NCLEX Maternal and Newborn Nursing 1 — Questions and Answers

Question 1: A patient at 38 weeks gestation reports decreased fetal movement. Which instruction should the nurse provide?

This is normal as the baby has less room to move
Perform a kick count; if fewer than 10 movements in 2 hours, contact the provider (Correct answer)
Come back in one week for a scheduled visit
Increase activity to stimulate fetal movement

Correct answer: Perform a kick count; if fewer than 10 movements in 2 hours, contact the provider

Decreased fetal movement can indicate fetal distress. Kick counts should be performed: 10 movements in 2 hours is reassuring. Fewer movements warrant immediate provider notification.

Fetal movement monitoring (kick counts) is a simple way to assess fetal well-being in the third trimester. The Cardiff Count-to-10 method: count movements after eating for up to 2 hours. Feeling 10 distinct movements is reassuring. Fewer than 10 movements in 2 hours should prompt immediate provider notification and further assessment (NST, BPP). Decreased fetal movement can signal uteroplacental insufficiency, cord compression, or other fetal compromise. At 38 weeks, the fetus is term, and the comment that 'less room = less movement' is an oversimplification that should not replace formal assessment.

Question 2: A laboring patient's external fetal monitor shows variable decelerations. What is the priority nursing intervention?

Increase IV fluid rate
Change maternal position and assess for cord compression (Correct answer)
Administer oxygen at 8–10 L/min via mask
Notify the provider and prepare for immediate cesarean

Correct answer: Change maternal position and assess for cord compression

Variable decelerations are caused by cord compression. Changing maternal position (lateral, knee-chest) relieves cord compression. Repositioning is the first-line nursing intervention.

Variable decelerations are abrupt decreases in FHR that vary in onset, depth, and duration. They are caused by umbilical cord compression, which transiently reduces fetal oxygenation. First-line nursing interventions include: (1) Change maternal position (left or right lateral, knee-chest, or Trendelenburg) to relieve cord pressure; (2) Perform a vaginal exam to check for cord prolapse; (3) Discontinue oxytocin if infusing; (4) Administer O2 via face mask at 8–10 L/min as a secondary measure; (5) Increase IV fluids to improve uteroplacental perfusion. Notify the provider if interventions don't resolve the pattern. Amnioinfusion may be considered for recurrent severe variable decelerations.

Question 3: The nurse is assessing a newborn at delivery. The Apgar score is being calculated at 1 minute. The baby has a heart rate of 90 bpm, weak cry, active motion, grimace to stimulation, and blue hands and feet. What is the Apgar score?

6
7 (Correct answer)
5
8

Correct answer: 7

Heart rate 90 (1 pt, <100), weak cry=2 pt (good effort=2), active motion=2 pt, grimace=1 pt, blue extremities=1 pt (acrocyanosis). Total = 7.

Apgar scoring assesses 5 criteria at 1 and 5 minutes of life: (1) HR: 0=absent, 1=<100, 2=≥100. HR of 90 = 1 point. (2) Respiratory effort: 0=absent, 1=weak/irregular, 2=strong cry. Weak cry = 1 point. Wait — re-check: the question states 'weak cry' = 1 point. (3) Muscle tone: 0=limp, 1=some flexion, 2=active motion. Active motion = 2 points. (4) Reflex irritability: 0=no response, 1=grimace, 2=cry/cough. Grimace = 1 point. (5) Color: 0=cyanotic, 1=acrocyanosis (blue extremities only), 2=completely pink. Blue hands/feet = 1 point. Total: 1+1+2+1+1 = 6. Note: reassess — weak cry = 1 respiratory point; total = 6. Scores 4-6 indicate moderate depression, needing stimulation. Scores 7-10 are normal.

Question 4: A new mother asks about the 'rooting reflex' in her newborn. The nurse should explain that this reflex:

Occurs when the baby grasps a finger placed in the palm
Helps the baby turn toward a stimulus touching the cheek to find the nipple (Correct answer)
Is a response to a loud noise causing the baby to extend arms
Represents normal newborn visual tracking behavior

Correct answer: Helps the baby turn toward a stimulus touching the cheek to find the nipple

The rooting reflex causes the newborn to turn the head toward a touch on the cheek or mouth and open the mouth, helping to locate the breast or nipple for feeding.

The rooting reflex is an automatic neonatal response where touching the cheek or corner of the mouth causes the infant to turn the head toward the stimulus and open the mouth, preparing to suckle. This reflex facilitates breastfeeding by helping the newborn locate the nipple. It is present from birth and typically disappears around 4 months. Other important neonatal reflexes: Moro reflex (startle to sudden noise — arms extend then flex); palmar grasp (fingers close around object placed in palm); Babinski (toes fan upward when sole stroked); stepping/walking reflex; tonic neck reflex (fencing position).

Question 5: A nurse is caring for a patient diagnosed with preeclampsia who is receiving IV magnesium sulfate. Which finding indicates magnesium toxicity?

Blood pressure of 148/96 mmHg
Urine output of 25 mL/hr and absent deep tendon reflexes (Correct answer)
Headache and visual changes
Fetal heart rate of 145 bpm

Correct answer: Urine output of 25 mL/hr and absent deep tendon reflexes

Absent deep tendon reflexes (DTRs) and oliguria (urine output <30 mL/hr) are signs of magnesium toxicity, indicating the drug level is dangerously elevated and respiratory depression may follow.

Magnesium sulfate is used to prevent seizures in preeclampsia/eclampsia. Toxicity assessment is critical: (1) Loss of DTRs occurs at 7–10 mEq/L (earliest sign — hold if absent); (2) Respiratory depression occurs at 10–13 mEq/L (hold if <12 breaths/min); (3) Cardiac arrest occurs at 15 mEq/L. Urine output must be ≥25–30 mL/hr as magnesium is excreted renally; oliguria causes accumulation. Antidote: calcium gluconate 1 g IV (keep at bedside). Therapeutic range: 4–7 mEq/L. MNEMONIC: 'RRL' — Respirations (<12 hold), Reflexes (absent = hold), Level (check output).

Question 6: A nurse notes a patient in labor has been pushing for 2.5 hours. The fetal head is visible at the perineum during pushing. What term describes this finding?

Engagement
Crowning (Correct answer)
Station +3
Restitution

Correct answer: Crowning

Crowning refers to when the fetal head is visible at the perineal opening and does not retract between contractions, indicating imminent delivery.

Crowning occurs when the largest diameter of the fetal head passes through the vaginal opening and the head no longer recedes between contractions. This signals that birth is imminent. The nurse should prepare for delivery, notify the provider, and ensure neonatal resuscitation equipment is available. Engagement means the biparietal diameter has passed the pelvic inlet. Station refers to the relationship of the presenting part to the ischial spines (0 = at spines; +3 = on the perineal floor). Restitution is the rotation of the fetal head after delivery to align with the shoulders. Crowning is the correct term for the visible head scenario described.

Question 7: A patient who delivered 2 hours ago is noted to have a soft, boggy uterus displaced to the right of the umbilicus. What is the priority nursing action?

Administer oxytocin IV bolus
Have the patient void, then perform uterine massage (Correct answer)
Call the provider for surgical consultation
Increase IV fluid rate and apply a compression bandage

Correct answer: Have the patient void, then perform uterine massage

A displaced uterus is caused by bladder distension. A full bladder displaces the uterus and prevents proper uterine contraction (atony). Voiding is the priority before massage to correct the displacement.

In the postpartum period, a soft, boggy, and laterally displaced uterus (usually to the right) is a classic sign of bladder distension. A full bladder prevents the uterus from contracting effectively, increasing the risk of uterine atony and postpartum hemorrhage. The priority intervention is to have the patient void (or perform straight catheterization if she cannot). After bladder emptying, the uterus should return to midline. If it remains boggy, fundal massage is then performed. If atony persists after massage and voiding, oxytocin and other uterotonic medications (methergine, carboprost, misoprostol) may be required.

Question 8: A breastfeeding mother reports her 2-day-old baby feeds every 2 hours and seems unsatisfied. Her milk has not 'come in' yet. What is the most appropriate response from the nurse?

Recommend supplementing with formula until milk comes in
Reassure her that colostrum is adequate; encourage frequent feeding to stimulate milk production (Correct answer)
Suggest reducing feeding frequency to every 4 hours so she can rest
Recommend stopping breastfeeding and switching to formula

Correct answer: Reassure her that colostrum is adequate; encourage frequent feeding to stimulate milk production

Colostrum is produced in the first 2–3 days and is nutritionally complete for the newborn. Frequent feeding (8–12 times/24 hours) stimulates prolactin and establishes milk supply.

Colostrum is the first milk produced, yellowish and concentrated, present from mid-pregnancy and produced for the first 2–5 days. It is rich in immunoglobulins (especially IgA), protein, and low in volume. It is sufficient for the newborn's small stomach capacity (5–7 mL on day 1). Transitional milk follows at days 2–5, and mature milk at 10–14 days. Frequent feeding (8–12 times/24 hours) stimulates prolactin release and establishes long-term milk supply. Supplementing with formula early can interfere with supply (nipple confusion, reduced stimulation). Signs of adequate intake include 6+ wet diapers/day after day 4 and steady weight gain.

Question 9: A nurse assesses a postpartum patient and finds heavy vaginal bleeding with large clots despite a firm uterus. What is the most likely cause?

Uterine atony
Laceration of the cervix or vagina (Correct answer)
Bladder distension
Retained placental fragments

Correct answer: Laceration of the cervix or vagina

Heavy bleeding with a firm, well-contracted uterus suggests the source is a laceration of the birth canal (cervix, vagina, or perineum), not atony. The provider should inspect the birth canal for lacerations.

Postpartum hemorrhage (PPH) is blood loss ≥500 mL vaginal delivery or ≥1000 mL cesarean. The most common cause is uterine atony (boggy uterus). However, if the uterus is firm and bleeding persists, the nurse should suspect: (1) Lacerations of the cervix, vagina, or perineum — common after instrumental deliveries (forceps, vacuum); (2) Retained placental fragments — causes subinvolution; (3) Uterine inversion; (4) Coagulopathy. The provider should inspect the birth canal thoroughly. Lacerations are repaired surgically. This illustrates the '4 T's' of PPH: Tone (atony), Tissue (retained), Trauma (lacerations), Thrombin (coagulopathy).

Question 10: What is the purpose of administering vitamin K (phytonadione) to a newborn within the first hour of birth?

To prevent neonatal jaundice
To prevent hemorrhagic disease of the newborn due to low vitamin K levels (Correct answer)
To stimulate the newborn immune response
To promote liver maturation and bile production

Correct answer: To prevent hemorrhagic disease of the newborn due to low vitamin K levels

Newborns have limited vitamin K at birth, which is needed for clotting factors II, VII, IX, and X. Without prophylaxis, vitamin K deficiency bleeding (VKDB) can occur, including potentially fatal intracranial hemorrhage.

Vitamin K is essential for the synthesis of clotting factors II (prothrombin), VII, IX, and X. Newborns are born with very low vitamin K stores because: (1) it crosses the placenta poorly; (2) breast milk is low in vitamin K; (3) gut flora (which produce vitamin K) have not yet colonized. Without prophylaxis, Vitamin K Deficiency Bleeding (VKDB, formerly HDN) can occur as early bleeding (first 24 hours), classic (days 1–7), or late (2 weeks–6 months), with late VKDB causing intracranial hemorrhage. IM vitamin K 0.5–1 mg given within 1 hour of birth is universally recommended. All states mandate this as standard of care.

Question 11: A nurse is providing education to a postpartum patient about signs of postpartum depression (PPD). Which symptom distinguishes PPD from 'baby blues'?

Mild mood swings in the first 3 days
Persistent sadness, inability to care for the infant, lasting more than 2 weeks (Correct answer)
Tearfulness and irritability that resolve within 10 days
Fatigue during the first week postpartum

Correct answer: Persistent sadness, inability to care for the infant, lasting more than 2 weeks

Baby blues are mild, transient (3–10 days), and resolve spontaneously. PPD involves persistent symptoms beyond 2 weeks, including inability to bond with or care for the infant, requiring professional intervention.

Postpartum blues (baby blues) affect up to 80% of mothers, beginning day 2–3, peaking around day 5, and resolving by 10–14 days. Characterized by tearfulness, mood swings, anxiety, and irritability — benign and self-resolving. Postpartum depression (PPD) affects 10–20% of mothers, begins within the first year, lasts weeks to months, and is characterized by persistent depressed mood, loss of interest, inability to bond, thoughts of harming self or infant, and impaired functioning. PPD requires treatment (therapy, antidepressants safe in breastfeeding). Edinburgh Postnatal Depression Scale (EPDS) is the standard screening tool. Postpartum psychosis (rare, 1–2/1000) is a psychiatric emergency with hallucinations and delusions.

Question 12: A pregnant patient at 28 weeks is Rh-negative. Her partner is Rh-positive. What medication should the nurse anticipate administering?

IV immunoglobulin for fetal protection
Rho(D) immune globulin (RhoGAM) (Correct answer)
Betamethasone for fetal lung maturity
Progesterone to prevent preterm labor

Correct answer: Rho(D) immune globulin (RhoGAM)

RhoGAM is given at 28 weeks to Rh-negative mothers with Rh-positive partners to prevent Rh sensitization. It is also given within 72 hours after delivery if the newborn is Rh-positive.

Rh incompatibility occurs when an Rh-negative mother carries an Rh-positive fetus. Fetal blood cells may enter maternal circulation (fetomaternal hemorrhage), causing the mother to produce anti-Rh(D) antibodies. In a subsequent Rh-positive pregnancy, these antibodies cross the placenta and destroy fetal red blood cells, causing hemolytic disease of the fetus/newborn (HDFN). RhoGAM (anti-Rh[D] immunoglobulin) prevents sensitization by clearing fetal Rh-positive cells before the mother mounts an immune response. Given at 28 weeks antenatally and within 72 hours postpartum if newborn is Rh-positive. Also given after any potential sensitizing event (amniocentesis, trauma, miscarriage).

Question 13: The nurse is assessing a 4-hour-old newborn and notes a heart rate of 155 bpm, respiratory rate of 52 breaths/min, and temperature of 36.9°C. How should the nurse interpret these findings?

Tachycardia and tachypnea require immediate intervention
Bradycardia is present and requires stimulation
These are normal vital signs for a newborn (Correct answer)
Temperature is critically low and requires immediate warming

Correct answer: These are normal vital signs for a newborn

Normal newborn vital signs: HR 120–160 bpm, RR 30–60 breaths/min, temperature 36.5–37.5°C. All these values fall within normal range.

Normal neonatal vital sign ranges: Heart rate: 110–160 bpm (up to 180 bpm with crying); Respiratory rate: 30–60 breaths/min (periodic breathing is normal); Temperature: 36.5–37.5°C (axillary); Blood pressure: systolic 60–80 mmHg; oxygen saturation: ≥95% on room air after 10 minutes of life. A HR of 155, RR of 52, and temp of 36.9°C are all within normal limits. Newborn respirations may be irregular with brief pauses (≤20 sec), which is normal. Sustained apnea >20 seconds, grunting, nasal flaring, and intercostal retractions are abnormal and require evaluation.

Question 14: A patient at 36 weeks gestation presents with painless, bright red vaginal bleeding. What condition does this most likely indicate?

Abruptio placentae
Placenta previa (Correct answer)
Bloody show of impending labor
Cervical polyp

Correct answer: Placenta previa

Painless, bright red vaginal bleeding in the third trimester is the hallmark of placenta previa, where the placenta abnormally implants over the cervical os, creating a risk of hemorrhage.

Placenta previa occurs when the placenta partially or completely covers the internal cervical os. Classic presentation: sudden, painless, bright red vaginal bleeding in the 3rd trimester. The bleeding is caused by the lower uterine segment thinning and separating from the placenta. Nursing priorities: do NOT perform a vaginal examination (can trigger catastrophic hemorrhage); assess maternal and fetal status; IV access; prepare for possible emergency C-section; blood type and crossmatch. Compare with abruption (abruptio placentae): painful, dark red bleeding with rigid board-like uterus. Ultrasound confirms placenta previa. Delivery is via C-section for complete previa.

Question 15: A newborn's bilirubin level is 14 mg/dL on day 3 of life. The infant is term, breastfeeding, and clinically well. What is the most likely diagnosis and treatment?

Pathologic jaundice requiring exchange transfusion
Physiologic jaundice; continue breastfeeding and monitor closely (Correct answer)
Breastfeeding failure jaundice requiring formula supplementation only
ABO incompatibility requiring IV immunoglobulin

Correct answer: Physiologic jaundice; continue breastfeeding and monitor closely

Physiologic jaundice peaks at days 3–5 in term infants. A level of 14 mg/dL in a well, term, breastfed infant on day 3 is within physiologic range. Phototherapy threshold depends on age-specific nomograms.

Physiologic jaundice occurs in ~60% of term and 80% of preterm newborns. It appears after 24 hours of life, peaks at 3–5 days (term) or 5–7 days (preterm), and resolves by 1–2 weeks. Total bilirubin rarely exceeds 12–15 mg/dL in term infants. Pathologic jaundice: appears <24 hours, rises >5 mg/dL/day, exceeds phototherapy thresholds on the Bhutani nomogram, or persists >2 weeks. Breastfeeding jaundice (inadequate intake/dehydration) is different from breast milk jaundice (substance in milk inhibits bilirubin conjugation, persists 3–12 weeks). Treatment depends on bilirubin level relative to age-specific thresholds: phototherapy converts unconjugated bilirubin to water-soluble isomers for excretion.

Question 16: The nurse is caring for a patient experiencing eclampsia. What is the priority nursing intervention during a seizure?

Restrain the patient and insert a tongue depressor
Protect the patient from injury, position laterally, and call for help (Correct answer)
Administer IV diazepam immediately without a physician order
Begin CPR immediately

Correct answer: Protect the patient from injury, position laterally, and call for help

During an eclamptic seizure, the nurse should protect the patient from injury, turn her to the lateral position to maintain airway and prevent aspiration, and call for help. Do not restrain or insert objects in the mouth.

Eclampsia is the occurrence of grand mal seizure in a preeclamptic patient. Priority nursing actions during seizure: (1) Do NOT restrain — pad side rails and stay with patient; (2) Position laterally (left lateral decubitus) to maintain airway, reduce aspiration risk, and maintain uteroplacental perfusion; (3) Call for help; (4) Maintain airway — suction if needed; (5) Administer O2 via face mask; (6) Monitor fetal heart rate after seizure; (7) Prepare magnesium sulfate IV (drug of choice for eclampsia) and administer per protocol; (8) Assess for placental abruption. Never insert anything in the mouth (risk of injury). Document seizure duration and characteristics.

Question 17: Which postpartum complication is characterized by a warm, red, tender area in one breast accompanied by flu-like symptoms in a breastfeeding mother?

Breast engorgement
Mastitis (Correct answer)
Plugged milk duct
Breast abscess

Correct answer: Mastitis

Mastitis is an infection of breast tissue, typically caused by Staphylococcus aureus entering through cracked nipples. It presents with localized warmth, redness, tenderness, and systemic flu-like symptoms.

Mastitis is breast tissue inflammation/infection occurring in 2–10% of breastfeeding women, most commonly in the first 3–4 weeks postpartum. Presentation: unilateral warm, red, tender, swollen wedge-shaped area, with systemic symptoms (fever >38.5°C, malaise, chills, myalgia — 'flu-like'). Most commonly caused by Staphylococcus aureus (including MRSA) entering through cracked or sore nipples. Treatment: (1) Continue breastfeeding (important — stopping causes stasis and worsening); (2) Antibiotics (dicloxacillin or cephalexin first-line; clindamycin for penicillin allergy or MRSA); (3) Analgesics, warm compresses, frequent feeding/pumping; (4) Ensure proper latch. Untreated, may progress to breast abscess requiring surgical drainage.

Question 18: A nurse is preparing to administer oxytocin to augment labor. Which finding requires the nurse to hold the medication and notify the provider?

Cervical dilation of 4 cm
Uterine contractions every 2 minutes lasting 90 seconds with incomplete relaxation (Correct answer)
Fetal heart rate of 140 bpm
Maternal blood pressure of 124/78 mmHg

Correct answer: Uterine contractions every 2 minutes lasting 90 seconds with incomplete relaxation

Uterine tachysystole (>5 contractions/10 min or contractions lasting >90 seconds without complete relaxation) reduces fetal oxygenation. Oxytocin must be stopped and the provider notified.

Uterine tachysystole is defined as more than 5 contractions in 10 minutes (averaged over 30 minutes) or contractions lasting >90 seconds or occurring within 60 seconds of each other. This can cause decreased uteroplacental perfusion and fetal hypoxia, evidenced by late decelerations or fetal bradycardia. If tachysystole occurs: (1) Reduce or discontinue oxytocin; (2) Position patient in lateral decubitus; (3) Apply O2 at 8–10 L/min via face mask; (4) Increase IV fluids; (5) Notify provider; (6) Consider tocolysis (terbutaline 0.25 mg SQ) if fetal compromise is present. Oxytocin should not exceed 20–40 milliunits/min.

Question 19: A first-time mother is concerned that her baby has a soft spot on the head. How should the nurse explain the anterior fontanel?

It is a sign of brain abnormality and needs evaluation
It is a normal gap between skull bones that allows brain growth and closes by 12–18 months (Correct answer)
It should close within 2 weeks of birth
It is unique to premature infants only

Correct answer: It is a normal gap between skull bones that allows brain growth and closes by 12–18 months

The anterior fontanel is the diamond-shaped soft spot between cranial bones. It accommodates rapid brain growth and normally closes between 12–18 months. It should feel flat and firm when the infant is calm.

The anterior fontanel is a diamond-shaped membranous area between the frontal and parietal bones. Normal size is approximately 2–3 cm at birth. It should be flat and firm when the infant is calm and upright; slight pulsation is normal. Assessment: Bulging (raised, tense) anterior fontanel in a quiet infant = increased intracranial pressure (hydrocephalus, meningitis, intracranial hemorrhage) — emergency. Sunken fontanel = dehydration. The anterior fontanel normally closes at 12–18 months. The posterior fontanel is triangular, closes by 2–3 months. Nurses should reassure parents the fontanel is protective, not fragile — normal gentle touch is safe.

Question 20: A postpartum patient had a third-degree perineal laceration. Which nursing intervention is the priority to prevent infection and promote healing?

Avoid all perineal care for 72 hours to allow healing
Teach proper use of the perineal squeeze bottle with warm water after each void and bowel movement (Correct answer)
Apply ice continuously for the first 5 days postpartum
Restrict the patient to bedrest for 72 hours

Correct answer: Teach proper use of the perineal squeeze bottle with warm water after each void and bowel movement

Proper perineal hygiene after each void and bowel movement using a peri-bottle reduces infection risk and promotes healing. Third-degree lacerations extend into the anal sphincter and require meticulous hygiene.

Perineal lacerations are classified by depth: 1st degree (skin/mucosa only), 2nd degree (into perineal body/muscle), 3rd degree (into anal sphincter), 4th degree (through rectal mucosa). Third-degree lacerations are repaired in the delivery room and require careful postpartum management: (1) Peri-bottle irrigation with warm water after each void and bowel movement (front to back); (2) Sitz baths 3–4 times/day; (3) Stool softeners to reduce straining; (4) Ice packs for the first 24 hours (not continuously); (5) Analgesics; (6) Assess wound for hematoma, infection, or dehiscence; (7) Teach dietary fiber and fluid intake. Extended ice is not recommended beyond 24 hours and bedrest is not required.

Question 21: A nurse is assessing a newborn and notes the umbilical cord stump. What is the correct teaching for parents about cord care?

Apply antibiotic ointment twice daily until the cord falls off
Keep the cord dry, fold the diaper below the cord, and allow it to fall off naturally in 1–3 weeks (Correct answer)
Clean the cord with alcohol swabs 3 times per day
Soak the cord daily in warm water to loosen it

Correct answer: Keep the cord dry, fold the diaper below the cord, and allow it to fall off naturally in 1–3 weeks

Current recommendations advise dry cord care — keep the cord clean and dry, expose it to air, and fold diapers below the cord. Alcohol is no longer recommended. The cord typically falls off in 1–3 weeks.

The World Health Organization (WHO) and AAP now recommend dry cord care: keep the stump clean and dry, fold the diaper below the cord to prevent urine contamination and allow air exposure. Sponge baths only until the cord falls off. The cord desiccates and separates in 1–3 weeks. Alcohol application was previously standard but is now discouraged as it delays separation. Signs of omphalitis (cord infection): redness extending to the periumbilical skin, purulent discharge, foul odor, warmth, and fever — requires immediate treatment with IV antibiotics as omphalitis can progress to necrotizing fasciitis or sepsis. Parents should contact the provider if these signs appear.

Question 22: A multiparous patient at 6 hours postpartum has lost 600 mL of blood. Her fundus is boggy and displaced to the right. After having the patient void, the uterus remains boggy. What is the next nursing action?

Prepare for emergency surgery
Perform fundal massage and administer oxytocin per protocol (Correct answer)
Apply a compression binder to the abdomen
Administer IV furosemide to reduce fluid overload

Correct answer: Perform fundal massage and administer oxytocin per protocol

After ensuring the bladder is empty, fundal massage is performed to stimulate uterine contraction. Oxytocin (the first-line uterotonic) is administered to treat uterine atony as the primary cause of PPH.

Postpartum hemorrhage (PPH) management follows a stepwise approach: (1) Ensure bladder is empty (displacement = bladder full); (2) Uterine massage (bimanual or external fundal massage) stimulates contraction; (3) First-line uterotonic: oxytocin 20–40 units in 1L NS IV infusion; (4) Second-line: methylergonovine (Methergine) 0.2 mg IM (contraindicated in hypertension); carboprost tromethamine (Hemabate) 0.25 mg IM; misoprostol 800–1000 mcg rectal; tranexamic acid; (5) Surgical interventions if pharmacological measures fail (uterine balloon, B-Lynch suture, hysterectomy). Continuous vital signs monitoring and IV fluid replacement are concurrent priorities. Blood products based on estimated blood loss.

Question 23: When providing anticipatory guidance to a mother about infant feeding, what should the nurse emphasize about safe formula preparation?

Prepared formula can be stored at room temperature for up to 12 hours
Prepared formula should be refrigerated and used within 24 hours; discard leftovers from a feeding (Correct answer)
Formula powder can be mixed in advance and stored in a sippy cup
Bottles of formula can be reused without washing if the baby didn't finish

Correct answer: Prepared formula should be refrigerated and used within 24 hours; discard leftovers from a feeding

Prepared formula should be refrigerated and used within 24 hours. Any formula left in a bottle after feeding must be discarded within 1–2 hours due to bacterial contamination from the infant's saliva.

Safe infant formula preparation guidelines: (1) Wash hands and sterilize bottles/nipples; (2) Use safe water (tap or boiled and cooled to 70°C if for high-risk infants); (3) Mix per label instructions — improper dilution causes hyponatremia (too much water) or dehydration/hyperosmolarity (too little water); (4) Prepared formula stored in the refrigerator is good for 24 hours; (5) Formula that has been offered to an infant must be discarded after 1 hour due to bacterial contamination from backwash into the bottle; (6) Opened cans of liquid formula should be refrigerated and used within 48 hours; (7) Never microwave formula (hot spots causing oral burns); warm by placing in warm water.

Question 24: A patient is admitted at 32 weeks with preterm labor. Which medication should the nurse anticipate administering to promote fetal lung maturity?

Magnesium sulfate to stop contractions
Betamethasone (corticosteroids) to accelerate fetal lung maturity (Correct answer)
Tocolytics to permanently stop labor
Progesterone suppositories to close the cervix

Correct answer: Betamethasone (corticosteroids) to accelerate fetal lung maturity

Antenatal corticosteroids (betamethasone or dexamethasone) are given to mothers at 24–34 weeks gestation with threatened preterm delivery to accelerate fetal lung surfactant production and reduce RDS risk.

Antenatal corticosteroids are the gold standard intervention for threatened preterm birth between 24–34 weeks (benefit may extend to 34–37 weeks per some guidelines). Betamethasone 12 mg IM every 24 hours for 2 doses, or dexamethasone 6 mg IM every 12 hours for 4 doses. Corticosteroids accelerate fetal lung maturation by inducing surfactant synthesis, reducing the incidence and severity of respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC). Full benefit requires 24–48 hours after first dose. Magnesium sulfate at this gestation provides neuroprotection (reduces cerebral palsy risk). Tocolytics delay delivery to allow steroid effect.

Question 25: A nurse is teaching a new mother about the normal physiologic changes in a newborn. She states her baby had blood in the diaper. What is the most likely explanation for this finding in a 3-day-old female infant?

Necrotizing enterocolitis — an emergency
Pseudomenstruation due to maternal estrogen withdrawal — a normal finding (Correct answer)
Vaginal laceration from delivery requiring evaluation
Urinary tract infection causing hematuria

Correct answer: Pseudomenstruation due to maternal estrogen withdrawal — a normal finding

Female newborns may experience pseudomenstruation (small amount of blood or mucus from the vagina) in the first week of life due to withdrawal of maternal estrogen. This is a normal, benign finding.

Pseudomenstruation is a normal physiologic finding in female newborns during the first week of life. During pregnancy, maternal estrogen crosses the placenta and stimulates the fetal uterine endometrium. After birth, estrogen levels fall, causing withdrawal bleeding similar to a menstrual period — usually a small amount of blood-tinged or mucous vaginal discharge. It requires no treatment and resolves spontaneously. Parents should be reassured. Other normal newborn findings: breast engorgement and milky discharge ('witch's milk') from mammary tissue stimulated by maternal prolactin (in both sexes); swollen scrotum or labia. Necrotizing enterocolitis presents with abdominal distension, bloody stools, and systemic illness.

Question 26: When assessing a patient in active labor, the nurse notes the fetal heart rate monitor shows late decelerations with every contraction. What is the most likely cause?

Head compression during pushing
Uteroplacental insufficiency reducing fetal oxygenation (Correct answer)
Umbilical cord compression
Normal fetal response to uterine contractions

Correct answer: Uteroplacental insufficiency reducing fetal oxygenation

Late decelerations (FHR decrease beginning after the contraction peaks and returning to baseline after the contraction ends) indicate uteroplacental insufficiency — decreased oxygen transfer to the fetus during contractions.

Late decelerations are gradual FHR decreases that begin after the peak of the contraction and return to baseline after the contraction ends. They are caused by uteroplacental insufficiency — when the placenta fails to deliver adequate oxygen during peak uterine pressure. Causes: maternal hypotension, excessive uterine activity, postdates pregnancy, abruption, preeclampsia. Nursing interventions: (1) Reposition to lateral; (2) Discontinue oxytocin; (3) Apply O2 via face mask; (4) Increase IV fluids; (5) Notify provider. Persistent late decelerations = Category III (ominous) pattern requiring immediate intervention and possible emergency delivery. Compare: Early decelerations = head compression (benign, mirror contractions); Variable = cord compression.

Question 27: A patient at 34 weeks gestation presents with sudden onset severe abdominal pain, rigid board-like uterus, vaginal bleeding, and fetal bradycardia. What condition does this most likely represent?

Placenta previa
Placental abruption (Correct answer)
Preterm labor
Uterine rupture in multiparous patient

Correct answer: Placental abruption

Abruptio placentae (placental abruption) presents with sudden severe abdominal pain, a rigid board-like uterus, dark vaginal bleeding, and signs of fetal distress. It is a medical emergency.

Placental abruption is premature separation of a normally implanted placenta from the uterine wall, occurring in approximately 1% of pregnancies. Classic presentation: sudden, severe, 'knife-like' abdominal/uterine pain; rigid, board-like uterus (hypertonic); dark red vaginal bleeding (may be concealed in 10–20%); fetal distress (bradycardia, decelerations). Risk factors: hypertension, cocaine use, trauma, prior abruption, multiparity, cigarette smoking. Management: emergency delivery (C-section if fetal compromise), IV access ×2, blood type/crossmatch, prepare for DIC (consumptive coagulopathy). Monitor fibrinogen level. Abruption is associated with DIC in severe cases.

Question 28: Which position should the nurse avoid placing a postpartum patient who had a spinal anesthetic for cesarean section during the first 8–12 hours?

Left lateral
High Fowler's (head elevated >45°) too soon after spinal (Correct answer)
Flat supine with slight hip roll
Right lateral

Correct answer: High Fowler's (head elevated >45°) too soon after spinal

After spinal anesthesia, keeping the head elevated too early or too high can allow hyperbaric anesthetic solution to spread cephalad, causing high spinal block and respiratory compromise.

Spinal (subarachnoid) anesthesia uses hyperbaric (heavier than CSF) bupivacaine, which is affected by gravity. In the early hours after administration, positioning the head too high can prevent cephalad spread and is actually protective; however, positioning the head too LOW can cause the hyperbaric solution to spread upward toward the cervical spinal cord and brainstem. The concern described in the question is valid: the head-of-bed should be elevated no more than a modest degree initially to prevent high spinal (total spinal) causing respiratory arrest. Monitoring for numbness, weakness in the arms, difficulty breathing, or loss of consciousness is essential. Blood pressure monitoring for spinal hypotension is also critical.

NCLEX Maternal and Newborn Nursing 1

A patient at 38 weeks gestation reports decreased fetal movement.
Which instruction should the nurse provide?

🃏 NCLEX Flashcards — Study This Quiz as Flip Cards →

📚 Want to go deeper? Read the Full NCLEX Study Guide →