ATI ReviewATI Review

Lucy Van Otterloo, RN, MSNLucy Van Otterloo, RN, MSN

Which hormone is directly responsible Which hormone is directly responsible for ovulation?for ovulation?

A. EstrogenA. Estrogen B. ProgesteroneB. Progesterone C. Luteinizing hormone (LH)C. Luteinizing hormone (LH) D. Follicle-stimulating hormone D. Follicle-stimulating hormone

(FSH)(FSH)

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

The physician prescribes the fertility drugs The physician prescribes the fertility drugs menotropins (Pergonal) and chorionic menotropins (Pergonal) and chorionic

gonadotropin (Pregnyl). The nurse should gonadotropin (Pregnyl). The nurse should instruct the client that the combined action instruct the client that the combined action

of these drugs is to:of these drugs is to:

A. Stimulate and promote ovulationA. Stimulate and promote ovulation B. Prepare the uterus for implantationB. Prepare the uterus for implantation C. Prevent endometriosis in the C. Prevent endometriosis in the

fallopian tubesfallopian tubes D. Facilitate patency of the fallopian D. Facilitate patency of the fallopian

tubestubes

A. Mentropins (Pergonal) stimulates A. Mentropins (Pergonal) stimulates maturation of the ovum and maturation of the ovum and chorionic gonadotropin (Pregnyl) chorionic gonadotropin (Pregnyl) stimulates ovulation, thus increasing stimulates ovulation, thus increasing the woman’s chance for fertilization the woman’s chance for fertilization and implantation.and implantation.

The time of ovulation can be determined by The time of ovulation can be determined by taking the basal temperature. During taking the basal temperature. During

ovulation the basal temperature:ovulation the basal temperature:

A. Drops markedlyA. Drops markedly B. Drops slightly and then risesB. Drops slightly and then rises C. Rises suddenly and then fallsC. Rises suddenly and then falls D. Rises markedly and remains highD. Rises markedly and remains high

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

A couple who recently emigrated from Israel A couple who recently emigrated from Israel are concerned about a genetic disease that are concerned about a genetic disease that is prevalent among Jewish people and speak is prevalent among Jewish people and speak to the clinic nurse. The nurse recommends to the clinic nurse. The nurse recommends

that they go for a genetic blood test to that they go for a genetic blood test to determine the possibility of any of their determine the possibility of any of their

children being born with:children being born with:

A. PKUA. PKU B. Cystic fibrosisB. Cystic fibrosis C. Cooley’s anemiaC. Cooley’s anemia D. Tay-Sachs diseaseD. Tay-Sachs disease

D. This is a genetic disorder D. This is a genetic disorder transmitted as an autosomal transmitted as an autosomal recessive trait that occurs primarily recessive trait that occurs primarily among Ashkenazi Jews.among Ashkenazi Jews.

After the first 3 months of pregnancy, the After the first 3 months of pregnancy, the chief source of estrogen and progesterone is chief source of estrogen and progesterone is

the:the:

A. PlacentaA. Placenta B. Adrenal cortexB. Adrenal cortex C. Corpus luteumC. Corpus luteum D. Anterior hypophysisD. Anterior hypophysis

A. When placental formation is A. When placental formation is complete, around the 12complete, around the 12thth week of week of pregnancy, it produces progesterone pregnancy, it produces progesterone and estrogenand estrogen

During prenatal development, fetal During prenatal development, fetal weight gain is greatest in the:weight gain is greatest in the:

A. First trimesterA. First trimester B. Third trimesterB. Third trimester C. Second trimesterC. Second trimester D. Implantation periodD. Implantation period

B. This is the period in which the B. This is the period in which the fetus stores deposits of fat.fetus stores deposits of fat.

In dealing with a couple identified as In dealing with a couple identified as having an infertility problem, the nurse having an infertility problem, the nurse

knows that:knows that:

A. Infertility is usually psychologic in A. Infertility is usually psychologic in originorigin

B. Infertility and sterility are B. Infertility and sterility are essentially the same problemessentially the same problem

C. The couple have been unable to C. The couple have been unable to have a child after trying for a yearhave a child after trying for a year

D. One partner has a problem that D. One partner has a problem that makes that person unable to have makes that person unable to have childrenchildren

C. Infertility is the inability of a C. Infertility is the inability of a couple to conceive after at least 1 couple to conceive after at least 1 year of adequate exposure to the year of adequate exposure to the possibility of pregnancy.possibility of pregnancy.

A test commonly used to determine the A test commonly used to determine the number, motility and activity of sperm is number, motility and activity of sperm is

the:the:

A. Rubin testA. Rubin test B. Friedman testB. Friedman test C. Postcoital testC. Postcoital test D. Papanicolaou testD. Papanicolaou test

C. This test determines the number C. This test determines the number and condition of sperm aspirated and condition of sperm aspirated from the cervix within 2 hours after from the cervix within 2 hours after intercourseintercourse

Which of the following is considered a Which of the following is considered a positive sign of pregnancy?positive sign of pregnancy?

A. A missed menstrual periodA. A missed menstrual period B. Abdominal enlargementB. Abdominal enlargement C. Fetal movement felt by providerC. Fetal movement felt by provider D. Positive pregnancy testD. Positive pregnancy test

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

The nurse is aware that an adaptation of The nurse is aware that an adaptation of pregnancy is an increased blood supply to pregnancy is an increased blood supply to the pelvic region that results in a purplish the pelvic region that results in a purplish

discoloration of the vaginal mucosa, which is discoloration of the vaginal mucosa, which is known as:known as:

A. Ladin’s signA. Ladin’s sign B. Hegar’s signB. Hegar’s sign C. Goodell’s signC. Goodell’s sign D. Chadwick’s signD. Chadwick’s sign

D. A purplish color results from D. A purplish color results from increased vascularity and blood increased vascularity and blood vessel engorgement of the vagina. vessel engorgement of the vagina. Ladin’s sign is increased vascularity Ladin’s sign is increased vascularity of the cervix. Hegar’s sign is of the cervix. Hegar’s sign is softening of the lower uterine softening of the lower uterine segment. Goodell’s sign is softening segment. Goodell’s sign is softening of the cervix.of the cervix.

The uterus rises out of the pelvis and The uterus rises out of the pelvis and becomes an abdominal organ at about becomes an abdominal organ at about

the the

A. 10A. 10thth week of pregnancy week of pregnancy B. 8B. 8thth week of pregnancy week of pregnancy C. 12C. 12thth week of pregnancy week of pregnancy D. 18D. 18thth week of pregnancy week of pregnancy

C. By this time the fetus and C. By this time the fetus and placenta have grown, expanding the placenta have grown, expanding the size of the uterus. The extended size of the uterus. The extended uterus expands into the abdominal uterus expands into the abdominal cavity.cavity.

The nurse plans teaching for a client The nurse plans teaching for a client scheduled for amniocentesis. It is scheduled for amniocentesis. It is MOST important for the nurse to MOST important for the nurse to

include which of the following include which of the following statements?statements?

A. The test assesses gestational age using A. The test assesses gestational age using the biparietal circumferencethe biparietal circumference

B. The test determines the gender of the B. The test determines the gender of the babybaby

C. The test is used to detect possible birth C. The test is used to detect possible birth defectsdefects

D. The test should not be completed if you D. The test should not be completed if you have a hx. of miscarriageshave a hx. of miscarriages

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

A pregnant client works at a computer A pregnant client works at a computer entering data. This would necessarily have entering data. This would necessarily have

implications for her plan of care during implications for her plan of care during pregnancy. The nurse should recommend pregnancy. The nurse should recommend

that the client:that the client:

A. Try to walk about every few hours A. Try to walk about every few hours during the workdayduring the workday

B. Ask for time in the morning and B. Ask for time in the morning and afternoon to elevate her legsafternoon to elevate her legs

C. Tell her employer she cannot work C. Tell her employer she cannot work beyond the second trimesterbeyond the second trimester

D. Ask for time in the morning and D. Ask for time in the morning and afternoon to obtain nourishmentafternoon to obtain nourishment

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

A client is concerned about gaining weight A client is concerned about gaining weight during pregnancy. The nurse explains that during pregnancy. The nurse explains that

the largest part of weight gain during the largest part of weight gain during pregnancy is because of:pregnancy is because of:

A. The fetusA. The fetus B. Fluid retentionB. Fluid retention C. Metabolic alterationsC. Metabolic alterations D. Increased blood volumeD. Increased blood volume

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

Amniotic fluid increases during pregnancy. Amniotic fluid increases during pregnancy. The nurse is aware that one of the major The nurse is aware that one of the major

functions of amniotic fluid and its increase functions of amniotic fluid and its increase during pregnancy is to:during pregnancy is to:

A. Provide antibodies to the fetusA. Provide antibodies to the fetus B. Increase nutrients to the fetusB. Increase nutrients to the fetus C. Maintain fetal temperature C. Maintain fetal temperature

stabilitystability D. Ease passage during deliveryD. Ease passage during delivery

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

Physiologic anemia during pregnancy Physiologic anemia during pregnancy is a result of:is a result of:

A. Decreased dietary intake of ironA. Decreased dietary intake of iron B. Increased plasma volume of the B. Increased plasma volume of the

mothermother C. Decreased erythropoiesis after C. Decreased erythropoiesis after

the first trimesterthe first trimester D. Increased detoxification demands D. Increased detoxification demands

on the mother’s liveron the mother’s liver

B. There is a 30% to 50% increase in B. There is a 30% to 50% increase in maternal plasma volume at the end maternal plasma volume at the end of the first trimester, leading to a of the first trimester, leading to a decrease in the concentration of decrease in the concentration of hemoglobin and erythrocytes.hemoglobin and erythrocytes.

In the 12In the 12thth week of gestation, a client week of gestation, a client completely expels the products of completely expels the products of

conception. Because the client is Rh-conception. Because the client is Rh-negative, the nurse must:negative, the nurse must:

A. Administer RhoGAM within 72 hoursA. Administer RhoGAM within 72 hours B. Make certain she receives RhoGAM B. Make certain she receives RhoGAM

on her first clinic visiton her first clinic visit C. Not give RhoGAM since it is not the C. Not give RhoGAM since it is not the

birth of a stillbornbirth of a stillborn D. Make certain the client does not D. Make certain the client does not

receive RhoGAM since the gestation receive RhoGAM since the gestation only lasted 12 weeksonly lasted 12 weeks

A. It is given within 72 hours A. It is given within 72 hours postpartum if the client has not been postpartum if the client has not been sensitized previously.sensitized previously.

A client at 12 weeks gestation comes to the A client at 12 weeks gestation comes to the prenatal clinic complaining of severe nausea prenatal clinic complaining of severe nausea and vomiting. The nurse suspects that this and vomiting. The nurse suspects that this

client has hyperemesis gravidarum and client has hyperemesis gravidarum and knows that this is frequently associated with:knows that this is frequently associated with:

A. Excessive amniotic fluidA. Excessive amniotic fluid B. A GI history of cholecystitisB. A GI history of cholecystitis C. High levels of chorionic C. High levels of chorionic

gonadotropingonadotropin D. Slowed secretion of free D. Slowed secretion of free

hydrochloric acidhydrochloric acid

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

The care of a client with placenta The care of a client with placenta previa includes:previa includes:

A. Vital signs at least once per shiftA. Vital signs at least once per shift B. A tap-water enema before B. A tap-water enema before

deliverydelivery C. Observation and recording of the C. Observation and recording of the

bleedingbleeding D. Limited ambulation until the D. Limited ambulation until the

bleeding stopsbleeding stops

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

A pregnant client develops thrombophlebitis A pregnant client develops thrombophlebitis of the left leg and is admitted to the hospital of the left leg and is admitted to the hospital for bedrest and anticoagulant therapy. The for bedrest and anticoagulant therapy. The

anticoagulant the nurse should expect to anticoagulant the nurse should expect to administer is:administer is:

A. HeparinA. Heparin B. DicumerolB. Dicumerol C. Diphenadione (Dipaxin)C. Diphenadione (Dipaxin) D. Wafarin (Coumadin)D. Wafarin (Coumadin)

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

A client who is 6 months pregnant comes to A client who is 6 months pregnant comes to the prenatal clinic complaining of painful the prenatal clinic complaining of painful

urination, flank tenderness, and hematuria. urination, flank tenderness, and hematuria. A diagnosis of pyelonephritis is made. An A diagnosis of pyelonephritis is made. An

important nursing intervention for the client important nursing intervention for the client at this time is:at this time is:

A. Limiting fluid intakeA. Limiting fluid intake B. Examining the urine for proteinB. Examining the urine for protein C. Observing for signs of preterm C. Observing for signs of preterm

laborlabor D. Maintaining her on a 2-gram D. Maintaining her on a 2-gram

sodium dietsodium diet

C. Pyelonephritis often causes C. Pyelonephritis often causes preterm labor, leading to increased preterm labor, leading to increased neonatal morbidity and mortality.neonatal morbidity and mortality.

When taking the health history, the nurse When taking the health history, the nurse correctly identifies that a client is at risk for correctly identifies that a client is at risk for

developing a hypertensive disorder of developing a hypertensive disorder of pregnancy when it is determined that the pregnancy when it is determined that the

client:client:

A. Is 31 years oldA. Is 31 years old B. Is an obese primigravidaB. Is an obese primigravida C. Has had six previous pregnanciesC. Has had six previous pregnancies D. Has been on oral contraceptives D. Has been on oral contraceptives

within 3 months of pregnancywithin 3 months of pregnancy

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

A pregnant client asks the clinic nurse how A pregnant client asks the clinic nurse how smoking will affect her baby. The nurse’s smoking will affect her baby. The nurse’s

response reflects the knowledge that:response reflects the knowledge that:

A. The placenta is permeable to A. The placenta is permeable to specific substancesspecific substances

B. Smoking relieves tension and the B. Smoking relieves tension and the fetus responds accordinglyfetus responds accordingly

C. Vasoconstriction will affect both C. Vasoconstriction will affect both fetal and maternal blood vesselsfetal and maternal blood vessels

D. Fetal and maternal circulation are D. Fetal and maternal circulation are separated by the placental barrierseparated by the placental barrier

C. Cigarette smoking or continued C. Cigarette smoking or continued exposure to secondary smoke causes exposure to secondary smoke causes both maternal and fetal both maternal and fetal vasoconstriction, resulting in fetal vasoconstriction, resulting in fetal growth restriction and increased fetal growth restriction and increased fetal and infant mortalityand infant mortality

The nurse auscultates the abdomen of a 38 The nurse auscultates the abdomen of a 38 weeks gestation to determine fetal heart weeks gestation to determine fetal heart

rate. If the fetal heartbeat is located in the rate. If the fetal heartbeat is located in the right lower quadrant, which of the following right lower quadrant, which of the following

is MOST likely the presenting part?is MOST likely the presenting part?

A. ShoulderA. Shoulder B. HeadB. Head C. FeetC. Feet D. ButtocksD. Buttocks

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

After doing Leopold’s maneuvers on a After doing Leopold’s maneuvers on a laboring cient, the nurse determines that the laboring cient, the nurse determines that the

fetus in in the ROP position. To best fetus in in the ROP position. To best auscultate the fetal heart tones, the Doppler auscultate the fetal heart tones, the Doppler

is placed:is placed:

A. Above the umbilicus in the midlineA. Above the umbilicus in the midline B. Above the umbilicus on the left sideB. Above the umbilicus on the left side C. Below the umbilicus on the right sideC. Below the umbilicus on the right side D. Below the umbilicus near the left D. Below the umbilicus near the left

groingroin

C. Fetal heart tones are best C. Fetal heart tones are best auscultated through the fetal back; auscultated through the fetal back; because the position is ROP, the back because the position is ROP, the back would be below the umbilicus and on would be below the umbilicus and on the right sidethe right side

When caring for a woman with a positive When caring for a woman with a positive contraction stress test, the nurse should be contraction stress test, the nurse should be most concerned with observing her for signs most concerned with observing her for signs

and symptoms of:and symptoms of:

A. PreeclampsiaA. Preeclampsia B. Placenta previaB. Placenta previa C. Imminent pretem deliveryC. Imminent pretem delivery D. Uteroplacental insufficiencyD. Uteroplacental insufficiency

D. A positive CST indicates a D. A positive CST indicates a compromised fetal heart rate during compromised fetal heart rate during contractions, which is associated contractions, which is associated with uteroplacental insufficiencywith uteroplacental insufficiency

A laboring woman’s uterine A laboring woman’s uterine contractions are being internally contractions are being internally monitored. When evaluating the monitored. When evaluating the

monitor tracing, which of the following monitor tracing, which of the following findings would be a source of concern findings would be a source of concern

and require further assessment?and require further assessment?

A. Frequency every 2.5 to 3 minutesA. Frequency every 2.5 to 3 minutes B. Duration of 80-85 secondsB. Duration of 80-85 seconds C. Intensity of 85-90 mmHgC. Intensity of 85-90 mmHg D. Resting pressure of 20-25 mmHgD. Resting pressure of 20-25 mmHg

Correct answer: D Correct answer: D – The resting pressure should be 15 The resting pressure should be 15

mmHg or lessmmHg or less

The nurse caring for women in labor The nurse caring for women in labor should be aware of signs should be aware of signs

characterizing reassuring FHR characterizing reassuring FHR patterns. A reassuring sign would be:patterns. A reassuring sign would be:

A. Moderate baseline variabilityA. Moderate baseline variability B. Average baseline FHR of 90-110 beats/minB. Average baseline FHR of 90-110 beats/min C. Transient episodic deceleration with movementC. Transient episodic deceleration with movement D. Late decelerations approx. every 3-4 D. Late decelerations approx. every 3-4

contractionscontractions

Correct answer: ACorrect answer: A– The baseline rate should be 110-160 The baseline rate should be 110-160

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

A laboring woman’s temperature is A laboring woman’s temperature is elevated as a result of an upper elevated as a result of an upper

respiratory infection. The FHR pattern respiratory infection. The FHR pattern that reflects maternal fever would be:that reflects maternal fever would be:

A. Diminished variabilityA. Diminished variability B. Variable decelerationsB. Variable decelerations C. TachycardiaC. Tachycardia D. Early decelerationsD. Early decelerations

Correct answer: CCorrect answer: C– The FHR increases as the maternal core The FHR increases as the maternal core

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

A nulliparous woman is in the active phase of labor A nulliparous woman is in the active phase of labor and her cervix has progressed to 6 cm dilation. The and her cervix has progressed to 6 cm dilation. The nurse caring for this woman evaluates the external nurse caring for this woman evaluates the external monitor tracing and notes the following: decrease in monitor tracing and notes the following: decrease in

FHR shortly after onset of several contractions, FHR shortly after onset of several contractions, returning to baseline rate by the end of the returning to baseline rate by the end of the

contractions; shape is uniform. Based on these contractions; shape is uniform. Based on these finding, the nurse should:finding, the nurse should:

A. Change the woman’s position to her left sideA. Change the woman’s position to her left side B. Document the finding on the woman’s chartB. Document the finding on the woman’s chart C. Notify the physicianC. Notify the physician D. Perform a vaginal examination to check for D. Perform a vaginal examination to check for

cord prolapsecord prolapse

Correct answer: BCorrect answer: B– The pattern described is an early The pattern described is an early

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

The nurse has auscultated a fetal heart The nurse has auscultated a fetal heart rate of 80. What should be the nurse’s rate of 80. What should be the nurse’s

initial action?initial action?

A. Position the client on her left sideA. Position the client on her left side B. Administer oxygen at 5L/minuteB. Administer oxygen at 5L/minute C. Notify the physician or nurse-midwifeC. Notify the physician or nurse-midwife D. Check the maternal pulseD. Check the maternal pulse

Correct answer: DCorrect answer: D– Key word is auscultated – the nurse may Key word is auscultated – the nurse may

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

At about 5 cm. dilation, a laboring client At about 5 cm. dilation, a laboring client receives medication for pain. The nurse is receives medication for pain. The nurse is aware that one of the medications given to aware that one of the medications given to women in labor that could cause respiratory women in labor that could cause respiratory

depression of the newborn is:depression of the newborn is:

A. ScopolamineA. Scopolamine B. PromazineB. Promazine C. Meperidine (Demerol)C. Meperidine (Demerol) D. Promethazine (Phergan)D. Promethazine (Phergan)

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

The nurse in the birthing suite has just The nurse in the birthing suite has just admitted the following four clients. Which admitted the following four clients. Which

one of these clients should the nurse prepare one of these clients should the nurse prepare for cesarean section?for cesarean section?

A. Multipara with a shoulder A. Multipara with a shoulder presentationpresentation

B. Multipara with a documented B. Multipara with a documented station of “floating”station of “floating”

C. Primigravida with a fetus C. Primigravida with a fetus presenting in occiput posteriorpresenting in occiput posterior

D. Primigravida with twin gestation D. Primigravida with twin gestation with lower most twin in vertex position.with lower most twin in vertex position.

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

A client is admitted to the hospital in active A client is admitted to the hospital in active labor. After an amniotomy the nurse would labor. After an amniotomy the nurse would

expect:expect:

A. Increased fetal heart rateA. Increased fetal heart rate B. Diminished bloody showB. Diminished bloody show C. Less discomfort with contractionsC. Less discomfort with contractions D. Progressive dilation and D. Progressive dilation and

effacementeffacement

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

During a client’s labor, the fetus’ head is at During a client’s labor, the fetus’ head is at station +1. This indicates that the station +1. This indicates that the

presenting part is:presenting part is:

A. On the perineumA. On the perineum B. High in the false pelvisB. High in the false pelvis C. Slightly below the ischial spinesC. Slightly below the ischial spines D. Slightly above the ischial spinesD. Slightly above the ischial spines

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

A client is admitted to the birthing suite in A client is admitted to the birthing suite in early active labor. The priority nursing early active labor. The priority nursing intervention on admission of this client intervention on admission of this client

would be:would be:

A. Auscultating the fetal heartA. Auscultating the fetal heart B. Taking an obstetric historyB. Taking an obstetric history C. Asking the client when she ate C. Asking the client when she ate

lastlast D. Ascertaining whether the D. Ascertaining whether the

membranes are rupturedmembranes are ruptured

A. Determining fetal well-being A. Determining fetal well-being supersedes all other measures. If supersedes all other measures. If the fetal heart rate is absent or the fetal heart rate is absent or persistently decelerating, immediate persistently decelerating, immediate intervention is required.intervention is required.

A client is admitted to the labor unit in the A client is admitted to the labor unit in the latent phase of the first stage of labor, with latent phase of the first stage of labor, with

contractions lasting 20 seconds. In assessing contractions lasting 20 seconds. In assessing the client’s emotional status, the nurse would the client’s emotional status, the nurse would

anticipate that the client will be:anticipate that the client will be:

A. SeriousA. Serious B. HappyB. Happy C. IrritableC. Irritable D. panickyD. panicky

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

A multigravida client is admitted in active A multigravida client is admitted in active labor. She is yelling, “Hurry! Hurry! The labor. She is yelling, “Hurry! Hurry! The

baby is coming!” What priority action by the baby is coming!” What priority action by the nurse is indicated? nurse is indicated?

A. Check the fetal heart tonesA. Check the fetal heart tones B. Time the contraction intervalB. Time the contraction interval C. Determine the presenting partC. Determine the presenting part D. Do a vaginal examinationD. Do a vaginal examination

D. A vaginal examination should be D. A vaginal examination should be performed to determine the performed to determine the presenting part so preparation can presenting part so preparation can be made for delivery.be made for delivery.

A nurse is assessing a client in labor and A nurse is assessing a client in labor and finds that her contractions are lasting 60 finds that her contractions are lasting 60

seconds every 4 minutes and that her cervix seconds every 4 minutes and that her cervix is 6 cm dilated. The nurse would document is 6 cm dilated. The nurse would document

that the client is in what stage of labor?that the client is in what stage of labor?

A. Active phaseA. Active phase B. Early phaseB. Early phase C. Latent phaseC. Latent phase D. Transitional phaseD. Transitional phase

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

The nurse teaches a pregnant woman to The nurse teaches a pregnant woman to avoid lying on her back during labor. The avoid lying on her back during labor. The

nurse has based this statement on the nurse has based this statement on the knowledge that the supine position can:knowledge that the supine position can:

A. Unduly prolong laborA. Unduly prolong labor B. Cause decreased placental B. Cause decreased placental

perfusionperfusion C. Lead to transient episodes of C. Lead to transient episodes of

hypertensionhypertension D. Interfere with free movement of D. Interfere with free movement of

the coccyxthe coccyx

B. This is because of impedance of B. This is because of impedance of venous return by the gravid uterus, venous return by the gravid uterus, which causes hypotension and which causes hypotension and decreased systemic perfusiondecreased systemic perfusion

The husband of a client who is in the transitional The husband of a client who is in the transitional phase of labor becomes very tense and nervous phase of labor becomes very tense and nervous

during this period and asks the nurse, “Do you think during this period and asks the nurse, “Do you think it is best for me to leave, since I don’t seem to do it is best for me to leave, since I don’t seem to do

my wife much good?” The most appropriate my wife much good?” The most appropriate response by the nurse would be:response by the nurse would be:

A. “This is the time your wife needs you. Don’t A. “This is the time your wife needs you. Don’t run out on her now.”run out on her now.”

B. “This is hard for you. Let me try to help you B. “This is hard for you. Let me try to help you coach her during this difficult phase.”coach her during this difficult phase.”

C. “I know this is hard for you. Why don’t you go C. “I know this is hard for you. Why don’t you go have a cup of coffee and relax and come back have a cup of coffee and relax and come back later if you feel like.”later if you feel like.”

D. “If you feel that way, you’d best go out and sit D. “If you feel that way, you’d best go out and sit in the waiting room for a while because you may in the waiting room for a while because you may transmit your anxiety to your wife.”transmit your anxiety to your wife.”

B. Both the father and the mother B. Both the father and the mother need additional support during the need additional support during the transitional stage of labortransitional stage of labor

A client who was admitted in active labor has A client who was admitted in active labor has only progressed from 2 cm to 3 cm in 8 only progressed from 2 cm to 3 cm in 8

hours. She is diagnosed as having hypotonic hours. She is diagnosed as having hypotonic dystocia and is given oxytocin to augment dystocia and is given oxytocin to augment

her contractions. The most important aspect her contractions. The most important aspect of nursing at this time is:of nursing at this time is:

A. Monitoring the FHRA. Monitoring the FHR B. Checking the perineum for bulgingB. Checking the perineum for bulging C. Preparing for an emergency C. Preparing for an emergency

cesarean birthcesarean birth D. Timing and recording length of D. Timing and recording length of

contractionscontractions

D. The oxytocic effect of Pitocin D. The oxytocic effect of Pitocin increases the intensity, duration and increases the intensity, duration and frequency of contractions; prolonged frequency of contractions; prolonged contractions will jeopardize the contractions will jeopardize the safety of the fetus and necessitate safety of the fetus and necessitate discontinuing the drugdiscontinuing the drug

An expectant couple asks the nurse about An expectant couple asks the nurse about the cause of low back pain in labor. The the cause of low back pain in labor. The

nurse replies that this pain occurs most when nurse replies that this pain occurs most when the position of the fetus is:the position of the fetus is:

A. BreechA. Breech B. TransverseB. Transverse C. Occiput anteriorC. Occiput anterior D. Occiput posteriorD. Occiput posterior

D. A persistent occiput posterior D. A persistent occiput posterior position causes intense back pain position causes intense back pain because of fetal compression of the because of fetal compression of the sacral nerves.sacral nerves.

A client is 39 weeks pregnant and in labor. A client is 39 weeks pregnant and in labor. Her physician has informed her that she will Her physician has informed her that she will have to have a cesarean birth because she have to have a cesarean birth because she

has:has:

A. GonorrheaA. Gonorrhea B. ChlamydiaB. Chlamydia C. Chronic hepatitisC. Chronic hepatitis D. Active genital herpesD. Active genital herpes

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

The nurse working in a triage clinic should The nurse working in a triage clinic should return which of the following client’s return which of the following client’s

telephone messages first?telephone messages first?

A. 37 weeks of gestation with SOBA. 37 weeks of gestation with SOB B. 10 weeks of gestation with breast B. 10 weeks of gestation with breast

tendernesstenderness C. 35 weeks of gestation with feet C. 35 weeks of gestation with feet

that well at the end of the daythat well at the end of the day D. 12 weeks of gestation with D. 12 weeks of gestation with

darkening blotches of skin over her darkening blotches of skin over her cheekbonescheekbones

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

When a client is admitted to the labor suite When a client is admitted to the labor suite with a BP of 130/90, 2+ proteinuria, and with a BP of 130/90, 2+ proteinuria, and edema of the hands and face, the nurse edema of the hands and face, the nurse

should ask the client about the presence of:should ask the client about the presence of:

A. Constipation, edema, visual problems, A. Constipation, edema, visual problems, headacheheadache

B. Visual disturbances, headaches, B. Visual disturbances, headaches, constipation, bleedingconstipation, bleeding

C. Leakage of fluid, bleeding, edema, pain C. Leakage of fluid, bleeding, edema, pain in the abdomenin the abdomen

D. Headache, visual disturbances, edema, D. Headache, visual disturbances, edema, pain in the abdomenpain in the abdomen

D. To ascertain the severity of D. To ascertain the severity of preeclampsia, these are the signs preeclampsia, these are the signs that must be assessed.that must be assessed.

The nurse is caring for a woman at 37 weeks The nurse is caring for a woman at 37 weeks gestation. The nurse would be MOST gestation. The nurse would be MOST concerned by which of the following concerned by which of the following

findings?findings?

A. The patient c/o right quadrant A. The patient c/o right quadrant painpain

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

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

A client is on magnesium sulfate therapy for A client is on magnesium sulfate therapy for severe preeclampsia. The nurse must be severe preeclampsia. The nurse must be

alert for the first sign of an excessive blood alert for the first sign of an excessive blood magnesium level, which is:magnesium level, which is:

A. Disturbance in sensoriumA. Disturbance in sensorium B. Increase in respiratory rateB. Increase in respiratory rate C. Development of cardiac C. Development of cardiac

dysrhythmiadysrhythmia D. Disappearance of the knee-jerk D. Disappearance of the knee-jerk

reflexreflex

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

A pregnant client is receiving magnesium A pregnant client is receiving magnesium sulfate for eclampsia. Which medication sulfate for eclampsia. Which medication

should the nurse have available as an should the nurse have available as an antidote for possible toxicity?antidote for possible toxicity?

A. Vitamin KA. Vitamin K B. Calcium gluconateB. Calcium gluconate C. Naloxone (Narcan)C. Naloxone (Narcan) D. Diazepam (Valium)D. Diazepam (Valium)

B. Calcium gluconate is the B. Calcium gluconate is the antagonist to magnesium sulfate that antagonist to magnesium sulfate that would be ordered if toxicity occurs.would be ordered if toxicity occurs.

A 26 year-old woman is brought to the emergency A 26 year-old woman is brought to the emergency room complaining of severe left lower quadrant room complaining of severe left lower quadrant

pain. She tells the nurse that she performed a home pain. She tells the nurse that she performed a home pregnancy test and believes she is 8 weeks pregnancy test and believes she is 8 weeks

pregnant. On admission the patient’s vital signs are pregnant. On admission the patient’s vital signs are pulse 90, BP 110/70, respirations 20. A half-hour pulse 90, BP 110/70, respirations 20. A half-hour

later her vital signs are pulse 120, BP 86/50, later her vital signs are pulse 120, BP 86/50, respirations 26. The nurse interprets the change in respirations 26. The nurse interprets the change in

the patient’s vital signs to mean that:the patient’s vital signs to mean that:

A. The patient’s pain may have increasedA. The patient’s pain may have increased B. The patient may be bleeding internallyB. The patient may be bleeding internally C. The patient may be frightenedC. The patient may be frightened D. The patient may have an infectionD. The patient may have an infection

B. Decreased BP equals decreased B. Decreased BP equals decreased intravascular volume; shock. BP intravascular volume; shock. BP increases with pain and fear. increases with pain and fear. Infection usually won’t change BP Infection usually won’t change BP unless in septic shock.unless in septic shock.

The nurse is caring for clients in the labor The nurse is caring for clients in the labor and delivery unit. The nurse notes that a and delivery unit. The nurse notes that a

client’s membranes have ruptured and the client’s membranes have ruptured and the amniotic fluid is meconium-stained. The amniotic fluid is meconium-stained. The

nurse determines that there is no prolapsed nurse determines that there is no prolapsed cord. Which of the following actions should cord. Which of the following actions should

the nurse take NEXT?the nurse take NEXT?

A. Contact the health care providerA. Contact the health care provider B. Assess fetal heart tonesB. Assess fetal heart tones C. Start an intravenous lineC. Start an intravenous line D. Obtain the client’s pulse and D. Obtain the client’s pulse and

blood pressureblood pressure

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

Abruptio placentae is most likely to Abruptio placentae is most likely to occur in a woman with:occur in a woman with:

A. Cardiac diseaseA. Cardiac disease B. HyperthyroidismB. Hyperthyroidism C. Gestational hypertensionC. Gestational hypertension D. Cephalopelvic disproportionD. Cephalopelvic disproportion

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

The nurse cares for an 18 year-old woman in The nurse cares for an 18 year-old woman in the labor unit. During the transitional phase the labor unit. During the transitional phase

of labor the umbilical cord becomes of labor the umbilical cord becomes prolapsed. The nurse should place the prolapsed. The nurse should place the

patient in which of the following positions? patient in which of the following positions?

A. LithotomyA. Lithotomy B. Side-lyingB. Side-lying C. Semi-fowlersC. Semi-fowlers D. TrendelenbergD. Trendelenberg

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

Despite medication, a client’s preterm labor Despite medication, a client’s preterm labor continues, her cervix dilates, and birth continues, her cervix dilates, and birth

appears inevitable. The nurse understands appears inevitable. The nurse understands the infant’s chance of extrauterine survival the infant’s chance of extrauterine survival

may improve if the physician orders:may improve if the physician orders:

A. Ampicillin by piggybackA. Ampicillin by piggyback B. Dexamethasone by infusionB. Dexamethasone by infusion C. An immediate cesarean deliveryC. An immediate cesarean delivery D. An intrauterine exchange D. An intrauterine exchange

transfusion transfusion

B. Steroids are given for a short B. Steroids are given for a short period before delivery; by some period before delivery; by some obscure mechanism, they help to obscure mechanism, they help to mature the fetus’ lungsmature the fetus’ lungs

A client experiences a normal newborn A client experiences a normal newborn delivery. After the placenta is delivered, the delivery. After the placenta is delivered, the physician orders a medication to be added to physician orders a medication to be added to

the IV solution. Which medication is the the IV solution. Which medication is the nurse most likely administering at this time?nurse most likely administering at this time?

A. PenicillinA. Penicillin B. AtropineB. Atropine C. OxytocinC. Oxytocin D. AquaMEPHYTON D. AquaMEPHYTON

C. Oxytocin (Pitocin) stimulates C. Oxytocin (Pitocin) stimulates uterine contractions. When oxytocin uterine contractions. When oxytocin is given after delivery of the is given after delivery of the placenta, the contractions stimulated placenta, the contractions stimulated by the drug help control bleeding.by the drug help control bleeding.

During the postpartum period after a During the postpartum period after a cesarean birth, the nurse examines the client cesarean birth, the nurse examines the client and identifies the presence of lochia serosa and identifies the presence of lochia serosa

and feels the fundus four fingerbreadths and feels the fundus four fingerbreadths below the umbilicus. This indicates that the below the umbilicus. This indicates that the

time elapsed is:time elapsed is: A. 1 to 3 days postpartumA. 1 to 3 days postpartum B. 4 to 5 days postpartumB. 4 to 5 days postpartum C. 6 to 7 days postpartumC. 6 to 7 days postpartum D. 8 to 9 days postpartumD. 8 to 9 days postpartum

B. The fundus descends one B. The fundus descends one fingerbreadth per day from the first fingerbreadth per day from the first postpartum day; lochia serosa begins postpartum day; lochia serosa begins to flow on the fifth day.to flow on the fifth day.

A client after a vaginal delivery is at risk for A client after a vaginal delivery is at risk for postpartum hemorrhage. Nursing education postpartum hemorrhage. Nursing education to prevent postpartum hemorrhage is based to prevent postpartum hemorrhage is based

on the knowledge that priority explanation for on the knowledge that priority explanation for the cause is:the cause is:

A. Laceration of the perineal areaA. Laceration of the perineal area B. Uterine ruptureB. Uterine rupture C. High parityC. High parity D. Uterine atonyD. Uterine atony

D. About 75% of all hemorrhages D. About 75% of all hemorrhages are due to uterine atony, which is the are due to uterine atony, which is the lack of uterine tone. Laceration of lack of uterine tone. Laceration of the perineal area, uterine rupture the perineal area, uterine rupture and high parity are other causes of and high parity are other causes of hemorrhage, but they are not as hemorrhage, but they are not as likely.likely.

The nurse working on the postpartum unit The nurse working on the postpartum unit should encourage clients to ambulate early should encourage clients to ambulate early

to:to:

A. Promote respirationsA. Promote respirations B. Increase the tone of the bladderB. Increase the tone of the bladder C. Maintain tone of abdominal C. Maintain tone of abdominal

musclesmuscles D. Increase peripheral vasomotor D. Increase peripheral vasomotor

activityactivity

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

Since having a baby by cesarean section, a Since having a baby by cesarean section, a client has walked to the nursery numerous client has walked to the nursery numerous times to see her baby each day. Two days times to see her baby each day. Two days postpartum, the client complains of pain in postpartum, the client complains of pain in the right leg. The nurse’s initial response the right leg. The nurse’s initial response

should be to:should be to:

A. Apply hot soaksA. Apply hot soaks B. Massage the affected limbB. Massage the affected limb C. Encourage ambulation and C. Encourage ambulation and

exerciseexercise D. Maintain bed rest and notify the D. Maintain bed rest and notify the

physicianphysician

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

A nurse assesses a client who delivered 1 A nurse assesses a client who delivered 1 hour ago. The fundus is firm and two hour ago. The fundus is firm and two

fingerbreadths below the umbilicus, and the fingerbreadths below the umbilicus, and the lochia is bright red. The client complains of lochia is bright red. The client complains of

having chills. What would the nurse having chills. What would the nurse recognize based on this assessment?recognize based on this assessment?

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

shockshock

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

When is a client most likely to When is a client most likely to experience postpartum depression?experience postpartum depression?

A. Within the first 48 hoursA. Within the first 48 hours B. Within the first 72 hoursB. Within the first 72 hours C. By the fourth or fifth dayC. By the fourth or fifth day D. During the second weekD. During the second week

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

When checking a client’s fundus on the When checking a client’s fundus on the second postpartum day, the nurse observes second postpartum day, the nurse observes that the fundus is above the umbilicus and that the fundus is above the umbilicus and displaced to the right. The nurse evaluates displaced to the right. The nurse evaluates

that the client probably has:that the client probably has:

A. A slow rate of involutionA. A slow rate of involution B. A full, overdistended bladderB. A full, overdistended bladder C. Retained placental fragmentsC. Retained placental fragments D. Overstretched uterine ligamentsD. Overstretched uterine ligaments

B. A distended bladder will displace B. A distended bladder will displace the fundus upward and laterallythe fundus upward and laterally

A postpartum client experiences a A postpartum client experiences a temperature spike of 101 F (38.3 C) 12 temperature spike of 101 F (38.3 C) 12

hours after delivery. What would the nurse hours after delivery. What would the nurse suspect?suspect?

A. InfectionA. Infection B. HemorrhageB. Hemorrhage C. DehydrationC. Dehydration D. A normal responseD. A normal response

C. Fever within the first 24 hours C. Fever within the first 24 hours postpartum indicates dehydration. postpartum indicates dehydration. After 24 hours, however, it is After 24 hours, however, it is indicative of a puerperal infection.indicative of a puerperal infection.

During early postpartum, when assessing a During early postpartum, when assessing a client’s episiotomy, the nurse identifies client’s episiotomy, the nurse identifies

edema with severe ecchymosis. Also, the edema with severe ecchymosis. Also, the client is complaining of severe perineal and client is complaining of severe perineal and

rectal pressure. The fundus is firm, and rectal pressure. The fundus is firm, and there is no lochia. The client’s vital signs are there is no lochia. The client’s vital signs are

T 99 F, P 108, R 20, BP 105/60. This T 99 F, P 108, R 20, BP 105/60. This assessment most likely indicates a:assessment most likely indicates a:

A. Urinary infectionA. Urinary infection B. Uterine infectionB. Uterine infection C. Vaginal hematomaC. Vaginal hematoma D. Postpartum hemorrhageD. Postpartum hemorrhage

C. These are classic signs and C. These are classic signs and symptoms of a vaginal hematomasymptoms of a vaginal hematoma

The nurse identifies that a woman needs The nurse identifies that a woman needs further teaching about breastfeeding her further teaching about breastfeeding her

newborn when she:newborn when she:

A. Leans forward and puts her breast A. Leans forward and puts her breast into the infant’s mouthinto the infant’s mouth

B. Holds the infant level with her B. Holds the infant level with her breast and in a side-lying positionbreast and in a side-lying position

C. Touches her nipple to the infant’s C. Touches her nipple to the infant’s lips when beginning the feedinglips when beginning the feeding

D. Puts her finger in the infant’s D. Puts her finger in the infant’s mouth to break the suction when mouth to break the suction when switching breastsswitching breasts

A. When the breast is pushed into A. When the breast is pushed into the infant’s mouth a typical response the infant’s mouth a typical response is for the mouth to close too soon, is for the mouth to close too soon, resulting in inadequate latching-onresulting in inadequate latching-on

The nurse should plan to teach a recently The nurse should plan to teach a recently delivered client who is formula-feeding her delivered client who is formula-feeding her

infant to minimize breast discomfort by:infant to minimize breast discomfort by:

A. Gently applying cocoa butterA. Gently applying cocoa butter B. Manually expressing colostrumB. Manually expressing colostrum C. Applying covered ice packs to her C. Applying covered ice packs to her

breastsbreasts D. Placing warm, wet washcloths on D. Placing warm, wet washcloths on

her nipplesher nipples

C. Covered ice packs promote C. Covered ice packs promote comfort by decreasing comfort by decreasing vasocongestionvasocongestion

A client with mastitis is concerned about A client with mastitis is concerned about breastfeeding her newborn infant. Which breastfeeding her newborn infant. Which recommendation should the nurse provide recommendation should the nurse provide

to the client?to the client?

A. Stop breastfeeding until after completing A. Stop breastfeeding until after completing antibioticsantibiotics

B. Supplement feeding with forumla until the B. Supplement feeding with forumla until the infection resolvesinfection resolves

C. Continue to breastfeed because mastitis C. Continue to breastfeed because mastitis will not infect the infantwill not infect the infant

D. Do not use analgesics because they may D. Do not use analgesics because they may be passed to the newborn through breast milkbe passed to the newborn through breast milk

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

A nurse makes all the following observations A nurse makes all the following observations of a mother who is interacting with her of a mother who is interacting with her newborn 8 hours after delivery. Which newborn 8 hours after delivery. Which observation would alert the nurse to a observation would alert the nurse to a

potential problem with the maternal-infant potential problem with the maternal-infant attachment?attachment?

A. The mother speaks to the newborn during A. The mother speaks to the newborn during crying spells.crying spells.

B. The mother undresses the newborn during B. The mother undresses the newborn during a diaper change.a diaper change.

C. The mother takes the newborn with her to C. The mother takes the newborn with her to the baby care classes.the baby care classes.

D. The mother consistently engages eye D. The mother consistently engages eye contact with the father as she feeds the contact with the father as she feeds the newborn.newborn.

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

During which phase of maternal During which phase of maternal psychological adaptation is it best for a psychological adaptation is it best for a

nurse to teach a postpartum client nurse to teach a postpartum client about caring for a newborn infant?about caring for a newborn infant?

A. Taking-inA. Taking-in B. Letting-goB. Letting-go C. Taking-holdC. Taking-hold D. Letting-downD. Letting-down

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

A 28 year-old woman has just delivered A 28 year-old woman has just delivered her first child, a boy weighing 6 lbs. her first child, a boy weighing 6 lbs.

and 2 oz. The Apgar scores at one and and 2 oz. The Apgar scores at one and five minutes are 8 and 9. The nurse five minutes are 8 and 9. The nurse

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

observation of this infantobservation of this infant

B. The newborn is making an optimal transition to B. The newborn is making an optimal transition to extrauterine lifeextrauterine life

C. The parents will need emotional support to deal with a C. The parents will need emotional support to deal with a less than perfect childless than perfect child

D. High Apgar scores correlate well with future emotional D. High Apgar scores correlate well with future emotional and intellectual developmentand intellectual development

B. Good Apgar. Nursery care is not B. Good Apgar. Nursery care is not needed and there is no relationship needed and there is no relationship between Apgar and future between Apgar and future emotional/intellectual development. emotional/intellectual development.

An infant born in the 36An infant born in the 36thth week of gestation week of gestation weighs 4 lbs 9 oz (2062 gms) and has an weighs 4 lbs 9 oz (2062 gms) and has an

Apgar of 7/9. On admission to the nursery, Apgar of 7/9. On admission to the nursery, it would be unnecessary for the nurse to:it would be unnecessary for the nurse to:

A. Record vital signsA. Record vital signs B. Administer oxygenB. Administer oxygen C. Support body temperatureC. Support body temperature D. Evaluate the newborn’s statusD. Evaluate the newborn’s status

B. The baby’s Apgar score (7/9) does B. The baby’s Apgar score (7/9) does not indicate a need for oxygen.not indicate a need for oxygen.

At 10 hours of age an infant has a large At 10 hours of age an infant has a large amount of mucus and becomes slightly amount of mucus and becomes slightly

cyanotic. The nurse should first:cyanotic. The nurse should first:

A. Insert a Levin tubeA. Insert a Levin tube B. Give the infant oxygenB. Give the infant oxygen C. Suction the mucus as neededC. Suction the mucus as needed D. Note the incident on the chartD. Note the incident on the chart

C. To maintain a patent airway and C. To maintain a patent airway and promote respiration and gaseous promote respiration and gaseous exchange, mucus must be removed.exchange, mucus must be removed.

When observing a newborn for signs of When observing a newborn for signs of pathologic jaundice, the nurse should be pathologic jaundice, the nurse should be

alert for:alert for:

A. Muscular irritability at birthA. Muscular irritability at birth B. Neurologic signs during the first B. Neurologic signs during the first

24 hours24 hours C. The appearance of jaundice C. The appearance of jaundice

during the first 24 hoursduring the first 24 hours D. Jaundice developing between the D. Jaundice developing between the

second and fourth day of lifesecond and fourth day of life

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

Which of the following observations of an 8 Which of the following observations of an 8 lb 4 oz newborn boy, if made by the nurse, lb 4 oz newborn boy, if made by the nurse,

would require an intervention?would require an intervention? A. The infant’s respirations are 36, A. The infant’s respirations are 36,

shallow and irregular in rate, rhythm, shallow and irregular in rate, rhythm, and depthand depth

B. Rapid pulsations are visible in the B. Rapid pulsations are visible in the fifth intercostal space, left midclavicular fifth intercostal space, left midclavicular lineline

C. The infant’s axillary temperature is C. The infant’s axillary temperature is 96.2 F (35.6 C)96.2 F (35.6 C)

D. There is asynchronous spontaneous D. There is asynchronous spontaneous movement of the infant’s extremitiesmovement of the infant’s extremities

C. Subnormal temperature indicates C. Subnormal temperature indicates prematurity, infection, low prematurity, infection, low environment temperature, environment temperature, inadequate clothing, and inadequate clothing, and dehydration. dehydration.

A newborn is diagnosed as having Erb’s A newborn is diagnosed as having Erb’s Palsy. The nurse is aware that this problem Palsy. The nurse is aware that this problem

is caused by:is caused by:

A. A disease acquired in uteroA. A disease acquired in utero B. An X-linked inheritance patternB. An X-linked inheritance pattern C. A tumor arising from muscle C. A tumor arising from muscle

tissuetissue D. An injury to the brachial plexus D. An injury to the brachial plexus

during birthduring birth

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

Asymmetric Moro reflexes are Asymmetric Moro reflexes are frequently associated with:frequently associated with:

A. Down’s syndromeA. Down’s syndrome B. Cranial nerve damageB. Cranial nerve damage C. Cerebral or cerebellar injuriesC. Cerebral or cerebellar injuries D. Brachial plexus, clavicle or D. Brachial plexus, clavicle or

humerus injurieshumerus injuries

D. Injury to the brachial plexus, D. Injury to the brachial plexus, clavicle, or humerus prevents clavicle, or humerus prevents abduction and adduction movements abduction and adduction movements of an upper extremity.of an upper extremity.

A newborn has asymmetric gluteal A newborn has asymmetric gluteal folds. The nurse suspects:folds. The nurse suspects:

A. CNS damageA. CNS damage B. Dysplasia of hipB. Dysplasia of hip C. An inguinal herniaC. An inguinal hernia D. Peripheral nervous system D. Peripheral nervous system

damagedamage

B. Asymmetric gluteal and leg folds B. Asymmetric gluteal and leg folds indicates hip dysplasia. Gluteal folds indicates hip dysplasia. Gluteal folds are elevated on the affected side. are elevated on the affected side.

A nurse is assessing a newborn and A nurse is assessing a newborn and recognizes which of the following as a sign recognizes which of the following as a sign

of postmaturity?of postmaturity?

A. Smooth, supple skinA. Smooth, supple skin B. Long, brittle fingernailsB. Long, brittle fingernails C. Well-developed eyebrowsC. Well-developed eyebrows D. Creases in the soles of the feetD. Creases in the soles of the feet

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

Which finding would be manifested in Which finding would be manifested in an infant with a myelomeningocele?an infant with a myelomeningocele?

A. Clubbed feet and muscle spasms A. Clubbed feet and muscle spasms in the legs and arms.in the legs and arms.

B. Obstruction of bowel and B. Obstruction of bowel and impaired bladder functionimpaired bladder function

C. Spastic movement of upper and C. Spastic movement of upper and lower extremitieslower extremities

D. Impaired bowel and bladder D. Impaired bowel and bladder function and paralysis of the legs.function and paralysis of the legs.

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

A new mother expresses concern over A new mother expresses concern over strabismus in her infant. What would the strabismus in her infant. What would the nurse explain to the mother regarding this nurse explain to the mother regarding this

condition?condition?

A. It is a normal finding in newbornsA. It is a normal finding in newborns B. This may be a permanent defectB. This may be a permanent defect C. It will require corrective surgeryC. It will require corrective surgery D. It will result in imparied visionD. It will result in imparied vision

A. Muscle control of the eyes in the A. Muscle control of the eyes in the newborn is undeveloped, resulting in newborn is undeveloped, resulting in temporary strabismus, or a cross-temporary strabismus, or a cross-eyed appearance. This is considered eyed appearance. This is considered normal in the newborn.normal in the newborn.

Which observation in a 24 hour-old newborn Which observation in a 24 hour-old newborn should be reported to the physician should be reported to the physician

immediately?immediately?

A. Blotchy, mottled skinA. Blotchy, mottled skin B. Positive Babinski reflexB. Positive Babinski reflex C. Tremors and spasms of all C. Tremors and spasms of all

extremitiesextremities D. High-pitched crying and arching D. High-pitched crying and arching

of the backof the back

D. A high-pitched cry and arching of D. A high-pitched cry and arching of the back are cardinal signs of a the back are cardinal signs of a neurological problem.neurological problem.