NCLEX MATERNITY 2 UPDATED 2026 QUESTIONS AND ANSWERS
The nurse is monitoring a client in active labor and notes that the client is having contractions
every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between
contractions is 100 beats per minute. Which nursing action is most appropriate?
A. Notify the primary health care provider (PHCP).
B. Continue to monitor the fetal heart rate.
C. Encourage the client to continue pushing with each contraction.
D. Instruct the client's coach to continue to encourage breathing techniques.
A. Notify the primary health care provider (PHCP).
A normal fetal heart rate is 110 to 160 beats per minute, and the fetal heart rate should be
within this range between contractions. Fetal bradycardia between contractions may indicate
the need for immediate medical management, and the PHCP needs to be notified. Options 2, 3,
and 4 are inappropriate nursing actions in this situation and delay necessary intervention.
The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse
notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which
action is most appropriate?
A. Notify the primary health care provider of the findings.
B. Reposition the client and check the monitor for changes in the fetal tracing.
C. Take the client's vital signs and tell the client that bed rest is required to conserve oxygen.
D. Document the findings and tell the client that the pattern on the monitor indicates fetal well-
being.
D. Document the findings and tell the client that the pattern on the monitor indicates fetal well-
being.
,Accelerations are transient increases in the fetal heart rate that often accompany contractions
or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal
wellbeing and adequate oxygen reserve. Options 1, 2, and 3 are inaccurate nursing actions and
are unnecessary.
The nurse is admitting a pregnant client to the labor room and attaches an external electronic
fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is
the next nursing action?
A. Identify the types of accelerations.
B. Assess the baseline fetal heart rate.
C. Determine the intensity of the contractions.
D. Determine the frequency of the contractions.
B. Assess the baseline fetal heart rate.
Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline
rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal
monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the
first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic
changes occur in response to the intermittent stress of uterine contractions and the baseline
beat-to-beat variability of the fetal heart rate.
The nurse is reviewing true and false labor signs with a multiparous client. The nurse
determines that the client understands the signs of true labor if the client makes which
statement?
A. "I won't be in labor until my baby drops."
B."My contractions will be felt in my abdominal area."
C. "My contractions will not be as painful if I walk around."
,D. "My contractions will last longer and be more intense."
D. "My contractions will last longer and be more intense."
True labor is present when contractions increase in duration and intensity. Lightening or
dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs
when the foetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the
abdominal area and contractions that ease with walking are signs of false labor.
Which assessment finding after an amniotomy needs to be conducted first?A. Cervical dilation
B. Bladder distention
C. Fetal heart rate pattern
D. Maternal blood pressure
C. Fetal heart rate pattern
Fetal heart rate is assessed immediately after amniotomy to detect any changes that may
indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal
examinations would be done because of the risk of infection. Bladder distention or maternal
blood pressure would not be the first thing to check after an amniotomy.
The nurse has been working with a laboring client and notes that the client has been pushing
effectively for 1 hour. What is the client's primary physiological need at this time?
A. Ambulation
B. Rest between contractions
C. Change positions frequently
D. Consume oral food and uids
B. Rest between contractions
, The birth process expends a great deal of energy, particularly during the transition stage.
Encouraging rest between contractions conserves maternal energy, facilitating voluntary
pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes
fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips
should be provided. Changing positions frequently is not the primary physiological need. Food
and fluids are likely to be withheld at this time.
The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The
client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60
seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been
120 to 122 beats per minute for the past hour. What is the priority nursing action?
A. Discontinue the infusion of oxytocin.
B. Notify the primary health care provider.
C. Place oxygen on at 8 to 10 L/minute via face mask.
D. Contact the client's primary support person(s) if not currently present.
A. Discontinue the infusion of oxytocin.
The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful
uterine contractions and decrease oxygenation to the placenta, resulting in decreased
variability. After stopping the oxytocin, the nurse would reposition the laboring client. Notifying
the primary health care provider, applying oxygen, and increasing the rate of the intravenous
(IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation,
but not the priority action. Contacting the client's primary support person(s) is not the priority
action at this time.
The nurse is performing an assessment on a client who has just been told that a pregnancy test
is positive. Which assessment finding indicates that the client is at risk for preterm labor?
A. The client is a 35-year-old primigravida.
The nurse is monitoring a client in active labor and notes that the client is having contractions
every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between
contractions is 100 beats per minute. Which nursing action is most appropriate?
A. Notify the primary health care provider (PHCP).
B. Continue to monitor the fetal heart rate.
C. Encourage the client to continue pushing with each contraction.
D. Instruct the client's coach to continue to encourage breathing techniques.
A. Notify the primary health care provider (PHCP).
A normal fetal heart rate is 110 to 160 beats per minute, and the fetal heart rate should be
within this range between contractions. Fetal bradycardia between contractions may indicate
the need for immediate medical management, and the PHCP needs to be notified. Options 2, 3,
and 4 are inappropriate nursing actions in this situation and delay necessary intervention.
The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse
notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which
action is most appropriate?
A. Notify the primary health care provider of the findings.
B. Reposition the client and check the monitor for changes in the fetal tracing.
C. Take the client's vital signs and tell the client that bed rest is required to conserve oxygen.
D. Document the findings and tell the client that the pattern on the monitor indicates fetal well-
being.
D. Document the findings and tell the client that the pattern on the monitor indicates fetal well-
being.
,Accelerations are transient increases in the fetal heart rate that often accompany contractions
or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal
wellbeing and adequate oxygen reserve. Options 1, 2, and 3 are inaccurate nursing actions and
are unnecessary.
The nurse is admitting a pregnant client to the labor room and attaches an external electronic
fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is
the next nursing action?
A. Identify the types of accelerations.
B. Assess the baseline fetal heart rate.
C. Determine the intensity of the contractions.
D. Determine the frequency of the contractions.
B. Assess the baseline fetal heart rate.
Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline
rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal
monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the
first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic
changes occur in response to the intermittent stress of uterine contractions and the baseline
beat-to-beat variability of the fetal heart rate.
The nurse is reviewing true and false labor signs with a multiparous client. The nurse
determines that the client understands the signs of true labor if the client makes which
statement?
A. "I won't be in labor until my baby drops."
B."My contractions will be felt in my abdominal area."
C. "My contractions will not be as painful if I walk around."
,D. "My contractions will last longer and be more intense."
D. "My contractions will last longer and be more intense."
True labor is present when contractions increase in duration and intensity. Lightening or
dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs
when the foetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the
abdominal area and contractions that ease with walking are signs of false labor.
Which assessment finding after an amniotomy needs to be conducted first?A. Cervical dilation
B. Bladder distention
C. Fetal heart rate pattern
D. Maternal blood pressure
C. Fetal heart rate pattern
Fetal heart rate is assessed immediately after amniotomy to detect any changes that may
indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal
examinations would be done because of the risk of infection. Bladder distention or maternal
blood pressure would not be the first thing to check after an amniotomy.
The nurse has been working with a laboring client and notes that the client has been pushing
effectively for 1 hour. What is the client's primary physiological need at this time?
A. Ambulation
B. Rest between contractions
C. Change positions frequently
D. Consume oral food and uids
B. Rest between contractions
, The birth process expends a great deal of energy, particularly during the transition stage.
Encouraging rest between contractions conserves maternal energy, facilitating voluntary
pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes
fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips
should be provided. Changing positions frequently is not the primary physiological need. Food
and fluids are likely to be withheld at this time.
The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The
client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60
seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been
120 to 122 beats per minute for the past hour. What is the priority nursing action?
A. Discontinue the infusion of oxytocin.
B. Notify the primary health care provider.
C. Place oxygen on at 8 to 10 L/minute via face mask.
D. Contact the client's primary support person(s) if not currently present.
A. Discontinue the infusion of oxytocin.
The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful
uterine contractions and decrease oxygenation to the placenta, resulting in decreased
variability. After stopping the oxytocin, the nurse would reposition the laboring client. Notifying
the primary health care provider, applying oxygen, and increasing the rate of the intravenous
(IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation,
but not the priority action. Contacting the client's primary support person(s) is not the priority
action at this time.
The nurse is performing an assessment on a client who has just been told that a pregnancy test
is positive. Which assessment finding indicates that the client is at risk for preterm labor?
A. The client is a 35-year-old primigravida.
