NCLEX-RN Exam dumps PDF | Exam-Dumps.net (Page: 53)

QUESTION: 131

Which of the following signs might indicate a complication during the labor process with vertex presentation?

Fetal tachycardia to 170 bpm during a contraction
Nausea and vomiting at 810 cm dilation
Contraction lasting 60 seconds
Appearance of dark-colored amniotic fluid

Answer(s): D

Explanation:

(A) Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. (B) Nausea and vomiting occur frequently during transition and are not a complication. (C) Contractions frequently last 6090 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. (D) Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.

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QUESTION: 131

Which of the following signs might indicate a complication during the labor process with vertex presentation?

Fetal tachycardia to 170 bpm during a contraction
Nausea and vomiting at 810 cm dilation
Contraction lasting 60 seconds
Appearance of dark-colored amniotic fluid

Answer(s): D

Explanation:

(A) Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. (B) Nausea and vomiting occur frequently during transition and are not a complication. (C) Contractions frequently last 6090 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. (D) Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.

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QUESTION: 132

Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, "Begin oxytocin induction at 1 mU/min." The nurse should:

Begin the oxytocin induction as ordered
Increase the dosage by 2 mU/min increments at15-minute intervals
Maintain the dosage when duration of contractions is 4060 seconds and frequency is at 2124 minute intervals
Question the order

Answer(s): D

Explanation:

(A) Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. (B) This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. (C) This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. (D) This answer is the appropriate nursing action because the scenario presents adysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.

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QUESTION: 132

Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, "Begin oxytocin induction at 1 mU/min." The nurse should:

Begin the oxytocin induction as ordered
Increase the dosage by 2 mU/min increments at15-minute intervals
Maintain the dosage when duration of contractions is 4060 seconds and frequency is at 2124 minute intervals
Question the order

Answer(s): D

Explanation:

(A) Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. (B) This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. (C) This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. (D) This answer is the appropriate nursing action because the scenario presents adysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.

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QUESTION: 133

A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?

"Keep breathing with your abdominal muscles as long as you can."
"Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 1620 times a minute with shallow chest breaths."
"Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles."
"If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well."

Answer(s): B

Explanation:

(A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a comfortable position in labor, but the Lamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles. (D) When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 69 breaths/min.

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NCLEX NCLEX-RN Exam (page: 53) NCLEX National Council Licensure Examination - -RN Updated on: 17-Feb-2026

QUESTION: 131

Explanation:

QUESTION: 131

Explanation:

QUESTION: 132

Explanation:

QUESTION: 132

Explanation:

QUESTION: 133

Explanation:

NCLEX NCLEX-RN Exam (page: 53)
NCLEX National Council Licensure Examination - -RN
Updated on: 17-Feb-2026