The nurse is evaluating a full-term multigravida who was induced 3 hours ago.

The nurse determines

that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor
indicates that the FHR decelerates at the onset of several contractions and returns to baseline before
each contraction ends. Which action should the nurse take?

A. Reapply the external transducer.

B. Insert intrauterine pressure catheter.

C. Discontinue the oxytocin infusion.

D. Continue to monitor labor progress.

D. Rationale: The fetal heart rate indicates early decelerations, which are not an ominous sign, so the
nurse should continue to monitor the labor progress (D) and document the findings in the client's
record. There is no reason to reapply the external transducer (A) if the FHR tracings are being captured.
(B and C) are not indicated at this time.

The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-
day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's
next fertile period occur?

A. January 14 to 15

B. January 22 to 23

C. January 29 to 30

D.February 6 to 7

C. Rationale: This client can expect her next period to begin 36 days from the first day of her last
menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first
day of the menstrual period. The client can expect ovulation to occur January 29 to 30 (C). (A, B, and D)
are incorrect.

A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is
getting lighter in color and asks when the flow will stop. How should the nurse respond?

A. 2 weeks

B. 10 days

C. When the placental site has healed

D.After the first time ovulation occurs

C. Rationale: The placental site in the uterus usually heals (C) in 3 to 6 weeks, and the lochial flow should
cease at that time. Between 2 and 6 weeks after childbirth, lochia alba occurs in most women (A). The
client is describing lochia serosa, a normal change in the lochial flow (B) between days 3 and 4 after
childbirth, which lasts to about day 10. (D) does not give the client the best information because
ovulation varies in the postpartum period and is influenced by lactation and hormonal responses as the
client's usual menstrual cycle resumes.

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the
first time?

A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely.

B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.

C. Her arms and hands receive the infant and she then cuddles the infant to her own body.

D. She eagerly reaches for the infant and then holds the infant close to her own body.

B. Rationale: Attachment and bonding theory indicates that most mothers will demonstrate behaviors
described in (B) during the first visit with the newborn, which may be at delivery or later. After the first
visit, the mother may exhibit different touching behaviors such as eagerly reaching for the infant and
cuddling the infant close to her (A, C, and D).

A client in active labor is becoming increasingly fearful because her contractions are occurring more
often than she had expected. Her partner is also becoming anxious. Which of the following should be
the focus of the nurse's response?

A. Telling the client and her partner that the labor process is often unpredictable

B. Informing the client that this means she will give birth sooner than expected

C. Asking the client and her partner if they would like the nurse to stay in the room

D. Affirming that the fetal heart rate is remaining within normal limits

C. Rationale: Offering to remain with the client and her partner (C) offers support without providing
false reassurance. The length of labor is not always predictable, but (A and B) do not offer the client the
support that is needed at this time. (D) may be reassuring regarding the fetal heart rate, but does not
provide the client the emotional support she needs at this time during the labor process.
In developing a teaching plan for expectant parents, the nurse decides to include information about
when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the
timing of closure of an infant's fontanels that should be included in this teaching plan?

A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week.

B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second
week.

C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first
month.

D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second
month.

D. Rationale: In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the
posterior fontanel closes by the end of the second month (D). These growth and development
milestones are frequently included in questions on the licensure examination. (A, B, and C) are incorrect.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood
pressure drops from 120/80 mm Hg to 90/60 mm Hg. Which action should the nurse take immediately?

A. Notify the health care provider or anesthesiologist.

B. Continue to assess the blood pressure every 5 minutes.

C. Place the client in a lateral position.

D. Turn off the continuous epidural.

C. Rationale:

The nurse should immediately turn the client to a lateral position (C) or place a pillow or wedge under
one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line
IV infusion and administering oxygen by face mask. If the blood pressure remains low after these
interventions or decreases further, the anesthesiologist or health care provider should be notified
immediately (A). To continue to monitor blood pressure without taking further action (B) could
constitute malpractice. (D) may also be warranted, but such action is based on hospital protocol.

A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become
HIV-infected. Which explanation should the nurse provide?

A. Most infants of HIV-positive women will continue to test positive for HIV antibodies.
B. Infants who have HIV-positive mothers carry the virus and will eventually develop the disease.

C. Medication taken during pregnancy to reduce the mother's viral load ensures that the infant is HIV-
negative.

D. HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer
present.

D. Rationale:

All newborns of HIV-positive mothers receive passive HIV antibodies from the mother, so the evaluation
of an infant for the HIV virus is determined at 18 months of age, when all the maternal antibodies are no
longer in the infant's blood (D). Passive HIV antibodies disappear in the infant within 18 months of age
(A). (B) is inaccurate. Although administration of HIV medication during pregnancy (C) can significantly
reduce the risk of vertical transmission, treatment does not ensure that the virus will not become
manifest in the infant.

When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach
concerning the newborn infant born at term gestation?

A. Milia are red marks made by forceps and will disappear within 7 to 10 days.

B. Meconium is the first stool and is usually yellow gold in color.

C. Vernix is a white cheesy substance, predominantly located in the skin folds.

D. Pseudostrabismus found in newborns is treated by minor surgery.

C. Rationale:

Vernix, found in the folds of the skin, is a characteristic of term infants (C). Milia (A) are not red marks
made by forceps but are white pinpoint spots usually found over the nose and chin that represent
blockage of the sebaceous glands. Meconium is the first stool (B), but it is tarry black, not yellow.
Pseudostrabismus (crossed eyes) is normal at birth (D) through the third or fourth month and does not
require surgery.

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In
developing a plan of care, the nurse should give the highest priority to which finding?

A. Cyanosis of the hands and feet

B. Skin color that is slightly jaundiced

C. Tiny white papules on the nose or chin

D. Red patches on the cheeks and trunk

B. Rationale:

Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further
evaluated in a newborn less than 24 hours old (B). Acrocyanosis (blue color of the hands and feet) is a
common finding in newborns; it occurs because the capillary system is immature (A). Milia (C) are small
white papules present on the nose and chin that are caused by sebaceous gland blockage, which
disappear in a few weeks. Small red patches on the cheeks and trunk (D) are called erythema toxicum
neonatorum, a common finding in newborns.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room.
She sure has a funny-looking head." Which response by the nurse is best?

A. "This is not an unusually shaped head, especially for a first baby."

B. "It may look odd, but newborn babies are often born with heads like that."

C. "That is normal. The head will return to a round shape within 7 to 10 days."

D. "Your pelvis was too small, so the head had to adjust to the birth canal."

C. Rationale:

(C) reassures the mother that this is normal in the newborn and provides correct information regarding
the return to a normal shape. Although (A) is correct, it implies that the client should not worry. Any
implied or spoken "don't worry" is usually the wrong answer. (B) is condescending and dismissing; the
mother is seeking reassurance and information. (D) is a negative statement and implies that molding is
the mother's fault.