NCLEX RN Practice Questions 11 (Exam Mode) By RNpedia.Com

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

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.

All of the choices are tasty, but the pregnant client needs a diet that is balanced and has increased amounts of calcium. Hamburger pattie, green beans, French fries, and iced tea is lacking in fruits and milk. Roast beef sandwich, potato chips, baked beans, and cola contains the potato chips, which contain a large amount of sodium. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea contains meat, fruit, potato salad, and yogurt, which has about 360mg of calcium. Fish sandwich, gelatin with fruit, and coffee is not the best diet because it lacks vegetables and milk products.

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. Repositioning the monitor is not indicated at this time. Asking the client to ambulate 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.

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, other answers are incorrect.

The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The signs elevated human chorionic gonadatropin, uterine enlargement , and breast enlargement and tenderness are subjective and might be related to other medical conditions. Elevated human chorionic gonadatropin and uterine enlargement may be related to a hydatidiform mole, and breast enlargement and tenderness is often present before menses or with the use of oral contraceptives.

Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will decrease the progression of labor.

The symptoms of painless vaginal bleeding are consistent with placenta previa. Checking for cervical dilation, checking for firmness of the uterus , and obtaining a detailed history 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.

Accelerations with movement are normal. Other choices in the answers indicate ominous findings on the fetal heart monitor.

The expected effect of Pitocin is cervical dilation. Pitocin causes more intense contractions, which can increase the pain, making a painless delivery incorrect. Cervical effacement is caused by pressure on the presenting part, so cervical effacement is incorrect. Infrequent contractions is opposite the action of Pitocin.

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 fetal heart tones 160bpm and a small amount of greenish fluid are incorrect. If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord, so a small segment of the umbilical cord is incorrect and would need to be reported immediately.

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. Notifying doctor might be necessary but not before turning the client to her side. Starting an IV is not necessary at this time. Readjusting the monitor is incorrect because there is no data to indicate that the monitor has been applied incorrectly.

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.Low estrogen level, thin endometrial lining , and low progesterone level 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.

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

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.

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. Hypoglycemic, small for gestational age is incorrect because the infant will not be small for gestational age. Hyperglycemic, large for gestational age is incorrect because the infant will not be hyperglycemic. Hyperglycemic, small for gestational age is incorrect because the infant will be large, not small, and will be hypoglycemic, not hyperglycemic.

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 reporting weight gain to the physician 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. If the client misses one or more pills, two pills should be taken per day for 1 week 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. Reporting changes in the menstrual flow to the physician is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.

Dilation of 2cm marks the end of the latent phase of labor. Answer "We have a name picked out for the baby." is a vague answer, answer "I need to push when I have a contraction." indicates the end of the first stage of labor, and answer "I can’t concentrate if anyone is touching me." indicates the transition phase.

The nurse decides to apply an external monitor because the membranes are intact. 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.

This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. The baby asleep. has no relation to the readings, so it’s incorrect; the umbilical cord is compressed results in a variable deceleration; and vagal response is indicative of an early deceleration.

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.

The client with hyperemesis has persistent nausea and vomiting. With vomiting comes dehydration. When the client is dehydrated, she will have metabolic acidosis.Respiratory alkalosis without dehydration and Respiratory acidosis without dehydration are incorrect because they are respiratory dehydration. Metabolic alkalosis with dehydration is incorrect because the client will not be in alkalosis with persistent vomiting.

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. Experiencing abdominal pain and frequent urination is a vague answer and can be related to a urinary tract infection.

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. Impaired gas exchange related to hyperventilation would be indicated during the transition phase. Alteration in placental perfusion related to maternal position and impaired physical mobility related to fetal-monitoring equipment are not correct in relation to the stem.

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). Performing an ultrasound exam is incorrect because there is no need for an ultrasound based on the finding