NCLEX-PN
Maternal NCLEX Questions Questions
Extract:
Question 1 of 5
Which clients are most likely to be identified as being at high risk for pregnancy complications? Select all that apply.
Correct Answer: A,B,D,F
Rationale: Multiple pregnancies, young age, hypertension, and spotting increase complication risks; twins or work hours are less significant.
Question 2 of 5
The nurse assesses the pregnant client who comes to the triage unit and determines that she is at 4/50/—1 and that the fetal HR is 148. What priority information should the nurse collect before proceeding?
Correct Answer: B
Rationale: Knowing the weeks of gestation is most important because if she is in premature labor, she may need to be given tocolytics to stop the process and to ensure adequate fetal lung maturity. If she is full term, the labor process could continue. The time and amount of last meal is important to know, but number of weeks’ gestation is more important. This client is dilated at 4 cm and in active labor. Who will attend the delivery should be identified during admission to the labor unit, but it is not the most important when being evaluated in triage. History of previous illnesses should be collected during admission to the labor unit, but it is not the most important when being evaluated in triage.
Question 3 of 5
The nurse identifies which factor as contributing to the client's stress?
Correct Answer: C
Rationale: Financial concerns are a common stressor during pregnancy, impacting the client's psychosocial well-being.
Question 4 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 5 of 5
The nurse informs the pregnant client that her laboratory test indicates she has iron-deficiency anemia. Based on this diagnosis, the nurse should monitor this client for which problems? Select all that apply.
Correct Answer: A,B,C
Rationale: Iron-deficiency anemia is associated with susceptibility to infection because oxygen is not transported effectively. Iron-deficiency anemia is associated with fatigue because oxygen is not transported effectively. Iron-deficiency anemia is associated with risk of preeclampsia because oxygen is not transported effectively. Iron-deficiency anemia is not associated with an increased risk of diabetes. Iron-deficiency anemia is not associated with an increased risk of congenital defects.