NCLEX Practice Questions — Set 33
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 nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?
Show answer and rationale
Correct answer: D. Assess the patency of the airway.
The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established
The nurse is reviewing a health care provider’s (HCP’s) prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the HCP to clarify that which medication should be given to the client and not withheld?
Show answer and rationale
Correct answer: A. Prednisone
Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. These last three medications may be withheld before surgery without undue effects on the client
The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?
Show answer and rationale
Correct answer: A. On the nonoperative side with the legs abducted
Positioning following a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and health care provider’s (HCP’s) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or sidelying on the operative side (unless specifically prescribed by the HCP) is avoided
A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position?
Show answer and rationale
Correct answer: A. Supine, with the amputated limb supported with pillows
The amputated limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the amputated limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check health care provider prescriptions regarding positioning following amputation
The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse develops a postoperative plan of care for the client and should include which intervention in the plan?
Show answer and rationale
Correct answer: D. Elevate and immobilize the grafted extremity.
Autografts placed over joints or on lower extremities are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon’s preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site
The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion?
Show answer and rationale
Correct answer: A. High Fowler’s
During insertion of a nasogastric tube, the client is placed in a sitting or high Fowler’s position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side, and low Fowler’s and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube
The nurse is preparing to instill medication into a client’s nasogastric tube. Which actions should the nurse take before instilling the medication? Select all that apply.
Show answer and rationale
Correct answer: C. all the above
By aspirating stomach contents the residual volume can be determined and the pH checked. A pH less than 3.5 verifies gastric placement. The suction should be turned off before the tubing is disconnected to check for residual volume; in addition, suction should remain off for 30 to 60 minutes following medication administration to allow for medication absorption. There is no need to remove the tube and place it in the other nostril in order to administer a feeding; in fact, this is an invasive procedure and is unnecessary
The nurse is preparing to administer medication through a nasogastric tube that isconnected to suction. To administer the medication, the nurse should take which action?
Show answer and rationale
Correct answer: D. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication.
If a client has a nasogastric tube connected to suction, the nurse should wait 30 to 60 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. The client should not be placed in the supine position because of the risk for aspiration. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered
The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct tube placement if which pH value is noted?
Show answer and rationale
Correct answer: B. 3.5
If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. Option 2 indicates a slightly acidic pH. Option 3 indicates a neutral pH. Option 4 indicates an alkaline pH
The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take?
Show answer and rationale
Correct answer: C. Place the tube in a bottle of sterile water.
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection
The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action?
Show answer and rationale
Correct answer: B. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.
Measuring the length of a nasogastric tube needed is done by placing the tube at the tip of the client’s nose and extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches. The remaining options identify incorrect procedures for measuring the length of the tube.
The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client?
Show answer and rationale
Correct answer: A. Stridor
Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the health care provider (HCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the health care provider
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate?
Show answer and rationale
Correct answer: A. Do nothing, because this is an expected finding.
Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in the suction control chamber and not intermittent. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy).
The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate nursing action?
Show answer and rationale
Correct answer: B. Pull back on the tube and wait until the respiratory distress subsides.
During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the health care provider immediately or remove the tube completely. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.
The clinic nurse is preparing to discuss the concepts of Kohlberg’s theory of moral development with a parent. What motivates good and bad actions for the child at the preconventional level?
Show answer and rationale
Correct answer: B. Punishment and reward
In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the child’s actions are good, the child is praised. If the child’s actions are bad, the child is punished. Options 1, 2, and 3 are incorrect for this stage of moral development
The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson’s psychosocial development theory, the nurse instructs the mother to take which measure?
Show answer and rationale
Correct answer: C. Allow the newborn infant to signal a need.
According to Erikson, the caregiver should not try to anticipate the newborn infant’s needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant’s signal would inhibit the development of trust and lead to mistrust of others
The mother of a 4-year-old child calls the clinic nurse and expresses concern because the child has been masturbating. Using Freud’s psychosexual stages of development, the nurse should make which response?
Show answer and rationale
Correct answer: B. "This is a normal behavior at this age."
According to Freud’s psychosexual stages of development, between the ages of 3 and 6 the child is in the phallic stage. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns. Therefore options 2, 3, and 4 are incorrect
The nursing instructor asks a nursing student to present a clinical conference to peers regarding Freud’s psychosexual stages of development, specifically the anal stage. The student plans the conference, knowing that which characteristic relates to this stage of development?
Show answer and rationale
Correct answer: B. This stage is associated with toilet training.
In general, toilet training occurs during the anal stage. According to Freud, the child gains pleasure from the elimination of feces and from their retention. Option 2 relates to the oral stage. Option 3 relates to the latency period. Option 4 relates to the phallic stage
The nursing instructor asks a nursing student to describe the formal operations stage of Piaget’s cognitive developmental theory. The correct response by the nursing student is which statement?
Show answer and rationale
Correct answer: A. "The child has the ability to think abstractly."
In the formal operations stage, the child has the ability to think abstractly and logically. Option 2 identifies the sensorimotor stage. Option 3 identifies the concrete operational stage. Option 4 identifies the preoperational stage
The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson’s psychosocial development theory, the nurse should make which response?
Show answer and rationale
Correct answer: C. "At this age, the child is developing his own personality."
According to Erikson, during school-age years (6 to 12 years of age), the child begins to move toward peers and friends and away from the parents for support. The child also begins to develop special interests that reflect his or her own developing personality instead of the parents. Therefore options 1, 2, and 4 are incorrect responses
The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg’s theory of moral development. What information should the nurse include in the session? Select all that apply.
Show answer and rationale
Correct answer: C. all the above
Kohlberg’s theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5 and 6 in his or her development of personal morality. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. It states that moral development progresses in relationship to cognitive development and that a person’s ability to make moral judgments develops over a period of time. In stage 1, ages 2 to 3 years (punishment-obedience orientation), children cannot reason as mature members of society. In stage 2, ages 4 to 7 years, (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned
A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson’s psychosocial development theory, which instruction(s) should the nurse provide to the parent? Select all that apply.
Show answer and rationale
Correct answer: D. a and c
According to Erikson, the child focuses on gaining some basic control over self and the environment and independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents’ wishes. Saying things like "no" or "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child’s behavior are necessary elements. Providing a simple explanation of why certain behaviors are unacceptable is an appropriate action. Options 2 and 3 do not address the child’s behavior. Option 5 is likely to produce a negative response during this normal developmental pattern
A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child’s fears?
Show answer and rationale
Correct answer: A. Encourage the child’s parents to stay with the child.
Although the preschooler already may be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Options 3 and 4 increase stress related to separation anxiety. Option 2 is unrelated to the subject of the question and, in addition, may not be appropriate for a child who may be immunocompromised and at risk for infection
The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate?
Show answer and rationale
Correct answer: C. Document the findings.
The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/minute. The normal apical heart rate is 90 to 130 beats/minute, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings
The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child?
Show answer and rationale
Correct answer: C. Uses a cup to drink
By age 2 years, the child can use a cup and spoon correctly but with some spilling. By age 3 to 4, the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting.
A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother?
Show answer and rationale
Correct answer: B. Inform the child of bedtime a few minutes before it is time for bed.
Toddlers often resist going to bed. Bedtime protests may be reduced by establishing a consistent beforebedtime routine and enforcing consistent limits regarding the child’s bedtime behavior. Informing the child of bedtime a few minutes before it is time for bed is the most appropriate option. Most toddlers take an afternoon nap and, until their second birthday, also may require a morning nap. Firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics
The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the mother?
Show answer and rationale
Correct answer: A. Allow the bottle if it contains water.
A toddler should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, sweetened water, or any other sweet liquid because of the risk of nursing (bottle-mouth) caries. If a bottle is allowed at nap time or bedtime, it should contain only water.
The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child?
Show answer and rationale
Correct answer: C. Crayons and a coloring book
In the preschooler, play is simple and imaginative, and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh. A radio or sports video are most appropriate for the adolescent. Large picture books are most appropriate for the infant.
A mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3- year-old is which?
Show answer and rationale
Correct answer: A. A wagon
Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, large trucks, and dolls are some of the appropriate toys. A farm set, a golf set, and jacks with marbles may contain items that the child could swallow.
Which intervention(s) are appropriate for the care of an infant? Select all that apply.
Show answer and rationale
Correct answer: C. all the above
Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to do so also. Additional interventions include playing a music box, radio, or television, or having a ticking clock or metronome nearby. Hanging a bright shiny object in midline within 20 to 25 cm of the infant’s face and hanging mobiles with contrasting colors, such as black and white, provide visual stimulation. Crying is an infant’s way of communicating; therefore the nurse would respond to the infant’s crying. The mother is taught to do so also. An infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, sweetened water, or another sweet liquid because of the risk of nursing (bottle-mouth) caries
The nurse is preparing to care for a dying client, and several family members are at the client’s bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.
Show answer and rationale
Correct answer: D. all the above
The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client’s or family member’s hand, if appropriate
The nurse is providing medication instructions to an older client who is taking digoxin (Lanoxin) daily. The nurse notes that which age-related body change could place the client at risk for digoxin toxicity?
Show answer and rationale
Correct answer: A. Decreased lean body mass and decreased glomerular filtration rate
The older client is at risk for medication toxicity because of decreased lean body mass and an ageassociated decreased glomerular filtration rate. Although options 1, 2, and 3 identify age-related changes that occur in the older client, they are not associated specifically with this risk
The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client?
Show answer and rationale
Correct answer: A. Allowing the client to choose social activities
Autonomy is the personal freedom to direct one’s own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and select solutions that allow continued personal freedom as long as others and their rights and property are not harmed. Loss of autonomy, and therefore independence, is a real fear of older clients. The correct option is the only one that allows the client to be a decision maker.
The home care nurse is visiting an older client whose spouse died 6 months ago. Which behavior by the client indicates ineffective coping?
Show answer and rationale
Correct answer: A. Neglecting personal grooming
Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. The correct option is indicative of a behavior that identifies an ineffective coping behavior in the grieving process
The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding care of an older client with hearing loss. Which should the nurse tell the UAP about older clients with hearing loss?
Show answer and rationale
Correct answer: B. They respond to low-pitched tones
Presbycusis refers to the age-related irreversible degenerative changes of the inner ear that lead to decreased hearing ability. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched voice tones are heard more easily and can be interpreted by the older client. Options 1, 2, and 4 are not accurate characteristics related to aging.
The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse?
Show answer and rationale
Correct answer: B. A 90-year-old woman who has advanced Parkinson’s disease
Elder abuse includes physical, sexual, or psychological abuse, misuse of property, and violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least one physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care.
The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I’m in everyone’s way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take?
Show answer and rationale
Correct answer: D. Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help.
Assisting clients and families to become aware of available community support systems is a role and responsibility of the nurse. Observing that the client has begun to be confined to his room makes it necessary for the nurse to intervene legally and ethically, so option 3 is not appropriate and is passive in terms of advocacy. Option 2 suggests committing the client to a nursing home and is a premature action on the nurse’s part. Although the data provided tell the nurse that this client requires nursing care, the nurse does not know the extent of the nursing care required. Option 1 is incorrect and judgmental
The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin?
Show answer and rationale
Correct answer: B. Crusting
The normal physiological changes that occur in the skin of older adults include thinning of the skin, loss of elasticity, deepening of expression lines, and wrinkling. Crusting noted on the skin would indicate a potential complication
The home health nurse is visiting a client for the first time. While assessing the client’s medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first?
Show answer and rationale
Correct answer: B. Determine whether there are medication duplications.
Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the HCP is the intervention after all other information has been collected.
The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological change(s) the nurse expects to note? Select all that apply.
Show answer and rationale
Correct answer: A. all the above
Anatomical changes to the eye affect the individual’s visual ability, leading to potential problems withactivities of daily living. Light adaptation and visual fields are reduced. Although lung function may decrease, the respiratory rate usually remains unchanged. Heart rate decreases and heart valves thicken. Age-related changes that affect the urinary tract increase an older client’s susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory usually is maintained. Change in sleep patterns is a consistent, agerelated change. Older persons experience an increased incidence of awakening after sleep onset
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?
Show answer and rationale
Correct answer: C. Rhythmic respirations with periods of apnea
Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons
The nurse notes documentation that a client has conductive hearing loss. The nurse understands that this type of hearing loss is caused by which problem?
Show answer and rationale
Correct answer: B. A physical obstruction to the transmission of sound waves
A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex.
While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. Which describes the sound of a heart murmur?
Show answer and rationale
Correct answer: A. Gentle blowing or swooshing noise
A heart murmur is an abnormal heart sound and is described as a gentle, blowing, swooshing sound. Lub-dub sounds are normal and represent the S1 (first) heart sound and S2 (second) heart sound, respectively. A pericardial friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt, highpitched snapping sound.
The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?
Show answer and rationale
Correct answer: A. Tests the six cardinal positions of gaze
Testing the six cardinal positions of gaze is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal).
The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski’s sign. Which finding did the nurse observe?
Show answer and rationale
Correct answer: C. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.
Brudzinski’s sign is tested with the client in the supine position. The nurse flexes the client’s head (gently moves the head to the chest) and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski’s sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig’s sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client’s upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?
Show answer and rationale
Correct answer: A. Wheezes
Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.
The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply.
Show answer and rationale
Correct answer: A. all the above
A focused assessment focuses on a limited or short-term problem, such as the client’s complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete assessment includes a complete health history and physical examination and forms a baseline database. Assessing the strength of peripheral pulses relates to a vascular assessment, which is not related to this client’s complaints. A musculoskeletal and neurological examination also is not related to this client’s complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete assessment. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.
The nursing student is preparing to teach a prenatal class about fetal circulation. Which statement should be included in the teaching plan?
Show answer and rationale
Correct answer: D. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta."
Blood pumped by the embryo’s heart leaves the embryo through two umbilical arteries. When oxygenated, the blood is returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and the umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus
A nursing student is assigned to care for a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement is correct regarding the ductus venosus?
Show answer and rationale
Correct answer: C. Connects the umbilical vein to the inferior vena cava
The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery
A pregnant client tells the clinic nurse that she wants to know the gender of her baby as soon as it can be determined. The nurse understands that the client should be able to find out the gender at 12 weeks’ gestation because of which factor?
Show answer and rationale
Correct answer: D. The appearance of the fetal external genitalia
By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the gender of the fetus can be determined visually. Differentiation of the external genitalia occurs at the end of the ninth week. Testes descend into the scrotal sac at the end of the thirty-eighth week. Internal differences in the male and female occur at the end of the seventh week
The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse’s best response?
Show answer and rationale
Correct answer: A. "It promotes the fertilized ovum’s normal implantation in the top portion of the uterus."
tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube. This initial growth of the fertilized ovum promotes its normal implantation in the fundal portion of the uterine corpus. Estrogen is a hormone produced by the ovarian follicles, corpus luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone secreted by the corpus luteum of the ovary, adrenal glands, and placenta during pregnancy. Luteinizing hormone and follicle-stimulating hormone are excreted by the anterior pituitary gland. The survival of the fertilized ovum does not depend on it staying in the fallopian tube for 3 days.
The nursing instructor asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid? Select all that apply.
Show answer and rationale
Correct answer: C. allthe above
The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid contains urine from the fetus and can be used to assess fetal kidney function. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus.
A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be most appropriate?
Show answer and rationale
Correct answer: C. "Do you plan to have any other children?"
Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future. Options 1, 3, and 4 are unrelated to this procedure.
The nurse should include which statement to a pregnant client found to have a gynecoid pelvis?
Show answer and rationale
Correct answer: C. "Your type of pelvis is the most favorable for labor and birth."
A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.
Which explanation should the nurse provide to the prenatal client about the purpose of the placenta?
Show answer and rationale
Correct answer: B. It is the way the baby gets food and oxygen.
The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, drugs, antibodies, and viruses can pass through the placenta
A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse’s best response?
Show answer and rationale
Correct answer: C. "Please share with me more about your concerns."
The nurse needs to establish trust when discussing sexual relationships with men. Open the conversation with broad statements to determine the true nature of the client’s concerns. The frequency of intercourse is not a relevant first question to establish trust. Testosterone declines with the aging process
The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects which finding?
Show answer and rationale
Correct answer: D. 30 cm
During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus’ age in weeks �2 cm. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process
The nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Which are probable signs of pregnancy? Select all that apply.
Show answer and rationale
Correct answer: B. all the above
The probable signs of pregnancy include uterine enlargement, Hegar’s sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell’s sign (softening of the cervix that occurs at the beginning of the second month), Chadwick’s sign (violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (rebounding of the fetus against the examiner’s fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotropin. Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography. Test-Taking Strategy: Focusing on the subject, probable signs of pregnancy, will assist in answering this question. Remember that detection of the fetal heart rate and an outline of the fetus via radiography or ultrasonography are positive signs of pregnancy.
A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is most appropriate?
Show answer and rationale
Correct answer: C. Inform the client that these contractions are common and may occur throughout the pregnancy.
Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, options 1, 2, and 4 are unnecessary and inappropriate actions
The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction should the nurse provide to the client?
Show answer and rationale
Correct answer: C. A cesarean section will be necessary if vaginal lesions are present at the time of labor.
For women with active lesions, either recurrent or primary at the time of labor, delivery should be by cesarean section to prevent the fetus from being in contact with the genital herpes. The safety of acyclovir has not been established during pregnancy, and it should be used only when a life-threatening infection is present. Clients should be advised to abstain from sexual contact while the lesions are present. If this is an initial infection, clients should continue to abstain until they become culture-negative because prolonged viral shedding may occur in such cases. Keeping the genital area clean and dry promotes healing
The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell’s sign. This finding is most closely associated with which characteristic?
Show answer and rationale
Correct answer: A. A softening of the cervix
At the beginning of the second month of gestation, the cervix becomes softer as a result of increased vascularity and hyperplasia, which cause Goodell’s sign. Cervical softening is noted by the examiner during pelvic examination. Goodell’s sign does not indicate the presence of fetal movement. Human chorionic gonadotropin noted in maternal urine is a probable sign of pregnancy. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is caused by blood circulating through the placenta.
A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19, 2014. Using N�gele’s rule, which expected date of delivery should the nurse document in the client’s chart?
Show answer and rationale
Correct answer: B. 42211
Accurate use of N�gele’s rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months and add 7 days to the first day of the last menstrual period, and then add 1 year to that date: first day of the last menstrual period, October 19, 2014; subtract 3 months, July 19, 2014; add 7 days, July 26, 2014; add 1 year, July 26, 2015
A pregnant client asks the nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?
Show answer and rationale
Correct answer: A. 14 and 18
Quickening is fetal movement that is felt by the mother. In the multiparous woman this may occur as early as the fourteenth to sixteenth weeks. The nulliparous woman may not notice these sensations until the eighteenth week or later. Options 1, 2, and 3 are incorrect time frames because quickening does not occur this early during pregnancy
The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which finding concerns the nurse and indicates the need for follow-up?
Show answer and rationale
Correct answer: A. Fetal heart rate of 180 beats/minute
The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160 to 170 beats/minute in the first trimester and slows with fetal growth. Near and at term, the fetal heart rate ranges from 110 to 160 beats/minute. Options 1, 2, and 4 are normal expected findings.
The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client’s chart?
Show answer and rationale
Correct answer: A. G = 2, T = 1, P = 0, A = 0, L = 1
Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies; T is term births, the number born at term (longer than 37 weeks); P is preterm births, the number born before 37 weeks’ gestation; A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks’ gestation; included in parity [number of births] if past 20 weeks’ gestation); and L is the number of current living children. A woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.
The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?
Show answer and rationale
Correct answer: B. An informed consent needs to be signed before the procedure.
Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest, but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in a health care provider’s private office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure
A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?
Show answer and rationale
Correct answer: C. "The vaginal discharge may be bothersome, but is a normal occurrence."
Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently
The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding?
Show answer and rationale
Correct answer: A. Normal
A reactive nonstress test is a normal result. To be considered reactive, the baseline fetal heart rate must be within normal range (120 to 160 beats/minute) with good long-term variability. In addition, two or more fetal heart rate accelerations of at least 15 beats/minute must occur, each with a duration of at least 15 seconds, in a 20- minute interval
A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?
Show answer and rationale
Correct answer: A. A normal test result
Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds’ duration in a 10-minute period. Options 2, 3, and 4 are incorrect interpretations.
A pregnant client tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client’s practice?
Show answer and rationale
Correct answer: C. Hemoglobin 9.1 g/dL
Pica practices often lead to iron deficiency anemia, resulting in a decreased hemoglobin level. The laboratory values in options 1, 2, and 4 are normal for the pregnant client.
A pregnant client asks the nurse about the types of exercises that are allowable during pregnancy. The nurse should tell that client that which exercise is safest?
Show answer and rationale
Correct answer: B. Swimming
Non-weight-bearing exercises are preferable to weight-bearing exercises during pregnancy. Exercises to avoid are shoulder standing and bicycling with the legs in the air because the knee-chest position should be avoided. Competitive or high-risk sports such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, and gymnastics should be avoided. Non-weight-bearing exercises such as swimming are allowable.
A health care provider has prescribed transvaginal ultrasonography for a clientin the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client?
Show answer and rationale
Correct answer: A. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel."
Transvaginal ultrasonography allows clear visibility of the uterus, gestational sac, embryo, and deep pelvic structures, such as the ovaries and fallopian tubes. The client is placed in a lithotomy position and a transvaginal probe, encased in a disposable cover and coated with a gel that provides lubrication and promotes conductivity, is inserted into the vagina. The client may feel more comfortable if she is allowed to insert the probe. The procedure takes about 10 to 15 minutes. Options 2 and 4 identify components of abdominal ultrasound
A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps?
Show answer and rationale
Correct answer: C. "Bend your foot toward your body while extending the knee when the cramps occur."
Leg cramps occur when the pregnant client stretches her leg and plantar flexes her foot. Dorsiflexion of the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting, and stops the cramping. Options 1, 3, and 4 are not measures that provide relief from leg cramps
A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.
Show answer and rationale
Correct answer: B. all the above
Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization as specified by the health care provider because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze
The nurse is describing cardiovascular system changes that occur during pregnancy to a client and understands that which finding would be normal for a client in the second trimester?
Show answer and rationale
Correct answer: C. Increase in pulse rate
Between 14 and 20 weeks’ gestation, the pulse rate increases about 10 to 15 beats/minute, which then persists to term. Options 2, 3, and 4 are incorrect. During pregnancy, the blood pressure usually is the same as the prepregnancy level, but then gradually decreases up to about 20 weeks of gestation. During the second trimester, systolic and diastolic pressures decrease by about 5 to 10 mm Hg. Constipation may occur as a result of decreased gastrointestinal motility or pressure of the uterus. During pregnancy, there is an accelerated production of red blood cells.
The nurse is providing instructions to a pregnant client with humanimmunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?
Show answer and rationale
Correct answer: D. "You will need to bottle-feed your newborn."
Perinatal transmission of human immunodeficiency virus (HIV) can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.
The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider?
Show answer and rationale
Correct answer: C. The client complains of a headache and blurred vision.
If the client complains of a headache and blurred vision, the HCP should be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal signs
A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief?
Show answer and rationale
Correct answer: C. "What can I do for you?"
When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents’ feelings
The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the clientindicates a need for further teaching?
Show answer and rationale
Correct answer: D. "I should avoid exercise because of the negative effects on insulin production."
Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or HCP’s office. Signs of infection need to be reported to the HCP.
The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply.
Show answer and rationale
Correct answer: A. all the above
The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. A lowgrade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia.
A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client’s teaching plan?
Show answer and rationale
Correct answer: D. Isoniazid plus rifampin (Rifadin) will be required for 9 months.
More than one medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required
The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)?
Show answer and rationale
Correct answer: D. A client who has a history of intravenous drug use
Human immunodeficiency virus (HIV) is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include individuals with persistent and recurrent sexually transmitted infections, individuals who have a history of multiple sexual partners, and individuals who have used intravenous drugs. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV
The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?
Show answer and rationale
Correct answer: A. "We want to attend a support group."
A support group can help the parents work through their pain by nonjudgmental sharing of feelings. The correct option identifies a statement that would indicate positive, normal grieving. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process
The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother’s knowledge of potential disease transmission to the newborn?
Show answer and rationale
Correct answer: D. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding
Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission. Option 1 will not affect disease transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for hepatitis B.
A client in the first trimester of pregnancy arrives at a health care clinic andreports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction?
Show answer and rationale
Correct answer: D. "I will maintain strict bed rest throughout the remainder of the pregnancy."
Strict bed rest throughout the remainder of the pregnancy is not required for a threatened abortion. The client is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding or as recommended by the health care provider. The client is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The client also should watch for the evidence of the passage of tissue
The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor?
Show answer and rationale
Correct answer: A. The cervix is dilated completely.
The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider?
Show answer and rationale
Correct answer: A. Fetal heart rate of 180 beats/minute
A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute couldindicate fetal distress and would warrant immediate notification of the HCP. By full term, a normal maternalhemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in plasma volume duringpregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readingsto facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normalpregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to15,000 cells/mm3 (up to 18,000 cells/mm3). During the immediate postpartum period, the white blood cell count maybe 25,000 to 30,000 cells/mm3 because of increased leukocytosis that occurs during delivery.
The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area?
Show answer and rationale
Correct answer: C. 1 cm above the ischial spine
Station is the measurement of the progress of descent in centimeters above or below the midplane fromthe presenting part to the ischial spine. It is measured in centimeters, and noted as a negative number above the line and as a positive number below the line. At the negative 1 (-1) station, the fetal presenting part is 1 cm above the ischial spine
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?
Show answer and rationale
Correct answer: A. Variable decelerations
Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.
The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?
Show answer and rationale
Correct answer: B. "I will begin abdominal exercises immediately."
A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery
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/minute. Which nursing action is most appropriate?
Show answer and rationale
Correct answer: B. Notify the health care provider (HCP).
A normal fetal heart rate is 110 to 160 beats/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 HCP or nurse-midwife 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?
Show answer and rationale
Correct answer: D. Document the findings and tell the mother 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 well-being 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?
Show answer and rationale
Correct answer: 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 she makes which statement?
Show answer and rationale
Correct answer: A. "My contractions will increase in duration and intensity."
True labor is present when contractions increase in duration and intensity. Lightening or dropping is also known as engagement and occurs when the fetus descends into the pelvis about 2 weeks before elivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.
Which assessment finding following an amniotomy should be conducted first?
Show answer and rationale
Correct answer: B. Fetal heart rate pattern
Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Bladder distention or maternal blood pressure would not be the first things to check after an amniotomy. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection.
The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client’s primary physiological need at this time?
Show answer and rationale
Correct answer: 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. Changing positions frequently is not the primary physiological need. Ambulation is encouraged during early labor. Ice chips should be provided. Food and fluids are likely to be withheld at this time
The nurse is assisting a client undergoing induction of labor at 41 weeks’ 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/minute for the past hour. What is the priority nursing action?
Show answer and rationale
Correct answer: C. Discontinue the infusion of oxytocin (Pitocin).
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 should reposition the laboring mother. Applying oxygen, increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin), and notifying the health care provider are also actions that are indicated in this situation. Contacting the client’s primary support person(s) is not the priority action at this time.
The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruption placentae. Which assessment finding should the nurse expect to note if this condition is present?
Show answer and rationale
Correct answer: C. Uterine tenderness
Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa
The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider’s prescriptions and should question which prescription?
Show answer and rationale
Correct answer: C. Obtain equipment for a manual pelvic examination.
Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia.
An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruption placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?
Show answer and rationale
Correct answer: D. Delivery of the fetus
Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of a client with abruptio placentae
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.
More NCLEX practice and review
Everything on this site tagged NCLEX lives in the NCLEX category.
Sources