Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 121

1. A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period wasFebruary 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:

A) November 23rd
B) December 26th
C) September 14th
D) December 9th

2. On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:

A) Take 2 ibuprofen (Motrin) tablets by mouth now because the baby will be returning for feeding in 20 minutes
B) Allow the infant to breast-feed at the next feeding time to empty the breasts
C) Apply ice packs to the breasts and wear a supportive, well-fitting bra
D) Take a warm shower and express milk from both breasts until empty

3. A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?

A) State nursing practice act
B) AWHONN Standards for the Nursing Care of Women and Newborns
C) American Nurses - Association Standards of Maternal- Child Health Nursing
D) International Council of Nurses - Code

4. A female client admitted to the labor and delivery unit thinks her bag of water 'broke' approximately 2 hours ago. She is having mild contractions 5 minutes apart.The most immediate nursing intervention would be to:

A) Note the color and amount of fluid on her clothes.
B) Assess the FHR.
C) Notify the physician.
D) Place the nitrazine test paper at the cervical os and note the color change.

5. A new mother experiences strong uterine contractions while breast-feeding her baby. She excitedly rings for the nurse. When the nurse arrives the mother tells her, 'Something is wrong. This is like my labor.' Which reply by the nurse identifies the physiological response of the client?

A) 'Your breasts are secreting a hormone that enters your bloodstream and causes your abdominal muscles to contract.'
B) 'Prolactin increases the blood supply to your uterus, and you are feeling the effects of this blood vessel engorgement.'
C) 'The same hormone that is released in response to the baby - s sucking, causing milk to flow, also causes the uterus to contract.'
D) 'There is probably a small blood clot or placental fragment in your uterus, and your uterus is contracting to expel it.'

1. Right Answer: A
Explanation: (A) Naeles rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract 3 months, and then add 1 year. (B) Naeles rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naeles rule. (C) Naeles rule presumes that the woman has a 28-day menstrual cycle, with conception occurringon the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naeles rule. (D) Naeles rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14thday of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naeles rule.

2. Right Answer: C
Explanation: (A) Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. (B) Breast- feeding every 1123 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottlefeeding mother. (C) Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Coopers ligament. In addition, breast binders or ace bandages may be used for some women. (D) Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.

3. Right Answer: A
Explanation: (A) The state nursing practice act determines the standard of care for the professional nurse. (B) AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. (C) American Nurses Association Standards are published as recommendations and guidelines for maternalchild health nursing. (D) The International Council of Nurses Code emphasizes the nurses obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.

4. Right Answer: B
Explanation: (A) Amniotic fluid is generally pale and straw colored. Meconium- stained amniotic fluid would indicate a previous hypoxic episode. This intervention, though appropriate, is not the immediate priority. (B) With rupture of the membranes, the umbilical cord may prolapse if the presenting part does not fill the pelvis.Assessing FHR ascertains fetal well-being. (C) More information regarding fetal status and assessing for membrane rupture is needed prior to contacting the physician. (D) Nitrazine test paper differentiates amniotic fluid from urine. Amniotic fluid is normally alkaline in contrast to urine, which is acidic. This intervention, though appropriate, is not the immediate priority.

5. Right Answer: C
Explanation: (A) Mammary growth as well as milk production and maintenance in the breast occur in response to hormones produced primarily by the hypothalamus and the pituitary gland. (B) Prolactin stimulates the alveolar cells of the breast to produce milk. It is important in the initiation of breast-feeding. (C) Oxytocin, which is released by the posterior pituitary, stimulates the let-down reflex by contraction of the myoepithelial cells surrounding the alveoli. In addition, it causes contractions of the uterus and uterine involution. (D) Afterpains may occur with retained placental fragments. A boggy uterus and continued bleeding are other symptoms that occur in response to retained placental fragments.

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