maternity NCLEX review
A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterus to determine if the placenta has detached. Which findings indicate to the nurse that placental detachment has occurred? Select all that apply.
-lengthening of umbilical cord -sudden gush dark blood from vagina -appearance of fetal membranes at introitus
The maternity nurse prepares the client for which techniques commonly used to relieve shoulder dystocia?
McRobert's maneuver
The nurse is caring for a newborn with respiratory distress syndrome (RDS). Which data obtained by the nurse indicate potential complications associated with this disorder?
No audible breath sounds in left lung; heart sounds louder in right side of chest
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 indicates that the client understands the instructions?
She should alternately contract and relax the muscles of the perineal area.
A woman who is 8 weeks pregnant complains to the nurse about nausea. Which advice should the nurse provide to this client about ways to assist with this problem? Select all that apply.
-avoid greasy foods - do not drink fluids with meals -eat 5-6 small meals each day
A woman who is 36 weeks pregnant arrives at the labor and delivery unit complaining of vaginal bleeding. Which signs/symptoms indicate that the client's bleeding is caused by placenta previa? Select all that apply.
-bright red bleeding -lack of uterine contractions
The nurse is working with a woman who has just been diagnosed with gestational diabetes mellitus. The nurse informs the client of which issues that may occur during this pregnancy because of this condition? Select all that apply.
-delayed lung maturation in neonate -increased chance of c/s -UTIS
The nurse is reading the primary health care provider's documentation regarding a pregnant client and notes that the primary health care provider has documented that the client has an android pelvic shape. Which descriptions apply to an android pelvis? Select all that apply.
-narrow wedge shape -unfavorable for vaginal delivery
The nurse is reviewing the laboratory results of a pregnant client and notes that the hemoglobin level is decreased. Physiological dilutional anemia is documented in the client's record by the primary health care provider. The nurse plans care, knowing that this type of anemia is a result of which situation?
increased blood vol. of mother during pregnancy
A pregnant client with severe uterine bleeding is admitted to the labor and birthing department. Which data should best alert the nurse to early signs of hypovolemic shock?
restlessness and agitation
The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse places the client at risk for uterine rupture?
shoulder dystocia
The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. The prenatal client asks the nurse to explain Chadwick's sign. Which information provided by the nurse is accurate? Select all that apply.
-probable sign of pregnancy - may be present as early as 6 weeks gestation -bluish discoloration of vagina and cervix
A client asks the nurse to describe how her baby is developing at 12 weeks gestation. Which milestones should the nurse identify as present at this time? Select all that apply.
-sex determined - kidneys excreting urine - blood forming in marrow
The nurse is monitoring the status of a client in active labor. The nurse interprets that which findings are consistent with dystocia? Select all that apply.
-signs of fetal distress - failure of fetus to descend - maternal anxiety
The nurse observes the client following delivery for normal maternal physiological changes that are anticipated. The nurse should document which expected changes? Select all that apply
-slowed pulse rate -elevated BP
The nurse is discussing prenatal testing with a woman who is approximately 6 weeks pregnant. The nurse shares which tests are expected to be conducted during the first trimester? Select all that apply.
-urinanalysis -rubella titer -cbc
Which history places a maternity client at risk for uterine rupture?
c/s
The nurse is reinforcing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further teaching?
change the perineum pad 3x a day
A client is brought to the labor unit. As the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. What should be the nurse's immediate action?
check the fetal heart rate
The nurse is reinforcing instructions to a pregnant client regarding the need to consume folic acid in the diet. The nurse determines that the client understands the instructions when the client states that it is necessary to include which food item in the diet?
green, leafy vegetables
The nurse is reviewing the record of a newborn infant and notes that the primary health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which indications on data collection of the infant? Select all that apply.
-Edema caused from bleeding below the brain's periosteum -Develops 24 to 48 hours following birth and may take 2 to 3 weeks to resolve
The clinic nurse is preparing to discuss cardiovascular changes of pregnancy in a prenatal class. Which information is appropriate for the nurse to present to this group? Select all that apply.
-at term, HR has increased 15-20 bpm -rbcs increase -in supine position, suppression of vena cavae will occur
A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which statement by the client identifies the need for further teaching regarding the hemorrhoids?
"Hemorrhoids are caused solely by the changes in hormones during pregnancy. They will go away within a day or two after the baby is born."
The nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for further teaching regarding possible complications of preeclampsia
"I should expect that my urine output will decrease."
The nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which statement indicates that the mother needs further teaching?
"I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."
After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further teaching if the new mother makes which statement?
"The only medications that I will take are prenatal vitamins and stool softeners."
Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?
"There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth
The nurse is reinforcing a teaching session to a group of adolescent pregnant clients and is discussing the importance of nutrition. The nurse includes which information in the discussion?
Describing the appropriate amount of weight gain required during the pregnancy
The parents of a neonate who is not circumcised asks the nurse why the foreskin should not be retracted. The nurse explains that retracting the foreskin should be avoided because which complication may occur?
adhesions
The nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which client problem should the nurse expect to note on the plan of care?
anxiety r/t to slow progress of labor
A client who is breastfeeding her newborn infant is experiencing nipple soreness. To relieve the soreness, which action should the nurse suggest to the client?
begin feeding on the less sore nipple
A pregnant client asks the prenatal clinic nurse what the fetal period of development means. Which is correct information about the fetal period?
longest period of fetal development
The nurse is reviewing the record of a client in the labor room. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?
minus (-)1 station
The nurse assisting in the care of a woman in labor should focus primarily on which client at the time of delivery?
newborn
The nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client makes which statement?
my cervix is completely dilated
The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which is noted?
presence of accelerations
The nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which should the nurse check first?
pulse
A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat a urinary tract infection. The mother expresses concern that her baby will be born with an infection. Which response should the nurse make to help reduce the maternal fears that the newborn will be born with an infection?
"Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today."
The clinic nurse is reviewing the records of the pregnant clients who will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection?
An adolescent with multiple heterosexual contacts
A newborn infant has coarctation of the aorta (COA). The nurse should expect to note which findings in the infant?
Bounding radial pulses and absent or weak femoral and pedal pulses
The nurse provides explanation to a client prescribed methylergonovine maleate in the immediate postpartum period. Which statement made by the client demonstrates understanding of the rationale for administration?
It will help prevent bleeding and control bleeding if it occurs.
The nurse is assisting a client who, at 38 weeks of gestation, reports feeling dizzy, lightheaded, and nauseated when attempting to lie down on the examining table. Her skin is pale and is both cool and moist to the touch. Which action should the nurse perform first?
Place a wedge pillow under the client's right side
The nurse assisting in the care of a newborn has a standing prescription to administer the hepatitis B vaccine to the infant. The nurse should plan to perform which action when carrying out this prescription?
obtain written parental consent
The nurse should prepare to give a prescribed oxytocic medication after delivery of which?
placenta
The nurse is caring for the postpartum client who is diagnosed with a low-lying placenta. The nurse monitors the client carefully for which complication?
postpartum hemorrhage
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?
the client is required to stay on bed rest
The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate?
the neonate cries incessantly
A client is a gravida IV, para III in her final trimester of pregnancy. She does not attend usual social functions because of the fear of stress incontinence. Her oldest child is in a school play, which she wants to attend. Which measure is appropriate to suggest to the client?
wear a perineal pad to the play
The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response?
within acceptable ranges
the nurse shares with a pregnant client that the result of her rubella screening is positive. Which is the nurse's response when asked by the client if it is safe for her 15-month-old toddler to receive the rubella vaccine?
"You are immune to the virus so it is safe for your toddler to receive the vaccine at this time."
Which documentation concerning the characteristics of amniotic fluid supports the determination that the fluid is normal? Select all that apply.
- basic PH -1000 ml is acceptable amount -pale, straw colored with flecks of vernix
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 are included in the plan of care? Select all that apply.
- maintaining bed rest -apply warm compresses to the affected area as prescribed -elevate affected extremity
A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breastfeed the baby as planned after delivery. The nurse makes which response to the client?
breastfeeding is allowed once the baby is vaccinated
The nurse is caring for a woman in the labor room. The primary health care provider prescribes an oxytocic medication for the woman to augment her labor. Which finding indicates a need to discontinue the oxytocic medication?
resting interval of 50 sec
The nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment
Ask the client to urinate and empty her bladder.
The nurse is caring for a client following a precipitate delivery. In addition to fundal massage, which nursing action can the nurse implement that will promote the birth of the placenta?
Putting the baby to the mother's breast and letting the baby suck
The nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which problem should receive highest priority?
dehydration
The nurse is monitoring the vital signs of a client after delivery of a healthy newborn one day ago and notes that the mother's apical pulse is 56 beats/min. Which nursing action is appropriate related to this finding?
document the finding
The nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick, white mucoid vaginal discharge is present. Based on these findings, the nurse determines that which action is the best?
document the findings
The nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which finding is least likely associated with DIC?
swelling of the calf of one leg
A nurse is reinforcing instructions to a client in the first trimester of pregnancy about measures to help with morning sickness. Which should the nurse include in the instructions? Select all that apply.
-Eat a low-fat diet. -Stop or decrease smoking. -Eat smaller, more frequent meals. -Consume adequate fluid between meals.
The nurse is reviewing the health history of a pregnant client. Which data noted in the client's health history would indicate a risk for spontaneous abortion?
syphillis
