NCLEX-RN
NCLEX RN Maternity Questions Questions
Extract:
Question 1 of 5
A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. She has had a prior pregnancy with pregnancy-induced hypertension. The assessments during this visit include BP 140/90, P 80, and +2 edema of the ankles and feet. Based on the client's past history and current assessment, what further information should the nurse obtain to determine if this client is becoming preeclamptic?
Correct Answer: C
Rationale: Proteinuria is a key indicator of preeclampsia, distinguishing it from gestational hypertension.
Question 2 of 5
A neonate born by cesarean delivery at 42 weeks' gestation, weighing 4.1 kg (9 lb, 1 oz), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. Which of the following nursing diagnoses would be the priority?
Correct Answer: D
Rationale: Tremors and increased respiratory rate suggest hypoglycemia due to depleted glycogen stores, a common issue in post-term neonates.
Question 3 of 5
After a vaginal delivery, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which of the following positions?
Correct Answer: D
Rationale: Placing the neonate on their back with the neck slightly extended opens the airway, facilitating effective oxygen delivery.
Question 4 of 5
Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm mercury with a nonreassuring fetal heart rate and pattern. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: Hyperstimulation (contractions >90 seconds, frequent, with high resting tone) and nonreassuring fetal heart rate indicate fetal distress. Stopping oxytocin is the first step to reduce uterine activity and improve fetal oxygenation. Repositioning, notifying the provider, or increasing fluids follow.
Question 5 of 5
A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's:
Correct Answer: D
Rationale: Temperature should be assessed to monitor for infection.