1.

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.NFatigue related to cesarean delivery and physical care demands of infant

2.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?
A.NHerpes
B. Trichomonas
C. Gonorrhea
D. Syphilis

3.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 formula for the infant until he becomes calm, and then offer the breast again.

4.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

5.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.

6.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

7.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.

8.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. "

9.A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The
home health nurse has taught her how to take her own blood pressure and gave her parameters to judge
a significant increase in blood pressure. When the client calls the clinic complaining of indigestion,
which instruction should the nurse provide?
A. Lie on your left side and call 911 for emergency assistance.
B. Take an antacid and call back if the pain has not subsided.
C. Take your blood pressure now and if it is seriously elevated, go to the hospital.
D. See your health care provider to obtain a prescription for a histamine blocking agent.

10.The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather
than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full
to eat anything else. Which is the best response by the nurse?
A. Remove all ice from the client's room.
B. Ask the client what foods she might consider eating.
C. Remind the client that what she eats affects her baby.
D. Notify the health care provider.

11.Which finding(s) is (are) of most concern to the nurse when caring for a woman in the first trimester
of pregnancy? (Select all that apply.)
A. Cramping with bright red spotting
B. Extreme tenderness of the breast
C. Lack of tenderness of the breast
D. Increased amounts of discharge
E. Increased right-side flank pain

12.Prior to discharge, what instructions should the nurse give to parents regarding the newborn's
umbilical cord care at home?
A. Wash the cord frequently with mild soap and water.
B. Cover the cord with a sterile dressing.
C. Allow the cord to air-dry as much as possible.
D. Apply baby lotion after the baby's daily bath.
13.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.

14.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

15.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

16.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.

17.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

18.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.

19.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.

20.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.

Answer key
1.C. Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility
(C) is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. (A and B)
are both caused by impaired bowel motility. (D) is not as important as impaired motility.

2.C. Rationale: 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. Ophthalmic ointment is not effective against (A, B, or D).
3.C. Rationale: 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 (C). After such a time out,
breastfeeding is often more successful. (A and D) would cause nipple confusion. (B) would only cause
the infant to be more resistant, resulting in the mother and infant to become more frustrated.

4.A. Rationale: 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. (B,
C, and D) are incorrect.

5.C. Rationale: 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 (C). (A) is inappropriate because the carbon dioxide level is
low, not the oxygen level. (B and D) are not specific for this situation.

6.D. Rationale: 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. (D) is closest to the time when parents would be ready for such classes. (A, B, and C) are
not the best times during a 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.

7.D. Rationale: This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body
temperature. The nurse should first determine the serum glucose level (D). (A) is an intervention for a
lethargic infant. (B) should be done based on the temperature, but first the glucose level should be
obtained. (C) helps raise the blood sugar, but first the nurse should determine the glucose level.

8.A. Rationale: 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 (A). (B) is incorrect because alcohol can immediately enter the breast milk. Nicotine is
transferred to the infant in breast milk (C). Taking a warm shower will stimulate the production of milk,
which will be more painful after breastfeedings (D).
9.C.Rationale: Checking the blood pressure for an elevation (C) is the best instruction to give at this
time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a
sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension.
Additional data are needed to confirm an emergency situation as described in (A). (B and D) ignore the
threat to client safety posed by a significant increase in blood pressure.

10.D. Rationale: The health care provider should be notified (D) when a client practices pica (craving
for and consumption of nonfood substances). The practice of pica may displace more nutritious foods
from the diet, and the client should be evaluated for anemia. (A) is overreacting and may be perceived
as punishment by the patient. (B) allows the dietary department to customize the client's tray but fails
to address physiologic problems associated with not consuming nutritious foods in pregnancy. (C) is
judgmental and blocks further communication.

11.A,C,E Rationale: (A and C) are signs of a possible miscarriage. Cramping with bright red bleeding
is a sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the breast is a
sign that hormone levels have declined and that a miscarriage is imminent. (E) could be a sign of an
ectopic pregnancy, which could be fatal if not discovered in time before rupture. (B and D) are normal
signs during the first trimester of a pregnancy.

12.C. Rationale: Recent studies have indicated that air drying or plain water application may be equal
to or more effective than alcohol in the cord healing process (C). (A, B, and D) are incorrect because
they promote moisture and increase the potential for infection.

13.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.

14.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.

15.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.

16.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).

17.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.

18.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.

19.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.
20.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.