When performing post partum assessment on a client, a 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 appropriate?
Select one:
a. Document the findings
b. Reassess the client in two hours
c. Encourage increase oral intake of fluids.
d. Notify the physician
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The nurse is obtaining the history of Pacita, a client in the third trimester who is visiting the
prenatal clinic for the first time. The client relates, “I have two small children at home. My
husband abandoned us last month when he learned I was pregnant!” The nurse recognizes that
the client may be:
Select one:
a. Angry at the father
b. Ambivalent about her pregnancy
c. Overwhelmed by the situation
d. Denying the reality of her pregnancy
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Nurse Zee was assigned in the delivery room. She is assessing a client immediately after delivery
of the placenta. Which statements made by the mother indicates uterine inversion and needs
immediate intervention?
Select one:
a. “My chest feels heavy.”
b. “My abdomen feels like it’s going to tear apart.”
c. “The pain I am feeling right now is unbearable!”
d. “I feel like throwing up.”
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A post-partum client is taking the vital signs of a client who delivered a healthy newborn infant
4 hours ago. The nurse notes that the client’s temperature is 100.2 F. Which of the following
actions would be appropriate?
Select one:
a. Increase hydration by encouraging oral fluids.
b. Retake the temperature in 15 minutes.
c. Notify the physician.
d. Document the findings.
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A patient in the ward tells the nurse, “I have something to tell you but you have to promise not
to tell anyone else.” What would be the best response of the nurse?
Select one:
a. “Ok, I will not tell anyone else if only my name will not be placed at stake.”
b. “I suggest that you should share that to your physician instead.”
c. “Ok. I promise to keep it a secret.”
d. “The information may need to be shared to the health team but will be held confidential.”
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Nurse Isabel is discussing the reproductive system with a group of young adults in the
community. One of them asks, “What is the normal expected frequency for sexual relations?”
Which response by the nurse is correct?
Select one:
a. “Normal sexual behaviors include any act mutually satisfying to both sexual partners.”
b. “Normal sexual behaviors can only be determined if both parties are committed to each
other and are sexually active.”
c. “Normal sexual behaviors should be discussed in private.”
d. “Normal sexual behaviors are not a part of my discussion.”
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Which of the following is the most frequent reason for postpartum hemorrhage?
Select one:
a. Disseminated intravascular coagulation.
b. Perineal lacerations.
c. Uterine atony.
d. Endometritis.
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A woman began labor around midnight. When she enters the hospital in active labor at noon, it
has been 16 hours since she last ate. What is the most important reason to report this to her
nurse-midwife?
Select one:
a. The woman’s labor coach may have also missed a meal.
b. This reflects the woman’s high level of anxiety since labor began.
c. A woman can become dehydrated during labor.
d. The woman has used poor judgment; she may have done something else wrong as well.
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The nurse explains the purpose of effleurage to Aurelia who is in early labor. The nurse tells the
client that effleurage is:
Select one:
a. A form of biofeedback to enhance bearing-down efforts during delivery.
b. Performed to stimulate uterine activity by contracting a specific muscle group while other
parts of the body rest.
c. The application of pressure to the sacrum to relieve backache.
d. Light stroking of the abdomen to facilitate relaxation during labor and provide tactile
stimulation to the fetus.
While assessing a client in active labor, the nurse relates to the client and her husband that the
fetus may be experi-encing late decelerations. The husband asks the nurse, “What can I do to
help?” The best response of the nurse would be:
Select one:
a. “You can assist your wife and gradually walk around the room.”
b. “I’m afraid there’s nothing you can do about the situation. We have to wait for the doctors
‘orders. I’ll in-form you as soon as I get hold of your physician.”
c. “I can leave my stethoscope so you can check the fetal heart rate every 30 minutes.”
d. “Prepare yourself and your wife for a cesarean delivery. She will be taken to the operating
room soon.”
Lily, 22 year old client complains to the nurse that she experiences pain during intercourse. The
nurse should docu-ment this finding as:
Select one:
a. Vaginismus
b. Dymennorhea
c. Dyspareunia
d. Clitoral dysfunction
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A nursing instructor is reviewing the menstrual cycle with a student nurse who will be
conducting a teaching session at the OB-GYNE ward. The instructor asks the student to describe
the follicle-stimulating hormone (FSH) and then the lutein-izing hormone (LH). The student
accurately responds by stating that:
Select one:
a. FSH and LH are secreted by the adrenal glands.
b. FSH and LH are released from the anterior pituitary gland.
c. FSH and LH are secreted by the corpus luteum of the ovary
d. FSH and LH stimulate the formation of milk during pregnancy.
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Mrs. Prado is a primigravida you meet at a prenatal clinic. You provide instructions to the
mother regarding exercise guidelines for labor preparation. The client understands your health
teachings when she states that:
Select one:
a. “I should never point my toes when doing leg exercises”
b. “I should point my toes when doing leg exercises.”
c. “I should practice second-stage pushing to increase intrauterine pressure”
d. “In doing Kegel’s exercises, I should rise from the floor, roll over to the side first and then
push myself up.”
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Which of the following describes why hypertonic contractions tend to become very painful?
Select one:
a. There is an increase in the length of labor because so many contractions are needed to
achieve cervical dilation.
b. More than one contraction may begin at the same time, as receptor points in the
myometrium act independently of each other.
c. The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells.
d. The number of uterine contractions is very low or infrequent.
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Why are postpartal women prone to urinary retention?
Select one:
a. Catheterization at the time of delivery reduces bladder tonicity.
b. Decreased bladder sensation results from edema due to pressure of birth.
c. Frequent partial voidings never relieve the bladder pressure.
d. Mild dehydration causes a concentrated urine volume in the bladder.
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Mr. Corpuz approaches the nurse’s station and tells the nurse, “My wife is in so much pain. We
both attended preg-nancy classes to make sure she has a normal delivery. It seems everything is
not going by as what the book says!” The best response of the nurse would be:
Select one:
a. “There’s no reason to be afraid sir, things will get better.”
b. “Mr. Corpuz, although your wife’s pattern of labor is not “textbook”, it is still within safe and
controlled limits.”
c. “Oh! Mr. Corpuz have you chosen a name for the baby yet? I can lend you book on baby
names and their meanings.”
d. “Not all pregnancies go by just fine. At least your wife’s progress is getting better.”
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The goal for a client with partial premature separation of the placenta is “the client will not
exhibit signs of fetal dis-tress."Which outcome documented by Nurse Zee would indicate that
this goal has been achieved?
Select one:
a. Short term variability present
b. No accelerations of FHR
c. Variable decelerations present
d. Fetal heart rate (FHR) of 170 to 180 beats/minute
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On their first pre-natal visit, Carlo and Ruby, both to be first-time parents told the nurse that
they are feeling anxious about the unexpected pregnancy. “I can’t even go out shopping
because I fear that I would faint in the mall”, Ruby states. “I can’t go the gym anymore after
work because I worry about leaving her alone at night.” Carlo said. The nurse together with the
couple developed a plan of care for them during the ante-partum stage. Based on the subjective
data obtained, the best expected outcome the nurse should strive for is:
Select one:
a. Wife states that she changed her routine and to avoid fatigue and stress.
b. Husband states that he has adjusted his lifestyle to accommodate his wife’s feeling of fatigue.
c. Couple states that they accept the physiologic changes of pregnancy as normal.
d. Couple states that they are able to continue their usual lifestyle through pregnancy.
Question 19
A woman experiences an amniotic fluid embolism as the placenta is delivered. Your first action
would be to
Select one:
a. tell the woman to take short, catchy breaths.
b. put firm pressure on the fundus of her uterus.
c. increase her intravenous fluid infusion rate.
d. administer oxygen by mask.
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On their second prenatal visit, Ruby talked to the nurse about not feeling nausea and vomiting
at all because she fol-lowed her grandmother’s advice about crossing over her husband while
he is asleep. She claims that it might have worked because Carlo usually feels nauseated in the
morning. What other information can the nurse give without offend-ing their cultural beliefs?
Select one:
a. “Many men experience such physical symptoms which are often the result of stress, anxiety
and empathy for the pregnant woman.”
b. “Perhaps you could ask your grandmother other ways on how to cure your husband’s
morning sickness.”
c. “I assure you, what your husband feels is not a result of what your grandmother believes in.
Your husband is just feeling stressed over your pregnancy.”
d. “Your husband is feeling emotionally disturbed or delusional because of his anxiety due to
your pregnancy.”
A 16 year old visits the clinic because she suspects she may be pregnant. When the pregnancy
test confirms this, the client tells the nurse. “I don’t know what I am going to do. My parents
don’t believe in abortion, but I just can’t have the baby.” A priority nursing diagnosis for this
client is:
Select one:
a. Health seeking behaviors related to suspicion of pregnancy.
b. Altered sexuality patterns related to confirmation of pregnancy
c. Knowledge deficit related to contraceptive methods.
d. Decisional conflict related to unwanted pregnancy
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Mimi, a 30-year old woman who is 2 months pregnant comes for her routine pre-natal visit.
Upon assessment, the nurse learned that she has a family history of hypercholesterolemia. The
nurse asks about her usual diet. Which state-ment if made by the client indicates a need for
further instruction?
Select one:
a. “Eggs are staple in my diet. I eat at least three eggs per week.”
b. “I plan on using olive oil for cooking my meat products.”
c. “I make sure that I take extra servings of meat and poultry per day.”
d. “I started taking wheat bread and milk for breakfast.”
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The nurse identifies that the husband of a client is reacting positively to his wife’s pregnancy
when, during the second trimester, he says:
Select one:
a. “I had to take a part-time job to cover the rent for a larger apartment.”
b. “I’m so proud of my wife. I’m already putting up a basketball court in our backyard.”
c. “They showed a childbirth movie in class last night that was so interesting that I hope I’ll be
able to watch my own baby’s birth.”
d. “I get so excited when I feel the baby kicking. I didn’t realize how strong those little legs are.”
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The nurse calls the physician regarding a new medication order for Aurelia because the dosage
prescribed is higher than the recommended dosage. The nurse is unable to contact the
physician and the medication is due to be adminis-tered. Which action should the nurse take?
Select one:
a. Administer the dose prescribed
b. Contact the nursing supervisor
c. Hold the medication until the physician can be contacted
d. Administer the recommended dose until the physician can be located.
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Which of the following would be most appropriate for the woman who experiences
dysfunctional labor in the first stage of labor?
Select one:
a. Provide ongoing communication about what is happening.
b. Hold all explanations until after the birth to conserve the woman’s energy.
c. Limit talking to things the woman asks questions about.
d. Tell her not to feel anxious or discouraged about what is happening.
Question 25
Which of the following would be most appropriate for the woman who experiences
dysfunctional labor in the first stage of labor?
Select one:
a.
b.
c.
d.
Provide ongoing communication about what is happening.
Hold all explanations until after the birth to conserve the woman’s energy.
Limit talking to things the woman asks questions about.
Tell her not to feel anxious or discouraged about what is happening.
Question 26
A Nurse is providing instructions to a Chinese client regarding prescribed dietary modifications.
During the teaching session, the client continuously turns away from the nurse. Which nursing
action is appropriate?
Select one:
a.
b.
c.
d.
Give the client a dietary booklet and return later to continue with the instructions.
. Walk around the client so that the nurse constantly faces the client.
Continue with the instruction, verifying client understanding.
Tell the client about the importance of the instructions for the maintenance of health
care.
Question 27
Nurse Angie is teaching a primipara client and her husband about the labor and delivery
process. She describes the maneuvers that the fetus goes through during the labor process
when the head is the presenting part. Place the maneu-vers below in the order in which the
nurse should explain that they occur. 1. Engagement 2. Descent 3. Flexion 4. Internal Rotation
Select one:
a.
b.
c.
d.
2, 4, 3, 1
1, 3, 2, 4
3, 1, 2, 4
1, 2, 4, 3
Engagement
Descent
Flexion
Internal rotation
-
WALA SA CHOICES, 1, 2, 3, 4 dapat
Question 28
Cam Pratt is a 22-year old primigravida you admit to a birthing unit in early labor. Her cervix is 4
cm dilated. The following questions apply to this situation: The doctor orders an epidural
anesthesia on stand-by in case Cam will not be able to tolerate the pain. You as the nurse are
aware that she will also need what IV fluid before administering the epidural:
Select one:
a.
b.
c.
d.
1000 ml Plain NSS
250 ml D5IMB
. 500 ml D5Water
1L Ringer’s Lactate
- not sure
Question 29
Nurse Jane is discussing with a Chinese-Filipino couple on what they should expect while the
mother is in labor. During the discussion, the client continually smiles and nods the head. The
nurse interprets this non-verbal behavior as:
Select one:
a.
b.
c.
d.
The client understands the preoperative
The client is agreeable to the required procedure
. Reflecting a cultural value
An acceptance of the treatment
Question 30
The postpartum nurse visits Heidi who is 6 hours post childbirth. Upon observation, which of
the following actions made by the client indicates that she is not undergoing a normal
puerperium phase?
Select one:
a. All she talks about is her labor and birthing experience.
b. b. She stares blankly at the baby and relates to the nurse, “is it really over?” then cries
hysterically.
c. When the baby cries, she panics then she asks her mother to get the baby.
d. She holds the child with a sense of wonder and tells herself, “I can’t believe she was in
my tummy for 9 months!”
Cam Pratt is a 22-year old primigravida you admit to a birthing unit in early labor. Her cervix is 4
cm dilated. The following questions apply to this situation: Upon admission, Cam told the nurse
that she is not worried about giving birth. “I didn’t think too much preparation was needed
because my sister who gave birth 3 months ago told me that she was given anesthesia for labor
pains. I think I should be given the same.” What would be a priority nursing diagnosis for the
client at this point:
Select one:
a. Risk for situational low esteem related to ineffectiveness and inability to use proper
childbirth method.
b. Knowledge deficit related to unfamiliarity with information on childbirth preparation.
c. Anxiety related to lack of knowledge about the normal labor process.
d. Health-seeking behaviors related to management of discomfort of labor.
Question 32
Nurse Madge is reviewing a prenatal class on the process of fetal circulation. One of the
mothers asks her to specifically describe the process through the umbilical cord. The best
response from the nurse is which of the following?
Select one:
a. The two veins in the umbilical cord carry blood that is high in carbon dioxide and other
waste products away from the fetus to the placenta.”
b. The one artery carries freshly oxygenated blood and nutrient-rich blood back from the
placenta and fe-tus.
c. . The two arteries in the umbilical cord carry blood that is high in carbon dioxide and
other waste products away from the fetus to the placenta.”
d. otherarteries carry freshly oxygenated blood and nutrient-rich blood back from the
placenta to the fetus.
Question 33
Lisa Simpson, a 17 year old female client visits the clinic for a routine physical examination. To
obtain information about the cleints sexual history, an appropriate question for the nurse to ask
is:
Select one:
a.
b.
c.
d.
Are you sexually active?
How many boyfriends have you had?
Have you ever been diagnosed with HIV?
Do you know the signs and symptoms of pregnancy?
Question 34
Nurse Sue is preparing a discharge plan for Mrs. House. Which of the following statement made
by the client would indicate a need for further information?
Select one:
a. “I will remove the vaginal douche from my shopping list.”
b. “I will tell my husband to transfer my work desk to the first floor, this way I am closer to
my baby’s room.”
c. “I can start my contraception pills when I get home today.”
d. . “Coitus is safe as soon as my lochia contains largely mucus.”
Question 35
While Pacita is dressing at the completion of her pelvic examination, she states, “Why must I be
pregnant now? It’s the wrong time.” It would be most therapeutic for the nurse to respond:
Select one:
a.
b.
c.
d.
“If you don’t want to be pregnant, there are alternatives.”
“This is a normal response to pregnancy.”
“You don’t seem happy about this pregnancy.”
“No time is ever the right time to be pregnant.”
Question 36
A Nurse is preparing a plan of care for a client who is a Jehovah’s Witness. The client has been
told that the surgery to excise the tumors in her breast is necessary. The nurse considers the
clients’ religious preference in developing the plan of care and documents that:
Select one:
a.
b.
c.
d.
Medication administration is not allowed.
Faith healing is practiced primarily.
Surgery is prohibited in this religious group.
The administration of blood and blood products is forbidden.
Question 37
The client seen in the health care clinic has tested positive for gonorrhea. The nurse anticipates
that which medication will be prescribed for the client based on this finding?
Select one:
a.
b.
c.
d.
Acyclovir (Zovirax)
Penicillin G benzathine
c. Azithromycin (Zithromax)
Ceftriaxone (Rocephin)
Question 38
Feliz is a newly registered nurse. Relatives of a patient who died under her care filed a case
against her and two other nurses in the General Hospital where she works. Apparently, they
failed to render proper man-agement to the client who suffered from cardiac arrest while in
labor. During questioning, the investigators noted in the patients’ chart that in her nurse’s notes,
Nurse Feliz wrote that she discontinued the patient’s oxytocin infusion. The investigators
questioned why she did this. According to nurse Feliz, she noted which of the following upon
assessment of the client?
Select one:
a. Early decelerations of the FHR.
b. Uterine hyperstimulation
Drowsiness
Fatigue
Question 39
Ruby asks the nurse in the clinic when she will be able to begin to feel the fetus move. The
nurse responds by telling the mother that fetal movements will be noted between which of the
following weeks of gestation?
Select one:
a.
b.
c.
d.
16 and 20
1, 6 and 10
8 and 10
d. 21-24
- GUYS 14 and 18 sagot dito
Question 40
Mrs. Bench has been prescribed estrogen after menopause. She is concerned about taking the
medication and asks the nurse about potential complications of hormone replacement therapy.
The nurse should explain to the client that one of the risks of the hormone replacement therapy
is an increased risk for:
Select one:
a.
b.
c.
d.
Osteoporosis
Hypercholesterolemia
Hypocalcemia
. Breast and uterine cancer
Karina, a 25 year old client arrives at the clinic for the first pre-natal assessment. The client tells
a nurse that the first day of her last menstrual period was April 12, 2021. Using Nagele’s rule,
the nurse determines the estimated date of con-finement as:
Select one:
a.
b.
c.
d.
January 28, 2022
December 28, 2021
December 19, 2021
January 19, 2022 ( guys pa’ verify if tama)
Question 42
Based on the statement made by the client in # 88, what would be the best response of the
nurse to explore the needs of the patient?
Select one:
a. “Don’t be so negative about it, your marriage will work out soon.”
b. “That’s silly. Marriage is supposed to bring out the best in you.”
c. “Well it’s about time you have a makeover and show your husband what he’s about to
lose.”
d. . “You mentioned you weren’t feeling yourself lately. Tell me when this feeling started.”
- DIKO ALAM JUMBLED NAMAN KASI, DIK AMMU KUNG SAAN YUNG NUMBER 88
Question 43
Cam Pratt is a 22-year old primigravida you admit to a birthing unit in early labor. Her cervix is 4
cm dilated. The following questions apply to this situation:When you entered Cam’s room to
take her vital signs, you find her lying on her back in her bed, crying. Her husband is standing in
the doorway and shouting, “My wife deserves better care than this!” What would be the best
action and response of the nurse?
Select one:
a. Assume an attentive position; “You both appear upset. Would you like to talk?”
b. Nod your head then walk out of the room without saying anything.
c. Tell the couple, “I will leave you both alone for a moment; I understand that you need to talk.”
Then walk out of the room.
d. Maintain eye contact; “You are frustrated because you and your doctor haven’t talked about
your birthing plans yet?”
Question 44
A client with severe preeclampsia is admitted to the maternity department. Which of the
following room assignments would be most appropriate for this client?
Select one:
a.
b.
c.
d.
A semi-private room across from the nurses’ station
A private room across the elevator
A private room two doors away from the nurses’ station
A semi-private room with another client who enjoys watching teleseryes.
Question 45
Which of the following is a safe step to take during an induction of labor?
Select one:
a. Urge the woman to remain on her back during labor to offer a good blood supply to the
uterine muscle.
b. Prepare oxytocin as a piggyback solution as prescribed, being extremely careful of the
dose used.
c. Avoid the continuous use of both uterine and fetal heart rate monitoring.
d. Observe that contractions are less than 5 minutes apart and less than 70 seconds in
duration.
Question 46
Which of the following meal trays would not be appropriate for the nurse to deliver to a
pregnant Muslim client from Julu-Sulu?
Select one:
a.
b.
c.
d.
Crab salad on a wheat bun, vegetables with dip, potato salad, milk
b. Sweet and sour chicken with rice and vegetables, mixed fruit, juice
Pasta Carbonara with shrimp and vegetables, salad, mixed fruit, iced tea
Pork roast, rice, vegetables, mixed fruit. Milk
Question 47
Nurse Pia who hears a watcher calling out for help, hurries down the hallway to the client’s
room and finds her preg-nant client lying on the floor. Nurse Pia performs a thorough
assessment, assists the client back to bed, notifies the physician of the incident and completes
and incident report. Which of the following should the nurse document on the incident report?
Select one:
a.
b.
c.
d.
The client fell out of bed.
The client became restless and tried to get out of bed
The client climbed over the side rails
The client was found lying on the floor
Question 48
Sarah, 20 years old, asks the nurse what is the most effective means of contraception as it has
0% failure rate. The nurse responds correctly by stating that the method the student is referring
to is:
Select one:
a.
b.
c.
d.
Tubal Ligation
Pills
Condom
Abstinence
Question 49
You assess that the fetus of a woman is in an occiput posterior position. Which of the following
identifies the way would you expect her labor to differ from others?
Select one:
a. Experience of additional back pain.
b. Need to have the baby manually rotated.
c. Necessity for vacuum extraction for delivery.
d. Shorter dilatational stage of labor.
Question 50
Margarita, a pregnant client is admitted in early labor. As she enters the labor room, she is
accompanied by her mother. What will be the appropriate action of the nurse?
Select one:
a. Allow the mother to enter but remind her that she should not leave the room to be able
to anticipate and assist to the needs of her daughter.
b. Allow the mother to enter to help her daughter get into bed then instruct her to stay in
waiting lounge after.
c. Stop the mother from entering and tell her that preferably the husband should
accompany the client in the labor room.
d. Welcome the client and her mother then acquaint them to the facilities of the room and
point out where to get the supplies such as towels and washcloths.
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A postpartal woman has a fourth-degree perineal laceration. Which of the following physician
orders would you question?
Select one:
a. Administration of acetaminophen and codeine for pain.
b. Administration of an enema. -ANSWER
c. Administration of a sitz bath.
d. Urging her to drink all the milk on her tray.
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The nurse is preparing to provide counseling to a post partum client. She has been experiencing
post partum blues since she gave birth. During counseling, the nurse should:
Select one:
a. Stand close to the client and speak loudly.
b. Use complex medical terminology
c. Avoid scientific or medical jargon
d. Speak only to the husband ANSWER
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A nurse is performing an initial assessment on a client who has just been told that a pregnancy
test is positive. All of these are risk factors for pre-term labor except?
Select one:
a. The client is a 16-year old primigravida who is of Malaysian-Filipino descent.
b. The client has a history of cardiac disease. ANSWER
c. The client lives in a crowded village near a rubber factory.
d. The client’s hemoglobin is 13.5 g/dL
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Nurse Sam then checks on Lara, another patient in labor who is receiving Oxytocin by
Intravenous infusion to stimu-late uterine contractions. Which assessment findings would
indicate to the nurse that the infusion needs to be discontin-ued?
Select one:
a. Increased urinary output
b. A fetal heart rate of 90 beats/minute ANSWER
c. Three contractions occurring within a 10-minute period
d. Adequate resting tone of the uterus palpated between contractions.
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The Nurse understands that because the arc of rotation is longer for an occipitoposterior
position, the labor is pro-longed. What will be a priority intervention of the nurse?
Select one:
a. Instruct significant other to provide back rubs to the mother as necessary.
b. Administer intravenous glucose solution.
c. Applying heat or cold compress for pain.
d. Assist the patient in emptying the bladder every 2 hours. ANSWER
A nurse should explain which of the following to a pregnant client found to have a gynecoid
pelvis?
Select one:
a. That she will need cesarean section because this type of pelvis is not favorable for normal
labor and vaginal delivery.
b. That her type of pelvis is a wide pelvis but has a shorter diameter.
c. That her type of pelvis is the most favorable for labor and birth. ANSWER
d. That her type of pelvis has a narrow pubic arch.
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A nurse is teaching a post-partum client about breast-feeding. Which of the following
instructions should the nurse include?
Select one:
a. Birth control measures are not necessary while breastfeeding.
b. The diet should include additional fluids. ANSWER
c. Soap should be used to cleanse the breasts.
d. Prenatal vitamins should be discontinued.
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A postpartal woman calls you into her room because she is having a very heavy lochia flow
containing large clots. Your first action would be to
Select one:
a. have her turn to her left side.
b. assess her blood pressure.
c. assess her perineum.
d. palpate her fundus. ANSWER
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Nurse Bianca is closely monitoring her pregnant client for hypovolemic shock and she notes the
following signs and symptoms: 1.Increased pulse rate 2.Decreased pulse rate 3.Increase Blood
pressure 4.Decreased blood pressure 5.Fetal Bradycardia 6.Fetal Tachycardia
Select one:
a. 2, 3, 6
b. 2, 4, 6
c. 1, 4, 5 ANSWER
d. 1, 3, 5
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During assessment, the nurse asks Sasha what she understands about the condition of the fetus
relating to its weight and position. Which of the following statements if made by the client
states that she understood the situation?
Select one:
a. “My doctor says that my baby’s position is normal and that it will not cause any problems
during delivery. His weight will be helpful in rotating through the pelvic arc.”
b. “My doctor says that my baby’s presenting head will fit my cervix snugly although his weight
may make it hard for him to rotate.”
c. “My doctor says that my baby’ head is directed diagonally and posteriorly. His weight will be
helpful in rotating through the pelvic arc.”
d. “My doctor says that my baby’s head is directed diagonally and posteriorly. His weight will be
a problem I suppose because of difficulty during internal rotation” ANSWER
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While teaching a prenatal class to future parents, the nurse emphasizes that smoking during
pregnancy can cause the newborn to have:
Select one:
a. Hypoglycemic reactions
b. High birth weight
c. Low birth weight ANSWER
d. Facial anomalies
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When completing an obstetric history from the patient, the nurse would document GTPALM for
this client as:
Select one:
a. G=3, T=2, P=0, A=0, L=1, M=1
b. G=2, T=0, P=0, A=0, L=1, M=0
c. G=2, T=1, P=0, A=0, L=1, M=0 ANSWER
d. G=2, T=1, P=1, A=O, L=1, M=1
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A client at her first visit to the prenatal clinic asks which immunization can be administered
safely to a pregnant wom-an. The nurse should reply:
Select one:
a. Rubeolla
b. Rubella ANSWER
c. Mumps
d. Hepatitis B Immunoglobulin
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The nurse is interviewing a 16-year old client during her initial prenatal clinic visit. The client is
beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an
immediate need for further investigation?
Select one:
a. “I don’t like my stomach anymore. Those brown lines are disgusting.”
b. “I don’t like my breasts anymore. These silver lines are ugly.”
c. “I don’t like my face anymore. I always look like I have been crying.” ANSWER
d. “I don’t like my figure anymore. My clothes are all too tight.”
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Nurse Ria is caring for a client in the second stage of labor. The client is experiencing uterine
contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes
this behavior as:
Select one:
a. Fear of losing control ANSWER
b. Valsalva maneuver
c. Exhaustion
d. Involuntary grunting
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. All of these are probable signs of
pregnancy except:
Select one:
a. Goodells’s Sign
b. (+) FHT ANSWER
c. Chadwick’s sign
d. Braxton Hicks contraction
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A Nurse has developed a plan of care for a client experiencing dystocia and includes several
nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which
intervention as the highest priority?
Select one:
a. Changing the clients’ position frequently
b. Keeping the significant other informed of the progress of labor.
c. Providing comfort measures
d. Monitoring fetal heart rate ANSWER
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Aurelia is admitted in the ward in early labor. One of the fetuses is a breech presentation. Of the
following interven-tions, which is the lowest priority in planning nursing care of this client?
Select one:
a. Measure fundal height.
b. Attach electronic fetal monitoring
c. Visually examine the perineum and vaginal opening. ANSWER
d. Prepare client for a possible cesarean section.
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Patricia is admitted to the hospital for poorly controlled gestational diabetes during her third
pregnancy. She left her two other children at home. An applicable nursing diagnosis is
Interrupted family Process related to hospitalization. Nurs-ing care for this client should include:
Select one:
a. Supporting her efforts to be discharged from the hospital as soon as she learns to administer
insulin.
b. Suggesting that a social worker visit the family weekly to perform a home and child care
evaluation.
c. Providing family members the opportunity to discuss their feelings regarding the
hospitalization.
d. Suggesting that she be allowed to leave the hospital every few days to visit her other
children.
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The nurse is reviewing true and false labor signs with Aurelia. The nurse determines that the
client understands the signs of true labor if she makes which statement?
Select one:
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 painful if I walk around.”
d. “My contractions will increase in duration and intensity.” ANSWER
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Jasmine, a 25 year old pregnant client at 38 weeks gestation is brought into the labor room.
Nurse Sam 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:
Select one:
a. Palpating the maternal radial pulse while listening to the fetal heart rate.
b. Performing Leopold’s maneuver first to determine the location of the fetal heart rate.
c. Placing the diaphragm of the Doppler on the mother’s abdomen.ANSWER
d. Noting whether the heart rate is greater than 140 beats/minute.
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A clinic nurse is instructing a pregnant client regarding dietary measures to promote a healthy
pregnancy. The nurse tells the client about the importance of an adequate intake of fluid daily.
Which statement by the client indicates an un-derstanding of the daily fluid requirement?
Select one:
a. “I should drink 8-10 glasses of fluid a day, and I can drink as many diet softdrinks as I want.”
ANSWER
b. “I should drink at least 8-10 glasses of fluid each day, of which 6 glasses should be Water at
least.”
c. “I should drink 12 glasses of fluid a day, and I can include the coffee or tea that I drink.”
d. “I should drink 12 glasses of fruit juices and milk everyday.”
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Mrs. Bieber is scheduled for cesarean delivery. Which of these procedures should Nurse Ria
hold preoperatively?
Select one:
a. Administration of Insulin SQ
b. Sonogram to determine fetal presentation ANSWER
c. A laboratory request for urinalysis
d. Blood typing and cross matching
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Cam Pratt is a 22-year old primigravida you admit to a birthing unit in early labor. Her cervix is 4
cm dilated. The following questions apply to this situation:In your plan of care for Cam, one of
your nursing interventions is to reduce anxiety with explanations of the labor process. Which of
the following will you take NOT include in making your outline for health teachings?
Select one:
a. The on-off effect differentiates the pain of labor contractions from that of a toothache or
headache which is continuous.
b. Do not assume everyone knows that contractions change in ch