Maternal Infant Nursing NCLEX Questions Answers and Rationale

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1.    Answer C. Taking brisk walks is one of the easiest ways to exercise during pregnancy. The client should begin by walking slowly for 10 to 15 minutes per day and increase gradually to a comfortable speed and a duration of 30 to 45 minutes per day. The pregnant client should avoid high-intensity aerobics because these greatly increase oxygen consumption; pregnancy itself not only increases oxygen consumption but reduces oxygen reserve. Starting from the 4th month of pregnancy, the client should avoid back-lying exercises because in this position the enlarged uterus may reduce blood flow through the vena cava. The client should avoid exercises that raise the heart rate over 140 beats/minute because the cardiovascular system already is stressed by increased blood volume during pregnancy.

2.    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.

3.    Answer A. In the first trimester, fetal heart sounds are loudest in the area of maximum intensity, just above the client’s symphysis pubis at the midline. Fetal heart sounds aren’t heard as well in the other locations.

4.    Answer B. Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it doesn’t promote sodium retention. Castor oil isn’t known to increase absorption of fat-soluble vitamins, although laxatives can decrease absorption if intestinal motility is increased.

5.    Answer B. The nurse must determine whether placenta previa or abruptio placentae is the problem. (Fifty percent of all clients with hypertension will develop abruptio placenta.) In this case, the presenting symptoms are highly suggestive of an abruption, so the nurse must determine the level of the uterus and mark that level on the client’s abdomen. She must also check the consistency of the uterus; a uterus that is filling with blood because the placenta has detached early is rigid. Bleeding from a placental previa is usually painless. A vaginal examination is contraindicated in the presence of bleeding. Most nurses haven’t been taught how to perform an ultrasound. If the client has a placental abruption, birth will most likely be by cesarean section.

6.    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.

7.    Answer D. Maternal alcohol use during pregnancy may cause fetal and neonatal central nervous system deficits such as learning disabilities. It also may lead to characteristic physical anomalies and growth retardation. Maternal alcohol use doesn’t cause alcohol addiction in the fetus or neonate. Anencephaly occurs when the cranial end of the neural tube fails to fuse before the 26th day of gestation; this condition isn’t related to maternal alcohol use. Down syndrome results from a chromosomal disorder.

8.    Answer: D. Transmission of HIV can occur through breast milk, so breast-feeding should be discouraged in this case.

9.    Answer A. During each prenatal checkup, the nurse should evaluate the client for edema, a possible sign of pregnancy-induced hypertension (PIH). If edema exists, the nurse should assess for high blood pressure and proteinuria — other signs of PIH. Hb is measured during the first prenatal visit and again at 24 to 28 weeks’ gestation and at 36 weeks’ gestation. The pelvis is measured and the Rh factor determined during the first prenatal visit.

10.    Answer A. The best instruction is to encourage the client to increase her intake of high-fiber foods (roughage) and to drink at least six glasses of water per day. Mild laxatives and stool softeners may be needed, but dietary changes should be tried first. Straining during defecation and diarrhea can stimulate uterine contractions, but telling the client to go to the evaluation unit doesn’t address her concern.

11.    Answer B. During pregnancy, increasing levels of estrogen — not progesterone — cause vascularization of the eustachian tubes, leading to such problems as earaches, impaired hearing, and a constant feeling of fullness in the ears. Nothing in the question implies that the client has a serious neurologic disorder or an ear infection.

12.    Answer D. For a client with hyperemesis gravidarum, the goal of nursing care is to achieve optimal fetal growth, which can be evaluated by monitoring uterine growth through fundal height assessment. The nurse shouldn’t assume that excessive vomiting signifies the client doesn’t accept the pregnancy. Clients with hyperemesis gravidarum rarely gain weight according to the expected pattern. They may be hospitalized briefly to regulate fluid and electrolyte status, but they don’t require hospitalization for the duration of pregnancy. In fact, hospitalization may add to the stress of pregnancy by causing family separation and financial concerns.

13.    Answer D. Glycosuria predisposes the pregnant diabetic client to vaginal infections (especially Candida vaginitis) and UTIs, because the hormonal changes of pregnancy affect vaginal pH and the bladder. Electrolyte imbalances and hypoglycemia aren’t associated with vaginal infections or UTIs. Insulin requirements may decrease in early pregnancy; however, as the client’s food intake improves and maternal and fetal glycogen stores increase, insulin requirements also rise.

14.    Answer C. The cause of hyperemesis gravidarum isn’t known. However, etiologic theories implicate hormonal alterations and allergic or psychosomatic conditions. No evidence suggests that hyperemesis gravidarum results from a neurologic disorder, inadequate nutrition, or hemolysis of fetal RBCs.

15.    Answer D. Because all medications can be potentially harmful to the growing fetus, telling the client to consult with her health care provider before taking any medications is the best teaching. The client needs to understand that any medication taken at any time during pregnancy can be teratogenic.

16.    Answer D. Being involved in the pregnancy helps reinforce a child’s position in the family and minimizes feelings of neglect and abandonment. Telling the child about the childbirth only 1 month before the due date wouldn’t allow enough time to prepare him for the sibling and would prevent him from conceptualizing the passage of time. Reassuring him that nothing will change would be misleading; instead, the parents should discuss which aspects of family life will be changed by the upcoming birth and which will remain the same. Parents should reward mature behavior and ignore immature behavior.

17.    Answer D. Increasing vitamin C enhances the absorption of iron supplements. Taking an iron supplement with milk, tea, or an antacid reduces the absorption of iron.

18.    Answer B. Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks of gestation.

19.    Answer B. Use of ritodrine can lead to pulmonary edema. Therefore, the nurse should assess for crackles and dyspnea. Blood glucose levels may temporarily rise, not fall, with ritodrine. Ritodrine may cause tachycardia, not bradycardia. Ritodrine may also cause hypokalemia, not hyperkalemia.

20.    Answer B. Prenatal vitamins commonly cause nausea and taking them on a full stomach may curb this. Switching brands may not be helpful and may be more costly. Orange juice tends to make pregnant women nauseated. The vitamins may be taken at night, rather than in the morning, to reduce nausea.

21.    Answer A. To prepare a client for amniocentesis, the nurse should ask her to empty her bladder to reduce the risk of bladder perforation. Before transabdominal ultrasound, the nurse may instruct the client to drink 1 L of fluid to fill the bladder (unless ultrasound is done before amniocentesis to locate the placenta). I.V. anesthesia isn’t given for amniocentesis. The client should be supine during the procedure; afterward, she should be placed on her left side to avoid supine hypotension, promote venous return, and ensure adequate cardiac output.

22.    Answer D. The indirect Coombs’ test measures the number of antibodies against fetal Rh-positive factor in maternal blood. The maternal blood Rh factor is determined before the indirect Coombs’ test is done. No maternal antibodies against fetal Rh-negative factor exist.

23.    Answer A. To relieve heartburn, the nurse should advise a pregnant client to eat smaller meals at shorter intervals; drink six to eight 8-oz glasses of fluid daily to minimize regurgitation and reflux of stomach contents; and avoid citrus juice, which may act as a gastric irritant and worsen heartburn, and sodium bicarbonate, which may disrupt the body’s sodium-potassium balance.

24.    Answer A. Drug exposure causes 1% of congenital anomalies.

25.    Answer A. Mature pregnant clients are at increased risk for PIH and are more likely to require cesarean delivery. Also, their fetuses and neonates have a higher mortality and a higher incidence of trisomies. Iron deficiency anemia, cephalopelvic disproportion, and STDs may occur in any client regardless of age.


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