Maternal/Newborn Test 2 NCLEX
Questions
A charge nurse is discussing the potential causes of variable decelerations with a
newly licensed nurse.
Which of the following should she include in the teaching? (Select all that apply.)
A. Short umbilical cord
B. Polyhydramnios
C. Umbilical cord compression
D. Uteroplacental insufficiency
E. Nuchal cord - ------------ANS: A, C, E
A client at a 6-week postpartum checkup comes in and says, "I'm so sad. I hate
taking care of the baby. I am just a terrible mother and I wish it would go away." The
LPN's first priority should be to perform:
A. an assessment for spiritual support
B. a review of her routine blood work that was drawn
C. a risk assessment for harm
D. a support system assessment - ------------ANS: C. a risk assessment for harm
A client is in the transition phase of labor irritably tells the nurse not to touch her. The
nurses best action would be to:
A. Ask for someone else to support the client
B. Tell the client to be cooperative and do as you say
C. Remind the client to focus on relaxation and breathing
D. Ask the client to push actively with each contraction - ------------ANS: C. Remind
the client to focus on relaxation and breathing
A client is scheduled for discharge 3 days post-cesarean delivery. The LPN enters to
find her crying and with no obvious evidence of a physical problem. The nurse
should:
A. say, "Can I call your minister for you?"
B. say, "You seem upset. Would you like to talk about it?"
C. say, "This is just postpartum blues and they will go away in a few days"
D. leave her alone and let her collect her emotions - ------------ANS: B. say, "You
seem upset. Would you like to talk about it?"
A client reports that her contractions started about 1 hr ago and decreased after
drinking two glasses of water and walking. She reports that contractions occur every
10 to 15 min and that she hasn't had any fluid leaking or vaginal bleeding. The nurse
should recognize that the client is experiencing which of the following?
,A. Braxton Hicks contractions
B. Rupture of membranes
C. Fetal descent
D. True contractions - ------------ANS: A. Braxton Hicks contractions
A client who is breastfeeding has mastitis. Which of the following should the nurse
reinforce to the client?
A. Use a breast pump until the condition subsides, and stop breastfeeding.
B. Nurse the infant only on the unaffected breast until resolved.
C. Completely empty each breast at each feeding.
D. Wear a breast binder until lactation has ceased. - ------------ANS: C. Completely
empty each breast at each feeding.
A newly licensed nurse is reviewing a fetal monitor tracing of a client in active labor
with the charge nurse. Which of the following should the nurse recognize as being
associated with fetal hypoxia? (Select all that apply.)
A. Fetal bradycardia
B. Fetal tachycardia
C. Absence of FHR variability
D. Early decelerations
E. Variable decelerations - ------------ANS: ABCE
A nurse in a provider's office is caring for a client who is breastfeeding and is 4 days
postpartum. The client reports breast engorgement. Which of the following
recommendations should the nurse make?
A. Apply cold cabbage leaves between feedings.
B. Place warm compresses right after feedings.
C. Apply breast milk to the nipples and allow them to air dry.
D. Use the various newborn positions for feedings. - ------------ANS: A. Apply cold
cabbage leaves between feedings.
A nurse is assisting with the care of a client being induced for labor who is being
monitored by an external electronic fetal monitor. The nurse notes that the FHR
variability is decreased and resembles a straight line. The client has not received any
pain medication. Which of the following should occur first before the nurse can apply
an internal scalp electrode?
A. Dilation
B. Rupture of membranes
C. Effacement
D. Engagement - ------------ANS: B. Rupture of membranes
A nurse is assisting with the care of a client in active labor. Which of the following will
Leopold maneuvers assist the nurse in determining? (Select all that apply.)
A. Presenting part
, B. Fetal attitude
C. Fetal lie
D. Position of the cervix
E. Degree of fetal descent into the pelvis - ------------ANS: A, B, C, E
A nurse is assisting with the care of a client who is in labor and observes late
decelerations on the electronic fetal monitor. Which of the following is the first action
the nurse should take?
A. Assist the client into the left-lateral position.
B. Assist with the application of a fetal scalp electrode. C. Assist with the insertion of
an IV catheter.
D. Assist the nurse with a vaginal exam. - ------------ANS: A. Assist the client into the
left-lateral position.
A nurse is assisting with the care of a client who is primipara and active labor who
received meperidine (Demerol) 50 mg IV bolus for pain 30 min prior to precipitous
delivery. The nurse should know that naloxone (Narcan) is to be administered to the
newborn for which of the following?
A. Hypoglycemia
B. Hyperbilirubinemia
C. Respiratory depression
D. Maternal substance use disorder - ------------ANS: C. Respiratory depression
Naloxone (Narcan) is an opioid antagonist that should be administered to the
newborn
for respiratory depression.
A nurse is assisting with the management of a client who is in active labor. Which of
the following
findings should the nurse report following epidural placement?
A. Blood pressure 89/54 mm Hg
B. 2+ pedal edema
C. Early decelerations
D. Fetal heart rate 160 - ------------ANS: A. Blood pressure 89/54 mm Hg
A nurse is caring
mother asks him to bring her the newborn. Which of the following is an appropriate
nursing intervention to promote father-infant bonding?
for a family who has a newborn. The father appears very anxious and nervous when
the
A. Hand the father the newborn and insist he change the diaper.
B. Ask the father why he is so anxious and nervous.
C. Tell the father that he will get used to the newborn in time.
D. Provide education about newborn care when the father is present. -
------------ANS: D. Provide education about newborn care when the father is present.
Questions
A charge nurse is discussing the potential causes of variable decelerations with a
newly licensed nurse.
Which of the following should she include in the teaching? (Select all that apply.)
A. Short umbilical cord
B. Polyhydramnios
C. Umbilical cord compression
D. Uteroplacental insufficiency
E. Nuchal cord - ------------ANS: A, C, E
A client at a 6-week postpartum checkup comes in and says, "I'm so sad. I hate
taking care of the baby. I am just a terrible mother and I wish it would go away." The
LPN's first priority should be to perform:
A. an assessment for spiritual support
B. a review of her routine blood work that was drawn
C. a risk assessment for harm
D. a support system assessment - ------------ANS: C. a risk assessment for harm
A client is in the transition phase of labor irritably tells the nurse not to touch her. The
nurses best action would be to:
A. Ask for someone else to support the client
B. Tell the client to be cooperative and do as you say
C. Remind the client to focus on relaxation and breathing
D. Ask the client to push actively with each contraction - ------------ANS: C. Remind
the client to focus on relaxation and breathing
A client is scheduled for discharge 3 days post-cesarean delivery. The LPN enters to
find her crying and with no obvious evidence of a physical problem. The nurse
should:
A. say, "Can I call your minister for you?"
B. say, "You seem upset. Would you like to talk about it?"
C. say, "This is just postpartum blues and they will go away in a few days"
D. leave her alone and let her collect her emotions - ------------ANS: B. say, "You
seem upset. Would you like to talk about it?"
A client reports that her contractions started about 1 hr ago and decreased after
drinking two glasses of water and walking. She reports that contractions occur every
10 to 15 min and that she hasn't had any fluid leaking or vaginal bleeding. The nurse
should recognize that the client is experiencing which of the following?
,A. Braxton Hicks contractions
B. Rupture of membranes
C. Fetal descent
D. True contractions - ------------ANS: A. Braxton Hicks contractions
A client who is breastfeeding has mastitis. Which of the following should the nurse
reinforce to the client?
A. Use a breast pump until the condition subsides, and stop breastfeeding.
B. Nurse the infant only on the unaffected breast until resolved.
C. Completely empty each breast at each feeding.
D. Wear a breast binder until lactation has ceased. - ------------ANS: C. Completely
empty each breast at each feeding.
A newly licensed nurse is reviewing a fetal monitor tracing of a client in active labor
with the charge nurse. Which of the following should the nurse recognize as being
associated with fetal hypoxia? (Select all that apply.)
A. Fetal bradycardia
B. Fetal tachycardia
C. Absence of FHR variability
D. Early decelerations
E. Variable decelerations - ------------ANS: ABCE
A nurse in a provider's office is caring for a client who is breastfeeding and is 4 days
postpartum. The client reports breast engorgement. Which of the following
recommendations should the nurse make?
A. Apply cold cabbage leaves between feedings.
B. Place warm compresses right after feedings.
C. Apply breast milk to the nipples and allow them to air dry.
D. Use the various newborn positions for feedings. - ------------ANS: A. Apply cold
cabbage leaves between feedings.
A nurse is assisting with the care of a client being induced for labor who is being
monitored by an external electronic fetal monitor. The nurse notes that the FHR
variability is decreased and resembles a straight line. The client has not received any
pain medication. Which of the following should occur first before the nurse can apply
an internal scalp electrode?
A. Dilation
B. Rupture of membranes
C. Effacement
D. Engagement - ------------ANS: B. Rupture of membranes
A nurse is assisting with the care of a client in active labor. Which of the following will
Leopold maneuvers assist the nurse in determining? (Select all that apply.)
A. Presenting part
, B. Fetal attitude
C. Fetal lie
D. Position of the cervix
E. Degree of fetal descent into the pelvis - ------------ANS: A, B, C, E
A nurse is assisting with the care of a client who is in labor and observes late
decelerations on the electronic fetal monitor. Which of the following is the first action
the nurse should take?
A. Assist the client into the left-lateral position.
B. Assist with the application of a fetal scalp electrode. C. Assist with the insertion of
an IV catheter.
D. Assist the nurse with a vaginal exam. - ------------ANS: A. Assist the client into the
left-lateral position.
A nurse is assisting with the care of a client who is primipara and active labor who
received meperidine (Demerol) 50 mg IV bolus for pain 30 min prior to precipitous
delivery. The nurse should know that naloxone (Narcan) is to be administered to the
newborn for which of the following?
A. Hypoglycemia
B. Hyperbilirubinemia
C. Respiratory depression
D. Maternal substance use disorder - ------------ANS: C. Respiratory depression
Naloxone (Narcan) is an opioid antagonist that should be administered to the
newborn
for respiratory depression.
A nurse is assisting with the management of a client who is in active labor. Which of
the following
findings should the nurse report following epidural placement?
A. Blood pressure 89/54 mm Hg
B. 2+ pedal edema
C. Early decelerations
D. Fetal heart rate 160 - ------------ANS: A. Blood pressure 89/54 mm Hg
A nurse is caring
mother asks him to bring her the newborn. Which of the following is an appropriate
nursing intervention to promote father-infant bonding?
for a family who has a newborn. The father appears very anxious and nervous when
the
A. Hand the father the newborn and insist he change the diaper.
B. Ask the father why he is so anxious and nervous.
C. Tell the father that he will get used to the newborn in time.
D. Provide education about newborn care when the father is present. -
------------ANS: D. Provide education about newborn care when the father is present.
