NCLEX-PN
NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
The nurse prepares the client for which pain management option during labor?
Correct Answer: A
Rationale: Epidural anesthesia is a common and effective pain management option during labor, tailored to the client's needs.
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
The laboring client is requesting IV pain medication instead of epidural anesthesia. The nurse determines that which factor would most definitely contraindicate the administration of nalbuphine hydrochloride?
Correct Answer: A
Rationale: Systemic medications, such as nalbuphine hydrochloride (Nubain), should not be administered when advanced dilation is present (transition stage of labor) because its use can lead to respiratory depression if given too close to the time of delivery. An FHR of 120 bpm is within normal parameters of 120 to 160 bpm. Reassuring FHR variability and accelerations are interpreted as adequate placental oxygenation and do not contraindicate administration of nalbuphine hydrochloride. If mild variable decelerations are present but the FHR pattern remains reassuring, nalbuphine hydrochloride can still be administered.
Question 5 of 5
The nurse is caring for the pregnant client at 20 weeks’ gestation. At what level should the nurse expect to palpate the client’s uterine height?
Correct Answer: C
Rationale: At 20 gestational weeks, the uterus should be at the level of the umbilicus. The uterine height is too low for 20 weeks’ gestation. At 13 weeks, the uterus would be approximately two finger-breadths above the symphysis pubis. The uterine height is too low for 20 weeks’ gestation. At 16 weeks, the uterus would be approximately halfway between the umbilicus and symphysis pubis. The uterine height is too high for 20 weeks’ gestation. At 22 weeks, the uterus would be two finger-breadths above the umbilicus.