NCLEX-PN
Maternal NCLEX Practice Questions Questions
Extract:
Question 1 of 5
Which sign of labor should the nurse teach the client to report immediately?
Correct Answer: C
Rationale: Rupture of membranes (water breaking) requires immediate reporting, as it may indicate the onset of labor or risk of infection.
Question 2 of 5
The laboring multigravida client’s last vaginal examination was 8/90/+1. The client now states feeling rectal pressure. Which action should the nurse perform first?
Correct Answer: D
Rationale: The nurse should first evaluate labor progress by performing another vaginal exam. Previously the client was almost fully effaced (90%), and fetal station was 1 cm below the ischial spines (+1). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part. The client needs to be fully dilated (10 cm, not 8 cm) and fully effaced (100%, not 90%) before being encouraged to push. Pushing too early may cause cervical edema and lacerations and may slow the labor process. Rectal pressure may indicate that the client has progressed since the last vaginal exam. Another vaginal exam should be performed before contacting the obstetrician or midwife. During labor, rectal pressure is usually not due to the need for a bowel movement because intestinal motility decreases.
Question 3 of 5
The nurse responds that, for clients with uncomplicated pregnancies, it is usually best to plan monthly visits for the first 28 weeks and then more frequent visits following which schedule?
Correct Answer: C
Rationale: Standard prenatal care involves monthly visits until 28 weeks, biweekly until 36 weeks, and weekly thereafter for uncomplicated pregnancies.
Question 4 of 5
Which instruction should the nurse provide about newborn feeding?
Correct Answer: B
Rationale: Feeding on demand supports the newborn's nutritional needs and promotes bonding and growth.
Question 5 of 5
Which statement made by a participant regarding remedies of heartburn and nausea indicates that teaching has been effective?
Correct Answer: A
Rationale: Frequent, small meals reduce stomach acid and nausea, unlike large meals or extra water, which may worsen symptoms.