NCLEX-RN
Maternity NCLEX RN Questions Questions
Extract:
Question 1 of 5
When developing the plan of care for a multigravid client with class III heart disease, which of the following areas should the nurse expect to assess frequently?
Correct Answer: D
Rationale: Class III heart disease indicates significant cardiac limitation, making tachycardia a critical sign of cardiac stress during labor. Frequent assessment ensures early detection of decompensation. Dehydration, nausea, or anemia are less immediate concerns.
Question 2 of 5
A primigravid client whose cervix is 7 cm dilated with the fetus at 0 station and in a left occipitoposterior (LOP) position requests pain relief for severe back pain. The nurse should:
Correct Answer: A
Rationale: LOP position often causes severe back pain due to the fetal occiput pressing against the sacrum. Firm sacral pressure (counterpressure) can alleviate this pain. Cesarean or precipitate delivery is not indicated unless other complications arise, and side-lying may help but is less specific.
Question 3 of 5
A multiparous client, 72 hours postpartum, reports a sudden gush of lochia rubra. The nurse should suspect:
Correct Answer: D
Rationale: A sudden gush of lochia rubra after 72 hours suggests retained placental fragments, which can cause hemorrhage.
Question 4 of 5
A nurse is discussing the contraceptive injection with a client. Which of the following side effects should the nurse mention?
Correct Answer: B
Rationale: The contraceptive injection may cause irregular bleeding and potential weight gain. It does not guarantee regular periods, cause permanent infertility, or significantly increase breast cancer risk.
Question 5 of 5
In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation?
Correct Answer: C
Rationale: The 'taking hold' phase is characterized by the mother becoming more active, showing interest in caring for the infant, and asking questions about infant care, as described in the scenario.