pediatrics/newborn
When the nurse observes that the client's heart rate increases during inspiration and decreases during expiration, the nurse reports that the client is demonstrating
sinus dysrhythmia.
The nurse is attempting to determine the ventricular rate and rhythm of a patient's telemetry strip. What should the nurse examine to determine this part of the analysis?
RR interval
The nurse is admitting a client to a telemetry unit with an atrial dysrhythmia. What symptoms will the nurse further evaluate?
chest pain
The nurse is assigned to care for several clients admitted to a telemetry unit. Which clients should the nurse assess first?
A client whose implantable cardioverter defibrillator (ICD) fired twice on the prior shift, requiring amiodarone IV
A nurse is assessing a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect?
Barrel-shaped chest
A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 sec. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take?
Continue to monitor the newborn routinely
A client with a recent myocardial infarction was admitted to the hospital with a new diagnosis of mitral valve regurgitation. Which assessment data obtained by the nurse should be immediately communicated to the health care provider?
Crackles audible throughout the lungs
A nurse is caring for a client at 35 weeks' gestation who has preeclampsia. Which of the following assessments provides the most accurate information regarding the clients fluid and electrolytes status?
Daily weight
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?
Elevated blood pressure
Which of the following nursing actions is most likely to foster a therapeutic nurse client relationship with a 2 year old client
Encouraging the child to hold their doll during the exam
A nurse is assessing a client who is pregnant, and reports increased nasal stuffiness. The nurse should inform the client of which of the following hormones is responsible for this discomfort
Estrogen
A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should a nurse include?
Hypoglycemia
A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching?
I should wear sandals as much as possible
A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication?
IV narcotics administered to the mother during labor
A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which following actions should the nurse take?
Offer the client hydrotherapy
A nurse is assessing a client who has hyperemesis gravidarum, which of the following findings should the nurse expect?
Presence of ketones in the urine
What is the drug of choice for a stable client with ventricular tachycardia?
Procainamide
A client with frequent premature ventricular contractions is prescribed amiodarone. The nurse will withhold the medication until the completion of which diagnostic test?
Pulmonary function
A nurse is reviewing the medical record of a client who is 20 weeks' gestation. Which of the following findings should the nurse identify as a presumptive indication of pregnancy?
Report of fetal movement by the client
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of this medication?
Serum potassium level 4.1 mEq/L
Which dysrhythmia is common in older clients?
Sinus bradycardia
A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include?
Sponge bathe the newborn every other day
A nurse is assessing a client at 27 weeks' gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect?
The fundal height measures greater than gestational age
A patient is being seen in a clinic to rule out mitral valve stenosis. Which assessment data would be most significant?
The patient reports shortness of breath when walking.
A nurse is caring for a client in labor whose cervix is dilated to 9cm. She is experiencing strong contractions every 2 min lasting 75 seconds. The nurse should recognize that the client is in which of the following stages of labor?
Transition phase of first stage
A school nurse is assessing an adolescent who has scoliosis. Which of the following finding should the nurse expect?
a unilateral rib hump
A nurse is preparing to feed an infant who has cleft lip and palate. Which of the following actions should the nurse plan?
burp the infant at least 2 to 3 times during the feeding
A nurse in the emergency department is caring for a toddler who has partial thickness burns to the right arm. Which of the following actions should the nurse take first?
cleanse the affected area with mild soap and water
The nurse assesses a client with a heart rate of 120 beats per minute. What are the known causes of sinus tachycardia?
hypovolemia
A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan?
increase fat content in the child's diet to 40% of total calories
A client with dilated cardiomyopathy is having frequent episodes of ventricular fibrillation. What medical treatment does the nurse anticipate the client will have to terminate the episode of ventricular fibrillation?
internal cardioverter defibrillator insertion
A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding of the teaching?
mononucleosis is caused by an infection with the Epstein- Barr virus
A nurse is caring for a school aged child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema?
palpate the dorsum of the child's feet
The client asks the nurse to explain what is meant by a ventricular bigeminy cardiac rhythm. What is the best response by the nurse?
"The rhythm has a normal beat, then a premature beat pattern."
The nurse is caring for a 32-year-old client admitted with a medical diagnosis of atrial fibrillation, related to "holiday heart" syndrome. A nursing student working with the nurse asks for information about "holiday heart" syndrome. Which is the best response by the nurse?
"This is the association of heart dysrhythmias, especially atrial fibrillation, with binge drinking."
The nurse cares for a 56-year-old client who received an implantable cardioverter defibrillator (ICD) 2 days prior. The client tells the nurse "My wife and I can never have sex again now that I have this ICD." What is the nurse best response by the nurse?
"You seem apprehensive about resuming sexual activity."
The nurse is working with a client with a new onset of atrial fibrillation during a three-month follow-up visit. The healthcare provider is planning a cardioversion, and the client asks the nurse why there is a wait for the treatment. What is the best response by the nurse?
"Your atrial chambers may contain blood clots now, so you must take an anticoagulant for a few weeks before the cardioversion."
The nurse is working on a telemetry unit. When the nurse is interpreting a client's heart rhythm, the nurse counts each large block on graph paper as how many seconds?
0.2
A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron?
1/2 cup Rasins
The nurse is assessing a client at her first prenatal visit and notes the fundal height is palpable at the level of the umbilicus. The nurse predicts the client is at which gestational age?
20 weeks
A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of gestation. the history includes one pregnancy, terminated by elective abortion at 9 weeks; the birth of twins at 35 weeks; and a spontaneous abortion at 15 weeks. According to the GTPAL, system, which of the following describes the client's current status?
4-0-1-22
The medical plan of treatment for chronic mitral regurgitation would include medications to reduce afterload, such as:
Angiotensin-converting enzyme (ACE) inhibitors.
The nurse is assessing a patient and feels a pulse with quick, sharp strokes that suddenly collapse. The nurse knows that this type of pulse is diagnostic for which disorder?
Aortic regurgitation
A nurse is caring for a child who is in Buck's traction following a leg fracture 24 hr. ago. Which of the following actions should the nurse take?
Assess the peripheral pulses once every 4 hrs.
The registered nurse reviewed the patient's vital signs and noted a consistent pattern of heart rate recordings between 48 and 58 bpm over a 24-hour period of time. What medication will cause bradycardia?
Atenolol
The nurse knows that electrocardiogram (ECG) characteristics of atrial fibrillation include what?
Atrial rate of 300 to 400
A nurse is caring for a client with a history of cardiac disease and type 2 diabetes. The nurse is closely monitoring the client's blood glucose level. Which medication is the client most likely taking?
Carvedilol
Which of the following responses to the parent reflects the best understanding of this clients nutritional needs?
Children who have diabetes will need adequate amounts of complex carbohydrates. It is acceptable to have a slice of pizza, as long as the carbohydrates are counted as part of the daily intake
A patient has had a successful heart transplant for end-stage heart disease. What immunosuppressant will be necessary for this patient to take to prevent rejection?
Cyclosporine
A client is diagnosed with mitral regurgitation. What does the nurse consider with the mechanics of cardiac hemodynamics?
Blood flows backward from the left ventricle into the left atrium during systole.
A nurse is caring for a client who is in labor. Which of the following methods will determine the frequency of the clients' contractions?
Evaluate the time from the beginning of a contraction to the beginning of the next contraction
The nurse is auscultating the heart of a client diagnosed with mitral valve prolapse. Which is often the first and only manifestation of mitral valve prolapse?
Extra heart sound
A young parent brings a 4-year-old child to the pediatric clinic with a mild fever and a red, spotty rash that is beginning to fade. The child's heart rate is rapid, and the rhythm is abnormal. The parent states the child has been healthy until about 3 weeks ago, when the child had a sore throat. The nurse suspects rheumatic carditis. What organism causes rheumatic carditis?
Group A beta-hemolytic strep
Which of the following findings indicates that the child is in the Erikson's psychosocial developmental stage of industry vs. inferiority?
Identifies math and music as a favorite school subjects.
A nurse is reviewing laboratory results for a client who is 37 weeks gestation. The nurse noes that the client is rubella non-immune is positive for group B hemolytic streptococcus and has blood type O negative. Which of the following actions should the nurse take?
Instruct the client to obtain a rubella immunization after delivery
Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?
Jugular vein distention
A nurse is providing education to a client who is 4 weeks postpartum and is breastfeeding. the client asks about weight loss. Which of the following responses should the nurse make?
Losing 2.2 pounds each month would be acceptable
The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely?
Magnesium
Which nursing intervention should a nurse perform to reduce cardiac workload in a client diagnosed with myocarditis?
Maintain the client on bed rest.
A client with atrial fibrillation, who does not respond to conventional treatment measures and who is not a candidate for cardioversion, would have what procedure recommended?
Maze procedure
The nurse expects to see which of the following characteristics on an ECG strip for a patient who has third-degree AV block?
More P waves than QRS complexes
A nursing instructor is reviewing the parts of an EKG strip with a group of students. One student asks about the names of all the EKG cardiac complex parts. Which of the following items are considered a part of the cardiac complex on an EKG strip? Choose all that apply.
P wave P-R interval T wave
A nurse is assessing a school age child who has meningitis. which of the following is the priority for the nurse to report to the provider?
Petechiae on the lower extremities
A nurse is caring for a client who is 38 weeks of gestation and is receiving oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first?
Place the client in a side laying position.
A healthy adult client is seeing a health care provider for an annual physical examination. While the nurse is taking the client's vital signs, the client states, "Occasionally, my heart skips a beat." The nurse believes that the client is experiencing what condition?
Premature atrial complex
A nurse is caring for a newly admitted school aged child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe?
Recombinant growth hormone
A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which following actions should the nurse plan to take?
Stand at the client's right side if the nurse is right-handed
A nurse is planning educational sessions for clients in a childbirth class. Which of the following findings should the nurse plan to instruct the clients to report immediately?
Swelling of the face and fingers
Which of the following is the most common complication of prosthetic valves?
Thromboembolism
Which electrocardiogram (ECG) characteristic is usually seen when a client's serum potassium level is low?
U wave
A nurse is assessing a client who is in the fourth stage of labor. Which of the following should the nurse expect?
Urinary retention
A nurse is assessing a client who is suspected of having hyperemesis gravidarum. Which of the following laboratory tests should the nurse check first?
Urine ketones
A nurse is caring for a client at 37 weeks' gestation who is undergoing a nonstress test. The FHR is 130/min without accelerations for the past 10 min. Which of the following actions should the nurse take?
Use vibroacoustic stimulation on the client for 3 sec
A nurse is reinforcing teaching about nutritional requirements during lactation for a client who is planning to breastfeed. Which of the following nutrients should the client increase during lactation?
Vitamin C
The nurse caring for a client with cardiomyopathy plans to have an education session with the client and the client's spouse about ways to improve cardiac output and reduce the workload of the heart. Which of the following instructions would help reduce preload?
When resting, sit up with the legs down to pool blood in the legs.
A nurse is providing teaching for a client who is pregnant and has type 1 diabetes mellitus. Which of the following statements should the nurse include in the teaching?
You should expect to decrease your insulin dosage immediately after you deliver your baby
Which of the follow statements is appropriate to make in response to the parents expressed concern?
Your child's weight is about in the center of the growth chart for their age
After evaluating a client for hypertension, a health care provider orders atenolol, 50 mg P.O. daily. Which therapeutic effect should atenolol have in treating hypertension?
Decreased cardiac output and decreased systolic and diastolic blood pressure
A nurse is caring for a school aged child who has diabetes mellitus and is admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment., which of the following findings should the nurse expect?
Deep respirations of 32/min
The nurse recognizes which as being true of cardioversion?
Defibrillator should be set to deliver a shock during the QRS complex.
A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching?
Do not become pregnant for at least 1 year
The nurse and student nurse are observing a cardioversion procedure. The nurse is correct to tell the student that electrical current will be initiated at which time?
During ventricular depolarization
A client with aortic regurgitation is admitted to the hospital. Which assessment findings would indicate left ventricular failure?
Dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND)
A nurse is assessing a school aged child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?
difficulty concentrating
A nurse is caring for a school age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops flushing of the skin and angioedema. After discontinuing the medication infusion which of the following medications should the nurse administer first?
epinephrine
A nurse is caring for a school aged child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
flank pain
A nurse is reviewing the lumbar puncture results of a school age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as in indication of bacterial meningitis?
increased protein concentration
A client reports headaches and "just not feeling right," which the client blames on ongoing sleep disturbances. Inspection reveals Janeway lesions on the bottoms of the client's feet. These symptoms may indicate:
infective endocarditis.
A nurse is assessing an infant who has ventricular septal defect. Which of the following findings should the nurse expect?
loud, harsh murmur
A nurse is caring for a client diagnosed with a mitral valve prolapse who is asymptomatic. What will nurse expect to be ordered for this client?
no treatment
A nurse is caring for an infant who is receiving IV fluids for treatment of Tetralogy of Fallot and begins to have a hyper cyanotic spell. Which of the following actions should the nurse take?
place the infant in knee chest position
A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?
playing dress-up
A nurse is creating a care of plan for a school age child who has heart disease and has developed heart failure. Which of the following should the nurse include in the plan?
provide small, frequent meals for the child
A nurse is providing discharge teaching to the parent of a school aged child who has moderate persistent asthma. Which of the following instructions should the nurse include?
pulmonary function tests will be performed every 12 to 24 mths to evaluate how your child is responding to will
A nurse is assigned to the medical intensive care unit. The nurse auscultates a water-hammer pulse. What will the sound resemble?
quick, sharp strokes that suddenly collapse
A nurse is conducting a health assessment for a 24 MTh old child. The nurse should expect which of the following findings?
slightly bowed or curved leg appearance, ability to build a tower of 6 blocks
A nurse is reviewing the lab report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following lab values indicates effectiveness of the current treatment?
sodium 140 mEq/L
A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus?
sodium 155 mEq/L
A nurse is caring for a 4-year child who has superficial partial thickness burns over 50% of his body. To meet nutritional needs of the child which of the following actions should the nurse plan to take
supplement the child's feedings with enteral feedings
A client has a heart rate greater than 155 beats/minute and the ECG shows a regular rhythm with a rate of 162 beats/minute. The client is intermittently alert and reports chest pain. P waves cannot be identified. What condition would the nurse expect the physician to diagnose?
supraventricular tachycardia
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurse's priority?
tachypnea
A nurse is interviewing a parent of an 18-month-old toddler during a well child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?
the toddler received tobramycin during a hospitalization 2 weeks ago
A nurse is caring for a client who has suspected ectopic pregnancy at 8 weeks of gestation. which of the following manifestations should the nurse expect to identify as consistent with the diagnoses?
unilateral, cramp-like abdominal pain
You prepare to assess the client,s vitals and draw the blood sample for the HbA1c. Their previous was 10%. The clients vitals are temp. 99.4 (37.4C) pulse 94 resp. 20 B/P 103/58. which of the following techniques shoul be used to ensure accurate B/P?
using a cuff with a width that covers 40% of the upper arm and the length that encircles at least 80% of the extremity
While auscultating the heart of a pediatric client who is recovering from acute rheumatic fever, the nurse hears a murmur. This sound may indicate:
valve damage.
During electrical cardioversion, the defibrillator is set to synchronize with the electrocardiogram (ECG) so that the electrical impulse discharges during
ventricular depolarization.
The nurse working in the emergency department places a client in anaphylactic shock on a cardiac monitor and sees the cardiac rhythm shown. Which dysrythmia should the nurse document?
ventricular tachycardia
A nurse is providing dietary teaching to the parent of a school aged child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?
white rice
A nurse in a provider's office is preparing to administer vaccines to a toddler. The toddler has had a clear runny nose for 2 days. The toddler is allergic to neomycin, eggs and gelatin. which of the following actions should the nurse plan to take?
withhold the measles, mumps and rubella (MMR) vaccine.
A nurse is receiving change of shift report for four children. Which of the following children should the nurse see first?
A school aged child who has sickle cell anemia and reports decreased vision in the left eye
A client has a medical diagnosis of an advanced first-degree atrioventricular block and is symptomatic. What initial treatment will the nurse be prepared to complete?
administer an IV bolus of atropine
A nurse in an emergency department is caring for school aged child who sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take?
apply an antimicrobial ointment to the affected area