NCLEX-PN
Maternal NCLEX Questions Questions
Extract:
Question 1 of 5
Which explanation by the nurse correctly describes the occurrence of identical twins?
Correct Answer: C
Rationale: Identical twins result from one fertilized ovum splitting into two identical embryos, sharing the same genetic material.
Question 2 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 3 of 5
While assessing the postpartum client who is 10 hours post—vaginal delivery, the nurse notes a perineal pad that is totally saturated. To determine the significance of this finding, which question should the nurse ask the client first?
Correct Answer: B
Rationale: Once the nurse has determined the length of time the pad has been in place, the nurse could decide if asking about uterine cramping is appropriate. The amount of lochia on a perineal pad is influenced by the individual client’s pad changing practices. Thus, the nurse should ask about the length of time the current pad has been in place before making a judgment about whether the amount is concerning. Although bladder incontinence could cause pad saturation, it is more important to ask about the length of time the pad has been in place. Based on the client’s answer, the nurse could decide if asking about bladder urgency or frequency needs further assessment. Passing clots may require more frequent pad change, but first the nurse should determine if the reason for the saturated pad is the length of time it has been in place.
Question 4 of 5
The nurse encourages which activity to reduce stress during pregnancy?
Correct Answer: A
Rationale: Prenatal yoga promotes relaxation and reduces stress, supporting maternal mental health during pregnancy.
Question 5 of 5
Which nursing instructions concerning exercise during pregnancy are accurate? Select all that apply.
Correct Answer: A,B,C
Rationale: Exercising in hot weather risks overheating, bouncing movements may strain joints, and hydration is crucial. Supine exercises are avoided late in pregnancy.