The nurse is caring for the pregnant client whose FHR tracing reveals

Maternal NCLEX Practice Questions

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Question 1 of 5.

The nurse is caring for the pregnant client whose FHR tracing reveals a reduction in variability over the last 40 minutes. The client has had occasional decelerations after the onset of a contraction that did not resolve until the contraction was over. The client suddenly has a prolonged deceleration that does not resolve, and the nurse immediately intervenes by calling for assistance. Place the nurse's interventions in the sequence that they should occur.

A. Administer oxygen via facemask
B. Have the HCP paged if the prolonged decelerations have not resolved.
C. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the heart rate remains low.
D. Increase the rate of the intravenous (IV) fluids
E. Assist the client into a different position
F. Prepare for a vaginal examination and fetal scalp stimulation

Correct arrangement

E. Assist the client into a different position
A. Administer oxygen via facemask
D. Increase the rate of the intravenous (IV) fluids
B. Have the HCP paged if the prolonged decelerations have not resolved.
F. Prepare for a vaginal examination and fetal scalp stimulation
C. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the heart rate remains low.

Explanation: Assist the client into a different position should be first. Repositioning is an attempt to increase the FHR in case of cord obstruction. Administer oxygen via facemask is next to increase oxygenation to the fetus. Increase the rate of the IV fluids next to treat possible hypotension, the most common cause of fetal bradycardia. Have the HCP paged if the prolonged decelerations have not resolved. The immediate focus should be on attempting to relieve the prolonged decelerations. Prepare for a vaginal examination and fetal scalp stimulation. This is performed to rule out cord prolapse and to provide stimulation to the fetal head. Place an indwelling urinary catheter in anticipation of emergency cesarean birth if the HR remains low.

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.