NCLEX-RN
Maternity NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse notices that a client who has just delivered her infant is short of breath, ashen in color, and begins to cough. She becomes limp on the delivery table. Determine the nursing actions in the order they should occur.
Correct Answer: C,A,D,E,B
Rationale: Assess responsiveness first, then secure the airway, breathing, and circulation.
Question 2 of 5
While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the client's physician immediately if the client exhibited which of the following?
Correct Answer: B
Rationale: Dyspnea may indicate a pulmonary embolism, a life-threatening complication requiring immediate attention.
Question 3 of 5
A primigravid client at 37 weeks' gestation with gestational diabetes is in active labor at 5 cm dilation. The nurse notes a blood glucose level of 45 mg/dL. What is the nurse's first action?
Correct Answer: B
Rationale: A blood glucose of 45 mg/dL indicates maternal hypoglycemia, common in gestational diabetes due to insulin use. Offering a high-carbohydrate snack is the first action to stabilize glucose safely. Dextrose is for severe cases, rechecking delays treatment, and notification follows initial management.
Question 4 of 5
A multiparous client, 72 hours postpartum, reports a sudden gush of lochia rubra. The nurse should suspect:
Correct Answer: D
Rationale: A sudden gush of lochia rubra after 72 hours suggests retained placental fragments, which can cause hemorrhage.
Question 5 of 5
After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she says which of the following?
Correct Answer: C
Rationale: Antibodies form after exposure to an Rh-positive fetus, typically not during the first pregnancy, explaining why sensitization did not occur previously.