NCLEX-PN
Health Promotion and Maintenance NCLEX Questions Questions
Extract:
Question 1 of 5
After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?
Correct Answer: C
Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided.
Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.
Question 2 of 5
A pregnant client is being educated by a nurse on nutrition and foods rich in folic acid. Which food item does the nurse inform the client contains the highest amount of folic acid?
Correct Answer: A
Rationale: Pinto beans contain the highest amount of folic acid among the options provided, with 294 mcg per 1-cup serving. Oranges contain 44 mcg per 1-cup serving, lettuce contains 60 mcg per 1-cup serving, and broccoli contains 78 mcg per 1-cup serving.
Therefore, pinto beans are the best choice for increasing folic acid intake during pregnancy. Choosing oranges, lettuce, or broccoli would not provide as much folic acid compared to pinto beans, making them less optimal choices for meeting folic acid requirements during pregnancy.
Question 3 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 4 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 5 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.