NCLEX-RN Certification Exam Questions with AI Explanations

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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QUESTION: 134

The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid "vena caval syndrome," a condition which:

Occurs when blood pressure increases sharply with changes in position
Results when blood flow from the extremities is blocked or slowed
Is seen mainly in first pregnancies
May require medication if positioning does not help

Answer(s): B

Explanation:

(A) Blood pressure changes are predominantly due to pressure of the gravid uterus. (B) Pressure of the gravid uterus on the inferior vena cava decreases blood return from lower extremities. (C) Inferior vena cava syndrome is experienced in the latter months of pregnancy regardless of parity. (D) There are no medications useful in the treatment of interior vena cava syndrome; alleviating pressure by position changes is effective.

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QUESTION: 134

The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid "vena caval syndrome," a condition which:

Occurs when blood pressure increases sharply with changes in position
Results when blood flow from the extremities is blocked or slowed
Is seen mainly in first pregnancies
May require medication if positioning does not help

Answer(s): B

Explanation:

(A) Blood pressure changes are predominantly due to pressure of the gravid uterus. (B) Pressure of the gravid uterus on the inferior vena cava decreases blood return from lower extremities. (C) Inferior vena cava syndrome is experienced in the latter months of pregnancy regardless of parity. (D) There are no medications useful in the treatment of interior vena cava syndrome; alleviating pressure by position changes is effective.

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QUESTION: 135

A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.
The nurse's first intervention should be to:

Check FHT
Notify the attending physician
Turn off the IV oxytocin
Prepare for the delivery because the client is probably in transition

Answer(s): C

Explanation:

(A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D) Contractions lasting 6090 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.

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QUESTION: 135

A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.
The nurse's first intervention should be to:

Check FHT
Notify the attending physician
Turn off the IV oxytocin
Prepare for the delivery because the client is probably in transition

Answer(s): C

Explanation:

(A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D) Contractions lasting 6090 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.

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QUESTION: 133

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QUESTION: 134

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QUESTION: 135

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QUESTION: 135

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