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NCLEX- RN Practice Exam 11 (PM)
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1. A gravida III 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?
- Fetal heart tones 160bpm
- A moderate amount of straw-colored fluid
- A small amount of greenish fluid
- A small segment of the umbilical cord
2. 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?
- “We have a name picked out for the baby.”
- “I need to push when I have a contraction.”
- “I can’t concentrate if anyone is touching me.”
- “When can I get my epidural?”
3. The client is having fetal heart rates of 90–110bpm during the contractions. The first action the nurse should take is:
- Reposition the monitor
- Turn the client to her left side
- Ask the client to ambulate
- Prepare the client for delivery
4. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:
- A painless delivery
- Cervical effacement
- Infrequent contractions
- Progressive cervical dilation
5. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?
- Anticipate the need for a Caesarean section
- Apply the fetal heart monitor
- Place the client in Genu Pectoral position
- Perform an ultrasound exam
6. A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
- The cervix is closed.
- The membranes are still intact.
- The fetal heart tones are within normal limits.
- The contractions are intense enough for insertion of an internal monitor.
7. The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primagravida as she completes the early phase of labor?
- Impaired gas exchange related to hyperventilation
- Alteration in placental perfusion related to maternal position
- Impaired physical mobility related to fetal-monitoring equipment
- Potential fluid volume deficit related to decreased fluid intake
8. As the client reaches 8cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?
- The baby is asleep.
- The umbilical cord is compressed.
- There is a vagal response.
- There is uteroplacental insufficiency.
9. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- Notify her doctor
- Start an IV
- Reposition the client
- Readjust the monitor
10. Which of the following is a characteristic of a reassuring fetal heart rate pattern?
- A fetal heart rate of 170–180bpm
- A baseline variability of 25–35bpm
- Ominous periodic changes
- Acceleration of FHR with fetal movements
11. The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
- The bladder fills more rapidly because of the medication used for the epidural.
- Her level of consciousness is such that she is in a trancelike state.
- The sensation of the bladder filling is diminished or lost.
- She is embarrassed to ask for the bedpan that frequently.
12. 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:
- Estrogen levels are low.
- Lutenizing hormone is high.
- The endometrial lining is thin.
- The progesterone level is low.
13. 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:
- Age of the client
- Frequency of intercourse
- Regularity of the menses
- Range of the client’s temperature
14. 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?
- Intrauterine device
- Oral contraceptives
- Contraceptive sponge
15. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy?
- Painless vaginal bleeding
- Abdominal cramping
- Throbbing pain in the upper quadrant
- Sudden, stabbing pain in the lower quadrant
16. 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?
- Hamburger pattie, green beans, French fries, and iced tea
- Roast beef sandwich, potato chips, baked beans, and cola
- Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea
- Fish sandwich, gelatin with fruit, and coffee
17. The client with hyperemesis gravidarum is at risk for developing:
- Respiratory alkalosis without dehydration
- Metabolic acidosis with dehydration
- Respiratory acidosis without dehydration
- Metabolic alkalosis with dehydration
18. A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:
- Elevated human chorionic gonadatropin
- The presence of fetal heart tones
- Uterine enlargement
- Breast enlargement and tenderness
19. The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
- Hypoglycemic, small for gestational age
- Hyperglycemic, large for gestational age
- Hypoglycemic, large for gestational age
- Hyperglycemic, small for gestational age
20. Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?
- Weight gain should be reported to the physician.
- An alternate method of birth control is needed when taking antibiotics.
- If the client misses one or more pills, two pills should be taken per day for 1 week.
- Changes in the menstrual flow should be reported to the physician.
21. The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
- Positive HIV
- Thyroid disease
22. 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:
- Assess the fetal heart tones
- Check for cervical dilation
- Check for firmness of the uterus
- Obtain a detailed history
23. 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:
- Her contractions are 2 minutes apart.
- She has back pain and a bloody discharge.
- She experiences abdominal pain and frequent urination.
- Her contractions are 5 minutes apart.
24. 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?
- Low birth weight
- Large for gestational age
- Preterm birth, but appropriate size for gestation
- Growth retardation in weight and length
25. 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:
- Within 72 hours of delivery
- Within 1 week of delivery
- Within 2 weeks of delivery
- Within 1 month of delivery
26. A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply.
- Cola is acceptable to drink on the day of the test.
- Tea and coffee are restricted on the day of the test.
- The test will take between 45 minutes and 2 hours.
- The hair should be washed the evening before the test.
- All medications need to be withheld on the day of the test.
- A nothing-by-mouth (NPO) status is required on the day of the test.
27. The nurse is providing discharge teaching to the client who was given a prescription for nifedipine (Adalat) for blood pressure management. Which instructions should the nurse include? Select all that apply.
- “Increase water intake.”
- “Increase calcium intake.”
- “Take pulse rate each day.”
- “Weigh at the same time each day.”
- “Palpitations may occur early in therapy.”
- “Be careful when rising from sitting to standing.”
28. A nurse is providing teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? Select all that apply.
- Tuck pant legs into socks.
- Wear closed shoes when hiking.
- Apply insect repellent containing DEET.
- Cover the ground with a blanket when sitting.
- Remove attached ticks by grasping with thumb and forefinger.
- Wear long sleeves and long pants in dark colors when in high-risk areas.
29. A nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides to the client. Select all that apply.
- Protect the stoma from water.
- Soaps should be avoided near the stoma.
- Wash the stoma daily using a washcloth.
- Use diluted alcohol on the stoma to clean it.
- Apply a thin layer of petroleum jelly to the skin surrounding the stoma.
- Use soft tissues to clean any secretions that accumulate around the stoma.
30. A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for fluid volume deficit?
- The client with cirrhosis
- The client with a colostomy
- The client with decreased kidney function
- The client with congestive heart failure (CHF)
Answers and Rationales
- Answer B is correct. 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.
- Answer D is correct. Dilation of 2cm 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.
- Answer B is correct. The normal fetal heart rate is 120–160bpm; 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.
- Answer D is correct. 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.
- Answer B is correct. 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 Genu Pectoral 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.
- Answer B is correct. 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.
- Answer D is correct. 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.
- Answer D is correct. 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.
- Answer C is correct. 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.
- Answer D is correct. Accelerations with movement are normal. Answers A, B, and C indicate ominous findings on the fetal heart monitor.
- Answer C is correct. 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.
- Answer B is correct. Lutenizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the release of lutenizing 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.
- Answer C is correct. 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.
- Answer C is correct. 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.
- Answer D is correct. 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.
- Answer C is correct. 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 360mg of calcium. Answer D is not the best diet because it lacks vegetables and milk products.
- Answer B is correct. 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.
- Answer B is correct. 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.
- Answer C is correct. 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.
- Answer B is correct. 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.
- Answer B is correct. 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.
- Answer A is correct. 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.
- Answer D is correct. 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.
- Answer A is correct. 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.
- Answer A is correct. 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.
- Answers: B, C, and D are correct. Pre-procedure instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test, and gels, hairsprays, and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test.
- Answers: C, D, E, and F are correct. Nifedipine is a calcium-channel blocker. Its therapeutic outcome is to decrease blood pressure. Its method of action is blockade of the calcium channels in vascular smooth muscle, promoting vasodilation. Side effects that can occur early in therapy include reflex tachycardia (palpitations) and first-dose hypotension, leading to orthostatic hypotension. Weight should be checked regularly to monitor for early signs of heart failure. Also the client is taught to take his or her own pulse. Nifedipine does not affect serum calcium levels. Increased water intake is not indicated in the client with cardiovascular disease.
- Answers: A, B, C, and D are correct. Measures to prevent tick bites focus on covering the body as completely as possible and spraying insect repellent containing DEET on the skin and clothing. Long sleeves and pants tucked into the socks along with closed shoes will offer some protection. Light-colored clothing should be worn so that ticks would be easily visible. Hikers should not sit directly on the ground and should cover the ground with an item such as a blanket. Ticks should be removed with tweezers.
- Answers: A, B, C, and E are correct. The client with a stoma should be instructed to wash the stoma daily with a washcloth. Soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. The client should be instructed to avoid applying alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum jelly applied to the skin around the stoma helps prevent cracking. The client is instructed to protect the stoma from water.
- Answer B is correct. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy. A client with cirrhosis, CHF, or decreased kidney function is at risk for fluid volume excess.