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NCLEX-RN Exam Questions - Part 33
1. In addition to changing the mothers position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina:
A) Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying.
B) Cover the cord with a wet sponge.
C) Apply a cord clamp to the exposed cord, and cover with a sterile towel.
D) Keep the cord warm and moist by continuous applications of warm, sterile saline compresses.
2. Which of the following signs might indicate a complication during the labor process with vertex presentation?
A) Fetal tachycardia to 170 bpm during a contraction
B) Nausea and vomiting at 8 - 10 cm dilation
C) Contraction lasting 60 seconds
D) Appearance of dark-colored amniotic fluid
3. A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.The nurses first intervention should be to:
A) Check FHT
B) Notify the attending physician
C) Turn off the IV oxytocin
D) Prepare for the delivery because the client is probably in transition
4. During a clients first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus.This may be due to:
A) Endometritis
B) Fibroid tumor on the uterus
C) Displacement due to bowel distention
D) Urine retention or a distended bladder
5. The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
A) Pulse rate of 50 - 70 bpm by her third postpartum day
B) Diuresis by her second or third postpartum day
C) Vaginal discharge or rubra, serosa, then rubra
D) Diaphoresis by her third postpartum day
A) Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying.
B) Cover the cord with a wet sponge.
C) Apply a cord clamp to the exposed cord, and cover with a sterile towel.
D) Keep the cord warm and moist by continuous applications of warm, sterile saline compresses.
2. Which of the following signs might indicate a complication during the labor process with vertex presentation?
A) Fetal tachycardia to 170 bpm during a contraction
B) Nausea and vomiting at 8 - 10 cm dilation
C) Contraction lasting 60 seconds
D) Appearance of dark-colored amniotic fluid
3. A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.The nurses first intervention should be to:
A) Check FHT
B) Notify the attending physician
C) Turn off the IV oxytocin
D) Prepare for the delivery because the client is probably in transition
4. During a clients first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus.This may be due to:
A) Endometritis
B) Fibroid tumor on the uterus
C) Displacement due to bowel distention
D) Urine retention or a distended bladder
5. The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
A) Pulse rate of 50 - 70 bpm by her third postpartum day
B) Diuresis by her second or third postpartum day
C) Vaginal discharge or rubra, serosa, then rubra
D) Diaphoresis by her third postpartum day
1. Right Answer: D
Explanation: (A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was 'wet' with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action.
2. Right Answer: D
Explanation: (A) Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. (B) Nausea and vomiting occur frequently during transition and are not a complication. (C) Contractions frequently last 6090 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. (D) Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.
3. Right Answer: C
Explanation: (A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Womens Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor;70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D)Contractions lasting 6090 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
4. Right Answer: D
Explanation: (A, B) Endometritis, urine retention, or bladder distention provide good distractors because they may delay involution but do not usually cause the uterus to be lateral. (C) Bowel distention and constipation are common in the postpartum period but do not displace the uterus laterally. (D) Urine retention or bladder distention commonly displaces the uterus to the right and may delay involution.
5. Right Answer: C
Explanation: (A) Bradycardia is an expected assessment during the postpartum period. (B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. (C) A return of rubra after the serosa period may indicate a postpartal complication. (D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state.
Explanation: (A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was 'wet' with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action.
2. Right Answer: D
Explanation: (A) Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. (B) Nausea and vomiting occur frequently during transition and are not a complication. (C) Contractions frequently last 6090 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. (D) Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.
3. Right Answer: C
Explanation: (A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Womens Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor;70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D)Contractions lasting 6090 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
4. Right Answer: D
Explanation: (A, B) Endometritis, urine retention, or bladder distention provide good distractors because they may delay involution but do not usually cause the uterus to be lateral. (C) Bowel distention and constipation are common in the postpartum period but do not displace the uterus laterally. (D) Urine retention or bladder distention commonly displaces the uterus to the right and may delay involution.
5. Right Answer: C
Explanation: (A) Bradycardia is an expected assessment during the postpartum period. (B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. (C) A return of rubra after the serosa period may indicate a postpartal complication. (D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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