NCLEX-PN
NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
In the process of preparing the client for discharge after cesarean section, the nurse addresses all of the following areas during discharge education. Which should be the priority advice for the client?
Correct Answer: B
Rationale: Although the client needs information about incision care, the priority need is for assistance at home so that she can get the rest needed for multiple demands. Because the client has had a surgical procedure, the priority consideration is for the mother to plan for additional assistance at home. Without this assistance, it is difficult for the mother to get the rest she needs for healing, pain control, and appropriate infant care. Infant care is important, but having assistance at home after a surgical procedure is more important. The need for increased rest is important, but she would not be able to obtain adequate rest without assistance at home.
Question 2 of 5
The pregnant client is experiencing low back pain. After determining that the client is not in labor, the nurse instructs the client to perform which exercises to increase comfort and decrease the incidence of the low back pain? Select all that apply.
Correct Answer: B,C,D
Rationale: Pelvic tilt exercises strengthen and stretch the abdominal and back muscles to relieve pain. Leg raises strengthen and stretch leg and abdominal muscles to relieve pain. Back stretch relieves pain from the back muscles caused by lordosis. Kegel exercises strengthen the pubococcygeal muscle, decreasing urinary leakage, but do not relieve back pain.
Stepping provides aerobic exercise, which is good for circulation but is not recommended to decrease low back pain.
Question 3 of 5
The postpartum client’s blood type is A negative, and her newborn infant’s blood type is AB negative. The client received RhoGAM in her second trimester and another dose in her third trimester, after a minor car accident. The client is preparing for discharge and asks the nurse when she will receive her RhoGAM injection. The nurse correctly responds with which statement?
Correct Answer: C
Rationale: The number of RhoGAM doses given in pregnancy does not affect whether or not the client receives a dose postpartum. Both the client and newborn are Rh negative; no dose is required. Rh immune globulin (RhoGAM) is administered to women with Rh negative blood types at approximately 28 weeks of gestation and again after any trauma, such as a car accident or fall. After delivery, RhoGAM is only indicated if the newborn has a positive blood type; both the client and newborn are Rh negative. For postpartum clients who require RhoGAM, the dose is given within 72 hours of delivery. However, no dose is necessary because the client and newborn are both Rh negative.
Question 4 of 5
The nurse identifies which factor as increasing the risk of gestational hypertension?
Correct Answer: B
Rationale: A family history of hypertension increases the risk of gestational hypertension, as genetics play a significant role.
Question 5 of 5
The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client’s leg. Which action by the nurse in response to the client’s bleeding is correct?
Correct Answer: A
Rationale: Lochia normally pools in the vagina when the postpartum client remains in a recumbent position for any length of time. When the client then stands, gravity causes the blood to flow out. As long as the nurse knows the fundus is firm and not bleeding, a simple explanation to the client is all that is required. There is no reason to return the client to bed; the fundus is firm. There is no reason to push the emergency call light. Increased bleeding is an expected response when standing for the first time. There is no reason to call the HCP.