NCLEX-PN
Maternity NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is caring for the pregnant client at the initial prenatal visit. Which universal screenings should the nurse complete? Select all that apply.
Correct Answer: A,D,E
Rationale: BP screening should be performed at the initial prenatal visit to establish a baseline and to evaluate for actual or potential problems. Domestic violence screening should be performed at the initial prenatal visit to determine fetal and maternal risk for harm. Screening for tobacco use should be performed at the initial prenatal visit to determine fetal and maternal risk. Smoking is associated with an increased risk for spontaneous abortion, preterm labor, and low birth weight. The use of routine urine dip assessments is unreliable in detecting proteinuria and is not always considered accurate. A urine sample should be collected and a UA completed to check for a UTI. The urine dipstick test is of insufficient sensitivity to be used as a screening tool for glycosuria and is not always considered accurate. A urine sample should be collected and a UA completed to check for the presence of glucose.
Question 2 of 5
The nurse is teaching the client who is wishing to travel by airplane during the first 36 weeks of her pregnancy. Which is the primary risk of air travel for this client that the nurse should address?
Correct Answer: B
Rationale: The primary risk with air travel during pregnancy is DVT. Pregnancy increases the risk of blood coagulation, and prolonged sitting produces venous stasis. Preterm labor is not associated with air travel. The threat of spontaneous abortion diminishes during the second trimester. Spontaneous abortion is not associated with air travel. Although nausea and vomiting can occur, they are not dangerous.
Question 3 of 5
The nurse, admitting a 40-week primigravida to the labor unit, just documented the results of a recent vaginal exam: 3/100/—2, RSP. How should the oncoming shift nurse interpret this documentation?
Correct Answer: C
Rationale: The nurse should interpret 3/100/—2, RSP as the cervix is 3 cm dilated, 100% effaced, and the fetus is 2 cm above the maternal ischial spines. RSP means that the fetus is to the right of the mother’s pelvis (R), with the sacrum as the specific presenting part (S), which is a breech position. This fetus is also posterior (P). At —2, the fetus is 2 cm above, not below, the maternal ischial spines. Two centimeters below the ischial spines would be recorded as +2. The cervix is 3 cm, not totally dilated.
Total dilation would be documented as 10 for the first number. Also, the cervix is 100% effaced, which is total effacement (shortening and thinning out). Fetal lie (relationship of long axis or spine of fetus to long axis of mother) is longitudinal, not transverse. The documentation does not specify if the fetal attitude is flexion.
Question 4 of 5
The nurse observes a sinusoidal FHR pattern on the monitor tracing. How should the nurse interpret this pattern?
Correct Answer: C
Rationale: A sinusoidal pattern, which is Drag and Drop, smooth, undulating, and uncommon, classically occurs with severe fetal anemia as a result of abnormal perinatal conditions. An FHR pattern having minimal variability (not a sinusoidal pattern) might indicate that the fetus is in a sleep state. Absent or minimal variability, not a sinusoidal FHR pattern, could indicate possible congenital anomalies. Moderate variability of the FHR (not a sinusoidal pattern) reflects normal fetal well-being.
Question 5 of 5
The nurse is caring for the client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during this stage of labor?
Correct Answer: A
Rationale: Maternal HR is normally increased due to pain resulting from increased catecholamine secretion, fear, anxiety, and increased blood volume. When the laboring client holds her breath and pushes against a closed glottis, intrathoracic pressure rises. Blood in the lungs is forced into the left atrium, leading to a transient increase (not decrease) in cardiac output. Although the WBCS increase to 25,000/mm3 to 30,000/mm3 during labor and early postpartum as a physiological response to stress, this is not a cardiovascular change. During the second stage of labor, the maternal intravascular volume is increased (not decreased) by 300 to 500 mL of blood from the contracting uterus.