The oncoming shift nurse assesses the fundus of the postpartum client

NCLEX Maternity Questions

Home / Nursing & Allied Health Certifications / NCLEX PN / Maternity

Question 1 of 5.

The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client's leg. Which action by the nurse in response to the client's bleeding is correct?

A. Explain that extra bleeding can occur with initial standing

B. Immediately assist the client back into bed

C. Push the emergency call light in the room

D. Call the HCP to report this increased bleeding

Explanation: Lochia normally pools in the vagina when the postpartum client remains in a recumbent position for any length of time. When the client then stands, gravity causes the blood to flow out. As long as the nurse knows the fundus is firm and not bleeding, a simple explanation to the client is all that is required. There is no reason to return the client to bed; the fundus is firm. There is no reason to push the emergency call light. Increased bleeding is an expected response when standing for the first time. There is no reason to call the HCP.

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.