NCLEX-RN
NCLEX RN Practice Questions Maternity Questions
Extract:
Question 1 of 5
Which of the following instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy?
Correct Answer: A
Rationale: Keeping the neonate's eyes completely covered protects them from potential retinal damage during phototherapy.
Question 2 of 5
Following a cesarean delivery for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other deliveries were like this." The nurse's response to the client is based on the understanding of which of the following?
Correct Answer: C
Rationale: Grief is a normal reaction to a complicated delivery.
Question 3 of 5
A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin (Pitocin) as ordered. The expected outcome of this drug is:
Correct Answer: B
Rationale: Oxytocin is used to augment labor by increasing contraction frequency, duration, and intensity. The expected outcome is regular contractions every 2–3 minutes, lasting 40–60 seconds, with moderate intensity and adequate resting tone, promoting effective labor progression. The other options describe unrealistic or unrelated effects.
Question 4 of 5
The physician who elects to perform a cesarean delivery on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, 'I'll sign it for her. She's too upset by what is happening to make this decision.' The nurse should:
Correct Answer: C
Rationale: The client must provide informed consent unless incapacitated. The nurse should ask the client to sign, ensuring she understands despite her distress. The husband cannot sign unless legally authorized, and dual signatures or physician witnessing are unnecessary.
Question 5 of 5
Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following?
Correct Answer: D
Rationale: Edema in the lower urinary tract, often from delivery trauma or epidural anesthesia, can cause urinary retention and bladder distention.