Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 104

1. At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?

A) Restrict fluid intake.
B) Use Alka-Seltzer as necessary.
C) Eat small, frequent bland meals.
D) Lie down after eating.

2. A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are:

A) Frustration, vague in communication
B) Seriousness, some difficulty following directions
C) Calmness, follows directions easily
D) Excitement, openness to instructions

3. The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:

A) Notifying the physician
B) Changing the client to the left lateral position
C) Continuing to monitor the FHR closely
D) Administering O2 at 8 L/min via face mask

4. A female client is admitted to the emergency department complaining of severe right-sided abdominal pain and vaginal spotting. She states that her last menstrual period was about 2 months ago. A positive pregnancy test result and ultrasonography confirm an ectopic pregnancy. The nurse could best explain to the client that her condition is caused by:

A) Abnormal development of the embryo
B) A distended or ruptured fallopian tube
C) A congenital abnormality of the tube
D) A malfunctioning of the placenta

5. A female client at 10 weeks gestation complains to her physician of slight vaginal bleeding and mild cramps. On examination, her physician determines that her cervix is closed. The client is exhibiting signs of:

A) An inevitable abortion
B) A threatened abortion
C) An incomplete abortion
D) A missed abortion

1. Right Answer: C
Explanation: (A) At least eight glasses of fluid per day are encouraged to help dilute stomach contents, thereby decreasing irritation. (B) Alka Seltzer contains aspirin, which is irritating to gastric mucosa, and therefore should be avoided. (C) Small, frequent bland meals help to decrease gastric pressure and to prevent reflux. (D) Lying down after meals may cause gastric reflux and prevents optimal gastric emptying.

2. Right Answer: A
Explanation: (A) During the transition phase, the mother may become frustrated and unclear in her communication owing to severe pain and fear of loss of control. (B) These behaviors are common in the active phase of labor. (C) These behavioral clues are seen in the latent phase of labor. (D) These characteristics are observed in the latent phase of labor.

3. Right Answer: C
Explanation: (A) Early decelerations are reassuring and do not warrant notification of the physician. (B) Because early decelerations is a reassuring pattern, it would not be necessary to change the clients position. (C) Early decelerations warrant the continuation of close FHR monitoring to distinguish them from more ominous signs.(D) O2 is not warranted in this situation, but it is warranted in situations involving variable and/or late decelerations.

4. Right Answer: B
Explanation: (A) The embryo itself may develop normally in the first several weeks of an ectopic pregnancy. (B) An ectopic pregnancy in the fallopian tube causes severe pain owing to the size of the growing embryo within the narrow lumen of the tube, causing distention and finally rupture within the first 12 weeks of pregnancy. (C) TheFallopian tube may either be normal or contain adhesions caused by a history of pelvic inflammatory disease or tubal surgeries, neither of which are congenital causes. (D) An ectopic pregnancy does not involve a dysfunctional placenta, but the implantation of the blastocyst outside the uterus.

5. Right Answer: B
Explanation: (A) An inevitable abortion includes the signs of cervical dilation and effacement as well as pain and bleeding. (B) A threatened abortion is a condition in which intrauterine bleeding occurs early in pregnancy, the cervix remains undilated, and the uterine contents are not necessarily expelled. (C) An incomplete abortion occurs when some portions of the products of conception are expelled from the uterus. (D) A missed abortion occurs when the embryo dies in utero and is retained in the uterus.

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