1. Mrs. Diez in her first trimester of pregnancy asks about her nutritional needs, if she needs to double her daily dietary servings. What is your best response?

a. eat just enoughb. double your food intake to ensure proper nutritionc. do not increase your calories in the first trimester but to add 300 calories during the 2nd and 3rd trimesterd. take some foods essential for the baby’s growth always.

2. During the antepartal stage, the nurse recognizes that the placenta is formed from the:

a. decidua capsularisb. decidua basalis and decidua verac. chorionic villi and decidua basalisd. chorionic villi and decidua vera

3. During a mother’s class, a pregnant mother asks at what stage is sex of offspring determined?

a. oogenesisb. capacitationc. miosisd. fertilization

4. A nurse is doing assessment of a pregnant at risk client. She knows that preterm birth least likely has a record of:

a. gestational age of 12 to 16 weeksb. intact membranes with clinical effacement of 50% or morec. gestational age of 20 to 37 weeksd. uterine contractions of four in 20 min

5. The nurse assess the pregnant woman. She refers the client to the hospital, and said she cannot give birth at home. She must be:

a. on her 5th pregnancyb. full termc. cephalic presentationd. primigravida

6. It was one of the prenatal visits that Mrs. Maragas learned about subtle signs of preterm labor. Aside from the sudden increase in hourly contractions within the 24 hr period, which among these should she least expect:a. rhythmic dull backache or pelvic ache with “heavy feeling”

b. uterine and intestinal crampingc. recurrent stabbing abdominal painsd. menstrual-like abdominal aches or thigh croup

7. Mrs. Osias is wheeled to the Delivery room at 10cms dilatation and the head is fast emerging. Awaiting the arrival of the attending physician, what is the initial action of the nurse?

a. support the head while the rest of the body is spontaneously deliveredb. push down on the fundus it helps expel the infantc. call the doctor STATd. deliver the shoulder by turning the presenting part to internal rotation

8. Mrs. Osias is kept informed of the progress of her delivery, after the delivery of the baby, the nurse expects to deliver the placenta. Expected time to deliver the placenta should be:

a. 10 -15 minsb. 3 – 10 minsc. 15 -20 minsd. 1 -3 mins

9. Mrs. Pantaleon is experiencing true labor contractions. She describes the discomforts as:

a. starting over the fundus, radiating downward to the cervixb. radiating upward and downward from the umbilicusc. localized over the fundus of the uterusd. beginning at the lower back and abdomen radiating over entire abdomen

10. The nurse is preparing the pregnant client for delivery. Care of the client includes positioning the client. The client is expected to assume:

a. sims or semi- sitting positionb. lying on the side with head elevatedc. any positiond. lithotomy position

11. The nurse doing vaginal exam on a woman in labor records: 25% cm, -1. The nurse understands it to be:

a. fetal presenting part is 1cm above the ischial spinesb. cervical dilation is 25% completed

c. progress of effacement is 5 cm completedd. fetal presenting part is 1cm

12. Janice, a pregnant mother attends a nutrition class. Janice is placed on a high protein diet. Janice should add to her meals:

a. rice and vegetablesb. fruits and vegetablec. beans and riced. potato and carrots

13. Mrs. Rapas has just delivered a handsome baby boy. Mrs. Rapas asks when she resume work? The nurse’s appropriate response is:

a. 6 weeksb. 1 weekc. 3 weeksd. 10 weeks

14. During the mother’s class, the nurse instructs women to submit regularly for mammogram. Its important to schedule mammogram:

a. When they first become sexually activeb. once on a regular yearly basisc. once a year for women older than 50 yearsd. when lump is detected by self examination

15. Rica, is on her fifth monthly prenatal check-up. During the last three visits, the nurse noted that Rica has slightly increased BP. The nurse expects Rica’s brachial blood pressure reading is highest when is:

a. lying on the right sideb. supinec. sittingd. lying on the left side

Situation : Regular prenatal check-up is important to assess the progress of pregnancy and to correct abnormalities.

16. Nurse Lisa is doing an assessment of a woman who thinks she is pregnant. Lisa is positive that the woman is pregnant if she notes:

a. bluish cervixb. fetal heart tonesc. facial chloasmad. tenderness of the breast

17. During assessment , the client claims she is pregnant because she feels the baby “flattering around”. Nurse Annie immediately considers this sign as a:

a. negative signb, presumptive signc. positive signd. probable sign

18. The nurse is aware that one of the complications of pregnancy is maternal death due to postpartal hemorrhage. The nurse’s best judgment of postpartal hemorrhage is bleeding of:

a. 500 mlb. 20 mlc. 400mld. 300ml

19. When assessing Sharon’s amniotic fluid, the nurse expects these findings:

a. cloudy with particlesb. odorlessc. crystallized ferming patternd. dark yellow

20. After delivery, the nurse checks for retained placenta. What is the nurse’s immediate response for retained placenta?

a. uterine contractionb. vaginal packingc. uterine massage d. administer stimulants

21. When caring for a client during the 2nd stage of labor, which of the following actions would beleast appropriate?

a. assisting the client with pushingb. ensuring the clients legs are positioned appropriatelyc. allowing the client clear liquidd. d. monitoring fetal heart rate

22. During one of the health center visits, a pregnant woman asks what to do with complaints of morning sickness. The nurse’s initial response is for the pregnant woman to take:

a. iced teab. buttered breadc. ice milkd. crackers

23. The nurse is doing an assessment on Josie, 2 months pregnant for complaints of nocturia. The nurse advised her to slow down on fluids at night. While in bed, it is also best for Josie to assume:

a. side-lying positionb. sitting positionc. supine positiond. fowler’s position

24. A nurse prepares a 24 hour old newborn for discharge. While doing assessment, the nurse notes that the respiratory status and expects the respiration to be;

a. shallow and regularb. gruntingc. irregular in rate and depthd. with crackles on auscultation

25. One day old mother is alarmed when she saw baby holding his breath for a few seconds and seemingly has stopped breathing. What is the nurse’s initial response?

a. reassure parents that this is an expected pattern of breathing for a newbornb. call the physicianc. bring the newborn to the clientd. inform the parents to ignore this observation as their baby is healthy

26. Which of the following should be the nurse initial action immediately following the birth of thebaby?

a. aspirating mucus from the infants nose and mouthb. drying the infant to stabilize infant's temperaturec. promoting parenteral bondingd. identifying the newborn

27.The first stage of labor begins with

a. true labor contractionsb. full dilatation of the cervixc. rupture of membranesd. delivery of the baby

28. The second stage of labor begins with

a. delivery of the babyb. full dilatationc. rupture of the membraned. true labor contractions

29. The nurse shows a mother how to change the diaper of her 18-hr old newborn. The mother then expresses concern about the bowel movement that is dark black-green in color. The nurse’s appropriate actions is to:

a. explain to the mother that the stool called meconium is characteristic of newborn’s first bowel stoolsb. inquire if she took iron during pregnancyc. inform the mother that the stool may harbor parasitesd. submit the stool for occult blood test

30. Another nurse’s responsibility is prevention of disease. One of the mothers attending a mother’s class asks why babies are prone to infection. The nurse is correct when she says:

a. their immune system is still undevelopedb. all babies have antibodies from their mothersc. babies are less exposed to harmful microorganismd. skin of babies are quite intact

Situation: Allan is a high school student who wants to know more about the reproductive system. He seeks consultation at the school clinic.

31. He asks the doctor, what body structure is responsible for the production of Follicle Stimulating Hormone (FSH) ? The nurse’s responses will likely be;

a. testesb. hypothalamusc. anterior pituitary glandd. kidney

32. Which of the function of vas deferens?

a. site of spermatogenesisb. storage for spermatozoac. conduit for spermatozoa

d. passage way for semen

33. The following are characteristics of normal sperms. Which one is not included?

a. life span is 72 hrsb. normal count is 60 – 120 million per mlc. pH is acidicd. volume per ejaculation in 3-5ml

34. A male gland located behind the bladder that is the source of about 60% of seminal fluid?

a. cowper’s glandb. prostate glandc. seminal vesiclesd. testes

35. The normal volume and sperm content of seminal fluid per ejaculation to be considered fertile is;

a. 1ml/100 million sperm cellsb. 3ml/300 million sperm cellsc. 3ml/30 million sperm cellsd. 1ml/ 20 million sperm cells

36. The male hormone testosterone, which maintains spermatogenesis, is synthesized and released by;

a. semeniferous tubulesb. sertoli’s cellsc. seminal vesiclesd. leydig’s cells

37. The vas deferens is a;

a. storage for spermatozoab. conduit for spermatozoac. site of spermatozoa productiond. passageway for semen

38. Which part of the testes is responsible in the production of spermatozoa?

a. seminiferous tubulesb. sertoli cells

c. cortexd. leydig cells

Situation : Ms. Emma Castillo is giving a lecture on Maternity nursing to a group of graduating nursing students. She is currently discussing the menstrual cycle.

39. The maturation and release of ovum is called;

a. fertilizationb. ovulationc. conceptiond. none of these

40. Which of the following follicles are actively producing hormones?

a. Primordial follicles and Graafian follicles b. Corpus Luteum and corpus albicansc. Corpus luteum and Graafian folliclesd. Primordial follicle and corpus albicans

41. Which of the following organs is not involved in hormone secretion?

a. ovariesb. hypothalamusc. uterusd. pituitary gland

41. An adolescent girl asked how much blood is usually lost every menstruation. The correct response to this question is:

a. from 2 to 4 tbsp of bloodb. from 2 to 4 tsp of bloodc. from 20 – 40 tbsp of bloodd. from 20 to 40 tsp of blood.

42. In the menstrual cycle, the proliferative phase which is characterized by the growth of endometrium is under the influence of;

a. progesterone b. estrogenc. human chorionic gonadotropind. corpus luteum

43. In counting the days of menstrual cycle, day is the;

a. first day of menstruation b. last day of menstruation c. day of ovulationd. a day before ovulation

44. The sign of ovulation where the cervical mucus can be stretched 10 to 12 cm is known as:

a. mittelschmerzb. spinnbarkheitc. both of thesed. none of these

45. The temperature elevation seen just before or during ovulation is caused by the:

a. thermogenic effect of progesteroneb. intraperitoneal irritation of the released ovumc. thermogenic effect of estrogen and FSHd. can be due to infection

46. Production of progesterone in a nonpregnant woman is a function of:

a. all of theseb. corpus luteumc. ovumd. graafian

47. Menstruation is ultimately due to:

a. progesterone withdrawalb. progestin stimulationc. estrogen withdrawald. estrogen stimulation

48. Which of the following regarding menarche is correct?

a. it occurs between ages 11 to 14b. it is a sign of pubertyc. all of thesed. it is indicative of sexual maturity

49. The follicular phase of the ovarian cycle may be said to be synonymous with:

a. proliferative phase of the endometrial cycle

b. postovulatory phase of the ovarian cyclec. secretory phase of the endometrial cycled. shedding of blood during the menstrual cycle.

50. . In a nutrition class, Amy a pregnant mother from a sectarian group claims to be on strict vegetarian diet. The nurse should advise intake of:

a. Vit. Cb. Vit. B12c. Vit Dd. Vit A

51. A pregnant woman was advised by the doctor to take folic acid. The nurse explains that it is especially needed primarily because it:

a. assists in growth of heart and lungsb. helps in coagulation of RBCc. is essential for cell and RBC formationd. helps in maternal circulation

52. . The nurse discovers a loop of the umbilical cord protruding through the vagina when preparing to perform vaginal examination. The most appropriate intervention is to:

a. call the physician immediatelyb. place a moist clean towel over the cord to prevent dryingc. immediately turn the client on her side and listen to FHRd. perform vaginal examination and apply upward digital pressure to the presenting part while having the mother assume a knee-chest position

53. . During augmentation of labor with IV oxytoxin, a multiparous client becomes pale and diaphoretic and complains of severe lower abdominal pain with a tearing sensation. Fetal distress is noted on the monitor. The nurse should suspect?

a. precipitate laborb. amniotic fluid embolusc. rupture of the uterusd. uterine prolapse

54. . A mother with mastitis is concerned about breast feeding while she has an active infection. The nurse should explain that:

a. the infant is protected by immunoglobulin in the breast milkb. the infant is not susceptible to the organism that cause mastitis

c. the organisms that cause mastitis is not passed in the milkd. the organisms will be inactivated by gastric acid 55. Which of the following signs of thrombophlebitis must the nurse educate the postpartal client to assess at home after discharge from the hospital?

a. muscle soreness in her legs after exerciseb. varicose veins in her legsc. local tenderness , heat and swellingd. bruising 56. Which of the following instruction should be included in the discharge teaching plan to assist the postpartal client early signs of complications?

a. the passage of clots as large as an orange is expectedb. report any decrease in the amount of brownish red lochiac. palpate the fundus daily to make sure it is softd. notify the health care provider for any increase in the amount of lochia or a return to a bright red bleeding

57. Which of the following interventions is appropriate to help a lactating client prevent mastitis?

a. apply vitamin E cream to soften nippleb. wear a tight supportive brac. when the client’s nipple is sore, offer the infant a bottled. encourage the client to breastfed her infant frequently

58. Upon assessment of postpartal client the nurse observes symptoms of infection. Which of the following symptoms indicate infection?

a. pinkish lochiab. bradycardiac. abdominal tendernessd. oral temp of 99.2 F

59. After the delivery of a large for gestational age infant, a client is noted to have bright red blood continuously tricking from the vagina. Her fundus is firm and located in the midline. What is the most likely cause of the bleeding?

a. lacerationsb. hematomac. uterine atonyd. retained fragments of conception

60. A client who is in the 1st trimester, is scheduled for an abdominal ultrasound. When explaining the reason for early pregnancy ultrasound, the nurse should tell the client which of the following?

a. the test will help to determine if your baby is in good position for deliveryb. the test will help to determine how many weeks you have been pregnantc. the test will help to determine if you have an intrauterine growth restrictiond. the test will help to determine if you have enough amniotic fluid

61. The client’s prenatal education includes danger signs to report. Which of the following, if reported would indicate that the client understood the teaching?

a. dizziness and blurred visionb. occasional nausea and vomitingc. no BM for 3 daysd. ankle edema

Questions 62 – 64

A 35 year old woman, gravida 3 para 2 is first seen in the antepartal clinic at 16 weeks gestation. At 24 weeks the doctor notes that her uterus is enlarged to size consistent with her at 24 weeks the doctor notes that her uterus is enlarged to size inconsistent with her estimated twins. Polyhydramnious is also noted.

62. Because of the presence of twins, the nurse would expect the patient to have a greater than the usual likelihood of which discomfort of pregnancy?

a. breast tendernessb. leucorrheac. varicose veinsd. urinary tract infections

63. The doctor tells the patient that her delivery will probably be slightly premature because this is very common with twins. Her chances of having a premature delivery are further increased by:

a. an excessive weight gainb.vulvar varicositiesc. recurrent vaginal infectionsd. polyhydramnios

64. The pastient goes into premature labor at 35 weeks. Which of the following complications of labor would the nurse anticipate because of her polyhydramnios?

a. vaginal bleedingb. ineffective uterine contractionsc. decrease in fetal heart rated. cephalopelvic disproportion

Questions 65 – 56

A 28 year old woman is 8 months pregnant. When she awakened this morning, she found herself lying in a pool of blood. She states that she was hospitalized in her seventh month for a bleeding episode. She does not have any pain associated with the bleeding.

65. Upon the patient’s admission to the labor room, the nurse should plan the interventions on the assumptions that the patient’s diagnosis is most:

a. abruption placentab. Placenta previac. dystociad.ruptured uterus

66. A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention?

a. urine specific gravity of 1,010b. serum potassium level of 4Eq/dlc. serum sodium 140 mEq/dld. ketones in the urine

67. The nurse is reviewing the client’s prenatal history. Which finding indicates a genetic risk factor?

a. the client is 25 yr oldb. the client has a child with cystic fibrosisc. the client was exposed to rubella at 25 weeks gestationd. the client has a history of preterm labor at 32 weeks gestation

68. While bottle feeding her neonate, a post partum client asks the nurse when she can expect her menstrual period to return. How should the midwife respond?

a. in 1 – 2 weeks

b. in 3 – 4 weeksc. in 7 – 9 weeksd. in 10 – 12 weeks

69. An early detection of ectopic pregnancy is paramount to preventing a life threatening-rupture. Which symptoms should the nurse to the possibility of an ectopic pregnancy?

a. abdominal pain, vaginal bleeding. And a positive pregnancyb. hyperemesis and weight lossc. amenorrhea and negative pregnancy testd. copious discharge of clear mucous and prolonged epigastric pain

70. A client who is being admitted to labor and delivery room has the following assessment findins:

gravida 2 para 1, estimated 40 weeks gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time?

a. placing the client in bed to begin in fetal monitoringb. preparing for immediate deliveryc. checking for ruptured membranesd. providing comfort measures

71. In the maternal attachment process, which of the following best describes an anticipated actions in the taking hold phase?

a. mother’s needs being met firstb. looking at the infantc. kissing embracing and caring for the childd. talking about the baby

72. For a client who is fully dilated, which of the following actions would be inappropriate during the second stage of labor?

a. positioning the mother for effective pushingb, preparing for the delivery of the babyc. assessing vital signs every 15 minsd. assessing for rupture of membrane

73. A client is 8 weeks pregnant. Which teaching topic is most appropriate at this time?

a. breathing techniques during laborb. common discomforts of pregnancy

c. infant care responsibilitiesd. neonatal nutrition

74. A client who is moving into active phase of labor, the nurse should include which of the following as priority care?

a. offer support by reviewing the short pant form of breathingb. administer a narcotic analgesia per doctor’s orderc. allow the mother to walk around the unitd. watch for the rupture of the membrane

75. During an annual check-up a client tells the nurse that she and her husband have decided to start a family . Ideally when should the nurse plan for childbirth education to begin and end?

a. begin early in the 3rd trimester and end 1 month after deliveryb. begin before conception and end 3 months after deliveryc. begin when the client learns that she is pregnant and end after deliveryd. begin at 5 months gestation and end at facility discharge

76. During the 4th stage of labor the client should be carefully assessed for:

a. uterine atonyb. complete cervical dilatationc. placental expulsiond. umbilical cord prolapse

77. Weng complains of constipation. The nurse should explain that constipation frequently occurs during pregnancy because of:

a. pressure of the growing uterus on the anusb. increased intake of milk as recommended during pregnancyc. the slowing of peristalsis in the GITd. changes in the metabolic rate

78. Weng begins labor close to her expected date of delivery and is admitted to the hospital. The nurse notices a gush of fluid from the client’s vagina. After checking the FHR the nurse should:

a. notify the physician immediately about the gush of fluid from the vaginab. place the client in modified lithotomy position and inspect the perineumc. keep the client flat in bed and elevate the legsd. place the client on her side and obtain her BP

79. After several hours of labor the physician orders oxytocin. When a client in labor is being infused with oxytocin, it is the nurse’s role:

a. obtain a physician order to slow the IV in the presence of hypertonic contractionsb. flush the IV tubing if the flow slows with the staff nurse permissionc. shut off the IV in the presence of hypertonic contractions and report to the nursed. monitor fetal heart tones every 2 hours

Questions 80- 84Jane 2 ½ months pregnant comes to the prenatal clinic for the first time.

80. Jane asks the clinic nurse how smoking will affect the baby. The nurse’s answer reflects the following knowledge:

a. fetal and maternal circulation are separated by the placental barrierb. the placenta is permeable to specific substancesc. smoking relieves tension and the fetus responds accordinglyd. vasoconstriction will affect both fetal and maternal blood vessels

81. Jane is concerned about the mask of pregnancy. The dark nipples and the dark line from her navel to her pubis. The nurse explains that these adaptations are caused by the hyperactivity of the:

a. adrenal glandb. thyroid glandc. ovariesd. pituitary gland

82. Jane complains of morning sickness. The nurse realizes that a predisposing factor that causes morning sickness during the 1st trimester of pregnancy is the adaptation to increased level of:

a. estrogenb. progesteronec. luteinizing hormoned. chorionic gonadotropin

83. The nurse can help Jane overcome morning sickness by suggesting she:

a. eat morning until the nausea subsidesb. take an antacid before bedtimec. request her physician to prescribe her anti-emeticd. eat dry toasted bread before arising

84. Jane delivers a healthy baby boy. Two days postpartum, after receiving a phone call from her babysitter informing her that her 2 yr old has been very upset since her admission to the hospital and not eating. Jane decided to ask for discharge out of the hospital. Staff members have been unable to contact her physician. Jane is ready to leave and asks that her infant to be given to her to dress and take home. Appropriate action would be:

a. explain to Jane that her infant must remain in the hospital until discharged by the physician.b. allow Jane time with the baby to cuddle him before she leaves but emphasize that the baby is a minor and legally must remain until orders for discharge are received.c. tell Jane that under the circumstances hospital policy prevents the staff from releasing the infant into her care, but she will be informed when he is dischargedd. give the baby to Jane to take home making sure she receives information regarding care and feeding of a 2 day old infant and any potential problem that may develop.

85. During her 4th clinic visit, a client who is 5 months pregnant tells the nurse that she was exposed rubella during the past week and asks whether she can be immunized now. How would the nurse respond?

a. yes, but immunization against rubella requires a physician orderb. No, because the live viral vaccine is contraindicated during pregnancy.c. yes, and you should consider pregnancy termination because rubella has a teratogenic effectd. no because the vaccine can be given only during 1st trimester of pregnancy

86. When caring for a client during the 2nd stage of labor, which of the following actions would be least appropriate?

a. assisting the client with pushingb. ensuring the clients legs are positioned appropriatelyc. allowing the client clear liquidd. monitoring fetal heart rate

87. Which of the following should be the nurse initial action immediately following the birth of the baby?

a. aspirating mucus from the infants nose and mouthb. drying the infant to stabilize infants temperaturec. promoting parenteral bonding

d. identifying the newborn

Question 88 - 90

Cathy, age 21 is 37 weeks pregnant. She is admitted to the hospital with preeclampsia and sudden abdominal pain.

88. On Cathy’s admission to the unit the nurse should observe for:

a. decrease in size of uterus, cessation of contractions, visible or concealed hemorrhageb. firm and tender uterus, concealed or external hemorrhage, shockc. increase in size uterus, visible bleeding, no associated paind. shock, decrease in size uterus, absence of external bleeding

89. The nurse realizes that the abdominal pain associated with abruption placenta is caused by:

a. hemorrhagic shockb. inflammatory reactionsc. blood in the uterine muscled. concealed hemorrhage

90. Cathy delivers a stillborn babygirl. To foster a healthy grieving response to the birth of stillborn child, the nurse best response to an expression of anger from Cathy would be:

a. it is God’s will we have to have faith that it was for the bestb. you are wrong you will have other childrenc. this is often happens when something is wrong with the babyd. you maybe wondering if something you did caused this

Questions 91 - 93

Christine , 9 months pregnant is admitted to the hospital with bleeding caused by possible placenta previa. The laboratory technician takes blood samples and IV fluids are begun.

91. The nurse is attending with a client with oxygen by mask. The client’s apprehension is increasing and she asked the nurse what is happening. The nurse tells her not to worry that she is going to be all right and everything is under control. The nurse statements are:

a. correct, since only the physician should explain why treatment are being done

b. proper, since the client’s anxieties would be increased if she knew the dangersc. adequate, since all preparations are routine and need no explanation.d. questionable, since the client has the right to know what treatment is being given and why

92.. Care for Christine includes:

a. withholding foods and fluidsb. encouraging ambulation and supervisionc. inspecting the hemorrhaged. avoiding all extraneous stimuli

93. If a vaginal examination is to be performed on Christine, the nurse should be prepared for an immediate:

a. induction of laborb. cesarean sectionc. forceps deliveryd. x-ray examination

Questions 94 - 95

Audril is 27 yr old, gravida 1 para o with a childhood history of rheumatic fever. She has been admitted to the hospital at 35 weeks gestation because of shortness of breath.

94. Normal hemodynamics of pregnancy that affect the pregnant cardiac client include the:

a. decrease in the number of RBCb. rise in cardiac output after the 34th weekc. gradually increasing size of the uterusd. cardiac acceleration in the last half of pregnancy

95. Shortly after admission. Audril goes into labor. To prevent cardiac decompensation during labor the nurse should:

a. position Audril on her side with shoulders elevatedb. maintain an IV infusion of potassium chloridec. administer sodium IV infusion with the IV nursed. administer oxytocin to strengthen contractions with doctor’s order

96. Intervention of a women in premature labor includes:

a. reassuring that the situation is under control

b. explaining why pain medication is kept at a minimumc. encouraging her not to bear downd. keeping her NPO to prevent abdominal distention

97. During the post partal period it is not uncommon for a new mother to have an increased cardiac output with tachycardia. The nurse should observe the client carefully for signs of:

a. irregular pulseb. respiratory distressc. increased vaginal bleedingd. hypovolemic shock

98. The nurse is caring for a woman who is in labor. She is 8cm dilated. To support her during this phase of labor the nurse should:

a. leave her alone most of the timeb. offer her back rub during contractionc. offer her sips of oral fluidd. provide her with warm blanket

99. A woman who is gravida 1 is in the active phase of labor. The fetal position is LOA. When the membranes rupture , the nurse should expect to see:

a. a large amount of bloody fluidb. a moderate amount of clear to straw colored fluidc. a small amount of greenish fluidd. a small segment of the umbilical cord

100. A woman’s cervix is completely dilated with the head at -2 station. The head has not descended in the past hour. What is the most appropriate initial assessment for the nurse to make?

a. assess to determine if the client’s bladder is distendedb. send the client for x-ray to determine fetal sizec. notify the surgical team so that an operative delivery can be plannedd. assess fetal status, including fetal heart tones , and scalp ph