61. Ans. C Excess, not insufficient, amniotic fluid may occur in a pregnant client with gestational diabetes.
A.B, & D Possible consequences of uncontrolled gestational diabetes.
62. Ans. C Fundal height measurement correlates directly to the number of weeks of gestation. At 24 weeks gestration, the desired measurement from the symphysis pubis to the fundus is 24 cm.
63. Ans. A Vertex presentation (flexion of the head) is the optimal presentation for passage through the birth canal.
B. unacceptable fetal position for vaginal birth and requires CS delivery.
C. Can be a difficult vaginal delivery
D. Can make it difficult for the fetal head to pass under the maternal symphysis pubis bone.
64. Ans. B. The 2nd stage of labor begins with complete dilation (10cm) and ends with the expulsion of the fetus.
B. 1st stage, is the stage of dilation, divided into 3 distinct phases: latent, active and transition
C. Begins with the birth of the infant and ends to expulsion of placenta
D. The 1st 4 hrs after placental expulsion, in which the client’s body begins the recovery process.
65. Ans. A One of the major adverse effects of epidural administration is hypotension. Option A helps prevent hypotension.
B.C, & D. Not necessary
66. Ans. C Prolonged dyspareunia (painful intercourse) may result when complications such as infection interfere with wound healing.
A. Minimal bleeding
B. Uterus is not affected; no disfigurement
D. There is hormonal fluctuation but not the result of episiotomy.
67. Ans. C In side lying position, cardiac output increase, stroke volume increases, and pulse rate decreases.
A. Supine – Bp can drop severely due to the pressure of the fetus and enlarged uterus on the vena cava, resulting in supine hypotensive or vena caval syndrome.
C, & D Neither sitting nor semi-Fowler’s position increase cardiac output or stroke volume
68. Ans. D. 4th maneuver assesses the descent of the presenting part into the pelvis
A. Determines the shape, size, consistency, and mobility of the form that is found
B. Determines the location of the fetal back and fetal extremities.
C. Reveals what part is presenting above the pelvic inlet.
69. Ans. B The second stage of labor begins at full cervical dilation (10cm) and ends when the infant is born. Crowning is present during this stage as the fetal head, pushed against the perineum , causes the vaginal introitus to open, allowing the fetal scalp to be visible.
A. Begins with true labor contractions and ends with complete cervical dilation.
C. The time the infant is born until the delivery of the placenta
D. From 1st to 4th hour following delivery of the placenta
70. Ans. C STV can be assessed only by using internal fetal monitoring and pressure-sensing catheter that is placed inside the uterine cavity
A. Maybe determined using external or internal fetal monitoring.
B. Observed with external and internal fetal monitoring and shows the fluctuation in FHR 6 to 10 beats occurring 3 to 10 times per minute.
D. Occur in response to contractions and fetal movement and maybe noted using external or internal fetal monitoring
71. Ans. B Renal plasma flow and glomerular filtration are decreased in PIH, so increasing oliguria indicates a worsening condition.
A. BP increases as a result of Increased peripheral resistance
C. Due to protein loss, sodium retention, and a lowered glomerular filtration rate, moving fluid from intravascular to extravascular spaces.
D. Epigastric discomfort maybe due to abdominal edema or pancreatic or hepatic ischemia.
72. Ans. A True labor is indicated by contractions that achieve cervical dilation.
B. C, & D, False labor
73. Ans. D Spontaneous accelerations are symmetrical, uniform increases in FHR. They indicate fetal well being, represent an intact CNS response to fetal movement or stimulation, and are not asstd with contraction.
A. & B Uniform acceleration are symmetric, Occur with contractions, and reflect the shape of the contraction.
C. Deceleration are periodic decreases in FHR from the baseline heart rate.
74. Ans. B Level 2 breathing techniques are useful when cervical dilation is between 4 & 6 cm
A. Useful for early contractions
C. & D For transition stage of labor
75. Ans. A. (Option A) characterizes the 1st stage of labor. Progressive maternal anxiety may occur but does not characterize this stage.
76. Ans. B Aveg. Length is 8 to 9 hrs.
A. C, & D. Labor maybe shorter or longer for the individual client, depending on the circumstance.
77. Ans. C Teaching the client how to express her breasts in a warm shower aids with letdown and will give a temporary relief.
A. Ice can promote comfort by decreasing blood flow (vasoconstriction), numbing, and discouraging further letdown of milk; however, this is followed by a rebound reaction of more letting down once ice is removed.
B. Not effective
D. No longer indicated for lactation supression
78. Ans. A Routine formula supplementation may intervene with establishing an adequate milk volume because decreased stimulation to the mother’s nipples affects hormonal levels and milk production.
B. Have Not been shown to influence milk volume
C. One drink containing alcohol generally tends to relax the mother, facilitating let down, excessive consumption may block letdown of milk to the infant, though supply is not necessarily affected.
D. Like to increase milk production.
79 Ans. C homan’s sign or pain on dorsiflexion may indicate DVT. Post partum women are at increases risk of DVT because of changes in clotting mechanisms to control bleeding at delivery.
A. Not classified as assessment technique
B.& D. Not routinely assessed in postpartum client
80. Ans. C Multiple gestation, breastfeeding, multiparity and conditions that cause overdistention of the uterus will increase the intensity of afterpains.
A & B Not directly asstd with increasing severity of afterpains.
D. Multiparity not primiparity
81. Ans. B. Bleeding is considered heavy when a woman saturates a sanitary pad in 1 hr.
A. Considered excessive when a pad is saturated in 15 minutes
C. Considered moderate, saturates in less than 6” (15cm) of a pad in an hour.
82. Ans. B. Lochia becomes pale pink or brown
A. For lochia rubra
D. Lochia alba
83. Ans. A During the taking in phase, which usually lasts 2 to 3 days, the mother is passive and dependent and expresses her own needs rather than the neonate’s needs.
B. C & D Taking hold phase; last from day 3 to 10th postpartum day.
84. Ans. D. Transitional milk comes after colostrums and usually last until 2 weeks postpartum.
A. Colostrums, a thin yellow fluid released by the breast before and up to 2 weeks postpartum.
B. hind milk, which satisfies the infant’s hunger and promotes weight gain, arrives approximately 10 minutes after each feeding starts.
C. White and thinner than transitional milk and is present after 2 weeks post partum
85. Ans. A A prolonged length of labor places the mother at increased risk of developing an infection.
B.C, & D. Don’t place the mother at risk of developing infection.
86. Ans. A Breast engorgement and dehydration are noninfectious cause of postpartum fevers.
B. & C. Are both postpartum infections.
D. Won’t cause elevation of temperature.
87. Ans. D Post partum bleeding is often the result of subinvolution of the uterus. Retained products of conception or infection often cause subinvolution.
A. & C Can cause immediate postg partum hemorrhage.
D. May also have post partum hemorrhage, if deficiency is not corrected at the time of delivery.
88. Ans. C. This drug produces smooth muscle depressive effect, the uterus should be assessed for uterine atony, which would increase the risk of post partum hemorrhage
A. It is considered more of an anticonvulsant than an antihypertensive
B & D. Not asstd with magnesium sulfate therapy
89. Ans. B. In the early postpartum period, there’sa an increase in glomerular filtration rate and a drop in progesterone levels, which results in rapid diuresis.
A. There should be no urinary urgency, though a woman may feel anxious about voiding
C. There s a minimal change in BP ff. childbirth, and a residual decrease in GI motility.
90. Ans. B “Postpartum blues”- a transient mood alteration that arises during the first 3 weeks postpartum and is typically self-limiting – affects 50 to 80% of post partum clients.
91. Answer C. Increased amounts of protein are needed for growth and maintenance of maternal and fetal tissues.
92. Answer C. In the side lying position are gravid uterus does not impede venous return; cardiac output increases, leading to improved uterine perfusion, uterine contractions and fetal oxygenation
93. Answer B. Nurses can become very blasé about the equipment used during labor and forget that it may be frightening for the lay person
94.ans. (a) Rationale – A person who is brittle diabetic is considered high-risk and will need to be monitored closely. Many obstetricians have expertise in management of medical complications and will recognize situations when the client needs referral to a maternal-fetal medicine specialist.
95. Answer C. Frequent nursing reduces the possibility of engorgement. A 10-minute period provides for complete emptying of the breast
96. Answer C. The nurse should expect an increase in blood volume by as much as 40% above prepregnant levels. During pregnancy, fluid in all body compartment increases
97. Answer A. There is placental transfer antibodies to the fetus. Also, antibodies are transferred from the mother in breast milk which continuous the protection fro a longer period of time, even into the adulthood. Although the neonate is protected by these antibodies, the fetus own antibody system is not functioning at birth
98. Answer C. The usually is done to palpate any masses or detect abnormalities in the rectum and is done after the vaginal examination to avoid contamination; gloves are changed between vaginal and recta; examination
99.Answer C. +1 station indicates that the fetal head is 1 cm below the ischial spines
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