NCLEX / SAUNDERS PRE-TEST QUESTIONS WITH CORRECT ANSWERS

NCLEX / SAUNDERS PRE-TEST QUESTIONS WITH CORRECT ANSWERS A postpartum nurse is caring for a client who had a placenta previa. Which nursing intervention does the nurse, reviewing the plan of care, identify as the priority for this client? A. Fundal assessment B. Monitoring of urine output C. Frequent assessment of lochia D. Inclusion of iron in every meal - Answer-C. Frequent assessment of lochia Rational: The placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding even when the fundus is firm. The nurse may first see an increase in lochia as a sign of hemorrhage. The nurse then must assess the client carefully for signs of deficient fluid volume as a result of postpartum hemorrhage. This assessment includes urine output and fundal assessment however these are not the priority. Dietary intake of iron is not related specifically to placenta previa. A rubella titer is performed on a woman who has just been told that she is pregnant. The results of the titer indicate that the mother is not immune to rubella. The nurse realizes the patient understands patient teaching if the patient makes which statement? A. "I may need to get a therapeutic abortion." B. "I will need an immunization against rubella immediately." C. "Immunization against rubella is required after delivery." D. "Antibiotics will be prescribed to prevent the infection." - Answer-C. "Immunization against rubella is required after delivery." Rational: A rubella titer is performed to determine the pregnant client's immunity to rubella. If the titer is less than 1:8, the woman is not immune. The client is then immunized after delivery. Because the vaccine contains live virus, the client should not be immunized during pregnancy. Antibiotics are not prescribed. Counseling the client on therapeutic abortion is incorrect. A nurse performing a fundal assessment after a vaginal birth notes that the fundus is above the umbilicus and displaced from the midline. What should the nurse do first? A. Massage the fundus B. Help the client void C. Document the findings D. Help the client ambulate - Answer-B. Help the client void