NCLEX-PN Test Prep - 1. When assessing a laboring client, the nurse ...

2022/2023 NCLEX-PN Test Prep

2(TWO)

Questions and Answers with Explanations

• When assessing a laboring client, the nurse finds a prolapsed cord. The

nurse should:

• Attempt to replace the cord
• Place the client on her left side
• Elevate the client’s hips
• Cover the cord with a dry, sterile gauze

Answer C: The client with a prolapsed cord should be treated by elevating

the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a Caesarean section can be performed. Do not attempt to replace the cord, as stated in answer A. Answer B is incorrect because turning the client to the left side will not help take pressure off the cord. Answer D is incorrect because the cord should be covered with a moist, sterile gauze, not dry gauze.

• The nurse is caring for a 30-year-old male admitted with a stab

wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?

• The tube will allow for equalization of the lung expansion.
• Chest tubes serve as a method of draining blood and serous fluid, and

assist in reinflating the lungs.

• Chest tubes relieve pain associated with a collapsed lung. D. Chest

tubes assist with cardiac function by stabilizing lung expansion.

Answer B: Chest tubes work to reinflate the lung and drain serous fluid. The

tube does not equalize expansion of the lungs, so answer A is incorrect. Pain is associated with collapse of the lung, and insertion of chest tubes is painful, so answer C is incorrect. Answer D is true but is not the primary rationale for performing chest tube insertion.

• A client who delivered this morning tells the nurse that she plans to

breastfeed her baby. The nurse is aware that successful breastfeeding is most

dependent on the:

• Mother’s educational level
• Infant’s birth weight
• Size of the mother’s breast
• Mother’s desire to breastfeed

Answer D: Success with breastfeeding depends on many factors, but the most

dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level, infant’s birth weight, and size of the mother’s breast have nothing to do with success, so answers A, B, and C are incorrect.

• The nurse is monitoring the progress of a client in labor. Which finding

should be reported to the physician immediately?

• The presence of scant bloody discharge
• Frequent urination
• The presence of green-tinged amniotic fluid
• Moderate uterine contractions

Answer C: Green-tinged amniotic fluid is indicative of meconium staining.

This finding indicates fetal distress. The presence of scant bloody discharge is normal, as are frequent urination and moderate uterine contractions, so answers A, B, and D are incorrect.

• The nurse is measuring the duration of the client’s contractions. Which

statement is true regarding the measurement of the duration of contractions? A. Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.

• Duration is measured by timing from the end of one contraction to the

beginning of the next contraction.

• Duration is measured by timing from the beginning of one contraction

to the end of the same contraction.

• Duration is measured by timing from the peak of one contraction to

the end of the same contraction.

Answer C: Duration is measured from the beginning of one contraction to

the end of the same contraction. Answer A is related to frequency. Answer B is incorrect because we do not measure from the end of the contraction to the beginning of the contraction. Duration also is not measured from the peak of the contraction to the end, as stated in answer D.

• The physician has ordered an intravenous infusion of Pitocin for the

induction of labor. When caring for the obstetric client receiving intravenous

Pitocin, the nurse should monitor for:

• Maternal hypoglycemia
• Fetal bradycardia
• Maternal hyperreflexia
• Fetal movement

Answer B: The client receiving Pitocin should be monitored for

decelerations. There is no association with Pitocin use and hypoglycemia, maternal hyperreflexia, or fetal movement, so answers A, C, and D are incorrect.

• A client with diabetes visits the prenatal clinic at 28 weeks gestation.

Which statement is true regarding insulin needs during pregnancy? A.Insulin requirements moderate as the pregnancy progresses.

• A decreased need for insulin occurs during the second trimester.
• Elevations in human chorionic gonadotrophin decrease the need for

insulin. D. Fetal development depends on adequate insulin regulation.

Answer D: During pregnancy, insulin needs increase during the second and

third trimesters; they do not decrease, as suggested in answer B. Insulin requirements do not moderate as the pregnancy progresses, so answer A is incorrect. Elevated human chorionic gonadotrophin elevate insulin needs; they do not decrease insulin needs. Thus, answer C is incorrect. Fetal development does depend on adequate nutrition and insulin regulation.

• A client in the prenatal clinic is assessed to have a blood pressure of

180/96. The nurse should give priority to:

• Providing a calm environment
• Obtaining a diet history

• Administering an analgesic
• Assessing fetal heart tones

Answer A: A calm environment is needed to prevent seizure activity. Any

stimulation can precipitate seizures. Assessing the fetal heart tones is important but is not the highest priority in this situation, so answer D is incorrect. Obtaining a diet history should be done later, so answer B is incorrect. Administering an analgesic is not indicated because there is no data in the stem to indicate pain, so answer C is incorrect.

• A primigravida, age 42, is 6 weeks pregnant. Based on the client’s age, her

infant is at risk for:

• Down syndrome
• Respiratory distress syndrome
• Turner’s syndrome
• Pathological jaundice

Answer A: The client who is age 42 is at risk for fetal anomalies such as Down

syndrome and other chromosomal aberrations. She is not at higher risk for respiratory distress syndrome or pathological jaundice, as stated in answers B and D. Turner’s syndrome, in answer C, is a genetic disorder that is not associated with age factors in pregnancy.

• A client with a missed abortion at 29 weeks gestation is admitted to the

hospital. The client will most likely be treated with:

• Magnesium sulfate
• Calcium gluconate
• Dinoprostone (Prostin E.)
• Bromocrystine (Pardel)

Answer C: The client with a missed abortion will have induction of labor.

Prostin E. is a form of prostaglandin used to soften the cervix. Magnesium sulfate is used for preterm labor and preeclampsia, not to induce labor, so answer A is incorrect. Calcium gluconate is the antidote for magnesium sulfate and is not used for this client, so answer B is incorrect. Pardel is dopamine receptor stimulant used to treat Parkinson’s disease; it was used