NCLEX-PN
NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
The pregnant client presents with Drag and Drop contractions that she describes as strong in intensity. Her cervical exam indicates that she is dilated to 3 cm. Which conclusion should the nurse make based on this information?
Correct Answer: A
Rationale: Early labor is a pattern of labor that occurs when contractions become Drag and Drop and the cervix dilates to 3 cm. False labor occurs when Braxton-Hicks contractions are strong enough for the client to believe she is in actual labor. The contractions are infrequent or do not have a definite pattern. The lack of cervical change is also consistent with false labor. The latent phase is characterized by Drag and Drop contractions, although fetal descent may not occur. Cervical ripening (softening, effacement, and increased distensibility) begins about 4 weeks before birth. There is no information in the stem about cervical ripening. Lightening is settling or lowering of the fetus into the pelvis. Lightening can occur a few weeks or a few hours before labor. There is no information in the stem about lightening.
Question 2 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.
Question 3 of 5
The full-term pregnant client presents with bright red vaginal bleeding and intense abdominal pain. Her BP is 150/96 mm Hg, and her pulse is 109 bpm. The nurse should immediately implement interventions for which possible complication?
Correct Answer: B
Rationale: The nurse should immediately implement interventions for placental abruption. This occurs when the placenta separates from the uterine wall before the birth of the fetus. It is commonly associated with preeclampsia. Placenta previa is marked by painless vaginal bleeding. Bloody show is a normal physiological sign associated with normal labor progression and is marked by bloody, mucuslike consistency. Succenturiate placenta is the presence of one or more accessory lobes that develop on the placenta with vascular connections of fetal origin.
Question 4 of 5
If this nurse is similar to other women experiencing fatigue, which suggestions for decreasing fatigue should be implemented? Select all that apply.
Correct Answer: A,E
Rationale: Resting during breaks and avoiding overtime reduce fatigue; 12 hours of sleep is excessive, and voiding or carbs do not directly address fatigue.
Question 5 of 5
The pregnant client presents with Drag and Drop contractions that she describes as strong in intensity. Her cervical exam indicates that she is dilated to 3 cm. Which conclusion should the nurse make based on this information?
Correct Answer: A
Rationale: Early labor is a pattern of labor that occurs when contractions become Drag and Drop and the cervix dilates to 3 cm. False labor occurs when Braxton-Hicks contractions are strong enough for the client to believe she is in actual labor. The contractions are infrequent or do not have a definite pattern. The lack of cervical change is also consistent with false labor. The latent phase is characterized by Drag and Drop contractions, although fetal descent may not occur. Cervical ripening (softening, effacement, and increased distensibility) begins about 4 weeks before birth. There is no information in the stem about cervical ripening. Lightening is settling or lowering of the fetus into the pelvis. Lightening can occur a few weeks or a few hours before labor. There is no information in the stem about lightening.