140 final exam Blueprint practice quiz

A nurse is providing education to a group of parents about the prevention of Reye's syndrome in children. Which statement by a parent indicates an understanding of the key preventive measure for Reye's syndrome? A) "I will give my child aspirin for fever or pain relief, especially during a viral illness." B) "I should administer ibuprofen instead of aspirin when my child has the flu or chickenpox." C) "Antibiotics should be given promptly if my child develops a viral infection." D) "A high-dose vitamin regimen will prevent Reye's syndrome during a viral infection."

B) "I should administer ibuprofen instead of aspirin when my child has the flu or chickenpox." A) This statement is incorrect and dangerous. Aspirin use in children, especially during viral illnesses like influenza or chickenpox, is associated with an increased risk of Reye's syndrome. B) This is the correct statement. Ibuprofen or other non-aspirin fever reducers/pain relievers should be used as alternatives to aspirin in children, particularly during viral infections, to reduce the risk of Reye's syndrome. C) Antibiotics are not effective against viral infections and are not relevant to the prevention of Reye's syndrome, which is associated with aspirin use. D) While a balanced diet is important for overall health, high-dose vitamin regimens have no proven role in the prevention of Reye's syndrome and are not recommended for this purpose. Reye's syndrome is a rare but serious condition that can affect the liver and brain. The most important preventive measure is to avoid giving aspirin to children, especially during viral illnesses.

A nurse is providing discharge teaching to a postpartum patient regarding lochia. Which of the following statements made by the patient indicates a need for further education? A) "I should call my healthcare provider if my lochia has a foul odor." B) "It is normal for my lochia to return to a bright red color two weeks after delivery." C) "I should expect the lochia to change from red to pinkish, then to a whitish color." D) "I will contact my healthcare provider if I pass clots larger than a quarter."

B) "It is normal for my lochia to return to a bright red color two weeks after delivery." A) This statement is correct. Foul-smelling lochia can be a sign of infection and warrants contacting a healthcare provider. B) This statement indicates a misunderstanding. Lochia returning to a bright red color after it has lightened (usually around the 10th day postpartum) can be a sign of late postpartum hemorrhage and should be reported to a healthcare provider. C) This statement is correct. Lochia typically changes from rubra (red) to serosa (pinkish) to alba (whitish) over the course of several weeks. D) This statement is also correct. Passing clots larger than a quarter can be a sign of excessive bleeding and should be reported.

A nurse is providing education to parents of a child diagnosed with an inborn error of metabolism. Which of the following statements made by the parents indicates a correct understanding of managing their child's condition? A) "We should follow a normal diet unless our child shows symptoms." B) "It's important for us to strictly adhere to the dietary restrictions recommended by our doctor." C) "Medications are not typically necessary for managing inborn errors of metabolism." D) "We only need to monitor our child's condition during periods of illness."

B) "It's important for us to strictly adhere to the dietary restrictions recommended by our doctor." A) Children with inborn errors of metabolism often require a special diet to manage their condition, regardless of whether they are currently symptomatic. B) This is the correct statement. Adherence to dietary restrictions is crucial in managing inborn errors of metabolism to prevent complications. C) Depending on the specific metabolic disorder, medications may be necessary to manage the condition effectively. D) Continuous monitoring and management of the condition are essential, not just during periods of illness, to prevent metabolic crises.

A nurse is teaching new parents about preventing heat loss in their newborn. Which of the following statements made by the parents indicates an understanding of the teaching? A) "We should place our baby directly on the cold changing table after a bath." B) "It's important to dry our baby immediately after a bath to prevent evaporation." C) "We can prevent heat loss by keeping the room cool and well-ventilated." D) "Swaddling the baby in thin blankets will help prevent radiation heat loss."

B) "It's important to dry our baby immediately after a bath to prevent evaporation." A) This statement is incorrect as placing a baby on a cold surface can lead to heat loss through conduction. B) This statement is correct. Drying the baby immediately after a bath prevents heat loss through evaporation. Newborns are particularly prone to heat loss through evaporation because of their relatively large body surface area and frequent baths. C) Keeping the room cool and well-ventilated might actually contribute to heat loss, particularly through convection. D) Swaddling in thin blankets is not effective in preventing radiation heat loss. Radiation heat loss can occur when the baby is near cold surfaces or objects, even if the baby is not in direct contact with them. Swaddling in warm blankets and keeping the baby away from cold surfaces can help prevent radiation heat loss.

A nurse is providing education to a group of new parents about infant growth. One parent asks about the expected weight gain for their infant. Which of the following responses by the nurse is accurate? A) "Infants typically gain about 1 pound per month for the first six months." B) "It's normal for an infant to double their birth weight by 6 months and triple it by their first birthday." C) "Most infants gain about 2 pounds per month during their first year." D) "Infants usually quadruple their birth weight by the end of the first year."

B) "It's normal for an infant to double their birth weight by 6 months and triple it by their first birthday." A) While infants typically gain weight rapidly, the rate of 1 pound per month for the first six months is an underestimation. The actual expected weight gain is about 1 to 1.5 pounds per month. B) This statement is correct. The general guideline is that infants double their birth weight by about 6 months of age and triple it by their first birthday. C) Gaining 2 pounds per month for the first year would lead to excessively high weight gain. The average is closer to 1 to 1.5 pounds per month. D) Quadrupling the birth weight by the end of the first year is excessive. The expected milestone is to triple the birth weight.

A nurse is providing education to new parents on how to properly bottle-feed their infant. Which statement by the parents indicates a need for further teaching? A) "We should always test the temperature of the formula on our wrist before feeding our baby." B) "It's okay to prop the bottle up if we're busy, as long as the baby is being watched." C) "We need to clean and sterilize the bottles and nipples after each feeding." D) "We should hold our baby in a semi-upright position during feedings."

B) "It's okay to prop the bottle up if we're busy, as long as the baby is being watched." A) Testing the formula's temperature on the wrist to ensure it's not too hot is a good practice and indicates an understanding of safe bottle feeding. B) Propping a bottle can lead to choking, ear infections, and tooth decay. It also deprives the baby of important physical contact and interaction during feeding. This statement indicates a misconception and a need for further teaching. C) Proper cleaning and sterilization of bottles and nipples are important to prevent contamination and illness, showing an understanding of proper bottle care. D) Holding the baby in a semi-upright position during bottle feeding is recommended to prevent choking and facilitate bonding, indicating correct knowledge.

A nurse is providing education to a group of parents about the MMR vaccine. Which of the following statements should the nurse include when discussing the MMR vaccine? A) "The MMR vaccine is typically given in a series of three doses." B) "The first dose of the MMR vaccine is usually administered at 12-15 months of age." C) "The MMR vaccine is a live virus vaccine and can cause mild versions of the diseases." D) "Children should receive the MMR vaccine only after they turn 2 years old.

B) "The first dose of the MMR vaccine is usually administered at 12-15 months of age." A) The MMR vaccine is given in two doses, not three. The first dose is typically given at 12-15 months of age, and the second dose is usually administered at 4-6 years of age. B) This is the correct statement. The first dose of the MMR vaccine is recommended at 12-15 months of age. C) While the MMR vaccine is a live virus vaccine, it does not cause the diseases it protects against. It may cause mild symptoms related to the vaccine but not the actual diseases of measles, mumps, or rubella. D) The first dose of the MMR vaccine is recommended before 2 years of age, typically at 12-15 months.

A nurse is providing discharge teaching to the parents of a child diagnosed with bacterial conjunctivitis. Which of the following statements made by the parents indicates a need for further teaching? A) "We should wash our hands frequently to prevent spreading the infection." B) "We can use the same washcloth to clean both of our child's eyes." C) "We will complete the full course of prescribed antibiotic eye drops." D) "We need to keep our child home from school until treatment has started."

B) "We can use the same washcloth to clean both of our child's eyes." A) Frequent hand washing is important in preventing the spread of conjunctivitis and is a correct practice. B) Using the same washcloth for both eyes can spread the infection from one eye to the other. Each eye should be cleaned with a separate, clean cloth, indicating a need for further teaching. C) Completing the full course of prescribed antibiotics is essential to ensure the infection is fully treated and to prevent resistance. D) Keeping the child home from school until treatment has started can help prevent the spread of the infection to others, which is a recommended practice.

A nurse is caring for a newborn with suspected congenital infection. The mother's prenatal history is significant for a fever and rash during the first trimester. Which of the following infections, part of the TORCH complex, should the nurse consider as a potential cause of the newborn's condition? A) Hepatitis B B) Cytomegalovirus (CMV) C) Human Immunodeficiency Virus (HIV) D) Measles

B) Cytomegalovirus (CMV) The TORCH complex includes a group of infections that can cause congenital anomalies or affect the newborn. It stands for Toxoplasmosis, Other (including syphilis, varicella-zoster, parvovirus B19, and HIV), Rubella, Cytomegalovirus (CMV), and Herpes infections. B) Cytomegalovirus (CMV) is a common cause of congenital infections and is associated with maternal symptoms such as fever and rash, which can pass to the fetus and cause various health problems in the newborn. CMV fits the described maternal history. A) Hepatitis B can be transmitted from mother to child, but it is not typically associated with maternal fever and rash. C) HIV is included in the "Other" category of TORCH, but maternal HIV infection doesn't typically present with fever and rash. D) Measles, while causing fever and rash in the mother, is not traditionally categorized under the TORCH complex. This question tests the nurse's understanding of the TORCH complex and its relevance in congenital infections.

A nurse is developing a care plan for a newly diagnosed adolescent with type 2 diabetes. Which of the following interventions should the nurse include in the treatment plan? Select all that apply. A) Prescribing insulin injections to be administered daily. B) Educating on the importance of regular physical activity. C) Implementing a balanced diet plan to control blood glucose levels. D) Monitoring blood glucose levels at least once a week. E) Providing education on the potential complications of diabetes.

B) Educating on the importance of regular physical activity. C) Implementing a balanced diet plan to control blood glucose levels. E) Providing education on the potential complications of diabetes. A) Insulin injections are not typically the first-line treatment for type 2 diabetes, especially in adolescents. Oral hypoglycemic agents or lifestyle modifications are usually tried first. B) Regular physical activity is a key component in managing type 2 diabetes, as it helps control blood glucose levels and maintain a healthy weight. C) A balanced diet is crucial in the management of type 2 diabetes, as it helps regulate blood sugar levels and can prevent complications. D) Monitoring blood glucose levels is important, but doing so only once a week may not be sufficient for managing diabetes. Typically, more frequent monitoring is recommended. E) Educating the patient about the potential complications of diabetes is important for long-term disease management and prevention of complications.

A nurse is observing a group of children in a pediatric clinic. According to Erikson's stages of psychosocial development, which behavior is developmentally appropriate for a preschool-aged child (3-5 years)? A) Demonstrating a strong sense of independence by wanting to dress themselves B) Engaging in imaginative play and taking on different roles C) Showing interest in building relationships with peers outside the family D) Struggling with feelings of inferiority when comparing themselves to peers

B) Engaging in imaginative play and taking on different roles A) Demonstrating a strong sense of independence by wanting to dress themselves is more characteristic of Erikson's stage of "Autonomy vs. Shame and Doubt," which typically occurs in toddlers (1-3 years). B) Engaging in imaginative play and assuming different roles is indicative of the "Initiative vs. Guilt" stage, which is typical for preschool-aged children (3-5 years). At this stage, children begin to assert power and control over their environment through directing play and other social interactions. C) Showing interest in building relationships with peers outside the family aligns with the "Industry vs. Inferiority" stage, which is typical for school-aged children (6-12 years). D) Struggling with feelings of inferiority when comparing themselves to peers is also a part of the "Industry vs. Inferiority" stage, relevant to school-aged children.

A nurse is obtaining an obstetric history from a pregnant patient using the GTPAL system. The patient reports the following history: one term delivery, one preterm delivery, one abortion at 8 weeks, and two living children. What is the correct GTPAL classification for this patient? A) G4 T1 P1 A1 L2 B) G5 T1 P1 A1 L2 C) G3 T1 P0 A1 L2 D) G3 T1 P1 A1 L1

B) G5 T1 P1 A1 L2 The GTPAL system is used to summarize a patient's obstetric history. It stands for Gravida, Term births, Preterm births, Abortions, and Living children. Gravida (G): Total number of pregnancies, including the current pregnancy. The patient has had four previous pregnancies (one term, one preterm, and one abortion) and is currently pregnant, making it a total of 5 pregnancies. Term births (T): Deliveries after 37 weeks. The patient has had one term delivery. Preterm births (P): Deliveries between 20 and 37 weeks. The patient has had one preterm delivery. Abortions (A): Pregnancies ending before 20 weeks, either spontaneous or induced. The patient had one abortion at 8 weeks. Living children (L): Number of living children. The patient has two living children. Therefore, the correct GTPAL classification for this patient is G5 T1 P1 A1 L2, making option B the correct answer.

A nurse is caring for a term newborn who is 48 hours old. The baby appears jaundiced. The nurse understands that jaundice at this stage is most likely due to: A) Excessive breakdown of fetal red blood cells. B) Inadequate liver function to excrete bilirubin. C) Maternal antibodies attacking the newborn's red blood cells. D) An infection in the newborn causing elevated bilirubin levels.

B) Inadequate liver function to excrete bilirubin. A) While the breakdown of fetal red blood cells contributes to bilirubin production, it is not typically the primary cause of jaundice in a term newborn at 48 hours old unless there is an underlying condition such as hemolysis. B) This is the most likely reason. Physiologic jaundice in newborns often results from the immature liver's inability to process and excrete bilirubin efficiently. This form of jaundice typically appears after the first 24 hours of life and resolves as the liver matures. C) Maternal antibodies attacking the newborn's red blood cells is a condition that can lead to hemolytic disease of the newborn, which is a different scenario from physiologic jaundice. D) While infection can cause elevated bilirubin levels, it is less likely to be the cause in a term, otherwise healthy newborn without other signs of infection.

A nurse is caring for a child with extensive burn injuries. Which of the following complications should the nurse monitor for in the acute phase of burn care? Select all that apply. A) Hypothermia B) Infection C) Fluid volume deficit D) Electrolyte imbalances E) Delayed wound healing

B) Infection C) Fluid volume deficit D) Electrolyte imbalances E) Delayed wound healing A) Hypothermia is a risk immediately following a burn injury due to skin damage, but in the acute phase of burn care, the focus is often on preventing hyperthermia due to inflammation and infection. B) Infection is a major concern with burn injuries due to the disruption of the skin's barrier function. C) Fluid volume deficit is a critical concern in burn patients, especially in the initial 24-48 hours, due to fluid loss from the injury and the body's response to the trauma. D) Electrolyte imbalances can occur due to fluid shifts, loss of electrolytes through wound exudate, and renal impairment. E) Delayed wound healing is a common complication of burns due to the extensive tissue damage and potential for infection.

A nurse is assessing a newborn who sustained a brachial plexus injury during birth. Which of the following findings would the nurse expect to observe in the newborn? A) Symmetrical Moro reflex in both arms. B) Limited or absent movement in the affected arm. C) Increased muscle tone in the affected arm. D) Consistent grip strength in both hands.

B) Limited or absent movement in the affected arm. A) The Moro reflex is often asymmetric or absent in the arm affected by a brachial plexus injury, not symmetrical. B) A brachial plexus injury results in weakness or paralysis of the arm, leading to limited or absent movement in the affected arm, making this the correct answer. C) Decreased, not increased, muscle tone is typically observed in the arm affected by a brachial plexus injury due to nerve damage. D) Grip strength is likely to be weaker or absent in the hand of the affected arm, not consistent with the unaffected hand. Brachial plexus injuries in newborns, often resulting from birth trauma, can cause varying degrees of nerve damage, affecting movement and sensation in the affected arm. The nurse's assessment should focus on identifying these characteristic findings to ensure appropriate management and referral for treatment.

A nurse is assessing a patient who believes she might be pregnant. Which of the following symptoms reported by the patient are considered presumptive signs of pregnancy? Select all that apply. A) Positive pregnancy test B) Nausea and vomiting C) Breast enlargement and tenderness D) Fetal movement felt by a healthcare provider E) Urinary frequency F) Amenorrhea

B) Nausea and vomiting C) Breast enlargement and tenderness E) Urinary frequency F) Amenorrhea Presumptive signs of pregnancy are those reported by the patient and are not definitive for pregnancy, but suggest the possibility of pregnancy. These signs can be caused by conditions other than pregnancy. B) Nausea and vomiting, often termed as "morning sickness," are common early symptoms of pregnancy. C) Breast enlargement and tenderness are frequently experienced in early pregnancy due to hormonal changes. E) Urinary frequency can occur due to hormonal changes and the growing uterus exerting pressure on the bladder. F) Amenorrhea, or the absence of menstruation, is often the first sign noticed by women, but can have causes other than pregnancy. The non-selected options, A and D, are not considered presumptive signs: A) A positive pregnancy test is a probable sign of pregnancy, as it detects the presence of hCG (human chorionic gonadotropin) hormone. D) Fetal movement felt by a healthcare provider is a positive sign of pregnancy, providing objective evidence of a developing fetus.

A nurse is caring for an infant diagnosed with bronchiolitis. Which of the following interventions should the nurse anticipate as part of the treatment plan for this patient? Select all that apply. A) Administering high-dose corticosteroids B) Providing supplemental oxygen if hypoxemia is present C) Encouraging increased fluid intake D) Prescribing broad-spectrum antibiotics E) Performing gentle nasal suctioning as needed

B) Providing supplemental oxygen if hypoxemia is present C) Encouraging increased fluid intake E) Performing gentle nasal suctioning as needed A) Corticosteroids are not typically used in the treatment of bronchiolitis, as there is little evidence to support their effectiveness in this condition. B) Supplemental oxygen may be necessary for infants with bronchiolitis who are experiencing hypoxemia (low blood oxygen levels). C) Maintaining adequate hydration is important in the treatment of bronchiolitis, especially if the infant is experiencing increased respiratory effort or fever. D) Antibiotics are not effective against bronchiolitis, as it is usually caused by a virus (such as the Respiratory Syncytial Virus, RSV). Antibiotics are only indicated if there is a bacterial co-infection. E) Gentle nasal suctioning can help clear mucus and ease breathing difficulties in infants with bronchiolitis.

A nurse is analyzing an electronic fetal monitor tracing for a laboring patient. The monitor shows a baseline fetal heart rate (FHR) of 155 bpm, with frequent, variable decelerations that decrease to 90 bpm and last 15-20 seconds before returning to the baseline. There are no significant changes in the FHR pattern with uterine contractions. What action should the nurse take based on this fetal heart rate pattern? A) Prepare for immediate delivery due to fetal distress. B) Reposition the patient, administer oxygen, and notify the healthcare provider. C) Continue routine monitoring as this is a normal FHR pattern. D) Increase intravenous fluids to improve placental perfusion.

B) Reposition the patient, administer oxygen, and notify the healthcare provider. The fetal heart rate pattern described indicates variable decelerations, which can be a sign of cord compression. The appropriate nursing response is to: Reposition the patient (often to the left lateral position) to relieve potential cord compression. Administer supplemental oxygen to increase fetal oxygenation. Notify the healthcare provider for further assessment and intervention. This response (option B) is an initial conservative measure to improve fetal status and potentially resolve the variable decelerations. Option A may be premature without further assessment and attempts at conservative management. Option C is incorrect as frequent variable decelerations can be concerning and warrant intervention. Option D, increasing IV fluids, is more appropriate for hypotension or oligohydramnios but does not directly address variable decelerations.

A nurse is caring for a pregnant patient who is receiving magnesium sulfate for the prevention of seizures associated with preeclampsia. Which of the following findings would be the most critical for the nurse to report immediately? A) Urine output of 30 mL/hr B) Respiratory rate of 10 breaths per minute C) Absent deep tendon reflexes D) Blood pressure of 150/100 mmHg

B) Respiratory rate of 10 breaths per minute Magnesium sulfate is commonly used in preeclampsia management to prevent seizures. However, it can lead to magnesium toxicity, particularly affecting the respiratory and neuromuscular systems. The most critical finding to report immediately is a respiratory rate of 10 breaths per minute (option B), as this indicates potential magnesium toxicity leading to respiratory depression, a life-threatening complication. A urine output of 30 mL/hr (option A) is at the lower limit of normal (30-50 mL/hr) but is not as immediately life-threatening as respiratory depression. Absent deep tendon reflexes (option C) are a sign of magnesium toxicity and should be monitored, but they are not as immediately critical as a decreased respiratory rate. Elevated blood pressure (option D) is a concern in preeclampsia, but the given value is not as immediately life-threatening as respiratory depression from magnesium toxicity. Therefore, the nurse should prioritize and report the respiratory rate of 10 breaths per minute immediately, as it requires urgent intervention.

A nurse is assessing a child for signs of dehydration. Which of the following findings would indicate moderate to severe dehydration in the child? Select all that apply. A) Moist mucous membranes B) Sunken fontanelles C) Decreased urine output D) Increased heart rate E) Elastic skin turgor

B) Sunken fontanelles C) Decreased urine output D) Increased heart rate A) Moist mucous membranes are typically a sign of adequate hydration. Dry mucous membranes would indicate dehydration. B) Sunken fontanelles in an infant are a sign of moderate to severe dehydration and indicate a decrease in intracranial pressure. C) Decreased urine output is a common sign of dehydration, as the body conserves water. D) Increased heart rate can occur in response to dehydration as the body tries to maintain adequate blood pressure and perfusion. E) Elastic skin turgor is a sign of good hydration. Poor skin turgor, where the skin remains tented after being pinched, would indicate dehydration.

A nurse is caring for a patient who has experienced a spinal cord injury. The nurse recognizes that the patient is likely experiencing neurogenic shock based on which of the following clinical findings? Select all that apply. A) Hypertension B) Warm, dry skin C) Bradycardia D) Flaccid paralysis below the level of the injury E) Respiratory distress

B) Warm, dry skin C) Bradycardia D) Flaccid paralysis below the level of the injury A) Hypotension, not hypertension, is a characteristic of neurogenic shock due to the loss of sympathetic tone and vasodilation. B) Warm, dry skin is observed in neurogenic shock due to vasodilation and the inability to constrict blood vessels below the level of the injury. C) Bradycardia is a common finding in neurogenic shock due to unopposed parasympathetic activity. D) Flaccid paralysis below the level of the injury is consistent with neurogenic shock following a spinal cord injury. E) Respiratory distress may occur in spinal cord injuries, especially if the injury is high on the spinal column, but it is not a direct symptom of neurogenic shock.

A nurse is providing education to a pregnant patient experiencing morning sickness. Which of the following recommendations made by the patient indicates a need for further teaching? A) "I will eat several small meals throughout the day instead of three large ones." B) "Drinking ginger tea may help alleviate my nausea." C) "I should lie down immediately after eating to help with digestion." D) "Eating dry toast or crackers before getting out of bed may help."

C) "I should lie down immediately after eating to help with digestion." The correct answer is C, as lying down immediately after eating can actually worsen nausea and vomiting in pregnancy. Remaining upright after meals helps in digestion and prevents the reflux of stomach contents, which can contribute to nausea. Responses A, B, and D are appropriate strategies for managing nausea in pregnancy: A) Eating small, frequent meals helps to avoid an overly full stomach, which can exacerbate nausea. B) Ginger is a natural remedy that can be effective in reducing nausea. D) Eating dry toast or crackers before getting up can help settle the stomach and reduce early morning nausea, which is often worse on an empty stomach.

A nurse is providing discharge instructions to the parents of a child who has just had a cast applied to their lower leg. Which statement by the parents indicates a need for further teaching? A) "We should keep the cast dry and cover it with plastic during baths." B) "We can use a hairdryer on a cool setting if the inside of the cast feels damp." C) "If our child complains of numbness or tingling, we should reposition the cast ourselves." D) "We will check the toes for any signs of swelling, blueness, or coldness."

C) "If our child complains of numbness or tingling, we should reposition the cast ourselves." A) Keeping the cast dry and covering it during baths is correct to prevent damage to the cast and skin irritation. B) Using a hairdryer on a cool setting to address dampness inside the cast is an appropriate recommendation. C) This statement is incorrect and indicates a need for further teaching. Numbness or tingling may indicate that the cast is too tight. Parents should not attempt to reposition or adjust the cast themselves but should seek medical attention. D) Monitoring for swelling, blueness, or coldness in the toes is important to ensure proper circulation and detect any issues with the cast.

A school nurse is providing a workshop for teachers about recognizing and intervening in bullying situations. Which of the following statements made by a teacher indicates a need for further education about bullying? A) "Bullying can occur in various forms, including physical, verbal, and cyberbullying." B) "Children who are bullied often show signs of anxiety, depression, and decreased academic achievement." C) "It's important to encourage children to handle bullying on their own to build resilience." D) "We should create a safe school environment where students feel comfortable reporting bullying."

C) "It's important to encourage children to handle bullying on their own to build resilience." A) Recognizing that bullying can take multiple forms is correct and demonstrates an understanding of the complexity of bullying behaviors. B) Acknowledging the psychological and academic impact of bullying on children is correct and reflects an understanding of the consequences of bullying. C) This statement is incorrect and demonstrates a need for further education. Encouraging children to handle bullying on their own can lead to worsening situations and feelings of isolation. It's important for adults to intervene and provide support. D) Creating a safe and supportive school environment where bullying can be reported without fear of retribution is an essential component of an effective anti-bullying strategy.

A nurse is educating a group of caregivers about the different types of seizures. Which of the following descriptions provided by the nurse correctly matches the type of seizure to its signs and symptoms? A) "Absence seizures are characterized by sudden, brief stiffening of the muscles, often causing a fall." B) "Tonic-clonic seizures involve a brief warning sensation followed by muscle stiffness and rhythmic jerking." C) "Myoclonic seizures are characterized by sudden, brief, shock-like jerks of a muscle or group of muscles." D) "Atonic seizures are often marked by head nodding and temporary loss of muscle tone, leading to falls."

C) "Myoclonic seizures are characterized by sudden, brief, shock-like jerks of a muscle or group of muscles." A) This description is more indicative of a tonic seizure, which involves sudden muscle stiffness, not an absence seizure. Absence seizures are characterized by brief periods of staring and unresponsiveness. B) Tonic-clonic seizures do often start with a tonic phase (muscle stiffness) followed by a clonic phase (rhythmic jerking), but they typically do not involve a brief warning sensation; that description is more fitting for an aura, which can precede any type of seizure. C) This statement is correct. Myoclonic seizures are characterized by sudden, brief jerks that can affect part of or the entire body. D) Atonic seizures, also known as drop attacks, involve a sudden loss of muscle tone, often leading to falls. They do not typically involve head nodding.

A nurse is teaching a group of nursing students about the cardiovascular changes that occur in a newborn immediately after birth. Which statement by a student indicates the need for further teaching? A) "The foramen ovale closes as a result of increased pressure in the left atrium compared to the right atrium." B) "Closure of the ductus arteriosus is initiated by increased oxygen levels in the newborn's blood." C) "The umbilical arteries and veins remain functional for several weeks after birth." D) "The increase in systemic vascular resistance after birth leads to closure of the ductus venosus."

C) "The umbilical arteries and veins remain functional for several weeks after birth." A) This statement is correct. The foramen ovale, an opening between the right and left atria in the fetal heart, typically closes after birth when the pressure in the left atrium exceeds that in the right atrium. B) This statement is accurate. The ductus arteriosus, a blood vessel that connects the pulmonary artery to the descending aorta in the fetus, closes in response to increased oxygen levels in the newborn's blood. C) This statement is incorrect and indicates a need for further teaching. The umbilical arteries and vein, which connect the fetus to the placenta, become nonfunctional after birth and quickly begin to close. D) This statement is correct. The ductus venosus, which shunts blood from the umbilical vein to the inferior vena cava in the fetus, closes due to an increase in systemic vascular resistance and a decrease in the flow of blood from the umbilical vein after birth.

A nurse is instructing new parents on safe practices for bottle feeding their infant. Which of the following statements made by the parents indicates a correct understanding of bottle feeding? A) "We can prepare bottles in advance and leave them at room temperature for up to 6 hours." B) "If our baby doesn't finish the bottle, we can refrigerate it and offer it again in a few hours." C) "We should discard any formula left in the bottle if our baby doesn't finish it within an hour." D) "It's safe to warm the bottle in a microwave for a quick feeding."

C) "We should discard any formula left in the bottle if our baby doesn't finish it within an hour." A) Preparing bottles in advance and leaving them at room temperature for extended periods can promote bacterial growth. This practice is not safe. B) Reusing formula that a baby didn't finish can also increase the risk of bacterial contamination. Leftover formula should be discarded. C) This statement is correct. Discarding any formula left in the bottle after a feeding reduces the risk of bacterial growth and ensures the baby is consuming fresh formula at each feeding. D) Warming a bottle in the microwave can create hot spots that might burn the baby's mouth. It's recommended to warm bottles by placing them in warm water.

A nurse is assessing a toddler who presents with a history of high fever for three days, which suddenly resolved, followed by the appearance of a rash. Based on this clinical presentation, the nurse suspects roseola. Which additional clinical manifestation is typically associated with roseola? A) Vesicular lesions in the oral cavity B) A "slapped cheek" facial rash C) A maculopapular rash that starts on the trunk and spreads to the face D) Intense itching and small blisters on the hands and feet

C) A maculopapular rash that starts on the trunk and spreads to the face A) Vesicular lesions in the oral cavity are more indicative of hand, foot, and mouth disease or herpangina, not roseola. B) A "slapped cheek" facial rash is characteristic of erythema infectiosum (fifth disease), caused by parvovirus B19. C) This is the correct answer. Roseola, typically caused by human herpesvirus 6, is known for high fever followed by a sudden rash that starts on the trunk and then spreads to the face and limbs. D) Intense itching and small blisters on the hands and feet are characteristic of hand, foot, and mouth disease, not roseola.

A nurse is caring for a pregnant patient who is Rh-negative and whose partner is Rh-positive. The patient is at 28 weeks of gestation and has no history of sensitization. Which of the following actions should the nurse anticipate? A) Administering Rhogam at 36 weeks gestation. B) Administering Rhogam within 72 hours after childbirth. C) Administering Rhogam at 28 weeks gestation and within 72 hours after childbirth. D) Withholding Rhogam because the patient has no history of sensitization.

C) Administering Rhogam at 28 weeks gestation and within 72 hours after childbirth. A) While Rhogam is often administered at 36 weeks, it is critical to provide it earlier at 28 weeks gestation for Rh-negative patients to prevent potential sensitization in the remainder of the pregnancy. B) Administering Rhogam within 72 hours after childbirth is correct for an Rh-negative mother to prevent sensitization after delivery, but it should also be given at 28 weeks gestation. C) This is the correct action. Rhogam should be administered at 28 weeks gestation to an Rh-negative patient to prevent sensitization for the current and future pregnancies and again within 72 hours after childbirth if the newborn is Rh-positive. D) Withholding Rhogam is not appropriate in this case, as the patient is at risk for developing antibodies against Rh-positive blood, which can affect future pregnancies. Rhogam (Rho(D) immune globulin) is used to prevent Rh sensitization in Rh-negative pregnant women, which can lead to hemolytic disease of the fetus and newborn in subsequent pregnancies. The timing of administration is crucial for its effectiveness.

A nurse is conducting a postpartum assessment on a patient who delivered a healthy baby 12 hours ago. Which of the following findings would require immediate intervention by the nurse? A) Mild afterpains B) Fundal height at the level of the umbilicus C) Bright red vaginal bleeding with clots larger than a golf ball D) Urinary frequency and burning sensation during urination

C) Bright red vaginal bleeding with clots larger than a golf ball A) Mild afterpains are normal as the uterus contracts back to its pre-pregnancy size. This is a common and expected finding in the postpartum period. B) The fundal height at the level of the umbilicus is an expected finding 12 hours post-delivery. The uterus typically contracts and decreases in size after birth, with the fundus (top of the uterus) descending from the level of the umbilicus at a rate of about one fingerbreadth (1 cm) per day. C) Bright red vaginal bleeding with clots larger than a golf ball can indicate postpartum hemorrhage, a serious complication that requires immediate intervention. Normal lochia (vaginal discharge after birth) should not contain large clots and should gradually decrease in volume and change in color from red to pink to white. D) Urinary frequency and burning during urination could be signs of a urinary tract infection, which, while important to address, is not as immediately life-threatening as postpartum hemorrhage.

A nurse is assessing a child with a suspected skin infection. Which of the following findings would be most indicative of impetigo? A) Large blisters on the torso that are filled with clear fluid B) Dry, red patches on the cheeks C) Honey-colored crusts on an erythematous base, typically around the mouth and nose D) White, scaly patches on the scalp

C) Honey-colored crusts on an erythematous base, typically around the mouth and nose A) Large blisters filled with clear fluid are more characteristic of bullous disorders or conditions like chickenpox, not impetigo. B) Dry, red patches on the cheeks are more indicative of conditions like eczema or psoriasis. C) Honey-colored crusts on an erythematous (red) base, particularly around the mouth and nose, are a classic presentation of impetigo. Impetigo is a common bacterial skin infection in children. D) White, scaly patches on the scalp are more suggestive of conditions like seborrheic dermatitis or scalp ringworm (tinea capitis), not impetigo.

A nurse is reviewing the laboratory results of a pediatric patient. Which of the following lab values would be indicative of hypothyroidism? A) Low T4 and low TSH levels B) High T4 and high TSH levels C) Low T4 and high TSH levels D) High T4 and low TSH levels

C) Low T4 and high TSH levels A) Low T4 and low TSH levels may suggest secondary (central) hypothyroidism due to hypothalamic or pituitary disorders, but not primary hypothyroidism. B) High T4 and high TSH levels are not typical of standard thyroid function and could indicate a rare form of thyroid hormone resistance or a TSH-secreting pituitary adenoma. C) This is the correct answer. In primary hypothyroidism, the thyroid gland is underactive and does not produce enough thyroid hormone (T4), leading to increased levels of thyroid-stimulating hormone (TSH) as the body attempts to stimulate the thyroid to produce more T4. D) High T4 and low TSH levels are typically seen in hyperthyroidism, where the thyroid gland is overactive.

A nurse is assessing a child who has sustained a burn injury. The burn appears to involve the full thickness of the skin, with areas of white, leathery skin, and no pain is reported in the most severely affected areas. How should the nurse classify this burn? A) First-degree burn (superficial) B) Second-degree burn (partial-thickness) C) Third-degree burn (full-thickness) D) Fourth-degree burn (full-thickness with deeper tissue involvement)

C) Third-degree burn (full-thickness) A) First-degree burns are superficial, affecting only the epidermis, and are typically characterized by redness and pain, but not white, leathery skin. B) Second-degree burns are partial-thickness burns that affect the epidermis and part of the dermis. They are usually painful and may appear red, blistered, and swollen. C) Third-degree burns are full-thickness burns that destroy the epidermis and dermis, possibly affecting underlying tissues. They may appear white, leathery, or charred, and the area may be painless due to nerve destruction, which is consistent with the described burn. D) Fourth-degree burns extend through the full thickness of the skin and into underlying fat, muscle, or bone. They are more severe than the description provided.

A nurse is caring for a preterm newborn with a patent ductus arteriosus (PDA). Which medication would the nurse anticipate administering to help close the PDA? A) Prostaglandin E1 (PGE1) B) Indomethacin C) Furosemide D) Digoxin

Correct Answer: B) Indomethacin A) Prostaglandin E1 (PGE1) is used to keep the ductus arteriosus open, typically in conditions such as congenital heart defects where blood flow bypassing the lungs is necessary until surgery can be performed. It is not used to close a PDA. B) Indomethacin, a nonsteroidal anti-inflammatory drug (NSAID), is commonly used to encourage closure of a PDA in preterm infants by inhibiting prostaglandins, which keep the ductus arteriosus open. C) Furosemide is a diuretic and might be used in heart conditions to manage fluid overload, but it does not directly contribute to closing a PDA. D) Digoxin is used to strengthen heart muscle contractions and control heart rate but does not have a direct effect on the closure of the ductus arteriosus.

A 24-year-old female patient has been prescribed a combination oral contraceptive pill. During her follow-up visit, the nurse provides education about the medication. Which of the following statements by the patient indicates a need for further teaching? A) "I should take the pill at the same time every day to maintain its effectiveness." B) "If I miss a dose, I should take it as soon as I remember and use backup contraception for the next 7 days." C) "I can expect to have regular, lighter menstrual periods while taking this pill." D) "I no longer need to use condoms since the pill will protect me from sexually transmitted infections (STIs)."

D) "I no longer need to use condoms since the pill will protect me from sexually transmitted infections (STIs)." This question assesses the patient's understanding of the use and limitations of oral contraceptives. The correct answer is D, as it reflects a common misconception about oral contraceptives. While oral contraceptives are effective in preventing pregnancy, they do not offer protection against sexually transmitted infections (STIs). It's important for patients to understand that using condoms in addition to oral contraceptives is necessary for STI prevention. Answers A and B demonstrate an understanding of the importance of adherence to the dosing schedule and the appropriate action to take in case of a missed dose. Answer C correctly identifies a typical effect of combination oral contraceptives on menstrual periods. Therefore, these statements do not indicate a need for further teaching.

A nurse is educating a pregnant woman who is nearing her due date about the differences between true and false labor. Which of the following statements made by the woman indicates a need for further teaching? A) "If I experience regular contractions that become stronger and closer together, it could be true labor." B) "False labor pains will go away if I change my position or start walking." C) "If my contractions don't increase in intensity and are irregular, it's probably false labor." D) "True labor contractions will stop with hydration and rest."

D) "True labor contractions will stop with hydration and rest." A) This statement is correct. In true labor, contractions typically become more regular, stronger, and closer together over time. B) This statement is accurate. False labor pains, or Braxton Hicks contractions, often decrease or stop with physical activity or position changes. C) This is also correct. False labor is characterized by irregular contractions that do not increase in intensity. D) This statement indicates a misunderstanding. True labor contractions will not stop with hydration and rest; they will continue and become more regular and intense. This is a key distinction between true and false labor.

A nurse is providing education to a group of young adults about sexually transmitted infections (STIs). When discussing Chlamydia, which statement by a participant indicates a need for further education? A) "Chlamydia can be asymptomatic, so regular screening is important." B) "Untreated Chlamydia can lead to infertility in both men and women." C) "Chlamydia is easily treatable with antibiotics like azithromycin." D) "Using barrier methods of contraception, like birth control pills, can prevent Chlamydia."

D) "Using barrier methods of contraception, like birth control pills, can prevent Chlamydia." The correct answer, D, reflects a misconception about the prevention of Chlamydia. Barrier methods of contraception, such as condoms, can reduce the risk of Chlamydia, but birth control pills do not offer protection against sexually transmitted infections. This statement indicates a need for further education regarding STI prevention methods. Responses A, B, and C demonstrate correct understanding: A) Recognizes that Chlamydia can be asymptomatic, making regular screening crucial, especially since many people with Chlamydia do not exhibit symptoms. B) Correctly notes that untreated Chlamydia can lead to complications such as infertility in both genders due to potential damage to reproductive organs. C) Accurately states that Chlamydia is treatable with antibiotics, with azithromycin being a common choice.

A nurse is assessing the vital signs of a full-term newborn. Which of the following vital sign values should the nurse recognize as abnormal and report immediately? A) Heart rate of 150 beats per minute B) Respiratory rate of 50 breaths per minute C) Axillary temperature of 97.8°F (36.6°C) D) Blood pressure of 60/40 mmHg

D) Blood pressure of 60/40 mmHg Normal vital signs in a full-term newborn are as follows: Heart Rate: 120-160 beats per minute. A heart rate of 150 beats per minute (option A) is within the normal range. Respiratory Rate: 30-60 breaths per minute. A respiratory rate of 50 breaths per minute (option B) falls within the normal range. Temperature: 97.7°F to 99.5°F (36.5°C to 37.5°C) when measured axillary. An axillary temperature of 97.8°F (36.6°C) (option C) is normal for a newborn. Blood Pressure: Typically ranges between 60-80/40-50 mmHg in a full-term newborn. A blood pressure of 60/40 mmHg (option D) is on the lower end of the normal range and may warrant further assessment, especially if accompanied by other signs of poor perfusion or illness.

During a routine prenatal visit, a nurse is reviewing the assessment findings of a patient who is 24 weeks pregnant. Which of the following findings should the nurse consider abnormal and report to the healthcare provider? A) Fundal height measuring 24 centimeters B) Fetal heart rate of 150 beats per minute C) Mild swelling of the ankles and feet at the end of the day D) Persistent headache and blurred vision

D) Persistent headache and blurred vision A) A fundal height measuring approximately the same number of centimeters as weeks of gestation (plus or minus 2 cm) is a normal finding. At 24 weeks, a fundal height of 24 cm is within normal limits. B) A fetal heart rate of 150 beats per minute is within the normal range for a fetus (normal is generally considered 110-160 bpm). C) Mild edema (swelling) of the ankles and feet is common in the second and third trimesters, especially at the end of the day. D) Persistent headache and blurred vision are concerning symptoms that may indicate preeclampsia, especially when they occur together. This finding warrants immediate assessment and intervention.

A school nurse is educating a group of students on the initial treatment of a sprained ankle using the RICE method. Which of the following instructions should the nurse include in the education? Select all that apply. A) "Rest the injured ankle to prevent further injury." B) "Keep the ankle lower than the level of your heart to reduce swelling." C) "Apply ice to the sprained ankle to reduce swelling and pain." D) "Compress the ankle with a bandage to minimize swelling." E) "Elevate the ankle above the level of the heart to reduce swelling."

A) "Rest the injured ankle to prevent further injury." C) "Apply ice to the sprained ankle to reduce swelling and pain." D) "Compress the ankle with a bandage to minimize swelling." E) "Elevate the ankle above the level of the heart to reduce swelling." A) Rest is a key component of the RICE method and helps to prevent further injury to the sprained area. B) Keeping the injured ankle lower than the heart would actually increase swelling. This statement is incorrect and should not be included. C) Ice helps to reduce both swelling and pain in the acute phase of a sprain. D) Compression, such as with an elastic bandage, helps to reduce swelling and provides support to the injured area. E) Elevation of the injured ankle above the level of the heart helps to minimize swelling by reducing blood flow to the area.

A nurse is conducting a health education session for parents on the risk factors for otitis media (OM) in children. Which of the following statements by a parent indicates a correct understanding of the risk factors for developing OM? Select all that apply. A) "Using pacifiers extensively can increase the risk of ear infections in my child." B) "Breastfeeding my baby will decrease their risk of getting ear infections." C) "Exposing my child to secondhand smoke does not affect their risk of ear infections." D) "Having my child sleep in an upright position can decrease the risk of ear infections." E) "Frequent upper respiratory infections can lead to a higher risk of ear infections."

A) "Using pacifiers extensively can increase the risk of ear infections in my child." B) "Breastfeeding my baby will decrease their risk of getting ear infections." D) "Having my child sleep in an upright position can decrease the risk of ear infections." E) "Frequent upper respiratory infections can lead to a higher risk of ear infections." A) Extensive pacifier use, especially beyond the age of 2, has been associated with an increased risk of OM. B) Breastfeeding is protective against OM, especially exclusive breastfeeding for the first six months. C) This statement is incorrect. Exposure to secondhand smoke increases the risk of ear infections in children. D) Positioning a child to sleep in an upright position can reduce the risk of OM by promoting better Eustachian tube drainage. E) Frequent upper respiratory infections increase the risk of OM due to the inflammation and blockage of the Eustachian tubes.

A nurse is providing education to a group of parents at a community health clinic. Which of the following information should the nurse include when discussing when it's appropriate to give vaccines to children? Select all that apply. A) "Vaccines can be administered even if your child has a mild illness, like a cold." B) "Vaccines should be delayed if your child is taking antibiotics." C) "Children with a history of anaphylactic reactions to a vaccine component should not receive further doses of that vaccine." D) "A mild fever following a previous vaccine is a contraindication to further vaccinations." E) "Vaccines should be postponed if your child has a moderate or severe illness with or without fever."

A) "Vaccines can be administered even if your child has a mild illness, like a cold." C) "Children with a history of anaphylactic reactions to a vaccine component should not receive further doses of that vaccine." E) "Vaccines should be postponed if your child has a moderate or severe illness with or without fever." A) It is generally safe to administer vaccines to children who have a mild illness, such as a cold, as this does not interfere with the immune response to the vaccine. B) Taking antibiotics is not a contraindication to vaccination, unless the antibiotics are being used to treat a moderate or severe illness. C) A history of anaphylactic reaction to a vaccine or its components is a contraindication to further doses of that vaccine. D) A mild fever following vaccination is a common side effect and is not a contraindication to future vaccinations. E) Vaccinations should generally be postponed if a child is experiencing a moderate or severe illness, as the illness may complicate the response to the vaccine or vice versa

A nurse is providing education to the parents of a child diagnosed with eczema. Which of the following statements by the parents indicates a need for further teaching? A) "We should bathe our child in hot water to keep the skin clean." B) "Applying moisturizer immediately after bathing can help retain moisture in the skin." C) "We'll avoid wool and synthetic fabrics that can irritate the skin." D) "It's important to keep our child's fingernails short to prevent skin damage from scratching."

A) "We should bathe our child in hot water to keep the skin clean." A) This statement indicates a misunderstanding. Bathing in hot water can dry out the skin and worsen eczema. Lukewarm water is recommended. B) Applying moisturizer immediately after a bath helps to lock in moisture, which is beneficial for eczema care. C) Avoiding irritants like wool and synthetic fabrics can help reduce eczema flare-ups and is a recommended practice. D) Keeping fingernails short is important to prevent skin damage from scratching, as eczema can be very itchy.

A nurse is assessing a child for possible lead poisoning. Which of the following signs and symptoms would the nurse expect to find in a child with lead poisoning? Select all that apply. A) Abdominal pain and constipation B) Hematuria and oliguria C) Developmental delays and behavioral problems D) Hypertension and tachycardia E) Ataxia and seizures

A) Abdominal pain and constipation C) Developmental delays and behavioral problems E) Ataxia and seizures A) Abdominal pain and constipation are common symptoms of lead poisoning in children, as lead affects the gastrointestinal system. B) Hematuria (blood in the urine) and oliguria (reduced urine output) are not typically associated with lead poisoning. C) Developmental delays and behavioral problems, such as attention disorders and hyperactivity, can be seen in children with lead poisoning due to its effects on the nervous system. D) Hypertension and tachycardia are not characteristic symptoms of lead poisoning. E) Neurological symptoms such as ataxia (lack of muscle coordination) and seizures can occur in severe cases of lead poisoning.

A nurse is caring for a child with hemophilia. Which of the following interventions should the nurse anticipate as part of the child's treatment plan? Select all that apply. A) Administering clotting factor concentrates as prescribed B) Encouraging participation in high-impact sports for joint health C) Educating the family on recognizing signs of internal bleeding D) Using nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management E) Applying RICE (rest, ice, compression, elevation) for joint bleeds

A) Administering clotting factor concentrates as prescribed C) Educating the family on recognizing signs of internal bleeding E) Applying RICE (rest, ice, compression, elevation) for joint bleeds A) The administration of clotting factor concentrates is a cornerstone of hemophilia treatment to replace the missing or deficient clotting factor. B) High-impact sports are generally discouraged in children with hemophilia due to the risk of bleeding, especially in joints and muscles. C) Educating the family about the signs of internal bleeding, such as joint pain and swelling, is crucial for early intervention and treatment. D) NSAIDs are usually avoided in hemophilia as they can exacerbate bleeding. Acetaminophen is often recommended for pain management instead. E) The RICE method is a standard approach to manage joint bleeds and reduce swelling and pain.

A nurse is calculating the estimated date of delivery (EDD) for a pregnant patient using Naegele's rule. The patient's last menstrual period started on November 10th. What is the estimated date of delivery? A) August 17th B) September 17th C) August 3rd D) September 3rd

A) August 17th Naegele's rule is a standard way of calculating the estimated date of delivery (EDD) for a pregnancy. According to this rule, you add one year, subtract three months, and add seven days to the first day of the last menstrual period (LMP). For a patient whose LMP began on November 10th, the calculation would be: Step 1: Add one year: November 10th of the following year. Step 2: Subtract three months: August 10th. Step 3: Add seven days: August 17th. Therefore, the estimated date of delivery would be August 17th. This makes option A the correct answer. The other dates do not accurately reflect the application of Naegele's rule to the given LMP date.

A nurse is assessing a newborn for coarctation of the aorta. Which of the following findings would be most indicative of this condition? A) Bounding pulses in the upper extremities and weak pulses in the lower extremities B) Central cyanosis that improves with crying C) A high-pitched murmur heard best at the left sternal border D) Bilateral crackles auscultated in the lower lung fields

A) Bounding pulses in the upper extremities and weak pulses in the lower extremities A) This is the correct answer. Coarctation of the aorta often presents with a significant difference in pulse strength and quality between the upper and lower extremities, due to the narrowing of the aorta after the branches that supply the upper body. B) Central cyanosis that improves with crying is more indicative of a cardiac condition where there is a mixing of oxygenated and deoxygenated blood, but it's not specifically indicative of coarctation of the aorta. C) A murmur may be present with coarctation of the aorta, but it is typically a systolic murmur heard best at the back or left scapular area. This choice is less specific and indicative than differential pulses. D) Bilateral crackles in the lungs may indicate pulmonary edema or other respiratory conditions but are not specific findings for coarctation of the aorta.

A nurse is reviewing the immunization record of a 5-year-old child during a routine check-up. Which of the following vaccines should the nurse expect to be scheduled for administration at this age if not already given? Select all that apply. A) DTaP (Diphtheria, Tetanus, and acellular Pertussis) B) MMR (Measles, Mumps, and Rubella) C) Varicella D) Hepatitis A E) Influenza

A) DTaP (Diphtheria, Tetanus, and acellular Pertussis) B) MMR (Measles, Mumps, and Rubella) C) Varicella A) The DTaP vaccine is typically administered to children at 4-6 years of age as part of the routine vaccination schedule. This would be the fifth dose in the series. B) The second dose of MMR is generally administered at 4-6 years of age, if not given earlier. C) The second dose of the Varicella (chickenpox) vaccine is usually given at 4-6 years of age. D) Hepatitis A vaccine is generally administered to children between 12 months and 23 months, with the second dose 6 months later. It's not typically scheduled for a 5-year-old unless they missed the vaccine at the recommended age. E) The Influenza vaccine is recommended annually for children (and adults), but it is not specific to the 5-year-old age group in the same way as the DTaP, MMR, and Varicella vaccines.

A nurse is assessing a child suspected of having intussusception. Which of the following clinical manifestations would the nurse expect to find? Select all that apply. A) Episodic abdominal pain with periods of calmness in between B) Vomiting that is bile-stained C) Stool that is loose and watery D) A sausage-shaped mass in the upper right quadrant of the abdomen E) "Currant jelly" stools

A) Episodic abdominal pain with periods of calmness in between B) Vomiting that is bile-stained D) A sausage-shaped mass in the upper right quadrant of the abdomen E) "Currant jelly" stools A) Episodic abdominal pain, often severe, with periods of calmness is a characteristic symptom of intussusception. The child may draw their knees to their chest during episodes of pain. B) Vomiting, which may include bile, can occur in intussusception due to obstruction of the intestines. C) Stool in intussusception is typically not loose and watery. Instead, it may be mixed with blood and mucus, resembling "currant jelly." D) A sausage-shaped mass in the abdomen, often felt in the upper right quadrant, is a classic physical finding in intussusception. E) "Currant jelly" stools, which are stools mixed with blood and mucus, are a classic sign of intussusception and result from mucosal irritation and bleeding.

A nurse is caring for a child with suspected adrenal insufficiency. Which of the following clinical manifestations would the nurse expect to find? Select all that apply. A) Hyperpigmentation of the skin and mucous membranes B) Hypertension and fluid retention C) Hypoglycemia and weight loss D) Excessive hair growth and acne E) Salt cravings and dehydration

A) Hyperpigmentation of the skin and mucous membranes C) Hypoglycemia and weight loss E) Salt cravings and dehydration A) Hyperpigmentation, especially in areas of friction and pressure, is a common sign of primary adrenal insufficiency (Addison's disease) due to an increase in melanocyte-stimulating hormone (MSH). B) Hypertension and fluid retention are more typically associated with conditions of excess cortisol, such as Cushing's syndrome, not adrenal insufficiency. C) Hypoglycemia and weight loss can occur in adrenal insufficiency due to the lack of cortisol, which is involved in glucose metabolism and appetite regulation. D) Excessive hair growth (hirsutism) and acne are more indicative of conditions associated with excess androgens, not adrenal insufficiency. E) Salt cravings and dehydration are symptoms of adrenal insufficiency, as aldosterone production (which regulates sodium retention) is often reduced.

A nurse is providing care for a newborn diagnosed with macrosomia. The mother had gestational diabetes that was poorly controlled during pregnancy. Which of the following complications should the nurse closely monitor for in the newborn? Select all that apply. A) Hypoglycemia B) Respiratory distress syndrome C) Jaundice D) Microcephaly E) Birth injuries, such as shoulder dystocia

A) Hypoglycemia B) Respiratory distress syndrome C) Jaundice E) Birth injuries, such as shoulder dystocia A) Newborns with macrosomia, especially those born to mothers with diabetes, are at increased risk for hypoglycemia soon after birth due to their increased insulin production in response to maternal hyperglycemia. B) Respiratory distress syndrome can occur in macrosomic infants, particularly if the gestational diabetes led to delayed lung maturation. C) Jaundice is more common in infants with macrosomia, partly due to polycythemia (an increased number of red blood cells), which increases the risk of bilirubinemia. D) Microcephaly, or a smaller-than-normal head, is not associated with macrosomia. Macrosomia refers to a larger-than-normal body size. E) Macrosomic infants are at a higher risk of birth injuries, such as shoulder dystocia, due to their larger size. Macrosomia, or a birth weight over 4,000 grams (8 pounds, 13 ounces), can lead to several complications. Nurses should be vigilant in monitoring for these complications and provide appropriate care and interventions as needed.

A nurse is providing care for a child diagnosed with nephrotic syndrome. Which of the following nursing interventions are appropriate for this patient? Select all that apply. A) Monitoring daily weight and fluid intake and output B) Encouraging a high-sodium diet C) Administering corticosteroids as prescribed D) Providing emotional support to the child and family E) Implementing infection control measures

A) Monitoring daily weight and fluid intake and output C) Administering corticosteroids as prescribed D) Providing emotional support to the child and family E) Implementing infection control measures A) Monitoring daily weight, along with fluid intake and output, is crucial in managing nephrotic syndrome, as it helps assess fluid status and response to therapy. B) A high-sodium diet is not recommended in nephrotic syndrome. In fact, sodium intake may be restricted to help manage edema. C) Corticosteroids are a standard part of treatment for nephrotic syndrome, as they help reduce inflammation in the kidneys. D) Providing emotional support is important, as the diagnosis and treatment of nephrotic syndrome can be stressful for both the child and their family. E) Implementing infection control measures is key, as patients with nephrotic syndrome are at increased risk of infection due to immunosuppressive therapy and altered immune response.

A nurse is assessing a child for possible asthma. Which of the following signs and symptoms, if reported by the child's parent, are consistent with asthma? Select all that apply. A) Persistent, dry cough, especially at night B) Wheezing sound during exhalation C) Elevated body temperature and chills D) Shortness of breath during physical activity E) Chest tightness and difficulty breathing

A) Persistent, dry cough, especially at night B) Wheezing sound during exhalation D) Shortness of breath during physical activity E) Chest tightness and difficulty breathing A) A persistent, dry cough, particularly at night, can be a sign of asthma as airways become more reactive and inflamed. B) Wheezing, a high-pitched whistling sound made while breathing, is characteristic of asthma and usually occurs during exhalation. C) Elevated body temperature and chills are more indicative of an infection and are not typical symptoms of asthma. D) Shortness of breath during physical activity is common in children with asthma due to the narrowing of the airways. E) Chest tightness and difficulty breathing are common symptoms of asthma due to the constriction and inflammation of the airways.

A nurse is providing care for an infant with myelomeningocele. Which of the following nursing interventions should be included in the care plan? Select all that apply. A) Positioning the infant prone to relieve pressure on the sac B) Assessing the infant's ability to move the lower extremities C) Monitoring for signs of infection at the sac site D) Frequently changing diapers to prevent contamination of the sac E) Encouraging the parents to cuddle the infant frequently to promote bonding

A) Positioning the infant prone to relieve pressure on the sac B) Assessing the infant's ability to move the lower extremities C) Monitoring for signs of infection at the sac site D) Frequently changing diapers to prevent contamination of the sac A) Prone positioning is important to prevent pressure on the sac, which can lead to rupture or infection. B) Assessing motor function is important to determine the extent of impairment due to the myelomeningocele. C) Monitoring for signs of infection is critical, as the sac is prone to infection and can lead to meningitis. D) Keeping the sac area clean and dry is essential to prevent infection. Diapers should be changed frequently and positioned in a way that prevents contamination. E) While encouraging bonding is important, this intervention is not specific to the care of an infant with myelomeningocele.

A nurse is caring for a preterm newborn diagnosed with Respiratory Distress Syndrome (RDS). Which of the following clinical findings would the nurse expect to observe? Select all that apply. A) Rapid and shallow breathing B) Flaring of the nostrils C) Decreased respiratory effort D) Audible grunting E) Cyanosis

A) Rapid and shallow breathing B) Flaring of the nostrils D) Audible grunting E) Cyanosis A) Rapid and shallow breathing is a common sign of RDS as the newborn attempts to increase oxygen intake and compensate for reduced lung function. B) Nostril flaring is an effort to increase airway diameter to facilitate breathing, often seen in respiratory distress. C) Decreased respiratory effort would be more indicative of respiratory failure or fatigue and not typical in the initial stages of RDS. D) Audible grunting is a sign of RDS. Grunting is caused by the newborn trying to increase airway pressure to keep the alveoli open. E) Cyanosis, or a bluish skin color, indicates hypoxemia and is a common finding in RDS. Respiratory Distress Syndrome is a common complication in preterm newborns due to the immaturity of the lungs and lack of sufficient surfactant. The nurse should be prepared to recognize these symptoms and understand the urgency of appropriate interventions to manage RDS.

A nurse is developing a care plan for an adolescent with a substance abuse problem. Which of the following interventions should be included in the plan? Select all that apply. A) Regularly scheduling meetings with a mental health counselor B) Administering prescribed medication for withdrawal symptoms as needed C) Implementing strict disciplinary actions for any substance use D) Encouraging participation in peer support groups E) Providing education on the effects of substances and coping strategies

A) Regularly scheduling meetings with a mental health counselor B) Administering prescribed medication for withdrawal symptoms as needed D) Encouraging participation in peer support groups E) Providing education on the effects of substances and coping strategies A) Therapy with a mental health counselor can be crucial for addressing the underlying issues contributing to substance abuse and for developing healthier coping mechanisms. B) Managing withdrawal symptoms with appropriate medication can be necessary for individuals experiencing physical dependence and withdrawal. C) While setting boundaries is important, strict disciplinary actions may not address the underlying issues of substance abuse and could potentially strain the patient-nurse relationship. D) Peer support groups, such as 12-step programs, provide a supportive environment for recovery and help reduce feelings of isolation. E) Education on the effects of substance abuse and teaching healthy coping strategies are key components of substance abuse treatment.

A nurse is performing a developmental assessment on a 2-year-old toddler. Which of the following motor skills, if demonstrated by the toddler, should the nurse consider as typical for this age? Select all that apply. A) Stacking a tower of six blocks B) Walking up stairs with alternating feet without support C) Drawing circles and squares on paper D) Kicking a ball forward without losing balance E) Running with a wide stance and arms out for balance

A) Stacking a tower of six blocks D) Kicking a ball forward without losing balance E) Running with a wide stance and arms out for balance A) Stacking a tower of six or more blocks is a developmentally appropriate fine motor skill for a 2-year-old. B) Walking up stairs with alternating feet without support is typically a skill developed around 3 years of age. C) Drawing circles and squares is a fine motor skill that usually develops around 3 years old. At 2 years, toddlers may start to scribble. D) Kicking a ball forward without losing balance is a gross motor skill expected in 2-year-old toddlers. E) Running with a wide stance and using arms for balance is typical for toddlers as they refine their gross motor skills.

A nurse is preparing to administer the first dose of the hepatitis B vaccine to a newborn. According to the Centers for Disease Control and Prevention (CDC) guidelines, which of the following is the correct protocol for the administration of this vaccine? A) The vaccine should be administered within the first 12 hours of life. B) The vaccine is delayed until the infant is 1 month old if the birth weight is less than 2,000 grams. C) The vaccine should be given intramuscularly in the deltoid muscle of the infant. D) The vaccine is contraindicated in infants born to mothers who are hepatitis B surface antigen (HBsAg) positive.

A) The vaccine should be administered within the first 12 hours of life. A) The CDC recommends that the first dose of the hepatitis B vaccine be administered within the first 12 hours of life for all medically stable infants weighing ≥2,000 grams at birth, regardless of maternal HBsAg status. B) For infants weighing less than 2,000 grams born to HBsAg-positive mothers, the vaccine (along with Hepatitis B Immune Globulin) should be administered within 12 hours of birth. For those born to HBsAg-negative mothers, the vaccine should be administered at 1 month of age or at hospital discharge. C) For newborns, the preferred site for the hepatitis B vaccine administration is the vastus lateralis muscle of the thigh, not the deltoid muscle. D) Infants born to HBsAg-positive mothers should receive the hepatitis B vaccine along with Hepatitis B Immune Globulin within 12 hours of birth, not contraindicated.

A nurse is documenting a seizure episode of a pediatric patient. Which of the following information is essential for the nurse to include in the patient's medical record? Select all that apply. A) Time and duration of the seizure B) Specific movements observed during the seizure C) The child's diet prior to the seizure D) Level of consciousness post-seizure E) Medications administered after the seizure

A) Time and duration of the seizure B) Specific movements observed during the seizure D) Level of consciousness post-seizure E) Medications administered after the seizure A) Documenting the time and duration of the seizure is crucial for treatment and diagnosis. It helps in understanding the severity and frequency of seizures. B) Recording specific movements (like jerking of limbs, eye rolling, etc.) provides valuable information about the type of seizure and affected brain areas. C) While the child's diet may be relevant in some cases (e.g., for patients with dietary triggers), it's not typically considered essential information for an immediate seizure event documentation. D) Noting the child's level of consciousness after the seizure, such as any confusion or drowsiness, is important for assessing the postictal state and recovery. E) Information about medications given after the seizure, including the type and dosage, is important for managing the patient's ongoing treatment and for future reference in case of recurrent seizures.

A nurse is performing a newborn assessment and observes the infant's responses to various stimuli. Which of the following findings should the nurse document as a normal newborn reflex? A) When stroked on the cheek, the newborn turns the head toward the same side and opens the mouth. B) When the newborn's palm is touched, the fingers curl tightly but the thumb remains straight. C) When held upright with feet touching a surface, the newborn makes crawling movements with the arms. D) When the newborn's foot is stroked, the toes curl outward.

A) When stroked on the cheek, the newborn turns the head toward the same side and opens the mouth. A) This describes the rooting reflex, which is a normal newborn reflex. It helps the baby turn toward the nipple or bottle for feeding and usually disappears around 4 months of age. B) The palmar grasp reflex involves curling of all fingers, including the thumb, when the palm is touched. Therefore, the description in option B is incomplete. C) The stepping reflex is when the newborn makes stepping movements when held upright with their feet touching a surface. It does not involve crawling movements with the arms. D) The Babinski reflex in newborns involves fanning out of the toes when the side of the foot is stroked, not curling outward.

A nurse is providing education to a patient with type 2 diabetes about the purpose and significance of the hemoglobin A1c (HbA1c) test. Which of the following statements by the patient indicates a need for further teaching? A) "The HbA1c test will show my average blood sugar levels over the past 3 months." B) "An HbA1c level below 5.7% indicates that my diabetes is well-managed." C) "I should have this test done at least once a year to monitor my diabetes." D) "The results of the HbA1c test can help adjust my medication regimen."

B) "An HbA1c level below 5.7% indicates that my diabetes is well-managed." A) This statement is correct. The HbA1c test reflects the average blood glucose levels over the past 2-3 months and is used to assess glucose control. B) An HbA1c level below 5.7% is considered normal and indicative of no diabetes. For patients with diabetes, a target HbA1c is typically set by the healthcare provider based on individual factors, but it's usually higher than 5.7%. This patient's statement indicates a misunderstanding of the target HbA1c levels for diabetes management. C) The frequency of HbA1c testing depends on the type of diabetes and how well it's controlled, but for many patients with diabetes, the test is recommended at least twice a year, not just once. D) The results of the HbA1c test are indeed used to guide adjustments in medication regimens, diet, and exercise plans in diabetes management.

A nurse is assisting a new mother with breastfeeding. The mother is concerned about her ability to produce enough milk for her newborn. Which of the following recommendations should the nurse provide to support lactation? Select all that apply. A) "Limit the amount of time the baby spends at each breast to avoid nipple soreness." B) "Breastfeed or pump frequently, about every 2-3 hours, to stimulate milk production." C) "Ensure proper latch-on technique to facilitate effective milk removal." D) "Drink plenty of fluids and maintain a well-balanced diet to support milk production." E) "Supplement with formula after each breastfeeding session to ensure the baby is getting enough."

B) "Breastfeed or pump frequently, about every 2-3 hours, to stimulate milk production." C) "Ensure proper latch-on technique to facilitate effective milk removal." D) "Drink plenty of fluids and maintain a well-balanced diet to support milk production." A) Limiting the time spent at each breast is not recommended as it can interfere with milk production and the baby's ability to get enough milk. Babies should be allowed to feed until they naturally release the breast, indicating they are satisfied. B) Frequent breastfeeding or pumping is key to establishing and maintaining a good milk supply. The principle of supply and demand applies here; more frequent nursing increases milk production. C) Proper latch-on technique is crucial for effective breastfeeding, as it helps the baby to effectively remove milk and stimulates continued milk production. D) Adequate hydration and nutrition are important for maintaining a healthy milk supply. Breastfeeding mothers need additional calories and should drink fluids to thirst. E) Supplementing with formula can decrease the baby's demand for breast milk, which can, in turn, decrease the mother's milk supply. It is generally not recommended to supplement with formula unless medically necessary.

A school nurse is conducting a health education session for a group of high school students and their parents about healthy sleep habits. Which statement by the nurse is accurate regarding sleep requirements for adolescents? A) "Adolescents need about 6-7 hours of sleep each night for optimal health and functioning." B) "For optimal health, adolescents should aim for at least 8-10 hours of sleep each night." C) "Most adolescents require over 11 hours of sleep each night for proper growth and development." D) "Sleep is not as crucial for adolescents as it is for younger children, so 5-6 hours is generally sufficient."

B) "For optimal health, adolescents should aim for at least 8-10 hours of sleep each night." A) 6-7 hours of sleep per night is below the recommended amount for adolescents and can lead to sleep deprivation. B) This is the correct statement. The American Academy of Pediatrics recommends that adolescents get between 8-10 hours of sleep per night for optimal health and functioning. C) Over 11 hours might be excessive for most adolescents and is more than the recommended amount. D) This statement is incorrect. Adequate sleep is crucial for adolescents, and 5-6 hours per night is not enough to meet their physiological and cognitive needs.

A nurse is providing education to a pregnant patient with a pre-pregnancy body mass index (BMI) of 18.0. The nurse knows that further teaching is needed when the patient makes which of the following statements about her expected weight gain during pregnancy? A) "I should aim to gain about 28 to 40 pounds during my pregnancy." B) "Gaining less than 25 pounds during my pregnancy is best for my health." C) "I need to gain more weight than someone with a normal pre-pregnancy BMI." D) "Eating nutrient-rich foods will help me reach the healthy weight gain target."

B) "Gaining less than 25 pounds during my pregnancy is best for my health." The correct answer is B, as it reflects a misunderstanding of the appropriate weight gain guidelines for a patient with a pre-pregnancy BMI of 18.0, which categorizes her as underweight. According to the American College of Obstetricians and Gynecologists (ACOG) guidelines, an underweight woman (BMI less than 18.5) should aim to gain about 28 to 40 pounds during pregnancy. A) This statement is correct and aligns with the ACOG guidelines for underweight women. C) This is accurate, as underweight women are advised to gain more weight than those with a normal BMI to support a healthy pregnancy. D) Emphasizing nutrient-rich foods is appropriate advice for achieving healthy weight gain during pregnancy.