The primigravida client has been pushing for 2 hours when the infant's

Maternal NCLEX Practice Questions

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Question 1 of 5.

The primigravida client has been pushing for 2 hours when the infant's head emerges. The infant fails to deliver, and the obstetrician states that the turtle sign has occurred. Which should be the nurse's interpretation of this information?

A. There is cephalopelvic disproportion.

B. The infant has a shoulder dystocia.

C. The infant's position is occiput posterior.

D. The infant's umbilical cord is prolapsed.

Explanation: The â€œturtle signâ€ occurs when the infant's head suddenly retracts back against the mother's perineum after emerging from the vagina, resembling a turtle pulling its head back into its shell. This head retraction is caused by the infant's anterior shoulder being caught on the back of the maternal pubic bone (shoulder dystocia), preventing delivery of the remainder of the infant. Cephalopelvic disproportion occurs when the head is too large to fit through the client's pelvis. Fetal descent ceases, and infant's head would not emerge. Persistent occiput posterior results in prolonged pushing; however, once the head is born, the remainder of the birth occurs without difficulty. A cord prolapse occurs when the umbilical cord enters the cervix before the fetal presenting part and is considered a medical emergency.

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.