Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 126

1. In teaching the client about proper umbilical cord care, the nurse recommends that:

A) Petrolatum be placed around the cord after the sponge bath
B) A belly binder be applied to prevent umbilical hernia
C) The area be cleansed at diaper changes with alcohol and inspected for redness or drainage
D) The cord clamp be left on until the cord stump separates

2. A baby is circumcised. Immediate postoperative care should include:

A) Applying a loose diaper
B) Keeping the baby NPO for 4 hours to avoid vomiting
C) Changing the dressing frequently using dry, sterile gauze
D) Taking the baby to his mother for cuddling

3. A 28-year-old multigravida has class II heart disease. At her prenatal visit at 34 weeks gestation, all of the following observations are made. Which would require intervention?

A) Weight gain of 2 kg in 4 weeks
B) Blood pressure of 128/78
C) Subjective data: shortness of breath after showering
D) Ankle edema reported present in late afternoon and evenings

4. A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?

A) Contractions every 2 minutes, lasting 100 seconds
B) Fetal heart decelerations during a contraction
C) Beat-to-beat variability between contractions
D) Fetal heart decelerations at the beginning of contractions

5. A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:

A) Place her in knee-chest position during the contraction
B) Use effleurage during the contraction
C) Apply strong sacral pressure during the contraction
D) Have her push with each contraction

1. Right Answer: C
Explanation: (A) Petrolatum does not allow the cord to dry and will encourage infection. (B) Belly binders do not facilitate drying of the cord and will encourage abdominal relaxation. (C) Frequent applications of alcohol will facilitate drying and discourage infection. (D) The cord clamp can be removed in 24 hours. Leaving it on is cumbersome and could pull on the cord unnecessarily.

2. Right Answer: D
Explanation: (A) A pressure diaper should be applied to discourage hemorrhage. (B) The baby can be fed by his mother soon after the procedure, once it is assessed that he is not in any distress and is stable. (C) Dressing changes should not be dry. Dry dressing will stick. (D) Cuddling after the procedure will hopefully quiet the baby.Feeding is also important if his feeding was withheld prior to the procedure or it is time for a feeding.

3. Right Answer: C
Explanation: (A) This is not an excessive weight gain indicative of fluid retention. (B) The blood pressure is within normal range. (C) Showering should not cause shortness of breath. This could be a sign ofcardiac decompensation. (D) Dependent ankle edema is normal late in the day among pregnant women. Progressive edema would be a dangerous development.

4. Right Answer: A
Explanation: (A) These are tetanic in nature and can cause rupture of the uterus. (B) The FHR decreases during contractions owing to vasoconstriction and should recover after the contraction. (C) Beat-to-beat variability is a normal finding and demonstrates fetal well-being. (D) The FHR may decrease at the beginning of a contraction owing to head compression.

5. Right Answer: C
Explanation: (A) This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. (B) Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. (C) Sacral pressure will counteract the pressure created by the position of the fetal head.(D) The client is not completely dilated. Pushing is contraindicated until the second stage of labor.

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