NCLEX-RN
NCLEX RN Maternity Questions Questions
Extract:
Question 1 of 5
A primigravid client at 39 weeks' gestation is admitted to the hospital in active labor. On admission, the client's cervix is 6 cm dilated. After 2 hours of active labor, the client's cervix is still dilated at 6 cm with 100% effacement at -1 station. Contractions are 3 to 5 minutes apart, lasting 45 seconds, and of moderate intensity. The nurse determines that the client is most likely experiencing which of the following?
Correct Answer: A
Rationale: Lack of cervical dilation (6 cm after 2 hours) despite adequate contractions suggests cephalopelvic disproportion, where the fetal head cannot pass through the pelvis. Prolonged latent phase occurs earlier, transition is at 8–10 cm, and hypotonic contractions are weaker.
Question 2 of 5
A client has obtained Plan B (levonorgestrel 0.75 mg, 2 tablets) as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which of the following responses?
Correct Answer: A
Rationale: Plan B is most effective when taken within 72 hours of unprotected intercourse, ideally as soon as possible. Waiting 3 to 4 days reduces its efficacy, indicating a need for further explanation.
Question 3 of 5
Commercial formulas contain 20 calories per ounce. A 1-day-old infant's weight in the morning was 8 lb and he was fed 45 mL at 2 a.m., 5:30 a.m., 8 a.m., 11 a.m., 2 p.m., 4:30 p.m., 8 p.m., and 10:30 p.m. What is the total amount of calories the infant received today?
Correct Answer: B
Rationale: The infant was fed 45 mL 8 times, totaling 360 mL. Since 1 oz ≈ 30 mL, 360 mL ÷ 30 mL/oz = 12 oz. At 20 calories per ounce, 12 oz × 20 cal/oz = 240 calories.
Question 4 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 5 of 5
A newborn with a cleft palate at 1 hour of life has a nursing diagnosis of Risk for Infection related to potential aspiration during feedings. Which of the following nursing actions would support the best feeding practice for this infant?
Correct Answer: A
Rationale: Using an appropriate nipple and bottle set designed for cleft palate infants minimizes aspiration risk during feedings.