NCLEX Review Questions – Answers & Rationales (Parts 2-4)

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free nclex questions answers

Maternal/Newborn

#1. Answer: A

Rationale:

The client in this early phase of the first stage of labor is having moderate to strong contractions at 5 minutes apart, cervix dilates from 4 cm to 7 cm, with some bloody show and membranes may rupture. In the transition phase, there will be strong contractions 1 to 2 minutes apart lasting 45 to 60 seconds or more with little rest in between, cervix dilates from 7 to 10 cm with a bloody show; client becomes more irritable, restless, agitated, highly emotional, belches, has leg tremors, perspires, pale white ring around mouth (circumoral pallor), flushed face, sudden nausea and vomiting, feels the need to have a bowel movement, and unable to communicate or follow directions. Second stage begins with full dilatation of the cervix and ends with the birth of the infant. Third stage occurs following the birth of the infant through expulsion of the placenta.

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#2. Answer: A

Rationale:

In a primipara, effacement usually occurs before dilatation begins. In a multipara, effacement and dilatation progress together. Effacement precedes dilatation or it can happen simultaneously with dilatation and is always necessary in the labor process.

#3. Answer: D

Rationale:

a. “Push gently with the next contraction”
This can be instructed during the active phase of labor.

b. “Take a deep breath and push now”
This can be instructed when the fetal presenting part is at the vaginal introitus and is ready for delivery.

c. “You probably need to move your bowels”
This can be instructed if the client is not yet in the active phase of labor.

d. “Do not bear down until the health team have examined you”
Quick assessment and evaluation has to be done to check if the cervix is 100% effaced and fully dilated at 10 cm.

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#4. Answer: B

Rationale:

a. Phases of the first stage of labor
The phases of the first stage of labor include latent, active and transition phase. They happen prior to the delivery of a newborn.

b. Cardinal movements of labor
The cardinal movements of labor are the different mechanisms of labor needed for the rotation and descent of vertex presentation through the true pelvis until the newborn is delivered. It consists of engagement, descent, flexion, internal rotation, extension, external rotation and expulsion.

c. Factors affecting labor
The different factors affecting labor can be easily remember by the acronym 6P – Powers, Passageway, Passenger, Position, Placenta and Psyche.

d. Factors that determine fetal position
This has something to do with the relationship of the reference point on fetal presenting part to maternal bony pelvis.

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#5. Answer: A

Rationale:

a. 30-60 minutes
A multipara can have an average length of 30-60 minutes in the second stage of labor.

b. 1-3 hours
A primipara have an average length of 1-3 hours in the second stage of labor.

c. 3-5 hours
This length of time may happen when there are complications that arise during the labor process and needs further management.

d. 5-10 hours
This length of time may happen when there are complications that arise during the labor process and needs further management.

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#6. Answer: A

Rationale:

a. Assess for presence of a full bladder.
Encourage the client in labor to void as necessary. Inform the client that a full bladder can hinder efficient uterine contractions. An empty bladder allows more space for the presenting part to pass through for delivery.

b. Suggest placement of an internal uterine pressure catheter to determine adequacy of contractions.
An intrauterine pressure catheter (IUPC) is a device placed into the amniotic space during labor in order to measure the strength of uterine contractions. This is not a priority to use at this time.

c. Encourage the woman to do deep breathing techniques.
Breathing techniques can help ease discomforts during contractions but is not a priority this at time.

d. Suggest to physician that oxytocin augmentation be started to stimulate labor.
Induction of labor may be done when labor process is not progressing normally. In this situation, assessment for a full bladder is the priority.

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#7. Answer: A

Rationale:

a. Red and moderate
Lochia rubra is expected 1-3 days after delivery. It is dark red in color and moderate in amount.

b. Continuous with red clots
Continuous lochial discharges with red clots needs further evaluation by a health care provider as this may indicate postpartum bleeding.

c. Brown and scanty
Lochia serosa is pinkish brown in color and scanty. It is expected 4-10 days after delivery.

d. Thin and white
Lochia alba is a thin yellowish white vaginal discharge. It is expected 11-21 days after delivery.

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#8. Answer: D

Rationale:

a. Inserting an indwelling urinary catheter
Ensure that the bladder is empty because a distended bladder prevents the uterus from fully contracting. If the client can’t void freely, the need to insert an indwelling urinary catheter is done to assess for intake and output. Report urine output if it is less than 30 ml/cc per hour as it can be a sign of bleeding.

b. Fundal massage
Fundal massage increases uterine tone and contractility, thereby minimizing blood loss. Perform fundal massage as indicated, to assist with uterine involution.

c. Administration of oxytocics
Oxytocics are administered for the management of postpartum bleeding due to uterine atony.

d. Perineal pad count
This has to be revised as the priority of care for this case is to control the postpartum bleeding.

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#9. Answer: C

Rationale:

a. Shock
Hypovolemic shock is a potential complication of postpartum hemorrhage and is not related to a full bladder.

b. Disseminated Intravascular Coagulation (DIC)
DIC is not caused by a full bladder. DIC is a coagulopathy in which clotting and anticlotting mechanisms occur at the same time. Coagulopathies are suspected when the usual measures to stimulate uterine contractions fail to stop vaginal bleeding.

c. Hemorrhage
The client is encouraged to void and empty the bladder as indicated after delivery to prevent a postpartum bleeding. Full bladder affects uterine contraction after delivery and it may promote development of uterine atony.

d. Infection
A postpartal infection is not mainly caused by a full bladder.

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#10. Answer: C

Rationale:

a. Uterus in the midline position
Within 6-12 hours after birth, the fundus is 1 cm above the umbilicus or at the level of the umbilicus and will descend 1-2 cm everyday. During the 6th day postpartum, the uterus is located between umbilicus and symphysis pubis.

b. Firm, round uterus
A well-contracted uterus is firm and round when palpated.

c. Fundus 2 fingerbreadths above the umbilicus
On postpartum day 1, the fundus should be 1 fingerbreadth below the umbilicus. In this case, further evaluation has to be done to know if the uterus has contracted well or if there are any other existing problem that needs immediate medical attention.

d. Fundus 1 fingerbreadth below the umbilicus
On postpartum day 1, the fundus should normally be 1 fingerbreadth below the umbilicus.

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#11. Answer: C

Rationale:

a. Slightly boggy and below the umbilicus
The uterus here is not firm and not well contracted. The client has to be evaluated for signs of postapartum bleeding.

b. Soft and either deviated to the right or left side of the abdomen
The client is encouraged to void freely as indicated. A distended bladder hinders efficient uterine contractions and may cause the uterus to deviate to the right or left side of the abdomen.

c. Firm and two to three fingerbreadths below the umbilicus
On postpartum day 2, the fundus of the client should be 2-3 fingerbreadths below the umbilicus, and so forth until the 10th day postpartum.

d. Firm and two to three fingerbreadths above the umbilicus
Within 6-12 hours after birth, the fundus is 1 cm above the umbilicus or at the level of the umbilicus and will descend 1-2 cm everyday.

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#12. Answer: A

Rationale:

a. Inflammation along the suture line
Use the acronym REEDA for perineum and episiotomy assessment: redness, edema, ecchymosis, discharge, and approximation of suture lines. An epsiotomy is usually sealed within 24 hours after delivery. An unusual perineal discomfort and inflammation along the suture line may indicate impending infection or hematoma.

b. Bruising
Bruising can be normally expected due to the pressure of the presenting part towards the perineum during the delivery of the newborn.

c. Mild edema
Mild edema can also be expected to the pressure of the presenting part towards the perineum during the delivery of the newborn.

d. Mild tenderness
Mild tenderness around the site is normal. A pain reliever can be taken as needed by the client.

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Gastrointestinal and Genitourinary

#13. Answer: D

Rationale:

a. Sardines and salmon
Fish with fine bones like sardines, herring, and salmon are have high calcium content.

b. Chocolate and cocoa
Chocolate and cocoa as well as dried fruits and nuts are also rich in calcium.

c. Ice cream and yogurt
Ice cream, yogurt, milk, and cheese are products that have high calcium content.

d. Gelatin Desserts
Gelatin does not contain any calcium nutrient.

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#14. Answer: A

Rationale:

a. Abdominal Distention
The client with Tracheoesophageal Fistula experiences Abdominal Distention as air builds up in the stomach.

b. Projectile vomiting
This is a common manifestation of client with Pyloric Stenosis.

c. Fecal impaction
This is common in clients with Hirschprung. This is a congenital disease caused by absence of parasympathetic ganglion cells.

d. Paroxysmal abdominal pain
This is common in intussusception wherein a part of the intestine slides into an adjacent part of the intestine.

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#15. Answer: C

Rationale:

a. Hirschsprung
This is the congenital absence of parasympathetic ganglion cells usually characterized by the absence of peristalsis and feces.

b. Tracheoesophageal Fistula
This is an abnormal connection (fistula) between the esophagus and the trachea. The client usually vomits after each swallow.

c. Pyloric Stenosis
There is a visible wave-like movement during and after feeding, as seen on exposed stomach.

d. Intussusception
This is a serious disorder in which a part of the intestine slides into an adjacent part of the intestine. This also called ”telescoping”.

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Fundamentals of Nursing

#16. Answer: A

Rationale:

a. A postoperative coronary bypass client who is about to be discharged.
The labor room nurse who is new to the cardiac unit must be assigned to clients with the least acute needs.

b. A newly admitted myocardial infarction client.
This client would require continuous assessment that is best carried out by experienced cardiac unit staff.

c. A client with unstable angina
Unstable client requires experienced staff.

d. A post-operative valve replacement client
This client also requires close monitoring that is best carried out by experienced cardiac unit staff.

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#17. Answer: D

Rationale:

a. Place fluorescein drops in the eye.
It is used to check for scratches on the cornea.

b. Patch the client’s eye.
Patching the eye does not help.

c. Test the client’s visual acuity.
This is done after irrigating the eye.

d. Irrigate the eye continuously with normal saline solution for 10 minutes.
This is the first action needed in order to flush the harmful chemical out of the eye.

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#18. Answer: D

Rationale:

a. Immediately perform Heimlich maneuver to expel the foreign body.
This is done if the client cannot speak and is displaying universal sign of choking such as clutching the throat with both hands.

b. Initiate CPR to restore cardiac function.
This is only done if the client has no breathing and pulse.

c. Perform head-tilt chin-lift maneuver to open airway.
This will not expel the foreign body. The head-tilt chin-lift maneuver is used in cardiopulmonary resuscitation.

d. Let the client cough until the foreign body is expelled.
Coughing is one of the body’s defense mechanisms. If the client is not able to expel the foreign body through coughing, then the nurse can perform Heimlich maneuver.

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#19. Answer: B

Rationale:

a. 110/70 when standing and 110/70 when lying down
This shows no changes in BP.

b. 150/90 when lying down and 140/80 when standing, and reports feeling dizzy
During orthostatic hypotension, the blood pressure usually drops by 10 mmHg and is accompanied by dizziness.

c. 140/80 when sitting and 140/80 when standing
This shows no changes in BP.

d. 130/70 lying down and 140/80 when sitting, and reports shortness of breath BP should drop by at least 10 mmHg for orthostatic hypotension.

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#20. Answer: B

Rationale:

a. Murphy’s sign
The Murphy’s sign is elicited in the presence of cholecystitis.

b. Rovsing sign
Palpation of the LLQ that results to pain at the RLQ is known as the Rovsing sign. It indicates an inflamed appendix.

c. Psoas sign
Psoas sign is elicited by extending the right hip while the client is lying on his side with knees extended. A positive Psoas sign indicates inflamed appendix.

d. Obturator sign
Obturator sign is elicited by internally rotating the flexed right hip. A positive Obturator sign indicates appendix inflammation as well.

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#21. Answer: C

Rationale:

a. Elevate the legs
When there is a suspected venous problem, this is the first intervention since unoxygenated blood needs to be oxygenated. This is contraindicated in arterial problems.

b. Exercise
This can make the present condition even worse.

c. Take a rest
This is the best nursing intervention for clients with suspected arterial problem. Rest is needed so that all parts of the body may be oxygenated.

d. Give hard candy
This is for clients experiencing hypoglycemia.

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#22. Answer: D

Rationale:

a. Insert 6-9 inches.
This is a the correct depth of urinary catheter insertion for a male client.

b. Position the client in a supine.
For males, it position for urinary catheter insertion should be a supine. For females, position for urinary catheter insertion should be dorsal recumbent.

c. Instruct the client to inhale through the mouth.
This is the correct breathing technique in reducing pain and anxiety associated with the insertion of urinary catheter.

d. Insert 2-3 inches.
This is the depth of urinary catheter insertion for a female client.

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#23. Answer: A

Rationale:

a. Directive leadership
Directive or autocratic style of leadership is most appropriate during emergency or crisis wherein there is no more sufficient time for discussion and group decision making. A directive leader is needed for clarity and organized health care delivery in cases of emergency or crisis.

b. Democratic leadership
The democratic style of leadership is used in most circumstances but is not effective during emergency situations.

c. Participative leadership
Participative leadership is also known as democratic leadership wherein the leader involves others in goal-setting, decision making, and problem solving. This style of leadership is preferred in ordinary circumstances.

d. Republican leadership
Such leadership in nursing does not exist.

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#24. Answer: A

Rationale:

a. Demonstrated skill
The person should be competent to perform the delegated task. Assessing of the delegate’s level of competence includes several factors like certificates, licenses, job description, skills checklist, and demonstrated skills.

b. Knowledge of nursing theories
Theoretical knowledge is not a sole basis for assessing the delegate’s level of competence.

c. Attitude and behavior
A delegate’s competence is not based on attitude and behavior.

d. Current rank of the delegate
Rank is not used as a basis for the safe delegation.

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#25. Answer: B

Rationale:

a. Delegate another task
A feedback should be given first before delegation of another task.

b. Provide feedback
It is important for the charge nurse to evaluate work output. High quality client care is achieved when a feedback is provided.

c. Recommend the staff to other team members
The statement is not a part of delegation.

d. Ask the client’s insight
The statement is not a part of delegation.

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