NCLEX Maternal Newborn EXAM QUESTION AND CORRECT ANSWER 2023/2024

NCLEX Maternal Newborn EXAM QUESTION AND CORRECT ANSWER 2023/2024 Causes of Late Decelerations -CORRECT ANSWER- Decreased blood flow to uterus or placenta resulting in fetus not receiving enough oxygen Cause of Variable decelerations -CORRECT ANSWER- umbilical cord compression Cause of Early Decelerations -CORRECT ANSWER- fetal head compression in birth canal Manifestations of Early Decelerations -CORRECT ANSWER- - uniform shape - slow onset - mirror contractions - return to baseline at end of contraction Manifestations of Late Decelerations -CORRECT ANSWER- - loss of HR variability - begin after peak of contraction - slow return to baseline - resolves after contraction Manifestations of Variable Decelerations -CORRECT ANSWER- - irregular and jagged appearance - no regard to contractions - potentially caused by: fetal movement, umbilical cord wrapped around neck, maternal position, ruptured membranes Nursing Interventions for fetal heart rate decelerations -CORRECT ANSWER- - Assess FHR baseline, variability, and reactivity Q15min during active labor - Contraction pattern, labor progress, and vital signs (including pain) Q15mins during active labor Nursing interventions for Variable decelerations -CORRECT ANSWER- - reposition mom (Left lateral position) - vaginal exam - administer oxygen - increase IV fluid intake Nursing intervention for Late Decelerations -CORRECT ANSWER- - Notify HCP - Change maternal position - increase IV rate - administer oxygen - decrease or stop oxytocin - emergent delivery by C-section Preeclampsia -CORRECT ANSWER- - begins after 20 weeks - BP > 140/90 - proteinuria - transient headaches - irritability - edema Risk factors for Preeclampsia -CORRECT ANSWER- - Hx of Preeclampsia - Chronic HTN - Obesity - DM - Multiple gestation pregnancy - kidney disease - Autoimmune disease - clotting disorders - baby conceived invitro - very young or older than 35 y/o Manifestations of Preeclampsia -CORRECT ANSWER- - proteinuria >500mg/24hrs - elevated liver enzymes and thrombocytopenia - severe headaches not relieved by analgesics - changes in vision: blurred vision, flashing lights, floaters - right upper quadrant pain - sudden weight gain (> 2lb in 24hrs or 5lb in 1 week) Assessment for Preeclampsia -CORRECT ANSWER- - vital signs and pain - assess fetal status - nonstress test - collection of 24 hr urine specimen - document findings - dim lights - limit visitors Priorities in Preeclampsia -CORRECT ANSWER- - maintain adequate fetal oxygenation and nutrition - address elevated BP - limit long-term complication Nursing Interventions for Preeclampsia -CORRECT ANSWER- - Monitor urine output and daily weights - monitor vital signs - monitor deep tendon reflexes - encourage lateral positioning - perform daily nonstress test and kick counts - decrease environmental stimuli - monitor labs and dx findings - closely monitor I/O - educate pt. and family Postpartum hemorrhage -CORRECT ANSWER- - loss of 500 ml after vaginal birth - loss of 1 L after C-section - greatest risk after first hour of birth - results in anemia and hypovolemic shock Risk factors of PPH -CORRECT ANSWER- - uterine atony - prolonged labor - precipitous labor - 5 or more pregnancies to term - oxytocin induced labor - placenta previa or abruptio placenta - MgSO4 - Retained placental fragments 4 T's of PPH -CORRECT ANSWER- Tone Trauma Tissue Thrombin Manifestations of PPH -CORRECT ANSWER- - increase or change in lochia pattern - uterine atony - passing blood clots larger than a quarter - perineal pad saturation in 15min or less - constant vaginal blood oozing, trickling or flow - Tachycardia - Hypotension - skin pale, cool and clammy - pale mucous membranes - oliguria Assessment in PPH -CORRECT ANSWER- - Boggy uterus, midline - saturated perineal pad - S/S of hypovolemia - assess source of bleeding Goals of Care for PPH -CORRECT ANSWER- - determine and correct underlying cause - fundal massage and bladder evaluation - catheterization if patient is unable to void Nursing Interventions in PPH -CORRECT ANSWER- - assess source of bleeding - ensure empty bladder - fundal massage - express clots - monitor VS and O2 (2-3L/min) - IV fluids - Medications to promote contractions or control hemorrhage Medications for PPH -CORRECT ANSWER- Oxytocin Methylergonovine Misoprostol Carboprost tromethamine APGAR scoring: Heart rate -CORRECT ANSWER- 0 = absent 1 = slow; below 100/min 2 = above 100/min APGAR scoring: Respiratory effort -CORRECT ANSWER- 0 = absent 1 = slow or weak 2 = good cry APGAR scoring: Reflex irritability -CORRECT ANSWER- 0 = no response 1 = grimace 2 = cry Apgar scoring: Muscle tone -CORRECT ANSWER- 0 = flaccid 1 = some flexion of the extremities 2 = well flexed APGAR scoring: Color -CORRECT ANSWER- 0 = pale or blue 1 = pink body with blue extremities (acrocyanosis) 2 = completely pink APGAR scoring Indications -CORRECT ANSWER- 0 - 3 = severe distress 4 - 6 = moderate difficulty 7 - 10 = minimal to no difficulty Potential indications for C-Section -CORRECT ANSWER- - malpresentation - nonreassuring FHT - placental abnormalities - high risk pregnancy - previous C-Section - multifetal gestation - umbilical cord prolapse - congenital malformations - maternal cardiac or respiratory disease A client asks the nurse what are indications for a cesarean birth. Provide three (3) reasons a cesarean birth may be necessary -CORRECT ANSWER- - malpresentation - cephalopevlic disproportions - high risk pregnancy - placental abnormalities - nonreassurring fetal heart tones - previous cesarean birth - dystocia - multiple gestations - umbilical cord prolapse - congenital malformations - maternal cardiac or respiratory disease A nurse is caring for a client in the postpartum phase. How should the nurse assess fundal height following delivery? -CORRECT ANSWER- - the fundus should be palpable midline and 2cm below the umbilicus - 1hr postpartum, the fundus will rise to the level of the umbilicus A nurse is caring for a postpartum client who is breastfeeding her newborn. Identify three (3) teaching points to discuss with the client regarding the postpartum infection, mastitis. -CORRECT ANSWER- 1. use ice pack or warm packs for discomfort nue breastfeeding frequently every 2-4hrs especially on affected side (completely empty milk to prevent stasis) 3. rest, take analgesics, and maintain fluid intake of at least 3L/day A nurse is providing discharge information to a postpartum client. Identify three (3) teaching points to discuss with the postpartum client prior to discharge regarding breastfeeding -CORRECT ANSWER- 1. Frequently pump or feed to prevent engorgement and stimulate milk production 2. Wear supportive bra to prevent clogged milk ducts 3. To relieve engorgement, take a warm shower or apply a cool compress before feedings to promote milk flow 4.For sore nipples, apply a small amount of breast milk to the nipple and allow to air dry A nurse is providing prenatal education. What common findings of pregnancy should be discussed in routine prenatal teaching? -CORRECT ANSWER- - N/V, fatigue, backache, varicosities, heartburn, activity, sexuality The nurse is reviewing the postpartum mother's complete blood count (CBC) at 24 hours after delivery and notes a white blood cell (WBC) count of 15,000 mm3. What action should the nurse take? -CORRECT ANSWER- Elevated WBC is an expected finding up to 14 days postpartum