At one minute after birth, a neonate is pink, except for blue extremit

NCLEX Maternity Questions

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Question 1 of 5.

At one minute after birth, a neonate is pink, except for blue extremities. The neonate is crying, gagging, and grimacing when the bulb syringe is used and has some flexion of extremities and an HR of 97. Based on the Apgar score, what should the nurse do next?

A. Notify the health care provider

B. Recheck the Apgar at 5 minutes after birth

C. Initiate resuscitation measures immediately

D. Swaddle and hand to mother for breastfeeding

Explanation: Rechecking the Apgar score at 5 minutes after birth will determine if the newborn is continuing to make a good transition to the extrauterine environment. Notifying the HCP is not necessary at this time. The one-minute Apgar score is 6, very close to the 7 to 10 normal limits. This newborn has a good cry, indicating good transition to the extrauterine environment thus far. Initiating resuscitation measures immediately is not necessary. This would be done if the newborn were not crying and demonstrated a blue or pale body. Swaddling and giving the newborn to the mother for breastfeeding are important but should occur after the 5-minute Apgar, if the score is WNL. Keeping this newborn in the radiant warmer, rather than giving him or her to the mother, will help prevent hypothermia and promote better transition to extrauterine life.

Question 2 of 5.

When the client asks the nurse about the viability of the ovum after ovulation, the nurse correctly explains that after ovulation, the ovum remains alive for how many hours?

A. 2 hours

B. 24 hours

C. 48 hours

D. 72 hours

Explanation: The ovum remains viable for approximately 24 hours after ovulation, during which it can be fertilized by sperm.

Question 3 of 5.

The nurse correctly sends a requisition and specimen for which laboratory test?

A. Alpha-fetoprotein (AFP)

B. Corticotropin-releasing hormone (CRH)

C. Human chorionic gonadotropin (hCG)

D. Follicle-stimulating hormone (FSH)

Explanation: Human chorionic gonadotropin (hCG) is the hormone tested to confirm pregnancy, as it is produced by the placenta shortly after implantation.

Question 4 of 5.

According to the TPAL method, which of the following reflects the client's obstetric history?

A. T-III, P-0, A-0, L-III

B. T-III, P-II, A-0, L-0

C. T-III, P-II, A-0, L-II

D. T-III, P-0, A-0, L-III

Explanation: TPAL: Term (3, one son and twin daughters), Preterm (0), Abortions (0), Living (3). The client has three term deliveries and three living children.

Question 5 of 5.

Which action by the nurse best ensures that an accurate fetal heart rate is obtained?

A. Assess the fetal heart rate when the client is lying on her right side.

B. Assess the fetal heart rate when the client reports fetal movement.

C. Assess the fetal heart rate between Braxton Hicks contractions.

D. Assess the maternal pulse and fetal heart rate, and compare the two.

Explanation: Comparing maternal pulse with fetal heart rate ensures the nurse is not mistaking the maternal pulse for the fetal heartbeat.