TEST BANK FOR NCLEX RN ACTUAL EXAM QUESTIONS AND ANSWERS GRADED A+

TEST BANK FOR NCLEX RN ACTUAL EXAM QUESTIONS AND ANSWERS GRADED A+ When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take? A. Continue monitoring because this is a normal occurrence. B. Turn client on right side. C. Decrease IV fluids. D. Report to physician or midwife. - ANS-Correct Answer: D (A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. (C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client. A client has been diagnosed as being preeclamptic. The physician orders magnesium sulfate. Magnesium sulfate (MgSO4) is used in the management of preeclampsia for: A. Prevention of seizures B. Prevention of uterine contractions C. Sedation D. Fetal lung protection Reveal Solution - ANS-Correct Answer: A (A) MgSO4 is classified as an anticonvulsant drug. In preeclampsia management, MgSO4 is used for prevention of seizures. (B) MgSO4 has been used to inhibit hyperactive labor, but results are questionable. (C) Negative side effects such as respiratory depression should not be confused with generalized sedation. (D)MgSO4 does not affect lung maturity. The infant should be assessed for neuromuscular and respiratory depression. Community vote distribution The predominant purpose of the first Apgar scoring of a newborn is to: A. Determine gross abnormal motor function B. Obtain a baseline for comparison with the infant's future adaptation to the environment C. Evaluate the infant's vital functions D. Determine the extent of congenital malformations Reveal Solution Discussion 8 Next Questions - ANS-Correct Answer: C (A) Apgar scores are not related to the infants care, but to the infants physical condition. (B) Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. (C) The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. (D) Congenital malformations are not one of the areas assessed with Apgar scores. Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities A. 7 B. 10 C. 8 D. 9 - ANS-Correct Answer: A (A) Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flex- ion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). (B) For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink. (C) For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. (D) For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point. Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is: A. 70 mg/dL and 120 mg/dL B. 100 mg/dL and 200 mg/dL C. 40 mg/dL and 130 mg/dL D. 90 mg/dL and 200 mg/dL Hide Solution Discussion 9 - ANS-Correct Answer: A (A) The recommended range is 70120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus. A pregnant woman at 36 weeks gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following foods will provide the greatest amount of protein when added to her intake of 100 mL of milk? A. Fifty milliliters light cream and 2 tbsp corn syrup B. Thirty grams powdered skim milk and 1 egg C. One small scoop (90 g) vanilla ice cream and 1 tbsp chocolate syrup D. One package vitamin-fortified gelatin drink - ANS-Correct Answer: B (A) This choice would provide more unwanted fat and sugar than protein. (B) Skim milk would add protein. Eggs are good sources of protein while low in fat and calories. (C) The benefit of protein from ice cream would be outweighed by the fat content. Chocolate syrup has caffeine, which is contraindicated or limited in pregnancy. (D) Although most animal proteins are higher in protein than plant proteins, gelatin is not. It loses protein during the processing for food consumption.