NCLEX-PN
Maternity NCLEX Questions Questions
Extract:
Question 1 of 5
Two hours after the client’s vaginal delivery, she reports feeling “several large, warm gushes of fluid” from her vagina. The nurse assesses the client’s perineum and finds a large pool of blood on the client’s bed. Which nursing action is priority?
Correct Answer: D
Rationale: A full bladder may displace the uterus, causing increased bleeding. However, a more complete assessment must be performed prior to getting the client out of bed to prevent increased bleeding and syncope. Vigorously massaging the uterus may result in inversion of the uterus. The client should not simply be reassured that heavy bleeding is expected because further assessment is necessary before concluding that the client’s blood loss is WNL. The nurse’s first action should be to support the lower uterine segment and to assess the fundus. Increased bleeding will occur if soft or “boggy.” Failing to support the lower uterine segment may result in inversion of the uterus.
Question 2 of 5
During the first postpartum checkup, the nurse is assessing whether the client’s chloasma has diminished. At which anatomical location is the nurse performing the assessment?
Correct Answer: D
Rationale: Chloasma does not appear on the perineum. Chloasma does not appear on the abdomen. Chloasma does not appear on the breasts. The nurse should be assessing the skin over the cheeks, nose, and forehead for chloasma.
Question 3 of 5
Which of the following is most indicative of the presence of hydatidiform mole?
Correct Answer: D
Rationale: A uterus larger than expected for gestational age is characteristic of hydatidiform mole, a gestational trophoblastic disease.
Question 4 of 5
The nurse is teaching the client who is wishing to travel by airplane during the first 36 weeks of her pregnancy. Which is the primary risk of air travel for this client that the nurse should address?
Correct Answer: B
Rationale: The primary risk with air travel during pregnancy is DVT. Pregnancy increases the risk of blood coagulation, and prolonged sitting produces venous stasis. Preterm labor is not associated with air travel. The threat of spontaneous abortion diminishes during the second trimester. Spontaneous abortion is not associated with air travel. Although nausea and vomiting can occur, they are not dangerous.
Question 5 of 5
Which safety measure should the nurse emphasize for newborn sleep?
Correct Answer: A
Rationale: Placing the newborn on their back to sleep reduces the risk of sudden infant death syndrome (SIDS).