NCLEX-PN Test #9 1 — Questions and Answers
Question 1: A nurse is assessing a newborn 1 hour after delivery. The infant is cyanotic in the hands and feet but pink in the trunk. Respiratory rate is 46 breaths/min and the infant is crying vigorously. What should the nurse document?
- Central cyanosis indicating cardiopulmonary compromise
- Acrocyanosis, a normal finding in a newborn (Correct answer)
- Respiratory distress requiring immediate intervention
- Peripheral vascular insufficiency requiring warming
Correct answer: Acrocyanosis, a normal finding in a newborn
Acrocyanosis (cyanosis of the hands and feet only) is a normal finding in the first 24–48 hours of life due to immature peripheral circulation. The trunk being pink and the newborn crying vigorously indicate adequate central oxygenation. Central cyanosis (blue trunk/lips) would be an abnormal finding requiring intervention.
Question 2: A postpartum client, 12 hours after a vaginal delivery, has a uterus that is displaced to the right of midline and is boggy. Which intervention should the nurse perform first?
- Administer oxytocin per standing order
- Massage the uterine fundus firmly
- Assist the client to void or insert a urinary catheter (Correct answer)
- Notify the provider of the finding immediately
Correct answer: Assist the client to void or insert a urinary catheter
A uterus displaced to the right and boggy is most commonly caused by a full bladder displacing the uterus and preventing adequate contraction. The priority intervention is to assist the client to void or catheterize the bladder. After emptying the bladder, the fundus should return to midline; then fundal massage can be performed if still boggy.
Question 3: A nurse is caring for a 4-year-old admitted with croup. The child suddenly develops inspiratory stridor at rest, nasal flaring, and intercostal retractions. Which action should the nurse take first?
- Administer a nebulized racemic epinephrine treatment as ordered
- Notify the provider and prepare for possible intubation
- Place the child in an upright position and notify the provider immediately (Correct answer)
- Apply a cool mist via a croup tent over the crib
Correct answer: Place the child in an upright position and notify the provider immediately
Stridor at rest with increased work of breathing (nasal flaring, retractions) indicates significant airway obstruction. The immediate actions are positioning the child upright (reduces work of breathing and improves airway patency) and notifying the provider for urgent intervention. While racemic epinephrine and possible intubation may be needed, positioning and notification happen first.
Question 4: A nurse is educating a client who is 28 weeks pregnant about signs that require immediate reporting. Which symptom is most concerning?
- Mild ankle swelling at the end of the day
- Increased frequency of urination
- Sudden onset of severe headache with visual changes (Correct answer)
- Occasional round ligament pain with position changes
Correct answer: Sudden onset of severe headache with visual changes
Sudden severe headache with visual changes (blurred vision, seeing spots) are classic warning signs of preeclampsia and impending eclampsia, which are obstetric emergencies. These symptoms must be reported immediately. Ankle swelling, urinary frequency, and round ligament pain are common normal discomforts of pregnancy.
Question 5: A nurse is preparing to administer the hepatitis B vaccine to a newborn. The mother asks, 'Why does my baby need this today?' Which response by the nurse is most accurate?
- 'It is required by law for all newborns before discharge.'
- 'Early vaccination provides protection before possible exposure through vertical transmission or blood.' (Correct answer)
- 'Your baby may have been exposed during delivery.'
- 'The vaccine prevents the baby from getting hepatitis A from contaminated food.'
Correct answer: 'Early vaccination provides protection before possible exposure through vertical transmission or blood.'
The hepatitis B vaccine is given at birth to protect the newborn from perinatal transmission (which can occur even if the mother is HBsAg-negative) and future bloodborne exposure. Hepatitis B is not caused by food; that is hepatitis A. Saying the baby 'may have been exposed' implies the mother is infected, which is not established.
Question 6: A nurse is caring for a child with epiglottitis who is drooling and sitting in a tripod position. Which nursing action is contraindicated?
- Keeping emergency intubation equipment at the bedside
- Allowing the child to remain in a position of comfort
- Using a tongue depressor to visualize the throat (Correct answer)
- Avoiding any procedure that would cause agitation
Correct answer: Using a tongue depressor to visualize the throat
Using a tongue depressor or attempting to visualize the throat in a child with epiglottitis is strictly contraindicated because it can cause complete airway obstruction and respiratory arrest. The child should be kept calm, in a position of comfort (usually tripod), and emergency airway equipment must be at bedside. Any procedure that causes crying or agitation must be avoided.
NCLEX-PN Test #9 1
A nurse is assessing a newborn 1 hour after delivery.
The infant is cyanotic in the hands and feet but pink in the trunk.
Respiratory rate is 46 breaths/min and the infant is crying vigorously.
What should the nurse document?