NCLEX RN Questions Maternal Newborn Nursing
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Question 1 of 5.
The nurse is taking the vital signs of a pregnant client in active labor. When she inflates the blood pressure cuff, she looks at the fetal monitor and notices that the fetal heart rate increases above baseline and then returns to baseline about 15 seconds later. What is the priority nursing action?
A. Notify the healthcare provider
B. Document and continue to monitor
C. Place the mother on her left side
D. Administer 100% FiO2 via face mask
Explanation: A fetal heart rate increase and return to baseline (acceleration) is a reassuring sign of fetal well-being, requiring only documentation and continued monitoring (B). Notifying the provider (A), repositioning (C), or administering oxygen (D) is unnecessary unless nonreassuring patterns are present.
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.