NCLEX Questions Flashcards
The nurse understands that there are possible signs of pregnancy and confirmation signs of pregnancy. What are the confirmation signs of pregnancy in a pregnant woman? Select all that apply:
A. Demonstration of a fetal heart separate from the mother’s
B. Fetal movements felt by an examiner
C. Visualization of the fetus by ultrasound
D. Lab test of blood or urine.
Answer: A, B, C
A. Demonstration of a fetal heart separate from the mother’s
B. Fetal movements felt by an examiner
C. Visualization of the fetus by ultrasound
The nurse is preparing to administer magnesium sulfate to their patient diagnosed with preeclampsia. What assessments are important to note before administration. Select all:
A. Deep tendon Reflexes.
B. Respiratory Rate.
C. Bowel Function.
D. Urinary Output.
E. Temperature.
Answer: A, B, D
A. Deep tendon reflexes
B. Respiratory rate
D. Urinary output
The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?
A. Two weeks before menstruation
B. Immediately after menstruation
C. Immediately before menstruation
D. Three weeks before menstruation
A. Rationale: Ovulation occurs 14 days before the first day of the menstrual period (A). Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle varies. (B, C, and D) are incorrect.
Which finding(s) is (are) of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.)
A. Cramping with bright red spotting
B. Extreme tenderness of the breast
C. Lack of tenderness of the breast
D. Increased amounts of discharge
E. Increased right-side flank pain
A,C,E Rationale: (A and C) are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client’s menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. (E) could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. (B and D) are normal signs during the first trimester of a pregnancy.
Which finding(s) is (are) of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.)
A. Cramping with bright red spotting
B. Extreme tenderness of the breast
C. Lack of tenderness of the breast
D. Increased amounts of discharge
E. Increased right-side flank pain
A,C,E Rationale: (A and C) are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client’s menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. (E) could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. (B and D) are normal signs during the first trimester of a pregnancy.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client?
A. Breastfeed the infant, ensuring that both breasts are completely emptied.
B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
A. Rationale:
Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts (A), eliminating the pressure on the inflamed breast tissue. (B) is less painful but does not facilitate complete emptying of the breast tissue. (C) will not relieve the engorgement on the affected side. (D) will not decrease antibiotic effects on the infant.
The client comes to the hospital assuming she is in labor. Which assessment finding(s) by the nurse would indicate that the client is in true labor? (Select all that apply.)
A. Pain in the lower back that radiates to abdomen
B. Contractions decreased in frequency with ambulation
C. Progressive cervical dilation and effacement
D. Discomfort localized in the abdomen
E. Regular and rhythmic painful contractions
A,C,E Rationale: These are all signs of true labor (A, C, and E). The others are signs of false labor (B and D).
While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:
A) Molding
B) Microcephaly
C) Caput succedaneum
D) Cephalhematoma
C
Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of the skull.
The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales?
A) Stop Rh sensitization
B) Increase erythopoiesis
C) Enhance bilirubin breakdown
D) Promote blood clotting
D
Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the liver. RhoGAM prevents Rh sensitization. Erythropoietin stimulates erythropoiesis. Phototherapy enhances bilirubin breakdown.
A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?
A) Urinary output of 20 mL per hour
B) Respiratory rate of 10 breaths/minute
C) Deep tendons reflexes 2+
D) Difficulty in arousing
Ans: C
With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium toxicity.
The nurse is reviewing the laboratory test results of a pregnant client. Which one of the following findings would alert the nurse to the development of HELLP syndrome?
A) Hyperglycemia
B) Elevated platelet count
C) Leukocytosis
D) Elevated liver enzymes
Ans: D
HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia or leukocytosis is not a part of this syndrome.
Which of the following would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia?
A) Calcium gluconate
B) Potassium chloride
C) Ferrous sulfate
D) Calcium carbonate
Ans: A
The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.
A nurse is teaching a pregnant woman with preterm premature rupture of membranes who is about to be discharged home about caring for herself. Which statement by the woman indicates a need for additional teaching?
A) “I need to keep a close eye on how active my baby is each day.”
B) “I need to call my doctor if my temperature increases.”
C) “It’s okay for my husband and me to have sexual intercourse.”
D) “I can shower but I shouldn’t take a tub bath.”
Ans: C
Feedback:
The woman with preterm premature rupture of membranes should monitor her baby’s activity by performing fetal kick counts daily, check her temperature and report any increases to the health care provider, not insert anything into her vagina or vaginal area, such as tampons or vaginal intercourse, and avoid sitting in a tub bath.
A nurse is assessing a pregnant woman with gestational hypertension. Which of the following would lead the nurse to suspect that the client has developed severe preeclampsia?
A) Urine protein 300 mg/24 hours
B) Blood pressure 150/96 mm Hg
C) Mild facial edema
D) Hyperreflexia
Ans: D
Severe preeclampsia is characterized by blood pressure over 160/110 mm Hg, urine protein levels greater than 500 mg/24 hours and hyperreflexia. Mild facial edema is associated with mild preeclampsia.
A nurse suspects that a pregnant client may be experiencing abruption placenta based on assessment of which of the following? (Select all that apply.)
A) Dark red vaginal bleeding
B) Insidious onset
C) Absence of pain
D) Rigid uterus
E) Absent fetal heart tones
Ans: A, D, E
Feedback:
Assessment findings associated with abruption placenta include a sudden onset, with concealed or visible bleeding, dark red bleeding, constant pain or uterine tenderness on palpation, firm to rigid uterine tone, and fetal distress or absent fetal heart tones.
