4.

Which of the following is a positive sign

of pregnancy?
a. Fetal movement felt by mother
b. Enlargement of the uterus
BSN 2_ P2 WEEK 1 POST TEST NUR c. (+) pregnancy test
195_MCN RLE d. (+) ultrasound
RATIONALE: A positive ultrasound will definitely
GENERAL INSTRUCTIONS: confirm that a woman is pregnant since the fetus in
Shade only those that apply to each question on your utero is directly visualized.
answer sheet.
Read the question carefully and choose the best 5. In the Batholonew’s rule of 4, when the level
answer. of the fundus is midway between the
STRICTLY NO ERASURES.
umbilicus and xyphoid process the estimated
1. You performed the leopold’s maneuver and
age of gestation (AOG) is:
found the following: breech presentation, fetal
a. 5th month
back at the right side of the mother. Based on
b. 6th month
these findings, you can hear the fetal heart
c. 7th month
beat (PMI) BEST in which location?
d. 8th month
a. Left lower quadrant
RATIONALE: In Bartholomew’s Rule of 4, the landmarks
b. Right lower quadrant
used are the symphysis pubis, umbilicus and xyphoid
c. Left upper quadrant
process. At the level of the umbilicus, the AOG is
d. Right upper quadrant
approximately 5 months and at the level of the xyphoid
RATIONALE: Right upper quadrant. The landmark to
process 9 months. Thus, midway between these two
look for when looking for PMI is the location of the fetal
landmarks would be considered as 7 months AOG.
back in relation to the right or left side of the mother
and the presentation, whether cephalic or breech. The
6. The following are ways of determining
best site is the fetal back nearest the head.
expected date of delivery (EDD) when the LMP
is unknown EXCEPT:
2. In Leopold’s maneuver #1, you palpated a soft
a. Naegele’s rule
broad mass that moves with the rest of the
b. Quickening
mass. The correct interpretation of this
c. Mc Donald’s rule
finding is:
d. Batholomew’s rule of 4
a. The mass palpated at the fundal part is the
RATIONALE: Naegele’s Rule is determined based on
head part.
the last menstrual period of the woman.
b. The presentation is breech.
c. The mass palpated is the back
7. If the LMP is Jan. 30, 2014 the expected date
d. The mass palpated is the buttocks.
of delivery (EDD) is
RATIONALE: The mass palpated is the buttocks.
a. Oct. 7, 2014
The palpated mass is the fetal buttocks since it is
b. Oct. 24, 2016
broad and soft and moves with the rest of the
c. Nov. 7, 2014
mass.
d. Nov. 8, 2015
RATIONALE: Based on the last menstrual period, the
3. In Leopold’s maneuver # 3 you palpated a
expected date of delivery is Nov. 7. The formula for the
hard round movable mass at the supra pubic
Naegele’s Rule is subtract 3 from the month and add 7
area. The correct interpretation is that the
to the day.
mass palpated is:
a. The buttocks because the presentation
8. The hormone responsible for a
is breech.
positive pregnancy test is:
b. The mass palpated is the head.
a. Estrogen
c. The mass is the fetal back.
b. Progesterone
d. The mass palpated is the fetal small part
c. Human Chorionic Gonadotropin
RATIONALE: The mass palpated is the head. When the
d. Follicle Stimulating Hormone
mass palpated is hard round and movable, it is the
fetal head.
RATIONALE: Human chorionic gonadotropin (HCG) is 14. It is a method used to palpate the gravid
the hormone secreted by the chorionic villi which is the uterus systematically and is of low cost, easy to
precursor of the placenta. In the early stage of perform, and non-invasive. It is used to
pregnancy. while the placenta is not yet fully determine the position, presentation, and
developed. the major hormone that sustains the engagement of the fetus in utero.
pregnancy is HCG. a. Naegele's Rule
b. Leopold's Maneuver
9. The most common normal position of the c. Ritgen's Maneuver
fetus in utero is: d. Fundal height measurement
a. Transverse Position
b. Vertical Position 15. All of the following except, are the steps
c. Oblique Position in performing the Leopold's Maneuver:
d. None of the Above a. Fundal Grip
RATIONALE: Vertical position means the fetal spine b. Umbilical Grip
is parallel to the maternal spine thus making it easy c. Fetal Position
for the fetus to go out the birth canal. Options A and d. Pawlik's Grip
C: If transverse or oblique. the fetus can’t be e. Pelvic Grip
delivered normally per vagina.
16. The uterine fundus right after delivery
10. During a prenatal visit, a patient tells you her of placenta is palpable at:
last menstrual period was May 21, 2016. a. Level of Xyphoid process
Based on the Naegele's Rule, when is the b. Level of umbilicus
estimated due date of her baby? c. Level of symphysis pubis
a. February 27, 2016 d. Midway between umbilicus and
b. March 19. 2017 symphysis pubis
c. February 28, 2017
d. April 16, 2016 17. During a prenatal visit a patient tells you her
last menstrual period was August 28, 2016.
11. The purpose of the 4th maneuver (also Based on the Naegele's Rule, when is the
known as Pawlick's grip) is to help determine estimated due date of her baby?*
whether the fetal head (in a cephalic a. July 4, 2017
presentation) has descended into the b. June 3, 2017
mother's pelvis and engaged in the cervix, c. June 4, 2017
TRUE OR FALSE. d. July 1, 2016
a. FALSE
b. TRUE 18. During a prenatal visit a patient tells you her
last menstrual period was March 14, 2016.
12. Patient RD returns for a routine visit at 12 Based on the Naegele's Rule, when is the
weeks of gestation. Which nursing assessment estimated due date of her baby?*
could the nurse use to verify the estimated due a. January 27, 2017
date (EDD) and estimate uterine/fetal growth? b. December 21, 2016
a. Leopold maneuvers c. December 28, 2016
b. Weight-gain pattern d. January 1, 2016
c. Vital signs and fetal heart tones
d. Height of the fundus 19. When measuring the fundal height of a
primigravida client, with 20 weeks gestation.
13. Which of the following fundal heights Nurse Irish would anticipate locating the
indicates less than 12 weeks’ gestation when fundal height at which of the following points?
the date of the LMP is unknown? a. Halfway between the client's symphysis
a. Uterus in the pelvis pubis and umbilicus-during 16 weeks/3
b. Uterus at the xiphoid months
c. Uterus in the abdomen b. At about the level of the client's umbilicus
d. Uterus at the umbilicus c. Between the client's umbilicus and
xyphoid process
 d. Near the client's xyphoid process
and compressing the diaphragm

20. The nurse is performing an abdominal

examination to the pregnant client and she
performs Leopold's Maneuvers. The nurse
determines which of the following after the
first maneuver?
ANSWER: 4 / D
a. Locating the fetal back
b. Locating the fetal head or breech is in
25. Which of the following pictures depicts a fetus in
the fundus
the frank breech position?
c. Locating part of the fetus in the inlet
d. Determination of fetal attitude

21. Now at 5 months of pregnancy, adolescent

Rhian asks about her baby's length. Using the
Haase's Rule, the nurse calculates fetal length
to be approximately:
a. 20 cm
b. 25 cm
c. 30 cm
d. 50 cm
ANSWER: 3 / C
22. A nurse has just performed a vaginal examination
on a client in labor. The nurse palpates the baby’s 26. While performing Leopold’s maneuvers on a
buttocks as facing the mother’s right side. Where woman in labor, the nurse palpates a hard round mass
should the nurse place the external fetal monitor in the fundal area, a flat surface on the left side, small
electrode? objects on the right side, and a soft round mass just
a. Left upper quadrant (LUQ) above the symphysis. Which of the following is a
b. Left lower quadrant (LLQ) reasonable conclusion by the nurse?
c. Right upper quadrant (RUQ) a. The fetal position is transverse
d. Right lower quadrant (RLQ) b. The fetal presentation is vertex
c. The fetal lie is vertical
23. Which of the following pictures depicts a fetus in d. The fetal attitude is flexed
the ROP position?
27. The labor and delivery nurse performs Leopold’s
Maneuvers. A soft round mass is felt in the fundal
region. A flat object is noted on the left and small
objects are noted on the right of the uterus. A hard
round mass is noted above the symphysis. Which of
the following positions is consistent with these
findings?
a. Left occipital anterior (LOA)
b. Left sacral posterior (LSP)
ANSWER: 1 / A
c. Right mentum anterior (RMA)
d. Right sacral posterior (RSP)
24. Which of the following pictures depicts a fetus in
the LSA position?
28. During a vaginal examination, the nurse palpates
fetal buttocks that are facing the left posterior and
are 1cm above the ischial spines. Which of the
following is consistent with this assessment?
a. LOA -1 station
b. LSP - 1 station
c. LMP +1 station
 d. LSA + 1 station a. place the baby on a warm surface (skin to
skin on the mother’s chest after thorough
29. What stage of gestation would you expect a drying)
nulliparous woman to begin to feel fetal b. dry the wet baby immediately after birth
movements? and covering with a warm dry cloth,
a. 18-20 weeks c. warm environment (25 degrees Celsius)
b. 10-12 weeks d. The drought of cold air should be avoided.
c. 22-24 weeks
d. 14-16 weeks 36. Procedure to prevent heat loss via radiation.
a. place the baby on a warm surface (skin to
30. Fundal height of a pregnant woman is skin on the mother’s chest after thorough
measured from . drying)
a. the top of the pubic bone to the top of b. dry the wet baby immediately after birth
the uterus and covering with a warm dry cloth,
b. the top of the pubic bone to the middle of c. warm environment (25 degrees Celsius)
the uterus d. The drought of cold air should be avoided.
c. the middle of the pubic bone to the bottom
of the uterus 37. 37. It’s commonly used to remove placental
d. the bottom of the pubic bone to the top of fragments inside the uterus. It is also used as a
the uterus hemostat or to prevent the flow of blood from an
e. the middle of the pubic bone to the top of open blood vessel by compression of the vessel.
the uterus
A. Kelly Forcep
31. These are the basic aspects must be taken into B. Ovum Forcep
account for performing Leopold Maneuvers, C. Uterine Curette
EXCEPT D. Vaginal Speculum
a. The examiner for the patient’s right side.
b. The maneuvers are bimanual. 38. This Forceps are primarily used for clamping
c. In the first 3 maneuvers, the test is facing large blood vessels or manipulating heavy tissue.
the patient and, in the 4th maneuver the They may also be used for soft tissue dissection. This
back is turned to the patient. instrument can be used as a clam, heat sink, or third
d. the middle of the pubic bone to the top of hand.
the uterus
a. Kelly Forcep
32. After 30 seconds of drying position the newborn is b. Ovum Forcep
prone on the mother’s abdomen or chest for early c. Forcep
skin to skin contact. d. Holder Forcep
a. TRUE
b. FALSE 39. It is Commonly used to receive delivered
placenta for assessment after vaginal delivery or
33. It is a thick, cheesy substance made up of sebum cesarean section.
and shed epithelial cells; a greasy deposit covering
the skin of the baby at birth. a. Kidney Basin
a. vernix caseosa b. placental container
b. vernic casosa c. Medical container
c. meconium d. Medical Basin
d. lanugo
40. Gynecologists use it to open the walls of the
34. After the umbilical pulsations stopped, clamp the vagina and examine the vagina and cervix.
cord at 2 cm from the umbilical base, clamp again at
5 cm from the base. a. Vaginal Speculum
a. TRUE b. Sims Vaginal Spatula
b. FALSE c. Vaginal Retractor
d. transvaginal Ultrasound
35. Procedure to prevent heat loss via evaporation.
 3.A second-day postpartum client with diabetes
mellitus has scant lochia with a foul odor and a
temperature of
101.6 degrees F. The physician suspects infection and
writes orders to treat the client. Which of the following
BSN 2_ P2 WEEK 2 POST TEST orders written by the physician would the nurse
NUR 195_MCN RLE complete first?
A. Obtain culture and sensitivity of lochia and urine
B. Administer Ceftriaxone (Rocephin)
GENERAL INSTRUCTIONS: C. Check the client's temperature
Shade only those that apply to each question on your D. Increase the intake of oral fluids.
answer sheet.
Read the question carefully and choose the best answer. RATIONALE: Culture and sensitivity results should be
STRICTLY NO ERASURES. obtained before any antibiotic therapy is begun to avoid
masking the microorganisms identified in the culture.
1.A nurse is teaching a postpartum client about Options B and D are standard parts of therapy for this
breast-feeding. Which of the following type of infection but are not completed first. Although
instructions should the nurse include? the client's temperature is monitored, checking the
temperature is not the first action.The data in the
A. The diet should include additional fluids question indicate that the temperature has already
B. Prenatal vitamins should be discontinued been checked.
C. Soap should be used to cleanse the breasts.
D. Birth control measures are unnecessary 4.A nurse obtains the vital signs on a mother who
while breast-feeding. delivered a healthy newborn infant 2 hours ago and
notes that the mother's temperature is 102 F. The
RATIONALE: A diet for a breast-feeding patient should appropriate nursing action would be to:
include additional fluids. Prenatal vitamins should be A. Notify the physician
taken as prescribed and soap should not be used on the B. Remove the blanket from the client's bed
breast because it removes natural oils which increases C. Document the finding and recheck the
the chance of cracked nipples. Breast-feeding is not a temperature in 4 hours.
sole method of contraception, so birth control measures D. Administer Acetaminophen (Tylenol) and recheck
should be resumed. the temperature in 4 hours.

2.A client who is breast-feeding her newborn infant RATIONALE: Vital signs are to return to normal within
is experiencing nipple soreness. To relieve the the first hour postpartum if no complication arise. If the
soreness, the nurse suggests that the client: temperature is greater than 2F above normal this may
A. Avoid rotating breast-feeding positions. indicate infection, and the physician should be notified.
B. Stop nursing until the nipples heal Options B, C, and D are inaccurate nursing interventions
C. Substitute a bottle-feeding until the nipples heal. for the client's temperature of 102F 2 hours following
D. Position the infant with the ear, shoulder, and hip in delivery.
straight alignment with the infant's stomach against
the mother. 5.A nurse is monitoring the amount of lochia drainage
in a client who is 2 hours postpartum and notes that the
RATIONALE: The nurse would suggest the mother client has saturated a perineal pad in 1 hour. The nurse
position the infant in this manner. Rotating reports the amount of lochial flow as:
breast-feeding positions; breaking suction with the little A. Scant
finger; nursing frequently; begin feeding on the less sore B. Light
nipple; not allowing the newborn to chew on the nipple C. Heavy
or to sleep holding the nipple in the mouth and applying D. Excessive
tea bags soaked in warm water to the nipple are also
measures to alleviate nipple soreness.
RATIONALE:Scant= <1 inch on pad in 1 hour
Light = <4 inches on pad in 1 hour
Moderate= <6 inches on pad in 1 hour
Heavy= Saturated pad in 1 hour A. at about 10 to 14 days
Excessive= Saturated pad in 15 minutes
6.A postpartum nurse is preparing to care for a woman B. at about 7 days
who has just delivered a healthy newborn infant. In the C. at 6 weeks
immediate postpartum period, the nurse plans to take D. 48 hours after the delivery of the baby.
the woman’s vital signs:
RATIONALE: This is when the uterus has entered back
A. Every 30 minutes during the first hour and into the pelvic cavity and is no longer palpable.
then every hour for the next two hours.
B. Every 15 minutes during the first hour and then 10. One hour after delivery where do you expect to
every 30 minutes for the next two hours. find the fundus of the uterus?
C. Every hour for the first 2 hours and then every
4 hours. A. 4 cm below the xiphoid process
D. Every 5 minutes for the first 30 minutes and B. right above the symphysis pubis
then every hour for the next 4 hours. C. At the umbilicus
D. 2 cm below the umbilicus
RATIONALE: The initial or acute period involves the first
6–12 hours postpartum. This is a time of rapid change 11. A nurse is preparing to perform a fundal
with a potential for immediate crises such as assessment on a postpartum client. The initial nursing
postpartum hemorrhage, uterine inversion, amniotic action in performing this assessment is which of the
fluid embolism, and eclampsia. following?

7. Your patient is 48 hours post-delivery. While A. Ask the client to turn on her side.
assessing fundal height, you would expect the fundal B. Ask the client to lie flat on her back with the
height to be? knees and legs flat and straight.
C. Ask the mother to urinate and empty her bladder.
A. 1 cm above the umbilicus D. Massage the fundus gently before determining
B. 2 cm above the umbilicus the level of the fundus.
C. 1 cm below the umbilicus
D. 2 cm below the umbilicus RATIONALE: Before starting the fundal assessment, the
nurse should ask the mother to empty her bladder so
RATIONALE: The fundal height will decrease by 1 cm that an accurate assessment can be done. The
per day below the umbilicus. Therefore, if the woman is postpartum recovery period covers the time period
48 hours postpartum (2 days) the fundal height will be from birth until approximately six to eight weeks after
2 cm BELOW the umbilicus. delivery. This is a time of healing and rejuvenation as
the mother’s body returns to prepregnancy states.
8. You’re providing discharge teaching to a new mother
who is going home after a vaginal delivery. The 12. A nurse in a Postpartum unit is instructing a
woman asks when the uterus will return to its pre- mother regarding lochia and the amount of expected
pregnancy size. Your response is? lochia drainage. The nurse instructs the mother that
the normal amount of lochia may vary but should
A. At about 14 days never exceed the need for:
B. At about 6 months
C. At about 6 weeks A. One peripad per day.
D. At about 7 days B. Two peripads per day.
C. Three peripads per day.
RATIONALE: The uterus will return to its pre-pregnancy D. Eight peripads per day.
state at about 6 weeks.
RATIONALE: The normal amount of lochia may vary
9. A nursing student, who you are precepting with the individual but should never exceed 4 to 8
during their OB rotation, asks you when the fundus peripads per day. The average number of peripads is 6
of the uterus is no longer palpable. You answer: per day.
Postpartum hemorrhage is defined as excessive blood
loss during or after the third stage of labor. The average
blood loss is 500 mL at vaginal delivery and 1000 mL at almost 50%. Once the
cesarean delivery.

13. A Postpartum nurse is providing instructions to a

woman after delivery of a healthy newborn infant.
The nurse instructs the mother that she should expect
normal bowel elimination to return:

A. One the day of the delivery

B. 3 days
C. 7 days
D. within 2 weeks PP

RATIONALE: After birth, the nurse should auscultate the

woman’s abdomen in all four quadrants to determine
the return of bowel sounds. Normal bowel elimination
usually returns 2 to 3 days PP. Surgery, anesthesia, and
the use of narcotics and pain control agents also
contribute to the longer period of altered bowel
function.

14. The following are the physiological maternal

changes that occur during the PP period. Select all that
apply.

I. Cervical involution occurs.

II. Vaginal distention decreases slowly.
III. Fundus begins to descend into the pelvis after
24 hours.
IV. Cardiac output decreases with resultant
tachycardia in the first 24 hours.
V. Digestive processes slow immediately.

A. I,III B.I,II,III
C. II,III D. all of the above

rationale :After 1 week the muscle begins to regenerate

and the cervix feels firm and the external os, is the
width of a pencil. The fundus begins to descent into the
pelvic cavity after 24 hours, a process known as
involution.

15. The nurse monitors his or her postpartum clients

carefully because which of the following
physiological changes occurs during the early
postpartum period?

A.Decreased urinary output.

B.Increased estrogen level.
C.Increased blood pressure.
D.Decreased blood volume.

RATIONALE: The blood volume does drop

precipitously during the early postpartum period.
During pregnancy, the blood volume increased by
placenta is delivered, the client no longer needs the
added blood volume.

16. To prevent infection, the nurse teaches the

postpartum client to perform which of the
following tasks?

A. Void at least every two hours.

B. Spray the perineum with a povidone-iodine
solution after toileting.
C. Change the peripad at each voiding.
D. Apply antibiotic ointment to the perineum daily.

RATIONALE: Clients should be advised to change

their pads at each voiding.It is unnecessary to apply
antibiotic ointment to the perineum after
delivery.The clients should void about every 2 hours,
but this action is not an infection control measure.

17. The nurse examines a woman one hour after

birth. The woman’s fundus is boggy, midline, and 1
cm below the umbilicus. Her lochial flow is profuse,
with two plum-sized clots. The nurse’s initial action
would be to:

A. Place her on a bedpan to empty her bladder.

B. Massage her fundus
C. Call the physician
D. Administer Methergine 0.2 mg IM which has
been ordered prn.

RATIONALE:A boggy or soft fundus indicates that

uterine atony is present. If uterine atony occurs,
healthcare providers should be ready for initial
medical management which is directed to the use of
medications to improve tone and induce uterine
contractions. Massaging the uterus is also effective,
as is ensuring an empty cavity. This is confirmed by
the profuse lochia and passage of clots. The first
action would be to massage the fundus until firm,
followed by options C and D, especially if the fundus
does not become or remain firm with massage.

18. Perineal care is an important infection control

measure. When evaluating a postpartum woman’s
perineal care technique, the nurse would recognize
the need for further instruction if the woman:

A. Uses soap and warm water to wash the vulva

and perineum.
B. Washes from symphysis pubis back to episiotomy.
C. Changes her perineal pad every 2 – 3 hours.
D. Uses the peri bottle to rinse upward into her vagina.
19. Which measure would be least effective b. push on the lax fundus of her uterus to cause
in preventing postpartum hemorrhage? the placenta to loosen

A. Administer Methergine 0.2 mg every 6 hours for

4 doses as ordered.
B. Encourage the woman to void every 2 hours.
C. Massage the fundus every hour for the first 24 hours
following birth.
D. Teach the woman the importance of rest
and nutrition to enhance healing.

RATIONALE:The fundus should be massaged only when

boggy or soft. Massaging a firm fundus could cause it to
relax. Uterine atony refers to the corpus uteri
myometrial cells inadequate contraction in response to
endogenous oxytocin that is released in the course of
delivery.

20. When making a visit to the home of a

postpartum woman one week after birth, the nurse
should recognize that the woman would
characteristically:

A. Express a strong need to review events and

her behavior during the process of labor and
birth.
B. Exhibit a reduced attention span, limiting
readiness to learn.
C. Vacillate between the desire to have her own
nurturing needs met and the need to take charge of
her own care and that of her newborn.
D. Have reestablished her role as a spouse/partner.

21. Suppose KeyP is having long and hard uterine

contractions. What length of contraction would
the nurse report as indicative of a potential safety
risk?
a. any length of contraction over 30 seconds
a. a contraction over 70 seconds in length
b. a contraction that peaks at 20 seconds
c. a contraction that appears intensely painful.

RATIONALE: The nurse should report any contraction 70

seconds long as it is long enough to compromise fetal
oxygenation. In the context of labor, pain is not
necessarily indicative of pathophysiology.

22. KeyP is anxious for her placenta to deliver so she

can move to a rocking chair ad help relieve her back
pain. to best facilitate KeyP’s wishes, which action is
best?
a. tug gently on the umbilical cord until
the placenta comes loose.
a. ask KeyP to continue hard pushing as she did
to birth her baby
c. assure her that a placenta loosens quickly 26. A baby is just delivered. Which of the
so the waiting time will not be long. following physiological changes is of highest
priority?
RATIONALE: The nurse should assure the patient
that a placenta loosens quickly so waiting time will
not be long. pulling on the cord, pushing on the
uterine.

23. The nurse is caring for a Muslim woman in

labor. It would be appropriate for the nurse to
include which of the following in the plan of care?
a. Encourage the father to hold his partner’s
hand during labor.
b. Ask the woman if she would like to speak with
her priest.
c. Provide the woman with a long-sleeved
hospital gown.
d. Place an order for the woman’s
postpartum vegetarian diet.
RATIONALE: Muslim women are expected to have
their elbows covered at all times. A long-sleeved
gown, therefore, should be provided for them

24. A full-term newborn was just born. Which

nursing intervention is important for the nurse to
perform first?
a. Remove wet blankets.
b. Assess Apgar score.
c. Insert eye prophylaxis.
d. Elicit the Moro reflex.

RATIONALE: The nurse must know which action is

performed first. Because hypothermia can
compromise a neonate’s transition to extrauterine
life, it is essential to dry the baby immediately to
minimize heat loss through evaporation. It is
important for the test taker to review cold stress
syndrome

25. A breastfeeding baby is born with a tight

frenulum. Which of the following is an important
assessment for the nurse to make?
a. Integrity of the baby’s uvula.
b. Presence of maternal nipple damage.
c. Presence of neonatal tongue injury.
d. The baby’s breathing pattern.

RATIONALE: The baby’s tongue must perform many

actions in order to breastfeed successfully. One of
the first actions the tongue must make is to extend
past the gum line. A tight frenulum precludes the
baby from being able to fully extend his or her
tongue.
a. Thermoregulation. frequently constipated. Which of the following is not
b. Spontaneous respirations. done to relieve constipation?
c. Extrauterine circulatory shift. a. Eat fruits and vegetable (papaya, camote tops etc.)
d. Successful feeding. b. Eat plenty of high roughage foods
c. Aerobics for atleast 30 minutes 3 times a day
RATIONALE: If a baby does not breathe, the remaining d. Increase fluid intake
physiological transitions cannot successfully take place.
RATIONALE: Postpartum women can still have
27. To decrease the possibility of a perineal exercise but not the active type of exercise. This could
laceration during delivery, the nurse performs which increase the risk of tearing the perineal repair
of the following interventions prior to the delivery?
a. Assists the woman into a squatting position. 31. It strengthens bulbocavernous muscles of the
b. Advises the woman to push only when she feels vagina that is helpful in promoting healing, increased
the urge. sexual responsiveness, help prevent stress
c. Encourages the woman to push slowly and steadily. incontinence:
d. Massages the perineum with mineral oil. a. Grantly Dick-Read Method
b. Bradley Technique
RATIONALE: During labor, nurses and nurse midwives c. Pelvic Floor Contractions
often massage a woman’s perineum to increase the d. Pelvic Rocking
elasticity of the tissue. Because the tissue is more
elastic, it is less inclined to tear during the delivery. In RATIONALE: Kegel’s Exercise or Pelvic Floor
addition, mothers are often encouraged to begin Contractions strengthens bulbocavernous muscles of
massaging the tissue during their last trimester. the vagina that is helpful in promoting healing,
increased sexual responsiveness, help prevent stress
28. The nurse teaches pregnant woman to incontinence
perform Kegel’s exercise regularly for which
purpose? 31. This type of laceration extends into the muscle
a. Strengthen the perineal muscles that surrounds the anal sphincter.
b. Prevents varicose veins in the perineum a. First Degree Laceration
c. Strengthen the abdominal wall muscles b. Second Degree Laceration
d. Prevent varicose veins c. Third Degree Laceration
d. Fourth Degree Laceration
RATIONALE: Kegel’s Exercise can help make the muscles
under the uterus, bladder, and bowel (large intestine) RATIONALE: Third degree Laceration extends into the
stronger. They can help both men and women who muscle that surrounds the anal sphincter. These tears
have problems with urine leakage or bowel control. sometimes require repair with anesthesia in an
operating room — rather than the delivery room — and
29. Jennylyn is so concerned about the development of might take longer than a few weeks to heal.
varicose veins. After providing health teachings
regarding the prevention of varicosities, Which of the 32. Celine, a postpartum woman who had a repair
following statements by the client below indicate a of her perineal laceration complained that she is
need for further education? frequently constipated. Which of the following is
a. “I should wear support hose.” not done to relieve constipation?
b. “I should be wearing flat, non-slip shoes that have a. Eat fruits and vegetable (papaya, camote tops etc.)
an arch support.” b. Eat plenty of high roughage foods
c. “I should avoid standing for a long period of time.” c. Aerobics for atleast 30 minutes 3 times a day
d. “I can wear knee-high hose as long I don’t leave d. Increase fluid intake
them on longer than 8 hours.”
RATIONALE: Postpartum women can still have
RATIONALE: Wearing knee-high hose or stockings for exercise but not the active type of exercise. This could
more than 8 hours can cause varicose veins increase the risk of tearing the perineal repair.

30. Celine, a postpartum woman who had a repair 33. Similar to Dick-Read approach with the addition of
of her perineal laceration complained that she is a labor coach that focuses on slow breathing & deep
relaxation for labor:
a. Grantly Dick-Read Method metabolize food to create heat. When they use up their
b. Bradley Technique food stores, they become hypoglycemic.
c. Pelvic Floor Contractions
d. Pelvic Rocking 37. The nursing instructor ask a nursing student to
explain the characteristics of the amniotic fluid.
RATIONALE: Similar to Dick-Read approach with the The student responds correctly by explaining
addition of a labor coach that focuses on slow breathing which as characteristics of amniotic fluid?
& deep relaxation for labor a. Allows for fetal movement
b. Surrounds, cushions, and protects the fetus
34. Which of the following nonpharmacological c. Maintains the body temperature of the fetus
interventions recommended by nurse-midwife may d. Can be used to measure fetal kidney function
help a client at full term to go into labor? Select all that e. Prevents large particles such as bacteria from
apply. passing to the fetus
a. Engage in sexual intercourse.
b. Ingest evening primrose oil. RATIONALE: The amniotic fluid surrounds, cushions,
c. Perform yoga exercises. and protects the fetus. It allows the fetus to move
d. Eat raw spinach. freely and maintains the body temperature of the fetus.
e. Massage the breast and nipples. In addition, the amniotic fluid contains urine from the
fetus and can be used to assess fetal kidney function.
RATIONALE: Nonpharmacological induction methods, he
or she could make some educated guesses by 38. Which purpose of placental functioning should
remembering that pharmacological medications for the nurse include in a prenatal class? Select all that
labor induction are prostaglandins and oxytocin. apply
a. It cushions and protects the baby
35. The nurse is providing acupressure for pain relief b. It maintains the temperature of the baby
to a woman in labor. Where is the best location for the c. It is the way the baby gets food and oxygen
acupressure to be applied? Select all that apply. d. It prevents all antibodies and viruses from passing
a. On the malleolus of the wrist. to the baby
b. Above the patella of the knee. e. It provides an exchange of nutrients and waste
c. On the medial aspect of the lower leg. products between the mother and the developing
d. At the top one-third of the sole of the foot. fetus
e. Below the medial epicondyle of the elbow.
RATIONALE: The placenta provides an exchange of
RATIONALE: Complementary therapies have been oxygen, nutrients, and waste products between the
shown to be of value in a number of clinical situations, mother and the fetus. The amniotic fluid surrounds,
including labor. The specific acupressure point on the cushions, and protects the fetus and maintains the body
leg is located about 3 cm above the inner malleolus in temperature of the fetus. Nutrients. medications,
the calf region. Acupressure has been shown to reduce antibodies, and viruses can pass through the placenta
the pain of labor contractions.
39. The nurse in a labor room is performing a
36. To reduce the risk of hypoglycemia in a full-term vaginal assessment on a pregnant client in labor.
newborn weighing 2,900 grams, what should the The nurse notes the presence of the umbilical cord
nurse do? protruding from the vagina. What is the first nursing
a. Maintain the infant’s temperature action with this finding?
above 97.7°F/36.5°C. a. gently push the cord into the vagina
b. Feed the infant glucose water every 3 hours b. place the client in Trendelenburg position
until breastfeeding well. c. Find the closest telephone and page the health
c. Assess blood glucose levels every 3 hours for the care provider stat
first twelve hours. d. call the delivery room to notify the staff that
d. Encourage the mother to breastfeed every 4 hours. the client will be transported immediately

RATIONALE: Hypoglycemia can result when a baby RATIONALE: When cord prolapse occurs, prompt
develops cold stress syndrome because babies must actions are taken to relieve cord compression.
40. A full-term newborn was just born. Which nursing
intervention is important for the nurse to perform
first?
a. Remove wet blankets.
b. Assess Apgar score.
c. Insert eye prophylaxis.
d. Elicit the Moro reflex

RATIONALE: The nurse must know which action is

performed first. Because hypothermia can compromise
a neonate’s transition to extrauterine life, it is essential
to dry the baby immediately to minimize heat loss
through evaporation. It is important for the test taker
to review cold stress syndrome increase fetal
oxygenation. The client should be positioned with the
hips higher than the head to shift the fetal presenting
part towards the diaphragm. The nurse should push the
call light to summon help, and the other staff members
should call the HCP and notify the delivery room.