NCLEX-RN
NCLEX RN Practice Questions Maternity Questions
Extract:
Question 1 of 5
A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which of the following is a priority nursing diagnosis?
Correct Answer: D
Rationale: During the transition phase (8–10 cm), intense and frequent contractions cause significant pain, making pain management the priority nursing diagnosis. Urinary elimination issues are less urgent, hyperventilation is a secondary concern, and coping issues are not as immediate as pain.
Question 2 of 5
Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client complains of severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in a position that is identified as which of the following?
Correct Answer: C
Rationale: Severe back pain in labor is commonly associated with a posterior occiput position (e.g., occipitoposterior), where the fetal head presses against the maternal sacrum. Breech, transverse, or anterior positions are less likely to cause intense back pain.
Question 3 of 5
A multigravid client admitted to the labor area is scheduled for a cesarean delivery under spinal anesthesia. After instructions by the anesthesiologist, the nurse determines that the client has understood the instructions when she says which of the following?
Correct Answer: B
Rationale: Spinal anesthesia carries a risk of post-dural puncture headache, which is treatable (e.g., with a blood patch). The side-lying position is for epidural, not spinal, anesthesia; blood pressure typically decreases; and spinal anesthesia is not easily reversed.
Question 4 of 5
A multigravid client at 39 weeks' gestation diagnosed with insulin-dependent diabetes is admitted for induction of labor with oxytocin (Pitocin). Which of the following should the nurse include in the teaching plan as a possible disadvantage of this procedure?
Correct Answer: B
Rationale: Oxytocin induction in diabetic clients increases metabolic demand, risking maternal hypoglycemia due to insulin use. Urinary frequency is unrelated, preterm birth is not a concern at 39 weeks, and neonatal jaundice is not directly linked.
Question 5 of 5
A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and delivery unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client delivers a healthy neonate vaginally with a midline episiotomy. Which of the following nursing diagnoses should the nurse identify as the priority for the client?
Correct Answer: D
Rationale: Prolonged rupture of membranes (>24 hours) and episiotomy increase infection risk, making this the priority post-delivery. Activity intolerance, sleep deprivation, and self-esteem are less urgent.