NCLEX-RN
NCLEX RN Practice Questions Maternity Questions
Extract:
Question 1 of 5
The nurse on the postpartum mother-baby unit is assigned to take care of four couplets and a new couplet will be admitted within the next 30 minutes. All assessments are complete. The nurse can delegate care for which couplet to the unlicensed nursing personnel?
Correct Answer: B
Rationale: The G4 P4 client with stable breastfeeding is appropriate for UAP delegation, as no complex medical needs are present.
Question 2 of 5
A primiparous client asks how to store breast milk safely at room temperature. The nurse should instruct the client that breast milk can be left at room temperature for up to:
Correct Answer: C
Rationale: Breast milk is safe at room temperature (up to 77°F) for up to 6 hours, minimizing bacterial growth.
Question 3 of 5
An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifier in the infant's mouth during these feedings. The nurse replies that the pacifier helps in what ways? Select all that apply.
Correct Answer: B,D
Rationale: The pacifier provides oral stimulation and reminds the infant how to suck, promoting oral motor development.
Question 4 of 5
Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following?
Correct Answer: D
Rationale: Edema in the lower urinary tract, often from delivery trauma or epidural anesthesia, can cause urinary retention and bladder distention.
Question 5 of 5
A multigravid client at 38 weeks' gestation, G4 P3, is 6 cm dilated with contractions every 3 minutes. The nurse observes meconium-stained amniotic fluid after spontaneous rupture of membranes. What is the priority nursing action?
Correct Answer: B
Rationale: Meconium-stained fluid raises the risk of fetal distress. Assessing the fetal heart rate pattern immediately ensures the fetus is tolerating labor. Cesarean delivery is not automatic, suctioning is irrelevant, and documentation follows assessment.