Final Exam (2,4,5)
Meperidine (Demerol) 35 mg IM is ordered for the laboring mother you are caring for in labor and delivery. You have Meperidine (Demerol) 50 mg/ml on hand. How many ml would the nurse administer to this client?
0.7 ml
Kantrex 30 mg bid is ordered IM for a 9 lb child. Kantrex is available in 75 mg/2ml. According to the drug literature, the recommended dose is 15 mg/kg/day in 2 divided doses. How much will you give per dose?
0.8 mL
Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate post operative period? A. Codeine B. Morphine C. Meperidine D. Methadone
B. Morphine
A nursing is administrating vancomycin intravenously and sets the pump to infuse the medication over 90 minutes. Which adverse reaction is the nurse trying to prevent? A. Hypertension B. Vomiting C. Flushing of the face, neck, and chest D. Headache
C. Flushing of the face, neck, and chest
The nurse is discussing sexuality with the parents of an adolescent girl with moderate cognitive impairment. Which should the nurse consider when dealing with this issue? a.Individuals with cognitive impairment need a well defined concrete code of sexual conduct b. sterilization is recommended for any adolescent with cognitive impairment c. sexual intercourse rarely occurs unless the individual with cognitive impairment is sexually abused d. sexual drive and interest are limited in individuals with cognitive impairment.
a.Individuals with cognitive impairment need a well defined concrete code of sexual conduct
The nurse in a pediatric clinic is counseling a parent who expresses concern about the toddler who plays alone at daycare and does not interact with the other children who are present. Which information does the nurse provide to alleviate the parent's concern? a. the toddler is exhibiting the normal behavior of solitary play b. parallel play is being exhibited and is normal at this age c. the toddler is likely to grow into a shy, introverted adult d. it is important for the child to learn to be alone at this age
b. parallel play is being exhibited and is normal at this age
The nurse is gathering health data on an adolescent who is 16 years of age. Which comment by the adolescent will cause the nurse to seek additional information? a. "I know that I have always been a skinny kid, but wish I could gain weight." b. "I try to keep my distance from a kid in my class who coughs all day long" c. "I have to be the clumsiest kid in the world. Always tripping over my own feet." d. "some days I just hate school. I want to get out and on to a job or college."
b. "I try to keep my distance from a kid in my class who coughs all day long"
The nurse is teaching a parenting class being held in a community clinic. The nurse is focusing on behaviors that will assist in increasing the number of children who score well in kindergarten readiness screening. Which comment by a parent indicates the need for additional information? a. "I am not athletic, but the kids would love an outdoor play area." b. "In our family we watch TV; books are a waste of money" c. I like the suggestion to label basic items for word recognition" d. practicing counting with the kids while traveling is a good idea"
b. "In our family we watch TV; books are a waste of money"
The nurse in a pediatric clinic is performing an assessment on an infant in the presence of both parents. The parents are short and moderately overweight. The father states, "we are going to do everything we can to raise a strong, tall, athletic child." How does the nurse respond? a. provides materials about healthy diets and lifestyles for families b. shares the impact of genetics on environmental conditions c. suggests to the parents how to alter their lifestyles d. recognizes the parents for having positive attitudes and goals
b. shares the impact of genetics on environmental conditions
The nurse should be aware that an effective plan to achieve adequate pain relief without maternal risk is most effective if: A. The mother and family's priorities and preferences are incorporated into the plan. B. The mother gives birth without any analgesic or anesthetic. C. The nurse informs the family of all alternative methods of pain relief available in the hospital setting. D. The primary health care provider decides the best pain relief for the mother and family.
A. The mother and family's priorities and preferences are incorporated into the plan. The assessment of the woman, her fetus, and her labor is a joint effort of the nurse and the primary health care providers, who consult with the woman about their findings and recommendations. The need of each woman are different, and many factors must be considered before a decision is made whether pharmacologic methods, nonpharmacologic methods, or a combination of the two will be used to manage labor pain.
The physician has ordered digoxin elixir 0.065 mg PO daily for an infant weighing 6 kg. The recommended dose is 10 to 12 mcg/kg/day. Is the dose safe? Prove mathematically
yes
A newborn of an HIV positive mother is being admitted to your nursery. The resident orders the baby to receive AZT 2 mg/kg IV every 6 h. The infant weighs 3.7 kg. How much AZT would you administer?
7.4 mg
An adolescent patient is to receive 50 mL of an antibiotic IV over 40 minutes. When using a microdrip how many drops per minute should the child receive?
75 gtt/min
A patient who is NPO has an order for 1000 ml of D5W 0.45% NS with 30 mEq of potassium over 12 hours. How many ml/h should the IV pump be programmed for?
83 ml/hr
A labor and delivery client has penicillin ordered 75,000 units IM. The bottle pharmacy sent is labeled 300,000 units/ml. How many ml would the nurse administer?
0.3 mL
A child with congestive heart failure is placed on a maintenance dosage of digoxin (Lanoxin). The dosage is 0.07mg/kg/day. and the childs weight is 7.2 kg. The physician prescribes the digoxin to be given once a day by mouth. Each dose will be ___ milligrams.
0.5 mg
A postoperative c-section patient experiences bradypnea after intrathecal administration of anesthesia. An order for Narcan 0.8 mg/h is written. Given a bag with a concentration of * mg in 100 mL of 0.9% NS, how many mL/h should the IV pump be programed for?
10 ml/h
A solution of 25,000 units of heparin in 500 mL of D5W is to infuse at 1000 units per hour. The IV pump would be set at __ ml/hr to deliver this ordered dose.
20 ml/hr
A patient with severe nausea and vomiting has a one-time order for Zofran 8mg IVPB over 15 minutes. The Zofran is diluted in 50 ml of D5W. The tubing drop factor is 15 gtt/ml. How many gtt/min should be given?
50 gtt/min
In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, which information would the nurse include? A. "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." B. "You will not need preoperative teaching because this is your second cesarean birth." C. "Because this is your second cesarean birth, you will recover faster." D. "Because this is a repeat procedure, you are at the lowest risk for complications."
A. "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." is the most appropriate statement. It is not accurate to state the woman is at the lowest risk for complications. Both maternal and fetal risks are associated with every cesarean section. "Because this is your second cesarean birth, you will recover faster" is not an accurate statement. Physiologic and psychologic recovery from a cesarean section is multifactorial and individual to each client each time. Preoperative teaching should always be performed, regardless of whether the client has already had this procedure.
A charge nurse is making assignments for a group of children on a pediatric unit. The charge nurse should avoid assigning the same nurse to care for a 2-year-old with respiratory syncytial virus (RSV) and: A. a 1 year old with a heart defect B. a 6 month old with sickle cell crisis C. an 18 month old with RSV D. a 9 year old 3 days post appendectomy
A. a 1 year old with a heart defect
The nurse recognizes that a woman is in true labor when she states: A. "The contractions in my uterus are getting stronger and closer together." B. "I passed some thick, pink mucus when I urinated this morning." C. "My bag of waters just broke." D. "My baby dropped, and I have to urinate more frequently now."
A. "The contractions in my uterus are getting stronger and closer together." Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, but it is not the indicator of true labor. Spontaneous rupture of membranes often occurs during the first stage of labor, but it is not the indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor, but this is not the indicator of true labor.
The nurse is doing a routine assessment on a 14-month old infant and notes that the anterior fontanel is closed. This should be interpreted as: A. A normal finding B. A questionable finding- the infant should be rechecked in 1 month C. An abnormal finding-indicates the need for developmental assessment D. An abnormal finding-indicates the need for immediate referral to a practitioner.
A. A normal finding
A woman is having her first child. She has been in labor for 15 hours. Two hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago her vaginal examination indicated that there had been no change. What abnormal labor patter is associated with this description. A. Arrest of active phase B. Protracted descent C. Prolonged latent phase D. Protracted active phase
A. Arrest of active phase With an arrest of the active phase, the progress of labor has stopped. This client has not had any anticipated cervical change, thus indicating an arrest of labor. In the nulliparous woman a prolonged latent phase typically would last more than 20 hours. A protracted active phase, the first or second stage of labor, would be prolonged (slow dilation). With protracted descent, the fetus would fail to descend at an anticipated rate during the deceleration phase and second stage of labor.
The nurse is taking a health history on an adolescent. What best describes how the chief complaint should be determined? A. Ask the adolescent, "Why did you come here today?" B. Interview the parent away from the adolescent to determine the chief complaint C. Use what the adolescent says to determine, in correct medical terminology, what the problem is. D. Ask for detailed listing of symptoms
A. Ask the adolescent, "Why did you come here today?"
A patient who is pregnant expresses a desire to attempt a vaginal delivery after a cesarean birth 2 years before. The primary care provider initiates trial of labor after cesarean (TOLAC) and vaginal birth after cesarean (CVAC) screening. The nurse is aware that which patient information will likely disqualify the patient for CVAC? A. Cesarean due to pelvic abnormalities B. A low transverse uterine scar C. Patient asks multiple questions D. First labor needed to be induced
A. Cesarean due to pelvic abnormalities
The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the woman's understanding of the instructions when she states, "True labor contractions will: A. Continue and get stronger even if I relax and take a shower." B. Subside when I walk around." C. Remain irregular but become stronger." D. Cause discomfort over the top of my uterus."
A. Continue and get stronger even if I relax and take a shower." True labor contractions occur regularly, becoming stronger, lasting longer, and occurring closer together. They may become intense during walking and continue despite comfort measures. Typically true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions often stop with walking or a change of position.
The type of injury a child is especially susceptible to at a specific age is most closely related to: A. Developmental level of the child B. Physical health of the child C. Number of responsible adults in the home D. Educational level of the child
A. Developmental level of the child
The nurse educator is in a childbirth education class discussing nonpharmacological ways nurses can assist to enhance labor and spontaneous vaginal delivery. Which of the following facts regarding nonpharmacologic approaches will the nurse use to help illustrate its benefits? A. Effleurage is performed in rhythm with breathing during a contraction. B. The client can achieve self-hypnosis with the Bradley Method C. Using peppermint aromatherapy oils will help promote relaxation D. Sterile water injections can be very useful for pelvic pain
A. Effleurage is performed in rhythm with breathing during a contraction.
A 9-year-old girl builds a clubhouse in her backyard. She hangs a sign outside her clubhouse that has "No boys allowed" printed on it. The childs parents are concerned that she is excluding their neighbors son and they are upset. What should the nurse tell the child's parents? A. Her behavior is common among school age children B. Her behavior is cause for concern and should be addressed C. They should have the child speak with a school counselor D. Her feeling about the boys will subside within the next year
A. Her behavior is common among school age children
The obstetric nurse is assessing the laboring patient for pain. Which of the following should the nurse identify in a pain assessment? Select all that apply A. Intensity of contractions B. Presence of FHR with intermittent auscultation C. Signs of anxiety D. Frequency and duration of contractions E. Presence of pain in the neck or back
A. Intensity of contractions C. Signs of anxiety D. Frequency and duration of contractions E. Presence of pain in the neck or back
The nurse is reading the patient's chart, which indicates the patient has a "gynecoid pelvis." What finding is expected in this patient? A. Wider outlet B. Shorter diameter between her coccyx and ischium C. Smaller inlet D. Narrower pubic arch
A. wider outlet
Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory? A) Massaging the woman's back B) Changing the woman's position C) Giving the prescribed medication D) Encouraging the woman to rest between contractions
A. Massaging the woman's back According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques such as massage or stroking, music, focal points, and imagery reduce or completely block the capacity of nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord and thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the woman's position, giving prescribed medication, and encouraging rest do not reduce or block the capacity of nerve pathways to transmit pain using the gate-control theory.
The baseline fetal heart rate (FHR) is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the patient's most recent 10-minute segment on the monitor strip and notes a late deceleration. This is likely to be caused by which physiologic alteration (Select all that apply)? A. Maternal supine hypotension B. Spontaneous fetal movement C. Compression of fetal head D. Cord around the baby's neck E. Placental abruption
A. Maternal supine hypotension E. Placental abruption
An appropriate play activity for a 7 month old infant to encourage visual stimulation is: A. Playing peek a boo B. Imitating animal sounds C. Playing pat-a-cake D. Showing how to clap hands
A. Playing peek a boo
Which assessment is least likely to be associated with a breech presentation? A. Post-term gestation B. Meconium-stained amniotic fluid C. Preterm labor and birth D. Fetal heart tones heard at or above the maternal umbilicus
A. Post-term gestation Post-term gestation is not likely to be seen with a breech presentation. The presence of meconium in a breech presentation may result from pressure on the fetal wall as it traverses the birth canal. Fetal heart tones heard at the level of the umbilical level of the mother are a typical finding in breech presentation because the fetal back would be located in the upper abdominal area. Breech presentations often occur in preterm births.
Which finding would the nurse consider abnormal when performing a physical assessment of a 6-month-old? A. Posterior fontanel is open B. Anterior fontanel is open C. Able to track and follows objects D. Beginning signs of tooth eruption
A. Posterior fontanel is open
In preparation for a cesarean birth, the nurse expects which medical-based peroperative interventions? Select all that apply. A. Prescription for sequential compression devices prior to surgery B. Verification that the woman has been NPO for 6 to 8 hours before surgery C. Assessment for risk of venous thromboembolism (VTE) D. Assessment of the woman's knowledge and educational needs E. Administration of narrow-spectrum prophylactic antibiotics
A. Prescription for sequential compression devices prior to surgery C. Assessment for risk of venous thromboembolism (VTE) E. Administration of narrow-spectrum prophylactic antibiotics
An 18-year old pregnant woman, gravida 1, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The woman states, "My contractions are so strong that I don't know what to do with myself." The nurse should: A. Recognize that pain is personalized for each individual. B. Disturb the woman as little as possible. C. Encourage the woman to lie on her side. D. Assess for fetal well-being.
A. Recognize that pain is personalized for each individual. Each woman's pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth. Assessing for fetal well-being includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal distress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the laboring woman. The client clearly needs support.
Which assessment should be a priority to monitor in a child receiving a narcotic pain relief? A. Respirations B. Blood pressure C. Oxygen saturation D. Bowel sounds
A. Respirations
A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to: A. Stimulate for fetal surfactant production B. Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy. C. Reduce maternal and fetal tachycardia associated with ritodrine administration D. Suppress uterine contractions
A. Stimulate for fetal surfactant production Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. Inderal would be given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.
Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? A. The vulva bulges and encircles the fetal head. B. Bloody mucus discharge increases. C. The fetal head is felt at 0 station during vaginal examination. D. The membranes rupture during a contraction.
A. The vulva bulges and encircles the fetal head. During the active pushing (descent) phase, the woman has strong urges to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor. The vulva stretches and begins to bulge encircling the fetal head. Birth of the head occurs when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth.
The nurse recommends to parents that peanuts are not a good snack food for toddlers. The nurses rationale for this action is that: A. They can be easily aspirated B. They cannot be entirely digested C. They are low in nutritive value D. They are very high in sodium
A. They can be easily aspirated
In relation to primary and secondary powers, the maternity nurse determines: A. Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs. B. Primary powers are responsible for effacement and dilation of the cervix. C. Effacement generally is well ahead of dilation in women giving birth for the first time; they are closer together in subsequent pregnancies. D. Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should now slow or inhibit dilation.
Ans: B Primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. Effacement generally is well ahead of dilation in first-timers; they are closer together in subsequent pregnancies. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so.
Identify the basic type of pelvis which includes the correct description and percentage of occurrence in women? A. Gynecoid: classic female; heart shaped;75% B. Android: resembling the male; wider oval; 15% C. Anthropoid: resembling the ape; narrower; 10% D. Platypelloid: flattened, wide shallow; 3%
Ans: D A platypelloid pelvis is flattened, wide, and shallow; about 3% of women have this shape. The gynecoid shape is a classic female shape, slightly ovoid and rounded; about 50% of women have this shape. An android, or malelike, pelvis is heart shaped; about 23% of women have this shape. An anthropoid, or apelike, pelvis is oval and wider; about 24% of women have this shape.
Evaluate the four stages of labor and determine which is correct for both definition and duration? A. Third state: active pushing to birth; 20 minutes (multiparous women), 50 minutes (first timer) B. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour C. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours D. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours.
Ans: D Full dilation may occur in less than 1 hour, but in first-time pregnancies it can take up to 20 hours. The second stage extends from full dilation to birth and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. The third stage extends from birth to expulsion of the placenta and lasts until homeostasis is reestablished (about 2 hours).
The nurse is providing care to a patient who is in labor. The patient's membranes rupture spontaneously, and the nurse notices meconium-stained amniotic fluid. Which action does the nurse immediately perform? Select all that apply A. Administer oxygen to the mother to help prevent fetal hypoxia. B. Alert the neonatal team of a possible meconium aspiration neonate C. Test the stained fluid for percentage of meconium content. D. Promote fetal well-being by placing the patient on her left side. E. Notify the primary care provider about the presence of meconium
B. Alert the neonatal team of a possible meconium aspiration neonate E. Notify the primary care provider about the presence of meconium
The nurse providing care for a woman with preterm labor who is receiving terbutaline would include which intervention to identify side effects of the drug? A. Assessing for bradycardia B. Assessing for chest discomfort and palpitations C. Assessing deep tendon reflexes (DTRs) D. Assessing for hypoglycemia
B. Assessing for chest discomfort and palpitations Terbutaline is a B2-adrenergic agonist that affects the cardiopulmonary and metabolic systems of the mother. Signs of cardiopulmonary decompensation would include chest pain and palpitations. Assessing DTRs would not address these concerns. B2- adrenergic agonist drugs cause tachycardia, not bradycardia. The metabolic effect leads to hyperglycemia, not hypoglycemia.
A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the woman to be: A. Admitted and prepared for a cesarean birth. B. Discharged home to await the onset of true labor. C. Discharged home with a sedative. D. Admitted for extended observation.
B. Discharged home to await the onset of true labor. This situation describes a woman with normal assessments who is probably in false labor and will likely not deliver rapidly once true labor begins. There is no indication that further assessments or observations are indicated; therefore, the patient will be discharged along with instructions to return when contractions increase in intensity and frequency. Neither a cesarean birth nor a sedative is required at this time.
You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80's. What additional nursing measures should you take? A. Insert a Foley catheter B. Notify the care provider immediately C. Scream for help D. Start pitocin
B. Notify the care provider immediately To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. If oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary care provider should be notified immediately. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a nonreassuring pattern, a cesarean section could be warranted, which would require a Foley catheter. However, the physician must make that determination. Pitocin may place additional stress on the fetus.
While assessing the development of a 9-month old client, the nurse asks the mother if the child actively looks for toys that are placed out of site. Which is the nurse assessing with this question to the parent? A. Centration B. Object permanence C. Transductive reasoning D. Conservation
B. Object permanence
The nurse is caring for a 31-year old female patient who is pregnant at 37 weeks and 5 days gestation. The patient is having contractions every 3 minutes and was found to have a platypelloid pelvis upon examination. The fetus has an estimated fetal weight of 7lbs and is in the LOA position. This patient is laboring on the birth ball, and her mother-in-law is helping her labor. The nurse is concerned about the five P's and their effect on the patient's labor. Which P is the nurse most likely concerned about based on the patients history. A. Psyche B. Passage C.Passenger D.Position
B. Passage
What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken. a. Call the provider, reposition the mother, and perform a vaginal examination. b. Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask. c. Administer oxygen to the mother, increase IV fluid, and notify the care provider. d. Perform a vaginal examination, reposition the mother, and provide oxygen via face mask.
B. Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask. Repositioning the mother, increasing intravenous (IV) fluid, and providing oxygen via face mask are correct nursing actions for intrauterine resuscitation. The nurse should initiate intrauterine resuscitation in an ABC manner, similar to basic life support. The first priority is to open the maternal and fetal vascular systems by repositioning the mother for improved perfusion. The secondary priority is to increase blood volume by increasing the IV fluid. The third priority is to optimize oxygenation of the circulatory volume by providing oxygen via face mask. If these interventions do not resolve the fetal heart rate issue quickly, the primary provider should be notified immediately.
The major consideration when selecting toys for a child who is cognitively impaired is: A. Ability to teach useful skills. B. Safety C. Ability to provide exercise. D. Age appropriateness
B. Safety Safety is the primary concern in selecting recreational and exercise activities for all children. This is especially true for children who are cognitively impaired. Age appropriateness, the ability to provide exercise, and the ability to teach useful skills are all factors to consider in the selection of toys, but safety is of paramount importance.
With regard to the turns and other adjustments of the fetus during the birthing process, known as the mechanism of labor, nurses are aware that: A. At birth the baby is said to achieve "restitution" (i.e. a return to the C- shape of the womb). B. The effects of the forces determining descent are modified by the shape of the woman's pelvis and the size of the fetal head. C. Asynclitism sometimes is achieved by means of the Leopold maneuver. D. The seven critical movements must progress in a more or less orderly sequence
B. The effects of the forces determining descent are modified by the shape of the woman's pelvis and the size of the fetal head. The size of the maternal pelvis and the ability of the fetal head to mold also affect the process. The seven identifiable movements of the mechanism of labor occur in combinations simultaneously, not in precise sequences. Asynclitism is the deflection of the baby's head; the Leopold maneuver is a means of judging descent by palpating the mother's abdomen. Restitution is the rotation of the baby's head after the infant is born.
The nurse providing care for a prenatal patient who is told she will require a cesarean delivery because of cephalopelvic disproportion. Which explanation of the condition will the nurse provide to the patient? A. The placenta is implanted in an unfavorable position in the uterus B. The size and/or shape of either the fetal head or patient's pelvis is an issue C. The patient had a surgery with an incision through the myometrium of the uterus D. The patient has a preexisting medical condition that supports cesarean birth.
B. The size and/or shape of either the fetal head or patient's pelvis is an issue
The major cause of death for children older than 1 year is: A. Cancer B. Unintentional injuries C. Congenital abnormalities D. Infection
B. Unintentional injuries
According to Erikson, the psychological task of a toddler is developing: A. Independence B. Initiative C. Autonomy D. Intimacy
C. Autonomy
While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse's first priority is to: A. Assist with amnioinfusion B. Notify the care provider C. Change the woman's position D. Insert a scalp electrode
C. Change the womans position Late decelerations may be caused by maternal supine hypotension syndrome. They usually are corrected when the woman turns on her side to displace the weight of the gravid uterus from the vena cava. If the fetus does not respond to primary nursing interventions for late decelerations, the nurse would continue with subsequent intrauterine resuscitation measures, including notifying the care provider. An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. The FHR pattern associated with this situation most likely reveals variable deceleration. A fetal scalp electrode would provide accurate data for evaluating the well-being of the fetus; however, this is not a nursing intervention that would alleviate late decelerations, nor is it the nurse's first priority.
In evaluating the effectiveness of oxytocin induction, the nurse would expect: A. The intensity of contractions to be at least 110 to 130 mm Hg B. At least 30 mU/min of oxytocin will be needed to achieve cervical dilation. C. Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart. D. Labor to progress at least 2 cm/hr dilation
C. Contractions lasting 40 to 90 secoterm-40nds, 2 to 3 minutes apart The goal of induction of labor would be to produce contractions that occur every 2 to 3 minutes and last 60 to 90 seconds. The intensity of the contractions should be 40 to 90 mm Hg by intrauterine pressure catheter. Cervical dilation of 1 cm/hr in the active phase of labor would be the goal in an oxytocin induction. The dose is increased by 1 to 2 mU/min at intervals of 30 to 60 minutes until the desired contraction pattern is achieved. Doses are increased up to a maximum of 20 to 40 mU/min.
A 52 pound child is to receive 150 mg of ibuprofen (childrens advil) for pain. The drug manual recommended dosage for ibuprofen is 5-10 mg/kg/dose every 6 h PRN. Prove mathematically that the ordered dosage is safe and therapeutic for this child.
Yes. safe range 118 mg-236mg
A lumbar puncture is needed on a school-age child. The most appropriate action to provide analgesia during this procedure is to apply: A. A transdermal fentanyl (Duragesic) patch immediately before the procedure B. 4% Liposomal Lidocaine (LMX) 15 minutes before the procedure C. Eutectic mixture of local anesthesia (EMLA) 1 hour before the procedure D. EMLA 30 mins before the procedure
C. Eutectic mixture of local anesthesia (EMLA) 1 hour before the procedure
A patient is being prepared for an unplanned cesarean section. Which pre-procedure information is most important for the nurse to report before the administration of regional anesthesia? A. Hypovolemia corrected with IV fluid administration B. Inability of the patient to sit on the bedside and flex forward C. Laboratory value indicating a low platelet count D. History of patient experiencing headaches after a spinal
C. Laboratory value indicating a low platelet count
While evaluating a fetal heart rate (FHR) which finding would concern the nurse during labor? A. Accelerations with fetal movement B. An average FHR of 126 beats/min C. Late decelerations D. Early decelerations
C. Late decelerations Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. They are considered ominous if persistent and uncorrected. Accelerations in the FHR are an indication of fetal well-being. Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelviz outlet; they generally are not a concern during normal labor.
The pediatric nurse understands that nonpharmacologic strategies for pain management: A. Make pharmacologic strategies unnecessary B. Usually take too long to implement C. May reduce pain perception D. Trick children into believing they do not have pain
C. May reduce pain perception
As the United States and Canada continue to become more culturally diverse, it is increasingly important for the nursing staff to recognize a wide range of varying cultural beliefs and practices. Nurses need to develop respect for these culturally diverse practices and learn to incorporate these into a mutually agreed on plan of care. Although it is common practice in the United States for the father of the baby to be present at the birth, in many societies this is not the case. When implementing care, the nurse would anticipate that a woman from which country would have the father of the baby in attendance? A. China B. Iran C. Mexico D. India
C. Mexico A woman from Mexico may be stoic about discomfort until the second stage, at which time she will request pain relief. Fathers and female relatives are usually in attendance during the second stage of labor. The father of the baby is expected to provide encouragement, support, and reassurance that all will be well. Fathers are usually not present in China. The Iranian father will not be present. Female support persons and female care providers are preferred. For many, a male caregiver is unacceptable. The father is usually not present in India, but female relatives are usually present. Natural childbirth methods are preferred.
A woman in labor has just received an epidural block. The most important nursing intervention is to: A) Limit parenteral fluids. B) Monitor the fetus for possible tachycardia C) Monitor the maternal blood pressure for possible hypotension. D) Monitor the maternal pulse for possible bradycardia
C. Monitor the maternal blood pressure for possible hypotension. The most important nursing intervention for a woman who has received an epidural block is to monitor the maternal blood pressure frequently for signs of hypotension. Intravenous fluids are increased for a woman receiving an epidural, to prevent hypotension. The nurse observes for signs of fetal bradycardia. The nurse monitors for signs of maternal tachycardia secondary to hypotension.
The nurse is talking with the parent of a child newly diagnosed with a chronic illness. The parent is upset and tearful. The nurse asks, "With whom do you talk when something is worrying you?" This should be interpreted as: A. A diversion of the present crisis to similar situations with which parent has dealt. B. An intervention to find someone to help parent. C. Part of assessing parent's available support systems. D. Inappropriate because parent is upset.
C. Part of assessing parent's available support systems. This question will provide information about the marital relationship (does the parent speak to the spouse?), alternate support systems, and ability to communicate. These are very important data for the nurse to obtain and an appropriate part of an accurate assessment. By assessing these areas, the nurse can facilitate the identification and use of community resources as needed. The nurse is obtaining information to help support the parent through the diagnosis. The parent is not in need of additional parenting help at this time.
The near-to-far direction of growth is referred to as: A. Cephalocaudal B. Sequential C. Proximodistal D. Mass to specific
C. Proximodistal
A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's intravenous fluid for a preprocedural bolus. She reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dl, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman? A) She is too far dilated B) She is anemic. C) She has thrombocytopenia D) She is septic
C. She has thrombocytopenia The platelet count indicates a coagulopathy, specifically, thrombocytopenia (low platelets), which is contraindicated to epidural analgesia/anethesia. Typically epidural analgesia/anesthesia is used in the laboring woman when a regular labor pattern has been achieved, as evidenced by progessive cervical change. The laboratory values show that the woman's hemoglobin and hematocrit are in the normal range and show a slight increase in the WBC count that is not uncommon in laboring women.
Brittany weighs 28 kg and is to receive ampicillin 300 mg IV q8h. The safe recommended range is 20-40 mg/kg/day. Is her daily dose in the safe range?
Yes. safe range 560mg-1120mg
Which factor is most important in predisposing toddlers to frequent infections such as otitis media, tonsillitis, and upper respiratory tract infections? A. Defense mechanisms are less efficient that those during infancy B. Respirations are abnormal C. Short, straight internal ear/throat structures and large tonsil/adenoid lymph tissue are present D. Pulse and respiratory rates are slower than those in infancy
C. Short, straight internal ear/throat structures and large tonsil/adenoid lymph tissue are present
A school-age child is diagnosed with a life-threatening illness. The parents want to protect their child from knowing the seriousness of the illness. The nurse should explain that: A. Terminally ill children usually choose not to discuss the seriousness of their illness. B. This will help the child cope effectively by denial. C. Terminally ill children know when they are seriously ill. D. This attitude is helpful to give parents time to cope.
C. Terminally ill children know when they are seriously ill. The child needs honest and accurate information about the illness, treatments, and prognosis. Children, even at a young age, realize that something is seriously wrong and that it involves them. The nurse should help the parents understand the importance of honesty. The child will know that something is wrongterm-0 because of the increased attention of health professionals. This would interfere with denial as a form of coping. Parents may need professional support and guidance from a nurse or social worker in this process. Children will usually tell others how much information they want about their condition.
The nurse in a pediatric clinic is performing well-baby checks. The nurse is checking an infant who is 7 months old for developmental milestones. Which finding is of greatest concern to the nurse? A. the infant exhibits a Babinski reflex B. The infant exhibits a lack of startle reflex to sound C. The infant remains flat when in a supine position D. The infant opens and closes her hands to grasp objects
C. The infant remains flat when in a supine position
The nurse is assessing a 6-month old healthy infant who weighed 6 pounds at birth. The nurse should expect the infant to now weigh approximately: A. 25 pounds B. 10 pounds C. 20 pounds D. 12 pounds
D. 12 pounds
Which should the nurse teach the parents is one of the most common causes of injury and death for a 9-month-old infant? A. Poisoning B. Dog bites C. Child abuse D. Aspiration
D. Aspiration
Which statement best describes the infant's physical development? A. Maternal iron stores persist during the first 12 months of life B. Anterior fontanel closes by age 6 to 10 months C. Binocularity is well established by age 8 months D. Birth weight doubles by age 5 months and triples by age 1 year
D. Birth weight doubles by age 5 months and triples by age 1 year
According to Piaget, school age is in which stage of cognitive development, or period of: A. Postconventional thought B. Formal operations C. Conventional thought D. Concrete operations
D. Concrete operations
When caring for a newborn with Downs Syndrome, the nurse should be aware that the most common congenital anomaly associated with Down syndrome is: A. Pyloric stenosis B. Hypospadias C. Congenital hip dysplasia D. Congenital heart disease
D. Congenital heart disease Congenital heart malformations, primarily septal defects, are very common congenital anomalies in Down syndrome. Hypospadias, pyloric stenosis, and congenital hip dysplasia are not frequent congenital anomalies associated with Down syndrome.
Increasing the infusion rate of nonadditive intravenous fluids can increase fetal oxygenation primarily by: a. Maintaining normal maternal temperature. b. Preventing normal maternal hypoglycemia. c. Increasing the oxygen-carrying capacity of the maternal blood. d. Expanding maternal blood volume.
D. Expanding maternal blood volume Filling the mother's vascular system makes more blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most intravenous fluids for laboring women are isotonic and do not provide extra glucose. Oxygen-carrying capacity is increased by adding more red blood cells.
A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should: a. Notify the woman's physician. b. Tell the woman to slow the pace of her breathing. c. Administer oxygen via a mask or nasal cannula. d. Help her breathe into a paper bag
D. Help her breathe into a paper bag This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. This enables her to rebreathe carbon dioxide and replace the bicarbonate ion.
As labor progresses, the nurse expects to assess that a client's contraction are developing which characteristics? A. More intense, less frequent, and of longer duration B. Constant in intensity and frequency but of shorter duration C. Constant in intensity, more frequent and of shorter duration D. More intense, more frequent, and of longer duration
D. More intense, more frequent, and of longer duration As labor progresses, contractions will become more intense, occur more frequently shorter resting period between contractions and have increasing durations. Less frequent or shorter duration impede labor.
The nurse is assisting with the preparation of a patient admitted for a planned cesarean birth. The patient has signed the consent form and discussed the elected regional anesthesia with the nurse anesthetist. Which is the most important action for the nurse related to anesthesia? A. Start an IV line and administer an IV fluid as ordered B. Verify the patient has been NPO for 6 to 8 hours. C. Administer preoperative medications per orders. D. Obtain a baseline fetal heart rate monitor strip.
D. Obtain a baseline fetal heart rate monitor strip
The nurse is providing care in PACU for a patient who just delivered a neonate via cesarean section. The patient reports tightness in her chest. Assessment findings include tachypnea, hypotension, and decreasing oxygen saturation levels. Which complication does the nurse report to the health care provider? A. Surgical-site infection B.Developing endometritis C. Postpartum hemorrhage D. Pulmonary embolism
D. Pulmonary embolism
The nurse is monitoring a patient who has been in prolonged labor. Which assessment finding will result in the nurse notifying the health care provider about the development of an emergent situation requiring a cesarean delivery? A. Maternal blood pressure indicative of hypotension B. Maternal exhaustion from prolonged uterine activity C. Increased maternal temperature related to infection D. Recognition of a fetal heart rate pattern intolerance of labor
D. Recognition of a fetal heart rate pattern intolerance of labor
A parent asks the nurse about how to respond to negativism in toddlers. The most appropriate recommendation is to: A. Provide more attention B. Ask child not always to say "no" C. Punish the child D. Reduce the opportunities for a "no" answer
D. Reduce the opportunities for a "no" answer
A father tells the nurse that his daughter wants the same plate and cup used at every meal, even if they go to a restaurant. The nurse should explain that this is: A. Regression, common at this age B. A sign that the child is spoiled. C. A way to exert unhealthy control D. Ritualism, common at this age.
D. Ritualism, common at this age.
Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth? A. The membranes rupture during a contraction B. The fetal head is felt at 0 station during vaginal examination C. Bloody mucus discharge increases. D. The vulva bulges and encircles the fetal head.
D. The vulva bulges and encircles the fetal head. A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth.
The patient is a 26-year old G1 P0 at 38 weeks, 2 days of gestation. She is at her provider's office for a visit and complains to the nurse of wrist pain, fatigue, increased discharge, and "feeling heavy". Which complaint could be a sign of impending labor? A. wrist pain B. Fatigue C. Heavy feeling D. Increased discharge
D. increased discharge
In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to possible side effects? a. Urine output of 160 mL in 4 hours b. Deep tendon reflexes 2+ and no clonus c. Respiratory rate of 16 breaths/min d. Serum magnesium level of 10 mg/dL
D. serum magnesium level of 10 mg/dL The therapeutic range for magnesium sulfate management is 5 to 8 mg/dL. A serum magnesium level of 10 mg/dL could lead to signs and symptoms of magnesium toxicity, including oliguria and respiratory distress. Urine output of 160 mL in 4 hours, deep tendon reflexes 2+ with no clonus, and respiratory rate of 16 breaths/min are normal findings.
The nurse is talking to the parent of a 13 month old child. The mother states, "my child does not make noises like "da" or "na" like my sister's baby, who is only 9 months old." which statement by the nurse would be most appropriate to make? a. "I am going to request a referral to a hearing specialist." b. "you should not compare your child to your sister's child." c. "I think your child is fine, but we will check again in 3 months." d. " you should ask the other parents what noises their children made at this age."
a. "I am going to request a referral to a hearing specialist."
Which aspect of cognition develops during adolescence? a. Capability to use a future time perspective b. Ability to place things in a sensible and logical order c. Ability to see things from the point of view of another d. Progress from making judgments based on what they see to making judgments based on what they reason
a. Capability to use a future time perspective
While developing an intrapartum care plan for the patient in early labor, it is important that the nurse recognize that psychosocial factors may influence a woman's experience of pain. These include (Select all that apply): a. Culture. b. Anxiety and fear. c. Previous experiences with pain. d. Intervention of caregivers. e. Support systems.
a. Culture. b. Anxiety and fear. c. Previous experiences with pain. e. Support systems.
Parents have learned that their 6-year-old child has autism. The nurse may help the parents to cope by explaining that the child may: a. Have an extremely developed skill in a particular area. b. Outgrow the condition by early adulthood. c. Have average social skills. d. Have age-appropriate language skills.
a. Have an extremely developed skill in a particular area.
Autism is a complex developmental disorder. The diagnostic criteria for autism include delayed or abnormal functioning in which area(s) with onset before age 3 years (select all that apply)? a. Language as used in social communication b. Gross motor development c. Growth below the 5th percentile for height and weight d. Symbolic or imaginative play e. Social interaction
a. Language as used in social communication d. Symbolic or imaginative play e. Social interaction
Four-year-old David is placed in Buck extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses that the skin of his right foot is pale with an absence of pulse. What should the nurse do first? a. Notify the practitioner of the changes noted. b. Give the child medication to relieve the pain. c. Reposition the child and notify physician. d. Chart the observations and check the extremity again in 15 minutes.
a. Notify the practitioner of the changes noted.
The nurse in a pediatric office is performing physical assessments on multiple patients. Which patient will the nurse specifically report to the physician because of physical assessment findings? a. The 3 year old patient with a history of prematurely closed fontanels who has a headache b. the 4 year old patient with a bp of 110/75 mm Hg, pulse of 98 bpm. c. the 3 year old patient with a soiled diaper, at the 70th percentile of weight and height d. the 2 year old patient with asthma who exhibits abdominal breathing at 26 breaths per minute
a. The 3 year old patient with a history of prematurely closed fontanels who has a headache
A parent brings an infant to the pediatric clinic and expresses concern about irritability and poor feeding, along with recent symptoms of flu lasting a few days. The nurse notices multiple raised mosquito bites on the infant. Which additional knowledge causes the nurse to suspect encephalitis? Select all that apply. a. a recent local outbreak of West Nile fever b. bulging fontanels when in a quiet state c. signs of facial and eyelid weakness d. loss of deep tendon reflexes e. drooling instead of swallowing saliva
a. a recent local outbreak of West Nile fever b. bulging fontanels when in a quiet state
The nurse works in a pediatric emergency (ED) and frequently sees adolescents who are victims of sexual abuse. Which assessment findings does the nurse recognize as placing an adolescent at greater risk for sexual assault? Select all that apply. a. an adolescent with developmental disabilities b. a female adolescent who dates older men or boys c. sexual promiscuity and alcohol/substance use d. frequent visit to the ED to seek attention e. adolescents with a history of depression and anxiety
a. an adolescent with developmental disabilities b. a female adolescent who dates older men or boys c. sexual promiscuity and alcohol/substance use
The nurse is doing a prehospitalization orientation for a 7 year old child who is scheduled for cardiac surgery. As part of the preparation, the nurse explains that she will not be able to talk because of an endotracheal tube but that she will be able to talk when it is removed. This explanation is: a. an appropriate part of the childs preparation b. the surgeons responsibility c. unnecessary d. too stressful for a young child
a. an appropriate part of the childs preparation
A young girl has just injured her ankle at school. In addition to calling the childs parents , the most appropriate immediate action by the school nurse is to: a. apply ice b. encourage child to assume a comfortable position c. obtain parental permission for administration of acetaminophen or aspirin d. observe for edema and discoloration
a. apply ice
A nurse is caring for a child who is near death. Which physical signs indicate the child is approaching death? Select all that apply a. change in respiratory pattern b. body feels warm c. tactile sensation decreasing d.difficulty swallowing e. speech becomes rapid
a. change in respiratory pattern c. tactile sensation decreasing d.difficulty swallowing
The nurse is caring for a 4 year old child immobilized by a fractured hip. Which complications should the nurse monitor? a. decreased metabolic rate b. positive nitrogen balance c. increased production of stress hormones d. hypocalcemia
a. decreased metabolic rate
The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome? Select all that apply a. inability to move extremity b. palpable distal pulse c. tingling of extremity d. severe pain not relieved by analgesics e. capillary refill to extremity of <3 seconds
a. inability to move extremity c. tingling of extremity d. severe pain not relieved by analgesics
A mother of a 9 month old infant asks the nurse about what toys are age appropriate. Using Piaget's theory of development, which toy does the nurse recommend? a. musical rattles b. picture books c. colorful mobiles d. building blocks
a. musical rattles
The RN in a pediatric office is preparing to administer oral medication to an infant. Before the actual administration of the medication, which initial action does the nurse take? a. obtain an accurate weight of the infant b. assist the caretaker in holding the infant supine c. provide the caretaker with written information d. acquire a calibrated syringe for administration
a. obtain an accurate weight of the infant
What represents the major stressor of hospitalization for children from middle infancy throughout the preschool years? a. Separation anxiety b. Loss of control c. Fear of bodily injury d. Fear of pain
a. separation anxiety
The nurse is assessing parental knowledge of temper tantrums. Which are true statements regarding temper tantrums? Select all that apply. a. temper tantrums are a common response to anger and frustration in toddlers. b. temper tantrums often include screaming, kicking, throwing things, and head banging. c. parents can effectively manage temper tantrums by giving in to the child's demands. d. children having temper tantrums should be safely isolated and ignored. e. parents can learn to anticipate times when tantrums are more likely to occur
a. temper tantrums are a common response to anger and frustration in toddlers. b. temper tantrums often include screaming, kicking, throwing things, and head banging. d. children having temper tantrums should be safely isolated and ignored. e. parents can learn to anticipate times when tantrums are more likely to occur
The pediatric nurse understands that fragile X syndrome is: a. the second most common genetic cause of cognitive impairment b. a chromosome defect that follows the pattern of x-linked recessive disorders c. a chromosome defect affecting only females d. the most common cause of noninherited cognitive impairment
a. the second most common genetic cause of cognitive impairment
The nurse is preparing to teach parents the importance of play in the newborn's and infant's life. Which information will the nurse plan to include in the class? Select all that apply. a. toys can help with physical and fine motor development b. play is how infants learn about their environment and themselves c. older siblings are encouraged to share their toys with the infant d. infants may be startled by their own images in a reflective toy. e. toys should provide a means of sensory stimulation for the infant.
a. toys can help with physical and fine motor development b. play is how infants learn about their environment and themselves e. toys should provide a means of sensory stimulation for the infant.
The nurse is interviewing a parent of a 9 month old infant during a well baby visit. Which statement by the parent causes the nurse concern about infant safety? a. "it really disturbed me to see my neighbors infant with a pacifier on a cord around the neck" b. "he loves to get his toys out of a big plastic storage bag on the doorknob" c. "he thinks the TV remote is a toy, so it is kept on a shelf too high for him to reach" d. "when we eat cooked vegetables, I cut a few into bite size pieces so he can try them"
b. "he loves to get his toys out of a big plastic storage bag on the doorknob"
A child with autism is hospitalized with asthma. The nurse should plan care so that the: a. Parents' expectations are met. b. Child's routine habits and preferences are maintained. c. Child is supported through the autistic crisis. d. Parents need not be at the hospital.
b. Child's routine habits and preferences are maintained.
Mark, a 9-year-old with Down syndrome, is mainstreamed into a regular third-grade class for part of the school day. His mother asks the school nurse about programs such as Cub Scouts that he might join. The nurses recommendation should be based on knowing that: a. Programs such as Cub Scouts are inappropriate for children who are cognitively impaired. b. Children with Down syndrome have the same need for socialization as other children. c. Children with Down syndrome socialize better with children who have similar disabilities. d. Parents of children with Down syndrome encourage programs such as scouting because they deny that their children have disabilities.
b. Children with Down syndrome have the same need for socialization as other children. Children of all ages need peer relationships. Children with Down syndrome should have peer experiences similar to those of other children, such as group outings, Cub Scouts, and Special Olympics, which can all help children with cognitive impairment to develop socialization skills. Although all children should have an opportunity to form a close relationship with someone of the same developmental level, it is appropriate for children with disabilities to develop relationships with children who do not have disabilities. The parents a reacting as advocates for their child.
An implanted ear prosthesis for children with sensorineural hearing loss is a(n): a. Hearing aid. c. Auditory implant. b. Cochlear implant. d. Amplification device.
b. Cochlear implant.
A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed nasal bridge, protruding tongue, and transverse palmar creases. These findings are most suggestive of: term-6 a. Microcephaly. b. Down syndrome. c. Cerebral palsy. d. Fragile X syndrome.
b. Down syndrome. These are characteristics associated with Down syndrome. The infant with microcephaly has a small head. Cerebral palsy is a diagnosis not usually made at birth. No characteristic physical signs are present. The infant with fragile X syndrome has increased head circumference; long, wide, and/or protruding ears; long, narrow face with prominent jaw; hypotonia; and high, arched palate.
Amy, age 6 years, needs to be hospitalized again because of a chronic illness. The clinic nurse overhears her school-age siblings tell her, "We are sick of Mom always sitting with you in the hospital and playing with you. It isn't fair that you get everything and we have to stay with the neighbors." The nurse's best assessment of this situation is that: a. The siblings are immature and probably spoiled. b. Jealousy and resentment are common reactions to the illness or hospitalization of a sibling. c. The family has ineffective coping mechanisms to deal with chronic illness. d. The siblings need to better understand their sister's illness and needs.
b. Jealousy and resentment are common reactions to the illness or hospitalization of a sibling.
Distortion of sound and problems in discrimination are characteristic of which type of hearing loss? a. Conductive b. Sensorineural c. Mixed conductive-sensorineural d. Central auditory imperceptive
b. Sensorineural
The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of the nursing assessment to detect early signs of a worsening condition is: a. posturing b. focal neurologic signs c. level of consciousness d. vital signs
c. level of consciousness
The nurse has received report on four children. Which child should the nurse assess first? a. an adolescent admitted after a motor vehicle accident who is oriented to person and place b. a preschool child with a head injury and decreasing level of consciousness c. a toddler in a persistent vegetative state with a low grade fever d. a school age child in a coma with stable vital signs
b. a preschool child with a head injury and decreasing level of consciousness
The nurse is presenting a class to high school females about decreasing the developmental risks related to pregnancy. Which information does the nurse consider to be the most important? a. early prenatal care is essential for a healthy pregnancy and baby b. all females of child bearing age should take 0.4 mg of folic acid daily c. important fetal development occurs before pregnancy is suspected d. Young women should begin taking 600 mg of calcium twice a day.
b. all females of child bearing age should take 0.4 mg of folic acid daily
The nurse is counseling parents about management of their children who are 2,4, and 6 years of age. One of the parents states, "We believe in Kohlberg's theory of social-moral development." The nurse is aware that the preconventional stage of this theory involves which characteristic? a. value systems are independent of authority figures and peers b. behavior is adjusted according to good/bad and right/wrong thinking c. a personal and functional value system is constructed by the child d. the focus of the child is on following rules and maintaining social order
b. behavior is adjusted according to good/bad and right/wrong thinking
Which clinical manifestations would suggest hydrocephalus in a neonate? a. closed fontanel and high pitched cry b. bulging fontanel and dilated scalp veins c. constant low pitched cry and restlessness d. depressed fontanel and decreased blood pressure
b. bulging fontanel and dilated scalp veins
The nurse is caring for a 1 year old patient after surgery for an intracranial shunt replacement. The nurse selects the FLACC scale for assessment because of the toddlers inability to participate in pain evaluation. The nurse will recognize which assessment finding as an indication of some level of pain? Select all that apply. a. legs are positioned normally and appear relaxed b. constantly frowns, clenched jaw, quivering chin c. squirms, shifting back and forth, tense d. cries steadily and loudly, sometimes screams or sobs e. answers to name, sucks thumb, and holds toy
b. constantly frowns, clenched jaw, quivering chin c. squirms, shifting back and forth, tense d. cries steadily and loudly, sometimes screams or sobs
An important nursing intervention when caring for a child who is experiencing a seizure is to: a. suction the child during a seizure to prevent aspiration b. describe and record the seizure activity observed c. restrain the child when seizure occurs to prevent bodily harm d. place a tongue blade between the teeth if they become clenched
b. describe and record the seizure activity observed
The Glascow Coma Scale consists of an assessment of what function? a. pupil reactivity and motor responses b. eye opening and verbal and motor responses c. intracranial pressure (ICP) and level of consciousness d. Level of consciousness and verbal response
b. eye opening and verbal and motor responses
The nurse in the neonatal intensive care unit is caring for an infant with myelomeningocele scheduled for surgical repair in the morning. Which early signs of infection should the nurse monitor on this infant? Select all that apply a. hypertension b. irritability c.temperature instability d. bradycardia e. lethargy
b. irritability c.temperature instability e. lethargy
The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as: a. eye trauma. b. neurosurgical emergency. c. severe brainstem damage. d. indication of brain death.
b. neurosurgical emergency.
The nurse in a pediatric emergency department is concerned when parents bring a 9 month old infant in for possible injury. X-rays indicate the infant has a broken leg. Which information causes the nurse to report possible physical abuse to the nursing supervisor? Select all that apply. a. the parents insist on simple, noninvasive medical care b. the infant buries his face in the mother's arm if the father talks. c. the father states the infant climbed a stepladder and fell d. the infant has been treated three times for injuries. e. the mother states she fell down the stairs with the baby.
b. the infant buries his face in the mother's arm if the father talks. c. the father states the infant climbed a stepladder and fell d. the infant has been treated three times for injuries. e. the mother states she fell down the stairs with the baby.
The nurse is providing care for a pediatric patient who received a concussion while playing football. The patient had a brief loss of consciousness and now reports a headache with a pain level of 6 on a 0 to 10 scale. The patient states "my team plays again in five days and I should be better." Which information is vital for the patient and parents to understand? a. the potential for long term headaches b. the risk of acquiring second impact syndrome c. a realistic timeframe regarding complete recovery d. type of equipment to prevent a second head injury
b. the risk of acquiring second impact syndrome
The nurse must suction a child with a tracheostomy. Interventions should include: a. Encouraging the child to cough to raise the secretions before suctioning. b. Selecting a catheter with a diameter three-fourths as large as the diameter of the tracheostomy tube. c. Ensuring that each pass of the suction catheter take no longer than 5 seconds. d. Allowing the child to rest after every 5 times the suction catheter is passed.
c. Ensuring that each pass of the suction catheter take no longer than 5 seconds.
The nurse in a pediatric clinic is assessing a female adolescent who is 15 years of age. When the nurse performs a sexuality assessment, the patient states, " I have never had anything but safe sex." Which approach does the nurse take next? a. provide birth control options b. inquire about treatment of an STI c. ask the patient to define "safe sex" d. ascertain the number of sex partners
c. ask the patient to define "safe sex"
The nurse is teaching the parents of a 7 year old child who has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which instructions should be included in the teaching? a. immobilize the shoulder to decrease pain in the arm b. allow the affected limb to hang down for 1 hour each day c. elevate casted arm when resting and when sitting up d. swelling of the fingers is to be expected for the next 48 hours
c. elevate casted arm when resting and when sitting up
An appropriate nursing diagnosis for a child with a cognitive dysfunction who has limited ability to anticipate danger is: a. impaired social interactions b. ineffective coping c. risk for injury d. deficient knowledge
c. risk for injury
Because of their striving for independence and productivity, which age group of children is particularly vulnerable to events that may lessen their feeling of control and power? a. preschoolers b. infants c. school age children d. toddlers
c. school age children
A 12-year old girl is noted to walk with an uneven gait, and her shoulders appear uneven. The left shoulder sits lower than the right shoulder, and her waist appears to be tilted from side to side. Which condition is the girl most likely experiencing? a. internal femoral torsion b. hip dysplasia c. scoliosis d. club foot
c. scoliosis
What should the nurse keep in mind when planning to communicate with a child has autism? a. the child has normal verbal communication b. the child is expected to use sign language c. the child may exhibit monotone speech and echolalia d. the child is not listening if she is not looking at the nurse
c. the child may exhibit monotone speech and echolalia
The pediatric nurse is providing care for a 14 year old female patient. After the patients parents leave the hospital, the patient begins to cry. The nurse explores the patients feelings using therapeutic communication. Which information causes the nurse to report suspected sexual abuse? a. the patient states that an older brother frequently "hurts" her b. the patient is frequently denied access to needed health care c. the patient reports frequent episodes of genital irritation d. the patient admits to multiple incidences of skipping school
c. the patient reports frequent episodes of genital irritation
Which nursing intervention is appropriate to assess for neurovascular competency in a child who fell off the monkey bars at school and hurt his arm? a. the amount of swelling noted in the extremity and pain intensity b. the length, diameter, and shape of the extremity c. the skin color, temperature, movement sensation, and capillary refill of the extremity d. the degree of motion and ability to position the extremity
c. the skin color, temperature, movement sensation, and capillary refill of the extremity
The nurse is visiting the home of a new mother and a 2 month old infant. The nurse notices the infant vigorously sucking on the fist and whining but not crying. The mother validates that the behavior is common. Which information does the nurse need to obtain from the mother? a. if the mother is breast or bottle feeding b. how long the infant sleeps at night c. what type of feeding schedule is followed d. if the infant draws up the legs when crying
c. what type of feeding schedule is followed
The nurse is screening adolescents for substance abuse. Which comment by an adolescent will require additional assessment by the nurse? a. "if I smoke, I pay my own way to college" b. "My grandpa died of lung cancer." c. "I cant afford any kind of smoking." d. "I don't smoke cigarettes"
d. "I don't smoke cigarettes"
The nurse is caring for an adolescent who had an external fixator placed after suffering a fracture of the wrist during a bicycle accident. Which statement by the adolescent would be expected about separation anxiety? a. " I will be embarrassed if my friends come to the hospital to visit" b. "I think I would like for mu sibling to visit me but not my friends" c. "I wish my parents could spend the night with me while I am in the hospital" d. "I hope my friends dont forget about visiting me"
d. "I hope my friends dont forget about visiting me"
As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or has late decelerations or loss of variability is nonreassuring and is associated with: a. Hypotension. b. Maternal drug use. c. Cord compression. d. Hypoxemia.
d. Hypoxemia Nonreassuring heart rate patterns are associated with fetal hypoxemia. Fetal bradycardia may be associated with maternal hypotension. Fetal variable decelerations are associated with cord compression. Maternal drug use is associated with fetal tachycardia.
A third-grade teacher discusses behavioral problems with a parent. The teacher states, " he walks around class making horrible sucking noises. He does not respond to me." Which information does the nurse seek from the student's parents? a. suggest the student be screened for possible developmental delays b. Inquire if the student is either diagnosed or medicated for ADHD c. ascertain if the student has experienced recent illness or fever d. ask if the student has been tested by a physician for seizure disorder
d. ask if the student has been tested by a physician for seizure disorder
A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, the nurse should explain that: a. traction is tried first b. surgical intervention is needed c. children outgrow this condition when they learn to walk d. frequent, serial casting is tried first
d. frequent, serial casting is tried first
The nurse is caring for a 13 year old patient diagnosed with adolescent idiopathic scoliosis. The curve in her back was treated by spinal fusion with rod insertion. Which is the priority nursing intervention in the postoperative period? a. ensure placement of indwelling urinary catheter b. promote adequate oral fluid intake c. maintain a straight back, no bending d. keep oxygen saturation within normal limits
d. keep oxygen saturation within normal limits
The nurse working in the emergency department of a pediatric care facility is receiving an adolescent patient with a gunshot wound to the head. The patient is unconscious but exhibiting signs of life threatening deterioration. Which action does the nurse take? a. keep attempting to reach the parents b. call the facility's legal advisor c. determine if the patient is emancipated d. prepare the patient for surgery
d. prepare the patient for surgery
The school nurse is present at a school assembly when a student fall to the floor with a seizure. Which intervention does the nurse initiate when providing care for the student during the seizure? a. remove or loosen any tight clothing around the neck or waist b. if incontinent, cover the student with a blanket or sheet c. provide comfort and promote resting in a quiet environment d. protect the student from injury related to seizure movement
d. protect the student from injury related to seizure movement
Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? a. coma b. obtundation c. persistent vegetative state d. stupor
d. stupor