NCLEX-PN
Maternal NCLEX Questions
Extract:
Question 1 of 5
The client in labor tells the nurse that it feels like her membranes just ruptured. Which assessment finding of the amniotic fluid would indicate that it is normal?
Correct Answer: D
Rationale: The pH of amniotic fluid is usually between 6.5 and 7.5, which is more alkaline than urine or purulent material. Normal amniotic fluid should be clear. Cloudiness could indicate the presence of meconium or an intrauterine infection. Amniotic fluid should have no odor. Any odor may indicate the presence of infection. Amniotic fluid should be clear. Meconium stained could indicate fetal distress.
Question 2 of 5
The nurse correctly instructs the client to contact the physician immediately under which circumstance?
Correct Answer: C
Rationale: Vaginal bleeding is a danger sign in pregnancy, potentially indicating miscarriage or placental issues, requiring immediate reporting.
Question 3 of 5
The nurse is caring for the pregnant client. Which assessment findings help the nurse determine that she may be in true labor? Select all that apply.
Correct Answer: A,B,E
Rationale: Progressive cervical dilation and effacement indicate true labor. In false labor, the contractions may occur for several hours, but there is no cervical change. In true labor, walking usually increases the intensity of contractions. In false labor, walking usually has little or no effect on contractions and may sometimes decrease the frequency, intensity, and duration of contractions. Contractions increase in duration and intensity during true labor, while there is usually no change in contractions during false labor. Warm tub baths and rest lessen contractions during false labor. In true labor, contractions do not decrease with warm tub baths or rest. Discomfort is usually in the client’s abdomen during false labor. Discomfort begins in the back and radiates around to the abdomen during true labor.
Question 4 of 5
Two hours after delivery, the mother tells the nurse that she will be bottle feeding. She asks what she can do to prevent the terrible pain experienced when her milk came in with her last baby. Which response by the nurse is most appropriate?
Correct Answer: C
Rationale: In comparison studies between breast binders and bras, mothers using binders experienced more engorgement and discomfort. Engorgement is not familial and not inevitable in bottle-feeding mothers. Wearing a supportive, well-fitting bra within 6 hours after birth can suppress lactation. The bra should be worn continuously, except for showering, until lactation is suppressed (usually 7 to 14 days). Signs of engorgement usually occur on the third to fifth postpartum day (not right after birth), and engorgement will spontaneously resolve by the tenth day postpartum.
Question 5 of 5
Which client would the nurse identify as being at highest risk for developing complications during pregnancy?
Correct Answer: D
Rationale: A 35-year-old gravida V client is at higher risk due to advanced maternal age and multiple pregnancies, increasing complication risks.