NCLEX-PN
Maternal NCLEX Questions Questions
Extract:
Question 1 of 5
Immediately after delivery of the client’s placenta, the nurse palpates the client’s uterine fundus. The fundus is firm and located halfway between the umbilicus and symphysis pubis. Which action should the nurse take based on the assessment findings?
Correct Answer: B
Rationale: Uterine massage is indicated only if the uterus does not feel firm and contracted. Immediately after birth, the uterus should contract, and the fundus should be located one-half to two-thirds of the way between the symphysis pubis and umbilicus. Thus the only action required is to document the assessment finding. There is no indication that the bladder is full. A full bladder will cause uterine displacement to either side of the abdomen. The uterus is firm; there is no reason to infer that increased vaginal bleeding would occur.
Question 2 of 5
The client expresses concerns related to nausea in the first trimester of pregnancy. Which recommendation should the nurse make?
Correct Answer: A
Rationale: The nurse should instruct the client to eat dry crackers before rising from bed. This typically relieves some of the nausea. Lying down when the nausea occurs may increase heartburn and reflux, thereby increasing nausea. Eating frequently may increase heartburn and reflux, thereby increasing nausea. Food items with ginger may help to alleviate nausea and are recommended (rather than avoided), including ginger tea.
Question 3 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 4 of 5
After gathering further information about the edema, the nurse advises the client to limit the intake of which substance?
Correct Answer: A
Rationale: Limiting sodium intake helps reduce fluid retention, which contributes to edema in pregnancy.
Question 5 of 5
The nurse asks the 12-hour postpartum client, who is breastfeeding her baby now, why she has not yet received a dinner tray. The client states that her mother is bringing curry and that she won’t be eating the hospital food tonight. Which response by the nurse is best?
Correct Answer: A
Rationale: Offering to order food later if the client changes her mind is the best response. Many clients have culturally based beliefs about food and beverages that should be consumed in the postpartum period. Unless contraindicated, nurses should support and encourage women to incorporate food preferences with cultural significance into their postpartum diet. Some breastfeeding infants are sensitive to certain flavors, seasonings, or foods, but, there is no evidence to support maternal food restrictions unless the infant shows a sensitivity. If there is a strong family history of a food allergy that causes anaphylaxis, such as a peanut allergy, these foods may be avoided. Many women would benefit from speaking to a dietician, but this client is not at any increased risk that would make a dietary consultation necessary. There are no food restrictions 12 hours after delivery unless there have been complications.