NCLEX-PN
Maternal NCLEX Questions
Extract:
Question 1 of 5
The nurse is caring for the client with mild preeclampsia. The nurse should monitor for which complications associated with mild preeclampsia? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Placental abruption can occur as a complication of preeclampsia due to hypoperfusion of the placenta and endothelial injury. Hyperbilirubinemia can occur as a complication of preeclampsia due to hypoperfusion to the liver. Nonreassuring fetal status can occur as a complication of preeclampsia due to hypoperfusion to the placenta. Severe preeclampsia can occur as a complication of preeclampsia if the BP remains uncontrolled. Gestational diabetes is not associated with preeclampsia.
Question 2 of 5
The nurse correctly assists the client into which position?
Correct Answer: A
Rationale: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.
Question 3 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 4 of 5
The Caucasian postpartum client asks the nurse if the stretch marks (striae gravidarum) on her abdomen will ever go away. Which response by the nurse is most accurate?
Correct Answer: D
Rationale: Stretch marks will fade but will not totally disappear. Stretch marks will fade and will not always appear reddened. There is no evidence that keeping the skin hydrated will lighten the appearance of the stretch marks. In Caucasian women, stretch marks will fade to a pale white over 3 to 6 months.
Question 5 of 5
The postpartum client, who is 24 hours post—vaginal birth and breastfeeding, asks the nurse when she can begin exercising to regain her prepregnancy body shape. Which response by the nurse is correct?
Correct Answer: A
Rationale: On the first postpartum day, the client should be taught to start abdominal breathing and pelvic rocking. Kegel exercises, which should have been taught during pregnancy, should be continued. Simple exercises should be added daily until, by 2 to 3 weeks postpartum, the mother should be able to do sit-ups and leg raises. Abdominal and pelvic exercises can begin right away and not wait for the 6-week postpartum checkup. There is no reason for the client to wait until the lochia has stopped before beginning exercises. There is no reason that a breastfeeding mother should not begin abdominal and pelvic exercises now.