NCLEX-PN
Maternal NCLEX Questions
Extract:
Question 1 of 5
The nurse just administered butorphanol tartrate as prescribed to the client in active labor. Following administration of butorphanol tartrate, what is the nurse’s most important action to help prevent side effects?
Correct Answer: D
Rationale: Evaluating maternal VS and pulse oximetry would determine changes in respiratory and cardiac status. Respiratory depression in both the mother and fetus can occur with butorphanol tartrate (Stadol). Although bladder distention is a possible side effect of butorphanol tartrate, it is not common and is not the most important assessment. Seizures are not a potential side effect of butorphanol tartrate. An itchy rash is not a potential side effect of butorphanol tartrate.
Question 2 of 5
To best enhance absorption of the iron supplement, which foods should the nurse recommend the client increase in her diet? Select all that apply.
Correct Answer: A,D
Rationale: Oranges and broccoli are rich in vitamin C, which enhances iron absorption, unlike the other options.
Question 3 of 5
The pregnant client tells the nurse that she thinks she is carrying twins. In reviewing the client’s history and medical records, the nurse should determine that which factors are associated with a multiple gestation? Select all that apply.
Correct Answer: A,B,D
Rationale: An elevated serum alpha-fetoprotein level (an oncofetal protein normally produced by the fetal liver and yolk sac) is associated with a multiple gestation. The use of reproductive technology such as artificial insemination or fertility drugs is associated with a multiple gestation. History of twins in the family is associated with a multiple gestation. Maternal age greater than 40 is not associated with multiple gestation. An elevated Hgb is not associated with multiple gestation.
Question 4 of 5
Which client would the nurse identify as being at highest risk for developing complications during pregnancy?
Correct Answer: D
Rationale: A 35-year-old gravida V client is at higher risk due to advanced maternal age and multiple pregnancies, increasing complication risks.
Question 5 of 5
The nurse instructs the client to report which newborn symptom immediately?
Correct Answer: B
Rationale: Inability to suck or feed is a serious symptom that may indicate neurological or health issues, requiring immediate reporting.