NCLEX Maternity Questions
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Question 1 of 5.
The client delivered a healthy newborn 4 hours ago after being induced with oxytocin. While being assisted to the bathroom to void for the first time after delivery, the client tells the nurse that she doesn't feel a need to urinate. Which explanation should the nurse provide when the client expresses surprise after voiding 900 mL of urine?
A. “A decreased sensation of bladder filling is normal after childbirth.â€
B. “The oxytocin you received in labor makes it difficult to feel voiding.â€
C. “You probably didn't empty completely. I will need to scan your bladder.â€
D. “Your bladder capacity is large; you likely won't void again for 6—8 hours.â€
Explanation: The nurse should explain about the decreased sensation of bladder filling after childbirth. It is not uncommon for the postpartum client to have increased bladder capacity, decreased sensitivity to fluid pressure, and a decreased sensation of bladder filling. Oxytocin (Pitocin) is not expected to cause a change in bladder sensation, but it does have an antidiuretic effect. There is no indication that the client didn't completely empty; a volume of 900 mL is a large amount. The postpartum client is at risk for bladder overdistention and should be encouraged to void every 2 to 4 hours.
Question 2 of 5.
When the client asks the nurse about the viability of the ovum after ovulation, the nurse correctly explains that after ovulation, the ovum remains alive for how many hours?
A. 2 hours
B. 24 hours
C. 48 hours
D. 72 hours
Explanation: The ovum remains viable for approximately 24 hours after ovulation, during which it can be fertilized by sperm.
Question 3 of 5.
The nurse correctly sends a requisition and specimen for which laboratory test?
A. Alpha-fetoprotein (AFP)
B. Corticotropin-releasing hormone (CRH)
C. Human chorionic gonadotropin (hCG)
D. Follicle-stimulating hormone (FSH)
Explanation: Human chorionic gonadotropin (hCG) is the hormone tested to confirm pregnancy, as it is produced by the placenta shortly after implantation.
Question 4 of 5.
According to the TPAL method, which of the following reflects the client's obstetric history?
A. T-III, P-0, A-0, L-III
B. T-III, P-II, A-0, L-0
C. T-III, P-II, A-0, L-II
D. T-III, P-0, A-0, L-III
Explanation: TPAL: Term (3, one son and twin daughters), Preterm (0), Abortions (0), Living (3). The client has three term deliveries and three living children.
Question 5 of 5.
Which action by the nurse best ensures that an accurate fetal heart rate is obtained?
A. Assess the fetal heart rate when the client is lying on her right side.
B. Assess the fetal heart rate when the client reports fetal movement.
C. Assess the fetal heart rate between Braxton Hicks contractions.
D. Assess the maternal pulse and fetal heart rate, and compare the two.
Explanation: Comparing maternal pulse with fetal heart rate ensures the nurse is not mistaking the maternal pulse for the fetal heartbeat.
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