NCLEX-RN
Maternity Questions NCLEX RN Quizlet Questions
Extract:
Question 1 of 5
A multigravid client at 40 weeks' gestation with a history of previous cesarean delivery is admitted for a trial of labor. The fetal monitor shows late decelerations. Which interventions should the nurse perform? Select all that apply.
Correct Answer: A,B,D
Rationale: Late decelerations suggest uteroplacental insufficiency. Administering oxygen, stopping oxytocin (if running), and increasing IV fluids improve fetal oxygenation and uterine perfusion. Right-side repositioning is less effective than left-side, and scalp electrodes are not the first step.
Question 2 of 5
Four days after a vaginal delivery, the client visits the clinic complaining of excessive lochia rubra with clots. The physician orders methylergonovine maleate (Methergine), 0.2 mg intramuscularly. Before administering this drug, the nurse should assess:
Correct Answer: A
Rationale: Methylergonovine can cause hypertension, so blood pressure assessment is essential before administration.
Question 3 of 5
A primiparous client who is bottle-feeding her neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age?
Correct Answer: B
Rationale: Solid foods are introduced around 6 months when the infant's digestive system is more mature.
Question 4 of 5
While a client is being admitted to the birthing unit she states, 'My water broke last night, but my labor started two hours ago.' Which of the following is a concern? Select all that apply.
Correct Answer: E
Rationale: Prolonged rupture of membranes (>18 hours) increases infection risk, and green fluid suggests meconium, indicating potential fetal distress. Normal blood pressure, bloody show, fetal heart rate variability, and fetal movement are not immediate concerns.
Question 5 of 5
Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following?
Correct Answer: D
Rationale: Edema in the lower urinary tract, often from delivery trauma or epidural anesthesia, can cause urinary retention and bladder distention.