the nurse is assessing a client who has recently found out she is pregnant which of the following statements would be a priority for the nurse to foll the nurse is assessing a client who has recently found out she is pregnant which of the following statements would be a priority for the nurse to foll
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Nursing Elites

NCLEX NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. The client is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?

Correct answer: “I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent.”

Rationale: The nurse should follow up on the client’s lack of a support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea. However, the priority is to address the client's statement about preparing to handle the pregnancy on her own due to the absence of nearby family support. This could have significant implications for the client's emotional well-being and ability to cope effectively throughout the pregnancy journey.

2. Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?

Correct answer: “I should not put the baby’s diaper on so that it covers the cord.”

Rationale: Parents should be taught not to cover the cord with a diaper to allow for air exposure and drying, preventing infection. The statement 'I should put alcohol on my baby’s cord 3–4 times a day' indicates a need for further teaching as current recommendations do not include using alcohol on the cord, which can interfere with natural healing. While it is normal for the cord to turn dark as it dries, so the statement 'I should call the physician if the cord becomes dark' is accurate, it is not the best answer for this question. Washing hands before and after caring for the cord is important to prevent the transfer of pathogens, so this statement does not require further teaching.

3. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:

Correct answer: Decrease maternal fluids.

Rationale: When fetal heart monitoring indicates fetal distress, interventions are aimed at improving oxygenation to the fetus. Increasing maternal fluids helps improve placental perfusion and oxygen delivery to the fetus. Administering oxygen also aids in increasing oxygen supply to the fetus. Turning the mother can help relieve pressure on the vena cava, optimizing blood flow to the placenta. Therefore, decreasing maternal fluids would not be performed as it can further compromise placental perfusion and fetal oxygenation, making it the exception. Decreasing maternal fluids could potentially exacerbate fetal distress by reducing oxygen delivery and nutrient supply to the fetus, which is contrary to the goal of managing fetal distress.

4. The nurse is teaching a client about communicable diseases and explains that a portal of entry is:

Correct answer: the respiratory system.

Rationale: The correct answer is 'the respiratory system.' A portal of entry is the path through which a microorganism enters the body. In the case of communicable diseases, the respiratory system can serve as a portal of entry for pathogens such as viruses or bacteria. Choices A, B, and C are incorrect. A 'vector' is an organism that transmits disease, not the entry point for pathogens. Contaminated water or food can act as sources or reservoirs of disease-causing microorganisms, not portals of entry.

5. A female client is seen in the clinic for a gynecological examination. The nurse begins collecting subjective data. Which topic does the nurse ask the client about first?

Correct answer: Her menstrual history

Rationale: The nurse should begin by asking the client about her menstrual history as it is usually nonthreatening. This information can provide insights into the client's reproductive health and any irregularities. Menstrual history is a common starting point for gynecological assessments and can help in understanding the client's overall health status. Asking about sexual history may be more sensitive and personal, not always appropriate to start with. Obstetrical history pertains to pregnancies and may not be relevant if the client has not been pregnant. Inquiring about the presence of vaginal drainage is important but is usually addressed after gathering more general information about the client's health.

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