. MATERNAL-NEWBORN
A woman enters the birthing center in active labor. She tells the nurse that her
membranes ruptured 26 hours ago. The nurse immediately takes the client's vital
signs. Which is the rationale for the nurse's actions?
Pulse rates rise the longer the membranes are ruptured
Respiratory rates decrease due to lack of fluid in the uterus
Prolonged rupture of membranes can lead to transient hypertension
Infection is a complication of prolonged rupture of membranes
26. A new client's pregnancy is confirmed at 10 weeks gestation. Her history
reveals that her first two pregnancies ended in spontaneous abortion at 12 and 20
weeks. She has a4-year-old and a set of 1-year-old twins. How should the nurse
record the client's current gravida and para status?
Gravida 2, para 3
Gravida 4, para 2
Gravida 5, para 2
Gravida 5, para 4
27. A 16-year-old client reports to the school nurse because of nausea and
vomiting. After exploring the signs and symptoms with the client, the nurse asks
the girl whether she could be pregnant. The girl confirms that she is pregnant, but
states that she does not know how it happened. Which nursing diagnosis is most
important?
Knowledge deficit related to the client's developmental stage and age
28. A client is admitted to the hospital for induction of labor. Which are the main
indications for labor induction?
Placenta previa and twins
Pregnancy-induced hypertension and postterm fetus
Breech position and prematurity
,Cephalopelvic disproportion and fetal distress
29. A client in active labor receives a regional anesthetic. Which is the main
purpose of regional anesthetics?
To relieve pain by decreasing the client's level of consciousness
To provide general loss of sensation by blocking sensory nerves to an area
To provide pain relief by blocking descending impulses from the central nervous
system
To relieve pain by decreasing the perception of pain leading to the pain centers in
the brain
30. The nursery nurse reviews a newborn's birth history and notes that the Apgar
scores were 5 at one minute after birth, and 7 at five minutes after birth. How
should the nurse interpret these scores? The infant:
needed brief oral and nasal suctioning.
required endotracheal intubation and bagging with a hand-held resuscitator.
was stillborn and required CPR.
required physical stimulation and supplemental oxygen.
31. With routine prenatal screening, a woman in the second trimester of pregnancy
is confirmed to have gestational diabetes. How may the nurse explain the role of
diet and insulin in the management of blood sugar during pregnancy?
"Insulin lowers an elevated blood sugar during pregnancy to meet the increased
metabolic needs of the baby."
32. A breastfeeding mother complains of cramping. Which is the main cause of the
client's afterpains?
Contractions of the uterus
,33. A client who is 37 weeks gestation comes to the office for a routine visit. This
is the client's first baby and she asks the nurse how she will know when labor
begins. Which signs indicate that true labor has begun?
Contractions that are irregular and decrease in intensity when walking
Abdominal pain that starts at the fundus and progresses to the lower back
Increased pressure on the bladder and urinary frequency
Expulsion of pink-tinged mucous and contractions that start in the lower back
34. A multiparous woman with a history of all vaginal births is admitted to the
hospital in labor. After several hours, the client's labor has not progressed and she
is getting tired and restless. The decision is made to proceed with cesarean
delivery. The nurse recognizes the client's knowledge deficit regarding the surgical
delivery and care afterbirth. Which is the appropriate expected outcome for
correction of the client's knowledge deficit? The client will:
demonstrate appropriate coping mechanisms needed to get through the surgery.
accept that the type of delivery will not affect the bonding with the baby.
verbalize understanding about the reason for the unplanned surgery.
demonstrate decreased anxiety and fear of the unknown.
35. The physician performs an amniotomy for a woman in labor. Which nursing
action should follow the procedure?
Assess the fluid for color, odor, and amount.
36. For a pregnant adolescent who is anemic, which foods should the nurse include
In the client's dietary plan to increase iron levels?
Milk and fish
Orange juice and apricots
, Chicken and cottage cheese
Pickles and peanut butter sandwiches
37. Which condition must occur in order for identical (monozygotic) twins to
develop?
One sperm fertilizes two ova
Two sperm fertilize two ova
One sperm fertilizes one ovum
Two sperm fertilize one ovum
38. Which fetal structure is responsible for carrying oxygenated blood from the
placenta to the fetus?
Ductus arteriosus
Umbilical artery
Portal vein
Umbilical vein
39. A client at 33 weeks gestation is admitted for suspected abruptio placenta.
Which factor in the client's history supports this diagnosis? The client states that
she:
used crack an hour before the symptoms began.
40. Which explanation is most appropriate when describing physiological jaundice
to the parents of a newborn?
"The baby has a minor incompatibility of the blood."
“The baby is breaking down the extra red blood cells that were present at birth.”
A woman enters the birthing center in active labor. She tells the nurse that her
membranes ruptured 26 hours ago. The nurse immediately takes the client's vital
signs. Which is the rationale for the nurse's actions?
Pulse rates rise the longer the membranes are ruptured
Respiratory rates decrease due to lack of fluid in the uterus
Prolonged rupture of membranes can lead to transient hypertension
Infection is a complication of prolonged rupture of membranes
26. A new client's pregnancy is confirmed at 10 weeks gestation. Her history
reveals that her first two pregnancies ended in spontaneous abortion at 12 and 20
weeks. She has a4-year-old and a set of 1-year-old twins. How should the nurse
record the client's current gravida and para status?
Gravida 2, para 3
Gravida 4, para 2
Gravida 5, para 2
Gravida 5, para 4
27. A 16-year-old client reports to the school nurse because of nausea and
vomiting. After exploring the signs and symptoms with the client, the nurse asks
the girl whether she could be pregnant. The girl confirms that she is pregnant, but
states that she does not know how it happened. Which nursing diagnosis is most
important?
Knowledge deficit related to the client's developmental stage and age
28. A client is admitted to the hospital for induction of labor. Which are the main
indications for labor induction?
Placenta previa and twins
Pregnancy-induced hypertension and postterm fetus
Breech position and prematurity
,Cephalopelvic disproportion and fetal distress
29. A client in active labor receives a regional anesthetic. Which is the main
purpose of regional anesthetics?
To relieve pain by decreasing the client's level of consciousness
To provide general loss of sensation by blocking sensory nerves to an area
To provide pain relief by blocking descending impulses from the central nervous
system
To relieve pain by decreasing the perception of pain leading to the pain centers in
the brain
30. The nursery nurse reviews a newborn's birth history and notes that the Apgar
scores were 5 at one minute after birth, and 7 at five minutes after birth. How
should the nurse interpret these scores? The infant:
needed brief oral and nasal suctioning.
required endotracheal intubation and bagging with a hand-held resuscitator.
was stillborn and required CPR.
required physical stimulation and supplemental oxygen.
31. With routine prenatal screening, a woman in the second trimester of pregnancy
is confirmed to have gestational diabetes. How may the nurse explain the role of
diet and insulin in the management of blood sugar during pregnancy?
"Insulin lowers an elevated blood sugar during pregnancy to meet the increased
metabolic needs of the baby."
32. A breastfeeding mother complains of cramping. Which is the main cause of the
client's afterpains?
Contractions of the uterus
,33. A client who is 37 weeks gestation comes to the office for a routine visit. This
is the client's first baby and she asks the nurse how she will know when labor
begins. Which signs indicate that true labor has begun?
Contractions that are irregular and decrease in intensity when walking
Abdominal pain that starts at the fundus and progresses to the lower back
Increased pressure on the bladder and urinary frequency
Expulsion of pink-tinged mucous and contractions that start in the lower back
34. A multiparous woman with a history of all vaginal births is admitted to the
hospital in labor. After several hours, the client's labor has not progressed and she
is getting tired and restless. The decision is made to proceed with cesarean
delivery. The nurse recognizes the client's knowledge deficit regarding the surgical
delivery and care afterbirth. Which is the appropriate expected outcome for
correction of the client's knowledge deficit? The client will:
demonstrate appropriate coping mechanisms needed to get through the surgery.
accept that the type of delivery will not affect the bonding with the baby.
verbalize understanding about the reason for the unplanned surgery.
demonstrate decreased anxiety and fear of the unknown.
35. The physician performs an amniotomy for a woman in labor. Which nursing
action should follow the procedure?
Assess the fluid for color, odor, and amount.
36. For a pregnant adolescent who is anemic, which foods should the nurse include
In the client's dietary plan to increase iron levels?
Milk and fish
Orange juice and apricots
, Chicken and cottage cheese
Pickles and peanut butter sandwiches
37. Which condition must occur in order for identical (monozygotic) twins to
develop?
One sperm fertilizes two ova
Two sperm fertilize two ova
One sperm fertilizes one ovum
Two sperm fertilize one ovum
38. Which fetal structure is responsible for carrying oxygenated blood from the
placenta to the fetus?
Ductus arteriosus
Umbilical artery
Portal vein
Umbilical vein
39. A client at 33 weeks gestation is admitted for suspected abruptio placenta.
Which factor in the client's history supports this diagnosis? The client states that
she:
used crack an hour before the symptoms began.
40. Which explanation is most appropriate when describing physiological jaundice
to the parents of a newborn?
"The baby has a minor incompatibility of the blood."
“The baby is breaking down the extra red blood cells that were present at birth.”
