Delivery Room/Newborn Care Evaluation

Name: ____________________________________ Date: ___________ Score: ______

1. The nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining self-
care measures for common discomforts of pregnancy, the nurse determines that the client understands
the instructions when she says:
A. “Nausea and vomiting can be decreased if I eat a few crackers before arising”
B. “If I start to leak colostrum, I should cleanse my nipples with soap and water”
C. “If I have a vaginal discharge, I should wear nylon underwear”
D. “Leg cramps can be alleviated if I put an ice pack on the area”
2. Thirty hours after delivery, the nurse in charge plans discharge teaching for the client about infant care.
By this time, the nurse expects that the phase of postpartal psychological adaptation that the client would
be in would be termed which of the following?
A. Taking in
B. Letting go
C. Taking hold
D. Resolution
3. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells
the client that the usual treatment for partial placenta previa is which of the following?
A. Activity limited to bed rest
B. Platelet infusion
C. Immediate cesarean delivery
D. Labor induction with oxytocin
4. Nurse Julia plans to instruct the postpartum client about methods to prevent breast engorgement.
Which of the following measures would the nurse include in the teaching plan?
A. Feeding the neonate a maximum of 5 minutes per side on the first day
B. Wearing a supportive brassiere with nipple shields
C. Breast-feeding the neonate at frequent intervals
D. Decreasing fluid intake for the first 24 to 48 hours
5. When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands
opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following
reflexes?
A. Startle reflex
B. Babinski reflex
C. Grasping reflex
D. Tonic neck reflex
6. A primigravida client at 25 weeks’ gestation visits the clinic and tells the nurse that her lower back
aches when she arrives home from work. The nurse should suggest that the client perform:
A. Tailor sitting
B. Leg lifting
C. Shoulder circling
D. Squatting exercises
7. Which of the following would the nurse Sandra most likely expect to find when assessing a pregnant
client with abruption placenta?
A. Excessive vaginal bleeding
B. Rigid, board-like abdomen
C. Titanic uterine contractions
D. Premature rupture of membranes
8. While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes
contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following
would be the nurse’s most appropriate action?
A. Note the fetal heart rate patterns
B. Notify the physician immediately
C. Administer oxygen at 6 liters by mask
D. Have the client pant-blow during the contractions
9. A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be
at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in?
A. Active phase
B. Latent phase
C. Expulsive phase
D. Transitional phase
10. A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding
for the past 8 hours. She has passed several cloth. What is the primary nursing diagnosis for this patient?
A. Knowledge deficit
B. Fluid volume deficit
C. Anticipatory grieving
D. Pain
11. A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms?
A. Proteinuria, headaches, vaginal bleeding
B. Headaches, double vision, vaginal bleeding
C. Proteinuria, headaches, double vision
D. Proteinuria, double vision, uterine contractions
12. Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith orders
I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient’s fluid intake and output
closely during oxytocin administration?
A. Oxytocin causes water intoxication
B. Oxytocin causes excessive thirst
C. Oxytocin is toxic to the kidneys
D. Oxytocin has a diuretic effect
13. Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent
hypothermia. What is a common source of radiant heat loss?
A. Low room humidity
B. Cold weight scale
C. Cools incubator walls
D. Cool room temperature
14. The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but
most difficult part of this stage?
A. Active phase
B. Complete phase
C. Latent phase
D. Transitional phase
15. After 3 days of breast-feeding, a postpartum patient reports nipple soreness. To relieve her
discomfort, the nurse should suggest that she:
A. Apply warm compresses to her nipples just before feedings
B. Lubricate her nipples with expressed milk before feeding
C. Dry her nipples with a soft towel after feedings
D. Apply soap directly to her nipples, and then rinse
16. Normal lochial findings in the first 24 hours post-delivery include:
A. Bright red blood
B. Large clots or tissue fragments
C. A foul odor
D. The complete absence of lochia
17. In stage 1 of labor, during the active phase, the cervix dilates?
A. 1-3 cm
B. 7-10 cm
C. 4-7 cm
D. 8-10 cm
18. The mother has delivered the placenta. You note that the shiny surface of the placenta was delivered
first. What delivery mechanism is this known as AND is this the maternal or baby’s surface of the
placenta?
A. Duncan mechanism, maternal
B. Schultze mechanism, maternal
C. Schultze mechanism, baby
D. Duncan mechanism, baby
19. During stage 3 of labor, you note a gush of blood and that the uterus changes shape from an oval
shape to globular shape. This indicates?
A. Postpartum hemorrhage
B. Imminent delivery of the baby
C. Signs of placental separation
D. Answers B and C
20. The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the
client is beginning the second stage of labor?
A. The contractions are regular.
B. The membranes have ruptured.
C. The cervix is dilated completely.
D. The client begins to expel clear vaginal fluid.
21. The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The
nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most
appropriate nursing action?
A. Administer oxygen via face mask.
B. Place the mother in a supine position.
C. Increase the rate of the oxytocin (Pitocin) intravenous infusion.
D. Document the findings and continue to monitor the fetal patterns.
22. A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care
provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely
outcome of the amniotomy?
A. Less pressure on her cervix
B. Decreased number of contractions
C. Increased efficiency of contractions
D. The need for increased maternal blood pressure monitoring
23. The 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/minute. Which nursing action is most appropriate?
A. Notify the health care provider (HCP).
B. Continue monitoring the fetal heart rate.
C. Encourage the client to continue pushing with each contraction.
D. Instruct the client's coach to continue to encourage breathing techniques.
24. The nurse is preforming an initial assessment on a client who has just been told that a pregnancy test
is positive. Which assessment finding indicates that the client is at risk for preterm labor?
A. The client is a 35-year-old primigravida
B. The client has a history of cardiac disease
C. The client's hemoglobin level is 13.5 g/dL
D. The client is a 20-year-old primigravida of average weight and height
25. What is the highest priority in the newborn assessment?
A. Reflex irritability
B. Breathing
C. Skin color
D. Muscle tone

B. APGAR Score: Fill in the blanks

Factor 0 1 2

Appearance

Pulse

Grimace
 Factor 0 1 2

Activity

Respiration

C. Compute for the EDD and AOG. Show your computations/solutions.

1. LMP – July 28, 2022

2. LMP – March 16, 2022

3. LMP – May 5, 2022

4. LMP – August 30, 2022

5. LMP – October 7, 2022

GOODLUCK …….