NCLEX-RN
NCLEX RN Maternity Questions Questions
Extract:
Question 1 of 5
The labor and delivery nurse is assigned to triage for the day. There are four clients already in rooms and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first?
Correct Answer: B
Rationale: A primipara at 8 cm, 100% effaced, and ready to push is in the second stage of labor, requiring immediate attention to prepare for delivery. Other clients are in earlier stages or need assessment but are less urgent.
Question 2 of 5
The nurse is teaching a multiparous breast-feeding client about managing mastitis. Which instruction is most appropriate?
Correct Answer: B
Rationale: Warm compresses before feeding promote milk flow and relieve duct blockage, aiding mastitis resolution.
Question 3 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.
Question 4 of 5
A 24-year-old primipara who has delivered a healthy neonate in the hospital's birthing center plans to bottle-feed her neonate. When developing the nutritional teaching plan for the mother, the nurse should determine that the number of calories required by the neonate each day per pound of body weight is which of the following?
Correct Answer: C
Rationale: Neonates require approximately 50-55 calories per pound of body weight daily for growth and development.
Question 5 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.