NCLEX Focus on Maternity Exam

A nonstress test is performed, and the health care provider documents "accelerations lasting less than 15 seconds throughout fetal movement." The nurse interprets these findings as:

c. Nonreactive

A nurse is caring for a client receiving an intravenous infusion of oxytocin to stimulate labor. Which finding would prompt the nurse to stop the infusion?

Nonreassuring fetal heart rate pattern

A nurse is monitoring a newborn who has been admitted to the nursery. The nurse notes that the anterior fontanel measures 4 cm across and bulges when the infant is at rest. Based of this observation, what is the appropriate nursing action?

Notifying the health care provider

A delivery room nurse performing an initial assessment on a newborn notes that the ears are low set. Based this finding, which nursing action is appropriate initially?

Notifying the health care provider.

A nurse is assessing a newborn infant with a diagnosis of gastroschisis. The nurse expects to note that the bowel is located:

Outside the abdominal cavity and not covered with a sac

A nurse teaching a pregnant client about measures to strengthen the pelvic floor instructs the client to: Walk half a mile 3 times a week Drink at least 2 quarts of fluid per day Perform Kegel exercises in 10 repetitions, three times per day Perform pelvic tilt exercises in 10 repetitions, three times per day

Perform Kegel exercises in 10 repetitions, three times per day

82. A nurse provides instruction regarding prenatal care to a client with a history of heart disease. The nurse tells the client that:

Physical activity should be limited

Rho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before administering the medication, the nurse reviews the client's history. Which finding is a contraindication to administration of the medication?

A previous hypersensitivity reaction to immune globulin

A nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)?

ANS: A, D a. A client with septicemia d. A client who had a cesarean section because of abruptio placentae

57. A nurse assessing a pregnant client's deep tendon reflexes notes a reflex of 2+. The nurse should:

Document the finding.

A nurse is assessing a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the nurse perform in response to this observation?

Documenting the finding

81. A nurse is conducting a home visit with a mother and her 1-week-old infant, who is at risk for acquired neonatal congenital syphilis. Which finding specific to this disease does the nurse look for while assessing the infant?

A copper-colored rash

A nurse working in a prenatal clinic is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify as being at risk for abruptio placentae?

A hypertensive client A pack-a-day smoker

A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. This nurse interprets this assessment data as:

A normal finding

After an unplanned cesarean section, the nurse finds the client in emotional distress, tearfully expressing bewilderment, sadness, and feelings of failure and regret because she could not deliver vaginally. Which conclusion should the nurse make?

The client is experiencing low self-esteem.

A nurse is reviewing the criteria for early discharge of a newborn infant. Which, if noted in the infant, would indicate that the criteria for early discharge have been met? The infant has urinated. The infant has passed 1 stool. Vital signs are documented as normal. The infant has completed one successful feeding. The infant has shown no evidence of jaundice in the first 6 hours of life.

The infant has urinated. The infant has passed 1 stool. Vital signs are documented as normal.

80. A nurse is performing an assessment of a female client with suspected mittelschmerz. Which question does the nurse ask the client to elicit data specific to this disorder?

"Do you have sharp pain on the right or left side of your pelvis?"

A client in the third trimester of pregnancy is complaining of urinary frequency, and the nurse instructs the client in measures to alleviate the discomfort. Which statement by the client indicates an understanding of these self-care measures?

"I need to drink at least 2000 mL of fluid a day."

A pregnant client is seen in the clinic for the first time. This is the client's first pregnancy, and the client tells the nurse that she has diabetes mellitus. The nurse provides instruction to the client regarding health care during pregnancy. Which statements by the client indicate the need for further instruction? "I need to follow the prescribed diabetic diet." "I need to limit my exercise while I'm pregnant." "I need to report signs of infection to my health care provider." "My insulin requirements may change while I'm pregnant." "I'll come back for a prenatal visit every month during my first trimester."

"I need to limit my exercise while I'm pregnant." "I'll come back for a prenatal visit every month during my first trimester."

A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction?

"I need to stay in bed for the rest of my pregnancy."

A postpartum nurse instructs a new mother in how to bathe her newborn. Which statement by the mother indicates a need for further instruction?

"I should bathe him after a feeding."

A nurse is reviewing the medical record of a pregnant client with sickle cell anemia. To which information related by the client would the nurse give the highest priority?

Drinking less than 4 glasses of fluid daily

A nurse is performing an assessment of a pregnant woman to determine whether labor has begun. For which sign of true labor does the nurse assess the client?

Contractions that begin in the lower abdomen and back and radiate over the entire abdomen

A multigravida asks a nurse when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted as early as:

14 to 16 weeks of gestation

A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat her urinary tract infection but expresses concern that her baby will be born with an infection. Which response should the nurse make to help ease these fears?

"Now that you have taken the medication as prescribed, we'll keep monitoring you closely and repeat the urine culture before you leave today."

A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. The appropriate response is:

"The newborn does have a risk of contracting the infection."

A nurse is monitoring a client after vaginal delivery notes a constant trickle of bright-red blood from the client's vagina. In which order would the nurse perform the following actions 1 Assessing the client's fundus 2 Checking the client's vital signs 3 Contacting the health care provider 4 Changing the client's peripads 5 Documenting the findings

1 Assessing the client's fundus 2 Checking the client's vital signs 3 Contacting the health care provider 4 Changing the client's peripads 5 Documenting the findings

A nurse is assessing the respiratory rate of a newborn. Which finding would the nurse document as normal?

50 breaths/min

A nurse caring for a client in the active stage of labor assesses the fetal status and notes a late deceleration on the monitor strip. Based on this finding, which nursing action is the priority?

Administering oxygen by way of face mask

A nurse teaching a pregnant client about the expectations and complications of pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions: a. Indicate that labor has started b. Are a common occurrence of pregnancy c. Must be reported to the health care provider d. Necessitate bed rest for the remainder of the pregnancy

ANS: B

A nurse is assisting a health care provider in performing a physical examination of a client who has just been told that she is pregnant. The health care provider tells the nurse that the Goodell sign is present. The nurse understands that this sign is indicative of: a. The presence of fetal movement b. A high risk for spontaneous abortion c. An increase in vascularity and hyptertrophy of the cervix d. The presence of human chorionic gonadotropin (hCG) in the urine

ANS: C

7. A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. The nurse tells the client:

ANS: D

A nurse performing an assessment of a pregnant client prepares to auscultate the fetal heart sounds, using a Doppler ultrasound stethoscope. By which week of gestation are fetal heart sounds audible with the use of this device? a. 4 weeks b. 6 weeks c. 8 weeks d. 12 weeks

ANS: D

A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as most likely the result of:

Anxiety and the need for support

4. A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid?

ANS: D Lima beans

A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result of 155 mg/dL (8.6 mmol/L). The nurse tells the client that:

Additional tests will likely be performed to confirm gestational diabetes

34. A nurse is caring for a client in labor who has sickle cell anemia. Which intervention does the nurse implement to help prevent a sickling crisis? Maintaining strict asepsis Monitoring the maternal vital signs Administering oxygen as prescribed Placing a wedge under the client's hip

Administering oxygen as prescribed

A woman in labor suddenly experiences chest pain and dyspnea, and the nurse suspects the presence of amniotic fluid embolism (AFE). The nurse immediately:

Administers oxygen to the woman

85. A nurse answers a call light in the room of a woman who was just admitted in early latent labor. The woman is lying flat on her back on the bed. The husband reports excitedly, "I think my wife is going into shock or something! She was just lying there, and then she turned so pale, and her hands are so clammy. She said she was dizzy and sick to her stomach." The nurse notes on the noninvasive blood pressure monitor that the woman's pulse is 58 beats/min and her blood pressure is 90/50 mm Hg. The nurse interprets these findings as indications that the woman is experiencing:

Altered tissue perfusion related to hypotensive syndrome (vena cava syndrome)

50. A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. The nurse tells the client that:

Alternating contraction and relaxation of the muscles of the perineal area should be practiced

After a vaginal delivery, a woman suddenly begins to complain of severe pelvic pain and extreme fullness in the vagina, and the nurse suspects uterine inversion. The nurse immediately prepares to:

Assist in repositioning the uterus through the vagina into a normal position

54. A nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia (CDH). Which assessment finding would the nurse specifically expect to note in the newborn?

Bowel sounds heard over the chest

Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which finding would the nurse expect to note?

C. Uterine tender to palpation

A nurse is caring for a client experiencing hypotonic labor contractions. The client is discouraged by the lack of progress with labor but refuses an amniotomy or oxytocin stimulation. The nurse determines that the client's behavior may be a result of:

Concern about her own and the baby's well-being

49. A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, the appropriate nursing action is:

Contacting the health care provider

A nurse is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the nurse to contact the health care provider? Complaint of feeling hot Enlargement of the breasts Diaphoresis and tachycardia Periods of fetal movement followed by quiet periods

Diaphoresis and tachycardia

78. A nurse is changing the diaper of a 1-day-old full-term female newborn. The nurse notes that the labia are edematous and darker than the surrounding skin and that a white mucous vaginal discharge is present. On the basis of these findings, the nurse determines that the appropriate action is:

Documenting the findings

55. A woman being seen in the prenatal clinic and complains of morning sickness that continues throughout the day. What does the nurse tell the client to do to overcome this discomfort?

Eat dry crackers every 2 hours to prevent an empty stomach

35. A nurse teaches a new mother how to perform umbilical cord care and how to recognize the signs of a cord infection. Which finding does the nurse tell the mother is an indicator of infection? A darkened, drying cord Edema at the base of the cord A brownish-black cord with pinkness around the base A brownish-black cord with some moistness at the base

Edema at the base of the cord

A nurse is preparing to assess the fetal heartbeat in a pregnant woman who is at gestational week 12. Which piece of equipment does the nurse use to assess the fetal heartbeat?

Electronic Doppler

A nurse is caring for a postpartum client who had a low-lying placenta. The nurse assesses the client most closely for:

Hemorrhage

A clinic nurse is developing a plan of care for a pregnant client with AIDS. Which problem does the nurse identify as the priority to be addressed in the plan of care?

History of IV drug use

A nurse is monitoring a pregnant client with sepsis for signs of disseminated intravascular coagulopathy (DIC). Which laboratory finding causes the nurse to suspect DIC?

Increased fibrin degradation products

43. Immediately after the delivery of a newborn infant, the nurse prepares to deliver the placenta. The nurse initially: Pulls on the placenta as it enters the vaginal canal Pulls on the umbilical cord as the mother bears down Applies strong traction on the cord when signs of separation occur Instructs the mother to push when signs of separation have occurred

Instructs the mother to push when signs of separation have occurred

32. After the delivery of a newborn, a nurse performs an initial assessment and determines that the Apgar score is 8. The nurse interprets this score as indicating that the infant: Requires vigorous resuscitation Is adjusting well to extrauterine life Requires some resuscitative intervention Is having difficulty adjusting to extrauterine life

Is adjusting well to extrauterine life

A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 19, 2017. Using Nagele's Rule, the nurse calculates the estimated date of delivery as:

June 26, 2018

A neonate is irritable, cries incessantly, and has a temperature of 99.4° F (37.4°C). The neonate is also tachypneic, diaphoretic, feeding poorly, and hyperactive in response to environmental stimuli. The nurse determines that these signs and symptoms are consistent with:

Neonatal abstinence syndrome

A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician's office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. The nurse immediately: Positions the client on her side Calls the health care provider to see the client Places a cool washcloth on the client's forehead Checks the client's blood pressure, pulse, and respirations

Positions the client on her side

A nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which situation would the nurse suspect based on this observation?

Pressure on the fetal head during a contraction

A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client's temperature and notes that it is 38° C (100.4° F). The most appropriate nursing action would be to:

c. Encourage the intake of oral fluids

79. A nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse plan to place the infant?

Prone

A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes, the client has a temperature of 100° F (37.8° C), and the client reports that she last ate 2 hours ago. The client also states that "everything happened so fast" and that she has had no preparation for the cesarean delivery. Which action should the nurse take first? Continuing to time the contractions Beginning teaching about the cesarean delivery Reporting the time of last food intake to the health care provider Giving acetaminophen to lower the client's temperature

Reporting the time of last food intake to the health care provider

A nurse notes that the laboratory report of a pregnant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia, and an increased erythrocyte sedimentation rate. Which laboratory test that would further confirm the presence of HIV does the nurse anticipate that the health care provider will prescribe?

T-lymphocyte determination

A nurse caring for a hospitalized client with a diagnosis of abruptio placentae and develops a nursing care plan incorporating interventions to be implemented in the event of shock. If signs of shock develop, to promote tissue oxygenation, the nurse would immediately:

Turn the client on her side

A nurse is monitoring a fetal heart rate (FHR). The nurse documents a reassuring FHR pattern in the record on noting:

Variability of 6 to 25 beats/min

24. A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity:

b. In 2 to 4 weeks

A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat?

d. Apple and whole-grain toast

A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate?

b. "This must be hard for you."

A nurse is preparing to perform the Leopold maneuvers on a pregnant client. The nurse should first:

c. Ask the client to empty her bladder

A nurse assists the health care provider in performing an amniotomy on a client in labor. In which order should the nurse perform the following actions after the amniotomy?

1 Determining the fetal heart rate 2 Noting the quantity, color, and odor of the amniotic fluid 3 Taking the client's temperature, pulse, and blood pressure 4 Replacing soiled underpads from beneath the client's buttocks 5 Planning evaluation of the client for signs and symptoms of infection

A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse tells the client that:

b. A rubella vaccine must be administered after childbirth

5. A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. The nurse tells the mother to:

b. Apply oil to the affected area on the infant's scalp

3. A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of:

c. Calcium gluconate

1. A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to:

c. Eat carbohydrates such as cereals, rice, and pasta

A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to:

c. Gently massage the breasts during breastfeeding to help empty the breasts

A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse:

c. Simultaneously provides pressure over the lower uterine segment

A nurse is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the nurse to contact the health care provider?

c. Strong-smelling amniotic fluid

A nurse is assessing the lochia of a client who delivered a viable newborn 1 hour ago. Which type of lochia would the nurse expect to note at this time?

d. Dark-red lochia rubra

26. A nurse performing an assessment of a pregnant client is preparing to take the client's blood pressure. The nurse positions the client:

d. In a sitting position with the arm in a horizontal position at heart level

A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client's oxygen saturation on pulse oximetry is 92%. The nurse first:

d. Instructs the client to take several deep breaths

A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table, and the nurse positions the client:

d. Supine with a wedge under the right hip

87. A pregnant woman at 38 weeks' gestation arrives at the emergency department, reporting bright-red vaginal bleeding but denying pain. On the basis of this information, the nurse determines that the client may be experiencing:

Placenta previa

A client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a persistent nonreassuring fetal heart rate pattern is present. The appropriate nursing action in this situation is: Preparing to induce labor Turning the client on her left side Preparing the client for a cesarean delivery Continuing to monitor the fetal heart rate pattern

Preparing the client for a cesarean delivery

A woman with severe preeclampsia delivers a healthy newborn infant and continues to receive magnesium sulfate therapy in the postpartum period. Twenty-four hours after delivery, the client begins passing more than 100 mL of urine every hour. The nurse recognizes this volume of urine output as an indication of:

Diminished edema and vasoconstriction in the brain and kidneys

A nurse is performing assessments every 30 minutes on a client who is receiving magnesium sulfate for preeclampsia. Which finding would prompt the nurse to contact the health care provider? Urine output of 20 mL Deep tendon reflexes of 2+ Respirations of 10 breaths/min Fetal heart tone of 116 beats/min

Respirations of 10 breaths/min

A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that:

d. The mother may need to take isoniazid, pyrazinamide, and rifampin (Rifadin) for a total of 9 months

During a prenatal visit, the nurse notes that an adolescent pregnant client with diabetes mellitus has lost 10 lb (4.5 kg) during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, "I don't eat regular meals." The appropriate response is: "Weight loss could hurt your baby." "Let's make a list of what you're eating." "I'll have the doctor review your diet history." "It's all right to gain weight during pregnancy."

"Let's make a list of what you're eating."

40. A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately: Lie down Contact the health care provider Drink 8 oz (240 ml) of diet soda Check her blood glucose level

Check her blood glucose level

A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is experiencing excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which assessment findings are indicative of complete uterine rupture? Fetal bradycardia Maternal tachypnea Excessive vaginal bleeding Increased uterine contractions Maternal complaint of sudden sharp abdominal pain

Fetal bradycardia Maternal tachypnea Maternal complaint of sudden sharp abdominal pain

A clinic nurse is performing an assessment of an HIV-positive pregnant woman during the 32nd week of gestation. Which finding requires further follow-up?

Increased shortness of breath and bilateral crackles in the lungs

31. A nurse is assisting a midwife who is assessing a client for ballottement. Which action does the nurse anticipate that the midwife will employ to test for ballottement? Assessing the cervix for thinning Auscultating for fetal heart sounds Performing a sudden tap on the cervix Palpating the abdomen for fetal movement

Performing a sudden tap on the cervix

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. The nurse tells the client that:

The infant should receive both the vaccine and hepatitis immune globulin soon after birth

A nurse is performing an assessment of a client who is at 20 weeks of gestation. The nurse asks the client to void, then measures the fundal height in centimeters. Which approximate measurement does the nurse expect to see?

a. 20 cm

23. A nurse is preparing to care for a client experiencing dystocia. To which intervention does the nurse give priority?

a. Monitoring fetal status

22. A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in the care of this client?

a. Providing pain relief

2. A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective?

d. The client experiences diuresis within 24 to 48 hours.