PNLE 2: MATERNAL AND CHILD HEALTH 6.

Which of the following would the nurse use as the

basis for the teaching plan when caring for a pregnant
1. For the client who is using oral contraceptives, the
teenager concerned about gaining too much weight
nurse informs the client about the need to take the pill
during pregnancy?
at the same time each day to accomplish which of the
following? A. 10 pounds per trimester

A. Decrease the incidence of nausea B. 1 pound per week for 40 weeks

B. Maintain hormonal levels C. ½ pound per week for 40 weeks

C. Reduce side effects D. A total gain of 25 to 30 pounds

D. Prevent drug interactions 7. The client tells the nurse that her last menstrual
period started on January 14 and ended on January
2. When teaching a client about contraception. Which
20. Using Nagele’s rule, the nurse determines her EDD
of the following would the nurse include as the most
to be which of the following?
effective method for preventing sexually transmitted
infections? A. September 27

A. Spermicides B. October 21

B. Diaphragm C. November 7

C. Condoms D. December 27

D. Vasectomy 8. When taking an obstetrical history on a pregnant

client who states, “I had a son born at 38 weeks
3. When preparing a woman who is 2 days postpartum
gestation, a daughter born at 30 weeks gestation and I
for discharge, recommendations for which of the
lost a baby at about 8 weeks,” the nurse should record
following contraceptive methods would be avoided?
her obstetrical history as which of the following?
A. Diaphragm
A. G2 T2 P0 A0 L2
B. Female condom
B. G3 T1 P1 A0 L2
C. Oral contraceptives
C. G3 T2 P0 A0 L2
D. Rhythm method
D. G4 T1 P1 A1 L2
4. For which of the following clients would the nurse
9. When preparing to listen to the fetal heart rate at
expect that an intrauterine device would not be
12 weeks’ gestation, the nurse would use which of the
recommended?
following?
A. Woman over age 35
A. Stethoscope placed midline at the umbilicus
B. Nulliparous woman
B. Doppler placed midline at the suprapubic
C. Promiscuous young adult region

D. Postpartum client C. Fetoscope placed midway between the

umbilicus and the xiphoid process
5. A client in her third trimester tells the nurse, “I’m
constipated all the time!” Which of the following D. External electronic fetal monitor placed at the
should the nurse recommend? umbilicus

A. Daily enemas 10.When developing a plan of care for a client newly

diagnosed with gestational diabetes, which of the
B. Laxatives following instructions would be the priority?
C. Increased fiber intake A. Dietary intake
D. Decreased fluid intake B. Medication
 C. Exercise C. Encourage her to wear a nursing brassiere

D. Glucose monitoring D. Use soap and water to clean the nipples

11.A client at 24 weeks gestation has gained 6 pounds 16.The nurse assesses the vital signs of a client, 4
in 4 weeks. Which of the following would be the hours’ postpartum that are as follows: BP 90/60;
priority when assessing the client? temperature 100.4ºF; pulse 100 weak, thready; R
20 per minute. Which of the following should the
A. Glucosuria
nurse do first?
B. Depression
A. Report the temperature to the physician
C. Hand/face edema
B. Recheck the blood pressure with another cuff
D. Dietary intake
C. Assess the uterus for firmness and position
12. A client 12 weeks’ pregnant come to the
D. Determine the amount of lochia
emergency department with abdominal cramping and
moderate vaginal bleeding. Speculum examination 17.The nurse assesses the postpartum vaginal
reveals 2 to 3 cms cervical dilation. The nurse discharge (lochia) on four clients. Which of the
would document these findings as which of the following assessments would warrant notification
following? of the physician?

A. Threatened abortion A. A dark red discharge on a 2-day postpartum

client
B. Imminent abortion
B. A pink to brownish discharge on a client who
C. Complete abortion
is 5 days postpartum
D. Missed abortion
C. Almost colorless to creamy discharge on a
13.Which of the following would be the priority client 2 weeks after delivery
nursing diagnosis for a client with an ectopic
D. A bright red discharge 5 days after delivery
pregnancy?
18.A postpartum client has a temperature of 101.4ºF,
A. Risk for infection
with a uterus that is tender when palpated, remains
B. Pain unusually large, and not descending as normally
expected. Which of the following should the nurse
C. Knowledge Deficit assess next?
D. Anticipatory Grieving A. Lochia
14.Before assessing the postpartum client’s uterus for B. Breasts
firmness and position in relation to the umbilicus and
midline, which of the following should the nurse do C. Incision
first?
D. Urine
A. Assess the vital signs
19.Which of the following is the priority focus of
B. Administer analgesia nursing practice with the current early postpartum
discharge?
C. Ambulate her in the hall
A. Promoting comfort and restoration of health
D. Assist her to urinate
B. Exploring the emotional status of the family
15.Which of the following should the nurse do when a
primipara who is lactating tells the nurse that she has C. Facilitating safe and effective self-and
sore nipples? newborn care

A. Tell her to breast feed more frequently D. Teaching about the importance of family
planning
B. Administer a narcotic before breast feeding
20. Which of the following actions would be least A. Call the assessment data to the physician’s
effective in maintaining a neutral thermal attention
environment for the newborn?
B. Start oxygen per nasal cannula at 2 L/min.
A. Placing infant under radiant warmer after
C. Suction the infant’s mouth and nares
bathing
D. Recognize this as normal first period of
B. Covering the scale with a warmed blanket
reactivity
prior to weighing
25.The nurse hears a mother telling a friend on the
C. Placing crib close to nursery window for family
telephone about umbilical cord care. Which of the
viewing
following statements by the mother indicates effective
D. Covering the infant’s head with a knit teaching?
stockinette
A. “Daily soap and water cleansing is best”
21.A newborn who has an asymmetrical Moro reflex
B. ‘Alcohol helps it dry and kills germs”
response should be further assessed for which of the
following? C. “An antibiotic ointment applied daily prevents
infection”
A. Talipes equinovarus
D. “He can have a tub bath each day”
B. Fractured clavicle
26.A newborn weighing 3000 grams and feeding every
C. Congenital hypothyroidism
4 hours needs 120 calories/kg of body weight every 24
D. Increased intracranial pressure hours for proper growth and development. How many
ounces of 20 cal/oz formula should this
22.During the first 4 hours after a male circumcision,
newborn receive at each feeding to meet nutritional
assessing for which of the following is the priority?
needs?
A. Infection
A. 2 ounces
B. Hemorrhage
B. 3 ounces
C. Discomfort
C. 4 ounces
D. Dehydration
D. 6 ounces
23.The mother asks the nurse. “What’s wrong with my
27.The postterm neonate with meconium-stained
son’s breasts? Why are they so enlarged?” Whish of
amniotic fluid needs care designed to especially
the following would be the best response by the
monitor for which of the following?
nurse?
A. Respiratory problems
A. “The breast tissue is inflamed from the
trauma experienced with birth” B. Gastrointestinal problems

B. “A decrease in material hormones present C. Integumentary problems

before birth causes enlargement,”
D. Elimination problems
C. “You should discuss this with your doctor. It
28.When measuring a client’s fundal height, which of
could be a malignancy”
the following techniques denotes the correct method
D. “The tissue has hypertrophied while the baby of measurement used by the nurse?
was in the uterus”
A. From the xiphoid process to the umbilicus
24. Immediately after birth the nurse notes the
B. From the symphysis pubis to the xiphoid
following on a male newborn: respirations 78; apical
process
hearth rate 160 BPM, nostril flaring; mild intercostal
C. From the symphysis pubis to the fundus
retractions; and grunting at the end of expiration.
Which of the following should the nurse do? D. From the fundus to the umbilicus
29.A client with severe preeclampsia is admitted with 34.A client at 8 weeks’ gestation calls complaining of
of BP 160/110, proteinuria, and severe pitting edema. slight nausea in the morning hours. Which of the
Which of the following would be most important to following client interventions should the
include in the client’s plan of care? nurse question?

A. Daily weights A. Taking 1 teaspoon of bicarbonate of soda in an

8-ounce glass of water
B. Seizure precautions
B. Eating a few low-sodium crackers before
C. Right lateral positioning
getting out of bed
D. Stress reduction
C. Avoiding the intake of liquids in the morning
30. A postpartum primipara asks the nurse, “When hours
can we have sexual intercourse again?” Which of the
D. Eating six small meals a day instead of thee
following would be the nurse’s best response?
large meals
A. “Anytime you both want to.”
35.The nurse documents positive ballottement in the
B. “As soon as choose a contraceptive method.” client’s prenatal record. The nurse understands that
this indicates which of the following?
C. “When the discharge has stopped and the
incision is healed.” A. Palpable contractions on the abdomen

D. “After your 6 weeks examination.” B. Passive movement of the unengaged fetus

31.When preparing to administer the vitamin K C. Fetal kicking felt by the client
injection to a neonate, the nurse would select which
D. Enlargement and softening of the uterus
of the following sites as appropriate for the injection?
36.During a pelvic exam the nurse notes a purple-blue
A. Deltoid muscle
tinge of the cervix. The nurse documents this as which
B. Anterior femoris muscle of the following?

C. Vastus lateralis muscle A. Braxton-Hicks sign

D. Gluteus maximus muscle B. Chadwick’s sign

32.When performing a pelvic examination, the nurse C. Goodell’s sign

observes a red swollen area on the right side of the
D. McDonald’s sign
vaginal orifice. The nurse would document this as
enlargement of which of the following? 37.During a prenatal class, the nurse explains the
rationale for breathing techniques during preparation
A. Clitoris
for labor based on the understanding that breathing
B. Parotid gland techniques are most important in achieving which of
the following?
C. Skene’s gland
A. Eliminate pain and give the expectant parents
D. Bartholin’s gland something to do
33.To differentiate as a female, the hormonal B. Reduce the risk of fetal distress by increasing
stimulation of the embryo that must occur involves uteroplacental perfusion
which of the following?
C. Facilitate relaxation, possibly reducing the
A. Increase in maternal estrogen secretion perception of pain
B. Decrease in maternal androgen secretion D. Eliminate pain so that less analgesia and
C. Secretion of androgen by the fetal gonad anesthesia are needed

D. Secretion of estrogen by the fetal gonad 38.After 4 hours of active labor, the nurse notes that
the contractions of a primigravida client are not strong
enough to dilate the cervix. Which of the
following would the nurse anticipate doing? B. In the lower-left maternal abdominal quadrant

A. Obtaining an order to begin IV oxytocin C. In the lower-right maternal abdominal

infusion quadrant

B. Administering a light sedative to allow the D. Above the maternal umbilicus and to the left
patient to rest for several hour of midline

C. Preparing for a cesarean section for failure to 43.The amniotic fluid of a client has a greenish tint.
progress The nurse interprets this to be the result of which of
the following?
D. Increasing the encouragement to the patient
when pushing begins A. Lanugo

39.A multigravida at 38 weeks’ gestation is admitted B. Hydramnio

with painless, bright red bleeding and mild
C. Meconium
contractions every 7 to 10 minutes. Which of
the following assessments should be avoided? D. Vernix
A. Maternal vital sign 44.A patient is in labor and has just been told she has
a breech presentation. The nurse should be
B. Fetal heart rate
particularly alert for which of the following?
C. Contraction monitoring
A. Quickening
D. Cervical dilation
B. Ophthalmia neonatorum
40.Which of the following would be the nurse’s most
C. Pica
appropriate response to a client who asks why she
must have a cesarean delivery if she has a complete D. Prolapsed umbilical cord
placenta previa?
45.When describing dizygotic twins to a couple, on
A. “You will have to ask your physician when he which of the following would the nurse base the
returns.” explanation?
B. “You need a cesarean to prevent A. Two ova fertilized by separate sperm
hemorrhage.”
B. Sharing of a common placenta
C. “The placenta is covering most of your cervix.”
C. Each ova with the same genotype
D. “The placenta is covering the opening of the
uterus and blocking your baby.” D. Sharing of a common chorion

41.The nurse understands that the fetal head is in 46.Which of the following refers to the single cell that
which of the following positions with a face reproduces itself after conception?
presentation? A. Chromosome
A. Completely flexed B. Blastocyst
B. Completely extended C. Zygote
C. Partially extended D. Trophoblast
D. Partially flexed 47.In the late 1950s, consumers and health care
42.With a fetus in the left-anterior breech professionals began challenging the routine use of
presentation, the nurse would expect the fetal heart analgesics and anesthetics during childbirth. Which of
rate would be most audible in which of the the following was an outgrowth of this concept?
following areas? A. Labor, delivery, recovery, postpartum (LDRP)
A. Above the maternal umbilicus and to the right B. Nurse-midwifery
of midline
 C. Clinical nurse specialist with oral contraceptives regardless of the time
the pill is taken.
D. Prepared childbirth
2. C . Condoms, when used correctly and
48.A client has a midpelvic contracture from a
consistently, are the most
previous pelvic injury due to a motor vehicle accident
effective contraceptive method or barrier
as a teenager. The nurse is aware that this could
against bacterial and viral sexually transmitted
prevent a fetus from passing through or around which infections. Although spermicides kill sperm,
structure during childbirth? they do not provide reliable protection against
the spread of sexually transmitted infections,
A. Symphysis pubis especially intracellular organisms such as HIV.
B. Sacral promontory Insertion and removal of the diaphragm along
with the use of the spermicides may cause
C. Ischial spines vaginal irritations, which could place the client
D. Pubic arch at risk for infection transmission. Male
sterilization eliminates spermatozoa from the
49.When teaching a group of adolescents about ejaculate, but it does not eliminate bacterial
variations in the length of the menstrual cycle, the and/or viral microorganisms that can cause
nurse understands that the underlying mechanism is sexually transmitted infections.
due to variations in which of the following phases? 3. A . The diaphragm must be fitted individually
to ensure effectiveness. Because of the
A. Menstrual phase
changes to the reproductive structures during
B. Proliferative phase pregnancy and following delivery, the
diaphragm must be refitted, usually at the
C. Secretory phase
6 weeks’ examination following childbirth or
D. Ischemic phase after a weight loss of 15 lbs or more. In
addition, for maximum effectiveness,
50.When teaching a group of adolescents about male spermicidal jelly should be placed in the dome
hormone production, which of the following would and around the rim. However, spermicidal
the nurse include as being produced by the Leydig jelly should not be inserted into the vagina
cells? until involution is completed at approximately
A. Follicle-stimulating hormone 6 weeks. Use of a female condom protects the
reproductive system from the introduction of
B. Testosterone semen or spermicides into the vagina and may
C. Leuteinizing hormone be used after childbirth. Oral contraceptives
may be started within the first postpartum
D. Gonadotropin releasing hormone week to ensure suppression of ovulation. For
the couple who has determined the female’s
fertile period, using the rhythm
method, avoidance of intercourse during this
period, is safe and effective.
Answers and Rationales
4. C . An IUD may increase the risk of pelvic
1. B . Regular timely ingestion of oral
inflammatory disease, especially in women
contraceptives is necessary to
with more than one sexual partner, because of
maintain hormonal levels of the drugs to
the increased risk of sexually transmitted
suppress the action of the hypothalamus and
infections. An UID should not be used if
anterior pituitary leading to inappropriate
the woman has an active or chronic pelvic
secretion of FSH and LH. Therefore, follicles do
infection, postpartum infection, endometrial
not mature, ovulation is inhibited, and
hyperplasia or carcinoma, or uterine
pregnancy is prevented. The estrogen content
abnormalities. Age is not a factor in
of the oral site contraceptive may cause the
determining the risks associated with IUD use.
nausea, regardless of when the pill is taken.
Most IUD users are over the age of 30.
Side effects and drug interactions may occur
 Although there is a slightly higher risk for day of LMP plus November indicates counting
infertility in women who have never been back 2 months (instead of 3 months) from
pregnant, the IUD is an acceptable option as January. To obtain the date of December 27, 7
long as the risk-benefit ratio is discussed. IUDs days were added to the last day of the LMP
may be inserted immediately after delivery, (rather than the first day of the LMP) and
but this is not recommended because of December indicates counting back only 1
the increased risk and rate of expulsion at this month (instead of 3 months) from January.
time.
8. D. The client has been pregnant four times,
5. C . During the third trimester, the enlarging including current pregnancy (G). Birth at 38
uterus places pressure on the intestines. This weeks’ gestation is considered full term (T),
coupled with the effect of hormones on while birth form 20 weeks to 38 weeks is
smooth muscle relaxation causes decreased considered preterm (P). A
intestinal motility (peristalsis). Increasing fiber spontaneous abortion occurred at 8 weeks
in the diet will help fecal matter pass more (A). She has two living children (L).
quickly through the intestinal tract, thus
9. B. At 12 weeks gestation, the uterus rises out
decreasing the amount of water that is
of the pelvis and is palpable above the
absorbed. As a result, stool is softer and easier
symphysis pubis. The Doppler intensifies the
to pass. Enemas could precipitate
sound of the fetal pulse rate so it is audible.
preterm labor and/or electrolyte loss and
The uterus has merely risen out of the
should be avoided. Laxatives may
pelvis into the abdominal cavity and is not at
cause preterm labor by stimulating peristalsis
the level of the umbilicus. The fetal heart rate
and may interfere with the absorption of
at this age is not audible with a stethoscope.
nutrients. Use for more than 1 week can also
The uterus at 12 weeks is just above the
lead to laxative dependency. Liquid in the diet
symphysis pubis in the abdominal cavity,
helps provide a semisolid, soft consistency to
not midway between the umbilicus and the
the stool. Eight to ten glasses of fluid per day
xiphoid process. At 12 weeks the FHR would
are essential to maintain hydration and
be difficult to auscultate with a fetoscope.
promote stool evacuation.
Although the external electronic fetal monitor
6. D . To ensure adequate fetal growth and would project the FHR, the uterus has
development during the 40 weeks of a not risen to the umbilicus at 12 weeks.
pregnancy, a total weight gain 25 to 30
10. A . Although all of the choices are important in
pounds is recommended: 1.5 pounds in the
the management of diabetes, diet therapy is
first 10 weeks; 9 pounds by 30 weeks; and
the mainstay of the treatment plan and
27.5 pounds by 40 weeks. The pregnant
should always be the priority. Women
woman should gain less weight in the first
diagnosed with gestational diabetes generally
and second trimester than in the third. During
need only diet therapy without medication to
the first trimester, the client should only gain
control their blood sugar levels. Exercise, is
1.5 pounds in the first 10 weeks, not 1 pound
important for all pregnant women and
per week. A weight gain of ½ pound per week
especially for diabetic women, because it
would be 20 pounds for the total pregnancy,
burns up glucose, thus decreasing blood sugar.
less than the recommended amount.
However, dietary intake, not exercise, is the
7. B . To calculate the EDD by Nagele’s rule, add 7 priority. All pregnant women with diabetes
days to the first day of the last menstrual should have periodic monitoring of serum
period and count back 3 months, changing the glucose. However, those with gestational
year appropriately. To obtain a date of diabetes generally do not need daily glucose
September 27, 7 days have been added to the monitoring. The standard of care recommends
last day of the LMP (rather than the first day a fasting and 2- hour postprandial blood sugar
of the LMP), plus 4 months (instead of 3 level every 2 weeks.
months) were counted back. To obtain the
11. C. After 20 weeks’ gestation, when there is a
date of November 7, 7 days have been
rapid weight gain, preeclampsia should be
subtracted (instead of added) from the first
 suspected, which may be caused by postpartum care, but is not necessary prior to
fluid retention manifested by edema, assessment of the uterus.
especially of the hands and face. The three
15. A. Feeding more frequently, about every 2
classic signs of preeclampsia are hypertension,
hours, will decrease the infant’s frantic,
edema, and proteinuria. Although urine is
vigorous sucking from hunger and will
checked for glucose at each clinic visit, this is
decrease breast engorgement, soften the
not the priority. Depression may cause either
breast, and promote ease of correct latching-
anorexia or excessive food intake, leading to
on for feeding. Narcotics administered prior to
excessive weight gain or loss. This is not,
breast feeding are passed through the breast
however, the priority consideration at this
milk to the infant, causing excessive
time. Weight gain thought to be caused
sleepiness. Nipple soreness is not severe
by excessive food intake would require a 24-
enough to warrant narcotic analgesia.
hour diet recall. However, excessive intake
All postpartum clients, especially lactating
would not be the primary consideration for
mothers, should wear a supportive brassiere
this client at this time.
with wide cotton straps. This does not,
12. B. Cramping and vaginal bleeding coupled however, prevent or reduce nipple soreness.
with cervical dilation signifies that termination Soaps are drying to the skin of the nipples
of the pregnancy is inevitable and cannot be and should not be used on the breasts of
prevented. Thus, the nurse would document lactating mothers. Dry nipple skin predisposes
an imminent abortion. In a to cracks and fissures, which can become sore
threatened abortion, cramping and vaginal and painful.
bleeding are present, but there is no cervical
16. D. A weak, thready pulse elevated to 100 BPM
dilation. The symptoms may subside or
may indicate impending hemorrhagic shock.
progress to abortion. In a complete abortion
An increased pulse is a compensatory
all the products of conception are expelled. A
mechanism of the body in response to
missed abortion is early fetal intrauterine
decreased fluid volume. Thus, the nurse
death without expulsion of the products of
should check the amount of lochia present.
conception.
Temperatures up to 100.48F in the first 24
13. B . For the client with an ectopic pregnancy, hours after birth are related to the
lower abdominal pain, usually unilateral, is the dehydrating effects of labor and are
primary symptom. Thus, pain is the priority. considered normal. Although rechecking the
Although the potential for infection is always blood pressure may be a correct choice of
present, the risk is low in ectopic pregnancy action, it is not the first action that should
because pathogenic microorganisms have not be implemented in light of the other data. The
been introduced from external sources. The data indicate a potential impending
client may have a limited knowledge of hemorrhage. Assessing the uterus for firmness
the pathology and treatment of the condition and position in relation to the umbilicus and
and will most likely experience grieving, but midline is important, but the nurse
this is not the priority at this time. should check the extent of vaginal bleeding
first. Then it would be appropriate to check
14. D. Before uterine assessment is performed, it
the uterus, which may be a possible cause of
is essential that the woman empty her
the hemorrhage.
bladder. A full bladder will interfere with the
accuracy of the assessment by elevating the 17. D. Any bright red vaginal discharge would be
uterus and displacing to the side of considered abnormal, but especially 5 days
the midline. Vital sign assessment is not after delivery, when the lochia is typically pink
necessary unless an abnormality in uterine to brownish. Lochia rubra, a dark red
assessment is identified. Uterine assessment discharge, is present for 2 to 3 days after
should not cause acute pain that requires delivery. Bright red vaginal bleeding at this
administration of analgesia. Ambulating the time suggests late postpartum hemorrhage,
client is an essential component of which occurs after the first 24 hours
following delivery and is generally caused by
 retained placental fragments or bleeding Covering the scale with a warmed blanket
disorders. Lochia rubra is the normal dark red prior to weighing prevents heat loss through
discharge occurring in the first 2 to 3 days conduction. A knit cap prevents heat loss from
after delivery, containing epithelial the head a large head, a large body surface
cells, erythrocyes, leukocytes and decidua. area of the newborn’s body.
Lochia serosa is a pink to
21. B. A fractured clavicle would prevent the
brownish serosanguineous discharge
normal Moro response of symmetrical
occurring from 3 to 10 days after delivery
sequential extension and abduction of the
that contains decidua, erythrocytes,
arms followed by flexion and adduction. In
leukocytes, cervical mucus,
talipes equinovarus (clubfoot) the foot is
and microorganisms. Lochia alba is an almost
turned medially, and in plantar flexion, with
colorless to yellowish discharge occurring
the heel elevated. The feet are not involved
from 10 days to 3 weeks after delivery and
with the Moro reflex. Hypothyroiddism has no
containing leukocytes, decidua, epithelial
effect on the primitive reflexes. Absence of
cells, fat, cervical mucus, cholesterol crystals,
the Moror reflex is the most significant single
and bacteria.
indicator of central nervous system status, but
18. A. The data suggests an infection of the it is not a sign of increased intracranial
endometrial lining of the uterus. The lochia pressure.
may be decreased or copious, dark brown in
22. B. Hemorrhage is a potential risk following any
appearance, and foul smelling, providing
surgical procedure. Although the infant has
further evidence of a possible infection. All
been given vitamin K to facilitate clotting,
the client’s data indicate a uterine problem,
the prophylactic dose is often not sufficient to
not a breast problem. Typically, transient
prevent bleeding. Although infection is a
fever, usually 101ºF, may be present with
possibility, signs will not appear within 4 hours
breast engorgement. Symptoms of mastitis
after the surgical procedure. The primary
include influenza-like manifestations.
discomfort of circumcision occurs during the
Localized infection of an episiotomy or C-
surgical procedure, not afterward. Although
section incision rarely causes
feedings are withheld prior to the
systemic symptoms, and uterine involution
circumcision, the chances of dehydration are
would not be affected. The client data do not
minimal.
include dysuria, frequency, or urgency,
symptoms of urinary tract infections, which 23. B . The presence of excessive estrogen and
would necessitate assessing the client’s urine. progesterone in the maternal fetal blood
followed by prompt withdrawal at birth
19. C. Because of early postpartum discharge and
precipitates breast engorgement, which will
limited time for teaching, the nurse’s priority
spontaneously resolve in 4 to 5 days after
is to facilitate the safe and effective care of
birth. The trauma of the birth process does
the client and newborn. Although promoting
not cause inflammation of the newborn’s
comfort and restoration of health, exploring
breast tissue. Newborns do not have breast
the family’s emotional status, and teaching
malignancy. This reply by the nurse would
about family planning are important in
cause the mother to have undue anxiety.
postpartum/newborn nursing care, they are
Breast tissue does not hypertrophy in the
not the priority focus in the limited time
fetus or newborns.
presented by early post-partum discharge.
24. D . The first 15 minutes to 1 hour after birth is
20. C. Heat loss by radiation occurs when the
the first period of reactivity involving
infant’s crib is placed too near cold walls or
respiratory and circulatory adaptation to
windows. Thus placing the newborn’s crib
extrauterine life. The data given reflect the
close to the viewing window would be least
normal changes during this time period. The
effective. Body heat is lost
infant’s assessment data reflect normal
through evaporation during bathing. Placing
adaptation. Thus, the physician does not need
the infant under the radiant warmer after
to be notified and oxygen is not needed. The
bathing will assist the infant to be rewarmed.
 data do not indicate the presence of choking, diuresis. Interventions to reduce stress and
gagging or coughing, which are signs of anxiety are very important to facilitate coping
excessive secretions. Suctioning is not and a sense of control, but seizure precautions
necessary. are the priority.

25. B. Application of 70% isopropyl alcohol to the 30. C. Cessation of the lochial discharge signifies
cord minimizes microorganisms (germicidal) healing of the endometrium. Risk of
and promotes drying. The cord should be kept hemorrhage and infection are minimal 3
dry until it falls off and the stump has healed. weeks after a normal vaginal delivery. Telling
Antibiotic ointment should only be used to the client anytime is inappropriate because
treat an infection, not as a prophylaxis. this response does not provide the client with
Infants should not be submerged in a tub of the specific information she is requesting.
water until the cord falls off and the stump Choice of a contraceptive method is
has completely healed. important, but not the specific criteria for safe
resumption of sexual activity. Culturally, the
26. B. To determine the amount of formula
6- weeks’ examination has been used as the
needed, do the following mathematical
time frame for resuming sexual activity, but it
calculation. 3 kg x 120 cal/kg per day = 360
may be resumed earlier.
calories/day feeding q 4 hours = 6 feedings per
day = 60 calories per feeding: 60 calories per 31. C . The middle third of the vastus lateralis is
feeding; 60 calories per feeding with formula the preferred injection site for vitamin K
20 cal/oz = 3 ounces per feeding. Based on the administration because it is free of blood
calculation. 2, 4 or 6 ounces are incorrect. vessels and nerves and is large enough to
absorb the medication. The deltoid muscle of
27. A. Intrauterine anoxia may cause relaxation of
a newborn is not large enough for a newborn
the anal sphincter and emptying of meconium
IM injection. Injections into this muscle in a
into the amniotic fluid. At birth some of
small child might cause damage to the radial
the meconium fluid may be aspirated, causing
nerve. The anterior femoris muscle is the next
mechanical obstruction or chemical
safest muscle to use in a newborn but is not
pneumonitis. The infant is not at increased
the safest. Because of the proximity of the
risk for gastrointestinal problems. Even though
sciatic nerve, the gluteus maximus muscle
the skin is stained with meconium, it is
should not be until the child has been walking
noninfectious (sterile) and nonirritating. The
2 years.
postterm meconiumstained infant is not at
additional risk for bowel or urinary problems. 32. D . Bartholin’s glands are the glands on either
side of the vaginal orifice. The clitoris is
28. C . The nurse should use a nonelastic, flexible,
female erectile tissue found in the perineal
paper measuring tape, placing the zero point
area above the urethra. The parotid glands are
on the superior border of the symphysis pubis
open into the mouth. Skene’s glands open into
and stretching the tape across the abdomen
the posterior wall of the female urinary
at the midline to the top of the fundus. The
meatus.
xiphoid and umbilicus are not appropriate
landmarks to use when measuring the height 33. D . The fetal gonad must secrete estrogen for
of the fundus (McDonald’s measurement). the embryo to differentiate as a female. An
increase in maternal estrogen secretion does
29. B . Women hospitalized with severe
not effect differentiation of the embryo, and
preeclampsia need decreased CNS stimulation
maternal estrogen secretion occurs in every
to prevent a seizure. Seizure precautions
pregnancy. Maternal androgen secretion
provide environmental safety should a seizure
remains the same as before pregnancy and
occur. Because of edema, daily weight is
does not effect differentiation. Secretion
important but not the priority. Preclampsia
of androgen by the fetal gonad would produce
causes vasospasm and therefore can reduce
a male fetus.
utero-placental perfusion. The client should
be placed on her left side to maximize blood 34. A . Using bicarbonate would increase the
flow, reduce blood pressure, and promote amount of sodium ingested, which can cause
 complications. Eating low-sodium crackers 40. D . A complete placenta previa occurs when
would be appropriate. Since liquids can the placenta covers the opening of the uterus,
increase nausea avoiding them in the morning thus blocking the passageway for the baby.
hours when nausea is usually the strongest is This response explains what a complete previa
appropriate. Eating six small meals a day is and the reason the baby cannot come out
would keep the stomach full, which often except by cesarean delivery. Telling the client
decrease nausea. to ask the physician is a poor response and
would increase the patient’s anxiety. Although
35. B . Ballottement indicates passive movement
a cesarean would help to prevent
of the unengaged fetus. Ballottement is not a
hemorrhage, the statement does not explain
contraction. Fetal kicking felt by the client
why the hemorrhage could occur. With a
represents quickening. Enlargement and
complete previa, the placenta is covering all
softening of the uterus is known as Piskacek’s
the cervix, not just most of it.
sign.
41. B . With a face presentation, the head is
36. B . Chadwick’s sign refers to the purple-blue
completely extended. With a vertex
tinge of the cervix. Braxton Hicks contractions
presentation, the head is completely or
are painless contractions beginning around
partially flexed. With a brow (forehead)
the 4th month. Goodell’s sign indicates
presentation, the head would be partially
softening of the cervix. Flexibility of the uterus
extended.
against the cervix is known as McDonald’s
sign. 42. D . With this presentation, the fetal upper
torso and back face the left upper maternal
37. C . Breathing techniques can raise the pain
abdominal wall. The fetal heart rate would be
threshold and reduce the perception of pain.
most audible above the maternal umbilicus
They also promote relaxation. Breathing
and to the left of the middle. The
techniques do not eliminate pain, but they
other positions would be incorrect.
can reduce it. Positioning, not
breathing, increases uteroplacental perfusion. 43. C. The greenish tint is due to the presence of
meconium. Lanugo is the soft, downy hair on
38. A . The client’s labor is hypotonic. The nurse
the shoulders and back of the fetus.
should call the physical and obtain an order
Hydramnios represents excessive amniotic
for an infusion of oxytocin, which will assist
fluid. Vernix is the white, cheesy
the uterus to contact more forcefully in an
substance covering the fetus.
attempt to dilate the cervix.
Administering light sedative would be done 44. D . In a breech position, because of the space
for hypertonic uterine contractions. between the presenting part and the cervix,
Preparing for cesarean section is unnecessary prolapse of the umbilical cord is common.
at this time. Oxytocin would increase the Quickening is the woman’s first perception of
uterine contractions and hopefully progress fetal movement. Ophthalmia
labor before a cesarean would be necessary. It neonatorum usually results from maternal
is too early to anticipate client pushing gonorrhea and is conjunctivitis. Pica refers
with contractions. to the oral intake of nonfood substances.

39. D . The signs indicate placenta previa and 45. A . Dizygotic (fraternal) twins involve two ova
vaginal exam to determine cervical dilation fertilized by separate sperm. Monozygotic
would not be done because it could cause (identical) twins involve a common placenta,
hemorrhage. Assessing maternal vital signs same genotype, and common chorion.
can help determine maternal
46. C . The zygote is the single cell that
physiologic status. Fetal heart rate is
reproduces itself after conception.
important to assess fetal well-being and
The chromosome is the material that makes
should be done. Monitoring the contractions
up the cell and is gained from each parent.
will help evaluate the progress of labor.
Blastocyst and trophoblast are later terms for
the embryo after zygote.
47. D . Prepared childbirth was the direct result of
the 1950’s challenging of the routine use of
analgesic and anesthetics during childbirth.
The LDRP was a much later concept and was
not a direct result of the challenging
of routine use of analgesics and anesthetics
during childbirth. Roles for nurse midwives
and clinical nurse specialists did not develop
from this challenge.

48. C . The ischial spines are located in the mid-

pelvic region and could be narrowed due to
the previous pelvic injury. The symphysis
pubis, sacral promontory, and pubic arch are
not part of the mid-pelvis.

49. B . Variations in the length of the menstrual

cycle are due to variations in the proliferative
phase. The menstrual, secretory and ischemic
phases do not contribute to this variation.

50. B . Testosterone is produced by the Leyding

cells in the seminiferous tubules. Follicle-
stimulating hormone and leuteinzing hormone
are released by the anterior pituitary gland.
The hypothalamus is responsible for releasing
gonadotropin-releasing hormone.