a nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago the nurse notes that the womans radial pulse rate is 55 beatsm
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Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?

Correct answer: C

Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided. Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.

2. A client, age 28, is 8 1/2 months pregnant. She is most likely to display which normal skin-color variation?

Correct answer: D

Rationale: Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face. This hyperpigmentation results from hormonal changes during pregnancy. Vitiligo is characterized by depigmented patches, erythema is redness of the skin due to increased blood flow, and cyanosis is a bluish discoloration due to poor circulation or lack of oxygen, none of which are typical skin-color variations during pregnancy. Therefore, in a pregnant client, the most likely normal skin-color variation to be displayed is chloasma.

3. When should rehabilitation services begin?

Correct answer: A

Rationale: Rehabilitation services should begin when the client enters the health care system to ensure early intervention and optimal outcomes. Initiating rehabilitation early can prevent complications, maximize recovery potential, and improve overall health outcomes. Choice B is incorrect because delaying rehabilitation until the client requests it may result in missed opportunities for timely intervention. Choice C is incorrect as waiting for the client's physical condition to stabilize can lead to unnecessary delays in starting the rehabilitation process, potentially slowing down recovery progress. Choice D is incorrect because starting rehabilitation only after discharge can hinder the recovery process by missing out on crucial early stages of intervention and support.

4. During the examination of a client's throat, a nurse touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which cranial nerves?

Correct answer: D

Rationale: The correct answer is cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). When the nurse touches the posterior pharyngeal wall with a tongue blade and elicits the gag reflex, it indicates normal function of these nerves. Cranial nerves V (trigeminal nerve) and VI (abducens nerve) are not directly responsible for the gag reflex. Cranial nerves XII (hypoglossal nerve) and VIII (vestibulocochlear nerve) are not directly involved in eliciting the gag reflex. Testing cranial nerve I involves smell function, and cranial nerve II is related to eye examinations, making them irrelevant in this scenario.

5. How does the family carry out its health care functions?

Correct answer: B

Rationale: Families play a crucial role in providing preventive health care to their members at home. This includes activities such as promoting healthy lifestyles, ensuring vaccinations, scheduling regular check-ups, and intervening early when health issues arise. Therefore, the correct answer is that the family provides preventive health care to its members at home. Choices A, C, and D are incorrect because families are expected to actively engage in preventive health care practices rather than providing very little preventive care, solely paying for health services, or making hospitalization decisions. The focus is on the proactive role of families in maintaining the health of their members.

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