Maternity and Pediatrics NCLEX PN Review
Which information should the nurse provide to the client about Leopold's maneuvers?
The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.
The client asks the nurse what the term involution means. Which description should the nurse give to the client?
The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day.
A pp client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when makes which statement?
"I don't need birth control because I will be breastfeeding." Amenorrhea may occur during breastfeeding, but the client can still ovulate without menstruating.
During a prenatal visit, the nurse is explaining dietary management to a client with DM. The nurse determine that the teaching has been effective when the client makes which statement?
"I need to increase the fiber in my diet to control my blood glucose and prevent constipation."
The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure?
Drink decaffeinated coffee and tea Caffeine may cause heartburn and needs to be avoided.
GTPAL acronym
G = Gravidity (number of pregnancies) T = Term (number born after 37 weeks) P = Preterm (number born before 37 weeks) A = Abortions/Miscarriages L = live births (number of living children)
The nurse is monitoring a client with mild gestational hypertension. Which data indicate that GH is a concern?
The client complains of a headache and blurred vision. These are symptoms of the worsening of the GH and is a concern that needs to be reported.
A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which of the following would indicate an abnormal physical finding that necessitates further testing?
Fetal heart rate of 180 beats per minute The FHR depends on the gestational age. It it 160 to 170 bpm during the first trimester, and it slows with fetal growth to approximately 120 to 160 bpm.
The nurse should check the client for which signs of preeclampsia?
- Proteinuria - Hypertension
A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?
"The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation." A contraction stress test assesses placental oxygenation and function and determines the fetus's ability to tolerate labor, as well as its well-being.
The nurse is talking to a pregnant client with HIV infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?
"You will need to bottle-feed your newborn." Transmission of HIV can occur in the postpartum period if the mother is breastfeeding. Clients who have HIV are advised not to breastfeed.
Which are the probable signs of pregnancy that the nurse should note?
- Ballottement - Chadwick's sign - Uterine enlargement - Braxton Hicks contractions
The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? (SATA) - Uterine rigidity - Uterine tenderness - Severe abdominal pain - Bright red vaginal bleeding - Soft, relaxed, nontender uterus
- Bright red vaginal bleeding - Soft, relaxed, nontender uterus
Which findings indicate to the nurse that placental separation has occured? (SATA) - Lengthening of umbilical cord - Sudden trickle or spurt of blood - Fundus is boggy following separation - Change from globular to discoid shape - Fetal membranes are seen at the introitus
- Lengthening of the umbilical cord - Sudden trickle or spurt of blood - Fetal membranes are seen at the introitus As the placenta separates, it settles downward into the lower uterine segment.
The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? (SATA) - Avoid stimulation - Decrease fluid intake - Expose all of the newborn's skin - Monitor the skin temperature closely - Reposition the newborn every 2 hours - Cover the newborn's eyes with shields or patches
- Monitor the skin temperature closely - Reposition the newborn every 2 hours - Cover the newborn's eyes with shields or patches Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn.
A nurse is preparing a list of self-care instructions for a pp client who has been diagnosed with mastitis. Which instructions should be included on the list? (SATA) - Rest during the acute phase - Wear a supportive, nonunderwire bra - Maintain a fluid intake of at least 3000 mL - Continue to breastfeed if the breasts are not too sore - Take prescribed antibiotics until the soreness subsides - Avoid decompression of the breasts by breastfeeding or pumping
- Rest during the acute phase - Wear a supportive, nonunderwire bra - Maintain a fluid intake of at least 3000 mL - Continue to breastfeed if the breasts are not too sore Mastitis is an infection of the lactating breast.
What are signs and symptoms of abruptio placentae?
- Severe abdominal pain - Uterine tenderness - Abdomen feels hard and board-like during palpitation - Uterine irritability as blood penetrates the myometrium
A client is currently 28 weeks gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in cm and should expect which finding?
26 cm During the second and third trimesters, the fundal height in cm approximately equals the fetus' age in weeks plus or minus 2 cm.
The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the exam, knowing that which routine labor procedure is contraindicated?
A manual pelvic exam Painless vaginal bleeding is a sign of possible placenta previa. A manual pelvic exam is contraindicated because it can lead to maternal and fetal hemorrhage.
The nurse should tell the mother that which is a sign of infection of the umbilical cord?
A moist cord with discharge Signs of infection include: moistness, oozing, discharge, and a reddened base. PHCP needs to notified, antibiotic treatment may be necessary.
The nurse notes that the HCP has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy?
A softening of the cervix This occurs during the early weeks of pregnancy. The cervix becomes softer as a result of pelvic vasoconstriction. This is found during the pelvic exam.
After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note?
At the level of the umbilicus After delivery, the uterine fundus should be at the level of the umbilicus or 1 to 3 fingerbreadths below it and in the midline of the abdomen.
The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first?
Baseline FHR
To bathe a newborn, the mother should be taught which intervention?
Begin with the eyes and face Bathing should start at the eyes and face, which are usually the cleanest areas.
The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action should be to monitor which clinical parameter?
Blood glucose level The most common metabolic complication in the post-term newborn is hypoglycemia, which can produce CNS abnormalities and cognitive impairment if it's not corrected immediately.
A primigravida's membranes rupture spontaneously. Which action should the nurse take first?
Determine the FHR The nurse immediately assesses the FHR to detect change associated with prolapse or the compression of the umbilical cord.
The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially?
Determine the maternal and fetal vital signs
A nurse is collecting data from a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks gestation. The nurse should document which gravida and para status on this client?
Gravida II, para I Gravida refers to a woman who is or who has been pregnant, regardless of the duration of the pregnancy. Parity (para) is a term that means the number of births after 20 weeks gestation.
A pregnant client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action?
Keep the client in a side-lying position Precipitous labor progresses quickly, with frequent contractions and short periods of relaxation between them. This does not allow for the maximal reperfusion of the placenta with oxygenated blood. Priority care includes the promotion of fetal oxygenation, maintaining a side-lying position can assist with providing blood flow to the uterus.
A client in her second trimester complains of frequent low back pain and ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts?
Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle. This position will produce the posture of the pelvic tilt while countering gravity as the force that leads to the edema of the lower extremities.
A mother is experiencing breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement?
Massage the breast before feeding to stimulate let-down
The nurse is caring for a pp client. At 4 hours pp, the client's temperature is 102F. Which is the appropriate nursing action?
Notify the RN who will then notify the PHCP During the first 24 hours pp, the temperature may be elevate as a result of dehydration. However, if the temperature is more than 2F above normal, this may indicate infection.
A client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours pp, the client's systolic BP dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 bpm. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action?
Prepare the client for surgery The information provided indicates that the client is experiencing blood loss. Surgery would be needed to stop the bleeding.
The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?
Red During the 4th stage of labor, the color of the lochia is bright red, and may last from 1 to 3 days. Then changes to a pinkish-brown and occurs from day 4 to 10. Finally, the lochia changes to a creamy white color that occurs from day 10 to 14.
To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?
Side-lying Pressure from the enlarged uterus on the aorta and the vena cava when the woman is supine can result in hypotension.
The nurse should monitor for which signs associated with respiratory distress syndrome in a preterm newborn?
Tachypnea and retractions The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions, or audible grunts
The client is undergoing an amniocentesis at 16 weeks gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?
The bladder must be full during the exam. Before 20 weeks gestation, the bladder must be kept full to support the weight of the uterus.
After an episiotomy, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it's firm. Which determination should the nurse make?
The bright red bleeding is abnormal and should be reported
