NCLEX Focus on Maternity Exam 2023 with complete
solution
A home care nurse is instructing a client with hyperemesis gravidarum about
measures to ease the nausea and vomiting. The nurse tells the client to:
Eat carbohydrates such as cereals, rice, and pasta
Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and
pasta provide important nutrients and help prevent a low blood glucose level, which can
cause nausea. Soups and other liquids should be taken between meals to avoid
distending the stomach and triggering nausea. Sitting upright after meals reduces
gastric reflux. Additionally, food portions should be small and foods with strong odors
should be eliminated from the diet, because food smells often incite nausea.
Test-Taking Strategy: Use the process of elimination and focus on the client's diagnosis
and the subject, ways to ease and prevent nausea and vomiting. Knowing that foods
high in fat may be difficult to digest will assist you in eliminating this option. Next
eliminate the option that involves consuming primarily soups and fluids at meals,
recalling that liquids will cause distention of the stomach. To select from the remaining
options, recall that lying down after meals can cause gastric reflux; this will direct you to
the correct option. Review measures to ease and prevent nausea and vomiting if you
had difficulty with this question.
A nurse is caring for a client with preeclampsia who is receiving a magnesium
sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that
the medication is effective?
The client experiences diuresis within 24 to 48 hours.
Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs
within 24 to 48 hours of the start of the infusion. As part of the therapeutic response,
renal perfusion is increased and the client is free of visual disturbances, headache,
epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when
the client's lower leg is supported and the foot is sharply dorsiflexed), and seizure
activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The
therapeutic magnesium level is 4 to 8 mg/dL (1.64 to 3.29 mmol/L). Reflexes range from
1+ to 2+ but should not be absent.
A client with preeclampsia who is receiving magnesium sulfate in an intravenous
infusion exhibits signs of magnesium toxicity. The nurse immediately prepares
for the administration of:
Calcium gluconate
Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the
effects of magnesium at the neuromuscular junction. It should be readily available
whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage
induced by the administration of oral anticoagulants such as warfarin sodium
(Coumadin). Protamine sulfate is the antidote in cases of hemorrhage induced by the
,administration of heparin. Naloxone hydrochloride is administered to treat opioid-
induced respiratory depression.
The maternity nurse is caring for a pregnant client with no history of
preeclampsia who is receiving a magnesium sulfate infusion. Why is this client
receiving this infusion?
To contract the uterus
To treat hypotension
To reverse extreme muscle weakness
To halt preterm labor contractions
To contract the uterus
A nurse instructs a pregnant client about foods that are high in folic acid. Which
item does the nurse tell the client is the best source of folic acid?
Lima beans
The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh
dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts,
refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein.
A nurse is providing instructions to a mother of an infant with seborrheic
dermatitis (cradle cap) about treatment of the condition. The nurse tells the
mother to:
Apply oil to the affected area on the infant's scalp
Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is
characterized by yellow, scaly, oily lesions. It sometimes results when parents do not
wash over the anterior fontanel carefully for fear that they will hurt the infant. Treatment
includes the application of oil (e.g., mineral oil) to the area to help soften the lesions
followed by gentle removal of the scaly lesions with a comb before the head is
shampooed. The nurse should teach the mother how to shampoo the scalp and explain
that she will not damage the fontanel with normal gentle shampooing. The scalp should
be rinsed well to remove all soap, which could cause irritation.
A nurse is monitoring a client who was given an epidural opioid for a cesarean
birth. The nurse notes that the client's oxygen saturation on pulse oximetry is
92%. The nurse first:
Instructs the client to take several deep breaths
If the client has been given an epidural opioid, the nurse should monitor the client's
respiratory status closely. If the oxygen saturation falls below 95%, the nurse instructs
the client to take several deep breaths to increase the level. Although the finding would
be documented, action is required to increase the oxygen saturation level. It is not
necessary to contact the health care provider. If the deep breaths fail to increase the
oxygen saturation level, the health care provider is notified and may prescribe oxygen.
A client who delivered a healthy newborn 11 days ago calls the clinic and tells the
nurse that she is experiencing a white vaginal discharge. The nurse tells the
client:
That this is a normal postpartum occurrence
,For the first 3 days following childbirth, lochia consists almost entirely of blood, with
small particles of decidua and mucus, and is called lochia rubra because of its red color.
The amount of blood decreases by about the fourth day, and which time the lochia
changes from red to pink or brown-tinged; this stage is called lochia serosa. By about
the 11th day, the erythrocyte component of lochia has decreased and the discharge
becomes white or cream-colored. This final stage is known as lochia alba. Lochia alba
contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria. It
is present in most women until the third week after childbirth but may persist for as long
as 6 weeks. Lochia alba is a normal finding during the postpartum course, and no
intervention is required, so the other options are incorrect.
A rubella antibody screen is performed in a pregnant client, and the results
indicate that the client is not immune to rubella. The nurse tells the client that:
A rubella vaccine must be administered after childbirth
A prenatal rubella antibody screen is performed in every pregnant woman to determine
whether she is immune to rubella, which can cause serious fetal anomalies. If she is not
immune, rubella vaccine is offered after childbirth to keep her from contracting rubella
during subsequent pregnancies. The vaccine is a live virus, and defects might occur in
the fetus if the vaccine were administered during pregnancy or if the mother were to
become pregnant soon after it was administered. Administering a rubella vaccine
immediately places the fetus at risk. Telling the client that she does not need to be
concerned about being exposed to rubella is incorrect, because the possibility of
exposure, which could be harmful to the fetus, does exist.
A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The
nurse takes the client's temperature and notes that it is 38° C (100.4° F). The most
appropriate nursing action would be to:
Encourage the intake of oral fluids
A temperature of 38° C (100.4° F) is common during the 24 hours after childbirth. It may
be the result of dehydration or normal postpartum leukocytosis. If the increased
temperature persists for longer than 24 hours or exceeds 38° C, infection is a possibility,
and the fever is reported to the health care provider or nurse midwife. Because the
client delivered her baby just 12 hours ago, the most appropriate nursing action is to
encourage the intake of oral fluids.
A nurse is assessing the uterine fundus of a client who has just delivered a baby
and notes that the fundus is boggy. The nurse massages the fundus, and then
presses to expel clots from the uterus. To prevent uterine inversion during this
procedure, the nurse:
Simultaneously provides pressure over the lower uterine segment
After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel
clots from the uterus. The nurse must also keep one hand pressed firmly just above the
symphysis (over the lower uterine segment) the entire time. Removing the clots allows
the uterus to contract properly. Providing pressure over the lower uterine segment
, prevents uterine inversion. Having the client void before uterine assessment will not
prevent uterine inversion. Telling the woman to bear down while the nurse performs
fundal message and asking the client to take slow, deep breaths during fundal
assessment also will not prevent uterine inversion.
A nurse is monitoring a client after vaginal delivery notes a constant trickle of
bright-red blood from the client's vagina. In which order would the nurse perform
the following actions?
Assessing the client's fundus
Checking the client's vital signs
Contacting the health care provider
Changing the client's peripads
Documenting the findings
A constant trickle of bright-red blood may indicate abnormal bleeding and requires
immediate attention. The nurse first checks the client's fundus. Once it has been
determined that the bleeding is not the result of a boggy uterus, the nurse should check
the vital signs to determine whether the blood loss has compromised the client's
condition. Next the nurse would contact the health care provider and report the
bleeding, fundal height and condition, and vital signs. After contacting the health care
provider the nurse would attend to the client's comfort needs, including, in this case,
frequent changes of peripads. The nurse would document the findings once
assessment and implementation had been completed and the client's condition was
considered stable.
A nonstress test is performed, and the health care provider documents
"accelerations lasting less than 15 seconds throughout fetal movement." The
nurse interprets these findings as:
Nonreactive
A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus.
The result requires two or more fetal heart rate accelerations of at least 15 beats/min
lasting at least 15 seconds from the beginning of the acceleration to the end, in
association with fetal movement, during a 20-minute period. A nonreactive test is an
abnormal test, showing no accelerations or accelerations of less than 15 beats/min or
lasting less than 15 seconds during a 40-minute observation. An inconclusive result is
one that cannot be interpreted because of the poor quality of the fetal heart rate
recording.
A stillborn infant was delivered a few hours ago. After the birth, the family
remains together, holding and touching the baby. Which statement by the nurse
is appropriate?
"This must be hard for you."
Therapeutic communication helps the mother, father, and other family members
express their feelings and emotions. "This must be hard for you" is a caring and
empathetic response, focused on feelings and encouraging communication. The other
options are nontherapeutic and may devalue the family members' feelings.
A nurse is providing nutritional counseling to pregnant client with a history of
cardiac disease. What does the nurse advise the client to eat?
solution
A home care nurse is instructing a client with hyperemesis gravidarum about
measures to ease the nausea and vomiting. The nurse tells the client to:
Eat carbohydrates such as cereals, rice, and pasta
Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and
pasta provide important nutrients and help prevent a low blood glucose level, which can
cause nausea. Soups and other liquids should be taken between meals to avoid
distending the stomach and triggering nausea. Sitting upright after meals reduces
gastric reflux. Additionally, food portions should be small and foods with strong odors
should be eliminated from the diet, because food smells often incite nausea.
Test-Taking Strategy: Use the process of elimination and focus on the client's diagnosis
and the subject, ways to ease and prevent nausea and vomiting. Knowing that foods
high in fat may be difficult to digest will assist you in eliminating this option. Next
eliminate the option that involves consuming primarily soups and fluids at meals,
recalling that liquids will cause distention of the stomach. To select from the remaining
options, recall that lying down after meals can cause gastric reflux; this will direct you to
the correct option. Review measures to ease and prevent nausea and vomiting if you
had difficulty with this question.
A nurse is caring for a client with preeclampsia who is receiving a magnesium
sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that
the medication is effective?
The client experiences diuresis within 24 to 48 hours.
Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs
within 24 to 48 hours of the start of the infusion. As part of the therapeutic response,
renal perfusion is increased and the client is free of visual disturbances, headache,
epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when
the client's lower leg is supported and the foot is sharply dorsiflexed), and seizure
activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The
therapeutic magnesium level is 4 to 8 mg/dL (1.64 to 3.29 mmol/L). Reflexes range from
1+ to 2+ but should not be absent.
A client with preeclampsia who is receiving magnesium sulfate in an intravenous
infusion exhibits signs of magnesium toxicity. The nurse immediately prepares
for the administration of:
Calcium gluconate
Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the
effects of magnesium at the neuromuscular junction. It should be readily available
whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage
induced by the administration of oral anticoagulants such as warfarin sodium
(Coumadin). Protamine sulfate is the antidote in cases of hemorrhage induced by the
,administration of heparin. Naloxone hydrochloride is administered to treat opioid-
induced respiratory depression.
The maternity nurse is caring for a pregnant client with no history of
preeclampsia who is receiving a magnesium sulfate infusion. Why is this client
receiving this infusion?
To contract the uterus
To treat hypotension
To reverse extreme muscle weakness
To halt preterm labor contractions
To contract the uterus
A nurse instructs a pregnant client about foods that are high in folic acid. Which
item does the nurse tell the client is the best source of folic acid?
Lima beans
The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh
dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts,
refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein.
A nurse is providing instructions to a mother of an infant with seborrheic
dermatitis (cradle cap) about treatment of the condition. The nurse tells the
mother to:
Apply oil to the affected area on the infant's scalp
Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is
characterized by yellow, scaly, oily lesions. It sometimes results when parents do not
wash over the anterior fontanel carefully for fear that they will hurt the infant. Treatment
includes the application of oil (e.g., mineral oil) to the area to help soften the lesions
followed by gentle removal of the scaly lesions with a comb before the head is
shampooed. The nurse should teach the mother how to shampoo the scalp and explain
that she will not damage the fontanel with normal gentle shampooing. The scalp should
be rinsed well to remove all soap, which could cause irritation.
A nurse is monitoring a client who was given an epidural opioid for a cesarean
birth. The nurse notes that the client's oxygen saturation on pulse oximetry is
92%. The nurse first:
Instructs the client to take several deep breaths
If the client has been given an epidural opioid, the nurse should monitor the client's
respiratory status closely. If the oxygen saturation falls below 95%, the nurse instructs
the client to take several deep breaths to increase the level. Although the finding would
be documented, action is required to increase the oxygen saturation level. It is not
necessary to contact the health care provider. If the deep breaths fail to increase the
oxygen saturation level, the health care provider is notified and may prescribe oxygen.
A client who delivered a healthy newborn 11 days ago calls the clinic and tells the
nurse that she is experiencing a white vaginal discharge. The nurse tells the
client:
That this is a normal postpartum occurrence
,For the first 3 days following childbirth, lochia consists almost entirely of blood, with
small particles of decidua and mucus, and is called lochia rubra because of its red color.
The amount of blood decreases by about the fourth day, and which time the lochia
changes from red to pink or brown-tinged; this stage is called lochia serosa. By about
the 11th day, the erythrocyte component of lochia has decreased and the discharge
becomes white or cream-colored. This final stage is known as lochia alba. Lochia alba
contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria. It
is present in most women until the third week after childbirth but may persist for as long
as 6 weeks. Lochia alba is a normal finding during the postpartum course, and no
intervention is required, so the other options are incorrect.
A rubella antibody screen is performed in a pregnant client, and the results
indicate that the client is not immune to rubella. The nurse tells the client that:
A rubella vaccine must be administered after childbirth
A prenatal rubella antibody screen is performed in every pregnant woman to determine
whether she is immune to rubella, which can cause serious fetal anomalies. If she is not
immune, rubella vaccine is offered after childbirth to keep her from contracting rubella
during subsequent pregnancies. The vaccine is a live virus, and defects might occur in
the fetus if the vaccine were administered during pregnancy or if the mother were to
become pregnant soon after it was administered. Administering a rubella vaccine
immediately places the fetus at risk. Telling the client that she does not need to be
concerned about being exposed to rubella is incorrect, because the possibility of
exposure, which could be harmful to the fetus, does exist.
A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The
nurse takes the client's temperature and notes that it is 38° C (100.4° F). The most
appropriate nursing action would be to:
Encourage the intake of oral fluids
A temperature of 38° C (100.4° F) is common during the 24 hours after childbirth. It may
be the result of dehydration or normal postpartum leukocytosis. If the increased
temperature persists for longer than 24 hours or exceeds 38° C, infection is a possibility,
and the fever is reported to the health care provider or nurse midwife. Because the
client delivered her baby just 12 hours ago, the most appropriate nursing action is to
encourage the intake of oral fluids.
A nurse is assessing the uterine fundus of a client who has just delivered a baby
and notes that the fundus is boggy. The nurse massages the fundus, and then
presses to expel clots from the uterus. To prevent uterine inversion during this
procedure, the nurse:
Simultaneously provides pressure over the lower uterine segment
After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel
clots from the uterus. The nurse must also keep one hand pressed firmly just above the
symphysis (over the lower uterine segment) the entire time. Removing the clots allows
the uterus to contract properly. Providing pressure over the lower uterine segment
, prevents uterine inversion. Having the client void before uterine assessment will not
prevent uterine inversion. Telling the woman to bear down while the nurse performs
fundal message and asking the client to take slow, deep breaths during fundal
assessment also will not prevent uterine inversion.
A nurse is monitoring a client after vaginal delivery notes a constant trickle of
bright-red blood from the client's vagina. In which order would the nurse perform
the following actions?
Assessing the client's fundus
Checking the client's vital signs
Contacting the health care provider
Changing the client's peripads
Documenting the findings
A constant trickle of bright-red blood may indicate abnormal bleeding and requires
immediate attention. The nurse first checks the client's fundus. Once it has been
determined that the bleeding is not the result of a boggy uterus, the nurse should check
the vital signs to determine whether the blood loss has compromised the client's
condition. Next the nurse would contact the health care provider and report the
bleeding, fundal height and condition, and vital signs. After contacting the health care
provider the nurse would attend to the client's comfort needs, including, in this case,
frequent changes of peripads. The nurse would document the findings once
assessment and implementation had been completed and the client's condition was
considered stable.
A nonstress test is performed, and the health care provider documents
"accelerations lasting less than 15 seconds throughout fetal movement." The
nurse interprets these findings as:
Nonreactive
A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus.
The result requires two or more fetal heart rate accelerations of at least 15 beats/min
lasting at least 15 seconds from the beginning of the acceleration to the end, in
association with fetal movement, during a 20-minute period. A nonreactive test is an
abnormal test, showing no accelerations or accelerations of less than 15 beats/min or
lasting less than 15 seconds during a 40-minute observation. An inconclusive result is
one that cannot be interpreted because of the poor quality of the fetal heart rate
recording.
A stillborn infant was delivered a few hours ago. After the birth, the family
remains together, holding and touching the baby. Which statement by the nurse
is appropriate?
"This must be hard for you."
Therapeutic communication helps the mother, father, and other family members
express their feelings and emotions. "This must be hard for you" is a caring and
empathetic response, focused on feelings and encouraging communication. The other
options are nontherapeutic and may devalue the family members' feelings.
A nurse is providing nutritional counseling to pregnant client with a history of
cardiac disease. What does the nurse advise the client to eat?
