NCLEX-RN
Maternity RN NCLEX Questions Questions
Extract:
Question 1 of 5
A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.
Question 2 of 5
A primigravid client in active labor with a fetus in LOP position complains of severe back pressure. Which of the following would be the priority nursing diagnosis for this client?
Correct Answer: D
Rationale: Severe back pain due to the LOP position is a priority, as it impacts the client's comfort and labor experience. Pain management (e.g., counterpressure) is critical. Anxiety, coping, and urinary retention are secondary concerns.
Question 3 of 5
I.V. oxytocin.png
Correct Answer: D
Rationale: Oxytocin (Pitocin) stimulates uterine contractions. If it causes excessive uterine activity (e.g., more than 5 contractions in 10 minutes or contractions lasting longer than 90 seconds), it can reduce placental perfusion
Question 4 of 5
While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, 'I think my water just broke.' Which of the following should the nurse do first?
Correct Answer: C
Rationale: Rupture of membranes can affect fetal well-being, particularly in preterm labor (36 weeks). Assessing the fetal heart rate pattern first ensures the fetus is not in distress (e.g., due to cord compression). Fluid characteristics and dilation are assessed next.
Question 5 of 5
A full-term client is admitted for induction of labor. When admitted, her cervix is 2/50/0. The initial goal is cervical ripening prior to labor induction. Which drug will prepare her cervix for induction?
Correct Answer: C
Rationale: Dinoprostone (Cervidil) is a prostaglandin used for cervical ripening in clients with an unfavorable cervix (e.g., 2 cm, 50% effaced). Nalbuphine is for pain, oxytocin induces contractions, and betamethasone promotes fetal lung maturity.