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NCLEX RN Maternity Questions Questions

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Question 1 of 5

Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm mercury with a nonreassuring fetal heart rate and pattern. Which of the following actions should the nurse take first?

Correct Answer: B

Rationale: Hyperstimulation (contractions >90 seconds, frequent, with high resting tone) and nonreassuring fetal heart rate indicate fetal distress. Stopping oxytocin is the first step to reduce uterine activity and improve fetal oxygenation. Repositioning, notifying the provider, or increasing fluids follow.

Question 2 of 5

The nurse is caring for a multiparous client 48 hours after cesarean delivery. Which finding indicates a potential complication?

Correct Answer: C

Rationale: Scant lochia serosa at 48 hours may indicate retained clots or infection, requiring further assessment.

Question 3 of 5

After administering hydralazine(Apresoline) 5 mg intravenously as ordered for a primigravid client with severe preeclampsia at 39 weeks' gestation, the nurse should assess the client for:

Correct Answer: A

Rationale: Tachycardia is a potential side effect of hydralazine.

Question 4 of 5

After instructing a multigravid client at 10 weeks' gestation diagnosed with chronic hypertension about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client states which of the following?

Correct Answer: B

Rationale: Chronic hypertension increases the risk of having a small-for-gestational-age infant.

Question 5 of 5

The cervix of a primigravid client in active labor who received epidural anesthesia 4 hours ago is now completely dilated, and the client is ready to begin pushing. Before the client begins to push, the nurse should assess:

Correct Answer: D

Rationale: A full bladder can impede fetal descent and increase discomfort during pushing. Assessing bladder status (and catheterizing if needed) is critical before pushing begins. Fetal heart rate, dilation, and membrane status should already be monitored but are not the priority at this moment.

Similar Questions

The physician orders intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which of the following medications should the nurse have readily available at the client's bedside?
A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. The nurse should next assess the client's:
A breast-feeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which of the following?
After instructing a primigravid client at 38 weeks' gestation about how preeclampsia can affect the client and the growing fetus, the nurse realizes that the client needs additional instruction when she says that preeclampsia can lead to which of the following?
The physician orders whole blood replacement for a multigravid client with abruptio placentae. Before administering the intravenous blood product, the nurse should first:

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