Maternal NCLEX Questions

Maternal NCLEX Questions Related

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The nurse is caring for the postpartum primiparous client who is 13 hours post—vaginal delivery. The nurse observes that the client is passive and hesitant about making decisions about her own and her newborn’s care. In response to this observation, which interventions should be implemented by the nurse? Select all that apply.

  • A. Question her closely about the presence of pain.
  • B. Ask if she would like to talk about her birth experience.
  • C. Encourage her to nap when her infant is napping.
  • D. Encourage attendance in teaching sessions about infant care.
  • E. Suggest that she begin to write her birth announcements.
Correct Answer: A,B,C

Rationale: Many women hesitate to ask for medication, as they believe their pain is expected. Thus, the nurse should ask the client about pain and assure her that there are methods to decrease her pain. During the initial postpartum “taking-in” phase, the client may have a great need to talk about her birthing experience and to ask questions for clarification as necessary. By encouraging this verbalization, the nurse helps the client to accept the experience and enables her to move to the next maternal phase. Physical discomfort can be intense initially postpartum and can interfere with rest. Sleep is a major need and should be encouraged. Anxiety and preoccupation with her new role often narrow the client’s perceptions, and information is not as easily assimilated at this time. Therefore, attending education sessions should be delayed if possible until the mother has completed this “taking in” phase. The client needs to suspend her involvement in everyday responsibilities during the “taking—in” phase, so writing birth announcements should be delayed until the mother has completed this phase.

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The client, who is 20 days postpartum, telephones the perinatal clinic to tell the nurse that she is having heavy, bright red bleeding since hospital discharge 18 days ago. Which instruction to the client is correct?

  • A. “You need to come to the clinic immediately.”
  • B. “Decrease physical activity until the bleeding stops.”
  • C. “There is no need for concern; this is expected after birth.”
  • D. “Call next week if the bleeding has not stopped by then.”
Correct Answer: A

Rationale: Lochia rubra that persists for longer than 2 weeks is suggestive of subinvolution of the uterus, which is the most common cause of delayed postpartum hemorrhage. The client should be seen in the clinic immediately to determine what is causing her abnormal lochial discharge. Increased physical activity can lead to increased lochial discharge, but the client is reporting continuous lochia rubra, which is abnormal. Lochia rubra is expected to last for up to 3 days after birth, not 20 days. Waiting until next week to be seen only delays determining the cause for her abnormal bleeding and increases the risk of the client for other complications.

The home care nurse is visiting the mother and her 6-day-old son. The nurse observes that the infant is sleeping in a crib on his back and has a blanket draped over his body. The mother had been sleeping in a nearby room. Which statements are appropriate for the nurse to make in response to this situation? Select all that apply.

  • A. “I’m glad to see that you are sleeping while your baby sleeps.”
  • B. “Having your baby sleep on his back reduces the risk of SIDS.”
  • C. “It is best for you to sleep in the same room as your newborn.”
  • D. “Position your baby on his tummy and side when he is awake.”
  • E. “When using a blanket, always tuck its sides under the mattress.”
Correct Answer: A,B,D

Rationale: This is an appropriate statement. Sleeping while the infant sleeps will help the mother get the rest she needs. This is an appropriate statement. The American Academy of Pediatricians recommends the supine position for infant sleeping to decrease the risk of SIDS. The mother should be in close proximity and ready to respond when the infant wakes and/or cries, but she does not need to sleep in the same room as the infant. This is an appropriate statement. While awake the infant should be positioned prone and side-lying to help build neck muscles and decrease the chance of deformation plagiocephaly. Deformation plagiocephaly is a malformation of the skull caused by consistently lying on the back. A blanket, if used, should swaddle the infant rather than being draped over the infant. Swaddling helps prevent suffocation. Tucking the blanket sides under the mattress does not prevent suffocation.

The laboring client tells the nurse that she wants to avoid an episiotomy if possible. Which response by the nurse is best?

  • A. “Usually making an episiotomy incision is avoided whenever possible.”
  • B. “Having an episiotomy reduces prolonged pushing and perineal trauma.”
  • C. “An episiotomy is routine because it can prevent pelvic floor damage.”
  • D. “Tell me more about your concerns about having an episiotomy.”
Correct Answer: A

Rationale: This statement is best. An episiotomy may be used in some circumstances but is usually avoided if possible. Use of episiotomy increases (not reduces) perineal trauma and increases healing time. Use of episiotomy is not routine, does not decrease pelvic floor damage, and may increase the severity of the trauma. Having the client tell the nurse more about her concerns regarding episiotomy is unnecessary and avoids responding to the client’s comment.

Which nursing instructions concerning exercise during pregnancy are accurate? Select all that apply.

  • A. Avoid exercising during hot, humid weather.
  • B. Avoid exercises involving bouncing or jumping movements.
  • C. Drink plenty of fluids before and after exercising.
  • D. Limit strenuous activity to no more than 60 minutes a session.
  • E. Perform exercises only in the supine position.
  • F. Limit exercising to once per week.
Correct Answer: A,B,C

Rationale: Exercising in hot weather risks overheating, bouncing movements may strain joints, and hydration is crucial. Supine exercises are avoided late in pregnancy.

The nurse assesses the client in her third trimester with suspected placenta previa. Which finding should the nurse associate with placenta previa?

  • A. Cervix is 100% effaced
  • B. Painless vaginal bleeding
  • C. The fetal lie is transverse
  • D. Absence of fetal movement
Correct Answer: B

Rationale: In placenta previa, the abnormal location of the placenta causes painless, bright red vaginal bleeding as the lower uterine segment stretches and thins. The nurse should not perform a vaginal examination to determine effacement on the client with suspected placenta previa. The lie of the fetus is not associated with placenta previa. An absence of fetal movement is always cause for concern but is not a primary symptom of placenta previa.

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