NCLEX Practice Exam for Maternal and Child Health Nursing 2

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1. Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that she is in labor, and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first?

  1. “Do you have any chronic illness?”
  2. “Do you have any allergies?”
  3. “What is your expected due date?”
  4. “Who will be with you during labor?”

2. A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess her uterine contractions?

  1. Every 5 minutes
  2. Every 15 minutes
  3. Every 30 minutes
  4. Every 60 minutes

3. A patient is in last trimester of pregnancy. Nurse Jane should instruct her to notify her primary health care provider immediately if she notices:

  1. Blurred vision
  2. Hemorrhoids
  3. Increased vaginal mucus
  4. Shortness of breath on exertion

4. The nurse in charge is reviewing a patient’s prenatal history. Which finding indicates a genetic risk factor?

  1. The patient is 25 years old
  2. The patient has a child with cystic fibrosis
  3. The patient was exposed to rubella at 36 weeks’ gestation
  4. The patient has a history of preterm labor at 32 weeks’ gestation

5. A adult female patient is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by;

  1. Return preovulatory basal body temperature
  2. Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd day of cycle
  3. 3 full days of elevated basal body temperature and clear, thin cervical mucus
  4. Breast tenderness and mittelschmerz

6. During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge should instruct the client to push the control button at which time?

  1. At the beginning of each fetal movement
  2. At the beginning of each contraction
  3. After every three fetal movements
  4. At the end of fetal movement

7. When evaluating a client’s knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse in charge that the client understands the information given to her?

  1. “I’ll report increased frequency of urination.”
  2. “If I have blurred or double vision, I should call the clinic immediately.”
  3. “If I feel tired after resting, I should report it immediately.”
  4. “Nausea should be reported immediately.”

8. When assessing a client during her first prenatal visit, the nurse discovers that the client had a reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the nurse give to this mother regarding breast-feeding success?

  1. “It’s contraindicated for you to breast-feed following this type of surgery.”
  2. “I support your commitment; however, you may have to supplement each feeding with formula.”
  3. “You should check with your surgeon to determine whether breast-feeding would be possible.”
  4. “You should be able to breast-feed without difficulty.”

9. Following a precipitous delivery, examination of the client’s vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client?

  1. Applying cold to limit edema during the first 12 to 24 hours
  2. Instructing the client to use two or more peripads to cushion the area
  3. Instructing the client on the use of sitz baths if ordered
  4. Instructing the client about the importance of perineal (Kegel) exercises

10. A client makes a routine visit to the prenatal clinic. Although she’s 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy. Dr. Diaz diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal:

  1. an empty gestational sac.
  2. grapelike clusters.
  3. a severely malformed fetus.
  4. an extrauterine pregnancy.

11. After completing a second vaginal examination of a client in labor, the nurse-midwife determines that the fetus is in the right occiput anterior position and at –1 station. Based on these findings, the nurse-midwife knows that the fetal presenting part is:

  1. 1 cm below the ischial spines.
  2. directly in line with the ischial spines.
  3. 1 cm above the ischial spines.
  4. in no relationship to the ischial spines.

12. Which of the following would be inappropriate to assess in a mother who’s breast-feeding?

  1. The attachment of the baby to the breast.
  2. The mother’s comfort level with positioning the baby.
  3. Audible swallowing.
  4. The baby’s lips smacking

13. During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done to identify fetal abnormalities. Between 18 and 40 weeks’ gestation, which procedure is used to detect fetal anomalies?

  1. Amniocentesis.
  2. Chorionic villi sampling.
  3. Fetoscopy.
  4. Ultrasound

14. A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate?

  1. The fetus should be delivered within 24 hours.
  2. The client should repeat the test in 24 hours.
  3. The fetus isn’t in distress at this time.
  4. The client should repeat the test in 1 week.

15. A client who’s 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the client’s preparation for parenting, the nurse might ask which question?

  1. “Are you planning to have epidural anesthesia?”
  2. “Have you begun prenatal classes?”
  3. “What changes have you made at home to get ready for the baby?”
  4. “Can you tell me about the meals you typically eat each day?”

16. A client who’s admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks’ gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time?

  1. Placing the client in bed to begin fetal monitoring.
  2. Preparing for immediate delivery.
  3. Checking for ruptured membranes.
  4. Providing comfort measures.

17. Nurse Roy is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?

  1. Change the client’s position.
  2. Prepare for emergency cesarean section.
  3. Check for placenta previa.
  4. Administer oxygen.

18. The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client?

  1. Risk for deficient fluid volume related to hemorrhage
  2. Risk for infection related to the type of delivery
  3. Pain related to the type of incision
  4. Urinary retention related to periurethral edema

19. Which change would the nurse identify as a progressive physiological change in postpartum period?

  1. Lactation
  2. Lochia
  3. Uterine involution
  4. Diuresis

20. A 39-year-old at 37 weeks’ gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client’s complaint of vaginal bleeding?

  1. Placenta previa
  2. Abruptio placentae
  3. Ectopic pregnancy
  4. Spontaneous abortion

21. A client with type 1 diabetes mellitus who’s a multigravida visits the clinic at 27 weeks gestation. The nurse should instruct the client that for most pregnant women with type 1 diabetes mellitus:

  1. Weekly fetal movement counts are made by the mother.
  2. Contraction stress testing is performed weekly.
  3. Induction of labor is begun at 34 weeks’ gestation.
  4. 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:

  1. Prevent seizures
  2. Reduce blood pressure
  3. Slow the process of labor
  4. Increase dieresis

23. What’s the approximate time that the blastocyst spends traveling to the uterus for implantation?

  1. 2 days
  2. 7 days
  3. 10 days
  4. 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?

  1. Shortens the second stage of labor
  2. Enlarges the pelvic inlet
  3. Prevents perineal edema
  4. 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?

  1. Nursing unit manager so appropriate agencies can be notified
  2. Head of the hospital’s security department
  3. Chaplain in case the fetus dies in utero
  4. 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?

  1. The vaccine prevents a future fetus from developing congenital anomalies
  2. Pregnancy should be avoided for 3 months after the immunization
  3. The client should avoid contact with children diagnosed with rubella
  4. The injection will provide immunity against the 7-day measles.

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

  1. Pad the side rails
  2. Place a pillow under the left buttock
  3. Insert a padded tongue blade into the mouth
  4. Maintain a patent airway

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

  1. Yogurt
  2. Cereal with milk
  3. Vegetable soup
  4. Peanut butter cookies

29. The multigravida mother with a history of rapid labor who us in active labor calls out to the nurse, “The baby is coming!” which of the following would be the nurse’s first action?

  1. Inspect the perineum
  2. Time the contractions
  3. Auscultate the fetal heart rate
  4. Contact the birth attendant

30. While assessing a primipara during the immediate postpartum period, the nurse in charge plans to use both hands to assess the client’s fundus to:

  1. Prevent uterine inversion
  2. Promote uterine involution
  3. Hasten the puerperium period
  4. Determine the size of the fundus
Answers and Rationales
  1. Answer C. When obtaining the history of a patient who may be in labor, the nurse’s highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illness, allergies, and support persons.
  2. Answer B. During the second stage of labor, the nurse should assess the strength, frequency, and duration of contraction every 15 minutes. If maternal or fetal problems are detected, more frequent monitoring is necessary. An interval of 30 to 60 minutes between assessments is too long because of variations in the length and duration of patient’s labor.
  3. Answer A. Blurred vision of other visual disturbance, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for both the patient and fetus. Although hemorrhoids may be a problem during pregnancy, they do not require immediate attention. Increased vaginal mucus and dyspnea on exertion are expected as pregnancy progresses.
  4. Answer B. Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. Maternal age is not a risk factor until age 35, when the incidence of chromosomal defects increases. Maternal exposure to rubella during the first trimester may cause congenital defects. Although a history or preterm labor may place the patient at risk for preterm labor, it does not correlate with genetic defects.
  5. Answer C. Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7 degrees F to 0.8 degrees F and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle is not significant. Breast tenderness and mittelschmerz are not reliable indicators of ovulation.
  6. Answer A. An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with the FHR. The FHR is assessed during uterine contractions in the oxytocin contraction test, not the NST. Pushing the control button after every three fetal movements or at the end of fetal movement wouldn’t allow accurate comparison of fetal movement and FHR changes.
  7. Answer B. Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy.
  8. Answer B. Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so breast-feeding after surgery is possible. Still, it’s good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mother’s ability to meet all of her baby’s nutritional needs, and some supplemental feeding may be required. Preparing the mother for this possibility is extremely important because the client’s psychological adaptation to mothering may be dependent on how successfully she breast-feeds.
  9. Answer B. Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration.
  10. Answer B. In a client with gestational trophoblastic disease, an ultrasound performed after the 3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been absorbed. Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy is seen with an ectopic pregnancy.
  11. Answer C. Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as –1, –2, or –3. A presenting part below the ischial spines, as +1, +2, or +3.
  12. Answer D. Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who’s smacking his lips isn’t well attached and can injure the mother’s nipples.
  13. Answer D. Ultrasound is used between 18 and 40 weeks’ gestation to identify normal fetal growth and detect fetal anomalies and other problems. Amniocentesis is done during the third trimester to determine fetal lung maturity. Chorionic villi sampling is performed at 8 to 12 weeks’ gestation to detect genetic disease. Fetoscopy is done at approximately 18 weeks’ gestation to observe the fetus directly and obtain a skin or blood sample.
  14. Answer C. The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn’t in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn’t within normal limits.
  15. Answer C. During the third trimester, the pregnant client typically perceives the fetus as a separate being. To verify that this has occurred, the nurse should ask whether she has made appropriate changes at home such as obtaining infant supplies and equipment. The type of anesthesia planned doesn’t reflect the client’s preparation for parenting. The client should have begun prenatal classes earlier in the pregnancy. The nurse should have obtained dietary information during the first trimester to give the client time to make any necessary changes.
  16. Answer B. This question requires an understanding of station as part of the intrapartal assessment process. Based on the client’s assessment findings, this client is ready for delivery, which is the nurse’s top priority. Placing the client in bed, checking for ruptured membranes, and providing comfort measures could be done, but the priority here is immediate delivery.
  17. Answer A. Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client’s position from supine to side-lying may immediately correct the problem. An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Administering oxygen may be helpful, but the priority is to change the woman’s position and relieve cord compression.
  18. Answer A. Hemorrhage jeopardizes the client’s oxygen supply — the first priority among human physiologic needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over diagnoses of Risk for infection, Pain, and Urinary retention.
  19. Answer A. Lactation is an example of a progressive physiological change that occurs during the postpartum period.
  20. Answer B. The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first, not third, trimester abortion and abruption placentae.
  21. Answer D. For most clients with type 1 diabetes mellitus, nonstress testing is done weekly until 32 weeks’ gestation and twice a week to assess fetal well-being.
  22. Answer A. The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyper stimulated neurologic system by interfering with signal transmission at the neuromascular junction.
  23. Answer B. The blastocyst takes approximately 1 week to travel to the uterus for implantation.
  24. Answer A. An episiotomy serves several purposes. It shortens the second stage of labor, substitutes a clean surgical incision for a tear, and decreases undue stretching of perineal muscles. An episiotomy helps prevent tearing of the rectum but it does not necessarily relieves pressure on the rectum. Tearing may still occur.
  25. Answer D. The fetus of a cocaine-addicted mother is at risk for hypoxia, meconium aspiration, and intrauterine growth retardation (IUGR). Therefore, the nurse must notify the physician of the client’s cocaine use because this knowledge will influence the care of the client and neonate. The information is used only in relation to the client’s care.
  26. Answer B. After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 3 months to prevent the possibility of the vaccine’s toxic effects to the fetus.
  27. Answer D. The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia.
  28. Answer A. In some birth settings, intravenous therapy is not used with low-risk clients. Thus, clients in early labor are encouraged to eat healthy snacks and drink fluid to avoid dehydration. Yogurt, which is an excellent source of calcium and riboflavin, is soft and easily digested. During pregnancy, gastric emptying time is delayed. In most hospital settings, clients are allowed only ice chips or clear liquids.
  29. Answer A. When the client says the baby is coming, the nurse should first inspect the perineum and observe for crowning to validate the client’s statement. If the client is not delivering precipitously, the nurse can calm her and use appropriate breathing techniques.
  30. Answer A. Using both hands to assess the fundus is useful for the prevention of uterine inversion.