NCLEX-PN
NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
The client in labor is requesting water therapy (hydrotherapy) to help provide pain relief and relaxation. Her recent vaginal exam was 2/50/—2. How should the nurse respond to the client’s request?
Correct Answer: A
Rationale: Hydrotherapy is usually initiated when the client is in active labor, at approximately 4 or 5 cm. This timing will help reduce the risk of prolonged labor and provide a welcome change when the contractions are becoming stronger and closer together. Changing position takes less effort while immersed in water, so women are encouraged to change positions more frequently to help facilitate the process of labor. FHR monitoring can be done just as easily during hydrotherapy, using a wireless external monitor, Doppler, or fetoscope. Internal electrodes can be placed during most types of hydrotherapy but is contraindicated during jet hydrotherapy. There is no time limit for laboring women to use hydrotherapy; they may stay as long as desired, unless complications develop during the labor process.
Question 2 of 5
The nurse advises the client to clean the newborn's umbilical cord with which substance?
Correct Answer: A
Rationale: Cleaning with alcohol or antiseptic as prescribed prevents infection until the cord stump falls off.
Question 3 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 4 of 5
According to the TPAL method, which of the following reflects the client's obstetric history?
Correct Answer: A
Rationale: TPAL: Term (3, one son and twin daughters), Preterm (0), Abortions (0), Living (3). The client has three term deliveries and three living children.
Question 5 of 5
The postpartum client, who had a forceps-assisted vaginal birth 4 hours ago, tells the nurse that she is having continuing perineal pain rated at 7 out of 10 and rectal pressure. An oral analgesic was given and ice applied to the perineum earlier. What should the nurse do now?
Correct Answer: B
Rationale: Reexamination of the perineum should be completed before calling the HCP to report the pain level. A forceps-assisted delivery can increase the risk of hematoma development. Rectal pressure and perineal pain can indicate a hematoma in the posterior vaginal wall. The nurse should closely examine the perineum and the vaginal introitus for ecchymosis and a bulging mass. Ambulation would not help the perineal pain. A stool softener would be appropriate to avoid constipation but would not help the immediate problem.