NGN NCLEX 204 EXAMPREP STUDY GUIDE
2026 PRACTICE QUESTIONS AND SOLUTIONS
◉ A client with a diagnosis of preeclampsia suddenly begins to
exhibit seizure activity. Which is the first action on the part of the
nurse?
a. Calling the physician
b. Inserting an oral airway
c. Turning the client on her side
d. Noting the time of the seizure. Answer: C
◉ A nurse is preparing to administer an injection of vitamin K to a
newborn. At which site would the nurse select to administer the
medication?. Answer: 3
The preferred injection site for the administration of vitamin K in
the newborn is the lateral aspect of the middle third of the vastus
lateralis muscle (the newborn's thigh). This muscle is the preferred
injection site because it is free of major blood vessels and nerves and
is large enough to absorb the medication
◉ A nurse performs a bedside glucose test on a newborn infant
whose mother has diabetes mellitus and obtains a reading of (2.164
mmol/L)35 mg/dL. The nurse would take which action first?
,Ask the mother to breastfeed the newborn
Bottle-feed the newborn with diluted glucose
Start an intravenous line for the administration of glucose
Ask the laboratory to perform a blood glucose test immediately.
Answer: D
Normal newborn levels are 40 mg/dL or greater. Glucose levels of
less than (2.22-2.298 mmol/L))40 to 45 mg/dL measured with
bedside glucose screening should be reported and verified in the
laboratory. Although feeding is an intervention, the result of a
bedside glucose must be verified by the laboratory. Some infants
need IV glucose to maintain glucose balance and prevent damage to
the brain.
◉ A pregnant woman is being admitted to the maternity unit. The
woman tells the nurse that she felt a large gush of fluid from her
vagina on the way to the hospital. The nurse detects a fetal heart rate
of 90 beats/min. On physical examination, the nurse finds that the
umbilical cord is protruding from the vagina. Which actions should
the nurse perform? Select all that apply.
Placing the woman in knee-chest position
Administering oxygen at 2 to 4 L/min by nasal cannula
Administering terbutaline to stop contractions
, With two gloved fingers, exerting upward pressure, into the vagina,
on the presenting part
Wrapping the cord loosely in a sterile towel saturated with warm
sterile normal saline solution. Answer: A, C, D
Oxygen should be administered at 8-10 L/min via face mask
◉ A nurse provides information to the mother of a child with
diarrhea about signs and symptoms that indicate the need to call the
primary health care provider. Which statement by the mother
indicates the need for further instruction?
"I'll call the doctor if she gets dizzy and acts sick."
"I'll call the doctor if she has severe stomach cramps."
"I'll call the doctor if her temperature is 102°F (38.9°C) or higher."
"I'll call the physician if she goes longer than 6 hours without
urinating.". Answer: C
Call doctor at temperature above 100.
◉ A nurse reviewing the medical history of an infant experiencing
gastroesophageal reflux (GER) would expect to note documentation
of which other issue?
Refusal to suck
Frequent diarrhea
Recurrent otitis media
2026 PRACTICE QUESTIONS AND SOLUTIONS
◉ A client with a diagnosis of preeclampsia suddenly begins to
exhibit seizure activity. Which is the first action on the part of the
nurse?
a. Calling the physician
b. Inserting an oral airway
c. Turning the client on her side
d. Noting the time of the seizure. Answer: C
◉ A nurse is preparing to administer an injection of vitamin K to a
newborn. At which site would the nurse select to administer the
medication?. Answer: 3
The preferred injection site for the administration of vitamin K in
the newborn is the lateral aspect of the middle third of the vastus
lateralis muscle (the newborn's thigh). This muscle is the preferred
injection site because it is free of major blood vessels and nerves and
is large enough to absorb the medication
◉ A nurse performs a bedside glucose test on a newborn infant
whose mother has diabetes mellitus and obtains a reading of (2.164
mmol/L)35 mg/dL. The nurse would take which action first?
,Ask the mother to breastfeed the newborn
Bottle-feed the newborn with diluted glucose
Start an intravenous line for the administration of glucose
Ask the laboratory to perform a blood glucose test immediately.
Answer: D
Normal newborn levels are 40 mg/dL or greater. Glucose levels of
less than (2.22-2.298 mmol/L))40 to 45 mg/dL measured with
bedside glucose screening should be reported and verified in the
laboratory. Although feeding is an intervention, the result of a
bedside glucose must be verified by the laboratory. Some infants
need IV glucose to maintain glucose balance and prevent damage to
the brain.
◉ A pregnant woman is being admitted to the maternity unit. The
woman tells the nurse that she felt a large gush of fluid from her
vagina on the way to the hospital. The nurse detects a fetal heart rate
of 90 beats/min. On physical examination, the nurse finds that the
umbilical cord is protruding from the vagina. Which actions should
the nurse perform? Select all that apply.
Placing the woman in knee-chest position
Administering oxygen at 2 to 4 L/min by nasal cannula
Administering terbutaline to stop contractions
, With two gloved fingers, exerting upward pressure, into the vagina,
on the presenting part
Wrapping the cord loosely in a sterile towel saturated with warm
sterile normal saline solution. Answer: A, C, D
Oxygen should be administered at 8-10 L/min via face mask
◉ A nurse provides information to the mother of a child with
diarrhea about signs and symptoms that indicate the need to call the
primary health care provider. Which statement by the mother
indicates the need for further instruction?
"I'll call the doctor if she gets dizzy and acts sick."
"I'll call the doctor if she has severe stomach cramps."
"I'll call the doctor if her temperature is 102°F (38.9°C) or higher."
"I'll call the physician if she goes longer than 6 hours without
urinating.". Answer: C
Call doctor at temperature above 100.
◉ A nurse reviewing the medical history of an infant experiencing
gastroesophageal reflux (GER) would expect to note documentation
of which other issue?
Refusal to suck
Frequent diarrhea
Recurrent otitis media
