Mother Baby NCLEX questions week 2
Which of the following is the priority nursing action during the immediate postpartum period? A. Palpate fundus. B. Check pain level. C. Perform pericare. D. Assess breasts.
A
Which of the following nursing interventions would be appropriate for the nurse to perform to achieve this client care goal: The client will not develop postpartum thrombophlebitis? A. Encourage early ambulation. B. Promote oral fluid intake. C. Massage the legs of the client twice daily, D. Provide the client with high-fiber foods.
A
A nurse is assisting an anesthesiologist who is inserting an epidural catheter. Which of the following positions should the nurse assist the woman into? A. Fetal position. B. Lithotomy position. C. Trendelenburg position. D. Lateral recumbent position.
A
Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate? A. Provide the woman with warm blankets. B. Put the woman in the Trendelenburg position. C. Notify the primary health care provider. D. Increase the intravenous infusion.
A
The labor and delivery nurse performs Leopold maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? A. Left occipital anterior (LOA). B. Left sacral posterior (LSP). C. Right mentum anterior (RMA). D. Right sacral posterior (RSP).
A
The nurse has provided teaching to a postop cesarean client who is being discharged on Colace (docusate sodium) 100 mg PO tid. Which of the following would indicate that the teaching was successful? A. The woman swallows the tablets whole. B. The woman takes the pills between meals. C. The woman calls the doctor if she develops a headache. D. The woman understands that her urine may turn orange.
A
The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? A. Intermittently apply ice packs to her axillae and breasts. B. Apply lanolin to her breasts and nipples every 3 hours. C. Express milk from the breasts every 3 hours. D. Ask the primary healthcare provider to order a milk suppressant.
A
The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station -2. Which of the following has the nurse palpated? A. Thin cervix. B. Bulging fetal membranes. C. Head at the pelvic outlet. D. Closed cervix.
A
Which of the following complementary therapies can a nurse suggest to a multiparous woman who is complaining of severe afterbirth pains? A. Lie prone with a small pillow cushioning her abdomen. B. Contract her abdominal muscles for a count of ten. C. Slowly ambulate in the hallways. D. Drink ice tea with lemon or lime.
A
A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman prenatal record before proceeding with the physical assessment? Select all that apply. A. Weight gain. B. Ethnicity and religion. C. Age. D. Type of insurance. E. Gravidity and parity.
A, B, C, E
When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. A. After vaginal examinations. B. Before administration of analgesics. C. Periodically at the end of a contraction. D. Every ten minutes. E. Before ambulating.
A, B, C, E
A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. A. Bulging perineum. B. Increased bloody show. C. Spontaneous rupture of the membranes. D. Uncontrollable urge to push. E. Inability to breathe through contractions.
A, B, D
A woman has just arrived at the labor and delivery suite. To report the client's status to her primary healthcare practitioner, which of the following assessments should the nurse perform? Select all that apply. A. Fetal heart rate. B. Contraction pattern. C. Urinalysis. D. Vital signs.Biophysical profile.
A, B, D
The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. A. The client who says. "If I feel a pain in my back and lower abdomen every 5 minutes." B. The client who says, "When I feel a gush of clear fluid from my vagina." C. The client who says, "When I go to the bathroom and see mucous plug on the toilet tissue." D. The client who says, "If I ever notice a greenish discharge from my vagina." E. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."
A, B, D
Which of the following actions would the nurse expect to perform immediately before a woman is to have regional anesthesia? Select all that apply. A. Assess fetal heart rate. B. Infuse 1,000 mL of Ringer's lactate. C. Place the woman in the Trendelenburg position. D. Monitor blood pressure every 5 minutes for 15 minutes. E. Have the woman empty her bladder.
A, B, E
A GI PO, 8 cm dilated, is to receive pain medication. The healthcare practitioner has decided to order an opiate analgesic with a medication that reduces some of the side effects of the analgesic. Which of the following medications would the nurse expect to be entered in conjunction with the analgesic medication? A. Seconal (secobarbital). B. Phenergan (promethazine). C. Stadol (butorphanol). D. Tylenol (acetaminophen).
B
A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? A. The client had poor childbirth education prior to labor. B. The client is exhibiting an expected behavior for labor. C. The client is becoming hypoxic and hypercapnic. D. The client needs her alpha-fetoprotein levels checked.
B
A client who delivered a 3,900-gram baby vaginally over a right mediolateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? A. "I will call the doctor to order a stool softener for you." B. "Your stitches are actually far away from your rectal area." C. "If you eat high-fiber foods and drink fluids you should have no problems." D. "If you use your topical anesthetic on your stitches you will feel much less pain.
B
A client, G2P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to take at this time? A. Assess the woman's temperature. B. Place a wedge under the woman's side. C. Place a blanket roll under the woman's feet. D. Assess the woman's pedal pulses.
B
A low-risk 38-weeks' gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? A. "Does it burn when you void?" B. You sound frightened." C. "That is just the mucous plug." D. "How much blood is there?"
B
Between contractions, a client in the active phase of labor states, "Not only do these contractions really hurt me, but what are they doing to my baby! I am so scared and I can't stop thinking about how my baby might be hurting, too. The patient requests medication to reduce her pain. It would be most appropriate for the nurse to suggest the client's primary healthcare provider to order which of the following labor pain-relieving methods A. Epidural. B. Nitrous oxide. C. Narcotic analgesic. D. Spinal.
B
During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm above the ischial spines. Which of the following is consistent with this assessment? A. LOA -1 station. B. LSP - station. C. LMP + 1 station. D. LSA +1 station.
B
Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following side effects? A. Paresthesias in her feet and legs. B. Drop in blood pressure. C. Increase in central venous pressure. D. Fetal heart accelerations.
B
The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? A. She is contracting q 5 min x 60 sec. B. Her cervix has dilated from 2 to 4 cm. C. Her membranes have ruptured D. The fetal head is engaged.
B
The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? A. Sacral promontory. B. Ischial spines. C. Cervix. D. Symphysis pubis.
B
The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following should the nurse include in the plan? A. Teach baby-care skills such as diapering. B. Discuss the labor and birth with the mother. C. Discuss contraceptive choices with the mother. D. Teach breastfeeding skills such as pumping.
B
The nurse takes a newborn to a primipara for a feeding. The mother holds the baby en face, strokes his cheek, and states that this is the first newborn she has ever held. Which of the following nursing assessments is most appropriate? A. Positive bonding and client needs little teaching. B. Positive bonding but teaching related to newborn care is needed. C. Poor bonding and referral to a child abuse agency is essential. D. Poor bonding but there is potential for positive mothering.
B
The practitioner is performing a fetal scalp stimulation test. Which of the following fetal responses would the nurse expect to see? A. Spontaneous fetal movement. B. Fetal heart acceleration. C. Increase in fetal heart variability. D. Resolution of late decelerations.
B
The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time? A. Estrogen. B. Prolactin. C. Human placental lactogen. D. Human chorionic gonadotropin.
B
Which of the following statements is true about breastfeeding mothers as compared to bottle-feeding mothers? A. Breastfeeding mothers usually involute completely by 3 weeks postpartum. B. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life. C. Breastfeeding mothers show higher levels of bone density after menopause. D. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum
B
One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this diagnosis? Select all that apply. A. The client will drink sufficient quantities of fluid. B. The client will have a stable white blood cell (WBC) count. C. The client will have a normal temperature. D. The client will have normal-smelling vaginal discharge. E. The client will take two or three sitz baths each day.
B, C, D
A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with "latch on" and recommends that the mother do which of the following? A. Use a nipple shield at each breastfeeding B. Cleanse the nipples with soap 3 times a day. C. Rotate the baby's positions at each feed. D. Bottle feed for 2 days then resume breastfeeding.
C
A gravid client at term called the labor suite at 7:00p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: A. "At 5:00p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." B. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." C. "I took a shower about a half hour ago. The contractions hurt more than they did before." D. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my nap."
C
A medication order reads: Methergine (ergonovine) 0.2 mg PO q 6 h x 4 doses. Which of the following assessments should be made before administering each do of this medication? A. Apical pulse. B. Lochia flow. C. Blood pressure. D. Episiotomy.
C
On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is -2 and the baseline fetal heart rate is 130 with no decelerations. Which of the following nursing actions is appropriate at this time? A. Coach the woman to hold her breath while pushing 3 to 4 times with each contraction, B. Administer oxygen via face mask at 8 to 10 liters per minute. C. Delay pushing until the baby descends further and the mother has a strong urge to push. D. Place the woman on her side and assess her oxygen saturation.
C
The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? A. Mentum anterior. B. Sacrum posterior. C. Occiput posterior. D. Scapula anterior.
C
The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects? A. Headache. B. Nausea. C. Cramping. D. Fatigue.
C
When performing Leopold maneuvers, the nurse note that the fetus is in the left occiput anterior position. Which is the best position for the nurse to place a fetoscope to hear the fetal heartbeat A. Left upper quadrant. B. Right upper quadrant. C. Left lower quadrant. D. Right lower quadrant.
C
While performing Leopold maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? A. The fetal position is transverse. B. The fetal presentation is vertex. C. The fetal lie is vertical. D. The fetal attitude is flexed.
C
A G2 P2002 who is postpartum 6 hours from a spontaneous vaginal delivery is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? A. Do nothing. This is a normal finding B. Massage the woman's fundus. C. Take the woman to the bathroom to void. D. Notify the woman's primary health care provider.
D
A laboring woman and two men enter the labor suite. One of the men states, "We and our surrogate are here for our baby's delivery: Where should we go? Which of the following responses by the nurse would be appropriate? A. Congratulate the surrogate on the gift she is giving the gay couple. B. Remind the men that labor and delivery experience is very stressful. C. Remind the men that the woman is the baby's mother. D. Ask the laboring woman whom she would like to be with her during labor.
D
A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her baby. Which of the following responses by the nurse is appropriate? A. Suggest that the woman bottle feed for a few days. B. Instruct the patient on how to massage her fundus C.Instruct the patient to feed using an alternate position. D. Discuss the action of breastfeeding hormones.
D
A nurse describes a client's contraction pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds to this description? A. Contractions lasting 60 seconds followed by a 1-minute rest period. B. Contractions lasting 120 seconds followed by a 2-minute rest period. C. Contractions lasting 2 minutes followed by a 60-second rest period. D. Contractions lasting 1 minute followed by a 120-second rest period.
D
A woman who states that she thinks she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client labor status? A. Leopold maneuvers. B. Fundal contractility: C. Fetal heart assessment. D. Vaginal examination.
D
A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? A. "The contractions are 5 to 20 minutes apart." B. "I saw a pink discharge on the toilet tissue when I went to the bathroom." C. "I have had cramping for the past 3 or 4 hours." D. "The contractions are about a minute long and I am unable to talk through them."
D
It is 4pm. A client, G1 P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies: A. "Laboring clients are never allowed to eat." B. "Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know." C. "The dinner tray should arrive in an hour or two." D. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."
D
The nurse hears the following information on a newly delivered client during shift report: 21 years old, married, GI PI001, 8 hours post-spontaneous vaginal delivery over an intact perineum; vitals 110/70, 98.6°F, 82, 18; fundus firm at umbilicus: moderate lochia rubra; ambulated to bathroom to void 4 times: breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? A. Fluid volume deficit r/t excess blood loss. B. Impaired skin integrity r/t vaginal delivery. C. Impaired urinary elimination r/t excess output. D. Knowledge deficit r/t lack of parenting experience.
D
The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend? A. ½ cup raw celery dipped in 1 ounce cream cheese. B. 8 ounces yogurt mixed with 1 medium banana. C. 12 ounces strawberry milk shake. D. 4. 1 1/2 cups raw broccoli.
D
The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? A. Provide the client with a nutritious meal. B. Encourage the client to take a nap. C. Assist the client with activities of daily living. D. Assure the client that she is an excellent mother.
D
A client informs the nurse that she intends to bottle feed her baby. Which of the following actions should the nurse encourage the client to perform: Select all that apply? A. Increase her fluid intake for a few days. B. Massage her breasts every 4 hours. C. Apply heat packs to her axillae. D. Wear a supportive bra 24 hours a day. E. Stand with her back toward the shower water.
D, E
