Maternal NCLEX
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Question 1 of 5.
The nurse receives report for four postpartum clients. In which order should the nurse assess the clients? Prioritize the clients in order from first to last.
- A. The client who had a normal, spontaneous vaginal delivery 30 minutes ago.
- B. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant.
- C. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding.
- D. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control.
- A. The client who had a normal, spontaneous vaginal delivery 30 minutes ago.
- D. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control.
- C. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding.
- B. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant.
Correct arrangement
Explanation: The client who had a normal, spontaneous vaginal delivery 30 minutes ago is priority. The first 2 hours after delivery is a time of transition, characterized by rapid changes in hemodynamic and physiological state for both the client and her newborn. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control should be assessed next. Although she is 8 hours postpartum and probably stable, she is receiving morphine, and her respiratory status should be monitored Drag and Droply. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding should be assessed next. Newborn infants should successfully breastfeed every 2—3 hours. Failing to breastfeed with adequate amount and frequency may lead to newborn complications such as excessive weight loss and jaundice. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant should be seen last; there is nothing indicating urgency.
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.
Related Questions
Which teaching method is most effective for prenatal education?
Which resource should the nurse recommend for additional prenatal education?
The nurse includes which activity to promote bonding with the fetus?
The nurse advises the client to practice which technique to cope with labor pain?