Developmental Stages and Transitions
A nurse performs a nonstress test on a pregnant client. The nurse determines that the results are nonreactive if which of the following findings is noted on the electronic monitoring recording strip?
Absence of accelerations after fetal movement
The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in a:
Booster seat with one of the car's seat belts placed over the child
A nurse is performing an external and ophthalmoscopic examination of an older client. Which age-related change would the nurse would expect to note?
Age-related changes of the retina include narrowed and straightened blood vessels, opaque gray arteries, and gray or yellow spots of hyaline degeneration, called drusen, near the macula
A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman's radial pulse rate is 55 beats per minute. On the basis of this finding, which action by the nurse is most appropriate?
Documenting the finding
The mother of a 5-year-old asks the nurse how often her child should undergo a dental examination. The nurse tells the mother that the child should have a dental examination:
Every 6 months
A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), the nurse determines that the client is:
Gravida 6, para 2
A nurse is discussing birth control methods with a client who is trying to decide which method to use. On which major factor that will provide the motivation needed for consistent implementation of a birth control method should the nurse focus?
Personal preference
A nurse, planning play activities for a hospitalized school-age child, uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse selects an activity that will assist the child in developing
A sense of industry
A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions?
"The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body."
An older female client asks a nurse why her hair has turned gray. Which of the following responses is most appropriate for the nurse to make to the client?
"A loss of melanin occurs in the normal aging process."
A woman receives a subarachnoid (spinal) block for a cesarean delivery. For which adverse effect of the block does the postpartum nurse monitor the woman?
Headache
A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. On the basis of this finding, the nurse determines that:
Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth
A nurse helps a young adult conduct a personal lifestyle assessment. The nurse carefully reviews the assessment with the young adult because such clients:
Ignore physical symptoms and postpone seeking health care
A nurse is assessing language development in a toddler from a bilingual family. The nurse expects that the child's language development:
Is slower than expected
A nurse is performing a skin and peripheral vascular assessment on a client in later adulthood. Which of the following observations would the nurse expect to note as an age-related finding?
Loss of hair on the lower legs
A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson's theory of psychosocial development. According to Erikson's theory, which of the following tasks represents the primary developmental task of this child?
Mastering useful skills and tools
Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus?
Midway between the symphysis pubis and umbilicus
A nurse is planning dietary measures for an older client who is experiencing dysphagia. Which of the following actions should the nurse include in the plan of care?
Monitoring the client during meals to ensure that food is swallowed
A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. The nurse should
Tell the mother that the infant's weight is increasing as expected
A mother of twin toddlers tells the nurse that she is concerned because she found her children involved in sex play and didn't know what to do. The nurse should tell the mother:
That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity
A home health care nurse is visiting a male African-American client who was recently discharged from the hospital. Which family member does the the nurse ensure is present when teaching the client about his prescribed medications?
The client's mother
A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to
Use water and a cotton swab and rub the teeth
Intramuscular phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomical site does the nurse administer it?
Vastus lateralis muscle
A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. The nurse tells the clients that:
Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses
A nurse is assessing the motor development of a 24-month-old child. Which of the following activities would the nurse expect the mother to report that the child can perform? Select all that apply.
• Align two or more blocks • Turn the pages of a book one at a time.
A nurse provides information to a pregnant client with hemorrhoids about measures that will alleviate her discomfort. Which of the following actions does the nurse tell the client to take? Select all that apply.
• Apply cool compresses to the hemorrhoids • Elevate her hips on a pillow when resting or during sleep
A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths per minute. On the basis of this finding, what is the most appropriate action for the nurse to take?
Documenting the findings
A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. The nurse should take which most appropriate action?
Gently stimulate the infant by rubbing his back while administering oxygen
A client in labor complains of back discomfort. Which position that will best aid in relieving the discomfort does the nurse encourage the mother to assume?
Hands and knees
A nurse is gathering subjective data from a client who is seeking a prescription for an oral contraceptive. To identify risk factors associated with the use of an oral contraceptive, which question does the nurse ask?
"Do you smoke cigarettes?"
A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information?
"Egg white should not be given to my infant because of the risk for an allergy."
A postpartum nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her health care provider. Which statement by the mother indicates a need for further information?
"Frequent urination and burning when I urinate are expected."
A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction?
"I need to wear additional antiperspirant and deodorant in warm weather."
A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed?
16 weeks
A Muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant. When planning for the physical assessment of the woman, the nurse ensures that:
A female physician examines the woman
A nurse in the newborn nursery, performing an assessment of a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant:
At the level of the nipples
A nurse gathering subjective data from a client during a health assessment plans to ask the client about the medical history of the client's extended family. About which family members would the nurse ask the client?
Aunts, uncles, grandparents, and cousins
A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over the:
Back of the fetus
A nurse in a daycare setting is planning play activities for 2- and 3-year-old children. Which of the following toys are most appropriate for these activities?
Blocks and push-pull toys
A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, the nurse tells the group that infants:
Rely on the fact that their needs will be met
A mother asks the nurse when her child should have his first dentist visit. The nurse tells the mother:
Soon after the first primary tooth erupts, usually around 1 year of age
A nurse is determining the estimated date of delivery for a pregnant client, using Nagele's rule, and notes documentation that the date of the client's last menstrual period was August 30, 2013. The nurse determines the estimated date of delivery to be:
June 6, 2014
A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, the nurse should:
Keep hospital routines as similar as possible to those at home
A nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is 1 hour postpartum and notes a 5-inch bloodstain (see figure). How does the nurse report the amount of lochial flow?
Moderate
Clomiphene (Clomid, Serophene) is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication and tells the couple that:
Multiple births occur in a small percentage of clomiphene-facilitated pregnancies
A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client's temperature is 100.6° F, the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. On the basis of these findings, what is the most appropriate nursing action?
Notify the nurse-midwife of the findings
A prescription is written to administer hepatitis B vaccine (Recombivax HB) to a newborn infant. Before administering the vaccine, the nurse should:
Obtain parental consent to administer the vaccine
A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant:
Overarticulates words
A nurse is reviewing the medical notes of a client seen by the physician to determine whether the client is pregnant. The nurse determines that pregnancy was confirmed if which of the following findings is documented?
Palpable fetal movement
A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately:
Position the mother so that her hips are elevated
The nurse provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information?
"I need to be sure to drink adequate fluids with my meals." Correct Understanding is Indicated in these statements: • "I need to avoid eating fried or greasy foods." • "I should eat five or six small meals a day rather than three full meals." • "I should keep dry crackers at my bedside and eat them before I get out of bed in the morning."
A nurse is assessing a fetal heart rate (FHR) and notes accelerations from the baseline rate when the fetus is moving. The nurse interprets this finding as:
A reassuring sign
A nurse is assessing a newborn infant for jaundice. Which of the following actions should the nurse take to assess the infant for its presence?
Apply pressure with a finger on the infant's forehead
A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?
Applying an ice pack to the perineum
A nurse is performing an admission assessment on an older client who will be seen by a physician in a health care clinic. When the nurse asks the client about sexual and reproductive function, he reports concern about sexual dysfunction. The nurse's next action should be to:
Ask the client about medications he is taking
A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing seedy, mustard-yellow stools. The nurse tells the mother:
That this is normal for breastfed infants
A nurse is caring for an older client who has a bronchopulmonary infection. The nurse monitors the client's ability to maintain a patent airway because the normal aging process:
Decreases an older client's ability to clear secretions
An amniocentesis is scheduled for a pregnant client who is in the third trimester of pregnancy. The nurse tells the client that the most common indication for amniocentesis during the third trimester is:
Determination of fetal lung maturity
A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. The nurse tells the client that:
Devices that apply pressure alone are available over the counter
A nurse is reviewing the medical record of an older client with presbycusis. Which of the following findings would the nurse expect to note in the client's record?
Difficulty hearing whispered words in the voice test
A nurse performing a neurological assessment of a client in later adulthood notes that the client has tremors of the hands. On the basis of this finding, the nurse should
Document the findings
A nurse is obtaining assessment data from an older client about sleep patterns. The client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. On the basis of these reported data, the nurse should:
Document the findings in the medical record
The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which of the following observations is a sign of physical readiness?
The child can remove his or her own clothing.
A nurse reviews the health history of a client who will be seeing the physician to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which of the following findings in the health history would cause the nurse to determine that use of a combination oral contraceptive is contraindicated?
The client has been treated for breast cancer.
The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. The nurse instructs the mother to:
Give the infant cool liquids or a Popsicle and hard foods such as dry toast
A female client asks a nurse about the advantages of using a female condom. The nurse tells the client that one advantage is:
That it offers protection against sexually transmitted infections (STIs)
A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse tells the client that:
That she may need to drink fluids before the test and may not void until the test has been completed
A nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign. The nurse reads the client's record and interprets this sign as indicating:
That the cervix was seen to be violet
A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother?
The immune system of an infant is immature, and the infant is at risk for infection."
A nurse is assessing the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age?
The infant says "Mama."
A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. The nurse tells the client that:
The test will need to be repeated during the pregnancy
A nurse in the pediatrician's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which of the following findings is noted?
The toes flare and the big toe is dorsiflexed.
A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz about car safety. The nurse tells the mother:
To secure the infant in the middle of the back seat in a rear-facing infant safety seat
A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if she:
Uncovers only the body part being washed
A sexually active adolescent asks the school nurse about the use of latex condoms and the prevention of sexually transmitted infections (STIs). The nurse tells the adolescent that:
Use of a latex condom can prevent transmission of STIs
The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse tells the mother that:
Body piercing is generally harmless as long as it is performed under sterile conditions
A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats per minute. On the basis of this finding, which priority action should the nurse take?
Checking the client's uterine fundus
A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push?
Blowing repeatedly in short puffs
A newborn infant's blood glucose level is analyzed by the laboratory. The laboratory staff calls the nurse and reports that the blood glucose level is 40 mg/dL. On the basis of this result, which action should the nurse take first?
Contact the nurse-midwife or physician
A nurse monitoring a client in labor notes this fetal heart rate pattern (early decelerations) on the electronic fetal monitoring strip. The most appropriate nursing action would be to:
Continue to monitor the client and fetal heart rate patterns
A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant's being brought into the home. Which of the following statements is the most appropriate response for the nurse to make to the client?
"Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth."
The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task?
Autonomy versus doubt and shame
A nurse is developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which of the following actions should the nurse include in the plan?
Encouraging bedtime reading or listening to music
A school nurse provides information to the parents of school-age children regarding appropriate dental care. The nurse tells the parents that their children should:
Brush and floss their teeth after meals and at bedtime
A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats per minute. The nurse should:
Document the findings
A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take on the basis of this finding?
Document the findings.
A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. On the basis of this finding, the nurse should:
Document these measurements in the infant's health-care record
A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR?
Doppler transducer
The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. The nurse should tell the parents:
That this is normal behavior for an adolescent
A nurse provides information to a client about the use of a diaphragm. Which of the following statements indicates to the nurse that the client needs further information on how to use the diaphragm?
"I can leave the diaphragm in place as long as I want after intercourse." Statements indicating correct understanding include: • "I need to reapply spermicidal cream with repeated intercourse." • "The diaphragm needs to be filled with spermicidal cream before insertion." • "The diaphragm can be inserted as long as 6 hours before intercourse."
A nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The nurse plans care knowing that the most likely primary concern of the teenager is:
Body image
A nurse is teaching a pregnant client about nutrition and food sources that are high in folic acid. Which of the following food items does the nurse tell the client contains the highest amount of folic acid?
Pinto beans
A nurse is assessing a fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take?
Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.
According to Erik Erikson's developmental theory, which of the following choices are developmental tasks of the middle adult?
Providing guidance during interactions with his children
A nurse is telling a pregnant client about the signs that must be reported to the physician or nurse-midwife. The nurse tells the client that the physician or nurse-midwife should be contacted if which of the following occurs?
Puffiness of the face
A sexually active married couple, discussing birth control methods with the nurse, express the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest?
Sterilization
A nurse is monitoring a woman who is receiving oxytocin (Pitocin) to induce labor. Which action should the nurse, on suddenly noting the presence of late decelerations on the fetal heart rate (FHR) monitor, take first?
Stopping the oxytocin infusion
The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician's office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. The nurse tells the mother:
That the crust is to be expected as a normal part of healing
A nurse is conducting a psychosocial assessment of a young adult. Which of the following observations would lead the nurse to determine that the client is demonstrating a sign of emotional health?
• The young adult verbalizes satisfaction with friendships. • The young adult has a sense of meaning and direction in life. C
A nurse is assisting a nurse-midwife in performing an amniotomy. After the procedure, the nurse should perform the following actions. Assign the correct order of priority to the items on the list, using 1 to indicate the first action and 5 the last.
(1) Assess the fetal heart rate (2) Assess the color, odor, and other characteristics of the amniotic fluid (3) Check the woman's heart rate and blood pressure (4) Assist the woman in cleaning the perineal area (5) Ask the woman about the need to void
