NCLEX Practice Exam 26 (10 Questions)

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Questions: 10 | Attempts: 4,409 | Updated: Aug 22, 2023

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NCLEX Practice Exam 26 (10 Questions) - Quiz

All questions are shown, but the results will only be given after you’ve finished the quiz. You are given 1 minute per question, a total of 10 minutes in this quiz.

Questions and Answers

1.

The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:
- A.
  
  Diabetes
- B.
  
  Positive HIV
- C.
  
  Hypertension
- D.
  
  Thyroid disease
Correct Answer
B. Positive HIV

Explanation
Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. The clients in answers A. C. and D—those with diabetes. hypertension. and thyroid disease—can be allowed to breastfeed.

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2.

A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:
- A.
  
  Assess the fetal heart tones
- B.
  
  Check for cervical dilation
- C.
  
  Check for firmness of the uterus
- D.
  
  Obtain a detailed history
Correct Answer
A. Assess the fetal heart tones

Explanation
The symptoms of painless vaginal bleeding are consistent with placenta previa. Answers B. C. and D are incorrect. Cervical check for dilation is contraindicated because this can increase the bleeding. Checking for firmness of the uterus can be done. but the first action should be to check the fetal heart tones. A detailed history can be done later.

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3.

A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
- A.
  
  Her contractions are 2 minutes apart.
- B.
  
  She has back pain and a bloody discharge.
- C.
  
  She experiences abdominal pain and frequent urination.
- D.
  
  Her contractions are 5 minutes apart.
Correct Answer
D. Her contractions are 5 minutes apart.

Explanation
The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. She should not wait until the contractions are every 2 minutes or until she has bloody discharge. so answers A and B are incorrect. Answer C is a vague answer and can be related to a urinary tract infection.

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4.

The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?
- A.
  
  Low birth weight
- B.
  
  Large for gestational age
- C.
  
  Preterm birth. but appropriate size for gestation
- D.
  
  Growth retardation in weight and length
Correct Answer
A. Low birth weight

Explanation
Infants of mothers who smoke are often low in birth weight. Infants who are large for gestational age are associated with diabetic mothers. so answer B is incorrect. Preterm births are associated with smoking. but not with appropriate size for gestation. making answer C incorrect. Growth retardation is associated with smoking. but this does not affect the infant length; therefore. answer D is incorrect.

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5.

The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis. RhoGam should be administered:
- A.
  
  Within 72 hours of delivery
- B.
  
  Within 1 week of delivery
- C.
  
  Within 2 weeks of delivery
- D.
  
  Within 1 month of delivery
Correct Answer
A. Within 72 hours of delivery

Explanation
To provide protection against antibody production. RhoGam should be given within 72 hours. The answers in B. C. and D are too late to provide antibody protection. RhoGam can also be given during pregnancy.

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6.

After the physician performs an amniotomy. the nurse’s first action should be to assess the:
- A.
  
  Degree of cervical dilation
- B.
  
  Fetal heart tones
- C.
  
  Client’s vital signs
- D.
  
  Client’s level of discomfort
Correct Answer
B. Fetal heart tones

Explanation
When the membranes rupture. there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones. such as bradycardia or tachycardia. should be reported. After the fetal heart tones are assessed. the nurse should evaluate the cervical dilation. vital signs. and level of discomfort. making answers A. C. and D incorrect.

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7.

A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5 cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor?
- A.
  
  Active
- B.
  
  Latent
- C.
  
  Transition
- D.
  
  Early
Correct Answer
A. Active

Explanation
The active phase of labor occurs when the client is dilated 4–7cm. The latent or early phase of labor is from 1cm to 3cm in dilation. so answers B and D are incorrect. The transition phase of labor is 8–10cm in dilation. making answer C incorrect.

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1
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8.

A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:
- A.
  
  Teaching the mother to provide tactile stimulation
- B.
  
  Wrapping the newborn snugly in a blanket
- C.
  
  Placing the newborn in the infant seat
- D.
  
  Initiating an early infant-stimulation program
Correct Answer
B. Wrapping the newborn snugly in a blanket

Explanation
The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Teaching the mother to provide tactile stimulation or provide for early infant stimulation are incorrect because he is irritable and needs quiet and little stimulation at this time. so answers A and D are incorrect. Placing the infant in an infant seat in answer C is incorrect because this will also cause movement that can increase muscle irritability.

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9.

A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia. the nurse should give priority to:
- A.
  
  Checking for cervical dilation
- B.
  
  Placing the client in a supine position
- C.
  
  Checking the client’s blood pressure
- D.
  
  Obtaining a fetal heart rate
Correct Answer
C. Checking the client’s blood pressure

Explanation
Following epidural anesthesia. the client should be checked for hypotension and signs of shock every 5 minutes for 15 minutes. The client can be checked for cervical dilation later after she is stable. The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing. Fetal heart tones should be assessed after the blood pressure is checked. Therefore. answers A. B. and D are incorrect.

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10.

The nurse is aware that the best way to prevent postoperative wound infection in the surgical client is to:
- A.
  
  Administer a prescribed antibiotic
- B.
  
  Wash her hands for 2 minutes before care
- C.
  
  Wear a mask when providing care
- D.
  
  Ask the client to cover her mouth when she coughs
Correct Answer
B. Wash her hands for 2 minutes before care

Explanation
The best way to prevent post-operative wound infection is hand washing. Use of prescribed antibiotics will treat infection. not prevent infections. making answer A incorrect. Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections; therefore. answers C and D are incorrect.

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Current Version
Aug 22, 2023

Quiz Edited by
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Jul 08, 2017

Quiz Created by
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NCLEX Practice Exam 26 (10 Questions)

The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:

A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:

A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:

The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?

The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis. RhoGam should be administered:

After the physician performs an amniotomy. the nurse’s first action should be to assess the:

A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5 cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor?

A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:

A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia. the nurse should give priority to:

The nurse is aware that the best way to prevent postoperative wound infection in the surgical client is to: