NCLEX-PN
Maternity NCLEX Questions Questions
Extract:
Question 1 of 5
Which of the following is most indicative of the presence of hydatidiform mole?
Correct Answer: D
Rationale: A uterus larger than expected for gestational age is characteristic of hydatidiform mole, a gestational trophoblastic disease.
Question 2 of 5
Where can the nurse expect to palpate the fundus at this time?
Correct Answer: C
Rationale: At 20 weeks' gestation, the fundus is typically palpated near the level of the umbilicus, reflecting uterine growth.
Question 3 of 5
The laboring client is experiencing problems, and the nurse is concerned about possible side effects from the epidural anesthetic just administered. Which problems should the nurse attribute to the epidural anesthetic? Select all that apply.
Correct Answer: A,C,D,E
Rationale: Breakthrough pain can occur when the continuous infusion rate of the anesthetic agent is below the recommended rate for a therapeutic dose. Breakthrough pain can also occur when the client has a full bladder or when the cervix is completely dilated. A spinal headache can be a complication of epidural anesthesia and occurs when the dura is accidently punctured during epidural placement. A sensory level of T10 is usually maintained during epidural anesthesia; most women are unable to feel a full bladder or to void after receiving an epidural anesthetic. Maternal temperature may be elevated to 100.1°F (37.8°
C) or higher with an epidural. Sympathetic blockade may decrease sweat production and diminish heat loss. Hypertension is a contraindication for epidural anesthesia. A major side effect of epidural anesthesia is hypotension (not hypertension) caused by a spinal blockade, which lowers peripheral resistance, decreases venous return to the heart, and subsequently lessens cardiac output and lowers BP.
Question 4 of 5
The nurse is assessing the postpartum client, who is 5 hours postdelivery. Initially, the nurse is unable to palpate the client’s uterine fundus. Prioritize the nurse’s actions to locate the client’s fundus by placing each step in the correct sequence.
Order the Items
Source Container
Correct Answer: E,A,C,B,D,F
Rationale: Position the client in supine so the height of the uterus is not influenced by an elevated position. Place the side of one hand just above the client’s symphysis pubis. This supports the lower uterine segment and prevents the inadvertent inversion of the uterus during palpation. Place the other hand at the level of the umbilicus. This is the expected location of the uterine fundus on the day of delivery. Press deeply into the abdomen to allow the massage to reach the fundus. Massage the abdomen in a circular motion. This massage should stimulate the uterus to contract and allow location of the fundus to be determined. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage. Involution could potentially be occurring more rapidly than expected if the client is breastfeeding and/or had an uncomplicated labor and birth.
Question 5 of 5
The pregnant client presents to a clinic with ongoing nausea, vomiting, and anorexia at 29 weeks’ gestation. Her Hgb level is 5 g/dL, and a blood smear reveals that newly formed RBCs are macrocytic. Which condition should the nurse further explore?
Correct Answer: B
Rationale: With the client’s symptoms and laboratory findings, the nurse should further explore folic acid deficiency. It is usually seen in the third trimester and coexists with iron-deficiency anemia. Sickle cell anemia is an inherited disorder in which the Hgb is abnormally formed. The chief symptom among individuals with sickle cell anemia is pain. Beta-thalassemia minor is an inherited hematological disorder. There is a defect in the synthesis of the beta chain within the Hgb molecule. Beta-thalassemia minor typically results in mild anemia. Beta-thalassemia major is an inherited hematological disorder. There is a defect in the synthesis of the beta chain within the Hgb molecule, but it is more severe than beta-thalassemia minor. Pregnancy in individuals with beta-thalassemia major is rare. Symptoms are usually severe anemia that warrants transfusion therapy.