Maternal NCLEX
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Question 1 of 5.
The nurse correctly instructs the client to contact the physician immediately under which circumstance?
A. When the first fetal movement is felt
B. If the breasts become tender
C. If vaginal bleeding occurs
D. When experiencing frequent urination
Explanation: Vaginal bleeding is a danger sign in pregnancy, potentially indicating miscarriage or placental issues, requiring immediate reporting.
Question 2 of 5.
The nurse correctly explains that the bleeding is the result of sloughing of which structure?
A. Endometrium
B. Myometrium
C. Epimetrium
D. None of the above
Explanation: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.
Question 3 of 5.
On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?
A. 5 months
B. 6 months
C. 7 months
D. 8 months
Explanation: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.
Question 4 of 5.
The nurse correctly assists the client into which position?
A. Lithotomy
B. Prone
C. Sims'
D. Trendelenburg's
Explanation: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.
Question 5 of 5.
Which response by the nurse is most accurate?
A. Fluorescent treponemal antibody absorption (FTA-ABS) test can detect this defect.
B. Hepatitis B surface antigen (HBsAg) test can detect this defect.
C. Maternal serum alpha-fetoprotein (AFP) test can detect this defect.
D. Venereal Disease Research Laboratory (VDRL) test can detect this defect.
Explanation: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.
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