While assessing the breastfeeding mother 24 hours postdelivery, the nu

Maternal NCLEX Practice Questions

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Question 1 of 5.

While assessing the breastfeeding mother 24 hours postdelivery, the nurse notes that the client's breasts are hard and painful. Which interventions should be implemented by the nurse? Select all that apply.

A. Tell her to feed a small amount from both breasts at each feeding.

B. Apply ice packs to the breasts at intervals between feedings.

C. Give supplemental formula at least once in a 24-hour period.

D. Administer an anti-inflammatory medication prescribed pm.

E. Apply warm, moist packs to the breasts between feedings.

F. Pump the breasts as needed to ensure complete emptying.

Explanation: Moving the baby from the initial breast to the second breast during the feeding, before the initial breast is completely emptied, may result in neither breast being totally emptied and thus promote continued engorgement. Because engorgement is caused, in part, by swelling of the breast tissue surrounding the milk gland ducts, applying ice at intervals between feedings will help to decrease this swelling. Giving supplemental formula, thus limiting the time the baby nurses at the breast, prevents total emptying of the breast and promotes increased engorgement. Administering anti-inflammatory medication will decrease breast pain and inflammation. Because heat application increases blood flow, moist heat packs would exacerbate the engorgement. Pumping the breasts may be necessary if the infant is unable to completely empty both breasts at each feeding. Pumping at this time will not cause a problematic increase in breast milk production.

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.