practice questions for exam 3
35. Which causes the symptoms in testicular torsion? 1. Twisting of the spermatic cord interrupts the blood supply. 2. Swelling of the scrotal sac leads to testicular displacement. 3. Unmanaged undescended testes cause testicular displacement. 4. Microthrombi formation in the vessels of the spermatic cord causes interruption of the blood supply.
1. Testicular torsion is caused by an interruption of the blood supply due to twisting of the spermatic cord.
6. The parent of a 5-year-old states that the child has been having diarrhea for 24 hours, vomited twice 2 hours ago, and now claims to be thirsty. The parent asks what to offer the child because the child is refusing Pedialyte. Which is the nurse ' s most appropriate response? 1. "You can offer clear diet soda such as Sprite and ginger ale." 2. "Pedialyte is really the best thing for your child, who, if thirsty enough, will eventually drink it." 3. "Pedialyte is really the best thing for your child. Allow your child some choice in the way to take it by offering small amounts in a spoon, medicine cup, or syringe." 4. "It really does not matter what your child drinks as long as it is kept down. Try offering small amounts of fl uids in medicine cups."
3. Pedialyte is the fi rst choice, as recommended by the American Academy of Pediatrics. Offering the child appropriate choices may allow the child to feel empowered and less likely to refuse the Pedialyte. Small, frequent amounts are usually better tolerated.
13. The clinical manifestations of minimal change nephrotic syndrome (MCNS) are due to which of the following? 1. Chemical changes in the composition of albumin. 2. Increased permeability of the glomeruli. 3. Obstruction of the capillaries of the glomeruli. 4. Loss of the kidneys 'ability to excrete waste and concentrate urine
2. Increased permeability of the glomeruli in MCNS allows large substances such as protein to pass through and be excreted in the urine.
34. The parents of a newborn diagnosed with a cleft lip and palate ask the nurse when their child ' s lip and palate will most likely be repaired. Which is the nurse ' s best response? 1. "The palate and the lip are usually repaired in the fi rst few weeks of life so that the baby can grow and gain weight." 2. "The palate and the lip are usually not repaired until the baby is approximately 6 months old so that the mouth has had enough time to grow." 3. "The lip is repaired in the fi rst few months of life, but the palate is not usually repaired until the child is 3 years old." 4. "The lip is repaired in the fi rst few weeks of life, but the palate is not usually repaired until the child is 18 months old."
4. The lip is repaired in the fi rst few weeks of life, but the palate is not usually repaired until the child is 18 months old.
10. A woman has just arrived at the labor and delivery suite. Before reporting the client's arrival to her primary healthcare practitioner, which of the following assessments should the nurse perform? Select all that apply. 1. Fetal heart rate. 2. Contraction pattern. 3. Urinalysis. 4. Vital signs. 5. Biophysical profile.
Answers 1, 2, and 4 are correct. 1. The nurse should assess the fetal heart rate before reporting the client's status to the healthcare provider. 2. The nurse should assess the contraction pattern before reporting the client's status. 4. The nurse should assess the woman's vital signs before reporting her status
37. Which should be included in the plan of care for a 14-month-old whose cleft palate was repaired 12 hours ago? Select all that apply. 1. Allow the infant to have familiar items of comfort such as a favorite stuffed animal and a "sippy" cup. 2. Once liquids have been tolerated, encourage a bland diet such as soup, Jell-O, and saltine crackers. 3. Administer pain medication on a regular schedule, as opposed to an as-needed schedule. 4. Use a Yankauer suction catheter on the infant ' s mouth to decrease the risk of aspiration of oral secretions. 5. When discharged, remove elbow restraints.
1, 3. 1. The child should not be allowed to use anything that creates suction in the mouth, such as pacifi ers or straws. "Sippy" cups are acceptable. 3. Pain medication should be administered regularly to avoid crying, which places stress on the suture line.
14. The nurse is caring for an infant newly diagnosed with Hirschsprung disease. What does the nurse understand about this infant ' s condition? Select all that apply. 1. There is a lack of peristalsis in the large intestine and an accumulation of bowel contents, leading to abdominal distention. 2. There is excessive peristalsis throughout the intestine, resulting in abdominal distention. 3. There is a small-bowel obstruction, leading to ribbon-like stools. 4. There is infl ammation throughout the large intestine, leading to accumulation of intestinal contents and abdominal distention. 5. There is an accumulation of bowel contents, leading to non-passage of stools.
1, 5. 1. In Hirschsprung disease, a portion of the large intestine has an area lacking in ganglion cells. This results in a lack of peristalsis as well as an accumulation of bowel contents and abdominal distention. 5. There is accumulation of stool above the aganglionic bowel, which does not allow stool to pass through.
4. A 4-month-old is brought to the emergency department with severe dehydration. The heart rate is 198, and her blood pressure is 68/38. The infant ' s anterior fontanel is sunken. The nurse notes that the infant does not cry when the intravenous line is inserted. The child ' s parents state that she has not "held anything down" in 18 hours. The nurse obtains a fi nger-stick blood sugar of 94. Which would the nurse expect to do immediately? 1. Administer a bolus of normal saline. 2. Administer a bolus of D 10W. 3. Administer a bolus of normal saline with 5% dextrose added to the solution. 4. Offer the child an oral rehydrating solution such as Pedialyte.
1. Dehydration is corrected with the administration of an isotonic solution, such as normal saline or lactated Ringer solution.
7. Which child is at risk for developing glomerulonephritis? 1. A 3-year-old who had impetigo 1 week ago. 2. A 5-year-old with a history of five UTIs in the previous year. 3. A 6-year-old with new-onset type 1 diabetes. 4. A 10-year-old recovering from viral pneumonia.
1. Impetigo is a skin infection caused by the streptococcal organism that is commonly associated with glomerulonephritis.
53. The fetal monitor tracing of a laboring client who is 9 cm dilated shows recurrent late decelerations. The nurse notes a moderate amount of greenish-colored amniotic fluid gush from the vagina after the healthcare provider performs an amniotomy. Which of the following conditions is the client at risk for, at this time? 1. Risk for infection related to rupture of membranes. 2. Risk for fetal injury related to possible intrauterine hypoxia. 3. Risk for impaired tissue integrity related to vaginal irritation. 4. Risk for maternal injury related to possible uterine rupture.
2. Green amniotic fluid in the presence of recurrent late decelerations suggests fetal stress due to intrauterine hypoxia.
24. Which needs to be present to diagnose hemolytic uremic syndrome (HUS)? 1. Increased red blood cells with a low reticulocyte count, increased platelet count, and renal failure. 2. Decreased red blood cells with a high reticulocyte count, decreased platelet count, and renal failure. 3. Increased red blood cells with a high reticulocyte count, increased platelet count, and renal failure. 4. Decreased red blood cells with a low reticulocyte count, decreased platelet count, and renal failure.
2. The triad in HUS includes decreased red blood cells (with a high reticulocyte count as the body attempts to produce more red blood cells), decreased platelet count, and renal failure.
36. The nurse is caring for a 4-month-old who has just had an isolated cleft lip repaired. Select the best position for the child in the immediate post-operative period. 1. Right side-lying. 2. Left side-lying. 3. Supine. 4. Prone.
3. The supine position is preferred because there is decreased risk of the infant rubbing the suture line.
33. A nurse is triaging four clients on the labor and delivery unit. Which of the following actions should be a priority for nursing care? 1. Check the blood sugar of a gestational diabetic. 2. Assess the vaginal blood loss of a client who is recovering from a spontaneous abortion. 3. Assess the patellar reflexes of a client with pre-eclampsia without severe features. 4. Check the fetal heart rate of a client whose membranes just ruptured.
4. The priority action for this nurse is to assess the fetal heart rate of a client whose membranes have just ruptured. The nurse is assessing for prolapsed cord, which is an obstetric emergency.
5. The pregnant mother of a child diagnosed with erythema infectiosum (fi fth disease) is crying, and says, "I am afraid. Will my unborn baby die? I have a planned cesarean section next week." Which statement would be the most therapeutic response? 1. "Let me get the physician to come and talk with you." 2. "I understand. I would be afraid, too." 3. "Would you like me to call your obstetrician to have you seen as soon as possible?" 4. "I understand you are afraid. Can we can talk about your concerns?"
4. There is less risk of fetal death in the second half of the pregnancy. It is more therapeutic to acknowledge a client ' s fears. After acknowledging her fears, the appropriate response would be to discuss concerns and clarify any misconceptions.
7. A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse gather from the woman's prenatal record when planning nursing care? Select all that apply. 1. Weight gain. 2. Ethnicity and religion. 3. Age. 4. Type of insurance. 5. Gravidity and parity
7. Answers 1, 2, 3, and 5 are correct. 1. The nurse should check the client's weight gain reported in her prenatal record. This will guide how the nurse plans for delivery and newborn care. 2. The client's ethnicity and religion should be noted. This allows the nurse to proceed in a culturally sensitive manner. 3. The client's age should be noted. Clients over age 35 (advanced maternal age) are at risk for prolonged labor and postpartum bleeding. 5. The client's gravidity and parity—how many times she has been pregnant and how many times she has given birth— should also be noted as a guide for the anticipated length of labor and client teaching that may be necessary.
81. Which of the following actions would the nurse expect to perform before a woman is to have regional anesthesia? Select all that apply. 1. Assess fetal heart rate. 2. Infuse 500-1,000 mL of Ringer's lactate solution. 3. Place the woman in the Trendelenburg position. 4. Monitor blood pressure every 5 minutes for 15 minutes. 5. Have the woman empty her bladder.
Answers 1, 2, 4, and 5 are correct. 1. Before a woman is given regional anesthesia, the nurse should assess the fetal heart rate to confirm fetal well-being. 2. The nurse should receive an order to infuse Ringer's lactate before the woman is given regional anesthesia. The anesthesiologist will determine the amount of IV fluid the woman should receive, based on her medical condition. A woman with pre-eclampsia should be on fluid restrictions and generally just 500 mL of IV solution is ordered. 4. A baseline blood pressure is necessary, and successive blood pressures will be monitored frequently after the epidural insertion is completed, as ordered by the anesthesia provider. 5. The nurse should ask the woman to empty her bladder. Because she may be unable to empty her bladder spontaneously after the epidural is inserted, this can prevent the immediate need for a catheterization after the epidural is in place.
87. The nurse in the obstetrician's office is caring for four prenatal clients with singleton pregnancies at 25 weeks' gestation. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor (PTL)? Select all that apply. 1. 38-year-old in an abusive relationship. 2. 34-year-old whose first child was born at 32 weeks' gestation. 3. 30-year-old whose baby has a two-vessel cord. 4. 26-year-old with a history of long menstrual periods. 5. 22-year-old who smokes 2 packs of cigarettes every day
Answers 1, 2, and 5 are correct. 1. This client is high risk for PTL because she is over 35 years of age and in an abusive relationship. 2. A previous preterm delivery places a client at increased risk of preterm labor. 5. A client who smokes cigarettes is at high risk for preterm labor
31. Immediately after a client's membranes rupture spontaneously, the nurse notes a loop of the umbilical cord protruding from the client's vagina. Which of the following actions are essential for the nurse to perform? Select all that apply. 1. Put the client in the knee-chest, or Trendelenburg position. 2. Assess the fetal heart rate by palpating the cord. 3. Administer oxygen by tight face mask. 4. Telephone the primary healthcare provider with the findings.
Answers 1, 3, and 4 are correct. 1. The first action the nurse should take is to place the client in the knee-chest, or Trendelenburg position 3. Oxygen should be administered. 4. The primary healthcare provider should be notified immediately.
75. A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? 1. 2 cm. 2. 4 cm. 3. 8 cm. 4. 10 cm
1. The nurse would expect the woman to be 2 cm dilated.
89. The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and −2 station. Which of the following has the nurse palpated? 1. Thin cervix. 2. Bulging fetal membranes. 3. Head at the pelvic outlet. 4. Closed cervix.
1. The cervix is thin
27. The nurse is providing discharge instructions to the parents of a child who had an appendectomy for a ruptured appendix 5 days ago. The nurse knows that further education is required when the parent states which of the following? Select all that apply. 1. "We will wait a few days before allowing our child to return to school." 2. "We will wait 2 weeks before allowing our child to return to sports." 3. "We will call the health-care provider ' s offi ce if we notice any drainage around the wound." 4. "We will encourage our child to go for walks every day." 5. "We will encourage our child to eat at every meal and offer snacks."
2, 3. 2. The child should wait 6 weeks before returning to any strenuous activity. 3. Any signs of infection should be reported to the surgeon
20. Which would the nurse most likely fi nd in the history of a child with hemolytic uremic syndrome (HUS)? Select all that apply. 1. Frequent UTIs and possible vesicoureteral refl ux (VUR). 2. Vomiting and diarrhea before admission. 3. Bee sting and localized edema of the site for 3 days. 4. Previously healthy with no signs of illness. 5. Anorexia and bruising.
2, 5 2. HUS is often preceded by diarrhea that may be caused by E. coli present in undercooked meat. 5. Anorexia and bruising (purura and/ or petechiae) are common clinical manifestations.
74. A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? 1. "I am so excited to be in labor." 2. "I can't stand this pain any longer!" 3. "I need ice chips because I'm so hot." 4. "I have to push the baby out right now!"
2. "I can't stand the pain!" is a comment consistent with a client in the transition phase of stage 1.
93. A 30-year-old client with an obstetrical history of G2 P0010 is in preterm labor. She is receiving nifedipine. Which of the following maternal assessments noted by the nurse must be reported to the primary healthcare provider immediately? 1. Heart rate of 100 bpm. 2. Wakefulness. 3. Audible rales. 4. Daily output of 2,000 mL.
3. Audible rales should be reported to the healthcare provider.
81. A client is scheduled to have an external version for a breech presentation. The nurse carefully assesses the client's chart knowing that which of the following is a contraindication to this procedure? 1. Station -2. 2. 38 weeks' gestation. 3. Reactive nonstress test (NST). 4. Previous cesarean section.
4. Previous cesarean section is a contraindication for external version.
45. A nurse is educating a pregnant woman regarding the moves a fetus makes during the birthing process. Please place the following cardinal movements of labor in order: 1. Descent. 2. Expulsion. 3. Extension. 4. External rotation. 5. Internal rotation.
The correct order of the movements listed is: 1, 5, 3, 4, 2. 1. Descent. 5. Internal rotation. 3. Extension. 4. External rotation. 2. Expulsion.
47. A client at 38 weeks' gestation is in labor and delivery with a painful, board-like abdomen. Which of the following assessments is appropriate at this time? 1. Fetal heart rate. 2. Cervical dilation. 3. White blood cell count. 4. Maternal lung sounds.
1. A fetal heart rate check is the appropriate assessment.
11. A client at 40 weeks' gestation has received misoprostol for cervical ripening. The nurse would be correct in carefully monitoring for which of the following signs and symptoms? 1. Diarrhea and back pain. 2. Hypothermia and rectal pressure. 3. Urinary retention and rash. 4. Tinnitus and respiratory distress.
1. A common side effect of misoprostol is diarrhea. Back pain could be a sign of the start of labor, since labor contractions are often first felt in the back.
12. Which statement by a parent is most consistent with minimal change nephrotic syndrome (MCNS)? 1. "My child missed 2 days of school last week because of a really bad cold." 2. "After camping last week, my child ' s legs were covered in bug bites." 3. "My child came home from school a week ago because of vomiting and stomach cramps." 4. "We have a pet turtle, but no one washes their hands after playing with the turtle."
1. An upper respiratory infection often precedes MCNS by a few days.
23. A child with hemolytic uremic syndrome (HUS) is very pale and lethargic. Stools have progressed from watery to bloody diarrhea. Blood work indicates low hemoglobin and hematocrit levels. The child has not had any urine output in 24 hours. The nurse expects administration of blood products and what else to be added to the plan of care? 1. Initiation of dialysis. 2. Close observation of the child ' s hemodynamic status. 3. Diuretic therapy to force urinary output. 4. Monitoring of urinary output.
1. Because the child is symptomatic, dialysis is the treatment of choice.
19. On examination of a full-term primiparous client, a labor nurse notes: active labor, right occiput anterior (ROA) position, 10 cm dilated, and +3 station (using a 5-cm scale). Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.
1. Descent is progressing well. The presenting part is 3 centimeters below the ischial spines, well into the birth canal.
22. The parents of a child being evaluated for appendicitis tell the nurse the health-care provider said their child has a positive Rovsing sign. They ask the nurse what this means. Which is the nurse ' s best response? 1. "Your child ' s health-care provider should answer that question." 2. "A positive Rovsing sign means the child feels pain in the right side of the abdomen when the left side is palpated." 3. "A positive Rovsing sign means pain is felt when the physician removes the hand from the abdomen." 4. "A positive Rovsing sign means pain is felt in the right lower quadrant when the child coughs."
2. A positive Rovsing sign occurs when the left lower quadrant is palpated and pain is felt in the right lower quadrant.
26. The nurse is caring for a 3-year-old who had an appendectomy 2 days ago. The child has a fever of 101.8°F (38.8°C) and breath sounds are slightly diminished in the right lower lobe. Which action is most appropriate? 1. Teach the child how to use an incentive spirometer. 2. Encourage the child to blow bubbles. 3. Obtain an order for intravenous antibiotics. 4. Obtain an order for acetaminophen (Tylenol).
2. Blowing bubbles is a developmentally appropriate way to help the preschooler take deep breaths and cough.
42. A nurse notes a sinusoidal fetal heart pattern while analyzing the fetal heart tracing of a newly admitted client. Which of the following actions should the nurse take at this time? 1. Encourage the client to breathe with contractions. 2. Notify the primary healthcare provider. 3. Increase the intravenous infusion. 4. Encourage the client to push with contractions.
2. Sinusoidal patterns are related to Rh isoimmunization, fetal anemia, severe fetal hypoxia, or a chronic fetal bleed. They also may occur transiently as a result of intravenous narcotic administration for pain. Because this client has just been admitted, medication administration is not a likely cause and a more serious condition could be the cause. The primary healthcare provider must be notified immediately.
6. Which would be the priority intervention for a child suspected of having varicella (chickenpox)? 1. Contact precautions. 2. Contact and droplet respiratory precautions. 3. Droplet respiratory precautions. 4. Universal precautions and standard precautions.
2. Varicella (chickenpox) is highly contagious. Contact and droplet respiratory precautions should be started immediately because the primary source of transmission is secretions of the respiratory tract (droplet) and also by contaminated objects. TEST-TAKING HINT: The test taker understands that the primary source of transmission of varicella (chickenpox) is secretions of the respiratory tract of infected persons (airborne). Transmission occurs by direct contact, skin lesions to a lesser extent, and contaminated objects.
56. During the delivery of a macrosomic baby, a client developed a fourth-degree laceration. The nurse has just reviewed with the client, the provider's education about the laceration. Which comment by the client indicates she understands the extent of her laceration? 1. "My laceration extended into the muscles around my anus." 2. "My laceration extended into my urinary meatus where I pee." 3. "My laceration extended through my rectal sphincter into my rectum." 4. "My laceration extended up to my clitoris."
3. A fourth-degree laceration extends through the rectal sphincter into the rectum.
15. The nurse is caring for a 3-month-old being evaluated for possible Hirschsprung disease. His parents call the nurse and show her his diaper containing a large amount of mucus and bloody diarrhea. The nurse notes that the infant is irritable and his abdomen appears very distended. Which should be the nurse ' s next action? 1. Reassure the parents that this is an expected fi nding and not uncommon. 2. Call a code for a potential cardiac arrest and stay with the infant. 3. Immediately obtain all vital signs with a quick head-to-toe assessment. 4. Obtain a stool sample for occult blood.
3. All vital signs need to be evaluated because the child with enterocolitis can quickly progress to a state of shock. A quick head-to-toe assessment will allow the nurse to evaluate the child ' s circulatory system.
48. The nurse is caring for a 5-month-old infant with a diagnosis of intussusception. The infant has periods of irritability during which the knees are brought to the chest and the infant cries, alternating with periods of lethargy. Vital signs are stable and within age-appropriate limits. The health-care provider elects to give an enema. The parents ask the purpose of the enema. Which is the nurse ' s most appropriate response? 1. "The enema will confi rm the diagnosis. If the test result is positive, your child will need to have surgery to correct the intussusception." 2. "The enema will confirm the diagnosis. Although very unlikely, the enema may also help fi x the intussusception so that your child will not immediately need surgery." 3. "The enema will help confirm the diagnosis and has a good chance of fixing the intussusception." 4. "The enema will help confirm the diagnosis and may temporarily fi x the intussusception. If the bowel returns to normal, there is a strong likelihood that the intussusception will recur."
3. In most cases of intussusception in young children, an enema is successful in reducing the intussusception.
42. A pregnant client at term called the labor suite at 1900, questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions hurt more than they did before." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my nap."
3. This response indicates that the labor contractions are increasing in intensity
17. The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? 1. Mentum anterior. 2. Sacrum posterior. 3. Occiput posterior. 4. Scapula anterior.
3. When a fetus is in the occiput posterior position, mothers frequently complain of severe back pain.
28. A client who is hepatitis B surface antigen positive is in active labor. Which action by the nurse is appropriate at this time? 1. Obtain an order from the obstetrician to prepare the client for cesarean delivery. 2. Obtain an order from the obstetrician to administer intravenous penicillin during labor and the immediate postpartum. 3. Obtain an order from the pediatrician to administer hepatitis B immune globulin and hepatitis B vaccine to the baby after birth. 4. Obtain an order from the pediatrician to place the baby in isolation after delivery.
3. Within 12 hours of birth, the baby should receive both the first injection of hepatitis B vaccine and HBIG (hepatitis B immune globulin).
37. A client with an obstetrical history of G3 P2002 is 6 cm dilated. The fetal monitor tracing shows recurrent late decelerations. The client's doctor informs her that the baby must be delivered by cesarean section. The client refuses to sign the informed consent. Which of the following actions by the nurse is appropriate? 1. Strongly encourage the client to sign the informed consent. 2. Prepare the client for the cesarean section. 3. Inform the client that the baby will likely die without the surgery. 4. Provide the client with ongoing labor support.
4. At this point the appropriate action for the nurse to take is to continue providing labor support. If accepted, emergency interventions, like providing oxygen by face mask and repositioning the client, would also be indicated.
54. The nurse is caring for a 14-year-old with celiac disease. The nurse knows that the patient understands the diet instructions by ordering which of the following meals? 1. Eggs, bacon, rye toast, and lactose-free milk. 2. Pancakes, orange juice, and sausage links. 3. Oat cereal, breakfast pastry, and nonfat skim milk. 4. Cheese, banana slices, rice cakes, and whole milk.
4. Cheese, banana slices, rice cakes, and whole milk do not contain gluten.
82. A client is scheduled for an external version. The nurse would expect to prepare which of the following medications to be administered prior to the procedure? 1. Oxytocin. 2. Methylergonovine. 3. Betamethasone. 4. Terbutaline.
4. Terbutaline is a smooth, muscle-relaxing agent. It would be administered prior to an external version to relax the uterus and prevent contractions.
51. A woman who is in active labor is told by her obstetrician, "Your baby's head is flexed." When she asks the nurse what that means, what should the nurse say? 1. The baby is in the breech position. 2. The baby is in the horizontal lie. 3. The baby's presenting part is engaged. 4. The baby's chin is resting on its chest
4. When the baby's chin is on its chest, the baby is in the flexed attitude.
79. On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor, but feels no urge to push. The fetus is at zero station and the baseline fetal heart rate is 130 bpm with no decelerations. Which of the following nursing actions is appropriate at this time? 1. Coach the woman to hold her breath while pushing 3 to 4 times with each contraction. 2. Administer oxygen via face mask at 8 to 10 liters per minute. 3. Allow the mother to labor down. 4. Place the woman on her side and assess her oxygen saturation.
1. It is recommended that women begin pushing once they are at 10 centimeters.
97. A client with a fetal demise is admitted to labor and delivery in the latent phase of labor. Which of the following behaviors would the nurse expect this client to exhibit? 1. Crying and sadness. 2. Talkative and excited. 3. Quietly doing rapid breathing. 4. Loudly chanting songs.
1. The nurse would expect the client to be crying and exhibiting sadness.
33. While evaluating the fetal heart rate (FHR) monitor tracing on a client in labor, the nurse notes that there are decelerations present. Which of the following assessments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart rate transducer in relation to the fetal position.
1. The relationship between the decelerations and the contractions will determine the type of deceleration pattern.
9. The parent of a child with glomerulonephritis asks the nurse why the urine is such a funny color. Which is the nurse ' s best response? 1. "It is not uncommon for the urine to be discolored when children are receiving steroids and blood pressure medications." 2. "There is blood in your child ' s urine that causes it to be tea-colored." 3. "Your child ' s urine is very concentrated, so it appears to be discolored." 4. "A ketogenic diet often causes the urine to be tea-colored."
2. Blood in the child ' s urine causes it to be tea-colored.
7. Which would be the priority intervention for a child diagnosed with chickenpox (varicella) who was prescribed diphenhydramine (Benadryl) for itching? 1. Give a warm bath with mild soap before lotion application. 2. Avoid Caladryl lotion while taking diphenhydramine (Benadryl). 3. Apply Caladryl lotion generously to decrease itching. 4. Give a cool shower with mild soap to decrease itching.
2. Caladryl lotion contains diphenhydramine (Benadryl), and the child would be at risk for toxicity if the Caladryl is applied to open lesions.
40. A client's assessments reveal that she is 4 cm dilated and 90% effaced with a fetal heart rate tracing showing recurrent late decelerations, minimal variability, and contractions every 3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals? 1. Completion of the first stage of labor. 2. Delivery of a healthy baby. 3. Safe pain medication management. 4. Prevention of a vaginal laceration.
2. The nurse's goal at this point must be the delivery of a healthy baby
4. An 18-month-old is discharged from the hospital after having a febrile seizure secondary to exanthem subitum (roseola). On discharge, the mother asks the nurse if her 6-year-old twins will get sick. Which teaching about the transmission of roseola would be most accurate? 1. The child should be isolated in the home until the vesicles have dried. 2. The child does not need to be isolated from the older siblings. 3. Administer acetaminophen to the older siblings to prevent seizures. 4. Monitor older children for seizure development.
2. The route of roseola transmission is unknown, and the disease is more commonly seen in children 6 months to 3 years of age, so siblings do not need to be isolated. TEST-TAKING HINT: The test taker should understand that the route of exanthema subitum (roseola) transmission is unknown, and the disease is usually limited to children 6 months to 3 years of age; isolation is not necessary.
57. The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions must the nurse perform at this time? 1. Place the client in the lateral recumbent position. 2. Carefully analyze the baseline data on the monitor tracing. 3. Administer oxygen to the mother via face mask. 4. Ask the mother to indicate when she feels fetal movement.
2. The variability of the fetal heart rate is determined by analyzing the fluctuations of the baseline rate.
90. Three clients at 30 weeks' gestation are on the labor and delivery unit in preterm labor. For which of the clients should the nurse question a doctor's order for beta agonist tocolytics? 1. A client with hypothyroidism. 2. A client with breast cancer. 3. A client with cardiac disease. 4. A client with asthma.
3. A history of cardiac disease would place a client who is to receive a beta agonist medication at risk because it affects the heart. The nurse should question this order.
55. Which would the nurse expect to be included to make the diagnosis of celiac disease in a child? 1. Obtain complete blood count and serum electrolytes. 2. Obtain complete blood count and stool sample; keep child NPO. 3. Obtain stool sample and prepare child for jejunal biopsy. 4. Obtain complete blood count and serum electrolytes; monitor child ' s response to gluten-containing diet.
3. A stool sample for analysis of fat and a jejunal biopsy can confirm the diagnosis.
19. There are four clients in active labor in the labor suite. Which of the clients should the nurse monitor carefully for a potential uterine rupture? 1. Age 15, G3 P0020, in active labor. 2. Age 22, G1 P0000, eclampsia. 3. Age 25, G4 P3003, last delivery by cesarean section. 4. Age 32, G2 P0100, first baby died during labor.
3. Any client who has had a previous cesarean section is at risk for uterine rupture.
69. A multipara with a fetus in the LOA position at +3 station has had no pain medica - tion during her labor. She is now in second stage. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? 1. "Epidurals do not work well when the pain level is above level 5." 2. "I will contact the doctor to get an order for an epidural right away." 3. "The baby is going to be born very soon. It is really too late for an epidural." 4. "I will check the fetal heart rate. You can have an epidural if it is over 120."
3. Because this woman is a multipara, the position is LOA, and the station is +3, this is an accurate statement.
7. The nurse is caring for a 9-month-old with diarrhea secondary to rotavirus. The child has not vomited and is mildly dehydrated. Which is likely to be included in the discharge teaching? 1. Administer loperamide (Imodium) as needed. 2. Administer bismuth subsalicylate (Kaopectate) as needed. 3. Continue breastfeeding per routine. 4. The infant may return to day care 24 hours after antibiotics have been started.
3. Breastfeeding is usually well tolerated and helps prevent death of intestinal villi and malabsorption.
25. The nurse is caring for a 5-year-old who has just returned from having an appendectomy. Which is the optimal way to manage pain? 1. Intravenous morphine as needed. 2. Liquid acetaminophen (Tylenol) with codeine as needed. 3. Morphine administered through a PCA pump. 4. Intramuscular morphine as needed.
3. Morphine administered through a PCA pump offers the child control over managing pain. The PCA pump also has the benefi t of offering a basal rate as well as an as-needed rate for optimal pain management.
5. The nurse is caring for a 2-year-old child who was admitted to the pediatric unit for moderate dehydration due to vomiting and diarrhea. The child is restless with periods of irritability. The child is afebrile with a heart rate of 148 and a blood pressure of 90/42. Baseline laboratory tests reveal the following: Na 152, Cl 119, and glucose 115. The parents state that the child has not urinated in 12 hours. After establishing a saline lock, the nurse reviews the physician ' s orders. Which order should the nurse question? 1. Administer a saline bolus of 10 mL/kg, which may be repeated if the child does not urinate. 2. Recheck serum electrolytes in 12 hours. 3. After the saline bolus, begin maintenance fl uids of D5 ¼ NS with 10 mEq KCl/L. 4. Give clear liquid diet as tolerated.
3. Potassium is contraindicated because the child has not yet urinated. Potassium is not added to the maintenance fl uid until kidney function has been verified.
44. The nurse is caring for an infant with pyloric stenosis. The parent asks if any future children will likely have pyloric stenosis. Which is the nurse ' s best response? 1. "You seem worried; would you like to discuss your concerns?" 2. "It is very rare for a family to have more than one child with pyloric stenosis." 3. "Pyloric stenosis can run in families. It is more common among males." 4. "Although there can be a genetic link, it is very unusual for girls to have pyloric stenosis."
3. Pyloric stenosis can run in families, and it is more common in males.
30. Immediately prior to an amniotomy, the external fetal heart monitor tracing shows 145 bpm with moderate variability and early decelerations. Immediately following the procedure, the tracing shows a fetal heart rate of 120 with a prolonged deceleration. A moderate amount of clear, amniotic fluid is seen on the bed linens. The nurse concludes that which of the following has occurred? 1. Placental abruption. 2. Eclampsia. 3. Prolapsed cord. 4. Succenturiate placenta
3. The drop in fetal heart rate with a prolonged deceleration indicates that the cord has likely prolapsed.
18. When performing Leopold maneuvers, the nurse notes that the fetus is in the left occiput anterior (LOA) position. Which is the best position for the nurse to place a fetoscope to hear the fetal heart rate? 1. Left upper quadrant. 2. Right upper quadrant. 3. Left lower quadrant. 4. Right lower quadrant
3. The fetoscope should be placed in the left lower quadrant for a fetus positioned in the LOA position as described in the question. This positions the fetoscope to record the fetal heart rate through the fetal back, which is recommended.
23. Which is the best position for an 8-year-old who has just returned to the pediatric unit after an appendectomy for a ruptured appendix? 1. Semi-Fowler. 2. Prone. 3. Right side-lying. 4. Left side-lying.
3. The right side-lying position promotes comfort and allows the peritoneal cavity to drain.
73. An anesthesiologist informs the nurse that a client scheduled for cesarean section will have the procedure under general anesthesia rather than regional anesthesia. Which of the following would warrant this decision? 1. The client has a history of drug addiction. 2. The client is allergic to morphine sulfate. 3. The client is a 13-year-old adolescent. 4. The client has had surgery for scoliosis.
4. A history of scoliosis surgery is a contraindication for spinal anesthesia.
8. A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status? 1. Leopold maneuvers. 2. Fundal tone. 3. Fetal heart rate assessment. 4. Cervical examination.
4. A vaginal examination of the cervix will provide the nurse with the best information about the status of labor.
67. A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? 1. Hold her breath for 20 seconds during every contraction. 2. Blow out forcefully during every contraction. 3. Push between contractions until the fetal head is visible. 4. Take a cleansing breath before bearing down.
4. By taking a cleansing breath before pushing, the woman is waiting until the contraction builds to its peak. Her pushes will be more effective at this point in the contraction.
16. A parent asks the nurse how to prevent the child from having minimal change nephrotic syndrome (MCNS) again. Which is the nurse ' s best response? 1. "It is very rare for a child to have a relapse after having fully recovered." 2. "Unfortunately, many children have cycles of relapse, and there is very little that can be done to prevent it." 3. "Your child is much less likely to get sick again if sodium is decreased in the diet." 4. "Try to keep your child away from sick children because relapses have been associated with infectious illnesses."
4. Exposure to infectious illness has been linked to the relapse of minimal change nephrotic syndrome.
12. A client with an obstetrical history of G3 P1010, is receiving oxytocin via IV pump at 3 milliunits/min. Her current contraction pattern is every 3 minutes × 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of the following interventions should the nurse take at this time? 1. Stop the infusion. 2. Give oxygen via face mask. 3. Change the client's position. 4. Monitor the client's labor client.
4. It is appropriate to monitor the client's labor.
67. A client with an internal fetal spiral electrode in place has just received an IV narcotic for pain relief. Which of the following monitor tracing changes should the nurse anticipate? 1. Early decelerations. 2. Late decelerations. 3. Minimal variability. 4. Accelerations after contractions.
3. Minimal variability would be expected as a result of narcotic administration.
61. The parents of a 3-year-old are concerned that the child is having "more accidents" during the day. Which questions would be appropriate for the nurse to ask to obtain more information? Select all that apply. 1. "Has there been a stressful event in the child ' s life, such as the birth of a sibling?" 2. "Has anyone else in the family had problems with accidents?" 3. "Does your child seem to be drinking more than usual?" 4. "Is your child more fussy, and does your child seem to be in pain when urinating?" 5. "Is your child having diffi culties at preschool?"
1, 2, 3, 4. 1. Stressors such as the birth of a sibling can lead to incontinence in a child who previously had bladder control. 2. A pattern of enuresis can often be seen in families. 3. Increased thirst and incontinence can be associated with diabetes. 4. Fussiness and incontinence can be associated with UTIs.
11. The parents of a child with glomerulonephritis ask how they will know their child is improving after they go home. Which are the nurse ' s best responses? Select all that apply. 1. "Your child ' s urine output will increase, and the urine will become less tea-colored." 2. "Your child will have more energy as lab tests become more normal." 3. "Your child ' s appetite will decrease as urine output increases." 4. "Your child ' s laboratory values will become more normal." 5. "Your child ' s weight will increase as the urine becomes less tea-colored."
1, 5. 1. When glomerulonephritis is improving, urine output increases, and the urine becomes less tea-colored. These are signs that can be monitored at home by the child ' s parents. 5. The child ' s weight will increase as the urine resumes a more normal color, indicating lab values are returning to normal and the child is better.
9. A client at 38 weeks' gestation with hypertension and oligohydramnios is being induced with IV oxytocin. She is contracting q 3 min × 60 to 90 seconds. She suddenly complains of abdominal pain. The nurse notices significant fetal heart rate bradycardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician.
1. Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin drip.
45. Which of the following is the appropriate nursing care outcome for a client who suddenly develops anaphylactoid syndrome of pregnancy (ASP) during labor? 1. Client will be infection free at discharge. 2. Client will exhibit normal breathing function at discharge. 3. Client will exhibit normal gastrointestinal function at discharge. 4. Client will void without pain at discharge.
2. Because ASP begins in the lungs, the appropriate nursing care outcome is that the client survives and is breathing normally at discharge.
35. The nurse is caring for a newborn with a cleft lip and palate. The mother states, "I will not be able to breastfeed my baby." Which is the nurse ' s best response? 1. "It sounds like you are feeling discouraged. Would you like to talk about it?" 2. "Sometimes breastfeeding is still an option for babies with a cleft lip and palate. Would you like more information?" 3. "Although breastfeeding is not an option, you can pump your milk and then feed it to your baby with a special nipple." 4. "We usually discourage breastfeeding babies with cleft lip and palate as it puts them at an increased risk for aspiration."
2. Some mothers are able to breastfeed their infants who have a cleft lip and palate. The breast can help fi ll in the cleft and help the infant create suction.
28. Which would be the priority intervention for the newborn of a mother positive for hepatitis antigen? 1. The newborn should be given the fi rst dose of hepatitis B vaccine by 2 months of age. 2. The newborn should receive the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. 3. The newborn should receive the hepatitis B vaccine and hepatitis B immune globulin within 24 hours of birth. 4. The newborn should receive hepatitis B immune globulin within 12 hours of birth.
2. The newborn should receive both hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth to prevent hepatitis B infection. TEST-TAKING HINT: The test taker should understand that infants born to mothers who test positive for hepatitis B antigen should receive hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth to prevent infection.
25. A 5-year-old is discharged from the hospital following the diagnosis of hemolytic uremic syndrome (HUS). The child has been free of diarrhea for 1 week, and renal function has returned. The parent asks the nurse when the child can return to school. Which is the nurse ' s best response? 1. "Immediately, as your child is no longer contagious." 2. "It would be best to keep your child home for a few more weeks because the immune system is weak, and there could be a relapse of HUS." 3. "Your child will be contagious for approximately another 10 days, so it is best to not allow a return just yet." 4. "It would be best to keep your child home to monitor urinary output."
3. Children with HUS are considered contagious for up to 17 days after the resolution of diarrhea and should be placed on contact isolation.
76. A client has been in the second stage of labor for 2½ hours. The fetal head is at +4 station and the fetal heart rate is showing recurrent late decelerations. The obstetrician advises the client that the baby will be delivered with forceps. Which of the following actions should the nurse take at this time? 1. Obtain a consent for the use of forceps. 2. Encourage the client to push between contractions. 3. Assess the fetal heart rate continuously. 4. Advise the client to refuse the use of forceps.
3. The FHR should always be assessed continuously in this situation with recurrent late decelerations. The FHR indicates fetal hypoxemia and possible hypoxia.
34. An adolescent woke up complaining of intense pain and swelling of the scrotal area and abdominal pain. He has vomited twice. Which should the nurse suggest? 1. Encourage him to drink clear liquids until the vomiting subsides; if he gets worse, bring him to the emergency room. 2. Bring him to the health-care provider ' s offi ce for evaluation. 3. Take him to the emergency department immediately. 4. Encourage him to rest; apply ice to the scrotal area and go to the emergency department if the pain does not improve.
3. The child is having symptoms of testicular torsion, which is a surgical emergency and needs immediate attention.
79. A client had an epidural inserted 2 hours ago. It is functioning well, the client is hemodynamically stable, and the client's labor is progressing as expected. Which of the following assessments is the highest priority at this time? 1. Assess blood pressure every 15 minutes. 2. Assess pulse rate every 1 hour. 3. Palpate the client's bladder. 4. Auscultate lungs.
3. The client's bladder should be palpated
24. The nurse is to receive a 4-year-old from the recovery room after an appendectomy. The parents have not seen the child since surgery and ask what to expect. Which is the nurse ' s best response? 1. "Your child will be very sleepy, have an intravenous line in the hand, and have a nasal tube to help drain the stomach. If your child needs pain medication, it will be given intravenously." 2. "Your child will be very sleepy, have an intravenous line in the hand, and have white stockings to help prevent blood clots. If your child needs pain medication, we will give it intravenously or provide a liquid to swallow." 3. "Your child will be wide awake and will have an intravenous line in the hand. If your child needs pain medication, we will give it intravenously or provide a liquid to swallow." 4. "Your child will be very sleepy and have an intravenous line in the hand. If your child needs pain medication, we will give it intravenously."
4. In the immediate postoperative period, the child is usually sleepy but can be roused. The child usually has an intravenous line for hydration and pain medication.
59. After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate variability. Which of the following interpretations should the nurse make in relation to this finding? 1. The fetus is becoming hypoxic. 2. The fetus is becoming alkalotic. 3. The fetus is in the middle of a sleep cycle. 4. The fetus has a healthy nervous system
4. Moderate variability is indicative of fetal health and well-being.
78. A nurse concludes that a woman is in the latent phase of labor. Which of the following signs/symptoms would lead a nurse to that conclusion? 1. The woman talks and laughs during contractions. 2. The woman complains about severe back labor. 3. The woman performs effleurage during a contraction. 4. The woman asks to go to the bathroom to defecate.
1. Talking and laughing are characteristic behaviors of the latent phase.
66. A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time? 1. Assess the fetal heart rate at least every 5 minutes during and after the contraction. 2. Encourage the woman to hold her breath and push during contractions. 3. Assess the pulse and respirations of the mother every 5 minutes. 4. Position the woman on her back with her knees on her chest.
1. The fetal heart rate should be assessed during and after a contraction, every 5 minutes during the second stage of labor
32. While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows moderate variability with a baseline of 140 bpm. What should the nurse do? 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous fluids.
1. The tracing is showing a normal fetal heart rate tracing. No intervention is needed.
46. A laboring client who has developed an apparent anaphylactic syndrome of pregnancy (ASP) response is not breathing and has no pulse. In addition to calling a code, which of the following actions by the nurse, who is alone with the client, is appropriate at this time? 1. Perform cardiac compressions and breaths in a 15 to 2 ratio. 2. Provide chest compressions at a depth of at least 2 inches. 3. Compress the chest at the lower ½ of the sternum. 4. Provide rescue breaths over a 10-second time frame.
2. Chest compressions should be delivered at a depth of at least 2 inches and no more than 2.4 inches
28. In addition to breathing with contractions, the nurse should encourage women in the first stage of labor to perform which of the following therapeutic actions? 1. Lying in the lithotomy position. 2. Performing effleurage. 3. Practicing Kegel exercises. 4. Pushing with each contraction
2. Effleurage is a light massage that can soothe the mother during labor.
52. During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred. Which of the following actions by the nurse is appropriate at this time? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the client's thighs sharply toward her abdomen. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the client's fundus
2. Flexing the client's hips sharply toward her abdomen, called the McRobert's maneuver, is appropriate.
30. What would be the best plan of care for a newborn whose mother ' s hepatitis B antigen status is unknown? 1. Give the infant the hepatitis B vaccine within 12 hours of birth. 2. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. 3. Give the infant the hepatitis B vaccine within 24 hours of birth. 4. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 24 hours of birth.
2. Infants born to mothers of unknown hepatitis B antigen status should be given the hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. TEST-TAKING HINT: The test taker should understand that infants born to mothers with unknown hepatitis B antigen status should be given the hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth.
66. A doctor orders a narcotic analgesic for a laboring client. In which of the following situations is it essential for the nurse to hold the medication and not administer it? 1. Contraction pattern is every 3 min x 60 sec. '2. Fetal monitor tracing shows late decelerations. ' 3. Client sleeps between contractions. 4. The blood pressure is 150/90.
2. Late decelerations are indicative of uteroplacental insufficiency and indicate fetal intolerance of labor. It is inappropriate to administer a central nervous system (CNS) depressant to the mother at this time.
20. A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 120 bpm with moderate variability. Which assessment is most important for the nurse to make at this time? 1. Contraction frequency and duration. 2. Maternal temperature. 3. Cervical dilation and effacement. 4. Maternal pulse rate.
2. Maternal temperature is the highest priority.
77. A woman with an obstetrical history of G1 P0000 at 40 weeks' gestation enters the labor suite stating that she is in labor. Upon examination the nurse finds that the woman is 2 cm dilated, 25% effaced, contracting every 12 minutes × 30 seconds. Fetal heart rate is 140 bpm with moderate variability and accelerations. What should the nurse conclude when reporting the findings to the primary healthcare practitioner? 1. The woman is at high risk and should be placed on tocolytics. 2. The woman is in latent labor and could be sent home. 3. The woman is at high risk and could be induced. 4. The woman is in active labor and should be admitted to the unit.
2. The woman is in latent labor. There is no need for her to be hospitalized at this time.
20. The nurse is administering omeprazole (Prilosec) to a 3-month-old with gastroesophageal refl ux (GER). The child ' s parents ask the nurse how the medication works. Which is the nurse ' s best response? 1. "Prilosec is a proton pump inhibitor that is commonly used for refl ux in infants." 2. "Prilosec decreases stomach acid, so it will not be as irritating when your child spits up." 3. "Prilosec helps food move through the stomach quicker, so there will be less chance for reflux." 4. "Prilosec relaxes the pressure of the lower esophageal sphincter."
2. This accurate description gives the parents information that is clear and concise.
68. The nurse is caring for two post-cesarean section clients in the post-anesthesia suite. One of the clients had her surgery under spinal anesthesia, while the other client had her surgery under epidural anesthesia. Which of the following is an important difference between the two types of anesthesia? 1. The level of the pain relief is lower in spinals. 2. Placement of the needle is higher in epidurals. 3. Epidurals do not fully sedate motor nerves. 4. Clients with spinal anesthesia complain of nausea and vomiting.
3. Epidurals do not fully sedate the motor nerves of the client. Epidural clients are capable of moving their lower extremities even when fully pain free.
11. While performing Leopold maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the follow - ing is a reasonable conclusion by the nurse? 1. The fetal position is transverse. 2. The fetal presentation is vertex. 3. The fetal lie is vertical. 4. The fetal attitude is flexed.
3. With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical, with the fetus in the breech position.
16. The nurse is caring for an 8-week-old male who has just been diagnosed with Hirschsprung disease. The parents ask what they should expect. Which is the nurse ' s best response? 1. "It is really an easy disease to manage. Most children are placed on stool softeners to help with constipation until it resolves." 2. "A permanent stool diversion, called a colostomy, will be placed by the surgeon to bypass the narrowed area." 3. "Daily bowel irrigations will help your child maintain regular bowel habits." 4. "Although your child will require surgery, there are different ways to manage the disease, depending on how much bowel is involved."
4. The aganglionic portion needs to be removed. Although most children have a temporary colostomy placed, many infants are able to bypass the colostomy and have the bowel immediately reattached.
53. The parent of a child being evaluated for celiac disease asks the nurse why it is important to make dietary changes. Which is the nurse ' s best response? 1. "The body ' s response to gluten causes damage to the mucosal cells in the intestine, leading to absorption problems." 2. "The body ' s response to consumption of anything containing gluten is to create special cells called villi, which leads to more diarrhea." 3. "The body ' s response to gluten causes the intestine to become more porous and hang on to more of the fat-soluble vitamins, leading to vitamin toxicity." 4. "The body ' s response to gluten causes damage to the mucosal cells, leading to malabsorption of water and hard, constipated stools."
1. The inability to digest protein leads to an accumulation of an amino acid that is toxic to the mucosal cells and villi, leading to absorption problems.
14. The parents of a child hospitalized with minimal change nephrotic syndrome (MCNS) ask why the last blood test revealed elevated lipids. Which is the nurse ' s best response? 1. "If your child had just eaten a fatty meal, the lipids may have been falsely elevated." 2. "It ' s not unusual to see elevated lipids in children because of the dietary habits of today." 3. "Because your child is losing so much protein, the liver is stimulated and makes more lipids." 4. "Your child ' s blood is very concentrated because of the edema, so the lipids are falsely elevated."
3. In MCNS, the lipids are truly elevated. Lipoprotein production is increased because of the increased stimulation of the liver caused by hypoalbuminemia.
15. A child with minimal change nephrotic syndrome (MCNS) has generalized edema. The skin appears stretched, and areas of breakdown are noted over the bony prominences. The child has been receiving furosemide (Lasix) twice daily for several days. Which does the nurse expect to be included in the treatment plan to reduce edema? 1. An increase in the amount and frequency of furosemide (Lasix). 2. Addition of a second diuretic, such as mannitol. 3. Administration of intravenous albumin. 4. Elimination of all fl uids and sodium from the child ' s diet.
3. In cases of severe edema, albumin is used to help return the fl uid to the bloodstream from the subcutaneous tissue.
45. The nurse is caring for an 8-week-old infant being evaluated for pyloric stenosis. Which statement by the parent would be typical for a child with this diagnosis? 1. "The baby is a very fussy eater and just does not want to eat." 2. "The baby tends to have a very forceful vomiting episode about 30 minutes after most feedings." 3. "The baby is always hungry after vomiting, so I feed her again." 4. "The baby is happy in spite of getting really upset after spitting up."
3. Infants with pyloric stenosis are always hungry and often appear malnourished.
8. Which combination of signs is commonly associated with glomerulonephritis? 1. Massive proteinuria, hematuria, decreased urinary output, and lethargy. 2. Mild proteinuria, increased urinary output, and lethargy. 3. Mild proteinuria, hematuria, decreased urinary output, and lethargy. 4. Massive proteinuria, decreased urinary output, and hypotension.
3. Mild-to-moderate proteinuria, hematuria, decreased urinary output, and lethargy are common fi ndings in glomerulonephritis.
72. A pregnant client with an obstetrical history of G3 P2002 had her two previous children by cesarean section. She would like to have a vaginal birth this time and requests a trial of labor after cesarean section (TOLAC). Which of the following situations would exclude a TOLAC and mandate that this delivery also be by cesarean? 1. The client refuses to have a regional anesthesia. 2. The client is postdates with intact membranes. 3. The baby is in the occiput posterior position. 4. The previous uterine incisions were vertical.
4. The presence of vertical incisions in the uterine wall is an absolute indication for a cesarean delivery.
73. A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply. 1. Lengthening of the umbilical cord. 2. Fetal heart rate assessment after each contraction. 3. Uterus rising in the abdomen and feeling globular. 4. Rapid cervical dilation to 10 centimeters. 5. Maternal complaints of intense rectal pressure.
Answers 1 and 3 are correct. 1. Lengthening of the umbilical cord is a positive sign of placental separation. 3. A globular uterus rising in the abdomen is a positive sign of placental separation.
13. The nurse is caring for an infant diagnosed with Hirschsprung disease. The mother states she is pregnant with a boy and wants to know if her new baby will likely have the disorder. Which is the nurse ' s best response? 1. "Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well." 2. "There is no evidence to support a genetic link, so it is very unlikely the baby will also have it." 3. "It is rarely seen in boys, so it is not likely your new baby will have Hirschsprung disease." 4. "Hirschsprung disease is seen only in girls, so your new baby will not be at risk."
1. There is a genetic component to Hirschsprung disease, so any future siblings are also at risk.
10. Which fi nding requires immediate attention in a child with glomerulonephritis? 1. Sleeping most of the day and being very "cranky" when awake; blood pressure is 170/90. 2. Urine output is 190 mL in an 8-hour period and is the color of Coca-Cola. 3. Complaining of a severe headache and photophobia. 4. Refusing breakfast and lunch and stating he "just is not hungry."
3. A severe headache and photophobia can be signs of encephalopathy due to hypertension, and the child needs immediate attention.
49. The nurse will soon receive a 4-month-old who has been diagnosed with intussusception. The infant is described as very lethargic with the following vital signs: T 101.8°F (38.7°C), HR 181, BP 68/38. The reporting nurse states the infant ' s abdomen is very rigid. Which is the most appropriate action for the receiving nurse? 1. Prepare to accompany the infant to a computed tomography scan to confi rm the diagnosis. 2. Prepare to accompany the infant to the radiology department for a reducing enema. 3. Prepare to start a second intravenous line to administer fl uids and antibiotics. 4. Prepare to get the infant ready for immediate surgical correction.
4. Intussusception with peritonitis is a surgical emergency, so preparing the infant for surgery is the nurse ' s top priority.
22. Which laboratory results besides hematuria are most consistent with hemolytic uremic syndrome (HUS)? 1. Massive proteinuria, elevated blood urea nitrogen and creatinine. 2. Mild proteinuria, decreased blood urea nitrogen and creatinine. 3. Mild proteinuria, increased blood urea nitrogen and creatinine. 4. Massive proteinuria, decreased blood urea nitrogen and creatinine.
3. Hematuria, mild proteinuria, and increased BUN and creatinine are all present in HUS.
9. The nurse receives a call from the parent of a 10-month-old who has vomited three times in the past 8 hours. The parent describes the baby as playful and wanting to drink. The parent asks the nurse what to give the child. Select the nurse ' s best response. 1. "Replace the next feeding with regular water, and see if that is better tolerated." 2. "Do not allow your baby to eat any solids; give half the normal formula feeding, and see if that is better tolerated." 3. "Do not let your baby eat or drink anything for 24 hours to give the stomach a chance to rest." 4. "Give your child ½ ounce of Pedialyte every 10 minutes. If vomiting continues, wait an hour, and then repeat what you previously gave."
4. Offering small amounts of clear liquids is usually well tolerated. If the child vomits, make NPO for an hour to allow the stomach to rest and then restart fl uids. The child in this scenario is described as playful and therefore does not appear to be at risk for dehydration.
91. In response to a patient's request, the nurse asks the patient's primary healthcare provider for medication to relieve the pain of labor. The healthcare provider orders self-administered inhaled nitrous oxide (N2O) in a N2O 50% / O2 50% mixture for the client. Which of the following common side effects should the nurse carefully monitor the client for? Select all that apply. 1. Nausea. 2. Hypotension. 3. Dehydration. 4. Light-headedness. 5. Late decelerations on the fetal heart rate tracing
Answers 1 and 4 are correct. 1. Both nausea and vomiting are side effects of nitrous oxide administration. 4. Patients often do exhibit lightheadedness when using N2O
12. At which time/s during the latent phase of labor should the nurse assess the fetal heart rate pattern of a low-risk woman with an obstetrical history of G1 P0000? Select all that apply. 1. With vaginal examinations. 2. Before administration of analgesics. 3. Periodically throughout several contractions. 4. Every 10 minutes. 5. Before ambulating
Answers 1, 2, 3, and 5 are correct. 1. The nurse should assess the fetal heart rate with all vaginal examinations. 2. The nurse should assess the fetal heart rate before giving the mother any analgesics. 3. The fetal heart rate should be assessed periodically at the end of a contraction. 5. The nurse should assess the fetal heart rate before the woman ambulates.
101. A client presents to the labor and delivery suite for a labor check. It is essential that the nurse note the client's status in relation to which of the following infectious diseases? Select all that apply. 1. Hepatitis B. 2. Rubeola. 3. Varicella. 4. Group B streptococcus. 5. HIV/AIDS.
Answers 1, 4, and 5 are correct. 1. The client's hepatitis B status should be assessed. 4. The client's group B streptococcus (GBS) status should be assessed. 5. The client's HIV/AIDS status should be assessed.
47. The nurse receives a call from the mother of a 6-month-old who describes her child as alternately sleepy and fussy. She states that her infant vomited once this morning and had two episodes of diarrhea. The last episode contained mucus and a small amount of blood. She asks the nurse what she should do. Which is the nurse ' s best response? 1. "Your infant will need to have some tests in the emergency department to determine whether anything serious is going on." 2. "Try feeding your infant in about 30 minutes; in the event of repeat vomiting, bring the infant to the emergency department for some tests and intravenous rehydration." 3. "Many infants display these symptoms when they develop an allergy to the formula they are receiving; try switching to a soy-based formula." 4. "Do not worry about the blood and mucus in the stool; it is not unusual for infants to have blood in their stools because their intestines are more sensitive."
1. The infant is displaying signs of intussusception. This is an emergency that needs to be evaluated to prevent ischemia and perforation
21. The manifestations of hemolytic uremic syndrome (HUS) are due primarily to which event? 1. The swollen lining of the small blood vessels damages the red blood cells, which are then removed by the spleen, leading to anemia. 2. There is a disturbance of the glomerular basement membrane, allowing large proteins to pass through. 3. The red blood cell changes shape, causing it to obstruct microcirculation. 4. There is a depression in the production of all formed elements of the blood
1. The swollen lining of the small blood vessels damages the red blood cells, which are then removed by the spleen.
15. A nurse is caring for a laboring woman who is in transition. She does not have an epidural for pain control. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions
15. Answers 2, 4, and 5 are correct 2. The bloody show increases as a woman enters the second stage of labor. 4. With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push. 5. The client's ability to work with her body's demands can change throughout the stages of labor. Often, the intensity of the contractions and the sensation of the fetus moving through the birth canal and stretching the tissues causes the client to cry out. Some scream; many push involuntarily.
10. The parents of a 4-year-old ask the nurse how to manage their child ' s constipation. Select the nurse ' s best response. 1. "Add 2 ounces of apple or pear juice to the child ' s diet." 2. "Be sure your child eats a lot of fresh fruit such as apples and bananas." 3. "Encourage your child to drink more fluids." 4. "Decrease bulky foods such as whole-grain breads and brown rice."
3. Increasing fl uid consumption helps to decrease the hardness of the stool.
33. The parent of a 7-year-old voices concern over the child ' s continued bed-wetting at night. The parent, on going to bed, has tried getting the child up at 11:30 p.m., but the child still wakes up wet. Which is the nurse ' s best response about what the parent should do next? 1. "There is a medication called DDAVP that decreases the volume of the urine. The physician thinks that will work for your child." 2. "When your child wakes up wet, be very fi rm and indicate how displeased you are. Have your child change the sheets to see how much work is involved." 3. "Limit fl uids in the evening and start a reward system in which your child can choose a reward after a certain number of dry nights." 4. "Bed-wetting alarms are readily available, and most children do very well with them."
3. Limiting the child ' s fl uids in the evening will help decrease the nocturnal urge to void. Providing positive reinforcement and allowing the child to choose a reward will increase the child ' s sense of control.
41. When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped or U-shaped decelerations to 80 from a baseline of 120. One occurred during a contraction, another occurred 10 seconds after the contraction, and a third occurred 40 seconds after yet another contraction. The nurse interprets these findings as resulting from which of the following? 1. Metabolic acidosis. 2. Head compression. 3. Cord compression. 4. Insufficient uteroplacental blood flow.
3. The contractions described in the scenario (variable decelerations) result from cord compression.
86. A nurse is caring for a primiparous client at 35 weeks' gestation. The client is having uterine contractions. Which of the following confirms that the client is in preterm labor? Select all that apply. 1. Contraction frequency every 15 minutes. 2. Effacement 10%. 3. Dilation 3 cm. 4. Cervical length of 2 cm. 5. Contraction duration of 30 seconds
3. The dilation of 3 cm combined with contractions is indicative of preterm labor. 4. A cervical length of 2 cm combined with contractions is indicative of preterm labor.
36. The nurse evaluates postoperative teaching for repair of testicular torsion as successful when the parent of an adolescent says which the following? 1. "I will encourage him to rest for a few days, but he can return to football practice in a week." 2. "I will keep him in bed for 4 days and let him gradually increase his activity after that." 3. "I will seek therapy as he ages because he is now infertile." 4. "I will make sure he does testicular self-examination monthly."
4. The child and family should be taught the importance of testicular self-examination.
21. A 10-year-old is being evaluated for possible appendicitis and complains of nausea and sharp abdominal pain in the right lower quadrant. An abdominal ultrasound is scheduled, and a blood count has been obtained. The child vomits, fi nds the pain relieved, and calls the nurse. Which should be the nurse ' s next action? 1. Cancel the ultrasound and obtain an order for oral ondansetron (Zofran). 2. Cancel the ultrasound and prepare to administer an intravenous bolus. 3. Prepare for the probable discharge of the patient. 4. Immediately notify the health-care provider of the child ' s status.
4. The health-care provider should be notifi ed immediately, because a sudden change or loss of pain
84. A client with an obstetrical history of G3 P2002 has just had an external version. The nurse monitors this client carefully for which of the following? 1. Decreased urinary output. 2. Elevated blood pressure. 3. Severe occipital headache. 4. Variable fetal heart decelerations.
4. The nurse should monitor the client carefully for variable fetal heart decelerations.