Maternity NCLEX Questions
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Question 1 of 5.
Two hours after the client's vaginal delivery, she reports feeling “several large, warm gushes of fluid†from her vagina. The nurse assesses the client's perineum and finds a large pool of blood on the client's bed. Which nursing action is priority?
A. Encourage the client to ambulate to the bathroom in order to empty her bladder.
B. Place two hands on the uterine fundus and prepare to vigorously massage the uterus.
C. Reassure the client that heavy bleeding is expected in the first few hours postpartum.
D. Support the lower uterine segment with one hand and assess the fundus with the other.
Explanation: A full bladder may displace the uterus, causing increased bleeding. However, a more complete assessment must be performed prior to getting the client out of bed to prevent increased bleeding and syncope. Vigorously massaging the uterus may result in inversion of the uterus. The client should not simply be reassured that heavy bleeding is expected because further assessment is necessary before concluding that the client's blood loss is WNL. The nurse's first action should be to support the lower uterine segment and to assess the fundus. Increased bleeding will occur if soft or “boggy.†Failing to support the lower uterine segment may result in inversion of the uterus.
Question 2 of 5.
The nurse correctly explains that fertilization usually takes place in which structure?
A. Fallopian tube
B. Ovary
C. Uterus
D. Vagina
Explanation: Fertilization typically occurs in the fallopian tube, where the sperm meets the ovum after ovulation.
Question 3 of 5.
If the client reports the following signs and symptoms, which one represents a probable sign of pregnancy?
A. Absence of monthly periods
B. Abdominal enlargement
C. Nausea and vomiting
D. Frequent urination
Explanation: Abdominal enlargement is a probable sign of pregnancy, as it is more objective and indicative of uterine growth.
Question 4 of 5.
On the basis of the client's statement, what can the nurse conclude?
A. The client is having twins.
B. The client is between 14 and 18 weeks' gestation.
C. The client is in the first trimester.
D. The client's due date will be difficult to calculate.
Explanation: Fetal movement in a multigravida is typically felt earlier, around 14-18 weeks, aligning with the client's report.
Question 5 of 5.
How early in a pregnancy can the nurse expect to hear the fetal heartbeat using a Doppler device?
A. 4 to 6 weeks
B. 8 to 10 weeks
C. 12 to 14 weeks
D. 16 to 18 weeks
Explanation: A fetal heartbeat can typically be detected by Doppler around 12-14 weeks, when the fetus is sufficiently developed.
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