1. A nurse is describing the process of fetal circulation to a client during a prenatal visit.

The nurse accurately tells the client that fetal circulation consists of: A. Two umbilical veins and one umbilical artery B. Two umbilical arteries and one umbilical vein C. Arteries carrying oxygenated blood to the fetus D. Veins carrying deoxygenated blood to the fetus Correct Answer: B Rationale: Blood pumped by the embryos heart leaves the embryo through two umbilical arteries. Once oxygenated, the blood is then returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen and nutrients to the fetus. Level of Cognitive Ability: Comprehension Reference: Saunders Comprehensive Review for NCLEX-RN 2nd Edition By: Linda Anne Silvestri Copyright 2002 by W.B. Saunders Company Pages 245-246 (Question #5) 2. A nurse prepares to assess a fetal heart beat. The nurse uses a fetoscope, knowing that the fetal heart beat can first be heard with a fetoscope at gestational week: A. 5 B. 10 C. 16 D. 20 Correct Answer: D Rationale: The fetal heart beat can first be heard with a fetoscope at 18 to 20 weeks of gestation. If a Doppler ultrasound device is used, the fetal heart rate can be detected as early as 8 to 12 weeks of gestation. Options A, B, and C are incorrect. Level of Cognitive Ability: Comprehension Reference: Saunders Comprehensive Review for NCLEX-RN 2nd Edition By: Linda Anne Silvestri Copyright 2002 by W.B. Saunders Company Pages 245-246 (Question #8) 3. A nurse is performing an assessment of a primipara who is being evaluated in a clinic during her second trimester of pregnancy. Which of the following indicates an abnormal physical finding necessitating further testing? A. Consistent increase in fundal height B. Fetal heart rate of 180 beats per minute Maternal & Child Nursing | BSN IV Benner, Stephannie L. Miranda Page 1

C. Braxton hicks contractions D. Quickening Correct Answer: B Rationale: The normal fetal heart rate is 120 o 160 beats per minute. Options A, C, and D are normal expected findings. Level of Cognitive Ability: Analysis Reference: Saunders Comprehensive Review for NCLEX-RN 2nd Edition By: Linda Anne Silvestri Copyright 2002 by W.B. Saunders Company Pages 249-251 (Question #3) 4. A nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects the findings to be which of the following? A. 22 cm B. 28 cm C. 36 cm D. 40 cm Correct Answer: B Rationale: During the second and third trimester (18-30 weeks), fundal height in centimeter approximately equals the fetuss age in weeks. 2 cm. at 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 2 weeks, the fundus is at the umbilicus, and at 36 weeks, the fundus is at the xiphoid process. Level of Cognitive Ability: Analysis Reference: Saunders Comprehensive Review for NCLEX-RN 2nd Edition By: Linda Anne Silvestri Copyright 2002 by W.B. Saunders Company Pages 250-251 (Question #5) 5. A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will b noted between: A. 6 and 8 weeks of gestation B. 8 and 10 weeks of gestation C. 10 and 12 weeks of gestation D. 14 and 16 weeks of gestation Correct Answer: D

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Rationale: Quickening is a fetal movement and may occur as early as 14th to 16th weeks of gestation. The expectant mother first notices subtle fetal movements during this time, which gradually increase in intensity. Options A, B, and C are incorrect. Level of Cognitive Ability: Application Reference: Saunders Comprehensive Review for NCLEX-RN 2nd Edition By: Linda Anne Silvestri Copyright 2002 by W.B. Saunders Company Pages 250-252 (Question #10) 6. A clinic has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement if made by the client indicates a need for further education? A. I should wear support hose B. I should be wearing flat nonslip shoes that have an arch support C. I should wear pantyhose D. I can wear knee-high hose as long as I dont leave them on longer than 8 Correct Answer: D Rationale: Varicose veins often develop in the lower extremities during pregnancy. Any constructive clothing, such as knee-high hose, impedes venous return from the lower legs and places the client at risk for developing varicosities. The client should be encouraged to wear support hose or pantyhose. Flat nonslip shoes with proper support are important to assist the pregnant women to maintain proper posture and balance and minimize falls. Level of Cognitive Ability: Analysis Reference: Saunders Comprehensive Review for NCLEX-RN 2nd Edition By: Linda Anne Silvestri Copyright 2002 by W.B. Saunders Company Pages 259-262 (Question #2) 7. The nurse is providing care for a postpartum client. Which of the following condition would place this client at greater risk for a postpartum hemorrhage? A. Hypertension B. Uterine infection C. Placenta previa D. Severe pain Correct Answer: C Rationale: The client with placenta previa is at greatest risk for postpartum hemorrhage. In placenta previa, the lower uterine segment doesnt contract as well as the fundal part of the uterus; therefore, more bleeding

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occurs. Hypertension, severe pain and uterine infection dont place the client at increased risk for postpartum hemorrhage. Level of Cognitive Ability: Comprehension Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages 523 (Question #2) 8. During the 3rd postpartum day, which of the following would the nurse be most likely to find in the client? A. Shes interested in learning more about newborn care B. She talks a lot about her birth experience C. She sleeps whenever the baby isnt present D. She requests help in choosing a name for the baby Correct Answer: A Rationale: The 3rd to 10th day of postpartum care is the taking-hold phase, in which the new mother strives for independence and is eager for her baby. Options B, C, and D describe the phase in which the mother relieves her birth experience. Level of Cognitive Ability: Comprehension Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages 524 (Question #5) 9. A client in the active phase of labor has a reactive fetal monitor strip and has been encouraged to walk. When she returns to bed for a monitor check, she complains of an urge to push. When performing a vaginal examination, the nurse accidentally ruptures the amniotic membranes, and as she withdraws her hand, the umbilical cord comes out. What should the nurse do next? A. Put the client in a knee-to-chest position B. Call the physician or midwife C. Push down on the uterine fundus D. Set up for a fetal blood sampling to assess for fetal acidosis Correct Answer: A Rationale: The knee-to-chest position gets the weight off the baby and umbilical cord, which would prevent blood flow. Calling the physician or midwife and setting up for blood sampling are important, but they have a lower priority than getting the baby off the cord. Pushing down on the fundus would increase the danger by further compromising blood flow.

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Level of Cognitive Ability: Analysis Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages 511 (Question #2) 10. The nurse can consider the fetuss head to be engaged when: A. The presenting part moves through the pelvis B. The fetal head rotates to pass through the ischial spines C. The fetal head extends as it passes under the symphysis pubis D. The biparietal diameter passes the pelvic inlet Correct Answer: D Rationale: The fetuss head is considered engaged when the biparietal diameter passes the pelvic inlet. The presenting part moving through the pelvis is called descent. The head flexing so that the chin moves closer to the chest is called flexion. Rotation of the head to pass through the ischial spines is called internal rotation. Extension of the head as it passes under the symphysis pubis is called extension. Level of Cognitive Ability: Analysis Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages 512 (Question #5) 11. A client is experiencing a true labor when her contraction pattern shows: A. Occasional irregular contractions B. Irregular contractions that increase in intensity C. Regular contractions that remain the same D. Regular contractions that increase in frequency and duration Correct Answer: D Rationale: Regular contractions that increase in frequency and duration as well as intensity indicate true labor. The other choices dont describe the contraction pattern of true labor. Level of Cognitive Ability: Knowledge Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins

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Copyright 2003 by Lippincott Williams & Wilkins Pages 512-513 (Question #6) 12. When late decelerations are noted by the nurse, the first action is to: A. Notify the physician STAT B. Position the client on her left side C. Administer oxygen via face mask D. Increase the drip rate of the intravenous fluid Correct Answer: B Rationale: Late decelerations are from decreased blood perfusion to the placenta or compression of the placenta. A position change should increase perfusion or decrease compression. The second action may be to give oxygen (C) as a palliative measure to increase oxygen concentration of whatever blood does get to the placenta. Both are treatments for late deceleration, but the nursing action is to change position first. Level of Cognitive Ability: Application Reference: Sandra Smiths Review for NCLEX-RN 10th Edition By: Sandra F. Smith Copyright 2001 by Prentice - Hall Inc., Upper Saddle River, New Jersey 07458 Pages: 482, 487 (Question #1) 13. A client is receiving magnesium sulfate to help suppress preterm labor. The nurse should watch for which sign of magnesium toxicity? A. Headache B. Loss of deep tendon reflexes C. Palpitations D. Dyspepsia Correct Answer: B Rationale: magnesium toxicity causes signs of central nervous system depression, such as loss of deep tendon reflexes, paralysis, respiratory depression, drowsiness, lethargy, blurred vision, slurred speech, and confusion. Headache may be an adverse effect of calcium channel blockers, which are sometimes used to treat preterm labor. Palpitations are an adverse effect of terbutaline and ritodrine, which are also used to treat preterm labor. Dyspepsia may occur as an adverse effect of indomethacin, a prostaglandin synthetase inhibitor, used to suppress preterm labor. Level of Cognitive Ability: Application Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins

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Pages 514 (Question #10) 14. During prenatal screening of a diabetic client, the nurse should keep in mind that the client is at increased risk for: A. Rh incompatibility B. Placenta previa C. Hyperemesis D. Stillbirth Correct Answer: D Rationale: diabetic clients are at increased risk for intrauterine fetal death after 36 weeks gestation. This factor must be weighed against the risks of delivery before 37 weeks and prematurity. The risk of Rh incompatibility, placenta previa, or hyperemesis isnt increased in the diabetic client. Level of Cognitive Ability: Knowledge Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages 491 (Question #2) 15. Which of the following is a normal physiological response in the early postpartum period? A. Urinary urgency B. Rapid diuresis C. Decrease in blood pressure D. Increased motility of the GI system Correct Answer: B Rationale: in the early postpartum period there is an increase in the glomerular filtration rate and a drop in progesterone levels, which result in rapid diuresis. There should be no urinary urgency, although a woman may be anxious about voiding. There is minimal change in blood pressure following childbirth and a residual decrease in gastrointestinal motility. Level of Cognitive Ability: Knowledge Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages 524 (Question #4) 16. A newly pregnant client who is a little overweight asks how much weight she should gain over the 9 months. The most appropriate answer is: A. For your size a little heavy, about 15 pounds would be best. Maternal & Child Nursing | BSN IV Benner, Stephannie L. Miranda Page 7

B. It really doesnt matter exactly how much weight you gain, as long as your diet is healthy. C. A gain of about 24-25 pounds is best for mother and baby. D. Because you are a little overweight, it would be best for you not to gain too much weight. Correct Answer: C Rationale: The optimum weight gain for both mothers and babys health is about 25 pounds. Dieting is contraindicated. There is a lower incidence of prematurity, stillbirths, and low birth-weight infants with a weight gain of at least 25 pounds. Level of Cognitive Ability: Knowledge Reference: Sandra Smiths Review for NCLEX-RN 10th Edition By: Sandra F. Smith Copyright 2001 by Prentice - Hall Inc., Upper Saddle River, New Jersey 07458 Pages: 486, 490 (Question #44) 17. A parent brings a 19-month-old toddler to the clinic for a well-child checkup. When palpating the toddlers fontanels, the nurse would expect to find: A. Closed anterior fontanel and open posterior fontanel. B. Open anterior fontanel and closed posterior fontanel. C. Closed anterior and posterior fontanels. D. Open anterior and posterior fontanels. Correct Answer: C Rationale: By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months. Level of Cognitive Ability: Knowledge Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages 561 (Question #1) 18. An infant is diagnosed with patent ductus arteriosus. Which of the following drugs may be administered in hopes of achieving pharmacologic closure of the defect? A. Digoxin (Lanoxin) B. Prednisone C. Furosemide (Lasix) D. Indomethacin (Indocin) Correct Answer: D Maternal & Child Nursing | BSN IV Benner, Stephannie L. Miranda Page 8

Rationale: Indomethacin is administered to an infant with patent ductus arteriosus in hopes of closing the defect. Digoxin and furosemide may be used to treat the symptoms associated with patent ductus arteriosus nut they dont achieve closure. Prednisone isnt used to treat the condition. Level of Cognitive Ability: Comprehension Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages 573 (Question #8) 19. The nurse is teaching a mother about the benefits of breast-feeding her infant. Which type of immunity is passed on to the infant during breast-feeding? A. Natural immunity B. Natural acquired active immunity C. Naturally acquired passive immunity D. Artificially acquired active immunity Correct Answer: C Rationale: Naturally acquired passive immunity is received through placental transfer and breast-feeding. Natural immunity is present at birth. Naturally acquired active immunity occurs when the immune system makes antibodies after exposure to disease. Artificially acquired immunity occurs when medically engineered substances are ingested or injected to stimulate the immune response against a specific disease (immunizations). Level of Cognitive Ability: Application Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages 603 (Question #4) 20. The nurse would anticipate a possible complication in infants delivered by cesarean section. This condition would be: A. Respiratory distress B. Renal impairment C. ABO incompatibility D. Kernicterus Correct Answer: A Rationale: During a normal birth, the fetus passes through the birth canal and pressure on the chest helps rid the fetus of amniotic fluid that has accumulated in the lungs. The baby delivered by cesarean section doesnt go through this process and therefore may develop respiratory problems. Maternal & Child Nursing | BSN IV Benner, Stephannie L. Miranda Page 9

Level of Cognitive Ability: Application Reference: Sandra Smiths Review for NCLEX-RN 10th Edition By: Sandra F. Smith Copyright 2001 by Prentice - Hall Inc., Upper Saddle River, New Jersey 07458 Pages: 482, 487 (Question #3) 21. An 11 lb. 6 oz. baby girl was delivered by cesarean section to a diabetic mother. The priority assessment of the infant of a diabetic mother would be for: A. Hypoglycemia B. Sepsis C. Hyperglycemia D. Hypercalcemia Correct Answer: A Rationale: infants of diabetic mothers are prone to develop hypoglycemia, respiratory distress, and hypocalcemia. The infant of a diabetic mother may develop sepsis (B), but usually from a cause unrelated to the diabetes itself. Hyperbilirubinemia is also fairly common in these infants. Level of Cognitive Ability: Application Reference: Sandra Smiths Review for NCLEX-RN 10th Edition By: Sandra F. Smith Copyright 2001 by Prentice - Hall Inc., Upper Saddle River, New Jersey 07458 Pages: 482, 487 (Question #7) 22. During a physical exam of an infant with congenital hip dysplasia, the nurse would observe and report which of the following characteristics? A. Symmetrical gluteal folds B. Limited adduction of the affected leg C. Femoral pulse when the hip is flexed and the leg is abducted D. Limited abduction of the affected leg Correct Answer: D Rationale: Abduction is limited in the affected leg. The nurse would also find asymmetrical gluteal folds and an absent femoral pulse when the affected leg is abducted. Level of Cognitive Ability: Application Reference: Sandra Smiths Review for NCLEX-RN 10th Edition

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By: Sandra F. Smith Copyright 2001 by Prentice - Hall Inc., Upper Saddle River, New Jersey 07458 Pages: 484, 488 (Question #24) 23. The nurses caring for a premature baby use careful hand washing techniques because they know premature infants are more susceptible to infection than full-term infants. Which of the following explains why premature infants are more likely to develop infection? A. Their liver enzymes are immature B. Premature babies may receive steroid drugs, which affects the immune system C. Premature infants receive few antibodies from the mother, because antibodies pass across the placenta during the last month of pregnancy D. Surfactant is decreased in premature infants Correct Answer: C Rationale: Deficient antibodies can lead to infection in the premature. Immaturity of the liver (A) is responsible for hyperbilirubinemia. White cell count would be related to potential infection. Lack of surfactant (D) occurs in premature who have RDS. Level of Cognitive Ability: Comprehension Reference: Sandra Smiths Review for NCLEX-RN 10th Edition By: Sandra F. Smith Copyright 2001 by Prentice - Hall Inc., Upper Saddle River, New Jersey 07458 Pages: 485, 489 (Question #33) 24. In the delivery room, a client has just delivered a healthy 7-pound baby boy. The physician instructs the nurse to suction the baby. The procedure that the nurse would use is to: A. Suction the nose first B. Suction the mouth first C. Suction neither the nose nor mouth until the physician gives further instructions D. Turn the baby on his side so mucus will drain out before suctioning Correct Answer: B Rationale: It is important to suction the mouth first. If the nose were to be suctioned first (A), stimulation of the delicate receptors in the nose could cause the infant to aspirate mucus from the mouth. Level of Cognitive Ability: Application Reference: Sandra Smiths Review for NCLEX-RN 10th Edition By: Sandra F. Smith Copyright 2001 by Prentice - Hall Inc., Upper Saddle River, New Jersey 07458

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Pages: 485, 489 (Question #34) 25. A mother tells the nurse that her 22-month-old child says no to everything. When scolded, the toddler becomes angry and starts crying loudly, but then immediately wants to be held. What is the best interpretation of this behavior? A. The toddler isnt effectively coping with stress. B. The toddlers need for affection isnt being met. C. This is normal behavior for a 2-year-old child. D. This behavior suggests the need for counseling. Correct Answer: C Rationale: Because toddlers are confronted with the conflict of achieving autonomy, yet relinquishing the much-enjoyed dependence on the affection of others, their negativism is a necessary assertion of selfcontrol. Therefore, this behavior is a normal part of childs growth and development. Nothing about the behavior indicates that the child is under stress, isnt receiving sufficient affection, or requires counseling. Level of Cognitive Ability: Comprehension Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages 563 (Question #7) 26. Which nursing intervention has priority when feeding an infant with a cleft lip or palate? A. Directing the flow of milk in the center of mouth B. Providing small, frequent feedings C. Avoiding breast-feeding D. Infrequent burping Correct Answer: B Rationale: Small, frequent feedings help to prevent fatigue and frustration in the infant. The flow of milk should be directed to side of the mouth. Breast-feeding may be possible. These infants need frequent burping because of the large amount of air swallowed while feeding. Level of Cognitive Ability: Analysis Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages 546 (Question #5) 27. Which action best explains the main role of surfactant in the neonate? A. Assist with ciliary body maturation in the upper airways Maternal & Child Nursing | BSN IV Benner, Stephannie L. Miranda Page 12

B. Helps maintain a rhythmic breathing pattern C. Promotes clearing mucus from the respiratory tract D. Helps the lungs remain expanded after the initiation of breathing Correct Answer: D Rationale: Surfactant works by reducing the surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Surfactant hasnt been shown to influence ciliary body maturation, clear the respiratory tract, or regulate the neonates breathing pattern. Level of Cognitive Ability: Knowledge Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages: 511 (Question #2) 28. While assessing a 2-hour-old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? A. Activate the blue code or emergency system B. Do nothing because acrocyanosis is normal in the neonate C. Immediately take the neonates temperature according to hospital policy D. Notify the physician of the need for a cardiac consult Correct Answer: B Rationale: Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldnt last more than 24 hours after birth. The other choices are inappropriate. Level of Cognitive Ability: Application Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages: 511 (Question #3) 29. When performing a neurologic assessment, which sign is considered a normal finding in a neonate? A. Doll eyes B. Sunset eyes C. Positive Babinskis sign D. Pupils that dont react to light Correct Answer: C

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Rationale: A positive Babinskis sign is present in infants until approximately age 1. A positive Babinskis reflex is normal in neonates but abnormal in adults. The appearance of sunset eyes, in which the sclera is visible above the iris, results from cranial nerve palsies and may indicate increased intracranial pressure. Doll eyes is also a neurologic response but its noted in adults. A neonates pupils normally react to light as in an adult. Level of Cognitive Ability: Analysis Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages: 513 (Question #8) 30. A clients mother asks the nurse why her newborn grandson is getting an injection of vitamin K. Which best explains why this drug is given to neonates? A. Vitamin K assists with coagulation B. Vitamin K assists the gut to mature C. Vitamin K initiates the immunization process D. Vitamin K protects the brain from excess fluid production Correct Answer: A Rationale: Vitamin K, deficient in the neonate, is needed to activate clotting factors II, VII, IX, and X. In the event of trauma, the neonate would be at risk for excessive bleeding. Vitamin K doesnt assist the gut to mature, but the gut produces vitamin K once maturity is achieved. Vitamin K doesnt influence fluid production in the brain or the immunization process. Level of Cognitive Ability: Application Reference: NCLEX-RN Review made Incredibly Easy! 2nd Edition By: Lippincott Williams & Wilkins Copyright 2003 by Lippincott Williams & Wilkins Pages: 513 (Question #10)

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