a nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her h a nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her h
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Nursing Elites

NCLEX NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. A new mother is being discharged from the maternity unit and provided with information about signs and symptoms to report to her health care provider. Which statement by the mother indicates a need for further information?

Correct answer: ''Frequent urination and burning when I urinate are expected.''

Rationale: The correct answer is 'Frequent urination and burning when I urinate are expected.' This statement by the mother indicates a need for further information because these symptoms are not normal and could indicate a urinary tract infection or another issue that needs medical attention. The other choices correctly reflect signs and symptoms that should be reported to the health care provider. Redness, swelling, or tenderness in the legs can indicate a blood clot, and feelings of pelvic fullness or pressure can be signs of a problem. Monitoring temperature is also important to ensure there is no infection or other complications postpartum.

2. The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?

Correct answer: “Be sure to call your physician if your vaginal discharge becomes bright red.”

Rationale: The correct answer is to instruct the postpartum client to call the physician if their vaginal discharge becomes bright red. The vaginal discharge after birth is called lochia, and a return to red or containing clots could indicate impending hemorrhage or infection, necessitating notification of the physician. Choice A is incorrect because although some tenderness may be expected, redness and fatigue are clinical manifestations of mastitis, not normal postpartum changes. Choice B is also incorrect as increased frequency of urination after vaginal delivery could indicate a urinary tract infection, not a normal postpartum change. Choice C is incorrect because running a low-grade temperature for a few days is not expected postpartum; an elevated temperature above 100°F should be reported to the physician as it could indicate infection.

3. During a petit mal seizure in the clinic, what should be the highest priority?

Correct answer: Provide a safe environment free of obstructions in the immediate area

Rationale: During a petit mal seizure, the highest priority is to provide a safe environment free of obstructions in the immediate area. This action aims to prevent injuries to the patient during the seizure. While calling a code or contacting the patient’s physician may be necessary at some point, immediate safety measures take precedence. Preventing excessive movement of the extremities is relevant but ensuring a safe environment is crucial to avoid harm during the seizure.

4. The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?

Correct answer: Muscle spasms

Rationale: The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.

5. The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?

Correct answer: The LPN should discard the residual before administering the tube feeding.

Rationale: The incorrect step is choice C. The residual should be discarded before administering the tube feeding. Discarding the residual is essential to prevent contamination and ensure accurate measurement of the enteral feeding. Elevating the head of the bed by at least 30 degrees (choice A) is correct as it helps prevent aspiration during feeding. Testing the pH level of the residual (choice D) ensures proper placement of the tube. Withholding feeding if the residual is greater than 200mL (choice B) is crucial to prevent overfeeding, making this statement correct.

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