NCLEX Practice Exam 24 (10 Questions)
All questions are shown, but the results will only be given after you’ve finished the quiz. You are given 1 minute per question, a total of 10 minutes in this quiz.
- 1.
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
Correct Answer
B. A moderate amount of straw-colored fluidExplanation
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.Rate this question:
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- 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?
- 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?”
Correct Answer
D. “When can I get my epidural?”Explanation
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.Rate this question:
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- 3.
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
Correct Answer
B. Turn the client to her left sideExplanation
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.Rate this question:
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- 4.
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
Correct Answer
D. Progressive cervical dilationExplanation
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.Rate this question:
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- 5.
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
Correct Answer
B. Apply the fetal heart monitorExplanation
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.Rate this question:
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- 6.
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.
Correct Answer
B. The membranes are still intact.Explanation
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.Rate this question:
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- 7.
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
Correct Answer
D. Potential fluid volume deficit related to decreased fluid intakeExplanation
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.Rate this question:
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- 8.
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.
Correct Answer
D. There is uteroplacental insufficiency.Explanation
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.Rate this question:
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- 9.
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
Correct Answer
C. Reposition the clientExplanation
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.Rate this question:
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- 10.
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
Correct Answer
D. Acceleration of FHR with fetal movementsExplanation
Accelerations with movement are normal. Answers A. B. and C indicate ominous findings on the fetal heart monitor.Rate this question:
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