NCLEX Maternal and Newborn Nursing 2 — Questions and Answers
Question 1: A laboring client at 6 cm dilation suddenly reports a strong urge to push. What should the nurse do first?
- Assess cervical dilation (Correct answer)
- Encourage the client to push
- Position the client on her left side
- Administer oxygen by mask
Correct answer: Assess cervical dilation
A vaginal exam confirms whether the client is fully dilated before any pushing to prevent cervical edema or laceration.
Question 2: Which finding in a postpartum client 12 hours after delivery requires immediate intervention?
- Lochia rubra with small clots
- A firm fundus at the umbilicus
- Saturating one pad in 15 minutes (Correct answer)
- Mild afterpains while breastfeeding
Correct answer: Saturating one pad in 15 minutes
Saturating a pad within 15 minutes signals postpartum hemorrhage requiring immediate assessment and intervention.
Question 3: A newborn's Apgar score at 1 minute is 6. What is the priority nursing action?
- Repeat the score in 10 minutes
- Stimulate and provide respiratory support (Correct answer)
- Document and continue routine care
- Administer vitamin K immediately
Correct answer: Stimulate and provide respiratory support
A 1-minute Apgar of 6 indicates moderate distress, so stimulation and respiratory support are the priority.
Question 4: A pregnant client at 28 weeks has a glucose challenge test result of 150 mg/dL. What does the nurse anticipate next?
- Starting insulin therapy
- A 3-hour glucose tolerance test (Correct answer)
- Immediate cesarean planning
- No further testing needed
Correct answer: A 3-hour glucose tolerance test
A 1-hour value of 140 mg/dL or higher requires a 3-hour glucose tolerance test to confirm gestational diabetes.
Question 5: Which sign indicates a positive Homans sign in a postpartum client?
- Pain with dorsiflexion of the foot (Correct answer)
- Swelling of the breasts
- Tenderness over the fundus
- Burning on urination
Correct answer: Pain with dorsiflexion of the foot
A positive Homans sign is calf pain with dorsiflexion, suggesting possible deep vein thrombosis.
Question 6: A breastfeeding mother reports cracked, sore nipples. What is the best nursing recommendation?
- Limit feeding to 5 minutes per side
- Ensure proper latch and positioning (Correct answer)
- Switch to formula temporarily
- Apply alcohol to harden the nipples
Correct answer: Ensure proper latch and positioning
Improper latch is the most common cause of sore nipples, so correcting positioning resolves the problem.
Question 7: A newborn is diagnosed with physiologic jaundice. When does this typically appear?
- Within the first 24 hours
- After 24 hours of life (Correct answer)
- Only after 2 weeks
- Immediately at birth
Correct answer: After 24 hours of life
Physiologic jaundice appears after 24 hours, whereas jaundice within the first 24 hours is pathologic.
NCLEX Maternal and Newborn Nursing 2
A laboring client at 6 cm dilation suddenly reports a strong urge to push.
What should the nurse do first?