Maternal and Child Health Nursing NCLEX Questions Part 1

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

a. Endometritis

b. Endometriosis

c. Salpingitis

d. Pelvic thrombophlebitis

2. A client at 36 weeks’ gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction?

a. The ultrasound will help to locate the placenta

b. The ultrasound identifies blood flow through the umbilical cord

c. The test will determine where to insert the needle

d. The ultrasound locates a pool of amniotic fluid

3. While the postpartum client is receiving herapin for thrombophlebitis, which of the following drugs would the nurse Mica expect to administer if the client develops complications related to heparin therapy?

a. Calcium gluconate

b. Protamine sulfate

c. Methylegonovine (Methergine)

d. Nitrofurantoin (macrodantin)

4. When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following?

a. Turn the neonate every 6 hours

b. Encourage the mother to discontinue breast-feeding

c. Notify the physician if the skin becomes bronze in color

d. Check the vital signs every 2 to 4 hours

5. A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective?

a. Back

b. Abdomen

c. Fundus

d. Perineum

6. The nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says:

a. “Nausea and vomiting can be decreased if I eat a few crackers before arising”

b. “If I start to leak colostrum, I should cleanse my nipples with soap and water”

c. “If I have a vaginal discharge, I should wear nylon underwear”

d. “Leg cramps can be alleviated if I put an ice pack on the area”

7. Thirty hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartal psychological adaptation that the client would be in would be termed which of the following?

a. Taking in

b. Letting go

c. Taking hold

d. Resolution

8. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following?

a. Activity limited to bed rest

b. Platelet infusion

c. Immediate cesarean delivery

d. Labor induction with oxytocin

9. Nurse Julia plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan?

a. Feeding the neonate a maximum of 5 minutes per side on the first day

b. Wearing a supportive brassiere with nipple shields

c. Breast-feeding the neonate at frequent intervals

d. Decreasing fluid intake for the first 24 to 48 hours

10. When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes?

a. Startle reflex

b. Babinski reflex

c. Grasping reflex

d. Tonic neck reflex

11. A primigravida client at 25 weeks’ gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform:

a. Tailor sitting

b. Leg lifting

c. Shoulder circling

d. Squatting exercises

12. Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?

a. Notify the neonate’s pediatrician immediately

b. Check the diaper and circumcision again in 30 minutes

c. Secure the diaper tightly to apply pressure on the site

d. Apply gently pressure to the site with a sterile gauze pad

13. Which of the following would the nurse Sandra most likely expect to find when assessing a pregnant client with abruption placenta?

a. Excessive vaginal bleeding

b. Rigid, boardlike abdomen

c. Titanic uterine contractions

d. Premature rupture of membranes

14. While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse’s most appropriate action?

a. Note the fetal heart rate patterns

b. Notify the physician immediately

c. Administer oxygen at 6 liters by mask

d. Have the client pant-blow during the contractions

15. A client tells the nurse, “I think my baby likes to hear me talk to him.” When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response?

a. High-pitched speech with tonal variations

b. Low-pitched speech with a sameness of tone

c. Cooing sounds rather than words

d. Repeated stimulation with loud sounds

16. A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in?

a. Active phase

b. Latent phase

c. Expulsive phase

d. Transitional phase

17. A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the nurse respond?

a. “Yes, it produces no adverse effect.”

b. “No, it can initiate premature uterine contractions.”

c. “No, it can promote sodium retention.”

d. “No, it can lead to increased absorption of fat-soluble vitamins.”

18. A patient in her 14^th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several cloth. What is the primary nursing diagnosis for this patient?

a. Knowledge deficit

b. Fluid volume deficit

c. Anticipatory grieving

d. Pain

19. Immediately after a delivery, the nurse-midwife assesses the neonate’s head for signs of molding. Which factors determine the type of molding?

a. Fetal body flexion or extension

b. Maternal age, body frame, and weight

c. Maternal and paternal ethnic backgrounds

d. Maternal parity and gravidity

20. For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied?

a. The membranes must rupture

b. The fetus must be at 0 station

c. The cervix must be dilated fully

d. The patient must receive anesthesia

21. A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in early part of the first stage of labor. Her pain is likely to be most intense:

a. Around the pelvic girdle

b. Around the pelvic girdle and in the upper arms

c. Around the pelvic girdle and at the perineum

d. At the perineum

22. A female adult patient is taking a progestin-only oral contraceptive, or minipill. Progestin use may increase the patient’s risk for:

a. Endometriosis

b. Female hypogonadism

c. Premenstrual syndrome

d. Tubal or ectopic pregnancy

23. A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms?

a. Proteinuria, headaches, vaginal bleeding

b. Headaches, double vision, vaginal bleeding

c. Proteinuria, headaches, double vision

d. Proteinuria, double vision, uterine contractions

24. Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient’s fluid intake and output closely during oxytocin administration?

a. Oxytoxin causes water intoxication

b. Oxytocin causes excessive thirst

c. Oxytoxin is toxic to the kidneys

d. Oxytoxin has a diuretic effect

25. Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss?

a. Low room humidity

b. Cold weight scale

c. Cools incubator walls

d. Cool room temperature

26. After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur?

a. Decreased peristalsis

b. Increase heart rate

c. Dry mucous membranes

d. Nausea and Vomiting

27. The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage?

a. Active phase

b. Complete phase

c. Latent phase

d. Transitional phase

28. After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she:

a. Apply warm compresses to her nipples just before feedings

b. Lubricate her nipples with expressed milk before feeding

c. Dry her nipples with a soft towel after feedings

d. Apply soap directly to her nipples, and then rinse

29. The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time?

a. Between 10 and 12 weeks’ gestation

b. Between 16 and 20 weeks’ gestation

c. Between 21 and 23 weeks’ gestation

d. Between 24 and 26 weeks’ gestation

30. Normal lochial findings in the first 24 hours post-delivery include:

a. Bright red blood

b. Large clots or tissue fragments

c. A foul odor

d. The complete absence of lochia

Answers and Rationale