NCLEX Maternal and Newborn Nursing 3 — Questions and Answers
Question 1: A client with preeclampsia is receiving magnesium sulfate. Which finding indicates magnesium toxicity?
- Brisk deep tendon reflexes
- Respiratory rate of 10 per minute (Correct answer)
- Blood pressure of 150/95
- Urine output of 50 mL/hour
Correct answer: Respiratory rate of 10 per minute
A respiratory rate below 12 indicates magnesium toxicity and requires stopping the infusion.
Question 2: What is the antidote for magnesium sulfate toxicity?
- Calcium gluconate (Correct answer)
- Naloxone
- Protamine sulfate
- Vitamin K
Correct answer: Calcium gluconate
Calcium gluconate reverses the effects of magnesium sulfate toxicity.
Question 3: A nurse is monitoring fetal heart rate and notes late decelerations. What is the priority action?
- Document as a normal finding
- Reposition the mother to her side (Correct answer)
- Increase the oxytocin infusion
- Prepare for immediate delivery
Correct answer: Reposition the mother to her side
Late decelerations indicate uteroplacental insufficiency, so repositioning to improve perfusion is the first action.
Question 4: A client at 38 weeks reports a gush of clear fluid from the vagina. What should the nurse assess first?
- Maternal blood pressure
- Fetal heart rate (Correct answer)
- Cervical effacement
- Maternal temperature
Correct answer: Fetal heart rate
After membrane rupture, fetal heart rate is assessed first to detect cord prolapse or distress.
Question 5: Which newborn reflex is checked by stroking the cheek and observing the head turn toward the stimulus?
- Moro reflex
- Rooting reflex (Correct answer)
- Babinski reflex
- Tonic neck reflex
Correct answer: Rooting reflex
The rooting reflex is elicited by stroking the cheek, causing the newborn to turn toward the touch to feed.
Question 6: A postpartum client who had an epidural is at increased risk for which complication?
- Hypertension
- Urinary retention (Correct answer)
- Hyperglycemia
- Tachycardia
Correct answer: Urinary retention
Epidural anesthesia reduces bladder sensation, increasing the risk of urinary retention.
Question 7: What is the recommended sleep position to reduce the risk of SIDS in newborns?
- Prone (on stomach)
- Supine (on back) (Correct answer)
- Side-lying
- Semi-Fowler's
Correct answer: Supine (on back)
Placing infants on their back to sleep significantly reduces the risk of sudden infant death syndrome.
NCLEX Maternal and Newborn Nursing 3
A client with preeclampsia is receiving magnesium sulfate.
Which finding indicates magnesium toxicity?