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WorksheetsNCLEX - LABOR AND DELIVERY Day2 (Part 1)
Total questions: 15
Worksheet time: 15mins
Name
Class
Date
1.
The nurse is caring for a newborn who has a cleft palate. Which of the following actions should the nurse take to promote oral intake until the cleft palate is surgically repaired? Select all that apply.
a)
Use specialty bottles or nipples.
b)
Burp the newborn often when feeding.
c)
Feed the newborn in an upright position.
d)
Initiate feeding as soon as possible after birth.
e)
Encourage the mother to exclusively breastfeed.
2.
The nurse is caring for a newborn at term gestation who is large for gestational age (LGA). Which of the following actions should the nurse take? Select all that apply.
a)
Assess the newborn for birth-related injuries.
b)
Monitor capillary blood glucose levels frequently.
c)
Encourage the mother to breastfeed the newborn every 2-3 hours.
d)
Inform the parents that an infusion of IV glucose is necessary for newborns who are LGA.
e)
Notify the health care provider if the capillary blood glucose level is < 40 mg/dL (2.2 mmol/L).
3.
The nurse is assessing a 4-day-old, full-term newborn who is being breastfed exclusively. Which of the following findings should the nurse recognize as a possible indication for breastfeeding supplementation?
a)
12% weight loss since birth.
b)
Cracked, peeling skin.
c)
Feeds every 2-3 hours.
d)
Runny, seedy, yellow stools.
4.
The nurse is assessing a newborn with an infection due to Candida albicans. Which assessment data support this diagnosis?
a)
Diffuse skin rash that resembles flea bites.
b)
Small, white cysts on the hard palate.
c)
Vesicles on the skin surrounding the lips.
d)
White, adherent patches on the tongue and palate.
5.
The nurse is assessing a newborn at 1 minute of life. The nurse notes the newborn is completely blue, has a heart rate of 110/min, and is emitting a weak cry. The newborn has active movement of extremities and grimaces when the nares are suctioned. Which of the following Apgar scores should the nurse assign the client?
a)
Apgar score of 4.
b)
Apgar score of 5.
c)
Apgar score of 6.
d)
Apgar score of 8.
6.
The nurse is talking with the parent of a 1-day-old newborn who had a circumcision using the plastic ring method. Which of the following statements by the parent would require follow-up?
a)
I will contact the health care provider if bleeding does not stop with gentle pressure.
b)
I should avoid using alcohol-based cleansing wipes during diaper changes.
c)
I need to leave the device in place and allow it to fall off on its own.
d)
I understand that yellow exudate on the area is a sign of infection.
7.
The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply.
a)
Respirations of 56 breaths per minute.
b)
Capillary glucose of 60 mg/dL (3.3 mmol/L).
c)
Holosystolic murmur auscultated at fourth intercostal space.
d)
Single transverse crease across palm of the hand.
e)
White papules on bridge of the nose.
8.
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply.
a)
Assist maternal pushing efforts by applying fundal pressure during each contraction.
b)
Document the time the fetal head was born.
c)
Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis.
d)
Prepare for a forceps-assisted birth.
e)
Request additional assistance from other nurses immediately.
9.
The nurse is observing a staff member caring for a client who had a vaginal birth 30 minutes ago. The client is having difficulty with breastfeeding and is requesting assistance. The nurse should intervene if the staff member is observed
a)
Providing supplemental formula feedings until improved breastfeeding occurs.
b)
Checking the newborn's position and sucking behavior during breastfeeding.
c)
Demonstrating to the client how to express breastmilk using the hand.
d)
Providing information on recognizing newborn hunger cues.
10.
The nurse is caring for a family after the birth of a newborn with anencephaly. Which nursing intervention should be implemented immediately after delivery?
a)
Instruct the parents that visitors should be restricted.
b)
Provide information to the parents about genetic counseling.
c)
Refer the parents to a perinatal loss support group.
d)
Wrap the newborn in warm blankets for the parents to hold.
11.
A laboring client reports feeling the need to have a bowel movement and begins vomiting. The nurse notes that the client's legs are trembling. What cervical examination finding would the nurse most expect this client to have?
a)
2 cm dilated, 50% effaced, -2 station.
b)
6 cm dilated, 70% effaced, -1 station.
c)
7 cm dilated, 80% effaced, 0 station.
d)
8 cm dilated, 100% effaced, +1 station.
12.
The nurse is talking about diaper changes with a client who is 48 hours postpartum. The client states, "I cannot change my baby's diaper as well as you can. Will you change it for me?" Which of the following responses would be appropriate for the nurse to make?
a)
Changing your baby's diaper now is important for the bonding process.
b)
I will stay at your bedside and watch while you change your baby's diaper.
c)
It is more important for you to take care of yourself now, so I will change your baby's diaper.
d)
It is time that you change your baby's diaper because you will have to do it by yourself after discharge.
13.
The nurse is caring for a newborn with jaundice who is receiving phototherapy. Follow-up would be required if the nurse
a)
Allows the parents to remove the client from phototherapy for feedings.
b)
Assists the parents in applying lotion to the client's dry, peeling skin.
c)
Covers the client's eyes with protective shields.
d)
Obtains the client's axillary temperature every 2 hours.
14.
The nurse is caring for a newborn. Which of the following signs would indicate neonatal abstinence syndrome? Select all that apply.
a)
Irritability and restlessness.
b)
Meconium ileus and floppy muscle tone.
c)
Microcephaly and cleft palate.
d)
Nasal congestion and frequent sneezing.
e)
Poor feeding and loose stools.
15.
The nurse is caring for a 1-day-old client who is irritable and has a high-pitched cry and tremors. The client's mother reports taking hydrocodone throughout the pregnancy. Which of the following actions should the nurse take?
a)
Avoid giving the newborn a pacifier.
b)
Swaddle and gently rock the newborn.
c)
Place the newborn in the supine position after feedings.
d)
Periodically use environmental lighting to stimulate the newborn.
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