A baby boy was born at 2:45 A.M. after a 35-week gestation. He weighed

NCLEX Maternal Newborn

Home / Nursing & Allied Health Certifications / NCLEX PN / Maternal-Newborn

Question 1 of 5.

A baby boy was born at 2:45 A.M. after a 35-week gestation. He weighed 1170 g. Upon admission to the premature nursery, he had slight respiratory distress, nasal flaring, grunting, intercostal retractions, and slight cyanosis. Apgar score at one minute was 4, and at five minutes, it was 6. Apical pulse is 164, respirations are 44, and axillary temperature is 96°F. What was the most likely cause of the baby's cyanosis?

A. Increased serum concentration of bilirubin

B. Inadequate oxygenation of arterial blood

C. Excessive number of red cells

D. Lack of subcutaneous fatty tissue

Explanation: Cyanosis in a preterm infant with respiratory distress is due to inadequate oxygenation from immature lungs.

Question 2 of 5.

The nurse is caring for a woman who had a hysterectomy. Which vascular complication should the nurse be especially alert for because of the location of the surgery?

A. Thrombophlebitis

B. Varicose veins

C. Cerebral embolism

D. Aortic aneurysm

Explanation: Pelvic surgery, like a hysterectomy, increases the risk of thrombophlebitis due to venous stasis and surgical trauma.

Question 3 of 5.

A woman is to have internal radiation as part of her treatment for cancer of the cervix. In teaching her about the preoperative preparation for this procedure, the nurse should include which information?

A. A high-residue diet will be ordered.

B. An indwelling catheter will be inserted.

C. A nasogastric tube will be inserted.

D. Several units of blood will be ready for transfusion if needed.

Explanation: An indwelling catheter is inserted to keep the bladder empty, reducing radiation exposure to nearby organs.

Question 4 of 5.

A young woman asks the nurse if oral contraceptives have any side effects. What is the best response for the nurse to make?

A. Nausea, fluid retention, and weight gain.'

B. Why do you ask? Look at the benefits.'

C. Are you concerned about something?'

D. Increased libido, decreased breast size, and diarrhea.'

Explanation: Nausea, fluid retention, and weight gain are common side effects of oral contraceptives, providing accurate information.

Question 5 of 5.

The nurse is discussing breast self-examination with a group of women in a clinic. One woman asks, 'When should I do this examination?' What is the best response for the nurse?

A. You should perform breast self-examination early in the morning for most accurate results.'

B. Breast self-examination should be done a few days after your period begins every month.'

C. Breast self-examination should be done by women after the age of 40 on the first of every month.'

D. Breast self-examination is best done just before you expect your menstrual period.'

Explanation: Performing breast self-examination a few days after menstruation, when breasts are less tender, ensures accuracy.