NCLEX RN ACTUAL EXAM 2024-2025 /RN NCLEX
ACTUAL EXAM 2024-2025 COMPLETE 100
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES
Terms in this set (23)
A 19-year-old primigravid Pushing during the first stage of labor, when the urge is
client at 38 weeks' gestation felt but the cervix is not completely dilated, may
is 7 cm dilated, and the produce cervical swelling, making labor more difficult.
presenting part is at +1 The client should be encouraged to use a pant-blow (or
station. The client tells the blow-blow) pattern of breathing to help overcome the
nurse, "I need to push!" urge to push. The McDonald procedure is used for
What should the nurse do cervical cerclage for an incompetent cervix and is
next? inappropriate here. Increasing the rate of oxygen and
Use the McDonald intravenous fluids will not alleviate the pressure that the
procedure to widen the client is feeling. The client should not push even if she
pelvic opening. feels the urge to do so because this may result in
Increase the rate of oxygen cervical edema at 7-cm dilation.
and intravenous fluids.
Instruct the client to use a
pant-blow pattern of
breathing.
Tell the client to push only
when absolutely necessary.
, A 25-year-old primiparous Several methods can be used to prevent nipple
client who gave birth 2 soreness. Placing as much of the areola as possible into
hours ago has decided to the neonate's mouth is one method. This action prevents
breastfeed her neonate. compression of the nipple between the neonate's gums,
Which instruction should which can cause nipple soreness. Other methods include
the nurse address as the changing position with each feeding, avoiding breast
highest priority in the engorgement, nursing more frequently, and feeding on
teaching plan about demand. Plastic liners are not helpful because they
preventing nipple prevent air circulation, thus promoting nipple soreness.
soreness? Instead, air drying is recommended. Pulling the baby's
keeping plastic liners in the mouth out smoothly after only 10 minutes may prevent
brassiere to keep the nipple the baby from getting the entire feeding and increases
drier nipple soreness. Any breast milk remaining on the
placing as much of the nipples should not be wiped off because the milk has
areola as possible into the healing properties.
baby's mouth
smoothly pulling the nipple
out of the mouth after 10
minutes
removing any remaining
milk left on the nipple with a
soft washcloth
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