Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 52

1. The physician is preparing to induce labor on a 40-week multigravida. The nurse should anticipate the administration of:

A) Oxytocin (Pitocin)
B) Progesterone
C) Vasopressin (Pitressin)
D) Ergonovine maleate

2. A primigravida is at term. The nurse can recognize the second stage of labor by the client - s desire to:

A) Push during contractions
B) Hyperventilate during contractions
C) Walk between contractions
D) Relax during contractions

3. A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:

A) Fourth stage of labor
B) Third stage of labor
C) Transition stage of labor
D) Second stage of labor

4. A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:

A) Assess the client - s respirations
B) Notify the physician
C) Auscultate fetal heart rate
D) Transfer to delivery suite

5. A pregnant client experiences a precipitous delivery. The nursing action during a precipitous delivery is to:

A) Control the delivery by guiding expulsion of fetus
B) Leave the room to call the physician
C) Push against the perineum to stop delivery
D) Cross client - s legs tightly

1. Right Answer: A
Explanation: (A) Oxytocin is a hormone secreted by the neurohypophysis during suckling and parturition that produces strong uterine contractions. (B) Progesterone has a quiescence effect on the uterus. (C) Vasopressin is an antidiuretic hormone that promotes water reabsorption by the renal tubules. (D) Ergonovine produces dystocia as a result of sustained uterine contractions.

2. Right Answer: A
Explanation: (A) The second stage of labor is characterized by uterine contractions, which cause the client to bear down. (B) Slow, deep, rhythmic breathing facilitates the laboring process. Hyperventilation is abnormal breathing resulting from loss of pain control. (C) The client should remain on bed rest during labor. (D) Contractions result in discomfort.

3. Right Answer: C
Explanation: (A) The fourth stage begins after expulsion of the placenta. Client symptoms are: fatigue; chills; scant, bloody vaginal discharge; and nausea. (B) The third stage is from birth to expulsion of placenta. Client symptoms are uterine contractions, gush of blood, and perineal pain. (C) The transition stage is characterized by strong uterine contractions and cervical dilation. Clientsymptoms are irritability, restlessness, belching, muscle tremors, nausea, and vomiting. (D) The second stage is characterized by full dilation of cervix. Client symptoms are perineal bulge, pushing with contractions, great irritability, and leg cramps.

4. Right Answer: C
Explanation: (A) Immediately following membrane rupture, the fetus is at risk for complications, not necessarily the mother. (B) The physician is notified after the nurse completes an assessment of the mothers and fetuss conditions. (C) Rupture of membranes facilitates fetal descent. A potential complication is cord prolapse, which is assessed by auscultating fetal heart rate. (D) Rupture of membranes does not necessarily indicate readiness to deliver.

5. Right Answer: A
Explanation: (A) Controlling the rapid delivery will reduce the risk of fetal injury and perineal lacerations. (B) The nurse should always remain with a client experiencing a precipitous delivery. (C) Pushing against the perineum may cause fetal distress. (D) Crossing of legs may cause fetal distress and does not stop the delivery process.

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