NCLEX-PN
Maternal NCLEX Questions Questions
Question 1 of 5
The laboring client’s amniotic membranes have just ruptured. Which nursing action should be priority?
Correct Answer: D
Rationale: The priority nursing action is to assess the FHR pattern for several minutes immediately after membrane rupture to determine fetal well being. The umbilical cord may prolapse as a result of the rupture, causing life-threatening changes in the FHR. The maternal temperature should be monitored during labor and at least every two hours after the membranes rupture to assess for possible infection. However, this is not the priority nursing action. Characteristics of the fluid (color, odor, and estimated amount) should be assessed and documented after rupture, but this is not the priority at this time. A vaginal exam that assesses the progress of labor does need to be performed right after membrane rupture, but it is not the priority.
Question 2 of 5
The laboring client just had a convulsion after being given regional anesthesia. Which interventions should the nurse implement? Select all that apply.
Correct Answer: A,C,D,E
Rationale: The client experiencing a convulsion related to anesthesia should first have an airway established. The client experiencing a convulsion related to anesthesia should receive 100% oxygen so that the mother and fetus remain oxygenated. Small doses of diazepam or thiopental can be administered to stop the convulsions. The anesthesiologist should be STAT paged to provide assistance; the convulsion was initiated by the regional anesthetic. The client’s head should be turned to the side if vomiting occurs, but the client typically remains in a left lateral tilt position so an airway can be maintained. Positioning on the right side can cause aortocaval compression.
Question 3 of 5
The nurse is teaching the postpartum client, who is breastfeeding, about returning to sexual activity after vaginal delivery. Which statement should the nurse include?
Correct Answer: B
Rationale: Oxytocin is released when the client has an orgasm and may cause breast milk to leak or squirt from the breasts. The production of breast milk may increase, not decrease. The nurse should inform the client that she may need lubrication with sexual intercourse because the low estrogen levels in the early postpartum period causes vaginal dryness. Women should refrain from sexual intercourse until lochia has ceased, which usually takes about 3 weeks. There is no need to wait two months if the lochia has ceased. The client’s HCP does not need to give approval to return to sexual activity.
Question 4 of 5
The nurse is caring for the client with a grade 3 placental abruption. Prioritize the prescribed interventions that the nurse should implement.
Order the Items
Source Container
Correct Answer: C,D,F,A,B,E
Rationale: Start oxygen at 2—4 liters per nasal cannula is priority to maximize fetal oxygenation. Administer lactated Ringer’s at 200 mL/hr to treat hypovolemia, increase blood flow, and maximize oxygenation. Continuous external fetal monitoring should be performed to identify fetal distress early. Obtain serum blood draw for clotting disorders, specifically DIC. Administer 1 unit whole blood is next and will depend on the amount of blood loss. Prepare for cesarean delivery if fetal distress would be last because it would depend on the client and fetal status.
Question 5 of 5
Which statement by the client indicates understanding of prenatal education?
Correct Answer: C
Rationale: Reporting decreased fetal movement is critical, as it may indicate fetal distress, showing the client understands key prenatal education.