Blog about quiz / question and answer NCLEX (National Council Licensure Examination) For Nursing Student, Example Question NCLEX RN and NCLEX PN. Exam for Nurse
1. A nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which of the following statements indicates that the mother needs further teaching?
A. “If my baby’s hands and feet are blue in color, it usually means that they are cold.”
B. “My baby should be drinking 2½ to 3 oz every 4 hours.”
C. “I understand that my baby will be susceptible to respiratory infections throughout all of his childhood.”
D. “A bluish discoloration around my baby’s mouth is a sign of lack of oxygen.”
Answer: C. “I understand that my baby will be susceptible to respiratory infections throughout all of his childhood.”
Rationale: Option 3 is not true for the postterm newborn. Once the meconium aspiration syndrome is resolved, the newborn should be cared for as any other newborn. Options 1, 2, and 4 are true statements and reflect understanding of discharge instructions.
Test-Taking Strategy: Use the process of elimination and note the key words needs further teaching. These words indicate a false response question and that you need to select the incorrect client statement. Noting that option 3 contains the absolute word “all” will assist in directing you to this option. Review home care instructions for the postterm newborn if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Maternity/Postpartum
Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 605-606, 844-846.
2. A nurse is assisting in collecting data on a large-for-gestational-age (LGA) newborn. Which technique would the nurse use to check for evidence of birth trauma?
A. Palpate the clavicles for a fracture
B. Listen to the heart for a cardiac defect
C. Blanch the skin for evidence of jaundice
D. Perform Ortolani maneuver for hip dislocation
Answer: A. Palpate the clavicles for a fracture
Rationale: Because of the neonate’s large size, there is an increased risk for shoulder dystocia. This may result in fractured clavicles and/or brachial plexus palsy. Other complications related to birth trauma include facial paralysis, phrenic nerve palsy, depressed skull fractures, hematomas, and bleeding. Option 2 is not related to birth trauma. Option 3 would not be present initially. Hip dislocation is congenital and is not caused by birth trauma.
Test-Taking Strategy: Use the process of elimination and focus on the issue of the question, checking for birth trauma. Think of trauma as an injury. Option 1 is the only option that identifies an injury. Review the techniques for checking for birth trauma if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Postpartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 742.
3. A nurse reviews the arterial blood gas report on a newborn with respiratory distress syndrome (RDS) who was recently weaned from the ventilator and placed in an oxygen hood at 50% oxygen. The results indicate a pH of 7.25, PaO2 80 mm Hg, PaCO2 50 mm Hg, and HCO 24 mEq. The nurse evaluates the blood gas report as indicating:
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: A. Respiratory acidosis
Rationale: In normal acid-base balance, the pH is 7.35 to 7.45. Normal PaO2 is 80 to 100 mm Hg and normal PaCO2 is 35 to 45 mm Hg. A decreased pH with an increased PaCO2 indicates a respiratory acidosis. Respiratory alkalosis is defined as a pH above 7.45 and a PaCO2 below 35 mm Hg. Metabolic acidosis exists with a pH below 7.35 and a HCO below 22 mEq/L. Metabolic alkalosis is defined as a pH above 7.45, along with a HCO above 27 mEq/L. Normal HCO is 22 to 27 mEq/L.
Test-Taking Strategy: This question requires knowledge about arterial blood gas interpretation. Recalling that a low pH indicates acidosis assists in eliminating options 2 and D. From the remaining options, recalling that in a respiratory condition the PaCO2 moves in an opposite direction as the pH will direct you to option A. Review the procedure for interpreting blood gases if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Postpartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 1083, 1190.
4. A nurse reviews the results of a bilirubin level on a 2-day-old jaundiced term newborn. The results indicate a total bilirubin level of 7.2 mg/dl. The newborn’s mother verbalizes concern over the bilirubin results. After interpreting the bilirubin results, the nurse’s response would include an explanation that the bilirubin level is:
A. Within acceptable ranges
B. Indicative of Rh incompatibility
C. Lower than normal for the newborn’s age
D. Indicative of a need for phototherapy
Answer: A. Within acceptable ranges
Rationale: Many newborns exhibit jaundice in the newborn period. Total bilirubin levels tend to peak on the second and third day after birth. These levels are between 5 and 10 mg/dl in the healthy newborn. Option 2 is not correct because the range given is not elevated for a 2-day-old newborn, and there is no data to support an Rh incompatibility. Term newborns are not treated with phototherapy until their bilirubin is above 12 mg/dl.
Test-Taking Strategy: Knowledge regarding normal bilirubin levels and expected levels in a 2-day-old jaundiced term newborn is required to answer this question. Remember many newborns exhibit jaundice in the newborn period, and total bilirubin levels tend to peak on the second and third day after birth. Review these levels if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 312.
Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 968.
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