NCLEX Questions On Maternal And Child Health Nursing

1. When evaluating a client's knowledge of symptoms to report during her pregnancy. which statement would indicate to the nurse in charge that the client understands the information given to her?

“I’ll report increased frequency of urination.”

“If I have blurred or double vision. I should call the clinic immediately.”

“If I feel tired after resting. I should report it immediately.”

“Nausea should be reported immediately.”

Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately.Option A: Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus.Options C and D: Clients generally experience fatigue and nausea during pregnancy.

Explanation

Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately.Option A: Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus.Options C and D: Clients generally experience fatigue and nausea during pregnancy.

2. Accompanied by her husband. a patient seeks admission to the labor and delivery area. The client states that she is in labor and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first?

“Do you have any chronic illness?”

“Do you have any allergies?”

“What is your expected due date?”

“Who will be with you during labor?”

When obtaining the history of a patient who may be in labor. the nurse’s highest priority is to determine her current status. particularly her due date. gravidity. and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later. the nurse should ask about chronic illness. allergies. and support persons.

Explanation

When obtaining the history of a patient who may be in labor. the nurse’s highest priority is to determine her current status. particularly her due date. gravidity. and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later. the nurse should ask about chronic illness. allergies. and support persons.

3. The nurse in-charge is reviewing a patient's prenatal history. Which finding indicates a genetic risk factor?

The patient is 25 years old

The patient has a child with cystic fibrosis

The patient was exposed to rubella at 36 weeks’ gestation

The patient has a history of preterm labor at 32 weeks’ gestation

Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder.Option A: Maternal age is not a risk factor until age 35. when the incidence of chromosomal defects increases.Option C: Maternal exposure to rubella during the first trimester may cause congenital defects.Option D: Although a history or preterm labor may place the patient at risk for preterm labor. it does not correlate with genetic defects.

Explanation

Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder.Option A: Maternal age is not a risk factor until age 35. when the incidence of chromosomal defects increases.Option C: Maternal exposure to rubella during the first trimester may cause congenital defects.Option D: Although a history or preterm labor may place the patient at risk for preterm labor. it does not correlate with genetic defects.

4. A patient is in her last trimester of pregnancy. Nurse Vickie should instruct her to notify her primary health care provider immediately if she notices:

Blurred vision

Hemorrhoids

Increased vaginal mucus

Shortness of breath on exertion

Blurred vision or other visual disturbance. excessive weight gain. edema. and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia. which has potentially serious consequences for both the patient and fetus.Option B: Although hemorrhoids may be a problem during pregnancy. they do not require immediate attention.Options C and D: Increased vaginal mucus and dyspnea on exertion are expected as pregnancy progress.

Explanation

Blurred vision or other visual disturbance. excessive weight gain. edema. and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia. which has potentially serious consequences for both the patient and fetus.Option B: Although hemorrhoids may be a problem during pregnancy. they do not require immediate attention.Options C and D: Increased vaginal mucus and dyspnea on exertion are expected as pregnancy progress.

5. An adult female patient is using the rhythm (calendar-basal body temperature) method of family planning. In this method. the unsafe period for sexual intercourse is indicated by:

Return preovulatory basal body temperature

Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd day of cycle

3 full days of elevated basal body temperature and clear. thin cervical mucus

Breast tenderness and mittelschmerz

Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7 degrees F to 0.8 degrees F and clear. thin cervical mucus.Option A: A return to the preovulatory body temperature indicates a safe period for sexual intercourse.Option B: A slight rise in basal temperature early in the cycle is not significant.Option D: Breast tenderness and mittelschmerz are not reliable indicators of ovulation.

Explanation

Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7 degrees F to 0.8 degrees F and clear. thin cervical mucus.Option A: A return to the preovulatory body temperature indicates a safe period for sexual intercourse.Option B: A slight rise in basal temperature early in the cycle is not significant.Option D: Breast tenderness and mittelschmerz are not reliable indicators of ovulation.

6. During a nonstress test (NST). the electronic tracing displays a relatively flat line for fetal movement. making it difficult to evaluate the fetal heart rate (FHR). To mark the strip. the nurse in charge should instruct the client to push the control button at which time?

At the beginning of each fetal movement

At the beginning of each contraction

After every three fetal movements

At the end of fetal movement

An NST assesses the FHR during fetal movement. In a healthy fetus. the FHR accelerates with each movement. By pushing the control button when a fetal movement starts. the client marks the strip to allow easy correlation of fetal movement with the FHR.Option B: The FHR is assessed during uterine contractions in the oxytocin contraction test. not the NST.Options C and D: Pushing the control button after every three fetal movements or at the end of fetal movement wouldn’t allow accurate comparison of fetal movement and FHR changes.

Explanation

An NST assesses the FHR during fetal movement. In a healthy fetus. the FHR accelerates with each movement. By pushing the control button when a fetal movement starts. the client marks the strip to allow easy correlation of fetal movement with the FHR.Option B: The FHR is assessed during uterine contractions in the oxytocin contraction test. not the NST.Options C and D: Pushing the control button after every three fetal movements or at the end of fetal movement wouldn’t allow accurate comparison of fetal movement and FHR changes.

7. A patient is in the second stage of labor. During this stage. how frequently should the nurse in charge assess her uterine contractions?

Every 5 minutes

Every 15 minutes

Every 30 minutes

Every 60 minutes

During the second stage of labor. the nurse should assess the strength. frequency. and duration of contraction every 15 minutes. If maternal or fetal problems are detected. more frequent monitoring is necessary.Options C and D: An interval of 30 to 60 minutes between assessments is too long because of variations in the length and duration of patient’s labor.

Explanation

During the second stage of labor. the nurse should assess the strength. frequency. and duration of contraction every 15 minutes. If maternal or fetal problems are detected. more frequent monitoring is necessary.Options C and D: An interval of 30 to 60 minutes between assessments is too long because of variations in the length and duration of patient’s labor.

8. When assessing a client during her first prenatal visit. the nurse discovers that the client had a reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the nurse give to this mother regarding breastfeeding success?

“It’s contraindicated for you to breastfeed following this type of surgery.”

“I support your commitment; however. you may have to supplement each feeding with formula.”

“You should check with your surgeon to determine whether breast-feeding would be possible.”

“You should be able to breastfeed without difficulty.”

Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts. so breast-feeding after surgery is possible. Still. it’s good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mother’s ability to meet all of her baby’s nutritional needs. and some supplemental feeding may be required. Preparing the mother for this possibility is extremely important because the client’s psychological adaptation to mothering may be dependent on how successfully she breast-feeds.

Explanation

Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts. so breast-feeding after surgery is possible. Still. it’s good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mother’s ability to meet all of her baby’s nutritional needs. and some supplemental feeding may be required. Preparing the mother for this possibility is extremely important because the client’s psychological adaptation to mothering may be dependent on how successfully she breast-feeds.

9. Which one do you like?

An empty gestational sac.

Grapelike clusters.

A severely malformed fetus.

An extrauterine pregnancy.

In a client with gestational trophoblastic disease. an ultrasound performed after the 3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been absorbed. Because there is no fetus. there can be no extrauterine pregnancy. An extrauterine pregnancy is seen with an ectopic pregnancy.

Explanation

In a client with gestational trophoblastic disease. an ultrasound performed after the 3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been absorbed. Because there is no fetus. there can be no extrauterine pregnancy. An extrauterine pregnancy is seen with an ectopic pregnancy.

10. Which one do you like?

Applying cold to limit edema during the first 12 to 24 hours

Instructing the client to use two or more peri pads to cushion the area

Instructing the client on the use of sitz baths if ordered

Instructing the client about the importance of perineal (Kegel) exercises

Using two or more peripads would do little to reduce the pain or promote perineal healing.Options A. C and D: Cold applications. sitz baths. and Kegel exercises are important measures when the client has a fourth-degree laceration.

Explanation

Using two or more peripads would do little to reduce the pain or promote perineal healing.Options A. C and D: Cold applications. sitz baths. and Kegel exercises are important measures when the client has a fourth-degree laceration.