NCLEX-PN
Maternal NCLEX Practice Questions Questions
Extract:
Question 1 of 5
The client who is 32 weeks pregnant asks how the nurse will monitor the baby’s growth and determine if the baby is “really okay.” Which assessments should the nurse identify for evaluating the fetus for adequate growth and viability? Select all that apply.
Correct Answer: B,E
Rationale: Adequate fetal growth is evaluated by measuring the fundal height. Auscultating the FHT assesses fetal viability. The presence of fetal (not maternal) heart tones starting at around 10-12 weeks is a standard to assess fetal growth and viability. The abdominal circumference does not provide information about fetal growth. The increase in abdominal girth could be due to weight gain or fluid retention, not just growth of the baby. Third-trimester ultrasound is neither routine nor advised for routine prenatal care because of the added cost and potential risk to the fetus.
Question 2 of 5
Before the pelvic examination, which intervention by the nurse is most appropriate?
Correct Answer: B
Rationale: Instructing the client to urinate ensures a comfortable examination by emptying the bladder, which can interfere with pelvic assessment.
Question 3 of 5
The nurse is assessing the laboring client who is morbidly obese. The nurse is unable to determine the fetal position. Which action should be performed by the nurse to obtain the most accurate method of determining fetal position in this client?
Correct Answer: D
Rationale: Real-time transabdominal ultrasound (US) is the most accurate assessment measure to determine the fetal position and is frequently available in the birthing setting. US images may be used to assess fetal lie, presentation, and position in the morbidly obese client. Inspection of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Palpation of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Vaginal examination can be used to determine fetal position, but because the client is obese, this is not the most accurate method.
Question 4 of 5
Which response by the nurse addresses the client's anxiety about childbirth?
Correct Answer: A
Rationale: Acknowledging anxiety as normal and offering coping strategies like breathing exercises supports the client emotionally.
Question 5 of 5
The nurse uses which tool to measure fundal height?
Correct Answer: A
Rationale: A tape measure is used to measure fundal height, assessing uterine growth and fetal development.