Published - Fri, 03 Mar 2023

NCLEX-RN Exam Questions - Part 28

1. A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:

A) Below the umbilicus toward left side of mother - s abdomen
B) Below the umbilicus toward right side of mother - s abdomen
C) At the umbilicus
D) Above the umbilicus to the left side of mother - s abdomen

2. In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?

A) Striae gravidarum
B) Chloasma
C) Dysuria
D) Colostrum

3. A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting15 seconds. The nurse interprets this test to be:

A) Nonreactive
B) Reactive
C) Positive
D) Negative

4. The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1 - 2 minutes; strong, large amount of 'bloody show.'The most appropriate nursing goal for this client would be:

A) Maintain client - s privacy.
B) Assist with assessment procedures.
C) Provide strategies to maintain client control.
D) Enlist additional caregiver support to ensure client - s safety.

5. A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the:

A) Presenting part is 2 cm above the level of the ischial spines
B) Biparietal diameter is at the level of the ischial spines
C) Presenting part is 2 cm below the level of the ischial spines
D) Biparietal diameter is 5 cm above the ischial spines

1. Right Answer: A
Explanation: (A) LOA identifies a fetus whose back is on its mothers left side, whose head is the presenting part, and whose back is toward its mothers anterior. It is easiest to auscultate fetal heart tones (FHTs) through the fetuss back. (B) The identified fetuss back is on its mothers left side, not right side. It is easiest to auscultateFHTs through the fetuss back. (C) In an LOA position, the fetuss head is presenting with the back to the left anterior side of the mother. The umbilicus is too high of a landmark for auscultating the fetuss heart rate through its back. (D) This is the correct auscultation point for a fetus in the left sacroanterior position, where the sacrum is presenting, not LOA.

2. Right Answer: C
Explanation: (A) Striae gravidarum are the normal stretch marks that frequently occur on the breasts, abdomen, and thighs as pregnancy progresses. (B) Chloasma is the'mask of pregnancy' that normally occurs in many pregnant women. (C) Dysuria is an abnormal danger sign during pregnancy and may indicate a urinary tract infection. (D) Colostrum is a yellow breast secretion that is normally present during the last trimester of pregnancy.

3. Right Answer: B
Explanation: (A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at least two accelerations of FHR with fetal movements, each 15 bpm, lasting 15 seconds or more, over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or oxytocin challenge test, not an NST.

4. Right Answer: C
Explanation: (A) Privacy may help the laboring client feel safer, but measures that enhance coping take priority. (B) The frequency of assessments do increase in transition, but helping the client to maintain control and cope with this phase of labor takes on importance. (C) This laboring client is in transition, the most difficult part of the first stage of labor because of decreased frequency, increased duration and intensity, and decreased resting phase of the uterine contraction. The clients ability to cope is most threatened during this phase of labor, and nursing actions aredirected toward helping the client to maintain control. (D) Safety is a concern throughout labor, but helping the client to cope takes on importance in transition.

5. Right Answer: C
Explanation: (A) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive.Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0.

80% DISCOUNT: NCLEX-RN PRACTICE EXAMS