Review Questions for the NCLEX® Examination

1. A 23-year-old primigravida arrives at the labor unit in early labor. Which assessment finding indicates that labor has begun?

• • 1. Decreased vaginal secretions
  • 2. Weight gain of 1 to 3 lb
  • 3. Bloody show
  • 4. Increased fetal movement
• 2. To determine fetal lie, presentation, and position, the caregiver uses which assessment technique?
  • 1. Abdominal ultrasound scan
  • 2. Fetal heart tone auscultation
  • 3. Palpation of contractions
  • 4. Leopold’s maneuvers
• 3. The fetal position is ROA. Where is the fetal presenting part in relation to the maternal pelvis?
  • 1. The occiput is facing the right side and the front of the maternal pelvis.
  • 2. The mentum is facing the right side and the front of the maternal pelvis.
  • 3. The occiput is facing the left side and the back of the maternal pelvis.
  • 4. The sacrum is facing the right side and the front of the maternal pelvis.
• 4. To assess the frequency of regular labor contractions, what should the nurse record?
  • 1. The interval between the peaks of the contractions
  • 2. The start of one contraction to the start of the next
  • 3. The end of one contraction to the start of the next
  • 4. How many contractions she has in 15 minutes.
• 5. A pregnant woman is attending childbirth classes. She asks the nurse teaching the class when she would have an internal fetal monitor applied. What is the best nursing response?
  • 1. “Because you have had a low-risk pregnancy, you are not considered a candidate for internal monitoring.”
  • 2. “Your health care provider decides when to apply the internal monitor.”
  • 3. “Your cervix must be 2 to 3 cm dilated and your membranes ruptured before an internal monitor can be applied.”
  • 4. “We can apply the internal monitor at any time after your membranes rupture.”
• 6. A woman tells the nurse she thinks her membranes have ruptured. What action by the nurse best validates rupture of membranes?
  • 1. Feeling the draw sheet for wetness
  • 2. Performing a nitrazine test
  • 3. Inserting a Foley catheter into the bladder
  • 4. Having the patient cough
• 7. A woman has progressed through her labor without difficulty. However, the fetal heart rate has been decreasing with each contraction for the past 15 minutes. The rate decreases from 150 to 125 bpm after the peak of the contraction and returns to 150 bpm 15 seconds after the contraction is finished. What phenomena do the clinical manifestations most support?
  • 1. Variable decelerations.
  • 2. Early decelerations.
  • 3. Late decelerations.
  • 4. Combination decelerations.
• 8. When the woman enters the transition phase to active labor, which behaviors should the nurse expect to see?
  • 1. A desire for personal contact and touch
  • 2. Sleepiness and quietness, with a desire for touch
  • 3. Responsiveness to teaching
  • 4. Irritability, resistance to touch, withdrawal
• 9. As the woman’s labor progresses, which assessment finding indicates that the second stage of labor has begun?
  • 1. Passage of a mucous plug
  • 2. Bearing-down reflex
  • 3. Dilation of the cervix to 7 cm
  • 4. Change in shape of the uterus
• 10. The nurse has just reviewed the fetal heart rate on an assigned laboring patient. What finding indicates the need to notify the charge nurse?
  • 1. Accelerations
  • 2. Early decelerations
  • 3. Average FHR of 126 bpm
  • 4. Late decelerations
• 11. Which maternal cardiovascular finding is expected during labor?
  • 1. Increased cardiac output
  • 2. Increased pulse rate
  • 3. Decreased white blood cell count
  • 4. Decreased blood pressure
• 12. The nurse notes accelerations with fetal movement. The nurse correctly recognizes that heart accelerations most commonly:
  • 1. Are reassuring.
  • 2. Are caused by umbilical cord compression.
  • 3. Warrant close observation.
  • 4. Are caused by uteroplacental insufficiency.
• 13. The patient delivers an 8-lb, 1-oz boy. Ten minutes later, there is a sudden gush of blood from her vagina. At the same time, the woman’s uterus becomes globular in shape and the umbilical cord lengthens. What do these findings most likely indicate?
  • 1. Separation of the placenta
  • 2. Uterine hemorrhage
  • 3. Cervical or vaginal laceration
  • 4. Uterine involution
• 14. A woman pregnant for the first time is dilated 3 cm, with contractions every 5 minutes. She is groaning and perspiring excessively and states that she did not attend childbirth classes. What is the most important nursing action?
  • 1. Notify the woman’s health care provider.
  • 2. Administer the prescribed narcotic analgesic.
  • 3. Ensure that her labor will be overseen.
  • 4. Give simple breathing and relaxation instructions.
• 15. When planning care for a woman whose membranes have ruptured, the nurse recognizes that the woman’s risk for what has increased?
  • 1. Intrauterine infection
  • 2. Hemorrhage
  • 3. Precipitous labor
  • 4. Supine hypotension
• 16. The nurse is caring for a patient in labor who has had meperidine (Demerol) for pain relief. Which side effects are commonly associated with this drug? (Select all that apply.)
  • 1. Dry mouth
  • 2. Tachycardia
  • 3. Bradycardia
  • 4. Pruritus
  • 5. Tachypnea
• 17. The nurse is preparing a patient for a scheduled cesarean section. The nurse will administer medications to reduce gastric acidity. Which medications may be used? (Select all that apply.)
  • 1. Sodium citrate (Bicitra)
  • 2. Ranitidine (Zantac)
  • 3. Cimetidine (Tagamet)
  • 4. Famotidine (Pepcid)
  • 5. Glycopyrrolate (Robinul)

True Labor or False Labor

Identify each of these as true labor (TL) or false labor (FL).

• 18. _____ Contractions rarely follow a pattern.
• 19. _____ Contractions frequently stop with ambulation or position change.
• 20. _____ Contractions seem to start in the lower back and then travel to the lower abdomen.
• 21. _____ The cervix softens, effaces, and dilates.
• 22. _____ No significant change in fetal position is seen.