Maternal NCLEX Questions
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Question 1 of 5.
The laboring client's amniotic membranes have just ruptured. Which nursing action should be priority?
A. Monitor maternal temperature.
B. Inspect characteristics of the fluid.
C. Perform a sterile vaginal examination.
D. Assess the fetal heart rate pattern.
Explanation: The priority nursing action is to assess the FHR pattern for several minutes immediately after membrane rupture to determine fetal well being. The umbilical cord may prolapse as a result of the rupture, causing life-threatening changes in the FHR. The maternal temperature should be monitored during labor and at least every two hours after the membranes rupture to assess for possible infection. However, this is not the priority nursing action. Characteristics of the fluid (color, odor, and estimated amount) should be assessed and documented after rupture, but this is not the priority at this time. A vaginal exam that assesses the progress of labor does need to be performed right after membrane rupture, but it is not the priority.
Question 2 of 5.
Which explanation by the nurse correctly describes the occurrence of identical twins?
A. Two separate ova are fertilized by identical sperm.
B. The mother releases two identical ova.
C. One fertilized ovum divides into two identical halves.
D. Two identical ova are fertilized by two identical sperm.
Explanation: Identical twins result from one fertilized ovum splitting into two identical embryos, sharing the same genetic material.
Question 3 of 5.
In the primigravid client, when is fetal movement typically felt for the first time?
A. Between 10 and 14 weeks' gestation
B. Between 16 and 20 weeks' gestation
C. Between 22 and 26 weeks' gestation
D. Between 28 and 32 weeks' gestation
Explanation: Primigravid women typically feel fetal movement (quickening) between 16 and 20 weeks, later than multigravida women.
Question 4 of 5.
Which method best promotes client comfort during the pelvic examination?
A. Have the client lift her head off the table.
B. Have the client press her back into the examination table.
C. Have the client tighten her buttocks.
D. Tell the client to let her knees fall outward.
Explanation: Letting the knees fall outward relaxes the pelvic muscles, reducing discomfort during the pelvic examination.
Question 5 of 5.
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.
Explanation: Exercising in hot weather risks overheating, bouncing movements may strain joints, and hydration is crucial. Supine exercises are avoided late in pregnancy.
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