NCLEX-PN
Maternal NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is caring for the client who is being evaluated for a suspected malpresentation. The fetus’s long axis is lying across the maternal abdomen, and the contour of the abdomen is elongated. Which should be the nurse’s documentation of the lie of the fetus?
Correct Answer: C
Rationale: A transverse lie occurs in 1 in 300 births and is marked by the fetus’s lying in a side-lying position across the abdomen. Vertex presentations result in the lie’s being vertical. Breech presentations result in the lie’s being vertical. A brow presentation is also a vertical lie.
Question 2 of 5
The nurse teaches the client to report which postpartum symptom immediately?
Correct Answer: B
Rationale: Foul-smelling lochia may indicate infection, requiring immediate reporting to prevent complications.
Question 3 of 5
Which clients are most likely to be identified as being at high risk for pregnancy complications? Select all that apply.
Correct Answer: A,B,D,F
Rationale: Multiple pregnancies, young age, hypertension, and spotting increase complication risks; twins or work hours are less significant.
Question 4 of 5
The nurse assesses the pregnant client who comes to the triage unit and determines that she is at 4/50/—1 and that the fetal HR is 148. What priority information should the nurse collect before proceeding?
Correct Answer: B
Rationale: Knowing the weeks of gestation is most important because if she is in premature labor, she may need to be given tocolytics to stop the process and to ensure adequate fetal lung maturity. If she is full term, the labor process could continue. The time and amount of last meal is important to know, but number of weeks’ gestation is more important. This client is dilated at 4 cm and in active labor. Who will attend the delivery should be identified during admission to the labor unit, but it is not the most important when being evaluated in triage. History of previous illnesses should be collected during admission to the labor unit, but it is not the most important when being evaluated in triage.
Question 5 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.