Maternal & Newborn NCLEX-RN Practice Exam — Set 3

A client at 41 weeks gestation undergoes a contraction stress test (CST). Late decelerations are noted with 50% of contractions. Which interpretation should the nurse document?

A client 2 hours postpartum received 10 units of oxytocin IM after placenta delivery. Fundus remains boggy after massage; lochia is heavy with clots; BP 100/60, HR 102. Which medication should the nurse anticipate next?

A 2-day-old newborn whose mother has type 1 diabetes has a glucose of 38 mg/dL. The newborn is asymptomatic (vigorous, normal tone, stable vitals). Which intervention should the nurse implement?

A client 48 hours after cesarean asks how much activity she can do at home. Which instructions should the nurse include? Select all that apply.

A client at 36 weeks reports decreased fetal movement for 24 hours. NST is nonreactive after 40 minutes; vibroacoustic stimulation produces no accelerations. What should the nurse anticipate as the next step?

A client 12 hours postpartum after uncomplicated vaginal delivery reports bad belly cramping while breastfeeding. Fundus is firm at 1 cm below umbilicus; lochia moderate rubra. Which response is most appropriate?

A client on oxytocin has contractions every 1.5 minutes lasting 100 seconds with late decelerations. BP 105/68 (baseline 110/70). Which action should the nurse take?

A client at 28 weeks is being taught about pregnancy warning signs. Which statement indicates correct understanding?

A 4-hour-old newborn at 34 weeks on CPAP for RDS has SpO2 drop to 85% with unchanged settings. The newborn is mottled with a distended abdomen. Which action should the nurse take first?

A 39-week client at 8 cm dilation suddenly reports a tearing abdominal pain. The previously visible fetal head retracts upward; FHR 70; client is hypotensive with a tender abdomen. Which condition does the nurse suspect?

An exclusively breastfeeding client 3 weeks postpartum had no bleeding for a week and now notices a small amount of bright red bleeding. She denies pain, fever, or foul odor. Which response is most appropriate?

A 12-hour-old newborn with NAS receiving morphine has a Finnegan score that decreased from 12 to 6 over 24 hours. Which action should the nurse anticipate?

A client at 38 weeks with two prior cesareans is undergoing TOLAC. Which finding would be the earliest indicator of possible uterine rupture?

A 48-hour-old term newborn (38 weeks, breastfeeding well, no risk factors; mother A+) has a total bilirubin of 14 mg/dL. Which intervention should the nurse anticipate?

A client at 30 weeks asks what to do if she thinks she's having preterm labor symptoms. Which response is most appropriate?

A 6-hour-old newborn (cesarean) has not voided. The bladder is palpable above the symphysis pubis. The newborn is otherwise stable and feeding well. Which action should the nurse take?

One hour after misoprostol 25 mcg vaginally for cervical ripening, a client has contractions every 1.5 minutes lasting 90 seconds. FHR 135 with moderate variability. Which action should the nurse take?

A client 4 hours postpartum requests an ice pack for perineal discomfort. Which instruction should the nurse provide regarding ice pack use?

A 24-hour-old term newborn has yellow discoloration of the face and chest. Feeding well, has passed meconium and voided ×3. Vitals stable. Which action should the nurse take?

A client at 35 weeks with gestational diabetes asks what will happen to her baby after delivery. Which response is most appropriate?

A client 2 days postpartum reports the episiotomy site hurts more today than yesterday. Site is erythematous and edematous with purulent drainage and areas of separation. Temperature 100.8°F. Which action should the nurse take first?

A laboring client (cervix 6 cm/90%/0) requests an epidural. Platelet count today is 85,000/μL. Which action should the nurse take?

Parents of a newborn discharged at 24 hours ask about upcoming vaccinations. Which information should the nurse include? Select all that apply.

A client receiving magnesium sulfate for severe preeclampsia has a magnesium level of 6.5 mEq/L (therapeutic 4-7), reports feeling warm and flushed, and has 2+ patellar reflexes. Which action should the nurse take?

A 2-hour-old newborn (39 weeks, scheduled cesarean without labor, mother received general anesthesia) has RR 68 with mild intercostal retractions. Which is the most likely cause?

A client 2 weeks postpartum reports a tender, red, warm area on her left calf without dyspnea or chest pain. BP 118/72, HR 88, RR 16, SpO2 98%. Which action should the nurse take first?

An active-labor client (cervix 7 cm, head +1) has been pushing for 30 minutes at the nurse's instruction; cervix remains 7 cm. Which action should the nurse take?

An 8-hour-old newborn whose mother is on methadone maintenance has a high-pitched cry, jitteriness, and hyperreflexia. Vitals stable. Which intervention should the nurse implement first?

A client 8 hours postpartum after vaginal delivery has a firm fundus at the umbilicus and moderate rubra lochia, but reports rectal pressure with inability to have a bowel movement. The nurse notes a large, firm, bulging mass on the left vaginal wall. Which condition does the nurse suspect?

An Rh-negative client at 28 weeks asks why she needs RhoGAM now when she received it after her last pregnancy. Which response is most appropriate?