NCLEX Question for Vaginal Delivery Normal Findings

Mrs. P. had a vaginal delivery of her second child two days ago. She is breast feeding the baby without difficulty. During a postpartum assessment on Mrs. P., the nurse would expect the following normal finding.

    a. Complaints of afterpains.
    b. Pinkish to brownish vaginal discharge.
    c. Voiding frequently, 50-57 ml per void.
    d. Fundus 1 cm above the umbilicus.

Correct Answer A. Afterpains occur more commonly in multiparas than in primiparas and are caused by intermittent uterine contractions.  Because oxytocin is released when the infant suckles, breast feeding also increase the severity of the after pains.
 

Lochia (term for vaginal discharge after birth) serosa occurs from bout the third until the tenth day after delivery and would not be observed on the second day; it is a pinkish to brownish color.
 

Catheterization would be required when the bladder is distended and the woman cannot void or when she is voiding small amounts (<100 ml) frequently.
 

After birth, the top of the fundus remains at the level of the umbilicus for about half a day; it then descends approximately one fingerbreadth per day until it can no longer be palpated on about the tenth day.

Read more »

Posted in: MCN NCLEX

NCLEX Question for 2 weeks After Delivery Assessment

A breast feeding mother is visited by the home health nurse two weeks after the delivery. The woman is febrile with flu like symptoms; on assessment the nurse notes a warm, reddened, painful area of the right breast. The best initial action of the nurse is to

    a. contact the physician for an order for antibiotics.
    b. advise the mother to stop breast feeding and pumping.
    c. assess the mother’s feeding technique and knowledge.
    d. obtain a sample of breast milk for culture.

Correct Answer: A. These symptoms are signs of infectious mastitis, usually caused by Staphylococcus aureus; a 10-day course of antibiotics is indicated.
 

In mastitis, an improved outcome, a decreased duration of symptoms, and decreased incidence of breast abscess result if the breasts continue to be emptied by either nursing or pumping.
 

It is important that breast feeding technique and knowledge be assessed when mastitis has occurred because there have been found to be contributing factors for this complication; however, it is not the best initial action of the nurse.
 

Diagnosis and treatment of mastitis are usually based on symptoms and physical examination, even while waiting for laboratory results; if there is a recurrence of the mastitis, most experts agree that a culture should be obtained.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Post Partum Assessment

Mrs. P. delivered her baby 12 hours ago. During the postpartum assessment, the uterus is found to be boggy with heavy lochia flow. The initial action of the nurse is to

    a. notify the physician or nurse midwife.
    b. administer prn oxytocin.
    c. encourage the woman to increase ambulation.
    d. massage the uterus until firm.

Correct Answer: D. A soft, boggy, uterus should be massaged until firm; clots may be expressed during massage and this often tends to contract the uterus more effectively.

If the uterus continues not to contract well or the bleeding is excessive, the physician or nurse midwife should be contacted; however, this is not the initial action of the nurse.

If the uterus continues to contract well or the bleeding is excessive, the physician or nurse midwife may order that oxytocin be administered; however, this is not the initial action of the nurse.

Ambulation is advised in the immediate postpartum period; however, this intervention is not related to the emergency situation described.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Newborn Bottle feeding

Mrs. B. is bottle feeding her newborn. The nurse evaluates the client understands how to safely manage formula when Mrs. B. states,

    a. “Prepared formula should be used within 48 hours.”
    b. “All bottles, caps, and nipples must be sterilized.”
    c. “A dishwasher is not sufficient for proper cleaning.”
    d. “Prepared formula must be refrigerated until used.”

Correct Answer D. Extra bottles of prepared formula are stored in the refrigerator and should be warmed slightly before feeding.

Bottles may be prepared individually, or up to one day’s supply of formula may be prepared at one time.
 

Cleanliness is essential, but sterilization is necessary only if the water source is questionable.
 

Bottles may be effectively prepared in dishwashers or washed thoroughly in warm soapy water and rinsed well; nipples should be washed and rinsed by hand.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Normal Vaginal Delivery Health Teaching Evaluation

A woman had a normal vaginal delivery 12 hours ago and is to be discharged from the birthing center. The nurse evaluates that the woman understands the teaching related to episiotomy and perineal area when she states,
    a. “I know the stitches will be removed at my postpartum clinic visit.”
    b. “The ice pack should be removed for 10 minutes before replacing it.”
    c. “The anesthetic spray, ten the heat lamp, will help lot.”
    d. “The water for the Sitz bath should be warm, about 102-1050 F.”

Correct Answer B: . To attain the maximum effect of reducing edema and providing  numbness of the tissues, the ice pack should remain in place approximately 20 minutes and then be removed for about 10 minutes before replacing it.

Stitches used for an episiotomy are absorbable and do not require removal.
 

Because of the danger of tissue burns, a woman must be cautioned not to apply anethetic spray before using a heat lamp.
 

Recently, cool sitz baths have gained popularity because they are effective in reducing perineal edema; therefore; it may be best to offer the woman a choice.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Prenatal Antibody Titer

A woman’s prenatal antibody titer shows that she is not immune to rubella and will receive the immunization after the delivery. The nurse would include which of the following instructions in the teaching plan?

    a. Pregnancy must be avoided for the next three months.
    b. Another immunization should be administered in the next pregnancy.
    c. Breast feeding should be postponed for five days after the injection.
    d. An injection will be needed after each succeeding pregnancy.

Correct ANswer: A. . To prevent intrauterine infection, which can result in miscarriage, stillbirth, and congenital rubella syndrome in the fetus, women who are immunized should be advised not to become pregnant for three months.
 

One immunization should result in the woman becoming immune to rubella; rubella vaccine is never administered during pregnancy because of the serious dangers to the fetus.
 

Receiving a rubella vaccination in the postpartum period is not a contraindication to breast feeding.
 

One immunization should result in the woman becoming immune to rubella; another antibody titer will be done in subsequent pregnancies for validation.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Breast Feeding

Mrs. N. has just delivered her first baby who will breast fed. The nurse should include which of the following instructions in the teaching plan?
    a. Try to schedule feedings at least every three to four hours.
    b. Wash nipples with soap and water before each feeding.
    c. Avoid nursing bras with plastic lining.
    d. Supplement with water between feedings when necessary.

Correct Answer C. Successful lactation is fostered by feeding soon after delivery and then feeding when the newborn is ready to nurse; signs of infant readiness include a wakeful state and rooting and sucking motions. 
 

Mothers are advised to simply wash their hands before breast feeding; washing the nipples is not necessary.  

The use of powders, creams, and soap is discouraged.
 

In a normal term infant who is being breast fed, supplemental water feedings are not needed; in fact; these feedings may impede breast feeding by decreasing the volume of breast milk required and also by feeding by creating “nipple confusion” in the infant.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Postpartum Period

Which of the following observations in the postpartum period would be of the most concern to the nurse?
 

   a. After the delivery, the mother touches the newborn with her fingertips.
    b. The new parents asked the nurse to recommend a good baby care book.
    c. A new father holds his son in the end face position while visiting.
    d. A new mother sits in the bed while her newborn lies awake in the crib.

Correct Answer: D. During the early postpartum period, evidence of maladaptive mothering may include limited handling or smiling at the infant; studies have shown that a predictable group of reciprocal interactions, between mother and baby, should take place with each encounter to foster and reinforce attachment.
 

Shortly after birth, the new mother examines her baby’s body with her fingertips looking for cues from the infant; fingertip touch causes the newborn to turn toward the touch.
 

Concern for ability to care for their newborn is an indicator of positive bonding and attachment.
 

For parents, the need for the newborn to open its eyes is nearly universal.  Babies held in the face-to-face (en face) position attempt to focus on the eyes of the holder; this strongly evokes parental feeling. 

Read more »

Posted in: MCN NCLEX

NCLEX Question for Cesarean Section Delivery Evaluation

Mrs. C. is scheduled for a cesarean section delivery due to transverse fetal lie. What is the best way for nurse to evaluate that Mrs. C. understands the procedure?
    a. Ask Mrs. C. about the help she will have at home after her delivery.
    b. Give Mrs. C. diagram of the body and ask her to draw the procedure for you.
    c. Ask Mrs. C. to tell you what she knows about the scheduled surgery.
    d.Provide Mrs. C. with a booklet explaining cesarean deliveries when she arrives at       the hospital.

Correct Answer: C. Asking for clarification of what Mrs. C. knows is the best way to evaluate what she understands of the procedure.  If the client has additional questions, the nurse can then clarify or amplify the information.      
 

Although it is important to have some help after discharge this question will not elicit information about her understanding of the procedure.      
 

This technique is useful in preparing young children for surgery, but is inappropriate for a normal adult.      
 

Although written information may be helpful to explain cesarean birth, providing it at the time of admission does not allow the nurse the opportunity to evaluate that the patient understands the procedures.    

Read more »

Posted in: MCN NCLEX

NCLEX Question for Active Labor at 4cm dilated 100% effaced, 0 station

Mrs.  B. is in active labor at 4 cm dilated, 100% effaced, and 0 station.  As she is ambulating she experiences a gush of fluid. What is the most appropriate initial action for the nurse to take?

a.    Send a specimen of the amniotic fluid to the laboratory for analysis.,

b.    Have Mrs. B. return to her room and place her in Trendelenburg position to prevent cord prolapse.

c.    Have Mrs. B. return to her room so that you can assess fetal status, including auscultation of fetal heart tones for one full minute.

d.    Call Mrs. B.’s physician because a cesarean delivery will be required.

Correct Answer: C. The most important nursing action after rupture of the membranes is careful fetal assessment, including fetal heart tones counted for one minute.

There is no known reason based on the available information to request amniotic fluid analysis.  Therefore, not only is this not an appropriate initial action, it is not required at all.

The presenting part is at 0 station.  At this station, it is unlikely that a cord prolapse would occur.  

 Trendelenburg would be sued only if an assessment confirmed this complication.

There is no information suggesting that Mrs. B. will require operative delivery.  It is more important to assess the client than anything else at this time.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Ruptured Membranes Plan of Care

Mrs. M., a primigravida, presents to the labor room with rupture of membranes at 40 weeks gestation.  Her cervix is 2 cm dilated and 100% effaced.  Contractions are every 10 minutes.  What should the nurse include in the plan of care?
a.    Allow Mrs. M. to ambulate as desired as long as the presenting part is engaged.

b.    Assessed fetal heart tones and maternal status every five minutes.

c..    Place Mrs. M. on an electronic fetal monitor for continuous assessment of labor.

d.    Send Mrs. M. home with instructions to return when contractions are every five minutes.

Correct Answer A.. Ambulation will help Mrs. M.’s contractions more effectively dilate the cervix.  As long as the presenting part is engaged, there is not increased risk of cord prolapse.
 

Assessments every five minutes are made during the second stage of labor. They are not required during the latent phase of first stage labor.
 

Although periodic assessments of mother and fetus are required, continuous monitoring is not indicated.
 

Although many patients in latent phase are sent home with instructions to return when contractions become more frequent, Mrs. M.’s ruptured membranes are a contraindication to that action.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Active Labor with 5cm Dilated Membranes itact and bulging

Ms. K. arrives at the birthing center in active labor.  On examination, the cervix is 5 cm dilated membranes intact and bulging, and the presenting part at – 1 station.  Ms. K asks if she can go for a walk. What is the best response for the nurse to give?
 

a.    “I think it would be best for you to remain in bed at this time because of the risk of cord prolapse.”
b.    “It’s fine for you to walk, but please stay nearby.  If you feel a gush of fluid, I will need to check you and your baby.”

c.    “It will be fine for you to walk because that will assist the natural body forces to bring the baby down the birth canal.

d.    “I would be glad to get you a bean bag chair or rocker instead.”

Correct Answer B:. Although there is always some risk of complications when membranes rupture, it is safe for Ms. K. to ambulate as long as she is rechecked if rupture of membranes occur.
 

Although cord prolapse can occur when the presenting part is not fully engaged, the incidence is highest with malpresentation, grand multiparity, multiple gestation, and low birthweight.
 

Although ambulation does support natural labor progress, this response is not the best one without anticipatory guidance.
 

Although the nurse may not feel comfortable allowing Ms. K. to walk, this response does not provide the client with any rationale for the nurse’s response and is therefore inappropriate.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Fetal Heart Tones

As the nurse assigned to Mrs. Q. you are listening to fetal heart tones.  Which of the following findings would you consider abnormal for a patient in active labor?

a.    A rate of 160 with no significant changes through a contraction
b.    A rate of 130 with accelerations to 150 with fetal movement
c.    A rate that varies between 120 and 130
d.    A rate of 170 with a drop to 140 during a contraction

Correct Answer D. A rate of 170 is suggestive of fetal tachycardia.  A drop to 140 during a contraction represents some periodic change, which is not a normal finding.

A rate of 160 is normal. The absence of changes during contractions is a reassuring finding.

A rate of 130 is normal.  Accelerations with fetal movement are a reassuring finding.

Baseline variability between 120 and 130is a normal finding.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Contraction Assessment

Which of the following is the best way for the nurse to assess contractions in a client presenting to the labor and delivery area?
 

a.    Place the client on the electronic fetal monitor with the labor toco at the fudus.

b.    As the client to describe the frequency, duration, and strength of her contractions.

c.    Use Leopold’s maneuvers to determine the quality of the uterine contractions.

d.    Place the fingertips of one hand on the fundus to determine frequency, duration, and strength of contractions.

Correct Answer D. The fingertips of one hand allow the nurse to feel when the contraction begins and ends and to determine the strength of by the firmness of the uterus.
 

Although the electronic fetal monitor can yield useful information as the patient continues to labor, it is not the best way for initial assessment to occur.
 

Self-report by the patient may be used to supplement the nurse’s assessment, but should not replace it.
 

Leopold’s maneuverses are used to determine fetal position prior to auscultation of heart rate. They do not provide information about contractions.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Using Leopold’s maneuvers

Using Leopold’s maneuvers to determine fetal position, the nurse finds that Mrs. L’s fetus is in a vertex position with the back on the left side.  Where is the best place for the nurse to listen for fetal heart tones?
 

a.    In the right upper quadrant of the mother’s abdomen.

b.    In the left upper quadrant of the mother’s abdomen.

c.    In the right lower quadrant of the mother’s abdomen.

d.    In the left lower quadrant of the mother’s abdomen.


Correct Answer D:. The left lower quadrant is the correct location since the back is on the left and the vertex is in the pelvis.
 

The right upper quadrant would be the place to auscultate if the back were on the right and the breech were in the pelvis.
 

The left upper quadrant would be the place to auscultate if the back were on the left and the breech were in the pelvis.
 

The right lower quadrant would be the place to auscultate if the back were on the right side.

Read more »

Posted in: MCN NCLEX

NCLEX Question for 36 weeks Gestation Prenatal visits

Mrs. D. is 36 weeks gestation and the nurse is talking with her during a prenatal visit.  Which statement indicates that Mrs. D. understands the onset of labor?
 

a.    “I need to go to the hospital as soon as the contractions become painful.”

b.    “If I experience bright red vaginal bleeding I know that I am about to deliver.”

c.    “I need to go to the hospital when I am having regular contractions and bloody show.”

d.    “My labor will not start until after my membranes rupture and I gush fluid.”

Correct Answer C. Regular contractions coupled with bloody show suggest that cervical changes are occurring as a result of contractions.
 

Perception of pain with contractions is not a reliable indicator of true labor.
 

Bright red vaginal leading is a sign of a complication, not the onset of labor.
 

Rupture of membranes does not necessarily occur prior to the onset of labor.

Read more »

Posted in: MCN NCLEX

NCLEX Question Healthy Behavior during Pregnancy

After a prenatal class on healthy behaviors during pregnancy, the nurse can evaluate that learning has occurred when a client states,
 

a.    “Alcohol in the first trimester of pregnancy is very dangerous, later it’s OK.”
b.    “Drinking alcohol during pregnancy is the most preventable cause of mental retardation”

c.    “Alcohol is bad during pregnancy, but a little with breast feeding helps with let-down

d.    “problems for the baby usually only occur with heavy drinking of alcohol.

Correct Answer B. Prenatal alcohol exposure is a preventable cause of birth defects and neurodevelopmental deficits; it is the leading most preventable cause of mental retardation.
 

Research confirms that infants suffer more severe abnormalities the earlier alcohol consumption occurs during gestation; but alcohol consumption in late pregnancy is also associated with intrauterine growth retardation and preterm delivery.
 

Women should not drink any alcohol when breast feeding.  It can cause drowsiness, weakness, decrease in linear growth, and abnormal weight gain in the infant; it may also decrease milk ejection.
 

No safe level has been determined for alcohol consumption during pregnancy.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Diabetic CLient who is planning for a pregnancy

The nurse includes the importance of self-monitoring of glucose in the care plan for a diabetic client planning a pregnancy. The goal of this monitoring is to prevent

a.    congenital malformations in the fetus

b.    maternal vasculopathy

c.    accelerated growth of the fetus.

d.    delayed maturation of fetal lungs.

Correct Answer A. There is increasing evidence that the degree of control for an insulin-dependent diabetic woman prior to conception greatly affects the fetal outcome. Studies find that poor maternal glucose control underlies the incidence of congenital malformations in the infants of diabetic mothers.

In diabetic woman with vascular disease, White’s class D, or one who has had diabetes for at least 20 years, even careful control of glucose at this point will not prevent these cardiovascular changes.

Macrosomia, excessive fetal growth, can occur in infants of diabetic mothers from hyperinsulinism; however, this is a concern in alter pregnancy, not at conception.

Infants of diabetic mothers have a higher incidence of respiratory distress syndrome because hypersulinism has a delaying effect on fetal lung maturation; however, this is a concern in later pregnancy.

Read more »

Posted in: MCN NCLEX

NCLEX Question for Class 3 Cardiac Disease Priority Nursing Diagnosis

A pregnant client with class 3 cardiac disease is seen during an initial prenatal visit. The nurse selects which of the following priority nursing diagnoses”
 

a.    Knowledge deficit related to self-care during pregnancy.

b.    Fear, client and family, related to pregnancy outcome

c.    Alteration in nutrition related to sodium-restricted diet.

d.    Activity intolerance related to compromised cardiac status

Correct Answer D:. Once pregnancy is established, the focus of management is on minimizing any extra cardiac demands on the pregnant woman.  In class 3 cardiac disease, the client experiences fatigue, palpitation, dyspnea, or angina when she undertakes less than ordinary activity.  Physical activity is markedly restricted; this includes bedrest throughout the pregnancy.
 

Pregnant women with cardiac disease do need to learn self-care to minimize the risk of complications; this, however, does not take priority over physiologic safety.
 

Pregnancies with serious complications instill fear in the client and family; however, physiological needs take priority.
 

Pregnant women with cardiac disease are likely to be placed on a sodium-restricted diet; however, this does not take priority over the risk of cardiac decompensation.

Read more »

Posted in: MCN NCLEX

NCLEX Question for 32 week Gestation who developed Mild PIH

Mrs. S., 32 weeks gestation, has developed mild PIH. The nurse evaluates that the client understands her treatment regimen when the client states,

a.    “it is most important not to miss any of my blood pressure medication.”
b.    I will watch my diet restrictions very carefully.”
c.    “I will spend most of my time in bed, on my left side.
d.    “I’m happy that this only happens during a first pregnancy.

Correct Answer C. Modified bedrest in the left lateral position may be advised for the client with mild PIH.  This position improves venous return and placental and renal perfusion; urine output increases, and blood pressure may stabilize or decrease.

If diastolic pressure exceed 110 mmHg, an antihypertensive drug may be administered IV in more severe PIH; in PIH,  placental perfusion is already compromised and lowering maternal blood pressure can further reduce perfusion and stress the fetus.

Dietary restrictions are no longer advised, and the client may follow a regular, well-balanced diet as tolerated.

Previous PIH predisposes to recurrence of PIH.

Read more »

Posted in: MCN NCLEX