NCLEX PN ACTUAL EXAM 2024 EXPERT CERTIFIED QUESTIONS AND CORRECT
VERIFIED ANSWERS WITH RATIONALES|ALREADY GRADED A+100% LATEST!
The nurse is collecting data from a pregnant client who is currently at 28 weeks'
gestation. At her prior prenatal visit, her fundal height measured 22 cm. The
nurse measures the fundal height at this visit in centimeters and should expect
which finding?
26 cm
During the second and third trimesters (18–30 weeks' gestation), the fundal
height in centimeters approximately equals the fetus's age in weeks plus or
minus 2 cm. In addition, at this point in the pregnancy, in a 4 week period, the
fundal height should increase approximately 4 cm. At 14 to 16 weeks'
gestation, the fundus can be located halfway between the symphysis pubis and
the umbilicus. At 20 to 22 weeks' gestation, the fundus is at the umbilicus, and
at term, the fundus is at the xiphoid process.
probable signs of pregnancy
Ballottement, Chadwick's sign, Uterine enlargement, Braxton Hicks
contractions
probable signs of pregnancy include uterine enlargement; Hegar's sign (the
compressibility and softening of the lower uterine segment that occurs at
about week 6); Goodell's sign (the softening of the cervix that occurs at the
beginning of the second month of pregnancy); Chadwick's sign (the violet
coloration of the mucous membranes of the cervix, vagina, and vulva that
,occurs at about week 4); ballottement (the rebounding of the fetus against the
examiner's fingers on palpation); Braxton Hicks contractions; and a positive
pregnancy test that measures for human chorionic gonadotropin.
amniocentesis at 16 weeks' gestation to detect the presence of biochemical or
chromosomal abnormalities. Which instructions should the nurse reinforce to
the client?
The bladder must be full during the examination.
Before 20 weeks' gestation, the bladder must be kept full during amniocentesis
to support the weight of the uterus. After 20 weeks' gestation, the bladder
should be emptied to minimize the chance of puncturing the placenta or fetus.
The client at 28 weeks' gestation is Rh negative and Coombs antibody negative.
The nurse determines that the client understands what the nurse has taught
her about Rh sensitization when the client makes which statement?
"I will tell the nurse at the hospital that I had an Rh shot during pregnancy."
As described in the question, it is accepted practice to administer Rho(D)
immune globulin to an Rh-negative woman at 28 weeks' gestation, with a
second injection within 72 hours of delivery. This prevents sensitization, which
could jeopardize a future pregnancy. For subsequent pregnancies or abortions,
the injections must be repeated, because the immunity is passive.
,contraction stress test
"The uterus is stimulated to contract by either small amounts of oxytocin or by
nipple stimulation."
The perinatal client is admitted to the obstetrical unit during an exacerbation of
a heart condition. When planning for the nutritional requirements of the client,
the nurse should consult with the dietitian to ensure which dietary measure?
A diet that is high in fluids and fiber to decrease constipation
Constipation causes the client to use Valsalva's maneuver. This causes blood to
rush to the heart and overload the cardiac system.
The nurse caring for a client with abruptio placentae is monitoring the client for
signs of disseminated intravascular coagulopathy (DIC). The nurse should
suspect DIC if which is observed?
Petechiae, oozing from injection sites, and hematuria
DIC is a state of diffuse clotting in which clotting factors are consumed, which
leads to widespread bleeding. Platelet counts are decreased, because they are
consumed by the process. Coagulation studies show no clot formation (clotting
times are thus prolonged), and fibrin plugs may clog the microvasculature
diffusely rather than in an isolated area.
, The client is in her second trimester of pregnancy. She complains of frequent
low back pain and ankle edema at the end of the day. The nurse should
recommend which measure to help relieve both discomforts?
Lie on the floor with the legs elevated onto a couch or padded chair, with the
hips and knees at a right angle.
The position described in option 4 will produce the posture of the pelvic tilt
while countering gravity as the force that leads to the edema of the lower
extremities.
The pregnant woman complains of being awakened frequently by leg cramps.
The nurse reinforces instructions to the client's partner and should tell the
client to perform which measure?
Dorsiflex the client's foot while extending the knee.
Leg cramps often occur when the pregnant woman stretches her leg and
plantar flexes her foot. Dorsiflexion of the foot while extending the knee
stretches the gastrocnemius muscle, prevents the muscle from contracting, and
halts the cramping.
The nurse is reinforcing instructions to a pregnant client regarding measures to
prevent heartburn. The nurse should instruct the client to take which best
measure?
Drink decaffeinated coffee and tea.
VERIFIED ANSWERS WITH RATIONALES|ALREADY GRADED A+100% LATEST!
The nurse is collecting data from a pregnant client who is currently at 28 weeks'
gestation. At her prior prenatal visit, her fundal height measured 22 cm. The
nurse measures the fundal height at this visit in centimeters and should expect
which finding?
26 cm
During the second and third trimesters (18–30 weeks' gestation), the fundal
height in centimeters approximately equals the fetus's age in weeks plus or
minus 2 cm. In addition, at this point in the pregnancy, in a 4 week period, the
fundal height should increase approximately 4 cm. At 14 to 16 weeks'
gestation, the fundus can be located halfway between the symphysis pubis and
the umbilicus. At 20 to 22 weeks' gestation, the fundus is at the umbilicus, and
at term, the fundus is at the xiphoid process.
probable signs of pregnancy
Ballottement, Chadwick's sign, Uterine enlargement, Braxton Hicks
contractions
probable signs of pregnancy include uterine enlargement; Hegar's sign (the
compressibility and softening of the lower uterine segment that occurs at
about week 6); Goodell's sign (the softening of the cervix that occurs at the
beginning of the second month of pregnancy); Chadwick's sign (the violet
coloration of the mucous membranes of the cervix, vagina, and vulva that
,occurs at about week 4); ballottement (the rebounding of the fetus against the
examiner's fingers on palpation); Braxton Hicks contractions; and a positive
pregnancy test that measures for human chorionic gonadotropin.
amniocentesis at 16 weeks' gestation to detect the presence of biochemical or
chromosomal abnormalities. Which instructions should the nurse reinforce to
the client?
The bladder must be full during the examination.
Before 20 weeks' gestation, the bladder must be kept full during amniocentesis
to support the weight of the uterus. After 20 weeks' gestation, the bladder
should be emptied to minimize the chance of puncturing the placenta or fetus.
The client at 28 weeks' gestation is Rh negative and Coombs antibody negative.
The nurse determines that the client understands what the nurse has taught
her about Rh sensitization when the client makes which statement?
"I will tell the nurse at the hospital that I had an Rh shot during pregnancy."
As described in the question, it is accepted practice to administer Rho(D)
immune globulin to an Rh-negative woman at 28 weeks' gestation, with a
second injection within 72 hours of delivery. This prevents sensitization, which
could jeopardize a future pregnancy. For subsequent pregnancies or abortions,
the injections must be repeated, because the immunity is passive.
,contraction stress test
"The uterus is stimulated to contract by either small amounts of oxytocin or by
nipple stimulation."
The perinatal client is admitted to the obstetrical unit during an exacerbation of
a heart condition. When planning for the nutritional requirements of the client,
the nurse should consult with the dietitian to ensure which dietary measure?
A diet that is high in fluids and fiber to decrease constipation
Constipation causes the client to use Valsalva's maneuver. This causes blood to
rush to the heart and overload the cardiac system.
The nurse caring for a client with abruptio placentae is monitoring the client for
signs of disseminated intravascular coagulopathy (DIC). The nurse should
suspect DIC if which is observed?
Petechiae, oozing from injection sites, and hematuria
DIC is a state of diffuse clotting in which clotting factors are consumed, which
leads to widespread bleeding. Platelet counts are decreased, because they are
consumed by the process. Coagulation studies show no clot formation (clotting
times are thus prolonged), and fibrin plugs may clog the microvasculature
diffusely rather than in an isolated area.
, The client is in her second trimester of pregnancy. She complains of frequent
low back pain and ankle edema at the end of the day. The nurse should
recommend which measure to help relieve both discomforts?
Lie on the floor with the legs elevated onto a couch or padded chair, with the
hips and knees at a right angle.
The position described in option 4 will produce the posture of the pelvic tilt
while countering gravity as the force that leads to the edema of the lower
extremities.
The pregnant woman complains of being awakened frequently by leg cramps.
The nurse reinforces instructions to the client's partner and should tell the
client to perform which measure?
Dorsiflex the client's foot while extending the knee.
Leg cramps often occur when the pregnant woman stretches her leg and
plantar flexes her foot. Dorsiflexion of the foot while extending the knee
stretches the gastrocnemius muscle, prevents the muscle from contracting, and
halts the cramping.
The nurse is reinforcing instructions to a pregnant client regarding measures to
prevent heartburn. The nurse should instruct the client to take which best
measure?
Drink decaffeinated coffee and tea.
