Question: A nurse is assessing a pregnant client in her third trimester. Which
assessment finding would be of most concern?
A) Fetal heart rate of 140 bpm
B) Fundal height measuring 30 cm
C) Severe headaches with visual disturbances
D) Mild edema of the lower extremities
Answer: C) Severe headaches with visual disturbances
Rationale: Severe headaches and visual disturbances may indicate gestational
hypertension or preeclampsia, which can pose serious risks to both the mother and
fetus. Other findings, like a normal fetal heart rate and fundal height, are expected.
,Question: During a prenatal visit, the nurse provides education about the signs of
preterm labor. Which statement by the client indicates a need for further teaching?
A) "I should report any increase in vaginal discharge."
B) "I can continue my usual activities unless I feel contractions."
C) "I should contact my healthcare provider if I experience back pain."
D) "If I notice a change in my baby's movements, I should wait a few days to see if it
improves."
Answer: D) "If I notice a change in my baby's movements, I should wait a few days to
see if it improves."
Rationale: Changes in fetal movement should be reported immediately; waiting is
not advisable as it can indicate fetal distress.
Question: A nurse is caring for a client who has just undergone a cesarean section.
Which nursing intervention is the highest priority?
A) Encouraging ambulation
B) Monitoring vital signs
C) Assessing the surgical incision
D) Administering pain medication
Answer: B) Monitoring vital signs
Rationale: After a cesarean section, the priority is to monitor vital signs for any signs
of complications such as hemorrhage or infection. Other interventions are important
but secondary.
Question: A woman in labor is requesting an epidural for pain management. What
should the nurse assess before administering the epidural?
A) Maternal blood type
B) Maternal vital signs
C) Fetal heart rate patterns
,D) Cervical dilation
Answer: B) Maternal vital signs
Rationale: Maternal vital signs are crucial to assess before administering an epidural
to ensure there are no contraindications such as hypotension.
Question: What is the primary purpose of administering Rho(D) immune globulin
(RhoGAM) to a Rh-negative mother?
A) To prevent maternal infection
B) To prevent hemolytic disease in the newborn
C) To enhance fetal growth
D) To stimulate uterine contractions
Answer: B) To prevent hemolytic disease in the newborn
Rationale: RhoGAM is administered to prevent the development of antibodies
against Rh-positive blood in Rh-negative mothers, thereby preventing hemolytic
disease in future pregnancies.
Question: A client at 32 weeks' gestation presents with painless vaginal bleeding.
What is the most likely cause of this finding?
A) Abruptio placentae
B) Placenta previa
C) Preterm labor
D) Uterine rupture
Answer: B) Placenta previa
Rationale: Placenta previa typically presents as painless vaginal bleeding in the third
trimester. Abruptio placentae is associated with painful bleeding, and preterm labor
is typically accompanied by contractions.
Question: A client who is 37 weeks pregnant reports a sudden gush of fluid from her
vagina. What is the nurse’s initial action?
, A) Check the fetal heart rate
B) Assess maternal blood pressure
C) Perform a sterile vaginal exam
D) Administer oxygen
Answer: A) Check the fetal heart rate
Rationale: The first priority is to assess fetal well-being, as ruptured membranes may
lead to cord prolapse, which can compromise the fetus. Monitoring the fetal heart
rate will help determine fetal distress.
Question: During a postpartum assessment, the nurse notes a firm fundus but a
steady trickle of bright red blood from the vagina. What is the most likely cause?
A) Uterine atony
B) Vaginal laceration
C) Retained placental fragments
D) Subinvolution of the uterus
Answer: B) Vaginal laceration
Rationale: A firm fundus with continued bleeding suggests a vaginal or cervical
laceration. Uterine atony and retained placental fragments typically cause a soft
uterus with bleeding.
Question: A nurse is reviewing discharge instructions with a postpartum client who is
breastfeeding. Which of the following should the nurse include?
A) "You should avoid drinking any water while breastfeeding."
B) "Alternate breasts with each feeding session."
C) "Limit your intake of high-fiber foods."
D) "Expect to ovulate within 2 weeks after delivery."
Answer: B) "Alternate breasts with each feeding session."
Rationale: Alternating breasts with each feeding helps ensure both breasts are
emptied, reducing the risk of engorgement and maintaining milk production.
Ovulation typically does not resume this early, especially in breastfeeding women.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Alvon. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $15.99. You're not tied to anything after your purchase.
