The laboring multigravida client's last vaginal examination was 8/90/+

Maternal NCLEX Practice Questions

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Question 1 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?

A. Encourage the client to push.

B. Notify the obstetrician or midwife.

C. Help the client to the bathroom.

D. Complete another vaginal exam.

Explanation: 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 2 of 5.

On the basis of the health history data, how should the nurse record the client's pregnancy status on the prenatal records?

A. Multipara

B. Primipara

C. Primigravida

D. Multigravida

Explanation: A primigravida is a woman pregnant for the first time, which matches the client's status of being possibly 2 months pregnant with no prior pregnancies.

Question 3 of 5.

Which assessment finding best represents a positive sign of pregnancy?

A. Palpable fetal outline

B. Blotchy tan facial skin

C. Positive pregnancy test

D. Fetal heartbeat

Explanation: A fetal heartbeat, detected by Doppler or ultrasound, is a positive sign of pregnancy, as it directly confirms the presence of a living fetus.

Question 4 of 5.

Before the pelvic examination, which intervention by the nurse is most appropriate?

A. Give the client an enema.

B. Instruct the client to urinate.

C. Shave the client's perineum.

D. Give the client a mild sedative.

Explanation: Instructing the client to urinate ensures a comfortable examination by emptying the bladder, which can interfere with pelvic assessment.

Question 5 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?

A. Weekly for the remainder of the pregnancy

B. Every 2 weeks for the remainder of the pregnancy

C. Every 2 weeks up to 36 weeks, then weekly for the last month

D. Weekly up to 36 weeks, then twice weekly for the last month

Explanation: Standard prenatal care involves monthly visits until 28 weeks, biweekly until 36 weeks, and weekly thereafter for uncomplicated pregnancies.