Situation: Julia, primagravida is brought to the labor room

with the following PE findings: Cervical dilation 8cm, fully

effaced +1, AOG: 39-40 weeks.
1. When is the first stage of labor considered to be achieved?

9. A nurse provides instructions to a malnourished client

regarding iron supplementation during pregnancy. Which
statement when made by the client would indicate an
understanding of the instructions?

a) presenting part is at station +1

b) cervix is 10 cm dilated
c) uterine contractions occur every 2-3 min. interval
d) cervix is gully effaced

a) the iron is best taken on empty stomach

b) meat does not provide iron and should be avoided
c) iron supplements will give me diarrhea
d) my body has all iron it needs and I don't need to take
supplement

2. Upon admission to the labor room, which of the following is

not a routine procedure considering her cervical dilation

10. Which of the following meals is best for pregnant woman?

a) mini prep. of the perineal area

b) keep on NPO
c) monitor vital signs and FHT
d) cleansing enema

a) turkey with green salad

b) angel food cake
c) hamburger with coffee
d) french fries with soda drink

3. Which of the following observation requires the nurse to

refer stat to the obstetricians?
a) frequent urination
b) blood-streak mucus in the vaginal discharge
c) sudden gush of amniotic fluid from the vagina
d) FHT is 110 during uterine contractions but returns to 130
after 10 seconds following contract
4. Which of the following signs indicate that delivery is near?
1. Julie verbalized her desire to defecate
2. uterine contractions increased in frequency duration and
intensity
3. the perineum is bulging
4. bloody show is increased
a) 1,2,3,4
b) 1,2,3
c) 1,2,4
5. After the delivery of the baby, which of the following
indicate placental separation?
1.
2.
3.
4.

protrusion of three or more inches of the umbilical cord

gradual descent of the uterus further into the pelvis
uterus becomes more firm and rounded
sudden spurt of blood from the vagina

a) 1,3,4
b) 1,2,4
c) 2,3,4
d) 1,2,3

6. The client is in active phase of labor. The physician has

administered epidural anesthesia. Which of the following
nursing actions should be given highest priority by the nurse?
a) ensuring patent IV access line
b) checking for rupture of membrane
c) monitoring duration of each contraction
d) providing food and fluids
7. The client is on her twelfth-week of pregnancy. She had
been diagnosed to have ruptured ectopic pregnancy. Which of
the following signs and symptoms are characteristic of the
condition?
a) profuse bright red vaginal bleeding
b) spotting, abdominal pain that radiates to the shoulder
c) elevated hemoglobin and hematocrit level
d) leukopenia, decreased body temperature
8.You are assessing a 32-week pregnant woman. Which of
the following is a biophysical nursing diagnosis?
a) body image disturbance
b) knowledge deficit
c) ambivalence
d) alteration in nutrition

11. Which of the following findings by the nurse indicates that

Methergine injection to a client, who had delivered 3 hours
ago, is effective?
a) uterus is 2 fingerbreadths below the umbilicus
b) uterus is boggy and at the level of the umbilicus
c) uterus is palpated on the right side of the abdomen
d) uterus is 2 fingerbreadths above the umbilicus
12. Which of the following statements when made by the
premenopausal woman indicates that she understands the
health teachings on breast self-examination (BSE)?
a) I will perform breast self-examination every first day of the
month
b) I will perform breast self-examination 5 days after
menstruation
c) I will perform breast self-examination 2 to 3 days after the
cycle
d) I will perform breast self-examination during menstrual
period
13. Which of the following signs and symptoms indicates
amniotic fluid embolism?
a) sudden onset of respiratory distress, chest pain, BP 90/60
mmHg, RR 26/min, PR 98bpm
b) restlessness, chest pain, BP 140/80 mmHg, RR 24/min, PR
70 bpm
c) difficulty of breathing, cold, clammy skin, BP 90/60 mmHg,
RR 12/min, PR 70 bpm
d) chest pain, shortness of breath, BP 160/90 mmHg, RR
28/min, PR 120 bpm
14. The client is in active labor, cervix is 8 cm dilated, is
nauseated, and irritable. Which of the following is appropriate
nursing action?
a) encourage the client to do pant-blow breathing exercises
b) encourage the client to push with each contractions
c) encourage the client to walk
d) encourage the client to turn to the right side
15. The client is in active labor. She is on oxytocin per IV
infusion drip. Which of the following situations would require
that the infusion be stopped?
a) the cervix is 8 cm, dilated, contractions occur every 3-5
minutes
b) contractions occur at less than 2 minute intervals or last
for longer than 90 seconds
c) the cervix is 6 cm, dilated, partially effaced, duration of
contractions is 50 to 60 seconds
d) contractions occur every 3-5 minutes, last 50 to 60
seconds

16. A pregnant woman is being given magnesium sulfate per

slow IV drip. This medication is intended to control
a) embolism
b) seizures
c) bleeding
d) uterine contractions
17. Abnormal fetal lie and position were noted. Which of the
following procedures does the nurse expect to be arranged
first, before external rotation (version) is done?
a) amniocentesis
b) ultrasound
c) fetal heart rate monitoring
d) x-ray

25. Which of the following assessment findings indicates

adverse reaction to Morphine Sulfate in a gravida 5 para 5
client?
a) elevated blood pressure
b) increased respiratory rate
c) boggy fundus of the uterus
d) restlessness
26. A baby has been delivered 2 hours ago by a diabetic
mother. The baby manifests high-pitched cry. The nurse
should assess for which of the following conditions?
a) fetal alcohol syndrome
b) increased intracranial pressure
c) prematurity
d) hypoglycemia

18. A client is 32 weeks pregnant. She experiences cord

prolapse and is in active labor. Which of the following should
be the most immediate action by the nurse?

27. Which of the following situations in a newborn

necessitates urgent attention by the nurse?

a) push the cord back into the uterus with a gloved hand
b) cover cord with sterile dry gauze
c) place the client in knee-chest position
d) prepare the client for immediate vaginal delivery

a) irregular respiratory patterns

b) body temperature of 36.5 degree centigrade
c) blood pressure of 65/41 mmHg
d) meconium staining on the infant's body

19. Who among these pregnant clients is at risk for bleeding?

28. A pregnant woman on 36 weeks gestation experiences

sudden gush of fluids from the vagina. Which of the following
should be the initial action by the nurse?

a) the client who has history of preterm delivery

b) the client who has twins in her present pregnancy
c) the client who is 18 years of age and is pregnant for the
first time
d) the client who is pregnant for the third time
20. Which of the following health teachings should be
included for a mother who complains of soreness of nipples
because of breastfeeding her infant?
a) wash your breast with soap and water
b) stop breatfeeding for few days
c) apply lanolin cream on the nipple
d) avoid wearing bra until soreness of nipples disappears
21. Which of the following indicates that Brethine
(Theophylline) is effective in a woman on premature labor?
a) uterine contractions become more frequent
b) uterine contractions stop
c) cervical dilatation progresses
d) rupture of membrane occurs
22. The woman isi n active labor. The presentation of the
fetus is left occiput posterior (LOP). Which of the following
measures should be included when caring for the client?
a) provide foods and fluids
b) assist the client to ambulate
c) provide back massage
d) allow the client to sleep
23. The postpartum client is bleeding heavily 2 hours after
delivery. The fundus of the uterus is firm; uterus at the center
of the abdomen. Which of the following actions should the
nurse do next?
a) change perineal pads
b) notify the physician
c) massage the uterus
d) check perineum
24. The client is on her second trimester of pregnancy. Her
BP is 159/95 mmHg. Which of the following would give clue to
make a diagnosis?
a) weight loss
b) increased urine output
c) protein in the urine
d) fundal height at the level of umbilicus

a) notify the physician

b) check the fluid pH
c) prepare the client for delivery
d) place the client in knee-to-chest position
29. The client with endometriosis is taking Danazol. Which of
the following is the expected effect of the medication?
a) it inhibits ovulation
b) it relieves uterine spasm
c) it reduces menstrual bleeding
d) it prevents pregnancy
30. The nurse is giving health teachings to several pregnant
clients. Which of the following statements of the clients
should be given highest priority by the nurse?
a) I enjoy working in the garden and keeping my hands dirty.
It relaxes me
b) I walk a mile every morning and 3 miles on weekends
c) I watch the recipes on TV shows and cook them
d) I drive myself to work
31. Which of the following findings should the nurse report to
the physician when observed in a 6-month old infant?
a) absent moro reflex
b) positive kernig's sign
c) positive babinski's sign
d) absent tonic neck reflex
32. A pregnant client is admitted in the emergency room,
with cervix fully dilated. Which of the following is the priority
action by the RN to facilitate proper bearing down?
a) put the client in sitting position with shoulders supported
b) put the client in lithotomy position
c) put the client in right side-lying position
d) put the client in semi-sitting position and use elbows for
support
33. The client is 3 days postpartum, and she bottle-feeds her
newborn. She complains of hardness and swelling of hr
breasts. Which of the following is the most essential
intervention?
a) apply ice cap over the breasts
b) massage the breasts

c) use breast pump to express the milk

d) apply warm compress over the breasts
34. A woman is in active labor. In what position does the
nurse properly place the client?
a) semi-fowler's position
b) side-lying position
c) trendelenburg position
supine position
35. The client has been diagnosed to have placenta previa.
Which of the following should be included in the nursing care
plan of the client? Select all that apply
a) promote bed rest with bathroom privileges
b) ask for prescription of internal fetal heart rate (FHR)
monitoring
c) perform vaginal examination every 8 hours
d) place the client in the left lateral position
e) administer blood transfusion as prescribed
f) administer Rh globulin as prescribed if the mother is Rh
negative
g) prepare for premature delivery or cesarean section
36. Several female patients want to have Papanicolaou
examination. Who among these patients should the nurse
advise not to have the examination? The patient who states
a) the first day of my menstruation came this morning and I
am bleeding profusely
b) I am 21 years old, and have not had any sex at all
c) I had the test 3 months ago and it was positive
d) I have herpes simplex virus (HSV) and had sex 2 weeks
ago
37. A mother who has just delivered a term baby, wants to
delay breastfeeding for 3 days. What is the best interpretation
of this mother's behavior?
a) she has knowledge deficit regarding breastfeeding
b) she doesn't want to breastfeed her child
c) she doesn't want to have bonding with her child
d) she doesn't want to accept her responsibility of caring for
her child
38. A primigravid client at 8 weeks gestation tells the nurse
that since having had sexual relations with a new partner 2
weeks ago, she has noticed flu-like symptoms, enlarged
lymph nodes, and clusters of vesicles on her vagina. The
nurse refers the client to a physician because the nurse
suspects which of the following sexually transmitted diseases.
a) gonorrhea
b) chlamydia trachomatis
c) syphilis
d) herpes genitalis
39. A middle-aged woman has just returned from the
recovery room after a right mastectomy. A top priority in
planning her care is to minimize the pain she is experiencing.
a) risk for ineffective airway clearance
b) alteration in comfort
c) potential for injury
d) alteration in nutrition
40. A patient who is on her 39 weeks gestation comes to the
hospital accopmpanied by her husband. She tells the nurse
she thinks she is in labor. Which of the following questions
should the nurse ask to help confirm if the patient is in true
labor?
a) do your contractions feel like severe menstrual cramps?
b) do you feel pressure in your legs
c) do you feel as if you can breathe easier?
d) does your pain increase in intensity when you are moving
around?

41. The client had been diagnosed to have PIH (pregnancyinduced hypertension). Which of the following should be
included in her care? Select all that apply
a) administer magnesium sulfate IV drip as ordered
b) check urine for presence of protein
c) have calcium gluconate readily available
d) monitor for elevated liver enzymes
e) observe for elevated platelet counts
f) encourage ambulation
42. A clinic nurse is teaching a pregnant client about the
warning signs in pregnancy. Which of the following, if
identified as a warning sign by the client would indicate that
she understands the teaching?
a) purplish discoloration of the vulva
b) visual disturbances
c) irregular, painless contractions
d) urinary frequency
43. The breastfeeding mother of infant with lactose
intolerance asks a nurse about dietary measures. The nurse
tells the mother to avoid
a) hard cheeses
b) green leafy vegetables
c) dried beans
d) egg yolk
44. A newborn has a temperature of 35.8 C, pulse rate of
126/min, respiratory rate of 65/min. What action should the
nurse take first?
a) dry the newborn and wrap him with blanket
b) put the newborn in a radiant warmer
c) check the newborn's blood sugar level
d) perform phototherapy to the newborn
45. The nurse on a night shift finds a multiparous patient 8
hours postpartum drenched in perspiration. The temperature
is 99F, pulse is 66 bpm, and BP is 120/80 mmHg. Which of
the following nursing diagnosis would be appropriate?
a) risk for infection related to birth trauma
b) ineffective thermoregulation related to hormonal changes
c) ineffective tissue perfusion
d) excess fluid volume related to normal postpartal dieresis
46. A mother complains of pain due to breast engorgement
and is bottle-feeding her newborn. Which action by the
mother needs follow-up?
a) the mother applies warm compress on her breasts
b) the mother wears support bra
c) the mother applies cold compress on her breasts
d) the mother takes prescribed analgesics
47. A nurse is assisting a client who is in first stage of labor
(active phase). A priority nursing action for the nurse is:
a) encourage the woman to blow out strong, short breaths
b) assist the client to a comfortable position in bed
c) monitor client's temperature every hour
d) evaluate fetal heart rate (FHR) every hour
48. A nurse on the obstetric unit is providing care to a woman
in the active phase of the first stage of labor. Which statement
if made by the mother should be a priority concern for the
nurse?
a) I will like to take a nap between contractions
b) I have not voided in the last hour, although I feel I need to
c) I am feeling some rectal pressure that is relieved when I
push
d) I am feeling contractions every 5 minutes

49. A nursing instructor asks a nursing student to describe

the procedure for performing the Helmlich maneuver on an
unconscious pregnant woman at 8 month's gestation. The
student describes the procedure correctly if the student states
that she or he will:

swelling
d) I should apply heat packs to the hemorrhoids to help the
hemorrhoids shrink
56. A nurse has performed a nonstress test on a pregnant
client and is reviewing the fetal monitor strip. The nurse
interprets the test as reactive and understands that this
indicates:

a) place the hands in the pelvis to perform the thrusts

b) perform abdominal thrusts until the object is dislodged
c) perform left lateral abdominal thrusts until the object is
dislodged
d) place a rolled blanket under the right abdominal flank and
hip area

a) normal findings
b) abnormal findings
c) the need for further evaluation
d) that the findings on the monitor were difficult to interpret

50. 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) connects the pulmonary artery to the aorta
b) is an opening between the right and left atria
c) connects the umbilical vein to the inferior vena cava
d) connects the umbilical artery to the inferior vena cava
51. A nurse is performing an assessment of primipara who is
being evaluated in clinic during her second trimester of
pregnancy. Which of the following indicates an abnormal
physical finding that necessities further testing?
a) quickening
b) braxton hicks contractions
c) consistent increase in fundal height
d) fetal heart rate of 180 bpm
52. A nurse is performing an assessment of a pregnant client
who is at 28 weeks of gestation. The nurse measures the
fundal height in centimeters and expects the finding to be
which of the following?

57. A nonstress test is performed on a client who is pregnant

and the results of the test indicate nonreactive findings. The
physician orders a contraction stress test to be done and the
results are documented as negative. The nurse interprets this
finding as indicating:
a) a normal test result
b) an abnormal test result
c) a high risk for fetal demise
d) the need for a cesarean delivery
58. A nurse is reviewing a nutritional plan of care with a
pregnant client and is identifying the food items highest in
folic acid. The nurse determines that the client understands
the foods that supply the highest amounts of folic acid if the
client states that she will include which of the following in the
daily diet?
a) milk
b) yogurt
c) bananas
d) leafy, green vegetables

a) 22 cm
b) 30 cm
c) 36 cm
d) 40 cm

59. A pregnant client tells a nurse that she has been craving
"unusual foods." 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.
Laboratory studies are performed on the client. The nurse
reviews the laboratory results and determines that which of
the following indicates a physiological consequence of this
client's practice?

53. A nurse is reviewing the record of a client who has just

been told that a pregnancy test is positive. The physician has
documented the presence of Goodell's sign. The nurse
determines that his sign indicates:

a) hematocrit, 38%
b) glucose, 86 mg/dL
c) hemoglobin, 9.1 g/dL
d) white blood cell count, 12,400 mm3

a) a softening of the cervix

b) the presence of fetal movement
c) the presence of human chorionic gonadotrophin in the
urine
d) a soft blowing sound that corresponds to the maternal
pulse during auscultation of the uterus.

60. A pregnant client who is at 30 weeks gestation comes to

the clinic for a routine visit, and the nurse performs an
assessment on the client. Which observation made by the
nurse during the assessment indicates need for teaching?

54. A nurse is assisting in performing an assessment on a

client who suspects that she is pregnant and is checking the
client for probable signs of pregnancy. Select all probable
signs of pregnancy.
a) ballotment
b) chadwick's sign
c) uterine enlargement
d) braxton hicks contractions
e) outline of fetus via radiography or ultrasonography
f) fetal heart rate detected by a nonelectronic device
55. A nurse is providing instructions regarding treatment of
hemorrhoids to a client who is in the second trimester of
pregnancy. Which statement by the client indicates a need for
further teaching?
a) I should avoid straining during bowel movements
b) I can gently replace the hemorrhoids into the rectum
c) I can apply ice packs to the hemorrhoids to reduce the

a) the client is wearing sneakers

b) the client is wearing knee-high hose
c) the client is wearing flat shoes with rubber soles
d) the client is wearing pants with an elastic waistband
61. A pregnant client visits a clinic for a scheduled prenatal
appointment. The client tells the nurse that she frequently
has a backache, and the nurse provides instructions regarding
measures that will assist in relieving the backache. Which
statement by the client indicates a need for further
instructions?
a) I should wear flat-heeled shoes
b) I should sleep on firm mattress
c) I should try to maintain good posture
d) I should do more exercises to strengthen my back muscles
62. A clinic nurse has instructed a pregnant client in
measures to prevent varicose veins during pregnancy. Which
statement by the client indicates a need for further
instructions?
a) I should wear panty hose

b) I should wear support hose

c) I should be wearing flat nonslip shoes that have good
support
d) I should wear knee-high hose as long as I don't leave them
on longer than 8 hours
63. A clinic nurse is providing instructions to a pregnant client
regarding measures that will assist in alleviating heartburn.
Which statement by the client indicates an understanding of
the instructions?
a) I should avoid between-meal snacks
b) I should lie down for an hour after eating
c) I should use spices for cooking rather than using salt
d) I should avoid eating foods that produce gas, such as
beans, vegetables, and fatty foods like deep fried chicken
64. A nurse in a health care clinic is instructing a pregnant
client about how to perform "kick counts." Which statement
by the client indicates a need for further instructions?
a) I will record the number of movements or kicks
b) I need to lie flat on my back to perform the procedure
c) a count of fewer than 10 kicks in a 12-hour period indicates
the need to contact the physician
d) I should place my hands on the largest part of my hands
on the largest part of my abdomen and concentrate on the
fetal movements to count the kicks
65. 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 if the client
makes which statement?
a) diet and insulin needs change during pregnancy
b) I will plan my diet based on the results of urine glucose
testing
c) I will need to eat 600 more calories every day since I am
pregnant
d) I can continue with the same diet as before pregnancy, as
long as it is well-balanced
66. A clinic nurse is performing a psychosocial assessment of
a client who has been told that she is pregnant. Which
assessment finding indicates to the nurse that the client is at
high risk for contracting immunodeficiency virus (HIV)?
a) a client who has a history of intravenous drug use
b) a client who has a significant other who is heterosexual
c) a client who has a history of sexually transmitted diseases
d) a client who has had one sexual partner for the past 10
years
67. A nurse in 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.
Which statement, if made by the client, indicates a
component of the normal grieving process?
a) we want to attend a support group
b) we never want to try to have a baby again
c) we are going to try to adopt a child immediately
d) we are okay, and we are going to have another baby
immediately
68. A nurse evaluates a hepatitis B-positive mother' ability for
safe bottle-feeding of her infant during postpartum
hospitalization. Which maternal action best exemplifies the
mother's knowledge of potential disease transmission to the
infant.
a) the mother requests that the window be closed before
feeding
b) the mother holds the infant properly during feeding and
burping
c) the mother tests the temperature of the formula before
initiating feeding
d) the mother washes and dries her hands before and

following self-care of the perineum and asks for a pair of

gloves before feeding
69. A home care nurse visits a pregnant client who has a
diagnosis of mild preeclampsia and who is being monitored
for gestational hypertension. Which assessment finding
indicates a worsening of the preeclampsia and the need to
notify the physician?
a) urinary output has increased
b) dependent edema has resolved
c) blood pressure reading is at the prenatal baseline
d) the client complaints of headache and blurred vision
70. A client with a 38-week twin gestation is admitted to a
birthing center in early labor. One of the fetuses is a breech
presentation. Of the following interventions, which is the
lowest priority in planning the nursing care of this client?
a) measure fundal height
b) attach electronic fetal monitoring
c) prepare the client for possible cesarean section
d) visually examine the perineum and vaginal opening
71.A nurse implements a teaching plan for a pregnant client
who is newly diagnosed with gestational diabetes mellitus.
Which statement, if made by the client, indicates a need for
further teaching?
a) I should stay on the diabetic diet
b) I should perform glucose monitoring at home
c) I should avoid exercise because of the negative effects on
insulin production
d) I should be aware of any infections and report signs of
infection immediately to my health care provider
72. A client has just had surgery to deliver a nonviable fetus
resulting from abruptio placentae. As a result of abruptio
placentae, the client develops disseminated intravascular
coagulation (DIC) and is told about the complication. The
client begins to cry and screams, "God, just let me die now!"
Which nursing diagnosis should direct care for this client at
time?
a) grieving related to the loss of the baby
b) situational low self-esteem related to being ill
c) deficient knowledge related to the disease process
d) hopelessness related to the loss of the baby and personal
health
73. 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) enlargement of the breast
b) complaints of feeling hot when the room is cool
c) periods of fetal movement followed by quiet periods
d) evidence of bleeding, such as in the gums, petechia, and
purpura
74. A nurse in a maternity unit is reviewing the records of the
clients on the unit. Which client would the nurse identify as
being at the greatest risk for developing disseminated
intravascular coagulation (DIC)?
a) a primigravida with mild preeclampsia
b) a primigravida who delivered a 10-lb baby 3 hours ago
c) a gravida II who has just been diagnosed with dead fetus
syndrome
d) a gravida IV who delivered 8 hours ago and has lost 500
ml of blood
75. A client in the first trimester of pregnancy arrives at a
health care clinic and reports that she has been experiencing
vaginal bleeding. A threatened abortion is suspected, and the
nurse instructs the client regarding management of care.
Which statement, if made by the client, indicates a need for

further instructions.
a) I will watch for the evidence of the passage of tissue
b) I will maintain strict bed rest throughout the remainder of
the pregnancy
c) I will count the number of perineal pads used on a daily
basis and note the amount and color of blood on the pad
d) I will avoid sexual intercourse until the bleeding has
stopped, and for 2 weeks following the last evidence of
bleeding
76. A nurse is reviewing true and false labor signs with
multiparous client. The nurse determines that the client
understands the signs of true labor if she makes which
statement?
a) I won't be in labor until the baby engages
b) my contractions will be felt in the abdominal area
c) my contractions will not be as painful if I walk around
d) my contractions will increase in duration and intensity
77. 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) ambulate
b) rest between contractions
c) change positions frequently
d) consume oral food and fluids

78. 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 noted?
a) the contractions are regular
b) the membranes have ruptured
c) the cervix is dilated completely
d) the client begins to expel clear vaginal fluids
79. A nurse is performing an assessment of a client who is
scheduled for a cesarean delivery. Which assessment finding
would indicate a need to contact the physician?
a) hemoglobin of 11.0 g/dL
b) fetal heart rate of 180 bpm
c) maternal pulse rate of 85 bpm
d) white blood cell count of 12,000/mm3
80. A nurse has provided discharge instructions to a client
who delivered a healthy newborn infant by cesarean delivery.
Which statement, if made by the client, indicates a need fro
further instructions?

a) increased urinary output

b) a fetal heart rate of 90 bpm
c) three contractions occurring within a 10-minute period
d) adequate resting tone of the uterus palpated between
contractions
83. 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 negative 1 (-1) station. The nurse determines
that the fetal presenting part is:
a) 1 inch below the coccyx
b) 1 inch below the iliac crest
c) 1 cm above the ischial spine
d) 1 fingerbreath below the symphysis pubis
84. nurse is monitoring a client in labor. The nurse suspects
umbilical cord compression. If which of the following is noted
on the external monitor tracing during a contraction?
a) late decelerations
b) early decelerations
c) short-term variability
d) variable decelerations
85. A labor and delivery room nurse has just received report
on four clients. The nurse should assess which client first?
a) a primiparous client in the active stage of labor
b) a multiparous client who was admitted for induction of
labor
c) a client who is not contracting but has suspected
premature rupture of the membranes
d) a client who has just received an Iv loading dose of
magnesium sulfate to stop preterm labor
86.A nurse is reviewing the physician's orders for a client
admitted for premature rupture of membranes. Gestational
age of the fetus is determined to be 37 weeks. Which
physician's order should the nurse question?
a) perform a vaginal examination every shift
b) monitor maternal vital signs every 4 hours
c) monitor fetal heart rate (FHR) continuously
d) administer ampicillin 1gm as an intravenous piggyback
(IVPB) every 6 hours
87. A nurse is providing emergency measures to a client in
labor who has been diagnosed with a prolapsed cord. The
mother becomes anxious and frightened and says to the
nurse, "Why are all of these people in here? Is my baby going
to be all right?" Which of the following nursing diagnosis
would be most appropriate for this client at this time?

a) I will begin abdominal exercises immediately

b) I will notify the physician if I develop a fever
c) I will turn on my side and push up with my arms to get out
of bed
d) I will lift nothing heavier than the newborn infant for at
least two weeks
81. A nurse is caring for a client in labor and prepares to
auscultate the fetal heart rate by using a Doppler ultrasound
device. The nurse accurately determines that the fetal heart
sounds are heard by:

a) fear
b) fatigue
c) powerlessness
d) ineffective coping

a) Noting whether the heart rate is greater than 140 bpm

b) placing the diaphragm of the Doppler on the mother's
abdomen
c) palpating the maternal radial pulse while listening to the
fetal heart rate
d) Performing Leopold's maneuver first to determine the
location of the fetal heart

a) infection
b) hemorrhage
c) chronic hypertension
d) disseminated intravascular coagulation

82. A nurse is caring for a client in labor who is receiving

oxytoxin (Pitocin) by intravenous infusion to stimulate uterine
contractions. Which assessment finding would indicate to the
nurse that the infusion needs to be discontinued?

88. A nurse in the postpartum unit is caring for a client who

has just delivered a newborn infant following a pregnancy
with a placenta previa. The nurse reviews the plan of care
and prepares to monitor the client for which of the following
risks associated with placenta previa?

89. A maternity nurse is caring for a client with abruptio

placentae and is monitoring the client for disseminated
intravascular coagulopathy. Which assessment finding is least
likely to be associated with DIC?
a) prolonged clotting times
b) decreased platelet count
c) swelling of the calf of one leg

d) petechiae, oozing from injection sites, and hematuria

90. A nurse is assessing a pregnant client in the second
trimester of pregnancy who was admitted to the maternity
unit with a suspected diagnosis of abruptio placentae. Which
of the following assessment findings would the nurse expect
to note if this condition is present?
a) a soft abdomen
b) uterine tenderness
c) absence of abdominal pain
d) painless, bright red vaginal bleeding
91. A nurse in labor room is assisting with the vaginal
delivery of a newborn infant. The nurse would monitor the
client closely for risk of uterine rupture if which of the
following occurred?
a) forcep delivery
b) schultz presentation
c) hypotonic contractions
d) weak bearing-down efforts
92. A clinic nurse is performing a prenatal assessment on a
pregnant client. The nurse would implement teaching related
to the risk of abruptio placentae if which of the following
information was obtained on assessment?
a) the client is 28 years of age
b) this is the second pregnancy
c) the client has a history of hypertension
d) the client performs moderate exercise on a regular daily
schedule
93. A nurse is performing an initial assessment on a client
who has just been told that pregnancy test is positive. Which
assessment finding would indicate that the client is at risk of
preterm labor?
a) the client is a 35-year old primigravida
b) the client has history of cardiac disease
c) the client's hemoglobin level is 13.5 g/dL
d) the client is a 20-year old primigravida of average weight
and height
94. A nurse in labor room is monitoring a client with
dysfunctional labor for signs of fetal or maternal compromise.
Which of the following assessment findings would alert the
nurse to compromise?
a) maternal fatigue
b) coordinated uterine contractions
c) progressive changes in the cervix
d) persistent nonreassuring fetal heart rate
95. A nurse is assigned to care for a client with hypotonic
uterine dysfunction and signs of slowing labor. The nurse is
reviewing the physician's orders and would expect to note
which of the following prescribed treatments for this
condition?
a) increased hydration
b) oxytocin (Pitoxin) infusion
c) medication that will provide sedation
d) administration of a tocolytic medication

96. A nurse is performing an assessment on a client

diagnosed with placenta previa. Which of these assessment
findings would the nurse expect to note? Select all that apply
a) uterine rigidity
b) uterine tenderness
c) severe abdominal pain
d) bright red vaginal bleeding
e) soft, relaxed, nontender uterus
f) fundal height may be greater than expected fro gestational
age
97. A nurse is caring for four 1-day postpartum clients. Which
client has an abnormal finding that would require further
intervention?
a) the client with mild after pains
b) the client with a pulse rate of 60 bpm
c) the client with colostrum discharge from both breast
d) the client with lochia that is red and has foul-smelling odor

98. A nursing student is preparing to perform a

cardiovascular assessment on a postpartum client. A nursing
instructor asks the student about the procedure to elicit
Homan's sign. Which response by the nursing student would
indicate an understanding of this assessment technique?
a) I will ask the client to raise her legs up to her waist and
then to lower her legs slowly
b) I will ask the client to raise her legs and to try to lower
them against pressure from my hand
c) I will ask the client to extend her legs flat on the bed, and I
will grasp her foot gently dorsiflex it forward
d) I will ask the client to extend her legs flat on the bed, and
I will grasp her foot and sharply extend it backward
99. A nurse is planning care for a postpartum client who had
a vaginal delivery 2 hours ago. The client had a midline
episiotomy and has several hemorrhoids. What is the priority
nursing diagnosis for this client?
a) acute pain
b) disturbed body image
c) impaired urinary elimination
d) risk for imbalanced fluid volume
100. A nurse is providing postpartum instructions to a client
who will be breast-feeding her newborn. The nurse
determines that the client has understood the instructions if
she makes which of the following statements? Select all that
apply.
a) I will use soap to wash my breasts often
b) drinking alcohol can affect my milk supply
c) the use of caffeine can decrease my milk supply
d) I will start my estrogen birth control pills again as soon as
I get home
e) I know if my breasts get engorged I will limit my breastfeeding and supplement the baby
f) I plan on having bottled water available in the refrigerator
so I can get additional fluids easily