Physiologic Adaptation NCLEX Review

1. Andrea is admitted to the labor suite is to be induced with oxytocin (Pitocin). One hour after starting to receive the medication, the nurse makes the following observations: Contractions are 80 seconds in duration and occur every 2 minutes. The nurse should:
a. Slow the maintenance intravenous solution infusion rate to 10 drops per minute
b. Increase the flow rate of the maintenance intravenous fluid
c. Discontinue the oxytocin infusion
d. Slow the oxytocin rate to keep vein open

2. A client in the labor room asks nurse Jasmine why she is receiving an antacid before her cesarean section. The nurse responds that antacids are given to:
a. Neutralize secretions in the stomach
b. Cause relaxation so the anesthesia will be more effective
c. Prevents nausea after surgery
d. Prevent the infant from swallowing excessive mucus once the incision is made

3. Which of the following manifestation would most concern by nurse Geneva caring for a client diagnosed with pregnancy induced hypertension (PIH)?
a. Trace of protein in the urine
b. Blood pressure 140/98
c. Minimal long-term variability with no accelerations
d. Fetal heart rate between 110 and 120 beats per minute

4. A client is prescribed tetracycline hydrochloride (Achromycin). Nurse Alex instructs the client to take the medicine:
a. On an empty stomach
b. One hour after eating
c. With milk
d. With orange juice

5. In teaching a group of nursing students about fetal development, nurse Trisha educator states the outermost part of the placenta is called the:
a. Amnion
b. Amniotic Sac
c. Chorion
d. Mesoderm

6. Which of the following reflexes would cause nurse Claire the most concern if observed in a newborn? When:
a. An object touches the mouth, the infant’s head turns toward the object
b. The sole and the ball of the foot are stroked, the toes flex
c. An object is placed in the infant’s palm, the infant’s fingers close around it
d. There is a loud noise, the infant extends their hands and legs

7. Nurse Josephine is caring for a client who is receiving magnesium sulfate for the treatment of severe preeclampsia. Which is the nurse’s priority intervention?
a. Monitoring fetal heart rate
b. Monitoring vital signs every hour
c. Assessing deep tendons reflexes
d. Assessing hourly urine output

8. A client has had a total abdominal hysterectomy under general anesthesia. Once the client has been returned to the hospital room from surgery, which should nurse Mariane do first to promote the client’s comfort?
a. Assess the client’s level of comfort and medicate as soon as necessary
b. Encourage the client to cough, turn, and deep breathe
c. Monitor the indwelling catheter
d. Change the client’s position

9. A client being seen in the doctor’s office is told she has a retroverted uterus. Nurse Jolina should explains that a retroverted uterus:
a. Does not have a cervix
b. Has a depressed arched fundus
c. Is tipped backward.
d. Is heart shaped

10. A client in the labor suite is receiving an intravenous solution and begins complaining of headache and dyspnea. Nurse Rebecca observes the client’s face is flushed and that she is tachycardic. The nurse should?
a. Discontinue the intravenous fluid and catheter
b. Slow the intravenous rate to keep vein open
c. Notify the physician
d. Check the indwelling catheter for urinary output

11. Nurse Alicia is teaching a health occupation class about menstruation and outlines the parameters of a normal menstrual flow. Which of the following indicates a lack of understanding regarding menstruation? The average:
a. Flow lasts 3 to 7 days
b. Cycle is approximately 28 days
c. Menstrual flow is 500 cc
d. Age of menarche is 12 years of age

12. When an antepartum client is ordered to have a contraction stress test, nurse Selena anticipates administering which of the following oxytocin drugs to complete this test?
a. Ergotamine tartrate (Ergostat)
b. Methylergonovine maleate (Methergine)
c. Ergonovine maleate (Ergotrate Maleate)
d. Oxytocin (Pitocin)

13. When teaching a client who is about to have a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO), nurse Helen should include which of the following information? This surgery will result in:
a. Menopause, and estrogen replacement therapy may br necessary
b. Hot flashes
c. Discomfort with sexual intercourse
d. A heavier menstrual flow

14. A client has just been returned to her room following a radical mastectomy. Which of the following actions would nurse Tanya take first?
a. Turn client only onto back and unaffected side
b. Begin range of motion exercises immediately on the affected side
c. Slowly abduct the affected side
d. Check blood pressure in the affected arm every four hours

15. A client has received an epidural anesthesia in the delivery room. Nurse Ruby knows the epidural is effective if the client:
a. Is able to push effective during the second stage of labor
b. Complains of unilateral numbness of her lower extremities
c. Describes feeling lightheaded
d. Has decreased long-term fetal variability

16. A client has been given instructions regarding breast self examinations. Which of the following statements made by nurse Lester by the client reflects an understanding of the instructions?
a. It is better if I stand upright when I examine my breasts
b. I am to use thumb and index finger when I feel for lumps
c. I should never examine my breast while in the shower because I might slip
d. I am to do the examination right after my period

17. Nurse Lei realizes the best position for a client diagnosed with pregnancy induced hypertension (PIH) would be:
a. Right side lying
b. Left side lying
c. Trendelenburg
d. Semi-Fowler’s

18. Which of the following drugs would nurse Tin knows to be inappropriate in the treatment of premature labor?
a. Ritodrine (Yutopar)
b. Nifedipine (Adalat)
c. Terbutaline (Brethine)
d. Betamethasone (Celstone)

19. A client in the labor room asks why an internal fetal scalp electrode must be placed on her baby. Nurse Raquel best response would be:
a. Don’t worry. Your baby is fine
b. You will need to asks the doctor
c. Meconium has been released which causes distress to your baby
d. I need to observe your baby more closely

20. A client being seen in a family planning clinic asks nurse Sammy how a fertilized egg grows in the uterus. The nurse explains that certain hormones help the zygote to implant in the uterus and grow. Which hormone is most responsible for maintaining the pregnancy?
a. Estrogen
b. Progesterone
c. Follicle stimulating hormone
d. Luteinizing hormones

21. Which clinical findings by nurse Olivia would warrant further evaluation of a client receiving ritodrine (Yutopar) for treatment of premature labor? A:
a. Maternal heart rate of 124/minutes for 10 minutes
b. Fetal heart rate of 174 bpm
c. Bllod pressure frop form 120/68 to 110/60
d. Respiratory rate of 34/minute for 10 minutes

22. Which of the following measures would be most appropriate for nurse Kim to implement with a client having back labor?
a. Rub lower back at the coccyx area with firm pressure during contractions
b. Increase the client intravenous rate to 150 ml per hour to help with hydration
c. Monitor fetal heart rate every 30 minutes
d. Encourage the client to pant with contractions

23. Nurse Roba is explaining why anesthesia is not given until a good labor pattern has been established. In the course of the teaching, the nurse tells the client the anesthesia:
a. Can cause fetal depression
b. Will not be effective in active labor
c. May prolong labor
d. May cause maternal hypertension

24. Nurse Wendy knows the therapeutic level of magnesium for an antepartum client with pregnancy induced hypertension (PIH) is:
a. 2-5 mg/dl
b. 3-6 mg/dl
c. 4-7 mg/dl
d. 6-9 mg/dl

25. A client has a diagnosis of abruption placentae. Nurse Cindy should assess the client’s laboratory results for:
a. Increased platelet count
b. Prolonged partial thromboplastin time
c. Increased fibrinogen level
d. Decreased clotting time:

Answers and rationale will be posted soon. More NCLEX review