NCLEX-RN Practice Questions

The signs described—irritability and the urge to vomit—are classic manifestations of the transition phase of the first stage of labor. This phase, characterized by cervical dilation from 8 to 10 cm, is the most intense part of labor. The powerful contractions, combined with rapid cervical changes and hormonal shifts, often lead to significant maternal discomfort, anxiety, irritability, nausea, and vomiting. The client may feel overwhelmed and lose the ability to cope, which are hallmark psychological and physiological responses during this specific period just before the second stage begins.

A. Fourth stage of labor: This is the immediate postpartum recovery period, beginning after the delivery of the placenta. The focus is on maternal stabilization, not active labor symptoms.

B. Third stage of labor: This stage begins after the birth of the baby and ends with the delivery of the placenta. The intense, painful contractions of the transition phase have ceased.

D. Second stage of labor: This is the "pushing" stage, which starts with full cervical dilation (10 cm) and ends with the baby's birth. The primary maternal sensation is an overwhelming urge to bear down.

1. Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R. (2020). Maternity & Women's Health Care (12th ed.). Elsevier. In Chapter 16, "Labor and Birth Processes," the transition phase (8 to 10 cm) is described with maternal characteristics including irritability, restlessness, and nausea/vomiting (p. 389, Table 16.3).

2. Ricci, S. S., Kyle, T., & Carman, S. (2021). Maternity and Pediatric Nursing (4th ed.). Wolters Kluwer. Chapter 14, "Labor and Birth Process," details the psychological responses during the transition phase, noting that women may become irritable, agitated, and feel out of control. It also lists nausea and vomiting as common physical findings (pp. 498-499).

3. University of California San Francisco (UCSF) Health. (n.d.). The Stages of Labor. In the section "First Stage of Labor," the transition phase is described as the most challenging, with symptoms that can include nausea, vomiting, and significant mood changes such as irritability. (Retrieved from UCSF Health's patient education resources on labor and delivery).

Oxytocin (Pitocin) is the synthetic form of the hormone responsible for stimulating uterine contractions. It is the primary and most common pharmacological agent administered to induce or augment labor. The goal of oxytocin infusion is to achieve a contraction pattern that mimics spontaneous labor, leading to cervical change and fetal descent. Its use requires careful titration and continuous electronic fetal monitoring to ensure the safety of both the mother and the fetus, as it carries risks such as uterine tachysystole (excessively frequent contractions) and potential fetal distress.

B. Progesterone: This hormone inhibits uterine contractility and is essential for maintaining pregnancy; it is not used to induce labor.

C. Vasopressin (Pitressin): This is an antidiuretic hormone used to treat conditions like diabetes insipidus and has no primary role in labor induction.

D. Ergonovine maleate: This drug is used to manage postpartum hemorrhage by causing sustained uterine contractions after delivery; it is contraindicated for labor induction.

1. American College of Obstetricians and Gynecologists (ACOG). (2009). ACOG Practice Bulletin No. 107: Induction of Labor. Obstetrics & Gynecology, 114(2, Part 1), 386-397. In the "Agents for Labor Induction" section, oxytocin is identified as the most common agent used for inducing labor in the United States (p. 391). https://doi.org/10.1097/AOG.0b013e3181b48ef5

2. Cunningham, F. G., Leveno, K. J., Bloom, S. L., et al. (2018). Williams Obstetrics (25th ed.). McGraw-Hill Education. Chapter 26, "Induction and Augmentation of Labor," details the pharmacology and clinical application of oxytocin, stating it is "one of the most commonly used medications in the United States" for labor induction.

3. Open RN Project. (2021). Nursing Care of the Childbearing Family. Chippewa Valley Technical College. Chapter 6, "Intrapartum," section on "Induction/Augmentation." This university-level open educational resource states, "Oxytocin is the most common medication used for labor induction." (This resource is licensed under CC BY 4.0).

Chronic alcohol consumption is a primary cause of folic acid deficiency anemia. Alcohol interferes with the intestinal absorption of folate, increases its excretion by the kidneys, and impairs its metabolism within the body. Furthermore, individuals with chronic alcoholism often have poor dietary intake, further reducing their folate levels. Therefore, assessing for regular alcohol use is the most critical step in identifying the likely etiology of this client's condition and planning appropriate interventions, which include both supplementation and addressing the underlying alcohol use.

A. “Do you take aspirin on a regular basis?”

Regular aspirin use can cause gastrointestinal bleeding, leading to iron deficiency anemia, not folic acid deficiency anemia.

C. “Do you eat red meat?”

Red meat is a primary source of vitamin B12 and iron; its absence is more indicative of pernicious or iron deficiency anemia.

D. “Have your stools been normal?”

Abnormal stools (e.g., melena) suggest gastrointestinal bleeding, a cause of iron deficiency anemia, not typically folic acid deficiency.

1. Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2020). Medical-surgical nursing: Assessment and management of clinical problems (11th ed.). Elsevier. In Chapter 30, Hematologic Problems, under the section "Megaloblastic Anemias," the text identifies chronic alcoholism as a common cause of folic acid deficiency due to its interference with folate absorption and metabolism (p. 621).

2. National Institutes of Health, Office of Dietary Supplements. (2022). Folate: Fact Sheet for Health Professionals. In the section "Groups at Risk of Folate Inadequacy," people with alcohol use disorder are listed as a primary risk group because alcohol interferes with folate absorption and increases its excretion.

3. Green, R., & Dwyre, D. M. (2015). The megaloblastic anemias. In K. J. Kaushansky, M. A. Lichtman, J. T. Prchal, M. M. Levi, O. W. Press, L. J. Burns, & M. Caligiuri (Eds.), Williams Hematology (9th ed.). McGraw-Hill Education. Chapter 44 discusses the pathophysiology, stating that alcoholism is one of the most common causes of folate deficiency in the Western world.

The primary pathophysiology of cystic fibrosis (CF) involves the production of abnormally thick, tenacious mucus in the respiratory tract. This mucus obstructs airways and creates an environment conducive to chronic bacterial infections, leading to progressive lung damage. Regular physical exercise serves as an effective airway clearance technique by helping to mobilize and expectorate these secretions. The ultimate aim of this intervention is to reduce the frequency and severity of pulmonary exacerbations and infections, thereby preserving lung function and improving long-term outcomes.

A. Create a sense of well-being and self-worth: While an important psychosocial benefit, this is a secondary outcome and not the primary physiological goal of exercise for managing CF's pulmonary pathology.

C. Establish an effective, habitual breathing pattern: Exercise strengthens respiratory muscles but the fundamental goal is not to change the breathing pattern itself, but to clear the physical obstruction caused by mucus.

D. Promote normal growth and development: Although exercise is beneficial for overall growth, the most critical and specific aim in the context of CF-related pulmonary problems is managing airway secretions and infection.

1. Radkte, T., Nevitt, S. J., Hebestreit, H., & Kriemler, S. (2020). Physical exercise training for cystic fibrosis. Cochrane Database of Systematic Reviews, (5), CD002768. https://doi.org/10.1002/14651858.CD002768.pub5 (In the "Authors' conclusions" section, the review notes that exercise may improve airway clearance, which is directly linked to managing infections.)

2. Hebestreit, H., Hulzebos, H. J., Schneiderman, J. E., Karila, C., & Boas, S. R. (2020). Cardiopulmonary exercise testing in cystic fibrosis. Journal of Cystic Fibrosis, 19, S20-S28. https://doi.org/10.1016/j.jcf.2019.10.017 (Section 2, "Why perform CPET in CF?", discusses how exercise capacity is linked to survival and how exercise interventions aim to improve clinical status, which is largely determined by pulmonary health and infection control.)

3. Johns Hopkins Medicine. (n.d.). Cystic Fibrosis: Treatments and drugs. Johns Hopkins All Children's Hospital. Retrieved from https://www.hopkinsallchildrens.org/Services/Pediatric-Pulmonology/Cystic-Fibrosis/Treatments-and-Drugs (Under "Airway Clearance Techniques," exercise is listed as a method to "help loosen the thick, sticky mucus in the lungs, so it can be cleared by coughing or huffing.")

The infant of a mother with type 1 diabetes is at significant risk for hypoglycemia following birth. During gestation, the fetus is exposed to high levels of maternal glucose, which stimulates the fetal pancreas to produce excess insulin (hyperinsulinemia). After birth, the maternal glucose supply is abruptly terminated, but the newborn's hyperinsulinemic state persists. This imbalance leads to a rapid uptake of glucose from the blood, causing hypoglycemia, which can occur within the first 1-3 hours of life. Therefore, the primary nursing goal is to monitor for and maintain a normal blood glucose level to prevent potential central nervous system injury.

A. Bonding: While bonding is an important psychosocial goal, it is not the primary physiological priority. Life-sustaining needs, such as preventing severe hypoglycemia, must be addressed first.

C. Maintain normal nutrition: Nutrition, specifically early and frequent feeding, is a key intervention to achieve the goal of euglycemia. The overarching goal itself is the maintenance of a stable blood sugar.

D. Monitor intake and output: This is a standard nursing assessment for all newborns but does not address the most immediate, life-threatening risk specific to an infant of a diabetic mother.

1. Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2018). Maternal child nursing care (6th ed.). Elsevier. In Chapter 25, "The High-Risk Newborn," the section on Infants of Diabetic Mothers explicitly states, "The priority of care is to monitor the infant for and prevent hypoglycemia" (p. 663).

2. Stoll, B. J., & Kliegman, R. M. (2020). The High-Risk Infant. In R. M. Kliegman, J. W. St. Geme III, N. J. Blum, S. S. Shah, R. E. Tasker, & K. M. Wilson (Eds.), Nelson Textbook of Pediatrics (21st ed., pp. 868-877). Elsevier. Chapter 112 discusses that infants of diabetic mothers have a high risk of hypoglycemia due to hyperinsulinism, making glucose homeostasis a primary management goal post-delivery.

3. Rozance, P. J., & Hay, W. W. (2016). Hypoglycemia in newborn infants: Features associated with adverse outcomes. Biology of the Neonate, 90(2), 74-86. https://doi.org/10.1159/000092217. This article highlights the pathophysiology of neonatal hypoglycemia in infants of diabetic mothers and emphasizes the critical importance of early detection and management to prevent adverse neurologic sequelae.

The client is experiencing significant stress and anxiety related to the potential diagnosis of cancer. In response, he is exhibiting dependent and demanding behaviors, which are characteristic of an earlier developmental stage. This unconscious reversion to a more childlike state to cope with overwhelming stress is known as regression. The client is abandoning mature coping mechanisms for behaviors that may have provided comfort and security during childhood.

A. Denial: This would involve the client refusing to accept the reality of his situation, such as by stating, "I'm not sick" or refusing the diagnostic tests.

B. Displacement: This would involve the client redirecting his fear or anger about the potential diagnosis onto a less threatening target, such as yelling at a family member.

D. Projection: This would involve the client attributing his own unacceptable feelings (e.g., fear, helplessness) to others, such as accusing the staff of being incompetent or scared.

1. Videbeck, S. L. (2020). Psychiatric-mental health nursing (8th ed.). Wolters Kluwer. In Chapter 14, "Anxiety, Anxiety Disorders, and Stress-Related Illness," regression is defined as "reverting to an earlier, more primitive and childlike pattern of behavior that may or may not have been previously exhibited" (p. 239, Table 14.1).

2. Townsend, M. C., & Morgan, K. I. (2018). Essentials of psychiatric mental health nursing: Concepts of care in evidence-based practice (7th ed.). F.A. Davis Company. Chapter 1, "Mental Health and Mental Illness," describes regression as a defense mechanism where an individual retreats "in response to stress to an earlier level of development and the comfort measures associated with that level of functioning" (p. 11, Table 1-2).

3. Horvath, P., & Baugh, J. (2015). Defense Mechanisms. In The Encyclopedia of Clinical Psychology. John Wiley & Sons, Ltd. This academic publication defines regression as a response to stress where an individual "returns to an earlier, more infantile, and safer stage of development." (DOI: 10.1002/9781118625392.wbecp471).

An intravenous pyelogram (IVP), also known as an excretory urogram, is a comprehensive diagnostic study that uses contrast dye to visualize the entire urinary tract. It can precisely locate a calculus within the kidney, ureter, or bladder. Crucially, it also provides functional information by demonstrating the degree of obstruction, which is indicated by delayed excretion of the dye and dilation of the urinary tract (hydronephrosis). This combination of anatomical and functional detail makes it the best diagnostic study among the choices to confirm the physician's suspicion of an obstructing stone.

A. Cystoscopy: This procedure is primarily for visualizing the bladder and urethra and is not the initial diagnostic tool for stones located higher in the ureters.

B. Kidneys, ureter, bladder, x-ray of abdomen: A KUB x-ray can miss radiolucent stones (e.g., uric acid stones) and provides no information on renal function or the degree of obstruction.

D. Ureterolithotomy: This is a surgical treatment to remove a stone from the ureter, not a diagnostic procedure to confirm its presence.

1. Hall, P. M. (2009). Nephrolithiasis: treatment, causes, and prevention. Cleveland Clinic Journal of Medicine, 76(10), 583–591. In the section "Diagnostic Evaluation" (p. 585), the article states that an intravenous pyelogram can "confirm the diagnosis and reveal the location of the stone and the degree of obstruction." https://doi.org/10.3949/ccjm.76a.09043

2. University of Virginia School of Medicine, Department of Radiology and Medical Imaging. (n.d.). Genitourinary Radiology Curriculum: Urolithiasis. Retrieved from https://www.med-ed.virginia.edu/courses/rad/gu/urolithiasis.html. In the section on "Intravenous Urogram (IVU)," the courseware notes that an IVU "provides both anatomic and functional information" and is excellent for "demonstrating the collecting systems, ureters, and bladder" and showing "the degree of obstruction."

3. Curhan, G. C., & Aronson, M. D. (2023). Diagnosis and acute management of suspected nephrolithiasis in adults. In UpToDate. Retrieved from Wolters Kluwer. (Accessed via institutional access). The section "Choice of imaging study" discusses that while noncontrast CT is now the preferred modality, intravenous pyelography (IVP) was the prior standard because it can "establish the diagnosis of a stone, determine its size and location, and assess the degree of obstruction."

The client's arterial blood gas (ABG) results show a pH of 7.28, which is below the normal range of 7.35-7.45, indicating acidosis. The PaCO2 is 60 mmHg, which is elevated above the normal range of 35-45 mmHg. An elevated PaCO2 reflects carbon dioxide retention, which causes the blood to become more acidic. The HCO3 is 24 mEq/L, which is within the normal range of 22-26 mEq/L. Because the primary cause of the acidosis is the elevated respiratory parameter (PaCO2) and the metabolic parameter (HCO3) is normal, the condition is identified as respiratory acidosis. This is consistent with an acute asthma exacerbation leading to impaired gas exchange.

A. Respiratory alkalosis is characterized by a high pH (>7.45) and a low PaCO2 (<35 mmHg), which is the opposite of the client's findings.

C. Metabolic alkalosis is characterized by a high pH (>7.45) and a high HCO3 (>26 mEq/L); the client's pH is low and HCO3 is normal.

D. Metabolic acidosis is characterized by a low pH (<7.35) and a low HCO3 (<22 mEq/L); the client's HCO3 is within the normal range.

1. University of Kansas School of Nursing. (n.d.). ABG Interpretation. In Advanced Practice Nursing Student Resources. Retrieved from https://www.kumc.edu/school-of-nursing/son-students/abg-interpretation.html. This resource outlines the systematic approach to ABG analysis, defining respiratory acidosis as a pH 45 mmHg.

2. Harding, M. M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis's medical-surgical nursing: Assessment and management of clinical problems (11th ed.). Elsevier. In Chapter 16, Fluid, Electrolyte, and Acid-Base Imbalances, Table 16-11 specifies the characteristics of respiratory acidosis as decreased plasma pH, increased PaCO2, and normal or increased HCO3 depending on compensation.

3. Papadakis, M. A., & McPhee, S. J. (Eds.). (2020). Current Medical Diagnosis & Treatment 2020. McGraw-Hill Education. In Chapter 21, Acid-Base Disorders, the section on "Respiratory Acidosis" states that it is characterized by a primary increase in PCO2 and a decrease in pH, commonly caused by hypoventilation from conditions like severe asthma.

4. Johns Hopkins Medicine. (n.d.). Arterial Blood Gas. Health Library. Retrieved from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/arterial-blood-gas. This university-affiliated patient education resource provides normal values and explains that high CO2 levels make the blood too acidic.

Phenytoin, an anticonvulsant, can cause severe and life-threatening hypersensitivity reactions, most notably Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). SJS is a medical emergency characterized by fever, malaise, and a painful, rapidly spreading rash with blistering of the skin and mucous membranes. This represents an acute toxic effect requiring immediate discontinuation of the drug. Nurses must educate the patient and family to report any sign of a rash immediately, as early recognition is critical to prevent progression and mortality.

B. Folate deficiency: This is a potential chronic adverse effect of long-term phenytoin therapy due to interference with folate metabolism, not an acute toxic reaction.

C. Leukopenic aplastic anemia: While phenytoin can cause severe hematologic toxicities like aplastic anemia, SJS is a more characteristic and frequently cited acute life-threatening reaction.

D. Granulocytosis and nephrosis: Phenytoin is associated with agranulocytosis (a decrease, not an increase, in granulocytes) and rare nephrotoxicity; this option is inaccurate.

1. Burchum, J. R., & Rosenthal, L. D. (2022). Lehne's pharmacology for nursing care (11th ed.). Elsevier. Chapter 23, Antiepileptic Drugs, section on Phenytoin [Dilantin], subsection on Adverse Effects, specifically notes the risk of Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) as rare but severe dermatologic reactions.

2. U.S. Food and Drug Administration. (2023). Highlights of Prescribing Information: DILANTIN (phenytoin sodium) extended capsules. Section 5, Warnings and Precautions, 5.3 Serious Dermatologic Reactions. The official label explicitly warns of life-threatening dermatologic reactions, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN).

3. Mockenhaupt, M. (2011). The diagnosis and treatment of Stevens-Johnson syndrome and toxic epidermal necrolysis. Deutsches Ärzteblatt International, 108(45), 772–782. https://doi.org/10.3238/arztebl.2011.0772. (Table 1 lists aromatic anticonvulsants, including phenytoin, as high-risk drugs for inducing SJS/TEN).

4. Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2019). Wong's nursing care of infants and children (11th ed.). Elsevier. Chapter 28, The Child with a Neurologic Condition, section on Pharmacologic Management of Seizures, discusses the adverse effects of antiepileptic drugs, highlighting the importance of monitoring for rash with medications like phenytoin.

The client's presentation is characteristic of conversion disorder, also known as Functional Neurological Symptom Disorder. This condition involves neurological symptoms, such as blindness, paralysis, or numbness, that cannot be explained by a medical evaluation or neurological condition. The onset of these symptoms is often associated with significant psychological stress or trauma, representing an unconscious "conversion" of emotional distress into a physical symptom. The diagnostic findings of no organic cause for the blindness, coupled with a history of recent trauma, strongly support this diagnosis.

A. Delusion: This is a fixed, false belief (a disturbance in thought content), not a physical sensory symptom like blindness.

B. Illusion: This is a misinterpretation of a real external sensory stimulus, such as seeing a shadow and thinking it is a person.

C. Hallucination: This is a false sensory perception without any real external stimulus, such as hearing voices when no one is present.

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). As cited in: Tollefson, J., & Bishop, L. (2021). Psychiatric-Mental Health Nursing: Foundational Concepts. University of West Florida Pressbooks. Chapter 10, "Somatic Symptom and Related Disorders," Section on Functional Neurological Symptom Disorder (Conversion Disorder). (This university courseware explains that the disorder involves one or more symptoms of altered voluntary motor or sensory function, with clinical findings showing incompatibility between the symptom and recognized neurological or medical conditions).

2. Aybek, S., & Perez, D. L. (2022). The clinical evaluation of functional neurological disorder. JAMA Neurology, 79(2), 203–212. https://doi.org/10.1001/jamaneurol.2021.4598 (This peer-reviewed article discusses the diagnostic criteria, emphasizing the essential rule-out of neurological disease and the frequent association with psychological stressors. See "Clinical Evaluation" section).

3. Reeves, R. R., & Ros-Rull, G. (2018). Differentiating Somatic Symptom Disorder, Functional Neurological Symptom Disorder, and Malingering. The Journal of the American Academy of Psychiatry and the Law, 46(3), 386–389. https://doi.org/10.29158/JAAPL.003781-18 (This publication clarifies the distinction between conversion disorder and other conditions, highlighting the lack of an organic basis for the neurological symptom).