NCLEX-PN
Maternal NCLEX Questions
Extract:
Question 1 of 5
The nurse is doing a one-minute Apgar score on a newborn and tells the parents that it is 7 points. When the parents ask what this means, how should the nurse best respond?
Correct Answer: C
Rationale: This response is best because a score of 7 to 10 is within a normal range and 并表示新生儿没有任何不适的迹象。A score of 7 to 10 is considered acceptable for a one-minute Apgar. However, when the scoring is repeated at 5 minutes of age, a score of 7 to 10, not just 10, is within normal range. The Apgar score is used to systematically assess an infant at one and five minutes after birth to determine if immediate care is necessary. It is not used to predict intelligence or neurological development. Although the Apgar score does mean that the newborn’s VS are WNL, the Apgar score is not designed to classify gestational age.
Question 2 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 3 of 5
The client in active labor has moderate to strong contractions occurring every 2 minutes and lasting 60 to 70 seconds. The client states extreme pain in the small of her back. Her abdomen reveals a small depression under the umbilicus. Which fetal position should the nurse document?
Correct Answer: B
Rationale: An occiput posterior position is characterized by intense back pain (back labor). A depression under the umbilicus occurs as a result of the posterior shoulder. When a fetus presents anterior, it is uncommon for the mother’s chief symptom to be back pain, and the uterus should appear smooth.
Question 4 of 5
Two hours after delivery, the mother tells the nurse that she will be bottle feeding. She asks what she can do to prevent the terrible pain experienced when her milk came in with her last baby. Which response by the nurse is most appropriate?
Correct Answer: C
Rationale: In comparison studies between breast binders and bras, mothers using binders experienced more engorgement and discomfort. Engorgement is not familial and not inevitable in bottle-feeding mothers. Wearing a supportive, well-fitting bra within 6 hours after birth can suppress lactation. The bra should be worn continuously, except for showering, until lactation is suppressed (usually 7 to 14 days). Signs of engorgement usually occur on the third to fifth postpartum day (not right after birth), and engorgement will spontaneously resolve by the tenth day postpartum.
Question 5 of 5
Which position should the nurse recommend to relieve round ligament pain?
Correct Answer: B
Rationale: Side-lying with a pillow between knees supports the abdomen and reduces strain on round ligaments, relieving pain.