NCLEX Practice Questions On Maternal And Child Health Nursing

1. The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy. the nurse determines that the client understands the instructions when she says:

“Nausea and vomiting can be decreased if I eat a few crackers before arising.”

“If I start to leak colostrum. I should cleanse my nipples with soap and water.”

“If I have a vaginal discharge. I should wear nylon underwear.”

“Leg cramps can be alleviated if I put an ice pack on the area.”

Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.

Explanation

Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.

2. While the postpartum client is receiving heparin for thrombophlebitis. which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy?

Calcium gluconate

Protamine sulfate

Methylergonovine (Methergine)

Nitrofurantoin (Macrodantin)

Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications caused by heparin overdose.

Explanation

Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications caused by heparin overdose.

3. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis. the nurse tells the client that the usual treatment for partial placenta previa is which of the following?

Activity limited to bed rest

Platelet infusion

Immediate cesarean delivery

Labor induction with oxytocin

Treatment of partial placenta previa includes bed rest. hydration. and careful monitoring of the client’s bleeding.

Explanation

Treatment of partial placenta previa includes bed rest. hydration. and careful monitoring of the client’s bleeding.

4. The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan?

Feeding the neonate a maximum of 5 minutes per side on the first day

Wearing a supportive brassiere with nipple shields

Breast-feeding the neonate at frequent intervals

Decreasing fluid intake for the first 24 to 48 hours

Prevention of breast engorgement is key. The best technique is to empty the breast regularly with feeding. Engorgement is less likely when the mother and neonate are together. as in single room maternity care continuous rooming-in. because nursing can be done conveniently to meet the neonate’s and mother’s needs.

Explanation

Prevention of breast engorgement is key. The best technique is to empty the breast regularly with feeding. Engorgement is less likely when the mother and neonate are together. as in single room maternity care continuous rooming-in. because nursing can be done conveniently to meet the neonate’s and mother’s needs.

5. When the nurse on duty accidentally bumps the bassinet. the neonate throws out its arms. hands opened. and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes?

Startle reflex

Babinski reflex

Grasping reflex

Tonic neck reflex

The Moro. or startle. reflex occurs when the neonate responds to stimuli by extending the arms. hands open. and then moving the arms in an embracing motion. The Moro reflex. present at birth. disappears at about age 3 months.

Explanation

The Moro. or startle. reflex occurs when the neonate responds to stimuli by extending the arms. hands open. and then moving the arms in an embracing motion. The Moro reflex. present at birth. disappears at about age 3 months.

6. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert?

Endometritis

Endometriosis

Salpingitis

Pelvic thrombophlebitis

Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes.Option A: Endometriosis does not occur after a strong labor and prolonged rupture of membranes.Option B: Salpingitis is a tubal infection and could occur if endometritis is not treated.Option C: Pelvic thrombophlebitis involves a clot formation. but it is not a complication of prolonged rupture of membranes.

Explanation

Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes.Option A: Endometriosis does not occur after a strong labor and prolonged rupture of membranes.Option B: Salpingitis is a tubal infection and could occur if endometritis is not treated.Option C: Pelvic thrombophlebitis involves a clot formation. but it is not a complication of prolonged rupture of membranes.

7. A client at 36 weeks gestation is scheduled for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound. which of the following client statements would indicate to the nurse in charge that the client needs further instruction?

The ultrasound will help to locate the placenta

The ultrasound identifies blood flow through the umbilical cord

The test will determine where to insert the needle

The ultrasound locates a pool of amniotic fluid

Before amniocentesis. a routine ultrasound is valuable in locating the placenta. locating a pool of amniotic fluid. and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.

Explanation

Before amniocentesis. a routine ultrasound is valuable in locating the placenta. locating a pool of amniotic fluid. and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.

8. When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice. the nurse in charge would expect to do which of the following?

Turn the neonate every 6 hours

Encourage the mother to discontinue breastfeeding

Notify the physician if the skin becomes bronze in color

Check the vital signs every 2 to 4 hours

While caring for an infant receiving phototherapy for treatment of jaundice. vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights.

Explanation

While caring for an infant receiving phototherapy for treatment of jaundice. vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights.

9. A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client. which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective?

Back

Abdomen

Fundus

Perineum

A bilateral pudendal block is used for vaginal deliveries to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair.

Explanation

A bilateral pudendal block is used for vaginal deliveries to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair.

10. Forty-eight hours after delivery. the nurse in charge plans discharge teaching for the client about infant care. By this time. the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following?

Taking in

Letting go

Taking hold

Resolution

Beginning after completion of the taking-in phase. the taking-hold phase lasts about 10 days. During this phase. the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time. she is ready to learn self-care and infant care skills.

Explanation

Beginning after completion of the taking-in phase. the taking-hold phase lasts about 10 days. During this phase. the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time. she is ready to learn self-care and infant care skills.