NCLEX-maternity and newborn

Which finding in fetal heart rate during a non-stress test would indicate to the nurse that a potential problem for the fetus may exist? 1. Increases 30 beats per minute for 20 seconds with fetal movement. 2. Increases 8 beats per minute for 10 seconds with fetal movement. 3. Remains unchanged with maternal movement. 4. Increases 5 beats per minute for 30 seconds with maternal movement.

2. Correct. A non-reactive test is when the FHR accelerates less than 15 beats per minute above baseline. This may indicate fetal compromise.

A 37 week pregnant woman presents to triage with reports of a headache and begins to have a seizure. What actions should the nurse take? Select all that apply 1. Place the client's head in the nurse's lap. 2. Administer oxygen. 3. Monitor tonic-clonic activity. 4. Place an oral airway into the client's mouth. 5. Administer diazepam.

1, 2. & 3. Correct: This client in triage experiencing a seizure should be gently lowered to the floor, with her head protected. Oxygen is needed to ensure supply of oxygen to mom and fetus. Seizure activity should be monitored for tonic and clonic phases of seizure, timing, and body part affected. seizures.

The nurse is having an education class for pregnant women. A question is raised about exercise. What is the nurse's best response? 1. Discuss with healthcare provider your current exercise regimen and history. 2. You can continue any exercise that you have been doing before pregnancy. 3. If you haven't already started an exercise program, you should wait until after delivery. 4. Exercise is required during pregnancy for a minimum of 15 minutes each day.

1. Correct: Best advice for pregnant women. The healthcare provider can individualize according to the physical condition of the woman and the stage of pregnancy.

How should the nurse respond to a pregnant client who asks, "How will I know when it is time to go to the hospital?" 1. "Go to the hospital immediately if your membranes rupture." 2. "You should leave for the hospital as soon as you lose your mucus plug." 3. "Go to the hospital when you have a burst of energy followed by a backache." 4. "You need to go to the hospital when contractions are 2 minutes apart."

1. Correct: Yes! This is the appropriate teaching. A gush or trickle of fluid from the vagina should be evaluated regardless of whether contractions are occurring. Infection and compression of the umbilical cord are possible complications.

A full term infant is being assessed 12 hours after birth. The infant's respiratory rate is 50 and shallow, with periods of apnea. What action by the nurse takes priority? 1. Apply oxygen by mask at 1 liter. 2. Prepare for emergency intubation. 3. Continue monitoring every 15 minutes. 4. Notify the primary healthcare provider stat.

3. Correct: Normal respirations in the healthy neonate are generally shallow and expected to be between 30 and 50 times per minute with short periods of apnea up to 5 seconds. This infant is displaying a normal respiratory status for the newborn. The nurse should continue to monitor the infant.

What term should the nurse use to document that a woman is pregnant for the first time? 1. Primigravida 2. Multigravida 3. Primipara 4. Multipara

1. Correct: A woman pregnant for the first time. The prefix "primi" means first. "Gravida" refers to a woman who is or has been pregnant, regardless of the duration or outcome of the pregnancy.

Which postpartum client should the nurse assign to a private room? 1. Has antibodies for Hepatitis C. 2. Is rubella non-immune. 3. Is rubella immune. 4. Has lupus antibodies.

1. Correct: This client should be in a private room for her protection and the protection of other postpartum women. The presence of antibodies for Hepatitis C indicates HCV infection and possibly impaired immune function due to liver damage. In addition, Hepatitis C is transmitted by contact with body fluids and it is likely that lochia will be found on toilet surfaces. It is also common for postpartum women to have some kind of wound (perineal laceration or episiotomy) and they will be at increased risk of HCV contaminated lochia coming into contact with their wound.

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should be assigned to the medical surgical nurse? 1. Total abdominal hysterectomy (TAH). 2. Client post C-section to be discharged home. 3. Breast Reduction. 4. Vaginal delivery of fetal demise. 5. 28 week gestation of bed rest. 6. Bladder suspension with anterior and posterior repair.

1., 3. and 6. Correct: When a nurse is pulled to another unit, always assign them like a brand new nurse. A client with a TAH, Breast reduction or bladder suspension require basic post-operative care. These are within the scope of knowledge of a brand new nurse with medical-surgical knowledge.

A nurse is caring for a multipara client in active labor who received morphine 4 mg IVP for pain. Thirty minutes later, the client had a precipitous delivery. What should the nurse prepare to administer to the newborn? 1. Oxygen 2. Naloxone 3. Glucose 4. Vitamin K

2. Correct: The primary side effect of opioids is respiratory depression, which is more likely to affect the newborn. Naloxone reverses opioid-induced respiratory depression. This newborn will need naloxone to reverse the effects of the narcotic that was given to mom 30 minutes earlier.

A pregnant client's initial blood work shows a negative rubella titer. The nurse is aware this result indicates what important course of action? 1. Client needs to be isolated until delivery. 2. Client is immune to rubella currently. 3. Client should be given rubella vaccine after delivery. 4. Client has never been exposed to rubella.

3. CORRECT: A negative titer indicates the client has no rubella antibodies present currently. But because the rubella vaccine contains a live virus, the client cannot be safely vaccinated until after delivery.

A client has just found out that she is pregnant and asks the nurse, "When is my baby due?" The client's last menstrual period began March 3. What date will the nurse calculate as the expected date of confinement? 1. December 3 2. December 7 3. December 10 4. December 13

3. Correct: The most common method of determining the expected date of confinement is by Nagele's rule. To use this method begin with the first day of the last menstrual period, add seven days, subtract 3 months and add one year. So the expected date of confinement for this client would be December 10.

The nurse is instructing expectant first-time mothers about the process of rooming-in while at the hospital. After discussing security protocols, one client asks the nurse what to do if no staff is available when toileting or showering assistance is needed. The nurse knows teaching was successful when another client responds with what statement? 1. "Only hand the baby to individuals wearing proper hospital I.D." 2. "Ask family member to watch infant while you're in the bathroom." 3. "Showering is not necessary since discharge is within 24 hours." 4. "Push baby in bassinet with you into bathroom if no one available."

4. CORRECT. There are many safety and security measures implemented to diminish the potential for newborn abductions. At no time should a newborn ever be left alone, even in the mother's room. In the unlikely event no authorized staff can assist the client in the bathroom, the newborn should be wheeled by the mother into the bathroom and kept in view at all times.

The nurse is working in the term nursery. Which task should be performed first on a newborn? 1. Prepare the circumcision equipment for a two day old newborn. 2. Assess the five minute APGAR of a newborn. 3. Perform the gestational age assessment on a 30 minute old newborn. 4. Obtain a blood sample for metabolic testing on a 24 hour old newborn

2. Correct: The APGAR is done to determine whether a newborn needs help breathing or is having heart trouble. It looks at the newborn's breathing effort, HR, muscle tone, reflexes, and skin color and is the most important initial assessment for a newborn

A nurse has provided postpartum discharge instructions to a client who had a cesarean section. What statement by the client would indicate to the nurse that further teaching is necessary? 1. "I will relax and contract my pelvic floor muscles 10 times, eight times a day." 2. "Driving is permitted in one week if I am pain free." 3. "Lifting anything heavier than my baby is not advised." 4. "I will not cross my legs while sitting."

2. Correct: This is an incorrect statement. C-sections require a much longer recovery. The client will not have the abdominal muscles to press down on the brake pedal in an emergency. Therefore, new moms who had C-sections should wait until after the three week postpartum appointment to drive.

A client has delivered a set of premature twins. The neonatal intensive care unit (NICU) notifies the charge nurse on the postpartum floor the death of one infant is expected within the hour. What is the priority action by the charge nurse? 1. Sit quietly with client and allow expression of feelings. 2. Instruct UAP to take mother to the NICU immediately. 3. Request hospital clergy to visit the mother right away. 4. Notify father of the baby about the current situation.

2. Correct: The priority action is to allow the mother to be with the infant and perhaps to hold the infant prior to demise to help in the grieving process. Escorting the mother immediately to the NICU can be accomplished by the UAP while the charge nurse initiates other actions needed by this client.

Which lab value on a client who is one day postpartum should the nurse report to the primary healthcare provider immediately? 1. Hemoglobin of 11 g/dL (110 g/L) (6.8266 mmol/L) 2. White Blood Cell count of 22,000 mm3 3. Hematocrit of 18% 4. Serum glucose of 80 mg/dL (4.44 mmol/L)

3. Correct: A hematocrit in postpartum women can drop as low as 20% (0.2) and not require transfusion in the absence of symptoms of hypovolemia. A hematocrit of 18% and lower should be reported even in the absence of dizziness, lightheadedness, shortness of breath with exertion, and syncope.

Post epidural anesthesia, a laboring client's blood pressure drops to 92/42. Which intervention by the nurse takes priority? 1. Elevate the head of the bed 2. Administer oxygen by face mask 3. Position client side-lying 4. Begin dopamine 5 mcg/kg/min

3. Correct: When you turn them on their side, this relieves pressure on the vena cava and the BP will go UP.

Which client should the nurse assign to a room closest to the nurse's station? 1. A multigravida admitted with a new diagnosis of gestational diabetes 2. A primigravida admitted with a diagnosis of placenta previa 3. A primigravida admitted with a diagnosis of complete abortion 4. A pregestational diabetic admitted for glycemic control

2. Correct: A client with a diagnosis of placenta previa is at high risk for bleeding and must be monitored closely. Placenta previa is a complication of pregnancy in which the placenta is either partially or wholly inserted in the lower uterine wall and blocks the cervix. It is the leading cause of antepartum hemorrhage. Clients with this complication will have to have a C-section to prevent harm to the mother and fetus from bleeding.

The nurse is assessing a newborn to determine gestational age. What findings by the nurse would indicate the infant is premature? Select all that apply 1. Folded ear pinna springs back slowly. 2. Peripheral cyanosis on feet and hands. 3. Shoulders and chest have moderate lanugo. 4. Vernix covering axilla, back and buttocks. 5. Feet soles entirely covered with creases.

1, 3. & 4. Correct: The nurse is assessing a neonate for indications of premature gestational age. In a full term infant, the ear pinna would spring back firmly and quickly, so a slow response indicates probable prematurity. Lanugo is also an indicator of gestational age. Lanugo that covers all the shoulders and chest indicate prematurity. Vernix is the waxy, cheesy coating that is noted on the neonate after birth. A large amount of vernix, in this case covering axilla, back and the buttocks, denotes prematurity.

A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider? 1. Puffy hands and face 2. Reports indigestion 3. Pedal edema 4. Trace proteinurea

1. Correct: Facial and upper extremity edema can be a sign of pre-eclampsia, which can endanger both the mother and fetus. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in a woman whose blood pressure had been normal. Even a slight rise in blood pressure may be a sign of preeclampsia. Left untreated, preeclampsia can lead to serious, even fatal, complications. Signs and symptoms of preeclampsia include hypertension and may include: Proteinuria; Severe headaches; Changes in vision; Upper abdominal pain; Nausea or vomiting; Decreased urine output; Thrombocytopenia; Impaired liver function; Shortness of breath; Sudden weight gain, and edema, particularly in face and hands.

A client comes to an obstetric clinic for a routine prenatal checkup at 32 weeks gestation. The nurse palpates the client's abdomen to determine fetal position so that fetal heart sounds can be assessed. It is determined that the fetal position is left occipital anterior (LOA). Where should the nurse place the Doppler to hear fetal heart sounds? 1. Below the umbilicus, on the mother's left side. 2. Below the umbilicus, on the mother's right side. 3. Above the umbilicus, on the mother's right side. 4. Above the umbilicus, on the mother's left side.

1. Correct: The point of maximal intensity of the fetus is on the mom's abdomen where the fetal heart tones (FHT) is the loudest, usually over the fetal back. Divide the mom's pelvis into 4 quadrants (right and left anterior and right and left posterior). The occiput of the head is the most common presenting part and is abbreviated O. The occiput and back are pressing against left side of mom's abdomen; FHT would be heard below umbilicus on left side.

All of the beds in a 10 bed Labor, Delivery, Recovery, Postpartum Unit (LDRP) are full when one of the nurses assigned that day calls in sick. A nurse from the Med surg unit is transferred to the LDRP unit. Which client should the charge nurse assign to this nurse? 1. Client at 32 weeks gestation on oral terbutaline with 4 contractions/hour. 2. One hour postpartum client with a continuous trickle of vaginal bleeding. 3. 2 hours postpartum client reporting intense perineal pain. 4. Client at 36 weeks gestation with a blood pressure of 148/92.

1. Correct: This client is at lowest risk for complications. She is having infrequent contractions and is not at high risk for preterm delivery. She is also receiving an oral tocolytic, terbutaline. Tocolytic agents are used to inhibit uterine contractions and suppress preterm labor. The medical surgical nurse should be able to safely provide care for this client.

A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration occurs? Select all that apply 1. Turn the client to the left side. 2. Administer oxygen. 3. Start an intravenous line. 4. Prep the mother for cesarian section. 5. Notify the primary healthcare provider.

1., 2. & 5. Correct: Late fetal heart rate decelerations are associated with fetal hypoxia and acidosis. Positioning the mother on her left side prevents compression of the vena cava. Oxygen administration increases maternal, then fetal blood level, thus treating current and preventing further development of hypoxia and acidosis. Failure to recognize fetal monitoring strip abnormalities and failure to report abnormalities to the primary healthcare provider are deviations from the standard of care.

Which manifestations, if noted in a pregnant client, would the nurse need to report to the primary healthcare provider? Select all that apply 1. Calf muscle irritability 2. Facial edema 3. Pressure on the bladder 4. Blurry vision 5. Hemoglobin of 11 mg/dL 6. Epigastric pain

1., 2., 4., & 6. Correct: These are danger signs/symptoms of pregnancy and need further investigation by the primary HCP. These signs could indicate preeclampsia, fluid and electrolyte disturbances, and other high risk complications during pregnancy

The nurse is teaching comfort measures to a postpartum client with an episiotomy and external hemorrhoids. Which teaching points should the nurse include? Select all that apply 1. Apply ice to perineum for first 12 hours. 2. Take sitz baths at temperature of 107.6°-111.2°F (42-44°C). 3. Use witch hazel compresses on rectal areas for hemorrhoids. 4. Take ibuprofen for pain. 5. Apply topical anesthetics to perineal area. 6. Avoid sexual intercourse until episiotomy has healed.

1., 3., 4., 5., & 6. Correct: Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Chemical ice packs or clean gloves filled with ice may be used during the first 12 hours after a vaginal birth. Witch hazel contains chemicals called tannins. When applied directly to the skin, witch hazel might help reduce swelling and help repair broken skin. Analgesics such as acetaminophen and nonsteroidal anti inflammatory drugs (NSAIDs) such as ibuprofen frequently are prescribed to provide relief for mild to moderate discomfort. Topical anesthetic may be used as needed to decrease surface discomfort and allow more comfortable ambulation. Sexual intercourse prior to healing of the episiotomy may contribute to further perineal damage.

When assessing a newborn following a breech delivery, what physical findings should the nurse report to the primary healthcare provider as positive indications of congenital hip dysplasia (CHD)? Select all that apply 1. Symmetrical gluteal folds. 2. Limited abduction of one leg. 3. Pain with the Barlow maneuver. 4. Presence of an Ortolani click. 5. Confirmed stepping reflex.

2 & 4. Correct: When assessing a newborn, the nurse must determine which findings are normally expected at birth versus abnormal findings that should be reported to the primary healthcare provider. Two expected findings suggestive of congenital hip dysplasia (CHD) include limited abduction of one leg and the presence of an Ortolani click when the affected hip is placed into the "frog-leg" position.

A primigravida client at 35 weeks gestation has been diagnosed with human papillomavirus (HPV). The nurse knows that the most important information to discuss with this client is what? 1. The infant will not be able to breast feed. 2. The mother will need frequent follow up Pap smears. 3. The fetus will need to be delivered by C-section. 4. The mother must start metronidazole immediately.

2. Correct: HPV is a sexually transmitted viral infection that can cause genital warts or even precancerous lesions. This virus is spread by direct contact with infected mucous membranes and is transmitted through sexual contact. Although HPV generally clears itself through the human immune system, clients diagnosed with this infection are recommended to have a follow-up Pap smear every six months for the first year, particularly if infected with HPV 16 or HPV 18.

A client at 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has priority? 1. Administer an antacid per standing orders. 2. Check client's blood pressure. 3. Call the primary healthcare provider immediately. 4. Assure client this is a normal discomfort of pregnancy.

3. Correct: Epigastric discomfort is commonly described as "heartburn" by pregnant clients, but epigastric discomfort is a symptom of impending rupture of the liver capsule and seizures associated with worsening PIH and eclampsia. As a new nurse we need to assume the worst. Call the primary healthcare provider.

A client's membranes spontaneously rupture at 10 cm dilation and +2 station. The nurse notes that the fluid is colored green. What client preparation is the priority nursing action? 1. Emergency cesarean delivery 2. Immediate high forceps delivery 3. Equipment for immediate suctioning of the newborn 4. Administration of IV oxytocin

3. Correct: Green stained fluid indicates fetal passage of meconium. The fetus must be suctioned by the healthcare provider when the head is still on the perineum and before the baby takes its first breath. This will remove any particulate matter from the meconium that may cause aspiration.

A client in active labor has an epidural catheter inserted for management of pain. Which finding should the nurse report to the primary health care provider? 1. Early decelerations 2. Fetal heart rate (FHR) 160/min 3. Blood pressure 90/62 4. Temperature of 99.6° F (37.5° C).

3. Correct: Hypotension is an adverse effect of epidural analgesia due to vasodilation. Maternal hypotension reduces blood supply to the placenta, decreasing fetal oxygen supply. Immediate intervention is required.

he nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely? 1. Hypocalcemia 2. Hypomagnesemia 3. Hyponatremia 4. Hypokalemia

4. Correct: Hyperemesis gravidarum is characterized by persistent severe pregnancy related nausea and vomiting. There is a large amount of potassium in the upper GI tract. A client with prolonged vomiting will lose potassium in the emesis. Additionally, the client is unable to replace the lost potassium due to the persistent nausea and vomiting.

A postpartum client who is 2 hours post vaginal delivery remains on a oxytocin infusion for bleeding. Upon examination, the nurse determines that the client's fundus is boggy and soft. What is the priority nursing intervention? 1. Ambulate in the room 2. Perform crede' exercises 3. Reassess the fundus in 30 minutes. 4. Massage the fundus.

4. Correct: If the fundus is boggy and soft, massaging the fundus until firm will increase uterine tone and decrease bleeding. This is the only option that will fix the problem.

A mother of a newborn is crying and tells the nurse, "I am worried about my baby. His Apgar score was 6 and the nurses had to help him breath for a while." What response should the nurse make to this mother? 1. "Don't worry about what score your baby received on the Apgar. The nurses know how to take care of him." 2. "Stop crying. Your baby is fine now and will continue to get stronger as the day progresses." 3. "Your baby's Apgar score was normal. The score was 6 at 1 minute which is typical." 4. "It is normal for you to feel this way. Let me explain what the Apgar score is used for."

4. Correct: This statement recognizes the mother's feelings and seeks to educate. Providing relevant information may decrease her anxiety and encourage further communication.