NCLEX-RN
Maternity NCLEX RN Questions Questions
Extract:
Question 1 of 5
The nurse assesses a primiparous client in labor for 20 hours. The nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which intravenous should the nurse perform? Select all that apply.
Correct Answer: A,C
Rationale: Late decelerations indicate uteroplacental insufficiency. Standard interventions include administering oxygen to improve fetal oxygenation and placing the client on her side to enhance uterine perfusion. Questioning pain relief or readjusting the monitor does not address the issue, and internal monitoring may be considered but is not the first step.
Question 2 of 5
A primigravid client in the second stage of labor feels the urge to push. The client has had no analgesia or anesthesia. Anatomically, which of the following would be the best position for the client to assume?
Correct Answer: D
Rationale: Squatting is anatomically optimal for pushing in the second stage as it widens the pelvic outlet, aligns the fetus with the birth canal, and uses gravity to aid descent. Dorsal recumbent and lithotomy positions restrict pelvic mobility, and hands and knees, while helpful for back pain, is less effective for pushing.
Question 3 of 5
A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse bases the response on the understanding that this therapy is commonly contraindicated for clients with which of the following?
Correct Answer: A
Rationale: Jet hydrotherapy (e.g., whirlpool tubs) is contraindicated with ruptured membranes due to the risk of infection from water entering the vaginal canal. Multifetal gestation, diabetes, and hypotonic labor are not absolute contraindications unless other complications are present.
Question 4 of 5
While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider if which of the following is noted?
Correct Answer: A
Rationale: Bronze-colored skin is a potential complication of phototherapy and should be reported to the health care provider.
Question 5 of 5
The nurse explains the complications of pregnancy that occur with diabetes to a primigravid client at 10 weeks' gestation who has a 5-year history of insulin-dependent diabetes. Which of the following, if stated by the client as a complication, indicates the need for additional teaching?
Correct Answer: B
Rationale: Twin-to-twin transfer is not a complication of diabetes.