NCLEX-RN Practice Test 21
The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
The infant of a diabetic mother is usually large for gestational age. After birth, glucose levels fall rapidly due to the absence of glucose from the mother. Option A is incorrect because the infant will not be small for gestational age. Option B is incorrect because the infant will not be hyperglycemic. Option D is incorrect because the infant will be large, not small, and will be hypoglycemic, not hyperglycemic.
Which nurse should be assigned to care for the postpartum client with preeclampsia?
The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. Option A: The nurse is a new staff to the unit hence lacking the experience needed. Options C and D: These nurses lack sufficient experience with a postpartum client.
The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. Option A: Negligence is failing to perform care for the client. a tort is a wrongful act committed Option B: A tort is a wrongful act committed on the client or their belongings Option C: Assault is a violent physical or verbal attack.
A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:
The nurse decides to apply an external monitor because the membranes are intact. Options A, C, and D: The cervix is dilated enough to use an internal monitor, if necessary. An internal monitor can be applied if the client is at 0-station. Contraction intensity has no bearing on the application of the fetal monitor.
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
If the child has bacterial pneumonia, a high fever is usually present. Option B: Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough. Options C and D: Rhinitis is often seen with viral pneumonia, and vomiting and diarrhea are usually not seen with pneumonia.
The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make?
Dilation of 2 cm marks the end of the latent phase of labor. Option A is a vague answer. Option B indicates the end of the first stage of labor. Option C indicates the transition phase.
A 25-year-old client with Grave’s disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?
Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. Options A, B, and D: The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss.
The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. Options A, C, and D: The clients with diabetes, hypertension, and thyroid disease—can be allowed to breastfeed.
The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
Infants of mothers who smoke are often low in birth weight. Option B: Infants who are large for gestational age are associated with diabetic mothers. Option C: Preterm births are associated with smoking, but not with appropriate size for gestation. Option D: Growth retardation is associated with smoking, but this does not affect the infant length.