NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following?
Correct Answer: B
Rationale: Solid foods introduced before 4-6 months of age are not compatible with the abilities of the GI tract and the nutritional needs of the infant. Production of milk is supply and demand. A common growth spurt occurs at 3 months of age, and more frequent nursing will increase the milk supply to satisfy the infant. Supplementation will decrease the infant's appetite and in turn decrease the milk supply. When the infant nurses less often or with less vigor, the amount of milk produced decreases. Rigid feeding schedules lead to a decreased milk supply, whereas frequent nursing signals the mother's body to produce a correspondingly increased amount of milk.
Question 2 of 5
A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station +2 means that the:
Correct Answer: C
Rationale: Station +2 means the presenting part is 2 cm below the ischial spines, indicating descent in the pelvis.
Question 3 of 5
A client with a history of asthma is admitted with complaints of wheezing. The nurse should give priority to:
Correct Answer: A
Rationale: Bronchodilators relieve wheezing in asthma by relaxing airway smooth muscles, improving airflow.
Question 4 of 5
The client is admitted with a diagnosis of preterm labor at 32 weeks gestation. The physician orders a tocolytic. The nurse should monitor for which complication?
Correct Answer: B
Rationale:
Tocolytics (e.g. nifedipine terbutaline) can cause maternal tachycardia as a side effect due to their effects on smooth muscle relaxation or beta-adrenergic stimulation. Fetal hypoglycemia macrosomia and maternal hypokalemia are not typical complications.
Question 5 of 5
The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?
Correct Answer: B
Rationale: In the taking-hold phase, the mother actively engages with the infant, such as calling the infant by name, indicating bonding.