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ATI Review
Lucy Van Otterloo, RN, MSN
Which hormone is directly responsible for
ovulation?
A.
 B.
 C.
 D.

Estrogen
Progesterone
Luteinizing hormone (LH)
Follicle-stimulating hormone (FSH)

C. LH initiates the ovulation process in
the ovary and works with FSH to stimulate
the growing follicle. Once the follicle
ruptures, LH continues to stimulate the
ruptured follicle to produce estrogen,
which stimulates the surge of LH from the
anterior pituitary, beginning the process
again.
The physician prescribes the fertility drugs
menotropins (Pergonal) and chorionic gonadotropin
(Pregnyl). The nurse should instruct the client that
the combined action of these drugs is to:
A. Stimulate and promote ovulation
 B. Prepare the uterus for implantation
 C. Prevent endometriosis in the fallopian
tubes
 D. Facilitate patency of the fallopian
tubes


A. Mentropins (Pergonal) stimulates
maturation of the ovum and chorionic
gonadotropin (Pregnyl) stimulates
ovulation, thus increasing the woman’s
chance for fertilization and implantation.
The time of ovulation can be determined by taking
the basal temperature. During ovulation the basal
temperature:
A.
 B.
 C.
 D.

Drops markedly
Drops slightly and then rises
Rises suddenly and then falls
Rises markedly and remains high

B. As ovulation approaches, there may be
a drop in the basal temperature because
of an increased production of estrogen;
when ovulation occurs, there will be a rise
in the basal temperature because of an
increased production of progesterone.
A couple who recently emigrated from Israel are
concerned about a genetic disease that is prevalent
among Jewish people and speak to the clinic nurse.
The nurse recommends that they go for a genetic
blood test to determine the possibility of any of
their children being born with:
A.
 B.
 C.
 D.

PKU
Cystic fibrosis
Cooley’s anemia
Tay-Sachs disease

D. This is a genetic disorder transmitted
as an autosomal recessive trait that occurs
primarily among Ashkenazi Jews.
After the first 3 months of pregnancy, the chief
source of estrogen and progesterone is the:
A.
 B.
 C.
 D.

Placenta
Adrenal cortex
Corpus luteum
Anterior hypophysis

A. When placental formation is complete,
around the 12th week of pregnancy, it
produces progesterone and estrogen
During prenatal development, fetal weight
gain is greatest in the:
A.
 B.
 C.
 D.

First trimester
Third trimester
Second trimester
Implantation period

B. This is the period in which the fetus
stores deposits of fat.
In dealing with a couple identified as having
an infertility problem, the nurse knows that:
A. Infertility is usually psychologic in
origin
 B. Infertility and sterility are essentially
the same problem
 C. The couple have been unable to have
a child after trying for a year
 D. One partner has a problem that makes
that person unable to have children


C. Infertility is the inability of a couple to
conceive after at least 1 year of adequate
exposure to the possibility of pregnancy.
A test commonly used to determine the number,
motility and activity of sperm is the:
A.
 B.
 C.
 D.

Rubin test
Friedman test
Postcoital test
Papanicolaou test

C. This test determines the number and
condition of sperm aspirated from the
cervix within 2 hours after intercourse
Which of the following is considered a
positive sign of pregnancy?
A.
 B.
 C.
 D.

A missed menstrual period
Abdominal enlargement
Fetal movement felt by provider
Positive pregnancy test

C. Positive pregnancy signs include fetal
heart sounds, fetal movement palpated by
an experienced examiner, and
visualization of fetus by ultrasound. All
other signs are presumptive or probable
and may indicate other conditions.
The nurse is aware that an adaptation of
pregnancy is an increased blood supply to the
pelvic region that results in a purplish discoloration
of the vaginal mucosa, which is known as:
A.
 B.
 C.
 D.

Ladin’s sign
Hegar’s sign
Goodell’s sign
Chadwick’s sign

D. A purplish color results from increased
vascularity and blood vessel engorgement
of the vagina. Ladin’s sign is increased
vascularity of the cervix. Hegar’s sign is
softening of the lower uterine segment.
Goodell’s sign is softening of the cervix.
The uterus rises out of the pelvis and
becomes an abdominal organ at about the
A.
 B.
 C.
 D.

10th week of pregnancy
8th week of pregnancy
12th week of pregnancy
18th week of pregnancy

C. By this time the fetus and placenta
have grown, expanding the size of the
uterus. The extended uterus expands into
the abdominal cavity.
The nurse plans teaching for a client
scheduled for amniocentesis. It is MOST
important for the nurse to include which of
the following statements?
A. The test assesses gestational age using the
biparietal circumference
 B. The test determines the gender of the baby
 C. The test is used to detect possible birth
defects
 D. The test should not be completed if you have
a hx. of miscarriages


C. Completed to determine genetic
disorders or neural tube defects; takes 2-4
weeks to obtain results. BPD is
determined by sonogram. Gender can be
done but that is not the primary reason.
Previous miscarriage is not a
contraindication. Procedure may cause
preterm labor.
A pregnant client works at a computer entering
data. This would necessarily have implications for
her plan of care during pregnancy. The nurse
should recommend that the client:
A. Try to walk about every few hours during the
workday
 B. Ask for time in the morning and afternoon to
elevate her legs
 C. Tell her employer she cannot work beyond
the second trimester
 D. Ask for time in the morning and afternoon to
obtain nourishment


A. Maintaining the sitting position for
prolonged periods may constrict the
vessels of the legs, particularly in the
popliteal spaces, as well as diminish
venous return. Walking contracts the
muscles of the legs, which apply gentle
pressure to the veins in the legs, thus
promoting venus return.
A client is concerned about gaining weight during
pregnancy. The nurse explains that the largest
part of weight gain during pregnancy is because
of:
A.
 B.
 C.
 D.

The fetus
Fluid retention
Metabolic alterations
Increased blood volume

A. The average weight gain during
pregnancy is 25 to 35 lbs; of this, the
fetus accounts for 7 to 8 lbs. or
approximately 30% of weight gain
Amniotic fluid increases during pregnancy. The
nurse is aware that one of the major functions of
amniotic fluid and its increase during pregnancy is
to:
A.
 B.
 C.
 D.

Provide antibodies to the fetus
Increase nutrients to the fetus
Maintain fetal temperature stability
Ease passage during delivery

C. The major functions of amniotic fluid
are to provide the fetus with a protective
cushion, keep the fetus at an even
temperature, and aid in dilation of the
cervix.
Physiologic anemia during pregnancy is a
result of:
A. Decreased dietary intake of iron
 B. Increased plasma volume of the
mother
 C. Decreased erythropoiesis after the first
trimester
 D. Increased detoxification demands on
the mother’s liver


B. There is a 30% to 50% increase in
maternal plasma volume at the end of the
first trimester, leading to a decrease in the
concentration of hemoglobin and
erythrocytes.
In the 12th week of gestation, a client completely
expels the products of conception. Because the
client is Rh-negative, the nurse must:
A. Administer RhoGAM within 72 hours
 B. Make certain she receives RhoGAM on
her first clinic visit
 C. Not give RhoGAM since it is not the
birth of a stillborn
 D. Make certain the client does not
receive RhoGAM since the gestation only
lasted 12 weeks


A. It is given within 72 hours postpartum
if the client has not been sensitized
previously.
A client at 12 weeks gestation comes to the
prenatal clinic complaining of severe nausea and
vomiting. The nurse suspects that this client has
hyperemesis gravidarum and knows that this is
frequently associated with:
A. Excessive amniotic fluid
 B. A GI history of cholecystitis
 C. High levels of chorionic gonadotropin
 D. Slowed secretion of free hydrochloric
acid


B. High levels of chorionic gonadotropin
frequently are associated with severe
vomiting of pregnancy; especially in the
presence of hydatidiform mole
(gestational trophoblastic disease) and
often in twin pregnancy
The care of a client with placenta previa
includes:
A. Vital signs at least once per shift
 B. A tap-water enema before delivery
 C. Observation and recording of the
bleeding
 D. Limited ambulation until the bleeding
stops


C. Continued bleeding can put the fetus
in jeopardy. The client should be
restricted to complete bed rest until
bleeding stops. Vital signs should be
recorded every 4 hours until bleeding
stops.
A pregnant client develops thrombophlebitis of the
left leg and is admitted to the hospital for bedrest
and anticoagulant therapy. The anticoagulant the
nurse should expect to administer is:
A.
 B.
 C.
 D.

Heparin
Dicumerol
Diphenadione (Dipaxin)
Wafarin (Coumadin)

A. Heparin is used because its molecular
size is too large to pass the placental
barrier. The other three drugs can pass
the placental barrier and cause
hemorrhage in the fetus.
A client who is 6 months pregnant comes to the
prenatal clinic complaining of painful urination,
flank tenderness, and hematuria. A diagnosis of
pyelonephritis is made. An important nursing
intervention for the client at this time is:
A. Limiting fluid intake
 B. Examining the urine for protein
 C. Observing for signs of preterm labor
 D. Maintaining her on a 2-gram sodium
diet


C. Pyelonephritis often causes preterm
labor, leading to increased neonatal
morbidity and mortality.
When taking the health history, the nurse correctly
identifies that a client is at risk for developing a
hypertensive disorder of pregnancy when it is
determined that the client:
A. Is 31 years old
 B. Is an obese primigravida
 C. Has had six previous pregnancies
 D. Has been on oral contraceptives within
3 months of pregnancy


B. First pregnancy and obesity are both
documented risk factors. The risk age for
a hypertensive disorder of pregnancy is
under 20 and over 35 years of age.
Multigravidity is not a risk factor and
neither is oral contraceptive use.
A pregnant client asks the clinic nurse how
smoking will affect her baby. The nurse’s
response reflects the knowledge that:
A. The placenta is permeable to specific
substances
 B. Smoking relieves tension and the fetus
responds accordingly
 C. Vasoconstriction will affect both fetal
and maternal blood vessels
 D. Fetal and maternal circulation are
separated by the placental barrier


C. Cigarette smoking or continued
exposure to secondary smoke causes both
maternal and fetal vasoconstriction,
resulting in fetal growth restriction and
increased fetal and infant mortality
The nurse auscultates the abdomen of a 38 weeks
gestation to determine fetal heart rate. If the fetal
heartbeat is located in the right lower quadrant,
which of the following is MOST likely the
presenting part?
A.
 B.
 C.
 D.

Shoulder
Head
Feet
Buttocks

B. With vertex presentation, ROA. Feet
(footling) or buttocks (frank) breech would
hear FHT in upper quadrant. Shoulder is
uncommon, only 1% of births.
After doing Leopold’s maneuvers on a laboring
cient, the nurse determines that the fetus in in the
ROP position. To best auscultate the fetal heart
tones, the Doppler is placed:
A.
 B.
 C.
 D.

Above the umbilicus in the midline
Above the umbilicus on the left side
Below the umbilicus on the right side
Below the umbilicus near the left groin

C. Fetal heart tones are best auscultated
through the fetal back; because the
position is ROP, the back would be below
the umbilicus and on the right side
When caring for a woman with a positive
contraction stress test, the nurse should be most
concerned with observing her for signs and
symptoms of:
A.
 B.
 C.
 D.

Preeclampsia
Placenta previa
Imminent pretem delivery
Uteroplacental insufficiency

D. A positive CST indicates a
compromised fetal heart rate during
contractions, which is associated with
uteroplacental insufficiency
A laboring woman’s uterine contractions are
being internally monitored. When
evaluating the monitor tracing, which of the
following findings would be a source of
concern and require further assessment?
A. Frequency every 2.5 to 3 minutes
 B. Duration of 80-85 seconds
 C. Intensity of 85-90 mmHg
 D. Resting pressure of 20-25 mmHg


Correct answer: D
– The resting pressure should be 15 mmHg or
less
The nurse caring for women in labor should
be aware of signs characterizing reassuring
FHR patterns. A reassuring sign would be:




A. Moderate baseline variability
B. Average baseline FHR of 90-110 beats/min
C. Transient episodic deceleration with movement
D. Late decelerations approx. every 3-4 contractions

Correct answer: A
– The baseline rate should be 110-160
beats/min; accelerations should occur with
featl movement; no late deceleration pattern
of any magnitude is reassuring
A laboring woman’s temperature is elevated
as a result of an upper respiratory infection.
The FHR pattern that reflects maternal fever
would be:
A. Diminished variability
 B. Variable decelerations
 C. Tachycardia
 D. Early decelerations


Correct answer: C
– The FHR increases as the maternal core body
temperature elevates, so tachycardia would
be the pattern exhibited. It is often a clue of
intrauterine infection because maternal fever
is often the first sign.
A nulliparous woman is in the active phase of labor and her
cervix has progressed to 6 cm dilation. The nurse caring
for this woman evaluates the external monitor tracing and
notes the following: decrease in FHR shortly after onset of
several contractions, returning to baseline rate by the end
of the contractions; shape is uniform. Based on these
finding, the nurse should:




A. Change the woman’s position to her left side
B. Document the finding on the woman’s chart
C. Notify the physician
D. Perform a vaginal examination to check for cord
prolapse

Correct answer: B
– The pattern described is an early deceleration
pattern, which is considered to be benign,
reassuring, and requiring no action other than
documentation of the finding.
The nurse has auscultated a fetal heart rate
of 80. What should be the nurse’s initial
action?
A. Position the client on her left side
 B. Administer oxygen at 5L/minute
 C. Notify the physician or nurse-midwife
 D. Check the maternal pulse


Correct answer: D
– Key word is auscultated – the nurse may be
hearing the maternal blood flow through the
uterus and not the fetal heart rate.
At about 5 cm. dilation, a laboring client receives
medication for pain. The nurse is aware that one
of the medications given to women in labor that
could cause respiratory depression of the newborn
is:
A.
 B.
 C.
 D.

Scopolamine
Promazine
Meperidine (Demerol)
Promethazine (Phergan)

C. Respiratory depression occurs with the
use of meperidine and produces
significant depression of the infant at birth
if circulating levels are high at time of
birth.
The nurse in the birthing suite has just admitted
the following four clients. Which one of these
clients should the nurse prepare for cesarean
section?
A. Multipara with a shoulder presentation
 B. Multipara with a documented station
of “floating”
 C. Primigravida with a fetus presenting in
occiput posterior
 D. Primigravida with twin gestation with
lower most twin in vertex position.


A. Multipara with a shoulder presentation
is indicative of a transverse lie; this
indicates the need for a cesarean section.
A client is admitted to the hospital in active labor.
After an amniotomy the nurse would expect:
A.
 B.
 C.
 D.

Increased fetal heart rate
Diminished bloody show
Less discomfort with contractions
Progressive dilation and effacement

D. Artificial rupture of membranes
(AROM) allows for more effective pressure
of the fetal head on the cervix, enhancing
dilation and effacement.
During a client’s labor, the fetus’ head is at station
+1. This indicates that the presenting part is:
A.
 B.
 C.
 D.

On the perineum
High in the false pelvis
Slightly below the ischial spines
Slightly above the ischial spines

C. The term station is used to indicate the
location of the presenting part. The level
of the tip of the ischial spines is
considered to be zero. The position of the
bony prominence of the fetal head is
described in centimeters – minus (above
the spines) or plus (below the spines)
A client is admitted to the birthing suite in early
active labor. The priority nursing intervention on
admission of this client would be:
A. Auscultating the fetal heart
 B. Taking an obstetric history
 C. Asking the client when she ate last
 D. Ascertaining whether the membranes
are ruptured


A. Determining fetal well-being
supersedes all other measures. If the
fetal heart rate is absent or persistently
decelerating, immediate intervention is
required.
A client is admitted to the labor unit in the latent
phase of the first stage of labor, with contractions
lasting 20 seconds. In assessing the client’s
emotional status, the nurse would anticipate that
the client will be:
A.
 B.
 C.
 D.

Serious
Happy
Irritable
panicky

B. In the first stage of labor when
complications are absent and contractions
are weak, the client experiences minimal
discomfort. She is usually excited, happy,
and eager. As labor progresses she
becomes more serious and is more likely
to become irritable, tired, and sometimes
panicky.
A multigravida client is admitted in active labor.
She is yelling, “Hurry! Hurry! The baby is coming!”
What priority action by the nurse is indicated?
A.
 B.
 C.
 D.

Check the fetal heart tones
Time the contraction interval
Determine the presenting part
Do a vaginal examination

D. A vaginal examination should be
performed to determine the presenting
part so preparation can be made for
delivery.
A nurse is assessing a client in labor and finds that
her contractions are lasting 60 seconds every 4
minutes and that her cervix is 6 cm dilated. The
nurse would document that the client is in what
stage of labor?
A.
 B.
 C.
 D.

Active phase
Early phase
Latent phase
Transitional phase

A. During active labor the contractions
begin to last longer and are occurring
more frequently. Cervical dilation occurs
rapidly during active labor and usually
progresses from 4 to 7 cm.
The nurse teaches a pregnant woman to avoid
lying on her back during labor. The nurse has
based this statement on the knowledge that the
supine position can:
A. Unduly prolong labor
 B. Cause decreased placental perfusion
 C. Lead to transient episodes of
hypertension
 D. Interfere with free movement of the
coccyx


B. This is because of impedance of
venous return by the gravid uterus, which
causes hypotension and decreased
systemic perfusion
The husband of a client who is in the transitional phase of
labor becomes very tense and nervous during this period
and asks the nurse, “Do you think it is best for me to leave,
since I don’t seem to do my wife much good?” The most
appropriate response by the nurse would be:
A. “This is the time your wife needs you. Don’t run out
on her now.”
 B. “This is hard for you. Let me try to help you coach
her during this difficult phase.”
 C. “I know this is hard for you. Why don’t you go have
a cup of coffee and relax and come back later if you feel
like.”
 D. “If you feel that way, you’d best go out and sit in the
waiting room for a while because you may transmit your
anxiety to your wife.”


B. Both the father and the mother need
additional support during the transitional
stage of labor
A client who was admitted in active labor has only
progressed from 2 cm to 3 cm in 8 hours. She is
diagnosed as having hypotonic dystocia and is
given oxytocin to augment her contractions. The
most important aspect of nursing at this time is:
A. Monitoring the FHR
 B. Checking the perineum for bulging
 C. Preparing for an emergency cesarean
birth
 D. Timing and recording length of
contractions


D. The oxytocic effect of Pitocin increases
the intensity, duration and frequency of
contractions; prolonged contractions will
jeopardize the safety of the fetus and
necessitate discontinuing the drug
An expectant couple asks the nurse about the
cause of low back pain in labor. The nurse replies
that this pain occurs most when the position of the
fetus is:
A.
 B.
 C.
 D.

Breech
Transverse
Occiput anterior
Occiput posterior

D. A persistent occiput posterior position
causes intense back pain because of fetal
compression of the sacral nerves.
A client is 39 weeks pregnant and in labor. Her
physician has informed her that she will have to
have a cesarean birth because she has:
A.
 B.
 C.
 D.

Gonorrhea
Chlamydia
Chronic hepatitis
Active genital herpes

D. Once the membranes have ruptured,
the active herpes infection ascends and
can infect the fetus; since herpes does not
cross the placenta, a cesarean birth can
decrease transfer of the virus to the fetus
The nurse working in a triage clinic should return
which of the following client’s telephone messages
first?
A. 37 weeks of gestation with SOB
 B. 10 weeks of gestation with breast
tenderness
 C. 35 weeks of gestation with feet that
well at the end of the day
 D. 12 weeks of gestation with darkening
blotches of skin over her cheekbones


A. The first call should be made to the
woman who is complaining of dyspnea. A
woman who is in her 37th week can have
dyspnea from the term gravid uterus
pushing up on her diaphragm, but she
may also be experiencing a respiratory
emergency such as pulmonary embolus.
When a client is admitted to the labor suite with a
BP of 130/90, 2+ proteinuria, and edema of the
hands and face, the nurse should ask the client
about the presence of:
A. Constipation, edema, visual problems,
headache
 B. Visual disturbances, headaches, constipation,
bleeding
 C. Leakage of fluid, bleeding, edema, pain in
the abdomen
 D. Headache, visual disturbances, edema, pain
in the abdomen


D. To ascertain the severity of
preeclampsia, these are the signs that
must be assessed.
The nurse is caring for a woman at 37 weeks
gestation. The nurse would be MOST concerned
by which of the following findings?
A.
 B.
 C.
 D.

The patient c/o right quadrant pain
BP 150/95
4+ proteinuria
3+ pitting edema

A. Indicates impaired liver function, sign
of impending eclampsia. B/P greater than
160/110 considered severe preeclampsia,
4+ proteinuria indicates severe
preeclampsia, and 3+ pitting edema is
indicative of mild preeclampsia
A client is on magnesium sulfate therapy for
severe preeclampsia. The nurse must be alert for
the first sign of an excessive blood magnesium
level, which is:
A.
 B.
 C.
 D.

Disturbance in sensorium
Increase in respiratory rate
Development of cardiac dysrhythmia
Disappearance of the knee-jerk reflex

D. Magnesium sulfate has a CNS
depressant effect therefore, toxic levels
will be reflected in decreased respiration
and the absence of the knee-jerk reflex.
Cardiac dysrhythmia occurs with increased
potassium not magnesium sulfate.
A pregnant client is receiving magnesium sulfate
for eclampsia. Which medication should the nurse
have available as an antidote for possible toxicity?
A.
 B.
 C.
 D.

Vitamin K
Calcium gluconate
Naloxone (Narcan)
Diazepam (Valium)

B. Calcium gluconate is the antagonist to
magnesium sulfate that would be ordered
if toxicity occurs.
A 26 year-old woman is brought to the emergency room
complaining of severe left lower quadrant pain. She tells
the nurse that she performed a home pregnancy test and
believes she is 8 weeks pregnant. On admission the
patient’s vital signs are pulse 90, BP 110/70, respirations
20. A half-hour later her vital signs are pulse 120, BP
86/50, respirations 26. The nurse interprets the change in
the patient’s vital signs to mean that:
A.
 B.
 C.
 D.

The patient’s pain may have increased
The patient may be bleeding internally
The patient may be frightened
The patient may have an infection

B. Decreased BP equals decreased
intravascular volume; shock. BP increases
with pain and fear. Infection usually won’t
change BP unless in septic shock.
The nurse is caring for clients in the labor and
delivery unit. The nurse notes that a client’s
membranes have ruptured and the amniotic fluid is
meconium-stained. The nurse determines that
there is no prolapsed cord. Which of the following
actions should the nurse take NEXT?
A. Contact the health care provider
 B. Assess fetal heart tones
 C. Start an intravenous line
 D. Obtain the client’s pulse and blood
pressure


B. Meconium-stained amniotic fluid may
be an ominous sign; assess for
nonreassuring fetal heart tone patternsfetal bradycardia, irregular FHR, late,
severe variables and prolonged
deceleration patterns; if fetal distress, turn
client to left side, give O2 and start IV.
Abruptio placentae is most likely to occur in
a woman with:
A.
 B.
 C.
 D.

Cardiac disease
Hyperthyroidism
Gestational hypertension
Cephalopelvic disproportion

C. Hypertension during pregnancy leads
to vasospasms; this in turn causes the
placenta to tear away from the uterine
wall.
The nurse cares for an 18 year-old woman in the
labor unit. During the transitional phase of labor
the umbilical cord becomes prolapsed. The nurse
should place the patient in which of the following
positions?
A.
 B.
 C.
 D.

Lithotomy
Side-lying
Semi-fowlers
Trendelenberg

D. Gravity relieves pressure on cord from
fetal head. Or put finder against
presenting part and shift weight off cord.
Lithotomy used for examination of vagina
or rectum. Side-lying removes weight
from vena cava, does not help with
prolapsed cord. Semi-fowlers aggravates
prolapsed cord.
Despite medication, a client’s preterm labor
continues, her cervix dilates, and birth appears
inevitable. The nurse understands the infant’s
chance of extrauterine survival may improve if the
physician orders:
A.
 B.
 C.
 D.

Ampicillin by piggyback
Dexamethasone by infusion
An immediate cesarean delivery
An intrauterine exchange transfusion

B. Steroids are given for a short period
before delivery; by some obscure
mechanism, they help to mature the fetus’
lungs
A client experiences a normal newborn delivery.
After the placenta is delivered, the physician orders
a medication to be added to the IV solution.
Which medication is the nurse most likely
administering at this time?
A.
 B.
 C.
 D.

Penicillin
Atropine
Oxytocin
AquaMEPHYTON

C. Oxytocin (Pitocin) stimulates uterine
contractions. When oxytocin is given after
delivery of the placenta, the contractions
stimulated by the drug help control
bleeding.
During the postpartum period after a cesarean
birth, the nurse examines the client and identifies
the presence of lochia serosa and feels the fundus
four fingerbreadths below the umbilicus. This
indicates that the time elapsed is:
A.
 B.
 C.
 D.

1 to 3 days postpartum
4 to 5 days postpartum
6 to 7 days postpartum
8 to 9 days postpartum

B. The fundus descends one
fingerbreadth per day from the first
postpartum day; lochia serosa begins to
flow on the fifth day.
A client after a vaginal delivery is at risk for
postpartum hemorrhage. Nursing education to
prevent postpartum hemorrhage is based on the
knowledge that priority explanation for the cause is:
A.
 B.
 C.
 D.

Laceration of the perineal area
Uterine rupture
High parity
Uterine atony

D. About 75% of all hemorrhages are due
to uterine atony, which is the lack of
uterine tone. Laceration of the perineal
area, uterine rupture and high parity are
other causes of hemorrhage, but they are
not as likely.
The nurse working on the postpartum unit should
encourage clients to ambulate early to:
A.
 B.
 C.
 D.

Promote respirations
Increase the tone of the bladder
Maintain tone of abdominal muscles
Increase peripheral vasomotor activity

D. There is extensive activation of the
blood clotting factor after delivery; this,
together with immobility, trauma or
sepsis, encourages thromboembolization,
which can be limited through activity.
Since having a baby by cesarean section, a client
has walked to the nursery numerous times to see
her baby each day. Two days postpartum, the
client complains of pain in the right leg. The
nurse’s initial response should be to:
A. Apply hot soaks
 B. Massage the affected limb
 C. Encourage ambulation and exercise
 D. Maintain bed rest and notify the
physician


D. Although thrombophlebitis is
suspected, before a definitive diagnosis
the client should be confined to bed so
that further complications may be
avoided.
A nurse assesses a client who delivered 1 hour
ago. The fundus is firm and two fingerbreadths
below the umbilicus, and the lochia is bright red.
The client complains of having chills. What would
the nurse recognize based on this assessment?
A.
 B.
 C.
 D.

An inverted uterus
Acute hemorrhage
A normal postpartum response
The early stage of hypovolemic shock

C. After delivery, the uterus continues to
contract and reduce in size. The client
should be covered and kept warm because
chills are a normal process immediately
after delivery. Red, bloody lochia is
normal at this time as well.
When is a client most likely to experience
postpartum depression?
A.
 B.
 C.
 D.

Within the first 48 hours
Within the first 72 hours
By the fourth or fifth day
During the second week

C. Elevated hormone levels begin to fall
by the fourth or fifth day after delivery.
This shift in hormones causes the
depressed mood. Depending on their
coping ability, some women may
experience more severe depression than
others.
When checking a client’s fundus on the second
postpartum day, the nurse observes that the
fundus is above the umbilicus and displaced to the
right. The nurse evaluates that the client probably
has:
A.
 B.
 C.
 D.

A slow rate of involution
A full, overdistended bladder
Retained placental fragments
Overstretched uterine ligaments

B. A distended bladder will displace the
fundus upward and laterally
A postpartum client experiences a temperature
spike of 101 F (38.3 C) 12 hours after delivery.
What would the nurse suspect?
A.
 B.
 C.
 D.

Infection
Hemorrhage
Dehydration
A normal response

C. Fever within the first 24 hours
postpartum indicates dehydration. After
24 hours, however, it is indicative of a
puerperal infection.
During early postpartum, when assessing a client’s
episiotomy, the nurse identifies edema with severe
ecchymosis. Also, the client is complaining of
severe perineal and rectal pressure. The fundus is
firm, and there is no lochia. The client’s vital signs
are T 99 F, P 108, R 20, BP 105/60. This
assessment most likely indicates a:
A.
 B.
 C.
 D.

Urinary infection
Uterine infection
Vaginal hematoma
Postpartum hemorrhage

C. These are classic signs and symptoms
of a vaginal hematoma
The nurse identifies that a woman needs further
teaching about breastfeeding her newborn when
she:
A. Leans forward and puts her breast into
the infant’s mouth
 B. Holds the infant level with her breast
and in a side-lying position
 C. Touches her nipple to the infant’s lips
when beginning the feeding
 D. Puts her finger in the infant’s mouth to
break the suction when switching breasts


A. When the breast is pushed into the
infant’s mouth a typical response is for the
mouth to close too soon, resulting in
inadequate latching-on
The nurse should plan to teach a recently
delivered client who is formula-feeding her infant
to minimize breast discomfort by:
A. Gently applying cocoa butter
 B. Manually expressing colostrum
 C. Applying covered ice packs to her
breasts
 D. Placing warm, wet washcloths on her
nipples


C. Covered ice packs promote comfort by
decreasing vasocongestion
A client with mastitis is concerned about
breastfeeding her newborn infant. Which
recommendation should the nurse provide to the
client?
A. Stop breastfeeding until after completing
antibiotics
 B. Supplement feeding with forumla until the
infection resolves
 C. Continue to breastfeed because mastitis will
not infect the infant
 D. Do not use analgesics because they may be
passed to the newborn through breast milk


C. The client with mastitis should be
encouraged to continue breastfeeding
while taking antibiotics for the infection.
No supplemental feedings is necessary
because breastfeeding does not need to
be altered and actually encourage
resolution of the infection. Analgesics are
safe and should be used as needed.
A nurse makes all the following observations of a
mother who is interacting with her newborn 8
hours after delivery. Which observation would
alert the nurse to a potential problem with the
maternal-infant attachment?
A. The mother speaks to the newborn during
crying spells.
 B. The mother undresses the newborn during a
diaper change.
 C. The mother takes the newborn with her to
the baby care classes.
 D. The mother consistently engages eye contact
with the father as she feeds the newborn.


D. Maternal-infant bonding is evidenced
by the mother-infant interactions. This
mother seems focused primarily on her
husband, which may indicate a problem
with bonding.
During which phase of maternal
psychological adaptation is it best for a
nurse to teach a postpartum client about
caring for a newborn infant?
A.
 B.
 C.
 D.

Taking-in
Letting-go
Taking-hold
Letting-down

C. Beginning after the completion of the
taking-in phase, the taking-hold phase
lasts about 7 days. During this phase, the
client is concerned with her need to
resume control of all facets of her life in a
competent manner. At this time, she is
ready to learn self-care and infant-care
skills.
A 28 year-old woman has just delivered her
first child, a boy weighing 6 lbs. and 2 oz.
The Apgar scores at one and five minutes
are 8 and 9. The nurse understands that:

A. An isolette should be ready in the nursery for close observation
of this infant

B. The newborn is making an optimal transition to extrauterine life

C. The parents will need emotional support to deal with a less than
perfect child

D. High Apgar scores correlate well with future emotional and
intellectual development

B. Good Apgar. Nursery care is not
needed and there is no relationship
between Apgar and future
emotional/intellectual development.
An infant born in the 36th week of gestation
weighs 4 lbs 9 oz (2062 gms) and has an Apgar of
7/9. On admission to the nursery, it would be
unnecessary for the nurse to:
A.
 B.
 C.
 D.

Record vital signs
Administer oxygen
Support body temperature
Evaluate the newborn’s status

B. The baby’s Apgar score (7/9) does not
indicate a need for oxygen.
At 10 hours of age an infant has a large amount of
mucus and becomes slightly cyanotic. The nurse
should first:
A.
 B.
 C.
 D.

Insert a Levin tube
Give the infant oxygen
Suction the mucus as needed
Note the incident on the chart

C. To maintain a patent airway and
promote respiration and gaseous
exchange, mucus must be removed.
When observing a newborn for signs of pathologic
jaundice, the nurse should be alert for:
A. Muscular irritability at birth
 B. Neurologic signs during the first 24
hours
 C. The appearance of jaundice during the
first 24 hours
 D. Jaundice developing between the
second and fourth day of life


C. Development of jaundice in the first 24
hours indicates hemolytic disease of the
newborn requiring immediate medical
investigation. Jaundice occurring between
48 and 72 hours after birth is a
consequence of the normal physiologic
breakdown of fetal RBCs and immaturity
of the liver.
Which of the following observations of an 8 lb 4 oz
newborn boy, if made by the nurse, would require
an intervention?
A. The infant’s respirations are 36,
shallow and irregular in rate, rhythm, and
depth
 B. Rapid pulsations are visible in the fifth
intercostal space, left midclavicular line
 C. The infant’s axillary temperature is
96.2 F (35.6 C)
 D. There is asynchronous spontaneous
movement of the infant’s extremities


C. Subnormal temperature indicates
prematurity, infection, low environment
temperature, inadequate clothing, and
dehydration.
A newborn is diagnosed as having Erb’s Palsy.
The nurse is aware that this problem is caused by:
A. A disease acquired in utero
 B. An X-linked inheritance pattern
 C. A tumor arising from muscle tissue
 D. An injury to the brachial plexus during
birth


D. The brachial plexus is injured by
excessive pressure during a difficult
delivery requiring the use of forceps or
during a breech delivery; it is considered a
birth injury and not related to genetic
factors or disease.
Asymmetric Moro reflexes are frequently
associated with:
A. Down’s syndrome
 B. Cranial nerve damage
 C. Cerebral or cerebellar injuries
 D. Brachial plexus, clavicle or humerus
injuries


D. Injury to the brachial plexus, clavicle,
or humerus prevents abduction and
adduction movements of an upper
extremity.
A newborn has asymmetric gluteal folds.
The nurse suspects:
A.
 B.
 C.
 D.

CNS damage
Dysplasia of hip
An inguinal hernia
Peripheral nervous system damage

B. Asymmetric gluteal and leg folds
indicates hip dysplasia. Gluteal folds are
elevated on the affected side.
A nurse is assessing a newborn and recognizes
which of the following as a sign of postmaturity?
A.
 B.
 C.
 D.

Smooth, supple skin
Long, brittle fingernails
Well-developed eyebrows
Creases in the soles of the feet

B. The fingernails begin to form around
12 weeks’ gestation. By 39 to 40 weeks,
the nails have covered the nailbeds. After
40 weeks, the nails begin to extend and
have a long appearance.
Which finding would be manifested in an
infant with a myelomeningocele?
A. Clubbed feet and muscle spasms in the
legs and arms.
 B. Obstruction of bowel and impaired
bladder function
 C. Spastic movement of upper and lower
extremities
 D. Impaired bowel and bladder function
and paralysis of the legs.


D. The nerves of the cauda equina are
involved with a myelomeningocele, which
results in lower extremity paralysis.
Innervation to the anal sphincter and the
bladder is decreased, causing
incontinence. Bowel function may be
affected, but there is no obstruction and
the upper extremities are not affected.
A new mother expresses concern over strabismus
in her infant. What would the nurse explain to the
mother regarding this condition?
A.
 B.
 C.
 D.

It is a normal finding in newborns
This may be a permanent defect
It will require corrective surgery
It will result in imparied vision

A. Muscle control of the eyes in the
newborn is undeveloped, resulting in
temporary strabismus, or a cross-eyed
appearance. This is considered normal in
the newborn.
Which observation in a 24 hour-old newborn
should be reported to the physician immediately?
A. Blotchy, mottled skin
 B. Positive Babinski reflex
 C. Tremors and spasms of all extremities
 D. High-pitched crying and arching of the
back


D. A high-pitched cry and arching of the
back are cardinal signs of a neurological
problem.