Final Assessment. Maternity for the NCLEX

A primigravida client is experiencing Braxton Hicks contractions. Which statement is true concerning these contractions?

A primigravida client at 26 weeks’ gestation has been administered a glucose tolerance test. What would the nurse anticipate as a normal finding?

Which statement about the results of a contraction stress test (CST; oxytocin challenge test) is considered accurate?

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?

The nurse is encouraging a pregnant woman to eat a diet rich in folic acid. Which of the following food sources would provide the most folic acid?

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?

A client reports that her last menstrual period was November 10. She asks the nurse, “When will my baby be due?” What is the best answer?

The nurse is assessing a client who is at 36 weeks gestation; this client has type 2 diabetes. The client says she is extremely upset by the fact that she will not be able to breastfeed her infant. The best nursing response would be based on what information?

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

The labor monitor tracing shows variable decelerations. What complication would the nurse anticipate is occurring?

The nurse assesses a client 12 hours after prolonged labor and delivery. What assessment data would cause the nurse the most concern?

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?

A client is 37 weeks pregnant and is admitted to the hospital with bright red vaginal bleeding and complaining of abdominal discomfort but without contractions. After assessing the client’s vital signs and determining the fetal heart rate, which is 105 beats/min, what is the most important information to obtain?

A multigravida client comes into the emergency room complaining of abdominal pain. She is at 30 weeks gestation. On assessment, the nurse observes complete dilation and effacement of the cervix with the perineal area bulging and the infant’s head crowning. The mother states she is feeling a strong urge to push. What is the best nursing action?

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.

The nurse encourages a client in labor to assume a side-lying position. What is the purpose of this position?

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?

The nurse is caring for a client who is at the beginning of her third trimester of pregnancy. The client has been admitted in preterm labor, and magnesium sulfate is being used. Contractions are occurring about every 4 to 5 minutes and last 1 to 1½ minutes; blood pressure is 130/88 mm Hg; respirations are 22 breaths/min; the pulse is 98 beats/min. What nursing observation would cause the nurse the most concern?

A client is receiving magnesium sulfate to help suppress preterm labor. The nurse should watch for signs of magnesium toxicity?

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 of the following circumstances is most likely to cause uterine atony leading to postpartum hemorrhage?

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

A pregnant client had an abruptio placentae after a hemorrhagic episode. An emergency delivery was completed. The client is stable, and the cesarean delivery was performed 2 days ago. During the postoperative period, the nurse is observing for potential complications. What would be important for the nurse to assess regarding the development of complications?

Ten days after delivery, a client is diagnosed with mastitis. The nurse would anticipate what assessment findings?

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?

Which of the following statements by the client reflects successful teaching during a natural family planning session?

To determine the ovulatory period, the client is to take her basal body temperature (BBT) daily. The nurse would determine that the client understands how to take her BBT when she says:

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

A single woman is discussing contraception with the nurse and expresses a preference for a diaphragm. Which factor in her history would make a diaphragm a poor choice?

The nurse is caring for a client at 37 weeks gestation, who was just told that she is group B streptococcus + (positive). The client states, “How could that happen? I only have sex with my husband. Will my baby be OK?” Based on this information, which of the following should the nurse communicate to the client?

A 38-year-old female client is seen for her 6-week postpartum examination by the nurse practitioner. The client was breastfeeding for a short time but discontinued 4 weeks ago. Her menses have resumed. She is contemplating another pregnancy in a year or so, but if she became pregnant before that, she would not mind. She is seeking contraception. She smokes one pack per day. The examination findings are normal, with the uterus being well involuted. Does the nurse understand which of the following birth control methods would be contraindicated for this client?

A woman is beginning oral combination contraceptives. She asks the nurse what she should do if she misses a pill. What would be the best nursing response?

The nurse is instructing a male client regarding a semen analysis test. The nurse would tell him to do which of the following? Select all that apply.

A nurse is involved in a family class on genetic counseling. A client asks what it means when an infant is born with an autosomal recessive inherited disorder. Select all that apply.

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?

A delivery room nurse is preparing a client for cesarean delivery to facilitate the birth of triplets. Which position will promote maximum uteroplacental perfusion during this surgery?

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 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.

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?

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?

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.

A woman whose menstrual cycle is 35 days long states that she often has a slight pain on one side of her lower abdomen on day 21 of her cycle. She wonders whether she has ovarian cancer. Which of the following is the nurse’s best response?

A 19-year-old client with multiple sex partners is being counseled about the hepatitis B vaccination. During the counseling sessions, which of the following should the nurse advise the client to receive?

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse gather from the woman’s prenatal record when planning nursing care? Select all that apply.

A postpartum client who is breastfeeding is being assessed. She delivered three days ago. Her breasts are firm and warm to the touch. When asked when she last fed the baby, she replied, “I fed the baby last evening. I let the nurses fed him in the nursery last night. I needed to rest.” Which of the following actions should the nurse take at this time?

A couple is seeking advice regarding actions that they can take to increase their potential success in becoming pregnant. Which of the following recommendations should the nurse give to the couple?

A client with an obstetrical history of G1 P0000 is having her first prenatal physical examination. Which of the following assessments should the nurse inform the client that she will have that day? Select all that apply.

A nurse is performing an assessment of a pregnant woman to determine whether labor has begun. For which sign of true labor does the nurse assess the client?

When a nurse teaches a woman about her menstrual cycle, which of the following information should be included as the most significant change during the follicular phase of the menstrual cycle?

A woman is pregnant. During amniocentesis, it is discovered that her child has Down’s syndrome with a mosaic chromosomal configuration. She asks the nurse what that means. What is the nurse’s best response?

A client has been notified that because of fallopian tube obstruction, her best option for becoming pregnant is through in-vitro fertilization. The client asks the nurse about the procedure. Which of the following responses is correct?