NCLEX-PN
Maternal NCLEX Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for the postpartum family. The nurse determines that paternal engrossment is occurring when which observation is made of the newborn’s father?
Correct Answer: B
Rationale: Not making face-to-face contact with the infant during communication demonstrates a lack of engrossment. In North American culture, engrossment is demonstrated by the father touching the infant, making eye contact with the infant, and verbalizing awareness of features in the newborn that are similar to his and that validate his claim to that newborn. Feelings of frustration are not uncommon to fathers and are characteristic of the second stage, or reality stage, of the transition to fatherhood but are not a sign of engrossment. A hesitation to touch the infant demonstrates a lack of engrossment.
Question 2 of 5
The nurse is assessing the laboring client who is morbidly obese. The nurse is unable to determine the fetal position. Which action should be performed by the nurse to obtain the most accurate method of determining fetal position in this client?
Correct Answer: D
Rationale: Real-time transabdominal ultrasound (US) is the most accurate assessment measure to determine the fetal position and is frequently available in the birthing setting. US images may be used to assess fetal lie, presentation, and position in the morbidly obese client. Inspection of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Palpation of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Vaginal examination can be used to determine fetal position, but because the client is obese, this is not the most accurate method.
Question 3 of 5
While assessing the breastfeeding mother 24 hours postdelivery, the nurse notes that the client’s breasts are hard and painful. Which interventions should be implemented by the nurse? Select all that apply.
Correct Answer: B,D,F
Rationale: Moving the baby from the initial breast to the second breast during the feeding, before the initial breast is completely emptied, may result in neither breast being totally emptied and thus promote continued engorgement. Because engorgement is caused, in part, by swelling of the breast tissue surrounding the milk gland ducts, applying ice at intervals between feedings will help to decrease this swelling. Giving supplemental formula, thus limiting the time the baby nurses at the breast, prevents total emptying of the breast and promotes increased engorgement. Administering anti-inflammatory medication will decrease breast pain and inflammation. Because heat application increases blood flow, moist heat packs would exacerbate the engorgement. Pumping the breasts may be necessary if the infant is unable to completely empty both breasts at each feeding. Pumping at this time will not cause a problematic increase in breast milk production.
Question 4 of 5
The client who is 32 weeks pregnant asks how the nurse will monitor the baby’s growth and determine if the baby is “really okay.” Which assessments should the nurse identify for evaluating the fetus for adequate growth and viability? Select all that apply.
Correct Answer: B,E
Rationale: Adequate fetal growth is evaluated by measuring the fundal height. Auscultating the FHT assesses fetal viability. The presence of fetal (not maternal) heart tones starting at around 10-12 weeks is a standard to assess fetal growth and viability. The abdominal circumference does not provide information about fetal growth. The increase in abdominal girth could be due to weight gain or fluid retention, not just growth of the baby. Third-trimester ultrasound is neither routine nor advised for routine prenatal care because of the added cost and potential risk to the fetus.
Question 5 of 5
The nurse is teaching the Muslim client how to correctly latch her baby to her breast for breastfeeding. Two student nurses are observing the instruction. Later, the client requests that the nurse not be allowed to provide her postpartum care. What most likely caused the client to be uncomfortable with the nurse?
Correct Answer: C
Rationale: Korean mothers resist breastfeeding in the hospital. Some Asian women believe colostrum is “bad,” and therefore they do not feed until actual breast milk is present. Most Muslim women breastfeed because the Koran encourages it; however, they are uncomfortable about breastfeeding in public situations and prefer privacy. Having two students observing the feeding process most likely would make the client uncomfortable, as she would desire more privacy. Some Asian cultures believe the newborn must be given boiled water until the milk is actually present.