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Parent Child Final Exam

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119. How does the nurse know that a client, at 40 weeks' gestation, is experiencing true labor? 1. cervical dilation 2. membranes rupture 3. fetal heart rate decreases 4. contractions become more intense

378. A newborn is being treated with phototherapy for hyperbilirubinemia. What is the nurse's role when providing phototherapy? 1. turning the infant every 2 hours 2. placing a diaper over the naked infant 3. maintaining the infant on daily 24-hour phototherapy 4. applying sterile gauze pad on the infant's umbilical stump

383. A nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually causes central cyanosis? 1. shunting of blood from right to left 2. shunting of blood from left to right 3. obstruction of blood flow from the left side of the heart 4. obstruction of blood flow between left and right sides of the heart

395. A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? Select all that apply. 1. _____ Cracked and peeling skin 2. _____ Long scalp hair and fingernails 3. _____ Red, puffy appearance of face and neck 4. _____ Vernix caseosa covering back and buttocks 5. _____ Creases on entire soles of feet and palms of hands

1,2,5

269. A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 and she has 2+ protein in her urine and edema of the hands and face. For which signs or symptoms should the nurse assess to determine if the client may be developing HELLP syndrome? Select all that apply. 1. headache 2. constipation 3. abdominal pain 4. vaginal bleeding 5. flulike symptoms

1,3,5

117. To confirm a tentative diagnosis of leukemia a bone marrow aspiration and biopsy are to be performed on a 4-year-old boy. The nurse gives an age-appropriate explanation of the procedure to the child. What else is involved in caring for this child? 1. telling the child that there will be pressure without pain 2. explaining to the child that he will sleep during the procedure 3. placing the child in the semi-Fowler position supported by pillows 4. asking the child to hold some nonsterile equipment during the test

125. A nurse is assessing a child with the diagnosis of hemophilia. In what part of the body does the nurse expect bleeding to occur? 1. brain 2. joints 3. intestines 4. pericardium

191. A client arrives at the clinic with swollen, tender breasts and flulike symptoms. A diagnosis of mastitis is made. What does the nurse plan to do? 1. assist her to wean the infant gradually 2. teach her to empty her breasts frequently 3. review breastfeeding techniques with her 4. send a sample of her milk to the lab for testing

206. The nurse explains to a pregnant client undergoing a nonstress test that the test is a way of evaluating the condition of the fetus by comparing the fetal heart rate with: 1. fetal lie 2. fetal movement 3. maternal blood pressure 4. maternal uterine contractions

209. Lab studies reveal that a pregnant client's blood type is O+. Problems related to the incompatibility may develop if the infant is: 1. Rh negative 2. Type A or B 3. Born preterm 4. Type O+

224. An infant with a cleft lip is fed with a special nipple. What should the nurse teach the parents about feeding their infant to minimize regurgitation? 1. offer a thickened formula 2. burp frequently during a feeding 3. place in an infant seat when feeding 4. position on the side with the bottle propped

268. What should the nurse assess before continuing the administration of IV magnesium sulfate therapy to a client with preeclampsia? 1. temperature and respirations 2. plantar reflexes and urinary output 3. urinary glucose and specific gravity 4. level of consciousness and funduscopic appearance

328. A newborn develops jaundice 72 hours after birth. What should the nurse explain to the parents is the probable cause of the jaundice? 1. an allergic response to the feedings 2. the physiologic destruction of fetal red blood cells 3. a temporary bile duct obstruction commonly found in newborns 4. the seepage of maternal Rh- blood into the neonate's bloodstream

329. A community health nurse visits an infant who was born at home 24 hours ago. When assessing the infant the nurse identifies slight jaundice of the face and trunk. What should the nurse do next? 1. plan for immediate admission to the hospital 2. obtain a practitioner's order for a bilirubin level 3. document this expected finding in the infant's record 4. arrange for the infant to have phototherapy in the home

346. A nurse assess that a newborn is in respiratory distress. Which signs confirm this assessment? Select all that apply. 1. Crackles 2. Cyanosis 3. Wheezing 4. Tachypnea 5. Retractions

2,4,5

144. An infant is admitted to the pediatric unit with the diagnosis of heart failure. What should the nurse include in the plan of care? 1. increase fluid intake 2. position flat on the back 3. offer small frequent feedings 4. measure head circumference

148. A client in labor is receiving a Pitocin infusion. What should the nurse do first when repetitive late decelerations of the fetal heart rate are observed? 1. administer oxygen 2. place the client on the left side 3. discontinue the oxytocin infusion 4. check the client's blood pressure

379. A nurse performs cupping, percussion, and postural drainage every 4 hours for a 6 month-old infant with cystic fibrosis. When is the best time for scheduling chest physiotherapy? 1. just before feedings 2. during each feeding 3. midway between feedings 4. immediately after every feeding

414. A 3-year-old child is admitted to the pediatric unit with a tentative diagnosis of Wilms tumor. The nurse obtains the child's health history from the parents. What does the child's history reveal that will aid in establishment of the diagnosis? 1. periorbital edema 2. projectile vomiting 3. abdominal swelling 4. low-grade temperature

421. A client at 18 weeks' gestation visits the prenatal clinic stating she still is very nauseated and vomits frequently. Physical examination reveals that she has a brown vaginal discharge and her blood pressure is 148/90. What condition does the nurse suspect the client is experiencing? 1. Dehydration 2. Choriocarcinoma 3. Hydatidiform mole 4. Threatened abortion

202. A client has a diagnosis of an unruptured tubal pregnancy. Which assessments correlate with this diagnosis? Select all that apply. 1. firm, rigid abdomen 2. referred shoulder pain 3. unilateral abdominal pain 4. history of STI 5. ecchymotic blueness around the umbilicus

3,4

115. A 4-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia. What signs and symptoms does the nurse expect when obtaining the health history and performing a physical assessment? Select all that apply. 1. edema 2. alopecia 3. anorexia 4. insomnia 5. petechiae

3,5

120. The nurse is interpreting the results of a nonstress test on a client at 41 weeks' gestation. After 20 minutes, which result is suggestive of fetal reactivity? 1. absent long-term variability 2. above average fetal baseline heart rate of 160 3. no late decelerations associated with contractions 4. 2 accelerations of 15 beats per minute lasting 15 seconds

130. A child with leukemia is to be discharged home on a protocol that includes several antineoplastic medications. What should the nurse plan to teach the parents? 1. use an electric toothbrush to provide meticulous oral care 2. limit their child's contact with peers to avoid being exposed to infections 3. withhold the antineoplastic medications when vomiting occurs to prevent additional episodes 4. notify the practitioner if the child has a temperature of 100F to obtain an antibiotic prescription

389. A newborn with a myelomeningocele is transferred immediately from the birthing room to the neonatal intensive care unit (NICU). What is the first nursing intervention? 1. Assess for paralysis 2. Start antibiotic prophylaxis 3. Provide routine newborn care 4. Apply a sterile saline dressing

405. What is a nurse's most important concern when caring for a client with a ruptured tubal pregnancy? 1. infection 2. hypervolemia 3. protein deficiency 4. diminished cardiac output

273. An amniotomy is performed to stimulate labor in a client who is at 42 weeks' gestation. Place the nursing care in order or priority. 1. check the fetal heart rate tracings 2. evaluate the client for signs of an infection 3. assess the characteristics of amniotic fluid 4. observe the perineum for umbilical cord prolapse

4,1,3,2

At what APGAR score at 5 minutes after birth should resuscitation be initiated? A. 1-3 B. 7-8 C. 9-10 D. 6-7

To prevent preterm labor from progressing, drugs are usually prescribed to halt the labor. The drugs commonly given are: A. Magnesium sulfate and terbutaline B. Prostaglandin and oxytocin C. Progesterone and estrogen D. Dexamethasone and prostaglandin

A child with impetigo has a 24 month old sister at home. What will you be sure to include in your teaching to the parents about this condition? A. Keep the child's nails short B. Separate towels and other linens used by the child C. Wash hands with antibacterial soap regularly D. Prevent the child from scratching the lesions E. Vacuum carpets and furniture regularly F. Store stuffed animals and toys in plastic bags for 5 days

A, B, C, D

A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)? A. Elevated blood pressure B. Negative urinary protein C. Facial edema D. Increased respirations

A, C

Lochia normally disappears after how many days postpartum? A. 5 days B. 7-10 days C. 18-21 days D. 28-30 days

A patient is currently 34 weeks pregnant with her first baby. Which findings below could indicate the development of preeclampsia in this patient that would need to be reported to the physician? Select all that apply: A. 1600: blood pressure 144/100, 1700: blood pressure 120/80 B. 3+ dipstick urine protein C. 1 hour glucose tolerance test 90 mg/dL D. 0800: blood pressure 142/92, 1230: blood pressure: 144/98 E. <300 mg/dL 24-hour urine protein

B, D

A 35-year-old female is in labor. The baby is engaged in the pelvis. As the nurse you know that this means that the fetal station is approximately? A. +1 B. 0 C. +2 D. -1

B. 0

A 2 year-old patient with cystic fibrosis is scheduled to take Pancrelipase. How will you administer this medication? A. orally with yogurt B. orally with pudding C. orally with applesauce D. orally with ice cream

C. orally with applesauce

A 5-year-old girl Hannah is recently diagnosed with Kawasaki disease. Apart from the identified symptoms of the disease, she may also likely develop which of the following? A. Sepsis B. Meningitis C. Mitral valve disease D. Aneurysm formation

A child is diagnosed with Wilms' tumor. During assessment, the nurse in charge expects to detect: A. Gross hematuria B. Dysuria C. Nausea and vomiting D. An abdominal mass

A laboring client has external electronic fetal monitoring in place. Which of the following assessment data can be determined by examining the fetal heart rate strip produced by the external electronic fetal monitor? A. Gender of the fetus B. Fetal position C. Labor progress D. Oxygenation

A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for: A. One peripad per day B. Two peripads per day C. Three peripads per day D. Eight peripads per day

Immediately before expulsion, which of the following cardinal movements occur? A. Descent B. Flexion C. Extension D. External rotation

What type of milk is present in the breasts 7 to 10 days PP? A. Colostrum B. Hind milk C. Mature milk D. Transitional milk

A parent brings her child into the clinic due to skin lesions that fail to heal. The lesions are red, reported to be itchy, and exhibit exudate. You suspect the child may have impetigo. What is a hallmark finding with this condition? A. Round patches with light pink centers B. Short grey lines on the skin C. Silver colored scales over the lesions D. Yellow crusts over the lesions

D. Yellow crusts over the lesions

When do most patients tend to develop gestational diabetes during pregnancy? A. usually during the 1-3 month of pregnancy B. usually during the 2-3 month of pregnancy C. usually during the 1-2 trimester of pregnancy D. usually during the 2-3 trimester of pregnancy

D. usually during the 2-3 trimester of pregnancy

A 39 week pregnant patient is in labor. The patient has preeclampsia. The patient is receiving IV Magnesium Sulfate. Which finding below indicates Magnesium Sulfate toxicity and requires you to notify the physician? A. Deep tendon reflex 4+ B. Respiratory rate of 13 breaths per minute C. Urinary output of 600 mL over 12 hours D. Clonus presenting in the lower extremities E. Patient reports flushing or feeling hot

E. Patient reports flushing or feeling hot The nurse should monitor for Magnesium Sulfate toxicity. Signs of this include: EARLY: flushing or feeling hot/warm, later on: decreased or absent reflexes (finding of 4+ Deep tendon reflex is considered HYPERreflexia), Respiratory rate less than 12 breaths per minute, Urinary output of less than 30 mL/hr, EKG changes.

272. An infusion of oxytocin is administered to a client for induction of labor. After several minutes the uterine monitor indicates contractions lasting 100 seconds with a frequency of 130 seconds. What is the next nursing action? 1. discontinue the infusion 2. check the fetal heart rate 3. slow the oxytocin rate 4. turn the client onto her left side

317. An infant with myelomeningocele is scheduled for surgery to close the defect. Which nursing action best facilitates parent-child-relationships in the preoperative period? 1. encouraging the parents to stroke the infant 2. allowing the parents to hold their infant in their arms 3. referring the parents to the Spina Bifida Association of America 4. teaching the parents to use special techniques when feeding the infant

354. Why is it important for the nurse to know the infant's gestational age and how it compares with the birthweight? 1. potential problems may be identified 2. infants lose weight during the first few days of life 3. infant's weight must be included on the admission record 4. health insurance companies need this information for evaluating benefits

396. What does the nurse expect concerning the alveoli in the lungs of a 28-week-gestation neonate? 1. they have a tendency to collapse with each breath 2. there usually is a sufficient supply of pulmonary surfactant 3. although apparently mature they cannot absorb adequate oxygen 4. oxygen is not released into the circulation because they overinflate

403. While a client is being prepared for surgery because of a ruptured tubal pregnancy, the client complains of feeling lightheaded. Her pulse is rapid, and her color is pale. What condition does the nurse suspect the client has? 1. shock 2. anxiety 3. infection 4. hyperoxia

437. A nurse is helping a child with juvenile idiopathic arthritis perform range-of-motion exercises. What outcome indicates that the exercises have been effective? 1. knees are more mobile 2. pedal pulses become stronger 3. statement that there is less pain 4. subcutaneous nodules at the joints recede

439. When assessing a child who has just had a short arm cast applied to a fractured right wrist the nurse discovers that the fingers of the right had are cool. What should the nurse do first? 1. compare the temperature of each hand 2. clip the edge of the cast to reduce pressure 3. elevate the right arm to reduce swelling 4. inform the practitioner of the circulatory impairment

449. A spinal fusion is performed on an adolescent with scoliosis. What postoperative nursing intervention is specifically related to surgery for scoliosis? 1. log-rolling every 2 hours 2. checking the dressing frequently 3. supervising deep breathing exercises 4. maintaining the supine position for 3 days

86. The nurse discusses the recommended weight gain during pregnancy with a newly pregnant client, who is 5 feet, 3 inches tall and weighs 125 pounds. The nurse explains that to achieve the recommended weight gain at term, the client should weigh about: 1. 150 lbs 2. 140 lbs 3. 135 lbs 4. 130 lbs

225. What is the primary focus of preoperative nursing care for an infant with a cleft lip? 1. avoiding crying 2. modifying feeding 3. preventing infection 4. minimizing handling

227. A nurse is feeding an infant with a recent surgical repair on a cleft lip. What does the nurse plan to do for the infant just after each feeding? 1. burp several times 2. rinse the suture line 3. place on the abdomen 4. hold for several minutes

228. A nurse is caring for an infant during the immediate postoperative period after surgical repair of a cleft lip. What is the priority nursing action for this infant? 1. keep restrained 2. minimize crying 3. oxygenate frequently 4. handle as little as possible

231. A mother of an infant diagnosed with Hirschsprung's disease asks the nurse about the disorder. The nurse plans to base the response on which of the following? 1. "Surgery will not be necessary" 2. "This disorder has an excellent prognosis" 3. "Special feedings will be necessary for several months" 4. "This disorder is caused by an inborn error of metabolism"

235. A client in labor is admitted with a suspected breech presentation. For what occurrence should the nurse be prepared? 1. uterine inertia 2. prolapsed cord 3. imminent birth 4. precipitate labor

236. An infant who had surgery for hypertrophic pyloric stenosis is being bottle fed by the mother. What should the nurse teach the mother about care after feeding to decrease the change of the infant vomiting? 1. rock for 20 minutes 2. place in an infant seat 3. keep awake for 20 minutes 4. position flat on the right side

249. A client who had Tocolytic therapy for preterm labor is being discharged. What instructions should the nurse include in the teaching plan? 1. restrict fluid intake 2. limit daily activities 3. monitor urine for protein 4. avoid deep-breathing exercises

266. A nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained? 1. call the practitioner 2. check the client's reflexes 3. determine the client's blood type 4. administer the prescribed IV normal saline

161. A 4-month-old infant who has a congenital heart defect develops heart failure and is exhibiting marked dyspnea at rest. The nurse determines that this finding can be attributed to: 1. anemia 2. hypovolemia 3. pulmonary edema 4. metabolic acidosis

184. The nurse in the postpartum unit is teaching self-care to a group of new mothers. What color does the nurse teach them the lochial discharge will be on the 4th postpartum day? 1. dark red 2. deep brown 3. pinkish brown 4. yellowish white

197. A client at her first visit to the prenatal clinic states that she has missed three menstrual periods and thinks she is carrying twins because her abdomen is so large. She now has a brownish vaginal discharge. Her blood pressure is elevated, indicating that she may have gestational hypertension. What condition does the nurse suspect the client may have? 1. renal failure 2. placenta previa 3. hydatidiform mole 4. abruptio placentae

226. A nurse is caring for a 1-month-old infant who had surgery to repair a cleft lip. What should the nurse use to facilitate feeding during the immediate postoperative period? 1. soft nipple 2. plastic spoon 3. feeding syringe 4. nasogastric tube

231. A nurse is caring for pregnant clients in the high-risk unit. In what disorder is stimulation of labor contraindicated? 1. diabetes mellitus 2. mild preeclampsia 3. total placenta previa 4. premature rupture of the membranes

302. What does the nurse do to elicit the Moro reflex during a newborn assessment? 1. turn the infant's head quickly to one side 2. strokes the infant's back alongside the spine 3. jars the infant's bassinet suddenly but gently 4. taps the infant's bridge of the nose briskly but lightly

314. A nurse is caring for an infant with a myelomeningocele. What does the nurse expect this infant to have that differentiates it from an infant with a meningocele? 1. enlarged head 2. sac over the lumbar area 3. affected lower extremities 4. infection of the spinal fluid

322. A nurse is teaching the parents of an infant with cerebral palsy how to provide optimum care. What should the nurse include in the teaching? 1. focus on cognitive rather than motor skills 2. maintain immobility of the limbs with splints 3. preserve muscle tone to prevent joint contractures 4. continue offering a special formula to limit gagging

146. The nurse is caring for a client who is in the first stage of labor. The fetal heart rate monitor displays irregular baseline with variability. What is the priority nursing intervention? 1. administering oxygen 2. notifying the practitioner 3. changing the client's position 4. continuing to monitor the client

147. A nurse is caring for an infant with heart failure. What treatment does the nurse anticipate? 1. open heart surgery 2. multiple operations during childhood 3. medications that are specific for infants and children 4. medications that are prescribed for both children and adults

208. A nurse is caring for a client at 42 week's gestation, who is having a contraction stress test. What does a positive test indicate? 1. placenta has stopped growing 2. fetal lungs have not yet matured 3. amniotic fluid is meconium stained 4. function of the placenta has diminished

A child with thalassemia was given desferoxamine (Desferal); which of the following should alert the nurse to notify the physician? A. Decreased hearing B. Hypertension C. Red urine D. Vomiting

A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be: A. Auscultating the fetal heart B. Taking an obstetric history C. Asking the client when she last ate D. Ascertaining whether the membranes were ruptured

A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: A. Connect the resuscitation bag to the oxygen outlet B. Turn on the apnea and cardiorespiratory monitors C. Set up the intravenous line with 5% dextrose in water D. Set the radiant warmer control temperature at 36.5* C (97.6*F)

A nurse is preparing Dinoprostone to a client to induce labor. Which of the following nursing intervention must be questioned? A. Have the client hold void before administration. B. Place the client on a side lying position for 30 to 60 minutes after the administration. C. Monitor maternal vital signs. D. Have the client void before administration.

Normal lochial findings in the first 24 hours post-delivery include: A. Bright red blood B. Large clots or tissue fragments C. A foul odor D. The complete absence of lochia

While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised? A. Sucking ability B. Respiratory status C. Locomotion D. GI function

Impetigo tends to be most commonly found on: A. Mouth B. Ears C. Nose D. Torso E. Toes

A, C

Select the systems below that are affected by cystic fibrosis: A. Reproductive B. Lymphatic C. Respiratory D. Gastrointestinal E. Neuro F. Integumentary

A, C, D, F

A patient with cystic fibrosis is diagnosed with pancreatic insufficiency. As the nurse you know that the patient will be lacking: A. Amylase B. Pepsin C. Protease D. Maltase E. Lipase

A, C, E

A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: A. Less pressure on her cervix B. Increased efficiency of contractions C. Decreased number of contractions D. The need for increased maternal blood pressure monitoring

A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the client's plan of care? A. Daily weights B. Seizure precautions C. Right lateral positioning D. Stress reduction

Mr. and Mrs. Smith's child has hemophilia; which of the following actions would you instruct them to avoid? A. Immobilizing the joint B. Lowering the injured area C. Applying cold to the area D. Applying pressure

A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Select all instructions that would be included on the list. A. Take the prescribed antibiotics until the soreness subsides. B. Wear supportive bra C. Avoid decompression of the breasts by breastfeeding or breast pump D. Rest during the acute phase E. Continue to breastfeed if the breasts are not too sore.

B, D, E

A 37-year-old female patient who is 36 weeks pregnant is diagnosed with mild preeclampsia. The nurse will include what information in the patient's education? Select all that apply: A. Report weight gain of >4 lbs in one week to physician B. Incorporate foods like eggs, nuts, fish, meat in your diet C. Follow a no salt diet D. Headache and vision changes are expected side effects of this condition and cause no reason for concern. E. Importance of monitoring urine protein at home F. Lying on left-side is recommended along with rest G. Report a decrease in fetal activity immediately

B, E, F, and G A is wrong because you report weight gain of >2 lbs (NOT 4 lbs) in one week.

You note that when a finger is placed under the toes of a newborn, the toes will curl downward. This is known as the __________? A. Babinski reflex B. Plantar grasp reflex C. Tonic Neck reflex D. Step reflex

B. Plantar grasp reflex

A client has just given birth at 42 weeks' gestation. When assessing the neonate, which physical finding is expected? A. A sleepy, lethargic baby B. Lanugo covering the body C. Desquamation of the epidermis D. Vernix caseosa covering the body

A client in preterm labor (32 weeks) who is dilated to 5cm has been given magnesium sulfate and the contractions have stopped. If the labor can be delayed for the next 2 days, which of the following medication does the nurse expect that will be prescribed? A. Fentanyl (Sublimaze). B. Sufentanil (Sufenta). C. Betamethasone (Celestone). D. Butorphanol tartrate (Stadol).

A client is prescribed with Methylergonovine, prior giving this medication, what is the priority assessment for the nurse to check? A. Deep tendon reflexes. B. Urine output. C. Blood pressure. D. Vaginal bleeding.

A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is: A. Not yet engaged B. Entering the pelvic inlet C. Below the ischial spines D. Visible at the vaginal opening

A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate? A. The fetus should be delivered within 24 hours. B. The client should repeat the test in 24 hours. C. The fetus isn't in distress at this time. D. The client should repeat the test in 1 week.

During an assessment of an infant, you note that when the infant's head is turned to the right side, the leg and arm on the right side will extend, while the leg and arm on the left side will flex. You document this as what type of reflex? A. Rooting Reflex B. Sucking Reflex C. Moro Reflex D. Tonic Neck Reflex

D. Tonic Neck Reflex

124. During labor the nurse encourages the client to void. The nurse considers that an overdistended urinary bladder during labor can: 1. predispose to uterine hemorrhage after birth 2. interfere with the assessment of cervical dilation 3. prevent the diagnosis of cephalopelvic disproportion 4. delay expulsion of the placenta after the birth of the neonate

263. A client at 36 weeks' gestation arrives at the prenatal clinic for a routine examination. The nurse identifies that client's blood pressure has increased from 102/60 to 134/88 and is concerned she may be developing mild preeclampsia. What other signs of mild preeclampsia does the nurse anticipate? 1. proteinuria of 1+ 2. mild ankle edema 3. episodes of dizziness on arising 4. weight gain of 2 lbs in 2 weeks

267. A client at 38 weeks' gestation is admitted to the high-risk unit because she gained 5 lbs in the previous week and there is a pronounced increase in blood pressure. What is the initial intervention in the client's plan of care? 1. preparing for an imminent caesarean birth 2. providing a dark, quiet room with minimal stimuli 3. initiating IV furosemide to promote diuresis 4. administering calcium gluconate to lower the blood pressure

373. A nurse in the pediatric clinic is assessing an 8 year-old child who has had asthma since infancy. What clinical findings require immediate intervention? 1. barrel chest 2. audible wheezing 3. heart rate of 105 beats per minute 4. respiratory rate of 30 breaths per minute

Postpartum Period: The fundus of the uterus is expected to go down normally postpartally about __ cm per day. A. 1.0 cm B. 2.0 cm C. 2.5 cm D. 3.0 cm

Which of the following describes the Babinski reflex? A. The newborn's toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot. B. The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise. C. The newborn turns the head in the direction of stimulus, opens the mouth, and begins to suck when cheek, lip, or corner of mouth is touched. D. The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface

Which of the following findings would be expected when assessing the postpartum client? A. Fundus 1 cm above the umbilicus 1 hour postpartum B. Fundus 1 cm above the umbilicus on postpartum day 3 C. Fundus palpable in the abdomen at 2 weeks postpartum D. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2

Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease? A. Susceptibility to respiratory infection B. Bleeding tendencies C. Frequent vomiting and diarrhea D. Seizure disorder

Which of the following would the nurse identify as the initial priority for a child with acute lymphocytic leukemia? A. Instituting infection control precautions B. Encouraging adequate intake of iron-rich foods C. Assisting with coping with chronic illness D. Administering medications via IM injections

Upon assessment the nurse found the following: fundus at 2 fingerbreadths above the umbilicus, last menstrual period (LMP) 5 months ago, fetal heart beat (FHB) not appreciated. Which of the following is the most possible diagnosis of this condition? A. Hydatidiform mole B. Missed abortion C. Pelvic inflammatory disease D. Ectopic pregnancy

A Hydatidiform mole begins as a pregnancy but early in the development of the embryo degeneration occurs. The proliferation of the vesicle-like substances is rapid causing the uterus to enlarge bigger than the expected size based on ages of gestation (AOG). In the situation given, the pregnancy is only 5 months but the size of the uterus is already above the umbilicus which is compatible with 7 months AOG. Also, no fetal heartbeat is appreciated because the pregnancy degenerated thus there is no appreciable fetal heart beat.

As the nurse you know which statements below are correct about the ductus arteriosus? Select all that apply: A. "The ductus arteriosus is a structure that should be present in all babies in utero." B. "The ductus arteriosus normally closes about 3 days after birth or sooner." C. "The purpose of the ductus arteriosus is to help carry blood that is entering the left side of the heart to the rest of the body, hence bypassing the lungs." D. "The ductus arteriosus connects the aorta to the pulmonary vein."

A, B Option A is correct because every newborn should have this structure, but it will close shortly after birth. Option C is wrong because the purpose of this structure is to help carry blood that is entering the RIGHT side (not left) of the heart to the rest of the body, hence bypassing the lungs. Option D is wrong because this structure connects the aorta to the pulmonary ARTERY (not vein).

A pregnant patient has a nonstress test performed. The results showed the baby had 4 fetal heart rate accelerations of at least 15 beats/min that lasted 15 seconds from start to finish in association with fetal movement during 20 minutes. The results of this would be documented as: A. "Reactive" Nonstress Test B. "Nonreactive" Nonstress Test C. Negative Contraction Stress Test D. Positive Contraction Stress Test

A. "Reactive" Nonstress Test

A client makes a routine visit to the prenatal clinic. Although she is 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy. Dr. Charles diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal: A. an empty gestational sac. B. grapelike clusters. C. a severely malformed fetus. D. an extrauterine pregnancy.

A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? A. Hypotension and Bradycardia B. Tachypnea and retractions C. Acrocyanosis and grunting D. The presence of a barrel chest with grunting

A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? A. Placing the client on complete bed rest B. Continuous electronic fetal monitoring C. An IV infusion of antibiotics D. Placing a code cart at the client's bedside

A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? A. Three contractions occurring within a 10-minute period B. A fetal heart rate of 90 beats per minute C. Adequate resting tone of the uterus palpated between contractions D. Increased urinary output

During the period of induction of labor, a client should be observed carefully for signs of: A. Severe pain B. Uterine tetany C. Hypoglycemia D. Umbilical cord prolapse

The drug usually given parenterally to enhance uterine contraction is: A. Terbutaline B. Pitocin C. Magnesium sulfate D. Lidocaine

The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is: A. Normal B. Indicates the presence of infection C. Indicates the need for increasing oral fluids D. Indicates the need for increasing ambulation

The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? A. Anemia B. Hypoglycemia C. Nitrogen loss D. Thrombosis

The nurse understands that the fetal head is in which of the following positions with a face presentation? A. Completely flexed B. Completely extended C. Partially extended D. Partially flexed

The uterine fundus right after delivery of placenta is palpable at A. Level of xiphoid process B. Level of umbilicus C. Level of symphysis pubis D. Midway between umbilicus and symphysis pubis

When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: A. Stop the oxytocin infusion B. Change the client's position C. Prepare for immediate delivery D. Take the client's blood pressure

When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? A. Document the findings B. Notify the physician C. Reassess the client in 2 hours D. Encourage increased intake of fluids

Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor? A. Weak contraction prolonged to more than 70 seconds B. Tetanic contractions prolonged to more than 90 seconds C. Increased pain with bright red vaginal bleeding D. Increased restlessness and anxiety

Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy? A. Risk for infection B. Pain C. Knowledge Deficit D. Anticipatory Grieving

Which of the following signs and symptoms will most likely make the nurse suspect that the patient is having hydatidiform mole? A. Slight bleeding B. Passage of clear vesicular mass per vagina C. Absence of fetal heart beat D. Enlargement of the uterus

B Hydatidiform mole (H-mole) is characterized by the degeneration of the chorionic villi wherein the villi becomes vesicle-like. These vesicle-like substances when expelled per vagina and is a definite sign that the woman has H-mole.

A baby is born at 37 weeks gestation to a mother with gestational diabetes. As the nurse you know at birth that the newborn is at risk for? Select all that apply: A. Hyperglycemia B. Hypoglycemia C. Respiratory distress D. Jaundice E. Hyperthermia

B, C

A patient has gestational diabetes and is currently 34 weeks pregnant. Which assessment findings below should you immediately report to the physician? Select all that apply: A. Blood glucose 129 mg/dL B. Blood pressure 190/102 C. Proteinuria D. Linea nigra E. Negative glycosuria

B, C

Select all the risk factors below that increases a woman's risk for developing preeclampsia: A. Nulligravida B. Primigravida C. BMI 34 D. Pregnant with twins E. Maternal history of preeclampsia F. Age: 25-years-old G. History of Lupus and Diabetes

B, C, D, E, and G Risk factors for preeclampsia include: History of preeclampsia or family history, first pregnancy (primigravida), significant health history prior to pregnancy: diabetes, lupus, high blood pressure, kidney disease, Obese: BMI >30, having more than one baby (twins, triplets etc.), age (young <18 or advanced >35).

Your patient is 36 weeks pregnant with severe preeclampsia. The physician has ordered lab work to assess for HELLP Syndrome. Which findings on the patient's lab results correlate with HELLP Syndrome? A. Hemoglobin 12 g/dL B. Platelets 90,000 μL C. ALT 100 IU/L D. AST 90 IU/L E. Glucose 350 mg/dL F. Abnormal RBC peripheral smear

B, C, D, and F HELLP Syndrome causes of Hemolysis of RBCs (abnormal RBC peripheral smear), Elevated Liver enzymes (>70 IU/L for AST or ALT), Low Platelets (<100,000 μL ).

You're providing education to a group of parents about impetigo. Which statement is CORRECT about this disease? A. "It tends to affect the preadolescent and adolescent population." B. "Cases of impetigo most likely to occur during the summer when the weather is warm." C. "Most cases of impetigo are not contagious." D. "Impetigo is caused by a mite parasite."

B. "Cases of impetigo most likely to occur during the summer when the weather is warm."

A 2 year old with impetigo is ordered topical antibiotic ointment. You're teaching the child's mother how to apply the ointment. Which action by the mother during application of the ointment requires you to re-educate the parent? A. The mother washes her hands before and after the application of the ointment. B. The mother applies a layer of ointment directly over the crust of the lesion. C. The mother uses warm water and antibacterial soap to cleanse the lesions prior to application of ointment. D. The mother uses a cotton swab to apply the ointment.

B. The mother applies a layer of ointment directly over the crust of the lesion.

When the Moro Reflex is stimulated in an infant, the infant will _____________the arms with the palms of the hands turned ___________ and then move the arms ___________ the body. A. flex, upward, away from B. extend, upward, back to C. flex, downward, back to D. extend, downward, away from

B. extend, upward, back to

A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the Preeclampsia and the need to notify the physician? A. Blood pressure reading is at the prenatal baseline B. Urinary output has increased C. The client complains of a headache and blurred vision D. Dependent edema has resolved

A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: A. Place the mother in the supine position B. Document the findings and continue to monitor the fetal patterns C. Administer oxygen via face mask D. Increase the rate of pitocin IV infusion

The lochia on the first few days after delivery is characterized as A. Pinkish with some blood clots B. Whitish with some mucus C. Reddish with some mucus D. Serous with some brown tinged mucus

The second stage of labor begins with ___ and ends with __? A. Begins with full dilatation of cervix and ends with delivery of placenta B. Begins with true labor pains and ends with delivery of baby C. Begins with complete dilatation and effacement of cervix and ends with delivery of baby D. Begins with passage of show and ends with full dilatation and effacement of cervix

Which condition or treatment best ensures lung maturity in an infant? A. Meconium in the amniotic fluid B. Glucocorticoid treatment just before delivery C. Lecithin to sphingomyelin ratio more than 2:1 D. Absence of phosphatidylglycerol in amniotic fluid

Which of the following represents the average amount of weight gained during pregnancy? A. 12 to 22 lb B. 15 to 25 lb C. 24 to 30 lb D. 25 to 40 lb

How would the nurse check for clonus in a patient with preeclampsia? A. Assess the patellar and bicep tendon with a reflex hammer and grade the reaction. B. Assess for muscular rigidity by having the patient extend the arms and place resistance against the arms. C. Assess for beating of the foot when the foot is quickly dorsiflexed. D. Assess for dorsiflexion of the foot by quickly plantar flexing the foot.

C. Assess for beating of the foot when the foot is quickly dorsiflexed.

A 4 year old is admitted to your unit with a severe case of impetigo. It is important the nurse follows _______________ while providing care to this patient: A. Droplet precautions B. Standard precautions only C. Contact precautions D. Airborne precaution

C. Contact precautions

A patient completes a one hour glucose tolerance test. The patient's result is 190 mg/dL. As the nurse you know that the next step in the patient's care is to? A. Continue monitoring pregnancy, the test is normal B. Reassess blood glucose in 2 weeks C. Notify the physician who will order the patient to take a 3 hour glucose tolerance test D. Provide education to the patient about how to manage gestational diabetes during pregnancy

C. Notify the physician who will order the patient to take a 3 hour glucose tolerance test

In a 3-month-old infant you assess the Babinski Reflex. What is the appropriate response in an infant at this age? A. The big toe plantar flexes and the other toes curl downward. B. All the toes curl downward. C. The big toe dorsiflexes and the other toes spread outward. D. The big toe plantar flexes and the other toes fan outward.

C. The big toe dorsiflexes and the other toes spread outward.

A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? A. The umbilical cord shortens in length and changes in color B. A soft and boggy uterus C. Maternal complaints of severe uterine cramping D. Changes in the shape of the uterus

Neonates of mothers with diabetes are at risk for which complication following birth? A. Atelectasis B. Microcephaly C. Pneumothorax D. Macrosomia

The twelve-year-old boy has fractured his arm because of a fall from his bike. After the injury has been casted, the nurse knows it is most important to perform all of the following assessments on the area distal to the injury except: A. capillary refill. B. radial and ulnar pulse. C. finger movement D. skin integrity

When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following? A. Turn the neonate every 6 hours B. Encourage the mother to discontinue breast-feeding C. Notify the physician if the skin becomes bronze in color D. Check the vital signs every 2 to 4 hours

When giving narcotic analgesics to mother in labor, the special consideration to follow is: A. The progress of labor is well established reaching the transitional stage B. Uterine contraction is progressing well and delivery of the baby is imminent C. Cervical dilatation has already reached at least 8 cm. and the station is at least (+)2 D. Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours.

When taking an obstetrical history on a pregnant client who states, "I had a son born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks,"the nurse should record her obstetrical history as which of the following? A. G2 T2 P0 A0 L2 B. G3 T1 P1 A0 L2 C. G3 T2 P0 A0 L2 D. G4 T1 P1 A1 L2

Which action best explains the main role of surfactant in the neonate? A. Assists with ciliary body maturation in the upper airways B. Helps maintain a rhythmic breathing pattern C. Promotes clearing mucus from the respiratory tract D. Helps the lungs remain expanded after the initiation of breathing

Which of the following characteristics will distinguish a postmature neonate at birth? A. Plenty of lanugo and vernix caseosa B. Lanugo mainly on the shoulders and vernix in the skin folds C. Pinkish skin with good turgor D. Almost leather-like, dry, cracked skin, negligible vernix caseosa

Which of the following disorders leads to cyanosis from deoxygenated blood entering the systemic arterial circulation? A. Aortic stenosis (AS) B. Coarctation of aorta C. Patent ductus arteriosus (PDA) D. Tetralogy of Fallot

Which of the following findings meets the criteria of a reassuring FHR pattern? A. FHR does not change as a result of fetal activity B. Average baseline rate ranges between 100 - 140 BPM C. Mild late deceleration patterns occur with some contractions D. Variability averages between 6 - 10 BPM

Which of the following nursing interventions would the nurse perform during the third stage of labor? A. Obtain a urine specimen and other laboratory tests. B. Assess uterine contractions every 30 minutes. C. Coach for effective client pushing D. Promote parent-newborn interaction.

A 32-year-old female is diagnosed with gestational diabetes. As the nurse you know that what test below is used to diagnose a patient with this condition? A. 1 hour glucose tolerance test B. 24 hour urine collection C. Hemoglobin A1C D. 3 hour glucose tolerance test

D. 3 hour glucose tolerance test

Cystic fibrosis is an autosomal recessive genetic disorder. Which option below best describes what most likely happens for a child to develop this condition? A. One parent, who is a carrier of the mutated gene, has to pass it to the child B. One of the parents has to have cystic fibrosis in order to pass it to their offspring C. Both of the parents must have cystic fibrosis in order for the child to develop it D. Both parents, who are carriers of the mutated gene, each pass one mutated gene to the child

D. Both parents, who are carriers of the mutated gene, each pass one mutated gene to the child

What landmark is used to assess fetal station? A. Iliac spine B. Pubic symphysis C. Ischium D. Ischial spine

D. Ischial spine

You note when a 2-month-old is held upright with the legs and feet touching the surface, the infant will appear to be walking on the surface. This reflex is called the? A. Bauer Crawling Reflex B. Push-to-Walk Reflex C. Babinski Reflex D. Step Reflex

D. Step Reflex

Select the option below that best describes how to assess the palmar grasp reflex: A. Stroke the cheek of the infant and assess if the head turns toward the stimuli. B. Stroke the sole of the foot starting at the heel to the outward part of the foot and assess if the big toe bends back and the other toes spread out. C. Hold the infant upright with the legs and feet touching a surface and assess if the infant will move the legs in a stepping motion. D. Stroke the inside of the infant's hand with an object and assess if the hand closes around the object.

D. Stroke the inside of the infant's hand with an object and assess if the hand closes around the object.

126. When providing care to a child with leukemia a nurse observes blood on the pillowcase and several bloody tissues. What blood component value on the child's lab results should the nurse verify? 1. platelets 2. neutrophils 3. erythrocytes 4. lymphoblasts

127. A nurse performs Leopold's maneuvers on a newly admitted client in labor. Palpation reveals a soft, firm mass in the fundus; a firm, smooth mass on the mother's left side; several knobs and protrusions on the mother's right side; and a hard, round movable mass in the pubic area with the brow on the right. Based on these findings, the nurse identifies that the fetal position is: 1. LOA 2. ROA 3. LMP 4. RMP

135. A child with thalassemia is being discharged from the hospital. What should the nurse include in the instructions to the parents? 1. minimize the risk of infection 2. offer frequent iron-rich meals 3. encourage increased fluid intake 4. restrict activity allowing only quiet play

137. A client in labor is admitted to the birthing room. The nurse's assessment reveals that the fetus is at -1 station. Where is the presenting part? 1. 1 cm above the ischial spines 2. 1 cm below the ischial spines 3. visible at the vaginal opening 4. at the level of the ischial spines

162. The mother of a 5-month-old infant with heart failure questions the necessity of weighing her baby every morning. The nurse's response is based on the fact that this daily information is important in determining: 1. fluid retention 2. kidney function 3. nutritional status 4. medication dosage

207. What should be included in the nursing care for a client at 41 weeks' gestation who is to have a contraction stress test? 1. having the client empty her bladder 2. placing the client in a supine position 3. informing the client about the need for cesarean birth 4. preparing the client for insertion of an internal monitor

232. A 3-week-old infant is admitted with a tentative diagnosis of hypertrophic pyloric stenosis. Before performing the admission assessment of the abdomen, the nurse bicycles the infant's legs. How does this help the nurse's assessment? 1. relaxes abdominal muscles 2. detects weak abdominal muscles 3. enables palpation of abdominal contour 4. improves assessment of abdominal rebound

247. A toddler who had a cleft palate repair is now able to tolerate fluids. What should the nurse use to offer the toddler fluids? 1. small cup 2. soft nipple 3. bulb syringe 4. Teflon-coated spoon

250. A client at 34 weeks' gestation is receiving terbutaline subcutaneously. Her contractions increase to every 5 minutes and her cervix dilates further to 4 cm. The Tocolytic is discontinued. What is the priority nursing care during this time? 1. promoting maternal-fetal well-being during labor 2. reducing the anxiety associated with preterm labor 3. supporting communication between the client and her partner 4. assisting the client and her partner with the breathing techniques needed as labor progresses

265. A nonstress test is scheduled for a client with preeclampsia. During the nonstress test the nurse concludes that if nonperiodic accelerations of the fetal heart rate occur with fetal movement, it probably indicates: 1. fetal well-being 2. fetal head compression 3. uteroplacental insufficiency 4. umbilical cord compression

334. The nurse assures a breastfeeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested? 1. Has several firm stools daily 2. Voids six or more times a day 3. Spits out a pacifier when offered 4. Awakens to feed about every four hours

351. Phototherapy is ordered for a preterm neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effect of the phototherapy? 1. Covering the trunk to prevent hypothermia 2. Using shields on the eyes to protect them from the light 3. Massaging vitamin E oil on the skin to minimize drying 4. Turning after each feeding to reduce exposure of each surface area

353. What is an appropriate nursing intervention for a neonate with respiratory distress syndrome? 1. avoid handling to conserve energy 2. position to promote respiratory efforts 3. assess for congenital birth defects to enable early treatment 4. set incubator ten degrees below body temperature to prevent shivering

377. A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy? 1. stimulates the liver to dispose of the bilirubin 2. breaks down the bilirubin into a conjugated form 3. facilitates the excretion of bilirubin by activating vitamin K 4. dissolves the bilirubin, allowing it to be excreted by the skin

422. After the removal of a hydatidiform mole, the nurse monitors the client's laboratory data during a follow-up visit. The nurse identifies that a prolonged elevation of the serum human chorionic gonadotropin (hCG) level is a danger sign. What condition is a possible outcome? 1. Uterine rupture 2. Choriocarcinoma 3. Hyperemesis gravidarum 4. Disseminated intravascular coagulation

431. The nurse is teaching the parents of an infant who will have frequent cast changes about cast care. What suggestion should be included in the teaching? 1. apply lotion to the skin at cast edges 2. check the skin at the edges of the cast 3. immerse the cast briefly during the tub bath 4. cover the damp cast edges with adhesive petals

469. A client is receiving an epidural anesthetic during labor. For which side effect should the nurse monitor the client? 1. hypertension 2. urinary retention 3. subnormal temperature 4. decreased level of consciousness

73. At a client's first visit to the prenatal clinic, the nurse asks the client when she had her last menstrual period so the estimated date of birth can be determined. The client responds, "January 21". Using Nagele's rule, what is the month and day of the clients' EDB? 1. October 21 2. October 28 3. November 21 4, November 28

237. A client in labor is admitted to the birthing unit. Assessment reveals that the fetus is in a footling breech presentation. What should the nurse consider about breech presentations when caring for this client? 1. severe back discomfort will occur 2. length of labor usually is shortened 3. caesarean birth probably will be necessary 4. meconium in the amniotic fluid is a sign of fetal hypoxia

246. Elbow restraints are ordered for an 18-month-old toddler who just had surgery for a cleft palate. The nurse explains to the parents that the restraints are used to prevent: 1. playing with unsterile toys 2. rolling to a supine position 3. putting fingers into the mouth 4. removing the NG tube

292. Immediately after birth, what is the first nursing intervention for the newborn with a 1 minute Apgar score of 7? 1. administer oxygen 2. perform a brief physical assessment 3. dry and place in a warm environment 4. cut the umbilical cord and attach a clamp

297. How should the nurse assess a newborn's grasp reflex? 1. put direct pressure along the sole of the newborn's foot 2. jar the crib and watch the movement of the newborn's hands 3. press examining fingers against the palms of the newborn's hands 4. hold the body upright and allow the newborn's feet to touch a surface

324. A nurse is concerned about helping the parents of an infant with cerebral palsy set long-term goals for the family. What is most important to understand when setting long-term goals? 1. cognitive impairments require special education 2. progressive deterioration requires future institutionalization 3. unknown extent of the disability require continual adjustments 4. diminished immune responses require protection from infection

341. In her 36th week of gestation, a client with type 1 diabetes has a 9-pound, 10-ounce infant by cesarean birth. For which condition should the nurse monitor when caring for this infant of a diabetic mother (IDM)? 1. Meconium ileus 2. Physiologic jaundice 3. Respiratory distress syndrome 4. Increased intracranial pressure

357. What characteristics does the nurse anticipate in an infant born at 32 weeks' gestation? 1. ear pinnae spring back when folded 2. palms and soles have definite creases 3. areolae and nipples are barely visible 4. square window sign shows a zero-degree angle

369. A nurse instills an antibiotic ophthalmic ointment into a newborn's eyes. What condition does this medication prevent? 1. Herpetic ophthalmia 2. Retrolental fibroplasia 3. Ophthalmia neonatorum 4. Hemorrhagic conjunctivitis

436. A nurse is caring for a child with juvenile idiopathic arthritis. What is most important for the nurse to attempt to prevent? 1. infection 2. hemarthrosis 3. contracture deformities 4. delayed intellectual development

482. To halt preterm labor, a client is started on terbutaline (Brethine). For which side effect of this medication should the nurse monitor the client? 1. Bradycardia 2. Hyperkalemia 3. Widening pulse pressure 4. Hypotonic uterine contractions

484. A client in labor is receiving a Pitocin infusion. For which adverse reaction from prolonged administration should the nurse monitor the client? 1. change in affect 2. hyperventilation 3. water intoxication 4. elevated temperature

147. During labor a client has an internal fetal monitor applied. The nurse should take action in response to a fetal heart rate that: 1. remains at 140 beats per minute during contractions 2. uniformly drops to 120 beats per minute unrelated to contractions 3. fluctuates from 130 to 140 beats per minute unrelated to contractions 4. repeatedly drops abruptly to 90 beats per minute unrelated to contractions

161. A nurse is observing the electronic fetal monitor as a client in labor enters the second stage. The nurse identifies early decelerations of the fetal heart rate with a return to the baseline at the end of each contraction. What does this usually indicate? 1. maternal diabetes 2. fetal cord prolapse 3. maternal hypotension 4. fetal head compression

190. A new mother wishes to breastfeed her infant and asks the nurse whether she needs to alter her diet. How should the nurse respond? 1. "Eat as you have been doing during your pregnancy." 2. "Drink a lot of milk and the added calcium will help you make milk." 3. "Your body produces the milk your baby needs as a result of vigorous sucking." 4. "You'll need greater amounts of the same foods you've been eating and more fluids."

245. A mother asks why her 2-year-old toddler's cleft palate was not repaired at the same time that the cleft lip was repaired. What is the best response by the nurse? 1. "Waiting leaves time for other birth defects to be detected and corrected" 2. "The cleft lip was so disfiguring that surgery was done as quickly as possible" 3. "Your surgeon prefers to separate the operations to minimize potential complications" 4. "The palate usually is repaired before a child starts to speak and some surgeons prefer to wait up to 2 years"

293. When checking a newborn's reflexes, the nurse is unable to elicit one reflex response that is often absent in neonates born vaginally in the breech presentation. How should the nurse attempt to elicit this response? 1. Move the thumb along the sole of the foot 2. Stroke the ulnar surface of the hand and fifth finger lightly 3. Touch the skinfold of the mouth and cheek on the same side 4. Hold in the upright position while pressing the feet flat on the crib mattress

306. A nurse is planning to use a newborn's foot to obtain blood for the required newborn metabolic testing. What part of the foot is the best site to use for the puncture? 1. big toe 2. foot pad 3. inner sole 4. outer heel

315. A nurse is caring for an infant who had surgery to correct myelomeningocele. What assessment provides data about a potential major complication for this infant? 1. daily weight 2. fluid output every 8 hours 3. blood pressure every 12 hours 4. daily head circumference measurements

343. A male born at 28 weeks' gestation weighs 2 pounds, 12 ounces. What does the nurse expect to observe when performing an assessment? 1. Staring eyes 2. Absence of lanugo 3. Descended testicles 4. Transparent red skin

343. The nurse is counseling the parents of a 12-year-old child with Duchenne muscular dystrophy about problems that may develop during adolescence. What body system does the nurse expect will be affected? 1. neurological 2. integumentary 3. gastrointestinal 4. cardiopulmonary

349. A nurse is assessing a newborn. Which sign should the nurse report? 1. Temperature 97.7 F 2. pale pink, rust-colored stain in the diaper 3. heart rate that decreases to 115 beats per minute 4. breathing pattern with recurrent sternal retractions

362. Which sign indicates to the nurse that a neonate is preterm? 1. Flexion of extremities 2. Absent femoral pulses 3. Positive Babinski reflex 4. Numerous superficial veins

435. A child hospitalized with juvenile idiopathic arthritis complains of pain in the knees. What intervention should help relieve the discomfort? 1. immobilizing the affected joints 2. massaging the swollen areas gently 3. placing several pillows under the knees 4. applying warm, moist compresses to the knees

438. A nurse is teaching a school-age child with juvenile idiopathic arthritis activities to prevent the loss of joint function. What should the nurse caution the child to avoid? 1. bicycle riding 2. walking to school 3. isometric exercises 4. sedentary activities

440. During the initial assessment of a 7 year-old child with a compound fracture of the wrist the nurse identifies a dark, wet area on the cast. What is the nurse's next action? 1. notify the practitioner about the stain 2. remove the stain with soap and water 3. check if the child was playing with a coloring pen 4. circle the area with a pen, noting the date and the time

447. The mother of a 10 year-old boy with mild scoliosis asks the nurse, "How long will my son have to continue his exercises before he is better?" How should the nurse respond? 1. "At your son's age the exercise program is done for several months" 2. "Wearing a brace daily probably will lead to a quicker improvement" 3. "Surgery may be necessary, but it will be less involved if the exercises are done" 4. "Even if he continues to exercise, improvement will not be known until he is fully grown"

465. A client at 31 weeks' gestation is admitted in preterm labor. She asks the nurse if there is any medication that can help stop the contractions. What is the nurse's response? 1. "An oxytocic." 2. "An analgesic." 3. "A corticosteroid." 4. "A beta-adrenergic."

466. While receiving tocolytic therapy for preterm labor the client begins to have muscle tremors and signs of nervousness. The client states, "My hear is racing." The nurse identifies that the client's pulse rate is 110 beats per minute and regular. What should the nurse do next? 1. discontinue the medication as per protocol 2. notify the practitioner that the preterm labor has restarted 3. obtain the client's lab results for electrolyte levels 4. reassure the client that these are expected side effects of the medication

96. A client at 28 weeks' gestation has gained 13 pounds and tells the nurse in the prenatal clinic that she is glad she has not gained as much weight as her sister did during her pregnancy. How should the nurse respond? 1. "Do you think you are getting fat?" 2. "Are you trying to watch your figure?" 3. "You have to eat right during pregnancy." 4. "Tell me what you have been eating lately."

A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? A. Document the findings and tell the mother that the monitor indicates fetal well-being B. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen C. Notify the physician or nurse midwife of the findings D. Reposition the mother and check the monitor for changes in the fetal tracing

A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert? A Endometritis B. Endometriosis C. Salpingitis D. Pelvic thrombophlebitis

After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing? A. Obtaining an order to begin IV oxytocin infusion B. Administering a light sedative to allow the patient to rest for several hour C. Preparing for a cesarean section for failure to progress D. Increasing the encouragement to the patient when pushing begins

Before giving a repeat dose of magnesium sulfate to a pre-eclamptic patient, the nurse should assess the patient's condition. Which of the following conditions will require the nurse to temporarily suspend a repeat dose of magnesium sulfate? A. 100 mL. urine output in 4 hours B. Knee jerk reflex is (+)2 C. Serum magnesium level is 10mEg/L. D. Respiratory rate of 16/min

Betty is a 9-year-old girl diagnosed with cystic fibrosis. Which of the following must Nurse Archie keep in mind when developing a care plan for the child? A. Pulmonary secretions are abnormally thick. B. Elevated levels of potassium are found in the sweat. C. CF is an autosomal dominant hereditary disorder. D. Obstruction of the endocrine glands occurs.

Clients with gestational diabetes are usually managed by which of the following therapies? A. Diet B. NPH insulin (long-acting) C. Oral hypoglycemic drugs D. Oral hypoglycemic drugs and insulin

During an internal examination, the nurse palpated the posterior fontanel to be at the left side of the mother at the upper quadrant. The interpretation is that the position of the fetus is: A. LOA B. ROP C. LOP D. ROA

Fetal presentation refers to which of the following descriptions? A. Fetal body part that enters the maternal pelvis first B. Relationship of the presenting part to the maternal pelvis C. Relationship of the long axis of the fetus to the long axis of the mother D. A classification according to the fetal part

For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? A. The membranes must rupture B. The fetus must be at 0 station C. The cervix must be dilated fully D. The patient must receive anesthesia

Kim is using bronchodilators for asthma. The side effects of these drugs that you need to monitor this patient for include: A. tachycardia, nausea, vomiting, heart palpitations, inability to sleep, restlessness, and seizures. B. tachycardia, headache, dyspnea, temp . 101 F, and wheezing. C. blurred vision, tachycardia, hypertension, headache, insomnia, and oliguria. D. restlessness, insomnia, blurred vision, hypertension, chest pain, and muscle weakness.

Methylergonovine (Methergine) is prescribed to a patient who is having a postpartum bleeding. Prior giving the medication, the nurse contacts the physician who prescribed the medication if which of the following condition is documented in the patient's chart? A. Ischemic heart disease. B. Hypotension C. Acute Gastroenteritis. D. Uterine Atony

Mr. and Mrs. Baker's only daughter is diagnosed with heart failure. Which of the following interventions would be appropriate to promote optimal nutrition for the infant? A. Replacing regular nipples with easy-to-suck ones B. Allowing the infant to feed for at least 1 hour C. Providing large feedings evenly spaced every 4 hours D. Offering formula that is high is sodium and calories

The diet that is appropriate in normal pregnancy should be high in A. Protein, minerals and vitamins B. Carbohydrates and vitamins C. Proteins, carbohydrates and fats D. Fats and minerals

The expected weight gain in a normal pregnancy during the 3rd trimester is A. 1 pound a week B. 2 pounds a week C. 10 lbs a month D. 10 lbs total weight gain in the 3rd trimester

Upon completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. Which of the following is a correct interpretation of the data? A. Fetal presenting part is 1 cm above the ischial spines B. Effacement is 4 cm from completion C. Dilation is 50% completed D. Fetus has achieved passage through the ischial spines

When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to: A. Prevent seizures B. Reduce blood pressure C. Slow the process of labor D. Increase dieresis

When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the following instructions would be the priority? A. Dietary intake B. Medication C. Exercise D. Glucose monitoring

When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as: A. An acceleration B. An early elevation C. A sonographic motion D. A tachycardic heart rate

When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes? A. Moro reflex B. Babinski reflex C. Grasping reflex D. Tonic neck reflex

Which of the following best describes preterm labor? A. Labor that begins after 20 weeks gestation and before 37 weeks gestation B. Labor that begins after 15 weeks gestation and before 37 weeks gestation C. Labor that begins after 24 weeks gestation and before 28 weeks gestation D. Labor that begins after 28 weeks gestation and before 40 weeks gestation

A 34-year-old female is currently 16 weeks pregnant. You're collecting the patient's health history. She has the following health history: gravida 5, para 4, BMI 28, hypertension, depression, and family history of Type 2 diabetes. Select below all the risk factors in this scenario that increases this patient's risk for developing gestational diabetes? A. 34-years-old B. 16 weeks pregnant C. Gravida 5, para 4 D. BMI 28 E. Hypertension F. Depression G. Family history of Type 2 diabetes

A, C, D, G

You're providing care to an 18-year-old male who has cystic fibrosis. Select all the possible complications this patient can experience due to cystic fibrosis: A. Blood glucose 255 mg/dL B. Hearing disturbances C. Hemoptysis D. Greasy, foul smelling stools E. Weight gain F. Meconium ileus G. Excessive mucus production H. Dyspnea I. Coughing J. Hyperoxemia K. Infertility

A, C, D, G, H, I, and K All these are complications of cystic fibrosis. Option B: hearing disturbances not common, Option E: weight LOSS rather than gain due to the inability to digest food due to lacking pancreatic enzymes, Option F: this only occurs in infants...remember meconium is the first "bowel movement" an infant experiences after birth...this patient here is 18-years-old, and Option J: high oxygen in the blood....no but rather low because of the thick mucus blocking air flow in the lungs, which will lead to hypoxia

A patient is scheduled to take Pancreatin. When will you administer this medication to the patient? A. Right before all meals and snacks B. Right before meals only C. Immediately after meals and snacks D. Immediately after meals only

A. Right before all meals and snacks

A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has a saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as: A. Excessive B. Heavy C. Light D. Scanty

A student nurse was asked by the nurse instructor to explain the procedure for the administration of erythromycin ointment to the eyes of the newborn. Which of the following statements made by the student indicates a need for further research? A. "I will instill the eye ointment into each of the newborn's conjunctival sacs." B. "I will flush the newborn's eyes after instilling the ointment." C. "I will clean the newborn's eyes before instilling the ointment." D. "I need to administer the eye ointment within an hour after maternal delivery."

Daya's child is scheduled for surgery due to myelomeningocele; the primary reason for surgical repair is which of the following? A. To prevent hydrocephalus B. To reduce the risk of infection C. To correct the neurologic defect D. To prevent seizure disorders

During which of the following stages of labor would the nurse assess "crowning"? A. First stage B. Second stage C. Third stage D. Fourth stage

Dustin who was diagnosed with Hirschsprung's disease has a fever and watery explosive diarrhea. Which of the following would Nurse Joyce do first? A. Administer an antidiarrheal. B. Notify the physician immediately. C. Monitor the child every 30 minutes. D. Nothing. (These findings are common in Hirschsprung's disease.)

Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse's immediate action would be to: A. Change the woman's position B. Stop the Pitocin C. Elevate the woman's legs D. Administer oxygen via a tight mask at 8 to 10 liters/minute

Mrs. Santos is on her 5th pregnancy and has a history of abortion in the 4th pregnancy and the first pregnancy was a twin. She is considered to be A. G 4 P 3 B. G 5 P 3 C. G 5 P 4 D. G 4 P 4

On which of the postpartum days can the client expect lochia serosa? A. Days 3 and 4 PP B. Days 3 to 10 PP C. Days 10-14 PP D. Days 14 to 42 PP

Right after birth, when the skin of the baby's trunk is pinkish but the soles of the feet and palm of the hands are bluish this is called: A. Syndactyly B. Acrocyanosis C. Peripheral cyanosis D. Cephalo-caudal cyanosis

The Andrews family has been taking good care of their youngest, Archie, who was diagnosed with asthma. Which of the following statements indicate a need for further home care teaching? A. "He should increase his fluid intake regularly to thin secretions." B. "We'll make sure that he avoids exercise to prevent attacks." C. He is to use his bronchodilator inhaler before the steroid inhaler." D. "We need to identify what things trigger his attacks."

You're caring for a 2-day-old infant with a large patent ductus arteriosus. The mother of the infant is anxious and asks you to explain her child's condition to her again. Which statement below BEST describes this condition? A. "The vessel connecting the aorta and pulmonary vein has closed prematurely, which is leading to increased blood flow to the lungs." B. "The vessel connecting the aorta and pulmonary artery has failed to close at birth, which is leading to a left-to-right shunt of blood." C. The vessel connecting the aorta and pulmonary vein has failed to close at birth, which is leading to a right-to-left shunt of blood." D. "The vessel connecting the aorta and pulmonary artery has closed prematurely, which is leading to a left-to-right shunt of blood."

B. "The vessel connecting the aorta and pulmonary artery has failed to close at birth, which is leading to a left-to-right shunt of blood."

A child has impetigo and is being treated with oral antibiotics. The father asks when the child can be allowed to return to school. Your answer is: A. After 72 hours from the start of the treatment B. After 24 hours from the start of the treatment C. After 48 hours from the start of the treatment D. After 1 week from the start of the treatment

B. After 24 hours from the start of the treatment

A nurse instructor is about to administer a vitamin K injection to a newborn. The student nurse asks the instructor regarding the purpose of the injection. The appropriate response would be: A. "The vitamin K provides active immunity." B. "The vitamin K will prevent the occurrence of hyperbilirubinemia." C. "The vitamin K will protect the newborn from bleeding." D. "The vitamin K will serve as protection against jaundice and anemia."

A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition? A. Medication that will provide sedation B. Increased hydration C. Oxytocin (Pitocin) infusion D. Administration of a tocolytic medication

A nurse is caring for a pregnant client with Preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from Preeclampsia to eclampsia, the nurse's first action is to: A. Administer magnesium sulfate intravenously B. Assess the blood pressure and fetal heart rate C. Clean and maintain an open airway D. Administer oxygen by face mask

A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. 1. Stop of Pitocin infusion 2. Perform a vaginal examination 3. Reposition the client 4. Check the client's blood pressure and heart rate 5. Administer oxygen by face mask at 8 to 10 L/min A. 1, 2, 3, 4, 5 B. 1, 4, 2, 3, 5 C. 1, 4, 3, 5, 2 D. 1, 2, 4, 5, 3

A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: A. Subcutaneous injection B. Intravenous injection C. Instillation of the preparation into the lungs through an endotracheal tube D. Intramuscular injection

A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: A. "You infant needs vitamin K to develop immunity." B. "The vitamin K will protect your infant from being jaundiced." C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." D. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."

A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): A. Sometimes uses vibroacoustic stimulation. B. Is an invasive test; however, contractions are stimulated. C. Is considered to have a negative result if no late decelerations are observed with the contractions. D. Is more effective than nonstress test (NST) if the membranes have already been ruptured.

A pregnant client is making her first Antepartum visit. She has a two year old son born at 40 weeks, a 5 year old daughter born at 38 weeks, and 7 year old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, the nurse should identify that the client is: A. G4 T3 P2 A1 L4 B. G5 T2 P2 A1 L4 C. G5 T2 P1 A1 L4 D. G4 T3 P1 A1 L4

A pregnant client is receiving magnesium sulfate therapy for the control of preeclampsia. A nurse discover that the client is encountering toxicity from the medication in which of the following assessment? A. Urine output of 25 ml/hr. B. The presence of deep tendon reflex. C. Respirations of 10 breaths per minute. D. Serum magnesium level of 7 mEq/L.

A woman who delivered normally per vaginam is expected to void within ___ hours after delivery. A. 3 hours B. 4 hours C. 6-8 hours D. 12-24 hours

A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium therapy is effective if: A. Ankle clonus in noted B. The blood pressure decreases C. Seizures do not occur D. Scotomas are present

After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: A. Above the umbilicus at the midline B. Above the umbilicus on the left side C. Below the umbilicus on the right side D. Below the umbilicus near the left groin

Baby Jonathan was born with cleft lip (CL); Nurse Barbara would be alert that which of the following will most likely be compromised? A. GI function B. Locomotion C. Sucking ability D. Respiratory status

Clay is an 8-year-old boy diagnosed with heart failure. Which of the following shows that he is strictly following the directed therapeutic regimen? A. Daily use of an antibiotic B. Pulse rate less than 50 beats/minute C. Normal weight for age D. Elevation in red blood cell (RBC) count

During a prenatal class, the nurse explains the rationale for breathing techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following? A. Eliminate pain and give the expectant parents something to do B. Reduce the risk of fetal distress by increasing uteroplacental perfusion C. Facilitate relaxation, possibly reducing the perception of pain D. Eliminate pain so that less analgesia and anesthesia are needed

Mr. and Ms. Byers' child failed to pass meconium within the first 24 hours after birth; this may indicate which of the following? A. Celiac disease B. Intussusception C. Hirschsprung's disease D. Abdominal-wall defect

Nurse Karen is providing postoperative care for Dustin who has cleft palate (CP); she should position the child in which of the following? A. In an infant seat B. In the supine position C. In the prone position D. On his side

Spina bifida is one of the possible neural tube defects that can occur during early embryological development. Which of the following definitions most accurately describes meningocele? A. Complete exposure of spinal cord and meninges B. Herniation of spinal cord and meninges into a sac C. Sac formation containing meninges and spinal fluid D. B and C E. Spinal cord tumor containing nerve roots

The hormone responsible for a positive pregnancy test is: A. Estrogen B. Progesterone C. Human Chorionic Gonadotropin D. Follicle Stimulating hormone

Which of the following is TRUE in Rh incompatibility? A. The condition can occur if the mother is Rh(+) and the fetus is Rh(-) B. Every pregnancy of an Rh(-) mother will result to erythroblastosis fetalis C. On the first pregnancy of the Rh(-) mother, the fetus will not be affected D. RhoGam is given only during the first pregnancy to prevent incompatibility

Which of the following tests is most effective in diagnosing hemophilia? A. Bleeding time B. Complete blood count (CBC) C. Partial thromboplastin time (PTT) D. Platelet count

A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the priority when assessing the client? A. Glucosuria B. Depression C. Hand/face edema D. Dietary intake

C After 20 weeks' gestation, when there is a rapid weight gain, preeclampsia should be suspected, which may be caused by fluid retention manifested by edema, especially of the hands and face. The three classic signs of preeclampsia are hypertension, edema, and proteinuria.

The long-term complications seen in thalassemia major are associated to which of the following? A. Anemia B. Growth retardation C. Hemochromatosis D. Splenomegaly

C Long-term complications arise from hemochromatosis, excessive iron deposits precipitating in the tissues and causing destruction.

When are most pregnant patients tested for gestational diabetes? A. 6-12 weeks gestation B. 12-20 weeks gestation C. 24-28 weeks gestation D. 34-36 week gestation

C. 24-28 weeks gestation

About one hour after eating a meal, your patient, who has cystic fibrosis, starts to experience abdominal pain and bloating. Then two hours later the patient has a bowel movement. The patient's stool appears to be greasy and have a foul odor. Which medication below that is being taken by the patient is not providing a desirable outcome for this patient and needs to be re-addressed by the physician? A. Guaifenesin B. Triamcinolone C. Pancrelipase D. Polyethylene Glycol

C. Pancrelipase

The nurse knows that preeclampsia tends to occur during what time in a pregnancy? A. before 20 weeks B. in the third trimester and postpartum C. after 20 weeks D. in the first and second trimester

C. after 20 weeks

A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? A. The client begins to expel clear vaginal fluid B. The contractions are regular C. The membranes have ruptured D. The cervix is dilated completely

A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching? A. "I need to take antibiotics, and I should begin to feel better in 24-48 hours." B. "I can use analgesics to assist in alleviating some of the discomfort." C. "I need to wear a supportive bra to relieve the discomfort." D. "I need to stop breastfeeding until this condition resolves."

A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? A. Switch to bottle feeding the baby for 2 weeks B. Stop the breast feedings and switch to bottle-feeding permanently C. Feed the newborn infant less frequently D. Continue to breastfeed every 2-4 hours

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines the client is experiencing toxicity from the medication if which of the following is noted on assessment? A. Presence of deep tendon reflexes B. Serum magnesium level of 6 mEq/L C. Proteinuria of +3 D. Respirations of 10 per minute

A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test? A. "I will need to have a full bladder for the test to be done accurately." B. "I should have my husband drive me home after the test because I may be nauseated." C. "This test will help to determine whether the baby has Down syndrome or a neural tube defect." D. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby."

Nurse Nancy is assessing a child with pyloric stenosis; she is likely to note which of the following? A. "Currant jelly" stools B. Regurgitation C. Steatorrhea D. Projectile vomiting

The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following assessments would warrant notification of the physician? A. A dark red discharge on a 2-day postpartum client B. A pink to brownish discharge on a client who is 5 days postpartum C. Almost colorless to creamy discharge on a client 2 weeks after delivery D. A bright red discharge 5 days after delivery

The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be: A. Severe postpartum headache B. Limited perception of bladder fullness C. Increase in respiratory rate D. Hypotension

Which of the following symptoms occurs with a hydatidiform mole? A. Heavy, bright red bleeding every 21 days B. Fetal cardiac motion after 6 weeks gestation C. Benign tumors found in the smooth muscle of the uterus D. "Snowstorm" pattern on ultrasound with no fetus or gestational sac

Which of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy? A. 10 pounds per trimester B. 1 pound per week for 40 weeks C. ½ pound per week for 40 weeks D. A total gain of 25 to 30 pounds

Which type of lochia should the nurse expect to find in a client 2 days PP? A. Foul-smelling B. Lochia serosa C. Lochia alba D. Lochia rubra

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