NCLEX-PN
NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
The client delivered a healthy newborn 4 hours ago after being induced with oxytocin. While being assisted to the bathroom to void for the first time after delivery, the client tells the nurse that she doesn’t feel a need to urinate. Which explanation should the nurse provide when the client expresses surprise after voiding 900 mL of urine?
Correct Answer: A
Rationale: The nurse should explain about the decreased sensation of bladder filling after childbirth. It is not uncommon for the postpartum client to have increased bladder capacity, decreased sensitivity to fluid pressure, and a decreased sensation of bladder filling. Oxytocin (Pitocin) is not expected to cause a change in bladder sensation, but it does have an antidiuretic effect. There is no indication that the client didn’t completely empty; a volume of 900 mL is a large amount. The postpartum client is at risk for bladder overdistention and should be encouraged to void every 2 to 4 hours.
Question 2 of 5
The primiparous client, who is bottle feeding her infant, asks the nurse when she can expect to start having her menstrual cycle again. Which response by the nurse is most accurate?
Correct Answer: A
Rationale: In nonlactating women, the average time to first ovulation is 45 days, and the return of menstruation usually happens within 6 to 10 weeks postbirth. Most women can expect to have lochial discharge for up to 24 days. However, the cessation of discharge is not related to the return of menstruation. The change in lochial color is not related to the return of menstruation. The return of ovulation and menstruation is associated with a rise in serum progesterone levels. Bottle feeding does not affect when this change occurs in the client’s body.
Question 3 of 5
The nurse is reviewing the laboratory test results of the pregnant client. Which laboratory test findings would require further follow-up from the nurse?
Correct Answer: A
Rationale: The normal Hgb level should be 12—16 g/dL in the pregnant client. The nurse should encourage iron-rich foods. The 50-g 1-hour glucose test should be less than 140. Values over 140 warrant a 3-hour glucose screen to determine if the client has gestational diabetes. The presence of glucose in the urine (glucosuria) is negative, which is a normal finding. Proteinuria in trace amounts is common in pregnant women, although higher protein concentrations should be evaluated.
Question 4 of 5
The nurse correctly sends a requisition and specimen for which laboratory test?
Correct Answer: C
Rationale: Human chorionic gonadotropin (hCG) is the hormone tested to confirm pregnancy, as it is produced by the placenta shortly after implantation.
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.