LGAC PRACTICE QUESTION IN MCN B

1. A nurse is conducting a prenatal teaching class and is reviewing the functions of the female
reproductive system. A client in the class asks the nurse about the function of the fallopian tubes. The
nurse tells the client that
a.
b.
c.
d.

Estrogen and progesterone are secreted from the fallopian tubes

The fallopian tubes are the passageway for the fetus
The fetus develops in the fallopian tubes
Fertilization occurs in the fallopian tubes

2. A nursing instructor is reviewing the menstrual cycle with a nursing student who will be conducting a
prenatal teaching session. The instructor asks the student to describe the follicle stimulating hormone
(FSH) and the luteinizing hormone (LH). The student accurately responds by stating that
a.
b.
c.
d.

FSH
FSH
FSH
FSH

and
and
and
and

LH
LH
LH
LH

are released from the anterior pituitary gland

are secreted by the corpus luteum of the ovary
are secreted by the adrenal glands
stimulate the formation of milk during pregnancy

3. A nurse employed in a prenatal clinic review a clients chart and notes that the physician documents
that the client has a gynecoid pelvis. The nurse plans care for this client, knowing that this type of
pelvis
a. Is not favorable for labor
b. Has a narrow pubic arch

c. Is a wide pelvis with a short diameter

d. Is the most favorable for labor and birth

4. A pregnant client asks a nurse about the purpose of the placenta. The nurse responds most
appropriately by telling the client that the placenta
a.
b.
c.
d.

Prevents antibodies and viruses from passing to the fetus

Cushions and protect the fetus
Provides an exchange of nutrients and waste products between the mother and the fetus
Maintains the body temperature of the fetus

5. 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.
b.
c.
d.

Two umbilical veins and one umbilical artery

Two umbilical arteries and one umbilical vein
Arteries carrying oxygenated blood to the fetus
Veins carrying deoxygenated blood to the fetus

6. A nursing student is assigned to a client in labor. A nursing instructor asks the student to describe
fetal circulation, specially the ductus venosus. The nursing instructor determines that the student
understands fetal circulation if the student states that the ductus venosus
a.
b.
c.
d.

Connects the pulmonary artery to the aorta

Is an opening between the right and left atriums
Connects the umbilical artery to the inferior vena cava
Connects the umbilical vein to the inferior vena cava

7. A nurse is caring for a client during the prenatal period. The client tells that nurse that she wants to
know the sex of the fetus as soon as it can be determined. The nurse responds to the client, knowing
that the sex of the fetus can be visually recognizable as early as week
a. 4
b. 6

c. 8
d. 12

8. A nurse prepares to assess a fetal heartbeat. The nurse use a fetoscope, knowing that the fetal
heartbeat first can be heard with a regular (nonelectronic) fetoscope at gestational week

a. 5
b. 10

c. 16
d. 20

9. During a prenatal visit at 38 weeks, a nurse assesses the fetal heart rate. The nurse determines that
the fetal heart rate is normal if which of the following is noted?
a. 80 beats per minute
c. 150 beats per minute
b. 100 beats per minute
d. 180 beats per minute
10. A pregnant adolescent client asks the nurse about the menstrual cycle. The nurse describes the cycle
and tells the adolescent that its normal duration is about
a. 14 days
b. 28 days

c. 30 days
d. 45 days

11. A client arrives at a prenatal clinic for the first prenatal assessment. The client tells a nurse that the
first day of her last menstrual period was September 19, 2005. Using Nageles rule, the nurse
determines the estimated date of confinement as
a. July 26, 2006
b. July 12, 2007

c. June 26, 2006

d. July 12, 2007

12. A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The
client has a healthy 5-year-old child that was delivered at 38 weeks and tells the nurse that she does
not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for
this client as
a.
b.
c.
d.

G
G
G
G

=
=
=
=

3,
2,
1,
2,

T
T
T
T

=
=
=
=

2,
0,
1,
0,

P
P
P
P

=
=
=
=

0,
1,
1,
0,

A
A
A
A

=
=
=
=

0,
0,
0,
0,

L
L
L
L

=
=
=
=

1
1
1
1

13. 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.
b.
c.
d.

Consistent increase in fundal height

Fetal heart rate of 180 beats per minute
Braxton Hicks contractions
Quickening

14. A nurse is providing instructions to a pregnant client with genital herpes about the measures that
need to be implemented to protect the fetus. The nurse tells the client that
a.
b.
c.
d.

Daily administration of acyclovir (Zovirax) is necessary during the entire pregnancy

Total abstinence from sexual intercourse is necessary during the entire pregnancy
Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present
A cesarean section will be necessary if vaginal lesions are present at the time of labor

15. 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. 30 cm

c. 36 cm
d. 40 cm

16. A pregnant client is seen in a health care clinic for a regular prenatal visit. The client tells the nurse
that she is experiencing irregular contractions, and the nurse determines that she is experiencing
Braxton Hicks contractions. Based on this finding, which nursing action is most appropriate?
a. Instruct the client to maintain bed rest for the remainder of the pregnancy
b. Inform the client that these are common and may occur throughout the pregnancy

c. Contact the physician

d. Call the maternity unit and inform them that the client will be admitted in a prelabor condition
17. A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive.
The physician has documented the presence of Goodells sign. The nurse determines that this sign
indicates
a.
b.
c.
d.

A softening of the cervix

A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus
The presence of human chorionic gonadotropin in the urine
The presence of fetal movement

18. A nursing instructor asks a nursing student who is preparing t assist with the assessment of a
pregnant client to describe the process of quickening. Which of the following statements if made by
the student indicates an understanding of this term?
a.
b.
c.
d.

It
It
It
It

is
is
is
is

the
the
the
the

irregular, painless contractions that occur throughout pregnancy

soft blowing sound that can be heard when the uterus is auscultated
fetal movement that is felt by the mother
thinning of the lower uterine segment

19 .A nurse midwife is performing an assessment of a pregnant client and is assessing the client for the
presence of ballottement. Which of the following would the nurse implement to test for the presence
of ballottement?
a.
b.
c.
d.

Auscultating for fetal heart sounds

Palpating the abdomen for fetal movement
Assessing the cervix for thinning
Initiating a gentle upward tap on the cervix

20. A pregnant 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 be 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

21 Physician has prescribed transvaginal ultrasonography for a woman in the first trimester of
pregnancy and the woman asks the nurse about the procedure. The nurse accurately provides which
of the following information to the client?
a. The procedure takes about 2 hours
b. Transmission gel is spread over the abdomen, and a transducer will be moved over the
abdomen to obtain the picture
c. It will be necessary to drink 1 to 2 qt of water before the examination
d. The transvaginal proble encased in a disposable cover and coated with a gel is inserted into
the vagina
22 Clinic nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy.
Which statement by the client indicates a need for further instructions
a.
b.
c.
d.

I
I
I
I

should
should
should
should

wear support hose

be wearing flat nonslip shoes that have an arch support
wear panty hose
wear knee-high hose as long as I dont leave them on longer than 8 hours

23. A pregnant client calls a clinic and tells a nurse that she is experiencing leg cramps and is awakened
by the cramps at night. To provide relief from the leg cramps, the nurse tells the client to
a. Dorsiflex the foot while extending the knee when the cramps occur
b. Dorsiflex the foot while flexing the knee when the cramps occur
c. Plantar flex the foot while flexing the knee when the cramps occur

d. Plantar flex the foot while extending the knee when the cramps occur
24. A clinic nurse is providing instructions to a pregnant client regarding measures that will assist in
alleviating heartburn. Which statement by the client indicates an understanding of these measures?
a.
b.
c.
d.

I
I
I
I

should
should
should
should

lie down for an hour after eating

avoid between-meal snacks
substitute spices for cooking rather than using saly
avoid eating gas-producing foods and fatty foods

25. A nurse in a health care clinic is instructing a pregnant woman in how to perform kick counts.
Which statement by the woman indicates a need for further instructions?
a. I should place my hands on the largest part of my abdomen and concentrate on the fetal
movements to count the kicks
b. I will record the number of movements or kicks
c. I need to lie flat on my back to perform the procedure
d. A count of fewer than 10 kicks in a 12-hour period indicates the need to contact the
physician

26. A clinic nurse is instructing a pregnant client regarding dietary measures to promote a healthy
pregnancy. The nurse instructs the client to have an adequate intake of fluid daily. Which statement
by the mother indicates an understanding of the daily fluid requirement?
a. I should drink
b. I should drink
c. I should drink
consume
d. I should drink
count

at least 8 to 10 glasses of fluid each day, of which 4 to 6 glasses are water

12 glasses of fruit juices or milk everyday
8 to 10 glasses of fluid a day and I can count all of the diet soft drinks that I
12 glasses of fluid a day, and I can include the coffee or tea that I drink in the

27. A nurse is instructing a pregnant client regarding measures to increase sources of iron in the diet.
The nurse tells the client to consume which food that contains the highest source of dietary iron?
a. Milk
b. Dark green, leafy vegetable

c. Potatoes
d. Cantaloupe

28. A nurse providing instructions regarding treatment for hemorrhoids to a client who is in the second
trimester of pregnancy. Which statement by the client indicates a need for further instruction?
a.
b.
c.
d.

I
I
I
I

can apply ice packs to the hemorrhoids to reduce the swelling

should apply heat packs to the hemorrhoids to help the hemorrhoids shrink
should avoid straining during bowel movements
can gently replace the hemorrhoids into the rectum

29. A nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to
assist in reducing breast tenderness. The nurse tells the client to
a.
b.
c.
d.

Avoid wearing a bra

Wash the nipples and areola area daily with soap, and massage the breasts with lotion
Wear tight-fitting blouses or dresses to provide support
Wash the breasts with warm water and keep them dry

30. A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the
procedure. The nurse tells the client that
a. The test is an invasive procedure and requires that an informed consent be signed
b. The test will take about 2 hours and will require close monitoring for 2 hours after the
procedure is completed

c. An ultrasound transducer that records fetal heart activity is secured over the abdomen where
the fetal heart is heard most clearly
d. The test is challenged or stressed by uterine contractions to obtain the necessary information
31. A nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the
documentation related to the results of the test. The nurse notes that the physician has documented
the test results as reactive. The nurse interprets that this result indicates
a.
b.
c.
d.

Normal findings
Abnormal findings
The need for further evaluation
That the findings on the monitor were difficult to interpret

32. A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The physician prescribes a contraction stress test, the test is performed, and the
nurse notes that the physician has documented the results as negative. The nurse interprets this
finding as indicating
a. A high risk for fetal demise
b. A normal test result

c. The need for a cesarean delivery

d. An abnormal test result

33. A nurse is reviewing a nutritional plan for care with a pregnant client and is identifying the food items
that are highest in folic acid. The nurse determines that the client understands which foods supply the
highest amounts of folic acid if the client states that she will include which of the following in the
daily diet?
a. A banana
b. Leafy, green vegetable

c. Milk
d. Yogurt

34. A pregnant client tells a nurse that she has been craving unusual foods. The nurse gathers
additional assessment data from the client and discovers that the client has been ingesting daily
amounts of white clay dirt from her backyard. Laboratory studies are performed on the client. The
nurse reviews the laboratory results and determines that which of the following indicates a
physiological consequence of this clients practice?
a. Hematocrit 38%
c. Glucose, 86 mg/dL
b. Hemoglobin, 9.1 g/dL
d. White blood cell count, 12,400/mm
35. A pregnant client who is at 30 weeks gestation comes to a clinic for a routine visit, and the nurse
performs an assessment on the client. Which observation made by the nurse during the assessment
indicates a need for teaching?
a.
b.
c.
d.

The
The
The
The

client
client
client
client

is
is
is
is

wearing
wearing
wearing
wearing

sneakers
flat shoes with rubber soles
pants with an elastic waistband
knee-high hose

36. A nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes
of constipation. The nurse includes in the plan of care measures to prevent the episodes of
constipation and plants to tell the client to
a.
b.
c.
d.

Take a mild stool softener daily in the evening

Drink 6 glasses of water per day
Consume a low-roughage diet
Use a Fleet enema when the episodes occur

37. A pregnant client visits a clinic for a scheduled prenatal appointment. On assessment the client tells
the nurse that she frequently has a backache, and the nurse provides instructions to the client
regarding measures that will assist in relieving the backache. Which statement by the client indicates
a need for further instructions regarding the measures to relieve the backache?
a. I need to try to maintain good posture

b. I should do more exercises to strengthen my back muscles

c. I should sleep on a firm mattress
d. I should wear low-heeled shoes
38. A nurse is providing instruction to a pregnant client who is scheduled for an amniocentesis. The nurse
tells the client that
a.
b.
c.
d.

A fever is expected following the procedure because of the trauma to the abdomen
Strict bed rest is required following the procedure
An informed consent will need to be signed before the procedure
Hospitalization is necessary for 24 hours following the procedure

39. A pregnant client in the first trimester calls a nurse at a healthy care clinic and reports that she has
noticed a thin, colorless, vaginal drainage. The nurse most appropriately tells the mother
a.
b.
c.
d.

To come to the clinic immediately

To report to the emergency room at the maternity center immediately
That the vaginal discharge may be bothersome but is a normal occurrence
To use tampons if the discharge is bothersome but to be sure to change the tampons every 2
hours
40. A pregnant client asks a nurse about the types of exercises that are allowable during the pregnancy.
The nurse would instruct the client that the safest exercise to engage in is which of the following?
a.
b.
c.
d.

Bicycling with the legs in the air

Swimming
Scuba diving
Low-weight gymnastics

41. A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe
preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the
client for
a.
b.
c.
d.

Any bleeding such as in the gums, petechiae, and purpura

Enlargement of the breasts
Periods of fetal movement followed by quiet periods
Complaints of feeling hot when the room is cool

42. A nurse in a maternity unit is reviewing the records of the clients on the unit. Which of the client
would the nurse identify as being at most risk for developing disseminated intravascular coagulation
(DIC)?
a.
b.
c.
d.

A
A
A
A

gravida IV who delivered 8 hours ago and has lost 500 mL of blood
gravida II who has just been diagnosed with dead fetus syndrome
primigravida with mild preeclampsia
primigravida who delivered a 10-lb baby 3 hours ago

43. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been
experiencing vaginal bleeding. A threatened abortion is suspected, and a nurse instructs the client
regarding management of care. Which statement if made by the client indicates a need for further
education?
a. I will maintain strict bed rest throughout the remainder of the pregnancy
b. I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following
the last evidence of bleeding
c. I will count the number of perineal pads used on a daily basis and note the amount and
color of blood on the pad
d. I will watch for the evidence of the passage of tissue
44. A prenatal nurse is providing instructions to a group of pregnant clients regarding measures to
prevent toxoplasmosis. Which statement if made by one of the clients indicates a need for further
instructions?

a. I need
b. I need
meat
c. I need
d. I need

to cook meat thoroughly

to avoid touching mucous membranes of the mouth or eyes while handling raw
to drink unpasteurized milk only
to avoid contact with materials that are possibly contaminated with cat feces

45. A pregnant woman reports to a health care clinic, complaining of loss of appetite, weight loss, and
fatigue. Following assessment of the woman, tuberculosis is suspected. A sputum culture is obtained
and identifies Mycobacterium tuberculosis. The nurse provides instructions to the mother regarding
therapeutic management of the tuberculosis. The nurse tells the client that
a.
b.
c.
d.

Medication will not be started until after delivery of the fetus

Isoniazid (INH) plus rifampin (Rifadin) will be required for a total of 9 months
The newborn infant will need to receive medication therapy immediately following birth
Therapeutic abortion is required

46. A clinic nurse is provided home care instructions to a client with a history of cardiac disease who has
just been told that she is pregnant. Which statement if made by the client indicates a need for further
education?
a. During the pregnancy, I need to avoid contact with other individuals as much as possible
to prevent infection
b. I need to avoid excessive weight gain to prevent increased demands on my heart
c. It is best that I rest on my left side to promote blood return to the heart
d. I need to try avoid stressful situations because stress increases the workload on the heart
47. A nurse is providing instructions to a maternity client with a history of cardiac disease regarding
appropriate dietary measures. Which statement if made by the client indicates an understanding of
the measures to take?
a.
b.
c.
d.

I
I
I
I

need to increase my fluid intake and intake of high-fiber foods

need to maintain a low-calorie diet to prevent any weight gain
need to lower my blood volume by limiting my fluids
do not need to be concerned about sodium intake during pregnancy

48. A clinic nurse is performing a psychosocial assessment of a client who has been told that she is
pregnant. Which of the following assessment findings would indicate to the nurse that the client is a
high risk for contracting human immunodeficiency virus (HIV)?
a.
b.
c.
d.

A history of intravenous drug use

A history of one sexual partner for the past 10 years
No history of any sexually transmitted diseases
A significant other who is heterosexual

49. A nurse in a maternity unit is providing emotional support to a client and her husband who are
preparing to be discharged from the hospital after the birth of a dead fetus. Which statement if made
by the client indicates a component of the normal grieving process?
a.
b.
c.
d.
50

We would really like to attend a support group

Were okay, and we are going to try to have another baby immediately
We never want to have a baby again
We are going to try to adopt a child immediately

Nurse assists a pregnant client with cardiac disease to identify resources to help
her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the
pregnant client to use these resources primarily to
a. Help the mother prepare for labor and delivery
b. Reduce excessive maternal stress and fatigue
c. Prepare the 18-month-old child for maternal separation during hospitalization

d. Avoid exposure to potential pathogens and resulting infections

51. A nurse evaluates a hepatitis B-positive clients ability to safely bottle-feed her infant during
postpartum hospitalization. Which maternal action best exemplifies the clients knowledge of potential
disease transmission to the infant?
a. The client tests the temperature of the formula before initiating feeding
b. The client holds the infant properly during feeding and burping
c. The client washes and dries her hands before and following self-care of the perineum and
asks for a pair of gloves before feeding
d. The client requests that the window be closed before feeding
52. A nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV)
regarding care to the newborn infant following delivery. The client asks the nurse about the feeding
options that are available. Which statement will the nurse provide to the client regarding feeding the
newborn infant?
a.
b.
c.
d.

You
You
You
You

will
will
will
will

be able to breast-feed for 6 months and then will need to switch to bottle-feeding
be able to breast-feed for 9 months and then will need to switch to bottle-feeding
need to feed the newborn infant by nasogastric tube feeding
need to bottle-feed the newborn infant

53. During the intrapartum period a nurse is caring for a laboring client with sickle cell disease. The
nurse ensures that the client receives appropriate intravenous fluid intake and oxygen consumption
primarily to
a.
b.
c.
d.

Stimulate the labor process

Avoid the necessity of a cesarean delivery
Prevent dehydration of hypoxemia
Eliminate the need for analgesic administration

54. A home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia and who is being
monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a
worsening of the preeclampsia and the need to notify the physician?
a.
b.
c.
d.

Blood pressure reading is at the prenatal baseline

Urinary output has increased
The client complains of a headache and blurred vision
Dependent edema has resolved

55. A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the
fetuses is a breech presentation. Of the following interventions, which will the nurse list as the lowest
priority in planning the nursing care of this client?
a.
b.
c.
d.

Attach electronic fetal monitoring

Prepare the client for a possible cesarean section
Measure fundal height
Visually examine the perineum and vaginal opening

56. A stillborn infant was delivered in the birthing suite a few hours ago. After the birth the family has
remained together, holding and touching the baby. Which statement by the nurse would further assist
the family in their initial period of grief?
a.
b.
c.
d.

Dont worry, there is nothing you could do to prevent this from happening
We need to take the baby from you now so that you can get some sleep
What have you named your lovely baby?
We will see to it that you have an early discharge so that you dont have to be reminded of
this experience

57. A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational
diabetes mellitus. Which statement if made by the client indicates a need for further education?

a.
b.
c.
d.

I need to stay on the diabetic diet

I will perform glucose monitoring at home
I need to avoid exercise because of the negative effects on insulin production
I need to be aware of any infections and report signs of infection immediately to my health
care provider

58. A primigravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension
(PIH). The nurse who is caring for the client is performing assessments every 30 minutes. Which
assessment finding would be of most concern to the nurse?
a. Urinary output of 20 mL since the previous assessment
b. Deep tendon reflexes of 2+
c. Respiratory rate of 10 breaths per minute
d. Fetal heart rate of 120 beats per minute
59. A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan of care for the
client and documents in the plan that if the client progresses from preeclampsia to eclampsia, the
nurses first action is to
a. Administer magnesium sulfate intravenously
b. Assess the blood pressure and fetal heart rate
c. Clear and maintain an open airway
d. Administer oxygen by face mask
60. A client has just had surgery to deliver a nonviable fetus resulting from abruption placenta. As a
result of the abruption placenta, the client develops disseminated intravascular coagulation (DIC) and
is told about the complication. The client begins to cry and screams, God, just let me die now!
Which nursing diagnosis should direct care for this client?
a.
b.
c.
d.

Hopelessness related to loss of baby and personal health

Deficient knowledge related to disease process
Situational low self-esteem related to being ill
Grieving related to loss of the baby

61. A nurse is caring for a client in labor. The nurse determines that the client is beginning the second
stage of labor when which of the following assessments is noted?
a.
b.
c.
d.
62.

The
The
The
The

client begins to expel clear vaginal fluid

contractions are regular
membranes have ruptured
cervix is dilated completely

A nurse in the labor room is caring for a client in the active stage of labor. The nurse is assessing
the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing
action is to
a.
b.
c.
d.

Place the mother in a supine position

Document the findings and continue to monitor the fetal patterns
Administer oxygen via face mask
Increase the rate of the oxytocin (Pitocin) IV infusion

63. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which
assessment finding would indicate a need to contact the physician?
a.
b.
c.
d.

Fetal heart rate of 180 beats per minute

White blood cell count of 12,000 cells/mm
Maternal pulse rate of 85 beats per minute
Hemoglobin of 11.0 g/dL

64. A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client
is transferred to the delivery room table, and the nurse places the client in the

a.
b.
c.
d.

Trendelenburgs position with the legs in stirrups

Semi-Fowler position with a pillow under the knees
Prone position with the legs separated and elevated
Supine position with a wedge under the right hip

65. A nurse has provided discharge instructions to a client who delivered a healthy newborn infant by
cesarean delivery. Which statement if made by the client indicates a need for further instructions?
a.
b.
c.
d.

I
I
I
I

will
will
will
will

notify the physician if I develop a fever

lift nothing heavier than the newborn infant for at least 2 weeks
begin abdominal exercises immediately
turn on my side and push up with my arms to get out of bed

66. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a
Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are
heard by
a.
b.
c.
d.

Noting if the heart rate is greater than 149 beats per minute
Placing the diaphragm of the Doppler on the mothers abdomen
Performing Leopolds maneuver first to determine the location of the fetal heart
Palpating the maternal radial pulse while listening to the fetal heart rate

67. A nurse is caring for a client in labor who is receiving oxytocin (Ptocin) by intravenous infusion to
stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion
needs to be discontinued?
a.
b.
c.
d.

Three contractions occurring within a 10-minute period

A fetal heart rate of 90 beats per minute
Adequate resting tone of the uterus palpated between contractions
Increased urinary output

68. A nurse is preparing to care for a client in labor. The physician has prescribed an intravenous infusion
of oxytocin (Pitocin). The nurse ensures that which of the following is implemented before initiating
the infusion?
a.
b.
c.
d.

Placing the client on complete bed rest

Continuous electronic fetal monitoring
An intravenous infusion of antibiotics
Placing a code cart at the clients bedside

69. A nurse is monitoring a client in active labor and notes that the client is having contractions every 3
minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100
beats per minute. Which of the following nursing actions is most appropriate?
a.
b.
c.
d.

Encourage the clients coach to continue to encourage breathing techniques

Encourage the client to continue pushing with each contraction
Continue monitoring the fetal heart rate
Notify the physician or nurse-midwife

70. A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes
the presence of episodic accelerations on the electronic fetal monitoring tracing. Which of the
following actions is most appropriate?
a. Document the findings and tell the mother that the monitor indicates fetal well-being
b. Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen
c. Notify the physician or nurse-midwife of the findings
d. Reposition the mother and check the monitor for changes in the fetal tracing
71. A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal
monitor to the clients abdomen. After attachment of the electronic fetal monitor, the initial nursing
assessment is which of the following?

a.
b.
c.
d.

Identifying the types of accelerations

Assessing the baseline fetal heart rate
Determining the frequency of the contractions
Determining the intensity of the contractions

72. A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has
documented that the fetus is at 1- station. The nurse determines that the fetal presenting part is
a.
b.
c.
d.

1cm above the ischial spine

1fingerbreadth below the symphysis pubis
1 inch below the coccyx
1 inch below the iliac crest

73. A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that
the clients hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that
the client is at risk for which of the following?
a. Anxiety
b. Low self-esteem

c. Hemorrhage
d. Postpartum infection

74. A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the
umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these
observations as signs of
a. hematoma
c. Uterine atony
b. Placenta previa
d. Placental separation
75 Client arrives at a birthing center in active labor. Her membranes are still intact, and the nursemidwife prepares to perform an amniotomy. A nurse who is assisting the nurse midwife explains to the
client that after this procedure, she will most likely have
a.
b.
c.
d.

Less pressure on her cervix

Increased efficiency of contractions
Decreased number of contractions
The need for increased maternal blood pressure

76. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the
following is noted on the external monitoring tracing during a contraction?
a. Early decelerations
b. Variable decelerations

c. Late decelerations
d. Short-term variability

77. A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that
effleurage is
a. A form of biofeedback to enhance bearing down efforts during delivery
b. Light stroking of the abdomen to facilitate relaxation during labor and provide tactile
stimulation to the fetus
c. The application of pressure to the sacrum to relieve a backache
d. Performed to stimulate uterine activity by contracting a specific muscle group while other
parts of the body rest
78. A client in labor has been pushing effectively for 1 hour. A nurse determines that the clients primary
physiological need at this time is to
a. Change positions frequently
b. Ambulate

c. Consume oral food and fluids

d. Rest between contractions

79. A client in labor is dilated 10 cm. at this time during labor, the nurse would plan to assess and
document the fetal heart rate at least
a. Before each contraction
b. Every 15 minutes

c. Every 30 minutes
d. Hourly

80

A nurse is caring for a client in the second stage of labor. The client is experiencing uterine
contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this
behavior as
a. Exhaustion
b. Fear of losing control

c. Involuntary grunting
d. Valsalvals maneuver