Actualtests NCLEX-RN. (All Versions Answered)

Actualtests NCLEX-RN. (All Versions Answered)-A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele's rule is: A. March 27 B. February 1 C. February 27 D. January 3 Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A)March 27 is a miscalculation. (B) February 1 is a miscalculation. (C) February 27 is the correct answer. To calculate the estimated date of confinement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. (D) January 3 is a miscalculation. QUESTION 2 The nurse practitioner determines that a client is approximately 9 weeks' gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as: A. Nausea and vomiting B. Quickening C. A 68 lb weight gain D. Abdominal enlargement Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) Nausea and vomiting are experienced by almost half of all pregnant women during the first 3 months of pregnancy as a result of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. (B) Quickening is the mother's perception of fetal movement and generally does not occur until 1820 weeks after the last menstrual period in primigravidas, but it may occur as early as 16 weeks in multigravidas. (C) During the first trimester there should be only a modest weight gain of 24 lb. It is not uncommon for women to lose weight during the first trimester owing to nausea and/or vomiting. (D) Physical changes are not apparent until the second trimester, when the uterus rises out of the pelvis. QUESTION 3 A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks' gestation. The nurse should be alert to which condition related to her age? A. Iron-deficiency anemia B. Sexually transmitted disease (STD) C. Intrauterine growth retardation D. Pregnancy-induced hypertension (PIH) Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) Iron-deficiency anemia can occur throughout pregnancy and is not age related. (B) STDs can occur prior to or during pregnancy and are not age related. (C) Intrauterine growth retardation is an abnormal process where fetal development and maturation are delayed. It is not age related. (D) Physical risks for the pregnant client older than 35 include increased risk for PIH, cesarean delivery, fetal and neonatal mortality, and trisomy. QUESTION 4 A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control? A. She is compliant with her diet as previously taught. B. She needs further instruction and reinforcement. C. She needs to increase her caloric intake. D. She needs to be placed on a restrictive diet immediately. Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. (B) Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 2730 lb over the 9-month period. With rapid and excessive weightgain, PIH should also be suspected. (C) She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. (D) Restrictive dieting is not recommended during pregnancy. QUESTION 5 Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is: A. 70 mg/dL and 120 mg/dL B. 100 mg/dL and 200 mg/dL C. 40 mg/dL and 130 mg/dL D. 90 mg/dL and 200 mg/dL Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: (A) The recommended range is 70120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus. QUESTION 6 When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take? A. Continue monitoring because this is a normal occurrence. B. Turn client on right side. D. Report to physician or midwife. Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. (C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client. QUESTION 7 The predominant purpose of the first Apgar scoring of a newborn is to: A. Determine gross abnormal motor function B. Obtain a baseline for comparison with the infant's future adaptation to the environment C. Evaluate the infant's vital functions D. Determine the extent of congenital malformations Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: (A) Apgar scores are not related to the infant's care, but to the infant's physical condition. (B) Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. (C) The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. (D) Congenital malformations are not one of the areas assessed with Apgar scores. QUESTION 8 A pregnant woman at 36 weeks' gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of 100 mL of milk? A. Fifty milliliters light cream and 2 tbsp corn syrup B. Thirty grams powdered skim milk and 1 egg D. One package vitamin-fortified gelatin drink Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: (A) This choice would provide more unwanted fat and sugar than protein. (B) Skim milk would add protein. Eggs are good sources of protein while low in fat and calories. (C) The benefit of protein from ice cream would be outweighed by the fat content. Chocolate syrup has caffeine, which is contraindicated or limited in pregnancy. (D) Although most animal proteins are higher in protein than plant proteins, gelatin is not. It loses protein during the processing for food consumption. QUESTION 9 Which of the following findings would be abnormal in a postpartal woman? A. Chills shortly after delivery B. Pulse rate of 60 bpm in morning on first postdelivery day C. Urinary output of 3000 mL on the second day after delivery D. An oral temperature of 101F (38.3C) on the third day after delivery Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (1224 hours) owing to diuresis. The kidneys must eliminate an estimated mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4F needs further investigation to identify any infectious process. QUESTION 10 What is the most effective method to identify early breast cancer lumps? A. Mammograms every 3 years B. Yearly checkups performed by physician C. Ultrasounds every 3 years D. Monthly breast self-examination Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: (A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are more effective forwomen older than 40. (B) Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast self-examination. (C) Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. (D) Monthly breast self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves. QUESTION 11 Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client's history? A. Menarche after age 13