HESI L3 practice exam

What nursing assessment is the priority focus for a client with major depression? Mood and affect. Suicidal ideation. Nutritional status. Fluid and electrolyte balance.

Suicidal ideation. Suicidal ideations are a major risk factor in a client with major depression. Although mood and affect are assessed while determining if the client has suicidal ideations, the client's risk for self-injury is the priority. The other assessments are not indicated at this time.

Which restraint should be used for a toddler after a cleft palate repair? Clove hitch. Mummy. Elbow. Jacket

Elbow. Elbow restraints prevent children from bending their arms and bringing their hands to the oral surgical site.

A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first? Secure samples of vaginal hair combings. Offer prophylactic antibiotic medication. Explain the rape protocol to the client. Implement crisis intervention counseling.

Explain the rape protocol to the client. Impact reactions of the acute phase of the rape-trauma syndrome include shock, emotional numbness, confusion, disbelief, restless, and agitated motor activity. First, the nurse should provide the client with an explanation of the forensic rape protocol and ask her permission to proceed with examination to minimize additional trauma during assessment and collection of evidence. After the collection of evidence, prophylactic antibiotic medication is provided and then crisis intervention counseling initiated.

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client? "Which symptom did you experience first?" "Are you eating large amounts of salty foods?" "Have you visited a foreign country recently?" "Do you have a history of rheumatic fever?"

"Do you have a history of rheumatic fever?" Obtaining a client's health history is a priority because clients with a history of rheumatic fever may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy.

A primigravida at 12-weeks gestation tells the nurse that she does not like diary products. Which food should the nurse recommend to increase the client's calcium intake? Canned clams. Fresh apricots. Canned sardines. Spaghetti with meat sauce.

Canned sardines. A 3 ounce can of sardines (with bones) provides about the same amount of calcium as 1 cup of milk (C). (A, B, and D) are not good sources for dietary calcium.

The nurse is caring for a client after a transurethral resection of the prostate (TURP) and determines the client's urinary catheter is not draining. What should the nurse implement? Reposition the catheter drainage tubing. Encourage the client to drink oral fluids. Irrigate the catheter. Change drainage unit tubing

Irrigate the catheter. Obstruction urinary flow after a TURP is most often due to blood clots, and sterile irrigation should be implemented to remove the clots that are blocking the catheter.

A child is brought to the emergency department with sweating, chills, and snake fang-like puncture marks on the calf. What action should the nurse implement after the type of snake is identified? Secure the antivenin. Ambulate the child. Apply a tourniquet to the leg. Reassure the child and parent.

Secure the antivenin. A snake's venom contains neurotoxins which causes muscle paralysis and depression of the respiratory system. Antivenom is essential to the child's survival because the child is showing signs of envenomation. When a bite or envenomation is located on an extremity, the extremity should be immobilized. The use of a tourniquet is not recommended. Envenomation is a potentially life-threatening condition.

The nurse is calculating the estimated date of confinement (EDC) using Ngele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? August 1. August 10. September 3. September 8.

September 8. Calculation of a client's EDC provides baseline data to monitor fetal gestation.N gele's rule uses the formula: subtract 3 months and add 7 days to the first day of the last normal menstrual period, so December 1 minus 3 months + 7 days is September 8.

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? A scalp laceration oozing blood. Serosanguineous nasal drainage. Headache rated "10" on a 0-10 scale. Dizziness, nausea and transient confusion.

Serosanguineous nasal drainage. Any nasal discharge following a head injury should be evaluated to determine the presence of cerebral spinal fluid which would indicate a tear in the dura making the client susceptible to meningitis.

An emergency department triage nurse is interviewing a female client who has a history of epilepsy with tonic-clonic seizures controlled by phenytoin (Dilantin). Which information is most significant in planning this client's care? She has missed 2 menstrual periods. She has had no dental care for several years. She ran out of her medication 4 days ago. She has smoked 3 packs of cigarettes a day for 10 years.

She ran out of her medication 4 days ago. Abruptly stopping anticonvulsant medications can precipitate seizures or the development of status epilepticus. Immediate seizure precautions and medication administration are necessary.

The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first? Offer oral fluids. Monitor vital signs. Evaluate ECT effectiveness. Encourage group participation.

Monitor vital signs. Sedatives, muscle relaxants, and an anticholinergic agent are often prescribed for a client during ECT. Vital signs should be monitored during recovery after the ECT procedure. The other actions are not indicated immediately post ECT.

A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is still very small. Which information supports the explanation that the nurse should provide? Side effects are less likely if therapy is started early. Collateral circulation increases as the tumor grows. Sensitivity of cancer cells to CT is based on cell cycle rate. The cell count of the tumor reduces by half with each dose

The cell count of the tumor reduces by half with each dose. Initiating chemotherapy while the tumor is small provides a better chance of eradicating all cancer cells because 50% of cancer cells or tumor cells are killed with each dose.

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate? "A home pregnancy test can be used right after your first missed period." "These tests are most accurate after you have missed your second period." "Home pregnancy tests often give false positives and should not be trusted." "The test can provide accurate information when used right after ovulation."

"A home pregnancy test can be used right after your first missed period." Home urine tests are based on the chemical detection of human chorionic gonadotrophin, which begins to increase 6 to 8 days after conception, and is best detected at 2 weeks gestation or immediately after the first missed period.

A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement? Discontinue the oxytocin (Pitocin) infusion. Place the client in a semi-Fowler's position. Inform the healthcare provider. Apply firm pressure to sacral area.

Apply firm pressure to sacral area. The discomfort of "back labor" can be minimized by the application of firm pressure to the sacral area.

A client in her second trimester of pregnancy asks if it is safe for her to have a drink with dinner. How should the nurse respond to the client? During second trimester beer can be consumed without harm to the fetus. Wine can be consumed several times a week after the first trimester. Only one drink with the evening meal is not harmful to the fetus. Abstinence is strongly recommended throughout the pregnancy.

Abstinence is strongly recommended throughout the pregnancy. A safe level of alcohol consumption during pregnancy has not yet been established, so although the consumption of occasional alcoholic beverages may not be harmful to the mother or her developing fetus, complete abstinence is strongly advised (D). Beer (A), wine (B) or any alcoholic drink (C) consumption is not recommended during the pregnancy.

A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? Notify the pediatrician immediately. Suction the infant's nares, then the oral cavity. Check the infant's oxygen saturation rate. Position the infant on the right side.

Check the infant's oxygen saturation rate. When possible, the nurse should first obtain measurable objective data; an oxygen saturation rate provides such information.

The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? Diabetes mellitus. Hypothyroidism. Parkinson's disease. Recurring pneumonia.

Diabetes mellitus. According to the National Stroke Association (2013), history of diabetes mellitus poses the greatest risk for developing a CVA, 2-4Xs more than those who do not have diabetes mellitus. The reason for this occurrence is related to the excess glucose circulating throughout the body not being utilizing by the cells of the body, leading to the increased fatty deposits or clots inside the blood vessels in the brain or neck, eventually causing a stroke.

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information? Males inherit the disorder with a greater frequency than females. Each pregnancy carries a 50% chance of inheriting the disorder. The disorders can occur in 25% of pregnancies. All children will be carriers of the disorder.

Each pregnancy carries a 50% chance of inheriting the disorder. According to the laws of inheritance, an autosomal dominant disorder has a 50% chance of being transmitted with each pregnancy, and if transmitted, the disorder will appear in the child.

The nurse is planning preconception care for a new female client. Which information should the nurse provide the client? Discuss various contraceptive methods to use until pregnancy is desired. Provide written or verbal information about prenatal care. Ask the client about risk factors associated with complications of pregnancy. Encourage healthy lifestyles for families desiring pregnancy.

Encourage healthy lifestyles for families desiring pregnancy. Preconception care has an overall goal to prepare the client for a healthy pregnancy. It begins with encouraging healthy lifestyle choises in the family and should focus on measures to assist the client in reducing lifestyle variables that may increase the risk for problems in pregnancy.

The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition? Gestational diabetes. Elevated blood pressure. Urinary tract infection. Swelling in lower extremities.

Gestational diabetes. The nurse should evaluate the client for gestational diabetes because terbutaline (Brethine) increases blood glucose levels.

An older female client is admitted to the psychiatric unit with a diagnosis of major depression. Which client statement indicates to the nurse that further assessment is indicated? I will die if my cat dies. I don't feel like eating this morning. I just went to my friend's funeral. Don't you have more important things to do?

I will die if my cat dies. Clients who use an analogy, such as a cat's death, may be describing themselves and can indicate the client's thought of suicide, which needs further assessment. The other statements are examples of decreased energy and mood levels and are not suicidal ideation at this time.

A client with Parkinson's disease is taking carbidopa-levodopa (Sinemet). Which observation by the nurse would indicate that the desired outcome of the medication is being achieved? Decreased blood pressure. Lessening of tremors. Increased salivation. Increased attention span.

Lessening of tremors. Sinemet increases the amount of levodopa to the CNS (dopamine to the brain). Increased amounts of dopamine improve the symptoms of Parkinson's, such as involuntary movements, resting tremors, shuffling gait, etc. Decreased drooling would be a desired effect, not increased salivation.

When assisting a client to relieve postpaturm uterine contractions, which nursing intervention would be most helpful for the nurse to take?" Lying client prone with a pillow on the abdomen. Asking the client to express milk via breast pump. Massaging the client's abdomen. Giving oxytocic medications.

Lying client prone with a pillow on the abdomen. Lying prone keeps the fundus contracted and is especially useful with multiparas, who commonly experience afterpains due to lack of uterine tone.

Which finding in a 19-year-old female client should trigger further assessment by the nurse? Menstruation has not occurred. Reports no tetanus immunization since childhood. Denies having any wisdom teeth. History of painful, inward growth on bottom of foot.

Menstruation has not occurred. Menstruation is an expected secondary sex characteristic that occurs with pubescence and typically occurs between the ages of 10 to 17, so the fact the client is 18 years old and has not experience menarche, should prompt further investigation to determine the cause of this primary amenorrhea.

A client in labor receives an epidural block. What intervention should the nurse implement first? Encourage oral fluids. Assess contractions. Monitor blood pressure. Obtain a radial pulse.

Monitor blood pressure. The risk for maternal hypotension is commonly increased by an epidural, so blood pressure should be monitored immediately after the first epidural dose (C) and for 15 minutes thereafter. Oral fluids should be encouraged to help keep the client hydrated (A), but the first action is to evaluate the client for side effects of the epidural block. Although (B and D) should be continuously monitored after an epidural, the first objective sign of epidural precipitated vasodilation is hypotension.

The nurse obtains a client's history that includes right mastectomy and radiation therapy for cancer of the breast 10 years ago. Which current health problem should the nurse consider is a consequence of the radiation therapy? Asthma. Myocardial infarction. Chronic esophagitis with gastroesophageal reflux. Pathologic fracture of two ribs on the right chest.

Pathologic fracture of two ribs on the right chest. The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle, so the occurence of two right-sided ribs with pathological fractures resulting without evidence of trauma is related to radiation damage.

The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching? Cuddles the baby close to her. Rocks and soothes the infant in her arms. Places the infant prone in the bassinet. Wraps the baby in a warm blanket after bathing.

Places the infant prone in the bassinet. The mother should be instructed to avoid placing the infant prone which is associated with an increased incidence of sudden infant death syndrome (SIDS).

The nurse is preparing a teaching plan about sudden infant death syndrome (SIDS) for a group of new mothers. Which instruction should the nurse include? Position the infant supine for sleep. Elevate head of the crib with the infant prone. Wrap the infant snugly for rest periods. Give the infant a feeding before daily naps.

Position the infant supine for sleep. Infants who sleep supine have the lowest incidence of sudden infant death syndrome (SIDS).The other options are not indicated in the prevention of SIDS.

During the initial outbreak of genital herpes simplex for a female client, what should be the nurse's primary focus in planning care? Promotion of comfort. Prevention of pregnancy. Instruction in condom use. Information about transmission.

Promotion of comfort. The initial outbreak of genital herpes simplex in a woman causes severe discomfort. Promotion of comfort is the first priority.

Preoperative nursing care for a child with Wilms' tumor should include which intervention? Gently percuss the abdomen for evidence of trapped air. Observe the abdomen for any noticeable discolorations. Apply cold compresses to the abdomen to reduce edema. Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN."

Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN." Prevention of abdominal palpation minimizes the risk of rupturing the encapsulated tumor and subsequent metastasis.

The nurse is working in a community clinic that serves a population comprised mainly of migrant families. In planning the use of resources for secondary prevention, which activity should be the priority? Skin testing for tuberculosis. Glucose monitoring for diabetes. Blood work for cardiovascular disease. Height and weight for altered nutrition.

Skin testing for tuberculosis. Secondary prevention focuses on health promotion, which includes screening, early detection and diagnosis of disease. Among migrant families, tuberculosis rates are unusually high and should be a priority focus for secondary prevention. Although the other options are important screenings, the incidence and the risk for spread of tuberculosis is a priority in this population.

Which topic should the nurse include in planning a primary prevention class for adolescents? Risk factors for heart disease. Dietary management of obesity. Suicide risks and prevention. Coping with stressful situations.

Suicide risks and prevention. Primary prevention focuses on health promotion and prevention of injury and illness.Since suicide is a leading cause of death in adolescents, including suicide risks and prevention is essential. Health screenings and interventions are designed to increase the probability of early diagnosis and treatment therefore,the other options are not indicated because they are secondary prevention topics for adolescents.

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) Select all that apply Some correct answers were not selected Mood swings. Panic attacks. Tearfulness. Decreased need for sleep. Disinterest in the infant.

Tearfulness. "Postpartum blues" is a common emotional response related to the rapid decrease in placental hormones after delivery and include mood swings, tearfulness, feeling low, emotional, and fatigued.

A client who reports feeling depressed tells the nurse on admitted, "I want to feel normal again." How should the nurse respond? How long have you felt this way? We are all here to help you get better. What do you think the hospital can do for you? Tell me more about how things are with you.

Tell me more about how things are with you. When a client offers psycho-emotional complaints as the reason for admission, open-ended statements that seek clarification and elaboration provide the nurse with information about the client's life experiences that helps the nurse empathize, establish rapport, and support the client while reexamining and expressing feelings. The other responses do not allow the client to vent and is not therapeutic.

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A college-age track runner with a sprained ankle. A lactating woman nursing her 3-day-old infant. A school-aged child with Type 2 diabetes. An elderly man being treated for a peptic ulcer.

A lactating woman nursing her 3-day-old infant. A lactating woman has the greatest need for additional protein intake. Orthopedic injuries, type 2 diabetes, and peptic ulcers are all conditions that require protein, but do not have the increased metabolic protein demands of lactation.

A client who has been taking levodopa PO TID to control the symptoms of Parkinson's disease has a new prescription for sustained release levodopa/carbidopa (Sinemet 25/100) PO BID. The client took his levodopa at 0800. Which instruction should the nurse include in the teaching plan for this client? "Take the first dose of Sinemet today, as soon as your prescription is filled." "Since you already took your levodopa, wait until tomorrow to take the Sinemet." "Take both drugs for the first week, then switch to taking only the Sinemet." "You can begin taking the Sinemet this evening, but do not take any more levodopa."

"You can begin taking the Sinemet this evening, but do not take any more levodopa." Carbidopa significantly reduces the need for levodopa in clients with Parkinson's disease, so the new prescription should not be started until eight hours after the previous dose of levodopa, but can be started the same day.

Which client is at highest risk for compromised psychological adjustment after a hysterectomy? A 46-year-old woman with three children and a recent promotion at work. A 55-year-old woman with abnormal bleeding and pain for 3 years. A 62-year-old widow who has three friends who had uncomplicated hysterectomies. A 29-year-old woman whose uterus ruptured after giving birth to her first child.

A 29-year-old woman whose uterus ruptured after giving birth to her first child. The client who is a primipara and is still in her childbearing years and is at highest risk for unresolved conflicts about the end of her childbearing opportunities.

Which nursing intervention is the priority during the fourth stage of labor? Promote bonding. Assess for hemorrhage. Provide comfort measures. Monitor uterine contractions.

Assess for hemorrhage. The fourth stage of labor starts after delivery of the placenta which leaves open uterine wall sinuses subject to bleeding. The main focus of the fourth stage is to monitor vital signs and assess for vaginal hemorrhage (B). Although promoting bonding (A) and providing comfort measures (C) are important, assessing for bleeding during the first hours after delivery is the highest priority. Although "after-pains" can occur after delivery, regular uterine contractions have ceased during the fourth stage (D).

When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? At 16-weeks gestation. At 20-weeks gestation. At 24-weeks gestation. At 30-weeks gestation.

At 30-weeks gestation. Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy when they are psychologically ready for the termination of the pregnancy, and the birth of their child is an immediate concern.

A client who has Trichomonas vaginalis receives a prescription for metronidazole (Flagyl). Which instruction should the nurse provide during client education? Do not ingest with diary products. Notify the clinic if the urine changes color. Obtain liver function tests every 3 months. Avoid over-the-counter antitussives.

Avoid over-the-counter antitussives. Flagyl can produce a disulfiram (Antabuse)-like reaction when combined with products containing alcohol, such as over-the-counter cough remedies, so the client should be informed to avoid ingesting any alcohol product during the use of Flagyl.

Which medications should the nurse caution the client about taking while receiving an opioid analgesic? Antacids. Benzodiazepines. Antihypertensives. Oral antidiabetics.

Benzodiazepines. Respiratory depression increases with the concurrent use of opioid analgesics and other central nervous system depressant agents, such as alcohol, barbiturates, and benzodiazepines. Antacids and antidiabetic agents do not interact with opiates to produce adverse effects. Antihypertensives may cause morphine-induced hypotension, but should not be withheld without notifying the healthcare provider.

A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? Biophysical profile (BPP). Ultrasound for fetal anomalies. Maternal serum alpha-fetoprotein (AF) screening. Percutaneous umbilical blood sampling (PUBS).

Biophysical profile (BPP). A BPP (biophysical profile) provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate. The client's gestation has progressed past the estimated date of confinement, so the major concern is fetal well-being related to an aging placenta, not screening for fetal anomalies.

While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding? Molding. Hemangioma. Cephalohematoma. Caput succedaneum.

Caput succedaneum. Caput succedaneum (D) is characterized by swelling of the soft tissues of the scalp that extends across suture lines. Molding (A) of the head results from adjustment of the infant's skull structure, which allows for the passage of the infant's head through the birth canal and is a common occurence in vaginal deliveries. Hemangioma (B) is a collection of blood vessels close to the skin. Cephalohematoma (C) is an edematous area caused by extravasation of blood between the skull bone and periosteum and does not cross the suture lines, which differentiates it from caput succedaneum.

A multigravida client arrives at the labor and delivery unit and tell the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next? Complete a sterile vaginal exam. Take maternal temperature every 2 hours. Prepare for an immediate cesarean birth. Obtain sterile suction equipment.

Complete a sterile vaginal exam. A vaginal exam should be performed after the rupture of membranes to determine the presence of a prolapsed cord.

A client who is breastfeeding develops engorged breasts on the third postpartum day. Which action should the nurse recommend to relieve breast engorgement? Avoid pumping her breasts. Continue breastfeeding every 2 hours. Skip a feeding to rest the breasts. Decrease fluid intake for at least 24 hours.

Continue breastfeeding every 2 hours. Breastfeeding every 2 hours should decrease the engorgement (B) and promote lactation that equals the neonate's demands. Skipping feedings (C) increases the symptoms of engorgement and may subsequently reduce milk production. Using a breast pump increases the amount of milk expressed which decreases engorgement and discomfort, so the client should be encouraged to pump, not (A). Decreasing fluid intake (D) does not alleviate the breast engorgement and is not recommended.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness? Wear a cotton bra. Increase nursing time gradually. Correctly place the infant on the breast. Manually express a small amount of milk before nursing.

Correctly place the infant on the breast. The most common cause of nipple soreness is incorrect positioning of the infant on the breast, e. g., grasping too little of the areola or grasping only the nipple.

Which postmenopausal client's complaint should the nurse refer to the healthcare provider? Breasts feel lumpy when palpated. History of white nipple discharge. Episodes of vaginal bleeding. Excessive diaphoresis occurs at night.

Episodes of vaginal bleeding. Postmenopausal vaginal bleeding may be an indication of endometrial cancer, which should be reported to the healthcare provider.

A client in active labor at 39-weeks gestation tells the nurse she feels a wet sensation on the perineum. The nurse notices pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal distress, what action should the nurse implement? Escort the client to the bathroom. Offer the client a bed pan. Perform a nitrazine test. Clean the perineal area.

Perform a nitrazine test. The normal characteristic of amniotic fluid is pale, straw-colored fluid, which may contain white flecks of vernix, with an alkaline pH, so (C) should be done to confirm the pH of the fluid. (A or B) may be indicated if the fluid is urine. (D) should be done after determining the type of fluid expelled.

A client at 35-weeks gestation visits the clinic for a prenatal check-up. Which complaint by the client warrants further assessment by the nurse? Periodic abdominal pain. Ankle edema in the afternoon. Backache with prolonged standing. Shortness of breath when climbing stairs.

Periodic abdominal pain. Abdominal pain (A) may indicate preterm labor or placental abnormalities, so specific information should be gathered about the intensity, location, and circumstances surrounding the pain. (B, C, and D) are expected findings at 35-weeks.

When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement? Record weight daily. Assess for signs of anemia. Document sleeping patterns. Teach parenting skills.

Record weight daily. The most definitive measure of improved nutrition in an infant is obtaining the infant's daily weight at the same time and ideally using the same scale and the infant fully naked.

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? The client's readiness to learn. The client's educational background. The order in which the information is presented. The extent to which the pregnancy was planned.

The client's readiness to learn. When teaching any client, readiness to learn is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be "ready to learn" about labor and delivery, but is probably very "ready to learn" about ways to relieve morning sickness.

A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply.) Select all that apply Dark, red vaginal bleeding. Lower back pain. Premature rupture of membranes. Increased uterine irritability. Bilateral pitting edema. A rigid abdomen.

The symptoms of abruptio placentae include dark red vaginal bleeding (A), increased uterine irritability (D), and a rigid abdomen (F). (B, C, and E) are findings not associated with abruptio placentae.

A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. What information is best for the nurse to provide? (Select all that apply.) Select all that apply Some correct answers were not selected Only marijuana cigarettes affect sperm count. Smoking can decrease the quantity and quality of sperm. The first semen analysis should be repeated to confirm sperm counts. Cessation of smoking improves general health and fertility. Sperm specimens should be collected in 2 subsequent days.

The use of tobacco, alcohol, and marijuana may affect a man's sperm counts.

The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? Two vessels: one artery and one vein. Two vessels: two arteries and no veins. Three vessels: two arteries and one vein. Three vessels: two veins and one artery.

Three vessels: two arteries and one vein. The normal umbilical cord contains three vessels: two arteries and one vein.

Which common side effect should the nurse alert a female client about when medroxyprogesterone (Depo-Provera) is prescribed? Leg or calf pain. Headaches or visual changes. Vaginal bleeding after discontinuing the medication. Jaundice during the first 3 weeks of administration.

Vaginal bleeding after discontinuing the medication. Approximately 3 to 7 days after the last cyclic dose of medroxyprogesterone, a female client may experience withdrawal vaginal bleeding.

The father of a newborn tells the nurse, "My son just died." How should the nurse respond? "I am sorry for your loss." "There is an angel in heaven." "I understand how you feel." "You can have other children."

"I am sorry for your loss." The nurse should acknowledge the loss with a simple but sincere comment, such as (A), which validates the experience and recognizes the feelings of the parents. Clich s (B and C) or advice (D) do not encourage the bereaved parents to tell their stories but can stifle the further expression of emotion.

A 30-year-old multiparous woman who has a 3-year-old boy and a newborn girl tells the nurse, "My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get home." How should the nurse respond? "Tell the older child that he is a big boy now and should love his new sister." "Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him." "Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn." "Regression in behaviors in the older child is a typical reaction so he needs attention at this time."

"Regression in behaviors in the older child is a typical reaction so he needs attention at this time." Preschool-aged children frequently regress in habits or behaviors, such as toileting and sleep habits, as a method of seeking attention, so the parents should distribute their attention between the children and include the preschooler during infant care.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best? "This is not an unusual shaped head, especially for a first baby." "It may look funny to you, but newborn babies are often born with heads like your baby's." "That is normal; the head will return to a round shape within 7 to 10 days." "Your pelvis was too small, so the baby's head had to adjust to the birth canal."

"That is normal; the head will return to a round shape within 7 to 10 days." Reassuring the mother that this is normal for a newborn head to have that appearance and provide correct information regarding the return to a "normal" shape is the best response.

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. When preparing to document the client's delivery history, it is important for the nurse to document in the client's record which GTPAL history? 3-1-2-0-3. 4-1-2-0-3. 2-1-2-1-2. 3-1-1-0-3.

3-1-1-0-3. The correct GTPAL is 3-1-1-0-3. The client has been pregnant 3 times which includes the current pregnancy (G-3), in addition, she had one full-term infant (T-1) and also had a preterm (P-1) twin pregnancy (a multifetal gestation is considered one birth when calculating parity). The client denied history of abortions (A-0), so this client has a total of 3 living children.

A newborn infant who is 24-hours-old is on a 4-hour feeding schedule of formula. To meet daily caloric needs, how many ounces are recommended at each feeding? 2 ounces. 4 ounces. 1.5 ounces. 3.5 ounces.

3.5 ounces. A newborn requires approximately 19 to 21 ounces of formula each day (six feedings per 24-hour period x 3.5 = 21). One-and-a-half to two ounces (A and C) may be insufficient to meet the newborn's calorie needs. (B) may cause the infant to spit-up due to over-feeding.

As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider? A 6-month-old with failure to thrive that has a closed anterior fontanel. A 24-month-old with gastroenteritis that has a closed posterior fontanel. A 2-month-old with chickenpox that has an open posterior fontanel. A 28-month-old with hydrocephalus that has an open anterior fontanel.

A 6-month-old with failure to thrive that has a closed anterior fontanel. At six months of age the anterior fontanel should be open, and it should not be closed until approximately 18 months of age. Premature closure of the fontanels is a condition called "craniosynostosis". The only treatment for this condition is surgery to reopen the fontanels, to allow and accommodate the infant's growing brain, otherwise if not surgical corrected, the infant will suffer severe neurological damage.

The nurse is assessing a client who is admitted with a diagnosis of depression. Which findings is characteristic of depression? Grandiose ideation. Self-destructive thoughts. Suspiciousness of others. A negative view of self and the future.

A negative view of self and the future. Negative self-image and feelings of hopelessness about the future are specific findings in depression. The other findings are not the underlying manifestations in depression.

The nurse is screening children at a local community health clinic for infectious diseases. Which child is at highest risk for hepatitis B virus (HBV)? A newborn. A 3-year-old. A 7-year-old. An 11-year-old.

A newborn. The highest incidence of HBV in children occurs in newborns (A) who acquire the infection perinatally from mothers who are HBV positive. (B, C, and D) are also at risk for contracting HBV if they are in contact with infected blood or blood products, but the newborn whose mother is HBV positive is at greatest risk because of recent contact with maternal blood during delivery.

The nurse is teaching a primigravida at 10-weeks gestation about the need to increase her intake of folic acid. Which explanation should the nurse provide that supports preventative perinatal care? The risk for neonatal cerebral palsy increases with folic acid deficiencies during pregnancy. Folic acid can significantly reduce the incidence of mental retardation. Adequate folic acid during embryogenesis reduces the incidence of neural tube defects. The incidence of congenital heart defects is related to folic acid intake deficiencies.

Adequate folic acid during embryogenesis reduces the incidence of neural tube defects. Folic acid can significantly reduce neural tube defects (C) if taken during early pregnancy. (A, B, or D) are not valid explanations.

An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement? Administer acetylcysteine (Mucocyst). Monitor cardiac rhythm for flat T waves. Check both serum AST and ALT levels. Prepare to administer Syrup of Ipecac.

Administer acetylcysteine (Mucocyst). Tylenol overdose is treated with immediate administration of Mucomyst to prevent hepatic insult. The other actions are not indicated.

The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The infant expels a bloody stool. What nursing action should the nurse implement? Institute contact precautions. Obtain a rectal temperature. Assess for abdominal distention. Decrease the amount of the feeding.

Assess for abdominal distention. Etiological factors playing an important role in the development of necrotizing enterocolitis (NEC), a complication common in premature infants, include intestinal ischemia, colonization by pathogenic bacteria, and substrate (formula feeding) in the intestinal lumen. Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of NEC. Nursing responsibilities include measuring the abdomen (C) and listening for bowel sounds. Contact precautions (A) are necessary if a contagious gastrointestinal infection is suspected. Rectal temperatures are contraindicated (B) because of the risk for perforation of the bowel. Oral or gavage feeding is stopped, not (D), until necrotizing enterocolitis is ruled out.

A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit? Choking, coughing, and cyanosis. Projectile vomiting and cyanosis. Apneic spells and grunting. Scaphoid abdomen and anorexia

Choking, coughing, and cyanosis. The "3 Cs" of esophageal atresia are coughing, chocking and cyanosis. They are caused by the overflow of secretions into the trachea.

A client on the mental health unit reports concerns about weight gain as a result of taking divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate a referral to which healthcare team member? Occupational therapist. Recreational therapist. Dietician. Physician.

Dietician. The nurse should ask for a referral to the dietician who can assist the client with meal planning for weight reduction. The other members of the healthcare team do not give guidance about meal planning.

The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? Begin as soon as your baby is born to establish a four-hour feeding schedule. Resting helps with milk production. Ask that your baby be fed at night in the nursery. Feed your baby every 2 to 3 hours or on demand, whichever comes first. Do not allow your baby to nurse any longer than the prescribed number of minutes.

Feed your baby every 2 to 3 hours or on demand, whichever comes first. Breastfeeding infants should be kept in the room with the mother and fed every 2 to 3 hours or on demand--whichever comes first.

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) Select all that apply Some correct answers were not selected Admission weight of 4 pounds, 15 ounces ( 2244 grams). Head to heel length of 17 inches (42.5 cm). Frontal occipital circumference of 12.5 inches (31.25 cm). Skin smooth with visible veins and abundant vernix. Anterior plantar crease and smooth heel surfaces. Full flexion of all extremities in resting supine position.

Head to heel length of 17 inches (42.5 cm). Frontal occipital circumference of 12.5 inches (31.25 cm). The normal full-term, appropriate for gestational age (AGA) newborn should fall between the measurement ranges of weight, 6-9 pounds (2700-4000 grams); length, 19-21 inches (48-53 cm); FOC, 13-14 inches (33-35 cm).

When evaluating maternal bonding, which of the following maternal behaviors exhibited by the client would the nurse most likely expect to see when a new mother receives her infant for the first time? She eagerly reaches for the infant, undresses the infant, and examines the infant completely. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. Her arms and hands receive the infant and she then cuddles the infant to her own body. She eagerly reaches for the infant and then holds the infant close to her own body.

Her arms and hands receive the infant and she then traces the infant's profile with her fingertips Attachment/bonding theory indicates that most mothers will demonstrate behaviors such as tracing the infant's profile with her fingertips during the initial visit with the newborn, which may be at delivery or later.

Which nursing intervention is most important when caring for a client receiving the antimetabolite cytosine arabinoside (Arc-C) for chemotherapy? Hydrate the client with IV fluids before and after infusion. Assess the client for numbness and tingling of extremities. Inspect the client's oral mucosa for ulcerations. Monitor the client's urine pH for increased acidity.

Inspect the client's oral mucosa for ulcerations. Cytosine arabinoside (Arc-C) affects the rapidly growing cells of the body, therefore stomatitis and mucosal ulcerations are key signs of antimetabolite toxicity.

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pad are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? Cleanse the perineum. Obtain a blood pressure. Palpate the firmness of the fundus. Inspect the perineum for lacerations.

Palpate the firmness of the fundus. A firm uterus is needed to control bleeding from the placental site of attachment on the uterine wall. The nurse should first assess for firmness and massage the fundus as indicated.

A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. Which assessment finding would provide the nurse the earliest indication that the client is experiencing primary side effects of terbutaline sulfate? Drowsiness and bradycardia. Depressed reflexes and increased respirations. Tachycardia and a feeling of nervousness. A flushed, warm feeling and a dry mouth.

Tachycardia and a feeling of nervousness. Terbutaline sulfate (Brethine), a beta-sympathomimetic drug which stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of "nervousness".

A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide? Many women imagine what their baby is like by interpreting fetal movements. The fetus in utero is capable of hearing and does respond to the mother's voice. The healthcare provider should address her concerns about her baby's hearing function. The interaction between the mother's voice and the fetus's response ensures bonding.

The fetus in utero is capable of hearing and does respond to the mother's voice. Fetal hearing and response to sound occurs by 24-weeks gestation, so the fetus can be soothed by the familiar sound of the mother's voice (B). There is no evidence to support the validity of maternal intuition about maternal-fetal relationships (A and D). (C) does not provide the mother with reassuring information.

A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? The length of labor and method of delivery. The infant's condition at birth and treatment received. The feeding method chosen by the parents. The history of drugs given to the mother during labor.

The infant's condition at birth and treatment received. Immediate care is most dependent on the infant's current status (i.e., Apgar scores at 1 and 5 minutes) and any treatment or resuscitation that was indicated.

A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching? When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection. While I am on vacation and when I return, I will not eat or drink anything that contains alcohol. I will notify the healthcare provider if I have a sore throat or flu-like symptoms. I will continue to take my benztropine mesylate (Cogentin) every day.

When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection. Photosensitivity is a side effect of Prolixin and a vacation in a tropical climate increases the client's chance of experiencing this side effect. The nurse should teach the client to avoid direct sun and wear sunscreen. The other client statements do not indicate the need for further teaching.

A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide? Estrogen deficiency causes the vaginal tissues to become dry and thinner. Infrequent intercourse results in the vaginal tissues losing their elasticity. Dehydration from inadequate fluid intake causes vulva tissue dryness. Lack of adequate stimulation is the most common reason for dyspareunia.

Estrogen deficiency causes the vaginal tissues to become dry and thinner. Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells, so vaginal tissues tend to become thinner, drier, and the rugae become smoother which reduces vaginal stretching that contributes to dyspareunia. The discomfort during intercourse, primary cause can be contributed to the decrease in estrogen hormone levels.

A client in active labor complains of cramps in her leg. What intervention should the nurse implement? Ask if she takes a daily calcium tablet. Extend the leg and dorsiflex the foot. Lower the leg off the side of the bed. Elevate the leg above the heart.

Extend the leg and dorsiflex the foot. Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable) (B), and putting the heel of the foot on the floor is the best means of relieving leg cramps. (A) is not related to leg cramps caused by reduced circulation to the foot. (C) is not likely to be helpful. (D) is used to promote venous return, but is not indicated for leg cramps.

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? Herpes. Staphylococcus. Gonorrhea. Syphilis.

Gonorrhea. Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmica neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia.

A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action? Assess newborn reflexes for signs of neurological impairment. Leave the infant in the room with the mother to foster attachment. Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia. Perform a gestational age assessment to determine if the infant is large-for-gestational-age.

Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia. The infant's birth weight falls within the parameter (4000 grams or greater) for a large-for-gestational-age (LGA) infant and should be assessed for hypoglycemia (C) and trauma. Early recognition of hypoglycemia requires immediate intervention and takes precedence over assessing newborn reflexes (A). Although the infant may remain in the room with the mother (B), frequent assessments of the newborn should be performed. Additional assessment tools (D) can be used after serum glucose levels are determined (C).

When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it increases salivation. increases the respiratory rate. leads to vomiting. stresses the suture line.

stresses the suture line. Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft lip repair.

When evaluating a laboring client's progress, which finding would be an indicative to the RN to encourage the client to begin pushing there is only an anterior or posterior lip of cervix left. the client describes the need to have a bowel movement. the cervix is completely dilated. the cervix is completely effaced.

the cervix is completely dilated. Pushing begins with the second stage of labor, i.e., when the cervix is completely dilated at 10 cm. If pushing begins prior to the cervix being completely dilated, the cervix can become edematous and may never completely dilate thus resulting in an operative delivery.

A female adult walks into a local community health clinic and tells the nurse that she is homeless and cannot seem to find help. Which statement indicates to the nurse that a client is feeling separated from society and hopeless? "I'm feeling really isolated from everyone and scared." "I feel like I cannot get enough food to live any longer." "I know that I will always be poor so what's the use of trying?" "People like me are never respected, no matter how well we do."

"I'm feeling really isolated from everyone and scared." Disenfranchisement refers to a feeling of separation from society (A). (B) is indicative of anxiety with possibly suicidal ideations. (C) indicates a "giving up-giving in" attitude. (D) might be indicative of depression, and additional assessment is needed to determine the client's feelings and degree of risk for self-harm or harm to others.

The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide? "She is almost sure to be less able to adapt than before." "It's highly likely that she will recover and return to her pre-illness state." "If you can interest her in something besides religion, it will help her stay well." "Cultural strains contribute to each woman's tendencies for recurrences of depression."

"It's highly likely that she will recover and return to her pre-illness state." Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested development of normal interpersonal skills. Erikson describes the successful resolution of a developmental crisis in the later years (older than 65-years) to include the achievement of a sense of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and accept the death of others (B). Depression is a component of normal grieving, and (A) does not represent susceptible adaptation to the developmental crisis of an older adult, "Integrity vs despair." (C and D) are judgmental and not therapeutic.

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) Select all that apply Some correct answers were not selected Litmus paper. Fetal scalp electrode. A sterile glove. An amniotic hook. Sterile vaginal speculum. A Doppler.

A single sterile glove, an amniotic hook , and Doppler are needed to check fetal heart tones are the necessary equipment for performing an amniotomy.

An emergency room anticipates an influx of injured clients from a large motor vehicle collision on a major freeway. Which client should the triage nurse send to the trauma staff for immediate intervention? A young adult male with a suspected closed head injury who has no respirations despite having his airway repositioned by the emergency medical team. An adult with a suspected intraabdominal bleed who was not breathing on arrival, but is currently responding since repositioning the airway. A teenager with a suspected fractured left leg whose respirations are 26 breaths/minute, capillary refill <2 seconds, and who can follow simple commands. A young adult with a facial laceration that is controlled by pressure and whose respiratory rate, capillary refill, and ability to follow commands are all WNL.

An adult with a suspected intraabdominal bleed who was not breathing on arrival, but is currently responding since repositioning the airway. A client with a suspected intraabdominal bleed who was not breathing on arrival, but is currently responding since repositioning the airway will be red tagged and attended to immediately.Red tagged clients have life-threatening injury and they require immediate treatment.

The nurse directs an unlicensed assistive personnel (UAP) to obtain the vital signs for a client who returns to the unit after having a mastectomy for cancer. What information should the nurse provide the UAP? Elevate the arm with an IV infusing on the operative side with a pillow. Apply the blood pressure cuff to the arm on the non-operative side. Position the arm on the operative side close to the body. Collect a fingerstick blood specimen from the arm on the operative side.

Apply the blood pressure cuff to the arm on the non-operative side. The nurse give the UAP the following instructions when providing care to a post-op mastectomy client. Blood pressure readings should be obtained from the arm on the nonoperative side to reduce the risk of injury of the extremity that may have compromised lymphatic drainage postoperatively. The arm on the operative side of the mastectomy should be elevated on a pillow above the level of the right atrium to facilitate lymphatic drainage.

The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take? Check the client for urinary bladder distention. Notify the healthcare provider of the nonreactive results. Have the mother stimulate the fetus to move. Ask the client if she has felt any fetal movement.

Ask the client if she has felt any fetal movement. The client should be asked if she has felt the fetus move. An NST is used to determine fetal well-being, and is often implemented when postmaturity is suspected. A "reactive" NST occurs if the FHR accelerates 15 bpm for 15 seconds in response to the fetus' own movement, a78 nd is "nonreactive" if no FHR acceleration occurs in response to fetal movement.

A client who had a miscarriage at 10-weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client's statements, which action should the nurse implement? Ready the client for discharge. Notify pastoral care to offer the client a blessing. Ask the client what name she had picked out for the infant. Inquire if the client would like to see what was obtained from her D&C.

Ask the client what name she had picked out for the infant. The client's cues about her preparation for the baby indicate her need to express her feelings of loss, so encouraging further discussion about the infant's name provides an opportunity to offer support. The other actions are not indicated.

The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first? Check the infant's arterial blood gases. Notify the pediatrician of the infant's vital signs. Assess the infant's blood glucose level. Encourage the infant to take the breast or sugar water.

Assess the infant's blood glucose level. The nurse should first assess the infant's blood glucose level (C), because the infant is displaying signs of hypothermia (normal newborn axillary temperature is 96 to 98 F) and hypoglycemia may occur as glucose is metabolized in an effort to meet cellular energy demands. The infant's respiratory and heart rates are within normal limits, so (A) is not a priority. (B and D) would be implemented after information regarding the blood sugar level has been obtained.

The multidisciplinary home health care team is discussing a female client diagnosed with Parkinson's disease. The home health care nurse reports the client is getting worse and her husband is no longer able to care for her in the home. Which action should the home health nurse implement first? Request a chaplain to counsel with the couple. Assign a home health care aide to provide care daily. Talk to the husband about placing his wife in a nursing home. Contact the client's children to discuss the situation.

Assign a home health care aide to provide care daily. The nurse should first ensure the client's safety by providing assistance in the home which will help both the client and her husband until other arrangements can be made.

The nurse is caring for a client receiving tamoxifen (Nolvadex) for the treatment of breast cancer. Which action should the nurse include in the client's plan of care? Increase fluid intake. Monitor sodium chloride intake. Assist the client in coping with hot flashes. Encourage milk products to increase calcium intake.

Assist the client in coping with hot flashes. Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so client education regarding menopausal-like symptoms should be included in the plan of care.

Which assessment finding should the nursery nurse report to the pediatric healthcare provider? Blood glucose level of 45 mg/dl. Blood pressure of 82/45 mmHg. Non-bulging anterior fontanel. Central cyanosis when crying.

Central cyanosis when crying. An infant who demonstrates central cyanosis when crying is manifesting poor adaptation to extrauterine life which should be reported to the healthcare provider for determination of a possible underlying cardiovascular problem. The other options are expected findings in newborn.

While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document? Molding. Cephalohematoma. Caput succedaneum. Bulging fontanel.

Cephalohematoma. A cephalohematoma (B) should be documented because it is a collection of blood beneath the periosteum of the cranial bone causing scalp swelling that does not cross the suture line. Molding (A) is overlapping of cranial bones that occurs as the fetal head accommodates for the descent through the vaginal vault. Caput succedaneum (C) is differentiated from a cephalohematoma by generalized edematous swelling of the presenting part of the head. Fontanel tension should feel slightly concave and well defined against the edges of the cranial bones, whereas a bulging anterior fontanel (D) is tense and distends from an increased intracranial pressure, such as seen in congenital hydrocephalus.

Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation? Decrease in pulse rate. Decrease in blood pressure. Increase in heart sounds (S1, S2). Increase in red blood cell production.

Decrease in pulse rate. Between 14 and 20 weeks gestation, the pulse increases about 10 to 15 beats/minute, which persists to term, so a decrease (A) should be assessed further. During the second trimester, both systolic and diastolic pressures decrease by about 5 to 10 mm Hg (B), a more audible splitting of S1 and S2 occurs (C), and there is an accelerated production of red blood cells (D).

A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response? Explain the effect of the follicle-stimulating and luteinizing hormones. Discuss perimenopause and related comfort measures. Assess lung fields and for a cough productive of blood-tinged mucous. Ask if a fever above 101 F (38.3 C) has occurred in the last 24 hours.

Discuss perimenopause and related comfort measures. The perimenopausal period begins about 10 years before menopause with the cessation of menstruation at the average ages of 52 to 54. Lower estrogen levels causes FSH and LH secretion in bursts (surges), which triggers vasomotor instability, night sweats, and hot flashes, so discussions about the perimenopausal body's changes, comfort measures, and treatment options should be provided.

When teaching a client with breast cancer about the prescribed radiation therapy for treatment, what information is important to include? Dry, itchy skin changes may occur. There is a possibility of long bone pain. Permanent pigment changes to the breast may result. A low-residue diet may be ordered to reduce the likelihood of diarrhea.

Dry, itchy skin changes may occur. Side effects from radiation to the breast most often include temporary skin changes such as: dryness, tenderness, redness, swelling, and pruritis.

The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling's repeated hospitalizations. Which is the best response that the nurse should offer? Inform the parent that the other children are too young to visit the hospital. Suggest that the other children visit a grandmother until the sibling returns home. Ask the mother if the children ask when the sibling will be discharged. Encourage the mother to have the children visit the hospitalized sibling.

Encourage the mother to have the children visit the hospitalized sibling. Siblings of a sick child will often be scared, concerned or confused. Needs of a sibling will be better met with factual information and contact with the ill child, so sibling visitation should be encouraged. Children may have difficulty expressing concerns, so the support of parents and other caregivers are needed to help alleviate their fears.

The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to make? Inform the mother that the injection was prescribed by the healthcare provider. Explore the mother's concerns about the infant receiving an injection of vitamin K. Explain that vitamin K is required by state law and compliance is mandatory. Remind the mother that all babies receive this shot and it is relatively painless.

Explore the mother's concerns about the infant receiving an injection of vitamin K. This mother's concerns should be explored (B) and any misconceptions cleared up before the vitamin K is injected. (A and C) are true but do not communicate the importance of vitamin K administration. Also, parents have the right to refuse the injection by signing a refusal form. (D) is providing false reassurance--all injections cause pain.

The nurse observes a male newborn who is displaying a rigid posture with his eyes tightly closed and grimacing as he is crying after an invasive procedure. The baby's blood pressure is elevated on the Dinamap display. What action should the nurse implement? Obtain a serum glucose level. Give the infant medication for pain. Feed the newborn 1 ounce of formula. Request a genetic consultation.

Give the infant medication for pain. A cry face (or crying with the eyes squeezed or closed tightly), a rigid posture, and an increase in blood pressure are indicative of pain in the neonate, so analgesia should be given for pain (B). The symptoms of hypoglycemia (A) are jitteriness and mottling. The signs of hunger include rooting, tongue extrusion and possibly crying (C). A high-pitched shrill cry is associated with neurologic and genetic anomalies (D).

The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns that the client has secondary syphilis. What precaution should the nurse implement? A mask should be worn by anyone entering the client's room. Handwashing is required before and after contact with the client. Gloves should be worn during direct contact with the client's skin. No precautions in addition to standard precautions are necessary.

Gloves should be worn during direct contact with the client's skin. The secondary stage of syphilis is a systemic blood-borne disease that presents with skin lesions and rashes that may drain the highly contagious spirochete, so gloves should be worn during direct contact with the client's skin. The client should be placed on "contact precautions".

A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? Frequent urinary tract infections. Inability to get pregnant. Premenstrual syndrome. Chronic use of laxatives.

Inability to get pregnant. Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility is another common finding associated with endometriosis.

A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? Length of labor and method of delivery. Infant's condition at birth and treatment received. Feeding method chosen by the parents. History of drugs given to the mother during labor.

Infant's condition at birth and treatment received. Immediate care is most dependent on the infant's current status (i. e., Apgar scores at 1 and 5 minutes) and any treatment or resuscitation that was indicated.

The nurse is caring for an irritable, lethargic 18-month-old child who swallowed several over-the-counter (OTC)antihistamine tablets an hour ago. What intervention should the nurse implement? Initiate gastric lavage. Administer naloxone. Give a dose of ipecac syrup. Encourage oral intake of water or milk.

Initiate gastric lavage. Gastric lavage should be implemented within 2 hours of ingestion to ensure gastric removal of a non-corrosive substance, such as an OTC antihistamine.

A 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? Supplementary iron is more efficiently utilized during pregnancy. It is difficult to consume 18 mg of additional iron by diet alone. Iron absorption is decreased in the GI tract during pregnancy. Iron is needed to prevent megaloblastic anemia in the last trimester.

It is difficult to consume 18 mg of additional iron by diet alone. Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and to meet the demands of pregnancy is difficult so iron supplements are often recommended.

A mother brings her 6-month-old infant to the clinic for a well-child checkup. She comments, "I want to go back to work, but I don't want my baby to suffer because I'll have less time at home." How should the nurse respond to the mother? Stay home until the child starts school. Find a good baby-sitter close to the house. Let's talk about the child care options that are best for the child. Go back to work now so the infant will get used to being with others.

Let's talk about the child care options that are best for the child. It is common for mothers to feel torn between their work and child and to have feelings of guilt. The nurse should assist the mother to explore her feelings on the subject while focusing on the optimal, appropriate, safe, and available options for her child.

A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug? Maternal blood pressure and respirations. Maternal and fetal heart rates. Hourly urinary output. Deep tendon reflexes.

Maternal and fetal heart rates. Terbutaline has effects on receptors. It acts as a sympathomimetic agent stimulating beta 1 receptors which cause tachycardia as a side effect and that is a reason why monitoring maternal and fetal heart rates is most important when terbutaline is being administered. It also affects beta 2 receptors which relaxes the uterus and that is the reason for its administration.

The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32-weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters the right ventricle, what is the priority nursing assessment? Assess fetal response to the procedure. Note any complaint of sudden chest pain. Monitor for premature ventricular contractions. Observe for maternal blood pressure changes.

Monitor for premature ventricular contractions. During and following the insertion of a pulmonary artery catheter (PAC), ECG activity should be monitored for the occurrence of any ventricular ectopy (C). Although fetal well-being (A) is important, the primary nursing assessment at this time is monitoring for immediate cardiac changes in the mother. Adverse cardiac responses to PAC insertion should first identify changes in the client's heart rhythm before the client complains of chest pain (B). Manual blood pressures (D) evaluate systemic perfusion, but the primary purpose in monitoring pulmonary artery pressures is to detect early cardiac changes due to left ventricular failure.

An infant with hyperbilirubinaemia is receiving phototherapy. What intervention should the nurse implement? Maintain NPO status. Monitor temperature. Apply skin lotion as prescribed. Change T-shirt every 3 hours.

Monitor temperature. Minor side effects of phototherapy include loose, green stools, transient rashes, hyperthermia, increased metabolic rate, dehydration, electrolyte disturbances, and priapism. Regular monitoring of the infant's temperature (B) allows evaluation of hyperthermia and dehydration. Extra oral fluids are provided to reduce the risk of dehydration, so NPO status is not necessary (A). Skin lotion is contraindicated (C) to prevent increased tanning or an increase in heat or skin "frying" effect. Clothing reduces the area of exposed skin to the lights, so T-shirts (D) should not be worn during phototherapy.

The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which side effect reported by the client is related to administration of this drug? My mouth feels like cotton. That stuff gives me indigestion. This pill gives me diarrhea. My urine looks pink.

My mouth feels like cotton. A dry mouth is an anticholinergic response that is an expected side effect of MAO inhibitors, such as phenelzine sulfate (Nardil). The other subjective reports are not related to this medication.

What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis? Monitor for signs of metabolic acidosis. Estimate the quantity of diarrhea stools. Place in a supine position after feeding. Observe for projectile vomiting.

Observe for projectile vomiting. In pyloric stenosis, the valve between stomach and small intestine enlarges blocking the passage of food. The nurse needs to ensure suctioning equipment is closed by to help prevent aspiration from the projectile vomiting episodes and monitor for the state of metabolic alkalosis, which is a classic sign of pyloric stenosis.

Which finding for a client in labor at 41-weeks gestation requires additional assessment by the nurse? Cervix dilated 2 cm and 50% effaced. Score of 8 on the biophysical profile. Fetal heart rate of 116 beats per minute. One fetal movement noted in an hour.

One fetal movement noted in an hour. A count of less than three fetal movements within 1 hour (D) warrants further evaluation using nonstress or contraction stress testing, biophysical profile, or a combination of these tests. A cervical exam of 2 cm and 50% effacement (A) and a fetal heart rate of 116 (C) are normal findings. A score of 8 on a biophysical profile (B) indicates a normal infant with low risk for chronic asphyxia.

Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate? Tactile stimulation. Commercial warm packs. Skin-to-skin contact with parent. Oral sucrose and nonnutritive sucking.

Oral sucrose and nonnutritive sucking. Studies of nonpharmacologic interventions for pain in the newborn most frequently indicate that the administration of oral sucrose and nonnutritive sucking (D), such as the provision of a pacifier, are effective in reducing objective indicators of pain after an invasive procedure. Other interventions, such as tactile stimulation (A) during apnea and bradycardic episodes and warm packs (B) for thermoregulation, have not been shown to reduce pain responses. Skin-to-skin contact (C) fosters neurobehavioral development and supporting parent-infant intimacy and attachment, but sucking behaviors provide the most effective pain-comfort responses.

What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast? Observe cyst size fluctuations as a sign of malignancy. Use estrogen supplements to reduce breast discomfort. Notify the healthcare provider if whitish nipple discharge occurs. Perform a breast self-exam (BSE) procedure monthly.

Perform a breast self-exam (BSE) procedure monthly. Fibrocystic changes in the breast are related to excess fibrous tissue, proliferation of mammary ducts and cyst formation that cause edema and nerve irritation. These changes obscure typical diagnostic tests, such as mammography, due to an increased breast density. Women with fibrocystic breasts should be instructed to carefully perform monthly BSE and consider changes in any previous "lumpiness." Fibrocystic disease does not increase the risk of breast cancer. Cyst size fluctuates with the menstrual cycle, and typically lessens after menopause, and responds with a heightened sensitivity to circulating estrogen.

Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks gestation? Pica. Pyrosis. Ptyalism. Decreased peristalsis.

Pica. Pica (A), the consumption of low- or non-nutrient substances, may cause more nutritious foods to be displaced from the diet, and depending on the substance ingested, may be toxic or interfere with the absorption of nutrients and minerals. Pyrosis or heartburn (B), ptyalism or excessive salivation (C), and decreased peristalsis (D) are normal findings during pregnancy.

Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation? Maintain the residual limb on three pillows at all times. Place a large tourniquet at the client's bedside. Apply constant, direct pressure to the residual limb. Do not allow the client to lie in the prone position.

Place a large tourniquet at the client's bedside. A large tourniquet should be placed in plain sight at the client's bedside, in the event severe bleeding occurs. The purpose is to have the tourniquet available to applied to the residual limb to control bleeding if hemorrhaging was to occur. The residual limb should not be placed on a pillow because a flexion contracture of the hip may result and the client should be encouraged to lie in the prone position to prevent flexion contracture of the hip.

The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occurring with the peak of each contraction. What action should the nurse implement? Notify the healthcare provider of fetal status. Give oxygen at 10 L per nasal cannula. Place the client in a side-lying position. Increase the flow rate of intravenous fluids.

Place the client in a side-lying position. Variable decelerations are caused by compression of the umbilical cord and are evidenced by V shape appearance, characterized by a rapid descent and ascent to and from the depth of the deceleration. To alleviate the pressure on the umbilical cord, the nurse should reposition the client into a side-lying position (C). Once the client is repositioned and evaluated, then (A, B, and D) should be implemented.

The nurse is assisting with the triage of clients at a large community disaster and finds a man lying on the ground, who states that the blast blew him out of a second story window. Which action should the nurse implement first? Logroll the client to his side and assess for back injuries. Perform a complete neurological assessment. Open the client's airway immediately. Place the nurse's hands around client's neck to stabilize.

Place the nurse's hands around client's neck to stabilize. A nurse is assisting with Triage at a large community disaster. She finds a man lying on the ground who states that he was blown from a second story window. The nurse should provide immobilization to prevent further spinal injury. The client should not be moved until equipment is provided to immobilize the neck.

A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? Prevention of deformities. Avoidance of joint trauma. Relief of joint inflammation. Improvement in joint strength.

Prevention of deformities. Splints may be used at night by clients with rheumatoid arthritis to prevent deformities caused by muscle spasms and contractures.

An adult female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?Schedule her to attend various group activities.Reinforce her ability to make her own decisions.Encourage her to identify feelings of anger.Provide a structured environment with little stimuli.

Provide a structured environment with little stimuli. Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment. Planning noncompetitive activities that can be carried out alone help to reduce stimuli. Impulsive decision-making is characteristic of clients with bipolar disorder and require the nurse to intervene when a client is making decisions. Anger is often repressed during depression, not mania.

A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider? Blood pressure of 100/60 mm Hg. Fetal heart rate of 120 to 125 beats/minute. Contractions occurring every 30 minutes. Respiratory rate of 11 breaths/minute.

Respiratory rate of 11 breaths/minute. A sign of magnesium toxicity is respiratory depression, so the client's respiration rate of 11 breaths/minute (D) should be reported to the healthcare provider. (A, B, and C) are expected findings for a 36-week gestation client with PIH.

A newborn who is breastfeeding is diagnosed with galactosemia. What action should the nurse implement? Stop the infant breastfeeding. Add amino acids to breast milk. Give galactokinase with breast milk. Substitute a lactose-containing formula.

Stop the infant breastfeeding. Galactosemia is a rare genetic disorder that involves an inborn error of carbohydrate metabolism in which a hepatic enzyme, galactokinase, involved in the conversion of galactose to glucose is absent. Treatment consists of eliminating all lactose-containing foods, including breast milk, so the infant should stop breastfeeding. Soy protein formula is the feeding of choice during infancy.

A 23-year-old client who is receiving Medicaid benefits is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client? Refer the client to a social worker to arrange for home care. Recommend perinatal care from an obstetrician, not a nurse-midwife. Teach the client why keeping prenatal care appointments is important. Advise the client that neonatal intensive care may be needed.

Teach the client why keeping prenatal care appointments is important. Regular prenatal visits should begin early in pregnancy to monitor health of the mother and development of the fetus.

A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide? Lymph node involvement is not significant. Small tumors are aggressive and indicate poor prognosis. The tumor's estrogen receptor guides treatment options. Stage I indicates metastasis.

The tumor's estrogen receptor guides treatment options. Treatment decisions and prediction of prognosis are related to the tumor's receptor status, such as estrogen and progesterone receptor status which commonly are well-differentiated, have a lower chance of recurrence, and are receptive to hormonal therapy. Tumor staging designates tumor size and spread of breast cancer cells into axillary lymph nodes, which is one of the most important prognostic factors in early-stage breast cancer.

A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. Which pattern of contractions should alert the nurse to discontinue the oxytocin infusion? Transition labor with contractions every 2 minutes, lasting 90 seconds each. Early labor with contractions every 5 minutes, lasting 40 seconds each. Active labor with contractions every 31 minutes, lasting 60 seconds each. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each.

Transition labor with contractions every 2 minutes, lasting 90 seconds each. The RN should discontinue the oxytocin infusion when it causes uterine hyperstimulation as evidenced by inadequate resting time between contractions. The oxytocin infusion should be discontinued because placental perfusion is impeded.

The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain? Type of reaction to loud noises. Any surgeries on the ears since birth. Drainage from the infant's ears. Number of ear infections since birth.

Type of reaction to loud noises. Ototoxicity diminishes hearing acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing an infant's reaction to loud noises (A) helps to determine an infant's risk for a hearing deficit related to a history of the mother taking an ototoxic drug, such as aspirin, while pregnant. (B, C, and D) are not associated with exposure to aspirin in utero.

A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity? Deep tendon reflexes 2+. Blood pressure 140/90. Respiratory rate 18/minute. Urine output 90 ml/4 hours.

Urine output 90 ml/4 hours. A client experiencing urine outputs of less than 100 ml/4 hours, absent DTRs, and a respiratory rate of less than 12 breaths/minute is exhibiting symptoms of magnisium sulfate toxicity and requires immediate attention.

A client who is sexual active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide? Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID). Getting pregnant while using an IUD is common and is not the best contraceptive choice. Relying on an IUD may be a safer choice for monogamous partners, but a barrier method provides a better option in preventing STD transmission. Selecting a contraceptive device should consider choosing a successful method used in the past.

Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID). The use of an IUD provides the client with no protection from STDs.

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs two weeks before menstruation. immediately after menstruation. immediately before menstruation. three weeks before menstruation.

two weeks before menstruation. Because menstruation varies for many women, the nurse should explain that ovulation occurs 14 days before the first day of the menstrual period.

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client? "Some care is required when touching the large soft area on top of your baby's head until the bones fuse together." "That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching the soft spot." "The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby." "There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair."

"There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair." The anterior fontanel or "large soft spot" has a strong epidermal membrane present, which can be touched. The posterior fontanel closes at 8-12 weeks. Providing this information to the client will alleviate her anxiety related to knowledge deficit

A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? Cervical dilation of 5 cm with 90% effacement. White blood cell count of 12,000/mm3. Hemoglobin of 12 mg/dl and hematocrit of 38%. A platelet count of 67,000/mm3.

A platelet count of 67,000/mm3. Thrombocytopenia (low platelet count) should be reported to the healthcare provider because it places the client at risk for bleeding when an epidural is administered.

A client at 28-weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? Contraction stress test. Internal fetal monitoring. Abdominal ultrasound. Lecithin-sphingomyelin ratio.

Abdominal ultrasound. Bright red, painless vaginal bleeding occuring after 20-weeks gestation can be an indicator of placenta previa, which is confirmed by abdominal ultrasound (C). (A, B and D) are invasive procedures that increase the risk for premature onset of labor, and are not indicated at this client's gestation.

The mother of a 12-year-old child tells the school nurse that her child refuses to go to school because of vague physical complaints that the healthcare provider indicates have no physiological basis. What action should the nurse take first? Evaluate the child's pattern of interacting with teachers and peers. Determine if homework assignments are too stressful for the child. Ask the mother if the child's sleep patterns have recently changed. Discuss with the child her perceptions of stressors in the home.

Ask the mother if the child's sleep patterns have recently changed. Changes in sleep patterns are a symptom of depression, so the nurse should inquire about recent sleep patterns and if indicated, conduct a full assessment for self-harm. The other options are potential sources of stress for this child and should be assessed, but identifying neurovegetative symptoms of depression have the highest priority.

The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply.) Select all that apply Some correct answers were not selected Shallow with an irregular rhythm. Chest breathing with nasal flaring. Diaphragmatic with chest retraction. Abdominal with synchronous chest movements. Heart rate of 158 beats per minute. Grunting heard with a stethoscope.

Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of respiratory distress in the infant.

An infant with developmental dysplasia of the hip is placed in a Pavlik harness. What instructions should the nurse include in a teaching plan for the parents? Apply lotion or powder to minimize skin irritation. Put clothing over harness for maximum effectiveness. Check for red areas under the straps three times a day. Use a thin absorbent disposable diaper over the harness.

Check for red areas under the straps three times a day. The Pavlik harness, which maintains the hips in abduction, is the most widely used device for developmental dysplasia of the hip. An infant who continuously wears a Pavlik harness is at risk for skin breakdown, so parents should be instructed to check two to three times a day for red areas under clothing and harness straps. To avoid direct contact with the skin, clothing and diapers should be placed under the straps.

What action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean section? Monitor urinary output via an indwelling catheter. Assess the abdominal dressings for drainage. Give the Ringer's Lactated infusion at 125 ml/hr. Check the firmness of the uterus every 15 minutes.

Check the firmness of the uterus every 15 minutes. A client's risk of postpartal hemorrhage is decreased when the uterus is firm after delivery of the infant. Assessment of fundus consistency q15 minutes provides frequent intervals to stimulate the fundus to contract and prevent bleeding.

The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? Cyanosis of the fingertips. Bradycardia and bradypnea. Presence of S3 and S4 heart sounds. 3+ pitting edema of the lower extremities

Cyanosis of the fingertips. Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands which may lead to gangrene.

While monitoring a client in active labor, the nurse observes a pattern of a 15-beat increases in the fetal heart rate that lasts 15 to 20 seconds and returns to baseline. Which information should the nurse report during shift change? Fetal well being with labor progression. Signs of uteroplacental insufficiency. Episodes of fetal head compression. Occurrences of cord compression.

Fetal well being with labor progression. Fetal heart rate accelerations that last 15 to 20 seconds are a sign of fetal well-being, so continuous external fetal monitoring should be continued (A). Uteroplacental insufficiency (B) causes late decelerations. Compression of the fetal head (C) results in early decelerations. Compression of the umbilical cord (D) is evidenced by variable decelerations.

A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain? Gravidity and parity. Time and amount of last oral intake. Date of last normal menstrual period. Frequency and intensity of contractions.

Date of last normal menstrual period. Evaluating the gestation of the pregnancy takes priority due to the risks involved when the fetus is preterm. If preterm labor is imminent and a reassuring fetal heart pattern is assessed, the healthcare provider may attempt to prolong the pregnancy by administering corticosteroids to mature the lungs of the fetus.

A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider? Decreased thyroid stimulating hormone level. Elevated liver function profile. Increased white blood cell count. Decreased hematocrit and hemoglobin levels.

Decreased thyroid stimulating hormone level. Hyperthyroidism causes an increased level of serum thyroid hormones (T3and T4), which inhibit the release of thyroid stimulation hormone (TSH). The nurse should notify the healthcare provider of the decreased TSH level, which may influence the client' s mood swings and behaviors. The other findings are commonly found in the homeless population because of poor sanitation, poor nutrition, and the prevalence of substance abuse.

The parents of an adolescent male with Ewing sarcoma ask the nurse what is the most significant factor contributing to their son's prognosis. Which factor should the nurse include when answering the parent's concern? Age of onset. Gender of child. Appearance on X-ray. Degree of metastasis.

Degree of metastasis. Ewing sarcoma is the second most common malignant bone tumor of children. Prognosis of this malignant tumor is most significantly related to the degree of metastasis during the early in the course of the disease.

A client receiving Doxorubicin (Adriamycin) intravenously (IV) complains of pain at the insertion site, and the nurse notes edema at the site. Which intervention is most important for the nurse to implement? Assess for erythema. Administer the antidote. Apply warm compresses. Discontinue the IV fluids.

Discontinue the IV fluids. Doxorubicin is an antineoplastic agent that causes inflammation, blistering, and necrosis of tissue upon extravasation. First, all IV fluids should be discontinued at the site to prevent further tissue damage by the vesicant.

The nurse tells a client in her first trimester that she should increase her daily intake of calcium to 1,200 mg during pregnancy. The client responds, "I don't like milk." What dietary adjustments should the nurse recommend? Increase organ meats in the diet. Eat more green, leafy vegetables. Add molasses and whole-grain breads to the diet. Choose more fresh citrus and other fruits daily.

Eat more green, leafy vegetables. For pregnant women who do not like milk, other sources of calcium include enriched cereals, legumes, nuts, dried fruits, green leafy vegetables (B), and canned salmon and sardines that contain bones. (A, C, and D) are not significant sources of calcium.

A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses, "You fat tub of lard! Get something done around here!" What is the best initial action for the nurse to take? Have the orderly escort the client to his room. Tell the client his healthcare provider will be notified if he continues to be verbally abusive. Redirect the client's energy by asking him to tidy the recreation room. Call the healthcare provider to obtain a prescription for a sedative

Redirect the client's energy by asking him to tidy the recreation room. Distracting the client, or redirecting his energy, prevents further escalation of the inappropriate behavior. The other actions are not indicated at this time and could escalate the abuse unnecessarily.

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? Patellar reflex 4+. Blood pressure 158/80. Four-hour urine output 240 ml. Respiration 12/minute.

Patellar reflex 4+. A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia, which is an indication of an impending seizure.

A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? White blood count of 10,000 mm3. Serum glucose of 115 mg/dl. Purulent sputum. Excessive hunger.

Purulent sputum. Steroids cause immunosuppression, and a purulent sputum is an indication of infection, so this symptom is of greatest concern.

The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up? Menstruation onset at age 9. Contraceptive method includes condoms only. Menstrual cycle occurs every 35 days. "Black-out" after one drink last night on a date.

"Black-out" after one drink last night on a date. A "black-out" typically occurs after ingestion of alcohol beverages that the client has no recall of experiences or one's behavior and is indicative of high blood alcohol levels. The client's experience of a "black-out" after one drink is suspicious of the client receiving a "date rape" drug, such as flunitrazepam ("Rohypnol"), and needs additional follow-up. The other findings do not need follow-up at this time.

A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. What response is best for the nurse to provide? "You do not have to tell him because this is not a reportable disease." "Because there is no cure for this disease, telling him is of no benefit to him or to you." "Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." "You should tell him, so he can feel as guilty and miserable as you do now, knowing that you have this disease."

"Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." Anger is a common emotional reaction when confronted with the diagnosis of a STI, and often lay blame and project this anger at the sexual partner. Although HPV is not a reportable disease in many states, all contacts should be informed of the infection, treatment, transmission, and precautions to minimize infecting others.

A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. What is the best response for the nurse to provide? "Tell your friends and family so that they can help you." "Get involved with a support group. I will give you some names." "Talk only to other friends who are infertile since only they can help." "Start adoption proceedings immediately since obtaining an infant is very difficult

"Get involved with a support group. I will give you some names." A support group provides a safe haven for the couple to share their feelings and experience and gain insight from others dealing with the same experience and let's them know they are not alone in their situation.

A client delivers twins, one is stillborn and the other is recovering in intensive care nursery. As the nurse provides assistance to the bathroom, the client softly crying, states, "I wish my baby could have lived." Which response is best for the nurse to provide? "Don't be sad. You'll need to be strong to care for your healthy baby." "Do you want to go to the nursery and see your baby?" "I am sorry for your loss. Do you want to talk about it?" "It is always sad to lose a baby. Would you like me to call your minister?"

"I am sorry for your loss. Do you want to talk about it?" The nurse should recognize the client's grief and offer an opportunity for the client to discuss her feelings (C). Telling the client not to be sad and that she needs to be strong (A) is invalidating and instructive by the nurse. (B and D) are incorrect responses because they deny the client's expressed grief and attempt to change the subject.

Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy? "Protein helps the fetus grow while I am pregnant." "Gestational diabetes is prevented by eating protein." "Anemia is averted by consuming enough protein." "My baby will develop strong teeth after he is born."

"Protein helps the fetus grow while I am pregnant." Adequate protein intake is essential to meet increasing demands of rapid growth of the fetus (A) and maternal changes during pregnancy, such as enlargement of the uterus, mammary glands, and placenta, increase in the maternal blood volume, and formation of amniotic fluid. Protein is essential for anabolism, but its consumption does not prevent gestational diabetes (B). Iron found in high protein foods, such as meat, helps prevent anemia (C), but the basic need for protein is the anabolic growth processes of the fetus. Although calcium is needed for fetal bone and teeth development (D), it is not found in all protein food sources.

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which response is best for the nurse provide? "Weigh the baby daily, and if she is gaining weight, she is eating enough." "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day." "Offer the baby extra bottle milk after her feeding, and see if she is still hungry." "If you're concerned, you might consider bottle feeding so that you can monitor her intake."

"Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day." An infant is hydrated when the urine is dilute (straw-colored) and frequency of voiding is >6 to 10 times/day. Infants feed 8-12 times in a 24 hour period.

The nursing education coordinator is creating employee orientation materials for staff nurses who plan to work at a clinic that serves a lower socioeconomic neighborhood. What information should the educator include regarding the clinic's client population? (Select all that apply.) Select all that apply Some correct answers were not selected Most of the clients are unemployed or disabled. Access to mass transit may be an issue. Clients will need reminders to bring insurance cards. Basic physiologic needs of this population are often unmet. Clients who are homebound will qualify for Medicaid. Nonadherence to healthcare recommendations is likely.

Access to mass transit may be an issue. Basic physiologic needs of this population are often unmet. The unemployed or disabled will likely comprise a majority of this clinic's clients .Lack of access to mass transit may affect the population's ability to keep health care appointments and low-income clients are at risk for basic physiologic needs being left unmet.

The parents of a child with Asperger's disorder asks the nurse to explain the differences between Asperger's and autism. Which information should the nurse share with the parents about Asperger's disorder that is not characteristic in autism? Obsession with moving objects. Repetitive patterns of behavior. Age-appropriate language development. Stereotypic movements and speech patterns.

Age-appropriate language development. Asperger's syndrome is a neurological condition, which falls under the autism spectrum and is considered one of the higher functioning spectrum's of autism. Individuals affected by this condition have a very high functioning of language skills and obsessed over single topics, but demonstrate very weak social skills, have difficulty interacting with others, and are considered emotionally stunted and display ritualistic behaviors.

The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information? A description of inflammation, infection, and tumors. Continuous visualization of intracranial neoplasms. Imaging of tumors without exposure to radiation. An image that describes metastatic sites of cancer.

An image that describes metastatic sites of cancer. PET scans provide information regarding certain diseases of the heart (determination of tissue viability), brain (dementia, Parkinson's disease), and early detection of tumors and their metastasis.

A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement next? Document the color of the lochia. Observe maternal vital signs. Assist the client to the bathroom. Notify the healthcare provider.

Assist the client to the bathroom. Fundus displacement commonly occurs in the early hours of the postpartum period due to urinary retention, so assisting the client to the bathroom (C) to void should be implement next. (A and B) can be completed after the client's bladder is emptied. (D) should only be implemented if the fundus does not become firm or lochial bleeding continues after the bladder is emptied.

The nurse is caring for a female client who is admitted for depression with the nursing diagnosis, "Self-esteem, chronic low." Which client response indicates to the nurse that the client has improved self-esteem? Identifies own strengths. Stops crying during every session. Talks with other clients about marital advice. Asks the nurse if her behavior has improved.

Identifies own strengths. Identifying one's personal strengths is an important part of increasing self-esteem. The other client behaviors do not indicate an improved self-esteem or self-confidence.

Which side effects should the nurse monitor for a client who is receiving dexamethasone (Decadron) following neurosurgery? (Select all that apply.) Select all that apply Some correct answers were not selected Mood swings. Decreased appetite. Increased weight gain. Serum glucose level of 65 mg/dl. Delayed incisional wound healing. Serum hemoglobin level of 9 mg/dl.

Dexamethasone (Decadron) is a long-acting glucocorticoid prescribed for neurosurgical procedures because it suppresses inflammation and has a low sodium-retaining ability, which is important in averting cerebral edema. However though the medication does produce the following side effects such as: mood swings; an increase in appetite, resulting in weight gain; hyperglycemia (serum glucose level above 120 mg/dl) which is related to the gluconeogenesis properties of corticosteroids; delayed in wound healing related to immune suppression properties; and complete blood count resulting in a decreased in WBC and hemoglobin (less than 12mg/dl). When a client is receiving dexamethasone, they should be monitor for these side effects.

Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor? Brighten the lighting so the mother can view the infant. Complete the newborn assessment as quickly as possible. Provide positive reinforcement for maternal care of infant. Encourage early initiation of breast or formula feeding.

Encourage early initiation of breast or formula feeding. (D) is the best of the interventions listed to encourage maternal-infant bonding. (A, B, and C) are all methods of promoting maternal-infant bonding but are not usually as effective as initiating infant feeding.

The nurse is assessing the coping behaviors of the parents whose child has been recently diagnosed with a chronic illness. What reaction by the parents is a positive step in the ability to cope with this new situation? Endowing the illness with meaning. Refusing to believe the child is ill. Entertaining an unrealistic future plan for the child. Placing complete faith in religion to the point of relinquishing own responsibility.

Endowing the illness with meaning. Coping mechanisms are behaviors directed at reducing the tension elicited by a crisis. Approach behaviors are coping mechanisms resulting in movement toward adjustment and resolution of the crisis. The parents' ability to assign the illness meaning within an existing medical, scientific, or spiritual philosophy of life is a long-term coping strategy significantly related to successful family functioning.

An infant born at 37-weeks gestation, weighing 4.1 kg (9.02 pounds) is 2 hours old and appears large for gestational age, flushed, and tremulous. What procedure should the nurse follow to implement a glucose screening? (Arrange the examination process from first on top to last on the bottom.)

Obtaining capillary blood for the glucose screening for a infant that is macrosomic and at risk for hypoglycemia should begin with wrapping the infant's foot with a heel warmer for 5 to 10 minutes to facilitate vasodilation to obtain an adequate blood sample volume. Next, a spring loaded automatic puncture device should be obtained to puncture the skin because it is less traumatic than a manual lancet. Then, the nurse's hand is used to restrain the foot as the puncture site on the lateral aspect of the heel is cleansed.

A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? Determine the client is anxious and allow him to sleep. Evaluate his blood pressure, pulse, and respiratory status. Review the client's pre-operative history for alcohol abuse. Continue to monitor the client for reactivity to anesthesia.

Evaluate his blood pressure, pulse, and respiratory status. Slurred speech in the post-operative client who received a local anesthetic is an atypical finding and may indicate neurological deficits that require further assessment, so obtaining the client's vital signs will provide information about possible cardiovascular complications, such as stroke.

The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37-weeks gestation. What nursing action should be implemented first? Provide tactile stimulation. Administer flow by 100% oxygen. Asses the functionality of the monitoring device. Evaluate the newborn's color and respirations.

Evaluate the newborn's color and respirations. Monitors are an effective method for continual appraisal of a neonate's respirations, but a visual assessment of the infant oxygenation and respiratory status (D) should be implemented first. If the infant is not breathing, then tactile stimulation (A) should be given for no longer than 10 to 15 seconds before initiating CPR. Oxygen should be administered or increased (B) after determining the neonate's respiratory status. If there is normal color and presence of respirations after assessment, then possible causes of a false alarm (C) should be investigated for mechanical malfunction of the device.

The nurse notes a pattern of the fetal heart rate decreasing after each contraction. What action should the nurse implement? Give 10 liters of oxygen via face mask. Prepare for an emergency cesarean section. Continue to monitor the fetal heart rate pattern. Obtain an oral maternal temperature.

Give 10 liters of oxygen via face mask. Late decelerations occur when there is reduced placental and fetal perfusion. Administering oxygen (A) increases the oxygen saturation in the blood thus increasing oxygen to the fetus. (B, C, and D) are inaccurate.

A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement? Position the head of the bed (HOB) flat. Withhold intravenous fluids. Administer a bolus of IV fluids. Give an antihypertensive medication.

Give an antihypertensive medication. Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an hour, and the client's current elevated blood pressure requires antihypertensive medication.

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate? Grief related to her perceptions about the loss of this child. Relief of ambivalent feelings experienced with this pregnancy. Shock because she may not have realized that she was pregnant. Guilt because she had not followed her healthcare provider's instructions.

Grief related to her perceptions about the loss of this child. Clients can experience Grief/loss response at all stages of pregnancy loss.

Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma? Numbness, tingling, and cramps in the extremities. Headache, diaphoresis, and palpitations. Cyanosis, fever, and classic signs of shock. Nausea, vomiting, and muscular weakness

Headache, diaphoresis, and palpitations. Pheochromocytoma is a catecholamine secreting non-cancerous tumor of the adrenal medulla, and a headache, profuse sweating and palpitations is the typical triad of symptoms depending upon the relative proportions of epinephrine and norepinephrine secretion. Surgical removal of the tumor is the only treatment.

A client in the first stage of active labor is using a shallow pattern of rapid breaths that is twice the normal adult breathing rate. The client complains of feeling light-headed, dizzy, and states that her fingers are tingling. What action should the nurse implement? Notify the healthcare provider. Help her breathe into a paper bag. Administer oxygen via nasal cannula. Tell the client to slow her breathing.

Help her breathe into a paper bag. Hyperventilation can precipitate respiratory alkalosis and cause light-headedness, dizziness, tingling of the fingers, and circumoral numbness. Breathing into a paper bag held tightly around the mouth and nose (B) enables the client to rebreathe carbon dioxide, which reduces depletion of carbonic acid. and compensates for the respiratory alkalosis. (A) is unnecessary, and (C and D) are less effective than (B).

A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is best for the nurse to make? I'll leave your tray here. I am available if you need anything else. You're not being poisoned. Why do you think someone is trying to poison you? No one on this unit has ever died from poisoning. You're safe here. I will talk to your healthcare provider about the possibility of changing your diet.

I'll leave your tray here. I am available if you need anything else. The nurse should not argue with a client who is paranoid nor demand that the client eat, but should be supportive and convey the nurse's availability if needed. The other responses are not indicated.

A community health nurse is conducting a neighborhood discussion group about disaster planning. What information regarding the transmission of anthrax should the nurse provide to the group? Infection is acquired when anthrax spores enter a host. Mature anthrax bacteria live dormant on inanimate objects. Spores cannot survive for extended periods outside of a living host. Anthrax is transmitted by respiratory droplets from person to person.

Infection is acquired when anthrax spores enter a host. Anthrax is an acute disease caused by the spore-forming bacterium Bacillus anthracis. Products made from infected animal materials, such as animal hair, wool, animal bone meal, or products made from these materials, such as rugs and drums, may transmit this disease by spore entrance via cutaneous, gastrointestinal, and respiratory or inhalational (A). Anthrax spores can remain viable in the environment for many years, but the mature bacteria, Bacillus anthracis, cannot survive long outside a host (B and C). Although anthrax spore aerosolization, spore resistance to environmental degradation, and a high fatality rate implicate it as a potential biological warfare threat, person-to-person (D) transmission is rare.

A client with rheumatoid arthritis is prescribed piroxicam (Feldene), a nonsteroidal anti-inflammatory drug (NSAID). Which effect is characteristic of (NSAIDs) used for treating rheumatoid arthritis? Production of replacement cartilage is stimulated. Further destruction of the articular cartilage is prevented. Inflammation is reduced by inhibiting prostaglandin synthesis. Bradykinin is inhibited, thereby reducing acute and chronic pain.

Inflammation is reduced by inhibiting prostaglandin synthesis. Nonsteroidal anti-inflammatory drugs (NSAIDs), used for treating rheumatoid arthritis, by inhibiting the synthesis of prostaglandins and providing relief from the associated pain.

A client comes in to the clinic for her six week postpartum check up and complains that her left breast is eythematous and painful. The client asks, "Can I still breastfeed my baby?" What is the best response for the nurse to provide? Advise to stop breastfeeding until the infection clears. Inform the client to continue breastfeeding. Begin all feedings with the infected breast. Tell the client to pump then discard the milk from the affected breast.

Inform the client to continue breastfeeding. The client should be encouraged to continue breastfeeding (B) because emptying the breast helps alleviate the pain and prevents abscess formation. (A, C, and D) are inaccurate instructions for a breastfeeding client with mastitis.

Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse perform next? Initiate positive pressure ventilation. Intervene after the one minute Apgar is assessed. Initiate CPR on the infant. Assess the infant's blood glucose level.

Initiate positive pressure ventilation. According to the neonatal resuscitation guidelines, the nurse should immediately begin positive pressure ventilation because this infant's vital signs are not within the normal range, and oxygen deprivation leads to cardiac depression in infants. (The normal newborn pulse is 100 to 160 beats/minute and respirations are 40 to 60 breaths/minute.)

Which action should the nurse implement when caring for a newborn immediately after birth? Keep the newborn's airway clear. Foster parent-newborn attachment. Administer eye prophylaxis and vitamin K. Dry the newborn and wrapping in a blanket

Keep the newborn's airway clear. The immediate care after birth should focus on assessment and stabilization of the newborn's respiratory effort and airway clearance (A). When is the infant is warm and identification is ensured, then the opportunity to foster parental attachment (B) should be provided. Eye prophylaxis and a vitamin K supplementation (C) is given after the newborn is stabilized and assessed. To facilitate respiratory stabilization, the newborn's skin is dried and covered with a warmed blanket (D) to prevent cold stress.

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2016. Based on Naegele's rule, what is the estimated date of delivery? April 25, 2017. May 9, 2017. May 29, 2017. June 2, 2017.

May 9, 2017 Since this client's first day of her last normal menstrual period occurred on August 2, 2017, the estimated date of delivery is May 9, 2018. Naegele's rule is used to calculate the expected date of delivery and is obtained by subtracting 3 months and adding 7 days beginning from the first day of the last normal menstrual period.

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? Encourage the mother to provide total care for her infant. Provide privacy so the mother can develop a relationship with the infant. Encourage the father to provide most of the infant's care during hospitalization. Meet the mother's physical needs and demonstrate warmth toward the infant.

Meet the mother's physical needs and demonstrate warmth toward the infant. It is most important to meet the mother's requirement for attention to her needs so that she can begin infant care-taking. Nurse theorist Reva Rubin describes the initial postpartal period as the "taking-in phase," which is characterized by maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and closeness to families and the newborn.

A hospital received a bomb threat. While the fire department personnel are evacuating the clients, what action should the charge nurse perform? Obtain a current roster of clients assigned to the unit. Ensure that the narcotics are secured and locked up. Move clients' medical records to a safe location. Notify the operator when the unit is evacuated.

Obtain a current roster of clients assigned to the unit. Obtaining a current roster of clients assigned to the unit (A) will help the fire department ensure that all clients are evacuated. In this possibly life-threatening situation, evacuation of personnel and clients is a high priority action, while (B and C) are low priority tasks. The hospital operator should also be evacuated (D).

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? Provide oral hydration. Have a complete blood count (CBC) drawn. Obtain a specimen for urine analysis. Place the client on strict bedrest.

Obtain a specimen for urine analysis. Obtaining a urine analysis should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection thus it should be ruled out first.

Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate (Methergine)? Pregnancy induced hypertension. Placenta previa. Gestational diabetes. Postpartum hemorrhage.

Pregnancy induced hypertension. Methergine is used for post-partum bleeding. A client's history of pregnancy-induced hypertension (A) is a contraindication for Methergine which causes vasoconstriction and increases blood pressure, so the routine standing order should be withheld and reported to the healthcare provider. (B, C, and D) are not contraindications for the use of Methergine.

The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome? Prevent the formation of effusion fluid. Remove fluid from the intrapleural space. Debulk tumor to maintain patency of air passages. Relieve empyema after pneumonectomy.

Prevent the formation of effusion fluid. Instillation of a sclerosing agent to create pleurodesis is aimed at preventing the formation of a pleural effusion by causing the pleural spaces sealed together, thereby preventing the accumulation of pleural fluid.

A client is taking danazol (Danocrine) for endometriosis and calls the clinic nurse to complain of a dark, swollen, and painful leg. What instructions should the nurse provide the client? Wear support stockings. Elevate both legs and apply heat. Proceed to the closest emergency room. Walk for 20 to 30 minutes to reduce muscle cramps.

Proceed to the closest emergency room. A dark, swollen, and painful leg is consistent with deep vein thrombosis (DVT), an adverse effect of danazol, so the client should be instructed to seek immediate emergency care.

A terrorist attack has occurred and several people have inhaled Ricin. Which intervention should the emergency department nurse implement when caring for these clients? Administer the antibiotic streptomycin, IV STAT. Provide all clients with the Ricin antidote. Implement strict respiratory isolation immediately. Provide supportive nursing care until antitoxin is available.

Provide supportive nursing care until antitoxin is available. Production of the Ricin antitoxin involves immunizing sheep with inactive ricin, which results in the production of antibodies that are harvested to produce a freeze-dried product for reconstitution and injection for victims exposed to Ricin poisoning. Although the antitoxin is ready to be manufactured, full licensing is likely in 5 years (2014).There is no known cure or treatment for Ricin exposure so supportive care should be provided until the antitoxin is available.

The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? Reduce activity level and notify the healthcare provider. Go to bed and assume a knee-chest position. Massage the uterus and go to the emergency room. Do not worry as this is a normal occurrence.

Reduce activity level and notify the healthcare provider. Lochia should progress in stages from rubra (red) to serosa (pinkish) to alba (whitish), and not return to red. The return to rubra usually indicates subinvolution or infection. If such a sign occurs, the mother should notify the clinic/healthcare provider and reduce her activity to conserve energy.

A resident of a long-term care facility is taking lithium carbonate (Eskalith) to treat bipolar disorder. Which instruction should the nurse provide to this client's caregivers? Offer the morning dose of the medicine before breakfast. Have the client chew the pill if it is difficult to swallow. Encourage high energy fluid intake by providing sports drinks or sodas. Report symptoms of hypothyroidism such as fatigue and constipation.

Report symptoms of hypothyroidism such as fatigue and constipation. Lithium carbonate (Eskalith) causes hypothyroidism in 1 to 4% of those clients receiving the medication, so caregivers should assess for signs of hypothyroidism, including fatigue and constipation (early signs) and myxedema or goiter (late symptoms).

The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand? Plan for a possible cesarean birth. Arrange for home uterine monitoring. Make arrangements for care at home. Report uterine cramping or low backache.

Report uterine cramping or low backache. Uterine cramping and low back pain (D) are symptoms of preterm labor and should be reported to the healthcare provider immediately because the cerclage may need to be removed. A cesarean birth can be planned (A) or the cerclage can be removed at 37-weeks gestation to prepare for a vaginal birth. Home uterine activity monitoring (B) is used to limit the woman's need for visits and to safely monitor her status at home. Bed rest is an element of care so the client should make arrangements for care at home (C) and someone to do household chores. (A, B, and C) do not have the priority of (D).

A 28-year-old G1 P0 client who is currently 32 weeks pregnant is started on IV magnesium sulfate after being diagnosed with severe preeclampsia. After determining the serum magnesium level to be 15 mEq/L, the nurse should expect which of the following manifestations in the client? ECG changes. Loss of reflexes. Respiratory distress. Cardiac arrest.

Respiratory distress. The therapeutic level of magnesium sulfate is 4 to 7 mEq/L. ECG changes occur at 5 to 10 mEq/L. Loss of reflexes is unavoidable at 8 to 12 mEq/L. At 15 mEq/L, the client may experience respiratory distress. At 25 mEq/L, cardiac arrest may occur.

An 18-month-old is admitted to the hospital with possible Hirschsprung's disease. When obtaining a nursing history, the nurse asks about bowel habits. What description of the disease? Foul-smelling and fatty. Bile-colored and watery. Semi-solid and yellow. Ribbon-like and brown.

Ribbon-like and brown. Hirschsprung's disease is a mechanical obstruction caused by inadequate motility in a part of the intestines. The condition results from failure of ganglion cells to migrate craniocaudally along the GI tract during gestation. The lack of peristalsis in the affected bowel segment causes constipation and small diameter, brown-colored stools (D). (A) is associated with cystic fibrosis. (B) is common in gastroenteritis. (C) is normal in breastfed neonates.

During a home health visit, a male client reports to the nurse that he felt a solid testicular mass during self-exam, but that it wasn't painful. What instruction should the nurse provide the client? Continue to monitor the mass until the next scheduled annual medical exam. Notify the healthcare provider if the mass becomes soft, painful, or starts to drain. Schedule an appointment with the healthcare provider for prompt evaluation. Testicular nodules are of concern only if they feel matted or are not easily movable.

Schedule an appointment with the healthcare provider for prompt evaluation. A painless testicular mass is an abnormal finding, and the nurse should instruct the client to obtain prompt medical evaluation. The other options place the client at risk, since they do not emphasize prompt medical evaluation.

The nurse is planning care for a client with major depression who is admitted to the unit after a recent suicide attempt. Which intervention has the highest priority for inclusion in this client's plan of care? Search the client's personal belongings. Introduce the client to others on the unit. Ask the client about recent stressful events. Move to a room that allows close observation.

Search the client's personal belongings. To safeguard that the client dose not have some means to inflict self harm, a routine search of personal belongings, which is a common safety policy, should be implemented until the client stabilizes and suicidal ideations abate. The other interventions are components of the plan of care that ensure a therapeutic milieu but are not the priority in ensuring safety from self-harm.

A client at 30-weeks gestation is in preterm labor. The healthcare provider prescribes two 12-mg doses of betamethasone (Celestone) intramuscularly every 12 hours. The client asks the nurse why she is receiving the Celestone. What information should the nurse use to explain the action of the medication? Suppresses uterine contractions. Stimulates fetal surfactant production. Reduces maternal and fetal tachycardia associated with terbutaline (Brethine) administration. Maintains adequate maternal respiratory effort and ventilation with magnesium administration.

Stimulates fetal surfactant production. Antenatal glucocorticoids, such as betamethasone (Celestone), are given IM to the mother to stimulate surfactant production in the fetus and accelerate fetal lung maturity, in the event the fetus is delivered prematurely to minimize respiratory distress syndrome associated with premature infants.

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? Tinnitus, vertigo, and hearing difficulties. Sudden, stabbing, severe pain over the lip and chin. Facial weakness and paralysis. Difficulty in chewing, talking, and swallowing.

Sudden, stabbing, severe pain over the lip and chin. Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (5th cranial). Women are more often afflicted with this condition and generally occurs in clients over the age of 50 years old.

A client calls the clinic and states that she forgot to take her oral contraceptives for the past two days. Which instruction is best for the nurse to provide to this client? Take 2 pills a day for 2 days and use an alternate method of contraception for 7 days. Quit the pills for this cycle, use an alternate method of contraception, and resume pills on the fifth day of menstruation. Take one extra pill per day for the rest of this cycle, then resume taking pills as usual next cycle. Take 4 pills now and use an alternate method of contraception for the rest of this cycle.

Take 2 pills a day for 2 days and use an alternate method of contraception for 7 days. If two pills are missed in a roll, the client should take 2 pills a day for two days and used an alternative form of birth control for seven days.

A client who is recently diagnosised with myasthenia gravis receives a prescription for pyridostigmine (Mestinon), a cholinergic agent. Which information should the nurse instruct the client to implement when taking this medication? Always take with meals to avoid gastrointestinal distress. Plan the doses close together for maximal therapeutic effect. Take the medication at least 30 minutes before eating meals. Avoid dairy products two hours before and after taking medications.

Take the medication at least 30 minutes before eating meals. The nurse should instruct the client to take the medication 30 minutes before meals with an empty stomach, which allows for the onset of action and therapeutic effects to be present during the meal to help improve swallowing and chewing. The doses should also be spaced evenly apart to optimize the effects of the medication.

When preparing a client who has had a total laryngectomy for discharge, what instruction is most important for the nurse to include in the discharge teaching? Recommend that the client carry suction equipment at all times. Instruct the client to have writing materials with him at all times. Tell the client to carry a medic alert card stating that he is a total neck breather. Tell the client not to travel alone.

Tell the client to carry a medic alert card stating that he is a total neck breather. It is imperative that total neck breathers carry a medic alert notice so, that if they have a cardiac arrest, mouth-to-neck breathing can be done.

The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding indicates that the nurse should discontinue the oxytocin infusion? The client needs to void. Amniotic membranes rupture. Uterine contractions occur every 8 to 10 minutes. The fetal heart rate is 180 bpm without variability.

The fetal heart rate is 180 bpm without variability. A fetal heart rate (FHR) without variability (D) is a non-reassuring finding that indicates the oxytocin should be discontinued, and the healthcare provider should be notified. A client's urge to void (A) is not an indication to discontinue the oxytocin infusion used for induction. The oxytocin infusion should not be discontinued when the amniotic membranes rupture (B) unless there are non-reassuring changes in the FHR pattern or uterine hyperstimulation occurs, and (C) does not qualify as uterine hyperstimulation.

An infant who weighs 3.8 kg is delivered vaginally at 39-weeks gestation with a nuchal cord after a 30-minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide the parents about this finding? Further assessment is indicated. Petechiae occurs with forceps delivery. An increased blood volume causes broken blood vessels. The pinpoint spots are benign and disappear within 48 hours.

The pinpoint spots are benign and disappear within 48 hours. Rapid delivery and a tight nuchal cord cause the presenting parts (head) to have bruising and pin point hemorrhages (petechiae), which are benign and usually disappear within two days after birth (D). (A) is not indicated. Birth injuries caused by forceps (B) present as linear configuration across both sides of the face and outline the placement of the forceps. (C) is inaccurate.

The nurse is designing a bioterrorism plan for a community. Which agents are transmitted person to person via respiratory or inhalation exposure? (Select all that apply.) Select all that apply Some correct answers were not selected Ricin. Pneumonic plague. Anthrax. Botulism. Smallpox. Brucellosis

The pneumonic plague can be transmitted person to person via respiratory droplets. Smallpox can produce aerosolized droplets of ruptured pock marks in the buccal cavity, thus aerosolizing the virus and causing respiratory transmission. The other options are not transmitted by person to person.

A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.) Select all that apply Some correct answers were not selected Obtain consent for the procedure. Initiate preoperative sedation. Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the procedure.

The usual preoperative preparation for proctosigmoidoscopy entails obtaining the client's consent to the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure, administration of an enema, and fasting on the morning of the procedure.

At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires immediate intervention? Uterine cramping. Abdominal tenderness. Systolic blood pressure < 100 mmHg. Intermittent nausea.

Uterine cramping. The client should be monitored for 1 to 2 hours following the procedure for the occurrence of uterine cramping (A) so that immediate intervention to decrease the risk of miscarriage can be initiated. This procedure (removal of a small piece of tissue from the fetal portion of the placenta) may cause initiation of labor. (B) may occur at the puncture site if the procedure was done transabdominally. (C and D) are normal findings during in the first trimester.

Which information about mammograms is most important to provide a post-menopausal female client? Breast self-examinations are not needed if annual mammograms are obtained. Radiation exposure is minimized by shielding the abdomen with a lead-lined apron. Yearly mammograms should be done regardless of previous normal x-rays. Women at high risk should have annual routine and ultrasound mammograms.

Yearly mammograms should be done regardless of previous normal x-rays. There are different recommendations from different agnecies. For a client with no risk factors, the earliest breast screening recommendation is a yearly mammogram at the age 40 and till the age of 54. After that every two years.The American College of OB/GYN still recommend starting mammograms starting at the age of 40 and yearly screeenings.The American Cancer Society new guidelines recommend starting at the age of 45 and thereafter till the age of 54 years old, then every two years. The US Preventive Services Task Force Services (USPSTS) recommends starting at the age of 50 years old and screenings every two years thereafter.