NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Extract:
Question 1 of 5
A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. The nurse provides the client with which information?
Correct Answer: B
Rationale: A rubella titer of less than 1:8 indicates that the client is not immune to rubella. In such cases, retesting will be necessary during the pregnancy. If the client is found to be non-immune, rubella immunization is required post-delivery.
Therefore, choices A, C, and D are incorrect.
Choice A suggests exposure, which cannot be confirmed by the titer result.
Choice C wrongly implies that the client has not developed immunity, which is not accurate.
Choice D is incorrect as the titer result is not within the normal immune range.
Question 2 of 5
When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:
Correct Answer: B
Rationale: Some studies have shown that ginseng enhances in vitro sperm motility, making
Choice B the correct response. It directly addresses the client's comments about taking ginseng and provides valuable information regarding its potential effect on sperm motility. Alternative therapies are often sought by couples struggling with infertility, and acknowledging the potential benefits of ginseng can empower the client.
Choice A is incorrect as it slightly misrepresents the evidence by overgeneralizing its effectiveness.
Choice C dismisses ginseng without acknowledging its potential benefits, potentially closing off a fruitful discussion with the client.
Choice D, while neutral, misses the opportunity to validate the client's choice and explore further options collaboratively. It is crucial for nurses to respect clients' choices, provide accurate information, and guide them effectively in exploring different alternatives.
Question 3 of 5
A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. On the basis of this finding, the nurse makes which determination?
Correct Answer: A
Rationale: A hepatitis B screen is performed to identify antigens in maternal blood. If antigens are present, it indicates that the mother is a carrier, and the newborn will need to receive hepatitis immune globulin and vaccine soon after birth to prevent transmission.
Therefore, choice A is correct.
Choices B and C are incorrect because the presence of antigens indicates a positive result, not a negative one or the absence of hepatitis B in the mother.
Choice D is incorrect as it suggests the client needs to receive the hepatitis B series of vaccines, which is not the immediate action required when antigens are found in the maternal blood.
Question 4 of 5
A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats/min. On the basis of this finding, which priority action should the nurse take?
Correct Answer: C
Rationale: During the fourth stage of labor, the woman's vital signs should be assessed every 15 minutes during the first hour. An increasing pulse rate is an early sign of excessive blood loss, as the heart beats faster to compensate for reduced blood volume. The blood pressure decreases as blood volume diminishes, but this is a later sign of hypovolemia. The most common reason for excessive postpartum bleeding is a uterus that is not firmly contracting and compressing open vessels at the placental site.
Therefore, the nurse should check the client's uterine fundus for firmness, height, and positioning. Checking the uterine fundus is the priority action as it helps determine if the client is bleeding excessively. Notifying the registered nurse immediately is not necessary unless the cause of bleeding is unclear and needs further intervention. Continuing to check vital signs without addressing the potential issue will delay necessary intervention. Documenting findings is important, but not the immediate priority when faced with a potential emergency situation like postpartum hemorrhage.
Question 5 of 5
A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), the nurse determines that the client is:
Correct Answer: B
Rationale: The term gravida refers to the number of pregnancies, of any duration, that a woman has had. Parity (para) refers to the number of pregnancies that have progressed past 20 weeks at delivery.
Therefore, this client is gravida 6 (pregnant for the sixth time), para 2 (has a son and a daughter). In this case, the correct answer is Gravida 6, para 2.
Choices A, C, and D are incorrect as they do not accurately reflect the information provided. Pregnancy outcomes are often described using the GTPAL acronym: gravida (G), term births (T), preterm births (P), abortions (
A), and live births (L). Applying this to the client's history, the GTPAL would be G = 6, T = 1, P = 1, A = 3, L = 2, which further confirms the correct answer.