Maternal and Newborn Nursing Flashcards
28 cards from real NCLEX practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 20 Maternal and Newborn Nursing flashcards as text
A patient at 38 weeks gestation reports decreased fetal movement. Which instruction should the nurse provide?
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.
A laboring patient's external fetal monitor shows variable decelerations. What is the priority nursing intervention?
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.
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?
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.
A new mother asks about the 'rooting reflex' in her newborn. The nurse should explain that this reflex:
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.
A nurse is caring for a patient diagnosed with preeclampsia who is receiving IV magnesium sulfate. Which finding indicates magnesium toxicity?
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.
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?
Answer: Crowning
Crowning refers to when the fetal head is visible at the perineal opening and does not retract between contractions, indicating imminent delivery.
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?
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.
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?
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.
A nurse assesses a postpartum patient and finds heavy vaginal bleeding with large clots despite a firm uterus. What is the most likely cause?
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.
What is the purpose of administering vitamin K (phytonadione) to a newborn within the first hour of birth?
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.
A nurse is providing education to a postpartum patient about signs of postpartum depression (PPD). Which symptom distinguishes PPD from 'baby blues'?
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.
A pregnant patient at 28 weeks is Rh-negative. Her partner is Rh-positive. What medication should the nurse anticipate administering?
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.
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?
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.
A patient at 36 weeks gestation presents with painless, bright red vaginal bleeding. What condition does this most likely indicate?
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.
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?
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.
The nurse is caring for a patient experiencing eclampsia. What is the priority nursing intervention during a seizure?
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.
Which postpartum complication is characterized by a warm, red, tender area in one breast accompanied by flu-like symptoms in a breastfeeding mother?
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.
A nurse is preparing to administer oxytocin to augment labor. Which finding requires the nurse to hold the medication and notify the provider?
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.
A first-time mother is concerned that her baby has a soft spot on the head. How should the nurse explain the anterior fontanel?
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.
A postpartum patient had a third-degree perineal laceration. Which nursing intervention is the priority to prevent infection and promote healing?
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.