NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Question 1 of 5
An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client's care plan?
Correct Answer: A
Rationale: In this scenario, the Rh-negative woman has been sensitized, posing a risk to any Rh-positive fetus she delivers. The most appropriate nursing action is to provide emotional support to help the family cope with the infant's condition. This includes addressing potential outcomes like death or neurological damage. Administering MICRhoGam (Choice B) to a sensitized woman is not recommended; it is only given post-abortion or ectopic pregnancy to prevent sensitization. Rh-immune globulin is not administered to the newborn (Choice C) in this case. Analyzing the maternal Direct Coombs' test (Choice D) is unnecessary; instead, an Indirect Coombs' test is used to assess sensitization. Therefore, the correct nursing action is to offer emotional support to the family, acknowledging the challenges they may face.
Question 2 of 5
A nurse is determining the estimated date of delivery for a pregnant client using Nagele's rule and notes documentation that the date of the client's last menstrual period was August 30, 2013. The nurse determines the estimated date of delivery to be which date?
Correct Answer: B
Rationale: Nagele's rule is a method used to estimate the date of delivery for pregnant clients. The rule involves subtracting 3 months and adding 7 days to the date of the first day of the last normal menstrual period, then adjusting the year. Subtracting 3 months from August 30, 2013, brings the date to May 30, 2013; adding 7 days results in June 6, 2013. Finally, after correcting the year, the estimated date of delivery is June 6, 2014. Therefore, the correct answer is June 6, 2014. Choices A, C, and D are incorrect because they do not follow the accurate calculation based on Nagele's rule.
Question 3 of 5
A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed?
Correct Answer: A
Rationale: Fetal movements (quickening) are first noticed by multigravida pregnant women at 16 to 20 weeks of gestation and gradually increase in frequency and strength. This is when the mother typically begins to feel the baby's movements. Choices B, C, and D are incorrect because fetal movements are not felt as early as 6, 8, or 12 weeks of gestation. At 6 weeks, the embryo's movements are not yet strong enough to be felt by the mother. By 8 weeks, the movements are still too subtle to be perceived. At 12 weeks, although fetal movements start, they are usually not strong enough to be felt by the mother.
Question 4 of 5
When teaching parents how their children learn sex role identification, the nurse should include which of the following statements?
Correct Answer: A
Rationale: Sex role identification begins during infancy as infants can identify body parts by the end of the first year. Preschoolers often engage in masturbation and sex play. School-age children continue to develop awareness of their sexual identity, including behaviors like hugging and kissing. Early adolescence sees further development influenced by sexual maturation and experimentation with sex roles. Therefore, the correct statement is that sex role identification begins in infancy. Choices B, C, and D are incorrect as they misrepresent the timeline of the development of sex role identification in children.
Question 5 of 5
While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6°F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?
Correct Answer: A
Rationale: The correct answer is to notify the registered nurse of the findings. In a pregnant client, the normal temperature range is 98°F to 99.6°F, with a pulse rate of 60 to 90 beats/min and respirations of 12 to 20 breaths/min. A temperature of 100.4°F or higher, along with an increased pulse rate and faster respirations, suggests a possible infection. Immediate notification of the registered nurse is crucial for further evaluation and intervention. While documenting the findings is essential, the priority lies in promptly escalating abnormal vital signs for assessment and management. Rechecking vital signs in 1 hour may delay necessary interventions for a deteriorating condition. Continuing to collect data is relevant but should not delay informing the registered nurse when abnormal vital signs are present.
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