A nonstress test is performed, and the physician documents “accelerations lasting less than 15 seconds
throughout the fetal movement.” The nurse interprets these findings as:
A. Normal
B. Reactive
C. Nonreactive Correct
D. Inconclusive
Rationale: A reactive nonstress test is a normal, or...
Maternity Evolve Exam
1. A nonstress test is performed, and the physician documents “accelerations lasting less than 15 seconds
throughout fetal movement.” The nurse interprets these findings as:
A. Normal
B. Reactive
C. Nonreactive Correct
D. Inconclusive
Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two
or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the
acceleration to the end, in association with fetal movement, during a 20minute period. A nonreactive test is an abnormal
test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40
minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart
rate recording.
TestTaking Strategy: Use the process of elimination. Eliminate a reactive nonstress test and a normal nonstress test first
because they are comparable or alike. To select from the remaining options, note the relationship between “less than 15
seconds” in the question and “nonreactive” in the correct option. If you had difficulty answering this question, review the
interpretation of nonstress test results.
2. A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than
2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased
variability. In light of these findings, the appropriate nursing action is:
A. Contacting the physician Correct
B. Documenting the findings
C. Continuing to monitor the client
D. Reassuring the client and her partner that labor is progressing normally
Rationale: Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer,
contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, persistently decreased
variability, or an irregular FHR. The normal FHR is 110 to 160 beats/min. Therefore, because the finding is abnormal, the
physician must be contacted. Continuing to monitor the client delays necessary intervention. Reassuring the client that
labor is progressing normally is incorrect. The nurse would document the data, actions taken, and the client’s response,
but, of the options provided, contacting the physician is the most appropriate.
TestTaking Strategy: Use the process of elimination and focus on the data in the question. Eliminate the options that are
comparable or alike and indicate that the data in the question are normal findings. Review normal assessment findings
during the labor process if you had difficulty with this question.
3. A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching
the baby. Which statement by the nurse is appropriate?
A. “I know how you feel.”
B. “This must be hard for you.” Correct
C. “Now you have an angel in heaven.”
, D. “You’re young. You can have other children.”
Rationale: Therapeutic communication helps the mother, father, and other family members express their feelings and
emotions. “This must be hard for you” is a caring and empathetic response, focused on feelings and encouraging
communication. The other options are nontherapeutic and may devalue the family members' feelings.
TestTaking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option
that is focused on the family members’ feelings. Review therapeutic communication techniques if you had difficulty with
this question.
4. A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to
rubella. The nurse tells the client that:
A. A rubella vaccine must be administered immediately
B. A rubella vaccine must be administered after childbirth Correct
C. She will not contract rubella if she is exposed to the disease
D. She does not need to be concerned about being exposed to rubella
Rationale: A prenatal rubella antibody screen is performed in every pregnant woman to determine whether she is immune
to rubella, which can cause serious fetal anomalies. If she is not immune, rubella vaccine is offered after childbirth to keep
her from contracting rubella during subsequent pregnancies. The vaccine is a live virus, and defects might occur in the
fetus if the vaccine were administered during pregnancy or if the mother were to become pregnant soon after it was
administered. Administering a rubella vaccine immediately places the fetus at risk. Telling the client that she does not
need to be concerned about being exposed to rubella is incorrect, because the possibility of exposure, which could be
harmful to the fetus, does exist.
TestTaking Strategy: Use the process of elimination. Eliminate first the options that are comparable or alike (i.e., the
client will not acquire rubella and does not need to be concerned about exposure). To select from the remaining options,
recall that rubella vaccine is a live virus; this will direct you to the correct option. Review rubella vaccine and its
implications during pregnancy if you had difficulty with this question.
5. A nurse caring for a client in the active stage of labor assesses the fetal status and notes a late deceleration on
the monitor strip. In light of this finding, which nursing action is the priority?
A. Documenting the finding
B. Preparing for immediate birth
C. Administering oxygen by way of face mask Correct
D. Increasing the rate of the oxytocin (Pitocin) infusion
Rationale: Late decelerations are a result of uteroplacental insufficiency stemming from decreased blood flow and oxygen
transfer to the fetus during uterine contractions. This causes hypoxemia; therefore oxygen is necessary, making the
administration of oxygen the correct choice. Late decelerations are considered an ominous sign but do not necessarily
require immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The
oxytocin would cause further hypoxemia, because the medication stimulates contractions, leading to increased
uteroplacental insufficiency. Although the finding needs to be documented, documentation is not the priority action in this
situation.
TestTaking Strategy: Note the strategic word “priority” in the question. Use your knowledge of the ABCs — airway,
, breathing, and circulation — to answer the question. This will direct you to the correct option, the one that addresses
oxygen. Review content on late decelerations if you had difficulty with this question.
6. A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally.
The nurse tells the client that:
A. The exercises should be delayed for 1 month to allow healing
B. Performing such exercises in the postpartum period may result in stress urinary incontinence
C. Alternating contraction and relaxation of the muscles of the perineal area should be practiced Correct
D. Abdominal exercises will be started while the client is in the hospital as a means of evaluating
tolerance
Rationale: Postpartum exercises may be started soon after birth, although the woman should be encouraged to begin with
simple exercises and gradually progress to more strenuous ones. Abdominal exercises are postponed until approximately
4 weeks after a cesarean birth. Kegel exercises (alternated contraction and relaxation of the muscles of the perineal area)
are extremely important in strengthening the muscle tone of the perineal area after vaginal birth. Kegel exercises help
restore the muscle tone that is often lost as pelvic tissues are stretched and torn during pregnancy and birth. Women who
maintain muscle strength may benefit years later, experiencing continued urinary continence.
TestTaking Strategy: Use the process of elimination. Note the relationship between the word “vaginally” in the question
and “perineal area” in the correct option. Review the purpose and benefit of Kegel exercises if you had difficulty with this
question.
7. A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal
bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which
statement by the client indicates the need for further instruction?
A. “I need to stay in bed for the rest of my pregnancy.” Correct
B. “I need to avoid having sex until the bleeding has stopped.”
C. “I need to watch for stuff that looks like tissue coming from my vagina.”
D. “I need to count the number of perineal pads that I use each day and make a note of the amount and
color of blood on each pad.”
Rationale: Strict bed rest throughout the remainder of the pregnancy is not required. The woman is advised to curtail
sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding, as recommended by the
physician or nursemidwife. The woman is instructed to count the perineal pads she uses each day and to note the
quantity and color of blood on each pad. The woman should also watch for the evidence of the passage of tissue.
TestTaking Strategy: Use the process of elimination. Note the strategic words “need for further instruction” in the
question, which indicate a negative event query and the need to select the incorrect client statement. Noting the words
“stay in bed for the rest of my pregnancy” will direct you to this option. Review therapeutic management for threatened
abortion if you had difficulty with this question.
8. A nurse is assessing the respiratory rate of a newborn. Which finding would the nurse document as normal?
A. 20 breaths/min
B. 25 breaths/min
, C. 50 breaths/min Correct
D. 70 breaths/min
Rationale: The normal respiratory rate for a newborn infant is 30 to 60 breaths/min. All of the other options are outside the
normal range.
TestTaking Strategy: Knowledge regarding the normal respiratory rate of a newborn is required to answer this question. If
you are unfamiliar with the normal ranges for newborn vital signs, review this content.
9. A nurse notes that the laboratory report of a pregnant client with suspected HIV infection indicates leukopenia,
thrombocytopenia, anemia, and an increased erythrocyte sedimentation rate. Which laboratory test that would further
confirm the presence of HIV does the nurse anticipate that the physician will prescribe?
A. Platelet count
B. Angiotensin level
C. Glomerular filtration rate
D. Tlymphocyte determination Correct
Rationale: HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV for Tlymphocytes
leads to significant cell destruction. Angiotensin is produced in the kidney and plays a role in blood pressure control.
Glomerular filtration rate is an indicator of kidney function. The platelet count is important and may be used as an indicator
of the effects of HIV, but the platelet count (thrombocytopenia) has already been addressed in the question.
TestTaking Strategy: Use the process of elimination, focusing on the subject, the presence of HIV. Eliminate the platelet
count, because this has already been addressed in the question (thrombocytopenia). Next eliminate the options that are
comparable or alike in that they are related to kidney function. If you had difficulty with this question, review the clinical
manifestations and pathology of HIV infection.
10. A nurse palpates the anterior fontanel of a neonate and notes that it feels soft.
This nurse interprets this assessment data as:
A. A normal finding Correct
B. Indicative of dehydration
C. Indicative of increased intracranial pressure
D. Indicative of decreased intracranial pressure
Rationale: The anterior fontanel, which is diamond shaped, is located on the top of the head. It measures 1 to 4 cm but
varies because of molding and individual differences. It normally closes by 12 to 18 months of age. It may be described as
soft, which is normal, or full and bulging, which may be indicative of increased intracranial pressure. Conversely, a
depressed fontanel could mean that the neonate is dehydrated.
TestTaking Strategy: Use the process of elimination, noting the strategic words “feels soft” in the question. Remember
that the anterior fontanel is soft in the neonate. If you had difficulty answering this question, review normal assessment
findings in the neonate.
11. A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be
taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately:
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