NUR 4455 MODULE 3 NCLEX ANSWERS WITH
RATIONALE
1. The nurse is assigned to care for a patient who is in early labor. When collecting data from the
patient, which should the nurse check first?
a. Baseline fetal heart rate
b. Intensity of contractions
c. Maternal bp
d. Freq. of contractions
Answer. A
Rationale: the nurse should first determine the baseline fetal heart rate this is the priority
2. Leopold’s maneuvers will be performed on a pregnant patient. The patient asks the nurse about
the procedure. Which information should the nurse provide to the patient about Leopold’s
maneuvers?
A. The maneuvers measure the height of the maternal fundus
B. The maneuvers determine the “lie” and attitude of the fetus
C. The maneuvers are systematic method for palpating the fetus through the maternal
back
D. The maneuvers are a systematic method for palpating the fetus through the maternal
abdominal wall
Answer: D
Rationale: Leopold maneuvers comprise a systematic method for palpating the fetus through
the maternal abdominal wall
3. The nurse is caring for a patient who is in labor. The nurse rechecks the clients blood pressure
and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse
should encourage the client to remain in which position?
a. Squatting
b. Side lying
c. Tailor sitting
d. Semi-fowlers
Answer: B
Rationale: Pressure from the enlarged uterus on the aorta and vena cava when the woman is
supine can result in hypotension. This can be relieved by having the women lie on her side
, 4. After a precipitous delivery the nurse note the new mother is passive and only touches her
newborn briefly with her fingertips. The nurse should do what to help the women process what
has happened
a. Encourage the mother to breastfeed soon after birth
b. Support the mother in her reaction to the newborn
c. Tell the mother that it is important to hold the baby
d. Document a complete account of the mothers reaction in the birth record
Answer: B
Rationale: Women who have experienced precipitous labor and delivery often describe feeling of
disbelief that their labor has progressed so rapidly. To assist the woman with understanding what has
happened, it is best to support the mother and her reaction to her newborn.
5. A primigravida’s membrane rupture spontaneously. Which actions should the nurse take first?
a. Determine the fetal heart rate
b. Prepare for immediate delivery
c. Monitor contractions pattern
d. Note the amount color and odor of the amniotic fluid
Answer: A
Rationale: When the membranes rupture, the nurse immediately assesses the fetal heart rate to
detect changes associated with prolapse or the compression of the umbilical cord. Monitoring the
contraction pattern and noting the amount, color, odor of the amniotic fluid may be performed, but
these would not be the first action.
6. After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen
and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of
which condition
a. Uterine atony
b. Placenta previa
c. Abruptio placentae
d. Placental separation
Answer: D
Rationale: As the placenta separates, it settles downward into the lower uterine segment, the
umbilical cord lengthens, and a sudden trickle or spurt of blood appears.
7. The nurse is assigned to assist with caring for a client who has been admitted to the labor unit.
The client is 9cm dilated and is experiencing precipitous labor. Which is the priority nursing
intervention?
a. Prepare for oxytocin infusion
b. Keep the patient in a side lying position
c. Prepare the client for epidural anesthesia
d. Encourage the client to start pushing with the contractions
, Answer: B
Rationale: Precipitous labor progresses quickly, with frequent contractions and short periods of
relaxation between them. This does not allow for the maximal reperfusion of the placenta with
oxygenated blood. Priority care of this client includes the promotion of fetal oxygen.
8. The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse
assists with the examination of the client, knowing that which routine labor procedure is
contraindicated?
a. Leopold’s maneuvers
b. A manual pelvic examination
c. Hemoglobin and hematocrit evaluation
d. External electronic fetal heart rate monitoring
Answer: B
Rationale: Painless vaginal bleeding is a sign of possible placenta previa. Digital examination of the
cervix is contraindicated because it can cause maternal and fetal hemorrhage.
Reference:
Silvestri, L. A. (2016). Saunders comprehensive review for the NCLEX-PN Examination (6th ed.). St. Louis,
MO: Elsevier.
Ashely:
1. A nurse is caring for an older adult client who has type 2 diabetes mellitus and reports difficulty
following the diet and remembering to take the prescribed medication. Which of the following actions
should the nurse take to promote client adherence to the treatment plan? (select all that apply)
a) Ask the dietitian to assist with meal planning.
The nurse provides resources to strengthen coping abilities by asking the dietitian to assist the client with
meal planning. This will improve client adherence.
b) Contact the clients support system.
With the client's consent, the nurse can contact members of the clients support system and encourage
the client to use this support during times of illness and stress to improve compliance.
c) Tell the client he should follow the providers instructions.
Telling the client he should follow the providers instructions will not likely improve the client's adherence
to the treatment plan. The nurse should determine why the client is not following the treatment plan.
RATIONALE
1. The nurse is assigned to care for a patient who is in early labor. When collecting data from the
patient, which should the nurse check first?
a. Baseline fetal heart rate
b. Intensity of contractions
c. Maternal bp
d. Freq. of contractions
Answer. A
Rationale: the nurse should first determine the baseline fetal heart rate this is the priority
2. Leopold’s maneuvers will be performed on a pregnant patient. The patient asks the nurse about
the procedure. Which information should the nurse provide to the patient about Leopold’s
maneuvers?
A. The maneuvers measure the height of the maternal fundus
B. The maneuvers determine the “lie” and attitude of the fetus
C. The maneuvers are systematic method for palpating the fetus through the maternal
back
D. The maneuvers are a systematic method for palpating the fetus through the maternal
abdominal wall
Answer: D
Rationale: Leopold maneuvers comprise a systematic method for palpating the fetus through
the maternal abdominal wall
3. The nurse is caring for a patient who is in labor. The nurse rechecks the clients blood pressure
and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse
should encourage the client to remain in which position?
a. Squatting
b. Side lying
c. Tailor sitting
d. Semi-fowlers
Answer: B
Rationale: Pressure from the enlarged uterus on the aorta and vena cava when the woman is
supine can result in hypotension. This can be relieved by having the women lie on her side
, 4. After a precipitous delivery the nurse note the new mother is passive and only touches her
newborn briefly with her fingertips. The nurse should do what to help the women process what
has happened
a. Encourage the mother to breastfeed soon after birth
b. Support the mother in her reaction to the newborn
c. Tell the mother that it is important to hold the baby
d. Document a complete account of the mothers reaction in the birth record
Answer: B
Rationale: Women who have experienced precipitous labor and delivery often describe feeling of
disbelief that their labor has progressed so rapidly. To assist the woman with understanding what has
happened, it is best to support the mother and her reaction to her newborn.
5. A primigravida’s membrane rupture spontaneously. Which actions should the nurse take first?
a. Determine the fetal heart rate
b. Prepare for immediate delivery
c. Monitor contractions pattern
d. Note the amount color and odor of the amniotic fluid
Answer: A
Rationale: When the membranes rupture, the nurse immediately assesses the fetal heart rate to
detect changes associated with prolapse or the compression of the umbilical cord. Monitoring the
contraction pattern and noting the amount, color, odor of the amniotic fluid may be performed, but
these would not be the first action.
6. After the client vaginally delivers a viable newborn, the nurse sees the umbilical cord lengthen
and observes a spurt of blood from the vagina. The nurse recognizes these findings as signs of
which condition
a. Uterine atony
b. Placenta previa
c. Abruptio placentae
d. Placental separation
Answer: D
Rationale: As the placenta separates, it settles downward into the lower uterine segment, the
umbilical cord lengthens, and a sudden trickle or spurt of blood appears.
7. The nurse is assigned to assist with caring for a client who has been admitted to the labor unit.
The client is 9cm dilated and is experiencing precipitous labor. Which is the priority nursing
intervention?
a. Prepare for oxytocin infusion
b. Keep the patient in a side lying position
c. Prepare the client for epidural anesthesia
d. Encourage the client to start pushing with the contractions
, Answer: B
Rationale: Precipitous labor progresses quickly, with frequent contractions and short periods of
relaxation between them. This does not allow for the maximal reperfusion of the placenta with
oxygenated blood. Priority care of this client includes the promotion of fetal oxygen.
8. The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse
assists with the examination of the client, knowing that which routine labor procedure is
contraindicated?
a. Leopold’s maneuvers
b. A manual pelvic examination
c. Hemoglobin and hematocrit evaluation
d. External electronic fetal heart rate monitoring
Answer: B
Rationale: Painless vaginal bleeding is a sign of possible placenta previa. Digital examination of the
cervix is contraindicated because it can cause maternal and fetal hemorrhage.
Reference:
Silvestri, L. A. (2016). Saunders comprehensive review for the NCLEX-PN Examination (6th ed.). St. Louis,
MO: Elsevier.
Ashely:
1. A nurse is caring for an older adult client who has type 2 diabetes mellitus and reports difficulty
following the diet and remembering to take the prescribed medication. Which of the following actions
should the nurse take to promote client adherence to the treatment plan? (select all that apply)
a) Ask the dietitian to assist with meal planning.
The nurse provides resources to strengthen coping abilities by asking the dietitian to assist the client with
meal planning. This will improve client adherence.
b) Contact the clients support system.
With the client's consent, the nurse can contact members of the clients support system and encourage
the client to use this support during times of illness and stress to improve compliance.
c) Tell the client he should follow the providers instructions.
Telling the client he should follow the providers instructions will not likely improve the client's adherence
to the treatment plan. The nurse should determine why the client is not following the treatment plan.
