NCLEX Practice Questions — Set 3
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
A staff RN and a nurse’s aide are caring for six clients. The RN delegates the following assignments to the nurse’s aide: vital signs, baths, and intake and output for all clients. What is the RN’s accountability for the delegated work?
Show answer and rationale
Correct answer: A. Define client parameters to the nurse’s aide that must be reported to the RN.
setting definite parameters will guide the nurse’s aide as to the priorities and what should be reported to the RN.
On a skilled nursing unit, an LVN/LPN reports to a staff nurse that a client is short of breath. What is the most important initial response by the RN?
Show answer and rationale
Correct answer: B. Ask the LVN/LPN to describe what is meant by shortness of breath.
more information is necessary in order to clarify the urgency of the situation. This information will help delineate and prioritize nursing interventions.
A night RN reports that a client, admitted with a diagnosis of gastric ulcer, is reporting syncope and dizziness. What should be the initial nursing intervention by the RN?
Show answer and rationale
Correct answer: D. Keep the client on bedrest.
the priority is to maintain client safety. With syncope and dizziness, the client is at high risk for falling.
A client, admitted to the emergency department with a myocardial infarction (MI), is experiencing chest pain and becomes profusely diaphoretic and apprehensive. What should be the initial intervention by the RN?
Show answer and rationale
Correct answer: B. Give the prn dose of morphine sulfate 3 mg IV push.
morphine sulfate is given for chest pain at a rate of 1 mg/min repeated every 5 minutes as needed to block pain perception. However, in myocardial ischemia it decreases anxiety and oxygen demand as it promotes vasodilation.
An RN observes another RN speaking harshly and reprimanding a client for being incontinent. What action should be taken?
Show answer and rationale
Correct answer: A. Advise the supervisor by writing an objective account of the incident.
Objective reporting allows for client advocacy while maintaining anonymity for the staff. It allows the supervisor to initiate corrective and therapeutic action with the person who is abusive, while protecting clients from such abuse in the future. Appropriate action is objective reporting and following the agency’s chain of command.
Which nursing intervention should be implemented before the deflation of a tracheostomy cuff?
Show answer and rationale
Correct answer: D. Suction the trachea and mouth.
secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated.
A client who is 23 years old, gravida 2, para 1 with a twin gestation, is admitted to labor and delivery at 29 weeks’ gestation with complaints of lower abdominal pain and decreased fetal movement. Which interventions should a nurse perform? Select all that apply.
Show answer and rationale
Correct answer: A. Place the client on electronic fetal monitor.
placing the client on an electronic fetal monitor is an appropriate intervention to evaluate uterine contractions and determine fetal well-being. Evaluate of fetal wellbeing is very important for this client because of her complaint of decreased fetal movement.
A postpartum nurse is caring for a client suspecting of having endometritis. What are the risk factors for developing endometritis? Select all that apply.
Show answer and rationale
Correct answer: B. Internal fetal monitoring.
internal fetal monitoring can act as a conduit for transmission of bacteria into the uterine cavity during labor and delivery, increasing the risk of developing postpartum endometritis.
A client who is a 38-year-old gravida 1, para 0 with type 2 non-insulin-dependent diabetes, is 6 weeks pregnant. She asks a clinic nurse how she should manage her diabetes now that she is pregnant. Which would be the most appropriate response by the nurse?
Show answer and rationale
Correct answer: C. "You can control your blood sugar with insulin injections."
insulin does not cross the placenta and is safe for use in pregnancy
A 26-year-old client, who is a gravida 1, para 1, delivered an 8-pound, 12-ounce female infant over an intact perineum 24 hours ago. Since the client’s delivery, an RN has observed that the client does not seem to show a lot of attention to her new infant. The client frequently lets her family take care of changing and holding the newborn. How should the RN interpret the client’s behavior?
Show answer and rationale
Correct answer: A. The client is showing expected behaviors for the taking-in period.
this client is demonstrating normal behavior for the taking-in period, which, according to Rubin, includes dependence and passivity that may last up to 3 days after delivery.
A client who is a 23-year-old primigravida is admitted for induction of labor for macrosomia. Upon assessment, an RN notes the client is having contractions every 2 minutes, lasting 60 seconds in duration. A physician orders misoprostol 25 mcg to be placed in the posterior fornix of the vagina. Which action should be taken by the RN?
Show answer and rationale
Correct answer: B. Withhold the dosage and notify the physician of contraction pattern.
this client is having very frequent uterine contractions and placing misoprostol is contraindicated for this client. The physician should be notified of the contraction pattern and withholding the misoprostol dose.
A client who is a 38-year-old multipara had an epidural during her last labor for pain control. She and her husband have chosen to decline any medication during this labor and delivery and ask an RN to help them achieve this goal. To best assist them during the second stage of labor, which action should be taken by the RN?
Show answer and rationale
Correct answer: A. Inform the couple about progress toward delivery and all procedures.
keeping the couple informed decreases anxiety, increases confidence in their ability to cope with an unmedicated labor and delivery, and helps accomplish their goals.
A client who is a primigravida is admitted in early labor at 38 weeks’ gestation. Her physician orders auscultation of fetal heart tones every 30 minutes. The RN knows that the most appropriate time to listen to fetal heart tones is:
Show answer and rationale
Correct answer: B. During a contraction and for 30 seconds after the contraction.
this is the correct procedure for fetal heart tone auscultation.
A client, who is a gravida 7, para 3, delivers a healthy 6- pound, 4-ounce infant. When an RN performs a postpartum assessment, the client states, "I hope this is our last baby because we can’t afford any more children." What is the best response by the nurse?
Show answer and rationale
Correct answer: D. "We can discuss different birth-control methods you can use."
it is appropriate to discuss birth control at the time when the client is asking questions and is receptive to teaching.
A nurse is caring for a client at 35 weeks’ gestation who has been admitted to an obstetrics unit with abruptio placentae. Which symptoms are likely to be a result of the placental abruption? Select all that apply.
Show answer and rationale
Correct answer: A. Tetanic uterine contractions.
a placental abruption causes tetanic uterine contractions in response to the placenta detaching from the uterine wall.
A nurse is providing discharge teaching to a 16-year-old primigravida client. The client is asking questions about her neonate’s care. Which methods should be used by the nurse to assist the client in learning to care for her newborn? Select all that apply.
Show answer and rationale
Correct answer: C. Provide written materials to reinforce teaching.
providing written materials is a suitable method for reinforcing teaching.
A client had a vaginal delivery 2 days ago. During the morning assessment, the client complains that excessive perspiration kept her awake all night. She is worried that there is a problem. Which response by a nurse would be the most appropriate?
Show answer and rationale
Correct answer: B. "Fluids that were retained during pregnancy are normally lost in this manner."
this explanation is factually true. Fluids are retained during pregnancy and lost in this manner. This is called postpartum diuresis and is commonly experienced about 24 to 48 hours after delivery.
A client is admitted in early labor. The client requests to ambulate to enhance the strength of her contractions. Which event should prompt an RN to return the client to bed and evaluate her condition?
Show answer and rationale
Correct answer: D. Intense pressure at the peak of contractions.
intense pressure at the peak of contractions may indicate the client is completely dilated and is close to delivery. A return to bed and a vaginal examination are needed to confirm this possibility.
A neonate is flaccid at delivery and is not breathing. A pediatrician orders positive-pressure ventilation using a mask attached to wall oxygen. While administering the oxygen, in which position should a nurse place the neonate?
Show answer and rationale
Correct answer: C. On the back, with the neck slightly extended.
placing the neonate on the back, with the neck slightly extended, will open the airway and facilitate ventilation.
Which observation of an 8-pound, 4-ounce neonate, if made by an RN, would require an intervention?
Show answer and rationale
Correct answer: D. The neonate’s axillary temperature is 96.2°F (35.6°C).
this subnormal temperature indicates prematurity, infection, low environment temperature, inadequate clothing, and/or dehydration and requires an intervention.
A client presents to a labor and delivery unit at 38 weeks’ gestation. Before applying an external fetal monitor, an RN performs Leopold’s maneuver and finds a hard, distinct mass in the upper right quadrant of the client’s uterus. Where should the RN anticipate finding the fetal heart tones?
Show answer and rationale
Correct answer: D. Above the umbilicus on the client’s right side.
the fetal head is in the upper right quadrant, the body will be on the right side with the heart tones in the upper quadrant above the umbilicus.
A pregnant client expresses concern about her gestational diabetes and asks an RN, "Does this mean I will be diabetic for the rest of my life?" Which is the most appropriate response by the RN?
Show answer and rationale
Correct answer: D. "There is a possibility that you may develop type 2 diabetes at some point in the future."
there is about a 75% chance that a woman with gestational diabetes will develop type 2 diabetes in the future.
A client gave birth 40 minutes ago. The placenta has not yet delivered. What is the most appropriate action for an RN to take at this time?
Show answer and rationale
Correct answer: C. Prepare the client for surgery.
the client has not delivered the placenta within 40 minutes; the physician will explore the uterus and may determine that the client has a placenta accreta, which would require surgical intervention.
During a routine ultrasound examination, a client, who is 33 weeks pregnant, states that she feels that her heart is pounding. She also reports feeling "hot and sweaty." Which intervention by a nurse is the most appropriate?
Show answer and rationale
Correct answer: A. Assist her to a left lateral position.
changing to a left lateral position helps to alleviate vena cava compression from the gravid uterus, and will reduce her discomfort.
A client who is 32 weeks’ gestation presents to a physician’s office for a routine prenatal checkup. Leopold’s maneuver reveals the fetal position as right occipitoanterior (ROA). At which site would an RN expect to find the fetal heart tone?
Show answer and rationale
Correct answer: B. Below the umbilicus, on the client’s right side.
the fetal head and back are pressing against the right side of the client’s abdomen; the fetal heart tones would be heard below the umbilicus on the right side.
An RN is completing a home visit with a client who delivered a full-term infant 4 days ago. The client states that she is exclusively bottle feeding her infant. Upon assessment, the RN notes white, curdlike patches on the newborn’s oral mucous membranes. Which action should the RN take?
Show answer and rationale
Correct answer: A. Explain that the newborn will need to receive some medication.
newborn most likely has thrush (oral candidiasis): white plaque on the oral mucous membranes, gums, or tongue. Treatment usually includes good hand washing and nystatin (Mycostatin).
During the examination of a newborn infant, an RN suspects congenital dislocation of the left hip. Which assessment finding would confirm the nurse’s suspicion?
Show answer and rationale
Correct answer: B. Asymmetry of the gluteal and thigh folds.
asymmetry of the gluteal and thigh folds is caused by restricted movement on the affected side, which is a symptom of congenital hip dislocation.
A nurse is caring for a client who is hospitalized with severe pregnancy-induced hypertension (PIH). What would be an appropriate nursing intervention for this client?
Show answer and rationale
Correct answer: A. Keep her on modified bedrest in a lateral position.
modified bedrest in a lateral position can decrease the client’s blood pressure and increase the placental perfusion.
The mother of a neonate with a clubfoot feels guilty because she believes she did something during her pregnancy to cause the deformity. A nurse should explain to the mother that the cause of clubfoot is:
Show answer and rationale
Correct answer: A. Unknown.
the cause of clubfoot isn’t known, but it is not related to anything a woman did during pregnancy to cause the malformation.
A nursing student is preparing to administer an injection of vitamin K, 1 mg IM, to a newborn. The student asks a nurse, "Where should I give the injection?" Which is the most accurate response by the nurse?
Show answer and rationale
Correct answer: D. Vastus lateralis.
the vastus lateralis is the proper injection site; it is a large muscle and avoids the nerve tracts.
A client, who is multiparous, delivered a 9-pound, 12-ounce baby girl at 41 3/7 weeks’ gestation. After 14 hours of labor, she had an arrest of descent and a cesarean section was performed. While performing an initial newborn assessment, what observations should a nurse expect to find in a neonate of this gestation? Select all that apply.
Show answer and rationale
Correct answer: D. Milia.
milia are clogged sebaceous glands usually found on the nose and are a normal finding in all gestational ages.
A client who is at 38 weeks’ gestation presents to labor and delivery and states, "I have water leaking down my legs." Which assessment by a nurse is most appropriate in this situation?
Show answer and rationale
Correct answer: D. Blood pressure check.
the fern test is done to check for ruptured membranes. It is positive if the amniotic sac has broken.
A nurse performs a sterile vaginal examination on a multiparous client at 37 weeks’ gestation. The client is 8 cm dilated, completely effaced, and a +1 station. She tells the nurse, "I can’t keep myself from pushing when I have a contraction." Which nursing intervention is most appropriate in this situation?
Show answer and rationale
Correct answer: A. Assist the client to pant-blow at the peak of contractions.
assisting the client to pant-blow at the peak of contractions will help her to avoid pushing before her cervix is completely dilated.
A client, who is gravida 1, para 0 at 40 weeks’ gestation, is in the active phase of labor. The client has had no identified risk factors during her prenatal care. A nurse evaluates the fetal monitor strip at 10:00 hours. The fetal heart rate (FHR) is 130 with moderate variability, and accelerations are present, but no decelerations. At what time should the nurse reevaluate the FHR?
Show answer and rationale
Correct answer: A. 10:30 a.m.
reevaluating the fetal heart rate tracing every 30 minutes is the recommended interval for a client who is low risk.
A client, who is gravida 4, para 3 at 39 weeks’ gestation, has no identified prenatal risk factors and is in early labor. The client declines electronic fetal monitoring (EFM), stating that she delivered her second baby at home without a monitor and everything went well. What is the most appropriate way for the nurse to handle this situation?
Show answer and rationale
Correct answer: B. Explain that she will need to be on the monitor for about 20 minutes to assess fetal well-being. If the initial tracing is reassuring, the baby may be monitored intermittently.
studies have shown that intermittent monitoring is a safe and effective method for monitoring fetal well-being for a low-risk pregnancy. This client fits the criteria for intermittent monitoring. In addition, the use of intermittent monitoring may depend on the hospital’s policy and procedure.
A nurse evaluates a fetal monitor tracing. The nurse should anticipate that an obstetrician will consider performing an amnioinfusion if the electronic fetal monitor tracing reveals:
Show answer and rationale
Correct answer: D. Baseline heart rate = 120, moderate variability present, and deep variable decelerations with every contraction.
this pattern has the potential for prolonged decelerations and fetal distress. An amnioinfusion will help cushion the umbilical cord compression and relieve or decrease the severity of the variable decelerations.
A client, who is gravida 1, para 0, presents to labor and delivery because her contractions have become regular, every 5 minutes, and she rates them a 5 on a pain scale of 1 to 10. She talks excitedly with her husband, who is to be her coach. She says that she is pleased that the happy day is finally here, but she is afraid that she will start screaming and she will not be able to handle it when the contractions get stronger. She and her husband have attended childbirth preparation classes. Based on her contractions pattern and her behavior, what are the most likely stage and phase of labor?
Show answer and rationale
Correct answer: D. First stage, latent phase.
this client is excited and talkative, suggesting she is in early labor or the latent phase of the first stage of labor.
Several hours after admission to a birthing center, a client, who is gravida 1, para 0, is dilated 5 cm. The cervix is completely effaced and the fetus is at a +1 station. When a contraction begins, the client kneels on the bed, rests her upper body against her husband, closes her eyes, and sways slowly while humming softly. At the end of the contraction, her husband gently places her on her side and she rests with her eyes closed until the next contraction begins. Which is the most appropriate nursing action for this client?
Show answer and rationale
Correct answer: B. Offer her clear liquids.
the client is coping well with her labor and, with the partner’s support, is using prepared childbirth techniques. Offering clear liquids would be an appropriate nursing action during the active phase of labor.
A client, who is gravida 3, para 1, is 8 cm dilated, completely effaced, and a +1 station. She becomes agitated and snaps at her husband and a nurse. She exclaims, "I can’t stand this anymore! I want a cesarean section!" What is the most appropriate response by the nurse at this time?
Show answer and rationale
Correct answer: D. "I understand you want a cesarean section, but you are in the transition phase of labor and your feelings are very common in this stage."
it validates the client’s feelings, gives an explanation for her condition, and does not promise anything to the client.
A nurse gives a report on a client who is 29 years old, gravida 2, para 1 at 32 weeks’ gestation. The fetus is in a vertex presentation and the water bag is intact. A vaginal examination was done 1 hour previously. At that time, the client’s cervix was 3 cm dilated and 80% effaced. The station was -2. Continuous EFM is ordered and IV fluids are infusing into the client’s left arm. Which is the most important nursing assessment at this time?
Show answer and rationale
Correct answer: A. The frequency and duration of contractions.
this client is at 32 weeks’ gestation, multipara, and 3 cm dilated. The contractions are the most important assessment in a client who is in preterm labor. If the contractions are close together, tocolytics will be required to decrease the contractions. If there are rare or no contractions, the nurse can focus on other assessments.
A client delivers a 7-pound, 4-ounce neonate at 38 weeks’ gestation. What observations, if found on initial assessment, should a nurse report to a physician? Select all that apply.
Show answer and rationale
Correct answer: A. Respiratory rate of 20.
the normal respiratory rate is 30 to 60 breaths/min. A rate of 20 is abnormal after birth and may indicate apnea and respiratory distress, and should be reported to the physician.
A client, who is gravida 1, para 0, is admitted to labor and delivery for induction of labor at 41 weeks’ gestation. Her cervical examination reveals her cervix to be closed and thick and the fetal head is out of the pelvis. Which medications should a nurse anticipate being ordered by a physician? Select all that apply.
Show answer and rationale
Correct answer: D. Cervidil.
cervidil is a prostaglandin E2 vaginal insert used to help ripen the cervix for induction of labor.
A 23-year-old client, who is gravida 3, para 2, delivered a baby by vacuum-assisted vaginal delivery 2 days ago. As part of the discharge teaching class, for which conditions should a nurse instruct the client to call a physician? Select all that apply.
Show answer and rationale
Correct answer: D. Pain that is not well controlled by prescription pain medication.
pain that is not well controlled by pain medication can be indicative of a postpartum complication, such as endometritis, and the physician should be notified.
A client, who is a primigravida at 10 weeks’ gestation, reports mild uterine cramping and slight vaginal spotting without passage of tissue. When assessed, no cervical dilation is noted. Which is the best action by the nurse?
Show answer and rationale
Correct answer: A. Anticipate that the woman will be sent home and placed on bedrest.
this client is experiencing a threatened abortion. At this gestation, there is no medical intervention to prevent miscarriage. Bedrest is the expected management.
A client, who is gravida 3, para 2 at 28 weeks’ gestation, exhibits glucosuria during her routine prenatal visit. A nurse knows that glucosuria during pregnancy indicates:
Show answer and rationale
Correct answer: D. An increased glomerular filtration of glucose.
glucosuria is most often secondary to the pregnancyrelated increased glomerular filtration of glucose without an increased tubular reabsorption.
A client, who is gravida 4, para 1 at 28 weeks’ gestation, completes a 1-hour glucose tolerance test. Her 1-hour blood sugar is 150 mg/dL. Which type of follow-up should a nurse recommend to this client?
Show answer and rationale
Correct answer: D. A 3-hour glucose tolerance test.
the abnormal 1-hour test results should be followed up by a 3-hour glucose tolerance test.
A client, who is at 32 weeks’ gestation, comes to a clinic for a routine prenatal visit. She is having discomfort related to constipation. The nurse should teach the client that the most appropriate measures to alleviate this problem include:
Show answer and rationale
Correct answer: D. Drinking 8-10 cups of water and take a daily walk.
pregnancy slows intestinal motility due to the influence of progesterone. Increasing fluid intake and exercise stimulates peristalsis and can relieve the discomfort of constipation.
A client, who is at 26 weeks’ gestation, presents for a routine appointment. The client asks a nurse why she is having trouble with constipation during her pregnancy. Which explanation by the nurse would be most accurate?
Show answer and rationale
Correct answer: C. The muscle movement of the intestines slows down, which causes dry, hard stools.
during pregnancy, progesterone causes peristalsis to slow the intestines so that more nutrients can be absorbed.
A client, who is gravida 6, para 2, is admitted to labor and delivery in early labor on October 18. A nurse palpates regular uterine contractions every 5 minutes with moderate intensity. A sterile vaginal examination reveals a soft cervix that is 2 cm dilated, 85% effaced, and a -2 station. Which admission information is most important in planning this client’s nursing care?
Show answer and rationale
Correct answer: C. The client’s LMP was January 2.
when using Naegele’s rule, this client’s EDD is October 8th. This makes the client 41 weeks and 3 days’ gestation on admission. This is the most important factor in planning her nursing care since this is a postdates pregnancy.
A pregnant client attends a first-trimester class on eating well for pregnancy. Which statement should indicate to a nurse that the client requires additional teaching?
Show answer and rationale
Correct answer: D. "My strange craving to eat laundry starch is a normal part of pregnancy."
strange cravings called pica are not a normal part of pregnancy and may be associated with iron deficiency.
A client, who is 22 years old, gravida 1, para 0, is admitted to an obstetrics unit with contractions every 8 to 10 minutes. A physical assessment reveals that her cervix is 3 cm dilated, 100% effaced, and a 0 station. During the admission process, a nurse asks the couple about their plans for pain relief during labor. The client and her support person state they planned to use prepared childbirth techniques. Based on the information provided, which pain relief method should the nurse expect the couple to use during this phase of labor?
Show answer and rationale
Correct answer: C. Slow, deep breathing.
this client is in the latent phase of labor; their plan is to use prepared childbirth techniques. Slow, deep breathing and relaxation techniques are used to relieve contraction pain during this phase.
A client, who is 37 years old, gravida 4, para 3 at 14 weeks’ gestation, asks a nurse, "Do you think I’m having a boy? All my other children are girls. If I don’t have a boy this time, my husband will really be disappointed in me." Which explanation by the nurse would be most accurate?
Show answer and rationale
Correct answer: C. "The father’s sperm determines if the baby is male or female."
meiosis results in the X and Y chromosomes of the male splitting so that each sperm carries either an X or a Y chromosome, thus determining the gender of the fetus.
A client at 12 weeks’ gestation is at her first prenatal visit. The client is given instructions to get prenatal labs and a multiple marker screen drawn at the laboratory. She asks a nurse about the purpose of the multiple marker screen. The nurse should inform the client that the conditions that may be detected with this test are: Select all that apply.
Show answer and rationale
Correct answer: D. Edwards’ syndrome.
Edwards’ syndrome (trisomy 18) is one of the conditions that may be detected by the multiple marker screen. It is a severe, usually lethal developmental disorder. It is characterized by cranial, neurological, facial, cardiac, and GI malformations.
A 24-hour-old neonate is icteric with a serum bilirubin level of 14 mg/100 mL. The mother’s blood type is O+; the blood type of the baby is B and has a positive direct Coombs’ test. The infant is being breastfed. Which measure should a nurse include in the neonate’s plan of care?
Show answer and rationale
Correct answer: D. Encourage the mother to increase the frequency of breastfeeding sessions.
early and frequent breastfeeding tends to lower serum bilirubin levels and avoids dehydration that increases the serum bilirubin level.
A client, who is gravida 2, para 0, has a routine ultrasound at 18 weeks’ gestation to confirm her estimated date of delivery; the ultrasound shows the fetus in a breech position. The client asks a nurse "Does this mean I will have to have a C-section?" Which response by the nurse would be most accurate?
Show answer and rationale
Correct answer: A. "Many babies are breech at this gestation; most turn to head-down by term."
approximately 96% of fetuses in a breech position will turn to a vertex position by term.
A laboring client, who is gravida 1, para 0, has had no change in her cervix for 2 hours and remains 9 to 10 cm dilated. The fetal head has remained at 0 station. A sterile vaginal examination reveals a position of occiput posterior. Which action by the nurse would be most appropriate?
Show answer and rationale
Correct answer: A. Assist the client to a hands-and-knees position.
maternal position changes such as sitting, kneeling, lateral, or hands and knees can assist fetal head rotation from an occipitoposterior to an occipitoanterior position.
A client with preterm contractions at 34 weeks’ gestation is dilated to 3 cm. A physician orders an amniocentesis for fetal lung maturity. Which laboratory test will provide the most information to a nurse about fetal lung maturity?
Show answer and rationale
Correct answer: C. Phosphatidylglycerol (PG).
phosphatidylglycerol (PG) is a major phospholipid of surfactant. The presence of PG in amniotic fluid indicates fetal lung maturity.
A client, who is gravida 6, para 4, has a routine ultrasound at 16 weeks’ gestation. The ultrasound shows that the client is carrying dizygotic twins. She asks a nurse what the difference is between monozygotic and dizygotic twins. Which explanation by the nurse would be most accurate?
Show answer and rationale
Correct answer: C. "Dizygotic twins come from two different eggs and sperm."
dizygotic twins develop from two different eggs fertilized by two different sperm.
A client, who is 18 years old, presents to a prenatal clinic because her menstrual period is 9 days late. She tells a nurse, "I’m sure I’m pregnant because my period is late and my breasts are tender." Which response by the nurse would be most appropriate?
Show answer and rationale
Correct answer: D. "A missed menstrual period and breast tenderness are presumptive signs of pregnancy."
presumptive signs of pregnancy are: amenorrhea, fatigue, breast tenderness and enlargement, morning sickness, and quickening, which are more subjective signs.
A client who is gravida 2, para 1 is seen in an emergency department at 14 weeks’ gestation with bright red vaginal bleeding and severe lower abdominal cramping. Which assessment finding is the most important observation at this time?
Show answer and rationale
Correct answer: A. Increasing heart rate.
an increased pulse in the presence of visible bleeding indicates excessive blood loss.
An anesthetist has just placed an epidural catheter dosed with bupivacaine hydrochloride (Marcaine) in a client in labor who is gravida 2, para 1 at 39 weeks’ gestation. For which side effect should a nurse observe this client?
Show answer and rationale
Correct answer: C. Hypotension.
with epidural anesthesia, the sympathetic nerves are also blocked by the medication, resulting in vasodilation and hypotension.
A nurse assesses a client who is 40 years old, gravida 11, para 9 at 14 weeks’ gestation, and has a history of thromboembolitic disease. The client is placed on daily heparin therapy. Which laboratory test will be the most important for this client?
Show answer and rationale
Correct answer: D. Partial thromboplastin time.
partial thromboplastin time is evaluated to determine the effectiveness of heparin therapy.
A client, who is 36 years old, has been trying to get pregnant for about 5 months. At her physician appointment, she states that she knows she should take folic acid supplements but dislikes taking pills. Which foods that are high in folic acid should a nurse suggest? Select all that apply.
Show answer and rationale
Correct answer: B. Spinach.
spinach is the richest source of folic acid, with about 130 mcg per serving. The recommended folic acid intake is 600 mcg/day during pregnancy.
A client has just completed the second stage of labor and has begun the third stage of labor. Which nursing action has priority at this time?
Show answer and rationale
Correct answer: C. Physical assessment of the neonate.
the client has just delivered; the placenta has not delivered yet. The newborn’s physical condition and Apgar scoring is a priority at 1 and 5 minutes after delivery.
A client, who delivered a full-term infant 45 minutes ago, is carefully examining her newborn during the initial breastfeeding. She asks a nurse, "My baby’s head is shaped like a bullet! Will it stay like that?" Which response by the nurse is most accurate?
Show answer and rationale
Correct answer: B. "That is called molding. It usually lasts for a few days."
molding is an overlapping of the fetal skull bones at the occiput of the skull. The infant skull has a bulletshaped appearance that quickly resolves.
A client, who is gravida 3, para 2, has a spontaneous vaginal delivery of a 6-pound baby girl over an intact perineum. She has an epidural for relief of labor pain. She is currently in the fourth stage of labor. Which nursing goal would be most appropriate for the client at this time?
Show answer and rationale
Correct answer: B. The client will maintain physiological homeostasis.
maintaining physiological homeostasis is the most important goal during the fourth stage of labor, the immediate postpartum period. The most common complication of the fourth stage of labor is uterine atony and hemorrhage.
A client, who is 19 years old, gravida 1, para 0, is admitted to labor and delivery with HELLP syndrome at 28 weeks’ gestation. A nurse knows that management for her condition should include: Select all that apply.
Show answer and rationale
Correct answer: D. Administration of corticosteroid.
the client who is 28 weeks’ gestation with HELLP syndrome will most likely have to be delivered before reaching full-term gestation. Administration of corticosteroid to help mature the fetal lungs would be an appropriate part of management for this client.
A nurse assesses a client who is 15 years old, gravida 1, para 0, and is 11 weeks’ gestation. Which prenatal laboratory test would indicate a risk factor for this client?
Show answer and rationale
Correct answer: A. Hemoglobin = 9 gm/dL.
the normal hemoglobin in pregnancy ranges from 11 to 12 gm/dL. This client is a teenager who is pregnant and is anemic.
A client, who is gravida 3, para 2 at 37 weeks’ gestation, is 5 cm dilated, 80% effaced, and a +1 station. She received epidural anesthesia with bupivacaine hydrochloride (Marcaine) for contraction pain 1 hour ago. Which nursing assessment is most important for this client at this time?
Show answer and rationale
Correct answer: B. Assessing the client hourly for bladder distention.
the client may not sense the urge to void due to decreased sensation to the area. Bladder distention can interfere with descent of the fetus and cause pain.
A client, who is gravida 1, para 0, arrives in a labor and delivery unit at 38 weeks’ gestation with mild irregular contractions. A sterile vaginal examination reveals the following: cervical dilation of 3 cm, 60% effaced, -1 station, and membranes intact. An external fetal monitor is placed and the fetal heart tracing reveals a baseline of 130 bpm, moderate variability, and accelerations to the 150s during contractions. Based on this information, which nursing action would be most appropriate?
Show answer and rationale
Correct answer: C. Send the client home and encourage her to ambulate.
this client is in prodromal labor. The fetal heart pattern is reassuring. There is no reason to admit the client to the hospital at this time. Ambulation at home may stimulate labor and descent of the presenting part, and decrease hospitalization time.
A client, who delivered 8 weeks ago, is exclusively breastfeeding, and asks for information on birth control methods that do not interfere with breast milk production. Which statement should indicate to a nurse that the client needs further instruction?
Show answer and rationale
Correct answer: A. "Breastfeeding itself is effective at preventing pregnancy."
high prolactin levels with exclusive breastfeeding can delay ovulation for up to 6 months. However, it is a very unpredictable method of birth control.
A nurse assesses a client who delivered an 8-pound, 6-ounce infant 2 hours ago. Which assessment findings are considered "normal" in a client during this time? Select all that apply.
Show answer and rationale
Correct answer: A. Fundus firm, at the umbilicus.
the fundus is usually at about the level of the umbilicus 2 hours after delivery.
A client delivered an 8-pound, 9-ounce neonate at 39 weeks’ gestation. Which observations, if found during the initial assessment, are normal findings and do not need to be reported to a physician? Select all that apply.
Show answer and rationale
Correct answer: A. Respiratory rate of 46.
the normal respiratory rate is 30 to 60 breaths/min. This finding does not require any intervention and does not need to be reported to the physician.
A client with type 1 insulin-dependent diabetes presents to a prenatal clinic at 17 weeks’ gestation for ?-fetoprotein testing. She asks a nurse why this test is being performed. Which explanation by the nurse would be most accurate?
Show answer and rationale
Correct answer: D. "This test is screening for neural tube defects."
the ?-fetoprotein (AFP) is a maternal blood test that screens for possible neural tube defects (the most common anomaly) in fetuses of a client with diabetes. It can also indicate the presence of Down syndrome.
A client entered the fourth stage of labor 30 minutes ago. During an assessment, a nurse notes that there is constant trickling of bright red vaginal blood in the presence of a contracted uterus midline at the umbilicus. Which action by the nurse would be most appropriate in this situation?
Show answer and rationale
Correct answer: A. Call the physician.
a constant trickling of bright red vaginal blood in the presence of a contracted uterus may be an unrepaired laceration of the birth canal. The physician must be notified so that the laceration can be repaired.
A client, who is a gravida 3, para 1, presents to labor and delivery at 41 4/7 weeks’ gestation for induction of labor. Her cervix is 2 cm dilated, 80% effaced, and a -3 station. A nurse anticipates that, in preparation for labor, a physician will likely order: Select all that apply.
Show answer and rationale
Correct answer: D. Pitocin at 2 milliunits/min IV.
pitocin at 2 milliunits/min IV is an appropriate dose for induction of labor in a client who is past her estimated date of delivery
A client, gravida 2, para 0, is admitted to a labor and delivery unit at 35 weeks’ gestation. Her blood pressure is 180/110 mm Hg, pulse 88, respirations 18, and temperature 98.6�F. Her urine dipstick shows 3+ proteinuria and a physical assessment reveals 3+ deep tendon reflexes. A physician orders magnesium sulfate to be infused at 2 gm/hr. Which action by a nurse indicates understanding of the possible side effects of magnesium sulfate?
Show answer and rationale
Correct answer: B. Darkening the room.
magnesium sulfate side effects include headaches and seizures. Darkening the room can help reduce the occurrence of these side effects.
A nurse enters the room of a client who is a 22-year-old primigravida who was 39 weeks’ gestation. The infant was delivered using vacuum extraction 3 hours ago. The client is in tears and says "When I first delivered, the baby breastfed for almost an hour, now the baby won’t wake up enough to take the nipple!" Which intervention would be most appropriate in this case?
Show answer and rationale
Correct answer: B. Instruct the client to let the baby sleep, because babies cluster-feed, and frequently sleep for several hours after the initial breastfeeding.
the infant’s suckling reflex is greatest from 45 minutes to 2 hours after birth. The baby may nurse several times close together (cluster feedings) and then sleep several hours without nursing.
A client, who is gravida 3, para 0 at 39 weeks’ gestation, is admitted to a labor and delivery unit in active labor. The physician performs an amniotomy. Which assessment finding should a nurse anticipate after the amniotomy?
Show answer and rationale
Correct answer: B. A moderate amount of straw-colored fluid.
a moderate amount of straw-colored fluid is a normal color and an amount of amniotic fluid that is expected after the artificial rupture of membranes.
A client, who is gravida 1, para 0, is admitted to labor and delivery with spontaneous rupture of membranes. A vaginal examination reveals clear fluid and the cervix is 2 cm dilated. Based on the information provided, which statement should a nurse expect this client to make?
Show answer and rationale
Correct answer: D. "We have a name picked out for the baby."
this client is a primigravida at 2 cm dilated. This is the first stage of labor, and latent phase. Typically, clients in this stage of labor are not in much pain, and are excited and talkative about what is happening.
A client, who is gravida 2, para 0 at 38 weeks’ gestation, is having sharp decreases in fetal heart rate from a baseline of 130 bpm to 90 to 110 bpm during the contractions. Which action should a nurse take first?
Show answer and rationale
Correct answer: B. Turn the client to her left side.
the first action the nurse should take is to turn the client to her left side, which may help resolve the variable decelerations.
A client, who is gravida 1, para 0, is dilated to 6 cm, 100% effaced, and a 0 station for the past 2 hours without any change in her cervix. A physician orders oxytocin (Pitocin) augmentation. When evaluating the effectiveness of IV oxytocin augmentation, which outcome should a nurse anticipate?
Show answer and rationale
Correct answer: C. Progressive cervical dilation.
this client has uterine dystocia, and the effectiveness of the oxytocin infusion is measured by a change in the dilation of the cervix.
A client, who is gravida 1, para 0 at 37 weeks’ gestation, is admitted to labor and delivery in active labor. A vaginal examination reveals a footling breech presentation. Which action should the nurse take first?
Show answer and rationale
Correct answer: B. Anticipate the need for a cesarean section.
the client will need a cesarean section as quickly as possible to avoid a vaginal delivery and possible head entrapment.
A client, who is gravida 2, para 1, is admitted to a birthing center. A nurse is using a Doppler to check fetal heart tones. The nurse finds fetal heart tones of 160 to 170 bpm. A vaginal examination reveals that the cervix is 4 cm dilated, with intact membranes and a -1 station. The nurse decides to apply an external fetal monitor rather than an internal monitor. Which is the best rationale for this decision?
Show answer and rationale
Correct answer: D. The membranes are still intact.
the nurse cannot artificially rupture the amniotic membranes in order to apply an internal fetal monitor. The only choice for continuous fetal monitoring is an external fetal monitor.
A client, who is gravida 1, para 0, presents to labor and delivery with contractions every 3 minutes. The client states that she has not felt the baby move for the last 2 hours. What action should the nurse take first?
Show answer and rationale
Correct answer: A. Place the client on an external fetal monitor.
decreased fetal movement may be a sign of hypoxia in the fetus or a fetal demise. Placing the client on a fetal monitor will assist the nurse to evaluate the fetal well-being.
A client, who is gravida 3, para 2, is 8 cm dilated, 100% effaced, and a 0 station. When evaluating the fetal monitor tracing, a nurse notes baseline heart rate 170 bpm, minimal variability, and consistent late decelerations. What is the most likely explanation of this pattern?
Show answer and rationale
Correct answer: B. There is uteroplacental insufficiency.
late decelerations are indicative of uteroplacental insufficiency, and tachycardia can be a sign of hypoxia as well.
A client, who is gravida 4, para 3, is 4 cm dilated, 80% effaced, and a +1 station. Assessment of the fetal monitor tracing reveals baseline 140 bpm, moderate variability, and accelerations and variable decelerations to 100 bpm. Which action should a nurse take first?
Show answer and rationale
Correct answer: D. Reposition the client.
repositioning the client will help to alleviate the variable decelerations. This should be the first action of the nurse.
A gravida 4, para 2 client with gestational diabetes is having nonstress tests twice a week. A nurse evaluates the fetal monitor strip. Which fetal heart rate pattern should the nurse interpret as reassuring?
Show answer and rationale
Correct answer: B. Acceleration of FHR with fetal movements.
accelerations are correlated with fetal movement and adequate oxygen reserves in the fetus.
A client presents to an emergency department at 8 weeks’ gestation. A physician suspects that the client has an ectopic (tubal) pregnancy. When performing an initial assessment, which symptom should a nurse recognize as consistent with a diagnosis of ectopic (tubal) pregnancy?
Show answer and rationale
Correct answer: C. Sudden, stabbing pain in the lower quadrant.
stabbing pain in the lower quadrant is a symptom of ectopic pregnancy. The pain is related to the stretching of the fallopian tube in the lower abdominal quadrant.
A client, who is 10 weeks’ gestation, has been having severe nausea for the past 3 weeks. She tells a nurse that she cannot eat anything. She has been diagnosed with hyperemesis gravidarum and is at risk for developing:
Show answer and rationale
Correct answer: C. Metabolic acidosis with dehydration.
hyperemesis leads to metabolic acidosis and dehydration.
A client presents to a prenatal clinic and tells a physician that she thinks she might be pregnant because she has not has a period for about 5 months. Which is the most definitive sign of pregnancy?
Show answer and rationale
Correct answer: D. The presence of fetal heart tones.
the presence of fetal heart tones is a positive sign of pregnancy.
A client, who is gravida 3, para 2 at 39 weeks’ gestation with poorly controlled gestational diabetes, has just given birth via cesarean section. A nurse will expect that the neonate will most likely be:
Show answer and rationale
Correct answer: B. Hypoglycemic, large for gestational age.
with poorly controlled gestational diabetes, the neonate will likely be hypoglycemic and large for gestational age.
A client, who is 44 years old, gravida 3, para 2, has just delivered a newborn suspected of having trisomy 21. Which characteristics should a nurse observe in an infant with this condition? Select all that apply.
Show answer and rationale
Correct answer: B. Simian creases.
simian creases are a typical finding in a newborn with trisomy 21.
A nursing student is performing an initial newborn assessment. The newborn is observed to have a cephalohematoma. What are the likely causes of this condition? Select all that apply.
Show answer and rationale
Correct answer: C. Prolonged second stage of labor.
prolonged second stage of labor is a long pushing stage that may result in a cephalohematoma, caused by the fetal head being in the birth canal for a prolonged period.
A client, who is 24 years old, gravida 4, para 3, has had no prenatal care and does not know when her last menstrual period was. She presents to labor and delivery completely dilated and crowning. She precipitously delivers a 5-pound, 6-ounce infant. The client’s urine toxicology screen shows methamphetamines. The client admits that she uses methamphetamine daily. Which observations should a nurse expect in the neonate that would be consistent with methamphetamine exposure in utero? Select all that apply.
Show answer and rationale
Correct answer: B. Cleft lip.
the developing fetus appears to be vulnerable to DNA damage from methamphetamine exposure because it hasn’t yet developed the enzymes that protect it against free radicals. Methamphetamines can cause neural tube defects such as cleft lip and palate.
A 27-year-old client, who is gravida 3, para 1, presents to a labor and delivery unit at 33 weeks’ gestation. She tells a nurse that she woke up this morning in a pool of blood about the size of an orange, but she has no abdominal cramping or pain. The nurse’s first action should be to:
Show answer and rationale
Correct answer: D. Assess the fetal heart tones.
the client likely has a placenta previa. Assessing the fetal heart tones for signs of fetal distress is the most important action.
A nurse is caring for a child diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory test would the nurse be least likely to obtain?
Show answer and rationale
Correct answer: C. Blood glucose.
obtaining a blood glucose level is not expected for a child diagnosed with SIADH since the priority measures involve blood and urine osmolality. Blood glucose is a likely laboratory test in a child with diabetes insipidus.
A physician prescribes digoxin (Lanoxin) for a toddler with congestive heart failure (CHF). Before administering the medication, it is most important for the nurse to:
Show answer and rationale
Correct answer: C. First obtain an apical heart rate.
the apical heart rate must always be obtained by the nurse prior to the administration of digoxin (Lanoxin) to a child. Unless otherwise prescribed, the medication is typically withheld for a heart rate below 90 to 110 bpm in young children.
A nurse prepares to administer spironolactone (Aldactone) to an infant with congenital heart disease. The nurse understands that the main purpose of this medication is to:
Show answer and rationale
Correct answer: A. Block aldosterone, which leads to diuresis.
spironolactone (Aldactone) is a diuretic that blocks aldosterone. Use of this medication is common among children with congenital heart disease for the prevention and treatment of congestive heart failure.
Which symptom(s), if present in a child, should a nurse recognize as being characteristic of Kawasaki disease? Select all that apply.
Show answer and rationale
Correct answer: B. Strawberry tongue.
strawberry tongue is a symptom of Kawasaki disease (mucocutaneous lymph node syndrome), occurring as the skin of the tongue sloughs off, leaving a bright red tongue with white spots.
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
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