Hesi
6. The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How many ml should the nurse administer?
.3
A child receives a prescription for amantadine 42 mg PO BID. Amantadine is available as a 50 mg/5 mL syrup. Using a supplied calibrated measuring device, how many mL should the nurse administer per dose? (round to nearest tenth).
0.5 mL
A client at 32 weeks' gestation is admitted to the prenatal unit in preterm labor. An infusion of magnesium sulfate is started. What physiologic response indicates to the nurse that the magnesium sulfate is having a therapeutic effect?
A decrease in frequency and duration of contractions
Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home?
Allow the cord to air dry as much as possible.
22. A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child's hair with permethrin (Nix) shampoo and calls his parents. What instruction should the nurse provide to the parents about treatment for head lice?
B. Wash the child's bed linens and clothing in hot soapy water.
49. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, and notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to the body size. Which action is most important for the nurse to take next?
C. Palpate the anterior fontanel for tension and bulding.
Which condition should the nurse recognize as a contraindication to tocolytic therapy?
Cardiac disease
An 8-year-old male client with nephrotic syndrome is receiving salt-poor human albumin IV. Which findings indicate to the nurse that the child is manifesting a therapeutic response?
Decreased periorbital edema
A male toddler is brought to the emergency center approximately three hours after swallowing tablets from his grandmother's bottle of digoxin (Lanoxin). What prescription should the nurse implement first
Give IV digoxin immune fab (Digibind)
The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate?
Gonorrhea.
While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to minutes. Which assessment should the nurse implement?
Inspect the posterior oropharynx
Why is meperidine (Demerol) contraindicated for pain relief in clients with sickle cell disease?
It can induce seizures
client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge?
It is difficult to consume 18 mg of additional iron by diet alone.
An adolescent who is taking antiretroviral therapy for HIV infection arrives at the clinic for a follow up visit. Which information is most important for the nurse to obtain?
Missing medication doses
A client at 32 weeks of gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates that therapeutic drug levels have been achieved?
Respiratory rate decreases from 24 to 16.
A pediatric client is placed on a drug regimen for management of aplastic anemia. What should the nurse identify as the expected outcome of this treatment?
Restore bone marrow function
The nurse is examining a client who believes she is pregnant. Which presumptive sign should the nurse recognize as a possible indication of pregnancy?
Urinary frequency
30. Which nursing intervention is most important to include in the plan of care for for a child with acute glomerulonephritis?
· Weight the child daily
The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in this client's teaching plan?
oral contraceptive use for at least one year
The nurse should explain to a 30-year-old gravid client that alpha-fetoprotein testing is recommended for which purpose?
screen for neural tube defects
A 26-year-old gravida 2, para 1 client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for the primary side effects of terbutaline sulfate, which are:
tachycardia and a feeling of nervousness.
17. A child who received multiple blood transfusions after correction of a congenital heart defects is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse before reporting to the healthcare provider?
· Calcium
20. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?
· Keep airway equipment at the bedside.
During a routine well-child exam, the nurse observes that a 12-month-old child is unable to pronounce any simple words or syllables. Which possible cause should the child be evaluated for first?
Hearing loss
A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?
The chorea or movements are temporary and will eventually disappear
52. The nurse is caring for a one-year-old child following surgical correction of hypospadias. What nursing action has the highest priority?
A. Monitor urinary output.
28. A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first?
A. Place the infant on the abdomen to protect the sac.
41. The nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child?
A. Reduce cerebral edema and lower intracranial pressure.
53. What goal is most important for the nurse to include in the plan of care for a client with gestational diabetes?
A. Restrict carbohydrate intake.
43. A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby, the infant's skin tastes salty. The nurse should prepare the mother for what standard diagnostic test to screen for cystic fibrosis (CF)?
A. Sweat-chloride test.
A 2-week-old female infant is hospitalized for the surgical repair of an umbilical hernia. After returning to the postoperative neonatal unit, her respiratory rate and heart rate have increased during the last hour. Which intervention should the nurse implement?
Administer a PRN analgesic prescription
A child with cataracts has an increased risk for developing which condition?
Amblyopia
54. A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?
B. Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby lactch on.
45. A newborn who was a breech presentation is admitted to the nursery. Which assessment procedure is a priority for the nurse to perform?
B. Babinski's reflex.
46. A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse to review before reporting to the healthcare provider?
B. Calcium.
34. A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?
B. Contact the healthcare provider.
42. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2 station. What action should the nurse implement first?
B. Determine current cervical dilation.
37. A 5-year-old child is admitted to the pediatric unit fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first?
B. Initiate normal saline IV at 50ml/hr.
12. The nurse has completed a teaching plan for the mother of a child who is taking digitalis and a diuretic for treatment of the heart failure. Choosing which lunch would indicate that the mother understands the best diet for her child?
B. Peanut butter and banana sandwich with orange juice.
47. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea ( sudden aimless movements of the arms and legs). Which information should the nurse tell to the parents?
B. The chorea or movements are temporary and will eventually disappear.
The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome?
Betamethasone (Celestone) 12 mg deep IM.
3. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this fiding?
Both the lower uterine segment and the fundus must be massaged.
A breastfeeding postpartum client is diagnosed with mastitis and antibiotic therapy is prescribed. What instruction should the nurse provide to this client?
Breastfeed the infant, ensuring that both breasts are completely emptied.
46. A blind litter girld, 8 year sold was admitted to the hospital .....
Bring familiarly toys from home, such as bear,doll.
25. The nurse is assessing a 9-year-old boy who has been admitted to the hospital with possible acute poststreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant?
C. A sore throat last week
26. A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide?
C. Apply hot packs just before each feeding.
48. The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?
C. Cries vigorously when stimulated.
A mother brings her 2-month old son to the clinic for a well-baby exam. During the assessment the nurse finds that the right testicle is not distended into the scrotum but the left is palpable. Which action should the nurse take?
Ask if the right testis has been seen in the scrotum before
A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most important for the nurse to include in the child's plan of care?
Assess for abdominal pain and vomiting
A 6-year old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol (Proventil). The child's mother tells the nurse that she uses this medication to open her son's airway when he is having trouble breathing. What is the nurse's best response?
Assure the mother that she is using the medication correctly
9. The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?
C. Exercise in a swimming pool.
38. A child who has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit?
C. Metabolic Alkalosis.
40. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for wich acid base alteration?
C. Metabolic acidosis
50. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis af eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?
C. Monitor Blood pressure, pulse, and respirations q4h.
21. A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?
C. Offer information about ultrasonography and genotyping to determine sex assignment.
13. A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation for this finding?
C. The TSH is high because of the low production of T4 by the thyroid.
44. A client with gestational diabetes is undergoing a non-stress test (NST) at 34-weeks gestation. The baseline fetal heart rate (FHR) is 144 beats/minute. The client is instructed to mark the fetal monitor paper by pressing a button attached to the fetal monitor each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. Which outcome indicates a reactive NST?
C. Two FHR accelerations of 15 beats/minute x 15 seconds are recorded.
32. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first?
C. obtain written consent for an emergency cesarean section.
11. Which toy is most appropriate for a 10-year-old child with acute rheumatic fever who is on strict bedrest?
Checkers
A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What foot should the nurse encourage this client to include in her diet?
Chicken.
23. During a 26-week gestation prenatal exam, a client reports occasional dizziness and lightheadness when she is lying down. What intervention is best for the nurse to recommend to this client.
D. Elevate the head with two pillows while sleeping.
39. Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What intervention has the greatest priority?
D. Have a meconium aspirator available at delivery.
14. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?
D. Stimulate the infant to cry.
The nurse is preparing to administer furosemide (lasix) to an adolescent who has developed congestive heart failure as the result of cystic fibrosis. Which condition would indicate the medication regime is being effective?
Decrease of crackles
A child with Grave's disease who is taking propranolol (Inderal) is seen in the clinic. The nurse should monitor the child for which therapeutic response?
Decreased heart rate
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
Urine output 90 ml/4 hours.
The healthcare provider prescribes terbutaline for a client in preterm labor. Before initating this prescription, it is most important for the nurse to assess the client for which of condition
gestational diabetes
The nurse is assisting in the care of a client who is in labor. The nurse notices that when the client pushes, the fetal heart rate slowly declines for 20 seconds before returning to baseline. How should the nurse identify this alteration in fetal heart rate?
Early deceleration
A client at 28 weeks of gestation calls the antepartal clinic and states that she just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?
"Come to the clinic today for an ultrasound." Third trimester painless bleeding is characteristic of a placenta previa.
The nurse is educating client who has been diagnosed with pregnancy-induced hypertension (PIH) and placed on a sodium restriction. Which statement by the client indicates that the teaching has been effective?
"I should avoid eating potato chips."
A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV infected. Which explanation should the nurse provide?
HIV infection is determined at 18 months of age when maternal HIV antibodies are no longer present.
27. A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution should the nurse administer? (Enter numeric value only)
13
Mr. and Mrs. Andrews' child was diagnosed with Duchenne's muscular dystrophy; which of the following usually is the first indication of the condition?
Difficulty running in the preschooler
A 5-year-old boy with leukemia is receiving chemotherapy through a peripherally inserted central catheter (PICC). Twenty minutes after the infusion is begun, the child feels dizzy and complains of itching. Which intervention should the nurse implement first?
Discontinue the medication infusion
A 3-year-old client being treated for sepsis has begun bleeding from multiple sites. The nurse's assessment reveals widespread petechiae and bleeding from the nose, mouth, and rectum. Laboratory results reveal a prolonged prothrombin time (PT), elevated d-dimer, and low platelet count. Which disorder should the nurse suspect?
Disseminated intravascular coagulation
35. A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the infusion pump? (Enter numeric value only)
75
The nurses determine that an infant admitted for surgical repair of inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?
Document the finding.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. What is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line in a newborn?
A cephalhematoma, which is caused by forceps trauma.
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?
A decrease in respiratory rate from 24 to 16.
The nurse is teaching an adolescent about the different methods of contraception. Which statement made by the adolescent indicates a need for further teaching?
A diaphragm is a soft rubber dome with a firm but pliable rim.
Which clinical manifestations would the nurse expect to assess in a child who has acute epiglottitis?
Drooling, dyspnea, and high fever.
8. The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and a 12-year-old sibling are the child bedside. Which instruction best supports this family?
A. " While waiting for the healthcare provider, only one visitor may stay with the child"
30. The mother of a 5-week-old tells the nurse that her baby has acne and asks if she can use her teenage son's acne cream, benzoyl peroxide, on the baby's face. Which answer should the nurse to provide?
A. " Your baby may be showing signs of a systemic disease and needs to be seen by a healthcare provider"
55. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply.)
A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad.
17. One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first?
A. Check the differential, since the WBC is normal for this client.
20. During a routine clinic visit, the nurse determines that a 5-year-old boy's blood pressure is 112/70. When calculating the child's blood pressure percentile, the nurse adjusts the calculation for age and height. What actions should the nurse implement next?
A. Compare the child's blood pressure with readings from previous visits.
24. The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse implement?
A. Document the vital signs in the record.
19. While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?
A. Inspect the posterior oropharynx.
18. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client's condition, what information is most important for the nurse to provide?
A. Maternal blood pressure.
36. The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has triple compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?
D. "What food does your baby usually eat in a normal day?"
51. During a well-child visit for their child, one of the parents who has an autosomal dominant disorder tells the nurse, "We don't plan on having any more children, since the next child is likely to inherit this disorder." How should the nurse respond?
D. Confirm that there is a 50% chance of their future children inheriting the disorder.
16. A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?
D. Contraction pattern.
10. A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not labor at this time?
D. Contractions decrease with walking.
29. An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take?
D. Determine the infant's blood sugar level.
31. The nurse is providing preoperative teaching to a teenaged client with appendicitis information should the nurse include about postoperative activity?
D. Early ambulation after surgery will be encouraged to reduce complications and promote healing.
15. At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?
D. Early postpartum, within 72 hours of delivery.
The 8-year-old client is 2 hours post tonsillectomy. Which intervention should the ambulatory care nurse implement for the client?
Encourage the client to drink clear liquids every 30 minutes.
The nurse is caring for an adolescent suspected of having mononucleosis. Which is the most common causative agent of infectious mononucleosis?
Epstein-Barr virus
An adolescent's mother calls the primary HCP's office to inquire about the results of her daughter's serum test results that were drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?
Explain that the information cannot be released without the 18-year olds permission
What is the most common side effect of radiation therapy in children?
Fatigue
A 16-year-old with acute myelocytic leukemia is receiving chemotherapy (CT) via an implanted medication port at the out-patient oncology clinic. What action should the nurse implement when the infusion is complete?
Flush the mediport with saline and a heparin solutions.
When reviewing the laboratory findings of a pregnant woman, the nurse determines that the alpha-fetoprotein (AFP) level is elevated. What information is most important for the nurse to use when interpreting this finding?
Gestational age.
The nurse is admitting a three month infant with a history of chronic constipation and poor weight gain. Which condition results in difficulty passing stool due to the inability of the internal rectal sphincter to relax?
Hirschsprung's disease
The nurse has administered Rh immune globulin to a client. The nurse should report which adverse effect of this medication to the health care immediately?
Hypertension
A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to the baseline after the contraction. What action should the nurse implement?
Increase the rate of the Pitocin infusion
The nurse is discussing risks associated with urinary changes during pregnancy with a group of nursing students. Which information should the nurse share with the students?
Increased urinary stagnation causes urinary tract infections
A nurse is teaching a class for mothers of premature infants, and is asked about "a shot for respiratory virus." What information about plaibizumab (Synagis) is correct?
It is recommended for infants who meet established high-risk criteria
A client visits the prenatal clinic for the first time. The client tells the nurse that her last menstrual period began June 10. The nurse uses Nägele's rule to calculate the EDB. What is the EDB?
March 17 (month -3, day +7)
Which instruction should the nurse include in the discharge teaching plan of a 7-year-old girl with a history of frequent urinary tract infections?
Monitor for changes in urinary odor
Which instructions should the nurse include in the discharge teaching plan of 7 year old girl with history of frequent urinary tract infections
Monitor for changes in urinary odor
A child has just had a tonsillectomy. Immediately after surgery, the nurse should position the child until fully awake in which of the following positions?
On the abdomen, with a pillow under the chest
A 38-year-old client attends the prenatal clinic for the first time. A nurse explains that several tests will be performed, one of which is the serum alpha-fetoprotein test. The client asks what the test will reveal. What should the nurse include in the reply?
Open neural tube defects
While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations?
Partial abruptio placentae
client at 38 weeks' gestation is admitted to the prenatal unit with preeclampsia. A loading dose of magnesium sulfate is administered, and the dosage is subsequently lowered to a maintenance dosage. What is the most important parameter for the nurse to assess while monitoring the client for magnesium sulfate toxicity?
Patellar reflex
Which treatment regimen reduces the risk of pneumococcal infection in a pediatric client with sickle cell anemia?
Penicillin prophylaxis
Six hours after an oxytocin induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement?
Place the client in a slight Trendelenburg position.
The nurse calls a client who is 4 days postpartum to follow-up about her transition with her newborn son at home. The woman tells the nurse, "I don't know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing?
Postpartum blues
In assessing a 10-year old newly diagnosed with osteomyelitis, which information is most important for the nurse to obtain?
Recent occurrence of infection
The nurse is educating a new RN about abnormal fetal heart rate (FHR) patterns. Which statement by the new RN indicates an understanding of what occurs with absent baseline FHR variability?
Recurrent late decelerations
A 9-week-old infant is scheduled for cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
Red blood cell count of 2.3 million/mm3
An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LRHR) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?
Sexual maturity differences between my daughter and her peers will disappear within a few years"
The nurse assesses a pregnant client who has received oxytocin. Upon assessment, the nurse finds uterine tachysystole with nonreassuring fetal heart rhythm. Which action should the nurse take first?
Stop the oxytocin
Which type of visual impairment is corrected by increasing visual stimulation to the weaker eye, by patching the stronger eye?
Strabismus
A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. What finding is most significant in planning care for this family?
The diaper area shows severe skin breakdown.
A mother brings her school-aged daughter to the pediatric clinic for evaluation of her anti-epileptic medication regimen. What information should the nurse provide to the mother?
The medication dose will be tapered over a period of 2 weeks when being discontinued
The parents of a 3-year old boy who has Duchenne muscular dystrophy ask, "How can our son have this disease? We are wondering if we should have any more children." What information should the nurse provide to parents?
This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
The nurse provides information about the human papilloma virus (HPV) vaccine to the mother of a 14-year-old adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent at this visit?
Use of protective barriers during sexual activity prevents most strains of HPV infection
The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to
eat a diet high in protein and vitamins C and D.
A nurse in the prenatal clinic assesses clients for signs of preeclampsia. What sign, other than increased blood pressure, may indicate preeclampsia?
Weight gain of 6 lb in 1 month
Which meal would be appropriate for the child with osteomyelitis to choose?
beef and bean burrito with cheese, carrot and celery sticks, and a glass of milk
7. The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug?
blood pressure 149/90
A client with gestational htn is active labor and receiving an infusion of magnesium sulfate. Which drug should the nurse available for signs of potential toxicity?
calcium gluconate
