NCLEX Maternal and Newborn Nursing

Question 1

A patient at 38 weeks gestation reports decreased fetal movement. Which instruction should the nurse provide?

Accepted Answer

Perform a kick count; if fewer than 10 movements in 2 hours, contact the provider

Answer

This is normal as the baby has less room to move

Answer

Come back in one week for a scheduled visit

Answer

Increase activity to stimulate fetal movement

Question 2

A laboring patient's external fetal monitor shows variable decelerations. What is the priority nursing intervention?

Accepted Answer

Change maternal position and assess for cord compression

Answer

Increase IV fluid rate

Answer

Administer oxygen at 8–10 L/min via mask

Answer

Notify the provider and prepare for immediate cesarean

Question 3

The nurse is assessing a newborn at delivery. The Apgar score is being calculated at 1 minute. The baby has a heart rate of 90 bpm, weak cry, active motion, grimace to stimulation, and blue hands and feet. What is the Apgar score?

Accepted Answer

7

Answer

6

Answer

5

Answer

8

Question 4

A new mother asks about the 'rooting reflex' in her newborn. The nurse should explain that this reflex:

Accepted Answer

Helps the baby turn toward a stimulus touching the cheek to find the nipple

Answer

Occurs when the baby grasps a finger placed in the palm

Answer

Is a response to a loud noise causing the baby to extend arms

Answer

Represents normal newborn visual tracking behavior

Question 5

A nurse is caring for a patient diagnosed with preeclampsia who is receiving IV magnesium sulfate. Which finding indicates magnesium toxicity?

Accepted Answer

Urine output of 25 mL/hr and absent deep tendon reflexes

Answer

Blood pressure of 148/96 mmHg

Answer

Headache and visual changes

Answer

Fetal heart rate of 145 bpm

Question 6

A nurse notes a patient in labor has been pushing for 2.5 hours. The fetal head is visible at the perineum during pushing. What term describes this finding?

Accepted Answer

Crowning

Answer

Engagement

Answer

Station +3

Answer

Restitution

Question 7

A patient who delivered 2 hours ago is noted to have a soft, boggy uterus displaced to the right of the umbilicus. What is the priority nursing action?

Accepted Answer

Have the patient void, then perform uterine massage

Answer

Administer oxytocin IV bolus

Answer

Call the provider for surgical consultation

Answer

Increase IV fluid rate and apply a compression bandage

Question 8

A breastfeeding mother reports her 2-day-old baby feeds every 2 hours and seems unsatisfied. Her milk has not 'come in' yet. What is the most appropriate response from the nurse?

Accepted Answer

Reassure her that colostrum is adequate; encourage frequent feeding to stimulate milk production

Answer

Recommend supplementing with formula until milk comes in

Answer

Suggest reducing feeding frequency to every 4 hours so she can rest

Answer

Recommend stopping breastfeeding and switching to formula

Question 9

A nurse assesses a postpartum patient and finds heavy vaginal bleeding with large clots despite a firm uterus. What is the most likely cause?

Accepted Answer

Laceration of the cervix or vagina

Answer

Uterine atony

Answer

Bladder distension

Answer

Retained placental fragments

Question 10

What is the purpose of administering vitamin K (phytonadione) to a newborn within the first hour of birth?

Accepted Answer

To prevent hemorrhagic disease of the newborn due to low vitamin K levels

Answer

To prevent neonatal jaundice

Answer

To stimulate the newborn immune response

Answer

To promote liver maturation and bile production