A nurse is caring for a client in the active first stage of labor who has just received an epidural block. Five minutes later, the client reports feeling dizzy, and the fetal heart rate monitor shows recurrent late decelerations with minimal variability. What is the nurse's priority action?
Turn the client to a lateral position and increase IV maintenance fluids
Administer oxygen at 10 L/min via non-rebreather mask
Prepare the client for an emergency cesarean birth
Administer IV ephedrine as prescribed to reverse sympathetic block
Show the answer and explanation
Answer: A. Turn the client to a lateral position and increase IV maintenance fluids
Topic: Epidural hypotension and fetal compromise
Epidural-induced sympathetic blockade frequently causes maternal hypotension, leading to uteroplacental insufficiency manifested by late decelerations. Repositioning to a lateral tilt relieves compression on the inferior vena cava, improves venous return, and restores uteroplacental perfusion.
Why the others are wrong
B – Applying oxygen is a secondary intrauterine resuscitation measure; correcting maternal hypotension via positioning and fluid bolus addresses the root cause first.
C – Preparing for immediate cesarean birth is premature before attempting intrauterine resuscitation measures to correct reversible uteroplacental insufficiency.
D – Administering ephedrine may be warranted if positioning and fluids fail to correct severe hypotension, but lateral repositioning and fluid bolus are the immediate first-line nursing interventions.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
52Question
A nurse is caring for a client at 34 weeks of gestation admitted with preterm premature rupture of membranes (PPROM). Which of the following clinical findings should the nurse report to the provider immediately?
Maternal temperature of 38.4°C (101.2°F)
Bilateral 1+ pitting edema in the lower extremities
Fetal heart rate baseline of 145/min with moderate variability
Contractions occurring every 10 to 12 minutes lasting 30 seconds
Show the answer and explanation
Answer: A. Maternal temperature of 38.4°C (101.2°F)
Topic: Preterm premature rupture of membranes infection signs
An elevated maternal temperature in a client with PPROM is a primary indicator of chorioamnionitis, an intrauterine infection that poses a severe risk to both the mother and the fetus. Immediate provider notification is essential to initiate broad-spectrum antibiotics and evaluate for delivery.
Why the others are wrong
B – Mild 1+ lower extremity edema is a common physiological finding during the third trimester and does not require immediate reporting in the absence of hypertension or proteinuria.
C – A baseline fetal heart rate of 145/min with moderate variability is a reassuring indicator of fetal well-being.
D – Irregular contractions occurring every 10 to 12 minutes are common with PPROM and do not represent active, progressive labor requiring immediate intervention unless accompanied by other complications.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
53Question
A nurse is caring for a postpartum client who gave birth vaginally 4 hours ago. Which clinical findings require immediate nursing intervention?
Select all that apply.
A firm midline fundus located two centimeters below the umbilicus
A continuous trickle of bright red blood from the vaginal introitus
Pain rating of 6 out of 10 localized to the perineum with mild edema
Client report of dizziness and feeling lightheaded when attempting to stand
Heart rate of 115/min and blood pressure of 88/52 mm Hg
Show the answers and explanation
Answers: B, D and E.
B – A continuous trickle of bright red blood from the vaginal introitus
D – Client report of dizziness and feeling lightheaded when attempting to stand
E – Heart rate of 115/min and blood pressure of 88/52 mm Hg
Topic: Postpartum hemorrhage and lacerations
A continuous trickle of bright red blood despite a firm fundus strongly suggests lacerations of the cervix or vagina, which require prompt repair. Dizziness, tachycardia (115/min), and hypotension (88/52 mm Hg) are classic signs of hypovolemic shock resulting from postpartum hemorrhage, demanding immediate evaluation and intervention. A firm midline fundus below the umbilicus is a normal expected finding indicating effective uterine contraction, and moderate localized perineal pain with mild edema is expected following a vaginal delivery.
Why the others are wrong
A – A firm, midline fundus located 2 cm below the umbilicus is a normal, expected finding indicating effective uterine involution and contraction.
C – Moderate localized perineal pain and mild edema are expected following a vaginal delivery and can be managed with ice packs and analgesics.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
54Question
A nurse is caring for a client at 34 weeks' gestation diagnosed with preterm premature rupture of membranes (PPROM). Which clinical finding requires immediate notification of the health care provider?
Maternal temperature of 38.2°C (100.8°F)
Moderate clear amniotic fluid pooling in the vaginal vault
Fetal heart rate baseline of 145/min with moderate variability
Uterine contractions occurring every 10 minutes lasting 20 seconds
Show the answer and explanation
Answer: A. Maternal temperature of 38.2°C (100.8°F)
Topic: PPROM infection signs
A maternal temperature of 38.2°C (100.8°F) or higher in the setting of PPROM is a primary indicator of chorioamnionitis (intra-amniotic infection), which requires prompt antibiotic therapy and often delivery to prevent maternal and neonatal sepsis. Clear fluid pooling, a reassuring fetal heart rate, and mild irregular contractions are expected findings managed expectantly in stable PPROM.
Why the others are wrong
B – Moderate clear amniotic fluid pooling is an expected ongoing finding after membrane rupture and does not indicate acute infection or distress.
C – A baseline fetal heart rate of 145/min with moderate variability is normal and reassuring.
D – Mild, infrequent uterine contractions are common after PPROM and are monitored expectantly unless they progress to regular, preterm labor patterns.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
55Question
A nurse is caring for a client at 28 weeks' gestation who is scheduled to receive a first dose of Rho(D) immune globulin. Which clinical circumstance must be verified prior to administering this medication?
The client has a negative indirect Coombs test.
The client's 1-hour glucose tolerance test is within normal limits.
The client has a reactive nonstress test.
The client's hemoglobin level is greater than 11.0 g/dL.
Show the answer and explanation
Answer: A. The client has a negative indirect Coombs test.
Topic: Antenatal Rh prophylaxis verification
Rho(D) immune globulin is administered routinely at 28 weeks' gestation to Rh-negative, unsensitized clients. Verifying a negative indirect Coombs (antibody screen) test confirms that the client has not already formed anti-D antibodies, ensuring the prophylaxis is safe and effective. If the indirect Coombs test is positive due to prior sensitization, Rho(D) immune globulin is unnecessary and ineffective.
Why the others are wrong
B – Glucose tolerance testing screens for gestational diabetes and is unrelated to Rh status or Rho(D) immune globulin administration.
C – A nonstress test evaluates fetal well-being but does not determine maternal Rh sensitization status.
D – Hemoglobin assesses for anemia; while important in pregnancy, it is not a prerequisite for administering Rh prophylaxis.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
56Question
A nurse is caring for a client at 34 weeks of gestation who is admitted with preterm labor and contractions. The provider prescribes betamethasone 12 mg IM now, to be repeated in 24 hours. Which maternal assessment finding requires immediate notification of the health care provider before administering the second dose?
Blood glucose of 165 mg/dL
Temperature of 38.2° C (100.8° F)
Heart rate of 110/min
Blood pressure of 132/84 mm Hg
Show the answer and explanation
Answer: B. Temperature of 38.2° C (100.8° F)
Topic: Betamethasone administration and infection screening
Antenatal corticosteroids such as betamethasone induce transient maternal hyperglycemia and mild tachycardia, but they also suppress the immune response and can mask or exacerbate underlying maternal infection. A temperature of 38.2° C (100.8° F) or higher strongly suggests chorioamnionitis or another infection, which is a contraindication or requires urgent antimicrobial coverage before administering further immunosuppressive steroids.
Why the others are wrong
A – Transient hyperglycemia (such as 165 mg/dL) is an expected side effect of corticosteroid administration, especially in clients with or without gestational diabetes, and requires monitoring rather than holding the dose.
C – A mild maternal heart rate increase to 110/min is a common sympathomimetic or metabolic response to betamethasone and does not necessitate withholding the medication.
D – A blood pressure of 132/84 mm Hg is mildly elevated but is within acceptable parameters and does not represent an acute contraindication to corticosteroid therapy.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
57Question
A labor and delivery nurse is monitoring a client in the active stage of labor receiving a continuous intravenous infusion of oxytocin. The external fetal monitor tracing reveals three late decelerations over a 20-minute window, with moderate baseline variability and a baseline rate of 145/min. Which of the following nursing interventions are appropriate?
Select all that apply.
Discontinue the oxytocin infusion immediately.
Reposition the client to a left lateral position.
Administer oxygen via non-rebreather mask at 10 L/min.
Perform a digital vaginal examination to assess for cord prolapse.
Increase the primary IV maintenance fluid rate.
Show the answers and explanation
Answers: A, B, C and E.
A – Discontinue the oxytocin infusion immediately.
B – Reposition the client to a left lateral position.
C – Administer oxygen via non-rebreather mask at 10 L/min.
E – Increase the primary IV maintenance fluid rate.
Topic: Late decelerations and intrauterine resuscitation
Late decelerations indicate uteroplacental insufficiency. Intrauterine resuscitation measures include stopping oxytocin to decrease uterine activity, repositioning the client to relieve aortocaval compression, administering oxygen to maximize maternal-fetal oxygen saturation, and increasing IV crystalloid fluids to expand maternal volume and improve placental perfusion. A digital vaginal examination is indicated for variable decelerations to check for cord prolapse, but is not the primary intervention for late decelerations unless rapid labor progress is suspected.
Why the others are wrong
D – A digital vaginal examination to assess for cord prolapse is the priority intervention when variable decelerations are present, whereas late decelerations stem from uteroplacental insufficiency and do not primarily indicate cord compression.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
58Question
A nurse is caring for a G2P1 client at 34 weeks of gestation admitted with suspected abruptio placentae. Which clinical findings should the nurse anticipate during the assessment?
Select all that apply.
Rigid, board-like abdomen
Painless, bright red vaginal bleeding
Dark red vaginal bleeding
Uterine tetany or hypertonicity
Fetal heart rate decelerations
Show the answers and explanation
Answers: A, C, D and E.
A – Rigid, board-like abdomen
C – Dark red vaginal bleeding
D – Uterine tetany or hypertonicity
E – Fetal heart rate decelerations
Topic: Abruptio placentae assessment
Abruptio placentae (premature separation of the normally implanted placenta) classically presents with dark red vaginal bleeding (or concealed hemorrhage), uterine tenderness, a rigid or board-like abdomen due to blood accumulating in the myometrium, uterine hypertonicity, and non-reassuring fetal heart rate patterns such as late or variable decelerations due to compromised uteroplacental perfusion.
Why the others are wrong
B – Painless, bright red vaginal bleeding is characteristic of placenta previa, not abruptio placentae.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
59Question
A 32-year-old primigravida at 34 weeks of gestation is admitted for evaluation of suspected gestational hypertension. Which assessment finding is most critical for the nurse to report immediately to the health care provider?
Blood pressure reading of 148/92 mm Hg
2+ pitting edema in the lower extremities bilaterally
Report of persistent frontal headache and blurred vision
Trace protein in the random urine dipstick test
Show the answer and explanation
Answer: C. Report of persistent frontal headache and blurred vision
Persistent frontal headache and visual disturbances such as blurred vision or scotoma are classic central nervous system symptoms of severe preeclampsia, indicating cerebral edema and an increased risk for eclamptic seizures. Prompt reporting is essential for initiating interventions such as magnesium sulfate therapy.
Why the others are wrong
A – A blood pressure of 148/92 mm Hg indicates hypertension requiring monitoring, but central nervous system symptoms represent a more acute threat of progression to eclampsia.
B – Bilateral lower extremity edema is a common physiological finding in third-trimester pregnancies due to dependent venous pressure and is not a primary indicator of severe end-organ compromise.
D – Trace proteinuria is a minor laboratory finding; severe preeclampsia typically involves 3+ or greater protein on dipstick testing or significant 24-hour protein excretion.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
60Question
A nurse is providing discharge instructions to a postpartum client who delivered a healthy term newborn 24 hours ago. Which statements by the client indicate a correct understanding of normal lochial progression and warning signs?
Select all that apply.
"My lochia should remain bright red and heavy for the next two weeks."
"I should expect the discharge to change from bright red to pink or brownish-pink within a week."
"Passing blood clots the size of a large grapefruit requires immediate notification of my doctor."
"A foul odor to the vaginal discharge or a return of bright red bleeding after it has faded are signs I need to report."
"By the second week, the discharge should become yellowish-white in color."
Show the answers and explanation
Answers: B, C, D and E.
B – "I should expect the discharge to change from bright red to pink or brownish-pink within a week."
C – "Passing blood clots the size of a large grapefruit requires immediate notification of my doctor."
D – "A foul odor to the vaginal discharge or a return of bright red bleeding after it has faded are signs I need to report."
E – "By the second week, the discharge should become yellowish-white in color."
Topic: Lochia progression and warning signs education
Lochia normally progresses from rubra (bright red, days 1-3) to serosa (pinkish-brown, days 4-10) to alba (yellowish-white, days 11-21+). Large clots (grapefruit size), foul odor, and secondary heavy bright red bleeding are abnormal and indicate potential hemorrhage or infection.
Why the others are wrong
A – Bright red, heavy lochia persisting for two weeks is abnormal and suggests retained placental fragments or subinvolution rather than normal lochia rubra.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
61Question
A nurse in the labor and delivery unit is caring for a client in the active stage of labor who is receiving an intravenous infusion of oxytocin. The external fetal monitor displays fetal heart rate baseline of 140/min with moderate variability, no accelerations, and recurrent late decelerations. Which nursing action is the absolute priority?
Increase the primary intravenous maintenance fluid infusion rate.
Discontinue the oxytocin infusion immediately.
Administer terbutaline 0.25 mg subcutaneously as prescribed.
Assist the client into a modified Sims or knee-chest position.
Show the answer and explanation
Answer: B. Discontinue the oxytocin infusion immediately.
Topic: Intrauterine resuscitation for late decelerations
Late decelerations indicate uteroplacental insufficiency. The primary and immediate intervention to reduce uterine activity and restore uteroplacental blood flow is to stop the exogenous oxytocin infusion, which is stimulating uterine contractions.
Why the others are wrong
A – Increasing maintenance fluids helps support maternal blood pressure, but stopping the oxytocin that causes uterine hyperactivity is the most critical first step.
C – Terbutaline is used to treat uterine tachysystole if stopping oxytocin and repositioning fail to resolve the decelerations, but it is not the immediate first action.
D – Repositioning the client relieves aortocaval compression and improves placental perfusion, but stopping the oxytocin infusion directly addresses the cause of hyperstimulation.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
62Question
A nurse is caring for a client at 34 weeks of gestation who is admitted with preterm labor. The primary healthcare provider prescribes betamethasone 12 mg intramuscularly now. Which of the following maternal assessments is most critical for the nurse to monitor closely following the administration of this medication?
Antenatal corticosteroids such as betamethasone promote fetal lung maturity but cause significant maternal hyperglycemia due to transient insulin resistance and enhanced gluconeogenesis. Clients, especially those with or at risk for gestational diabetes, require frequent blood glucose monitoring for several days following administration.
Why the others are wrong
A – Deep tendon reflexes are monitored when a client is receiving magnesium sulfate therapy for neuroprotection or preeclampsia management, not betamethasone.
C – Platelet counts are monitored in clients with suspected preeclampsia or HELLP syndrome, not as a primary side effect of corticosteroid administration.
D – Serum creatinine assesses renal function and is monitored in hypertensive disorders of pregnancy or nephrotoxic drug therapy, not corticosteroid administration.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
63Question
A nurse is providing discharge instructions to a postpartum client who delivered a healthy newborn 48 hours ago. Which of the following statements by the client indicate a correct understanding of normal postpartum physiological changes and when to notify the healthcare provider?
Select all that apply.
"I should expect my lochia to transition from bright red to brownish and then yellowish-white over the next few weeks."
"Passing blood clots the size of a golf ball is completely normal during the first week postpartum."
"Experiencing significant night sweats as my body gets rid of extra fluid is a normal finding."
"I will call my doctor immediately if I develop calf pain, swelling, or tenderness in one leg."
"My menstrual cycle will likely return within two weeks if I choose to formula feed my baby."
Show the answers and explanation
Answers: A, C and D.
A – "I should expect my lochia to transition from bright red to brownish and then yellowish-white over the next few weeks."
C – "Experiencing significant night sweats as my body gets rid of extra fluid is a normal finding."
D – "I will call my doctor immediately if I develop calf pain, swelling, or tenderness in one leg."
Topic: Postpartum discharge warning signs and physiology
Postpartum diuresis and diaphoresis (night sweats) are normal mechanisms for eliminating excess pregnancy volume. Lochia progresses normally from rubra to serosa to alba. Unilateral leg pain and swelling are warning signs of deep vein thrombosis requiring immediate reporting. Golf-ball sized clots are abnormal and indicate potential postpartum hemorrhage.
Why the others are wrong
B – Passing blood clots larger than a plum or golf ball is a warning sign of potential postpartum hemorrhage or retained placental fragments and must be reported immediately.
E – For non-lactating clients, menstruation typically resumes within 6 to 10 weeks postpartum, whereas two weeks is too soon for physiological recovery of the hypothalamic-pituitary-ovarian axis.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
NCLEX-RN is a registered trademark of the National Council of State Boards of Nursing, Inc. (NCSBN). This site is not affiliated with, sponsored by or endorsed by the owner of that mark.
Nursing