NCLEX Questions of the Daily 104th Edition

NCLEX Questions of the Daily 104th Edition

1. A nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother’s temperature and notes that it is 100.4° F (38° C). Which nursing action would be appropriate?

A. Encourage oral fluids
B. Notify the registered nurse immediately
C. Administer acetaminophen (Tylenol)
D. Remove the blankets from the mother and recheck her temperature in 30 minutes

Answer: A. Encourage oral fluids

Rationale: Temperatures up to 100.4° F (38° C) in a mother during the first 24 hours after birth are often related to the dehydrating effects of labor. Increasing hydration by encouraging oral fluids will help bring the temperature to a normal reading. Options 2, 3, and 4 are unnecessary actions at this time.

Test-Taking Strategy: Focus on the data in the question and recall the normal findings in the mother in the immediate postpartum period. Knowing that labor has a dehydrating effect will direct you to option A. Review the expected postpartum findings if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 196-197.

2. A nurse in the postpartum unit is assigned to care for a client who delivered a full-term healthy baby. The nurse receives report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman’s pulse is 90 beats per minute (BPM) and is weak and thready. This finding would indicate which of the following to the nurse?

A. A normal pulse rate following delivery
B. A normal pulse rate following a loss of 500 mL of blood
C. The mother is very excited about the delivery of the baby
D. This may be a sign of hemorrhage or shock

Answer: D. This may be a sign of hemorrhage or shock

Rationale: A pulse range of 50 to 70 BPM is normal in a mother following delivery and may occur for the first 1 to 2 days after delivery. A weak and thready or rapid pulse is abnormal and may be a sign of hemorrhage or shock. Particular attention should be paid to the pulse rate when there has been a blood loss of 500 mL or greater during or after delivery. Options 1, 2, and 3 are incorrect interpretations.

Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are similar. Next note the key words weak and thready. These words should direct you to option 4 because it indicates an abnormality. Review normal postpartum findings 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: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 197.

3. A nurse is reinforcing instructions to a client who had an episiotomy during the birthing process. Which statement by the client would indicate a need for further instructions?

A. “I can apply a local anesthetic spray to the area.”
B. “I can apply ice to the area.”
C. “I should tighten the perineum before I sit and then relax it slowly after being seated.”
D. “I should take sitz baths three or four times a day and test the water temperature to be sure that it is at 115° F.”

Answer: D. “I should take sitz baths three or four times a day and test the water temperature to be sure that it is at 115° F.”

Rationale: The client should be instructed in measures to decrease discomfort following episiotomy and perineal swelling. Gluteal muscle tightening reduces direct pressure on the perineum, so discomfort is minimized. Ice decreases circulation, promotes vasoconstriction, reduces edema, and promotes a local anesthetic effect. Local anesthetic sprays reduce uncomfortable sensations. Heat from sitz baths increases circulation to the perineum, thereby promoting oxygenation and healing, which reduces discomfort. However, the water temperature should not be any greater than 100° F to 105° F.

Test-Taking Strategy: Note the key words a need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Basic principles related to the temperature of the water for bathing or soaks will direct you to option D. Review these basic principles if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Teaching/Learning
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 246.

4. A nurse is reinforcing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further instructions?

A. “I should avoid wearing a bra at this time.”
B. “I should apply ice packs to the breasts.”
C. “I can take analgesics for the discomfort.”
D. “I should wear a breast binder while my breasts are engorged.”

Answer: D. “I should wear a breast binder while my breasts are engorged.”

Rationale: Wearing a bra or applying a breast binder applies pressure, which reduces congestion and discomfort. Ice packs reduce circulation and thus congestion and also provide an anesthetic effect. Analgesics help relieve the pain.

Test-Taking Strategy: Note the key words need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that breast engorgement involves congestion and discomfort will direct you to option A. Options 2, 3, and 4 will assist in relieving the discomfort and congestion. Review the measures that will relieve breast engorgement if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Teaching/Learning
Content Area: Maternity/Postpartum
Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 777-778.

Read also:

• NCLEX Questions of the Days 103th Edition
• NCLEX Practical Nursing 102th Edition
• NCLEX Practical Nursing with Answers 101th Edition

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