1. A 24-year-old primigravida is admitted to the labor and delivery unit

with contractions that are 5 minutes apart. She is determined to be in the

active phase of the first stage of labor. Which of the following nursing

interventions is most appropriate at this time?

 A. Encourage ambulation to promote labor progress.

 B. Administer pain medication as ordered.

 C. Prepare for immediate delivery.

 D. Monitor fetal heart rate continuously.

 **Answer: D.** Continuous fetal heart rate monitoring is essential

during active labor to assess fetal well-being.

2. During a routine prenatal visit, a nurse assesses a client at 28 weeks

gestation and notes a fundal height measurement that exceeds the

gestational age by 6 cm. What should be the nurse's next action?

 A. Schedule an ultrasound to assess for multiple gestation.

 B. Reassure the client that variations in fundal height are normal.

 C. Advise the client to reduce physical activity.

 D. Perform a glucose tolerance test to evaluate for gestational diabetes.

 **Answer: A.** An ultrasound can help determine if the increased

fundal height is due to multiple gestation or another factor such as

polyhydramnios.

3. A nurse is caring for a postpartum client who delivered vaginally 12

hours ago. The client reports a headache and visual changes. Which of the

following actions should the nurse take first?

 A. Administer analgesics for headache.

 B. Check blood pressure and assess for preeclampsia.

 C. Encourage fluid intake to prevent dehydration.

 D. Perform a neurological assessment.

 **Answer: B.** Headache and visual changes can be signs of

preeclampsia, and checking blood pressure should be the initial step.

4. In teaching a pregnant client about breastfeeding, which of the

following points should the nurse emphasize as a key benefit of

breastfeeding?

 A. It helps the uterus return to its pre-pregnancy size more quickly.

 B. It provides optimal nutrition tailored to the infant's needs.

 C. It is more economical than formula feeding