NCLEX OB/PEDS Questions

The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction? 1. "I will clean up any spills from the diaper with diluted alcohol." 2. "I will wash baby bottles, nipples, and pacifiers in the dishwasher." 3. "I will be sure to prepare foods that are high in calories and high in protein." 4. "I will be sure to wash my hands carefully before and after caring for my infant."

1. "I will clean up any spills from the diaper with diluted alcohol." rationale: clean with bleach not alcohol

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply. 1. Place the infant in a private room. 2. Ensure that the infant's head is in a flexed position. 3. Wear a mask, gown, and gloves when in contact with the infant. 4. Place the infant in a tent that delivers warm humidified air. 5. Position the infant on the side, with the head lower than the chest. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

1. Place the infant in a private room. 3. Wear a mask, gown, and gloves when in contact with the infant. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1."I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 4."I will start my estrogen birth control pills again as soon as I get home." 5."I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby." 6."I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

1."I should wear a bra that provides support." 2."Drinking alcohol can affect my milk supply." 3."The use of caffeine can decrease my milk supply." 6."I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your newborn by nasogastric tube feeding." 3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

1."You will need to bottle-feed your newborn."

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 1.A primigravida with abruptio placenta 2.A primigravida who delivered a 10-lb infant 3 hours ago 3.A gravida 2 who has just been diagnosed with dead fetus syndrome 4.A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood 5.A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension

1.A primigravida with abruptio placenta 3.A gravida 2 who has just been diagnosed with dead fetus syndrome 5.A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension Rationale:In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Predisposing conditions include abruptio placentae, amniotic fluid embolism, gestational hypertension, HELLP syndrome, intrauterine fetal death, liver disease, sepsis, severe postpartum hemorrhage, and blood loss

The nurse is performing an assessment on a 10-year-old child suspected to have Hodgkin's disease. Which assessment findings are specifically characteristic of this disease? Select all that apply. 1.Abdominal pain 2.Fever and malaise 3.Anorexia and weight loss 4.Painful, enlarged inguinal lymph nodes 5.Painless, firm, and movable adenopathy in the cervical area

1.Abdominal pain 5.Painless, firm, and movable adenopathy in the cervical area

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1.Administer oxygen via face mask. 2.Place the mother in a supine position. 3.Increase the rate of the oxytocin intravenous infusion. 4.Document the findings and continue to monitor the fetal patterns.

1.Administer oxygen via face mask.

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. 1.Allows for fetal movement 2.Surrounds, cushions, and protects the fetus 3.Maintains the body temperature of the fetus 4.Can be used to measure fetal kidney function 5.Prevents large particles such as bacteria from passing to the fetus 6.Provides an exchange of nutrients and waste products between the mother and the fetus

1.Allows for fetal movement 2.Surrounds, cushions, and protects the fetus 3.Maintains the body temperature of the fetus 4.Can be used to measure fetal kidney function

The nurse is caring for a child diagnosed with erythemia infectiosum (fifth disease). Which clinical manifestation should the nurse expect to note in the child? 1.An intense fiery red edematous rash on the cheeks 2.Pinkish-rose maculopapular rash on the face, neck, and scalp 3.Reddish and pinpoint petechiae spots found on the soft palate 4.Small bluish-white spots with a red base found on the buccal mucosa

1.An intense fiery red edematous rash on the cheeks

An infant of a mother infected with human immunodeficiency virus (HIV) is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses the infant for which sign? 1.Cough 2.Liver failure 3.Watery stool 4.Nuchal rigidity

1.Cough

The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply. 1.Easy bruising occurs. 2.Gum bleeding occurs. 3.It is a hereditary bleeding disorder. 4.Treatment and care are similar to that for hemophilia. 5.It is characterized by extremely high creatinine levels. 6.The disorder causes platelets to adhere to damaged endothelium.

1.Easy bruising occurs. 2.Gum bleeding occurs. 3.It is a hereditary bleeding disorder. 4.Treatment and care are similar to that for hemophilia. 6.The disorder causes platelets to adhere to damaged endothelium.

The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis? 1."His pediatrician said his kidneys are working well." 2."I noticed his urine was the color of cola lately." 3."I'm so glad they didn't find any protein in his urine." 4."The nurse who admitted my child said his blood pressure was low."

2."I noticed his urine was the color of cola lately."

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? 1.Warm, dry skin 2.Decreased wheezing 3.Pulse rate of 90 beats per minute 4.Respirations of 18 breaths per minute

2.Decreased wheezing

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats per minute for the past hour. What is the priority nursing action? 1.Notify the primary health care provider. 2.Discontinue the infusion of oxytocin. 3.Place oxygen on at 8 to 10 L/minute via face mask. 4.Contact the client's primary support person(s) if not currently present.

2.Discontinue the infusion of oxytocin. Rationale: The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1.G = 3, T = 2, P = 0, A = 0, L = 1 2.G = 2, T = 1, P = 0, A = 0, L = 1 3.G = 1, T = 1, P = 1, A = 0, L = 1 4.G = 2, T = 0, P = 0, A = 0, L = 1

2.G = 2, T = 1, P = 0, A = 0, L = 1

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2020. Using Näegele's rule, which expected date of delivery should the nurse document in the client's chart? 1.July 12, 2021 2.July 26, 2021 3.August 12, 2021 4.August 26, 2021

2.July 26, 2021

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? 1.Initiate strict enteric precautions. 2.Move the infant to a private room. 3.Leave the infant in the present room, because RSV is not contagious. 4.Inform the staff that using standard precautions is all that is necessary when caring for the child.

2.Move the infant to a private room.

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1.The client is a 35-year-old primigravida. 2.The client has a history of cardiac disease. 3.The client's hemoglobin level is 13.5 g/dL (135 mmol/L). 4.The client is a 20-year-old primigravida of average weight and height.

2.The client has a history of cardiac disease.

The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1.Monitor fetal heart rate continuously. 2.Monitor maternal vital signs frequently. 3.Perform a vaginal examination every shift. 4.Administer an antibiotic per prescription and per agency protocol.

3. Perform a vaginal examination every shift.

A 6-year-old child with human immunodeficiency virus (HIV) infection has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child? 1."The pain will go away if you lie still and let the medicine work." 2."Try not to think about it. The more you think it hurts, the more it will hurt." 3."I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less." 4."Every time it hurts, press on the call button and I will give you something to make the pain go all away."

3."I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less."

Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder? 1."Treatment needs to be started as soon as possible." 2."I realize my infant will require follow-up care until fully grown." 3."I need to bring my infant back to the clinic in 1 month for a new cast." 4."I need to come to the clinic every week with my infant for the casting."

3."I need to bring my infant back to the clinic in 1 month for a new cast."

A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. What is the nurse's best response? 1. "It's very costly, and chemotherapy works just as well." 2. "I'm not sure. I'll discuss it with the primary health care provider." 3. "Sometimes age has to do with the decision for radiation therapy." 4. "The primary health care provider would prefer that you discuss treatment options with the oncologist."

3."Sometimes age has to do with the decision for radiation therapy."

Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. 1.It cushions and protects the baby. 2.It maintains the temperature of the baby. 3.It is the way the baby gets food and oxygen. 4.It prevents all antibodies and viruses from passing to the baby. 5.It provides an exchange of nutrients and waste products between the mother and developing fetus.

3.It is the way the baby gets food and oxygen. 5.It provides an exchange of nutrients and waste products between the mother and developing fetus.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action? 1.Document the finding. 2.Check the mother's heart rate. 3.Notify the obstetrician (OB). 4.Tell the client that the fetal heart rate is normal.

3.Notify the obstetrician (OB). The FHR depends on gestational age and ranges from 160 to 170 beats per minute in the first trimester but slows with fetal growth to 110 to 160 beats per minute. If the FHR is less than 110 beats per minute or more than 160 beats per minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the OB. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the OB needs to be notified.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3.Rigid extension and pronation of the arms and legs

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1.The contractions are regular. 2.The membranes have ruptured. 3.The cervix is dilated completely. 4.The client begins to expel clear vaginal fluid. 5.The Ferguson reflex is initiated from perineal pressure.

3.The cervix is dilated completely. 5.The Ferguson reflex is initiated from perineal pressure.

Which question should the nurse ask the parents of a child suspected of having glomerulonephritis? 1."Did your child fall off a bike onto the handlebars?" 2."Has the child had persistent nausea and vomiting?" 3."Has the child been itching or had a rash anytime in the last week?" 4."Has the child had a sore throat or a throat infection in the last few weeks?"

4."Has the child had a sore throat or a throat infection in the last few weeks?"

The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The pediatrician has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV infection. The nurse should make which most appropriate response to the mother? 1."I am so pleased also that everything has turned out fine." 2."Because symptoms have not developed, it is unlikely that your infant will develop HIV infection." 3."Everything looks great, but be sure to return with your infant next month for the scheduled visit." 4."Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

4."Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? 1.Side or prone 2.Back or prone 3.Stomach with the face turned 4.Back rather than on the stomach

4.Back rather than on the stomach

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1.Nausea 2.Irritability 3.Headache 4.Bradycardia

4.Bradycardia

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1.Enlargement of the breasts 2.Complaints of feeling hot when the room is cool 3.Periods of fetal movement followed by quiet periods 4.Evidence of bleeding, such as in the gums, petechiae, and purpura

4.Evidence of bleeding, such as in the gums, petechiae, and purpura

The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant? 1.Diarrhea 2.Projectile vomiting 3.Regurgitation of feedings 4.Foul-smelling ribbon-like stools

4.Foul-smelling ribbon-like stools

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan? 1.Assessing hearing loss 2.Monitoring urine output 3.Changing body position every 2 hours 4.Providing a quiet atmosphere with dimmed lighting

4.Providing a quiet atmosphere with dimmed lighting

The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)? 1.Urinary output has increased. 2.Dependent edema has resolved. 3.Blood pressure reading is at the prenatal baseline. 4.The client complains of a headache and blurred vision.

4.The client complains of a headache and blurred vision.

A diagnosis of Hodgkin's disease is suspected in a 12-year-old child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease? 1.Elevated vanillylmandelic acid urinary levels 2.The presence of blast cells in the bone marrow 3.The presence of Epstein-Barr virus in the blood 4.The presence of Reed-Sternberg cells in the lymph nodes

4.The presence of Reed-Sternberg cells in the lymph node

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1.Variability 2.Accelerations 3.Early decelerations 4.Variable decelerations

4.Variable decelerations