NCLEX Maternity

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. A. proteinuria B. hypertension C. low-grade fever D. generalized edema E. increased pulse rate F. increased respiratory rate

A, B

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. A. age 54 B. body mass index of 28 C. previous difficulty with fertility D. administration of oxytocin for induction E. potassium level of 3.6

A, B, C

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis Which instructions should be included on the list? Select all that apply. A. Wear a supportive bra B. Rest during the acute phase C. Maintain a fluid intake of at least 3000 mL/day D. Take the prescribed antibiotics until the soreness subsides E. Avoid decompression of the breasts by breast-feeding or breast pumping

A, B, C, D

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting HIV? Select all that apply. A. the client has a history of intravenous drug use B. the client has a significant other who is heterosexual C. the client has a history of sexually transmitted infections D. the client has had one sexual partner for the past 10 years E. the client has a previous history of gestational diabetes mellitus

A, C

A nonstress test is performed on a client who is pregnant, and the results of the test indicate non reactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? A. a normal test result B. an abnormal test result C. a high risk for fetal demise D. the need for a cesarean birth

A.

An ultrasound was preformed on a client at term gestation who is expecting moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? A. delivery of the fetus B. strict monitoring of intake and output C. complete bed rest for the remainder of the pregnancy D. the need for weekly monitoring of coagulation studies until the time of delivery

A.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority action? A. provide pain relief measures B. prepare the client for an amniotomy C. promote ambulation every 30 minutes D. monitor the oxytocin infusion closely

A.

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? A. we want to attend a support group B. we never want to try to have a baby again C. we are going to try to adopt a child immediately D. we are okay, and we are going to try to have another baby immediately

A.

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? A. I will need to increase my insulin dosage during the first 3 months of pregnancy B. my insulin dose will likely need to be increased during the second and third trimester C. episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy D. my insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding

A.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? A. change in vital signs B. signs of heavy bruising C. complaints of intense pain D. complaints of a tearing sensation

A.

The nurse is planning to admit a pregnant client who is obese. In planning care this client, which potential client needs should the nurse anticipate? Select all that apply. A. bed rest as a necessary preventive measure may be prescribed B. routine administration of subcutaneous heparin may be prescribed C. an overbed lift may be necessary if the client requires a cesarean section D. less frequent cleansing of a c-section incision, if present, may be prescribed E. thromobembolism stockings or sequential compression devices may be prescribed

B, C, E

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. A. A primigravida with mild preeclampsia B. a gravida II who had just been diagnosed with dead fetus syndrome C. a primigravida who delivered a 10-lb infant 3 hours ago D. a gravida IV who delivered 8 hours ago and has lost 500 mL of blood E. a primigravida at 29 weeks gestation who was recently diagnosed with severe preeclampsia

B, E

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? A. Come to the clinic immediately B. the vaginal discharge may be bothersome, but it is a normal occurence C. report to the emergency department at the maternity center immediately D. report to the emergency department at the maternity center immediately

B.

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? A. encourage the mother to breast-feed soon after birth B. support the mother in her reaction to the newborn infant C. tell the other that it is important to hold the newborn infant D. document a complete account of the mother's reaction on the birth record

B.

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? A. gently push the cord into the vagina B. place the client in the trendelenburg position C. find the closest telephone and page the health care provider stat D. call the delivery room to notify the staff that the client will be transported immediately

B.

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? A. soft abdomen B. uterine tenderness C. absence of abdominal pain D. painless, bright red vaginal bleeding

B.

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? A. a temperature of 100.4 B. An increase in the pulse rate from 88 to 102 bpm C. A blood pressure change from 130/88 to 124/80 mmHg D. An increase in the respiratory rate from 18 to 22 breaths/min

B.

The nurse is preforming an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? A. the client is a 35 year-old primigravida B. the client has a history of cardiac disease C. the client's hemoglobin level is 13.5 D. the client is a 20 year-old primigravida of average weight and height

B.

A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to preform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. A. less pressure on her cervix B. decreased number of contractions C. increased efficiency of contractions D. the need for increased maternal blood pressure monitoring E. the need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

C, E

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. A. The contractions are regular B. the membranes have ruptured C. the cervix is dilated completely D. the client begins to expel clear vaginal fluid E. The spontaneous urge to push is initiated from perineal pressure

C, E

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? A. a primiparous client who delivered 4 hours ago B. a primiparous client who delivered 6 hours ago C. a multiparous client who delivered a large baby after oxytocin induction D. a primiparous client who delivered 6 hours ago and had an epidural

C.

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instructions should the nurse provide? A. strict bed rest is necessary after the procedure B. hospitalization is necessary for 24 hours after the procedure C. an informed consent needs to be signed before the procedure D. a fever is expected after the procedure because of the trauma to the abdomen

C.

The postpartum nurse is assessing a client who delivered a healthy infant by c-section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? A. paleness of the calf area B. coolness of the calf area C. enlarged, hardened veins D. Palpable doralis pedis

C.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. A. uterine rigidity B. uterine tenderness C. severe abdominal pain D. bright red vaginal bleeding E. soft, relaxed, nontender uterus F. fundal height may be greater than expected for gestational age

D, E, F

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? A. encourage ambulation hourly B. assess vital signs every 4 hours C. measure fundal height every 4 hours D. prepare an ice pack for application to the area

D.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? A. variability B. accelerations C. early decelerations D. variable decelerations

D.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? A. I should breast feed every 2-3 hours B. I should change the breast pads frequently C. I should wash my hands well before breast-feeding D. I should wash my nipples daily with soap and water

D.