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Free NCLEX-RN Exam Braindumps (page: 208)

Page 208 of 431
PDF with 862 Questions

A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:

  1. Decreased cardiac output related to excessive bleeding
  2. Potential for fluid volume excess related to fluid resuscitation
  3. Anxiety related to threat to self
  4. Alteration in parenting related to potential fetal injury

Answer(s): A

Explanation:

(A) Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. (B) This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. (C) The client's expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. (D) Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother or the fetus. Delivery of the fetus will be postponed until fetal maturity is achieved and survival is likely.



A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:

  1. Decreased cardiac output related to excessive bleeding
  2. Potential for fluid volume excess related to fluid resuscitation
  3. Anxiety related to threat to self
  4. Alteration in parenting related to potential fetal injury

Answer(s): A

Explanation:

(A) Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. (B) This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. (C) The client's expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. (D) Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother or the fetus. Delivery of the fetus will be postponed until fetal maturity is achieved and survival is likely.



A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that:

  1. Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices
  2. Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods
  3. It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily
  4. He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds. Milk intake should be limited to 1 qt/day

Answer(s): D

Explanation:

(A) If the infant is given the bottle first, he will be less likely to be hungry enough to eat the solid foods. (B) Milk is deficient in iron, vitamin C, zinc, and fluoride. It does not provide an adequate diet. (C) The vitamin supplement will help, but the infant needs an iron supplement. (D) Giving the solid food when the infant is hungriest will increase the likelihood that he will eat. The more solid food he takes, the less milk he will desire.



A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that:

  1. Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices
  2. Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods
  3. It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily
  4. He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds. Milk intake should be limited to 1 qt/day

Answer(s): D

Explanation:

(A) If the infant is given the bottle first, he will be less likely to be hungry enough to eat the solid foods. (B) Milk is deficient in iron, vitamin C, zinc, and fluoride. It does not provide an adequate diet. (C) The vitamin supplement will help, but the infant needs an iron supplement. (D) Giving the solid food when the infant is hungriest will increase the likelihood that he will eat. The more solid food he takes, the less milk he will desire.



Page 208 of 431



Post your Comments and Discuss NCLEX NCLEX-RN exam with other Community members:

Naveen Ahlam commented on November 29, 2024
Great stuff
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Isadora Guimarães commented on November 10, 2024
Very good to study
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Marydee commented on April 02, 2020
Just purchased, will see if it is the real deal. Will give a further update later!
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