NCLEX-RN EXAM QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS VERIFIED

NCLEX-RN EXAM QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS VERIFIED Terms in this set (23) When an infant resumes taking oral feedings after surgery to correct intussusception, the parents comment that the child seems to suck on the pacifier more since the surgery. The nurse explains that sucking on a pacifier: provides an outlet for emotional tension. indicates readiness to take solid foods. indicates intestinal motility. is an attempt to get attention from the parents. Sucking provides the infant with a sense of security and comfort. It also is an outlet for releasing tension. The infant should not be discouraged from sucking on the pacifier. Fussiness after feeding may indicate that the infant's appetite is not satisfied. Sucking is not manipulative in the sense of seeking parental attention. A 19-year-old primigravid client at 38 weeks' gestation is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, "I need to push!" What should the nurse do next? Use the McDonald procedure to widen the pelvic opening. Increase the rate of oxygen and intravenous fluids. Instruct the client to use a pant-blow pattern of breathing. Tell the client to push only when absolutely necessary. Pushing during the first stage of labor, when the urge is felt but the cervix is not completely dilated, may produce cervical swelling, making labor more difficult. The client should be encouraged to use a pant-blow (or blow-blow) pattern of breathing to help overcome the urge to push. The McDonald procedure is used for cervical cerclage for an incompetent cervix and is inappropriate here. Increasing the rate of oxygen and intravenous fluids will not alleviate the pressure that the client is feeling. The client should not push even if she feels the urge to do so because this may result in cervical edema at 7-cm dilation. During the second day postpartum, the nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with a little assistance from her partner. According to Reva Rubin's "phases of bonding," which of the following is the appropriate phase the woman is experiencing? the taking-in phase the taking-hold phase the binding-in phase the letting-go phase The taking-in phase is the period after birth characterized by the women's dependency and passivity with others. Maternal needs are dominant and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The taking-hold phase is the period after birth characterized by a woman becoming more independent and most interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together. A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask which question? "Have you ever had osteomyelitis?" "Do you have any cats at home?" "Do you have any birds at home?" "Have you recently had a rubeola vaccination?" TORCH refers to Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus — agents that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting raw meat, or through contact with raw meat followed by improper hand washing. Osteomyelitis, a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH infections. A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth, breasts begin to produce milk within what time period? 12 hours 24 hours 2 to 4 days 7 days If the client begins breastfeeding early and often after birth, the breasts begin to fill with milk within 48 to 96 hours, or 2 to 4 days. The breasts secrete colostrum for the first 24 to 48 hours, which is beneficial to the neonate because of the immunoglobulins contained in colostrum. The parent of a toddler hospitalized for episodes of diarrhea reports that when the toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, "I don't know what to do!" After the nurse teaches the parent about ways to manage this behavior, which statement by the parent indicates that the nurse's teaching was successful? "Next time she screams and throws her legs, I'll ignore the behavior." "I'll allow her to have what she wants once in a while." "I'll explain why she cannot have what she wants." "When she behaves like this, I'll tell her that she is being a bad girl." The child is demonstrating behavior associated with temper tantrums, which are relatively frequent normal occurrences during toddlerhood as the child attempts to develop a sense of autonomy. The development of autonomy requires opportunities for the child to make decisions and express individuality. Ignoring the outbursts is probably the best strategy. Doing so avoids rewarding the behavior and helps the child to learn limits, promoting the development of self-control. However, the mother should intervene in a temper tantrum if the child is likely to injure herself. Allowing the child to have what she wants occasionally would typically add to the problems associated with temper tantrums because doing so rewards the behavior and prevents the child from developing self-control. Toddlers do not possess the capacity to understand explanations about behavior. Expressing disappointment in the child's behavior or telling her that she is being a bad girl reinforces feelings of guilt and shame, thus interfering with the child's ability to develop a sense of autonomy.