37

22). A pregnant client at 35 weeks gestation has brisk, painless vaginal bleeding. The health care provider suspects placenta previa. The nurse should prepare for which procedures? Select all that apply.

- Blood draw for hemoglobin - Electronic fetal monitoring - Pelvic ultrasound Wrong: 1,6

39). A child in the emergency department had a cast placed on the right arm for a nondisplaced fracture. The client is being discharged home with pain medications. Which statement by the parent indicates that additional teaching is required?

"A tingling or burning sensation within the first 24-48 hours is not a concern."

1). A nurse is caring for a school-age client who has fever, somnolence, and a skin rash from suspected meningococcal meningitis. Which interventions should be implemented for this client? Select all that apply.

- Allow the client to self-position for comfort - Keep the client on NPO status - Minimize the environmental stimuli Missed: 3 Wrong: 2

27). The nurse is caring for a full-term newborn following vaginal delivery. Which nursing interventions should be implemented? Select all that apply.

- Always wear gloves when handling the newborn before bathing - Cover the newborn to maintain a body temperature of 97.5-99 F (36.4-37.2 C) - Give a single dose of vitamin K intramuscularly - Suction the pharynx first, then the nasal passages

38). The nurse is reinforcing teaching to a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain in pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which of the following statements made by the client indicates an understanding about weight gain?

"I should gain about 30 lb (13.6 kg) during pregnancy." Missed: 2 Wrong: 3

35). A child is scheduled to have an electroencephalogram (EEG). Which statement by the parent indicates understanding of the teaching?

"I will wash my child's hair using shampoo the morning of the procedure."

48). A nurse is speaking with the parent of a toddler who believes the child has a hearing deficit. Which findings support this suspected diagnosis? Select all that apply.

- Behavior appears withdrawn - Monotone speech - Speaks with a loud voice Wrong: 2

40). A couple is excited about finding out the sex of their baby during ultrasound at 14 weeks gestation. What is the nurse's best response?

"If the baby is in the right position, the genitalia may be visualized."

15). A 2-month-old recently diagnosed with developmental dysplasia of the hip is beginning treatment with a Pavlik harness. Which instructions should the nurse reinforce to the parents? Select all that apply.

- "Dress the child in a shirt and knee socks under the straps." - "Lightly massage the skin under the straps daily." - "Place the diaper under the straps."

20). A nurse is reinforcing information on formula preparation for a client with a newborn. Which statements by the client indicate proper understanding? Select all that apply.

- "I must wash the top of the concentrated formula can before opening it." - "Prepared formula should be kept in the refrigerator and discarded after 48 hours." Missed: 5 Wrong: 3,4

29). A 28-year-old client is admitted to the labor and delivery unit for severe preeclampsia. She is started on IV magnesium sulfate. Which signs indicate that the client has developed magnesium sulfate toxicity? Select all that apply.

- 0/4 patellar reflex - Respirations are 10/min Missed: 1 Wrong: 3,5

37). A client is at 24 weeks gestation and preeclampsia-eclampsia syndrome is suspected. Which of the following are significant signs/symptoms criteria related to this syndrome? Select all that apply.

- 300 mg/24 hr (0.3 g/day) protein in urine - Headache, blurry vision Missed: 4 Wrong: 3,5

46). A male infant is born at 28 weeks gestation. What assessment findings would the nurse expect the newborn to exhibit? Select all that apply.

- Abundant lanugo on the shoulders and back - Eyelids that are fully open - Smooth, pink skin with visible veins Missed: 4 Wrong: 5

2). A practical nurse (PN) is assisting the registered nurse in caring for a client on oxytocin to induce labor. Which assessments does the PN anticipate during the infusion? Select all that apply.

- Blood pressure - Fetal heart rate tracings - Intake and output - Uterine contraction pattern - Vaginal examination Missed: 6 Cervical dilation - The rate of oxytocin infusion may be gradually reduced when the client is in the active phase of labor, about 5-6 cm of cervical dilation. Oxytocin may be stopped or reduced after the client's membranes rupture (Option 6).

28). The nurse is reinforcing teaching to the mother of a newborn about gastroesophageal reflux. What does the nurse suggest to help prevent reflux? Select all that apply.

- Burp infant during and after feeds - Offer infant smaller but more frequent feeds - Place infant on tummy after feeding Missed: 5 Wrong: 2

36). The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply.

- Capillary glucose of 60 mg/dL (3.3 mmol/L) - Respirations of 56 breaths per minute - White papules on bridge of the nose Missed: 3 Wrong: 2

24). A 36-year-old multigravida is admitted with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures does the practical nurse anticipate in this client's plan of care? Select all that apply.

- Check deep tendon reflex frequently - Ensure bright lighting in rooms to prevent falls - Have suction equipment ready to use - Monitor for right upper quadrant pain

41). When assessing neonates in the nursery, the practical nurse should report which findings to the registered nurse? Select all that apply.

- Chest wall retractions - Head circumference of 30 cm - Jaundice of the head and sclera - No voiding in 24 hours Missed: 1,3

7). Which assessment findings should the nurse anticipate in a child with suspected acute otitis media (AOM)? Select all that apply.

- Frequent pulling on the affected ear - Refusal to eat - Restlessness and irritability Wrong: 5

8). A nurse is caring for a 3-month-old infant who has bacterial meningitis. Which clinical findings support this diagnosis? Select all that apply.

- Frequent seizures - .High-pitched cry - Poor feeding - Vomiting Missed:3 Wrong: 1

49). A pregnant client in the third trimester completes an intake form for a clinic visit. Which signs and symptoms are priority problems for the nurse to evaluate? Select all that apply.

- Frequent urination with dysuria and nocturia - Headache and blurred vision - Nonmalodorous, copious, clear vaginal discharge

47). The nurse checks the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has a high risk of early postpartum hemorrhage? Select all that apply.

- Grand multiparity - Infant birth weight of 9 lb, 2 oz (4139 g) - Third stage of labor lasting 1 hour

9). A client at 21 weeks gestation has intense heartburn (pyrosis). What should the nurse recommend? Select all that apply.

- High-protein, low-fat diet - Six small meals a day Wrong: 3

17). A client at 34 weeks gestation has constipation. The client has been taking 325 mg ferrous sulfate tid for anemia since the last appointment 4 weeks ago. Which instructions should the nurse reinforce for this client? Select all that apply.

- Increase intake of fruits and vegetables - Moderate-intensity regular exercise Missed: 3 Wrong: 4

19). A nurse is reinforcing teaching to a breastfeeding client who has been diagnosed with mastitis of the right breast. Which instructions should be included? Select all that apply.

- Increase oral fluid intake - Take ibuprofen as needed for pain Wrong: 5

30). A pregnant client at 30 weeks gestation comes to the prenatal clinic. Which vaccines may be administered safely at this prenatal visit? Select all that apply.

- Influenza injection - Tetanus, diphtheria, and pertussis

13). A practical nurse is collaborating with the registered nurse to form a care plan for a client diagnosed with placenta previa at 33 weeks gestation. What does the nurse anticipate being included in the plan of care? Select all that apply.

- Nonstress test 1 or 2 times a week - Prepare for cesarean birth at any time - Type and screen blood Missed: 2

12). The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply.

- Plantar creases up the entire sole - Toes fan outward when the lateral sole surface is stroked - White pearl-like cysts on gum margins Missed: 1 Wrong: 4,5

6). A nurse is caring for a pregnant client who has hyperemesis gravidarum. Which assessment findings should the nurse anticipate? Select all that apply.

- Positive urine ketones (moderate) - Pulse 106/min Missed: 3,4 Wrong: 1,5

23). The summer camp nurse and parent of a 9-year-old with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply.

- Stationary bicycling -Swimming - Yoga Missed: 3, 5 Wrong: 2

51). The nurse is returning the results of a urine pregnancy test to a client currently taking several medications. Which of the following prescriptions are contraindicated in pregnancy? Select all that apply.

-Doxycycline -Isotretinoin -Lisinopril

42). The practical nurse is collecting data on several clients in the antepartum unit. Which client should the practical nurse report to the registered nurse for further assessment?

25 weeks gestation, hemoglobin is 9 g/dL Missed: 2 Wrong: 36 weeks gestation, white blood cell count is 13,000/mm3

10). The nurse is performing an assessment on a febrile 2-year-old with suspected otitis media. Which action would be appropriate?

Perform otoscopic examination at the end of the assessment Missed: 2 Wrong: 1

21). The practical nurse is collecting data on several clients waiting to be seen in the prenatal clinic. Which client situation is most important to report to the registered nurse?

32 weeks gestation client taking ibuprofen for moderate back pain

26). A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first?

Administer rectal diazepam

34). A woman who had a cesarean delivery 5 hours ago now appears anxious and reports shortness of breath. The practical nurse should assess for which priority problem before notifying the registered nurse?

Calf warmth and redness

14). A newborn has a large myelomeningocele. What nursing intervention is priority?

Cover the area with a sterile, moist dressing Missed: 2 Wrong: 4

16). A 7-month-old infant is admitted to the unit with suspected bacterial meningitis after receiving an initial dose of antibiotics in the emergency department. Frequent monitoring of which of the following is most important?

Fontanel assessment

4). The practical nurse is monitoring a client 12 hours after the prolonged vaginal delivery of a term infant. Which finding should be reported to the registered nurse?

Foul-smelling lochia

31). A pregnant client provides the following obstetric history to the nurse at the first prenatal visit: Elective abortion at age 17; a 5-year-old daughter born at 40 weeks gestation; and 3-year-old twin boys born at 34 weeks gestation. Using the GTPAL system, which option is correct?

G4, T1, P1, A1, L3 Missed: 3 Wrong: 2 Explanation: In this scenario, the client is a G4 T1 P1 A1 L3. She is gravida (G) 4 as she has a history of 4 pregnancies (which includes the present pregnancy) (Option 3).

25). A pregnant client comes in for a routine first prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. Where would the nurse expect to palpate the uterine fundus in this client?

Just above the symphysis pubis

11). A nurse is planning to test the visual acuity of a 7-year-old. Which is the best way to test visual acuity in this child?

Position the child at a distance of 10 ft (3 m) from a chart Missed: 3 Wrong: 1

43). The nurse is assessing a 4-week-old infant during a routine office visit. Which assessment finding is most likely to alert the nurse to the presence of right hip developmental dysplasia?

Presence of extra gluteal folds on right side

3). The health care provider (HCP) prescribes a 10-day course of amoxicillin for a 1-year-old diagnosed with acute otitis media (AOM). Which instruction is most important for the nurse to review with the child's parents?

Return to the office if the child does not improve within 48-72 hours

32). A client at 38 weeks gestation is in labor and receiving an oxytocin infusion. The continuous fetal heart rate (FHR) monitor displays the strip shown in the exhibit. Which action by the nurse is most appropriate? Click on the exhibit button for additional information.

Review medication administration record

45). A client in the postpartum unit has a temperature of 100.9 F (38.3 C) and tachycardia on the second day following a cesarean delivery. Examination shows uterine tenderness, fundus +2 above the umbilicus, moderate lochia rubra with a foul smell, and chills. Which prescription should the nurse implement first?

Serum laboratory draws for blood culture and sensitivity

5). A 1-year-old child who goes to day care is recovering from an episode of otitis media. Which intervention is most important for the nurse to reinforce to the parents in order to prevent recurrence?

Smoking cessation by the parents

50). Prior to discharge of a child with a ventriculoperitoneal (VP) shunt, the nurse reinforces teaching to the caregiver about when to contact the health care provider. The caregiver shows understanding of the instructions by contacting the health care provider about which symptom?

The child vomits after awakening from a nap and again 1 hour later

18). The nurse is preparing to assess a client visiting the women's health clinic. The client's obstetric history is documented as G5T1P2A1L2. Which interpretation of this notation is correct?

The client had 1 birth at 37 wk 0 d gestation or beyond Missed: 1 Wrong: 2

33). A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate?

Vaginal hematoma