Friday, August 26, 2016

NCLEX Practice Exam 6 (50 Items)

This exam has 50 items with a hefty chunk of questions about labor and delivery, emergency room nursing, and disaster management.

Guidelines
  • Read each question carefully and choose the best answer.
  • Answers and rationales are given below. Be sure to read them.
NCLEX Practice Exam 6 (50 Items)
Just Scroll Down For All questions and answers
1. The client is having an arteriogram. During the procedure, the client tells the nurse, “I’m feeling really hot.” Which response would be best?

A. “You are having an allergic reaction. I will get an order for Benadryl.”

B. “That feeling of warmth is normal when the dye is injected.”

C. “That feeling of warmth indicates that the clots in the coronary vessels are dissolving.”

D. “I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing.”

2. The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?

A. The nursing assistant wears gloves while giving the client a bath.

B. The nurse wears goggles while drawing blood from the client.

C. The doctor washes his hands before examining the client.

D. The nurse wears gloves to take the client’s vital signs.

3. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?

A. The client loses consciousness.

B. The client vomits.

C. The client’s ECG indicates tachycardia.

D. The client has a grand mal seizure.

4. The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:

A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep

B. Scrape the skin with a piece of cardboard and bring it to the clinic

C. Obtain a stool specimen in the afternoon

D. Bring a hair sample to the clinic for evaluation

5. The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?

A. Treatment is not recommended for children less than 10 years of age.

B. The entire family should be treated.

C. Medication therapy will continue for 1 year.

D. Intravenous antibiotic therapy will be ordered.

6. The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

A. The client receiving linear accelerator radiation therapy for lung cancer

B. The client with a radium implant for cervical cancer

C. The client who has just been administered soluble brachytherapy for thyroid cancer

D. The client who returned from placement of iridium seeds for prostate cancer

7. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

A. The client with Cushing’s disease

B. The client with diabetes

C. The client with acromegaly

D. The client with myxedema

8. The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:

A. Negligence

B. Tort

C. Assault

D. Malpractice

9. Which assignment should not be performed by the licensed practical nurse?

A. Inserting a Foley catheter

B. Discontinuing a nasogastric tube

C. Obtaining a sputum specimen

D. Starting a blood transfusion

10. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?

A. Continuing to monitor the vital signs

B. Contacting the physician

C. Asking the client how he feels

D. Asking the LPN to continue the post-op care

11. Which nurse should be assigned to care for the postpartum client with preeclampsia?

A. The RN with 2 weeks of experience in postpartum

B. The RN with 3 years of experience in labor and delivery

C. The RN with 10 years of experience in surgery

D. The RN with 1 year of experience in the neonatal intensive care unit

12. Which information should be reported to the state Board of Nursing?

A. The facility fails to provide literature in both Spanish and English.

B. The narcotic count has been incorrect on the unit for the past 3 days.

C. The client fails to receive an itemized account of his bills and services received during his hospital stay.

D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

13. The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:

A. Call the Board of Nursing

B. File a formal reprimand

C. Terminate the nurse

D. Charge the nurse with a tort

14. The home health nurse is planning for the day’s visits. Which client should be seen first?

A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube

B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension

C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line

D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

15. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?

A. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis

B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm

C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury

D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain

16. The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eye drops, the nurse should recognize that it is essential to consider which of the following?

A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.

B. The child should be allowed to instill his own eye drops.

C. The mother should be allowed to instill the eyedrops.

D. If the eye is clear from any redness or edema, the eyedrops should be held.

17. The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?

A. “It is okay to give my child white grape juice for breakfast.”

B. “My child can have a grilled cheese sandwich for lunch.”

C. “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”

D. “For a snack, my child can have ice cream.”

18. A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?

A. Ask the parent/guardian to leave the room when assessments are being performed.

B. Ask the parent/guardian to take the child’s favorite blanket home because anything from the outside should not be brought into the hospital.

C. Ask the parent/guardian to room-in with the child.

D. If the child is screaming, tell him this is inappropriate behavior.

19. Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?

A. Remove the mold and clean every week.

B. Store the hearing aid in a warm place.

C. Clean the lint from the hearing aid with a toothpick.

D. Change the batteries weekly.

20. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

A. Body image disturbance

B. Impaired verbal communication

C. Risk for aspiration

D. Pain

21. A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

A. High fever

B. Nonproductive cough

C. Rhinitis

D. Vomiting and diarrhea

22. The nurse is caring for a client admitted with epiglottitis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?

A. Intravenous access supplies

B. A tracheostomy set

C. Intravenous fluid administration pump

D. Supplemental oxygen

23. A 25-year-old client with Grave’s disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

A. Bradycardia

B. Decreased appetite

C. Exophthalmos

D. Weight gain

24. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?

A. Ham sandwich on whole-wheat toast

B. Spaghetti and meatballs

C. Hamburger with ketchup

D. Cheese omelet

25. The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?

A. Notify the physician

B. Recheck the O2 saturation level in 15 minutes

C. Apply oxygen by mask

D. Assess the pulse


26. A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy?

A. Fetal heart tones 160bpm

B. A moderate amount of straw-colored fluid

C. A small amount of greenish fluid

D. A small segment of the umbilical cord

27. The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make?

A. “We have a name picked out for the baby.”

B. “I need to push when I have a contraction.”

C. “I can’t concentrate if anyone is touching me.”

D. “When can I get my epidural?”

28. The client is having fetal heart rates of 90–110 bpm during the contractions. The first action the nurse should take is:

A. Reposition the monitor

B. Turn the client to her left side

C. Ask the client to ambulate

D. Prepare the client for delivery

29. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:

A. A painless delivery

B. Cervical effacement

C. Infrequent contractions

D. Progressive cervical dilation

30. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?

A. Anticipate the need for a Caesarean section

B. Apply the fetal heart monitor

C. Place the client in Genupectoral position

D. Perform an ultrasound exam

31. A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:

A. The cervix is closed.

B. The membranes are still intact.

C. The fetal heart tones are within normal limits.

D. The contractions are intense enough for insertion of an internal monitor.

32. The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?

A. Impaired gas exchange related to hyperventilation

B. Alteration in placental perfusion related to maternal position

C. Impaired physical mobility related to fetal-monitoring equipment

D. Potential fluid volume deficit related to decreased fluid intake

33. As the client reaches 8 cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175 bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?

A. The baby is asleep.

B. The umbilical cord is compressed.

C. There is a vagal response.

D. There is uteroplacental insufficiency.

34. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:

A. Notify her doctor

B. Start an IV

C. Reposition the client

D. Readjust the monitor

35. Which of the following is a characteristic of a reassuring fetal heart rate pattern?

A. A fetal heart rate of 170–180 bpm

B. A baseline variability of 25–35 bpm

C. Ominous periodic changes

D. Acceleration of FHR with fetal movements


36. The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

A. The bladder fills more rapidly because of the medication used for the epidural.

B. Her level of consciousness is such that she is in a trancelike state.

C. The sensation of the bladder filling is diminished or lost.

D. She is embarrassed to ask for the bedpan that frequently.

37. A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:

A. Estrogen levels are low.

B. Luteinizing hormone is high.

C. The endometrial lining is thin.

D. The progesterone level is low.

38. A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:

A. Age of the client

B. Frequency of intercourse

C. Regularity of the menses

D. Range of the client’s temperature

39. A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?

A. Intrauterine device

B. Oral contraceptives

C. Diaphragm

D. Contraceptive sponge


40. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy?

A. Painless vaginal bleeding

B. Abdominal cramping

C. Throbbing pain in the upper quadrant

D. Sudden, stabbing pain in the lower quadrant

41. The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?

A. Hamburger pattie, green beans, French fries, and iced tea

B. Roast beef sandwich, potato chips, baked beans, and cola

C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea

D. Fish sandwich, gelatin with fruit, and coffee

42. The client with hyperemesis gravidarum is at risk for developing:

A. Respiratory alkalosis without dehydration

B. Metabolic acidosis with dehydration

C. Respiratory acidosis without dehydration

D. Metabolic alkalosis with dehydration

43. A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

A. Elevated human chorionic gonadotropin

B. The presence of fetal heart tones

C. Uterine enlargement

D. Breast enlargement and tenderness

44. The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:

A. Hypoglycemic, small for gestational age

B. Hyperglycemic, large for gestational age

C. Hypoglycemic, large for gestational age

D. Hyperglycemic, small for gestational age

45. Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?

A. Weight gain should be reported to the physician.

B. An alternate method of birth control is needed when taking antibiotics.

C. If the client misses one or more pills, two pills should be taken per day for 1 week.

D. Changes in the menstrual flow should be reported to the physician.

46. The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:

A. Diabetes

B. Positive HIV

C. Hypertension

D. Thyroid disease

47. A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:

A. Assess the fetal heart tones

B. Check for cervical dilation

C. Check for firmness of the uterus

D. Obtain a detailed history

48. A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:

A. Her contractions are 2 minutes apart.

B. She has back pain and a bloody discharge.

C. She experiences abdominal pain and frequent urination.

D. Her contractions are 5 minutes apart.

49. The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?

A. Low birth weight

B. Large for gestational age

C. Preterm birth, but appropriate size for gestation

D. Growth retardation in weight and length

50. The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:

A. Within 72 hours of delivery

B. Within 1 week of delivery

C. Within 2 weeks of delivery

D. Within 1 month of delivery


Answers and Rationale
1. Answer: B. “That feeling of warmth is normal when the dye is injected.”

It is normal for the client to have a warm sensation when dye is injected. Answers A, C, and D indicate that the nurse believes that the hot feeling is abnormal, so they are incorrect.

2. Answer: D. The nurse wears gloves to take the client’s vital signs.

It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant staphylococcus aureus, gloves should be worn. The health care workers in answers A, B, and C indicate knowledge of infection control by their actions.

3. Answer: D. The client has a grand mal seizure.

During ECT, the client will have a grand mal seizure. This indicates completion of the electroconvulsive therapy. Answers A, B, and C do not indicate that the ECT has been effective, so are incorrect.

4. Answer: A. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep

Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrape the skin, collect a stool specimen, or bring a sample of hair, so answers B, C, and D are incorrect.

5. Answer: B. The entire family should be treated.

Enterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answers A, C, and D are incorrect statements.

6. Answer: A. The client receiving linear accelerator radiation therapy for lung cancer

The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department, so the client is not radioactive. The clients in answers B, C, and D pose a risk to the pregnant nurse. These clients are radioactive in very small doses, especially upon returning from the procedures. For approximately 72 hours, the clients should dispose of urine and feces in special containers and use plastic spoons and forks.

7. Answer: A. The client with Cushing’s disease

The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immunosuppressed. In answer B, the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hypothyroidism or myxedema and poses no risk to others or himself.

8. Answer: D. Malpractice

The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. Answers A, B, and C are incorrect because they apply to other wrongful acts. Negligence is failing to perform care for the client; a tort is a wrongful act committed on the client or their belongings; and assault is a violent physical or verbal attack.

9. Answer: D. Starting a blood transfusion

The licensed practical nurse should not be assigned to begin a blood transfusion. The licensed practical nurse can insert a Foley catheter, discontinue a nasogastric tube, and collect sputum specimen; therefore, answers A, B, and C are incorrect.

10. Answer: B. Contacting the physician

The vital signs are abnormal and should be reported immediately. Continuing to monitor the vital signs can result in deterioration of the client’s condition, making answer A incorrect. Asking the client how he feels in answer C will only provide subjective data, and the nurse in answer D is not the best nurse to assign because this client is unstable.

11. Answer: B. The RN with 3 years of experience in labor and delivery

The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. The nurse in answer A is a new nurse to the unit, and the nurses in answers C and D have no experience with the postpartum client.

12. Answer: B. The narcotic count has been incorrect on the unit for the past 3 days.

The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to care for the client with hepatitis might result in termination, but is not of interest to the Joint Commission.

13. Answer: B. File a formal reprimand

The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance. Therefore, Answers A, C, and D are incorrect.

14. Answer: D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is methicillin-resistant staphylococcus aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. The clients in answers A, B, and C are more stable and can be seen later.

15. Answer: B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm

The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. The clients in answers A, C, and D need to be placed in separate rooms due to the serious natures of their injuries.

16. Answer: A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.

Before instilling eye drops, the nurse should cleanse the area with water. A 6-year-old child is not developmentally ready to instill his own eyedrops, so answer B is incorrect. Although the mother of the child can instill the eyedrops, the area must be cleansed before administration, making answer C incorrect. Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered, so answer D is incorrect.

17. Answer: C. “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”

Remember the ABCs (airway, breathing, circulation) when answering this question. Answer C because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. Answers A, B, and C are incorrect because white grape juice, a grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child.

18. Answer: C. Ask the parent/guardian to room-in with the child.

The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Allowing the child to have items that are familiar to him is allowed and encouraged; therefore, answers A and B are incorrect. Answer D is not part of the nurse’s responsibilities.

19. Answer: B. Store the hearing aid in a warm place.

The hearing aid should be stored in a warm, dry place. It should be cleaned daily but should not be moldy, so answer A is incorrect. A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aide, making answer C incorrect. Changing the batteries weekly, as in answer D, is not necessary.

20. Answer: C. Risk for aspiration

Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Although answers B and D might be appropriate for this child, answer C should have the highest priority. Answer A does not apply for a child who has undergone a tonsillectomy.

21. Answer: A. High fever

If the child has bacterial pneumonia, a high fever is usually present. Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough, making answer B incorrect. Rhinitis is often seen with viral pneumonia, and vomiting and diarrhea are usually not seen with pneumonia, so answers C and D are incorrect.

22. Answer: B. A tracheostomy se

For a child with epiglottitis and the possibility of complete obstruction of the airway, emergency tracheostomy equipment should always be kept at the bedside. Intravenous supplies, fluid, and oxygen will not treat an obstruction; therefore, answers A, C, and D are incorrect.

23. Answer: C. Exophthalmos

Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss; therefore, answers A, B, and D are incorrect.

24. Answer: D. Cheese omelet

The child with celiac disease should be on a gluten-free diet. Answers A, B, and C all contain gluten, while answer D gives the only choice of foods that does not contain gluten.

25. Answer: C. Apply oxygen by mask

Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation, so answers A and D are incorrect. The normal oxygen saturation for a child is 92%–100%, making answer B incorrect.


26. Answer: B. A moderate amount of straw-colored fluid

An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. Fetal heart tones of 160 indicate tachycardia, and greenish fluid is indicative of meconium, so answers A and C are incorrect. If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord, so answer D is incorrect and would need to be reported immediately.

27. Answer: D. “When can I get my epidural?”

Dilation of 2 cm marks the end of the latent phase of labor. Answer A is a vague answer, answer B indicates the end of the first stage of labor, and answer C indicates the transition phase.

28. Answer: B. Turn the client to her left side

The normal fetal heart rate is 120–160 bpm; 100–110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Answer A is not indicated at this time. Answer C is not the best action for clients experiencing bradycardia. There is no data to indicate the need to move the client to the delivery room at this time.

29. Answer: D. Progressive cervical dilation

The expected effect of Pitocin is cervical dilation. Pitocin causes more intense contractions, which can increase the pain, making answer A incorrect. Cervical effacement is caused by pressure on the presenting part, so answer B is incorrect. Answer C is opposite the action of Pitocin.

30. Answer: B. Apply the fetal heart monitor

Applying a fetal heart monitor is the correct action at this time. There is no need to prepare for a Caesarean section or to place the client in Genupectoral position (knee-chest), so answers A and C are incorrect. Answer D is incorrect because there is no need for an ultrasound based on the finding.

31. Answer: B. The membranes are still intact.

The nurse decides to apply an external monitor because the membranes are intact. Answers A, C, and D are incorrect. The cervix is dilated enough to use an internal monitor, if necessary. An internal monitor can be applied if the client is at 0-station. Contraction intensity has no bearing on the application of the fetal monitor.

32. Answer: D. Potential fluid volume deficit related to decreased fluid intake

Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid volume deficit. In answer A, impaired gas exchange related to hyperventilation would be indicated during the transition phase. Answers B and C are not correct in relation to the stem.

33. Answer: D. There is uteroplacental insufficiency.

This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Answer A has no relation to the readings, so it’s incorrect; answer B results in a variable deceleration; and answer C is indicative of an early deceleration.

34. Answer: C. Reposition the client

The initial action by the nurse observing a late deceleration should turn the client to the side—preferably, the left side. Administering oxygen is also indicated. Answer A might be necessary but not before turning the client to her side. Answer B is not necessary at this time. Answer D is incorrect because there is no data to indicate that the monitor has been applied incorrectly.

35. Answer: D. Acceleration of FHR with fetal movements

Accelerations with movement are normal. Answers A, B, and C indicate ominous findings on the fetal heart monitor.

36. Answer: C. The sensation of the bladder filling is diminished or lost.

Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will decrease the progression of labor. Answers A, B, and D are incorrect for the stem.

37. Answer: B. Luteinizing hormone is high.

Luteinizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the release of luteinizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in preparation for conception, which occurs within the next 10–12 hours after the LH levels peak. Answers A, C, and D are incorrect because estrogen levels are high at the beginning of ovulation, the endometrial lining is thick, not thin, and the progesterone levels are high, not low.

38. Answer: C. Regularity of the menses

The success of the rhythm method of birth control is dependent on the client’s menses being regular. It is not dependent on the age of the client, frequency of intercourse, or range of the client’s temperature; therefore, answers A, B, and D are incorrect.

39. Answer: C. Diaphragm

The best method of birth control for the client with diabetes is the diaphragm. A permanent intrauterine device can cause a continuing inflammatory response in diabetics that should be avoided, oral contraceptives tend to elevate blood glucose levels, and contraceptive sponges are not good at preventing pregnancy. Therefore, answers A, B, and D are incorrect.

40. Answer: D. Sudden, stabbing pain in the lower quadrant

The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. The client will complain of sudden, stabbing pain in the lower quadrant that radiates down the leg or up into the chest. Painless vaginal bleeding is a sign of placenta previa, abdominal cramping is a sign of labor, and throbbing pain in the upper quadrant is not a sign of an ectopic pregnancy, making answers A, B, and C incorrect.

41. Answer: C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea

All of the choices are tasty, but the pregnant client needs a diet that is balanced and has increased amounts of calcium. Answer A is lacking in fruits and milk. Answer B contains the potato chips, which contain a large amount of sodium. Answer C contains meat, fruit, potato salad, and yogurt, which has about 360 mg of calcium. Answer D is not the best diet because it lacks vegetables and milk products.

42. Answer: B. Metabolic acidosis with dehydration

The client with hyperemesis has persistent nausea and vomiting. With vomiting comes dehydration. When the client is dehydrated, she will have metabolic acidosis. Answers A and C are incorrect because they are respiratory dehydration. Answer D is incorrect because the client will not be in alkalosis with persistent vomiting.

43. Answer: B. The presence of fetal heart tones

The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The signs in answers A, C, and D are subjective and might be related to other medical conditions. Answers A and C may be related to a hydatidiform mole, and answer D is often present before menses or with the use of oral contraceptives.

44. Answer: C. Hypoglycemic, large for gestational age

The infant of a diabetic mother is usually large for gestational age. After birth, glucose levels fall rapidly due to the absence of glucose from the mother. Answer A is incorrect because the infant will not be small for gestational age. Answer B is incorrect because the infant will not be hyperglycemic. Answer D is incorrect because the infant will be large, not small, and will be hypoglycemic, not hyperglycemic.

45. Answer: B. An alternate method of birth control is needed when taking antibiotics.

When the client is taking oral contraceptives and begins antibiotics, another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately 5–10 pounds of weight gain is not unusual, so answer A is incorrect. If the client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the pill. Answer C is incorrect. If she misses two, she should take two; if she misses more than two, she should take the missed pills but use another method of birth control for the remainder of the cycle. Answer D is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.

46. Answer: B. Positive HIV

Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. The clients in answers A, C, and D—those with diabetes, hypertension, and thyroid disease—can be allowed to breastfeed.

47. Answer: A. Assess the fetal heart tones

The symptoms of painless vaginal bleeding are consistent with placenta previa. Answers B, C, and D are incorrect. Cervical check for dilation is contraindicated because this can increase the bleeding. Checking for firmness of the uterus can be done, but the first action should be to check the fetal heart tones. A detailed history can be done later.

48. Answer: D. Her contractions are 5 minutes apart.

The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. She should not wait until the contractions are every 2 minutes or until she has bloody discharge, so answers A and B are incorrect. Answer C is a vague answer and can be related to a urinary tract infection.

49. Answer: A. Low birth weight

Infants of mothers who smoke are often low in birth weight. Infants who are large for gestational age are associated with diabetic mothers, so answer B is incorrect. Preterm births are associated with smoking, but not with appropriate size for gestation, making answer C incorrect. Growth retardation is associated with smoking, but this does not affect the infant length; therefore, answer D is incorrect.

50. Answer: A. Within 72 hours of delivery

To provide protection against antibody production, RhoGam should be given within 72 hours. The answers in B, C, and D are too late to provide antibody protection. RhoGam can also be given during pregnancy.


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