Вы находитесь на странице: 1из 12


A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is
experiencing hypertonic uterine contractions. What is the top priority of the nurse?
A. Stop of Pitocin infusion
B. Perform a vaginal examination
C. Reposition the client
D. Administer oxygen by face mask at 8 to 10 L/min

A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the physicians orders and would expect to note
which of the following prescribed treatments for this condition?
A. Medication that will provide sedation
B. Increased hydration
C. Oxytocin (Pitocin) infusion
D. Administration of a tocolytic medication

3. A nurse in the labor room is preparing to care for a client with hypertonic uterine
dysfunction. The nurse is told that the client is experiencing uncoordinated contractions
that are erratic in their frequency, duration, and intensity. The priority nursing intervention
would be to:
A. Monitor the Pitocin infusion closely
B. Provide pain relief measures
C. Prepare the client for an amniotomy
D. Promote ambulation every 30 minutes
4. A nurse is developing a plan of care for a client experiencing dystocia and includes
several nursing interventions in the plan of care. The nurse prioritizes the plan of care
and selects which of the following nursing interventions as the highest priority?
A. Keeping the significant other informed of the progress of the labor
B. Providing comfort measures
C. Monitoring fetal heart rate
D. Changing the clients position frequently
5. A 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 of the following risks associated with
placenta previa?
A. Disseminated intravascular coagulation
B. Chronic hypertension
C. Infection
D. Hemorrhage
6. A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was
admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of
the following assessment findings would the nurse expect to note if this condition is
A. Absence of abdominal pain
B. A soft abdomen
C. Uterine tenderness/pain
D. Painless, bright red vaginal bleeding

7. A maternity nurse is preparing for the admission of a client in the 3 rd trimester of

pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of
placenta previa. The nurse reviews the physicians orders and would question which
A. Prepare the client for an ultrasound
B. Obtain equipment for external electronic fetal heart monitoring
C. Obtain equipment for a manual pelvic examination
D. Prepare to draw a Hgb and Hct blood sample
8. An ultrasound is performed on a client at term gestation that is experiencing moderate
vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is
present. Based on these findings, the nurse would prepare the client for:
A. Complete bed rest for the remainder of the pregnancy
B. Delivery of the fetus
C. Strict monitoring of intake and output
D. The need for weekly monitoring of coagulation studies until the time of delivery

A 38-year-old primigravid woman at 38 weeks gestationcomes to the physician for a

prenatal visit. She has no complaints. Her blood pressure is 140/90 mm Hg. Her booking
blood pressure at 8 weeks gestation was 110/68 mm Hg and she has no history of
hypertension. She has no proteinuria on urine dipstick evaluation. Her physical
examination is normal for a woman at 38 weeks gestation. Laboratory evaluation shows:
Leukocyte count 11,500/mm3
Hematocrit 33%
Platelets 212,000/mm3
BUN 12 mg/dL
Serum creatinine 0.6 mg/dL
A nonstress test is reactive, and ultrasound demonstrates an amniotic fluid index of 13
with a fetus in the 50th percentile for growth. Repeat evaluation several hours later
demonstrates a blood pressure of 142/90 mm Hg with no proteinuria. Three days later
the patient goes into labor and has a normal vaginal delivery. At 6 weeks postpartum,
her blood pressure is 110/74 mm Hg.Which of the following is the most likely diagnosis
of this patients elevated blood pressure?

Chronic hypertension
Gestational hypertension

10. After walking for 30 minutes, Mrs. Cruz now has blood tinged mucous on her underpad.
This indicates:
A. The fetus has had a bowel movement.
B. The amniotic sac has ruptured.
C. The client has fallen and sustained internal injury while walking.
D. The cervix is opening more rapidly.
11. The nurse plans to check Mrs. Cruz bladder. The rationale for this action is that the
urinary bladder should not be allowed to become distended primarily because a full
bladder tends to


Increase the risk of urinary incontinence.

Predispose to a prolapse of the umbilical cord.
Interfere with the observation of uterine contractions.
Prevent the descent of the fetus into the birth canal.

12. The physician has ordered Betamethasone for the client. The nurse should explain to
the client that the purpose of betamethasone is to
A. Prevent the development of respiratory distress syndrome in the infant.
B. Stop the contractions in the mother.
C. Decrease the chance of intrauterine infection.
D. Prevent the development of hypoglycemia in the infant.
13. Which of the following statements best describes hyperemesis gravidarum?
A. Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the
absence of other medical problems.
B. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional
imbalances in the absence of other medical problems.
C. Loss of appetite and continuous vomiting that commonly results in dehydration
and ultimately decreasing maternal nutrients
D. Severe nausea and diarrhea that can cause gastrointestinal irritation and
possibly internal bleeding
14. Which of the following would the nurse identify as a classic sign of PIH?
A. Edema of the feet and ankles
B. Edema of the hands and face
C. Weight gain of 1 lb/week
D. Early morning headache
15. Which of the following factors would the nurse suspect as predisposing a client to
placenta previa?
A. Multiple gestation
B. Uterine anomalies
C. Abdominal trauma
D. Renal or vascular disease

Situation 1: Cora, 9 months pregnant, is admitted to the hospital with bleeding caused by
possible placenta previa. The laboratory technician takes blood samples and IV fluids are
16. A client with placenta previa is likely to present with:
A. Hard, tender uterus
B. Painless, bright-red vaginal bleeding after the 20th week of gestation
C. A sluggish fetus with weak heart sounds on auscultation
D. Bleeding during the first trimester
Answer: B
Rationale: With placenta previa, the client has painless, bright-red vaginal bleeding after the
20th week of gestation that starts without warning and stops spontaneously. Palpation
reveals a soft, non-tender uterus, and auscultation reveals an active fetus with good heart

sounds. Also, bleeding commonly occurs during the third trimester. (Straight As in MaternalNeonatal Nursing, 2nd Edition)

17. Nursing care for Cora includes:

Withholding foods and fluids
Encouraging ambulation and supervision
Inspecting the hemorrhage
Avoiding all extraneous stimuli
Answer: C
Rationale: To prevent further maternal and fetal complication, clients must be continuously
observed for blood loss by the monitoring of external bleeding and the counting and
weighing of pads.
18. The nurse following the physicians order, begins administering oxygen by mask. The
clients apprehension is increasing and she asked the nurse what is happening. The
nurse tells her not to worry, that she is going to be all right and everything is under
control. The nurse statements are:
A. Correct, since only the physician should explain why treatment are being done
B. Proper, since the clients anxieties would be increased if she knew the dangers
C. Adequate, since all preparations are routine and need no explanation
D. Questionable, since the client has the right to know what treatment is being given and
Answer: D
Rationale: The client has the right to a complete and accurate explanation of treatment.



19. If a vaginal examination is to be performed on Cora, the nurse should be prepared for an
Induction of labor
c. Forceps delivery
Cesarean delivery
d. X-ray examination
Answer: B
Rationale: Vaginal exam might precipitate severe bleeding, which could be life threatening to
the mother and infant and necessitate immediate CS delivery.
20. The care of a client with placenta previa includes:
Vital signs at least once per shift
A tap-water enema before delivery
Observation and recording of the bleeding
Limited ambulation until the bleeding stops
Answer: C
Rationale: Observation and documentation of bleeding are independent nursing functions
and necessary for implementing safe care, because hemorrhage and shock can be lifethreatening.
Situation 2: Helen, age 20, is 37 weeks pregnant. She is admitted to the hospital with
preeclampsia, moderate vaginal bleeding, and sudden abdominal pain. The results of the
ultrasound indicate that abruptio placenta is present.
21. Based on these findings, the nurse would prepare the client for:
A. Complete bed rest for the remainder of the pregnancy
B. Delivery of the fetus
C. Strict monitoring of intake and output

D. The need for weekly monitoring of coagulation studies until the time of delivery
Answer: B
Rationale: The goal of management in abruptio placenta is to control the hemorrhage and
deliver the fetus a soon as possible. Delivery is the treatment of choice if the fetus is at term
gestation, or if bleeding is moderate to severe, and the mother or fetus is in jeopardy.
(Saunders, 3rd Edition)
22. On Helens admission to the unit the nurse should observe for:
A. Decrease in size of uterus, cessation of contractions, visible or concealed hemorrhage
B. Firm and tender uterus, concealed or external hemorrhage, shock
C. Increase in size uterus, visible bleeding, no associated pain
D. Shock, decrease in size uterus, absence of external bleeding
Answer: B
Rationale: Signs of mild to moderate placental separation include uterine discomfort and
tenderness because of concealed bleeding. Visible bleeding maybe scant, moderate or



23. The nurse realizes that the abdominal pain associated with abruption placenta is caused
Hemorrhagic shock
Inflammatory reactions
Blood in the uterine muscle
Concealed hemorrhage
Answer: D
Rationale: The blood cannot escape from behind the placenta. Thus the abdomen becomes
board like and painful because of the entrapment.
24. Helen is given a unit of blood. The realizes that this is necessary, since the bleeding
following severe abruptio placenta is usually caused by:
Hypofibrinogenemia c. Thrombocytopenia
d. Polycythemia
Answer: A
Rationale: Clotting defects are common in moderate and severe abruption placentae
because of the loss of fibrinogen from severe internal bleeding.
25. A nurse is monitoring Helen for Disseminated Intravascular Coagulopathy. Which
assessment finding is least likely to be associated with DIC?
A. Swelling of the calf on one leg
B. Prolonged clotting times
C. Decreased platelet count
D. Petechiae, oozing from injection sites, and hematuria
Answer: A
Rationale: These signs are most likely associated with thrombophlebitis.
Situation 5: A pregnant client has delayed her first prenatal visit. She visits the prenatal clinic
only after she starts to experience edema of the feet and hands. The nurse takes a history and
physical assessment to begin Mrs. Barton's care.
26. The client's response to one of the nurse's questions is, This is my third pregnancy. I
miscarried twice, the first time I was 8 weeks pregnant, and the last time I was 26 weeks


pregnant. The nurse correctly records Mrs. Barton's pregnancy status as:
G2, P0, A1
c. G3, P0, A2
G2, P1, A1
d. G3, P1, A1
Answer: D
Rationale: G3 (total of 3 pregnancies: present pregnancy plus the two miscarriage); P1
(second miscarriage at 26 weeks AOG); A1 (first miscarriage at 8 weeks AOG). Gravida
pertains to the number of pregnancies regardless of the duration. Para pertains to the
number of pregnancies that lasted more than 20 weeks, regardless of the outcome. Abortion
pertains to the number of terminated pregnancies, not reaching the age of 20 weeks (age of
27. During the examination, while client is lying in a lithotomy position, the client complains
of dizziness and nausea. What would be an appropriate nursing action to relieve the
client's discomfort?
A. Administering an antiemetic ordered by the physician
B. Offering small sips of ginger ale
C. Assisting to a side-lying position temporarily
D. Discontinuing the examination
Answer: C
Rationale: Lying supine for a prolonged period of time, with the legs in a lithotomy position.
The weight of the growing uterus presses the vena cava against the vertebrae, obstructing
blood flow to the lower extremities. This causes a decrease ion blood return to the heart,
and consequently decreased cardiac output and hypotension, manifesting as nausea and
dizziness, lightheadedness, faintness and palpitations. Assisting the client in a side-lying
position relieves pressure on the vena cava, thus improving blood circulation.




28. Diplopia was noted during the assessment of Mrs. Barton. This condition is described
Elevated pigmentation of the skin
Double vision
Facial edema
Answer: B
Rationale: Diplopia is described as having double vision. Women with PIH commonly report
spots before their eyes, or having double vision.
29. The physician asks the nurse to make sure his pregnant patient's next appointment is
scheduled correctly. The patient is in her 33rd week. Her next appointment should be in:
1 month
c. 2 weeks
3 weeks
d. 1 week
Answer: C
Rationale: First visit may be made as soon as the woman suspects she is pregnant.
Subsequent visits are as follows: monthly until the 8 th month; every 2 weeks during the 8 th
month, and weekly during the 9th month. More frequent visits are scheduled if problems
arise. The client is 8 months pregnant (33 weeks), so the next visit will be scheduled after
2 weeks.
30. Mrs. Barton reports that the last day of her last menstrual period was May 11, 2009. Her
menstruation lasted for 5 days. Her expected date of delivery will be:
February 14, 2010
c. August 4, 2010


February 18, 2010

d. August 18, 2010
Answer: A
A. February 14, 2010
Her first day of LMP is May 7, 2009.
Use Naegel's rule: month-3; day+7; year+1
Situation 6: Nene is a 26-year-old woman you admit to a birthing room. Shes been having
contractions 45 seconds long and 3 minutes apart for the last 6 hours. She tells you she wants
to have her baby natural without analgesia or anesthesia. Her husband is in the army assigned
overseas, so he is not with her. Although her sister lives only two blocks from the birthing center,
Nene doesnt want her called. She asks if she can talk to her mother on the telephone. As you
finish assessing contractions, she screams with pain and shouts, Ginagawa ko na ang lahat ng
makakaya ko! Kailan ba matatapos ang paghihirap kong ito?
31. Nene did not recognize for over an hour that she was in labor. A sign of true labor is:
a. Sudden increased energy from epinephrine release
b. Nagging but constant pain in the lower back
c. Urinary urgency from increased bladder pressure
d. Show or release of the cervical mucus plug
Answer: D
Rationale: Signs of true labor involve uterine and cervical changes. As the cervix softens
and ripens, the mucus plug that filled the cervical canal during pregnancy (operculum) is
expelled. The exposed cervical capillaries seep blood as a result of pressure exerted by the
fetus. The blood, mixed with mucus, takes on a pink tinge and is referred to as show or
bloody show.
32. Nene asks which fetal position and presentation are ideal. Your best answer would be:
a. Right occipitoanterior full flexion
b. Left transverse anterior in moderate flexion
c. Right occipitoposterior with no flexion
d. Left sacroanterior with flexion
Answer: A
Rationale: A fetus is born fastest from ROA/LOA position. Full flexion (chin touches the
sternum, arms are flexed and folded on the chest, thighs are flexed onto the abdomen, and
the calves are pressed against the posterior aspect of the thighs) allows the smallest
diameter of the skull to enter to the pelvis.
33. Nene is having long and hard uterine contraction. What length of contraction would you
report as abnormal?
a. Any length over 30 seconds
b. A contraction over 70 seconds in length
c.A contraction that peaks at 20 seconds
d. A contraction shorter than 60 seconds
Answer: B

Rationale: Uterine contractions lasting longer than 70 seconds should be reported, because
contractions of this length begin to compromise fetal well-being by interfering with adequate
uterine artery filling. (Pillitteri, Maternal and Child Health Nursing, 5 th Edition)
34. You assess Nenes uterine contractions. In relation to the contraction, when does a late
deceleration begin?
a. 45 seconds after the contraction is over
b. 30 seconds after the start of a contraction
c. After every tenth or more contraction
d. After a typical contraction ends
Answer: B
Rationale: Late decelerations are those that are delayed until 30 to 45 seconds after the
onset of a contraction, and continue beyond the end of the contraction. This is an ominous
pattern in labor, because it suggests uteroplacental insufficiency. (Pillitteri, Maternal and
Child Health Nursing, 5th Edition)
35. Immediately after the membranes rupture, which of the following should the nurse
a. Check the presence of infection
b. Assess for prolapsed umbilical cord
c. Check for maternal heart rate
d. Assess the color of the amniotic fluid
Answer: B
Rationale: When membranes rupture, amniotic fluid is allowed to escape. The nurse should
check for prolapse of the umbilical cord because there is a possibility that a loop of cord will
escape with the fluid, which can cu off the oxygen supply to the fetus.
Situation 7: Sexually Transmitted Diseases are important to identify during pregnancy because
of its potential effect on the pregnancy, fetus, or newborn. The following questions pertain to
36. Frankie, a promiscuous woman in Manila, submits herself to the clinic for check-up. She
complains of vaginal irritation, redness and a thick cream cheese-like vaginal discharge.
As a nurse, you will suspect that Frankie is having a vaginal infection caused by:
a. Gardnerella vaginalis
b. Candida albicans
c. Treponema pallidum
d. Herpes simplex virus type 2
Answer: B
Rationale: Vaginal infection with Candida albicans (Candidiasis) is characterized by red and
irritated vagina, pruritus, and thick vaginal discharge that resemble cream cheese.
37. Cecil comes to the health center. Her doctor examines Cecils vaginal secretions and
finds out that she has Trichomoniasis infection. Trichomoniasis is diagnosed through
which of the following methods?
a. Vaginal secretions are examined in a wet slide that has been treated with potassium
b. Vaginal speculum is used to obtain secretions from the cervix
c. A litmus paper is used to test if the vaginal secretions are infected with Trichomoniasis
d. Vaginal secretions are examined on a wet slide treated with zephiram solution
Answer: A

Rationale: Trichomoniais is diagnosed by examination of vaginal secretions on a wet slide

that has been treated with potassium hydroxide. (Pillitteri, Maternal and Child Health
Nursing, 5th Edition)

38. The drug of choice for a client with Trichomoniasis

a. Flagyl
c. Monistat
b. Cotrimazole
d. Zovira
Answer: A
Rationale: The drug of choice for Trichomoniasis a single-dose oral metronidazole (Flagyl).
39. Jarisch-Herxheimer reaction maybe experienced by the client with syphilis after therapy
with benzathine penicillin G. The characteristic manifestation of Jarisch-Herxheimer
reaction are:
a. Rashes, itchiness, hives and pruritus
b. Confusion, drowsiness, and numbness of extremities
c. Sudden episode of hypotension, fever, tachycardia, and muscle aches
d. Episodes of nausea and vomiting, with bradypnea and bradycardia
Answer: C
Rationale: After therapy with benzathine penicillin G, a woman may experience sudden
episode of hypotension, fever, tachycardia and muscle aches, which is known as the
Jarisch-Herxheimer reaction. This occurs when large quantities of toxins are released into
the body as spirochetes die, due to antibiotic treatment. Typically the death of these
spirochetes and the associated release of endotoxins occur faster than the body can
remove the toxins via the natural detoxification process performed by the kidneys and liver.
The reaction lasts about 24 hours and then fades. (Pillitteri, Maternal and Child Health
Nursing, 5th Edition)
40. Cryocautery may be used in removing the lesions of a client with venereal warts. The
healing period after cryocautery may be completed in 4-6 weeks but may cause some
discomforts to the woman. What measures can alleviate these discomforts?
a. Kegels exercise
b. Cool air
c. Topical steroids
d. Sitz bath and lidocaine cream
Answer: D
Rationale: With cryocautery, edema at the site is evident immediately. Lesions become
gangrenous, and sloughing occurs in 7 days. Healing will be complete in 4 to 6 weeks with
only slight depigmentation at the site. Sitz baths hand lidocaine cream may be soothing
during the healing period. (Pillitteri, Maternal and Child Health Nursing, 5th Edition)
Situation 10: A professional nurse should know how to respond in these varied health situations.
41. RhoGAM is given to Rh-negative women to prevent maternal sensitization from
occurring. The nurse is aware that in addition to pregnancy, Rh-negative women would
also receive this medication after which of the following?
a. Unsuccessful artificial insemination procedure
b. Blood transfusion after hemorrhage
c. Therapeutic or spontaneous abortion
d. Head injury from a car accident

Answer: C
Rationale: Therapeutic or spontaneous abortion causes mixing of the fetal blood (RH+) and
maternal blood (Rh-). This could trigger the production of maternal antibodies against the
circulating Rh+ blood. The circulating antibodies in the maternal blood will destroy future
pregnancies with a Rh+ blood. Rhogam is given 72 hours post delivery to prevent
production of maternal antibodies.
42. The breathing technique that the mother should be instructed to use as the fetus' head
is crowning is:
a. Blowing
c. Shallow
b. Slow chest
d. Accelerated-decelerated
Answer: A
Rationale: Blowing forcefully through the mouth controls the strong urge to push and allows
for a more controlled birth of the head.
43. When providing prenatal education to a pregnant woman with asthma, which of the
following would be important for the nurse to do?
a. Demonstrate how to assess her blood glucose levels
b. Teach correct administration of subcutaneous bronchodilators
c. Ensure she seeks treatment for any acute exacerbation
d. Explain that she should avoid steroids during her pregnancy
Answer: D
Rationale: Steroids cause cleft lip/palate in newborns.
44. Which of the following conditions would cause an insulin-dependent diabetic client the
most difficulty during her pregnancy?
a. Rh incompatibility
b. Placenta Previa
c. Hyperemesis Gravidarum
d. Abruptio Placenta
Answer: C
Rationale: Both conditions predispose the mother to accumulating high levels of ketone
bodies in the blood.

45. Which of the following would the nurse use as the basis for the teaching plan when
caring for a pregnant teenager concerned about gaining too much weight during
a. 10 pounds per trimester
b. 1 pound per week for 40 weeks
c. pound per week for 40 weeks
d. A total gain of 25 to 30 pounds
Answer: D
Rationale: To ensure adequate fetal growth and development during pregnancy, a total
weight gain 25 to 30 lbs (other books: 25 to 35 lbs) pounds is recommended: 1 lb per month
in the first trimester; and 1 lb per week in the last two trimesters.
Situation12: Awareness of the complications that may accompany pregnancy is essential in
order to render apt nursing management.

46. In which of the following clients would the nurse suspect anemia?
A. Client in her first trimester with a hemoglobin level of 12 g/dL
B. Client in her second trimester with a hemoglobin level of 11 g/dL
C. Client in her third trimester with a hemoglobin level of 8 g/dL
D. Client in her first trimester with a hemoglobin level of 10.5 g/dL
Answer: C
Rationale: Anemia during pregnancy is described as a hemoglobin level of 10 g/dL or less
during the second and third trimesters. Thus, the nurse would suspect anemia in the client in
her third trimester with hemoglobin of 8 g/dL. Hemoglobin levels of 12 g/dL, 11 g/dL, and
10.5 g/dL are above the cut-off range for the diagnosis of anemia. (Lippincotts Review
Series: Maternal-Newborn Nursing, 4th Edition)
47. Which of the following would the nurse identify as a classic sign of PIH?
A. Edema of the feet and ankles
B. Edema of the hands and face
C. Weight gain of 1 lb/week
D. Early morning headache
Answer: B
Rationale: This is the classic sign of PIH.
48. Which of the following may happen if the uterus becomes overstimulated by oxytocin
during the induction of labor?
A. Weak contractions prolonged to more than 70 seconds
B. Tetanic contractions prolonged to more than 90 seconds
C. Increased pain with bright red vaginal bleeding
D. Increased restlessness and anxiety
Answer: B
Rationale: Hyperstimulation of the uterus such as with oxytocin during the induction of labor
may result in tetanic contractions prolonged to more than 90 seconds.

49. Which of the following best describes preterm labor?

A. Labor that begins after 20 weeks gestation and before 37 weeks gestation
B. Labor that begins after 15 weeks gestation and before 37 weeks gestation
C. Labor that begins after 24 weeks gestation and before 28 weeks gestation
D. Labor that begins after 28 weeks gestation and before 40 weeks gestation
Answer: A
Rationale: Preterm labor is best described as labor that begins after 20 weeks gestation and
before 37 weeks gestation. (Lippincotts Review Series: Maternal-Newborn Nursing, 4 th

50. The nurse evaluates that the danger of a seizure in a woman with eclampsia subsides:
After labor begins
After delivery occurs
24 hours postpartum
48 hours postpartum
Answer: D
Rationale: The danger of a seizure in a woman with eclampsia subsides when postpartum

diuresis has occurred, usually 48 hours after delivery. The risk for seizures may remain for
up to two weeks after delivery. (Mosbys Comprehensive Review of Nursing for NCLEX-RN
Examination, 18th Edition)