NCLEX-RN
NCLEX RN Questions with Detailed Explanations Questions
Extract:
Question 1 of 5
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart A. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart B. What should the nurse do next?
Correct Answer: B
Rationale: The neonate’s Apgar score has been improving since birth. (The birth score is 6; the current score is 9.) The nurse should continue to assess the neonate. There is no indication that oxygen is
needed since the color is improving, and stimulating the baby is not necessary as the he is now fl exing his extremities.
Question 2 of 5
The nurse is assessing the perineal changes of a woman in the second stage of labor. The nurse expects to see which of the following changes?
Correct Answer: D
Rationale: Crowning, when the fetal head is visible at the vaginal opening, is the expected perineal change in the second stage of labor, indicating imminent delivery.
Question 3 of 5
A client with a history of liver failure is admitted with hepatic encephalopathy. The nurse should monitor the client for which of the following?
Correct Answer: A
Rationale: Asterixis (flapping tremor) is a hallmark sign of hepatic encephalopathy due to ammonia buildup.
Question 4 of 5
A nulliparous client says that she and her husband plan to use a diaphragm with spermicide to prevent conception. Which of the following should the nurse include as the action of spermicides when teaching the client?
Correct Answer: A
Rationale: Spermicides destroy spermatozoa before they can enter the cervix, preventing fertilization.
Question 5 of 5
The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the chart for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 3:30 p.m. is 75%. What should the nurse do first?
Correct Answer: C
Rationale: A pulse oximetry reading of 75% is concerning but may be due to probe misplacement. Reassessing the reading first confirms accuracy before escalating to invasive measures like blood gases.