NGN NCLEX RN ACTUAL EXAM-With 100% Verified Solutions-2024-2025, Exams of Nursing

Download NGN NCLEX RN ACTUAL EXAM-With 100% Verified Solutions-2024-2025 and more Exams Nursing in PDF only on Docsity! NGN NCLEX RN ACTUAL EXAM-With 100% Verified Solutions-2024-2025 Question 1 A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Ngeles rule is: A. March 27 B. February 1 C. February 27 D. January 3 Correct Answer: C (A)March 27 is a miscalculation. (B) February 1 is a miscalculation. (C) February 27 is the correct answer. To calculate the estimated date of confinement using Nageles rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. (D) January 3 is a miscalculation. Question 2 The nurse practitioner determines that a client is approximately 9 weeks gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as: A. Nausea and vomiting B. Quickening C. A 6-8 lb weight gain D. Abdominal enlargement Correct Answer: A (A) Nausea and vomiting are experienced by almost half of all pregnant women during the first 3 months of pregnancy as a result of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. (B) Quickening is the mothers perception of fetal movement and generally does not occur until 1820 weeks after the last menstrual period in primigravidas, but it may occur as early as 16 weeks in multigravidas. (C) During the first trimester there should be only a modest weight gain of 24 Ib. It is not uncommon for women to lose weight during the first trimester owing to nausea and/or vomiting. (D) Physical changes are not apparent until the second trimester, when the uterus rises out of the pelvis. Question 3 A client is 6 weeks pregnant. During her first prenatal visit, she asks, "How much alcohol is safe to drink during pregnancy?" The nurse's response is: A. Up to 1 oz daily B. Up to 2 oz daily C. Up to 4 oz weekly D. No alcohol Correct Answer: D (A, B, C) No amount of alcohol has been determined safe for pregnant women. Alcohol should be avoided owing to the risk of fetal alcohol syndrome. (D) The recommended safe dosage of alcohol consumption during pregnancy is none. Question 4 A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks gestation. The nurse should be alert to which condition related to her age? A. lron-deficiency anemia B. Sexually transmitted disease (STD) C. Intrauterine growth retardation D. Pregnancy-induced hypertension (PIH) Correct Answer: D (A) lron-deficiency anemia can occur throughout pregnancy and is not age related. (B) STDs can occur prior to or during pregnancy and are not age related. (C) Intrauterine growth retardation is an abnormal process where fetal development and maturation are delayed. It is not age related. (D) Physical risks for the pregnant client older than 35 include increased risk for PIH, cesarean delivery, fetal and neonatal mortality, and trisomy. Question 5 A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control? A. She is compliant with her diet as previously taught. B. She needs further instruction and reinforcement. C. She needs to increase her caloric intake. D. She needs to be placed on a restrictive diet immediately. Correct Answer: B (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. Question 11 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 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. Question 12 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 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. Question 13 The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, "It’s not so easy for me to just go right to the hospital like that." After acknowledging her feelings, which of these approaches by the nurse would probably be best? A. Stress to the client that her husband would want her to do what is best for her health. B. Explore with the client her perceptions of why she is unable to go to the hospital. C. Repeat the physician’s reasons for advising immediate hospitalization. D. Explain to the client that she is ultimately responsible for her own welfare and that of her baby. Correct Answer: B (A) This answer does not hold the client accountable for her own health. (B) The nurse should explore potential reasons for the clients anxiety: are there small children at home, is the husband out of town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of hospitalization. (C) Repeating the physicians reason for recommending hospitalization may not aid the client in dealing with her reasons for anxiety. (D) The concern for self and welfare of baby may be secondary to a woman who is in a crisis situation. The nurse should explore the clients potential reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband who is overseas and not able to return on short notice? Question 14 Which of the following findings would be abnormal in a postpartal woman? A. Chills shortly after delivery B. Pulse rate of 60 bpm in morning on first postdelivery day C. Urinary output of 3000 mL on the second day after delivery D. An oral temperature of 101F (38.3C) on the third day after delivery Correct Answer: D (A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early postpartal period (1224 hours) owing to diuresis. The kidneys must eliminate an estimated 20003000 mL of extracellular fluid associated with a normal pregnancy. (D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4F needs further investigation to identify any infectious process. Question 15 What is the most effective method to identify early breast cancer lumps? A. Mammograms every 3 years B. Yearly checkups performed by physician C. Ultrasounds every 3 years D. Monthly breast self-examination Correct Answer: D (A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are more effective for women older than 40. (B) Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast self-examination. (C) Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. (D) Monthly breast self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves. Question 16 Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client’s history? A. Menarche after age 13 B. Nulliparity C. Maternal family history of breast cancer D. Early menopause Correct Answer: C (A) Women who begin menarche late (after 13 years old) have a lower risk of developing breast cancer than women who have begun earlier. Average age for menarche is 12.5 years. (B) Women who have never been pregnant have an increased risk for breast cancer, but a positive family history poses an even greater risk. (C) A positive family history puts a woman at an increased risk of developing breast cancer. It is recommended that mammography screening begin 5 years before the age at which an immediate female relative was diagnosed with breast cancer. (D) Early menopause decreases the risk of developing breast cancer. Question 17 Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer? A. Diaphanography Question 22 A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhea. The nurse notices a slight tremor in his left hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate? A. Administer a stat dose of lithium as necessary. B. Recognize this as an expected response to lithium. C. Request an order for a stat blood lithium level. D. Give an oral dose of lithium antidote. Correct Answer: C (A) These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal. (B) These are toxic effects of lithium therapy. (C) The client is exhibiting symptoms of lithium toxicity, which may be validated by lab studies. (D) There is no known lithium antidote. Question 23 Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder? A. Playing cards with other clients B. Working crossword puzzles C. Playing tennis with a staff member D. Sewing beads on a leather belt Correct Answer: C (A) This activity is too competitive, and the manic client might become abusive toward the other clients. (B) During mania, the clients attention span is too short to accomplish this task. (C) This activity uses gross motor skills, eases tension, and expands excess energy. A staff member is better equipped to interact therapeutically with clients. (D) This activity requires the use of fine motor skills and is very tedious. Question 24 A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time? A. Small, frequent feedings of foods that can be carried B. Tube feedings with nutritional supplements C. Allowing him to eat when and what he wants D. Giving him a quiet place where he can sit down to eat meals Correct Answer: A (A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when other methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of client may forget to eat. (D) The manic client is unable to sit down to eat full meals. Question 25 Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, "| wish | were dead because | am worthless to everyone; | guess | am just no good." Which response by the nurse is most appropriate at this time? A. "| don’t think you are worthless. I’m glad to see you, and we will help you." B. "Don't you think this is a sign of your illness?" C. "| know with your wife and new baby that you do have a lot to live for." D. "You've been feeling sad and alone for some time now?" Correct Answer: D (A) This response does not acknowledge the clients feelings. (B) This is a closed question and does not encourage communication. (C) This response negates the clients feelings and does not require a response from the client. (D) This acknowledges the clients implied thoughts and feelings and encourages a response. Question 26 Which of the following statements relevant to a suicidal client is correct? A. The more specific a client's plan, the more likely he or she is to attempt suicide. B. A client who is unsuccessful at a first suicide attempt is not likely to make future attempts. C. A client who threatens suicide is just seeking attention and is not likely to attempt suicide. D. Nurses who care for a client who has attempted suicide should not make any reference to the word "suicide" in order to protect the client's ego. Correct Answer: A (A) This is a high-risk factor for potential suicide. (B) A previous suicide attempt is a definite risk factor for subsequent attempts. (C) Every threat of suicide should be taken seriously. (D) The client should be asked directly about his or her intent to do bodily harm. The client is never hurt by direct, respectful questions. Question 27 The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine? A. Because fluoxetine is a tricyclic antidepressant, it may precipitate a hypertensive crisis. B. The therapeutic effect of the drug occurs 2-4 weeks after treatment is begun. C. Foods such as aged cheese, yogurt, soy sauce, and bananas should not be eaten with this drug. D. Fluoxetine may be administered safely in combination with monoamine oxidase (MAO) inhibitors. Correct Answer: B (A) Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant. (B) This statement is true. (C) These foods are high in tyramine and should be avoided when the client is taking MAO inhibitors. Fluoxetine is not an MAO inhibitor. (D) Fatal reactions have been reported in clients receiving fluoxetine in combination with MAO inhibitors. Question 28 The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks at the nurse and says, "My life is so bad no one can do anything to help me." The most helpful initial response by the nurse would be: A. "It concerns me that you feel so badly when you have so many positive things in your life." B. "It will take a few weeks for you to feel better, so you need to be patient." C. "You are telling me that you are feeling hopeless at this point?" D. "Let's play cards with some of the other clients to get your mind off your problems for now." Correct Answer: C (A) This response does not acknowledge the clients feelings and may increase his feelings of guilt. (B) This response denotes false reassurance. (C) This response acknowledges the clients feelings and invites a response. (D) This response changes the subject and does not allow the client to talk about his feelings. Question 29 A long-term goal for the nurse in planning care for a depressed, suicidal client would be to: A. Provide him with a safe and structured environment. B. Assist him to develop more effective coping mechanisms. C. Have him sign a "no-suicide" contract. D. Isolate him from stressful situations that may precipitate a depressive episode. Correct Answer: B (A) This statement represents a short-term goal. (B) Long-term therapy should be directed toward assisting the client to cope effectively with stress. (C) Suicide contracts represent short-term A. Kidney (urinary system) B. Brain (nervous system) C. Heart (circulatory system) D. Lungs (respiratory system) Correct Answer: 8 (A) The kidney can survive after 30 minutes of water submersion. (B) The cerebral neurons sustain irreversible damage after 46 minutes of water submersion. (C) The heart can survive up to 30 minutes of water submersion. (D) The lungs can survive up to 30 minutes of water submersion. Question 36 One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is: A. Peripheral circulatory collapse B. Syndrome of inappropriate antiduretic hormone C. Cerebral edema resulting in hydrocephalus D. Auditory nerve damage resulting in permanent hearing loss A Correct Answer: Explanation (A) Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia resulting in death. (B) Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (C) Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome. (D) Auditory nerve damage resulting in permanent hearing loss is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. Question 37 An 8-year-old child comes to the physician's office complaining of swelling and pain in the knees. His mother says, "The swelling occurred for no reason, and it keeps getting worse." The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history? A. A decreased urinary output and flank pain B. A fever of over 103F occurring over the last 2-3 weeks C. Rashes covering the palms of the hands and the soles of the feet D. Headaches, malaise, or sore throat Correct Answer: D (A) Urinary tract symptoms are not commonly associated with Lyme disease. (B) A fever of 103F is not characteristic of Lyme disease. (C) The rash that is associated with Lyme disease does not appear on the palms of the hands and the soles of the feet. (D) Classic symptoms of Lyme disease include headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough. Question 38 The most commonly known vectors of Lyme disease are: A. Mites B. Fleas C. Ticks D. Mosquitoes Correct Answer: C (A) Mites are not the common vector of Lyme disease. (B) Fleas are not the common vector of Lyme disease. (C) Ticks are the common vector of Lyme disease. (D) Mosquitoes are not the common vector of Lyme disease. Question 39 A laboratory technique specific for diagnosing Lyme disease is: A. Polymerase chain reaction B. Heterophil antibody test C. Decreased serum calcium level D. Increased serum potassium level Correct Answer: A (A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level. Question 40 The nurse would expect to include which of the following when planning the management of the client with Lyme disease? A. Complete bed rest for 6-8 weeks B. Tetracycline treatment C. IV amphotericin B D. High-protein diet with limited fluids Correct Answer: B (A) The client is not placed on complete bed rest for 6 weeks. (B) Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. (C) lV amphotericin B is the treatment for histoplasmosis. (D) The client is not restricted to a high- protein diet with limited fluids. Question 41 A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child? A. Blood pressure B. Serum potassium level C. Urine output D. Pulse rate Correct Answer: C (A) Blood pressure can remain normotensive even in a state of hypovolemia. (B) Serum potassium is not reliable for determining adequacy of fluid resuscitation. (C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D) Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation. Question 42 Proper positioning for the child who is in Bryant's traction is: A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed B. Both legs extended, and the hips are not flexed C. The affected leg extended with slight hip flexion D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed Correct Answer: A (A) The child’s weight supplies the countertraction for Bryants traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle. Both legs are suspended by skin traction. (B) The child in Bucks extension traction maintains the legs extended and parallel to the bed. (C) The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. (D) The child in "90-90" traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed. A. That is covered with vesicular scabs all in the macular stage B. That appears profusely on the trunk and sparsely on the extremities C. That first appears on the neck and spreads downward D. That appears especially on the cheeks, which gives a'slapped-cheek" appearance Correct Answer: B (A) A rash with vesicular scabs in all stages (macule, papule, vesicle, and crusts). (B) A rash that appears profusely on the trunk and sparsely on the extremities. (C) Arash that first appears on the neck and spreads downward is characteristic of rubeola and rubella. (D) A rash, especially on the cheeks, that gives a "slapped-cheek" appearance is characteristic of roseola. Question 49 Discharge teaching was effective if the parents of a child with atopic dermatitis could state the importance of: A. Maintaining a high-humidified environment B. Furry, soft stuffed animals for play C. Showering 3-4 times a day D. Wrapping hands in soft cotton gloves Correct Answer: D (A) Maintaining a low-humidified environment. (B) Avoiding furry, soft stuffed animals for play, which may increase symptoms of allergy. (C) Avoiding showering, which irritates the dermatitis, and encouraging bathing 4 times a day in colloid bath for temporary relief. (D) Wrapping hands in soft cotton gloves to prevent skin damage during scratching. Question 50 The priority nursing goal when working with an autistic child is: A. To establish trust with the child B. To maintain communication with the family C. To promote involvement in school activities D. To maintain nutritional requirements Correct Answer: A (A) The priority nursing goal when working with an autistic child is establishing a trusting relationship. (B) Maintaining a relationship with the family is important but having the trust of the child is a priority. (C) To promote involvement in school activities is inappropriate for a child who is autistic. (D) Maintaining nutritional requirements is not the primary problem of the autistic child. Question 51 The child with iron poisoning is given lV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to: A. Discontinue the IV B. Stop the medication, and begin a normal saline infusion C. Take all vital signs, and report to the physician D. Assess urinary output, and if it is 30 mL an hour, maintain current treatment Correct Answer: B (A) The IV line should not be discontinued because other IV medications will be needed. (B) Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the childs obvious allergic reaction. Question 52 As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is: A. Enlarged penis B. Secondary lymphadenitis C. Epididymitis D. Hepatomegaly Correct Answer: C (A) An enlarged penis is not a sign of chlamydia. (B) Secondary lymphadenitis is a complication of lymphogranuloma venereum. (C) Untreated chlamydial infection can spread from the urethra, causing epididymitis, which presents as a tender, scrotal swelling. (D) Hepatomegaly is not a complication. Question 53 When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child: A. Fruit juices B. Diluted carbonated drinks C. Soy-based, lactose-free formula D. Regular formulas mixed with electrolyte solutions Correct Answer: C (A) Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhea. (B) Diluted soft drinks have a high-carbohydrate content, which aggravates the diarrhea. (C) Soy-based, lactose-free formula reduces stool output and duration of diarrhea in most infants. (D) Regular formulas contain lactose, which can increase diarrhea. Question 54 The primary reason that an increase in heart rate (100 bpm) detrimental to the client with a myocardial infarction (Ml) is that: A. Stroke volume and blood pressure will drop proportionately B. Systolic ejection time will decrease, thereby decreasing cardiac output C. Decreased contractile strength will occur due to decreased filling time D. Decreased coronary artery perfusion due to decreased diastolic filling time will occur, which will increase ischemic damage to the myocardium Correct Answer: D (A) Decreased stroke volume and blood pressure will occur secondary to decreased diastolic filling. (B) Tachycardia primarily decreases diastole; systolic time changes very little. (C) Contractility decreases owing to the decreased filling time and decreased time for fiber lengthening. (D) Decreased 02 supply due to decreased time for filling of the coronary arteries increases ischemia and infarct size. Tachycardia primarily robs the heart of diastolic time, which is the primary time for coronary artery filling. Question 55 To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and 02 demand will occur with which of the following? A. Positive inotropic therapy B. Negative chronotropic therapy C. Increase in balance of myocardial 02 supply and demand D. Afterload reduction therapy Correct Answer: A (A) Inotropic therapy will increase contractility, which will increase myocardial 02 demand. (B) Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The goal in the care of the MI client with angina is to maintain a balance between myocardial 02 supply and demand. (D) Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and 02 demand. (A) Pericarditis can cause dyspnea but primarily causes chest pain. (B) Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. (C) The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. (D) Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position. Question 61 When a client questions the nurse as to the purpose of exercise electrocardiography (ECG) in the diagnosis of cardiovascular disorders, the nurses response should be based on the fact that: A. The test provides a baseline for further tests B. The procedure simulates usual daily activity and myocardial performance C. The client can be monitored while cardiac conditioning and heart toning are done D. Ischemia can be diagnosed because exercise increasesO2 consumption and demand Correct Answer: D (A) The purpose of the study is not to provide a baseline for further tests. (B) The test causes an increase in 02 demand beyond that required to perform usual daily activities. (C) Monitoring does occur, but the test is not for the purpose of cardiac toning and conditioning. (D) Exercise ECG, or stress testing, is designed to elevate the peripheral and myocardial needs for 02 to evaluate the ability of the myocardium and coronary arteries to meet the additional demands. Question 62 In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically: A. Decreased pulmonary blood flow and cyanosis B. Increased pressure in the pulmonary veins and pulmonary edema C. Systemic venous engorgement D. Increased left ventricular systolic pressures and hypertrophy Correct Answer: D (A) These signs are seen in pulmonic stenosis or in response to pulmonary congestion and edema and mitral stenosis. (B) These signs are seen primarily in mitral stenosis or as a late sign in aortic stenosis after left ventricular failure. (C) These signs are seen primarily in right-sided heart valve dysfunction. (D) Left ventricular hypertrophy occurs to increase muscle mass and overcome the stenosis; left ventricular pressures increase as left ventricular volume increases owing to insufficient emptying. Question 63 The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to: A. Digoxin (Lanoxin) B. Lidocaine (Xylocaine) C. Quinidine gluconate or sulfate (Quinaglute,Quinidex) D. Nitroglycerin IV (Tridil) Correct Answer: B (A) Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. (B) Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. (C) Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. (D) Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing. Question 64 Which of the following ECG changes would be seen as a positive myocardial stress test response? A. Hyperacute T wave B. Prolongation of the PR interval C. ST-segment depression D. Pathological Q wave Correct Answer: C (A) Hyperacute T waves occur with hyperkalemia. (B) Prolongation of the P R interval occurs with first- degree AV block. (C) Horizontal ST-segment depression of>1 mm during exercise is definitely a positive criterion on the exercise ECG test. (D) Patho-logical Q waves occur with MI. Question 65 Assessment of the client with pericarditis may reveal which of the following? A. Ventricular gallop and substernal chest pain B. Narrowed pulse pressure and shortness of breath C. Pericardial friction rub and pain on deep inspiration D. Pericardial tamponade and widened pulse pressure Correct Answer: C (A) No S3 or S4 are noted with pericarditis. (B) No change in pulse pressure occurs. (C) The symptoms of pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature, and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep inspiration. (D) Tamponade is not typically seen early on, and no change in pulse pressure occurs. Question 66 Clinical manifestations seen in left-sided rather than in right-sided heart failure are: A. Elevated central venous pressure and peripheral edema B. Dyspnea and jaundice C. Hypotension and hepatomegaly D. Decreased peripheral perfusion and rales Correct Answer: D (A, B, C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated central venous pressure. (D) Clinical manifestations of left-sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales. Question 67 Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy? A. Positive inotropes B. Vasodilators C. Diuretics D. Antidysrhythmics Correct Answer: A (A) Positive inotropic agents should not be administered owing to their action of increasing myocardial contractility. Increased ventricular contractility would increase outflow tract obstruction in the client with hypertrophic cardiomyopathy. (B) Vasodilators are not typically prescribed but are not contraindicated. (C) Diuretics are used with caution to avoid causing hypovolemia. (D) Antidysrhythmics are typically needed to treat both atrial and ventricular dysrhythmias. Question 68 To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration? A. Stinging, burning when placed under the tongue B. Temporary blurring of vision C. Generalized urticaria with prolonged use D. Urinary frequency Correct Answer: A (A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation. Question 74 In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by: A. Auscultating bilateral breath sounds B. Palpating for presence of crepitus C. Palpating for trachial deviation D. Auscultating heart sounds Correct Answer: C (A) No change in the breath sounds occurs as a direct result of the mediastinal shift. (B) Crepitus can occur owing to the primary disorder, not to the mediastinal shift. (C) Mediastinal shift occurs primarily with tension pneumothorax, but it can occur with very large hemothorax or pneumothorax. Mediastinal shift causes trachial deviation and deviation of the hearts point of maximum impulse. (D) No change in the heart sounds occurs as a result of the mediastinal shift. Question 75 Priapism may be a sign of: A. Altered neurological function B. Imminent death C. Urinary incontinence D. Reproductive dysfunction Correct Answer: A (A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather than incontinence, may occur. (D) Reproductive dysfunction may be a secondary problem. Question 76 When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that: A. In neurogenic shock, the skin is warm and dry B. In hypovolemic shock, there is a bradycardia C. In hypovolemic shock, capillary refill is less than 2 seconds D. In neurogenic shock, there is delayed capillary refill Correct Answer: A (A) Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia resulting from the lack of sympathetic balance to parasympathetic stimuli from the vagus nerve, and the loss of the ability to sweat below the level of injury. In neurogenic shock, the client is hypotensive but bradycardiac with warm, dry skin. (B) In hypovolemic shock, the client is hypotensive and tachycardiac with cool skin. (C) In hypovolemic shock, the capillary refill would be>5 seconds. (D) In neurogenic shock, there is no capillary delay, the vascular beds are dilated, and peripheral flow is good. Question 77 Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)? A. Increased core body temperature B. Decreased serum osmolality C. Administration of hypo-osmolar fluids D. Decreased PaCO2 Correct Answer: D (A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo-osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edema. (D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known. Question 78 A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental 02, and establishing IV access, the next nursing intervention would be to: A. Pass a nasogastric tube through the left nostril B. Place a 4 X 4 gauze in the nares to impede the flow C. Gently suction the nasal drainage to protect the airway D. Perform a halo test and glucose level on the drainage Correct Answer: D (A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain tissue or sinuses. (B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy. Question 79 A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report: A. Dizziness and tachypnea B. Circumoral pallor and lightheadedness C. Headache and facial flushing D. Pallor and itching of the face and neck Correct Answer: C (A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms. Question 80 The initial treatment for a client with a liquid chemical burn injury is to: A. Irrigate the area with neutralizing solutions B. Flush the exposed area with large amounts of water C. Inject calcium chloride into the burned area D. Apply lanolin ointment to the area Correct Answer: B (A) In the past, neutralizing solutions were recommended, but presently there is concern that these solutions extend the depth of burn area. (B) The use of large amounts of water to flush the area is recommended for chemical burns. (C) Calcium chloride is not recommended therapy and would likely worsen the problem. (D) Lanolin is of no benefit in the initial treatment of a chemical injury and may actually extend a thermal injury. Question 81 The most important reason to closely assess circumferential burns at least every hour is that they may result in: A. Hypovolemia Question 86 The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment: A. Decreases hypertrophic scar formation B. Assists with ambulation C. Covers burn scars and decreases the psychological impact during recovery D. Increases venous return and cardiac output by normalizing fluid status Correct Answer: A (A) Tubular support, such as that received with a Jobst garment, applies tension of 1020 mm Hg. This amount of uniform pressure is necessary to prevent or reduce hypertrophic scarring. Clients typically wear a pressure garment for 612 months during the recovery phase of their care. (B) Pressure garments have no ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments do not normalize fluid status. Question 87 A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet? A. Celery B. Potatoes C. Tomatoes D. Liver Correct Answer: B (A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron. Question 88 Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema? A. Distant breath sounds B. Increased heart sounds C. Decreased anteroposterior chest diameter D. Collapsed neck veins Correct Answer: A (A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema. Question 89 The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should: A. Increase his nasal 02 to 6 L/min B. Place him in a lateral Sims’ position C. Encourage pursed-lip breathing D. Have him breathe into a paper bag Correct Answer: C (A) Giving too high a concentration of 02 to a client with emphysema may remove his stimulus to breathe. (B) The client should sit forward with his hands on his knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the face of a client extremely short of breath may cause anxiety and further increase dyspnea. Question 90 Signs and symptoms of an allergy attack include which of the following? A. Wheezing on inspiration B. Increased respiratory rate C. Circumoral cyanosis D. Prolonged expiration Correct Answer: D (A) Wheezing occurs during expiration when air movement is impaired because of constricted edematous bronchial lumina. (B) Respirations are difficult, but the rate is frequently normal. (C) The circumoral area is usually pale. Cyanosis is not an early sign of hypoxia. (D) Expiration is prolonged because the alveoli are greatly distended and air trapping occurs. Question 91 A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay- colored stools. His admitting diagnosis is "rule out hepatitis." Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis. Which of the following represents a high-risk group for contracting this disease? A. Heterosexual males B. Oncology nurses C. American Indians D. Jehovah's Witnesses Correct Answer: B (A) Homosexual males, not heterosexual males, are at high risk for contracting hepatitis. (B) Oncology nurses are employed in high-risk areas and perform invasive procedures that expose them to potential sources of infection. (C) The literature does not support the idea that any ethnic groups are at higher risk. (D) There is no evidence that any religious groups are at higher risk. Question 92 A diagnosis of hepatitis C is confirmed by a male clients physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C? A. The potential for chronic liver disease is minimal. B. The onset of symptoms is abrupt. C. The incubation period is 2-26 weeks. D. There is an effective vaccine for hepatitis B, but not for hepatitis C. Correct Answer: C (A) Hepatitis C and B may result in chronic liver disease. Hepatitis A has a low potential for chronic liver disease. (B) Hepatitis C and B have insidious onsets. Hepatitis A has an abrupt onset. (C) Incubation periods are as follows: hepatitis C is 226 weeks, hepatitis B is 620 weeks, and hepatitis A is 26 weeks. (D) Only hepatitis B has an effective vaccine. Question 93 The nurse is aware that nutrition is an important aspect of care for a client with hepatitis. Which of the following diets would be most therapeutic? A. High protein and low carbohydrate B. Low calorie and low protein C. High carbohydrate and high calorie D. Low carbohydrate and high calorie (A) Blood sugar levels increase when the body responds to stress and illness. (B) Blood sugar levels increase when the body responds to stress and illness. (C) Hyperglycemia occurs because glucose is produced as the body responds to the stress and illness of cellulitis. (D) Blood sugar levels remain elevated as long as the body responds to stress and illness. Question 99 The physician has ordered that a daily exercise program be instituted by a client with type | diabetes following his discharge from the hospital. Discharge instructions about exercise should include which of the following? A. Exercise should be performed 30 minutes before meals. B. A snack may be needed before and/or during exercise. C. Hyperglycemia may occur 2-4 hours after exercise. D. The blood glucose level should be 100 mg or below before exercise is begun. Correct Answer: B (A) Exercise should not be performed before meals because the blood sugar is usually lower just prior to eating; therefore, there is an increased risk for hypoglycemia. (B) Exercise lowers blood sugar levels; therefore, a snack may be needed to maintain the appropriate glucose level. (C) Exercise lowers blood sugar levels. (D) Exercise lowers blood sugar levels. If the blood glucose level is 100 mg or below at the start of exercise, the potential for hypoglycemia is greater. Question 100 Dietary planning is an essential part of the diabetic client’s regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning? A. 50% complex carbohydrate, 20%-25% protein, 20%-25% fat B. 45% complex carbohydrate, 25%-30% protein, 30%-35% fat C. 70% complex carbohydrate, 20%-30% protein, 10%-20% fat D. 60% complex carbohydrate, 12%-15% protein, 20%-25% fat Correct Answer: D (A) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney as it is metabolized. (B) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney. (C) The percentage of carbohydrates is too high; the percent range of protein is too high, and of fat, too low. (D) This combination provides enough carbohydrates to maintain blood glucose levels, enough protein to maintain body repair, and enough fat to ensure palatability. Question 101 A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, "Oh dear, | feel like | have to urinate again!" Which of the following is the most appropriate initial nursing response? A. Assure her that this is most likely the result of bladder spasms. B. Check the collection bag and tubing to verify that the catheter is draining properly. C. Instruct her to do Kegel exercises to diminish the urge to void. D. Ask her if she has felt this way before. Correct Answer: B (A) Although this may be an appropriate response, the initial response would be to assure the patency of the catheter. (B) The most frequent reason for an urge to void with an indwelling catheter is blocked tubing. This response would be the best initial response. (C) Kegel exercises while a retention catheter is in place would not help to prevent a voiding urge and could irritate the urethral sphincter. (D) Though the nurse would want to ascertain whether the client has felt the same urge to void before, the initial response should be to assure the patency of the catheter. Question 102 In cleansing the perineal area around the site of catheter insertion, the nurse would: A. Wipe the catheter toward the urinary meatus B. Wipe the catheter away from the urinary meatus C. Apply a small amount of talcum powder after drying the perineal area D. Gently insert the catheter another '/2 inch after cleansing to prevent irritation from the balloon Correct Answer: B (A) Wiping toward the urinary meatus would transport microorganisms from the external tubing to the urethra, thereby increasing the risk of bladder infection. (B) Wiping away from the urinary meatus would remove microorganisms from the point of insertion of the catheter, thereby decreasing the risk of bladder infection. (C) Talcum powder should not be applied following catheter care, because powders contribute to moisture retention and infection likelihood. (D) The catheter should never be inserted further into the urethra, because this would serve no useful purpose and would increase the risk of infection. Question 103 Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include: A. Cleanse area around the meatus twice a day B. Empty the catheter drainage bag at least daily C. Change the catheter tubing and bag every 48 hours D. Maintain fluid intake of 1200-1500 mL every day Correct Answer: A (A) Catheter site care is to be done at least twice daily to prevent pathogen growth at the catheter insertion site. (B) Catheter drainage bags are usually emptied every 8 hours to prevent urine stasis and pathogen growth. (C) Tubing and collection bags are not changed this often, because research studies have not demonstrated the efficacy of this practice. (D) Fluid intake needs to be in the 20002500 mL range if possible to help irrigate the bladder and prevent infection. Question 104 A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will: A. Drink at least 8 oz of cranberry juice daily B. Maintain a fluid intake of at least 2000 mL daily C. Wash her hands before and after voiding D. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps Correct Answer: D (A) Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission. (D) Restricting fluid intake would contribute to urinary stasis, which in turn would contribute to bacterial growth. Question 105 An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction? A. Boardlike, rigid abdomen Question 110 The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include: A. Blurred vision and dizziness B. Eye pain and itching C. Feeling of eye pressure and headache D. Eye discharge and hemoptysis Correct Answer: B (A) Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage. (B) Eye pain is a symptom of hemorrhage within the eye, and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or infection. (D) Some eye discharge might be anticipated if an infection is present; hemoptysis would not. Question 111 The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching? A. "| will wash my hands before instilling eye medications." B. "| will wear sunglasses when going outside." C. "| will wear an eye patch for the first 3 postoperative days." D. "| will maintain the sterility of the eye medications." Correct Answer: C (A) Hand washing would be an important action designed to prevent transmission of pathogens from the hands to the eye. (B) Wearing sunglasses when going outside will prevent airborne pathogens from entering the eye. (C) Eye patches are most frequently ordered to be worn while the client sleeps or naps, not constantly for this length of time. (D) Eye medications are sterile; clients need to be taught how to maintain this sterility. Question 112 With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccination against influenza. Why is this assessment important? A. Influenza is growing in our society. B. Older clients generally are sicker than others when stricken with flu. C. Older clients have less effective immune systems. D. Older clients have more exposure to the causative agents. Correct Answer: C (A) Although influenza is common, the elderly are more at risk because of decreased effectiveness of their immune system, not because the incidence is increasing. (B) Older clients have the same degree of illness when stricken as other populations. (C) As people age, their immune system becomes less effective, increasing their risk for influenza. (D) Older clients have no more exposure to the causative agents than do school-age children, for example. Question 113 In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because: A. The proteins needed for tissue repair are diminished. B. The iron stores needed for tissue repair are inadequate. C. A decreased serum albumin level indicates kidney disease. D. A decreased serum albumin causes fluid movement into the blood vessels, causing dehydration. Correct Answer: A (A) Serum albumin levels indicate the adequacy of protein stores available for tissue repair. (B) Serum albumin does not measure iron stores. (C) Serum albumin levels do not measure kidney function. (D) A decreased serum albumin level would cause fluid movement out of blood vessels, not into them. Question 114 Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels? A. Broiled fish with rice B. Bran flakes with fresh peaches C. Lasagna with garlic bread D. Cauliflower and lettuce salad Correct Answer: A (A) Broiled fish and rice are both excellent sources of protein. (B) Fresh fruits are not a good source of protein. (C) Foods in the bread group are not high in protein. (D) Most vegetables are not high in protein; peas and beans are the major vegetables higher in protein. Question 115 The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include: A. Ordering a full liquid diet for her B. Ordering five small meals for her C. Ordering a mechanical soft diet for her D. Ordering a puréed diet for her Correct Answer: C (A) Full liquids would be difficult to swallow if the muscle control of the swallowing act is affected; this is a probable reason for her difficulties, given her medical diagnosis of multiple sclerosis. (B) Five small meals would do little if anything to decrease her swallowing difficulties, other than assure that she tires less easily. (C) A mechanical soft diet should be easier to chew and swallow, because foods would be more evenly consistent. (D) A pureed diet would cause her to regress more than might be needed; the mechanical soft diet should be tried first. Question 116 When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease? A. "| will not eat any raw or uncooked vegetables." B. "I will limit my alcohol to one cocktail per day." C. "| will look into attending Alcoholics Anonymous meetings." D. "I will report any changes in bowel movements to my doctor." Correct Answer: C (A) Raw or uncooked vegetables are all right to eat postdischarge. (B) This client must avoid any alcohol intake. (C) The client displays Question 122 Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug? A. Limit fluids to 500 mL/day. B. Administer 2 hours before meals. C. Observe for skin rash and diarrhea. D. Monitor blood pressure, pulse. Correct Answer: C (A) Fluids up to 25003000 mL/day are needed to prevent kidney stones. (B) The client should be instructed to take oral preparations with meals or snacks to lessen gastric irritation. (C) Sulfasalazine causes skin rash and diarrhea. (D) Blood pressure and pulse are not altered by sulfasalazine. Question 123 Other drugs may be ordered to manage a client's ulcerative colitis. Which of the following medications, if ordered, would the nurse question? A. Methylprednisolone sodium succinate (Solu-Medrol) B. Loperamide (Imodium) C. Psyllium D. 6-Mercaptopurine Correct Answer: D (A) Methylprednisolone sodium succinate is used for its anti-inflammatory effects. (B) Loperamide would be used to control diarrhea. (C) Psyllium may improve consistency of stools by providing bulk. (D) An immunosuppressant such as 6- mercaptopurine is used for chronic unrelenting Crohns disease. Question 124 A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should: A. Explain that he will be kept NPO for 24 hours before the exam B. Practice with him so he will be able to hold his breath for 1 minute C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver D. Explain that his vital signs will be checked frequently after the test Correct Answer: D (A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 510 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock. Question 125 After a liver biopsy, the best position for the client is: A. High Fowler B. Prone C. Supine D. Right lateral Correct Answer: D (A) This position does not help to prevent bleeding. (B) This position does not help to prevent bleeding. (C) This position does not help to prevent bleeding. (D) The right lateral position would allow pressure on the liver to prevent bleeding. Question 126 A complication for which the nurse should be alert following a liver biopsy is: A. Hepatic coma B. Jaundice C. Ascites D. Shock Correct Answer: D (A) Hepatic coma may occur in liver disease due to the increased NH3levels, not due to liver biopsy. (B) Jaundice may occur due to increased bilirubin levels, not due to liver biopsy. (C) Ascites would occur due to portal hypertension, not due to liver biopsy. (D) Hemorrhage and shock are the most likely complications after liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver. Question 127 Which nursing implication is appropriate for a client undergoing a paracentesis? A. Have the client void before the procedure. B. Keep the client NPO. C. Observe the client for hypertension following the procedure. D. Place the client on the right side following the procedure. Correct Answer: A (A) A full bladder would impede withdrawal of ascitic fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock and hypertension. (D) No position change is needed after the procedure. Question 128 The nurse would assess the client’s correct understanding of the fertility awareness methods that enhance conception, if the client stated that: A. "My sexual partner and | should have intercourse when my cervical mucosa is thick and cloudy." B. "At ovulation, my basal body temperature should rise about 0.5F." C. "| should douche immediately after intercourse." D. "My sexual partner and | should have sexual intercourse on day 14 of my cycle regardless of the length of the cycle." Correct Answer: B (A) At ovulation, the cervical mucus is increased, stretchable, and watery clear. (B) Under the influence of progesterone, the basal body temperature increases slightly after ovulation. (C) To enhance fertility, measures should be taken that promote retention of sperm rather than removal. (D) Ovulation, the optimal time for conception, occurs 14+2 days before the next menses; therefore, the date of ovulation is directly related to the length of the menstrual cycle. Question 129 A couple is planning the conception of their first child. The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulation should occur on day: A. 14+2 days B. 16+2 days C. 20+2 days D. 22+2 days Correct Answer: C (A) Ovulation is dependent on average length of menstrual cycle, not standard 14 days. (B) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 16). (C) Ovulation occurs 14+2 days before next menses (34 minus 14 equals 20). (D) Ovulation occurs 14+2 days before next menses (34 minus 14 does not equal 22). (G = 3), regardless of the length of the pregnancy, and has had two prior pregnancies with birth after the 20th week (P = 2), whether infant was alive or dead. (C) This answer is an incorrect application of gravida and para. The client is currently pregnant for the third time (G = 3, not 2); prior pregnancies lasted longer than 20 weeks (therefore, P = 2, not 1). (D) This is an incorrect application of gravida and para. Client is currently pregnant for third time (G = 3, not 2). Question 134 A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate (MgS04) therapy, the nurse knows it is safe to repeat the dosage if: A. Deep tendon reflexes are absent B. Urine output is 20 mL/hr C. MgSO4serum levels are>15 mg/dL D. Respirations are>16 breaths/min Correct Answer: D (A) MgSO4is a central nervous system depressant. Loss of reflexes is often the first sign of developing toxicity. (B) Urinary output at <25 mL/hr or 100 mL in 4 hours may result in the accumulation of toxic levels of magnesium. (C) The therapeutic serum range for MgSO4is 68 mg/dL. Higher levels indicate toxicity. (D) Respirations of>16 breaths/min indicate that toxic levels of magnesium have not been reached. Medication administration would be safe. Question 135 Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH? A. 136/88 to 144/93 B. 132/78 to 124/76 C. 114/70 to 140/88 D. 140/90 to 148/98 Correct Answer: C (A) These blood pressure changes reflect only an 8 mm Hg systolic and a 5 mm Hg diastolic increase, which is insufficient for blood pressure changes indicating PIH. (B) These blood pressure changes reflect a decrease in systolic pressure of 8 mm Hg and diastolic pressure of 2 mm Hg; these values are not indicative of blood pressure increases reflecting PIH. (C) The definition of PIH is an increase in systolic blood pressure of 30 mm Hg and/or diastolic blood pressure of 15 mm Hg. These blood pressures reflect a change of 26 mm Hg systolically and 18mm Hg diastolically. (D) These blood pressures reflect a change of only 8 mm Hg systolically and 8 mm Hg diastolically, which is insufficient for blood pressure changes indicating PIH. Question 136 In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle? A. Menstrual phase B. Proliferative phase C. Secretory phase D. Ischemic phase Correct Answer: C (A) Menses occurs during the menstrual phase, during which levels of both estrogen and progesterone are decreased. (B) The ovarian hormone responsible for the proliferative phase, during which the uterine endometrium enlarges, is estrogen. (C) The ovarian hormone responsible for the secretory phase is progesterone, which is secreted by the corpus luteum and causes marked swelling in the uterine endometrium. (D) The corpus luteum begins to degenerate in the ischemic phase, causing a fall in both estrogen and progesterone. Question 137 A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full- term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to: A. Gently pull the infant away B. Withdraw the breast from the infant's mouth C. Compress the areolar tissue until the infant drops the nipple from her mouth D. Insert a clean finger into the baby’s mouth beside the nipple Correct Answer: D (A) In pulling the infant away from the breast without breaking suction, nipple trauma is likely to occur. (B) In pulling the breast away from the infant without breaking suction, nipple trauma is likely to occur. (C) Compressing the maternal tissue does not break the suction of the infant on the breast and can cause nipple trauma. (D) By inserting a finger into the infants mouth beside the nipple, the lactating mother can break the suction and the nipple can be removed without trauma. Question 138 A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to: A. Notify the physician B. Place the client on a pad count C. Massage the uterus and re-evaluate in 30 minutes D. Have the client void and then re-evaluate the fundus Correct Answer: D (A) The nurse should initiate actions to remove the most frequent cause of uterine displacement, which involves emptying the bladder. Notifying the physician is an inappropriate nursing action. (B) The pad count gives an estimate of blood loss, which is likely to increase with a boggy uterus; but this action does not remove the most frequent cause of uterine displacement, which is a full bladder. (C) Massage may firm the uterus temporarily, but if a full bladder is not emptied, the uterus will remain displaced and is likely to relax again. (D) The most common cause of uterine displacement is a full bladder. Question 139 A client delivered her first-born son 4 hours ago. She asks the nurse what the white cheeselike substance is under the baby’s arms. The nurse should respond: A. "This is a normal skin variation in newborns. It will go away in a few days." B. "Let me have a closer look at it. The baby may have an infection." C. "This material, called vernix, covered the baby before it was born. It will disappear in a few days." D. "Babies sometimes have sebaceous glands that get plugged at birth. This substance is an example of that condition." Correct Answer: C (A) This response identifies the fact that vernix is a normal neonatal variation, but it does not teach the client medical terms that may be useful in understanding other healthcare personnel. (B) This response may raise maternal anxiety and incorrectly identifies a normal neonatal variation. (C) This response correctly identifies this neonatal variation and helps the client to understand medical terms as well as the characteristics of her newborn. (D) Blocked sebaceous glands produce milia, particularly present on the nose. Question 144 A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the: A. Presenting part is 2 cm above the level of the ischial spines B. Biparietal diameter is at the level of the ischial spines C. Presenting part is 2 cm below the level of the ischial spines D. Biparietal diameter is 5 cm above the ischial spines Correct Answer: C (A) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive. Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0. Question 145 A pregnant client is at the clinic for a third trimester prenatal visit. During this examination, it has been determined that her fetus is in a vertex presentation with the occiput located in her right anterior quadrant. On her chart this would be noted as: A. Right occipitoposterior B. Right occipitoanterior C. Right sacroanterior D. LOA Correct Answer: B (A) The fetus in the right occipitoposterior position would be presenting with the occiput in the maternal right posterior quadrant. (B) Fetal position is defined by the location of the fetal presenting part in the four quadrants of the maternal pelvis. The right occipitoanterior is a fetus presenting with the occiput in mothers right anterior quadrant. (C) The fetus in right sacroanterior position would be presenting a sacrum, not an occiput. (D) The fetus in left occipitoanterior position would be presenting with the occiput in the mothers left anterior quadrant. Question 146 Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, "Begin oxytocin induction at 1 mU/min." The nurse should: A. Begin the oxytocin induction as ordered B. Increase the dosage by 2 mU/min increments at15-minute intervals C. Maintain the dosage when duration of contractions is 40-60 seconds and frequency is at 2‘/2-4 minute intervals D. Question the order Correct Answer: D (A) Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. (B) This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. (C) This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. (D) This answer is the appropriate nursing action because the scenario presents a dysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD. Question 147 A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse? A. "Keep breathing with your abdominal muscles as long as you can." B. "Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16-20 times a minute with shallow chest breaths." C. "Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles." D. "If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well." Correct Answer: B (A) Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. (B) In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. (C) It is important to assume a comfortable position in labor, but the Lamazeprepared laboring woman is taught to breathe with her chest, not abdominal, muscles. (D) When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 69 breaths/min. Question 148 A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching? A. "If he develops diarrhea lasting for more than 2-3 days, | will contact the doctor or nurse." B. "I should anticipate that he will gain about 1 Ib/day now that he is on continuous feedings." C. "It is important to keep the head of his bed elevated or sit him in the chair during feedings." D. "| should use prepared or open formula within 24 hours and store unused portions in the refrigerator." Correct Answer: B (A) Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. (B) A consistent weight gain of more than 0.22 kg/day (12 |b/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. (C) Elevating the clients head prevents reflux and thus formula from entering the airway. (D) Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis. Question 149 A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as "a cramp in my leg." An appropriate nursing action is to: A. Assess for pain with plantiflexion B. Assess for edema and heat of the right leg C. Instruct him to rub the cramp out of his leg D. Elevate right lower extremity with pillows propped under the knee Correct Answer: B (A) Calf pain with dorsiflexion of the foot (Homans sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. (B) Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall. (C) Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. (D) A pillow behind the knee can be constricting and further impair blood flow. B. Rinse the mouth and gargle with warm water after each use of the inhaler C. Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection D. Rinse the mouth before each use to eliminate colonization of bacteria Correct Answer: B (A) It is sufficient to rinse the plastic holders with warm water at least once per day. (B) It is important to rinse the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid left in the oral cavity. (C) Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the stomach. "Neutralizing" the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of fungal infections. (D) Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral mucous membranes following the use of the inhaler. Question 155 Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to: A. Eat high-calorie, high-protein foods B. Take vitamin supplementation C. Eliminate intake of milk and milk products D. Eat small, frequent meals Correct Answer: C (A) Protein is vital for the maintenance of muscle to aid in breathing. A high-calorie diet using higher fat than carbohydrate content is given because clients are unable to breathe off the excess CO2that is an end product of carbohydrate metabolism. (B) Inadequate nutritional status, in particular, deficiencies in vitamins A and C, decreases resistance to infection. (C) Milk does not make mucus thicker. It may coat the back of the throat and make it feel thicker. Rinsing the mouth with water after drinking milk will prevent this problem. (D) Small, frequent meals minimize a fullness sensation and reduce pressure on the diaphragm. The work of breathing and SOB are also reduced. Question 156 A dose of theophylline may need to be altered if a client with COPD: A. ls allergic to morphine B. Has a history of arthritis C. Operates machinery D. Is concurrently on cimetidine for ulcers Correct Answer: D (A) The effects of morphine or an allergic response to the drug will not affect theophylline clearance. (B) Xanthines are used cautiously in clients with severe cardiac disease, liver disease, cor pulmonale, hypertension, or hyperthyroidism. Arthritis does not influence the dosage of theophylline. (C) Theophylline does not cause sedation or drowsiness. Conversely, its side effects may be exhibited by central nervous system stimulation. (D) Cimetidine decreases theophylline clearance from the system and increases theophylline levels in the blood, thus increasing the risk of toxicity. Question 157 The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because: A. Immediate treatment of mild PIH includes the administration of a variety of medications B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation C. Self-discipline is required to control caloric intake throughout the pregnancy D. The client may not recognize the early symptoms of PIH Correct Answer: D (A) Mild PIH is not treated with medications. (B) Emotional stress is not the cause of blood pressure elevation in PIH. (C) Excessive caloric intake is not the cause of weight gain in PIH. (D) The client most frequently is not aware of the signs and symptoms in mild PIH. Question 158 Which of the following changes in blood pressure readings should be of greatest concern to the nurse when assessing a prenatal client? A. 130/88 to 144/92 B. 136/90 to 148/100 C. 150/96 to 160/104 D. 118/70 to 130/88 Correct Answer: D (A, B, C) The individuals systolic and diastolic changes are more significant than the relatively high initial blood pressure readings. (D) The systolic pressure went up 12 mm Hg and the diastolic pressure 18 mm Hg. This is a more significant rise than the increases in AC choices, and client should receive more frequent evaluations and care. Question 159 A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 Ib from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The clients weight increase is most likely due to: A. Overeating and subsequent obesity B. Obesity prior to conception C. Hypertension due to kidney lesions D. Fluid retention Correct Answer: D (A) Overeating can lead to obesity, but not to edema. (B) There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. (C) Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. (D) The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH. Question 160 MgS04 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and: A. Vasoconstrictive B. Vasodilative C. Hypertensive D. Antiemetic Correct Answer: B (A) An anticonvulsant effect is the goal of drug therapy for PIH. However, we would not want to increase the vasoconstriction that is already present. This would make the symptoms more severe. (B) An anticon-vulsant effect and vasodilation are the desired outcomes when Question 165 In addition to changing the mothers position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina: A. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying. B. Cover the cord with a wet sponge. C. Apply a cord clamp to the exposed cord, and cover with a sterile towel. D. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses. Correct Answer: D (A) Saline should be warmed; waiting 15 minutes may not keep the cord moist. (B) This choice does not specify what the sponge was "wet" with. (C) This measure would stop circulation to the fetus. (D) The cord should be kept warm and moist to maintain fetal circulation. This measure is an accepted nursing action. Question 166 Which of the following signs might indicate a complication during the labor process with vertex presentation? A. Fetal tachycardia to 170 bpm during a contraction B. Nausea and vomiting at 8-10 cm dilation C. Contraction lasting 60 seconds D. Appearance of dark-colored amniotic fluid Correct Answer: D (A) Fetal tachycardia may indicate fetal hypoxia; however, 170 bpmis only mild tachycardia. (B) Nausea and vomiting occur frequently during transition and are not a complication. (C) Contractions frequently last 6090 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. (D) Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part. Question 167 A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurses first intervention should be to: A. Check FHT B. Notify the attending physician C. Turn off the IV oxytocin D. Prepare for the delivery because the client is probably in transition Correct Answer: C (A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Womens Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D) Contractions lasting 6090 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor. Question 168 During a clients first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. This may be due to: A. Endometritis B. Fibroid tumor on the uterus C. Displacement due to bowel distention D. Urine retention or a distended bladder Correct Answer: D (A, B) Endometritis, urine retention, or bladder distention provide good distractors because they may delay involution but do not usually cause the uterus to be lateral. (C) Bowel distention and constipation are common in the postpartum period but do not displace the uterus laterally. (D) Urine retention or bladder distention commonly displaces the uterus to the right and may delay involution. Question 169 The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay? A. Pulse rate of 50-70 bpm by her third postpartum day B. Diuresis by her second or third postpartum day C. Vaginal discharge or rubra, serosa, then rubra D. Diaphoresis by her third postpartum day Correct Answer: C (A) Bradycardia is an expected assessment during the postpartum period. (B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. (C) A return of rubra after the serosa period may indicate a postpartal complication. (D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state. Question 170 A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of: A. Afterbirth pains B. Constipation C. Cystitis D. A hematoma of the vagina or vulva Correct Answer: D (A) Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. (B) Constipation may cause rectal pressure but is not usually associated with "severe pain." (C) Cystitis may cause pain, but the location is different. (D) Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client. Question 171 After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurses appropriate response is: A. "No vegetable exchanges are allowed." B. "Corn and other starchy vegetables are considered to be bread exchanges." Question 176 A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest? A. A pull toy to encourage locomotion B. A mobile to improve hand-eye coordination C. A large toy with movable parts to improve pincer grasp D. Various large colored blocks to teach visual discrimination Correct Answer: A (A) Increased locomotive skills make push-pull toys appropriate for the energetic toddler. (B) Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand-eye coordination forms the foundation of other movements. (C) At age 8 months, infants begin to have pincer grasp. Toys that help infants develop the pincer grasp are recommended for this age group. (D) Various large colored blocks are suggested toys for infants 612 months of age to help visual stimulation. Question 177 A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention? A. Increased pulse rate B. Increased expectorate of secretions C. Decreased inspiratory difficulty D. Increased respiratory rate Correct Answer: C (A) A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac stimulation. (B) Medications used to treat asthma are designed to decrease bronchospasm, not to increase expectorate of secretions. (C) Epinephrine decreased inspiratory difficulty by stimulating -, 1, and 2-receptors causing sympathomimetic stimulation (e.g., bronchodilation). (D) The person with asthma fights to inspire sufficient air thus increasing respiratory rate. Question 178 Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause of this alteration? A. Altered surfactant production B. Paradoxical movements of the chest wall C. Increased airway resistance D. Continuous changes in respiratory rate and depth Correct Answer: C (A) Altered surfactant production is found in sudden infant death syndrome. (B) Paradoxical breathing occurs when a negative intrathoracic pressure is transmitted to the abdomen by a weakened, poorly functioning diaphragm. (C) Asthma is characterized by spasm and constriction of the airways resulting in increased resistance to airflow. (D) If the pulmonary tree is obstructed for any reason, inspired air has difficulty overcoming the resistance and getting out. The rate of respiration increases in order to compensate, thus increasing air exchange. Question 179 A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to: A. Give the child 15 mL of syrup of ipecac. B. Give the child 10 mL of syrup of ipecac with a sip of water. C. Give the child 1 cup of water to induce vomiting. D. Bring the child to the ER immediately. Correct Answer: D (A) Before giving any emetic, the substance ingested must be known. (B) At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. (C) Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. (D) Vomiting should never be induced in an unconscious client because of the risk of aspiration. Question 180 A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate? A. Put in a nasogastric tube and lavage the child’s stomach. B. Monitor muscular status. C. Teach mother poison prevention techniques. D. Place child on respiratory assistance. Correct Answer: A (A) The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The childs unconscious state prohibits forced emesis. (B) Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. (C) The mothers anxiety is probably so high that preventive guidance will be ineffective. (D) Respiratory assistance is not needed if the childs respiratory function is unaltered. Question 181 A parent told the public health nurse that her 6-year-old son has been taking tetracycline for a chronic skin condition. The parent asked if this could cause any problems for the child. What should the nurse explain to the parent? A. Giving tetracycline to a child younger than 8 years may cause permanent staining of his teeth. B. If you give tetracycline with milk, it may be absorbed readily. C. The medication should be given to adults, not children. D. Secondary infections of chronic skin disorders do not respond to antibiotics. Correct Answer: A (A) Tetracycline should be avoided during tooth development because it interferes with enamel formation and dental pigmentation. (B) Milk interferes with the absorption of tetracyclines. (C) Children older than 9 years or past the tooth development stage may be given tetracycline. (D) Secondary infections of chronic skin disorders may respond to antibiotics such as penicillin or tetracyclines. Question 182 A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation? A. Responsive to touch, wants to be held B. Uncomforted by touch, refuses bottle C. Maintains eye-to-eye contact D. Finicky eater, easily pacified, cuddly A. Place a tongue blade in the child’s mouth. B. Restrain the child so he will not injure himself. C. Go to the nurses station and call the physician. D. Move furniture out of the way and place a blanket under his head. Correct Answer: D (A) The nurse should not put anything in the childs mouth during a seizure; this action could obstruct the airway. (B) Restraining the childs movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head. Question 187 A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes? A. Oral B.IM C.IV D. Aerosol Correct Answer: D (A) Ribavirin is not supplied in an oral form. (B) Ribavirin is administered by aerosol in order to decrease the duration of viral shedding within the infected tissue. (C) Ribavirin is not approved for IV use to treat respiratory syncytial virus. (D) Ribavirin is a synthetic antiviral agent supplied as a crystalline powder that is reconstituted with sterile water. A Small Aerosol Particle Generator unit aerosolizes the medication for delivery by oxygen hood, croup tent, or aerosol mask. Question 188 A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications? A. Fluid volume deficit B. Fluid volume excess C. Decreased cardiac output D. Severe hypotension Correct Answer: B (A) Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. (B) Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. (C) Increased cardiac output results as fluids shift back to the vascular compartment. (D) Hypertension is the result of hypervolemia. Question 189 Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and full thickness burns to 25% of her body? A. Urine output B. Edema C. Hypertension D. Bulging fontanelle Correct Answer: A (A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. (B) Edema is an indication of increased capillary permeability following a burn injury. (C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age. Question 190 A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the childs mother for the home treatment of croup? A. Take him in the bathroom, turn on the hot water, and close the door. B. Give him a dose of antihistamine. C. Give large amounts of clear liquids if drooling occurs. D. Place him near a cool mist vaporizer and encourage crying. Correct Answer: A (A) Initial home treatment of croup includes placing the child in an environment of high humidity to liquefy and mobilize secretions. (B) Antihistamines should be avoided because they can cause thickening of secretions. (C) Drooling is a characteristic sign of airway obstruction and the child should be taken directly to the emergency room. (D) Crying increases respiratory distress and hypoxia in the child with croup. The nurse should promote methods that will calm the child. Question 191 A 7-year-old child is brought to the ER at midnight by his mother after symptoms appeared abruptly. The nurse's initial assessment reveals a temperature of 104.5°F (40.3°C), difficulty swallowing, drooling, absence of a spontaneous cough, and agitation. These symptoms are indicative of which one of the following? A. Acute tracheitis B. Acute spasmodic croup C. Acute epiglottis D. Acute laryngotracheobronchitis Correct Answer: C (A) Clinical manifestations of acute tracheitis include a 23 day history of URI, croupy cough, stridor, purulent secretions, high fever. (B) Clinical manifestations of spasmodic croup include a history of URI, croupy cough, stridor, dyspnea, low-grade fever, and a slow progression. The age group most affected is 3 months to 3 years. (C) Three clinical observations have been found to be predictive of epiglottitis: the presence of drooling, absence of spontaneous cough, and agitation. Epiglottitis has a rapid onset that is accompanied by high fever and dysphagia. (D) Clinical manifestations of acute laryngotracheobronchitis (LTB) include slow onset with a history of URI, low-grade fever, stridor, brassy cough, and irritability. Question 196 A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with: A. Transient depression B. Mild depression C. Moderate depression D. Severe depression Correct Answer: D (A) Transient depression manifests as sadness or the "blues" as seen with everyday disappointments and is not necessarily dysfunctional. (B) Mild depression manifests as symptoms seen with grief response, such as denial, sadness, withdrawal, somatic symptoms, and frequent or continuous thoughts of the loss. (C) Moderate depression manifests as feelings of sadness, negativism; low self-esteem; rumination about lifes failures; decreased interest in grooming and eating; and possibly sleep disturbances. These symptoms are consistent with dysthymia. (D) Severe depression manifests as feelings of total despair, hopelessness, emptiness, inability to feel pleasure; possibly extreme psychomotor retardation; inattention to hygiene; delusional thinking; confusion; self-blame; and suicidal thoughts. These symptoms are consistent with major depression. Question 197 A 56-year-old psychiatric inpatient has had recurring episodes of depression and chronic low self- esteem. She feels that her family does not want her around, experiences a sense of helplessness, and has a negative view of herself. To assist the client in focusing on her strengths and positive traits, a strategy used by the nurse would be to: A. Tell the client to attend all structured activities on the unit B. Encourage or direct client to attend activities that offer simple methods to attain success C. Increase the client’s self-esteem by asking that she make all decisions regarding attendance in group activities D. Not allow any dependent behaviors by the client because she must learn independence and will have to ask for any assistance from staff Correct Answer: B (A) The nurse should encourage activities gradually, as clients energy level and tolerance for shared activities improve. (B) Activities that focus on strengths and accomplishments, with uncomplicated tasks, minimize failure and increase self-worth. (C) Asking a client to set a goal to make all decisions about attending group activities is unrealistic, and such decisions are not always under the clients control; this sets up the client for further failure and possibly decreased self-worth. (D) Encouragement toward independence does promote increased feelings of selfworth; however, clients may need assistance with decision making and problem solving for various situations and on an individual basis. Question 198 A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, "I just couldn't take it anymore." The nurse's best response to this disclosure would be: A. "You shouldn't do things like that, just tell someone you feel bad." B. "Tell me more about what you couldn't take anymore." C. "I’m sure you probably didn’t mean to kill yourself." D. "How long have you been in the hospital." Correct Answer: B (A) Disapproving gives the impression that the nurse has a right to pass judgment on the clients thoughts, actions, or ideas. (B) Giving a broad opening gives the client encouragement to continue with verbalization. (C) Failing to acknowledge the clients feelings conveys a lack of understanding and empathy. (D) Changing the subject takes the conversation away from the client and is indicative of the nurses anxiety or insensitivity. Question 199 A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurses intervention would be to: A. Confront the client with the fact that she will have to eat more from her tray to sustain her B. Try to get the client to focus on her eating by offering a detailed discussion on the importance of nutrition C. Let her have snacks and drinks anytime that she wants them because she will not eat at regular meal times D. Not expect the client to sit down for complete meals; monitor intake, offering snacks and juice frequently Correct Answer: D (A) The manic clients mood may easily change from euphoric to irritable. The nurse should avoid confrontation and let the client know what she can do, rather than what she cannot. (B) Although helpful to refocus or redirect the manic client to discuss only one topic at a time, distractibility is very high and its best to avoid long discussions. (C) Manic clients have a tendency to manipulate persons in their environment. Staff should monitor intake, including at mealtime and snacks, and be consistent in their approach to meeting nutritional needs. (D) Manic clients may not sit and eat complete meals, but they can carry foods and liquids from regular meals with them. Staff can monitor and give high-caloric and high-energy snacks and liquids. Question 200 Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the clients depression alert the nurse to prioritize problems and care by addressing which of the following problems first: A. Nutritional status B. Impaired thinking C. Possible harm to self D. Rest and activity impairment Correct Answer: C (A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine clients sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present. Question 201 The nurse is assessing and getting a history from a client treated for depression with a monoamine oxidase (MAO) antidepressant. The most serious side effect associated with this antidepressant and the ingestion of tyramine in aged foods may be: A. Hypertensive crisis B. Severe rash D. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat. Correct Answer: A (A) Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. (B) Distraction does not focus on the clients need for control. (C) Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. (D) Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior. Question 206 A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, "| know that alcohol is a problem for some people, but | can stop whenever | want to. I’m never sick or miss work, and no one can complain about me." During the initial assessment, the best response by the nurse would be: A. "The fact is you are an alcoholic or you wouldn't be here." B. "| understand it took strength to admit yourself to the unit, and | will do my part to help you to stay alcohol- free." C. "If you can stop drinking when you want to, why don’t you stop?" D. "It’s good that you can stop drinking when you want to." Correct Answer: B (A) Direct confrontation initially is nontherapeutic and may result in the client becoming frustrated and wanting to leave. (B) A positive, supportive attitude builds trust, and identifying positive strength raises self-esteem. Offering help allows the client to feel that he is not alone in dealing with problems. (C) Asking the client why or to give an explanation for his behavior puts him in a position of having to justify his behavior to the nurse. (D) Giving approval or placing a value on feelings or a behavior may limit the clients freedom to behave in a way that may displease another. This response may lead to seeking praise instead of progress. Question 207 A 79-year-old client with Alzheimer’s disease is exhibiting significant memory impairment, cognitive impairment, extremely impaired judgment in social situations, and agitation when placed in a new situation or around unfamiliar people. The nurse should include the following strategy in the client’s care: A. Maintain routines and usual structure and adhere to schedules. B. Encourage the client to attend all structured activities on the unit, whether she wants to or not. C. Ask the client to go to an activity once. If she gives no response right away, change the question around, asking the same thing. D. Give the client two or three choices to decide what she wants to do. Correct Answer: A (A) Alzheimers clients cope poorly with changes in routine because of memory deficits. Schedule changes cause confusion and frustration, whereas adhering to schedules is helpful and supports orientation. (B) Insisting that the client go to all unit activities may antagonize her and increase her agitation because of cognitive impairments. It may be better to allow the client time for calming down or distraction rather than to insist that she attend every activity. (C) When repeating a question, allow time first for a response; then use the same words the second time to avoid further confusion. (D) The nurse should avoid giving several choices at once. Cognitively impaired clients will become more frustrated with making decisions. Question 208 The nurse working with a client who is out of control should follow a model of intervention that includes which of the following? A. Approach the client on a continuum of least restrictive care. B. Challenge client’s behavior immediately with steps to prevent injury to self or others. C. Leave the aggressive client to himself or herself, and take other clients away. D. To ensure safety of other clients, place client in seclusion immediately when he or she begins shouting. Correct Answer: A (A) Approaching a clients aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). (B) Approaching a client in a challenging manner is threatening and inappropriate. A nonchallenging and calm approach reflects staff in control and may increase clients internal control. (C) It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. (D) Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention. Question 209 When planning care for the passive-aggressive client, the nurse includes the following goal: A. Allow the client to use humor, because this may be the only way this client can express self. B. Allow the client to express anger by using "I" messages, such as "I was angry when . . .," etc. C. Allow the client to have time away from therapeutic responsibilities. D. Allow the client to give excuses if he forgets to give staff information. Correct Answer: B (A) Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. (B) Use of "I" messages demonstrates proper use of assertive behavior to express anger instead of passive- aggressive behavior. (C) Client is expected to complete share of work in therapeutic community because he has often obstructed others efforts by failing to do his share. (D) Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable. Question 210 A client calls the prenatal clinic to schedule an appointment. She states she has missed three menstrual periods and thinks she might be pregnant. During her first visit to the prenatal clinic, it is confirmed that she is pregnant. The registered nurse (RN) learns that her last menstrual period began on June 10. According to Ngeles rule, the estimated date of confinement is: A. March 17 B. June 3 C. August 30 D. January 10 Correct Answer: A (A) Using Ngeles rule, count back 3 calendar months from the first day of the last menstrual period. The answer is March 10. Then add 7 days and 1 year, which would be March 17 of the following year. (B, C, D) This date is incorrect. Question 211 At 16 weeks gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to: (A) Ritodrine is a sympathomimetic 2-adrenergic agonist that can cause an elevation of blood glucose and plasma insulin in pregnant women. Hyperglycemia can occur in women with abnormal carbohydrate metabolism because of their inability to release more insulin. (B) Hypokalemia can occur resulting from the action of the _-mimetics. It results from a displacement of the extracellular potassium into the intracellular space. (C) Ritodrine causes vasodilation of vessel walls, which can lead to hypotension. The body compensates by increasing heart rate and pulse pressure. (D) There is a lowering of serum iron resulting from the action of _- mimetics to activate hematopoiesis. Question 215 At 32 weeks’ gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, "How do | prepare for the test | am scheduled for?" The RN will most likely inform her of the following instructions to help prepare her for the test: A. "You need to know that an IV is always started before the test." B. "You will need to drink 6 to 8 glasses of water to fill your bladder." C. "Do not eat any food or drink any liquids before the test is started." D. "You will have to remain as still as you possibly can." Correct Answer: D (A) An IV line is not started in a nonstress test, because this test is used as an indicator of fetal well- being. This test measures fetal activity and heart rate acceleration. (B) The bladder does not have to be full prior to this test. It is not a sonogram test where a full bladder enables other structures to be scanned. (C) It has been proved that eating or drinking liquids prior to the test can assist in increasing fetal activity. (D) Any maternal activity will interfere with the results of the test. Question 216 After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted 15 seconds and occurred 3 times during the 20- minute test. The RN knows that these test results will be interpreted as: A. A reactive test B. A nonreactive test C. An unsatisfactory test D. A negative test Correct Answer: A (A) A nonstress test that shows at least two accelerations of the fetal heart rate of 15 bpm with fetal activity, lasting 15 seconds over a 20- minute period. (B) Reactive criteria are not met. The accelerations of the fetal heart rate are not at least 15 bpm and do not last 15 seconds. This could mean fetal well-being is compromised. Usually a contraction stress test is ordered if the nonstress test results are negative. (C) An unsatisfactory test means the data cannot be interpreted, or there was inadequate fetal activity. If this happens, usually the test is ordered to be done at a later date. (D) A negative test is a term used to describe the results of a contraction stress test. Question 217 At 38 weeks gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing? A. "lam cold." B. "| have a backache." C. "| feel dizzy." D. "| am nauseous.” Correct Answer: C (A) Cold is not a symptom of hyperventilation. This could be due to the temperature of the room. (B) Backache is not a symptom of hyperventilation. This is probably due to the gravid uterus and its effect on the back muscles, or it may be due to the clients position in bed. (C) Dizziness is the first symptom of hyperventilation. It occurs because the body is eliminating too much C02. (D) Nausea is not a symptom of hyperventilation. It could be a symptom of pain. Question 218 After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis? A. One centimeter below the ischial spines B. One centimeter above the ischial spines C. Has not entered the pelvic inlet yet D. Located in the pelvic outlet Correct Answer: B (A) The ischial spines are located on both sides of the midpelvis. These spines mark the diameter of the narrowest part of the pelvis that the fetus will encounter. They are not sharp protrusions that will harm the fetus. Station refers to the relationship between the ischial spines in the pelvis and the fetus. The ischial spines are designated at 0 station. If the presenting part of the fetus is located above the ischial spines, a negative number is assigned, noting the number of centimeters above the ischial spines. Therefore, 1 centimeter below the ischial spines is designated as +1 station. (B) See explanation in A. One centimeter above the ischial spines is designated as +1 station. (C) The pelvic inlet is the first part of the pelvis that the fetus enters in routine delivery. The midpelvis is the second part of the pelvis to be entered by the fetus. The ischial spines are located on both sides of the midpelvis. (D) The pelvic outlet is the last part of the pelvis that the fetus will enter. When the fetus reaches this part of the pelvis, birth is near. Question 219 A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the clients fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process: A. Decreases the overall time of the labor process B. Prolongs the client's first stage of labor C. Decreases the time of the client's first stage of labor D. Prolongs the client’s third stage of labor Correct Answer: B (A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an anterior position. Pressure on the sacral nerves is increased, and it takes the fetus a longer time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the larger diameter of the fetal head enters the pelvis first, it will have a more difficult time accommodating to the pelvis; therefore, it will take a longer time for the fetus to move through the pelvis. (C) It will increase the time of labor because the larger diameter of the fetal head will have a more difficult time accommodating to the pelvic inlet and thus will move through the pelvis slower. (D) In the third stage of labor the placenta is delivered; therefore, the infant has been delivered.