NCLEX-PN
Maternity NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is evaluating the client in triage for possible labor. The client’s contractions are every 3 to 4 minutes, 60 to 70 seconds in duration, and moderate by palpation. Her cervical exam in the office was illustration 1. Her current exam is illustration 2. What conclusions should the nurse draw from illustration 2?
Correct Answer: C
Rationale: In illustration 2, the client is completely effaced and has some dilation. Illustration 1 (not illustration 2) shows that the client is neither effaced nor dilated. The cervical opening is minimally dilated, not completely dilated, and completely effaced. Illustration 2 shows some dilation.
Question 2 of 5
The nurse explains that, in addition to increased blood volume, which other condition causes varicose veins during pregnancy?
Correct Answer: A
Rationale: Impaired venous return, due to the uterus compressing veins, causes varicose veins, compounded by increased blood volume.
Question 3 of 5
The nurse is counseling the client who is trying to become pregnant. To promote fetal health when the client is unaware of a pregnancy, the nurse should stress the inclusion of which nutrient in daily food intake?
Correct Answer: C
Rationale: The nurse should educate the client about the need for adequate folic acid intake. Folic acid is important in preventing neural tube defects, especially during the first four weeks of fetal development. Potassium is important in preventing leg cramps during pregnancy, but this is usually not an issue during the first four weeks of gestation. Calcium is important for fetal development of bones, teeth, heart, nerves, and muscles, but the fetus will take calcium from the mother. Calcium is more important to maternal health than fetal development. Sodium is important for maintaining optimal electrolyte balance but is typically ingested in more than adequate amounts in a typical diet.
Question 4 of 5
The nurse is evaluating a breastfeeding session. The nurse determines that the infant has appropriately latched on to the mother’s breast when which observations are made? Select all that apply.
Correct Answer: A,D,E,F
Rationale: If the latch is correct, the mother should feel only a firm tugging and not pain or pinching when the infant sucks. A smacking or clicking noise heard when the infant sucks is an indication that the latch is incorrect and that the infant’s tongue may be inappropriately placed. Sucking only on the mother’s nipple will cause sore nipples, and milk will not be ejected from the milk ducts. When an infant is correctly latched to the breast, 2 to 3 centimeters (1/3 to 3/4 inch) of areola should be covered by the infant’s mouth. If this occurs, it will result in the infant’s nose, mouth, and chin touching the breast. When the infant is latched correctly, the cheeks will be rounded rather than dimpled. When the infant is latched correctly, the swallowing will be audible.
Question 5 of 5
Where can the nurse expect to palpate the fundus at this time?
Correct Answer: C
Rationale: At 20 weeks' gestation, the fundus is typically palpated near the level of the umbilicus, reflecting uterine growth.