maternal nclex

7/21/2019 Maternal Nclex

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The nurse is counseling a couple who has sought information about conceiving. Thecouple asks the nurse to explain when ovulation usually occurs. Which statement by

the nurse is correct?Rationale:

Ovulation occurs 14 days before the first day of the menstrual period (A). Whileovulation can occur in the middle of the cycle, or 2 weeks after menstruation, this is

only true for a woman who has a perfect 28-day cycle. For many women, the lengthof their menstrual cycle varies.

A. Two weeks before menstruation

B. Immediately after menstruation

C. Immediately before menstruation

D. Three weeks before menstruation

SubmitIncorrect | Correct Answer: A

When preparing a class on newborn care for expectant parents, what content is

correct for the nurse to teach concerning the newborn infant born at term gestation?Rationale:

Vernix, found in the folds of the skin, is a characteristic of term infants (C). Milia (A)are not red marks made by forceps but are white, pinpoint spots usually found over

the nose and chin that represent blockage of the sebaceous glands. Meconium is thefirst stool (B) but it is tarry-black, not yellow. (D) (crossed eyes) is normal at birth

and up through the third or fourth month, but does not require surgery.

A. Milia are red marks made by forceps and will disappear

within 7 to 10 days.

B. Meconium is the first stool and is usually yellow gold incolor.

C. Vernix is a white, cheesy substance, predominantly

located in the skin folds.

D. Pseudostrabismus found in newborns is treated by minorsurgery.

SubmitCorrect | Correct Answer: C

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeedingmy first child, but I would like to try with this baby." Which intervention should the

nurse implement first?

Rationale:Infants respond to breastfeeding best when feeding is initiated in the active phase

soon after delivery (D). (A and B) might provide interesting data, but gathering this

information is not as important as providing support and instructions to the newmother. While (C) is also true, this response by the nurse might seem judgmental to

a new mother.

A. Assess the husband's feelings about his wife's decision tobreastfeed their baby.

B. Ask the woman to describe why she was unsuccessful with

breastfeeding her last child.

C. Encourage the woman to develop a positive attitude aboutbreastfeeding to help ensure success.


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C. Allow the cord to air dry as much as possible.

D. Apply baby lotion after the baby's daily bath.


A client at 32 weeks of gestation is hospitalized with severe pregnancy-induced

hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms.Which assessment finding indicates that therapeutic drug levels have been achieved?

Rationale:Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased

respiratory rate (C) indicates that the drug is effective. However, a respiratory ratebelow 12 indicates toxic effects. (A) indicate high CNS irritability. Urinary output

must be monitored when administering magnesium sulfate and should be at least 30ml per hour. (B) indicates that the magnesium sulfate is not at a toxic level, but does

not indicate that a therapeutic level has been achieved. (D) is not specifically relatedto magnesium sulfate. The therapeutic level of magnesium sulfate for a PIH client is

4.8 to 9.6 mg/dl.

A. Deep tendon reflexes increase to 4+.

B. Urinary output increases to 50 ml/hr.C. Respiratory rate decreases from 24 to 16.

D. Body temperature decreases to 97.8 F.


REVIEW MODE: MaternityQuestion 8 of 50

HomeCalculatorHelp BackNextClient teaching is an important part of the perinatal nurse's role. Which factor has

the greatest influence on successful teaching of the pregnant client?Rationale:

When teaching any client, readiness to learn is related to how much the client hasinvested in what is being taught (A), or how important the material is to their

particular life. For example, the client with severe morning sickness in the firsttrimester may not be "ready to learn" about labor and delivery, but is probably very

"ready to learn" about ways to relieve morning sickness. (B and C) are factors thatmay influence learning, but they are not as influential as (A). Even if a pregnancy is

planned and very desirable (D), the client must be ready to learn the contentpresented.

A. The client's investment in what is being taught

B. The couple's highest levels of education

C. The order in which the information is presented

D. The extent to which the pregnancy was planned


The nurse is using the Silverman-Anderson index to assess an infant with respiratory

distress and determines that the infant is demonstrating marked nasal flaring, anaudible expiratory grunt, and just visible intercostal and xiphoid retractions. Which

score should the nurse assign using this scale?Rationale:

The Silverman-Anderson index is an assessment scale that scores a newborn's


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respiratory statusgrade 0, 1, or 2 for each component, which includes synchrony ofthe chest and abdomen, retractions, nasal flaring, and expiratory grunt. No

respiratory distress is graded 0, a total of 10 indicates maximum respiratory distress.This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is

assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plusgrade one for just visible retractions, which is a total score of 5 (C). (A, B, and D)

are not accurate.A. 3

B. 4

C. 5

D. 8


in this infant's discharge teaching plan?Rationale:

It is important that the hips of infants with hip dysplasia are maintained in anabducted position, which can be accomplished by using the Pavlik harness (A), which

keeps the hips and knees flexed, the hips abducted, and the femoral head in theacetabulum. Early treatment often negates the need for surgery, and (B) is not

indicated until approximately 6 months of age. (C) is not indicated for hip dysplasia.It is best for the pediatrician to monitor hip joint mobility, and teaching the parents

to perform this technique is likely to increase their anxiety (D).

A. Observe the parents apply a Pavlik harness.

B. Provide a referral for an orthopedic surgeon.

C. Schedule a physical therapy follow-up home visit.

D. Teach the parents to check for hip joint mobility.


Which maternal behavior is the nurse most likely to see when a new mother receivesher infant for the first time?

Rationale:Attachment/bonding theory indicates that most mothers will demonstrate behaviors

described in (B) during the first visit with the newborn, which may be at delivery orlater. After the first visit, the mother may exhibit different touching behaviors such

as eagerly reaching for the infant and cuddling the infant close to her (A, C, and D).

A. She eagerly reaches for the infant, undresses the infant,and examines the infant completely.

B. Her arms and hands receive the infant and she then traces

the infant's profile with her fingertips.

C. Her arms and hands receive the infant and she thencuddles the infant to her own body.

D. She eagerly reaches for the infant and then holds the infant

close to her own body.

SubmitCorrect | Correct Answer: B

head." Which response by the nurse is best?


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B. The anterior fontanel closes at 5 to 7 months and the

posterior by the end of the second week.

C. The anterior fontanel closes at 8 to 11 months and theposterior by the end of the first month.

D. The anterior fontanel closes at 12 to 18 months and the

posterior by the end of the second month.

SubmitIncorrect | Correct Answer: D

A new mother asks the nurse, "How do I know that my daughter is getting enough

breast milk?" Which explanation is appropriate?Rationale:

The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day) (B), if theinfant is adequately hydrated. Although a weight gain (A) of 30 grams/day is

indicative of adequate nutrition, most home scales do not measure this accuratelyand this suggestion is likely to make the mother very anxious. (C) causes nipple

confusion and diminishes the mother's milk production. (D) does not answer theclient's question.

A. "Weigh the baby daily, and if she is gaining weight, she isgetting enough to eat."

B. "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day."

C. "Offer the baby extra bottle milk after her feeding, and see

if she is still hungry."

D. "If you're concerned, you might consider bottle feeding sothat you can monitor her intake."

SubmitIncorrect | Correct Answer: B

During the transition phase of labor, a client complains of tingling and numbness inher fingers and tells the nurse that she feels like she is going to pass out. What

action should the nurse take?Rationale:

Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, andcauses transient respiratory alkalosis, so the client should cup both hands over her

mouth and nose (D) so she can rebreathe carbon dioxide. (A, B, and C) do not help

restore carbon dioxide levels as effectively as rebreathing air in the cupped hands, orfrom a paper bag.

A. Encourage her to pant between contractions and blow withcontractions.

B. Coach her to take a deep cleansing breath and then

refocus.C. Instruct her to pant three times and then exhale through

pursed lips.

D. Have her cup both hands over her nose and mouth while

breathing.



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The nurse is evaluating a full-term multigravida who was induced 3 hours ago. Thenurse determines the client is dilated 7 cm, is 100% effaced at 0 station, with intact

membranes. The monitor indicates the fetal heart rate (FHR) decelerates at theonset of several contractions and returns to baseline before each contraction ends.

What action should the nurse take?Rationale:

The fetal heart rate indicates early decelerations, which are not an ominous sign, sothe nurse should continue to monitor the labor progress (D) and document thefindings in the client's record. There is no reason to reapply the external transducer

(A) if the FHR tracings are being captured. (B and C) are not indicated at this time.

A. Reapply the external transducer.

B. Insert intrauterine pressure catheter.

C. Discontinue the oxytocin infusion.

D. Continue to monitor labor progress.

SubmitCorrect | Correct Answer: D

A mother who is breastfeeding her baby receives instructions from the nurse. Which

instruction is most effective in preventing nipple soreness?Rationale:

The most common cause of nipple soreness is incorrect positioning (C) of the infanton the breast for latch-on. The baby's body is in alignment with ears, shoulders, and

hips in a straight line with nose, cheeks, and chin touching the breast. (A) helpsprevent chafing and nonbinding support aids in prevention of discomfort from the

stretching of Cooper's ligament. (B) is important, but is not necessary for all women.(D) helps soften an engorged breast and encourages correct infant latch-on, but is

not the best answer.

A. Wear a cotton bra with nonbinding support.

B. Increase nursing time gradually over several days.

C. Ensure that the baby is positioned correctly for latch-on.

D. Manually express a small amount of milk before nursing.


A client who delivered a healthy infant 5 days ago calls the clinic nurse and reportsthat her lochia is getting lighter in color and asks when the flow will stop. How should

the nurse respond?Rationale:

The placenta site in the uterus usually heals (C) in 3 to 6 weeks, and the lochial flowshould cease at that time. Between 2 and 6 weeks after childbirth period, lochia alba

occurs in most women (A). The client is describing lochia serosa, a normal change inthe lochial flow (B) between day 3 or 4 after childbirth and lasts to about day 10. (D)

does not give the client the best information because ovulation varies in thepostpartum period and is influenced by lactation and hormonal responses as the

client's usual menstrual cycle resumes.

A. 2 weeks

B. 10 days

C. When the placenta site has healed

D. After the first time ovulation occurs

Submit


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Incorrect | Correct Answer: CA 41-week multigravida is receiving oxytocin (Pitocin) to augment labor.

Contractions are firm and occurring every 5 minutes, with a 30- to 40-secondduration. The fetal heart rate increases with each contraction and returns to the

baseline after the contraction. What action should the nurse implement?Rationale:

The goal of labor augmentation is to produce firm contractions that occur every 2 to3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress.

Fetal heart rate accelerations are a normal response to contractions, so the Pitocininfusion should be increased (D) per protocol to stimulate the frequency and

intensity of contractions. (A and C) are indicated for fetal stress. A sterile vaginalexam (B) places the client at risk for infection and should be performed when the

client exhibits signs of progressing labor, which is not indicated at this time.

A. Place a wedge under the client's left side.

B. Determine cervical dilation and effacement.

C. Administer 10 L of oxygen via face mask.

D. Increase the rate of the Pitocin infusion.


A client comes to the OB clinic for her first prenatal visit, and complains of feeling

nauseated every morning. The client tells the nurse, "I'm having second thoughts

about wanting to have this baby." Which response is best for the nurse to make?Rationale:

While ambivalence is normal during the first trimester, (D) is the best nursingresponse at this time. It is reflective and keeps the lines of communication open. (A)

is not the best response because it offers false reassurance. (B) dismisses the client'sfeelings. In addition, the nurse should use communication skills that encourage this

type of discussion, not shift responsibility to the care provider. While (C) mayeventually be discussed, it is not the most important information to obtain at this

time.

A. "It's normal to feel ambivalent about a pregnancy whenyou are not feeling well."

B. "I think you should discuss these feelings with your

healthcare provider."

C. "How does the father of your child feel about your havingthis baby?"

D. "Tell me about these second thoughts you are having

about this pregnancy."


A new mother is having trouble breastfeeding her newborn son. He is making franticrooting motions and will not grasp the nipple. Which intervention should the nurse

implement?Rationale:

The infant is becoming frustrated and so is the mother; both need a "time-out." Themother should be encouraged to comfort the infant and to relax herself (C). After

such a "time-out," breastfeeding is often more successful. (A and D) would causenipple confusion. (B) would only cause the infant to be more resistant and both the

mother and infant to be more frustrated.


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A. Encourage frequent use of a pacifier so the infant becomes

accustomed to sucking.

B. Hold the infant's head firmly against the breast until helatches onto the nipple.

C. Encourage the mother to stop feeding for a few minutes

and comfort the infant.

D. Provide formula for the infant until he becomes calm andthen offer the breast again.


An expectant father tells the nurse he fears that his wife "is losing her mind." He

states she is constantly rubbing her abdomen and talking to the baby, and that she

actually reprimands the baby when it moves too much. What recommendationshould the nurse make to this expectant father?

Rationale:

These behaviors are positive signs of maternal/fetal bonding (D) and do not reflect

ambivalence (B). No intervention is needed. Quickening, the first perception of fetalmovement, occurs at 17 to 20 weeks of gestation and begins a new phase ofprenatal bonding during the second trimester. (A and C) are not necessary because

the behaviors displayed are normal.

A. Suggest that his wife seek professional counseling to dealwith her symptoms.

B. Explain that his wife is exhibiting ambivalence about the

pregnancy.

C. Ask him to report similar abnormal behaviors at the nextprenatal visit.

D. Reassure him that normal maternal/fetal bonding is

occurring.Submit

Incorrect | Correct Answer: DTwenty minutes after a continuous epidural anesthetic is administered, a laboringclient's blood pressure drops from 120/80 to 90/60. What action should the nurse

take immediately?Rationale:

The nurse should immediately turn the client to a lateral position (C) or place apillow or wedge under one hip to deflect the uterus. Other immediate interventions

include increasing the rate of the main line IV infusion and administering oxygen byface mask at 10 to 12 L/min. If the blood pressure remains low after these

interventions or decreases further, the anesthesiologist/healthcare provider should

be notified immediately (A). (B), without taking any further action, would constitutemalpractice. (D) may also be warranted, but such action is based on hospitalprotocol.

A. Notify the healthcare provider or anesthesiologist

immediately.

B. Continue to assess the blood pressure every 5 minutes.

C. Place the client in a lateral position.

D. Turn off the continuous epidural.


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A client at 28 weeks of gestation calls the antepartal clinic and states that she just

experienced a small amount of vaginal bleeding, which she describes as bright red.

The bleeding has subsided. She further states that she is not experiencing anyuterine contractions or abdominal pain. What instruction should the nurse provide?

Rationale:Third trimester painless bleeding is characteristic of a placenta previa. Bright redbleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first

incidence life threatening, nor cause for hypovolemic shock. Diagnosis is confirmedby transabdominal ultrasound (A). Bleeding that has a sudden onset and is

accompanied by intense uterine pain indicates abruptio placenta, which is lifethreatening to the mother and fetus. If those symptoms were described then (B)

would be appropriate. (C) does not address the cause of the symptoms. The client isnot describing symptoms of a UTI (D).

A. "Come to the clinic today for an ultrasound."

B. "Go immediately to the emergency department."

C. "Lie on your left side for about 1 hour and see if the

bleeding stops."

D. "Bring a urine specimen to the lab tomorrow to determine

if you have a urinary tract infection."


A 26-year-old gravida 2, para 1 client is admitted to the hospital at 28 weeks of

gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25mg subcutaneously to stop her labor contractions. The nurse plans to monitor for the

primary side effects of terbutaline sulfate, which areRationale:

Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-

adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergicagonist properties of the drug may cause tachycardia, increased cardiac output,restlessness, headache, and a feeling of "nervousness" (C). (A) is not a side effect.

(B and D) are side effects of magnesium sulfate.

A. drowsiness and paroxysmal bradycardia.

B. depressed reflexes and increased respirations.

C. tachycardia and a feeling of nervousness.

D. a flushed, warm feeling and a dry mouth.

SubmitIncorrect | Correct Answer: C

A client at 30 weeks of gestation is on bedrest at home because of increased blood

pressure. The home health nurse has taught her how to take her own blood pressureand given her parameters to judge a significant increase in blood pressure. When the

client calls the clinic complaining of indigestion, which instruction should the nurseprovide?

Rationale:

Checking the blood pressure for an elevation (C) is the best instruction to give at thistime. A blood pressure exceeding 140/90 or increased by 15 mm Hg diastolic and/or

30 mm Hg systolic is indicative of preeclampsia. Epigastric pain can be a sign of animpending seizure (eclampsia), a life-threatening complication of PIH. Additional


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data are needed to confirm an emergency situation as described in (A). (B and D)ignore the threat to client safety posed by a significant increase in blood pressure.

A. "Lie on your left side and call 911 for emergency

assistance."

B. "Take an antacid and call back if the pain has not subsided

within 1 hour."C. "Take your blood pressure now, and if it is seriously

elevated, go to the hospital."

D. "See your healthcare provider to obtain a prescription for a

histamine-blocking agent."


A 25-year-old client has a positive pregnancy test. One year ago she had aspontaneous abortion at 3 months of gestation. What is the correct description of

this client that should be documented in the medical record?

Rationale:

This is the client's second pregnancy or second "gravid" event, so (C) is correct. Thespontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks),so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of

gestation or beyond. (A) does not take into account the current pregnancy nor does(B), which also counts the miscarriage as a "para," an incorrect recording. While (D)

is correct concerning gravidity, para 1 is incorrect.

A. Gravida 1, para 0

B. Gravida 1, para 1

C. Gravida 2, para 0

D. Gravida 2, para 1

Submit

Incorrect | Correct Answer: CThe nurse instructs a laboring client to use accelerated-blow breathing. The clientbegins to complain of tingling fingers and dizziness. What action should the nurse

take?Rationale:

Tingling fingers and dizziness are signs of hyperventilation (blowing off too muchcarbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be

facilitated by breathing into a paper bag or cupped hands (C). (A) is inappropriate

since the carbon dioxide level is low, not the oxygen level. (B and D) are not specificfor this situation.

A. Administer oxygen by face mask.

B. Notify the healthcare provider of the client's symptoms.

C. Have the client breathe into her cupped hands.D. Check the client's blood pressure and fetal heart rate.


One hour following a normal vaginal delivery, a newborn infant boy's axillarytemperature is 96 F, his lower lip is shaking, and when the nurse assesses for a

Moro reflex, his hands shake. What intervention should the nurse implement first?


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Rationale:This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body

temperature. The nurse should first determine the serum glucose level (D). (A) is anintervention for a lethargic infant. (B) should be done based on the temperature, but

first the glucose level should be obtained. (C) helps to raise the blood sugar, but firstthe nurse should determine the glucose level.

A. Stimulate the infant to cry.B. Wrap the infant in warm blankets.

C. Feed the infant formula.

D. Obtain a serum glucose level.


When reviewing the laboratory findings of a pregnant woman, the nurse determines

that the alpha-fetoprotein (AFP) level is elevated. What information is mostimportant for the nurse to use when interpreting this finding?

Rationale:Correct interpretation of concentration of AFP requires precise knowledge of

gestational age (A). High levels after 15 weeks of gestation can indicate a neuraltube defect, such as spina bifida and anencephaly. (B, C, and D) are all important

data to gather when assessing an antepartal client, but they do not have theimportance of (A) in assessing AFP.

A. Gestational age

B. Maternal age

C. Urine protein

D. Parity


A 38-week primigravida who works as a secretary and sits at a computer 8 hours

each day tells the nurse that her feet have begun to swell. Which instruction will aidin the prevention of pooling of blood in the lower extremities?

Rationale:Pooling of blood in the lower extremities results from the enlarged uterus exerting

pressure on the pelvic veins. Moving about every hour (C) will straighten out thepelvic veins and increase venous return. (A) would increase venous return from

varicose veins in the lower extremities, but would be of little help with swelling. (B)might be helpful with generalized edema (which could be an indication of PIH) but is

not specific for edematous lower extremities. (D) does not specifically addressvenous return in this particular case. There is no indication in the question that

constrictive clothing is a problem.

A. Wear support stockings.

B. Reduce salt in the diet.

C. Move about every hour.

D. Avoid constrictive clothing.


A mother expresses fear about changing the infant's diaper after circumcision. Whichinformation should the nurse include in the teaching plan?


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Rationale:With each diaper change, the glans penis should be washed with warm water to

remove any urine or feces and petroleum ointment (C) should be applied to preventthe diaper from sticking to the healing surface. Prepackaged wipes (A) often contain

other products that may irritate the site. The yellow exudate, which covers the glanspenis as the area heals and epithelializes, is not an infective process and should not

be removed (B). If bleeding occurs at home, the client should be instructed to applygentle pressure (D) to the site of the bleeding with a sterile gauze square and callthe healthcare provider.

A. Cleanse the penis with prepackaged diaper wipes every 3

to 4 hours.

B. Wash off the yellow exudate on the glans once every day

to prevent infection.

C. Place petroleum ointment around the glans with each

diaper change and cleansing.

D. Apply pressure by squeezing the penis with the fingers for

5 minutes if bleeding occurs.


A client in active labor is becoming increasingly fearful because her contractions areoccurring more often than she expected. Her partner is also becoming anxious. The

nurse's response should focus on which content?Rationale:

Offering to remain with the client and her partner (C) offers support withoutproviding false reassurance. The length of labor is not always predictable, but (A and

B) do not offer the client the support that is needed at this time. (D) may bereassuring regarding the fetal heart rate, but it does not provide the client the

emotional support she needs at this time during the labor process.

A. Telling the client and her partner that the labor process is

often unpredictable

B. Informing the client that this means she will give birth

sooner than expected

C. Asking the client and her partner if they would like the

nurse stay in the room

D. Affirming that the fetal heart rate is remaining within

normal limits


The nurse observes an antepartum client, on bedrest for preterm labor, eating ice

rather than the food on her breakfast tray. The client states that she has beencraving ice and then feels too full to eat anything else. What is the best response bythe nurse?

Rationale:The healthcare provider should be notified (D) when a client practices pica (craving

for and consumption of nonfood substances). The practice of pica may displace more

nutritious foods from the diet and the client should be evaluated for anemia. (A) isoverreacting and may be perceived as punishment by the patient. (B) allows the

dietary department to customize the client's tray, but fails to address physiologic


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encouraged not to smoke during pregnancy. (A, C, and D) have not been clearlyassociated with smoking during pregnancy, but there is a strong correlation between

smoking and lower birth weights.

A. Lower Apgar score recorded at delivery

B. Lower initial weight documented at birth

C. Higher oxygen use to stimulate breathingD. Higher prevalence of congenital anomalies


On admission to the prenatal clinic, a client tells the nurse that her last menstrualperiod began on February 15 and that previously her periods were regular (28-day

cycle). Her pregnancy test is positive. What is this client's expected date of birth(EDB)?

Rationale:(A) correctly applies Ngele's rule for estimating the due date by counting back 3

months from the first day of the last menstrual period (January, December,November) and adding 7 days (15 + 7 = 22). (B, C, and D) are not correctly

calculated.A. 22-Nov

B. 8-Nov

C. 22-Dec

D. 22-Oct


The nurse calls a client who is 4 days postpartum to follow-up about her transition

with her newborn son at home. The woman tells the nurse, "I don't know what iswrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which

adjustment phase should the nurse determine the client is experiencing?

Rationale:During the postpartum period when serum hormone levels fall, women are

emotionally labile, often crying easily for no apparent reason. This phase iscommonly called postpartum blues (B), which peaks around the fifth postpartum

day. The taking-in phase (A) is the period following birth when the mother focuseson her own psychological needs, typically this period lasts for 24 hours. Crying is not

a maladaptive attachment response (C). It indicates a normal physical and emotionalresponse. The letting-go phase (D) is when the mother sees the child as a separate

individual.

A. Taking-in phase

B. Postpartum blues

C. Attachment difficultyD. Letting-go phase


A client who is 3 days postpartum and breastfeeding asks the nurse how to reducebreast engorgement. Which instruction should the nurse provide?

Rationale:The mother should be instructed to attempt feeding her infant every 2 hours (B)

while massaging the breasts as the infant is feeding. If the infant does not feed


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adequately and empty the breast, using a breast pump (A) helps to extract the milkand relieve some of the discomfort. Dehydration irritates swollen breast tissue (C).

Skipping feedings (D) may cause further engorgement and discomfort.

A. Avoid using the breast pump.

B. Breastfeed the infant every 2 hours.

C. Reduce fluid intake for 24 hours.D. Skip feedings to let the sore breasts rest.


The nurse is counseling a client who wants to become pregnant. She tells the nursethat she has a 36-day menstrual cycle and the first day of her last menstrual period

was January 8. When will the client's next fertile period occur?Rationale:

This client can expect her next period to begin 36 days from the first day of her lastmenstrual period. Her next period would begin on February 12. Ovulation occurs 14

days before the first day of the menstrual period. The client can expect ovulation tooccur January 29 to 30 (C).

A. January 14 to 15

B. January 22 to 23

C. January 29 to 30

D. February 6 to 7


An off-duty nurse finds a woman in a supermarket parking lot delivering an infant

while her husband is screaming for someone to help his wife. Which intervention has

the highest priority?Rationale:

Putting the newborn to breast (D) will help contract the uterus and prevent a

postpartum hemorrhage. This intervention has the highest priority. (A) is notnecessary; the infant can be transported attached to the placenta. (B) is an

important psychosocial need, but does not have the priority of (D). Although thehusband is an important part of family-centered care, he is not the most important

concern at this time (C).

A. Use thread to tie off the umbilical cord.

B. Provide as much privacy as possible for the woman.

C. Reassure the husband and try to keep him calm.

D. Put the newborn to breast.


A breastfeeding postpartum client is diagnosed with mastitis and antibiotic therapy isprescribed. What instruction should the nurse provide to this client?

Rationale:Mastitis (caused by plugged milk ducts) is related to breast engorgement, and

breastfeeding during mastitis facilitates the complete emptying of engorged breasts(A), eliminating the pressure on the inflamed breast tissue. (B) is less painful but

does not facilitate complete emptying of the breast tissue. (C) will not relieve theengorgement on the affected side. (D) will not decrease antibiotic effects on the

infant.


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A. Breastfeed the infant, ensuring that both breasts are

completely emptied.

B. Feed expressed breast milk to avoid pain of infant latchingonto the infected breast.

C. Breastfeed on the unaffected breast only until the mastitis

subsides.

D. Dilute expressed breast milk with sterile water to reduceantibiotic effect on infant.


The nurse is preparing a laboring client for an amniotomy. Immediately after the

procedure is completed, it is most important for the nurse to obtain which

information?Rationale:

The FHR should be assessed before and after the procedure to detect changes that

may indicate presence of cord compression or prolapse (C). An amniotomy (artificial

rupture of membranes or AROM) is used to stimulate labor when the condition of thecervix is favorable. The fluid should be assessed for color, odor, and consistency. (A)should be assessed every 15 to 20 minutes during labor, but is not specific for

AROM. (B) is monitored hourly after the membranes are ruptured to detectdevelopment of amnionitis. (D) should be determined for all laboring clients.

A. Maternal blood pressure

B. Maternal temperature

C. Fetal heart rate

D. Serum white blood count (WBC)


When assessing a client at 12 weeks of gestation, the nurse recommends that sheand her husband consider attending childbirth preparation classes. When is the besttime for the couple to attend these classes?

Rationale:Learning is facilitated by an interested pupil. The couple is most interested in

childbirth toward the end of the pregnancy when they are beginning to anticipate theonset of labor and the birth of their child is an immediate concern. (D) is closest to

the time parents would be ready for such classes. (A, B, and C) are not the best

times during a pregnancy for the couple to attend childbirth education classes. Atthese times they will have other teaching needs. Early pregnancy classes often

include topics such as nutrition, anticipating physiologic changes and coping with

normal discomforts of pregnancy, fetal development, maternal and fetal risk factorsincluding warning signs to be aware of, and evolving roles of the mother and her

significant others.

A. At 16 weeks of gestation

B. At 20 weeks of gestation

C. At 24 weeks of gestation

D. At 30 weeks of gestation



19/19

A nurse receives shift change report for a newborn who is 12 hours post vaginaldelivery. In developing a plan of care, the nurse should give the highest priority to

which finding?Rationale:

Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin whichshould be further evaluated in a newborn less than 24 hours old (B). Acrocyanosis

(blue color of the hands and feet) is a common finding in newborns that occursbecause the capillary system is immature (A). Milia (C) are small white papulespresent on the nose and chin that are caused by a blockage of sebaceous glands,

which disappear in a few weeks. Small red patches on the cheeks and trunk (D) are

called erythema toxicum neonatorum, a common finding in newborns.

A. Cyanosis of both the hands and feet

B. Skin color that is slightly jaundiced

C. Tiny white papules on the nose or chin

D. Red patches on the cheeks and trunk


maternal nclex

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