NCLEX Practice Questions — Set 27
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
The registered nurse is delegating client assignments on a maternity unit. Which of the following assignments should the nurse delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: B. Document the characteristics of a woman’s lochia
Providing the care to a woman suspected of abruptio placentae and a woman in her 37th week of gestation experiencing dyspnea both require the skills of a registered nurse. A woman in her 37th week of gestation experiencing dyspnea may have a pulmonary embolus and requires the critical thinking skills of the registered nurse. Teaching a pregnancy class should be done by a registered nurse. A licensed practical nurse may document a woman’s lochia.
A pregnant client asks the nurse when the stretch marks will disappear. The most appropriate response by the nurse is
Show answer and rationale
Correct answer: D. "They will fade but do not totally disappear."
The stretch marks a pregnant woman experiences will fade after the birth of the infant, but will not totally disappear.
When caring for the mother with premature rupture of the membranes, the nurse monitors the mother and fetus for indications of
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Correct answer: D. chorioamnionitis.
Loss of the protective barrier provided by the membranes increases the risk of infection (chorioamnionitis). The likelihood of placenta previa, hemorrhage, and arrest of descent are not increased by rupture of the membranes.
The nurse should monitor for which of the following fetal life-threatening emergencies when the fetal head is not engaged and the membranes rupture?
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Correct answer: C. Cord prolapse
Although uterine hyperstimulation, placenta previa, and abruptio placentae all pose a threat to the fetus, only cord prolapse is the direct result of rupture of membranes. Although the other conditions pose a threat to the mother as well as the fetus, cord prolapse threatens only fetal well-being.
When observing a mother receiving oxytocin (Pitocin) for induction of labor, which of the following should the nurse assess for?
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Correct answer: C. Uterine hyperstimulation
Oxytocin (Pitocin) is an oxytocic drug used in the treatment of induction or stimulation of labor at term. Excessive use of oxytocin is associated with uterine hyperstimulation.
After observing variable decelerations of the fetal heart rate on the fetal monitor tracing, the nurse should plan to care for a possible
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Correct answer: B. cord compression.
Variable decelerations are caused by cord compression. Head compression, uteroplacental insufficiency, and cardiac conduction defect are associated with other types of periodic changes in fetal heart rate.
The nurse observes early decelerations of the fetal heart rate on the fetal monitor tracing of a mother who has an epidural anesthesia and denies pain with the contractions. Which of the following is the intervention the nurse should take?
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Correct answer: C. Perform a sterile vaginal examination
Early decelerations of the fetal heart rate may indicate the cervix is dilated and the labor may have progressed to the second stage. Changing the position of the mother from side to side is the intervention if umbilical cord compression is suspected. An amnioinfusion is the instillation of an isotonic glucose-free solution into the uterus to form a cushion for the umbilical cord or to thin out the meconium. It is also used when cord compression is present. Administration of oxygen is also performed when cord compression is suspected, because the oxygen will saturate the mother’s blood, with the goal of supplying an adequate oxygen source to the fetus when the cord compression is relieved.
The nurse should monitor for complications of disseminated intravascular coagulation (DIC) after observing which of the following decelerations of the fetal heart rate on the fetal monitor tracing? Decelerations that are
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Correct answer: D. variable in shape and timing.
Variable decelerations most frequently occur after rupture of the membranes. They are variable in shape and timing.
Which of the following fetal heart rate patterns would the nurse anticipate seeing from a fetus with anencephaly?
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Correct answer: C. Absent long-term variability
Absent long-term variability seen on the fetal heart monitor is present in congenital brain anomalies such as anencephaly. Anencephaly is a fatal condition in which the infant is born with a severely underdeveloped brain and skull. The infant most certainly dies shortly after birth.
After noting early decelerations on the fetal monitor tracing, the nurse should
Show answer and rationale
Correct answer: A. continue to observe the tracing.
Early decelerations do not reflect fetal jeopardy. Observation for the source of head compression (e.g., possible descent of fetal head) is all that is indicated.
In planning the care for the following four clients, which of the clients is a priority for the nurse to begin preoperative instructions and preparation for cesarean section?
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Correct answer: C. A client with a complete placenta previa
Although a client with a complete placenta abruptio, a client experiencing variable decelerations, or a client with a fever may require a cesarean birth, complete placenta previa always mandates a cesarean birth.
A mother in labor is admitted with profuse, bright red vaginal bleeding and late decelerations on the fetal monitor. Which of the following questions is a priority for the nurse to ask the client to determine whether the source of the bleeding is placenta previa or abruptio placentae?
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Correct answer: B. "Are you having pain?"
Both placenta previa and abruptio placentae can lead to uteroplacental insufficiency and threaten fetal well-being. The bleeding of placenta previa is usually painless and different from that with abruptio placentae. Questions regarding fever and gravida or para can be asked later. Headache and blurred vision are clinical manifestations of pre-eclampsia.
The nurse is caring for a mother at 32�weeks of gestation who thinks her "water broke" about 1�hour prior to arrival at the hospital. The nurse should prepare the client for which procedure to evaluate the status of the membranes?
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Correct answer: A. Fern test
A sterile speculum exam is performed to obtain a sample of vaginal fluid for a fern test to evaluate the status of the membranes. In the fern test, a sample of fluid is obtained from the vagina with a cotton-tipped applicator during a speculum exam. The fluid-soaked applicator is swabbed over a glass slide and examined under the microscope. A frondlike pattern indicates the presence of amniotic fluid. A digital exam should be deferred until the status of the membranes is determined. Ultrasound would not detect the leakage of a small amount of fluid. The nurse might obtain a vaginal group B beta strep culture after rupture of the membranes is confirmed by the fern test.
The nurse is reviewing the laboratory results of a mother in labor. Which of the following nursing actions should the nurse implement with a white blood cell count of 14,000?
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Correct answer: C. Continue to monitor the client
During labor, a white blood cell count of 14,000 is normal, due to the physical stress of labor. No further action is necessary.
Which of the following nursing interventions should the nurse take after assessing slight respiratory alkalosis on the arterial blood gas analysis of a pregnant client?
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Correct answer: B. No action needed
During pregnancy, a slight respiratory alkalosis occurs, resulting from the 30-40% increase in tidal volume. The increased PaO2 and the decreased PCO2 of the maternal circulation facilitate the removal of the carbon dioxide from the fetal circulation. The decreased PCO2 of the mother is compensated by the increased renal excretion of the bicarbonate permitting the arterial pH to remain in the normal range. No action is necessary.
The nurse is admitting a mother in labor who reports a small amount of dark red, mucoid vaginal discharge. The nurse should
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Correct answer: C. proceed with the admission.
The mother is describing "bloody show," a normal finding in a mother in labor. This does not reflect coagulopathy, so no laboratory studies are indicated. Notifying the physician, obtaining coagulation studies, and preparing for a cesarean section apply to bright red vaginal bleeding, which is an abnormal finding.
The nurse is caring for a mother in labor whose membranes spontaneously rupture. The amniotic fluid is wine-colored. The appropriate action is to
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Correct answer: D. notify the physician and review the fetal monitor tracing.
The "port wine" staining of the fluid is associated with abruptio placentae. Continuing to observe could place the mother and fetus in jeopardy. Obtaining a culture or testing with Nitrazine paper is not indicated. The nurse should notify the physician and monitor the fetus for evidence of abruptio placentae.
After a mother receives epidural anesthesia for labor and vaginal delivery, the nurse should evaluate the expected outcome of
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Correct answer: B. a decrease in sensation and motor control of lower extremities, bladder, and vasomotor tone.
Epidural anesthesia for labor and delivery produces anesthesia from T10 caudal to block both first- and second-stage pain. The block is usually higher for cesarean delivery. Correctly administered, regional anesthesia does not produce sedation or loss of consciousness. A postdural epidural headache results from an accidental puncture of the dura, which creates a larger hole and increases the incidence of postdural epidural headache. An epidural may lengthen the second stage of labor, resulting in a decreased ability of the mother to push. A heaviness in the legs and numb feet indicate the epidural catheter has gone into the subarachnoid space and should be withdrawn.
The nurse is caring for a newly delivered Asian mother and notes the family has piled blankets on the mother and brought her hot water and soup. The nurse understands this behavior is
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Correct answer: D. an indication of the cultural beliefs about birth.
Many cultures consider the postpartum mother to be in a "cold" state, and keep the mother warm to help regain the heat lost in childbirth. Although the family may have concerns about room temperature or modesty, drinking warm liquids is a cultural practice. To prevent fever is not correct because the practice of drinking hot liquids is cultural, not medical.
The nurse should perform which of the following hourly assessments when a pregnant woman is receiving magnesium sulfate for preeclampsia and eclampsia?
Show answer and rationale
Correct answer: B. Deep tendon reflexes
Magnesium sulfate decreases neuromuscular transmission of impulses; thus, reflexes would be affected. Also, loss of the patellar reflex is the first sign of magnesium sulfate toxicity. Urine output and respiratory status are also assessed hourly or more often.
Which of the following is a priority for the nurse to assess in a mother receiving magnesium sulfate?
Show answer and rationale
Correct answer: C. Loss of patellar reflex
Adverse reactions to magnesium sulfate include diaphoresis, flushing, and decreased respirations. Loss of deep tendon reflexes, including the patellar reflex, is a sign of impending toxicity and is the priority assessment.
When the nurse notes an absent patellar reflex in a client receiving magnesium sulfate, the correct action is
Show answer and rationale
Correct answer: C. discontinue the infusion per protocol.
Because an absent patellar reflex is an early sign of toxicity, the magnesium sulfate infusion should be discontinued and the physician notified. Administering IV fluids or oxygen would not treat the toxicity. Increasing the rate would increase toxicity.
A client who is pre-eclamptic complains of blurred vision and scotomata to the nurse. The nurse should report this as indicating which of the following?
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Correct answer: B. Cerebral edema
Visual disturbances may reflect cerebral edema in the pre-eclamptic client.
The registered nurse is preparing clinical assignments for a maternity unit. Which of the following assignments should the nurse delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: D. Walk a woman in labor to the delivery room
Administering oxytocin (Pitocin), instructing a mother on the clinical manifestations of eclampsia, and initiating magnesium sulfate to a mother experiencing toxemia should all be performed by a registered nurse. A licensed practical nurse may walk a woman in labor to the delivery room.
Twelve hours after delivery, the nurse assesses a client’s vital signs. Which of the following findings should be reported?
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Correct answer: B. Pulse of 96
Relative bradycardia is normal after delivery due to an increased maternal blood volume. The presence of tachycardia warrants exploration. Temperature of 37.8�C or 100.2�F, respiratory rate of 18 bpm, and blood pressure of 120/80 are all normal variants of vital signs.
After assessing a postpartum client’s breast, diagnosed with mastitis, the nurse notices a red streak and tenderness around the right areola. Which of the following is the most important nursing intervention?
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Correct answer: B. Instruct the client to empty the breasts frequently
It is important to empty the breasts frequently to prevent milk stasis. Warm soaks would be warranted for an infection. Pain medication is appropriate and will help during breast feeding. The milk stasis allows the infection a warm medium to continue to grow and proliferate.
During the 24-hour postpartum assessment, the nurse anticipates the uterine fundus to be in which of the following positions?
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Correct answer: C. U/U
U/U is a normal involution of the uterus and indicates a normal process of healing. U/3, U/4, and a uterus that is unable to palpate because it is too low in the pelvic cavity all indicate that the uterus is further along in the involution process.
The nurse is giving a client who is postpartum the discharge instructions from the hospital. The nurse should instruct the client to return immediately for evaluation if which of the following occurs?
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Correct answer: A. Bleeding becomes heavier than a heavy period
Bleeding heavier than a period after discharge indicates hemorrhage and warrants evaluation. A temperature under 38�C, or 100.4�F, is insignificant. Slight swelling in the lower legs without redness or pain is a normal variant after delivery, due to excess fluids. The development of small hemorrhoids is a normal finding during the postpartum period.
A client phones the nurse to express concern about having intercourse 6�weeks after delivery. She is breast feeding and reports that intercourse is uncomfortable. Which of the following is the appropriate response by the nurse?
Show answer and rationale
Correct answer: D. "Your estrogen levels are low and there is decreased mucus production and dryness."
Estrogen allows for the production of mucous in the vaginal area. The estrogen levels return at a slower pace if a woman is breast feeding exclusively. Abdominal fat has no effect on intercourse. Vaginal rugae reappear 3�weeks after delivery. Distention would not lead to discomfort.
A client who had a vaginal delivery the previous day asks the nurse what it meant when she was informed that she had a thirddegree laceration. The nurse’s response should be based on the understanding that a thirddegree laceration is characterized by a tear
Show answer and rationale
Correct answer: C. that extends through the anal sphincter.
A third-degree laceration goes through the perineal muscle layer with involvement of the anal sphincter. A tear through the skin and into the muscles defines a first-degree laceration. A tear that involves the anterior rectal wall defines a fourth-degree laceration. A tear that extends through the perineal muscle layer defines a second-degree laceration.
A client who had breast augmentation 1�year ago asks the nurse after delivery if she will be able to breast feed. Based on knowledge of breast feeding, the nurse provides which of the following responses?
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Correct answer: C. "You will be unable to breast feed only if the milk ducts were severed."
If the milk ducts were severed during breast augmentation surgery, breast feeding will not be possible due to the lack of a functioning ductal system. Surgery alters the breast’s collection system. Implants have not been found to alter milk composition. Breast surgery does not lead to an increased risk of infection.
The nurse caring for a client who delivered 1�hour ago assesses the uterine fundus to be displaced to the right. Which of the following is the priority intervention the nurse should implement?
Show answer and rationale
Correct answer: C. Reevaluate the client after assisting to the bathroom to void
Excessive bleeding can occur with bladder distention because the uterus cannot fully contract. Frequent voiding is therefore important to prevent this from happening and putting the postpartum client at risk for hemorrhage. Although taking the client’s vitals, checking the client’s perineal area, and checking the client’s legs for swelling are all important to assess, they are not the priority with the findings observed.
A postpartum client delivered a baby 24�hours ago. The client’s blood type is O2. The baby’s blood type has come back O1. The nurse evaluates the need for RhoGam and concludes that RhoGam is
Show answer and rationale
Correct answer: D. needed because the baby has a positive antibody.
The Rh-negative client who delivers an Rh-positive infant receives RhoGam to prevent the formation of antibodies that might complicate future pregnancies. The nurse should look at Rh factor, not blood type. RhoGam must be given within 72�hours of delivery. The only clients who need RhoGam are those with an Rh-negative blood type who have an Rh-positive infant.
A client who is HIV positive has just given birth to her first child by cesarean section. The client received an antiviral medication during pregnancy and received the same medication through an IV during the delivery process. The client asks the nurse what is the risk of giving the baby HIV. Which of the following is the appropriate response by the nurse?
Show answer and rationale
Correct answer: A. "1%."
Current treatment with antiviral medications has greatly reduced the transmission to 1% after a surgical delivery through this prophylactic treatment plan.
Which of the following is the most appropriate consideration to include in the plan of care for an Asian postpartum client who delivered 3�days ago and refuses to drink ice water or use ice packs on her perineum?
Show answer and rationale
Correct answer: B. It is an important cultural belief
Cultural values influence personal self-care. The Asian culture believes that exposure to cool air leads to infection; therefore, Asian mothers will not put themselves at risk for this through oral fluids or ice packs.
A client delivered an infant 12�hours ago and has lots of questions regarding care, but shows little initiative in caring for the newborn. According to Rubin’s theory, the nurse identifies this as which stage the client is exhibiting?
Show answer and rationale
Correct answer: A. Taking-in phase
The taking-in stage usually occurs during the first 24�hours postpartum. This is a time when the client is concerned about her own needs and illustrates little initiative in performing infant care.
A postpartum client’s complete blood count reflects a white blood cell count immediately after delivery of 14,000 per cubed mm. The nurse reports this as
Show answer and rationale
Correct answer: B. elevated but normal following delivery.
An increase in the white blood count is a protective mechanism after delivery. It helps to protect the client from infection and is in response to the stress associated with the labor process.
The nurse is reviewing physician orders for a client in the postpartum period in the hospital who is exhibiting clinical manifestations of pulmonary emboli (PE). Which of the following procedures should the nurse ensure is done first?
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Correct answer: A. Pulmonary angiogram
A pulmonary angiogram is considered the definitive test because x-rays can visualize the emboli after catheterization and contrast dye is injected. A spiral CT scan is the test used if the V/Q scan is not diagnostic. The V/Q scan is only suggestive and not a definitive test for PE. A duplex ultrasonogram is a test that shows a disruption of blood flow in the lower legs.
When preparing a client who is not pregnant for an oral glucose tolerance test (OGTT or GTT), it is essential for the nurse to explain that the client must drink what amount of glucose?
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Correct answer: C. 75�grams
Drinking 25 or 50�grams of glucose is not enough to challenge the pancreas when evaluating for diabetes mellitus; 100�grams is widely used to screen for gestational diabetes mellitus; 75�grams of glucose is the recommended glucose load to screen the nonpregnant pancreas for diabetes mellitus or impaired glucose tolerance.
A client after a vaginal delivery is at risk for postpartum hemorrhage. Nursing education to prevent postpartum hemorrhage is based on the knowledge that priority explanation for the cause is
Show answer and rationale
Correct answer: A. uterine atony.
About 75% of all hemorrhages are due to uterine atony, which is the lack of uterine tone. Laceration of the perineal area, uterine rupture, and high parity are other causes of hemorrhage, but they are not as likely.
While assessing a client who just delivered a baby weighing 9 lb and 6 oz, the nurse assesses a firm fundus that is midline at U/U. There is also a constant trickle of blood from the vaginal area. Which of the following is the priority nursing intervention?
Show answer and rationale
Correct answer: D. Notify the physician of a possible laceration
The bleeding from a laceration is not due to uterine atony but to a lacerated area in the perineal, vaginal, or cervical area. It is a priority to notify the physician of a possible laceration. The uterus is firm midline and at an appropriate level.
A client with a history of hypertension had an oxytocin drug ordered due to increased bleeding after delivery. The nurse appropriately administers which of the following drugs?
Show answer and rationale
Correct answer: B. Oxytocin (Pitocin)
Oxytocin (Pitocin) may cause hypotension, but this would not be of much concern in a client who is hypertensive. Hypertension is an adverse reaction to both methylergonovine maleate (Methergine) and ergonovine (Ergotrate). These drugs would be contraindicated for the client with hypertension. Aspirin inhibits the synthesis of clotting factors and can increase the risk of bleeding.
Following giving birth, a client complains of excruciating pain around her labial area. Upon assessment, the nurse observes a bluish, bulging area just under the skin on the left labia majora. The nurse reports this as a(n)
Show answer and rationale
Correct answer: A. hematoma.
Extreme pain is a classic indication of a hematoma. This pain is caused by pressure from the swelling of tissues in the pelvic area from damage to a vessel wall.
A client who delivered an infant 3�days ago is complaining of pain, frequency of urination, and nausea. The nurse takes the client’s temperature and it is 38.9�C, or 102�F. Which of the following is the priority intervention?
Show answer and rationale
Correct answer: B. Call the physician to obtain an order for a urine specimen for culture
Pain, frequency of urination, and nausea are all common clinical manifestations of a urinary tract infection. The postpartum client is at risk due to decreased tone and sensation of the bladder after delivery. Because the ureters are enlarged after delivery due to the effects of pregnancy, infection may travel up to the kidneys. It is therefore very important to have prompt intervention and treatment started immediately. It is important to notify the physician of any deviations.
The nurse is caring for a client postoperatively following a cesarean section. It is a priority for the nurse to monitor the client for
Show answer and rationale
Correct answer: C. infection.
The nurse should closely monitor a client postoperatively for infection, which has an incidence ranging from 4-12% due to increased tissue trauma. Postpartum depression, dehydration, and blood clots are possible complications, but they occur at a lower incidence.
The registered nurse is delegating nursing tasks on a postpartum maternity unit. Which of the following tasks should the nurse delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: D. Maintain an accurate intake and output
Assessing the postdelivery fundus, administering oxytocin (Pitocin), and reporting abnormal lochia are all skills that should be performed by a registered nurse. Maintaining an accurate intake and output is a task that can be delegated to a licensed practical nurse. The client experiences diuresis after delivery.
Which of the following is a priority for the nurse to monitor in an infant born to a mother who has diabetes mellitus?
Show answer and rationale
Correct answer: C. Hypoglycemia
Maternal hyperglycemia causes the fetus to produce more insulin. After delivery, when maternal glucose is suddenly withdrawn, this�excessive insulin produces neonatal hypoglycemia. Although Rh sensitization, ABO incompatibility, and hypothermia may be appropriate to assess in any newborn, they are not associated with maternal diabetes.
Based on an understanding of maternal hyperglycemia, which of the following is a priority to assess in the newborn?
Show answer and rationale
Correct answer: C. Cardiac anomalies
Maternal hyperglycemia has a teratogenic effect. Infants born to mothers with insulin dependence are at greater risk for cardiac anomalies.
The nurse is preparing to administer vitamin K to an infant when the mother asks why her newborn is receiving a vitamin K injection. Which of the following is the most appropriate response? "Vitamin K is administered to
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Correct answer: A. "protect against intracranial hemorrhage."
An injection of prophylactic vitamin K is administered by intramuscular (IM) injection into the newborn’s thigh during the first hour of life to stimulate the production of vitamin K by the bacteria in the newborn’s intestine. Because the newborn’s intestinal tract is considered to be sterile at birth, serious consequences, such as central nervous system hemorrhages, may result if vitamin K is not administered. Deficiencies rapidly occur within the first 2 to 3�days of life. Heel sticks and IM injections do not cause excessive bleeding in the normal newborn. Petechiae are associated with abnormalities of coagulation, not with adaptation to extrauterine life.
When preparing the delivery room to care for the newborn, which of the following should the nurse obtain?
Show answer and rationale
Correct answer: B. A radiant warmer
Due to the high ratio of a newborn’s body surface to weight and the inability to shiver, newborns are at risk for hypothermia. Newborns lose heat to the environment through conduction, radiation, evaporation, and convection. A radiant warmer decreases these losses. Applying cool washcloths would increase heat loss. Clothing would prevent warmth from reaching the skin. Formula is not indicated immediately after delivery.
The nurse caring for a large-for-gestational-age newborn monitors blood glucose to detect hypoglycemia as the result of
Show answer and rationale
Correct answer: C. hyperinsulinemia.
Large-for-gestational-age newborns are likely to develop hyperinsulinemia in order to adapt to elevated maternal blood glucose. When the delivery of maternal glucose ceases with the clamping of the cord, the newborn’s blood sugar may plummet. Large-for-gestational-age newborns do not have limited glycogen stores. Although they may have excessive fat stores, this does not cause hypoglycemia. A large ratio of body surface to weight ratio is true of all newborns.
The nurse admitting a preterm newborn to the nursery should assess the newborn for which of the following?
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Correct answer: D. Respiratory distress
Preterm newborns may not have adequate pulmonary surfactant. This increases the work of breathing and may cause respiratory distress and failure. Shoulder dystonia, clavicle fractures, and palsies are complications associated with larger newborns.
The nurse caring for a newborn of an Rh-negative mother determines the newborn may be at risk for which of the following?
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Correct answer: D. Hemolytic disease
Rh sensitization is the most common cause of maternal immunization and hemolysis (destruction of the red blood cells) in the newborn. The sensitized Rh-negative mother produces antibodies to the Rh factor. In the Rh-positive fetus and newborn, these antibodies cause hemolysis. Petechiae, sepsis, and cardiac anomalies are not associated with hemolytic disease of the newborn.
After reviewing the medical record of a mother, the nurse evaluates a type A fetus to be at risk of ABO incompatibility from the mother because she has a blood type of
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Correct answer: C. O.
Type O persons produce both anti-A and anti-B antibodies. Type AB persons produce no antibodies. Type A and type B persons produce the antibody to the opposite type. For example, a type B person would produce anti-A antibodies. ABO incompatibility occurs when a type O mother is pregnant with a type A or type B fetus. The mother may develop antibodies that may result in hemolysis in the fetus and newborn. The infants may go on to develop hyperbilirubinemia, requiring phototherapy.
The nurse reviewing a newborn’s chart informs the parents that ABO incompatibility is not possible in their newborn because the mother’s blood type is
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Correct answer: C. AB.
Type O persons produce both anti-A and anti-B antibodies. Type AB persons produce no antibodies. Type A and type B persons produce the antibody to the opposite type. For example, a type B person would produce anti-A antibodies. No ABO incompatibility occurs with a type AB mother regardless of the fetus’s blood type.
Based on an understanding of plantar creases in the newborn, the nurse assesses plantar creases immediately after birth because
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Correct answer: A. fluid loss may give the appearance of more plantar creases.
Newborns lose fluid in the first few days, which may produce the appearance of more plantar creases. The process of footprinting does not obscure the crease. Acrocyanosis and drying of the surface of the skin do not affect the creases.
The parents of a newborn ask why their newborn is undergoing testing for inborn errors of metabolism, congenital adrenal hyperplasia, and hypothyroidism. The nurse informs the parents that the priority reason that all newborns are tested is to
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Correct answer: B. detect conditions that require special diet and drugs.
Early detection and treatment of inborn errors of metabolism, congenital adrenal hyperplasia, and hypothyroidism will prevent complications and disabilities, such as mental retardation and developmental delays. These conditions are preventable.
The nurse is performing a newborn assessment�and evaluates a collection of blood�beneath the newborn’s scalp that does not�cross suture lines. The nurse documents this as
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Correct answer: D. cephalohematoma.
Cephalohematoma is the collection of blood between a cranial bone and its periosteum. Because it is contained by the periosteum, the cephalohematoma does not cross suture lines. Caput succedaneum is a soft tissue swelling that does cross the suture line. Occiput and sinciput are anatomical points on the head.
The nurse is assessing a newborn following delivery. Which of the following assessments is abnormal and determines that further evaluation is needed?
Show answer and rationale
Correct answer: A. Noisy breath sounds
A newborn’s skin should be pink or rosy as circulation improves. An infant’s heart rate should decrease from a high of 150 to 160 beats per minute to a rate of between 130 and 140 beats per minute. Noisy breath sounds may indicate an obstruction of the air flow through the nares and oropharynx. Suctioning with a bulb syringe may clear the nasal passage of fluid and debris. As a result, the breath sounds would become quiet. Axillary infant temperature should be between 36.5�C and 37.6�C, or 97.7�F and 99.7�F.
The nurse is assessing the reflexes of a newborn. The nurse assesses which of the following reflexes by placing a finger in the newborn’s mouth?
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Correct answer: C. Sucking reflex
The sucking reflex is tested by placing something, such as a finger, in the infant’s mouth and seeing if the infant begins to suck on the object. The Moro reflex is tested by suddenly lowering the newborn’s body. The infant should demonstrate a bilateral arm extension and leg flexion. The rooting reflex is tested by stroking the cheek. The infant may open the mouth. The Babinski reflex is tested by firmly stroking the plantar surface. The anticipated response is the incurving of the toes as in plantar the grasp, with uncurling and fanning out.
The nurse assesses which of the following reflexes by lifting the newborn’s body slightly�above the crib, followed by suddenly�lowering the body and observing for�bilateral arm extension and leg flexion?
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Correct answer: B. Moro reflex
The Moro reflex is assessed by lifting the newborn’s body slightly above the crib, followed by suddenly lowering the body and observing for bilateral arm extension and leg flexion. The Babinski reflex is tested by firmly stroking the plantar surface. The palmar grasp is assessed by watching the infant wrap fingers around an object placed across the palm. The�Gallant reflex is performed by holding an infant prone and stroking the lateral aspect of the leg from below the knee superiorly to the buttocks.
The nurse documents which of the following reflexes as being responsible for an infant incurving the toes with uncurling and fanning out of the toes when the lateral plantar surface is stroked?
Show answer and rationale
Correct answer: C. Babinski reflex
The Babinski reflex is tested by firmly stroking the plantar surface. The anticipated outcome is�the incurving of the toes with uncurling and fanning out of the toes. The Moro reflex is tested by suddenly lowering the newborn’s body. The expected outcome is bilateral arm extension and leg flexion. The rooting reflex is tested by stroking the cheek. The anticipated outcome is the infant turning the head in the direction of the stroking and opening the mouth. The Gallant reflex is performed by holding an infant prone and stroking the lateral aspect of the leg from below the knee superiorly to the buttocks. The infant reacts by moving the buttocks toward the side that is stroked in a curving movement.
The parents of a newborn ask the nurse why their infant must be tested for phenylketonuria. The appropriate response by the nurse is "to
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Correct answer: B. prevent mental retardation."
Phenylketonuria is deficiency of phenylalanine hydroxylase, which results in failure to metabolize phenylalanine. A deficiency of phenylalanine may result in mental retardation. Cystic fibrosis is a chronic lung disease in which recurrent infections occur, resulting from the inability of the ciliated epithelium to secrete mucus. Osteogenesis imperfecta type I involves osteoporosis and recurrent fractures of the long bones. It is characterized by blue sclera, conductive deafness, and discolored teeth. Polycystic kidney disease causes cysts in the kidneys, liver, pancreas, and spleen. Hematuria and proteinuria result.
The parents of a newborn ask the nurse why the�doctor said the infant must be tested for galactosemia. The nurse should inform the parents that galactosemia is an inborn error of metabolism, in which the newborn cannot metabolize which of the following?
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Correct answer: B. Lactose
Galactosemia is a deficiency in beta galactosidase, which results in failure to properly metabolize lactose.
The nurse evaluates a newborn to have which�of the following STORCH (syphilis, toxoplasmosis, rubella, cytomegalovirus, and herpes) diseases because the newborn’s mother handled cat feces and ate raw or undercooked meat during pregnancy?
Show answer and rationale
Correct answer: D. Toxoplasmosis
Toxoplasmosis is a STORCH disease transmitted by handling cat feces or eating raw and undercooked meat. Cytomegalovirus, herpes, and rubella are diseases that are transmitted by humans.
The nurse should inform a mother that which of the following occupations during pregnancy puts the infant at risk for developing cytomegalovirus?
Show answer and rationale
Correct answer: D. Day care worker
Cytomegalovirus is transmitted in the urine of infected persons. Individuals who work in day care during pregnancy put the infant at risk for developing cytomegalovirus. Toxoplasmosis is transmitted by cat feces and by eating raw or undercooked meat.
The registered nurse is preparing clinical assignments for a newborn care unit. Which of�the following clinical assignments should the�nurse delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: D. Administer vitamin K to an infant
A licensed practical nurse may administer vitamin K to an infant. Assessing an infant for cephalohematoma, monitoring an infant for tachypnea, and instructing the parents of an infant on normal nutrition are nursing tasks that require the skills of a registered nurse.
The nurse is teaching a well-baby class to a group of pregnant clients on the characteristics of the feces of newborns and toddlers. Which of the following should the nurse include?
Show answer and rationale
Correct answer: D. For the first 24 hours, the feces passed by the newborn are black, tarry, and sticky
For the first 24 hours of life, the feces of the newborn are called meconium stools and are black, tarry, and sticky. Generally by the third day of life, the stools become greenish brown to yellowish brown, thin, and less sticky than the meconium stool. Infants who are breastfed have stools that are bright yellow or golden colored and pasty. Infants who are bottle-fed have stools that are pale yellow to tan colored and formed.
The nurse is preparing a client for an ultrasound of her uterus. Which of the following nursing interventions should the nurse perform prior to sending the client for the examination?
Show answer and rationale
Correct answer: D. Have the client drink two glasses of water
An ultrasound uses high-frequency sound waves to provide an image of an organ. An ultrasound of the uterus requires that the bladder be full in order to visualize the uterus; thus, the client needs to drink fluids prior to the examination. An ultrasound does not use contrast media, such as iodine preparations, and metal objects, such as jewelry and hair clips, are not contraindicated for an ultrasound. Having the client void before the examination would prevent the visualization of the uterus.
Which of the following statements by the nurse should be included in the instructions for a client with endometriosis who is scheduled for a laparoscopy?
Show answer and rationale
Correct answer: A. "Do not drink carbonated beverages for 48�hours after the procedure."
Clients having a laparoscopy should refrain from drinking carbonated beverages for 48�hours after the procedure because the beverages may react with the carbon dioxide used in the procedure, causing vomiting. The laparoscope is inserted through a stab wound, thus eliminating the necessity of a surgical incision and dressing. A blue dye is not used for assessment of endometriosis. Clients having laparoscopy normally have mild pain in the shoulder area due to the insufflation of carbon dioxide during the procedure.
Which of the following should the nurse include in the instructions for a client who is to have a cervical biopsy?
Show answer and rationale
Correct answer: C. The procedure must be scheduled for 1�week after menses begin
A cervical biopsy must be scheduled for 1�week after menses begin to minimize the possibility that the client might be pregnant. The client should be NPO after midnight for the procedure. The client should not douche or have intercourse for 48�hours before the procedure. The client should not have sexual intercourse until the biopsy site has healed, which is at least 72�hours after the procedure.
A client beginning menopause asks the nurse, "What can I expect if I don’t go on hormone replacement therapy?" The best response of the nurse should be which of the following?
Show answer and rationale
Correct answer: B. "You may be more prone to fracturing a bone if you fall or injure yourself, so you will need to be very careful."
Menopausal women who do not take estrogen replacement therapy are at risk for developing osteoporosis and will be more prone to fractures. Some of the manifestations of menopause do not disappear, such as vaginal and urethral atrophy. Women going through menopause will have irregular menses, not spotting. Women beginning menopause are still ovulating irregularly and may get pregnant if contraception is not used.
The nurse instructs a client in menopause to eat foods that are high in calcium. The nurse includes which of the following foods that has the highest calcium content in these instructions?
Show answer and rationale
Correct answer: A. Ice cream
Calcium is present in all of the food groups, but is highest in dairy products. Ice cream contains 1406 mg per serving. Low-fat plain yogurt contains 415 mg per serving. Eggnog contains 330 mg per serving and an egg omelet contains 47 mg per serving.
Which of the following nursing diagnoses would be most important for the nurse to include in the nursing care plan for a 55-year-old client who has had amenorrhea for 1�year?
Show answer and rationale
Correct answer: A. Risk for impaired physical mobility
Menopause is considered complete after amenorrhea for 1�year in the older adult woman. A menopausal client is at risk for impaired mobility due to osteoporosis in the spine. Menopausal women can continue to function sexually and perform self-care measures. Although the skin becomes dryer in menopause, it is not of major consequence.
The nurse assesses a client with a vesicovaginal fistula to have which of the following?
Show answer and rationale
Correct answer: A. Urine leaking continuously from the bladder into the vagina
A fistula is an abnormal opening between two organs or between an organ and the external body. The name of the fistula identifies the two areas of the body that are connected by the abnormal opening. Therefore, a vesicovaginal fistula connects the bladder with the vagina, resulting in urine from the bladder leaking continuously out the vagina. Fecal material in the vagina would be a rectovaginal fistula and urine passing from the urethra into the vagina would be a urethrovaginal fistula. The passage of urine from the ureter to the vagina is a ureterovaginal fistula.
The nurse includes which of the following in the discharge instructions for a client with a rectovaginal fistula?
Show answer and rationale
Correct answer: D. Avoid straining to have a bowel movement
Clients with rectovaginal fistulas are advised not to strain to have a bowel movement, because the increase in pressure aggravates the fistula and usually increases the size of the opening. Clients are advised to use either cleansing or deodorizing douches during the course of treatment. Clients with rectovaginal fistulas are prone to bacterial infections rather than fungal infections. Fluid intake should not be limited as this would cause constipation, which in turn puts pressure on the site of the fistula when one strains to have a bowel movement.
The client who had a rectovaginal fistula surgically repaired a year ago asks the nurse, "Why does the surgeon want to see me again in 6�months?" The best response of the nurse would be, "The surgeon
Show answer and rationale
Correct answer: B. wants to monitor the site to be sure the fistula hasn’t returned."
Rectovaginal fistulas that are surgically repaired may recur within 2�years after the repair, necessitating follow-up care for a 2-year period. Paregoric is prescribed to inhibit bowel action and would be contraindicated for a rectovaginal fistula. Weight gain would not be a consequence of this type of surgery and would not be a contributing factor for a recurrence of the fistula. A rectovaginal fistula is repaired internally and any related perineal irritation should have healed shortly after the surgery.
The nurse monitors the urinary output every 4 hours of a postoperative client who had a cystocele and rectocele repair (anterior and posterior colporrhaphy). Which of the following measurements is the maximum amount of urine that should accumulate in the bladder?
Show answer and rationale
Correct answer: C. 100 ml
The client who has a cystocele and rectocele repair should not have more than 100 ml of urine accumulating in the bladder to prevent tension on the suture line. Amounts of 150 ml, 200 ml, and 250 ml enlarge the bladder sufficiently to put pressure on the operative site.
Which of the following assessment findings is an anticipated finding for the client with a rectocele?
Show answer and rationale
Correct answer: C. Hemorrhoids
A rectocele is herniation of the rectum into the vagina. As a rectocele enlarges, the client has difficulty having a bowel movement, becomes constipated, and begins to strain to have a bowel movement, resulting in hemorrhoids. A rectocele does not affect the urinary tract. Tarry stools would occur with gastrointestinal bleeding at a site remote from the rectum.
Which of the following statements by the nurse should be included in the instructions for a client receiving treatment for vaginitis?
Show answer and rationale
Correct answer: D. "The vagina needs to be acidic to decrease your chance of another infection."
The normal pH of the vagina is approximately 3.5 to 5.5 and it is the acidic nature of the vaginal discharge that protects the vagina from infection by bacteria. Douching decreases the amount of normal vaginal discharge, which alters the acid nature of the vagina. Sexual intercourse, with or without protection, should not be done when a vaginal infection is present. A water-soluble lubricant has no therapeutic value in the treatment of vaginitis.
The nurse should monitor which of the following clients for a potential vaginal infection?
Show answer and rationale
Correct answer: C. A client given broad-spectrum antibiotics for a wound infection
Broad-spectrum antibiotics decrease the quantity of helpful bacteria as well as harmful bacteria, so a client on broad-spectrum antibiotics for a period of time may develop vaginitis due to a decrease in the normal vaginal flora. Use of sanitary napkins has not been related to vaginal infections, but tampon use is the suspected cause of toxic shock syndrome, a bacterial infection. A sexually active menopausal client would not normally be at risk for vaginitis. Trimethoprimsulfamethoxazole (Bactrim), an antibacterial prescribed for urinary tract infections, does not normally alter the flora in the vagina and rectum.
Which of the following assessment findings would indicate to the nurse that a client with a history of gonorrhea is experiencing a complication of the disease?
Show answer and rationale
Correct answer: A. Inability to conceive
One of the complications of gonorrhea is sterility, caused by scarring of the fallopian tubes during the course of the disease and resulting in strictures. A cottage cheese-like vaginal discharge would occur with the client with candidiasis, a fungal infection. Multiple ruptured vesicles on the vagina and perineum occur when the client has herpesvirus type 2. A client having heavy vaginal bleeding after several missed periods is probably experiencing a miscarriage, which indicates that the conceived ovum was transported through the fallopian tube to the uterus.
The nurse should include which of the following questions in a nursing history from a client admitted with pelvic inflammatory disease (PID)?
Show answer and rationale
Correct answer: D. "Have you ever used an intrauterine device?"
Clients who use or have used intrauterine devices are at risk for developing pelvic inflammatory disease (PID). The discharge for PID is foul smelling and purulent, not bloody with clots. Clients with PID may have fever and chills, but the temperature elevation is not sudden, and they do not normally have spotting after intercourse.
The nurse develops a plan of care for the immediate postoperative period for a client who had an abdominal hysterectomy. The plan should include measures to
Show answer and rationale
Correct answer: C. assess for abdominal distention.
Abdominal distention in a postoperative client who had an abdominal hysterectomy could be an indication of the complication of a paralytic ileus. Intake and output should be assessed more frequently than every shift to detect postoperative complications of urinary retention and paralytic ileus. Wound suction catheters should remain open to prevent abscess formation. Clients should be ambulated the evening of surgery to prevent thrombophlebitis.
The nurse is collecting a nursing history from a client admitted with an ectopic pregnancy. Which of the following questions should the nurse ask?
Show answer and rationale
Correct answer: C. "Have you ever had an infection in your pelvis?"
Clients who have had previous pelvic infections, such as chlamydia, gonorrhea, or pelvic inflammatory disease, are at risk for having an ectopic pregnancy, due to the strictures and adhesions created by these conditions. The cause of an ectopic pregnancy is not related to a problem with the male partner. Women at risk for an ectopic pregnancy are women who have had induced abortions, not miscarriages. Ectopic pregnancies are not genetic.
The registered nurse is preparing the clinical assignments on a women’s health unit. Which of the following assignments would be appropriate to delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: B. Ask a woman about an allergy prior to a diagnostic test
A registered nurse may delegate asking a woman about an allergy prior to a diagnostic test. Performing an admission assessment, conducting a health history, and developing a plan of care involve the skills of a registered nurse.
A client diagnosed with social phobia asks the nurse about the likelihood of children inheriting this disorder from their parents. Which of the following is the most appropriate response by the nurse?
Show answer and rationale
Correct answer: B. "The chances of developing social phobia increase about 10% if a parent has the disorder."
Although the precise mechanism of inheritance is unknown, developing a social phobia is 11% more likely if a family member has the disorder.
Which of the following should be the priority consideration for the nurse caring for a client performing overt rituals?
Show answer and rationale
Correct answer: C. Performing the ritual serves to decrease the client’s anxiety
The purpose served by rituals is anxiety reduction. A ritual should only be interrupted as part of a carefully crafted program of exposure response prevention. The rationale the client gives for the ritual is seldom helpful in decreasing the behavior. The substitution of a less disruptive behavior only prolongs the treatment process.
Which of the following instructions should the nurse give a client about relaxation techniques?
Show answer and rationale
Correct answer: D. Relaxation techniques are most effective when practiced regularly
The ability to effectively use relaxation techniques takes significant practice. Although heart rate often decreases during relaxation, monitoring it is unnecessary. Very young children can effectively use relaxation techniques. Relaxation can be safely and effectively used on most occasions.
While educating a client who has a social phobia about the use of a selective serotonin reuptake inhibitor (SSRI), the nurse assesses the client’s knowledge about the drug. The client tells the nurse the physician explained that the drug will correct a "chemical imbalance" but states being unsure about what that means. Which of the following is the appropriate response by the nurse?
Show answer and rationale
Correct answer: C. "Sometimes the brain produces too little of a chemical called serotonin and the SSRI corrects this."
The nurse should tell the client that a SSRI produces the chemical serotonin in the brain of a client who naturally produces too little. This is a simple but accurate explanation that makes sense of why this particular drug will help. The nurse, along with the physician, is responsible for medication education. This client already admitted to knowing about it. The nurse is responsible for knowing what a chemical imbalance means.
A client with a dog phobia has undergone desensitization to this stimulus. The nurse evaluates which of the following client behaviors that indicates the treatment was successful?
Show answer and rationale
Correct answer: A. The client can pet the neighbor’s dog without undue anxiety
Success in phobic desensitization is shown when the client is able to do what the average person can do without undue anxiety. Clients with phobias routinely believe their fears are unreasonable before treatment begins. A client visiting a dog shelter three times a week and stating that fears are greatly diminished are both steps in the overall desensitization process, but they are not the end result.
While preparing a client for surgery the next day, the nurse observes that the client is having trouble paying attention to instructions, is trembling, and has sweaty palms, a rapid heart rate, and rapid respirations. The client states, "All I can think about is this surgery tomorrow, and whether everything will go all right. The nurse notifies the physician that the client’s level of anxiety is
Show answer and rationale
Correct answer: A. severe.
When the client begins to display frank sympathetic arousal clinical manifestations and verbalize distress, the level of anxiety is severe.
Which of the following client assessments on the use of a benzodiazepine would be a priority concern to the nurse?
Show answer and rationale
Correct answer: C. A history of alcohol or substance abuse
Because benzodiazepines have a serious abuse potential, they are generally contraindicated for clients with a history of alcohol or substance abuse. A lack of adequate coping skills, a closed head injury, and a diet high in tyraminerich foods are not factors in prescribing benzodiazepines.
When a client has panic-level anxiety, plans for nursing intervention should include
Show answer and rationale
Correct answer: C. staying with the client.
Staying with the client reduces the anxiety and helps assure safety. Darkening the room may increase anxiety for a client whose perceptions may already be distorted. When in a panic level of anxiety, a client can focus only on the present and cannot think clearly enough to describe usual behaviors. Security would only be necessary if the client loses behavioral control.
A client diagnosed with generalized anxiety disorder reports feeling increasingly ineffective at work and at home states, "I’m letting everyone down. I don’t know what to do anymore." Which of the following diagnoses should the nurse select as most appropriate?
Show answer and rationale
Correct answer: A. Role performance, ineffective
A client who has a generalized anxiety disorder expresses difficulty in performing usual roles in work and family environments. There is no evidence that the client’s thinking is not reality based. There is no particular decision with which the client is wrestling. There is no indication that the client is facing any change in circumstances.
While assessing a new client, the nurse asks the client about any fears. The client states, "Well, I’ve been afraid to go up and down the basement steps since my hip replacement last fall. I let my children do the laundry." The nurse should evaluate this response as
Show answer and rationale
Correct answer: A. normal anxiety.
It is adaptive and normal for people to be afraid to trust the reliability of a recently repaired joint. There is no indication that the client’s motive is to avoid work. The client is not afraid of the stairs themselves but is afraid of getting hurt. There is no indication that this fear has persisted for a long time.
A client being assessed for anxiety disorder relates to the nurse a concern with many physical clinical manifestations. The client states, "My heart races, my chest gets tight, and I can’t breathe. I must be having a heart attack." Which of the following is the nurse’s most appropriate response?
Show answer and rationale
Correct answer: D. "Those clinical manifestations, although frightening, are very common with anxiety."
Accurate information about the physical clinical manifestations of anxiety can be reassuring. Telling the client that the clinical manifestations are frightening and common in anxiety not only reassures the client but lets the client know the etiology of the clinical manifestations. Asking a client if anyone in the family has had a heart attack will likely increase anxiety and will not help to address the client’s main concern. Telling a client that the doctor should run some tests only reinforces the concern with physical manifestations. It is inappropriate to selfdisclose and will not likely comfort the client.
The nurse is reviewing the care plan for a client diagnosed with generalized anxiety disorder. Which of the following is an appropriate client goal? The client will
Show answer and rationale
Correct answer: B. report tolerating the presence of mild anxiety during activities.
It is an unrealistic goal for clients with generalized anxiety disorder to be anxiety-free. Being able to tolerate mild anxiety so the client can perform activities is a realistic goal. Describing a traumatic event, reporting no dissociative episodes, and confronting a phobic stimulus are not goals for a general anxiety disorder.
A new client in a mental health center program asks the nurse about the purpose of an assigned cognitive reframing group. Which of the following explanations should the nurse give?
Show answer and rationale
Correct answer: C. "This group will help you change your faulty beliefs."
Cognitive reframing and restructuring can help clients change maladaptive beliefs that negatively affect emotions and behavior. Helping a client with short-term memory and socializing more effectively with others occurs in other groups. Psychosocial assessment is not typically done in groups.
The nurse is assessing an obviously anxious client. Which of the following approaches should the nurse use?
Show answer and rationale
Correct answer: C. Ask specific, direct questions about the anxiety
Specific, direct questions will help the client become aware of the anxiety and give pertinent information about it. Not questioning the client until the anxiety has subsided or not mentioning the anxiety unless the client does avoids assessing the client’s anxiety, which must be done for the assessment to proceed. Teaching a client a relaxation exercise is an intervention, without adequate assessment and premature.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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