NCLEX Question of The Day (Maternity) 36th Edition

NCLEX Question of The Day (Maternity) 36th Edition

1. A nurse is monitoring a client who is receiving oxytocin (Pitocin) to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which of the following is noted?

A. Contractions occurring every 3 minutes
B. Fetal tachycardia
C. Soft uterine tone palpated between contractions
D. Increased urinary output

Answer: B. Fetal tachycardia

Rationale: Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia from excessive uterine activity. The nurse should also assure that the uterus maintains an adequate resting tone between contractions. Options 1, 3, and 4 are not indications of a problem.

Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. Option 2 is the only option that indicates a problem with circulation. Review care to the client receiving an infusion of oxytocin if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 245.

2. A nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin (Pitocin). The nurse suggests including which of the following in the plan of care?

A. Maintain complete bed rest
B. Notify the neonatal resuscitation team
C. Administer antibiotics
D. Maintain continuous electronic fetal monitoring

Answer: D. Maintain continuous electronic fetal monitoring

Rationale: Maternal and fetal well-being is monitored before and during oxytocin administration including fetal heart rate, uterine contractions and tone, and maternal blood pressure. There are no data in the question that indicate the presence of maternal or fetal complications that would require antibiotics, complete bed rest, or notifying the neonatal resuscitation team.

Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. This will direct you to option D. Review care to the client receiving an infusion of oxytocin if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 245.

3. A client arrives at the birthing center in active labor. Her membranes are still intact, and the nurse-midwife performs an amniotomy. The nurse explains to the client that after this procedure, she will most likely have:

A. Less pressure on her cervix
B. Increased efficiency of contractions
C. Decreased number of contractions
D. The need for increased blood pressure (BP) monitoring

Answer: B. Increased efficiency of contractions

Rationale: Rupturing of membranes, if they do not rupture spontaneously, allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Rupturing of the membranes does not require the need for increased monitoring of the BP.

Test-Taking Strategy: Note the key words most likely. Recalling the purpose and effects of amniotomy will direct you to the correct option. If you had difficulty with this question, review the purpose of this procedure.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 176-177.

4. A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs:

A. General anesthesia
B. To push with her contractions
C. To be left totally alone
D. To regain her breathing pattern

Answer: D. To regain her breathing pattern

Rationale: When the woman enters this phase of labor, her anxiety level tends to increase as she senses the fairly constant intensification of contractions and pain. The client may need help regaining focus and her breathing pattern. General anesthesia is not needed in this situation. The nurse encourages the woman to refrain from pushing until the cervix is completely dilated. The client may be terrified of being left alone during this phase of labor.

Test-Taking Strategy: Focus on the issue of the question. Note the relation between the words “hyperventilates” in the question and “breathing pattern” in the correct option. Review care to the client in the transition stage of labor if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 145.

5. A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, “I don’t need the cesarean section after all because I think my baby has moved around.” The appropriate response by the nurse is which of the following?

A. “Tell me what you mean when you say that your baby has moved.”
B. “That would be impossible because babies don’t move around this late.”
C. “The physician is all set to go and cannot change plans now.”
D. “You need to listen to your obstetrician; the physician knows what he is doing.”

Answer: A. “Tell me what you mean when you say that your baby has moved.”

Rationale: Anxiety is an expected and normal reaction to surgery and within limits is functional. The nurse should remain with the client and let the client express her fears and concerns. Option 1 encourages the client to express concerns because it uses the therapeutic communication tool of paraphrasing that validates and clarifies. Options 2, 3, and 4 do not, and are blocks to communication.

Test-Taking Strategy: Use therapeutic communication techniques. Option 1 most directly relates to the comment made by the client. Always select a response that encourages the client to express concerns. Review therapeutic communication techniques if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Maternity/Intrapartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 30-31.

Source : NCLEX example quiz and answer

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