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NCLEX-RN Exam Questions - Part 134
1. A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of:
A) Lung immaturity
B) Intrauterine growth retardation (IUGR)
C) Intrauterine infection
D) Neural tube defect
2. On admission to the postpartal unit, the nurses assessment identifies the clients fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right.This is most likely an indication of:
A) Normal involution
B) A full bladder
C) An infection pain
D) A hemorrhage
3. A client - s membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
A) Assess quantity of fluid.
B) Assess color and odor of fluid.
C) Document on fetal monitor strip and chart.
D) Assess fetal heart rate (FHR).
4. The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:
A) A low birth weight
B) A birth defect
C) Anemia
D) Nicotine withdrawal
5. Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
A) Hemoglobin 17.2 g/dL
B) Platelets 250,000/mm3
C) Serum glucose 30 mg/dL
D) White blood cells 18,000/mm3
A) Lung immaturity
B) Intrauterine growth retardation (IUGR)
C) Intrauterine infection
D) Neural tube defect
2. On admission to the postpartal unit, the nurses assessment identifies the clients fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right.This is most likely an indication of:
A) Normal involution
B) A full bladder
C) An infection pain
D) A hemorrhage
3. A client - s membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
A) Assess quantity of fluid.
B) Assess color and odor of fluid.
C) Document on fetal monitor strip and chart.
D) Assess fetal heart rate (FHR).
4. The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:
A) A low birth weight
B) A birth defect
C) Anemia
D) Nicotine withdrawal
5. Which of the following blood values would require further nursing action in a newborn who is 4 hours old?
A) Hemoglobin 17.2 g/dL
B) Platelets 250,000/mm3
C) Serum glucose 30 mg/dL
D) White blood cells 18,000/mm3
1. Right Answer: A
Explanation: (A) At about 3032 weeks gestation, the amounts of the surfactants, lecithin, and sphingomyelin become equal. As the fetal lungs mature, the concentration of lecithin begins to exceed that of sphingomyelin. At 35 weeks, the L/S ratio is 2:1. Respiratory distress syndrome is unlikely if birth occurs at this time. (B) IUGR is associated with compromised uteroplacental perfusion or with viral infections, chromosomal disorders, congenital malformations, and maternal malnutrition. IUGR is not specifically assessed by analysis of the L/S ratio. (C) Analysis of the L/S ratio is not an assessment used to confirm intrauterine infection. (D) Elevated levels of _-fetoprotein in maternal serum or in amniotic fluid have been found to reflect open neural tube defects, such as spina bifida and anencephaly.
2. Right Answer: B
Explanation: (A) Immediately after expulsion of the placenta, the fundus should be in the midline and remain firm. (B) A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus. (C) Symptoms of infection may include unusual uterine discomfort, temperature elevation, and foul-smelling lochia. The stem of this question does not address any of these factors. (D) While excessive bleeding is associated with a soft, boggy uterus, the stem of this question includes displacement of the uterus, which is more commonly associated with bladder distention.
3. Right Answer: D
Explanation: (A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well-being, but it does not take priority over assessment of FHR. (B)Greenish-brown discoloration of amniotic fluid indicates presence of meconium. Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.
4. Right Answer: A
Explanation: (A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in the fetus. (B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus, it has not been directly linked to fetal anomalies. (C) Smoking during pregnancy has not been directly linked to anemia in the fetus. (D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn.
5. Right Answer: C
Explanation: (A) The normal range for hemoglobin in the newborn is 1719 g/dL; 17.2 g/dL is within normal limits. (B) A normal value range for platelets in the newborn is150,000400,000 mm3; 250,000/mm3 is within normal range. (C) A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention. (D) On the day of birth, a white blood cell count of 18,00040,000/mm3 is normal in the newborn.
Explanation: (A) At about 3032 weeks gestation, the amounts of the surfactants, lecithin, and sphingomyelin become equal. As the fetal lungs mature, the concentration of lecithin begins to exceed that of sphingomyelin. At 35 weeks, the L/S ratio is 2:1. Respiratory distress syndrome is unlikely if birth occurs at this time. (B) IUGR is associated with compromised uteroplacental perfusion or with viral infections, chromosomal disorders, congenital malformations, and maternal malnutrition. IUGR is not specifically assessed by analysis of the L/S ratio. (C) Analysis of the L/S ratio is not an assessment used to confirm intrauterine infection. (D) Elevated levels of _-fetoprotein in maternal serum or in amniotic fluid have been found to reflect open neural tube defects, such as spina bifida and anencephaly.
2. Right Answer: B
Explanation: (A) Immediately after expulsion of the placenta, the fundus should be in the midline and remain firm. (B) A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus. (C) Symptoms of infection may include unusual uterine discomfort, temperature elevation, and foul-smelling lochia. The stem of this question does not address any of these factors. (D) While excessive bleeding is associated with a soft, boggy uterus, the stem of this question includes displacement of the uterus, which is more commonly associated with bladder distention.
3. Right Answer: D
Explanation: (A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well-being, but it does not take priority over assessment of FHR. (B)Greenish-brown discoloration of amniotic fluid indicates presence of meconium. Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.
4. Right Answer: A
Explanation: (A) Women who smoke during pregnancy are at increased risk for miscarriage, preterm labor, and IUGR in the fetus. (B) Although smoking produces harmful effects on the maternal vascular system and the developing fetus, it has not been directly linked to fetal anomalies. (C) Smoking during pregnancy has not been directly linked to anemia in the fetus. (D) Smoking during pregnancy has not been linked to nicotine withdrawal symptoms in the newborn.
5. Right Answer: C
Explanation: (A) The normal range for hemoglobin in the newborn is 1719 g/dL; 17.2 g/dL is within normal limits. (B) A normal value range for platelets in the newborn is150,000400,000 mm3; 250,000/mm3 is within normal range. (C) A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention. (D) On the day of birth, a white blood cell count of 18,00040,000/mm3 is normal in the newborn.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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