NCLEX-RN
Maternity NCLEX RN Questions Questions
Extract:
Question 1 of 5
Assessment reveals that the fetus of a multigravid client is at +1 station and 8 cm dilated. Based on these data, the nurse should first:
Correct Answer: C
Rationale: At 8 cm dilation and +1 station, the client is in the transition phase but not fully dilated (10 cm). Pushing before full dilation can lead to cervical edema or lacerations. Encouraging the client to breathe through the urge to push helps prevent premature pushing while supporting labor progression. Increasing the epidural rate or assisting with pushing is inappropriate at this stage, and while family support is valuable, it is not the priority.
Question 2 of 5
The nurse is caring for a primiparous client and her neonate immediately after delivery. The neonate was born at 41 weeks' gestation and weighs 4,082 g (9 lb). Assessing for signs and symptoms of which of the following conditions should be a priority in the neonate?
Correct Answer: B
Rationale: Large-for-gestational-age neonates (e.g., 4,082 g) are at risk for hypoglycemia due to increased metabolic demand and potential maternal diabetes. Hypoglycemia screening is a priority. Anemia, delayed meconium, or hyperbilirubinemia are less immediate.
Question 3 of 5
A neonate born at 29 weeks' gestation received nasal continuous positive airway pressure. The neonate is receiving oxygen at 1 L/minute via nasal cannula at a fraction of inspired oxygen (FiO₂) of 0.23. The pulse oximetry reading is 70% saturation. In which order of priority from first to last should the nurse take these actions?
Order the Items
Source Container
Correct Answer: B,C,D,A
Rationale: First, ensure the pulse oximeter is accurate (
B).
Then, assess clinical signs like color (
C) and respiratory effort (
D). Finally, adjust $\mathrm{FiO}_2$ (
A) if needed based on findings.
Question 4 of 5
In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation?
Correct Answer: C
Rationale: The 'taking hold' phase is characterized by the mother becoming more active, showing interest in caring for the infant, and asking questions about infant care, as described in the scenario.
Question 5 of 5
A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean delivery because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine (Nubain) intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain the decreased variability is most likely caused by which of the following?
Correct Answer: D
Rationale: Nalbuphine, an opioid, can reduce fetal heart rate variability by depressing the central nervous system, a common side effect. Maternal fatigue, malposition, or small-for-gestational-age fetus are less likely causes.