NCLEX RN PEARSON VUE
The labor and delivery nurse would make it a priority to assess which two newborn body systems
immediately after birth?
a. Gastrointestinal and hepatic
b. Urinary and hematologic
c. Neurologic and temperature control
d. Respiratory and cardiovascular
Rationale: To begin life, the infant must make the adaptations to establish respirations and circulation. These
two changes are crucial to life. All other body systems become established over a longer period of time.
A primigravida client of 16 weeks' gestation states that she has not yet felt fetal
movement. What is the nurse's best response?
a. "Your fetus will move any day now. Call me in a week if you don't feel it."
b. "Your fetus will begin moving at about 20 weeks' gestation."
c. "You should have been feeling the movement already."
d. "Your fetus has been moving for the past 9 weeks without you feeling it. You will
feel it within a month."
Rationale: The embryo’s muscles spontaneously contract beginning at 7 weeks. The mother
perceives sensations of movement of the fetus from 16 to 20 weeks’ gestation. A primigravida
usually perceives movement closer to 20 weeks.
The client experienced an 18-hour labor with a second stage that lasted 2 hours. When the nurse bring
the infant into the room 1 hour after delivery, the client tells the nurse to leave the infant in the crib an
shows no interest in holding the newborn. The nurse should record which nursing diagnosis in the plan
of care?
a. Ineffective Individual Coping related to assuming parental role
b. Powerlessness related to loss of individual choices
c. Fatigue related to prolonged labor
d. Anxiety related to feelings of incompetence in parenting role
Rationale: Although this client is not demonstrating positive signs of bonding at this time, it is
important to look at her history before concluding that she is not bonding well with her infant.
This client just experienced a long labor and the influence of fatigue on the attachment process
should be considered. It is important to continue to assess infant bonding with this client
throughout her hospitalization to reach a nursing judgment based on evidence.
,A client with a strong family tendency toward hypertension denies he will get high blood pressure
because he watches what he eats, gets plenty of exercise, and maintains a normal weight. When
implementing the plan of care, the nurse would do which of the following?
a. Praise the client and reassure him that these actions will prevent him from becoming hypertensive.
b. Emphasize that no matter what he does, the client will eventually develop hypertension because of hi
family history.
c. Recognize the client's efforts towards a healthy lifestyle and emphasis that early detection is essential
to prevent complications.
d. Recommend that the client request antihypertensive medications prophylactically because of his
family history.
Rationale: Lifestyle modifications and recognition of risk factors are important parts of prevention of long-
term complications. Encouraging the client to maintain his current lifestyle and follow up with health
screening would be the best plan of action
A mother brings a 3-year-old child to the clinic for a well-child checkup. The child has not been to th
clinic since 6 months of age. The nurse determines that which activity is the priority of care for this
child?
a. Assess growth and development.
b. Begin dental care.
c. Complete hearing screening.
d. Update vaccinations.
Rationale: Every time a child enters the health care system, the immunization status should be checked. Som
children have uncertain history of immunization because of parental noncompliance or special circumstances
such as being refugees. Once immunization status has been determined, the nurse can go on to make routine
assessments.
Which statement, if made by a client receiving dietary instruction for atherosclerosis, would indicate a
need for further discussion?
a. "Margarine has less fat than butter, so I will no longer use butter."
b. "I will steam, bake, or broil my foods."
c. "American cheese has 76 percent fat calories."
d. "I will increase my consumption of fruits and vegetables."
Rationale: Atherosclerosis indicates the need to adopt a low-fat diet. Both butter and margarine
have 4 grams of fat per serving, making the client’s statement incorrect and in need of further
clarification. The responses in the other options are correct.
,The nurse would encourage the new mother to use which breastfeeding position to enable optimal
control of the newborn's head while giving the mother a full view of the infant's cheeks and jaw?
a. Lying-down position
b. Cradle position
c. Clutch (football) position
d. Across-the-lap position
Rationale: The football, or clutch, position provides the mother with more control of the
newborn’s head and full view of face.
The nurse is teaching a class on newborn care to a group of expectant parents. In explaining why
parents need to protect the infant from heat loss, the nurse should discuss which characteristic of the
infant's skin that is responsible for heat loss?
a. Lanugo
b. Nonfunctioning sebaceous glands
c. Nonfunctioning apocrine glands
d. Thinner skin
Rationale: At birth, the infant’s skin is thin with little subcutaneous fat. In addition, the infant has
a greater proportion of body surface area relative to the amount of water present in the skin.
The nurse caring for a 15-year-old primipara who delivered yesterday identifies this nursing diagnosis
Risk for altered Parenting related to knowledge deficit in newborn care. Which is the most appropriat
intervention when planning this client's discharge teaching?
a. Have the client watch a video on newborn care.
b. Give her information about a support group for adolescent mothers.
c. Demonstrate how to care for the newborn and have the client return the demonstration.
d. Give the client printed instructions on newborn care.
Rationale: Although all of the options may be appropriate, demonstrating newborn care will
allow the client to ask questions and gain confidence as she cares for her baby. Having her return
the demonstration will allow the nurse to evaluate the teaching.
, The clinic nurse is conducting health screenings. Which client assessment findings indicate that client
teaching is needed about the risk for stroke?
Select all that apply.
a. Weight 205 lbs and height 5 feet 4 inches
b. Blood pressure 164/92 mmHg
c. Eats bran for breakfast daily
d. Smokes ½ pack of cigarettes per day
e. Serum cholesterol level is 172 mg/dL
Rationale:
• Obesity is a modifiable risk factor for stroke.
• Hypertension is a modifiable risk factor for stroke.
• Eating a diet containing fiber helps keep cholesterol levels low and is not a risk factor for
stroke.
• Cigarette smoking is a modifiable risk factor for stroke.
• Hypercholesterolemia (cholesterol level greater than 200 mg) would also be a risk factor,
but this client’s level is less than 200 mg/dL.
The nurse doing health promotion in an ambulatory women's health clinic would plan to teach Kegel
exercises to a woman with which condition?
a. Menopause
b. Uterine prolapse
c. Urinary tract infection
d. Premenstrual syndrome
Rationale: Uterine prolapse is caused by weakened pelvic muscles, which can be strengthened by
Kegel exercises. The other conditions are not treated with Kegel exercises.
The pregnant client is 7 centimeters, 100% effaced, and at a +1 station. The fetus is in a face
presentation. The nurse concludes that teaching has been effective when the client's husband makes
which statement?
a. "Our baby will come out face first."
b. "Our baby will come out facing one hip."
c. "Our baby will come out buttocks first."
d. "Our baby will come out with the back of the head first."
Rationale: Presentation refers to the part of the fetus that is coming through the cervix and birth
canal first. Thus a face presentation occurs when the face is coming through first.
The labor and delivery nurse would make it a priority to assess which two newborn body systems
immediately after birth?
a. Gastrointestinal and hepatic
b. Urinary and hematologic
c. Neurologic and temperature control
d. Respiratory and cardiovascular
Rationale: To begin life, the infant must make the adaptations to establish respirations and circulation. These
two changes are crucial to life. All other body systems become established over a longer period of time.
A primigravida client of 16 weeks' gestation states that she has not yet felt fetal
movement. What is the nurse's best response?
a. "Your fetus will move any day now. Call me in a week if you don't feel it."
b. "Your fetus will begin moving at about 20 weeks' gestation."
c. "You should have been feeling the movement already."
d. "Your fetus has been moving for the past 9 weeks without you feeling it. You will
feel it within a month."
Rationale: The embryo’s muscles spontaneously contract beginning at 7 weeks. The mother
perceives sensations of movement of the fetus from 16 to 20 weeks’ gestation. A primigravida
usually perceives movement closer to 20 weeks.
The client experienced an 18-hour labor with a second stage that lasted 2 hours. When the nurse bring
the infant into the room 1 hour after delivery, the client tells the nurse to leave the infant in the crib an
shows no interest in holding the newborn. The nurse should record which nursing diagnosis in the plan
of care?
a. Ineffective Individual Coping related to assuming parental role
b. Powerlessness related to loss of individual choices
c. Fatigue related to prolonged labor
d. Anxiety related to feelings of incompetence in parenting role
Rationale: Although this client is not demonstrating positive signs of bonding at this time, it is
important to look at her history before concluding that she is not bonding well with her infant.
This client just experienced a long labor and the influence of fatigue on the attachment process
should be considered. It is important to continue to assess infant bonding with this client
throughout her hospitalization to reach a nursing judgment based on evidence.
,A client with a strong family tendency toward hypertension denies he will get high blood pressure
because he watches what he eats, gets plenty of exercise, and maintains a normal weight. When
implementing the plan of care, the nurse would do which of the following?
a. Praise the client and reassure him that these actions will prevent him from becoming hypertensive.
b. Emphasize that no matter what he does, the client will eventually develop hypertension because of hi
family history.
c. Recognize the client's efforts towards a healthy lifestyle and emphasis that early detection is essential
to prevent complications.
d. Recommend that the client request antihypertensive medications prophylactically because of his
family history.
Rationale: Lifestyle modifications and recognition of risk factors are important parts of prevention of long-
term complications. Encouraging the client to maintain his current lifestyle and follow up with health
screening would be the best plan of action
A mother brings a 3-year-old child to the clinic for a well-child checkup. The child has not been to th
clinic since 6 months of age. The nurse determines that which activity is the priority of care for this
child?
a. Assess growth and development.
b. Begin dental care.
c. Complete hearing screening.
d. Update vaccinations.
Rationale: Every time a child enters the health care system, the immunization status should be checked. Som
children have uncertain history of immunization because of parental noncompliance or special circumstances
such as being refugees. Once immunization status has been determined, the nurse can go on to make routine
assessments.
Which statement, if made by a client receiving dietary instruction for atherosclerosis, would indicate a
need for further discussion?
a. "Margarine has less fat than butter, so I will no longer use butter."
b. "I will steam, bake, or broil my foods."
c. "American cheese has 76 percent fat calories."
d. "I will increase my consumption of fruits and vegetables."
Rationale: Atherosclerosis indicates the need to adopt a low-fat diet. Both butter and margarine
have 4 grams of fat per serving, making the client’s statement incorrect and in need of further
clarification. The responses in the other options are correct.
,The nurse would encourage the new mother to use which breastfeeding position to enable optimal
control of the newborn's head while giving the mother a full view of the infant's cheeks and jaw?
a. Lying-down position
b. Cradle position
c. Clutch (football) position
d. Across-the-lap position
Rationale: The football, or clutch, position provides the mother with more control of the
newborn’s head and full view of face.
The nurse is teaching a class on newborn care to a group of expectant parents. In explaining why
parents need to protect the infant from heat loss, the nurse should discuss which characteristic of the
infant's skin that is responsible for heat loss?
a. Lanugo
b. Nonfunctioning sebaceous glands
c. Nonfunctioning apocrine glands
d. Thinner skin
Rationale: At birth, the infant’s skin is thin with little subcutaneous fat. In addition, the infant has
a greater proportion of body surface area relative to the amount of water present in the skin.
The nurse caring for a 15-year-old primipara who delivered yesterday identifies this nursing diagnosis
Risk for altered Parenting related to knowledge deficit in newborn care. Which is the most appropriat
intervention when planning this client's discharge teaching?
a. Have the client watch a video on newborn care.
b. Give her information about a support group for adolescent mothers.
c. Demonstrate how to care for the newborn and have the client return the demonstration.
d. Give the client printed instructions on newborn care.
Rationale: Although all of the options may be appropriate, demonstrating newborn care will
allow the client to ask questions and gain confidence as she cares for her baby. Having her return
the demonstration will allow the nurse to evaluate the teaching.
, The clinic nurse is conducting health screenings. Which client assessment findings indicate that client
teaching is needed about the risk for stroke?
Select all that apply.
a. Weight 205 lbs and height 5 feet 4 inches
b. Blood pressure 164/92 mmHg
c. Eats bran for breakfast daily
d. Smokes ½ pack of cigarettes per day
e. Serum cholesterol level is 172 mg/dL
Rationale:
• Obesity is a modifiable risk factor for stroke.
• Hypertension is a modifiable risk factor for stroke.
• Eating a diet containing fiber helps keep cholesterol levels low and is not a risk factor for
stroke.
• Cigarette smoking is a modifiable risk factor for stroke.
• Hypercholesterolemia (cholesterol level greater than 200 mg) would also be a risk factor,
but this client’s level is less than 200 mg/dL.
The nurse doing health promotion in an ambulatory women's health clinic would plan to teach Kegel
exercises to a woman with which condition?
a. Menopause
b. Uterine prolapse
c. Urinary tract infection
d. Premenstrual syndrome
Rationale: Uterine prolapse is caused by weakened pelvic muscles, which can be strengthened by
Kegel exercises. The other conditions are not treated with Kegel exercises.
The pregnant client is 7 centimeters, 100% effaced, and at a +1 station. The fetus is in a face
presentation. The nurse concludes that teaching has been effective when the client's husband makes
which statement?
a. "Our baby will come out face first."
b. "Our baby will come out facing one hip."
c. "Our baby will come out buttocks first."
d. "Our baby will come out with the back of the head first."
Rationale: Presentation refers to the part of the fetus that is coming through the cervix and birth
canal first. Thus a face presentation occurs when the face is coming through first.
