NCLEX REVIEW- Maternity
The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?
"Circumcision has been delayed to save tissue for surgical repair."
A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be appropriate?
"Do you plan to have any other children?"
The nurse attempts to encourage a new mother to understand and to accept the cesarean section that was necessary to deliver her baby, rather than to focus on the surgical aspect of the procedure. Which nursing statement would provide the best encouragement?
"Tell me about the delivery of your baby."
A pregnant client who has gestational diabetes mellitus tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response would best support the client?
"The better control of your blood glucose means less effects; let's review your plan of care."
The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse instructs the mother to increase her daily caloric intake by which amount?
500 calories per day
A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior the nurse should suspect the client is how far dilated?
8 to 10 cm
The nurse is assigned to care for a primigravida who is having a precipitate delivery. Which maternal finding does the nurse expect to note?
Decreased periods of uterine relaxation between contractions
The nurse is caring for the nullipara woman in labor. The nurse understands that the health care provider must be contacted if which condition becomes apparent?
Decreased periods of uterine relaxation between contractions
A primigravida's membranes rupture spontaneously. Which action should the nurse take first?
Determine the fetal heart rate.
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?
Encourage oral fluid intake.
In the prenatal clinic, the nurse is gathering data from a new client for the health history information. Which action is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?
Establish a therapeutic relationship between the nurse and pregnant client.
Which safety measures that should be implemented when working in the newborn nursery? Select all that apply.
Adhere to standard precautions. The parents should be instructed to not release their infant to anyone wearing improper identification. 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 assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action?
Ambulate frequently.
The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.
Ballottement Chadwick's sign Uterine enlargement Braxton Hicks contractions
The nurse is assisting in caring for a client who has a placenta previa. The nurse understands that a cervical examination should not be performed on the client primarily because it could do which?
Cause hemorrhage.
A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint which should the nurse do first?
Check for signs of thrombophlebitis.
A pregnant client is positive for the human immunodeficiency virus (HIV). Based on this information, the nurse makes which determination?
HIV antibodies are detected on the enzyme-linked immunosorbent assay (ELISA) test.
A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client's health record, the nurse notes that the laboratory values indicate low hemoglobin and hematocrit levels. Which problem does the data best support?
High risk for infection
The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action?
Keep the client in a side-lying position.
A prenatal client has acquired the sexually transmitted infection, condyloma acuminatum (human papillomavirus). When assisting in planning care, which treatment should the nurse consider to be safe for this client?
Laser therapy
The nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at minus one station. The nurse determines that the fetal presenting part is in which position?
1 cm above the ischial spines
A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks?
12 to 16
The nurse is reinforcing instructions to a new breast-feeding mother. Which factor is important to promote an effective and positive learning experience?
A positive nurse-client relationship
The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which findings would place the client at risk for preterm labor?
A urinary tract infection
A pregnant client has just been admitted to the hospital with severe preeclampsia. The nurse knows it is important to monitor for additional complications at this time. Which assessment would be part of the plan of care?
Any bleeding, such as in the gums, petechiae, and purpura
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which additional sign would be consistent with fetal alcohol syndrome (FAS)?
Microcephaly and increased respiratory effort
The nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?
Notify the registered nurse.
The nurse is caring for a client who is in labor. The nurse rechecks the client's 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?
Side-lying
The nurse is collecting data from a client with placenta previa during an office visit. The nurse should check which item as first priority?
Signs of fetal distress
The nurse is providing emotional support to a client who experienced a spontaneous abortion. The nurse can best assist the client by planning care that focuses on which psychosocial issue?
The feelings of guilt that is often associated with grief
A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs what?
To regain her breathing pattern
A client in the prenatal clinic presents with a blood pressure reading of 134/90 mm Hg, which is an elevation from last month's reading of 104/66 mm Hg. Which additional sign or symptom suggests to the nurse that the client has mild preeclampsia?
Trace amount of protein
A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week? Fill in the blank.
week 5
A pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. Which nursing response would best support the client?
"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."
During a routine prenatal visit, a client complains of gingivitis and gums that bleed easily with brushing. When assisting to plan the care for the client, the nurse includes a goal that addresses proper nutrition to minimize this problem. The nurse determines that the goal has been achieved when the client makes which statement?
"I am eating fresh fruits and vegetables for snacks and for dessert each day."
The nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client should alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy?
"I need to gain only 10 pounds so that my baby will be small like I am."
The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?
"I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."
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."
A perinatal client with a history of heart disease has been instructed on care at home. Which statement made by the client would indicate the need for further teaching?
"It is best to rest on my right side."
The nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the student about the function of progesterone. Which response made by the student indicates an understanding of the function of this hormone?
"It maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus."
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."
A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response would best support the client?
"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."
A client is 8 weeks pregnant and has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, and she is reluctant to attend because of the nausea and vomiting. This has placed a strain on the husband-wife relationship. Which statement by the nurse indicates an understanding of the problem?
"You feel you are having difficulty fulfilling your role as a wife."
The nurse is collecting data from a prenatal client. The nurse determines that which places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?
A history of intravenous (IV) drug use in the past year
The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated?
A manual pelvic examination
The nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. Which finding should the nurse expect to note in a healthy breast-feeding mother and newborn?
A mother breast-feeding with the newborn in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow
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 health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which?
A softening of the cervix
The goal for the postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should perform which action?
Administer anticoagulants as prescribed.
The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip?
Maternal vital signs
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.
During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. Which is the primary purpose of this action?
Assist in preventing dehydration and hypoxemia.
A perinatal client is at risk for toxoplasmosis. Which instruction should the nurse reinforce with the client to prevent exposure to this disease?
Avoid exposure to litter boxes used by cats.
The nurse is caring for a client in labor. The nurse reviews the health care provider's prescriptions and notes that the client has a prescription for butorphanol tartrate. The nurse understands that the action of this medication is to have which effect?
Decrease pain.
The nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action is appropriate?
Encourage oral fluids.
The nursing student is preparing to instill a medication into the eyes of a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication for the prophylaxis of ophthalmia neonatorum and gonococcal infection. The student correctly identifies which medication?
Erythromycin
The nurse caring for a client who is receiving oxytocin (Pitocin) for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding which is the nurse's priority action?
Stop the oxytocin infusion.
The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse should tell the client that these exercises are for which purpose?
Strengthen the pelvic floor in preparation for delivery.
The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time?
Fear about what is happening
The nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted?
Fetal tachycardia
The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?
Have the client empty her bladder.
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?
Have the mother place the infant in the bassinet and assist the mother in dressing the baby.
The nurse-midwife is conducting a session on the process of fertilization with a group of nursing students. The nurse-midwife asks a student to identify the structure where fertilization of an ovum takes place. Which identified by the student indicates an understanding of this process?
In the fallopian tube
The nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which action is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia?
Increase the frequency of breast-feeding.
A pregnant woman reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following an assessment, tuberculosis is suspected. A sputum culture is obtained and identifies the Mycobacterium tuberculosis in the sputum. The nurse reinforces instructions to the client regarding therapeutic management of tuberculosis. Which statement is included in therapeutic management?
Isoniazid (INH) plus rifampin (Rifadin) will be required for a total of 9 months.
The nurse is reinforcing teaching to 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 purpose of estrogen?
It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.
A pregnant client in the prenatal clinic states that her last menstrual period (LMP) began April 5 and ended April 12. According to Nägele's rule, which would be the estimated date of delivery (EDD)?
January 12
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, 2016. Using Nägele's rule, the nurse determines the estimated date of birth is which?
July 27, 2017
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
A woman with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?
Macrosomia
The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin (Pitocin). The nurse should include which in the plan of care?
Maintain continuous electronic fetal monitoring.
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?
Maintaining standard precautions at all times while caring for the neonate
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?
Massage the breasts before feeding to stimulate let-down.
The nurse is assisting in conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by taking which action?
Massaging the abdomen during contractions using both hands in a circular motion
The maternity nurse prepares the client for which techniques commonly used to relieve shoulder dystocia?
McRoberts' maneuver
The nurse is assigned to care for a client admitted with severe preeclampsia. Which is the priority nursing intervention for this client?
Minimizing the client's exposure to external stimuli
The nurse is reviewing the record of a client in the labor room. The nurse midwife noted the following documentation. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?
Minus (-) 1 station
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.
A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse should monitor this client for which symptom of this complication?
Oozing from injection sites
The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. The nurse collects data, knowing that in this condition, the viscera are in which location?
Outside of the abdominal cavity but covered with a translucent sac
A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that the primary hormone that stimulates postpartum contractions is which?
Oxytocin
The nurse is reinforcing instructions to a pregnant client regarding measures that will strengthen the perineal floor muscles. Which should the nurse include in the instructions?
Perform Kegel exercises in 10 repetitions, three times per day.
The nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should take which action?
Place the client in a supine position and place a wedge under the right hip.
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 which condition?
Placental separation
A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching?
The client is wearing knee-high hose.
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?
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.
A client has just experienced a precipitate delivery. The nurse observes that the mother is lying quietly in bed and touches the infant only briefly and occasionally. How should the nurse be most therapeutic in this situation?
Provide support to the mother.
Immediately following the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. Which action is appropriate to deliver the placenta?
Pull gently on the cord as the mother bears down.
A client who consumes alcohol frequently is in the first trimester of pregnancy. Which is the expected outcome when the nurse initiates interventions to assist the client to cease alcohol consumption?
Reducing the risk of teratogenic effects to developing fetal organs, tissues, and structures
The nurse observes the client following delivery for normal maternal physiological changes that are anticipated. The nurse should document which expected changes?
Slowed pulse rate and elevated blood pressure
After a precipitate delivery, the nurse notes that a new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which action first to help the woman process what has happened?
Support the mother no matter what her reaction is to the newborn.
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.
Which should be included in the plan of care for a pregnant teenager to reinforce instructions regarding dental care?
Tell the dental office staff that she is pregnant.
The nurse is providing education to the client with gestational diabetes who was recently placed on insulin therapy. Which information should the nurse tell the client about insulin needs during the second and third trimesters of pregnancy?
The insulin needs will increase.
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.
The nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented finding is unassociated with this disorder?
The passage of bloody mucous stool
In caring for a preterm newborn's skin, which special characteristics should the nurse expect to note?
Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture
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.
Urinary tract infections Increased chance of cesarean birth Delayed lung maturation in the neonate
The nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body area, knowing that venous congestion is commonly noted in which area?
Vulva
The nurse is preparing a client for an emergency cesarean delivery. Which information regarding the client has priority?
When was the last time the client ate or drank?