NCLEX-PN
Free NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
The nurse is caring for the client in labor. Which assessment finding would help the nurse determine whether the client is in the third stage of labor?
Correct Answer: A
Rationale: The third stage of labor lasts from the birth of the baby until the placenta is expelled. Lengthening of the fetal cord is one of several signs indicating placental separation. Bloody show is pink and mucoid in nature and occurs during the first and second stages of labor. During the third stage, there may be increased vaginal bleeding that is bright or dark red. A strong urge to push may occur during the first and second stages of labor. More frequent contractions occur during the first and second stages of labor.
Question 2 of 5
The nurse’s assessment findings of the pregnant client include darkening of areola and nipple, presence of Goodell’s sign, leukorrhea, HR 124 bpm, dysuria, and heartburn. Of these findings, how many require further evaluation?
Correct Answer: 3
Rationale: There are three abnormal findings that require further evaluation. Leukorrhea needs to be distinguished from a vaginal infection, such as Candida albicans or a sexually transmitted infection. Heart rate can increase by 10 to 15 bpm during pregnancy, but an increase to 124 bpm is too high. Dysuria may be a sign of a UTI. Darkening of the areola and nipple, Goodell’s sign, and heartburn are normal findings during pregnancy and do not require further evaluation.
Question 3 of 5
Twenty-four hours after the birth of her first child, the 25-year-old single client tells the nurse that she has several different male sex partners and asks the nurse to recommend an appropriate birth control method for her. Considering her lifestyle, which method of birth control should the nurse suggest?
Correct Answer: C
Rationale: IUDs offer no protection against STIs. They are recommended for women who are in a stable, mutually monogamous relationship. Depot-medroxyprogesterone acetate (Depo-Provera) is a long-acting progestin that is highly effective for birth control. A single injection will provide contraception for 3 months but does not offer protection against STIs. A female condom does provide protection against some of the pathogens that cause STIs, and it would be readily available over the counter. A diaphragm offers no protection against STIs.
Question 4 of 5
A 5-minute-old newborn in a delivery room has a good cry, HR 88, well flexed, good reflex irritability, and blue extremities with a completely pink body. What Apgar score would the nurse document for this newborn?
Correct Answer: 8
Rationale: The newborn would receive one point because the HR is below 100 bpm, two points for a good cry (respiratory effort), two points for being well flexed (muscle tone), two points for good reflex irritability (reflex response), and one point for a pink body with blue extremities (color).
Question 5 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.