NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client who is gravida 1 para 1 vaginally delivered a 7-lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:
Correct Answer: D
Rationale: Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. The uterus descends into the pelvic cavity at approximately 10-12 postpartal days and can no longer be palpated abdominally. Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. An enlarged uterus may indicate subinvolution or postpartal hemorrhage. Immediately following delivery, the uterus lies midline, about midway between the umbilicus and the symphysis pubis.
Question 2 of 5
The nurse is caring for a client with a history of a mastectomy who is receiving Tamoxifen (Nolvadex). The nurse should teach the client to:
Correct Answer: A
Rationale: Tamoxifen increases the risk of endometrial cancer, so vaginal bleeding must be reported immediately. Sun exposure, caffeine, and fluid intake are not primary concerns.
Question 3 of 5
A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:
Correct Answer: B
Rationale: This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help.
Question 4 of 5
The nurse is caring for a client with a diagnosis of molar pregnancy. Which complication is most likely to occur?
Correct Answer: A
Rationale: Molar pregnancy can progress to choriocarcinoma a malignant tumor in rare cases. Fetal distress and preterm labor are not risks as there is no viable fetus and hypoglycemia is unrelated.
Question 5 of 5
The client at 30 weeks gestation is admitted with a diagnosis of preterm labor. The nurse should prepare to administer which medication?
Correct Answer: D
Rationale: In preterm labor at 30 weeks betamethasone is given for fetal lung maturity terbutaline or magnesium sulfate may be used as tocolytics to halt contractions and magnesium sulfate may also provide fetal neuroprotection. All are appropriate.