NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician's office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. The nurse provides which information to the mother?
- A. That it could indicate a sign of an infection and the infant's temperature should be checked every 2 hours
- B. That the crust is to be expected as a normal part of healing
- C. To bring the infant to the pediatrician's office to be checked
- D. To remove the crust, using a warm, wet face cloth and a mild soap
Correct answer: B
Rationale: After circumcision, a yellow crust may form over the circumcision site, which is a normal part of healing and should not be removed. The mother should be reassured that this crust is to be expected. Yellow crusting or discharge is not indicative of an infection, and there is no need to notify the pediatrician. Checking the infant's temperature every 2 hours is unnecessary and may cause unnecessary alarm to the mother.
2. In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases?
- A. measles, polio, pertussis, hepatitis B
- B. diphtheria, pertussis, polio, tetanus
- C. rubella, polio, pertussis, hepatitis A
- D. measles, mumps, rubella, polio
Correct answer: B
Rationale: By 12 months of age, children should have received vaccines for diphtheria, pertussis, polio, and tetanus (DTaP and IPV). The correct answer is B as it includes these vaccines that are typically administered in the first year of life. Measles, mumps, and rubella (MMR) vaccination usually begins at 12 months of age but is not expected to be completed by this time. Choices A and C are incorrect as they include diseases that are not part of the routine immunization schedule for a 12-month-old child.
3. A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if the mother performs which action?
- A. Uses a cotton-tipped swab to carefully clean inside the infant's nose
- B. Uncovers only the body part being washed
- C. Washes the diaper area first
- D. Washes the infant's chest first
Correct answer: B
Rationale: When bathing a newborn, it is crucial to follow a specific sequence for thorough cleaning and safety. The correct sequence includes starting with the eyes and face, then moving to the external ear, areas behind the ears, neck, hands, arms, legs, and finally the diaper area. Keeping the infant warm is essential, so only the body part being washed should be uncovered. Using a cotton-tipped swab to clean inside the infant's nose is not recommended due to the risk of injury if the infant moves suddenly. Washing the diaper area first is incorrect as it should be done towards the end of the bath to prevent contamination. Washing the infant's chest first is also incorrect as it deviates from the recommended bathing sequence for a newborn.
4. A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?
- A. centration
- B. causality
- C. nonreversibility
- D. conservation
Correct answer: D
Rationale: The ability of a preschooler to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn't change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper, or moved to the paper. Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another. Non-reversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.
5. After reviewing the child's immunization record, which scheduled vaccine should the nurse prepare to administer next?
- A. Hib
- B. IPV
- C. MMR
- D. DTaP
Correct answer: D
Rationale: The correct answer is DTaP. DTaP is administered at 2, 4, and 6 months of age; between 15 and 18 months of age; and between 4 and 6 years of age. Since the child has only received three doses of this vaccine, the next dose of DTaP should be administered. The other options are incorrect because Hib is administered at 2, 4, and 6 months of age and between 12 and 15 months; IPV is administered at 2, 4, and 6 months of age and between 4 and 6 years of age; MMR is administered between 12 and 15 months of age and again between 4 and 6 years of age.
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