Maternity NCLEX questions

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.

- "I should wear a bra that provides support." - "Drinking alcohol can affect my milk supply." - "The use of caffeine can decrease my milk supply." - "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply.

- "The ductus arteriosus allows blood to bypass the fetal lungs." - "One vein carries oxygenated blood from the placenta to the fetus." - "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta."

The nurse in a maternity unit is reviewing the client's records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.

- A primigravida with abruptio placenta - A gravida 2 who has just been diagnosed with dead fetus syndrome - A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client need should the nurse anticipate? Select all that apply.

- Administration of subcutaneous heparin post-delivery as prescribed. - An overbed lift may be necessary if the client requires a cesarean section. - Thromboembolism stockings or sequential compression devices may be prescribed.

The nurse is monitoring a client who is in the active stage of labor. The nurse documents 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.

- Age 54 years - Body mass index of 28 - Previous difficulty with fertility

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply.

- Allows for fetal movements - Surrounds, cushions, and protects the fetus - Maintains the body temperature of the fetus - Can be used to measure fetal kidney function

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy? Select all that apply.

- Ballottement - Chadwick's sign - Uterine enlargement - Positive pregnancy test

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply.

- Cyanosis - Tachypnea - Retractions - Audible grunts

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply.

- Flushing - Decreased respirations - Extreme muscle weakness

A client arrives at a birthing center in active labor. After examination, it is determined that her membranes are still intact -2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.

- Increased efficiency of contractions - The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn. Select all that apply.

- Irritability - Constant crying - Difficult to comfort

Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply.

- It is the way the baby gets food and oxygen. - It provides an exchange of nutrients and waste products between the mother and developing fetus.

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply.

- Monitor skin temperature closely. - Reposition the newborn every 2 hours. - Cover the newborn's eyes with eye shields or patches.

A rubella titer results of a 1-day postpartum client is less than 1:8 and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.

- Pregnancy needs to be avoided 1 to 3 months. - The vaccine is administered by the subcutaneous route. - Exposure to immunosuppressed individuals needs to be avoided. - A hypersensitivity reaction can occur if the client has an allergy to eggs.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply.

- Respirations of 10 breaths per minute - Urine output of 20 mL in an hour

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.

- The cervix is dilated completely. - The Ferguson reflex is initiated from perineal pressure.

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply.

- Uterine hyperstimulation - Late decelerations of the fetal heart rate

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.

- Wear a supportive bra. - Rest during the acute phase. - Maintain a fluid intake of at least 3000 mL/day. - Continue to breast-feed if the breasts are not too sore.

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate?

"Do you plan to have any other children?"

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction?

"I need to lie flat on my back to perform the procedure."

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

"I should avoid exercise because of the negative effects on insulin production."

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

"I should drink adequate fluids and increase my intake of high-fiber foods."

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breastfeeding her newborn. Which client statement would indicate a need for further instruction?

"I should wash my nipples daily with soap and water."

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction?

"I will ask my nurse to attend to my infant if I am napping and my husband is not here."

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?

"I will begin abdominal exercises immediately."

The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed about administration of the eye medication?

"I will flush the eyes after instilling the ointment."

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the management of care. Which statement made by the client indicates a need for further instruction?

"I will maintain strict bed rest throughout the remainder of the pregnancy."

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?

"I will need to increase my insulin dosage during the first 3 months of pregnancy."

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus?

"It connects the umbilical vein to the inferior vena cava."

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response?

"It promotes the fertilized ovum's normal implantation in the top portion of the uterus."

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

"My contractions will increase in duration and intensity."

The nurse prepares to administer phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide?

"Newborns are deficient in vitamin K, and this injection prevents your newborns from bleeding."

A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response?

"Please share with me more about your concerns."

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?

"The vaginal discharge may be bothersome, but it is a normal occurrence."

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?

"We want to attend a support group."

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief?

"What can I do for you?"

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to 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."

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis?

"Your type of pelvis is the most favorable for labor and birth."

The nurse is reviewing the record of a client in the labor room and notes that the primary health care provider has documented that the fetal presenting part is at +1 station. This documented finding indicates that the fetal presenting is located at which area? Refer to figure.

3

The postpartum nurse is providing instructions to a client after a birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?

3 days postpartum

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage?

A multiparous client who delivered a large baby after oxytocin induction

A nonstress test is performed on a client who is pregnant, and the results of the test indicate non-reactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?

A normal test result

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn infant after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which following additional sign would be consistent with FAS?

Abnormal palmar creases

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

Administer oxygen via face mask.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?

Administer oxygen, 8 to 10 L/minute, by face mask.

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?

Administer oxygen, 8 to 10 L/minute, via face mask.

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?

An increase in the pulse rate from 88 to 102 beats per minute.

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?

An informed consent needs to be signed before the procedure.

Rh (D) immune globulin is prescribed for a client after delivery, and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose of the woman states that it will protect her next baby from which condition?

Being affected by Rh incompatibility

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, what medication does the nurse anticipate will be prescribed?

Betamethosone

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment?

Blood pressure

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.

Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?

Bring the infant to the clinic.

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 indicated the presence of a hematoma?

Changes in vital signs

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?

Client pain level

The nurse is a neonatal intensive care unit (NICU) receives a telephone call to prepare for admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority?

Connect the resuscitation bag to the oxygen outlet.

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially?

Contact the obstetrician (OB) and inform him or her of this finding.

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother?

Continue to breast-feed every 2 to 4 hours.

An ultrasound is performed on a client at term gestation who is experiencing 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?

Delivery of the fetus

The nurse is assisting a client undergoing induction of labor at 41 weeks gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats per minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate?

Document the findings.

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?

Drying the infant with a warm blanket

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?

Encouraging fluid intake

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present?

Enlarged, hardened veins

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

Evidence of bleeding, such as in the gums, petechiae, and purpura

Which assessment finding after an amniotomy should be conducted first?

Fetal heart pattern

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks gestation. Which assessment finding indicates the need to contact the primary health care provider? (PHCP)

Fetal heart rate of 180 beats per minute.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?

G = 2, T = 1, P = 0, A = 0, L =1

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

Hemorrhage

The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia?

Hypertension

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 F. What is the priority nursing action?

Increasing hydration by encouraging oral fluids.

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?

Inform the client that these contractions are common and may occur throughout the pregnancy

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate?

Instruct the client to request help when getting out of bed.

The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route?

Intratracheal

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan?

Isoniazid plus rifampin will be required for 9 months.

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2020. Using Nagele's rule, which expected date of delivery should the nurse document in the client's chart?

July 26, 2021

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?

Maintaining safety because of low blood glucose levels

The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care?

Maintaining standard precautions at all times while caring for the newborn

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action?

Massage the fundus until it is firm.

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?

Massage the fundus until it is firm.

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?

Monitor the newborn's response to feedings and weight gain pattern.

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

Monitoring the fetal heart rate.

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs?

Naloxone

The nurse is assessing a client in the fourth stage of labor that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action?

Notify the obstetrician (OB).

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action?

Notify the obstetrician (OB).

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes they are larger than 1 cm. Which nursing action is most appropriate?

Notify the obstetrician (OB).

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is most appropriate?

Notify the primary health care provider (PHCP).

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescription and should question which prescription?

Obtain equipment for a manual pelvic examination.

The nurse is reviewing the primary health care provider's (PHCP) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?

Perform a vaginal examination every shift.

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the obstetrician who prescribed the medication if which condition is documented in the client's medical history?

Peripheral vascular disease

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise?

Persistent nonreassuring fetal heart rate

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?

Place the client in Trendelenburg's position.

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?

Prepare an ice pack for application to the area.

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?

Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.

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 nursing action?

Provide pain relief measures.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?

Supine position with a wedge under the right hip.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help process the delivery?

Support the mother in her reaction to the newborn infant.

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 16 weeks' gestation because of which factor?

The appearance of the fetal external genitalia.

The home care nurse visits a pregnant client who has diagnosis of preecclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)?

The client complains of a headache and blurred vision.

The nurse is performing 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?

The client has a history of cardiac disease.

The nurse is performing an assessment of a pregnant client who is at 28 weeks gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30cm. How should the nurse interpret this finding?

The client is measuring normal for gestational age.

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?

The client with lochia is red and has a foul-smelling odor

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?

The diet should include additional fluids.

The nurse evaluates the ability of a hepatitis B positive mother to provide safe bottle feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?

The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

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?

Uterine tenderness

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?

Variable decelerations