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NCLEX RN Maternity Questions Questions

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Question 1 of 5

The nurse is assessing the perineal changes of a multigravid client in the second stage of labor. The illustration below represents which of the following perineal changes?

Correct Answer: D

Rationale: If the illustration shows the fetal head visible at the perineum with no retraction between contractions, and the perineal area appears bulging or stretched, this indicates crowning — the point at which birth is imminent.

Question 2 of 5

A 30-year-old woman, G 4, P 4, has delivered a healthy term female neonate by cesarean delivery due to a nonreassuring fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client's retention catheter and observes that the client's urine is slightly red tinged. Which of the following should the nurse do next?

Correct Answer: C

Rationale: Red-tinged urine may indicate catheter trauma or misplacement, requiring assessment of catheter placement.

Question 3 of 5

The nurse on a mother-baby unit who is working on the night shift is revising the planning worksheet for the remaining 2 hours of the shift. The nurse has the following tasks and orders to complete prior to the 7 a.m. change of shift. Using the work plan below, how should the nurse organize the following tasks so that everything is completed by 7 a.m.?

Order the Items

Source Container

Draw blood for the ordered laboratory tests (CBCs) on 3 postpartum clients with report on charts by shift change.
Start IV of D5 1/2 NS at keep vein open (KVO) rate on postpartum client just prior to change of shift.
Complete admission assessment of newborn turned over to nurse at 5 a.m.
Draw newborn bilirubin level at 6 a.m.

Correct Answer: A,C,D,B

Rationale: 5:00 - Complete admission assessment; 5:30 - Draw CBCs; 6:00 - Draw bilirubin; 6:30 - Start IV. This ensures timely completion.

Question 4 of 5

A nurse is discussing the withdrawal method with a client. Which of the following client statements indicates a need for further teaching?

Correct Answer: C

Rationale: The withdrawal method does not provide protection against STIs, indicating a need for further teaching. The other statements are correct regarding its high failure rate, need for withdrawal before ejaculation, and requirement for timing and control.

Question 5 of 5

After instruction of a primigravid client at 8 weeks' gestation diagnosed with class I heart disease about self-care during pregnancy, which of the following client statements would indicate the need for additional teaching?

Correct Answer: C

Rationale: Reducing protein intake is not recommended for clients with heart disease.

Similar Questions

A nurse is counseling a client about the use of a diaphragm for contraception. Which of the following instructions should the nurse include?
A primigravid client at 39 weeks' gestation is admitted in early labor with contractions every 6 minutes. The nurse notes a fetal heart rate of 145 bpm with occasional variable decelerations. What is the nurse's first action?
The physician orders docusate sodium (Colace) 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?
A woman who is Rh-negative has delivered an Rh-positive infant. The nurse explains to the client that she will receive RhoGAM. The nurse determines that the client understands the purpose of RhoGAM when she states:
When developing the plan of care for a multiparous client in active labor who receives an epidural anesthetic, which of the following would the nurse anticipate that the physician will order if the client develops moderate hypotension?

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