NCLEX Updated NCLEX-RN Exam Questions and Answers by julian

(A) The infant has not ingested any protein immediately after birth, which is necessary to detect excessive serum phenylalanine. (B) It is important that the infant take in 2–3 full days of milk or formula feedings to preclude a false-negative reading. (C) At 2–3 days of age, inadequate milk could have been ingested owing to a delay in the initial feeding. (D) The biochemical buildup of serum phenylalanine is detectable after 2–3 days of milk or formula ingestion.

(A) Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. (B) A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. (C) Although all of these answers are very important in assessment, the highest priority is assessment of suicide potential, because this could cause the greatest harm to the client. Feeling there is no other way out, abused spouses may consider suicide. (D) The spouse may be self-medicating herself with alcohol or drugs to escape an awful situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should encourage the spouse to seek counseling and not to return to the home.

(A) Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. (B) Fluid volume deficit is being treated with IV fluid replacement. (C) Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. (D) Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.

(A) At 10 weeks, the fundus is located slightly above the symphysis pubis. (B) At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. (C) At 20 weeks, the fundus is located approximately at the umbilicus. (D) At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.