Question 1

A client with diabetes, who is in the late third trimester, has a nonstress test twice weekly. The 20-minute test showed three fetal heart rate accelerations that exceeded the baseline by 15 beats/minute and that lasted longer than 15 seconds. The nurse knows these results are consistent with which interpretation of a nonstress test?

Accepted Answer

Answer reason: After 32 weeks, the standard criterion is at least two accelerations of ≥15 bpm above baseline lasting ≥15 seconds within a 20-minute window. This tracing shows three qualifying accelerations in 20 minutes, meeting and exceeding the threshold for reactivity. “Positive/negative” terminology is primarily used for contraction stress testing rather than NST interpretation. A nonreactive NST would fail to meet the acceleration criteria and would prompt further evaluation.

Question 2

Which nursing intervention for a pregnant adolescent client has the highest priority during the first trimester?

Accepted Answer

Answer reason: During the first trimester, priority nursing care emphasizes health promotion that supports fetal organogenesis and maternal physiologic changes. Pregnant adolescents are at higher risk for inadequate caloric and micronutrient intake because they may still be growing themselves, increasing risk for poor weight gain and fetal growth restriction. Early nutritional assessment and targeted counseling helps optimize folate, iron, calcium, and overall intake and can prevent complications across the pregnancy. A common distractor is early glucose tolerance testing, which is typically done at 24–28 weeks unless the patient has significant risk factors that warrant earlier screening.

Question 3

A nurse is performing Leopold’s maneuvers on a client in the early stages of labor. The nurse is most concerned when which of the following occurs?

Accepted Answer

Answer reason: Leopold’s maneuvers are used to identify fetal lie and presentation by distinguishing the fetal head (firm, round, ballotable) from the breech (softer, less defined). In a normal vertex presentation, the head should be in the lower uterine segment, but it is not found in the fundus at all—so detecting a head-like mass “in the lower fundus” suggests abnormal positioning/interpretation consistent with malpresentation or an unengaged, atypical lie that can complicate labor. By contrast, a soft, less-defined mass in the upper uterus is typical for the breech when the fetus is cephalic, and a smooth firm area on the side is consistent with the fetal back. The concerning finding is the one that implies the fetal head is not appropriately located relative to the uterine segments, raising risk for difficult labor and the need for further assessment (e.g., vaginal exam/ultrasound).

Question 4

A nurse is examining a client in active labor who has had spontaneous rupture of the amniotic membrane and notes a protruding umbilical cord. What is the priority nursing action the nurse should take?

Accepted Answer

Answer reason: The core priority with a prolapsed umbilical cord is to immediately relieve cord compression to preserve fetal oxygenation and prevent acute hypoxia. Positioning the client head-down (or knee-chest) uses gravity to lift the presenting fetal part off the cord, buying time while urgent obstetric interventions are initiated. Attempting to replace the cord increases trauma and vasospasm risk, and encouraging pushing worsens compression. Covering the cord is supportive if it is exposed, but it does not address the immediate life-threatening problem of occluded blood flow.

Question 5

A 30-year-old multiparous client admitted to the labor-and-delivery unit has not received prenatal care for this pregnancy. What is the most important data for the nurse to obtain?

Accepted Answer

Answer reason: With no prenatal care, establishing gestational age quickly helps interpret fetal monitoring, determine viability thresholds, and anticipate complications (e.g., preterm labor vs term labor). This data point also supports estimating the due date and correlating findings such as fundal height or ultrasound results if obtained. By contrast, insurance information and number of siblings do not affect immediate clinical management, and the STD history presented is not the most critical form (client’s current risk/symptoms matter more than family history) for urgent obstetric planning.

Question 6

A nurse determines that teaching about Kegel exercises has been effective when the client makes which statement?

Accepted Answer

Answer reason:  Kegel exercises are pelvic floor muscle contractions aimed at improving tone and circulation to the perineal area after childbirth. Increased local blood flow supports tissue healing and helps restore strength, reducing risks of urinary stress incontinence and pelvic floor weakness. Lochia is uterine shedding managed by involution and uterine contraction rather than pelvic floor exercises. Bowel function and postpartum weight loss are influenced more by diet, hydration, ambulation, and overall activity than by isolated pelvic floor strengthening.

Question 7

A client who is positive for human immunodeficiency virus (HIV) tells a nurse she would like to breastfeed. Which is the best response by the nurse?

Accepted Answer

Answer reason:  Breastfeeding is contraindicated for clients with HIV because the virus can be present in breast milk and can infect the infant. The nurse’s best response is factual, safety-focused education that addresses the primary risk to the newborn. Statements about bonding or general benefits of breast milk are inappropriate when they conflict with infection-prevention guidance. Reducing postpartum hemorrhage is not the central issue and does not outweigh the risk of vertical transmission.

Question 8

A nurse is performing an assessment of a postpartum client 2 hours after delivery and notes heavy bleeding with large clots. What is the most appropriate initial action by the nurse?

Accepted Answer

Answer reason: The priority initial nursing action is to stimulate uterine contraction by assessing tone and performing firm fundal massage to reduce hemorrhage. Bimanual uterine compression is typically a more advanced intervention performed when massage and uterotonics are ineffective and often requires provider involvement. Medications such as ergonovine and provider notification are important, but immediate bedside action to control bleeding is indicated first while escalating care in parallel.

Question 9

The nurse reviews the assessment findings of a postpartum client who has experienced a vaginal birth. The nurse determines that which finding is normal?

Accepted Answer

Answer reason: Calf redness or swelling is concerning for deep vein thrombosis and is not expected postpartum. The uterine fundus typically is no longer palpable abdominally by about 10–14 days as involution progresses; persistence suggests subinvolution. Lochia rubra should transition to serosa and then alba within days to weeks; dark red bleeding for 6 weeks suggests abnormal or secondary postpartum hemorrhage.

Question 10

A client with mastitis tells the nurse she is concerned about breastfeeding her neonate. What is the best response by the nurse?

Accepted Answer

Answer reason: Mastitis is typically a localized breast infection/inflammation, and continued breastfeeding (or effective milk removal) helps relieve milk stasis and supports resolution while maintaining supply. In most cases, breastfeeding is safe for the infant even when the mother is receiving compatible antibiotics, and stopping can worsen engorgement and symptoms. Routine formula supplementation is unnecessary unless breastfeeding is not possible, and it risks reduced milk production. Analgesics such as ibuprofen/acetaminophen are generally compatible with breastfeeding and improve comfort to support continued feeding.

Question 11

A client who is breastfeeding reports pain, redness, and swelling in her right breast. What is the most important information for the nurse to give the client?

Accepted Answer

Answer reason: Breast pain with localized redness and swelling during lactation is most consistent with a plugged duct or mastitis, where improving milk flow and relieving engorgement are key to symptom improvement. Warm, moist compresses increase circulation and help soften tissue to promote drainage, reducing inflammation and discomfort. Tight bras can worsen obstruction by compressing ducts, and permanent cessation of breastfeeding is inappropriate and can increase milk stasis and symptoms. Antibiotics may be needed for mastitis, but the key immediate nursing teaching is supportive care to facilitate breast emptying and comfort.

Question 12

A nurse is caring for a client in active labor. Which observation would cause the nurse to suspect fetal distress?

Accepted Answer

Answer reason: Fetal scalp pH of 7.14 Fetal distress is suggested by evidence of fetal hypoxia/acidemia, which is reflected by a low fetal scalp blood pH. A pH in the low 7.1 range indicates significant acidosis and is more concerning than normal baseline fetal heart rate findings. A baseline FHR of 144 bpm is within the normal 110–160 range, and accelerations and long-term (moderate) variability are reassuring signs of adequate oxygenation and intact neurologic function. Therefore, the abnormal scalp pH is the key observation indicating suspected fetal compromise requiring prompt evaluation/intervention.

Question 13

A maternity client tells the nurse her husband is behaving in strange ways since she became pregnant. He’s having morning sickness, has put on weight, complains of intestinal pains, and is acting like he’s pregnant. The nurse interprets this as indicating which of the following?

Accepted Answer

Answer reason: g., nausea, weight gain, abdominal discomfort) during the partner’s pregnancy. The described cluster of morning sickness, weight gain, and intestinal pains fits this pattern and is typically considered a normal psychosocial response rather than pathology. It does not, by itself, indicate a defense mechanism such as reaction formation, which would involve overcompensation of unacceptable feelings rather than somatic symptoms mimicking pregnancy. Counseling may be helpful if distress or dysfunction is significant, but the presentation as described is most consistent with a normal variant.

Question 14

The nurse explained the process of cervical effacement to the client in early labor. Which statement by the client indicates that she understands the information?

Accepted Answer

Answer reason:  Effacement is the progressive shortening and thinning of the cervix as it is pulled upward into the lower uterine segment during labor, described clinically as becoming “paper-thin” (0–100%). This statement accurately reflects that definition and indicates correct understanding of the term. Option A describes cervical dilation (opening from 0 to about 10 cm), which is a different cervical change. Membrane rupture and fetal position changes may occur during labor but are not the defining concept of effacement.

Question 15

The continuous electronic FHR monitor tracing on the laboring client is no longer recording. How should the nurse immediately respond?

Accepted Answer

Answer reason: Loss of an external FHR tracing is most commonly a monitoring/positioning problem rather than sudden fetal compromise. The immediate nursing action is to troubleshoot the equipment and maternal position to rapidly restore fetal signal acquisition (e.g., ensure coupling gel and correct transducer placement over the fetal back). Calling for help or applying oxygen is premature without evidence of fetal distress, and oxygen is not a first-line intervention for a presumed equipment issue. If troubleshooting fails promptly, then confirming the fetal heart rate by intermittent auscultation becomes the next step while continuing evaluation.

Question 16

The client in labor received an epidural anesthesia 20 minutes ago. The nurse assesses that the client’s BP is 98/62 mm Hg and that the client is lying supine. What should the nurse do next?

Accepted Answer

Answer reason: Epidural anesthesia can cause maternal hypotension from sympathetic blockade, and a supine position in late pregnancy worsens this via aortocaval compression, reducing venous return and uteroplacental perfusion. Turning the patient to the left immediately relieves vena cava compression and is the fastest, safest first nursing intervention to improve preload and blood pressure. This positioning also supports fetal oxygenation while additional measures are prepared if needed. IV fluid bolus may be appropriate if hypotension persists, but correcting supine hypotension is the priority action when the client is found lying supine.

Question 17

The pregnant client asks the nurse, who is teaching a prepared childbirth class, when she should expect to feel fetal movement. The nurse responds that fetal movement usually can first be felt during which time frame?

Accepted Answer

Answer reason: Most clients, especially in a first pregnancy, begin noticing these subtle movements around 18–20 weeks as fetal size and strength increase. Earlier gestational ranges are when fetal movement may be seen on ultrasound but is usually too faint for the client to perceive. A later window would delay expected normal maternal perception and could lead to unnecessary concern if movement is not felt by then.

Question 18

The nurse is reviewing the laboratory report from the first prenatal visit of the pregnant client. Which laboratory result should the nurse most definitely discuss with the HCP?

Accepted Answer

Answer reason: g., colposcopy) and a pregnancy-appropriate management plan. Pregnancy does not eliminate the need to address cervical cancer screening abnormalities; instead, care is adjusted to protect both maternal safety and fetal well-being. By contrast, hemoglobin/hematocrit values at this level can be consistent with the physiologic hemodilution of pregnancy, and the listed WBC count is within normal limits. The urine pH and specific gravity shown are not, by themselves, urgent indicators of pathology without accompanying symptoms or abnormal findings (e.g., protein, glucose, nitrites, ketones).

Question 19

The nurse is caring for the client who is Rh negative at 13 weeks’ gestation. The client is having cramping and has moderate vaginal bleeding. Which HCP order should the nurse question?

Accepted Answer

Answer reason: Continuous external fetal monitoring is generally not feasible or clinically useful at 13 weeks because the fetus is too small for reliable continuous tocodynamometry and fetal heart rate tracing (this is typically used in viable or near-viable gestations, often ≥20 weeks). With first-trimester bleeding and cramping, priority evaluation focuses on confirming intrauterine pregnancy/viability and assessing for miscarriage or ectopic pregnancy, which ultrasound and serial beta-hCG directly address. In an Rh-negative client with bleeding, administering anti-D immune globulin is appropriate to reduce the risk of Rh sensitization. Therefore, the order for continuous external fetal monitoring is the one that should be questioned as inconsistent with gestational age and expected diagnostic utility.

Question 20

A client with painless vaginal bleeding at 28 weeks’ gestation has just been diagnosed as having placenta previa. Which statement by the client indicates that she understands the nurse’s teaching?

Accepted Answer

Answer reason:  Placenta previa places the client at risk for recurrent, potentially massive antepartum hemorrhage, so teaching focuses on minimizing triggers for bleeding and ensuring rapid access to emergency care. Activity restriction and rest are commonly prescribed to reduce uterine irritability and mechanical disruption near the placental implantation site. In contrast, vaginal intercourse and other strenuous activities can precipitate bleeding and are typically contraindicated with previa. Travel (including flying) can delay access to immediate obstetric services if bleeding occurs, so it is generally discouraged when previa is symptomatic or unstable.

Question 21

A nurse is taking an initial history on a pregnant client, who asks about the chances of having dizygotic twins. Which statement by the nurse is correct?

Accepted Answer

Answer reason: Dizygotic twinning is primarily driven by multiple ovulation, which becomes more common as maternal age increases (particularly in the 30s) due to changes in gonadotropin stimulation. Therefore, advancing maternal age increases the likelihood of releasing more than one ovum in a cycle, raising the chance of fraternal twins. In contrast, fertility drugs and assisted reproduction increase the probability of multiple ovulation and thus increase the risk, making the statement denying this incorrect. Additionally, dizygotic twinning is more frequent in women of African ancestry and with higher parity, so the options stating the opposite are not accurate.

Question 22

The nurse is teaching a student nurse about the GTPAL system, which documents a client’s previous pregnancies. Which statement most accurately describes this system?

Accepted Answer

Answer reason: The correct option matches the T-P-A-L components, which are the clinically meaningful descriptors used in prenatal documentation and handoff communication. Options that use “neonates” rather than births/outcomes or include nonstandard categories (e.g., “problem pregnancies,” “anencephalic neonates”) do not reflect the accepted GTPAL definitions. Using the correct framework helps avoid errors when assessing risk factors and planning antepartum care.

Question 23

A client with a term, uncomplicated pregnancy comes into the labor-anddelivery unit in early labor saying that she thinks her water has broken. Which action by a nurse would be most appropriate?

Accepted Answer

Answer reason: Initial intrapartum nursing care prioritizes assessment to confirm/characterize suspected rupture of membranes and identify immediate risks to mother and fetus. Timing helps estimate duration of membrane rupture, which affects infection risk and guides ongoing monitoring and provider notification urgency. Observing color/amount/odor screens for concerning findings such as meconium-stained fluid, malodor suggesting infection, or scant fluid that may indicate prolonged leaking. Preparing for delivery or ordering specialized testing is premature in an uncomplicated term client without first completing this focused assessment; the provider can then be notified based on findings.

Question 24

During the labor of a client with a breech presentation, the amniotic membranes rupture. Meconium is present in the amniotic fluid. The client asks the nurse what this means. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: Meconium-stained amniotic fluid most commonly reflects fetal stress/hypoxia leading to vagal stimulation and relaxation of the anal sphincter with passage of meconium in utero. In the intrapartum setting, this finding warrants concern for compromised fetal status and closer fetal monitoring and readiness for neonatal resuscitation due to aspiration risk. A prolonged labor can be associated with stress, but it does not specifically explain meconium as well as fetal compromise does. It is not related to maternal-fetal blood incompatibility, and it should not be framed as “normal,” even if breech presentation can be associated with meconium passage.

Question 25

A nurse administers oxytocin (Pitocin) to a client to induce labor. The nurse determines that immediate intervention is necessary when the client presents with which finding?

Accepted Answer

Answer reason: Contractions that are too long and too frequent (minimal rest between them) indicate excessive uterine activity and require immediate nursing action (stop oxytocin, reposition, IV bolus, oxygen per protocol, notify provider). Dehydration signs may require treatment but are not as emergent as uterine hyperstimulation while on oxytocin. A fetal heart rate of 160 bpm can be mild tachycardia and is concerning in context, but the most direct, oxytocin-specific emergency cue here is the contraction pattern itself.

Question 26

Prior to administration of the rubella vaccine, what is the most important information for the nurse to teach the client?

Accepted Answer

Answer reason: Live attenuated vaccines are contraindicated during pregnancy due to a theoretical risk of fetal infection and congenital anomalies, so preventing conception after immunization is the key safety teaching. Postpartum rubella immunization is commonly given to protect future pregnancies, but the client must use reliable contraception for the recommended interval to avoid exposing an early embryo. Breastfeeding is not a contraindication to rubella/MMR vaccination, so that teaching would be unsafe. Also, arthralgia and mild rash can occur after rubella vaccine (especially in adult women), and characterizing them as uncommon is less clinically important than pregnancy avoidance counseling.

Question 27

Which activity by a client indicates that a nurse’s teaching about perineal care has been effective?

Accepted Answer

Answer reason: Postpartum perineal care aims to reduce infection risk and promote healing by gently cleansing the area without introducing bacteria or disrupting tissues. Using a peri-bottle (spray bottle) after voiding and stooling helps rinse away urine and fecal contaminants while minimizing friction on sore or swollen perineal tissue. Wiping back to front increases the chance of moving rectal bacteria toward the urethra/vagina, raising UTI/endometritis risk. Douching is contraindicated postpartum because it can force bacteria upward and irritate healing tissues. Pad changes should be frequent (often with each void or when soiled), so limiting to three times daily is inadequate for hygiene and infection prevention.

Question 28

Three days after discharge, a client who is bottle feeding her neonate calls the postpartum floor and asks the nurse what she can do for breast engorgement. What is the best response by the nurse?

Accepted Answer

Answer reason: Engorgement in a non-breastfeeding postpartum client is managed by suppressing lactation and minimizing breast stimulation to reduce milk production and discomfort. Firm breast support helps decrease edema and reduces stimulation that can perpetuate let-down and ongoing milk supply. Warm water exposure can increase vasodilation and trigger milk let-down, worsening engorgement when the goal is suppression. Dietary milk intake does not drive lactation, and engorgement around postpartum day 3 is a common physiologic timing, not an automatic reason for urgent provider contact unless infection signs are present.

Question 29

A nurse at a prenatal clinic is assessing a young pregnant client who expresses behaviors related to drug and alcohol abuse. Which statement indicates the client's child is at high risk of fetal alcohol syndrome (FAS)?

Accepted Answer

Answer reason: " Fetal alcohol syndrome risk increases with heavy, chronic maternal alcohol intake because ethanol is a teratogen that crosses the placenta and disrupts fetal growth and neurodevelopment. Daily consumption of a large amount of beer indicates sustained exposure and is most strongly associated with FAS compared with isolated low-dose intake. Cocaine or marijuana use poses other serious fetal risks, but they do not define FAS, which is specifically linked to alcohol. One glass of wine once is still discouraged in pregnancy, yet it is not as predictive of the high FAS risk implied by ongoing heavy drinking.

Question 30

The client in labor is requesting water therapy (hydrotherapy) to help provide pain relief and relaxation. Her recent vaginal exam was 2/50/—2. How should the nurse respond to the client's request?

Accepted Answer

Answer reason: " Hydrotherapy is typically offered once labor is active because early immersion in latent labor can slow uterine activity and prolong labor. A cervical exam of 2 cm dilation and 50% effacement suggests latent/early labor rather than active labor, so the safest, most appropriate nursing response is to set expectations about timing. This response also supports comfort measures while still aligning with common institutional criteria for tub use (e.g., reassuring fetal status and established labor). A common distractor is focusing on monitoring difficulty; while monitoring may be less convenient, it is not the primary reason to defer hydrotherapy at this stage.

Question 31

The client has been in labor for 21 hours. Induction was started 16 hours ago, and she is now dilated 5 cm. She has made little progress, and there has been no fetal descent. The I-CP identifies cephalopelvic disproportion (CPD). The nurse should prepare the client for which mode of delivery?

Accepted Answer

Answer reason: Prolonged labor with minimal cervical change and no fetal descent despite induction strongly supports arrest of labor from obstruction rather than inadequate contractions alone. When CPD is identified, operative vaginal methods are inappropriate because they require an engaged, low fetal head and do not resolve an obstructed passage. Preparing for surgical birth is the safest mode to reduce maternal and fetal morbidity from continued prolonged labor.

Question 32

The nurse, admitting a 40-week primigravida to the labor unit, just documented the results of a recent vaginal exam: 3/100/—2, RSP. How should the oncoming shift nurse interpret this documentation?

Accepted Answer

Answer reason: Intrapartum vaginal exam shorthand typically documents dilation/effacement/station plus fetal position. “100” indicates complete (100%) effacement, and “RSP” indicates a sacral position consistent with a breech presentation rather than a cephalic presentation, so the key interpretive focus is that the cervix is fully effaced and advanced in labor assessment. The “—2” is a station measurement referenced to the ischial spines, reflecting descent/engagement terminology in labor charting. Option A misreads station because negative stations are above the ischial spines, not below, making it unsafe to interpret as “2 cm below.”.

Question 33

At one minute after birth, a neonate is pink, except for blue extremities. The neonate is crying, gagging, and grimacing when the bulb syringe is used and has some flexion of extremities and an HR of 97. Based on the Apgar score, what should the nurse do next?

Accepted Answer

Answer reason: This infant’s findings correspond to an Apgar of 7 (acrocyanosis=1, HR

Question 34

The laboring client is requesting IV pain medication instead of epidural anesthesia. The nurse determines that which factor would most definitely contraindicate the administration of nalbuphine hydrochloride?

Accepted Answer

Answer reason: Full cervical dilation and complete effacement indicate birth is imminent, making it likely the newborn will be delivered while peak maternal drug effect is still present. This creates the highest risk for depressed neonatal respirations and poor neonatal adaptation at delivery. By contrast, the fetal heart rate findings listed are within or consistent with reassuring patterns and do not, by themselves, constitute a contraindication to maternal IV opioid analgesia.

Question 35

The nurse is caring for a 30-year-old, single female who delivered a term newborn. What is the best way for the nurse to assess the impact of the newborn on the client’s lifestyle?

Accepted Answer

Answer reason: Assessing lifestyle impact is best done through direct, patient-centered questioning that explores expected role changes, resources, and coping plans after discharge. This open-ended question elicits the client’s preparedness for infant care, anticipated adjustments in time, sleep, work, finances, and support systems—core elements of lifestyle change. Observation of visitors or relationships provides indirect, incomplete data and can be misleading in the hospital environment. Reviewing the prenatal record reflects past patterns but does not evaluate the client’s current adaptation and concrete plans for integrating newborn care into daily life.

Question 36

The nurse discovers that an African couple from Kenya has not named their 48-hour-old, full-term newborn, and the infant and mother are being discharged to home. Which action should the nurse take in response to this information?

Accepted Answer

Answer reason: Naming practices vary widely by culture and may not indicate impaired bonding, so the priority is culturally sensitive assessment and support rather than imposing a naming deadline. The nurse should promote and observe other bonding behaviors (holding, eye contact, talking to the infant, responding to cues, feeding involvement) to support healthy parent–infant attachment. Requiring a name or delaying discharge is unnecessary and risks cultural insensitivity without evidence of a safety or attachment problem. Documentation alone does not address the nursing goal of supporting family adaptation and attachment during the postpartum period.

Question 37

Immediately after delivery of the client’s placenta, the nurse palpates the client’s uterine fundus. The fundus is firm and located halfway between the umbilicus and symphysis pubis. Which action should the nurse take based on the assessment findings?

Accepted Answer

Answer reason: A fundal height halfway between the symphysis pubis and the umbilicus is an expected normal location right after placental delivery. Because the finding is normal, the appropriate nursing action is to record it rather than intervene. Fundal massage is indicated when the uterus is boggy, and assessment for bladder distention is more relevant when the fundus is displaced (often up and to the side).

Question 38

When looking in the mirror at her abdomen, the postpartum client says to the nurse, “My stomach still looks like I’m pregnant!” The nurse explains that the abdominal muscles, which separate during pregnancy, will undergo which change?

Accepted Answer

Answer reason: Targeted postpartum core-strengthening helps approximate the rectus muscles and restore functional tone, which addresses the client’s concern about a persistent abdominal “bulge.” Expecting full tone to return within a week is unrealistic and inconsistent with normal postpartum musculoskeletal recovery. The change is not primarily dependent on losing pregnancy weight, because the separation is a structural/tonal issue rather than just adiposity.

Question 39

The client, whose parity is 1, had a vaginal delivery 6 days ago and arrived home yesterday after treatment for endometritis. The home health nurse visits the client and plans teaching after seeing which most concerning item in the client’s bathroom?

Accepted Answer

Answer reason: Postpartum infection risk is reduced by avoiding introduction of bacteria into the uterus while the cervix remains partially open and lochia is present. Tampon use in the early postpartum period can trap blood and provide a medium for bacterial growth, and insertion can introduce organisms, which is especially concerning after recent endometritis. The most appropriate teaching is to use perineal pads only until cleared by the provider (often until after the postpartum check) and to monitor for fever, uterine tenderness, and foul-smelling lochia. The other items reflect general hygiene or household safety concerns but are less directly linked to recurrence or worsening of postpartum uterine infection.

Question 40

The Caucasian postpartum client asks the nurse if the stretch marks (striae gravidarum) on her abdomen will ever go away. Which response by the nurse is most accurate?

Accepted Answer

Answer reason: " Striae gravidarum are dermal changes from connective tissue stretching and microtears, so they do not fully resolve but typically become much less noticeable over time. Postpartum, the initial reddish/purplish marks gradually lose vascularity and commonly transition to silvery/pale lines within months. A statement that they will totally disappear in a month is unrealistic and inaccurate. They also do not remain permanently raised and reddened, and hydration may improve skin comfort but does not determine the characteristic color change/timeline.

Question 41

The client, who is 20 days postpartum, telephones the perinatal clinic to tell the nurse that she is having heavy, bright red bleeding since hospital discharge 18 days ago. Which instruction to the client is correct?

Accepted Answer

Answer reason: " Heavy, persistent bright-red bleeding nearly 3 weeks postpartum is abnormal and suggests secondary postpartum hemorrhage from causes such as subinvolution, retained products, or infection. This requires prompt in-person assessment (vital signs, uterine tone/size, bleeding amount, possible ultrasound and labs) to prevent hemodynamic compromise. Advising rest alone delays evaluation and can miss a potentially serious complication. Reassuring the client or telling her to wait another week is unsafe because ongoing heavy bleeding is not expected at this stage of lochia progression.

Question 42

The client with mastitis asks the nurse if she should stop breastfeeding because she has developed a breast infection. Which response by the nurse is best?

Accepted Answer

Answer reason:  Frequent and effective milk removal is a key principle in managing mastitis because milk stasis worsens inflammation and pain. Continuing breastfeeding (or pumping if needed) helps empty the breast, improves ductal drainage, and typically leads to faster symptom resolution when combined with appropriate supportive care and antibiotics when indicated. Breastfeeding is generally safe for the infant in uncomplicated mastitis, so stopping solely due to fear of infecting the baby is not evidence-based. Recommendations to pause feeding until symptoms improve or for a set time delay effective drainage and can increase the risk of abscess formation and worsening discomfort.

Question 43

Twenty-four hours after the birth of her first child, the 25-year-old single client tells the nurse that she has several different male sex partners and asks the nurse to recommend an appropriate birth control method for her. Considering her lifestyle, which method of birth control should the nurse suggest?

Accepted Answer

Answer reason: This method provides long-acting, highly effective pregnancy prevention for about 3 months per dose without needing action at each sexual encounter. Barrier methods (e.g., diaphragm) are more user-dependent and have higher typical-use failure rates, and an IUD does not address the client’s elevated STI risk and may be less appropriate to initiate immediately in this context. Spermicides containing nonoxynol-9 can increase mucosal irritation and may raise susceptibility to HIV/STIs with frequent use, making that option a poor fit for someone with multiple partners.

Question 44

The nurse is teaching the postpartum client, who is breastfeeding, about returning to sexual activity after vaginal delivery. Which statement should the nurse include?

Accepted Answer

Answer reason:  Breastfeeding suppresses estrogen levels, which commonly leads to vaginal dryness and dyspareunia in the early postpartum period. Recommending a water-based lubricant is a practical, safe teaching point that promotes comfort and supports resumption of sexual activity when the client feels ready. Orgasm does not meaningfully reduce milk supply, although some women may notice transient let-down. A fixed “two months” restriction and deferring to another provider are not accurate, client-centered postpartum guidance for an uncomplicated vaginal delivery.

Question 45

The nurse is providing nutrition counseling to the client during her first prenatal clinical visit. Which statement, if made by the client, indicates that the client has an understanding of some of the nutritional requirements during pregnancy?

Accepted Answer

Answer reason:  Pregnancy nutrition teaching emphasizes meeting increased needs for key nutrients (especially calcium/protein) without unnecessary excess calories. Using dairy alternatives like cheese can appropriately help meet calcium requirements when a client dislikes milk. The “eating for two” idea commonly leads to excessive caloric intake and inappropriate weight gain. Overweight clients generally still need adequate, balanced intake rather than restrictive dieting, and pregnancy nutrition often includes small frequent meals/snacks rather than limiting intake to only three meals.

Question 46

The 22-year-old client, who is experiencing vaginal bleeding in the first trimester of pregnancy, fears that she has lost her baby at 8 weeks. Which definitive test result should indicate to the nurse that the client's fetus has been lost?

Accepted Answer

Answer reason: At around 8 weeks’ gestation, absence of fetal cardiac activity on ultrasound (when an embryo should have a detectable heartbeat) indicates nonviability. By contrast, declining hCG or low progesterone can suggest a failing pregnancy but are not diagnostic because values vary and may overlap with viable pregnancies. Crown–rump length is used for dating gestation and does not, by itself, determine viability without accompanying cardiac activity findings.

Question 47

A 21-year-old female client arrives at the emergency department with complaints of cramping, abdominal pain, and mild vaginal bleeding. Pelvic examination shows a left adnexal mass that is tender when palpated. Culdocentesis shows blood in the cul-de-sac. The nurse suspects this client may have which condition?

Accepted Answer

Answer reason: The combination of cramping abdominal pain, mild vaginal bleeding, and a tender adnexal mass strongly supports this diagnosis in a reproductive-age client. Abruptio placentae occurs in established intrauterine pregnancy and presents with uterine tenderness/bleeding rather than an adnexal mass. PID can cause adnexal tenderness, but it does not typically produce free intraperitoneal blood on culdocentesis in this presentation.

Question 48

The nurse assesses a client at 34 weeks’ gestation who arrives at the emergency department with severe abdominal pain, uterine tenderness, and an increased uterine tone. The client denies vaginal bleeding. The external fetal monitor shows fetal distress with severe, variable decelerations. The client most likely has which condition?

Accepted Answer

Answer reason: This causes uteroplacental insufficiency, which commonly produces fetal distress on monitoring. Vaginal bleeding may be absent when the hemorrhage is concealed behind the placenta, so denial of bleeding does not exclude the diagnosis. Placenta previa classically presents with painless bright-red bleeding and a soft, non-tender uterus, making it a less fitting explanation for these findings.

Question 49

A client is diagnosed with preterm labor at 28 weeks’ gestation. Later, she comes to the emergency department saying, “I think I’m in labor.” The nurse should expect her physical examination to show which condition?

Accepted Answer

Answer reason: In a patient reporting labor symptoms at 28 weeks, the key finding confirming preterm labor is cervical dilation occurring with a regular contraction pattern. Irregular contractions without cervical change are more consistent with false labor/Braxton Hicks and do not meet criteria for labor. Pain alone without dilation also does not establish labor because contractions may be uncomfortable yet nonproductive.

Question 50

A client hospitalized for preterm labor tells the nurse she’s having occasional contractions. Which nursing intervention would be the most appropriate?

Accepted Answer

Answer reason: Encourage her to empty her bladder and drink plenty of fluids and give I.V. fluids. Dehydration and bladder distention are common, reversible triggers for uterine irritability and can increase the frequency of contractions in pregnancy. Initial nursing management for occasional contractions in a hospitalized preterm-labor patient is to reduce modifiable stimuli by hydrating and ensuring the bladder is emptied, while continuing assessment for true labor progression. Ambulation can intensify uterine activity and is not a first-line nursing action when preterm labor is a concern. Education and epidural analgesia do not address the immediate physiologic contributors and may delay interventions aimed at decreasing contractions.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Ante-Intra-Postpartum Care NCLEX Practice Test

Continue Learning