NCLEX NCLEX-RN Exam Questions & Answers

Correct Answer: D

(A) In pulling the infant away from the breast without breaking suction, nipple trauma is likely to occur. (B) In pulling the breast away from the infant without breaking suction, nipple trauma is likely to occur. (C) Compressing the maternal tissue does not break the suction of the infant on the breast and can cause nipple trauma. (D) By inserting a finger into the infant's mouth beside the nipple, the lactating mother can break the suction and the nipple can be removed without trauma.

Correct Answer: D

(A) Acetaminophen (Tylenol) has analgesic and antipyretic actions approximately equivalent to those of aspirin. It produces analgesia possibly by action on the peripheral nervous system. It reduces fever by direct action on the hypothalamus heat-regulating center with consequent peripheral vasodilation. It is generally used for temporary relief of mild to moderate pain, such as a simple headache, minor joint and muscle pains, and control of fever. (B) Meperidine is a narcotic agonist analgesic with properties similar to morphine except that it has a shorter duration of action and produces less depression of urinary retention and smooth muscle spasm. It is used for moderate to severe pain, for a preoperative medication, for support of anesthesia, and for obstetrical analgesia. In a postoperative TURP client, it would be used in conjunction with other medications for relief of moderate to severe pain, but not specifically for bladder spasms associated with TURP surgery. (C) Promethazine hydrochloride is an antihistamine, antiemetic preparation. It exerts antiserotonin, anticholinergic, and local anesthetic actions. It is used for symptomatic relief of various allergic conditions, motion sickness, nausea, and vomiting. It is used for preoperative, postoperative, and obstetrical sedation and as an adjunct to analgesics for control of pain. (D) This answer is correct because aminocaproic acid is prescribed specifically for hematuria. Aminocaproic acid is excreted in the urine. The nurse should be alert for possible signs of thrombosis, particularly in the extremities.

Correct Answer: D

(A) Assessing the quantity of amniotic fluid is important as an indication of maternal fetal well-being, but it does not take priority over assessment of FHR. (B) Greenish-brown discoloration of amniotic fluid indicates presence of meconium.

Foul odor may indicate presence of infection. Both of these are important assessment data, but they do not take priority over possible lifethreatening compression of the umbilical cord. (C) Documentation is important, but it does not take priority over the possible life-threatening compression of the umbilical cord. (D) If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.