NCLEX Maternity Nursing Questions and Answers, Exams of Nursing

Download NCLEX Maternity Nursing Questions and Answers and more Exams Nursing in PDF only on Docsity! NCLEX Maternity Nursing Questions and Answers The nursing student is preparing to teach a prenatal class about fetal circulation. Which statement should be included in the teaching plan? "One artery carries oxygenated blood from the placenta to the fetus." 2."Two arteries carry oxygenated blood from the placenta to the fetus." 3. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 4. "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta." - Ans 3. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." A nursing student is assigned to care for a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement is correct regarding the ductus venosus? 1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria 3. Connects the umbilical vein to the inferior vena cava 4. Connects the umbilical artery to the inferior vena cava - Ans 3. Connects the umbilical vein to the inferior vena cava A pregnant client tells the clinic nurse that she wants to know the gender of her baby as soon as it can be determined. The nurse understands that the client should be able to find out the gender at 12 weeks' gestation because of which factor? 1. The appearance of the fetal external genitalia 2. The beginning of differentiation in the fetal groin 3. The fetal testes are descended into the scrotal sac 4. The internal differences in males and females become apparent - Ans 1. The appearance of the fetal external genitalia The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's heart rate. 3. Notify the health care provider (HCP). 4. Tell the client that the fetal heart rate is normal. - Ans 3. Notify the health care provider (HCP). The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? 1. "It promotes the fertilized ovum's chances of survival." 2. "It promotes the fertilized ovum's exposure to estrogen and progesterone." 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 4. "It promotes the fertilized ovum's exposure to luteinizing hormone and follicle- stimulating hormone." - Ans 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." The nursing instructor asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid? Select all that apply. 1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus - Ans 1. Allows for fetal movement 4. A cesarean section will be necessary if vaginal lesions are present at the time of labor. - Ans 4. A cesarean section will be necessary if vaginal lesions are present at the time of labor. The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sign. This finding is most closely associated with which characteristic? 1. A softening of the cervix 2. The presence of fetal movement 3. The presence of human chorionic gonadotropin in the urine 4. A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus - Ans 1. A softening of the cervix A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19, 2014. Using Nägele's rule, which expected date of delivery should the nurse document in the client's chart? 1. July 12, 2014 2. July 26, 2015 3. August 12, 2015 4. August 26, 2015 - Ans 2. July 26, 2015 The health care provider (HCP) is assessing the client for the presence of ballottement. To make this determination, the HCP should take which action? 1. Auscultate for fetal heart sounds. 2. Assess the cervix for compressibility. 3. Palpate the abdomen for fetal movement. 4. Initiate a gentle upward tap on the cervix. - Ans 4. Initiate a gentle upward tap on the cervix. A pregnant client asks the nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation? - Ans 14 and 18 The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which finding concerns the nurse and indicates the need for follow-up? - Ans Fetal heart rate of 180 beats/minute The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? - Ans G = 2, T = 1, P = 0, A = 0, L = 1 The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? - Ans An informed consent needs to be signed before the procedure. A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? - Ans "The vaginal discharge may be bothersome, but is a normal occurrence." The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding? - Ans Normal A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? - Ans A normal test result A pregnant client tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice? - Ans Hemoglobin 9.1 g/dL A pregnant client asks the nurse about the types of exercises that are allowable during pregnancy. The nurse should tell that client that which exercise is safest? - Ans Swimming A health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client? - Ans "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel." The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions? - Ans "I should wear knee-high hose, but I should not leave them on longer than 8 hours." A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps? - Ans "Bend your foot toward your body while extending the knee when the cramps occur." A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. - Ans 2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions? - Ans "I need to lie flat on my back to perform the procedure." The nurse is providing instructions regarding treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction? - Ans "I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink." The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide? - Ans Wash the breasts with warm water and keep them dry. The nurse is describing cardiovascular system changes that occur during pregnancy to a client and understands that which finding would be normal for a client in the second trimester? - Ans Increase in pulse rate The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions? - Ans Administer oxygen via face mask. The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider? - Ans Fetal heart rate of 180 beats/minute The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? - Ans 1 cm above the ischial spine A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy? - Ans Increased efficiency of contractions The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? - Ans Variable decelerations A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? - Ans Supine position with a wedge under the right hip The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? - Ans "I will begin abdominal exercises immediately." The 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 beats/minute. Which nursing action is most appropriate? - Ans Notify the health care provider (HCP). The 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 action is most appropriate? - Ans Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? - Ans Assess the baseline fetal heart rate. The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? - Ans "My contractions will increase in duration and intensity." Which assessment finding following an amniotomy should be conducted first? - Ans Fetal heart rate pattern The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? - Ans Rest between contractions The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? - Ans Discontinue the infusion of oxytocin (Pitocin). The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? - Ans Uterine tenderness The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? - Ans Obtain equipment for a manual pelvic examination. An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? - Ans Delivery of the fetus The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? - Ans The client has a history of cardiac disease The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia? - Ans Hypotonic After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery? - Ans Support the mother in her reaction to the newborn infant. The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise? - Ans Persistent nonreassuring fetal heart rate The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? - Ans Provide pain relief measures. The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? - Ans Perform a vaginal examination every shift The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? - Ans Monitoring the fetal heart rate Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? - Ans Administer oxygen, 8 to 10 L/minute, via face mask The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? - Ans Hemorrhage The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply. - Ans 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6.