NCLEX-Maternity and Newborn: Practice Questions and Answers, Exams of Obstetrics

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NCLEX-maternity and newborn

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. - ANS 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 assessing a newborn to determine gestational age. What findings by the nurse would indicate the infant is premature? Select all that apply
6. Folded ear pinna springs back slowly.
7. Peripheral cyanosis on feet and hands.
8. Shoulders and chest have moderate lanugo.
9. Vernix covering axilla, back and buttocks.
10. Feet soles entirely covered with creases. - ANS 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.

• ANS 2. Correct: If the neonate's toes curl downward when the soles of the feet are stroked, it may be evidence that neurologic damage from asphyxia has occurred. A normal response would be for the toes to curl fan out when the soles of the feet are stroked.
• ANS 1. Incorrect: Naloxone is not indicated here. Naloxone reverses the effects of morphine. There is nothing in the stem indicating that the client received a narcotic.

2. Correct: The side-lying position will relieve pressure from the aorta thus getting more oxygen to the fetus.
3. Correct: Stop the oxytocin infusion. During uterine contraction, blood flow through the uterus slows reducing fetal oxygenation. These intense contractions may be the cause of the late decelerations.
4. Correct: Increasing the IV fluid expands the client's blood volume and improves placental perfusion.
5. Correct: The primary healthcare provider should be notified as continued late decelerations may mean the fetus needs to be delivered immediately via C-section.
6. Correct: Administering oxygen to increase the client's blood oxygen saturation will make more oxygen available to the fetus. The nurse is educating a group of sexually active teenagers about Chlamydia. What should the nurse teach these clients to prevent them from acquiring or transmitting this disease?
7. Use a latex condom when having sex to protect against Chlamydia.
8. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination.
9. Suggest that the teens be screened for Chlamydia.
10. Reassure the teens that if they have no symptoms, they have no disease.
11. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months. - ANS

• ANS 3. Correct: Spermicidal agents have an approximately 25% failure rate in preventing pregnancy. These agents kill sperm by destroying the protective surface of sperm and preventing metabolic activities necessary for survival

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 - ANS 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. 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?
5. "Don't worry about what score your baby received on the Apgar. The nurses know how to take care of him."
6. "Stop crying. Your baby is fine now and will continue to get stronger as the day progresses."
7. "Your baby's Apgar score was normal. The score was 6 at 1 minute which is typical."
8. "It is normal for you to feel this way. Let me explain what the Apgar score is used for." - ANS 4. Correct: This statement recognizes the mother's feelings and seeks to educate. Providing relevant information may decrease her anxiety and encourage further communication. 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. - ANS 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 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?
7. Ambulate in the room
   2. Perform crede' exercises
8. Reassess the fundus in 30 minutes.
9. Massage the fundus. - ANS 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 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 - ANS 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.

Decreased urine output; Thrombocytopenia; Impaired liver function; Shortness of breath; Sudden weight gain, and edema, particularly in face and hands. 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. - ANS 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. The nurse is having an education class for pregnant women. A question is raised about exercise. What is the nurse's best response?
5. Discuss with healthcare provider your current exercise regimen and history.
6. You can continue any exercise that you have been doing before pregnancy.
7. If you haven't already started an exercise program, you should wait until after delivery.
8. Exercise is required during pregnancy for a minimum of 15 minutes each day. - ANS 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.

• ANS 2. Correct: This client is entering the third trimester when the risk of preterm labor and delivery are highest. Women who are aware of the consequences of preterm birth may be more likely to take action to prevent it. Signs and symptoms of preterm labor should be recognized and reported immediately to the primary healthcare provider.
• ANS 4. Correct: Labor can progress rapidly even in a primipara. As the fetal presenting part descends, pressure is placed on the rectum and many women report that it feels as though they need to have a bowel movement. The symptoms described indicate that the client has fully dilated and is at +1 or better station, and delivery may be imminent.

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. - ANS 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. 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
5. Symmetrical gluteal folds.
6. Limited abduction of one leg.
7. Pain with the Barlow maneuver.
8. Presence of an Ortolani click.
9. Confirmed stepping reflex. - ANS 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. Which lab value on a client who is one day postpartum should the nurse report to the primary healthcare provider immediately?
10. Hemoglobin of 11 g/dL (110 g/L) (6.8266 mmol/L)
11. White Blood Cell count of 22,000 mm
12. Hematocrit of 18%

• ANS 3. Correct: Cold stress is the biggest danger to a newborn. A newborn is wet, and evaporation will rapidly cool the baby, which can cause hypoglycemia and respiratory distress. The stimulus of drying the skin also promotes vigorous crying and lung expansion in most healthy infants. 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 - ANS 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. 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
5. Turn the client to the left side.
6. Administer oxygen.
7. Start an intravenous line.
8. Prep the mother for cesarian section.
9. Notify the primary healthcare provider. - ANS 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. 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?
10. 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. - ANS 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. 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 - ANS 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 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?
5. Below the umbilicus, on the mother's left side.
6. Below the umbilicus, on the mother's right side.
7. Above the umbilicus, on the mother's right side.
8. Above the umbilicus, on the mother's left side. - ANS 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

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." - ANS 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. 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?
   5. Oxygen
3. Naloxone
   3. Glucose
4. Vitamin K - ANS 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 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?
5. Early decelerations
6. Fetal heart rate (FHR) 160/min
   3. Blood pressure 90/
7. Temperature of 99.6° F (37.5° C). - ANS 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.

• ANS 1., 3., 4. & 5. Correct: Are all indicators of adequate fluid intake in a newborn. Gaining weight, a heart rate between 70 to 190 beats per minute (BMP), six to eight wet diapers a day and periods of contentment after feedings alternate with periods of wakefulness indicate adequate breast feeding.
• ANS 2., & 5. Correct: False labor or Braxton Hicks contractions are mild, irregular frequency, and intermittent; decrease in frequency, duration, and intensity with walking or position changes; often stop with sleep or comfort measures such as oral hydration or emptying of the bladder. False labor contractions are typically felt as a tightening or pulling sensation of the top of the uterus. In contrast, true labor contractions are more commonly felt in the lower back and gradually sweep around to the lower abdomen. 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. - ANS 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.

• ANS 1, 4, & 5. Correct: The LPN scope of practice varies from state to state, although basic tasks are consistent. Taking vital signs, even initially, is among the tasks that can be delegated to the LPN. Other appropriate duties include collecting urine for ordered tests and even obtaining a vaginal swab. These can definitely be delegated to a licensed practical nurse. 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.