NCLEX-PN
Free NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
Before hospitalization, an adolescent client had decided to give up her newborn for adoption. The client had an uncomplicated vaginal delivery and is still committed to her decision. Which intervention should the nurse exclude?
Correct Answer: D
Rationale: Offering to transfer the client is appropriate and would not be excluded. The postpartum unit may be filled with sounds and sights that may distress the client. It would be appropriate for the nurse to discuss possible ambivalence with the client, as she may have increased feelings of attachment, love, and grief after delivery. Having those feelings does not necessarily mean that the client has made the wrong decision. Initiating a case management or social work consult is appropriate and would not be excluded. The client may not have support systems available because she may not have disclosed her pregnancy to others. The adolescent may not have disclosed the pregnancy to family. Although it would be appropriate for the nurse to explore the client’s support system with the client, the nurse should not contact the client’s family.
Question 2 of 5
The laboring client is experiencing dyspnea, diaphoresis, tachycardia, and hypotension while lying on her back. Which intervention should the nurse implement immediately?
Correct Answer: A
Rationale: When the laboring client lies flat on her back, the gravid uterus completely occludes the inferior vena cava and laterally displaces the subrenal aorta. This aortocaval compression reduces maternal cardiac output, producing dyspnea, diaphoresis, tachycardia, and hypotension. Other symptoms include air hunger, nausea, and weakness. A left side-lying position decreases aortocaval compression. Lying on the right side increases aortocaval compression. Notifying the obstetrician is not the first intervention. The obstetrician would be notified if symptoms are not relieved by a left side-lying position. Applying oxygen may be needed, but first the client should be placed left side-lying.
Question 3 of 5
An LPN asks an RN to assist in locating the fundus of the client who is 8 hours post—vaginal delivery. Place an X at the location on the client’s abdomen where the RN should direct the LPN to begin to palpate the fundus.
Order the Items
Source Container
Correct Answer: Level of the umbilicus
Rationale: Six to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus due to blood and clots that remain within the uterus and changes in ligament support. Thus, the RN should direct the LPN to locate the client’s fundus at the level of the umbilicus.
Question 4 of 5
The nurse advises the client to keep the newborn's crib free of which item?
Correct Answer: A
Rationale: Soft toys and blankets in the crib increase the risk of suffocation and SIDS, and should be avoided.
Question 5 of 5
The 38-year-old pregnant client at 22 weeks’ gestation has just been told she has hydramnios after undergoing a sonogram for size greater than dates. The nurse should further assess for which conditions associated with hydramnios? Select all that apply.
Correct Answer: A,B,D
Rationale: In cases of anencephaly, the fetus is thought to urinate excessively because of overstimulation of the cerebrospinal centers, resulting in hydramnios. The nurse should further assess for gestational diabetes. Hydramnios is thought to occur from excessive fetal urination due to fetal hyperglycemia. Infants with mothers infected with toxoplasmosis, rubella, CMV, or herpes simplex virus infections (TORCH) are more likely to have hydramnios due to the inflammatory response and fluid accumulation. Chronic hypertension is not associated with excess amniotic fluid. Preeclampsia is not associated with excess amniotic fluid.