NCLEX-RN Practice Test 20

Question 1

As the client reaches 8 cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175 bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?

Accepted Answer

There is uteroplacental insufficiency.

Answer

Late decelerations, characterized by a gradual decrease in fetal heart rate that begins after the peak of the contraction and returns to baseline after the contraction ends, are a classic sign of uteroplacental insufficiency. This indicates that the fetus is experiencing hypoxia due to inadequate oxygen exchange across the placenta. The baseline tachycardia and minimal variability further support fetal distress, requiring immediate intervention.

Question 2

A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:

Accepted Answer

Luteinizing hormone is high.

Answer

Conception is most likely to occur around the time of ovulation. A surge in luteinizing hormone (LH) is the hormonal trigger for ovulation, which is the release of a mature egg from the ovary. Therefore, when luteinizing hormone levels are high, ovulation is imminent or occurring, marking the most fertile period for conception.

Question 3

A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

Accepted Answer

The presence of fetal heart tones

Answer

Definitive (positive) signs of pregnancy are those that are directly attributable to the fetus and cannot be confused with other conditions. The presence of fetal heart tones, either heard by auscultation or visualized on ultrasound, is a positive sign. Other signs like elevated hCG or uterine enlargement are presumptive or probable, as they can have other causes.

Question 4

In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:

Accepted Answer

Progressive cervical dilation

Answer

Pitocin (oxytocin) is administered to stimulate uterine contractions and promote labor progression. For a client with secondary dystocia, an effective response to Pitocin would be evidence of progressive cervical dilation and effacement. This indicates that the contractions are effectively thinning and opening the cervix, leading towards a successful delivery.

Question 5

The home health nurse is planning for the day’s visits. Which client should be seen first?

Accepted Answer

The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

Answer

The client with multiple sclerosis receiving cortisone via a centrally placed venous catheter is the highest priority. Cortisone is an immunosuppressant, and a central line poses a significant risk for infection, which could be life-threatening in an immunocompromised patient. This client requires immediate assessment for signs of infection or catheter complications, making it the most urgent visit.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-RN Practice Test 20