NCLEX MATERNITY|| NCLEX
MATERNAL NEWBORN EXAM 2023
LATEST UPDATE ||GRADED A+
A term neonate's mother is O-negative, and cord studies indicate that the
neonate is A-positive. Which of the following would be least likely if the
neonate developed hemolytic disease? - ANSWER- Weight loss greater
than 10%
RATIONALES: Although weight loss may be greater than 10%, the
most important assessments must include those addressing the
problem of a rising bilirubin. Neonates who develop severe jaundice
as a result of Rh and ABO incompatibility will exhibit lethargy or
irritability and poor feeding patterns. If bilirubin levels are high
enough to cross the blood brain barrier (usually 20 mg and higher),
the neonate is at serious risk for neurologic impairment due to
permanent cell damage (kernicterus
A full-term neonate is diagnosed with hydrocephalus. Nursing
assessment is most likely to reveal: - ANSWER- wide or bulging
fontanels.
RATIONALES: Hydrocephalus typically causes an enlarged head
with wide or bulging fontanels, an excessive diameter (increased
occipitofrontal diameter), a shiny scalp with prominent veins,
,separation of the suture lines, and downward-slanting eyes. Other
findings in hydrocephalus include bradycardia, apneic episodes,
vomiting, irritability, excessive crying, and reduced alertnes
A client who used heroin during her pregnancy delivers a neonate. When
assessing the neonate, the nurse expects to find - ANSWER- irritability
and poor sucking
RATIONALES: Neonates of heroin-addicted mothers are physically
dependent on the drug and experience withdrawal when the drug is
no longer supplied. Signs of heroin withdrawal include irritability,
poor sucking, and restlessness. Lethargy isn't associated with
neonatal heroin addiction. A flattened nose, small eyes, and thin lips
are seen in infants with fetal alcohol syndrome. Heroin use during
pregnancy hasn't been linked to specific congenital anomalies.
Accompanied by her husband, a client seeks admission to the labor and
delivery area
. She states that she's in labor and says she attended the facility clinic for
prenatal care. Which question should the nurse ask her first? -
ANSWER- "What is your expected due date?"
RATIONALES: When obtaining the history of a client who may be
in labor, the nurse's highest priority is to determine her current
status, particularly her due date, gravidity, and parity. Gravidity
and parity affect the duration of labor and the potential for labor
complications. Later, the nurse should ask about chronic illnesses,
allergies, and support persons.
,A primigravid client, age 20, has just completed a difficult, forceps-
assisted delivery of twins. Her labor was unusually long and required
oxytocin (Pitocin) augmentation. The nurse who's caring for her should
stay alert for - ANSWER- uterine atony
RATIONALES: Multiple fetuses, extended labor stimulation with
oxytocin, and traumatic delivery commonly are associated with
uterine atony, which may lead to postpartum hemorrhage. Uterine
inversion may precede or follow delivery and commonly results
from apparent excessive traction on the umbilical cord and attempts
to deliver the placenta manually. Uterine involution and some
uterine discomfort are normal after delivery.
The nurse is assessing a client on the 2nd postpartum day. Under normal
circumstances, the tone and location of the client's fundus is: -
ANSWER- firm and two fingerbreadths below the umbilicus
RATIONALES: By the 2nd postpartum day, the fundus should be
firm and two fingerbreadths below the umbilicus. The fundus
should be at the level of the umbilicus on the day of delivery and
falls below the umbilicus by approximately one fingerbreadth (1 cm)
per day, until it has contracted into the pelvis by the 9th or 10th day.
The fundus should be firm, not soft. A soft or boggy fundus indicates
that the uterus isn't contracting properly. The fundus should be
palpated in the midline of the abdomen; if the woman has a full
bladder, however, the fundus may be deviated to the right or left.
Which of the following describes a preterm neonate - ANSWER- A
neonate born at less than 37 weeks' gestation regardless of weight
, RATIONALES: A preterm neonate is a neonate born at less than 37
weeks' gestation regardless of what the neonate weighs. Neonates
weighing less than 2,500 g are described as low-birth-weight
neonates. A neonate who's small for gestational age weighs below the
10th percentile (or two standard deviations below the mean) as a
result of intrauterine growth retardation.
Which of the following is the primary reason for putting breast-feeding
neonates to the breast immediately after delivery? - ANSWER- Breast-
feeding neonates immediately after birth establishes a learned response
RATIONALES: Immediately following birth, most neonates are
quietly alert and are ready to nurse. Therefore, this is an ideal time
to begin breast-feeding. Also, as one of the first postbirth
experiences, the neonate is able to develop a learned response for
feeding. The other answers are acceptable, but they don't consider
the importance of developing responses as part of breast-feeding
succes
The nurse demonstrates infant bathing to a primiparous client. Which
statement by the client indicates a lack of understanding? - ANSWER- 2.
"I have all kinds of pretty, scented soaps and lotions to bathe the baby
with.
RATIONALES: Scented and medicated soaps and lotions aren't
recommended for infants because they may alter the skin pH,
making the skin less able to fight infection. Bathing the infant in a
warm room, sponge-bathing the infant until the cord area heals, and
washing the eyes and face first are appropriate activities and
indicate an understanding of teaching regarding infant bathing
MATERNAL NEWBORN EXAM 2023
LATEST UPDATE ||GRADED A+
A term neonate's mother is O-negative, and cord studies indicate that the
neonate is A-positive. Which of the following would be least likely if the
neonate developed hemolytic disease? - ANSWER- Weight loss greater
than 10%
RATIONALES: Although weight loss may be greater than 10%, the
most important assessments must include those addressing the
problem of a rising bilirubin. Neonates who develop severe jaundice
as a result of Rh and ABO incompatibility will exhibit lethargy or
irritability and poor feeding patterns. If bilirubin levels are high
enough to cross the blood brain barrier (usually 20 mg and higher),
the neonate is at serious risk for neurologic impairment due to
permanent cell damage (kernicterus
A full-term neonate is diagnosed with hydrocephalus. Nursing
assessment is most likely to reveal: - ANSWER- wide or bulging
fontanels.
RATIONALES: Hydrocephalus typically causes an enlarged head
with wide or bulging fontanels, an excessive diameter (increased
occipitofrontal diameter), a shiny scalp with prominent veins,
,separation of the suture lines, and downward-slanting eyes. Other
findings in hydrocephalus include bradycardia, apneic episodes,
vomiting, irritability, excessive crying, and reduced alertnes
A client who used heroin during her pregnancy delivers a neonate. When
assessing the neonate, the nurse expects to find - ANSWER- irritability
and poor sucking
RATIONALES: Neonates of heroin-addicted mothers are physically
dependent on the drug and experience withdrawal when the drug is
no longer supplied. Signs of heroin withdrawal include irritability,
poor sucking, and restlessness. Lethargy isn't associated with
neonatal heroin addiction. A flattened nose, small eyes, and thin lips
are seen in infants with fetal alcohol syndrome. Heroin use during
pregnancy hasn't been linked to specific congenital anomalies.
Accompanied by her husband, a client seeks admission to the labor and
delivery area
. She states that she's in labor and says she attended the facility clinic for
prenatal care. Which question should the nurse ask her first? -
ANSWER- "What is your expected due date?"
RATIONALES: When obtaining the history of a client who may be
in labor, the nurse's highest priority is to determine her current
status, particularly her due date, gravidity, and parity. Gravidity
and parity affect the duration of labor and the potential for labor
complications. Later, the nurse should ask about chronic illnesses,
allergies, and support persons.
,A primigravid client, age 20, has just completed a difficult, forceps-
assisted delivery of twins. Her labor was unusually long and required
oxytocin (Pitocin) augmentation. The nurse who's caring for her should
stay alert for - ANSWER- uterine atony
RATIONALES: Multiple fetuses, extended labor stimulation with
oxytocin, and traumatic delivery commonly are associated with
uterine atony, which may lead to postpartum hemorrhage. Uterine
inversion may precede or follow delivery and commonly results
from apparent excessive traction on the umbilical cord and attempts
to deliver the placenta manually. Uterine involution and some
uterine discomfort are normal after delivery.
The nurse is assessing a client on the 2nd postpartum day. Under normal
circumstances, the tone and location of the client's fundus is: -
ANSWER- firm and two fingerbreadths below the umbilicus
RATIONALES: By the 2nd postpartum day, the fundus should be
firm and two fingerbreadths below the umbilicus. The fundus
should be at the level of the umbilicus on the day of delivery and
falls below the umbilicus by approximately one fingerbreadth (1 cm)
per day, until it has contracted into the pelvis by the 9th or 10th day.
The fundus should be firm, not soft. A soft or boggy fundus indicates
that the uterus isn't contracting properly. The fundus should be
palpated in the midline of the abdomen; if the woman has a full
bladder, however, the fundus may be deviated to the right or left.
Which of the following describes a preterm neonate - ANSWER- A
neonate born at less than 37 weeks' gestation regardless of weight
, RATIONALES: A preterm neonate is a neonate born at less than 37
weeks' gestation regardless of what the neonate weighs. Neonates
weighing less than 2,500 g are described as low-birth-weight
neonates. A neonate who's small for gestational age weighs below the
10th percentile (or two standard deviations below the mean) as a
result of intrauterine growth retardation.
Which of the following is the primary reason for putting breast-feeding
neonates to the breast immediately after delivery? - ANSWER- Breast-
feeding neonates immediately after birth establishes a learned response
RATIONALES: Immediately following birth, most neonates are
quietly alert and are ready to nurse. Therefore, this is an ideal time
to begin breast-feeding. Also, as one of the first postbirth
experiences, the neonate is able to develop a learned response for
feeding. The other answers are acceptable, but they don't consider
the importance of developing responses as part of breast-feeding
succes
The nurse demonstrates infant bathing to a primiparous client. Which
statement by the client indicates a lack of understanding? - ANSWER- 2.
"I have all kinds of pretty, scented soaps and lotions to bathe the baby
with.
RATIONALES: Scented and medicated soaps and lotions aren't
recommended for infants because they may alter the skin pH,
making the skin less able to fight infection. Bathing the infant in a
warm room, sponge-bathing the infant until the cord area heals, and
washing the eyes and face first are appropriate activities and
indicate an understanding of teaching regarding infant bathing
