Maternal & Newborn NCLEX-RN Practice Exam — Set 2

The nurse is caring for a client at 32 weeks gestation who presents with a blood pressure of 158/94 mm Hg, 2+ proteinuria, and deep tendon reflexes of 3+. The client reports a headache that "won't go away" and notes swelling in her face and hands. Which of the following interventions should the nurse implement first?

The nurse is assessing a newborn who is 12 hours old and was born at 41 weeks gestation via vacuum-assisted delivery. The parent reports the baby "hasn't wanted to eat for the past 3 hours and seems really tired." The nurse notes a high-pitched cry, poor feeding effort, and a yellow-orange skin color visible on the abdomen. Which of the following actions should the nurse take first?

A client who is 24 hours postpartum after an uncomplicated vaginal delivery reports soaking through an entire pad in about 10 minutes and passing golf-ball-sized clots. The client is pale and diaphoretic. The fundus is boggy and displaced to the right, and the perineal pad is saturated with bright red blood. Which of the following actions should the nurse take first?

A client at 39 weeks gestation is receiving oxytocin for labor augmentation. The fetal heart rate baseline is 145 with moderate variability, but repetitive late decelerations have occurred with each contraction over the past 15 minutes. Contractions are every 2 minutes lasting 80 seconds. Which of the following actions should the nurse take?

A G2P1 client at 38 weeks gestation is being induced with oxytocin for gestational hypertension. Cervix is now 4 cm/70%/-1 with FHR baseline 140. Two hours later, after requesting an epidural, the FHR shows minimal variability and recurrent variable decelerations to 90 beats/min lasting 45 seconds. Which intervention should the nurse implement first?

A client 10 hours postpartum after vacuum-assisted delivery reports perineal pain rated 9/10 unrelieved by ibuprofen. The nurse notes a large, bulging, bluish discoloration on the left vaginal wall. BP 98/52, HR 118, RR 20. Fundus is firm at the umbilicus with moderate rubra lochia. Which action should the nurse take?

The nurse is assessing a 30-minute-old newborn born at 35 weeks gestation. RR 72 with nasal flaring, expiratory grunting, intercostal retractions, and SpO2 88% on room air. The newborn is supine in a radiant warmer. Which action should the nurse take first?

A G1P0 at 28 weeks gestation calls reporting low back pain, mild cramping for several hours, and a small amount of pink discharge. She denies leaking fluid or vaginal bleeding. Which response by the nurse is most appropriate?

A client 48 hours post-cesarean who plans to formula-feed reports firm, painful breasts. Which instruction should the nurse include?

A client at 34 weeks gestation has a positive nitrazine test and ferning consistent with PROM. She is not contracting; FHR 145 with moderate variability. Which interventions should the nurse anticipate? Select all that apply.

A client receiving magnesium sulfate for severe preeclampsia has BP 142/88, HR 88, RR 14, absent deep tendon reflexes, and 80 mL urine output over 4 hours. Which action should the nurse take first?

A 4-hour-old newborn (mother with poorly controlled GDM, 9 lb 2 oz) is jittery, has a weak cry, and is difficult to arouse. Which action should the nurse take?

A 36-week pregnant client presents with painless, bright red vaginal bleeding (one peripad) starting suddenly 1 hour ago. FHR 155 with moderate variability. She denies contractions, pain, or trauma. Which interventions should the nurse implement? Select all that apply.

A client 2 hours postpartum has a firm midline fundus at the umbilicus, moderate rubra lochia with small clots, a 4-inch area of bright red blood on the perineal pad, BP 118/72, HR 88, and 6/10 perineal pain. Which action should the nurse take?

Parents ask why their newborn needs a vitamin K injection. Which response is most appropriate?

A client at 37 weeks undergoes a biophysical profile. Which result requires immediate intervention?

An active-labor client with cervix 7 cm/100%/0 has been pushing with each contraction for 2 hours at staff direction. FHR remains reassuring. Which action should the nurse take?

An 18-hour-old term newborn has not passed meconium. Abdomen is distended and firm; bilious emesis x2 in 1 hour; refusing feedings. Mother had inadequate prenatal care. Which condition should the nurse suspect?

A client 1 hour after a precipitous delivery has a boggy fundus displaced to the right, heavy rubra lochia with large clots, BP 100/58, HR 110. Which action should the nurse take first?

A client at 10 weeks with hyperemesis gravidarum has lost 5 lb in 2 weeks and "can't keep anything down." Which instruction should the nurse include?

A 24-hour-old newborn of an HBsAg-positive mother received hepatitis B vaccine and HBIG at birth. Which statement by the mother indicates correct understanding?

A client at 40 weeks is admitted for postdates induction. Cervix is 1 cm/30%/-3 with a Bishop score of 3. The nurse understands this Bishop score indicates which of the following?

A laboring client on epidural has BP drop from 118/72 to 86/48 over 5 minutes with new late decelerations. She is supine with a wedge under the right hip. Which action should the nurse take first?

A client 2 weeks postpartum reports a fever of 101.5°F for 2 days plus a red, hot, very painful right breast while breastfeeding. Which response is most appropriate?

A client 8 hours post-cesarean (spinal anesthesia) reports a severe headache that is relieved when lying flat and worsens upright. Which intervention should the nurse implement first?

Parents of a healthy newborn discharged at 48 hours ask when the first well-child visit should occur. Which response is most appropriate?

A client at 39 weeks in labor has spontaneous rupture of membranes with thick, green-tinged fluid. FHR baseline 145, moderate variability, no decelerations. Which action should the nurse take?

A 6-hour-old newborn has RR 36 with 8-10 second pauses followed by rapid breathing. SpO2 95% on room air; no flaring, grunting, or retractions. Which action should the nurse take?

A client at 35 weeks has sudden severe constant abdominal pain, rigid tender abdomen, moderate dark red bleeding, BP 90/50, HR 130, FHR 90 with minimal variability. Which condition does the nurse suspect?

An 8-hour-old newborn has bluish hands and feet but pink trunk and mucous membranes; vital signs stable, SpO2 96% on room air. Which action should the nurse take?