EVOLVE - MATERNITY UNCOMPLICATED PREGNANCY EXAM
ACTUAL EXAM 200 QUESTIONS AND CORRECT DETAILED
ANSWERS
A 14-year-old emancipated minor at 22 weeks' gestation comes in for her second
prenatal examination. As she enters the examination room with her mother, she tells
the nurse that she does not want her mother present for the examination. What
should the nurse say? - ANSWER: Telling the mother, "I'm sorry, but I need to ask
you to stay in the waiting area."
Which finding indicates the development of a complication resulting from the
presence of bilateral cephalhematomas? - ANSWER: Skin color
What findings occur with supine hypotensive syndrome? (Select all that apply.) -
ANSWER: 2 Feeling of faintness
4 Increased venous pressure
6 Decreased systolic pressure
Immediately after the third stage of labor a nurse administers the prescribed
oxytocin (Pitocin) infusion. Why is this medication administered? - ANSWER: To help
the uterus contract
Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her
left leg and she is admitted to the hospital for bedrest and anticoagulant therapy.
Which anticoagulant does the nurse expect to administer? - ANSWER: Continuous
infusion of heparin
A local anesthetic (pudendal block) is administered to a client as second-stage labor
begins. For what side effect does the nurse monitor for the client? - ANSWER:
Decreased blood pressure
A 24-year-old client who has been told that she is pregnant is at her first prenatal
visit. She is 5 feet 6 inches tall and weighs 130 lb. What should the nutrition plan
regarding her daily caloric intake include? - ANSWER: 340 more calories during the
second trimester
A primigravida at 34 weeks' gestation tells the nurse that she is beginning to
experience some lower back pain. What should the nurse recommend that the client
do? (Select all that apply.) - ANSWER: 1 Wear low-heeled shoes
4 Perform pelvic tilt exercises several times a day
A nurse who is caring for a mother and her newborn infant reviews their record. In
light of the data the record contains, what nursing intervention is required? -
ANSWER: Maternal rubella vaccination
,The nurse is interpreting the results of a nonstress test (NST) on a client at 41 weeks'
gestation. Which result after 20 minutes is suggestive of fetal reactivity? - ANSWER:
Two accelerations of 15 beats/min lasting 15 seconds
During labor the nurse encourages the client to void periodically. The nurse knows
that an over distended urinary bladder during labor can: - ANSWER: Predispose the
client to uterine hemorrhage after birth
A pregnant woman tells a nurse in the prenatal clinic that she knows that folic acid is
very important during pregnancy and that she is taking a prescribed supplement. She
asks the nurse what foods contain folic acid (folate) so she may add them to her diet
in its natural form. Which foods should the nurse recommend? (Select all that apply.)
- ANSWER: 4 Black and pinto beans
5 Enriched bread and pasta
What nursing action is the priority for a client in the second stage of labor? -
ANSWER: Promote effective pushing by the client
A nurse is teaching a client to care for her episiotomy after discharge. What priority
instruction should the nurse include? - ANSWER: Perform perineal care after
toileting until healing occurs.
One hour after a birth a nurse palpates a client's fundus to determine whether
involution is taking place. The fundus is firm, in the midline, and two fingerbreadths
below the umbilicus. What should the nurse do next? - ANSWER: Continue periodic
evaluations and record the findings
At 5 am, 2 hours after a long labor and vaginal birth, a client is transferred to the
postpartum unit. What is the nurse's priority when planning morning care for this
client? - ANSWER: Planning nursing care activities that provide time for the client
to rest and sleep
A nurse is being oriented to a prenatal clinic after graduation. The new nurse takes a
course on several tests during pregnancy. Place the tests in the order in which they
should be performed during pregnancy. - ANSWER: 1 Sickle cell screening
2 α-Fetoprotein (AFP) testing for neural tube defects
3 Serum glucose for gestational diabetes
4 Fetal movement test
5 Group B Streptococcus culture
Which position does the nurse teach the client to avoid when she experiences back
pain during labor? - ANSWER: Supine position
A postpartum client is being prepared for discharge. The laboratory report indicates
that she has a white blood cell (WBC) count of 16,000/dL. What is the next nursing
action? - ANSWER: Placing the report in the client's record because this is an
expected postpartum finding
, A nurse assesses a new mother who is breastfeeding. The client asks how to care for
her nipples. What should the nurse recommend? - ANSWER: Spreading breast milk
on the nipples after the feeding and allowing them to air dry
A client is receiving an oxytocin (Pitocin) infusion for induction of labor. The uterine
graph on the electronic monitor indicates no rest period between contractions, and
this is confirmed on palpation. What should the nurse do first? - ANSWER: Turn the
oxytocin infusion off
A contraction stress test (CST) is performed on a client at 40 weeks' gestation. The
findings are interpreted as negative. What does the nurse conclude from this
interpretation? - ANSWER: There will be weekly retesting because, at this time, the
fetus has oxygen reserves.
What are the indicators of nutritional risk in pregnancy in a client who is of normal
weight? (Select all that apply.) - ANSWER: 1 Smoker
2 Twin gestation
During a prenatal visit a client who is at 36 weeks' gestation states that she is having
uncomfortable irregular contractions. How should the nurse respond? - ANSWER:
"Walk around until they subside."
A woman's pregnancy has been uneventful, and she has gained 25 lb. At term her
hemoglobin level is 10.6 g/dL and her hematocrit is 31%. What does the nurse
identify as the reason for these hemoglobin and hematocrit levels? - ANSWER:
Hemodilution
During a routine prenatal visit, a client tells a nurse that she gets leg cramps. What
condition does the nurse suspect, and what suggestion is made to correct the
problem? - ANSWER: Hypocalcemia; increase her intake of milk
During prenatal classes the nurse teaches the difference between true labor and
false labor. How does the nurse explain the difference? - ANSWER: Cervix effaces and
dilates during true labor.
A nurse is checking the external fetal monitor of a client in active labor. Which fetal
heart pattern indicates cord compression? - ANSWER: Abrupt decreases in fetal
heart rate that are unrelated to the contractions
A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The
nurse determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises
to 160 on two occasions and 157 once during a 20-minute period. Each of the
episodes in which the heart rate is increased lasts 20 seconds. What action should
the nurse take? - ANSWER: Discontinuing the test because the pattern is reassuring
ACTUAL EXAM 200 QUESTIONS AND CORRECT DETAILED
ANSWERS
A 14-year-old emancipated minor at 22 weeks' gestation comes in for her second
prenatal examination. As she enters the examination room with her mother, she tells
the nurse that she does not want her mother present for the examination. What
should the nurse say? - ANSWER: Telling the mother, "I'm sorry, but I need to ask
you to stay in the waiting area."
Which finding indicates the development of a complication resulting from the
presence of bilateral cephalhematomas? - ANSWER: Skin color
What findings occur with supine hypotensive syndrome? (Select all that apply.) -
ANSWER: 2 Feeling of faintness
4 Increased venous pressure
6 Decreased systolic pressure
Immediately after the third stage of labor a nurse administers the prescribed
oxytocin (Pitocin) infusion. Why is this medication administered? - ANSWER: To help
the uterus contract
Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her
left leg and she is admitted to the hospital for bedrest and anticoagulant therapy.
Which anticoagulant does the nurse expect to administer? - ANSWER: Continuous
infusion of heparin
A local anesthetic (pudendal block) is administered to a client as second-stage labor
begins. For what side effect does the nurse monitor for the client? - ANSWER:
Decreased blood pressure
A 24-year-old client who has been told that she is pregnant is at her first prenatal
visit. She is 5 feet 6 inches tall and weighs 130 lb. What should the nutrition plan
regarding her daily caloric intake include? - ANSWER: 340 more calories during the
second trimester
A primigravida at 34 weeks' gestation tells the nurse that she is beginning to
experience some lower back pain. What should the nurse recommend that the client
do? (Select all that apply.) - ANSWER: 1 Wear low-heeled shoes
4 Perform pelvic tilt exercises several times a day
A nurse who is caring for a mother and her newborn infant reviews their record. In
light of the data the record contains, what nursing intervention is required? -
ANSWER: Maternal rubella vaccination
,The nurse is interpreting the results of a nonstress test (NST) on a client at 41 weeks'
gestation. Which result after 20 minutes is suggestive of fetal reactivity? - ANSWER:
Two accelerations of 15 beats/min lasting 15 seconds
During labor the nurse encourages the client to void periodically. The nurse knows
that an over distended urinary bladder during labor can: - ANSWER: Predispose the
client to uterine hemorrhage after birth
A pregnant woman tells a nurse in the prenatal clinic that she knows that folic acid is
very important during pregnancy and that she is taking a prescribed supplement. She
asks the nurse what foods contain folic acid (folate) so she may add them to her diet
in its natural form. Which foods should the nurse recommend? (Select all that apply.)
- ANSWER: 4 Black and pinto beans
5 Enriched bread and pasta
What nursing action is the priority for a client in the second stage of labor? -
ANSWER: Promote effective pushing by the client
A nurse is teaching a client to care for her episiotomy after discharge. What priority
instruction should the nurse include? - ANSWER: Perform perineal care after
toileting until healing occurs.
One hour after a birth a nurse palpates a client's fundus to determine whether
involution is taking place. The fundus is firm, in the midline, and two fingerbreadths
below the umbilicus. What should the nurse do next? - ANSWER: Continue periodic
evaluations and record the findings
At 5 am, 2 hours after a long labor and vaginal birth, a client is transferred to the
postpartum unit. What is the nurse's priority when planning morning care for this
client? - ANSWER: Planning nursing care activities that provide time for the client
to rest and sleep
A nurse is being oriented to a prenatal clinic after graduation. The new nurse takes a
course on several tests during pregnancy. Place the tests in the order in which they
should be performed during pregnancy. - ANSWER: 1 Sickle cell screening
2 α-Fetoprotein (AFP) testing for neural tube defects
3 Serum glucose for gestational diabetes
4 Fetal movement test
5 Group B Streptococcus culture
Which position does the nurse teach the client to avoid when she experiences back
pain during labor? - ANSWER: Supine position
A postpartum client is being prepared for discharge. The laboratory report indicates
that she has a white blood cell (WBC) count of 16,000/dL. What is the next nursing
action? - ANSWER: Placing the report in the client's record because this is an
expected postpartum finding
, A nurse assesses a new mother who is breastfeeding. The client asks how to care for
her nipples. What should the nurse recommend? - ANSWER: Spreading breast milk
on the nipples after the feeding and allowing them to air dry
A client is receiving an oxytocin (Pitocin) infusion for induction of labor. The uterine
graph on the electronic monitor indicates no rest period between contractions, and
this is confirmed on palpation. What should the nurse do first? - ANSWER: Turn the
oxytocin infusion off
A contraction stress test (CST) is performed on a client at 40 weeks' gestation. The
findings are interpreted as negative. What does the nurse conclude from this
interpretation? - ANSWER: There will be weekly retesting because, at this time, the
fetus has oxygen reserves.
What are the indicators of nutritional risk in pregnancy in a client who is of normal
weight? (Select all that apply.) - ANSWER: 1 Smoker
2 Twin gestation
During a prenatal visit a client who is at 36 weeks' gestation states that she is having
uncomfortable irregular contractions. How should the nurse respond? - ANSWER:
"Walk around until they subside."
A woman's pregnancy has been uneventful, and she has gained 25 lb. At term her
hemoglobin level is 10.6 g/dL and her hematocrit is 31%. What does the nurse
identify as the reason for these hemoglobin and hematocrit levels? - ANSWER:
Hemodilution
During a routine prenatal visit, a client tells a nurse that she gets leg cramps. What
condition does the nurse suspect, and what suggestion is made to correct the
problem? - ANSWER: Hypocalcemia; increase her intake of milk
During prenatal classes the nurse teaches the difference between true labor and
false labor. How does the nurse explain the difference? - ANSWER: Cervix effaces and
dilates during true labor.
A nurse is checking the external fetal monitor of a client in active labor. Which fetal
heart pattern indicates cord compression? - ANSWER: Abrupt decreases in fetal
heart rate that are unrelated to the contractions
A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The
nurse determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises
to 160 on two occasions and 157 once during a 20-minute period. Each of the
episodes in which the heart rate is increased lasts 20 seconds. What action should
the nurse take? - ANSWER: Discontinuing the test because the pattern is reassuring
