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2018-2019 MATERNITY NCLEX QUIZ
20 Questions and Answers
1) The nurse if working with 4 clients on the obstetrical unit. Which client will be the highest priority for a cesarean section?
a) Client 40 weeks gestations whose fetus weighs 8lb by ultrasound estimation
b) Client at 37 weeks gestation with fetus in the right occiput posterior (ROP) position
c) Client at 32 weeks gestation with fetus in breech position
d) Client at 38 weeks gestation with active herpes lesions
2) After instruction of a primigravid client at 8 weeks gestation attempting to manage early morning nausea and vomiting, which client statement indicates the need for additional teaching.
- “I will eat dry crackers or toast before arising in the morning.”
- “I will drink adequate fluids separate from my meals or snacks.”
- “I will eat two large meals daily with frequent protein snacks.”
- “I will snack on a small amount of carbohydrates throughout the day.”
3) The nurse notices that a client who has just given birth is short of breath, ashen in color, and begins to cough. She becomes limp on the birthing table. At last assessment 30 minutes ago, her temperature was 98 degrees F (36.7), pulse was 78eats/min, and respirations were 16 breaths/min. Determine the nursing actions in the order they should occur. All options must be used.
a) Open airway using head tilt-chin lift #4
b) Activate staff to activate emergency response system. #2
c) Establish unresponsiveness #1
d) Give two breaths. #5
e) Begin compressions #3
4) The nurse and an unlicensed assistance personnel (UAP) are caring for clients in a birthing center. Which
tasks should the nurse delegate to the UAP? Select all that apply:
a) Emptying a urinary catheter from a postpartum patient
b) Assisting an active labor client with breathing and relaxation
c) Ambulating a post-cesarean client to the bathroom
d) Calculating hourly IV totals for a preterm labor client
e) Intake and output catheterization for culture and sensitivity
f) Calling a report of normal findings to the health care provider
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5) Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first?
a) A client at 13 weeks gestation who is experiencing nausea and vomiting three times a days with +1
ketones in her urine
b) A client at 37 weeks gestation who is an insulin-dependent diabetic and experiencing 3 to 4 fetal
movements per day
c) A client 32 weeks gestation who has preeclampsia and +3 proteinuria and who is returning or evaluation
of epigastric pain
d) A client at 17 weeks gestation who is not feeling fetal moving at this point in her pregnancy.
6) A primiparous client, who has just given birth to a healthy term neonoate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which response?
a) Disappointment in the baby’s gender
b) Greif over the ending of the pregnancy
c) A normal reponse to the birth
d) Indication of post-partum blues
7) The cervix of a 15-year-old primigravid client who has been admitted to the labor area is 2 cm dilate and 50% effaced. Her membranes are intact, and contractions are every 5 to 6 minutes. Which interventions should the nurse recommend at this time?
a) Resting in the right lateral recumbant positon
b) Lying in the left lateral recumbent position
c) Walking around the hallway
d) Sitting in a comfortable chair for a period of time
8) A primigravid client is admitted as an outpatient for an external cephalic version. Which factors would be a contraindication for the procedure?
a) Multiple gestation
b) Breech presentation
c) Maternal Rh-negative blood type
d) History of gestational diabetes
9) A primigravid is admitted to the labor area with ruptured membranes and contractions occurring ever 2-3 minutes, lasting 45 seconds. After 3 hours of labor, the client’s contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. What is the expected outcome of this drug?
a) The cervix will begin to dilate 2cm/h
b) Contractions will occur every 2 to 3 minutes, lasting 40 to 60 seconds, with moderate intensity resting
tone between contractions.
c) The cervix will change from firm to soft, efface to 40% to 50%, and move from posterior to anterior
positions.
d) Contractions will be every 2 minutes, lasting 60-90 seconds, with intrauterine pressure of 70 mm Hg
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10) A 21-year old primigravid client at 40 weeks gestations is admitted to the hospital in acute labor. The clients cevix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which is a priority nursing intervention?
a) Urinary retention
b) Hyperventitaion
c) Ineffective coping
d) Pain
11) The health care provider (HCP) has prescribed prostaglandin gel to be administered vaginally to a newly admitted primigravid client. Which finding indicates that the client has had a therapeutic response to the medications?
a) Resting period of two minutes between contractions
b) Decreasing nausea in labor
c) Softening of the cervix and beginning of effacement
d) Leaking of clear amniotic fluid in small amounts
12) The nurse assesses a primiparous client with ruptured membranes in labor for 20 hours. The nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which interventions should the nurse perform? Select all that apply.
a) Administer oxygen via mask to the client
b) Questioning the client about the effectiveness of pain relief
c) Placing the client on her side
d) Readjusting the monitor to a more comfortable position
e) Applying an internal fetal monitor
13) A client is admitted with a suspected abruptio placentae. The nurse should assess the client for which signs and symptoms? Select all that apply?
a) Bleeding that is concealed or apparent?
b) Abdominal rigidity
c) Painful abdomen
d) Painless bleeding
e) Large placenta
f) Bleeding that stops spontaneously
14) The health care provider (HCP) has performed an amniotomy on a laboring client. Which details must be included in the documentation of this procedure? Select all that apply?
a) Time of rupture
b) Color and clarity of fluid
c) Fetal heart rate (FHR) and pattern before and after the procedure
d) Size of amnio hook used during the procedure
e) Odor and amount of fluid
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15) What action does the nurse anticipate completing at the end of the second stage of labor before the delivery of the placenta in the spontaneous vaginal birth of a term newborn? Select all that apply.
a) Assigning APGAR scores
b) Administering oxytocin
c) Assisting with perineal repairs
d) Drying the newborn
e) Initiating skin to skin care
f) Taking newborn vital signs
16) During a scheduled cesarean birth of a primigravid client with a fetus at 39 weeks gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which problem?
a) Congenital anomalies
b) Pulmonary hypertension
c) Meconium aspiration syndrome
d) Respiratory distress syndrome
17) A newly postpartum primiparous client asks the nurse, “Can my baby see?” Which statement about neonatal vision should the nurse include in explanation?
a) Neonates primarily focus on moving objects.
b) They can see objects up to 12 inches.
c) Usually they see clearly by about 2 days after birth.
d) Neonates primarily distinguish light from dark.
18) The nurse working on the postpartum unit is in charge of a team that included an unlicensed assistive personnel (UAP). Which task would the nurse question if completed by the UAP caring for a 1 days postpartum client?
a) Changing the perineal pad and reporting the drainage.
b) Teaching the mother the latch the infant onto the breast.
c) Reinforcing good hygiene while assisting the client with washing the perineum.
d) Assisting the client with ambulation shortly after birth.
19) While caring for a postpartum client who is receiving treatment with bed rest and intravenous heparin therapy for a deep vein thrombosis, the nurse should contact the client’s health care provider (HCP) immediately if the client exhibits which symptoms?
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