NCLEX-PN
Maternal NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse correctly informs the participants that women who smoke during pregnancy have a greater risk of which problem?
Correct Answer: A
Rationale: Smoking during pregnancy increases the risk of premature delivery due to reduced oxygen and nutrient delivery to the fetus.
Question 2 of 5
The student nurse reports to an experienced nurse finding a warm, red, tender area on the left calf of the client who is 48 hours post—vaginal delivery. The nurse assesses the client and explains to the student that postpartum clients are at increased risk for thrombophlebitis due to which factors? Select all that apply.
Correct Answer: A,D,E,F
Rationale: During pregnancy, fibrinogen levels increase, and this increase continues to be present in the postpartum period. The increased levels can contribute to clot formation. There is not a shift of fluid from the interstitial to the vascular spaces in the postpartum period. Actual blood volume increases during pregnancy and is further increased immediately after delivery. This fluid volume is eventually lost through diuresis during the first postpartum week. Postpartum hormonal changes do occur, but they do not affect the vascular basement membranes. Elevation of the legs in stirrups during delivery leads to pooling of blood and vascular stasis. Dilation of the veins in the lower extremities occurs during pregnancy and increases the risk of venous stasis. Compression of the common iliac vein occurs during pregnancy due to an enlarging fetus and increases the risk of venous stasis.
Question 3 of 5
The pregnant client presents with vaginal bleeding and increasing cramping. Her exam reveals that the cervical os is open. Which term should the nurse expect to see in the client’s chart notation to most accurately describe the client’s condition?
Correct Answer: C
Rationale: In imminent abortion, the client’s bleeding and cramping increase and the cervix is open, which indicates that abortion is imminent or inevitable. In ectopic pregnancy, the pregnancy is outside of the uterus, and intervention is indicated to resolve the pregnancy. A complete abortion indicates that the contents of the pregnancy have been passed. In an incomplete abortion, a portion of the pregnancy has been expelled, and a portion remains in the uterus.
Question 4 of 5
The pregnant client asks the nurse, who is teaching a prepared childbirth class, when she should expect to feel fetal movement. The nurse responds that fetal movement usually can first be felt during which time frame?
Correct Answer: C
Rationale: Subtle fetal movement (quickening) can be felt as early as 18 to 20 weeks of gestation, and it gradually increases in intensity. Eight to 12 weeks of pregnancy is too early to expect the first fetal movement to be felt. Twelve to 16 weeks of pregnancy is too early to expect the first fetal movement to be felt. Twenty-two to 26 weeks of pregnancy is later than expected to feel the first fetal movement.
Question 5 of 5
Immediately after delivery of the client’s placenta, the nurse palpates the client’s uterine fundus. The fundus is firm and located halfway between the umbilicus and symphysis pubis. Which action should the nurse take based on the assessment findings?
Correct Answer: B
Rationale: Uterine massage is indicated only if the uterus does not feel firm and contracted. Immediately after birth, the uterus should contract, and the fundus should be located one-half to two-thirds of the way between the symphysis pubis and umbilicus. Thus the only action required is to document the assessment finding. There is no indication that the bladder is full. A full bladder will cause uterine displacement to either side of the abdomen. The uterus is firm; there is no reason to infer that increased vaginal bleeding would occur.