NCLEX : Patient-Specific Care

Study concepts, example questions & explanations for NCLEX

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Example Questions

Example Question #93 : Ethics, Processing, And Care

What is a normal hematocrit for a newborn?

Possible Answers:

35-40%

50-75%

60-80%

45-65%

Correct answer:

45-65%

Explanation:

Normal hematocrit in a newborn is 45-65%. This is measured via heel-stick just after delivery. This test is useful in assessing for anemia (suggested by a low hematocrit) and polycythemia (suggested by a hematocrit over 65%). 

Example Question #21 : Patient Specific Care

Which of the following should be encouraged in a person presenting with mastitis?

Possible Answers:

Wear loose-fitting bra

Go to urgent care if a high fever develops

Breast feed as much as possible

All of these are correct

Correct answer:

All of these are correct

Explanation:

The most common treatment for mastitis is frequent breastfeeding, along with rest and loosening of any tight-fitting clothing. Most cases of mastitis are non-infectious and do not require antibiotics. However, high fever can be a sign of infectious mastitis, and may require pharmaceutical intervention. 

Example Question #754 : Nclex

At what age does an infant learn object permanence?

Possible Answers:

6-8 months

2-4 months

3-5 months

5-6 months

Correct answer:

5-6 months

Explanation:

Object permanence is the understanding that an object still exists even when it can not be seen, heard, or touched. It is often tested by placing an object on a surface, then covering that object and allowing the infant to attempt to uncover it, thus demonstrating a knowledge that the object remains present though it is hidden. 

Example Question #22 : Patient Specific Care

Which of the following is not a part of the APGAR score?

Possible Answers:

Respiration

Activity

Appearance

Gurgling

Correct answer:

Gurgling

Explanation:

The APGAR score is a test of newborn health and physical function, designed to assess a newborn for need of emergency assistance. The factors used to calculate the score are the following:

  • Appearance
  • Pulse 
  • Grimace response 
  • Activity 
  • Respiration

Example Question #14 : Infant And Postpartum Care

Which of the following behaviors would be under the category "grimace" in the APGAR score?

Possible Answers:

All of these

Coughing

Sneezing

Pulling away

Correct answer:

All of these

Explanation:

The "grimace" category of the APGAR score actually refers to a wide variety of reflexive behavior. These include sneezing and coughing, crying on stimulation, pulling away, and facial expression.

Example Question #101 : Ethics, Processing, And Care

At what time after birth is the APGAR score calculated?

Possible Answers:

At one and five minutes

At one, five, and ten minutes

At five minutes only

At one minute only

Correct answer:

At one and five minutes

Explanation:

The APGAR score is calculated one minute after birth, and then again at five minutes after birth. It is common for infants to be born with depressed respiration, cyanosis, and other physical signs of struggle that are quickly resolved within five minutes after birth. If signs of respiratory or cardiovascular distress do not improve by this time, however, emergency intervention may be required. 

Example Question #11 : Infant And Postpartum Care

You have just calculated a newborn's five minute APGAR score as 5. What is the proper response?

Possible Answers:

Do nothing: this is a normal score

Monitor closely: this is a moderately depressed score

Emergency intervention: this is a severely depressed score

Do nothing: this is a perfect score

Correct answer:

Monitor closely: this is a moderately depressed score

Explanation:

The APGAR scale goes from 0-10. A score of 0-3 would indicate severe depression of function, 4-6 would indicate moderate depression, and 7-10 would be a normal, healthy score. In the case of moderate depression, the newborn should be monitored closely. Immediate emergency intervention may not be required, as healthy neonates can have moderately low APGAR score indicators that improve in the first few hours of life.  

Example Question #23 : Patient Specific Care

What is a normal heart rate for a newborn two hours postpartum?

Possible Answers:

110-160 bpm

60-90 bpm

140-190 bpm

80-110 bpm

Correct answer:

110-160 bpm

Explanation:

A newborn's heart rate is significantly higher than that of an adult. Normal heart rate for a newborn two hours postpartum is 110-160 beats per minute. Heart rate decreases in the first year of life to 80-140 beats per minute.

Example Question #21 : Patient Specific Care

A nurse assists in the delivery of a healthy 7 lb, 4 oz infant. Six days later the parents call the clinic with some concern. They state that their daughter has begun to lose weight - she has lost nearly 10 oz since birth, despite breastfeeding regularly. How should the nurse counsel this couple? 

Possible Answers:

This is normal - a breastfed baby will generally lose 5-10% of their birthweight in the first week of life.

This is an emergency; the couple should bring their infant to the emergency department

This is not normal but not yet a cause for concern

This is abnormal and cause for serious concern

Correct answer:

This is normal - a breastfed baby will generally lose 5-10% of their birthweight in the first week of life.

Explanation:

It is normal for infants to lose 5-10% of their birth weight in the first seven days of their lives. In a healthy baby, this weight will be regained by the end of their second week. Infants who are born ill or premature may take longer to regain this weight. If an infant has passed the second week of life and it has not returned to or surpassed it's birthweight, the family may need to seek lactation counseling or bring the infant in for further evaluation.

Example Question #11 : Infant And Postpartum Care

Which of the following is a test for hip dysplasia in an infant?

Possible Answers:

Ortolani test

Faber test

Thomas test

Ober test

Correct answer:

Ortolani test

Explanation:

An examiner can look for hip dysplasia in an infant using the Ortolani test. This is performed by placing the child supine, then flexing the hip and knee to 90 degrees. They would then gently abduct the leg while placing downward pressure on the greater trochanter. In a healthy joint, the hip will move freely. In hip dysplasia, there will be a feeling of a "clunk" as the femoral head is relocated into the acetabulum. The Ober test, Thomas test, and Faber test all check for hip stability and injury in adult populations, rather than pediatric.

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