NCLEX 25 QUESTIONS

The nurse is admitting a newborn infant to the nursery and notes that the primary health care provider has documented that the newborn has an omphalocele. Which interventions are approperiate for the nurse to use with this newborn? Select all 1. Protect defect from trauma 2. Monitor mechanical ventilation 3. Bottle feed 2 ounces of formula every 2 hours 4. Administer prophylactic antibiotics as prescribed 5. Keep viscera moist with saline soaked dressings

1. Protect defect from trauma 4. Administer prophylactic antibiotics as prescribed 5. Keep viscera moist with saline soaked dressings

The nurse is collecting data on a pregant client and is preparing to take the client's blood pressure. In which position would the nurse place the client?

In a sitting position

The nurse is collecting data from a client who is pregnant with twins. The nurse understands that which complications are more likely to occur with a twin pregnancy? Select all 1. Preterm labor 2. Posterm labor 3. Maternal anemia 4. Oligohydramnios 5. Gestational diabetes

1.Preterm labor, 3.Maternal anemia

The nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document which findings as a normal FHR pattern?

150 beats per minute, moderate variability

A client asks the nurse to describe how her developing baby will get enough blood and oxygen. The nurse responds that the fetal circulatory system accomplishes this task by which means? Select all 1. Completely shutting off circulation of fetal lung tissue 2. Bypassing the fetal lungs to circulate oxygen rich blood 3. Using fetal lungs and liver to promote gas exchange 4. Using the fetus's beating heart to pump blood into the circulatory system 5. Carrying more oxygen on fetal hemoglobin than maternal hemoglobin 6. Making the fetal cardiac output higher per unit of body weight than the maternal cardiac output

2. Bypassing the fetal lungs to circulate oxygen rich blood 4. Using the fetus's beating heart to pump blood in the circulatory blood 5. Carrying more oxygen on fetal hemoglobin than maternal hemoglobin 6. Making the fetal cardiac output higher per unit of body weight than the maternal cardiac output

A client experiences subinvolution during the puerperium. The nurse recalls that which factors are the most common cause for this occurance? Select all 1. High estrogen levels 2. Maternal hypertension 3. Elevated progesterone levels 4. Retained placental fragments 5. Maternal reproductive tract infections

4. Retained placental fragments 5. Maternal reproductive tract infections

The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this datum indicate to the nurse?

A normal finding

The goal for a postpartum client with deep thrombophlebitis is to prevent the complication of pulmary embolism. In planning care to assist in meeting this goal, the nurse would perform which action?

Administer anticoagulants as prescribed

A young pregnant woman with diabetes mellitus has lost 10 pounds during the first 15 weeks of gestation. The client tells the nurse. "I do not regular meals." Based on the client's statement which is the best response by the nurse?

Can you tell me more about what you are eating?

The nurse is assigned to care for a primigravida who is having a prescipitate delivery. Which maternal finding does the nurse expect to note?

Decreased periods of uterine relaxation between contractions

The nurse is caring for a client receiving magnesium sulfate for preeclampsia. During the administration of this medication, which would the nurse speciifically monitor?

Deep tendon relexes

The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time?

Fear about what is happening

The nurse is moitoring a client who is receiving oxytocin to augment labor. The nurse determines that the dosage would be decreased and notifies the registered nurse if which is noted?

Fetal tachycardia

A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client's health record, the nurse notes that the laboratory values indicate low hemoglobin and hematocrit levels. Which problem do the data best support?

High risk for infection

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?

I will tell the nurse at the hospital that I had an Rh shot during pregnancy

A mother is breast-feeding her newborn baby and experiences breast engorgement. The nurse would encourage the mother to do which to provide relief of the engorgement?

Massage the breasts before feeding to stimulate let-down

The nurse is caring for a woman who has delivered a baby after a pregnancy complicated with placenta previa. Which complication is the client most at risk for developing?

Postpartum hemorrhage

A client is admitted to the labor and delivery suite with an intauterine fetal demis. The nurse determines that the discussion with parents was effective in preparing them for the delivery whe the parents make which response?

Request to hold the infant following delivery

A postpartum client ask the nurse when she may resume sexual activity. Which response would the nurse give to the client?

Sexual activity activity may be resumed in about 3 weeks when episiotomy has healed and the lochia has stopped

As a part of discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. Which response by the client indicates that the client understands the instructions?

She should alternately contract & relax the muscles

The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse places the client at risk for uterine rupture?

Shoulder dystocia

The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse would tell the client that these exercises are for which purpose?

Strengthen the pelvic floor in preperation for delivery

During initial data collection of a client who is pregnant, the nurse notes that the laboratory report shows leukopenia, thormbocytopenia, anemia, and an elevated erythrocyte sedimentation rate. The nurse suspects human immunodeficiency virus (HIV). Which laboratory study further supports the presence of HIV?

T lymphocyte levels

The nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse would select which injection site?

The lateral aspect of the middle third of the vastusl lateralis muscle

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term INVOLUTION means. Which description would the nurse give to the client?

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1cm/day