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NCLEX- MATERNITY WITH RATIONALES EXAM with answers The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A. Two weeks b$9.49
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NCLEX- MATERNITY WITH RATIONALES EXAM with answers The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A. Two weeks b
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NCLEX- MATERNITY WITH RATIONALES
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NCLEX- MATERNITY WITH RATIONALES
NCLEX- MATERNITY WITH RATIONALES EXAM with
answers
The nurse is counseling a couple who has sought information about conceiving. The
couple asks the nurse to explain when ovulation usually occurs. Which statement by the
nurse is correct?
A. Two weeks before menstruation
B. Immediately aft...
NCLEX- MATERNITY WITH RATIONALES EXAM with
answers
The nurse is counseling a couple who has sought information about conceiving. The
couple asks the nurse to explain when ovulation usually occurs. Which statement by the
nurse is correct?
A. Two weeks before menstruation
B. Immediately after menstruation
C. Immediately before menstruation
D. Three weeks before menstruation - ANSWERSA. Rationale: Ovulation occurs 14
days before the first day of the menstrual period (A). Although ovulation can occur in the
middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has
a perfect 28-day cycle. For many women, the length of the menstrual cycle varies. (B,
C, and D) are incorrect.
The nurse instructs a laboring client to use accelerated blow breathing. The client
begins to complain of tingling fingers and dizziness. Which action should the nurse
take?
A. Administer oxygen by face mask.
B. Notify the health care provider of the client's symptoms.
C. Have the client breathe into her cupped hands.
D. Check the client's blood pressure and fetal heart rate. - ANSWERSC. Rationale:
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon
dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated
by breathing into a paper bag or cupped hands (C). (A) is inappropriate because the
carbon dioxide level is low, not the oxygen level. (B and D) are not specific for this
situation.
A client who delivered by cesarean section 24 hours ago is using a patient-controlled
analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since
surgery. She is now complaining of nausea and bloating, and states that because she
had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis
has the highest priority?
A. Altered nutrition, less than body requirements for lactation
B. Alteration in comfort related to nausea and abdominal distention
C. Impaired bowel motility related to pain medication and immobility
D.NFatigue related to cesarean delivery and physical care demands of infant -
ANSWERSC. Rationale: Impaired bowel motility caused by surgical anesthesia, pain
medication, and immobility (C) is the priority nursing diagnosis and addresses the
potential problem of a paralytic ileus. (A and B) are both caused by impaired bowel
motility. (D) is not as important as impaired motility.
The nurse is teaching care of the newborn to a childbirth preparation class and
describes the need for administering antibiotic ointment into the eyes of the newborn.
, An expectant father asks, "What type of disease causes infections in babies that can be
prevented by using this ointment?" Which response by the nurse is accurate?
A.NHerpes
B. Trichomonas
C. Gonorrhea
D. Syphilis - ANSWERSC. Rationale: Erythromycin ointment is instilled into the lower
conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an
infection caused by gonorrhea (C), and inclusion conjunctivitis, an infection caused by
Chlamydia. The infant may be exposed to these bacteria when passing through the birth
canal. Ophthalmic ointment is not effective against (A, B, or D).
A new mother is having trouble breastfeeding her newborn. The child is making frantic
rooting motions and will not grasp the nipple. Which intervention should the nurse
implement?
A. Encourage frequent use of a pacifier so that the infant becomes accustomed to
sucking.
B. Hold the infant's head firmly against the breast until he latches onto the nipple.
C. Encourage the mother to stop feeding for a few minutes and comfort the infant.
D. Provide formula for the infant until he becomes calm, and then offer the breast
again. - ANSWERSC. Rationale: The infant is becoming frustrated and so is the mother;
both need a time out. The mother should be encouraged to comfort the infant and to
relax herself (C). After such a time out, breastfeeding is often more successful. (A and
D) would cause nipple confusion. (B) would only cause the infant to be more resistant,
resulting in the mother and infant to become more frustrated.
When assessing a client at 12 weeks of gestation, the nurse recommends that she and
her husband consider attending childbirth preparation classes. When is the best time for
the couple to attend these classes?
A. At 16 weeks of gestation
B. At 20 weeks of gestation
C. At 24 weeks of gestation
D. At 30 weeks of gestation - ANSWERSD. Rationale: Learning is facilitated by an
interested pupil. The couple is most interested in childbirth toward the end of the
pregnancy, when they are beginning to anticipate the onset of labor and the birth of their
child. (D) is closest to the time when parents would be ready for such classes. (A, B,
and C) are not the best times during a pregnancy for the couple to attend childbirth
education classes. At these times they will have other teaching needs. Early pregnancy
classes often include topics such as nutrition, physiologic changes, coping with normal
discomforts of pregnancy, fetal development, maternal and fetal risk factors, and
evolving roles of the mother and her significant others.
One hour following a normal vaginal delivery, a newborn infant boy's axillary
temperature is 96° F, his lower lip is shaking and, when the nurse assesses for a Moro
reflex, the boy's hands shake. Which intervention should the nurse implement first?
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