NCLEX-PN Test #6 2 — Questions and Answers
Question 1: A client at 34 weeks gestation presents with painless, bright red vaginal bleeding. Which condition does the nurse suspect?
- Abruptio placentae
- Placenta previa (Correct answer)
- Bloody show of labor
- Cervical polyp
Correct answer: Placenta previa
Painless, bright red vaginal bleeding in the third trimester is the hallmark of placenta previa (abnormal placental implantation over the cervical os). Abruptio placentae typically presents with painful, dark red bleeding and a rigid uterus. A vaginal examination is contraindicated until placenta previa is ruled out by ultrasound.
Question 2: A client with preeclampsia is receiving IV magnesium sulfate. Which finding indicates magnesium toxicity?
- Deep tendon reflexes (DTRs) 2+
- Respiratory rate of 10 breaths per minute (Correct answer)
- Blood pressure of 148/92 mmHg
- Urine output of 35 mL/hour
Correct answer: Respiratory rate of 10 breaths per minute
Respiratory depression (rate < 12/min) is a sign of magnesium toxicity. Loss of deep tendon reflexes (areflexia) is the earliest sign of toxicity. Normal therapeutic monitoring includes DTRs every hour, urine output ≥25 mL/hr, and respirations ≥12/min. The antidote is calcium gluconate.
Question 3: An APGAR score of 6 is assigned to a newborn at 1 minute. What is the priority nursing intervention?
- Document the score and continue routine newborn care
- Initiate CPR immediately
- Provide stimulation, dry the infant, and administer supplemental oxygen (Correct answer)
- Administer naloxone for respiratory depression
Correct answer: Provide stimulation, dry the infant, and administer supplemental oxygen
APGAR 4–6 indicates moderate newborn depression requiring intervention. The initial actions are stimulation (rubbing back, flicking feet), drying, warming, and supplemental oxygen. Scores 0–3 require immediate resuscitation. Naloxone is only given for known opioid exposure causing respiratory depression.
Question 4: The nurse is caring for a client with HELLP syndrome. Which laboratory findings are consistent with this diagnosis?
- Elevated hemoglobin, elevated platelet count, elevated liver enzymes
- Hemolysis (low Hgb), elevated liver enzymes, low platelet count (Correct answer)
- Normal CBC with elevated BUN and creatinine
- Elevated WBC, elevated CRP, normal platelet count
Correct answer: Hemolysis (low Hgb), elevated liver enzymes, low platelet count
HELLP syndrome stands for Hemolysis, Elevated Liver enzymes, and Low Platelet count. It is a severe variant of preeclampsia with potentially fatal complications including DIC, liver rupture, and placental abruption. Prompt delivery is the definitive treatment.
Question 5: The PN is assessing a newborn at 24 hours of life and notes jaundice involving the face and upper chest. Which type of jaundice is this most likely?
- Pathological jaundice — requires immediate phototherapy
- Physiological jaundice — expected normal finding (Correct answer)
- Rh incompatibility — requires exchange transfusion
- Breastfeeding-associated jaundice — mother must stop nursing
Correct answer: Physiological jaundice — expected normal finding
Physiological jaundice appears after 24 hours of age and progresses in a head-to-toe pattern as bilirubin levels rise. It is caused by the breakdown of fetal hemoglobin and immature liver conjugation. Jaundice appearing within the first 24 hours of life is pathological and requires urgent evaluation.
Question 6: A client at 38 weeks gestation has group B Streptococcus (GBS) positive culture. Which intrapartum nursing action is most important?
- Schedule a cesarean section to prevent neonatal transmission
- Administer prophylactic IV penicillin at least 4 hours before delivery (Correct answer)
- Apply topical antibiotics to the birth canal
- Initiate IV antibiotics only if the client develops a fever in labor
Correct answer: Administer prophylactic IV penicillin at least 4 hours before delivery
Intrapartum antibiotic prophylaxis (IAP) with IV penicillin G (or ampicillin) is the standard of care for GBS-positive clients. The goal is to achieve adequate antibiotic levels in the fetus/neonate to prevent early-onset GBS neonatal sepsis. At least 4 hours before delivery provides optimal protection.
NCLEX-PN Test #6 2
A client at 34 weeks gestation presents with painless, bright red vaginal bleeding.
Which condition does the nurse suspect?