NCLEX-RN
Maternity NCLEX RN Questions Questions
Extract:
Question 1 of 5
A primigravid client who has had a prolonged labor but now is completely dilated has received epidural anesthesia. Which of the following should the nurse include in the teaching plan about pushing?
Correct Answer: C
Rationale: Pushing with an open glottis (exhaling during effort) is effective and reduces the risk of Valsalva maneuver complications. Prolonged pushing (1–3 minutes) is unrealistic, holding breath is discouraged, and with epidurals, the urge to push may be diminished.
Question 2 of 5
The nurse on the night shift finds a multiparous client, 8 hours postpartum, drenched in perspiration. The client's temperature is 99°F (36.8°C), the pulse is 68 bpm, and the blood pressure is 120/80 mm Hg. Which of the following nursing diagnoses is a priority?
Correct Answer: B
Rationale: Profuse sweating and normal vital signs suggest ineffective thermoregulation due to hormonal shifts, a common postpartum occurrence.
Question 3 of 5
The physician orders oxytocin to be added to the intravenous fluids of a 30-year-old multigravid client at 37 weeks' gestation with twins after vaginal delivery. The nurse should administer the oxytocin after delivery of which of the following?
Correct Answer: C
Rationale: Oxytocin is administered post-delivery of both twins and placentas to promote uterine contraction and prevent postpartum hemorrhage. Administering earlier risks complications with the second twin or placentas.
Question 4 of 5
While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer an ordered hepatitis B intramuscular injection at 4 hours after birth. Which of the following actions should the nurse do first?
Correct Answer: D
Rationale: Applying clean gloves ensures infection control and safety during the administration of the injection.
Question 5 of 5
A 19-year-old primigravid client at 38 weeks' gestation is admitted to the hospital in active labor that began 8 hours ago. When the client's cervix is 7 cm dilated and the presenting part is at +1 station, the client tells the nurse, 'I need to push!' Which of the following would the nurse do next?
Correct Answer: C
Rationale: At 7 cm dilation, the client is not fully dilated, and pushing can cause cervical trauma. A pant-blow breathing pattern helps manage the urge to push until full dilation. The McDonald procedure is for cervical cerclage, and increasing oxygen/fluids or encouraging pushing is inappropriate.