NCLEX RN Practice Questions Maternal Newborn
Home / Nursing & Allied Health Certifications / NCLEX RN / RN Maternal Newborn
Question 1 of 5.
Extract:The nurse in the emergency department is caring for a 37-year-old female client. • History and Physical 0830: A 37-year-old nulliparous woman at 36 weeks gestation presents to the emergency department with complaints of severe headache, blurred vision, and upper abdominal pain. She reports feeling generally unwell and fatigued for the past 24 hours. Her pregnancy has been uncomplicated until now, with consistent prenatal care. On arrival, her vital signs are: blood pressure 160/100 mmHg, heart rate 88 bpm, respiratory rate 20 breaths per minute, temperature 98.6°F (37°C), and oxygen saturation 98% on room air. Physical exam reveals mild lower extremity edema and no signs of trauma. Fetal monitoring shows a baseline heart rate of 150 bpm with moderate variability, no accelerations, and no decelerations. The client has no uterine contractions. Orders 0830 • Complete Blood Count (CBC) • Comprehensive Metabolic Panel (CMP) • Urinalysis (UA) • Continuous Fetal Monitoring
The nurse is considering the client's intake information. Which findings warrant immediate follow-up by the nurse? Select all that apply.
A. Blood pressure of 160/100 mmHg
B. Heart rate of 88 bpm
C. Severe headache
D. Respiratory rate of 20 breaths/min
E. Blurred vision
F. Upper abdominal pain
Explanation: The findings that warrant immediate follow-up in this client include elevated blood pressure, severe headache, blurred vision, and upper abdominal pain. These symptoms may indicate significant physiological changes that could affect both maternal and fetal well-being. A markedly high blood pressure reading is a priority concern in any pregnant client, as it can compromise organ perfusion. Neurological symptoms such as headache and visual disturbances suggest possible central nervous system involvement and should be promptly evaluated. Upper abdominal pain may reflect underlying complications and requires immediate assessment to prevent deterioration. The remaining findings, heart rate of 88 bpm, respiratory rate of 20 breaths per minute, oxygen saturation of 98% on room air, a reassuring fetal heart rate with moderate variability, absence of uterine contractions, and mild lower extremity edema, are within normal limits or expected variations in late pregnancy. These findings do not indicate acute instability and, while they should be monitored, they do not require urgent follow-up at this time.
Question 2 of 5.
The nurse is reviewing antepartum tests for a client newly admitted to the labor and delivery unit. Which diagnostic test requires follow-up? See the exhibit.
A. Contraction stress test (CST)
B. Nonstress test (NST)
C. Fetal heart rate via transabdominal ultrasound
D. Vaginal culture for group B streptococcus (GBS)
Explanation: A contraction stress test (CST) requires follow-up if results are positive or equivocal, indicating potential fetal distress, as it assesses fetal response to uterine contractions.
Question 3 of 5.
You are seeing patients in an outpatient obstetrical clinic for their regularly scheduled prenatal appointments. Your patient is a G2P1 32-year-old woman who is 32 weeks pregnant. She says to you that she is concerned because she thinks she is developing striae gravidarum. When you assess the patient, what would you expect to see if she does present with this condition? Select the correct image.
A. Qstn 8-A- MN
B. Qstn 8-B- MN
C. Qstn 8-C- MN
D. Qstn 8-D- MN
Explanation: Striae gravidarum are stretch marks, typically reddish or silvery lines on the abdomen, breasts, or thighs, caused by skin stretching during pregnancy.
Question 4 of 5.
The nurse working on the labor and delivery floor is aware that which of the following maternal infections may increase the risk of developing congenital heart defects in the fetus?
A. Parainfluenza
B. Adenovirus
C. Rubella
D. Measles
Explanation: Rubella infection during pregnancy is associated with congenital heart defects in the fetus.
Question 5 of 5.
The nurse is supervising a nursing student to teach a pregnant client about a scheduled chorionic villus sampling (CVS) test. Which statement, if made by the nursing student, would require follow-up?
A. You will need to provide both a urine and blood sample for this test.
B. Drink plenty of water prior to this test and do not empty your bladder.
C. An ultrasound will be used during this procedure to guide the needle.
D. It is okay to eat and drink on the day of the procedure.
Explanation: CVS does not typically require urine or blood samples, as it involves sampling placental tissue.
Related Questions