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NCLEX-RN Exam Questions - Part 106
1. The postpartum nurse should include which of the following instructions to breast-feeding mothers?
A) Limit feeding times for several days to avoid nipple soreness.
B) Wash the nipples with soap and water before and after each feeding.
C) Daily caloric intake should be increased by 500 cal.
D) Breast milk is totally digestible by the baby because it contains lactose.
2. At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?
A) Apical pulse of 52 bpm
B) Uterine fundus palpable left of midline
C) No bowel movement since delivery
D) Oral temperature of 100.4¦F
3. The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks gestation. An appropriate response by the nurse would be:
A) 'It must be God - s will and probably is for the best.'
B) 'This must be a difficult time for you. Would you like to talk about it?'
C) 'I - m sure your other children will be a comfort for you.'
D) 'Don - t worry, you - re still young. If I were you I - d just try again.'
4. A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
A) Prevents the development of ophthalmia neonatorum
B) Assists the baby - s clotting mechanism
C) Breaks down bilirubin in the skin into substances that can be excreted in stool or urine
D) Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)
5. After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her sons circumcision?
A) 'I - ll make sure I soak the gauze with warm water first, before I take it off each time.'
B) 'I - ll make sure that I report any drainage around where they operated.'
C) 'I - ll apply alcohol to the area daily to clean it and prevent any infection.'
D) 'I - ll keep a close watch on it for a day or two.'
A) Limit feeding times for several days to avoid nipple soreness.
B) Wash the nipples with soap and water before and after each feeding.
C) Daily caloric intake should be increased by 500 cal.
D) Breast milk is totally digestible by the baby because it contains lactose.
2. At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?
A) Apical pulse of 52 bpm
B) Uterine fundus palpable left of midline
C) No bowel movement since delivery
D) Oral temperature of 100.4¦F
3. The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks gestation. An appropriate response by the nurse would be:
A) 'It must be God - s will and probably is for the best.'
B) 'This must be a difficult time for you. Would you like to talk about it?'
C) 'I - m sure your other children will be a comfort for you.'
D) 'Don - t worry, you - re still young. If I were you I - d just try again.'
4. A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
A) Prevents the development of ophthalmia neonatorum
B) Assists the baby - s clotting mechanism
C) Breaks down bilirubin in the skin into substances that can be excreted in stool or urine
D) Increases levels of unconjugated bilirubin, thereby preventing kernicterus (brain damage)
5. After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered. Which statement shows that the client will properly care for her sons circumcision?
A) 'I - ll make sure I soak the gauze with warm water first, before I take it off each time.'
B) 'I - ll make sure that I report any drainage around where they operated.'
C) 'I - ll apply alcohol to the area daily to clean it and prevent any infection.'
D) 'I - ll keep a close watch on it for a day or two.'
1. Right Answer: C
Explanation: (A) Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. (B) Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. (C) For optimal milk production, an additional 500 kcal over maintenance levels are needed daily. (D) Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants.
2. Right Answer: B
Explanation: (A) Bradycardia of 5070 bpm may be considered normal postpartally because the heart compensates for the decreased resistance in the pelvis. (B) The uterus is displaced from the midline by a full bladder. This condition could lead to a boggy uterus and increased risk of postpartal hemorrhage; therefore, the bladder should be kept empty. (C) Re-establishment of normal bowel function is delayed into the first postpartum week. (D) A postpartum womans oral temperature may go as high as 100.4_F within 24 hours of delivery resulting from muscular exertion, dehydration, and hormonal changes.
3. Right Answer: B
Explanation: (A) This response is nontherapeutic because it belittles the clients response and gives a meaningless rationalization. (B) This response acknowledges the clients feelings and demonstrates the therapeutic offering of self by the nurse. (C) This response is nontherapeutic because it does not focus on the clients feelings and offers false reassurance. (D) This response is nontherapeutic because it belittles the clients feelings and offers her advice.
4. Right Answer: C
Explanation: (A) The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. (B) The administration of vitamin K(AquaMEPHYTON) assists the infants clotting mechanism. (C) Excessive bilirubin accumulates when the infants liver cannothandle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. (D) Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
5. Right Answer: A
Explanation: (A) Before petrolatum gauze is removed, it should be soaked with warm water to prevent trauma to adherent tissues. (B) A yellow exudate often forms normally over the surgical site. Only if it becomes foul-smelling and purulent would it need to be reported. (C) Alcohol should never be used on the site; this would be extremely painful to the infant. (D) Special care and observance should continue until the site is completely covered with clean, pink granulation tissue, which could take 710 days.
Explanation: (A) Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. (B) Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. (C) For optimal milk production, an additional 500 kcal over maintenance levels are needed daily. (D) Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants.
2. Right Answer: B
Explanation: (A) Bradycardia of 5070 bpm may be considered normal postpartally because the heart compensates for the decreased resistance in the pelvis. (B) The uterus is displaced from the midline by a full bladder. This condition could lead to a boggy uterus and increased risk of postpartal hemorrhage; therefore, the bladder should be kept empty. (C) Re-establishment of normal bowel function is delayed into the first postpartum week. (D) A postpartum womans oral temperature may go as high as 100.4_F within 24 hours of delivery resulting from muscular exertion, dehydration, and hormonal changes.
3. Right Answer: B
Explanation: (A) This response is nontherapeutic because it belittles the clients response and gives a meaningless rationalization. (B) This response acknowledges the clients feelings and demonstrates the therapeutic offering of self by the nurse. (C) This response is nontherapeutic because it does not focus on the clients feelings and offers false reassurance. (D) This response is nontherapeutic because it belittles the clients feelings and offers her advice.
4. Right Answer: C
Explanation: (A) The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. (B) The administration of vitamin K(AquaMEPHYTON) assists the infants clotting mechanism. (C) Excessive bilirubin accumulates when the infants liver cannothandle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. (D) Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
5. Right Answer: A
Explanation: (A) Before petrolatum gauze is removed, it should be soaked with warm water to prevent trauma to adherent tissues. (B) A yellow exudate often forms normally over the surgical site. Only if it becomes foul-smelling and purulent would it need to be reported. (C) Alcohol should never be used on the site; this would be extremely painful to the infant. (D) Special care and observance should continue until the site is completely covered with clean, pink granulation tissue, which could take 710 days.
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