NCLEX-RN
NCLEX RN Maternity Questions Questions
Extract:
Question 1 of 5
When developing the plan of care for a multiparous client in active labor who receives an epidural anesthetic, which of the following would the nurse anticipate that the physician will order if the client develops moderate hypotension?
Correct Answer: A
Rationale: Ephedrine sulfate is commonly used to treat epidural-related hypotension by increasing blood pressure through vasoconstriction and cardiac stimulation. Epinephrine is for emergencies, methylergonovine treats uterine atony, and atropine addresses bradycardia.
Question 2 of 5
A neonate born by cesarean delivery at 42 weeks' gestation, weighing 4.1 kg (9 lb, 1 oz), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. Which of the following nursing diagnoses would be the priority?
Correct Answer: D
Rationale: Tremors and increased respiratory rate suggest hypoglycemia due to depleted glycogen stores, a common issue in post-term neonates.
Question 3 of 5
A primigravid client at 39 weeks' gestation is admitted to the hospital in active labor. On admission, the client's cervix is 6 cm dilated. After 2 hours of active labor, the client's cervix is still dilated at 6 cm with 100% effacement at -1 station. Contractions are 3 to 5 minutes apart, lasting 45 seconds, and of moderate intensity. The nurse determines that the client is most likely experiencing which of the following?
Correct Answer: A
Rationale: Lack of cervical dilation (6 cm after 2 hours) despite adequate contractions suggests cephalopelvic disproportion, where the fetal head cannot pass through the pelvis. Prolonged latent phase occurs earlier, transition is at 8–10 cm, and hypotonic contractions are weaker.
Question 4 of 5
A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.
Question 5 of 5
The nurse is assessing the perineal changes of a multigravid client in the second stage of labor. The illustration below represents which of the following perineal changes?
Correct Answer: D
Rationale: If the illustration shows the fetal head visible at the perineum with no retraction between contractions, and the perineal area appears bulging or stretched, this indicates crowning — the point at which birth is imminent.