Post-epidural birth client has fundus 2 cm above umbilicus, deviated to right, and no urge to void. Best action?

Perform intermittent urinary catheterization

Change pad and provide perineal care

What instructions should nurse give client with mastitis?

Stop breastfeeding until resolved

Which statement about diabetes and preconception health is accurate?

Elevated hemoglobin A1c increases birth defect risk

I'll need more insulin during first trimester

I'm at risk of miscarriage even if controlled

Less monitoring needed in third trimester

Client with diabetes reports breast tenderness, discharge, and urinary frequency. Most important nursing action?

Assess discharge characteristics

Which actions are appropriate for client with suspected placental abruption after trauma?

Obtain a blood specimen for type and cross-match

Insert a large-bore peripheral venous access device

Administer subcutaneous terbutaline

Assess the client's vital signs every 4 hours

What is the best action for nurse based on third trimester lab values?

Complete the client assessment and documentation

Draw another sample to repeat the complete blood count

Prepare for transfusion of packed RBCs

Request a prescription for iron supplementation

Client post-cesarean diagnosed with postpartum endometritis. Which prescription is priority?

Methylergonovine PO every 4 hours

What nursing advice relieves breast engorgement for non-breastfeeding postpartum client?

Use chilled, fresh cabbage leaves on breasts throughout the day

Apply heat frequently to both breasts

Manually express milk several times a day

Massage breasts from the base to the nipple 3 or 4 times a day

Which postpartum findings 12 hours after vaginal delivery need follow-up?

Temperature of 100°F (37.8°C)

Discomfort during fundal massage

Which behavior suggests postpartum psychosis?

Disorganized behavior and delusions at day 5

Tearfulness and feeling overwhelmed at day 3

Worry and hypervigilance at 6 months

Depression and insomnia at 2 months

Which first-trimester client requires priority teaching?

Gardens and eats homegrown vegetables

Has gained 4 lb since prepregnancy

Reports thin white vaginal discharge

Which postpartum statement on day 5 warrants concern?

Bleeding like a heavy period with clots

Bright red blood in bowel movement

Hands feel tingly when holding baby

Which action is priority for client 2 hrs post vaginal delivery who soaked pad in 20 mins and has boggy, right-deviated fundus?

Assist client to void using bedpan

Administer oxygen via nonrebreather

Which order should the nurse clarify for a client with boggy fundus and elevated BP?

Check hemoglobin and hematocrit

Which education should be provided for preeclampsia without severe features?

Perform fetal kick counts daily

Report headaches and vision changes

NCLEX - MATERNITY Day2

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23 questions

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MULTIPLE CHOICE QUESTION

1 min • 1 pt

Which postpartum finding requires immediate intervention?

Lochia soaking pad every 2 hours

Persistent headache and blurred vision

Red, painful nipple

Strong-smelling vaginal discharge

MULTIPLE CHOICE QUESTION

1 min • 1 pt

Which finding in a client hospitalized for preeclampsia requires immediate follow-up?

Dark red vaginal bleeding

Edema of the hands and face

Elevated liver enzymes

Urine output of 150 mL in 4 hours

MULTIPLE CHOICE QUESTION

1 min • 1 pt

Which lab test should be ordered for a client at 20 weeks who reports eating powdered cornstarch?

Urine culture and sensitivity

Serum hCG

Hematocrit and hemoglobin

Fecal occult blood test

MULTIPLE CHOICE QUESTION

1 min • 1 pt

Which statement by client at 8 weeks gestation shows correct understanding of pregnancy weight gain?

I should gain 10–15 lb during first trimester

I should gain about 30 lb total during pregnancy

I should gain no more than 0.5 lb per week in third trimester

Less than 20 lb total will be easier to lose after birth

MULTIPLE CHOICE QUESTION

1 min • 1 pt

Which statement about glucose challenge test at 24 weeks requires follow-up?

I need to fast for 12 hours before the test

I'll drink a 50-g glucose solution

The test requires no food intake for 1 hour afterward

A 3-hour glucose tolerance test may follow

MULTIPLE SELECT QUESTION

1 min • 1 pt

Which findings indicate positive signs of pregnancy?

Cervical softening

Fetal heart tones via Doppler

Positive hCG test

Client report of fetal movement

Fetal visualization via ultrasound

MULTIPLE CHOICE QUESTION

1 min • 1 pt

What should be included in teaching after cervical cerclage placement?

The cerclage will be removed at 28 weeks

Report back pain or discomfort

Check the strings weekly

Weekly contraction stress tests will be needed

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