CHAPTER 22: RISK CONDITIONS RELATED TO
PREGNANCY
204. The nurse is providing instructions to a pregnant
client with human immunodeficiency virus (HIV)
infection regarding care to the newborn after
delivery. The client asks the nurse about the feeding
options that are available. Which response should the
nurse make to the client?
1. “You will need to bottle-feed your newborn.”
2. “You will need to feed your newborn by
nasogastric tube feeding.”
3. “You will be able to breast-feed for 6 months and
then will need to switch to bottle-feeding.”
4. “You will be able to breast-feed for 9 months and
then will need to switch to bottle-feeding.”
205. 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)?
1. Urinary output has increased.
2. Dependent edema has resolved.
3. Blood pressure reading is at the prenatal baseline.
4. The client complains of a headache and blurred
vision.
206. A stillborn baby was delivered in the birthing suite a
few hours ago. After the delivery, the family remained
together, holding and touching the baby. Which
statement by the nurse would assist the family in their
period of grief?
1. “What can I do for you?”
2. “Now you have an angel in heaven.”
3. “Don’t worry, there is nothing you could have
done to prevent this from happening.”
4. “We will see to it that you have an early discharge
so that you don’t have to be reminded of this
experience.”
207. 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?
1. “I should stay on the diabetic diet.”
2. “I should perform glucose monitoring at home.”
3. “I should avoid exercise because of the negative
effects
on
insulin
production.”
4. “I should be aware of any infections and report
signs of infection immediately to my obstetrician.”
208. 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?
1. Enlargement of the breasts
2. Complaints of feeling hot when the room is cool
3. Periods of fetal movement followed by quiet
periods
4. Evidence of bleeding, such as in the gums,
petechiae, and purpura
209. The nurse in a maternity unit is reviewing the clients’
records. Which clients should the nurse identify as
being at the most risk for developing disseminated
intravascular coagulation (DIC)? Select all that apply.
1. A primigravida with abruptio placenta
2. A primigravida who delivered a 10-lb infant 3 hours
ago
3. A gravida 2 who has just been diagnosed with
dead fetus syndrome
4. A gravida 4 who delivered 8 hours ago and has lost
500 mL of blood
5. A primigravida at 29 weeks of gestation who was
recently diagnosed with gestational hypertension
210. 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?
1. Hypertension
2. Low-grade fever
3. Generalized edema
4. Increased pulse rate
211. The nurse is assessing a pregnant client with type 1
diabetes mellitus about her understanding regarding
changing insulin needs during pregnancy. The nurse
determines that further teaching is needed if the
client makes which statement?
1. “I will need to increase my insulin dosage during the
first 3 months of pregnancy.”
2. “My insulin dose will likely need to be increased
during the second and third trimesters.”
3. “Episodes of hypoglycemia are more likely to occur
during the first 3 months of pregnancy.”
4. “My insulin needs should return to prepregnant
levels within 7 to 10 days after birth if I am bottlefeeding.”
212. A pregnant client reports to a health care clinic,
complaining of loss of appetite, weight loss, and
fatigue. After assessment of the client, tuberculosis is
suspected. A sputum culture is obtained and
identifies Mycobacterium tuberculosis. Which
instruction should the nurse include in the client’s
teaching plan?
1. Therapeutic abortion is required.
2. Isoniazid plus rifampin will be required for 9
months.
3. She will have to stay at home until treatment is
completed.
4. Medication will not be started until after delivery
of the fetus.
213. 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?
1. “I should increase my sodium intake during
pregnancy.”
2. “I should lower my blood volume by limiting my
fluids.”
3. “I should maintain a low-calorie diet to prevent any
weight gain.” 4. “I should drink adequate fluids and
increase my intake of high- fiber foods.”
214. The clinic nurse is performing a psychosocial
assessment of a client who has been told that she 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.
1. The client has a history of intravenous drug use.
2. The client has a significant other who is
heterosexual.
3. The client has a history of sexually transmitted
infections.
4. The client has had one sexual partner for the past
10 years.
5. The client has a previous history of gestational
diabetes mellitus.
215. The nurse in a maternity unit is providing emotional
support to a client and her significant other who are
preparing to be discharged from the hospital after the
birth of a dead fetus. Which statement made by the
client indicates a component of the normal grieving
process?
1. “We want to attend a support group.”
2. “We never want to try to have a baby again.”
3. “We are going to try to adopt a child immediately.”
4. “We are okay, and we are going to try to have
another baby immediately.”
216. The nurse evaluates the ability of a hepatitis B–
positive mother to provide safe bottle-feeding to her
newborn during postpartum hospitalization. Which
maternal action best exemplifies the mother’s
knowledge of potential disease transmission to the
newborn?
1. The mother requests that the window be closed
before feeding.
2. The mother holds the newborn properly during
feeding
and
burping.
3. The mother tests the temperature of the formula
before
initiating
feeding.
4. The mother washes and dries her hands before and
after self-care of the perineum and asks for a pair of
gloves before feeding.
217. A client in the first trimester of pregnancy arrives at a
health care clinic and reports that she has been
experiencing vaginal bleeding. A threatened abortion
is suspected, and the nurse instructs the client
regarding management of care. Which statement
made by the client indicates a need for further
instruction?
1. “I will watch to see if I pass any tissue.”
2. “I will maintain strict bed rest throughout the
remainder of the pregnancy.”
3. “I will count the number of perineal pads used on a
daily basis and note the amount and color of blood on
the pad.”
4. “I will avoid sexual intercourse until the bleeding
has stopped and for 2 weeks following the last
episode of bleeding.”
218. The nurse is planning to admit a pregnant client who
is obese. In planning care for this client, which
potential client needs should the nurse anticipate?
Select all that apply.
1. Bed rest as a necessary preventive measure may be
prescribed.
2. Administration of subcutaneous heparin
postdelivery
as
prescribed.
3. An overbed lift may be necessary if the client
requires
a
cesarean
section.
4. Less frequent cleansing of a cesarean incision, if
present,
may
be
prescribed.
5. Thromboembolism stockings or sequential
compression devices may be prescribed.
219. 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 should the
nurse expect to note if this condition is present?
1. Soft abdomen
2. Uterine tenderness
3. Absence of abdominal pain
4. Painless, bright red vaginal bleeding
220. 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
should question which prescription?
1. Prepare the client for an ultrasound.
2. Obtain equipment for a manual pelvic examination.
3. Prepare to draw a hemoglobin and hematocrit
blood sample.
4. Obtain equipment for external electronic fetal
heart rate monitoring.
221. 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 should prepare the client for which
anticipated prescription?
1. Delivery of the fetus
2. Strict monitoring of intake and output
3. Complete bed rest for the remainder of the
pregnancy
4. The need for weekly monitoring of coagulation
studies until the time of delivery
222. 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?
1. Infection
2. Hemorrhage
3. Chronic hypertension
4. Disseminated intravascular coagulation
223. The nurse is performing an assessment on a client
diagnosed with placenta previa. Which assessment findings
should 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
CHAPTER 24: PROBLEMS WITH LABOR & BIRTH
238. 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?
1. The client is a 35-year-old primigravida.
2. The client has a history of cardiac disease.
3. The client’s hemoglobin level is 13.5 g/dL (135
mmol/L).
4. The client is a 20-year-old primigravida of average
weight and height.
239. 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
that which risk factors in the client’s history placed
her at risk for this complication? Select all that apply.
1. Age 54 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)
240. The nurse in a birthing room is monitoring a client
with dysfunctional labor for signs of fetal or maternal
compromise. Which assessment finding should alert
the nurse to a compromise?
1. Maternal fatigue
2. Coordinated uterine contractions
3. Progressive changes in the cervix
4. Persistent nonreassuring fetal heart rate
241. 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?
1.
Provide
pain
relief
measures.
2. Prepare the client for an amniotomy.
3. Promote ambulation every 30 minutes.
4. Monitor the oxytocin infusion closely.
242. 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 should the nurse question?
1. Monitor fetal heart rate continuously.
2. Monitor maternal vital signs frequently.
3. Perform a vaginal examination every shift.
4. Administer an antibiotic per prescription and per
agency protocol.
243. 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?
1. Providing comfort measures
2. Monitoring the fetal heart rate
3. Changing the client’s position frequently
4. Keeping the significant other informed of the
progress of the labor
244. 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?
1. Slow the intravenous flow rate.
2. Continue the oxytocin drip if infusing.
3. Place the client in a high Fowler’s position.
4. Administer oxygen, 8 to 10 L/minute, via face
mask.
245. 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?
1. Gently push the cord into the vagina.
2. Place the client in Trendelenburg’s position.
3. Find the closest telephone and page the primary
health care provider stat.
4. Call the delivery room to notify the staff that the
client will be transported immediately.
CHAPTER 26: POSTPARTUM COMPLICATIONS
258. The nurse is monitoring a client in the immediate
postpartum period for signs of hemorrhage. Which
sign, if noted, would be an early sign of excessive
blood loss?
1. A temperature of 100.4° F (38° C)
2. An increase in the pulse rate from 88 to 102 beats
per minute
3. A blood pressure change from 130/88 to 124/80
mm Hg
4. An increase in the respiratory rate from 18 to 22
breaths per minute
259. The nurse is preparing a list of self-care instructions
for a postpartum client who was diagnosed with
mastitis. Which instructions should be included on
the list? Select all that apply.
1. Wear a supportive bra.
2. Rest during the acute phase.
3. Maintain a fluid intake of at least 3000 mL/day.
4. Continue to breast-feed if the breasts are not too
sore.
5. Take the prescribed antibiotics until the soreness
subsides.
6. Avoid decompression of the breasts by breastfeeding or breast pump.
260. The nurse is providing instructions about measures to
prevent postpartum mastitis to a client who is breastfeeding her newborn. Which client statement would
indicate a need for further instruction?
1. “I should breast-feed every 2 to 3 hours.”
2. “I should change the breast pads frequently.”
3. “I should wash my hands well before breastfeeding.”
4. “I should wash my nipples daily with soap and
water.”
261. The postpartum nurse is assessing a client who
delivered a healthy infant by cesarean section for
signs and symptoms of superficial venous thrombosis.
Which sign should the nurse note if superficial venous
thrombosis were present?
1. Paleness of the calf area
2. Coolness of the calf area
3. Enlarged, hardened veins
4. Palpable dorsalis pedis pulses
262. A client in a postpartum unit complains of sudden
sharp chest pain and dyspnea. The nurse notes that
the client is tachycardic and the respiratory rate is
elevated. The nurse suspects a pulmonary embolism.
Which should be the initial nursing action?
1.
Initiate
an
intravenous
line.
2.
Assess
the
client’s
blood
pressure.
3. Prepare to administer morphine sulfate.
4. Administer oxygen, 8 to 10 L/minute, by face mask.
263. The nurse is assessing a client in the fourth stage of
labor and notes that the fundus is firm, but that
bleeding is excessive. Which should be the initial
nursing action?
1. Record the findings.
2. Massage the fundus.
3. Notify the obstetrician (OB).
4. Place the client in Trendelenburg’s position.
264. The nurse is preparing to care for four assigned
clients. Which client is at most risk for hemorrhage?
1. A primiparous client who delivered 4 hours ago
2. A multiparous client who delivered 6 hours ago
3. A multiparous client who delivered a large baby
after
oxytocin
induction
4. A primiparous client who delivered 6 hours ago and
had epidural anesthesia
265. A postpartum client is diagnosed with cystitis. The
nurse should plan for which priority action in the care
of the client?
1. Providing sitz baths
2.
Encouraging
fluid
intake
3.
Placing
ice
on
the
perineum
4. Monitoring hemoglobin and hematocrit levels
266. The nurse is monitoring a postpartum client who
received epidural anesthesia for delivery for the
presence of a vulvar hematoma. Which assessment
finding would best indicate the presence of a
hematoma?
1. Changes in vital signs
2. Signs of heavy bruising
3. Complaints of intense pain
4. Complaints of a tearing sensation
267. The nurse is creating a plan of care for a postpartum
client with a small vulvar hematoma. The nurse
should include which specific action during the first 12
hours after delivery?
1. Encourage ambulation hourly.
2. Assess vital signs every 4 hours.
3. Measure fundal height every 4 hours.
4. Prepare an ice pack for application to the area.
268. On assessment of a postpartum client, the nurse
notes that the uterus feels soft and boggy. The nurse
should take which initial action?
1. Document the findings.
2. Elevate the client’s legs.
3. Massage the fundus until it is firm.
4. Push on the uterus to assist in expressing
clots.
CHAPTER 28: MATERNITY & NEWBORN
MEDICATIONS
284. The nurse is monitoring a client who is receiving
oxytocin to induce labor. Which assessment findings
should cause the nurse to immediately discontinue
the oxytocin infusion? Select all that apply.
1. Fatigue
2. Drowsiness
3. Uterine hyperstimulation
4. Late decelerations of the fetal heart rate 5. Early
decelerations of the fetal heart rate
285. A pregnant client is receiving magnesium sulfate for
the management of preeclampsia. The nurse
determines that the client is experiencing toxicity
from the medication if which findings are noted on
assessment? Select all that apply.
1. Proteinuria of 3 +
2. Respirations of 10 breaths per minute
3. Presence of deep tendon reflexes
4. Urine output of 20 mL in an hour
5. Serum magnesium level of 4 mEq/L (2 mmol/L)
286. The nurse asks a nursing student to describe the
procedure for administering erythromycin ointment
to the eyes of a newborn. Which student statement
indicates that further teaching is needed about
administration of the eye medication?
1. “I will flush the eyes after instilling the ointment.”
2. “I will clean the newborn’s eyes before instilling
ointment.” 3. “I need to administer the eye ointment
within 1 hour after delivery.”
4. “I will instill the eye ointment into each of the
newborn’s conjunctival sacs.”
287. A client in preterm labor (31 weeks) who is dilated to
4 cm has been started on magnesium sulfate and
contractions have stopped. If the client’s labor can be
inhibited for the next 48 hours, the nurse anticipates
a prescription for which medication?
1. Nalbuphine
2. Betamethasone
3. Rho(D) immune globulin
4. Dinoprostone vaginal insert
288. Methylergonovine is prescribed for a woman to treat
postpartum hemorrhage. Before administration of
methylergonovine, what is the priority assessment?
1. Uterine tone
2. Blood pressure
3. Amount of lochia
4. Deep tendon reflexes
289. The nurse is preparing to administer exogenous
surfactant to a premature infant who has respiratory
distress syndrome. The nurse prepares to administer
the medication by which route?
1. Intradermal
2. Intratracheal
3. Subcutaneous
4. Intramuscular
290. An opioid analgesic is administered to a client in labor.
The nurse assigned to care for the client ensures that
which medication is readily accessible should
respiratory depression occur?
1. Naloxone
2. Morphine sulfate
3. Betamethasone
4. Hydromorphone hydrochloride
291. Rho(D) immune globulin is prescribed for a client after
delivery, and the nurse provides information to the
client about the purpose of the medication. The nurse
determines that the woman understands the purpose
if the woman states that it will protect her next baby
from which condition?
1. Having Rh-positive blood
2. Developing a rubella infection
3. Developing physiological jaundice
4. Being affected by Rh incompatibility
292. Methylergonovine is prescribed for a client with
postpartum hemorrhage. Before administering the
medication, the nurse should contact the obstetrician
who prescribed the medication if which condition is
documented in the client’s medical history?
1. Hypotension
2. Hypothyroidism
3. Diabetes mellitus
4. Peripheral vascular disease
293. The nurse is monitoring a client in preterm labor who
is receiving intravenous magnesium sulfate. The
nurse should monitor for which adverse effects of this
medication? Select all that apply.
1. Flushing
2. Hypertension
3. Increased urine output
4. Depressed respirations
5. Extreme muscle weakness
6. Hyperactive deep tendon reflexes