Unit 2: NCLEX practice questions, Unit 3: Practice Questions for Ch. 21, Unit 3: Respiratory Practice Questions
8) A client's fetus is estimated to weigh 4500 g (9 lb, 14 oz). Which statement indicates that additional teaching about the size of the baby is needed? 1. "His blood sugars could be high after he is born." 2. "I am at risk for excessive bleeding after delivery." 3. "My perineum could experience trauma during the birth." 4. "His shoulders could get stuck and a collar bone broken."
1. "His blood sugars could be high after he is born."
Which statements should the nurse include in the discharge medication teaching for a child diagnosed with asthma who is prescribed cromolyn sodium (a mast cell stabilizer)? Select all that apply. 1. "The medication works to prevent exacerbations." 2. "The medication should be administered at the first symptom of an asthmatic attack." 3. "The medication should be taken on a daily basis." 4. "The medication should not be administered if the child has a cold." 5. "The medication desensitizes the child against specific allergens."
1. "The medication works to prevent exacerbations." 3. "The medication should be taken on a daily basis."
Which neonate requires a close nursing assessment for the development of retinopathy of prematurity (ROP)? 1. 28-weeks'-gestation infant who has been on long-term oxygen and weighed 1400 g 2. 32-weeks'-gestation infant of African heritage with a congenital heart defect who needed no oxygen and weighed 1850 g 3. 28-weeks'-gestation female infant who was on short-term oxygen, weighed 1420 g, and was treated with phototherapy 4. 36-weeks'-gestation, small-for-gestational-age infant who was in an oxyhood for 12 hours and weighed 1800 g
1. 28-weeks'-gestation infant who has been on long-term oxygen and weighed 1400 g
3) The nurse is making client assignments for the next shift. Which client is most likely to experience a complicated labor pattern? 1. 34-year-old gravida 6 at 39 weeks' gestation with twins 2. 43-year-old gravida 2 at 37 weeks' gestation with hypertension 3. 22-year-old gravida 1 at 23 weeks' gestation with ruptured membranes 4. 30-year-old gravida 3 at 41 weeks' gestation and estimated fetal weight 7 lb, 8 oz
1. 34-year-old gravida 6 at 39 weeks' gestation with twins
Which nursing diagnosis should the nurse include in the plan of care for an infant diagnosed with acute bronchiolitis due to respiratory syncytial virus (RSV)? 1. Activity Intolerance 2. Ineffective Peripheral Tissue Perfusion 3. Acute Pain 4. Decreased Cardiac Output
1. Activity Intolerance
If the baby was born with its head flexed and its anterior skull is more enlarged, on what should the nurse focus when assessing this newborn? Select all that apply. 1. Airway 2. Amount of bruising 3. Meconium aspiration 4. Degree of facial edema 5. Neck and head movement
1. Airway 2. Amount of bruising 4. Degree of facial edema 5. Neck and head movement
Which should the nurse include in the plan of care for a pediatric client who is diagnosed with periorbital ecchymosis? Select all that apply. 1. Apply ice to the site for 5 to 15 minutes every hour for the first 1 to 2 days. 2. Apply warm compresses beginning on day 3. 3. Apply antibiotic ointment to the conjunctiva for 7 to 10 days. 4. Apply a patch to the affected eye for 5 to 7 days. 5. Apply antibiotic drops to the conjunctiva for 7 to 10 days.
1. Apply ice to the site for 5 to 15 minutes every hour for the first 1 to 2 days. 2. Apply warm compresses beginning on day 3.
Which nursing actions are appropriate when providing care to a pediatric client who has sustained a smoke-inhalation injury? Select all that apply. 1. Assessing for respiratory distress 2. Auscultating the lungs for wheezing 3. Prescribing oxygen for low saturations 4. Administering prescribed prophylactic antibiotic therapy 5. Providing support to the family
1. Assessing for respiratory distress 2. Auscultating the lungs for wheezing 5. Providing support to the family
Which common eye disorders should the nurse include in a teaching session for the parents of pediatric clients? Select all that apply. 1. Hyperopia 2. Myopia 3. Astigmatism 4. Strabismus 5. Cataracts
1. Hyperopia 2. Myopia 3. Astigmatism
Which visual screenings should the school nurse conduct when conducting annual assessments for school-age children? Select all that apply. 1. Light reflex assessment 2. Cover-uncover test 3. Acuity testing 4. Visualization of the tympanic membrane 5. Cranial nerve VIII testing
1. Light reflex assessment 2. Cover-uncover test 3. Acuity testing
Which should the nurse assess to determine oxygenation during the respiratory assessment for a pediatric client? Select all that apply. 1. Mucous membranes 2. Nail beds 3. Skin 4. Sclerae 5. Corneas
1. Mucous membranes 2. Nail beds 3. Skin
Which independent nursing action is appropriate for a 2-month-old infant who is a direct admission to the pediatric unit with a diagnosis of ALTE (apparent life-threatening event)? 1. Place the child on an apnea monitor. 2. Place the child on nasal cannula oxygen. 3. Draw blood for arterial blood gases. 4. Place the child on contact isolation.
1. Place the child on an apnea monitor.
Which topics should the nurse include in a teaching session to the parents of a 10-month-old infant who experiences frequent ear infections? Select all that apply. 1. Prohibiting tobacco smoke in the home 2. Avoiding use of a pacifier while the child is sleeping 3. Breastfeeding the infant 4. Cleaning the child's ears nightly with peroxide 5. Avoiding use of wood-burning stoves
1. Prohibiting tobacco smoke in the home 2. Avoiding use of a pacifier while the child is sleeping 5. Avoiding use of wood-burning stoves
19) The nurse is assisting in the preparation of a pregnant client in labor for intrauterine resuscitation. For which fetal finding is this intervention indicated? Select all that apply. 1. Prolonged decelerations 2. Persistent late decelerations 3. Last fetal movement 5 minutes ago 4. Fetal heart rate 140 beats per minute 5. Persistent and severe variable decelerations
1. Prolonged decelerations 2. Persistent late decelerations 5. Persistent and severe variable decelerations
Which is the rationale for why young children are more prone to otitis media that the nurse should include in the teaching session with a parent? 1. The eustachian tube is shorter, wider, and horizontal in younger children. 2. The eustachian tube is shorter, more narrow, and horizontal in younger children. 3. The eustachian tube is longer, wider, and vertical in younger children. 4. The eustachian tube is longer, more narrow, and vertical in younger children.
1. The eustachian tube is shorter, wider, and horizontal in younger children.
A toddler-age client presents to the emergency department with a sore throat and difficulty swallowing. The nurse suspects acute epiglottitis. Which nursing action is avoided based on the current assessment data? 1. Throat culture 2. Medical history 3. Vital signs 4. Auscultation of breath sounds
1. Throat culture
Which assessment finding is considered normal for a school-age client? 1. Tonsils are large and seem to fill the throat. 2. Child is complaining of sore throat and drooling 3. White patches are observed on the tonsils. 4. Throat appears red, and child has a low-grade fever
1. Tonsils are large and seem to fill the throat.
Which nursing action is appropriate when providing care to a child with a mild hearing loss who reads lips to enhance adaptation during hospitalization? 1. Touching the child lightly before speaking 2. Using a picture board as the main means of communication 3. Speaking in a loud voice while facing the child 4. Speaking directly to the parents for communication
1. Touching the child lightly before speaking
The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for treatment of tuberculosis because she saw that the child's urine was orange. Which response by the nurse is accurate? 1. "Encourage your child to drink cranberry juice." 2. "An orange discoloration of urine is expected while your child is on this medication." 3. "Bring your child to the clinic for a urinalysis." 4. "Bring your child to the clinic for a radiograph of the kidneys."
2. "An orange discoloration of urine is expected while your child is on this medication."
Which parental statements indicate correct understanding of the care that is needed for a pediatric client after the insertion of tympanostomy tubes? Select all that apply. 1. "It is important to limit my child's diet after surgery and only allow soft, bland foods." 2. "I should restrict my child to quiet activities after surgery." 3. "I should plan to administer a decongestant to my child for 1 to 2 weeks following surgery." 4. "It is important for my child to drink plenty of fluids after the procedure." 5. "I will remind my child to use ear plugs prior to showering and swimming."
2. "I should restrict my child to quiet activities after surgery." 4. "It is important for my child to drink plenty of fluids after the procedure." 5. "I will remind my child to use ear plugs prior to showering and swimming."
The mother of a toddler-age client states, "My daughter seems to be at an increased risk for complications associated with respiratory infections." Which response by the nurse is accurate? 1. "You are incorrect in your assessment." 2. "The younger child's airways are smaller and more easily occluded." 3. "Air passages are more likely to become blocked with mucus because younger children make more mucus than older children." 4. "Toddlers do not breathe as deeply as do older children."
2. "The younger child's airways are smaller and more easily occluded."
Which parental statements indicate correct understanding of the anatomy and physiology of the infant's mouth, nose, and throat? Select all that apply. 1. "My baby will breathe through her mouth during the first 3 months of life." 2. "When my baby has a cold she may have trouble with bottle feedings." 3. "My baby's tonsils will be largest during infancy." 4. "I should expect my baby's first tooth to erupt during the first 6 months of life." 5. "I should expect my baby to lose her first tooth during the first year of life."
2. "When my baby has a cold she may have trouble with bottle feedings." 4. "I should expect my baby's first tooth to erupt during the first 6 months of life."
Which pediatric clients would require a nursing assessment for blunt chest trauma? Select all that apply. 1. A preschool-age client who is admitted after a house fire. 2. A toddler-age client who is admitted for injuries sustained in a motor vehicle accident. 3. A school-age client who is admitted for observation after a skateboarding accident. 4. An adolescent client admitted for an asthma exacerbation. 5. An infant admitted to rule out cystic fibrosis.
2. A toddler-age client who is admitted for injuries sustained in a motor vehicle accident. 3. A school-age client who is admitted for observation after a skateboarding accident.
Which should the nurse include in the plan of care for a pediatric client diagnosed with otitis media with effusion? Select all that apply. 1. Administration of antibiotic drops per order 2. Administration of pain relief measures 3. Assessment of hearing acuity over several months 4. Assessment of speech 5. Assessment of development
2. Administration of pain relief measures 3. Assessment of hearing acuity over several months 4. Assessment of speech 5. Assessment of development
Which nursing action is appropriate for the parents of a 4-month-old infant who died due to sudden infant death syndrome (SIDS)? 1. Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints 2. Allowing parents to hold, touch, and rock the infant 3. Advising parents that an autopsy is not necessary 4. Interviewing parents to determine the cause of the incident
2. Allowing parents to hold, touch, and rock the infant
14) A client with cephalopelvic disproportion (CPD) develops tachysystolic labor patterns. Which treatment should the nurse anticipate? 1. Amniotomy 2. Cesarean section 3. Nipple stimulation 4. Oxytocin administration
2. Cesarean section
9) The membranes of a client in labor have spontaneously ruptured and the fluid is meconium stained. The fetal heart tones are 100 to 105. Which nursing action is most important? 1. Notify the surgical team of an impending cesarean. 2. Change the client's position from Fowler to left lateral. 3. Insert a Foley catheter with the assistance of another nurse. 4. Decrease the IV of lactated Ringer solution to 50 mL/hour.
2. Change the client's position from Fowler to left lateral.
21) The nurse is caring for a client who delivered a 38 weeks' gestation stillborn fetus. What should the nurse do to support the client at this time? Select all that apply. 1. Remove the fetus from the room. 2. Clean the fetus and wrap in a blanket. 3. Ask the client if she would like to hold the baby. 4. Instruct on postdelivery care to be completed in the home. 5. Ask if other family members would like to spend time with the baby.
2. Clean the fetus and wrap in a blanket. 3. Ask the client if she would like to hold the baby. 4. Instruct on postdelivery care to be completed in the home.
10) The nurse is caring for a client who is a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is most important to take at this time? 1. Perform a Leopold maneuver. 2. Complete a sterile vaginal examination. 3. Obtain an order for pain medication. 4. Assess the odor of the amniotic fluid.
2. Complete a sterile vaginal examination.
Which is the priority nursing assessment for a pediatric client who is postoperative for tonsillectomy? 1. Arrhythmias 2. Dehydration 3. Increased blood sugar 4. Increased urinary output
2. Dehydration
Which nursing assessment data would indicate that a pediatric client sustained a large pulmonary contusion in a motor vehicle crash? Select all that apply. 1. Eupnea 2. Dyspnea 3. Hemoptysis 4. Fever 5. Crackles
2. Dyspnea 3. Hemoptysis 4. Fever 5. Crackles
16) The multiparous client at 33 weeks has experienced an intrauterine fetal demise. What finding requires immediate intervention? 1. Temperature 99°F 2. Fibrinogen level 50 mg/dL 3. Platelet count 210,000/cmm 4. Family refusing fetal autopsy
2. Fibrinogen level 50 mg/dL
Which is the reason for a healthcare provider to recommend that a preschool-age male client with a documented hearing loss should attend preschool at least 2 days per week? 1. Help the child recognize his hearing deficit. 2. Increase the child's socialization skills. 3. Improve the child's immunity by increased exposure to organisms. 4. Teach other children that children are different.
2. Increase the child's socialization skills.
A nurse is caring for a visually impaired school-age child. Which is the priority nursing intervention during the admission process to the hospital? 1. Explaining playroom policies 2. Orienting the child to where furniture is placed in the room 3. Taking the child on a tour of the unit 4. Letting the child touch equipment that will be used during the child's hospitalization
2. Orienting the child to where furniture is placed in the room
The nurse palpates a shoulder during vaginal check, what action should the nurse take to address this finding? 1. Position the client on the left side. 2. Prepare the client for cesarean section. 3. Place a wedge under the client's right hip. 4. Increase intravenous fluids and apply oxygen.
2. Prepare the client for cesarean section.
5) A primiparous client is at 42 weeks' gestation. What order should the nurse question? 1. Begin non-stress test now. 2. Return to the clinic in 1 week. 3. Obtain biophysical profile today. 4. Schedule labor induction for tomorrow.
2. Return to the clinic in 1 week.
Which positions are appropriate for the nurse to include in a plan of care for the infant who is diagnosed with acute respiratory distress? Select all that apply. 1. Upright 2. Semi-Fowler position 3. Prone position 4. With the infant's head hyperextended 5. With the infant's head in a sniffing position
2. Semi-Fowler position 5. With the infant's head in a sniffing position
Which data collected during the respiratory assessment would indicate the pediatric client is compromised? Select all that apply. 1. Lung sounds clear to auscultation 2. Stridor 3. Substernal retractions 4. Nasal flaring 5. Strong cry
2. Stridor 3. Substernal retractions 4. Nasal flaring
Which nursing action is appropriate when providing care to a newborn with a respiratory rate of 102 breaths per minute with lungs that are clear to auscultation? 1. Administering the bath to the neonate in the nursery 2. Transferring to the neonatal intensive care unit for further observation 3. Allowing the neonate to room-in to promote bonding 4. Providing the first feeding in the nursery
2. Transferring to the neonatal intensive care unit for further observation
Which parental statement indicates correct understanding regarding pancreatic enzyme administration in the treatment of cystic fibrosis? 1. "I will administer this medication 4 times each day." 2. "I will administer this medication twice each day." 3. "I will administer this medication with meals and snacks." 4. "I will administer this medication every 6 hours around the clock."
3. "I will administer this medication with meals and snacks."
Which parental statement indicates correct understanding of discharge instructions for a pediatric client after a tonsillectomy? 1. "We will call the healthcare provider for any indication of ear pain." 2. "We will be sure to give our child adequate amounts of citrus juices." 3. "We will plan on administering acetaminophen (Tylenol) for pain." 4. "We will keep our child on bed rest for 10 days after the surgery."
3. "We will plan on administering acetaminophen (Tylenol) for pain."
6) A multiparous client at term is in active labor with intact membranes. A Leopold maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What healthcare provider order is most important? 1. Artificially rupture membranes. 2. Apply internal fetal scalp electrode. 3. Alert the surgical team of urgent cesarean. 4.Monitor maternal blood pressure every 15 minutes
3. Alert the surgical team of urgent cesarean.
2) A client who is pregnant with her first child has been laboring for 14 hours with very minimal progress. Cervical dilatation and effacement are slow, and the nurse is unable to verify engagement of the presenting fetal part. What condition should the nurse suspect may be affecting the client's labor? 1. Prolapsed cord 2. Placenta accreta 3. Cephalopelvic disproportion (CPD) 4.Occiput anterior (OA) fetal position
3. Cephalopelvic disproportion (CPD)
A neonate is diagnosed with a herpes simplex viral infection of the eye. Which medication should the nurse prepare to administer? 1. Oral erythromycin 2. Fluoroquinolone eyedrops or ointment 3. Parenteral acyclovir (Zovirax) and vidarabine (VIRA-A) ophthalmic ointment 4. Intravenous penicillin
3. Parenteral acyclovir (Zovirax) and vidarabine (VIRA-A) ophthalmic ointment
Which screening tool should the nurse use to screen a pediatric client for esotropia? 1. Examine the eye with an otoscope. 2. Check for the "red reflex" in the eyes. 3. Perform the cover-uncover test. 4. Use a tonometer to evaluate the eyes.
3. Perform the cover-uncover test.
Which nursing actions are appropriate when providing care to a 12-year-old client who has lost several teeth as a result of a facial injury? Select all that apply. 1. Not worrying about the tooth loss, as children this age still have their "baby" teeth 2. Only handling the lost tooth by the roots and avoiding touching the crown of the tooth 3. Rinsing the lost tooth with sterile saline 4. Placing the tooth back into its socket and taking the child to an emergency dental facility 5. Keeping the tooth clean and dry during transport to an emergency dental facility
3. Rinsing the lost tooth with sterile saline 4. Placing the tooth back into its socket and taking the child to an emergency dental facility
13) A client who delivered 30 minutes ago is being prepared for manual removal of the placenta. What should the nurse complete as a priority? 1. Bottle-feed the infant. 2. Send the placenta to pathology. 3. Start an IV of lactated Ringer solution. 4. Apply antiembolism stockings.
3. Start an IV of lactated Ringer solution.
Which should the nurse include in a teaching session for the mother of a 3-year-old client who is concerned about her child choking? 1. Show the mother how to do cardiac compressions and rescue breathing. 2. Recommend the mother perform back blows and chest thrusts. 3. Teach the mother how to perform abdominal thrusts. 4. Tell the mother to do nothing until the child loses consciousness.
3. Teach the mother how to perform abdominal thrusts.
Which is an appropriate nursing intervention for a child who experiences epistaxis? 1. Laying the child down and applying a warm pack. 2. Tilting the child's head back, squeezing the bridge of the nose, and applying a warm moist pack to the nose. 3. Tilting the child's head forward, squeezing the nares below the nasal bone, and applying ice to the nose. 4. Immediately packing the nares with a cotton ball soaked with phenylephrine (Neo-Synephrine).
3. Tilting the child's head forward, squeezing the nares below the nasal bone, and applying ice to the nose.
Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented? 1. "We're glad the dog can continue to sleep in our child's room." 2. "We'll keep the plants in our child's room dusted." 3. "We'll be sure to use the fireplace often to keep the house warm in the winter." 4. "We will replace the carpet in our child's bedroom with tile."
4. "We will replace the carpet in our child's bedroom with tile."
Which should the nurse include in the discharge instructions for the parents of an infant who is diagnosed with acute otitis media? 1. Keep the baby in a flat position during sleep. 2. Administer a decongestant. 3. Place the baby to sleep with a pacifier. 4. Administer acetaminophen (Tylenol) to relieve discomfort.
4. Administer acetaminophen (Tylenol) to relieve discomfort.
1) After a lengthy labor and delivery, a client suddenly complains of chest pain and dyspnea. The client is cyanotic, has tachycardia and blood pressure decreased to 78/36 mmHg. Based on these assessment findings, which health problem is the client experiencing? 1. Infection 2. Placenta accreta 3. Hypertensive crisis 4. Amniotic fluid embolus
4. Amniotic fluid embolus
12) A client with a suspected small pelvis is dilated at 6 cm. The fetus has an estimated weight of 4200 g (9 lb, 4 oz). What is the most important action for the client at this time? 1. Encourage oral fluids and carbohydrate intake. 2. Assess the cervix for change every 8 hours. 3. Inform the couple that labor might be prolonged. 4. Assist the client to squat during the second stage.
4. Assist the client to squat during the second stage.
Which is a priority nursing assessment the nurse includes in the plan of care for a pediatric client who has received a cochlear implant? 1. Ringing in the ears 2. Pharyngitis 3. Hearing loss 4. Bacterial meningitis
4. Bacterial meningitis
4) A client at 39 weeks' gestation was assessed 2 hours ago as being 3 cm dilated, 40% effaced, and +1 station and experienced contractions every 5 minutes with duration 40 seconds and intensity 50 mmHg. Currently, the client is 4 cm dilated, 40% effaced, and +1 station with frequency of contractions every 3 minutes with 40 to 50 seconds' duration with intensity of 40 mmHg. What action should the nurse make a priority at this time? 1. Start oxygen at 8 L/min. 2. Give terbutaline to stop the preterm labor. 3. Have anesthesia provider give the client an epidural. 4. Begin oxytocin after assessing for cephalopelvic disproportion (CPD).
4. Begin oxytocin after assessing for cephalopelvic disproportion (CPD).
Which is the priority nursing action for a child who presents in the emergency department after a motor vehicle accident with a sucking wound of the chest? 1. Placing the child in a Trendelenburg position 2. Beginning rescue breathing for the child 3. Beginning cardiac resuscitation for the child 4. Covering the child's wound with an air occlusive dressing
4. Covering the child's wound with an air occlusive dressing
A nurse is caring for a visually impaired 20-month-old client who has not begun to walk. Which nursing diagnosis would be appropriate for this child? 1. Self-care Deficit 2. Impaired Physical Mobility 3. Impaired Home Maintenance 4. Delayed Development
4. Delayed Development
Which immunization should the nurse include in a teaching session for parents of a toddler-age client to decrease the risk for epiglottitis? 1. Hepatitis B 2. Polio 3. Measles, mumps, and rubella (MMR) 4. Haemophilus influenzae type B (HIB)
4. Haemophilus influenzae type B (HIB)
11) The charge nurse is reviewing charting completed on clients in the maternal-child triage unit. Which entry requires immediate intervention? 1. Multipara at 32 weeks: "Oligohydramnios per ultrasound secondary to fetal renal agenesis." 2. Primipara at 41 weeks: "Client reports leaking clear fluid from her vagina for 7 hours." 3. Primipara at 24 weeks diagnosed with polyhydramnios: "Client reporting shortness of breath." 4. Multipara at 34 weeks diagnosed with oligohydramnios: "Cervix 6 cm, −2 station, up to walk in hallway."
4. Multipara at 34 weeks diagnosed with oligohydramnios: "Cervix 6 cm, −2 station, up to walk in hallway."
7) What should the nurse anticipate the labor pattern for a fetal occiput posterior position to be? 1. Precipitous 2. Rapid during transition 3. Shorter than average during the latent phase 4. Prolonged with regard to the overall length of labor
4. Prolonged with regard to the overall length of labor
Which information should the nurse include in a teaching session regarding treatment for the common cold in the pediatric population? 1. Aspirin should be taken for alleviation of fever if the common cold is contracted. 2. Antibiotics will eliminate the nasopharyngitis virus. 3. Vaccinations can prevent contraction of a nasopharyngitis virus. 4. Proper hand washing can prevent the spread of the common cold.
4. Proper hand washing can prevent the spread of the common cold.
Which is the priority nursing action for a premature neonate who is experiencing apnea? 1. Administering oxygen 2. Performing back blows and chest thrusts 3. Calling a code blue 4. Providing stimulation by stroking the back
4. Providing stimulation by stroking the back
15) For delivery, a client received a midline episiotomy, which extended into a third-degree laceration. What should the nurse include when explaining the location of the episiotomy to the client? 1. "Up near your urethra." 2. "Into the muscle layer." 3. "Through your rectal mucosa." 4."Through your rectal sphincter."
4."Through your rectal sphincter."
Which assessment data would cause the nurse to suspect that a newborn requires further testing for cystic fibrosis? 1. Rectal prolapse 2. Constipation 3. Steatorrheic stools 4.Meconium ileus
4.Meconium ileus
A pregnant client admits during a prenatal visit to using heroin and asks for help to stop using. What is the best advice the nurse can give her? A."We need to get you admitted to the hospital because you need monitoring and medication." B."Stop using all drugs right now and just stay at home till the withdrawal symptoms have passed." C. "There is nothing we can do during the pregnancy, but we can help the baby with withdrawal after he's born." D. "Let me call the social worker to find you a Narcotics Anonymous group."
A."We need to get you admitted to the hospital because you need monitoring and medication."
Which of the following is true of asthma management in pregnancy? A.The medication regimen should be modified to reduce danger to the fetus. B.It usually improves in pregnancy, so the mother can stop her medications. C.Treatment approaches are the same as those for nonpregnant women. D. Medications can be reduced because of the increased oxygen-carrying capacity of fetal hemoglobin.
C.Treatment approaches are the same as those for nonpregnant women.
A parent calls the clinic to determine whether a 6-month-old infant needs to be seen by a healthcare provider for cold-like symptoms. Which questions yield answers that will provide the nurse with the information needed to respond to the parent? (Select all that apply.) a. "Is the infant wheezing?" b. "Does the infant have nasal drainage?" c. "What makes you think that your baby might need to be seen in the clinic?" d. "Does the infant cough?" e. "What is the infant's temperature?"
a. "Is the infant wheezing?" c. "What makes you think that your baby might need to be seen in the clinic?" e. "What is the infant's temperature?"
The nurse is teaching a prenatal class about respiratory infections. Which statement by a parent indicates that further teaching is necessary? a. "When my newborn has a stuffy nose, he will be okay because newborns are obligatory mouth breathers." b. "Children's narrower airways cause them to breathe harder when they are congested." c. "The only time a newborn breathes through the mouth is when he's crying." d. "I should keep my newborn's nose clean so he can breathe and eat without difficulty."
a. "When my newborn has a stuffy nose, he will be okay because newborns are obligatory mouth breathers."
What would be considered an abnormal finding upon the initial physical assessment of the newborn? What would be considered an abnormal finding upon the initial physical assessment of the newborn? a. A two-vessel cord b. APGARs of 8 at 1 minute and 9 at 5 minutes c. Newborn required suctioning of the mouth and nares immediately after delivery. d. Loud, continued crying b. APGARs of 8 at 1 minute and 9 at 5 minutes c. Newborn required suctioning of the mouth and nares immediately after delivery. d. Loud, continued crying
a. A two-vessel cord
In addition to an impaired gas exchange, which other diagnosis will a child in the early stages often have as well? a. Anxiety related to hypoxia b. Fatigue related to air trapping c. Injury related to fatigue and dehydration d. Delayed Development related to hypoxia
a. Anxiety related to hypoxia
A client at 30 weeks' gestation is admitted to the maternity unit with vaginal bleeding. What should be the nurse's initial action? a. Assess blood pressure and pulse. b. Count and weigh peripads. c. Observe for pallor, clammy skin, and perspiration. d. Start an intravenous infusion drip.
a. Assess blood pressure and pulse.
What factors influence the outcomes of the at-risk newborn? (Select all that apply.) a. Birth weight b. Gestational age c. Type and length of newborn illness d. Environmental factors e. Maternal factors
a. Birth weight b. Gestational age c. Type and length of newborn illness d. Environmental factors e. Maternal factors
The nurse is conducting an intake interview for a new prenatal client. A review of her records and self-reported history reveals she is a G6P1132 and the current pregnancy was diagnosed as a twin gestation in the emergency department the week before. What significant risk should be taken into account in the care of this client? a. Cervical insufficiency b. Postterm pregnancy c. Placenta previa d. Placental abruption
a. Cervical insufficiency
What symptoms would indicate respiratory distress in the newborn? (Select all that apply.) a. Changes in color or activity b. Grunting c. Facial grimacing d. Chest retractions
a. Changes in color or activity b. Grunting c. Facial grimacing d. Chest retractions
Before giving a newborn the first sponge bath, the nurse must first: a. Check the temperature. b. Decrease room lighting. c. Weigh the baby. d. Check capillary refill.
a. Check the temperature.
A nurse is admitting a laboring client with a breech presentation. Which complication occurs more frequently in the setting of breech presentation? a. Cord prolapse b. Neonatal hypoglycemia c. Respiratory distress d. Retained placenta
a. Cord prolapse
The mother of a 2-year-old calls the clinic nurse in a panic, stating, "I think my child swallowed a marble!" Which signs does the nurse know are indicative of a foreign-body aspiration? a. Coughing and dysphonia b. Fear and wheezing c. Hypoxia and choking d. Nasal flaring and crying
a. Coughing and dysphonia
Your client in her fourth month of her pregnancy is suspected to have an incompetent cervix. Which diagnostic measures might the nurse expect to be ordered to confirm the diagnosis? (Select all that apply.) a. Determining a history of second-trimester abortions b. Serial pelvic examinations c. Serial ultrasounds d. Determining a history of drug abuse
a. Determining a history of second-trimester abortions b. Serial pelvic examinations c. Serial ultrasounds
The need for resuscitation of the newborn at risk can be anticipated if what risk factors are present? (Select all that apply.) a. Difficult birth b. Fetal scalp/capillary blood sample pH > 7.3 c. Prolonged labor d. Significant intrapartum bleeding
a. Difficult birth c. Prolonged labor d. Significant intrapartum bleeding
A neonate whose mother declined prenatal ultrasounds is admitted to the special care nursery. His estimated gestational age by LMP was 42 weeks and 2 days. His 5-minute Apgar score was 6 and the nurse notes his skin is loose and peeling. This infant is likely to be affected by: a. Dysmaturity syndrome. b. Brachial plexus palsy. c. Hypoxia. d. Sepsis.
a. Dysmaturity syndrome.
The nurse is caring for a baby in the special care nursery whose mother did not have prenatal care. His gestational age is estimated to be 34 weeks and he displays features and behaviors that are consistent with Fetal Alcohol Spectrum Disorder. When reviewing his orders, which of the following should the nurse be sure is included? a. Echocardiogram (ultrasound of the heart) b. Thyroid function panel c. IV pyelogram (scan of the kidneys with contrast) d. Ophthalmology consult
a. Echocardiogram (ultrasound of the heart)
Which is the best explanation of how to elicit the "square window sign"? a. Flex the newborn's hand to the ventral forearm until resistance is felt. Measure the angle formed at the wrist. b. Measure flexion of the elbow and extension of the arms at the newborn's side for 5 seconds, then release them. c. The thigh is flexed on the abdomen/chest and the nurse places the index finger of the other hand behind the newborn's ankle to extend the lower leg until resistance is met. The angle formed is measured. d. Draw an arm across the chest toward the newborn's opposite shoulder until resistance is met.
a. Flex the newborn's hand to the ventral forearm until resistance is felt. Measure the angle formed at the wrist.
A client at 15 weeks' gestation presents to the prenatal clinic with painless, thin, brown vaginal bleeding. Other assessment data include a hemoglobin of 10 and complaints of severe nausea and vomiting. What diagnosis should the nurse suspect? a. Hydatidiform mole b. Placenta previa c. Prolapsed cord d. Abruptio placentae
a. Hydatidiform mole
The physiologic alterations of RDS (respiratory distress syndrome) can produce: a. Hypoxia. b. Respiratory alkalosis. c. Hemoglobinopathies. d. Metabolic alkalosis.
a. Hypoxia.
Clinical manifestations that indicate a newborn may be experiencing overheating include: a. Increased heart rate, increased blood pressure, and increased restlessness. b. Decreased blood pressure and lethargy. c. Increased respiratory rate, perspiration over forehead and torso, and decreased blood pressure. d. Increased heart rate, increased blood pressure, decreased oxygen consumption.
a. Increased heart rate, increased blood pressure, and increased restlessness.
The nurse is caring for a child following a tonsillectomy. Which nursing diagnosis is the greatest priority for this child? a. Ineffective Airway Clearance related to impaired swallowing and bleeding b. Risk for Ineffective Breathing Pattern related to obstruction by enlarged tonsils c. Risk for Deficient Fluid Volume related to inadequate intake d. Acute Pain related to inflammation of the pharynx
a. Ineffective Airway Clearance related to impaired swallowing and bleeding
Which statement by a 17-year-old girl indicates the need for additional counseling regarding the use of medications for TB treatment? a. Isoniazid: "I should take this when I eat." b. Rifampin: "My contact lenses will turn orange." c. Isoniazid: "No more drinking parties for me." d. Rifampin: "I need to stop taking my birth control pills."
a. Isoniazid: "I should take this when I eat."
A parent asks the nurse why her children get fewer ear infections as they grow older. On which aspects of the infant's Eustachian tube does the nurse base her answer? a. It is shorter, wider, and more horizontal than an older child's Eustachian tube. b. It is shorter, wider, and more diagonal than an older child's Eustachian tube. c. It is shorter, narrower, and more diagonal than an older child's Eustachian tube. d. It is shorter, narrower, and more horizontal than an older child's Eustachian tube.
a. It is shorter, wider, and more horizontal than an older child's Eustachian tube.
Understanding the transition from intrauterine to extrauterine life, what intervention is most appropriate when working with an infant of a diabetic mother? a. Make frequent blood glucose checks. b. Obtain lab work to look for infection. c. Administer IV fluids. d. Place under a radiant warmer bed immediately.
a. Make frequent blood glucose checks.
The nurse is caring for a laboring client with sickle cell anemia. Which therapy should the nurse anticipate the primary healthcare provider ordering? a. Oxygen b. Diuretics c. Magnesium sulfate d. Bronchodilators
a. Oxygen
A 12-year-old is being treated for acute respiratory distress syndrome. Which assessment finding would be indicative of the nursing diagnosis Impaired Gas Exchange? a. Oxygen saturation of 62% b. Heart rate of 100 bpm c. Respiratory rate of 30/min d. Bicarbonate level of 38
a. Oxygen saturation of 62%
The client asks for information about ectopic pregnancy. The nurse correctly responds by the risk for ectopic pregnancy is increased by: (Select all that apply.) a. Pelvic inflammatory disease (PID). b. Endometriosis. c. Presence of an IUD. d. In utero exposure to diethylstilbestrol (DES).
a. Pelvic inflammatory disease (PID). b. Endometriosis. c. Presence of an IUD. d. In utero exposure to diethylstilbestrol (DES).
An 8-year-old is admitted to the hospital with a severe sore throat, fever of 102°F, difficulty speaking, and ear pain. Which diagnosis does the nurse suspect based on these clinical manifestations? a. Peritonsillar abscess b. Strep throat c. Viral pharyngitis d. Tonsillitis
a. Peritonsillar abscess
A newborn continually falls asleep at the breast. Which intervention is appropriate when promoting effective breastfeeding by this infant? a. Removing all newborn coverings except a diaper b. Increasing the room temperature c. Minimizing tactile stimulation d. Avoiding speaking to the baby
a. Removing all newborn coverings except a diaper
4. A prenatal client with diabetes asks the nurse about pregnancy-related complications for her baby from diabetes. For what is the baby at risk when the mother has diabetes? (Select all that apply.) a. Sacral agenesis b. Hyperactivity c. Macrosomia d. Respiratory distress syndrome
a. Sacral agenesis c. Macrosomia d. Respiratory distress syndrome
A client who has admitted to heavy alcohol use throughout her pregnancy just delivered a 6-pound baby. Which sign or symptom in the mother should the nurse anticipate in the 12-48-hour postpartum period? a. Seizures b. Hypotension c. Fever d. Bradycardia
a. Seizures
Which tasks should the nurse perform rather than delegate to an assistant? (Select all that apply.) a. Suctioning a 2-year-old with a tracheostomy b. Changing the diaper of the 3-month-old infant recovering from RSV c. Walking with a 2-year-old who has an IV receiving antibiotics for pneumonia d. Relieving the nurse who is watching a 2-year-old with croup, because he now sounds quiet e. Taking the temperature of an 8-month-old infant with bronchiolitis whose respirations are 68 and who is irritable
a. Suctioning a 2-year-old with a tracheostomy d. Relieving the nurse who is watching a 2-year-old with croup, because he now sounds quiet e. Taking the temperature of an 8-month-old infant with bronchiolitis whose respirations are 68 and who is irritable
The nurse is providing prenatal care to an asymptomatic HIV-infected client. Which nursing intervention should take priority? a. Taking her temperature b. Performing a hearing test c. Performing a vision test d. Assessing reflexes
a. Taking her temperature
A 4-year-old child with croup is brought to the emergency department. The child is anxious and crying and has a high-pitched stridor, retractions, and a barky cough. After administration of cool mist therapy, which assessment finding would indicate significant improvement in the child's respiratory status? a. The child is less anxious. b. The respiratory rate is decreased. c. Wheezing is less loud. d. The child drinks 8 ounces of fluid.
a. The child is less anxious.
Which statement best describes the newborn's transition to extrauterine life? a. The risk of mortality and morbidity is statistically high during this period. b. Due to frequent monitoring of the newborn, it is difficult to bond with parents during this period. c. The procedure for estimating gestational age done on each newborn is a rigorous exam, and difficult for the newborn to tolerate. d. Because of stimulation, both tactile and auditory, by family members and healthcare professionals, the newborn is unable to rest, and depletion of the immune system occurs.
a. The risk of mortality and morbidity is statistically high during this period.
An 8-year-old child is diagnosed with viral pneumonia and sent home from the clinic without an antibiotic prescription. The symptoms worsen, and the child returns to the clinic a week later with signs of a higher fever, listlessness, and a harsh, productive cough. The child's mother states, "I knew a prescription for antibiotics was needed." Which response by the nurse is the most appropriate? a. "It is better to wait to make sure so we don't use antibiotics unnecessarily. This approach also saves healthcare dollars." b. "Antibiotics are not effective for viral pneumonia. Bacteria can grow later in the course of the illness, requiring the need for antibiotics at that time." c. "You do not want to expose your child to medication unnecessarily. Now it is necessary, because it is bacterial pneumonia." d. "Sometimes we just do not know. I'm glad you came back in."
b. "Antibiotics are not effective for viral pneumonia. Bacteria can grow later in the course of the illness, requiring the need for antibiotics at that time."
A client whose blood type is A negative declines RhoGAM, stating "I don't believe in vaccinations." The blood type of the father of the baby is unknown. What is the nurse's best response? a. "That's fine as long as you've done your research on it." b. "Declining this is can create very serious problems in future pregnancies." c. "You have to have RhoGAM if your blood is Rh negative." d. "Consider how irresponsible it is to put your children at risk."
b. "Declining this is can create very serious problems in future pregnancies."
The nurse at the clinic is teaching a class on childhood upper respiratory infections to parents of preschoolers. Which statement about tonsillectomy indicates further teaching is necessary? a. "I will call the healthcare provider if my child develops a fever of 102°F after a tonsillectomy." b. "I know that a sore throat 7 days after a tonsillectomy indicates an ear infection." c. "I should use acetaminophen for pain after a tonsillectomy." d. "I can use an ice collar to help decrease swelling."
b. "I know that a sore throat 7 days after a tonsillectomy indicates an ear infection."
The parents of a preterm baby express concern that vaccinations will "overload" the baby's immune system and tell the nurse they are thinking of declining them. What is the nurse's best response? a. "That's a wise idea. Talk to your pediatrician about a delayed vaccination schedule for when the baby is stronger." b. "Preterm babies tolerate vaccines very well and are at higher risk from vaccine-preventable diseases." c. "There is mounting evidence that vaccine safety is unproven, so many people are avoiding them altogether." d. "Not vaccinating your baby is irresponsible. Declining will trigger an inquiry from child protection agencies."
b. "Preterm babies tolerate vaccines very well and are at higher risk from vaccine-preventable diseases."
The nurse is caring for an infant born precipitously at 29 weeks' gestation. The mother presented for care in active labor and was hospitalized for approximately 4 hours before the baby was born. On day 1 of life, the infant is diagnosed with respiratory distress syndrome and the mother asks what is causing this problem. What is the nurse's best response? a. "When babies are born very small, they are not strong enough to breathe properly." b. "Term babies produce a substance that allows the air sacs in their lungs to inflate. Your baby doesn't have that yet." c. "Since your baby can't nurse, low blood sugar has depressed the respiratory centers in his brain." d. "Preterm babies are very susceptible to infection. Your baby has a lung infection similar to pneumonia."
b. "Term babies produce a substance that allows the air sacs in their lungs to inflate. Your baby doesn't have that yet."
The nurse is caring for a client who is not in labor but has been diagnosed with ruptured membranes at 30 weeks' gestation. For what intervention should the nurse prepare? a. Induction of labor b. Administration of magnesium sulfate c. Digital vaginal examination d. Amnioinfusion
b. Administration of magnesium sulfate
The nurse is caring for a prenatal client at 38 weeks' gestation whose ultrasound reveals polyhydramnios. She complains of shortness of breath and has 2+ pitting edema in her lower extremities. The nurse anticipates preparation for: a. Delivery by cesarean. b. Amniocentesis. c. Intravenous antibiotics. d. Amnioinfusion.
b. Amniocentesis.
A limp 10-year-old boy is carried into the emergency department by a parent who states that the child has a severe nosebleed. What is the priority action by the nurse? a. Administering oxygen b. Assessing for airway patency c. Obtaining a history d. Suctioning the blood
b. Assessing for airway patency
What are appropriate nursing actions for facilitating family-newborn attachment? (Select all that apply.) a. Take the newborn to the nursery for periods of sleep. b. Assist with an interactive bath. c. Take the newborn to the nursery for IV antibiotic therapy. d. Encourage sibling visitation whenever possible.
b. Assist with an interactive bath. d. Encourage sibling visitation whenever possible.
A mother who requested discharge 24 hours after a normal vaginal birth calls the nurse the following day. She states she is worried because the baby is having episodes of crying, wants to nurse every 2 hours, and is having irregular breathing, and the temperature under her arm is 95.2°F. What is most important for the nurse to investigate further? a. Crying b. Axillary temperature of 95.2°F c. Irregular respirations d. Feeding every 2 hours
b. Axillary temperature of 95.2°F
When transitioning a preterm, SGA infant to oral feeding, the most important nursing consideration is: a. Limiting calories to avoid overloading the GI system. b. Closely observing for signs of fatigue to avoid calorie expenditure greater than intake. c. Limiting parental involvement to be sure the proper technique is maintained. d. Making the transition as rapid as possible, so gavage feeding can be discontinued.
b. Closely observing for signs of fatigue to avoid calorie expenditure greater than intake.
Identify a potential long-term complication of the small-for-gestational-age newborn. a. Hyperglycemia b. Cognitive difficulties c. Leukocytosis d. Hyperthermia
b. Cognitive difficulties
What is the best way for the nurse to determine adequate hydration in the preterm infant? a. Examination of the skin and mucous membranes b. Daily or twice-daily weight c. Urinary catheterization and measurement of urine output d. Observation for a sunken anterior fontanelle
b. Daily or twice-daily weight
A postpartum client who admits to heavy alcohol use asks the nurse about breastfeeding her baby. The nurse correctly teaches this client that excessive alcohol consumption while breastfeeding may: a. Cause seizure disorders in the newborn. b. Decrease the maternal milk letdown reflex. c. Cause mental retardation in the newborn. d. Increase the maternal letdown reflex.
b. Decrease the maternal milk letdown reflex.
The nurse is assessing for descent of the testes in a full-term newborn. The nurse is unable to locate the testes in the scrotal sac. What would be an appropriate intervention for this finding? a. Assess hourly until the testes descend into the scrotal sac. b. Document findings and explain to parents that this will be evaluated again before discharge and at each health supervision visit until the testes are palpable in the scrotal sac. c. Make newborn NPO in preparation for surgery. d. Note that there is an absence of rugae on the scrotum, indicating testicular development is not mature.
b. Document findings and explain to parents that this will be evaluated again before discharge and at each health supervision visit until the testes are palpable in the scrotal sac.
A prenatal client is receiving home care for severe hyperemesis gravidarum. If the client does not respond to standard treatment, the nurse will anticipate adding which of the following therapies on an outpatient basis? a. Total parenteral nutrition b. IV fluids c. Low-fat soft diet d. Complex carbohydrates with limited liquids
b. IV fluids
The nurse is teaching a client with diabetes about insulin requirements during pregnancy. Which statement is true regarding insulin requirements? a. Insulin needs increase early in the first trimester. b. Insulin needs increase late in the first trimester. c. Insulin needs decrease early in the third trimester. d. Insulin needs decrease late in the third trimester
b. Insulin needs increase late in the first trimester.
The preterm newborn is experiencing vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea. What is the best explanation for these symptoms? a. Traumatic birth b. Maternal substance abuse c. Sepsis d. Gestational diabetes
b. Maternal substance abuse
The nurse is completing a history for a new client in the prenatal clinic. The client states that she has had a successfully repaired ventricular septal defect with no further problems. The nurse anticipates to order what for this client? a. Anticoagulant therapy b. No treatment is indicated. c. Antibiotic prophylaxis d. Cardiology evaluation with cardiac stress testing
b. No treatment is indicated.
The nurse weighs a breastfed infant delivered by cesarean at about 48 hours of life. The weight is 3348 g. The documented birth weight was 3600 g. The previous shift report states the infant is nursing well. What is the most appropriate nursing action? a. Supplement the baby with 2 oz of formula. b. Review the feeding record, counsel the mother as needed, and repeat the weight the next day. c. Have the mother pump her breasts and measure the output. d. Notify the primary healthcare provider.
b. Review the feeding record, counsel the mother as needed, and repeat the weight the next day.
A newborn is born at 38 weeks' gestation weighing 2250 grams. Which is the most appropriate nursing diagnosis? a. Ineffective Airway Clearance b. Risk for Altered Body Temperature c. Acute Pain d. Altered Nutrition: More than Body Requirements
b. Risk for Altered Body Temperature
It is estimated that the newborn is slightly over 42 weeks' gestation according to an ultrasound performed in the first trimester of the pregnancy. What is the highest-priority nursing diagnosis for the newborn during delivery? a. Altered Health Maintenance b. Risk for Injury c. Altered Tissue Perfusion d. Altered Nutrition: More than Body Requirements
b. Risk for Injury
In neonatal resuscitation management, which of the following is not included as critical assessment data? a. Respiratory rate b. Skin color c. Heart rate d. Pulse oximetry measurement
b. Skin color
The nurse is assessing a client receiving magnesium for neuroprotection in the setting of preterm rupture of membranes at 25 weeks' gestation. Which finding should be reported to the primary healthcare provider? a. Maternal complaints of muscle weakness b. Temperature of 100.6°F c. Blood pressure 90/50 d. Minimal FHR variability
b. Temperature of 100.6°F
Which of the following may indicate hemolytic disease of the newborn? a. The placenta is decreased in size. b. The neonate demonstrates pleural and pericardial effusion. c. The infant's bilirubin level is decreased. d. The neonate's spleen and liver are abnormally small.
b. The neonate demonstrates pleural and pericardial effusion.
Why would a primary healthcare provider order a Coombs' test? a. To determine the blood type of the infant b. To determine whether jaundice is due to Rh or ABO incompatibility c. To determine a positive left shift indicating possible infection d. To check hemoglobin and hematocrit levels
b. To determine whether jaundice is due to Rh or ABO incompatibility
A nurse explains why a 4-year-old presenting with respiratory distress has retractions. Which statement by the parent indicates that the teaching was understood? a. "When distress occurs, children swallow air, leading to expansion of the rib cage and retractions." b. "Retractions occur in all children, because their ribs are soft and pliable. They are not related to respiratory distress." c. "Children breathe primarily with their diaphragm, but when distress occurs, the muscles between the rib cage work with extra effort to move air through narrow airways." d. "Children breathe primarily with the muscles between the ribs, so when distress occurs, the extra work of breathing causes retractions."
c. "Children breathe primarily with their diaphragm, but when distress occurs, the muscles between the rib cage work with extra effort to move air through narrow airways."
A school nurse initiates an asthma action plan after checking a student's peak expiratory flow averages after three readings. Which peak expiratory flow average indicates that no action be taken? a. 35% b. 65% c. 85% d. 40%
c. 85%
In which child does the nurse anticipate a potential respiratory arrest following an assessment? a. A 5-month-old infant with RSV who is sleeping and has a respiratory rate of 24 b. A 2-year-old with epiglottitis who was intubated in the emergency department c. A 6-year-old with asthma who was previously wheezing and now has decreased breath sounds d. A 4-year-old, status post-tension pneumothorax from a motor vehicle accident with a chest tube in place, who complains of pain
c. A 6-year-old with asthma who was previously wheezing and now has decreased breath sounds
Which comments by the parents of a 7-year-old child with asthma indicate comprehension of instructions regarding medication use for control of the illness? a. The medications are too complicated for a 7-year-old to understand. b. If a spacer is used, a whistling sound indicates that the medication is being inhaled correctly. c. A spacer used on an inhaler helps trap the medication so it is inhaled more readily. d. Dry powder inhalers are for adult use only.
c. A spacer used on an inhaler helps trap the medication so it is inhaled more readily.
The nurse is caring for a laboring client with a known history of cocaine abuse. What complication is most likely for this client? a. Placenta previa b. Prolapsed cord c. Abruptio placentae d. Polyhydramnios
c. Abruptio placentae
A client with type 1 diabetes is admitted to the labor and birthing unit. What nursing action should the nurse perform first? a. Obtain prenatal record. b. Check urine for protein. c. Assess blood sugar level. d. Obtain a CBC.
c. Assess blood sugar level.
To assist the nurse in providing comprehensive care, which subjective data are pertinent to document? a. Height/weight/Body Mass Index b. Gestational examination results c. Available support system d. Newborn screening results
c. Available support system
Which is the preferred method of taking a newborn's temperature? a. Rectal b. Tympanic c. Axillary d. Oral
c. Axillary
What is the most appropriate nursing action when signs of fatigue occur in the newborn, such as loss of eye contact, decreased muscle tension, and closure of the eyelids? a. Increase IV fluids. b. Administer sedation medications. c. Discourage parent tactile stimulation. d. Administer blow by oxygen.
c. Discourage parent tactile stimulation.
The nurse is assisting at the birth of a term baby after a normal prenatal and labor course. The membranes rupture spontaneously during the second stage and there is significant meconium staining. At birth, the baby is fully flexed and centrally pink with a lusty cry. What is the most appropriate nursing action? a. Call for transfer to the neonatal intensive care unit for further evaluation. b. Place the baby on a radiant warmer and deep suction the nose and pharynx. c. Dry the baby and continue assessment on the mother's chest. d. Place the baby on a radiant warmer and administer oxygen by mask.
c. Dry the baby and continue assessment on the mother's chest.
The highest-priority intervention the nurse must perform before resuscitating a newborn with asphyxia is: a. Inserting an endotracheal tube. b. Measuring oxygen saturation. c. Establishing effective ventilations. d. Initiating chest compressions.
c. Establishing effective ventilations.
The nurse is reviewing the lab tests of four prenatal clients. Which lab finding would support the diagnosis of hyperemesis gravidarum? a. Hypercalcemia b. Hyperkalemia c. Hypokalemia d. Hypocalcemia
c. Hypokalemia
Which is the most appropriate nursing diagnosis for a newborn who has meconium aspiration syndrome? a. Pain b. Hyperthermia c. Impaired Gas Exchange d. Altered Nutrition: More than Body Requirements
c. Impaired Gas Exchange
What is true of physiologic jaundice? a. Jaundice usually stays visible for 20-25 days. b. Jaundice is considered an abnormal process that occurs during transition from intrauterine to extrauterine life and appears before 24 hours of life. c. It is considered a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life. d. There is no statistical difference between breastfed and bottle-fed babies regarding bilirubin levels.
c. It is considered a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life.
A client is diagnosed with preterm labor at 28 weeks' gestation. She asks the nurse what is going to happen to her baby if she is born now. The nurse's responses are based on the knowledge that the most significant problems for this infant will be associated with: a. Low birth weight. b. Feeding problems. c. Lung maturity. d. Skeletal injuries.
c. Lung maturity.
The nurse is assuming care of a woman whose baby was stillborn at term. Which nursing action is most appropriate? a. Restrict visitors. b. Avoid mentioning the baby. c. Offer her photographs of the baby. d. Stay at the bedside continuously.
c. Offer her photographs of the baby.
What is the correct way to perform external cardiac massage on an infant with a detectable heart rate? a. Place two fingers one finger-width below the nipple line and compress one half to one inch. b. Place one thumb one finger-width below the nipple line and compress at a 5:1 ratio. c. Place both thumbs over the lower third of the sternum with fingers wrapped around and supporting the back. d. Use the heel of one hand at the nipple line and compress at a ratio of 5:1.
c. Place both thumbs over the lower third of the sternum with fingers wrapped around and supporting the back.
A client denies domestic violence at her first prenatal visit. What is the best plan for future screening? a. Repeat screening at the initial visit for all subsequent pregnancies. b. The requirements for screening are satisfied by this negative result. c. Repeat screening in each trimester and postpartum. d. Repeat screening annually.
c. Repeat screening in each trimester and postpartum.
A client at 17 weeks' gestation is admitted to the labor and birth unit. Her chief complaint is abdominal cramping and vaginal spotting. What is the priority nursing diagnosis for this prenatal client? a. Risk for Ineffective Coping related to unknown outcome of pregnancy b. Knowledge Deficit related to management of vaginal bleeding c. Risk for Infection related to spontaneous abortion d. Impaired Physical Mobility related to continuous fetal monitoring
c. Risk for Infection related to spontaneous abortion
The nurse is caring for a client at 40 weeks' gestation who is has been experiencing prolonged labor. The nurse-midwife estimates the fetal weight at 4600 g. Which complication will the nurse anticipate at the birth? a. Occiput posterior delivery b. Meconium aspiration c. Shoulder dystocia d. Neonatal sepsis
c. Shoulder dystocia
What are common symptoms of polycythemia? a. Apnea, hypotension, and hyperthermia b. Orthopnea, tachypnea, and hyperbilirubinemia c. Tachycardia, respiratory distress, and hyperbilirubinemia d. Bradycardia, hypotension, and leukopenia
c. Tachycardia, respiratory distress, and hyperbilirubinemia
A prenatal nurse is assessing a client at 34 weeks' gestation who complains of vaginal irritation and thin, vaginal discharge that is "a funny color." What should be the nurse's initial action? a. Prepare for a nonstress test. b. Obtain vaginal cultures for STIs. c. Test the fluid with nitrazine paper. d. Test the urine for bacteria.
c. Test the fluid with nitrazine paper.
Which is true of a 38-weeks'-gestation newborn when testing for head lag? a. The nurse should see total head lag. b. The newborn holds the head in front of the body lines. c. The newborn can support her head momentarily. d. The newborn lifts her head momentarily while both legs lift off the table top momentarily.
c. The newborn can support her head momentarily.
A prenatal client at 16 weeks' gestation presents to the clinic with unexplained, bright red bleeding; cramping; and backache for the past 2 days. A pelvic exam reveals a closed cervix. What type of abortion does this indicate? a. Imminent b. Missed c. Threatened d. Incomplete
c. Threatened
The nurse is discussing betamethasone's effects on fetal lung maturity with a group of students. Which statement by a student demonstrates understanding of the effects of betamethasone? a. "It prevents delivery until the lungs are mature." b. "It increases capillary permeability in the lungs" c. "It alters the oxygen-carrying capacity of fetal hemoglobin." d. "It promotes surfactant production in the alveoli."
d. "It promotes surfactant production in the alveoli."
The nurse weighs a newborn who is 1 day old. It is noted that the newborn has lost 10 grams from the previous day. Which responses from the nurse to the parents are appropriate? a. "This is acceptable, and your newborn more than likely will continue to lose close to 20% of the birth weight over the next few days, but then regain it by 2 weeks." b. "I am concerned about the weight loss, and feel the physician should be notified." c. "This will be very alarming if your baby continues to lose weight over the next 2 days. We will watch closely." d. "We will continue to monitor closely, but it is expected that each baby will lose weight as fluids shift within a few days after delivery."
d. "We will continue to monitor closely, but it is expected that each baby will lose weight as fluids shift within a few days after delivery."
A frequent blood glucose test may be indicated for which newborn? a. A newborn with increased temperature and increased heart rate b. A newborn that is inconsolable c. A newborn with suspected hypothyroidism d. A newborn that is large for gestational age
d. A newborn that is large for gestational age
The nurse is performing a pelvic exam on a laboring client and discovers a loop of cord in the vagina. What is the initial nursing action? a. Administer oxygen at 5 L per minute. b. Call the primary healthcare provider or nurse-midwife. c. Place the client in a side-lying position. d. Apply upward pressure on the presenting part
d. Apply upward pressure on the presenting part
The nurse is assessing a prenatal client diagnosed with possible placenta previa. What signs and symptoms should the nurse expect this client to demonstrate? a. Dark red vaginal bleeding b. Severe abdominal pain c. Absence of fetal heart sounds d. Bright red vaginal bleeding
d. Bright red vaginal bleeding
A client presents to the primary healthcare provider's office with complaints of right-sided abdominal pain, dizziness, and vaginal bleeding. A pelvic exam determines the client to be at 10 weeks' gestation with adnexal tenderness. What diagnosis should the nurse suspect? a. Threatened abortion b. Appendicitis c. Cholelithiasis d. Ectopic pregnancy
d. Ectopic pregnancy
What is the best intervention a nurse can utilize to promote parent-infant attachment? a. Allow for privacy. b. Contact support families that have been through the same diagnosis with their own child and allow time to discuss the situation. c. Provide an extensive handbook with information related to the preterm newborn. d. Encourage rooming in.
d. Encourage rooming in.
The nurse is counseling a prenatal client regarding the need to take folic acid supplements during pregnancy. The nurse also encourages the client to eat foods high in folic acid, such as: a. Fruits and fruit juice. b. Rice and pasta. c. Eggs and yogurt. d. Fresh green leafy vegetables and legumes.
d. Fresh green leafy vegetables and legumes.
The highest-priority nursing diagnosis for a neonate experiencing RDS is: a. Altered Nutrition: More than Body Requirements. b. Alterations in Parenting. c. Acute Pain. d. Impaired Gas Exchange related to inadequate lung surfactant.
d. Impaired Gas Exchange related to inadequate lung surfactant.
What is the best rationale for removing the cord clamp within 24 hours? a. It decreases the risk for infection. b. Waiting longer than 24 hours will make the clamp difficult to remove. c. To reassess the number of vessels found within the cord d. It decreases the chance of tension injury to the area.
d. It decreases the chance of tension injury to the area.
What rationale supports drawing the newborn screen after 24 hours from the time of delivery? a. Hemoglobinopathies are most evident at 24-36 hours of life. b. There is overdiagnosis of congenital adrenal hyperplasia if drawn before 24 hours of life. c. Cystic fibrosis is not apparent in the blood of the newborn until 24 hours postdelivery. d. It is well documented that there is a decrease in sensitivity of the screening if obtained before 24 hours of life, resulting in underdiagnosing of PKU.
d. It is well documented that there is a decrease in sensitivity of the screening if obtained before 24 hours of life, resulting in underdiagnosing of PKU.
A newborn appears large for gestational age, while a lower score for neurological maturation is noted on gestational exam. Which answer best explains this outcome? a. Maternal preeclampsia b. Maternal analgesia and anesthesia c. Maternal hypertension d. Maternal diabetes
d. Maternal diabetes
What is the best explanation for correlating the nursing diagnosis Risk for Infection and the preterm infant? a. Preterm babies have immature cardiovascular systems. b. Preterm babies have immature neurological systems. c. Preterm babies have immature gastrointestinal systems. d. Preterm newborns have immature immune systems.
d. Preterm newborns have immature immune systems.
The primary goal for the drug-dependent newborn is to reduce withdrawal symptoms and promote adequate respiration, temperature, and nutrition. What intervention best reflects that goal? a. Monitor for hyperthermia. b. NPO status c. Administer medications such as methadone. d. Proper positioning on right side-lying or in semi-Fowler.
d. Proper positioning on right side-lying or in semi-Fowler.
What is the most appropriate nursing action for a newborn demonstrating acrocyanosis? a. Administer IV fluids. b. Suction vigorously. c. Place in the Trendelenburg position. d. Swaddle in blankets.
d. Swaddle in blankets.
The nurse is examining an infant at 1 hour of life and notes a small, flat, pink lesion between the eyebrows that becomes more pronounced with crying. This should be documented as a(n): a. Nevus flammeus. b. Nevus vasculosus. c. Erythema toxicum. d. Telangiectatic nevus.
d. Telangiectatic nevus.
The nurse is caring for a laboring client with type 1 diabetes. What is the expected effect of labor on the woman's insulin requirements? a. Insulin is generally not required in labor. b. Close monitoring is unnecessary because requirements are predictable. c. They are consistently increased. d. They are likely to decrease.
d. They are likely to decrease.
The nurse is caring for a third-trimester prenatal client admitted with bright red, painless vaginal bleeding. What nursing intervention is not recommended? a. Intravenous fluids with lactated Ringer's b. Assessment of the fetal heart rate with continuous monitoring c. Application of a pulse oximeter d. Vaginal exams
d. Vaginal exams