Maternal/Newborn Test 2 NCLEX Questions

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PNLE B

10 terms Raf 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
• 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"
• "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
• 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
• 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
• Increase the frequency
• Increase the intensity
• Stop the contractions
• 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
• 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
• 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
• 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
• The presenting part has entered the true pelvis

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
• 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.
• Contractions are regular, becoming stronger and lasting longer.

The nurse is caring for a client who is 3 cm dilated and 80?faced, 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
• 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?faced, and the

presenting part is 5 cm above the ischial spine.

• The cervix is 5 cm dilated, 80?faced, and the

presenting part is 1 cm below the ischial spine.

• The cervix is 5 cm dilated, 80?faced, and the

presenting part is 1 cm above the ischial spine.

• The cervix is 5?faced, 80 cm dilated, and the

presenting part is 1 cm above the ischial spine.

• The cervix is 5 cm dilated, 80?faced, and the presenting part is 1 cm above

the ischial spine.The nurse is checking the client's chart and notes the abbreviation ROA. The nurse knows this means that the

presenting part is:

• Occiput. The fetal position is at the left side of the

maternal pelvis, occiput directed toward anterior (front) of passage.

• Occiput. The fetal position is at the right side of the

maternal pelvis, occiput directed toward anterior (front) of passage.

• Occiput. The fetal position is at the left side of the

maternal pelvis, occiput directed toward anterior (front) of passage.

• Occiput. The fetal position is at the right side of the

maternal pelvis, occiput transverse.

• Occiput. The fetal position is at the right side of the maternal pelvis, occiput

directed toward anterior (front) of passage.

The nurse is caring for a Mexican client during labor.Which of the following interventions should the nurse be prepared to perform?

• Ask the father to leave when client is ready to push.
• Ask the client if she needs pain medication while she is

in the 1st stage of labor.

• Ask the client if she needs pain medication when she

reaches the 2nd stage of labor.

• Ask the client if she needs pain medication when she

has reached 10 cm.

• Ask the client if she needs pain medication when she reaches the 2nd stage of

labor.You are caring for a client who delivered her baby by cesarean section 15 minutes ago and is in the recovery room. Her vital signs are stable but she is not yet awake.What is the nursing priority for this client?

• Deep breathing exercises
• Pain control
• Applying the sequential compression device
• Maintaining a patent airway
• Maintaining a patent airway

Precipitous labor can be defined as labor that lasts:

• More than 30 hours.
• Less than 10 hours.
• Less than 3 hours.
• Less than 5 hours.
• Less than 3 hours.

Your client has been in labor for 2 hours and suddenly states, "The baby is coming." What should be your first action?

• Give the client a dose of Demerol as ordered.
• Have the client use slow-paced breathing.
• Tell the client to calm down. She is not in labor.
• Check to see if the fetus is crowning.
• Check to see if the fetus is crowning.

Which of the following side effects can occur following the insertion of an epidural catheter?

• Tachycardia
• Hypertension
• Hypotension
• Drowsiness
• Hypotension

The nurse is caring for a client who is 4 days postpartum.The client states that her discharge has returned to a bright red color. What is the nurse's first action?

• Take the client's temperature.
• Notify the RN, obstetrician, or midwife.
• Do nothing; this is a normal finding.
• Prepare the sitz bath.
• Notify the RN, obstetrician, or midwife.