Maternity and Child Nursing NCLEX Practice Exam Questions

1. Answer: D

Rationale: Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they anticipate the onset of labor and the birth of their child. (D) is closest to the time when parents would be ready for such classes. (A, B, and C) are not the best times during pregnancy for the couple to attend childbirth education classes. At these times, they will have other teaching needs. Early pregnancy classes often include nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her significant others.

2. Answer: C

Rationale: Checking the blood pressure for an elevation (C) is the best instruction to give at this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension. Additional data are needed to confirm an emergency situation as described in (A). (B and D) ignore the threat to client safety posed by a significant increase in blood pressure.

3. Answer: A, C, E

Rationale: (A and C) are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client’s menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. (E) could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. (B and D) are normal signs during the first trimester of pregnancy.

4. Answer: D

Rationale:  In the normal infant, the anterior fontanel closes at 12 to 18 months of age, and the posterior fontanel closes by the end of the second month (D). These growth and development milestones are frequently included in questions on the licensure examination. (A, B, and C) are incorrect.

5. Answer: A, B, D

Rationale: Risks of CVS include failure to obtain tissue, rupture of membranes, leakage of amniotic fluid, bleeding, intrauterine infection, maternal tissue contamination of the specimen, and Rh alloimmunization. CVS testing has a higher rate of spontaneous abortion than amniocentesis. Other complications include fetal limb defects and abnormalities of the fetal face and jaw.

6. Answer: C

Rationale: Early in pregnancy, the sphingomyelin concentration in amniotic fluid is greater than the concentration of lecithin, and so the L/S ratio is low (lecithin levels are low, and sphingomyelin levels are high). At about 32 weeks gestation, sphingomyelin levels begin to fall, and the amount of lecithin begins to increase. By 35 weeks gestation, an L/S ratio of 2:1 (also reported as 2.0) is usually achieved in the normal fetus.

7. Answer: B

Rationale: During pregnancy, the amniotic fluid protects against injury. After 20 weeks of pregnancy, the fluid volume ranges from 700-1000 mL. Some of the amniotic fluid is contributed by the fetus’s excreting urine. Amniotic fluid is slightly alkaline.

8. Answer: C

Rationale: Progesterone decreases the contractility of the uterus, thus preventing uterine contractions that might cause spontaneous abortion. Progesterone must be present in high levels for implantation to occur. After 10 weeks, the placenta takes over the production of progesterone. hCG reaches its maximum level at 50-70 days gestation.

9. Answer: D

Rationale: Differentiation of hard and soft palate are structures developed by 16 weeks gestation. Myelination of the spinal cord begins at 20 weeks gestation. Soft earlobes with little cartilage develop at 36 weeks gestation. Teeth form hard tissue (enamel) at 18 weeks gestation.

10. Answer: C

Rationale: Breastfeeding can be initiated immediately after birth. This immediate mother-newborn contact takes advantage of the newborn’s natural alertness and fosters bonding. This contact also reduces maternal bleeding and stabilizes the newborn’s temperature, blood glucose level, and respiratory rate. It is not associated with maturing the sucking reflex, encouraging the development of maternal antibodies, or aiding in clearing the newborn’s respiratory passages.

11. Answer: B

Rationale: A newborn’s temperature is typically maintained at 36.5 to 37.5 degrees C (97.7 to 99.7 degrees F). Since this newborn’s temperature is significantly lower, the nurse should gradually institute measures to rewarm the newborn. Assessment of gestational age is completed regardless of the newborn’s temperature. Observation would be inappropriate because lack of action may lead to a further lowering of the temperature. The nurse should notify the physician of the newborn’s current temperature since it is outside normal parameters.

12. Answer: C

Rationale: Biophysical profile is a comprehensive test that would be used to assess the client’s fetal status at 28 weeks gestation. Ultrasound for physical structure is limited to identifying the growth and development of the fetus, and does not assess for other parameters of fetal well-being. Women with a high-risk factor will probably begin having NSTs at 30-32 weeks gestation and at frequent intervals for the remainder of the pregnancy. Amniocentesis late in pregnancy is used to test for lung maturity, not overall fetal status in labor, and when performed earlier, it is used to test for specific disorders.

13. Answer: D

Answer: After having the client void, assist her to a lithotomy position for a transvaginal ultrasound. Preparation for a transabdominal ultrasound includes encouraging the client to drink 1.5 quarts of fluid, maintaining a full bladder, and applying transmission gel over the client’s abdomen.

14. Answer: A, B, C

Rationale: The ability to accurately establish fetal age by ultrasound is lost in the third trimester because fetal growth is not as uniform as in the first two trimesters; however, ultrasound can be used to approximate gestational age within 1-3 weeks accuracy during the third trimester. A comprehensive ultrasound is used to detect anatomical defects, not gestational age. Ultrasound is not used to determine gender.

15. Answer: A, B, C

Rationale: “The fetus contributes to the volume of amniotic fluid by excreting urine.” Approximately 400 mL of amniotic fluid flows out of the fetal lungs each day. The fetus swallows about 600 mL of the fluid in 24 hours. An average volume of amniotic fluid is necessary for good fetal movement. Regular movement is necessary for good musculoskeletal development.

16. Answer: C

Rationale: Fertilized egg stays in the fallopian tube for about 72-96 hours, or 3-4 days. However, during the first 24 hours of fertilization, mitosis occurs, and the cell keeps on dividing as it makes its way to the uterus for implantation.

17. Answer: D

Rationale: The positive signs of pregnancy are completely objective, cannot be confused with a pathologic state, and offer conclusive proof of pregnancy. The fetal heartbeat can be detected with an electronic Doppler device as early as weeks 10-12 of pregnancy. Pregnancy tests detect the presence of hCG in the maternal blood or urine. These are not considered a positive sign of pregnancy because other conditions can cause elevated hCG levels. Physical changes, like Godell’s sign and uterine enlargement, can also have other causes and do not confirm pregnancy. The subjective changes of pregnancy, like amenorrhea, are the symptoms the woman experiences and reports. Because other conditions can cause them, they cannot be considered proof of pregnancy.

18. Answer: A

Rationale: When CSF leaks out of the epidural space, a severe headache in the patient can occur. A blood patch can be performed by a physician to close the site. The small amount of blood is withdrawn from the mother’s arm, and the blood clots in the space.

19. Answer: B

Rationale: A postpartum patient is at risk of hemorrhage following delivery; often, the physician will order a hemoglobin level 1-2 days after delivery to check the mother’s risk status. A level of 9.9 g/dL is lower than average for a female patient, but is not necessarily low enough to warrant a blood transfusion.

20. Answer: C, D, E

Rationale: Pre-eclampsia is a state that develops during pregnancy in which a mother has high blood pressure and starts losing protein into the urine.Certain risks that increase such as a first-time pregnancy, advanced maternal age, overweight or obesity in the mother, and pregnancy with multiple babies.

21. Answer: B

Rationale: Cardiopulmonary resuscitation and AED can be used on a pregnant patient with some modifications. If the nurse must perform chest compressions, she should still provide the same rate as to a non-pregnant patient, but she may need to slightly displace the uterus to perform the compressions.

22. Answer: C

Rationale: The presence of surface-active phospholipids is not an indication of Down syndrome. This result reveals the fetal lungs are mature and in no way indicate risk for preterm labor. The detection of the presence of pulmonary surfactants, surface-active phospholipids, in amniotic fluid has been used to determine fetal lung maturity or the ability of the lungs to function after birth. This occurs at approximately 35 weeks of gestation. Meconium should not be present in the amniotic fluid.

23. Answer: B.

Rationale: Systolic blood pressure exceeding 160 mm Hg indicates severe hypertension in the patient. The nurse should alert the health care provider and obtain a prescription for antihypertensive medications, such as nifedipine (Adalat) and labetalol hydrochloride (Normodyne). Magnesium sulfate would be administered if the patient was experiencing eclamptic seizures. Oral and intravenous fluids are restricted when the patient is at risk for pulmonary edema. Monitoring FHR and UCs is a priority when the patient experiences a trauma so that any complications can be addressed immediately.

24. Answer: D

Rationale: Hyperemesis gravidarum is characterized by excessive vomiting during pregnancy, which causes nutritional deficiency and weight loss. The presence of ketonuria is another indication of this disorder. Preeclampsia refers to hypertension and proteinuria in patients after 20 weeks of gestation. Hyperthyroid disorder may be one of the causes of hyperemesis gravidarum. Gestationaconditionension also develops after 20 weeks of pregnancy.

25. Answer: A, B, C

Rationale: The spotting of blood with the cervical os closed and mild uterine cramping in the first trimester indicates a threatened miscarriage. Therefore the nurse needs to assess progesterone levels, transvaginal ultrasounds, and measurement of hCG to determine whether the fetus is alive and within the uterus. Blood pressure measurements do not help determine the fetal status. KB assay is prescribed to identify fetal-to-maternal bleeding, usually after a trauma.

26. Answer: A

Rationale: Once the vomiting has stopped, feedings are started in small amounts at frequent intervals. In the beginning, limited amounts of oral fluids and bland foods such as crackers, toast, or baked chicken are offered. Clear fluids alone do not contain enough calories and contain no protein. Most women are able to take nourishment by mouth after several days of treatment. They should be encouraged to eat small, frequent meals and foods that sound appealing (e.g., nongreasy, dry, sweet, and salty foods).

27. Answer: A.

Rationale: Bleeding is the most dangerous problem, which impacts the mother’s well-being as well as that of her fetus. The decreasing blood volume would cause increases in pulse and respiration and a decrease in blood pressure. The fetus often responds to decreased oxygenation as a result of bleeding, causing a reduction in perfusion. This causes the fetus’s heart rate to increase above the normal 120–160 beats per minute range. The other options have measurements in the “normal” range and would not reflect a patient’s physical status deterioration.

28. Answer: B, C, E

Rationale: The diet for hyperemesis includes: (1) Avoid an empty stomach. Eat frequently, at least every 2 to 3 hours. Separate liquids from solids and alternate every 2 to 3 hours. (2) Eat a high-protein snack at bedtime. (3) Eat dry, bland, low-fat, and high-protein foods. Cold foods may be better tolerated than those served at a warm temperature. (4) In general, eat what sounds good to you rather than trying to balance your meals. (5) Follow the salty and sweet approach; even so-called junk foods are okay. (6) Eat protein after sweets. (7) Dairy products may stay down more easily than other foods. (8) If you vomit even when your stomach is empty, try sucking on a Popsicle. (9) Try ginger tea. Peel and finely dice a knuckle-sized piece of ginger and place it in a mug of boiling water. Steep for 5 to 8 minutes and add brown sugar to taste. (10) Try warm ginger ale (with sugar, not artificial sweetener) or water with a slice of lemon. (11) Drink liquids from a cup with a lid.

29. Answer: B, C, D

Rationale: The nurse adds a local anesthetic to the solution to reduce the pain caused by the injection. The Z-track technique is used to inject the drug to safely inject the drug into the intramuscular (IM) tissue. The nurse gently massages the site after administering the injection to reduce pain. The nurse administers two separate injections of 5 g in each buttock. Magnesium sulfate injections are administered in the IM layer and not the subcutaneous layer.

30. Answer: C

Rationale: The nurse administers the prescribed Rho(D) immunoglobulin to the patient to protect the patient from isoimmunization. The nurse needs to obtain a prescription for magnesium sulfate if there are eclamptic seizures in a patient with preeclampsia. Oxytocin (Pitocin) is administered to prevent bleeding after birth or the evacuation of the uterus. Magnetic resonance imaging (MRI) is used to assess injuries in a patient after trauma.

References

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