Questions 81

NCLEX-RN

NCLEX-RN Test Bank

Maternity Questions NCLEX RN Quizlet Questions

Extract:


Question 1 of 5

The nurse managing the admission nursery is beginning the shift. There are 2 infants under the care of a primary staff nurse and are remaining in the nursery while their mothers sleep. One newborn is waiting to be transferred to the special care nursery (SCN) with a diagnosis of possible sepsis. The SCN cannot accept a transfer for 30 minutes. The nurse has been notified that another infant has been born and is breathing at a rate of 80 bpm and needs to be admitted to the nursery. There are also two infants who are waiting for social services to determine discharge plans. There can be no other additions to the nursery until at least one newborn leaves the area. How should the nurse manage this situation?

Correct Answer: C

Rationale: Calling social services to expedite discharge of one of the waiting infants allows space for the new admission with a high respiratory rate, which requires urgent assessment.

Question 2 of 5

The nurse is working on a busy labor and delivery unit with other nurses and a licensed practical nurse. Which of the following labor clients would the nurse assign to the licensed practical nurse?

Correct Answer: D

Rationale: A G 2, P 1 client with a history of hyperemesis gravidarum is low-risk, suitable for an LPN's scope (e.g., vital signs, basic care). Clients with gestational diabetes, preterm labor (35 weeks), or meconium-stained fluid (G 1, P 0) require RN assessment due to higher risk.

Question 3 of 5

A primiparous client has just delivered her baby. The physician has informed the labor nurse that he believes the uterus has inverted. Which of the following would help to confirm this diagnosis? Select all that apply.

Correct Answer: A,E

Rationale: Uterine inversion is characterized by the uterus turning inside out, often leading to hypotension (due to shock) and inability to palpate the fundus abdominally. A gush of blood may occur but is not specific, severe pain is less common, the uterus is not typically hard, and diaphoresis is a secondary symptom.

Question 4 of 5

A multigravid client at 40 weeks' gestation with a history of previous cesarean delivery is admitted for a trial of labor. The fetal monitor shows late decelerations. Which interventions should the nurse perform? Select all that apply.

Correct Answer: A,B,D

Rationale: Late decelerations suggest uteroplacental insufficiency. Administering oxygen, stopping oxytocin (if running), and increasing IV fluids improve fetal oxygenation and uterine perfusion. Right-side repositioning is less effective than left-side, and scalp electrodes are not the first step.

Question 5 of 5

A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which of the following would the nurse do first?

Correct Answer: A

Rationale: Checking the fetal heart rate is the first action to ensure fetal well-being.

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