NCLEX_ Maternal
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? Select one: a. "Have you noticed any bloody show or fluid coming from your vagina?" b. "Have you felt fetal movement over the last 24 hours?" c. "What happens to your contractions when you move about?" d. "When did your contractions begin?"
a. "Have you noticed any bloody show or fluid coming from your vagina?" CORRECT. Vaginal discharge of blood or fluid may indicate cervical dilation, and potentially rupture of membranes. False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. Contractions are felt in the lower back or above the umbilicus and often stop with comfort measures (like oral hydration). There is usually no vaginal discharge with false labor.
A nurse is assessing a client during her first prenatal visit. The client reports that her last normal period began on April 22. Use Nagele's rule to calculate this client's expected date of birth (EDB). Use the MMDD format to enter exactly four numerals, with no spaces or punctuation between the numbers. Select one: a. 0129 b. 0729 c. 0722 d. 0122
a. 0129 To use Nagele's rule subtract 3 months and add 7 days to the first day of the client's last normal menstrual period.
A nurse is collecting data on newborn. Which of the following is an expected finding? Select one: a. Babinski reflex present b. Respirations 21 to 24/min c. Pulse rate 70 to 80/min d. Decorticate reflex
a. Babinski reflex present The Babinski reflex is present for the first year of life. The reflex is elicited by stroking the outer edge of the sole of an infant's foot up toward the toes. The infant's toes fan upward and out.
A breastfeeding mother develops engorgement on her third postpartum day. Which of the following statements by the client indicates a need for further teaching? Select one: a. I will offer my baby a bottle following each feeding. b. I will feed my baby every 2 hours. c. I will use a breast pump if my breasts do not soften. d. I will apply warm packs to each breast prior to feeding.
a. I will offer my baby a bottle following each feeding. Bottle feeding while breastfeeding could lead to nipple confusion and interfere with successful breastfeeding. This mother needs further teaching.
A nurse is teaching a client the correct use a diaphragm as a method of contraception. Which of the following statements is correct? Select one: a. Leave diaphragm in place for at least 6 hours post coitus b. Do not use any cream or jelly with the diaphragm c. Insert diaphragm at least 8 hours prior to sexual intercourse d. Douche promptly after removing the diaphragm
a. Leave diaphragm in place for at least 6 hours post coitus The diaphragm should be left in place for at least 6 hours post intercourse.
A nurse is positioning a client on the operating room table in preparation for a cesarean birth. Which of the following is the correct position? Select one: a. Supine position with foam wedge positioned under one hip. b. Lithotomy position with a foam wedge behind the shoulders. c. Modified Trendelenburg position with a foam wedge under the legs. d. Left lateral position with a foam wedge between the legs.
a. Supine position with foam wedge positioned under one hip. The supine position is appropriate for abdominal surgery (cesarean birth), and a wedge under one hip laterally tilts the client and reduces uterine weight on the vena cava and descending aorta. This helps maintain optimal perfusion of oxygenated blood to the fetus during the procedure.
A nurse is educating a parent of a newborn about safety measures. Which of the following statements made by the client would indicate a need for further teaching? Select one: a. "My baby's car seat should be in the back seat facing backwards." b. "Once my baby begins to roll over it is okay to use a small pillow in the crib." c. "I should never leave my baby unattended with pets or other children." d. "I should always support my baby's head when I pick him up."
b. "Once my baby begins to roll over it is okay to use a small pillow in the crib." CORRECT. It is never safe to have a pillow or a soft surface in the crib because of the danger of suffocation.
A postpartum client is reporting heavy vaginal blood flow. The nurse correctly understands which of the following assessments has the highest priority? Select one: a. Assessing vital signs both lying and sitting b. Assess the fundus for tone and position c. Assess episiotomy for bleeding d. Assess the client's last voiding
b. Assess the fundus for tone and position The most common cause of early post-partum bleeding is uterine atony. Even before assessing vital signs, the nurse should determine if the uterus is firm and midline in the abdomen. If it is not, fundal massage is urgently indicated, and if it is not midline, voiding is indicated, as a full bladder will displace the uterus and contribute to uterine atony
The client asks the nurse to explain the difference between true and false labor. Which of the following is an example of true labor? Select one: a. In true labor walking will cause contractions to slow down b. In true labor the cervix will dilate and efface c. In true labor contractions are felt in the abdomen above the umbilicus d. In true labor the presenting part is engaged
b. In true labor the cervix will dilate and efface Progressive changes in dilation and effacement are the ultimate signs of true labor.
A nurse is caring for a newborn diagnosed with a neonatal infection. Which of the following risk factors is most important to the care of this client? Select one: a. Documented birth trauma. b. Maternal history of cytomegalovirus. c. Increased size of neonate's heart. d. A decreased number of functional alveoli.
b. Maternal history of cytomegalovirus. Cytomegalovirus can be transferred via the placenta directly onto the fetal circulatory system and transmitted directly from infected amniotic fluid.
Thirty minutes after admission to the nursery an infant appeared jittery and exhibits a weak, high pitched cry. Which of the following would be the nurse's priority action? Select one: a. Hold and comfort the infant to stop the crying. b. Perform a heel stick to check serum glucose. c. Feed the infant oral feeding. d. Obtain an order for a drug screening blood test.
b. Perform a heel stick to check serum glucose. The priority action is to confirm the serum glucose before proceeding. A blood glucose level less than 40-45 mg/dL by heel stick is an urgent situation requiring therapy with glucose - generally orally.
The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response? Select one: a. The purpose of the NST helps to determine gestational age. b. The purpose of the NST is to assess the fetal CNS. c. The purpose of the NST is to determine fetal lie. d. The purpose of the NST is to determine fetal breathing.
b. The purpose of the NST is to assess the fetal CNS. This is the primary purpose of a NST. The test monitors the response of the FHR to fetal movement. This allows the nurse to assess the FHR in relationship to the fetal movement
A client in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The nurse recognizes that the behaviors must likely indicate which of the following? Select one: a. The taking-hold phase of maternal psychosocial adaptation. b. The taking-in phase of maternal postpartum adjustment. c. Postpartum role transition. d. Positive mother-infant bonding.
b. The taking-in phase of maternal postpartum adjustment. The taking-in phase begins immediately following birth and lasts a few hours to a couple of days. It is characterized by the mother being excited and talkative, reliving her birthing experience, and focusing on her own needs and the overall health of her newborn.
A client in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The nurse recognizes that these behaviors likely indicate which of the following? Select one: a. Postpartum role transition. b. The taking-in phase of maternal postpartum adjustment. The taking-in phase begins immediately following birth and lasts a few hours to a couple of days. It is characterized by the mother being excited and talkative, reliving her birthing experience, and focusing on her own needs and the overall health of her newborn. c. Positive mother-infant bonding. d. The taking-hold phase of maternal psychosocial adaptation.
b. The taking-in phase of maternal postpartum adjustment. The taking-in phase begins immediately following birth and lasts a few hours to a couple of days. It is characterized by the mother being excited and talkative, reliving her birthing experience, and focusing on her own needs and the overall health of her newborn.
A nurse is providing a tour of the labor and delivery unit to expectant parents. Which statement made by the mother indicates a need for further education? Select one: a. "When the baby is born, my thumb print will be taken along with the baby's footprint." b. "When the baby is returned to us from the nursery, we should check the baby's identification band." c. "We will need to remove the baby's ankle identification band during diaper changes." d. "We will request to see picture identification badges for all facility staff who care for our baby."
c. "We will need to remove the baby's ankle identification band during diaper changes." CORRECT. This statement indicates a need for further education. The mother, newborn, and significant other are identified by plastic identification bands with permanent locks that must be cut to be removed. Per most hospitals' policies, newborns will be provided with both ankle and armband identification. These identification bands should not be removed for any reason until the newborn is discharged from the hospital.
A nurse is assessing a client in the immediate postpartum period. The fundus is boggy and deviated to the left of the umbilicus. Which of the following is the most appropriate intervention? Select one: a. Reassess client in 30 minutes b. Assess lochia c. Assist client to void d. Begin an oxytocin infusion
c. Assist client to void A displaced and boggy uterus most likely indicate a full bladder and assisting the client to void would have the highest priority.
A nurse is caring for a neonate who exhibits abstinence syndrome and demonstrates clinical manifestations of the condition. Which assessment finding is associate with this condition? Select one: a. Negative Startle reflex b. Increased drowiness c. Hypothermia d. Diminished tendon reflexes
c. Hypothermia Correct - Thermal regulation issues are noted with this condition, such as hypothermia or hyperthermia.
A client with gestational diabetes gave birth to a 9 pound neonate 12 hours ago. The neonate is presenting with a high pitched cry and jitteriness. Which of the following is the nurse's priority intervention? Select one: a. Provide oxygen via oxyhood b. Administer subcutaneous insulin c. Offer the neonate breast milk or formula d. Place the neonate under a radiant warmer
c. Offer the neonate breast milk or formula A neonate of a diabetic mother is at risk for hypoglycemia. High glucose loads are present in the infant in utero. When maternal blood glucose via the placenta abruptly stops at birth, the neonate experiences a rapid drop in blood sugar. Signs of hypoglycemia in the neonate are jitteriness, lethargy, poor muscle tone, apnea, high pitched cry, and vomiting. Nursing interventions should focus on monitoring for sign of complications associated with hypoglycemia.
Thirty minutes following initiation of oxytocin infusion a client's contractions are lasting 95 seconds and coming one minute apart. Late decelerations are observed on the fetal monitor. Which of the following is the correct priority nursing intervention? Select one: a. Notify provider and prepare for an emergency cesarean birth b. Assess vital signs and apply O2 via facemask. c. Stop pitocin infusion and assess contractions and fetal heart rate. d. Stop the pitocin infusion and administer terbutaline 0.25 mg.
c. Stop pitocin infusion and assess contractions and fetal heart rate. If there are any signs of fetal or maternal distress the priority intervention would be to stop the Pitocin infusion. Pitocin should be discontinued with any of the following: prolonged or excessively strong contractions; signs of any fetal hypoxia and or fetal distress; signs of uterine or placenta abruptio; evidence of an antidiuretic affect; and hypertension
A nurse is caring for a client who has been prescribed magnesium sulfate for pregnancy induced hypertension. On admission the client's B/P is 160/90 mm Hg and urine output is 25mL/hr. Following initiation of magnesium sulfate, which of the following symptoms should be reported to the provider? Select one: a. The client is voiding 40 mL/hr b. The client reports feeling flushed and warm c. The client is drowsy and difficult to rouse d. The client's blood pressure is 130/70 mm Hg
c. The client is drowsy and difficult to rouse If the client is sleepy and difficult to rouse she may be experiencing symptoms of magnesium sulfate toxicity. This should be immediately reported to the provider.
A nurse is performing a fundal assessment on the client's second postpartum day. Which of the following should the nurse expect if the client is experiencing normal involution? Select one: a. The fundus will be one centimeter above the umbilicus. b. The fundus will be at the level of the umbilicus. c. The fundus will be one centimeter below the umbilicus. The fundus descends 1-2 cms per day, so from the highest point of 1 cm above the umbilicus at 12 hours, it should be 0 to 1 cms below the umbilicus on day two d. The fundus will be two centimeters below the umbilicus.
c. The fundus will be one centimeter below the umbilicus. The fundus descends 1-2 cms per day, so from the highest point of 1 cm above the umbilicus at 12 hours, it should be 0 to 1 cms below the umbilicus on day two
A nurse is caring for a client who is 11 weeks pregnant. Which of the following is an appropriate psychological task for the client? Select one: a. Verbalize concerns about the health care facility b. Begin to think about names for the baby c. View morning sickness as tolerable d. Accept the fact that she is pregnant
d. Accept the fact that she is pregnant The developmental task during the first trimester is to accept the reality of the pregnancy. Accepting the reality of being pregnant allows the client to see a provider and get prenatal care.
A nurse is caring for a client diagnosed with pre-eclampsia. The client is receiving magnesium sulfate IV. Which of the following assessment findings is the first sign of magnesium toxicity? Select one: a. Respiratory depression b. Nausea and vomiting c. Visual blurring d. Decreased deep tendon reflexes
d. Decreased deep tendon reflexes Magnesium Sulfate reduces striated muscle contractions due to a depressant effect on the CNS. It blocks neuromuscular transmission. Toxic signs of Magnesium sulfate include diminished tendon reflexes, hypotension and prolonged PR intervals. Later signs include absence of reflexes.
A client at 35 weeks gestation is admitted to the birthing unit with preterm labor. Which of the following assessments would require the nurse to immediately notify the provider? Select one: a. B/P 138/80mmHg, contractions every 3-4 minutes b. FHR 140 b/min: good variability, contractions every 3-4 minutes c. B/P 110/60mmHg, trace protein, contractions every 3-4 minutes d. FHR 120 b/min with late decelerations, contractions- every 1-2 minutes
d. FHR 120 b/min with late decelerations, contractions- every 1-2 minutes Late decelerations are signs of placental insufficiency which can cause fetal hypoxemia. The nurse should notify PCP immediately.
A nurse is caring for a client who has been prescribed magnesium sulfate as tocolytic therapy. Several hours after the infusion was started, contractions ceased. Which of the following is the best analysis of this data? Select one: a. The medication dose should be increased b. Deep tendon reflexes should be assessed c. The medication dose should be decreased d. The drug is having a therapeutic effect
d. The drug is having a therapeutic effect
A nurse is caring for a client who is reporting lower abdominal pain. The client has a positive pregnancy test and is estimated to be 10 weeks pregnant. Which of the following best support a possible ectopic pregnancy? Select one: a. Edematous face, hands, and ankles. b. Steady bleeding with lower abdominal pain. c. Absence of fetal heart tones and fetal movement. d. Unilateral stabbing abdominal lower abdominal pain.
d. Unilateral stabbing abdominal lower abdominal pain. As the fetus develops, it eventually exceeds the diameter of the fallopian tube and ruptures the tube, creating an internal hemorrhage. There may or may not be blood from the vagina. The symptoms may include unilateral stabbing pain and tenderness in the lower abdominal quadrant, and commonly referred shoulder pain from blood irritation of the diaphragm or phrenic nerve. There may be nausea and vomiting, and symptoms of shock.
