The nurse is caring for the client who has been in the second stage of

Maternity NCLEX Questions

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Question 1 of 5.

The nurse is caring for the client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during this stage of labor?

A. An increase in maternal heart rate

B. A decrease in the cardiac output

C. An increase in the white blood cell (WBC) count

D. A decreased intravascular volume during contractions

Explanation: Maternal HR is normally increased due to pain resulting from increased catecholamine secretion, fear, anxiety, and increased blood volume. When the laboring client holds her breath and pushes against a closed glottis, intrathoracic pressure rises. Blood in the lungs is forced into the left atrium, leading to a transient increase (not decrease) in cardiac output. Although the WBCS increase to 25,000/mm3 to 30,000/mm3 during labor and early postpartum as a physiological response to stress, this is not a cardiovascular change. During the second stage of labor, the maternal intravascular volume is increased (not decreased) by 300 to 500 mL of blood from the contracting uterus.

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.