NCLEX-PN
Maternal NCLEX Questions
Extract:
Question 1 of 5
The nurse’s laboring client is being electronically monitored during her labor. The baseline FHR throughout the labor has been in the 130s. In the last 2 hours, the baseline has decreased to the 100s. How should the nurse document this FHR?
Correct Answer: B
Rationale: An FHR baseline less than 110 is classified as bradycardia. Tachycardia occurs when the baseline is greater than 160 bpm. A prolonged deceleration is defined as a change from the baseline FHR that occurs for 2 to 10 minutes before returning to baseline. A late deceleration is a gradual decrease and return of the FHR to baseline, associated with a uterine contraction. A decrease to the 100s is not within the normal range. The normal FHR is 120 to 160 bpm.
Question 2 of 5
The client in labor tells the nurse that it feels like her membranes just ruptured. Which assessment finding of the amniotic fluid would indicate that it is normal?
Correct Answer: D
Rationale: The pH of amniotic fluid is usually between 6.5 and 7.5, which is more alkaline than urine or purulent material. Normal amniotic fluid should be clear. Cloudiness could indicate the presence of meconium or an intrauterine infection. Amniotic fluid should have no odor. Any odor may indicate the presence of infection. Amniotic fluid should be clear. Meconium stained could indicate fetal distress.
Question 3 of 5
Which response by the nurse is most accurate?
Correct Answer: C
Rationale: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.
Question 4 of 5
The nurse advises the client that this test is typically performed at what time during the pregnancy?
Correct Answer: B
Rationale: Amniocentesis is typically performed early in the second trimester (15-20 weeks) to assess for genetic abnormalities.
Question 5 of 5
The nurse correctly assists the client into which position?
Correct Answer: A
Rationale: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.