NCLEX-PN
Maternal NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is caring for the postpartum primiparous client who is 13 hours post—vaginal delivery. The nurse observes that the client is passive and hesitant about making decisions about her own and her newborn’s care. In response to this observation, which interventions should be implemented by the nurse? Select all that apply.
Correct Answer: A,B,C
Rationale: Many women hesitate to ask for medication, as they believe their pain is expected. Thus, the nurse should ask the client about pain and assure her that there are methods to decrease her pain. During the initial postpartum “taking-in” phase, the client may have a great need to talk about her birthing experience and to ask questions for clarification as necessary. By encouraging this verbalization, the nurse helps the client to accept the experience and enables her to move to the next maternal phase. Physical discomfort can be intense initially postpartum and can interfere with rest. Sleep is a major need and should be encouraged. Anxiety and preoccupation with her new role often narrow the client’s perceptions, and information is not as easily assimilated at this time.
Therefore, attending education sessions should be delayed if possible until the mother has completed this “taking in” phase. The client needs to suspend her involvement in everyday responsibilities during the “taking—in” phase, so writing birth announcements should be delayed until the mother has completed this phase.
Question 2 of 5
The nurse is caring for the 30-weeks-pregnant client who is having contractions every 1½ to 2 minutes with spontaneous rupture of membranes 2 hours ago. Her cervix is 8 cm dilated and 100% effaced. The nurse determines that delivery is imminent. What intervention is the most important at this time?
Correct Answer: C
Rationale: The most important intervention is to notify the neonatal team of the delivery because the team members will be needed for respiratory support and possible resuscitation.
Tocolytic agents, such as nifedipine (Procardia), can be used for short-term intervention to slow down contractions and delay birth, but it is too late to administer a tocolytic agent. Teaching is important but is not appropriate at this time. A cesarean birth is indicated if there are other obstetrical needs.
Question 3 of 5
The laboring client just had a convulsion after being given regional anesthesia. Which interventions should the nurse implement? Select all that apply.
Correct Answer: A,C,D,E
Rationale: The client experiencing a convulsion related to anesthesia should first have an airway established. The client experiencing a convulsion related to anesthesia should receive 100% oxygen so that the mother and fetus remain oxygenated. Small doses of diazepam or thiopental can be administered to stop the convulsions. The anesthesiologist should be STAT paged to provide assistance; the convulsion was initiated by the regional anesthetic. The client’s head should be turned to the side if vomiting occurs, but the client typically remains in a left lateral tilt position so an airway can be maintained. Positioning on the right side can cause aortocaval compression.
Question 4 of 5
Immediately after delivery of the client’s placenta, the nurse palpates the client’s uterine fundus. The fundus is firm and located halfway between the umbilicus and symphysis pubis. Which action should the nurse take based on the assessment findings?
Correct Answer: B
Rationale: Uterine massage is indicated only if the uterus does not feel firm and contracted. Immediately after birth, the uterus should contract, and the fundus should be located one-half to two-thirds of the way between the symphysis pubis and umbilicus. Thus the only action required is to document the assessment finding. There is no indication that the bladder is full. A full bladder will cause uterine displacement to either side of the abdomen. The uterus is firm; there is no reason to infer that increased vaginal bleeding would occur.
Question 5 of 5
The pregnant client asks the nurse, who is teaching a prepared childbirth class, when she should expect to feel fetal movement. The nurse responds that fetal movement usually can first be felt during which time frame?
Correct Answer: C
Rationale: Subtle fetal movement (quickening) can be felt as early as 18 to 20 weeks of gestation, and it gradually increases in intensity. Eight to 12 weeks of pregnancy is too early to expect the first fetal movement to be felt. Twelve to 16 weeks of pregnancy is too early to expect the first fetal movement to be felt. Twenty-two to 26 weeks of pregnancy is later than expected to feel the first fetal movement.