Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 53

1. Following a vaginal delivery, the postpartum nurse should observe for:

A) Dystocia, kraurosis
B) Chadwick - s sign
C) Fatigue, hemorrhoids
D) Hemorrhage and infection

2. A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering:

A) Oxytocin
B) Magnesium sulfate (MgSO4)
C) Ampicillin
D) Tetracycline

3. A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking reflex. The nurse should suspect:

A) Central nervous system damage
B) Hypoglycemia
C) Hyperglycemia
D) These are normal newborn responses to extrauterine life

4. A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:

A) Maintain O2at <40%
B) Maintain O2at>40%
C) Give moist O2at>40%
D) Maintain on 100% O2

5. A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:

A) Demand that she relax
B) Ask what is the problem
C) Stand or sit next to her
D) Give her something to do

1. Right Answer: D
Explanation: (A) Dystocia is difficult labor. The delivery has occurred. Kraurosis is atrophy and dryness of skin and any mucous membrane (vulva). (B) Chadwicks sign is a bluish color of vaginal mucosa suggestive of pregnancy. (C) Fatigue is a common symptom in the postpartal period. Hemorrhoids may occur with pregnancy. (D)Hemorrhage and infection are potential complications of vaginal delivery. Hemorrhage may result from retained placental fragments or soft uterus. Infection may occur from the introduction of organisms into the uterus during the delivery.

2. Right Answer: C
Explanation: (A) Oxytocin is prescribed to stimulate uterine contractions. (B) MgSO4is a central nervous system depressant prescribed to prevent and control convulsions related to preeclampsia. (C) Ampicillin is a penicillin derivative with no known teratogenic effects.This is the safest antibiotic during pregnancy. (D) Tetracycline stains teeth yellow and is not as safe as ampicillin during pregnancy.

3. Right Answer: B
Explanation: (A) Central nervous system damage presents as seizures, decreased arousal, and absence of newborn reflexes. (B) In a diabetic mother, the infant is exposed to high serum glucose. The fetal pancreas produces large amounts of insulin, which causes hypoglycemia after birth. (C) Hypoglycemia is a common newborn problem. Increased insulin production causes hypoglycemia, not hyperglycemia. (D) These are not normal adaptive behaviors to extrauterine life.

4. Right Answer: A
Explanation: (A) Retrolental fibroplasia is the result of prolonged exposure to high levels of O2in premature infants. Complications are hemorrhage and retinal detachment. (B,C, D) O2concentration is too high.

5. Right Answer: C
Explanation: (A) This nursing action is too controlling and authoritative. It could increase the clients anxiety level. (B) In her anxiety state, the client cannot rationally identify a problem. (C) This nursing action conveys a message of caring and security. (D) Giving the client a task would increase her anxiety. This would be a late nursing action.

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