Maternal Newborn NCLEX RN Questions
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Question 1 of 5.
Extract:The nurse is caring for a 31-year-old female client. Item 2 of 5 Nurses' Notes 1300: Client is a 31-year-old G2P2 who delivered a healthy female infant (7 lb 14 oz; 3.57 kg) at 39 weeks gestation via spontaneous vaginal delivery. Labor was augmented with oxytocin, and the estimated blood loss at delivery was 400 mL. She was GBS positive and received appropriate antibiotic treatment during labor. Her obstetric history includes anemia during pregnancy and a prior vacuum-assisted delivery complicated by a retained placenta. At approximately one hour postpartum, the fundus is firm and midline at the level of the umbilicus, and lochia is moderate rubra. A second-degree perineal laceration was repaired with 2-0 vicryl. However, the client reports feeling light-headed, appears pale, and her peripad is saturated within 20 minutes. 1315: Client appears diaphoretic and states, “I feel dizzy and something is wrong.†On assessment, fundus is boggy, above the umbilicus, lochia is heavy, with large clots noted. Orders 1315 • Complete Blood Count (CBC)
Based on the assessment findings, the nurse determines that the client is most likely experiencing due to
A. Cardiogenic shock
B. postpartum hemorrhage
C. infection
D. uterine atony
E. Group beta strep
F. fluid loss
Explanation: The client is most likely experiencing postpartum hemorrhage (B) due to uterine atony (D). The boggy fundus, heavy lochia with large clots, and symptoms like dizziness and diaphoresis suggest excessive bleeding caused by the uterus failing to contract effectively after delivery.
Question 2 of 5.
The nurse is teaching a client about newly prescribed iron supplementation. Which of the following information should the nurse include?
A. To minimize an upset stomach, take the iron supplements with milk.
B. Consume the iron supplements with meals.
C. Take the iron supplement with orange juice.
D. Iron supplements may cause diarrhea, and you should eat foods low in fiber.
Explanation: Vitamin C (in orange juice) enhances iron absorption. Milk can inhibit absorption due to calcium, and iron is more likely to cause constipation than diarrhea.
Question 3 of 5.
The nurse is providing care to an 11-week pregnant client who is complaining about hemorrhoids. The nurse recognizes that hemorrhoids can occur due to pressure on the rectal veins from the growing fetus. Which of the following measures is not recommended for alleviating hemorrhoid pain in this client?
A. Instruct the client to use mineral oil to soften her stools.
B. Rest in a side-lying position daily.
C. Increase the client's fiber and water intake.
D. Apply a cold compress to the area.
Explanation: Mineral oil is not recommended during pregnancy due to potential nutrient absorption interference. The other measures help reduce hemorrhoid discomfort.
Question 4 of 5.
The nurse is caring for a client who is experiencing nausea associated with her pregnancy. The nurse should recommend that the client Select all that apply.
A. eat dry crackers before getting out of bed in the morning.
B. consume fluids at least 30 minutes before or after solid food.
C. lie down soon after eating.
D. brush their teeth immediately after a meal.
E. avoid overfilling your stomach.
Explanation: These measures help reduce nausea by stabilizing stomach acid and preventing overfilling. Lying down after eating or brushing teeth immediately may worsen nausea.
Question 5 of 5.
The nurse is preparing to measure the fundal height of a client at 16 gestational weeks. The nurse should prepare the client for this assessment by instructing the client to
A. lay in a side-lying position with the knees bent.
B. prepare for the insertion of an intravenous (IV) catheter.
C. not to eat or drink two hours after this assessment.
D. empty their bladder.
Explanation: An empty bladder ensures accurate fundal height measurement by reducing interference from a full bladder.
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