NCLEX-PN
Maternity NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is assessing the postpartum client, who is 5 hours postdelivery. Initially, the nurse is unable to palpate the client’s uterine fundus. Prioritize the nurse’s actions to locate the client’s fundus by placing each step in the correct sequence.
Correct Answer: E,A,C,B,D,F
Rationale: Position the client in supine so the height of the uterus is not influenced by an elevated position. Place the side of one hand just above the client’s symphysis pubis. This supports the lower uterine segment and prevents the inadvertent inversion of the uterus during palpation. Place the other hand at the level of the umbilicus. This is the expected location of the uterine fundus on the day of delivery. Press deeply into the abdomen to allow the massage to reach the fundus. Massage the abdomen in a circular motion. This massage should stimulate the uterus to contract and allow location of the fundus to be determined. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage. Involution could potentially be occurring more rapidly than expected if the client is breastfeeding and/or had an uncomplicated labor and birth.
Question 2 of 5
The nurse is providing nutrition counseling to the client during her first prenatal clinical visit. Which statement, if made by the client, indicates that the client has an understanding of some of the nutritional requirements during pregnancy?
Correct Answer: A
Rationale: Cheese is a milk product and is an alternative to milk. This statement indicates understanding of nutritional requirements regarding milk and milk products. Caloric intake needs to increase by 300 kcal per day during pregnancy to meet increased metabolic needs. However, “I’m eating for two” is a common misconception and leads to caloric intake greater than necessary. Caloric intake needs to increase by 300 kcal per day and should not be limited during pregnancy. Nutritional snacks throughout the day can provide for steady blood glucose levels and decrease the nausea associated with pregnancy. A limit of only three meals per day may not provide the client with enough calories to meet increased metabolic needs or may cause the client to eat more at each meal and increase nausea and bloating.
Question 3 of 5
The nurse observes a sinusoidal FHR pattern on the monitor tracing. How should the nurse interpret this pattern?
Correct Answer: C
Rationale: A sinusoidal pattern, which is Drag and Drop, smooth, undulating, and uncommon, classically occurs with severe fetal anemia as a result of abnormal perinatal conditions. An FHR pattern having minimal variability (not a sinusoidal pattern) might indicate that the fetus is in a sleep state. Absent or minimal variability, not a sinusoidal FHR pattern, could indicate possible congenital anomalies. Moderate variability of the FHR (not a sinusoidal pattern) reflects normal fetal well-being.
Question 4 of 5
The nurse is counseling the client who is trying to become pregnant. To promote fetal health when the client is unaware of a pregnancy, the nurse should stress the inclusion of which nutrient in daily food intake?
Correct Answer: C
Rationale: The nurse should educate the client about the need for adequate folic acid intake. Folic acid is important in preventing neural tube defects, especially during the first four weeks of fetal development. Potassium is important in preventing leg cramps during pregnancy, but this is usually not an issue during the first four weeks of gestation. Calcium is important for fetal development of bones, teeth, heart, nerves, and muscles, but the fetus will take calcium from the mother. Calcium is more important to maternal health than fetal development. Sodium is important for maintaining optimal electrolyte balance but is typically ingested in more than adequate amounts in a typical diet.
Question 5 of 5
The client at 32 weeks’ gestation presents to a hospital with a severe headache. Her admission BP is 184/104 mm Hg. Based on the assessment and findings of the serum laboratory report, which most severe complication warrants the nurse’s further assessment?
Correct Answer: D
Rationale: It is most important for the nurse to further assess for HELLP syndrome, a variation of pregnancy-induced hypertension characterized by hemolysis (elevated bilirubin), elevated liver enzymes, and low platelets. The laboratory results do not show the serum creatinine level, so no inferences can be made about renal failure. Although liver enzymes are elevated, HELLP syndrome is a more severe complication associated with pregnancy. Preeclampsia commonly coexists with HELLP syndrome; however, these laboratory findings show worsening symptoms that are associated with HELLP syndrome.