The nurse is caring for a toddler with a cardiac defect who has had se

NCLEX Maternal Newborn

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Question 1 of 5.

The nurse is caring for a toddler with a cardiac defect who has had several episodes of congestive heart failure in the past few months. Which data would be the most useful to the nurse in assessing the child's current congestive heart failure?

A. The degree of clubbing of the child's fingers and toes

B. Amount of fluid and food intake

C. Recent fluctuations in weight

D. The degree of sacral edema

Explanation: Recent weight fluctuations are the most reliable indicator of fluid retention or loss in congestive heart failure.

Question 2 of 5.

The nurse is caring for a woman who had a hysterectomy. Which vascular complication should the nurse be especially alert for because of the location of the surgery?

A. Thrombophlebitis

B. Varicose veins

C. Cerebral embolism

D. Aortic aneurysm

Explanation: Pelvic surgery, like a hysterectomy, increases the risk of thrombophlebitis due to venous stasis and surgical trauma.

Question 3 of 5.

A woman is to have internal radiation as part of her treatment for cancer of the cervix. In teaching her about the preoperative preparation for this procedure, the nurse should include which information?

A. A high-residue diet will be ordered.

B. An indwelling catheter will be inserted.

C. A nasogastric tube will be inserted.

D. Several units of blood will be ready for transfusion if needed.

Explanation: An indwelling catheter is inserted to keep the bladder empty, reducing radiation exposure to nearby organs.

Question 4 of 5.

A young woman asks the nurse if oral contraceptives have any side effects. What is the best response for the nurse to make?

A. Nausea, fluid retention, and weight gain.'

B. Why do you ask? Look at the benefits.'

C. Are you concerned about something?'

D. Increased libido, decreased breast size, and diarrhea.'

Explanation: Nausea, fluid retention, and weight gain are common side effects of oral contraceptives, providing accurate information.

Question 5 of 5.

The nurse is discussing breast self-examination with a group of women in a clinic. One woman asks, 'When should I do this examination?' What is the best response for the nurse?

A. You should perform breast self-examination early in the morning for most accurate results.'

B. Breast self-examination should be done a few days after your period begins every month.'

C. Breast self-examination should be done by women after the age of 40 on the first of every month.'

D. Breast self-examination is best done just before you expect your menstrual period.'

Explanation: Performing breast self-examination a few days after menstruation, when breasts are less tender, ensures accuracy.