Published - Fri, 03 Mar 2023

NCLEX-RN Exam Questions - Part 29

1. A pregnant client is at the clinic for a third trimester prenatal visit. During this examination, it has been determined that her fetus is in a vertex presentation with the occiput located in her right anterior quadrant. On her chart this would be noted as:

A) Right occipitoposterior
B) Right occipitoanterior
C) Right sacroanterior
D) LOA

2. Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, 'Begin oxytocin induction at 1 mU/min.' The nurse should:

A) Begin the oxytocin induction as ordered
B) Increase the dosage by 2 mU/min increments at15-minute intervals
C) Maintain the dosage when duration of contractions is 40 - 60 seconds and frequency is at 21â?2 - 4 minute intervals
D) Question the order

3. A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?

A) 'Keep breathing with your abdominal muscles as long as you can.'
B) 'Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16 - 20 times a minute with shallow chest breaths.'
C) 'Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.'
D) 'If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well.'

4. A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?

A) 'If he develops diarrhea lasting for more than 2 - 3 days, I will contact the doctor or nurse.'
B) 'I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings.'
C) 'It is important to keep the head of his bed elevated or sit him in the chair during feedings.'
D) 'I should use prepared or open formula within 24 hours and store unused portions in the refrigerator.'

5. A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as 'a cramp in my leg.' An appropriate nursing action is to:

A) Assess for pain with plantiflexion
B) Assess for edema and heat of the right leg
C) Instruct him to rub the cramp out of his leg
D) Elevate right lower extremity with pillows propped under the knee

1. Right Answer: B
Explanation: (A) The fetus in the right occipitoposterior position would be presenting with the occiput in the maternal right posterior quadrant. (B) Fetal position is defined by the location of the fetal presenting part in the four quadrants of the maternal pelvis. The right occipitoanterior is a fetus presenting with the occiput in mothers right anterior quadrant. (C) The fetus in right sacroanterior position would be presenting a sacrum, not an occiput. (D) The fetus in left occipitoanterior position would be presenting with the occiput in the mothers left anterior quadrant.

2. Right Answer: D
Explanation: (A) Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. (B) This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. (C) This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. (D) This answer is the appropriate nursing action because the scenario presents adysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.

3. Right Answer: B
Explanation: (A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a comfortable position in labor, but theLamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles. (D) When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 69 breaths/min.

4. Right Answer: B
Explanation: (A) Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel.Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. (B) A consistent weight gain of more than 0.22 kg/day (12 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. (C) Elevating the clients head prevents reflux and thus formula from entering the airway. (D) Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.

5. Right Answer: B
Explanation: (A) Calf pain with dorsiflexion of the foot (Homans sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. (B) Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall. (C)Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. (D) A pillow behind the knee can be constricting and further impair blood flow.

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