NCLEX-PN
Maternal NCLEX Practice Questions Questions
Extract:
Question 1 of 5
Which condition increases the risk of congenital anomalies in the fetus?
Correct Answer: A
Rationale: Maternal diabetes, if poorly controlled, increases the risk of congenital anomalies due to elevated blood glucose levels.
Question 2 of 5
The nurse is caring for the postpartum family. The nurse determines that paternal engrossment is occurring when which observation is made of the newborn’s father?
Correct Answer: B
Rationale: Not making face-to-face contact with the infant during communication demonstrates a lack of engrossment. In North American culture, engrossment is demonstrated by the father touching the infant, making eye contact with the infant, and verbalizing awareness of features in the newborn that are similar to his and that validate his claim to that newborn. Feelings of frustration are not uncommon to fathers and are characteristic of the second stage, or reality stage, of the transition to fatherhood but are not a sign of engrossment. A hesitation to touch the infant demonstrates a lack of engrossment.
Question 3 of 5
The client, whose parity is 1, had a vaginal delivery 6 days ago and arrived home yesterday after treatment for endometritis. The home health nurse visits the client and plans teaching after seeing which most concerning item in the client’s bathroom?
Correct Answer: A
Rationale: The nurse should plan teaching about the use of tampons during postpartum. The tampon may irritate or dry the vagina, holds lochia in the body, and increases the risk of infection. The client should be instructed to wear a peripad. Loofas or bath sponges for bathing the body postpartum are not contraindicated. While it is a good idea to hang towels neatly so that they dry more rapidly and reduce mold growth, this is not a priority for teaching. The bathroom cleaner would be dangerous to an older child who is more mobile, but the client’s parity is 1. The client would be wise to start considering safety issues by placing this out of reach, but this is not the priority teaching item.
Question 4 of 5
The 22-year-old client, who is experiencing vaginal bleeding in the first trimester of pregnancy, fears that she has lost her baby at 8 weeks. Which definitive test result should indicate to the nurse that the client’s fetus has been lost?
Correct Answer: C
Rationale: Ultrasound is used to determine if the fetus has died. The lack of fetal heart activity in a pregnancy over 6 weeks determines a fetal loss. Falling BHCG levels do not conclusively diagnose fetal demise. Low progesterone levels do not conclusively diagnose fetal demise. Crown-rump length determines only the fetal gestational age.
Question 5 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.