NCLEX-PN
Free NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
The laboring client is experiencing dyspnea, diaphoresis, tachycardia, and hypotension while lying on her back. Which intervention should the nurse implement immediately?
Correct Answer: A
Rationale: When the laboring client lies flat on her back, the gravid uterus completely occludes the inferior vena cava and laterally displaces the subrenal aorta. This aortocaval compression reduces maternal cardiac output, producing dyspnea, diaphoresis, tachycardia, and hypotension. Other symptoms include air hunger, nausea, and weakness. A left side-lying position decreases aortocaval compression. Lying on the right side increases aortocaval compression. Notifying the obstetrician is not the first intervention. The obstetrician would be notified if symptoms are not relieved by a left side-lying position. Applying oxygen may be needed, but first the client should be placed left side-lying.
Question 2 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.
Question 3 of 5
Which response by the nurse is correct concerning the legal threshold of viability?
Correct Answer: C
Rationale: The legal threshold of viability is typically 20-24 weeks, when a fetus may survive outside the womb with medical support.
Question 4 of 5
To improve sperm production, the nurse should instruct the client's husband to avoid which activities? Select all that apply.
Correct Answer: B,E
Rationale: High temperatures from hot tubs can impair sperm production by overheating the testes. Smoking cigarettes negatively affects sperm quality and quantity.
Question 5 of 5
Which fetal heart rate must the nurse report immediately to the physician?
Correct Answer: A
Rationale: A fetal heart rate of 100 beats/minute is below the normal range (110-160 bpm) and may indicate fetal distress, requiring immediate reporting.