EVOLVE - MATERNITY UNCOMPLICATED PREGNANCY
EXAM 2024-2025 COMPLETE 200 ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) GRADED A+
While monitoring the fetal heart rate (FHR) of a client in labor, the nurse identifies an
increase of 15 beats more than the baseline rate of 135 beats/min that lasts 15
seconds. How should the nurse document this event? - Correct Answer - An
acceleration
A 42-year-old client undergoes amniocentesis during the 16th week of gestation
because of concern about Down syndrome. What additional information about the fetus
will examination of the amniotic fluid reveal at this time? - Correct Answer - Neural tube
defect
A multigravida in active phase of labor says, "I feel all wet. I think I urinated." What
should the nurse do first? - Correct Answer - Inspect her perineal area
A nurse is caring for a client in the first stage of labor and an external fetal heart monitor
is in place. What do the tracings indicate? - Correct Answer - Variable decelerations
A nurse is assigned an adolescent who gave birth 12 hours ago. She continually talks
on the phone to her friends and does not respond when her new baby cries. What is the
best immediate intervention? - Correct Answer - Modeling appropriate behaviors that
encourage infant bonding
A woman who is 28 weeks pregnant calls the clinic to report that she is frightened
because she is leaking breast milk. The best response is to tell her that: - Correct
Answer - This can be a normal occurrence during pregnancy
pg. 1
,During a routine 32-week prenatal visit, a client tells the nurse that she has had difficulty
sleeping on her back at night. What should the nurse advise the client about her
position when she sleeps? - Correct Answer - "Turn from side to side."
The transmission of which microorganism that causes maternal mastitis is minimized by
frequent handwashing by nursing staff members? - Correct Answer - Staphylococcus
aureus
A woman has just received the news that she is pregnant. She is ambivalent about the
pregnancy because she had planned to go back to work when her youngest child
started school next year. What developmental task of pregnancy must the woman
accomplish in the first trimester of pregnancy? - Correct Answer - Accept that she is
pregnant
When performing Leopold maneuvers on a client who has been admitted to the birthing
room, the nurse identifies a firm, round prominence over the symphysis pubis; a
smooth, convex structure along her right side; irregular lumps along her left side; and a
soft roundness in the fundus. What is the fetal position? - Correct Answer - ROA
-The fetus is in a right occiput anterior (ROA) position; the prominence over the
symphysis suggests a vertex and the fetal occiput and back are in the right anterior
quadrant. Left occiput posterior (LOP) is ruled out because the occiput is not located in
the left posterior quadrant; the occiput and back are on the mother's right side. Right
sacral anterior (RAS) is ruled out because the fetus is in a vertex, not a breech,
presentation. Left occipital anterior (LOA) is ruled out by the presence of irregular lumps
on the left side, suggesting that the fetus's back is in the mother's right quadrant.
A nurse concludes that a laboring couple has benefited from the Lamaze method of
childbirth preparation when during the transition phase of labor, they use the breathing
pattern known as: - Correct Answer - Pant-blow
-Panting and blowing keeps the glottis open so the mother cannot hold her breath and
bear down.
A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about
45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100
beats/min on the internal fetal monitor. What is the next nursing action? - Correct
Answer - Notifying the health care provider
pg. 2
, -Bradycardia (baseline FHR slower than 110 beats/min) indicates that the fetus may be
compromised, requiring medical intervention. Resuming continuous fetal heart
monitoring may be dangerous; the fetus may be compromised, and time should not be
spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at
this time. The expected FHR is 110 to 160 beats/min between contractions.
The fetus of a client in labor is found to be at +1 station. What location does +1 station
describe? - Correct Answer - Just below the ischial spines
The nurse is caring for a client whose labor is to be induced. What is the nurse's
responsibility when a client's labor is being stimulated with an oxytocin (Pitocin)
infusion? - Correct Answer - Stopping the infusion if contractions become hypertonic
A client in active labor becomes very uncomfortable and asks a nurse for pain
medication. Nalbuphine (Nubian) is prescribed. How does this medication relieve pain?
- Correct Answer - By acting on opioid receptors to reduce pain
-Nalbuphine (Nubian) is classified as an opioid analgesic and is effective in relieving
pain; it induces little or no newborn respiratory depression. Nalbuphine does not induce
amnesia, act as an anesthetic, or induce sleep.
A client is admitted to the birthing unit in active labor. Amniotomy is performed by the
health care provider. What physiological change does the nurse expect to occur after
the procedure? - Correct Answer - Progressive dilation and effacement
A nurse is teaching a primigravida about how she can identify the onset of labor. What
clinical indicator of labor would necessitate the client to call her health care provider? -
Correct Answer - Rupture of membranes or contractions 5 minutes apart
A woman who has just delivered an infant asks to take the placenta home with her and
her new baby on discharge. What is the most appropriate response? - Correct Answer -
"I need to check the hospital protocol for our policy on that practice."
The nurse is caring for a client who has just received epidural anesthesia. Which finding
would be of most concern? - Correct Answer - Hypotension
pg. 3
EXAM 2024-2025 COMPLETE 200 ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) GRADED A+
While monitoring the fetal heart rate (FHR) of a client in labor, the nurse identifies an
increase of 15 beats more than the baseline rate of 135 beats/min that lasts 15
seconds. How should the nurse document this event? - Correct Answer - An
acceleration
A 42-year-old client undergoes amniocentesis during the 16th week of gestation
because of concern about Down syndrome. What additional information about the fetus
will examination of the amniotic fluid reveal at this time? - Correct Answer - Neural tube
defect
A multigravida in active phase of labor says, "I feel all wet. I think I urinated." What
should the nurse do first? - Correct Answer - Inspect her perineal area
A nurse is caring for a client in the first stage of labor and an external fetal heart monitor
is in place. What do the tracings indicate? - Correct Answer - Variable decelerations
A nurse is assigned an adolescent who gave birth 12 hours ago. She continually talks
on the phone to her friends and does not respond when her new baby cries. What is the
best immediate intervention? - Correct Answer - Modeling appropriate behaviors that
encourage infant bonding
A woman who is 28 weeks pregnant calls the clinic to report that she is frightened
because she is leaking breast milk. The best response is to tell her that: - Correct
Answer - This can be a normal occurrence during pregnancy
pg. 1
,During a routine 32-week prenatal visit, a client tells the nurse that she has had difficulty
sleeping on her back at night. What should the nurse advise the client about her
position when she sleeps? - Correct Answer - "Turn from side to side."
The transmission of which microorganism that causes maternal mastitis is minimized by
frequent handwashing by nursing staff members? - Correct Answer - Staphylococcus
aureus
A woman has just received the news that she is pregnant. She is ambivalent about the
pregnancy because she had planned to go back to work when her youngest child
started school next year. What developmental task of pregnancy must the woman
accomplish in the first trimester of pregnancy? - Correct Answer - Accept that she is
pregnant
When performing Leopold maneuvers on a client who has been admitted to the birthing
room, the nurse identifies a firm, round prominence over the symphysis pubis; a
smooth, convex structure along her right side; irregular lumps along her left side; and a
soft roundness in the fundus. What is the fetal position? - Correct Answer - ROA
-The fetus is in a right occiput anterior (ROA) position; the prominence over the
symphysis suggests a vertex and the fetal occiput and back are in the right anterior
quadrant. Left occiput posterior (LOP) is ruled out because the occiput is not located in
the left posterior quadrant; the occiput and back are on the mother's right side. Right
sacral anterior (RAS) is ruled out because the fetus is in a vertex, not a breech,
presentation. Left occipital anterior (LOA) is ruled out by the presence of irregular lumps
on the left side, suggesting that the fetus's back is in the mother's right quadrant.
A nurse concludes that a laboring couple has benefited from the Lamaze method of
childbirth preparation when during the transition phase of labor, they use the breathing
pattern known as: - Correct Answer - Pant-blow
-Panting and blowing keeps the glottis open so the mother cannot hold her breath and
bear down.
A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about
45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100
beats/min on the internal fetal monitor. What is the next nursing action? - Correct
Answer - Notifying the health care provider
pg. 2
, -Bradycardia (baseline FHR slower than 110 beats/min) indicates that the fetus may be
compromised, requiring medical intervention. Resuming continuous fetal heart
monitoring may be dangerous; the fetus may be compromised, and time should not be
spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at
this time. The expected FHR is 110 to 160 beats/min between contractions.
The fetus of a client in labor is found to be at +1 station. What location does +1 station
describe? - Correct Answer - Just below the ischial spines
The nurse is caring for a client whose labor is to be induced. What is the nurse's
responsibility when a client's labor is being stimulated with an oxytocin (Pitocin)
infusion? - Correct Answer - Stopping the infusion if contractions become hypertonic
A client in active labor becomes very uncomfortable and asks a nurse for pain
medication. Nalbuphine (Nubian) is prescribed. How does this medication relieve pain?
- Correct Answer - By acting on opioid receptors to reduce pain
-Nalbuphine (Nubian) is classified as an opioid analgesic and is effective in relieving
pain; it induces little or no newborn respiratory depression. Nalbuphine does not induce
amnesia, act as an anesthetic, or induce sleep.
A client is admitted to the birthing unit in active labor. Amniotomy is performed by the
health care provider. What physiological change does the nurse expect to occur after
the procedure? - Correct Answer - Progressive dilation and effacement
A nurse is teaching a primigravida about how she can identify the onset of labor. What
clinical indicator of labor would necessitate the client to call her health care provider? -
Correct Answer - Rupture of membranes or contractions 5 minutes apart
A woman who has just delivered an infant asks to take the placenta home with her and
her new baby on discharge. What is the most appropriate response? - Correct Answer -
"I need to check the hospital protocol for our policy on that practice."
The nurse is caring for a client who has just received epidural anesthesia. Which finding
would be of most concern? - Correct Answer - Hypotension
pg. 3
