Maternity NCLEX Questions
The nurse suspects that the client has a pulmonary embolism when the client exhibits which signs and symptoms? 1.Dyspnea, tachypnea, and tachycardia 2.Dry cough, shortness of breath, and back pain 3.Edema, skin tenderness, and increased skin temperature 4.Hematemesis, chest pain, and a feeling of impending doom
1. Dyspnea, tachypnea, and tachycardia
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? 1.Red 2.Pink 3.White 4.Serosanguineous
1. Red
The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.1.Rest during the acute phase. 2.Wear a supportive, nonunderwire bra. 3.Maintain a fluid intake of at least 3000 mL. 4.Continue to breastfeed if the breasts are not too sore. 5.Take the prescribed antibiotics until the soreness subsides. 6.Avoid decompression of the breasts by breastfeeding or breast pump
1. Rest during the acute phase 2. Wear a supportive, nonunderwire bra 3. Maintain a fluid intake of at least 3000 mL 4. Continue to breastfeed if the breasts are not too sore
The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which would most likely indicate a hematoma? 1.Changes in vital signs 2.Signs of heavy bruising 3.Complaints of a tearing sensation 4.Complaints of lower abdominal discomfort
1.Changes in vital signs
The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which? 1.Uterine atony 2.Bladder distention 3.Endometrial infection 4.Retained placental fragments
2. Bladder distention
The nurse has reinforced instructions to a new mother about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she makes which statement?1."Strenuous exercises should be started while in the hospital." 2."Exercise should be delayed for 4 weeks to allow healing time." 3."The use of postpartum exercises can result in stress urinary incontinence." 4."I should alternately contract and relax the muscles of the perineal area."
4. I should alternately contract and relax the muscles of the perineal area.
A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn 2 hours ago. The mother's temperature is 100° F (38° C). What is the initial nursing action? 1.Document the finding. 2.Encourage oral fluid intake. 3.Notify the health care provider. 4.Administer acetaminophen (Tylenol).
2. Encourage oral fluid intake
The nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the health care provider? 1.Uterine cramping while breast-feeding 2.Pain, redness, or swelling in the breasts 3.Diaphoresis that occurs during the night 4.Existence of a serosanguineous vaginal drainage
2. Pain, redness, or swelling in the breasts
Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression? 1.The mother is caring for the infant in a loving manner. 2.The mother constantly complains of tiredness and fatigue. 3.The mother demonstrates an interest in the surroundings. 4.The mother looks forward to visits from the father of the newborn.
2. The mother constantly complains of tiredness and fatigue
The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which? 1.A normal finding 2.The presence of infection 3.The need for increasing oral fluids 4.The need for increasing ambulation
2. The presence of infection
Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression? 1.The mother is caring for the infant in a loving manner. 2.The mother constantly complains of tiredness and fatigue. 3.The mother demonstrates an interest in the surroundings. 4.The mother looks forward to visits from the father of the newborn.
2.The mother constantly complains of tiredness and fatigue.
A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus, expecting to note which uterine fundus position? 1.To the left of the abdomen 2.To the right of the abdomen 3.At the level of the umbilicus 4.Two fingerbreadths above the symphysis pubis
3. At the level of the umbilicus
The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is important for the nurse to take at this time? 1.Assist the client to breast-feed. 2.Encourage food and fluid intake. 3.Check the uterine fundus and lochia. 4.Provide privacy for the parents and their newborn.
3. Check the uterine fundus and locia
The nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers? 1.If triple dye has been applied to the cord, it is not necessary to do anything else to it. 2.All that is necessary is to wash the cord with antibacterial soap, allowing it to air dry once a day. 3.Clean around the cord with plain water as needed until the cord falls off 4.Gently apply alcohol to the cord, being careful not to move the cord because it will cause the newborn pain.
3. Clean around the cord with plain water as needed until the cord falls off
As a part of discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. Which response by the client would indicate that the client understands the instructions? 1.Strenuous exercises should be avoided for at least 6 months. 2.Exercise should be postponed for 4 weeks to allow healing time. 3.She should alternately contract and relax the muscles of the perineal area. 4.The use of postpartum exercises can eliminate stress urinary incontinence.
3. She should alternately contract and relax the muscles of the perineal area
A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation? 1.The client is unable to nurse the baby. 2.The client is an older first-time mother. 3.The client is required to stay on bed rest. 4.The client is considering giving the baby up for adoption.
3.The client is required to stay on bed rest.
The nurse is reinforcing instructions to a client who had an episiotomy during the birthing process. Which statement by the client would indicate a need for further teaching? 1."I can apply ice to the area." 2."I can apply a local anesthetic spray to the area." 3."I should tighten the perineum before I sit and then relax it slowly after being seated." 4."I should take sitz baths 3 or 4 times a day and test the water temperature to be sure that it is at 115° F."
4. I should take sitz baths 3 or 4 times a day and test the water temperature to be sure that it is at 115 F
The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care? 1.Alcohol is the only agent used to clean the cord. 2.It takes 21 days for the cord to dry up and fall off. 3.Cord care is done only at birth to control bleeding. 4.The process of keeping the cord clean and dry will decrease bacterial growth.
4. . The process of keeping the cord clean and dry will decrease bacterial growth
The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. The nurse understands that this ointment is characterized by which description? 1.Administered at room temperature to prevent side effects 2.More irritating to the newborn's eyes than silver nitrate drops 3.Staining to the infant's skin and must be wiped off immediately 4.Effective in protecting the newborn from Neisseria gonorrhoeae and Chlamydia
4. Effective in protecting the newborn from Niesseria gonorrhoeae and chlamydia
The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action?1.Maintaining strict bed rest 2.Monitoring the vital signs every 2 hours 3.Performing firm fundal massage every 2 hours 4.Keeping the client and her family members informed of her progress
4. Keeping the client and her family members informed of her progress
A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement? 1.Breastfeed only during the daytime hours. 2.Apply cold compresses to the breast before feeding. 3.Avoid the use of a bra while the breasts are engorged. 4.Massage the breasts before feeding to stimulate let-down.
4. Massage the breasts before feeding to stimulate let-down
The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. On the basis of this diagnosis, the nurse should plan which action? 1.Reassuring the client 2.Applying perineal pressure 3.Monitoring the fundal height 4.Preparing the client for surgery
4. Preparing the client for surgery
The nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse should select which injection site? 1.The gluteal muscle 2.The lower aspect of the rectus femoris muscle 3.The medial aspect of the upper third of the vastus lateralis muscle 4.The lateral aspect of the middle third of the vastus lateralis muscle
4. The lateral aspect of the middle third of the vastus lateralis muscle
The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client? 1.The inverted uterus returning to normal 2.The gradual reversal of the uterine muscle into the abdominal cavity 3.The descent of the uterus into the pelvic cavity, which occurs at a rate of 2 cm/day 4.The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day
4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1cm/day
The nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by initiating which action?1 .Wrapping the newborn in a blanket 2.Closing the doors to the delivery room 3.Drying the newborn with a warm blanket 4.Warming the crib pad before placing the newborn in the crib
4. Wrapping the crib pad before placing the newborn in the crib
The nurse is caring for a woman who has delivered a baby after a pregnancy with a placenta previa. Which complication would the client be at risk for? 1.Coagulopathy 2.Postpartum infection 3.Chronic hypertension 4.Postpartum hemorrhage
4. postpartum hemorrhage
A client had a cesarean delivery with a low transverse uterine incision. Which is the benefit of this type of incision? 1.It requires that a vertical skin incision be made. 2.It can be extended if a larger incision is needed. 3.It is the best choice with a placenta previa on the lower anterior uterine wall. 4.It allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.
4.It allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.
The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which problem is most likely to occur during this stage? 1.Anxiety related to childbirth 2.Pain because of the process of labor or birth 3.Fatigue resulting from physical exertion during labor 4.Urinary retention caused by the loss of sensation to void and rapid bladder filling
4.Urinary retention caused by the loss of sensation to void and rapid bladder filling
A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement? 1."I don't need birth control because I will be breastfeeding." 2."I need to increase my caloric intake by 500 calories a day." 3."I shouldn't use soap to wash my breasts because I will be breastfeeding." 4."I need to be sure that I increase my fluid intake and take my prenatal vitamins while breastfeeding."
1. I don't need birth control because I will be breastfeeding
A postpartum nurse is reinforcing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instructions should the nurse provide to the mother? 1.Increase the frequency of the breast-feeding. 2.Stop the breast-feedings and switch to bottle-feeding permanently. 3.Provide bottled-water feedings between the breast-feeding sessions. 4.Switch to bottle-feeding the baby during the period of high bilirubin levels, and feed less frequently.
1. Increase the frequency of the breast-feeding
The nurse is checking lochia discharge on a client in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. Which interpretation should the nurse make about this finding? 1.Is normal 2.Indicates that the client is hemorrhaging 3.Indicates the need to increase oral fluids 4.Indicates the need to contact the health care provider
1. Is normal
A new mother is attempting to breast-feed for the first time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breast-feeding the newborn? 1.Massage the breast, applying gentle pressure on the areola. 2.Have the mother grasp the nipples between the thumb and forefinger and tug firmly to get the nipple to protrude. 3.Have the mother take a cool shower, allowing the water to run over the breasts because this will encourage the nipples to protrude. 4.Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp.
4. Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp
The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions would be included in the plan of care? Select all that apply. 1.Maintaining bed rest 2.Elevating the affected extremity 3.Administering anticoagulants daily 4.Administering anti-inflammatory agents every 4 hours 5.Applying warm compresses to the affected area as prescribed
1. Maintaining bed rest 2. Elevating the affected extremity 5. Applying warm compress to the affected area as prescribed
The nurse caring for a breast-feeding postpartum client plans to include avoidance of soaps on the nipples, frequent changing of breast pads, and intermittent exposure of nipples to the air. These interventions are implemented to prevent which complication? 1.Mastitis 2.Engorgement 3.Newborn colic 4.Let-down reflex
1. Mastitis
The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings in the newborn should alert the nurse to the possibility of this syndrome? 1.Hypotension and bradycardia 2.Tachypnea and retractions 3.Acrocyanosis and grunting 4.The presence of a barrel chest with acrocyanosis
2. Tachypnea and retractions
The pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. The nurse should make which statement to address the client's concern? 1."Don't worry about your baby, complications are rare." 2."You will not have any problems if you follow the advice the health care provider has given you." 3."Your baby will need to spend a few days in the neonatal intensive care unit following delivery." 4."The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."
4. The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential
The nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement by the client indicates a need for further teaching? 1."I need to take the antibiotics as prescribed." 2."I need to take warm sitz baths to promote healing." 3."I need to apply warm compresses to provide comfort." 4."I need to isolate my infant for 48 hours after the starting the antibiotics."
4."I need to isolate my infant for 48 hours after the starting the antibiotics."
A mother is breastfeeding her newborn. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which suggestion to the client? 1.Avoid rotating breastfeeding positions so that the nipple will toughen. 2.Stop nursing during the period of nipple soreness to allow the nipples to heal. 3.Nurse the newborn infant less frequently and substitute a bottle feeding until the nipples become less sore. 4.Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.
4. Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's
A nursing instructor is observing a nursing student caring for a newborn with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by which action? 1.Covering the bladder with Tegaderm 2.Covering the bladder with a dry, sterile dressing 3.Covering the bladder with a sterile, nonadhering moist dressing 4.Applying sterile water soaks and a dry, sterile dressing to the mucosa
3. Covering the bladder with sterile, noadhering moist dressing
After episiotomy and the delivery of a newborn, 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 is firm. Which determination should the nurse make? 1.This is a normal expectation after episiotomy. 2.The mother should be allowed bathroom privileges only. 3.The bright red bleeding is abnormal and should be reported. 4.The perineal assessment should be performed more frequently.
3. The bright red bleeding is abnormal and should be reported
The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV) positive. The nurse understands that which should be included in the plan of care?1.Monitoring the neonate's vital signs routinely 2.Maintaining standard precautions at all times while caring for the neonate 3.Instructing breastfeeding mothers regarding the treatment of their nipples with an antifungal cream 4.Initiating a referral to evaluate for blindness, deafness, learning, or behavioral problems in the neonate
2. Maintaining standard precautions at all times while caring for the neonate
The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which statement should the nurse make to the client? 1."Visitors are not allowed to hold the baby." 2."The infant will not be allowed in the room at all." 3."There is no danger of the newborn contracting the disease." 4."Hands should be washed thoroughly before holding the infant."
4."Hands should be washed thoroughly before holding the infant."
A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed? 1."I will be sure to wash my hands before feeding the newborn." 2."I will breastfeed, especially for the first 6 weeks postpartum." 3."I will be sure to wash my hands before and after bathroom use." 4."I will administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery."
2. I will breastfeed, especially for the first 6 weeks postpartum
Oxytocin (Pitocin) is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effective response from the medication? 1.Milk production 2.Uterine contractions 3.Increased urinary output 4.Decreased afterbirth pains
2. Uterine contractions
A new mother attempting breast-feeding for the first time has developed mastitis. She states, "My breasts look terrible and I think that I will stop breast-feeding." The nurse plans care knowing that the client is concerned about which problem? 1.Infection 2.Body image 3.Newborn nutrition 4.Feelings of inadequacy
2.Body image
The nurse in the postpartum unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed which amount? 1.One pad a day 2.Two pads a day 3.Three pads a day 4.Eight pads a day
4. Eight pads a day
The nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, which nursing action would be the most appropriate? 1.Place the infant back in the bassinet. 2.Diaper the infant while it is lying on the bed. 3.Place the infant in the bassinet and take the baby back to the nursery. 4.Have the mother place the infant in the bassinet and assist the mother in dressing the baby.
4. Have the mother place the infant in the bassinet and assist the mother in dressing the baby
Which safety measures that should be implemented when working in the newborn nursery? Select all that apply. 1.Adhere to standard precautions. 2.Place bassinets 1 foot apart from one another. 3.It is acceptable for nurses who are ill to work in the nursery. 4.An identification bracelet should be placed on the infant only after the initial bath is completed. 5.The parents should be instructed to not release their infant to anyone wearing improper identification. 6.The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room. 1. Adhere to standard precautions 5. The parents should be instructed to not release their infant to anyone wearing improper identification 6. The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room
1. Adhere to standard precautions 5. The parents should be instructed to not release their infant to anyone wearing improper identification 6. The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room
The nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which data, if noted in the infant, indicate that the criterion for early discharge has not been met? 1.The infant has evidence of significant jaundice. 2.Vital signs are documented as normal and stable. 3.The infant has urinated and passed at least one stool. 4.The infant has completed at least two successful feedings.
1. The infant has evidence of significant jaundice
The parents of a neonate who is not circumcised request information on how to clean the newborn's penis. Which is the correct response for the nurse to make to the parents? 1."Retract the foreskin and cleanse with every diaper change." 2."Retract the foreskin and cleanse the glans when bathing the neonate." 3."Avoid retracting the foreskin to cleanse the glans because this may cause adhesions." 4."Retract the foreskin no farther than it will easily go and replace it over the glans after cleaning."
3."Avoid retracting the foreskin to cleanse the glans because this may cause adhesions."
