NCLEX-PN
NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
Which action by the nurse best ensures that an accurate fetal heart rate is obtained?
Correct Answer: D
Rationale: Comparing maternal pulse with fetal heart rate ensures the nurse is not mistaking the maternal pulse for the fetal heartbeat.
Question 2 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 3 of 5
The client in labor is requesting water therapy (hydrotherapy) to help provide pain relief and relaxation. Her recent vaginal exam was 2/50/—2. How should the nurse respond to the client’s request?
Correct Answer: A
Rationale: Hydrotherapy is usually initiated when the client is in active labor, at approximately 4 or 5 cm. This timing will help reduce the risk of prolonged labor and provide a welcome change when the contractions are becoming stronger and closer together. Changing position takes less effort while immersed in water, so women are encouraged to change positions more frequently to help facilitate the process of labor. FHR monitoring can be done just as easily during hydrotherapy, using a wireless external monitor, Doppler, or fetoscope. Internal electrodes can be placed during most types of hydrotherapy but is contraindicated during jet hydrotherapy. There is no time limit for laboring women to use hydrotherapy; they may stay as long as desired, unless complications develop during the labor process.
Question 4 of 5
The nurse is caring for the antepartum client with a velamentous cord insertion. The client asks what symptom she would most likely experience first if one of the vessels should tear. The nurse should respond that she would most likely experience which symptom first?
Correct Answer: A
Rationale: In a velamentous cord insertion, vessels of the cord divide some distance from the placenta in the placental membrane. Thus, the most likely first symptom would be vaginal bleeding. Abdominal cramping is unlikely to occur; velamentous cord insertion is not related to uterine activity. Contractions are unlikely to occur; velamentous cord insertion is not related to uterine activity. An abruption, when the placenta comes off the uterine wall, results in severe abdominal pain.
Question 5 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.