NCLEX-PN
NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
While assessing the prenatal client, the nurse found a number of concerning problems. Place the concerning problems in the sequence that they should be addressed by the nurse.
Correct Answer: D,A,C,B
Rationale: Has intense pelvic pain is most concerning and should be addressed first by the nurse. It could be a symptom of a serious medical condition, such as a miscarriage, ectopic pregnancy, or appendicitis. This symptom represents a possible pathology that could warrant immediate surgical intervention. Currently bleeding and cramping should be addressed next. It could be associated with the pelvic pain and could be a symptom of a serious medical condition, such as a miscarriage or ectopic pregnancy. Currently using tobacco can put the client at risk for multiple adverse outcomes and should be addressed, although it is not an immediately concerning factor. Previous varicella infection is important to document but poses no risk to the client or the fetus, so it is the least important to address.
Question 2 of 5
When looking in the mirror at her abdomen, the postpartum client says to the nurse, “My stomach still looks like I’m pregnant!” The nurse explains that the abdominal muscles, which separate during pregnancy, will undergo which change?
Correct Answer: B
Rationale: For most women, it takes about 6 weeks (not one week) to regain abdominal wall muscle tone to the prepregnancy state, and usually only with exercise. The “still-pregnant” appearance is caused by relaxation of the abdominal wall muscles. With exercise, most women can regain prepregnancy abdominal muscle tone within about 6 weeks. If the client delivers a very large infant, the abdominal muscles may separate, but the separation will become less apparent over time. Weight loss alone will not strengthen the abdominal muscles.
Question 3 of 5
The nurse recognizes which behavior as a sign of potential depression in a pregnant client?
Correct Answer: B
Rationale: Persistent sadness and withdrawal are hallmark signs of depression, requiring further assessment and intervention.
Question 4 of 5
The nurse is caring for the antepartum client with a velamentous cord insertion. The client asks what symptom she would most likely experience first if one of the vessels should tear. The nurse should respond that she would most likely experience which symptom first?
Correct Answer: A
Rationale: In a velamentous cord insertion, vessels of the cord divide some distance from the placenta in the placental membrane. Thus, the most likely first symptom would be vaginal bleeding. Abdominal cramping is unlikely to occur; velamentous cord insertion is not related to uterine activity. Contractions are unlikely to occur; velamentous cord insertion is not related to uterine activity. An abruption, when the placenta comes off the uterine wall, results in severe abdominal pain.
Question 5 of 5
The continuous electronic FHR monitor tracing on the laboring client is no longer recording. How should the nurse immediately respond?
Correct Answer: B
Rationale: When the FHR monitor tracing is no longer recording, the nurse should first check for adequate gel under the transducer. There needs to be adequate gel under the transducer for good conduction, and adding gel frequently corrects the problem. Assessing for adequate gel under the transducer and repositioning should be done before assuming there is a problem with the baby’s HR. There is no indication to give oxygen to the client. Auscultating FHR by fetoscope and assessing maternal VS could be completed, but not until the transducer has been checked.