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Maternity NCLEX Review 101- questions reviewed & correctly answered.
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Maternity NCLEX Review 101- questionsreviewed & correctly answered.
The nurse is assigned to care for a client in the immediate postpartum period who received epidural
anesthesia for delivery, and the nurse monitors the client for complications. Which would most likely
indicate a hematoma?
1.Changes in vital signs
2.Signs of heavy bruising
3.Complaints of a tearing sensation
4.Complaints of lower abdominal discomfort ANS - 1.Changes in vital signs
Rationale:
Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with vulvar
hematoma. Options 3 and 4 are inaccurate for a client who is anesthetized. Heavy bruising may be
noted, but vital sign changes are most likely to indicate the presence of a hematoma.
The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received
an epidural. Which problem is most likely to occur during this stage?
1.Anxiety related to childbirth
2.Pain because of the process of labor or birth
3.Fatigue resulting from physical exertion during labor
, 4.Urinary retention caused by the loss of sensation to void and rapid bladder filling ANS - 4.Urinary
retention caused by the loss of sensation to void and rapid bladder filling
Rationale:
The fourth stage of labor is the period of time from 1 to 4 hours after delivery, when the woman's body
begins to readjust and relax. Options 1 and 2 relate to the first stage of labor. Option 3 relates to the
second stage of labor. Option 4 is related to the third and fourth stages of labor.
The parents of a neonate who is not circumcised request information on how to clean the newborn's
penis. Which is the correct response for the nurse to make to the parents?
1."Retract the foreskin and cleanse with every diaper change."
2."Retract the foreskin and cleanse the glans when bathing the neonate."
3."Avoid retracting the foreskin to cleanse the glans because this may cause adhesions."
4."Retract the foreskin no farther than it will easily go and replace it over the glans after cleaning." ANS
- 3."Avoid retracting the foreskin to cleanse the glans because this may cause adhesions."
Rationale:
In newborn males, the prepuce is continuous with the epidermis of the glans and is nonretractable.
Forced retraction may cause adhesions to develop. Separation should be allowed to occur naturally,
which will take place between 3 years and 5 years of age. Most foreskins are retractable by 3 years of
age and should be pushed back gently for cleaning once a week.
Which safety measures that should be implemented when working in the newborn nursery? Select all
that apply.
1.Adhere to standard precautions.
2.Place bassinets 1 foot apart from one another.
,3.It is acceptable for nurses who are ill to work in the nursery.
4.An identification bracelet should be placed on the infant only after the initial bath is completed.
5.The parents should be instructed to not release their infant to anyone wearing improper
identification.
6.
The mother should be fingerprinted and the infant should be footprinted on the identification card
before removing the infant from the delivery room. ANS - 1.Adhere to standard precautions.
5.The parents should be instructed to not release their infant to anyone wearing improper identification.
6.The mother should be fingerprinted and the infant should be footprinted on the identification card
before removing the infant from the delivery room.
Rationale:
Newborn safety, infection prevention, and abduction prevention are major responsibilities for nurses
working in the newborn nursery. Standard precaution guidelines need to be followed to prevent
transmission of bacteria and other illnesses to newborns. Following safety precautions to prevent
newborn abduction includes footprinting the newborn along with fingerprinting of the mother on the
identification card. This also includes placing bracelet identification on the mother and infant before
removing the newborn from the delivery room. Educating parents to release their newborn only to
those wearing proper identification is key in preventing newborn abductions in the inpatient situation.
Bassinets are to be 3 feet apart. Nurses who are ill should not be working in the nursery.
The nurse is assisting in administering beractant (Survanta) to a premature infant who has respiratory
distress syndrome. The nurse understands that the medication should be administered by which route?
1.Intradermal
2.Intratracheal
3.Subcutaneous
, 4.Intramuscular ANS - 2.Intratracheal
Rationale:
Respiratory distress is common in premature neonates and may be due to lung immaturity as a result of
surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is
administered by the intratracheal route. Options 1, 3, and 4 are not routes of administration for this
medication.
The nurse is reviewing the procedure for vitamin K injection in a newborn. Which information is included
in the procedure?
1. Inject at a 45-degree angle.
2. Use a 22-gauge, 1-inch needle for the injection.
3. Do not massage the injection site after administration.
4. Inject into skin that has been cleansed and allowed to have alcohol dry on the puncture site for 1
minute. ANS - 4. Inject into skin that has been cleansed and allowed to have alcohol dry on the
puncture site for 1 minute.
Rationale:
Vitamin K is given in the middle third of the vastus lateralis muscle using a 25-gauge, ⅝-inch needle. It is
injected into skin that has been cleansed or allowed to alcohol dry for 1 minute to remove organisms
and prevent infection. It is given at a 90-degree angle. The site is massaged after removing the needle to
increase absorption.
The advantages of using spinal anesthesia for delivery of a fetus include which? Select all that apply.
1. Ease of administration
2. Absence of fetal hypoxia
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