1. Which behaviors would be exhibited during the letting-go phase of maternal role adaptation. Select all that apply.
A. Emergence of family unit
B. Dependent behaviors
C. Sexual intimacy relationship continuing
D. Defining one’s individual roles
E. Being talkative and excited about becoming a mother
2. While making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically:
A. Express a strong need to review the events and her behavior during the process of labor and birth.
B. Exhibit a reduced attention span, limiting readiness to learn.
C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn.
D. Have reestablished her role as a spouse or partner.
3. Which of the following is the most common kind of placental adherence seen in pregnant women?
B. Placenta previa
4. A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time?
A. Biophysical profile
C. Maternal serum alpha-fetoprotein (MSAFP)
D. Transvaginal ultrasound
5. A nurse providing care for the antepartum woman should understand that the contraction stress test (CST):
A. Sometimes uses vibroacoustic stimulation.
B. Is an invasive test; however, contractions are stimulated.
C. Is considered to have a negative result if no late decelerations are observed with the contractions.
D. Is more effective than nonstress test (NST) if the membranes have already been ruptured.
6. In the past, factors to determine whether a woman was likely to have a high-risk pregnancy were evaluated primarily from a medical point of view. A broader, more comprehensive approach to high-risk pregnancy has been adopted. There are now four categories based on threats to the health of the woman and the outcome of pregnancy. Which of the options listed here is not included as a category?
7. A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test?
A. “I will need to have a full bladder for the test to be done accurately.”
B. “I should have my husband drive me home after the test because I may be nauseated.”
C. “This test will help to determine whether the baby has Down syndrome or a neural tube defect.”
D. “This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby.”
8. What is an appropriate indicator for performing a contraction stress test?
A. Increased fetal movement and small for gestational age
B. Maternal diabetes mellitus and postmaturity
C. Adolescent pregnancy and poor prenatal care
D. History of preterm labor and intrauterine growth restriction
9. The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis?
A. Doppler blood flow analysis
B. Contraction stress test (CST)
D. Daily fetal movement counts
10. A nurse is providing instruction for an obstetrical patient to perform a daily fetal movement count (DFMC). Which instructions could be included in the plan of care? Select all that apply.
A. The fetal alarm signal is reached when there are no fetal movements noted for 5 hours.
B. The patient can monitor fetal activity once daily for a 60-minute period and note activity.
C. Monitor fetal activity two times a day either after meals or before bed for a period of 2 hours or until 10 fetal movements are noted.
D. Count all fetal movements in a 12-hour period daily until 10 fetal movements are noted.
11. A patient has undergone an amniocentesis for evaluation of fetal well-being. Which intervention would be included in the nurse’s plan of care after the procedure? Select all that apply.
A. Perform ultrasound to determine fetal positioning.
B. Observe the patient for possible uterine contractions.
C. Administer RhoGAM to the patient if she is Rh negative.
D. Perform a mini catheterization to obtain a urine specimen to assess for bleeding.
12. With regard to small-for-gestational-age (SGA) infants and intrauterine growth restriction (IUGR), nurses should be aware that:
A. In the first trimester, diseases or abnormalities result in asymmetric IUGR.
B. Infants with asymmetric IUGR have the potential for normal growth and development.
C. In asymmetric IUGR, weight is slightly more than SGA, whereas length and head circumference are somewhat less than SGA.
D. Symmetric IUGR occurs in the later stages of pregnancy.
13. A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?
A. Altered nutrition, less than body requirements for lactation
B. Alteration in comfort related to nausea and abdominal distention
C. Impaired bowel motility related to pain medication and immobility
D. Fatigue related to cesarean delivery and physical care demands of infant
14. The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, “What type of disease causes infections in babies that can be prevented by using this ointment?” Which response by the nurse is accurate?
15. A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?
A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking.
B. Hold the infant’s head firmly against the breast until he latches onto the nipple.
C. Encourage the mother to stop feeding for a few minutes and comfort the infant.
D. Provide a formula for the infant until he becomes calm, and then offer the breast again.
16. The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?
A. Two weeks before menstruation
B. Immediately after menstruation
C. Immediately before menstruation
D. Three weeks before menstruation
17. The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take?
A. Administer oxygen by face mask.
B. Notify the health care provider of the client’s symptoms.
C. Have the client breathe into her cupped hands.
D. Check the client’s blood pressure and fetal heart rate.
18. When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
A. At 16 weeks of gestation
B. At 20 weeks of gestation
C. At 24 weeks of gestation
D. At 30 weeks of gestation
19. One hour following a normal vaginal delivery, a newborn infant boy’s axillary temperature is 96° F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy’s hands shake. Which intervention should the nurse implement first?
A. Stimulate the infant to cry.
B. Wrap the infant in warm blankets.
C. Feed the infant formula.
D. Obtain a serum glucose level.
20. Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn?
A. “Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period.”
B. “Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk.”
C. “I can start smoking cigarettes while breastfeeding because it will not affect my breast milk.”
D. “When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings.”
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Answers and Rationale
1. Answer: A, C, and D
The emergence of family unit, sexual intimacy relationship continuing and defining one’s individual roles represent interdependent behaviors associated with the letting-go phase.
Option B: Dependent behaviors are exhibited in the taking-in phase.
Option E: Being talkative and excited about becoming a mother represents the taking-hold phase and is an example of dependent-independent behaviors.
2. Answer: C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn.
One week after birth the woman should exhibit behaviors characteristic of the dependent-independent or taking-hold stage. She still has needs for nurturing and acceptance by others.
Options A and B: Wanting to discuss the events of her labor and delivery are characteristics of the taking-in stage, as are a limited readiness to learn and reduced attention span; this stage lasts from the first 24 hours until 2 days after delivery.
Option D: Having reestablished her role as a spouse reflects the letting-go stage, which indicates that psychosocial recovery is complete.
3. Answer: A. Accreta
Placenta accreta is the most common kind of placental adherence seen in pregnant women and is characterized by slight penetration of myometrium.
Option B: In placenta previa, the placenta does not embed correctly and results in what is known as a low-lying placenta. It can be marginal, partial, or complete in how it covers the cervical os, and it increases the patient’s risk for painless vaginal bleeding during the pregnancy and/or delivery process.
Option C: Placenta percreta leads to perforation of the uterus and is the most serious and invasive of all types of accrete.
Option D: Placenta increta leads to deep penetration of the myometrium.
4. Answer: D. Transvaginal ultrasound
An ultrasound is the method of biophysical assessment of the infant that is performed at this gestational age. Transvaginal ultrasound is especially useful for obese women, whose thick abdominal layers cannot be penetrated adequately with the abdominal approach.
Option A: A biophysical profile is a method of biophysical assessment of fetal well-being in the third trimester.
Option B: An amniocentesis is performed after the fourteenth week of pregnancy.
Option C: A MSAFP test is performed from week 15 to week 22 of the gestation (weeks 16 to 18 are ideal).
5. Answer: C. Is considered to have a negative result if no late decelerations are observed with the contractions.
No late decelerations indicate a positive CST result.
Option A: Vibroacoustic stimulation is sometimes used with NST.
Option B: CST is invasive if stimulation is performed by IV oxytocin but not if by nipple stimulation.
Option D: CST is contraindicated if the membranes have ruptured.
6. Answer: C. Geographic
The fourth category is correctly referred to as the sociodemographic risk category.
7. Answer: D. “This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby.”
The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements.
Option A: An ultrasound requires a full bladder.
Option B: An amniocentesis is a test after which a pregnant woman should be driven home.
Option C: A maternal serum alpha-fetoprotein test is used in conjunction with unconjugated estriol levels and human chorionic gonadotropin helps to detect Down syndrome.
8. Answer: B. Maternal diabetes mellitus and postmaturity
Option A: Decreased fetal movement is an indicator for performing a contraction stress test; the size (small for gestational age) is not an indicator.
Option C: Although adolescent pregnancy and poor prenatal care are risk factors for poor fetal outcomes, they are not indicators for performing a contraction stress test.
Option D: Intrauterine growth restriction is an indicator; history of a previous stillbirth, not preterm labor, is another indicator.
9. Answer: A. Doppler blood flow analysis
Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the placenta. It is a helpful tool in the management of high-risk pregnancy due to intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labor.
Option B: Because of the potential risk of inducing labor and causing fetal distress, a CST is not performed on a woman whose fetus is preterm.
Option C: Indications for an amniocentesis include diagnosis of genetic disorders or congenital anomalies, assessment of the pulmonary maturity, and the diagnosis of fetal hemolytic disease, not IUGR.
Option D: Fetal kick count monitoring is performed to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenation. Although it may be a useful tool at some point later in this woman’s pregnancy, it is not used to diagnose IUGR.
10. Answer: B, C, and D
The fetal alarm signal is reached when no fetal movements are noted for a period of 12 hours.
11. Answer: B and C
Ultrasound is used prior to the procedure as a visualization aid to assist with insertion of the transabdominal needle. There is no need to assess the urine for bleeding as this is not considered to be a typical presentation or complication.
12. Answer: B. Infants with asymmetric IUGR have the potential for normal growth and development.
The infant with asymmetric IUGR has the potential for normal growth and development.
SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy.
Option A: IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester, as a result of disease or abnormalities.
Option C: Weight is less than the 10th percentile, but the head circumference is greater than the 10th percentile (within normal limits).
Option D: IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester, as a result of disease or abnormalities;
13. Answer: C. Impaired bowel motility related to pain medication and immobility
Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus.
Options A and B are both caused by impaired bowel motility.
Option D is not as important as impaired motility.
14. Answer: C. Gonorrhea
Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea (C), and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal.
Options A, B, and D: Ophthalmic ointment is not effective against Trichomonas, Gonorrhea, and Syphilis.
15. Answer: C. Encourage the mother to stop feeding for a few minutes and comfort the infant.
The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful.
Options A and D would cause nipple confusion.
Option B would only cause the infant to be more resistant, resulting in the mother and infant to become more frustrated.
16. Answer: A. Two weeks before menstruation
Ovulation occurs 14 days before the first day of the menstrual period (A). Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle varies.
17. Answer: C. Have the client breathe into her cupped hands.
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands. (A) (B and D)
Option A is inappropriate because the carbon dioxide level is low, not the oxygen level.
Options B and D are not specific for this situation.
18. Answer: D. At 30 weeks of gestation
Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy when they are beginning to anticipate the onset of labor and the birth of their child. At 30 weeks, is closest to the time when parents would be ready for such classes.
Options A, B, and C are not the best times during pregnancy for the couple to attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy classes often include topics such as nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her significant others.
19. Answer: D. Obtain a serum glucose level.
This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first, determine the serum glucose level.
Option A is an intervention for a lethargic infant.
Option B should be done based on the temperature, but first the glucose level should be obtained.
Option C helps raise the blood sugar, but first, the nurse should determine the glucose level.
20. Answer: A. “Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period.”
Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method.
Option B is incorrect because alcohol can immediately enter the breast milk.
Option C: Nicotine is transferred to the infant in breast milk
Option D: Taking a warm shower will stimulate the production of milk, which will be more painful after breastfeedings