NCLEX-RN Maternity: Antepartum Review with
Practice Questions & Verified Answers
A nurse is developing a plan of care for a client experiencing dystocia, and includes
several nursing interventions in the plan. The nurse prioritizes the plan and selects
which nursing intervention as the highest priority? - correct answersThe priority in the
plan of care would include the intervention that addresses the physiological integrity of
the fetus. Although providing comfort measures, changing the client's position
frequently, and keeping the significant other informed of the progress of the labor are
components of the plan of care, fetal status is the priority.
A nurse performs a vaginal assessment on a pregnant client in labor. On assessment,
the nurse notes the presence of the umbilical cord protruding from the vagina. Which is
the initial nursing action? - correct answersWhen cord prolapse occurs, prompt actions
are taken to relieve cord compression and increase fetal oxygenation. The mother
should be positioned with her hips higher than her head to shift the fetal presenting part
toward the diaphragm. The nurse should push the call light to summon help, and other
staff members should call the health care provider and notify the delivery room. If the
cord is protruding from the vagina, no attempt should be made to replace it because
that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face
mask is administered to the mother to increase fetal oxygenation.
The nurse is reviewing the record of a pregnant client seen in the health care clinic for
the first prenatal visit. Which data, if noted on the client's record, would alert the nurse
that the client is at risk for a spontaneous abortion? - correct answersMaternal infections
such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There
is no evidence that genital herpes is a causative agent in abortion, although the
presence of active lesions at the time of birth presents concerns. Maternal age greater
than 40 and diabetes mellitus are considered high-risk factors in a pregnancy but are
related to an increased risk of congenital malformations, not abortions.
A nurse performs a vaginal assessment on a pregnant client in labor. On assessment,
the nurse notes the presence of the umbilical cord protruding from the vagina. Which is
the initial nursing action? - <<<Answer>>>When cord prolapse occurs, prompt actions
are taken to relieve cord compression and increase fetal oxygenation. The mother
should be positioned with her hips higher than her head to shift the fetal presenting part
toward the diaphragm. The nurse should push the call light to summon help, and other
staff members should call the health care provider and notify the delivery room. If the
cord is protruding from the vagina, no attempt should be made to replace it because
that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face
mask is administered to the mother to increase fetal oxygenation.
The nurse is reviewing the record of a pregnant client seen in the health care clinic for
the first prenatal visit. Which data, if noted on the client's record, would alert the nurse
that the client is at risk for a spontaneous abortion? - <<<Answer>>>Maternal infections
, such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There
is no evidence that genital herpes is a causative agent in abortion, although the
presence of active lesions at the time of birth presents concerns. Maternal age greater
than 40 and diabetes mellitus are considered high-risk factors in a pregnancy but are
related to an increased risk of congenital malformations, not abortions.
The nurse is monitoring a client in labor. The nurse suspects umbilical cord
compression if which is noted on the external monitor tracing during a contraction? -
<<<Answer>>>Variable decelerations occur if the umbilical cord becomes compressed,
reducing blood flow between the placenta and the fetus. Variability refers to fluctuations
in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur
with fetal movement. Early decelerations result from pressure on the fetal head during a
contraction.
A pregnant client visits a clinic for a scheduled prenatal appointment. The client tells the
nurse that she frequently has a backache, and the nurse provides instructions regarding
measures that will assist in relieving the backache. Which statement by the client
indicates a need for further instructions? - <<<Answer>>>Some measures that will
assist in relieving a backache include maintaining good posture and body mechanics,
resting and avoiding fatigue, wearing flat-heeled shoes, and sleeping on a firm mattress.
The back discomfort that occurs in a pregnant client is often caused by the exaggerated
lumbar and cervicothoracic curves resulting from a change in the center of gravity
because of the enlarged uterus. Performing more exercises to strengthen the back
muscles could be harmful to a pregnant client.
A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery,
the family remained together, holding and touching the baby. Which statement by the
nurse would further assist the family in their initial period of grief? -
<<<Answer>>>When a loss or death occurs, the nurse should ensure that parents have
been honestly told about the situation by their health care provider or others on the
health care team. It is important for the nurse to be with the parents at this time and to
use therapeutic communication techniques. The nurse must also consider cultural and
religious practices and beliefs. The correct option provides a supportive, giving, and
caring response. Options 2, 3, and 4 are blocks to communication and devalue the
parents' feelings.
The nurse in a maternity unit is reviewing the clients' records. Which client would the
nurse identify as being at the most risk for developing disseminated intravascular
coagulation? - <<<Answer>>>In a pregnant client, disseminated intravascular
coagulation (DIC) is a condition in which the clotting cascade is activated, resulting in
the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk
factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is
not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a
risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage
Practice Questions & Verified Answers
A nurse is developing a plan of care for a client experiencing dystocia, and includes
several nursing interventions in the plan. The nurse prioritizes the plan and selects
which nursing intervention as the highest priority? - correct answersThe priority in the
plan of care would include the intervention that addresses the physiological integrity of
the fetus. Although providing comfort measures, changing the client's position
frequently, and keeping the significant other informed of the progress of the labor are
components of the plan of care, fetal status is the priority.
A nurse performs a vaginal assessment on a pregnant client in labor. On assessment,
the nurse notes the presence of the umbilical cord protruding from the vagina. Which is
the initial nursing action? - correct answersWhen cord prolapse occurs, prompt actions
are taken to relieve cord compression and increase fetal oxygenation. The mother
should be positioned with her hips higher than her head to shift the fetal presenting part
toward the diaphragm. The nurse should push the call light to summon help, and other
staff members should call the health care provider and notify the delivery room. If the
cord is protruding from the vagina, no attempt should be made to replace it because
that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face
mask is administered to the mother to increase fetal oxygenation.
The nurse is reviewing the record of a pregnant client seen in the health care clinic for
the first prenatal visit. Which data, if noted on the client's record, would alert the nurse
that the client is at risk for a spontaneous abortion? - correct answersMaternal infections
such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There
is no evidence that genital herpes is a causative agent in abortion, although the
presence of active lesions at the time of birth presents concerns. Maternal age greater
than 40 and diabetes mellitus are considered high-risk factors in a pregnancy but are
related to an increased risk of congenital malformations, not abortions.
A nurse performs a vaginal assessment on a pregnant client in labor. On assessment,
the nurse notes the presence of the umbilical cord protruding from the vagina. Which is
the initial nursing action? - <<<Answer>>>When cord prolapse occurs, prompt actions
are taken to relieve cord compression and increase fetal oxygenation. The mother
should be positioned with her hips higher than her head to shift the fetal presenting part
toward the diaphragm. The nurse should push the call light to summon help, and other
staff members should call the health care provider and notify the delivery room. If the
cord is protruding from the vagina, no attempt should be made to replace it because
that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face
mask is administered to the mother to increase fetal oxygenation.
The nurse is reviewing the record of a pregnant client seen in the health care clinic for
the first prenatal visit. Which data, if noted on the client's record, would alert the nurse
that the client is at risk for a spontaneous abortion? - <<<Answer>>>Maternal infections
, such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There
is no evidence that genital herpes is a causative agent in abortion, although the
presence of active lesions at the time of birth presents concerns. Maternal age greater
than 40 and diabetes mellitus are considered high-risk factors in a pregnancy but are
related to an increased risk of congenital malformations, not abortions.
The nurse is monitoring a client in labor. The nurse suspects umbilical cord
compression if which is noted on the external monitor tracing during a contraction? -
<<<Answer>>>Variable decelerations occur if the umbilical cord becomes compressed,
reducing blood flow between the placenta and the fetus. Variability refers to fluctuations
in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur
with fetal movement. Early decelerations result from pressure on the fetal head during a
contraction.
A pregnant client visits a clinic for a scheduled prenatal appointment. The client tells the
nurse that she frequently has a backache, and the nurse provides instructions regarding
measures that will assist in relieving the backache. Which statement by the client
indicates a need for further instructions? - <<<Answer>>>Some measures that will
assist in relieving a backache include maintaining good posture and body mechanics,
resting and avoiding fatigue, wearing flat-heeled shoes, and sleeping on a firm mattress.
The back discomfort that occurs in a pregnant client is often caused by the exaggerated
lumbar and cervicothoracic curves resulting from a change in the center of gravity
because of the enlarged uterus. Performing more exercises to strengthen the back
muscles could be harmful to a pregnant client.
A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery,
the family remained together, holding and touching the baby. Which statement by the
nurse would further assist the family in their initial period of grief? -
<<<Answer>>>When a loss or death occurs, the nurse should ensure that parents have
been honestly told about the situation by their health care provider or others on the
health care team. It is important for the nurse to be with the parents at this time and to
use therapeutic communication techniques. The nurse must also consider cultural and
religious practices and beliefs. The correct option provides a supportive, giving, and
caring response. Options 2, 3, and 4 are blocks to communication and devalue the
parents' feelings.
The nurse in a maternity unit is reviewing the clients' records. Which client would the
nurse identify as being at the most risk for developing disseminated intravascular
coagulation? - <<<Answer>>>In a pregnant client, disseminated intravascular
coagulation (DIC) is a condition in which the clotting cascade is activated, resulting in
the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk
factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is
not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a
risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage
