NCLEX Simulator Canada 2024

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Category: NCLEX CAT

 

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1. How should a nurse direct care for a client in the transition phase of the first stage of labor?

  • Decrease IV fluid intake.
  • Help the client to maintain control.
  • Reduce the client’s discomfort with medications.
  • Institute simple breathing patterns during contractions.

2. A client is admitted to the birthing unit in active labor. What should the nurse expect after an amniotomy is performed?

  • Diminished bloody show
  • Increased and more variable FHR
  • Less discomfort with contractions
  • Progressive dilation and effacement

3. During labor a client who has been receiving epidural anes­thesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse’s immediate reaction?

  • Turn the client on her side.
  • Notify the health care provider.
  • Check the vaginal area for bleeding
  • Monitor the fetal heart rate every three minutes

4. At 9 PM visiting hours are officially over, but the sister of a newly admitted postpartum client remains at the bedside. What is the most appropriate nursing intervention?

  • Remind the client’s sister that visiting hours are over.
  • Get written permission from the client for her sister to remain.
  • Call the evening nursing supervisor to tactfully handle the situation.
  • Encourage the sister to participate in care as much as the client wishes.

5. A nurse assesses the frequency of a client’s contractions by timing them from the beginning of a contraction:

  • until the uterus starts to relax.
  • to the end of a second contraction.
  • until the uterus completely relaxes.
  • to the beginning of the next contraction.

6. A nurse is caring for a primigravida during labor. What does the nurse observe that indicates birth is about to take place?

  • Bloody discharge from the vagina increases.
  • Perineum begins to bulge with each contraction.
  • Client becomes irritable and stops following instructions.
  • Contractions occur more frequently, are stronger, and last longer.

7. A primigravida who is at 40 weeks’ gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm dilation and the presenting part at —1 station. After obtaining the fetal heart rate and maternal vital signs, what should the nurse do next?

  • Teach the client how to push with each contraction.
  • Encourage the client to perform pattern-paced breathing.
  • Provide the client with comfort measures used for women in labor.
  • Prepare to have the client’s blood typed and crossmatched for a possible transfusion.

8. A multigravida has a spontaneous vaginal birth. Five minutes later the placenta is expelled. Where does a nurse expect to locate the uterine fundus at this time?

  • In the pelvic cavity
  • Just below the xiphoid process
  • At the umbilicus and in the right quadrant
  • Halfway between the symphysis pubis and the umbilicus

9. What is a common problem that confronts the client in labor when an external fetal monitor has been applied to her abdomen?

  • Intrusion on movement
  • Inability to take sedatives
  • Interference with breathing techniques
  • Increased frequency of vaginal examinations

10. At a prenatal visit a client who is at 36 weeks’ gestation states that she is having uncomfortable irregular contractions. What should the nurse recommend?

  • “Lie down until they stop."
  • “Walk around until they subside.”
  • “Time the contractions for 30 minutes.”
  • “Take 2 extra-strength aspirins if the discomfort persists.”

11. A client in labor begins to experience contractions 2 to 3 minutes apart that last about 45 seconds. Between contractions the nurse identifies a fetal heart rate of 100 beats/min on the internal fetal monitor. What is the next nursing action?

  • Notify the health care provider.
  • Resume continuous fetal heart monitoring.
  • Continue to monitor the maternal vital signs.
  • Document the fetal heart rate as an expected response to contractions.

12. After a client gives birth, what physiologic occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled?

  • Relaxation of the uterus
  • Descent of the uterus in the abdomen
  • Appearance of a sudden gush of blood
  • Retraction of the umbilical cord into the vagina

13. Why should a nurse teach pregnant women the importance of conserving the “spurt of energy” before labor?

  • Energy helps to increase the progesterone level.
  • Fatigue may influence the need for pain medication
  • Energy is needed to push during the first stage of labor.
  • Fatigue will increase the intensity of the uterine contractions.

14. A client’s membranes rupture while her labor is being augmented with an oxytocin (Pitocin) infusion. A nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. What action should the nurse take next?

  • Change the clients position.
  • Take the client’s blood pressure.
  • Stop the client’s oxytocin infusion.
  • Prepare the client for an immediate birth.

15. A laboring client is to have a pudendal block. What should a nurse teach the client about the effects of the pudendal block?

  • Bladder sensation may be lost.
  • She will not feel an episiotomy.
  • She may lose the ability to push.
  • Contractions will no longer be felt.

16. A client is admitted to the birthing suite in early active labor. Which nursing action takes priority during the admission process?

  • Auscultating the fetal heart
  • Obtaining an obstetric history
  • Determining when the last meal was eaten
  • Ascertaining whether the membranes have ruptured

17. A primigravida who is at 35 weeks’ gestation is diagnosed with hydramnios. For what should the nurse assess the newborn?

  • Cardiac defect
  • Kidney disorder
  • Diabetes mellitus
  • Esophageal atresia

18. The membranes of a client who is at 39 weeks’ gestation have ruptured spontaneously. Examination in the emergency department revealed that her cervix is 4 cm dilated and 75% effaced, and the fetal heart rate is 136 beats/min. She and her partner are admitted to the birthing unit. What should the nurse do upon their arrival?

  • Place the client in bed and attach an external fetal monitor.
  • Have the client undress while taking her history from her partner.
  • Introduce the staff nurses to the couple and try to make them feel welcome.
  • Ask the couple to wait in the examining room while notifying the health care provider.

19. After performing Leopold maneuvers on a laboring client, a nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler be placed to best auscultate fetal heart tones?

  • Above the umbilicus in the midline
  • Above the umbilicus on the left side
  • Below the umbilicus on the right side
  • Below the umbilicus near the left groin

20. A nurse teaches a postpartum client how to care for her episiotomy to prevent infection. Which behavior indicates that the teaching was effective?

  • The perineal pad is changed twice daily.
  • She washes her hands whenever a perineal pad is changed.
  • She rinses her perineum with water after using an analgesic spray.
  • The perineum is cleansed from the anus toward the symphysis pubis.

21. A client is bleeding excessively after the birth of a neonate. The health care provider orders fundal massage and pre scribes an IV infusion containing 10 units of oxytocin (Pitocin) at 100 mL/hr. A nurses evaluation of the clients responses to these interventions is BP: 135/90 mm Hg; uterus: boggy at 3 cm above the umbilicus and displaced to the right; perineal pad: saturated with bright red lochia. What is the nurse’s next action?

  • Increase the infusion rate.
  • Assess for a distended bladder.
  • Continue to perform fundal massage.
  • Continue to assess the blood pressure.

22. A client in active labor becomes very uncomfortable and asks a nurse for pain medication. Nalbuphine (Nubain) is prescribed. How does this medication relieve pain?

  • Produces amnesia
  • Acts as a preliminary anesthetic
  • Induces sleep until the time of birth
  • Acts on opioid receptors to reduce pain

23. A client and her partner are working together during the woman’s labor. The client’s cervix is now dilated 7 cm, and the presenting part is low in the midpelvis. What should the nurse instruct the partner to do that would alleviate the client’s discomfort during contractions?

  • Deep breathe slowly.
  • Perform pelvic rocking.
  • Use the panting technique.
  • Begin pattern-paced breathing.

24. Which breathing technique should the nurse instruct the client to use as the head of the fetus is crowning?

  • Shallow
  • Blowing
  • Slow chest
  • Modified paced

25. During the postpartum period, a client tells a nurse she is having leg cramps. Which foods should the nurse encourage the client to eat?

  • Liver and raisins
  • Cheese and broccoli
  • Eggs and lean meats
  • Whole wheat breads and cereals

26. A nurse is evaluating the effectiveness of fundal massage on a postpartum client 3 hours after giving birth. An IV infusion of 10 units of oxytocin (Pitocin) is infusing at 100 mL/hr. Her blood pressure is 135/90, the uterus is boggy at 3 cm above the umbilicus and displaced to the right, and her perineal pad is saturated with lochia rubra. What should the nurse do next?

  • Massage the fundus again.
  • Notify the health care provider.
  • Assist the client to the bathroom.
  • Increase the IV infusion rate as prescribed.

27. The cervix of a client in labor is fully dilated and effaced. The head of the fetus is at +2 station. What should the nurse encourage the client to do during contractions?

  • Relax by closing her eyes.
  • Push with her glottis open.
  • Blow to slow the birth process.
  • Pant to prevent cervical edema.

28. When a client’s legs are placed in stirrups for birth, the nurse confirms that both legs are positioned simultaneously to prevent:

  • venous stasis in the legs.
  • pressure on the perineum.
  • excessive pull on the fascia.
  • trauma to the uterine ligaments.

29. A client who just gave birth has three young children at home. She comments to the nursery nurse that she must prop the baby during feedings when she returns home because she has too much to do, and anyway holding babies during feedings spoils them. What is the nurse’s best response?

  • “You seem concerned about time. Let’s talk about it.”
  • “That’s up to you, since you have to do what works for you.”
  • “Holding the baby when feeding is important for development.”
  • “It is not safe to prop a bottle. The baby could aspirate the fluid.”

30. A pregnant woman at 39 weeks’ gestation arrives in the triage area of the birthing unit, stating she thinks her “water broke.” What should the nurse do first?

  • Auscultate the fetal heart to determine fetal well-being.
  • Perform Leopold’s maneuvers to rule out a breech presentation.
  • Check the vaginal introitus for the presence of the umbilical cord.
  • Do a nitrazine test on the vaginal fluid for verification of ruptured membranes.

31. When monitoring the FHR of a client in labor, the nurse identifies an elevation of 15 beats more than the baseline rate of 135 beats/min lasting for 15 seconds. How should the nurse document this event?

  • An acceleration
  • An early elevation
  • A sonographic motion
  • A tachycardic heart rate

32. Why should a nurse withhold food and oral fluids as a laboring client approaches the second stage of labor?

  • The mechanical and chemical digestive processes require energy that is needed for labor.
  • Undigested food and fluid may cause nausea and vomiting and limit the choice of anesthesia.
  • The gastric phase of digestion stimulates the release of hydrochloric acid and may cause dyspepsia.
  • Food and fluid will further aggravate gastric peristalsis, which is already increased because of the stress of labor.

33. A nurse observes that a client is voiding frequently in small amounts 8 hours after giving birth. What should the nurse conclude about this small output of urine during the early postpartum period?

  • It may indicate retention of urine with overflow.
  • It may be indicative of beginning glomerulonephritis.
  • This is common because less fluid is excreted after birth.
  • This is common because fluid intake diminishes after birth.

34. A primipara has just given birth at 37 weeks’ gestation. What should the nurse do to help promote the attachment process between the mother and her newborn?

  • Teach how to breastfeed the baby.
  • Encourage continuous rooming-in.
  • Assign one nurse to care for both of them.
  • Allow extra visiting privileges in the nursery.

35. A multigravida of Asian descent weighs 104 pounds, having gained 14 pounds during the pregnancy. On her second postpartum day, the client’s temperature is 100.2° F. She is anorectic and rarely gets out of bed. What should the nurse do?

  • Ask the nursing supervisor to discuss this with the health care provider.
  • Encourage the family to bring in special foods preferred in their culture.
  • Order a high-protein milkshake as a between-meal snack to stimulate her appetite.
  • Explain to the family that the dietician plans nutritious meals that the client should eat.

36. A nurse is caring for an obese client in early labor. The anesthesiologist discussed several types of analgesia/ anesthesia with the client and recommended one. The client requests clarification before signing the consent form. Which type did the anesthesiologist recommend?

  • Epidural anesthesia
  • Oral opioid analgesia
  • Pudendal nerve anesthesia
  • IV infusion of opioid analgesia

37. A primigravida is admitted to the birthing unit in early labor. A pelvic examination reveals that her cervix is 100%effaced and 3 cm dilated. The fetal head is at +1 station. In what area of the client’s pelvis is the fetal occiput?

  • Not yet engaged
  • Below the ischial spines
  • Entering the pelvic inlet
  • Visible at the vaginal opening

38. A client’s membranes spontaneously rupture during active labor. The nurse inspects the perineum and determines that the umbilical cord is not visible. What is the next nursing action?

  • Auscultate the FHR.
  • Time the contractions.
  • Call the health care provider.
  • Obtain the maternal vital signs.

39. A client who is at 12 weeks’ gestation tells a nurse at the prenatal clinic that she has severe nausea and frequent vomit­ing. The nurse suspects that the client has hyperemesis gravi­darum. With what disorder is this frequently associated?

  • History of cholecystitis
  • Large amount of amniotic fluid
  • High levels of chorionic gonadotropin
  • Decreased secretion of hydrochloric acid

40. A 42-year-old client has an amniocentesis during the 16th week of gestation because of concern about Down syn­drome. What additional information about the fetus will examination of the amniotic fluid reveal at this time?

  • Lung maturity
  • Type 1 diabetes
  • Cardiac anomaly
  • Neural tube defect

41. When palpating a clients fundus on the second postpartum day, a nurse identifies that it is above the umbilicus and displaced to the right. What does the nurse conclude?

  • There is a slow rate of involution.
  • There are retained placental fragments.
  • The bladder has become overdistended.
  • The uterine ligaments are overstretched.

42. A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable. She frequently states, “I cannot stand this a minute longer.” What does this behavior indicate to the nurse caring for her?

  • There was no preparation for labor.
  • She should receive an analgesic for pain.
  • She is entering the transition phase of labor.
  • Hypertonic uterine contractions are developing.

43. A pregnant client asks the clinic nurse how smoking will affect her baby. What information about cigarette smoking will influence the nurse’s response?

  • It relieves tension and the fetus responds accordingly.
  • The resulting vasoconstriction affects both fetal and maternal blood vessels
  • Substances contained in smoke diffuse through the pla­centa and compromise the fetus’s well-being.
  • Effects are limited because fetal circulation and maternal circulation are separated by the placental barrier.

44. The husband of a client who is in the transition phase of the first stage of labor becomes very tense and anxious during this period and asks a nurse, “Do you think it is best for me to leave, since I don’t seem to be doing my wife much good?” What is the nurse’s best response?

  • “This is the time your wife needs you. Don’t run out on her now.”
  • This is hard for you. Let me try to help you coach her during this difficult phase.”
  • “I know this is hard for you. You should go have a cup of coffee to help you relax and then come back in a little while.”
  • “If you feel that way, you’d best go out and sit in the father’s waiting room for a while. You may transmit your anxiety to your wife.”

45. Three weeks after giving birth, a client develops a deep vein thrombophlebitis of the left leg and is admitted to the hos pital for bed rest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer?

  • Clopidogrel (Plavix)
  • Warfarin (Coumadin)
  • Continuous infusion of heparin
  • Intermittent doses of a low molecular weight heparin

46. How does the nurse identify true labor as opposed to false labor?

  • Cervical dilation is progressive.
  • Contractions stop when the client walks around.
  • Clients’ contractions progress only in a side-lying position.
  • Contractions occur immediately after the membranes rupture.

47. When is it most important for a female client to know that a fetus may be structurally damaged by the ingestion of drugs?

  • During early adolescence
  • Throughout the entire pregnancy
  • When planning to become pregnant
  • At the beginning of the first trimester

48. For what complication should a nurse monitor a client when an oxytocin (Pitocin) infusion is used to induce labor?

  • Intense pain
  • Uterine tetany
  • Hypoglycemia
  • Umbilical cord prolapse

49. A nurse is caring for a primigravida during labor. At 7 cm dilation a prescribed pain medication is administered. Which medication requires monitoring of the newborn for the side effect of respiratory depression?

  • Butorphanol (Stadol)
  • Hydroxyzine (Vistaril)
  • Promethazine (Phenergan)
  • Diphenhydramine (Benadryl)

50. A nurse observes a laboring client’s amniotic fluid and decides that it is the expected color. What description of amniotic fluid supports this conclusion?

  • Clear, dark amber, and contains shreds of mucus
  • Straw-colored, clear, and contains little white specks
  • Milky, greenish yellow, and contains shreds of mucus
  • Greenish yellow, cloudy, and contains little white specks