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    Exam Review

    1. A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?
      A)
      Client report of frequent uterine contractions
      B)
      Less than 2.5 cm of rubra lochia on perineal pad
      C)
      Client report of increased thirst
      D)
      Fundus palpable to right of midline
    2. The nurse is performing a newborn assessment and evaluates a collection of blood beneath the newborn's scalp that does not cross the suture lines. The nurse documents this finding as
      A)
      Sinciput
      B)
      Occiput posterior
      C)
      Caput succedaneum
      D)
      Cephalohematoma
    3. A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh,(D) immunoglobulin. Which of the following should be included in the teaching?
      A)
      It prevents the formation of Rh antibodies in mothers who are Rh negative.
      B)
      It prevents the formation of Rh antibodies in newborns who are Rh positive.
      C)
      It destroys Rh antibodies in newborns who are Rh positive.
      D)
      It destroys Rh antibodies in mothers who are Rh negative.
    4. A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?
      A)
      "You should place your nipple and some of the areola into her mouth."
      B)
      "Babies know instinctively how much of the nipple to take into their mouth."
      C)
      "Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth."
      D)
      "Your baby's mouth is rather small so she will only take part of the nipple."
    Page 1 of 25

    Exam Review

    1. At midpoint during pregnancy, you review beginning signs of labor with a client. One of the beginning signs of labor you would review is:
      A)
      sharp, right-sided abdominal pain.
      B)
      a sudden gush of clear fluid from the vagina
      C)
      an increased pulse rate and upper abdominal pain
      D)
      excessive fatigue and headache.
    2. A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?
      A)
      Right lower
      B)
      Right upper
      C)
      Left
      D)
      upper
      E)
      Left lower
    3. A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?
      A)
      Accidental lacerations
      B)
      Acrocyanosis.
      C)
      Hypothermia
      D)
      Respiratory distress
    4. A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?
      A)
      Apply a fetal scalp electrode.
      B)
      Change the client's position.
      C)
      Increase the rate of the IV infusion.
      D)
      Administer oxygen at 10 L/min via a nonrebreather mask.
    Page 2 of 25

    Exam Review

    1. A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?
      A)
      Blood pressure 80/56 mm Hg
      B)
      The client reports perfuse itching.
      C)
      Temperature 38.2°C (100.8°F)
      D)
      The client reports weakness of the lower extremities.
    2. A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?
      A)
      Insert a urinary catheter.
      B)
      Massage the fundus.
      C)
      Administer an analgesic.
      D)
      Have the client urinate.
    3. A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?
      A)
      1+ pitting sacral edema
      B)
      Deep tendon reflexes of +1
      C)
      Blood pressure 148/98 mm Hg
      D)
      3+ protein in the urine
    4. A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min. last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
      A)
      Discontinue the infusion of the IV oxytocin.
      B)
      Decrease the rate of infusion of the maintenance IV solution.
      C)
      Increase the rate of infusion of the IV oxytocin.
      D)
      Slow the client's rate of breathing.
    Page 3 of 25

    Exam Review

    1. A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?
      A)
      "This could result in profound bleeding."
      B)
      "This could initiate preterm labor."
      C)
      "There is an increased risk of rupture of the membranes."
      D)
      "There is an increased risk of introducing infection."
    2. A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?
      A)
      Administer oxytocin infusion.
      B)
      Evaluate the firmness of the uterus.
      C)
      `obtain a type and crossmatch.
      D)
      Initiate oxygen therapy by nonrebreather mask.
    3. A nurse is preparing to administer amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)
    4. What is the most effective way for a nurse to assess a woman's usual food intake during her pregnancy?
      A)
      Ask her to describe her intake for the last 24 hours.
      B)
      Ask her to describe her total intake for a week
      C)
      Assess a list she makes describing a good diet
      D)
      Assess her skin for hydration and color.
    Page 4 of 25

    Exam Review

    1. A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?
      A)
      A client who is scheduled for discharge following a laparoscopic tubal ligation
      B)
      A client who experienced a vaginal birth 24 hr ago and reports no bleeding
      C)
      A client who has preeclampsia with a BP of 138/90 mm Hg
      D)
      A client who experienced a cesarean birth 4 hr ago and reports pain
    2. Which information is important for a woman to understand before undergoing a scheduled tubal ligation?
      A)
      The procedure will reduce her menstrual flow in amount
      B)
      She should schedule it to be done just before a menstrual flow
      C)
      She will have lessened dysmenorrhea following the procedure
      D)
      She must think of the procedure as irreversible.
    3. A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?
      A)
      A newborn who is 18 hr post-delivery and has acrocyanosis
      B)
      A newborn who is 12 hr post-delivery and has a temperature of 37.5° C (99.5° F)
      C)
      A newborn who is 24 hr post-delivery and has not voided
      D)
      A newborn who is 24-hr post-delivery and has not passed meconium
    4. A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?
      A)
      Hold the newborn vertically allowing one foot to touch the table surface.
      B)
      Perform a sharp hand clap near the infant.
      C)
      Turn the newborn's head quickly to one side.
      D)
      Place a finger at the base of the newborn's toes.
    Page 5 of 25

    Exam Review

    1. What is the most likely cause of early decelerations in the fetal heart rate (FHR) pattern?
      A)
      Spontaneous rupture of membranes
      B)
      Uteroplacental insufficiency
      C)
      Umbilical cord compression
      D)
      Altered fetal cerebral blood flow
    2. A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?
      A)
      2 cm above the umbilicus
      B)
      To the right of the umbilicus
      C)
      One fingerbreadth above the symphysis pubis
      D)
      At the level of the umbilicus
    3. A nurse is performing a physical examination of-a client who is 1 day postpartum. Which of the following findings requires immediate intervention?
      A)
      Displaced fundus from the midline
      B)
      Fundal height below the umbilicus
      C)
      Increased urine output
      D)
      Decreased urge to void
    4. A nurse is caring for a client who experienced a vaginal birth 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase?
      A)
      Eagerness to learn newborn care skills
      B)
      Lack of appetite
      C)
      Expressions of excitement
      D)
      Focus on the family unit and its members
    Page 6 of 25