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Free NCLEX-PN Exam Braindumps

Which is the best way to position a client’s neck for palpation of the thyroid?

  1. flexed toward the side being examined
  2. hyperextended directly backward
  3. flexed away from the side being examined
  4. flexed directly forward

Answer(s): A

Explanation:

Flexed toward the side being examined.



A client, age 28, is 81⁄2 months pregnant.
She is most likely to display which normal skin-color variation?

  1. vitiligo
  2. erythema
  3. cyanosis
  4. chloasma

Answer(s): D

Explanation:

Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face. This hyperpigmentation results from hormonal changes.



An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client’s care plan?

  1. emotional support to help the family deal with feelings of guilt about the infant’s condition
  2. administration of MICRhoGam to the woman within 72 hours of delivery
  3. administration of Rh-immune globulin to the newborn within 1 hour of delivery
  4. lab analysis of maternal Direct Coombs’ test

Answer(s): A

Explanation:

If a woman is sensitized to the Rh factor, it poses a threat to any Rh-positive fetus she delivers.
The nurse needs to provide emotional support to help the family deal with the infant’s condition, which might involve a host of conditions that could lead to death or marked neurological damage.
RhoGam is never given to a woman already sensitized. If not previously sensitized, MICRhoGam (a smaller dose of Rh immune globulin) is given after an abortion or ectopic pregnancy to prevent sensitization. If not sensitized, RhoGam is given to the woman within 72 hours of delivery. Rh-immune globulin is never given to the newborn.
To determine if sensitization has occurred, an Indirect Coombs’ is drawn on the mother to measure the number of Rh-positive antibodies.



The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?

  1. Make a referral for grief counseling.
  2. Allow the woman to see her baby initially, and then discourage further visits.
  3. Provide opportunities for the woman to express her feelings.
  4. Inform the woman she has the right to change her mind about relinquishment.

Answer(s): C

Explanation:

Most women who relinquish their infants at birth have come to that decision with a great deal of love and pain. They have made plans in advance.
The nurse needs to first provide them with opportunities to express their feelings that might include grief, loneliness, and guilt.
A referral for grief counseling might be appropriate if no other support system exists or the mother indicates that she wants assistance working through her grief. If the nurse assesses that the grief process is abnormal, a referral is also appropriate.
The mother has probably already made a decision about whether or not she wants to see her baby. The nurse should ask her and make arrangements for that to happen if the mother requests it. Seeing the baby might aid in the grief process. Until relinquishment occurs, this is the mother’s baby and she should be allowed to see it as often as she wants. The mother does have the right to change her mind until final legal arrangements are made. But suggesting this option might lead her to think that the nurse believes she shouldn’t relinquish her baby.






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