NCLEX-PN Test #20 3 — Questions and Answers
Question 1: A client at 38 weeks gestation arrives in labor and delivery reporting regular contractions every 5 minutes. The nurse performs a vaginal examination and finds the cervix is 4 cm dilated, 80% effaced, and the fetus is at 0 station. Which phase/stage of labor does this represent?
- Latent phase of the first stage of labor
- Active phase of the first stage of labor (Correct answer)
- Second stage of labor (pushing phase)
- Transition phase (8–10 cm dilation)
Correct answer: Active phase of the first stage of labor
The active phase of the first stage of labor begins at approximately 4–6 cm dilation and is characterized by regular, increasingly intense contractions. The latent phase is 0–3 cm with irregular contractions. The second stage begins with complete dilation (10 cm) and ends with birth. Transition (8–10 cm) is the most intense portion of the first stage.
Question 2: A nurse is monitoring a client in active labor. The fetal heart rate monitor shows late decelerations with each contraction. What is the priority nursing action?
- Increase the oxytocin infusion rate to speed delivery
- Document and continue monitoring for the next 20 minutes
- Reposition the client to the left lateral position, administer O₂ via face mask, and notify the provider (Correct answer)
- Apply a spiral electrode for internal fetal monitoring only
Correct answer: Reposition the client to the left lateral position, administer O₂ via face mask, and notify the provider
Late decelerations (FHR nadir after contraction peak) indicate uteroplacental insufficiency — reduced oxygen delivery to the fetus. Priority actions: (1) reposition to left lateral (relieves aortic/caval compression, improves placental perfusion), (2) administer O₂ by face mask at 8–10 L/min, (3) stop oxytocin if infusing, (4) notify provider. Left lateral position is the priority first step.
Question 3: A client delivers a healthy newborn. The nurse is performing the initial assessment. Which newborn finding requires immediate intervention?
- Molding of the skull
- Cyanosis of the hands and feet (acrocyanosis) at 5 minutes of life
- Respiratory rate of 68 breaths per minute with nasal flaring (Correct answer)
- Subconjunctival hemorrhage in both eyes
Correct answer: Respiratory rate of 68 breaths per minute with nasal flaring
RR of 68/min exceeds the normal neonatal range (30–60/min), and nasal flaring is a sign of respiratory distress. Immediate intervention and notification of the neonatal team are required. Molding and acrocyanosis at 5 minutes are normal. Subconjunctival hemorrhage from delivery is benign and self-resolving.
Question 4: The nurse is providing postpartum care to a client who delivered 2 days ago. The client reports a hard, tender, red area on the left breast with flu-like symptoms and a temperature of 38.9°C. What condition does the nurse suspect?
- Breast engorgement from milk let-down
- Mastitis — breast tissue infection requiring antibiotics (Correct answer)
- Plugged milk duct — managed with massage and warmth only
- Inflammatory breast cancer — requires urgent evaluation
Correct answer: Mastitis — breast tissue infection requiring antibiotics
Mastitis is a breast infection occurring most commonly in breastfeeding women in the first 6 weeks postpartum. Signs include localized erythema, warmth, and induration with systemic symptoms (fever, chills, myalgia). Treatment includes antibiotics (dicloxacillin or cephalexin), continued breastfeeding or pumping (do not stop — reduces risk of abscess), and analgesics.
Question 5: A client at 32 weeks gestation has a biophysical profile (BPP) score of 6 out of 10. What does this score indicate?
- Fetal well-being is reassured — no intervention needed
- Equivocal result — possible fetal compromise; further evaluation or delivery may be needed (Correct answer)
- Confirmed fetal well-being with high accuracy
- Definitive fetal compromise — immediate delivery is required
Correct answer: Equivocal result — possible fetal compromise; further evaluation or delivery may be needed
BPP scores (out of 10): 8–10 = normal/reassuring; 6 = equivocal (possible fetal compromise) — intervention depends on gestational age and clinical context; ≤4 = abnormal — suggests significant fetal compromise and possible immediate delivery. Each of 5 parameters (NST, breathing, movement, tone, fluid) contributes 2 points.
Question 6: The PN is caring for a client with a third-degree perineal laceration after vaginal delivery. Which nursing intervention is the priority in the first 24 hours?
- Encourage a high-residue diet to stimulate bowel recovery
- Apply ice packs to the perineum and administer prescribed analgesics; monitor for signs of infection and hematoma (Correct answer)
- Encourage the client to perform Kegel exercises immediately
- Withhold all oral fluids to prevent the need for urination and pain
Correct answer: Apply ice packs to the perineum and administer prescribed analgesics; monitor for signs of infection and hematoma
Third-degree lacerations (extending through the external anal sphincter) require aggressive pain management and wound monitoring. Priorities: ice packs in the first 24 hours (reduce edema and pain), prescribed analgesics, stool softeners (prevent straining), and monitoring for infection or hematoma. A high-fiber diet and adequate fluids prevent constipation. Kegel exercises are deferred until healing occurs.
NCLEX-PN Test #20 3
A client at 38 weeks gestation arrives in labor and delivery reporting regular contractions every 5 minutes.
The nurse performs a vaginal examination and finds the cervix is 4 cm dilated, 80% effaced, and the fetus is at 0 station.
Which phase/stage of labor does this represent?