🎯 High-Yield Points for This Topic
- Preeclampsia: BP ≥140/90, proteinuria, oedema; priority = seizure prevention (magnesium sulphate)
- Postpartum haemorrhage: uterine atony is #1 cause; massage fundus, Oxytocin first-line
- Placenta praevia: painless bleeding; NO vaginal exam; complete bed rest
- Abruptio placentae: painful bleeding, rigid abdomen, fetal distress
- APGAR score at 1 and 5 minutes: appearance, pulse, grimace, activity, respiration
[Infographic: Maternity & OB NCLEX Questions Key Concepts — Clinical Manifestations, Nursing Interventions, Priority Actions]
Practice Questions
Question 1
A primigravida at 34 weeks gestation presents with severe headache, visual disturbances, and blood pressure of 168/110 mmHg. Which action does the nurse take FIRST?
✓ Correct: Position in left lateral recumbent position and notify provider
This presentation describes severe preeclampsia. The priority action is to position the client in left lateral recumbent position (increases uteroplacental blood flow) and immediately notify the provider. This is an obstetric emergency. Medication (magnesium sulphate to prevent seizures, antihypertensives) will follow provider notification. The left lateral position relieves aortocaval compression.
This presentation describes severe preeclampsia. The priority action is to position the client in left lateral recumbent position (increases uteroplacental blood flow) and immediately notify the provider. This is an obstetric emergency. Medication (magnesium sulphate to prevent seizures, antihypertensives) will follow provider notification. The left lateral position relieves aortocaval compression.
Question 2
A nurse is assessing a postpartum client 2 hours after vaginal delivery. The fundus is boggy and displaced to the right. Which action is FIRST?
✓ Correct: Have the client void, then reassess and massage the fundus
A boggy, displaced fundus indicates uterine atony with a possible full bladder causing the displacement. The first action is to have the client void — a full bladder is the most common cause of uterine displacement and prevents the uterus from contracting. After voiding, reassess the fundus and massage if still boggy. Oxytocin may be needed, but first address the most likely correctable cause.
A boggy, displaced fundus indicates uterine atony with a possible full bladder causing the displacement. The first action is to have the client void — a full bladder is the most common cause of uterine displacement and prevents the uterus from contracting. After voiding, reassess the fundus and massage if still boggy. Oxytocin may be needed, but first address the most likely correctable cause.
Question 3
A client at 38 weeks gestation reports painless bright red vaginal bleeding. Which action does the nurse take?
✓ Correct: Place on external fetal monitor and notify provider; do NOT perform vaginal exam
Painless bright red vaginal bleeding in the third trimester is the classic presentation of placenta praevia. A vaginal examination is STRICTLY CONTRAINDICATED — it can perforate the placenta and cause massive haemorrhage. The nurse must apply continuous external fetal monitoring, establish IV access, and notify the provider immediately. Caesarean section is typically required.
Painless bright red vaginal bleeding in the third trimester is the classic presentation of placenta praevia. A vaginal examination is STRICTLY CONTRAINDICATED — it can perforate the placenta and cause massive haemorrhage. The nurse must apply continuous external fetal monitoring, establish IV access, and notify the provider immediately. Caesarean section is typically required.
Question 4
A newborn's APGAR score is assessed at 1 minute of life. Heart rate 110 bpm, weak cry, some flexion, grimace response to stimulation, and body pink with blue extremities. What is the APGAR score?
✓ Correct: 6
APGAR scoring: Appearance (blue extremities, pink body) = 1; Pulse (HR 110) = 2; Grimace (grimace response) = 1; Activity (some flexion) = 1; Respiration (weak cry) = 1. Total = 6. Score 7-10 = normal; 4-6 = requires stimulation/monitoring; 0-3 = requires resuscitation. A score of 6 at 1 minute warrants stimulation and reassessment at 5 minutes.
APGAR scoring: Appearance (blue extremities, pink body) = 1; Pulse (HR 110) = 2; Grimace (grimace response) = 1; Activity (some flexion) = 1; Respiration (weak cry) = 1. Total = 6. Score 7-10 = normal; 4-6 = requires stimulation/monitoring; 0-3 = requires resuscitation. A score of 6 at 1 minute warrants stimulation and reassessment at 5 minutes.
Question 5
A client 24 hours postpartum reports calf tenderness, swelling, and warmth. What does the nurse assess FIRST?
✓ Correct: Homans sign and notify the provider
Unilateral calf tenderness, swelling, and warmth in the postpartum period strongly suggests deep vein thrombosis — a serious and potentially life-threatening complication. The nurse should assess Homans sign (though low sensitivity) and immediately notify the provider. Anticoagulation therapy may be required. Ambulation and warm compresses could dislodge a clot and are contraindicated without provider direction.
Unilateral calf tenderness, swelling, and warmth in the postpartum period strongly suggests deep vein thrombosis — a serious and potentially life-threatening complication. The nurse should assess Homans sign (though low sensitivity) and immediately notify the provider. Anticoagulation therapy may be required. Ambulation and warm compresses could dislodge a clot and are contraindicated without provider direction.
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[Clinical Concept Map: Maternity & OB NCLEX Questions — Pathophysiology, Assessment Findings, Nursing Actions]