The nurse observes on the monitor tracing of the client in the transit

Free NCLEX Maternity Questions

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Question 1 of 5.

The nurse observes on the monitor tracing of the client in the transition phase of labor that the baseline FHR is 160 and that there is moderate variability with V-shaped decelerations unrelated to contractions. What should the nurse do first?

A. Prepare for delivery.

B. Notify the obstetrician.

C. Apply oxygen nasally.

D. Reposition the client.

Explanation: Repositioning the client to her side or to knee-chest should be done first to take the pressure off the umbilical cord. Variable decelerations usually result from cord compression and stretching during fetal descent. The fetus has a normal baseline HR and good variability. There is no indication that immediate delivery is necessary. Other measures could correct the V-shaped (variable) decelerations. Other nursing measures are used to correct the V-shaped (variable) decelerations prior to contacting the obstetrician (or midwife). Repositioning the client should be implemented prior to giving her oxygen.

Question 2 of 5.

To improve sperm production, the nurse should instruct the client's husband to avoid which activities? Select all that apply.

A. Swimming in chlorinated water

B. Sitting in hot tubs

C. Wearing boxer shorts

D. Wearing colored underwear

E. Smoking cigarettes

F. Refraining from strenuous exercise

Explanation: High temperatures from hot tubs can impair sperm production by overheating the testes. Smoking cigarettes negatively affects sperm quality and quantity.

Question 3 of 5.

Which response by the nurse about Chadwick's sign is most accurate?

A. It's a bluish discoloration of the cervix, vagina, and vulva that occurs as a result of the presence of an increased number of blood vessels.

B. It's a softening of the cervix that occurs because of an increased amount of blood flowing to the reproductive organs.

C. It's a dark brown line extending from the umbilicus to the symphysis pubis that occurs as a result of hormonal changes.

D. None of the above

Explanation: Chadwick's sign is the bluish discoloration of the cervix, vagina, and vulva due to increased vascularity, a probable sign of pregnancy.

Question 4 of 5.

Using Naegele's Rule, the nurse can assume the client's expected delivery date to be approximately which date?

A. 13-Nov

B. 23-Nov

C. 3-Dec

D. 20-Dec

Explanation: Naegele's Rule: Subtract 3 months from the first day of the last menstrual period (March 13) and add 7 days, resulting in December 3.

Question 5 of 5.

Which fetal heart rate must the nurse report immediately to the physician?

A. 100 beats/minute

B. 120 beats/minute

C. 140 beats/minute

D. 160 beats/minute

Explanation: A fetal heart rate of 100 beats/minute is below the normal range (110-160 bpm) and may indicate fetal distress, requiring immediate reporting.