LVN Maternal & Newborn Nursing 2 — Questions and Answers
Question 1: A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which condition does the nurse suspect first?
- Placental abruption
- Placenta previa (Correct answer)
- Preterm labor
- Cervical polyp
Correct answer: Placenta previa
Painless, bright red bleeding in the third trimester is the classic presentation of placenta previa.
Question 2: The nurse is caring for a client with severe preeclampsia receiving magnesium sulfate. Which finding requires immediate intervention?
- Urinary output of 35 mL/hr
- Respiratory rate of 10 breaths/min (Correct answer)
- Mild headache
- Deep tendon reflexes 2+
Correct answer: Respiratory rate of 10 breaths/min
A respiratory rate below 12 breaths/min indicates magnesium toxicity and requires immediate intervention.
Question 3: When assessing a postpartum client's fundus 12 hours after delivery, the nurse notes it is deviated to the right. What is the priority action?
- Massage the fundus firmly
- Assist the client to ambulate
- Ask the client to void or catheterize (Correct answer)
- Administer oxytocin as ordered
Correct answer: Ask the client to void or catheterize
A deviated uterus is most commonly caused by a full bladder, which must be emptied to allow the uterus to contract midline.
Question 4: A newborn has an Apgar score of 4 at 1 minute. What is the priority nursing action?
- Continue observation and rescore at 5 minutes
- Begin positive pressure ventilation (Correct answer)
- Administer epinephrine
- Place the infant skin-to-skin with the mother
Correct answer: Begin positive pressure ventilation
An Apgar score of 4–6 indicates moderate distress and requires stimulation and positive pressure ventilation if breathing is inadequate.
Question 5: Which intervention is most appropriate for a client in the latent phase of labor experiencing back pain?
- Administer epidural analgesia immediately
- Apply counterpressure to the sacral area (Correct answer)
- Encourage the client to lie supine
- Restrict oral fluid intake
Correct answer: Apply counterpressure to the sacral area
Sacral counterpressure is a non-pharmacologic comfort measure that relieves back pain commonly associated with occiput posterior positioning.
Question 6: A breastfeeding mother asks the nurse why her infant feeds every 1.5 to 2 hours. What is the best response?
- Your milk supply is likely insufficient
- Breast milk digests quickly and the stomach empties faster than formula (Correct answer)
- The infant may have a metabolic disorder
- Frequent feeding indicates the infant is not latching correctly
Correct answer: Breast milk digests quickly and the stomach empties faster than formula
Breast milk is more easily digested than formula, causing the stomach to empty faster and prompting more frequent feeding.
Question 7: A client at 38 weeks reports decreased fetal movement. After a biophysical profile score of 6/10, what does the nurse anticipate?
- Repeat BPP in 24 hours (Correct answer)
- Immediate delivery
- Increased fetal movement testing only
- Reassurance that the score is normal
Correct answer: Repeat BPP in 24 hours
A BPP score of 6/10 is equivocal and typically prompts repeat testing within 24 hours or further evaluation.
LVN Maternal & Newborn Nursing 2
A client at 32 weeks gestation presents with painless, bright red vaginal bleeding.
Which condition does the nurse suspect first?