Maternity Chap 22
The nurse instructs the mother of a 2-year-old who is taking iron supplements for anemia that some foods reduce the absorption of iron. What would be the best example provided by the nurse? a. Red meat b. Green, leafy vegetables c. Acidic fruit juices d. Egg yolks
d
Where is the best site for giving an IM injection to a 15-month-old child? a. Ventrogluteal muscle b. Dorsogluteal muscle c. Deltoid muscle d. Vastus lateralis muscle
d
Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity? a. Discard the residual and increase the volume of feeding by the amount of residual. b. Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding. c. Refill the syringe with formula after it has completely emptied. d. Position the child on the right side after a feeding.
d
Which strategy might the nurse use when administering oral medications to a young child who is reluctant? a. Mix the medication with chocolate milk. b. Tell the child that the medication is candy. c. Give the medication quickly if the child is crying. d. Offer the child fruit juice after the medication is swallowed
d
What intervention should the nurse implement after topical administration of hydrocortisone cream to the buttocks and abdomen of an infant? a. Diaper the infant snugly with a disposable diaper. b. Cover the area with a transparent dressing. c. Apply a cloth diaper. d. Place the infant on a plastic pad, undiapered.
c
Which intervention will the nurse implement when suctioning a tracheostomy? a. Suction for two to three breaths. b. Clear the catheter with water after suctioning for reuse. c. Apply suction for no more than 15 seconds. d. Establish a regular schedule for suctioning.
c
Why is a tympanic thermometer considered more accurate than other types of thermometers? a. The thermometer probe is blunt and wide. b. It takes a brief time to register. c. The tympanic membrane shares circulation with the hypothalamus. d. The tympanic membrane and the brain have the same temperature
c
A 9-year-old child is preparing for a lumbar puncture. What position will the nurse explain the child will assume for this procedure? a. On your stomach with your head turned to the side. b. On your side, keeping the legs bent and the head arched back. c. On your back with your legs extended straight out. d. On your side with the knees bent and the head close to the knees.
d
What emergency action should be implemented for airway obstruction in the infant? a. Six to 10 midsternal thrusts b. Five back blows followed by five chest thrusts c. Five chest thrusts followed by five back blows d. Abdominal thrusts until the object is expelled
b
What is the best pulse location for the nurse to use when assessing the pulse rate on a 12-month-old infant? a. Brachial b. Apical c. Radial d. Femoral
b
Which observation on entering the hospital room lets the nurse know that there is a need for the parents to receive safety education to prevent unintentional injury? a. The blanket is not tucked into the mattress. b. Diapers and wipes are stacked at the foot of the crib. c. The crib side is locked in the up position. d. Pillows are stacked on the bedside table.
b
How often should a child who has a continuous intravenous infusion should be assessed? a. Hourly b. Every 2 hours c. Every 3 hours d. Every 4 hours
a
The nurse preparing to administer medication to a 2-month-old infant discovers there is no ID bracelet on the child. What should be the next action by the nurse? a. Give the medication after confirming the childs name from the foot of the crib. b. Ask the charge nurse to give the medicine. c. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine. d. Delay the medication until the admissions office can supply a new ID bracelet.
c
What factor does the nurse explain affects the infants physiological response to medications? a. Faster metabolism in the liver b. Slower intestinal transit c. Immature kidney function d. Increased secretion of hydrochloric acid
c
Gentamicin ear drops are prescribed for a 4-year-old child. How would the nurse position the auricle when administering the ear drops? a. Up and back b. Down and back c. Up and out d. Down and out
a
Which restraint is most appropriate for the insertion of an intravenous line in a scalp vein of an infant? a. Mummy b. Clove hitch c. Jacket d. Elbow
a
Informed consent for a minor guarantees that the parent or legal guardian understands what aspect(s) of a procedure? (Select all that apply.) a. Purpose of the procedure b. Risks associated with the procedure c. That no suit can be brought for damages d. That the document must be signed and witnessed e. That information was given
a, b, d, e
Which specific drug(s) should be checked with a second licensed nurse prior to administration? (Select all that apply.) a. Insulin b. Digoxin c. Vasodilators d. Calcium salts e. Anticoagulants
a, b, d, e
What should the nurse assess to determine the method of transportation for a pediatric patient? (Select all that apply.) a. Age b. Race c. Vital signs d. Distance to travel e. Level of consciousness
a, d, e
A 15-year-old patient returns to the pediatric unit following a lumbar puncture. What initial position will the nurse maintain for this patient? a. Left side-lying b. Supine c. Prone d. Semi-Fowlers
b
A 4-year-old asks tearfully if the IM injection will hurt. What is the nurses most effective response? a. No. It is over before you know it. b. Yes. It will sting a little. c. No. Would you like to see the syringe? d. Yes. Your mom and I are going to hold you to help you be still
b
An infants dry diaper weighs 2.5 grams. The wet diaper weighs 47 grams. How would the nurse record the infants urine output? a. 47 mL b. 44.5 mL c. 43.5 mL d. 40.5 m
b
The nurse instructed an adolescent female about collecting a clean-catch urine specimen. What statement made by the adolescent led the nurse to determine she understood the instructions? a. I should wash my perineum with soap and water, then begin to urinate. b. I clean the perineum from front to back with an antiseptic wipe before I urinate. c. Ill collect the first stream of urine in a sterile container. d. I will discard the first void and collect a freshly voided specimen 30 minutes later.
b
The pediatric nurse completes an assessment on all patients assigned during evening shift at the hospital. Which patient assessment requires immediate intervention? a. Toddler with an axillary temperature of 99 F b. School-age child with widening pulse pressure c. Infant pulse rate of 100 beats per minute d. Adolescent with a respiratory rate of 28 breaths per minute
b
The prescription for a 4-month-old is penicillin G 150,000 units intramuscularly bid. The drug is supplied as a unit dose of 600,000 units in a 5-mL vial. How many milliliters (mL) should the nurse provide? a. 1.25 b. 1.4 c. 1.6 d. 1.8
b
A 3-year-old patient is admitted to the pediatric unit with a fever of 103 F. Which actions will the nurse implement? (Select all that apply.) a. Assess rectal temperature every 4 hours. b. Administer Acetaminophen as ordered. c. Assess skin turgor. d. Restrict fluids. e. Assess level of consciousness.
b, c, e
A parent tells the nurse, Im not sure how to give this medicine to my infant. How would the nurse teach the parent to best administer an oral suspension? a. Pour the medication into a small cup and allowing the infant to drink it. b. Place the medication in a nipple and having the infant suck the nipple. c. Use an oral syringe and placing the medication in the side of the infants mouth. d. Administer the medication with a dropper onto the back of the infants tongue
c
The nurse is caring for a 4-year-old child. What will the nurse expect the childs daily urinary output to be? a. 400 to 500 mL b. 500 to 600 mL c. 600 to 700 mL d. 700 to 1000 mL
c
