NCLEX-PN
NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
At one minute after birth, a neonate is pink, except for blue extremities. The neonate is crying, gagging, and grimacing when the bulb syringe is used and has some flexion of extremities and an HR of 97. Based on the Apgar score, what should the nurse do next?
Correct Answer: B
Rationale: Rechecking the Apgar score at 5 minutes after birth will determine if the newborn is continuing to make a good transition to the extrauterine environment. Notifying the HCP is not necessary at this time. The one-minute Apgar score is 6, very close to the 7 to 10 normal limits. This newborn has a good cry, indicating good transition to the extrauterine environment thus far. Initiating resuscitation measures immediately is not necessary. This would be done if the newborn were not crying and demonstrated a blue or pale body. Swaddling and giving the newborn to the mother for breastfeeding are important but should occur after the 5-minute Apgar, if the score is WNL. Keeping this newborn in the radiant warmer, rather than giving him or her to the mother, will help prevent hypothermia and promote better transition to extrauterine life.
Question 2 of 5
When the nurse discusses the tasks to be accomplished during the client's visit at 24 weeks' gestation, which routine test will be performed?
Correct Answer: B
Rationale: The glucose tolerance test is routinely performed around 24-28 weeks to screen for gestational diabetes.
Question 3 of 5
When the client asks the nurse about the viability of the ovum after ovulation, the nurse correctly explains that after ovulation, the ovum remains alive for how many hours?
Correct Answer: B
Rationale: The ovum remains viable for approximately 24 hours after ovulation, during which it can be fertilized by sperm.
Question 4 of 5
The laboring client is requesting IV pain medication instead of epidural anesthesia. The nurse determines that which factor would most definitely contraindicate the administration of nalbuphine hydrochloride?
Correct Answer: A
Rationale: Systemic medications, such as nalbuphine hydrochloride (Nubain), should not be administered when advanced dilation is present (transition stage of labor) because its use can lead to respiratory depression if given too close to the time of delivery. An FHR of 120 bpm is within normal parameters of 120 to 160 bpm. Reassuring FHR variability and accelerations are interpreted as adequate placental oxygenation and do not contraindicate administration of nalbuphine hydrochloride. If mild variable decelerations are present but the FHR pattern remains reassuring, nalbuphine hydrochloride can still be administered.
Question 5 of 5
The pregnant client presents with Drag and Drop contractions that she describes as strong in intensity. Her cervical exam indicates that she is dilated to 3 cm. Which conclusion should the nurse make based on this information?
Correct Answer: A
Rationale: Early labor is a pattern of labor that occurs when contractions become Drag and Drop and the cervix dilates to 3 cm. False labor occurs when Braxton-Hicks contractions are strong enough for the client to believe she is in actual labor. The contractions are infrequent or do not have a definite pattern. The lack of cervical change is also consistent with false labor. The latent phase is characterized by Drag and Drop contractions, although fetal descent may not occur. Cervical ripening (softening, effacement, and increased distensibility) begins about 4 weeks before birth. There is no information in the stem about cervical ripening. Lightening is settling or lowering of the fetus into the pelvis. Lightening can occur a few weeks or a few hours before labor. There is no information in the stem about lightening.