NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. Around what age do children typically start to develop 'stranger anxiety'?
- A. 9 months
- B. 6 months
- C. 3 months
- D. 12 months
Correct answer: B
Rationale: The correct answer is '6 months.' At around this age, children typically start to develop 'stranger anxiety' as they become more aware of unfamiliar faces and may start showing signs of distress or anxiety around strangers. At 3 months, infants are still very young and unlikely to display stranger anxiety. While by 9 or 12 months, children have usually already developed some level of stranger anxiety, it typically starts around 6 months, making it the most appropriate answer in this context.
2. A nurse is telling a pregnant client about the signs that must be reported to the health care provider. The nurse tells the client that the health care provider should be contacted if which occurs?
- A. Puffiness of the face
- B. Breast tenderness
- C. Morning sickness
- D. Urinary frequency
Correct answer: A
Rationale: During pregnancy, it is important to be aware of danger signs that warrant contacting the healthcare provider. Puffiness of the face, especially around the eyes, can indicate a serious condition like preeclampsia. Other danger signs include vaginal bleeding, rupture of membranes, severe abdominal pain, visual disturbances, persistent vomiting, and changes in fetal movements. Morning sickness, breast tenderness, and urinary frequency are common symptoms of pregnancy and are not typically concerning unless they become severe or persistent, and do not usually require immediate medical attention.
3. A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which part of the fetus?
- A. Back of the fetus
- B. Carotid artery in the neck of the fetus
- C. Brachial area of one extremity of the fetus
- D. Chest of the fetus
Correct answer: A
Rationale: The nurse would use the Leopold maneuvers to identify the position of the fetus and determine the location of the fetal back. The fetal heart rate (FHR) is most easily heard through the fetal back because it usually lies closest to the surface of the maternal abdomen. Auscultation of the FHR over the chest, carotid artery, or brachial area is not possible due to the fetal position within the maternal abdomen. Placing the fetoscope over the carotid artery or brachial area would not yield the fetal heart rate, and the chest area is not typically used for auscultating the FHR.
4. The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which observation is a sign of physical readiness?
- A. The child no longer has temper tantrums.
- B. The child can remove his or her own clothing.
- C. The child has been walking for 2 years.
- D. The child can eat using a fork and knife.
Correct answer: B
Rationale: Signs of physical readiness for toilet training include the child's ability to remove his or her own clothing. This ability indicates the child has developed the necessary fine motor skills to manage clothing during toilet training. The other choices are incorrect because temper tantrums, walking for a specific period, and using utensils are not indicators of physical readiness for toilet training.
5. A nurse is assisting with data collection on the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age?
- A. The infant babbles single consonants
- B. The infant babbles
- C. The infant says 'Mama.'
- D. The infant says 'Mama.'
Correct answer: D
Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as 'Mama,' 'Daddy,' 'bye-bye,' and 'baby,' begin to have meaning. A 1- to 3-month-old infant produces cooing sounds. Babbling is common in a 3- to 4-month-old. Single-consonant babbling occurs between 6 and 8 months of age. Therefore, the milestone of the infant saying 'Mama' is the most appropriate for a 9-month-old, indicating early language development. The other choices are developmentally inaccurate for a 9-month-old infant.
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