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Test Prep NCLEX-PN Exam
National Council Licensure Examination(NCLEX-PN) (Page 14 )

Updated On: 30-Jan-2026
Page 14 of 204
PDF with 1015 Questions

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.



While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?

  1. Ask the parents to allow the infant to lay on her stomach to promote muscle development.
  2. Notify the physician because a developmental or neurological evaluation is indicated.
  3. Document the findings as normal in the nurse’s notes.
  4. Explain to the parents that their child is likely to be mentally retarded.

Answer(s): B

Explanation:

Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation.
Laying the infant on her stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. These findings are not normal for a 6- month-old infant.
Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurologic and other metabolic disorders. Some of those disorders might have mental retardation as a component.
However, this child needs to have the referral to determine the cause of the head lag first.



A preschooler has successfully completed the test item “counts 5 blocks” on the Denver II test. This pass is evidence of which of the following developmental concepts?

  1. centration
  2. causality
  3. nonreversibility
  4. conservation

Answer(s): D

Explanation:

The ability to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn’t change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper or moved to the paper.
Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another.
Nonreversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.



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