Maternity NCLEX Questions
Home / Nursing & Allied Health Certifications / NCLEX PN / Maternity
Question 1 of 5.
The nurse, admitting a 40-week primigravida to the labor unit, just documented the results of a recent vaginal exam: 3/100/—2, RSP. How should the oncoming shift nurse interpret this documentation?
A. The fetus is approximately 2 cm below maternal ischial spines.
B. The cervix is totally dilated and effaced, with fetal engagement.
C. The fetus is breech and posterior to the client's pelvis.
D. The fetal lie is transverse, and the fetal attitude is flexion.
Explanation: The nurse should interpret 3/100/—2, RSP as the cervix is 3 cm dilated, 100% effaced, and the fetus is 2 cm above the maternal ischial spines. RSP means that the fetus is to the right of the mother's pelvis (R), with the sacrum as the specific presenting part (S), which is a breech position. This fetus is also posterior (P). At —2, the fetus is 2 cm above, not below, the maternal ischial spines. Two centimeters below the ischial spines would be recorded as +2. The cervix is 3 cm, not totally dilated. Total dilation would be documented as 10 for the first number. Also, the cervix is 100% effaced, which is total effacement (shortening and thinning out). Fetal lie (relationship of long axis or spine of fetus to long axis of mother) is longitudinal, not transverse. The documentation does not specify if the fetal attitude is flexion.
Question 2 of 5.
The nurse correctly explains that fertilization usually takes place in which structure?
A. Fallopian tube
B. Ovary
C. Uterus
D. Vagina
Explanation: Fertilization typically occurs in the fallopian tube, where the sperm meets the ovum after ovulation.
Question 3 of 5.
If the client reports the following signs and symptoms, which one represents a probable sign of pregnancy?
A. Absence of monthly periods
B. Abdominal enlargement
C. Nausea and vomiting
D. Frequent urination
Explanation: Abdominal enlargement is a probable sign of pregnancy, as it is more objective and indicative of uterine growth.
Question 4 of 5.
On the basis of the client's statement, what can the nurse conclude?
A. The client is having twins.
B. The client is between 14 and 18 weeks' gestation.
C. The client is in the first trimester.
D. The client's due date will be difficult to calculate.
Explanation: Fetal movement in a multigravida is typically felt earlier, around 14-18 weeks, aligning with the client's report.
Question 5 of 5.
How early in a pregnancy can the nurse expect to hear the fetal heartbeat using a Doppler device?
A. 4 to 6 weeks
B. 8 to 10 weeks
C. 12 to 14 weeks
D. 16 to 18 weeks
Explanation: A fetal heartbeat can typically be detected by Doppler around 12-14 weeks, when the fetus is sufficiently developed.
Related Questions