Maternity Nclex questions
A 28-week-gestation newborn experienced birth asphyxia at the time of delivery. What is a
long-term complication of birth asphyxia?
a)Necrotizing enterocolitis
b)Retinopathy of prematurity
c)Intraventricular hemorrhage
d)Anemia of prematurity - ANS-C
Birth asphyxia will cause an insult to the brain, and more often than not will cause a bleed or
intraventricular hemorrhage. Birth asphyxia is not directly correlated with NEC, retinopathy of
prematurity, or anemia of prematurity. These are common for the premature infant, but not
necessarily birth asphyxia.
\A client at 28 weeks gestation is admitted to the labor and birth unit. Which test would most
likely be used to assess the client's comprehensive fetal status?
a) Ultrasound for physical structure
b) Nonstress test (NST)
c) Biophysical profile (BPP)
d) Amniocentesis - ANS-C.
Biophysical profile is a comprehensive test that would be used to assess the client's fetal
status at 28 weeks gestation. Ultrasound for physical structure is limited to identifying the
growth and development of the fetus, and does not assess for other parameters of fetal
well-being. Women with a high-risk factor will probably begin having NSTs at 30-32 weeks
gestation and at frequent intervals for the remainder of the pregnancy. Amniocentesis late in
pregnancy is used to test for lung maturity, not overall fetal status in labor, and when
performed earlier it is used to test for specific disorders.
\A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken.
The nurse explains that this behavior indicates which of the following?
A) Normal progression of behavior
B) Probable hypoglycemia
C) Physiological abnormality
D) Inadequate oxygenation - ANS-A
From 30 to 120 minutes of age, the newborn enters the second stage of transition, that of
sleep or a decrease in activity. More information would be needed to determine if
hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.
\A client states that she had a spontaneous abortion 12 months ago. The client asks if her
hormones may have contributed to the loss of the pregnancy. The nurse's response is based
upon her knowledge of which of the following facts?
a) Implantation occurs when progesterone levels are low.
,b) hCG reaches a maximum level at 4 weeks gestation.
c) Progesterone decreases the contractility of the uterus.
d) Progesterone is only produced by the corpus luteum during pregnancy. - ANS-C
Progesterone decreases the contractility of the uterus, thus preventing uterine contractions
that might cause spontaneous abortion. Progesterone must be present in high levels for
implantation to occur. After 10 weeks, the placenta takes over the production of
progesterone. hCG reaches its maximum level at 50-70 days gestation.
\A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is
almost black. Which response by the nurse would be most appropriate?
A) "You probably took iron during your pregnancy."
B) "This is meconium stool, normal for a newborn."
C) "I'll take a sample and check it for possible bleeding."
D) "This is unusual and I need to report this." - ANS-B
Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This
is a normal finding. Iron can cause stool to turn black, but this would not be the case here.
The stool is a normal occurrence and does not need to be checked for blood or reported.
\A new mother reports that her newborn often spits up after feeding. Assessment reveals
regurgitation. The nurse responds based on the understanding that this most likely is due to
which of the following?
A) Placing the newborn prone after feeding
B) Limited ability of digestive enzymes
C) Underdeveloped pyloric sphincter
D) Relaxed cardiac sphincter - ANS-D
The cardiac sphincter and nervous control of the stomach is immature, which may lead to
uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is
unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited
in their ability to digest complex carbohydrates and fats; this results in fatty stools, not
regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower
esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the
reflux of gastric contents.
\A nurse is teaching a group of first-trimester prenatal clients about the discomforts of
pregnancy. A client asks the nurse, "What causes my nausea and vomiting?" The nurse
responds indicating which of the following as being contributing factors to first-trimester
emesis? Select all that apply.
a) Human chorionic gonadotropin
b) Estrogen
c) Alterations in carbohydrate metabolism
d) Prostaglandins - ANS-A, C
Nausea and vomiting are common during the first trimester because of elevated human
chorionic gonadotropin levels and changed carbohydrate metabolism. Estrogen stimulates
the growth of the uterus and breast tissue. Prostaglandins stimulate uterine contractions.
, \A nurse is teaching a group of student nurses about amniotic fluid. Which of the following
statements by the student nurse reflects an understanding of the fetus's contribution to the
quality of amniotic fluid? Select all that apply.
a) "The fetus contributes to the volume of amniotic fluid by excreting urine."
b) "Approximately 400 mL of amniotic fluid flows out of the fetal lungs each day."
c) "The fetus swallows about 600 mL of the fluid in 24 hours."
d) "A fetus can move freely and develop normally, even if there is no amniotic fluid." -
ANS-A, B, C
"The fetus contributes to the volume of amniotic fluid by excreting urine." Approximately 400
mL of amniotic fluid flows out of the fetal lungs each day. The fetus swallows about 600 mL
of the fluid in 24 hours. A normal volume of amniotic fluid is necessary for good fetal
movement. Normal movement is necessary for good musculoskeletal development.
\A pregnant client asks why ultrasound is used so frequently during pregnancy. The nurse's
response is based on her knowledge that the advantages of ultrasound include which of the
following? Select all that apply.
a)"It is noninvasive and painless."
b)"It can be used to estimate gestational age."
c)"Results are immediate."
d)"The ultrasound is the only test to determine gender." - ANS-A, B, C
The ability to establish fetal age accurately by ultrasound is lost in the third trimester
because fetal growth is not as uniform as it is in the first two trimesters; however, ultrasound
can be used to approximate gestational age within 1-3 weeks' accuracy during the third
trimester. A comprehensive ultrasound is used to detect anatomical defects, not gestational
age. Ultrasound is not used to determine gender.
\A pregnant client is concerned about a blow to the abdomen if she continues to play
basketball during her pregnancy. The nurse's response is based upon her knowledge of
which of the following facts concerning amniotic fluid?
a) The total amount of amniotic fluid during pregnancy is 300 mL.
b) Amniotic fluid functions as a cushion to protect against mechanical injury.
c) The fetus does not contribute to the production of amniotic fluid.
d) Amniotic fluid is slightly acidic. - ANS-B
During pregnancy, the amniotic fluid protects against injury. After 20 weeks of pregnancy,
fluid volume ranges from 700-1000 mL. Some of the amniotic fluid is contributed by the
fetus's excreting urine. Amniotic fluid is slightly alkaline.
\A prenatal client at 22 weeks gestation is scheduled for an amniocentesis. Which nursing
action would apply to any client undergoing this procedure? Select all that apply.
a)Assess for bleeding.
b)Administer Rh immune globulin to the client.
c)Cleanse skin with alcohol.
d)Assess vital signs and fetal heart rate. - ANS-A, D
A 28-week-gestation newborn experienced birth asphyxia at the time of delivery. What is a
long-term complication of birth asphyxia?
a)Necrotizing enterocolitis
b)Retinopathy of prematurity
c)Intraventricular hemorrhage
d)Anemia of prematurity - ANS-C
Birth asphyxia will cause an insult to the brain, and more often than not will cause a bleed or
intraventricular hemorrhage. Birth asphyxia is not directly correlated with NEC, retinopathy of
prematurity, or anemia of prematurity. These are common for the premature infant, but not
necessarily birth asphyxia.
\A client at 28 weeks gestation is admitted to the labor and birth unit. Which test would most
likely be used to assess the client's comprehensive fetal status?
a) Ultrasound for physical structure
b) Nonstress test (NST)
c) Biophysical profile (BPP)
d) Amniocentesis - ANS-C.
Biophysical profile is a comprehensive test that would be used to assess the client's fetal
status at 28 weeks gestation. Ultrasound for physical structure is limited to identifying the
growth and development of the fetus, and does not assess for other parameters of fetal
well-being. Women with a high-risk factor will probably begin having NSTs at 30-32 weeks
gestation and at frequent intervals for the remainder of the pregnancy. Amniocentesis late in
pregnancy is used to test for lung maturity, not overall fetal status in labor, and when
performed earlier it is used to test for specific disorders.
\A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken.
The nurse explains that this behavior indicates which of the following?
A) Normal progression of behavior
B) Probable hypoglycemia
C) Physiological abnormality
D) Inadequate oxygenation - ANS-A
From 30 to 120 minutes of age, the newborn enters the second stage of transition, that of
sleep or a decrease in activity. More information would be needed to determine if
hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.
\A client states that she had a spontaneous abortion 12 months ago. The client asks if her
hormones may have contributed to the loss of the pregnancy. The nurse's response is based
upon her knowledge of which of the following facts?
a) Implantation occurs when progesterone levels are low.
,b) hCG reaches a maximum level at 4 weeks gestation.
c) Progesterone decreases the contractility of the uterus.
d) Progesterone is only produced by the corpus luteum during pregnancy. - ANS-C
Progesterone decreases the contractility of the uterus, thus preventing uterine contractions
that might cause spontaneous abortion. Progesterone must be present in high levels for
implantation to occur. After 10 weeks, the placenta takes over the production of
progesterone. hCG reaches its maximum level at 50-70 days gestation.
\A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is
almost black. Which response by the nurse would be most appropriate?
A) "You probably took iron during your pregnancy."
B) "This is meconium stool, normal for a newborn."
C) "I'll take a sample and check it for possible bleeding."
D) "This is unusual and I need to report this." - ANS-B
Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This
is a normal finding. Iron can cause stool to turn black, but this would not be the case here.
The stool is a normal occurrence and does not need to be checked for blood or reported.
\A new mother reports that her newborn often spits up after feeding. Assessment reveals
regurgitation. The nurse responds based on the understanding that this most likely is due to
which of the following?
A) Placing the newborn prone after feeding
B) Limited ability of digestive enzymes
C) Underdeveloped pyloric sphincter
D) Relaxed cardiac sphincter - ANS-D
The cardiac sphincter and nervous control of the stomach is immature, which may lead to
uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is
unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited
in their ability to digest complex carbohydrates and fats; this results in fatty stools, not
regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower
esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the
reflux of gastric contents.
\A nurse is teaching a group of first-trimester prenatal clients about the discomforts of
pregnancy. A client asks the nurse, "What causes my nausea and vomiting?" The nurse
responds indicating which of the following as being contributing factors to first-trimester
emesis? Select all that apply.
a) Human chorionic gonadotropin
b) Estrogen
c) Alterations in carbohydrate metabolism
d) Prostaglandins - ANS-A, C
Nausea and vomiting are common during the first trimester because of elevated human
chorionic gonadotropin levels and changed carbohydrate metabolism. Estrogen stimulates
the growth of the uterus and breast tissue. Prostaglandins stimulate uterine contractions.
, \A nurse is teaching a group of student nurses about amniotic fluid. Which of the following
statements by the student nurse reflects an understanding of the fetus's contribution to the
quality of amniotic fluid? Select all that apply.
a) "The fetus contributes to the volume of amniotic fluid by excreting urine."
b) "Approximately 400 mL of amniotic fluid flows out of the fetal lungs each day."
c) "The fetus swallows about 600 mL of the fluid in 24 hours."
d) "A fetus can move freely and develop normally, even if there is no amniotic fluid." -
ANS-A, B, C
"The fetus contributes to the volume of amniotic fluid by excreting urine." Approximately 400
mL of amniotic fluid flows out of the fetal lungs each day. The fetus swallows about 600 mL
of the fluid in 24 hours. A normal volume of amniotic fluid is necessary for good fetal
movement. Normal movement is necessary for good musculoskeletal development.
\A pregnant client asks why ultrasound is used so frequently during pregnancy. The nurse's
response is based on her knowledge that the advantages of ultrasound include which of the
following? Select all that apply.
a)"It is noninvasive and painless."
b)"It can be used to estimate gestational age."
c)"Results are immediate."
d)"The ultrasound is the only test to determine gender." - ANS-A, B, C
The ability to establish fetal age accurately by ultrasound is lost in the third trimester
because fetal growth is not as uniform as it is in the first two trimesters; however, ultrasound
can be used to approximate gestational age within 1-3 weeks' accuracy during the third
trimester. A comprehensive ultrasound is used to detect anatomical defects, not gestational
age. Ultrasound is not used to determine gender.
\A pregnant client is concerned about a blow to the abdomen if she continues to play
basketball during her pregnancy. The nurse's response is based upon her knowledge of
which of the following facts concerning amniotic fluid?
a) The total amount of amniotic fluid during pregnancy is 300 mL.
b) Amniotic fluid functions as a cushion to protect against mechanical injury.
c) The fetus does not contribute to the production of amniotic fluid.
d) Amniotic fluid is slightly acidic. - ANS-B
During pregnancy, the amniotic fluid protects against injury. After 20 weeks of pregnancy,
fluid volume ranges from 700-1000 mL. Some of the amniotic fluid is contributed by the
fetus's excreting urine. Amniotic fluid is slightly alkaline.
\A prenatal client at 22 weeks gestation is scheduled for an amniocentesis. Which nursing
action would apply to any client undergoing this procedure? Select all that apply.
a)Assess for bleeding.
b)Administer Rh immune globulin to the client.
c)Cleanse skin with alcohol.
d)Assess vital signs and fetal heart rate. - ANS-A, D
