Saunders NCLEX-RN Test Bank
Saunders NCLEX-RN Test Bank Questions And
Answers(100% CORRECT ANSWERS) WITH
RATIONALES/ GUARANTEED PASS
GRADED A+
A postpartum nurse is caring for a client who had a placenta previa. Which nursing intervention does
the nurse, reviewing the plan of care, identify as the priority for this client?
A) Fundal assessment
B) Monitoring of urine output
C) Frequent assessment of lochia
D) Inclusion of iron in every meal –
Correct Answer :Answer: C
A+ TEST BANK 1
, Saunders NCLEX-RN Test Bank
Rationale: The placenta is implanted in the lower uterine segment, which does not contain the same
intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding even
when the fundus is firm. The nurse may first see an increase in lochia as a sign of hemorrhage. The
nurse then must assess the client carefully for signs of deficient fluid volume as a result of postpartum
hemorrhage. This assessment includes urine output and fundal assessment however these are not the
priority. Dietary intake of iron is not related specifically to placenta previa.
A rubella titer is performed on a woman who has just been told that she is pregnant. The results of the
titer indicate that the mother is not immune to rubella. The nurse tells the client that:
A) A therapeutic abortion should be considered
B) Immunization against rubella is required immediately
C) Immunization against rubella is required after delivery D) Antibiotics will be prescribed to prevent
the infection –
Correct Answer :Answer: C
Rationale: A rubella titer is performed to determine the pregnant client's immunity to rubella. If the
titer is less than 1:8, the woman is not immune. The client is then immunized after delivery. Because
the vaccine contains live virus, the client should not be immunized during pregnancy. Antibiotics are
not prescribed. Counseling the client on therapeutic abortion is incorrect.
A nurse provides information to a pregnant client about foods that are high in iron. Which food,
suggested by the client after this discussion, indicates that the client requires further instruction?
A) Spinach
B) Tomatoes
C) Lima beans
D) Whole-grain bread –
Correct Answer :Answer: B
Rationale: Foods that are high in iron include red meat, whole-grain bread and cereals, lima beans,
raisins, spinach, and broccoli. Tomatoes are high in vitamin C.
A+ TEST BANK 2
, Saunders NCLEX-RN Test Bank
A nurse performing a fundal assessment after a vaginal birth notes that the fundus is above the
umbilicus and displaced from the midline. What should the nurse do first?
A) Massage the fundus
B) Help the client void
C) Document the findings
D) Help the client ambulate –
Correct Answer :Answer: B
Rationale:
After a vaginal birth, the fundus should be firmly contracted and at or near the level of the umbilicus.
If the uterus is above the expected level or displaced from the midline position (usually to the right),
the bladder may be distended. The nurse would help the client void and then reassess the location of
the fundus. Fundal massage is indicated if the fundus is difficult to locate or is soft or boggy.
Ambulation is not appropriate. Although the nurse would document the findings, the most
appropriate initial action would be to help the client void.
A contraction stress test is scheduled, and the nurse provides instructions to the client regarding the
test. Which of the following pieces of information should the nurse give to the client? Select all that
apply.
A) An internal fetal monitor is attached.
B) The client will walk on a treadmill until contractions begin.
C) A positive test result indicates a need for further evaluation.
D) Special body movements will be performed to stimulate contractions.
E) The client may be asked to massage one or both nipples to stimulate uterine contractions. –
Correct Answer :Answer: C, E
Rationale:
A contraction stress test is used to assess placental oxygenation and function, determine the fetus'
capacity to tolerate labor, and determine fetal well-being; it is performed if the nonstress test result is
abnormal. The fetus is exposed to the stressor of contractions to assess the adequacy of placental
perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a
20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract either with the
A+ TEST BANK 3
, Saunders NCLEX-RN Test Bank
administration of a dilute dose of oxytocin (Pitocin) or by having the mother stimulate the nipples until
three palpable contractions with a duration of 40 seconds or more in a 10-minute period have been
achieved. Frequent maternal blood pressure readings are taken, and the client is monitored closely if
increasing doses of oxytocin are given. A positive contraction stress test result indicates that the fetus
may be compromised and requires continued monitoring and further evaluation. A negative result
indicates fetal well-being.
A nurse is assessing a client during her first prenatal visit to the clinic. The nurse takes the client's
temperature: 100.8° F. Which of the following actions on the part of the nurse is appropriate?
A) Notifying the physician
B) Documenting the temperature
C) Retaking the temperature rectally
D) Informing the client that a temperature of 100.8 °F is normal during pregnancy –
Correct Answer :Answer: A
Rationale:
The normal temperature during pregnancy is 98° to 99.6° F (36.2° to 37.6° C). A higher temperature
requires physician notification, because it may indicate an infection that requires medical
management. The temperature would be documented, but this is not the most appropriate action,
because the temperature is abnormal. Taking the temperature rectally is an unnecessarily invasive way
of reassessing the client's temperature. The nurse could retake the temperature again orally to make
sure that the original reading was correct. A temperature of 100.8° F is not normal during pregnancy.
Therefore the most appropriate nursing action is notification of the physician.
A clinic nurse reviews the record of a pregnant client and notes that the physician has documented
that the client exhibits the Hegar sign. The nurse understands that:
A) Fetal movement is being felt by the mother
B) A soft blowing sound can be heard when the uterus is auscultated
C) Softening and compressibility of the lower uterine segment has been detected
D) The client is experiencing irregular painless contractions during the pregnancy –
A+ TEST BANK 4
Saunders NCLEX-RN Test Bank Questions And
Answers(100% CORRECT ANSWERS) WITH
RATIONALES/ GUARANTEED PASS
GRADED A+
A postpartum nurse is caring for a client who had a placenta previa. Which nursing intervention does
the nurse, reviewing the plan of care, identify as the priority for this client?
A) Fundal assessment
B) Monitoring of urine output
C) Frequent assessment of lochia
D) Inclusion of iron in every meal –
Correct Answer :Answer: C
A+ TEST BANK 1
, Saunders NCLEX-RN Test Bank
Rationale: The placenta is implanted in the lower uterine segment, which does not contain the same
intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding even
when the fundus is firm. The nurse may first see an increase in lochia as a sign of hemorrhage. The
nurse then must assess the client carefully for signs of deficient fluid volume as a result of postpartum
hemorrhage. This assessment includes urine output and fundal assessment however these are not the
priority. Dietary intake of iron is not related specifically to placenta previa.
A rubella titer is performed on a woman who has just been told that she is pregnant. The results of the
titer indicate that the mother is not immune to rubella. The nurse tells the client that:
A) A therapeutic abortion should be considered
B) Immunization against rubella is required immediately
C) Immunization against rubella is required after delivery D) Antibiotics will be prescribed to prevent
the infection –
Correct Answer :Answer: C
Rationale: A rubella titer is performed to determine the pregnant client's immunity to rubella. If the
titer is less than 1:8, the woman is not immune. The client is then immunized after delivery. Because
the vaccine contains live virus, the client should not be immunized during pregnancy. Antibiotics are
not prescribed. Counseling the client on therapeutic abortion is incorrect.
A nurse provides information to a pregnant client about foods that are high in iron. Which food,
suggested by the client after this discussion, indicates that the client requires further instruction?
A) Spinach
B) Tomatoes
C) Lima beans
D) Whole-grain bread –
Correct Answer :Answer: B
Rationale: Foods that are high in iron include red meat, whole-grain bread and cereals, lima beans,
raisins, spinach, and broccoli. Tomatoes are high in vitamin C.
A+ TEST BANK 2
, Saunders NCLEX-RN Test Bank
A nurse performing a fundal assessment after a vaginal birth notes that the fundus is above the
umbilicus and displaced from the midline. What should the nurse do first?
A) Massage the fundus
B) Help the client void
C) Document the findings
D) Help the client ambulate –
Correct Answer :Answer: B
Rationale:
After a vaginal birth, the fundus should be firmly contracted and at or near the level of the umbilicus.
If the uterus is above the expected level or displaced from the midline position (usually to the right),
the bladder may be distended. The nurse would help the client void and then reassess the location of
the fundus. Fundal massage is indicated if the fundus is difficult to locate or is soft or boggy.
Ambulation is not appropriate. Although the nurse would document the findings, the most
appropriate initial action would be to help the client void.
A contraction stress test is scheduled, and the nurse provides instructions to the client regarding the
test. Which of the following pieces of information should the nurse give to the client? Select all that
apply.
A) An internal fetal monitor is attached.
B) The client will walk on a treadmill until contractions begin.
C) A positive test result indicates a need for further evaluation.
D) Special body movements will be performed to stimulate contractions.
E) The client may be asked to massage one or both nipples to stimulate uterine contractions. –
Correct Answer :Answer: C, E
Rationale:
A contraction stress test is used to assess placental oxygenation and function, determine the fetus'
capacity to tolerate labor, and determine fetal well-being; it is performed if the nonstress test result is
abnormal. The fetus is exposed to the stressor of contractions to assess the adequacy of placental
perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a
20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract either with the
A+ TEST BANK 3
, Saunders NCLEX-RN Test Bank
administration of a dilute dose of oxytocin (Pitocin) or by having the mother stimulate the nipples until
three palpable contractions with a duration of 40 seconds or more in a 10-minute period have been
achieved. Frequent maternal blood pressure readings are taken, and the client is monitored closely if
increasing doses of oxytocin are given. A positive contraction stress test result indicates that the fetus
may be compromised and requires continued monitoring and further evaluation. A negative result
indicates fetal well-being.
A nurse is assessing a client during her first prenatal visit to the clinic. The nurse takes the client's
temperature: 100.8° F. Which of the following actions on the part of the nurse is appropriate?
A) Notifying the physician
B) Documenting the temperature
C) Retaking the temperature rectally
D) Informing the client that a temperature of 100.8 °F is normal during pregnancy –
Correct Answer :Answer: A
Rationale:
The normal temperature during pregnancy is 98° to 99.6° F (36.2° to 37.6° C). A higher temperature
requires physician notification, because it may indicate an infection that requires medical
management. The temperature would be documented, but this is not the most appropriate action,
because the temperature is abnormal. Taking the temperature rectally is an unnecessarily invasive way
of reassessing the client's temperature. The nurse could retake the temperature again orally to make
sure that the original reading was correct. A temperature of 100.8° F is not normal during pregnancy.
Therefore the most appropriate nursing action is notification of the physician.
A clinic nurse reviews the record of a pregnant client and notes that the physician has documented
that the client exhibits the Hegar sign. The nurse understands that:
A) Fetal movement is being felt by the mother
B) A soft blowing sound can be heard when the uterus is auscultated
C) Softening and compressibility of the lower uterine segment has been detected
D) The client is experiencing irregular painless contractions during the pregnancy –
A+ TEST BANK 4
