NUR 190 EAQ - Health Promotion and Maintenance

When does the Babinski reflex disappear?

After 12 months.

How does the nurse know that a client at 40 weeks' gestation is experiencing true labor?

Cervical dilation.

Which content should the nurse emphasize in a prepared childbirth class?

Education, exercise, and breathing techniques.

The parents of an overweight adolescent girl tell the nurse that they are concerned that their daughter feels inferior to her sister, who is an attractive, successful college senior. They ask the nurse what they can do about this problem. What should the nurse do?

Encourage the parents to give the adolescent recognition for her strong points.

A client at 22 weeks' gestation asks the nurse how to prevent back pain as her pregnancy progresses. What does the nurse suggest that she wear?

Low-heeled shoes.

Which topic would be most appropriate for health education for adolescents?

Safe sexual practices.

Which risk factors are associated with the future development of osteoporosis in women? Select all that apply.

-Cigarette smoking -Familial predisposition -Inadequate intake of dietary calcium

A nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? Select all that apply.

-Foramen ovale -Ductus arteriosus

The nurse is obtaining a health history from a client with endometriosis. What consequences can occur as a result of this disorder? Select all that apply.

-Metrorrhagia -Bowel structures -Voiding difficulties

What physiological changes that occur with aging must be taken into consideration when the nurse provides care for the older adult? Select all that apply.

-Urinary urgency -Loss of skin elasticity -Swallowing difficulties -Elevated blood pressure

At what age does the anterior fontanel of the skull close?

12 to 18 months.

How many deciduous teeth would be present in a 10-month-old infant?

4.

A 6-year-old child begins sucking her thumb after surgery. The child did not engage in this behavior before the surgery. What is the best action for the nurse to take?

Accepting the thumb-sucking.

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing?

Babinski.

After teaching a client about a low-fat diet, what is most important for the nurse to document?

Client's ability to plan a low-fat meal.

On the third day of a 2-year-old toddler's hospitalization the nurse notes that the child, who had been screaming and crying inconsolably, has begun to regress and is now lying quietly in the crib with a blanket. What stage of separation anxiety has developed?

Despair.

A woman's pregnancy has been uneventful, and she has gained 25 lb. At term her hemoglobin level is 10.6 g/dL, and her hematocrit is 31%. What does the nurse identify as the reason for these hemoglobin and hematocrit levels?

Hemodilution.

Which two groups of American women have the highest breast and cervical cancer mortality rates?

Hispanic and African American.

A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound?

In the preoperative period.

When performing Leopold maneuvers on a client who has been admitted to the birthing room, the nurse identifies a firm, round prominence over the symphysis pubis; a smooth, convex structure along her right side; irregular lumps along her left side; and a soft roundness in the fundus. What is the fetal position?

ROA.

A client arrives at the clinic with swollen, tender breasts and flulike symptoms. A diagnosis of mastitis is made. What does the nurse plan to do?

Teach her to empty her breasts frequently.

A client arrives in the birthing room with the fetal head crowning. Birth is imminent. What should the nurse instruct the client to do?

Use the pant-breathing pattern.

Which complication is a primipara with a second-degree laceration and repair most likely to experience during the postpartum period?

Difficulty voiding spontaneously.

The LPN is caring for a multipara who has just given birth to a large-for-gestational-age (LGA) infant. Which statement indicates to the nurse that the patient understands how to maintain a contracted uterus?

"I'll massage my uterus regularly to keep it firm."

A nurse is preparing an intramuscular injection to be administered to a 2-year-old child. What approach is the most therapeutic?

"This might hurt, but it's important that you be very still."

A nursing instructor asks a nursing student to describe the cognitive changes in toddlers. Which statement by the student indicates the need for further teaching?

"Toddlers are unable to represent objects and places with symbols."

While caring for a client who gave birth 1day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreath below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats/min, and respirations are 16 breaths/min. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action?

Asking the client when she last changed the perineal pad.

How should the nurse assess a newborn's grasp reflex?

By pressing the examining fingers against the palms of the newborn's hands.

A client expresses a desire to breast-feed her preterm neonate, who is in the neonatal intensive care unit (NICU). The client states that she will pump her breasts until her baby is ready to breast-feed. The infant has been sucking on a pacifier for 1 week in accordance with protocol. How should the nurse respond to the mother's request?

By supporting the client's decision and explaining that the infant may lie close to her breast for nippling as desired.

A nurse is caring for a 9-month-old infant with gluten-induced enteropathy. What common term for this disorder should the nurse use when discussing the infant's diagnosis with the parents?

Celiac disease.

A nurse is caring for a 15-year-old client who is undergoing chemotherapy for leukemia. The nurse expects that adolescents with health problems are most concerned about what?

Feeling different regarding changes in body image.

During the examination of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record?

First.

A newborn's immunization program is started. While discussing the immunization schedule for the first 6 months with the parents, the nurse informs them that infants usually are not immunized against what?

Measles.

The parents of a newborn arrive for the first clinic appointment. Accompanying them is their 18-month-old toddler. At the beginning of the intake interview the nurse notes that the mother is formula-feeding the infant, the toddler is playing on the floor, and the father is reading a magazine. What should the nurse ask the father to do at this time?

Participate in the discussion.

A husband who is coaching his wife during labor demonstrates an understanding of the transition phase of labor when, as his wife starts to push with each contraction, he instructs her to do what?

Take quick, shallow breaths, and then blow.