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NCLEX RN· RN Maternity · NCLEX RN Practice Questions Maternity

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which of the following is a priority nursing diagnosis?

A. Impaired urinary elimination related to nothing-by-mouth status.
B. Risk for injury related to hyperventilation and dizziness.
C. Ineffective coping related to lack of confidence.
D. Pain related to increasing frequency and intensity of uterine contractions.

Expert Explanatory Rationale

Correct Answer: Pain related to increasing frequency and intensity of uterine contractions.

Question 2 of 5

At a home visit, the nurse assesses a neonate delivered vaginally at 41 weeks' gestation 5 days ago, noting the following findings: frequent hiccups; loose, watery stool in diaper; red rash on face; and dry, peeling skin; which of these findings warrants further assessment?

A. Frequent hiccups.
B. Loose, watery stool in diaper.
C. Pink papular vesicles on the face.
D. Dry, peeling skin.

Expert Explanatory Rationale

Correct Answer: Loose, watery stool in diaper.

Question 3 of 5

Initial assessment of a term female neonate about 4 hours old reveals a normal anterior fontanel. The nurse documents its shape as which of the following?

A. Oval.
B. Square.
C. Diamond shaped.
D. Triangular.

Expert Explanatory Rationale

Correct Answer: Diamond shaped.

Question 4 of 5

A client at 4 weeks postpartum tells the nurse that she can't cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider because the mother should be evaluated further for?

A. Postpartum blues.
B. Postpartum depression.
C. Poor bonding.
D. Infant abuse.

Expert Explanatory Rationale

Correct Answer: Postpartum depression.

Question 5 of 5

A multigravid client at 38 weeks' gestation, G4 P3, is 6 cm dilated with contractions every 3 minutes. The nurse observes meconium-stained amniotic fluid after spontaneous rupture of membranes. What is the priority nursing action?

A. Prepare for immediate cesarean delivery.
B. Assess the fetal heart rate pattern.
C. Suction the client's oropharynx.
D. Document the fluid characteristics.

Expert Explanatory Rationale

Correct Answer: Assess the fetal heart rate pattern.

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