NUR PERS - Module 5: Nursing Perspective 2
B.
The best position that encourages the drainage of lochia by gravity is: A. Dorsal Recumbent position B. Fowler's position C. Sim's position D. Trendelenburg's position
B.
A pregnant teen is to have prenatal testing. She is afraid of needles and wants to know the least invasive way she can get the testing done. The nurse should suggest which testing procedure? A. Triple marker screen B. Ultrasound examination C. Amniocentesis D. Chorionic villus sampling
B.
A nurse who is called to a client's room notes that the client's cesarean incision has separated. Which of the following actions is the highest priority for the nurse to perform? A. Elevate the head of the client's bed slightly B. Notify the surgeon C. Flex the client's knees D. Cover the wound with sterile wet dressings.
B.
A parent tells the nurse that the 3-month old infant is fussy, spits up constantly, and has a lot of gas, and there is a family history of allergies. These symptoms are related to which diagnosis? A. Failure to thrive B. Sensitive to cow's milk C. Phenylketonuria D. Pancreatic insufficiency
D.
A parent who is Jehovah's Witness has a child with leukemia and a very low RBC count. The nurse should recognize that the family faces which dilemma? A. Numerous dietary kosher laws exist B. A belief that only Allah cures illness C. Desire for anointing of the sick D. Opposition to transfusion and vaccines
A.
A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? A. Assess deep tendon reflexes. B. Obtain blood count. C. Obtain routine urinalysis. D. Assess baseline weight.
D.
A pregnant diabetic has been diagnosed with hydramnios. Which of the following would explain this finding? A. Recurring hypoglycemic episodes. B. Placental vascular damage. C. Fetal sacral agenesis. D. Excessive fetal urination.
D.
A client, 32 weeks' gestation with placenta previa, is on total bed rest. The physician expects her to be hospitalized on bed rest until her cesarean section, which is scheduled for 38 weeks' gestation. To prevent complications while in the hospital, the nurse should do which of the following? 1. Perform passive range-of-motion exercises 2. Restrict the fluid intake of the client 3. Decorate the room with pictures of family 4. Encourage the client to eat a high-fiber diet 5. Teach the client deep-breathing exercises A. 1,2,3,4 B. 1,2,4,5 C. 2,3,4,5 D. 1,3,4,5
B.
A 14-year old sustained a grade III concussion while playing football. Which statement by the parents indicates that further education is needed? A. "Our child will not be able to play football until recovery is complete" B. "Our child needs to get back to school quickly, as there are midterms next week" C. "Our child's headache headaches may continue for the next 6 months, we should call the physician if the headaches get worse" D. "If our child suffers another concussion before recovery is complete, brain injury will be compounded"
D.
A 17-month old is brought into the clinic, and the nurse notes the toddler has tooth decay on the maxillary upper incisors. Which tactic(s) would the nurse suggest to wean the toddler from the bottle? i. Hide the bottle and tell the toddler that is not needed anymore ii. Put only tap water in the bottle iii. Give the bottle only at night iv. Give the toddler a pacifier and take the bottle away v. Do not give any bottles before bed A. i, ii, iii, iv, v B. i, ii, iii C. i, ii, iv D. i, ii, v
B.
A 2-day old baby is being readied for discharge but looks jaundiced. The nurse reviews the baby's birth records and notes that the baby has A blood type, and the mother has O blood type. The nurse should check which blood test? A. Hepatitis B titer B. Total bilirubin C. CBC D. Sedimentation rate
A.
A 2-year old is brought to the emergency department for fever and ear pain. The parents report the child has had many ear infections and that polyethylene cubes have been recommended, but the parents cannot afford surgery. The child is diagnosed with bilateral otitis media. The toddler is carrying a baby bottle full of juice, and a parent is carrying a pack of cigarettes. Which one preventive measure could be taught to the parents to decrease the incidence of ear infections? A. Wean the toddler from the bottle B. Give the toddler a decongestant before bedtime C. Encourage the parent to smoke outside the house D. Have the child's hearing checked
A.
A 24-week-gravid client is being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days." Which of the following is the most appropriate action for the nurse to perform next? A. Take the woman's blood pressure. B. Ask the woman about stressors at work. C. Assess the woman's fundal height. D. Inquire whether or not the client has allergies.
C.
A 25-year-old client is admitted with the following history: 12 weeks pregnant, vaginal bleeding, no fetal heartbeat seen on ultrasound. The nurse would expect the doctor to write an order to prepare the client for which of the following? A. Nonstress testing B. Cervical cerclage C. Dilation and curettage D. Amniocentesis
B.
A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? A. Low serum creatinine. B. Epigastric pain. C. High serum protein. D. Bloody stools.
C.
A 27 year old was admitted for pre-eclampsia. The physician ordered 4 gms magnesium sulphate IV as a loading dose. On hand was 50% magnesium sulphate (50 gms in 100 ml). How many millilitres will the nurse administer? A. 4.0 ml B. 6.0 ml C. 8.0 ml
B.
A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? A. Quantity of vaginal bleeding B. Presence of abdominal pain C. Maternal blood pressure D. Leopold's maneuver results
C.
A 32-week-gestation client states that she "thinks" she is leaking amniotic fluid. Which of the following tests could be performed to determine whether the membranes had ruptured? A. Amniocentesis. B. Biophysical profile. C. Fern test. D. Kernig assessment.
D.
A 38-week-gestation woman is in labor and delivery with a painful, board-like abdomen and progressively larger serial girth measurements. Which of the following assessments is appropriate at this time? A. Maternal lung sounds. B. Cervical dilation. C. White blood cell count. D. Fetal heart rate.
A.
A 5-month old with a lumbar myelomeningocele is admitted to the unit with an Arnold-Chiari malformation. The infant has which other diagnosis? A. Hydrocephalus B. Anencephaly C. Tethering of the spinal cord D. Perinatal hemorrhage
D.
A 7-year old child in a classroom is disruptive with loud talking, has a short attention span, and has difficulty organizing work. Which is the most likely diagnosis for this child? A. Enuresis B. Sexual abuse C. Learning disability D. Attention-deficit-hyperactivity disorder
A.
A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min × 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? A. Turn off oxytocin B. Administer oxygen via facemask C. Call the obstetrician D.Reposition the patient
D.
A breastfeeding woman calls the pediatric nurse with the following complaint: "I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I have my husband feed the baby until I get better?" Which of the following replies by the nurse is appropriate at this time? A. "In addition to giving the baby formula, you should wear a surgical face mask when you are around him." B. "Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes." C. "Don't forget to pump your breasts every 3 hours while the baby is being fed the prescribed formula." D. "The best way to keep your baby from getting sick is for you to keep breastfeed- ing him rather than switching him to formula."
A.
A child assigned to the nurse's floor has a dysfluency. The nurse should recognize what symptoms? A. Stuttering B. Substitution of one sound for another C. Speaking in a monotone D. Hypernasal speech
A.
A child is taking haloperidol (Haldol) for schizophrenia and the family has been instructed to watch for extrapyramidal side effects. Which are the characteristics of these side effects? A. Abnormal movements and twitches B. Inappropriate behaviors C. Excessive aggressiveness D. Thoughts of suicide
D.
A child with moderate asthma is wheezing and coughing. Which test should the nurse perform before the health care provider sees the child? A. Skin testing for allergens B. PCO2 levels C. Metered dose inhaler D. Peak flow
B.
A client comes into the labor-and-delivery suite stating that her membranes ruptured about 5 hours ago, but that she is not having contractions. She wants to be examined to see if she is dilating. She states that her baby has stopped moving, but she wants to return to work if she is not in labor. What should the nurse do next? A. She should be evaluated for fetal heart rate and check for prolapsed cord B. The client will be routinely admitted because she will most likely develop a regular contraction pattern soon C. The client should be sent home to rest in a familiar environment until she is in true labor D. Following a vaginal examination to check for dilation, the client will most likely be allowed to return to work until her contractions are in a regular pattern
A.
A client has had increasing blood pressure and is suspected of having mild pre-eclampsia. She started on magnesium sulphate intravenously. WHich of the following is the specific mechanism of action of the drug? A. Central nervous system depressant that prevents seizures B. Central nervous system stimulant to maintain a stable blood pressure C. Smooth muscle relaxant that decreases uterine contractions D. Antihypertensive to lower blood pressure
C.
A client has just entered the labor and delivery suite with ruptured membranes for 2 hours, fetal heart rate of 146, contractions every 5 minutes × 60 seconds, and a history of herpes simplex type 2. She has no observable lesions. After notifying the doctor of the admission, which of the following is the appropriate action for the nurse to take? A. Prepare the client for surgery. B. Place the bed in Trendelenburg position. C. Check dilation and effacement. D. Check the biophysical profile results.
E.
A client is receiving terbutaline (Brethine) for preterm labor. Which of the following findings would warrant stopping the infusion? Select that apply. A. Change in beat-to-beat variability from minimal to moderate. B. Change in the amniotic sac from intact to ruptured. C. Change ion contraction pattern from q 3 min x 90 sec to q 2 x 60 secs, D. Change in fetal heart pattern from no decelerations to early decelerations. E. Change in fetal heart rate from 160 bpm to 210 bpm
D.
A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make? A. Check patellar reflexes. B. Assess for dependent edema. C. Place the client flat in bed. D. Auscultate lung fields.
D.
A client who has been diagnosed with severe preeclampsia is being administered magnesium sulfate via IV pump. Which of the following medications must the nurse have immediately available in the client's room? A. Morphine Sulfate B. Meperidine (Demerol) C. Naloxone (Narcan) D. Calcium gluconate
C.
A client who is newly diagnosed with gestational diabetes with FBS of 115 mg/d and with two elevated result in OGTT. Which of the following might be the management for the patient. A. A combination of diet and oral hypoglycemics. B. A combination of diet, exercise and insulin. C. Diet modification. D. A combination of exercise and oral hypoglycemics.
A.
A client who is scheduled for CS delivery. Which assessment finding need to contact the physician? A. FHT 180 bpm. B. Maternal pulse rate 76 bpm C. WBC - 9,000 mg/di D. Blood glucose 100
C.
A client with a fetal demise is admitted to labor and delivery in the latent phase of labor. Which of the following behaviors would the nurse expect this client to exhibit? A. Talkative and excited. B. Quietly doing rapid breathing. C. Crying and sad. D. Loudly chanting songs
C.
A client with mild preeclampsia who has been advised to be on bed rest at home asks why doing so is necessary. Which of the following is the best response for the nurse to give the client? A. "Bed rest will help to relieve your nausea and anorexia." B. "The position change will prevent the placenta from separating." C. "Reclining will increase the amount of oxygen that your baby gets." D. "Bed rest will help you to conserve energy for your labor."
C.
A client's assessments reveal that she is 4 cm dilated and 80% effaced with a fetal heart tracing showing frequent late decelerations and strong contractions every 3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals? A. Prevention of a vaginal laceration. B. Completion of the first stage of labor. C. Delivery of a healthy baby. D. Safe pain medication management.
B.
A nurse remarks to a 38-week-gravid client, "It looks like your face and hands are swollen." The client responds, "Yes, you're right. Why do you ask?" The nurse's response is based on the fact that the changes may be caused by which of the following? A. Altered splenic circulation. B. Altered glomerular filtration. C. Cardiac failure. D. Hepatic insufficiency.
C.
A client, 39 weeks' gestation, fetal heart baseline at 144 bpm, tells the admitting labor and delivery room nurse that she has had to wear a pad for the past 4 days "because I keep leaking urine." Which of the following is an appropriate action for the nurse to perform at this time? A. Obtain a urine culture to check for a urinary tract infection. B. Percuss the woman's uterus and monitor for ballottement. C. Assess the fluid with nitrazine and see if the paper turns blue. D. Palpate the woman's bladder to check for urinary retention.
C.
A client, G2 P1001, telephones the gynecology office complaining of left-sided pain. Which of the following questions by the triage nurse would help to determine whether the one-sided pain is due to an ectopic pregnancy? A. "How old were you when you first got your period?" B. "Did you have any complications with your first pregnancy?" C. "When was the first day of your last menstrual period?" D. "When did you have your pregnancy test done?"
C.
A client, G3 P2002, 40 weeks' gestation, who has vaginal candidiasis, has just been admitted in early labor. Which of the following should the nurse advise the woman? A. She will be treated with antibiotics during labor B. She may need a cesarean delivery. C. The baby may develop thrush after delivery. D. The baby will be isolated for at least one day.
A.
A client, G8 P3406, 14 weeks' gestation, is being seen in the prenatal clinic. During the nurse's prenatal teaching session, the nurse will emphasize that the woman should notify the obstetric office immediately if she notes which of the following? A. Signs and symptoms of labor B. Swelling of the feet C. Appearance of spider veins D. Change in fetal movement
A.
A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is "bleeding and saturating a pad about every 1/2 hour.' Which of the following is an appropriate response by the nurse? A. The physician should see you. Please go to the emergency department." B. "Pushing during a bowel movement may have loosened your stitches." C. "That is normal. You are starting to menstruate again". D. "You should stay on complete bed rest until the bleeding subsides"
C.
A delirious patient is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets. The nurse monitors this client carefully for which of the following intrapartal complications? A. Prolonged labor. B. Retained placenta. C. Abruptio placentae. D. Prolapsed cord.
A.
A diabetic client is to receive 5 units regular and 15 units NPH insulin at 0800. To administer the medication appropriately, what should the nurse do? A. Draw 5 units regular first and 15 units NPH second into the same syringe and inject. B. Mix 5 units regular and 15 units NPH in a vial before drawing the full 20 units into a syringe and inject. C. Draw 5 units regular in one syringe and 15 units NPH in a second syringe and inject in different locations. D. Draw 15 units NPH first and 5 units regular second into the same syringe and inject.
B.
A fixed splitting of the S2 heart sound is heard in an otherwise healthy child. This is a diagnostic sign of which cardiac defect? A. Mitral regurgitation B. Atrial septal defect C. Functional murmur D. Pericardial friction rub
D.
A full-term client, contracting every 15 min × 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time? A.Intravenous fluid administration B.Intermittent fetal heart auscultation C.Nipple stimulation D.Vaginal examination
A.
A gravid client with 4+ proteinuria and 4+ reflexes is admitted to the hospital. The nurse must closely monitor the woman for which of the following? A. Grand mal seizure. B. Fractured pelvis. C. High platelet count. D. Explosive diarrhea.
C.
A gravid client, 27 weeks' gestation, has been diagnosed with gestational diabetes. Which of the following therapies will most likely be ordered for this client? A. Oral hypoglycemic agents. B. Inhaled insulin. C. Diet control with exercise. D. Regular insulin injections.
D.
A gravid client, G6 P5005, 24 weeks' gestation, has been admitted to the hospital for placenta previa. Which of the following is an appropriate long-term goal for this client? A. The client will call her children shortly after admission. B. The client will have a reactive nonstress test on day 2 of hospitalization. C. The client will state an understanding of need for complete bed rest. D. The client will be symptom free until at least 37 weeks' gestation.
D.
A newborn with suspended hydrocephalus is transferred to the intensive care unit for further evaluation and treatment. The infant's nurse knows which of the following? A. To use sedation as needed to keep the baby from crying or being fussy B. To keep the crib in a flat and neutral position C. To expect the infant to sleep more than and infant without hydrocephalus D. Do not use any scalp veins for intravenous infusions
D.
A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? A. Respiratory rate is 16 rpm. B. Client has no grand mal seizures. C. Urinary output is 30 mL/hr. D. Client has no patellar reflex response
C.
A nurse is about to inject RhoGAM into an Rh-negative mother. Which of the following is the preferred site for the injection? A. Dorsogluteal B. Vastus Lateralis C.Deltoid D.Ventrogluteal
A.
A nurse is assigned to care for a client with hypertonic uterine dysfunction and experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which of the following is the priority nursing intervention? A. Monitor the oxytocin (Pitocin) infusion closely B. Prepare the client for an amniotomy C. Provide pain relief measures D. Promote ambulation very 30 minutes
C.
A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of slowing labor. Which of the following prescribed treatments for this condition? A. Increased hydration B. Administer tocolytic medication C. Oxytocin (Pitocin) Infusion D. Medication that will provide sedation
D.
A nurse is assigned to care for a woman with preeclampsia. The nurse plans to initiate which action to provide a safe environment? A. Maintain fluid and sodium restriction B. Take the vital signs every 4 hours C. Turn off room lights and draw the window shades D. Encourage visits from family and friends for psychosocial support
D.
A nurse is caring for a 25-year-old client who has just had a spontaneous first trimester abortion. Which of the following comments by the nurse is appropriate? A. "At least you weren't very far along." B. "You can try again very soon." C. "It is probably better this way" D. "I'm here to talk if you would like."
A.
A nurse is counseling a preeclamptic client about her diet. Which should the nurse encourage the woman to do? A. Eat a well-balanced diet. B. Restrict sodium intake. C. Increase intake of fluids. D. Avoid simple sugars.
C.
A nurse is performing an assessment on four 22-week-pregnant clients. The nurse reports to the obstetrician that which of the clients may be carrying twins? A. The client who states that she feels huge. B. The client with a weight gain of 13 pounds. C. The client whose fundal height measurement is 26 cm. D. The client whose alpha-fetoprotein level is one-half normal.
C.
A nurse is working in a well-child clinic administering immunizations to preschoolers. Which procedure will minimize local reactions to the injections? A. Apply EMLA cream 1 hour before B. Change the needle on the syringe after drawing up the biological drug C. Inject into the vastus laterals or ventrogluteal muscle D. Use distraction such as telling the child to hold the breath
C.
A preterm labor client, 30 weeks' gestation, who ruptured membranes 4 hours ago, is being given IM dexamethasone (Decadron). When she asks why she is receiving the drug, the nurse replies: A. "To help to stop your labor contractions." B. "To decrease the pain from contractions." C. "To help to mature your baby's lungs." D. "To decrease the pain from the contractions."
A.
A sports physical examination is being performed on a 12-year old male. He is evaluated as a Tanner stage II. Which physical characteristics would the nurse expect? A. Enlarging penis B. Height spurt C. Gynecomastia D. Deepening voice
C.
A teenager is legally blind. The teen is wearing thick glasses and is carrying some schoolbooks. Which question should the nurse ask the teen? A. "Just how blind are you?" B. "Can you see enough to read those books?" C. "Tell me what you can see in this room." D. "Is your vision worse than 20/200 in either of your eyes?"
D.
A woman has been diagnosed with a ruptured ectopic pregnancy. Which of the following signs/symptoms is characteristic of this diagnosis? A. Dark brown rectal bleeding B. Severe nausea and vomiting C. Marked hyperthermia D. Sharp unilateral pain
A.
A woman has been in the second stage of labor for 21/2 hours. The fetal head is at +4 station and the fetal heart is showing mild late decelerations. The obstetrician advises the woman that the baby will be delivered with forceps. Which of the following actions should the nurse take at this time? A. Assess the fetal heart rate after each contraction. B. Advise the woman to refuse the use of forceps. C. Obtain a consent for the use of forceps. D. Encourage the woman to push between contractions.
C.
A woman is to receive RhoGAM at 28 weeks gestation. Which of the following actions must the nurse perform before giving the injection? A. Assess that the direct Coombs' test is positive B. Validate that the baby is Rh-negative C. Verify the identity of the woman D. Reconstitue the globulin with sterile water.
A.
A woman on IV magnesium sulphate for PIH has respirations of 10 and depressed deep tendon reflexes. Besides discontinuing the medication, which of the following nursing actions would be most appropriate? A. Administer calcium gluconate B. Stimulate the client to take deep breaths C. Administer naloxone (Narcan) D. Monitor for increased uterine contractions
D.
A woman who is at 32 week's gestation has had ruptured membranes for 26 hours. A nurse should assess the woman for which of the following manifestations? A. Dependent edema B. Elevated temperature C. Constipation D. Proteinuria
B.
A woman who is hepatitis B-surface antigen positive is in active labor. Which action by the nurse is appropriate at this time? A. Obtain an order from the obstetrician to administer ampicillin during labor and the immediate postpartum B. Obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth. C. Obtain an order from the pediatrician to place the baby in isolation after delivery D. Obtain an order from the obstetrician to prepare the client for cesarean delivery.
A.
A woman, 39 weeks' gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus. Which of the following actions by the nurse is appropriate? A. Follow standard infectious disease precautions. B. Notify the health care practitioner for a surgical delivery C. Wear a mask whenever the perineum is exposed D. Notify the nursery of the imminent delivery of an infected neonate.
C.
A young woman tells a nurse she is pregnant and concerned that her boyfriend may be "slow" mentally. The nurse should do which activity first? A. Develop a pedigree B. Take a family history C. Inform the provider about the concern D. Refer the client for genetic counseling
C.
An infant at 12 hours of age has a positive Coombs test result and a bilirubin level of 18 mg/dl. The provider has ordered an exchange transfusion for the infant. As the transfusion is procesding, the nurse should watch for which sign? A. Increasing jaundice B. Lethargy C.Temperature instability D. Irritability
C.
Angelica was noted to have a (+) Homan's sign confirming that she has thrombophlebitis. How is Homan's sign elicited? A. Raising the leg and then bending the knee B. Slightly bending the knee and dorsiflexing the ankle C. Bending the knee in 90° and then dorsíflexing the ankle D. Straightening the knee and then dorsiflexing the ankle
B.
An 11-month old was born at 28 weeks gestation and required 2 weeks of ventilation. The baby is currently well and is being seen in the clinic. The physician recommends that the baby receive preventive therapy for respiratory syncytial virus (RV) for the next 5 months since cold season is approaching. Which medication will be ordered? A. Respiratory syncytial virus immune globulin B. Ribavirin C. Palivizumab D. Pneumoccal vaccine
D.
An 18-month old, who attends day care, has been having a barking, hoarse-sounding cough that comes in spasms with very noisy respirations for the last 2 nights. The parent is concerned that the child has picked up an infection at day care. The day-care staff indicates the child does not cough during the day, has no fever, and is eating and drinking well. This description is most likely which condition? A. Laryngotracheobronchitis B. Bacterial tracheitis C. Asthma D. Acute spasmodic laryngitis
D.
An adolescent is complaining of knees swelling and hurting, hands and feet being cold all the time, frequent headaches and a red rash on the cheeks and nose. Which does the nurse suspect? A. Multiple sclerosis B. Normal adolescent concerns C. Myasthenia gravis D. Systemic Iupus erythematosus
D.
During a prenatal interview, a client tells the nurse "My mother told me she had toxemia during her pregnancy and almost died!" Which of the following questions should the nurse ask in response to this statement? A. "Does your mother have a cardiac condition?" B. "Does your mother have diabetes now?" C. "Did your mother tell you what she was toxic from?" D. "Did your mother say whether she had a seizure or not?"
D.
During the delivery of a macrosomic baby, the woman develops a fourth-degree laceration. How should the nurse document the extent of the laceration in the woman's medical record? A. Into the musculature of the buttock. B. Through the urinary meatus. C. Into the head of the clitoris. D. Through the rectal sphincter.
B.
During the nurse's assessment, a child begins to have a generalized tonic-clonic seizure. The drug of choice and method of administration the nurse expects the health care provider to order are which of the following? A. Lorazepam and diazepam, combined in an intravenous solution of D5W. B. Lorazepam given intravenously or diazepam given directly into vein C. Phenobarbital administered in an intravenous solution of D5W 0.45 normal saline D. Phenytoin in a dextrose solution given intravenously over 1 hour
B.
Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first? A. Assess the fetal heart rate. B. Put the client in the knee-chest position. C. Administer oxygen by tight face mask. D. Telephone the obstetrician with the findings.
D.
Immediately after an amniotomy has been performed which of the priority nursing intervention should be to check: A. For bladder distention B. For cervical dilation C. Maternal blood pressure D. Fetal heart rate pattern
A.
In Endometritis, fever usually occurs on the: A. 2nd - 3rd postpartal day B. 5th - 6th postpartal day C. 3rd - 4th postpartal day D. 4th - 5th postpartal day
B.
In a client with PIH receiving magnesium sulfate therapy, which of the following medications should the nurse have on hand? A.Ergonovine B. Calcium Gluconate C. Morphine sulfate D. Methylergonovine
B.
Lucia was admitted to the labor room due to complain of severe back pain. Upon Leopold's maneuver, the nurse found out that the fetus is in left occipito-posterior (LOP) position. To manage back pain, what is appropriate action of the nurse? A. Provide adequate amount of fluid B. Offer back rub C. Instruct client to ambulate D. Facilitate turning position
A.
Magnesium sulphate is used in the treatment of pre-eclampsia to: A. Prevent seizures B. Increase urine output C. Decrease edema D. Decrease blood pressure
D.
Methotrexate is ordered for mothers with Retained Placental Fragments. What is the mechanism of action of Methotrexate A. To relieve pain B. To prevent infection. C. To stimulate contraction of the uterus D. To destroy retained placental tissue
B.
Mildred is gravida III para I. Her first child weighed 4100 gms. at birth. She had a spontaneous abortion early in her second pregnancy. With her current pregnancy, her GTT shows elevated blood sugar levels. Since the client has no history of diabetes except during her pregnancies, which of the following the client be classified? A. Type I diabetes mellitus B. Gestational diabetes mellitus
D.
Nurse Marie is caring for a pregnant client who has been diagnosed with diabetes mellitus 2 years prior to this pregnancy. Her physician told her that her insulin needs will increase during pregnancy. Which of the following best explains the mother's condition? A. Maternal Insulin has to cross the placenta to support the fetus B. The placenta produces a hormone that increases maternal glucose levels C. Her Diabetic condition is becoming more severe D. The placenta produces a hormone that decreases the effectiveness of maternal insulin
B.
On the second day postpartum, the nurse asks the new mother to describe her vaginal bleeding. What should the nurse expect the postpartum mother to answer? A.Thin and White B. Red and Moderate C.Red with Clots D.Scant and Brown
C.
Parents are concerned that their pediatrician suspects Turner syndrome in their newborn. Which physical characteristics lead to this suspicion? A. Cleft lip and palate B. Weak, high-pitched cry C. Webbed neck and lymphedema D. Long arms and small genitalia
C.
Parents are concerned that their toddler refuses to sleep in the new toddler bed and wonder what to do. The nurse explains that the child using "global organization". What does the nurse mean by this term? A. The pre-operational phase of developing cognitive thought starts around 3 years old B. The child is self-centered and does not want to learn C. The child sees changing to a toddler bed as changing the whole process of sleeping and going to bed D. The toddler may have a phobia on the bed
C.
Parents are concerned that their toddler refuses to sleep in the new toddler bed and wonder what to do. The nurse explains the child is using "global organization". What does the nurse mean by this term? A. "The pre-operational phase of developing cognitive thought starts around 3 years old" B. "The child is self-centered and does not want to learn" C. "The child sees changing to a toddler bed as changing the whole process of sleeping and going to bed" D. "The toddler may have a phobia to the bed"
B.
Parents are frustrated with toilet training their 2-year old. Both parents work full time and claim they do not have time to spend on toilet training. What suggestions can the nurse give the parents to decrease their frustration? A. "You will have to invest some time if the child is to be toilet-trained" B. "A child needs to be both physically and psychologically ready to learn the skills needed to be continent" C. "Do you think your child is stubborn?" D. "Have the child sit on the toilet until the child voids"
A.
Parents are told by the genetic counselor that they have a 1:4 probability of having a second child with Cystic Fibrosis (CF). They already have one child who is affected. The parents state their risk is lower now than when they had the previous child. What should the nurse tell the parents about the 1:4 probability? A. Each pregnancy is an independent event B. The probability of having another child with CF is twice as likely as it was when they had the first child C. The probability of having a healthy child is twice as likely with this pregnancy D. The probability of miscarrying is greater now than with the previous pregnancy
C.
Parents are told they should start taking their toddler to the dentist. They are concerned that their child is too young and the dentist will be too harsh with the child. The nurse suggests the parents to do which of the following before the dental visit? A. Tell the child it will not hurt B. Warn that they will have the dentist give a needle in case of bad behavior C. Tell the child they will go along to the dentist so that they can model comfortable safe behavior D. Offer the child a treat for good behavior
C.
Parents are told they should start taking their toddler to the dentist. They are concerned their child is too young and that the dentist will be too harsh with the child. The nurse suggests the parents do which of the following before the dental visit? A. Tell the child it will not hurt B, Warn that they will have the dentist give a needle in case of bad behavior C. Tell the child they will go along to the dentist so that they can model comfortable, safe behavior D. Offer the child a treat for good behavior
B.
Parents confide to the nurse that their child, who is 35 months old, does not talk and spends hours sitting on the floor watching the ceiling fan go around. They are concerned their child may have autism. The nurse should ask the parents which question? A. "Does your child have brothers or sisters?" B. "Does your child seek you out for comfort and love?" C. "Do you have trouble getting babysitters for your child?" D. "Does your child receive speech therapy?"
A.
Parents express concern that their 5 year old has started having more temper tantrums. The parents want to know if this is normal for this age. What should the nurse ask the parents about the tantrums? i. "Do you notice and praise your child when your child does something right?" ii. "Are the tantrums related to one specific aspect of life?" iii. "Are the tantrums causing any harm to self or others?" iv. "Have you consulted the Internet for any suggestions?" v. "How do you handle your child during a tantrum?" A. i, ii, iii, v B. i, ii, iii, iv, v C. i, iii, v D. i, ii, iii, iv
B.
Parents of a 2-year old with Down syndrome are told the child should be screened for audiovisual instability. The nurse tells the parents that which of the following are symptoms of instabijity? A. Mental retardation B. Neck pain and torticollis C. Vision and hearing loss D. Early onset of puberty
A.
Postpartum Infection is the second leading cause of maternal mortality. Which of the following are the predisposing factor of postpartum Infection? 1. Retained Placental Fragments 2. Large baby (>9 lbs.) 3. Cesarean birth 4. Prolonged rupture of membranes A. 1,2,4 B. 3,4 only C. 1,2,3 D. 1,3,4
B.
Princess has a 3 cm hematoma in the perineum after giving birth to a baby boy, she was complaining to much pain in her perineum. What is the appropriate nursing action of the nurse to address the patient concerned. A. Blood evacuation B. Application of ice pack C. Administer analgesics D. Ligation of the bleeding vessel
A.
Retained Placental Fragments are the main cause of Late Postpartum Hemorrhage. The following are the Clinical Manifestation of Retained Placental Fragment that includes which of the following? 1. Abdominal Pain or Tendernes 2. (+) hCG blood serum sample 3. Boggy Uterus 4. Slow, brownish oozing of blood (10th day) 5. Low persistent back pain A. 1,2,3, 4 & 5 B. 2,3 & 4 C. 1,2,4&5 D. 1,2,&5
B.
The characteristic signs and symptoms of pregnancy-induced hypertension (PIH) include: A. Epigastric pain, diastolic pressure of 90 mmHg, dizziness B. BP increase of 30 mmHg systolic, 15 mmHg diastolic above the baseline, greater than 1+ proteinuria, and edema greater than 1+ C. Trace of proteinuria, BP increase greater than 15 mmHg above the systolic baseline and lower extremity edema D. Hypertension, glucosuria and upper body edema
D.
The diagnosis of pregnancy-induced hypertension (PIH) is suspected if the following are found: A. Hypertension and glucosuria B. Ankle edema and glucosuria C. Ankle edema and Hyporeflexia D. Hypertension and proteinuria
A.
The effect of LOP to the labor process is that it: A.Prolongs active phase of labor B. Induces cervical dilation C.Prolongs latent phase of labor D.Decreases duration of labor
D.
The first assessable objective sign of a seizure in a client with eclampsia is frequently: A. Spots or flashes of light before the eyes B. Epigastric pain, nausea and vomiting C. Persistent headache and blurred vision D. Rolling of the eyes to one side with a fixed stare
D.
The nurse anticipates lip edema to a laboring mother due to fetal malpresentation in the utero. What should the nurse action to address the concern? A. OGT Insertion B. Catheterization should be performed C. Intubate the mother D. Monitor the vital signs of the mother and fetus.
A.
The nurse evaluates that the danger of seizure in a woman with eclampsia ends: A. 48 hours postpartum B. 24 hours postpartum C. After labor begins D. After delivery occurs
D.
The nurse goes to kindergarten classroom to evaluate a rash. A 5-year old has patches of itchy vesicles on the chest and face. The teacher tells the nurse the child had a runny nose a couple of days ago. The nurse suspects that the rash is caused by which virus? A. Fifth disease (Parovirus) B. Roseola (Herpes virus) C. Scarlet fever (group A beta hemolytic streptococcus) D. Chickenpox (varicella zoster)
B.
The nurse goes to the kindergarten classroom to evaluate a rash. A 5-year old has patches of itchy vesicles on the chest and face. The teacher tells the nurse the child had a runny nose a couple of days ago. The nurse suspects that the rash is caused by which virus? A. Fifth disease B. Chickenpox C. Roseola D. Scarlet fever
D.
The nurse has administered benadryl to a post cs client who is experiencing side effects from the parenteral morphine sulphate that was administered 30 mins earlier, which of the following actions should the nurse perform ff the administration of the drug? A. Ask any visitors to leave the room. B. Position the woman slightly elevated on her left side C. Monitor the urinary hourly D. Supervise while the woman holds her newborn.
A.
The nurse identifies the following nursing diagnosis for a client undergoing an emergency cesarean section: Risk for ineffective individual coping related to emergency procedure. Which of the following nursing interventions would be appropriate in relation to this diagnosis? A. Explain all procedures slowly and carefully B. Apply antiembolic boots bilaterally C. Monitor the FH and maternal vital signs D. Administer an antacid per MD orders
A.
The nurse in the emergency department is caring for an 8-month old who suffered a concussion from an automobile accident. The infant was in the car seat at the time. The nurse should assess the infant for which symptoms? A. Sweating, irritability, and pallor B. Plethora and hyperthermia C. Crying with fear D. Negative Babinski reflex
A.
The nurse is assisting in the delivery of a baby via vacuum extraction. Which of the following nursing diagnoses for the gravida is appropriate at this time? A. Risk for impaired skin integrity. B. Risk for body image disturbance. C. Risk for ineffective sexuality pattern. D. Risk for impaired parenting.
A.
The nurse is caring for a child dying from leukemia. The parents want to know how comfortable the nurse is in giving doses of pain medication that are larger than customary. Which of ethical principle of care are the parents asking about? A. Double effect B. Justice C. Honesty D. Beneficence
C.
The nurse is caring for a client in labor experiencing hypertonic contractions. Which of the following nursing are appropriate to the client? 1. Comfort measures like backrub and warm shower 2. Bed Rest 3. Tocolytics 4. Mild Sedation A. 2, 3 B. 1.3 C. 1,2 D. 3,4
A.
The nurse is caring for a client who was just admitted to the hospital to rule out ectopic pregnancy. Which of the following orders is the most important for the nurse to perform? A.Assess for dizziness and Weakness B.Obtain urine for urinalysis and culture C.Document the time the client's last meal D.Take the client's temperature
B.
The nurse is caring for a laboring gravida who is 43 weeks pregnant. For which of the following should the nurse carefully monitor this client and fetus? A. Hyperthermia B. Late decelerations C. Hypotension D. Early decelerations
B.
The nurse is caring for a newborn with Erb palsy and phrenic paralysis. The most effective way to promote respiratory effort is for the nurse to position the newborn in what way? A. Supine B. On the affected side C. On the unaffected side D. Prone
C.
The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? A. Place the bed in the high Fowler's position. B. Provide visual and auditory stimulation. C. Pad the client's bed rails and headboard. D. Check each urine for presence of ketones.
B. C. D. E.
The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the client who had which of the follow- ing deliveries asks why she must receive a RhoGAM injection? Select all that apply. A. Birth of Rh-negative twins at 35 weeks' gestation. B. Abortion at 10 week's gestation C. Amniocentesis at 16 weeks' gestation D. Fetal demise at 24 weeks' gestation E. Delivery of a 40-week-gestation, Rh positive baby
D.
The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate? A.Massage the uterus B. Administer oxytocin as ordered C.Assist the client to the bathroom D. Notify the obstetrician
A.
The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take? A. Increase the intravenous infusion rate. B. Administer oxygen via nasal cannula. C. Remove the internal fetal monitor electrode. D. Place the client in high Fowler's position.
B.
The nurse is working in a clinic, and the next patient is an infant with deaf parents. In addition to providing an interpreter for the deaf, the nurse should incorporate what additional aid in communicating with the family? A. Talk just as with hearing families B. Maintain good eye contact to let them read the nurse's lips C. Explain procedures thoroughly D. Recommend a trained hearing dog
D.
The nurse is working in a school health clinic, and a child comes in complaining of "something in my eye". What should the nurse do first? A. Have the child wash hands B. Refer the child to an opthalmologist C. Wash out the affected eye with tap water D. Examine the eye for a foreign body
A.
The nurse is working in a school health clinic, and a teen mentions that her older sister just had a baby born with a myelomeningocele. The teen is wondering if there is anything she can do to prevent this from happening to her baby when she decides to have children. Which is the best response? A. Take a multivitamin with folic acid daily B. Eat more fruits and vegetables daily C. Have breakfast every morning D. There is nothing that can be done to decrease the risk
D.
The nurse is working in the newborn nursery and accidentally bumps the crib of one of the babies. This baby demonstrates a Moro reflex. The nurse sees this baby in which posture? A. Trunk extended upward and head lifted B. When placed on abdomen, crawling movement occurs C. A "fencing" posture D. Extremities extended and abducted and fingers fanned
D.
The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following is the initial nursing action? A. Call the DR to notify the staff B. Find the closest telephone and page the physician stat. C. Gently push the cors into the vagina D. Place the client in Trendelenburg's Position
D.
The nurse on the previous shift charted that a newborn demonstrated cutis marmorata. The nurse now caring for the baby should check which vital sign? A. Blood pressure B. Respirations C. Skin color D. Temperature
D.
The nurse performs an assessment on the client and notes that the fetal heart rate is 90 beats/min. and that the umbilical cord is protruding from the vagina. What is the appropriate nursing action? A. Start an intravenous (IV) line B. Administer a tocolytic drug C. Place in High-fowler's position D. Wrap the cord in a sterile gauze saturated with warm sterile normal saline
D.
The nurse performs an assessment to the client, it was found out that the umbilical cord is protruding from the vagina. Which of the following actions of the nurse should be performed immediately? A. Place patient in prone position B. Maternal complaints of severe pain C. Place patient in prone position D. Position patient modified Trendelenburg
D.
The nurse should expect to observe which behavior in a 3-week-multigravida postpartum client with postpartum depression A. Feelings of infanticide B. Feelings of failure as a mother. 4 Concerns about sibling jealousy C. Difficulty with breastfeeding latch D. Feelings of failure as a mother
B.
The parent of a newborn wants to know what the newborn screening test does? What is the nurse's best response? A. "It detects a larger number of congenital diseases" B. "It screens for phenylketonuria and hypothyroidism" C. "Parents chooses which diseases to screen for" D. "Screens for congenital diseases that insurance companies cover"
B.
The parent of a school-aged child who is paraplegic and uses a wheelchair states that the child is allergic to latex. Which is the most important intervention for this child? A. Giving antihistamines and steroids after procedures B. Prevention of contact with latex products C. Doing a radioallergosorbent test before each procedure D. Using only non latex gloves when doing procedures
C.
The parents of a 19-year old ask the nurse what they should do in terms of long-term care placement for their severely disabled child. Which is the nurse's best response? A. "How much do you want?" B. "Do you have other children who could take your child into their home?" C. "Do you have a detailed plan of care?" D. "Are you working with an agency or social worker about this matter?"
A.
The parents of an infant with hydrocephalus ask about future activities in which their child can participate in school and as an adolescent. The nurse should tell the parents which of the following is appropriate? A. A helmet should be worn during any activity that could lead to head injury B. Only non-contact sports should be pursued, such as swimming or tennis C. Because of the risk of shunt system infection, swimming is not a sports option D. The child should wear a MedicAlert bracelet; then there is no need to be concerned about the shunt
C.
The physician ordered 0.25 mg terbutaline every hour subcutaneously for a young woman in premature labor. The nurse had 0.2 mg/ml on hand. How many milliliters should the nurse administer? A.1.50ml B.1.0 ml C.1.25ml D.0.5ml
D.
The posture of a healthy term newborn is described as: A. Hypotonic B. Asymmetric C. Extended D. Flexed
B.
The pregnant mother came for prenatal check-up. During assessment it was revealed that she has Type 2 Diabetes Mellitus and positive for pregnancy test. Ultrasound result shows, she is 5 weeks pregnant. The nurse anticipates, which of the following treatment should be included in the plan of care? A. Insulin and metformin B. Insulin and diet modification C. Insulin, Diet and metformin D. Oral hypoglycemic agent will be prescribe
C.
The pregnant mother is suspected with gestational diabetes and was instructed to undergo series of test for confirmatory. Which of the following laboratory test will the nurse expect to be prescribed? A. Fasting Blood Glucose B. OGTT C. All may be prescribed D. HBA1C
B.
The uterus failure to revert to its prepregnant state through gradual reduction in size and placement. The condition is also known as: A. Uterine Atony B. Subinvolution C. Disseminated Intravascular D. Endometritis Coagulation
B.
Three preschool children and their foreign-born parents come to a homeless shelter. The family has been homeless for 3 months. The children appear somewhat unkempt but nourished. One of the children has several enlarged cervical lymph nodes and is running a low-grade fever. Which chronic infectious illness should be suspected in the child? A. Chlamydial pneumonia B. Tuberculosis C. Pertussis (whooping cough) D. Asthma
D.
What should the nurse explain to a client who is experiencing premature contractions in the thirty-fifth week of gestation with the cervix dilated 2 cm is planning to have coitus? A. Is permitted as long as penile penetration is shallow B. Need not be restricted in any way C. Should be restricted to the side-lying position D. Prohibited, as it may stimulate labor
C.
What should the nurse teach the parent of a child with suspected meningitis? A. Antibiotics are not initiated until the cerebrospinal fluid cultures are definitive for specificity to prevent resistance B. Antibiotics are useless against viral infections, so they are not used for meningitis C. Antibiotics should be started before the cerebrospinal fluid cultures are definitive; culture results may take up to 3 days D. Antibiotic initiation is based on the age, signs and symptoms of the child, not on the causative agent
B.
When administering MgSO4 for treatment of pregnancy-induced hypertension (PIH), which of the following findings are of concern? A.Sixteen respirations per minute B. Urinary output less than 20 ml/hr C. Irritability and nervousness D. Reflexes of 2+
D.
Which approach gives the most support to parents grieving over a terminally ill newborn? A. State "You are both still young and will be able to have more children" B. Avoid the parents; let them ask you questions C. Offer rationalizations for the child's terminal illness D. State "You are still feeling all the pain of your child's illness"
D.
Which are early signs and symptoms of hydrocephalus in infants? A. Confusion, headache, diplopia B. Rapid head growth, poor feeding, confusion C. Papilledema, irritability, headache D. Full fontanels, poor feeding, rapid head growth
C.
Which immedinte post-operative care for the shunt placement in an infant diagnosed with hydrocephalus? A. Wet-to-dry dressing changes at both the shunt insertion site and the abdominal incision site B. Measure the child's head at least once a day C. Position the infant's head off the shunt site for the first 2 post-operative days D. Complete vital signs and neurological checks every 4 hours
C.
Which is the nurse's best approach to teach high school students about smoking prevention? A. Discuss health consequences of smoking B. Use scare tactics and point out the negative effects of smoking C. Offer alternatives to smoking such as chewing gums or doing activities that distract D. Have the adolescents talk with their parents
D.
Which is the primary goal of a newborn with a cleft of the soft palate? A. Prevent ear infections B. Help the mother bond with the baby C. Repair the cleft palate D. Establish feeding and sucking
A.
Which is/are the most common, nonlethal complication(s) occurring from meningitis? A. Cranial nerve deficits B. Epilepsy C. Bleeding intracranially D. Cerebral palsy
B.
Which of the following findings should the nurse expect when assessing a client, 8 weeks' gestation, with gestational trophoblastic disease (hydatidiform mole)? A. Suicidal ideations. B. Dark brown vaginal bleeding. C. Protracted pain. D. Variable fetal heart decelerations
D.
Which of the following findings would the nurse expect to see when assessing a first- trimester gravida suspected of having gestational trophoblastic disease (hydatidiform mole) that the nurse would not expect to see when assessing a first-trimester gravida with a normal pregnancy? 1. Hematocrit 39% 2. Grape-like clusters passed from the vagina 3. Markedly elevated blood pressure 4. White blood cell count 8,000/mm3 5. Hypertrophied breast tissue A. 2,4 B. 1,2 C. 2,5 D. 2,3
B.
Which of the following nursing care of women should be included in mother experiencing premature labor? A. Keeping them NPO to prevent abdominal distention B. Encouraging them not to bear down C. Explaining why pain medication is kept at a minimum D. Reassuring them that the situation is under control
C.
Which of the following situations is considered a vaginal delivery emergency? A. Third stage of labor lasting 20 minutes B. Three-vessel cord C. Shoulder dystocia D. Fetal heart dropping during contractions
C.
Which outcome is expected in a breasted newborn? A. Voids spontaneously within 12 hours of life B. Loses 10% of body weight in the first 5 days C. Regains birth weight by the 14th day of life D. Awakens spontaneously for all feedings
B.
Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma? A. Bleeding B. Pain C. Redness D. Warmth
C.
Which would the nurse assess in a 4-week old infant who has developmental dysplasia of the hip and is wearing a Pavlik harness? A. Diaper dermatitis B. Talipes equinovarus C. Leg shortening and limited abduction D. Pain
B.
While assisting with a lumbar puncture procedure on an infant or small child, the nurse shuld do which of the following? A. Have the patient in a clean diaper to avoid contamination of the site B. Monitor the patient's cardiorespiratory status at all times C. Position the patient in the prone position with the head to the left D. Start an intravenous line to facilitate use of conscious sedation
