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NCLEX-maternity and newborn questions with actual answers.
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NCLEX-maternity and newbornquestions with actual answers.
A 37 week pregnant woman presents to triage with reports of a headache and begins to have a seizure.
What actions should the nurse take?
Select all that apply
1. Place the client's head in the nurse's lap.
2. Administer oxygen.
3. Monitor tonic-clonic activity.
4. Place an oral airway into the client's mouth.
5. Administer diazepam. ANS - 1, 2. & 3. Correct: This client in triage experiencing a seizure should be
gently lowered to the floor, with her head protected. Oxygen is needed to ensure supply of oxygen to
mom and fetus. Seizure activity should be monitored for tonic and clonic phases of seizure, timing, and
body part affected.
seizures.
The nurse is assessing a newborn to determine gestational age. What findings by the nurse would
indicate the infant is premature?
Select all that apply
1. Folded ear pinna springs back slowly.
2. Peripheral cyanosis on feet and hands.
3. Shoulders and chest have moderate lanugo.
4. Vernix covering axilla, back and buttocks.
5. Feet soles entirely covered with creases. ANS - 1, 3. & 4. Correct: The nurse is assessing a neonate for
indications of premature gestational age. In a full term infant, the ear pinna would spring back firmly
and quickly, so a slow response indicates probable prematurity. Lanugo is also an indicator of gestational
age. Lanugo that covers all the shoulders and chest indicate prematurity. Vernix is the waxy, cheesy
coating that is noted on the neonate after birth. A large amount of vernix, in this case covering axilla,
back and the buttocks, denotes prematurity.
, ANS - 2. Correct: If the neonate's toes curl downward when the soles of the feet are stroked, it may be
evidence that neurologic damage from asphyxia has occurred. A normal response would be for the toes
to curl fan out when the soles of the feet are stroked.
ANS - 1. Incorrect: Naloxone is not indicated here. Naloxone reverses the effects of morphine. There is
nothing in the stem indicating that the client received a narcotic.
2. Correct: The side-lying position will relieve pressure from the aorta thus getting more oxygen to the
fetus.
3. Correct: Stop the oxytocin infusion. During uterine contraction, blood flow through the uterus slows
reducing fetal oxygenation. These intense contractions may be the cause of the late decelerations.
4. Correct: Increasing the IV fluid expands the client's blood volume and improves placental perfusion.
5. Correct: The primary healthcare provider should be notified as continued late decelerations may
mean the fetus needs to be delivered immediately via C-section.
6. Correct: Administering oxygen to increase the client's blood oxygen saturation will make more oxygen
available to the fetus.
The nurse is educating a group of sexually active teenagers about Chlamydia. What should the nurse
teach these clients to prevent them from acquiring or transmitting this disease ?
1. Use a latex condom when having sex to protect against Chlamydia.
2. Seek the advice of a primary healthcare provider if there is vaginal discharge or burning on urination.
3. Suggest that the teens be screened for Chlamydia.
4. Reassure the teens that if they have no symptoms, they have no disease.
5. Take prescribed medication if diagnosed with Chlamydia, and repeat screening in three months. ANS
-
ANS - 3. Correct: Spermicidal agents have an approximately 25% failure rate in preventing pregnancy.
These agents kill sperm by destroying the protective surface of sperm and preventing metabolic
activities necessary for survival
he nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely?
1. Hypocalcemia
2. Hypomagnesemia
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