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NCLEX-RN Exam Questions - Part 125
1. In counseling a client, the nurse emphasizes the danger signals during pregnancy. On the next visit, the client identifies which of the following as a danger signal that should be reported immediately?
A) Backache
B) Leaking of clear yellow fluid from breasts
C) Constipation with hemorrhoids
D) Visual changes
2. The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold - s maneuvers by having her:
A) Empty her bladder
B) Lie on her left side
C) Place her arms over her head
D) Force fluids 1 hour prior to procedure
3. Before giving methergine postpartum, the nurse should assess the client for:
A) Decreased amount of lochial flow
B) Elevated blood pressure
C) Flushing
D) Afterpains
4. A 24-hours postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:
A) Assist her with a sitz bath
B) Administer the prescribed medication for pain
C) Teach her Kegel exercises
D) Apply an ice pack
5. The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
A) Wear gloves for the procedure
B) Place and adjust the pad from back to front
C) Cleanse and wipe the perineum from front to back
D) Protect the outer surface of the pad from contamination
A) Backache
B) Leaking of clear yellow fluid from breasts
C) Constipation with hemorrhoids
D) Visual changes
2. The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold - s maneuvers by having her:
A) Empty her bladder
B) Lie on her left side
C) Place her arms over her head
D) Force fluids 1 hour prior to procedure
3. Before giving methergine postpartum, the nurse should assess the client for:
A) Decreased amount of lochial flow
B) Elevated blood pressure
C) Flushing
D) Afterpains
4. A 24-hours postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:
A) Assist her with a sitz bath
B) Administer the prescribed medication for pain
C) Teach her Kegel exercises
D) Apply an ice pack
5. The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
A) Wear gloves for the procedure
B) Place and adjust the pad from back to front
C) Cleanse and wipe the perineum from front to back
D) Protect the outer surface of the pad from contamination
1. Right Answer: D
Explanation: (A) Backache is a common complaint during pregnancy. Proper body mechanics, pelvic rock, back rubs, and other comfort measures should relieve the discomfort. In the presence of uterine contractions, the backache would radiate to the lower abdomen. (B) Colostrum is normal and can be present anytime in the second half of pregnancy. (C) Constipation and hemorrhoids are common and do need attention, but they do not constitute a dangerous situation. (D) Visual changes are possibly related to PIH. The client should be assessed immediately to rule out or prevent worsening of PIH.
2. Right Answer: A
Explanation: (A) A full bladder would cause discomfort and possible urinary incontinence during the exam. (B) The left side-lying position would not accommodate the exam.The head of the exam table or bed can be slightly elevated to prevent supine hypotension. (C) Arms extended over the head would cause the abdomen to be tighter and less easily palpable. (D) Forcing fluids would encourage a full bladder, which is not desired for the exam.
3. Right Answer: B
Explanation: (A) Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. (B) Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. (C) Flushing is not a side effect of methergine. (D) Afterpains are increased with methergine usage. The client should be informed that this is a normal response.
4. Right Answer: A
Explanation: (A) Warm, moist heat will promote circulation and provide comfort. A sitz bath should be tried before medication is given. (B) Pain medication can be given when other comfort measures such as a sitz bath and topical applications are ineffective. (C) Kegel exercises facilitate sitting by decreasing tension on the episiotomy.They will not be effective for pain control or sustained comfort level. (D) Ice packs are appropriate to apply in the first 12 hours postdelivery to produce vasoconstriction and to reduce edema to the area.
5. Right Answer: C
Explanation: (A) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions.(B) The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. (C) Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. (D) The inner surface of the pad should not be touched to maintain asepsis.
Explanation: (A) Backache is a common complaint during pregnancy. Proper body mechanics, pelvic rock, back rubs, and other comfort measures should relieve the discomfort. In the presence of uterine contractions, the backache would radiate to the lower abdomen. (B) Colostrum is normal and can be present anytime in the second half of pregnancy. (C) Constipation and hemorrhoids are common and do need attention, but they do not constitute a dangerous situation. (D) Visual changes are possibly related to PIH. The client should be assessed immediately to rule out or prevent worsening of PIH.
2. Right Answer: A
Explanation: (A) A full bladder would cause discomfort and possible urinary incontinence during the exam. (B) The left side-lying position would not accommodate the exam.The head of the exam table or bed can be slightly elevated to prevent supine hypotension. (C) Arms extended over the head would cause the abdomen to be tighter and less easily palpable. (D) Forcing fluids would encourage a full bladder, which is not desired for the exam.
3. Right Answer: B
Explanation: (A) Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. (B) Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. (C) Flushing is not a side effect of methergine. (D) Afterpains are increased with methergine usage. The client should be informed that this is a normal response.
4. Right Answer: A
Explanation: (A) Warm, moist heat will promote circulation and provide comfort. A sitz bath should be tried before medication is given. (B) Pain medication can be given when other comfort measures such as a sitz bath and topical applications are ineffective. (C) Kegel exercises facilitate sitting by decreasing tension on the episiotomy.They will not be effective for pain control or sustained comfort level. (D) Ice packs are appropriate to apply in the first 12 hours postdelivery to produce vasoconstriction and to reduce edema to the area.
5. Right Answer: C
Explanation: (A) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions.(B) The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. (C) Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. (D) The inner surface of the pad should not be touched to maintain asepsis.
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