NCLEX-PN
Maternal NCLEX Questions
Extract:
Question 1 of 5
The client presents with vaginal bleeding at 7 weeks. Which action should be taken by the nurse first?
Correct Answer: A
Rationale: Assessing the client’s VS should be completed first. Bleeding can cause hypotension. Although preparing examination equipment is important, the nurse should first focus on the client. Having oxygen available is important, but there is no indication that the client needs oxygen at this time. Assessing the client’s response is important, but assessment of physiological problems should occur first.
Question 2 of 5
Which advice can the nurse give to relieve the client's backache? Select all that apply.
Correct Answer: A,D,E,F
Rationale: Tight clothing, high heels, and improper lifting exacerbate backaches; low-heeled shoes, proper lifting, and loose clothing help relieve strain.
Question 3 of 5
The postpartum client is being admitted for mastitis. The nurse should prepare the client for which interventions? Select all that apply.
Correct Answer: B,C,D,F
Rationale: Rest is important to promote healing. Bed rest may be initially prescribed for 24 hours. Treatment for mastitis includes administration of antibiotics to treat the infection. Application of warm packs decreases pain and promotes milk flow and breast emptying. Treatment for mastitis includes anti-inflammatory medications to treat fever and decrease breast inflammation. Increasing fluid intake to at least 2 to 3 liters is recommended, not limiting intake. If the breasts continue to be emptied by either breastfeeding or pumping, the duration of symptoms and the incidence of a breast abscess are decreased.
Question 4 of 5
The nurse just administered butorphanol tartrate as prescribed to the client in active labor. Following administration of butorphanol tartrate, what is the nurse’s most important action to help prevent side effects?
Correct Answer: D
Rationale: Evaluating maternal VS and pulse oximetry would determine changes in respiratory and cardiac status. Respiratory depression in both the mother and fetus can occur with butorphanol tartrate (Stadol). Although bladder distention is a possible side effect of butorphanol tartrate, it is not common and is not the most important assessment. Seizures are not a potential side effect of butorphanol tartrate. An itchy rash is not a potential side effect of butorphanol tartrate.
Question 5 of 5
The nurse is caring for the client who just gave birth. Which observation of the client should lead the nurse to be concerned about the client’s attachment to her male infant?
Correct Answer: D
Rationale: Seeking information about infant care is a sign that the mother is developing attachment to her infant. Pointing out family traits or characteristics seen in the newborn is a sign that the mother is developing attachment. Calling the infant by name is a sign that the mother is developing attachment to her infant. Attachment is demonstrated by expressing satisfaction with a baby’s appearance and sex. Frequent expressions of dissatisfaction with the sex of the infant should be concerning and followed up.