NCLEX RN Questions Maternal Newborn Nursing
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Question 1 of 5.
Extract:The nurse is caring for a newborn who just had a circumcision Item 1 of 1 • Nurses' Note 1730 – First diaper change since circumcision. Three dried blood spots were noted in the diaper and a moderate amount of straw-colored urine. The diaper was changed, and petroleum jelly was reapplied to the penis. Erythema was noted at the tip of the penis. No crying or signs of pain distress were observed during the diaper change. Reviewed after-care instructions to the parents. • Vital Signs Axillary Temperature 97.0o F (36o C) Pulse 134/minute Respirations 44/minute O2 saturation 96% on room air
Click to specify if the statements made by the parent indicate effective teaching or require follow-up
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Explanation: After reviewing aftercare instructions with the parents of a newborn who just had a circumcision, the nurse should follow up with the parents if they state that they will wipe off any yellow exudate that may appear. This is a normal finding and will disappear within a week. Premoistened alcohol-based baby wipes should be avoided because they irritate the incision and cause discomfort to the infant. Infants should always ride in a rear-facing car seat, in the back seat, even after a circumcision. While the car seat may irritate, the infant's safety is essential, and riding anywhere else but a rear-facing car seat is dangerous. It would indicate effective teaching if the client states they will fasten the diaper loosely while the circumcision heals. This prevents the penis from adhering to the diaper and causing irritation.
Question 2 of 5.
The nurse is conducting a prenatal class with a group of clients. Which vitamin should the nurse encourage to prevent neural tube defects in the newborn?
A. Folic acid
B. Vitamin B12
C. Vitamin E
D. Iron
Explanation: Folic acid is critical for neural tube closure in early fetal development, reducing the risk of defects like spina bifida.
Question 3 of 5.
The nurse is reviewing a client's contraction stress test results. Which action should the nurse take based on the results? Click the exhibit button for additional client information.
A. obtain an order for a biophysical screening
B. document the results as within normal limits
C. perform Leopold maneuvers
D. obtain a urine specimen and assess for proteinuria
Explanation: A positive or equivocal CST result suggests fetal compromise, warranting further evaluation with a biophysical profile.
Question 4 of 5.
At 25 weeks gestation, a pregnant client presents with a uterine growth size that is less than expected, decreased fetal movement, and an easily palpable fetus. Which of the following is this likely related to?
A. Oligohydramnios
B. Macrosomia
C. Hydramnios
D. Amniotic fluid embolism
Explanation: Oligohydramnios (low amniotic fluid) can cause reduced uterine size, decreased fetal movement, and easier palpation of the fetus.
Question 5 of 5.
A pregnant client who is Rh-negative is ordered an indirect Coombs' test. The nurse understands that the purpose of this test is to determine
A. if antibodies are present from previous exposure to Rh-positive blood.
B. the amount of time that it takes for fetal blood to clot.
C. the blood type, Rh factor, and antibody titer of the newborn.
D. if the fetus has a risk of developing pernicious anemia later in life.
Explanation: The indirect Coombs' test detects maternal antibodies against Rh-positive fetal blood, indicating potential Rh isoimmunization.
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