NCLEX-PN
Maternal NCLEX Practice Questions Questions
Extract:
Question 1 of 5
Which cultural consideration should the nurse include in prenatal education?
Correct Answer: A
Rationale: Respecting the client's dietary preferences and cultural beliefs ensures culturally sensitive and effective prenatal education.
Question 2 of 5
The client, who had a vaginal delivery 18 hours ago, asks the nurse how she should take care of her perineal laceration. Which statements by the nurse are appropriate? Select all that apply.
Correct Answer: B,D,E,F
Rationale: The peripad should be changed more frequently to reduce the risk of infection. Lochia amount should never exceed a moderate amount (less than a 6-inch stain on a perineal pad). A warm sitz bath is used after the first 24 hours to provide comfort, increase circulation to the area, and reduce the incidence of infection. Perineal lacerations are repaired with sutures that dissolve. Clients do not need to have perineal sutures removed. Cleansing the perineum after each void with the peri-bottle of water provides comfort and helps reduce the chance of infection. Washing with mild soap and rinsing with water each 24 hours reduces the risk of infection. Teaching the client to watch for signs and symptoms of infection is important and allows the client to be an active participant in her care.
Question 3 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 4 of 5
The client who is 32 weeks pregnant asks how the nurse will monitor the baby’s growth and determine if the baby is “really okay.” Which assessments should the nurse identify for evaluating the fetus for adequate growth and viability? Select all that apply.
Correct Answer: B,E
Rationale: Adequate fetal growth is evaluated by measuring the fundal height. Auscultating the FHT assesses fetal viability. The presence of fetal (not maternal) heart tones starting at around 10-12 weeks is a standard to assess fetal growth and viability. The abdominal circumference does not provide information about fetal growth. The increase in abdominal girth could be due to weight gain or fluid retention, not just growth of the baby. Third-trimester ultrasound is neither routine nor advised for routine prenatal care because of the added cost and potential risk to the fetus.
Question 5 of 5
The postpartum client delivered a full-term infant 2 days previously. The client states to the nurse, “My breasts seem to be growing, and my bra no longer fits.” Which statement should be the basis for the nurse’s response to the client’s concern?
Correct Answer: D
Rationale: Infection in the breast tissue results in flulike symptoms and redness and tenderness of the breast. It is usually unilateral and does not cause bilateral breast enlargement. Fluid is not retained during the postpartum period; rather, clients experience diuresis of the excess fluid volume accumulated during pregnancy. Fullness in both breasts would not be the result of thrombi formation. Symptoms of thrombi include redness, pain, and increased skin temperature over the thrombi. Breast tissue increases as breast milk forms, so a bra that was adequate during pregnancy may no longer be adequate by the second or third postpartum day.