NCLEX-PN Test #20 3

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?

Accepted Answer

Active phase of the first stage of labor

Answer

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?

Accepted Answer

Reposition the client to the left lateral position, administer O₂ via face mask, and notify the provider

Answer

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?

Accepted Answer

Respiratory rate of 68 breaths per minute with nasal flaring

Answer

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?

Accepted Answer

Mastitis — breast tissue infection requiring antibiotics

Answer

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?

Accepted Answer

Equivocal result — possible fetal compromise; further evaluation or delivery may be needed

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #20 3