Maternity Intrapartum NCLEX Practice Exam New Latest Version Updated 2023-2024, Exams of Nursing

Download Maternity Intrapartum NCLEX Practice Exam New Latest Version Updated 2023-2024 and more Exams Nursing in PDF only on Docsity! Maternity Intrapartum NCLEX Practice Exam New Latest Version Updated 2023-2024 with All 55 Questions and Answers A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? A. Swelling of the calf in one leg B. Prolonged clotting times C. Decreased platelet count D. Petechiae, oozing from injection sites, and hematuria --------- Correct Answer --------- Correct Answer: A. Swelling of the calf in one leg DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis. Which measure would be least effective in preventing postpartum hemorrhage? A. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered. B. Encourage the woman to void every 2 hours. C. Massage the fundus every hour for the first 24 hours following birth. D. Teach the woman the importance of rest and nutrition to enhance healing. --------- Correct Answer --------- Correct Answer: C. Massage the fundus every hour for the first 24 hours following birth. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Uterine atony is the most common cause of postpartum hemorrhage. Brisk blood flow after delivery of the placenta unresponsive to transabdominal massage should prompt immediate action including bimanual compression of the uterus and use of uterotonic medications. Massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand compresses the fundus from above through the abdominal wall. A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? A. Absence of abdominal pain B. A soft abdomen C. Uterine tenderness/pain D. Painless, bright red vaginal bleeding --------- Correct Answer --------- Correct Answer: C. Uterine tenderness/pain In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompany placental abruption, especially with a central abruption and trapped blood behind the placenta. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding. A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order? A. Prepare the client for an ultrasound. B. Obtain equipment for external electronic fetal heart monitoring. C. Obtain equipment for a manual pelvic examination. D. Prepare to draw a Hgb and Hct blood sample. --------- Correct Answer --------- Correct Answer: C. Obtain equipment for a manual pelvic examination. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for: A. Complete bed rest for the remainder of the pregnancy. B. Delivery of the fetus. C. Strict monitoring of intake and output. D. The need for weekly monitoring of coagulation studies until the time of delivery. ------- -- Correct Answer --------- Correct Answer: B. Delivery of the fetus. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy. 25. Question A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred? A. Hypotonic contractions B. Forceps delivery C. Schultz delivery D. Weak bearing down efforts --------- Correct Answer --------- Correct Answer: B. Forceps delivery. Excessive fundal pressure, forceps delivery, violent bearing down efforts, tumultuous labor, and shoulder dystocia can place a woman at risk for traumatic uterine rupture. When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as: A. An acceleration B. An early elevation C. A sonographic motion D. A tachycardia --------- Correct Answer --------- Correct Answer: A. An acceleration An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute. A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is: A. Breech B. Transverse C. Occiput anterior D. Occiput posterior --------- Correct Answer --------- Correct Answer: D. Occiput posterior A persistent occiput posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain. The breathing technique that the mother should be instructed to use as the fetus' head is crowning is: A. Blowing B. Slow chest C. Shallow D. Accelerated-decelerated --------- Correct Answer --------- Correct Answer: A. Blowing. Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head. A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? A. Three contractions occurring within a 10-minute period B. Increased urinary output C. Adequate resting tone of the uterus palpated between contractions D. A fetal heart rate of 90 beats per minute --------- Correct Answer --------- Correct Answer: D. A fetal heart rate of 90 beats per minute A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue Pitocin. A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? A. Placing the client on complete bed rest B. Continuous electronic fetal monitoring C. An IV infusion of antibiotics D. Placing a code cart at the client's bedside --------- Correct Answer --------- Correct Answer: B. Continuous electronic fetal monitoring Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin. Continuous electronic fetal monitoring should be performed for a minimum of 20 minutes before starting oxytocin and should be continued until the baby is delivered. A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? A. Encourage the client's coach to continue to encourage breathing exercises. B. Encourage the client to continue pushing with each contraction. C. Continue monitoring the fetal heart rate. D. Notify the physician or nurse-midwife. --------- Correct Answer --------- Correct Answer: D. Notify the physician or nurse-midwife. A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse-midwife needs to be notified. A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? A. Document the findings and tell the mother that the monitor indicates fetal well-being. B. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. C. Notify the physician or nurse-midwife of the findings. D. Reposition the mother and check the monitor for changes in the fetal tracing. --------- Correct Answer --------- Correct Answer: A. Document the findings and tell the mother that the monitor indicates fetal well-being. Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve. A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After the attachment of the monitor, the initial nursing assessment is which of the following? A. Identifying the types of accelerations B. Assessing the baseline fetal heart rate C. Determining the frequency of the contractions D. Determining the intensity of the contractions --------- Correct Answer --------- Correct Answer: B. Assessing the baseline fetal heart rate Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur. Options 1 and 3 are important to assess, but not as the first priority. A nurse is reviewing the record of a client in the labor room and notes that the nurse- midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal presenting part is: A. 1 cm above the ischial spine B. 1 fingerbreadth below the symphysis pubis C. 1 inch below the coccyx D. 1 inch below the iliac crest --------- Correct Answer --------- Correct Answer: A. 1 cm above the ischial spine Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. At -1 station, the fetal presenting part is 1 cm above the ischial spines. A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client's hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following? A. A loud mouth B. Low self-esteem C. Hemorrhage D. Postpartum infections --------- Correct Answer --------- Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Good nutrition is the best way to prevent anemia if the woman is pregnant or trying to become pregnant. Eating foods high in iron content (such as dark green leafy vegetables, red meat, fortified cereals, eggs, and peanuts vitamins to ensure that the woman has enough iron and folic acid. Make sure to get at least 27 mg of iron each day. If the woman does become anemic during pregnancy, it can usually be treated by taking iron supplements. A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: A. Hematoma B. Placenta previa Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate labor that slows. Hypotonic labor is an abnormal labor pattern, notable especially during the active phase of labor, characterized by poor and inadequate uterine contractions that are ineffective to cause cervical dilation, effacement, and fetal descent, leading to a prolonged or protracted delivery. A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to: A. Monitor the Pitocin infusion closely B. Provide pain relief measures C. Prepare the client for an amniotomy D. Promote ambulation every 30 minutes --------- Correct Answer --------- Correct Answer: B. Provide pain relief measures Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. The psychological preparation of patients before labor appears to improve pain tolerance during labor. This should begin during routine antenatal visits and the counseling for labor analgesia. This preparation may serve to reduce the need for neuraxial analgesia in labor, which is a probable predisposing factor for hypocontractile labor. A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority? A. Keeping the significant other informed of the progress of the labor. B. Providing comfort measures. C. Monitoring fetal heart rate. D. Changing the client's position frequently. --------- Correct Answer --------- Correct Answer: C. Monitoring fetal heart rate. The priority is to monitor the fetal heart rate. The continuous monitoring of the external fetal heart rate provides insight into fetal well-being. The assessment of the fetal heart rate could be performed utilizing external or internal fetal heart rate monitoring A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor: A. Over the fetus that is most anterior to the mother's abdomen. B. Over the fetus that is most posterior to the mother's abdomen. C. So that each fetal heart rate is monitored separately. D. So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus. --------- Correct Answer --------- Correct Answer: C. So that each fetal heart rate is monitored separately. In a client with a multifetal pregnancy, each fetal heart rate is monitored separately. Simultaneous monitoring of twins is preferable to non simultaneous monitoring to discriminate between their separate FHRs A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? A. Disseminated intravascular coagulation B. Chronic hypertension C. Infection D. Hemorrhage --------- Correct Answer --------- Correct Answer: D. Hemorrhage Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. Vaginal bleeding secondary to placenta previa can lead to postpartum hemorrhage requiring a blood transfusion, hysterectomy, maternal intensive care admission, septicemia, and maternal death. A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? A. The umbilical cord shortens in length and changes in color B. A soft and boggy uterus C. Maternal complaints of severe uterine cramping D. Changes in the shape of the uterus --------- Correct Answer --------- Correct Answer: D. Changes in the shape of the uterus Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus (vaginal), a firmly contracted uterus, and the uterus changing from a discoid (like a disk) to a globular (like a globe) shape. The client may experience vaginal fullness, but not severe uterine cramping. A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? A. Place the client in Trendelenburg's position. B. Call the delivery room to notify the staff that the client will be transported immediately. C. Gently push the cord into the vagina. D. Find the closest telephone and stat page the physician. --------- Correct Answer ------- -- Correct Answer: A. Place the client in Trendelenburg's position. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation. Correct Answer: A. Place the client in Trendelenburg's position. place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. During the period of induction of labor, a client should be observed carefully for signs of: A. Severe pain B. Uterine tetany C. Hypoglycemia D. Umbilical cord prolapse --------- Correct Answer --------- Correct Answer: B. Uterine tetany. Uterine tetany could result from the use of oxytocin to induce labor. Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise. A client arrives at the hospital in the second stage of labor. The fetus' head is crowning, the client is bearing down, and the birth appears imminent. The nurse should: A. Transfer her immediately by stretcher to the birthing unit. B. Tell her to breathe through her mouth and not to bear down. C. Instruct the client to pant during contractions and to breathe through her mouth. D. Support the perineum with the hand to prevent tearing and tell the client to pant. ------ --- Correct Answer --------- Correct Answer: D. Support the perineum with the hand to prevent tearing and tell the client to pant. Gentle pressure is applied to the baby's head as it emerges so it is not born too rapidly. The head is never held back, and it should be supported as it emerges so there will beno vaginal lacerations. It is impossible to push and pant at the same time. A laboring client is to have a pudendal block. The nurse plans to tell the client that once the block is working, she: A. Will not feel the episiotomy B. May lose bladder sensation C. May lose the ability to push D. Will no longer feel contractions --------- Correct Answer --------- Correct Answer: C. May lose the ability to push A pudendal block is a local anesthetic injection given as a treatment for pain in the second stage of labor (pushing) just before the delivery of the baby. It is administered through the vaginal wall and into the pudendal nerve in the pelvis, providing anesthesia to the perineum. The numbing effect of the pudendal block may cause the woman to D. A classification according to the fetal part. --------- Correct Answer --------- Correct Answer: A. Fetal body part that enters the maternal pelvis first. Presentation is the fetal body part that enters the pelvis first; it's classified by the presenting part; the three main presentations are cephalic/occipital, breech, and shoulder. A client is admitted to the L & D suite at 36 weeks' gestation. She has a history of C- section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms? A. Hysteria compounded by the flu B. Placental abruption C. Uterine rupture D. Dysfunctional labor --------- Correct Answer --------- Correct Answer: C. Uterine rupture. Uterine rupture is a medical emergency that may occur before or during labor. Signs and symptoms typically include abdominal pain that may ease after uterine rupture, vomiting, vaginal bleeding, hypovolemic shock, and fetal distress. With placental abruption, the client typically complains of vaginal bleeding and constant abdominal pain. Upon completion of a vaginal examination on a laboring woman, the nurse records 50%, 6 cm, -1. Which of the following is a correct interpretation of the data? A. Fetal presenting part is 1 cm above the ischial spines. B. Effacement is 4 cm from completion. C. Dilation is 50% completed. D. Fetus has achieved passage through the ischial spines. --------- Correct Answer ------- -- Correct Answer: A. Fetal presenting part is 1 cm above the ischial spines. Station of - 1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. A station of zero would indicate that the presenting part has passed through the inlet and is at the level of the ischial spines or is engaged. Which of the following findings meets the criteria of a reassuring FHR pattern? A. FHR does not change as a result of fetal activity. B. Average baseline rate ranges between 100 - 140 BPM. C. Mild late deceleration patterns occur with some contractions. D. Variability averages between 6 - 10 BPM. --------- Correct Answer --------- Correct Answer: D. Variability averages between 6 - 10 BPM. Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system. The FHR is under constant variation from the baseline. This variability reflects a healthy nervous system, chemoreceptors, baroreceptors and cardiac responsiveness. Prematurity decreases variability; therefore, there is little rate fluctuation before 28 weeks. Variability should be normal after 32 weeks. Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse's immediate action would be to: A. Change the woman's position B. Stop the Pitocin C. Elevate the woman's legs D. Administer oxygen via a tight mask at 8 to 10 liters/minute --------- Correct Answer ---- ----- Correct Answer: B. Stop the Pitocin Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocin which stimulates the uterus to contract. The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be: A. Severe postpartum headache B. Limited perception of bladder fullness C. Increase in respiratory rate D. Hypotension --------- Correct Answer --------- Correct Answer: D. Hypotension. Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain adequate blood pressure. Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: A. Uses soap and warm water to wash the vulva and perineum. B. Washes from symphysis pubis back to episiotomy. C. Changes her perineal pad every 2 - 3 hours. D. Uses the peri bottle to rinse upward into her vagina. --------- Correct Answer --------- Correct Answer: D. Uses the peri bottle to rinse upward into her vagina. The peri bottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix. When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically: A. Express a strong need to review events and her behavior during the process of labor and birth. B. Exhibit a reduced attention span, limiting readiness to learn. C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. D. Have reestablished her role as a spouse/partner. --------- Correct Answer --------- Correct Answer: C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. One week after birth the woman should exhibit behaviors characteristic of the taking- hold stage as described in option C. This stage lasts for as long as 4 to 5 weeks after birth. Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A. Tell the woman she can rest after she feeds her baby. B. Recognize this as a behavior of the taking-hold stage. C. Record the behavior as ineffective maternal-newborn attachment. D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time. --------- Correct Answer --------- Correct Answer: D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well- being in order to effectively care for their baby. Parents can facilitate the adjustment of their other children to a new baby by: A. Having the children choose or make a gift to give to the new baby upon its arrival home. B. Emphasizing activities that keep the new baby and other children together. C. Having the mother carry the new baby into the home so she can show the other children the new baby. D. Reducing stress on others by limiting their involvement in the care of the new baby. -- ------- Correct Answer --------- Correct Answer: A. Having the children choose or make a gift to give to the new baby upon its arrival home. Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them.