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NCLEX RN Quiz of The Day (Maternity Quiz) 38th Edition 2019 / 2020 / 2021
1. A nurse prepares to explain the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage:
A. Is a form of biofeedback to enhance bearing down efforts during delivery
B. Is light stroking of the abdomen to facilitate relaxation during labor
C. Is the application of pressure to the sacrum to relieve a backache
D. Stimulates uterine activity by contracting a specific muscle group while other parts of the body rest
Answer: B. Is light stroking of the abdomen to facilitate relaxation during labor
Rationale: Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Options 1, 3, and 4 are incorrect descriptions.
Test-Taking Strategy: Use the process of elimination. Eliminate option 1 because the focus during delivery is the client. Option 4 focuses on promotion of uterine activity rather than relaxation. Eliminate option 3 because not all labor clients experience backache. Remember, all methods of childbirth preparation promote relaxation and enhance client coping with the event. Review the components of effleurage if you had difficulty with this question.
Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 65.
2. A client asks, “What does it mean that the baby is at minus one?” After providing information, the nurse determines client understanding if the client states the fetal presenting part is isolated:
A. 1 cm above the ischial spines
B. 1 finger breadth below the symphysis pubis
C. 1 inch below the coccyx
D. 1 inch below the iliac crest
Answer: A. 1 cm above the ischial spines
Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. Options 2, 3, and 4 are incorrect.
Test-Taking Strategy: Use the process of elimination. The question requires you to know that station is measured in centimeters and uses the ischial spines as a reference point. Only option 1 incorporates this information. Also, options 2, 3, and 4 are similar in the use of the word “below,” which would be represented by a positive measurement in determining station. Review station 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. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 87.
3. A nurse assisting to monitor a client in labor is told that the client’s cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client’s psychological status, the nurse anticipates the client to reflect an attitude of:
A. Excitement
B. Helplessness
C. Irritability
D. Seriousness
Answer: A. Excitement
Rationale: In the late phase of the second stage of labor, contractions are usually mild. The woman feels able to cope with the discomfort and may be relieved that labor has begun. Excitement is high about the impending birth. Options 2, 3, and 4 represent psychological states often noted late in labor when discomfort and fatigue are greater and coping ability may be reduced.
Test-Taking Strategy: Use the process of elimination. The question requires you to understand the usual psychological state of the client in the second stage of labor. Note that option 1 is different from the other options in that it reflects a positive view characteristic of the second stage of labor, when coping is adequate and discomfort is mild. Review the psychosocial responses to labor if you had difficulty with this question.
Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 145-146.
4. A nurse observes that the client in the second stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as:
A. Exhaustion
B. Fear of losing control
C. Involuntary grunting
D. Valsalva maneuver
Answer: B. Fear of losing control
Rationale: Pains, helplessness, and fear of losing control are possible client responses in the second stage of labor. Whimpering, high-pitched cries, and crying out in pain are indicative of losing control, while low-pitched grunting sounds usually indicate a woman is working effectively with contractions.
Test-Taking Strategy: Use the process of elimination. Note that options 1, 3, and 4 identify similar psychological responses. If you are unfamiliar with the psychological responses that occur in the second stage of labor, review this content.
Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 146.
5. A pregnant client has been pushing effectively for 1 hour, and the presenting part is at a +2 station. The nurse determines that the client’s primary physiological need at this time is:
A. Change in position
B. Intravenous analgesia
C. Oral food and fluids
D. Rest between contractions
Answer: D. Rest between contractions
Rationale: The birth process expends a great deal of energy. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion is also enhanced, which enhances fetal tolerance of the stress of labor. There are no data in the question to indicate that option 1 is necessary. Option 2 is incorrect because this action would likely cause central nervous system depression in the infant. Option 3 is incorrect because food and fluids are likely withheld at this time, except for ice chips.
Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Recalling that the need to conserve energy is important will direct you to option D. Review care to the client in labor if you had difficulty with this question.
Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum References:
Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 145.
Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 584.
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