PN 131 Comprehensive Final NCLEX Practice
You're assessing the one minute APGAR score of a newborn baby. On assessment, you note the
following about your newborn patient: heart rate 130, pink body and hands with cyanotic feet,
weak cry, flexion of the arms and legs, active movement and crying when stimulated. What is
your patient's APGAR score?*
A. APGAR 9
B. APGAR 10
C. APGAR 8
D. APGAR 5 - correct answer C: APGAR 8.....A: 1, P: 2, G, 2, A: 2, R: 1
You're assessing the one minute APGAR score of a newborn baby. On assessment, you note the
following about your newborn patient: heart rate 101, cyanotic body and extremities, no
response to stimulation, no flexion of extremities, and strong cry. What is your patient's APGAR
score?*
A. APGAR 4
B. APGAR 6
C. APGAR 3
D. APGAR 2 - correct answer A: APGAR 4.....A: 0, P: 2, G, 0, A: 0, R: 2
A newborn's five minute APGAR score is 5. Which of the following nursing interventions will you
provide to this newborn?*
A. Routine post-delivery care
B. Continue to monitor and reassess the APGAR score in 10 minutes.
C. Some resuscitation assistance such as oxygen and rubbing baby's back and reassess APGAR
score.
D. Full resuscitation assistance is needed and reassess APGAR score. - correct answer C. Scoring
Interventions are as follows: 7-10: no interventions, baby doing good just needs routine post-
delivery care, 4-6: some resuscitation assistance required like oxygen, suction.... stimulate the
baby, rub baby's back, 0-3: needs full resuscitation
Regarding the scenario in the question above, when would you reassess the APGAR?*
A. 2 minutes
B. 10 minutes
C. 5 minutes
,D. No reassessment of the APGAR score is needed. - correct answer B. The APGAR score is
performed at 1 minute and 5 minutes after birth and reassessed at 10 minutes (5 minutes later)
after birth, IF the score is 6 or less.
You're assessing the five minute APGAR score of a newborn baby. On assessment, you note the
following about your newborn patient: pink body and hands with cyanotic feet, heart rate 109,
grimace to stimulation, flaccid, and irregular cry. What is your patient's APGAR score?*
A. APGAR 8
B. APGAR 5
C. APGAR 6
D. APGAR 3 - correct answer B. APGAR 5:...A: 1, P: 2, G, 1, A: 0, R: 1
You're assessing the five minute APGAR score of a newborn baby. On assessment, you note the
following about your newborn patient: heart rate 97, no response to stimulation, flaccid,
absent respirations, cyanotic throughout. What is your patient's APGAR score?*
A. APGAR 2
B. APGAR 3
C. APGAR 0
D. APGAR 1 - correct answer D. APGAR 1:...A: 0, P: 1, G, 0, A: 0, R: 0
A newborn's one minute APGAR score is 8. Which of the following nursing interventions will
you provide to this newborn?*
A. Routine post-delivery care
B. Full resuscitation assistance is needed and reassess APGAR score
C. Continue to monitor and reassess the APGAR score in 10 minutes
D. Some resuscitation assistance such as oxygen - correct answer A. Scoring Interventions are
as follows: 7-10: no interventions, baby doing good just needs routine post-delivery care, 4-6:
some resuscitation assistance required like oxygen, suction.... stimulate the baby, rub baby's
back, 0-3: needs full resuscitation *Remember the APGAR scoring is performed at 1 minute and
5 minutes after birth and reassessed at 10 minutes (5 minutes later) after birth if the score is 6
or less
A woman, who is 22 weeks pregnant, has a routine ultrasound performed. The ultrasound
shows that the placenta is located at the edge of the cervical opening. As the nurse you know
that which statement is FALSE about this finding:*
A. This is known as marginal placenta previa.
,B. The placenta may move upward as the pregnancy progresses and needs to be re-evaluated
with another ultrasound at about 32 weeks gestation.
C. The patient will need to have a c-section and cannot deliver vaginally.
D. The woman should report any bleeding immediately to the doctor. - correct answer C. All the
other options are CORRECT. Option C is FALSE. This is a type of placenta previa called marginal
(or low-lying). There is a chance the woman can delivery vaginally, but if the placenta was
completely over the cervix or partially covering it a c-section would be required. At the 20 week
ultrasound the location of the placenta is detected. The location will be re-evaluated at about
32 weeks. If a placenta is found to be low lying there is a chance the placenta will move upward
(away from the cervix) as the uterus grows to accommodate the baby.
Your patient who is 34 weeks pregnant is diagnosed with total placenta previa. The patient is A
positive. What nursing interventions below will you include in the patient's care? Select all that
apply:*
A. Routine vaginal examinations
B. Monitoring vital signs
C. Administer RhoGAM per MD order
D. Assess internal fetal monitoring
E. Placing patient on side-lying position
F. Monitoring pad count
G. Monitoring CBC and clotting levels - correct answer B, E, F, and G. Option A is WRONG
because vaginal exams are avoided to prevent causing damage to the placenta presenting at
the cervical opening. Option C is WRONG because the patient is A positive and does NOT need
RhoGAM, which is for patients who are RH negative. Option D is WRONG because external
monitoring should be used NOT internal, which can damage the placenta at the cervical
opening.
A 28 year old female, who is 33 weeks pregnant with her second child, has uncontrolled
hypertension. What risk factor below found in the patient's health history places her at risk for
abruptio placentae?*
A. childhood polio
B. preeclampisa
C. c-section
, D. her age - correct answer B. Preeclampisa is a risk factor for experiencing abruptio placentae.
The patient is at risk for developing this condition again since she is currently experiencing
uncontrolled hypertension with this pregnancy.
A 36 year old woman, who is 38 weeks pregnant, reports having dark red bleeding. The patient
experienced abruptio placentae with her last pregnancy at 29 weeks. What other signs and
symptoms can present with abruptio placentae? Select all that apply:*
A. Decrease in fundal height
B. Hard abdomen
C. Fetal distress
D. Abnormal fetal position
E. Tender uterus - correct answer B, C, and E. Option A is wrong because there may be an
INCREASE in fundal height (not decrease) due to concealed bleeding. Option D is wrong because
this tends to occur in placenta previa because the placenta attaches too low in the uterus at the
cervical opening.
Select all the patients below who are at risk for developing placenta previa:*
A. A 37 year old woman who is pregnant with her 7th child.
B. A 28 year old pregnant female with chronic hypertension.
C. A 25 year old female who is 36 weeks pregnant that has experienced trauma to abdomen.
D. A 20 year old pregnant female who is a cocaine user. - correct answer A and D. Risk factors
for developing placenta previa include: Maternal age >35 years old, multiples (twins etc.),
already had a baby, drug use: cocaine or smoking, surgery to the uterus that will leave scarring:
fibroid removal, c-section etc.
You're performing a head-to-toe assessment on a patient admitted with abruptio placentae.
Which of the following assessment findings would you immediately report to the physician?*
A. Oozing around the IV site
B. Tender uterus
C. Hard abdomen
D. Vaginal bleeding - correct answer A. Oozing around the IV site can indicate the patient is
entering into DIC (disseminated intravascular coagulation) because clotting levels have been
depleted. Therefore, the MD should be notified. Option B, C, and D are findings found in this
condition, but Option A is a SEVERE complication that can develop from it.
Which statement is TRUE regarding abruptio placenta?*
You're assessing the one minute APGAR score of a newborn baby. On assessment, you note the
following about your newborn patient: heart rate 130, pink body and hands with cyanotic feet,
weak cry, flexion of the arms and legs, active movement and crying when stimulated. What is
your patient's APGAR score?*
A. APGAR 9
B. APGAR 10
C. APGAR 8
D. APGAR 5 - correct answer C: APGAR 8.....A: 1, P: 2, G, 2, A: 2, R: 1
You're assessing the one minute APGAR score of a newborn baby. On assessment, you note the
following about your newborn patient: heart rate 101, cyanotic body and extremities, no
response to stimulation, no flexion of extremities, and strong cry. What is your patient's APGAR
score?*
A. APGAR 4
B. APGAR 6
C. APGAR 3
D. APGAR 2 - correct answer A: APGAR 4.....A: 0, P: 2, G, 0, A: 0, R: 2
A newborn's five minute APGAR score is 5. Which of the following nursing interventions will you
provide to this newborn?*
A. Routine post-delivery care
B. Continue to monitor and reassess the APGAR score in 10 minutes.
C. Some resuscitation assistance such as oxygen and rubbing baby's back and reassess APGAR
score.
D. Full resuscitation assistance is needed and reassess APGAR score. - correct answer C. Scoring
Interventions are as follows: 7-10: no interventions, baby doing good just needs routine post-
delivery care, 4-6: some resuscitation assistance required like oxygen, suction.... stimulate the
baby, rub baby's back, 0-3: needs full resuscitation
Regarding the scenario in the question above, when would you reassess the APGAR?*
A. 2 minutes
B. 10 minutes
C. 5 minutes
,D. No reassessment of the APGAR score is needed. - correct answer B. The APGAR score is
performed at 1 minute and 5 minutes after birth and reassessed at 10 minutes (5 minutes later)
after birth, IF the score is 6 or less.
You're assessing the five minute APGAR score of a newborn baby. On assessment, you note the
following about your newborn patient: pink body and hands with cyanotic feet, heart rate 109,
grimace to stimulation, flaccid, and irregular cry. What is your patient's APGAR score?*
A. APGAR 8
B. APGAR 5
C. APGAR 6
D. APGAR 3 - correct answer B. APGAR 5:...A: 1, P: 2, G, 1, A: 0, R: 1
You're assessing the five minute APGAR score of a newborn baby. On assessment, you note the
following about your newborn patient: heart rate 97, no response to stimulation, flaccid,
absent respirations, cyanotic throughout. What is your patient's APGAR score?*
A. APGAR 2
B. APGAR 3
C. APGAR 0
D. APGAR 1 - correct answer D. APGAR 1:...A: 0, P: 1, G, 0, A: 0, R: 0
A newborn's one minute APGAR score is 8. Which of the following nursing interventions will
you provide to this newborn?*
A. Routine post-delivery care
B. Full resuscitation assistance is needed and reassess APGAR score
C. Continue to monitor and reassess the APGAR score in 10 minutes
D. Some resuscitation assistance such as oxygen - correct answer A. Scoring Interventions are
as follows: 7-10: no interventions, baby doing good just needs routine post-delivery care, 4-6:
some resuscitation assistance required like oxygen, suction.... stimulate the baby, rub baby's
back, 0-3: needs full resuscitation *Remember the APGAR scoring is performed at 1 minute and
5 minutes after birth and reassessed at 10 minutes (5 minutes later) after birth if the score is 6
or less
A woman, who is 22 weeks pregnant, has a routine ultrasound performed. The ultrasound
shows that the placenta is located at the edge of the cervical opening. As the nurse you know
that which statement is FALSE about this finding:*
A. This is known as marginal placenta previa.
,B. The placenta may move upward as the pregnancy progresses and needs to be re-evaluated
with another ultrasound at about 32 weeks gestation.
C. The patient will need to have a c-section and cannot deliver vaginally.
D. The woman should report any bleeding immediately to the doctor. - correct answer C. All the
other options are CORRECT. Option C is FALSE. This is a type of placenta previa called marginal
(or low-lying). There is a chance the woman can delivery vaginally, but if the placenta was
completely over the cervix or partially covering it a c-section would be required. At the 20 week
ultrasound the location of the placenta is detected. The location will be re-evaluated at about
32 weeks. If a placenta is found to be low lying there is a chance the placenta will move upward
(away from the cervix) as the uterus grows to accommodate the baby.
Your patient who is 34 weeks pregnant is diagnosed with total placenta previa. The patient is A
positive. What nursing interventions below will you include in the patient's care? Select all that
apply:*
A. Routine vaginal examinations
B. Monitoring vital signs
C. Administer RhoGAM per MD order
D. Assess internal fetal monitoring
E. Placing patient on side-lying position
F. Monitoring pad count
G. Monitoring CBC and clotting levels - correct answer B, E, F, and G. Option A is WRONG
because vaginal exams are avoided to prevent causing damage to the placenta presenting at
the cervical opening. Option C is WRONG because the patient is A positive and does NOT need
RhoGAM, which is for patients who are RH negative. Option D is WRONG because external
monitoring should be used NOT internal, which can damage the placenta at the cervical
opening.
A 28 year old female, who is 33 weeks pregnant with her second child, has uncontrolled
hypertension. What risk factor below found in the patient's health history places her at risk for
abruptio placentae?*
A. childhood polio
B. preeclampisa
C. c-section
, D. her age - correct answer B. Preeclampisa is a risk factor for experiencing abruptio placentae.
The patient is at risk for developing this condition again since she is currently experiencing
uncontrolled hypertension with this pregnancy.
A 36 year old woman, who is 38 weeks pregnant, reports having dark red bleeding. The patient
experienced abruptio placentae with her last pregnancy at 29 weeks. What other signs and
symptoms can present with abruptio placentae? Select all that apply:*
A. Decrease in fundal height
B. Hard abdomen
C. Fetal distress
D. Abnormal fetal position
E. Tender uterus - correct answer B, C, and E. Option A is wrong because there may be an
INCREASE in fundal height (not decrease) due to concealed bleeding. Option D is wrong because
this tends to occur in placenta previa because the placenta attaches too low in the uterus at the
cervical opening.
Select all the patients below who are at risk for developing placenta previa:*
A. A 37 year old woman who is pregnant with her 7th child.
B. A 28 year old pregnant female with chronic hypertension.
C. A 25 year old female who is 36 weeks pregnant that has experienced trauma to abdomen.
D. A 20 year old pregnant female who is a cocaine user. - correct answer A and D. Risk factors
for developing placenta previa include: Maternal age >35 years old, multiples (twins etc.),
already had a baby, drug use: cocaine or smoking, surgery to the uterus that will leave scarring:
fibroid removal, c-section etc.
You're performing a head-to-toe assessment on a patient admitted with abruptio placentae.
Which of the following assessment findings would you immediately report to the physician?*
A. Oozing around the IV site
B. Tender uterus
C. Hard abdomen
D. Vaginal bleeding - correct answer A. Oozing around the IV site can indicate the patient is
entering into DIC (disseminated intravascular coagulation) because clotting levels have been
depleted. Therefore, the MD should be notified. Option B, C, and D are findings found in this
condition, but Option A is a SEVERE complication that can develop from it.
Which statement is TRUE regarding abruptio placenta?*
