NCLEX-PN
Maternal NCLEX Questions
Extract:
Question 1 of 5
Which position should the nurse recommend to relieve round ligament pain?
Correct Answer: B
Rationale: Side-lying with a pillow between knees supports the abdomen and reduces strain on round ligaments, relieving pain.
Question 2 of 5
Two hours after delivery, the mother tells the nurse that she will be bottle feeding. She asks what she can do to prevent the terrible pain experienced when her milk came in with her last baby. Which response by the nurse is most appropriate?
Correct Answer: C
Rationale: In comparison studies between breast binders and bras, mothers using binders experienced more engorgement and discomfort. Engorgement is not familial and not inevitable in bottle-feeding mothers. Wearing a supportive, well-fitting bra within 6 hours after birth can suppress lactation. The bra should be worn continuously, except for showering, until lactation is suppressed (usually 7 to 14 days). Signs of engorgement usually occur on the third to fifth postpartum day (not right after birth), and engorgement will spontaneously resolve by the tenth day postpartum.
Question 3 of 5
The nurse receives report for four postpartum clients. In which order should the nurse assess the clients? Prioritize the clients in order from first to last.
Order the Items
Source Container
Correct Answer: A,D,C,B
Rationale: The client who had a normal, spontaneous vaginal delivery 30 minutes ago is priority. The first 2 hours after delivery is a time of transition, characterized by rapid changes in hemodynamic and physiological state for both the client and her newborn. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control should be assessed next. Although she is 8 hours postpartum and probably stable, she is receiving morphine, and her respiratory status should be monitored Drag and Droply. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding should be assessed next. Newborn infants should successfully breastfeed every 2—3 hours. Failing to breastfeed with adequate amount and frequency may lead to newborn complications such as excessive weight loss and jaundice. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant should be seen last; there is nothing indicating urgency.
Question 4 of 5
The nurse reviews information and assesses the laboring client at 42 weeks’ gestation before an HCP induces labor. Which findings should be reported to the HCP because they are contraindications to labor induction? Select all that apply.
Correct Answer: A,B,E
Rationale: Inducing labor with an umbilical cord prolapsed can cause fetal trauma and is contraindicated. This should be reported to the HCP. Inducing labor with a transverse fetal lie can produce trauma to the fetus and mother and is contraindicated. This should be reported to the HCP. Women with a previous cesarean incision should not be stimulated because it is a contraindication for a vaginal birth and warrants an immediate repeat cesarean birth. This should be reported to the HCP. Lack of progressive cervical dilation is an indication for labor induction, not a contraindication. Premature rupture of the membranes is an indication for labor induction, not a contraindication.
Question 5 of 5
The nurse is caring for the client with mild preeclampsia. The nurse should monitor for which complications associated with mild preeclampsia? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Placental abruption can occur as a complication of preeclampsia due to hypoperfusion of the placenta and endothelial injury. Hyperbilirubinemia can occur as a complication of preeclampsia due to hypoperfusion to the liver. Nonreassuring fetal status can occur as a complication of preeclampsia due to hypoperfusion to the placenta. Severe preeclampsia can occur as a complication of preeclampsia if the BP remains uncontrolled. Gestational diabetes is not associated with preeclampsia.