Maternal Infant Nursing NCLEX Questions Part 2
1. Nurse Julia is aware that Labor is divided into how many stages?
2. Pen, a nurse-midwife determines that a client is in the second stage of labor and may start pushing. What marks the beginning of the second stage, and what marks the end?
a. Cervical dilation of 7 to 8 cm; complete cervical dilation
b. Complete cervical dilation; delivery of the neonate
c. Cervical dilation of 7 to 8 cm; delivery of the placenta
d. Complete cervical dilation; delivery of the placenta
3. Jannah, who is in labor receives epidural anesthesia. The nurse should assess carefully for which adverse reaction to the anesthetic agent?
a. Hypotensive crisis
b. Fetal tachycardia
c. Renal toxicity
d. Increased beat-to-beat variability in the fetal heart rate (FHR)
4. Nurse Venice is aware that one of the following is the most serious adverse effect associated with oxytocin (Pitocin) administration during labor?
a. Tetanic contractions
b. Elevated blood pressure
c. Early decelerations of fetal heart rate
d. Water intoxication
5. Nurse Olive asseses a client for evidence of postpartum hemorrhage during the third stage of labor. Early signs of this postpartum complication include:
a. an increased pulse rate, decreased respiratory rate, and increased blood pressure.
b. a decreased pulse rate, increased respiratory rate, and increased blood pressure.
c. a decreased pulse rate, decreased respiratory rate, and increased blood pressure.
d. an increased pulse rate, increased respiratory rate, and decreased blood pressure.
6. To promote comfort during labor, Nurse Michelle advises a client to assume certain positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia?
a. Lateral position
b. Squatting position
c. Supine position
d. Standing position
7. After delivering a neonate, a client delivers the placenta. At this time, where does nurse Adam expect to palpate the uterine fundus?
a. At the midline, 0.4″ to 0.8″ (1 to 2 cm) above the umbilicus
b. At the midline, 0.4″ to 0.8″ (1 to 2 cm) below the umbilicus
c. Left of the midline, 0.8″ to 1″ (2 to 3 cm) above the umbilicus
d. Left of the midline, 0.8″ to 1″ (2 to 3 cm) below the umbilicus
8. During the active phase of the first stage of labor, Maricris undergoes an amniotomy. After this procedure, which nursing diagnosis takes the highest priority?
a. Deficient knowledge related to amniotomy
b. Ineffective fetal cerebral tissue perfusion related to cord compression
c. Pain related to increasing strength of contractions
d. Risk for infection related to rupture of membranes
9. A client with active genital herpes is admitted to the labor and delivery area during the first stage of labor. Which type of birth should nurse Roy anticipate for this client?
a. Mid forceps
b. Low forceps
10. After a client enters the second stage of labor, nurse Blessy notes that her amniotic fluid is port-wine colored. What does this finding suggest?
a. Increased bloody show
b. Normal amniotic fluid
c. Abruptio placentae
11. Clariz arrives at the health care facility, stating that her bed linens were wet when she woke up this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor?
a. Active phase
b. Latent phase
c. Expulsive phase
d. Transitional phase
12. A client in labor tells April that she feels a strong urge to push. Physical examination reveals that her cervix is not completely dilated. The nurse-midwife tells her not to push yet. What is the rationale for this instruction?
a. Early pushing may cause edema and impede fetal descent.
b. The nurse-midwife isn’t ready to assist her.
c. The fetus hasn’t rotated into the proper position.
d. Pushing at this time may cause rupture of the membranes.
13. An assisted birth using forceps or a vacuum extractor may be performed for ineffective pushing, for large infants, to shorten the second stage of labor, or for a malpresentation. Nurse Sally is caring for the mother following an assisted birth should keep which of the following in mind?
a. A vacuum extractor is safer than forceps because it causes less trauma to the baby and the mother’s perineum.
b. The baby will develop a cephalohematoma as a result of the instrumentation.
c. The use of instruments during the birth process is a fairly rare occurrence.
d. Additional nursing interventions are needed to ensure an uncomplicated postpartum.
14. Nurse Divina is aware that the following would be an inappropriate indication of placental detachment?
a. An abrupt lengthening of the cord
b. An increase in the number of contractions
c. Relaxation of the uterus
d. Increased vaginal bleeding
15. When reviewing a fetal monitor strip, nurse Roy looks for reassuring and nonreassuring fetal heart rate (FHR) patterns. Which pattern is nonreassuring?
a. FHR that accelerates to baseline tachycardia
b. Baseline FHR that doesn’t increase
c. Variable FHR pattern that begins and ends abruptly
d. Short-term variability that doesn’t decrease
16. Nurse Adrian is aware that an expected fetal adverse reaction to meperidine (Demerol) during labor is:
a. decreased beat-to-beat variability.
c. late decelerations.
d. none known
17. During labor, Amy greatly relies on her husband for support. They previously attended childbirth education classes, and now he’s working with her on comfort measures. Which nursing diagnosis would be appropriate for this couple?
a. Ineffective family coping: Compromised related to labor
b. Readiness for enhanced family coping related to participation in pregnancy and delivery
c. Powerlessness related to pain
d. Ineffective role performance related to involvement with the pregnancy
18. Late in the first stage of labor, Olivia receives a spinal block to relieve discomfort. A short time later, her husband tells the nurse that his wife feels dizzy and is complaining of numbness around her lips. What do the client’s symptoms suggest?
a. Anesthesia overdose
b. Transition to the second stage of labor
19. Denice with intrauterine growth retardation is admitted to the labor and delivery unit and started on an I.V. infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her plan of care?
a. Carefully titrating the oxytocin based on her pattern of labor
b. Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes
c. Allowing the client to ambulate as tolerated
d. Helping the client use breathing exercises to manage her contractions
20. Lou is in the first stage of labor enters the labor and delivery area. She seems anxious and tells the nurse that she hasn’t attended childbirth education classes. Her husband, who accompanies her, is also unprepared for childbirth. Which nursing intervention would be most effective for the couple at this time?
a. Teach the client progressive muscle relaxation.
b. Instruct the husband on touch, massage, and breathing patterns.
c. Use hypnosis on the client and her husband.
d. Teach the client and her husband about pain transmission.
21. Which of the following physiologic changes during labor makes it necessary for nurse Hazel to assess blood pressure frequently?
a. Blood pressure decreases as a sign of maternal pain.
b. Alterations in cardiovascular function affect the fetus
c. Blood pressure decreases at the peak of each contraction.
d. Decreased blood pressure is the first sign of preeclampsia.
22. During the fourth stage of labor, Jessica should be assessed carefully for:
a. uterine atony
b. complete cervical dilation
c. placental expulsion
d. umbilical cord prolapse
23. Several minutes after a vaginal delivery, nursing assessment reveals blood gushing from the client’s vagina, umbilical cord lengthening, and a globular-shaped uterus. Nurse Luz should suspect which condition?
a. Cervical or vaginal laceration
b. Placental separation
c. Postpartum hemorrhage
d. Uterine involution
24. Nurse Mariane is caring for a client who’s in labor. The physician still isn’t present. After the baby’s head is delivered, which nursing intervention would be most appropriate?
a. Checking for the umbilical cord around the baby’s neck\
b. Placing antibiotic ointment in the baby’s eyes
c. Turning the baby’s head to the side to drain secretions
d. Assessing the baby for respirations
25. Vicky, who is in labor shouts to the nurse, “My baby is coming right now! I feel like I have to push!” An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate?
a. Gently pulling at the baby’s head as it’s delivered
b. Holding the baby’s head back until the physician arrives
c. Applying gentle pressure to the baby’s head as it’s delivered
d. Placing the mother in the Trendelenburg position until the physician arrives
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