NCLEX-PN Maternal And Women's Health Nursing
EAQ Questions And Answers Rated A+
A client making her first visit to the prenatal clinic asks which immunization can be
administered safely to a pregnant woman. What should the nurse tell her?
1
Rubella (measles)
2
Rubeola (German measles)
Correct 3
Inactive influenza
4
Varicella (chicken pox) - ANSWER The inactive influenza and diphtheria, tetanus,
pertussis (dTAP) immunizations can be safely administered during the first trimester of
pregnancy, although dTAP is recommended at 27 to 36 weeks gestation to provide
immunity to the mother and infant. The inactivated influenza vaccine may be given
because it is a killed virus vaccine and will not have a teratogenic effect. Rubella
(measles) and rubeola (German measles) vaccines are both live viruses that should
never be administered during pregnancy because they can have teratogenic effects.
Varicella (chicken pox) immunization is not given because it may cause birth defects in
the fetus.
During labor a client begins to experience dizziness and tingling of her hands. What
should the nurse instruct the client to do?
1
Breathe into her cupped hands
2
,Pant during the next three contractions
3
Hold her breath with the next contraction
4 - ANSWER Dizziness and tingling of the hands are signs of respiratory alkalosis, most
likely the result of hyperventilating. Breathing into cupped hands or a paper bag
promotes the rebreathing of carbon dioxide. Panting during the next three contractions
could cause the client to hyperventilate more. Holding her breath with the next
contraction will not improve the client's respiratory alkalosis. Using a fast, deep, or
shallow breathing pattern could cause the client to hyperventilate more.
A client gives birth vaginally, with a midline episiotomy, to an infant who weighs 8 lb 13
oz (4000 g). An ice pack is applied to the perineum to ease the swelling and pain. The
client complains, "This pain in my vaginal and rectum is excruciating, and my vagina
feels so full and heavy." What does the nurse suspect as the cause of the pain?
1
Full bladder
2
Vaginal hematoma
3
Infected episiotomy
4
Enlarged hemorrhoid - ANSWER A vaginal hematoma caused by fetal head pressure
during the birthing process can result in severe pain. Bladder distention causes
abdominal, not perineal, discomfort. Although the episiotomy may cause pain, it should
not be excruciating; it is too early for an infection to have developed. Although
hemorrhoids may cause perineal discomfort, they should not cause the vagina to feel
full and heavy.
A nurse is teaching a primigravida about how she can identify the onset of labor. What
clinical indicator of labor would necessitate the client to call her health care provider?
1
Bloody show and back pressure occurring with no contractions
2
Irregular contractions coming 10 minutes apart
3
Rupture of membranes or contractions 5 minutes apart
4
,Contractions 12 minutes apart and lasting about 30 seconds - ANSWER When the
membranes rupture the potential for infection is increased, and when the contractions
are 5 to 8 minutes apart they are usually of sufficient force to warrant professional
supervision. Bloody show and back pressure may be early signs of labor or signs of
posterior fetal position, but it is too early to notify the health care provider. The other
options indicate that it is too soon in the labor process to call the health care provider;
the client should remain with her family and keep moving around at home.
What common problem affects the client in labor when an external fetal monitor has
been applied to her abdomen?
1
Intrusion on movement
2
Inability to take sedatives
3
Interference with breathing techniques
4
Increased frequency of vaginal examinations - ANSWER Because the client is attached
to a machine and movement may alter the tracings, movement is discouraged.
Placement of the external monitor leads does not interfere with the administration of
sedatives. An external monitor does not interfere with breathing techniques. An external
monitor does not necessitate more frequent vaginal examinations.
A client who had tocolytic therapy for preterm labor is being discharged. What
instructions should the nurse include in the teaching plan?
1
Restrict fluid intake.
Correct 2
Limit daily activities.
Incorrect 3
Monitor urine for protein.
4
Avoid deep-breathing exercises - ANSWER Although it has not been proved that
bedrest limits preterm labor, it is often recommended; activities are restricted to
bathroom privileges and movement to a daytime resting area. Fluid intake should not be
restricted; hydration should be maintained. Monitoring of the urinary protein level is
, included in the care of a client with preeclampsia, not preterm labor. Deep-breathing
exercises do not influence preterm labor.
A woman comes into the clinic and states that she is thinking about becoming pregnant.
What can the woman do to improve the health of her baby before she becomes
pregnant?
1
Go buy maternity clothes
2
Start running 3 miles a day
3
Start taking prenatal vitamins
4
Buy a crib for the baby to sleep in - ANSWER Folic acid is important for the pregnant
woman; a lack of folic acid can result in neural tube defects, including spina bifida. The
time during fetal development when this occurs is very early in the pregnancy, when the
woman may not even realize that she is pregnant. Taking prenatal vitamins with
adequate folic acid can greatly reduce this birth defect. Although exercise is good for
the pregnant woman and infant, it is not necessary to start running 3 miles a day,
especially if this is something the client has never done before. Running may not be
healthy for the soon-to-be mother and infant if it is a new activity; however, if this is what
the woman normally does, she will be encouraged to continue. Buying maternity clothes
or a crib is not necessary at this stage, and neither of these directly objects affects the
health of the baby.
Phototherapy is prescribed for a neonate with hyperbilirubinemia. Which nursing
intervention is appropriate to reduce the potentially harmful side effect of the
phototherapy?
1
Covering the trunk to prevent hypothermia
2
Using shields on the eyes to protect them from the light
3
Massaging vitamin E oil into the skin to minimize drying
4
Turning after each feeding to reduce exposure of each surface area - ANSWER The
lights used for phototherapy can damage the infant's eyes, and eye shields are standard
equipment. Maximal effectiveness is achieved when the infant's entire skin surface is
EAQ Questions And Answers Rated A+
A client making her first visit to the prenatal clinic asks which immunization can be
administered safely to a pregnant woman. What should the nurse tell her?
1
Rubella (measles)
2
Rubeola (German measles)
Correct 3
Inactive influenza
4
Varicella (chicken pox) - ANSWER The inactive influenza and diphtheria, tetanus,
pertussis (dTAP) immunizations can be safely administered during the first trimester of
pregnancy, although dTAP is recommended at 27 to 36 weeks gestation to provide
immunity to the mother and infant. The inactivated influenza vaccine may be given
because it is a killed virus vaccine and will not have a teratogenic effect. Rubella
(measles) and rubeola (German measles) vaccines are both live viruses that should
never be administered during pregnancy because they can have teratogenic effects.
Varicella (chicken pox) immunization is not given because it may cause birth defects in
the fetus.
During labor a client begins to experience dizziness and tingling of her hands. What
should the nurse instruct the client to do?
1
Breathe into her cupped hands
2
,Pant during the next three contractions
3
Hold her breath with the next contraction
4 - ANSWER Dizziness and tingling of the hands are signs of respiratory alkalosis, most
likely the result of hyperventilating. Breathing into cupped hands or a paper bag
promotes the rebreathing of carbon dioxide. Panting during the next three contractions
could cause the client to hyperventilate more. Holding her breath with the next
contraction will not improve the client's respiratory alkalosis. Using a fast, deep, or
shallow breathing pattern could cause the client to hyperventilate more.
A client gives birth vaginally, with a midline episiotomy, to an infant who weighs 8 lb 13
oz (4000 g). An ice pack is applied to the perineum to ease the swelling and pain. The
client complains, "This pain in my vaginal and rectum is excruciating, and my vagina
feels so full and heavy." What does the nurse suspect as the cause of the pain?
1
Full bladder
2
Vaginal hematoma
3
Infected episiotomy
4
Enlarged hemorrhoid - ANSWER A vaginal hematoma caused by fetal head pressure
during the birthing process can result in severe pain. Bladder distention causes
abdominal, not perineal, discomfort. Although the episiotomy may cause pain, it should
not be excruciating; it is too early for an infection to have developed. Although
hemorrhoids may cause perineal discomfort, they should not cause the vagina to feel
full and heavy.
A nurse is teaching a primigravida about how she can identify the onset of labor. What
clinical indicator of labor would necessitate the client to call her health care provider?
1
Bloody show and back pressure occurring with no contractions
2
Irregular contractions coming 10 minutes apart
3
Rupture of membranes or contractions 5 minutes apart
4
,Contractions 12 minutes apart and lasting about 30 seconds - ANSWER When the
membranes rupture the potential for infection is increased, and when the contractions
are 5 to 8 minutes apart they are usually of sufficient force to warrant professional
supervision. Bloody show and back pressure may be early signs of labor or signs of
posterior fetal position, but it is too early to notify the health care provider. The other
options indicate that it is too soon in the labor process to call the health care provider;
the client should remain with her family and keep moving around at home.
What common problem affects the client in labor when an external fetal monitor has
been applied to her abdomen?
1
Intrusion on movement
2
Inability to take sedatives
3
Interference with breathing techniques
4
Increased frequency of vaginal examinations - ANSWER Because the client is attached
to a machine and movement may alter the tracings, movement is discouraged.
Placement of the external monitor leads does not interfere with the administration of
sedatives. An external monitor does not interfere with breathing techniques. An external
monitor does not necessitate more frequent vaginal examinations.
A client who had tocolytic therapy for preterm labor is being discharged. What
instructions should the nurse include in the teaching plan?
1
Restrict fluid intake.
Correct 2
Limit daily activities.
Incorrect 3
Monitor urine for protein.
4
Avoid deep-breathing exercises - ANSWER Although it has not been proved that
bedrest limits preterm labor, it is often recommended; activities are restricted to
bathroom privileges and movement to a daytime resting area. Fluid intake should not be
restricted; hydration should be maintained. Monitoring of the urinary protein level is
, included in the care of a client with preeclampsia, not preterm labor. Deep-breathing
exercises do not influence preterm labor.
A woman comes into the clinic and states that she is thinking about becoming pregnant.
What can the woman do to improve the health of her baby before she becomes
pregnant?
1
Go buy maternity clothes
2
Start running 3 miles a day
3
Start taking prenatal vitamins
4
Buy a crib for the baby to sleep in - ANSWER Folic acid is important for the pregnant
woman; a lack of folic acid can result in neural tube defects, including spina bifida. The
time during fetal development when this occurs is very early in the pregnancy, when the
woman may not even realize that she is pregnant. Taking prenatal vitamins with
adequate folic acid can greatly reduce this birth defect. Although exercise is good for
the pregnant woman and infant, it is not necessary to start running 3 miles a day,
especially if this is something the client has never done before. Running may not be
healthy for the soon-to-be mother and infant if it is a new activity; however, if this is what
the woman normally does, she will be encouraged to continue. Buying maternity clothes
or a crib is not necessary at this stage, and neither of these directly objects affects the
health of the baby.
Phototherapy is prescribed for a neonate with hyperbilirubinemia. Which nursing
intervention is appropriate to reduce the potentially harmful side effect of the
phototherapy?
1
Covering the trunk to prevent hypothermia
2
Using shields on the eyes to protect them from the light
3
Massaging vitamin E oil into the skin to minimize drying
4
Turning after each feeding to reduce exposure of each surface area - ANSWER The
lights used for phototherapy can damage the infant's eyes, and eye shields are standard
equipment. Maximal effectiveness is achieved when the infant's entire skin surface is
