the nurse is assisting with data collection on a well baby examination the nurse measures the head circumference and it is the same as the chest circu
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Nursing Elites

NCLEX-PN

2024 PN NCLEX Questions

1. During a well-baby examination, the nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, what action should the nurse take?

Correct answer: A

Rationale: The head circumference growth rate during the first year is approximately 0.4 inches (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. In this case, where the head circumference matches the chest circumference, it is a normal finding in infants around 10-12 months. Therefore, the most appropriate action is to document these measurements in the infant's health care record. Suspecting hydrocephalus or suggesting a skull x-ray would be premature and not indicated based on this measurement. Similarly, telling the mother that the infant is growing faster than expected is not accurate and could cause unnecessary concern.

2. A client is scheduled to undergo a Papanicolaou (Pap) test in 1 week. Which statement does the nurse make to the client?

Correct answer: B

Rationale: The correct answer is to 'Avoid intercourse for 24 hours before the scheduled examination.' The Pap test is used to screen for cervical cancer. It is not performed during menstruation or if a heavy infectious discharge is present. Before the test, the client should not douche, have intercourse, or insert anything into the vagina within 24 hours. Instructing the client to use pads instead of a tampon when menstruating can interfere with the test results due to the presence of blood. Douching before the exam is discouraged as it can alter the cervical cells' appearance, affecting the test's accuracy. Obtaining a sample of vaginal discharge for inspection is not a standard pre-Pap test instruction and is unnecessary for the test.

3. Before administering the hepatitis B vaccine to a newborn infant, what should the nurse do?

Correct answer: D

Rationale: Before administering the hepatitis B vaccine to a newborn infant, the nurse must obtain parental consent. Hepatitis B vaccine is typically given at birth, 1 month, and 6 months of age. Checking the infant for jaundice, checking the temperature, and requesting a hepatitis blood screen are unnecessary in this context. Parental consent is crucial for any medical intervention involving minors.

4. During a health assessment interview, the client tells the nurse that she has some vaginal drainage. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client?

Correct answer: D

Rationale: If the client reports having vaginal drainage and concerns about a possible STI, it is essential for the nurse to gather more information about the discharge. Asking about the color of the discharge helps in determining its characteristics, which can be crucial in identifying potential causes. The color, consistency, odor, and associated symptoms can provide valuable insights into the underlying issue. Statements A and B are relevant questions but not as immediate or specific to addressing the client's concern about the discharge. Statement C dismisses the client's worries and does not encourage further assessment, which is not appropriate in this context.

5. A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?

Correct answer: B

Rationale: The correct first step is to assess the client's current diet by asking her to provide a list of the types of foods she eats. This assessment will help the nurse determine a personalized dietary plan based on the guidelines from the American Diabetes Association and the American Heart Association. Providing the client with copies of the guidelines is important but not the initial action. A high-protein diet plan may not be suitable for all clients aiming to prevent heart disease and diabetes. While providing information on risk factors is important, it is not the primary step in assisting the client with determining a suitable diet for disease prevention.

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