NCLEX-PN
Maternal NCLEX Practice Questions Questions
Extract:
Question 1 of 5
The client, who had a vaginal delivery 18 hours ago, asks the nurse how she should take care of her perineal laceration. Which statements by the nurse are appropriate? Select all that apply.
Correct Answer: B,D,E,F
Rationale: The peripad should be changed more frequently to reduce the risk of infection. Lochia amount should never exceed a moderate amount (less than a 6-inch stain on a perineal pad). A warm sitz bath is used after the first 24 hours to provide comfort, increase circulation to the area, and reduce the incidence of infection. Perineal lacerations are repaired with sutures that dissolve. Clients do not need to have perineal sutures removed. Cleansing the perineum after each void with the peri-bottle of water provides comfort and helps reduce the chance of infection. Washing with mild soap and rinsing with water each 24 hours reduces the risk of infection. Teaching the client to watch for signs and symptoms of infection is important and allows the client to be an active participant in her care.
Question 2 of 5
The nurse is caring for the postpartum family. The nurse determines that paternal engrossment is occurring when which observation is made of the newborn’s father?
Correct Answer: B
Rationale: Not making face-to-face contact with the infant during communication demonstrates a lack of engrossment. In North American culture, engrossment is demonstrated by the father touching the infant, making eye contact with the infant, and verbalizing awareness of features in the newborn that are similar to his and that validate his claim to that newborn. Feelings of frustration are not uncommon to fathers and are characteristic of the second stage, or reality stage, of the transition to fatherhood but are not a sign of engrossment. A hesitation to touch the infant demonstrates a lack of engrossment.
Question 3 of 5
The client who is actively bleeding due to a spontaneous abortion asks the nurse why this is happening. The nurse advises the client that the majority of first-trimester losses are related to which problem?
Correct Answer: D
Rationale: Chromosomal abnormalities account for the majority of first-trimester spontaneous abortions. Cervical incompetence can result in spontaneous abortion but does not account for the majority. Chronic maternal disease can result in spontaneous abortion but does not account for the majority. Poor implantation can result in spontaneous abortion but does not account for the majority.
Question 4 of 5
The client, who had a vaginal delivery 18 hours ago, asks the nurse how she should take care of her perineal laceration. Which statements by the nurse are appropriate? Select all that apply.
Correct Answer: B,D,E,F
Rationale: The peripad should be changed more frequently to reduce the risk of infection. Lochia amount should never exceed a moderate amount (less than a 6-inch stain on a perineal pad). A warm sitz bath is used after the first 24 hours to provide comfort, increase circulation to the area, and reduce the incidence of infection. Perineal lacerations are repaired with sutures that dissolve. Clients do not need to have perineal sutures removed. Cleansing the perineum after each void with the peri-bottle of water provides comfort and helps reduce the chance of infection. Washing with mild soap and rinsing with water each 24 hours reduces the risk of infection. Teaching the client to watch for signs and symptoms of infection is important and allows the client to be an active participant in her care.
Question 5 of 5
The 22-year-old client, who is experiencing vaginal bleeding in the first trimester of pregnancy, fears that she has lost her baby at 8 weeks. Which definitive test result should indicate to the nurse that the client’s fetus has been lost?
Correct Answer: C
Rationale: Ultrasound is used to determine if the fetus has died. The lack of fetal heart activity in a pregnancy over 6 weeks determines a fetal loss. Falling BHCG levels do not conclusively diagnose fetal demise. Low progesterone levels do not conclusively diagnose fetal demise. Crown-rump length determines only the fetal gestational age.