NCLEX Practice Exam 26 (10 Questions)

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

Diabetes

Positive HIV

Hypertension

Thyroid disease

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.

Explanation

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.

2. 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

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.

Explanation

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.

3. After the physician performs an amniotomy. the nurse's first action should be to assess the:

Degree of cervical dilation

Fetal heart tones

Client’s vital signs

Client’s level of discomfort

When the membranes rupture. there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones. such as bradycardia or tachycardia. should be reported. After the fetal heart tones are assessed. the nurse should evaluate the cervical dilation. vital signs. and level of discomfort. making answers A. C. and D incorrect.

Explanation

When the membranes rupture. there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones. such as bradycardia or tachycardia. should be reported. After the fetal heart tones are assessed. the nurse should evaluate the cervical dilation. vital signs. and level of discomfort. making answers A. C. and D incorrect.

4. 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

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.

Explanation

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.

5. A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client's cervix is 5 cm dilated with 75% effacement. Based on the nurse's assessment the client is in which phase of labor?

Active

Latent

Transition

Early

The active phase of labor occurs when the client is dilated 4–7cm. The latent or early phase of labor is from 1cm to 3cm in dilation. so answers B and D are incorrect. The transition phase of labor is 8–10cm in dilation. making answer C incorrect.

Explanation

The active phase of labor occurs when the client is dilated 4–7cm. The latent or early phase of labor is from 1cm to 3cm in dilation. so answers B and D are incorrect. The transition phase of labor is 8–10cm in dilation. making answer C incorrect.

6. 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

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.

Explanation

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.

7. The nurse is aware that the best way to prevent postoperative wound infection in the surgical client is to:

Administer a prescribed antibiotic

Wash her hands for 2 minutes before care

Wear a mask when providing care

Ask the client to cover her mouth when she coughs

The best way to prevent post-operative wound infection is hand washing. Use of prescribed antibiotics will treat infection. not prevent infections. making answer A incorrect. Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections; therefore. answers C and D are incorrect.

Explanation

The best way to prevent post-operative wound infection is hand washing. Use of prescribed antibiotics will treat infection. not prevent infections. making answer A incorrect. Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections; therefore. answers C and D are incorrect.

8. A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia. the nurse should give priority to:

Checking for cervical dilation

Placing the client in a supine position

Checking the client’s blood pressure

Obtaining a fetal heart rate

Following epidural anesthesia. the client should be checked for hypotension and signs of shock every 5 minutes for 15 minutes. The client can be checked for cervical dilation later after she is stable. The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing. Fetal heart tones should be assessed after the blood pressure is checked. Therefore. answers A. B. and D are incorrect.

Explanation

Following epidural anesthesia. the client should be checked for hypotension and signs of shock every 5 minutes for 15 minutes. The client can be checked for cervical dilation later after she is stable. The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing. Fetal heart tones should be assessed after the blood pressure is checked. Therefore. answers A. B. and D are incorrect.

9. 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.

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.

Explanation

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.

10. A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:

Teaching the mother to provide tactile stimulation

Wrapping the newborn snugly in a blanket

Placing the newborn in the infant seat

Initiating an early infant-stimulation program

The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Teaching the mother to provide tactile stimulation or provide for early infant stimulation are incorrect because he is irritable and needs quiet and little stimulation at this time. so answers A and D are incorrect. Placing the infant in an infant seat in answer C is incorrect because this will also cause movement that can increase muscle irritability.

Explanation

The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Teaching the mother to provide tactile stimulation or provide for early infant stimulation are incorrect because he is irritable and needs quiet and little stimulation at this time. so answers A and D are incorrect. Placing the infant in an infant seat in answer C is incorrect because this will also cause movement that can increase muscle irritability.