Answers and Rationales for NCLEX-RN Practice Exam Part 5

View the NCLEX-RN Practice Test Part 5

1.      Answer B is correct. An amniotomy is an artificial rupture of membranes and normal amniotic fluid is straw-colored and odorless. Fetal heart tones of 160 indicate tachycardia, and greenish fluid is indicative of meconium, so answers A and C are incorrect. If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord, so answer D is incorrect and would need to be reported immediately.

2.      Answer D is correct. Dilation of 2cm marks the end of the latent phase of labor. Answer A is a vague answer, answer B indicates the end of the first stage of labor, and answer C indicates the transition phase.

3.      Answer B is correct. The normal fetal heart rate is 120–160bpm; 100–110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Answer A is not indicated at this time. Answer C is not the best action for clients experiencing bradycardia. There is no data to indicate the need to move the client to the delivery room at this time.

4.      Answer D is correct. The expected effect of Pitocin is cervical dilation. Pitocin causes more intense contractions, which can increase the pain, making answer A incorrect. Cervical effacement is caused by pressure on the presenting part, so answer B is incorrect. Answer C is opposite the action of Pitocin.

5.      Answer B is correct. Applying a fetal heart monitor is the correct action at this time. There is no need to prepare for a Caesarean section or to place the client in Genu Pectoral position (knee-chest), so answers A and C are incorrect. Answer D is incorrect because there is no need for an ultrasound based on the finding.

6.      Answer B is correct. The nurse decides to apply an external monitor because the membranes are intact. Answers A, C, and D are incorrect. The cervix is dilated enough to use an internal monitor, if necessary. An internal monitor can be applied if the client is at 0-station. Contraction intensity has no bearing on the application of the fetal monitor.

7.      Answer D is correct. Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid volume deficit. In answer A, impaired gas exchange related to hyperventilation would be indicated during the transition phase. Answers B and C are not correct in relation to the stem.

8.      Answer D is correct. This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Answer A has no relation to the readings, so it’s incorrect; answer B results in a variable deceleration; and answer C is indicative of an early deceleration.

9.      Answer C is correct. The initial action by the nurse observing a late deceleration should turn the client to the side—preferably, the left side. Administering oxygen is also indicated. Answer A might be necessary but not before turning the client to her side. Answer B is not necessary at this time. Answer D is incorrect because there is no data to indicate that the monitor has been applied incorrectly.

10.  Answer D is correct. Accelerations with movement are normal. Answers A, B, and C indicate ominous findings on the fetal heart monitor.

11.  Answer C is correct. Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will decrease the progression of labor. Answers A, B, and D are incorrect for the stem.

12.  Answer B is correct. Lutenizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the release of lutenizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in preparation for conception, which occurs within the next 10–12 hours after the LH levels peak. Answers A, C, and D are incorrect because estrogen levels are high at the beginning of ovulation, the endometrial lining is thick, not thin, and the progesterone levels are high, not low.

13.  Answer C is correct. The success of the rhythm method of birth control is dependent on the client’s menses being regular. It is not dependent on the age of the client, frequency of intercourse, or range of the client’s temperature; therefore, answers A, B, and D are incorrect.

14.  Answer C is correct. The best method of birth control for the client with diabetes is the diaphragm. A permanent intrauterine device can cause a continuing inflammatory response in diabetics that should be avoided, oral contraceptives tend to elevate blood glucose levels, and contraceptive sponges are not good at preventing pregnancy. Therefore, answers A, B, and D are incorrect.

15.  Answer D is correct. The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. The client will complain of sudden, stabbing pain in the lower quadrant that radiates down the leg or up into the chest. Painless vaginal bleeding is a sign of placenta previa, abdominal cramping is a sign of labor, and throbbing pain in the upper quadrant is not a sign of an ectopic pregnancy, making answers A, B, and C incorrect.

16.  Answer C is correct. All of the choices are tasty, but the pregnant client needs a diet that is balanced and has increased amounts of calcium. Answer A is lacking in fruits and milk. Answer B contains the potato chips, which contain a large amount of sodium. Answer C contains meat, fruit, potato salad, and yogurt, which has about 360mg of calcium. Answer D is not the best diet because it lacks vegetables and milk products.

17.  Answer B is correct. The client with hyperemesis has persistent nausea and vomiting. With vomiting comes dehydration. When the client is dehydrated, she will have metabolic acidosis. Answers A and C are incorrect because they are respiratory dehydration. Answer D is incorrect because the client will not be in alkalosis with persistent vomiting.

18.  Answer B is correct. The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The signs in answers A, C, and D are subjective and might be related to other medical conditions. Answers A and C may be related to a hydatidiform mole, and answer D is often present before menses or with the use of oral contraceptives.

19.  Answer C is correct. The infant of a diabetic mother is usually large for gestational age. After birth, glucose levels fall rapidly due to the absence of glucose from the mother. Answer A is incorrect because the infant will not be small for gestational age. Answer B is incorrect because the infant will not be hyperglycemic. Answer D is incorrect because the infant will be large, not small, and will be hypoglycemic, not hyperglycemic.

20.  Answer B is correct. When the client is taking oral contraceptives and begins antibiotics, another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately 5–10 pounds of weight gain is not unusual, so answer A is incorrect. If the client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the pill. Answer C is incorrect. If she misses two, she should take two; if she misses more than two, she should take the missed pills but use another method of birth control for the remainder of the cycle. Answer D is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.

21.  Answer B is correct. Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. The clients in answers A, C, and D—those with diabetes, hypertension, and thyroid disease—can be allowed to breastfeed.

22.  Answer A is correct. The symptoms of painless vaginal bleeding are consistent with placenta previa. Answers B, C, and D are incorrect. Cervical check for dilation is contraindicated because this can increase the bleeding. Checking for firmness of the uterus can be done, but the first action should be to check the fetal heart tones. A detailed history can be done later.

23.  Answer D is correct. The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. She should not wait until the contractions are every 2 minutes or until she has bloody discharge, so answers A and B are incorrect. Answer C is a vague answer and can be related to a urinary tract infection.

24.  Answer A is correct. Infants of mothers who smoke are often low in birth weight. Infants who are large for gestational age are associated with diabetic mothers, so answer B is incorrect. Preterm births are associated with smoking, but not with appropriate size for gestation, making answer C incorrect. Growth retardation is associated with smoking, but this does not affect the infant length; therefore, answer D is incorrect.

25.  Answer A is correct. To provide protection against antibody production, RhoGam should be given within 72 hours. The answers in B, C, and D are too late to provide antibody protection. RhoGam can also be given during pregnancy.

Leave a Reply