212 EAQ mastery quiz
While assessing an infant, the nurse finds the presence of white, adherent patches on the tongue, palate, and inner aspects of the cheeks. The mother also states that the infant is refusing to suck the milk. Which medication does the nurse expect to be prescribed? A. Acyclovir (Zovirax) B. Vidarabine (Vira-A) C. Nystatin (Mycostatin) D. Fluconazole (Diflucan)
C. Nystatin (Mycostatin) Rationale: White, adherent patches on the tongue, palate, and inner aspects of the infant's cheeks indicate oral candidiasis or thrush. Oral candidiasis is caused by a fungus called candida albicans. Nystatin (Mycostatin) is an antifungal agent prescribed to treat oral thrush in an infant. Acyclovir (Zovirax) and vidarabine (Vira-A) are antiviral agents and are not used to treat oral candidiasis in the infant. Fluconazole (Diflucan) can effectively treat oral thrush but its use in infants is not approved by the Food and Drug Administration.
The fetus of a woman in labor is at +1 station. At what place in the pelvic area does the nurse conclude that the presenting part is located? A. Not yet engaged B. Entering the pelvic inlet C. Below the ischial spines D. Visible at the vaginal opening
C. Below the ischial spines Rationale: A +1 station indicates that the fetal presenting part is 1 cm below the ischial spines, which are the points of engagement. Entrance of the pelvic inlet is designated as 0 station or as a negative number. The head must be at +3 to +5 to be visible at the vaginal opening.
A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the next nursing action? A. Notifying the health care provider B. Resuming continuous fetal heart monitoring C. Continuing to monitor the maternal vital signs D. Documenting the fetal heart rate as an expected response to contractions
A. Notifying the health care provider Rationale: Bradycardia (baseline FHR slower than 110 beats/min) indicates that the fetus may be compromised, requiring medical intervention. Resuming continuous fetal heart monitoring may be dangerous; the fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. The expected FHR is 110 to 160 beats/min between contractions.
During a follow-up visit, the nurse finds that the adolescent uses artificial tanning methods and has phototoxic reactions on the skin. What is the nurse's best response? A. "You should wear goggles if you insist on using the tanning booth." B. "You should perform sunbathing for 1 hour just before getting tanned." C. "You should refrain from using broad spectrum sunscreens just before tanning." D. "You should use sunscreen with sun protective factor of 10 after getting tanned."
A. "You should wear goggles if you insist on using the tanning booth." Rationale: Serious corneal burning can occur in adolescents while they are in the tanning booth. Therefore, adolescents should wear goggles while they are in tanning booths. Sunbathing for extended periods should not be done. Adolescents should use a broad spectrum sunscreen to prevent exposure to harmful ultraviolet rays. Sunscreens with sun protective factor of 15 should be used to ensure safety.
At 5 am, 2 hours after a long labor and vaginal birth, a client is transferred to the postpartum unit. What is the nurse's priority when planning morning care for this client? A. Planning nursing care activities that provide time for the client to rest and sleep B. Preparing for the probability of hemorrhage by massaging the client's uterus frequently C. Arranging an individual session in which the client can learn about successful breastfeeding D. Anticipating safety needs by instructing the client to remain in bed and call for assistance whenever ambulating
A. Planning nursing care activities that provide time for the client to rest and sleep Rationale: After laboring all night the client is tired and needs uninterrupted rest. Massaging the fundus frequently is unnecessary unless the uterus becomes boggy. Providing a lesson on breastfeeding is premature. The client is not ready to learn because she needs to rest and sleep after a long labor. It is necessary for the client to call for assistance only the first time she ambulates; otherwise the client may ambulate ad libitum.
The nurse reviews the blood test results of a client at 24 weeks' gestation. Which finding should be reported to the health care provider? A. Platelets: 230,000 mm3 B. Hemoglobin: 10.8 g/dL C. Fasting blood glucose: 90 mg/dL D. White blood cell count: 10,000 mm3
B. Hemoglobin: 10.8 g/dL Rationale: The hemoglobin level of a healthy individual is 12 to 16 g/dL. During pregnancy it may decrease as a result of an increased blood volume, especially during the second trimester. The hemodilution is greater than a concomitant increase in RBC production, causing physiologic anemia. If the hemoglobin decreases to less than 11 g/dL, anemia, probably due to a deficiency of iron or folic acid, is diagnosed. Iron supplementation may need to be increased. The expected platelet level is 150,000 to 400,000 mm3. There should be no significant change in this level throughout pregnancy. The expected fasting blood glucose is 70 to 105 mg/dL; there should be no significant change in this level throughout pregnancy. The expected white blood cell count is 5,000 to 10,000 mm3, and during pregnancy it is 5,000 to 15,000 mm3; it begins to rise in the second trimester and peaks in the third trimester.
Select the priority intervention for a pregnant client whose monitor strip shows fetal heart rate decelerations characterized by a rapid descent and ascent to and from the lowest point of the deceleration. A. Elevating the legs B. Repositioning the client from side to side C. Increasing the rate of intravenous infusion D. Administering oxygen by way of facemask
B. Repositioning the client from side to side Rationale: A deceleration with a rapid descent and ascent to and from the lowest point of the deceleration is a variable deceleration caused by cord compression. Changing the client's position from side to side promotes release of the compression. Oxygen given while the cord remains compressed will not provide fetal oxygenation. Increasing the rate of intravenous fluid administration and elevating the legs are interventions for placental perfusion problems and do not affect cord compression.
The nurse is teaching a mother about the developmental behaviors of a 7-month-old infant. Which statement by the mother indicates the need for further teaching? A. "I can try foods of different tastes for my child." B. "I should encourage my child to play peek-a-boo games." C. "I can leave my child with my new friend for some time." D. "I should buy a toothbrush with soft bristles for my child."
C. "I can leave my child with my new friend for some time." Rationale: The fear of strangers increases in infants by 7 months of age. Therefore, the mother should not leave the infant with new people. The 7-month-old infant has taste preferences; therefore, the mother can try foods with different tastes for the child. The 7-month-old infant enjoys peak-a-boo games; therefore, the mother can play this game with the child. The 7-month-old infant has eruption of the upper central teeth; therefore, the mother can buy a toothbrush with soft bristles for the child to maintain oral hygiene.
What is the best nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station? A. Document the fetal heart rate every 5 minutes. B. Call the anesthesia department to alert the staff there of an imminent birth. C. Assist the client's coach in helping her with the use of breathing techniques. D. Suggest that the client accept the PRN medication for pain that has been prescribed.
C. Assist the client's coach in helping her with the use of breathing techniques. Rationale: The client is in the early part of the first stage of labor, and it is important to help the partner with the role of coach. It is not necessary to check the fetal heart rate every 5 minutes until the second stage of labor. The first stage of labor is not as stressful for the fetus as the second stage of labor. Birth is not imminent at this time; the client is only dilated 4 cm. Suggesting that there is discomfort may increase anxiety and produce greater discomfort.
A newborn male infant was circumcised 2 hours ago. Thirty minutes later, the nurse notes blood oozing from the penis. Which intervention should the nurse implement? A. Cleansing the area with warm water and mild soap B. Applying Vaseline gauze over the area of bleeding C. Documenting the amount of bleeding in the infant's chart D. Donning sterile gloves and applying direct pressure, using sterile gauze
D. Donning sterile gloves and applying direct pressure, using sterile gauze Rationale: Applying direct pressure to an area of bleeding will compress vessels and stop the bleeding. Cleansing the area, applying Vaseline gauze, or documenting the amount of bleeding will not decrease or stop the bleeding.
A client is admitted to the emergency department in active labor. The client is bearing down, the fetal head is crowning, and birth appears imminent. What should the nurse instruct the client to do? A. Take slow, deep breaths B. Hold her breath and push with each contraction. C. Breathe faster than usual with long cleansing breaths. D. Pant and then exhale through the mouth with pursed lips.
D. Pant and then exhale through the mouth with pursed lips. Rationale: The client cannot bear down when panting and exhaling. The objective is to control the birth and prevent injury to both mother and newborn. The nurse should place a hand on the perineum to apply gentle pressure and then support the head as it emerges. Slow breaths enhance relaxation; this type of breathing is impossible to achieve when the fetal head is crowning. Holding the breath and pushing will result in a precipitous birth that could cause injury to both mother and newborn. Breathing faster than usual and taking long cleansing breaths are impossible to achieve when the fetal head is crowning.
After assessing the behavior of a 3-year-old child, the nurse concludes that the child is slow to warm up. Which behavior helps the nurse reach this conclusion? A. The child has predictable habits in different environments. B. The child consistently expresses a negative mood in various environments. C. The child responds enthusiastically to a new environment. D. The child adapts gradually to a new environment with repeated contact.
D. The child adapts gradually to a new environment with repeated contact. Rationale: The child who is slow to warm up will react with mild intensity to a new stimulus. Such children show slow adaptation to new environments only when pressured with repeated contact. The child who has an easygoing temperament will have predictable habits. However, a child with a slow to warm up temperament will respond with passive resistance. A difficult child consistently expresses a negative mood. However, a child with a slow to warm up temperament will show a negative mood initially, which later changes as the child warms up to the new situation. The child who has an easygoing temperament will respond enthusiastically to a new environment.