NCLEX Maternal Exam #2 QUESTIONS AND VERIFIED SOLUTIONS 2024/2025
(Retained placental fragments or infection cause subinvolution of the uterus. Therefore the nurse
should assess the patient for any placental fragments in the uterus. Estrogen and progesterone
stimulate massive growth of the uterus during pregnancy. In the postpartum stage, the hormone levels
are reduced and, therefore, do not affect involution of the uterus. Platelet aggregation causes uterine
muscle contraction, but it does not result in involution of the uterus.) - (ANSWER)The nurse assesses a
postpartum patient several hours after delivery and suspects that the uterus is subinvoluted. What
could be a potential etiology for this finding?
A. Estrogen levels
B. Progesterone levels
C. Impaired platelet aggregation
D. Retained placental fragments
A client in the prenatal clinic complains of nausea and vomiting. Which intervention should
the nurse suggest?
a. Eat dry crackers or toast before arising in the morning.
b. Consume liquids with meals.
c. Eat foods high in fiber.
d. Brush teeth right after eating. - (ANSWER)Eat dry crackers or toast before arising in the morning.
Rationale: Eating dry crackers or toast before arising in the morning is a good intervention for a
client complaining of prenatal nausea. Foods high in fiber help with constipation problems, not
with nausea. Brushing teeth after meals can trigger vomiting. Consuming liquids with meals can
cause over-distention of the stomach.
A nurse is teaching psychosocial development to a group of adolescents. The nurse expects
teens in which stage of adolescence to be most able to recognize STDs and pregnancy as risks of
unprotected sex?
,NCLEX Maternal Exam #2 QUESTIONS AND VERIFIED SOLUTIONS 2024/2025
a. Late adolescence.
b. Preadolescence.
c. Middle adolescence.
d. Early adolescence. - (ANSWER)Late adolescence.
Rationale: In late adolescence (ages 18-19 years), teens are more at ease with their individuality
and decision-making ability. They can think abstractly and anticipate consequences. Late
adolescents are capable of formal operational thought. They learn to solve problems, to
conceptualize, and to make decisions. These abilities help them see themselves as having control, which
leads to the ability to understand and accept the consequences of their behavior.
Which behavior reported by a parent of an 18-month-old toddler would the nurse report to the
pediatrician as a cause for concern? - (ANSWER)Walks by holding onto furniture
The nurse is preparing an antenatal patient for an initial assessment. What is the first task that
the nurse should perform?
a. Prepare the client for a pelvic exam.
b. Instruct the client to provide a clean urine specimen.
c. Draw blood for routine tests.
d. Provide the client with a gown. - (ANSWER)Instruct the client to provide a clean urine specimen.
Rationale: After obtaining the history, prepare the woman for the physical examination. The
physical examination begins with assessment of vital signs; then the woman's body is examined.
The pelvic examination is performed last. Before the examination, the woman should provide a
clean urine specimen. When her bladder is empty, the woman is more comfortable during the
pelvic examination and the examiner can palpate the pelvic organs more easily. After the woman
empties her bladder, ask her to disrobe, and give her a gown and sheet or some other protective
covering. Drawing blood for routine tests is the last task performed. Lab tests may be added
,NCLEX Maternal Exam #2 QUESTIONS AND VERIFIED SOLUTIONS 2024/2025
based on assessment data from the physical exam.
Signs of Pregnancy - (ANSWER)presumptive, probable, and positive
D
(A firm, muscular wall with less adipose tissue would ensure that the patient is able to regain the
prepregnancy abdominal tone after delivery. Thus the nurse should advise the patient to do static
abdominal exercises during pregnancy. The abdominal tone is not a factor based on which the nurse can
determine whether the patient would have a normal vaginal delivery. Patients with weak abdominal
muscles, especially those who have multifetal gestation or a large fetus, are at the risk of having
diastasis recti abdominis. These abdominal striations usually do not fade away completely. Although the
abdominal skin retains its tone, some striae always remain.) - (ANSWER)The nurse advises a pregnant
patient to do static abdominal exercises. How would these exercises benefit the patient?
A. They will lead to a normal vaginal childbirth.
B. The patient will have diastasis recti abdominis.
C. The patient will not have any abdominal striations.
D. They will help the patient to gain proper abdominal tone after delivery.
The nurse assessing growth and development of a 2-year-old child would expect to find that: -
(ANSWER)the child jumps with both feet.
Presumptive Signs - (ANSWER)Aren't conclusive; leave client to believe they are pregnant: amenorrhea,
breast sensitivity, chadwicks sign (blue vagina & cervix), fatigue, fingernail changes, urinary frequency,
weight gain
The nurse in the prenatal clinic is planning care for a pregnant 15-year-old client. The nurse
knows that this adolescent is at risk for which maternal complication?
a. Cesarean birth.
, NCLEX Maternal Exam #2 QUESTIONS AND VERIFIED SOLUTIONS 2024/2025
b. Hypoglycemia.
c. Postpartum hemorrhage.
d. Pre-eclampsia. - (ANSWER)Pre-eclampsia
Rationale: Adolescents are at increased risk for pre-eclampsia. Postpartum hemorrhage is a
complication of multiparity. Hypoglycemia is a complication of diabetes. Cesarean birth is a
high-risk factor for clients over 35 years of age.
A second-trimester client in the prenatal clinic complains of ankle edema. Which intervention
should the nurse suggest?
a. Elevate legs when sitting.
b. Stretching exercises before bedtime.
c. Practice plantar flexion when standing.
d. Wear ankle socks daily. - (ANSWER)Elevate legs when sitting.
Rationale: Elevating the legs when sitting will assist circulation and therefore reduce edema.
Dorsiflexion and avoiding any restrictive bands around the ankles are appropriate to prevent
ankle edema. Stretching exercises before bedtime help relieve leg cramps.
A nurse is evaluating the background of four teenagers. Which statements by the teens should
the nurse recognize as psychosocial factors contributing to the risk of pregnancy for these teens?
Select all that apply.
a. "I just want someone to love me."
b. "I'd leave my boyfriend, but I'm afraid of what he might do."
c. "I have a hard time feeling good about myself."
d. "I want a prescription for oral contraceptives." - (ANSWER)"I just want someone to love me."
"I have a hard time feeling good about myself."
(Retained placental fragments or infection cause subinvolution of the uterus. Therefore the nurse
should assess the patient for any placental fragments in the uterus. Estrogen and progesterone
stimulate massive growth of the uterus during pregnancy. In the postpartum stage, the hormone levels
are reduced and, therefore, do not affect involution of the uterus. Platelet aggregation causes uterine
muscle contraction, but it does not result in involution of the uterus.) - (ANSWER)The nurse assesses a
postpartum patient several hours after delivery and suspects that the uterus is subinvoluted. What
could be a potential etiology for this finding?
A. Estrogen levels
B. Progesterone levels
C. Impaired platelet aggregation
D. Retained placental fragments
A client in the prenatal clinic complains of nausea and vomiting. Which intervention should
the nurse suggest?
a. Eat dry crackers or toast before arising in the morning.
b. Consume liquids with meals.
c. Eat foods high in fiber.
d. Brush teeth right after eating. - (ANSWER)Eat dry crackers or toast before arising in the morning.
Rationale: Eating dry crackers or toast before arising in the morning is a good intervention for a
client complaining of prenatal nausea. Foods high in fiber help with constipation problems, not
with nausea. Brushing teeth after meals can trigger vomiting. Consuming liquids with meals can
cause over-distention of the stomach.
A nurse is teaching psychosocial development to a group of adolescents. The nurse expects
teens in which stage of adolescence to be most able to recognize STDs and pregnancy as risks of
unprotected sex?
,NCLEX Maternal Exam #2 QUESTIONS AND VERIFIED SOLUTIONS 2024/2025
a. Late adolescence.
b. Preadolescence.
c. Middle adolescence.
d. Early adolescence. - (ANSWER)Late adolescence.
Rationale: In late adolescence (ages 18-19 years), teens are more at ease with their individuality
and decision-making ability. They can think abstractly and anticipate consequences. Late
adolescents are capable of formal operational thought. They learn to solve problems, to
conceptualize, and to make decisions. These abilities help them see themselves as having control, which
leads to the ability to understand and accept the consequences of their behavior.
Which behavior reported by a parent of an 18-month-old toddler would the nurse report to the
pediatrician as a cause for concern? - (ANSWER)Walks by holding onto furniture
The nurse is preparing an antenatal patient for an initial assessment. What is the first task that
the nurse should perform?
a. Prepare the client for a pelvic exam.
b. Instruct the client to provide a clean urine specimen.
c. Draw blood for routine tests.
d. Provide the client with a gown. - (ANSWER)Instruct the client to provide a clean urine specimen.
Rationale: After obtaining the history, prepare the woman for the physical examination. The
physical examination begins with assessment of vital signs; then the woman's body is examined.
The pelvic examination is performed last. Before the examination, the woman should provide a
clean urine specimen. When her bladder is empty, the woman is more comfortable during the
pelvic examination and the examiner can palpate the pelvic organs more easily. After the woman
empties her bladder, ask her to disrobe, and give her a gown and sheet or some other protective
covering. Drawing blood for routine tests is the last task performed. Lab tests may be added
,NCLEX Maternal Exam #2 QUESTIONS AND VERIFIED SOLUTIONS 2024/2025
based on assessment data from the physical exam.
Signs of Pregnancy - (ANSWER)presumptive, probable, and positive
D
(A firm, muscular wall with less adipose tissue would ensure that the patient is able to regain the
prepregnancy abdominal tone after delivery. Thus the nurse should advise the patient to do static
abdominal exercises during pregnancy. The abdominal tone is not a factor based on which the nurse can
determine whether the patient would have a normal vaginal delivery. Patients with weak abdominal
muscles, especially those who have multifetal gestation or a large fetus, are at the risk of having
diastasis recti abdominis. These abdominal striations usually do not fade away completely. Although the
abdominal skin retains its tone, some striae always remain.) - (ANSWER)The nurse advises a pregnant
patient to do static abdominal exercises. How would these exercises benefit the patient?
A. They will lead to a normal vaginal childbirth.
B. The patient will have diastasis recti abdominis.
C. The patient will not have any abdominal striations.
D. They will help the patient to gain proper abdominal tone after delivery.
The nurse assessing growth and development of a 2-year-old child would expect to find that: -
(ANSWER)the child jumps with both feet.
Presumptive Signs - (ANSWER)Aren't conclusive; leave client to believe they are pregnant: amenorrhea,
breast sensitivity, chadwicks sign (blue vagina & cervix), fatigue, fingernail changes, urinary frequency,
weight gain
The nurse in the prenatal clinic is planning care for a pregnant 15-year-old client. The nurse
knows that this adolescent is at risk for which maternal complication?
a. Cesarean birth.
, NCLEX Maternal Exam #2 QUESTIONS AND VERIFIED SOLUTIONS 2024/2025
b. Hypoglycemia.
c. Postpartum hemorrhage.
d. Pre-eclampsia. - (ANSWER)Pre-eclampsia
Rationale: Adolescents are at increased risk for pre-eclampsia. Postpartum hemorrhage is a
complication of multiparity. Hypoglycemia is a complication of diabetes. Cesarean birth is a
high-risk factor for clients over 35 years of age.
A second-trimester client in the prenatal clinic complains of ankle edema. Which intervention
should the nurse suggest?
a. Elevate legs when sitting.
b. Stretching exercises before bedtime.
c. Practice plantar flexion when standing.
d. Wear ankle socks daily. - (ANSWER)Elevate legs when sitting.
Rationale: Elevating the legs when sitting will assist circulation and therefore reduce edema.
Dorsiflexion and avoiding any restrictive bands around the ankles are appropriate to prevent
ankle edema. Stretching exercises before bedtime help relieve leg cramps.
A nurse is evaluating the background of four teenagers. Which statements by the teens should
the nurse recognize as psychosocial factors contributing to the risk of pregnancy for these teens?
Select all that apply.
a. "I just want someone to love me."
b. "I'd leave my boyfriend, but I'm afraid of what he might do."
c. "I have a hard time feeling good about myself."
d. "I want a prescription for oral contraceptives." - (ANSWER)"I just want someone to love me."
"I have a hard time feeling good about myself."
