NCLEX-PN
Maternal NCLEX Practice Questions Questions
Extract:
Question 1 of 5
Twenty-four hours post—vaginal delivery, the postpartum client tells the nurse that she is concerned because she has not had a bowel movement (BM) since before delivery. Which action should be taken by the nurse?
Correct Answer: A
Rationale: A spontaneous BM may not occur for 2 to 3 days after childbirth due to decreased muscle tone in the intestines during labor and the immediate postpartum period, possible prelabor diarrhea, and decreased food intake and dehydration during labor. Thus, documentation of the lack of a BM is the only action required. There is no need to notify the HCP for a normal finding. A laxative is unnecessary since a BM is not expected for 2 to 3 days postdelivery. Bowel sounds are not altered by a vaginal delivery, even though the passage of stool through the intestines is slowed.
Question 2 of 5
Which instruction should the nurse provide about newborn feeding?
Correct Answer: B
Rationale: Feeding on demand supports the newborn's nutritional needs and promotes bonding and growth.
Question 3 of 5
The primigravida client has been pushing for 2 hours when the infant’s head emerges. The infant fails to deliver, and the obstetrician states that the turtle sign has occurred. Which should be the nurse’s interpretation of this information?
Correct Answer: B
Rationale: The “turtle sign” occurs when the infant’s head suddenly retracts back against the mother’s perineum after emerging from the vagina, resembling a turtle pulling its head back into its shell. This head retraction is caused by the infant’s anterior shoulder being caught on the back of the maternal pubic bone (shoulder dystocia), preventing delivery of the remainder of the infant. Cephalopelvic disproportion occurs when the head is too large to fit through the client’s pelvis. Fetal descent ceases, and infant’s head would not emerge. Persistent occiput posterior results in prolonged pushing; however, once the head is born, the remainder of the birth occurs without difficulty. A cord prolapse occurs when the umbilical cord enters the cervix before the fetal presenting part and is considered a medical emergency.
Question 4 of 5
Before teaching the client about the nutritional needs during pregnancy, which nursing intervention is most appropriate?
Correct Answer: B
Rationale: Assessing the client's eating patterns and preferences provides a baseline for tailored nutritional education.
Question 5 of 5
On the basis of the health history data, how should the nurse record the client's pregnancy status on the prenatal records?
Correct Answer: C
Rationale: A primigravida is a woman pregnant for the first time, which matches the client's status of being possibly 2 months pregnant with no prior pregnancies.