NCLEX Review Post Test Prepared by: Maria Nazarethe Sulit, RN

1. A nurse is caring for a client who was admitted to the maternity unit at 8a... the client has contractions occurring every 2 minutes, lasting 1.5 minutes, and is dilated 4 cm which cervical effacement of 60%. At 10.30AM., the contractions cease. The client complains of chest pain and manifests signs and symptoms of shock. The nurse quickly plans care suspecting which of the following? a. abruptio placentae b. Placenta previa c. Ruptured uterus d. Preterm labor 2. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM, the vital signs were T-99.8 degrees Fahrenheit, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings may be an early indication that the client is developing a complication of labor? a. FHT 175 beats / min b. 100 degress degrees Fahrenheit c. Cervical dilation 4 cm d. BP 138/88 mmhg 3. A nurse is gathering date from a 16 year old pregnant client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement by the client indicates an immediate need for further investigation? a. “I don’t like my face anymore. I always look like I have been crying” b. “I don’t like my breasts anymore. These silver lines are ugly” c. “I don’t like my stomach anymore. The brown line is disgusting” d. “I don’t like my figure anymore. My clothes are all too tight” 4. A nurse is reading the physcian’s documentation regarding a pregnant client and notes that the physician has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is? a. rounded and most favorable for a vaginal birth b. Narrow and oval and not the most favorable for a vaginal birth c. Wedge-shaped and narrow and nonfavorable for a vaginal birth d. flat and non-favorable for a vaginal birth 5. During a routine prenatal visit the client states, “ I have not been able to get my wedding ring off for the last two days. I guess the heat is making my fingers swell. “ the nurse needs to further check: a. The client for blood pressure changes and protein in the urine b. Height of the fundus as compared to the date of her last visit c. The blood glucose level d. for any vaginal discharge 6. A perinatal client with a history of heart disease has been instructed on care at home. Which statement by the client would indicate that the client understands her needs? a. “there is no restriction on people who visit me” b. “I should avoid stressful situations”

c. “my weight gain is not important’ d. “I should rest on my right side” 7. During the prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which of the following heart rates is noted? a. 80 beats per minute b. 100 beats per minute c. 150 beats per minute d. 180 beats per minute 8. A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the students understands the structure of the ductus venosus if the student states that it: a. Connects the pulmonary artery to the aorta b. Is an opening between the right and left atria c. Connects the umbilical artery to the inferior vena cava d. Connects the umbilical vein to the inferior vena cava 9. A pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client’s partner and tells the partner to a. Dorsiflex the client’s foot while flexing the knee b. Dorsiflex the client’s foot while extending the knee c. Plantarflex the client’s foot while flexing the knee d. Plantarlex the client’s foot while extending the knee 10. A multiparous client thought to be at 14 weeks’ gestation based on uterine size visits the prenatal clinic complaining of such severe morning sickness that “she has not been able to keep anything down for a week.” Owing to the client’s excessive vomiting, the nurse assesses the client’s urinalysis results for which of the following? a. White blood cells b. Albumin c. Glucose d. Acetone 11. A primigravida in active labor is about 10 days post-term. The client desires a bilateral pudendal block anesthetic before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective? a. back b. abdomen c. fundus d. perineum 12. After teaching a pregnant client about the potential complications of amniocentesis that must be reported immediately, the nurse determines that the client understands the instruction when she says the she should immediately report which of the following? a. nausea b. vaginal bleeding c. urinary frequency d. irregular, painless uterine tightness

13. While assessing a postpartum client, the nurse observes signs and symptoms of infection. A specific clinical manifestation of infection would be a. generalized rash b. dark red lochia c. bradycardia d. discomfort and tenderness of the abdomen 14. If RhoGAM is given to a mother after delivering a healthy baby, the condition that must be present for the globulin to be effective is that the a. Baby is Rh negative b. Mother has no titer in her blood c. Mother has some titer in her blood d. Mother is Rh positive 15. Serology test for syphilis is given to pregnant women. The nurse explains to the client that the reason this test is given is because? a. Latent syphilis becomes highly active during pregnancy due to hormonal changes b. Syphilis may be passed to the infant during delivery c. Syphilis may be passed to the fetus after 4 months of pregnancy d. Syphilis is no longer a problem, but the law still requires the test 16. A client has just delivered her first baby. Hyperbilirubinemia is anticipated because of Rh incompatibility. Hyperbilirubinemia occurs with Rh incompatibility between mother and fetus because? a. The mother’s blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in infants b. The mother’s blood contains the Rh factor and the infant’s does not, and antibodies are formed in the fetus that destroy RBC c. The infant develops a congenital defect shortly after birth that causes the destruction of RBC d. The mother has a history of previous yellow jaundice caused by a blood transfusion, which was passed to the fetus through the placenta 17. The nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings? a. presence of menses b. uterine enlargement c. breast sensitivity d. fetal heart tones 18. The nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean section may be necessary? a. increased maternal blood pressure of 150/90 mmhg b. decreased amount of vaginal bleeding c. fetal heart rate of 80 beats per minute d. maternal heart rate of 65 beats per minute 19. The newborn baby of client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a new born is a. peripheral acrocyanosis b. bradycardia c. lethargy d. jaundice

20. When client at 39 weeks’ gestation arrives in the birthing suite she says, “I think my membranes have ruptured.” When confirming if the membranes have ruptured, the nurse should: a. Test the leakage fluid with nitrazine paper & observe color changes b. Take the client’s temperature because ruptured membranes predispose to infection c. Avoid performing a vaginal examination d. Have the client provide a clean catch urine specimen and send it to laboratory for a culture 21. After a cesarean birth, the nurse performs fundal checks every 15 minutes. During one check the nurse notes that the fundus is soft and boggy. The priority nursing action at this time is to: a. Elevate the client’s legs b. Massage the client’s fundus c. Increase the PITOCIN drip rate d. Examine the client’s perineum for bleeding 22. As the nurse inspects the perineum of a client who has been admitted in early labor, the client suddenly turns pale and says she feels as if she is going to faint even though she is lying flat on her back. The nurse should a. elevate her feet b. elevate her head c. turn her left side d. start oxygen and IV fluids 23. An expectant couple asks the nurse about the cause of low back pain in labor. The nurse replies that this pain occurs most often when the position of the baby is a. breech b. transverse c. occiput anterior d. occiput posterior 24. A primigravida client states that about 2 weeks before labor, breathing became easier but urination more frequent. Identify this common experience a. descent b. dilation c. lightening d. quickening 25. A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred? a. hypotonic contractions b. forceps delivery c. Schultz presentation d. Weak bearing down efforts 26. A nurse has developed a plan of care for a client experiencing dystocia and included several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority? a. keeping the significant other informed of the progress of the labor b. providing comfort measures c. monitoring fetal heart rate d. changing the client’s position frequently

27. A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as a. exhaustion b. fear of losing control c. involuntary grunting d. valsava’s maneuver 28. A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is a. a form of biofeedback to enhance bearing down efforts during delivery b. light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus c. the application of pressure to the sacrum to relieve backache d. performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest 29. The uterus rises out of the pelvis and becomes an abdominal organ at about the: a. 8th wk. of pregnancy b. 18th wk. of pregnancy c. 10th wk. of pregnancy d. 12th wk. of pregnancy 30. During pregnancy, the uterine musculature hypertrophies and is greatly stretched as the fetus grows. This stretching: a. by itself inhibits uterine contraction until oxytocin stimulates the birth process b. is prevented from stimulating uterine contraction by high levels of estrogen during late pregnancy c. inhibits uterine contraction along with the combined inhibitory effects of estrogen and progesterone d. would ordinarily stimulate uterine contraction but is prevented by high levels of progesterone during pregnancy 31. At the end of the first trimester of pregnancy, a client complains of feeling tired. The nurse recognizes that this probably related to cardiovascular changes that a. Decrease BP b. Increase hematocrit c. Increased blood volume d. Decrease cardiac output 32. The nurse palpates the abdomen of Mrs. Mendoza. At 5-month gestation, what levels of the abdomen can the fundic height-by palpated? a. Symphysis pubis b. Midpoint between umbilicus and xiphoid c. Midpoint between sysphysis pubis and umbilicus d. Umbilicus 33. A nurse is caring for a client who was admitted to the maternity unit at 8a... the client has contractions occurring every 2 minutes, lasting 1.5 minutes, and is dilated 4 cm which cervical effacement of 60%. At 10.30AM., the contractions cease. The client complains of chest pain and manifests signs and symptoms of shock. The nurse quickly plans care suspecting which of the following? a. abruptio placentae b. Placenta previa c. Ruptured uterus d. Preterm labor

34. Which drug would the nurse expect to administer to a woman with infertility secondary to anovulation to suppress the hypothalamus? a. clomiphene (clomid) b. bromocriptine (parlodel) c. levothyroxine (synthroid) d. testosterone cypionate 35. Which finding is most characteristic of perineal hematoma? a. Fever b. Lethargy c. positive Homan's sign d. severe vulvar pain 36. Which drug would the nurse expect to administer to a woman experiencing subinvolution of the uterus? a. Heparin b. Methylergonovine c. warfarin d. Protamine 37. On the second postpartum day, where would the nurse expect to palpate the fundus? a. 1 cm. above the umbilicus b. at the level of the umbilicus c. 1 cm. below the umbilicus d. 2 cm. below the umbilicus 38. Which of the following are possible causes of early postpartum hemorrhage? Select all that apply a. uterine atony b. PROM c. perineal laceration d. small size for gestational age e. retained placental fragments f. DIC 39. Which of the following would the nurse administer as antidote for Terbutaline? a. calcium gluconate b. propranolol c. vitamin K d. protamine sulfate 40. Which of the following signs indicate that the placenta has separated and is ready to be delivered a. slowing of vaginal bleeding b. cessation of uterine contractions c. lengthening of the umbilical cord d. round firm uterine shape e. discoid uterine shape f. sudden gush of vaginal blood 41. During the transition phase of the first stage labor, which of the following occurs? a. irregular short contractions b. feeling the urge to push

c. onset of the first contractions d. cervical dilatation of 4 to 7 cm 42. Which of the following drugs is used to treat the candidal infection of a pregnant woman? a. doxycycline (vibramycin) b. azithromycin (zithromax) c. acyclovir (zovirax) d. miconazole (monistat) 43. Two hours after birth, the neonate begins to gag and turn a dusky color. What is the nurse's first action? a. calm the neonate b. notify the physician c. provide oxygen using a face mask d. aspirate the nose and mouth with a bulb syringe 44. Which of the following findings would lead the prenatal clinic nurse to suspect that the client has mild pre-eclampsia? Select all that apply a. Hypertension b. Seizures c. Hypotension d. Edema e. Proteinuria f. blurry vision 45. A newly diagnosed pregnant client tells the nurse, "If I'm going to have all of these discomforts, I'm not sure I want to be pregnant!" The nurse interprets the client's statement as an indication of which of the following? a. fear of pregnancy outcome b. rejection of pregnancy c. normal ambivalence d. inability to care for the newborn 46. Before advising a 24 year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs and symptoms of which of the following? a. Anemia b. Hypertension c. Dysmenorrheal d. acne vulgaris 47. Which of the following drugs does the nurse expect to be ordered if preterm delivery is inevitable? a. yutopar (ritodrine) b. pitocin (oxytocin) c. bricanyl (terbutaline) d. betamethasone 48. The client who had undergone cesarean section is receiving Demerol (Meperidine HCL). Which of the following drugs does the nurse anticipate to be ordered by the physician to prevent hypertension? a. plasil ( metochlopramine) b. compazine ( prochlorperazine) c. tigan ( trimethobenzamide) d. phenergan (promethazine)

49. The charge nurse assigned a postpartum client with thrombophlebitis to an RN. Which of the following actions by the RN needs intervention by the charge nurse? a. the RN elevates the legs of the client with pillows b. the RN applies support hose to the client c. the RN massages the legs of the client d. the RN applies moist heat on the legs of the client 50. The client with urinary tract infection has been prescribed to take nitrofurantoin. Which of the following will enhance effectiveness of the medication? a. cranberry juice b. tomato juice c. strawberry juice d. grapefruit juice 51. The postpartum client who delivered her newborn 5 hours ago is receiving methergine (methylergonovine maleate). Which of the following should be given highest priority when monitoring the client? a. perineal pad count b. vital signs c. intake and output d. calf pain 52. The postpartum client who delivered her newborn 4 days ago has been observed by the nurse to have started assuming tasks of mothering. She has started doing tasks for herself, not asking assistance. In which postpartum stage of regeneration is the client? a. taking-in phase b. taking-hold phase c. letting-go phase d. recovery phase 53. The mother who breastfeeds her newborn experiences pain from engorgement, 2 days after delivery. Which of the following actions by the LVN needs intervention by the RN? a. The LVN advises the mother to wear support bra b. The LVN applies ice pack over the mother's engorged breasts c. The LVN applies warm compress over the mother's engorged breasts d. The LVN administers the prescribed analgesics 54. The pregnant client had undergone delivery with forceps. She develops hematoma in the perineal area. Which of the following is inappropriate nursing action to relieve discomfort from hematoma? a. apply ice at hematoma site for the firat 24 hours b. perform warm sitz bath for the first 24 hours c. administer analgesic as prescribed d. perform urinary catheterization as ordered 55. The mother had breastfed her newborn. Which of the following actions of the mother indicates the need for further teaching? a. the mother inserts a clean finger into the baby's mouth before removing him from breast b. the mother burps the baby after feeding from each breast c. the mother places the baby on the left side after feeding d. the mother exposes her nipples to air for 10-20 minutes after feeding

56. The client has delivered a live baby boy 4 hours ago. Which of the following findings should be given highest priority by the nurse? a. bright red vaginal discharge b. fundus at the level of the umbilicus, palpated towards the right side of the abdomen c. urine output of 250 ml since after delivery d. body temperature of 37.6 C 57. The client is in active labor. Fetal heart rate monitoring is done. Bradycardia is noted at the start of uterine contraction. The nurse correctly interprets this finding as indicative of: a. head compression b. prolapsed cord c. uteropracental insufficiency d. false labor 58. The pregnant client is the latent phase of labor. Which of the following findings characterize this stage of labor? a. the client is helpless and restless b. the client feels out of control c. the client is talkative and eager d. the client is tired and anxious 59. The nurse is performing Leopold's maneuver. During the first maneuver, the fetal part palpated is hard, round and movable. The nurse concludes that the fetal presentation is: a. Cephalic b. Breech c. Shoulder d. Footling 60. The nurse is caring for several clients who are in active labor. Which among these clients should she give highest priority? a. the client with prolapsed cord b. the client with BP of 160/100 mmHg c. the client with oliguria d. the client with headache and blurred vision 61. The nurse is giving health teachings to a pregnant client. Which of the following information should be included for prevention of toxoplasmosis? a. avoid traveling to foreign countries during the entire pregnancy b. avoid persons with cough and colds c. avoid eating raw meats or handling cat litters d. avoid overcrowded places 62. The pregnant client will undergo Alpha-fetoprotein level determination. Which of the following specimen is required? a. maternal blood sample b. blood from chorionic villi c. amniotic fluid d. cervical secretions 63. The mother reported to the clinic for prenatal check-up. She asks the nurse when will the sex of the fetus be determined by the ultrasound. Which of the following would be the most appropriate response by the nurse? a. on the 16th week of pregnancy b. on the 20th week of pregnancy

c. on the 24th week of pregnancy d. on the 28th week of pregnancy 64. Which of the following potential problems should the nurse be alert for in a client with pregnancy-induced hypertension (PIH) a. abruptio placenta b. post term delivery c. uterine inversion d. placenta previa 65. Which of the following anti-tubecular drugs is most appropriate to be administered to a neonate delivered by tuberculosis - infected mother? a. Streptomycin b. Ethambutol c. Rifampicin d. INH (isoniazid) 66. Which of the following assessment indicates that the newborn is delivered fullterm? a. Lanugo is woolly patches b. skin is dry and cracked c. fingernails extend beyond fingertips d. profuse scalp hair 67. The client is on her first trimester of pregnancy. She is experiencing nausea and vomiting each morning that she wakes up. Which of the following should not be included when giving health teachings to this client? a. take small, frequent feedings b. take dry toast or crackers c. take anti-emetics d. take low-fat diet 68. Which of the following findings indicate s that Yutopar (Ritodrine) is effective? a. decreased frequency of uterine contractions b. increased duration of uterine contractions c. increased frequency of uterine contractions d. increased duration and frequency of uterine contractions 69. Identify what fetal position is presented in the picture. ________________

70. A pregnant client came in to the Prenatal clinic for a routine check-up at 5 months AOG. What is the estimated fetal length? ________________cm 71. A pregnant client came in to the Prenatal clinic for a routine check-up. The nurse was able to measure a fundal height of 19 cm. What is the estimated age of gestation of the fetus? ___________weeks

72. Identify what fetal presentation is shown in the picture. ________________

73. Identify what fetal attitude is shown in the picture. ________________

74. Identify the fetal lie that is shown in the picture. ________________

75. The nurse is performing Leopold’s Maneuver to a pregnant client. Mark the spot where the nurse is most likely place the transducer of the Doppler to listen to the FHR.

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