NCLEX-PN Test #9 1

Question 1

A nurse is assessing a newborn 1 hour after delivery.
The infant is cyanotic in the hands and feet but pink in the trunk.
Respiratory rate is 46 breaths/min and the infant is crying vigorously.
What should the nurse document?

Accepted Answer

Acrocyanosis, a normal finding in a newborn

Answer

Central cyanosis indicating cardiopulmonary compromise

Answer

Respiratory distress requiring immediate intervention

Answer

Peripheral vascular insufficiency requiring warming

Question 2

A postpartum client, 12 hours after a vaginal delivery, has a uterus that is displaced to the right of midline and is boggy. Which intervention should the nurse perform first?

Accepted Answer

Assist the client to void or insert a urinary catheter

Answer

Administer oxytocin per standing order

Answer

Massage the uterine fundus firmly

Answer

Notify the provider of the finding immediately

Question 3

A nurse is caring for a 4-year-old admitted with croup. The child suddenly develops inspiratory stridor at rest, nasal flaring, and intercostal retractions. Which action should the nurse take first?

Accepted Answer

Place the child in an upright position and notify the provider immediately

Answer

Administer a nebulized racemic epinephrine treatment as ordered

Answer

Notify the provider and prepare for possible intubation

Answer

Apply a cool mist via a croup tent over the crib

Question 4

A nurse is educating a client who is 28 weeks pregnant about signs that require immediate reporting. Which symptom is most concerning?

Accepted Answer

Sudden onset of severe headache with visual changes

Answer

Mild ankle swelling at the end of the day

Answer

Increased frequency of urination

Answer

Occasional round ligament pain with position changes

Question 5

A nurse is preparing to administer the hepatitis B vaccine to a newborn. The mother asks, 'Why does my baby need this today?' Which response by the nurse is most accurate?

Accepted Answer

'Early vaccination provides protection before possible exposure through vertical transmission or blood.'

Answer

'It is required by law for all newborns before discharge.'

Answer

'Your baby may have been exposed during delivery.'

Answer

'The vaccine prevents the baby from getting hepatitis A from contaminated food.'

Question 6

A nurse is caring for a child with epiglottitis who is drooling and sitting in a tripod position. Which nursing action is contraindicated?

Accepted Answer

Using a tongue depressor to visualize the throat

Answer

Keeping emergency intubation equipment at the bedside

Answer

Allowing the child to remain in a position of comfort

Answer

Avoiding any procedure that would cause agitation