NCLEX-PN
Maternal NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is preparing to administer 2 mg hydromorphone hydrochloride to the client who is 28 hours post—cesarean section. The medication available is in a concentration of 4 mg/mL. How many milliliters should the nurse administer?
Correct Answer: 0.5 mL
Rationale: (2 mg / 4 mg) x 1 mL = 0.5 mL. The nurse should administer 0.5 mL hydromorphone hydrochloride (Dilaudid).
Question 2 of 5
In the primigravid client, when is fetal movement typically felt for the first time?
Correct Answer: B
Rationale: Primigravid women typically feel fetal movement (quickening) between 16 and 20 weeks, later than multigravida women.
Question 3 of 5
Which client statement indicates a need for immediate intervention?
Correct Answer: C
Rationale: A lack of fetal movement may indicate fetal distress, requiring immediate assessment and intervention.
Question 4 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 5 of 5
The client expresses concerns related to nausea in the first trimester of pregnancy. Which recommendation should the nurse make?
Correct Answer: A
Rationale: The nurse should instruct the client to eat dry crackers before rising from bed. This typically relieves some of the nausea. Lying down when the nausea occurs may increase heartburn and reflux, thereby increasing nausea. Eating frequently may increase heartburn and reflux, thereby increasing nausea. Food items with ginger may help to alleviate nausea and are recommended (rather than avoided), including ginger tea.