Exam 4

When giving a postpartum client self-care instructions, the nurse instructs the client to report heavy or excessive bleeding. Which client statement indicates the nurse's teaching has been effective? A. I will call the doctor if I saturate a pad in one hour or less B. I will call the doctor if I have to change my pad at night C. I will call the doctor if I notice any blood clots in my pad D. I will call the doctor if bleeding continues beyond the 5th postpartum day

A. I will call the doctor if I saturate a pad in one hour or less

A newborn has severe coarctation of the aorta. What signs and symptoms would you expect to find in this patient? SATA A. Very strong, bounding pulses in the upper extremities B. Cool legs and feet C. Machine-like murmur only on systole D. Tet spells with activity E. Severe cyanosis F. Absent/diminished femoral pulses

A. Very strong, bounding pulses in the upper extremities B. Cool legs and feet F. Absent/diminished femoral pulses

After admitting a child with an atrial septal defect, you start developing a nursing care plan. What nursing diagnoses can you include in the patient's plan of care based on the complications that arise from this condition? Select all that apply: A. activity intolerance B. risk for infection C. decrease cardiac output D. excess fluid volume E. risk for aspiration

A. activity intolerance B. risk for infection C. decrease cardiac output D. excess fluid volume

On completing a fundal assessment, the nurse notes the fundus is firm and left of midline. What is the appropriate action? A. ask the client to empty her bladder B. straight catheterize the client immediately C. call the client's provider for direction? D. vigorously massage the fundus

A. ask the client to empty her bladder

The nurse is interviewing a client diagnosed with mastitis. Which information would require further intervention by the nurse? A. breastfeeding every 6 hours B. breastfeeding on the affected breast first C. increasing daily fluid intake D. emptying the affected breast completely with each feeding

A. breastfeeding every 6 hours Need to be breastfeeding every 2-4 hours

As the nurse you know that some patients who have coarctation of the aorta will develop collateral circulation of the arteries due to the abnormality on the aorta. Which option below indicates a patient is experiencing collateral circulation? A. chest x-ray that demonstrates notching on the ribs B. a harsh diastolic murmur on inspiration at the 2nd intercostal space C. ejection fraction of 12% on an echocardiogram D. chest x-ray that demonstrates cardiomegaly

A. chest x-ray that demonstrates notching on the ribs

The postpartum nurse is assessing the client who is 1 day post vaginal delivery and notes that the fundus is at umbilicus, and the client has moderate lochia on her peri-pad. Which intervention should the nurse implement? A. continue to monitor the client B. notify the provider C. assess the client's vital signs D. place the client on I&O monitoring

A. continue to monitor the client

A nurse is performing an assessment of a postpartum client 2 hours after birth and notes heavy bleeding with large clots. What should be the nurse's initial action? A. massaging the fundus firmly B. performing bimanual uterine compressions C. administering ergonovine D. notifying the provider

A. massaging the fundus firmly

An echocardiogram shows that your patient has an atrial septal defect located at the bottom of the septum near the tricuspid and mitral valves. As the nurse you know this is what type of atrial septal defect (ASD)? A. ostium primum B. ostium secundum C. sinus venosus D. coronary sinus

A. ostium primum

Which interventions would be most appropriate for the nurse to implement when caring for a 3 year old child diagnosed with cystic fibrosis? A. schedule the child's chest physiotherapy 1 hour prior to meals B. elevate the child's head of bed on 6in blocks while sleeping C. apply continuous positive airway pressure (CPAP) during the day D. administer oxygen via nasal cannula at 6L/min

A. schedule the child's chest physiotherapy 1 hour prior to meals

A nurse suspects that a client may have developed a pulmonary embolism. Which symptoms would validate the nurse's suspicion? SATA A. sudden dyspnea and chest pain B. chills and fever C. bradycardia and hypertension D. confusion and fainting E. cough with bloody sputum

A. sudden dyspnea and chest pain D. confusion and fainting E. cough with bloody sputum

The nurse is caring for children on a pediatric unit. Which child should the nurse assess first? A. the 1 month old child exhibiting substernal retractions and nasal flaring B. the 3 month old child whose mother reports a salty taste on the skin C. the 6 month old child whose respiratory rate is 42 breaths per minute D. the 8 month old child who has a "whooping" throaty cough

A. the 1 month old child exhibiting substernal retractions and nasal flaring

What is true about the aorta? SATA A. the ascending aorta branches off to supply the coronary arteries of the heart B. it is the 3rd largest artery in the body C. the aorta comes off the right ventricle and supplies oxygenated blood to the body D. the aortic arch branches off to supply the head, neck, and upper extremities

A. the ascending aorta branches off to supply the coronary arteries of the heart D. the aortic arch branches off to supply the head, neck, and upper extremities

The 5 year old is 1 hour post right femoral cardiac catheterization. Which data would warrant immediate intervention by the nurse? A. the child's right foot capillary refill is greater than 3 seconds B. the child is very groggy and refuses to drink any liquids C. the child's right foot is warm to touch and is pink D. the child is lying very still with the right leg extended

A. the child's right foot capillary refill is greater than 3 seconds

Which behavior should the nurse expect to observe in a client on the 4th postpartum day? A. the client asks many questions about the baby's care B. the client wants to relate her birth experience C. the client asks the nurse to select her meals for her D. the client asks the nurse to help her bathe

A. the client asks many questions about the baby's care Stage 1-> taking in; want to relive birth experience, relies heavily on the nurse (Kid rides the bike with training wheels and parent pushing them) Stage 2-> taking-hold; want to try stuff but want to know we are still there for them (Kid rides the bike with just training wheels while parent watches) Stage 3-> letting go; want to do it all on their own (Kid rides the bike without training wheels and doesn't care if the parent watches)

You're providing discharge education to the parents of a child who just had surgery to repair coarctation of the aorta. What should the nurse include in the teaching about issues that can arise after surgery that must be closely monitored by a cardiologist? Select all that apply: A. dilation of the aorta B. restenosis of the aorta C. hyperglycemia D. hypertension

B. restenosis of the aorta D. hypertension

The nurse is teaching the parents of a 1 year old child diagnosed with congestive heart failure. Which interventions should the nurse discuss with the parents? SATA A. encourage the parents to limit the child's activities B. teach the parents how to take the child's pulse C. discuss the signs and symptoms of digoxin toxicity D. measure the child's daily intake and output E. tell the parents to feed the child a daily serving of bananas

B. teach the parents how to take the child's pulse C. discuss the signs and symptoms of digoxin toxicity E. tell the parents to feed the child a daily serving of bananas

The chare nurse on a pediatric cardiovascular unit is checking laboratory values. Which laboratory result would require intervention by the charge nurse? A. the 1 year old child's potassium level is 3.8 B. the 2 year old child's digoxin level is 2.5 C. the 4 year old child's sodium level is 140 D. the 10 year old child's lead level is 8

B. the 2 year old child's digoxin level is 2.5 normal digoxin level is 0.8-2.0

The charge nurse has received laboratory results for client on the postpartum unit. Which client would warrant intervention by the nurse? A. the client whose WBC count is 18,000 B. the client whose platelet count is 32,000 C. the client whose creatinine level is 0.8 D. the client whose serum glucose level is 145

B. the client whose platelet count is 32,000

The mother yells for the nurse, stating "I think my child swallowed one of the little toys." The child is lying in the bed. Which actions should the nurse implement? Put in order! A. look in the mouth for any foreign object B. perform a head-tilt/chin-lift maneuver C. listen and assess for breath sounds D. attempt to administer a rescue breath E. shake the child and call the child's name

E. shake the child and call the child's name B. perform a head-tilt/chin-lift maneuver A. look in the mouth for any foreign object C. listen and assess for breath sounds D. attempt to administer a rescue breath

True or False: Atrial septal defects are characterized by a hole in the interatrial septum that allows blood to mix in the right and left atria, which are the lower chambers of the heart

False

The 2 year old child diagnosed with tetralogy of fallot is playing in the room and suddenly squats. Which action should the nurse implement? A. allow the child to stay in that position B. pick the child up and place in bed C. place oxygen on the child immediately D. ask the child if something is wrong

A. allow the child to stay in that position

The mother of a male child diagnosed with an upper respiratory infection (a cold) asks the nurse, "Why didn't the doctor give my son antibiotics so he will be better?" What is the nurse's best response? A. You are worried your child will not get well without antibiotics B. A cold is a virus that does not require antibiotic therapy C. Antibiotic therapy causes diarrhea in most children who take it D. Antibiotics are very expensive and your insurance won't cover it

B. A cold is a virus that does not require antibiotic therapy

The nurse is prioritizing care of a client in the immediate postpartum period. What is the nurse's priority assessment? SATA A. blood glucose level B. electrocardiogram (ECG) C. height of the fundus D. blood pressure E. urinary output

C. height of the fundus D. blood pressure E. urinary output

A client had a spontaneous vaginal birth after 18 hours of labor. Her vaginal bleeding is estimated to be 550 mL. Which nursing intervention should be a priority while caring for this client? A. avoid massaging the uterus B. monitor vital signs every hour C. empty the client's bladder D. elevate the head of the bed to increase blood flow

C. empty the client's bladder Emptying the bladder will help with uterine contractions

The 8 year old child is 2 hours post tonsillectomy. Which intervention should the ambulatory care nurse implement for the child? A. notify the dietary department to bring a soft, regular diet B. keep the child in the supine position with the HOB elevated C. encourage the child to drink clear liquids every 30 minutes D. tell the child to cough and deep breathe every 2 hours

C. encourage the child to drink clear liquids every 30 minutes

Which intervention should the nurse implement to calm the 3-year-old child for an electrocardiogram (ECG)? A. allow the child to play with the ECG leads B. ask the parents to leave the child's room C. encourage the mother to stroke the child's head during the ECG D. give the child a lollipop if they behave

C. encourage the mother to stroke the child's head during the ECG

The child diagnosed with pneumonia is being discharged home. Which intervention should the nurse discuss with the child's parents? A. Instruct the parents to assess the child's lungs every 2 hours B. tell the parents not to allow anyone to smoke in the child's room C. encourage the parents to use a cool-mint humidifier D. recommend the parents limit the child's fluid intake

C. encourage the parents to use a cool-mint humidifier Parents cannot assess lungs No one who smokes should be near the kid Fluid intake should be increased

A client reports increasing severity of afterpains. What condition should the nurse look for in the client's history that may explain this symptom? A. bottle feeding B. diabetes C. multiple gestation D. primiparity

C. multiple gestation afterpains may be more severe in breastfeeding women, multiple gestation, multiparity and other conditions that may cause overdistention of the uterus.

A breastfeeding mother who is experiencing breast engorgement asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement? A. applying ice B. applying a breast binder C. teaching how to express the breasts D. administering bromocriptine

C. teaching how to express the breasts

Which clinical manifestations would the nurse expect to assess in a child who has epiglottitis? A. snoring respirations and mouth breathing during sleep B. otalgia and purulent, foul-smelling otorrhea C. bilateral crackles and grayish, green sputum D. drooling, dyspnea, and high fever

D. drooling, dyspnea, and high fever

A client who is HIV positive tells the nurse that she would like to breastfeed. What is the nurse's best response? A. Breastfeeding will help reduce the risk of hemorrhage B. Breastmilk is better than formula for the baby C. Breastfeeding will help with bonding D. Breast milk can transmit HIV to your baby

D. Breast milk can transmit HIV to your baby

While performing the morning postpartum assessment, the nurse notices that a client's perineal pad is completely saturated with lochia rubra. What action should the nurse take first? A. vigorously massage the fundus B. call the provider immediately C. have the charge nurse review the assessment D. ask the client when she last changed her peri-pad

D. ask the client when she last changed her peri-pad

The postpartum client who is being discharged home has not bathed or brushed her hair and does not hold or cuddle her infant. Which action should the nurse implement prior to discharging the client? A. ask the chaplain to come talk to the client B. insist the client dress and feed the infant C. notify the hospital social worker D. encourage the client to ventilate her feelings

D. encourage the client to ventilate her feelings

You're caring for a 2-year-old patient who has a large atrial septal defect that needs repair. This defect is causing complications. These complications are arising from an abnormal shunting of blood throughout the heart. As the nurse, you know that a __________________ shunt is occurring in the heart due to the defect. A. right to left B. right C. left D. left to right

D. left to right

True or False: Atrial septal defects can lead to a decrease in lung blood flow.

False

A patient is diagnosed with a large atrial septal defect. You're providing information for the patient on the complications related to this condition. What topics will you include in the patient's education? Select all that apply: A. tet spells B. heart failure C. stroke D. pulmonary hypertension E. rheumatic fever

B. heart failure C. stroke D. pulmonary hypertension

The 4 year old child is brought to the pediatric clinic with complaints of a sore throat. Which priority action should the nurse implement? A. have the child gargle with salt water B. obtain a throat culture for strep C. give the child a throat lozenge D. do not open the child's mouth

B. obtain a throat culture for strep

The 6 year old child is brought to the emergency department with wheezing and short of breath. Which intervention should the nurse implement first? A. start an intravenous line B. elevate the HOB C. administer aminophylline, a bronchodilator D. perform a peak flow meter test

B. elevate the HOB Correct order of these 4: 1. elevate HOB 2. start IV 3. give aminophylline 4. peak flow meter test if in distress, do not assess

Which structure allows blood to flow from the right to left atrium in utero that should close after birth? A. ductus arteriosus B. foramen ovale C. ductus venosus D. legamentum teres

B. foramen ovale

The unlicensed assistive personnel (UAP) tells the nurse the postpartum client has T 98.2F, P 124, RR 30, BP 88/60. Which action should the nurse implement first? A. ask the UAP when the last vital signs were obtained B. go to the room and check the client immediately C. notify the client's provider D. check the client's hemoglobin and hematocrit levels

B. go to the room and check the client immediately

The nurse is preparing a plan of care for a client who has had a cesarean birth. What information should the nurse include in the discharge plan? A. douche frequently after being discharged B. do coughing a deep breathing exercises C. begin doing situps 2 weeks post-op D. do side-rolling exercises

B. do coughing a deep breathing exercises

You are caring for a child with coarctation of the aorta and educating the parents about the child's condition. Which statement by the parents demonstrates they understood the pathophysiology of this defect? A. This condition can lead to right-sided heart failure B. The narrowing of the aorta leads to a high blood pressure in the arteries that are found before the site of narrowing in the aorta C. The dilation of the aorta leads to a decreased blood pressure in the arteries that are found after the site of dilation D. The upper and lower extremities will experience a decrease in blood flow due to the defect in the aorta

B. The narrowing of the aorta leads to a high blood pressure in the arteries that are found before the site of narrowing in the aorta

The 18 month old child diagnosed with Kawasaki disease is prescribed salicylate (aspirin) therapy. Which action should the nurse implement? A. contact the provider to verify the order B. administer the medication as prescribed by the provider C. give an antacid when administering the medication D. do not administer the aspirin because of Reye syndrome

B. administer the medication as prescribed by the provider

After the birth of a newborn with severe coarctation of the aorta, the physician orders a prostaglandin infusion. As the nurse you know that this medication will have what type of therapeutic effects? Select all that apply: A. prevent the foramen ovale from closing B. allow a connection between the aorta and pulmonary artery C. decrease the workload on the left ventricle D. increase blood flow to the lower extremities

B. allow a connection between the aorta and pulmonary artery C. decrease the workload on the left ventricle D. increase blood flow to the lower extremities

You're performing a head-to-toe assessment on a newborn with severe coarctation of the aorta. You note a systolic heart murmur. Where is this heart murmur best auscultated in a patient with this condition? A. at the 4th intercostal space left of the sternal border B. at the left interscapular area C. at the 2nd intercostal space right to the sternal border D. at the mid-subclavicular line right of the sternal border

B. at the left interscapular area

The nurse is teaching a client with newly diagnosed mastitis about her condition. The client asks the nurse what caused her to develop mastitis. What is the nurse's best response? A. you are breastfeeding too frequently B. bacteria from the neonate's mouth has caused this C. you are wearing a bra that did not provide adequate support D. expressing milk when your breasts become engorged causes this

B. bacteria from the neonate's mouth has caused this

The nurse is assessing a postpartum client who has lochia serosa. The client asks the nurse how long she should expect this type of bleeding to continue. The nurse replies, "your bleeding should stop on: A. days 3 to 4 postpartum B. days 3 to 10 postpartum C. days 10 to 14 postpartum D. days 14 to 42 postpartum

B. days 3 to 10 postpartum

The mother of a 2 year old diagnosed with pertussis, or whooping cough, who is in the convalescent stage tells the nurse her child is still coughing at night. Which statement is the nurse's best response? A. I will make an appointment for your child to see the doctor today B. You should give your child an over-the-counter cough suppressant C. Your child may have a cough for several months after having pertussis D. Take your child into the bathroom and turn on the hot shower

C. Your child may have a cough for several months after having pertussis

The nurse is teaching the 10 year old diagnosed with hyperlipidemia about dietary food choice. Which school cafeteria menu selection indicates the child understands the teaching? A. chicken nuggets, mashed potatoes, and gravy and whole milk B. roast beef sandwich, potato chips, and 2% milk C. baked fish, vegetable medley, and bottled water D. pepperoni pizza, fruit cocktail, and juice

C. baked fish, vegetable medley, and bottled water

Which client should the postpartum nurse assess first after receiving the morning shift report? A. the client who is complaining of cramps when breastfeeding B. the client who used one peri-pad during the night C. the client who has an edematous and warm right calf D. the client who is crying because her husband went to work

C. the client who has an edematous and warm right calf

A nurse is teaching a client about Kegel exercises. The nurse determines that teaching has been successful when the client states: A. they assist with lochia removal B. they promote the return of normal bowel function C. they promote blood flow, and allow for healing and strengthening of musculature D. they assist the mother in burning calories for rapid postpartum weight loss

C. they promote blood flow, and allow for healing and strengthening of musculature

The nurse reviews the assessment findings of a postpartum client who has experienced a vaginal birth. Which assessment finding should the nurse consider normal for this client? A. redness or swelling in the calves B. a palpable uterine fundus beyond 10 days postpartum C. vaginal dryness after the lochial flow has ended D. dark red lochia for approximately 6 weeks after birth

C. vaginal dryness after the lochial flow has ended

The client is 1 day postpartum, and the nurse notes the fundus is displaced laterally to the right. Which nursing intervention should be implemented first? A. prepare to insert an indwelling urinary catheter B. assess the bladder using the bladder scanner C. massage the client's fundus for 2 minutes D. assist the client to the bathroom to urinate

D. assist the client to the bathroom to urinate

Which finding in a postpartum client requires further nursing assessment? A. fundus at the umbilicus at one hour postpartum B. fundus 3cm below the umbilicus on postpartum day 3 C. fundus not palpable in the abdomen at 2 weeks post partum D. fundus slightly to the right, and 2 cm above the umbilicus at postpartum day 2

D. fundus slightly to the right, and 2 cm above the umbilicus at postpartum day 2

You're assessing the heart sounds of a child with an atrial septal defect. You note a heart murmur at the 2nd intercostal space at the left upper sternal border. Heart murmurs noted in patients with an atrial septal defect are called? A. holosystolic murmurs B. diastolic murmurs C. early systolic murmurs D. midsystolic murmurs

D. midsystolic murmurs

Which signs and symptoms would the nurse expect in the 1 year old child diagnosed with an acyanotic cardiovascular defect? A. buccal and peripheral cyanosis B. clubbing of the fingers and barrel chest C. increased urine output and tented tissue tugor D. periorbital/facial edema and jugular vein distention (JVD)

D. periorbital/facial edema and jugular vein distention (JVD)

The nurse is caring for children on a pediatric unit. Which client should the nurse assess first after receiving change-of-shift report? A. the 1 year old child with a ventricular septal defect (VSD) who has 1+ pitting edema B. the 2 year old child with bacterial endocarditis who has a low-grade fever C. the 3 year old child with rheumatic fever who's white blood cell count is 8000 D. the 4 year old child with heart disease whose pulse is 138 and blood pressure is 74/42

D. the 4 year old child with heart disease whose pulse is 138 and blood pressure is 74/42