Maternal Infant Nursing NCLEX Questions Part 2 Answers and Rationale
1. Answer D. Labor is divided into four stages: first stage, onset of labor to full dilation; second stage, full dilation to birth of the baby; third stage, birth of the placenta; and fourth stage, 1-hour postpartum. The first stage is divided into three phases: early, active, and transition.
2. Answer B. The second stage of labor begins with complete cervical dilation and ends with delivery of the neonate.
3. Answer A. Hypotensive crisis may occur after epidural anesthesia administration as the anesthetic agent spreads through the spinal canal, blocking sympathetic innervation. Other signs and symptoms of hypotensive crisis associated with epidural anesthesia may include fetal bradycardia (not tachycardia) and decreased (not increased) beat-to-beat variability in the FHR. Urine retention, not renal toxicity, may occur during the postpartum period.
4. Answer A. Tetanic contractions are the most serious adverse effect associated with administering oxytocin. When tetanic contractions occur, the fetus is at high risk for hypoxia and the mother is at risk for uterine rupture. The client may be at risk for pulmonary edema if large amounts of oxytocin have been administered, and this drug can also increase blood pressure. However, pulmonary edema and increased blood pressure aren’t the most serious adverse effects. Early decelerations of fetal heart rate aren’t associated with oxytocin administration.
5. Answer D. An increased pulse rate followed by an increased respiratory rate and decreased blood pressure may be the first signs of postpartum hemorrhage and hypovolemic shock.
6. Answer C. The supine position causes compression of the client’s aorta and inferior vena cava by the fetus. This, in turn, inhibits maternal circulation, leading to maternal hypotension and, ultimately, fetal hypoxia. The other positions promote comfort and aid labor progress. For instance, the lateral, or side-lying, position improves maternal and fetal circulation, enhances comfort, increases maternal relaxation, reduces muscle tension, and eliminates pressure points. The squatting position promotes comfort by taking advantage of gravity. The standing position also takes advantage of gravity and aligns the fetus with the pelvic angle.
7. Answer B. After delivery of the placenta, the fundus is normally firmly contracted at the midline, 0.4" to 0.8" (1 to 2 cm) below the umbilicus.
8. Answer B. Amniotomy increases the risk of cord prolapse. If the prolapsed cord is compressed by the presenting fetal part, the fetal blood supply may be impaired, jeopardizing the fetal oxygen supply. Because lack of oxygen to the fetus may cause fetal death, the nursing diagnosis of Ineffective fetal cerebral tissue perfusion takes priority over diagnoses of Deficient knowledge, Pain, and Risk for infection.
9. Answer D. For a client with active genital herpes, cesarean birth helps avoid infection transmission to the neonate, which would occur during a vaginal birth. Mid forceps and low forceps are types of vaginal births that could transmit the herpes infection to the neonate. Induction is used only during vaginal birth; therefore, it’s inappropriate for this client.
10. Answer C. Port-wine-colored amniotic fluid isn’t normal and may indicate abruptio placentae. Increased bloody show is a normal finding and causes light pink amniotic fluid. Meconium turns amniotic fluid green
11. Answer B. The latent phase of the first stage of labor is associated with irregular, short, mild contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort. During the active phase, the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds’ duration occur every 2 to 5 minutes. Fetal descent continues throughout the active phase and into the transitional phase, when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds’ duration occur every 1½ to 2 minutes. The first stage of labor doesn’t include an expulsive phase.
12. Answer A. Pushing (bearing down) before the cervix is completely dilated may cause edema and tissue damage and may impede fetal descent. Telling the client not to push because the nurse-midwife isn’t ready to assist is inappropriate and unprofessional. If the cervix were completely dilated, the nurse-midwife could assist the client in changing position to help reposition the fetus. The client’s membranes should have ruptured already.
13. Answer A. When used properly, a vacuum extractor is a safer delivery with fewer complications for the mother and the baby than a forceps delivery. Cephalohematomas occur more often in assisted births than in unassisted births. Instruments are used during delivery when individually necessary. No additional nursing interventions are needed during the postpartum period.
14. Answer C. Relaxation isn’t an indication for detachment of the placenta. An abrupt lengthening of the cord, an increase in the number of contractions, and an increase in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus.
15. Answer A. In a nonreassuring pattern, the FHR accelerates to baseline tachycardia as the fetus attempts to compensate for a growing oxygen deficit. A reassuring variable pattern has an abrupt onset and end. The baseline FHR doesn’t increase and short-term variability doesn’t decrease.
16. Answer A. Possible fetal adverse reactions include both moderate central nervous system depression and decreased beat-to-beat variability. Bradycardia and late decelerations don’t occur as a result of meperidine administration.
17. Answer B. The client and her husband are working together for a common goal. He’s offering support, and they’re sharing the experience of childbirth, making Readiness for enhanced family coping related to participation in pregnancy and delivery an appropriate nursing diagnosis. The other options suggest that the couple have a problem that isn’t indicated in the question.
18. Answer A. Dizziness, circumoral numbness, and slurred speech indicate anesthesia overdose. Transition to the second stage of labor is marked by an increased urge to push, an increase in bloody show, grunting, gaping of the anus, involuntary defecation, thrashing about, loss of control over breathing techniques, and nausea and vomiting. Anxiety and dehydration rarely cause dizziness or circumoral numbness.
19. Answer C. Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn’t be allowed to ambulate. Carefully titrating the oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include.
20. Answer B. If the unprepared client has a support person, the nurse should focus on that person’s supporting role, demonstrating touch, massage, and simple breathing patterns. The other options are inappropriate at this time because they may make the client and her husband more anxious.
21. Answer B. During contractions, blood pressure increases and blood flow to the intervillous spaces decreases, compromising the fetal blood supply. Therefore, the nurse should frequently assess the client’s blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. During pain and contractions, the maternal blood pressure usually increases, rather than decreases. Preeclampsia causes the blood pressure to increase — not decrease.
22. Answer A. Uterine atony should be carefully assessed during the fourth stage. The second stage of labor begins with complete cervical dilation and ends with birth. The third stage begins immediately after birth and ends with the separation and expulsion of the placenta. Immediately after delivery, the placenta is evaluated carefully for completeness, and the client is assessed for excessive bleeding or a relaxed uterus. Umbilical cord prolapse, displacement of the umbilical cord to a position at or below the fetus’s presenting part, occurs most commonly when amniotic membranes rupture before fetal descent. The client should be assessed for a visible or palpable umbilical cord in the birth canal, violent fetal activity, or fetal bradycardia with variable deceleration during contractions. The presence of umbilical cord prolapse requires an emergency delivery.
23. Answer B. Placental separation is characterized by a sudden gush or trickle of blood from the vagina, further protrusion of the umbilical cord from the vagina, a globular-shaped uterus, and an increase in fundal height. With cervical or vaginal laceration, the nurse notes a consistent flow of bright red blood from the vagina. With postpartum hemorrhage, usually caused by uterine atony, the uterus isn’t globular. Uterine involution can’t begin until the placenta has been delivered.
24. Answer A. After the baby’s head is delivered, the nurse should check for the cord around the baby’s neck. If the cord is around the neck, it should be gently lifted over the baby’s head. Antibiotic ointment is administered to the baby after birth, not during delivery of the head, to prevent gonorrheal conjunctivitis. The baby’s head isn’t turned during delivery. After delivery, the baby is held with the head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the baby’s mouth. Assessing the baby’s respiratory status should be done immediately after delivery.
25. Answer C. Gentle pressure applied to the baby’s head as it’s delivered prevents rapid expulsion, which can cause brain damage to the baby and perineal tearing in the mother. Never pull at the baby’s head or hold the head back. Placing the mother in the Trendelenburg position won’t halt labor and may cause respiratory difficulties.
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