NCLEX Sample Questions For Maternal And Child Health Nursing

1. The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says:

“Nausea and vomiting can be decreased if I eat a few crackers before arising.”

“If I start to leak colostrum, I should cleanse my nipples with soap and water.”

“If I have a vaginal discharge, I should wear nylon underwear.”

“Leg cramps can be alleviated if I put an ice pack on the area.”

Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.

Explanation

Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.

2. Normal lochial findings in the first 24 hours post-delivery include:

Bright red blood

Large clots or tissue fragments

A foul odor

The complete absence of lochia

Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may the absence of lochia.

Explanation

Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may the absence of lochia.

3. Nurse Julia plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan?

Feeding the neonate a maximum of 5 minutes per side on the first day

Wearing a supportive brassiere with nipple shields

Breastfeeding the neonate at frequent intervals

Decreasing fluid intake for the first 24 to 48 hours

Prevention of breast engorgement is key. The best technique is to empty the breast regularly with feeding. Engorgement is less likely when the mother and neonate are together, as in single-room maternity care continuous rooming in, because nursing can be done conveniently to meet the neonate’s and mother’s needs.

Explanation

Prevention of breast engorgement is key. The best technique is to empty the breast regularly with feeding. Engorgement is less likely when the mother and neonate are together, as in single-room maternity care continuous rooming in, because nursing can be done conveniently to meet the neonate’s and mother’s needs.

4. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following?

Activity limited to bed rest

Platelet infusion

Immediate cesarean delivery

Labor induction with oxytocin

Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client’s bleeding.

Explanation

Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client’s bleeding.

5. When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms and hands open and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes?

Startle reflex

Babinski reflex

Grasping reflex

Tonic neck reflex

The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms and hands open and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months.

Explanation

The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms and hands open and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months.

6. A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms?

Proteinuria, headaches, vaginal bleeding

Headaches, double vision, vaginal bleeding

Proteinuria, headaches, double vision

Proteinuria, double vision, uterine contractions

A patient with pregnancy-induced hypertension complains of headaches, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Vaginal bleeding and uterine contractions are not associated with pregnancy-induced hypertension.

Explanation

A patient with pregnancy-induced hypertension complains of headaches, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Vaginal bleeding and uterine contractions are not associated with pregnancy-induced hypertension.

7. The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time?

Between 10 and 12 weeks gestation

Between 16 and 20 weeks gestation

Between 21 and 23 weeks gestation

Between 24 and 26 weeks gestation

A pregnant woman can usually detect fetal movement (quickening) between 16 and 20 weeks gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.

Explanation

A pregnant woman can usually detect fetal movement (quickening) between 16 and 20 weeks gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.

8. While the postpartum client is receiving herein for thrombophlebitis, which of the following drugs would the nurse Mica expect to administer if the client develops complications related to heparin therapy?

Calcium gluconate

Protamine sulfate

Methylergonovine (Methergine)

Nitrofurantoin (macrodantin)

Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications caused by heparin overdose.

Explanation

Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications caused by heparin overdose.

9. A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the nurse respond?

“Yes, it produces no adverse effect.”

“No, it can initiate premature uterine contractions.”

“No, it can promote sodium retention.”

“No, it can lead to increased absorption of fat-soluble vitamins.”

Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oils are not known to increase the absorption of fat-soluble vitamins, although laxatives, in general, may decrease absorption if intestinal motility is increased.

Explanation

Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oils are not known to increase the absorption of fat-soluble vitamins, although laxatives, in general, may decrease absorption if intestinal motility is increased.

10. Immediately after delivery, the nurse-midwife assesses the neonate’s head for signs of molding. Which factors determine the type of molding?

Fetal body flexion or extension

Maternal age, body frame, and weight

Maternal and paternal ethnic backgrounds

Maternal parity and gravidity

Fetal attitude—the overall degree of body flexion or extension—determines the type of molding in the head of a neonate. Molding is not influenced by maternal age, body frame, weight, parity, gravidity, or maternal and paternal ethnic backgrounds.

Explanation

Fetal attitude—the overall degree of body flexion or extension—determines the type of molding in the head of a neonate. Molding is not influenced by maternal age, body frame, weight, parity, gravidity, or maternal and paternal ethnic backgrounds.

11. Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?

Notify the neonate’s pediatrician immediately

Check the diaper and circumcision again in 30 minutes

Secure the diaper tightly to apply pressure on the site

Apply gently pressure to the site with a sterile gauze pad

If bleeding occurs after the circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs.

Explanation

If bleeding occurs after the circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs.

12. When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following?

Turn the neonate every 6 hours.

Encourage the mother to discontinue breastfeeding.

Notify the physician if the skin becomes bronze in color.

Check the vital signs every 2 to 4 hours.

While caring for an infant receiving phototherapy for the treatment of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights.

Explanation

While caring for an infant receiving phototherapy for the treatment of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights.

13. A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective?

Back

Abdomen

Fundus

Perineum

A bilateral pudendal block is used for vaginal deliveries to relieve pain, primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair.

Explanation

A bilateral pudendal block is used for vaginal deliveries to relieve pain, primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair.

14. For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied?

The membranes must rupture

The fetus must be at 0 station

The cervix must be dilated fully

The patient must receive anesthesia

Internal EFM can be applied after the patient’s membranes have ruptured when the fetus is at least at the -1 station and when the cervix is dilated at least 2 cm. although the patient may receive anesthesia, it is not required before the application of an internal EFM device.

Explanation

Internal EFM can be applied after the patient’s membranes have ruptured when the fetus is at least at the -1 station and when the cervix is dilated at least 2 cm. although the patient may receive anesthesia, it is not required before the application of an internal EFM device.

15. The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage?

Active phase

Complete phase

Latent phase

Transitional phase

The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds. The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that start out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.

Explanation

The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds. The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that start out moderately intense, grow stronger, and last about 60 seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions.

16. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert?

Endometritis

Endometriosis

Salpingitis

Pelvic thrombophlebitis

Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Endometriosis does not occur after strong labor and prolonged rupture of membranes. Salpingitis is a tubal infection and could occur if endometritis is not treated. Pelvic thrombophlebitis involves clot formation, but it is not a complication of prolonged rupture of membranes.

Explanation

Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Endometriosis does not occur after strong labor and prolonged rupture of membranes. Salpingitis is a tubal infection and could occur if endometritis is not treated. Pelvic thrombophlebitis involves clot formation, but it is not a complication of prolonged rupture of membranes.

17. A primigravida client at 25 weeks’ gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform the following:

Tailor sitting

Leg lifting

Shoulder circling

Squatting exercises

Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time.

Explanation

Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time.

18. A client at 36 weeks gestation is scheduled for a routine ultrasound prior to amniocentesis. After teaching the client about the purpose of the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction?

The ultrasound will help to locate the placenta.

The ultrasound identifies blood flow through the umbilical cord.

The test will determine where to insert the needle.

The ultrasound locates a pool of amniotic fluid.

Before amniocentesis, routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.

Explanation

Before amniocentesis, routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.

19. A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clothes. What is the primary nursing diagnosis for this patient?

Knowledge deficit

Fluid volume deficit

Anticipatory grieving

Pain

If bleeding and cloth are excessive, this patient may become hypovolemic. A pad count should be instituted. Although the other diagnoses are applicable to this patient, they are not the primary diagnosis.

Explanation

If bleeding and cloth are excessive, this patient may become hypovolemic. A pad count should be instituted. Although the other diagnoses are applicable to this patient, they are not the primary diagnosis.

20. A 31-year-old multipara is admitted to the birthing room after an initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 stations. What phase of labor is she in?

Active phase

Latent phase

Expulsive phase

Transitional phase

The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. The latent phase extends from 0 to 3 cm; it is mild in nature. The active phase extends from 4 to 7 cm; it is moderate for the patient. The expulsive phase begins immediately after birth and ends with the separation and expulsion of the placenta.

Explanation

The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. The latent phase extends from 0 to 3 cm; it is mild in nature. The active phase extends from 4 to 7 cm; it is moderate for the patient. The expulsive phase begins immediately after birth and ends with the separation and expulsion of the placenta.

21. A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in the early part of the first stage of labor. Her pain is likely to be most intense:

Around the pelvic girdle

Around the pelvic girdle and in the upper arms

Around the pelvic girdle and at the perineum

At the perineum

During most of the first stage of labor, pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage, the pain spreads to the upper legs and perineum. During the late part of the second stage and during childbirth, intense pain occurs at the perineum. Upper arm pain is not common during the ant stage of labor.

Explanation

During most of the first stage of labor, pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage, the pain spreads to the upper legs and perineum. During the late part of the second stage and during childbirth, intense pain occurs at the perineum. Upper arm pain is not common during the ant stage of labor.

22. Which of the following would the nurse Sandra most likely expect to find when assessing a pregnant client with an abruption placenta?

Excessive vaginal bleeding

Rigid, boardlike abdomen

Titanic uterine contractions

Premature rupture of membranes

The most common assessment finding in a client with an abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common.

Explanation

The most common assessment finding in a client with an abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common.

23. Thirty hours after delivery, the nurse in charge plans discharges, teaching the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following?

Taking in

Letting go

Taking hold

Resolution

The beginning after the completion of the taking-in phase, the taking-hold phase lasts about 10 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills.

Explanation

The beginning after the completion of the taking-in phase, the taking-hold phase lasts about 10 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills.

24. After 3 days of breastfeeding, a postpartum patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she:

Apply warm compresses to her nipples just before feedings

Lubricate her nipples with expressed milk before feeding

Dry her nipples with a soft towel after feedings

Apply soap directly to her nipples, and then rinse

Measures that help relieve nipple soreness in a breast-feeding patient include lubricating the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feeding, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples.

Explanation

Measures that help relieve nipple soreness in a breast-feeding patient include lubricating the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feeding, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples.

25. A female adult patient is taking a progestin-only oral contraceptive or minipill. Progestin use may increase the patient’s risk for:

Endometriosis

Female hypogonadism

Premenstrual syndrome

Tubal or ectopic pregnancy

Women taking the mini pill have a higher incidence of tubal and ectopic pregnancies, possibly because progestin slows ovum transport through the fallopian tubes. Endometriosis, female hypogonadism, and premenstrual syndrome are not associated with progestin-only oral contraceptives.

Explanation

Women taking the mini pill have a higher incidence of tubal and ectopic pregnancies, possibly because progestin slows ovum transport through the fallopian tubes. Endometriosis, female hypogonadism, and premenstrual syndrome are not associated with progestin-only oral contraceptives.

26. Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient’s fluid intake and output closely during oxytocin administration?

Oxytocin causes water intoxication

Oxytocin causes excessive thirst

Oxytocin is toxic to the kidneys

Oxytocin has a diuretic effect

The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results from the work of labor and limited oral fluid intake—not oxytocin. Oxytocin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect.

Explanation

The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results from the work of labor and limited oral fluid intake—not oxytocin. Oxytocin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect.

27. A client tells the nurse, “I think my baby likes to hear me talk to him.” When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response?

High-pitched speech with tonal variations

Low-pitched speech with the sameness of tone

Cooing sounds rather than words

Repeated stimulation with loud sounds

Providing stimulation and speaking to neonates is important. Some authorities believe that speech is the most important type of sensory stimulation for a neonate. Neonates respond best to speech with tonal variations and a high-pitched voice. A neonate can hear all sounds louder than about 55 decibels.

Explanation

Providing stimulation and speaking to neonates is important. Some authorities believe that speech is the most important type of sensory stimulation for a neonate. Neonates respond best to speech with tonal variations and a high-pitched voice. A neonate can hear all sounds louder than about 55 decibels.

28. Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss?

Low room humidity

Cold weight scale

Cools incubator walls

Cool room temperature

The common source of radiant heat loss includes cool incubator walls and windows. Low room humidity promotes evaporative heat loss. When the skin directly contacts a cooler object, such as a cold weight scale, conductive heat loss may occur. A cool room temperature may lead to convective heat loss.

Explanation

The common source of radiant heat loss includes cool incubator walls and windows. Low room humidity promotes evaporative heat loss. When the skin directly contacts a cooler object, such as a cold weight scale, conductive heat loss may occur. A cool room temperature may lead to convective heat loss.

29. After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur?

Decreased peristalsis

Increase heart rate

Dry mucous membranes

Nausea and Vomiting

Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating may gently increase.

Explanation

Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating may gently increase.

30. While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse’s most appropriate action?

Note the fetal heart rate patterns

Notify the physician immediately

Administer oxygen at 6 liters by mask

Have the client pant-blow during the contractions

The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists.

Explanation

The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists.