NCLEX-PN
Maternal NCLEX Practice Questions Questions
Extract:
Question 1 of 5
The nurse is assessing the laboring client who is morbidly obese. The nurse is unable to determine the fetal position. Which action should be performed by the nurse to obtain the most accurate method of determining fetal position in this client?
Correct Answer: D
Rationale: Real-time transabdominal ultrasound (US) is the most accurate assessment measure to determine the fetal position and is frequently available in the birthing setting. US images may be used to assess fetal lie, presentation, and position in the morbidly obese client. Inspection of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Palpation of the abdomen can be used to determine fetal position, but because the client is obese, this is not the most accurate method. Vaginal examination can be used to determine fetal position, but because the client is obese, this is not the most accurate method.
Question 2 of 5
The primigravida client has been pushing for 2 hours when the infant’s head emerges. The infant fails to deliver, and the obstetrician states that the turtle sign has occurred. Which should be the nurse’s interpretation of this information?
Correct Answer: B
Rationale: The “turtle sign” occurs when the infant’s head suddenly retracts back against the mother’s perineum after emerging from the vagina, resembling a turtle pulling its head back into its shell. This head retraction is caused by the infant’s anterior shoulder being caught on the back of the maternal pubic bone (shoulder dystocia), preventing delivery of the remainder of the infant. Cephalopelvic disproportion occurs when the head is too large to fit through the client’s pelvis. Fetal descent ceases, and infant’s head would not emerge. Persistent occiput posterior results in prolonged pushing; however, once the head is born, the remainder of the birth occurs without difficulty. A cord prolapse occurs when the umbilical cord enters the cervix before the fetal presenting part and is considered a medical emergency.
Question 3 of 5
The nurse is about to auscultate an FHR on the client in triage. What information should the nurse determine first in order to find the correct placement for auscultation?
Correct Answer: A
Rationale: The nurse should first perform Leopold’s maneuvers to determine the fetal position. This will enable proper placement of the Doppler device over the location of the FHR. The position of the placenta can provide important information. However, if the Doppler device is placed over the placenta, the nurse will hear a swishing sound and not the FHR. The FHR is still assessed regardless of the presence of contractions. The nurse who has difficulty obtaining an FHR because of a contraction can listen again once the contraction has concluded. Ultrasonic gel is used with any ultrasound device and allows for the conduction of sound and continuous contact of the device with the maternal abdomen. In order to apply the gel to the correct location, the position of the fetus must be known.
Question 4 of 5
The nurse is caring for the pregnant client whose FHR tracing reveals a reduction in variability over the last 40 minutes. The client has had occasional decelerations after the onset of a contraction that did not resolve until the contraction was over. The client suddenly has a prolonged deceleration that does not resolve, and the nurse immediately intervenes by calling for assistance. Place the nurse’s interventions in the sequence that they should occur.
Order the Items
Source Container
Correct Answer: E,A,D,B,F,C
Rationale: Assist the client into a different position should be first. Repositioning is an attempt to increase the FHR in case of cord obstruction. Administer oxygen via facemask is next to increase oxygenation to the fetus. Increase the rate of the IV fluids next to treat possible hypotension, the most common cause of fetal bradycardia. Have the HCP paged if the prolonged decelerations have not resolved. The immediate focus should be on attempting to relieve the prolonged decelerations. Prepare for a vaginal examination and fetal scalp stimulation. This is performed to rule out cord prolapse and to provide stimulation to the fetal head. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the HR remains low.
Question 5 of 5
The client has been in labor for 21 hours. Induction was started 16 hours ago, and she is now dilated 5 cm. She has made little progress, and there has been no fetal descent. The HCP identifies cephalopelvic disproportion (CPD). The nurse should prepare the client for which mode of delivery?
Correct Answer: D
Rationale: A fetus diagnosed with CPD is unable to be delivered vaginally and requires a cesarean section birth. A vaginal delivery is contraindicated once CPD has been identified due to the risk of fetal and maternal trauma. Forceps delivery is contraindicated once CPD has been identified due to the risk of fetal and maternal trauma. Vacuum delivery is contraindicated once CPD has been identified due to the risk of fetal and maternal trauma.