NCLEX Maternity Nursing

A 31 week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the clients labor can be inhibited for the next 48 hours, what medication does the nurse anticipate will be prescribed:

Betamethasone

The nurse is caring for a post term neonate immediately after admission to the nursery. The priority nursing action would be to monitor:

Blood Glucose Levels.

Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine the priority nursing action is to check the:

Blood Pressure.

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which of the following would indicate an abnormal physical finding that necessitates further testing:

Fetal heart rate of 180 beats per minute.

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn infant. The nurse is monitoring for signs of placental separation, knowing that which of the following indicates that the placenta has separated:

A change in the uterine contour.

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The students responds correctly by stating that which of the following are functions of amniotic fluid:

-Allows for fetal movement -Is a measure of kidney functions -Surrounds, cushions, and protects the fetus. -Maintains the body temperature of the fetus.

The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. What are the probable signs of pregnancy that the nurse should recognize:

-Ballottement -Chadwicks sign -Uterine enlargement -Braxton Hicks Contractions.

The nurse is collecting data from a client who has been diagnosed with placenta previa. Choose the findings that the nurse would expect to note:

-Bright red vaginal bleeding. -Soft, relaxed, non-tender uterus

A nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse monitors for which adverse effects of this medication:

-Flushing -Depressed respirations -Extreme muscle weakness

The nurse is preparing to care for a newborn who is receiving phototherapy. Choose the measures that would be implemented:

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

A nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. The nurse checks for causes of the seizure activity by:

-Obtaining a history regarding factors that may occur before the seizure activity.

The nurse is monitoring a pregnant client with gestational hypertension who at risk for preeclampsia. The nurse checks the client for which classic signs of preeclampsia:

-Proteinuria -Hypertension -Generalized edema

A nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure:

-Time the seizure -Stay with the child -Move furniture away from the child

The nurse is preparing a list of self care instructions for a postpartum client who has been diagnosed with mastitis. Choose the instructions that would be included on the list.

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

A

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During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which of the following heart rate is noted:

150 Beats per minute

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between:

16 and 20 weeks gestation.

The nurse is collecting data from a pregnant client who is at 28 weeks gestation. The nurse measures the fundal height in centimeters and expects the finding to be which of the following:

28 cm

The perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse would consult with the dietitian to ensure which of the following:

A diet that is high in fluids and fiber to decrease constipation.

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client knowing that a routine labor procedure that is contraindicated with this client's situation is:

A manual pelvic examination.

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for infection. The nurse tells the mother that which of the following is a sign of infection:

A moist cord with discharge.

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the physician has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of:

A softening of the cervix.

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 of the following additional signs would be consistent with FAS:

Abnormal palmar creases

The nurse suspects that the client has a pulmonary embolism. The most important nursing action is to:

Administer oxygen by face mask, as prescribed.

The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse encourages the woman to take which priority action:

Ambulate Frequently

RHO (D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a newborn infant, and the nurse provides information to the woman about the purpose of the medication. the nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following:

Being affected by Rh incompatibility.

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. The nurse responds to the client, knowing that the fallopian tubes:

Are where fertilization occurs.

After delivery, the nurse checks the height of the uterine fundus. The nurse expects that the position of the fundus would most likely be noted:

At the level of the umbilicus.

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, it is MOST important for the nurse to first determine which of the following:

Baseline Fetal Heart Rate.

The nurse is reinforcing measures regarding the care of the newborn with a mother. To Bathe the newborn should be taught to:

Begin with the face and eyes

A mother arrives at the emergency department with her 5 year old child and states that the child fell off the bunk bed. A head injury is suspected and a nurse is monitoring the child continuously for signs of increased intracranial pressure (ICP) Which of the following is a LATE sign of increased ICP in this child:

Bradycardia

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help make decisions regarding newborn care. The nurse determines that additional guidance is needed if the woman states that she will:

Breast-feed, especially for the first 6 weeks postpartum.

The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then:

Checks the vital signs.

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. if the client progresses from preeclampsia to eclampsia, the nurse's first action should be to:

Clear and maintain an open airway.

Which of the following laboratory results would verify the diagnosis of bacterial meningitis:

Cloudy cerebrospinal fluid with high protein and low glucose levels.

While assisting with the measurement of fundal height, the client at 36 weeks gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy. the nurse determines that this is most likely a result of:

Compression of the Vena Cava.

The nurse in the newborn nursery receives a telephone call to prepare for admission of an infant born at 43 weeks gestation with Apgar scores 1 and 4. When planning for admission of this infant, the nurse's highest priority should be to:

Connect the resuscitation bag to the oxygen outlet.

A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the students states that it:

Connects the umbilical vein to the inferior vena cava.

Primigravida's membranes rupture spontaneously. The nurse first action is to:

Determine the fetal heart rate.

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. On admission, the nurse would initially:

Determine the maternal and fetal vital signs

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the clients partner and tells the partner to:

Dorsiflex the clients foot while extending the knee.

The nurse is providing instructions to a pregnant client with heartburn regarding measures that will alleviate the discomfort. The nurse instructs the client to:

Drink decaffeinated coffee and tea.

After birth, the nurse prevents hypothermia as a result of evaporation in the newborn by:

Drying the baby with a warm Blanket.

A nursing student is assigned to care for an adolescent female client in the health care clinic and the instructor reviews the menstrual cycle with the student. The instructor determines that the student understands the process of the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) if the student states:

FSH and LH are released from the anterior pituitary gland.

The nurse is collecting data during the 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 she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as:

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

The nurse is collecting data during the admissions assessment of a client who is pregnant with triplets. The client also has a 3 year old child who was born at 19 weeks gestation. The nurse would document which gravida and para status on this client:

Gravida II, Para I

A postpartum client is getting ready for discharge. The nurse suspects that the client is in need of further teaching related to breast feeding, when she states:

I don't need birth control since I will be breast feeding.

During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client states:

I need to increase the fiber in my diet to control my blood glucose and prevent constipation.

A nursing instructor asks a nursing student to describe the procedure for administering erythromy ointment to the eyes of the neonate. The instructor determines that the student needs to research this procedure further if the students states:

I will flush the eyes after instilling the ointment.

A nurse reinforces instructions to the mother of a child who has been hospitalized with the croup. Which of the following statements if made by the mother would indicate the need for further instruction:

I will give my child cough syrup if a cough develops.

The client at 28 weeks gestation is Rh negative and coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client states:

I will tell the nurse at the hospital that I had RhoGAM during pregnancy.

Leopold's maneuvers will be preformed on a pregnant client. The client asks the nurse about the procedure. The nurse responds, knowing that this procedure:

Is a systematic method for palpating the fetus through the maternal abdominal wall.

A child has been diagnosed with meningococcal meningitis. Which of the following isolation techniques is appropriate:

Isolation precautions for at least 24 hours after the initiation of antibiotics.

The nursing instructor asks a nursing student to describe the process of quickening. Which of the following statements, if made by the student indicates and understanding of this term:

It is the fetal movement that is felt by the mother.

The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which of the following purposes of estrogen:

It stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation.

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20, 2012. Using Nagele's rule, the Nurse determines the estimated date of birth to be:

July 27, 2013

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 would:

Keep the client and her family members informed of her progress.

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9cm dilated and is experiencing precipitous labor. A priority nursing action is to:

Keep the client in a side lying position.

Which of the following represents a primary characteristic of autism:

Lack of social interaction and awareness

The nurse is caring for a client who is in labor. The nurse rechecks the clients blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position:

Left Lateral

The client is in her second trimester of pregnancy. she complains of frequent low back pain and ankle edema at the end of the day. The nurse recommends which measure to help relieve both discomforts:

Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

The nurse is assigned to assist with caring for a neonate born to a mother with acquired immunodeficiency syndrome (AIDS). The nurse understands that which of the following should be included in the plan of care:

Maintain standard precautions at all times while caring for the neonate.

A mother is breast-feeding her newborn baby and experiences breast engorgement. The nurse encourages the mother to do which of the following to provide relief of the engorgement:

Massage the breasts before feeding to stimulate let-down.

The client at 38 weeks of gestation is admitted to the birthing center in early labor. The client is carrying twins, and one of the fetuses is in a breech presentation. The nurse assists with planning care for the client and identifies which of the following as the lowest priority for the care of this client:

Measuring the fundal height.

Epidural analgesia is administered to a woman for pain relief after a Cesarean birth. The nurse is assigned to care for the woman ensures that which medication is readily available if respiratory depression occurs:

Naloxone (Narcan)

A client asks the nurse why her newborn baby needs an injection of vitamin K. The nurse makes which statement to the client:

Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding.

A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings, the priority nursing intervention is to:

Notify the Registered Nurse (RN) immediately.

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's tempature is 102F (38.9C). The appropriate nursing action would be to:

Notify the registered nurse, who will then contact the health care provider (HCP).

A nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infants level of consciousness diminishes, a priority intervention is:

Palpating the anterior fontanel

Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, a nurse contacts the health care provider who prescribed the medication if which of the following conditions is documented in the clients medical history:

Peripheral vascular disease

A child has been diagnosed with Reyes syndrome. The nurse understands that a major symptom associated with reyes syndrome is:

Persistent vomiting

The nurse caring for a client with abruption placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse would suspect DIC if he or she observes:

Petechiae, oozing from injection sites, and hematuria.

After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of:

Placental separation

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling the nurse should:

Prepare an ice pack for application to the area.

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 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 valvar hematoma. On the basis of this diagnosis, the nurse would plan to:

Prepare the client for surgery.

The nurse administers erythromycin ointment (0.5%) to the newborns eyes. and the mother asks the nurse why this is done. The nurse tells the client that this is routinely done to:

Prevent ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection.

The client asks the nurse about the purpose if placenta. The nurse plans to respond to the client, knowing that the placenta:

Provides an exchange of nutrients and waste products between the mother and the fetus.

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. The nurse expects the lochia to be:

Red

A neonate has just been circumcised. The nurse would expect the surgical site to appear:

Reddened, with a small amount of bloody drainage.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that the client is experiencing toxicity from the medication of which of the following is noted on data collection:

Respirations of 10 breaths per minute.

A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium sulfate therapy is effective if:

Seizures do not occur.

The appropriate child position after a tonsillectomy is which of the following position:

Side lying position

A child has a basilar skull fracture. Which of the following health care providers prescriptions should the nurse question:

Suction via the nasotracheal route as needed.

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse places the client in the:

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. The nurse would do which of the following to help the woman process what has happened?

Support the mother in her reaction to the newborn infant.

Which data collection finding would indicate the possibility of sexual abuse of a child:

Swelling of the genitals

Preterm newborns are at risk for developing respiratory distress syndrome (RDS) The nurse monitors for the clinical signs associated with RDS, knowing that theses signs include:

Tachypnea and Retractions

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding which nursing action is appropriate:

Tell the client that these are common and they may occur throughout the pregnancy.

The client is undergoing an amniocentesis at 16 weeks gestation to detect the presence of biochemical or chromosomal abnormalities. The nurse instructs the client:

That the bladder must be full during the exam.

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. The most accurate description of the test includes which of the following:

The Uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation.

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. The nurse determines that:

The bright red bleeding is abnormal and should be reported.

The nurse is doing a 48 hour postpartum check on a client with mild gestational hypertension (GH). Which of the following data indicate that the GH is not resolving:

The client complains of a headache and blurred vision

The nurse has a teaching session with a malnourished client regarding iron supplementation prevent anemia during pregnancy. Which of the following statements, if made by the client, would indicate successful learning:

The iron is needed for the red blood cells.

The nurse working in a prenatal clinic reviews a client's chart and notes that the health care provider documents that the client has a gynecoid pelvis. The nurse understands that this type of pelvis is:

The most favorable for labor and birth.

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. The nurse responds to the client, knowing that involution is:

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1cm/day

The nurse is planning to teach cord care to a new mother. The nurse plans to tell the mother that:

The process of keeping the cord clean and dry will decrease bacterial growth.

A nursing student is asked to describe the size of the uterus in a non-pregnant client:

The uterus weighs about 2 ounces.

After a tonsillectomy the child begins to vomit bright red blood. The initial nursing action would be to:

Turn the child to the side

The nurse is assisting with caring for a client with abruptio placenta. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse would first:

Turn the client onto her side.

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse tells the client that fetal circulation consists of:

Two umbilical arteries and one umbilical vein.

A nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse discontinues the oxytocin infusion and notifies the registered nurse if which of the following is noted on data collection of the client:

Uterine Hyperstimulations.

The nurse is assigned to assist with caring for a client with abruption placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruption placenta is accompanied by which additional finding:

Uterine tenderness on palpation.

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dysphea. The nurse would initially check the:

Vital Signs.

After a tonsillectomy which of the following fluid or food items would be appropriate to offer to the child:

Yellow jell-O

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which of the following information to the client:

You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed.