2300 Final Review
A 26 year old primiparous client is seen in the urgent care clinic 2 weeks after delivering a viable female neonate. Client, who is breast-feeding, is diagnosed with infectious mastitis of the right breast. Client asks the nurse, "Can I continue breast-feeding?" Which of the following responses would be most appropriate? A." You can continue to breast-feed, feeding a your baby more frequently." B."You can continue once your symptoms begin to decrease." C."You must discontinue breast-feeding until antibiotic therapy is completed." D."You must stop breast-feeding because the breast is contaminated."
A
After instructing a primiparous client who is bottle-feeding, which of the following client statements indicates client needs further teaching? A."I'll burp him after 15 minutes of feeding him formula." B."After he takes one-half ounce of formula, I'll burp him." C."I'll burp him while he is in a upright position." D."I'll gently pat his back to get him to burp"
A
Assessment of a term neonate at 2 hours after birth reveals a heart rate of 110 bpm. Periods of apnea approximately 25 to 30 seconds in length and mild cyanosis around the mouth. The nurse notifies the pediatrician based on the interpretation that these findings may lead to which condition? A.Respiratory arrest B.Bronchial pneumonia C.Intraventricular hemorrhage D.Epiglottitis
A
Delegation is the process of transferring work to subordinates. A nurse manager can appropriately delegate which task? A.Scheduling staff assignments for the next month B.Terminating a nursing assistant for insubordination C.Deciding on Salary increases for licensed practical nurses after they complete orientation D.Telling a staff nurse to initiate disciplinary action against one of her peers
A
The nurse makes a home visit to a 3-day old full term neonate who weighed 3,912 g (8 lb. 10 oz) at birth. Today the neonate who is being bottle-fed weighs 3,572g (7 lb, 14 oz). Which of the following instructions would the nurse most likely give to the mother? A.Continue feeding every 3 to 4 hours since the weight loss is normal. B.Contact the physician if the weight loss continues over the next few days. C.Switch to a soy-based formula because the current one seems inadequate. D.Change to a higher - calorie formula to prevent further weight loss.
A
The role of the nurse in hospitals includes managing other members of the health care team. A. True B. False
A
While making a home visit to a primiparous client and her 3 day old son, the nurse observes, the mother changing the baby's disposable diaper. Before putting the clean diaper on the neonate, the mother begins to apply baby power to the neonate's buttocks. Which of the following statements about baby powder would the nurse relate to the mother? A.It may cause pneumonia to develop B.It helps prevent diaper rash C.It keeps the diaper from adhering to the skin D.It can result in allergies late in life
A
36 week PG woman presents complaining of mid-epigastric tenderness, nausea & vomiting. Looks unwell. BP is 146/100; lab test show normal renal function, low platelet count, AST level of 80 IU/L (elevated liver enzymes, & hemolysis with a microangiopathic blood smear. Diagnosed with HELLP. Which of the following is the most important initial therapeutic intervention for this patient? A. Bedrest until fetal reaches 40 weeks B. Immediate delivery C. Platelet infusion to prevent bleeding D. Right upper quadrant ultrasound
B
A client delivered vaginally two hours ago and has a third-degree laceration. Ice in place on her perineum. However, perineum is slightly edematous and client is complaining of pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time? A.Begin sitz baths B.Administer pain medication per order C.Replace ice packs to the perineum D.Initiate anesthetic sprays to the perineum
B
A nurse manager of an ICU can NOT be held legally responsible in a court of law for which action performed by the unit's staff? A.A nursing assistant administers IV medications to a client in ICU B.A staff nurse refuses to follow physician's order to administer medication because administering the dosage ordered could seriously harm the client C.A nursing assistant attempts to initiate I.V. therapy D.A staff nurse fill 's client prescription at the hospital pharmacy because the pharmacist on duty is busy
B
A prim parous client who is bottle feeding her neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which of the following responses by the nurse would be most appropriate? A."Your menstrual cycle will return in 3 to 4 weeks." B."It will probably be 6 to 10 weeks before it starts again." C."You can expect your menses to start in 12 to 14 weeks." D."Your menses will return in 16 to 18 weeks."
B
A viable female neonate delivered vaginally at term has Apgar scores of 9 at 1 minute and 10 at 5 minutes after birth. Immediately postpartum, the nurse keeps the infant under a radiant warmer away from the cooling ducts in the room to prevent heat loss by which of the following mechanisms A.Evaporation B.Convection C.Conduction D.Radiation
B
After instructing a primiparous client about episiotomy care, which of the following client statements indicates successful teaching? A "I'll use hot, sudsy water to clean the episiotomy area." B. "I wipe the area from front to back using a blotting motion." C. "Before bedtime, I'll use a cold water sitz bath." D. "I can use ice packs for 3 to 4 days after delivery."
B
Approximately 90 minutes after birth, the nurse encourages the mother of a term neonate to do which of the following? A.Feed the neonate B.Allow the neonate to sleep C.Get to know the neonate D.Change the neonate's diaper
B
At which of the following locations would the nurse expect to palpate the fundus of a prim parous client 12 hrs. after delivery of a neonate? A.Halfway between the umbilicus and the symphysis pubis B.At the level of the umbilicus C.Just below the level of the umbilicus D.Above the level of the umbilicus
B
Mrs. Jones now asks: " This hurt a lot. I don't want to have another baby for a long time. If I continue to breast feed I won't have to worry about it, right?" You respond: A."That's right." B." That may or may not be correct." C." Odds are you will get pregnant." D." What's wrong with you? Jordan Junior needs a sibling."
B
When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which of the following? A.Chorioretinitis from cytomegalovirus. B.Blindness secondary to gonorrhea. C.Cataracts from beta-hemolytic streptococcus. D.Strabismus resulting from neonatal maturation.
B
While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the pediatrician? A. Red reflect in the eyes B. Expiratory grunt C. Respiratory rate of 45 breaths/minute D. Prominent xiphoid process.
B
A 6 lb, 8 oz. neonate was delivered vaginally at 38 weeks gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, overall pale white in color. The Apgar score is: A. 2 B. 3 C. 4 D. 6
C
A client is in the first hour of her recovery after a vaginal deliver. During an assessment, the lochia is moderate, bright red and trickling from the vagina. Nurse locates fundus at the umbilicus: firm and midline with no palpable bladder. Client vital signs remain at their baseline. Based on this information, the nurse would implement which of the following actions? A.Increase the I.V. rate B.Recheck the admission hematocrit and hemoglobin levels C.Report the finding to the health care provider. D.Document the findings as normal
C
A nurse is completing discharge teaching for a client who is hospitalized for total hip replacement. The client asks the nurse why there is a case manager involved and expresses confusion about who is in charge. The client states, "I thought my doctor manages my care." Which is the best response by the nurse? •A) "No, I manage your care." •B) "You are correct; the doctor is responsible for managing your care." •C) "A case manager coordinates everyone involved in your care to ensure your needs are met." •D) "The case manager delegates your care to the nurse."
C
If using a 4 or 5 column nursing care plan what elements are included : A.Medical diagnosis, medications, standard course of the disease, evaluation B.Medical diagnosis, nurses name caring for client, medications, evaluation C.Nursing diagnosis, goals or desire outcomes, nursing interventions, evaluation D. Nursing diagnosis, goals or desire outcomes, nursing interventions, evaluation
C
Initial assessment of a term female neonate about 4 hours old reveals a normal anterior fontanel. The nurse documents its shape as which of the following? A.Oval B.Square C.Diamond shaped D.Triangular
C
Nurse is assessing a cesarean section client who delivered 12 hours ago. Findings include: distended abdomen with faint bowel sounds x 1 quadrant, fundus firm at umbilicus, lochia scant rubra, and pain rated 4 on a scale of 1 to 10. IV and Foley catheter have been discontinued; client medicated 3 hours ago for pain. When planning care for this client, what should the nurse identify as the highest priority interventions? A.Medicate the client B.Incentive spirometry C.Ambulate the client D.Encourage caring for infant
C
Primiparous client who underwent a caesarean delivery 30 minutes ago is a candidate for Rho(D) immune globulin (RhoGAM). Nurse anticipates administering this ordered medication within which time frame after delivery? A.8 hours B.24 hours C.72 hours D.96 hours
C
The physician orders an intramuscular injection of phytonadione (AquaMephtyton) Vitamin K for a term neonate. The nurse explains to the mother this medication is used to prevent which of the following? A.Hypoglycemia B.Hyperbilirubinemia C.Hemorrhage D.Polycythemia
C
This course is being run in what type of format: A.Lecture only no interaction B.Lecture only with some interaction C.Flipped Classroom concept D.Online format
C
When developing a plan of care for a prim parous client during the first 12 hours after vaginal delivery, which of the following concerns of the client should be the nurse's primary focus of care? A.The neonate B.The family C.The client's own comfort D.The client's significant other
C
Which concept refers to the role of a professional nurse in client advocacy? A.The nurse makes decisions for clients who can't make decisions for themselves B.The nurse follows the basic standards of care and hospital policies and procedures for providing care for clients C.The nurse promotes and protects the clients interests and rights D.The nurse adapts a paternalistic approach toward the care of clients
C
Which of the following observations would the nurse expect when assessing the gestational age of a neonate delivered at term? A.Ear lying flat against the head B.Absence of rugae in the scrotum C.Sole creases covering the entire foot D.Square window sign angle of 90 degrees
C
Which statement is true concerning informed consent? A.Minors are permitted to give informed consent B.The Professional nurse and physician may both obtain informed consent C.The client must be fully informed regarding treatment, tests, surgery and the risks and benefits prior to giving informed consent D.Mentally competent and incompetent clients can legally give informed consent
C
While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which of the following responses would be most appropriate? A."It's of no concern because it is such a small amount." B."The cause is usually related to swallowing blood during the delivery." C."Sometimes baby girls have this from hormones received from the mother." D."This vaginal spotting is caused by hemorrhagic disease of the newborn"
C
38 year old woman is 36 weeks pregnant presents with HTN since age 34 with requires antihypertensive drugs. Prior to PG her BP was 130/70. During first trimester: BP 120/60; has risen in recent weeks to 150/95. Complaining of worsening lower extremity edema. 24 hour urine shows 1500 mg of protein. Lab values for electrolytes, liver function tests platelet count are normal. What is the patient's diagnosis? A. Chronic essential hypertension B. Eclampsia C. HELLP syndrome D. Preeclampsia
D
A 27 year old female 30 weeks pregnant presents to her MD for routine follow-up: BP 150/105 Hg; previously normotensive. Urinalysis reveals 1+ proteinuria. Serum uric acid level is 5.0mg/dl. Platelet count & liver function tests - normal. 24 hr Urine collection: 1.1 grams of protein Which of the following does this patient most likely have? A.Chronic hypertension B.Gestational Hypertension C.Normal Blood pressure for pregnancy D.Pre-eclampsia
D
A nurse working in the triage area of an emergency department sees that several pediatric clients arrive simultaneously. Which client should be treated first? A.A crying 4 year old child with a laceration on his scalp B.A 3 year old child with a barking cough and flushed appearance C.A 3 year old child with Down syndrome who's pale and asleep in his mother's arms D.A 2 year old child with stridorus breath sounds, sitting up in his mother's arms and drooling
D
A nurse, who works in a clinic environment, places great emphasis on cost control, customer satisfaction, health promotion, and preventive services. The primary focus of this nurse is representative of which type of healthcare system? •A) Functional method •B) Client-focused care •C) Case method •D) Managed care
D
The nurse is caring for a postpartum client who delivered vaginally 4 hours ago and has not voided since delivery. Feeling has returned to her perineal area; she ambulated to bathroom and attempted to void twice. Ice is on her edematous perineum. Uterus is 3 fingerbreadths above the umbilicus, to the right of midline and firm only with massage. What would be the priority nursing actions? A.Evaluate the client with a bladder scan B.Insert a Foley catheter C.Medicate the client with a nonsteroidal anti-inflammatory drug (NSAID) D. Massage the fundus until it is firm and perform a one-time catheterization on the client
D
Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the clients bladder, finding it distended. The nurse interprets this finding based on understanding the client's bladder distention is most likely caused by which of the following? A.Prolonged first stage of labor B.Urinary tract infection C.Pressure of the uterus on the bladder D.Edema in the lower urinary tract area
D
While making a home visit to a postpartum client on day 11, nurse would anticipate client's lochia would be which color? A. Dark red B. Pink C. Brown D. White
D
While the nurse is preparing to assist a primparous client to bathroom to void 6 hours after a vaginal delivery under epidural anesthesia, client says she feels dizzy when sitting up on side of bed. Nurse explains this is most likely caused by which of the following? A.Effects of the anesthetic during labor. B.Hemorrhage during the delivery process C.Effects of analgesics used during labor D.Decreased blood volume in the vascular system
D
