Maternity Nclex style

Questions and Answers

After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which of the following purposes stated by the client would indicate to the nurse that the teaching was effective?

Ensures quick placenta delivery.

Enlarges the pelvic inlet.

Prevents perineal edema.

Shortens the second stage of labor. (correct)

A primigravida client at about 35 weeks gestation in active labor has had no prenatal care and admitted to cocaine use during the pregnancy. Which of the following persons must the nurse notify?

Nursing unit manager so appropriate agencies can be notified. (correct)

Physician who will attend the delivery of the infant.

Head of the hospital’s security department.

Chaplain in case the fetus dies in utero.

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse in charge should include which of the following?

The injection will provide immunity against the 7-day measles.

The vaccine prevents a future fetus from developing congenital anomalies.

The client should avoid contact with children diagnosed with rubella.

Pregnancy should be avoided for 3 months after the immunization. (correct)

A client with eclampsia begins to experience a seizure. Which of the following would the nurse in charge do first?

Maintain a patent airway. Signup and view all the answers

While caring for a multigravida client in early labor in a birthing center, which of the following foods would be best if the client requests a snack?

Cereal with milk Signup and view all the answers

The multigravida mother with a history of rapid labor who is in active labor calls out to the nurse, 'The baby is coming!' Which of the following would be the nurse's first action?

Contact the birth attendant. Signup and view all the answers

Which behaviors would be exhibited during the letting-go phase of maternal role adaptation? Select all that apply.

Defining one's individual roles. Signup and view all the answers

While making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically:

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. Signup and view all the answers

Which of the following is the most common kind of placental adherence seen in pregnant women?

Accreta Signup and view all the answers

A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time?

Maternal serum alpha-fetoprotein (MSAFP) Signup and view all the answers

Which of the following statements regarding the contraction stress test (CST) is true?

Is considered to have a negative result if no late decelerations are observed with the contractions. Signup and view all the answers

Which option is not included as a category for evaluating high-risk pregnancy based on threats to the health of the woman?

Geographic Signup and view all the answers

Which statement indicates a 36-week pregnant woman's correct understanding of a nonstress test?

This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby. Signup and view all the answers

What is an appropriate indicator for performing a contraction stress test?

History of preterm labor and intrauterine growth restriction. Signup and view all the answers

Along with ultrasound, what would be another tool useful in confirming the diagnosis of fetal growth restriction?

Doppler blood flow analysis Signup and view all the answers

Which instructions could be included in the plan of care for a daily fetal movement count (DFMC)? Select all that apply.

Monitor fetal activity two times a day either after meals or before bed for a period of 2 hours or until 10 fetal movements are noted. Signup and view all the answers

Which intervention would be included in the nurse’s plan of care after an amniocentesis?

Administer RhoGAM to the patient if she is Rh-negative. Signup and view all the answers

Regarding small-for-gestational-age (SGA) infants and intrauterine growth restriction (IUGR), which statement is true?

Infants with asymmetric IUGR have the potential for normal growth and development. Signup and view all the answers

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Which nursing diagnosis has the highest priority?

Alteration in comfort related to nausea and abdominal distention. Signup and view all the answers

What type of disease causes infections in babies that can be prevented by using antibiotic ointment in the eyes of the newborn?

Gonorrhea Signup and view all the answers

A new mother is having trouble breastfeeding her newborn. Which intervention should the nurse implement?

Encourage the mother to stop feeding for a few minutes and comfort the infant. Signup and view all the answers

For which of the following would the nurse be alert in a postpartum patient who was in labor for 30 hours and had ruptured membranes for 24 hours?

Endometritis Signup and view all the answers

Which client statement indicates that further instruction is needed about the purpose of the ultrasound prior to amniocentesis?

The test will determine where to insert the needle. Signup and view all the answers

Which drug would the nurse expect to administer if a postpartum client develops complications related to heparin therapy?

Protamine sulfate Signup and view all the answers

What is the expected intervention for a 3-day-old neonate receiving phototherapy for jaundice?

Notify the physician if the skin becomes bronze in color. Signup and view all the answers

Which area identified by a client seeking a bilateral pudendal block would indicate effective teaching regarding anesthesia?

Perineum Signup and view all the answers

What statement indicates that a client understands self-care measures for common discomforts of pregnancy?

Nausea and vomiting can be decreased if I eat a few crackers before rising. Signup and view all the answers

What phase of postpartum psychological adaptation would a client be in 48 hours after delivery?

Taking in Signup and view all the answers

What is the usual treatment for a patient diagnosed with partial placenta previa?

Activity limited to bed rest Signup and view all the answers

Which measure should the nurse include in the teaching plan to prevent breast engorgement?

Breastfeeding the neonate at frequent intervals. Signup and view all the answers

What is indicated by a neonate throwing out its arms and hands during an accidental bump of the bassinet?

Startle reflex Signup and view all the answers

Which exercise should the nurse suggest to a primigravida client at 25 weeks gestation with lower back aches?

Tailor sitting Signup and view all the answers

What should the nurse do first upon observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?

Secure the diaper tightly to apply pressure on the site. Signup and view all the answers

Which assessment finding would be expected in a pregnant client with abruption placenta?

Rigid, board-like abdomen Signup and view all the answers

What is the nurse's most appropriate action when a client in active labor with twins is observed to have contractions every 7 to 8 minutes?

Note the fetal heart rate patterns. Signup and view all the answers

Which means of stimulating sound can elicit the best response in a neonate when the nurse discusses sound stimulation?

High-pitched speech with tonal variations. Signup and view all the answers

What phase of labor is a multipara likely in if her cervix is at 8 cm, completely effaced, and at 0 station?

Active phase Signup and view all the answers

How should the nurse respond to a pregnant patient asking if she can take castor oil for constipation?

No, it can initiate premature uterine contractions. Signup and view all the answers

In a patient presenting with abdominal cramping and vaginal bleeding at 14 weeks pregnant, what is the primary nursing diagnosis?

Anticipatory grieving Signup and view all the answers

Which factors determine the type of molding observed in a neonate's head immediately after delivery?

Fetal body flexion or extension Signup and view all the answers

What must occur before an internal electronic fetal monitoring device can be applied during active labor?

The membranes must rupture. Signup and view all the answers

In the early part of the first stage of labor, where is the pain likely to be most intense for a primigravida?

Around the pelvic girdle Signup and view all the answers

What risk is associated with a female patient taking a progestin-only oral contraceptive or mini pill?

Tubal or ectopic pregnancy Signup and view all the answers

What symptoms are likely to be observed in a patient with pregnancy-induced hypertension?

Proteinuria, headaches, double vision Signup and view all the answers

Why should the nurse monitor a patient’s fluid intake and output closely during intravenous administration of oxytocin?

Oxytocin causes water intoxication. Signup and view all the answers

What is a common source of radiant heat loss in neonates?

Cool incubator walls Signup and view all the answers

What adverse effect is most likely to occur after administering bethanechol to a patient with urine retention?

Nausea and vomiting Signup and view all the answers

What is the shortest but most difficult part of the first stage of labor?

Transitional phase Signup and view all the answers

What should a nurse suggest to a postpartum patient reporting nipple soreness after 3 days of breastfeeding?

Lubricate her nipples with expressed milk before feeding. Signup and view all the answers

At what point should the patient expect to feel fetal movement during pregnancy?

Between 16 and 20 weeks’ gestation. Signup and view all the answers

What are normal lochial findings within the first 24 hours post-delivery?

Bright red blood Signup and view all the answers

What is the first question the nurse should ask when a patient in labor states she attended the hospital clinic for prenatal care?

What is your expected due date? Signup and view all the answers

How frequently should the nurse assess uterine contractions in a patient during the second stage of labor?

Every 15 minutes. Signup and view all the answers

What symptom should a nurse instruct a client in her last trimester to report immediately?

Blurred vision Signup and view all the answers

What indicates a genetic risk factor in reviewing a patient’s prenatal history?

The patient has a child with cystic fibrosis. Signup and view all the answers

In the rhythm (calendar-basal body temperature) method of family planning, what indicates the unsafe period for intercourse?

3 full days of elevated basal body temperature and clear, thin cervical mucus. Signup and view all the answers

During a nonstress test (NST), when should the client push the control button?

At the beginning of each fetal movement. Signup and view all the answers

What statement indicates a client understands the symptoms to report during pregnancy?

If I have blurred or double vision, I should call the clinic immediately. Signup and view all the answers

What guidance should the nurse give to a mother with a history of reduction mammoplasty who wants to breastfeed?

You should check with your surgeon to determine whether breastfeeding would be possible. Signup and view all the answers

What would be contraindicated when caring for a client with a fourth-degree laceration following a precipitous delivery?

Instructing the client about the importance of perineal (Kegel) exercises. Signup and view all the answers

In a 14-weeks pregnant patient with an enlarged uterus, what would ultrasonography likely reveal if gestational trophoblastic disease is diagnosed?

Grapelike clusters. Signup and view all the answers

What does a biophysical profile (BPP) score of 8 indicate for a 30-week pregnant client?

The fetus isn't in distress at this time. Signup and view all the answers

What question might the nurse ask a 36-week pregnant client to assess her preparation for parenting?

What changes have you made at home to get ready for the baby? Signup and view all the answers

Given the assessment findings of a client in labor, what is the priority action?

Preparing for immediate delivery. Signup and view all the answers

What is the first intervention for a client in labor when variable decelerations in the fetal heart rate are observed?

Change the client’s position. Signup and view all the answers

Which nursing diagnosis takes priority for a postpartum client who had a vaginal delivery with a midline episiotomy?

Pain related to the type of incision. Signup and view all the answers

What is considered a progressive physiological change in the postpartum period?

Uterine involution Signup and view all the answers

What complication is most likely causing vaginal bleeding in a 39-year-old at 37 weeks gestation after using cocaine?

Abruptio placentae Signup and view all the answers

What should the nurse instruct a client with type 1 diabetes mellitus at 27 weeks gestation regarding management during pregnancy?

Nonstress testing is performed weekly until 32 weeks’ gestation. Signup and view all the answers

What is the approximate time that the blastocyst spends traveling to the uterus for implantation?

5 to 7 days Signup and view all the answers

Study Notes

Postpartum Complications

Monitor for endometritis in patients with prolonged labor and ruptured membranes.
Onset of endometriosis is not typically influenced by labor duration.
Complications such as salpingitis and pelvic thrombophlebitis require vigilance in postpartum assessments.

Ultrasound and Amniocentesis

Ultrasound aids in determining placental location and assessing blood flow through the umbilical cord prior to an amniocentesis.
Statements indicating misunderstanding include believing the ultrasound only locates amniotic fluid, missing its broader diagnostic function.

Heparin Therapy

Protamine sulfate is administered in cases of heparin therapy complications, not calcium gluconate or methylergonovine.

Neonatal Phototherapy

Phototherapy requires frequent assessment of vital signs, supporting skin condition, and parental engagement in the process.

Labor Pain Management

A bilateral pudendal block provides relief primarily to the perineum, indicating effective patient education on pain management.

Common Pregnancy Discomforts

Advise on managing nausea through dietary changes, while emphasizing proper hygiene for nipple care and the importance of breathable underwear to prevent discomfort.

Postpartum Psychological Phases

The client typically enters the taking in phase 48 hours after delivery, indicating engagement with the infant’s needs.

Partial Placenta Previa Management

Treatment usually involves bed rest and close monitoring rather than immediate cesarean delivery, platelet infusion, or labor induction.

Breastfeeding and Engorgement

Strategies to prevent breast engorgement include frequent breastfeeding and appropriate supportive garments, not limiting feeding duration drastically.

Neonate Responses

A startle reflex is identified by sudden movements such as throwing arms and opening hands in response to unexpected stimuli.

Pain Relief Suggestions for Pregnant Clients

Suggest shoulder circling for back pain, focusing on gentle, non-strenuous exercises, rather than tailor sitting or squatting.

Neonate Circumcision Monitoring

Upon observing bright red bleeding post-circumcision, initially apply gentle pressure at the site before further assessment.

Placental Abruption Indicators

Signs of placental abruption include rigid abdominal tone and excessive vaginal bleeding.

Labor Nursing Actions

Priority actions during active labor include monitoring fetal heart patterns and potentially preparing for delivery based on uterine contractions.

Neonatal Sound Stimulation

Engage neonates with high-pitched speech to elicit optimal responses, using tonal variations rather than loud or repetitive sounds.

Phases of Labor

The patient is in the active phase of labor at 8 cm dilation, indicative of a progressive stage towards delivery.

Constipation Remedies in Pregnancy

Advise against castor oil for constipation due to its potential to stimulate premature contractions.

Identifying Complications in Pregnancy

Abdominal cramping and vaginal bleeding warrant immediate evaluation for possible miscarriages or other serious complications.

Factors Causing Neonatal Molding

Factors influencing head molding include fetal positioning during labor rather than maternal age or ethnic background.

EFM Application Prerequisites

Ruptured membranes must be confirmed before applying internal electronic fetal monitoring.

Labor Pain Dynamics

In the early labor stage, pain localization is primarily around the pelvic girdle, evolving throughout labor stages.

Progestin Contraceptive Risks

Progestin-only contraceptives may elevate risks like ectopic pregnancy rather than other listed issues.

Pregnancy-Induced Hypertension Symptoms

Symptoms include proteinuria and headaches, indicating potential complications requiring close monitoring.

Oxytocin Administration Guidelines

Close monitoring of fluid intake is essential during oxytocin administration to prevent water intoxication.

Neonate Heat Loss Prevention

Address common sources of radiant heat loss such as cool incubator walls, to prevent neonatal hypothermia.

Adverse Effects of Bethanechol

Expect nausea and vomiting as common adverse effects following administration to treat urinary retention.

Labor Stages Assessments

The latency phase is the shortest segment but often the most challenging, requiring vigilance in monitoring.

Breastfeeding Comfort Techniques

Recommend using expressed milk for lubrication and avoid soaps which may irritate the nipples.

Expecting Fetal Movements

Movement is typically felt between 16 and 20 weeks of gestation, marking an important milestone for mothers.

Lochial Changes Post Delivery

Normal findings within the first 24 hours should include bright red blood without large clots or foul odors.

Initial Admission Questions for Labor Patients

First, inquire about the client's expected due date to assess the labor timeline.

Uterine Contraction Assessment Frequency

During the second stage of labor, assess contractions every 15 minutes to monitor progression.

Emergency Symptoms in Late Pregnancy

Notify healthcare providers immediately for concerning symptoms such as blurred vision or shortness of breath.

Identifying Genetic Risk Factors

A family history of cystic fibrosis is a significant genetic risk indicator that must be noted.

Rhythm Method in Contraception

Unsafe periods for intercourse are determined by elevated basal body temperature, indicative of ovulation.

Nonstress Test Parameters

Patients should press the control button during each fetal movement for accurate fetal monitoring.

Recognizing Important Symptoms in Pregnancy

Understanding urgent symptoms like blurred vision reflects client education effectiveness.

Breastfeeding After Mammoplasty

Post-reduction mammoplasty, successful breastfeeding may require supplementation, indicating possible challenges.

Fourth-Degree Laceration Care

Avoid excessive pressure and adhere to proper healing techniques to ensure recovery in cases of severe lacerations.

Gestational Trophoblastic Disease Findings

Ultrasound typically reveals grapelike clusters, indicating abnormal tissue development instead of a healthy fetus.

Fetal Presentation Assessment

A finding of (-1) station indicates the fetal head is positioned 1 cm above the ischial spines.

Inappropriate Breastfeeding Assessments

The baby's lips smacking does not serve as a constructive assessment indicator.

Detecting Fetal Abnormalities

Between 18 and 40 weeks, ultrasound is a common procedure for identifying fetal anomalies.

BPP Score Interpretations

A BPP score of 8 indicates that the fetus is stable and not currently in distress.

Parenting Preparation Assessments

Assess readiness for parenting by asking about preparations at home for the baby's arrival.

Labor Priorities for Multigravida

Immediate delivery preparation is prioritized for clients experiencing frequent contractions and high fetal station.

Monitoring Variable Decelerations

First action upon observing variable decelerations should involve changing the client's position for optimal fetal heart monitoring.

Postpartum Priority Nursing Diagnosis

Pain management takes precedence for clients experiencing significant discomfort after vaginal deliveries.

Physiological Changes Postpartum

Possible diuresis reflects a progressive physiological adjustment during the postpartum recovery period.

Cocaine Use and Complications

Cocaine use is strongly associated with abruptio placentae, indicated by subsequent vaginal bleeding.

Diabetes Management in Pregnancy

Expect regular nonstress testing performed weekly in most cases of pregnancy with type 1 diabetes.

Magnesium Sulfate Administration Purpose

Administer magnesium sulfate primarily to prevent seizures in patients diagnosed with preeclampsia.

Blastocyst Implantation Timeline

The blastocyst typically takes around 7 days to travel to the uterus for implantation.

Episiotomy Understanding

Understanding that episiotomies aim to enlarge the vaginal opening, thus aiding in delivery.

Notification of Drug Use During Pregnancy

Mandatory reporting is required when mothers expose their infants to risks such as cocaine use during pregnancy.

Postpartum Rubella Vaccine Education

Post-rubella vaccination, it is essential to avoid pregnancy for at least 3 months to prevent fetal complications.

Eclampsia Seizure Management

Initial actions during an eclampsia seizure should prioritize maintaining an open airway for patient safety.

Nutritional Considerations in Labor

Quick, beneficial snack options like yogurt are best for clients in early labor to maintain energy levels.

Emergency Actions During Rapid Labor

In cases of rapid labor, immediate inspection of the perineum is crucial to evaluate for impending delivery.### Maternal and Postpartum Assessment
Assessing the fundus in a primipara postpartum with both hands prevents uterine inversion.
During the letting-go phase, behaviors include the emergence of the family unit, defining individual roles, and sexual intimacy continuation.
One week postpartum, women may express a need to review labor events and vacillate between wanting nurturing and taking charge of care.

Placental Health and Adherence Types

The most common placental adherence is Accreta.
Other types include Increta and Percreta, which refer to varying degrees of abnormal placental attachment.

Diagnostic Tools and Testing

For a 40-year-old woman with a high BMI at 10 weeks, suggest a Maternal Serum Alpha-Fetoprotein (MSAFP) test.
A contraction stress test (CST) is considered negative if no late decelerations occur during contractions.
Nonstress test (NST) is less effective than CST if membranes are ruptured.

High-Risk Pregnancy Categories

Four categories of high-risk pregnancies are: Biophysical, Psychosocial, Environmental, and Geographic; Geographic is not included.

Nonstress Test and Monitoring

During a nonstress test at 36 weeks gestation, fetal activity and heart rate accelerations are monitored without needing a full bladder.
Contraction stress tests are indicated for history of preterm labor and fetal growth restriction.

Daily Fetal Movement Count Guidelines

Fetal alarm signal is no movement for 5 hours; monitor activity for 60 minutes once daily or until 10 movements are noted.
Count fetal movements at least twice daily after meals or before bed.

Post-Amniocentesis Care

After amniocentesis, observe for uterine contractions, and administer RhoGAM if the patient is Rh-negative.
An ultrasound may verify fetal positioning post-procedure.

SGA and IUGR Awareness

Asymmetric IUGR generally results from early pregnancy issues, with potential for normal growth in infants.
Symmetric IUGR typically occurs later in pregnancy.

Post-Cesarean Section Nursing Priorities

For a new cesarean patient with nausea and weakness, the priority nursing diagnosis is altered nutrition.
Address comfort related to nausea and bloating, and impaired bowel motility as subsequent concerns.

Newborn Eye Care

Antibiotic ointment is used to prevent gonorrheal infections, which can cause serious eye issues in newborns.

Breastfeeding Challenges

If a newborn struggles to latch, provide comfort rather than using a pacifier or formula; allow the infant to calm before retrying breastfeeding.

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Description

This quiz focuses on key concepts and nursing interventions related to postpartum care and prenatal assessments at 36 weeks gestation. It includes questions about complications such as endometritis and the role of ultrasounds before procedures like amniocentesis. Test your knowledge and ensure you're prepared for real-life scenarios in maternity nursing.