NCLEX Maternal Newborn

Extract:

Question 1 of 5

During the early period following a right modified radical mastectomy, which nursing action would be appropriate to include in the client's plan of care?

Correct Answer: D

Rationale: Elevating the right arm reduces edema and promotes lymphatic drainage post-mastectomy.

Question 2 of 5

The nurse is caring for a woman who is 30 weeks gestation, has gained 17 pounds during the pregnancy, and has a blood pressure of 110/70. The woman states that she feels warmer than everyone around her. Which interpretation of these findings is most correct?

A. All of these findings are normal. B. Her weight gain is excessive for this point in pregnancy. C. The blood pressure is abnormal. D. She should be evaluated for a serious infection because pregnant women are usually cooler than other people.

Correct Answer: A

Rationale: A 17-pound weight gain at 30 weeks, normal blood pressure, and feeling warm are typical in pregnancy due to increased metabolism.

Question 3 of 5

A 6-year-old child with tetralogy of Fallot is being admitted for surgery. What is most important to teach the child during the preoperative period?

A. Strict hand washing technique B. How to cough and deep breathe C. The importance of drinking plenty of fluids D. Positions of comfort

Correct Answer: B

Rationale: Teaching coughing and deep breathing prepares the child for postoperative recovery, reducing respiratory complications.

Question 4 of 5

After her examination by the physician, the antepartal client tells the nurse that the doctor said she had positive Chadwick's and Goodell's signs. She asks the nurse what this means. What is the best response for the nurse to make?

A. Chadwick's sign is a dark blue coloring of the vagina and cervix. Goodell's sign is softening of the cervix of the uterus.' B. These help to confirm pregnancy. They refer to color changes and changes in the uterus caused by increased hormones of pregnancy.' C. Those are medical terms. You don't need to be concerned about them.' D. It refers to changes that occasionally happen in pregnancy but are unlikely to cause problems.'

Correct Answer: A

Rationale: Chadwick's sign is bluish discoloration of the vagina/cervix, and Goodell's sign is cervical softening, both confirming pregnancy.

Question 5 of 5

The nurse is caring for a toddler with a cardiac defect who has had several episodes of congestive heart failure in the past few months. Which data would be the most useful to the nurse in assessing the child's current congestive heart failure?

A. The degree of clubbing of the child's fingers and toes B. Amount of fluid and food intake C. Recent fluctuations in weight D. The degree of sacral edema

Correct Answer: C

Rationale: Recent weight fluctuations are the most reliable indicator of fluid retention or loss in congestive heart failure.

NCLEX Maternal Newborn | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN