Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 77

1. A client has been diagnosed with thrombophlebitis. She asks, 'What is the most likely cause of thrombophlebitis during my pregnancy?' The nurse explains:

A) Increased levels of the coagulation factors and a decrease in fibrinolysis
B) An inadequate production of platelets
C) An inadequate intake of folic acid during pregnancy
D) An increase in fibrinolysis and a decrease in coagulation factors

2. Following the delivery of a healthy newborn, a client has developed thrombophlebitis and is receiving heparin IV. What are the signs and symptoms of a heparin overdose for which the nurse would need to observe during postpartum care of the client?

A) Dysuria
B) Epistaxis, hematuria, dysuria
C) Vertigo, hematuria, ecchymosis
D) Hematuria, ecchymosis, and epistaxis

3. A client who is a breast-feeding mother develops mastitis. The clinical signs and symptoms of mastitis include:

A) Marked engorgement, elevated temperature, chills, and breast pain with an area that is red and hardened
B) Marked engorgement and breast pain
C) Elevated temperature and general malaise
D) Cracked nipple with complaints of soreness

4. A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 78 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:

A) Her cervix shows she will likely deliver soon
B) The nurse should not be alarmed because mild uterine activity is common at 32 weeks - gestation
C) She may be in preterm labor because this is more common with multiple pregnancies
D) She most likely has a urinary tract infection (UTI) because this is common with pregnancy

5. The most frequent cause of early postpartum hemorrhage is:

A) Hematoma
B) Coagulation disorders
C) Uterine atony
D) Retained placental fragments

1. Right Answer: A
Explanation: (A) During pregnancy, the potential for thromboses increases owing to the increased levels of coagulation factors and a decrease in the breakdown of fibrin. (B)An inadequate production of platelets would result in thrombocytopenia with resulting signs and symptoms of bleeding such as petechiae, hematuria, or hematemesis. (C) A deficiency of folic acid during pregnancy produces a megaloblastic anemia. It is usually found in combination with iron deficiency. (D) This combination would result in bleeding disorders because more fibrin would be broken down and fewer clotting factors would be available.

2. Right Answer: D
Explanation: (A) Dysuria is not a common symptom of heparin overdose. (B) Although epistaxis and hematuria are common symptoms of heparin overdose, dysuria is not. (C)Vertigo is not a common symptom of heparin overdose. (D) Hematuria, ecchymosis, and epistaxis are the most common signs and symptoms of a heparin overdose. Others are thrombocytopenia, elevated liver enzymes, and local injection site complications.

3. Right Answer: A
Explanation: (A) Mastitis is a bacterial inflammation of the breast tissue found primarily in breast-feeding mothers. The bacteria usually enter the breast through a cracked nipple, or the infection results from stasis of milk behind a blocked duct. (B) With breast engorgement during breast-feeding, there may be marked breast pain.This is not necessarily a sign of infection. (C) Women may become ill during breast-feeding with other bacterial or viral infections that are not related to mastitis.(D) Improper care of the nipples or improper positioning of the infant during breastfeeding may result in cracked or sore nipples.

4. Right Answer: C
Explanation: (A) Her cervical exam is normal. There are no cervical changes at this time. (B) Braxton Hicks contractions may be common throughout pregnancy, but they are not regular. (C) Rhythmical contractions in conjunction with low back pain and pelvic pressure at 32 weeks in a woman carrying triplets are of great concern. She may be in preterm labor. (D) UTIs are common in pregnancy due to the enlarging uterus compressing the ureters and the stasis of urine. The woman would be more likely to complain of urinary frequency and urgency, fever or chills, and malodorous urine with a UTI.

5. Right Answer: C
Explanation: (A) Hematomas, which are the result of damage to a vessel wall without laceration of the tissue, are a cause, though not the most frequent cause. (B) Coagulation disorders are among the causes of postpartal hemorrhage, but they are less common. (C) The most frequent causes of hemorrhage in the postpartal period are related to an interference with involution of the uterus. Uterine atony is the most frequent cause, occurring in the first 24 hours after delivery. (D) Retained placental fragments are also a cause, although these bleeds usually occur 714 days after delivery.

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