NCLEX-RN
RN NCLEX Maternal Neonatal Nursing Questions
Extract:
Question 1 of 5
Assessment of a 23-year-old primigravid client at term who is admitted to the birthing unit in active labor reveals that her cervix is 4 cm dilated and 100% effaced. Contractions are occurring every 4 minutes. The nurse is developing a care plan with the client to relieve pain based on the gate-control theory of pain. The nurse should explain which of the following to the client?
Correct Answer: D
Rationale: The gate-control theory posits that pain signals are modulated in the spinal cord, where non-painful stimuli (e.g., touch) can 'close the gate' to pain transmission. Input from large fibers closes the gate, perception varies but is not the mechanism, and slow breathing helps manage pain but does not open the gate.
Question 2 of 5
The nurse is catheterizing a client who cannot void after a normal delivery 8 hours ago. The nurse begins the catheterization process and the client asks the nurse if Betadine was used to clean the meatus for the catheterization. The nurse realizes that the client is allergic to Betadine and the client is reacting to the cleansing agent. The nurse should take the following steps in order of priority from first to last.
Order the Items
Source Container
Correct Answer: B,D,C,A,E
Rationale: First, clean the Betadine to stop the reaction, ask about the reaction to assess severity, notify the physician, document the incident, and file an incident report.
Question 3 of 5
A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks no English and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which of the following responses indicates that the client may be approaching delivery?
Correct Answer: D
Rationale: Animated facial expressions (e.g., grimacing, distress) may indicate transition or second-stage labor, suggesting imminent delivery. Late decelerations indicate fetal distress, speaking to family is nonspecific, and early decelerations are normal.
Question 4 of 5
The father of a neonate diagnosed with gastroschisis tells the nurse that his wife had planned on breast-feeding the neonate. Which of the following should the nurse include in the preoperative teaching plan about feeding the neonate?
Correct Answer: A
Rationale: The neonate must remain NPO before surgery to prevent complications related to the exposed intestines.
Question 5 of 5
After teaching a diabetic primigravida about symptoms of hyperglycemia and hypoglycemia, the nurse determines that the client understands the instruction when she says that hyperglycemia may be manifested by which of the following?
Correct Answer: A
Rationale: Dehydration is a symptom of hyperglycemia.