NCLEX-PN
Maternal NCLEX Practice Questions Questions
Extract:
Question 1 of 5
The client, who is Chinese American and pregnant, is receiving nutritional counseling about the need for increased amounts of calcium in her diet. Which response by the nurse is most helpful when the client states she does not consume any dairy products?
Correct Answer: C
Rationale: Assessing the client’s intake of calcium-rich foods is the best response. Both fortified tofu and leafy green vegetables are high in calcium and are common foods consumed in the Chinese American diet. Although asking about the client’s perception of dairy products shows cultural sensitivity, the client has already stated she does not consume these. This statement is not the most helpful regarding helping the client to increase calcium intake in her diet. The nurse is making a recommendation without further assessing the client’s dietary preferences. Soy milk should be calcium fortified; yet, according to research the calcium content can be as much as 85 percent less than the amount indicated on the product label. Both rice milk fortified with calcium and nettle tea are sources of calcium; however, the nurse is making an assumption that the client consumes these beverages.
Question 2 of 5
While assessing the breastfeeding mother 24 hours postdelivery, the nurse notes that the client’s breasts are hard and painful. Which interventions should be implemented by the nurse? Select all that apply.
Correct Answer: B,D,F
Rationale: Moving the baby from the initial breast to the second breast during the feeding, before the initial breast is completely emptied, may result in neither breast being totally emptied and thus promote continued engorgement. Because engorgement is caused, in part, by swelling of the breast tissue surrounding the milk gland ducts, applying ice at intervals between feedings will help to decrease this swelling. Giving supplemental formula, thus limiting the time the baby nurses at the breast, prevents total emptying of the breast and promotes increased engorgement. Administering anti-inflammatory medication will decrease breast pain and inflammation. Because heat application increases blood flow, moist heat packs would exacerbate the engorgement. Pumping the breasts may be necessary if the infant is unable to completely empty both breasts at each feeding. Pumping at this time will not cause a problematic increase in breast milk production.
Question 3 of 5
Which of the following should the nurse plan to have available when providing nursing care to this client? Select all that apply.
Correct Answer: A,B,C,F
Rationale: Hyperemesis gravidarum with dehydration requires I.V. fluids, intake/output monitoring, oxygen if needed, and suction for vomiting.
Question 4 of 5
The client has been in labor for 21 hours. Induction was started 16 hours ago, and she is now dilated 5 cm. She has made little progress, and there has been no fetal descent. The HCP identifies cephalopelvic disproportion (CPD). The nurse should prepare the client for which mode of delivery?
Correct Answer: D
Rationale: A fetus diagnosed with CPD is unable to be delivered vaginally and requires a cesarean section birth. A vaginal delivery is contraindicated once CPD has been identified due to the risk of fetal and maternal trauma. Forceps delivery is contraindicated once CPD has been identified due to the risk of fetal and maternal trauma. Vacuum delivery is contraindicated once CPD has been identified due to the risk of fetal and maternal trauma.
Question 5 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.