ATI Review

Lucy Van Otterloo, RN, MSN

Which hormone is directly responsible

for ovulation?
A.

Estrogen
B. Progesterone
C. Luteinizing hormone (LH)
D. Follicle-stimulating hormone
(FSH)

 C.

LH initiates the ovulation process

in the ovary and works with FSH to
stimulate the growing follicle. Once
the follicle ruptures, LH continues to
stimulate the ruptured follicle to
produce estrogen, which stimulates
the surge of LH from the anterior
pituitary, beginning the process
again.

The physician prescribes the fertility drugs

menotropins (Pergonal) and chorionic
gonadotropin (Pregnyl). The nurse should
instruct the client that the combined action
of these drugs is to:
A.

Stimulate and promote ovulation

B. Prepare the uterus for implantation
C. Prevent endometriosis in the
fallopian tubes
D. Facilitate patency of the fallopian
tubes

 A.

Mentropins (Pergonal) stimulates

maturation of the ovum and
chorionic gonadotropin (Pregnyl)
stimulates ovulation, thus increasing
the womans chance for fertilization
and implantation.

The time of ovulation can be determined by

taking the basal temperature. During
ovulation the basal temperature:
A.
B.
C.
D.

Drops markedly
Drops slightly and then rises
Rises suddenly and then falls
Rises markedly and remains high

 B.

As ovulation approaches, there

may be a drop in the basal
temperature because of an increased
production of estrogen; when
ovulation occurs, there will be a rise
in the basal temperature because of
an increased production of
progesterone.

A couple who recently emigrated from Israel

are concerned about a genetic disease that
is prevalent among Jewish people and speak
to the clinic nurse. The nurse recommends
that they go for a genetic blood test to
determine the possibility of any of their
children being born with:
A.
B.
C.
D.

PKU
Cystic fibrosis
Cooleys anemia
Tay-Sachs disease

 D.

This is a genetic disorder

transmitted as an autosomal
recessive trait that occurs primarily
among Ashkenazi Jews.

After the first 3 months of pregnancy, the

chief source of estrogen and progesterone is
the:
A.
B.
C.
D.

Placenta
Adrenal cortex
Corpus luteum
Anterior hypophysis

 A.

When placental formation is

complete, around the 12th week of
pregnancy, it produces progesterone
and estrogen

During prenatal development, fetal

weight gain is greatest in the:

A.
B.
C.
D.

First trimester
Third trimester
Second trimester
Implantation period

 B.

This is the period in which the

fetus stores deposits of fat.

In dealing with a couple identified as

having an infertility problem, the nurse
knows that:
A.

Infertility is usually psychologic in

origin
B. Infertility and sterility are essentially
the same problem
C. The couple have been unable to
have a child after trying for a year
D. One partner has a problem that
makes that person unable to have
children

 C.

Infertility is the inability of a

couple to conceive after at least 1
year of adequate exposure to the
possibility of pregnancy.

A test commonly used to determine the

number, motility and activity of sperm is
the:

A.
B.
C.
D.

Rubin test
Friedman test
Postcoital test
Papanicolaou test

 C.

This test determines the number

and condition of sperm aspirated
from the cervix within 2 hours after
intercourse

Which of the following is considered a

positive sign of pregnancy?
A.
B.
C.
D.

A missed menstrual period

Abdominal enlargement
Fetal movement felt by provider
Positive pregnancy test

 C.

Positive pregnancy signs include

fetal heart sounds, fetal movement
palpated by an experienced
examiner, and visualization of fetus
by ultrasound. All other signs are
presumptive or probable and may
indicate other conditions.

The nurse is aware that an adaptation of

pregnancy is an increased blood supply to
the pelvic region that results in a purplish
discoloration of the vaginal mucosa, which is
known as:
A.
B.
C.
D.

Ladins sign
Hegars sign
Goodells sign
Chadwicks sign

 D.

A purplish color results from

increased vascularity and blood
vessel engorgement of the vagina.
Ladins sign is increased vascularity
of the cervix. Hegars sign is
softening of the lower uterine
segment. Goodells sign is softening
of the cervix.

The uterus rises out of the pelvis and

becomes an abdominal organ at about
the
A.
B.
C.
D.

10th week of pregnancy

8th week of pregnancy
12th week of pregnancy
18th week of pregnancy

 C.

By this time the fetus and

placenta have grown, expanding the
size of the uterus. The extended
uterus expands into the abdominal
cavity.

The nurse plans teaching for a client

scheduled for amniocentesis. It is
MOST important for the nurse to
include which of the following
statements?

A. The test assesses gestational age using the

biparietal circumference
B. The test determines the gender of the baby
C. The test is used to detect possible birth
defects
D. The test should not be completed if you
have a hx. of miscarriages

 C.

Completed to determine genetic

disorders or neural tube defects;
takes 2-4 weeks to obtain results.
BPD is determined by sonogram.
Gender can be done but that is not
the primary reason. Previous
miscarriage is not a contraindication.
Procedure may cause preterm labor.

A pregnant client works at a computer

entering data. This would necessarily have
implications for her plan of care during
pregnancy. The nurse should recommend
that the client:

A. Try to walk about every few hours

during the workday
B. Ask for time in the morning and
afternoon to elevate her legs
C. Tell her employer she cannot work
beyond the second trimester
D. Ask for time in the morning and
afternoon to obtain nourishment

 A.

Maintaining the sitting position for

prolonged periods may constrict the
vessels of the legs, particularly in the
popliteal spaces, as well as diminish
venous return. Walking contracts the
muscles of the legs, which apply
gentle pressure to the veins in the
legs, thus promoting venus return.

A client is concerned about gaining weight

during pregnancy. The nurse explains that
the largest part of weight gain during
pregnancy is because of:
A.
B.
C.
D.

The fetus
Fluid retention
Metabolic alterations
Increased blood volume

 A.

The average weight gain during

pregnancy is 25 to 35 lbs; of this, the
fetus accounts for 7 to 8 lbs. or
approximately 30% of weight gain

Amniotic fluid increases during pregnancy.

The nurse is aware that one of the major
functions of amniotic fluid and its increase
during pregnancy is to:
A.

Provide antibodies to the fetus

B. Increase nutrients to the fetus
C. Maintain fetal temperature
stability
D. Ease passage during delivery

 C.

The major functions of amniotic

fluid are to provide the fetus with a
protective cushion, keep the fetus at
an even temperature, and aid in
dilation of the cervix.

Physiologic anemia during pregnancy

is a result of:
A.

Decreased dietary intake of iron

B. Increased plasma volume of the
mother
C. Decreased erythropoiesis after
the first trimester
D. Increased detoxification demands
on the mothers liver

 B.

There is a 30% to 50% increase in

maternal plasma volume at the end
of the first trimester, leading to a
decrease in the concentration of
hemoglobin and erythrocytes.

In the 12th week of gestation, a client

completely expels the products of
conception. Because the client is Rhnegative, the nurse must:
A.

Administer RhoGAM within 72 hours

B. Make certain she receives RhoGAM
on her first clinic visit
C. Not give RhoGAM since it is not the
birth of a stillborn
D. Make certain the client does not
receive RhoGAM since the gestation
only lasted 12 weeks

 A.

It is given within 72 hours

postpartum if the client has not been
sensitized previously.

A client at 12 weeks gestation comes to the

prenatal clinic complaining of severe nausea
and vomiting. The nurse suspects that this
client has hyperemesis gravidarum and
knows that this is frequently associated with:
A.

Excessive amniotic fluid

B. A GI history of cholecystitis
C. High levels of chorionic
gonadotropin
D. Slowed secretion of free
hydrochloric acid

 B.

High levels of chorionic

gonadotropin frequently are
associated with severe vomiting of
pregnancy; especially in the
presence of hydatidiform mole
(gestational trophoblastic disease)
and often in twin pregnancy

The care of a client with placenta

previa includes:
A.

Vital signs at least once per shift

B. A tap-water enema before
delivery
C. Observation and recording of the
bleeding
D. Limited ambulation until the
bleeding stops

 C.

Continued bleeding can put the

fetus in jeopardy. The client should
be restricted to complete bed rest
until bleeding stops. Vital signs
should be recorded every 4 hours
until bleeding stops.

A pregnant client develops thrombophlebitis

of the left leg and is admitted to the hospital
for bedrest and anticoagulant therapy. The
anticoagulant the nurse should expect to
administer is:
A.
B.
C.
D.

Heparin
Dicumerol
Diphenadione (Dipaxin)
Wafarin (Coumadin)

 A.

Heparin is used because its

molecular size is too large to pass
the placental barrier. The other three
drugs can pass the placental barrier
and cause hemorrhage in the fetus.

A client who is 6 months pregnant comes to

the prenatal clinic complaining of painful
urination, flank tenderness, and hematuria.
A diagnosis of pyelonephritis is made. An
important nursing intervention for the client
at this time is:
A.

Limiting fluid intake

B. Examining the urine for protein
C. Observing for signs of preterm
labor
D. Maintaining her on a 2-gram
sodium diet

 C.

Pyelonephritis often causes

preterm labor, leading to increased
neonatal morbidity and mortality.

When taking the health history, the nurse

correctly identifies that a client is at risk for
developing a hypertensive disorder of
pregnancy when it is determined that the
client:
A.

Is 31 years old
B. Is an obese primigravida
C. Has had six previous pregnancies
D. Has been on oral contraceptives
within 3 months of pregnancy

 B.

First pregnancy and obesity are

both documented risk factors. The
risk age for a hypertensive disorder
of pregnancy is under 20 and over 35
years of age. Multigravidity is not a
risk factor and neither is oral
contraceptive use.

A pregnant client asks the clinic nurse how

smoking will affect her baby. The nurses
response reflects the knowledge that:
A.

The placenta is permeable to

specific substances
B. Smoking relieves tension and the
fetus responds accordingly
C. Vasoconstriction will affect both
fetal and maternal blood vessels
D. Fetal and maternal circulation are
separated by the placental barrier

 C.

Cigarette smoking or continued

exposure to secondary smoke causes
both maternal and fetal
vasoconstriction, resulting in fetal
growth restriction and increased fetal
and infant mortality

The nurse auscultates the abdomen of a 38

weeks gestation to determine fetal heart
rate. If the fetal heartbeat is located in the
right lower quadrant, which of the following
is MOST likely the presenting part?
A.
B.
C.
D.

Shoulder
Head
Feet
Buttocks

 B.

With vertex presentation, ROA.

Feet (footling) or buttocks (frank)
breech would hear FHT in upper
quadrant. Shoulder is uncommon,
only 1% of births.

After doing Leopolds maneuvers on a

laboring cient, the nurse determines that the
fetus in in the ROP position. To best
auscultate the fetal heart tones, the Doppler
is placed:
A.

Above the umbilicus in the midline

B. Above the umbilicus on the left side
C. Below the umbilicus on the right side
D. Below the umbilicus near the left
groin

 C.

Fetal heart tones are best

auscultated through the fetal back;
because the position is ROP, the back
would be below the umbilicus and on
the right side

When caring for a woman with a positive

contraction stress test, the nurse should be
most concerned with observing her for signs
and symptoms of:
A.
B.
C.
D.

Preeclampsia
Placenta previa
Imminent pretem delivery
Uteroplacental insufficiency

 D.

A positive CST indicates a

compromised fetal heart rate during
contractions, which is associated
with uteroplacental insufficiency

A laboring womans uterine

contractions are being internally
monitored. When evaluating the
monitor tracing, which of the following
findings would be a source of concern
and require further assessment?
A.

Frequency every 2.5 to 3 minutes

B. Duration of 80-85 seconds
C. Intensity of 85-90 mmHg
D. Resting pressure of 20-25 mmHg

 Correct

answer: D

The resting pressure should be 15

mmHg or less

The nurse caring for women in labor

should be aware of signs
characterizing reassuring FHR
patterns. A reassuring sign would be:

A. Moderate baseline variability

B. Average baseline FHR of 90-110 beats/min
C. Transient episodic deceleration with movement
D. Late decelerations approx. every 3-4
contractions

 Correct

answer: A

The baseline rate should be 110-160

beats/min; accelerations should occur
with featl movement; no late
deceleration pattern of any magnitude is
reassuring

A laboring womans temperature is

elevated as a result of an upper
respiratory infection. The FHR pattern
that reflects maternal fever would be:

A. Diminished variability
B. Variable decelerations
C. Tachycardia
D. Early decelerations

 Correct

answer: C

The FHR increases as the maternal core

body temperature elevates, so
tachycardia would be the pattern
exhibited. It is often a clue of
intrauterine infection because maternal
fever is often the first sign.

A nulliparous woman is in the active phase of labor

and her cervix has progressed to 6 cm dilation. The
nurse caring for this woman evaluates the external
monitor tracing and notes the following: decrease in
FHR shortly after onset of several contractions,
returning to baseline rate by the end of the
contractions; shape is uniform. Based on these
finding, the nurse should:

A. Change the womans position to her left side

B. Document the finding on the womans chart
C. Notify the physician
D. Perform a vaginal examination to check for
cord prolapse

 Correct

answer: B

The pattern described is an early

deceleration pattern, which is
considered to be benign, reassuring, and
requiring no action other than
documentation of the finding.

The nurse has auscultated a fetal heart

rate of 80. What should be the nurses
initial action?

A.

Position the client on her left side

B. Administer oxygen at 5L/minute
C. Notify the physician or nurse-midwife
D. Check the maternal pulse

 Correct

answer: D

Key word is auscultated the nurse may

be hearing the maternal blood flow
through the uterus and not the fetal
heart rate.

At about 5 cm. dilation, a laboring client

receives medication for pain. The nurse is
aware that one of the medications given to
women in labor that could cause respiratory
depression of the newborn is:
A.
B.
C.
D.

Scopolamine
Promazine
Meperidine (Demerol)
Promethazine (Phergan)

 C.

Respiratory depression occurs

with the use of meperidine and
produces significant depression of
the infant at birth if circulating levels
are high at time of birth.

The nurse in the birthing suite has just

admitted the following four clients. Which
one of these clients should the nurse prepare
for cesarean section?
A.

Multipara with a shoulder

presentation
B. Multipara with a documented station
of floating
C. Primigravida with a fetus presenting
in occiput posterior
D. Primigravida with twin gestation
with lower most twin in vertex position.

 A.

Multipara with a shoulder

presentation is indicative of a
transverse lie; this indicates the need
for a cesarean section.

A client is admitted to the hospital in active

labor. After an amniotomy the nurse would
expect:

A.

Increased fetal heart rate

B. Diminished bloody show
C. Less discomfort with contractions
D. Progressive dilation and
effacement

 D.

Artificial rupture of membranes

(AROM) allows for more effective
pressure of the fetal head on the
cervix, enhancing dilation and
effacement.

During a clients labor, the fetus head is at

station +1. This indicates that the
presenting part is:
A.
B.
C.
D.

On the perineum
High in the false pelvis
Slightly below the ischial spines
Slightly above the ischial spines

 C.

The term station is used to

indicate the location of the
presenting part. The level of the tip
of the ischial spines is considered to
be zero. The position of the bony
prominence of the fetal head is
described in centimeters minus
(above the spines) or plus (below the
spines)

A client is admitted to the birthing suite in

early active labor. The priority nursing
intervention on admission of this client
would be:

A.

Auscultating the fetal heart

B. Taking an obstetric history
C. Asking the client when she ate
last
D. Ascertaining whether the
membranes are ruptured

 A.

Determining fetal well-being

supersedes all other measures. If
the fetal heart rate is absent or
persistently decelerating, immediate
intervention is required.

A client is admitted to the labor unit in the

latent phase of the first stage of labor, with
contractions lasting 20 seconds. In assessing
the clients emotional status, the nurse would
anticipate that the client will be:
A.
B.
C.
D.

Serious
Happy
Irritable
panicky

 B.

In the first stage of labor when

complications are absent and
contractions are weak, the client
experiences minimal discomfort. She
is usually excited, happy, and eager.
As labor progresses she becomes
more serious and is more likely to
become irritable, tired, and
sometimes panicky.

A multigravida client is admitted in active

labor. She is yelling, Hurry! Hurry! The
baby is coming! What priority action by the
nurse is indicated?
A.
B.
C.
D.

Check the fetal heart tones

Time the contraction interval
Determine the presenting part
Do a vaginal examination

 D.

A vaginal examination should be

performed to determine the
presenting part so preparation can
be made for delivery.

A nurse is assessing a client in labor and

finds that her contractions are lasting 60
seconds every 4 minutes and that her cervix
is 6 cm dilated. The nurse would document
that the client is in what stage of labor?
A.
B.
C.
D.

Active phase
Early phase
Latent phase
Transitional phase

 A.

During active labor the

contractions begin to last longer and
are occurring more frequently.
Cervical dilation occurs rapidly
during active labor and usually
progresses from 4 to 7 cm.

The nurse teaches a pregnant woman to

avoid lying on her back during labor. The
nurse has based this statement on the
knowledge that the supine position can:
A.

Unduly prolong labor

B. Cause decreased placental perfusion
C. Lead to transient episodes of
hypertension
D. Interfere with free movement of the
coccyx

 B.

This is because of impedance of

venous return by the gravid uterus,
which causes hypotension and
decreased systemic perfusion

The husband of a client who is in the transitional

phase of labor becomes very tense and nervous
during this period and asks the nurse, Do you think
it is best for me to leave, since I dont seem to do
my wife much good? The most appropriate
response by the nurse would be:

A. This is the time your wife needs you. Dont

run out on her now.
B. This is hard for you. Let me try to help you
coach her during this difficult phase.
C. I know this is hard for you. Why dont you go
have a cup of coffee and relax and come back
later if you feel like.
D. If you feel that way, youd best go out and sit
in the waiting room for a while because you may
transmit your anxiety to your wife.

 B.

Both the father and the mother

need additional support during the
transitional stage of labor

A client who was admitted in active labor has

only progressed from 2 cm to 3 cm in 8
hours. She is diagnosed as having hypotonic
dystocia and is given oxytocin to augment
her contractions. The most important aspect
of nursing at this time is:
A.

Monitoring the FHR

B. Checking the perineum for bulging
C. Preparing for an emergency
cesarean birth
D. Timing and recording length of
contractions

 D.

The oxytocic effect of Pitocin

increases the intensity, duration and
frequency of contractions; prolonged
contractions will jeopardize the
safety of the fetus and necessitate
discontinuing the drug

An expectant couple asks the nurse about

the cause of low back pain in labor. The
nurse replies that this pain occurs most when
the position of the fetus is:
A.
B.
C.
D.

Breech
Transverse
Occiput anterior
Occiput posterior

 D.

A persistent occiput posterior

position causes intense back pain
because of fetal compression of the
sacral nerves.

A client is 39 weeks pregnant and in labor.

Her physician has informed her that she will
have to have a cesarean birth because she
has:
A.
B.
C.
D.

Gonorrhea
Chlamydia
Chronic hepatitis
Active genital herpes

 D.

Once the membranes have

ruptured, the active herpes infection
ascends and can infect the fetus;
since herpes does not cross the
placenta, a cesarean birth can
decrease transfer of the virus to the
fetus

The nurse working in a triage clinic should

return which of the following clients
telephone messages first?
A.

37 weeks of gestation with SOB

B. 10 weeks of gestation with breast
tenderness
C. 35 weeks of gestation with feet
that well at the end of the day
D. 12 weeks of gestation with
darkening blotches of skin over her
cheekbones

 A.

The first call should be made to

the woman who is complaining of
dyspnea. A woman who is in her 37 th
week can have dyspnea from the
term gravid uterus pushing up on her
diaphragm, but she may also be
experiencing a respiratory
emergency such as pulmonary
embolus.

When a client is admitted to the labor suite

with a BP of 130/90, 2+ proteinuria, and
edema of the hands and face, the nurse
should ask the client about the presence of:

A. Constipation, edema, visual problems,

headache
B. Visual disturbances, headaches,
constipation, bleeding
C. Leakage of fluid, bleeding, edema, pain
in the abdomen
D. Headache, visual disturbances, edema,
pain in the abdomen

 D.

To ascertain the severity of

preeclampsia, these are the signs
that must be assessed.

The nurse is caring for a woman at 37 weeks

gestation. The nurse would be MOST
concerned by which of the following
findings?
A.

The patient c/o right quadrant

pain
B. BP 150/95
C. 4+ proteinuria
D. 3+ pitting edema

 A.

Indicates impaired liver function,

sign of impending eclampsia. B/P
greater than 160/110 considered
severe preeclampsia, 4+ proteinuria
indicates severe preeclampsia, and
3+ pitting edema is indicative of mild
preeclampsia

A client is on magnesium sulfate therapy for

severe preeclampsia. The nurse must be
alert for the first sign of an excessive blood
magnesium level, which is:
A.

Disturbance in sensorium
B. Increase in respiratory rate
C. Development of cardiac
dysrhythmia
D. Disappearance of the knee-jerk
reflex

 D.

Magnesium sulfate has a CNS

depressant effect therefore, toxic
levels will be reflected in decreased
respiration and the absence of the
knee-jerk reflex. Cardiac
dysrhythmia occurs with increased
potassium not magnesium sulfate.

A pregnant client is receiving magnesium

sulfate for eclampsia. Which medication
should the nurse have available as an
antidote for possible toxicity?
A.
B.
C.
D.

Vitamin K
Calcium gluconate
Naloxone (Narcan)
Diazepam (Valium)

 B.

Calcium gluconate is the

antagonist to magnesium sulfate that
would be ordered if toxicity occurs.

A 26 year-old woman is brought to the emergency

room complaining of severe left lower quadrant
pain. She tells the nurse that she performed a home
pregnancy test and believes she is 8 weeks
pregnant. On admission the patients vital signs are
pulse 90, BP 110/70, respirations 20. A half-hour
later her vital signs are pulse 120, BP 86/50,
respirations 26. The nurse interprets the change in
the patients vital signs to mean that:
A.

The patients pain may have increased

B. The patient may be bleeding internally
C. The patient may be frightened
D. The patient may have an infection

 B.

Decreased BP equals decreased

intravascular volume; shock. BP
increases with pain and fear.
Infection usually wont change BP
unless in septic shock.

The nurse is caring for clients in the labor

and delivery unit. The nurse notes that a
clients membranes have ruptured and the
amniotic fluid is meconium-stained. The
nurse determines that there is no prolapsed
cord. Which of the following actions should
the nurse take NEXT?

A. Contact the health care provider

B. Assess fetal heart tones
C. Start an intravenous line
D. Obtain the clients pulse and blood
pressure

 B.

Meconium-stained amniotic fluid

may be an ominous sign; assess for
nonreassuring fetal heart tone
patterns-fetal bradycardia, irregular
FHR, late, severe variables and
prolonged deceleration patterns; if
fetal distress, turn client to left side,
give O2 and start IV.

Abruptio placentae is most likely to

occur in a woman with:
A.
B.
C.
D.

Cardiac disease
Hyperthyroidism
Gestational hypertension
Cephalopelvic disproportion

 C.

Hypertension during pregnancy

leads to vasospasms; this in turn
causes the placenta to tear away
from the uterine wall.

The nurse cares for an 18 year-old woman in

the labor unit. During the transitional phase
of labor the umbilical cord becomes
prolapsed. The nurse should place the
patient in which of the following positions?
A.
B.
C.
D.

Lithotomy
Side-lying
Semi-fowlers
Trendelenberg

 D.

Gravity relieves pressure on cord

from fetal head. Or put finder against
presenting part and shift weight off
cord. Lithotomy used for
examination of vagina or rectum.
Side-lying removes weight from vena
cava, does not help with prolapsed
cord. Semi-fowlers aggravates
prolapsed cord.

Despite medication, a clients preterm labor

continues, her cervix dilates, and birth
appears inevitable. The nurse understands
the infants chance of extrauterine survival
may improve if the physician orders:
A.

Ampicillin by piggyback
B. Dexamethasone by infusion
C. An immediate cesarean delivery
D. An intrauterine exchange
transfusion

 B.

Steroids are given for a short

period before delivery; by some
obscure mechanism, they help to
mature the fetus lungs

A client experiences a normal newborn

delivery. After the placenta is delivered, the
physician orders a medication to be added to
the IV solution. Which medication is the
nurse most likely administering at this time?
A.
B.
C.
D.

Penicillin
Atropine
Oxytocin
AquaMEPHYTON

 C.

Oxytocin (Pitocin) stimulates

uterine contractions. When oxytocin
is given after delivery of the
placenta, the contractions stimulated
by the drug help control bleeding.

During the postpartum period after a

cesarean birth, the nurse examines the client
and identifies the presence of lochia serosa
and feels the fundus four fingerbreadths
below the umbilicus. This indicates that the
time elapsed is:
A.
B.
C.
D.

1 to 3 days postpartum
4 to 5 days postpartum
6 to 7 days postpartum
8 to 9 days postpartum

 B.

The fundus descends one

fingerbreadth per day from the first
postpartum day; lochia serosa begins
to flow on the fifth day.

A client after a vaginal delivery is at risk for

postpartum hemorrhage. Nursing education
to prevent postpartum hemorrhage is based
on the knowledge that priority explanation for
the cause is:
A.
B.
C.
D.

Laceration of the perineal area

Uterine rupture
High parity
Uterine atony

 D.

About 75% of all hemorrhages are

due to uterine atony, which is the
lack of uterine tone. Laceration of
the perineal area, uterine rupture
and high parity are other causes of
hemorrhage, but they are not as
likely.

The nurse working on the postpartum unit

should encourage clients to ambulate early
to:

A.

Promote respirations
B. Increase the tone of the bladder
C. Maintain tone of abdominal
muscles
D. Increase peripheral vasomotor
activity

 D.

There is extensive activation of

the blood clotting factor after
delivery; this, together with
immobility, trauma or sepsis,
encourages thromboembolization,
which can be limited through activity.

Since having a baby by cesarean section, a

client has walked to the nursery numerous
times to see her baby each day. Two days
postpartum, the client complains of pain in
the right leg. The nurses initial response
should be to:
A.

Apply hot soaks

B. Massage the affected limb
C. Encourage ambulation and
exercise
D. Maintain bed rest and notify the
physician

 D.

Although thrombophlebitis is
suspected, before a definitive
diagnosis the client should be
confined to bed so that further
complications may be avoided.

A nurse assesses a client who delivered 1

hour ago. The fundus is firm and two
fingerbreadths below the umbilicus, and the
lochia is bright red. The client complains of
having chills. What would the nurse
recognize based on this assessment?
A.

An inverted uterus
B. Acute hemorrhage
C. A normal postpartum response
D. The early stage of hypovolemic
shock

 C.

After delivery, the uterus

continues to contract and reduce in
size. The client should be covered
and kept warm because chills are a
normal process immediately after
delivery. Red, bloody lochia is normal
at this time as well.

When is a client most likely to

experience postpartum depression?
A.
B.
C.
D.

Within the first 48 hours

Within the first 72 hours
By the fourth or fifth day
During the second week

 C.

Elevated hormone levels begin to

fall by the fourth or fifth day after
delivery. This shift in hormones
causes the depressed mood.
Depending on their coping ability,
some women may experience more
severe depression than others.

When checking a clients fundus on the

second postpartum day, the nurse observes
that the fundus is above the umbilicus and
displaced to the right. The nurse evaluates
that the client probably has:
A.
B.
C.
D.

A slow rate of involution

A full, overdistended bladder
Retained placental fragments
Overstretched uterine ligaments

 B.

A distended bladder will displace

the fundus upward and laterally

A postpartum client experiences a

temperature spike of 101 F (38.3 C) 12 hours
after delivery. What would the nurse
suspect?
A.
B.
C.
D.

Infection
Hemorrhage
Dehydration
A normal response

 C.

Fever within the first 24 hours

postpartum indicates dehydration.
After 24 hours, however, it is
indicative of a puerperal infection.

During early postpartum, when assessing a

clients episiotomy, the nurse identifies
edema with severe ecchymosis. Also, the
client is complaining of severe perineal and
rectal pressure. The fundus is firm, and
there is no lochia. The clients vital signs are
T 99 F, P 108, R 20, BP 105/60. This
assessment most likely indicates a:
A.
B.
C.
D.

Urinary infection
Uterine infection
Vaginal hematoma
Postpartum hemorrhage

 C.

These are classic signs and

symptoms of a vaginal hematoma

The nurse identifies that a woman needs

further teaching about breastfeeding her
newborn when she:
A.

Leans forward and puts her breast

into the infants mouth
B. Holds the infant level with her breast
and in a side-lying position
C. Touches her nipple to the infants
lips when beginning the feeding
D. Puts her finger in the infants mouth
to break the suction when switching
breasts

 A.

When the breast is pushed into

the infants mouth a typical response
is for the mouth to close too soon,
resulting in inadequate latching-on

The nurse should plan to teach a recently

delivered client who is formula-feeding her
infant to minimize breast discomfort by:
A.

Gently applying cocoa butter

B. Manually expressing colostrum
C. Applying covered ice packs to her
breasts
D. Placing warm, wet washcloths on
her nipples

 C.

Covered ice packs promote

comfort by decreasing
vasocongestion

A client with mastitis is concerned about

breastfeeding her newborn infant. Which
recommendation should the nurse provide to
the client?

A. Stop breastfeeding until after completing

antibiotics
B. Supplement feeding with forumla until the
infection resolves
C. Continue to breastfeed because mastitis
will not infect the infant
D. Do not use analgesics because they may
be passed to the newborn through breast milk

 C.

The client with mastitis should be

encouraged to continue breastfeeding
while taking antibiotics for the
infection. No supplemental feedings
is necessary because breastfeeding
does not need to be altered and
actually encourage resolution of the
infection. Analgesics are safe and
should be used as needed.

A nurse makes all the following observations

of a mother who is interacting with her
newborn 8 hours after delivery. Which
observation would alert the nurse to a
potential problem with the maternal-infant
attachment?
A. The mother speaks to the newborn during
crying spells.
B. The mother undresses the newborn during a
diaper change.
C. The mother takes the newborn with her to
the baby care classes.
D. The mother consistently engages eye
contact with the father as she feeds the
newborn.

 D.

Maternal-infant bonding is
evidenced by the mother-infant
interactions. This mother seems
focused primarily on her husband,
which may indicate a problem with
bonding.

During which phase of maternal

psychological adaptation is it best for a
nurse to teach a postpartum client
about caring for a newborn infant?
A.
B.
C.
D.

Taking-in
Letting-go
Taking-hold
Letting-down

 C.

Beginning after the completion of

the taking-in phase, the taking-hold
phase lasts about 7 days. During
this phase, the client is concerned
with her need to resume control of all
facets of her life in a competent
manner. At this time, she is ready to
learn self-care and infant-care skills.

A 28 year-old woman has just delivered

her first child, a boy weighing 6 lbs.
and 2 oz. The Apgar scores at one and
five minutes are 8 and 9. The nurse
understands that:

A. An isolette should be ready in the nursery for close

observation of this infant

B. The newborn is making an optimal transition to extrauterine

life

C. The parents will need emotional support to deal with a less

than perfect child

D. High Apgar scores correlate well with future emotional and

intellectual development

 B.

Good Apgar. Nursery care is not

needed and there is no relationship
between Apgar and future
emotional/intellectual development.

An infant born in the 36th week of gestation

weighs 4 lbs 9 oz (2062 gms) and has an
Apgar of 7/9. On admission to the nursery,
it would be unnecessary for the nurse to:
A.
B.
C.
D.

Record vital signs

Administer oxygen
Support body temperature
Evaluate the newborns status

 B.

The babys Apgar score (7/9) does

not indicate a need for oxygen.

At 10 hours of age an infant has a large

amount of mucus and becomes slightly
cyanotic. The nurse should first:
A.
B.
C.
D.

Insert a Levin tube

Give the infant oxygen
Suction the mucus as needed
Note the incident on the chart

 C.

To maintain a patent airway and

promote respiration and gaseous
exchange, mucus must be removed.

When observing a newborn for signs of

pathologic jaundice, the nurse should be
alert for:
A.

Muscular irritability at birth

B. Neurologic signs during the first
24 hours
C. The appearance of jaundice
during the first 24 hours
D. Jaundice developing between the
second and fourth day of life

 C.

Development of jaundice in the

first 24 hours indicates hemolytic
disease of the newborn requiring
immediate medical investigation.
Jaundice occurring between 48 and
72 hours after birth is a consequence
of the normal physiologic breakdown
of fetal RBCs and immaturity of the
liver.

Which of the following observations of an 8

lb 4 oz newborn boy, if made by the nurse,
would require an intervention?

A. The infants respirations are 36,

shallow and irregular in rate, rhythm,
and depth
B. Rapid pulsations are visible in the
fifth intercostal space, left midclavicular
line
C. The infants axillary temperature is
96.2 F (35.6 C)
D. There is asynchronous spontaneous
movement of the infants extremities

 C.

Subnormal temperature indicates

prematurity, infection, low
environment temperature,
inadequate clothing, and
dehydration.

A newborn is diagnosed as having Erbs

Palsy. The nurse is aware that this problem
is caused by:
A.

A disease acquired in utero

B. An X-linked inheritance pattern
C. A tumor arising from muscle
tissue
D. An injury to the brachial plexus
during birth

 D.

The brachial plexus is injured by

excessive pressure during a difficult
delivery requiring the use of forceps
or during a breech delivery; it is
considered a birth injury and not
related to genetic factors or disease.

Asymmetric Moro reflexes are

frequently associated with:
A.

Downs syndrome
B. Cranial nerve damage
C. Cerebral or cerebellar injuries
D. Brachial plexus, clavicle or
humerus injuries

 D.

Injury to the brachial plexus,

clavicle, or humerus prevents
abduction and adduction movements
of an upper extremity.

A newborn has asymmetric gluteal

folds. The nurse suspects:
A.

CNS damage
B. Dysplasia of hip
C. An inguinal hernia
D. Peripheral nervous system
damage

 B.

Asymmetric gluteal and leg folds

indicates hip dysplasia. Gluteal folds
are elevated on the affected side.

A nurse is assessing a newborn and

recognizes which of the following as a sign
of postmaturity?
A.
B.
C.
D.

Smooth, supple skin

Long, brittle fingernails
Well-developed eyebrows
Creases in the soles of the feet

 B.

The fingernails begin to form

around 12 weeks gestation. By 39 to
40 weeks, the nails have covered the
nailbeds. After 40 weeks, the nails
begin to extend and have a long
appearance.

Which finding would be manifested in

an infant with a myelomeningocele?
A.

Clubbed feet and muscle spasms

in the legs and arms.
B. Obstruction of bowel and impaired
bladder function
C. Spastic movement of upper and
lower extremities
D. Impaired bowel and bladder
function and paralysis of the legs.

D. The nerves of the cauda equina

are involved with a
myelomeningocele, which results in
lower extremity paralysis. Innervation
to the anal sphincter and the bladder
is decreased, causing incontinence.
Bowel function may be affected, but
there is no obstruction and the upper
extremities are not affected.

A new mother expresses concern over

strabismus in her infant. What would the
nurse explain to the mother regarding this
condition?
A.
B.
C.
D.

It is a normal finding in newborns

This may be a permanent defect
It will require corrective surgery
It will result in imparied vision

 A.

Muscle control of the eyes in the

newborn is undeveloped, resulting in
temporary strabismus, or a crosseyed appearance. This is considered
normal in the newborn.

Which observation in a 24 hour-old newborn

should be reported to the physician
immediately?
A.

Blotchy, mottled skin

B. Positive Babinski reflex
C. Tremors and spasms of all
extremities
D. High-pitched crying and arching
of the back

 D.

A high-pitched cry and arching of

the back are cardinal signs of a
neurological problem.