LPN Maternal and Neonatal Nursing 3 — Questions and Answers
Question 1: A nurse is caring for a client with preeclampsia who is receiving magnesium sulfate. Which assessment finding requires the nurse to hold the medication and notify the provider?
- Urine output of 35 mL/hr
- Respiratory rate of 10 breaths/min (Correct answer)
- Mild headache rated 3/10
- Deep tendon reflexes rated 2+
Correct answer: Respiratory rate of 10 breaths/min
A respiratory rate below 12 breaths/min indicates magnesium toxicity, which can cause respiratory depression and arrest.
Question 2: Which breastfeeding position is most beneficial for a mother who delivered by cesarean section to avoid incision discomfort?
- Cradle hold
- Cross-cradle hold
- Football (clutch) hold (Correct answer)
- Laid-back (biological nurturing) position
Correct answer: Football (clutch) hold
The football hold keeps the infant away from the abdominal incision, making it the most comfortable position after a cesarean delivery.
Question 3: A newborn's APGAR score at 1 minute is 5. What is the most appropriate nursing action?
- Continue routine newborn care and reassess at 5 minutes
- Begin chest compressions immediately
- Provide stimulation and supplemental oxygen, then reassess at 5 minutes (Correct answer)
- Administer epinephrine per NRP protocol
Correct answer: Provide stimulation and supplemental oxygen, then reassess at 5 minutes
An APGAR score of 4–6 indicates moderate depression requiring stimulation and supplemental oxygen, with reassessment at 5 minutes.
Question 4: A nurse is teaching a pregnant client about warning signs. Which symptom should the client report immediately during the third trimester?
- Mild ankle edema at the end of the day
- Fetal movement of 10 kicks in 2 hours
- Sudden decrease in fetal movement (Correct answer)
- Increase in urinary frequency
Correct answer: Sudden decrease in fetal movement
A sudden decrease in fetal movement may indicate fetal distress and requires immediate evaluation.
Question 5: The nurse is assessing a newborn and notes jaundice visible on the face and chest at 18 hours of life. Which action is most appropriate?
- Document as physiological jaundice and continue routine care
- Encourage frequent breastfeeding and obtain a serum bilirubin level (Correct answer)
- Place the infant under phototherapy without further assessment
- Prepare the infant for an exchange transfusion
Correct answer: Encourage frequent breastfeeding and obtain a serum bilirubin level
Jaundice appearing before 24 hours of life is pathological and requires a serum bilirubin level along with frequent feeding to promote bilirubin excretion.
Question 6: A client in the third trimester reports right upper quadrant pain, headache, and visual disturbances. The nurse measures a BP of 158/106 mmHg. Which condition does the nurse suspect?
- HELLP syndrome (Correct answer)
- Gestational hypertension
- Hyperemesis gravidarum
- Cholestasis of pregnancy
Correct answer: HELLP syndrome
HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) presents with RUQ pain, headache, visual changes, and severe hypertension.
Question 7: Which action by the nurse best promotes successful breastfeeding in the first hour after delivery?
- Weigh the newborn immediately after delivery
- Give the newborn a pacifier to practice sucking
- Place the newborn skin-to-skin on the mother's chest (Correct answer)
- Administer a bottle of formula to ensure adequate nutrition
Correct answer: Place the newborn skin-to-skin on the mother's chest
Skin-to-skin contact in the first hour promotes the newborn's rooting reflex and facilitates early latching and successful breastfeeding initiation.
LPN Maternal and Neonatal Nursing 3
A nurse is caring for a client with preeclampsia who is receiving magnesium sulfate.
Which assessment finding requires the nurse to hold the medication and notify the provider?