Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 122

1. A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, 'Why did this happen to my baby?' is:

A) 'It - s God - s will. It was probably for the best. There was something probably wrong with your baby.'
B) 'You - re young. You can have other children later.'
C) 'I know your other children will be a great comfort to you.'
D) 'I can see you - re upset. Would you like to see and hold your baby?'

2. A client - s prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:

A) In the immediate postpartum period
B) After the first trimester
C) At 28 weeks - gestation
D) Within 72 hours postpartum

3. A 24-year-old woman who is gravida 1 reports, 'I can - t take iron pills because they make me sick.' She continues, 'My bowels aren - t moving either.' In counseling her based on these complaints, the nurse - s most appropriate response would be, 'It would be beneficial for you to eat . . .

A) prunes.'
B) green leafy vegetables.'
C) red meat.'
D) eggs.'

4. A 26-year-old female client presents at 10 weeks gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The clients previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?

A) Age>25 years
B) Maternal weight
C) Previous birth of an infant weighing>9 lb
D) Family history of heart disease

5. The nurse assesses a clients monitor strip and finds the following: uterine contractions every 34 minutes, lasting 6070 seconds; FHR baseline 134146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?

A) Notify physician of nonreassuring FHR pattern.
B) Turn the client to her left side.
C) Start IV for fetal distress and administer O2 at 6 - 8 liters by mask.
D) Evaluate to see if the monitor strip is reassuring.

1. Right Answer: D
Explanation: (A) The mother and the father require support; the nurse should not minimize their grief in this situation. (B) Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. (C) Attachment to this infant occurs during the pregnancy for both the mother and father.Siblings will not replace their feelings or minimize their loss of this infant. (D) Holding and viewing the infant decreases denial and may facilitate the grief process.The nurse should prepare family members for how the infant appears ('she is bruised') and provide support.

2. Right Answer: A
Explanation: (A) The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization. (B) Rubella infection during the second trimester may result in permanent hearing loss for the fetus. (C) RhoGam is the drug generally administered at 28 weeks gestation to Rh-negative women. It is contraindicated to administer rubella vaccine during pregnancy. (D) RhoGam is the drug administered within 72 hours postpartum to Rh-negative women to prevent the development of antibodies to fetal cells.

3. Right Answer: A
Explanation: (A) Prunes provide fiber to decrease constipation and are an excellent source of dietary iron, as the prenatal client is not taking her supplemental iron and iron- deficiency anemia is common during pregnancy. (B) Green leafy vegetables provide a source of fiber and iron; however, prunes are a better source of both. (C)Red meat is a good iron source but will not address the constipation problem. (D) Eggs are a good iron source but do not address the constipation problem.

4. Right Answer: C
Explanation: (A) Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. (B) The clients weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. (C) The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. (D) A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy.

5. Right Answer: D
Explanation: (A) These indices are within normal parameters; therefore, the nurse does not need to contact the physician. (B) The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. (C) These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. (D) Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions.During the active phase of labor, the frequency of uterine contractions is every 24 minutes, with an appropriate duration of 60 sec.

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