1.
On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period
began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This
client's expected date of delivery (EDD) is
A) November 22.
Feedback: CORRECT
B) November 8.
Feedback: INCORRECT
C)
D) October 22.
Feedback: INCORRECT
Feedback: INCORRECT
(A) correctly applies Nägele’s rule for estimating the due date by counting back 3 months from the first day
of the last menstrual period (January, December, November) and adding 7 days (15+7=22).
Points Earned: 0.0/1.0
Correct Answer(s): A
2.
Which action should the nurse implement when preparing to measure the fundal height of a pregnant
client?
A)
B) Request the client lie on her left side.
Feedback: INCORRECT
C) Perform Leopold’s maneuvers first.
Feedback: INCORRECT
D) Give the client some cold juice to drink.
Feedback: INCORRECT
Feedback: INCORRECT
To accurately measure the fundal height, the bladder must be empty (A) to avoid elevation of the uterus.
Fundal height is not measured with the client lying on her side (B). Leopold's maneuvers are performed to
assess fetal position and the expected location of the point of maximal impulse (PMI) for fetal heart rate
,(C). Cold juice (D) does not affect the fundal height measurement, but may be given to arouse the fetus if
the fetus appears to be sleeping during a non-stress test.
Points Earned: 0.0/1.0
Correct Answer(s): A
3.
In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index, the nurse
determines the infant has synchronized chest and abdominal movement, just visible lower chest retractions,
just visible xiphoid retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on
auscultation. What Silverman-Anderson score should the nurse assign to this infant? (Enter numeral value
only.)
Feedback: INCORRECT
A Silverman-Anderson Index has five categories with scores of 0, 1, or 2. The total score ranges from 0 to
10. Four of the these assessment findings should receive a score of 1, and the 5th finding (synchronized
chest and abdominal movement) receives a score of 0. Therefore, the total score is 4. A total score of 0
means the infant has no dyspnea, a total score of 10 indicates maximum respiratory distress.
Points Earned: 0.0/1.0
Correct Answer(s): 4
4.
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first
time?
A) She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
Feedback: INCORRECT
B) Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
Feedback: CORRECT
C) Her arms and hands receive the infant and she then cuddles the infant to her own body.
Feedback: INCORRECT
D)
Feedback: INCORRECT
Attachment/bonding theory indicates that most mothers will demonstrate behaviors described in (B) during
the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may
exhibit greater affection such as eagerly reaching, hugging, etc. (A, C, and D).
Points Earned: 0.0/1.0
Correct Answer(s): B
,5.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous
IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate
toxicity?
A) Deep tendon reflexes 2+.
Feedback: INCORRECT
B) Blood pressure 140/90.
Feedback: INCORRECT
C) Respiratory rate 18/minute.
Feedback: INCORRECT
D) Urine output 90 ml/4 hours.
Feedback: CORRECT
Feedback: INCORRECT
Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12
breaths/minute are cardinal signs of magnesium sulfate toxicity. (A, B, and C) do not indicate a magnesium
sulfate toxicity.
Points Earned: 0.0/1.0
Correct Answer(s): D
6.
An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly
rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too
much. What recommendation should the nurse make to this expectant father?
A) Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns
with the childbirth education nurse.
Feedback: INCORRECT
B) Help him to understand that his wife is experiencing normal symptoms of ambivalence about the
pregnancy and no action is needed.
Feedback: INCORRECT
C) Ask him to observe his wife's behavior carefully for the next few weeks and report any similar
behavior to the nurse at the next prenatal visit.
Feedback: INCORRECT
, D) Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the
mother feels fetal movement.
Feedback: CORRECT
Feedback: INCORRECT
These behaviors are positive signs of maternal/fetal bonding (D) and do not reflect ambivalence (B). No
intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks
gestation and begins a new phase of prenatal bonding during the second trimester. Although (A) is not
wrong, it dismisses the father's concerns. (C) is not indicated.
Points Earned: 0.0/1.0
Correct Answer(s): D
7.
A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on
Nägele’s rule, what is the estimated date of delivery?
A) April 25, 2007.
Feedback: INCORRECT
B)
C) May 29, 2007.
Feedback: INCORRECT
D) June 2, 2007.
Feedback: INCORRECT
Feedback: INCORRECT
Since this woman's first day of her last normal menstrual period occurred on August 2, 2006, the estimated
date of delivery is May 9, 2007 (B). Nägele’s rule is used to calculate the expected date of delivery, and is
obtained by subtracting 3 months and adding 7 days beginning from the first day of the last normal
menstrual period. (A, C, and D) are incorrect calculations.
Points Earned: 0.0/1.0
Correct Answer(s): B
8.
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of
labor. Which assessment findings are of greatest concern?
A) Edema, basilar rales, and an irregular pulse.
Feedback: CORRECT
On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period
began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This
client's expected date of delivery (EDD) is
A) November 22.
Feedback: CORRECT
B) November 8.
Feedback: INCORRECT
C)
D) October 22.
Feedback: INCORRECT
Feedback: INCORRECT
(A) correctly applies Nägele’s rule for estimating the due date by counting back 3 months from the first day
of the last menstrual period (January, December, November) and adding 7 days (15+7=22).
Points Earned: 0.0/1.0
Correct Answer(s): A
2.
Which action should the nurse implement when preparing to measure the fundal height of a pregnant
client?
A)
B) Request the client lie on her left side.
Feedback: INCORRECT
C) Perform Leopold’s maneuvers first.
Feedback: INCORRECT
D) Give the client some cold juice to drink.
Feedback: INCORRECT
Feedback: INCORRECT
To accurately measure the fundal height, the bladder must be empty (A) to avoid elevation of the uterus.
Fundal height is not measured with the client lying on her side (B). Leopold's maneuvers are performed to
assess fetal position and the expected location of the point of maximal impulse (PMI) for fetal heart rate
,(C). Cold juice (D) does not affect the fundal height measurement, but may be given to arouse the fetus if
the fetus appears to be sleeping during a non-stress test.
Points Earned: 0.0/1.0
Correct Answer(s): A
3.
In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index, the nurse
determines the infant has synchronized chest and abdominal movement, just visible lower chest retractions,
just visible xiphoid retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on
auscultation. What Silverman-Anderson score should the nurse assign to this infant? (Enter numeral value
only.)
Feedback: INCORRECT
A Silverman-Anderson Index has five categories with scores of 0, 1, or 2. The total score ranges from 0 to
10. Four of the these assessment findings should receive a score of 1, and the 5th finding (synchronized
chest and abdominal movement) receives a score of 0. Therefore, the total score is 4. A total score of 0
means the infant has no dyspnea, a total score of 10 indicates maximum respiratory distress.
Points Earned: 0.0/1.0
Correct Answer(s): 4
4.
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first
time?
A) She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
Feedback: INCORRECT
B) Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
Feedback: CORRECT
C) Her arms and hands receive the infant and she then cuddles the infant to her own body.
Feedback: INCORRECT
D)
Feedback: INCORRECT
Attachment/bonding theory indicates that most mothers will demonstrate behaviors described in (B) during
the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may
exhibit greater affection such as eagerly reaching, hugging, etc. (A, C, and D).
Points Earned: 0.0/1.0
Correct Answer(s): B
,5.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous
IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate
toxicity?
A) Deep tendon reflexes 2+.
Feedback: INCORRECT
B) Blood pressure 140/90.
Feedback: INCORRECT
C) Respiratory rate 18/minute.
Feedback: INCORRECT
D) Urine output 90 ml/4 hours.
Feedback: CORRECT
Feedback: INCORRECT
Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12
breaths/minute are cardinal signs of magnesium sulfate toxicity. (A, B, and C) do not indicate a magnesium
sulfate toxicity.
Points Earned: 0.0/1.0
Correct Answer(s): D
6.
An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly
rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too
much. What recommendation should the nurse make to this expectant father?
A) Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns
with the childbirth education nurse.
Feedback: INCORRECT
B) Help him to understand that his wife is experiencing normal symptoms of ambivalence about the
pregnancy and no action is needed.
Feedback: INCORRECT
C) Ask him to observe his wife's behavior carefully for the next few weeks and report any similar
behavior to the nurse at the next prenatal visit.
Feedback: INCORRECT
, D) Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the
mother feels fetal movement.
Feedback: CORRECT
Feedback: INCORRECT
These behaviors are positive signs of maternal/fetal bonding (D) and do not reflect ambivalence (B). No
intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks
gestation and begins a new phase of prenatal bonding during the second trimester. Although (A) is not
wrong, it dismisses the father's concerns. (C) is not indicated.
Points Earned: 0.0/1.0
Correct Answer(s): D
7.
A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on
Nägele’s rule, what is the estimated date of delivery?
A) April 25, 2007.
Feedback: INCORRECT
B)
C) May 29, 2007.
Feedback: INCORRECT
D) June 2, 2007.
Feedback: INCORRECT
Feedback: INCORRECT
Since this woman's first day of her last normal menstrual period occurred on August 2, 2006, the estimated
date of delivery is May 9, 2007 (B). Nägele’s rule is used to calculate the expected date of delivery, and is
obtained by subtracting 3 months and adding 7 days beginning from the first day of the last normal
menstrual period. (A, C, and D) are incorrect calculations.
Points Earned: 0.0/1.0
Correct Answer(s): B
8.
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of
labor. Which assessment findings are of greatest concern?
A) Edema, basilar rales, and an irregular pulse.
Feedback: CORRECT
