MATERNAL NEWBORN EXAM
VERSION 1
Which of the following are probable signs, strongly indicating pregnancy?
Incorrect: The presence of fetal heart sounds is a positive sign of pregnancy;
quickening is a presumptive Sign of pregnancy.
Incorrect: These are presumptive signs. They may indicate pregnancy or they may
be caused by other conditions, such as disease processes.
Correct: These are probable signs that strongly indicate pregnancy. Hegar’s
sign is a softening of the lower uterine segment, and Chadwick's sign is the
bluish or purplish color of the cervix as a result of the increased blood supply
and increased estrogen. Ballottement occurs when the cervix is tapped by an
examiner's finger and the fetus floats upward in the amniotic fluid and then
falls downward.
Incorrect: These are presumptive signs that might indicate pregnancy, but they
might be caused by other conditions, such as disease processes.
Presence of fetal heart sounds and quickening
Missed menstrual periods, nausea, and vomiting
Hegar's sign, Chadwick's sign, and ballottement
Increased urination and tenderness of the breasts
7. Two hours after delivery the nurse assesses the client and documents that the
fundus is soft, boggy, above the level of the umbilicus, and displaced to the right
side. The nurse encourages the client to void. Which is the rationale for this
nursing action?
,Correct: Bladder distention can lead to postpartum hemorrhage. A full
bladder displaces the uterus causing it not to contract properly. Emptying the
bladder allows the uterus to contract more firmly.
Incorrect: A distended bladder rises out of the abdomen, causing the uterus to be
displaced and increasing the risk of hemorrhage. It does not affect the perineum.
Incorrect: Bladder distention can lead to urinary stasis and infection. This,
however, does not relate to the soft, boggy uterus or the potential for hemorrhage.
Incorrect: Massaging is uncomfortable regardless of whether the bladder is full or
not. A full bladder displaces the uterus causing it not to contract properly, which
may lead to postpartum hemorrhage.
A full bladder prevents normal contractions of the uterus.
An overdistended bladder may press against the episiotomy causing dehiscence.
Distention of the bladder can cause urinary stasis and infection.
It makes the client more comfortable when the fundus is massaged.
8. Which site is preferred for giving an IM injection to a newborn?
Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred
site for injections in the newborn because of lack of muscle mass.
Correct: The middle third of the vastus lateralis is the preferred site for
injections.
Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred
site for injections in the newborn because of lack of muscle mass.
Incorrect: Newborns do not receive injections in the dorsogluteal site (gluteus
maximus) due to decreased muscle mass.
Ventrogluteal
Vastus lateralis
,Rectus femoris
Dorsogluteal
9. During the first twelve hours following a normal vaginal delivery, the client
voids 2,000 mL of urine. How should the nurse interpret this finding?
Incorrect: Urinary tract infections are common during pregnancy and in the
postpartum period. Urinary frequency is a common finding. However, voiding
large amounts of urine is not a sign of a UTI.
Incorrect: High output renal failure occurs with injury/trauma to the kidneys. There
has been no damage to the kidneys. Incorrect: Most women do receive some IV
fluids during labor and delivery, however the IV rates are carefully calculated
according to weight.
Correct: During pregnancy, the circulating blood volume increases by about
50%. In order to get rid of the excess fluid volume after delivery, the woman
experiences an increased amount of urine output during the first few hours.
Urinary tract infection
High output renal failure
Excessive use of IV fluids during delivery
Normal diuresis after delivery
10. If a pregnant client diagnosed with gestational diabetes cannot maintain control
of her blood sugar by diet alone, which medication will she receive?
Incorrect: Glucophage is an oral hypoglycemic. Oral hypoglycemic cross the
placenta and can cause damage to the fetus. They are not used in gestational
diabetes for that reason.
Incorrect: Glucagon is a hormone used to raise blood sugar and manage severe
hypoglycemia. Clients with gestational diabetes have hyperglycemia.
, Correct: Insulin is the drug of choice for gestational diabetes. Insulin lowers
the client's blood sugar without harming the fetus.
Incorrect: DiaBeta is an oral hypoglycemic drug. Oral hypoglycemic agents cross
the placenta and can cause damage to the fetus. They are not used for gestational
diabetes for that reason.
Metformin (Glucophage)
Glucagon
Insulin
Glyburide (DiaBeta)
11. Which assessment finding indicates that placental separation has occurred
during the third stage of labor?
Incorrect: There is usually an increase in bleeding (a sudden gush of blood) when
the placenta separates.
Incorrect: Contractions continue in an attempt to expel the placenta. The
contractions may not be as intense, but they do not stop. Also, fundal massage
helps contract the uterus preventing postpartum bleeding.
Incorrect: Shaking and chills occur about 10-15 minutes after the delivery of the
baby, but are not related to the placental detachment. They are a result of the
release of pressure on pelvic nerves and the release of epinephrine during labor.
Correct: As the placenta detaches, the cord that has been clamped becomes
longer as it slides out of the vagina.
Decreased vaginal bleeding
Contractions stop
Maternal shaking and chills
Lengthening of the umbilical cord
VERSION 1
Which of the following are probable signs, strongly indicating pregnancy?
Incorrect: The presence of fetal heart sounds is a positive sign of pregnancy;
quickening is a presumptive Sign of pregnancy.
Incorrect: These are presumptive signs. They may indicate pregnancy or they may
be caused by other conditions, such as disease processes.
Correct: These are probable signs that strongly indicate pregnancy. Hegar’s
sign is a softening of the lower uterine segment, and Chadwick's sign is the
bluish or purplish color of the cervix as a result of the increased blood supply
and increased estrogen. Ballottement occurs when the cervix is tapped by an
examiner's finger and the fetus floats upward in the amniotic fluid and then
falls downward.
Incorrect: These are presumptive signs that might indicate pregnancy, but they
might be caused by other conditions, such as disease processes.
Presence of fetal heart sounds and quickening
Missed menstrual periods, nausea, and vomiting
Hegar's sign, Chadwick's sign, and ballottement
Increased urination and tenderness of the breasts
7. Two hours after delivery the nurse assesses the client and documents that the
fundus is soft, boggy, above the level of the umbilicus, and displaced to the right
side. The nurse encourages the client to void. Which is the rationale for this
nursing action?
,Correct: Bladder distention can lead to postpartum hemorrhage. A full
bladder displaces the uterus causing it not to contract properly. Emptying the
bladder allows the uterus to contract more firmly.
Incorrect: A distended bladder rises out of the abdomen, causing the uterus to be
displaced and increasing the risk of hemorrhage. It does not affect the perineum.
Incorrect: Bladder distention can lead to urinary stasis and infection. This,
however, does not relate to the soft, boggy uterus or the potential for hemorrhage.
Incorrect: Massaging is uncomfortable regardless of whether the bladder is full or
not. A full bladder displaces the uterus causing it not to contract properly, which
may lead to postpartum hemorrhage.
A full bladder prevents normal contractions of the uterus.
An overdistended bladder may press against the episiotomy causing dehiscence.
Distention of the bladder can cause urinary stasis and infection.
It makes the client more comfortable when the fundus is massaged.
8. Which site is preferred for giving an IM injection to a newborn?
Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred
site for injections in the newborn because of lack of muscle mass.
Correct: The middle third of the vastus lateralis is the preferred site for
injections.
Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred
site for injections in the newborn because of lack of muscle mass.
Incorrect: Newborns do not receive injections in the dorsogluteal site (gluteus
maximus) due to decreased muscle mass.
Ventrogluteal
Vastus lateralis
,Rectus femoris
Dorsogluteal
9. During the first twelve hours following a normal vaginal delivery, the client
voids 2,000 mL of urine. How should the nurse interpret this finding?
Incorrect: Urinary tract infections are common during pregnancy and in the
postpartum period. Urinary frequency is a common finding. However, voiding
large amounts of urine is not a sign of a UTI.
Incorrect: High output renal failure occurs with injury/trauma to the kidneys. There
has been no damage to the kidneys. Incorrect: Most women do receive some IV
fluids during labor and delivery, however the IV rates are carefully calculated
according to weight.
Correct: During pregnancy, the circulating blood volume increases by about
50%. In order to get rid of the excess fluid volume after delivery, the woman
experiences an increased amount of urine output during the first few hours.
Urinary tract infection
High output renal failure
Excessive use of IV fluids during delivery
Normal diuresis after delivery
10. If a pregnant client diagnosed with gestational diabetes cannot maintain control
of her blood sugar by diet alone, which medication will she receive?
Incorrect: Glucophage is an oral hypoglycemic. Oral hypoglycemic cross the
placenta and can cause damage to the fetus. They are not used in gestational
diabetes for that reason.
Incorrect: Glucagon is a hormone used to raise blood sugar and manage severe
hypoglycemia. Clients with gestational diabetes have hyperglycemia.
, Correct: Insulin is the drug of choice for gestational diabetes. Insulin lowers
the client's blood sugar without harming the fetus.
Incorrect: DiaBeta is an oral hypoglycemic drug. Oral hypoglycemic agents cross
the placenta and can cause damage to the fetus. They are not used for gestational
diabetes for that reason.
Metformin (Glucophage)
Glucagon
Insulin
Glyburide (DiaBeta)
11. Which assessment finding indicates that placental separation has occurred
during the third stage of labor?
Incorrect: There is usually an increase in bleeding (a sudden gush of blood) when
the placenta separates.
Incorrect: Contractions continue in an attempt to expel the placenta. The
contractions may not be as intense, but they do not stop. Also, fundal massage
helps contract the uterus preventing postpartum bleeding.
Incorrect: Shaking and chills occur about 10-15 minutes after the delivery of the
baby, but are not related to the placental detachment. They are a result of the
release of pressure on pelvic nerves and the release of epinephrine during labor.
Correct: As the placenta detaches, the cord that has been clamped becomes
longer as it slides out of the vagina.
Decreased vaginal bleeding
Contractions stop
Maternal shaking and chills
Lengthening of the umbilical cord
