The correct answer is choice A.

Choice A rationale:

Fetal heart tones detected by ultrasound are a positive sign of pregnancy because they provide direct evidence of a fetus.

Choice B rationale:

Breast tenderness is a presumptive sign of pregnancy, not a positive one, as it can be caused by other conditions such as premenstrual syndrome.

Choice C rationale:

A positive urine pregnancy test is a probable sign of pregnancy, not a positive one, as it measures the presence of hCG, a hormone produced during pregnancy. However, certain medications and medical conditions can also produce hCG.

Choice D rationale:

Fatigue is a presumptive sign of pregnancy, not a positive one, as it can be caused by various other conditions such as stress or illness.

The correct answer is choice A.

Choice A rationale:

An internal examination could disturb the placenta and cause profound bleeding, which is a life-threatening condition for both the mother and the fetus.

Choice B rationale:

While there is always a risk of introducing infection during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.

Choice C rationale:

An internal examination could potentially initiate preterm labor, but this is not the primary concern with placenta previa.

Choice D rationale:

While there is a risk of rupture of the amniotic membranes during an internal examination, this is not the primary reason to avoid it in a client with placenta previa.

The correct answer is choice C.

Choice A rationale:

Keeping the baby’s head covered helps to prevent heat loss, as newborns lose a significant amount of heat through their heads.

Choice B rationale:

Keeping the baby’s bassinet away from fans and air conditioning helps to maintain a stable body temperature.

Choice C rationale:

Newborns’ temperatures are typically checked every 3 to 4 hours, not every hour, and are usually done axillary, not rectally.

Choice D rationale:

Placing the baby on the mother’s stomach and covering her with a warm blanket promotes skin-to-skin contact and helps to maintain the baby’s body temperature.

The correct answer is choice D.

Choice A rationale:

Cervix dilation of 5 cm with 50% effacement is a sign of active phase of the first stage of labor, not the end of it.

Choice B rationale:

Rupturing of fetal membranes can occur at any time during labor, not specifically at the end of the first stage.

Choice C rationale:

Start of regular contractions is a sign of the onset of labor, not the end of the first stage.

Choice D rationale:

Cervix dilation of 10 cm with 100% effacement indicates the end of the first stage of labor and the beginning of the second stage.

The correct answer is choice B.

Choice A rationale:

Stimulating the infant to cry is important, but it is not the first action to be taken.

Choice B rationale:

Clearing the respiratory tract is the first action to be taken to ensure the newborn can breathe properly.

Choice C rationale:

Drying the infant off and covering the head is done after the respiratory tract is cleared.

Choice D rationale:

Cutting the umbilical cord is done after the infant is stabilized.

The correct answer is choice C.

Choice A rationale:

Sitz baths cause perineal vasodilation, not vasoconstriction, and this does not directly affect bleeding.

Choice B rationale:

The duration of a sitz bath does not necessarily correlate with its therapeutic effect.

Choice C rationale:

Sitz baths increase the blood supply to the perineal area, promoting healing and providing relief from discomfort.

Choice D rationale:

Sitz baths do not increase the risk of postpartum infection when done properly.

The correct answer is choice D. When the cervix is fully dilated.

Choice A rationale:

The arrival of the health care provider does not determine when the laboring client should push. This is dependent on the dilation of the cervix.

Choice B rationale:

Seeing the fetal head is not the determinant for when the laboring client should push. The cervix needs to be fully dilated.

Choice C rationale:

The nurse wanting the client to push is not the correct time for the laboring client to push. The cervix needs to be fully dilated.

Choice D rationale:

The laboring client is encouraged to push when the cervix is fully dilated. This is to avoid birth trauma.

The correct answer is choice A. She did her perineal care independently.

Choice A rationale:

Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.

Choice B rationale:

Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.

Choice C rationale:

Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.

Choice D rationale:

Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.

The correct answer is choice A. She did her perineal care independently.

Choice A rationale:

Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.

Choice B rationale:

Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.

Choice C rationale:

Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.

Choice D rationale:

Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.

The correct answer is choice A.

Choice A rationale:

The glucose challenge test is used to check for gestational diabetes during pregnancy. People at average risk of gestational diabetes usually have this test done during the second trimester, generally between 24 and 28 weeks of pregnancy.

Choice B rationale:

This is too early in the pregnancy to screen for gestational diabetes. The body’s response to sugar changes as the pregnancy progresses, so testing is typically done later.

Choice C rationale:

This is still a bit early for the screening. The recommended time is between 24 and 28 weeks of gestation.

Choice D rationale:

This is too late in the pregnancy for the screening. The recommended time is between 24 and 28 weeks of gestation.

The correct answer is choice B.

Choice A rationale:

The term “-1” in a vaginal examination does not refer to the effacement of the cervix. Effacement is usually expressed as a percentage.

Choice B rationale:

In a vaginal examination, “-1” refers to the station of the fetus. A “-1” station means that the presenting part of the fetus (usually the head) is 1 cm above the ischial spines.

Choice C rationale:

The term “-1” in a vaginal examination does not refer to the dilation of the cervix. Dilation is usually measured in centimeters, from 0 (no dilation) to 10 (fully dilated).

Choice D rationale:

A “-1” station does not mean that the presenting part is below the ischial spines. It means that it is above the ischial spines.

The correct answer is choice C.

Choice A rationale:

While Vitamin E is important for many bodily functions, it is not the primary supplement recommended to prevent neural tube defects.

Choice B rationale:

Calcium is crucial for bone health, but it does not play a direct role in preventing neural tube defects.

Choice C rationale:

Folic acid is recommended for all people capable of becoming pregnant to consume 400 micrograms (mcg) daily to prevent neural tube defects (NTDs)3.

Choice D rationale:

Iron is important for preventing anemia, especially during pregnancy, but it does not prevent neural tube defects.

The correct answer is choice D.

Choice A rationale:

This statement describes the second stage of labor, not the third. The second stage begins with full cervical dilation and ends with the delivery of the fetus.

Choice B rationale:

The third stage of labor does not end 48 hours after the delivery of the placenta. This choice is incorrect.

Choice C rationale:

While it’s important to ensure no placental fragments remain, the third stage of labor technically ends with the delivery of the placenta, not at this later point.

Choice D rationale:

This is the correct definition of the third stage of labor. It begins with the delivery of the fetus and ends with the delivery of the placenta.

The correct answer is choice C.

Choice A rationale:

While it’s important to monitor a newborn’s glucose level, it’s not the immediate priority following birth.

Choice B rationale:

Placing the infant in the bassinet is not the immediate priority. The newborn needs to be dried and warmed first to prevent hypothermia.

Choice C rationale:

Drying the newborn and placing it skin-to-skin on the mother helps prevent hypothermia and promotes bonding. This is the immediate priority.

Choice D rationale:

A full head-to-toe assessment is important, but it’s not the immediate priority following birth.

The correct answer is choice D.

Choice A rationale:

While some mothers with postpartum depression may have thoughts of harming their infant, it’s not the most common manifestation.

Choice B rationale:

Postpartum depression typically begins within the first few weeks after childbirth, not necessarily within 48 hours.

Choice C rationale:

Psychotic behavior is more commonly associated with postpartum psychosis, a rare and severe form of postpartum psychiatric illness, not postpartum depression.

Choice D rationale:

Women with a history of depression are indeed more likely to experience postpartum depression. This is the correct answer.

The correct answer is choice D.

Choice A rationale:

Heart rate and respiratory effort are two of the five parameters of the Apgar score. However, this choice is incomplete as it does not include all five parameters.

Choice B rationale:

Temperature is not a parameter of the Apgar score. Tone is a parameter, but this choice is incomplete as it does not include all five parameters.

Choice C rationale:

Color is a parameter of the Apgar score. However, this choice is incomplete as it does not include all five parameters.

Choice D rationale:

The Apgar score is based on five parameters: heart rate, breaths per minute (respiratory effort), irritability (response to stimulation), tone (muscle tone), and color. Therefore, this choice is correct.

The correct answer is choice C.

Choice A rationale:

Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.

Choice B rationale:

Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.

Choice C rationale:

The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.

Choice D rationale:

Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.

The correct answer is choice D.

Choice A rationale:

Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh negative.

Choice B rationale:

Rho (D) immunoglobulin is not administered when both the client and the newborn are Rh positive.

Choice C rationale:

Rho (D) immunoglobulin is not administered when the client is Rh positive and the newborn is Rh negative.

Choice D rationale:

Rho (D) immunoglobulin is administered when the client is Rh negative and the newborn is Rh positive. Therefore, this choice is correct.

The correct answer is choice B.

Choice A rationale:

Cabbage leaves have been used for many years for relief of breast engorgement. They can be crushed slightly until the juice is visible and then chilled in the refrigerator before applying to the breasts.

Choice B rationale:

Applying hot packs during feeding can actually increase blood flow and make engorgement worse. Cold packs should be used after feeding to help reduce swelling.

Choice C rationale:

Applying ice packs after feeding can help reduce swelling and provide relief from engorgement.

Choice D rationale:

Frequent breastfeeding can help to relieve engorgement. The breasts should be emptied completely at each feeding.

The correct answer is choice C.

Choice A rationale:

While it’s true that breastfed infants may lose 5% to 10% of their birth weight in the first few days, this is not exclusive to breastfed infants.

Choice B rationale:

Formula-fed babies may gain weight more quickly than breastfed babies, but they do not typically show an increase in weight by day 3.

Choice C rationale:

Both formula-fed and breastfed newborns can lose 5% to 10% of their birth weight in the first few days.

Choice D rationale:

While formula-fed newborns may gain weight more quickly than breastfed newborns, they do not typically gain 3% to 5% of the initial birth weight in the first 48 hours.

The correct answer is choice B.

Choice A rationale:

Vitamin K is given to newborns to prevent bleeding disorders, not eye conditions.

Choice B rationale:

Erythromycin ophthalmic ointment is commonly used for prophylaxis of neonatal conjunctivitis (pink eye) caused by Neisseria gonorrhoeae and Chlamydia trachomatis.

Choice C rationale:

Gentamicin ophthalmic ointment can be used to treat bacterial infections of the eye, but it is not typically used for prophylaxis of neonatal eye conditions.

Choice D rationale:

Silver nitrate solution was once used for prophylaxis of neonatal eye conditions, but it is no longer commonly used due to the risk of chemical conjunctivitis.

The correct answer is choice D. Chronic alcohol use.

Choice A rationale:

Active herpes simplex infection during pregnancy can lead to neonatal herpes, which is a serious condition, but it does not cause the symptoms described.

Choice B rationale:

Chronic cocaine use during pregnancy can lead to premature birth and low birth weight, but it does not typically result in the specific symptoms described.

Choice C rationale:

Folic acid deficiency during pregnancy can lead to neural tube defects, which can cause a range of symptoms, but not the specific ones described.

Choice D rationale:

Chronic alcohol use during pregnancy can lead to Fetal Alcohol Syndrome, which includes slow growth, cognitive and intellectual deficits, and the facial abnormalities described.

The correct answer is choice D. At the level of the umbilicus.

Choice A rationale:

The uterine fundus is not typically found to the right of the umbilicus after delivery.

Choice B rationale:

The uterine fundus is not typically found 2 cm above the umbilicus after delivery.

Choice C rationale:

The uterine fundus is not typically found one fingerbreadth above the symphysis pubis after delivery.

Choice D rationale:

After delivery, the uterine fundus is typically found at the level of the umbilicus.

The correct answer is choice C.

Choice A rationale:

Generalized vasospasm is not a symptom of abruptio placenta. It is more associated with conditions like preeclampsia.

Choice B rationale:

Abruptio placenta is usually associated with painful dark red vaginal bleeding, not painless bright red bleeding.

Choice C rationale:

“Knife-like” abdominal pain with vaginal bleeding is a classic symptom of abruptio placenta.

Choice D rationale:

Increased fetal movement is not a symptom of abruptio placenta. In fact, fetal movement may decrease due to distress.

The correct answer is choice B.

Choice A rationale:

Brownish vaginal discharge can be a sign of labor but it is not definitive.

Choice B rationale:

Cervical dilation is a definitive sign that labor has started.

Choice C rationale:

Presence of amniotic fluid in the vaginal vault can indicate rupture of membranes but it does not confirm labor.

Choice D rationale:

Pain above the umbilicus is not a typical sign of labor.