Question 1

A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention?

Accepted Answer

Answer reason: It requires urgent assessment of blood pressure and neurologic status and prompt escalation for antihypertensive therapy and seizure prophylaxis (eg, magnesium sulfate) per protocol. By contrast, lochia soaking a pad every 2 hours can be within expected postpartum bleeding parameters depending on timing and trend, and the other findings more often suggest localized infection that is typically less immediately life-threatening. The priority is preventing maternal neurologic catastrophe by treating suspected severe postpartum hypertension promptly.

Question 2

Which best describes an indication for performing Leopold’s maneuvers on a client in labor?

Accepted Answer

Answer reason: Identifying more than one fetus is an appropriate indication because palpation may detect multiple fetal poles/parts and an atypical uterine contour that suggests multifetal gestation and prompts confirmation and delivery planning. Bladder fullness is assessed by history/palpation and addressed with toileting/catheterization rather than Leopold’s maneuvers. Placental abruption and cervical laceration are evaluated based on bleeding pattern, pain, uterine tone, fetal status, and exam findings—not by abdominal palpation maneuvers aimed at fetal position.

Question 3

Rho (D) immune globulin (RhoGAM) is prescribed for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which of the following?

Accepted Answer

Answer reason: Rho(D) immune globulin provides passive anti-D antibodies that bind any fetal Rh-positive red blood cells that entered the maternal circulation during the abortion, preventing the mother’s immune system from becoming sensitized. By blocking maternal alloimmunization, it prevents the mother from forming her own anti-D IgG that could cross the placenta in a subsequent pregnancy and cause hemolytic disease of the fetus/newborn. It does not affect the fetus’s Rh type, which is genetically determined. It also does not prevent miscarriage directly; it specifically prevents immune-mediated complications in future Rh-positive pregnancies.

Question 4

The nurse learns that a client who is 6 days postpartum has persistent lochia rubra. What does this assessment finding suggest to the nurse?

Accepted Answer

Answer reason: Retained products of conception prevent effective uterine involution and can cause ongoing bright/red lochia rather than the expected transition to lochia serosa by about day 3–4. A cervical laceration typically causes early postpartum heavy bleeding with a firm uterus, not a delayed persistent rubra pattern at day 6. Over-adequate uterine contraction would reduce bleeding rather than prolong it, and a coagulation disorder would more often present with generalized abnormal bleeding/bruising or uncontrolled hemorrhage rather than an isolated delayed lochia pattern.

Question 5

Which of the following positions is best for a client with preeclampsia who is in labor?

Accepted Answer

Answer reason: Left lateral positioning reduces aortocaval compression by the gravid uterus, improving venous return, cardiac output, renal perfusion, and placental blood flow, which supports fetal oxygenation. Supine positioning can worsen hypotension and decrease placental perfusion due to vena cava compression, risking fetal compromise. Trendelenburg is not appropriate for preeclampsia in labor and may worsen respiratory mechanics. High Fowler's can be used for comfort or breathing but does not address aortocaval compression as effectively as left lateral.

Question 6

The home care nurse is visiting a postpartum client. The nurse reviews the information in the client's medical record and collects data on the client. The nurse should suspect endometritis if which finding is noted?

Accepted Answer

Answer reason: A fever starting on day 3 is therefore a key red flag for this complication and warrants further assessment and prompt treatment. A mildly elevated WBC count can be a normal postpartum physiologic finding and is not specific for infection by itself. Lochia rubra on day 2 is expected normal postpartum bleeding, and breast engorgement is a common lactation-related change rather than a uterine infection sign.

Question 7

The nurse cares for a client at 30 weeks gestation at risk of delivering preterm. Which of the following medication would the nurse anticipate the primary healthcare provider (PHCP) to prescribe?

Accepted Answer

Answer reason: Preterm labor risk at 30 weeks is managed with tocolysis to inhibit uterine contractions and prolong pregnancy long enough for interventions like antenatal corticosteroids to improve fetal lung maturity. Nifedipine, a calcium channel blocker, relaxes uterine smooth muscle by decreasing calcium influx, making it a common first-line tocolytic. Oxytocin and misoprostol both stimulate uterine contractions and are used for induction/augmentation, which would worsen preterm labor risk. Penicillin G is used for intrapartum group B strep prophylaxis or specific infections, not for stopping contractions.

Question 8

You're performing a routine assessment on a mother post-delivery. The uterus is soft and displaced to the left of the umbilicus. What is your next nursing action?

Accepted Answer

Answer reason: A boggy uterus indicates uterine atony, which is a leading cause of postpartum hemorrhage and requires immediate nursing intervention. Deviation to the left commonly suggests bladder distention, which prevents effective uterine contraction and keeps the fundus from being midline. The priority is to promote uterine tone (massage) and relieve bladder distention by helping the client void, which typically restores a firm, midline fundus. Simply monitoring delays treatment, and provider notification/PRN oxytocin may be needed if measures fail, but first-line nursing actions are to massage and assist to void.

Question 9

A pregnant client is discussing symptoms with the nurse. She describes a feeling like “bubbles” in her uterus. What sign of pregnancy is this?

Accepted Answer

Answer reason: Presumptive signs are subjective symptoms felt and reported by the client rather than objectively verified by the examiner. The sensation of “bubbles” corresponds to quickening (first perceived fetal movement), which is a classic subjective indicator early in mid-pregnancy. Probable signs are objective but not diagnostic (e.g., Goodell/Chadwick signs, Braxton Hicks, positive urine test), whereas positive signs are definitive evidence of a fetus (e.g., fetal heart tones, ultrasound visualization). Therefore this symptom best fits the presumptive category rather than probable or positive.

Question 10

A client calls the health care provider’s office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of human chorionic gonadotropin (hCG) in the urine. The nurse understands this indicates which finding?

Accepted Answer

Answer reason: However, it is not diagnostic because certain conditions (e.g., trophoblastic disease, some tumors, recent pregnancy loss) can also produce measurable hCG. Positive (diagnostic) signs require direct evidence of a fetus such as fetal heart tones or ultrasound visualization of the fetus. Presumptive signs are subjective symptoms (e.g., amenorrhea, nausea) that are less reliable than laboratory detection of hCG.

Question 11

A primigravid client at 16 weeks' gestation has had an amniocentesis and has received teaching concerning signs and symptoms to report. Which statement indicates that the client needs further teaching?

Accepted Answer

Answer reason: " After amniocentesis, key reportable findings are those suggesting membrane rupture, bleeding, or infection because they indicate potential complications such as miscarriage, hemorrhage, or chorioamnionitis. At 16 weeks, consistent fetal movement is often not yet reliably perceived (quickening commonly occurs later), so using decreased fetal movement as a trigger to call reflects misunderstanding of normal gestational expectations. In contrast, leaking vaginal fluid can signal amniotic fluid loss, bleeding can indicate placental or procedural complications, and fever can indicate infection—each requires prompt reporting. Therefore this statement is the one showing need for further teaching.

Question 12

Which of the following statements by a primigravid client about the amniotic fluid and sac indicates the need for further teaching?

Accepted Answer

Answer reason: " Amniotic fluid primarily provides fetal protection, allows movement for musculoskeletal development, helps maintain a stable intrauterine temperature, and reduces the risk of cord compression. Fetal nutrition and oxygenation are supplied through the placenta and umbilical cord via maternal circulation, not by the fluid itself. While the fetus does swallow amniotic fluid and it contributes to gastrointestinal maturation and fluid balance, it is not the source of nutrients required for growth. The other statements reflect recognized protective or supportive functions of the amniotic fluid/sac in pregnancy and labor.

Question 13

A pregnant woman states that she frequently ingests laundry starch. The nurse should assess the client for?

Accepted Answer

Answer reason: Pica is the compulsive ingestion of nonfood substances and, in pregnancy, is commonly associated with iron deficiency. Laundry starch ingestion is a classic pica behavior and can both signal and worsen iron-deficiency by displacing nutrient-dense foods. Therefore the priority assessment is for signs/symptoms and labs consistent with anemia (e.g., fatigue, pallor, low hemoglobin/hematocrit). The other options are not the typical nutritional deficiency linkage tested with pica in pregnancy.

Question 14

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)?

Accepted Answer

Answer reason: The most direct initial evaluation is to assess for anemia using hemoglobin and hematocrit, which guides need for iron supplementation and further iron studies if abnormal. Measuring hCG is not relevant at 20 weeks for this presentation, and WBC does not evaluate the suspected deficiency state. Folate deficiency can cause anemia, but cornstarch cravings specifically point more toward iron deficiency than folate deficiency.

Question 15

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?

Accepted Answer

Answer reason: Feeding on demand (or at least every 2–3 hours) helps match milk production to infant intake and maintains adequate drainage of the breasts. Limiting time at the breast can worsen engorgement by preventing complete emptying, while fluid restriction does not meaningfully decrease milk production and can risk dehydration. Nipple shields are not a standard preventive measure for engorgement and may interfere with latch and milk transfer if used unnecessarily.

Question 16

A clinic nurse is caring for a client with a suspected diagnosis of gestational hypertension. The nurse assesses the client, expecting to note which set of findings if gestational hypertension is present?

Accepted Answer

Answer reason: New-onset elevated blood pressure after 20 weeks’ gestation with protein in the urine represents the classic clinical pattern that suggests progression beyond isolated gestational hypertension and raises concern for preeclampsia-spectrum disease, which requires closer monitoring and management. Ketonuria, glycosuria, obesity, and tachycardia are not defining findings for gestational hypertension and more commonly reflect metabolic status, diabetes risk, dehydration/starvation, or nonspecific physiologic responses. Because proteinuria is a key risk marker for maternal-fetal complications, it is the most clinically relevant associated finding among the options.

Question 17

A nurse is caring for a client who is 48 hr postpartum and reports the episiotomy incision is pulling and stinging. Which action should the nurse implement?

Accepted Answer

Answer reason: At ~48 hours postpartum, comfort measures transition from cold therapy to moist heat to promote perineal circulation, decrease muscle spasm, and support wound healing after an episiotomy. Warm sitz baths reduce the “pulling/stinging” sensation by improving blood flow and providing gentle cleansing, which also helps prevent infection. Ice packs are most effective in the first 24 hours to limit edema and bruising; after that they can be less helpful and may impede circulation. Narcotics are not first-line for localized episiotomy discomfort because nonpharmacologic measures and non-opioid analgesics are typically safer and sufficient, especially when caring for a newborn.

Question 18

A client asks the nurse why taking folic acid is so important before and during pregnancy. The nurse should instruct the client that?

Accepted Answer

Answer reason:  Folate is essential for DNA synthesis and rapid cell division, making it critical in early embryogenesis when the neural tube is closing. Adequate periconceptional supplementation significantly reduces the risk of neural tube defects such as spina bifida and anencephaly. Folate also supports maternal erythropoiesis, helping prevent folate-deficiency megaloblastic anemia during pregnancy when demands increase. The distractors confuse folate with other nutrients: regulation of glucose is not its primary role, iron absorption is mainly enhanced by vitamin C, and blood clotting is primarily vitamin K–dependent.

Question 19

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?

Accepted Answer

Answer reason: " In early pregnancy, increased estrogen and greater vaginal/cervical gland activity commonly cause leukorrhea that is thin and clear/white and not associated with irritation or foul odor. This presentation is typically a normal physiologic change and is best managed with reassurance and hygiene education. Urgent evaluation is more appropriate when drainage suggests membrane rupture (watery gush/persistent leaking), infection (odor, itching, fever), or bleeding/cramping. Advising tampon use is unsafe in pregnancy because it can increase infection risk and is not recommended for managing routine discharge.

Question 20

The nurse in a health care clinic is instructing a pregnant client how to perform “kick counts.” Which statement by the client indicates a need for further instruction?

Accepted Answer

Answer reason: ” Kick counts are performed in a position that optimizes uteroplacental perfusion and maternal comfort, typically side-lying (often left lateral) or semi-Fowler. Lying flat supine in pregnancy can compress the inferior vena cava, decreasing venous return and uterine blood flow, which may cause maternal hypotension, dizziness, and altered fetal oxygenation. Therefore, this statement reflects incorrect technique and a need for teaching about safe positioning during fetal movement counting. The other statements align with standard instruction to focus on fetal movements and document counts, and to repeat counting and/or notify the provider when movements are reduced.

Question 21

During episiotomy repair, woman is kept in?

Accepted Answer

Answer reason: The dorsal lithotomy position (supine with hips flexed/abducted and knees flexed, often supported in stirrups) provides direct exposure of the episiotomy site and allows effective retraction, lighting, and instrument handling. It also facilitates assessment of bleeding and proper layer-by-layer closure of vaginal mucosa, perineal muscles, and skin. Sims’ or Fowler’s positions limit perineal exposure, and simple supine without hip flexion/abduction does not reliably provide adequate access for repair.

Question 22

A prenatal client has been diagnosed with a vaginal infection from the organism Candida albicans. Which finding(s) should the nurse expect to note on assessment of the client?

Accepted Answer

Answer reason: Pregnancy increases risk due to hormonal effects on vaginal glycogen and pH, which promotes Candida overgrowth and symptomatic inflammation. Costovertebral angle pain suggests upper urinary tract involvement (e.g., pyelonephritis), not a localized yeast vaginitis. Proteinuria with edema and hypertension points toward a hypertensive disorder of pregnancy rather than an infectious vaginitis process.

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