A 16-year-old girl at 28 weeks' gestation arrives at the prenatal clinic with her mother for a routine sonogram. Before the procedure, the girl asks that the nurse not reveal the fetus's sex if it should become apparent. Afterward, the mother asks the nurse the sex of the fetus. In light of the mot...
EAQ 153 NCLEX questions Correctly
Solved 2024
A 16-year-old girl at 28 weeks' gestation arrives at the prenatal clinic with her mother for a routine
sonogram. Before the procedure, the girl asks that the nurse not reveal the fetus's sex if it should
become apparent. Afterward, the mother asks the nurse the sex of the fetus. In light of the mother-
daughter relationship, the best response by the nurse is:
1. "That information is not available at this time."
2. "I'm not allowed to divulge confidential information."
3. "Your daughter asked me not to give that information to anyone."
4. "The sex of the baby isn't the most important information at this time." - ✔ ✔ 1. "That information
is not available at this time."
Rationale:
Stating that the information is not available at this time supports the client's right to confidentiality
without antagonizing the client's mother. Stating that the sex of the baby isn't the most important
information at this time is a judgmental, nontherapeutic statement. Although the other responses
protect the client's right to confidentiality, they could disrupt the relationship between the client and
her mother.
A 30-year-old client with a 35-day menstrual cycle is trying to become pregnant. The nurse counsels the
client and her partner about the optimal timing of intercourse during the cycle. The nurse determines
that the counseling has been effective when the couple state that they should have intercourse on the:
1. 12th day of the cycle
2. 14th day of the cycle
,3. 21st day of the cycle
4. 25th day of the cycle - ✔ ✔ 3. 21st day of the cycle
Rationale:
Ovulation usually occurs 14 days before menses; in a 35-day cycle, ovulation may occur as late as the
21st day. Day 12 day of the cycle is the proliferative phase of the cycle; ovulation has not yet occurred. If
the woman had a 28-day cycle, ovulation is expected 14th day of the cycle. By the 25th day of the cycle,
the ovum in this woman has passed out of the fallopian tube and can no longer be fertilized.
A 4-day-old male infant with exstrophy of the bladder and ambiguous genitalia is in the neonatal
intensive care unit. The everted bladder is inflamed, and there is continual leakage of urine onto the
surrounding skin. What is the nurse's initial concern in trying to support the infant's mother?
1. Promoting her acceptance of her baby as he is
2. Preparing her for the surgery that her baby will require
3. Teaching her how to fulfill her baby's urinary needs
4. Instructing her in ways to meet her baby's emotional needs - ✔ ✔ 1. Promoting her acceptance of
her baby as he is
Rationale:
Before learning to care for her newborn emotionally and physically, the mother needs to begin to accept
him as he is. It is too soon to prepare the mother for the impending surgery. The priority at this time is
helping her accept her baby. Teaching the mother how to fulfill her baby's urinary needs is important,
but teaching will be more effective if the mother first accepts the infant with the defect. The mother will
be better able to meet her baby's emotional needs after she has accepted him.
A 60-year-old woman is admitted for a vaginal hysterectomy and anterior and posterior repair of the
vaginal wall. While taking the nursing history the nurse expects the client to state that one of the
reasons she is having surgery is because she has been experiencing:
Increased intraabdominal pressure associated with lifting, coughing, or laughing, in conjunction with a
relaxed pelvic musculature and a bladder displaced into the vagina, results in inability to suppress
urination. Hematuria is usually associated with urinary tract infection, bladder tumor, or renal calculi,
not with cystocele or rectocele. Dysmenorrhea is usually associated with pelvic inflammatory disease,
endometriosis, or cervical stenosis, not with cystocele or rectocele; the client is probably
postmenopausal. Pain on urination is usually associated with urinary infection, not with cystocele or
rectocele.
A client asks a nurse about the most common problem associated with the use of an intrauterine device
(IUD). What answer should the nurse provide?
1. Perforation of the uterus
2. Spontaneous device expulsion
3. Discomfort associated with coitus
4. Development of vaginal infections - ✔ ✔ 2. Spontaneous device expulsion
Rationale:
The IUD may cause irritability of the myometrium, inducing contraction of the uterus and expulsion of
the device. Perforation of the uterus is a rare, rather than a common, occurrence. Clients do not report
, discomfort during coitus when an IUD is in place. Increased incidence of vaginal infections is not
reported with the use of an IUD.
A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure the:
1. Respiratory rate.
2. Amount of oxygen in the blood.
3. Percentage of hemoglobin-carrying oxygen.
4. Amount of carbon dioxide in the blood. - ✔ ✔ 3. Percentage of hemoglobin-carrying oxygen
Rationale:
The pulse oximeter measures the oxygen saturation of blood by determining the percentage of
hemoglobin-carrying oxygen. A pulse oximeter does not interpret the amount of oxygen or carbon
dioxide carried in the blood, nor does it measure respiratory rate.
A client at 16 weeks' gestation is to have a sonogram followed by amniocentesis. When should the nurse
direct the client to void?
1. Immediately before each procedure begins
2. An hour before the procedures are scheduled to begin
3. After the sonogram but before amniocentesis
4. Before the first sonogram tracing and after the last tracing - ✔ ✔ 3. After the sonogram but before
amniocentesis
Rationale:
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