Maternity Exam 1 NCLEX Qs Advanced Test 2023/2024

A laboring woman is lying in the supine position. The most appropriate nursing action is to: a. Ask her to turn to one side. b. Elevate her feet and legs. c. Take her blood pressure. d. Determine whether there is fetal tachycardia. - answers a. may cause heavy uterus to put pressure on the vena cava. reducing blood to her heart. relieved by having her turn to one side. Which action best explains the main role of surfactant in the neonate? A) Assists with ciliary body maturation in the upper airways B) Helps maintain a rhythmic breathing pattern C) Promotes clearing mucus from the respiratory tract D) Helps the lungs remain expanded after the initiation of breathing - answers D) Helps the lungs remain expanded after the initiation of breathing Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: 1.Tell the woman she can rest after she feeds her baby 2.Recognize this as a behavior of the taking-hold stage 3.Record the behavior as ineffective maternal-newborn attachment 4.Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time - answers 4. Response 1 does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby Which anticipatory guidance action by the nurse makes role transition to parenthood easier? a. Helps the new parents identify resources b. Recommends employing babysitters frequently c. Tells the parents about the realities of parenthood d. Offers a home phone number and tells parents to call if they have a question - answers A Available resources within the community can assist the parents in role transition. Some parents may not be able to afford babysitters. Also, this removes them from the parenthood role. Each adult sees parenthood in a different light. They cannot be compared. Searching out resources for the parents is an important task. However, the nurse should not give her personal number to clients. A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? A) Negative Coombs test B) Bleeding from the nose and ear C) Jaundice after the first 24 hours of life D) Jaundice within the first 24 hours of life - answers D The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result To promote bonding and attachment immediately after birth, which action should the nurse take? a. Assist the mother in feeding her baby. b. Allow the mother quiet time with her infant. c. Teach the mother about the concepts of bonding and attachment. d. Assist the mother in assuming an en face position with her newborn. - answers D Assisting the mother in assuming an en face position with her newborn will support the bonding process. After birth is a good time to initiate breastfeeding, but first the mother needs time to explore the new infant and begin the bonding process. The mother should be given as much privacy as possible; however, nursing assessments must still be continued during this critical time. The mother has just delivered and is more focused on the infant; she will not be receptive to teaching at this time. The term reciprocal attachment behavior refers to which of the following? a. Behavior during the sensitive period when the infant is in the quiet alert stage b. Positive feedback an infant exhibits toward parents during the attachment process c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact d. Behavior by the infant during the sensitive period to elicit feelings of "falling in love" from the parents - answers B In this definition, reciprocal refers to the feedback from the infant during the attachment process. The quiet alert state is a good time for bonding but does not define reciprocal attachment. Reciprocal attachment deals with feedback behavior and is not unidirectional. Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the physician of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the client in emptying her bladder. - answers d. urinary retention can cause distention of the bladder. which will lift and displace uterus it will go up and right. this intervention needs to be done before we notify doc. if we do the intervention and she still is distended then we need to call doc. and then do fundal massage. Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching? 1. The vaccine is safe in clients with egg allergies 2. Breast-feeding isn't compatible with the vaccine 3. Transient arthralgia and rash are common adverse effects 4. The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects - answers 4. The client must understand that she must not become pregnant for 3 months after the vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck eggs so an allergic reaction may occur in clients with egg allergies. The virus is not transmitted into the breast milk, so clients may continue to breastfeed after the vaccination. Transient arthralgia and rash are common adverse effects of the vaccine. The best way for the nurse to promote and support the maternal-infant bonding process is to: a. Help the mother identify her positive feelings toward the newborn. b. Encourage the mother to provide all newborn care. c. Assist the family with rooming-in. d. Return the newborn to the nursery during sleep periods. - answers c. we want to have close and frequent interaction between baby and mom. best facilitated by rooming in helping her identify her feelings is helpful but not the first priority A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate? A) Document the findings B) Contact the physician C) Circle the amount of bloody drainage on the dressing and reassess in 30 minutes D) Reinforce the dressing - answers A) Document the findings yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician. Because the findings identified in the question are normal, the nurse would document the assessment. Fran delivered a 9 lb, 10 oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch diameter puddle of blood. What is your first action? a. Call for help b. Assess the fundus for firmness c. Take her blood pressure d. Check the perineum for lacerations - answers B Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated. A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? A) Hypotension and Bradycardia B) Tachypnea and retractions C) Acrocyanosis and grunting D) The presence of a barrel chest with grunting - answers B) Tachypnea and retractions : The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? 1. Retained placental fragments 2. Urinary tract infection 3. Cervical laceration 4. Uterine atony - answers 3. Continuous seepage of blood may be due to cervical or vaginal lacerations if the uterus is firm and contracting. Retained placental fragments and uterine atony may cause subinvolution of the uterus, making it soft, boggy, and larger than expected. UTI won't cause vaginal bleeding, although hematuria may be present. A first-time father is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, which point should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak at 5 to 7 mg/dL between the second and fourth days of life. d. This condition is also known as breast milk jaundice. - answers c. bilirubin of this type peaks at 5 between 2 to 4 days of life. within normal limits patho in 24 hours and is caused by blood incompatibility breast fed is by 2 weeks of life and is caused by breast milk insufficiency. After giving birth to a healthy infant boy, a primiparous woman, 16 years old, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is Risk for impaired parenting related to deficient knowledge of newborn care. In planning for the woman's discharge, what should the nurse be certain to include in the plan of care? a. Instruct the patient how to feed and bathe her infant. b. Give the patient written information on bathing her infant. c. Advise the patient that all mothers instinctively know how to care for their infants. d. Provide time for the patient to bathe her infant after she views an infant bath demonstration. - answers d. Provide time for the patient to bathe her infant after she views an infant bath demonstration. Having the mother demonstrate infant care is a valuable method of assessing the client's understanding of her newly acquired knowledge, especially in this age group, because she may inadvertently neglect her child. During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting-go b. Taking-in c. Taking-on d. Taking-hold - answers A Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment. In the taking-in phase, the mother is primarily focused on her own needs. There is no taking-on phase of maternal adjustment. During the taking-hold phase, the mother assumes responsibility for her own care and shifts her attention to the infant The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is to: a. Tell the mother she must pay attention to her infant. b. Show the mother how the infant initiates interaction and pays attention to her. c. Demonstrate for the mother different positions for holding her infant while feeding. d. Arrange for the mother to watch a video on parent-infant interaction. - answers b. Show the mother how the infant initiates interaction and pays attention to her. A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately: A) Wrap the tape measure around the infant's head and measure just above the eyebrows. B) Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes C) Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes D) Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth - answers C) Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes To measure the head circumference, the nurse should place the tape measure under the infant's head, wrap the tape around the occiput, and measure just above the eyebrows so that the largest area of the occiput is included. New parents are asked to sign the consent for their son to be circumcised. They ask for the nurse's opinion of the procedure. How should the nurse respond? 1. "You should talk to the physician about this if you have any questions." 2. "Let's talk about it because there are advantages and disadvantages." 3. "It is a safe procedure and it is best for male infants to be circumcised." 4. "Although it may be a somewhat painful experience for the baby, I would allow it if I were you." - answers 2 This response permits exploration of the parents' wishes and leads to assisting them in making their own decision. 1 This response blocks further discussion; the nurse can answer some of the questions and refer those that cannot be answered to the practitioner. 3 This is a value judgment; it denies the parents' right to decide. 4 This response might frighten the parents; it denies the parents their power of decision. Mosbys NCLEX review The nurse is caring for a client who is in the taking-in phase of the postpartum period. The area of health teaching that the client will be most responsive to is: 1. Perineal care 2. Infant feeding 3. Infant hygiene 4. Family planning - answers 1 During the taking-in phase a woman is primarily concerned with being cared for and being cared about. 2 This is best taught during the taking-hold phase of postpartum adjustment. 3 This is best taught during the taking-hold phase of postpartum adjustment. 4 This is not a primary concern during the immediate postpartum period. Mosbys NCLEX review A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: A) Subcutaneous injection B) Intravenous injection C) Instillation of the preparation into the lungs through an endotracheal tube D) Intramuscular injection - answers C) Instillation of the preparation into the lungs through an endotracheal tube The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube. A postpartum adolescent mother confides to the nurse that she hopes her baby will be good and sleep through the night. What should the nurse plan to teach the client to do? 1. Talk softly and cuddle her baby when crying occurs 2. Keep her baby awake for longer periods during the day 3. Ensure sleep by adding cereal to her baby's bedtime bottle 4. Put a soft and brightly colored toy next to her baby at bedtime - answers 1 The mother needs to learn the realities of infant behaviors and how to cope with them; holding and talking to her infant are consoling measures. 2 It is unhealthy to disrupt a neonate's sleep pattern. 3 The infant is too young to be given cereal. 4 At this age a toy is not meaningful and is an inadequate substitute for parental attention. Mosbys NCLEX review The husband of a woman who had her fourth child 3 weeks ago states she has been irritable and crying since bringing her newborn home. The nurse tries to assist him in understanding the situation by stating that: 1. Having four children is tiring and assistance may be needed 2. His wife probably has postpartum blues and it will soon pass 3. This behavior is common after birth and he should not be too concerned 4. Women often express themselves by crying and he should allow her to continue - answers 1 This statement acknowledges the situation and suggests a possible solution to the problem. 2 Postpartum blues occurs earlier; this may be postpartum depression and should not be dismissed lightly. 3 This response is not only false reassurance, but it does not address the problem that is evident in the situation. 4 This is stereotyping and nontherapeutic. Mosbys NCLEX review What common concern of the mother after an unexpected cesarean birth should the nurse anticipate? 1. Postoperative pain 2. Prolonged period of hospitalization 3. Inability to assume the mothering role 4. Sense of failure in the birthing process - answers 4 An unplanned cesarean birth can result in guilt, disappointment, anger, and a sense of failure as a woman. 1 This is not usually a common concern. 2 The hospital stay is not exceptionally prolonged; the client usually is discharged within 2 to 4 days. 3 Mothers who have had a cesarean birth can assume the mothering role to the same degree as women who have had a vaginal birth. Mosbys NCLEX review A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn? A) Sleepiness B) Cuddles when being held C) Lethargy D) Incessant crying - answers D) Incessant crying A newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and posture rather than cuddle when being held. A nurse is instructing a client to cough and deep breathe after an emergency cesarean birth. The client says, "Get out of here