NUR404 exam 3

The nurse is preparing to assess a school-age child who is experiencing pain in theleft femur area. When conducting this assessment, at which point should the nurse assess the painful region? A. last B. first C. after measuring vital signs D. before the abdominal assessment

A If a child has a sensitive or painful body part, palpate that area last. Otherwise, the child may be unwilling to allow other parts to be touched in fear of additional pain. The painful regions should not be assessed first, after measuring vital signs, or before the abdominal assessment.

The nurse is assessing a term newborn. Which finding should the nurse expect when assessing the patterns of sole creases? A. creases on two-thirds of the foot B. heel creases but no anterior creases C. longitudinal but no horizontal creases D. creases covering one fourth of the foot

A The foot of a term newborn has many crisscrossed lines on the sole, covering approximately two-thirds of the foot. If these creases cover less than two- thirds of the foot or are absent, it suggests the infant is preterm.

The nurse is teaching new parents how to calculate the amount of formula to feed their newborn each day. The baby weighs 8 lb. How much formula should the nurse teach the parents to provide each day? A. 20 to 24 oz B. 30 to 36 oz C. 42 to 54 oz D. 60 to 72 oz

A The total fluid ingested for 24 hours must be sufficient to meet the infant's fluid needs and is calculated by determining 75 to 90 ml or 2.5 to 3.0 oz of fluid per pound of body weight per day. Because the infant weighs 8 lb, the amount of formula would be between 8.0 x 2.5, or 20 oz, and 8.0 x 3.0, or 24 oz. The other choices are inaccurate calculations for the amount of formula to provide to an infant weighing 8 lb.

A nurse is monitoring the serum drug level of a pregnant client with preeclampsia who is receiving a continuous infusion of magnesium sulfate. For which level would the nurse continue the infusion? A. 6.8 mg/100ml B. 8.4 mg/100 ml C. 9.2 mg/100 ml D. 10.6 mg/100 ml

A Therapeutic serum blood levels for magnesium sulfate should be maintained at 5-8 mg/100 ml. If blood serum levels rise above this, respiratory depression, cardiac arrhythmias, and cardiac arrest can occur.

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate? A. postterm B. preterm C. SGA D. LGA

A These characteristics are consistent with a postterm infant. An SGA infant has some of these same characteristics but does not exhibit long fingernails. A preterm infant has translucent skin, and an LGA infant has excessive subcutaneous fat.

A nurse is preparing to conduct a class for a group of parents with school-age children about healthy nutrition. Which nutrients would the nurse include as especially important for this age group? Select all that apply. A. calcium B. iron C. flouride D. vitamin B E. vitamin C

A, B, C Although a well-balanced intake of all nutrients is important, both girls and boys require more iron in prepuberty than they did between the ages of 7 and 10 years. Adequate calcium and fluoride intake remains important to ensure good teeth and bone growth.

A 3-year-old you meet has phenylketonuria. Which food would you question if you saw it on his lunch tray? A. a dish of pears B. chocolate pudding C. lettuce leaves D. orange juice

B Milk is high in phenylalanine. Therefore, milk and milk products are contraindicated.

A newborn is prescribed to receive vitamin K (Aqua-Mephyton) 0.5 mg intramuscularly. What should the nurse do when providing this medication to the newborn? A. Administer the medication in the deltoid muscle. B. Administer the medication into the anterolateral muscle. C. Provide the medication immediately before breastfeeding. D. Notify the physician of swelling and irritation at the injection site.

B Vitamin K should be administered into a large muscle such as the anterolateral muscle of the newborn's thigh. The deltoid muscle is not used for intramuscular injections in the newborn. The medication should be given so as not to interrupt breastfeeding. Swelling and irritation at the injection site is a possible adverse reaction and does not necessarily need to be reported to the physician.

The nurse is explaining the process of breast milk production with a client pregnant with her first child. What should the nurse include when providing this teaching? Select all that apply. A. Breast milk is thin, yellow, and watery. B. For the first 3 to 4 days, the breast milk is colostrum. C. Uterine cramping is a contraindication to breastfeeding. D. True breast milk comes in by the 10th day after giving birth. E. Most mothers have breast milk by the first day after giving birth

B, D For the first 3 to 4 days after delivery, the breast milk is colostrum. The consistency changes to true breast milk by the 10th postpartum day. Colostrum is thin, yellow, and watery. Uterine cramping occurs as a result of oxytocin released during breastfeeding and is not a contraindication to breastfeeding but an expected occurrence. Most mothers do not have breast milk by the first day after giving birth.

The developmental task of the school-aged period, according to Erikson, is gaining a sense of: A. autonomy versus shame. B. independence versus dependence. C. industry versus inferiority. D. identity versus failure.

C The school-age years, according to Erickson, are the stage of industry versus inferiority. The developmental stage helps increase the child's sense of self worth. Industry is associated with the child's increased interest in knowledge and the development of social skills. Autonomy versus shame is the developmental tasks of 1 to 3 year old children. Erickson's stages do not include the developmental tasks of independence versus dependence nor identity versus failure.

A pregnant client is hospitalized because of preeclampsia. Magnesium sulfate is ordered to prevent eclampsia. When preparing to administer the magnesium sulfate, the nurse would ensure that which medication would be readily available? A. hydralazine B. labetalol C. calcium gluconate D. nifedipine

C When administering magnesium sulfate, the nurse would make sure that calcium gluconate is readily available should the client develop signs and symptoms of magnesium toxicity. Hydralazine, labetalol, and nifedipine are other drugs that may be used to control hypertension instead of magnesium sulfate.

The nurse is monitoring a pregnant client who is receiving intravenous magnesium sulfate for eclampsia. During the last assessment, the nurse was unable to elicit a patellar reflex. What should the nurse do? A. Check the fetal heart rate. B. Measure blood pressure. C. Stop the current infusion. D. Increase the infusion rate.

C When infusing magnesium sulfate, the nurse should stop the infusion if deep tendon reflexes are absent. Checking the fetal heart rate and measuring blood pressure could waste time and provide the client with more magnesium sulfate. The infusion rate should not be increased because this could lead to cardiac dysrhythmias and respiratory depression.

The nurse is caring for a 7-year-old client who suffered extensive burns from a house fire. Which finding in the client's history most concerns the nurse? A. The child appears withdrawn and frightened. B. The child's clothing was burned when exiting the home. C. The child was home alone when the fire started. D. The child was trapped in a burning bedroom.

D When a child is confined in a closed space during a fire, the child can inhale a great deal of smoke, causing respiratory tract burns or irritation. This would lead the nurse to further assess for respiratory complications, which is a priority at this time. Burned clothing could indicate burns of the child's body and requires further assessment. However, this is not a priority over assessing the client's airway and ability to breathe. The client appearing withdrawn and frightened and being home alone at such a young age would be concerning to the nurse and warrant follow-up once the client is determined to be stable.

When teaching a woman about ingesting drugs while breastfeeding, which statement is most accurate? A. Almost all drugs are excreted to some extent in breast milk. B. A mother can plan on taking common over-the-counter drugs without difficulty. C. A mother has to limit her exposure to opioids and sedatives while breastfeeding. D. A mother should halt breastfeeding for 1 week after taking any drug.

A Almost all drugs are excreted in breast milk, over-the-counter as well as prescription.

The nurse is caring for a small-for-gestational-age infant born to a drug- dependent client. For which manifestations should the nurse assess as evidence of withdrawal symptoms in the newborn? Select all that apply. A. tremors B. convulsions C. high-pitched cry D. constant movement E. sluggish respiratory rate

A, B, C, D Infants of drug-dependent women tend to be small for gestational age. If the client took a drug close to birth, the infant may show withdrawal symptoms shortly after birth that include tremors, convulsions, high-pitched cry, and constant movement. Respiratory rate would be rapid and not sluggish.

While reviewing a newborn's hospital record, which of the following would be most important for you to locate? A. how he was positioned in utero (posterior or anterior) B. if he breathed spontaneously at birth C. if his mother used prepared childbirth D. if he was a planned pregnancy

B Although all of these are important, inability to breathe spontaneously at birth has the potential to have the most long-term consequences.

A woman develops gestational diabetes. Which assessment should she make daily? A. Test her urine for protein with a chemical reagent strip. B. Measure her abdominal diameter with a tape measure. C. Measure her uterine height by hand-span distance. D. Measure serum for glucose level by a finger prick.

D Assessing serum glucose reveals both hyperglycemia and hypoglycemia.

On inspecting a newborn's abdomen, which finding would you note as abnormal? A. abdomen slightly protuberant (rounded) B. liver palpable 2 cm under the right costal margin C. bowel sounds present at two to three per minute D. clear drainage at the base of the umbilical cord

D Clear drainage at the base of the umbilical cord suggests the child may have a patent urachus or a fistula to the bladder.

The nurse is caring for a newborn that weighed 7 lb 3 oz (3220 g) at birth. What action should the nurse take first based on this weight? A. Plot the weight on a gestational age graph. B. Ask for a physician to examine the newborn. C. Draw additional blood work for cholesterol level. D. Turn off the radiant heat warmer for physical assessment.

A A newborn's weight is important because it helps to determine maturity as well as establish a baseline against which all other weights can be compared. The birth weight of newborns varies depending on the racial, nutritional, intrauterine, and genetic factors that were present during conception and pregnancy. The weight in relation to the gestational age should be plotted on a standard neonatal graph. The nurse does not need to ask a physician to examine the newborn. There is no evidence to suggest that the infant needs a cholesterol level drawn. The weight does not influence if the newborn needs to be placed in a radiant heat warmer.

During a home visit, a new mother is concerned that, after three meconium stools, her newborn has had a bright green stool. What should the nurse explain to the mother? A. This is a normal finding. B. This is most likely a symptom of diarrhea. C. The baby may be developing an allergy to breastmilk. D. The child will need to be isolated until the stool can be cultured.

A After meconium stools, the newborn's stool changes in color and consistency. This is a transitional stool and is green. It might look like diarrhea. This does not indicate that the baby is developing an allergy to breast milk or that the child needs to be isolated until the stool can be cultured.

A nurse should recognize that which laboratory result would be most consistent with a diagnosis of diabetes mellitus? A. proteinuria B. a fasting blood glucose less than 126 mg/dl C. a fasting blood glucose greater than 126 mg/dl D. glucose in the urine

C A fasting blood glucose greater than 126 mg/dl is diagnostic for diabetes mellitus.

Some children with iron-deficiency anemia may be prescribed iron dextran by injection. This should be injected: A. intradermally. B. subcutaneously. C. intramuscularly. D. via Z-track technique

D Iron dextran stains the skin unless it is given by a technique that does not allow it to flow back into the superficial skin.

A new mother asks the nurse, "Are there any medicines that I can or cannot take since I'm breastfeeding?" Which response by the nurse would be best? A. "Always check with your provider because almost all drugs are excreted to some extent in breast milk." B. "You can take medicines but stop breastfeeding for 1 week after taking it." C. "It shouldn't be a problem if you take any common over-the-counter medicines." D. "You need to stay away from any opioid pain medicines and sedatives while breastfeeding."

A Almost any drug may cross into the acinar cells and be secreted in breast milk. As a general rule, the mother should take no drug unless prescribed or approved by her primary care provider while breastfeeding. Halting breastfeeding could impact the mother's ability to continue at a later time.

A child with attention deficit hyperactivity disorder (ADHD) is prescribed methylphenidate hydrochloride. What should the nurse instruct the parents regarding an adverse effect of this medication? A. Anorexia B. Sleepiness C. Garbled speech D. Rapid increase in height

A An adverse effect of methylphenidate hydrochloride is anorexia. Sleepiness and garbled speech are not adverse effects of this medication. Children taking this medication can develop growth suppression and not accelerated growth in height.

A client is admitted with a diagnosis of ruptured ectopic pregnancy. For what should the nurse anticipate preparing the client? A. immediate surgery B. internal uterine monitoring C. bed rest for the next 4 weeks D. intravenous administration of a tocolytic

A An ectopic pregnancy is one in which implantation occurred outside the uterine cavity, usually within the fallopian tube. As the embryo grows, the fallopian tube can rupture. The therapy for ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or repair the damaged fallopian tube. There is no reason to begin uterine monitoring. The client does not need to be on bed rest for 4 weeks. A tocolytic is not needed because the client is not in labor.

A 7-year-old child has taken money from a sibling's dresser on two occasions. When counseling the parent about this behavior, what would the nurse advise? A. "You may need to remind your child about property rights." B. "You should buy your other child a bank that cannot be opened." C. "Stealing is unusual for a 7-year-old child." D. You should talk to the child's teacher about putting less pressure on your child."

A Antisocial behaviors develop during the school-age years. Between the ages of 6 and 8 years, the child has difficulty understanding the concept of ownership and property rights. At this age, children often take things because they like the look of an item. By age 9, children learn to respect other's possessions and property. Buying a more secure bank may keep the child from taking the money, but it does not take into consideration the child's developmental level. The behavior is a developmental issue and not an emotional issue of having too much pressure.

An 8-year-old child is being treated for tonic-clonic seizures. What should the nurse emphasize when teaching the parents about this disorder? A. The child should maintain an active lifestyle. B. Immediately provide medication if a seizure begins. C. Have the child carry a padded tongue blade with her at all times. D. Ensure quiet time late in the day, when seizure activity is most likely to occur.

A As a rule, children with seizures should attend regular school and participate in physical education classes and active sports. Antiseizure medication is ineffective during a seizure because most medication needs to achieve a therapeutic level to be effective. Padded tongue blades are not used in people with a seizure disorder. There is no specific time of day when a seizure can occur.

The nurse notices that a newborn has a white discharge from his breasts. The nurse would explain to his parents that this is: A. caused by his mother's hormones. B. a suggestion he may need chromosomal studies. C. a sign that he has a pituitary tumor. D. caused by exposure to cool air.

A Both male and female newborns may have a milky breast discharge from being under the influence of female hormones in utero.

A client who is in labor in planning to breastfeed the newborn. The client asks the nurse, "I an really excited to breastfeed my newborn. When can I do it?" Which response by the nurse is appropriate? A. "You can breastfeed within 1 hour of your newborn's birth." B. "You can start once the newborn has been allowed to rest." C. "For the first 24 hours, your newborn will get water and then you can breastfeed." D. "Breastfeeding can start after your newborn has had one feeding of formula."

A Breastfeeding should begin as soon after birth as possible, within 1 hour of birth, ideally while the parent is still in the birthing room and while the newborn is in the first reactivity period. Breastfeeding should not wait until after the newborn rests. Twenty-four hours is too long to wait to begin breastfeeding. Mixing breastfeeding and formula feeding is not recommended.

The nurse is making a follow-up visit to the home of a family with a baby newly diagnosed with cystic fibrosis. Which outcome indicates that the parents are adjusting to the child's care needs? A. Baby has gained weight. B. Baby's foul-smelling stool. C. Baby produces large stool twice a day. D. Baby appears flushed and is warm to touch.

A Children with cystic fibrosis need pancreatic enzyme replacements to help absorb nutrients. The baby gaining weight indicates that these supplements are effective. Foul-smelling stool indicates that additional intervention is needed because fat is not being absorbed. Large stools indicate that nutrients are not being adequately absorbed. Flushing and warmth could indicate a fever or that the home environment is too warm for the child. If children with cystic fibrosis become overheated, they begin to lose excessive sodium and chloride through perspiration and become dehydrated.

The nurse is planning care for a school-age child diagnosed with growth hormone deficiency. Which diagnosis should the nurse select to help the child with this health problem? A. Risk for situational low self-esteem related to short stature B. Ineffective tissue perfusion related to infantile blood vessels C. Impaired skin integrity related to overproduction of melanin D. Risk for self-directed violence related to oversecretion of epinephrine

A Children with short stature tend to report feeling of lower quality of life largely related to discrimination. The nurse may need to remind parents to assign duties and responsibilities to children that match their chronologic age, not their physical size, in order to promote children's feelings of maturity and self-esteem. A child that differs in any way from peers may be the victim of bullying. The nurse should alert the parent to this possibility and assess for this at well-child visits to help protect the child's quality of life. Tissue perfusion is not affected by this disorder. This disorder does not cause impaired skin integrity. There is no overproduction of epinephrine with this disorder.

The nurse sees a school-aged child in an ambulatory setting because of rheumatic fever. Which of the following would the nurse expect to find revealed by the health history? A. knee pain, abdominal rash, subcutaneous nodules B. an elevated temperature, back pain, loss of hair C. fatigue, slow pulse, frequent urination D. loss of weight, abdominal pain, chest pain

A Classic signs of rheumatic fever are joint pain, a rash on the trunk, and subcutaneous nodules near major joints.

The nurse is preparing an education session on the 2030 National Health Goals to prevent complications of pregnancy. What should the nurse include as the best preventive measure to eliminate complications of pregnancy? A. Encourage all pregnant clients to have prenatal care. B. Suggest all pregnant clients keep weight gain to a minimum. C. Recommend all pregnant clients engage in exercise most days of the week. D. Counsel all pregnant clients to select low-fat dairy products rich in calcium.

A Encouraging all women to come for prenatal care is the best preventive measure for eliminating complications of pregnancy. Weight gain, exercise, and calcium intake are not identified as specific measures to prevent complications of pregnancy.

The nurse is caring for a school-aged child newly diagnosed with type 1 diabetes mellitus. Which nursing action supports the 2030 National Health Goals to reduce the long-term complications from this disease process? A. Schedule the child and parents to attend diabetes education classes. B. Explain how the child's physical abilities will be affected during school. C. Recommend homeschooling so the mother can provide the needed medications. D. Discuss admission to a rehabilitation facility to learn self-care with this disease process.

A Endocrine disorders tend to be long-term with lifetime consequences. Reducing the incidence of consequences or improving care has long-term implications. A 2020 National Health Goal related to endocrine disorders includes increasing the proportion of persons with diabetes who receive formal diabetes education. To support this goal, the nurse should schedule the child and parents to attend diabetes education classes. There are no 2030 National Health Goals to address alteration in physical abilities, homeschooling with type 1 diabetes mellitus, or the need to be admitted to a rehabilitation facility to learn self-care.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because, with increased lung tension: A. the ductus arteriosus remains open. B. the foramen ovale closes prematurely. C. there are aortic valve strictures. D. the pulmonary artery closes.

A Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

A pregnant client late in the second trimester comes to the emergency department with a report of painless, bright red vaginal bleeding. The client states, "It started all of a sudden and now it seems to have stopped." Placenta previa is suspected. Which action should the nurse implement immediately for this client? A. Determine fetal heart sounds using an external monitor. B. Prepare the client for an immediate cesarean birth. C. Assist with insertion of internal monitoring to assess uterine pressure. D. Prepare the client for a pelvic examination to assess rupture of membranes

A For placenta previa, the nurse should attach external monitoring equipment to record fetal heart sounds and uterine contractions. Internal monitoring is contraindicated. A pelvic or rectal examination should never be done with painless bleeding late in pregnancy because any agitation of the cervix when there is a placenta previa might tear the placenta further and initiate massive hemorrhage, which could be fatal to both the pregnant client and fetus. The decision to birth the fetus depends on the point at which a diagnosis of placenta previa is made and the age of the gestation. If labor has begun, bleeding is continuing, or the fetus is being compromised (measured by the response of the fetal heart rate to contractions), birth must be accomplished regardless of gestational age. If the bleeding has stopped, the fetal heart sounds are of good quality, pregnant client vital signs are good, and the fetus is not yet 36 weeks of age, a client is usually managed by expectant watching.

The nurse is caring for a hospitalized 10-year-old client. Which nursing action is most appropriate? A. Consistently reinforce the child's self-worth. B. Discourage the child from assisting with dressing change. C. Correct each of the child's mistakes to ensure learning. D. Structure a competitive environment between clients.

A Helping school-aged clients experience satisfaction in projects, social activities, family life, and school helps them gain a sense of industry. Reinforcing self-worth provides this satisfaction. The child should not be discouraged from participating in his or her care. The child's mistakes may need corrected to learn; however, the child has to be allowed to make mistakes in a safe environment to promote learning. Pointing out these mistakes needs to be done with care. Competition between clients will not facilitate growth and development or psychosocial development.

The nurse is caring for a child who has just received a cast for a brokenwrist. The parents ask, "Why do we need to keep the arm up on a pillow?" Which response by the nurse is appropriate? A. "Keeping the arm raised helps to lessen the swelling." B. "Using a pillow helps to promote healing." C. "There is less chance of infection when the arm is kept elevated." D. "Positioning the arm like upward helps to make sure the bones stay aligned."

A If an extremity has been casted, the client should keep it elevated witha pillow to prevent edema in the fractured area. Elevating a casted extremity does not promote healing or discourage infection. The cast will ensure proper bone alignment.

The nurse is assessing a school-aged child with sickle-cell anemia. Which assessment finding is consistent with this child's diagnosis? A. Slightly yellow sclera B. Enlarged mandibular growth C. Increased growth of long bones D. Depigmented areas on the abdomen

A In sickle-cell anemia, eye scleras become icteric or yellowed from the release of bilirubin from the destruction of the sickled cells. Mandibular and long bone growth and depigmentation are not manifestations of this health problem.

To prevent further sickle cell crisis, the nurse would advise the parents of a child with sickle cell anemia to: A. notify a health care provider if the child develops an upper respiratory infection. B. prevent the child from drinking an excess amount of fluids per day. C. encourage the child to participate in school activities, such as long-distance running. D. administer an iron supplement daily.

A Infections caused by the Streptococcus pneumoniae can be lethal to a child with sickle cell, because they can cause overwhelming sepsis or meningitis. By 2 months of age the child should be started on Penicillin V as prophylaxis against pneumococcal infections. The child should receive the 7 valent pneumococcal series in infancy. After 2 years of age the child should receive the 23 valent pneumococcal vaccine. He or she should also be immunized against meningitis. Participating in strenuous activities such as running and limiting the amount of fluids leads to a reduction of oxygen and dehydration. This can lead to the increased sickling of cells. The anemia of sickle cell disease is not the result of iron deficiency. It is the result of the abnormal shape of the red blood cell. Administering iron will not correct the anemia.

A nurse is teaching new parents about caring for their newborn's umbilical cord. The nurse determines that the teaching was successful based on which statement made by the parents? A. "It is important that we keep the area dry." B. "We need to keep the area covered with dry gauze." C. "The best thing to do is wash it often with soap and water." D. "Once a day, we apply a small amount of petroleum jelly."

A It is important to remind the parents to continue to keep the cord dry until it falls off. Until the cord falls off, they should fold diapers below the level of the umbilical cord, so that when the diaper becomes wet, the cord does not become wet also. The nurse should not teach the parents to cover the umbilical cord with dry gauze, wash it with soap and water, or apply petroleum jelly to the site.

The nurse is caring for a large-for-gestational-age infant born to a client with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant? A. to detect rebound hypoglycemia B. to determine insulin dosage to administer C. to explain the effects of maternal hyperglycemia on the baby D. to estimate the amount of calories to provide the infant through formula

A Large-for-gestational age infants need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes that was poorly controlled, the infant would have had an increased blood glucose level in utero to match the mother's glucose level; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia. Frequent blood glucose monitoring in large-for-gestational-age infants is not done to determine insulin dosage, to explain the effects of maternal hyperglycemia on the baby, or to estimate the amount of calories to provide the infant through formula.

On physical examination, the nurse discovers that a 6-year-old child's palatine tonsils are somewhat enlarged in the back of the throat. What would be the nurse's best action? A. Record this as a normal finding in an early school-age child. B. Suggest the health care provider examine the child for breathing difficulty. C. Take the child's temperature; this must be tonsillitis. D. Give the child something for pain

A Lymphoid tissue reaches maximum growth in early school-aged children. The tonsils may decrease in size somewhat from the preschool years but they remain larger than those of adolescents. The tonsils and adenoids may appear larger than normal even in the absence of infection. The nurse would be correct to document this as a normal finding. The child would not need pain medication nor an examination for respiratory problems if this a normal finding.

The nurse is evaluating care provided to a client in the third trimester of pregnancy who has been diagnosed with gestational hypertension. Which finding indicates that treatment has been successful for this client? A. urine protein 0 B. increased perspiration C. weight gain of 1 lb/week D. diastolic blood pressure 20 mm Hg over normal level

A Manifestations of gestational hypertension include elevated blood pressure, edema, and proteinuria. Absence of protein in the urine indicates that treatment has been successful. Increased perspiration is not a manifestation of gestational hypertension. A weight gain of 1 lb/week in the client who is in the third trimester of pregnancy is an indication of ongoing edema. A diastolic blood pressure that is 20 mm Hg over normal level is an indication of ongoing hypertension

Which of the following correctly identifies the daily caloric requirement per pound fora newborn? A. 50 to 55 B. 100 to 120 C. 150 to 170 D. 200 to 225

A Newborns have rapid metabolisms and need proportionally more calories per pound than adults.

A 9-year-old girl tells the nurse about belonging to a girls' social media club. How does belonging to this group support the child's development? A. fulfills peer group needs B. teaches the child leadership skills C. helps the child develop autonomy D. encourages the child to learn rules

A Nine-year-olds take the values of their peer group very seriously. This is typically the friend or club age because children form groups. This type of club does not teach the child leadership skills, develop autonomy, or learn rules.

A 10-year-old child spends 2 hours alone every afternoon before the parents arrive home from work. Which safety measure should the nurse suggest the parents teach the child? A. preparing a no-cook snack after school B. lighting candles in case there is a power failure C. wearing the house key prominently around the neck D. telling people at school about being home alone for added safety

A Parents should plan after-school snacks for the child who does not require cooking to prevent burns. Lighting candles could be a fire hazard if they are left unattended. Wearing the house key around the neck could indicate that the child will be home alone. Telling people at school about being home alone could encourage a break-in or other action against the child.

A school-age child comes into the emergency clinic complaining of knee pain that started while playing soccer. What will the nurse most likely observe when assessing this child's knee? A. edema B. erythema C. contusions D. mottled skin

A Participation in sports such as soccer is a frequent cause of knee injuries in children and usually involves the ligaments surrounding the knee. Immediately after the injury, the child reports severe pain in the knee, and localized edema becomes evident. Erythema, contusions, and mottled skin are not associated with a knee injury caused by participation in a sport.

A pregnant client with a history of premature cervical dilatation undergoes cervical cerclage. Which outcome indicates that this procedure has been successful? A. The client delivers a full-term fetus at 39 weeks' gestation. B. The client's membranes spontaneously rupture at week 30 of gestation. C. The client experiences minimal vaginal bleeding throughout the pregnancy. D. The client has reduced shortness of breath and abdominal pain during the pregnancy.

A Premature cervical dilatation is when the cervix dilates prematurely and cannot retain a fetus until term. After the loss of one child because of premature cervical dilatation, a surgical operation termed cervical cerclage can be performed to prevent this from happening in a second pregnancy. This procedure is the use of purse-string sutures placed in the cervix to strengthen the cervix and prevent it from dilating until the end of pregnancy. Evidence that this procedure is effective would be the client delivering a full-term fetus at 39 weeks' gestation. Spontaneous rupture of the membranes could indicate that the procedure was not successful. Vaginal bleeding could indicate another health problem or that the procedure was not successful. This procedure does not impact the client's respirations or amount of abdominal pain while pregnant. These manifestations could indicate another health problem with the pregnancy.

The nurse instructs the parents of a newborn on actions to prevent sudden infant death syndrome (SIDS). Which observation indicates that teaching has been effective? A. The newborn is placed on the back to sleep. B. The mother removes a pacifier from the baby's mouth. C. The baby is on an every-2-hour formula-feeding schedule. D. The parents signed a waiver refusing routine immunizations after birth.

A Putting newborns to sleep on the back has decreased the incidence of SIDS by 50% to 60%. Other recommendations to decrease SIDS include using a pacifier, breastfeeding, and having routine immunizations. Removing the pacifier, bottle feeding, and refusing routine immunizations after birth all increase the infant's risk for experiencing SIDS.

While planning care for a 7-year-old client, the nurse reminds the parents that childrenat this age are experiencing the "eraser" year. What does this mean? A. The child wants to perform well. B. The child believes in magical thinking. C. The child is learning to write during this year. D. The child tends to "erase" misdeeds or lie excessively

A Seven-year-olds concentrate on fine motor skills, and this year has been called the "eraser" year because children are never quite content with what they have done. They set too high a standard for themselves and then have difficulty performing at that level. Toddlers believe in magical thinking. The child has already learned how to write. The eraser year does not mean that the child is erasing misdeeds or lying.

The nurse is preparing teaching materials for a family whose child is prescribed somatropin for a growth hormone deficiency. What should the nurse instruct the parents about the administration of this medication? A. This medication must be given by injection. B. This medication must be given in the morning before school. C. Hip or knee pain is an expected adverse effect of this medication. D. This medication does not interact with any other types of medication.

A Somatropin is administered by injection. It is best given at the hour of sleep because that is when growth hormone is released. Hip or knee pain could indicate a slipped capital epiphysis and should be reported to the health care provider. The nurse should urge the parents to inform all health care providers that the child is receiving this medication to avoid medication interactions.

A 7-year-old child is diagnosed as having type 1 diabetes. What is one of the first symptoms usually noticed by parents when this illness develops? A. loss of weight B. craving for sweets C. severe itching D. swelling of soft tissue

A The classic signs of type 1 diabetes are polydipsia, polyuria, and polyphagia. With polyphagia, the child has an increased appetite and increased hunger, and the child eats all the time but is losing weight. This occurs because the lack of energy sugar supplies causes the muscle tissues and the fat stores to shrink. The lack of insulin also reduces the ability of the body's cells to use glucose. This leads to starvation of the cells. Loss of weight is an early symptom parents see first. They tend to equate the increased appetite as normal with growing, but become concerned when the child starts losing weight even though the child is eating. Itching and swelling are not signs of diabetes. A craving for sweets is normal for a child, especially one who is growing rapidly.

After completing a physical assessment of a newborn, the nurse notifies the healthcare provider about which finding? A. scaphoid abdomen B. absence of bleeding at the base of the umbilical cord C. bowel sounds present at two-to-three per minute D. liver palpable 2 cm under the right costal margin

A The contour of a newborn abdomen looks slightly protuberant. A scaphoid or sunken appearance suggests missing abdominal contents or a diaphragmatic hernia (bowel or other abdominal organs positioned in the chest instead of the abdomen). Bowel sounds show the bowel is beginning peristalsis and should be present within 1 hour after birth. On the right side, the edge of the liver is usually palpable 1 to 2 cm below the costal margin. There should be no bleeding at the base of the cord and it should not appear wet.

A mother is concerned that a school-age child will pick up the habit of smoking because so many children in the school smoke. What should the nurse instruct the mother about this behavior? A. Be a role model and do not smoke. B. Remind the child that smoking costs money. C. Discuss other tobacco choices that can be used instead. D. Explain that the child can experiment with smoking when older.

A To discourage the use of tobacco by school-age children, parents need to be role models of excellent nonsmoking health behavior in hopes children will follow their good example. Explaining that smoking costs money might not make an impact on a school-age child's decision to start smoking. Discussing other tobacco choices is inappropriate because smokeless tobacco also has associated health risks. The child should be encouraged to refrain from smoking throughout life.

A client with type 2 diabetes mellitus is planning to become pregnant within the next several months. What should the nurse instruct the client to support the 2020 National Health Goals of reducing the complications of pregnancy from diabetes? A. Avoid episodes of hyperglycemia. B. Reduce the current exercise regimen by half. C. Limit the intake of carbohydrates and fats in the diet. D. Reduce the use of insulin for blood glucose coverage.

A To support the 2020 National Health Goals, the nurse should instruct the client to enter pregnancy without hyperglycemia. This action helps reduce congenital anomalies in newborns. Reducing exercise, limiting carbohydrates and fats, and reducing the use of insulin for blood glucose coverage does not support the 2020 National Health Goals to reduce the complications of pregnancy associated with diabetes.

A gravida 2 para 1 client in preterm labor was administered terbutaline sulfate to stop the progression of labor and then discharged. What should the nurse teach the client to help prevent the reoccurrence of preterm labor? Select all that apply. A. Drink 8 to 10 glasses of fluid each day. B. Report any signs of ruptured membranes. C. Remain on bed rest except to use the bathroom. D. Lie flat on the back should uterine contractions occur. E. Engage in mild activities of daily living with frequent rest periods.

A, B, C To reduce the onset of preterm labor, the nurse should instruct the client to drink 8 to 10 glasses of fluid each day to remain hydrated. The client should also report any signs of ruptured membranes and remain on bed rest unless using the bathroom. Should uterine contractions begin, the client should be instructed to lie on either the right or left side to increase blood return to the uterus. The client should not engage in any activity other than bed rest with bathroom privileges.

The nurse is instructing the parents of a preterm infant about the care the infant will receive within the neonatal intensive care unit. What should the nurse include whenteaching the parents at this time? Select all that apply. A. Bring in a small toy to be placed in the baby's bassinette. B. Coordinate the times to visit the baby with the primary nurse. C. Ask the nurse to explain the equipment and the purpose for their use. D. Write down the name of the baby's primary nurse and primary care provider. E. Limit telephone calls to the care area since the nurses will not be able to respond.

A, B, C, D When teaching parents of a newborn in the intensive care unit, the nurse should encourage the parents to bring in a small toy to be placed in the baby's bassinette. The parents should also coordinate the times to visit the baby with the primary nurse so that quality time will be available. The parents should be reminded to ask questions about equipment being used for the baby's care. The name of the primary nurse and primary care provider should be recorded in case the parents have any questions. Telephone calls are encouraged and should not be limited. The parents play an active part in the care of the baby.

While providing care, the nurse suspects that a preterm infant is developing respiratory distress. What did the nurse most likely assess in this client? Select all that apply. A. grunting B. nasal flaring C. intercostal retractions D. oxygen saturation 96% E. increasing respiratory rate

A, B, C, E A steadily increasing respiratory rate, grunting, and nasal flaring are often the first signs of obstruction or respiratory compromise in newborns. If these are present, undress the baby's chest and look for intercostal retractions, which reflect the degree of difficulty the newborn is having in drawing in air. Oxygen saturation of 96% is within normal limits and does not indicate respiratory distress.

The nurse is planning developmental care for a preterm infant in the neonatal intensive care unit. Which interventions should the nurse include in this client's plan of care? Select all that apply. A. Provide audio stimulation with the use of music. B. Stop procedures if the infant shows signs of distress. C. Provide a nest with blankets to provide a sense of security. D. Provide tactile stimulation by tickling the bottom of the feet. E. Provide care consistently so the infant develops sleep/wake cycles.

A, B, C, E Developmental care for a preterm infant in the neonatal intensive care unit should include audio stimulation, stop procedures at signs of distress, provide a nest of blankets for security, and provide consistent care so sleep/wake cycles develop. Tactile stimulation should be provided by gentle back rubbing or massage. Tickling the feet would be too harsh for this young client.

The nurse manager of a labor and delivery unit is reviewing the skill set needed for the nursing staff to meet the 2020 National Health Goals regarding preterm births. Which skills should the manager validate that the nursing staff has to meet these goals? Select all that apply. A. resuscitation at birth B. actions to prevent apnea C. identify characteristics of preterm labor D. actions to prevent maternal hypotension E. interventions to prevent intraventricular hemorrhage

A, B, C, E Nurses can help the nation achieve the 2020 National Health Goals for preterm births by teaching women the symptoms of preterm labor so that birth can be delayed until infants reach term. Nurses also need to be prepared for resuscitation at birth of high-risk infants and to plan developmental care that can help prevent conditions such as apnea and intraventricular hemorrhage. Actions to prevent maternal hypotension would not help achieve the 2020 National Health Goals for preterm labor.

The nurse is evaluating a new mother's ability to breastfeed her infant. Which criteria indicate that the mother is able to breastfeed independently? Select all that apply. A. Nipples are everted. B. Breasts are soft and nontender. C. Mother holds the nipple in the baby's mouth. D. Baby swallows spontaneously and frequently. E. Nurse places pillows under the baby for support.

A, B, D The LATCH breastfeeding charting system is used to measure a mother's ability to breastfeed independently. Criteria that indicate the mother can breastfeed independently include everted nipples, breasts are soft and nontender, and the baby swallows spontaneously and frequently. The mother having to hold the nipple in the baby's mouth and the nurse assisting with positioning indicate the mother is not independent in breastfeeding.

The nurse is instructing the mother of a school-age child with a leg cast about cast care at home. What should the nurse include in this teaching? Select all that apply. A. Cover the cast with a plastic bag to bathe. B. Remind the mother that nothing is to be put down the cast. C. Recommend using magic markers for autographs. D. Use the cool setting on a hair dryer to ease itchy skin. E. Encourage usual activities but restrict strenuous actions.

A, B, D, E When teaching the mother about cast care at home, the nurse should include covering the cast with a plastic bag while bathing so the cast does not get wet; not placing anything down the cast; using the cool setting on a hair dryer to ease itching; and encourage usual activities but reducing strenuous activities while the cast is in place. Magic markers should not be used for autographs because the ink can seep into the cast material.

A parent of a child diagnosed with seizures states, "I've heard about a special diet that may control seizures, I think it's called ketogenic. What can you tell me about it?" Which are appropriate responses by the nurse? Select all that apply. A. "About 40% to 50% of children who follow the diet have really good results." B. "The diet consists of high fat foods." C. "Children are encouraged to eat a lot of breads and pasta on this diet." D. "Most families find this diet is easy to incorporate into their life." E. "Protein is limited in this diet."

A, B, E A ketogenic diet has been proven highly effective in 40% to 50% of the children who are started on it. The diet is high fat and low carbohydrate and protein. Bread and pasta are typically high in carbohydrates which are limited in this diet. This diet can be difficult for families to adhere to and incorporate into their lifestyle.

The nurse is caring for a school-age child recovering from an open reduction for a fractured femur. Which assessment findings indicate that the child is developing an infection? Select all that apply. A. lethargy B. increased pulse rate C. reduced pulse in the ankle D. cyanosis of the casted foot E. increased body temperature

A, B, E Children with an open reduction are prone to infection. The nurse should suspect an infection if the systemic symptoms of increased pulse, increased temperature, and lethargy are present. Reduced pulse in the ankle and cyanosis of the casted foot are manifestations of compartment syndrome.

A preterm infant in the neonatal intensive care unit is receiving care for inadaquate fluid balance. What did the nurse assess that supports this nursing diagnosis? Select all that apply. A. specific gravity of 1.022 B. respiratory rate of 40 breaths/min C. urine output less than 2 ml/kg/hr D. heart rate of 135 beats/min E. abdominal skin temperature of 96.9°F

A, C An output less than 2 ml/kg/hr or a specific gravity greater than 1.015 to 1.020 suggests inadequate fluid intake. Respiratory rate of 40 breaths/min, heart rate of 135 beats/min, and abdominal skin temperature of 96.9°F are all within normal limits and do not suggest inadequate fluid balance.

The nurse is concerned that a pregnant client is developing polyhydramnios. What did the nurse assess in this client? Select all that apply. A. tense uterus B. sudden weight loss C. extreme shortness of breath D. difficulty hearing fetal heart rate E. uterus larger than expected for gestation week

A, C, D, E Polyhydramnios is an excessive amount of amniotic fluid. The first sign of this disorder may be a rapid enlargement of the uterus. The uterus becomes tense, and the client experiences shortness of breath because of the uterus pressing on the diaphragm. Auscultating the fetal heart rate can be difficult because of depth of the increased amount of fluid surrounding the fetus. The uterus will be larger than expected for the client's gestational week.

The nurse is planning to instruct a new mother on care of the newborn. Which instructions support the 2030 National Health Goals for the newborn? Select all that apply. A. Place the infant on the back to sleep. B. Wash the baby's hair at least once a week. C. Continue to breast-feed the baby until age 6 months. D. Bath the baby from the most soiled to the cleanest areas. E. Do not provide the baby with a bottle while falling asleep.

A, C, E Nurses can help achieve 2030 National Health Goals by encouraging mothers to continue breastfeeding through the first 6 months of life. The mother should be instructed to place the infants on the back to sleep and on the danger of tooth decay from allowing a baby to drink from a bottle of milk or juice while falling asleep. Bathing should be from the most clean to the most soiled and hair should be washed daily. Bathing and hair washing do not impact the achievement of the 2020 National Health Goals.

A school-age child is brought to the emergency department after being hit in the mouth with a baseball bat during Little League. The child has lost two deciduous teeth, and one permanent front tooth is loose. What care should the nurse prepare to provide to this client? Select all that apply. A. Administer prescribed oral antibiotic. B. Wash the deciduous teeth with saline to be wired into place. C. Instruct the parents and the child that the jaw will need to be wired shut. D. Explain that an X-ray may be done to make sure that the jaw was not fractured. E. Explain that a chest X-ray will be done to make sure that other teeth are not in the lungs.

A, D With dental fractures, deciduous teeth may not be replaced. If the blow to the teeth was extensive, an X-ray may be done to ensure that the upper orlower jaw is not fractured. The client will be prescribed an oral antibiotic. The jaw does not need to be wired shut unless it is fractured. A chest X-ray would be done if the missing teeth are unaccountable.

A nurse is caring for a newborn born 36 hours ago to a pregnant client participating in a methadone maintenance program. The nurse determines the newborn is experiencing withdrawal based on which assessment finding(s)? Select all that apply. A. irritability B. weak, mild crying C. bradypnea D. frequent sneezing E. clonus

A, D, E Signs and symptoms of withdrawal in the newborn include irritability; disturbed sleep pattern; constant movement, possibly leading to abrasions on the elbows, knees, or nose; tremors; frequent sneezing; shrill, high-pitched cry (not a weak, mild cry); hyperreflexia and clonus (neuromuscular irritability); convulsions; tachypnea/rapid respirations (not bradypnea), possibly so severe that it leads to hyperventilation and alkalosis; and vomiting and diarrhea, leading to large fluid losses and secondary dehydration.

A nurse is planning the care for a newborn delivered vaginally about 90 minutes ago. The medical record of the pregnant client and newborn reveals the following: -Pregnant client: type 1 diabetes -Fetus: cephalic presentation -Vaginal delivery at 38.4 weeks' gestation -Rupture of membranes at 35 weeks' gestation -Newborn's Apgar score 5 at 1 minute, 6 at 5 minutes -Amniotic fluid: positive for meconium The nurse determines that the newborn is at risk for respiratory problems based on which finding in the medical record? Select all that apply. A. pregnant client's history of diabetes B. fetal presentation C. gestational age at birth D. timing of membrane rupture E. Apgar score F. amniotic fluid appearance

A, D, E, F For this newborn, predisposing factors include the pregnant client's history of diabetes, premature rupture of membranes (roughly 3 weeks prior to birth), the newborn's Apgar score, and meconium in the amniotic fluid. Other factors include low birth weight, intrauterine growth restriction, pregnant client's use of barbiturates or opioids close to birth, irregularities detected by fetal heart monitor during labor, cord prolapse, postmaturity (postterm), small for gestational age, breech birth, multiple birth, and anomalies of the chest, heart, or respiratory tract.

A primigravid at 35 weeks' gestation arrives at the emergency department unsure if her membranes have ruptured. The nurse tests the client's fluid from the vagina with nitrazine paper. The paper turns blue. The nonstress test reveals a heart rate of 142 beats/minute and good variability. Occasional contractions are noted. What will the nurse include in the discharge teaching? Select all that apply. A. "Avoid douching until after the birth." B. "You may resume sex as desired." C. "Take a tub bath at least once per day." D. "Return to your normal teaching duties and rest at lunchtime." E. "Measure oral temperature twice per day and report any elevation."

A, E When the nitrazine paper turns blue, it indicates a rupture of membranes. Many times labor will occur shortly afterward. When that does not occur, the client with preterm rupture of membranes is at risk for developing an infection. The nurse should instruct the client to avoid douching and measure oral temperature twice per day. Sex and tub baths should be avoided because these could introduce an infection into the uterus. Activities that require the client to be on her feet for hours at a time, such as classroom teaching, are not suggested.

A preterm infant is transferred to a distant hospital for care. When her parents visit her, which action would be most important for the nurse to urge them to do? A. Call the baby by her name. B. Touch and, if possible, hold her. C. Stand so the baby can see them. D. Bring a piece of clothing for her.

B Preterm infants may be hospitalized for an extended time, so parents need to be encouraged to touch and interact with the infant to begin bonding.

Which nursing diagnosis would best apply to a child with rheumatic fever? A. Ineffective breathing pattern related to cardiomegaly B. Activity intolerance related to inability of heart to sustain extraworkload C. Disturbed sleep pattern related to hyperexcitability D. Risk for self-directed violence related to development of cerebral anoxia

B Acute rheumatic fever affects the joints, central nervous system, skin, and soft tissue. It causes chronic, progressive damage to the heart and valves. Children with rheumatic fever need to reduce activity to relieve stress on the heart and joints during the course of the illness. Rheumatic fever does not produce cardiomegaly nor does it interfere with respirations or the ability to oxygenate the body. Children with rheumatic fever may develop chorea. These movements are involuntary and are not related to hyperexcitability

The nurse suspects that a child is demonstrating signs of attention deficit hyperactivity disorder (ADHD). What behavior did the nurse most likely assess in this child? A. Unrealistic fears B. A lack of concentration C. Persistent disobedience D. A lack of affection for others

B Attention deficit hyperactivity disorder (ADHD) is characterized by three major behaviors: inattention, impulsiveness, and hyperactivity. Inattention or a lack of concentration makes children become easily distracted and often may not seem to listen or complete tasks effectively. Unrealistic fears, persistent disobedience, and a lack of affection for others are not characteristics of ADHD.

A woman who is Rh negative asks the nurse how many children she will be able to have before Rh incompatibility causes them to die in utero. The nurse's best response would be that: A. no more than three children is recommended. B. as long as she receives Rho(D) immune globulin, there is no limit. C. only her next child will be affected. D. she will have to ask her primary care provider.

B Because Rho(D) immune globulin supplies passive antibodies, it prevents the woman from forming antibodies. Without antibodies that could affect the fetus, the woman could have as many children as she wants.

Which of the following is an advantage of breastfeeding for the infant? A. Breast milk is more difficult to digest, so it makes the infant feel fuller longer. B. Breast milk contains antibodies and thus decreases the possibility of gastrointestinal illnesses. C. It takes less effort for an infant to suck at a breast than from a bottle. D. Breast milk leads to firmer stools, increasing bowel tone.

B Breast milk contains antibodies that are instrumental in reducing gastrointestinal infections.

Which of the following statements is true about breastfeeding? A. Breastfeeding increases the risk of breast cancer. B. Breastfeeding offers a good chance for bonding with the infant. C. Uterine involution is slowed by breastfeeding. D. Breastfeeding mothers have a decreased risk of developing thrombophlebitis.

B Breastfeeding reduces the risk of breast cancer and enhances uterine involution. It provides the opportunity for mother-infant bonding.

A client with diabetes who is in the second trimester of pregnancy notes that the usual dose of insulin to maintain blood glucose levels has been increasing over the last few weeks. What should the nurse explain to the client about insulin during pregnancy? A. The fetus is using insulin to maintain blood glucose level in utero. B. Insulin resistance develops because of human placental lactogen hormone and other hormones. C. An increase in circulating blood volume during pregnancy deactivates insulin. D. The change in diet causes an increased need for insulin to maintain blood glucose levels.

B Clients with diabetes who become pregnant develop insulin resistance as the pregnancy progresses or the insulin does not seem as effective during pregnancy. This phenomenon is believed to be caused by the presence of the hormone human placental lactogen and high levels of cortisol, estrogen, progesterone, and catecholamines. The increased need for insulin is not because of the fetus using insulin to maintain blood glucose level in utero. The client's increased circulating blood volume is not deactivating insulin. The client's change in diet might necessitate an adjustment in insulin dosage, but this would vary according to blood

The nurse is teaching a child with type 1 diabetes mellitus to administer insulin. The child is receiving a combination of short-acting and long-acting insulin. The nurse knows that the child has appropriately learned the technique when the child: A. administers the insulin into a doll at a 30-degree angle. B. draws up the short-acting insulin into the syringe first. C. wipes off the needle with an alcohol swab. D. administers the insulin intramuscularly into rotating sites

B Drawing up the short-acting insulin first prevents mixing a long-acting form into the vial of short-acting insulin. This maintains the short-acting insulin for an emergency. Insulin is given subcutaneously not intramuscularly. A SQ injection is administered at a 90-degree angle if the person can grasp 2 in (5 cm) of skin. If only 1 in (2.5 cm) of skin can be grasped, then the injection should be given at a 45 degree angle. The needle is sterile. It should not be wiped with an alcohol swab. Only the top of the insulin vial should be wiped with an alcohol swab.

The nurse is caring for a child with a broken wrist that has just been placed in a cast.The nurse would elevate the arm to: A. promote healing. B. prevent edema. C. discourage infection. D. ensure proper bone alignment.

B Edema tends to be dependent. Elevating the arm, therefore, would reduce swelling from the injury. Elevation of the arm would not promote healing or discourage infection. The cast will maintain proper bone alignment.

A common symptom that would alert the nurse that a preterm infant isdeveloping respiratory distress syndrome is: A. inspiratory stridor. B. expiratory grunting. C. expiratory wheezing. D. inspiratory "crowing."

B Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).

The nurse is caring for a 10-year-old child with growth hormone (GH) deficiency. Which therapy would you anticipate will be prescribed for the child? A. Short-term aldosterone provocation B. Injections of GH C. Oral administration of somatotropin D. Long-term blocking of beta cells

B Growth hormone (GH) deficiency occurs when the anterior pituitary is unable to produce enough hormone for usual growth. Somatotropin is the name of the growth hormone administered. Administering subcutaneous GH to the child helps correct this deficiency. The GH dosage is 0.2 to 0.3 mg/kg given daily. It is not administered orally. Aldosterone causes sodium to be retained and a provocation would be the administration of diuretics to reduce the sodium. Beta cells are found in the heart muscles, smooth muscles, airways, and arteries. They are also found in the pancreas to secrete insulin. None of these cell actions are related to the anterior pituitary.

A 6-year-old child is brought to the facility by the parents who report that the child has had a fever for the past 2 days and now is reporting ear pain and pressure. The nurse conducts an otoscopic exam and suspects an inner ear infection based on which assessment finding? A. dark-brown substance lining the ear canal B. bulging tympanic membrane C. clearly discernible malleus D. presence of cone of light

B If an ear infection is present, the tympanic membrane will appear reddened and will often bulge forward so the malleus is no longer discernible and the cone of light is absent. Wax (i.e., cerumen) in the ear canals appears as a dark- brown, glistening substance or flaky amber.

A breastfeeding mother asks the nurse how long her baby should breastfeed at each breast after she is home. What would be the nurse's best answer? A. no longer than 3 minutes each feeding to prevent soreness B. The average baby empties a breast in 15 minutes. C. at least a half-hour at each breast to ensure emptying D. 1 or 2 minutes is an average time interval

B If infants continue to suck after breasts are emptied, they can cause nipple soreness; it takes about 15 minutes for an infant to empty a breast.

Which assessment finding indicates to the nurse that a newborn has hip subluxation? A. inward rotation of the right foot B. inability of the right hip to abduct C. crying on straightening of the right leg D. drawing of the legs underneath while prone

B If the hip joint seems to lock short of this distance of 180 degrees, hip subluxation is suggested. Inward rotation of the right foot, crying when straightening the leg, or drawing the legs underneath when prone does not indicate hip subluxation.

Before discharging a school-age child being treated for a snake bite, the nurse instructs the child in ways to prevent additional bites in the future. Which statement indicates that teaching provided to this child has been effective? A. "I should wear long pants when outdoors." B. "I should look at and under rocks before touching them." C. "I should stay away from going outside in case there are snakes." D. "I should bring a snake deterrent when on walks."

B In order to avoid snake bite, it is important to know common characteristics of snakes and safety rules when in an area where they are common. Common safety rules to avoid snake bites include being aware that snakes like to sit in the sun on warm rocks. They also frequently exist around rocks. The child should look at a rock before touching it to avoid touching or startling a snake.

A pregnant client is developing HELLP syndrome. During labor, which order should the nurse question? A. Assess urine output every hour. B. Prepare for epidural anesthesia. C. Position on the left side during labor. D. Assess blood pressure every 15 minutes.

B In the HELLP syndrome, clients develop low platelet counts. With a low platelet count, injections such as epidural anesthesia are contraindicated. This is the order that the nurse should question. The client's urine output should be assessed every hour because renal failure is a complication of this syndrome. Positioning on the left side during labor will help blood flow to the uterus. Assessing blood pressure every 15 minutes is appropriate for the client with this syndrome.

The nurse is discussing home safety with the parents of a 10-year-old client. Which statement by the client's parents most concerns the nurse? A. "Our child is home alone for an hour each day." B. "Our child swims alone before we get home from work." C. "Our child refuses to eat any green vegetables." D. "We do our best to keep no-cook snacks in the home."

B Latchkey children need to learn to be independent but safe. The nurse would be most concerned about the child swimming while no one else is at the home. If the child becomes endangered while swimming, there is no one there to assist. It is common for children at this age to be home alone between arriving home from school and when the parents arrive home from work. This is not an issue, as long as the child knows and follows safety rules. There are other ways the child can gain nutrition beyond green vegetables. No-cook snacks should be kept in the home as this ensures the child does not use the oven or stove to prepare a meal when hungry. This statement requires follow-up, but is not more concerning than swimming alone.

The nurse knows that being able to tell time helps a child become more independent. At which age should the nurse expect a school-age child to begin to tell time? A. 6 years old B. 7 years old C. 8 years old D. 9 years old

B Most 7-year-olds can tell the time in hours, but they may have trouble with concepts such as "half past" and "quarter to," especially with the prevalence of digital clocks. Six-yearolds still define objects by use. Eight- and nine-year-olds have moved past telling time and are interested in mastering other things.

On inspection, the nurse notes that a newborn has a normal newborn head/body proportion. This proportion for the head is: A. one-half his total length. B. one-fourth his total length. C. one-sixth his total length. D. one-eighth his total length.

B Newborn heads are large in proportion to their body, or one-fourth of their total length.

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? A. an infant whose labor began with ruptured membranes B. an infant who had difficulty establishing respirations at birth C. an infant who has marked acrocyanosis of his hands and feet D. an infant whose mother craved chocolate during pregnancy

B Newborns use a great many calories in their effort to achieve effective respirations. Infants who had difficulty establishing respirations need to be assessed for hypoglycemia.

Any individual taking phenobarbital for a seizure disorder should be taught: A. to brush his or her teeth four times a day. B. never to discontinue the drug abruptly. C. never to go swimming. D. to avoid foods containing caffeine.

B Phenobarbital should always be tapered, not stopped abruptly, or seizures from the child's dependency on the drug can result.

On an Apgar evaluation, how is reflex irritability tested? A. raising the infant's head and letting it fall back B. flicking the soles of the feet and observing the response C. dorsiflexing a foot against pressure resistance D. tightly flexing the infant's trunk and then releasing it

B Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or evaluating the response to a catheter passed into the nose.

The parents of a school-aged child with school refusal have received professional guidance by the school psychologist, pediatrician, and three different psychiatrists. Based on this, which nursing diagnosis would be most appropriate? A. Disturbed thought processes related to delusional behavior B. Compromised parental coping related to inability to assist with school fears C. Noncompliance with expected school behavior related to school phobia D. Ineffective tissue perfusion, cerebral, related to anxiety over attending school

B School refusal is a fear of attending school. Some of the behaviors of this problem include frequent absences, skipping classes, or being chronically late. School refusal may be a problem for both the parent and child. When parents have multiple professionals focusing on the same issue, there is an inability of the parent to find and apply an appropriate treatment. A child with school refusal oes not have a delusional pattern. It is a strong fear. The parents in this situation are seeking help. That does not demonstrate noncompliance. Ineffective tissue perfusion is not the cause of anxiety.

A school-aged child develops school phobia. When counseling her mother, the nurse would advise her that the accepted action is to: A. keep her child home until this fear passes. B. make her child attend school every day. C. allow her child to decide daily if she wants to go to school or not. D. ask the teacher to decide if the child should come to school or not each day.

B School refusal or phobia may result from both a parent not wanting a child to attend school and a child not wanting to leave a parent. Th nurse's role is to help them work together while keeping the child in school to resolve the issue.

What would be the physiologic basis for a placenta previa? A. a loose placental implantation B. low placental implantation C. a placenta with multiple lobes D. a uterus with a midseptum

B The cause of placenta previa is usually unknown, but for some reason the placenta is implanted low instead of high on the uterus.

After hospital discharge, the parent of a child newly diagnosed with type 1 diabetes mellitus telephones the nurse because the child is acting confused and very sleepy. Which emergency measure would the nurse suggest the parent carry out before bringing the child to see the health care provider? A. Give the child one unit of regular insulin. B. Give the child a glass of orange juice. C. Give the child nothing by mouth so that a blood sugar can be drawn at the healthcare provider's office. D. Give the child a glass of orange juice with one unit regular insulin in it.

B The child is experiencing symptoms of hypoglycemia. Administering a form of glucose would help relieve them. This can be glucose tablets or a rapidly absorbable carbohydrate such as orange juice. This should be followed by a snack of complex carbohydrates and protein within 30 to 60 minutes. Insulin cannot be absorbed when taken orally and administering insulin would make the hypoglycemia worse. Withholding treatment waiting to get to the health care provider's office may cause the hypoglycemia to worsen and be a risk to the child's life. Children with diabetes and their parents need to be taught to recognize and treat the symptoms of hypoglycemia.

A nurse is caring for a pregnant client with preeclampsia who is receiving magnesium sulfate to prevent eclampsia. The client is in labor and is receiving epidural anesthesia. When checking the client's deep tendon reflexes, which reflex is most appropriate for the nurse to assess? A. blink B. triceps C. patellar D. ankle jerk

B The easiest deep tendon reflex to assess is the patellar reflex (i.e., knee jerk). If an epidural block has been given for labor anesthesia, the nurse should assess the biceps or triceps reflex. The blink reflex is not a deep tendon reflex and would provide no information about magnesium levels. Although the ankle jerk reflex is a deep tendon reflex, it is not used in this situation.

The nurse is evaluating teaching provided to a school-age child and parents about the medication pancrelipase for cystic fibrosis. Which observation indicates that the teachinghas been effective? A. The child chews an enteric form of the medication. B. The child takes a dose before having an afternoon snack. C. The father tells the child that diarrhea is expected with this medication. D. The mother opens the capsule and some medication spills on the fingers.

B The enzyme replacement pancrelipase is used for the treatment of cystic fibrosis. Evidence that teaching has been effective is the child taking a dose of the medication before having an afternoon snack because this medication is to be taken before all meals and snacks. The enteric form of the medication should not be chewed. Diarrhea is an adverse effect of this medication and should be reported to the health care provider. This medication should not be spilled on the skin because it may irritate the skin.

A client who has just given birth to her first baby asks the nurse for help with breastfeeding. Which nursing diagnosis would be the most appropriate for the client at this time? A. powerlessness B. health-seeking behaviors C. readiness for enhanced coping D. anxiety related to breastfeeding

B The new mother is asking the nurse for help with breastfeeding, which supports the nursing diagnosis of health-seeking behaviors. The client requesting help with breastfeeding does not indicate powerlessness, readiness for enhanced coping, or anxiety related to breastfeeding.

While making a visit to the home of a family with a school-age child, the nurse observes a hunting rifle leaning against the wall in the dining room. Which nursing diagnosis should the nurse use to guide interventions for the family at this time? A. anxiety B. risk for injury C. health-seeking behaviors D. readiness for enhanced parenting

B The nursing diagnosis appropriate for this situation is risk for injury because the firearm is in the dining room. The parents need instruction about safety precautions with firearms and school-age children. There is no evidence of anxiety. The parents are not asking for health-related information. The parents are not demonstrating readiness to learn more about parenting

Hypoglycemia in a mature infant is defined as a blood glucose level belowwhich amount? A. 100 mg/100 ml whole blood B. 80 mg/100 ml whole blood C. 45 mg/100 ml whole blood D. 30 mg/100 ml whole blood

C Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 45 mg/100 ml whole blood is considered hypoglycemia.

A nurse is providing care to a 3-day-old newborn who is receiving phototherapy to treat hyperbilirubinemia. The nurse determines that the treatment is effective based on assessment of the newborn's stools appearing as which color? A. brownish-black B. green C. mustard yellow D. reddish-brown

B The stools of a newborn under bilirubin lights are often green because of the excessive bilirubin being excreted as a result of the therapy. The stools are also frequently loose and may be irritating to the skin. Urine may be dark-colored from urobilinogen formation.

A nurse is assessing for ankle clonus in a pregnant client with preeclampsia who is receiving magnesium sulfate. Which action would be appropriate for the nurse to do? A. Have the client wiggle the toes. B. Dorsiflex the foot three times rapidly. C. Stroke the bottom of the client's foot from heel to toe. D. Ask the client to plantar flex the foot.

B To elicit ankle clonus, the nurse will dorsiflex the client's foot three times in rapid succession. When taking the hand away, the nurse observes the foot. If no further motion is present, no ankle clonus is present. If the foot continues to move involuntarily, clonus is present.

A newborn is being breastfed. To evaluate nutritional adequacy, you should be aware that breast milk contains an average of how many calories? A. 12 calories per ounce B. 20 calories per ounce C. 24 calories per ounce D. 30 calories per ounce

B Twenty calories per ounce is not only the calorie content of breast milk but also that of commercial formulas.

A newborn infant has loose, yellow stools. Although the infant is healthy, his mother is concerned that this means he is allergic to breast milk. The nurse would explain to her that: A. she might try burping the infant more frequently. B. the stools of breastfed infants are normally loose. C. she might consider changing to a soybean formula. D. her child may need to be investigated for bile duct disease.

B Until infants begin to eat solid food, their stools are yellow and slightly loose.

A pregnant client is receiving magnesium sulfate to prevent eclampsia via a continuous intravenous infusion. Hourly assessments are recorded in the chart above. Which assessment(s) finding leads the nurse to stop the infusion immediately? Select all that apply. A. patellar reflex B. urine output C. ankle clonus D. level of consciousness E. respiratory rate

B, C The most evident symptoms of overdose from magnesium sulfate administration include decreased urine output, depressed respirations, reduced consciousness, and decreased deep tendon reflexes. Because magnesium is excreted from the body almost entirely through the urine, urine output must be monitored closely to ensure adequate elimination. Therefore, before administering further magnesium sulfate, ensure that urine output is at least 30 ml/hr with a specific gravity of 1.010 or lower. Respirations should be above 12 breaths/min, a client should be able to answer questions (e.g., what's your name, what's your address, etc), ankle clonus should be minimal, and deep tendon reflexes should be present. The client's urine output and severe ankle clonus indicate possible toxicity and the need to stop the infusion. The other findings are within acceptable parameters.

The school nurse is reviewing content to include in an assembly planned for school-age children that focuses on the 2020 National Health Goals for safety. What should the schoolnurse include in this presentation? Select all that apply. A. Encourage the children to play outdoors and get exercise every day. B. Stress the need to sit in age-appropriate seats in cars and wear seatbelts. C. Remind children how important it is to brush the teeth and see the dentist. D. Explain how important it is for children to wear safety helmets when bicycling. E. Offer suggestions to ensure an adequate intake of fruits and vegetables each day

B, D Nurses can help the nation achieve the 2020 National Health Goals by urging children to follow safety rules for automobile and bicycle safety. Playing outdoors, getting exercise, and having an adequate intake of fruits and vegetables would be appropriate for nutritional goals. Brushing the teeth and seeing the dentist would be appropriate for health promotion goals.

The mother of a school-age child is distraught because the child has been diagnosed with obesity. What actions should the nurse suggest to the mother to help the child with this problem? Select all that apply. A. Explain that obesity will lead to an early death. B. Maintain a balanced eating approach in the home. C. Purchase books explaining the latest ways to lose weight. D. Seek out a preteen weight loss group for the child to participate in. E. Encourage increased activity such as walking the dog afterschool.

B, D, E Strategies to help the school-age child with obesity include maintaining a healthy eating approach in the home, seeking a weight loss group with other preteens for the child to attend, and encouraging increased activity. Explaining that obesity will lead to an early death could cause the child to become obsessed with dieting and create an eating disorder. The child should not be encouraged to use fad diets to lose weight.

During a home visit, the nurse learns that a new mother is experiencingbreast engorgement. What should the nurse recommend to help alleviate this problem? A. discontinuing breastfeeding for 24 hours B. having her apply lanolin cream to each breast C. encouraging her to wear a firm-fitting bra D. decreasing her fluid intake to below 500 ml per 24 hours

C A mild analgesic for pain relief and breast support from a firm-fitting bra may provide relief from engorgement. Also, a common suggestion to relieve breast engorgement is to empty the breasts of milk by having the infant suck more often or at least continue to suck as much as before. Breastfeeding should not be discontinued. Applying cream to the breasts will not help with engorgement. The mother does not need to be placed on a fluid restriction.

A nurse is reviewing the blood sugar test results of a child diagnosed with type 1 diabetes: -Before meal: 84 mg/dL (4.66 mmol/l) -1 hour after meal: 160 mg/dL (8.88 mmol/l) -2 hours after meal: 180 mg/dL (9.99 mmol/l) -Middle of the night: 92 mg/dL (5.11 mmol/l) Which result would lead the nurse to notify the health care provider? A. before meal B. 1 hour after meal C. 2 hours after meal D. middle of the night

C Acceptable blood glucose levels for a child 2 hours after a meal would range from 80 to 150 mg/dL (4.44 to 8.32 mmol/l). This child's level is above the range at 180 mg/dL (9.99 mmol/l). The other levels are within the acceptable ranges (before meal—70 to 110 mg/dL (3.89 to 6.11 mmol/l); 1 hour after meal— 90 to 180 mg/dL (5.0 to 10.0 mmol/l); and middle of night—70 to 120 mg/dL (3.89 to 6.66 mmol/l).

The nurse assesses a newborn's Apgar score at birth and documents that it is normal. Which score did the nurse most likely record? A. 1 B. 4 C. 8 D. 13

C An Apgar score between 7 and 10 indicates that the infant scored as high as 70% to 90% of all infants at 1 and 5 minutes after birth and is adjusting well to extrauterine life. A score of 4 to 6 indicates a guarded condition, and the newborn may need clearing of the airway and supplementary oxygen. A score <4 indicates serious danger of respiratory or cardiovascular failure, and the newborn needs resuscitation. Ten is the maximum number on the Apgar scoring system.

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: A. 1 to 2. B. 5 to 9. C. 7 to 10. D. 12 to 15.

C An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.

A new parent is concerned that the infant is not going to receive enough calories from breast milk to grow. When teaching the parent about caloric requirements, how many total calories per day are required by the infant? A. 50 to 55 B. 75 to 100 C. 110 to 120 D. 150 to 200

C An infant up to 2 months of age requires 110 to 120 calories per kilogram of body weight or 50 to 55 kcal/lb every 24 hours to provide an adequate amount for maintenance and growth.

A mother asks you how she can judge that her infant is receiving sufficient breast milk. What would be the most appropriate response? A. "You need to weigh the infant before and after each feeding." B. "The infant should sleep at least 3 hours between feedings." C. "The infant should gain weight and have six wet diapers daily." D. "The infant should not become constipated."

C An infant who is voiding adequately is undoubtedly receiving adequate fluid.

The nurse encourages a woman with gestational diabetes to maintain an activeexercise period during pregnancy. Prior to this exercise period, the nurse would advise her to take which action? A. Inject a bolus of insulin. B. Eat a high-carbohydrate snack. C. Eat a sustaining-carbohydrate snack. D. Add a bolus of long-acting insulin.

C Because exercise uses up glucose, women with diabetes should take a sustaining-carbohydrate snack before hard exercise to prevent hypoglycemia.

The nurse notices that a child is spitting up small amounts of blood in the immediate postoperative period after a tonsillectomy. What would be the best intervention? A. Suction the back of the throat. B. Encourage the child to cough. C. Continue to assess for bleeding. D. Notify the health care immediately.

C Children will have a small amount of blood mixed with saliva following a tonsillectomy. Suctioning or coughing could irritate the surgical site and cause hemorrhage.

The nurse observes a school-age child categorize specific desk and clothing items in his hospital room. What cognitive behavior has this child mastered? A. decentering B. conservation C. class inclusion D. accommodation

C Class inclusion is the ability to understand that objects can belong to more than one classification. A school-age child can categorize objects in many ways. Decentering isthe ability to project oneself into another person's situation. Accommodation is the ability to adapt thought processes to fit what is perceived. Conservation is the ability to appreciate that a change in shape does not mean a change in size.

Typical development for the school-aged child includes playing games with friends. At what age are children typically ready for games that include playing on a team that has a winner or loser? A. 5 years B. 7 years C. 10 years D. 13 years

C Consider growth and development when advising. Erikson's stages can be helpful in determining. Before about 10 years, children are unable to lose a game and still maintain the self-concept that they are good people.

An infant with suspected cystic fibrosis is scheduled for a duodenal analysis. The parent asks, "I thought cystic fibrosis affects the lungs. So how will this test help?" Which response by the nurse would be appropriate? A. "This test helps to show how the lungs are affecting other parts of the body." B. "This test checks how well your child is digesting fat." C. "This test helps show how much of the pancreas is affected." D. "This test will show if your child will need surgery."

C Duodenal secretions may be used to detect pancreatic enzymes and reveal the extent of pancreatic involvement. Although all pancreatic enzymes (lipase, trypsin, and amylase) are affected with cystic fibrosis, a duodenal analysis analyzes secretions from the duodenum for trypsin content, the easiest pancreatic enzyme to assay. The test focuses on pancreatic involvement, not the lungs nor the need for surgery. A stool analysis reveals the fat content and lack of trypsin in the stool.

A pregnant woman diagnosed with diabetes should be instructed to perform which action? A. Discontinue insulin injections until 15 weeks gestation. B. Ingest a smaller amount of food prior to sleep to prevent nocturnal hyperglycemia. C. Notify the primary care provider if unable to eat because of nausea and vomiting. D. Prepare foods with increased carbohydrates to provide needed calories.

C During pregnancy, the insulin levels change in response to the production of HPL. The client needs to alert her provider if she is not able to eat or hold down appropriate amounts of nutrition. The client is at risk for episodes of hypoglycemia during the first trimester. She should never discontinue insulin therapy without her provider's directions. The increase of carbohydrates needs to be balanced with protein, and smaller meals would result in hypoglycemia rather than hyperglycemia.

When planning activities for school-age children, the nurse organizes games that include competition. At which age are these kinds of games preferred by children? A. 7 years old B. 8 years old C. 10 years old D. 12 years old

C During the 10th year, children become very interested in rules and fairness. Before this time, they gave younger children breaks in games, allowing extra turns or hints. Now, they strictly enforce rules. At age 7 years, imaginative play decreases and more props are used. Children who are 8 years old like table games but avoid competitive ones because they hate to lose. Twelve-year-olds enjoy all types of activities that may or may not include competition

On the fourth day postpartum, a woman develops breast engorgement. Which measure would be best to recommend to her as a means of alleviating this problem? A. discontinuing breastfeeding for 24 hours B. decreasing her fluid intake to below 500 ml per 24 hours C. encouraging her to continue regular breastfeeding D. having her apply lanolin cream to each breast

C Engorgement (a feeling of fullness in the breasts) can be alleviated by the infant breastfeeding.

A 6-year-old is seen in a mental health clinic for possible hyperactivity. His mother reports that he is just "all boy." He has always been active and does not like to sit still for more than a minute. Which data would be most important to assess to help evaluate his behavior? A. Whether he was breastfed or bottle-fed as an infant B. Family medical history for circulatory illnesses C. A review of the boy's typical day D. Medical history for communicable diseases

C Evaluating whether children are hyperactive requires a careful history documenting attention span and activities.

The nurse is reviewing the plan of care for a pregnant client experiencing a threatened miscarriage. Which outcome would be appropriate for this client? A. Bed rest is maintained until all bleeding stops. B. Less than one perineal pad is saturated per hour. C. Bleeding spontaneously stops within 24 to 48 hours. D. Normal coitus is resumed 1 week after the episode.

C For a threatened miscarriage, an outcome for care would be that all bleeding would spontaneously stop within 24 to 48 hours. Bed rest is not recommended for a threatened miscarriage because blood will pool in the vagina. Vaginal bleeding that saturates a perineal pad in 1 hour is an emergency and could indicate an incomplete or complete miscarriage. Normal coitus should be withheld for 2 weeks after a threatened miscarriage.

A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears? A. Only people who are known to the staff are permitted in the nursery. B. Keeping the baby in the mother's room at all times is the best approach. C. Both the mother and infant have identification bands that need to match. D. Security questions everyone before permitting them access to the hospital.

C Hospitals have an identification banding system where the mother's and the infant's identification bands are to match. Only people with proper hospital identification should be permitted into the nursery. Keeping the baby in the mother's room at all times could be dangerous because the baby could be left unattended, permitting someone an opportunity to abduct the infant. Security does not routinely question everyone before permitting them access to the hospital.

The nurse is caring for a child immediately following a tonsillectomy. The child requests something to drink. Which action by the nurse is best? A. Inform the child he or she can have nothing to drink for a few hours. B. Provide the child with a red popsicle to eat. C. Give the child a few ice chips to consume. D. Assess the child's gag reflex before giving oral fluids.

C Ice chips are soothing and appropriate for the child at this time. The child should not consume anything red to limit confusion between red coloring and blood. Otherwise, a popsicle would be allowed. The child does not have to wait hours following the procedure to drink. Once the child is awake, ice chips may be offered and the diet increased as tolerated, based on the prescription. The nurse would not assess the gag reflex; nothing should be placed in the child's mouth/throat as this would increase the risk of hemorrhage and infection.

The school nurse is observing a child in the classroom. The child is speaking and then suddenly stops and stares for about 5 seconds and then continues speaking. The nurse charts this as what type of seizure? A. tonic-clonic B. febrile C. absence D. partial (focal) seizures

C In absence seizures, a child will have a staring spell that lasts for a few seconds. Tonic-clonic seizures consist of all body muscles rapidly contract and relax. Febrile seizures are associated with a rapid rise in body temperature and follow the tonic-clonic pattern. Partial (focal) seizures originate from a specific brain area. The seizure movement will be localized to a certain part of the body.

The nurse is completing the health history for the parents of school-age child admitted with a ruptured spleen. For which activity should the nurse assess as the possible cause for this child's injury? A. shooting pool B. skateboarding C. playing baseball D. playing basketball

C In children, the spleen is the most frequently injured organ when there is abdominal trauma. Frequent causes of injury can result from an object such as a baseball bat, a high-speed motor vehicle accident without restraint or with a seat belt without a shoulder strap, child maltreatment, or a fall from a height greater than 20 feet. Injuries to the spleen are not associated with shooting pool or skateboarding or playing basketball.

A woman who began breastfeeding develops sore nipples. The nurse bases her response on which of the following? A. She will have to discontinue breastfeeding. B. To prevent getting an infection, she will need an antibiotic prescribed. C. Exposing her nipples to air after each feeding should help. D. Allowing the infant to suck for longer periods during each feeding will toughen her nipples.

C Longer periods of sucking might irritate nipples; exposing the nipples to air can help.

When examining a newborn's eyes, the nurse would expect which assessment? A. follows your finger a full 180 degrees B. has a white rather than a red reflex C. follows a light to the midline D. produces tears when he cries

C Newborns do not usually follow past the midline until 3 months of age. They do not tear

A pregnant woman is admitted to the hospital with a diagnosis of placentaprevia. Which action would be the priority for this woman on admission? A. performing a vaginal examination to assess the extent of bleeding B. helping the woman remain ambulatory to reduce bleeding C. assessing fetal heart tones by use of an external monitor D. assessing uterine contractions by an internal pressure gauge

C Not disrupting the placenta is a prime responsibility in caring for a patient with placenta previa, so an external fetal monitor would be used. An internal monitor, a vaginal examination, and remaining ambulatory could all disrupt the placenta and thus are contraindicated.

With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity? A. 40 mm Hg B. 50 mm Hg C. 100 mm Hg D. 180 mm Hg

C Retinal capillaries can be damaged by excessive oxygen levels. Keeping the Pa02 level under 100 mm Hg helps prevent this.

The nurse is instructing the parents of a child with sickle cell anemia on safety precautions. What should the nurse emphasize during this teaching? A. Suggest the child participate in sports activities without restriction. B. Treat upper respiratory infections with over-the-counter medication. C. Ensure a consistent and daily intake of adequate fluids to prevent dehydration. D. Remind parents that the child should avoid immunizations to preventthe introduction of bacteria into the body

C Safety interventions for the child with sickle cell anemia include ensuring an adequate daily intake of fluids to prevent dehydration. Dehydration will precipitate a crisis, which can be avoided. The child should avoid contact sports and longdistance running. Upper respiratory infections should be reported to the health care provider so appropriate treatment can be provided. Routine health care such as immunizations should be provided in order to prevent common childhood illnesses.

The nurse is caring for a child who is having a seizure. What is the appropriate action by the nurse? A. Attempt to place oxygen on the child so they don't become cyanotic. B. Hold the child's arms and legs still so they aren't injured. C. Attempt to turn the child on their side to prevent aspiration. D. Place a bite block or oral airway into the child's mouth to prevent biting of the tongue.

C Safety measures include turning the child on their side or abdomen with their head turned to the side to prevent aspiration. Slight cyanosis may be noted but administration of oxygen is not needed due to the short time of the tonic-clonic stage. Do not attempt to restrain or place objects into the child's mouth. These actions may further injure the child.

A school-aged child is admitted to the hospital with a vaso-occlusive sickle cell crisis. Which measure in the child's care plan should be given priority? A. Beginning active range-of-motion exercises B. Seeing that the child ingests a protein-rich diet C. Maintaining fluids through an intravenousline D. Encouraging the child to take deep breaths hourly

C Sickle cells clump together and prevent normal blood flow. This leads to tissue hypoxia. With a vaso-occlusive crisis, the cells are clumped together and prevent blood flow to the joint or organ. The blood with the clumped sickled cells is very viscous. Adequate hydration is crucial in relieving the problems of a vaso- occlusive crisis. The hydration dilutes the blood and decreases the viscosity. During a crisis the recommended fluid intake (IV and PO) is 150 ml/kg/day. During a vaso- occlusive crisis, the child has severe pain. The goal is to get the pain under control and increase blood flow. Range-of-motion exercises will add to the increased pain during this period of time, so should not be started until crisis in under control. The diet and hourly deep breaths are important, but they are not crucial to correcting the crisis.

To administer oxygen by bag and mask to a newborn, you would position the baby A. in Trendelenburg's position. B. on the back with the neck slightly flexed. C. on the back with the head slightly extended. D. in any position desired. Position is unimportant as long as the tongue is pulled forward.

C Slightly extending the neck best opens the airway (a "sniffing" position). Trendelenburg is rarely used with newborns because it increases cerebral vascular pressure.

A 6-year-old child was diagnosed as having streptococcal pharyngitis. At the follow-up visit, the nurse will assess the child for which potential complication? A. swollen lymph nodes that obstruct the airway B. infection that may cause a tooth abscess C. development of rheumatic fever D. nephrosis of the kidney

C The Group A strain of streptococci causing streptococcal pharyngitis can cause a hypersensitivity reaction that results in either rheumatic fever or glomerulonephritis. Swollen lymph nodes obstructing the airway would occur during the illness, not afterward. They would have been addressed at an emergency visit, rather than at the routine follow-up visit. The organism will not affect the teeth.

The nurse is assessing eye alignment in a 6-year-old child. Which assessment method is most appropriate? A. asking the child to stare at a distant mark B. asking the child to touch the finger to the nose C. covering one eye and then removing the cover D. turning a bright light on and then off

C The assessment of eye muscle strength can be done using two tests. The Hirschberg test involves using a penlight. The penlight is placed in the middle of the nurse's face and the child is instructed to look at it. A small dot of reflected light seen in the iris should be symmetrical in both eyes. The "cover" test involves covering both eyes after instructing the child to focus on an interesting object. While the child is focusing with the first eye, remove the cover from the second eye and observe for movement. This covering allows a deviated eye to wander while covered and straighten when uncovered. Eye tests require the child to stare at a distant mark. Neurological tests have the child touch the finger to the nose. Bright lights, directed at the eyes, test pupil response.

The nurse is preparing a formula feeding for a preterm infant. Which will most likely be prescribed for this client? A. glucose water B. 20 calories per ounce C. 22 calories per ounce D. iron supplements

C The caloric concentration of formulas used for preterm infants is usually 22 calories per ounce compared with 20 calories per ounce for a term baby. Glucose water will not provide the infant with adequate calories. Iron supplementation will depend on laboratory values.

A parent tells the nurse that the 6-year-old child has been biting his fingernails since beginning first grade. After analysis, the cause is determined to be increased stress.What advice would the nurse give the parent regarding this behavior? A. Encourage the child to drink more milk for stronger nails. B. Distract the child by teaching a new skill, such as whistling. C. Allow some time every day for the child to talk about new experiences D. Allow the child to choose a reward for not biting the nails.

C The developmental task of the school-age child is industry. They are busy learning, achieving, and exploring. With school comes separation from the parents, new people, new activities. Beginning school can be a time of extreme stress for children. Biting the nails can be a symptom that something is concerning the child. Spending time with the child and allowing the child time to discuss these new experiences of school helps the child to put experiences in perspective and begin to deal with them. Allowing the child a reward for not biting the nails does not address the underlying issue of why the child is biting the nails in the first place. The underlying issue is emotionally based, so adding milk or providing a distraction will not correct the problem.

The most important assessment of neurovascular status to make after spinal surgical instrumentation is: A. check the nail beds of the fingers for capillary refill. B. determine the presence of brachial pulses. C. assess the legs for warmth. D. ask if the child has pain.

C The edema that accompanies spinal instrumentation surgery can impair circulation to lower extremities. The lower extremities are affected and need to be assessed over the nail beds of the fingers. The brachial pulse is in the arm. Most children will have pain after surgery.

A pediatric client has just been diagnosed with diabetes. What would the nurse do first? A. Educate the client on stress management. B. Regulate nutrition. C. Check blood glucose levels. D. Administer insulin.

C The nurse must check the insulin level before it can be administered. Once a need is established, then insulin administration becomes the priority intervention. Stress management, glucose checks, and nutritional consultation can all be implemented once therapy with insulin begins.

A pregnant client is being admitted for severe preeclampsia. In which room location should the nurse place this client? A. near the nursery B. next to the elevator C. in a darkened room D. across from the nurse's station

C With preeclampsia with severe features, most women are hospitalized so that they can be closely monitored. Visitors are usually restricted to support people such as a partner, father of the child, mother, or older children. Raise bed side rails to help prevent injury if a seizure should occur. The room should be darkened if possible because a bright light can also trigger seizures. However, the room should not be so dark that caregivers need to use a flashlight to make assessments. Sudden noises, such as noises from the nursery, elevator or nurse's station can trigger a seizure in a woman with preeclampsia with severe features.

At an amniocentesis just prior to birth, the lecithin/sphingomyelin ratio (L/S) of a fetus was determined to be 1:1. Based on this, she is prone to which type of respiratory problem following birth? A. wheezing from excess fluid accumulation B. bronchial constriction from room air C. alveolar collapse on expiration D. inspiratory constricture from air contaminants

C Without adequate surfactant, infants are unable to sustain respiratory function and, thus, develop respiratory distress syndrome with alveolar collapse on expiration.

A nurse is developing a teaching plan for the parents about medications prescribed to address the pulmonary issues for their child diagnosed with cystic fibrosis. Medication therapy focuses on keeping the lungs clear and treating infection. Which medication(s) will the nurse likely include in this plan? Select all that apply. A. dextromethorphan B. codeine C. dicloxacillin D. albuterol E. dornase alfa

C, D, E Children may be given aerosol therapy by means of a nebulizer to provide antibiotics such as dicloxacillin, bronchodilators such as albuterol A, and a mucolytic, such as dornase alfa, which can be added to the mist to aid in diluting and liquefying secretions. Cough suppressants, such as dextromethorphan and codeine, should be avoided because secretions must be removed to promote effective air exchange and prevent infection.

During a home visit, a new mother tells the nurse that her nipples are sore from breastfeeding. What should the nurse instruct the mother at this time? Select all that apply. A. Insert plastic liners into the nursing bra. B. Apply petroleum jelly to the nipples before feeding. C. Expose the nipples to air so the nipple dries. D. Position the baby differently for each feeding. E. Massage a few drops of breast milk to the areola.

C, D, E To help with sore nipples from breastfeeding, the nurse should instruct the mother to expose the nipples to air so the nipple dries, position the baby differently for each feeding, and massage a few drops of breast milk to the areola. The mother should be discouraged from applying petroleum jelly to the nipples or inserting plastic liners into the nursing bra because these prevent air from circulating around the breast.

The nurse is concerned that a pregnant client is experiencing abruptio placentae. What did the nurse assess in this client? A. increased blood pressure and oliguria B. pain in a lower quadrant and increased pulse rate C. painless vaginal bleeding and a fall in blood pressure D. sharp fundal pain and discomfort between contractions

D Abruptio placentae is characterized by a sharp, stabbing pain high in the uterine fundus as the initial separation occurs. Manifestations of abruptio placentae do not include increased blood pressure, oliguria, pain in the lower quadrant, increased pule rate, painless vaginal bleeding, or a fall in blood pressure.

A nurse is working with the parents of a child just diagnosed with attention deficit hyperactivity disorder (ADHD). Which aspect will the nurse emphasize as crucial for the child? A. medication therapy B. ongoing counseling C. varying level of discipline D. structured learning environment

D Although medication and counseling/support are important, a structured learning environment is crucial for children with attention deficit hyperactivity disorder (ADHD). Children and adolescents with ADHD respond best in an environment that is structured and predictable, with clear and consistent rules and expectations.

The nurse instructs a preadolescent child with type 1 diabetes mellitus how to self administer an injection of short-acting and long-acting insulin. Which observation indicates to the nurse that teaching has been successful? A. administers the insulin intramuscularly B. wipes off the needle with an alcohol swab C. administers the insulin at a 30-degree angle D. draws up the short-acting insulin into the syringe first

D Clients should be taught that when insulin is being mixed in one syringe, the regular or short-acting insulin should be drawn into the syringe first. Insulin is injected into subcutaneous tissue. The needle should not be wiped off with alcohol before injecting. Insulin should be administered at a 90-degree angle to the skin surface.

On the first day postpartum, a new mother is concerned that her milk has not yet "come in." The nurse would explain to her that: A. most mothers do have milk by 1 day postpartum. B. she will not have breast milk until 7 days postpartum. C. her infant must not be sucking well or she would have milk by now. D. breast milk normally comes in on the third or fourth postpartum day

D Colostrum has been forming since the fourth month of pregnancy; milk forms on the third or fourth postpartum day.

Fractures in children are always potentially serious injuries. Which child with a fracture would you observe most closely for complication? A. one who has a greenstick radial injury B. one who has an ulnar fracture C. one who has a fractured patella D. one who has an elbow fracture

D Elbow injuries are particularly dangerous because edema can interfere with blood vessels and nerves that pass beside the joint. The radius and ulna are long bones and would not be at increased risk for complications. The patella is the knee and can be maintained in a straight position for casting.

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital? A. The baby has a changing area. B. The kitchen has a refrigerator. C. The windows are covered with screens. D. The baby sleeps with the mother in bed.

D Evidence that an inadequate home environment assessment was performed as the baby is sleeping with the mother. The American Academy of Pediatrics recommends newborns have their own crib as a step toward preventing sudden infant death syndrome. The baby having a changing area, the kitchen having a refrigerator, and the windows covered with screens indicate that the home environment is adequate to support the needs of a newborn.

The nurse is identifying nursing diagnoses for a client with gestational hypertension. Which diagnosis would be the most appropriate for this client? A. risk for injury related to fetal distress B. imbalanced nutrition related to decreased sodium levels C. ineffective tissue perfusion related to poor heart contraction D. ineffective tissue perfusion related to vasoconstriction of blood vessels

D In gestational hypertension, vasospasm occurs in both small and large arteries during pregnancy. This can lead to ineffective tissue perfusion. There is no evidence to suggest that the fetus is in distress. There is no enough information to support imbalanced nutrition. Gestational hypertension does not affect heart contractions.

The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment? A. inspecting the genital area for irritated skin B. inspecting if the urethral opening appears circular C. palpating if testes are descended into the scrotal sac D. retracting the foreskin over the glans to assess for secretions

D In most male newborns, the foreskin slides back poorly from the meatal opening, so the nurse should not try to retract it. The nurse should inspect the area for irritated skin, inspect the urethral opening, and palpate the testes in the scrotal sac.

While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-clonic seizure. Which nursing action is priority? A. Administer lorazepam rectally to the client. B. Refer the client to a neurologist. C. Discuss dietary therapy with the client's caregivers. D. Protect the child from hitting the arms against the bed.

D Keeping the child safe during a seizure is the highest priority. The nurse will protect the child from hitting the arms on the bed or other nearby objects. If the seizure continues, lorazepam may be indicated to stop the seizure. The client would be referred to a neurologist for follow-up care; however, this is not apriority. Dietary therapy is considered for clients with chronic seizure disorders who do not respond to medication therapy.

The nurse assesses the head circumference of a mature newborn. Which measurement does the nurse identify as a possible cause for concern? A. 34.2 cm B. 35.2 cm C. 34.8 cm D. 37.4.cm

D Measurements vary, but in a mature newborn, the head circumference is usually 34 to 35 cm (13.5 to 14 in.). A mature newborn with a head circumference greater than 37 cm (14.8 in.) or less than 33 cm (13.2 in.) should be carefully assessed for neurologic involvement, although some well newborns have these measurements.

The mother of a school-age child is distraught over the ongoing oppositional behavior demonstrated by the child at home and at school. Which nursing diagnosis should the nurse select as appropriate for the child and family? A. Risk for self-directed violence related to impulsivity B. Situational low self-esteem related to lack of successful coping strategies C. Impaired social interaction related to short attention span and distractibility D. Interrupted family processes related to inability of child to follow instructions

D Oppositional defiant disorders consist of long-term hostile, negativistic, or defiant behaviors that result in disturbed functioning in academic and social domains. Children typically have difficulty controlling their temper; such anger is often directed at an authority figure. The disorder develops most frequently in late preschool or early school age. The diagnosis most appropriate for this child and parent is interrupted family processes. There is no evidence to suggest that the child is at risk for self-directed violence, low self-esteem, or impaired social interaction.

The nurse assists with the application of a full-body plaster cast to a child. The child immediately becomes diaphoretic and reports feeling hot. Which nursing intervention would be indicated? A. Observe the child for infection. B. Suggest removal of the cast to the orthopedist. C. Moisten the cast with cool water. D. Advise the child that this is to be expected.

D Plaster becomes hot as it sets. Even with fiberglass casts, there will be a warm feeling inside the cast when it is drying. This is a normal expectation about which to educate the child before the application of the cast. If discomfort continues, the nurse should notify the health care provider. Infection would not present in this way with a cast application. A cast should not be moistened. If it does become wet, the cast should be dried with a hair dryer. There are some newer types of casts which can get wet but the nurse should know this before applying any moisture.

A preterm infant is placed on ventilatory assistance for respiratory distress syndrome. In light of her lung pathology, which additional ventilatory measure would you anticipate planning? A. administration of chilled oxygen to reduce lung spasm B. increased inspiratory pressure; decreased expiratory pressure C. administration of dry oxygen to avoid over-humidification D. positive end-expiratory pressure to increase oxygenation

D Positive end-expiratory pressure, like expiratory grunting, prevents alveoli from fully closing on expiration and reduces the respiratory effort needed for inspiration.

A new mother is ambivalent about breastfeeding and agrees to do it for at least 3 months. What response should the nurse provide to the client at this time that would support the 2030 National Health Goals? A. Breastfeeding helps the mother return to prepregnancy weight faster. B. Three months is the recommended time frame for the baby's nutrition. C. Breast milk can be donated so that preterm infants can have additional nutrition. D. Six months to 1 year of age is the best time frame to support the baby's growth needs

D Six months of exclusive breastfeeding and breastfeeding to 1 year of age are part of the 2030 National Health Goals for breastfeeding. Although breastfeeding can help the mother return to prepregnancy weight, this is not a 2020 National Health Goal for breastfeeding. Three months is not the recommended time frame for the baby's nutrition. Breast milk can be donated; however, this is not a 2020 National Health Goal for breastfeeding.

A 9-year-old is hospitalized for a long-term illness. The best project to give the to help achieve the child's developmental task would be: A. a scrapbook that will take 3 weeks to complete. B. a puppet show that will take 2 weeks to plan. C. watching her favorite program on television. D. sewing a purse that will take one afternoon.

D Small projects that can be completed quickly offer a sense of reward and are best to help children develop a sense of industry.

Which change in insulin is most likely to occur in a woman during pregnancy? A. enhanced secretion from normal B. not released because of pressure on the pancreas C. unavailable because it is used by the fetus D. less effective than normal

D Somatotropin released by the placenta makes insulin less effective. This is a safeguard against hypoglycemia.

It is determined that a preschooler developed anemia after exposure to an insecticide. What should the nurse teach the parents before the child is discharged from the hospital? A. Schedule weekly chelating treatments. B. Provide the child with a high-protein diet. C. Schedule hospital visits to desensitize the child to the insecticide. D. Ensure that the child has no further exposure to the insecticide.

D The first step in therapy is to immediately ensure that the child is never exposed to the substance again. Chelation therapy is to remove excess iron from the blood and body. A highprotein diet is not indicated for this health problem. The child does not need weekly hospital visits for desensitization.

A client with diabetes is in the first trimester of pregnancy and is currently having difficulty keeping blood glucose levels within normal limits. The client explains that she has been "eating for two" so the baby is healthy. How should the nurse respond to the client? A. "Elevated blood glucose levels cause low birth weights in infants." B. "Elevated blood glucose levels ensure the baby has mature lungs at birth." C. "Elevated blood glucose levels hasten the development of the fetus in utero." D. "Elevated blood glucose levels in the first trimester have been linked to congenital anomalies."

D The first trimester of pregnancy is the most important time for fetal development. If the client can control hyperglycemia during this time, the chances of a congenital anomaly are greatly reduced. Infants of clients with poorly controlled diabetes tend to be large. At birth, babies born to clients with uncontrolled diabetes are prone to respiratory distress syndrome. Elevated blood glucose levels do not hasten the development of the fetus in utero and can lead to hydramnios.

A nurse is preparing a class for a group of parents of school-age children about language development and problems with speech articulation, specifically difficulty pronouncing specific letters. The nurse would inform the parents that a referral for initiating speech therapy may be necessary for these problems after which which age? A. 5 years B. 6 years C. 7 years D. 8 years

D The most common problem of a school-age child is articulation. The child has difficulty pronouncing s, z, th, l, r, and w or substitutes w for r ("westroom" instead of "restroom") or r for l ("radies' room" instead of "ladies' room"). This is most noticeable during the first and second grades (age 6 and 7 respectively); it usually disappears by the third grade, (around 8 years of age).

A pregnant client had decided to breastfeed the infant but, after delivery, tells the nurse that formula feeding would be the best choice for her now. What nursing diagnosis should the nurse use to plan this client's care? A. anxiety B. ineffective coping C. imbalanced nutrition D. risk for impaired parenting

D The mother has decided to forgo breastfeeding for formula feeding. This decision could place the mother at risk for impaired parenting because of the need to formula feed the infant. The mother's decision does not support the diagnoses of anxiety and ineffective coping. It is unlikely that the infant will have imbalanced nutrition related to formula feeding.

A school-aged child is diagnosed with streptococcal pharyngitis. What should the nurse teach the parents about the care that this child will need at home? A. Expect the lymph nodes to swell and obstruct the airway. B. Regular activity level should be encouraged as soon as possible. C. Be aware that the infection may spread and cause a tooth abscess. D. Complete the entire course of antibiotics to prevent rheumatic fever.

D The nurse should help parents understand the importance of completing the full prescribed days of therapy in order to ensure all the streptococci are eradicated. If they are not, the child may develop a hypersensitivity or autoimmune reaction to group A streptococcus that can result in rheumatic fever. Lymph node swelling should not occur if antibiotic therapy is initiated and continued as prescribed. The nurse should instruct parents about the importance of rest. This type of infection is not known to cause tooth abscesses.

When caring for a newborn several hours after birth, what would the nurse assess as a normal newborn's respiratory rate? A. 12 to 16 breaths/min B. 16 to 20 breaths/min C. 20 to 30 breaths/min D. 30 to 60 breaths/min

D The respiratory rate of a newborn in the first few minutes of life may be as high as 80 breaths/min. Because respiratory activity is established and maintained over the next hour, this rate will settle to an average of 30 to 60 breaths/min. Respiration rates less than 30 breaths/min should be reported to the health care provider for evaluation.

A woman has been diagnosed as having gestational hypertension. Which symptom for this condition is the most typical? A. increased perspiration B. weight loss C. susceptibility to infection D. blood pressure elevation

D The symptom of gestational hypertension is blood pressure elevation (140/90 mm Hg) identified after 20 weeks' gestation without proteinuria.

A woman of 16 weeks' gestation telephones the nurse because she has passed some "berrylike" blood clots and now has continued dark brown vaginal bleeding. Which action would the nurse instruct the woman to do? A. "Maintain bed rest, and count the number of perineal pads used." B. "Come to the health care facility if uterine contractions begin." C. "Continue normal activity, but take the pulse every hour." D. "Come to the health facility with any vaginal material passed."

D This is a typical time in pregnancy for gestational trophoblastic disease to present. Asking the woman to bring any material passed vaginally would be important so the material can be assessed for this.

The nurse is talking with a parent of an adolescent who is newly diagnosed with type 2 diabetes and asks, "How could this happen? No one in our family has diabetes." What response would be appropriate? A. "This is caused by the pancreas not making enough insulin." B. "This disorder usually occurs when inadequate calories are ingested on a regular basis." C. "Because this disorder is genetic, someone in the family will eventually develop the illness." D. "This is caused by insulin resistance from previous pancreatic injury or generalized infection."

D Type 2 diabetes is now seen in overweight adolescents as well as those who eat a diet high in fats and carbohydrates and do not exercise regularly. Pancreatic malfunction is not a cause of type 2 diabetes. This disorder is not linked to inadequate ingestion of daily calories. This disorder may have a genetic link, but environmental factors such as obesity, diet, and exercise can influence its development. Type 2 diabetes is a result of insulin resistance in the metabolism of glucose to maintain normal blood glucose levels, but it is not associated with infection or a previous pancreatic injury.