418 Final
A nurse is teaching an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrate an understanding of the teaching? A. I will use my peak flow meter whenever I fell SOB B. I will continue to take my medication when my peak flow rate is in the green zone. C. I need to use the average of 3 readings when I measure my flow rate D. My asthma is being controlled if my flow rate is in the yellow
b
32 weeks gestational development
32 wks: - Bones are fully developed. Lungs are maturing. - Increased amounts of adipose tissue are present.
A nurse is teaching the parents of a 10-year-old child who has iron-deficiency anemia. Which of the following statements by a parent indicates an understanding of the teaching? A. I will give my child an iron tablet once each day at bedtime B. I will administer the iron tablet with orange juice. C. I will encourage my child to take an antacid with the iron tablet D. I will crush the iron tablet prior to giving it to my child
b
There are no indications of retractions, grunting, or nasal flaring. Which of the following actions should the nurse take? A. Request a prescription for continuous positive airway pressure (CPAP) B. Initiate close observation of the newborn for indications of respiratory distress C. Consult a respiratory therapist for chest physiotherapy D. Request an order for nitric oxide therapy.
b
nurse is reviewing the lab values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect? A. Gestational diabetes B. Preterm labor C. Inadequate milk supply D. Inadequate uterine growth
b
Postpartum Hemorrhage and meds to give
blood loss greater than 500 mL after a vaginal birth or 1000 mL after a cesarean birth meds: methergine
If a toddler needs to increase their respiratory expansion how would you get them to expand their lungs?
blowing bubbles blowing a pinwheel
A nurse is assessing a 4-year-old child for growth and developmental milestones during a well-child visit. Which of the following findings suggests a possible delay in development? A. Inability to tie shoes B. Adding 3 parts to a stick figure C. Speaking using 2 or 3-word sentences D. Inability to walk backward.
c
A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration? A. Bulging anterior fontanel B. Bradycardia C. Tachypnea D. Polyuria
c
A nurse is assessing a 7 yr old childs psychosocial development. Which of the following findings should the nuse recognize asan indicator for further evaluation? A. The child prefers playmates of same sex BThe child is competitive whil playing board games C. The child complains daily about going to school D. The child enjoys spending time alone
c
A nurse is assessing a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration? A. Slight thirst B. Capillary refill of 3 seconds C. Deep, rapid respirations D. Decreased tear production
c
A nurse is caring for an adolescent who has end-stage renal disease and is scheduled for peritoneal dialysis. Which of the following actions should the nurse take? A. Position the adolescent supine during the procure B. Have the adolescent drink 240 mL (8 oz) of fluid prior to the procedure. C. Obtain the adolescent's weight prior to the procedure. D. Monitor the adolescent's vital signs every 4 hours during the procedure.
c
A nurse is planning care for a preschooler who is scheduled for a surgical procedure. The nurse should identify the preschooler is in which of the following of Eriksons psychological stages of development? A. Industry vs. Inferiority (school age) B. Trust vs. Mistrust (infant ) C. Initiative vs. guilt (preschooler) D. Identity vs. role confusion (adolescent)
c
A nurse is providing teaching to the family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the teaching? A. Donepezil might slow the progression of the disorder. B. My child will prefer group therapy with other children. C. We can help our child by structuring our daily routine. D. Our child probably has this condition as a result of prematurity.
c
nurse is present at the time of the child's death following a terminal illness. Which of the following statements should the nurse make to the child's parent? A. If you'll excuse me, I'll go call the funeral home to have them pick up your child. B. Your child is no longer suffering. C. I will miss your child's infectious laugh; it always made me smile. D. You should consider how to share the news of your child's death with her siblings.
c
A nurse is assessing a client who is 30 weeks gestation and has gestational hypertension. Which of the following findings should the nurse identify as an indication that the client needs a biophysical profile? A. Fundal height 30 cm B. Fetal movement count 12 kicks in 12 hours C. Fetal HR 136/min D. Nonreactive non-stress test
d
A nurse is caring for a client in early stages of labor who has preeclampsia with severe features. WHich of the following interventions should the nurse perform? A. Assess the FHR and contractions hourly B. Encourage oral intake of clear low Na+ fluids C. Instruct client to ambulate during early phase of labor D. Implement seizure precautions
d
A nurse is caring for an infant who is 6 months old and has moderate dehydration. Which of the following findings should the nurse expect? A. Absent tears B. Weight loss >10% C. Lethargy D. Dry mucous membranes
d
A nurse is providing teaching to the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets. Which of the following statements by the parent indicates an understanding of the teaching? A. I should expect my child to gain weight while taking this medication B. I should expect this medication to decrease my child's heart rate C. I should crush the medication and put it in my child's food D. I should give this medication to my child half an hour before breakfast.
d
A school nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse plan to administer to the child? A. Zafirlukast B. Budesonide C. Montelukast D. Albuterol
d
information should the nurse include in the teaching? A. Crush the medication and mix it in your child's food. B. Administer the medication 1 hour before bedtime. C. Expect your child to have cloudy urine while he is taking this medication. D. Weigh your child twice per week while he is taking this medication.
d
End of Life: STAGES OF GRIEF
denial, anger, bargaining, depression, acceptance
gestational development 16 wks
6 wks: - Lanugo present on head - Meconium is formed in intestines - Teeth begin to form - Sucking motions are made with mouth - Skin is transparent
Breast feed baby urine output
6-8 diapers a day feed every 2-3 hours
A nurse is caring for a newborn immediately following birth. Which of the following ations should the nurse take first ? A. Weigh newborn B. Insert eye ointment C. Administer vitamin K D. Dry newborn
ANS. D.
A nurse is preparing to administer furosemide (Lasix) 2 mg/kg/dose PO every 12 hr to an infant who weighs 12 lb. Available is furosemide oral solution 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth.)
ANS: 1.1 mL
A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority? A. Measure the client's weight daily B. Check for tears C. Palpate the frontanel D. Assess skin turgor
a
Gestational development 12 weeks
12 wks: - RBC are produced in liver - fusion of palate is complete - External genitalia develop - Eyelids are closed - FHR tone can be heard by doppler
36 weeks gestational development
36 wks: - Lanugo begins to disappear. - Labia majora and minora are equally prominent. - Testes are in upper portion of scrotum.
40 weeks gestational development
40 wks: - Fetus is considered full term at 38 weeks. - All organs/systems are fully developed.
postpartum uterus assessment
B-breast U-uterus B- bladder B-bowel L-lochia E extremities E Emotions
culturally congruent care
care that fits the person's life patterns, values, and a set of meanings
Nurse dependent
needs care 24 hours by nurse
gestational development 20 weeks
20 wks: - Lanugo covers body - Vernix caseosa covers body - Nails form - Brown fat develops
gestational development 24 weeks
24 wks: - Eyes are developed - Alveoli form in lungs (surfactant produced) - Footprints and fingerprints forming - Resp movement can be detected
28 weeks gestational development
28 wks: - Eyelids are open. Adipose tissue develops rapidly. - The respiratory system has developed to a point where gas exchange is possible, but lungs are not fully mature
A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Post-term birth B. Macrosomia C. Respiratory distress syndrome D. Maternal gestational diabetes
ANS: C. RDS is a risk factor for NEC. Respiratory distress causes intestinal ischemia secondary to hypoxia.
A pt is 48 hours post-delivery. While assessing fundal height, the nurse would expect the fundal height to be?
ANS: 2 cm below umbilicus. (1 cm per 24 hours )
A nurse is caring for an adolescent who weighs 57 kg. What is the adolescent's daily maintenance fluid requirement? (Round the answer to the nearest whole number.)
ANS: 2240 mL/day 100mL/kg x first 10 kg 50mL/kg x second 10kg 20mL/kg x remainder weight in Kg 1000+500+740=2240
A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 6 mL/kg IV to infuse over 2 hr to an infant who weighs 8 kg. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number.)
ANS: 24 mL/hr
Which of the following behaviors would be under the category "grimace" in the Apgar score? Select all that apply. A. Sneezing B. Grasping C. Coughing D. Pulling away
ANS: A, C, D
A nurse working on a maternal-newborn unit is teaching a group of newly licensed nurses about assisting new mothers with breastfeeding. The nurse should include which of the following infant conditions as a contraindication for breastfeeding? A. Galactosemia B. Hyperbilirubinemia C. Glycogen storage disease D. Hypothyroidism
ANS: A. An infant who has galactosemia cannot metabolize lactose. Breast milk contains lactose, which can cause failure to thrive, cirrhosis, developmental delays, and even death in affected infants. An infant who has galactosemia is fed with formula made with milk substitutes.
A nurse is reviewing the risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors shoulds the nurse include? A. Gestational diabetes B. Planned pregnancy C. Being married D. Post-term birth
ANS: A. Gestational diabetes increases the risk of postpartum depression. Other risk factors include infertility treatment, pregnancy complications, preterm birth, and a history of mood disorder.
A nurse is initiating phototherapy for a newborn who has hyperbilirubinemia. Which of the following actions should the nurse take? A. Place an opaque mask over the newborn's eyes B. Apply lotion to the newborn's skin twice daily C. Dress the newborn in a diaper and t-shit D. Check the newborn's temperature twice daily.
ANS: A. The nurse should cover the newborn's eyes with an opaque mask to prevent retinal damage from the ultraviolet light used in phototherapy. Also, ensure the baby's eyes are closed before applying the eye mask.
nurse is reviewing the lab report of a newborn who has a blood type of B-. The mother is O+. The lab results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate? A. Hyperbilirubinemia B. Central cyanosis C. Intracranial hemorrhage D. Cardiomyopathy
ANS: A. The nurse should identify that some infants of mothers with type O blood are at an increased risk of developing hyperbilirubinemia because these mothers possess naturally occurring A and B antibodies, which are transferred across the placenta to the fetus.
A nurse is assessing a 2-month-old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8 (4 lb) B. Heart rate of 125/min C. Soft, flat fontanel D. Systemic murmur
ANS: A. The weight gain indicates increased fluid and worsening of the child's HR; therefore, the nurse should report this finding to the provider.
A nurse is caring for a client who is at 28 weeks gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer? A. Oxytocin B. Nifedipine C. Dinoprostone D. Misoprostol
ANS: B. Nifedipine is a tocolytic medication that is administered to stop preterm labor.
A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? A. Atrial septal defect B. Renal agenesis C. Spinal Bifida D. Hydrocephalus
ANS: B. Oligohydramnios is a volume of amniotic fluid that is <300 mL during the third trimester of pregnancy. This occurs when there is a renal system dysfunction or obstructive uropathy. The absence of fetal kidneys will cause oligohydramnios.
A nurse is teaching the parents of a 10-year-old child who has iron-deficiency anemia. Which of the following statements by a parent indicates an understanding of the teaching? A. I will give my child an iron tablet once each day at bedtime B. I will administer the iron tablet with orange juice. C. I will encourage my child to take an antacid with the iron tablet D. I will crush the iron tablet prior to giving it to my child
ANS: B. The intake of citrus juice with iron will increase the iron's absorption.
A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take? A. Measure the newborns length from aterior fontanel to heel B. Measure newborns weight while wearing a clean diaper C. Measure circumference of newborns head just above eyebrows D. Mmeasure circumference of neewborns chest with tape measure 2 cm below the nipple line
ANS: C.
A nurse is teaching a client who is postpartum and breastfeeding. Which of the following statements should the nurse include? A. You will need to wait 3 months before resuming sexual intercourse B. You don't need to use contraception until you are 4 months postpartum C. As long as you breastfeed, you will experience an overproduction of vaginal lubrication D. A reduction in sexual interest could indicate postpartum depression
ANS: D. Manifestations of postpartum depression include decreased libido, feelings of sadness or anxiety, difficulty sleeping, or loss of appetite
A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription of phototherapy. Which of the following interventions should the nurse include in the plan? A. Discontinue therapy if a fine rash appears B. Place moisturizing lotion on the newborn's skin C. Supplement feedings with 1 oz of glucose water every 4 hours D. Change the newborn's position every 2 to 3 hours
ANS: D. This will help maximize skin exposure to the light in phototherapy.
A- appearance/color of baby, its normal to have cyanosis immediately after birth 0=pale or blue 1= pink body blue extremities 2= pink P- pulse 0=absent 1= less than 100 2= greater than 100 G- grimace, gentle rubbing of soles 0=no response 1= grimacing 2= crying A- activity (flaccid or moving limbs) 0=flaccid 1= some flexion 2= well flexed extremities R- respiratory rate 0= absent 1=slow, weak cry 2= good strong cry
APGAR- do at 1 min and 5 min, in each category you get 0,1, or 2 --0-3 indicates severe distress --4 to 6 indicates moderate difficulty with transition to extrauterine life --7 to 10 indicates stable status
ACES
Adverse childhood experiences are traumatic events that occur before a child reaches the age of 18 Aces are typically categorized by abuse neglect and household dysfunction
A nurse is reviewing the lab report of a toddler who is receiving chemotherapy for leukemia. Which of the following lab values should the nurse report to the provider? A. Platelets 150,000/mm^3 B. Hgb 6 g/dL C. WBC 6,000/mm^3 D. Potassium 4.5 mEq/L
b
Sensory processing disorder interventions
As a nurse you can lower lights and adjust stimuli Early intervention is key Individual and family therapy Tactile stimulation - short periods of exposure to stimuli to build tolerance ● Massagers ● Vibrating toothbrush ● Aromatherapy ● Weighted vests ● Reduced light ● Distraction
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take? A. Administer the medication while the infant is supine. B. Give the medication at the side of the infant's mouth. C. Add the medication to a full bottle of the infant's formula. D. Administer the medication slowly while holding the nares closed.
B. Give the medication at the side of the infant's mouth.
A nurse is teaching the parents of an infant who has acute otitis media about how to administer antibiotic eardrops. Which of the following instructions should the nurse include? A. Chill the medication prior to administration. B. Massage the anterior area of the infant's ear following administration C. Hyperextend the infant's neck during administration. D. Pull the auricle up and back during medication administration.
B. Massage the anterior area of the infant's ear following administration
Q:A nurse is completing a pain assessment on an infant. Which of the following pain scales should the nurse use? A. FACES B. FLACC C. Oucher D. Non-communicating childrens pain checklist
B: FLACC
A nurse is caring for a client in active labor who is experiencing hypotension following epidural placement. Which of the following actions should the nurse take? A. Decrease IV fluids B. Give O2 at 2L a min via NC C. Place client in lateral postiion D. Administer indomethacin
C. Place client in lateral position
medically fragile
Children who need skilled nursing care with or without medical equipment to support vital functions.
End of life care for children
Family centered care in end of life ● Communication should be compassionate, cognitively appropriate, and based on health care providers assessment ● Nurse communication with each member of the care team on an individual basis ensures optimum care of the patient and family Morphine used for pain control - not to be given if RR <17 breaths/minute
medically complex
Medically complex: conditions that range from functionality that's limited, to life threatening and requires consistent/ongoing specialized care
Risks for preeclampsia
Mult. gestations chronic HTN kidney disease DM
Still birth
Support patient through the grieving process. • Acknowledge their loss. • Nurse should recommend private time with the baby, but the patient may decline. • They are allowed to change their mind later if they wish to see the baby. • Parent may take home baby blanket, baby hat, pictures, and hand/foot molds to help with their grieving process of not going home with anything
Adolescents major depressive disorder
S—sleep disturbances • A—anhedonia (inability to experience pleasure) • D—despair • F—fatigue • A—appetite changes • C—concentration • E—emotional sensitivity • S—suicidal ideation May also experience: • Irritability • Social withdrawal • Changes in eating or sleeping patterns
A nurse is assessing a 12 hr old newborn with mild jaundice of the face and trunk. Which of the following actions should the nurse take? A.. Administer phytonadione B. Obtain a stat prescription for a billirubin level C. Obtain a bagged urine specimen D. Perform a gestational age assessment
b
A nurse is assessing a child who has ventricular septal defect. Which of the following findings should the nurse expect? A. Diastolic murmur B. Murmur at the left sternal border C. Cyanosis that increases with crying D. Widened pulse pressure
b
Therapeutic milleu benefits for teens
This is a treatment that provides structure and safety Includes group therapy, community meetings, and education classes
ADHD Interventions
Tx: • Individual and family therapy • Behavior management • Providing emotional support • Promoting self-esteem • Medication: • Amphetamines mixed with salts (Adderall XR), • Methylphenidate (Concerta), • Lisdexamfetamine dimesylate (Vyvanse), • Daytrana transdermal patch, • Atomoxetine HCl (Strattera), • Guanfacine (Tenex or Intuniv)—nonstimulant
A nurse is providing education to a client who is at 34 weeks of gestation about a non-stress test (NST). Which of the following pieces of information should the nurse include? A. It will take about 10 min to complete the test B. You might have to drink orange juice during the test C. During the test, you will be asked to massage your nipples D. During the test, you will receive medication to relax your uterus.
b
A nurse is caring for a client who is experiencing preterm labor. Which of the following medications should the nurse anticipate administering to enhance fetal lung maturation? A. Betamethasone B. Nifedipine C. Indomethacin D. Verapamil
a
A nurse is creating a plan of care for a child who has aplastic anemia. Which of the following interventions should the nurse include? A. Initiate protective-environment isolation for the child. B. Apply pressure for 1-2 min at the puncture site following blood specimen collection C. Mix the child's ferrous sulfate elixir BID into a glass of milk for administration D. Check the child's blood glucose level Q4hr
a
A nurse is planning a smoking cessation program for the women of childbearing age. Which of the following risks is associated with smoking during pregnancy? A. Infant developmental delay B. Maternal osteoporosis C. Maternal ulcers D. Infant lung cancer
a
A nurse is planning care for a preschool aged child who has autism and is being admitted to the facility. WHich of the following actions should the nurse tak? A. Encourage the paretns to bring the childs favorite stuffed animal B. Give the child choices when planning daily activities C. Administer phenytoin 3 x per dya D. Provide shared room ith another child
a
Adolescents psychosocial stage
identity vs role confusion This stage plays an essential role in developing a sense of personal identity which will continue to influence behavior and development for the rest of a person's life. Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self. During adolescence, children explore their independence and develop a sense of self. Those who receive proper encouragement and reinforcement through personal exploration will emerge from this stage with a strong sense of self and feelings of independence and control. Those who remain unsure of their beliefs and desires will feel insecure and confused about themselves and the future. Adolescent Ages: lack of judgement, able to understand things more conceptually than younger groups, nursing: address as adult, acknowledge need for privacy
risk factors for postpartum respiratory complications
peripartum cardiomyopathy the heart doesn't pump as hard as it's supposed to, which results in fluid buildup because the blood isn't being circulated properly. This buildup can cause fluid in the lungs, which leads to shortness of breath, and can cause swelling in the legs.
Dark red and painful placenta
placenta abruption
bright red and painless
placentae previa
fetal viability
that point in pregnancy at which the fetus is capable of prolonged life outside the mother's womb weeks 22-25
Social Interaction with infant:
• Talk to the infant when providing care to console him or her. • Use music and sounds to assist in soothing the infant. • Quickly respond to the infant's crying by feeding, diapering, or picking up the infant, all the while talking to the child about what you think he or she is communicating (Fig. 3-15). • Use sing-song approaches to communication—singing and music can quickly gain the infant's attention, as does wide-eyed, high-pitched communication (Traub, 2016). • Incorporate visual, auditory, tactile, and kinesthetic stimulation into nursing care and activities. • If the hospital uses child-care specialists who come and provide interaction, include such specialists in the provision of the child's care. • Incorporate continuance of care so that the same nurses are providing care as much as possible. The infant will become familiar with the nursing staff. • Incorporate consistency in nursing care and contact to allow the infant to develop trust.
Culturally competent care
• establish rapport with pt. • understand their needs, rituals, • be an advocate. • cultural and spiritual competence is key to being able to take care of patients involve the family • ask what their needs are • be an active listener • observe verbal / nonverbal cues be mindful (ex: not everyone handshakes) • know when you need an interpreter