HPA exam 3 ATI Practice

spica cast...proper skin care?

-check exposed areas for signs of redness or irritation -inspect the inside edges of the cast to look for extra pieces of cast material -provide regular sponge baths for the client

the patient has preeclampsia and is receiving and infusion of mag sulfate. Which of the following actions will be implemented? SATA

-monitor urine output -assess DTR

The nurse teaches the parents of an infant with developmental dysplasia of the hip how to handle their child in a Pavlik harness. Which of the following is most appropriate? 1. Fitting the diaper under the straps. 2. Leaving the harness off while the infant sleeps. 3. Checking for skin redness under straps every other day. 4. Putting powder on the skin under the straps every day.

1. Fitting the diaper under the straps

Which would the nurse expect to assess on a 3-week-old infant with developmental dysplasia of the hip (DDH)? Select all that apply. 1. Excessive hip abduction. 2. Femoral lengthening of an affected leg. 3. Asymmetry of gluteal and thigh folds. 4. Pain when lying prone. 5. Positive Ortolani test

3. Asymmetry of gluteal and thigh folds. 5. Positive Ortolani test

Which should the nurse stress to the parents of an infant in a Pavlik harness for treatment of developmental dysplasia of the hip (DDH)? 1. Put socks on over the foot pieces of the harness to help stabilize the harness. 2. Use lotions or powder on the skin to prevent rubbing of straps. 3. Remove harness during diaper changes for ease of cleaning diaper area. 4. Check under the straps at least two to three times daily for red areas.

4. Check under the straps at least two to three times daily for red areas.

placement of spica cast

A cast applied from the chest to the thighs or knees

A nurse is caring for an infant and notices an audible click in their left hip. Which of the following diagnostic test should the nurse expect the provider to perform? (SATA) a. Barlow test b. Babinski sign c. Manipulation of the foot and ankle d. Ortolani test e. Ponseti method

A. Barlow test D. Ortolani test -both used to assess developmental dysplasia of the hip for infants. the provider will flex the infants hips and knees into the right angle position

A patient at 30wks was in a fight and hit in the abdomen. The pt is Rh neg. What orders can be anticipated? a. CST and admit for observation b. Fetal fibronectin, betamethasone 12 mg and repeat in 24 hrs c. CBC, coags, type and screen, indirect Coombs test, rhogam if indicated d. Prepare for C section, obtain neonatology consult

CBC, coags, type and screen, indirect Coombs test, rhogam if indicated

A nurse is caring for a toddler who has hip dysplasia and has been placed in a hip spica cast. The child's guardian asks the nurse why a Pavlik harness is not being used. Which of the following responses should the nurse make? a. "The Pavlik harness is used for children with scoliosis, not hip dysplasia" b. "The Pavlik harness is used for school-aged children" c. "The Pavlik harness cannot be used for your child because her condition is too severe" d. "The Pavlik harness is used for infants less than 6 months of age"

a. "The Pavlik harness is used for infants less than 6 months of age"

A nurse is completing preoperative teaching with an adolescent client who is scheduled to receive spinal instrumentation for scoliosis. Which of the following information should the nurse include in the teaching? a. "You will go home the same day of surgery" b. "You will have minimal pain" c. "You will need to receive blood" d. "You will not be able to eat until the day after surgery"

a. "You will need to receive blood"

A nurse is providing teaching to the parent of a child who has a neuroblastoma. Which of the following statements should the nurse include in the teaching? SATA a. "chemo and radiation may be necessary for treatment" b. "your child will need a bone marrow biopsy" c. "your child will be paralyzed because of this tumor" d. "most children are diagnosed around age 12" e. "your child will need surgery for resection of the tumor"

a. "chemo and radiation may be necessary for treatment" b. "your child will need a bone marrow biopsy" e. "your child will need surgery for resection of the tumor"

A nurse is caring for a client at 32wks and has placenta previa. The nurse notes that the patient is actively bleeding. Which of the following medications should the nurse expect the provider will prescribe? a. Betamethasone b. Indomethacin c. Nifedpine d. Mythylergonovine

a. Betamethasone

A nurse is caring for a child who is experiencing neuropathy d/t chemo. Which of the following are manifestations of neuropathy? SATA a. Constipation b. Skin breakdown c. Foot drop d. Jaw pain e. Hemorrhage cystitis

a. Constipation b. Skin breakdown c. Foot drop

A nurse is caring for a postpartum client who delivered their third infant 2 days ago. Which of the following manifestations could indicate postpartum depression? SATA a. Fatigue b. Insomnia c. Euphoria d. Flat affect e. Delusions

a. Fatigue b. Insomnia d. Flat affect

A nurse is assessing a child who has epiglottitis. Which of the following findings should the nurse expect? SATA a. Hoarseness and difficulty speaking b. Difficulty swallowing c. Low grade fever d. Drooling e. Dry, barking cough f. Stridor

a. Hoarseness and difficulty speaking b. Difficulty swallowing d. Drooling f. Stridor

A nurse is providing home care instructions to a parent of a child receiving chemo. Which of the following instructions should the nurse include? SATA a. Manifestations of infection b. Bleeding precautions c. Hand hygiene d. Homeschooling e. Airborne precautions

a. Manifestations of infection b. Bleeding precautions c. Hand hygiene

A nurse is reviewing the diagnostic findings for a preschool age child who is suspected of having CF. Which of the following findings should the nurse identify as an indication of CF? a. Sweat chloride content 85 mEq/L b. Increased blood levels of fat-soluble vitamins c. 72hr stool analysis sample indicating hard, packed stools d. CXR negative for atelectasis

a. Sweat chloride content 85 mEq/L

A nurse is admitting a child who has CF. Which of the following medications should the nurse plan to include in the plan of care? SATA a. Tobramycin b. Loperamide c. Fat soluble vitamins d. Albuterol e. Dornase alfa

a. Tobramycin c. Fat soluble vitamins d. Albuterol e. Dornase alfa

A nurse is performing an admission assessment for a child who has CF. Which of the following findings should the nurse expect? SATA a. Wheezing b. Clubbing of fingers and toes c. Barrel shaped chest d. Thin, watery mucous e. Rapid growth spurts

a. Wheezing b. Clubbing of fingers and toes c. Barrel shaped chest

A nurse is providing care for a patient who has a marginal abruptio placentae. Which of the following are risk factors for developing the condition? SATA a. Fetal position b. Blunt abdominal trauma c. Cocaine use d. Maternal age e. Cigarette smoking

a. blunt abdominal trauma b. cocaine use d. cigarette smoking

An infant diagnosed with pyloric stenosis is admitted with history of vomiting for several days. Which nursing diagnosis would be the priority? a. Deficient fluid volume r/t prolonged vomiting b. Ineffective airway clearance r/t impaired swallowing c. Imbalance nutrition: less than body requirements r/t prolonged vomiting d. Anxiety r/t loss of body control

a. deficient fluid volume r/t prolonged vomiting

A nurse is assessing an infant who has hypertrophic pyloric stenosis. Which of the following manifestations should the nurse expect? SATA a. Projectile vomiting b. Dry mucous membranes c. Currant jelly stools d. Sausage shaped abdominal mass e. Constant hunger

a. projectile vomiting b. dry mucous membranes e. constant hunger

A nurse is administering mag sulfate IV for seizure prophylaxis to a pt with severe preeclampsia. Which of the following indicates mag sulfate toxicity? SATA a. Respirations less than 12/min b. Urinary output less than 25 mL/hr c. Hyperreflexia DTR d. Decreased LOC e. Flushing and sweating

a. respirations less than 12/min b. urinary output less than 25 mL/hr d. decreased LOC

A nurse is assessing an infant who has coarctation of the aorta. Which of the following findings should the nurse expect? (SATA) a. weak femoral pulses b. cool skin of lower extremities c. severe cyanosis d. clubbing of the fingers e. low blood pressure

a. weak femoral pulses b. cool skin of lower extremities e. low blood pressure

A nurse is providing discharge teaching for a child who has CF. Which of the following instructions should the nurse include? a. Provide a low calorie, low protein diet b. Administer pancreatic enzymes with meals and snacks c. Implement a fluid restriction during times of infection d. Restrict physical activity

b. Administer pancreatic enzymes with meals and snacks

A nurse is assessing a child who has leukemia. Which of the following are early manifestations of leukemia? SATA a. Hematuria b. Anorexia c. Petechiae d. Ulcerations of the mouth e. Unsteady gait

b. Anorexia c. Petechiae e. Unsteady gait

A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurses priority? a. Reinforce the need to take antipsychotics as prescribed b. Ask the client if they have thoughts of harming themselves or their infant c. Monitor the infant for indications of failure to thrive d. Review the clients medical record for a history of bipolar disorder

b. Ask the client if they have thoughts of harming themselves or their infant

Which assessment finding might indicate placental abruption? a. Bright red bleeding b. Board like abdomen c. Insidious onset d. Painless bleeding

b. Board like abdomen

A nurse is assessing a child who has a neuroblastoma of the adrenal gland. Which of the following are manifestations of metastasis from the primary site? SATA a. Weight gain b. Bone pain c. Periorbital ecchymoses d. Proptosis e. Weight loss

b. Bone pain c. Periorbital ecchymoses d. Proptosis e. Weight loss

A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following manifestations? SATA a. Paranoia that their infant will be harmed b. Concerns about lack of income to pay bills c. Anxiety about assuming a new role as a parent d. Rapid decline in estrogen and progesterone e. Feeling of inadequacy with the new role as a parent

b. Concerns about lack of income to pay bills c. Anxiety about assuming a new role as a parent d. Rapid decline in estrogen and progesterone e. Feeling of inadequacy with the new role as a parent

A nurse is assessing an infant who has heart failure. Which of the following findings should the nurse expect? SATA a. Bradycardia b. Cool extremities c. Peripheral edema d. Increased urinary output e. Nasal flaring

b. Cool extremities c. Peripheral edema e. Nasal flaring

What clinical finding can you expect with placental abruption? a. Bright red bleeding b. Fetal HR decelerations c. Soft relaxed uterus d. No prenatal care

b. Fetal HR decelerations

A nurse is caring for a toddler who has a Wilms tumor. Which of the following actions should the nurse take? a. Palpate the childs abdomen to identify the size of the tumor b. Prepare the child for surgery c. Teach the parents about dialysis d. Obtain a 24hr urine from the child

b. Prepare the child for surgery

A 2 year old is hospitalized with suspected intussusception. Which finding is associated with intussusception? a. Ribbon like stools b. Currant jelly stool c. Palpable mass over the flank d. Projectile vomiting

b. current jelly stool

Which risk factor places a patient at increased risk for placenta previa? a. Short interval between pregnancy b. Previous uterine surgery c. First pregnancy d. Short umbilical cord

b. previous uterine surgery

A nurse is providing teaching to a caregiver of an infant with a prescription for digoxin. Which of the following instructions should the nurse include? a. "do not offer your baby fluids after giving the medication" b. "digoxin increases your baby's heart rate" c. "give the correct dose of medication at regularly scheduled times" d. "if your baby vomits a dose, you should repeat the dose to ensure the correct amount is received"

c. "give the correct dose of medication at regularly scheduled times"

A nurse is teaching the parent of a child who has a Wilms tumor. Which of the following statements should the nurse include in the teaching? SATA a. "your child will need chemo for 12 months" b. "Wilms tumors are typically genetic in nature" c. "surgery is done usually within 48 hrs of diagnosis" d. "palpating the tumor could cause spread of the cancer" e. "further treatments will start immediately after surgery"

c. "surgery is done usually within 48 hrs of diagnosis" d. "palpating the tumor could cause spread of the cancer" e. "further treatments will start immediately after surgery"

Which question would be most helpful in obtaining a nursing history from the mother of an infant with suspected intussusception? a. "is your child eating normally?" b. "how often has your child been vomiting?" c. "what does your child's stool look like?" d. "when did your child last urinate?"

c. "what does your child's stool look like?"

A nurse is caring for a child who is postop following surgical removal of a Wilms tumor. Which of the following assessments is an indication to continue NPO status? a. Abdominal girth 1cm larger than yesterday b. Report of pain at perioperative site c. Absent bowel sounds d. Passing of flatus every 30 min

c. Absent bowel sounds

A nurse is caring for a child who has oral mucositis. Which of the following actions should the nurse take? SATA a. Swab the mucosa with lemon glycerin swabs b. Apply viscous lidocaine c. Offer soft foods d. Use a soft, disposable toothbrush for oral care e. Encourage gargling with a warm saline mouthwash

c. Offer soft foods d. Use a soft, disposable toothbrush for oral care e. Encourage gargling with a warm saline mouthwash

A nurse is caring for a child following an above the knee amputation. Which of the following actions should the nurse take? a. Avoid discussing the amputation b. Administer aspirin for phantom pain c. Prepare the child for a prosthetic fitting d. Maintain the affected limb in the dependent position

c. Prepare the child for a prosthetic fitting

What instructions would you provide for a patient managing placenta previa at home? a. Moderate exercise is recommended b. When your contractions are 5 mins apart come to the hospital c. Rest on your L side as often as possible d. Call your provider if there is no fetal movement for 2 days

c. Rest on your L side as often as possible

A nurse is planning care for an infant who is scheduled for a lumbar puncture. Which of the following actions should the nurse include in the plan of care? a. Cleanse the thoracic area of the infants back with antiseptic solution b. Apply a eutectic mixture of local anesthetic cream just before the procedure begins c. Restrain the infant during the procedure to prevent movement d. Position the infant with his head extended and chin raised

c. Restrain the infant during the procedure to prevent movement

A nurse is caring for an adolescent who has a new diagnosis of osteosarcoma. Which of the following actions should the nurse take first? a. Ensure that the adolescent has a referral to a psychiatrist b. Prepare a teaching plan to educate the adolescent in detail about the diagnosis and treatment c. Spend time with the adolescent to answer any questions d. Perform a mental status exam to assess the adolescents thought patterns

c. Spend time with the adolescent to answer any questions

Which procedure is contraindicated in a patient with placenta previa? a. C-section b. Blood transfusion c. Vaginal exam d. Ultrasound

c. vaginal exam

Plaster spica cast nursing care

check the temperature of the infants toes every hour for at least the first 24 hours

A nurse is caring for a patient who is recieiving IV mag sulfate. Which of the following medications should the nurse anticipate administering if mag sulfate toxicity is suspected? a. Nifedipine b. Pyridoxine c. Ferrous sulfate d. Calcium gluconate

d. Calcium gluconate

A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these manifestations? a. Postpartum fatigue b. Postpartum psychosis c. Letting go phase d. Postpartum blues

d. Postpartum blues

A nurse is assessing a child with pyloric stenosis. She is likely to note which of the following? a. Currant jelly stools b. Regurgitation c. Steatorrhea d. Projectile vomiting

d. projectile vomiting

...abruptio placentae...complications associated with this problem?

hypovolemic shock

....at 24 weeks...painless, bright red vaginal bleeding. Which of the following conditions does the nurse expect?

placenta previa

....37 weeks gestation....the healthcare provider should be called immediatley:

severe headache and blurred vision

Nursing instructions: 13 year old female with scoliosis who is discharged with a brace?

wear a cotton tshirt under the brace