Maternal NCLEX Practice Questions
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Question 1 of 5.
The pregnant client presents to the ED with a large amount of painless, bright red bleeding. She looks to be about 30 to 34 weeks pregnant based on her uterine size. She speaks limited English and is unable to communicate with the staff. Which actions should the nurse take? Select all that apply.
A. Call for an interpreter for this client.
B. Establish an intravenous access.
C. Auscultate for fetal heart tones.
D. Place the client into a lithotomy position.
E. Perform a digital pelvic examination.
Explanation: The nurse should call for an interpreter so that the client is able to communicate. An IV access should be performed by the nurse to administer any needed medications. Auscultating FHT will provide information about fetal well-being. Positioning the client in a lithotomy position can cause abdominal pain, and there is no indication that birth is imminent. The pregnant client who presents in later pregnancy should never have a digital pelvic examination because this could cause additional bleeding, especially if she has placenta previa.
Question 2 of 5.
On the basis of the health history data, how should the nurse record the client's pregnancy status on the prenatal records?
A. Multipara
B. Primipara
C. Primigravida
D. Multigravida
Explanation: A primigravida is a woman pregnant for the first time, which matches the client's status of being possibly 2 months pregnant with no prior pregnancies.
Question 3 of 5.
Which assessment finding best represents a positive sign of pregnancy?
A. Palpable fetal outline
B. Blotchy tan facial skin
C. Positive pregnancy test
D. Fetal heartbeat
Explanation: A fetal heartbeat, detected by Doppler or ultrasound, is a positive sign of pregnancy, as it directly confirms the presence of a living fetus.
Question 4 of 5.
Before the pelvic examination, which intervention by the nurse is most appropriate?
A. Give the client an enema.
B. Instruct the client to urinate.
C. Shave the client's perineum.
D. Give the client a mild sedative.
Explanation: Instructing the client to urinate ensures a comfortable examination by emptying the bladder, which can interfere with pelvic assessment.
Question 5 of 5.
The nurse responds that, for clients with uncomplicated pregnancies, it is usually best to plan monthly visits for the first 28 weeks and then more frequent visits following which schedule?
A. Weekly for the remainder of the pregnancy
B. Every 2 weeks for the remainder of the pregnancy
C. Every 2 weeks up to 36 weeks, then weekly for the last month
D. Weekly up to 36 weeks, then twice weekly for the last month
Explanation: Standard prenatal care involves monthly visits until 28 weeks, biweekly until 36 weeks, and weekly thereafter for uncomplicated pregnancies.
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