NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Extract:
Question 1 of 5
A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8-10 cm. The nurse correctly documents the finding as:
Correct Answer: C
Rationale: Spinnbarkheit is the term for stretchy, elastic cervical mucus at ovulation, indicating fertility. Ferning requires microscopic examination, and inhospitable mucus inhibits sperm motility.
Question 2 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.
Question 3 of 5
The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?
Correct Answer: A
Rationale: Rugs and clutter are a primary cause of falls in the home and should be eliminated if possible to decrease the risk of a fall.
Question 4 of 5
When a nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign, what does this indicate?
Correct Answer: A
Rationale: The correct interpretation of the Chadwick sign is that the cervix appears violet in color. This sign is a probable sign of pregnancy, characterized by the violet coloration of the cervix due to increased vascularity of the pelvic organs. It is not a definitive positive sign of pregnancy but rather a probable one.
Choices B and D are incorrect as cervical softening is known as the Goodell sign, and thinning of the cervix is referred to as the Hegar sign. These signs are also probable signs of pregnancy, but they do not specifically indicate the Chadwick sign.
Question 5 of 5
A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. The nurse provides which instruction?
Correct Answer: C
Rationale: The correct answer is 'Devices that apply pressure alone are available over the counter.' Acupressure over the Neiguan acupuncture point can be used as a complementary alternative therapy to relieve nausea during pregnancy. It can be performed with devices that apply pressure alone, which are available over the counter. Acupressure devices that apply electrical impulses over this point require a prescription. It is not safe to try any type of complementary alternative therapy during pregnancy, as some may be harmful to the mother and fetus.
Therefore, the nurse should instruct the client about the availability of over-the-counter pressure devices for acupressure, which are generally safe to use.