NCLEX questions-Maternity (with rationales)

NCLEX questions-Maternity (with rationales) A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A. Altered nutrition, less than body requirements for lactation B. Alteration in comfort related to nausea and abdominal distention C. Impaired bowel motility related to pain medication and immobility D.NFatigue related to cesarean delivery and physical care demands of infant Ans- C. Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility (C) is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. (A and B) are both caused by impaired bowel motility. (D) is not as important as impaired motility. The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? A.NHerpes B. Trichomonas C. Gonorrhea D. Syphilis Ans- C. Rationale: Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea (C), and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. Ophthalmic ointment is not effective against (A, B, or D). A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B. Hold the infant's head firmly against the breast until he latches onto the nipple. C. Encourage the mother to stop feeding for a few minutes and comfort the infant. D. Provide formula for the infant until he becomes calm, and then offer the breast again. Ans- C. Rationale: The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself (C). After such a time out, breastfeeding is often more successful. (A and D) would cause nipple confusion. (B) would only cause the infant to be more resistant, resulting in the mother and infant to become more frustrated. The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A. Two weeks before menstruation B. Immediately after menstruation C. Immediately before menstruation D. Three weeks before menstruation Ans- A. Rationale: Ovulation occurs 14 days before the first day of the menstrual period (A). Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle varies. (B, C, and D) are incorrect. The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take? A. Administer oxygen by face mask. B. Notify the health care provider of the client's symptoms. C. Have the client breathe into her cupped hands. D. Check the client's blood pressure and fetal heart rate. Ans- C. Rationale: Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands (C). (A) is inappropriate because the carbon dioxide level is low, not the oxygen level. (B and D) are not specific for this situation. When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. At 16 weeks of gestation B. At 20 weeks of gestation C. At 24 weeks of gestation D. At 30 weeks of gestation Ans- D. Rationale: Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to anticipate the onset of labor and the birth of their child. (D) is closest to the time when parents would be ready for such classes. (A, B, and C) are not the best times during a pregnancy for the couple to attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy classes often include topics such as nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her significant others. One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first? A. Stimulate the infant to cry. B. Wrap the infant in warm blankets. C. Feed the infant formula. D. Obtain a serum glucose level. Ans- D. Rationale: This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level (D). (A) is an intervention for a lethargic infant. (B) should be done based on the temperature, but first the glucose level should be obtained. (C) helps raise the blood sugar, but first the nurse should determine the glucose level. Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk. " C. "I can start smoking cigarettes while breastfeeding because it will not affect my breast milk. " D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings. " Ans- A. Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method (A). (B) is incorrect because alcohol can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk (C). Taking a warm shower will stimulate the production of milk, which will be more painful after breastfeedings (D). A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide? A. Lie on your left side and call 911 for emergency assistance. B. Take an antacid and call back if the pain has not subsided. C. Take your blood pressure now and if it is seriously elevated, go to the hospital. D. See your health care provider to obtain a prescription for a histamine blocking agent. AnsC.Rationale: Checking the blood pressure for an elevation (C) is the best instruction to give at this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension. Additional data are needed to confirm an emergency situation as described in (A). (B and D) ignore the threat to client safety posed by a significant increase in blood pressure. The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse? A. Remove all ice from the client's room. B. Ask the client what foods she might consider eating. C. Remind the client that what she eats affects her baby. D. Notify the health care provider. Ans- D. Rationale: The health care provider should be notified (D) when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet, and the client should be evaluated for anemia. (A) is overreacting and may be perceived as punishment by the patient. (B) allows the dietary department to customize the client's tray but fails to address physiologic problems associated with not consuming nutritious foods in pregnancy. (C) is judgmental and blocks further communication. Which finding(s) is (are) of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.) A. Cramping with bright red spotting B. Extreme tenderness of the breast C. Lack of tenderness of the breast D. Increased amounts of discharge E. Increased right-side flank pain Ans- A,C,E Rationale: (A and C) are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. (E) could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. (B and D) are normal signs during the first trimester of a pregnancy. Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home? A. Wash the cord frequently with mild soap and water. B. Cover the cord with a sterile dressing. C. Allow the cord to air-dry as much as possible. D. Apply baby lotion after the baby's daily bath. Ans- C. Rationale: Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process (C). (A, B, and D) are incorrect because they promote moisture and increase the potential for infection. The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take? A. Reapply the external transducer. B. Insert intrauterine pressure catheter. C. Discontinue the oxytocin infusion. D. Continue to monitor labor progress. Ans- D. Rationale: The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress (D) and document the findings in the client's record. There is no reason to reapply the external transducer (A) if the FHR tracings are being captured. (B and C) are not indicated at this time. The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36- day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A. January 14 to 15 B. January 22 to 23 C. January 29 to 30 D.February 6 to 7 Ans- C. Rationale: This client can expect her next period