1. Answer C. Exposure to air helps dry the cord. Good hand washing is the prime mechanism for preventing infection. Washing the surrounding area is fine but wetting the cord keeps it moist and predisposes it to infection. It is important to check for complications of bleeding and drainage that might occur.
2. Answer B. Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%, but the test does not positively confirm pregnancy.
3. Answer B. The child develops language skills between the ages of one and three. A six-month-old child is learning to sit alone. The child begins to use a spoon at 12-15 months of age. The baby pulls himself to a standing position about ten months of age.
4. Answer D. According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using something concrete, like a model will help the child understand the explanation of the heart surgery.
5. Answer D. The elderly are better able to distinguish between red and blue because of the difference in wavelengths. The elderly are better able to distinguish between blue and gold because of the difference in wavelengths. The elderly are better able to distinguish between red and green because of the difference in wavelengths. Red and green color blindness is an inherited disorder that is unrelated to age. The elderly have poor blue-green discrimination. The effects of age are greatest on short wavelengths. These changes are related to the yellowing of the lens with age.
6. Answer C. The hospitalized adolescent may see each of these as a threat, but the major threat that they feel when hospitalized is the fear of altered body image, because of the emphasis on physical appearance.
7. Answer C. Universal precautions are necessary for all clients but a specific assessment of the client’s temperature will give an indication the client is becoming infected. Oxytocin may be needed to induce labor if it is not progressing, but it is not done initially.Temperature elevation will indicate beginning infection. This is the most important measure to help assess the client for infections, since the lost mucous plug and the ruptured membranes increase the potential for ascending bacteria from the reproductive tract. This will infect the fetus, membranes, and uterine cavity. More frequent vaginal examinations are not recommended, as frequent vaginal exams can increase chances of infection.
8. Answer B. The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test.
9. Answer B. A review of dietary modifications is important once the woman is pregnant. However, it is not of primary importance when considering pregnancy. Pregnancy makes metabolic control of diabetes more difficult. It is essential that the client start prenatal care early so that potential complications can be controlled or minimized by the efforts of the client and health care team. The alternative of adoption is not necessary just because the client is a diabetic. Many diabetic women have pregnancies with successful outcomes if they receive good care. While there is some risk to the pregnant diabetic woman, it is not considered a major health risk. The greater risk is to the fetus.
10. Answer B. According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living.
11. Answer D. Having to tell families may also be a factor contributing to stress but is not the major stressor. Cost may also be a contributing factor to stress but is not usually the major factor. The inconvenience of multiple tests may also be a factor contributing to stress but is not usually the major factor. Sexual activity "on demand” is the major cause of stress for most infertile couples.
12. Answer A. The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.
13. Answer A. Holding the bottle so the nipple is always filled with formula prevents the baby from sucking air. Sucking air can cause gastric distention and intestinal gas pains. A seven-pound baby should be getting 50 calories per pound: 350 calories per day. Standardized formulas have 20 calories per ounce. This seven-pound baby needs 17.5 ounces per day. 17.5 ounces per day divided by 6-8 feedings equals 2-3 ounces per feeding. A normal newborn without feeding problems could be burped halfway through the feeding and again at the end. If burping needs to be at intervals, it should be done by ounces or half ounces, not minutes. Microwaving is not recommended as a method of warming due to the uneven heating of the formula. If used, the formula should be shaken after warming and the temperature then checked with a drop on the wrist. The recommended method of warming is to place the bottle in a pan of hot water to warm, and then check the temperature on the wrist before feeding.
14. Answer A. Chadwick’s sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4 weeks of pregnancy, that is caused by vasocongestion.
15. Answer D. The elderly are better able to distinguish between red and blue because of the difference in wavelengths. Red and green color blindness is an inherited disorder that is unrelated to age. The elderly have poor blue-green discrimination. The effects of age are greatest on short wavelengths. These changes are related to the yellowing of the lens with age.
16. Answer D. Assessment is always the first step in planning teaching for any client.
17. Answer A. In pregnancy, constipation results from decreased gastric motility and increased water reabsorption in the colon caused by increased levels of progesterone. Increasing fluid intake to three liters a day will help prevent constipation. The client should increase fluid intake, increase roughage in the diet, and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Iron supplements are necessary during pregnancy, as ordered, and should not be discontinued. The client should increase fluid intake, increase roughage in the diet, and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Mineral oil is especially bad to use as a laxative because it decreases the absorption of fat-soluble vitamins (A, D, E, K) if taken near mealtimes.
18. Answer D. Cooperative play is typical of the preschool period.
19. Answer C. According to Erikson”s theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry, and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss.
20. Answer D. Beef and beans are an excellent source of protein as is skim milk. Strawberries are a good source of Vitamin C.
Moe NCLEX Questions
Passing the NCLEX made easy