NCLEX-PN
Maternal NCLEX Questions
Extract:
Question 1 of 5
Which finding indicates a need for further evaluation during a prenatal visit?
Correct Answer: B
Rationale: Trace protein in urine may indicate early preeclampsia or kidney issues, warranting further evaluation.
Question 2 of 5
The nurse correctly instructs the client to contact the physician immediately under which circumstance?
Correct Answer: C
Rationale: Vaginal bleeding is a danger sign in pregnancy, potentially indicating miscarriage or placental issues, requiring immediate reporting.
Question 3 of 5
Which finding indicates a need for further evaluation during a prenatal visit?
Correct Answer: B
Rationale: Trace protein in urine may indicate early preeclampsia or kidney issues, warranting further evaluation.
Question 4 of 5
The nurse instructs the client with hyperemesis gravidarum to avoid which trigger?
Correct Answer: B
Rationale: Strong odors can exacerbate nausea and vomiting in hyperemesis gravidarum, worsening symptoms.
Question 5 of 5
The client, who had preeclampsia and delivered vaginally 4 hours ago, is still receiving magnesium sulfate IV. When assessing the client’s deep tendon reflexes (DTRs), the nurse finds that they are both weak, at 1+, whereas previously they were 2+ and 3+. Which actions should the nurse plan? Select all that apply.
Correct Answer: A,C,D
Rationale: The HCP should be notified about the decreased DTRs because weakening of these may indicate magnesium sulfate toxicity. Increasing the magnesium sulfate dose would worsen the situation and could lead to a depressed respiratory rate. Any time the client is receiving a magnesium sulfate infusion, the nurse should be prepared for the possibility of needing the antidote, calcium gluconate. The nurse should assess the client’s vital signs and level of consciousness, as decreased level of consciousness and respiratory effort are serious side effects of magnesium sulfate. The nurse should ask the HCP about drawing a serum magnesium level (not a serum calcium level) to determine whether the client is experiencing magnesium toxicity.