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

Decreased fetal movement can indicate fetal distress. Kick counts should be performed: 10 movements in 2 hours is reassuring. Fewer movements warrant immediate provider notification.

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

Variable decelerations are caused by cord compression. Changing maternal position (lateral, knee-chest) relieves cord compression. Repositioning is the first-line nursing intervention.

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

Heart rate 90 (1 pt, <100), weak cry=2 pt (good effort=2), active motion=2 pt, grimace=1 pt, blue extremities=1 pt (acrocyanosis). Total = 7.

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

The rooting reflex causes the newborn to turn the head toward a touch on the cheek or mouth and open the mouth, helping to locate the breast or nipple for feeding.

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

Absent deep tendon reflexes (DTRs) and oliguria (urine output <30 mL/hr) are signs of magnesium toxicity, indicating the drug level is dangerously elevated and respiratory depression may follow.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Maternal and Newborn Nursing