NCLEX-PN
Maternal NCLEX Practice Questions Questions
Extract:
Question 1 of 5
While assessing the breastfeeding mother 24 hours postdelivery, the nurse notes that the client’s breasts are hard and painful. Which interventions should be implemented by the nurse? Select all that apply.
Correct Answer: B,D,F
Rationale: Moving the baby from the initial breast to the second breast during the feeding, before the initial breast is completely emptied, may result in neither breast being totally emptied and thus promote continued engorgement. Because engorgement is caused, in part, by swelling of the breast tissue surrounding the milk gland ducts, applying ice at intervals between feedings will help to decrease this swelling. Giving supplemental formula, thus limiting the time the baby nurses at the breast, prevents total emptying of the breast and promotes increased engorgement. Administering anti-inflammatory medication will decrease breast pain and inflammation. Because heat application increases blood flow, moist heat packs would exacerbate the engorgement. Pumping the breasts may be necessary if the infant is unable to completely empty both breasts at each feeding. Pumping at this time will not cause a problematic increase in breast milk production.
Question 2 of 5
Which sign of labor should the nurse teach the client to report immediately?
Correct Answer: C
Rationale: Rupture of membranes (water breaking) requires immediate reporting, as it may indicate the onset of labor or risk of infection.
Question 3 of 5
The nurse uses which tool to measure fundal height?
Correct Answer: A
Rationale: A tape measure is used to measure fundal height, assessing uterine growth and fetal development.
Question 4 of 5
The nurse is caring for the pregnant client whose FHR tracing reveals a reduction in variability over the last 40 minutes. The client has had occasional decelerations after the onset of a contraction that did not resolve until the contraction was over. The client suddenly has a prolonged deceleration that does not resolve, and the nurse immediately intervenes by calling for assistance. Place the nurse’s interventions in the sequence that they should occur.
Order the Items
Source Container
Correct Answer: E,A,D,B,F,C
Rationale: Assist the client into a different position should be first. Repositioning is an attempt to increase the FHR in case of cord obstruction. Administer oxygen via facemask is next to increase oxygenation to the fetus. Increase the rate of the IV fluids next to treat possible hypotension, the most common cause of fetal bradycardia. Have the HCP paged if the prolonged decelerations have not resolved. The immediate focus should be on attempting to relieve the prolonged decelerations. Prepare for a vaginal examination and fetal scalp stimulation. This is performed to rule out cord prolapse and to provide stimulation to the fetal head. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the HR remains low.
Question 5 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.