable or alike and can thus be eliminated first. From the remaining options, knowing that Braxton Hicks contractions are common and can occur throughout pregnancy will assist with directing you to the correct option. Review the physiology associated with Braxton Hicks contractions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Antepartum Reference: Leifer, pp. 50, 126. 2011.

224. After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. The nurse determines that: 1. This is a normal expectation after episiotomy. 2. The mother should be allowed bathroom privileges only. 3. The bright red bleeding is abnormal and should bereported. 4. The perineal assessment should be performed morefrequently.

3. The bright red bleeding is abnormal and should bereported. Rationale: Lochial flow should be distinguished from bleeding that originates from a laceration or an episiotomy, which is usually brighter red than lochia and presents as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported. Therefore, the other options are incorrect interpretations. Test-Taking Strategy: Note the strategic words "trickle" and "bright red." This should be an indication that the flow is not normal. Review the lochial flow and the complications associated with episiotomy if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum References: Christensen, Kockrow, p. 849. 2011. Foundations of nursing. Leifer, p. 202. 2011.

During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client states: 1. "I can eat more sweets now, because I need more calories." 2. "I need more fat in my diet so that the baby can gain enough weight." 3. "I need to eat a high-protein, low-carbohydrate diet now to control my blood glucose." 4. "I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

4. "I need to increase the fiber in my diet to control my blood glucose and prevent constipation." Rationale: An increase in calories is needed during pregnancy, but concentrated sugars should be avoided, because they may cause hyperglycemia. The fat intake should be 20% to 30% of the total calories. The client with diabetes needs about 50% to 60% of her caloric intake from carbohydrates and about 12% to 20% from protein. High-fiber foods will control blood glucose levels and prevent constipation. Test-Taking Strategy: Note the strategic words "teaching has been effective." Use the process of elimination and your knowledge regarding diabetes mellitus and diet therapy to direct you to the correct option. Review the components of the diabetic diet if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/ Evaluation Content Area: Maternity/ Antepartum References: Christensen, Kockrow, pp. 905- 907. 2011. Foundations of nursing. Leifer, pp. 99- 100. 2011.

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse places the client in the: 1. Prone position 2. Semi-Fowler's position 3. Trendelenburg's position 4. Supine position with a wedge under the right hip

4. Supine position with a wedge under the right hip Rationale: Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities, thereby decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently to the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides for the displacement of the uterus. A prone or semi-Fowler's position is not practical for this type of abdominal surgery. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, thus decreasing respiratory capacity and oxygenation. Test-Taking Strategy: Note the strategic words "maintain the optimal perfusion." Use the process of elimination, and visualize each of the positions and their effect on the fetus. Review client positioning if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Intrapartum References: Leifer, p. 209. 2011. McKinney, James, Murray, Ashwill, pp. 400, 448. 2009.

The nurse working in a prenatal clinic reviews a client's chart and notes that the health care provider documents that the client has a gynecoid pelvis. The nurse understands that this type of pelvis is: 1. Not favorable for labor 2. Not normally a female pelvis type 3. A wide pelvis with a short diameter 4. The most favorable for labor and birth

4. The most favorable for labor and birth Rationale: A gynecoid pelvis is a normal female pelvis, and it is the most favorable for successful labor and birth. An android pelvis would not be favorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. The platypelloid pelvis has a wide transverse diameter, but the anteroposterior diameter is short, thus making the outlet inadequate. Test-Taking Strategy: Knowledge regarding pelvic types is required to answer this question. Remember that the gynecoid pelvis is the normal female pelvis. Review pelvic types if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Antepartum Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Antepartum Reference: Leifer, p. 25. 2011.

A&P Review: Platypelloid Pelvis

a. Flat shape with an oval inlet b. The transverse diameter is wide, but the anteroposterior diameter is short, thus making labor and birth difficult

A&P Review: Ovarian hormones

1. Ovarian hormones include the follicle-stimulating hormone (FSH) and luteinizing hormone (LH). 2. The hormones are released by the anterior pituitary gland. 3. The hormones produce changes in the ovaries. 4. Secretion of ovarian hormones leads to changes in the endometrium.

A&P Review: Vagina

1. A muscular tube that extends from the cervix to the vaginal opening in the perineum 2. Known as the birth canal 3. Passage between the cervical os and the external environment a. Passageway for menstrual blood flow b. Passageway for fetus c. Passageway for penis for intercourse

A&P Review: Ovaries

1. Form and expel ova 2. Primary source of estrogen and progesterone

A&P Review: Cervix

1. Internal os of the cervix opens into the body of the uterine cavity. 2. Cervical canal is located between the internal cervical os and the external cervical os. 3. External cervical os opens into the vagina.

A&P Review: True pelvis

1. Lies below the pelvic brim (the lower, curved, bony canal) 2. Consists of the pelvic inlet, the mid pelvis, and the pelvic outlet

A&P Review: Uterus

1. Muscular organ shaped like an upside-down pear in which the fetus develops. 2. Cavity from which menstruation occurs

A&P Review: Fallopian tubes

1. Muscular tubes (oviducts) that are approximate to the ovaries and that connect into the uterus 2. Provide transportation for the ova from the ovaries to the uterus

A&P Review: False pelvis

1. Shallow portion above the pelvic brim 2. Supports the abdominal viscera

A&P Review: Preovulatory Phase

1. The hypothalamus releases gonadotropin -releasing hormone through the portal system to the anterior pituitary system. 2. Secretion of follicle-stimulating hormone (FSH) by the anterior lobe of the pituitary gland stimulates growth of follicles. 3. Most follicles die, leaving one to mature into a large graafian follicle. 4. Estrogen produced by the follicle stimulates increased secretions of luteinizing hormone (LH) by the anterior lobe of the pituitary gland. 5. The follicle ruptures and releases an ovum into the peritoneal cavity.

A&P Review: Luteal Phase

1. The luteal phase begins with ovulation. 2. Body temperature drops and then rises by 0.5 ° to 1 ° F around the time of ovulation. 3. Corpus luteum is formed from follicle cells that remain in the ovary following ovulation. 4. Corpus luteum secretes estrogen and progesterone during the remaining 14 days of the cycle. 5. Corpus luteum degenerates if the ovum is not fertilized, and secretion of estrogen and progesterone declines. 6. The decline of estrogen and progesterone stimulates the anterior pituitary to secrete more FSH and LH, initiating a new reproductive cycle.

A&P Review: Menstrual Phase

1. The menstrual phase consists of 4 to 6 days of bleeding as the endometrium breaks down because of the decreased levels of estrogen and progesterone. 2. The level of FSH increases, enabling the beginning of a new cycle.

A&P Review: Proliferative Phase

1. The proliferative phase lasts about 9 days. 2. Estrogen stimulates proliferation and growth of the endometrium. 3. As estrogen increases, it suppresses secretion of FSH and increases secretion of LH. 4. Secretion of LH stimulates ovulation and the development of the corpus luteum. 5. Ovulation occurs between days 12 and 16. 6. The estrogen level is high and the progesterone level is low.

A&P Review: Secretory Phase

1. The secretory phase lasts about 12 days and follows ovulation. 2. This phase is initiated in response to the increase in LH level. 3. The graafian follicle is replaced by the corpus luteum. 4. The corpus luteum secretes progesterone and estrogen. 5. Progesterone prepares the endometrium for pregnancy if a fertilized ovum is implanted.

The nurse is assisting with caring for a client with abruptio placenta. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse would first: 1. Monitor the urinary output. 2. Monitor the maternal pulse. 3. Turn the client onto her side. 4. Monitor the maternal blood pressure.

3. Turn the client onto her side. Rationale: With a pregnant client who is in shock, the nurse would want to increase perfusion to the placenta. A simple way to do this that requires no equipment is to turn the mother on her side. This would increase blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. The nurse would immediately contact the registered nurse, who would then contact the health care provider. The other options would follow quickly. Test-Taking Strategy: Note the strategic word "first." Eliminate options 2 and 4, because they are comparable or alike. Recalling that positioning will affect the status of blood flow will assist with directing you to option 3 from the remaining options. Review the care of the pregnant client in shock if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Critical Care Reference: McKinney, James, Murray, Ashwill, p. 692. 2009.

A&P Review: Android Pelvis

Heart-shaped or angulated. Resembles a male pelvis. Not favorable for labor. Narrow pelvic planes can cause slow descent and mid-pelvis arrest.

A&P Review: Gynecoid Pelvis

Normal female pelvis. Transversely rounded or blunt. The gynecoid pelvis is most favorable for successful labor and birth.

Define: labor

A coordinated sequence of rhythmic, involuntary uterine contractions that result in the effacement and dilation of cervix. This is followed by the expulsion of the products of conception.

Define: newborn

A human offspring from the time of birth to day 28 of life; also called a neonate.

Define: Nägele's rule

A way to determine the estimated date of birth that works on the premise that the woman has a 28-day menstrual cycle. Subtract 3 months from the first day of last menstrual period, add 7 days, and then adjust the year.

A&P Review: Anthropoid Pelvis

Oval shape. The outlet is adequate, with a normal or moderately narrow pubic arch

Define: quickening

The maternal perception of fetal movement, which usually appears around 16 to 20 weeks' gestation.

Define: parity

The number of pregnancies that have reached viability, regardless of whether the infants were alive or stillborn.

Define: placenta

The organ that provides for the exchange of nutrients and waste products between the fetus and the mother and that produces hormones to maintain pregnancy. It develops by the third month of gestation, and is also called the afterbirth.

A&P Review: Menstrual cycle

The regularly recurring physiological changes in the endometrium that culminate in its shedding; may vary in duration, with average of approximately 28 days; ovarian and uterine changes occur.

Define: lochia

Vaginal discharge from the uterus that consists of blood from the vessels of the placental site, tissue debris from the decidua, and mucus. Lochia lasts for 2 to 6 weeks postpartum, and is differentiated by color: rubra, serosa, or alba.

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student states: 1. "I will flush the eyes after instilling the ointment." 2. "I will cleanse the neonate's eyes before instilling theointment." 3. "The administration of the eye ointment is within 1 hour after delivery." 4. "I will instill the eye ointment into each of the neonate's conjunctival sacs."

1. "I will flush the eyes after instilling the ointment." Rationale: Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after the instillation of the medication, because the flush will wash away the administered medication. Options 2, 3, and 4 are correct statements regarding the procedure for administering eye medication to the neonate. Test-Taking Strategy: Use the process of elimination, and note the strategic words "needs to research." These words indicate a negative event query and ask you to select an option that is an incorrect statement. Visualize the effect of each statement. This will direct you to option 1. Review the procedure for administering eye medication to the neonate if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Newborn References: Kee, Hayes, McCuistion, p. 439. 2009. Lehne, p. 1136. 2010.

The nursing instructor asks a nursing student to describe the process of quickening. Which of the following statements, if made by the student, indicates an understanding of this term? 1. "It is the fetal movement that is felt by the mother." 2. "It is the compressibility of the lower uterine segment." 3. "It is the irregular, painless contractions that occur throughout pregnancy." 4. "It is the soft blowing sound that can be heard when the uterus is auscultated."

1. "It is the fetal movement that is felt by the mother." Rationale: Quickening is fetal movement that appears usually at week 16 to 20, when the expectant mother first notices subtle fetal movements that gradually increase in intensity. A compressibility of the lower uterine segment occurs at about 6 weeks' gestation and is called Hegar's sign. Braxton Hicks contractions are irregular, painless contractions that may occur throughout pregnancy. A soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus; this is known as uterine souffle. This sound is the result of blood circulation to the placenta, and it corresponds with the maternal pulse. Test-Taking Strategy: Use the process of elimination and your knowledge regarding the term quickening to answer this question. Review quickening if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/ Antepartum Reference: Leifer, p. 49. 2011.

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn infant. The nurse is monitoring for signs of placental separation, knowing that which of the following indicates that the placenta has separated? 1. A change in the uterine contour 2. Sudden and sharp abdominal pain 3. A shortening of the umbilical cord 4. A decrease in blood loss from the introitus

1. A change in the uterine contour Rationale: Signs of placental separation include the lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to a globular shape. The client may experience vaginal fullness but not sudden and sharp abdominal pain. Test-Taking Strategy: Use the process of elimination. Thinking about what one would expect to occur when the placenta separates will assist you to eliminate options 3 and 4. Option 2 is eliminated because of the words "sudden and sharp." Review the signs of placental separation if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Intrapartum Reference: Leifer, p. 146. 2011.

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, it is most important for the nurse to first determine which of the following? 1. Baseline fetal heart rate 2. Intensity of contractions 3. Maternal blood pressure 4. Frequency of contractions

1. Baseline fetal heart rate Rationale: The nurse should first determine the baseline fetal heart rate. Although options 2, 3, and 4 are components of the data collection process, the fetal heart rate is the priority. Test-Taking Strategy: Note the strategic word "first." Use the ABCs— airway, breathing, and circulation— when selecting an answer. Fetal heart rate reflects the use of the ABCs. Review the care of the client in labor if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Intrapartum References: Christensen, Kockrow, p. 819. 2011. Foundations of nursing. Leifer, 2011. pp. 132- 133, 140.

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught to: 1. Begin with the eyes and face. 2. Start with the dirtiest area first. 3. Begin with the feet and work upward. 4. Only wash the diaper area, because this is the only part of the baby that gets soiled.

1. Begin with the eyes and face. Rationale: Bathing should start at the eyes and face, which are usually the cleanest areas. Next, the external ears and behind the ears are cleansed. The newborn's neck should be washed, because formula, breast milk, or lint will often accumulate in the folds of the neck. The hands and arms are then washed. The baby's legs are washed, with the diaper area being washed last. Test-Taking Strategy: Use the basic techniques of bathing a client to answer the question. Remember, when bathing an adult or a baby, start with the cleanest part of the body and proceed to the dirtiest part. Options 2, 3, and 4 are incorrect. Review the techniques for bathing a newborn if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Newborn References: Christensen, Kockrow, p. 965. 2011. Foundations of nursing. Leifer, p. 296. 2011.

Preterm newborns are at risk for developing respiratory distress syndrome (RDS). The nurse monitors for the clinical signs associated with RDS, knowing that these signs include: 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. The presence of a barrel chest with acrocyanosis

1. Tachypnea and retractions Rationale: The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is a bluish discoloration of the hands and feet that is associated with immature peripheral circulation, and it is not uncommon during the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of RDS. Test-Taking Strategy: Use the process of elimination. Recalling that acrocyanosis may be a normal sign in a newborn infant will assist you with eliminating options 2 and 4. From the remaining options, it is necessary to be familiar with the signs of RDS. In addition, note the relationship between the diagnosis and the signs noted in option 1. Review the signs of RDS if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Newborn References: Christensen, Kockrow, p. 917. 2011. Foundations of nursing. Leifer, pp. 307-308. 2011.

The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. The nurse instructs the client: 1. That the bladder must be full during the exam 2. That the bladder must be empty during the exam 3. She will be given RhoGAM because she is Rh positive 4. Not to eat or drink anything 4 to 6 hours before the exam

1. That the bladder must be full during the exam Rationale: Before 20 weeks' gestation, the bladder must be kept full during amniocentesis to support the weight of the uterus. After 20 weeks' gestation, the bladder should be emptied to minimize the chance of puncturing the placenta or fetus. Rh0 (D) immune globulin (RhoGAM) is administered to Rh-negative woman because of the risk of contact with the fetal blood during the exam. There are no fluid or food restrictions. Monitoring the fetal heart tones and the vital signs throughout and after the exam is an important intervention. Test-Taking Strategy: Focus on the strategic words "16 weeks' gestation." Remember that before 20 weeks' gestation, the bladder must be kept full to support the weight of the uterus. Review client instructions for amniocentesis if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Antepartum References: Leifer, p. 81. 2011. Pagana, Pagana, p. 51. 2009. Mosby's diagnostic and laboratory test reference.

The perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse would consult with the dietitian to ensure which of the following? 1. A low-calorie diet to ensure the absence of weight gain 2. A diet that is high in fluids and fiber to decrease constipation 3. A diet that is low in fluids and fiber to decrease blood volume 4. Unlimited sodium intake to increase the circulating blood volume

2. A diet that is high in fluids and fiber to decrease constipation Rationale: Constipation causes the client to use Valsalva's maneuver. This causes blood to rush to the heart and overload the cardiac system. The absence of weight gain is not recommended during pregnancy. Diets that are low in fluid and fiber cause a decrease in blood volume, which in turn deprives the fetus of nutrients. Too much sodium could cause an overload to the circulating blood volume and contribute to the cardiac condition. Test-Taking Strategy: Use the process of elimination, and try to relate the situation to something with which you are familiar. Look for options that would apply to any heart condition, think about the needs of a pregnant client, and use the process of elimination. Review dietary measures for the client with cardiac disease if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Planning Content Area: Maternity/ Antepartum Reference: Leifer, pp. 65, 101- 102. 2011.

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that a routine labor procedure that is contraindicated with this client's situation is: 1. Leopold's maneuvers 2. A manual pelvic examination 3. Hemoglobin and hematocrit evaluation 4. External electronic fetal heart rate monitoring

2. A manual pelvic examination Rationale: Painless vaginal bleeding is a sign of possible placenta previa. Digital examination of the cervix is contraindicated because it can lead to maternal and fetal hemorrhage. Leopold's maneuvers can reveal a nonengaged presenting part or malpresentation, both of which often accompany placenta previa because of the placenta filling the lower uterine segment. Hemoglobin and hematocrit values help estimate the amount of blood loss. External electronic fetal monitoring is crucial for evaluating the status of the fetus, which is at risk for severe hypoxia. Options 1, 3, and 4 are procedures that would not place the client at further risk. Test-Taking Strategy: Use the process of elimination, and note the strategic word "contraindicated." Option 2 is the only procedure that is invasive to the pregnancy and that endangers the physiological safety of the client and fetus. Review the care of the client with placenta previa if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Intrapartum Reference: Leifer, pp. 88- 90. 2011.

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for infection. The nurse tells the mother that which of the following is a sign of infection? 1. A darkened drying stump 2. A moist cord with discharge 3. A purple stump that shows pinkness around the base 4. A purple stump that shows some moistness at the base

2. A moist cord with discharge Rationale: Signs of infection of the umbilical cord are moistness, oozing, discharge, and a reddened base. If signs of infection occur, the health care provider is notified. Antibiotic treatment may be necessary. Test-Taking Strategy: Use the process of elimination. Options 1 and 3 identify normal signs and are eliminated first. From the remaining options, noting the word "discharge" in option 2 will direct you to this option. Review the signs and symptoms of infection if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Newborn Reference: Leifer, pp. 218-219. 2011.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn infant after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which of the following additional signs would be consistent with FAS? 1. A length of 19 inches 2. Abnormal palmar creases 3. A birth weight of 6 pounds and 14 ounces 4. A head circumference that is appropriate for gestational age

2. Abnormal palmar creases Rationale: Features of newborn infants who are diagnosed with FAS include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal findings in the full-term newborn infant. Test-Taking Strategy: Use the process of elimination and your knowledge regarding the normal findings in the full-term newborn infant to answer this question. Note that options 1, 3, and 4 are comparable or alike and that they represent normal findings. Review the content related to normal newborn infant findings and FAS if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Newborn Reference: Leifer, p. 109. 2011.

After delivery, the nurse checks the height of the uterine fundus. The nurse expects that the position of the fundus would most likely be noted: 1. To the right of the abdomen 2. At the level of the umbilicus 3. About 4 cm above the level of the umbilicus 4. One fingerbreadth above the symphysis pubis

2. At the level of the umbilicus Rationale: After delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. If the fundus is 4 cm above the umbilicus, this may indicate that there are blood clots in the uterus that need to be expelled by fundal massage. If the fundus is noted to the right of the abdomen, it may indicate a full bladder. By about 10 days postpartum, the uterus will be in the symphysis pubis area. Test-Taking Strategy: Note the strategic words "after delivery" and visualize the process of involution.Remember that after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. Review expected postdelivery findings if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Leifer, p. 201. 2011.

The nurse is caring for a post term neonate immediately after admission to the nursery. The priority nursing action would be to monitor: 1. Urinary output 2. Blood glucose levels 3. Total bilirubin levels 4. Hemoglobin and hematocrit level

2. Blood glucose levels Rationale: The most common metabolic complication in the postterm newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if it is not corrected immediately. Urinary output, although important, is not the highest priority action. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery. Hemoglobin and hematocrit levels are monitored, because the postterm neonate may exhibit polycythemia; however, this also does not require immediate attention. Test-Taking Strategy: Use the process of elimination, and note the strategic word "priority." Recalling that hypoglycemia is a primary concern in the postterm newborn will direct you to the correct option. Review the care of the postterm newborn if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Newborn Reference: Leifer, p. 318. 2011.

Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the priority nursing action is to check the: 1. Uterine tone 2. Blood pressure 3. Amount of lochia 4. Deep tendon reflexes

2. Blood pressure Rationale: Methylergonovine, which is an ergot alkaloid, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority before the administration of the medication is to check the blood pressure. The health care provider should be notified if hypertension is present. Although options 1, 3, and 4 may be components of the postpartum data collection procedures, option 2 is related specifically to the administration of this medication. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 first, because they are comparable or alike and related to one another. From the remaining options, use the ABCs—airway, breathing, and circulation. Obtaining the blood pressure is a method of checking circulation. Review the adverse effects of methylergonovine if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Hodgson, Kizior, p. 744. 2011.

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. The nurse determines that additional guidance is needed if the woman states that she will: 1. Be sure to wash her hands before feeding the newborn. 2. Breast-feed, especially for the first 6 weeks postpartum. 3. Be sure to wash her hands before and after bathroom use. 4. Administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery.

2. Breast-feed, especially for the first 6 weeks postpartum. Rationale: The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum periods. HIV transmission can occur during breast-feeding; thus, HIV-positive clients need to bottle-feed their neonates. Antiviral medications will be prescribed for the neonate for the first 6 weeks of life. The principles related to handwashing need to be taught to the mother. Test-Taking Strategy: Use the process of elimination, and note the strategic words "additional guidance is needed." These words indicate a negative event query and ask you to select an option that is an incorrect statement. Options 1 and 3 can be eliminated first, because they are comparable or alike. From the remaining options, recalling the modes of transmission of HIV from the mother to the newborn will direct you to option 2. Review these modes of HIV transmission if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Fundamental Skills: Safety/Infection Control Reference: Leifer, p. 222. 2011.

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse's first action should be to: 1. Administer oxygen by face mask. 2. Clear and maintain an open airway. 3.Check the blood pressure and the fetal heart tones. 4. Prepare for the administration of intravenous magnesium sulfate.

2. Clear and maintain an open airway. Rationale: The first actions are to maintain an open airway and to prevent injuries to the client. The client should be turned to the side and monitored for airway compromise. Options 1, 3, and 4 may be components of care, but they are not the first actions. Test-Taking Strategy: Note the strategic word "first." Use the ABCs— airway, breathing, and circulation— to answer this question. Airway is the first priority. Review the care of the client with eclampsia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Critical Care Reference: Perry, Hockenberry, Lowdermilk, Wilson, pp. 346-347. 2010.

After birth, the nurse prevents hypothermia as a result of evaporation in the newborn by: 1. Warming the crib pad 2. Closing the doors of the room 3. Drying the baby with a warm blanket 4. Turning on the overhead radiant warmer

2. Closing the doors of the room 3. Drying the baby with a warm blanket Rationale: Evaporation occurs when moisture from the newborn's wet body surface dissipates heat along with moisture. By keeping the newborn dry (and by drying the wet newborn at birth), evaporation is prevented. Conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface. Test-Taking Strategy: Recalling the methods of preventing heat loss in a newborn and focusing on the subject of evaporation will direct you to the correct option. Review the methods of heat loss if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Newborn Reference: Leifer, pp. 150, 215. 2011.

The nurse in the newborn nursery receives a telephone call to prepare for the admission of an infant born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for thead mission of this infant, the nurse's highest priority should beto: 1. Turn on the apnea and cardiorespiratory monitor. 2. Connect the resuscitation bag to the oxygen outlet. 3. Set up the intravenous line with 5% dextrose in water. 4. Set the radiant warmer control temperature at 36.5° C(97.6° F).

2. Connect the resuscitation bag to the oxygen outlet. Rationale: The highest priority during the admission to the nursery of a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they are of lower initial priority. The newborn infant will be placed on a cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support and may be prescribed. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress. Test-Taking Strategy: Use the process of elimination, and note the strategic words "highest priority." This question asks you to prioritize care on the basis of information about a newborn infant's condition. Use the ABCs— airway, breathing, and circulation. A method of planning for airway support is to have the resuscitation bag connected to an oxygen source. Review the care of the newborn infant with low Apgar scores if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Critical Care Reference: Perry, Hockenberry, Lowdermilk, Wilson, pp. 644, 647. 2010.

The nurse is providing instructions to a pregnant client with heartburn regarding measures that will alleviate the discomfort. The nurse instructs the client to: 1. Eliminate between-meal snacks. 2. Drink decaffeinated coffee and tea. 3. Lie down for 30 minutes after eating. 4. Substitute salt in cooking for other spices.

2. Drink decaffeinated coffee and tea. Rationale: Spices tend to trigger heartburn. Caffeine, like spices, may cause heartburn and needs to be avoided. Eating smaller, more frequent portions is preferable to eating three large meals to control heartburn. Lying down after meals is likely to lead to the reflux of stomach contents and cause heartburn. Salt leads to the retention of fluid.. Test-Taking Strategy: Use the process of elimination, focus on the subject, and recall those items that cause heartburn. This will direct you to option 2. Review the measures that alleviate heartburn if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/ Antepartum Reference: Leifer, p. 66. 2011.

The nurse is collecting data during the admission assessment of a client who is pregnant with twins. client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as: 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1

2. G = 2, T = 1, P = 0, A = 0, L = 1 Rationale: Pregnancy outcomes can be described with the GTPAL acronym: G = gravidity (number of pregnancies); T = term births (number born after 37 weeks); P = preterm births (number born before 37 weeks' gestation); A = abortions/ miscarriages (number of abortions/ miscarriages); L = live births (number of live births or living children). Therefore, a woman who is pregnant with twins and who already has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 0, and the number of term births is 1. The number of abortions is 0, and the number of live births is 1. Test-Taking Strategy: Specific knowledge about GTPAL is needed to answer this question. Your knowledge and understanding will direct you to option 2. Review the GTPAL method of describing pregnancy outcomes if you had difficulty answering this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Antepartum References: Leifer, pp. 47- 48. 2011. McKinney, James, Murray, Ashwill, pp. 262- 263. 2009.

The nurse is collecting data during the admission assessment of a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse would document which gravida and para status on this client? 1. Gravida I, para I 2. Gravida II, para I 3. Gravida II, para II 4. Gravida III, para II

2. Gravida II, para I Rationale: Gravida is a term that refers to a woman who is or who has been pregnant, regardless of the duration of the pregnancy. Parity is a term that means the number of births after 20 weeks' gestation; it does not reflect the number of fetuses or infants. Options 1, 3, and 4 are incorrect on the basis of these definitions. Test-Taking Strategy: Knowledge of the terms gravida and parity is necessary to answer this question correctly. Remember that gravida refers to a woman who is or has been pregnant, regardless of the duration of the pregnancy. Parity means the number of births past 20 weeks' gestation. Review the definitions of these terms if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Antepartum Reference: Leifer, pp. 47- 48. 2011.

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. A priority nursing action is to: 1. Prepare for an oxytocin infusion. 2. Keep the client in a side-lying position. 3. Prepare the client for epidural anesthesia. 4. Encourage the client to start pushing with the contractions.

2. Keep the client in a side-lying position. Rationale: Precipitous labor progresses quickly, with frequent contractions and short periods of relaxation between them. This does not allow for the maximal reperfusion of the placenta with oxygenated blood. Priority care of this client includes the promotion of fetal oxygenation. A side-lying position can assist with providing blood flow to the uterus by preventing vena cava and abdominal aorta compression. Further stimulation with oxytocin is contraindicated. There may not be enough time to administer epidural anesthesia before delivery with such quick progression. Pushing with contractions is not indicated, especially with this type of labor. The controlled delivery of the fetus is essential to prevent maternal and fetal injury. Test-Taking Strategy: Note the strategic words "precipitous" and "priority." Use the ABCs— airway, breathing, and circulation— and consider the baby's as well as the mother's needs. Option 2 will promote fetal oxygenation. Review the care of the client with precipitous labor if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Intrapartum Reference: Leifer, pp. 53, 137. 2011.

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position? 1. Squatting 2. Left lateral 3. Tailor sitting 4. Semi-Fowler's

2. Left lateral Rationale: Pressure from the enlarged uterus on the aorta and the vena cava when the woman is supine can result in hypotension. This can be relieved by having the woman lie on her left side. Options 1, 3, and 4 are incorrect because they would not prevent hypotension. Test-Taking Strategy: Use the process of elimination and your knowledge of the anatomy of the pregnant uterus and the physiological response caused by pressure on the large abdominal vessels. Note that options 1, 3, and 4 are all comparable or alike in that the client would be upright. Review nursing measures for the hypotensive pregnant client if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Intrapartum Reference: Leifer, p. 53. 2011.

The nurse is assigned to assist with caring for a neonate born to a mother with acquired immunodeficiency syndrome(AIDS). The nurse understands that which of the following should be included in the plan of care? 1. Monitor the neonate's vital signs routinely. 2. Maintain standard precautions at all times while caring for the neonate. 3. Instruct breast-feeding mothers regarding the treatment of their nipples with an antifungal cream. 4. Initiate a referral to evaluate for blindness, deafness, learning, or behavioral problems in the neonate.

2. Maintain standard precautions at all times while caring for the neonate. Rationale: The neonate born to a mother with AIDS must be cared for with strict attention to standard precautions. This prevents the transmission of the infection from the neonate, if he or she is infected, to others, and it prevents the transmission of other infectious agents to the possibly immunocompromised neonate. A mother with AIDS should not breast-feed. Options 1 and 4 are not specifically associated with the care of a potentially AIDS-infected neonate. Test-Taking Strategy: Use the process of elimination and your knowledge regarding the care of a neonate infant born to a woman with AIDS. Eliminate options 1 and 4 first, because they are not specifically associated with the care of a potentially infected neonate. Recalling that AIDS-infected mothers should not breast-feed will direct you to option 2. Review the care of a neonate born to a woman with AIDS if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Newborn References: Christensen, Kockrow, pp. 903-904. 2011. Foundations of nursing. Leifer, pp. 733, 771. 2011.

A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings, the priority nursing intervention is to: 1. Monitor the maternal vital signs. 2. Notify the registered nurse (RN) immediately. 3. Continue monitoring labor and the fetal heart rate. 4. Encourage relaxation and breathing techniques between contractions.

2. Notify the registered nurse (RN) immediately. Rationale: Fetal bradycardia between contractions may indicate the need for immediate medical management. The nurse would immediately contact the RN, who would then contact the health care provider. Options 1, 3, and 4 will delay necessary and immediate interventions. Test-Taking Strategy: Use the ABCs— airway, breathing, and circulation. Note that the woman is in active labor and the fetal heart rate is below normal. It is imperative that the circulation in the fetus be restored to normal limits. Review the care of the client in active labor if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Intrapartum References: Christensen, Kockrow, p. 822. 2011. Foundations of nursing. Leifer. p. 133. 2011. McKinney, James, Murray, Ashwill, p. 398. 2009.

A neonate has just been circumcised. The nurse would expect the surgical site to appear: 1. Pink, without drainage 2. Reddened, with a small amount of bloody drainage 3. Reddened, with a small amount of yellow exudate on theglans 4. Reddened, with a large amount of bloody drainage that requires a dressing change every 30 minutes

2. Reddened, with a small amount of bloody drainage Rationale: The glans penis is normally dark red. After circumcision, a small amount of bloody drainage is expected. During the normal healing process, the glans becomes covered with a yellow exudate. If excessive bleeding is noted from the circumcision, the nurse applies gentle pressure to the site of bleeding with a sterile gauze pad. If the bleeding is not controlled, the health care provider is notified, because a blood vessel may need to be ligated. Test-Taking Strategy: Use the process of elimination, and focus on the subject of the expected appearance. Remember that a small amount of bloody drainage is expected. Review the expected findings after circumcision if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Newborn References: Christensen, Kockrow, pp. 850, 875-876. 2011. Foundations of nursing. Leifer, pp. 290-292. 2011.

A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium sulfate therapy is effective if: 1. Scotomas are present. 2. Seizures do not occur. 3. Ankle clonus is noted. 4. The blood pressure decreases.

2. Seizures do not occur. Rationale: For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Magnesium sulfate is an anticonvulsant rather than an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Scotomas are areas of complete or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure. Ankle clonus indicates hyperreflexia and may precede the onset of eclampsia. Test-Taking Strategy: Use the process of elimination. Knowing that magnesium sulfate is an anticonvulsant will direct you to option 2. Review the actions and uses of magnesium sulfate if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Intrapartum References: Hodgson, Kizior, p. 709. 2011. Leifer, p. 94. 2011.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. The nurse would do which of the following to help the woman process what has happened? 1. Encourage the mother to breast-feed soon after birth. 2. Support the mother in her reaction to the newborn infant. 3. Tell the mother that it is important to hold the newborn infant. 4. Document a complete account of the mother's reaction in the birth record.

2. Support the mother in her reaction to the newborn infant. Rationale: Women who have experienced precipitous labor and delivery often describe feelings of disbelief that their labor has progressed so rapidly. To assist the woman with understanding what has happened, it is best to support the mother in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the mother's feelings. Test-Taking Strategy: Use therapeutic communication techniques. Option 2 is the only choice that acknowledges the mother's feelings. Review the care of the mother after a precipitous birth if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Maternity/ Intrapartum Reference: Christensen, Kockrow, pp. 834- 836. 2011. Foundations of nursing.

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placenta is accompanied by which additional finding? 1. Soft abdomen on palpation 2. Uterine tenderness on palpation 3. No complaints of abdominal pain 4. Lack of uterine irritability or tetanic contractions

2. Uterine tenderness on palpation Rationale: Vaginal bleeding in a pregnant client is most often caused by placenta previa or a placental abruption. Uterine tenderness accompanies abruptio placentae, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A sustained tetanic contraction can occur if the client is in labor and the uterine muscle cannot relax. Test-Taking Strategy: Note the subject of the question, abruptio placentae. It can be easy to confuse a placenta previa and abruption. Remember, the difference involves the presence of uterine pain and tenderness with an abruptio placenta as opposed to painless bleeding with a placenta previa. Options 1, 3, and 4 describe the absence of a sign or symptom of abruptio placentae, whereas option 2 is the only one that describes the presence of one. Review the signs of abruptio placentae if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Intrapartum References: Christensen, Kockrow, pp. 892- 893. 2011. Foundations of nursing. Leifer. p. 90. 2011.

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. The nurse responds to the client, knowing that the fallopian tubes: 1. Are the organ of copulation 2. Are where the fetus develops 3. Are where fertilization occurs 4. Secrete estrogen and progesterone

3. Are where fertilization occurs Rationale: Each fallopian tube is a hollow muscular tube that transports a mature oocyte for final maturation and fertilization. Fertilization typically occurs near the boundary between the ampulla and the isthmus of the tube. The vagina is the organ of copulation, and the fetus develops in the uterus. Estrogen is a hormone that is produced by the ovarian follicles, the corpus luteum, the adrenal cortex, and the placenta during pregnancy. Progesterone is a hormone that is secreted by the corpus luteum of the ovary, the adrenal glands, and the placenta during pregnancy. Test-Taking Strategy: Recalling the anatomy and physiology of the female reproductive system will direct you to the correct option. Remember that fertilization occurs in the fallopian tube. Review the female reproductive system if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Antepartum Reference: Leifer, p. 25. 2011.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and tells the partner to: 1. Dorsiflex the client's foot while flexing the knee. 2. Plantarflex the client's foot while flexing the knee. 3. Dorsiflex the client's foot while extending the knee. 4. Plantarflex the client's foot while extending the knee.

3. Dorsiflex the client's foot while extending the knee. Rationale: Leg cramps often occur when the pregnant woman stretches her leg and plantarflexes her foot. Dorsiflexion of the foot while extending the knee stretches the gastrocnemius muscle, prevents the muscle from contracting, and halts the cramping. Therefore, the remaining options are incorrect. Test-Taking Strategy: Use the process of elimination. Knowledge regarding the actions that will alleviate muscle cramps will assist you with answering the question. Visualize each of the descriptions in the options to help direct you to the correct option. Review the measures to alleviate muscle cramps if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/ Antepartum Reference: Leifer, p. 66. 2011.

Epidural analgesia is administered to a woman for pain relief after a cesarean birth. The nurse assigned to care for the woman ensures that which medication is readily available ifr espiratory depression occurs? 1. Betamethasone 2. Morphine sulfate 3. Naloxone (Narcan) 4. Meperidine hydrochloride (Demerol)

3. Naloxone (Narcan) Rationale: Opioids are used for epidural analgesia. An adverse effect of epidural analgesia is a delayed respiratory depression. Naloxone (Narcan) is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Morphine sulfate and meperidine hydrochloride are opioid analgesics. Betamethasone is a corticosteroid that is administered to enhance fetal lung maturity. Test-Taking Strategy: Use the process of elimination, and focus on the subject of the question: the antidote for respiratory depression. Eliminate options 2 and 4 first, knowing that these medications are opioid analgesics. Next, eliminate option 1, knowing that this medication is a corticosteroid. Review the purposes and actions of these medications if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Hodgson, Kizior, pp. 802-803. 2011.

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client states: 1. "I know I can never have another child." 2. "I am glad I won't have to have these shots if I have another child." 3. "I will have to have an injection once a month until the baby is born." 4. "I will tell the nurse at the hospital that I had RhoGAM during pregnancy."

4. "I will tell the nurse at the hospital that I had RhoGAM during pregnancy." Rationale: As described in the question, it is accepted practice to administer Rh0 (D) immune globulin (RhoGAM) to an Rh-negative woman at 28 weeks' gestation, with a second injection within 72 hours of delivery. This prevents sensitization, which could jeopardize a future pregnancy. For subsequent pregnancies or abortions, the injections must be repeated, because the immunity is passive. Options 1, 2, and 3 are inaccurate information. Test-Taking Strategy: Note the strategic words "that the client understands." Recalling the guidelines regarding the administration of RhoGAM will direct you to the correct option. Review Rh sensitization if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Evaluation Content Area: Maternity/ Antepartum References: Christensen, Kockrow, pp. 855- 856. 2011. Foundations of nursing. Leifer, p. 81. 2011.

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which of the following information to theclient? 1. "You will be isolated from your newborn after delivery." 2. "There is little risk to your baby during your pregnancy, birth, and after delivery." 3. "Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at birth." 4. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

4. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed." Rationale: If herpetic genital lesions are present at the time of delivery, a cesarean delivery will be necessary to reduce the risk of infecting the neonate. In the absence of herpetic genital lesions, a vaginal delivery may be indicated, unless there are other reasons for performing a cesarean delivery. Maternal isolation is not necessary, but potentially exposed neonates should be cultured on the day of delivery. Test-Taking Strategy: Use the process of elimination. Focusing on the subject of a positive history of genital herpes and recalling the risks to the neonate will direct you to the correct option. Review the methods of transmission of genital herpes to the neonate if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills: Safety/Infection Control Reference: Perry, Hockenberry, Lowdermilk, Wilson, p. 106. 2010.

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between: 1. 6 and 8 weeks' gestation 2. 8 and 10 weeks' gestation 3. 10 and 12 weeks' gestation 4. 16 and 20 weeks' gestation

4. 16 and 20 weeks' gestation Rationale: Quickening is fetal movement that usually first occurs between 16 and 20 weeks' gestation. The expectant mother first notices subtle fetal movements during this time, and these gradually increase in intensity. Options 1, 2, and 3 are incorrect; these gestational time frames are too early for quickening. Test-Taking Strategy: Use the process of elimination and your knowledge regarding the occurrence of quickening. In this situation, it is best to select the option that indicates the greatest length of gestational time. Review the process of quickening if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/ Antepartum Reference: Christensen, Kockrow, p. 786. 2011. Foundations of nursing.

The nurse suspects that the client has a pulmonary embolism. The most important nursing action is to: 1. Monitor the vital signs. 2. Elevate the head of the bed. 3. Increase the intravenous flow rate. 4. Administer oxygen by face mask, as prescribed.

4. Administer oxygen by face mask, as prescribed. Rationale: Because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration. Options 1 and 2 may be components of the plan of care, but they are not the most important actions. The nurse would not increase the intravenous rate without a prescription from the health care provider to do so. Test-Taking Strategy: Note the strategic words "most important," and use the ABCs—airway, breathing, and circulation. This will direct you to the correct option - oxygen is the priority. Review the care of the client in the event of a pulmonary embolism if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care References: McKinney, James, Murray, Ashwill, p. 705. 2009. Swearingen, p. 127. 2012.

Rh0(D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a newborn infant, and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following? 1. Having Rh-positive blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility

4. Being affected by Rh incompatibility Rationale: Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rhnegative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the baby's Rh-positive blood can enter the maternal circulation, thus causing the woman's immune system to form antibodies against the Rh-positive blood. The administration of Rh0(D) immune globulin prevents the woman from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen. Test-Taking Strategy: Use the process of elimination. Options 2 and 3 can be eliminated first. From the remaining options, note the relationship between the name of the medication, Rh0(D) immune globulin, and the word "incompatibility" in the correct option. Review the purpose of Rh0(D) immune globulin if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Postpartum References: Hodgson, Kizior, pp. 1007-1008. 2011. Kee, Hayes, McCuistion, p. 867. 2009.

The nurse is collecting data from a client who has been diagnosed with placenta previa. Choose the findings that the nurse would expect to note. Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus

4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus Rationale: Painless bright red vaginal bleeding during the second or third trimester of pregnancy is a sign of placenta previa. The client will have a soft and relaxed nontender uterus. In clients with abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. Additionally, with abruptio placentae, the abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. Test-Taking Strategy: Remember that the difference between placenta previa and abruptio placentae involves the presence of uterine pain and tenderness with an abruption as opposed to painless bleeding with a previa. Review the signs of placenta previa and abruptio placentae if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Intrapartum Reference: Leifer, pp. 89- 90. 2011.

While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of: 1. A full bladder 2. Emotional instability 3. Insufficient iron intake 4. Compression of the vena cava

4. Compression of the vena cava Rationale: Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome during pregnancy. Having the woman turn onto her left side or elevating the right buttock during fundal height measurement will prevent or correct the problem. Options 1, 2, and 3 are not the cause of the problem described in the question. Test-Taking Strategy: Focus on the data in the question, and recall the complications associated with pregnancy. Use the ABCs—airway, breathing, and circulation— to direct you to the correct option. Review the interventions for supine hypotension syndrome 13543-13553 if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Antepartum Reference: Leifer, p. 53. 2011.

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, the nurse would initially: 1. Estimate the fetal size. 2. Check pelvic adequacy. 3. Administer an analgesic. 4. Determine the maternal and fetal vital signs.

4. Determine the maternal and fetal vital signs.Rationale: To evaluate a woman's physical well-being, her temperature, pulse, respirations, and blood pressure (as well as the fetal heartbeat) are checked. Option 3 is incorrect, because it would be too premature for an analgesic; medication given too early tends to slow or stop labor contractions. Options 1 and 2 are incorrect. These assessments should be performed by the health care provider during prenatal visits. Test-Taking Strategy: Note the strategic word "initially," and use the ABCs— airway, breathing, and circulation; this will direct you to the correct option. Remember, measuring the vital signs is the priority. Review the care of the client in labor if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Intrapartum Reference: McKinney, James, Murray, Ashwill, pp. 355, 361. 2009.

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which of the following would indicate an abnormal physical finding that necessitates further testing? 1. Quickening 2. Braxton Hicks contractions 3. Consistent increase in fundal height 4. Fetal heart rate of 180 beats per minute

4. Fetal heart rate of 180 beats per minute Rationale: The fetal heart rate depends on the gestational age. It is 160 to 170 beats per minute during the first trimester, and it slows with fetal growth to approximately 120 to 160 beats per minute. Options 1, 2, and 3 are normal expected findings. Test-Taking Strategy: Note the strategic words "indicate an abnormal physical finding." Recalling the normal fetal heart rate will direct you to the correct option. Review the normal assessment findings of pregnancy if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Antepartum Reference: Christensen, Kockrow, p. 822. 2011. Foundations of nursing.

The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which of the following purposes of estrogen? 1. It maintains the uterine lining for implantation. 2. It stimulates the metabolism of glucose, and converts glucose to fat. 3. It prevents the involution of the corpus luteum, and maintains the production of progesterone until the placenta is formed. 4. It stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation.

4. It stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation. Rationale: Estrogen stimulates uterine development to provide an environment for the fetus, and it stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat. Human chorionic gonadotropin prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. Test-Taking Strategy: Recalling the functions of various hormones related to pregnancy will direct you to the correct option. Remember that estrogen stimulates uterine development to provide an environment for the fetus and that it stimulates the breasts to prepare for lactation. Review these various hormones if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/ Antepartum Reference: Leifer, p. 39. 2011.

The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse recommends which measure to help relieve both discomforts? 1. Lie on the left side with the feet dorsiflexed. 2. Soak the feet in hot water after performing 10 pelvic tilt exercises. 3. Lie on the right side with the feet elevated on a pillow and a heating pad on the back. 4. Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

4. Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle. Rationale: The position described in option 4 will produce the posture of the pelvic tilt while countering gravity as the force that leads to the edema of the lower extremities. Although the other options may seem useful, options 2 and 3 identify heat, which should be prescribed by the health care provider (HCP). Option 1 will not relieve back pain and ankle edema. Test-Taking Strategy: Use the process of elimination. Focus on the subject of the question, back pain and ankle edema. Eliminate options 2 and 3, because the application of heat needs to be prescribed by the HCP. From the remaining options, focus on the subject to direct you to the correct option. Review the measures that will reduce these discomforts if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Implementation Content Area: Maternity/ Antepartum Reference: Leifer, p. 65. 2011.

A mother is breast-feeding her newborn baby and experiences breast engorgement. The nurse encourages the mother to do which of the following to provide relief of the engorgement? 1. Breast-feed only during the daytime hours. 2. Apply cold compresses to the breast before feeding. 3. Avoid the use of a bra while the breasts are engorged. 4. Massage the breasts before feeding to stimulate let-down.

4. Massage the breasts before feeding to stimulate let-down. Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down, wearing a supportive and wellfitting bra at all times, taking a warm shower or applying warm compresses just before feeding, and alternating breasts during feeding. Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate option 1 because of the closed-ended word "only." From the remaining options, recalling the self-care measures that promote the comfort of the mother with breast engorgement will direct you to the correct option. Review these measures if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum References: Leifer, pp. 227-228. 2011. Perry, Hockenberry, Lowdermilk, Wilson, pp. 696-697. 2010.

The nurse is preparing to care for a newborn who is receiving phototherapy. Choose the measures that would be implemented. Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake.3. Expose all of the newborn's skin. 4. Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches.

4. Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches. Rationale: Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Injury from treatment (e.g., eye damage, dehydration, sensory deprivation) can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with shields or patches to ensure that the eyelids are closed. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow for eye contact. The nurse measures the quantity of light every 8 hours, monitors the skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours, and he or she is monitored for bronze baby syndrome, which is a grayish-brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia, because rebound elevations are normal after therapy is discontinued. Test-Taking Strategy: Focus on the subject of phototherapy. Recalling that injury from treatment and sensory deprivation can occur will assist you with determining the correct interventions. Review the interventions for the newborn who is receiving phototherapy if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Newborn Reference: Leifer, pp. 341-342. 2011.

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). The appropriate nursing action would be to: 1. Apply cool packs to the abdomen. 2. Continue to monitor the temperature. 3. Remove the blanket from the client's bed. 4. Notify the registered nurse, who will then contact the health care provider (HCP).

4. Notify the registered nurse, who will then contact the health care provider (HCP). Rationale: During the first 24 hours postpartum, the mother's temperature may be elevated as a result of dehydration. However, if the temperature is more than 2° F above normal, this may indicate infection, and the HCP will need to be notified. Applying cool packs to the abdomen is an inappropriate action and additionally, this action requires a prescription. The remaining options may be a component of care but are not the most appropriate based on the data in the question. Test-Taking Strategy: Use the process of elimination. Focus on the strategic words "4 hours" and "102° F." Noting that this temperature is extreme as compared with the normal temperature will direct you to option 4. Review the expected postpartum findings if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, p. 232. 2011.

Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, a nurse contacts the health care provider who prescribed the medication if which of the following conditions is documented in the client's medical history? 1. Hypotension 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease

4. Peripheral vascular disease Rationale: Methylergonovine is an ergot alkaloid that is used to treat postpartum hemorrhage. Ergot alkaloids are avoided in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, eclampsia, or preeclampsia, because these conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options 1, 2, and 3 are not contraindications related to the use of ergot alkaloids. Test-Taking Strategy: Use the process of elimination. Recalling that ergot alkaloids produce vasoconstriction will direct you to option 4. Review the effects of ergot alkaloids and the associated contraindications if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Hodgson, Kizior, p. 743. 2011.

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse would suspect DIC if he or she observes: 1. Rapid clotting times 2. Pain and swelling of the calf of one leg 3. Laboratory values that indicate increased platelets 4. Petechiae, oozing from injection sites, and hematuria

4. Petechiae, oozing from injection sites, and hematuria Rationale: DIC is a state of diffuse clotting in which clotting factors are consumed, which leads to widespread bleeding. Platelet counts are decreased, because they are consumed by the process. Coagulation studies show no clot formation (clotting times are thus prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 on the basis of the knowledge that DIC is a widespread problem rather than a localized one. Eliminate options 1 and 3 next, because they are comparable or alike. Review the signs related to DIC if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Antepartum References: Christensen, Kockrow, pp. 893- 894. 2011. Foundations of nursing. Leifer, p. 90. 2011.

After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of: 1. Uterine atony 2. Placenta previa 3. Abruptio placentae 4. Placental separation

4. Placental separation Rationale: As the placenta separates, it settles downward into the lower uterine segment, the umbilical cord lengthens, and a sudden trickle or spurt of blood appears. The clinical manifestations identified in the question are not related to options 1, 2, and 3. Test-Taking Strategy: Use the process of elimination. Note that options 1, 2, and 3 are comparable or alike in that they represent complications associated with pregnancy. Option 4 indicates a normal finding after the vaginal delivery of the newborn. Review this stage of labor if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Data Collection Content Area: Maternity/ Intrapartum Reference: Leifer, p. 146. 2011.

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should: 1. Check the vital signs every 4 hours. 2. Measure the fundal height every 4 hours. 3. Prepare a heat pack for application to the area. 4. Prepare an ice pack for application to the area.

4. Prepare an ice pack for application to the area. Rationale: The application of ice will reduce the swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 3 will not reduce swelling. Test-Taking Strategy: Use the process of elimination. Focus on the subject of the question—the reduction of swelling. This will assist you with eliminating options 1 and 2. Recalling the principles related to heat and cold will direct you to option 4. Review the nursing care of the client with a hematoma if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, pp. 204, 239-240. 2011.

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped20 points, the diastolic BP dropped 10 points, and her pulse is120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. On the basis of this diagnosis, the nurse would plan to: 1. Reassure the client. 2. Apply perineal pressure. 3. Monitor the fundal height. 4. Prepare the client for surgery.

4. Prepare the client for surgery. Rationale: The information provided in the question indicates that the client is experiencing blood loss. Surgery would be indicated for this complication to stop the bleeding. Options 1, 2, and 3 would not assist with controlling the bleeding in this emergency situation. Test-Taking Strategy: Focus on the information provided in the question and note that the client has a vulvar hematoma. Note that the signs and symptoms in the question indicate the presence of bleeding; this should direct you to the correct option. Review the nursing interventions related to vulvar hematomas if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum References: Leifer, p. 239. 2011. McKinney, James, Murray, Ashwill, p. 698. 2009.

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse tells the client that this is routinely done to: 1. Prevent cataracts in the neonate born to a woman who is susceptible to rubella. 2. Protect the neonate's eyes from possible infections acquired while hospitalized. 3. Minimize the spread of microorganisms to the neonate from invasive procedures during labor. 4. Prevent ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection.

4. Prevent ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection. Rationale: Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacteria Neisseria gonorrhoeae. The preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes of administering this medication to the newborn infant. Test-Taking Strategy: Use the process of elimination and your knowledge of the purpose of administering erythromycin ophthalmic ointment to the newborn infant. Remember that erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment of ophthalmia neonatorum in newborns. Review the initial care of the newborn infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Newborn Reference: Leifer, pp. 152-153. 2011.

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client, knowing that the placenta: 1. Cushions and protects the fetus 2. Maintains the body temperature of the fetus 3. Surrounds the fetus and allows for fetal movement 4. Provides an exchange of nutrients and waste products between the mother and the fetus

4. Provides an exchange of nutrients and waste products between the mother and the fetus Rationale: The placenta provides an exchange of nutrients and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and allows for fetal movement. The amniotic fluid also maintains the body temperature of the fetus. Test-Taking Strategy: Knowledge regarding the purpose of the placenta and amniotic fluid is required to answer this question. Remember that the placenta provides nutrients. Review the structure and function of the placenta and the amniotic fluid if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/ Planning Content Area: Maternity/ Antepartum Reference: Leifer, pp. 38- 39. 2011.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication if which of the following is noted on data collection? 1. Proteinuria of 3 + 2. Presence of deep tendon reflexes 3. Serum magnesium level of 6 mEq/L 4. Respirations of 10 breaths per minute

4. Respirations of 10 breaths per minute Rationale: Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression (respiratory rate less than 12 breaths per minute), a loss of deep tendon reflexes, and a sudden drop in the fetal heart rate, maternal heart rate, and blood pressure. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L or 5 to 8 mg/dL. Proteinuria of 3 + is likely to be noted in a client with preeclampsia. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first, because it is a normal finding. Next, eliminate option 3, knowing that the therapeutic serum level of magnesium is between 4 and 7.5 mEq/L. From the remaining options, recalling that proteinuria of 3 + would be noted in a client with preeclampsia will direct you to the correct option. Review the adverse effects of magnesium sulfate if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum References: Lehne, pp. 511-512. 2010. Leifer, p. 94. 2011.

The nurse is planning to teach cord care to a new mother. The nurse plans to tell the mother that: 1. Alcohol is the only agent used to clean the cord. 2. It takes 21 days for the cord to dry up and fall off. 3. Cord care is done only at birth to control bleeding. 4. The process of keeping the cord clean and dry will decrease bacterial growth.

4. The process of keeping the cord clean and dry will decrease bacterial growth. Rationale: The cord should be kept clean and dry to decrease bacterial growth; this includes keeping the diaper folded below the cord to keep urine away from the cord. The cord should be cleansed two to three times a day. It usually falls off within 7 to 14 days. Agents other than alcohol may be prescribed to clean the cord. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3, noting the closed-ended word "only." Recall that cord care is required until the cord dries up and falls off, and that agents other than alcohol may be prescribed for cord care. Option 2 is incorrect, because the cord should fall off between 7 and 14 days after birth. Review the concepts of cord care if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Newborn Reference: Leifer, pp. 218-219. 2011.