NCLEX-PN
Maternal NCLEX Questions
Extract:
Question 1 of 5
The nurse identifies which sign as indicative of postpartum depression?
Correct Answer: B
Rationale: Persistent feelings of hopelessness are a key indicator of postpartum depression, requiring intervention.
Question 2 of 5
The nurse is caring for four postpartum clients. Which client should be the nurse’s priority for monitoring for uterine atony?
Correct Answer: B
Rationale: Although the client post—cesarean birth for a breech baby may be at risk for uterine atony and should be monitored, the client who delivered a macrosomic baby is more at risk. This client is the nurse’s priority for monitoring for uterine atony. A macrosomic baby stretches the client’s uterus, and thus the muscle fibers of the myometrium, beyond the usual pregnancy size. After delivery the muscles are unable to contract effectively. A firm fundus indicates that the client’s uterine muscles are contracting. Oxytocin (Pitocin) is being administered to increase uterine contractions. Although prolonged use of oxytocin can result in uterine exhaustion, two hours of use is not prolonged.
Question 3 of 5
The nurse is doing a one-minute Apgar score on a newborn and tells the parents that it is 7 points. When the parents ask what this means, how should the nurse best respond?
Correct Answer: C
Rationale: This response is best because a score of 7 to 10 is within a normal range and 并表示新生儿没有任何不适的迹象。A score of 7 to 10 is considered acceptable for a one-minute Apgar. However, when the scoring is repeated at 5 minutes of age, a score of 7 to 10, not just 10, is within normal range. The Apgar score is used to systematically assess an infant at one and five minutes after birth to determine if immediate care is necessary. It is not used to predict intelligence or neurological development. Although the Apgar score does mean that the newborn’s VS are WNL, the Apgar score is not designed to classify gestational age.
Question 4 of 5
The nurse notifies the HCP after feeling a pulsating mass during the vaginal examination of a newly admitted full-term pregnant client. Which HCP order should the nurse question?
Correct Answer: C
Rationale: The nurse should question the administration of oxytocin (Pitocin). Oxytocin is used for stimulating contraction of the uterus. Uterine contractions can cause further umbilical cord compression. The pulsating mass indicates umbilical cord prolapse, which is a medical emergency. If vaginal birth is not imminent, a cesarean section is preferred in order to prevent hypoxic acidosis. Placing the client in a knee-chest position relieves pressure on the umbilical cord. Terbutaline (Brethine) is a tocolytic agent used to reduce contractions.
Question 5 of 5
The nurse instructs the client with hyperemesis gravidarum to avoid which trigger?
Correct Answer: B
Rationale: Strong odors can exacerbate nausea and vomiting in hyperemesis gravidarum, worsening symptoms.