LPN Maternal and Neonatal Nursing 2 — Questions and Answers
Question 1: A nurse is assessing a postpartum client 2 hours after delivery. The fundus is firm, located 2 cm above the umbilicus, and deviated to the right. What is the most likely cause?
- Normal uterine involution
- Urinary bladder distension (Correct answer)
- Uterine atony
- Retained placental fragments
Correct answer: Urinary bladder distension
A deviated uterus, especially to the right, typically indicates a full bladder that is displacing the uterus.
Question 2: Which assessment finding in a newborn at 24 hours of life requires immediate nursing intervention?
- Respiratory rate of 48 breaths/min
- Axillary temperature of 97.2°F (36.2°C)
- Blood glucose of 38 mg/dL (Correct answer)
- Heart rate of 148 beats/min
Correct answer: Blood glucose of 38 mg/dL
A blood glucose below 40–45 mg/dL in a neonate indicates hypoglycemia and requires immediate feeding or IV dextrose.
Question 3: A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which condition should the nurse suspect first?
- Placental abruption
- Placenta previa (Correct answer)
- Preterm labor
- Bloody show
Correct answer: Placenta previa
Painless, bright red vaginal bleeding in the third trimester is the classic presentation of placenta previa.
Question 4: When performing a fundal assessment on a postpartum client, the nurse finds the fundus is boggy. What is the priority nursing action?
- Notify the physician immediately
- Perform uterine massage (Correct answer)
- Increase IV fluid rate
- Administer oxytocin per protocol
Correct answer: Perform uterine massage
A boggy fundus indicates uterine atony, and the first intervention is uterine fundal massage to stimulate contraction.
Question 5: The nurse is teaching a new mother about newborn care. Which statement about umbilical cord care is most accurate?
- Apply antibiotic ointment daily to prevent infection
- Keep the cord dry and expose it to air to promote drying (Correct answer)
- Submerge the infant in a tub bath until the cord falls off
- Cover the cord with a bandage to protect it from bacteria
Correct answer: Keep the cord dry and expose it to air to promote drying
Keeping the cord dry and exposed to air promotes drying and separation, and current guidelines recommend dry care rather than antiseptic application.
Question 6: A nurse is caring for a client in active labor. The fetal heart rate tracing shows late decelerations with minimal variability. What is the priority nursing action?
- Reposition the mother to the left lateral position (Correct answer)
- Prepare for immediate cesarean delivery
- Increase the rate of oxytocin infusion
- Administer oxygen via non-rebreather mask at 10 L/min
Correct answer: Reposition the mother to the left lateral position
Repositioning to the left lateral position relieves aortocaval compression and is the first intervention for late decelerations.
Question 7: A neonate born at 38 weeks gestation has a Ballard score assessment. Which physical characteristic indicates greater gestational maturity?
- Abundant lanugo covering the body
- Smooth skin with few creases on the soles
- Well-curved ear pinna with firm recoil (Correct answer)
- Widely separated labia majora
Correct answer: Well-curved ear pinna with firm recoil
A well-curved ear pinna with firm, instant recoil indicates greater neuromuscular maturity associated with full-term gestation.
LPN Maternal and Neonatal Nursing 2
A nurse is assessing a postpartum client 2 hours after delivery.
The fundus is firm, located 2 cm above the umbilicus, and deviated to the right.
What is the most likely cause?