312 exam 2 PrepU

The nurse is caring for a child with heart failure related to a congenital heart defect. One of the nursing diagnoses identified includes "Excess fluid volume." During a family care planning conference. the parents ask why this diagnosis applies to their child. What is the best response by the nurse?

"Cardiac problems cause the heart to not pump effectively, which causes swelling in the body and fluid in the lungs."

The nurse is taking a health history of a 6-week-old boy with a suspected cardiovascular disorder. Which response by the mother would lead the nurse to suspect that the child is experiencing heart failure?

"He gets sweaty when he eats."

The nurse is taking a health history of a toddler with a suspected congenital heart defect. Which response by the mother could indicate that the child is experiencing hypercyanotic spells?

"He likes to stop and squat wherever he walks."

The clinic nurse talks with the parent of a child with Down syndrome. The parent states, "I thought my 1-year-old would be walking by now. I am concerned." What response by the nurse is best?

"Milestones are often delayed for children with Down Syndrome."

The father of a child with mononucleosis is concerned with his child's fever and cough. The father asks when antibiotic therapy will begin. What is the best response by the nurse?

"Mononucleosis is a viral infection so an antibiotic isn't used. We address the symptoms with appropriate therapy."

A client at 36 weeks' gestation comes in for her weekly primary care provider visit. She tells the nurse, "I am having contractions, but they are irregular and go away when I rest. Do you think I am going into labor?" The best response by the nurse would be:

"These are called Braxton-Hicks contractions and are preparing your body for labor but are not 'true' labor contractions."

A pregnant woman in the 36th week of gestation reports that her feet are quite swollen at the end of the day. After careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. Which intervention is appropriate for the nurse to suggest?

"Try elevating your legs when you sit."

The nurse is caring for an infant with Down syndrome who has been diagnosed with atrioventricular canal defect. The parents asks the nurse, "Why do you not put oxygen on our baby more often when his lips and fingernails are blue?" What is the best response by the nurse?

"While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help."

The nurse is caring for a pediatric client diagnosed with tetralogy of Fallot. After speaking with the physician, the parents state to the nurse, "The doctor said something about our child having too many red blood cells. We don't understand how that could happen?" What is the best response by the nurse?

"Your child's body is trying to compensate for the low blood oxygen levels from the heart defect by making more red blood cells, but this makes the heart actually work harder."

A nurse measures a pregnant woman's fundal height and finds it to be 28 cm. The nurse interprets this to indicate that the client is at how many weeks' gestation?

28 weeks' gestation

A child with a diagnosis of Down syndrome has which chromosomal abnormality?

3 copies of trisomy 21 has occurred instead of 2 copies.

A young child in the clinic has watery eyes and reddened conjunctiva. The child keeps the eyes closed a lot, because it hurts to have them open. Which problem does the nurse suspect for this client?

Conjunctivitis

A woman in her third trimester is suffering from heartburn. What should the nurse advise her to do?

Eat small meals frequently rather than large meals.

The nurse is instructing the parents of a child with sickle cell anemia on safety precautions. What should the nurse emphasize during this teaching?

Ensure a consistent and daily intake of adequate fluids to prevent dehydration.

A nurse is preparing a presentation about genetic disorders in children. What cause would the nurse include as the most common inherited cause of intellectual disability?

Fragile X syndrome

A parent brings a 2-year-old child to the health clinic with reports of diarrhea, vomiting, and abdominal pain. The father tells the nurse that he is a single parent and his child is enrolled in a local day care center. Based on this information, what gastrointestinal condition might the nurse suspect?

Gastroenteritis

A child is diagnosed with sickle cell anemia. Which test will the nurse expect the primary health care provider to prescribe for this client?

Hemoglobin level

A child is at risk for infection related to a respiratory disorder. What would the nurse educate the family on to prevent infection?

Hygiene, handwashing

What measure at home could help a child with an upper respiratory infection breathe more easily?

Increasing room humidity

During a follow-up visit, the parents of a 5-month-old infant diagnosed with congenital heart disease tell the nurse, "We're just so tired and emotionally spent. All these tests and examinations are overwhelming. We just want to have a normal life. We're so focused on the baby that it seems like our 3-year-old is lost in the shuffle." Which nursing diagnosis would the nurse identify as most appropriate?

Interrupted family processes related to demands of caring for the ill child

The nurse is assessing an adolescent newly diagnosed with a genetic disorder. The parent states this is the first time the family was made aware of any genetic concerns with the child. What genetic disorder is this child's likely diagnosis?

Klinefelter syndrome

The nurse has developed a plan of care for a 12-month-old hospitalized with dehydration as a result of rotavirus. Which intervention would the nurse include in the plan of care?

Maintaining the intravenous (IV) fluid rate as ordered

Included in the nursing care plan for the child receiving total parenteral nutrition (TPN) will be which intervention?

Regularly monitoring the child's blood glucose

The nurse is caring for a 6-month-old infant diagnosed with otitis media. Which clinical manifestation would likely have been noted in this child?

Shaking the head and pulling the ear

The parents of a child with a bleeding disorder ask the nurse about appropriate activities and sports that they should encourage the child to participate in. What activity would be the safest for the nurse to suggest?

Swimming

A mother asks the nurse if the reason the infant has a congenital heart defect is because of something she did while pregnant. What is the best response by the nurse?

There are several reasons an infant can have a heart defect; let's talk about those causes.

A mother asks why her infant with a cyanotic heart defect turns blue. What is the nurse's best explanation?

This is due to a decreased amount of oxygen to the peripheral tissue.

The use of what during pregnancy is potentially most harmful to the fetus?

alcohol

The nursing instructor is teaching a class on the nutritional needs of the pregnant client. The instructor determines the session is successful when the students correctly choose which supplement as being known to prevent up to 70% of CNS birth defects?

folic acid

If constipation is a problem for a woman during pregnancy, which measure would be best to recommend?

increased fiber intake

The nurse is reviewing the medical record of a child with a cleft lip and palate. When reviewing the child's history, what would the nurse identify as a risk factor for this condition?

mother age 42 with pregnancy

Which condition is a part of normal newborn screening?

phenylketonuria

A pregnant client in her second trimester visits a health care center. She informs the nurse that at times she experiences difficulty breathing. What would the nurse identify as the most likely cause of the client's report?

pressure on the diaphragm by the growing fetus

A nursing student correctly identifies which action to be the best way to prevent complications of pregnancy?

receiving prenatal care

While enrolled in a geography course, a student nurse learns that diarrheal illness is deadly for large numbers of infants in Third World countries. What vaccine will this nursing student identify as part of the solution to this problem?

rotavirus (RV)

A child with a cardiac structural defect is receiving oxygen therapy. In which position should the child be placed to promote optimal benefits?

semi-Fowler

The nurse is performing an assessment of a 6-year-old girl with Turner syndrome. What finding would the nurse most likely assess?

short stature and slow growth

A nurse urges a pregnant client at the first prenatal office visit to begin taking iron supplements immediately. What is the rationale for this intervention?

to avoid anemia

The nurse has administered oral penicillin as ordered for prophylaxis of endocarditis. The nurse instructs the parents to immediately report which reaction?

wheezing

If there is a foreign body in the larynx, how will the client present?

with stridor