1

INSTRUCTORS COPY
FINAL COACHING
PART III
B. Decrease in rate during the midportion of
1. True labor can be differentiated from prodromal or contraction
false labor in that in true labor there is a C. Increase in rate following the rupture of
A. Strengthening of uterine contractions with membranes
walking D. Increase in rate when engagement begins
B. Failure of presenting part to descend 11. The nursing assessment of a woman in labor reveals
C. Lack of cervical dilation contractions lasting 60 seconds and 4 minutes apart;
D. Cessation of uterine contractions with walking cervix is 6 cm and dilated. The woman is in what
2. Which of the following statement best describe the phase of the first stage of labor?
characteristic of true contraction? A. Latent phase
A. True contractions begin in the lower abdomen B. Active phase
B. True contractions are difficult to determine C. Transition phase
because they come and go D. Early phase I
C. True contractions have a regularity and 12. Nursing assessment reveals active labor, breech
become more intense over time presentation, ruptured membranes and passage of
D. True contractions decrease with activity meconium stained amniotic fluid. The nurse valuates
3. The nurse is assessing between false and true labor. this as:
What does she ask the patient to do? A. A fetus in distress
A. Bear down B. A normal assessment
B. Walk around C. A sign of labor is progressing
C. Time the contractions D. Indicative of CS
D. Do breathing exercise 13. The bag of water is ruptured artificially when the fetal
4. The birth hazard unassociated with breech delivery is: head is engaged in order to
A. Intracranial hemorrhage A. Enable the bag of water to rupture
B. Cephalhematoma spontaneously if possible, thus avoiding difficult
C. Compression of the cord and painful instrumentation
D. Separation of placenta prior to delivery of the B. Prevent prolapse of the umbilical cord during
head the forceful expulsion of amniotic fluid from
5. Assessment findings indicate that patient is 3 cm the sac
dilated, and contractions every 6 minutes lasting 40 C. Ensure that small amount of amniotic fluid would
seconds. The nurse should monitor the FHT be left in the upper portion of the amniotic sac
A. Every 15 minutes D. Have the amniotic sac in a dependent position
B. Every 30 minutes that could be reached without difficulty
A. Every 60 minutes 14. The cervix is considered completely dilated when the
C. Every 90 minutes diameter of the os is:
6. When a patient is admitted to the unit in active labor. A. 6 cm
What is the initial action the nurse should take? B. 8 cm
A. Assess for ruptured membranes C. 10 cm
B. Take V/S and check FHT D. 12 cm
C. Perform the Leopold’s maneuvers 15. In timing the contraction the nurse should notify the
D. Catheterize for urine specimen physician if she detects a contraction lasting longer
7. Which of the following statement best describe a than
normal female pelvis A. 30 seconds
A. Sacrum well hollowed, coccyx movable, B. 60 seconds
spines not prominent, wide pubic arch C. 90 seconds
B. Flat sacrum, movable coccyx, prominent spines, D. 120 seconds
wide pubic arch 16. The mechanics of the second stage of labor differ
C. Sacrum deeply hollowed, immovable coccyx, from the first stage in that during the second stage
narrow pubic arch, spines not prominent A. The lower uterine segment contracts more than
D. Flat sacrum, movable coccyx, prominent spines, the fundus
wide pubic arch B. The abdominal muscles assist in the
8. The most effective method of determining if the pelvis expulsion of the fetus
is adequate to allow the passage of the fetus C. The joint of the pelvis are stretched and
vaginally is: dislocated
A. Pelvimetry D. All muscles involved in fetal propulsion undergo
B. X-ray examination Tetany
C. Assessment of characteristics of contractions 17. The fetal head is engaged when
D. Duration of labor A. The vertex of the skull is level with the
9. What does it mean during labor when the nurse symphysis pubis
assesses the fetal presenting part at “plus one”? B. The biparietal diameter has passed the pelvic
A. One inch above ischial spines inlet
B. One inch below ischial spines C. The head rotates from the transverse to the AP
C. One cm above ischial spines position
D. One cm below ischial spine D. The head has descended beyond the external os
10.The nurse should be aware that which of the following 18. To determine the fetal position during labor the nurse
variations in FHT may be considered normal should assess which of the following
A. Decrease in rate during the second stage of A. First body part of the fetus felt by the nurse upon
labor vaginal examination

1
 2
B. Relationship of a fixed point of the fetus to B. At some point, the fetus experienced oxygen
the quadrants of the maternal pelvis deprivation
C. Relationship of the furthermost fetal part to the C. The fetus is in distress and should be delivered
ischial spines of the maternal pelvis immediately
D. Relationship of the long axis to the mother’s D. The fetus is not experiencing any undue stress
body 28. An electronic fetal monitor is attached. The fetal
19. During the early second stage of labor FHT should monitoring strip shows an FHR deceleration
be taken at least every occurring about 30 seconds after each contraction
A. 2-4 minutes begins; the FHR return to baseline after the
B. 5 to 10 minutes contraction is over. This type of deceleration is
C. 10 to 20 minutes caused by:
D. 20 to 30 minutes A. Fetal head compression
20. The changes in shape of the infant’s head that occur B. Umbilical cord compression
owing to pressure from the walls of birth canal are C. Uteroplacental insufficiency
called D. Cardiac anomalies
A. Molding 29. The fetal monitoring strip shows an FHR deceleration
B. Cephalhematoma occurring about 30 seconds after each contraction
C. Microcephaly begins; the FHR return to baseline after the
D. Caput succedaneum contraction is over. With this type of deceleration, the
21. If crowning occurs while the nurse is alone with the nurse’s first action should be to:
patient, the nurse should A. Increase the IV flow rate
A. Place a sterile water over the infant’s head and B. Call the physician
apply manual pressure until a physician arrives C. Position the woman in labor on the left side
B. Place a mask over the woman’s face and D. Continue monitoring the FHR
administer a few drops of ether to delay the 30. A woman is active labor cries out, “I’m feeling a lot of
delivery pressure. I want to push.” The nurse notes that her
C. Call for help, stay with the patient and guide cervix is dilated 7 cm. How should the nurse
the slow delivery of the head between respond?
contractions A. Tell the woman to begin to push, then call the
D. Instruct the woman to hold her knees together physician
and leave to obtain help from an experienced B. Tell the woman to breath by blowing air
nurse through her mouth when she feels the urge
22. The most common position for the fetus at birth is to push
A. Right occiput anterior C. Instruct the woman to breath when she gets the
B. Left occiput anterior urge to push
C. Right occiput posterior D. Instruct the woman to hold her breath when she
D. Left occiput posterior gets the urge to push
23. The second stage of labor ends with 31. A woman is in labor for 6 hours. Her contractions are
A. Complete cervical dilation occurring every 2 minutes and lasting 70 seconds.
B. Bulging of the perineum She is diaphoretic, restless, and irritable, moaning
C. Delivery of the baby that she “can’t take it anymore.” According to this
D. Removal of the placenta assessment findings, which phase of labor she is in?
24. The fetal heart rate variability is not affected by A. Latent phase
A. Maternal sleep B. Second stage
B. The second stage of labor C. Third stage
C. Fetal sleep D. Transitional phase
D. Maternal drug use 32. Which procedure would be best to determine if the
25. The nurse is timing the contractions in a patient who woman has spontaneously ruptured amniotic
is 7 cm dilated. The nurse should time the membranes?
contractions A. A CBC
A. From the beginning of a contraction to end B. A fern test
B. From the beginning of a contraction to the C. Urinalysis
beginning of the next D. A vaginal exam
C. From the end of a contraction to the beginning of 33. A woman is experiencing true labor when her
the next contraction pattern shows
D. From the end of a contraction to the end of the A. Occasional irregular contractions
next contraction B. Irregular contractions that increase in intensity
26. A woman in labor comes to the labor and delivery C. Regular contractions that remain the same
area with ruptured membranes, contractions that D. Regular contractions that increase in
occur every 3 minutes and last 50 to 60 seconds. frequency and duration over time
The fetus is in the LOA position. The nurse’s first 34.The nurse is to perform Leopold’s maneuvers on a
action should be to: pregnant woman. What instructions does the nurse
A. Check the FHR give the patient just before the assessment?
B. Call the physician A. Take slow, deep breaths to relieve pain
C. Check the vaginal fluid with nitrazine paper B. Do not eat the night before the procedure
D. Admit the patient to the labor and delivery area C. Remain on strict bedrest prior to procedure
27. A woman in labor was admitted with ruptured D. Urinate before the procedure
membranes. Assessment indicates that the FHT is 35. The nurse performs Leopold’s maneuvers to assess
audible in left lower quadrant. When asked to A. Fetal position
describe the amniotic fluid, the woman states that it B. Cervical dilation
was brown-tinged. This indicates that C. Fetal well-being
A. The fetus has an infection D. Stage of labor

2
 3
36. During the active phase of labor the woman reports A. 5 cm cervical dilation
severe back pain that becomes increasingly intense B. 80% cervical effacement
during contractions. The nurse should place the C. Contractions every 5 to 8 minutes
woman in which position D. Station –3
A. Supine position 44. The fetal monitor strips shows an FHR deceleration
B. Semi-Fowler’s occurring during the increment of a contraction,
C. Squatting reaching its lowest point at the acme of the
D. Side lying on the side of the fetal back contraction, and returning to baseline during the
37. The nurse should encourage the woman to void decrement of the contraction. This type of
frequently during labor primarily to deceleration indicates
A. Enhance fetal descent A. Fetal distress
B. Prevent UTI B. Uteropalcental insufficiency
C. Strengthen the perineal and vaginal muscles C. Fetal vagal nerve stimulation
D. Assess the urine specimen for albumin D. Umbilical cord compression
38. Assessment indicates that the woman’s membranes 45. During labor, the nurse assesses the woman’s BP
rupture several hours ago before admission. Which A. During the increment of a contraction
action would be the nurse’s priority in caring for her? B. Between contractions
A. Monitor BP C. During the decrement of a contraction
B. Monitoring her I and O D. During the acme of contraction
C. Providing frequent perineal care 46. The fetal monitor strips shows an FHR deceleration
D. Measuring her temperature every 2 hours occurring during the increment of a contraction,
39. A woman in labor with complete cervical dilation reaching its lowest point at the acme of the
begins pushing during contractions, the FHR drops to contraction, and returning to baseline during the
approximately 90 BPM and then quickly returns to decrement of the contraction. This type of
the baseline when she stops pushing. This sudden deceleration indicates
change is probably the result of A. Maternal hypoxia
A. Maternal position B. Fetal lung maturity
B. Maternal drug use C. Fetal movement
C. Fetal abnormality D. Fetal well-being
D. Umbilical cord compression 47. Which factor would be most helpful in assessing the
adequacy of the woman’s placental perfusion?
40. Assessment reveals cervical dilation of 5 cm cervical A. The duration and intensity of her contraction
effacement 80%, station -3 frequency of contractions B. Her ability to cope with discomfort of labor
5 to 8 minutes, duration of contractions 40-50 C. The duration of the rest phases between
seconds, membranes ruptured spontaneously 1 hour contractions
prior to admission, vertex presentation, LOA position. D. The effectiveness of her breathing techniques
Based on assessment, the fetal presenting part is: during a contraction
A. At the level of the pelvic inlet 48. If a laboring woman breathes improperly when using
B. At the level of the ischial spines of childbirth preparation, the result could be which of
C. 1 cm below the ischial spines the following?
D. At the perineum A. Increased pulse
41. Assessment reveals cervical dilation of 5 cm cervical B. Hyperventilation
effacement 80%, station -3 frequency of contractions C. Hypertension
5 to 8 minutes, duration of contractions 40-50 D. FHR deceleration
seconds, membranes ruptured spontaneously 1 hour 49. A woman in labor complains of tingling sensation and
prior to admission, vertex presentation, LOA position. numbness of her hands and feet and she uses her
The FHR should be most audible in which quadrant breathing techniques. These symptoms indicate:
of the woman’s abdomen? A. Respiratory alkalosis
A. Left upper quadrant B. Metabolic alkalosis
B. Left lower quadrant C. Respiratory acidosis
C. Right upper quadrant D. Metabolic acidosis
D. Right lower quadrant 50. A woman in labor complains of tingling sensation and
42. The LOA position means that numbness of her hands and feet. She breathes
A. Lie is longitudinal and the fetal occiput is deeply and rapidly. Which nursing action would best
directed toward the left posterior portion of the alleviate the woman’s complaints?
maternal pelvis A. Administering 4L of oxygen by face mask
B. Lie is transverse and fetal mentum is directed B. Increasing her IVF of dextrose 5% in LR solution
toward the left posterior portion of the maternal C. Telling her to exhale into her cupped hands
pelvis and then reinhale
C. Lie is longitudinal and the fetal occiput is D. Having her exhale into a paper bag
directed toward the left anterior portion of 51. A woman progresses through labor until cervical
the maternal pelvis dilation is 10 cm. Which breathing technique, besides
D. Lie is oblique and fetal anterior fontanel is cleansing breaths, should the woman use during
directed toward the left posterior portion of the contractions at this time?
maternal pelvis A. Modified paced breathing at no more than twice
43. Assessment reveals cervical dilation of 5 cm cervical her normal respiratory rate
effacement 80%, station -3 frequency of contractions B. Patterned paced breathing at no more than 4
5 to 8 minutes, duration of contractions 40-50 times her normal respiratory rate
seconds, membranes ruptured spontaneously 1 hour C. Breath holding 5 to 6 seconds while pushing
prior to admission, vertex presentation, LOA position. with open glottis
The physician places the woman on bed rest. Which D. Breath holding for 10 to 15 seconds with a
assessment finding necessitates this action? closed glottis during long, sustained pushes

3
 4
52. A woman in labor experiences cramps in her right FHR 130 to 140 BPM. The physician prescribed
leg. These cramps probably are the result of: oxytocin to augment labor. Which nursing
A. A low serum calcium level intervention is NOT appropriate for her?
B. Pressure on the lumbo-sacral nerve plexus A. Piggybacking the oxytocin into the Y-site closest
C. Pressure on the pudendal nerve to the IV insertion site
D. A calcium-potassium imbalance B. Explaining oxytocin administration and what to
53. Which of the following statements best explain the expect
purpose of effleurage during labor? C. Placing her in high Fowler’s position
A. This is massage of the legs to remove cramps D. Assessing the FHR and contraction pattern
that occur during labor every 15 minutes
B. This is gentle massage of the abdomen to 60. A woman in labor is connected to fetal monitoring
facilitate relaxation device. The nurse notes contractions every 1-minute,
C. This is application of pressure over the sacral last 60 seconds, and result in uterine pressure of 90
area to relieve backache mmHg. The FHR is 160 to 170 BPM with normal
D. This is a form of biofeedback for relaxation variability. The nurse’s initial action should be to:
54. Shortly before delivery the woman receives pudendal A. Record the time the contractions increased in
block anesthesia. After receiving the pudendal block, intensity
which reactions the woman is likely to experience? B. Continue monitoring the contractions and FHR
A. Delayed voiding after delivery because the C. Discontinue oxytocin administration
nerves supplying the bladder are numb D. Notify the physician
B. Complete relief from the discomfort of uterine 61. After the woman receives epidural block anesthesia,
contractions during labor the nurse should immediately:
C. Numbness of the legs after delivery A. Assess the FHR
D. Numbness of the birth canal and the B. Assess the woman’s BP, pulse, and
perineum to allow pushing during delivery respirations
55. The physician performs midline episiotomy. This C. Administer oxygen via face mask
procedure is performed for all of the following D. Place the woman in semi-Fowler’s position
reasons EXCEPT to: 62. Assessment findings on a woman in labor include
A. Prevent perineal laceration cervical dilation of 4 cm, 100% effaced, station 0,
B. Avoid stretching and tearing of the perineum contractions every 5 to 6 minutes lasting 50 to
C. Shorten the third stage of labor 60seconds, membranes intact, FHR 140 to 150 BPM
D. Reduce the incidence of subsequent perineal loudest in the upper left quadrant, and hard round
relaxation with cystocele or rectocele mass palpable at the level of the fundus. Assessment
56. How should the nurse prepare the prescribed findings indicate that the fetus is in
oxytocin to be administered with 1L of dextrose 5% in A. Breech presentation
water? B. Cephalic presentation
A. Add 10U of oxytocin to main IV line C. Posterior position
B. Add 10U of oxytocin to 1L of prescribed solution, D. Transverse lie
then piggyback the solution to main IV line 63. Assessment findings on a woman in labor include
C. Add 10U of oxytocin to 1L of prescribed cervical dilation of 4 cm, 100% effaced, station 0,
solution using an infusion control device, contractions every 5 to 6 minutes lasting 50 to
and then piggyback the solution to the main 60seconds, membranes intact, FHR 140 to 150 BPM
IV line. loudest in the upper left quadrant, and hard round
D. Add 10U of oxytocin to 500 ml of prescribed mass palpable at the level of the fundus. While
solution using an infusion control device, then monitoring the FHR membranes rupture
piggyback the solution to the main IV line spontaneously revealing meconium-stained amniotic
57. Which factor is a contraindication for using oxytocin fluid. The nurse’s initial action should be to:
to augment labor? A. Prepare the woman for CS delivery because of
A. Fetal distress fetal distress
B. Prolonged labor B. Notify the physician
C. An extended period since rupture of membranes C. Determine the FHR
D. Postmaturity D. Place the woman in left side lying position
58. Assessment reveals cervical dilation of 5 cm cervical because amniotic fluid indicates fetal distress
effacement 65%, station -1 frequency of contractions 64. Assessment reveals cervical dilation of 5 cm cervical
5 to 8 minutes, duration of contractions 30-50 effacement 80%, station +3 frequency of contractions
seconds, membranes ruptured spontaneously 12 5 to 8 minutes, duration of contractions 40-50
hour prior to admission, FHR 130 to 140 BPM. The seconds, membranes ruptured spontaneously 1 hour
physician prescribed oxytocin to augment labor. prior to admission, vertex presentation, LOA position.
Which nursing diagnosis on the woman’s care plan The woman asks the nurse if it is all right for her to
has the HIGHEST PRIORITY during oxytocin get up and walk around. The nurse’s best response
administration? should be
A. Pain R/T uterine contraction A. “You should stay in bed; walking may interfere
B. Fear R/T unknown outcome with proper uterine contractions”
C. Knowledge deficit R/T use of oxytocin during B. “I can’t make a decision on that, you will have to
labor ask the doctor.”
D. Potential for altered uterine tissue perfusion C. “You will have to stay in bed; otherwise your
R/T uterine contractions contractions cannot be timed and no one can
59. A woman in labor is admitted. Assessment reveals listen to the FHR”
cervical dilation of 5 cm cervical effacement 65%, D. “It’s quite all right for you to be up and about
station -1 frequency of contractions 5 to 8 minutes, as long as you feel comfortable and your
duration of contractions 30-50 seconds, membranes membranes are intact”
ruptured spontaneously 12 hour prior to admission,

4
 5
65. A woman in labor progresses to 7 to 8 cm dilated 76. The nurse notes bright red bleeding in a patient who
and the vertex is low in the midpelvis. To alleviate delivered 26 hours ago. What is the probable
discomfort during contractions, the nurse should cause of bleeding?
instruct the woman to A. Uterine atony
A. Pant during contractions B. Normal bleeding
B. Abdominal breathe C. Perineal laceration
C. Chest breathe D. Placental fragments
D. Pant between contractions 77. The nurse is aware that the nursing action that would
66. If labor is progressing satisfactorily, when would it be be best promote parent-infant attachment behaviors
appropriate to administer medication such as would be:
Demerol? A. Encouraging rooming-in, with parental infant
A. 3 cm dilation care
B. 4 cm dilation B. Keeping the new family together immediately
C. 5 cm dilation postpartum
D. 7 cm dilation C. Restricting visitation on the postpartum unit
67. Demerol 50 mg and Phenergan 50 mg are ordered to D. Supporting the parents’ choice of breastfeeding
be administered IM. This medication would: 78. The nurse is aware that during the taking-in phase of
A. Induce sleep until the time of delivery the postpartum period the area of health teaching
B. Increase pain threshold, resulting I relaxation that the mother will be most responsive to is:
C. Act as amnesic drug A. Family Planning
D. Act as a preliminary anesthesia B. Infant feeding
68. The beginning of the second stage of labor can be C. Infant hygiene
recognized by the client’s desire to: D. Perineal care
A. Relax during contractions 79. A woman’s labor does not progress and a cesarean
B. Push during contractions delivery is performed. Afterwards she tells the nurse
C. Pant during contractions that she is a “natural childbirth flunkie.” The
D. Blow during contractions postpartal phase of adjustment that the statement
69. A woman is positioned on the delivery table; both most closely typifies is:
legs should be placed simultaneously in the stirrups A. Taking hold
to prevent: B. Working through
A. Excessive pull on the fascia C. Taking in
B. Pressure on the perineum D. Letting go
C. Trauma to the uterine ligaments 80. A mother chooses to bottle feed her newborn
D. Venous stasis in the legs because this will cause the least interference with full
70. A G3P2 is in labor and is progressing rapidly. When resumption of her teaching practice. Before
should she be moved into the delivery room? discharge the nurse should teach her that if breast
A. Cervix is dilated 2-4 cm engorgement occurs, she should
B. Cervix is dilated 7-8 cm A. Take 2 aspirins every 4 hours
C. Cervix is dilated 10 cm B. Apply hot compresses to the breasts
D. At the onset of labor C. Wear a tightly fitted brassiere
71. Which of the following is observed first when D. Cease drinking milk for 2 weeks
placenta begins to separate? 81. Twenty-four hours after uncomplicated labor and
A. Lengthening of the cord delivery, the mother’s CBC revels WBC of
B. Sudden gush of blood 17,000/mm3. The nurse would interpret the woman’s
C. Abdomen becomes globular and firm WBC count as being indicative of:
D. Sudden rise of the fundus A. A bacterial infection of the reproductive system
72. The placenta should be delivered within the period of B. An acute sexually transmitted viral disease
time following delivery? C. A normal decrease in WBC
A. 1-2 minutes D. A normal response to labor process
B. 3-10 minutes 82. Which of the following statement best describe
C. 15-20 minutes puerperium?
D. 20-30 minutes A. 4-6 hours period after delivery during which the
73. Ten minutes after the delivery, the placenta is still placenta is completely expelled
intact. What action does the nurse take? B. A phase of the fourth stage of labor
A. Gently pull on the cord to initiate separation C. A term to indicate progressive changes of the
B. Call the physician back to the delivery room breast 4 to 6 weeks after delivery
C. Push gently, but firmly on the fundus D. A 6 week period after delivery, during which
D. Allow the infant to suck the breast the reproductive organs return to non-
74. About 15 minutes after delivery, the woman begins to pregnant state
complain about chills. The most appropriate action 83. A woman G1P1 delivered a 7-lb male infant. She
by the nurse would be to: plans to breast feed the baby. On the first day
A. Notify the physician of the problem postpartum day, the nurse notes that the woman’s
B. Cover with a blanket fundus is above the umbilicus and to the left of the
C. Administer acetaminophen as ordered midline. What would the nurse initially suspect?
D. Increase the IV infusion rate A. A full bladder
75. The nurse assesses the postpartum mother during B. Retained placental fragments
the fourth stage of labor for: C. Uterine atony
A. Level of maternal love D. Uterine inertia
B. Distention of the bladder 84. Ellen complains of tenderness and swelling of the
C. Ability to relax breasts. The nurse explains that she is
D. Knowledge of the newborn behavior experiencing primary breast engorgement, which
lasts for

5
 6
A. 1 to 2 days and milk production during pregnancy and following
B. 3 to 4 days pregnancy?
C. 5 to 6 days A. FSH
D. 7 to 8 days B. Oxytocin
85. Which of the following would the nurse teach the C. Prolactin
postpartum woman to include in her daily care to D. Placental lactogen
keep the nipples in good condition for 94. The first day after delivery, the husband tells the
breastfeeding to prevent potential for infection? nurse that his wife has been talking constantly about
A. Wash with soap and water before each her recent delivery experience. He asks the nurse if
feeding this is normal maternal behavior after delivery. The
B. Keep the nipples dry and clean nurse’s best response is:
C. Cover the nipples with a dry and clean plastic A. Divert her attention away from the delivery
pad B. Do you feel uncomfortable talking about the
D. Cleanse with antiseptic solution three times a delivery experience?
day C. This is a normal reaction; it allows her to
86. Which of the following statement best explain why accept the reality of birth
the postpartum mother voids large amount of urine D. It’s a clear sign that your wife needs psychiatric
frequently? evaluation
A. A sign of urinary retention and overflow 95. A mother plans to bottle-feed her son. She asks the
B. A normal body’s response to reduce nurse when her menstruation will return. The nurse
extracellular fluid acquired during correctly states that non-breastfeeding mothers
pregnancy typically resume menstruating in about:
C. A result of decreased bladder tone due to A. 4 to 6 weeks
anesthesia during labor B. 6-8 weeks
D. An indication of a bladder infection C. 3-6 months
87. The period immediately following birth is divided into D. 4-8 month
significant phases. The phase in which the mother’s 96. The major reason for a 3-week prescription for
needs have to be met before she can meet the resumption of sexual intercourse is to prevent
baby’s needs is called A. Tearing of the episiotomy
A. Taking-in phase B. Vaginal and cervical infection
B. Transition phase C. Bladder infection
C. Taking-hold phase D. Dyspareunia
D. Bonding phase 97. After uncomplicated vaginal delivery the mother
88. A woman is discharged on her third postpartum day. complains of severe cramping. The nurse knows that
What type of lochia should be noted? such
A. Lochia alba cramping commonly associated with
B. Lochia serosa A. Infection
C. Lochia rubra B. Retained placental fragments
D. Lochia rugae C. Uterine involution
89. If the fundus of the uterus is felt at the umbilicus D. Bladder distension
immediately after delivery of the placenta, 98. The nurse prepares to help the mother ambulate for
the nurse should take which one of the following the first time after vaginal delivery. Which statement
nursing actions? about early ambulation is true?
A. Catheterize the patient A. It may cause hypotensive episodes
B. Massage the fundus to make it firm B. It facilitates uterine involution
C. Administer Methergine C. It requires no special nursing intervention
D. Support the mother, because this represents a D. It should not be attempted for at least 10 hours
normal fundus placement after delivery
90. Two days after delivery, the nurse assesses a heavy 99. The nurse should assess for a functional let-down
amount of lochia rubra containing reflex. Which sign indicates that the mother’s let-down
four blood clots about the size of one-peso coin. This is functioning properly?
assessment is: A. The neonate’s vigorous sucking at the breast
A. Normal for 2 days post-delivery B. Nipple soreness
B. Normal for 4 days post-delivery C. Leakage of milk from one breast while the
C. Abnormal because it is lochia serosa neonate nurses at the other breast
D. A sign of complication or hemorrhage D. A feeling of breast fullness
91. Which one of the following conditions would alert the 100. After 2 breastfeeding sessions, the mother tells the
nurse for a possible postpartum hemorrhage? nurse, “when I breastfeed my baby, the cramping
A. Delivery of twins after 16 hours of labor gets much worse.” T he nurse’s best response is:
B. Cesarean birth A. Breastfeeding cause the uterus to contract. I
C. Premature delivery can give you something for pain before you
D. First delivery of 7 lb baby boy 2 hours after breastfeed
rupture of membranes B. Let me watch while you breastfeed; your
92. In explaining the pattern of discharge following technique may be causing this problem
delivery, the nurse explains that lochia will C. The cramping is normal, but you can not take
be heavier: any medication while you are breastfeeding
A. In the morning D. The cramping will pass. You just need to
B. At night continue with the breastfeeding
C. As lochia cessation nears
D. Toward the end of lactation END OF TEST
93. Which hormone works with estrogen and
progesterone to stimulate the breast? development