Comprehensive Review for the NCLEXPN EXAM Maternity Questions And Answers With Rationales.
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Course
NCLEXPN
Institution
NCLEXPN
Comprehensive Review for the NCLEXPN EXAM Maternity Questions And
Answers With Rationales.
20 minutes after a continuous epidural anesthetic is administered, a laboring clients
blood pressure drops from 120/80 to 90/60 mmHG. What action should the practical
nurse take immediately?
A) notif...
Comprehensive Review for the NCLEX-
PN EXAM Maternity Questions And
Answers With Rationales.
20 minutes after a continuous epidural anesthetic is administered, a laboring clients
blood pressure drops from 120/80 to 90/60 mmHG. What action should the practical
nurse take immediately?
A) notify the registered nurse or anesthesiologist
B) continue to assess the blood-pressure q5 minutes
C) place the client in a lateral position
D) turn off the continuous epidural - ANS C) place the client in a lateral position
Rationale: placing a client in the lateral position and placing a pillow or wedge
under one hip will deflect the uterus
The total bilirubin level of a 36-hour, breast-feeding newborn is 14 mg/dL. Based on this
finding, which intervention should the practical nurse implement?
A) provide phototherapy for 30 minutes q8h
B) Feed the newborn with sterile water hourly
C) encourage the mother to breast-feed frequently
D) assess the newborns blood glucose level - ANS C) encourage the mother to
breast feed frequently
Rationale: breast milk provides calories and enhances G.I. motility, which will
assist the bowel in eliminating bilirubin. The total bilirubin level is 6 to 12 mg/dL
after day one of life. The infant’s bilirubin level is beginning to climb, and the
infant should be monitored to prevent further complications.
,A new mother is having trouble breast-feeding her newborn son. He's making frantic
rooting motions and will not grasp the nipple. Which intervention should the practical
nurse implement?
A) encourage frequent use of a pacifier so that the infant becomes accustomed to
sucking
B) hold the infants 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 -
ANS C) encourage the mother to stop feeding for a few minutes and comfort the
infant
Rationale: the infant is becoming frustrated and so is the mother; both need a
timeout. The mother should be encouraged to comfort the infant and to relax
herself. After such a timeout, breast-feeding is often more successful.
Before discharge, what information should the practical nurse give to parents regarding
the newborn's umbilical cord care at home?
A) wash the cord frequently with mild soap and water
B) Cover the cord with a sterile dressing
C) allow the cord to air dry as much as possible
D) apply baby lotion after the baby's daily bath - ANS C) allow the cord to air dry as
much as possible
Rationale: recent studies indicate that air drying or plain water application may be
equal to or more effective than alcohol in the cord healing process
The nurse is preparing a 3-day-old, full term newborn for discharge home. The baby's
mother is HIV-positive. For which procedure should the practical nurse wear gloves?
(Select all that apply)
A) diaper changes
, B) obtaining vital signs
C) formula feeding
D) newborn hearing screening
E) heel stick for metabolic screening
F) discharge bath - ANS A, E) diaper changes and heel stick for metabolic
screening
Rationale: after the infant has been given the admission bath, the PN should wear
gloves only in those situations in which there is a potential for the presence of
HIV positive blood and body fluids.
The nurse is taking the temperature of a client who is 6 hours postpartum. The nurse
notes that the client’s temperature is 100.4°F. Which intervention should the nurse
implement?
A) encourage fluids to increase hydration
B) recheck the temperature and 15 minutes
C) place an ice pack on the clients forehead
D) call the physician for an order for acetaminophen (Tylenol) - ANS A) encourage
fluids to increase hydration
Rationale: it is normal for the postpartum client to have a temperature up to
100.4°F because of dehydration caused by labor. The most appropriate
intervention is to encourage fluids to rehydrate the patient.
As part of the preoperative plan of care for a client who is scheduled for a repeat
cesarean section, the practical nurse plans to administer the nonparticulate antacid
sodium citrate by mouth. What is the purpose of administering this drug preoperatively?
A) prevent postoperative nausea and vomiting
B) raise the gastric pH to above 2.5
C) improve gastric motility
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