NCLEX-RN
NCLEX RN Practice Questions Maternity Questions
Extract:
Question 1 of 5
When caring for a multiparous client who is human immunodeficiency virus (HIV)-positive and asking to breast-feed her neonate as soon as possible, which of the following instructions about breast milk should the nurse include in the teaching plan?
Correct Answer: D
Rationale: Breast milk from an HIV-positive mother can transmit the virus to the neonate, so breastfeeding is contraindicated to prevent HIV transmission.
Question 2 of 5
Initial assessment of a term female neonate about 4 hours old reveals a normal anterior fontanel. The nurse documents its shape as which of the following?
Correct Answer: C
Rationale: The anterior fontanel in a term neonate is typically diamond-shaped.
Question 3 of 5
A neonate delivered at 40 weeks' gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75 %. The nurse should:
Correct Answer: B
Rationale: A pulse oximetry reading of 75% indicates hypoxemia, and providing supplemental oxygen is the priority.
Question 4 of 5
While caring for a multiparous client 4 hours after vaginal delivery of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/minute. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should:
Correct Answer: A
Rationale: A slightly elevated temperature (99.8°F) within the first 24 hours is normal; continued monitoring is appropriate with otherwise normal findings.
Question 5 of 5
While assessing a primigravid client admitted at 36 weeks' gestation, the nurse observes multiple bruises on the client's face, neck, and abdomen. When asked about the bruises, the client admits that her boyfriend beats her now and then and says, 'I want to leave him because I'm afraid he will hurt the baby.' Which of the following actions is the nurse's priority?
Correct Answer: C
Rationale: Suspected domestic violence requires referral to a social worker to provide resources (e.g., shelters, counseling) and ensure maternal-fetal safety. Advising immediate leaving is impractical, fetal movement assessment is secondary, and reporting to the supervisor does not directly help the client.