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NCLEX NCLEX-RN Exam Questions
National Council Licensure Examination - NCLEX-RN (Page 42 )

Updated On: 10-Mar-2026
Page 42 of 345
PDF with 862 Questions

A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting
15 seconds. The nurse interprets this test to be:

  1. Nonreactive
  2. Reactive
  3. Positive
  4. Negative

Answer(s): B

Explanation:

(A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at least two accelerations of FHR with fetal movements, each 15 bpm, lasting 15 seconds or more, over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or oxytocin challenge test, not an NST.



A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting
15 seconds. The nurse interprets this test to be:

  1. Nonreactive
  2. Reactive
  3. Positive
  4. Negative

Answer(s): B

Explanation:

(A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at least two accelerations of FHR with fetal movements, each 15 bpm, lasting 15 seconds or more, over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or oxytocin challenge test, not an NST.



The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1­2 minutes; strong, large amount of "bloody show." The most appropriate nursing goal for this client would be:

  1. Maintain client's privacy.
  2. Assist with assessment procedures.
  3. Provide strategies to maintain client control.
  4. Enlist additional caregiver support to ensure client's safety.

Answer(s): C

Explanation:

(A) Privacy may help the laboring client feel safer, but measures that enhance coping take priority. (B) The frequency of assessments do increase in transition, but helping the client to maintain control and cope with this phase of labor takes on importance. (C) This laboring client is in transition, the most difficult part of the first stage of labor because of decreased frequency, increased duration and intensity, and decreased resting phase of the uterine contraction. The client's ability to cope is most threatened during this phase of labor, and nursing actions aredirected toward helping the client to maintain control. (D) Safety is a concern throughout labor, but helping the client to cope takes on importance in transition.



The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1­2 minutes; strong, large amount of "bloody show." The most appropriate nursing goal for this client would be:

  1. Maintain client's privacy.
  2. Assist with assessment procedures.
  3. Provide strategies to maintain client control.
  4. Enlist additional caregiver support to ensure client's safety.

Answer(s): C

Explanation:

(A) Privacy may help the laboring client feel safer, but measures that enhance coping take priority. (B) The frequency of assessments do increase in transition, but helping the client to maintain control and cope with this phase of labor takes on importance. (C) This laboring client is in transition, the most difficult part of the first stage of labor because of decreased frequency, increased duration and intensity, and decreased resting phase of the uterine contraction. The client's ability to cope is most threatened during this phase of labor, and nursing actions aredirected toward helping the client to maintain control. (D) Safety is a concern throughout labor, but helping the client to cope takes on importance in transition.



A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:

  1. Explain that he will be kept NPO for 24 hours before the exam
  2. Practice with him so he will be able to hold his breath for 1 minute
  3. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
  4. Explain that his vital signs will be checked frequently after the test

Answer(s): D

Explanation:

(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.



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