NCLEX-maternity and newborn exam
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. - CORRECT 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
1. Folded ear pinna springs back slowly.
2. Peripheral cyanosis on feet and hands.
3. Shoulders and chest have moderate lanugo.
4. Vernix covering axilla, back and buttocks.
5. Feet soles entirely covered with creases. - CORRECT 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.
, - CORRECT 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.
- CORRECT 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 ?
1. Use a latex condom when having sex to protect against Chlamydia.
2. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination.
3. Suggest that the teens be screened for Chlamydia.
4. Reassure the teens that if they have no symptoms, they have no disease.
5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months. -
CORRECT ANS
- CORRECT 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
, he nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely?
1. Hypocalcemia
2. Hypomagnesemia
3. Hyponatremia
4. Hypokalemia - CORRECT ANS 4. Correct: Hyperemesis gravidarum is characterized by persistent
severe pregnancy related nausea and vomiting. There is a large amount of potassium in the upper GI
tract. A client with prolonged vomiting will lose potassium in the emesis. Additionally, the client is
unable to replace the lost potassium due to the persistent nausea and vomiting.
Post epidural anesthesia, a laboring client's blood pressure drops to 92/42. Which intervention by the
nurse takes priority?
1. Elevate the head of the bed
2. Administer oxygen by face mask
3. Position client side-lying
4. Begin dopamine 5 mcg/kg/min - CORRECT ANS 3. Correct: When you turn them on their side, this
relieves pressure on the vena cava and the BP will go UP.
All of the beds in a 10 bed Labor, Delivery, Recovery, Postpartum Unit (LDRP) are full when one of the
nurses assigned that day calls in sick. A nurse from the Med surg unit is transferred to the LDRP unit.
Which client should the charge nurse assign to this nurse?
1. Client at 32 weeks gestation on oral terbutaline with 4 contractions/hour.
2. One hour postpartum client with a continuous trickle of vaginal bleeding.
3. 2 hours postpartum client reporting intense perineal pain.
4. Client at 36 weeks gestation with a blood pressure of 148/92. - CORRECT ANS 1. Correct: This client is
at lowest risk for complications. She is having infrequent contractions and is not at high risk for preterm
delivery. She is also receiving an oral tocolytic, terbutaline. Tocolytic agents are used to inhibit uterine
contractions and suppress preterm labor. The medical surgical nurse should be able to safely provide
care for this client.
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. - CORRECT 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
1. Folded ear pinna springs back slowly.
2. Peripheral cyanosis on feet and hands.
3. Shoulders and chest have moderate lanugo.
4. Vernix covering axilla, back and buttocks.
5. Feet soles entirely covered with creases. - CORRECT 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.
, - CORRECT 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.
- CORRECT 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 ?
1. Use a latex condom when having sex to protect against Chlamydia.
2. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination.
3. Suggest that the teens be screened for Chlamydia.
4. Reassure the teens that if they have no symptoms, they have no disease.
5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months. -
CORRECT ANS
- CORRECT 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
, he nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely?
1. Hypocalcemia
2. Hypomagnesemia
3. Hyponatremia
4. Hypokalemia - CORRECT ANS 4. Correct: Hyperemesis gravidarum is characterized by persistent
severe pregnancy related nausea and vomiting. There is a large amount of potassium in the upper GI
tract. A client with prolonged vomiting will lose potassium in the emesis. Additionally, the client is
unable to replace the lost potassium due to the persistent nausea and vomiting.
Post epidural anesthesia, a laboring client's blood pressure drops to 92/42. Which intervention by the
nurse takes priority?
1. Elevate the head of the bed
2. Administer oxygen by face mask
3. Position client side-lying
4. Begin dopamine 5 mcg/kg/min - CORRECT ANS 3. Correct: When you turn them on their side, this
relieves pressure on the vena cava and the BP will go UP.
All of the beds in a 10 bed Labor, Delivery, Recovery, Postpartum Unit (LDRP) are full when one of the
nurses assigned that day calls in sick. A nurse from the Med surg unit is transferred to the LDRP unit.
Which client should the charge nurse assign to this nurse?
1. Client at 32 weeks gestation on oral terbutaline with 4 contractions/hour.
2. One hour postpartum client with a continuous trickle of vaginal bleeding.
3. 2 hours postpartum client reporting intense perineal pain.
4. Client at 36 weeks gestation with a blood pressure of 148/92. - CORRECT ANS 1. Correct: This client is
at lowest risk for complications. She is having infrequent contractions and is not at high risk for preterm
delivery. She is also receiving an oral tocolytic, terbutaline. Tocolytic agents are used to inhibit uterine
contractions and suppress preterm labor. The medical surgical nurse should be able to safely provide
care for this client.
