NCLEX-RN
NCLEX RN Maternity Questions Questions
Extract:
Question 1 of 5
A newborn who is 20 hours old has a respiratory rate of 66 , is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98 ; he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before delivery. Based on these data, the nurse should include which of the following in the management of the infant's care?
Correct Answer: B
Rationale: The concern with this infant is sepsis based on prolonged rupture of membranes before delivery. Blood cultures would provide an accurate diagnosis of sepsis, but will take 48 hours from the time drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the parents is also part of care management while awaiting culture results.
Question 2 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 3 of 5
A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin (Pitocin) as ordered. The expected outcome of this drug is:
Correct Answer: B
Rationale: Oxytocin is used to augment labor by increasing contraction frequency, duration, and intensity. The expected outcome is regular contractions every 2–3 minutes, lasting 40–60 seconds, with moderate intensity and adequate resting tone, promoting effective labor progression. The other options describe unrealistic or unrelated effects.
Question 4 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 5 of 5
A nurse is counseling a client about the use of a diaphragm for contraception. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Using spermicide with the diaphragm for each act of intercourse is essential for effectiveness. The diaphragm can be inserted up to 6 hours before and left in place for at least 6 hours after intercourse but not more than 24 hours. It should be stored in a clean, dry container, not necessarily airtight.