On admission to the postpartal unit, the nurse's assessment identifies

NCLEX RN Free Practice Questions

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Question 1 of 5.

On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of:

A. Normal involution

B. A full bladder

C. An infection pain

D. A hemorrhage

Explanation: A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus.

Question 2 of 5.

The nurse is preparing to administer an injection to a six-month-old when she notices a white dot in the infant's right pupil. The nurse should:

A. Report the finding to the physician immediately.

B. Record the finding and give the infant's injection.

C. Recognize that the finding is a variation of normal.

D. Check both eyes for the presence of the red reflex.

Explanation: A white dot in the pupil (leukocoria) may indicate retinoblastoma or other serious conditions, requiring immediate reporting to the physician for evaluation.

Question 3 of 5.

A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400 mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?

A. Fever, sore throat, weakness

B. Dry mouth, constipation, blurred vision

C. Lethargy, slurred speech, thirst

D. Fatigue, drowsiness, photosensitivity

Explanation: Fever, sore throat, and weakness may indicate agranulocytosis, a serious side effect of chlorpromazine requiring immediate medical attention.

Question 4 of 5.

The physician has ordered a paracentesis for a client with severe abdominal ascites. Before the procedure, the nurse should:

A. Provide the client with a urinal

B. Prep the area by shaving the abdomen

C. Encourage the client to drink extra fluids

D. Request an ultrasound of the abdomen

Explanation: Providing a urinal ensures the bladder is empty, reducing the risk of bladder puncture during paracentesis, a priority before the procedure.

Question 5 of 5.

A new mother tells the nurse that she is getting a new microwave so that her husband can help prepare the baby's feedings. The nurse should:

A. Explain that a microwave should never be used to warm the baby's bottles.

B. Tell the mother that microwaving is the best way to prevent bacteria in the formula.

C. Tell the mother to shake the bottle vigorously for one minute after warming in the microwave.

D. Instruct the parents to always leave the top of the bottle open while microwaving so heat can escape.

Explanation: Microwaving baby bottles can cause uneven heating, leading to burns, so it should be avoided; warming under running water or in a bottle warmer is safer.