Maternity Practice Exam - 50 questions.
During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take?
Have her cup both hands over her nose and mouth while bre...
During the transition phase of labor, a client complains of tingling and numbness
in her fingers and tells the nurse that she feels like she is going to pass out. What
action should the nurse take?
Have her cup both hands over her nose and mouth while breathing.
Rationale: Hyperventilation blows off carbon dioxide, depletes carbonic acid in the
blood, and causes transient respiratory alkalosis, so the client should cup both hands
over her mouth and nose so she can rebreathe carbon dioxide.
A client who delivered by cesarean section 24 hours ago is using a PCA pump for
pain control. Her oral intake has been ice chips only since surgery. She is now
complaining of nausea and bloating, and states that because she had nothing to
eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the
highest priority?
Impaired bowel motility related to pain medication and immobility.Impaired bowel
motility caused by surgical anesthesia, pain medication, and immobility is the priority
nursing diagnosis and addresses the potential problem of a paralytic ileus.
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation is appropriate?
"Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a
day."
The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day) , if the infant is
adequately hydrated. Although a weight gain of 30 grams/day is indicative of adequate
nutrition, most home scales do not measure this accurately and this suggestion is likely
to make the mother very anxious.
The nurse is counseling a couple who has sought information about conceiving.
The couple asks the nurse to explain when ovulation usually occurs. Which
statement by the nurse is correct?
, Two weeks before menstruation.
Ovulation occurs 14 days before the first day of the menstrual period . While ovulation
can occur in the middle of the cycle, or 2 weeks after menstruation, this is only true for a
woman who has a perfect 28-day cycle. For many women, the length of their menstrual
cycle varies.
The nurse is evaluating a full-term multigravida who was induced 3 hours ago.
The nurse determines the client is dilated 7 cm, is 100% effaced at 0 station, with
intact membranes. The monitor indicates the fetal heart rate (FHR) decelerates at
the onset of several contractions and returns to baseline before each contraction
ends. What action should the nurse take?
Continue to monitor labor progress.
The fetal heart rate indicates early decelerations, which are not an ominous sign, so the
nurse should continue to monitor the labor progress and document the findings in the
client's record.
The nurse instructs a laboring client to use accelerated-blow breathing. The client
begins to complain of tingling fingers and dizziness. What action should the
nurse take?
Have the client breathe into her cupped hands.
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon
dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated
by breathing into a paper bag or cupped hands .
Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized swelling on the right side of his head. What is the most likely
cause of this accumulation of blood between the periosteum and skull that does
not cross the suture line in a newborn?
A cephalhematoma, which is caused by forceps trauma.
Cephalhematoma , a slight abnormal variation of the newborn, usually arises within the
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