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Which position would the nurse document when the fetal head is in the anterior position, well flexed, at the level of the ischial spines, and the fetal back is on the maternal right side between the midline and lateral surface of the abdomen?
Left occiput anterior (LOA), +4 station
Left shoulder anterior (LOA), -2 station
Right occiput anterior (ROA), 0 station
Right shoulder transverse (RST), -3 station
Correct Answer:
C Right occiput anterior (ROA), 0 station
Explanation of Correct Answer
The fetal head is described as well flexed and in the anterior position, which places the occiput toward the front of the maternal pelvis. Since the fetal back is on the maternal right side, the correct notation is Right occiput anterior (ROA). The fetal head being at the level of the ischial spines corresponds to a 0 station. The other options include incorrect positions, stations, or presenting parts (shoulder instead of occiput).
When providing instructions to a pregnant client regarding an amniocentesis, which information would the nurse include? Select all that apply.
Hospitalization is necessary for 48 hours after the procedure
This test will require aspiration of amniotic fluid
Changing of abdominal curvature is a normal finding
Ultrasound will be used during this procedure
A fever is expected after the procedure due to the trauma to the abdomen
Patients who are Rh negative will need RhoGAM after the procedure
Correct Answers:
B This test will require aspiration of amniotic fluid
D Ultrasound will be used during this procedure
F Patients who are Rh negative will need RhoGAM after the procedure
Explanation of Correct Answers
B This test will require aspiration of amniotic fluid
Amniocentesis involves inserting a needle into the amniotic sac under sterile conditions to aspirate amniotic fluid for genetic, maturity, or infection testing. This is the primary purpose of the procedure.
D Ultrasound will be used during this procedure
Ultrasound guidance is always used during amniocentesis to locate the fetus and placenta, ensuring needle insertion is safe and avoiding harm to fetal structures.
F Patients who are Rh negative will need RhoGAM after the procedure
Because amniocentesis carries a risk of maternal-fetal blood mixing, Rh-negative clients must receive Rho(D) immune globulin (RhoGAM) to prevent isoimmunization and complications in the current or future pregnancies.
The nurse assesses the head circumference of a mature newborn. Which measurement does the nurse identify as a possible cause for concern?
34.2 cm
35.2 cm
34.8 cm
37.4 cm
Correct Answer:
D. 37.4 cm
Explanation of Correct Answer
The normal head circumference for a term newborn ranges from 32 to 36 cm. A measurement of 37.4 cm is above the expected range and may indicate conditions such as hydrocephalus or other abnormalities requiring further evaluation. Measurements of 34.2, 34.8, and 35.2 cm all fall within the normal limits for a mature newborn.
The nurse is caring for a client whose fetus is +4 station and in vertex presentation. The nurse notices the fetus heart rate drops from 160 to 120. The nurse plans and implements care with which consideration in mind?
Severe back discomfort will occur for the client
A cesarean birth probably will be necessary
The fetus is experiencing increased intracranial pressure
The decreased heart rate is from meconium in the amniotic fluid
Correct Answer:
C The fetus is experiencing increased intracranial pressure
Explanation of Correct Answer
At a +4 station, the fetal head is deep in the maternal pelvis, very close to delivery. A temporary drop in fetal heart rate at this point usually represents an early deceleration, which occurs from head compression. This compression increases intracranial pressure, stimulating the vagus nerve and causing a predictable slowing of the fetal heart rate. It is considered a benign, expected finding in the second stage of labor, not requiring a cesarean or emergent intervention.
Which of the following correctly identifies the daily caloric requirement per pound for a newborn?
50 to 55
100 to 120
150 to 170
200 to 225
Correct Answer:
A. 50 to 55
Explanation of Correct Answer
Newborns require approximately 50–55 calories per pound per day to meet their rapid growth and high energy demands. This ensures adequate nutrition to support weight gain, brain development, and organ growth. In metric measurements, this equates to about 100–120 calories per kilogram per day. Options B, C, and D reflect higher ranges that are either incorrectly converted or excessive for a newborn’s needs.
A nurse is providing education about introducing new foods to the guardians of a 4-month-old infant. The nurse should recommend that the caregiver introduce which of the following foods first?
Strained yellow vegetables
Iron-fortified cereals
Pureed fruits
Whole milk
Correct Answer:
b) Iron-fortified cereals
Explanation of Correct Answer
The first solid food recommended for infants around 4 to 6 months is iron-fortified single-grain cereal, such as rice cereal. It provides an essential source of iron, which supports growth and prevents anemia as the infant’s iron stores from birth begin to decline. Other foods like vegetables and fruits follow later, while cow’s milk is not recommended until after 12 months.
The parents of a newborn are concerned that something is wrong with their newborn's eyesight. What should the nurse instruct the parents as being an expected finding in the newborn?
Produces tears when he cries
Follows a light to the midline
Has a white rather than a red reflex
Follows the finger a full 180 degrees
Correct Answer:
B. Follows a light to the midline
Explanation of Correct Answer
Newborns have limited visual ability and can briefly follow a light or object to the midline, but not beyond. Tear production usually begins around 2 to 3 months, not at birth. A red reflex is normal; a white reflex is abnormal and may indicate retinoblastoma or cataracts. Following a finger a full 180 degrees is beyond the visual capacity of a newborn.
When teaching a mother to care for her newborn's umbilical cord, which of the following instructions would you include?
Keeping it dry
Washing it with soap and water
Applying petroleum jelly to it daily
Covering it with dry gauze
Correct Answer:
A. Keeping it dry
Explanation of Correct Answer
The primary care for a newborn’s umbilical cord stump is to keep it clean and dry until it naturally falls off, usually within 1–2 weeks. Exposing the stump to air and folding diapers below it promotes faster drying and healing. Soap, ointments, petroleum jelly, or routine dressings are not recommended, as they may delay drying or increase infection risk.
Which question is most important to ask a client who arrives to the birthing unit with birth imminent?
When did your contractions begin
When is your baby's expected due date
Have your membranes ruptured
Is this your first pregnancy
Correct Answer:
C Have your membranes ruptured
Explanation of Correct Answer
When birth is imminent, determining whether the membranes have ruptured is a priority because ruptured membranes increase the risk of infection and may lead to cord prolapse, especially if the presenting part is not engaged. This assessment directly affects immediate care decisions to ensure both maternal and fetal safety. While contraction history, due date, and parity are relevant, they are not as urgent in the critical moment of an imminent delivery.
A client recently is planned for an epidural catheter in the second stage of labor. Which assessments and interventions are necessary once an epidural catheter has been inserted? Select all that apply.
Have oxygen available in case of hypotension
Maintain intravenous fluid administration
Position the client supine for ease of monitoring
Monitor fetal heart rate and labor progress per hospital protocol
Check the bladder for distention every 2 hours
Administer an oxytocin infusion to maintain the labor pattern
Correct Answers:
A Have oxygen available in case of hypotension
B Maintain intravenous fluid administration
D Monitor fetal heart rate and labor progress per hospital protocol
E Check the bladder for distention every 2 hours
Explanation of Correct Answers
A Have oxygen available in case of hypotension
Epidural anesthesia can cause vasodilation and maternal hypotension, leading to reduced uteroplacental perfusion. Oxygen should be readily available to support maternal and fetal oxygenation if hypotension occurs.
B Maintain intravenous fluid administration
IV fluids are important to prevent or treat hypotension associated with epidurals. A fluid bolus is often given before insertion, and fluids are continued throughout labor.
D Monitor fetal heart rate and labor progress per hospital protocol
Epidural anesthesia can impact uterine contractions and fetal heart patterns, so continuous monitoring is essential to assess fetal well-being and labor progression.
E Check the bladder for distention every 2 hours
Epidural anesthesia decreases bladder sensation and may cause urinary retention. Regular assessment and catheterization, if needed, prevent bladder overdistension and complications.
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