NCLEX-PN
Maternal NCLEX Questions Questions
Extract:
Question 1 of 5
The laboring client’s amniotic membranes have just ruptured. Which nursing action should be priority?
Correct Answer: D
Rationale: The priority nursing action is to assess the FHR pattern for several minutes immediately after membrane rupture to determine fetal well being. The umbilical cord may prolapse as a result of the rupture, causing life-threatening changes in the FHR. The maternal temperature should be monitored during labor and at least every two hours after the membranes rupture to assess for possible infection. However, this is not the priority nursing action. Characteristics of the fluid (color, odor, and estimated amount) should be assessed and documented after rupture, but this is not the priority at this time. A vaginal exam that assesses the progress of labor does need to be performed right after membrane rupture, but it is not the priority.
Question 2 of 5
The nurse asks the 12-hour postpartum client, who is breastfeeding her baby now, why she has not yet received a dinner tray. The client states that her mother is bringing curry and that she won’t be eating the hospital food tonight. Which response by the nurse is best?
Correct Answer: A
Rationale: Offering to order food later if the client changes her mind is the best response. Many clients have culturally based beliefs about food and beverages that should be consumed in the postpartum period. Unless contraindicated, nurses should support and encourage women to incorporate food preferences with cultural significance into their postpartum diet. Some breastfeeding infants are sensitive to certain flavors, seasonings, or foods, but, there is no evidence to support maternal food restrictions unless the infant shows a sensitivity. If there is a strong family history of a food allergy that causes anaphylaxis, such as a peanut allergy, these foods may be avoided. Many women would benefit from speaking to a dietician, but this client is not at any increased risk that would make a dietary consultation necessary. There are no food restrictions 12 hours after delivery unless there have been complications.
Question 3 of 5
After gathering further information about the edema, the nurse advises the client to limit the intake of which substance?
Correct Answer: A
Rationale: Limiting sodium intake helps reduce fluid retention, which contributes to edema in pregnancy.
Question 4 of 5
The nurse explains that true labor contractions are characterized by which feature?
Correct Answer: B
Rationale: True labor contractions increase in intensity and frequency, distinguishing them from false labor.
Question 5 of 5
Which nursing instruction given to the client complaining about shortness of breath is most appropriate?
Correct Answer: D
Rationale: Sleeping with the upper body elevated reduces pressure on the diaphragm, easing shortness of breath.