EXAM 2

Which of the following variables are scored on a biophysical profile? Select all that apply. 1. fetal tone 2. fetal position 3. fetal movement 4. amniotic fluid index 5. fetal breathing movements 6. contraction stress test result

1, 3, 4, 5

A client at 10 weeks' gestation phones the prenatal clinic to report that she is experiencing some vaginal bleeding and abdominal cramping. The nurse arranges for her to go to the local hospital. The vaginal examination reveals that her cervix is dilated 2 cm. What diagnosis should the nurse expect? 1. septic abortion 2. inevitable abortion 3. threatened abortion 4. incomplete abortion

2 - Once cervical dilation has begun, the abortion is classified as inevitable. - In septic abortion the cervix is dilated and there is bleeding, but malodorous discharge is also present. - Bleeding and cramping may be present in a threatened abortion; however, the cervix is still closed. - The products of conception have been partially expelled in an incomplete abortion.

Which of these statements about pregnancy in the adolescent population are true? Select all that apply. 1. Infants of teen mothers are at risk of delivering babies late. 2. Pregnant adolescents often seek out less prenatal care. 3. Adolescent mothers need competent daycare for their infants. 4. Infants of adolescent mothers are at increased risk for prematurity. 5. Fetuses of adolescent mothers are at higher risk for chromosomal defects.

2, 3, 4 - Pregnancies in older mothers are at greater risk for chromosomal defects.

A child has cystic fibrosis. Which verbalization by the parents about their plan for the child's dietary regimen provides evidence that they understand the nurse's instructions? 1. Restrict fluids during mealtimes. 2. Discontinue the use of salt when cooking. 3. Provide high-calorie foods between meals. 4. Eliminate whole-milk products from the diet.

3

A nurse is caring for several school-aged children with cystic fibrosis. Why does the nurse anticipate that these children will probably be small and underdeveloped for their age? 1. There is muscle atrophy from lack of motor activity. 2. There is decreased secretion of pituitary growth hormone. 3. These children digest little food because pancreatic enzymes are blocked. 4. These children have anorexia with minimal amounts of nutritional intake.

3

While reviewing laboratory results of clients seen at the maternity clinic, the nurse notes that one client's maternal serum alpha-fetoprotein level is lower than expected. What does the nurse recognizes that this may be associated with? 1. Fetal demise 2. Down syndrome 3. Neural tube defects 4. Esophageal obstruction

2

During which week of pregnancy does placental development occur? 1. First 2. Third 3. Fifth 4. Seventh

2

The nurse is caring for a client who has had a spontaneous abortion. Which complication should the nurse assess this client for? 1. hemorrhage 2. dehydration 3. hypertension 4. subinvolution

1 - Hemorrhage may result if placental tissue is retained or uterine atony occurs.

A nurse is educating parents about the nutritional concerns of their newly diagnosed 2-year-old child with cystic fibrosis. The nurse should include which management strategies in the education session? Select all that apply. 1. Fat-soluble vitamin supplementation 2. Possible night time feeding required if weight cannot be maintained 3. Additional table salt is required 4. Diet that is high in calories & high in protein 5. Fat is not restricted unless the steatorrhea cannot be controlled by increased pancreatic enzymes.

1, 2, 3, 4, 5

An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? Select all that apply. 1. Limiting fluid intake 2. Instilling saline nose drops 3. Maintaining contact precautions 4. Suctioning mucus with a bulb syringe 5. Administering warm humidified oxygen

2, 3, 4

Which medications does the nurse expect to be prescribed for a preschooler with newly diagnosed cystic fibrosis? Select all that apply. 1. Steroids 2. Antibiotics 3. Antihistamines 4. Pancreatic enzymes 5. Fat-soluble vitamins

2, 4, 5

The nurse is interpreting the results of a nonstress test (NST) on a client at 41 weeks' gestation. Which result after 20 minutes is suggestive of fetal reactivity? 1. Absence of long-term variability 2. Above-average fetal baseline heart rate of 160 beats/min 3. No late decelerations associated with contractions 4. Two accelerations of 15 beats/min lasting 15 seconds

4

A client comes to the clinic for her routine prenatal visit at 28-weeks' gestation. What assessments will be done during this visit? Select all that apply. 1. Fundal height 2. Non-stress test 3. Alpha-fetoprotein screening 4. Blood pressure 5. Weight

1, 4, 5 - A non-stress test is usually perform toward the end of pregnancy - An alpha-fetoprotein screening is usually performed at week 10-13

A client with diabetes mellitus is having a contraction stress test (CST) at 39 weeks' gestation. Which result would the nurse interpret as a positive CST? 1. There are 2 accelerations of the fetal heart rate and 2 contractions seen in 20 minutes 2. Three contractions lasting 40 seconds occur during 10 minutes, late decelerations occur with each contraction 3. Three contractions lasting 60 seconds occur during 10-minutes without late decelerations 4. There are fetal heart rate accelerations of 15 beats/min, lasting 15 seconds with contractions

2

The nurse is providing care to an infant who is diagnosed with cystic fibrosis (CF). Which parental statement indicates the need for further education related to the potential for poor growth? 1. "My child's diagnosis causes delayed bone growth." 2. "My child will have a poor appetite, which will lead to poor growth." 3. "My child will have increased oxygen demands, which will lead to poor growth." 4. "My child will have a decreased ability to absorb nutrients, which will cause poor growth."

2

A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention? 1. Administering an antiviral agent 2. Clustering care to conserve energy 3. Offering oral fluids to promote hydration 4.Providing an antitussive agent whenever necessary

2 - Often the infant will have a decreased pulmonary reserve, and the clustering of care is essential to provide for periods of rest.

The nurse teaches a client who is about to undergo an amniocentesis that ultrasonography will be performed just before the procedure to determine what? 1. Gestational age of the fetus 2. Amount of fluid in the amniotic sac 3. Position of the fetus and the placenta 4. Location of the umbilical cord and placenta

3

A community health nurse is conducting a preconception class for a group of women in their mid- 20's about preparing their bodies for pregnancy. What information should the nurse include in the teaching session? Select all that apply. 1. Use only herbal supplements if any medications are needed 2. Get immunizations up-to-date 3. See a dentist every 6 months 4. Take a folic acid supplement 5. Exercise regularly and eat a well-balanced diet

2, 3, 4, 5

The health care provider orders montelukast (Singulair) for a 10-year-old child who has moderate, persistent asthma. What information should be included when teaching the family about this medication? Select all that apply. 1. The child will require chest physiotherapy immediately after giving this medication 2. This medication decreases inflammation 3. This medication decreases the need for quick relief medication to treat acute exacerbations of asthma 4. This medication has not been researched in children so watch for side effects 5. Administer the medication in the evening

2, 3, 5

A 12-year-old child with cystic fibrosis is to receive four pancrelipase capsules five times a day. The nurse explains that the medication should be taken with meals and snacks to accomplish which goal? 1. Enhance oxygenation 2. Limit excretion of fats 3. Facilitate nutrient utilization 4. Prevent iron-deficiency anemia

3

A nurse manager is providing a class on cystic fibrosis for the pediatric staff nurses. Physiologic adaptations to cystic fibrosis are a result of which problem? 1. Dysfunction of sweat glands 2. Inactivity of respiratory tract cilia 3. Pathology of mucus-secreting glands 4. Overproduction of endocrine gland activity

3

During a physical examination in the prenatal clinic the client's vaginal mucosa is noted to have a purplish discoloration. Which sign should the nurse document in the client's clinical record? 1. Hegar 2. Goodell 3. Chadwick 4. Braxton Hicks

3

Several hours after admission of a child to the pediatric unit with laryngotracheobronchitis (viral croup), the nurse determines that tachypnea and tachycardia, accompanied by intercostal and substernal retractions and increased restlessness, have developed. What is the priority nursing action? 1. Suctioning secretions from the trachea 2. Dislodging mucus by striking the back 3. Reporting the respiratory status to the practitioner 4. Increasing the concentration of oxygen being delivered

3

The parents of a toddler with newly diagnosed cystic fibrosis (CF) tell a nurse that even though they were told it is an inherited disorder, there is no history of CF in the family. How can the nurse clarify the way in which the disease was inherited? 1. It is a mutated gene. 2. It involves an X-linked gene. 3. The inheritance is autosomal recessive. 4. The inheritance is autosomal dominant.

3

A nurse is teaching a family planning class about ovulation and conception. The nurse should instruct the class that the ovum is thought to be viable for what period of time after ovulation? 1. 1 to 6 hours 2. 12 to 18 hours 3. 24 to 36 hours 4. 48 to 72 hours

3 - The ovum is capable of being fertilized for 24 to 36 hours after ovulation. After this time it travels a variable distance between the fallopian tube and uterus and, if not fertilized, disintegrates and is phagocytized by leukocytes. The ovum is viable for longer than 36 hours; however, the ovum is not fertilizable after 36 hours.

A pregnant client states that she is worried because her sister had an ectopic pregnancy and had to have surgery. She asks you, "What are the signs of an ectopic pregnancy?" Which of the following does the nurse identify as signs of a possible ectopic pregnancy? Select all that apply. 1. Increased fatigue during the day 2. Nausea each morning upon awakening 3. Irregular vaginal spotting or bleeding 4. Pain, usually unilateral, over the lower abdomen 5. New onset hypertension

3, 4

During her first prenatal visit, a pregnant client relates that she had an elective abortion 5 years ago and a miscarriage in the first trimester 1 year ago. What does the nurse document as this client's 5-digit GTPAL? _______

30020

The nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she is 5 months pregnant. Which positive sign of pregnancy should the nurse evaluate in this client? 1. Quickening 2. Enlarged abdomen 3. Cervical color change 4. Audible fetal heartbeat

4

Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. For what condition should the nurse assess the newborn? 1. Cardiac defect 2. Kidney disorder 3. Diabetes mellitus 4. Esophageal atresia

4 - Esophageal atresia is associated with hydramnios. There is usually a history of polyhydramnios because the fetus in unable to swallow the amniotic fluid. - Cardiac defects are not associated with hydramnios. - Kidney disorders are associated with oligohydramnios, not hydramnios. - Diabetes in the newborn is not associated with hydramnios.

The nurse is caring for a school-aged child with cystic fibrosis. Which pathophysiologic factor has the greatest impact on the child's health status and is of priority in the care plan? 1. Extremely thick mucus causes obstructed airways. 2. There is acute inflammation of the lung parenchyma. 3. Endocrine glands secrete increased levels of hormones. 4. Increased irritability of the airways results in obstruction.

1

The parents of a 12-year-old boy with cystic fibrosis (CF) ask the nurse why he needs a glucose tolerance test. What information should the nurse consider before replying? 1. Pancreatic scarring predisposes the child to diabetes. 2. The thickened mucus blocks the insulin-secreting glands. 3. The test reveals the degree to which the child adheres to the diet. 4. Adjustments of the dosage of pancreatic enzymes are based on the results of the test.

1

A pregnant client in the third trimester tells the nurse in the prenatal clinic that she is experiencing heartburn after every meal. Which explanation should the nurse provide regarding the cause of the heartburn? 1. "The esophageal sphincter relaxes and allows acid to be regurgitated." 2. "In pregnancy, gastric motility increases, causing a burning sensation." 3. "In pregnancy, gastric pH increases, causing acid to enter the esophagus." 4. "In pregnancy, the pyloric sphincter relaxes, allowing acid to enter the intestine."

1

The parents of a 3-year-old child who has recurrent attacks of acute spasmodic laryngitis (spasmodic croup) ask the nurse why this happens to their child. What is the best rationale for the nurse to convey why this is a disorder of young children? 1. They have small airways. 2. They are mouth breathers. 3. They have immature immune systems. 4. They are prone to upper respiratory infections.

1

The prenatal nurse palpates the uterus of a client who is at 12 weeks' gestation. The uterus is enlarged as expected. What else does the nurse determine about the uterus? 1. It is just above the symphysis pubis. 2. It is buried deep in the pelvic cavity. 3. It is three fingerbreadths above the symphysis pubis. 4. It is causing noticeable bulging of the abdominal wall.

1

Which hormone is crucial for ovulation and complete maturation of a client's ovarian follicles? 1. Luteinizing hormone 2. Follicle stimulating hormone 3. Gonadotropin releasing hormone 4. Human chorionic gonadotropin hormone

1

What will a nurse teach the parents of a toddler with newly diagnosed cystic fibrosis about the administration of vitamins A, D, E, and K? 1. Offer them in a water-miscible form. 2. Give them during meals and snack times. 3. The dosage is based on the child's height and weight. 4. Present them to the child with fruit juice rather than milk.

1 - Because children with cystic fibrosis do not absorb fat-soluble vitamins effectively, they should be given in a water-miscible form.

An infant with bronchiolitis caused by respiratory syncytial virus (RSV) is admitted to the pediatric unit. What does the nurse expect the prescribed treatment to include? 1. Humidified cool air and adequate hydration 2. Postural drainage and oxygen by hood 3. Bronchodilators and cough suppressants 4. Corticosteroids and broad-spectrum antibiotics

1 - humidified cool air to decrease the inflammation - adequate hydration to prevent insensible fluid loss from tachypnea

The nurse is caring for a newly diagnosed 10-year-old child with asthma. Education should include which management strategies? Select all that apply. 1. How to administer the metered dose inhaler correctly 2. How to read the Asthma Action Plan 3. Understanding when to call the pulmonologist or go to the emergency department 4. The purpose of using the Peak Flow Meter 5. Remove all allergens from the home and avoid contact, when possible

1, 2, 3, 4, 5

A client identified as having a high-risk pregnancy is about to undergo a contraction stress test (CST). Which factor would compel the nurse to question this prescription? 1. Blurred vision 2. vaginal bleeding 3. sickle cell disease 4. increasing hypertension

2 - Bleeding may indicate placenta previa or abruptio placentae, which will be aggravated by contractions from the use of oxytocin. - Although blurred vision may indicate preeclampsia, a CST is not contraindicated. Fetal tolerance of the stress of contractions should be assessed. - Although sickling or arteriolar spasms could diminish oxygen perfusion to the placenta and compromise the fetus during labor, a CST is not contraindicated.

What is the priority nursing care immediately after an amniocentesis? 1. Giving perineal care after the procedure 2. Encouraging lots of fluids every hour 3. Changing the abdominal dressing 4. Monitoring for signs of uterine contractions

4 - It is possible that stimulation of the uterus resulting from the amniocentesis will initiate uterine contractions. - Perineal care is not necessary, because an amniocentesis is not done by way of the vagina. - Encouraging fluids every hour is irrelevant, because the amount of amniotic fluid is not influenced by fluid ingestion. - Changing the abdominal dressing is not necessary, because the needlestick site seals immediately.

The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is utilized in order to do what? 1. estimate fetal age 2. detect hydrocephalus 3. rule out congenital defects 4. approximate fetal linear growth

1

Which interventions would be the most beneficial for the nurse to discuss with the parents of a child who has had repeated admissions for respiratory syncytial virus/ bronchiolitis? Select all that apply. 1. Practice frequent hand washing 2. Consider alternatives to sending the child to daycare 3. Encourage physical activity and play 4. Do not smoke and avoid all secondhand smoke around the child 5. Avoid contact with sick people

1, 2, 4, 5

A young pregnant adolescent reports bleeding and abdominal pain and is diagnosed with an ectopic pregnancy. Which risk factors should the nurse look for in the client? Select all that apply. 1. habit of smoking 2. irregular menses 3. use of contraceptive pills 4. damage to the fallopian tubes 5. hx of pelvic inflammatory disease

1, 4, 5

A preschooler is admitted to the pediatric floor with signs of worsening respiratory distress. List the interventions in the order they should be performed. A. Administer antipyretic and antibiotics as ordered B. Apply oxygen and titrate flow as needed C. Administer ordered nebuilzer via face mask D. Elevate head of bed and reposition the child E. Collect sputum and send to lab

D, B, C, E, A