NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Extract:
Question 1 of 5
A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push?
Correct Answer: B
Rationale: If a woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and breath-holding, helping overcome the urge to push strenuously. The woman would be encouraged to blow repeatedly, using short puffs, when the urge to push is strong. This breathing technique allows for controlled exhalation and helps prevent unnecessary pushing. Cleansing breaths (deep inspiration and expiration at the beginning and end of each contraction) are encouraged during the first stage of labor to provide oxygenation and reduce myometrial hypoxia and to promote relaxation. Holding her breath and using the Valsalva maneuver (choice
A) is not recommended as it can increase intra-abdominal pressure and decrease venous return, potentially compromising fetal oxygenation. Deep inspiration and expiration at the beginning and end of each contraction (choice
D) are more suitable for relaxation and oxygenation purposes rather than managing the urge to push.
Question 2 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 3 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 4 of 5
What is a chemical reaction between drugs before their administration or absorption known as?
Correct Answer: A
Rationale: A chemical reaction between drugs before their administration or absorption is termed a drug incompatibility. This phenomenon commonly occurs when drug solutions are mixed before intravenous administration but can also happen with orally administered drugs.
Choices B, C, and D are incorrect because side effects, adverse events, and allergic responses typically occur after the drugs have been administered and absorbed, not before.
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.