NCLEX Maternity Questions
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Question 1 of 5.
The nurse is caring for the low-risk laboring client during the first stage of labor. When should the nurse assess the FHR pattern? Select all that apply.
A. Before administering medications
B. At least every fifteen minutes
C. After vaginal examinations
D. During a hard contraction
E. When giving oxytocin
Explanation: The FHR may be affected by medications given to the mother. Therefore, a baseline FHR should be determined before giving any medication to the laboring client and then assessed again after giving the medication. The FHR should be assessed after each vaginal examination because the fetus could change positions, or be stressed by the intrusion of the examiner's fingers, or intact membranes could have ruptured. The FHR should be assessed every 30 minutes (not 15 minutes) during the first stage of labor if the client is categorized as low risk. The FHR should be assessed every 15 minutes during the second stage of labor. Although the FHR could be listened to during a contraction, it may be difficult due to muffling of the sounds and maternal movement. It is most important to listen before and after the contraction to more accurately detect FHR decelerations. If the client is classified as low risk, she should not be receiving oxytocin (Pitocin) for labor augmentation or induction.
Question 2 of 5.
When the client asks the nurse about the viability of the ovum after ovulation, the nurse correctly explains that after ovulation, the ovum remains alive for how many hours?
A. 2 hours
B. 24 hours
C. 48 hours
D. 72 hours
Explanation: The ovum remains viable for approximately 24 hours after ovulation, during which it can be fertilized by sperm.
Question 3 of 5.
The nurse correctly sends a requisition and specimen for which laboratory test?
A. Alpha-fetoprotein (AFP)
B. Corticotropin-releasing hormone (CRH)
C. Human chorionic gonadotropin (hCG)
D. Follicle-stimulating hormone (FSH)
Explanation: Human chorionic gonadotropin (hCG) is the hormone tested to confirm pregnancy, as it is produced by the placenta shortly after implantation.
Question 4 of 5.
According to the TPAL method, which of the following reflects the client's obstetric history?
A. T-III, P-0, A-0, L-III
B. T-III, P-II, A-0, L-0
C. T-III, P-II, A-0, L-II
D. T-III, P-0, A-0, L-III
Explanation: TPAL: Term (3, one son and twin daughters), Preterm (0), Abortions (0), Living (3). The client has three term deliveries and three living children.
Question 5 of 5.
Which action by the nurse best ensures that an accurate fetal heart rate is obtained?
A. Assess the fetal heart rate when the client is lying on her right side.
B. Assess the fetal heart rate when the client reports fetal movement.
C. Assess the fetal heart rate between Braxton Hicks contractions.
D. Assess the maternal pulse and fetal heart rate, and compare the two.
Explanation: Comparing maternal pulse with fetal heart rate ensures the nurse is not mistaking the maternal pulse for the fetal heartbeat.
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