NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
A female client at 37 weeks' gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a 20-minute period. Her results would be classified as:
Correct Answer: B
Rationale: A contraction stress test is unnecessary following a reactive (normal) nonstress test. The results are considered reactive, indicating that the fetus is not showing distress.
Therefore, a contraction stress test, which is a more in-depth test for fetal distress, is unnecessary. A nonreactive test would show fewer than two fetal movements or a failure of the FHR to increase at least 15 bpm with the movements in a 20-minute period. A contraction stress test should follow a nonreactive nonstress test to validate fetal distress.
Question 2 of 5
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, 'What is the greatest risk to my baby if it is born prematurely?' The RN's answer should be:
Correct Answer: D
Rationale: Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to a premature infant. The greatest risk to a premature infant is the lack of development of the lungs, which can lead to respiratory distress syndrome due to insufficient surfactant production.
Question 3 of 5
A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include:
Correct Answer: C
Rationale: A rigid, boardlike abdomen is an assessment finding indicative of placenta abruptio. A cause of postbirth hemorrhage is uterine atony. With placenta previa, uterine tone is within normal range. The placenta is located directly over the cervical os in complete previa. Blood will escape through the os, resulting in the uterus and abdomen remaining soft and relaxed. In placenta abruptio, hypertonicity of the uterus is caused by the entrapment of blood between the placenta and uterine wall, a retroplacental bleed. This does not exist in placenta previa.
Question 4 of 5
The client is prescribed ipratropium (Atrovent) and albuterol (Proventil) via inhaler. Which instruction should the nurse include?
Correct Answer: A
Rationale: Albuterol, a bronchodilator, is used first to open airways, followed by ipratropium, an anticholinergic, to maintain bronchodilation. Simultaneous or single daily use is incorrect.
Question 5 of 5
Which newborn assessment is considered an abnormal finding that requires immediate attention?
Correct Answer: C
Rationale: Jitteriness and shaking in a newborn may indicate hypoglycemia seizures or neurological issues requiring immediate attention. Cyanosis of hands and feet (acrocyanosis) three umbilical vessels and harlequin sign are normal or benign findings.