NCLEX Exam: Obstetrical Nursing – Antepartum (50 3. “It is the fetal movement that is felt by the mother.

”
Items) 4. “It is the thinning of the lower uterine segment.”
9. A nurse midwife is performing an assessment of a
1. A nursing instructor is conducting lecture and is pregnant client and is assessing the client for the
reviewing the functions of the female reproductive presence of ballottement. Which of the following would
system. She asks Mark to describe the follicle- the nurse implement to test for the presence of
stimulating hormone (FSH) and the luteinizing ballottement?
hormone (LH). Mark accurately responds by stating 1. Auscultating for fetal heart sounds
that: 2. Palpating the abdomen for fetal movement
1. FSH and LH are released from the anterior pituitary gland. 3. Assessing the cervix for thinning
2. FSH and LH are secreted by the corpus luteum of the ovary 4. Initiating a gentle upward tap on the cervix
3. FSH and LH are secreted by the adrenal glands 10. A nurse is assisting in performing an assessment on
4. FSH and LH stimulate the formation of milk during a client who suspects that she is pregnant and is
pregnancy. checking the client for probable signs of
2. A nurse is describing the process of fetal circulation pregnancy. Select all probable signs of pregnancy.
to a client during a prenatal visit. The nurse accurately 1. Uterine enlargement
tells the client that fetal circulation consists of: 2. Fetal heart rate detected by nonelectric device
1. Two umbilical veins and one umbilical artery 3. Outline of the fetus via radiography or ultrasound
2. Two umbilical arteries and one umbilical vein 4. Chadwick’s sign
3. Arteries carrying oxygenated blood to the fetus 5. Braxton Hicks contractions
4. Veins carrying deoxygenated blood to the fetus 6. Ballottement
3. During a prenatal visit at 38 weeks, a nurse assesses 11. A pregnant client calls the clinic and tells a nurse
the fetal heart rate. The nurse determines that the fetal that she is experiencing leg cramps and is awakened by
heart rate is normal if which of the following is noted? the cramps at night. To provide relief from the leg
1. 80 BPM cramps, the nurse tells the client to:
2. 100 BPM 1. Dorsiflex the foot while extending the knee when the
3. 150 BPM cramps occur
4. 180 BPM 2. Dorsiflex the foot while flexing the knee when the cramps
4. A client arrives at a prenatal clinic for the first occur
prenatal assessment. The client tells a nurse that the 3. Plantar flex the foot while flexing the knee when the
first day of her last menstrual period was September cramps occur
19th, 2013. Using Naegele’s rule, the nurse determines 4. Plantar flex the foot while extending the knee when the
the estimated date of confinement as: cramps occur.
1. July 26, 2013 12. A nurse is providing instructions to a client in the
2. June 12, 2014 first trimester of pregnancy regarding measures to
3. June 26, 2014 assist in reducing breast tenderness. The nurse tells
4. July 12, 2014 the client to:
5. A nurse is collecting data during an admission 1. Avoid wearing a bra
assessment of a client who is pregnant with twins. The 2. Wash the nipples and areola area daily with soap, and
client has a healthy 5-year old child that was delivered massage the breasts with lotion.
at 37 weeks and tells the nurse that she doesn’t have 3. Wear tight-fitting blouses or dresses to provide support
any history of abortion or fetal demise. The nurse 4. Wash the breasts with warm water and keep them dry
would document the GTPAL for this client as: 13. A pregnant client in the last trimester has been
1. G = 3, T = 2, P = 0, A = 0, L =1 admitted to the hospital with a diagnosis of severe
2. G = 2, T = 0, P = 1, A = 0, L =1 preeclampsia. A nurse monitors for complications
3. G = 1, T = 1. P = 1, A = 0, L = 1 associated with the diagnosis and assesses the client
4. G = 2, T = 0, P = 0, A = 0, L = 1 for:
6. A nurse is performing an assessment of a primipara 1. Any bleeding, such as in the gums, petechiae, and purpura.
who is being evaluated in a clinic during her second 2. Enlargement of the breasts
trimester of pregnancy. Which of the following 3. Periods of fetal movement followed by quiet periods
indicates an abnormal physical finding necessitating 4. Complaints of feeling hot when the room is cool
further testing? 14. A client in the first trimester of pregnancy arrives
1. Consistent increase in fundal height at a health care clinic and reports that she has been
2. Fetal heart rate of 180 BPM experiencing vaginal bleeding. A threatened abortion is
3. Braxton hicks contractions suspected, and the nurse instructs the client regarding
4. Quickening management of care. Which statement, if made by the
7. A nurse is reviewing the record of a client who has client, indicates a need for further education?
just been told that a pregnancy test is positive. The 1. “I will maintain strict bedrest throughout the remainder of
physician has documented the presence of a Goodell’s pregnancy.”
sign. The nurse determines this sign indicates: 2. “I will avoid sexual intercourse until the bleeding has
1. A softening of the cervix stopped, and for 2 weeks following the last evidence of
2. A soft blowing sound that corresponds to the maternal bleeding.”
pulse during auscultation of the uterus. 3. “I will count the number of perineal pads used on a daily
3. The presence of hCG in the urine basis and note the amount and color of blood on the pad.”
4. The presence of fetal movement 4. “I will watch for the evidence of the passage of tissue.”
8. A nursing instructor asks a nursing student who is 15. A prenatal nurse is providing instructions to a
preparing to assist with the assessment of a pregnant group of pregnant client regarding measures to prevent
client to describe the process of quickening. Which of toxoplasmosis. Which statement if made by one of the
the following statements if made by the student clients indicates a need for further instructions?
indicates an understanding of this term? 1. “I need to cook meat thoroughly.”
1. “It is the irregular, painless contractions that occur 2. “I need to avoid touching mucous membranes of the
throughout pregnancy.” mouth or eyes while handling raw meat.”
2. “It is the soft blowing sound that can be heard when the 3. “I need to drink unpasteurized milk only.”
uterus is auscultated.”
4. “I need to avoid contact with materials that are possibly 3. Seizures do not occur
contaminated with cat feces.” 4. Scotomas are present
16. A homecare nurse visits a pregnant client who has 24. A nurse is caring for a pregnant client with severe
a diagnosis of mild Preeclampsia and who is being preeclampsia who is receiving IV magnesium sulfate.
monitored for pregnancy induced hypertension (PIH). Select all nursing interventions that apply in the care
Which assessment finding indicates a worsening of the for the client.
Preeclampsia and the need to notify the physician? 1. Monitor maternal vital signs every 2 hours
1. Blood pressure reading is at the prenatal baseline 2. Notify the physician if respirations are less than 18 per
2. Urinary output has increased minute.
3. The client complains of a headache and blurred vision 3. Monitor renal function and cardiac function closely
4. Dependent edema has resolved 4. Keep calcium gluconate on hand in case of a magnesium
17. A nurse implements a teaching plan for a pregnant sulfate overdose
client who is newly diagnosed with gestational 5. Monitor deep tendon reflexes hourly
diabetes. Which statement if made by the client 6. Monitor I and O’s hourly
indicates a need for further education? 7. Notify the physician if urinary output is less than 30 ml per
1. “I need to stay on the diabetic diet.” hour.
2. “I will perform glucose monitoring at home.” 25. In the 12th week of gestation, a client completely
3. “I need to avoid exercise because of the negative effects of expels the products of conception. Because the client is
insulin production.” Rh negative, the nurse must:
4. “I need to be aware of any infections and report signs of 1. Administer RhoGAM within 72 hours
infection immediately to my health care provider.” 2. Make certain she receives RhoGAM on her first clinic visit
18. A primigravida is receiving magnesium sulfate for 3. Not give RhoGAM, since it is not used with the birth of a
the treatment of pregnancy induced hypertension stillborn
(PIH). The nurse who is caring for the client is 4. Make certain the client does not receive RhoGAM, since the
performing assessments every 30 minutes. Which gestation only lasted 12 weeks.
assessment finding would be of most concern to the 26. In a lecture on sexual functioning, the nurse plans
nurse? to include the fact that ovulation occurs when the:
1. Urinary output of 20 ml since the previous assessment 1. Oxytocin is too high
2. Deep tendon reflexes of 2+ 2. Blood level of LH is too high
3. Respiratory rate of 10 BPM 3. Progesterone level is high
4. Fetal heart rate of 120 BPM 4. Endometrial wall is sloughed off.
19. A nurse is caring for a pregnant client with 27. The chief function of progesterone is the:
Preeclampsia. The nurse prepares a plan of care for the 1. Development of the female reproductive system
client and documents in the plan that if the client 2. Stimulation of the follicles for ovulation to occur
progresses from Preeclampsia to eclampsia, the nurse’s 3. Preparation of the uterus to receive a fertilized egg
first action is to: 4. Establishment of secondary male sex characteristics
1. Administer magnesium sulfate intravenously 28. The developing cells are called a fetus from the:
2. Assess the blood pressure and fetal heart rate 1. Time the fetal heart is heard
3. Clean and maintain an open airway 2. Eighth week to the time of birth
4. Administer oxygen by face mask 3. Implantation of the fertilized ovum
20. A nurse is monitoring a pregnant client with 4. End of the send week to the onset of labor
pregnancy induced hypertension who is at risk for 29. After the first four months of pregnancy, the chief
Preeclampsia. The nurse checks the client for which source of estrogen and progesterone is the:
specific signs of Preeclampsia (select all that apply)? 1. Placenta
1. Elevated blood pressure 2. Adrenal cortex
2. Negative urinary protein 3. Corpus luteum
3. Facial edema 4. Anterior hypophysis
4. Increased respirations 30. The nurse recognizes that an expected change in
21. Rho (D) immune globulin (RhoGAM) is prescribed the hematologic system that occurs during the
for a woman following delivery of a newborn infant and 2nd trimester of pregnancy is:
the nurse provides information to the woman about the 1. A decrease in WBC’s
purpose of the medication. The nurse determines that 2. In increase in hematocrit
the woman understands the purpose of the medication 3. An increase in blood volume
if the woman states that it will protect her next baby 4. A decrease in sedimentation rate
from which of the following? 31. The nurse is aware than an adaptation of pregnancy
1. Being affected by Rh incompatibility is an increased blood supply to the pelvic region that
2. Having Rh positive blood results in a purplish discoloration of the vaginal
3. Developing a rubella infection mucosa, which is known as:
4. Developing physiological jaundice 1. Ladin’s sign
22. A pregnant client is receiving magnesium sulfate 2. Hegar’s sign
for the management of preeclampsia. A nurse 3. Goodell’s sign
determines the client is experiencing toxicity from the 4. Chadwick’s sign
medication if which of the following is noted on 32. A pregnant client is making her
assessment? first Antepartum visit. She has a two year old son born
1. Presence of deep tendon reflexes at 40 weeks, a 5 year old daughter born at 38 weeks,
2. Serum magnesium level of 6 mEq/L and 7 year old twin daughters born at 35 weeks. She
3. Proteinuria of +3 had a spontaneous abortion 3 years ago at 10 weeks.
4. Respirations of 10 per minute Using the GTPAL format, the nurse should identify that
23. A woman with preeclampsia is receiving the client is:
magnesium sulfate. The nurse assigned to care for the 1. G4 T3 P2 A1 L4
client determines that the magnesium therapy is 2. G5 T2 P2 A1 L4
effective if: 3. G5 T2 P1 A1 L4
1. Ankle clonus in noted 4. G4 T3 P1 A1 L4
2. The blood pressure decreases
33. An expected cardiopulmonary adaptation 1. Mastitis
experienced by most pregnant women is: 2. Metabolic alkalosis
1. Tachycardia 3. Physiologic anemia
2. Dyspnea at rest 4. Respiratory acidosis
3. Progression of dependent edema 44. A 21-year old client, 6 weeks’ pregnant is
4. Shortness of breath on exertion diagnosed with hyperemesis gravidarum. This
34. Nutritional planning for a newly pregnant woman of excessive vomiting during pregnancy will often result
average height and weighing 145 pounds should in which of the following conditions?
include: 1. Bowel perforation
1. A decrease of 200 calories a day 2. Electrolyte imbalance
2. An increase of 300 calories a day 3. Miscarriage
3. An increase of 500 calories a day 4. Pregnancy induced hypertension (PIH)
4. A maintenance of her present caloric intake per day 45. Clients with gestational diabetes are usually
35. During a prenatal examination, the nurse draws managed by which of the following therapies?
blood from a young Rh negative client and explain that 1. Diet
an indirect Coombs test will be performed to predict 2. NPH insulin (long-acting)
whether the fetus is at risk for: 3. Oral hypoglycemic drugs
1. Acute hemolytic disease 4. Oral hypoglycemic drugs and insulin
2. Respiratory distress syndrome 46. The antagonist for magnesium sulfate should be
3. Protein metabolic deficiency readily available to any client receiving IV magnesium.
4. Physiologic hyperbilirubinemia Which of the following drugs is the antidote for
36. When involved in prenatal teaching, the nurse magnesium toxicity?
should advise the clients that an increase in vaginal 1. Calcium gluconate
secretions during pregnancy is called leukorrhea and is 2. Hydralazine (Apresoline)
caused by increased: 3. Narcan
1. Metabolic rates 4. RhoGAM
2. Production of estrogen 47. Which of the following answers best describes the
3. Functioning of the Bartholin glands stage of pregnancy in which maternal and fetal blood
4. Supply of sodium chloride to the cells of the vagina are exchanged?
37. A 26-year old multigravida is 14 weeks’ pregnant 1. Conception
and is scheduled for an alpha-fetoprotein test. She asks 2. 9 weeks’ gestation, when the fetal heart is well developed
the nurse, “What does the alpha-fetoprotein test 3. 32-34 weeks gestation
indicate?” The nurse bases a response on the 4. maternal and fetal blood are never exchanged
knowledge that this test can detect: 48. Gravida refers to which of the following
1. Kidney defects descriptions?
2. Cardiac defects 1. A serious pregnancy
3. Neural tube defects 2. Number of times a female has been pregnant
4. Urinary tract defects 3. Number of children a female has delivered
38. At a prenatal visit at 36 weeks’ gestation, a client 4. Number of term pregnancies a female has had.
complains of discomfort with irregularly occurring 49. A pregnant woman at 32 weeks’ gestation
contractions. The nurse instructs the client to: complains of feeling dizzy and lightheaded while her
1. Lie down until they stop fundal height is being measured. Her skin is pale and
2. Walk around until they subside moist. The nurse’s initial response would be to:
3. Time contraction for 30 minutes 1. Assess the woman’s blood pressure and pulse
4. Take 10 grains of aspirin for the discomfort 2. Have the woman breathe into a paper bag
39. The nurse teaches a pregnant woman to avoid lying 3. Raise the woman’s legs
on her back. The nurse has based this statement on the 4. Turn the woman on her side.
knowledge that the supine position can: 50. A pregnant woman’s last menstrual period began
1. Unduly prolong labor on April 8, 2005, and ended on April 13. Using
2. Cause decreased placental perfusion Naegele’s rule her estimated date of birth would be:
3. Lead to transient episodes of hypotension 1. January 15, 2006
4. Interfere with free movement of the coccyx 2. January 20, 2006
40. The pituitary hormone that stimulates the secretion 3. July 1, 2006
of milk from the mammary glands is: 4. November 5, 2005
1. Prolactin
2. Oxytocin
3. Estrogen NCLEX Exam: Obstetrical Nursing – Intrapartum (60
4. Progesterone Items)
41. Which of the following symptoms occurs with a
hydatidiform mole? 1. A nurse is caring for a client in labor. The nurse
1. Heavy, bright red bleeding every 21 days determines that the client is beginning in the 2nd stage
2. Fetal cardiac motion after 6 weeks gestation of labor when which of the following assessments is
3. Benign tumors found in the smooth muscle of the uterus noted?
4. “Snowstorm” pattern on ultrasound with no fetus or 1. The client begins to expel clear vaginal fluid
gestational sac 2. The contractions are regular
42. Which of the following terms applies to the 3. The membranes have ruptured
tiny, blanched, slightly raised end arterioles found on 4. The cervix is dilated completely
the face, neck, arms, and chest during pregnancy? 2. A nurse in the labor room is caring for a client in the
1. Epulis active phases of labor. The nurse is assessing the fetal
2. Linea nigra patterns and notes a late deceleration on the monitor
3. Striae gravidarum strip. The most appropriate nursing action is to:
4. Telangiectasias 1. Place the mother in the supine position
43. Which of the following conditions is common in 2. Document the findings and continue to monitor the fetal
pregnant women in the 2nd trimester of pregnancy? patterns
3. Administer oxygen via face mask 1. Identifying the types of accelerations
4. Increase the rate of pitocin IV infusion 2. Assessing the baseline fetal heart rate
3. A nurse is performing an assessment of a client who 3. Determining the frequency of the contractions
is scheduled for a cesarean delivery. Which assessment 4. Determining the intensity of the contractions
finding would indicate a need to contact the physician? 11. A nurse is reviewing the record of a client in the
1. Fetal heart rate of 180 beats per minute labor room and notes that the nurse midwife has
2. White blood cell count of 12,000 documented that the fetus is at (-1) station. The nurse
3. Maternal pulse rate of 85 beats per minute determines that the fetal presenting part is:
4. Hemoglobin of 11.0 g/dL 1. 1 cm above the ischial spine
4. A client in labor is transported to the delivery room 2. 1 fingerbreadth below the symphysis pubis
and is prepared for a cesarean delivery. The client is 3. 1 inch below the coccyx
transferred to the delivery room table, and the nurse 4. 1 inch below the iliac crest
places the client in the: 12. A pregnant client is admitted to the labor room. An
1. Trendelenburg’s position with the legs in stirrups assessment is performed, and the nurse notes that the
2. Semi-Fowler position with a pillow under the knees client’s hemoglobin and hematocrit levels are low,
3. Prone position with the legs separated and elevated indicating anemia. The nurse determines that the client
4. Supine position with a wedge under the right hip is at risk for which of the following?
5. A nurse is caring for a client in labor and prepares to 1. A loud mouth
auscultate the fetal heart rate by using a Doppler 2. Low self-esteem
ultrasound device. The nurse most accurately 3. Hemorrhage
determines that the fetal heart sounds are heard by: 4. Postpartum infections
1. Noting if the heart rate is greater than 140 BPM 13. A nurse assists in the vaginal delivery of a newborn
2. Placing the diaphragm of the Doppler on the mother infant. After the delivery, the nurse observes the
abdomen umbilical cord lengthen and a spurt of blood from the
3. Performing Leopold’s maneuvers first to determine the vagina. The nurse documents these observations as
location of the fetal heart signs of:
4. Palpating the maternal radial pulse while listening to the 1. Hematoma
fetal heart rate 2. Placenta previa
6. A nurse is caring for a client in labor who is receiving 3. Uterine atony
Pitocin by IV infusion to stimulate uterine contractions. 4. Placental separation
Which assessment finding would indicate to the nurse 14. A client arrives at a birthing center in active labor.
that the infusion needs to be discontinued? Her membranes are still intact, and the nurse-midwife
1. Three contractions occurring within a 10-minute period prepares to perform an amniotomy. A nurse who is
2. A fetal heart rate of 90 beats per minute assisting the nurse-midwife explains to the client that
3. Adequate resting tone of the uterus palpated between after this procedure, she will most likely have:
contractions 1. Less pressure on her cervix
4. Increased urinary output 2. Increased efficiency of contractions
7. A nurse is beginning to care for a client in labor. The 3. Decreased number of contractions
physician has prescribed an IV infusion of Pitocin. The 4. The need for increased maternal blood pressure monitoring
nurse ensures that which of the following is 15. A nurse is monitoring a client in labor. The nurse
implemented before initiating the infusion? suspects umbilical cord compression if which of the
1. Placing the client on complete bed rest following is noted on the external monitor tracing
2. Continuous electronic fetal monitoring during a contraction?
3. An IV infusion of antibiotics 1. Early decelerations
4. Placing a code cart at the client’s bedside 2. Variable decelerations
8. A nurse is monitoring a client in active labor and 3. Late decelerations
notes that the client is having contractions every 3 4. Short-term variability
minutes that last 45 seconds. The nurse notes that the 16. A nurse explains the purpose of effleurage to a
fetal heart rate between contractions is 100 BPM. client in early labor. The nurse tells the client that
Which of the following nursing actions is most effleurage is:
appropriate? 1. A form of biofeedback to enhance bearing down efforts
1. Encourage the client’s coach to continue to encourage during delivery
breathing exercises 2. Light stroking of the abdomen to facilitate relaxation during
2. Encourage the client to continue pushing with each labor and provide tactile stimulation to the fetus
contraction 3. The application of pressure to the sacrum to relieve a
3. Continue monitoring the fetal heart rate backache
4. Notify the physician or nurse midwife 4. Performed to stimulate uterine activity by contracting a
9. A nurse is caring for a client in labor and is specific muscle group while other parts of the body rest
monitoring the fetal heart rate patterns. The nurse 17. A nurse is caring for a client in the second stage of
notes the presence of episodic accelerations on the labor. The client is experiencing uterine contractions
electronic fetal monitor tracing. Which of the following every 2 minutes and cries out in pain with each
actions is most appropriate? contraction. The nurse recognizes this behavior as:
1. Document the findings and tell the mother that the monitor 1. Exhaustion
indicates fetal well-being 2. Fear of losing control
2. Take the mother’s vital signs and tell the mother that bed 3. Involuntary grunting
rest is required to conserve oxygen. 4. Valsalva’s maneuver
3. Notify the physician or nurse midwife of the findings. 18. A nurse is monitoring a client in labor who is
4. Reposition the mother and check the monitor for changes receiving Pitocin and notes that the client is
in the fetal tracing experiencing hypertonic uterine contractions. List in
10. A nurse is admitting a pregnant client to the labor order of priority the actions that the nurse takes.
room and attaches an external electronic fetal monitor 1. Stop of Pitocin infusion (1)
to the client’s abdomen. After attachment of the 2. Perform a vaginal examination (3)
monitor, the initial nursing assessment is which of the 3. Reposition the client (5)
following?
4. Check the client’s blood pressure and heart rate (2) 26. A maternity nurse is caring for a client with
5. Administer oxygen by face mask at 8 to 10 L/min (4) abruptio placenta and is monitoring the client for
19. A nurse is assigned to care for a client with disseminated intravascular coagulopathy. Which
hypotonic uterine dysfunction and signs of a slowing assessment finding is least likely to be associated with
labor. The nurse is reviewing the physician’s orders and disseminated intravascular coagulation?
would expect to note which of the following prescribed 1. Swelling of the calf in one leg
treatments for this condition? 2. Prolonged clotting times
1. Medication that will provide sedation 3. Decreased platelet count
2. Increased hydration 4. Petechiae, oozing from injection sites, and hematuria
3. Oxytocin (Pitocin) infusion 27. A nurse is assessing a pregnant client in the
4. Administration of a tocolytic medication 2nd trimester of pregnancy who was admitted to the
20. A nurse in the labor room is preparing to care for a maternity unit with a suspected diagnosis of abruptio
client with hypertonic uterine dysfunction. The nurse is placentae. Which of the following assessment findings
told that the client is experiencing uncoordinated would the nurse expect to note if this condition is
contractions that are erratic in their frequency, present?
duration, and intensity. The priority nursing 1. Absence of abdominal pain
intervention would be to: 2. A soft abdomen
1. Monitor the Pitocin infusion closely 3. Uterine tenderness/pain
2. Provide pain relief measures 4. Painless, bright red vaginal bleeding
3. Prepare the client for an amniotomy 28. A maternity nurse is preparing for the admission of
4. Promote ambulation every 30 minutes a client in the 3rd trimester of pregnancy that is
21. A nurse is developing a plan of care for a client experiencing vaginal bleeding and has a suspected
experiencing dystocia and includes several nursing diagnosis of placenta previa. The nurse reviews the
interventions in the plan of care. The nurse prioritizes physician’s orders and would question which order?
the plan of care and selects which of the following 1. Prepare the client for an ultrasound
nursing interventions as the highest priority? 2. Obtain equipment for external electronic fetal heart
1. Keeping the significant other informed of the progress of monitoring
the labor 3. Obtain equipment for a manual pelvic examination
2. Providing comfort measures 4. Prepare to draw a Hgb and Hct blood sample
3. Monitoring fetal heart rate 29. An ultrasound is performed on a client at term
4. Changing the client’s position frequently gestation that is experiencing moderate vaginal
22. A maternity nurse is preparing to care for a bleeding. The results of the ultrasound indicate that an
pregnant client in labor who will be delivering twins. abruptio placenta is present. Based on these findings,
The nurse monitors the fetal heart rates by placing the the nurse would prepare the client for:
external fetal monitor: 1. Complete bed rest for the remainder of the pregnancy
1. Over the fetus that is most anterior to the mother’s 2. Delivery of the fetus
abdomen 3. Strict monitoring of intake and output
2. Over the fetus that is most posterior to the mother’s 4. The need for weekly monitoring of coagulation studies until
abdomen the time of delivery
3. So that each fetal heart rate is monitored separately 30. A nurse in a labor room is assisting with the vaginal
4. So that one fetus is monitored for a 15-minute period delivery of a newborn infant. The nurse would monitor
followed by a 15 minute fetal monitoring period for the the client closely for the risk of uterine rupture if which
second fetus of the following occurred?
23. A nurse in the postpartum unit is caring for a client 1. Hypotonic contractions
who has just delivered a newborn infant following a 2. Forceps delivery
pregnancy with placenta previa. The nurse reviews the 3. Schultz delivery
plan of care and prepares to monitor the client for 4. Weak bearing down efforts
which of the following risks associated with placenta 31. A client is admitted to the birthing suite in early
previa? active labor. The priority nursing intervention on
1. Disseminated intravascular coagulation admission of this client would be:
2. Chronic hypertension 1. Auscultating the fetal heart
3. Infection 2. Taking an obstetric history
4. Hemorrhage 3. Asking the client when she last ate
24. A nurse in the delivery room is assisting with the 4. Ascertaining whether the membranes were ruptured
delivery of a newborn infant. After the delivery of the 32. A client who is gravida 1, para 0 is admitted in
newborn, the nurse assists in delivering the placenta. labor. Her cervix is 100% effaced, and she is dilated to
Which observation would indicate that the placenta has 3 cm. Her fetus is at +1 station. The nurse is aware
separated from the uterine wall and is ready for that the fetus’ head is:
delivery? 1. Not yet engaged
1. The umbilical cord shortens in length and changes in color 2. Entering the pelvic inlet
2. A soft and boggy uterus 3. Below the ischial spines
3. Maternal complaints of severe uterine cramping 4. Visible at the vaginal opening
4. Changes in the shape of the uterus 33. After doing Leopold’s maneuvers, the nurse
25. A nurse in the labor room is performing a vaginal determines that the fetus is in the ROP position. To
assessment on a pregnant client in labor. The nurse best auscultate the fetal heart tones, the Doppler is
notes the presence of the umbilical cord protruding placed:
from the vagina. Which of the following would be the 1. Above the umbilicus at the midline
initial nursing action? 2. Above the umbilicus on the left side
1. Place the client in Trendelenburg’s position 3. Below the umbilicus on the right side
2. Call the delivery room to notify the staff that the client will 4. Below the umbilicus near the left groin
be transported immediately 34. The physician asks the nurse the frequency of a
3. Gently push the cord into the vagina laboring client’s contractions. The nurse assesses the
4. Find the closest telephone and stat page the physician client’s contractions by timing from the beginning of
one contraction:
1. Until the time it is completely over 44. Which of the following observations indicates fetal
2. To the end of a second contraction distress?
3. To the beginning of the next contraction 1. Fetal scalp pH of 7.14
4. Until the time that the uterus becomes very firm 2. Fetal heart rate of 144 beats/minute
35. The nurse observes the client’s amniotic fluid and 3. Acceleration of fetal heart rate with contractions
decides that it appears normal, because it is: 4. Presence of long term variability
1. Clear and dark amber in color 45. Which of the following fetal positions is most
2. Milky, greenish yellow, containing shreds of mucus favorable for birth?
3. Clear, almost colorless, and containing little white specks 1. Vertex presentation
4. Cloudy, greenish-yellow, and containing little white specks 2. Transverse lie
36. At 38 weeks gestation, a client is having late 3. Frank breech presentation
decelerations. The fetal pulse oximeter shows 75% to 4. Posterior position of the fetal head
85%. The nurse should: 46. A laboring client has external electronic fetal
1. Discontinue the catheter, if the reading is not above 80% monitoring in place. Which of the following assessment
2. Discontinue the catheter, if the reading does not go below data can be determined by examining the fetal heart
30% rate strip produced by the external electronic fetal
3. Advance the catheter until the reading is above 90% and monitor?
continue monitoring 1. Gender of the fetus
4. Reposition the catheter, recheck the reading, and if it is 2. Fetal position
55%, keep monitoring 3. Labor progress
37. When examining the fetal monitor strip after 4. Oxygenation
rupture of the membranes in a laboring client, the 47. A laboring client is in the first stage of labor and
nurse notes variable decelerations in the fetal heart has progressed from 4 to 7 cm in cervical dilation. In
rate. The nurse should: which of the following phases of the first stage does
1. Stop the oxytocin infusion cervical dilation occur most rapidly?
2. Change the client’s position 1. Preparatory phase
3. Prepare for immediate delivery 2. Latent phase
4. Take the client’s blood pressure 3. Active phase
38. When monitoring the fetal heart rate of a client in 4. Transition phase
labor, the nurse identifies an elevation of 15 beats 48. A multiparous client who has been in labor for 2
above the baseline rate of 135 beats per minute lasting hours states that she feels the urge to move her
for 15 seconds. This should be documented as: bowels. How should the nurse respond?
1. An acceleration 1. Let the client get up to use the potty
2. An early elevation 2. Allow the client to use a bedpan
3. A sonographic motion 3. Perform a pelvic examination
4. A tachycardic heart rate 4. Check the fetal heart rate
39. A laboring client complains of low back pain. The 49. Labor is a series of events affected by the
nurse replies that this pain occurs most when the coordination of the five essential factors. One of these
position of the fetus is: is the passenger (fetus). Which are the other four
1. Breech factors?
2. Transverse 1. Contractions, passageway, placental position and function,
3. Occiput anterior pattern of care
4. Occiput posterior 2. Contractions, maternal response, placental position,
40. The breathing technique that the mother should be psychological response
instructed to use as the fetus’ head is crowning is: 3. Passageway, contractions, placental position and function,
1. Blowing psychological response
2. Slow chest 4. Passageway, placental position and function, paternal
3. Shallow response, psychological response
4. Accelerated-decelerated 50. Fetal presentation refers to which of the following
41. During the period of induction of labor, a client descriptions?
should be observed carefully for signs of: 1. Fetal body part that enters the maternal pelvis first
1. Severe pain 2. Relationship of the presenting part to the maternal pelvis
2. Uterine tetany 3. Relationship of the long axis of the fetus to the long axis of
3. Hypoglycemia the mother
4. Umbilical cord prolapse 4. A classification according to the fetal part
42. A client arrives at the hospital in the second stage 51. A client is admitted to the L & D suite at 36 weeks’
of labor. The fetus’ head is crowning, the client is gestation. She has a history of C-section and complains
bearing down, and the birth appears imminent. The of severe abdominal pain that started less than 1 hour
nurse should: earlier. When the nurse palpates tetanic contractions,
1. Transfer her immediately by stretcher to the birthing unit the client again complains of severe pain. After the
2. Tell her to breathe through her mouth and not to bear client vomits, she states that the pain is better and
down then passes out. Which is the probable cause of her
3. Instruct the client to pant during contractions and to signs and symptoms?
breathe through her mouth 1. Hysteria compounded by the flu
4. Support the perineum with the hand to prevent tearing and 2. Placental abruption
tell the client to pant 3. Uterine rupture
43. A laboring client is to have a pudendal block. The 4. Dysfunctional labor
nurse plans to tell the client that once the block is 52. Upon completion of a vaginal examination on a
working she: laboring woman, the nurse records: 50%, 6 cm, -1.
1. Will not feel the episiotomy Which of the following is a correct interpretation of the
2. May lose bladder sensation data?
3. May lose the ability to push 1. Fetal presenting part is 1 cm above the ischial spines
4. Will no longer feel contractions 2. Effacement is 4 cm from completion
3. Dilation is 50% completed 4. Reducing stress on other children by limiting their
4. Fetus has achieved passage through the ischial spines involvement in the care of the new baby
53. Which of the following findings meets the criteria of
a reassuring FHR pattern? NCLEX Exam: Obstetrical Nursing – Postpartum (55
1. FHR does not change as a result of fetal activity Items)
2. Average baseline rate ranges between 100 – 140 BPM
3. Mild late deceleration patterns occur with some 1. A postpartum nurse is preparing to care for a woman
contractions who has just delivered a healthy newborn infant. In the
4. Variability averages between 6 – 10 BPM immediate postpartum period the nurse plans to take
54. Late deceleration patterns are noted when the woman’s vital signs:
assessing the monitor tracing of a woman whose labor 1. Every 30 minutes during the first hour and then every hour
is being induced with an infusion of Pitocin. The for the next two hours.
woman is in a side-lying position, and her vital signs 2. Every 15 minutes during the first hour and then every 30
are stable and fall within a normal range. Contractions minutes for the next two hours.
are intense, last 90 seconds, and occur every 1 1/2 to 2 3. Every hour for the first 2 hours and then every 4 hours
minutes. The nurse’s immediate action would be to: 4. Every 5 minutes for the first 30 minutes and then every
1. Change the woman’s position hour for the next 4 hours.
2. Stop the Pitocin 2. A postpartum nurse is taking the vital signs of a
3. Elevate the woman’s legs woman who delivered a healthy newborn infant 4 hours
4. Administer oxygen via a tight mask at 8 to 10 liters/minute ago. The nurse notes that the mother’s temperature is
55. The nurse should realize that the most common and 100.2*F. Which of the following actions would be most
potentially harmful maternal complication of epidural appropriate?
anesthesia would be: 1. Retake the temperature in 15 minutes
1. Severe postpartum headache 2. Notify the physician
2. Limited perception of bladder fullness 3. Document the findings
3. Increase in respiratory rate 4. Increase hydration by encouraging oral fluids
4. Hypotension 3. The nurse is assessing a client who is 6 hours PP
56. Perineal care is an important infection control after delivering a full-term healthy infant. The client
measure. When evaluating a postpartum woman’s complains to the nurse of feelings of faintness and
perineal care technique, the nurse would recognize the dizziness. Which of the following nursing actions would
need for further instruction if the woman: be most appropriate?
1. Uses soap and warm water to wash the vulva and 1. Obtain hemoglobin and hematocrit levels
perineum 2. Instruct the mother to request help when getting out of
2. Washes from symphysis pubis back to episiotomy bed
3. Changes her perineal pad every 2 – 3 hours 3. Elevate the mother’s legs
4. Uses the peribottle to rinse upward into her vagina 4. Inform the nursery room nurse to avoid bringing the
57. Which measure would be least effective in newborn infant to the mother until the feelings of
preventing postpartum hemorrhage? lightheadedness and dizziness have subsided.
1. Administer Methergine 0.2 mg every 6 hours for 4 doses as 4. A nurse is preparing to perform a fundal assessment
ordered on a postpartum client. The initial nursing action in
2. Encourage the woman to void every 2 hours performing this assessment is which of the following?
3. Massage the fundus every hour for the first 24 hours 1. Ask the client to turn on her side
following birth 2. Ask the client to lie flat on her back with the knees and
4. Teach the woman the importance of rest and nutrition to legs flat and straight.
enhance healing 3. Ask the mother to urinate and empty her bladder
58. When making a visit to the home of a postpartum 4. Massage the fundus gently before determining the level of
woman one week after birth, the nurse should the fundus.
recognize that the woman would characteristically: 5. The nurse is assessing the lochia on a 1 day PP
1. Express a strong need to review events and her behavior patient. The nurse notes that the lochia is red and has a
during the process of labor and birth foul-smelling odor. The nurse determines that this
2. Exhibit a reduced attention span, limiting readiness to assessment finding is:
learn 1. Normal
3. Vacillate between the desire to have her own nurturing 2. Indicates the presence of infection
needs met and the need to take charge of her own care and 3. Indicates the need for increasing oral fluids
that of her newborn 4. Indicates the need for increasing ambulation
4. Have reestablished her role as a spouse/partner 6. When performing a PP assessment on a client, the
59. Four hours after a difficult labor and birth, a nurse notes the presence of clots in the lochia. The
primiparous woman refuses to feed her baby, stating nurse examines the clots and notes that they are larger
that she is too tired and just wants to sleep. The nurse than 1 cm. Which of the following nursing actions is
should: most appropriate?
1. Tell the woman she can rest after she feeds her baby 1. Document the findings
2. Recognize this as a behavior of the taking-hold stage 2. Notify the physician
3. Record the behavior as ineffective maternal-newborn 3. Reassess the client in 2 hours
attachment 4. Encourage increased intake of fluids.
4. Take the baby back to the nursery, reassuring the woman 7. A nurse in a PP unit is instructing a mother regarding
that her rest is a priority at this time lochia and the amount of expected lochia drainage. The
60. Parents can facilitate the adjustment of their other nurse instructs the mother that the normal amount of
children to a new baby by: lochia may vary but should never exceed the need for:
1. Having the children choose or make a gift to give to the 1. One peripad per day
new baby upon its arrival home 2. Two peripads per day
2. Emphasizing activities that keep the new baby and other 3. Three peripads per day
children together 4. Eight peripads per day
3. Having the mother carry the new baby into the home so 8. A PP nurse is providing instructions to a woman after
she can show the other children the new baby delivery of a healthy newborn infant. The nurse
instructs the mother that she should expect normal following statements if made by the mother indicates a
bowel elimination to return: need for further teaching?
1. One the day of the delivery 1. “I need to take antibiotics, and I should begin to feel better
2. 3 days PP in 24-48 hours.”
3. 7 days PP 2. “I can use analgesics to assist in alleviating some of the
4. within 2 weeks PP discomfort.”
9. Select all of the physiological maternal changes that 3. “I need to wear a supportive bra to relieve the discomfort.”
occur during the PP period. 4. “I need to stop breastfeeding until this condition resolves.”
1. Cervical involution ceases immediately 17. A PP client is being treated for DVT. The nurse
2. Vaginal distention decreases slowly understands that the client’s response to treatment will
3. Fundus begins to descend into the pelvis after 24 hours be evaluated by regularly assessing the client for:
4. Cardiac output decreases with resultant tachycardia in the 1. Dysuria, ecchymosis, and vertigo
first 24 hours 2. Epistaxis, hematuria, and dysuria
5. Digestive processes slow immediately. 3. Hematuria, ecchymosis, and epistaxis
10. A nurse is caring for a PP woman who has received 4. Hematuria, ecchymosis, and vertigo
epidural anesthesia and is monitoring the woman for 18. A nurse performs an assessment on a client who is
the presence of a vulva hematoma. Which of the 4 hours PP. The nurse notes that the client has cool,
following assessment findings would best indicate the clammy skin and is restless and excessively thirsty. The
presence of a hematoma? nurse prepares immediately to:
1. Complaints of a tearing sensation 1. Assess for hypovolemia and notify the health care provider
2. Complaints of intense pain 2. Begin hourly pad counts and reassure the client
3. Changes in vital signs 3. Begin fundal massage and start oxygen by mask
4. Signs of heavy bruising 4. Elevate the head of the bed and assess vital signs
11. A nurse is developing a plan of care for a PP woman 19. A nurse is assessing a client in the 4th stage if
with a small vulvar hematoma. The nurse includes labor and notes that the fundus is firm but that
which specific intervention in the plan during the first bleeding is excessive. The initial nursing action would
12 hours following the delivery of this client? be which of the following?
1. Assess vital signs every 4 hours 1. Massage the fundus
2. Inform health care provider of assessment findings 2. Place the mother in the Trendelenburg’s position
3. Measure fundal height every 4 hours 3. Notify the physician
4. Prepare an ice pack for application to the area. 4. Record the findings
12. A new mother received epidural anesthesia during 20. A nurse is caring for a PP client with a diagnosis of
labor and had a forceps delivery after pushing 2 hours. DVT who is receiving a continuous intravenous infusion
At 6 hours PP, her systolic blood pressure has dropped of heparin sodium. Which of the following laboratory
20 points, her diastolic BP has dropped 10 points, and results will the nurse specifically review to determine if
her pulse is 120 beats per minute. The client is anxious an effective and appropriate dose of the heparin is
and restless. On further assessment, a vulvar being delivered?
hematoma is verified. After notifying the health care 1. Prothrombin time
provider, the nurse immediately plans to: 2. International normalized ratio
1. Monitor fundal height 3. Activated partial thromboplastin time
2. Apply perineal pressure 4. Platelet count
3. Prepare the client for surgery. 21. A nurse is preparing a list of self-care instructions
4. Reassure the client for a PP client who was diagnosed with mastitis. Select
13. A nurse is monitoring a new mother in the PP all instructions that would be included on the list.
period for signs of hemorrhage. Which of the following 1. Take the prescribed antibiotics until the soreness subsides.
signs, if noted in the mother, would be an early sign of 2. Wear supportive bra
excessive blood loss? 3. Avoid decompression of the breasts by breastfeeding or
1. A temperature of 100.4*F breast pump
2. An increase in the pulse from 88 to 102 BPM 4. Rest during the acute phase
3. An increase in the respiratory rate from 18 to 22 breaths 5. Continue to breastfeed if the breasts are not too sore.
per minute 22. Methergine or pitocin is prescribed for a woman to
4. A blood pressure change from 130/88 to 124/80 mm Hg treat PP hemorrhage. Before administration of these
14. A nurse is preparing to assess the uterine fundus of medications, the priority nursing assessment is to
a client in the immediate postpartum period. When the check the:
nurse locates the fundus, she notes that the uterus 1. Amount of lochia
feels soft and boggy. Which of the following nursing 2. Blood pressure
interventions would be most appropriate initially? 3. Deep tendon reflexes
1. Massage the fundus until it is firm 4. Uterine tone
2. Elevate the mothers legs 23. Methergine or pitocin are prescribed for a client
3. Push on the uterus to assist in expressing clots with PP hemorrhage. Before administering the
4. Encourage the mother to void medication(s), the nurse contacts the health provider
15. A PP nurse is assessing a mother who delivered a who prescribed the medication(s) in which of the
healthy newborn infant by C-section. The nurse is following conditions is documented in the client’s
assessing for signs and symptoms of superficial venous medical history?
thrombosis. Which of the following signs or symptoms 1. Peripheral vascular disease
would the nurse note if superficial venous thrombosis 2. Hypothyroidism
were present? 3. Hypotension
1. Paleness of the calf area 4. Type 1 diabetes
2. Enlarged, hardened veins 24. Which of the following factors might result in a
3. Coolness of the calf area decreased supply of breastmilk in a PP mother?
4. Palpable dorsalis pedis pulses 1. Supplemental feedings with formula
16. A nurse is providing instructions to a mother who 2. Maternal diet high in vitamin C
has been diagnosed with mastitis. Which of the 3. An alcoholic drink
4. Frequent feedings
25. Which of the following interventions would be 1. The vaccine is safe in clients with egg allergies
helpful to a breastfeeding mother who is experiencing 2. Breast-feeding isn’t compatible with the vaccine
engorged breasts? 3. Transient arthralgia and rash are common adverse effects
1. Applying ice 4. The client should avoid getting pregnant for 3 months after
2. Applying a breast binder the vaccine because the vaccine has teratogenic effects
3. Teaching how to express her breasts in a warm shower 36. Which of the following changes best described the
4. Administering bromocriptine (Parlodel) insulin needs of a client with type 1 diabetes who has
26. On completing a fundal assessment, the nurse just delivered an infant vaginally without
notes the fundus is situated on the client’s left complications?
abdomen. Which of the following actions is 1. Increase
appropriate? 2. Decrease
1. Ask the client to empty her bladder 3. Remain the same as before pregnancy
2. Straight catheterize the client immediately 4. Remain the same as during pregnancy
3. Call the client’s health provider for direction 37. Which of the following responses is most
4. Straight catheterize the client for half of her uterine appropriate for a mother with diabetes who wants to
volume breastfeed her infant but is concerned about the effects
27. The nurse is about the give a Type 2 diabetic her of breastfeeding on her health?
insulin before breakfast on her first day postpartum. 1. Mothers with diabetes who breastfeed have a hard time
Which of the following answers best describes insulin controlling their insulin needs
requirements immediately postpartum? 2. Mothers with diabetes shouldn’t breastfeed because of
1. Lower than during her pregnancy potential complications
2. Higher than during her pregnancy 3. Mothers with diabetes shouldn’t breastfeed; insulin
3. Lower than before she became pregnant requirements are doubled.
4. Higher than before she became pregnant 4. Mothers with diabetes may breastfeed; insulin
28. Which of the following findings would be expected requirements may decrease from breastfeeding.
when assessing the postpartum client? 38. On the first PP night, a client requests that her
1. Fundus 1 cm above the umbilicus 1 hour postpartum baby be sent back to the nursery so she can get some
2. Fundus 1 cm above the umbilicus on postpartum day 3 sleep. The client is most likely in which of the following
3. Fundus palpable in the abdomen at 2 weeks postpartum phases?
4. Fundus slightly to the right; 2 cm above umbilicus on 1. Depression phase
postpartum day 2 2. Letting-go phase
29. A client is complaining of painful contractions, 3. Taking-hold phase
or afterpains, on postpartum day 2. Which of the 4. Taking-in phase
following conditions could increase the severity of 39. Which of the following physiological responses is
afterpains? considered normal in the early postpartum period?
1. Bottle-feeding 1. Urinary urgency and dysuria
2. Diabetes 2. Rapid diuresis
3. Multiple gestation 3. Decrease in blood pressure
4. Primiparity 4. Increase motility of the GI system
30. On which of the postpartum days can the client 40. During the 3rd PP day, which of the following
expect lochia serosa? observations about the client would the nurse be most
1. Days 3 and 4 PP likely to make?
2. Days 3 to 10 PP 1. The client appears interested in learning about neonatal
3. Days 10-14 PP care
4. Days 14 to 42 PP 2. The client talks a lot about her birth experience
31. Which of the following behaviors characterizes the 3. The client sleeps whenever the neonate isn’t present
PP mother in the taking inphase? 4. The client requests help in choosing a name for the
1. Passive and dependant neonate.
2. Striving for independence and autonomy 41. Which of the following circumstances is most likely
3. Curious and interested in care of the baby to cause uterine atony and lead to PP hemorrhage?
4. Exhibiting maximum readiness for new learning 1. Hypertension
32. Which of the following complications may be 2. Cervical and vaginal tears
indicated by continuous seepage of blood from the 3. Urine retention
vagina of a PP client, when palpation of the uterus 4. Endometritis
reveals a firm uterus 1 cm below the umbilicus? 42. Which type of lochia should the nurse expect to find
1. Retained placental fragments in a client 2 days PP?
2. Urinary tract infection 1. Foul-smelling
3. Cervical laceration 2. Lochia serosa
4. Uterine atony 3. Lochia alba
33. What type of milk is present in the breasts 7 to 10 4. Lochia rubra
days PP? 43. After expulsion of the placenta in a client who has
1. Colostrum six living children, an infusion of lactated ringer’s
2. Hind milk solution with 10 units of pitocin is ordered. The nurse
3. Mature milk understands that this is indicated for this client
4. Transitional milk because:
34. Which of the following complications is most likely 1. She had a precipitate birth
responsible for a delayed postpartum hemorrhage? 2. This was an extramural birth
1. Cervical laceration 3. Retained placental fragments must be expelled
2. Clotting deficiency 4. Multigravidas are at increased risk for uterine atony.
3. Perineal laceration 44. As part of the postpartum assessment, the nurse
4. Uterine subinvolution examines the breasts of a primiparous breastfeeding
35. Before giving a PP client the rubella vaccine, which woman who is one day postpartum. An expected
of the following facts should the nurse include in client finding would be:
teaching?
1. Soft, non-tender; colostrum is present 52. Four hours after a difficult labor and birth, a
2. Leakage of milk at let down primiparous woman refuses to feed her baby, stating
3. Swollen, warm, and tender upon palpation that she is too tired and just wants to sleep. The nurse
4. A few blisters and a bruise on each areola should:
45. Following the birth of her baby, a woman expresses 1. Tell the woman she can rest after she feeds her baby
concern about the weight she gained during pregnancy 2. Recognize this as a behavior of the taking-hold stage
and how quickly she can lose it now that the baby is 3. Record the behavior as ineffective maternal-newborn
born. The nurse, in describing the expected pattern of attachment
weight loss, should begin by telling this woman that: 4. Take the baby back to the nursery, reassuring the woman
1. Return to pre pregnant weight is usually achieved by the that her rest is a priority at this time
end of the postpartum period 53. Parents can facilitate the adjustment of their other
2. Fluid loss from diuresis, diaphoresis, and bleeding accounts children to a new baby by:
for about a 3 pound weight loss 1. Having the children choose or make a gift to give to the
3. The expected weight loss immediately after birth averages new baby upon its arrival home
about 11 to 13 pounds 2. Emphasizing activities that keep the new baby and other
4. Lactation will inhibit weight loss since caloric intake must children together
increase to support milk production 3. Having the mother carry the new baby into the home so
46. Which of the following findings would be a source she can show the other children the new baby
of concern if noted during the assessment of a woman 4. Reducing stress on other children by limiting their
who is 12 hours postpartum? involvement in the care of the new baby
1. Postural hypotension 54. A primiparous woman is in the taking-in stage of
2. Temperature of 100.4°F psychosocial recovery and adjustment following
3. Bradycardia — pulse rate of 55 BPM birth. The nurse, recognizing the needs of women
4. Pain in left calf with dorsiflexion of left foot during this stage, should:
47. The nurse examines a woman one hour after 1. Foster an active role in the baby’s care
birth. The woman’s fundus is boggy, midline, and 1 cm 2. Provide time for the mother to reflect on the events of and
below the umbilicus. Her lochial flow is profuse, with her behavior during childbirth
two plum-sized clots. The nurse’s initial action would 3. Recognize the woman’s limited attention span by giving her
be to: written materials to read when she gets home rather than
1. Place her on a bedpan to empty her bladder doing a teaching session now
2. Massage her fundus 4. Promote maternal independence by encouraging her to
3. Call the physician meet her own hygiene and comfort needs
4. Administer Methergine 0.2 mg IM which has been ordered 55. All of the following are important in the immediate
prn care of the premature neonate. Which nursing activity
48. When performing a postpartum check, the nurse should have the greatest priority?
should: 1. Instillation of antibiotic in the eyes
1. Assist the woman into a lateral position with upper leg 2. Identification by bracelet and foot prints
flexed forward to facilitate the examination of her perineum 3. Placement in a warm environment
2. Assist the woman into a supine position with her arms 4. Neurological assessment to determine gestational age
above her head and her legs extended for the examination of
her abdomen
3. Instruct the woman to avoid urinating just before the NCLEX Exam: Newborn Nursing Care (50 Items)
examination since a full bladder will facilitate fundal palpation
4. Wash hands and put on sterile gloves before beginning the 1. A nurse in a delivery room is assisting with the
check delivery of a newborn infant. After the delivery, the
49. Perineal care is an important infection control nurse prepares to prevent heat loss in the newborn
measure. When evaluating a postpartum woman’s resulting from evaporation by:
perineal care technique, the nurse would recognize the 1. Warming the crib pad
need for further instruction if the woman: 2. Turning on the overhead radiant warmer
1. Uses soap and warm water to wash the vulva and 3. Closing the doors to the room
perineum 4. Drying the infant in a warm blanket
2. Washes from symphysis pubis back to episiotomy 2. A nurse is assessing a newborn infant following
3. Changes her perineal pad every 2 – 3 hours circumcision and notes that the circumcised area is red
4. Uses the peribottle to rinse upward into her vagina with a small amount of bloody drainage. Which of the
50. Which measure would be least effective in following nursing actions would be most appropriate?
preventing postpartum hemorrhage? 1. Document the findings
1. Administer Methergine 0.2 mg every 6 hours for 4 doses as 2. Contact the physician
ordered 3. Circle the amount of bloody drainage on the dressing and
2. Encourage the woman to void every 2 hours reassess in 30 minutes
3. Massage the fundus every hour for the first 24 hours 4. Reinforce the dressing
following birth 3. A nurse in the newborn nursery is monitoring a
4. Teach the woman the importance of rest and nutrition to preterm newborn infant for respiratory distress
enhance healing syndrome. Which assessment signs if noted in the
51. When making a visit to the home of a postpartum newborn infant would alert the nurse to the possibility
woman one week after birth, the nurse should of this syndrome?
recognize that the woman would characteristically: 1. Hypotension and Bradycardia
1. Express a strong need to review events and her behavior 2. Tachypnea and retractions
during the process of labor and birth 3. Acrocyanosis and grunting
2. Exhibit a reduced attention span, limiting readiness to 4. The presence of a barrel chest with grunting
learn 4. A nurse in a newborn nursery is performing an
3. Vacillate between the desire to have her own nurturing assessment of a newborn infant. The nurse is preparing
needs met and the need to take charge of her own care and to measure the head circumference of the infant. The
that of her newborn nurse would most appropriately:
4. Have reestablished her role as a spouse/partner
1. Wrap the tape measure around the infant’s head and conjunctival sacs within one hour after birth.”
measure just above the eyebrows. 4. “Administration of the eye ointment may be delayed until
2. Place the tape measure under the infants head at the base an hour or so after birth so that eye contact and parent-infant
of the skull and wrap around to the front just above the eyes attachment and bonding can occur.”
3. Place the tape measure under the infants head, wrap 12. A baby is born precipitously in the ER. The nurses
around the occiput, and measure just above the eyes initial action should be to:
4. Place the tape measure at the back of the infant’s head, 1. Establish an airway for the baby
wrap around across the ears, and measure across the infant’s 2. Ascertain the condition of the fundus
mouth. 3. Quickly tie and cut the umbilical cord
5. A postpartum nurse is providing instructions to the 4. Move mother and baby to the birthing unit
mother of a newborn infant with hyperbilirubinemia 13. The primary critical observation for Apgar scoring is
who is being breastfed. The nurse provides which most the:
appropriate instructions to the mother? 1. Heart rate
1. Switch to bottle feeding the baby for 2 weeks 2. Respiratory rate
2. Stop the breast feedings and switch to bottle-feeding 3. Presence of meconium
permanently 4. Evaluation of the Moro reflex
3. Feed the newborn infant less frequently 14. When performing a newborn assessment, the nurse
4. Continue to breast-feed every 2-4 hours should measure the vital signs in the following
6. A nurse on the newborn nursery floor is caring for a sequence:
neonate. On assessment the infant is exhibiting signs 1. Pulse, respirations, temperature
of cyanosis, tachypnea, nasal flaring, and grunting. 2. Temperature, pulse, respirations
Respiratory distress syndrome is diagnosed, and the 3. Respirations, temperature, pulse
physician prescribes surfactant replacement therapy. 4. Respirations, pulse, temperature
The nurse would prepare to administer this therapy by: 15. Within 3 minutes after birth the normal heart rate
1. Subcutaneous injection of the infant may range between:
2. Intravenous injection 1. 100 and 180
3. Instillation of the preparation into the lungs through an 2. 130 and 170
endotracheal tube 3. 120 and 160
4. Intramuscular injection 4. 100 and 130
7. A nurse is assessing a newborn infant who was born 16. The expected respiratory rate of a neonate within 3
to a mother who is addicted to drugs. Which of the minutes of birth may be as high as:
following assessment findings would the nurse expect 1. 50
to note during the assessment of this newborn? 2. 60
1. Sleepiness 3. 80
2. Cuddles when being held 4. 100
3. Lethargy 17. The nurse is aware that a healthy newborn’s
4. Incessant crying respirations are:
8. A nurse prepares to administer a vitamin K injection 1. Regular, abdominal, 40-50 per minute, deep
to a newborn infant. The mother asks the nurse why 2. Irregular, abdominal, 30-60 per minute, shallow
her newborn infant needs the injection. The best 3. Irregular, initiated by chest wall, 30-60 per minute, deep
response by the nurse would be: 4. Regular, initiated by the chest wall, 40-60 per minute,
1. “You infant needs vitamin K to develop immunity.” shallow
2. “The vitamin K will protect your infant from being 18. To help limit the development of hyperbilirubinemia
jaundiced.” in the neonate, the plan of care should include:
3. “Newborn infants are deficient in vitamin K, and this 1. Monitoring for the passage of meconium each shift
injection prevents your infant from abnormal bleeding.” 2. Instituting phototherapy for 30 minutes every 6 hours
4. “Newborn infants have sterile bowels, and vitamin K 3. Substituting breastfeeding for formula during the 2nd day
promotes the growth of bacteria in the bowel.” after birth
9. A nurse in a newborn nursery receives a phone call 4. Supplementing breastfeeding with glucose water during the
to prepare for the admission of a 43-week-gestation first 24 hours
newborn with Apgar scores of 1 and 4. In planning for 19. A newborn has small, whitish, pinpoint spots over
the admission of this infant, the nurse’s highest priority the nose, which the nurse knows are caused by
should be to: retained sebaceous secretions. When charting this
1. Connect the resuscitation bag to the oxygen outlet observation, the nurse identifies it as:
2. Turn on the apnea and cardiorespiratory monitors 1. Milia
3. Set up the intravenous line with 5% dextrose in water 2. Lanugo
4. Set the radiant warmer control temperature at 36.5* C 3. Whiteheads
(97.6*F) 4. Mongolian spots
10. Vitamin K is prescribed for a neonate. A nurse 20. When newborns have been on formula for 36-48
prepares to administer the medication in which muscle hours, they should have a:
site? 1. Screening for PKU
1. Deltoid 2. Vitamin K injection
2. Triceps 3. Test for necrotizing enterocolitis
3. Vastus lateralis 4. Heel stick for blood glucose level
4. Biceps 21. The nurse decides on a teaching plan for a new
11. A nursing instructor asks a nursing student to mother and her infant. The plan should include:
describe the procedure for administering erythromycin 1. Discussing the matter with her in a non-threatening
ointment into the eyes if a neonate. The instructor manner
determines that the student needs to research this 2. Showing by example and explanation how to care for the
procedure further if the student states: infant
1. “I will cleanse the neonate’s eyes before instilling 3. Setting up a schedule for teaching the mother how to care
ointment.” for her baby
2. “I will flush the eyes after instilling the ointment.” 4. Supplying the emotional support to the mother and
3. “I will instill the eye ointment into each of the neonate’s encouraging her independence
22. Which action best explains the main role of 32. When attempting to interact with a neonate
surfactant in the neonate? experiencing drug withdrawal, which behavior would
1. Assists with ciliary body maturation in the upper airways indicate that the neonate is willing to interact?
2. Helps maintain a rhythmic breathing pattern 1. Gaze aversion
3. Promotes clearing mucus from the respiratory tract 2. Hiccups
4. Helps the lungs remain expanded after the initiation of 3. Quiet alert state
breathing 4. Yawning
23. While assessing a 2-hour old neonate, the nurse 33. When teaching umbilical cord care to a new
observes the neonate to have acrocyanosis. Which of mother, the nurse would include which information?
the following nursing actions should be performed 1. Apply peroxide to the cord with each diaper change
initially? 2. Cover the cord with petroleum jelly after bathing
1. Activate the code blue or emergency system 3. Keep the cord dry and open to air
2. Do nothing because acrocyanosis is normal in the neonate 4. Wash the cord with soap and water each day during a tub
3. Immediately take the newborn’s temperature according to bath
hospital policy 34. A mother of a term neonate asks what the thick,
4. Notify the physician of the need for a cardiac consult white, cheesy coating is on his skin. Which correctly
24. The nurse is aware that a neonate of a mother with describes this finding?
diabetes is at risk for what complication? 1. Lanugo
1. Anemia 2. Milia
2. Hypoglycemia 3. Nevus flammeus
3. Nitrogen loss 4. Vernix
4. Thrombosis 35. Which condition or treatment best ensures lung
25. A client with group AB blood whose husband has maturity in an infant?
group O has just given birth. The major sign of ABO 1. Meconium in the amniotic fluid
blood incompatibility in the neonate is which 2. Glucocorticoid treatment just before delivery
complication or test result? 3. Lecithin to sphingomyelin ratio more than 2:1
1. Negative Coombs test 4. Absence of phosphatidylglycerol in amniotic fluid
2. Bleeding from the nose and ear 36. When performing nursing care for a neonate after a
3. Jaundice after the first 24 hours of life birth, which intervention has the highest nursing
4. Jaundice within the first 24 hours of life priority?
26. A client has just given birth at 42 weeks’ gestation. 1. Obtain a dextrostix
When assessing the neonate, which physical finding is 2. Give the initial bath
expected? 3. Give the vitamin K injection
1. A sleepy, lethargic baby 4. Cover the neonates head with a cap
2. Lanugo covering the body 37. When performing an assessment on a neonate,
3. Desquamation of the epidermis which assessment finding is most suggestive of
4. Vernix caseosa covering the body hypothermia?
27. After reviewing the client’s maternal history of 1. Bradycardia
magnesium sulfate during labor, which condition would 2. Hyperglycemia
the nurse anticipate as a potential problem in the 3. Metabolic alkalosis
neonate? 4. Shivering
1. Hypoglycemia 38. A woman delivers a 3.250 g neonate at 42 weeks’
2. Jitteriness gestation. Which physical finding is expected during an
3. Respiratory depression examination if this neonate?
4. Tachycardia 1. Abundant lanugo
28. Neonates of mothers with diabetes are at risk for 2. Absence of sole creases
which complication following birth? 3. Breast bud of 1-2 mm in diameter
1. Atelectasis 4. Leathery, cracked, and wrinkled skin
2. Microcephaly 39. A healthy term neonate born by C-section was
3. Pneumothorax admitted to the transitional nursery 30 minutes ago
4. Macrosomia and placed under a radiant warmer. The neonate has
29. By keeping the nursery temperature warm and an axillary temperature of 99.5oF, a respiratory rate of
wrapping the neonate in blankets, the nurse is 80 breaths/minute, and a heel stick glucose value of 60
preventing which type of heat loss? mg/dl. Which action should the nurse take?
1. Conduction 1. Wrap the neonate warmly and place her in an open crib
2. Convection 2. Administer an oral glucose feeding of 10% dextrose in
3. Evaporation water
4. Radiation 3. Increase the temperature setting on the radiant warmer
30. A neonate has been diagnosed with caput 4. Obtain an order for IV fluid administration
succedaneum. Which statement is correct about this 40. Which neonatal behavior is most commonly
condition? associated with fetal alcohol syndrome (FAS)?
1. It usually resolves in 3-6 weeks 1. Hypoactivity
2. It doesn’t cross the cranial suture line 2. High birth weight
3. It’s a collection of blood between the skull and the 3. Poor wake and sleep patterns
periosteum 4. High threshold of stimulation
4. It involves swelling of tissue over the presenting part of the 41. Which of the following behaviors would indicate
presenting head that a client was bonding with her baby?
31. The most common neonatal sepsis and meningitis 1. The client asks her husband to give the baby a bottle of
infections seen within 24 hours after birth are caused water.
by which organism? 2. The client talks to the baby and picks him up when he
1. Candida albicans cries.
2. Chlamydia trachomatis 3. The client feeds the baby every three hours.
3. Escherichia coli 4. The client asks the nurse to recommend a good child care
4. Group B beta-hemolytic streptococci manual.
42. A newborn’s mother is alarmed to find small 1. as soon as possible after the infant’s birth.
amounts of blood on her infant girl’s diaper. When the 2. after the mother has rested for 4-6 hours.
nurse checks the infant’s urine it is straw colored and 3. during the infant’s second period of reactivity.
has no offensive odor. Which explanation to the 4. after the infant has taken sterile water without
newborn’s mother is most appropriate? complications.
1. “It appears your baby has a kidney infection” 50. The nurse is preparing to discharge a multipara 24
2. “Breast-fed babies often experience this type of bleeding hours after a vaginal delivery. The client is breast-
problem due to lack of vitamin C in the breast milk” feeding her newborn. The nurse instructs the client
3. “The baby probably passed a small kidney stone” that if engorgement occurs the client should
4. “Some infants experience menstruation like bleeding when 1. wear a tight fitting bra or breast binder.
hormones from the mother are not available” 2. apply warm, moist heat to the breasts.
43. An insulin-dependent diabetic delivered a 10-pound 3. contact the nurse midwife for a lactation suppressant.
male. When the baby is brought to the nursery, the 4. restrict fluid intake to 1000 ml. daily .
priority of care is to
1. clean the umbilical cord with Betadine to prevent infection
2. give the baby a bath NCLEX Exam: Pediatric Nursing 1 (50 Items)
3. call the laboratory to collect a PKU screening test
4. check the baby’s serum glucose level and administer 1. Molly, with suspected rheumatic fever, is admitted to
glucose if < 40 mg/dL the pediatric unit. When obtaining the child’s history,
44. Soon after delivery a neonate is admitted to the the nurse considers which information to be most
central nursery. The nursery nurse begins the initial important?
assessment by a. A fever that started 3 days ago
1. auscultate bowel sounds. b. Lack of interest in food
2. determining chest circumference. c. A recent episode of pharyngitis
3. inspecting the posture, color, and respiratory effort. d. Vomiting for 2 days
4. checking for identifying birthmarks. 2. Nurse Analiza is administering a medication via the
45. The home health nurse visits the Cox family 2 intraosseous route to a child. Intraosseous drug
weeks after hospital discharge. She observes that the administration is typically used when a child is:
umbilical cord has dried and fallen off. The area a. Under age 3
appears healed with no drainage or erythema present. b. Over age 3
The mother can be instructed to c. Critically ill and under age 3
1. cover the umbilicus with a band-aid. d. Critically ill and over age 3
2. continue to clean the stump with alcohol for one week. 3. When assessing a child’s cultural background, the
3. apply an antibiotic ointment to the stump. nurse in charge should keep in mind that:
4. give him a bath in an infant tub now. a. Cultural background usually has little bearing on a family’s
46. A neonate is admitted to a hospital’s central health practices
nursery. The neonate’s vital signs are: temperature = b. Physical characteristics mark the child as part of a
96.5 degrees F., heart rate = 120 bpm, and respirations particular culture
= 40/minute. The infant is pink with slight c. Heritage dictates a group’s shared values
acrocyanosis. The priority nursing diagnosis for the d. Behavioral patterns are passed from one generation to the
neonate is next
1. Ineffective thermoregulation related to 4. While examining a 2-year-old child, the nurse in
fluctuating environmental temperatures. charge sees that the anterior fontanel is open. The
2. Potential for infection related to lack of immunity. nurse should:
3. Altered nutrition, less than body requirements related to a. Notify the doctor
diminished sucking reflex. b. Look for other signs of abuse
4. Altered elimination pattern related to lack of nourishment. c. Recognize this as a normal finding
47. The nurse hears the mother of a 5-pound neonate d. Ask about a family history of Tay-Sachs disease
telling a friend on the telephone, “As soon as I get 5. The nurse is aware that the most common
home, I’ll give him some cereal to get him to gain assessment finding in a child with ulcerative colitis is:
weight?” The nurse recognizes the need for further a. Intense abdominal cramps
instruction about infant feeding and tells her b. Profuse diarrhea
1. “If you give the baby cereal, be sure to use Rice to prevent c. Anal fissures
allergy.” d. Abdominal distention
2. “The baby is not able to swallow cereal, because he is too 6. When administering an I.M. injection to an infant,
small.” the nurse in charge should use which site?
3. “The infant’s digestive tract cannot handle complex a. Deltoid
carbohydrates like cereal.” b. Dorsogluteal
4. “If you want him to gain weight, just double his daily c. Ventrogluteal
intake of formula.” d. Vastus lateralis
48. The nurse instructs a primipara about safety 7. A child with a poor nutritional status and weight loss
considerations for the neonate. The nurse determines is at risk for a negative nitrogen balance. To help
that the client does not understand the instructions diagnose this problem, the nurse in charge anticipates
when she says that the doctor will order which laboratory test?
1. “All neonates should be in an approved car seat when in an a. Total iron-binding capacity
automobile.” b. Hemoglobin
2. “It’s acceptable to prop the infant’s bottle once in a while.” c. Total protein
3. “Pillows should not be used in the infant’s crib.” d. Serum transferrin
4. “Infants should never be left unattended on an unguarded 8. When developing a plan of care for a male
surface.” adolescent, the nurse considers the child’s psychosocial
49. The nurse manager is presenting education to her needs. During adolescence, psychosocial development
staff to promote consistency in the interventions used focuses on:
with lactating mothers. She emphasizes that the a. Becoming industrious
optimum time to initiate lactation is b. Establishing an identity
c. Achieving intimacy b. Initiating a teenage parent support group with first – and –
d. Developing initiative second-time mothers
9. When developing a plan care for a hospitalized child, c. Using audiovisual aids that show discussions of feelings and
nurse Mica knows that children in which age group are skills
most likely to view illness as a punishment for d. Providing age-appropriate reading materials
misdeeds? 18. When performing a physical examination on an
a. Infancy infant, the nurse in charge notes abnormally low-set
b. Preschool age ears. This findings is associated with:
c. School age a. Otogenous tetanus
d. Adolescence b. Tracheoesophageal fistula
10. Nurse Sunshine suspects that a child, age 4, is c. Congenital heart defects
being neglected physically. To best assess the child’s d. Renal anomalies
nutritional status, the nurse should ask the parents 19. Nurse Walter should expect a 3-year-old child to be
which question? able to perform which action?
a. “Has your child always been so thin?” a. Ride a tricycle
b. “Is your child a picky eater?” b. Tie the shoelaces
c. “What did your child eat for breakfast?” c. Roller-skates
d. “Do you think your child eats enough?” d. Jump rope
11. A female child, age 2, is brought to the emergency 20. Nurse Kim is teaching a group of parents about
department after ingesting an unknown number of otitis media. When discussing why children are
aspirin tablets about 30 minutes earlier. On entering predisposed to this disorder, the nurse should mention
the examination room, the child is crying and clinging the significance of which anatomical feature?
to the mother. Which data should the nurse obtain a. Eustachian tubes
first? b. Nasopharynx
a. Heart rate, respiratory rate, and blood pressure c. Tympanic membrane
b. Recent exposure to communicable diseases d. External ear canal
c. Number of immunizations received 21. The nurse is evaluating a female child with acute
d. Height and weight poststreptococcal glomerulonephritis for signs of
12. A mother asks the nurse how to handle her 5-year- improvement. Which finding typically is the earliest
old child, who recently started wetting the pants after sign of improvement?
being completely toilet trained. The child just started a. Increased urine output
attending nursery school 2 days a week. Which b. Increased appetite
principle should guide the nurse’s response? c. Increased energy level
a. The child forgets previously learned skills d. Decreased diarrhea
b. The child experiences growth while regressing, regrouping, 22. Dr. Jones prescribes corticosteroids for a child with
and then progressing nephritic syndrome. What is the primary purpose of
c. The parents may refer less mature behaviors administering corticosteroids to this child?
d. The child returns to a level of behavior that increases the a. To increase blood pressure
sense of security. b. To reduce inflammation
13. A female child, age 6, is brought to the health clinic c. To decrease proteinuria
for a routine checkup. To assess the child’s vision, the d. To prevent infection
nurse should ask: 23. Parents bring their infant to the clinic, seeking
a. “Do you have any problems seeing different colors?” treatment for vomiting and diarrhea that has lasted for
b. “Do you have trouble seeing at night?” 2 days. On assessment, the nurse in charge detects dry
c. “Do you have problems with glare?” mucous membranes and lethargy. What other findings
d. “How are you doing in school?” suggests a fluid volume deficit?
14. During a well-baby visit, Liza asks the nurse when a. A sunken fontanel
she should start giving her infant solid foods. The nurse b. Decreased pulse rate
should instruct her to introduce which solid food first? c. Increased blood pressure
a. Applesauce d. Low urine specific gravity
b. Egg whites 24. How should the nurse prepare a suspension before
c. Rice cereal administration?
d. Yogurt a. By diluting it with normal saline solution
15. To decrease the likelihood of bradyarrhythmias in b. By diluting it with 5% dextrose solution
children during endotracheal intubation, c. By shaking it so that all the drug particles are dispersed
succinylcholine (Anectine) is used with which of the uniformly
following agents? d. By crushing remaining particles with a mortar and pestle
a. Epinephrine (Adrenalin) 25. What should be the initial bolus of crystalloid fluid
b. Isoproterenol (Isuprel) replacement for a pediatric patient in shock?
c. Atropine sulfate a. 20 ml/kg
d. Lidocaine hydrochloride (Xylocaine) b. 10 ml/kg
16. A 1-year-and 2-month-old child weighing 26 lb c. 30 ml/kg
(11.8 kg) is admitted for traction to treat congenital d. 15 ml/kg
hip dislocation. When preparing the patient’s room, the 26. Lily , age 5, with intelligence quotient of 65 is
nurse anticipates using which traction system? admitted to the hospital for evaluation. When planning
a. Bryant’s traction care, the nurse should keep in mind that this child is:
b. Buck’s extension traction a. Within the lower range of normal intelligence
c. Overhead suspension traction b. Mildly retarded but educable
d. 90-90 traction c. Moderately retarded but trainable
17. Hannah, age 12, is 7 months pregnant. When d. Completely dependent on others for care
teaching parenting skills to an adolescent, the nurse 27. Mandy, age 12, is brought to the clinic for
knows that which teaching strategy is least effective? evaluation for a suspected eating disorder. To best
a. Providing a one-on-one demonstration and requesting a assess the effects of role and relationship patterns on
return demonstration, using a live infant model the child’s nutritional intake, the nurse should ask:
a. “What activities do you engage in during the day?” c. (+) moro reflex
b. “Do you have any allergies to foods?” d. heart rate is 80 bpm
c. “Do you like yourself physically?” 38. Which of the following situations increase risk of
d. “What kinds of food do you like to eat?” lead poisoning in children?
28. Sudden infant death syndrome (SIDS) is one of the a. playing in the park with heavy traffic and with many
most common causes of death in infants. At what age is vehicles passing by
the diagnosis of SIDS most likely? b. playing sand in the park
a. At 1 to 2 years of age c. playing plastic balls with other children
b. At I week to 1 year of age, peaking at 2 to 4 months d. playing with stuffed toys at home
c. At 6 months to 1 year of age, peaking at 10 months 39. An inborn error of metabolism that causes
d. At 6 to 8 weeks of age premature destruction of RBC?
29. When evaluating a severely depressed adolescent, a. G6PD
the nurse knows that one indicator of a high risk for b. Hemocystinuria
suicide is: c. Phenylketonuria
a. Depression d. Celiac Disease
b. Excessive sleepiness 40. Which of the following blood study results would
c. A history of cocaine use the nurse expect as most likely when caring for the
d. A preoccupation with death child with iron deficiency anemia?
30. A child is diagnosed with Wilms’ tumor. During a. Increased hemoglobin
assessment, the nurse in charge expects to detect: b. Normal hematocrit
a. Gross hematuria c. Decreased mean corpuscular volume (MCV)
b. Dysuria d. Normal total iron-binding capacity (TIBC)
c. Nausea and vomiting 41. The nurse answers a call bell and finds a frightened
d. An abdominal mass mother whose child, the patient, is having a seizure.
31. Which of the following would be inappropriate Which of these actions should the nurse take?
when administering chemotherapy to a child? a. The nurse should insert a padded tongue blade in the
a. Monitoring the child for both general and specific adverse patient’s mouth to prevent the child from swallowing or
effects choking on his tongue.
b. Observing the child for 10 minutes to note for signs of b. The nurse should help the mother restrain the child to
anaphylaxis prevent him from injuring himself.
c. Administering medication through a free-flowing c. The nurse should call the operator to page for seizure
intravenous line assistance.
d. Assessing for signs of infusion infiltration and irritation d. The nurse should clear the area and position the client
32. Which of the following is the best method for safely.
performing a physical examination on a toddler 42. At the community center, the nurse leads an
a. From head to toe adolescent health information group, which often
b. Distally to proximally expands into other areas of discussion. She knows that
c. From abdomen to toes, the to head these youths are trying to find out “who they are,” and
d. From least to most intrusive discussion often focuses on which directions they want
33. Which of the following organisms is responsible for to take in school and life, as well as peer relationships.
the development of rheumatic fever? According to Erikson, this stage is known as:
a. Streptococcal pneumonia a. identity vs. role confusion.
b. Haemophilus influenza b. adolescent rebellion.
c. Group A β-hemolytic streptococcus c. career experimentation.
d. Staphylococcus aureus d. relationship testing
34. Which of the following is most likely associated 43. The nurse is assessing a 9-month-old boy for a
with a cerebrovascular accident (CVA) resulting from well-baby check up. Which of the following
congenital heart disease? observations would be of most concern?
a. Polycythemia a. The baby cannot say “mama” when he wants his mother.
b. Cardiomyopathy b. The mother has not given him finger foods.
c. Endocarditis c. The child does not sit unsupported.
d. Low blood pressure d. The baby cries whenever the mother goes out.
35. How does the nurse appropriately administer 44. Cherry, the mother of an 11-month-old girl,
mycostatin suspension in an infant? Elizabeth, is in the clinic for her daughter’s
a. Have the infant drink water, and then administer immunizations. She expresses concern to the nurse
mycostatin in a syringe that Elizabeth cannot yet walk. The nurse correctly
b. Place mycostatin on the nipple of the feeding bottle and replies that, according to the Denver Developmental
have the infant suck it Screen, the median age for walking is:
c. Mix mycostatin with formula a. 12 months.
d. Swab mycostatin on the affected areas b. 15 months.
36. A mother tells the nurse that she is very worried c. 10 months.
because her 2-year old child does not finish his meals. d. 14 months.
What should the nurse advise the mother? 45. Sunshine, age 13, has had a lumbar puncture to
a. make the child seat with the family in the dining room until examine the CSF to determine if bacterial infection
he finishes his meal exists. The best position to keep her in after the
b. provide quiet environment for the child before meals procedure is:
c. do not give snacks to the child before meals a. prone for two hours to prevent aspiration, should she
d. put the child on a chair and feed him vomit.
37. The nurse is assessing a newborn who had b. semi-fowler’s so she can watch TV for five hours and be
undergone vaginal delivery. Which of the following entertained.
findings is least likely to be observed in a normal c. supine for several hours, to prevent headache.
newborn? d. on her right sides to encourage return of CSF
a. uneven head shape 46. Buck’s traction with a 10 lb. weight is securing a
b. respirations are irregular, abdominal, 30-60 bpm patient’s leg while she is waiting for surgery to repair a
hip fracture. It is important to check circulation- 4. When caring for a 3-day-old neonate who is
sensation-movement: receiving phototherapy to treat jaundice, the nurse in
a. every shift. charge would expect to do which of the following?
b. every day. a. Turn the neonate every 6 hours
c. every 4 hours. b. Encourage the mother to discontinue breast-feeding
d. every 15 minutes. c. Notify the physician if the skin becomes bronze in color
47. Kim is using bronchodilators for asthma. The side d. Check the vital signs every 2 to 4 hours
effects of these drugs that you need to monitor this 5. A primigravida in active labor is about 9 days post-
patient for include: term. The client desires a bilateral pudendal block
a. tachycardia, nausea, vomiting, heart palpitations, inability anesthesia before delivery. After the nurse explains
to sleep, restlessness, and seizures. this type of anesthesia to the client, which of the
b. tachycardia, headache, dyspnea, temp . 101 F, and following locations identified by the client as the area
wheezing. of relief would indicate to the nurse that the teaching
c. blurred vision, tachycardia, hypertension, headache, was effective?
insomnia, and oliguria. a. Back
d. restlessness, insomnia, blurred vision, hypertension, chest b. Abdomen
pain, and muscle weakness. c. Fundus
48. The adolescent patient has symptoms of d. Perineum
meningitis: nuchal rigidity, fever, vomiting, and 6. The nurse is caring for a primigravida at about 2
lethargy. The nurse knows to prepare for the following months and 1 week gestation. After explaining self-
test: care measures for common discomforts of pregnancy,
a. blood culture. the nurse determines that the client understands the
b. throat and ear culture. instructions when she says:
c. CAT scan. a. “Nausea and vomiting can be decreased if I eat a few
d. lumbar puncture. crackers before arising”
49. The nurse is drawing blood from the diabetic b. “If I start to leak colostrum, I should cleanse my nipples
patient for a glycosylated hemoglobin test. She with soap and water”
explains to the woman that the test is used to c. “If I have a vaginal discharge, I should wear nylon
determine: underwear”
a. the highest glucose level in the past week. d. “Leg cramps can be alleviated if I put an ice pack on the
b. her insulin level. area”
c. glucose levels over the past several months. 7. Thirty hours after delivery, the nurse in charge plans
d. her usual fasting glucose level. discharge teaching for the client about infant care. By
50. The twelve-year-old boy has fractured his arm this time, the nurse expects that the phase of
because of a fall from his bike. After the injury has postpartum psychological adaptation that the client
been casted, the nurse knows it is most important to would be in would be termed which of the following?
perform all of the following assessments on the area a. Taking in
distal to the injury except: b. Letting go
a. capillary refill. c. Taking hold
b. radial and ulnar pulse. d. Resolution
c. finger movement 8. A pregnant client is diagnosed with partial placenta
d. skin integrity previa. In explaining the diagnosis, the nurse tells the
client that the usual treatment for partial placenta
previa is which of the following?
NCLEX Exam: Maternal and Child Health Nursing 1 (30 a. Activity limited to bed rest
Items) b. Platelet infusion
c. Immediate cesarean delivery
1. A postpartum patient was in labor for 30 hours and d. Labor induction with oxytocin
had ruptured membranes for 24 hours. For which of the 9. The nurse plans to instruct the postpartum client
following would the nurse be alert? about methods to prevent breast engorgement. Which
a. Endometritis of the following measures would the nurse include in
b. Endometriosis the teaching plan?
c. Salpingitis a. Feeding the neonate a maximum of 5 minutes per side on
d. Pelvic thrombophlebitis the first day
2. A client at 36 weeks gestation is schedule for a b. Wearing a supportive brassiere with nipple shields
routine ultrasound prior to an amniocentesis. After c. Breast-feeding the neonate at frequent intervals
teaching the client about the purpose for the d. Decreasing fluid intake for the first 24 to 48 hours
ultrasound, which of the following client statements 10. When the nurse on duty accidentally bumps the
would indicate to the nurse in charge that the client bassinet, the neonate throws out its arms, hands
needs further instruction? opened, and begins to cry. The nurse interprets this
a. The ultrasound will help to locate the placenta reaction as indicative of which of the following
b. The ultrasound identifies blood flow through the umbilical reflexes?
cord a. Startle reflex
c. The test will determine where to insert the needle b. Babinski reflex
d. The ultrasound locates a pool of amniotic fluid c. Grasping reflex
3. While the postpartum client is receiving heparin for d. Tonic neck reflex
thrombophlebitis, which of the following drugs would 11. A primigravida client at 25 weeks gestation visits
the nurse expect to administer if the client develops the clinic and tells the nurse that her lower back aches
complications related to heparin therapy? when she arrives home from work. The nurse should
a. Calcium gluconate suggest that the client perform:
b. Protamine sulfate a. Tailor sitting
c. Methylergonovine (Methergine) b. Leg lifting
d. Nitrofurantoin (macrodantin) c. Shoulder circling
d. Squatting exercises
12. Which of the following would the nurse in charge 21. A primigravida patient is admitted to the labor
do first after observing a 2-cm circle of bright red delivery area. Assessment reveals that she is in early
bleeding on the diaper of a neonate who just had a part of the first stage of labor. Her pain is likely to be
circumcision? most intense:
a. Notify the neonate’s pediatrician immediately a. Around the pelvic girdle
b. Check the diaper and circumcision again in 30 minutes b. Around the pelvic girdle and in the upper arms
c. Secure the diaper tightly to apply pressure on the site c. Around the pelvic girdle and at the perineum
d. Apply gentle pressure to the site with a sterile gauze pad d. At the perineum
13. Which of the following would the nurse most likely 22. A female adult patient is taking a progestin-only
expect to find when assessing a pregnant client with oral contraceptive, or mini pill. Progestin use may
abruption placenta? increase the patient’s risk for:
a. Excessive vaginal bleeding a. Endometriosis
b. Rigid, board-like abdomen b. Female hypogonadism
c. Titanic uterine contractions c. Premenstrual syndrome
d. Premature rupture of membranes d. Tubal or ectopic pregnancy
14. While the client is in active labor with twins and the 23. A patient with pregnancy-induced hypertension
cervix is 5 cm dilates, the nurse observes contractions probably exhibits which of the following symptoms?
occurring at a rate of every 7 to 8 minutes in a 30- a. Proteinuria, headaches, vaginal bleeding
minute period. Which of the following would be the b. Headaches, double vision, vaginal bleeding
nurse’s most appropriate action? c. Proteinuria, headaches, double vision
a. Note the fetal heart rate patterns d. Proteinuria, double vision, uterine contractions
b. Notify the physician immediately 24. Because cervical effacement and dilation are not
c. Administer oxygen at 6 liters by mask progressing in a patient in labor,the doctor orders I.V.
d. Have the client pant-blow during the contractions administration of oxytocin (Pitocin). Why must the
15. A client tells the nurse, “I think my baby likes to nurse monitor the patient’s fluid intake and output
hear me talk to him.” When discussing neonates and closely during oxytocin administration?
stimulation with sound, which of the following would a. Oxytocin causes water intoxication
the nurse include as a means to elicit the best b. Oxytocin causes excessive thirst
response? c. Oxytocin is toxic to the kidneys
a. High-pitched speech with tonal variations d. Oxytocin has a diuretic effect
b. Low-pitched speech with a sameness of tone 25. Five hours after birth, a neonate is transferred to
c. Cooing sounds rather than words the nursery, where the nurse intervenes to prevent
d. Repeated stimulation with loud sounds hypothermia. What is a common source of radiant heat
16. A 31-year-old multipara is admitted to the birthing loss?
room after initial examination reveals her cervix to be a. Low room humidity
at 8 cm, completely effaced (100 %), and at 0 station. b. Cold weight scale
What phase of labor is she in? c. Cools incubator walls
a. Active phase d. Cool room temperature
b. Latent phase 26. After administering bethanechol to a patient with
c. Expulsive phase urine retention, the nurse in charge monitors the
d. Transitional phase patient for adverse effects. Which is most likely to
17. A pregnant patient asks the nurse if she can take occur?
castor oil for her constipation. How should the nurse a. Decreased peristalsis
respond? b. Increase heart rate
a. “Yes, it produces no adverse effect.” c. Dry mucous membranes
b. “No, it can initiate premature uterine contractions.” d. Nausea and Vomiting
c. “No, it can promote sodium retention.” 27. The nurse in charge is caring for a patient who is in
d. “No, it can lead to increased absorption of fat-soluble the first stage of labor. What is the shortest but most
vitamins.” difficult part of this stage?
18. A patient in her 14th week of pregnancy has a. Active phase
presented with abdominal cramping and vaginal b. Complete phase
bleeding for the past 8 hours. She has passed several c. Latent phase
cloth. What is the primary nursing diagnosis for this d. Transitional phase
patient? 28. After 3 days of breast-feeding, a postpartal patient
a. Knowledge deficit reports nipple soreness. To relieve her discomfort, the
b. Fluid volume deficit nurse should suggest that she:
c. Anticipatory grieving a. Apply warm compresses to her nipples just before feedings
d. Pain b. Lubricate her nipples with expressed milk before feeding
19. Immediately after a delivery, the nurse-midwife c. Dry her nipples with a soft towel after feedings
assesses the neonate’s head for signs of molding. d. Apply soap directly to her nipples, and then rinse
Which factors determine the type of molding? 29. The nurse is developing a teaching plan for a
a. Fetal body flexion or extension patient who is 8 weeks pregnant. The nurse should tell
b. Maternal age, body frame, and weight the patient that she can expect to feel the fetus move
c. Maternal and paternal ethnic backgrounds at which time?
d. Maternal parity and gravidity a. Between 10 and 12 weeks’ gestation
20. For a patient in active labor, the nurse-midwife b. Between 16 and 20 weeks’ gestation
plans to use an internal electronic fetal monitoring c. Between 21 and 23 weeks’ gestation
(EFM) device. What must occur before the internal EFM d. Between 24 and 26 weeks’ gestation
can be applied? 30. Normal lochial findings in the first 24 hours post-
a. The membranes must rupture delivery include:
b. The fetus must be at 0 station a. Bright red blood
c. The cervix must be dilated fully b. Large clots or tissue fragments
d. The patient must receive anesthesia c. A foul odor
d. The complete absence of lochia
 breast-feeding would be possible.”
NCLEX Exam: Maternal and Child Health Nursing 2 (30 d. “You should be able to breastfeed without difficulty.”
Items) 9. Following a precipitous delivery, examination of the
client’s vagina reveals a fourth-degree laceration.
1. Accompanied by her husband, a patient seeks Which of the following would be contraindicated when
admission to the labor and delivery area. The client caring for this client?
states that she is in labor and says she attended the a. Applying cold to limit edema during the first 12 to 24 hours
hospital clinic for prenatal care. Which question should b. Instructing the client to use two or more peri pads to
the nurse ask her first? cushion the area
a. “Do you have any chronic illness?” c. Instructing the client on the use of sitz baths if ordered
b. “Do you have any allergies?” d. Instructing the client about the importance of perineal
c. “What is your expected due date?” (Kegel) exercises
d. “Who will be with you during labor?” 10. A client makes a routine visit to the prenatal clinic.
2. A patient is in the second stage of labor. During this Although she is 14 weeks pregnant, the size of her
stage, how frequently should the nurse in charge uterus approximates that in an 18- to 20-week
assess her uterine contractions? pregnancy. Dr. Charles diagnoses gestational
a. Every 5 minutes trophoblastic disease and orders ultrasonography. The
b. Every 15 minutes nurse expects ultrasonography to reveal:
c. Every 30 minutes a. an empty gestational sac.
d. Every 60 minutes b. grapelike clusters.
3. A patient is in her last trimester of pregnancy. Nurse c. a severely malformed fetus.
Vickie should instruct her to notify her primary health d. an extrauterine pregnancy.
care provider immediately if she notices: 11. After completing a second vaginal examination of a
a. Blurred vision client in labor, the nurse-midwife determines that the
b. Hemorrhoids fetus is in the right occiput anterior position and at (–
c. Increased vaginal mucus 1) station. Based on these findings, the nurse-midwife
d. Shortness of breath on exertion knows that the fetal presenting part is:
4. The nurse in-charge is reviewing a patient’s prenatal a. 1 cm below the ischial spines.
history. Which finding indicates a genetic risk factor? b. directly in line with the ischial spines.
a. The patient is 25 years old c. 1 cm above the ischial spines.
b. The patient has a child with cystic fibrosis d. in no relationship to the ischial spines.
c. The patient was exposed to rubella at 36 weeks’ gestation 12. Which of the following would be inappropriate to
d. The patient has a history of preterm labor at 32 weeks’ assess in a mother who’s breastfeeding?
gestation a. The attachment of the baby to the breast.
5. A adult female patient is using the rhythm (calendar- b. The mother’s comfort level with positioning the baby.
basal body temperature) method of family planning. In c. Audible swallowing.
this method, the unsafe period for sexual intercourse is d. The baby’s lips smacking
indicated by: 13. During a prenatal visit at 4 months gestation, a
a. Return preovulatory basal body temperature pregnant client asks whether tests can be done to
b. Basal body temperature increase of 0.1 degrees to 0.2 identify fetal abnormalities. Between 18 and 40 weeks
degrees on the 2nd or 3rd day of cycle gestation, which procedure is used to detect fetal
c. 3 full days of elevated basal body temperature and clear, anomalies?
thin cervical mucus a. Amniocentesis.
d. Breast tenderness and mittelschmerz b. Chorionic villi sampling.
6. During a nonstress test (NST), the electronic tracing c. Fetoscopy.
displays a relatively flat line for fetal movement, d. Ultrasound
making it difficult to evaluate the fetal heart rate 14. A client, 30 weeks pregnant, is scheduled for a
(FHR). To mark the strip, the nurse in charge should biophysical profile (BPP) to evaluate the health of her
instruct the client to push the control button at which fetus. Her BPP score is 8. What does this score
time? indicate?
a. At the beginning of each fetal movement a. The fetus should be delivered within 24 hours.
b. At the beginning of each contraction b. The client should repeat the test in 24 hours.
c. After every three fetal movements c. The fetus isn’t in distress at this time.
d. At the end of fetal movement d. The client should repeat the test in 1 week.
7. When evaluating a client’s knowledge of symptoms 15. A client who is 36 weeks pregnant comes to the
to report during her pregnancy, which statement would clinic for a prenatal checkup. To assess the client’s
indicate to the nurse in charge that the client preparation for parenting, the nurse might ask which
understands the information given to her? question?
a. “I’ll report increased frequency of urination.” a. “Are you planning to have epidural anesthesia?”
b. “If I have blurred or double vision, I should call the clinic b. “Have you begun prenatal classes?”
immediately.” c. “What changes have you made at home to get ready for
c. “If I feel tired after resting, I should report it immediately.” the baby?”
d. “Nausea should be reported immediately.” d. “Can you tell me about the meals you typically eat each
8. When assessing a client during her first prenatal day?”
visit, the nurse discovers that the client had a reduction 16. A client who’s admitted to labor and delivery has
mammoplasty. The mother indicates she wants to the following assessment findings: gravida 2 para 1,
breast-feed. What information should the nurse give to estimated 40 weeks gestation, contractions 2 minutes
this mother regarding breastfeeding success? apart, lasting 45 seconds, vertex +4 station. Which of
a. “It’s contraindicated for you to breastfeed following this the following would be the priority at this time?
type of surgery.” a. Placing the client in bed to begin fetal monitoring.
b. “I support your commitment; however, you may have to b. Preparing for immediate delivery.
supplement each feeding with formula.” c. Checking for ruptured membranes.
c. “You should check with your surgeon to determine whether d. Providing comfort measures.
17. The nurse is caring for a client in labor. The a. The vaccine prevents a future fetus from developing
external fetal monitor shows a pattern of variable congenital anomalies
decelerations in fetal heart rate. What should the nurse b. Pregnancy should be avoided for 3 months after the
do first? immunization
a. Change the client’s position. c. The client should avoid contact with children diagnosed
b. Prepare for emergency cesarean section. with rubella
c. Check for placenta previa. d. The injection will provide immunity against the 7-day
d. Administer oxygen. measles.
18. The nurse in charge is caring for a postpartum 27. A client with eclampsia begins to experience a
client who had a vaginal delivery with a midline seizure. Which of the following would the nurse in
episiotomy. Which nursing diagnosis takes priority for charge do first?
this client? a. Pad the side rails
a. Risk for deficient fluid volume related to hemorrhage b. Place a pillow under the left buttock
b. Risk for infection related to the type of delivery c. Insert a padded tongue blade into the mouth
c. Pain related to the type of incision d. Maintain a patent airway
d. Urinary retention related to periurethral edema 28. While caring for a multigravida client in early labor
19. Which change would the nurse identify as a in a birthing center, which of the following foods would
progressive physiological change in postpartum period? be best if the client requests a snack?
a. Lactation a. Yogurt
b. Lochia b. Cereal with milk
c. Uterine involution c. Vegetable soup
d. Diuresis d. Peanut butter cookies
20. A 39-year-old at 37 weeks gestation is admitted to 29. The multigravida mother with a history of rapid
the hospital with complaints of vaginal bleeding labor who us in active labor calls out to the nurse, “The
following the use of cocaine 1 hour earlier. Which baby is coming!” which of the following would be the
complication is most likely causing the client’s nurse’s first action?
complaint of vaginal bleeding? a. Inspect the perineum
a. Placenta previa b. Time the contractions
b. Abruptio placentae c. Auscultate the fetal heart rate
c. Ectopic pregnancy d. Contact the birth attendant
d. Spontaneous abortion 30. While assessing a primipara during the immediate
21. A client with type 1 diabetes mellitus who is a postpartum period, the nurse in charge plans to use
multigravida visits the clinic at 27 weeks gestation. The both hands to assess the client’s fundus to:
nurse should instruct the client that for most pregnant a. Prevent uterine inversion
women with type 1 diabetes mellitus: b. Promote uterine involution
a. Weekly fetal movement counts are made by the mother. c. Hasten the puerperium period
b. Contraction stress testing is performed weekly. d. Determine the size of the fundus
c. Induction of labor is begun at 34 weeks’ gestation.
d. Nonstress testing is performed weekly until 32 weeks’
gestation
22. When administering magnesium sulfate to a client
with preeclampsia, the nurse understands that this
drug is given to:
a. Prevent seizures
b. Reduce blood pressure
c. Slow the process of labor
d. Increase dieresis
23. What is the approximate time that the blastocyst
spends traveling to the uterus for implantation?
a. 2 days
b. 7 days
c. 10 days
d. 14 weeks
24. 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?
a. Shortens the second stage of labor
b. Enlarges the pelvic inlet
c. Prevents perineal edema
d. Ensures quick placenta delivery
25. A primigravida client at about 35 weeks gestation
in active labor has had no prenatal care and admits to
cocaine use during the pregnancy. Which of the
following persons must the nurse notify?
a. Nursing unit manager so appropriate agencies can be
notified
b. Head of the hospital’s security department
c. Chaplain in case the fetus dies in utero
d. Physician who will attend the delivery of the infant
26. 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?