1 . Which woman is most likely to experience strong afterpains?
a. A woman who experienced oligohydramnios
b. A woman who is a gravida 4, para
... [Show More] 4-0-0-4
c. A woman who is bottle-feeding her infant
d. A woman whose infant weighed 5 pounds, 3 ounces
Ans B . A woman who is a gravida, para 4-0-0-4
2. What are the most common causes for subinvolution of the uterus?
Retained placental fragments and infection
Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of
subinvolution are retained placental fragments and infection. Subinvolution may be caused by an
infection and result in hemorrhage. Multiple gestations may cause uterine atony, resulting in postpartum
hemorrhaging. Uterine tetany and overproduction of oxytocin do not cause subinvolution.
3. A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal, and the
estimated blood loss (EBL) was approximately 1500 mL. When assessing the woman's vital signs, the
nurse would be concerned to see:
a. Temperature 37.9° C, heart rate 120, respirations 20, blood pressure (BP) 90/50.
b. Temperature 37.4° C, heart rate 88, respirations 36, BP 126/68.
c. Temperature 38° C, heart rate 80, respirations 16, BP 110/80.
d. Temperature 36.8° C, heart rate 60, respirations 18, BP 140/90.
Ans A
4, Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during
the puerperium?
a. Varicosities of the legs
b. Carpal tunnel syndrome
c. Periodic numbness and tingling of the fingers
d. Headaches
Ans D
5. Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the
right of the umbilicus?
a. Notify the physician of an impending hemorrhage.
b. Assess the blood pressure and pulse.
c. Evaluate the lochia.
d. Assist the patient in emptying her bladder.
Ans D
6 . Rho immune globulin will be ordered postpartum if which situation occurs?
a. Mother Rh?2-, baby Rh+
c. Mother Rh+, baby Rh+
b. Mother Rh?2-, baby Rh?2-
d. Mother Rh+, baby Rh?2-
Ans A
Rh?2- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream
when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal
circulation before sensitization occurs. If mother and baby are both Rh+ or Rh?2- the blood types are
alike, so no antibody formation would be anticipated. If the Rh+ blood of the mother comes in contact
with the Rh?2- blood of the infant, no antibodies would develop because the antigens are in the
mother's blood, not the infant's.
7 On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely
saturated a perineal pad within 15 minutes. The nurse's first action is to:
a. Begin an intravenous (IV) infusion of Ringer's lactate solution.
b. Assess the woman's vital signs.
c. Call the woman's primary health care provider.
d. Massage the woman's fundus.
Ans D
The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive
blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the
first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage;
assessing vital signs should not be the nurse's first action. The physician would be notified after the
nurse completes the assessment of the woman.
8. A woman arrives at the clinic seeking confirmation that she is pregnant. The following information is
obtained: She is 24 years old with a body mass index (BMI) of 17.5. She admits to having used cocaine
"several times" during the past year and drinks alcohol occasionally. Her blood pressure (BP) is 108/70
mm Hg, her pulse rate is 72 beats/min, and her respiratory rate is 16 breaths/min. The family history is
positive for diabetes mellitus and cancer. Her sister recently gave birth to an infant with a neural tube
defect (NTD). Which characteristics place the woman in a high risk category?
a. Blood pressure, age, BMI
b. Drug/alcohol use, age, family history
c. Family history, blood pressure, BMI
d. Family history, BMI, drug/alcohol abuse
Ans. D
9. Which assessments are included in the fetal BPP? (Select all that apply.)
Ans: a,b,c,d
a. Fetal movement
b. Fetal tone
c. Fetal heart rate
d. AFI
e. Placental grade
10. Biophysical risks include factors that originate with either the mother or the fetus and affect the
functioning of either one or both. The nurse who provides prenatal care should have an understanding
of these risk factors. Match the specific pregnancy problem with the related risk factor.
a. Polyhydramnios
b. IUGR (maternal cause)
c. Oligohydramnios
d. Chromosomal abnormalities
e. IUGR (fetoplacental cause)
1. Premature rupture of membranes C (oligohydramnios)
2. Advanced maternal age D( chromosomal abnormalities)
3. Fetal congenital anomalies A( polyhydramnios)
4. Abnormal placenta development E(IUGR)Fetoplacental cause
5. Smoking, alcohol, and illicit drug use B( IUGR) Maternal cause
11. The nurse is planning the care for a laboring client with diabetes mellitus. This client is at greater risk
for which clinical finding?
a. Oligohydramnios
b. Polyhydramnios (amniotic fluid)
c. Post term pregnancy
d. Chromosomal abnormalities
ans B
12. Which statements regarding physiologic jaundice are accurate? (Select all that apply.)
a, b, c
a. Neonatal jaundice is common; however, kernicterus is rare.
b. Appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process.
c. Because jaundice may not appear before discharge, parents need instruction on how to assess for
jaundice and when to call for medical
13. Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the
ball of the foot?
a .Babinski
b. Stepping
c. Tonic neck
d. Plantar grasp
ANS: A
The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The stepping reflex
occurs when infants are held upright, with their heel touching a solid surface, and the infant appears to
be walking. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by
newborns when in a supine position. Plantar grasp reflex is similar to the palmar grasp reflex; when the
area below the toes is touched, the infant's toes curl over the nurse's finger.
14. While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn
symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and
forefinger, and he has a slight tremor. The nurse would document this finding as a positive:
a. Tonic neck reflex.
b. Glabellar (Myerson) reflex.
c. Babinski reflex.
d. Moro reflex.
Ans D
15. Pain should be regularly assessed in all newborns. If the infant is displaying physiologic or behavioral
cues that indicate pain, then measures should be taken to manage the pain. Which interventions are
examples of nonpharmacologic pain management techniques? (Select all that apply.) (A, B,C,D).
a. Swaddling
b. Nonnutritive sucking
c. Skin-to-skin contact with the mother
d. Sucrose
e. Acetaminophen
ans a,b,c,d
16. As recently as 2005, the AAP revised safe sleep practices to assist in the prevention of SIDS. The
nurse should model these practices in the hospital and incorporate this information into the teaching
plan for new parents. Which practices are ideal for role modeling? (Select all that apply.) A, C, D
a. Fully supine position for all sleep
b. Side-sleeping position as an acceptable alternative
c. Tummy time for play
d. Infant sleep sacks or buntings
e. Soft mattress
Ans A,C, D
17. What is the nurse's initial action when caring for an infant with a slightly decreased temperature is to
A. Notify the physician immediately
B. Wrap the infant in two warmed blankets and place a cap on the head
C. Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours
D. Change the formula, because this is a sign of formula intolerance
Ans B
18. A mother expresses fear about changing her infant's diaper after he is circumcised. What does the
woman need to be taught to take care of the infant when she gets home?
A) Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B) Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding
occurs.
C) Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper
change.
D) Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.
Ans C
19. Which actions are examples of appropriate techniques to wake a sleepy infant for breastfeeding?
(Select all that apply.)
a. Unwrap the infant.
b. Change the diaper.
c. Talk to the infant.
d. Slap the infant's hands and feet.
e. Apply a cold towel to the infant's abdomen.
Ans A, B, C
20. A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What
signs and symptoms should the nurse include in her discussion? (Select all that apply.)
a. Breast tenderness
b. Warmth in the breast
c. An area of redness on the breast often resembling the shape of a pie wedge
d. A small white blister on the tip of the nipple
e. Fever and flulike symptoms
ans. A,B,C,D
21. Which statements concerning the benefits or limitations of breastfeeding are accurate? (Select all
that apply.)
a. Breast milk changes over time to meet the changing needs as infants grow.
b. Breastfeeding increases the risk of childhood obesity.
c. Breast milk and breastfeeding may enhance cognitive development.
d. Long-term studies have shown that the benefits of breast milk continue after the infant is weaned.
e. Benefits to the infant include a reduced incidence of SIDS
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