NCLEX - MATERNITY Day1 (Part 1)

Which lifestyle changes should the nurse recommend to reduce heartburn during pregnancy?

• Avoid intake of dairy products
• Drink large amounts of fluid with meals
• Eat several small meals each day
• Eliminate fried, fatty foods
• Lie down on the left side after meals

Answer explanation

Option 1: Avoid intake of dairy products

Option 2: Drink large amounts of fluid with meals

Option 3: Eat several small meals each day

Option 4: Eliminate fried, fatty foods

Option 5: Lie down on the left side after meals

Correct Option(s): 3,4

Explanation: Heartburn is caused by progesterone relaxing the esophageal sphincter and stomach displacement. Recommended changes include small frequent meals and avoiding fried/fatty foods. Dairy is beneficial, large fluid intake with meals worsens reflux, and lying down increases discomfort.

Client post forceps-assisted vaginal birth reports severe vaginal pain and fullness. Fundus is firm and midline with scant lochia rubra. What is the most likely cause?

• Uterine atony
• Vaginal hematoma
• Cervical lacerations
• Inversion of the uterus

Answer explanation

Option 1: Uterine atony

Option 2: Vaginal hematoma

Option 3: Cervical lacerations

Option 4: Inversion of the uterus

Correct Option(s): 2

Explanation: Vaginal hematoma presents with firm uterus, scant lochia, and pressure or fullness. It results from vessel rupture during operative delivery. Other options show excessive bleeding or uterine inversion symptoms.

Which client findings in a prenatal clinic require further assessment?

• Client at 9 weeks gestation with a 2 lb weight gain
• Client at 15 weeks with headaches relieved by acetaminophen
• Client at 19 weeks with bleeding gums
• Client at 20 weeks with increase in diastolic BP by 15 mm Hg

Answer explanation

Option 1: Client at 9 weeks gestation with a 2 lb weight gain

Option 2: Client at 15 weeks with headaches relieved by acetaminophen

Option 3: Client at 19 weeks with bleeding gums

Option 4: Client at 20 weeks with increase in diastolic BP by 15 mm Hg

Correct Option(s): 4

Explanation: Blood pressure should decrease slightly during mid-pregnancy. A rise in diastolic BP may indicate gestational hypertension and warrants further evaluation.

Which statement indicates correct understanding of breastfeeding technique?

• I will feed my baby for 5–10 minutes on each breast
• I will hold my baby on their back with the head turned toward my breast
• If I need to reposition my baby's latch, I will use my finger to break the suction first
• The baby's mouth should grasp only the nipple without the areola

Answer explanation

Option 1: I will feed my baby for 5–10 minutes on each breast

Option 2: I will hold my baby on their back with the head turned toward my breast

Option 3: If I need to reposition my baby's latch, I will use my finger to break the suction first

Option 4: The baby's mouth should grasp only the nipple without the areola

Correct Option(s): 3

Explanation: Breaking suction with a finger prevents nipple trauma. Proper latch includes areola, and feeding should last at least 15–20 minutes per breast.

Post-cesarean client is restless, tachycardic, and dyspneic. What is the priority?

• Obtain pulse oximetry
• Offer PRN pain medication
• Check legs for warmth and redness
• Teach breathing and relaxation techniques

Answer explanation

Option 1: Obtain pulse oximetry

Option 2: Offer PRN pain medication

Option 3: Check legs for warmth and redness

Option 4: Teach breathing and relaxation techniques

Correct Option(s): 1

Explanation: Symptoms suggest possible pulmonary embolism. Pulse oximetry is the fastest way to assess respiratory compromise.

Client at 8 weeks reports morning sickness. Most appropriate nurse response?

• Consume hot foods
• Drink 2 glasses of water with each meal
• Consume a dry, high-carbohydrate snack
• Tell client nausea will pass in a few weeks

Answer explanation

Option 1: Consume hot foods

Option 2: Drink 2 glasses of water with each meal

Option 3: Consume a dry, high-carbohydrate snack

Option 4: Tell client nausea will pass in a few weeks

Correct Option(s): 3

Explanation: High-carb dry foods (like toast/crackers) reduce nausea. Fluids should be taken between meals, not with them.

Which vaccines are safe during pregnancy at 30 weeks gestation?

• Influenza injection
• Influenza nasal spray
• Measles, mumps, rubella
• Tetanus, diphtheria, pertussis
• Varicella

Answer explanation

Option 1: Influenza injection

Option 2: Influenza nasal spray

Option 3: Measles, mumps, rubella

Option 4: Tetanus, diphtheria, pertussis

Option 5: Varicella

Correct Option(s): 1,4

Explanation: Influenza injection and Tdap are inactivated and safe. MMR, nasal spray, and varicella are live vaccines and contraindicated in pregnancy.

Signs of magnesium sulfate toxicity in client receiving therapy at 37 weeks gestation?

• Absent patellar reflex
• Blood pressure of 156/84 mm Hg
• Client voiding 600 mL in 8 hours
• Respiratory rate of 10/min
• Somnolence

Answer explanation

Option 1: Absent patellar reflex

Option 2: Blood pressure of 156/84 mm Hg

Option 3: Client voiding 600 mL in 8 hours

Option 4: Respiratory rate of 10/min

Option 5: Somnolence

Correct Option(s): 1,4,5

Explanation: Toxicity presents as hyporeflexia, respiratory depression, and excessive drowsiness. BP may stay elevated due to preeclampsia; urine output here is normal.

Which recommendations help a pregnant client with constipation from iron supplements?

• Consume dairy products with iron pills
• Continue daily moderate exercise
• Increase intake of whole grain foods
• Limit coffee to 3 cups daily
• Take stimulant laxatives daily

Answer explanation

Option 1: Consume dairy products with iron pills

Option 2: Continue daily moderate exercise

Option 3: Increase intake of whole grain foods

Option 4: Limit coffee to 3 cups daily

Option 5: Take stimulant laxatives daily

Correct Option(s): 2,3

Explanation: Exercise and fiber help reduce constipation. Dairy inhibits iron absorption; excessive coffee and stimulant laxatives are discouraged during pregnancy.

Which nurse statement about molar pregnancy needs correction?

• A uterine evacuation procedure is the typical treatment for removing the abnormal tissue
• I can provide you with resources for coping with the perinatal loss if needed
• You may start trying to conceive again as soon as you and your partner feel ready
• You will need Rh immune globulin following a molar pregnancy because you have an Rh-negative blood type

Answer explanation

Option 1: A uterine evacuation procedure is the typical treatment for removing the abnormal tissue

Option 2: I can provide you with resources for coping with the perinatal loss if needed

Option 3: You may start trying to conceive again as soon as you and your partner feel ready

Option 4: You will need Rh immune globulin following a molar pregnancy because you have an Rh-negative blood type

Correct Option(s): 3

Explanation: Pregnancy should be delayed for 6–12 months post-evacuation to monitor for persistent trophoblastic disease.