01. A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of the
following assessments is the nurse's priority?
Amount of lochia
When using the airway, breathing, circulation approach to client care, the nurse should place the
priority in the immediate postpartum period on assessing the amount of postpartum lochia.
The greatest risk to the client is bleeding and postpartum hemorrhage.
02. A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior
position. The client is dilated to 8 cm and reports back pain. Which of the following actions
should the nurse take?
Apply sacral counterpressure
The nurse should apply sacral counterpressure to assist in relieving back labor pain related to
fetal posterior position.
03. A nurse is demonstrating to a client how to bathe her newborn. In which order should the
nurse perform the following actions? (Move the steps into the box on the right, placing them in
the selected order of performance. Use all the steps.)
Wipe the newborn’s eyes from the inner canthus outward.
Wash the newborn’s neck by lifting the newborn’s chin.
Cleanse the skin around the newborn’s umbilical cord stump.
Wash the newborn’s legs and feet.
Clean the newborn’s diaper area.
The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty,
approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus
outward using plain water. The nurse should then wash the newborn's neck by lifting the
newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump
followed by washing the newborn's legs and feet. The last step of the bath should be to clean the
newborn's diaper area.
04. A nurse is caring for a client and her partner who have experienced a fetal death. Which of
the following actions should the nurse take?
Take photos of the newborn to give to the parents.
The nurse should create a memory box that includes mementos of the newborn (for example,
photos, the newborn's ID bands, the newborn's hat, and the newborn's blanket).
,05. A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction
stress test. The nurse should plan to prepare the client for which of the following diagnostic
tests?
Biophysical profile
A positive contraction stress test indicates that further evaluation of the fetus is necessary. A
biophysical profile will provide further evaluation with real-time ultrasound.
06. A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia.
Which of the following laboratory results should the nurse report to the provider?
Platelets 50,000/mm3
A platelet count of 50,000/mm3 is below the expected reference range, which can indicate
disseminated intravascular coagulation. The nurse should report this result to the provider.
07. A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard
Score. Which of the following findings should the nurse expect?
Minimal arm recoil
The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased
muscular tone, or minimal arm recoil.
08. A nurse is assessing a newborn following a circumcision. Which of the following findings
should the nurse identify as an indication that the newborn is experiencing pain?
Chin quivering
Behavioral responses to a newborn's pain include facial expressions (for example, chin
quivering, grimacing, and furrowing of the brow).
09. A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor
(SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an
indication of withdrawal from an SSRI?
Vomiting
Expected clinical manifestation associated with fetal exposure to SSRIs include irritability,
agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.
Tachypnea – Hypoglycemia -- Low birth weight
10. A nurse is developing a plan of care for a newborn who is to undergo phototherapy for
hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Remove all clothing from the newborn except the diaper.
The nurse should remove all the newborn's clothing except the diaper while under phototherapy.
Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin.
, 11. A nurse is creating a plan of care for a client who is postpartum and adheres to traditional
Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in
the plan of care?
Protect the client’s head and feet from cold air.
Protecting the client's head and feet from cold air should be included in the plan of care because
this is a traditional Hispanic practice during the postpartum period.
12. A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions
should the nurse take prior to applying an external transducer for fetal monitoring?
Perform Leopold maneuvers.
The nurse should perform Leopold maneuvers to assess the position of the fetus to best
determine the optimal placement for the external fetal monitoring transducer
13. A nurse is caring for a client who is in active labor and has had no cervical change in the last
4 hr. Which of the following statements should the nurse make?
“Your provider will insert an intrauterine pressure catheter to monitor the strength of your
contractions.”
Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction
intensity, which will identify whether or not the contractions are adequate for progression of
labor.
14. A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock.
After notifying the provider, which of the following actions should the nurse take next?
Massage the client’s fundus.
The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is
to massage the client's fundus to expel clots and promote contractions.
15. A nurse is reviewing the medical record of a client who is one day postpartum. The client had
a vaginal birth with a fourth-degree perineal laceration. The nurse should contact the provider
regarding which of the following prescriptions?
Bisacodyl rectal suppository daily as needed for constipation
The nurse should not administer a rectal suppository or enema to a client who has a fourth-
degree perineal laceration. These can cause separation of the suture line, bleeding, or infection.
16. A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse
enters the room and observes the client having a seizure. After turning the client's head to one
side, which of the following actions should the nurse take next?
Administer oxygen via a nonrebreather mask.
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