NCLEX-PN
Maternal NCLEX Questions
Extract:
Question 1 of 5
The client is hospitalized at 30 weeks’ gestation in preterm labor. A test is performed to determine the lecithin to sphingomyelin (L/S) ratio, with results indicating a ratio less than 2:1. The nurse planning care for the client should expect to implement which interventions? Select all that apply.
Correct Answer: B,C,D
Rationale: Bed rest will maximize placental oxygenation while fetal lung maturity continues. The client should be prepared for a nonstress test. This is used to monitor for uterine contractions and labor. Labor needs to be stopped until the fetal lungs are more fully developed. Betamethasone (Celestone Soluspan) is a corticosteroid and is given to stimulate fetal lung maturity. Hydralazine (Apresoline) is an antihypertensive agent and is administered to clients experiencing preeclampsia, not preterm labor. Metronidazole (Flagyl) is an antiprotozoal and antibacterial agent used to treat a vaginal infection; there is no indication that the client has a vaginal infection.
Question 2 of 5
The nurse just administered butorphanol tartrate as prescribed to the client in active labor. Following administration of butorphanol tartrate, what is the nurse’s most important action to help prevent side effects?
Correct Answer: D
Rationale: Evaluating maternal VS and pulse oximetry would determine changes in respiratory and cardiac status. Respiratory depression in both the mother and fetus can occur with butorphanol tartrate (Stadol). Although bladder distention is a possible side effect of butorphanol tartrate, it is not common and is not the most important assessment. Seizures are not a potential side effect of butorphanol tartrate. An itchy rash is not a potential side effect of butorphanol tartrate.
Question 3 of 5
The client in labor tells the nurse that it feels like her membranes just ruptured. Which assessment finding of the amniotic fluid would indicate that it is normal?
Correct Answer: D
Rationale: The pH of amniotic fluid is usually between 6.5 and 7.5, which is more alkaline than urine or purulent material. Normal amniotic fluid should be clear. Cloudiness could indicate the presence of meconium or an intrauterine infection. Amniotic fluid should have no odor. Any odor may indicate the presence of infection. Amniotic fluid should be clear. Meconium stained could indicate fetal distress.
Question 4 of 5
The nurse is caring for the pregnant client. Which assessment findings help the nurse determine that she may be in true labor? Select all that apply.
Correct Answer: A,B,E
Rationale: Progressive cervical dilation and effacement indicate true labor. In false labor, the contractions may occur for several hours, but there is no cervical change. In true labor, walking usually increases the intensity of contractions. In false labor, walking usually has little or no effect on contractions and may sometimes decrease the frequency, intensity, and duration of contractions. Contractions increase in duration and intensity during true labor, while there is usually no change in contractions during false labor. Warm tub baths and rest lessen contractions during false labor. In true labor, contractions do not decrease with warm tub baths or rest. Discomfort is usually in the client’s abdomen during false labor. Discomfort begins in the back and radiates around to the abdomen during true labor.
Question 5 of 5
The nurse notifies the HCP after feeling a pulsating mass during the vaginal examination of a newly admitted full-term pregnant client. Which HCP order should the nurse question?
Correct Answer: C
Rationale: The nurse should question the administration of oxytocin (Pitocin). Oxytocin is used for stimulating contraction of the uterus. Uterine contractions can cause further umbilical cord compression. The pulsating mass indicates umbilical cord prolapse, which is a medical emergency. If vaginal birth is not imminent, a cesarean section is preferred in order to prevent hypoxic acidosis. Placing the client in a knee-chest position relieves pressure on the umbilical cord. Terbutaline (Brethine) is a tocolytic agent used to reduce contractions.