NUR 145 MASTERY EXAM – SY 2024 - 2025

Situation A: A 32-year-old woman, G2P1, presents to the emergency department at 10 weeks of

gestation with complaints of vaginal bleeding and cramping for the past 24 hours. An ultrasound
reveals the absence of a fetal heartbeat, and the cervix is partially open. The patient is diagnosed
with an incomplete miscarriage. Her vital signs are stable, and she is not experiencing excessive
bleeding. The patient is emotionally distressed and anxious about the situation.

1. What should be the initial nursing intervention for this patient?

A. Administer pain relief medication immediately

B. Provide emotional support and explain the situation
C. Prepare the patient for immediate surgical evacuation
D. Start an IV line and administer fluids

Correct Answer: B. Provide emotional support and explain the situation

Rationale:

The patient's vital signs are stable, and she is not experiencing excessive bleeding. While
physiological needs are a priority in emergencies, this patient is emotionally distressed and
anxious, requiring psychological support as the initial intervention. This approach aligns with the
holistic care model in nursing, which prioritizes the patient’s emotional and psychological well-
being, especially during significant life events like a miscarriage.

2. Considering the patient's stable vital signs and incomplete miscarriage, what is an appropriate
management option to discuss with the patient?

A. Immediate surgical evacuation (D&C)

B. Medical management with misoprostol
C. Expectant management (watchful waiting)
D. All of the above

Correct Answer: D. All of the above

Rationale:

In the case of an incomplete miscarriage with stable vital signs and no excessive bleeding, all
three management options are appropriate depending on the patient's preference, clinical findings,
and availability of resources. Each option should be discussed with the patient, including the risks,
benefits, and likely outcomes, to help her make an informed decision.

3. Considering the patient’s emotional distress, what is an appropriate referral that the nurse
should consider?

A. Referral to a gynecologist for further evaluation

B. Referral to a support group or counselor specializing in pregnancy loss
C. Referral to a nutritionist for dietary advice
D. Referral to a physical therapist for post-procedure rehabilitation

Correct Answer: B. Referral to a support group or counselor specializing in pregnancy

loss

Rationale:

The patient's emotional distress following a miscarriage highlights the need for psychological
support. Referring the patient to a support group or counselor specializing in pregnancy loss
provides her with an avenue to process her emotions, cope with grief, and connect with others
who have had similar experiences. This type of support is integral to her overall well-being and
recovery, addressing the emotional and psychological aspects of her care.
Situation B:

A 29-year-old woman, G1P0, is admitted to the emergency department at 12 weeks of gestation

with complaints of severe abdominal pain, heavy vaginal bleeding, and dizziness. She reports
passing large clots and has been feeling increasingly weak. An ultrasound shows retained products
of conception, and her hemoglobin level is significantly low. The patient is diagnosed with a
complication of miscarriage known as a "complete miscarriage with hemorrhage."

4. What is the most immediate concern for this patient based on her symptoms and clinical
findings?

A. Risk of infection from retained products of conception

B. Risk of severe blood loss and hypovolemic shock
C. Risk of future fertility issues
D. Risk of uterine rupture

Correct Answer: B. Risk of severe blood loss and hypovolemic shock

Rationale:

The patient’s symptoms—severe abdominal pain, heavy vaginal bleeding, dizziness, passage of
clots, and significantly low hemoglobin—indicate acute blood loss leading to a risk of
hypovolemic shock. This condition is life-threatening and requires immediate intervention to
stabilize the patient.

5. What is the most appropriate initial intervention to address the patient’s condition?

A. Administer IV fluids and blood transfusion

B. Start broad-spectrum antibiotics
C. Provide antiemetic medication
D. Schedule a follow-up ultrasound

Correct Answer: A. Administer IV fluids and blood transfusion

Rationale:

The patient's condition—characterized by severe blood loss, low hemoglobin levels, and symptoms
of hemodynamic instability (e.g., dizziness, weakness)—requires immediate stabilization of
circulation to prevent hypovolemic shock. Administering IV fluids helps restore circulating blood
volume, while a blood transfusion addresses the significant anemia caused by hemorrhage.

6. You’re performing a head-to-toe assessment on a patient admitted with abruptio placentae.

Which of the following findings should be reported to the physician immediately due to its potential
significance in this condition?

A. Oozing around the IV site

B. Tender uterus
C. Hard abdomen
D. Vaginal bleeding

Correct Answer: A. Oozing around the IV site

Rationale:

Oozing around the IV site is a potential sign of disseminated intravascular coagulation (DIC),
a life-threatening complication of abruptio placentae. DIC occurs when widespread clotting in small
vessels depletes clotting factors and platelets, leading to bleeding at sites like the IV insertion
point. This finding is critical and requires immediate reporting and intervention to prevent further
deterioration.
Situation C: A 34-year-old woman, G3P2, presents to the emergency department at 28 weeks of
gestation with painless vaginal bleeding. An ultrasound confirms the diagnosis of placenta previa,
where the placenta is located partially covering the cervical os. The patient reports no contractions
or abdominal pain, but she is anxious about the bleeding. Her vital signs are stable, and she has a
history of a previous cesarean section. The physician decides to admit her for close monitoring and
management.

7. What is the most appropriate initial intervention for this patient upon admission?

A. Administer intravenous fluids and monitor for signs of preterm labor

B. Prepare the patient for immediate cesarean section
C. Advise bed rest and arrange for a follow-up ultrasound
D. Initiate corticosteroid therapy for fetal lung maturity

Correct Answer: A. Administer intravenous fluids and monitor for signs of preterm labor

Rationale:

The patient presents with painless vaginal bleeding in the context of placenta previa, a condition
requiring careful monitoring to prevent complications such as hemorrhage or preterm labor. Initial
interventions should focus on stabilizing the patient and closely monitoring for signs of
labor or further bleeding.

8. Given the diagnosis of placenta previa, which mode of delivery is typically planned for this
patient?

A. Vaginal delivery
B. Elective cesarean section
C. Induction of labor
D. Assisted vaginal delivery

Correct Answer: B. Elective cesarean section

Rationale:

In cases of placenta previa, where the placenta is partially or completely covering the
cervical os, a cesarean section is typically the safest mode of delivery to prevent life-
threatening complications such as severe hemorrhage during labor.

9. Which of the following is a potential complication of placenta previa that the healthcare team
should monitor for?

A. Placental abruption
B. Uterine rupture
C. Preterm labor
D. Hyperemesis gravidarum

Correct Answer: C. Preterm labor

Rationale:

Preterm labor is a common complication associated with placenta previa due to the
irritation of the uterine wall caused by the low-lying placenta and bleeding episodes.
Uterine contractions can be triggered by bleeding, increasing the risk of preterm
delivery.

10. If the patient with placenta previa experiences a sudden increase in vaginal bleeding and a
drop in blood pressure, what is the most appropriate immediate action?

A. Prepare the patient for an emergency cesarean section

B. Administer blood transfusions and continue monitoring
C. Perform a manual examination to assess the placenta
D. Increase the rate of intravenous fluids and monitor for further changes
Correct Answer: D. Increase the rate of intravenous fluids and monitor for further changes

Rationale:

A sudden increase in vaginal bleeding with a drop in blood pressure suggests acute blood loss,
which can lead to hypovolemic shock. The most immediate priority is to stabilize the patient
by increasing the rate of intravenous fluids (e.g., crystalloids) to restore circulating volume and
maintain blood pressure.

Situation D: A 30-year-old woman, G2P1, is admitted to the labor and delivery unit at 32 weeks
of gestation with severe abdominal pain, vaginal bleeding, and uterine contractions. She reports
that the pain started suddenly and has been progressively worsening. An ultrasound and physical
examination confirm the diagnosis of abruptio placentae. The patient’s blood pressure is elevated,
and she exhibits signs of fetal distress. Her vital signs include a heart rate of 98 beats per minute
and a blood pressure of 140/90 mmHg.

11 What is the most critical initial intervention for this patient with abruptio placentae?

A. Administer intravenous fluids and blood products

B. Initiate fetal monitoring and prepare for emergency cesarean section
C. Start antihypertensive medication
D. Perform a detailed ultrasound to assess placental detachment

Correct Answer: B. Initiate fetal monitoring and prepare for emergency cesarean section

Rationale:

The patient presents with abruptio placentae, a serious obstetric emergency involving the
premature separation of the placenta from the uterine wall, leading to bleeding, abdominal pain,
and potential fetal distress. The most critical initial intervention is to initiate fetal monitoring
to assess fetal well-being and prepare for emergency cesarean section if fetal distress or
maternal condition worsens.

12. What is a key nursing consideration during the acute management of a patient with abruptio
placentae?

A. Encouraging the patient to eat a high-protein diet

B. Monitoring for signs of disseminated intravascular coagulation (DIC)
C. Advising on early ambulation to reduce discomfort
D. Providing education about elective induction of labor
Correct Answer: B. Monitoring for signs of disseminated intravascular coagulation (DIC)

Rationale:

A key nursing consideration during the acute management of abruptio placentae is to closely
monitor for signs of disseminated intravascular coagulation (DIC). Abruptio placentae can
lead to widespread clotting in the small blood vessels, which depletes clotting factors and
platelets, increasing the risk of severe bleeding. Monitoring for signs of DIC, such as oozing from
IV sites, bleeding from gums, or a decrease in platelets, is crucial for timely intervention.

13. If the fetal heart rate monitoring reveals persistent decelerations and the maternal condition
continues to deteriorate, what is the most appropriate next step?

A. Continue with current management and reassess in one hour

B. Perform an immediate emergency cesarean section
C. Administer additional intravenous fluids and recheck maternal vitals
D. Consult with a dietitian to review nutritional needs
Correct Answer: B. Perform an immediate emergency cesarean section

Rationale:
In the setting of persistent fetal decelerations and maternal deterioration, the most
appropriate next step is to perform an immediate emergency cesarean section. Persistent
decelerations typically indicate fetal distress, which, combined with a deteriorating maternal
condition, requires urgent delivery to prevent further fetal compromise or potential maternal
morbidity.

14 A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal

bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the
client’s complaint of vaginal bleeding?

A. Placenta previa

B. Abruptio placentae

C. Ectopic pregnancy

D. Spontaneous abortion

Correct Answer: B. Abruptio placentae

Rationale:

The most likely complication causing vaginal bleeding in this patient is abruptio placentae.
Cocaine use is a known risk factor for placental abruption, which is the premature separation of
the placenta from the uterine wall. This condition leads to vaginal bleeding, abdominal pain, and
uterine contractions, and can result in fetal distress, preterm labor, or maternal complications.
Cocaine can cause vasoconstriction, which impairs placental blood flow, increasing the risk of
placental abruption.

Situation C; A 27-year-old woman, G1P0, presents to the emergency department at 34 weeks of

gestation with a headache, visual disturbances, and swelling in her hands and feet. Her blood
pressure is recorded at 170/110 mmHg. She reports having gained 10 pounds in the past week
and has experienced intermittent abdominal pain. Laboratory tests reveal elevated liver enzymes
and proteinuria. An ultrasound shows no fetal distress, but the patient exhibits symptoms
consistent with severe preeclampsia. During the assessment, the patient suddenly experiences a
generalized tonic-clonic seizure, indicating eclampsia.

15. What is the most urgent intervention required for this patient who has just experienced a
seizure?

A. Administer magnesium sulfate to prevent further seizures

B. Prepare the patient for immediate induction of labor
C. Administer intravenous antihypertensive medications
D. Arrange for a detailed ultrasound to assess fetal well-being

Correct Answer: A. Administer magnesium sulfate to prevent further seizures

Rationale:

The patient is experiencing eclampsia, a severe complication of preeclampsia, characterized by the

onset of seizures. The most urgent intervention is to administer magnesium sulfate, which is the
first-line treatment to prevent further seizures and manage eclampsia. Magnesium sulfate works
as a neuroprotective agent by stabilizing the neuronal membrane and reducing the risk of
additional seizures.

16. What is an important nursing action to monitor for when managing a patient on magnesium
sulfate?

A. Monitor for signs of hyperglycemia

B. Assess for deep tendon reflexes and signs of respiratory depression
C. Check for signs of bleeding tendencies
D. Monitor for signs of fetal distress via continuous fetal monitoring
Correct Answer: B. Assess for deep tendon reflexes and signs of respiratory depression

Rationale: When managing a patient on magnesium sulfate, it is crucial to monitor for signs
of magnesium toxicity, which can manifest as loss of deep tendon reflexes and respiratory
depression. Magnesium sulfate is a central nervous system depressant, and excessive levels can
impair neuromuscular function, leading to these signs.

17. A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe
pitting edema. Which of the following would be most important to include in the client’s plan of
care?

A. Daily weights
B. Seizure precautions
C. Right lateral positioning
D. Stress reduction

Correct Answer: B. Seizure precautions

Rationale:

For a client with severe preeclampsia, the most important intervention is seizure
precautions. Severe preeclampsia increases the risk of eclampsia, which is the onset of
seizures due to the hypertension and systemic effects of the condition. Implementing
seizure precautions, such as ensuring the bed is in a low position, padding side rails, and
having suction equipment available, is critical to prevent injury in the event of a seizure.

18. A 28 year old female, who is 33 weeks pregnant with her second child, has uncontrolled
hypertension. What risk factor below found in the patient’s health history places her at risk for
abruptio placentae?

A. childhood polio

B. preeclampisa

C. c-section

D. her age

Correct Answer: B. Preeclampsia

Rationale:

Preeclampsia is a significant risk factor for abruptio placentae. This condition, characterized
by high blood pressure and potential organ damage (such as proteinuria and liver
dysfunction), can lead to placental abruption, where the placenta prematurely separates
from the uterine wall. The underlying hypertension and vascular changes associated
with preeclampsia contribute to this risk.

19. The following signs and symptoms are associated with placenta previa EXCEPT:

A. Painless bright red bleeding

B. Hard, tender uterus

C. Normal fetal heart rate

D. Abnormal fetal position

Correct Answer: B. Hard, tender uterus

Rationale:

The primary characteristic of placenta previa is painless vaginal bleeding, often described as
bright red in color, due to the placenta being located near or covering the cervix.

In contrast, a hard, tender uterus is more indicative of placental abruption, not placenta
previa. In placental abruption, the placenta prematurely detaches from the uterine wall, often
causing painful uterine contractions and abdominal tenderness.
Situation D: Sheila, 38 years, G7P6 is admitted to the hospital because of painless
vaginal bleeding at 34 weeks AOG.

20. The most likely diagnosis for Sheila is

a. placenta previa
b. abruption placenta
c. ruptured tubal pregnancy
d. incompetent cervix
Correct Answer: a. Placenta previa

Rationale:

Sheila's symptoms of painless vaginal bleeding at 34 weeks of gestation are most consistent
with placenta previa. Placenta previa occurs when the placenta is positioned over or near
the cervical os, and as the cervix begins to dilate and efface, it can lead to painless vaginal
bleeding. This bleeding is usually bright red in color and is a hallmark of placenta previa.

21. After Sheila’s bleeding is controlled and vital signs are stable, what would the nurse anticipate
to confirm diagnosis?

a. doctor will perform vaginal examination

b. client will undergo Non-stress test
c. ultrasound will be done to the client
d. complete physical assessment

Correct Answer: c. Ultrasound will be done to the client

Rationale:

An ultrasound is the safest and most accurate method to confirm the diagnosis of placenta
previa. It allows the healthcare team to visualize the location of the placenta in relation
to the cervical os and assess for any abnormalities. A transabdominal ultrasound is typically
performed first, and if needed, a transvaginal ultrasound may be done as it provides better
clarity.

22. The nurse instructs and encourages a client admitted to the hospital with placenta previa
about the importance of:

a. Breathing deeply to ensure that the fetus gets oxygen

b. Remaining on her back to minimize pressure on the cervix
c. Lying on her side to avoid putting pressure on the vena cava
d. Avoiding intercourse for 2 weeks after bleeding stops

Correct Answer: c. Lying on her side to avoid putting pressure on the vena cava

Rationale:

Lying on the side, particularly the left side, helps to improve maternal blood flow by
avoiding compression of the vena cava by the gravid uterus. This position ensures better
blood circulation to the placenta and fetus, reducing the risk of compromised oxygen
and nutrient delivery.

23. The nurse reviews the physician’s orders and would question which order?

a. Prepare the client for an ultrasound

b. Perform enema to relieve constipation
c. Prepare to draw a hemoglobin and hematocrit blood sample
d. Obtain equipment for external electronic fetal heart rate monitoring.
Correct Answer: b. Perform enema to relieve constipation

Rationale:

Performing an enema is contraindicated in patients with placenta previa because the

procedure can stimulate uterine contractions or increase pressure on the cervix,
potentially worsening the bleeding and causing further complications. Any intervention
that risks trauma or stimulation of the uterus or cervix should be avoided in this
condition.

24. Upon examination, the nurse observed the following: the fundus is 2 fingerbreadths above the
umbilicus, the last menstrual period was 5 months ago, and the fetal heartbeat is not detected.
Which of the following is the most likely diagnosis?

A. Hydatidiform mole
B. Missed abortion
C. Pelvic inflammatory disease
D. Ectopic pregnancy

Correct Answer: A. Hydatidiform mole

Rationale:

The combination of an enlarged uterus for gestational age (fundus 2 fingerbreadths above
the umbilicus at 5 months), the absence of fetal heart tones, and symptoms such as
irregular bleeding (not mentioned but often present in such cases) strongly suggests a
hydatidiform mole. This is a type of gestational trophoblastic disease where abnormal
trophoblastic tissue grows in place of a viable pregnancy, resulting in the absence of a
fetus despite uterine enlargement.

25. Which of the following is a key diagnostic tool for detecting a molar pregnancy?

A. Ultrasound
B. MRI
C. Blood test for progesterone
D. Urine test for protein

Correct Answer: A. Ultrasound

Rationale:

An ultrasound is the key diagnostic tool for detecting a molar pregnancy. It provides
imaging of the uterus that can reveal the characteristic findings of a molar pregnancy,
such as:

A "snowstorm" pattern, indicating multiple small cystic spaces in the uterus.

The absence of a fetus or an abnormal fetal appearance in the case of a partial mole.

Ultrasound is non-invasive and provides immediate, reliable information to confirm the

diagnosis.

26. What symptom of molar pregnancy is most commonly associated with excessive growth of
trophoblastic tissue?

A. Rapidly enlarging uterus

B. Breast tenderness
C. Frequent fatigue
D. Constipation
Correct Answer: A. Rapidly enlarging uterus

Rationale:

In a molar pregnancy, the excessive growth of trophoblastic tissue causes the uterus to
grow abnormally fast, resulting in a uterus that is disproportionately larger than expected
for gestational age. This is a hallmark symptom and is often associated with other signs
like severe nausea and vomiting due to extremely elevated beta-hCG levels.

27. In molar pregnancy, what type of vaginal discharge is often reported?

A. Clear fluid
B. Thick, white discharge
C. Grape-like vesicles
D. Blood-streaked mucus

Correct Answer: C. Grape-like vesicles

Rationale:

In a molar pregnancy, patients may report passing grape-like vesicles in their vaginal
discharge. These vesicles are a result of the abnormal growth of the trophoblastic tissue
forming fluid-filled cystic structures, characteristic of the condition. This symptom is
highly indicative of a hydatidiform mole and is often accompanied by vaginal bleeding.

28. Which of the following is an important nursing consideration in the post-operative care of a
patient who has undergone evacuation for a molar pregnancy?

A. Monitoring for signs of infection

B. Encouraging a high-protein diet
C. Advising on exercise routines
D. Scheduling a follow-up for contraceptive counseling

Correct Answer: A. Monitoring for signs of infection

Rationale:

Post-operative care for a patient who has undergone evacuation for a molar pregnancy
involves close monitoring for complications, such as infection. Signs of infection include
fever, foul-smelling vaginal discharge, or abdominal pain. Infection can occur due to
retained trophoblastic tissue or as a complication of the surgical procedure, making
vigilance crucial.

29. Which of the following is a common cause of an incompetent cervix?

A. Previous cervical surgery

B. Hypertension
C. Diabetes mellitus
D. Urinary tract infections
Correct Answer: A. Previous cervical surgery

Rationale:

Incompetent cervix is often caused by structural damage or abnormalities of the cervix.

A common cause is previous cervical surgery, such as cervical conization or loop
electrosurgical excision procedure (LEEP), which can weaken the cervical tissue. Other
risk factors include trauma during childbirth, uterine anomalies, or a history of cervical
insufficiency.

30. What is the primary purpose of McDonald's cerclage and Shirodkar cerclage?

A. To treat urinary incontinence

B. To prevent preterm labor due to an incompetent cervix
C. To correct uterine prolapse
D. To alleviate pelvic pain
Correct Answer: B. To prevent preterm labor due to an incompetent cervix

Rationale:

The primary purpose of both McDonald's cerclage and Shirodkar cerclage is to reinforce a
weakened or incompetent cervix, thereby preventing preterm labor and pregnancy loss.
These procedures involve placing a stitch (suture) around the cervix to keep it closed
during pregnancy, typically performed between 12 and 14 weeks of gestation.

31. How does a McDonald's cerclage procedure typically differ from a Shirodkar cerclage
procedure?

A. McDonald's cerclage uses a purse-string suture, while Shirodkar cerclage places the suture
higher in the cervix
B. McDonald's cerclage is done abdominally, while Shirodkar cerclage is done vaginally
C. McDonald's cerclage is performed earlier in pregnancy than Shirodkar cerclage
D. McDonald's cerclage requires general anesthesia, while Shirodkar cerclage does not

Correct Answer: A. McDonald's cerclage uses a purse-string suture, while Shirodkar

cerclage places the suture higher in the cervix

Rationale:

The McDonald's cerclage and Shirodkar cerclage both aim to prevent preterm labor by
providing additional support to the cervix, but they differ in the surgical technique used
to place the suture.

32. What is a key characteristic of a missed miscarriage?

A. Heavy vaginal bleeding and severe cramping

B. No fetal heartbeat detected, but no tissue passed
C. Partial expulsion of pregnancy tissue
D. Cervix is closed and no tissue passed

Correct Answer: B. No fetal heartbeat detected, but no tissue passed

Rationale:

A missed miscarriage (also known as a silent miscarriage) occurs when the fetus has died,
but the body has not yet expelled the pregnancy tissue. This typically presents with no
fetal heartbeat on ultrasound, but the pregnancy tissue remains in the uterus, and there is
no immediate expulsion of the tissue.

33. Which type of miscarriage involves the cervix opening, but the pregnancy continues?

A. Inevitable miscarriage
B. Threatened miscarriage
C. Incomplete miscarriage
D. Complete miscarriage

Correct Answer: A. Inevitable miscarriage

Rationale:

An inevitable miscarriage occurs when the cervix has begun to dilate (open), and the
pregnancy can no longer be maintained, but the pregnancy tissue has not yet been
expelled. This typically leads to a miscarriage, but the process of expulsion is imminent
or inevitable.
34. What is a potential complication for the fetus of a pregnant client with poorly controlled pre-
gestational GDM?

A) Low birth weight

B) Macrosomia (large birth weight)
C) Hypoglycemia after birth
D) Respiratory distress syndrome
Correct Answer: B. Macrosomia (large birth weight)

Rationale:

Poorly controlled pre-gestational diabetes mellitus (GDM) can lead to macrosomia, which is
characterized by an unusually large fetus. This occurs because high blood sugar levels in
the mother can lead to excessive glucose transfer to the fetus, causing the fetal
pancreas to produce more insulin. This excess insulin acts as a growth hormone, leading
to increased fetal growth, particularly in the abdomen, resulting in macrosomia.

35. What is a recommended approach for managing pregnant clients with pre-gestational
substance abuse disorder?

A) Immediate cessation of all substances at the start of pregnancy.

B) Gradual reduction of substance use under medical supervision.
C) Continued substance use without modification.
D) Increased consumption of prenatal vitamins.
Correct Answer: B. Gradual reduction of substance use under medical supervision.

Rationale:

For pregnant women with pre-gestational substance abuse disorder, the safest approach is a
gradual reduction of substance use under medical supervision. Abrupt cessation of certain
substances, such as alcohol, opioids, or benzodiazepines, can lead to withdrawal
symptoms that may harm both the mother and fetus. Therefore, healthcare providers
often recommend tapering or supervised management of the withdrawal process,
particularly with substances that can cause dangerous withdrawal syndromes.

36. Which intervention is crucial for preventing Rh sensitization in Rh-negative pregnant clients?

A) Administering Rh immunoglobulin (RhIg)

B) Administering aspirin
C) Prescribing antibiotics
D) Initiating antiviral therapy
Correct Answer: A. Administering Rh immunoglobulin (RhIg)

Rationale:

The most crucial intervention for preventing Rh sensitization in Rh-negative pregnant

clients is the administration of Rh immunoglobulin (RhIg). RhIg is a blood product that
contains antibodies to the Rh factor, and it prevents the mother's immune system from
developing antibodies against Rh-positive fetal blood cells. This is particularly important
during pregnancy and delivery, as sensitization can occur when Rh-negative mothers are
exposed to Rh-positive fetal blood cells, leading to hemolytic disease of the newborn in
subsequent pregnancies.

37. What is a primary goal of antiretroviral therapy (ART) for pregnant clients with pre-gestational
HIV/AIDS?

A) Preventing preterm labor

B) Treating hypertension
C) Reducing maternal viral load
D) Preventing gestational diabetes
Correct Answer: C. Reducing maternal viral load

Rationale:The primary goal of antiretroviral therapy (ART) for pregnant clients with pre-
gestational HIV/AIDS is to reduce the maternal viral load to undetectable levels. Lowering
the viral load reduces the risk of vertical transmission (mother-to-child transmission) of HIV
during pregnancy, labor, and delivery. ART is critical in improving maternal health, preventing
HIV-related complications, and minimizing the likelihood of transmitting the virus to the fetus.By
achieving a low or undetectable viral load, ART also significantly reduces the risk of neonatal
HIV infection and improves birth outcomes.

38.When should antiretroviral therapy (ART) be initiated in pregnant clients with HIV/AIDS?

A) After delivery
B) During the third trimester
C) Immediately upon diagnosis
D) Only if symptoms worsen

Correct Answer: C. Immediately upon diagnosis

Rationale:

Antiretroviral therapy (ART) should be initiated immediately upon diagnosis for pregnant
clients with HIV/AIDS. The goal of starting ART as soon as possible is to reduce the maternal
viral load and prevent transmission of HIV to the fetus during pregnancy, labor, and delivery.
Early initiation of ART improves maternal health, helps achieve viral suppression, and minimizes
the risk of vertical transmission (mother-to-child transmission) of HIV.

Starting ART early also improves birth outcomes and reduces the risk of complications
associated with untreated HIV, such as opportunistic infections, maternal AIDS, and preterm birth.

39.What antenatal test is important for monitoring fetal well-being in pregnancies complicated by
HIV/AIDS?

A) Amniocentesis
B) Non-stress test (NST)
C) Chorionic villus sampling (CVS)
D) Biophysical profile (BPP)
Correct Answer: B. Non-stress test (NST)

Rationale:

The Non-stress test (NST) is an important antenatal test for monitoring fetal well-being in
pregnancies complicated by HIV/AIDS. This test is commonly used to assess fetal heart
rate (FHR) patterns in response to fetal movements. A healthy fetus typically shows
accelerations in the heart rate with movement, indicating good oxygenation and fetal
health.

In pregnancies complicated by HIV/AIDS, NST is a non-invasive and routine method to

monitor fetal health and detect any signs of fetal distress. It helps ensure that the fetus is
not experiencing any compromised oxygenation or other complications related to maternal
HIV infection or ART.

40. The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the
following prescribed treatments for this condition?

a.) Medication that will provide sedation

b.) Increased hydration
c.) Oxytocin (Pitocin) infusion
d.)Administration of a tocolytic medication
Correct Answer: c.) Oxytocin (Pitocin) infusion

Rationale:

Oxytocin (Pitocin) is commonly used to manage hypotonic uterine dysfunction. This condition
is characterized by weak or ineffective uterine contractions that lead to a slowing of labor
progress. Oxytocin is a synthetic form of the hormone oxytocin, which stimulates uterine
contractions and helps increase the frequency, duration, and intensity of contractions, thus
promoting more effective labor progression.

In this situation, the goal of Pitocin infusion is to augment labor by promoting stronger
contractions, especially in cases where labor has slowed due to hypotonic contractions.
41. Who are at risk for shoulder dystocia? Select all that applies.

1.) Previous shoulder dystocia

2.) Gestational Diabetes

3.) Post term labor

4.) Prolonged 2nd stage of labor

a.) all of the above

b.) none of the above

c.) all but 4

d.) 2 and 4 only

Correct Answer: a.) all of the above

Rationale:

Shoulder dystocia occurs when the infant's shoulder(s) become stuck during delivery,
typically after the head has been delivered. The following risk factors are associated
with an increased likelihood of shoulder dystocia:

42. The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the
following prescribed treatments for this condition?

a.) Medication that will provide sedation

b.) Increased hydration
c.) Oxytocin (Pitocin) infusion
d.)Administration of a tocolytic medication

Correct Answer: c.) Oxytocin (Pitocin) infusion

Rationale:

Hypotonic uterine dysfunction is characterized by weak, ineffective uterine contractions,

which can result in slowed or stalled labor. In this case, the goal is to stimulate stronger and
more effective contractions to help progress the labor. Oxytocin (Pitocin) is commonly
administered to augment labor in cases of hypotonic uterine dysfunction. It is a synthetic
hormone that stimulates uterine contractions, promoting a more efficient labor process.

43. A pregnant woman is admitted to the hospital with a diagnosis of abruptio placenta. Which of
the following statement would best describe the patient’s diagnosis?

A. It is the low implantation of the placenta in the uterus as the cervix softens & begins to efface &
dilate, placental sinuses are opened causing progressive hemorrhages

B. It is the premature separation of the normally implanted placenta after the 20th week of
pregnancy, typically with severe hemorrhage

C. It separates only at the edges causing vaginal bleeding & a little pain

D. The placenta separates first at the center, blood pools under the placenta & is hidden from view

Correct Answer: B. It is the premature separation of the normally implanted placenta

after the 20th week of pregnancy, typically with severe hemorrhage.

Rationale:

Abruptio placentae, also known as placental abruption, refers to the premature separation
of the normally implanted placenta from the uterine wall, which typically occurs after the
20th week of pregnancy. This condition is associated with severe hemorrhage and can lead to
significant maternal and fetal complications, including fetal distress, preterm birth, and maternal
shock. The bleeding may be external or concealed, and the degree of separation can vary.

44. A pregnant client was admitted at 2:00 pm with a cervical dilation of 5cm and was ordered by
the Obstetrician to monitor her progress of labor after 4 hours you checked her cervical dilation is
still the same. What type of dysfunctional labor in first trimester does the client is experiencing?

A. Prolonged Latent Phase

B. Protracted Active Phase

C. Prolonged Deceleration Phase

D. Secondary Arrest of Dilatation

Correct Answer: A. Prolonged Latent Phase

Rationale:

The latent phase of labor is the initial phase of the first stage of labor when the cervix begins to
dilate from 0 to 6 cm. It is typically characterized by slow cervical dilation and may last for a
variable amount of time. If the cervix is still at 5 cm after 4 hours, this is considered a
prolonged latent phase, as it suggests that the labor is progressing slower than expected.

45.You are giving a health teaching to a patient who is diagnosed with Infection of the Perineum.
Which of the following health teaching that you cannot give for home management?

A. Drainage of infected site and packing with iodoform gauze on the open lesion

B. Sitz baths, moist, warm compresses, Hubbard tank treatments to hasten drainage & cleanse the
area

C. Remind woman to change perineal pads frequently to prevent recontamination or vaginal

infection

D. Ask woman to wipe from front to back after bowel movement

Correct Answer: A. Drainage of infected site and packing with iodoform gauze on the
open lesion

Rationale:

For a patient diagnosed with an infection of the perineum, drainage of an infected site and
packing with iodoform gauze should be performed by a healthcare provider and not as
home management. The procedure involves sterile techniques, proper wound care, and
sometimes follow-up care to monitor for complications, making it inappropriate for self-
management at home without medical supervision.

46. This occur during the 1st 10 days postpartum, some women have feelings of sadness as a
response to the anticlimactic feeling after birth and is related to hormonal shifts:

A. Postpartal Blues

B. Postpartal Depression

C. Postpartal Psychosis

D. Postpartal Mood Swing

Correct Answer: A. Postpartal Blues

Rationale:

Postpartal Blues, also known as "baby blues," is a common and temporary condition that
occurs in the first 10 days postpartum. It is characterized by feelings of sadness, mood
swings, irritability, and tearfulness, which often arise as a response to the hormonal
shifts following childbirth. It is typically a transient experience and does not require
medical intervention.

47. A type of Assisted Reproductive Technique wherein instillation of sperm into the female
reproductive tract to aid conception:

A. Therapeutic Insemination

B. In Vitro Fertilization

C. Gamete Intrafallopian Transfer (GIFT)

D. Zygote Intrafallopian Transfer (ZIFT)

E. Surrogate Embryo Transfer

Correct Answer: A. Therapeutic Insemination

Rationale:

Therapeutic insemination (also known as artificial insemination) is an assisted reproductive

technique (ART) where sperm is introduced into the female reproductive tract (either
the cervix or uterus) to assist in conception. This technique is commonly used for cases
of male infertility, low sperm count, or when there is a need to bypass certain fertility
issues.

48. Criteria for puerperal infection include:

a. temp greater than 38 degrees on 2 separate occasions at least 24 hours apart following the first
24 hours after delivery
b. temp greater than 38.5 degrees on 2 separate occasions at least 24 hours apart following the
first 24 hours after delivery
c. temp greater than 38 degrees for more than 24 hours following the first 24 hours after delivery
d. none of the above

Correct Answer: a. temp greater than 38 degrees on 2 separate occasions at least 24

hours apart following the first 24 hours after delivery

Rationale:

Puerperal infection (also known as postpartum infection) is characterized by an infection of the

reproductive tract following childbirth. The criteria for diagnosing puerperal infection typically
include a fever:

49. Risk Factors for puerperal infections include:

1. low socioeconomic status
2. women who have had operative delivery
3. History of premature rupture of membranes
4. long delivery
5. shoe who have had multiple pelvic exams

a.) all of the above

b.) 1, 2 and 3

c.) 2, 3 and 4

d.) 4 and 5

Correct Answer: a.) all of the above

Rationale:

Puerperal infections (postpartum infections) are infections that occur in the reproductive tract
following childbirth. Various risk factors can increase a woman’s likelihood of developing a
puerperal infection. These include:

Low socioeconomic status

Women from lower socioeconomic backgrounds may face barriers to proper prenatal care,
hygiene, or timely medical intervention, increasing the risk of infection.
Women who have had operative delivery
Operative deliveries, such as cesarean sections, forceps, or vacuum-assisted deliveries, increase
the risk of infection due to surgical incisions and possible trauma to the uterus or vaginal tissue.

History of premature rupture of membranes

Premature rupture of membranes (PROM) increases the risk of infection because the protective
barrier of the amniotic sac is compromised, allowing bacteria to ascend from the vaginal canal into
the uterus.

Long delivery
Prolonged labor increases the risk of infection due to prolonged exposure of the birth canal and
uterus to potential pathogens. It also increases the likelihood of interventions like catheterization
or manual examinations.

Women who have had multiple pelvic exams

Multiple pelvic exams during labor and delivery can introduce bacteria into the uterus, increasing
the risk of infection.

50.) A 28-year-old postpartum patient presents to the clinic with complaints of breast pain,
swelling, redness, and fever. The nurse suspects mastitis. Which of the following nursing
interventions is most appropriate for this patient?

A. Advise the patient to stop breastfeeding immediately to prevent further infection.

B. Recommend the patient to apply warm compresses to the affected breast and continue
breastfeeding.

C. Suggest the patient to wear tight-fitting bras to provide breast support.

D. Instruct the patient to only pump and discard breast milk from the affected breast.

Correct Answer: B. Recommend the patient to apply warm compresses to the affected breast and
continue breastfeeding.

Rationale:

Mastitis is an infection of the breast tissue, commonly occurring in breastfeeding women. It

typically presents with breast pain, swelling, redness, and sometimes fever. The most appropriate
nursing intervention is to:

 Apply warm compresses to the affected breast to help relieve pain and encourage milk
flow.
 Continue breastfeeding or pumping, as frequent emptying of the breast helps clear the
infection and prevents further engorgement, which can worsen the condition. This also
helps to maintain milk production.