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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 51 )

Updated On: 12-Jan-2026
Page 51 of 345
PDF with 862 Questions

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 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 schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, "My doctor is in love with me and wants to marry me." This client is using which of the following defense mechanisms?

  1. Displacement
  2. Projection
  3. Reaction formation
  4. Suppression

Answer(s): B

Explanation:

(A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing one's thoughts or feelings to another person. (C) Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant thoughts or experiences.
Topic 2, Question Set B



A client has been diagnosed as being preeclamptic. The physician orders magnesium sulfate. Magnesium sulfate (MgSO4) is used in the management of preeclampsia for:

  1. Prevention of seizures
  2. Prevention of uterine contractions
  3. Sedation
  4. Fetal lung protection

Answer(s): A

Explanation:

(A) MgSO4 is classified as an anticonvulsant drug. In preeclampsia management, MgSO4 is used for prevention of seizures. (B) MgSO4 has been used to inhibit hyperactive labor, but results are questionable. (C) Negative side effects such as respiratory depression should not be confused with generalized sedation. (D) MgSO4 does not affect lung maturity. The infant should be assessed for neuromuscular and respiratory depression.



The nurse is aware that nutrition is an important aspect of care for a client with hepatitis. Which of the following diets would be most therapeutic?

  1. High protein and low carbohydrate
  2. Low calorie and low protein
  3. High carbohydrate and high calorie
  4. Low carbohydrate and high calorie

Answer(s): C

Explanation:

(A) Protein increases the workload of the liver. Increased carbohydrates provide needed calories and promote palatability. (B) Dietary intake should be adequate to ensure wound healing. (C) Increased carbohydrates provide needed calories. (D) A highcalorie diet is best obtained from carbohydrates because of their palatability. Fats increase the workload of the liver.



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