Final Assessment. Maternity for NCLEX.

A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When does the client call the clinic complaining of indigestion? Which instruction should the nurse provide?

Which statement indicates to the nurse that a couple is coping with the stress of infertility treatment?

The nurse is concerned that which viral infection if experienced by an adult male, may cause infertility?

What information would the nurse gather before scheduling a client’s endometrial biopsy?

The client, who is married and has three children, has come to the family planning clinic asking about a birth control method that is most effective and sanctioned by the Roman Catholic Church. What would be the nurse’s best recommendation?

The client has come to the clinic for her first prenatal visit. During the pelvic examination, the examiner indicates that vaginal mucosa has a bluish color. The nurse should document which assessment as positive?

With regard to normal changes in the reproductive system during pregnancy, the nurse should teach the pregnant client about which of the following?

After walking for 30 minutes, the laboring client now has blood-tinged mucus on her underpad. Which of the following is the most appropriate interpretation by the nurse?

After the administration of an epidural block for labor analgesia, the client’s blood pressure decreases from 130 / 75 to 90 / 50. The nurse should assist the woman to do which of the following?

The client in labor is showing the following result on the fetal monitor. Which intervention should the nurse implement first?

Which client should the postpartum nurse assess first after receiving the a.m. shift report?

The nurse walks into the client’s room to check on the mother and her newborn. The client states another nurse just took her baby back to the nursery. Which intervention should the nurse implement first?

With regard to the postpartum uterus, nurses should be aware that:

With regard to the noncontraceptive medical effects of combined oral contraceptive pills (COCs), nurses should be aware that:

The nurse working in a women’s health clinic is returning telephone calls. Which client should the nurse contact first?

With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that:

With regard to the estimation and interpretation of the recurrence of risks for genetic disorders, nurses should be aware that:

Which antepartum client should the charge nurse assign to the most experienced nurse?

The client in labor is diagnosed with gestational hypertension and has preeclampsia. Which interventions should the nurse implement? Select all that apply.

A pregnant woman at 12 weeks’ gestation tells the nurse that she is a vegetarian. What would be the first appropriate nursing action?

With regard to the care management of preterm labor, nurses should be aware that:

With regard to the assessment of female, male, and couple infertility, nurses should be aware that:

Which action by a newly graduated RN during a delivery complicated by shoulder dystocia would require immediate correction by the nurse who is orienting her?

Which statements by a new father indicate that additional discharge teaching is needed for this family, who had their first baby 24 hours ago? Select all that apply.

While assessing a 29-year-old gravida 2, para 2 patient who had a normal spontaneous vaginal delivery 30 minutes ago, the nurse notes a large amount of red vaginal bleeding. What would be the first priority of nursing action?

With regard to endometriosis, nurses should be aware that:

A 30-year-old gravida 1, para 0 woman at 39 weeks’ gestation experienced a fetal demise and has just delivered a female infant. Her husband is at the bedside. Which are the appropriate nursing actions at this time? Select all that apply.

With regard to dysfunctional labor, nurses should be aware that:

A 27-year-old patient underwent a primary cesarean section because of a breech presentation 24 hours ago. Which assessment finding would be of the most concern?

While working in the prenatal clinic, you care for a very diverse group of patients. When planning interventions for these families, you realize that acceptance of the interventions will be most influenced by:

While interviewing a 31-year-old woman before her routine gynecologic examination, the nurse collects data about the client’s recent menstrual cycles. The nurse should collect additional information with which statement?

While instructing a couple regarding birth control, the nurse should be aware that the method called natural family planning:

While conducting a health history the nurse becomes concerned that a client with type 1 diabetes mellitus who is 12 weeks pregnant is at risk for complications. For which complication should the nurse plan interventions at this time?

A 3-day-old breast-fed infant is brought to the clinic by his parents for routine assessment following a normal full-term delivery without complications. Which statement by the parents suggests an abnormal finding on a newborn of this age?

Which statement would indicate that the client requires additional instruction about breast self-examination?

A patient in the obstetric clinic is at 8 weeks’ gestation. She tells the nurse of her plans to travel next month to visit family in a country that is affected by the Zika virus. What is the priority counseling by the nurse today?

A female same-sex couple is being seen in the clinic today. They inform the nurse that they are planning a pregnancy and plan to use donor sperm to be inseminated into one of the women. What is the priority education at this time?

The client’s fetal heart rate (FHR) is 150 before a contraction begins. During the contraction, the FHR falls to 110 and returns to the baseline 30 seconds after the contraction ends. What is the priority nursing action in response to this finding?

The fetal heart rate (FHR) baseline is 145 beats per minute with short-term variability of 12 beats per minute. The nurse should take which action at this time?

Which options for saying goodbye would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl?

The fetal heart rate (FHR) shows variable decelerations. Which activity carried out by the nurse could decrease or eliminate this pattern?

Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?

Which newborn reflex is elicited by the nurse when she stroking the lateral sole of the infant’s foot from the heel to the ball of the foot?

The nurse is attending a primipara, pregnant woman. Which method of pain management is safest for a gravida 3 para 2 admitted at 8 cm cervical dilation?

A nurse is conducting a seminar on pregnancy and childbirth,  a participant asks which maternal event is abnormal in the early postpartum period and the best nurse response is?

The nurse establishes that an example of a contraindication for the application of internal monitoring devices  is a maternal condition like: 

The laboring client has begun to make guttural, grunting sounds during contractions. The nursing plan of care should now include which nursing intervention?

The nurse is attending a postpartum pregnant woman. Which finding 12 hours after birth requires further assessment?

When, during the normal postpartum course, would the nurse expect to note the fundal assessment descent?

When the nurse is alone with a battered patient, the patient seems extremely anxious and says, “It was all my fault. The house was so messy when he got home and I know he hates that.” The best response by the nurse is:

When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?

When providing care for a pregnant woman, the nurse should be aware that one of the most frequently reported maternal medical risk factors is:

When evaluating a patient whose primary complaint is amenorrhea, the nurse must be aware that lack of menstruation is most often the result of:

A goal on the nursing care plan is “to facilitate parent-infant bonding.” Which nursing intervention should take priority in order to attain this goal?

When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is:

When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal:

When a woman is diagnosed with postpartum depression (PPD) with psychotic features, one of the main concerns is that she may:

What infection is contracted mostly by first-time mothers who are breastfeeding?

During a prenatal visit, the nurse notes that an adolescent pregnant client with diabetes mellitus has lost 10 lb during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, “I don’t eat regular meals.” The appropriate response is:

A woman gave birth to a healthy baby 2 weeks ago. What type of lochia would the nurse expect to find when assessing this patient?

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness?

An expectant father tells the nurse he fears that his wife “is losing her mind.” He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father?

To help clients manage discomfort and pain during labor, nurses should be aware that:

A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction?

A nurse is caring for a client who is in the third stage of labor. Which characteristic behaviors does the nurse anticipate at this stage. Select all that apply.

The woman’s family members are present when the home care maternal-child nurse arrives for a postpartum and newborn visit. What should the nurse do?

The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 stations, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take?

A client who is 3 days postpartum and breastfeeding ask the nurse how to reduce breast engorgement. Which instruction should the nurse provide?

On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously, her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client’s expected date of birth (EDB)?

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan?

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client?

The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information?

Case study

Ms. N is a 20-year-old gravida 1, para 0 (G1P0) woman who begins her prenatal care today at 24 weeks gestation. She says that she didn’t know she was pregnant until now. Her prepregnancy body mass index was 23. She has gained 30 lb (13.6 kg) so far. She admits that she eats poorly and smokes a half-pack of cigarettes daily but claims to use no other substances. She lives with her boyfriend and has no immediate family in the area. She reports no significant medical, surgical, or family history. The RN is taking her history and drawing samples for laboratory work today on this first prenatal visit.

What would be the priority topics in client teaching today? Select all that apply.