Maternal-Neonatal pt 1

A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond? "No, it can promote sodium retention." "No, it can initiate premature uterine contractions." "Yes, it produces no adverse effects." "No, it can lead to increased absorption of fat-soluble vitamins."

"No, it can initiate premature uterine contractions." Explanation:Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it doesn't promote sodium retention. Castor oil isn't known to increase absorption of fat-soluble vitamins, although laxatives can decrease absorption if intestinal motility is increased.

The parents of a child with cystic fibrosis ask the nurse why their child must receive supplemental pancreatic enzymes. Which response by the nurse would be most appropriate? "Pancreatic enzymes help prevent meconium ileus." "Pancreatic enzymes prevent intestinal mucus accumulation." "Pancreatic enzymes promote adequate rest." "Pancreatic enzymes promote absorption of nutrients and fat."

"Pancreatic enzymes promote absorption of nutrients and fat." Explanation: Pancreatic enzymes are given to a child with cystic fibrosis to aid fat and protein digestion. They don't promote rest or prevent mucus accumulation or meconium ileus.

The nurse is preparing a child, age 4, for cardiac catheterization. Which explanation of the procedure is most appropriate? "You must sleep the whole time that the test is being done." "The test usually takes an hour." "The special medicine will feel warm when it's put in the tubing." "Don't worry. It won't hurt."

"The special medicine will feel warm when it's put in the tubing."

A nurse is reviewing a neonate's discharge instructions about umbilical cord care with new parents. The nurse determines that the parents understand the information when they state that the cord will most likely fall off how many days after birth? 1 to 2 days 15 to 30 days 7 to 10 days 3 to 4 days

7 to 10 days Explanation: The umbilical stump deteriorates over the first 7 to 10 days postpartum due to dry gangrene and usually falls off by day 10.

A client with preeclampsia is scheduled to undergo a nonstress test (NST) and asks the nurse why this test is being performed. When responding to the client, which condition would the nurse most likely include as the reason? intrauterine growth restriction (IUGR) fetal well-being anemia oligohydramnios

fetal well-being Explanation: An NST is based on the theory that a healthy fetus has transient fetal heart rate accelerations with fetal movement. Because uteroplacental circulation is compromised in clients with preeclampsia, an NST would usually show a lack of these accelerations, which indicate a nonreactive NST. An NST cannot detect anemia in a fetus. Serial ultrasounds will detect IUGR and oligohydramnios in a fetus.

A 30-year-old client comes to the office for a routine prenatal visit. After reading the chart entry shown, the nurse should prepare the client for which study? triple screen amniocentesis indirect Coombs test 1-hour glucose tolerance test

1-hour glucose tolerance test Explanation: A 1-hour glucose tolerance test is recommended to screen for gestational diabetes if the client is obese, has glycosuria or a family history of diabetes, lost a fetus for unexplained reasons, or gave birth to a large-for-gestational-age neonate. A triple screen tests for chromosomal abnormalities. The indirect Coombs test screens maternal blood for red blood cell antibodies. Amniocentesis is used to detect fetal abnormalities.

A client, 6 weeks' pregnant, is diagnosed with hyperemesis gravidarum. The nurse should monitor the client for the development of which condition? bowel perforation miscarriage electrolyte imbalance gestational hypertension

2. Electrolyte imbalance Excessive vomiting in clients with hyperemesis gravidarum commonly causes weight loss and fluid, electrolyte, and acid-base imbalances. Gestational hypertension and bowel perforation aren't related to hyperemesis. The effects of hyperemesis on the fetus depend on the severity of the disorder. Clients with severe hyperemesis may have a low-birth-weight infant, but the disorder isn't generally life-threatening

What is a normal systolic blood pressure for a 3-year-old child? 100 mm Hg 86 mm Hg 120 mm Hg 60 mm Hg

86 mm Hg Explanation: Using the formula systolic blood pressure = 80 + (age in years × 2), the estimated blood pressure for a 3-year-old child is 80 + (3 × 2) = 86.

A client who's pregnant with her second child comes to the clinic reporting a pulling and tightening sensation over her pubic bone every 15 minutes. She reports no vaginal fluid leakage. Because she has just entered her 36th week of pregnancy, she's apprehensive about her symptoms. Vaginal examination discloses a closed, thick, posterior cervix. These findings suggest that the client is experiencing: true labor contractions. Braxton Hicks contractions. back labor. fetal distress.

Braxton Hicks contractions. Explanation: Braxton Hicks contractions cause pulling or tightening sensations, primarily over the pubic bone. Although these contractions may occur throughout pregnancy, they're most noticeable during the last 6 weeks of gestation in primigravid clients and the last 3 to 4 months in multiparous clients. With Braxton Hicks contractions, the cervix is closed, thick, and posterior, rather than dilated and thin as in true labor. Back labor refers to pain that typically starts in the back. Fetal distress doesn't cause contractions, although it may cause sharp abdominal pain. Decreased or absent fetal movements, green-tinged or yellowish green-tinged fluid, or port-wine- colored fluid may also indicate fetal distress. Pain from true labor contractions typically starts in the back and moves to the front of the fundus as a band of pressure that peaks and subsides in a regular pattern.

An 18-month-old Hispanic toddler admitted to the hospital with bronchitis has red marks on his upper chest over both sides of his body. The mother states that she has been treating him at home. Which treatment has the mother most likely been administering to her toddler? Reflexology Coin rubbing Acupuncture Rolfing

Coin rubbing Explanation: Coin rubbing, also known as Cao Gío, is used by many cultures to relieve pain. Bruising commonly occurs with the rubbing and can be easily mistaken for child abuse. The other options are examples of alternative therapies used by a variety of other cultures.

When bathing a neonate who is one hour old, which nursing action is most important? Bathe in a tub of warm water. Place on a table covered with blankets, and give a sponge bath. Keep under a radiant warmer, and give a sponge bath. Wash only hands and head because the condition isn't stable enough to have a complete bath.

Keep under a radiant warmer, and give a sponge bath. Explanation: During the first several hours after delivery, a neonate's thermal regulatory system is adapting to extrauterine life. When bathing a neonate under a radiant warmer, the external heat decreases the chances for cold stress by decreasing the number of internal mechanisms the neonate must use to stay warm. Bathing a neonate on a table, where she's exposed to air drafts and cooler air currents, can set her up for cold stress. Bathing the neonate in a tub and then removing her increases her heat loss and metabolism. Washing only the hands and head would chill the neonate and reduce thermoregulation because most heat is lost through the head.

The parent of a preschooler with chickenpox asks the nurse about measures to make the child comfortable. The nurse instructs the parent to avoid administering aspirin or any other product that contains salicylates. When given to children with chickenpox, aspirin has been linked to which disorder? Scarlet fever Rheumatic fever Reye syndrome Guillain-Barre syndrome

Reye syndrome Explanation: Research shows a correlation between the use of aspirin during an episode of chickenpox and the development of Reye syndrome (a disorder characterized by brain and liver toxicity). Therefore, the nurse should instruct the parent to avoid administering aspirin and other products that contain salicylates and to consult a primary care provider or pharmacist before administering any medication to a child with chickenpox. Acetaminophen and ibuprofen are safe to administer for pain and control of fever in a child with chickenpox or other viral illness.

How does the nurse assess the rooting reflex of a neonate? Stroking the sole of the neonate's foot Touching the neonate's lips Stroking the neonate's cheek Placing an object in the neonate's palm

Stroking the neonate's cheek Explanation: The rooting reflex is elicited by stroking the neonate's cheek or stroking near the corner of the neonate's mouth. The neonate turns the head in the direction of the stroking, looking for food. This reflex disappears by 6 weeks. Other options refer to other reflexes seen in neonates: The palmar grasp reflex is elicited by placing an object in the palm of a neonate; the neonate's fingers close around it. This reflex disappears between ages 6 and 9 months. The Babinski reflex is elicited by stroking the neonate's foot, on the side of the sole, from the heel toward the toes. A neonate will fan his toes, producing a positive Babinski sign, until about age 3 months. The sucking reflex is seen when the neonate's lips are touched and lasts for about 6 months.

The nurse observes small, white papules surrounded by erythematous dermatitis on a neonate's skin. How will the nurse document this finding? erythema toxicum cutis marmorata Mongolian spots Epstein pearls

erythema toxicum Explanation: Erythema toxicum has lesions that appear and disappear on the face, trunk, and limbs. They're small, white or yellow papules or vesicles with erythematous dermatitis. Cutis marmorata is bluish mottling of the skin. Epstein pearls, found in the mouth, are similar to facial milia. Mongolian spots are large macules or patches that are gray or blue-green.

A child with suspected rheumatic fever is admitted to the pediatric unit. When collecting data on the child's history, the nurse considers which information to be most important? A fever that started 3 days ago Lack of interest in food A recent episode of pharyngitis Vomiting for 2 days

A recent episode of pharyngitis Explanation: A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the child may have a history of fever or vomiting or lack interest in food, these findings aren't specific to rheumatic fever.

The nurse is participating in the care of a client who has given birth to a 7 pound, 4 ounce baby. The nurse observes bleeding saturating the pad. What is the priority intervention at this time to control the bleeding? Massage the fundus. Administer oxytocin as ordered. Replace the pad and apply pressure to the vagina. Increase the IV fluids.

Massage the fundus. Explanation: The initial intervention is to massage the fundus because it may relax after birth. The fundus should be firm and midline. For the first hour after birth, the height of the fundus is at the umbilicus or even slightly above it and then decreases one fingerbreadth in size daily. Never palpate the uterus without supporting the lower segment because it may invert and cause massive hemorrhage.

The nurse is weighing a 3-month-old infant of Mediterranean descent during a routine examination in a family health center. The nurse recognizes the bluish discoloration of the skin on the lower back as which condition? milia lanugo vernix caseosa Mongolian spots

Mongolian spots Explanation: Bluish discolorations of the skin, which are common in babies of Black, Native American/First Nations, and Mediterranean descent, are called Mongolian spots. Pinpoint pimples caused by obstruction of sebaceous glands are called milia. The fine hair covering the body of a neonate is called lanugo. Vernix caseosa is a cheeselike substance that covers the skin of a neonate.

The nurse is caring for an adolescent with syphilis. What factor must the nurse determine before the client can be treated? portal of entry size of the chancre names of sexual contacts existence of medication allergies

existence of medication allergies Explanation: The treatment of choice for syphilis is penicillin; clients allergic to penicillin must be given another antibiotic. The other information is not necessary before treatment can begin.

The nurse is to administer IV fluids to an infant. Which safeguard would be most important for the nurse to use? administering fluid at slowest rate by infant weight use of a gravity infusion set with a filter use of a micro drop (mini drip) infusion set use of an intravenous infusion pump

use of an intravenous infusion pump Explanation: Use of an infusion pump to regulate the flow rate is the appropriate safeguard because infants and children are particularly vulnerable to IV fluid overload. Using a gravity infusion set or a micro drop infusion set does not permit sufficiently accurate flow to protect against fluid overload. Administering fluid at the slowest possible rate may not benefit the infant.

A client is 2 days postpartum and is experiencing bleeding. She asks the nurse, "Will it always be like this?" Which statement by the nurse would be the most accurate? "This is your menstrual cycle and will last 6 weeks." "This is lochia alba and will last 4 weeks." "This is lochia serosa and will last 2 days." "This is lochia rubra and will last 3 to 4 days."

"This is lochia rubra and will last 3 to 4 days." Explanation: Lochia rubra, which is made up of blood, mucus, and tissue debris, lasts 3 to 4 days. Lochia serosa, which consists of blood, mucus, and leukocytes, lasts from day 3 to day 10 postpartum. Lochia alba, which consists largely of mucus, lasts from day 10 to day 14 postpartum. Lochia alba may last up to 6 weeks postpartum. Postpartum bleeding is not the menstrual cycle.

The nurse is documenting a prenatal history of gravida 4, para 2 on the woman's clinic paperwork. The paperwork is sent to the birthing center for review. Upon the expectant mother's admission to the birthing center, the admission nurse is most correct to confirm which prenatal history? A client has been pregnant 4 times and had 2 children born after 20 weeks of gestation. A client has been pregnant 4 times and had 2 cesarean deliveries. A client has been pregnant 4 times and had 2 miscarriages. A client has been pregnant 4 times and had 2 spontaneous abortions.

A client has been pregnant 4 times and had 2 children born after 20 weeks of gestation.

A 2-year-old is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches. The nurse needs to auscultate the child's breath sounds. What is the most appropriate way for the nurse to approach the child? Expose the child's chest quickly, and auscultate breath sounds as quickly and efficiently as possible. Ask the parent to wait outside until the examination is over. Tell the child that the nurse is going to listen to his chest with the stethoscope. Allow the child to handle the stethoscope before listening to the lungs.

Allow the child to handle the stethoscope before listening to the lungs. Explanation: Toddlers are naturally curious about their environment, and letting them handle minor equipment is distracting, helps allay their fears, and allows them to gain trust with the nurse. The nurse should only expose one area at a time during evaluation and should approach the child slowly and unhurriedly. The caregiver should be encouraged to hold and console the child. Telling the child about listening to the child's chest at first approach may increase the child's fear.

A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and: a high fever. sudden onset. dysphagia. a barking cough.

a barking cough. Explanation: Croup is an acute viral respiratory illness characterized by a barking cough. Fever is usually low grade. Croup has a gradual onset, and dysphagia isn't a symptom.

An 8-month-old infant has been diagnosed with developmental dysplasia of the hip (DDH). What is the most significant finding the nurse would expect in the perinatal history related to DDH? mother's exercise routine during the third trimester breech presentation at birth serum calcium level at birth Apgar score of 4 at 1 minute and 6 at 5 minutes

breech presentation at birth Explanation: Breech presentation is commonly associated with DDH. The mother's exercise routine during the third trimester, serum calcium level at birth, and an Apgar score of 4 at 1 minute and 6 at 5 minutes have no relation to hip dysplasia.

A neonate has developed a major infection. Which gram-positive bacteria most likely contributed to this problem? Escherichia coli group B streptococci pseudomonas aeruginosa Klebsiella species

group B streptococci Explanation: Group B streptococci are gram-positive cocci to which the neonate is exposed if these bacteria are colonized in the vaginal tract. E. coli, Klebsiella species, and P. aeruginosa are gram-negative rods that produce 78% to 85% of the bacterial infection in neonates.

A nurse is caring for a client who gave birth yesterday and had a right mediolateral episiotomy performed. The client asks the nurse, "What can I do to get pain relief from my episiotomy?" Which response by the nurse would be most appropriate? "Perform perineal care after voiding or a bowel movement." "Apply a cold pack to your perineum." "Stay hydrated to keep the pain at a low level." "Take a nice warm sitz bath every 4 hours."

"Apply a cold pack to your perineum." Explanation: Applying a cold pack to an episiotomy during the first 24 hours after birth may reduce edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a sitz bath may reduce discomfort by promoting circulation and healing. Although perineal care should be performed after each voiding and bowel movement, its purpose is to prevent infection, not reduce discomfort. Drinking plenty of fluids is also important, especially for breast-feeding clients, but it does not relieve perineal discomfort.

The nurse is reinforcing education with parents about therapeutic management of their neonate diagnosed with congenital hypothyroidism. Which response by a parent would indicate the need for further education? "Treatment should begin as soon as possible after diagnosis is made." "My baby will need regular measurements of his thyroxine levels." "As my baby grows, his thyroid gland will mature and he won't need medications." "Treatment involves lifelong thyroid hormone replacement therapy."

"As my baby grows, his thyroid gland will mature and he won't need medications."

A male neonate has just been circumcised. When reviewing the neonate's plan of care after this procedure, which intervention would the nurse most likely perform first? Change the diaper every 10 minutes. Apply petroleum gauze to the site for 24 hours. Apply alcohol to the site. Keep the neonate in the prone position.

Apply petroleum gauze to the site for 24 hours. Explanation: Petroleum gauze is applied to the site for the first 24 hours to prevent the skin edges from sticking to the diaper. Alcohol is contraindicated for circumcision care. Diapers are changed more frequently to inspect the site, but not every 10 minutes. Neonates are initially kept in the supine position.

The nurse is caring for a client who just delivered triplets. Which intervention by the nurse is most important? Assessing fundal tone and lochia flow Applying a cold pack to the perineal area Administering analgesics, as ordered Encouraging the client to void by offering the bedpan

Assessing fundal tone and lochia flow Explanation: Clients who deliver multiples are at a higher risk for postpartum hemorrhage because of overdistention of the uterus, which leads to uterine atony. Assessing fundal tone and lochia flow helps determine the risk of hemorrhage. Applying cold packs to the perineum, administering analgesics as ordered, and offering the bed pan are important interventions but don't take priority over assessing for and preventing postpartum hemorrhage.

A 16-month-old with a history of hydrocephalus is admitted with an infected ventriculoperitoneal shunt. Which assessment takes priority in this toddler? Measure head circumference every shift. Monitor for signs of increased intracranial pressure. Assess the toddler's head for pressure ulcers. Monitor the toddler for signs of neglect.

Monitor for signs of increased intracranial pressure. Explanation: Monitoring the toddler for signs of increased intracranial pressure, such as vomiting, hypertension, bradycardia, and seizures, takes priority. Head circumference should be measured but it doesn't take priority over monitoring for increased intracranial pressure. There are no findings to suggest neglect in this case. Children with shunts don't commonly have pressure ulcers.

A nurse is caring for a client who delivered a healthy full-term baby 2 hours ago by cesarean section. When assessing this client, which finding requires immediate nursing action? Tachycardia and hypotension Gush of vaginal blood when the client stands up Blood stain 2" (5.1 cm) in diameter on the abdominal dressing Reports of abdominal pain

Tachycardia and hypotension Explanation: A rising pulse rate and falling blood pressure may be signs of hemorrhage. Lochia pools in the vagina of a postpartum woman who has been sitting and may suddenly gush out when she stands up. A 2" blood stain on a fresh surgical incision isn't a cause for immediate concern; however, the area of blood should be circled and timed. An increase in size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. It's normal for a woman who has had a cesarean section to feel pain at the incision site after her anesthesia has worn off.

A primigravida client is 16 weeks pregnant. Which client instruction would be most important to reinforce in order to prevent toxoplasmosis? having antibody titers routinely drawn keeping dogs outside cooking meats thoroughly washing all vegetables

cooking meats thoroughly

A client's membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures the client's temperature at 101.8° F (38.8° C). After initiating prescribed antibiotic therapy, the nurse should prepare the client for: delivery. sonography. amniocentesis. tocolytic drug therapy.

delivery

The nurse is monitoring an infant with bronchiolitis for dehydration. What intervention is the highest priority? measuring intake and output checking blood levels every 4 hours collecting a urinalysis every 8 hours weighing each diaper

measuring intake and output Explanation: Accurate measurement of intake and output is essential to assess for dehydration. Blood levels may be obtained daily or every other day. A urinalysis every 8 hours is not necessary. Urine-specific gravities are recommended, but can be obtained with diaper changes. Weighing diapers is a way of measuring output only.

A pregnant client at term is in the first stage of labor and has an electronic fetal monitoring (EFM) device in place. Which EFM pattern suggests adequate uteroplacental-fetal perfusion? persistent fetal bradycardia variable decelerations moderate variability late decelerations

moderate variability Explanation: A fetal heart rate with moderate variability (amplitude range of 6 to 25 beats/minute) accurately predicts adequate uteroplacental-fetal perfusion. Persistent fetal bradycardia may indicate hypoxia, arrhythmia, or umbilical cord compression. Variable decelerations also suggest umbilical cord compression. Late decelerations may reflect decreased blood flow and oxygen to the intervillous spaces during contractions.

The charge nurse in a labor and delivery unit has one RN and one LPN caring for multiple clients at different stages of labor. Which client should be assigned to the LPN? A client in the second stage of labor who is requesting to go the bathroom. A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit. A client who is in the fourth stage of labor with fundus above the umbilicus and bleeding with moderate amount of clots. A client in the third stage of labor with a moderate amount of blood trickling in a steady stream.

A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit. Explanation: Care of the clients who are nearing delivery should be assigned to the RN because of the need for assessment. The skills of the LPN can be best used by assigning him or her to those clients who are in the early stages of labor. A client postpartum who is bleeding needs assessment, which is a scope of practice of the RN and not the LPN.

Which of the following behaviors would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? A decrease in intensity of contractions Episodes of nausea and vomiting An increased sense of rectal pressure An increase in fetal heart rate variability

An increased sense of rectal pressure Explanation: An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior. Contractions don't decrease in intensity, fetal heart rate variability doesn't change, and nausea and vomiting usually don't occur.

The nurse is providing care to a postpartum client with mastitis. As part of the client's teaching plan, the nurse is reinforcing information about the condition. Which information should the nurse emphasize? Symptoms include fever, chills, malaise, and localized breast tenderness. A breast abscess is a common complication of mastitis. Mastitis usually develops in both breasts of a breast-feeding client. The most common pathogen is group A beta-hemolytic streptococci.

Symptoms include fever, chills, malaise, and localized breast tenderness. Explanation: Mastitis is an infection of the breast characterized by flulike symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.

A nurse is caring for a client who delivered a healthy full-term baby 2 hours ago by cesarean section. When assessing this client, which finding requires immediate nursing action? Reports of abdominal pain Gush of vaginal blood when the client stands up Tachycardia and hypotension Blood stain 2" (5.1 cm) in diameter on the abdominal dressing

Tachycardia and hypotension

When collecting data on a girl, age 10, the nurse keeps in mind that the first sign of sexual maturity in girls is: breast bud development. pubic hair. axillary hair. menarche.

breast bud development. Explanation: Breast bud development — elevation of the nipple and areola to form a breast bud — is the first sign of sexual maturity in girls. Sexual maturation continues with the appearance of pubic hair, axillary hair, and menarche, consecutively.

An 8-month-old infant has been diagnosed with developmental dysplasia of the hip (DDH). What is the most significant finding the nurse would expect in the perinatal history related to DDH? breech presentation at birth Apgar score of 4 at 1 minute and 6 at 5 minutes mother's exercise routine during the third trimester serum calcium level at birth

breech presentation at birth Explanation: Breech presentation is commonly associated with DDH. The mother's exercise routine during the third trimester, serum calcium level at birth, and an Apgar score of 4 at 1 minute and 6 at 5 minutes have no relation to hip dysplasia.

A child with asthma is receiving theophylline. The nurse knows that theophylline is administered primarily to: decrease coughing induced by postnasal drip. dilate the bronchioles. reduce airway inflammation. eradicate the infection.

dilate the bronchioles. Explanation: Methylxanthines, such as theophylline, are highly potent bronchodilators used to relieve asthma symptoms. Antihistamines typically are used to relieve a cough induced by postnasal drip; corticosteroids, to reduce airway inflammation; and antibiotics, to treat infection.

A nurse is assisting with the care of a pregnant client experiencing mild active bleeding from placenta previa. The nurse suspects that an emergency cesarean birth may be necessary based on which finding? maternal heart rate of 78 beats/minute maternal blood pressure of 130/82 mm Hg fetal heart rate of 80 beats/minute absence of pooling of vaginal bleeding under the client

fetal heart rate of 80 beats/minute Explanation: A fetal heart rate of 80 beats/minute indicates fetal distress, indicating the need for a cesarean birth. Maternal blood pressure and heart rate would be considered within normal parameters. Bleeding, especially if noted as pooling under the client, indicates active bleeding and an indication that cesarean birth may be necessary.

The nurse is planning care for a school-age client. Which action is most appropriate for the nurse to include? assigning multiple nurses to the client to help reduce boredom asking caregivers to leave during procedures to allow privacy teaching the client about procedures and conditions using basic medical language restricting the client to quiet activities such as reading instead of playing video games

teaching the client about procedures and conditions using basic medical language Explanation: School-age clients can be taught about procedures and conditions using correct, basic medical language and should be encouraged to ask questions. Assigning multiple nurses will impede the continuity of care and should be avoided. Caregivers should be permitted to remain with their child during procedures to comfort the child if they so desire. The child should be permitted to engage in distracting activities such as age-appropriate video games and not be restricted to only quiet activities. Suggested diversions should be based on an individual assessment as well as client and caregiver preferences.

A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the healthcare surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make healthcare decisions for the fetus, who's responsible for making them? the court system, because the client isn't married and is legally responsible for the neonate the client's parents, because they're blood relatives the client's best friend, who's the sperm donor the client's partner

the client's partner Explanation: A legal document stating that the client's partner is the healthcare surrogate for the client and the fetus authorizes the partner to make decisions on behalf of the client or the fetus if the client isn't able to do so. Before insemination, a donor signs a legal document waiving rights to the child; therefore, the donor has no authority to make healthcare decisions on behalf of the client or the fetus. Pregnancy at any age results in emancipation; parents don't have rights to make healthcare decisions for pregnant adolescents. The court system wouldn't make the decision if the client has designated a legal healthcare surrogate.

A client is diagnosed with placenta previa at 28 weeks' gestation. Which procedure should the nurse prepare the client for? ultrasound examination every 2 to 3 weeks antenatal steroids after 34 weeks' gestation stat culture and sensitivity scheduled birth of the fetus before fetal maturity

ultrasound examination every 2 to 3 weeks Explanation: Fetal surveillance through ultrasound examination every 2 to 3 weeks is indicated to evaluate fetal growth, amniotic fluid, and placental location in clients with placenta previa being expectantly managed. A stat culture and sensitivity would be done for severe bleeding, or maternal or fetal distress, and is not part of expectant management. Antenatal steroids may be given to clients between 26 and 32 weeks' gestation to enhance fetal lung maturity. In a hemodynamically stable mother, birth of the fetus should be delayed until fetal lung maturity is attained.

A neonate was born 2 days ago. The mother is being prepared for discharge and voices concern because her neonate's birth weight has declined by 2 oz. She states that she'll continue to breast-feed but will supplement after each breast-feeding with 4 oz of formula. Which response by the nurse would be best? "That's a good idea. It's difficult to determine if your breast-fed baby is getting enough to eat." "Supplementing with formula is never recommended for breast-feeding infants." "It's normal for a neonate to lose 6% to 10% of its birth weight. While supplementing is acceptable, remember that your baby's stomach can hold only about 3 oz (90 mL)." "To determine if the baby is getting enough, you should weigh the baby before and after each feeding."

"It's normal for a neonate to lose 6% to 10% of its birth weight. While supplementing is acceptable, remember that your baby's stomach can hold only about 3 oz (90 mL)." Explanation: Normal neonatal weight loss can range from 6% to 10% of birth weight. A decrease in weight of 2 oz would be considered within normal range. The normal neonate's stomach holds about 3 oz (90 mL). A breast-fed neonate's continued weight gain is an indication that he is eating a sufficient amount. While the premature or low-birth-weight neonate is weighed before and after eating in the clinical setting, this isn't an action that's ordinarily taken for the normal neonate at home. Supplementation of breast-fed neonates, especially with large amounts (such as 4 oz), should be discouraged because it would reduce milk supply and volume. Additionally, it would distend the neonate's stomach and lead to possible regurgitation.

A neonate was born 2 days ago. The mother is being prepared for discharge and voices concern because her neonate's birth weight has declined by 2 oz. She states that she'll continue to breast-feed but will supplement after each breast-feeding with 4 oz of formula. Which response by the nurse would be best? "That's a good idea. It's difficult to determine if your breast-fed baby is getting enough to eat." "Supplementing with formula is never recommended for breast-feeding infants." "To determine if the baby is getting enough, you should weigh the baby before and after each feeding." "It's normal for a neonate to lose 6% to 10% of its birth weight. While supplementing is acceptable, remember that your baby's stomach can hold only about 3 oz (90 mL)."

"It's normal for a neonate to lose 6% to 10% of its birth weight. While supplementing is acceptable, remember that your baby's stomach can hold only about 3 oz (90 mL)." Explanation: Normal neonatal weight loss can range from 6% to 10% of birth weight. A decrease in weight of 2 oz would be considered within normal range. The normal neonate's stomach holds about 3 oz (90 mL). A breast-fed neonate's continued weight gain is an indication that he is eating a sufficient amount. While the premature or low-birth-weight neonate is weighed before and after eating in the clinical setting, this isn't an action that's ordinarily taken for the normal neonate at home. Supplementation of breast-fed neonates, especially with large amounts (such as 4 oz), should be discouraged because it would reduce milk supply and volume. Additionally, it would distend the neonate's stomach and lead to possible regurgitation.

A client who is 24 weeks pregnant is diagnosed with preeclampsia. She is prescribed bed rest at home and a referral for home health visits by a community health nurse. The nurse is reviewing the discharge instructions with the client. The nurse determines that the client understands the reasons for home health visits base on which client statement? "The community health nurse will give me my vitamins and antihypertensive medications." "The community health nurse will help fix my meals and do laundry." "The community health nurse will give me prenatal care so that I won't have to see my health care provider." "The community health nurse will check me and my baby and talk with my health care provider."

"The community health nurse will check me and my baby and talk with my health care provider." Explanation: Community health nurses provide skilled nursing care, such as evaluating and monitoring blood pressure, providing treatments and education, and communicating with health care providers. For the prenatal client with preeclampsia, this care may include assessing the therapeutic effects of antihypertensive medications, evaluating fetal heart tones, and providing nutrition counseling. The professional nurse does not fix meals in the home or do laundry; this service may be provided by a home health aide or housekeeper. The community health nurse educates the client about taking her own medications, including the proper time, dose, frequency, and adverse effects. The community health nurse does not replace the care provided by the client's health care provider.

Which of the following behaviors would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? An increased sense of rectal pressure A decrease in intensity of contractions An increase in fetal heart rate variability Episodes of nausea and vomiting

An increased sense of rectal pressure Explanation: An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior. Contractions don't decrease in intensity, fetal heart rate variability doesn't change, and nausea and vomiting usually don't occur.

Which care intervention is appropriate for the fourth stage of labor? Assisting with breathing techniques Encouraging rest between contractions Observing the perineum for show and bulging Assessing lochia and the location and consistency of the fundus

Assessing lochia and the location and consistency of the fundus Explanation: The fourth stage of labor is the first hour after delivery. During this stage, the nurse should assess lochia and the location and consistency of the fundus, encourage bonding with the infant, and initiate breast-feeding. During the first, second, and third stages of labor, the nurse should assist with breathing techniques and encourage rest between contractions. During the second stage, the nurse should observe the perineum for show and bulging.

Which care intervention is appropriate for the fourth stage of labor? Assisting with breathing techniques Observing the perineum for show and bulging Assessing lochia and the location and consistency of the fundus Encouraging rest between contractions

Assessing lochia and the location and consistency of the fundus Explanation: The fourth stage of labor is the first hour after delivery. During this stage, the nurse should assess lochia and the location and consistency of the fundus, encourage bonding with the infant, and initiate breast-feeding. During the first, second, and third stages of labor, the nurse should assist with breathing techniques and encourage rest between contractions. During the second stage, the nurse should observe the perineum for show and bulging.

During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate? Contractions will be weaker, longer, and more effective. Contractions will be stronger, shorter, and less uncomfortable. Contractions will be stronger and more uncomfortable and will peak more abruptly. Contractions will be stronger and shorter and will peak more slowly.

Contractions will be stronger and more uncomfortable and will peak more abruptly. Explanation: Oxytocin administration causes stronger, more uncomfortable contractions, which peak more abruptly than spontaneous contractions. Oxytocin doesn't affect the duration of contractions.

When bathing a neonate who is one hour old, which nursing action is most important? Keep under a radiant warmer, and give a sponge bath. Wash only hands and head because the condition isn't stable enough to have a complete bath. Place on a table covered with blankets, and give a sponge bath. Bathe in a tub of warm water.

Keep under a radiant warmer, and give a sponge bath. Explanation: During the first several hours after delivery, a neonate's thermal regulatory system is adapting to extrauterine life. When bathing a neonate under a radiant warmer, the external heat decreases the chances for cold stress by decreasing the number of internal mechanisms the neonate must use to stay warm. Bathing a neonate on a table, where she's exposed to air drafts and cooler air currents, can set her up for cold stress. Bathing the neonate in a tub and then removing her increases her heat loss and metabolism. Washing only the hands and head would chill the neonate and reduce thermoregulation because most heat is lost through the head.

A nurse is caring for a client during the fourth stage of labor. Which intervention by the nurse can prevent uterine atony? Massage the fundus. Asses fundal height. Measure blood loss. Catheterize the client.

Massage the fundus. Explanation: Massaging the fundus helps expel clots and improve uterine contraction. Assessing the fundal height will not aid in uterine contraction. Measuring blood loss and catheterizing the client are actions that can be taken during the fourth stage of labor, but it will not prevent uterine atony.

The nurse is assessing a client whose membranes ruptured prematurely 12 hours ago. Which is the nurse's highest priority to evaluate when collecting data on this client? White blood cell (WBC) count Maternal vital signs and fetal heart rate (FHR) Cervical effacement and dilation Frequency and duration of contractions

Maternal vital signs and fetal heart rate (FHR) Explanation: After premature rupture of the membranes (PROM), monitoring maternal vital signs and FHR takes priority. Maternal vital signs, especially temperature and pulse, may suggest maternal infection caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this client because it requires a pelvic examination, which may introduce pathogens into the birth canal. Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and FHR can and therefore provides less current information.

A client who is 34 weeks' pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal, and the client is not in labor. Which intervention would be most appropriate at this time? Allow the client to ambulate with assistance. Assist client to go void. Monitor the amount of vaginal blood loss. Notify the health care provider if the fetal heart rate is 140 beats/minute.

Monitor the amount of vaginal blood loss. Explanation: The nurse should estimate the amount of blood loss in a client with placenta previa by weighing perineal pads or counting the number of pads saturated over a period of time. The health care provider should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (such as hypotension and tachycardia). The client should be placed on bed rest and not allowed to ambulate. A normal fetal heart rate is 120 to 160 beats/minute; the health care provider does not need to be notified of a fetal heart rate of 140 beats/minute.

A 4-month-old infant is taken to the pediatrician by his parents because they're concerned about his frequent respiratory infections, poor feeding habits, frequent vomiting, and colic. The physician notes that the baby has failed to gain expected weight and recommends that the baby have a sweat test performed to detect possible cystic fibrosis. To prepare the parents for the test, the nurse should explain that: the baby will need to fast before the test. a sample of blood will be necessary. a low-sodium diet is necessary for 24 hours before the test. a low-intensity, painless electrical current is applied to the skin.

a low-intensity, painless electrical current is applied to the skin. Explanation: Because cystic fibrosis clients have elevated levels of sodium and chloride in their sweat, a sweat test is performed to confirm this disorder. After pilocarpine (a cholinergic medication that induces sweating) is applied to a gauze pad and placed on the arm, a low-intensity, painless electrical current is applied for several minutes. The arm is then washed off, and a filter paper is placed over the site with forceps to collect the sweat. Elevated levels of sodium and chloride are diagnostic of cystic fibrosis. No fasting is necessary before this test and no blood sample is required. A low-sodium diet isn't required before the test.

A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at increased risk for fetal distress? maternal weight gain of 30 lb (13.6 kg) maternal age of 22 years blood pressure of 146/94 mm Hg treatment for syphilis at 15 weeks' gestation

blood pressure of 146/94 mm Hg Explanation: Hypertension is defined as blood pressure levels of above 140 mm Hg systolic and 90 mm Hg diastolic that are present after 20 weeks' gestation in women with previously normal blood pressure. Hypertension reduces blood flow to the placenta; it can also cause intrauterine growth restriction and other problems that make the fetus less able to tolerate the stress of labor. A weight gain of 30 lb is within the expected parameters for a healthy pregnancy. A 22-year-old client is not at increased risk for complications due to age. Syphilis that has been treated does not pose an additional risk to the fetus.

A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at increased risk for fetal distress? maternal weight gain of 30 lb (13.6 kg) maternal age of 22 years blood pressure of 146/94 mm Hg treatment for syphilis at 15 weeks' gestation

blood pressure of 146/94 mm Hg Explanation: Hypertension is defined as blood pressure levels of above 140 mm Hg systolic and 90 mm Hg diastolic that are present after 20 weeks' gestation in women with previously normal blood pressure. Hypertension reduces blood flow to the placenta; it can also cause intrauterine growth restriction and other problems that make the fetus less able to tolerate the stress of labor. A weight gain of 30 lb is within the expected parameters for a healthy pregnancy. A 22-year-old client is not at increased risk for complications due to age. Syphilis that has been treated does not pose an additional risk to the fetus.

Parents tell the nurse that they want to begin toilet training their 22-month-old child. What is the most important factor regarding toilet training that the nurse should stress to the parents? the parents' positive attitude consistency in approach developmental readiness of the child developmental level of the child's peers

developmental readiness of the child Explanation: If the child is not developmentally ready, the child and parent will become frustrated during toilet training. Consistency is important once toilet training has started, but it is not the most important factor. The parent's positive attitude is also important but only after the child is determined to be ready. A child's developmental level is individualized, so comparison to peers is not useful.

Which findings would be considered positive signs of pregnancy? fatigue and skin changes quickening and breast enlargement fetal heartbeat and fetal movement on palpation abdominal enlargement and Braxton Hicks contractions

fetal heartbeat and fetal movement on palpation Explanation: Fetal heartbeat and fetal movement on palpation are considered positive signs of pregnancy because they can't be caused by any other condition. Fatigue can be caused by chronic illness or anemia. Skin changes can result from cardiopulmonary disorders, estrogen-progesterone hormonal contraceptives, obesity, or a pelvic tumor. Excessive flatus or increased peristalsis can cause the perception of quickening. Breast changes can be related to hyperprolactinemia induced by tranquilizers, infection, prolactin-secreting pituitary tumor, pseudocyesis, or premenstrual syndrome. Abdominal enlargement can result from ascites, obesity, or a uterine or pelvic tumor, and the perception of Braxton Hicks contractions can result from hematometra or a uterine tumor.

An adolescent is started on valproic acid to treat seizures. Which statement should be included when educating the adolescent? "This medication has no adverse effects." "Early morning dosing is recommended to decrease insomnia." "Drowsiness and irritability are common." "A common adverse effect is weight gain."

"A common adverse effect is weight gain." Explanation: Weight gain is a common adverse effect of valproic acid. Drowsiness and irritability are adverse effects more commonly associated with phenobarbital. Felbamate more commonly causes insomnia.

The parent of an adolescent diagnosed with Legg-Calvé-Perthes disease (LCPD) asks the nurse, "What caused this condition?" Which nursing response is appropriate? "Taking antibiotics causes this disorder." "Exposure to toxins in the womb can result in this condition." "The health care provider can give you more information." "The hip joint has been damaged due to lack of blood supply."

"The hip joint has been damaged due to lack of blood supply." Explanation: Legg-Calvé-Perthes disease (LCPD) is a disease of one or both hips. The nurse will convey that this condition results from a lack of blood supply to the hip joint. Poor blood supply to bones results in fractures and poor bone healing. The cause of this spontaneous, yet temporary, reduction of blood flow to the femoral head is unknown. It may be caused by an injury or another disease process. It tends to run in families and affects boys five times more frequently than girls. The nurse will not defer the question to the health care provider, as a reasonable and objective response can be given. LCPD is not caused by exposure to toxins in the womb nor by taking antibiotics.

The nursing instructor asks a nursing student approximately how much time is required for the blastocyst to reach the uterus for implantation. What timeframe does the student provide to the instructor? 2 days 10 days 14 weeks 7 days

7 days

When caring for a client during the second stage of labor, which action would be most appropriate? Assisting the client with ambulation Encouraging the client to void every 2 hours Allowing the client clear liquids Assisting the mother with pushing

Assisting the mother with pushing Explanation: Nursing care for the client during the second stage of labor should include assisting the mother with pushing, helping position her legs for maximum pushing effectiveness, and monitoring the fetal heart rate. During this time, the client is usually offered ice chips rather than clear liquids. The client should be encouraged to ambulate and void every 2 hours during the first stage of labor, not the second.

When teaching the mother of a 17-month-old child about toilet training, which instruction would initially be most appropriate? Be sure the child is ready before starting to toilet train. Remove the diaper and use training pants to begin the process. Place the toddler on the potty chair every 2 hours for 10 minutes. Offer a reward every time the child has a bowel movement in the potty chair.

Be sure the child is ready before starting to toilet train.

While caring for a 2-day-old neonate, a nurse notices the left side of the neonate reddens for 2 to 3 minutes. The nurse interprets this as suggestive of what finding? tet spells contact dermatitis environmental conditions harlequin color change

harlequin color change Explanation: Harlequin color change is a benign disorder related to the immaturity of the hypothalamic centers that control the tone of peripheral blood vessels. A newborn who has been lying on its side may appear reddened on the dependent side. The color fades on position change. Contact dermatitis isn't short-lived. Changes in environmental conditions can cause diffuse bilateral mottling of the skin. Tet spells are associated with tetralogy of Fallot and cause cyanotic changes.

At 15 weeks' gestation, a client is scheduled for a serum alpha-fetoprotein (AFP) test. During data collection, which maternal history finding would the nurse suspects indicate a need for this test? Family history of spina bifida in a sister Family history of Down syndrome on the father's side History of gestational diabetes during a previous pregnancy History of spotting during the first month of the current pregnancy

Family history of spina bifida in a sister Explanation: A family history of neural tube defects such as spina bifida increases the risk of carrying a fetus with a neural tube defect. An abnormally high AFP level in the client's serum or amniotic fluid suggests such defects. Although a low AFP level has been correlated with Down syndrome, it isn't the most accurate indicator. No known correlation exists between gestational diabetes or early vaginal spotting and a certain AFP level at 15 to 20 weeks' gestation.

A mother brings her preschool child to the emergency department after he ingested an unknown quantity of acetaminophen. Which treatment will the physician probably prescribe next? Administration of a dose of ipecac syrup Insertion of a nasogastric tube and administration of an antacid I.V. infusion of normal saline solution Gastric lavage and administration of acetylcysteine

Gastric lavage and administration of acetylcysteine Explanation: Gastric lavage or acetylcysteine administration are indicated after acetaminophen ingestion. Ipecac syrup is no longer recommended due to the risks associated with induced vomiting. An antacid isn't an effective treatment for poisoning. Infusing normal saline solution I.V. may be helpful in treating dehydration caused by vomiting but in itself isn't effective in eliminating the poisonous substance.

The nurse receives a report on a client who delivered a healthy neonate 1 hour ago. What should the nurse monitor during the immediate postpartum period of this client? Blood glucose level Height of fundus Stool test for occult blood Heart rhythm via electrocardiogram (ECG)

Height of fundus Explanation: A focused physical examination should be performed every 15 minutes for the first 1 to 2 hours postpartum, including assessment of the fundus, lochia, perineum, blood pressure, pulse, and bladder function. A blood glucose level must be obtained only if the client has risk factors for an unstable blood glucose level, or if she has symptoms of an altered blood glucose level. An ECG would be necessary only if the client is at risk for cardiac difficulty. A stool test for occult blood generally wouldn't be valid during the immediate po

A client is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to varicella (chickenpox) 1 week ago. When, if at all, would this client require isolation? Isolation is not required at this time. Isolation would be required 10 days after exposure. Immediate isolation in a private room is required . Isolation would be required 12 days after exposure.

Immediate isolation in a private room is required . Explanation: The incubation period for varicella (chickenpox) is 2 to 3 weeks, usually 13 to 17 days. A client is commonly isolated 1 week after exposure to avoid the risk of a breakout. A person is infectious from 1 day before eruption of lesions to 6 days after the vesicles have formed crusts.

The nurse is administering medication to a 6-week-old infant. Which factor is the nurse most correct to identify as likely to decrease the infant's ability for drug metabolism? Reduced protein-binding ability Inefficient liver function Decreased glomerular filtration Increased tubular secretion

Inefficient liver function Explanation: When administering medications to pediatric clients, the nurse must understand pharmacokinetics. Inefficient liver function potentially decreases drug metabolism in the infant. As the liver matures during the first year of life, drug metabolism improves. Decreased glomerular filtration and increased tubular secretion may affect drug excretion rather than metabolism. Reduced protein-binding ability may affect drug distribution but not metabolism.

A 3-month-old admitted to the pediatric unit with meningococcal meningitis has just been assessed by the registered nurse. Which nursing intervention has the highest priority at this time? Instituting droplet precautions Administering acetaminophen Obtaining history information from the parents Orienting the parents to the pediatric unit

Instituting droplet precautions Explanation: Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn't take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don't take priority.

A licensed practical nurse (LPN) who typically works in the nursery is being cross-trained to work with postpartum clients. The charge nurse is busy with a delivery and assigns her to complete hourly rounds on the unit. As she enters a client's room, the LPN notices that a client looks pale and shaky. Which action should she take? Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data. Find another LPN to help assess the client. Inform the nurse-manager that the client needs to be assessed by a registered nurse. Tell the client to press the call button for a regular staff nurse.

Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data. Explanation: Licensed professionals are always held accountable for practicing according to the level of education they've attained. The LPN is held accountable within the standards of practice for an LPN. It's within the scope of practice for an LPN to collect vital signs data and complete a cursory examination of the client's fundus and flow. The client shouldn't be left alone until data collected indicates it's safe to leave the room. If the client is unstable, the LPN needs to stay with her and call for help.

A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal? Preventing infection Providing adequate nutrition Ensuring adequate hydration Preventing contracture deformity

Preventing infection Explanation: Preventing infection is the nurse's primary preoperative goal for a neonate with myelomeningocele. Although the other options are relevant for this neonate, they're secondary to preventing infection.

A client in the first stage of labor is being monitored with an external fetal monitor. The nurse notes variable decelerations on the monitoring strip. Which action should the nurse take? Assist the client with ambulation. Reposition the client to right lateral position. Assist the client to a supine position. Reposition the client to left lateral position.

Reposition the client to left lateral position. Explanation: Variable decelerations are transient drops in the fetal heart rate that can occur before, during, or after a contraction. The left lateral position (not the right lateral position) is the ideal position for any pregnant client because it prevents maternal hypotension caused by inferior vena cava compression, which reduces placental perfusion. Supine positioning may cause inferior vena cava compression. Pregnant individuals can't safely assume the prone position.

The nurse is collecting data on an 8-month-old infant during a wellness checkup. Which of the following is a normal developmental task for an infant this age? Saying two words Sitting without support Feeding himself with a spoon Playing patty-cake

Sitting without support

The nurse is reviewing the history of a postpartum client. Which history factor strongly suggests that this client will experience afterpains? The client is a gravida 6, para 5. The client delivered at 39 weeks' gestation. The client has decided to bottle-feed her neonate. The client smokes cigarettes.

The client is a gravida 6, para 5. Explanation: In a multiparous client, decreased uterine muscle tone leads to alternating relaxation and contraction during uterine involution; this, in turn, causes afterpains. A gestation of 39 weeks and a history of cigarette smoking don't contribute directly to afterpains. A breast-feeding (not bottle-feeding) client may experience afterpains from oxytocin release, which stimulates the uterus to contract and thus enhances involution. However, the decision to bottle-feed doesn't cause afterpains.

A postpartum client recovering from spinal anesthesia with morphine reports that her nose itches. Which would the nurse suspect as the cause? The client may be still be partially sedated and imagining this feeling. The client may be having a reaction to a material she encountered in the delivery room. The client is experiencing a common effect due to a morphine-based anesthetic. Postpartum itching is common after birth because of hormonal changes.

The client is experiencing a common effect due to a morphine-based anesthetic. Explanation: Morphine causes a relatively high incidence of itching when used in spinal anesthesia. The itching usually begins at the tip of the nose, possibly becoming more generalized. Antipruritics, such as diphenhydramine or hydroxyzine hydrochloride, may be prescribed after the use of morphine. Itching on the tip of the nose isn't typical of an allergic reaction nor is it caused by postpartum hormonal changes. The client is awake and speaking appropriately, so she is alert.

A 4-year-old client with a chest tube is placed on water seal drainage system. Which statement is correct? The water level rises with inhalation. Bubbling is seen in the suction chamber. Bubbling is seen in the water seal chamber. Water seal is obtained by clamping the tube.

The water level rises with inhalation. Explanation: The water seal chamber is functioning appropriately when the water level rises in the chamber with inhalation and falls with expiration. This shows that negative pressure required in the lung is being maintained. Bubbling in the suction chamber should only be seen when suction is being used. Bubbling in the water seal chamber generally indicates the presence of an air leak. The chest tube should never be clamped; a tension pneumothorax may occur. Water seal is activated when the suction is disconnected.

The nurse is reinforcing education with an adolescent about gonorrhea. Which information should be included? It is caused by Treponema pallidum. Treatment of sexual partners is an essential part of treatment. It is usually treated by multidose administration of penicillin. It may be contracted through contact with a contaminated toilet seat.

Treatment of sexual partners is an essential part of treatment. Explanation: Adolescents should be taught that treatment is needed for all sexual partners. Treponema pallidum is the causative organism of syphilis, not gonorrhea. The medication of choice is a single dose of IM ceftriaxone in males and a single oral dose of cefixime in females. Gonorrhea cannot be contracted from a contaminated toilet seat.

A child is diagnosed with Wilms' tumor. During data collection, the nurse expects to detect: an abdominal mass. nausea and vomiting. gross hematuria. dysuria.

an abdominal mass.

A 10-year-old child has been experiencing insatiable thirst and urinating excessively and the serum glucose is normal. Which condition is the child most likely experiencing? type 2 diabetes type 1 diabetes hyperthyroidism diabetes insipidus

diabetes insipidus Explanation: Polydipsia and polyuria with normal serum glucose are indicative of diabetes insipidus. Interview and laboratory results can determine whether the origin is neurogenic or nephrogenic. Type 1 or 2 diabetes mellitus present with an elevated serum glucose. A child with hyperthyroidism may present as dehydrated from the excessive sweating and rapid respirations that accompany this hypermetabolic state.

A new mother is discharged 16 hours after a vaginal birth. After reviewing the client's discharge instructions, the nurse determines that the teaching was successful when the client states that she will contact her health care provider if she develops which symptom? the increased flow of bright red lochia fatigue with weight loss a uterus that is no longer palpable abdominally after 2 weeks vaginal tenderness and dryness during sexual activity

increased flow of bright red lochia Explanation: New mothers should be aware of complications that can occur after discharge. A change in the color of lochia to bright red with increased flow may indicate retained placental fragments. Vaginal tenderness and dryness during sexual activity, an abdominally impalpable uterus after 2 weeks, and fatigue and weight loss are normal symptoms after birth; in addition, many clients are usually advised not to resume sexual activity for several weeks after birth.

The nurse is caring for a postpartum client with diabetes who has developed an infection. The nurse would monitor this client for which complication? ketoacidosis anemia respiratory alkalosis respiratory acidosis

ketoacidosis Explanation: Clients with diabetes who become pregnant tend to become sicker and develop illnesses more quickly than pregnant clients without diabetes. Severe infections in diabetes can lead to diabetic ketoacidosis. Anemia, respiratory acidosis, and respiratory alkalosis aren't generally associated with infections in clients with diabetes.

A nurse is reviewing the medical record of a neonate. Which data from the record would the nurse identify as the best indicator of fetal lung maturity? absence of phosphatidylglycerol in amniotic fluid lecithin to sphingomyelin ratio of more than 2:1 glucocorticoid treatment just before birth meconium in the amniotic fluid

lecithin to sphingomyelin ratio of more than 2:1 Explanation: Lecithin and sphingomyelin are phospholipids that help compose surfactant in the lungs; lecithin peaks at 36 weeks, and sphingomyelin concentrations remain stable. Meconium is released due to fetal stress before birth, but it's chronic fetal stress that matures lungs. Glucocorticoids must be given at least 48 hours before birth. The presence of phosphatidylglycerol indicates lung maturity.

A person calls the neonatal intensive care unit stating that his child is receiving care there. He tells the nurse that he and the mother "aren't together," and requests information about his child's condition. The nurse should provide only general demographic information to the caller. obtain more data before giving the caller any confidential information. consult a lawyer before giving the caller any confidential information. request that the caller bring proof of insurance to the hospital.

obtain more data before giving the caller any confidential information. Explanation: The nurse must gather more information from the mother and the caller to determine whether she may give the caller information about the neonate. Consulting a lawyer before giving the caller more information is not the most appropriate response at this point. Giving the caller general demographic information is not correct; doing so divulges information before it's confirmed whether the caller is allowed to have access to it. Requesting that the caller present proof of insurance is irrelevant.

The nurse caring for an infant with pyloric stenosis should be alert for which classic sign or symptom? loss of appetite chronic diarrhea projectile vomiting excessive drooling

projectile vomiting Explanation: The obstruction seen in pyloric stenosis doesn't allow food to pass through to the duodenum. The classic sign of projectile vomiting occurs when the stomach becomes full, and the infant vomits for relief. Drooling would not be a finding in a child with pyloric stenosis but rather in a child with tracheoesophageal fistula. Chronic hunger is commonly seen. There's no diarrhea because food doesn't pass the stomach.

A nurse is providing care to a postpartum client on her second day. What appearance does the nurse anticipate the lochia will have on the second postpartum day? brown and scant amount red with moderate flow thin consistency and white in color continuous flow with red clots

red with moderate flow Explanation: During the first three postpartum days, lochia appears red (lochia rubra) with moderate flow. However, the client should not soak more than one pad every hour. A continuous flow of moderately clotted blood from the vagina is not normal and should be reported. Clots may indicate retained pieces of placenta. Lochia changes to pink or brown (lochia serosa) after 3 to 10 days. By day 10, the lochia should be white (lochia alba) and continue for several weeks.

A pregnant client arrives in the emergency department and states, "My baby is coming." The nurse sees a portion of the umbilical cord protruding from the vagina. Why should the nurse apply manual pressure to the baby's head? to rupture the membranes to slow the delivery process to relieve pressure on the umbilical cord to reinsert the umbilical cord

to relieve pressure on the umbilical cord Explanation: Manual pressure is applied to the baby's head by gently pushing up with the fingers to relieve pressure on the umbilical cord. This intervention is effective if the cord begins to pulsate. The mother may also be placed in the knee-chest or Trendelenburg position to ensure blood flow to the baby. This intervention isn't done to slow the delivery process. A prolapsed cord necessitates emergency cesarean section. The nurse shouldn't attempt to reinsert the umbilical cord because this would further compromise blood flow. At this point, the membranes are probably ruptured.

A multiparous client has given birth vaginally to a healthy neonate. It is now her first postpartum day. Which factor would the nurse identify as putting this client at risk for developing hemorrhage? hemoglobin level of 12 g/dL uterine atony thrombophlebitis moderate amount of lochia rubra

uterine atony Explanation: Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is at higher risk for hemorrhage. Thrombophlebitis doesn't increase the risk of hemorrhage during the postpartum period. The client's hemoglobin level and lochia flow are within acceptable limits.

A pregnant client has received dinoprostone for cervical ripening. The nurse would monitor the client for which most common adverse effect of this drug? euphoria vomiting constipation uterine inversion

vomiting Explanation: Headache, nausea, vomiting, chills, fever, and hypertension are adverse effects of dinoprostone. Euphoria and uterine inversion are rare adverse effects of this drug. Diarrhea, not constipation, is a possible adverse effect.

The nurse caring for an infant with pyloric stenosis should be alert for which classic sign or symptom? loss of appetite chronic diarrhea projectile vomiting excessive drooling

vprojectile vomiting Explanation: The obstruction seen in pyloric stenosis doesn't allow food to pass through to the duodenum. The classic sign of projectile vomiting occurs when the stomach becomes full, and the infant vomits for relief. Drooling would not be a finding in a child with pyloric stenosis but rather in a child with tracheoesophageal fistula. Chronic hunger is commonly seen. There's no diarrhea because food doesn't pass the stomach.

A physician is administering a medication by intraosseous infusion to a child. Intraosseous drug administration is typically used for a child who is: younger than age 3. older than age 3 in an emergency situation when I.V. access isn't available. younger than age 3 in an emergency situation when I.V. access isn't available. older than age 3.

younger than age 3 in an emergency situation when I.V. access isn't available.