Saunders Comprehensive Review for NCLEX RN-Maternity Nursing Content Area
Exam -2
Overall Score 79% out of 100
questions
Name
7/27/2021
1. The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks'
gestation. What is the priority nursing action for this client?
Ans: Assess for signs and symptoms of labor.
Rationale:
As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor.
This client is not at high risk for infection. Daily ultrasound exams are not necessary for this
client. A nonstress test may be done, but not every 4 hours.
2. After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to
85 beats/minute. Which should be the nurse's priority action
Ans: Assess the vagina and cervix with a gloved hand.
Rationale:
It is most common to see an umbilical cord prolapsed directly after the rupture of membranes,
when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced
by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the
fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's
membranes, the nurse's initial action should be to glove the examining hand and insert 2 fingers
into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of
the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-
chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord
and relieving compression is the first intervention that should be implemented; therefore, option
1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression
in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this
occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.
3. The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding
regarding changing insulin needs during pregnancy. The nurse determines that further teaching
is needed if the client makes which statement?
1
, Ans: "I will need to increase my insulin dosage during the first 3 months of pregnancy."
Rationale:
Insulin needs decrease in the first trimester of pregnancy because of increased insulin production
by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3,
and 4 are accurate and signify that the client understands control of her diabetes during
pregnancy.
4. The nurse is preparing to teach a new mother how to sponge bathe a 1-day-old newborn.
Which actions should the nurse take? Select all that apply.
Ans: Pat the baby dry gently.
Support the newborn's body during the bath
Make sure that the room temperature is 75º F (23.9º C).
Cleanse one body area at a time keeping other body areas covered.
Rationale:
Washing the hair comes toward the end of the bath so that the baby does not get cold. There is no
need to use shampoo on the scalp and hair; water is sufficient. The newborn is supported
throughout the procedure and one body area at a time is cleansed keeping other body areas
covered to prevent chilling. The room temperature is also kept warm at 75º F (23.9º C) to prevent
chilling. Each area is patted dry after washing; rubbing the skin will irritate it.
5. The nurse reviews the assessment history for a client with a suspected ectopic pregnancy.
Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply.
Ans: Use of fertility medications
History of Chlamydia
Use of an intrauterine device
History of pelvic inflammatory disease (PID)
Rationale:
An ectopic pregnancy is one that establishes itself somewhere other than inside the uterus.
Multiple factors may predispose a woman to an ectopic pregnancy. Fertility medications, history
of sexually transmitted infections, intrauterine devices, and PID have all been associated with
ectopic pregnancy. There are no data to support any additional risk for ectopic pregnancy with
the use of the diaphragm.
6. A client in the prenatal clinic asks the nurse about the delivery date. The nurse notes that the
client's record indicates that the client began her last menses on March 7, 2021, and ended the
menses on March 14, 2021. Using Naegele's rule, the nurse should tell the client that the
estimated date of delivery is what date? Fill in the blank. Record your answer using 6 digits
(mmddyy).
2
Exam -2
Overall Score 79% out of 100
questions
Name
7/27/2021
1. The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks'
gestation. What is the priority nursing action for this client?
Ans: Assess for signs and symptoms of labor.
Rationale:
As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor.
This client is not at high risk for infection. Daily ultrasound exams are not necessary for this
client. A nonstress test may be done, but not every 4 hours.
2. After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to
85 beats/minute. Which should be the nurse's priority action
Ans: Assess the vagina and cervix with a gloved hand.
Rationale:
It is most common to see an umbilical cord prolapsed directly after the rupture of membranes,
when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced
by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the
fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's
membranes, the nurse's initial action should be to glove the examining hand and insert 2 fingers
into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of
the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-
chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord
and relieving compression is the first intervention that should be implemented; therefore, option
1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression
in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this
occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.
3. The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding
regarding changing insulin needs during pregnancy. The nurse determines that further teaching
is needed if the client makes which statement?
1
, Ans: "I will need to increase my insulin dosage during the first 3 months of pregnancy."
Rationale:
Insulin needs decrease in the first trimester of pregnancy because of increased insulin production
by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3,
and 4 are accurate and signify that the client understands control of her diabetes during
pregnancy.
4. The nurse is preparing to teach a new mother how to sponge bathe a 1-day-old newborn.
Which actions should the nurse take? Select all that apply.
Ans: Pat the baby dry gently.
Support the newborn's body during the bath
Make sure that the room temperature is 75º F (23.9º C).
Cleanse one body area at a time keeping other body areas covered.
Rationale:
Washing the hair comes toward the end of the bath so that the baby does not get cold. There is no
need to use shampoo on the scalp and hair; water is sufficient. The newborn is supported
throughout the procedure and one body area at a time is cleansed keeping other body areas
covered to prevent chilling. The room temperature is also kept warm at 75º F (23.9º C) to prevent
chilling. Each area is patted dry after washing; rubbing the skin will irritate it.
5. The nurse reviews the assessment history for a client with a suspected ectopic pregnancy.
Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply.
Ans: Use of fertility medications
History of Chlamydia
Use of an intrauterine device
History of pelvic inflammatory disease (PID)
Rationale:
An ectopic pregnancy is one that establishes itself somewhere other than inside the uterus.
Multiple factors may predispose a woman to an ectopic pregnancy. Fertility medications, history
of sexually transmitted infections, intrauterine devices, and PID have all been associated with
ectopic pregnancy. There are no data to support any additional risk for ectopic pregnancy with
the use of the diaphragm.
6. A client in the prenatal clinic asks the nurse about the delivery date. The nurse notes that the
client's record indicates that the client began her last menses on March 7, 2021, and ended the
menses on March 14, 2021. Using Naegele's rule, the nurse should tell the client that the
estimated date of delivery is what date? Fill in the blank. Record your answer using 6 digits
(mmddyy).
2
