Maternity NCLEX Questions

Extract:

Question 1 of 5

The nurse is evaluating the 39-weeks-pregnant client who reports greenish, foul-smelling vaginal discharge. Her temperature is 101.6°F (38.7°C), and the FHR is 120 with minimal variability and no accelerations. The client’s group beta streptococcus (GBS) culture is positive. Which interventions should the nurse plan to implement? Select all that apply.

Correct Answer: A,C,D,E

Rationale: Because this client is not in labor and chorioamnionitis is possible, a cesarean birth is indicated. The client should be given antibiotics as prescribed to treat the infection. Because epidural anesthesia offers the least risk to the fetus, preparation for epidural anesthesia should begin. The pediatrician or neonatologist should be notified and available for the impending delivery. Starting oxytocin (Pitocin) would prolong the time to delivery. Administering a cervical ripening agent would prolong the time to delivery.

Question 2 of 5

The postpartum client suffered a fourth-degree perineal laceration during her vaginal birth. Which interventions should the nurse add to the client’s plan of care? Select all that apply.

A. Limit ambulation to bathroom privileges only. B. Decrease fluid intake to 1000 mL every 24 hours. C. Instruct the client on a high-fiber diet. D. Monitor the uterus for firmness every 2 hours. E. Give pm prescribed stool softeners in the am. and at h.s.

Correct Answer: C,E

Rationale: Activity should be increased, not decreased, to reduce the potential for constipation. Fluids should be increased, not decreased, to reduce the potential for dehydration and constipation. The client with a fourth-degree perineal laceration should be instructed to increase dietary fiber to help maintain bowel continence and decrease perineal trauma from constipation. A perineal laceration will not affect the condition of the uterus; there is no need to increase uterine monitoring. The client with a fourth-degree perineal laceration should be given a stool softener bid to help maintain bowel continence and decrease perineal trauma from constipation.

Question 3 of 5

The client, who delivered a 4200-g baby 4 hours ago, continues to have bright red, heavy vaginal bleeding. The nurse assesses the client’s fundus and finds it to be firm and midway between the symphysis pubis and umbilicus. What should the nurse do next?

A. Continue to monitor the client’s bleeding and weigh the peripads. B. Call the client’s HCP and request an additional visual examination. C. Prepare to give oxytocin to stimulate uterine muscle contraction. D. Document the findings as normal with no interventions needed at that time.

Correct Answer: B

Rationale: Although the nurse would definitely need to continue to monitor the amount and quality of bleeding, additional intervention is also needed. The nurse should consider the possibility of a vaginal wall or cervical laceration, which could produce heavy, bright red bleeding. The HCP should be notified and asked to perform a visual exam of the vagina to assess for possible lacerations in need of repair. Preparing to administer oxytocin (Pitocin) would be appropriate if the source of bleeding was suspected to be uterine atony, but the uterus is firm and in the expected location. Documenting the findings without further intervention would lead to a failure to identify the source of increased bleeding resulting in possible client injury. Further assessments and interventions are needed.

Question 4 of 5

The nurse explains that, in addition to increased blood volume, which other condition causes varicose veins during pregnancy?

A. Impaired venous return B. Decreased cardiac output C. Altered center of gravity D. Impaired kidney function

Correct Answer: A

Rationale: Impaired venous return, due to the uterus compressing veins, causes varicose veins, compounded by increased blood volume.

Question 5 of 5

The nurse is caring for the pregnant client at the initial prenatal visit. Which universal screenings should the nurse complete? Select all that apply.

A. Taking the client’s blood pressure B. Doing a urine dipstick test for protein C. Doing a urine dipstick test for glucose D. Asking questions about domestic violence E. Asking questions about use of tobacco

Correct Answer: A,D,E

Rationale: BP screening should be performed at the initial prenatal visit to establish a baseline and to evaluate for actual or potential problems. Domestic violence screening should be performed at the initial prenatal visit to determine fetal and maternal risk for harm. Screening for tobacco use should be performed at the initial prenatal visit to determine fetal and maternal risk. Smoking is associated with an increased risk for spontaneous abortion, preterm labor, and low birth weight. The use of routine urine dip assessments is unreliable in detecting proteinuria and is not always considered accurate. A urine sample should be collected and a UA completed to check for a UTI. The urine dipstick test is of insufficient sensitivity to be used as a screening tool for glycosuria and is not always considered accurate. A urine sample should be collected and a UA completed to check for the presence of glucose.

Maternity NCLEX Questions | Nurselytic

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