NCLEX Maternal and Newborn Nursing 2

Question 1

A laboring client at 6 cm dilation suddenly reports a strong urge to push. What should the nurse do first?

Accepted Answer

Assess cervical dilation

Answer

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?

Accepted Answer

Saturating one pad in 15 minutes

Answer

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?

Accepted Answer

Stimulate and provide respiratory support

Answer

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?

Accepted Answer

A 3-hour glucose tolerance test

Answer

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?

Accepted Answer

Pain with dorsiflexion of the foot

Answer

A positive Homans sign is calf pain with dorsiflexion, suggesting possible deep vein thrombosis.

NCLEX Practice Test