NCLEX-PN
Free NCLEX Maternity Questions Questions
Extract:
Question 1 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 2 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.
Question 3 of 5
The nurse observes on the monitor tracing of the client in the transition phase of labor that the baseline FHR is 160 and that there is moderate variability with V-shaped decelerations unrelated to contractions. What should the nurse do first?
Correct Answer: D
Rationale: Repositioning the client to her side or to knee-chest should be done first to take the pressure off the umbilical cord. Variable decelerations usually result from cord compression and stretching during fetal descent. The fetus has a normal baseline HR and good variability. There is no indication that immediate delivery is necessary. Other measures could correct the V-shaped (variable) decelerations. Other nursing measures are used to correct the V-shaped (variable) decelerations prior to contacting the obstetrician (or midwife). Repositioning the client should be implemented prior to giving her oxygen.
Question 4 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 5 of 5
The pregnant client tells the nurse that she smokes two packs per day (PPD) of cigarettes, has smoked in other pregnancies, and has never had any problems. What is the nurse’s best response?
Correct Answer: A
Rationale: The nurse is acknowledging that the client did not experience problems with her other pregnancies but is also informing the client that smoking can cause maternal and fetal problems during pregnancy. Telling the client to stop smoking for the baby’s sake is confrontational, making the client less likely to listen to the nurse’s teaching. Although spontaneous abortion is associated with tobacco use during pregnancy, the nurse is using a scare tactic rather than therapeutic communication. Smoking can lead to a fetus that is small for gestational age, not a large baby. Decreasing her smoking intake should be suggested; however, it does not eliminate the risk to the baby completely.