NCLEX-PN
NCLEX Maternity Questions Questions
Question 1 of 5
The nurse is caring for the pregnant client at 20 weeks’ gestation. At what level should the nurse expect to palpate the client’s uterine height?
Correct Answer: C
Rationale: At 20 gestational weeks, the uterus should be at the level of the umbilicus. The uterine height is too low for 20 weeks’ gestation. At 13 weeks, the uterus would be approximately two finger-breadths above the symphysis pubis. The uterine height is too low for 20 weeks’ gestation. At 16 weeks, the uterus would be approximately halfway between the umbilicus and symphysis pubis. The uterine height is too high for 20 weeks’ gestation. At 22 weeks, the uterus would be two finger-breadths above the umbilicus.
Question 2 of 5
The nurse is reviewing the medication history of the client during preconception counseling. The client reports taking isotretinoin for acne. Which is the nurse’s best response?
Correct Answer: C
Rationale: The best response is to have the client consult her HCP so another medication can be prescribed. This response indicates that isotretinoin (Accutane) is not safe but that alternative medications can be prescribed. Responding to the client emphatically can create anxiety and fear. Telling the client that getting pregnant is not an option is a paternal response and does not facilitate open communication. Clients must wait one month after cessation of isotretinoin before becoming pregnant.
Question 3 of 5
The first-trimester pregnant client asks the nurse if the activities in which she participates are safe in the first trimester. Which activity should the nurse verify as a safe activity during the client’s first trimester?
Correct Answer: D
Rationale: Sexual activity is not contraindicated in pregnancy unless a specific risk factor is identified. Hair coloring should be avoided in the first trimester because the chemicals can be absorbed and pose a risk to the developing fetus. Hot tub use should be avoided because it increases the client’s body temperature. Maternal hyperthermia during the first trimester raises concerns about possible spontaneous abortion, CNS defects, and failure of neural tube closure. Exposure to pesticides during pregnancy increases the risk for preterm birth, intrauterine growth restriction, childhood developmental delays, and infertility later in adulthood.
Question 4 of 5
The continuous electronic FHR monitor tracing on the laboring client is no longer recording. How should the nurse immediately respond?
Correct Answer: B
Rationale: When the FHR monitor tracing is no longer recording, the nurse should first check for adequate gel under the transducer. There needs to be adequate gel under the transducer for good conduction, and adding gel frequently corrects the problem. Assessing for adequate gel under the transducer and repositioning should be done before assuming there is a problem with the baby’s HR. There is no indication to give oxygen to the client. Auscultating FHR by fetoscope and assessing maternal VS could be completed, but not until the transducer has been checked.
Question 5 of 5
If this nurse is similar to other women experiencing fatigue, which suggestions for decreasing fatigue should be implemented? Select all that apply.
Correct Answer: A,E
Rationale: Resting during breaks and avoiding overtime reduce fatigue; 12 hours of sleep is excessive, and voiding or carbs do not directly address fatigue.