NCLEX-PN
NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
The nurse explained the process of cervical effacement to the client in early labor. Which statement by the client indicates that she understands the information?
Correct Answer: B
Rationale: In cervical effacement, the cervix progressively changes from a thick and long structure, to paper thin. This statement indicates that the client understands the information. Widening of the cervix describes cervical dilation, not effacement. Cervical changes will not cause membranes to rupture. The power of contractions causes cervical changes (effacement and dilation) and, possibly, membrane rupture. Cervical changes will not help the fetus to change position. Fetal descent is thought to occur from the pressure of contractions, especially from the fundus, and from the pressure of the amniotic fluid. Fetal position changes also occur from the fetal head and body adjusting to the maternal pelvis as they descend.
Question 2 of 5
The nurse is caring for the low-risk laboring client during the first stage of labor. When should the nurse assess the FHR pattern? Select all that apply.
Correct Answer: A,C
Rationale: The FHR may be affected by medications given to the mother.
Therefore, a baseline FHR should be determined before giving any medication to the laboring client and then assessed again after giving the medication. The FHR should be assessed after each vaginal examination because the fetus could change positions, or be stressed by the intrusion of the examiner’s fingers, or intact membranes could have ruptured. The FHR should be assessed every 30 minutes (not 15 minutes) during the first stage of labor if the client is categorized as low risk. The FHR should be assessed every 15 minutes during the second stage of labor. Although the FHR could be listened to during a contraction, it may be difficult due to muffling of the sounds and maternal movement. It is most important to listen before and after the contraction to more accurately detect FHR decelerations. If the client is classified as low risk, she should not be receiving oxytocin (Pitocin) for labor augmentation or induction.
Question 3 of 5
When the client asks the nurse about the viability of the ovum after ovulation, the nurse correctly explains that after ovulation, the ovum remains alive for how many hours?
Correct Answer: B
Rationale: The ovum remains viable for approximately 24 hours after ovulation, during which it can be fertilized by sperm.
Question 4 of 5
If this nurse is similar to other women experiencing fatigue, which suggestions for decreasing fatigue should be implemented? Select all that apply.
Correct Answer: A,E
Rationale: Resting during breaks and avoiding overtime reduce fatigue; 12 hours of sleep is excessive, and voiding or carbs do not directly address fatigue.
Question 5 of 5
The nurse recognizes which behavior as a sign of potential depression in a pregnant client?
Correct Answer: B
Rationale: Persistent sadness and withdrawal are hallmark signs of depression, requiring further assessment and intervention.