Published - Fri, 03 Mar 2023

NCLEX-RN Exam Questions - Part 27

1. Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH?

A) 136/88 to 144/93
B) 132/78 to 124/76
C) 114/70 to 140/88
D) 140/90 to 148/98

2. In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle?

A) Menstrual phase
B) Proliferative phase
C) Secretory phase
D) Ischemic phase

3. A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:

A) Gently pull the infant away
B) Withdraw the breast from the infant - s mouth
C) Compress the areolar tissue until the infant drops the nipple from her mouth
D) Insert a clean finger into the baby - s mouth beside the nipple

4. A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:

A) Notify the physician
B) Place the client on a pad count
C) Massage the uterus and re-evaluate in 30 minutes
D) Have the client void and then re-evaluate the fundus

5. A client delivered her first-born son 4 hours ago. She asks the nurse what the white cheeselike substance is under the baby - s arms. The nurse should respond:

A) 'This is a normal skin variation in newborns. It will go away in a few days.'
B) 'Let me have a closer look at it. The baby may have an infection.'
C) 'This material, called vernix, covered the baby before it was born. It will disappear in a few days.'
D) 'Babies sometimes have sebaceous glands that get plugged at birth. This substance is an example of that condition.'

1. Right Answer: C
Explanation: (A) These blood pressure changes reflect only an 8 mm Hg systolic and a 5 mm Hg diastolic increase, which is insufficient for blood pressure changes indicatingPIH. (B) These blood pressure changes reflect a decrease in systolic pressure of 8 mm Hg and diastolic pressure of 2 mm Hg; these values are not indicative of blood pressure increases reflecting PIH. (C) The definition of PIH is an increase in systolic blood pressure of 30 mm Hg and/or diastolic blood pressure of 15 mmHg. These blood pressures reflect a change of 26 mm Hg systolically and 18mm Hg diastolically. (D) These blood pressures reflect a change of only 8 mm Hg systolically and 8 mm Hg diastolically, which is insufficient for blood pressure changes indicating PIH.

2. Right Answer: C
Explanation: (A) Menses occurs during the menstrual phase, during which levels of both estrogen and progesterone are decreased. (B) The ovarian hormone responsible for the proliferative phase, during which the uterine endometrium enlarges, is estrogen. (C) The ovarian hormone responsible for the secretory phase is progesterone, which is secreted by the corpus luteum and causes marked swelling in the uterine endometrium. (D) The corpus luteum begins to degenerate in the ischemic phase, causing a fall in both estrogen and progesterone.

3. Right Answer: D
Explanation: (A) In pulling the infant away from the breast without breaking suction, nipple trauma is likely to occur. (B) In pulling the breast away from the infant without breaking suction, nipple trauma is likely to occur. (C) Compressing the maternal tissue does not break the suction of the infant on the breast and can cause nipple trauma. (D) By inserting a finger into the infants mouth beside the nipple, the lactating mother can break the suction and the nipple can be removed without trauma.

4. Right Answer: D
Explanation: (A) The nurse should initiate actions to remove the most frequent cause of uterine displacement, which involves emptying the bladder. Notifying the physician is an inappropriate nursing action. (B) The pad count gives an estimate of blood loss, which is likely to increase with a boggy uterus; but this action does not remove the most frequent cause of uterine displacement, which is a full bladder. (C) Massage may firm the uterus temporarily, but if a full bladder is not emptied, the uterus will remain displaced and is likely to relax again. (D) The most common cause of uterine displacement is a full bladder.

5. Right Answer: C
Explanation: (A) This response identifies the fact that vernix is a normal neonatal variation, but it does not teach the client medical terms that may be useful in understanding other healthcare personnel. (B) This response may raise maternal anxiety and incorrectly identifies a normal neonatal variation. (C) This response correctly identifies this neonatal variation and helps the client to understand medical terms as well as the characteristics of her newborn. (D) Blocked sebaceous glands produce milia, particularly present on the nose.

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