NCLEX-PN
Maternal NCLEX Questions Questions
Extract:
Question 1 of 5
The student nurse reports to an experienced nurse finding a warm, red, tender area on the left calf of the client who is 48 hours post—vaginal delivery. The nurse assesses the client and explains to the student that postpartum clients are at increased risk for thrombophlebitis due to which factors? Select all that apply.
Correct Answer: A,D,E,F
Rationale: During pregnancy, fibrinogen levels increase, and this increase continues to be present in the postpartum period. The increased levels can contribute to clot formation. There is not a shift of fluid from the interstitial to the vascular spaces in the postpartum period. Actual blood volume increases during pregnancy and is further increased immediately after delivery. This fluid volume is eventually lost through diuresis during the first postpartum week. Postpartum hormonal changes do occur, but they do not affect the vascular basement membranes. Elevation of the legs in stirrups during delivery leads to pooling of blood and vascular stasis. Dilation of the veins in the lower extremities occurs during pregnancy and increases the risk of venous stasis. Compression of the common iliac vein occurs during pregnancy due to an enlarging fetus and increases the risk of venous stasis.
Question 2 of 5
When the client asks why folic acid is important, which response by the nurse is most accurate?
Correct Answer: A
Rationale: Folic acid is critical for preventing neural tube defects like spina bifida by supporting early fetal development.
Question 3 of 5
When one participant asks the nurse what can be done to relieve leg cramps while working, which instruction by the nurse is correct?
Correct Answer: C
Rationale: Pointing toes toward the head (dorsiflexion) relieves leg cramps by stretching the calf muscles, unlike the other options.
Question 4 of 5
The pregnant client presents with vaginal bleeding and increasing cramping. Her exam reveals that the cervical os is open. Which term should the nurse expect to see in the client’s chart notation to most accurately describe the client’s condition?
Correct Answer: C
Rationale: In imminent abortion, the client’s bleeding and cramping increase and the cervix is open, which indicates that abortion is imminent or inevitable. In ectopic pregnancy, the pregnancy is outside of the uterus, and intervention is indicated to resolve the pregnancy. A complete abortion indicates that the contents of the pregnancy have been passed. In an incomplete abortion, a portion of the pregnancy has been expelled, and a portion remains in the uterus.
Question 5 of 5
The nurse is caring for multiple clients. The nurse determines that which client would be a candidate for intermittent fetal monitoring during labor?
Correct Answer: B
Rationale: The client who is overdue by 7 days but has a reassuring FHR pattern is able to have intermittent fetal monitoring. Women with a previous cesarean birth are at an increased risk for uterine rupture. Women with preeclampsia are at an increased risk for placental insufficiency and need continuous monitoring during labor. Women with gestational diabetes are at an increased risk for placental insufficiency and need continuous monitoring during labor.