MATERNAL AND CHILD NURSING

1. A nurse is conducting a prenatal teaching class and is reviewing the functions of the female reproductive system. A
client in the class asks the nurse about the function of the fallopian tubes. The nurse tells the client that
a. Estrogen and progesterone are secreted from the fallopian tubes
b. The fallopian tubes are the passageway for the fetus
c. The fetus develops in the fallopian tubes
d. Fertilization occurs in the fallopian tubes
2. A nursing instructor is reviewing the menstrual cycle with a nursing student who will be conducting a prenatal teaching
session. The instructor asks the student to describe the follicle stimulating hormone F!"# and the luteinizing
hormone $"#. The student accurately responds by stating that
a. F!" and $" are released from the anterior pituitary gland
b. F!" and $" are secreted by the corpus luteum of the ovary
c. F!" and $" are secreted by the adrenal glands
d. F!" and $" stimulate the formation of milk during pregnancy
%. A nurse employed in a prenatal clinic review a client&s chart and notes that the physician documents that the client has
a gynecoid pelvis. The nurse plans care for this client' knowing that this type of pelvis
a. (s not favorable for labor c. (s a wide pelvis with a short diameter
b. "as a narrow pubic arch d. (s the most favorable for labor and birth
). A pregnant client asks a nurse about the purpose of the placenta. The nurse responds most appropriately by telling
the client that the placenta
a. *revents antibodies and viruses from passing to the fetus
b. +ushions and protect the fetus
c. *rovides an e,change of nutrients and waste products between the mother and the fetus
d. -aintains the body temperature of the fetus
.. A nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse accurately tells the
client that fetal circulation consists of
a. Two umbilical veins and one umbilical artery
b. Two umbilical arteries and one umbilical vein
c. Arteries carrying o,ygenated blood to the fetus
d. /eins carrying deo,ygenated blood to the fetus
0. A nursing student is assigned to a client in labor. A nursing instructor asks the student to describe fetal circulation'
specially the ductus venosus. The nursing instructor determines that the student understands fetal circulation if the
student states that the ductus venosus
a. +onnects the pulmonary artery to the aorta
b. (s an opening between the right and left atriums
c. +onnects the umbilical artery to the inferior vena cava
d. +onnects the umbilical vein to the inferior vena cava
1. A nurse is caring for a client during the prenatal period. The client tells that nurse that she wants to know the se, of
the fetus as soon as it can be determined. The nurse responds to the client' knowing that the se, of the fetus can be
visually recognizable as early as week
a. ) c. 2
b. 0 d. 12
1
2. A nurse prepares to assess a fetal heartbeat. The nurse use a fetoscope' knowing that the fetal heartbeat first can be
heard with a regular nonelectronic# fetoscope at gestational week
a. . c. 10
b. 13 d. 23
4. 5uring a prenatal visit at %2 weeks' a nurse assesses the fetal heart rate. The nurse determines that the fetal heart
rate is normal if which of the following is noted6
a. 23 beats per minute c. 1.3 beats per minute
b. 133 beats per minute d. 123 beats per minute
13. A pregnant adolescent client asks the nurse about the menstrual cycle. The nurse describes the cycle and tells the
adolescent that its normal duration is about
a. 1) days c. %3 days
b. 22 days d. ). days
11. A client arrives at a prenatal clinic for the first prenatal assessment. The client tells a nurse that the first day of her last
menstrual period was !eptember 14' 233.. 7sing 8agele&s rule' the nurse determines the estimated date of
confinement as
a. 9uly 20' 2330 c. 9une 20' 2330
b. 9uly 12' 2331 d. 9uly 12' 2331

12. A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a
healthy .:year:old child that was delivered at %2 weeks and tells the nurse that she does not have a history of any
type of abortion or fetal demise. The nurse would document the ;T*A$ for this client as
a. ; < %' T < 2' * < 3' A < 3' $ < 1
b. ; < 2' T < 3' * < 1' A < 3' $ < 1
c. ; < 1' T < 1' * < 1' A < 3' $ < 1
d. ; < 2' T < 3' * < 3' A < 3' $ < 1
1%. A nurse is performing an assessment of a primipara who is being evaluated in a clinic during her second trimester of
pregnancy. =hich of the following indicates an abnormal physical finding necessitating further testing6
a. +onsistent increase in fundal height
b. Fetal heart rate of 123 beats per minute
c. >ra,ton "icks contractions
d. ?uickening
1). A nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be
implemented to protect the fetus. The nurse tells the client that
a. 5aily administration of acyclovir @ovira,# is necessary during the entire pregnancy
b. Total abstinence from se,ual intercourse is necessary during the entire pregnancy
c. !itz baths need to be taken every ) hours while awake if vaginal lesions are present
d. A cesarean section will be necessary if vaginal lesions are present at the time of labor
1.. A nurse is performing an assessment of a pregnant client who is at 22 weeks of gestation. The nurse measures the
fundal height in centimeters and e,pects the findings to be which of the following6
a. 22 cm c. %0 cm
b. %3 cm d. )3 cm
2
10. A pregnant client is seen in a health care clinic for a regular prenatal visit. The client tells the nurse that she is
e,periencing irregular contractions' and the nurse determines that she is e,periencing >ra,ton "icks contractions.
>ased on this finding' which nursing action is most appropriate6
a. (nstruct the client to maintain bed rest for the remainder of the pregnancy
b. (nform the client that these are common and may occur throughout the pregnancy
c. +ontact the physician
d. +all the maternity unit and inform them that the client will be admitted in a prelabor condition
11. A nurse is reviewing the record of a client who has Aust been told that a pregnancy test is positive. The physician has
documented the presence of ;oodell&s sign. The nurse determines that this sign indicates
a. A softening of the cervi,
b. A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus
c. The presence of human chorionic gonadotropin in the urine
d. The presence of fetal movement
12. A nursing instructor asks a nursing student who is preparing t assist with the assessment of a pregnant client to
describe the process of Buickening. =hich of the following statements if made by the student indicates an
understanding of this term6
a. C(t is the irregular' painless contractions that occur throughout pregnancyD
b. C(t is the soft blowing sound that can be heard when the uterus is auscultatedD
c. C(t is the fetal movement that is felt by the motherD
d. C(t is the thinning of the lower uterine segmentD
14 .A nurse midwife is performing an assessment of a pregnant client and is assessing the client for the presence of
ballottement. =hich of the following would the nurse implement to test for the presence of ballottement6
a. Auscultating for fetal heart sounds
b. *alpating the abdomen for fetal movement
c. Assessing the cervi, for thinning
d. (nitiating a gentle upward tap on the cervi,
23. A pregnant 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
a. 0 and 2 weeks of gestation c. 13 and 12 weeks of gestation
b. 2 and 13 weeks of gestation d. 1) and 10 weeks of gestation
21 *hysician has prescribed transvaginal ultrasonography for a woman in the first trimester of pregnancy and the
woman asks the nurse about the procedure. The nurse accurately provides which of the following information to the
client6
a. The procedure takes about 2 hours
b. Transmission gel is spread over the abdomen' and a transducer will be moved over the abdomen to obtain
the picture
c. (t will be necessary to drink 1 to 2 Bt of water before the e,amination
d. The transvaginal proble encased in a disposable cover and coated with a gel is inserted into the vagina
22 +linic nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. =hich
statement by the client indicates a need for further instructionsD
a. C( should wear support hoseD
b. C( should be wearing flat nonslip shoes that have an arch supportD
c. C( should wear panty hoseD
d. C( should wear knee:high hose as long as ( don&t leave them on longer than 2 hoursD
e.
3
2%. A pregnant client calls a clinic and tells a nurse that she is e,periencing leg cramps and is awakened by the cramps at
night. To provide relief from the leg cramps' the nurse tells the client to
a. 5orsifle, the foot while e,tending the knee when the cramps occur
b. 5orsifle, the foot while fle,ing the knee when the cramps occur
c. *lantar fle, the foot while fle,ing the knee when the cramps occur
d. *lantar fle, the foot while e,tending the knee when the cramps occur
2). A clinic nurse is providing instructions to a pregnant client regarding measures that will assist in alleviating heartburn.
=hich statement by the client indicates an understanding of these measures6
a. C( should lie down for an hour after eatingD
b. C( should avoid between:meal snacksD
c. C( should substitute spices for cooking rather than using salyD
d. C( should avoid eating gas:producing foods and fatty foodsD
2.. A nurse in a health care clinic is instructing a pregnant woman in how to perform Ckick countsD. =hich statement by
the woman indicates a need for further instructions6
a. C( should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count
the kicksD
b. C( will record the number of movements or kicksD
c. C( need to lie flat on my back to perform the procedureD
d. CA count of fewer than 13 kicks in a 12:hour period indicates the need to contact the physicianD
20. A clinic nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse
instructs the client to have an adeBuate intake of fluid daily. =hich statement by the mother indicates an
understanding of the daily fluid reBuirement6
a. C( should drink at least 2 to 13 glasses of fluid each day' of which ) to 0 glasses are waterD
b. C( should drink 12 glasses of fruit Auices or milk everydayD
c. C( should drink 2 to 13 glasses of fluid a day and ( can count all of the diet soft drinks that ( consumeD
d. C( should drink 12 glasses of fluid a day' and ( can include the coffee or tea that ( drink in the countD
21. A nurse is instructing a pregnant client regarding measures to increase sources of iron in the diet. The nurse tells the
client to consume which food that contains the highest source of dietary iron6
a. -ilk c. *otatoes
b. 5ark green' leafy vegetable d. +antaloupe
22. A nurse providing instructions regarding treatment for hemorrhoids to a client who is in the second trimester of
pregnancy. =hich statement by the client indicates a need for further instruction6
a. C( can apply ice packs to the hemorrhoids to reduce the swellingD
b. C( should apply heat packs to the hemorrhoids to help the hemorrhoids shrinkD
c. C( should avoid straining during bowel movementsD
d. C( can gently replace the hemorrhoids into the rectumD
24. A nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing
breast tenderness. The nurse tells the client to
a. Avoid wearing a bra
b. =ash the nipples and areola area daily with soap' and massage the breasts with lotion
c. =ear tight:fitting blouses or dresses to provide support
d. =ash the breasts with warm water and keep them dry
4
%3. A nonstress test is prescribed for a pregnant client' and the client asks the nurse about the procedure. The nurse tells
the client that
a. The test is an invasive procedure and reBuires that an informed consent be signed
b. The test will take about 2 hours and will reBuire close monitoring for 2 hours after the procedure is completed
c. An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is
heard most clearly
d. The test is challenged or stressed by uterine contractions to obtain the necessary information
%1. A nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to
the results of the test. The nurse notes that the physician has documented the test results as reactive. The nurse
interprets that this result indicates
a. 8ormal findings
b. Abnormal findings
c. The need for further evaluation
d. That the findings on the monitor were difficult to interpret
%2. A nonstress test is performed on a client who is pregnant' and the results of the test indicate non:reactive findings.
The physician prescribes a contraction stress test' the test is performed' and the nurse notes that the physician has
documented the results as negative. The nurse interprets this finding as indicating
a. A high risk for fetal demise c. The need for a cesarean delivery
b. A normal test result d. An abnormal test result
%%. A nurse is reviewing a nutritional plan for care with a pregnant client and is identifying the food items that are highest
in folic acid. The nurse determines that the client understands which foods supply the highest amounts of folic acid if
the client states that she will include which of the following in the daily diet6
a. A banana c. -ilk
b. $eafy' green vegetable d. Eogurt
%). A pregnant client tells a nurse that she has been craving Cunusual foodsD. The nurse gathers additional assessment
data from the client and discovers that the client has been ingesting daily amounts of white clay dirt from her
backyard. $aboratory studies are performed on the client. The nurse reviews the laboratory results and determines
that which of the following indicates a physiological conseBuence of this client&s practice6
a. "ematocrit %2F c. ;lucose' 20 mgGd$
b. "emoglobin' 4.1 gGd$ d. =hite blood cell count' 12')33GmmH
%.. A pregnant client who is at %3 weeks& gestation comes to a clinic for a routine visit' and the nurse performs an
assessment on the client. =hich observation made by the nurse during the assessment indicates a need for
teaching6
a. The client is wearing sneakers
b. The client is wearing flat shoes with rubber soles
c. The client is wearing pants with an elastic waistband
d. The client is wearing knee:high hose
%0. A nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation.
The nurse includes in the plan of care measures to prevent the episodes of constipation and plants to tell the client to
a. Take a mild stool softener daily in the evening
b. 5rink 0 glasses of water per day
c. +onsume a low:roughage diet
d. 7se a Fleet enema when the episodes occur
5
%1. A pregnant client visits a clinic for a scheduled prenatal appointment. In assessment the client tells the nurse that she
freBuently has a backache' and the nurse provides instructions to the client regarding measures that will assist in
relieving the backache. =hich statement by the client indicates a need for further instructions regarding the measures
to relieve the backache6
a. C( need to try to maintain good postureD
b. C( should do more e,ercises to strengthen my back musclesD
c. C( should sleep on a firm mattressD
d. C( should wear low:heeled shoesD
%2. A nurse is providing instruction to a pregnant client who is scheduled for an amniocentesis. The nurse tells the client
that
a. A fever is e,pected following the procedure because of the trauma to the abdomen
b. !trict bed rest is reBuired following the procedure
c. An informed consent will need to be signed before the procedure
d. "ospitalization is necessary for 2) hours following the procedure
%4. A pregnant client in the first trimester calls a nurse at a healthy care clinic and reports that she has noticed a thin'
colorless' vaginal drainage. The nurse most appropriately tells the mother
a. To come to the clinic immediately
b. To report to the emergency room at the maternity center immediately
c. That the vaginal discharge may be bothersome but is a normal occurrence
d. To use tampons if the discharge is bothersome but to be sure to change the tampons every 2 hours
)3. A pregnant client asks a nurse about the types of e,ercises that are allowable during the pregnancy. The nurse would
instruct the client that the safest e,ercise to engage in is which of the following6
a. >icycling with the legs in the air
b. !wimming
c. !cuba diving
d. $ow:weight gymnastics
)1. A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A
nurse monitors for complications associated with the diagnosis and assesses the client for
a. Any bleeding such as in the gums' petechiae' and purpura
b. Enlargement of the breasts
c. *eriods of fetal movement followed by Buiet periods
d. +omplaints of feeling hot when the room is cool
)2. A nurse in a maternity unit is reviewing the records of the clients on the unit. =hich of the client would the nurse
identify as being at most risk for developing disseminated intravascular coagulation 5(+#6
a. A gravida (/ who delivered 2 hours ago and has lost .33 m$ of blood
b. A gravida (( who has Aust been diagnosed with dead fetus syndrome
c. A primigravida with mild preeclampsia
d. A primigravida who delivered a 13:lb baby % hours ago
)%. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been e,periencing
vaginal bleeding. A threatened abortion is suspected' and a nurse instructs the client regarding management of care.
=hich statement if made by the client indicates a need for further education6
a. C( will maintain strict bed rest throughout the remainder of the pregnancyD
b. C( will avoid se,ual intercourse until the bleeding has stopped' and for 2 weeks following the last evidence
of bleedingD
c. C( will count the number of perineal pads used on a daily basis and note the amount and color of blood on
the padD
d. C( will watch for the evidence of the passage of tissueD
6
)). A prenatal nurse is providing instructions to a group of pregnant clients regarding measures to prevent to,oplasmosis.
=hich statement if made by one of the clients indicates a need for further instructions6
a. C( need to cook meat thoroughlyD
b. C( need to avoid touching mucous membranes of the mouth or eyes while handling raw meatD
c. C( need to drink unpasteurized milk only
d. C( need to avoid contact with materials that are possibly contaminated with cat fecesD
).. A pregnant woman reports to a health care clinic' complaining of loss of appetite' weight loss' and fatigue. Following
assessment of the woman' tuberculosis is suspected. A sputum culture is obtained and identifies -ycobacterium
tuberculosis. The nurse provides instructions to the mother regarding therapeutic management of the tuberculosis.
The nurse tells the client that
a. -edication will not be started until after delivery of the fetus
b. (soniazid (8"# plus rifampin Jifadin# will be reBuired for a total of 4 months
c. The newborn infant will need to receive medication therapy immediately following birth
d. Therapeutic abortion is reBuired
)0. A clinic nurse is provided home care instructions to a client with a history of cardiac disease who has Aust been told
that she is pregnant. =hich statement if made by the client indicates a need for further education6
a. C5uring the pregnancy' ( need to avoid contact with other individuals as much as possible to prevent
infectionD
b. C( need to avoid e,cessive weight gain to prevent increased demands on my heartD
c. C(t is best that ( rest on my left side to promote blood return to the heartD
d. C( need to try avoid stressful situations because stress increases the workload on the heartD
)1. A nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary
measures. =hich statement if made by the client indicates an understanding of the measures to take6
a. C( need to increase my fluid intake and intake of high:fiber foodsD
b. C( need to maintain a low:calorie diet to prevent any weight gainD
c. C( need to lower my blood volume by limiting my fluidsD
d. C( do not need to be concerned about sodium intake during pregnancyD
)2. A clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. =hich of
the following assessment findings would indicate to the nurse that the client is a high risk for contracting human
immunodeficiency virus "(/#6
a. A history of intravenous drug use
b. A history of one se,ual partner for the past 13 years
c. 8o history of any se,ually transmitted diseases
d. A significant other who is heterose,ual
)4. A nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be
discharged from the hospital after the birth of a dead fetus. =hich statement if made by the client indicates a
component of the normal grieving process6
a. C=e would really like to attend a support groupD
b. C=e&re okay' and we are going to try to have another baby immediatelyD
c. C=e never want to have a baby againD
d. C=e are going to try to adopt a child immediatelyD
.3 8urse assists a pregnant client with cardiac disease to identify resources to help her care for her
12:month:old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these
resources primarily to
a. "elp the mother prepare for labor and delivery
b. Jeduce e,cessive maternal stress and fatigue
c. *repare the 12:month:old child for maternal separation during hospitalization
7
d. Avoid e,posure to potential pathogens and resulting infections
.1. A nurse evaluates a hepatitis >:positive client&s ability to safely bottle:feed her infant during postpartum
hospitalization. =hich maternal action best e,emplifies the client&s knowledge of potential disease transmission to the
infant6
a. The client tests the temperature of the formula before initiating feeding
b. The client holds the infant properly during feeding and burping
c. The client washes and dries her hands before and following self:care of the perineum and asks for a pair
of gloves before feeding
d. The client reBuests that the window be closed before feeding
.2. A nurse is providing instructions to a pregnant client with human immunodeficiency virus "(/# regarding care to the
newborn infant following delivery. The client asks the nurse about the feeding options that are available. =hich
statement will the nurse provide to the client regarding feeding the newborn infant6
a. CEou will be able to breast:feed for 0 months and then will need to switch to bottle:feedingD
b. CEou will be able to breast:feed for 4 months and then will need to switch to bottle:feedingD
c. CEou will need to feed the newborn infant by nasogastric tube feedingD
d. CEou will need to bottle:feed the newborn infantD
.%. 5uring the intrapartum period a nurse is caring for a laboring client with sickle cell disease. The nurse ensures that the
client receives appropriate intravenous fluid intake and o,ygen consumption primarily to
a. !timulate the labor process
b. Avoid the necessity of a cesarean delivery
c. *revent dehydration of hypo,emia
d. Eliminate the need for analgesic administration
.). A home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia and who is being monitored for
pregnancy induced hypertension *("#. =hich assessment finding indicates a worsening of the preeclampsia and the
need to notify the physician6
a. >lood pressure reading is at the prenatal baseline
b. 7rinary output has increased
c. The client complains of a headache and blurred vision
d. 5ependent edema has resolved
... A client with a %2:week twin gestation is admitted to a birthing center in early labor. Ine of the fetuses is a breech
presentation. If the following interventions' which will the nurse list as the lowest priority in planning the nursing care
of this client6
a. Attach electronic fetal monitoring
b. *repare the client for a possible cesarean section
c. -easure fundal height
d. /isually e,amine the perineum and vaginal opening
.0. A stillborn infant was delivered in the birthing suite a few hours ago. After the birth the family has remained together'
holding and touching the baby. =hich statement by the nurse would further assist the family in their initial period of
grief6
a. C5on&t worry' there is nothing you could do to prevent this from happeningD
b. C=e need to take the baby from you now so that you can get some sleepD
c. C=hat have you named your lovely baby6D
d. C=e will see to it that you have an early discharge so that you don&t have to be reminded of this
e,perienceD
8
.1. A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus.
=hich statement if made by the client indicates a need for further education6
a. C( need to stay on the diabetic dietD
b. C( will perform glucose monitoring at homeD
c. C( need to avoid e,ercise because of the negative effects on insulin productionD
d. C( need to be aware of any infections and report signs of infection immediately to my health care providerD
.2. A primigravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension *("#. The nurse
who is caring for the client is performing assessments every %3 minutes. =hich assessment finding would be of most
concern to the nurse6
a. 7rinary output of 23 m$ since the previous assessment
b. 5eep tendon refle,es of 2K
c. Jespiratory rate of 13 breaths per minute
d. Fetal heart rate of 123 beats per minute
.4. A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan of care for the client and
documents in the plan that if the client progresses from preeclampsia to eclampsia' the nurse&s first action is to
a. Administer magnesium sulfate intravenously
b. Assess the blood pressure and fetal heart rate
c. +lear and maintain an open airway
d. Administer o,ygen by face mask
03. A client has Aust had surgery to deliver a nonviable fetus resulting from abruption placenta. As a result of the abruption
placenta' the client develops disseminated intravascular coagulation 5(+# and is told about the complication. The
client begins to cry and screams' C;od' Aust let me die nowLD =hich nursing diagnosis should direct care for this
client6
a. "opelessness related to loss of baby and personal health
b. 5eficient knowledge related to disease process
c. !ituational low self:esteem related to being ill
d. ;rieving related to loss of the baby
01. A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when
which of the following assessments is noted6
a. The client begins to e,pel clear vaginal fluid
b. The contractions are regular
c. The membranes have ruptured
d. The cervi, is dilated completely
02. A nurse in the labor room is caring for a client in the active stage of labor. The nurse is assessing the fetal patterns
and notes a late deceleration on the monitor strip. The most appropriate nursing action is to
a. *lace the mother in a supine position
b. 5ocument the findings and continue to monitor the fetal patterns
c. Administer o,ygen via face mask
d. (ncrease the rate of the o,ytocin *itocin# (/ infusion
0%. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. =hich assessment finding
would indicate a need to contact the physician6
a. Fetal heart rate of 123 beats per minute
b. =hite blood cell count of 12'333 cellsGmmH
c. -aternal pulse rate of 2. beats per minute
d. "emoglobin of 11.3 gGd$
9
0). A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to
the delivery room table' and the nurse places the client in the
a. Trendelenburg&s position with the legs in stirrups
b. !emi:Fowler position with a pillow under the knees
c. *rone position with the legs separated and elevated
d. !upine position with a wedge under the right hip
0.. A nurse has provided discharge instructions to a client who delivered a healthy newborn infant by cesarean delivery.
=hich statement if made by the client indicates a need for further instructions6
a. C( will notify the physician if ( develop a feverD
b. C( will lift nothing heavier than the newborn infant for at least 2 weeksD
c. C( will begin abdominal e,ercises immediatelyD
d. C( will turn on my side and push up with my arms to get out of bedD
00. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a 5oppler ultrasound
device. The nurse most accurately determines that the fetal heart sounds are heard by
a. 8oting if the heart rate is greater than 1)4 beats per minute
b. *lacing the diaphragm of the 5oppler on the mother&s abdomen
c. *erforming $eopold&s maneuver first to determine the location of the fetal heart
d. *alpating the maternal radial pulse while listening to the fetal heart rate
01. A nurse is caring for a client in labor who is receiving o,ytocin *tocin# by intravenous infusion to stimulate uterine
contractions. =hich assessment finding would indicate to the nurse that the infusion needs to be discontinued6
a. Three contractions occurring within a 13:minute period
b. A fetal heart rate of 43 beats per minute
c. AdeBuate resting tone of the uterus palpated between contractions
d. (ncreased urinary output
02. A nurse is preparing to care for a client in labor. The physician has prescribed an intravenous infusion of o,ytocin
*itocin#. The nurse ensures that which of the following is implemented before initiating the infusion6
a. *lacing the client on complete bed rest
b. +ontinuous electronic fetal monitoring
c. An intravenous infusion of antibiotics
d. *lacing a code cart at the client&s bedside
04. A nurse is monitoring a client in active labor and notes that the client is having contractions every % minutes that last
). seconds. The nurse notes that the fetal heart rate between contractions is 133 beats per minute. =hich of the
following nursing actions is most appropriate6
a. Encourage the client&s coach to continue to encourage breathing techniBues
b. Encourage the client to continue pushing with each contraction
c. +ontinue monitoring the fetal heart rate
d. 8otify the physician or nurse:midwife
13. A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of
episodic accelerations on the electronic fetal monitoring tracing. =hich of the following actions is most appropriate6
a. 5ocument the findings and tell the mother that the monitor indicates fetal well:being
b. Take the mother&s vital signs and tell the mother that bed rest is reBuired to conserve o,ygen
c. 8otify the physician or nurse:midwife of the findings
d. Jeposition the mother and check the monitor for changes in the fetal tracing
10
11. A nurse is admitting a pregnant client to the labor room and attaches an e,ternal electronic fetal monitor to the client&s
abdomen. After attachment of the electronic fetal monitor' the initial nursing assessment is which of the following6
a. (dentifying the types of accelerations
b. Assessing the baseline fetal heart rate
c. 5etermining the freBuency of the contractions
d. 5etermining the intensity of the contractions
12. A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the
fetus is at 1: station. The nurse determines that the fetal presenting part is
a. 1cm above the ischial spine
b. 1fingerbreadth below the symphysis pubis
c. 1 inch below the coccy,
d. 1 inch below the iliac crest
1%. A pregnant client is admitted to the labor room. An assessment is performed' and the nurse notes that the client&s
hemoglobin and hematocrit levels are low' indicating anemia. The nurse determines that the client is at risk for which
of the following6
a. An,iety c. "emorrhage
b. $ow self:esteem d. *ostpartum infection
1). A nurse assists in the vaginal delivery of a newborn infant. After the delivery' the nurse observes the umbilical cord
lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of
a. hematoma c. 7terine atony
b. *lacenta previa d. *lacental separation
1. +lient arrives at a birthing center in active labor. "er membranes are still intact' and the nurse:midwife prepares to
perform an amniotomy. A nurse who is assisting the nurse midwife e,plains to the client that after this procedure' she
will most likely have
a. $ess pressure on her cervi,
b. (ncreased efficiency of contractions
c. 5ecreased number of contractions
d. The need for increased maternal blood pressure
10. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is
noted on the e,ternal monitoring tracing during a contraction6
a. Early decelerations c. $ate decelerations
b. /ariable decelerations d. !hort:term variability
11. A nurse e,plains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is
a. A form of biofeedback to enhance bearing down efforts during delivery
b. $ight stroking of the abdomen to facilitate rela,ation during labor and provide tactile stimulation to the fetus
c. The application of pressure to the sacrum to relieve a backache
d. *erformed to stimulate uterine activity by contracting a specific muscle group while other parts of the body
rest
12. A client in labor has been pushing effectively for 1 hour. A nurse determines that the client&s primary physiological
need at this time is to
a. +hange positions freBuently c. +onsume oral food and fluids
b. Ambulate d. Jest between contractions
11
14. A client in labor is dilated 13 cm. at this time during labor' the nurse would plan to assess and document the fetal heart
rate at least
a. >efore each contraction c. Every %3 minutes
b. Every 1. minutes d. "ourly
23 A nurse is caring for a client in the second stage of labor. The client is e,periencing uterine contractions every 2
minutes and cries out in pain with each contraction. The nurse recognizes this behavior as
a. E,haustion c. (nvoluntary grunting
b. Fear of losing control d. /alsalval&s maneuver
12
BULLETS IN MCN
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 isthmus of the tube.
Follicle:stimulating hormone and $"' when stimulated by gonadotropin:releasing hormone from the hypothalamus
are released from the anterior pituitary gland to stimulate follicular growth and development' growth of the
graafian follicle and the production of progesterone.
A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth.
The placenta provides an e,change of nutrients and waste products between the mother and the fetus.
>lood pumped by the embryo&s heart leaves the embryo through two umbilical arteries.
The ductus venosus connects the umbilical vein to the inferior vena cava.
>y the end of the twelfth week' the e,ternal genitalia of the fetus have developed to such a degree that the se, of
the fetus can be determined visually.
The fetal heartbeat first can be heard with a regular nonelectronic# fetoscope at 12 to 23 weeks of gestation.
The fetal heart rate depends on gestational age and ranges from 103 to 113 beats per minute in the first trimester
but slows with fetal growth to 123 to 103 beats per minute near or at term.
The normal duration of the menstrual cycle is about 22 days' although it may range from 23 to ). days.
Accurate use of 8agele&s rule reBuires that the woman have a regular 22:day menstrual cycle. Add 1 days to the
first day of the last menstrual period' subtract % months' and then add 1 year to that date.
*regnancy outcomes can be described with the acronym ;T*A$. ; is gravidity' the number of pregnancies.
The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 103 to 113 beats
per minute in the first trimester and slows with fetal growth.
For women with active lesions' either recurrent or primary at the time of labor' delivery should be by cesarean
section to prevent the fetus from being in contact with the gential herpes.
5uring the second and third trimesters weeks 12 to %3# fundal height in centimeters appro,imately eBuals the
fetus&s age in week plus or minus 2 cm.
>ra,ton "icks contractions are irregular' painless contractions that may occur intermittently throughout pregnancy.
(n the early weeks of pregnancy the cervi, becomes softer as a result of increased vascularity and hyperplasia'
which causes ;oodell&s sign.
?uickening is fetal movement and may occur as early as the si,teenth to eighteenth week of gestation' and the
e,pectant mother first notices subtle fetal movements that gradually increase in intensity.
>allottement is a techniBue of palpating a floating structure by bouncing it gently and feeling it rebound.
?uickening is fetal movement and may occur as early as the fourteenth to si,teenth week of gestation. The nurse
e,pectant mother first notices subtle fetal movements during this time' which gradually increase in intensity.
Transvaginal ultrasonography allows clear visibility of the uterus' gestational sac' embryo and deep pelvic
structures such as the ovaries and fallopian tubes.
/aricose veins often develop in the lower e,tremities during pregnancy. Any constrictive clothing' such as knee
high hose' impedes venous return from the lower legs and places the client at risk for developing varicosities.
$eg cramps occur when the pregnant woman stretches the leg and plantar fle,es the foot.
$ying down is likely to lead to reflu, of stomach contents' especially immediately following a meal. The client
should be instructed to avoid spices along with salt because spices will trigger heartburn.
The woman should sit or lie Buietly on her side to perform kick counts. $ying flat on the back is not necessary to
perform this procedure' can cause discomfort and present a risk of vena cava hypotensive# syndrome.
The nurse should instruct the client to have an adeBuate fluid intake daily to assist in digestion and in the
management of constipation. The pregnant woman should consume at least 2 to 13 2 oz# glasses of fluid each
day' of which ) to 0 glasses are water.
5ietary sources of iron include lean meats' liver' shellfish' dark green leafy vegetables' legumes' whole grains'
and enriched grains' cereals and molasses.
-easures that provide relief from hemorrhoids include avoiding constipation and straining during bowel
movements' applying ice packs to reduce the hemorrhoidal swelling' gently replacing the hemorrhoids into the
rectumM using stool softeners' ointments or sprays as prescribedM and assuming certain position to relieve
pressure on the hemorrhoids.
The pregnant woman should be instructed to wash the breasts with warm water and keep them dry. The woman
should be instructed to avoid using soap on the nipples and areola area to prevent the drying of tissues.
The nonstress test taken about 23 to %3 minutes. The test is termed nonstress because it consists of monitoring
onlyM the fetus is not challenged or stressed by uterine contractions to obtain the necessary data.
13
A reactive nonstress test is a normal result. To be considered reactive' the baseline fetal heart rate must be within
normal range 123 to 103 beats per minute# with good long:term variability.
+ontractions stress test results may be interpreted as negative normal#' positive abnormal# or eBuivocal. A
negative test result indicates that no late decelerations occurred in the fetal heart rate' although the fetus was
stressed by three contractions of at least )3 seconds& duration in a 13:minute period.
$eafy' green vegetables are rich in folate folic acid#. >ananas provide potassiumM milk and yogurt supply calcium.
*ica cravings often lead to iron deficiency anemia' resulting in lowered hemoglobin.
/aricose veins often develop in the lower e,tremities during pregnancy. Any constricting clothing such as knee:
high hose impede venous return from the lower legs and thus place the client at higher risk for developing
varicosities.
The nurse should instruct the client to drink 0 glasses per day and to consume a diet that includes roughage to
prevent the constipation.
!ome of the measures that will assist in relieving a backache include maintaining good posture and body
mechanics' resting and avoiding fatigue' wearing low:heeled shoes' and sleeping on a firm mattress.
>ecause amniocentesis is an invasive procedure' informed consent will need to be obtained before the
procedure.
$eukorrhea begins during the first trimester. -any women notice a thin' colorless or yellow vaginal discharge
throughout pregnancy.
8on:weight:bearing e,ercises are preferable to weight:bearing e,ercises during pregnancy. E,ercises to avoid
are shoulder standing and bicycling with the legs in the air because the knee:chest position should be avoided.
!evere preeclampsia can trigger disseminated intravascular coagulation 5(+# because of the widespread
damage to vascular integrity. >leeding is an early sign of 5(+ and should be reported to the health care provider if
noted on assessment.
5ead fetus syndrome is considered a risk factor for 5(+. "emorrhage is a risk factor with 5(+M however' a loss of
.33 ml is not considered hemorrhage.
!trict bed rest throughout the remainder of the pregnancy is not reBuired. The woman is advised to curtail se,ual
activities until bleeding has ceased' and for 2 weeks following the last evidence of bleeding or as recommended
by the physician or other health care provider.
All pregnant women should be advised to do the following to prevent the development of to,oplasmosis.
-ore than one medication may be used to prevent growth of resistant organisms in the pregnant woman with
tuberculosis. Treatment must continue for a prolonged period of time.
To avoid infections' visitors with active infections should not be allowed to visit the clientM otherwise restrictions are
not reBuired.
+onstipation can cause the client to use /alsalva&s maneuver. The maneuver can cause blood to rush to the heart
and overload the cardiac system.
"uman immunodeficiency virus "(/# is transmitted by intimate se,ual contact and the e,change of body fluids'
e,posure to infected blood' and transmission from an infected woman to her fetus.
A support group can help the parents work through their pain by nonAudgmental sharing of feelings.
A variety of factors can cause increased emotional stress during pregnancy' resulting in further cardiac
complications. The client known cardiac disease is at greater risk for such complications.
"epatitis > virus is highly contagious when transmitted by direct contact with blood and body fluids of infected
persons.
*erinatal transmission of "(/ can occur during the antepartal period' during labor and birth' or in the postpartum
period if the mother is breast:feeding.
A variety of conditions' including dehydratiohn' hypo,emia' infection and e,ertion' can stimulate the sickling
process during the intrapartum period.
(f the client complains of a headache and blurred vision' the physician should be notified because these are signs
of worsening preeclampsia.
$ow priority because fundal height should be measured at each antepartal clinic visit' not in the intrapartum
period.
8urse should be able to e,plore measures that assist the family to create memories of the newborn infant so that
the e,istence of the child is confirmed and the parents can complete the grieving process.
E,ercise is safe for the client with gestational diabetes mellitus and is helpful in lowering the blood glucose level.
5ietary modifications are the mainstay of treatment' and the client is placed on a standard diabetic diet.
-agnesium sulfate depresses the respiratory rate. (f the respiratory rate is less than 12 breaths per minute' the
physician or other health care provider needs to be notified.
14
The immediate care during a seizure eclampsia# is to ensure a patent airway.
>y seeing no way out of the situation e,cept for death' the client meets the criteria for hopelessness. A person
who lacks hope feels that life is too much to handle.
The second stage of labor begins when the cervi, is dilated completely and ends with birth of the neonate.
$ate decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and o,ygen to the
fetus during the uterine contractions.
A normal fetal heart rate is 123 to 103 beats per minute. A count of 123 beats per minute could indicate fetal
distress and wound warrant physician notification.
/ena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk
and e,tremities.
Abdominal e,ercises should not start immediately following abdominal surgery' and the client should wait at least
% to ) weeks postoperatively to allow for healing of the incision.
The nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate
F"J# to differentiate the two.
A normal fetal heart rate is 123 to 103 beats per minute. >radycardia or late or variable decelerations indicate fetal
distress and the need to discontinue the o,ytocin.
+ontinuous electronic fetal monitoring should be implemented during an intravenous infusion of o,ytocin.
A normal fetal heart rate is 123 to 103 beats per minute. Fetal bradycardia between contractions may indicate the
need for immediate medical management' and the physician or nurse midwife needs to be notified.
Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by
fetal movement.
Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be
identified if they occur. The intensity of contractions is assessed by an internal fetal monitor' not an e,ternal fetal
monitor.
!tation is the relationship of the presenting part to an imaginary line drawn between the inschial spines' is
measured in centimeters' and is noted as a negative number above the line and a positive number below the line.
Anemic women have a greater likelihood of cardiac decompensation during labor' postpartum infection and poor
wound healing.
As the placenta separates' it settles downward into the lower uterine segment. The umbilical cord lengthens' and
a sudden trickle or blood appears.
Amniotomy artificial rupture of the membranes# can be used to induce labor when the condition of the cervi, is
favorable ripe# or to augment labor if the process begins to slow.
/ariable deceleration occur if the umbilical cord becomes compressed' thus reducing blood flow between the
placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction.
Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before
transition to promote rela,ation and relieve mild to moderate pain.
The birth process e,pends a great deal of energy. Encouraging rest between contractions conserves maternal
energy' facilitating voluntary pushing efforts with contractions.
The second stage of labor begins when the cervi, is dilated completely 13 cm#. -aternal pulse' blood pressure'
and fetal heart rate are assessed every . to 1. minutesM some agency protocols recommend assessment after
each contraction.
*ains' helplessness' panicking and fear of losing control are possible behaviors in the second stage of labor.
15