Maternity NCLEX Questions

Maternity NCLEX Questions Related

Review Maternity NCLEX Questions related questions and content

The nurse, admitting a 40-week primigravida to the labor unit, just documented the results of a recent vaginal exam: 3/100/—2, RSP. How should the oncoming shift nurse interpret this documentation?

  • A. The fetus is approximately 2 cm below maternal ischial spines.
  • B. The cervix is totally dilated and effaced, with fetal engagement.
  • C. The fetus is breech and posterior to the client’s pelvis.
  • D. The fetal lie is transverse, and the fetal attitude is flexion.
Correct Answer: C

Rationale: The nurse should interpret 3/100/—2, RSP as the cervix is 3 cm dilated, 100% effaced, and the fetus is 2 cm above the maternal ischial spines. RSP means that the fetus is to the right of the mother’s pelvis (R), with the sacrum as the specific presenting part (S), which is a breech position. This fetus is also posterior (P). At —2, the fetus is 2 cm above, not below, the maternal ischial spines. Two centimeters below the ischial spines would be recorded as +2. The cervix is 3 cm, not totally dilated. Total dilation would be documented as 10 for the first number. Also, the cervix is 100% effaced, which is total effacement (shortening and thinning out). Fetal lie (relationship of long axis or spine of fetus to long axis of mother) is longitudinal, not transverse. The documentation does not specify if the fetal attitude is flexion.

You may also like to solve these questions

Which of the following is most indicative of the presence of hydatidiform mole?

  • A. A blotchy brown discoloration on the face
  • B. A positive Chadwick's sign
  • C. The presence of ballottement
  • D. A uterus that is larger than expected
Correct Answer: D

Rationale: A uterus larger than expected for gestational age is characteristic of hydatidiform mole, a gestational trophoblastic disease.

The nurse teaches the client to recognize which early labor sign?

  • A. Bloody show
  • B. Fatigue
  • C. Increased appetite
  • D. Mild nausea
Correct Answer: A

Rationale: Bloody show, a mucous discharge tinged with blood, is a common early labor sign as the cervix begins to dilate.

During the first postpartum checkup, the nurse is assessing whether the client’s chloasma has diminished. At which anatomical location is the nurse performing the assessment?

  • A. Perineum
  • B. Abdomen
  • C. Breasts
  • D. Face
Correct Answer: D

Rationale: Chloasma does not appear on the perineum. Chloasma does not appear on the abdomen. Chloasma does not appear on the breasts. The nurse should be assessing the skin over the cheeks, nose, and forehead for chloasma.

The nurse correctly explains that fertilization usually takes place in which structure?

  • A. Fallopian tube
  • B. Ovary
  • C. Uterus
  • D. Vagina
Correct Answer: A

Rationale: Fertilization typically occurs in the fallopian tube, where the sperm meets the ovum after ovulation.

The postpartum client delivered a healthy newborn 36 hours previously. The nurse finds the client crying and asks what is wrong. The client replies, “Nothing, really. I’m not in pain or anything, but I just seem to cry a lot for no reason.” What should be the nurse’s first intervention?

  • A. Call the client’s support person to come and sit with her.
  • B. Remind her that she has a healthy baby and that she shouldn’t be crying.
  • C. Contact the HCP to have the counselor come see the client.
  • D. Ask the client to discuss her birth experience.
Correct Answer: D

Rationale: The client’s support person should be given information about postpartum blues before the client is discharged from the hospital. However, contacting that individual should not be the first intervention. Reminding the client that she has a healthy baby is a nontherapeutic communication technique that implies disapproval of the client’s actions. There is no need to notify the HCP, as postpartum blues is a common self-limiting postpartum occurrence. A key feature of postpartum blues is episodic tearfulness without an identifiable reason. Interventions for postpartum blues include allowing the client to relive her birth experience.

Copyright © 2025 Nokea. All rights reserved.