NCLEX-PN
Free NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
The client at 31 weeks’ gestation is diagnosed with mild preeclampsia and placed on home management. What information should the nurse include when providing home management instructions? Select all that apply.
Correct Answer: B,D,E
Rationale: A sudden weight gain could indicate that the mild preeclampsia is uncontrolled and the client is retaining fluid. The HCP should be consulted. Stretching and ROM exercises can help prevent thrombophlebitis and venous stasis. The lateral recumbent position improves uteroplacental blood flow, reduces maternal BP, and promotes diuresis. A diagnosis of mild preeclampsia does not require hospitalization during the antepartum period unless home management fails to reduce the client’s BP, or other complications occur. BP monitoring every 4 to 6 hours is recommended for the client with mild preeclampsia, but the BP can be taken by the client and does not require a consult with home care.
Question 2 of 5
Which response by the nurse is correct concerning the legal threshold of viability?
Correct Answer: C
Rationale: The legal threshold of viability is typically 20-24 weeks, when a fetus may survive outside the womb with medical support.
Question 3 of 5
The clinic nurse reviews the laboratory results illustrated from the postpartum client who is 3 days postdelivery. What should the nurse do in response to these results?
Correct Answer: A
Rationale: The only action required is to document the findings; all values are within expected parameters. Nonpathological leukocytosis often occurs during labor and in the immediate postpartum period because labor produces a mild pro-inflammatory state. WBCs should return to normal by the end of the first postpartum week. Hct and Hgb will begin to decrease on postpartum day 3 or 4 from hemodilution. Assessing the client’s lochia is unnecessary with these results. Assessing the client’s temperature is unnecessary with these results. Notifying the HCP is unnecessary with these results.
Question 4 of 5
The nurse is reviewing the laboratory report from the first prenatal visit of the pregnant client. Which laboratory result should the nurse most definitely discuss with the HCP?
Correct Answer: C
Rationale: A Pap smear with HPV changes reflects an abnormal result. HPV changes are a risk factor for cervical cancer. The nurse should discuss the result with the HCP because it requires further assessment and follow-up. A normal Hgb is 12—15 g/dL; nutritional counseling should be initiated when the Hgb is less than 12 g/dL. An Hct of 33% is also low (normal Hct value = 38% to 47%; this decreases by 4% to 7% in pregnancy), but increasing the Hgb with iron-rich foods should also raise the Hct. A WBC count of 7000/mm3 is within the normal range of 5000 to 12,000/mm3. A urine pH of 7.4 is within the normal range of 4.6 to 8.0; the specific gravity is within the normal range of 1.010 to 1.025.
Question 5 of 5
Which response by the nurse about Chadwick's sign is most accurate?
Correct Answer: A
Rationale: Chadwick's sign is the bluish discoloration of the cervix, vagina, and vulva due to increased vascularity, a probable sign of pregnancy.