Maternity and Newborn NCLEX RN Questions
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Question 1 of 5.
The nurse is assessing a client in labor and observes a fetal heart rate of 190 beats per minute. The nurse should take which appropriate action? Select all that apply.
A. Place the client in a left side lying position
B. Decrease the rate of intravenous fluids
C. Administer oxygen
D. Obtain a prescription for intravenous oxytocin
E. Place the client in the Trendelenburg position
Explanation: A fetal heart rate of 190 bpm indicates tachycardia, suggesting distress. Placing the client on the left side (A) improves placental perfusion. Administering oxygen (C) enhances fetal oxygenation. Decreasing IV fluids (B) is not indicated unless fluid overload is present. Oxytocin (D) could worsen distress. Trendelenburg (E) is used for cord prolapse, not tachycardia.
Question 2 of 5.
The nurse is caring for a client in the third trimester of pregnancy. Which of the following assessment findings would be expected? Select All That Apply.
A. Persistent abdominal pain
B. Increased fetal movement
C. Swollen ankles and feet
D. Weight loss
E. Decreased frequency of urination
Explanation: Increased fetal movement and swollen ankles/feet are normal due to fetal growth and fluid retention. Persistent abdominal pain, weight loss, and decreased urination are concerning and require investigation.
Question 3 of 5.
Your pregnant client has been hospitalized with hyperemesis gravidarum. She is given ondansetron to treat this illness. What serious side effects should the hospital nurses be watching for?
A. Continued nausea and vomiting
B. Prolonged QT interval
C. Respiratory distress
D. Constipation
Explanation: Ondansetron can cause prolonged QT interval, a serious cardiac risk, requiring monitoring.
Question 4 of 5.
The nurse is performing an obstetrics history on a client who is pregnant at 25 gestational weeks. The client reports giving birth to twins at 31 weeks of gestation. She had a stillborn infant at 23 weeks gestation and a spontaneous abortion at 12 weeks gestation. The nurse is correct in documenting her GTPAL as
A. G4-T0-P2-A1-L2
B. G4-T0-P1-A2-L2
C. G4-T0-P1-A2-L3
D. G4-T1-P1-A1-L2
Explanation: GTPAL: G4 (4 pregnancies), T0 (no term births), P2 (twins at 31 weeks, preterm), A1 (spontaneous abortion), L2 (two living children from twins).
Question 5 of 5.
The nurse is caring for a pregnant client who has a rubella infection. Which of the following issues is the client's fetus at risk of developing? Select all that apply.
A. intrauterine growth restriction (IUGR)
B. hemolytic disease
C. hydrocephaly
D. large for gestational age (LGA)
E. stillbirth
Explanation: Rubella can cause congenital rubella syndrome, leading to IUGR, hydrocephaly, and stillbirth. Hemolytic disease and LGA are unrelated.
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