Maternity nursing is a crucial component of the NCLEX exam, focusing on the care of women during pregnancy, childbirth, and the postpartum period, as well as the care of newborns. This article will provide 14 NCLEX-style questions related to maternity nursing, along with detailed answers and explanations to help you understand the concepts and improve your test-taking skills.
Question 1
A pregnant woman at 28 weeks gestation comes to the clinic for a routine prenatal visit. Which of the following assessments is most important at this time?
A. Blood pressure measurement
B. Fetal heart rate monitoring
C. Fundal height measurement
D. Urine glucose testing
Answer: C. Fundal height measurement
Explanation: At 28 weeks gestation, measuring the fundal height is crucial as it helps assess fetal growth and development. The fundal height should correlate with the gestational age in weeks, plus or minus 2 cm. Blood pressure, fetal heart rate, and urine glucose testing are also important but are routine assessments at every visit, not specifically emphasized at 28 weeks.
Question 2
A nurse is caring for a client in labor who is receiving oxytocin (Pitocin) for induction. Which of the following is the priority nursing action?
A. Monitor maternal blood pressure
B. Assess fetal heart rate
C. Measure urine output
D. Check cervical dilation
Answer: B. Assess fetal heart rate
Explanation: The priority action when administering oxytocin is to monitor the fetal heart rate closely. Oxytocin can cause uterine hyperstimulation, which can lead to fetal distress. While monitoring maternal blood pressure, urine output, and cervical dilation are important, ensuring fetal well-being takes precedence.
Question 3
A postpartum client is experiencing heavy bleeding. Which of the following actions should the nurse take first?
A. Administer oxytocin
B. Perform fundal massage
C. Check vital signs
D. Call the healthcare provider
Answer: B. Perform fundal massage
Explanation: The first action in the case of postpartum hemorrhage is to perform a fundal massage to help the uterus contract and reduce bleeding. Administering oxytocin, checking vital signs, and calling the healthcare provider are also important but should follow the immediate action of fundal massage.
Question 4
A nurse is teaching a client about breastfeeding. Which of the following statements indicates a need for further teaching?
A. "I should feed my baby every 2-3 hours."
B. "I will alternate breasts during each feeding."
C. "I can give my baby water between feedings."
D. "I should ensure my baby latches on properly."
Answer: C. "I can give my baby water between feedings."
Explanation: Breastfed infants do not need additional water between feedings as breast milk provides adequate hydration. The other statements are correct and indicate proper understanding of breastfeeding techniques.
Question 5
A nurse is caring for a newborn with jaundice. Which of the following interventions is most appropriate?
A. Administer vitamin K
B. Encourage frequent feedings
C. Keep the newborn under a radiant warmer
D. Perform a heel stick for blood glucose
Answer: B. Encourage frequent feedings
Explanation: Frequent feedings help promote bilirubin excretion through stools and urine, which is essential in managing jaundice. Administering vitamin K, using a radiant warmer, and checking blood glucose are important but not directly related to treating jaundice.
Question 6
A client at 36 weeks gestation presents with severe headache, visual disturbances, and epigastric pain. Which condition should the nurse suspect?
A. Gestational diabetes
B. Preeclampsia
C. Placenta previa
D. Preterm labor
Answer: B. Preeclampsia
Explanation: Severe headache, visual disturbances, and epigastric pain are classic signs of preeclampsia, a hypertensive disorder of pregnancy. Gestational diabetes, placenta previa, and preterm labor do not typically present with these symptoms.
Question 7
A nurse is assessing a newborn who is 5 minutes old. The newborn has a heart rate of 110, a weak cry, some flexion of extremities, a grimace response to stimulation, and a pink body with blue extremities. What is the Apgar score?
A. 5
B. 6
C. 7
D. 8
Answer: B. 6
Explanation: The Apgar score is calculated as follows:
- Heart rate: 110 (2 points)
- Respiratory effort: weak cry (1 point)
- Muscle tone: some flexion (1 point)
- Reflex irritability: grimace (1 point)
- Color: pink body, blue extremities (1 point) Total score: 6
Question 8
A nurse is providing discharge teaching to a postpartum client about signs of postpartum depression. Which of the following should be included?
A. Feeling overwhelmed and anxious
B. Experiencing mood swings
C. Having difficulty sleeping
D. All of the above
Answer: D. All of the above
Explanation: Postpartum depression can manifest as feeling overwhelmed and anxious, experiencing mood swings, and having difficulty sleeping. It is important for the client to recognize these signs and seek help if they occur.
Question 9
A client in labor is receiving an epidural for pain management. Which of the following is a priority nursing intervention?
A. Monitor for hypotension
B. Check for urinary retention
C. Assess pain level
D. Encourage position changes
Answer: A. Monitor for hypotension
Explanation: Hypotension is a common side effect of epidural anesthesia and can affect both the mother and the fetus. Monitoring blood pressure is crucial. Checking for urinary retention, assessing pain level, and encouraging position changes are also important but secondary to monitoring for hypotension.
Question 10
A nurse is caring for a client with preterm labor who is receiving magnesium sulfate. Which of the following findings indicates magnesium toxicity?
A. Respiratory rate of 16 breaths per minute
B. Deep tendon reflexes of +2
C. Urine output of 30 mL/hour
D. Absence of deep tendon reflexes
Answer: D. Absence of deep tendon reflexes
Explanation: Absence of deep tendon reflexes is a sign of magnesium toxicity. Other signs include respiratory depression, decreased urine output, and altered mental status. The other findings are within normal limits.
Question 11
A nurse is teaching a client about the use of Rh immunoglobulin (RhoGAM). Which statement indicates the client understands the teaching?
A. "I will need this injection if my baby is Rh-positive."
B. "I will receive this injection during my first trimester."
C. "This injection will prevent me from developing antibodies against Rh-positive blood."
D. "I will need this injection only if I have a miscarriage."
Answer: C. "This injection will prevent me from developing antibodies against Rh-positive blood."
Explanation: Rh immunoglobulin (RhoGAM) is given to prevent the development of antibodies against Rh-positive blood in an Rh-negative mother. It is typically administered at 28 weeks gestation and within 72 hours after delivery if the baby is Rh-positive. It is also given after any event where fetal-maternal blood mixing could occur, such as miscarriage.
Question 12
A nurse is caring for a client who is 1 hour postpartum. The client reports feeling dizzy and lightheaded. Which of the following actions should the nurse take first?
A. Check the client's blood pressure
B. Assess the client's fundus
C. Encourage the client to drink fluids
D. Assist the client to a sitting position
Answer: A. Check the client's blood pressure
Explanation: The first action should be to check the client's blood pressure to assess for hypotension, which could be causing the dizziness and lightheadedness. Assessing the fundus, encouraging fluid intake, and assisting to a sitting position are also important but should follow the initial assessment of blood pressure.
Question 13
A nurse is providing care to a newborn who is small for gestational age (SGA). Which of the following is a priority nursing intervention?
A. Monitor blood glucose levels
B. Assess for jaundice
C. Encourage frequent feedings
D. Keep the newborn warm
Answer: A. Monitor blood glucose levels
Explanation: Newborns who are small for gestational age are at risk for hypoglycemia. Monitoring blood glucose levels is the priority intervention. Assessing for jaundice, encouraging frequent feedings, and keeping the newborn warm are also important but secondary to monitoring glucose levels.
Question 14
A nurse is caring for a client in the second stage of labor. Which of the following actions should the nurse take?
A. Encourage the client to push with each contraction
B. Administer pain medication
C. Perform a sterile vaginal exam
D. Prepare for cesarean delivery
Answer: A. Encourage the client to push with each contraction
Explanation: During the second stage of labor, the nurse should encourage the client to push with each contraction to facilitate the delivery of the baby. Administering pain medication, performing a sterile vaginal exam, and preparing for cesarean delivery are not the primary actions during this stage.
Conclusion
Maternity nursing is a vital area of focus for the NCLEX exam, encompassing the care of pregnant women, new mothers, and newborns. Understanding the rationale behind each question and answer is essential for success. By studying these 14 NCLEX-style questions and their detailed explanations, you can enhance your knowledge and confidence in maternity nursing, ultimately improving your performance on the exam.
