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

Acrocyanosis (cyanosis of the hands and feet only) is a normal finding in the first 24–48 hours of life due to immature peripheral circulation. The trunk being pink and the newborn crying vigorously indicate adequate central oxygenation. Central cyanosis (blue trunk/lips) would be an abnormal finding requiring intervention.

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

A uterus displaced to the right and boggy is most commonly caused by a full bladder displacing the uterus and preventing adequate contraction. The priority intervention is to assist the client to void or catheterize the bladder. After emptying the bladder, the fundus should return to midline; then fundal massage can be performed if still boggy.

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

Stridor at rest with increased work of breathing (nasal flaring, retractions) indicates significant airway obstruction. The immediate actions are positioning the child upright (reduces work of breathing and improves airway patency) and notifying the provider for urgent intervention. While racemic epinephrine and possible intubation may be needed, positioning and notification happen first.

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

Sudden severe headache with visual changes (blurred vision, seeing spots) are classic warning signs of preeclampsia and impending eclampsia, which are obstetric emergencies. These symptoms must be reported immediately. Ankle swelling, urinary frequency, and round ligament pain are common normal discomforts of pregnancy.

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

The hepatitis B vaccine is given at birth to protect the newborn from perinatal transmission (which can occur even if the mother is HBsAg-negative) and future bloodborne exposure. Hepatitis B is not caused by food; that is hepatitis A. Saying the baby 'may have been exposed' implies the mother is infected, which is not established.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #9 1