NCLEX-PN
Free NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
The laboring client in the first stage of labor is talking and laughing with her husband. The nurse should conclude that the client is probably in what phase?
Correct Answer: D
Rationale: During the latent phase (1—3 cm), the client is usually happy and talkative. During the transition phase (8—10 cm), the client is usually more restless, irritable, and more likely to lose control. During the active phase (4—7 cm), the client may become more anxious and fatigued and needs to concentrate on breathing techniques to cope with the increasingly stronger contractions. The client who is actively pushing is focusing on how effective she is in the descent of the fetus and concentrating on how she is coping with contractions. She is usually not expressing happiness or laughter, and is not talkative.
Question 2 of 5
Which instruction is most appropriate for a client with a history of preterm birth?
Correct Answer: A
Rationale: Monitoring for uterine contractions is critical for a client with a history of preterm birth to detect early signs of preterm labor.
Question 3 of 5
The nurse considers prenatal teaching successful when the class correctly identifies which of the following as a danger sign of pregnancy?
Correct Answer: A
Rationale: Headache and swelling of the face and fingers may indicate preeclampsia, a serious condition requiring immediate attention.
Question 4 of 5
The nurse practitioner informs the new nurse that the laboring client’s monitor is showing prolonged decelerations. Which interpretation by the new nurse is correct?
Correct Answer: C
Rationale: A prolonged deceleration occurs when the FHR decreases 15 bpm or more below baseline for at least 2 but not more than 10 minutes. The prolonged deceleration may resolve spontaneously or with the aid of interventions. A U- or V-shaped pattern with abrupt decrease in the FHR to less than 70 bpm, lasting more than 60 seconds, describes variable (not prolonged) deceleration typically associated with cord compression. Any episodic or periodic acceleration of FHR that lasts 2 minutes or more but less than 10 minutes in duration describes prolonged acceleration, not deceleration. The fetal heart monitor is monitoring the FHR and not the mother’s heart rate.
Question 5 of 5
The laboring client suddenly experiences a dramatic drop in the FHR from the 150s to the 110s. A vaginal exam reveals the presence of the fetal cord protruding through the cervix. What should be the nurse’s first intervention?
Correct Answer: A
Rationale: The nurse should first exert continuous pressure on the presenting part to prevent further cord compression. This is continued until birth, which is usually by cesarean section. The bed should be placed in Trendelenburg position to further prevent pressure on the cord, but only after pressure is placed on the presenting part. A catheter may be inserted and 500 mL of warmed saline instilled to help float the head and prevent further compression, but only after pressure is placed on the presenting part. The fetus is continually monitored throughout until birth.