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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 20 )

Updated On: 12-Jan-2026
Page 20 of 345
PDF with 862 Questions

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?

  1. "I am cold."
  2. "I have a backache."
  3. "I feel dizzy."
  4. "I am nauseous."

Answer(s): C

Explanation:

(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 client's position in bed. (C) Dizziness is the first symptom of hyperventilation. It occurs because the body is eliminating too much CO2. (D) Nausea is not a symptom of hyperventilation. It could be a symptom of pain.



A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:

  1. Decreases the overall time of the labor process
  2. Prolongs the client's first stage of labor
  3. Decreases the time of the client's first stage of labor
  4. Prolongs the client's third stage of labor

Answer(s): B

Explanation:

(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.



A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?

  1. 5 mg
  2. 0.5 mg
  3. 0.05 mg
  4. 20 mg

Answer(s): A

Explanation:

(A) 1 mg = 0.1 mL, then 0.5 mL X= 55 mg. (B) Thisanswer is a miscalculation. (C) This answer is a miscalculation. (D) This answer is a miscalculation.



A mother who is breast-feeding her newborn asks the RN, "How can I express milk from my breasts manually?" The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to:

  1. Alternately compress and release each nipple
  2. Roll the nipple and gently pull the nipple forward
  3. Slide the thumb and index finger forward from the outer border of the areola toward the end of the nipple
  4. Compress and release each breast at the outer border of the areola

Answer(s): D

Explanation:

(A) Manipulation of nipples will cause soreness and trauma. (B) Pulling the nipples will cause discomfort and soreness. (C) Sliding the thumb and index finger forward over the nipple will cause soreness. (D) The best method to express milk from the breast is to position the thumb and index finger at the outer border of the areola and compress. This is the location of the milk sinuses.



A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?

  1. Bulging fontanelles
  2. Seizure
  3. Headache
  4. Ataxia

Answer(s): C

Explanation:

(A) Bulging fontanelles are a symptom of increased intracranial pressure in infants. (B) Seizure is a late sign of increased intracranial pressure. (C) Headache is a very early symptom of increased intracranial pressure in the child. (D) Ataxia is a late sign of increased intracranial pressure.



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