Learn NCLEX RN PN 2019 / 2020 / 2021 40th Edition
Learn NCLEX RN PN 2019 / 2020 / 2021 40th Edition
1. While a client is holding and talking to her newborn immediately following delivery, she begins to cry. The nurse interprets this behavior as indicating the client is:
A. Disappointed with the baby’s gender
B. Experiencing a normal response to birth
C. Grieving over the loss of the pregnancy
D. Likely to demonstrate malattachment
Answer: B. Experiencing a normal response to birth
Rationale: The birth of a baby is an emotionally charged moment for new parents. Crying can be a normal expression of emotions surrounding birth. Holding, eye contact, and touch are signs of healthy maternal-newborn attachment. Options 1, 3, and 4 are incorrect interpretations.
Test-Taking Strategy: Use the process of elimination. The question requires knowledge of normal attachment behaviors and maternal emotional responses following birth. Options 1, 3, and 4 are similar in that they all represent an abnormal response. Review maternal responses following delivery if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Postpartum
References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 146.
McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 492.
2. A nurse is caring for a client during the immediate recovery phase or fourth stage of labor. The nurse’s most important action at this time is to:
A. Check the uterine fundus and lochia
B. Assist the client to breast-feed
C. Encourage food and fluid intake
D. Provide privacy for the parents and their newborn
Answer: A. Check the uterine fundus and lochia
Rationale: A potential complication following delivery is hemorrhage. The most significant source of bleeding is the site where the placenta is implanted. It is critical that the uterus remain contracted, and vaginal blood flow is monitored every 15 minutes for the first 1 to 2 hours. Options 2, 3, and 4 are not the most important nursing actions.
Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. Checking uterine position and consistency and the amount and character of lochia provides information about blood loss and circulatory status. Options 2, 3, and 4 are less important at this time. Review care to the client in the immediate postpartum period if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 497.
3. A nurse is assigned to care for a client in the immediate postpartum period who received methylergonovine maleate (Methergine). The nurse determines the medication is effective when the client says:
A. “At least now I can sleep.”
B. “I feel less nauseated.”
C. “My afterpains are really strong.”
D. “The pain is less intense.”
Answer: C. “My afterpains are really strong.”
Rationale: Methylergonovine maleate (Methergine) is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used postpartally to stimulate the uterus to contract and control excessive blood loss. The client statements in options 1, 2, and 4 are not related to this medication.
Test-Taking Strategy: Knowledge regarding the action and use of this medication is required to answer this question. Remember, methylergonovine maleate (Methergine) is an ergot alkaloid that stimulates smooth muscles. If you are unfamiliar with this medication, review this content.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 247.
4. A child is diagnosed with lactose intolerance. The child’s mother asks the nurse about the disease. The appropriate nursing response is which of the following?
A. “It is the inability to fully digest the protein part of wheat, barley, rye, and oats.”
B. “It is the inability to tolerate sugar found in dairy products.”
C. “It results from the absence of ganglion cells in the rectum.”
D. “It results from increased bowel motility that leads to spasm and pain.”
Answer: B. “It is the inability to tolerate sugar found in dairy products.”
Rationale: Lactose intolerance is the inability to tolerate lactose, the sugar found in dairy products. It results from absence or deficiency of lactase, an enzyme found in the secretions of the small intestine required for the digestion of lactose. Option 1 describes celiac disease. Option 3 describes Hirschsprung’s disease. Option 4 describes irritable bowel syndrome.
Test-Taking Strategy: Use the process of elimination. Note the relation between “lactose intolerance” in the question and the words “inability to tolerate sugar” in option B. If you are unfamiliar with this disorder, review this content.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Child Health
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 65.
5. A nurse is reviewing the health record of a child with a diagnosis of celiac disease. Which clinical manifestation would the nurse expect to note documented in the health record?
A. Frothy diarrhea
B. Profuse watery diarrhea and vomiting
C. Foul-smelling ribbon stools
D. Diffuse abdominal pain unrelated to meals or activity
Answer: B. Profuse watery diarrhea and vomiting
Rationale: Celiac disease causes profuse watery diarrhea and vomiting. Option 1 is a clinical manifestation of lactose intolerance. Option 3 is a clinical manifestation of Hirschsprung’s disease. Option 4 is a clinical manifestation of irritable bowel syndrome.
Test-Taking Strategy: Knowledge regarding the clinical manifestations associated with celiac disease is required to answer this question. Remember, celiac disease causes profuse watery diarrhea and vomiting. Review the clinical manifestations associated with this disorder if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 238.
Source : NCLEX example quiz and answer
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