1. A nurse is assessing a client who has gestational diabetes mellitus and is experiencing
hyperglycemia. Which of the following findings should the nurse expect?
a. Reports increased urinary output
i. MY ANSWER: Increased urinary output, nausea and vomiting, reports of thirst,
abdominal pain, constipation, drowsiness, and headaches are manifestations of
hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine
positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL.
b. Diaphoresis. Diaphoresis or clammy skin is a finding of hypoglycemia. Flushed, dry skin is a
manifestation of hyperglycemia.
c. Reports blurred vision. Blurred or double vision is a finding of hypoglycemia. A report of dim
vision is a manifestation of hyperglycemia.
d. Shallow respirations. Shallow respirations are a finding of hypoglycemia. Rapid breathing is a
manifestation of hyperglycemia.
2. A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the
following actions should the nurse take?
a. Administer penicillin G 2.4 million units IM to the client. The nurse should
administer penicillin G 2.4 million units IM to a client who has syphilis.
b. Instruct the client to schedule an annual pelvic examination. The nurse should instruct the client
to schedule a pelvic examination every 6 months.
c. Tell the client she will start medication for HIV immediately after delivery.
The nurse should tell the client that treatment for HIV will be during the prenatal and
perinatal periods. Treatment with antiretroviral prophylaxis such as zidovudine, triple-drug
antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during pregnancy
have been reported to decrease the transmission of the virus to the newborn.
d. Report the client's condition to the local health department.
i. MY ANSWER. The nurse should report the condition to the local health department. HIV
is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is
required to be reported.
3. A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives.
Which of the following findings should the nurse include as an adverse effect of the medication?
a. Depression.
i. MY ANSWER. The nurse should instruct the client that depression is a common adverse
effect of combined oral contraceptives. Other common adverse effects of the medication
include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast
tenderness.
b. Polyuria. Fluid retention can occur due to an excess of estrogen. Polyuria is not a common
adverse effect of the medication.
c. Hypotension. Hypertension, rather than hypotension, is a common adverse effect of combined
oral contraceptives.
d. Urticaria. Urticaria is not a common adverse effect of combined oral contraceptives.
4. A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for
misoprostol. Which of the following instruction should the nurse include in the teaching?
a. "I can administer oxytocin 4 hours after the insertion of the medication."
, i. MY ANSWER. The nurse can administer oxytocin no sooner than 4 hr after the last dose
of misoprostol. Oxytocin can be administered following misoprostol for clients who have
cervical ripening and have not begun labor.
b. "You will need a full bladder prior to the insertion of the medication." The nurse should instruct
the client to void prior to the administration of the medication.
c. "Remain in a side-lying position for 15 minutes after the medication is inserted." The nurse
should instruct the client to remain in a side-lying position for 30 to 40 min after the insertion.
d. "An antacid will be given 20 minutes prior to the insertion of the medication." The nurse should
avoid administering aluminum hydroxide and magnesium-containing antacids with misoprostol.
5. A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following
actions should the nurse take?
a. Administer antiviral medication. Currently, there are no antiviral medications available to treat
fifth disease.
b. Schedule an ultrasound examination.
i. MY ANSWER: The nurse should schedule serial ultrasound examinations to monitor the
fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the
virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.
c. Administer Haemophilus influenzae type b vaccine. The Haemophilus influenzae type b vaccine
is given during infancy and childhood to protect against multiple infections caused by
Haemophilus influenzae type b, not fifth disease. Currently, there are no vaccines to protect
against fifth disease.
d. Schedule an indirect Coombs' test. An indirect Coombs' test determines whether the client has
antibodies to the Rh antigen. The titer determines the prenatal client's sensitization and if there is
Rh incompatibility.
6. A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following
techniques should the nurse use to help minimize the pain of the procedure for the newborn?
a. Apply a cool pack for 10 min to the heel prior to the puncture. A cool pack will constrict the
blood vessels, making it more difficult to obtain an adequate specimen. The nurse should apply a
warm pack prior to the puncture.
b. Request a prescription for IM analgesic. The pain experienced from a heel stick is too brief to
warrant risking the adverse effects of parenteral analgesia.
c. Use a manual lance blade to pierce the skin. A spring-loaded, automatic puncture device is
recommended to minimize pain by ensuring that the depth of the puncture is not too deep,
avoiding injury to the newborn.
d. Place the newborn skin to skin on the mother's chest.
i. MY ANSWER: Placing the newborn skin to skin on the mother's chest is an effective
technique to significantly decrease the newborn's pain level and anxiety. The nurse should
implement this technique before, during, and after the procedure.
7. A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord
protruding from the vagina. After calling for assistance, which of the following actions should the nurse
take?
a. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part.
, i. MY ANSWER: The nurse should quickly apply gloves and insert two fingers into the
vagina toward the cervix, exerting upward pressure onto the presenting part to relieve
umbilical cord compression and increase oxygenation to the fetus.
b. Wrap the visible cord tightly with sterile, dry gauze. The nurse should wrap the visible cord with
a loose sterile towel saturated with warm 0.9% sodium chloride solution, rather than with sterile,
dry gauze.
c. Apply oxygen to the client at 2 L/min via nasal cannula. The nurse should apply oxygen to the
client at 8 to 10 L/min via nonbreather mask.
d. Place the client in the lithotomy position and apply fundal pressure. The nurse should place the
client into a modified Sims position, knee-chest position, or extreme Trendelenburg to attempt to
relieve the compression of the umbilical cord.
8. A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption.
Which of the following laboratory tests should the nurse expect the provider to prescribe?
a. Kleihauer-Betke test
i. MY ANSWER: The nurse should expect the provider to prescribe a Kleihauer-Betke test
for a client who has suspected placental abruption to determine if fetal blood is in
maternal circulation. This test is useful to determine if Rho-(D) immune globulin therapy
should be administered to a client who is Rh-negative.
b. Progesterone serum level. A progesterone serum level helps to determine if a client is pregnant
and if the pregnancy is ectopic.
c. Lecithin/sphingomyelin (L/S) ratio. Lecithin/sphingomyelin (L/S) ratio is done as a part of an
amniocentesis to evaluate fetal lung maturity.
d. Maternal Alpha-fetoprotein (AFP). Maternal Alpha-fetoprotein (AFP) is a laboratory test used to
assess for neural tube defects or chromosome disorders.
9. A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the
following complications should the nurse assess?
a. Abruptio placenta
i. MY ANSWER: Cocaine use increases the risk for vasoconstriction and possible abruptio
placenta.
b. Placenta previa. This is not a common complication associated with cocaine use.
c. Preeclampsia. This is not a common complication associated with cocaine use.
d. Maternal bradycardia. This is not a common complication associated with cocaine use.
10. A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should
the nurse expect?
a. 2+ deep tendon reflexes. The nurse should identify that a client who has severe preeclampsia can
have hyperactive reflexes of 3+ or 4+. Deep tendon reflexes of 2+ is indicative of an active or
expected response.
hyperglycemia. Which of the following findings should the nurse expect?
a. Reports increased urinary output
i. MY ANSWER: Increased urinary output, nausea and vomiting, reports of thirst,
abdominal pain, constipation, drowsiness, and headaches are manifestations of
hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine
positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL.
b. Diaphoresis. Diaphoresis or clammy skin is a finding of hypoglycemia. Flushed, dry skin is a
manifestation of hyperglycemia.
c. Reports blurred vision. Blurred or double vision is a finding of hypoglycemia. A report of dim
vision is a manifestation of hyperglycemia.
d. Shallow respirations. Shallow respirations are a finding of hypoglycemia. Rapid breathing is a
manifestation of hyperglycemia.
2. A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the
following actions should the nurse take?
a. Administer penicillin G 2.4 million units IM to the client. The nurse should
administer penicillin G 2.4 million units IM to a client who has syphilis.
b. Instruct the client to schedule an annual pelvic examination. The nurse should instruct the client
to schedule a pelvic examination every 6 months.
c. Tell the client she will start medication for HIV immediately after delivery.
The nurse should tell the client that treatment for HIV will be during the prenatal and
perinatal periods. Treatment with antiretroviral prophylaxis such as zidovudine, triple-drug
antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during pregnancy
have been reported to decrease the transmission of the virus to the newborn.
d. Report the client's condition to the local health department.
i. MY ANSWER. The nurse should report the condition to the local health department. HIV
is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is
required to be reported.
3. A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives.
Which of the following findings should the nurse include as an adverse effect of the medication?
a. Depression.
i. MY ANSWER. The nurse should instruct the client that depression is a common adverse
effect of combined oral contraceptives. Other common adverse effects of the medication
include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast
tenderness.
b. Polyuria. Fluid retention can occur due to an excess of estrogen. Polyuria is not a common
adverse effect of the medication.
c. Hypotension. Hypertension, rather than hypotension, is a common adverse effect of combined
oral contraceptives.
d. Urticaria. Urticaria is not a common adverse effect of combined oral contraceptives.
4. A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for
misoprostol. Which of the following instruction should the nurse include in the teaching?
a. "I can administer oxytocin 4 hours after the insertion of the medication."
, i. MY ANSWER. The nurse can administer oxytocin no sooner than 4 hr after the last dose
of misoprostol. Oxytocin can be administered following misoprostol for clients who have
cervical ripening and have not begun labor.
b. "You will need a full bladder prior to the insertion of the medication." The nurse should instruct
the client to void prior to the administration of the medication.
c. "Remain in a side-lying position for 15 minutes after the medication is inserted." The nurse
should instruct the client to remain in a side-lying position for 30 to 40 min after the insertion.
d. "An antacid will be given 20 minutes prior to the insertion of the medication." The nurse should
avoid administering aluminum hydroxide and magnesium-containing antacids with misoprostol.
5. A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following
actions should the nurse take?
a. Administer antiviral medication. Currently, there are no antiviral medications available to treat
fifth disease.
b. Schedule an ultrasound examination.
i. MY ANSWER: The nurse should schedule serial ultrasound examinations to monitor the
fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the
virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.
c. Administer Haemophilus influenzae type b vaccine. The Haemophilus influenzae type b vaccine
is given during infancy and childhood to protect against multiple infections caused by
Haemophilus influenzae type b, not fifth disease. Currently, there are no vaccines to protect
against fifth disease.
d. Schedule an indirect Coombs' test. An indirect Coombs' test determines whether the client has
antibodies to the Rh antigen. The titer determines the prenatal client's sensitization and if there is
Rh incompatibility.
6. A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following
techniques should the nurse use to help minimize the pain of the procedure for the newborn?
a. Apply a cool pack for 10 min to the heel prior to the puncture. A cool pack will constrict the
blood vessels, making it more difficult to obtain an adequate specimen. The nurse should apply a
warm pack prior to the puncture.
b. Request a prescription for IM analgesic. The pain experienced from a heel stick is too brief to
warrant risking the adverse effects of parenteral analgesia.
c. Use a manual lance blade to pierce the skin. A spring-loaded, automatic puncture device is
recommended to minimize pain by ensuring that the depth of the puncture is not too deep,
avoiding injury to the newborn.
d. Place the newborn skin to skin on the mother's chest.
i. MY ANSWER: Placing the newborn skin to skin on the mother's chest is an effective
technique to significantly decrease the newborn's pain level and anxiety. The nurse should
implement this technique before, during, and after the procedure.
7. A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord
protruding from the vagina. After calling for assistance, which of the following actions should the nurse
take?
a. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part.
, i. MY ANSWER: The nurse should quickly apply gloves and insert two fingers into the
vagina toward the cervix, exerting upward pressure onto the presenting part to relieve
umbilical cord compression and increase oxygenation to the fetus.
b. Wrap the visible cord tightly with sterile, dry gauze. The nurse should wrap the visible cord with
a loose sterile towel saturated with warm 0.9% sodium chloride solution, rather than with sterile,
dry gauze.
c. Apply oxygen to the client at 2 L/min via nasal cannula. The nurse should apply oxygen to the
client at 8 to 10 L/min via nonbreather mask.
d. Place the client in the lithotomy position and apply fundal pressure. The nurse should place the
client into a modified Sims position, knee-chest position, or extreme Trendelenburg to attempt to
relieve the compression of the umbilical cord.
8. A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption.
Which of the following laboratory tests should the nurse expect the provider to prescribe?
a. Kleihauer-Betke test
i. MY ANSWER: The nurse should expect the provider to prescribe a Kleihauer-Betke test
for a client who has suspected placental abruption to determine if fetal blood is in
maternal circulation. This test is useful to determine if Rho-(D) immune globulin therapy
should be administered to a client who is Rh-negative.
b. Progesterone serum level. A progesterone serum level helps to determine if a client is pregnant
and if the pregnancy is ectopic.
c. Lecithin/sphingomyelin (L/S) ratio. Lecithin/sphingomyelin (L/S) ratio is done as a part of an
amniocentesis to evaluate fetal lung maturity.
d. Maternal Alpha-fetoprotein (AFP). Maternal Alpha-fetoprotein (AFP) is a laboratory test used to
assess for neural tube defects or chromosome disorders.
9. A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the
following complications should the nurse assess?
a. Abruptio placenta
i. MY ANSWER: Cocaine use increases the risk for vasoconstriction and possible abruptio
placenta.
b. Placenta previa. This is not a common complication associated with cocaine use.
c. Preeclampsia. This is not a common complication associated with cocaine use.
d. Maternal bradycardia. This is not a common complication associated with cocaine use.
10. A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should
the nurse expect?
a. 2+ deep tendon reflexes. The nurse should identify that a client who has severe preeclampsia can
have hyperactive reflexes of 3+ or 4+. Deep tendon reflexes of 2+ is indicative of an active or
expected response.
