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Free NCLEX-PN Exam Braindumps (page: 18)

Page 18 of 254
PDF with 1015 Questions

When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?

  1. nausea and vomiting
  2. itching
  3. urinary retention
  4. somnolence

Answer(s): B

Explanation:

A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours.
Nausea and vomiting might occur 4-7 hours after injection.
Urinary retention is a side effect of postpartum epidural morphine but is not assessed as such within the first 3 hours.
Somnolence is a rare side effect.



The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?

  1. “It is normal for your breasts to be tender. You should call the physician if you also have redness and fatigue.”
  2. “Because your baby was delivered vaginally, you might have to urinate more frequently.”
  3. “It is normal to run a low-grade temperature for a few days. If it is higher than 100° F, call your physician.”
  4. “Be sure to call your physician if your vaginal discharge becomes bright red.”

Answer(s): D

Explanation:

The vaginal discharge after birth is called lochia, and it changes from red (rubra) to serosa (clear) on the third postpartum day. If it returns to red or contains clots, it could signal impending hemorrhage or infection and the physician should be notified.
It is not normal for the breasts to be tender. If the breasts become engorged, they might be tender and the mother might need to be given additional instructions on breast care. Tenderness, redness, and fatigue are clinical manifestations of mastitis and should be reported to the physician.
A woman should void in normal patterns and frequency after birth. Increased frequency is a sign of a urinary tract infection and should be reported to the physician.
By the time of discharge, the woman’s temperature should be normal. Elevations should be reported to the physician.



The parents of a 2-year-old child ask the nurse how they can teach their child to quit taking toys away from other children.

Which of the following statements by the nurse offers the parents the best explanation of their child’s behavior?

  1. “Your child is egocentric. Egocentricity is normal for 2-year-old children. He believes other children want him to have their toys.”
  2. “Your child is showing negativity. He doesn’t want other children to have the toys he wants.”
  3. “Your child is demonstrating magical thinking. He believes he can make the other children want him to play with their toys.”
  4. “Your child is engaging in domestic imitation. He is doing what he has seen other children do.”

Answer(s): A

Explanation:

Two-year-old children are very egocentric. They believe everything and everyone is concerned about them. They believe other children want them to have their toys. This is different than believing they can make other children want them to have all the toys, as in magical thinking, which normally occurs in preschool-age children.
Toddlers are very negative, but this is expressed by refusal of requests made to them.
Domestic imitation does occur in preschool-age children, but it refers to the imitation of household chores and roles performed by adults, not the imitation of other children.



Which of the following infant behaviors demonstrates the concept of object permanence?

  1. The infant cries when his mother leaves the room.
  2. The infant looks at the floor to find a toy that he was playing with and dropped.
  3. The infant picks up another toy after the one he was playing with rolls under the couch.
  4. The infant participates in a game of patty-cake.

Answer(s): B

Explanation:

Object permanence occurs when the infant learns that something/someone still exists even though they might not be able to see it/them. This develops between 9 and 10 months of age. If the infant cries when his mother leaves the room, it might be because he believes she is no longer in the house when he can’t see her. If an infant picks up another toy after the one he is playing with rolls under the couch and the infant fails to look for it, he believes the toy that rolled under the couch no longer exists.
Patty-cake is a game infants engage in but, it has nothing to do with object permanence.
An infant game that does show object permanence is peek-a-boo. In this game, an infant continues to hunt for a hidden face because he believes it is still there.






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