MATERNITY NCLEX QUESTIONS
1. Adverse effects of Oxytocin (Pitocin) include ____.
A. Hypertension
B. Hypotension
C. Bradycardia
D. Diarrhea - ANS-Answer: B
\1. The fetal monitor of a woman currently in active labor on Pitocin shows decelerations
appearing to the right of every contraction. What is the priority nursing intervention?
A) Notify the provider
B) Administer oxygen via non-rebreather at 8-10 L/min and elevate the clients legs
C) Continue with labor support because these are normal during labor, as long as the fetus
HR goes back to baseline after each deceleration
D) Immediately turn off Pitocin and place client in side-lying position - ANS-Answer/rationale:
D
While you should notify the provider and administer oxygen, the first step should be to stop
the mother from having more contractions by turning off the Pitocin because these are late
decelerations and signify the fetus is in distress due to a problem with the placenta. Late
decelerations are not normal and indicate the mother will most likely need an assisted
vaginal birth or a cesarean section.
\2. A 30-year old woman with history of type I DM goes into labor during her 38th week of
gestation. She had regular prenatal care, but her blood glucose levels were poorly
controlled. Infant was delivered by CS due to failure of fetus to descend during second stage
of labor. APGAR scores were 8 and 9 at 1 and 5 minutes, respectively. PE shows an infant
large for gestational age but otherwise normal. Which of the following metabolic
disturbances is most likely to develop:
A) Diabetic Ketoacidosis
B) Hyperthyroidism
C) Persistent Hypoglycemia
D) Transient Hyperglycemia
E) Transient Hypoglycemia - ANS-Answer/rationale: E
Neonates born to patients with poorly controlled diabetes are exposed to high maternal
glucose levels in utero. This results in excessive fetal insulin production and islet
hyperplasia. Fetal hyperinsulinemia persists for several days after birth and predisposes the
infant to transient hypoglycemia.
\2. A woman is 37 weeks pregnant and experiencing contractions lasting an average of 35
seconds with varying frequency, her last ones being 12 minutes apart, 8 minutes apart and
then 25 minutes. She is 2 cm dilated, her physician would explain that she is in the .... -
ANS-1st Stage, latent phase of labor
Rationale:
1st stage: (latent) frequency 5-30 minutes, duration 30-40seconds, dilation 0-3cm
( active) frequency 3-5 minutes, duration 40-70 seconds, dilation 4-7cm
(transition) frequency 2-3 minutes, duration, 45-90 seconds, 10 cm dilated
, Second stage: full dilation, progresses to contractions every 1-2 minutes
Third stage: delivery of the neonate
fourth stage: delivery of the placenta
\2. You as the nurse are about to perform a newborn assessment. Which of the following
tools do you need to have at your side? (Select all that apply).
A. Stethoscope
B. Mask
C. Bulb Syringe
D. Scale
E. BP Cuff - ANS-Answer: A, C, D
\3. After birth, the number of wet diapers is counted to measure the baby's hydration status.
How many wet diapers a day ensures adequate hydration?
A. 2-3
B. 4-5
C. 6-8
D. 9 - ANS-Answer: C
\A 25 year old female is 25 weeks pregnant. she has had one previous pregnancy at 35
weeks and the baby is now 2 years old. she has no history of abortion - ANS-G=2, T=0, P=1,
A= 0, L=1
So I think the answer would be
G=2, T=0, P=1, A= 0, L=1
More complete description of pregnancy outcomesGTPALG-gravidaT-term>37
weeksP-preterm <37 weeksA-abortions (SAB or TAB)L- living children
\A 26 year old woman presents to her OB because she missed her last menstrual period.
She reports fatigue, nausea, and urinary frequency. The provider interprets these findings as
which indication of pregnancy?
A. Probable
B. Presumptive
C. Positive
D. Negative - ANS-A. Probable
\A 34 year old woman at 32 weeks gestation is admitted to the hospital with a severe
headache, blurred vision, and a BP of 160/112. After placing the patient on bed rest, which
of the following nursing actions should the nurse perform next?
A. Obtain the patient's weight
B. Place the patient in the Trendelenburg position
C. Assess the patient's fundal height.
D. Assess the patient's deep tendon reflexes (DTRs) - ANS-Rationale: The correct answer is
D. This patient is presenting with symptoms of severe preeclampsia which is a serious
complication in pregnancy. The medication most commonly used to treat preeclampsia is
magnesium sulfate to produce CNS depression and prevent maternal seizures. Baseline
DTRs should be determined as the nurse should anticipate order for magnesium sulfate.
Depressed DTRs indicate elevated magnesium levels. Placing the patient in the
Trendelenburg position is an inappropriate action for preeclampsia. Assessing the fundal
height is not a priority at this time.
1. Adverse effects of Oxytocin (Pitocin) include ____.
A. Hypertension
B. Hypotension
C. Bradycardia
D. Diarrhea - ANS-Answer: B
\1. The fetal monitor of a woman currently in active labor on Pitocin shows decelerations
appearing to the right of every contraction. What is the priority nursing intervention?
A) Notify the provider
B) Administer oxygen via non-rebreather at 8-10 L/min and elevate the clients legs
C) Continue with labor support because these are normal during labor, as long as the fetus
HR goes back to baseline after each deceleration
D) Immediately turn off Pitocin and place client in side-lying position - ANS-Answer/rationale:
D
While you should notify the provider and administer oxygen, the first step should be to stop
the mother from having more contractions by turning off the Pitocin because these are late
decelerations and signify the fetus is in distress due to a problem with the placenta. Late
decelerations are not normal and indicate the mother will most likely need an assisted
vaginal birth or a cesarean section.
\2. A 30-year old woman with history of type I DM goes into labor during her 38th week of
gestation. She had regular prenatal care, but her blood glucose levels were poorly
controlled. Infant was delivered by CS due to failure of fetus to descend during second stage
of labor. APGAR scores were 8 and 9 at 1 and 5 minutes, respectively. PE shows an infant
large for gestational age but otherwise normal. Which of the following metabolic
disturbances is most likely to develop:
A) Diabetic Ketoacidosis
B) Hyperthyroidism
C) Persistent Hypoglycemia
D) Transient Hyperglycemia
E) Transient Hypoglycemia - ANS-Answer/rationale: E
Neonates born to patients with poorly controlled diabetes are exposed to high maternal
glucose levels in utero. This results in excessive fetal insulin production and islet
hyperplasia. Fetal hyperinsulinemia persists for several days after birth and predisposes the
infant to transient hypoglycemia.
\2. A woman is 37 weeks pregnant and experiencing contractions lasting an average of 35
seconds with varying frequency, her last ones being 12 minutes apart, 8 minutes apart and
then 25 minutes. She is 2 cm dilated, her physician would explain that she is in the .... -
ANS-1st Stage, latent phase of labor
Rationale:
1st stage: (latent) frequency 5-30 minutes, duration 30-40seconds, dilation 0-3cm
( active) frequency 3-5 minutes, duration 40-70 seconds, dilation 4-7cm
(transition) frequency 2-3 minutes, duration, 45-90 seconds, 10 cm dilated
, Second stage: full dilation, progresses to contractions every 1-2 minutes
Third stage: delivery of the neonate
fourth stage: delivery of the placenta
\2. You as the nurse are about to perform a newborn assessment. Which of the following
tools do you need to have at your side? (Select all that apply).
A. Stethoscope
B. Mask
C. Bulb Syringe
D. Scale
E. BP Cuff - ANS-Answer: A, C, D
\3. After birth, the number of wet diapers is counted to measure the baby's hydration status.
How many wet diapers a day ensures adequate hydration?
A. 2-3
B. 4-5
C. 6-8
D. 9 - ANS-Answer: C
\A 25 year old female is 25 weeks pregnant. she has had one previous pregnancy at 35
weeks and the baby is now 2 years old. she has no history of abortion - ANS-G=2, T=0, P=1,
A= 0, L=1
So I think the answer would be
G=2, T=0, P=1, A= 0, L=1
More complete description of pregnancy outcomesGTPALG-gravidaT-term>37
weeksP-preterm <37 weeksA-abortions (SAB or TAB)L- living children
\A 26 year old woman presents to her OB because she missed her last menstrual period.
She reports fatigue, nausea, and urinary frequency. The provider interprets these findings as
which indication of pregnancy?
A. Probable
B. Presumptive
C. Positive
D. Negative - ANS-A. Probable
\A 34 year old woman at 32 weeks gestation is admitted to the hospital with a severe
headache, blurred vision, and a BP of 160/112. After placing the patient on bed rest, which
of the following nursing actions should the nurse perform next?
A. Obtain the patient's weight
B. Place the patient in the Trendelenburg position
C. Assess the patient's fundal height.
D. Assess the patient's deep tendon reflexes (DTRs) - ANS-Rationale: The correct answer is
D. This patient is presenting with symptoms of severe preeclampsia which is a serious
complication in pregnancy. The medication most commonly used to treat preeclampsia is
magnesium sulfate to produce CNS depression and prevent maternal seizures. Baseline
DTRs should be determined as the nurse should anticipate order for magnesium sulfate.
Depressed DTRs indicate elevated magnesium levels. Placing the patient in the
Trendelenburg position is an inappropriate action for preeclampsia. Assessing the fundal
height is not a priority at this time.
