MaternalNewborn Test 2 NCLEX Questions

Maternal/Newborn Test 2 NCLEX Questions 2024/25 Based on the hormonal theory of labor, the nurse anticipates a rise in which of the following to begin a chain of hormonal events that cause labor?

• Cortisol
• Oxytocin
• Progesterone
• Estrogen - ANSWER A. Cortisol

The nurse would recognize that the client has experienced lightening when the pregnant woman

reports:

• "I can breath much better"
• "My ankles are less swollen"
• "I don't have to urinate as often now"
• "My lower back pain has been relieved" - ANSWER A. "I can breath

much better" Fetus has descended into pelvis, relieving pressure on diaphragm The primary nurse performs a vaginal examination and finds a prolapsed cord. The nurses

priority action will be to:

• Give medication to hasten a vaginal delivery
• Keep the client in a back-lying position
• Make arrangements for an emergency cesarean section
• Get the cord back to its original location - ANSWER C. Make

arrangements for an emergency cesarean section Position client to take pressure off cord while awaiting surgery When the fetus is found to be in a vertex presentation, the nurse anticipates the presenting fetal

part will be the:

• Forehead
• Face
• Buttocks
• Occiput - ANSWER D. Occiput

A nurse is caring for a client in labor who complains of feeling faint. The nurse turns the client onto her side in order to have what effect on contractions?

• Little or no effect 1 / 3

• Increase the frequency
• Increase the intensity
• Stop the contractions - ANSWER C. Increase the intensity

Also less frequent The nurse recognizes that the client is in latent phase of the first stage of Labor. This phase is

best described as lasting from:

• Undilated cervix to a 2cm dilation
• Onset of contractions to 4cm
• Cervix is dilated 4cm to dilation of 8cm
• No contraction to contractions every 3 minutes - ANSWER B. Onset

of contractions to 4cm The nurse, working on a labor and delivery unit, anticipates active labor for a primagravida will last how long?

• 16-18h
• 12-14h
• 8-10h
• 4-6h - ANSWER D. 4-6h

A client is in the transition phase of labor irritably tells the nurse not to touch her. The nurses

best action would be to:

• Ask for someone else to support the client
• Tell the client to be cooperative and do as you say
• Remind the client to focus on relaxation and breathing
• Ask the client to push actively with each contraction - ANSWER C.

Remind the client to focus on relaxation and breathing The student nurse asks the primary nurse to explain what the obstetrician meant when telling the client that engagement has occurred. The primary nurses best response would be to explain that:

• The fetus has now become ballotable
• The presenting part has entered the true pelvis
• The presenting part is just above the Ischial spine
• There is now observable crowning - ANSWER B. The presenting

part has entered the true pelvis 2 / 3

While caring for the client in the fourth stage of labor the nurse discovers that the client has saturated two perineal pads during the first hour. What is the nurses priority action?

• Notify the primary nurse immediately
• Assure the client that this is normal
• Put the client on the bedpan to void
• Start a count of the pads and chart it - ANSWER A. Notify the

primary nurse immediately Any bleeding in excess of one pad per hour is abnormal The nurse admits a client who suspects she is in labor to the labor and delivery unit. Which of the following characteristics would indicate the client is in true labor?

• Contractions are regular, becoming stronger and lasting longer.
• Cervix shows no significant change.
• Contractions stop when the client is ambulating.
• Contractions are irregular. - ANSWER A. Contractions are regular,

becoming stronger and lasting longer.The nurse is caring for a client who is 3 cm dilated and 80% effaced, with her fetus at -1 station.The client states she is beginning to experience discomfort with each contraction. Which of the following breathing techniques would be appropriate?

• Cleansing breath
• Slow-paced breathing
• Patterned-paced breathing
• Modified-paced breathing - ANSWER B. Slow-paced breathing

The following data have been recorded on the client's chart: 5/80/+1. How does the nurse interpret this data?

• The cervix is 5 cm dilated, 80% effaced, and the presenting part is 5 cm above the ischial

spine.

• The cervix is 5 cm dilated, 80% effaced, and the presenting part is 1 cm below the ischial

spine.

• The cervix is 5 cm dilated, 80% effaced, and the presenting part is 1 cm above the ischial

spine.

• The cervix is 5% effaced, 80 cm dilated, and the presenting part is 1 cm above the ischial

spine. - ANSWER C. The cervix is 5 cm dilated, 80% effaced, and the presenting part is 1 cm above the ischial spine.

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