Health Promotion and Maintenance NCLEX Questions

Health Promotion and Maintenance NCLEX Questions Related

Review Health Promotion and Maintenance NCLEX Questions related questions and content

A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push?

  • A. Holding her breath and using the Valsalva maneuver
  • B. Blowing repeatedly in short puffs
  • C. Cleansing breaths
  • D. Deep inspiration and expiration at the beginning and end, respectively, of each contraction
Correct Answer: B

Rationale: If a woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and breath-holding, helping overcome the urge to push strenuously. The woman would be encouraged to blow repeatedly, using short puffs, when the urge to push is strong. This breathing technique allows for controlled exhalation and helps prevent unnecessary pushing. Cleansing breaths (deep inspiration and expiration at the beginning and end of each contraction) are encouraged during the first stage of labor to provide oxygenation and reduce myometrial hypoxia and to promote relaxation. Holding her breath and using the Valsalva maneuver (choice A) is not recommended as it can increase intra-abdominal pressure and decrease venous return, potentially compromising fetal oxygenation. Deep inspiration and expiration at the beginning and end of each contraction (choice D) are more suitable for relaxation and oxygenation purposes rather than managing the urge to push.

You may also like to solve these questions

A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), the nurse determines that the client is:

  • A. Gravida 2, para 6
  • B. Gravida 6, para 2
  • C. Gravida 3, para 6
  • D. Gravida 2, para 2
Correct Answer: B

Rationale: The term gravida refers to the number of pregnancies, of any duration, that a woman has had. Parity (para) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Therefore, this client is gravida 6 (pregnant for the sixth time), para 2 (has a son and a daughter). In this case, the correct answer is Gravida 6, para 2. Choices A, C, and D are incorrect as they do not accurately reflect the information provided. Pregnancy outcomes are often described using the GTPAL acronym: gravida (G), term births (T), preterm births (P), abortions (A), and live births (L). Applying this to the client's history, the GTPAL would be G = 6, T = 1, P = 1, A = 3, L = 2, which further confirms the correct answer.

A nurse assisting with data collection plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal which disorder?

  • A. Loss of hearing acuity
  • B. A problem with balance
  • C. A problem with distant hearing
  • D. A problem discriminating high-pitched and low-pitched sounds
Correct Answer: B

Rationale: The Romberg test is a balance assessment that evaluates cerebellar function. During the test, the client stands with feet together and eyes closed, aiming to maintain balance for about 20 seconds. This test helps identify issues related to balance and proprioception, not hearing acuity or sound discrimination. Choices C and D are incorrect as the Romberg test focuses on balance, not distant hearing or sound discrimination.

To improve overall health, the nurse should place the highest priority on assisting a client to make lifestyle changes for which of the following habits?

  • A. drinking a six-pack of beer each day
  • B. eating an occasional chocolate bar
  • C. exercising twice a week
  • D. using relaxation exercises to deal with stress
Correct Answer: A

Rationale: To improve overall health, the nurse should prioritize assisting the client in making lifestyle changes that have the most significant impact on health. Drinking a six-pack of beer each day can have serious negative effects on health, including liver damage, increased risk of chronic diseases, and addiction. By addressing this habit first, the nurse can make a substantial positive difference in the client's health. Eating an occasional chocolate bar, exercising twice a week, and using relaxation exercises to deal with stress are beneficial habits, but they are not as detrimental to health as excessive alcohol consumption. Therefore, they are not the highest priority for immediate lifestyle changes to improve health.

A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct?

  • A. Setting the room temperature at a comfortable level
  • B. Placing a chair for the client across from the nurse's desk
  • C. Providing seating for the client so that the client faces a strong light
  • D. Setting up seating so that the client and nurse are not at eye level
Correct Answer: A

Rationale: When preparing the physical environment for an interview with a client, it is crucial to ensure the client's comfort. Setting the room temperature at a comfortable level is essential for the client's well-being. Additionally, providing privacy, sufficient lighting, and removing distractions are crucial factors. It is recommended to maintain a distance of around 4 to 5 feet between the client and the nurse. Seating should be arranged so that the client and nurse are at eye level to facilitate effective communication and prevent barriers. Placing a chair across from the nurse's desk may create a physical barrier, positioning the client to face a strong light can be uncomfortable and distracting, and setting up seating so that the client and nurse are not at eye level may impede effective communication.

When planning for the physical assessment of the woman, the nurse ensures that which occurs?

  • A. The woman is examined by a female health care provider.
  • B. The woman's husband remains in the examining room at all times.
  • C. The woman is examined without any other people in the examining room.
  • D. Written permission is obtained from the woman to obtain subjective health data.
Correct Answer: A

Rationale: In many cultures, including Muslim, Hindu, and Latino, modesty is important, and exposure of a woman's genitals to men is considered demeaning. To respect the patient's cultural beliefs and modesty, it is best for a female health care provider to perform the examination. This practice helps to ensure the patient's comfort and adherence to cultural norms. Having the woman examined without any other people in the room (Choice C) may not address the cultural sensitivity required for this situation. Having the woman's husband remain in the examining room at all times (Choice B) may not align with the patient's cultural preferences and may cause discomfort. Written permission from the woman to obtain subjective health data (Choice D) is not directly related to ensuring a culturally sensitive physical assessment in this context.

Copyright © 2025 Nokea. All rights reserved.