Question 1

The registered nurse (RN) identifies a fetal heart rate (FHR) pattern indicating early deceleration with a 20 beats/minute decrease and understands that this finding is related to what event?

Accepted Answer

Answer reason: This produces a gradual, symmetric decrease in FHR that mirrors the contraction pattern and is generally considered a benign, expected finding in active labor. A 20 bpm drop can still fit early decelerations as long as onset-to-nadir is gradual and timing matches the contraction. In contrast, umbilical cord compression classically causes variable decelerations, and maternal hypotension is more associated with late decelerations from uteroplacental insufficiency.

Question 2

The nurse is supervising a student nurse who is performing a fundal assessment on a postpartum client. Which statement by the student nurse indicates a need for follow-up?

Accepted Answer

Answer reason: " Immediately after birth, the uterine fundus is expected to be firm, midline, and at the level of the umbilicus or slightly below it, then it descends gradually over subsequent days. A specific expectation of being 2 cm below the umbilicus by 12 hours is not the typical benchmark taught for normal involution in the immediate postpartum period. In contrast, lactation-triggered oxytocin appropriately increases uterine tone and supports involution, and the uterus generally returns near its nonpregnant size by about 6 weeks. By around 2 weeks postpartum, the uterus has involuted into the pelvis, making the fundus no longer palpable abdominally under normal conditions.

Question 3

The nurse is planning care for a client who is 16 years old and 12 weeks pregnant. Which of the following statements should the nurse include while discussing the client’s plan of care?

Accepted Answer

Answer reason: " Pregnant adolescents have higher nutritional needs because they are supporting fetal growth while often still growing themselves. Increasing intake of protein and calcium-containing foods helps meet requirements for fetal tissue development and maternal bone health. Routine exercise like swimming is generally safe in uncomplicated pregnancy, so recommending stopping activity outright is unnecessary and overly restrictive. Age alone does not mandate a third-trimester nonstress test, and minors can often consent to prenatal care under many jurisdictions’ minor consent laws, so requiring maternal consent is not universally accurate.

Question 4

A client has a temperature of 100.2°F 4 hours after delivery. What is the appropriate action for the nurse to take?

Accepted Answer

Answer reason: A low-grade temperature in the first 24 hours postpartum is commonly due to dehydration, exertion, and fluid shifts from labor rather than infection. The safest initial nursing action is to address likely physiologic causes by promoting oral hydration and reassessing trends and associated symptoms. Postpartum infection is more concerning when fever is at least 100.4°F (38°C) after the first 24 hours or is persistent and accompanied by uterine tenderness, foul lochia, or other signs. Jumping to antibiotics assumes an infection without sufficient criteria, and analgesics may improve comfort but do not address the likely etiology or the need for ongoing assessment.

Question 5

After walking for 30 minutes, the laboring client now has blood-tinged mucus on her underpad. Which of the following is the most appropriate interpretation by the nurse?

Accepted Answer

Answer reason: Blood-tinged mucus (“bloody show”) is caused by cervical effacement and dilation with disruption of small cervical capillaries and release of the mucus plug during labor. Walking can intensify contractions and increase cervical change, making this finding expected as labor progresses. Rupture of membranes is characterized by a gush or continuous trickle of clear/pale fluid rather than mucus mixed with blood. Meconium passage would stain fluid green/brown and suggests fetal stress, not a mucus-blood mixture on the pad.

Question 6

Which technique should the nurse recommend to the postpartum patient in order to prevent nipple trauma?

Accepted Answer

Answer reason: Nipple trauma in breastfeeding most commonly results from a shallow latch that concentrates friction and pressure on the nipple. Ensuring a deep latch places the nipple toward the junction of the hard and soft palate so the infant compresses more areolar tissue rather than pinching the nipple itself. This improves milk transfer and reduces pain, cracking, and bleeding. Limiting feeds or washing with soap can worsen outcomes by reducing effective milk removal or drying/irritating skin, and assessment alone does not prevent injury without correcting latch/positioning.

Question 7

The nurse is monitoring a client in labor and observes the fetal heart rate (FHR) tracing on the electronic monitor. The tracing shows a baseline FHR of 130 beats per minute (bpm) with fluctuations of 6 to 25 bpm around the baseline. The nurse correctly interprets this finding as which of the following?

Accepted Answer

Answer reason: Variability reflects intact fetal autonomic nervous system function and adequate oxygenation. Fluctuations of 6–25 bpm meet the definition of moderate variability, which is the most reassuring baseline characteristic on FHR monitoring. This finding supports fetal well-being and does not by itself require corrective intrauterine resuscitation measures. In contrast, absent (

Question 8

A patient’s chart identifies them as being a G4 P1203. How many living children does this patient currently have?

Accepted Answer

Answer reason: For P1203, the “3” indicates the patient currently has three living children, regardless of how many pregnancies or birth events occurred. Gravida (G4) counts total pregnancies, while parity components describe outcomes (term, preterm, abortions) and living. A common error is to equate gravida or total parity with living children, but multiple gestations and losses make the “living” digit the reliable count.

Question 9

To prevent breast engorgement, what should the new breastfeeding mother be instructed to do?

Accepted Answer

Answer reason: Engorgement is primarily caused by milk stasis and breast vascular congestion, so prevention focuses on regular, effective milk removal. Feeding often with adequate duration promotes complete emptying, matches milk production to infant demand, and reduces ductal obstruction and swelling. Spacing feeds to every 4 hours increases milk accumulation and makes engorgement more likely. Cold packs are typically used after feeds to decrease swelling and discomfort, while restricting maternal fluids does not prevent engorgement and can risk dehydration.

Question 10

The nurse is caring for a prenatal client with gingivitis during their fourth-month clinic visit. The client mentions having a tooth extraction planned for the following month and is wondering whether or not they can proceed with the procedure. What information will the nurse provide the prenatal individual?

Accepted Answer

Answer reason: Elective and necessary dental care is generally best timed in the second trimester because organogenesis has passed and the uterus is not yet large enough to make supine positioning uncomfortable or increase vena cava compression risk. A tooth extraction in the following month (around 5 months gestation) typically falls in this safer window, and untreated oral infection/inflammation can worsen pregnancy outcomes. Waiting until after delivery is unnecessary for indicated dental treatment and can prolong infection and pain. The third trimester is less ideal due to increased aspiration risk, aortocaval compression in supine positions, and greater likelihood of preterm contractions with stress. Antiviral prophylaxis is not a routine or evidence-based requirement for dental extraction in pregnancy.

Question 11

When the mother’s membranes rupture during labor, the fetal heart rate should be observed for the occurrence of which pattern?

Accepted Answer

Answer reason: Cord compression classically produces abrupt, variable decreases in fetal heart rate that vary in timing and shape relative to contractions. This is why immediate and ongoing FHR assessment after ROM is prioritized to detect evolving cord compromise early. By contrast, early decelerations are typically benign and reflect fetal head compression during contractions, not the key complication associated with ROM.

Question 12

The nurse reviews a client's antepartum nonstress test results as reactive. The nurse interprets this finding as?

Accepted Answer

Answer reason: A reactive nonstress test indicates adequate fetal oxygenation and intact neurologic responsiveness, demonstrated by accelerations with fetal movement. The defining criterion is at least two qualifying accelerations during a 20-minute window (typically ≥15 bpm for ≥15 seconds in pregnancies ≥32 weeks). The absence of late decelerations is reassuring but does not by itself define a reactive NST, and late decelerations suggest uteroplacental insufficiency. Accelerations that are

Question 13

A healthy fetal nervous system is indicated by which of the following findings in the fetal heart rate?

Accepted Answer

Answer reason: Moderate variability (6–25 bpm fluctuations) is the hallmark of a well-oxygenated fetus with an intact CNS and is therefore the most reassuring baseline pattern. Absent or minimal variability can indicate fetal sleep, CNS depressant medications, prematurity, or hypoxemia/acidemia and is less reassuring. Marked variability can occur transiently but is not the classic indicator of a stable, healthy fetal neurologic status compared with moderate variability.

Question 14

The time from when the baby is delivered until the delivery of the placenta is known as which stage of labor?

Accepted Answer

Answer reason: The interval after the newborn is delivered and before the placenta is delivered corresponds to placental separation and expulsion. This is classically designated as the third stage of labor. A common distractor is the second stage, which ends with delivery of the baby, not the placenta. The fourth stage refers to the early postpartum period (typically the first 1–2 hours) focused on maternal stabilization and hemorrhage surveillance.

Question 15

A breastfeeding patient who was discharged yesterday calls to ask about a tender hard area on her right breast. What should the nurse’s first response be?

Accepted Answer

Answer reason: A localized tender, firm area in a breastfeeding patient shortly postpartum most commonly reflects milk stasis/plugged duct rather than infection, and initial management is conservative to restore milk flow. Warm compresses/heat and gentle massage toward the nipple before and during feeds help relieve the obstruction and prevent progression to mastitis. Immediate antibiotics are not first-line unless there are systemic signs (fever, flu-like symptoms) or clear infectious findings. Advising the patient to stop breastfeeding is unsafe because continued emptying of the breast is part of treatment and reduces complications.

Question 16

In preparing a primigravida for breastfeeding, which of the following will you do?

Accepted Answer

Answer reason: Oxytocin causes uterine contraction and involution, which helps compress uterine blood vessels and reduces postpartum bleeding risk. This teaching prepares the primigravida by linking breastfeeding initiation with an immediate maternal benefit and reinforces early skin-to-skin/early latch practices. By contrast, routine washing before and after each feeding is unnecessary and can dry/irritate the nipples, increasing soreness and potentially interfering with successful breastfeeding.

Question 17

A patient has just undergone a contraction stress test. What is the result if the patient had 3 contractions in 10 minutes with no late decelerations of FHR?

Accepted Answer

Answer reason: An adequate test requires at least 3 contractions in 10 minutes, and absence of late decelerations indicates reassuring fetal oxygenation reserve. Therefore this pattern meets criteria for a normal/“passing” result. A common distractor is “positive,” which is reserved for late decelerations with contractions, suggesting uteroplacental insufficiency.

Question 18

The nurse provides prenatal teaching to a pregnant patient and advises them to consume how many extra calories per day in the first trimester of pregnancy?

Accepted Answer

Answer reason: Routine guidance is no extra calories in the first trimester, then increased intake later as fetal growth accelerates. The 300-calorie increase is typically associated with the second trimester (and higher needs may apply in the third trimester). Therefore, advising no additional daily calories in the first trimester best matches standard prenatal nutrition teaching.

Question 19

A nurse is caring for a pregnant patient who has phenylketonuria (PKU). Which of the following foods should this patient choose to eat?

Accepted Answer

Answer reason: Foods highest in phenylalanine are high-protein items, especially meats and many dairy products. Among the options, pasta is predominantly carbohydrate and typically lower in protein/phenylalanine load than chicken, steak, or yogurt, making it the best choice within this list. A common pitfall is choosing “low-fat” dairy, but fat content does not reduce phenylalanine because the issue is protein-derived amino acids. Ongoing management also includes using prescribed medical foods/formulas to meet pregnancy protein needs while keeping phenylalanine within target range.

Question 20

Which of the following is a positive sign of pregnancy?

Accepted Answer

Answer reason: Palpation of fetal movement by an examiner is a classic positive sign because it reflects fetal activity rather than maternal physiologic changes. By contrast, nausea and a urine/serum pregnancy test are presumptive/probable findings because they can occur with other conditions or yield false-positive results. Ballottement is considered a probable sign since it suggests, but does not prove, a fetus is present.

Question 21

Which of the following circumstances is most likely to cause uterine atony and lead to early postpartum hemorrhage?

Accepted Answer

Answer reason: A distended bladder mechanically displaces the uterus and interferes with effective contraction, increasing the risk of uterine atony and heavy bleeding. This is why assessing fundal firmness and ensuring bladder emptying (voiding or catheterization when needed) are key immediate postpartum interventions. By contrast, cervical/vaginal lacerations can cause postpartum bleeding, but they do not cause uterine atony and typically present with a firm, well-contracted uterus. Hypertension and endometritis are not the typical primary triggers of early uterine atony in the immediate postpartum period.

Question 22

A nurse is developing a care plan for a pregnant client at 30 weeks gestation with complaints of frequent episodes of heartburn and constipation. Which of the following interventions would the nurse include in the teaching?

Accepted Answer

Answer reason: Pregnancy commonly causes reflux and constipation due to progesterone-related smooth muscle relaxation and uterine pressure slowing GI motility. Teaching should prioritize safe, nonpharmacologic measures that improve bowel motility and reduce constipation while being appropriate in late pregnancy. Increased dietary fiber and regular activity help soften stools, promote peristalsis, and can indirectly reduce reflux by improving gastric emptying patterns. In contrast, spicy/fatty foods and lying down after meals worsen GERD symptoms by decreasing LES tone and promoting reflux. Medication selection and prescribing are not nursing teaching interventions and should be deferred to the provider when lifestyle measures are insufficient.

Question 23

The nurse working at the county hospital is admitting a client who is Rh-negative to the labor and delivery unit. The client is gravida 2, para 0. Which assessment data is most important for the nurse to assess?

Accepted Answer

Answer reason: The key principle is prevention of Rh alloimmunization, which can occur whenever fetal Rh-positive blood enters an Rh-negative mother’s circulation. If anti-D immune globulin was not given after a prior pregnancy loss/termination or other sensitizing event, the client may already be sensitized, placing the current fetus at risk for hemolytic disease. Confirming prior Rhogam receipt most directly determines whether prophylaxis was provided and helps guide urgency of antibody screening and follow-up. Details like spacing between pregnancies do not change sensitization risk as much as whether prophylaxis was administered after exposure. Asking only why the first pregnancy was not viable is less specific than determining whether anti-D prophylaxis was given.

Question 24

A woman who is 35-weeks pregnant calls the triage line for assistance. She is complaining of a bad headache and states Tylenol is not helping. She says, “Ibuprofen works better for me, can I take that instead?” What is the best response from the nurse?

Accepted Answer

Answer reason: “I’m sorry but ibuprofen is not safe for the baby. Are you having any other symptoms? If you are available today, we’d like to see you in the office and make sure you are ok.” NSAIDs should generally be avoided in the third trimester because they can cause premature closure of the fetal ductus arteriosus and contribute to fetal renal impairment with oligohydramnios. A severe headache at 35 weeks is also a potential warning sign of preeclampsia, so the nurse should further assess for associated symptoms (e.g., visual changes, RUQ/epigastric pain) and arrange prompt evaluation. This response prioritizes both medication safety and appropriate escalation for a potentially serious pregnancy complication. Options suggesting ibuprofen use or offering only comfort measures fail to address the fetal risk and the need to rule out hypertensive disease.

Question 25

The nurse providing care for the laboring woman should understand that maternal hypotension can result in?

Accepted Answer

Answer reason: This pathophysiology is described as reduced placental perfusion, which is the direct mechanism behind fetal hypoxia patterns seen with maternal hypotension (e.g., after epidural or supine hypotensive syndrome). Early decelerations are typically caused by fetal head compression with vagal stimulation and are not an effect of poor perfusion. Spontaneous rupture of membranes relates to membrane integrity and labor mechanics rather than maternal hemodynamics. Fetal dysrhythmias can occur with significant hypoxia but are less specific than the primary perfusion problem caused by hypotension.

Question 26

The nurse is educating a pregnant patient. Which vitamin should the nurse tell the patient prevents neural tube defects during fetal development?

Accepted Answer

Answer reason: Periconceptional folic acid supplementation significantly reduces the risk of neural tube defects such as spina bifida and anencephaly. This is why prenatal counseling emphasizes starting supplementation before conception and continuing through early pregnancy. Other B vitamins listed have important metabolic roles but are not the key nutrient proven to prevent neural tube defects.

Question 27

The nurse educates a patient seeking a progestin-only subdermal implant that this device provides contraception for how long?

Accepted Answer

Answer reason: Patient education should emphasize the evidence-based replacement interval so contraception is not relied on past its effective window. The implant provides reliable pregnancy prevention for 3 years by continuously releasing progestin to suppress ovulation and thicken cervical mucus. Longer durations (e.g., 5 or 10 years) are characteristic of some intrauterine devices, not the progestin-only subdermal implant.

Question 28

Which position can help rotate a fetus from posterior to anterior position?

Accepted Answer

Answer reason: The hands-and-knees position reduces pressure on the maternal sacrum and can help an occiput posterior fetus rotate to occiput anterior during labor. This is a common, low-risk nursing intervention for malposition when the patient is stable. Lithotomy is typically used for delivery procedures and does not promote rotation, and Trendelenburg is not a standard maneuver for correcting occiput posterior positioning.

Question 29

A patient reports cracked/sore nipples, unilateral breast erythema, and flu-like symptoms. Which condition should the nurse anticipate?

Accepted Answer

Answer reason: Cracked or sore nipples are a common portal of entry for bacteria (often Staphylococcus aureus), making this symptom cluster highly suggestive. Candidiasis more often causes burning nipple pain and shiny/flaky areola with possible infant thrush, without prominent unilateral breast erythema and systemic illness. Influenza can cause systemic symptoms but does not explain focal breast redness, and nipple inversion is a structural finding rather than an acute infectious picture.

Question 30

What is the expected fundal height for a patient at 24 weeks gestation?

Accepted Answer

Answer reason: At 24 weeks, the expected measurement is therefore around 24 cm with an acceptable normal range of roughly 22–26 cm. Among the choices, the range that best captures this expected value while remaining within a normal clinical spread is 20–24 cm. Options extending well above the week-based estimate suggest a size-date discrepancy (e.g., macrosomia, polyhydramnios, or multifetal gestation) if confirmed on repeat measurement and ultrasound.

Question 31

A client’s last menstrual period (LMP) was July 14, 2024. What is her estimated due date (EDD) using Naegele’s Rule?

Accepted Answer

Answer reason: From July 14, 2024, adding 7 days gives July 21, 2024. Subtracting 3 months yields April 21, 2024, and adding 1 year gives April 21, 2025. Choices that keep the same day of month or shift the date in the wrong direction reflect common calculation errors with the +7 days and −3 months steps.

Question 32

A pregnant client in the first trimester reports to the nurse that she has noticed a thin, colorless vaginal drainage. As a response, which is an appropriate statement by the nurse?

Accepted Answer

Answer reason: ” In early pregnancy, increased estrogen and increased blood flow to the reproductive tract commonly cause leukorrhea—a thin, clear/white, nonirritating discharge. This finding is expected when it is not foul-smelling, green/yellow, bloody, or associated with itching, burning, fever, or pelvic pain. Immediate provider notification and bed rest are not indicated for uncomplicated physiologic discharge. Tampons should be avoided in pregnancy because they can increase infection risk; pads/liners and hygiene are safer choices.

Question 33

The nurse and new graduate nurse are preparing a client for an amniocentesis who is 15 weeks pregnant and has a blood type of A (-). Which statement indicates that the new graduate nurse understands this procedure?

Accepted Answer

Answer reason: " After amniocentesis, the client should be taught to report signs of complications such as significant abdominal pain/cramping, vaginal bleeding, fever, or fluid leakage because these can indicate membrane rupture, infection, or preterm labor. New-onset or worsening abdominal pain is therefore an abnormal finding that warrants prompt evaluation. In an Rh-negative pregnant client, Rh immune globulin is typically indicated after the procedure to prevent alloimmunization, making the statement that it is not required incorrect. Vaginal fluid leakage is a warning sign (possible amniotic fluid leak), not an expected outcome, and leg swelling is not a priority complication of this procedure.

Question 34

For how long after receiving the rubella vaccine should pregnancy be avoided?

Accepted Answer

Answer reason: The rubella-containing vaccine (e.g., MMR) is live, so clients should be counseled to avoid conception for at least 4 weeks after vaccination. This aligns with immunization guidance used in obstetric counseling and preconception care to reduce avoidable risk. Longer avoidance periods (e.g., 3 or 6 months) are not required for rubella vaccination, and a 7-day window is too short to meet the recommended safety interval.

Question 35

Gravida refers to which of the following descriptions?

Accepted Answer

Answer reason: Gravida is an obstetric history term that counts all pregnancies a client has had, regardless of outcome or gestational age at the end of the pregnancy. This includes current pregnancy and any prior pregnancies ending in birth, miscarriage, or abortion. In contrast, delivery counts (parity) are based on births at a specified gestational threshold (commonly ≥20 weeks), not simply being pregnant. Therefore the definition that best matches gravida is the count of times pregnant.

Question 36

Which of the following methods of contraception would not be appropriate for a breastfeeding patient?

Accepted Answer

Answer reason: This makes combined oral contraceptives a poor choice compared with non-estrogen methods. Progestin-only pills are preferred during breastfeeding because they have minimal impact on milk supply and are considered compatible with lactation. Nonhormonal options like the copper IUD and barrier methods like a diaphragm are also appropriate choices for breastfeeding patients.

Question 37

The nurse educates a patient receiving an IUD that they should take what action each month?

Accepted Answer

Answer reason: Monthly string checks after menses (or on a consistent monthly schedule) are a standard patient-education point to confirm the device is still in place. If strings feel longer/shorter or cannot be felt, the patient should use backup contraception and contact the provider for evaluation. Routine confirmatory imaging, STI testing, or pregnancy testing are not recommended monthly unless symptoms, exposure risk, or a missed period/concern for pregnancy occurs.

Question 38

The fetal heart rate does not accelerate during a nonstress test. What should be done next?

Accepted Answer

Answer reason: The recommended next step is to perform a confirmatory, more comprehensive assessment of fetal well-being, typically a biophysical profile or a contraction stress test, to better evaluate oxygenation and placental reserve. Repeating the NST can be considered after measures like vibroacoustic stimulation, but a persistently nonreactive result requires escalation to additional testing rather than reassurance. Amniocentesis does not directly evaluate acute fetal status and is not the immediate follow-up for a nonreactive NST.

Question 39

Which finding of the urine is consistent with a patient who has hyperemesis gravidarum?

Accepted Answer

Answer reason: This produces ketone bodies that are excreted in the urine, making urinary ketones a key marker of dehydration and inadequate caloric intake in pregnancy. Glycosuria is more suggestive of gestational diabetes or lowered renal glucose threshold in pregnancy rather than severe vomiting. Proteinuria would raise concern for preeclampsia, and hematuria suggests urinary tract pathology, neither being the typical urine finding from hyperemesis.

Question 40

You are working in a prenatal clinic. A patient in her first trimester of pregnancy informs you that she was exposed to a child with chickenpox. She had chickenpox herself as a child but is concerned about the risk to her developing baby. What is the most appropriate response?

Accepted Answer

Answer reason: A history of prior chickenpox infection indicates immunity to varicella-zoster virus. Therefore, the client is not at risk for primary infection, which is the condition associated with fetal complications. Live varicella vaccine is contraindicated during pregnancy, and invasive testing such as amniocentesis is unnecessary in an immune patient.

Question 41

A primigravida in the third trimester is diagnosed with moderate anemia requiring rapid correction. What is the most appropriate treatment regimen?

Accepted Answer

Answer reason: In the third trimester, moderate anemia requires faster correction to support maternal oxygenation and fetal needs. Parenteral iron provides a more rapid increase in hemoglobin compared to oral therapy. Oral iron is slower, and combination or IM regimens are less appropriate or outdated compared to standard parenteral approaches.

Question 42

A client in the third month of her first pregnancy reports having multiple sexual partners and is unsure of the baby's father. Which nursing intervention is the priority?

Accepted Answer

Answer reason: HIV screening is a priority in pregnancy, especially in clients with multiple sexual partners, because early detection allows for interventions that significantly reduce maternal-to-fetal transmission. While broader STI testing is important, HIV screening has the most immediate impact on fetal outcomes and is therefore prioritized.

Question 43

Safe delivery is best conducted by?

Accepted Answer

Answer reason: A trained birth attendant can monitor labor progress, assess fetal and maternal status, and initiate or arrange prompt referral for hemorrhage, obstructed labor, hypertensive emergencies, or neonatal distress. They are also equipped to maintain asepsis and provide immediate newborn care (thermal protection, airway support, early breastfeeding). Relatives or community elders may offer support but typically lack the clinical training required to prevent, detect, and manage obstetric and neonatal emergencies safely.

Question 44

A nulliparous patient wishing to undergo labor induction receives a Bishop score. Which of the following scores indicates maternal readiness for labor induction in this nulliparous patient?

Accepted Answer

Answer reason: In nulliparous patients, a score of at least 8 is commonly used to indicate a favorable cervix and higher probability of successful induction. Lower scores (e.g., 6) suggest an unfavorable cervix where cervical ripening is often needed before starting induction agents. Higher values (9 or 11) are also favorable, but the question asks for the threshold that indicates readiness in a nulliparous patient.

Question 45

When the shiny portion of the placenta comes out first is called which of the following mechanisms?

Accepted Answer

Answer reason: In the Schultze mechanism, separation begins centrally and the fetal surface (smooth/shiny amnion) presents first, often with blood concealed behind the placenta until expulsion. This directly matches the description of the “shiny portion” coming out first. By contrast, the Duncan mechanism separates from the margin and the rough maternal surface appears first with more visible bleeding.

Question 46

A nurse is caring for a postpartum patient and notes that the patient’s perineal pad has been saturated within 15 minutes. How should this amount of lochia be documented?

Accepted Answer

Answer reason: Saturating a pad in 15 minutes represents abnormally rapid bleeding consistent with the highest documentation category used in many nursing references. This finding warrants prompt assessment of uterine tone and evaluation for retained products or lacerations, not routine documentation only. A common distractor is “heavy,” which typically corresponds to a pad saturated in about an hour rather than in minutes.

Question 47

Immediately after the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. what is the appropriate action to deliver the placenta?

Accepted Answer

Answer reason: Having the mother push during a contraction supports controlled delivery while minimizing the risk of uterine inversion and hemorrhage. Routine pulling on the cord or applying traction before separation can avulse the cord or invert the uterus, creating an obstetric emergency. Manual separation with instruments is not a routine nursing action and is reserved for retained placenta under provider management with appropriate anesthesia and asepsis.

Question 48

The nurse is counseling a patient who had a prior pregnancy with chromosomal abnormalities incompatible with life. The patient is 17 weeks pregnant and wishes to have testing for chromosomal abnormalities performed at this time. Which procedure should the nurse counsel the patient about?

Accepted Answer

Answer reason: At 17 weeks, this timing aligns with the standard window and provides definitive diagnostic information (not just screening). Chorionic villus sampling is typically performed earlier (about 10–13 weeks) and is therefore not the preferred procedure at this gestational age. A stress test evaluates fetal well-being later in pregnancy, and ultrasound can suggest markers but does not definitively diagnose most chromosomal abnormalities.

Question 49

A nurse is caring for a patient with possible premature rupture of membranes (PROM). The nurse tests the pH of the vaginal fluid. PROM will be confirmed if the nitrazine paper turns what color?

Accepted Answer

Answer reason: Amniotic fluid is more alkaline than normal vaginal secretions, so a higher pH supports rupture of membranes. Nitrazine paper turns blue in the presence of alkaline fluid (classically pH > 6.5), which is consistent with amniotic fluid leakage. Yellow/orange/green indicate more acidic ranges that are closer to typical vaginal pH and therefore do not confirm PROM. Because false positives can occur (e.g., blood, semen, infection), this test is interpreted in clinical context, but the expected confirmatory color change is alkaline/blue.

Question 50

The nurse is providing prenatal teaching to a pregnant patient with a pre-pregnancy BMI of 23. How much total weight does the nurse advise this patient to gain during pregnancy?

Accepted Answer

Answer reason: Recommended gestational weight gain is based on pre-pregnancy BMI categories. A BMI of 23 is in the normal range (about 18.5–24.9), for which typical guidance is a total gain of 25–35 lb in a singleton pregnancy to support fetal growth while minimizing maternal and fetal complications. Gains lower than this range are more appropriate for underweight/insufficient gain scenarios and can increase risk of small-for-gestational-age outcomes. Higher ranges are generally reserved for underweight patients and would be excessive for a normal BMI, increasing risk for macrosomia and gestational complications.

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