POST TEST
OBSTETRIC NURSING PART I
1. A patient, G2P1102, who delivered her baby 8
hours ago, now has a temperature of 100.2oF.
Which of the following is the appropriate nursing
intervention at this time?
a. Notify the doctor to get an order for
acetaminophen.
b. Request an infectious disease consult from
the doctor.
c. Provide the woman with cool compresses.
d. Encourage intake of water and other fluids.
2. A 3-day-postpartum breastfeeding woman is
being assessed. Her breasts are firm and warm
to the touch. When asked when she last fed the
baby her reply is, “I fed the baby last evening. I
let the nurses feed him in the nursery last night.
I needed to rest.” Which of the following actions
should the nurse take at this time?
a. Encourage the woman exclusively to
breastfeed her baby.
b. Have the woman massage her breasts
hourly.
c. Obtain an order to culture her expressed
breast milk.
d. Take the temperature and pulse rate of the
woman.
3. A G2P2002, who is postpartum 6 hours from a
spontaneous vaginal delivery, is assessed. The
nurse notes that the fundus is firm at the
umbilicus, there is heavy lochia, and perineal
sutures are intact. Which of the following
actions should the nurse take at this time?
a. Do nothing. This is a normal finding.
b. Massage the woman’s fundus.
c. Take the woman to the bathroom to void.
d. Notify the woman’s primary health care
provider.
4. A multigravid, postpartum woman reports
severe abdominal cramping whenever she
nurses her infant. Which of the following
responses by the nurse is appropriate?
a. Suggest that the woman bottlefeed for a few
days.
b. Instruct the patient on how to massage her
fundus.
c. Instruct the patient to feed using an
alternate position.
d. Discuss the action of breastfeeding
hormones.
5. The nurse monitors his or her postpartum
clients carefully because which of the following
physiological changes occurs during the early
postpartum period?
a. Decreased urinary output.
b. Increased blood pressure.
c. Decreased blood volume.
d. Increased estrogen level.
6. The nurse is evaluating the involution of a
woman who is 3 days postpartum. Which of the
following findings would the nurse evaluate as
normal?
a. Fundus 1 cm above the umbilicus, lochia
rosa.
b. Fundus 2 cm above the umbilicus, lochia
alba.
c. Fundus 2 cm below the umbilicus, lochia
rubra.
d. Fundus 3 cm below the umbilicus, lochia
serosa.
7. The nurse is assessing the midline episiotomy
on a postpartum client. Which of the following
findings should the nurse expect to see?
a. Moderate serosanguinous drainage.
b. Well-approximated edges.
c. Ecchymotic area distal to the episiotomy.
d. An area of redness adjacent to the incision.
8. The nurse is examining a 2-day postpartum
client whose fundus is 2 cm below the umbilicus
and whose bright red lochia saturates about 4
inches of a pad in 1 hour. What should the
nurse document in the nursing record?
a. Abnormal involution, lochia rubra heavy.
b. Abnormal involution, lochia serosa scant.
c. Normal involution, lochia rubra moderate.
d. Normal involution, lochia serosa heavy.
9. The nurse palpates a distended bladder on a
woman who delivered vaginally 2 hours earlier.
The woman refuses to go to the bathroom, “I
really don’t need to go.” Which of the following
responses by the nurse is appropriate?
a. “Okay. I must be palpating your uterus.”
b. “I understand but I still would like you to try
to urinate.”
c. “You still must be numb from the local
anesthesia.”
d. “That is a problem. I will have to catheterize
you.”
10. A client, G1P0101, postpartum 1 day, is
assessed. The nurse notes that the client’s
lochia rubra is moderate and her fundus is
boggy 2 cm above the umbilicus and deviated to
the right. Which of the following actions should
the nurse take first?
a. Notify the woman’s primary health care
provider.
b. Massage the woman’s fundus.
c. Escort the woman to the bathroom to
urinate.
d. Check the quantity of lochia on the peripad.
11. The nurse is providing instructions to a pregnant
client who is scheduled for an amniocentesis.
What instruction would the nurse provide?
a. Strict bed rest is required after the
procedure.
b. Hospitalization is necessary for 24 hours
after the procedure.
c. An informed consent needs to be signed
before the procedure.
d. A fever is expected after the procedure
because of the trauma to the abdomen.
12. A nonstress test is performed on a client who is
pregnant, and the results of the test indicate
nonreactive findings. The primary health care
provider prescribes a contraction stress test,
and the results are documented as negative.
How would the nurse document this finding?
a. A normal test result
b. An abnormal test result
c. A high risk for fetal demise
d. The need for a cesarean section
13. A rubella titer result of a 1-day postpartum
client is less than 1:8, and a rubella virus
vaccine is prescribed to be administered before
discharge. The nurse provides which information
to the client about the vaccine? Select all that
apply.
1. Breast/chest-feeding needs to be stopped
for 3months.
2. Pregnancy needs to be avoided for 1 to 3
months.
3. The vaccine is administered by the
subcutaneous route.
4. Exposure to immunosuppressed individuals
needs to be avoided.
5. A hypersensitivity reaction can occur if the
client has an allergy to eggs.
6. The area of the injection needs to be
covered with a sterile gauze for 1 week.
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a. 1 2 3 4 5
c. 3 4 5
b. 2 3 4 5
d. 4 5
14. The nurse in a health care clinic is instructing a
pregnant client how to perform “kick counts.”
Which statement by the client indicates a need
for further instruction?
a. “I will record the number of movements or
kicks.”
b. “I need to lie flat on my back to perform the
procedure.”
c. “If I count fewer than 10 kicks in a 2-hour
period, it could be because my baby is
sleeping.”
d. “I need to place my hands on the largest
part of my abdomen and concentrate on the
fetal movements to count the kicks.”
15. A pregnant client in the first trimester calls the
nurse at a health care clinic and reports noticing
a thin,colorless vaginal drainage. The nurse
would make which statement to the client?
a. “Come to the clinic immediately.”
b. “The vaginal discharge may be bothersome,
but is a normal occurrence.”
c. “Report to the emergency department at the
maternity center immediately.”
d. “Use tampons if the discharge is
bothersome, but be sure to change the
tampons every 2 hours.”
16. The 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 notes that the fundal height is
30 cm. How would the nurse interpret this
finding?
a. The client is measuring large for gestational
age.
b. The client is measuring small for gestational
age.
c. The client is measuring normal for
gestational age.
d. More evidence is needed to determine size
for gestational age.
17. A pregnant client is seen for a regular prenatal
visit and tells the nurse about experiencing
irregular contractions. The nurse determines
that the client is experiencing Braxton Hicks
contractions. On the basis of this finding, which
nursing action is appropriate?
a. Contact the primary health care provider.
b. Instruct the client to maintain bed rest for
the remainder of the pregnancy.
c. Inform the client that these contractions are
common and may occur throughout the
pregnancy.
d. Call the maternity unit and inform them that
the client will be admitted in a preterm labor
condition.
18. The nurse is collecting data during an admission
assessment of a client who is pregnant with
twins. The client has a healthy 5-year-old child
who was delivered at 38 weeks and tells the
nurse that there is no history of any type of
abortion or fetal demise. Using GTPAL, what
would the nurse document in the client’s chart?
a. G = 3, T = 2, P = 0, A = 0, L = 1
b. G = 2, T = 1, P = 0, A = 0, L = 1
c. G = 1, T = 1, P = 1, A = 0, L = 1
d. G = 2, T = 0, P = 0, A = 0, L = 1
19. The nurse is providing instructions to a pregnant
client with human immunodeficiency virus (HIV)
infection regarding care of the newborn after
delivery. The client asks the nurse about the
feeding options that are available. Which
response would the nurse make to the client?
a. “You will need to bottle-feed your newborn.”
b. “You will need to feed your newborn by
nasogastric tube feeding.”
c. “You will be able to breast/chest-feed for 6
months and then will need to switch to
bottle-feeding.”
d. “You will be able to breast/chest-feed for 9
months and then will need to switch to
bottle-feeding.”
20. The home care nurse visits a pregnant client
who has a diagnosis of preeclampsia. Which
assessment finding indicates a worsening of the
preeclampsia and the need to notify the primary
health care provider (PHCP)?
a. Urinary output has increased.
b. Dependent edema has resolved.
c. Blood pressure reading is at the prenatal
baseline.
d. The client complains of a headache and
blurred vision.
21. The nurse implements a teaching plan for a
pregnant client who is newly diagnosed with
gestational diabetes mellitus. Which statement
made by the client indicates a need for further
teaching?
a. “I need to stay on the diabetic diet.”
b. “I need to perform glucose monitoring at
home.”
c. “I need to avoid exercise because of the
negative effects on insulin production.”
d. “I need to be aware of any infections and
report signs of infection immediately to my
obstetrician.”
22. The nurse is performing an assessment on a
pregnant client in the last trimester with a
diagnosis of preeclampsia. The nurse reviews
the assessment findings and determines that
which finding is most closely associated with a
complication of this diagnosis?
a. Enlargement of the breasts
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,
petechiae, and purpura
23. The nurse in a maternity unit is reviewing the
clients’ records. Which clients would the nurse
identify as being at the most risk for developing
disseminated intravascular coagulation (DIC)?
Select all that apply.
a. A primigravida with abruptio placentae
b. A primigravida who delivered a 10-lb infant
3 hours ago
c. A gravida 2 who has just been diagnosed
with dead fetus syndrome
d. A gravida 4 who delivered 8 hours ago and
has lost 500 mL of blood
e. A primigravida at 29 weeks of gestation who
was recently diagnosed with gestational
hypertension
24. The home care nurse is monitoring a pregnant
client who is at risk for preeclampsia. At each
home care visit, the nurse assesses the client
for which sign of preeclampsia?
a. Hypertension
b. Low-grade fever
c. Generalized edema
d. Increased pulse rate
25. The nurse is assessing a pregnant client with
type 1 diabetes mellitus about an understanding
regarding changing insulin needs during
pregnancy. The nurse determines that further
teaching is needed if the client makes which
statement?
a. “I will need to increase my insulin dosage
during the first 3 months of pregnancy.”
b. “My insulin dose will probably need to be
increased during the second and third
trimesters.”
c. “Episodes of hypoglycemia are more likely to
occur during the first 3 months of
pregnancy.”
d. “My insulin needs will return to prepregnant
levels within 7 to 10 days after birth if I am
bottle feeding.”
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26. A pregnant client reports to a health care clinic,
complaining of loss of appetite, cough, weight
loss, and fatigue. After assessment of the client,
tuberculosis is suspected. A sputum culture is
obtained and identifies Mycobacterium
tuberculosis. Which instruction would the nurse
include in the client’s teaching plan?
a. Therapeutic abortion is required.
b. Isoniazid plus rifampin will be required for 9
months.
c. The client will have to stay at home until
treatment is completed.
d. Medication will not be started until after
delivery of the fetus.
27. The nurse is providing instructions to a pregnant
client with a history of cardiac disease regarding
appropriate dietary measures. Which statement,
if made by the client, indicates an
understanding of the information provided by
the nurse?
a. “I need to increase my sodium intake during
pregnancy.”
b. “I need to lower my blood volume by
limiting my fluids.”
c. “I need to maintain a low-calorie diet to
prevent any weight gain.”
d. “I need to drink adequate fluids and increase
my intake of high-fiber foods.”
28. The clinic nurse is performing a psychosocial
assessment of a client who is pregnant. Which
assessment findings indicate to the nurse that
the client is at risk for contracting human
immunodeficiency virus (HIV)? Select all that
apply.
a. The client has a history of intravenous drug
use.
b. The client has a significant other who is
heterosexual.
c. The client has a history of sexually
transmitted infections.
d. The client has had one sexual partner for the
past 10 years.
e. The client has a previous history of
gestational diabetes mellitus.
29. The nurse evaluates the ability of a hepatitis B–
positive birthing parent to provide safe bottlefeeding to the newborn during postpartum
hospitalization. Which action best exemplifies
the birthing parent’s knowledge of potential
disease transmission to the newborn?
a. The birthing parent requests that the
window be closed before feeding.
b. The birthing parent holds the newborn
properly during feeding and burping.
c. The birthing parent tests the temperature of
the formula before initiating feeding.
d. The birthing parent washes and dries the
hands before and after self-care of the
perineum and asks for a pair of gloves
before feeding.
30. A client in the first trimester of pregnancy
arrives at a health care clinic and reports has
been experiencing vaginal bleeding. A
threatened abortion is suspected, and the nurse
instructs the client regarding management of
care. Which statement made by the client
indicates a need for further instruction?
a. “I will watch to see if I pass any 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 episode of bleeding.”
31. The 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
assessment finding would the nurse expect to
note if this condition is present?
a. Soft abdomen
b. Uterine tenderness
c. Absence of abdominal pain
d. Painless, bright red vaginal bleeding
32. The maternity nurse is preparing for the
admission of a client in the third trimester of
pregnancy who is experiencing vaginal bleeding
and has a suspected diagnosis of placenta
previa. The nurse reviews the primary health
care provider’s prescriptions and would question
which prescription?
a. Prepare the client for an ultrasound.
b. Obtain equipment for a manual pelvic
examination.
c. Prepare to draw a hemoglobin and
hematocrit blood sample.
d. Obtain equipment for external electronic
fetal heart rate monitoring.
33. An ultrasound is performed on a client at term
gestation who is experiencing moderate vaginal
bleeding. The results of the ultrasound indicate
that abruptio placentae is present. On the basis
of these findings, the nurse would prepare the
client for which anticipated prescription?
a. Delivery of the fetus
b. Strict monitoring of intake and output
c. Complete bed rest for the remainder of the
pregnancy
d. The need for weekly monitoring of
coagulation studies until the time of delivery
34. The nurse in the postpartum unit is caring for a
client who has just delivered a newborn infant
following a pregnancy with placenta previa. The
nurse reviews the plan of care and prepares to
monitor the client for which risk associated with
placenta previa?
a. Infection
b. Hemorrhage
c. Chronic hypertension
d. Disseminated intravascular coagulation
35. The nurse is performing an assessment on a
client diagnosed with placenta previa. Which
assessment findings would the nurse expect to
note? Select all that apply.
1. Uterine rigidity
2. Uterine tenderness
3. Severe abdominal pain
4. Bright red vaginal bleeding
5. Soft, relaxed, nontender uterus
6. Fundal height may be greater than expected
for gestational age
a. 1 2 3
c. 4 5 6
b. 2 3 4
d. All of the above
36. The nurse is performing an assessment on a
client who has just been told that a pregnancy
test is positive. Which assessment finding
indicates that the client is at risk for preterm
labor?
a. The client is a 35-year-old primigravida.
b. The client has a history of cardiac disease.
c. The client’s hemoglobin level is 13.5 g/dL
(135mmol/L).
d. The client is a 20-year-old primigravida of
average weight and height.
37. The nurse is monitoring a client who is in the
active stage of labor. The nurse documents that
the client is experiencing labor dystocia. The
nurse determines which risk factors in the
client’s history places the client at risk for this
complication? Select all that apply.
1. Age 45 years
2. Body mass index of 28
3. Previous difficulty with fertility
4. Administration of oxytocin for induction
5. Potassium level of 3.6 mEq/L (3.6 mmol/L)
a. 1 2 3
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b. 1 2 3 4
c. All of the above
d. None of the above
38. The nurse in a birthing room is monitoring a
client with dystocia for signs of fetal or maternal
compromise. Which assessment finding would
alert the nurse to a compromise?
a. Maternal fatigue
b. Coordinated uterine contractions
c. Progressive changes in the cervix
d. Persistent nonreassuring fetal heart rate
39. The nurse in a labor room is preparing to care
for a client with hypertonic uterine contractions.
The nurse is told that the client is experiencing
uncoordinated contractions that are erratic in
their frequency, duration, and intensity. What is
the priority nursing action?
a. Provide pain relief measures.
b. Prepare the client for an amniotomy.
c. Promote ambulation every 30 minutes.
d. Monitor the oxytocin infusion closely.
40. The nurse is reviewing the primary health care
provider’s (PHCP’s) prescriptions for a client
admitted for premature rupture of the
membranes. Gestational age of the fetus is
determined to be 37 weeks. Which prescription
would the nurse question?
a. Monitor fetal heart rate continuously.
b. Monitor maternal vital signs frequently.
c. Perform a vaginal examination every shift.
d. Administer an antibiotic per prescription and
per agency protocol.
41. The nurse has created a plan of care for a client
experiencing dystocia and includes several
nursing actions in the plan of care. What is the
priority nursing action?
a. Providing comfort measures
b. Monitoring the fetal heart rate
c. Changing the client’s position frequently
d. Keeping the significant other informed of the
progress of the labor
42. Fetal distress is occurring with a laboring client.
As the nurse prepares the client for a cesarean
birth, what is the most important nursing
action?
a. Slow the intravenous flow rate.
b. Continue the oxytocin drip if infusing.
c. Place the client in a high Fowler’s position.
d. Administer oxygen, 8 to 10 L/minute, via
face mask.
43. The nurse in a labor room is performing a
vaginal assessment on a pregnant client in
labor. The nurse notes the presence of the
umbilical cord protruding from the vagina. What
is the first nursing action with this finding?
a. Gently push the cord into the vagina.
b. Place the client in Trendelenburg’s position.
c. Find the closest telephone and page the
primary health care provider stat.
d. Call the delivery room to notify the staff that
the client will be transported immediately.
44. The postpartum nurse is taking the vital signs of
a client who delivered a healthy newborn 4
hours ago. The nurse notes that the client’s
temperature is 100.2° F (37.8°C). What is the
priority nursing action?
a. Document the findings.
b. Notify the obstetrician.
c. Retake the temperature in 15 minutes.
d. Increase hydration by encouraging oral
fluids.
45. The nurse is assessing a client who is 6 hours
postpartum after delivering a full-term healthy
newborn. The client complains to the nurse of
feelings of dizziness. Which nursing action is
most appropriate?
a. Raise the head of the client’s bed.
b. Obtain hemoglobin and hematocrit levels.
c. Instruct the client to request help when
getting out of bed.
d. Inform the nursery room nurse to avoid
bringing the newborn to the client until the
client’s symptoms have subsided.
46. The postpartum nurse is providing instructions
to a client after the birth of a healthy newborn.
Which time frame would the nurse relay to the
client regarding the return of bowel function?
a. 3 days postpartum
b. 7 days postpartum
c. On the day of birth
d. Within 2 weeks postpartum
47. The nurse is planning care for a postpartum
client who had a vaginal delivery 2 hours ago.
The client required an episiotomy and has
several hemorrhoids. What is the priority
nursing consideration for this client?
a. Client pain level
b. Inadequate urinary output
c. Client perception of body changes
d. Potential for imbalanced body fluid volume
48. The nurse is providing postpartum instructions
to a client who will be breast-feeding/chestfeeding the newborn. The nurse determines that
the client has understood the instructions if the
client makes which statements? Select all that
apply.
1. “I need to wear a bra that provides
support.”
2. “Drinking alcohol can affect my milk supply.”
3. “I will start my estrogen birth control pills
again as soon as I get home.”
4. “I know if my breasts/chest get engorged, I
will limit my breast-feeding/chest-feeding
and supplement the baby.”
5. “I plan on having bottled water available in
the refrigerator so I can get additional fluids
easily.”
a. 1 2 3
c. 1 2 5
b. 1 2 4
d. All of the above
49. The nurse is teaching a postpartum client about
breast-feeding/chest-feeding. Which instruction
would the nurse plan to include in the teaching
session?
a. The diet needs to include additional fluids.
b. Prenatal vitamins need to be discontinued.
c. Soap needs to be used to cleanse the
breasts/chest.
d. Birth control measures are unnecessary
while breast-feeding/chest-feeding.
50. The nurse is preparing to assess the uterine
fundus of a client in the immediate postpartum
period. After locating the fundus, the nurse
notes that the uterus feels soft and boggy.
Which nursing intervention is appropriate?
a. Elevate the client’s legs.
b. Massage the fundus until it is firm.
c. Ask the client to turn on the left side.
d. Push on the uterus to assist in expressing
clots.
51. The nurse is caring for four 1-day postpartum
clients. Which client assessment requires the
need for follow-up?
a. The client with mild afterpains
b. The client with a pulse rate of 60 beats per
minute
c. The client with colostrum discharge from
both breasts/chest
d. The client with lochia that is red and has a
foul-smelling odor
52. When performing a postpartum assessment on
a client, the nurse notes the presence of clots in
the lochia. The nurse examines the clots and
notes that they are larger than 1 cm. Which
nursing action is
a. most appropriate?
b. Document the findings.
c. Notify the obstetrician (OB).
d. Reassess the client in 2 hours.
e. Encourage increased oral intake of fluids.
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53. The nurse is monitoring the amount of lochia
drainage in a client who is 2 hours postpartum
and notes that the client has saturated a
perineal pad in 15 minutes. What action would
the nurse take initially?
a. Document the finding.
b. Encourage the client to ambulate.
c. Encourage the client to increase fluid intake.
d. Contact the obstetrician (OB) to report this
finding.
54. The nurse has provided discharge instructions to
a client who delivered a healthy newborn by
cesarean delivery. Which statement made by
the client indicates a need for further
instruction?
a. “I will begin abdominal exercises
immediately.”
b. “I will notify my obstetrician 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 my newborn
baby for at least 2 weeks.”
55. A patient, 32 weeks pregnant with severe
headache, is admitted to the hospital with
preeclampsia. In addition to obtaining baseline
vital signs and placing the client on bed rest,
the physician ordered the following four items.
Which of the orders should the nurse perform
first?
a. Assess deep tendon reflexes.
b. Obtain complete blood count.
c. Assess baseline weight.
d. Obtain routine urinalysis.
56. A 32-week-gestation client was last seen in the
prenatal client at 28 weeks’ gestation. Which of
the following changes should the nurse bring to
the attention of the certified nurse midwife?
a. Weight change from 128 pounds to 138
pounds.
b. Pulse rate change from 88 bpm to 92 bpm.
c. Blood pressure change from 120/80 to
118/78.
d. Respiratory rate change from 16 rpm to 20
rpm.
57. A 24-week-gravid client is being seen in the
prenatal clinic. She states, “I have had a terrible
headache for the past 2 days.” Which of the
following is the most appropriate action for the
nurse to perform next?
a. Inquire whether or not the client has
allergies.
b. Take the woman’s blood pressure.
c. Assess the woman’s fundal height.
d. Ask the woman about stressors at work.
58. A client has severe preeclampsia. The nurse
would expect the primary health care
practitioner to order tests to assess the fetus for
which of the following?
a. Severe anemia.
b. Hypoprothrombinemia.
c. Craniosynostosis.
d. Intrauterine growth restriction.
59. A client with 4 protein and 4 reflexes is admitted
to the hospital with severe preeclampsia. The
nurse must closely monitor the woman for
which of the following?
a. Grand mal seizure.
b. High platelet count.
c. Explosive diarrhea.
d. Fractured pelvis.
60. The nurse is grading a woman’s reflexes. Which
of the following grades would indicate reflexes
that are slightly brisker than normal?
a. 1.
b. 2.
c. 3.
d. 4.
61. A 26-week-gestation woman is diagnosed with
severe preeclampsia with HELLP syndrome. The
nurse will assess for which of the following
signs/symptoms?
a. Low serum creatinine.
b. High serum protein.
c. Bloody stools.
d. Epigastric pain.
62. A nurse is caring for a 25-year-old client who
has just had a spontaneous first trimester
abortion. Which of the following comments by
the nurse is appropriate?
a. “You can try again very soon.”
b. “It is probably better this way.”
c. “At least you weren’t very far along.”
d. “I’m here to talk if you would like.”
63. A 25-year-old client is admitted with the
following history: 12 weeks pregnant, vaginal
bleeding, no fetal heart beat seen on
ultrasound. The nurse would expect the doctor
to write an order to prepare the client for which
of the following?
a. Cervical cerclage.
b. Amniocentesis.
c. Nonstress testing.
d. Dilation and curettage.
64. A client’s admitting medical diagnosis is thirdtrimester bleeding: rule out placenta previa.
Each time the nurse enters the client’s room,
the woman asks: “Please tell me, do you think
the baby will be all right?” Which of the
following is an appropriate nursing diagnosis for
this client?
a. Hopelessness related to possible fetal loss.
b. Anxiety related to unidentified diagnosis.
c. Situational low self-esteem related to blood
loss.
d. Potential for altered parenting related to
inexperience.
65. Which of the following long-term goals is
appropriate for a client, 10 weeks’ gestation,
who is diagnosed with gestational trophoblastic
disease (hydatiform mole)?
a. Client will be cancer-free 1 year from
diagnosis.
b. Client will deliver her baby at full term
without complications.
c. Client will be pain-free 3 months after
diagnosis.
d. Client will have normal hemoglobin and
hematocrit at delivery.
66. Which of the following findings should the nurse
expect when assessing a client, 8 weeks’
gestation, with gestational trophoblastic disease
(hydatiform mole)?
a. Protracted pain.
b. Variable fetal heart decelerations.
c. Dark brown vaginal bleeding.
d. Suicidal ideations.
67. Which of the following findings should be
reported to the primary health care practitioner
when assessing a first-trimester gravida
suspected of having gestational trophoblastic
disease (hydatiform mole)?
a. Hematocrit 39%.
b. Grape-like clusters passed from the vagina.
c. White blood cell count 8000/mm3
d. Hypertrophied breast tissue.
68. Which finding should the nurse expect when
assessing a client with placenta previa?
a. Severe occipital headache.
b. History of renal disease.
c. Previous premature delivery.
d. Painless vaginal bleeding.
69. A woman has been diagnosed with a ruptured
ectopic pregnancy. Which of the following
signs/symptoms is characteristic of this
diagnosis?
a. Dark brown rectal bleeding.
b. Severe nausea and vomiting.
c. Sharp unilateral pain.
70. A client, G2P1001, telephones the gynecology
office complaining of left-sided pain. Which of
the following questions by the triage nurse
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would help to determine whether the one-sided
pain is due to an ectopic pregnancy?
a. “When did you have your pregnancy test
done?”
b. “When was the first day of your last
menstrual period?”
c. “Did you have any complications with your
first pregnancy?”
d. “How old were you when you first got your
period?”
71. A woman, 8 weeks pregnant, is admitted to the
obstetric unit with a diagnosis of threatened
abortion. Which of the following tests would
help to determine whether the woman is
carrying a viable or a nonviable pregnancy?
a. Luteinizing hormone level.
b. Endometrial biopsy.
c. Hysterosalpinogram.
d. Serum progesterone level.
72. The nurse is caring for a client who was just
admitted to the hospital to rule out ectopic
pregnancy. Which of the following orders is the
most important for the nurse to perform?
a. Assess the client’s temperature.
b. Document the time of the client’s last meal.
c. Obtain urine for urinalysis and culture.
d. Report complaints of dizziness or weakness.
73. A 12-week-gravid client presents in the
emergency department with abdominal cramps
and scant dark red bleeding. What should the
nurse assess this client for?
a. Shortness of breath.
b. Enlarging abdominal girth.
c. Hyperreflexia and clonus.
d. Fetal heart dysrhythmias.
74. A woman, G4P0210 and 12 weeks’ gestation,
has been admitted to the labor and delivery
suite for a cerclage procedure. Which of the
following long-term outcomes is appropriate for
this client?
a. The client will gain less than 25 pounds
during the pregnancy.
b. The client will deliver after 37 weeks’
gestation.
c. The client will have a normal blood glucose
throughout the pregnancy.
d. The client will deliver a baby that is
appropriate for gestational age.
75. A type 1 diabetic client has developed
polyhydramnios. The client should be taught to
report which of the following?
a. Uterine contractions.
b. Reduced urinary output.
c. Marked fatigue.
d. Puerperal rash.
76. A pregnant diabetic has been diagnosed with
hydramnios. Which of the following would
explain this finding?
a. Excessive fetal urination.
b. Recurring hypoglycemic episodes.
c. Fetal sacral agenesis.
d. Placental vascular damage.
77. A gravid woman has sickle cell anemia. Which of
the following situations could precipitate a vasoocclusive crisis in this woman?
a. Hypoxia.
b. Alkalosis.
c. Fluid overload.
d. Hyperglycemia.
78. A gravid woman with sickle cell anemia is
admitted in vaso-occlusive crisis. Which of the
following is the priority intervention that the
nurse must perform?
a. Administer narcotic analgesics.
b. Apply heat to swollen joints.
c. Place on strict bed rest.
d. Infuse intravenous solution.
79. A lecithin:sphingomyelin (L/S) ratio has been
ordered by a pregnant woman’s obstetrician.
Which of the following data will the nurse learn
from this test?
a. Coagulability of maternal blood.
b. Maturation of the fetal lungs.
c. Potential for fetal development of
erythroblastosis fetalis.
d. Potential for maternal development of
gestational diabetes.
80. The laboratory reported the L/S ratio results
from an amniocentesis as 1:1. How should the
nurse interpret the result?
a. The baby is premature.
b. The mother is high risk for hemorrhage.
c. The infant has kernicterus.
d. The mother is high risk for eclampsia.
81. An ultrasound is being done on an Rh-negative
woman. Which of the following pregnancy
findings would indicate that the baby has
developed erythroblastosis fetalis?
a. Caudal agenesis.
b. Cardiomegaly.
c. Oligohydramnios.
d. Hyperemia.
82. A woman is to receive RhoGAM at 28 weeks’
gestation. What action must the nurse take
before giving the injection?
a. Validate that the baby is Rh negative.
b. Assess that the direct Coombs’ test is
positive.
c. Verify the identity of the woman.
d. Reconstitute the globulin with sterile water.
83. A nurse is about to inject RhoGAM into an Rhnegative mother. Which of the following is the
preferred site for the injection?
a. Deltoid.
b. Dorsogluteal.
c. Vastus lateralis.
d. Ventrogluteal.
84. A woman is recovering at the gynecologist’s
office following a late first-trimester
spontaneous abortion. At this time, it is
essential for the nurse to check which of the
following?
a. Maternal rubella titer.
b. Past obstetric history.
c. Maternal blood type.
d. Cervical patency.
85. At 28 weeks’ gestation, an Rh-negative woman
receives RhoGAM. Which of the following would
indicate that the medication is effective?
a. The baby’s Rh status changes to Rh
negative.
b. The mother produces no Rh antibodies.
c. The baby produces no Rh antibodies.
d. The mother’s Rh status changes to Rh
positive.
86. It is discovered that a 28-week-gestation gravid
is leaking amniotic fluid. Before the client is sent
home on bed rest, the nurse teaches her which
of the following?
a. Perform a nitrazine test every morning upon
awakening.
b. Immediately report any breast tenderness to
the primary health care practitioner.
c. Abstain from engaging in vaginal intercourse
for the rest of the pregnancy.
d. Carefully weigh all of her saturated peripads.
87. A 32-weeks’ gestation client states that she
“thinks” she is leaking amniotic fluid. Which of
the following tests could be performed to
determine whether the membranes had
ruptured?
a. Fern test.
b. Biophysical profile.
c. Amniocentesis.
d. Kernig sign.
88. A pregnant Latina is being seen in the prenatal
clinic with diarrhea, fever, stiff neck, and
headache. Upon inquiry, the nurse learns that
the woman drinks unpasteurized milk and eats
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soft cheese daily. For which of the following
bacterial infections should this woman be
assessed?
a. Staphylococcus aureus.
b. Streptococcus albicans.
c. Pseudomonas aeruginosa.
d. Listeria monocytogenes.
89. A patient who is 24 weeks pregnant has been
diagnosed with syphilis. She asks the nurse how
the infection will affect the baby. The nurse’s
response should be based on which of the
following?
a. She is high risk for premature rupture of the
membranes.
b. The baby will be born with congenital
syphilis.
c. Penicillin therapy will reduce the risk to the
fetus.
d. The fetus will likely be born with a cardiac
defect.
90. Prenatal teaching for a pregnant woman should
include instructions to do which of the following?
a. Refrain from touching her pet bird.
b. Wear gloves when gardening.
c. Cook pork until medium well.
d. Avoid sleeping with the dog.
91. A child has been diagnosed with rubella. What
must the pediatric nurse teach the child’s
parents to do?
a. Notify any exposed pregnant friends.
b. Give penicillin po every 6 hours for 10 full
days.
c. Observe the child for signs of respiratory
distress.
d. Administer diphenhydramine every 4 hours
as needed.
92. A woman enters the prenatal clinic accompanied
by her partner. When she is asked by the nurse
about her reason for seeking care, the woman
looks down as her partner states, “She says she
thinks she’s pregnant. She constantly complains
of feeling tired. And her vomiting is disgusting!”
Which of the following is the priority action for
the nurse to perform?
a. Ask the woman what times of the day her
fatigue seems to be most severe.
b. Recommend to the couple that they have a
pregnancy test done as soon as possible.
c. Continue the interview of the woman in
private.
d. Offer suggestions on ways to decrease the
vomiting.
93. The nurse is providing health teaching to a
group of women of childbearing age. One
woman, who states that she is a smoker, asks
about its impact on the pregnancy. The nurse
responds that which of the following fetal
complications can develop if the mother
smokes?
a. Genetic changes in the fetal reproductive
system.
b. Extensive central nervous system damage.
c. Addiction to the nicotine inhaled from the
cigarette.
d. Fetal intrauterine growth restriction.
94. A client has been admitted with a diagnosis of
hyperemesis gravidarum. Which of the following
orders written by the primary health care
provider is highest priority for the nurse to
complete?
a. Obtain complete blood count.
b. Start intravenous with multivitamins.
c. Check admission weight.
d. Obtain urine for urinalysis.
95. An ultrasound has identified that a client’s
pregnancy is complicated by oligohydramnios.
The nurse would expect that an ultrasound may
show that the baby has which of the following
structural defects?
a. Dysplastic kidneys.
b. Coarctation of the aorta.
c. Hydrocephalus.
d. Hepatic cirrhosis.
96. An ultrasound has identified that a client’s
pregnancy is complicated by hydramnios. The
nurse would expect that an ultrasound may
show that the baby has which of the following
structural defects?
a. Pulmonic stenosis.
b. Tracheoesophageal fistula.
c. Ventriculoseptal defect.
d. Developmental hip dysplasia.
97. The physician has ordered oxytocin (Pitocin) for
induction for 4 gravidas. In which of the
following situations should the nurse refuse to
comply with the order?
a. Primigravida with a transverse lie.
b. Multigravida with cerebral palsy.
c. Primigravida who is 14 years old.
d. Multigravida who has type 1 diabetes.
98. A client, 38 weeks’ gestation, is being induced
with IV oxytocin (Pitocin) for hypertension and
oligohydramnios. She is contracting q 3 min 60
to 90 seconds. She suddenly complains of
abdominal pain accompanied by significant fetal
heart bradycardia. Which of the following
interventions should the nurse perform first?
a. Turn off the oxytocin infusion.
b. Administer oxygen via face mask.
c. Reposition the patient.
d. Call the obstetrician.
99. An induction of a 42-week gravida with IV
oxytocin (Pitocin) is begun at 0900 at a
a. rate of 0.5 milliunits per minute. The
woman’s primary physician orders: Increase
b. the oxytocin drip by 0.5 milliunits per
minute every 10 minutes until contractions
c. are every 3 minutes 60 seconds. The nurse
refuses to comply with the order.
100. Which of the following is the rationale for the
nurse’s action?
a. Fetal distress has been noted in labors when
oxytocin dosages greater than 2 milliunits
per minute are administered.
b. The relatively long half-life of oxytocin can
result in unsafe intravascular concentrations
of the drug.
c. It is unsafe practice to administer oxytocin
intravenously to a woman who is carrying a
postdates fetus.
d. A contraction duration of 60 seconds can
lead to fetal compromise in a baby that is
postmature.
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