NCLEX RN Practice Questions Free

NCLEX RN Practice Questions Free Related

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A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U+1 in contrast to the previous assessment of U-2. The immediate nursing response is to:

  • A. Administer methergine IM
  • B. Remove the retained placental fragments
  • C. Assist the client to the bathroom and provide cues to stimulate urination
  • D. Massage the fundus until firm
Correct Answer: D

Rationale: Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. Removal of retained placental fragments is done by the physician and is not the first response. If the fundus rises and is deviated, particularly to the right, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void. A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.

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The nurse is caring for a client with a diagnosis of gestational diabetes. Which laboratory test is most appropriate to monitor?

  • A. Hemoglobin A1c
  • B. Fasting blood glucose
  • C. Both A and B
  • D. Neither A nor B
Correct Answer: C

Rationale: Hemoglobin A1c reflects long-term glucose control and fasting blood glucose monitors daily management in gestational diabetes. Both tests are appropriate to ensure optimal maternal and fetal outcomes.

A client with a history of Cushing’s syndrome is admitted with complaints of weight gain. The nurse should expect the client to have:

  • A. Moon face
  • B. Weight loss
  • C. Hypotension
  • D. Bradycardia
Correct Answer: A

Rationale: Cushing’s syndrome causes excess cortisol, leading to moon face, central obesity, and weight gain.

An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder?

  • A. Partial thromboplastin time
  • B. Platelet count
  • C. Complete blood count
  • D. Bleeding time
Correct Answer: A

Rationale: Partial thromboplastic time measures activity of thromboplastin, which depends on the intrinsic clotting factors deficient in children who are hemophiliacs. Platelet counts are normal in hemophilia. Hemophilia does not affect the complete blood count. Bleeding times are normal in hemophiliacs. They measure the time interval for the bleeding from small superficial wounds to cease.

A mother calls the clinic to report that her otherwise healthy newborn has a rash on his forehead and face. The nurse should tell the mother:

  • A. To use a mild soap when washing the newborn's face
  • B. That many newborns have a rash that will go away by one month of life
  • C. That the rash indicates illness and she needs to bring the newborn in immediately
  • D. To check for signs of illness among family members
Correct Answer: B

Rationale: Many newborns develop erythema toxicum or milia benign rashes that resolve within a month. This is the most likely explanation for a healthy newborn’s facial rash. Immediate evaluation or family illness checks are unnecessary unless other symptoms are present.

The nurse is caring for a client with a diagnosis of gestational diabetes. Which symptom is most likely to be present?

  • A. Polyuria
  • B. Fetal macrosomia
  • C. Both A and B
  • D. Neither A nor B
Correct Answer: C

Rationale: Gestational diabetes causes maternal polyuria (from hyperglycemia) and fetal macrosomia (from fetal hyperinsulinemia). Both are common symptoms affecting mother and fetus.

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