Maternal-Child Final Exam
78.The nurse is caring for a preschool aged child who needs a computerized tomography(CT) scan. Which action would the nurse use to best prepare the child for this diagnostic test?
Help the child to pretend that the CT scan machine is a camera
A toddler insists on brushing his own teeth and dressing himself. What advice would you give his parents regarding this?
Helping with his own cares allows him to experience autonomy
during a routine well child check an 8 year old child is having her visual acuity assessed. She reports that her vision is blurry at a close range and clear at far range. Which of the following diagnoses is consistent with these symptoms?
Hyperopia
Which fluid should the nurse offer to help keep a post tonsillectomy child orally hydrated?
Ice chips
A preadolescent client a member of a single parent family has abdominal pain and the health care provider suspects that an appendectomy might need to be performed. The patient father is asking for a second opinion whereas the mother tells the nurse to do whatever needs to be done to help the patient. What does the nurse need to assess before moving forward with planning care for this patient?
Identify the custodial parent
The nurse is providing discharge teaching to the child and her family following inpatient treatment for anaphylaxis. Which of the following statements by the patient or family would indicate the need for more instruction?
If my symptoms resolve after injection, I should stay home and rest for the remainder of the day
The nurse assesses that a fetus is in a breech presentation. Where would you auscultate for fetal heart sounds?
High in the abdomen
An 8 year old child presents with diagnosis of sickle cell anemia. The child is hospitalized and the nurse recognizes which of the following as the initial nursing intervention?
Hydration and pain management
A nurse in an emergent setting is caring for a child with a superficial burn of the foot. Which of the following is the immediate priority?
Relieving pain and discomfort
The nurse is preparing to administer blood products to the pediatric client. Which of the following reflects safe practice in administration of blood products?
Remain with the patient for the first 15 minutes of the infusion
A nurse performs an admission assessment on a child and suspects physical abuse. Based on the suspicion the primary legal nursing responsibility is to do which of the following?
Report the case in which the abuse is suspected to the local authorities and your supervisor or charge nurse
What should the nurse teach the parents of a child with tetralogy of fallot to do if the child suddenly becomes cyanotic and dyspneic?
Place in a knee chest position
The nurse evaluates teaching provided to a school age child and parents about the medication pancrealipase for cystic fibrosis. Which observation indicates that teaching has been effective?
The child takes a dose before having an afternoon snack
The nurse should expect the anterior fontanel to close at what age?
12 to 18 months
A toddler is prescribed to receive 50mg of an antibiotic. The medication available is 250mg is 5ml. How many milliliters of the medication should the nurse provide to the patient?
1ml
79.Prenatal testing is done to identify health issues that may interfere with the developing fetus. During which time frame would the nurse expect the 1 hour glucose tolerance test to be ordered on a healthy primigravida?
24-28 weeks gestation
Utilize the GTPAL system to classify a woman who is currently 18 weeks pregnant. This is her 4th pregnancy. She gave birth to one baby vaginally , at 26 weeks who died experienced a miscarriage and has one living child who was delivered at 38 weeks gestation.
4.1.1.1.1
The school nurse is observing a child in the classroom. The child is speaking then suddenly stops and stares for about 5 seconds and then continues speaking. The nurse charts this experience as what type of seizure?
Absence
The nurse in labor and delivery is monitoring a client at 38 weeks gestation who presents for a nonstress test (NST), in performing a nonstress test the nurse will observe for and document which of the following? (SATA)
Accelerations in the fetal heart rate Fetal tone Decelerations in the fetal heart rate Variability in the fetal hear rate
A student nurse notes that the population of a sexually transmitted infection (STI) health clinic consist largely of teenagers. The nurse explains that adolescents are at a greater risk for contracting STIs because of which factor?
Adolescents are risk takers and believe they are invincible
A hospitalized 2 year old child with croup is receiving corticosteroid tharapy and the mother asks why the provider did not prescribe antibiotics? What is the nurses best response to the mother?
Antibiotics are not indicated unless a bacterial infection is the cause of the illness
A nurse is caring for a school age child who has had a cardiac catheterization. The child tells the nurse that her bandage is too wet. The nurse finds the bandage and bed soaked with blood. What is the appropriate initial nursing action?
Apply direct pressure above the catheterization site
after an hour of oxytocin therapy, a laboring patient experiences contractions that last for a duration of 90 seconds occurring at a frequency of every 2 minutes. What priority action should the nurse take?
Assess the cervix for full dilation
Upon assessment of a 3-year old who has been diagnosed with croup, the nurse notes stridor while the child is asleep. Which of the following interventions would the nurse expect to perform to this client?
Assisting with racemic epinephrine nebulizer therapy
A school nurse is preparing an educational presentation to a group of teens, parents and teachers about how to prevent skin cancer. Which topics to be included in the presentation ? (SATA)
Avoid getting a severe sunburn It is important to avoid tanning beds Sunscreen application needs to include tops of ears and back of neck Children need to apply sunscreen if out in the sun for longer than 60 minutes There is a direct association between two or more episodes of sunburn and development of malignant melanoma
The nurse visits the foster home of a newborn with failure to thrive syndrome. Which observation indicates a successful outcome for this child s care?
Child eagerly takes a bottle and is gaining weight
During a routine well child visit the mother of a preadolescent client asks the nurse to explain signs of sexual abuse. The mother is concerned because an older male has been making comments and overtly admiring the child when playing outdoors. What signs of sexual abuse should the nurse tell the mother to look for? (SATA)
Child reports abdominal pain Child has a change in school performance Child demonstrates anxiety or trouble sleeping Child does not want to be left alone with a certain adult
The triage nurse is assessing a patient who has presented to the emergency department with complains of pain in the left lower leg and ankle after a fall. On assessment the nurse notes swelling to the lateral aspect of the left ankle. Point tenderness and crepitus on palpation. The nurse plans care for the patient recognizing that this presentation is most consistent with which of the following injuries?
Compartment syndrome
A nurse is reviewing discharge instructions with the family of a child diagnosed with a urinary tract infection. Which instruction should the nurse include with discharge teaching regarding medications?
Complete the entire course of antibiotics ordered by the provider
The nurse is participating in a preschool health screening program. What are appropriate secondary health promotion activities? (SATA)
Conduct vision tests Conduct hearing tests Review immunizations received
Your client attempted suicide with a medication overdose. Which intervention would be most effective in preventing an adolescent from attempting suicide again?
Coordinate involvement of a mental health provider to allow child to express feelings
The nurse is instructing the mother of a school age with a leg cast about cast care at home. What should the nurse include in this teaching?(SATA)
Cover the cast with a plastic bag to bathe Remind that nothing is to be put inside the cast Use the cool setting on a hair dryer to ease itchy skin Remain as active as possible with appropriate modifications.
The nurse is concerning that a school age child is developing pneumonia. What did the nurse most likely assess in this client?(SATA)
Crackles (rales) Elevated temperature Productive harsh cough
The nurse is reviewing normal and abnormal changes in pregnancy with a woman who is 32 weeks pregnant. Which of the following abnormal changes should the nurse address first?
Decreased or absent fetal movement
An infant is bought to the emergency department with poor skin turgor, weight loss lethargy and tachycardia. What does the nurse suspect is the problem?
Dehydration
What is the most important observation the nurse should watch for in a newborn who has a salt losing form of congenital adrenal hyperplasia?
Dehydration
A 6-month-old infant is admitted to the hospital because of a fever. When you obtain a health history, what data would the nurse obtain first?
Details about the fever
A 6 year old has a diagnosis of streptococcal pharyngitis . when planning care the nurse evaluate the clients symptoms for which of the following dangerous outcomers?
Development of rheumatic fever
The nurse is instructing an adolescent regarding sexual activity. What can the nurse include in her teaching?(select all that apply)
Do not be influenced by friends to have sex The only 100% effective method of preventing pregnancy is abstinence Learn about safe sex practices
A child is taking valproic acid for epilepsy. What important should the nurse explain to the parents?
Do not discontinue the drug abruptly
40.The nurse is teaching a child with type 1 diabetes mellitus to administer her own insulin. The child is receiving a combination of short acting and long-acting insulin . How will the nurse know that the child has appropriately learned the technique?
Draws up the short acting insulin into the syringe first
The nurse in the cardiac clinic is caring for a new patient who has been referred to the clinic due to a new heart murmur heard by the pediatrician during the well-child exam. What noninvasive diagnostic testing does the nurse expect the cardiologist to order first?
Echocardiogram
An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler is to:
Encourage parents to room in
A 5-year-old child is placed in skeletal traction to immobilize a fracture. What is it important for the nurse to encourage the parents to do with the child during immobilization?
Engage the child in therapeutic play while confined to this position
The nurse is instructing the parents of a child with sickle cell anemia on safety precautions. What should the nurse emphasize during this teaching?
Ensure a consistent and daily intake of adequate fluids to prevent dehydration.
The nurse in the newborn nursery is reviewing the physicians order to prepare a 2 day old newborn for circumcision. Which of the following findings on assessment of this patient would be a contraindication to the procedure?
Epispadias
A 12 year old child has pyelonephritis. Which of the following would the nurse expect to observe when assessing the child? (SATA)
Flank pain Costovertebral angle tenderness Fever
a child is experiencing anaphylactic shock. Which provider order would the nurse complete first?
Give Epinephrine IM
The parents of a child with acute glomerulonephritis ask the nurse to explain the cause of the disease. What organism should the nurse instruct the parents as being the cause for the disorder?
Group A beta hemolytic streptococci
A 24 year old G2P1001 presents to the office for her 36 week visit. Which of the following labs would the nurse expect the provider to order as routine, scheduled testing?
Group Beta strep culture
A health teaching that the nurse would provide for parents of an immunosuppressed child focuses on which important measure?
Hand washing
The nurse is preparing to assess a toddler during a routine health maintenance visit. Which assessment will the nurse perform to determine the childs growth milestone?
Height and weight
A 3 month old is admitted to the hospital for failure to thrive. Which of the following are indications of failure to thrive in a 3 month old infant?
Infant falls below 5% in growth percentiles
The nurse is caring for a 10year old child with growth hormone deficiency. Which therapy would you anticipate being prescribed for the child?
Injections of growth hormone
A 4-year-old child with a urinary tract infection is scheduled to have a voiding cystourethrogram. What would a nurse do to prepare for the child for this procedure?
Insert foley catheter for installation of contrast
A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting, Therapeutic management of this child will begin with which nursing intervention?
Intravenous fluids
The student nurse is preparing education for the parents of a 6-year-old that will begin iron supplementation following a diagnosis of iron deficiency anemia. What should be included in the education? (select all that apply)
Iron should be given with a glass of orange juice Iron may cause black tarry stools Iron may cause constipation
Which statement by the nurse is most likely to gain the cooperation of a young child?
It is time for you to drink your medicine now
The nurse is caring for a school age recovering from an open reduction for a fractured femur. Which assessment findings indicate that the child is developing an infectionZ? (select all that apply)
Lethargy Increased pulse rate Increased body temperature
The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What is the most essential part of the nursing assessment to detect early signs of a worsening condition?
Level of consciousness
a 7 year old child is diagnosed with type 1 diabetes. What is one of the symptoms noticed by parents when this illness develops in the develops in the child?
Loss of weight
67.The nurse is caring for a newborn diagnosed with patent ductus arteriosus. Which finding will the nurse assess that is consistent with this diagnosis?
Machine like murmur heard at the left sub clavicular margin
The mother of a school age child is distraught because the child has been diagnosed with obesity. What teaching will the nurse provide to the family regarding achieving the goal of BMI within normal range?(select all that apply)
Maintain a balanced eating approach in the home Encourage participation in a new sport in which the child has an interest Encourage increased activity such as walking the dog after school.
A 2 year old is diagnosed with osteomyelitis. Which of the following would you anticipate as a primary nursing intervention to include in the plan of care?
Maintaining intravenous antibiotic therapy
During an assessment the nurse determines that a 3-month old baby has a Moro reflex. What does this finding indicates to the nurse?
Most 3month -old's still have a Moro reflex
Parents asks the nurse why their premature infant is receiving a feeding through the mouth rather than the nose. What is the best explanation by the nurse?
Newborns are obligate nose breathers so nasogastric their breathing
Management of primary dysmenorrhea often requires a multifaceted approach. The nurse who provides care for a client with this condition should be aware that the optional pharmacological therapy for pain relief is:
Non-steroidal anti inflammatory drugs (NSAIDS)
63. a nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?
Painless bright red vaginal bleeding
A patient in labor with chronic back pain tells the nurse about taking a dose of hydrocodone/acetaminophen (vicodin) for labor pain prior to coming to the hospital. What should the nurse prepare to do after the fetus is delivered?
Perform ongoing assessment of the infant for withdrawal symptoms after delivery
88.A nurse is caring for a client who is in the first stage of labor with report of ruptured membranes prior to admission to the labor unit. The nurse observes the fetal heart rate changes baseline from 150/min to 110/min. during a vaginal exam. The nurse notes a pulsation at the cervix. Which of the following actions should the nurse perform first?
Place the client in the supine position
A woman is 39 weeks gestation with severe abdominal pain that remains constant. She is being admitted to the labor and delivery unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes, has dark red vaginal bleeding, and a tense rigid abdomen. What should the nurse suspect at this time?
Placenta abruption
The nurse is caring for a chronically ill adolescent. The nurse recommends which of the following to prevent the pediatric client from feeling lonely
Plan activities so there are time for rest periods
A nurse is caring for a child who is experiencing a generalized tonic/clonic seizure. Which of the following is the priority action for the nurse to take?
Position the child in aside- lying position
The nurse in the pediatric clinic is providing teaching to the family of a 1month old infant with gastroesophageal reflux. Which of the following will be included in the teaching?
Position upright for 30 minutes after feedings
Which technique should the nurse use to administer eardrops to a 4 year old child?
Pull the pinna of the ear up and back
The clinic is providing a federally approved car seat to an infant's family. The nurse should explain that the safest place to install the car seat in the vehicle is:
Rear facing in back seat
A newborn is diagnosed with coarctation of the aorta. Which assessment should the nurse make when caring for this infant?
Recording an upper extremity blood pressure
A child in kidney failure has had a kidney transplant. What should the nurse include in the teaching regarding postoperative care?
Reduce socialization for infection control precautions???
The nurse is planning care for a preschool age child diagnosed with meningitis. What should the nurse identify as a priority goal for these patients care?
Reduce the pain related to nuchal rigidity
What education should a nurse provide to a parent to help their child complete Eriksons developmental task during the infant period?
Respond to the child's needs consistently.
The nurse obtains a stool specimen for ova and parasites. Which of the following is the responsibility of the nurse?
See that it arrives at the laboratory promptly
A terminally ill child is awake at 2AM and continues to put on the call light. What should the nurse do regarding this child's behavior?
Sit with the child until sleep comes
The nurse is caring for an adolescent female after a sexual assault. She notes which of the following to be consistent with post-traumatic stress disorder (PTSD) (select all that apply)
Sleep Disturbances Hypervigilance Flashbacks Withdrawal from family
An infant is prescribed digoxin. The nurse teaches the parents that the action of digoxin is to do which of the following?
Slow and strengthen her heartbeat
a nurse is providing care to a 9 year old child who has fractured his left distal radius. Which of the following actions should be included he plan of care for this patient? (SATA)
Stabilize the injury Elevate the arm Assess neurovascular status
Which personal protective equipment will the nurse wear while inserting a urinary catheter on a child positive for HIV and tuberculosis?(SATA)
Sterile gloves N-95 respirator Disposable gown Protective eye shield
A toddler who has Kawasaki disease (KD) is admitted to the pediatric unit. Which of the following findings should the nurse expect to observe during the physical assessment?(SATA)
Strawberry tongue Edema of hands and feet Conductivities without exudate
A nurse in the newborn nursery is monitoring a newborn infant for respiratory distress syndrome. Which assessment signs, if noted in the newborn would alert the nurse to the possibility of this syndrome?
Tachypnea and retractions
The nurse is caring for an 8 month old baby diagnosed with spastic cerebral palsy. Which assessment finding supports this medical diagnosis?
The child has a strong Moro reflex when startled
The nurse is visiting the home of family with a previous history of physical neglect. Which observation indicates that interventions have not been successful?
The father allows the children to stay home from school whenever they desire
The nurse is evaluating outcomes about a family's ability to care for an adolescent child who is recovering from a spinal cord injury. Which statements indicate that this family is transitioning in a healthy manner?
The mother and father state the ability to provide care for the child is becoming easier.
After cardiac surgery, a child has chest tubes inserted that are attached to an underwater seal drainage system. When should the nurse be prepared to clamp chest tubes?
The tube becomes disconnected
A parent of a school aged child is distressed to learn of the child is diagnosed with type 2diabetes mellitus. The parent asks the nurse how this could happen because no one in the family has diabetes. Which response is most accurate?
This disorder is associated with metabolic disturbances that result in insulin resistance
A 6 month old girl is diagnosed as having atopic dermatitis. When interviewing her parents they describe the following care measures. Which one would lead you to think more health teaching is needed?
To dry lesions the father applies alcohol to lesions daily
The nurse on the pediatric unit is caring for a child admitted for epiglottis. Which of the following would be appropriate positioning for this patient?
Upright
The nurse is concerned that a pregnant patient is using cocaine. What should the nurse suggest to the health care provider to confirm this suspicious?
Urinalysis
A 7 year old child presents to the pediatric clinic with a reported history of low grade fever followed by the development of a rash. On assessment the nurse notes multiple red papules vesicles and crusted lesions scattered over the trunk face and extremities, What disease/disorder would the nurse expect the client is exhibiting?
Varicella (Chicken pox)
A 4 year old child is being prepared to undergo a bronchoscopy to remove an aspirated pea. Which statement by the parent would the nurse determine the need for further teaching?
We will be able to take our child home immediately after the procedure is completed.
The pediatric nurse is assessing a 4 -month old infant in the clinic. The childs mother explains that they recently visited a theme park and afterward learned that there had been four (4) cases of measles diagnosed in children who had visited the park on the same day. When providing education to the mother regarding how she can protect her child from measles infection, the most appropriate statement for the nurse to make is which of the following?
Your daughter will be able to receive the measles vaccine after 12 months of age
